Health Education

Mental health promotion through supported further education: The value of

Antonovsky's salutogenic model of health
Ian Morrison Stephen M. Clift
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Health Education, Vol. 106 Iss 5 pp. 365 - 380

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Mental health
Mental health promotion through promotion
supported further education
The value of Antonovskys salutogenic
model of health 365
Ian Morrison and Stephen M. Clift Received May 2005
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Faculty of Health and Social Welfare Studies, Accepted December 2005

Canterbury Christ Church University, Canterbury, UK

Abstract
Purpose The purpose of this research is to report on an evaluation of a programme of supported
education in a Further Education context for students with long-term mental health problems, based
on Antonovskys Salutogenic model of health. The students are referred by the Community Mental
Health Team.
Design/methodology/approach Three consecutive cohorts of students (n 148, 93 male, 55
female; average age 39.5 years) undertaking the programme, completed Antonovskys Short-form
Sense of Coherence scale (the SOC13) on entry to the programme, and when exiting from it. Qualitative
feedback from the second cohort of students was examined to establish the processes at work in the
programme. This identified a number of themes relating to the processes at work in the programme
and its outcomes (Peer Support, Learning Support, Learning Effects, Symptom Reduction and Positive
Affect) and provided a basis for designing short questionnaires, which were completed by the second
cohort. Data from these questionnaires and the SOC13 were used to build a causal model of the
processes at work in the programme.
Findings The overall change between the entry and exit SOC13 scores was not significant.
However, students with SOC13 scores below 52 (total n 81, 52 male, 29 female; average age 42.8
years) made statistically significant positive gains. In this initially low scoring group, 70 per cent
improved their exit SOC13 score, 2 per cent remained constant, and 28 per cent reported lower exit
SOC13 scores. The causal model from the whole of the second cohort of students suggests that peer
support is the initial factor contributing to the success of the programme by positively influencing
learning effects of the programme and the uptake of learning support. In turn, learning effects reduced
symptoms and this had the effect of raising positive affect. Raised positive affect reduced the need for
learning support and was positively linked to entry and exit SOC13 scores.
Practical implications This research has implications for budget holders, health promotion staff
and allied professionals in the collaborative use of resources to help people recovering from or
managing mental health difficulties move forward in their lives.
Originality/value This study highlights the need for community collaborative social initiatives to
be properly funded and validated. Approaches to evaluation could usefully be formulated on the basis
of Antonovskys model. Professionals need to consider investing in creating peer support and positive
affect when working with people with mental health needs.
Keywords Health education, Mental health services, Further education, Learning
Paper type Research paper

Introduction
Health and education Health Education
Vol. 106 No. 5, 2006
A number of large-scale studies in the UK (Hammond, 2002; Montgomery and Schoon, pp. 365-380
q Emerald Group Publishing Limited
1997; Bynner and Egerton, 2001) indicate the protective effects for health of education 0965-4283
and academic qualifications. Similarly, American research studies (Grossman and DOI 10.1108/09654280610685956
 HE Kaestner, 1997) show that in both the black and the white populations, years of formal
106,5 schooling is the most important correlate of good health and that schooling is more
important for health than occupation or income. This is particularly true when the link
from poor health to low income, is controlled. The consistent finding of an association
between involvement in education and health may arise as a result of the better
economic success and quality of life that those with qualifications are more likely to
366 enjoy. Or conversely, a lack of educational and economic success may result in social
isolation, low self-esteem and low confidence, which can lead to poor health.
Evidence that mental health can be improved by the involvement in education is
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provided by Hoffman and Mastriannis (1993) comparison of a supported education

programme for psychiatric inpatients with a standard inpatient treatment. They found
that:
. . . patients participating in the supported education service sustained stronger student
identities, returned to college at higher rates, maintained higher academic aspirations, and
reported greater ease in the transition to more normative settings following hospitalisation
(Hoffman and Mastrianni, 1993, p. 109).
In the present study, the possible health benefits of involvement in a supported
education programme for people with long-term mental health needs were explored
using the salutogenic model of health developed by Antonovsky (1987). Antonovskys
model of health has been used to promote health in schools, (Paulus, 1995 quoted in
Bengel et al., 1999), and Lena and Bengt (1998) draw on Antonovsky in their report on
learning as a health promoting process as part of the WHO (1993) Health Promoting
Schools project in Sweden.

