Sense of Coherence and Biopsychosocial Health in Spanish Adolescents

1 Short title: SENSE OF COHERENCE AND HEALTH Sense of coherence and biopsychosocial health in Spanish adolescents Irene García-Moya1, Carmen Moreno1, and Francisco Rivera2 1Universidad de Sevilla (Spain) 2Universidad de Huelva (Spain) The HBSC study in Spain was supported by an agreement signed among the Ministerio de Sanidad, Política Social e Igualdad and the Universidad de Sevilla. In addition, this work is supported by the Ministerio de Educación through the National Program FPU [grant number: AP2009-0978]. Correspondence concerning this article should be addressed to Irene García- Moya. Departamento de Psicología Evolutiva y de la Educación. Universidad de Sevilla. C/ Camilo José Cela, s/n. 41018. Seville (Spain). Phone: +34 954554331. E- mail: irene[email protected] This version is published under a Creative Commons CC-BY-NC-ND licence 2 Abstract The aim of this study was to analyse the effect of the SOC on the main components of biopsychosocial health separately, thereby contributing to a better understanding of the relationship between the SOC and health in adolescence. The sample consisted of 7,580 Spanish adolescents aged 13 to 18 who had participated in the 2009/10 edition of the WHO international survey Health Behaviour in School-aged Children. Using multivariate analysis of variance, the effects of the SOC and demographic variables (including interaction effects between them) on different health components were analysed. A higher SOC was associated with better self-rated health, lower frequency of somatic and psychological complaints and higher quality of life and life satisfaction. Thus, results support the association between SOC and positive health outcomes, especially for the psychological components of health. In addition, the effect of SOC on the various health components was homogeneous among all of the adolescents, regardless of gender and age. Keywords: sense of coherence; adolescence; health; salutogenesis. 3 In its beginnings, psychology had a tendency to focus on psychoanalitical and behavioural approaches in explaining human behaviour and to neglect the subjective aspects of life experience. That way, it was not up to the 70s that psychology scholars started to include the study of subjective aspects of experience in their theories and research (for a detailed review, see Sirgy et al., 2006). More recently, positive psychology has emerged as a new current that underlines the importance of a change in the focus of psychology, from repairing problems to building positive qualities (Seligman & Csikszentmihalyi, 2000), and research on subjective well-being has considerably expanded. In developmental psychology, a characterization of adolescence as a conflictive developmental stage, full of risks and problems, has dominated the field for decades and led to the predominance of research devoted to the study of problematic behaviours, among others substance use and antisocial behaviours. Adolescent health was conceptualized as the absence of risk behaviours and subjective well-being and positive aspects of adolescent development were only rarely studied. In addition, preventive approaches became the norm in intervention programs. As a reaction against this negative view of adolescence that still holds sway in our society and the mass media, the Positive Youth Development has been proposed as an alternative new perspective (Lerner, Phelps, Forman, & Bowers, 2009) that, while recognising the existence of developmental challenges in adolescence, emphasizes the youth potentialities and strengths, and states that preventing youth risk behaviour is not enough to promote positive development. Accordingly, a wider range of health indicators have been incorporated to the study of adolescent mental health, including subjective well-being (Diener, 2000; Park, 2004), and health promotion interventions 4 based on the adolescents’ assets have been underlined as necessary complementary actions to the aforementioned preventive programs (Morgan & Ziglio, 2010; Oliva et al., 2010). The current study is guided by an approach that perfectly fits with the Positive Youth Development model: salutogenesis. The aim of the salutogenic model, proposed by Antonovsky (1987), is to determine what creates health and, especially, what factors can help an individual move toward the healthy pole of the health-disease continuum. The salutogenic model acknowledges