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Resilience, misfortune, and mortality: evidence that sense of coherence is a marker of social stress adaptive capacity
Paul G. Surteesa,b,4, Nicholas W.J. Wainwrighta,b, Kay-Tee Khawc
a Strangeways Research Laboratory, Worts Causeway, Cambridge, UK Department of Public Health and Primary Care, University of Cambridge, Worts Causeway, Cambridge, UK c Clinical Gerontology Unit, Addenbrooke’s Hospital, University of Cambridge School of Clinical Medicine, Cambridge, UK b
Received 16 November 2005; received in revised form 6 February 2006; accepted 16 February 2006
Abstract Objective: The purpose of this study is to test the hypothesis that sense of coherence (SOC) distinguishes adaptive capacity to adverse event experience. Methods: A population-based cohort of 20,921 men and women completed a postal assessment of their lifetime experience of specific adverse events and a measure of their SOC. Reports of 111,857 events allowed construction of measures of event impact and adaptation. Results: Those with a weak SOC reported significantly slower adaptation to the adverse effects of their event experiences than those with a strong SOC ( Pb.0001). During mean
Keywords: Adaptation; Life events; Mortality; Resilience; Sense of coherence
follow-up of 6.7 years, 1617 deaths were recorded. A one standard deviation increase in mean adaptation score (representing slower adaptation) was associated with a 6% increase in mortality rate ( P=.03) after adjusting for age and sex. Measures of event occurrence and impact were less strongly associated with SOC and were not significantly associated with mortality. Conclusion: These results suggest that SOC is a potential marker of an individual’s social stress adaptive capacity, which is predictive of mortality. D 2006 Elsevier Inc. All rights reserved.
Introduction The suggestion that nonspecific physiological systems are activated by adverse agents that can be both health protective and restorative but can also promote pathogenesis was expressed in the early work of Hans Selye , represented through his concept of the bGeneral Adaptation Syndrome.Q Selye  considered that while no disease was bpurely a disease of adaptation . . . conversely, there is no disease in which adaptive phenomena play no partQ (p. 630). Subsequent work has built upon this insight, for example, through the concepts of ballostasisQ (defined as an adaptive process to achieve stability through change) and ballostatic loadQ (representative of the cumulative physiological cost of adaptation) [3,4]. In addition, while studies
4 Corresponding author. Strangeways Research Laboratory, Worts Causeway, CB1 8RN Cambridge, UK. Tel.: +44 1223 740651; fax: +44 1223 740147. E-mail address: email@example.com (P.G. Surtees). 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2006.02.014
of health status following adverse experience have been associated with a diversity of outcomes, they have provided strong evidence of the existence of individual differences in resilience [5–10]. Such individual differences have perhaps been most evident in studies of the health outcomes of people subsequent to their exposure to profoundly stressful circumstances, including (for example) concentration camp experience , shipwreck , and terrorist attacks [13 – 16]. Not all individuals exposed to adverse or even traumatic circumstance experience health change [17,18]. In consequence, identification of individual differences in adaptive capacity to adversity exposure could aid understanding of disease susceptibility and advance coping research. Sense of coherence (SOC) is a theoretical construct founded upon the observations of Holocaust survivors. Antonovsky et al  defined SOC to represent the salutogenic resources available to an individual through the belief that what happens in their life is comprehensible (that is rational, predictable, structured, and understand-
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able), manageable (in that adequate and sufficient resources are perceived to be available to aid difficulty resolution as they arise), and meaningful (such that the demands created by adversity exposure are seen as challenges and are worthy of engagement). Sense of coherence was hypothesized, therefore, as a flexible and adaptive dispositional orientation enabling successful coping with adverse experience . Based upon data collected from participants in the Norfolk (UK) European Prospective Investigation into Cancer (EPIC-Norfolk) study , we have previously demonstrated SOC to be strongly associated with mortality . We now test the hypothesis that SOC distinguishes adaptive capacity to adverse event experience, specifically, that a strong SOC will be associated with the report of more rapid adaptation than a weak SOC and, secondly, that social stress adaptive capacity, indexed through reports of actual experience of stressful life events, will be associated with all-cause mortality.