Antonovskys salutogenic model of health

In Antonovskys model, good health is promoted through generalised resistance
resources. It is when resistance resources are inadequate to restore health balance, or
manage stress, that an organism breaks down (Antonovsky, 1972). These resistance
resources are represented by the concept of Sense of Coherence (SOC), which consists of
three components: comprehensibility, manageability and meaningfulness
(Antonovsky, 1987 and 1993), and are defined as follows:
Sense of coherence. A global orientation that expresses the extent to which one has a
pervasive, enduring though dynamic feeling of confidence that:
(1) the stimuli deriving from ones internal and external environments in the course
of living are structured, predictable, and explicable;
(2) the resources are available to one to meet the demands posed by the stimuli; and
(3) these demands are challenges, worthy of investment and engagement
(Antonovsky, 1987, p. 19).

Comprehensibility. The person who experiences the world as comprehensible expects

that future stimuli will be predictable or, when they do come as surprises, will be
orderable and explicable.
Manageability. People who experience their world as manageable have the sense
that, aided by their own resources or by those of trustworthy others, they will be able
to cope.
 Meaningfulness. A person who experiences the world as meaningful will not be Mental health
overcome by unhappy experiences but will experience them as challenges, be promotion
determined to seek meaning in them, and do his/her best to overcome them with
dignity (Carstens and Spangenberg, 1997, p. 1212).
Antonovsky (1993, p. 725) summarises that: Resources were seen as leading to life
experiences which promoted the development of a strong SOC. A way of seeing the
world which facilitated successful coping with the innumerable, complex stressors 367
confronting us in the course of living.
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SOC questionnaire
The original Sense Of Coherence (SOC) was operationalised by means of the Sense Of
Coherence questionnaire entitled the Orientation To Life Questionnaire (Antonovsky,
1987). This is a 29-item self-report measure that operationalises the construct (Carstens
and Spangenberg, 1997) with each item having a seven-point assessment scale.
A 13-item short form version, which is a selection of questions from the 29-item
questionnaire, was developed at the same time as the original scale for use with
populations for whom the response burden might be an issue (Antonovsky, 1987). This
short form version has been shown to be reliable (Antonovsky, 1993), and is used in
this study of people with long-term mental health needs, as completion of
questionnaires is often a significant burden due to difficulties with concentration.
The 29 items were based on accounts given during 51 qualitative interviews in
which the people who had been subjected to severe trauma, yet seemed to come to
terms with their lives remarkably well, talked about their experiences (Antonovsky,
1987). The statements identified as representing a general attitude towards life were
analysed using Guttmanss facet-technique [described in Shye et al. (1994)]. The
purpose of constructing the questionnaire was to provide a measure of Sense Of
Coherence in order to test the core hypothesis that the SOC is causally related to health
status (Antonovsky, 1987). The questionnaire is presented as an Appendix
(Antonovsky, 1987) and question 8 is given here as an example:
until now your life has had: with anchoring points no clear goals or purpose and very
clear goals and purpose at the low and high ends respectively of a seven point Likert scale.
This question is scored positively, but some questions have reverse scoring.
These questionnaires have been shown to be highly reliable and valid (Antonovsky,
1993).