the importance of certain resources (among others, knowledge, social support, money and cultural capital—the so-called general resistance resources or GRRs) to cope appropriately with stressful situations and it incorporates a new disposition of paramount importance for a better understanding of health: sense of coherence (SOC). SOC is a worldview facilitated by the GRRs and is related to the ability to use GRRs in a way that promotes effective coping with life’s demands. Specifically, SOC is defined as a global disposition that includes confidence in three areas: life events are ordered, understandable and structured (comprehensibility); the necessary resources to address life events are attainable (manageability); and life’s demands are challenges worthy of investing effort (meaningfulness). The presence of these three inextricably related components (comprehensibility, manageability and meaningfulness) results in a strong SOC, which, in turn, facilitates successful coping with everyday life stressors and satisfactory adaptation (Antonovsky, 1987), even in the face of adversity (e.g., Braun- Lewensohn, Sagy, & Roth, 2011). 5 An increasing amount of research indicates that individuals with a strong SOC tend to have better health and quality of life. However, although a review of more than 500 works on this topic points in that direction (Eriksson & Lindström, 2006, 2007), it is necessary to deepen the analysis of the relationships between SOC and various health components. For instance, one of the problems that arises in the study of quality of life is that the vast majority of research has focused on clinical samples, usually patients with a specific disease condition (Eriksson & Lindström, 2007). Moreover, several studies seem to hint that the association between SOC and the physical components of health may be weaker than the relationship between SOC and psychological health (e.g. Schnyder, Büchi, Mörgeli, Sensky, & Klaghofer, 1999), but this subject would benefit from more research. Furthermore, in-depth analyses of the potential interactions between SOC and demographic variables, such as gender and age, are needed (Eriksson & Lindström, 2006). In adolescence, a strong SOC is associated with a healthy lifestyle (Mattila et al., 2011), whereas a low SOC tends to be related to unhealthy habits, such as skipping breakfast, alcohol use and positive attitudes towards drug consumption (Myrin & Lagerström, 2006). In addition, SOC has shown positive associations with health and well-being in adolescents from different countries (Lindström & Eriksson, 2010). Nevertheless, the aforementioned unresolved questions in the study of SOC and health in general population apply particularly in the study of SOC in adolescents. In fact, research on this developmental stage has been comparatively scarce, and the various aspects of health have received unequal attention. Hence, most studies on SOC and health in adolescence have focused on psychosomatic complaints, providing 6 extensive evidence that psychosomatic complaints are less frequent in adolescents with a strong SOC (Moksnes, Rannestad, Byrne, & Espnes, 2010; Simonsson, Nilsson, Leppert, & Diwan, 2008; Torsheim, Aaroe, & Wold, 2001). Similarly, the relationship between SOC and quality of life has frequently been studied in adolescence, but, as in the case of adult populations, studies have focused on samples of patients with specific diseases (Nio, 2010; Räty, Larsson, & Söderfeldt, 2003). Finally, it is difficult to find studies that include SOC and self-rated health (Honkinen, Suominen, Välimaa, Helenius, & Rautava, 2005), and the relationship between SOC and life satisfaction in adolescence has not been directly studied. Additionally, the interactions between SOC and demographic variables have not yet been explored. This omission may be attributed to the contradictory results obtained for the effects of gender and age on adolescent SOC (for a detailed review, see Rivera, García-Moya, Moreno, & Ramos, 2013). Thus, when gender differences have been identified in a studied health component, researchers have typically opted for separate analyses of boys and girls (e.g. Koushede & Holstein, 2009; Simonsson et al., 2008). Finally, increasing attention has been paid to SOC in international publications from 1985 to 2010 (Lindström & Eriksson, 2010), but research on SOC in Spain remains scarce (Rivera, Ramos, Moreno, & Hernán, 2011) due to the delayed incorporation of SOC into Spanish research, as indicated by the publication of the first article on this topic in 1997. The state of the art described in the preceding paragraphs illustrates the relevance of research on SOC and health among Spanish adolescents and the need to deepen the analysis of the relationships between SOC and health in adolescence. 