The sense of coherence and incidence of cancer—role of follow-up time and age at baseline

doi:10.1016/j.jpsychores.2006.01.017

Journal of Psychosomatic Research

Volume 61, Issue 2, August 2006, Pages 205-211

https://doi.org/10.1016/j.jpsychores.2006.01.017 Get rights and content

Abstract

Objective

We studied the effect of the sense of coherence (SOC) on cancer incidence, the role of age at baseline, and the length of the follow-up in that association.

Methods

Five thousand eight hundred sixty-six middle-aged men initially in working life were followed up for 12 years after measurement of the SOC. The relative risks (RRs) of cancer were estimated using Cox regression models.

Results

For all cancers combined in 8-year follow-up, those with a weak SOC had a higher RR of cancer 1.52 [95% confidence interval (CI), 1.12–2.06] than those with a strong SOC. However, the effect weakened in 12-year follow-up (RR 1.14; 95% CI 0.93–1.42). The greatest risk was seen in a subcohort consisting of those aged ≥55 years at baseline with a weak SOC: the RR was 1.65 (1.12–2.43) in 8-year follow-up and 1.40 (1.05–1.85) in 12-year follow-up.

Conclusion

A strong SOC seemed to delay the onset of cancer more clearly among men over 55 years of age.

Introduction

Aaron Antonovsky's [1], [2] salutogenic approach focuses on what keeps people healthy instead of why they fall ill. The result of Antonovsky's deliberations was the concept “sense of coherence” (SOC) consisting of three components, namely, (a) comprehensibility, (b) manageability, and (c) meaningfulness. Antonovsky describes this as a global orientation that expresses the extent to which one has a pervasive, enduring, though dynamic feeling of confidence that (a) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable, and explicable; (b) the resources are available to one to meet the demands posed by these stimuli; and (c) these demands are challenges, worthy of investment and engagement [2].

The association of the SOC with different diseases including psychiatric conditions like depression and suicidality has been studied [3], [4], [5], [6]. Large population-based follow-up studies on the SOC and mortality or morbidity are still very rare. One recent study was carried out in England, the EPIC-Norfolk Study [7], where there was a strong negative association between the SOC and all-cause mortality and a weak negative association with cancer mortality. In the Helsinki Heart Study (HHS), the risk of all-cause mortality for those with a weak SOC compared with those with a strong SOC was 1.23 (NS), while white-collar workers with a weak SOC had a significantly higher relative risk (RR), 2.27, of death when compared to white-collar workers with a strong SOC [8].

Here we report the HHS 12-year follow-up and explore the effect of the SOC on the incidence of cancer with special focus on time-related factors: we studied whether the risk persisted over increasing follow-up time and explored the role of age at baseline in SOC–cancer association.

Section snippets

The HHS

The HHS was a 5-year randomized, double-blind, placebo-controlled primary prevention trial of gemfibrozil, a lipid-lowering drug [9], [10]. The participants were selected via two successive screenings from among those employed at two state agencies and five industrial companies. All male employees aged 40–55 years were invited to the first screening. To be eligible for the trial as well as for the second screening, the subjects' non-HDL cholesterol level had to be 5.2 mmol/L or higher, and for

Association of the SOC with some risk factors for cancer

There was a higher percentage of blue-collar workers among those with a weak SOC than among those with a strong SOC (Table 1). Those with a weak SOC were more often heavy smokers (20.0%) than those with a moderate or strong SOC. They were also more often heavy consumers of alcohol (15.3%) compared to those with a strong SOC (10.3%). Of those with a strong SOC, 38.0% belonged to the oldest age group compared to 34.6% of those with a weak SOC. The association of the SOC with all these factors was

Discussion

Our main findings were that among those with a strong SOC, the occurrence of cancer was delayed but not prevented: the risk of cancer was inversely associated with the level of the SOC during the first 8 years of follow-up, but this difference almost disappeared during the longer 12-year follow-up, especially in the younger cohort (<55 years). In the older cohorts (≥55 years), the difference remained even during the 12-year follow-up.

In the EPIC-Norfolk Study [7], an association between the SOC

Conclusion

In individuals with a strong SOC, the incidence of cancer was lower than in those with a weak SOC after a short period of follow-up. During the full 12-year follow-up, the difference remained significant only among the oldest participants. Thus, a strong SOC seemed to delay the onset of cancer more among older than among younger men.

Acknowledgments

The authors thank the Finnish Work Environment Fund for financing the study. We also thank Virginia Mattila, Language Centre, University of Tampere, for revision of the English.