Sense of Coherence (SOC) and health

The link between SOC and specific health indicators has been established by research.
Studies by Larsson and Kallenberg (1999) and Lundberg and Nystrom Peck (1994)
involving large representative samples of the Swedish population, showed that SOC
correlated strongly with measures of somatic and psychological health. For both
genders, a clear negative relationship between SOC score and symptom scores was
found. Lutgendorf et al. (1999) studied the impact of voluntary housing re-location on
older American adults, and found that high SOC protected against the harmful effect of
stress on immune system function.
Thus research evidence indicates that SOC scores relate to health status, that low
scores indicate potential mental health needs, and that high SOC scores protect
 HE individuals against life events. Initiatives designed to strengthen individuals SOC are
106,5 attractive from a health promotion viewpoint (Antonovsky, 1996), however, there is no
evidence to show that SOC scores can be strengthened by a health promotion
intervention specifically designed to do so (Frankenhoff, 1998). Further, Antonovsky
(1998) hypothesised that the strength of a persons SOC is more or less stabilised by
roughly the age of 30, having by that time had enough life experiences to form his or
368 her SOC. Also, Antonovsky (1998) continues that a person with a weak SOC in
adulthood would manifest a cyclical pattern of deteriorating health and a weakening
SOC.
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The supported education programme

Programme details
The education programme in this study provides supported education for people
with mental health needs wishing to enter a Further Education College and access a
mainstream course. It consists of a series of stepping stone courses starting
off-campus in NHS day services and leads on to an introductory course on-campus.
The student then chooses a mainstream course and there is continued support
available from the support programme as necessary. Students have a medical mental
health diagnosis and are referred to the programme by NHS staff through a
co-ordinating occupational therapist at each locality who also provides the link
between the students referrer and a personal tutor in college. Most of the students
passing through the programme successfully completed their qualifications and some
moved on to university courses or employment.

Student health profile

Many of the students involved in this study have been ill for as many as 10 years and
have been hospitalised on several occasions, and some for an extended period of time.
The student cohort includes the full range of diagnosis from paranoid schizophrenia,
bi-polar disorder (manic depression), clinical depression, and the affective disorders.
Some are self-harmers, have grandeur or hear voices. They report loss of confidence,
anxiety and lack of social support and have lost the ability to mix in groups and travel
on public transport. For many, their mental ill health is enduring and so will always be
with them to some extent. It is therefore a case of managing their illness rather than
expecting complete recovery. The majority are smokers.

Student study characteristics

As students, this cohort tends to have a lack of concentration, poor organisational
abilities, poor long and/or short-term memory and inconsistent attendance. They
require frequent breaks and immediate attention to needs and their negative moods can
be infectious. These characteristics may be due to their illness, or the side effects of
medication or treatment (Thompson and Mathias, 1994). Life and study skills may also
have been lost due to lack of practice (Maudslay, 2001), or in some cases may never
have been acquired due to chronic illness interfering with their education.

Programme design
The design of the programme was guided by Antonovskys model of health and the
components of meaningfulness, comprehensibility, and manageability, in relation to
 the needs of each student. This process was informed by the use of Antonovskys Mental health
health model in health promoting schools in Germany (Paulus, 1995 quoted in Bengel promotion
et al., 1999), and Sweden (Lena and Bengt, 1998).
The programme aims to develop key skills of problem solving, working with others,
responsibility for own learning, application of numbers, communication and
information technology in line with the common framework for key skills adopted
in Colleges and Universities throughout the UK. The resources of the programme 369
include personal tutor support in the form of goal setting, action planning, subject
liaison, the support of Learning Support Assistants (LSA), and educational and career
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guidance. The processes involved in the programme are designed to raise the students
confidence and self-esteem and engender peer support. Thus the total support offered
consists of guidance from teaching and support staff, and the peer support of students
with one another (see Figure 1).

Method
Research questions
The research questions examined in this study were:
(1) Can a programme, designed to strengthen SOC, change individuals SOC scores
over time?
(2) Does an individuals SOC score at entry to the programme have a bearing on
change during the programme?
(3) If changes do occur, what are the causal factors facilitating change?