7 Therefore, the aims of this study are to analyse the effect of gender and age on Spanish adolescents’ SOC and to explore the relationships between SOC and several health components in adolescence while taking into account the potential moderating effect of demographic variables. This process will produce an assessment and comparison on the magnitude of the relationships between SOC and the main components of biopsychosocial health: self-rated health, somatic complaints, psychological complaints, health-related quality of life and life satisfaction. Method Participants A representative sample of Spanish adolescents was selected as part of the 2010 edition of the WHO international survey Health Behaviour in School-aged Children (HBSC) in Spain by means of a random multi-stage sampling stratified by conglomerates that took into account geographic area, type of school and educational level. The international protocol dictates the selection of adolescents aged 11, 13 and 15, but the Spanish part of the study also included the pair ages and the 17-18 year-olds to obtain a more complete sample of adolescents. In the current study, the sample consisted of 7,580 adolescents (3,672 boys and 3,908 girls) aged 13 to 18, with a mean age of 15.41 years. Younger adolescents were not included because the assessment of SOC was not part of the questionnaire for 11-12 year-olds. Measures Measures were selected from the HBSC 2010 Spanish questionnaire, an instrument that has been approved by the Experimentation Ethical Committee of the 8 University of Seville, indicating that it complies with all ethical requirements for human research in Spain and the European Union. The following content was selected based on the objectives of this study: - Demographic variables. Gender and age of the adolescents. Three different age groups were considered: 13-14 years old, 15-16 years old and 17-18 years old. - SOC. The SOC-29 (Antonovsky, 1987) was employed for the assessment of SOC. This instrument consists of 29 items answered on a 7-point Likert scale. This instrument has shown good reliability and validity in several countries (Antonovsky, 1993; Eriksson & Lindström, 2005). The scale provides a global SOC score as well as separate scores for each component (comprehensibility, manageability and meaningfulness). Antonovsky (1993) stated that although the three components of SOC are conceptually different, they are inextricably related, thereby suggesting the use of a global score. This recommendation has been followed in the present work, in which Cronbach’s alpha was .87. In addition, to use SOC as an independent variable, adolescents were classified into three groups according to their global SOC score. The cut-off points were based on tertiles, a frequently used strategy in previous studies with adolescent samples (e.g. Honkinen et al., 2005; Koushede & Holstein, 2009) due to the lack of validated cut-off points to distinguish high, medium and low levels of SOC. Given that differences in the original scores (ranging from 1 to 7 points) are not straightforward to interpret, identifying three subgroups facilitates meaningful comparisons among participants according to their SOC. Finally, the health variables employed in this study represent the main components of biopsychosocial health, as shown by the fact that they have been used as 9 indicators of a composite factorial score on global health that has shown to be appropriate for adolescents from several countries (Ramos, Moreno, Rivera, Gaspar, & Morgan, 2012). Specifically, the following internationally well-known measures of physical and psychological aspects of health were employed: - Self-rated health. This is a subjective measure of health status that is based on adolescents’ perception and assessment of their own health. Specifically, the question is, Would you say your health is…? The answer values are Poor, Fair, Good or Excellent, coded on a scale from 1 to 4. The self-rated health scale is a well-established measure of perceived health, and its usefulness has been proven in large epidemiological surveys (Idler & Benyamini, 1997). - Somatic and psychological