Adverse events in adulthood Evidence of lifetime adverse event experience was limited to circumstances considered most likely to be remembered reliably over an extended period. These were based upon those included in the questionnaire version of the List of Threatening Experiences [25,26]. A total of 16 specific adverse events were assessed, including serious illnesses (injuries or assaults) experienced by the participant (or a first-degree relative), relationship events (concerning separation, divorce, or termination of pregnancy), work events (retirement, redundancy, or being fired), and loss experiences through death (of first-degree relatives). Participants were requested to report up to two most recent experiences of each specific event. Opportunity was also provided to report (up to two) other particularly unpleasant or disappointing lifetime event experiences. In addition to event timing (within one year of occurrence), participants were asked to rate the impact of each event (on a four-point scale: not at all, a little, moderately, extremely) through answering the question, bHow much did this upset you at the time?Q and to rate their degree of adaptation to each event experience by the time of assessment (also on a fourpoint scale: completely, mostly, a little, not at all) through answering the question bDo you feel that you have got over this now?Q Statistical analysis For each participant, the total number of events and mean impact and adaptation scores of all events reported were calculated. Events involving participant’s own illness were excluded from analysis. For each event, responses to the impact and adaptation questions were assigned numerical values on a scale from 1 to 4 (for impact: not at all=1, a little=2, moderately=3, extremely=4; and for adaptation: completely=1, mostly=2, a little=3, not at all=4). Where no events were reported, impact and adaptation scores could not be assigned. Analysis was repeated according to event subsets of divorce/separation, loss (death of first-degree relatives), retirement, nonspecific (unpleasant or disappointing) lifetime event experiences, and other events (not otherwise listed). Differences in the mean number of events reported, mean impact, and mean adaptation scores were evaluated through ANOVA and are presented according to weak and strong SOC (scored previously as strong=0, 1, and weak=2 to 6 ). Effect sizes are presented as differences in means divided by the standard deviation (S.D.) (of scale scores). Progressive adaptation to events with increasing elapsed time is presented graphically as the mean reported adaptation score for all events experienced in each year relative to the time of questionnaire completion. Means and 95% confidence intervals (CIs) for the total number of events reported and their impact and adaptation are presented graphically according to increasing SOC scale score (increasingly weak SOC). For ease of comparison, the scale
Method Participants and measures During 1993 to 1997, participants were recruited to the EPIC-Norfolk study through general practice age–sex registers. The study was approved by the Norwich District Health Authority Ethics Committee, and all participants gave signed informed consent (see Ref.  for further details of study design and participant assessments). The social and psychological status of 20,921 participants (9101 men and 11,820 women) was assessed during 1996 to 2000 through their completion of the Health and Life Experiences Questionnaire (HLEQ), with a response rate of 73.2% of the total eligible sample of 28,582 (see Ref.  for further details). All deaths among EPIC-Norfolk HLEQ study participants to 31st October 2004 were recorded through linkage with data from the United Kingdom Office for National Statistics. Sense of coherence The HLEQ included a three-item SOC questionnaire  designed to assess the component constructs of comprehensibility, manageability, and meaningfulness by single questions: (a) bDo you usually feel that the things that happen to you in your daily life are hard to understand?Q (comprehensibility); (b) bDo you usually see a solution to problems and difficulties that other people find hopeless?Q (manageability), and (c) bDo you usually feel that your daily life is a source of personal satisfaction?Q (meaningfulness). Response choice was yes, usually (scored 0); yes, sometimes (scored 1); and no (scored 2). Comprehensibility was reverse scored. The three items were summed to provide a total SOC scale score within the range 0 to 6 with a higher score representing a weaker SOC.
P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227
range of the y-axis of each graph is set at two S.D.’s for each event variable. Because impact scores varied according to event type, and adaptation scores varied according to both event type and elapsed time since event occurrence, analysis was repeated using indices of impact (I-Impact) and adaptation (I-Adapt) constructed to take this into account (see Appendix for further details). Percentage variation in SOC scale scores was calculated through the R 2 statistic from linear regression. Finally, Poisson regression models, taking account of duration of follow-up, were used to investigate the associations between the event variables and all-cause mortality. Results are presented as rate ratios (95% CIs) per S.D. increase in each event variable.