Figure 1.
SOC components of the
open door programme
 HE Design and structure of the study
106,5 This study attempted to assess the impact of an on-going supported education
programme in a natural institutional setting. It was not practical to set-up a RCT
design or controlled comparison with the participant group, for practical and ethical
reasons, (Gorard et al., 2002; Lilford, 2003; Donovan et al., 2002). Nevertheless, it is felt
that research in the social sciences should be as scientific and rigorous as possible.
370 This approach would lead to the choice of methods being congruent to the problem in
hand without seeking to mimic approaches in medical research, which may in fact be
unsuitable. In the present study, therefore, the following approach was adopted:
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.
The study was carried out over three academic years, with data gathered from all
the students from three separate cohorts. This allowed for an element of
replication in assessing the impact of the programme.
.
Short form SOC13 scores were obtained from participants in each cohort at an
early stage following recruitment into the programme, and shortly before they
left it. In order to address research questions one and two, comparisons were
made between entry and exit scores for each cohort group.
.
Students evaluation of the programme was obtained from all the students in the
second cohort, and this information was used to construct additional short
questionnaires to measure key themes emerging from participants accounts. In
order to address research question three, these questionnaires were then used
with all students in the second cohort, together with their SOC13 scores, to
construct a model of change.

Participants in the study

The student cohorts participating in the study were: 2000-2001 40 male, 26 female;
2001-2002 24 male, 19 female; 2002-2003 29 male, 10 female.
This resulted in a total of 148 participants (93 male, 55 female) of average age 39.5
years. As a comparison with the general English population, the national average age
in 2002 was 39.3 years (Womack, 2004).

SOC questionnaire used

The short form SOC13 (Antonovsky, 1987) was used in this study of people with
long-term mental health needs in order to reduce completion burden.

Students evaluation of the programme

The end of year evaluation of the second cohort (29 male, 12 female), was in the form
of a written account in response to an open question on how the experience of the
course had been for them. This format was used to reduce leading the students with a
questionnaire or prescriptive guidelines, and to obtain their own thoughts for analysis
to be grounded in their own accounts. Students wrote 300 words on average, with a
total of over eleven thousand words produced.
Student accounts were initially read to determine whether they reflected the
theoretical concepts guiding the programme and also to discover if there were any
other themes expressed. During this process, an extensive initial list of codes was
devised based upon the SOC components and other relevant theoretical concepts, from
health promotion and motivation psychology. This was in order to test theory, whilst
at the same time being sensitive to any other themes emerging from these data. The
 build-up of emerging codes was a progressive and iterative process as new codes were Mental health
discovered and previously examined scripts were revisited. This process was aided by promotion
the text analysis software package winMAX 98 pro (Kuckartz, 1998), which helped to
manage the large scale of the task and reduce the possibility of human error, and
increase confidence in the reliability of the coding. When no further themes emerged,
codes were clustered into categories. Five general categories emerged from the
analysis: Peer Support, Learning Support, Learning Effects, Symptom Reduction and 371
Positive Affect.
In order to test if these categories had validity, specifically designed instruments
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were constructed and administered to all the second cohort students. An existing four
item questionnaire used by Ostir et al. (2000) reflected closely the category of positive
affect emerging from the students feedback and this was used as a model for
developing four further short questionnaires to measure the other themes. The
positive affect questionnaire consisted of four statements (e.g. I feel hopeful about the
future) with a choice of agreement between a four point Likert Scale, with 0
representing Rarely or None of the Time, 1 Some or Little of the Time, 2 Occasionally
or a Moderate Amount of Time, and 3 Most or All the Time.
Short questionnaires were developed to the same format for:
(1) Peer Support (6 questions, e.g. Since coming to College, I feel I belong to a
student group).
(2) Learning Support (4 questions, e.g. Having the Learning Support Assistant
available in class is important to me).
(3) Learning Effects (6 questions, e.g. The feeling of regular achievement helps
motivate me).
(4) Symptom Reduction (4 questions, e.g. Through my involvement in learning I
feel more confident).

Having devised these questionnaires, the second cohort of students was then asked to
respond to each of them in order to provide systematic data on their experiences of the
programme for the purpose of model construction.