complaints. These variables were assessed by means of the HBSC Symptom Checklist (King, Wold, Tudor-Smith, & Harel, 1996), a non-clinical measure of physical and mental health that assesses the frequency of psychosomatic symptoms in the last 6 months. This is an 8-item scale that has been validated in adolescent samples and provides separate information about two interrelated components (Haugland & Wold, 2001), psychological complaints (feeling nervous, feeling low, irritability and sleeping difficulties) and somatic complaints (headache, abdominal pain, backache and dizziness). The score ranges from 1 to 5, with higher scores representing a higher frequency of the evaluated type of complaint. In the current study, Cronbach’s alpha for the dimensions psychological and somatic complaints were .78 and .71, respectively. - Health-related quality of life. The Kidscreen-10 Index (Ravens-Sieberer & The European Kidscreen Group, 2006) was used to assess quality of life. The Kidscreen-10 16 frequency of psychological symptoms. In contrast, the associations of SOC with selfrated health and physical complaints were lower in magnitude, with small to moderate effect sizes. This finding seems to support the hypothesis that the association between SOC and psychological aspects of health is stronger than the association with the physical aspects of health (Lindström & Eriksson, 2010; Schnyder et al., 1999). Furthermore, the results suggest noticeable consistency in the relationship between SOC and all health components in adolescent boys and girls from all of the examined age groups. Thus, although the well-documented gender inequalities in health appeared in the analysis of self-rated health, psychosomatic complaints and, to a lesser extent, quality of life (Bisseger et al., 2005; Cavallo et al., 2006), the effect of SOC on the various health components was homogeneous among all of the adolescents, regardless of gender and age. An indication of this homogeneity was the absence of significant interaction effects between demographic variables and SOC, which was found for all of the examined health components (self-rated health, somatic complaints, psychological complaints, health-related quality of life and life satisfaction). These results reinforce the idea that SOC does not have the tentative and unstable character during adolescence that was initially attributed to it (Antonovsky, 1987). On the contrary, SOC seems to act as a useful predictor of health in adolescence, as supported by its associations with positive health outcomes, which have been considered similar to those described in adult populations (Eriksson & Lindström, 2006; Torsheim et al., 2001). Some limitations must be considered in the interpretation of the results of this work. The main limitation involves the cross-sectional design of the study, which does 17 not allow us to draw conclusions about the direction of the examined relationships or to identify causal relationships between the variables. Furthermore, the unavailability of validated cut-off points to distinguish between high, medium and low levels of SOC may be seen as a methodological weakness. However, the use of cut-off points derived from tertiles is supported in the present study by a large and representative sample of Spanish adolescents, which supports the applied cut-off points and the results obtained by their application. Despite the aforementioned limitations, this work contributes significantly to broadening existing knowledge on the relationships between SOC and health in several ways. First, this study specifies the nature of the relationships between SOC and health through an analysis and comparison of the relationships between SOC and the main components of biopsychosocial health: self-rated health, somatic complaints, psychological complaints, health-related quality of life and life satisfaction. Second, this study represents a first step in the analysis of a pending question in research on SOC and health: the possible interaction effects between SOC and demographic variables (Eriksson & Lindström, 2006). To our knowledge, this work is also the first to study the relationship between SOC and quality of life in a normative sample of adolescents, and it is a pioneering work in the study of the relationships between SOC and life satisfaction in adolescence, making valuable contributions to future research aimed at expanding knowledge on these topics. Finally, this study represents an important contribution to the study of SOC in Spain, where research about SOC has been scarce. 