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Current research adopting the salutogenic perspective has demonstrated a positive effect of SOC on health. More specifically, it seems that groups low in SOC are especially vulnerable to the hardships in life (Surtees et al., 2007), leading to poorer lifestyle choices (Wainwright et al., 2008), increased disease incidence and mortality risks (Poppius et al., 2006; Super et al., 2014) and reduced mental health (Eriksson and Lindström, 2007). Researchers have also begun to study how SOC develops in childhood and early adulthood (García-Moya et al., 2013; Marsh et al., 2007; Slootjes et al., 2017; Super et al., 2016), showing the complexity of the salutogenic model of health with its interplay between resources, stressors and SOC in determining a healthy development.
Research on positive youth development through sport is confronted with a number of limitations: it lacks a clear theoretical basis of mechanisms underlying life skill development through sport, it has a narrow focus on the sports setting thereby neglecting the interplay between life domains in reaching positive youth development, and the mechanisms underlying the transfer process of newly acquired skills and competences from the sports setting to other life domains are unclear.
This study aims to advance research in in this field by applying theoretical insights from the salutogenic model of health to address the aforementioned limitations.
The salutogenic model of health describes how health and well-being develops in challenging or stressful situations and offers an interesting perspective on the mechanisms underlying youth developmental processes while simultaneously aligning well with the tenets of the positive youth development approach. The application of the salutogenic model of health offered a number of interesting theoretical insights to further understand 1) the mechanisms underlying positive youth development through sport (i.e., enhancing comprehensibility, manageability and meaningfulness), 2) that youth development arises in the interaction between an individual’s stressors, resources and sense of coherence across different life domains, and 3) the central role of both generalized and resistance resources and sense of coherence in the transfer of life skills between life domains. Given that sense of coherence plays a vital role in the healthy development of individuals and the transfer of life skills across life domains, it would make sense to strengthen the sense of coherence of youths in sports programs.
Based on this theoretical analysis, several recommendations and considerations for further research on positive youth development through sport are provided.
Sense of coherence and 22-year all-cause mortality in adult men
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Citation Excerpt :
Moreover, in an 8-year follow-up study, Wainwright and colleagues showed that measures of lifestyle choices i.e. cigarette smoking, physical activity, dietary intake of fruit, vegetables and fiber explained some of the association of SOC with all-cause mortality [38]. Prospective studies have shown a strong association between SOC and ill-health such as cancer incidence across 8 years [39] and risk of diabetes up to 18 years later [40]. Sense of coherence may also be related to mortality through some biological pathways.
Sense of coherence (SOC) is a central construct in Antonovsky’s salutogenic theory, which focuses on people’s health-promoting and health-protecting characteristics. We examined prospectively the association of SOC with all-cause mortality during 22 years (1989–2011).
The data of 585 men from the Israel longitudinal study of Glucose Intolerance, Obesity, and Hypertension (The Israel GOH) comprised the analytic sample. Participants were 48–67 years old at study entry (1989). Information on sociodemographic, medical history and health-related risk factors were obtained at baseline through a face-to-face interview. Participants completed Antonovsky’s 29-item SOC scale. Information on all-cause mortality was obtained from the Israeli Mortality Register (1989 through 2011). We evaluated the effect of SOC on time-to-death using multiple Cox proportional hazard regression.
Controlling for sociodemographic, smoking status and morbidities, there was strong evidence of an association between SOC and 22-year all-cause mortality [adjusted hazard ratio (aHR) = 0.992, 95% CI 0.986–0.998 per unit]. Strong SOC was associated with a 35% reduction in all-cause mortality relative to weak SOC (aHR = 0.653, 95% CI 0.454–0.939). There was no convincing evidence of a survival advantage for individuals with intermediate level of SOC relative to persons reporting weak SOC (aHR = 0.821, 95% CI 0.595–1.134).
Our study provides strong evidence of an association between SOC and mortality, above and beyond potential confounding factors and established risk factors. Considerable more research is needed on the role of SOC in health and survival and the potential pathways linking SOC and health.
Personality variables as predictors of early non-metastatic colorectal cancer patients' psychological distress and health-related quality of life: A one-year prospective study
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Citation Excerpt :
It has been used within the general Greek population and with medical patients [23,35]. Sense of Coherence (SOC), is defined as a global orientation based on a person's pervasive confidence that internal and external stimuli are structured and predictable; that the resources needed to meet these demands are available; and that these demands are seen as challenges, worthy of investment, and engagement [18,20]. The SOC scale is a reliable, valid and cross-culturally applicable instrument measuring how people manage stressful situations and stay well and predicts outcome in various mental or physical illnesses [36].
We aimed to assess the course of early non-metastatic colorectal cancer patients’ psychological distress and health-related quality of life (HRQOL) and to identify relevant clinical and psychological predictors during a one-year period.
Of the 144 early non-metastatic colorectal cancer patients initially assessed for psychological distress symptoms (SCL-90-R), HRQOL (WHOQOL-BREF), sense of coherence (SOC), defense mechanisms (LSI) and hostility (HDHQ), 84 (58.3%) completed the one-year follow-up. Mean (SD) age was 65.1 (9.8) years and 67.4% were male. Mean (SD) disease duration was 1.7 (2.2) years, with 49.3% being diagnosed within the last six months. In 75.0% the site was at colon and in 25.0% at rectum; 2.1% had stage I, 59.0% stage II and 38.9% stage III disease.
Paranoid ideation, psychoticism, interpersonal sensitivity, anxiety and depressive symptoms increased significantly over the one-year period of the study and most of the HRQOL components were significantly decreased over the same period. Men were at greater risk for further developing depressive symptomatology. Low SOC was independent predictor of depression, while hostility independently predicted anxiety, interpersonal sensitivity and psychoticism symptoms. General psychological distress and low SOC were independent predictors of HRQOL, while repression was also an independent predictor of Physical HRQOL.
In early non-metastatic colorectal cancer patients, psychological distress symptoms are increased and HRQOL is decreased over one-year period. Symptoms of psychological distress are strong predictors of HRQOL, while personality variables can also predict psychological distress symptoms’ increase and HRQOL decrease over time, and this could be relevant to psychological interventions.
An investigation of the correlates of sense of coherence in a sample of Brazilians with head and neck cancer
2010, Oral Oncology
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These controversies may be due for instance to small sample size, different populations studied, and different instruments used to measure alcohol and tobacco consumption. The literature, including a systematic review, reports SOC to be associated with better self-rated and clinical health, however, no association between SOC and any of the clinical characteristics was found in our study.43 One suggestion is that the low level of education and socioeconomic condition of our subjects may have affected their illness perception,44,45 thus not reflecting the clinical characteristics of their disease.
The aim of this study was to investigate the correlates of Sense of Coherence (SOC) in Head and Neck (H&N) cancer patients during the initial months following their diagnosis. A sample of 162 subjects with newly diagnosed H&N cancer was recruited from a Brazilian hospital. SOC was evaluated using a validated instrument, and these data plus socio-demographic, behavioural and clinical data were collected using interviews. Correlates of SOC in the sample were analysed using multiple linear regression. The mean SOC score was 63.8 and the mean age was 57.7 years. Most of the subjects were male, had a partner and had low levels of education. The cancers were mainly in the oral cavity and diagnosed at a late stage. Analyses demonstrated that subjects who were men, who had a partner, who were working and those with an opportunity to talk openly had higher (i.e. stronger) SOC. No statistically significant association was observed between SOC and clinical variables or tobacco and alcohol consumption. These results suggest an association between SOC and socio-demographic and psychosocial covariates only in this sample of Brazilian H&N cancer patients.
Better oral health related quality of life: Type of prosthesis or psychological robustness?
2010, Journal of Dentistry
Sense of coherence (SOC) is an individual-based coping characteristic and believed to influence a person's ability to adapt to life stressors, such as edentulism and using complete denture. Thus, SOC may mediate the effect of prosthetic treatment on quality of life.
1. To simultaneously test the effect of type of treatment and sense of coherence on oral health related quality of life (OHRQoL) in edentate elders and to identify any interaction. 2. To report the level of sense of coherence among a sample of edentate elders.
Data were collected and analysed cross-sectionally at a 1-year follow-up from 173 edentulous elders who had randomly received mandibular-implant overdentures or conventional dentures, both opposed by new conventional maxillary dentures. The dependent outcome variable, oral health related quality of life, was measured using the Oral Health Impact Profile (OHIP-20). Independent variables included SOC and prosthesis type, as well as socio-demographic variables. SOC was evaluated using the 13-item likert scale of The Orientation to Life questionnaire.
The group mean SOC score was 70.28 (SD = 9.6). Married or coupled people had significantly higher SOC scores than those who were separated, single or divorced (p = 0.04). General linear model analyses demonstrated that there was a statistically significant main effect for type of prosthesis, F(1.169) = 0.71, p = 0.008, with no interaction with SOC.
The results of this study suggest that, in edentulous elders, SOC does not mediate the effect of the type of prosthetic treatment on oral health related quality of life.
The Sense of Coherence: Measurement Issues
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View all citing articles on Scopus