Results Completed SOC scores were available for 20,579 (of 20,921) HLEQ participants (8974 men and 11,605 women, aged between 41 and 80 years). Internal consistency of the three-item SOC scale, as measured by Chronbach’s a, was .35. Of those participants who completed the scale, 8619 were classified as having a strong SOC and 11,960 as having a weak SOC. The mean SOC scale score was 1.84 (S.D.=1.15). Women reported a weaker SOC than men (with mean scores 1.68 and 1.96 for men and women, respectively, Pb.0001). Sense of coherence was strongest for those aged 60 to 69 years (mean scores 1.88, 1.86, 1.78, 1.88, for those aged 41 to 49, 50 to 59, 60 to 69, 70 to 80 years, respectively, Pb.0001). The total number of adverse events reported was 111,857 (mean=5.35, S.D.=2.48, range=0 to 18 out of a possible maximum of 27 including previous occurrences). Women reported more events than men (with a mean of 5.27 events reported by men and 5.41 by women, Pb.0001). Of these events, 5513 were divorce/separation events, 19,783 retirement events, 9565 nonspecific events, 40,642 loss, and 36,354 other events. Table 1 shows the mean numbers of reported events together with their mean impact and adaptation scores according to SOC scale score. While those with a weak SOC reported more events than those with a strong SOC, the magnitude of this difference was small (effect size=0.04). A more pronounced difference was observed
such that those with a weak SOC reported that their event experiences upset them more than for those with a strong SOC (effect size=0.23). However, the largest difference was observed for adaptation scores, whereby those with a weak SOC reported that they had not got over the events experienced to the same extent as those with a strong SOC (effect size=0.37). Participants with a weak SOC reported less retirement events than those with a strong SOC (a difference that persisted with adjustment for age) but more of all other events (with the biggest difference being for nonspecific events). Reported impact scores were higher for those with a weak SOC for all event types, with the largest difference being for retirement events. Adaptation scores were consistently higher across all event types (representing slower adaptation) for those with a weak as compared to a strong SOC. Fig. 1A shows mean adaptation scores plotted according to the timing of (all) reported adverse event experiences relative to questionnaire completion. The figure confirms that those with a weak SOC report slower adaptation to the adverse effects of events than those with a strong SOC, and also reveals that differences persist for many years. Fig. 1B– F shows that these differences in adaptation are consistent across all event types. For all events experienced (Fig. 1A), the mean difference in adaptation scores for those with a weak as compared to strong SOC was greatest for those events experienced within 10 years of HLEQ completion (mean difference=0.28, effect size=0.38) and was stable thereafter [difference=0.17, effect size=0.29, for events experienced 10 to 19 years before questionnaire completion, 0.16 (0.26) for events between 20 and 29 years ago, and 0.16 (0.25) for events experienced 30 years or more prior to questionnaire completion]. Indices both of impact (I-Impact) and adaptation (IAdapt) were calculated to take account of variations by event type and by timing of event exposures (see Appendix). I-Impact scores were higher (representing greater impact) for women than for men (mean scores=À0.28 for men, and 0.22 for women, effect size=0.50) and were lower (representing lower impact) for participants who were older (mean scores 0.12, 0.11, À0.04, and À0.16 for those aged 41 to 49, 50 to 59, 60 to 69, and 70 to 80 years, respectively; effect size across age range=0.29). I-Adapt scores were higher (representing
Table 1 Mean number of adverse life events in adulthood, mean impact, and mean adaptation according to a weak vs. a strong SOC Mean number of events SOC Any event Divorce/separation event Retirement events Loss events Non specific event Other events
Mean adaptation ES
Weak 5.41 0.27 0.91 1.98 0.50 1.77
Strong 5.32 0.26 1.00 1.90 0.44 1.73
P value .006 .04 b.0001 b.0001 b.0001 .04
Weak 3.13 3.36 1.61 3.53 3.82 3.23
Strong 2.98 3.27 1.43 3.44 3.77 3.12
P value b.0001 .002 b.0001 b.0001 b.0001 b.0001
Weak 1.57 1.44 1.25 1.64 2.05 1.45
Strong 1.37 1.24 1.12 1.45 1.73 1.28
ESa 0.37 0.34 0.25 0.30 0.35 0.28
P value b.0001 b.0001 b.0001 b.0001 b.0001 b.0001
0.04 0.03 À0.10 0.07 0.09 0.03
0.23 0.09 0.23 0.14 0.12 0.13
ES=effect size=difference in means/S.D.
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Fig. 1. Mean adaptation scores by elapsed time: (A) all adverse events in adulthood; (B) divorce/separation events; (C) retirement events; (D) loss events; (E) nonspecific events; and (F) other events, for those with a strong (solid line) and weak (dashed line) SOC.