18 References Antonovsky, A. (1987). Unraveling the mystery of health. How people manage stress and stay well. San Francisco. CA: Jossey-Bass. Antonovsky, A. (1993). The structure and properties of the sense of coherence scale. Social Science & Medicine, 36, 725–733. http://dx.doi.org/10.1016/0277- 9536(93)90033-Z Bisseger, C., Cloetta, B., von Rueden, U., Abel, T., Ravens-Sieberer, U., & The European Kidscreen Group (2005). Health-related quality of life: Gender differences in childhood and adolescence. Social and Preventive Medicine, 50, 281–291. http://dx.doi.org/10.1007/s00038-005-4094-2 Braun-Lewensohn, O., Sagy, S., & Roth, G. (2011). Brief report: Adolescents under missile attacks: Sense of coherence as a mediator between exposure and stressrelated reactions. Journal of Adolescence, 34, 195–197. http://dx.doi.org/10.1016/j.adolescence.2010.01.006 Cantril, H. (1965). The pattern of human concerns. New Brunswick, NJ: Rutgers University Press. Cavallo, F., Zambon, A., Borraccino, A., Ravens-Sieberer, U., Torsheim, T., Lemma, P., & the HBSC Positive Health Group (2006). Girls growing through adolescence have a higher risk of poor health. Quality of Life Research, 15, 1577–1585. http://dx.doi.org/10.1007/s11136-006-0037-5 19 Cohen, J. (1977). Statistical power analysis for behavioral sciences (revised Ed.). New York, NY: Academic Press. Cohen, J., Cohen, P., West, S. G., & Aiken, L. (2003). Applied multiple regression/correlation analysis for the behavioural sciences. London, UK: Lawrence Erlbaum Associates. Diener, E. (2000). Subjetive Well-being. The science of happiness and a proposal for a national index. American Psychologist, 55, 34–43. http://dx.doi.org/10.1037//0003-066X.55.1.34 Eriksson, M., & Lindström, B. (2005). Validity of Antonovsky’s sense of coherence scale: A systematic review. Journal of Epidemiology and Community Health, 59, 460–466. http://dx.doi.org/10.1136/jech.2003.018085 Eriksson, M., & Lindström, B. (2006). Antonovsky’s sense of coherence scale and the relation with health: A systematic review. Journal of Epidemiology and Community Health, 60, 376–381. http://dx.doi.org/10.1136/jech.2005.041616 Eriksson, M., & Lindström, B. (2007). Antonovsky’s sense of coherence scale and the relation with quality of life: A systematic review. Journal of Epidemiology and Community Health, 61, 938–944. http://dx.doi.org/10.1136/jech.2006.056028 Haugland, S., & Wold, B. (2001). Subjective health complaints in adolescence– Reliability and validity of survey methods. Journal of Adolescence, 24, 611–624. http://dx.doi.org/10.1006/jado.2000.0393 20 Honkinen, P. K., Suominen, S. B., Välimaa, R. S., Helenius, H. Y., & Rautava, P. T. (2005). Factors associated with perceived health among 12-year-old school children. Relevance of physical exercise and sense of coherence. Scandinavian Journal of Public Health, 33, 35–41. http://dx.doi.org/10.1080/14034940410028307 Idler, E. L., & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–37. http://dx.doi.org/10.2307/2955359 King, A., Wold, B., Tudor-Smith, C., & Harel, Y. (1996). The health of the youth: A cross-national survey. Copenhague, Denmark: WHO Regional Publications. European Series No 69. Koushede, V., & Holstein, B. E. (2009). Sense of coherence and medicine use for headache among adolescents. Journal of Adolescent Health, 45, 149–155. http://dx.doi.org/10.1016/j.jadohealth.2008.12.009 Lerner, J. V., Phelps, E., Forman, Y., & Bowers, E. P. (2009). Positive youth development. In R. M. Lerner & L. Steinberg (Eds.), Handbook of adolescent psychology, Vol 1: Individual bases of adolescent development (3rd ed., pp. 524– 558). Hoboken, NJ: John Wiley & Sons. Lindström, B., & Eriksson, M. (2010). The hitchhiker’s guide to salutogenesis. Helsinki, Finland: Folkhälsan Research Center Health Promotion Research. Mattila, M. L., Rautava, P., Honkinen, P.