View full text

Original articleThe sense of coherence and incidence of cancer—role of follow-up time and age at baseline

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

The HHS

Association of the SOC with some risk factors for cancer

Discussion

Conclusion

Acknowledgments

Soc Sci Med

Patient Educ Couns

Clin Psychol Rev

Crit Rev Oncol Hematol

Pers Individ Differ

Health, stress and coping: new perspectives on mental and physical well-being

Unraveling the mystery of health

Sense of coherence, self-esteem, depression and hopelessness as correlates of reattempting suicide

Br J Clin Psychol

Kohaerenzgefuehl und psychosomatischer Behandlungserfolg. Eine empirische Untersuchung zur Salutogenese

Psychother Psychosom Med Psychol

Major depression: a breakdown in sense of coherence?

Psychol Rep

Suicidal ideation and sense of coherence in male conscripts

Acta Psychiatr Scand

Sense of coherence and mortality in men and women in the EPIC-Norfolk United Kingdom prospective cohort study

Am J Epidemiol

The sense of coherence, occupation and all-cause mortality in the Helsinki Heart Study

Eur J Epidemiol

Helsinki Heart Study: primary prevention trial with gemfibrozil in middle-aged men with dyslipidaemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease

N Engl J Med

Original article
The sense of coherence and incidence of cancer—role of follow-up time and age at baseline