Model construction
Information was thus available for the second cohort of students on SOC13 scores on
entry and exit to the programme, together with participants assessment of the
programme using the Positive Affect scale and the specifically constructed scales
described above.
Use was then made of SPSS 9.0 for Windows to calculate Pearson correlations
among these measures. Correlations indicate only the pattern of relationships between
the variables assessed and in themselves do not give information on possible directions
of influence or causality. In order therefore to construct a hypothetical model of
patterns of influence, the procedure described by Cox and Wermuth (1996) was
followed to construct the most appropriate model of relationships between these
measures to show possible mechanisms producing changes in SOC13 scores.
 HE Results
106,5 Research questions 1 and 2
Research questions 1 and 2 ask: Can a programme specifically designed to strengthen
SOC do so, and if so, does an individuals score on entry have a bearing upon the
outcome?.
Students SOC13 score distribution is shown in Table I, and comparison is made
372 with the SOC13 distributions of a large representative sample of the Swedish
population (Larsson and Kallenberg, 1999), as there is no such data available for the
British population.
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There is a 14-17-point difference between the mean entry SOC13 scores of the three
students cohorts as compared to the Swedish population, and the student distributions
have slightly larger standard deviations.
The lower scoring half of the student group (i.e. below the mean SOC13 score of 52)
aligns approximately with the lower sixth of the general Swedish population (i.e. less
than one standard deviation below the population mean (65-11 54). This lower sixth
of the general population might be the people that could be expected to experience
some form of mental ill health in the course of a year (SEU, 2004).
For each of the three cohorts, the overall change between the entry and exit mean
scores was positive, but small and not significant. In order to examine if entry SOC
score had an effect upon outcomes, the student data were split at the mean and
correlated t-tests used to assess change.
Students with entry SOC13 scores above the mean for the student cohort remained
stable with no statistically significant change. Any change occurring was of the range
2.1 per cent to 4 per cent reduction and was probably due to regression to the mean
effects as described by Morton and Torgerson (2003). In marked contrast, students
starting below the mean made statistically significant positive changes (see Table II) of
between 12.7 per cent and 18.0 per cent. In these groups (total N 81, 52 male, 29
female; average age 42.8 years) 70 per cent improved their exit SOC13 score, 2 per cent
remained constant, and 28 per cent had lower exit SOC13 scores.

Group Year Sample size Mean SD

Table I. Swedes 1995 1,901 65.3 10.64
SOC13 Scores of Students 2000 66 51.6 13.13
representative samples Students 2001 43 48.4 14.51
the Swedish population Students 2002 39 51.0 18.15
and all the students in the
present study Source: Larsson and Kallenberg, 1999 (for Swedish data)

Table II. Entry SOC13 Exit SOC13

SOC13 entry and exit Cohort (n) Mean SD Mean SD p (two-tailed)
comparisons for entry
scores below 52 for three 2000-2001 (33) 41.63 8.19 46.91 11.35 p # 0.05
cohorts of students 2001-2002 (17) 30.64 5.40 36.14 7.65 p # 0.05
(paired t-test) 2202-2003 (22) 38.31 8.84 43.46 11.55 p # 0.001
 In summary, the low SOC13 scoring groups whose entry SOC13 scores were below the Mental health
mean for the student cohort made statistically significant positive changes, and those promotion
above the typical mean remained stable and did not show significant change.

Research question 3
Research question 3 asks: What are the causal factors facilitating change?. 373
Table III shows the Pearson correlations among the variables measured for cohort
two. While the direction of correlation values was predictable for a number of pairings
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(e.g. it was expected that SOC13 at entry and exit would be positively correlated) this
was not true for all possible combinations of variables and accordingly the decision
was taken to consistently use 2-tailed criteria for judging significance, with a critical
value of p # 0.10.
Several aspects of these results are noteworthy:
.
the correlation between SOC13 at entry and exit is 0.64, indicating a substantial
degree of reliability over one year;
.
the four-item Positive Affect scale is significantly correlated with SOC13 at entry
and exit;
.
the Symptom Reduction scale is correlated with exit SOC13 and Positive Affect,
but not with entry SOC13;
.
learning Support and Peer Support are correlated with one another and with
Learning Effects, but none of these variables is correlated with SOC13 at either
entry or exit;
.
the only significant negative correlation observed was between Positive Affect
and Learning Support; and
.
finally, and most strikingly of all, Symptom Reduction and Learning Effects are
highly correlated.