-L., Ojanlatva, A., Jaakkola, S., Aromaa, M., … Sillanpaa, M. (2011). Sense of coherence and health behaviour in 21 adolescence. Acta Paediatrica, 100, 1590-1595. http://dx.doi.org/10.1111/j.1651-2227.2011.02376.x Moksnes, U. K., Rannestad, T., Byrne, D. G., & Espnes, G. A. (2010). The association between stress, sense of coherence and subjective health complaints in adolescents: Sense of coherence as a potential moderator. Stress and Health, 27, 157–165. http://dx.doi.org/10.1002/smi.1353 Morgan, A., & Ziglio, E. (2010). Revitalising the public health evidence base: An asset model. In A. Morgan, M. Davies, & E. Ziglio (Eds.), Health assets in a global context (pp. 3–16). London, UK: Springer. Myrin, B., & Lagerström, M. (2006). Health behaviour and sense of coherence among pupils aged 14–15. Scandinavian Journal of Caring Sciences, 20, 339-346. http://dx.doi.org/10.1111/j.1471-6712.2006.00413.x Natvig, G. K., Hanestad, B. R., & Samdal, O. (2006). The role of the student: Salutogenic o pathogenic? International Journal of Nursing Practice, 12, 280– 287. http://dx.doi.org/10.1111/j.1440-172X.2006.00583.x Nilsson, K. W., Starrin, B., Simonsson, B., & Leppert, J. (2007). Alcohol-related problems among adolescents and the role of a sense of coherence. International Journal of Social Welfare, 16, 159–167. http://dx.doi.org/10.1111/j.1468- 2397.2006.00452.x Nio, K. (2010). Sense of coherence in adolescents with congenital cardiac disease. Cardiology in the Young, 20, 538–546. http://dx.doi.org/10.1017/S1047951110000685 22 Oliva, A., Ríos, M., Antolín, L., Parra, A., Hernando, A., & Pertegal, M-A. (2010). Más allá del déficit: Construyendo un modelo de desarrollo positivo adolescente [Beyond the deficit: Building a model of positive youth development]. Infancia y Aprendizaje, 33, 223–234. http://dx.doi.org/10.1174/021037010791114562 Park, N. (2004). The role of subjective well-being in positive youth development. The ANNALS of the American Academy of Political and Social Science, 591, 25–39. http://dx.doi.org/10.1177/0002716203260078 Ramos, P., Moreno, C., Rivera, F., Gaspar, M., & Morgan, A. (2012). Analysis of social inequalities in health through an integrated measure of perceived and experienced health in Spanish and Portuguese adolescents. Journal of Health Psychology, 17, 57–67. http://dx.doi.org/10.1177/1359105311406154 Räty, L. K. A., Larsson, B. M. W., & Söderfeldt, B. A. (2003). Health-related quality of life in youth: A comparison between adolescents and young adults with uncomplicated epilepsy and healthy controls. Journal of Adolescent Health, 33, 252–258. http://dx.doi.org/10.1016/S1054-139X(03)00101-0 Ravens-Sieberer, U., & The European Kidscreen Group. (2006). The KIDSCREEN questionnaires. Quality of life questionnaires for children and adolescents – handbook. Lengerich, Germany: Pabst Science Publisher. Rivera, F., García-Moya, I., Moreno, C., & Ramos, P. (2013). Developmental contexts and sense of coherence in adolescence: A systematic review. Journal of Health Psychology, 18, 800-812. http://dx.doi.org/10.1177/1359105312455077 23 Rivera, F., Ramos, P., Moreno, C., & Hernán, M. (2011). Análisis del modelo salutogénico en España: Aplicación en salud pública e implicaciones para el modelo de activos en salud [Salutogenic model analysis in Spain: Application in public health and implications for asset health model]. Revista Española de Salud Pública, 85, 137–147. Schnyder, U., Büchi, S., Mörgeli, H., Sensky, T., & Klaghofer, R. (1999). Sense of coherence – A mediator between disability and handicap? Psychotherapy and Psychosomatics, 68, 102–110. http://dx.doi.org/10.1159/000012320 Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive Psychology. An Introduction. American Psychologist, 55, 5–14. http://dx.doi.org/10.1037//0003- 066X.55.1.5 Simonsson, B., Nilsson, K. Leppert, J., & Diwan, V. (2008). Psychosomatic complaints and sense of coherence among adolescents in a county in Sweden: A crosssectional school survey. BioPsychoSocial Medicine, 2, 4. http://dx.doi.org/10.1186/1751-0759-2-4 Sirgy, M. J., Michalos, A. C., Ferriss, A. L., Easterlin, R. A., Patrick, D., & Pavot, W. (2006). The quality-of-life (QOL) research movement: Past, present, and future. Social Indicators Research, 76, 343–466. http://dx.doi.org/10.1007/s11205-005- 2877-8 Torsheim, T., Aaroe, L. E., & Wold, B. (2001). Sense of coherence and school-related stress as predictors of subjective health complaints in early adolescence: 24 Interactive, indirect or direct relationships? Social Science & Medicine, 53, 603– 614. http://dx.doi.org/10.1016/S0277-9536(00)00370-1 Wolf, F. M. (1986). Meta-analysis: Quantitative methods for research synthesis. Beverly Hills, CA: Sage. Received March 31, 2012 Revision received August 29, 2012 Accepted September 21, 2012 25 Table 1. Descriptive statistics of SOC according to gender and age N M SD Gender Boys 3672 4.62 .74 Girls 3908 4.55 .76 Age 13-14 years 2302 4.74 .81 15-16 years 3348 4.55 .73 17-18 years 1930 4.47 .70 Total 7580 4.59 .75