Model construction (Cox and Wermuth)

In undertaking the model construction process, it was decided to keep all correlations
significant at the p # 0.10 level. Only two pairs of variables were significantly

Entry Exit Learning Peer Learning Symptom Positive

SOC13 SOC13 support support effect reduction affect

Entry SOC13 0.64 * * * 20.06 0.05 0.10 0.26 0.58 * * *

Exit SOC13 20.17 0.04 0.04 0.35 * * 0.66 * * *
Learning
support 0.40 * * 0.37 * * 0.18 2 0.30 *
Peer support 0.50 * * * 0.32 * 2 0.03
Learning
effect 0.86 * * * 0.12
Symptom
reduction 0.37 * *
Table III.
Notes: Sig. two-tailed *p # 0.10; * *p # 0.05; * * *p # 0.01 Correlation matrix
 HE correlated at the 0.05 , p , 0.10 level: Positive Affect-Learning Support, 2 0.30, and
106,5 Peer Support-Symptom Reduction, 0.32.
In constructing a topographical model of the retained element pairings, alternative
connection arrangements are a possibility, and in particular, those between Peer
Support, Learning Support, and Learning Effects. It was therefore necessary to carry
out partial correlations in order to control the effects of other elements for each possible
374 arrangement of pairings.
The strongly correlated pair, Exit SOC13-Positive Affect (0.66) was chosen as the
starting point for analysis and, controlling for all other elements, the partial correlation
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was found to be 0.35 (still significant at p , 0.10 two tailed). Then the correlations
between the elements radiating out from the Exit SOC13 were tested, and any
intermediate elements were controlled by partial correlation. Following this, in the
same way, the correlations between the elements radiating out from Positive Affect
were tested, including all the alternative connection arrangements.
For the Positive Affect-Learning Support pairing, for example (initial correlation
2 0.30 p # 0.10), partial correlation analysis (controlling for Symptom Reduction,
Learning Effects and Peer Support) resulted in a stronger partial correlation of 2 0.37
( p # 0.05 two-tailed), and so justified including this pathway in the model.
The other pairing with marginal significance, but kept for further partial correlation
analysis, Peer Support-Symptom Reduction, was not significant, when controlling for
Learning Effects and was discarded. Also, correlations between Symptom
Reduction-Exit SOC13, and Learning Support-Learning Effects, were not significant
when controlling for Positive Affect or Peer Support and so were discarded from the
model.
The model resulting from this procedure is shown in Figure 2.

Discussion
Strengthening of SOC
The low SOC13 scoring groups whose entry SOC13 scores were below the typical mean
for the student cohort and equivalent to the lower sixth of the general population (i.e.
below 52) made statistically significant positive changes. Those above the typical
mean (i.e. 52 and above) remained stable and did not significantly change in the
potentially stressful college environment.
The indication here is that SOC13 score can be increased for those with a weak SOC,
which is likely to be individuals with low starting scores below 52. Antonovsky (1998)
hypothesised that the strength of a persons SOC is more or less stabilised by roughly
the age of 30, having by that time had enough life experiences to form his or her SOC.
Also, Antonovsky (1998) continues that a person with a weak SOC in adulthood would
manifest a cyclical pattern of deteriorating health and a weakening SOC. However, this
study indicates that those with weak SOC (or a weakened SOC through a major life
experience such as trauma), can become stronger and improve their position on the
health/disease continuum. It is the maturity of an individual SOC score, rather than
age, that indicates the possibility for strengthening an SOC score.
From the above discussion, it appears that: the supported education programme is
assisting 70 per cent of students with mental health needs whose SOC13 scores are
below 52, (and who probably match the scores of those in the general population who
will experience some form of mental ill health in any one year), to move their SOC13
 Mental health
promotion

375
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Figure 2.
Model of Pearson partial
correlations (all the
students in the second
cohort)

scores in a positive direction and that this shift is around 28 per cent of the maximum
required to achieve exact alignment with the general population.
With this non-controlled method there was the possibility that there may have been
a compromising concurrent initiative that had been the cause of the observed change in
SOC13 scores. The possibility of this eventuality had been addressed through a
monitoring dialogue with the co-ordinating occupational therapists in order to ensure
that this had not been the case. This eventuality had been thought to be unlikely due to
the wide geographic area the programme covered and in any case would have been
transparent due to the extensive co-ordinating management required. If there had been
some unknown parallel confounding initiative common to all geographic sites and
 HE applicable to the variety of diagnosis, then this initiative would also have had to be
106,5 sensitive to SOC13 scores i.e. have no effect on subjects with starting scores above 52.
This is not thought likely for a pathogenic initiative, which would have had treatment
effects independent of SOC13 score.

The mechanism for change

376 A model of the operational processes at work within the programme shows that Peer
Support, engendered at the onset of the programme, is the key-contributing factor to
the success of the uptake of Learning Support, which could be seen as stigmatising.
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Also, Peer Support is associated with the production of Learning Effects. This is in
conjunction with Learning Support, as would be expected. The Learning Effects of
education produced health improvements by Symptom Reduction, which in turn raised
Positive Affect. Raised Positive Affect is the ultimate contributor to raised SOC13 score
and also acts to reduce the need for Learning Support, which indicates reduced need or
progression.

Learning effects and time scale for change

This study examined three different student cohorts, each over a period of one
academic year. The point here is that the Learning Effects creating the SOC13 score
improvement have taken one academic year to achieve. This indicates the requirement
of time in order to successfully complete this process. Education is therefore an ideal
vehicle for this purpose of strengthening SOC, as most people understand that to gain a
meaningful qualification takes this long, and longer, and therefore will commit to it.
Once those starting with SOC13 scores under 52 had strengthened their scores via
the process of learning, they were then just as likely to progress to higher level studies
or employment, as students starting with SOC13 scores above 52. As with any other
student, his or her previous attainment and present aspirations would dictate what
these achievements would be.
For health planners and fund-holders, the message is that a balance is required
between short-term initiatives that can engage many people, but might have short-term
gains with no sustainable progression, against this long-term initiative that can make a
real change to an individuals SOC and provide progression towards employment or
university.

SOC and peer support

Particularly pertinent to this study is the reported relationship between SOC13 score
and factors indicating social isolation and lack of social support. Larsson and
Kallenberg (1996) comment that people living alone or with few friends, reported
significantly lower SOC13 scores.
Similarly, Nyamathi (1991) conducted a five year study of 581 women in Los
Angeles who were participants in drug rehabilitation programmes (n 183) or were
homeless (n 398), of which 192 were prostitutes and 78 had sexual partners who
used intravenous drugs. Normative data searches showed this cohort as the lowest
mean score of published data. Surprisingly this cohort had a slightly higher equivalent
mean SOC13 score of 54.96 (Nyamathi used a modified version of SOC13) compared to
the students mean SOC13 score of 51.55, which confirms the relative difficulty faced
by those with mental health needs in coping with stress.
 The purpose of the Nyamathi (1991) study was to investigate the relationship Mental health
between Sense Of Coherence, self-esteem and support availability on emotional promotion
distress, somatic complaints and high-risk behaviours in minority women at risk
for HIV infection. Findings showed that women who were high in self-esteem and
stronger in SOC reported significantly less emotional distress and significantly fewer
high-risk behaviours and in addition, women who were high in any of the three
resources, reported lower somatic complaints (Nyamathi, 1991). 377
SOC and positive affect
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It is not unreasonable to expect that with the reduction of the symptoms of low
confidence, social isolation, and high anxiety etc., that Positive Affect scores will
increase and that this in turn would have a direct benefit to health and a reduction in
the uptake of Learning Support. It maybe, as Ostir et al. (2000) suggest, that Positive
Affect, or emotional well-being, is different from the absence of depression or Negative
Affect and that the two can co-exist at different degrees (e.g. a person distressed by
depression could still feel that they have a future).

The process of health improvement through education

The student cohorts studied had long-term mental health needs and were all on State
Benefits and so were economically disadvantaged. Health improvements gained at this
point in time could not therefore be attributable to economic success that may happen
in the future, but due the to the process of learning with its meaningful activity,
comprehensible structure, and manageability through supportive resources.

Pathogenic/salutogenic relationship
As this initiative involves people being supported by, or moving from, a pathogenic
paradigm, it is useful to discuss the relationship between the pathogenic and
salutogenic paradigms.
Korotkov (1998) points out that Antonovsky (1987) did not reject the pathogenic
approach, but viewed it as complementary to the salutogenic orientation, although he
neglected to show how his views could be integrated (Korotkov, 1998). In this regard, it
seems that the relationship between the two paradigms changes depending upon the
position of the individual in the health cycle, as suggested below:
.
Trauma or chronic stress leads to health breakdown.
.
Pathogenic intervention follows.
.
Recovery Stage. Rehabilitation through occupational therapy and health
promotion through salutogenic intervention i.e. strengthen/improve SOC score.
.
Prevention Stage. Health promotion through salutogenic intervention at time of
stressful life changes i.e. strengthen / maintain SOC score.

In this way, the two paradigms act together to complement each other and are not seen
as mutually exclusive or threatening. The interface between the pathogenic and
salutogenic paradigms occurs at the point where the individual is either beginning to
cope, or beginning not to cope, with normal daily living. It would be at the time of
beginning to cope well with normal daily living that an individual could be referred to
the education programme, for example, as he or she would be judged ready for
 HE college. Or conversely, a student would be referred back to his or her key worker, if he
106,5 or she were not coping with the college environment.
In considering planning the pathogenic/salutogenic balance and the consequent
ratio of spend with respect to effectiveness, Grossman and Kaestner (1997) suggest that
if the policy is to improve the level of health of the population, or certain groups of the
population, given the high correlation between health and schooling, it might appear
378 relevant to increase government outlays on schooling. In fact, they cite Auster et al.
(1996) as suggesting that the rate of return on increases in health via higher schooling
outlays far exceeds the rate of return on increases in health via medical care outlays.
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Conclusions
The results of this study show that:
.
Supported education can substantially raise the SOC13 score of those individuals
with low entry scores (i.e. below 52). A statistically significant positive
improvement was found for this group.
.
Antonovskys (1987) salutogenic model of health is a suitable perspective upon
which to base health promotion interventions and to evaluate them afterwards.
.
It is the activity of learning that improves health, not just the benefits its
attainment brings later.
.
For the allied professions, encouragement of Peer Support through team building
and Positive Affect through providing purpose and growth is worthy of
investment of time and money.
.
An alternative, non RCT methodology has been developed that is suitable for
social interventions both in respect to rigour and ethics.

Recommendations
In order to address the items identified in this study, it is recommended that:
.
Antonovskys (1987) salutogenic model is a valuable framework for the
planning and evaluation of mental health promotion;
.
allied health professions need to be more aware of the model and the contribution
of Peer Support and Positive Affect through Learning Effects in strengthening
SOC;
.
supported education programmes of the type studied here should be more widely
developed, monitored and evaluated;
.
a wider range of health measures should be adopted in such monitoring and
evaluation;
.
health planners and fund holders should give consideration to the pathogenic /
salutogenic balance in healthcare provision and the consequent ratio of spend
with respect to effectiveness;
.
health planners and fund holders should give consideration to the balance of
short-term / long-term initiatives in healthcare provision and the consequent
ratio of spend with respect to effectiveness; and
.
health planners and fund holders should pursue the financial benefits in the
collaborative use of existing funding.
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Corresponding author
Ian Morrison can be contacted at: ian-.morrison@virgin.net

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