slower adaptation) for women than for men (mean scores=À0.17 for men, and 0.13 for women; effect size=0.30) and were lower (representing more rapid adaptation) for participants who were older (mean scores 0.10, 0.08, À0.06, and À0.09 for those aged 41 to 49, 50 to 59, 60 to 69, and 70 to 80 years, respectively; effect size across age range=0.19). Fig. 2 shows the mean number of events reported, mean impact, and mean adaptation according to increasing SOC score (progressively weaker SOC). This reveals that increasingly weak SOC was associated with progressive increases in all of these adverse event measures. In addition, it shows that the magnitude of these differences was again least for the total number of events reported, greater for impact scores, and greater still for adaptation. The pattern of results was the same for I-Impact and I-Adapt, and the
magnitude of differences was greater as compared to their respective crude measures (data not shown). The percentage variation in SOC scale scores explained by these adverse event measures was least for the total number of adverse events experienced (only 0.1% of variation explained), greater for impact scores (1.9%), and greater still for adaptation (5.6%). Percentage variation explained by IImpact was 2.0% and by I-Adapt was 5.8%. During mean follow-up of 6.7 years, 1617 deaths were recorded (including 939 men and 678 women). Table 2 shows that neither adverse event experience nor impact was associated with mortality, but that stress adaptive capacity was associated with mortality. One S.D. increase in adaptation was associated with a 6% increase in mortality rate ( P=.03) after adjustment for age and sex. Similarly, IImpact was not associated with mortality, whereas a 1 S.D.
Fig. 2. Association (means and 95% CIs) between measures of adverse event experience in adulthood and SOC score (higher score represents progressively weaker SOC). (A) Number of events; (B) impact scores; (C) adaptation scores. Plotted range on y-axis is standardized at two S.D.’s for each adversity variable.
P.G. Surtees et al. / Journal of Psychosomatic Research 61 (2006) 221–227 Table 2 Association between the number of adverse events reported, mean impact and mean adaptation (of all events reported), and all-cause mortality (adjusted for age and sex) Deaths 1617 Events reported Mean impact Mean adaptation 0.98 1.03 1.06 (0.93–1.03) (0.98–1.09) (1.01–1.12) Rate ratio 95% CI
Rate ratios (95% CIs) per S.D. increase in each measure.
increase in I-Adapt score was associated with a 7% increase in mortality rate after adjustment for age and sex (rate ratio=1.07; 95% CI, 1.02–1.13; P=.008).
Discussion This study has provided strong evidence in support of the hypothesis that SOC distinguishes adaptive capacity to adverse event experience. Specifically, study participants with a strong SOC reported more rapid adaptation to their experience of social adversity than those with a weak SOC, whether social adversity was defined by all types of events or just when restricted to specific circumstances. In addition, the results suggested that a relatively slower capacity to adapt to the consequences of adverse experience was associated with increased mortality, whether adaptive capacity was defined by either a crude (mean) measure of adaptation or the I-Adapt index, that included consideration of adverse event type and event timing. In contrast, measures of event occurrence and impact were less strongly associated with SOC and were not associated with mortality. These results may be seen to provide support to some of the fundamental ideas underlying Antonovsky’s concept of salutogenesis, including a focus on bactive adaptation to an inevitably stressor-rich environmentQ (see Ref. , p. 9), recognition that bthe greater the stressor load, the more important the role of salutary factorsQ (see Ref. , p. 159), and that adverse experiences bare open-ended in their proximal as well as their distal consequences for healthQ (see Ref. , p. 970). While the current study has major design strengths, including the cohort size (with nearly 21,000 participants and over 100,000 adverse life events assessed), and prospective ascertainment of mortality (with 1617 deaths from all-causes over a 7-year follow-up), a number of potential limitations may restrict the generalizability of findings. The study cohort is an older population (age range, 41 to 80 years). The study design includes a retrospective account of lifetime experience of stressful life events, the design relies on a single assessment of SOC contemporaneous with the assessment of adversity, and SOC was operationalized by Antonovsky  initially as a 29-item questionnaire, whereas the assessment in this study was based upon a simplified three-item measure. While the internal consistency of the three-item measure was low in
this sample (Chronbach’s a=.35), this is likely to be partially due to the small number of scale items. In addition, the original developers of the scale reported satisfactory shortterm test–retest reliability and validity for the three-item measure (see Ref.  for further details). However, other studies using longer scales have questioned the stability of SOC over time periods of up to 5 years [29,30]. Previous analysis of this cohort revealed a strong relationship between SOC and all-cause mortality, such that a one S.D. increase in SOC scale score (representing weaker SOC) was associated with a 19% increased rate of mortality (see Ref. [22,31] for further details), and with some support from other work . While the association observed here between adaptation to the adverse effects of life events and all-cause mortality was not of the same magnitude, together, these results provide evidence that the association between SOC and mortality may be partially mediated by an individual’s capacity to deal with stressful situations. While recent evidence has been published demonstrating that SOC moderates the impact of negative life events (experienced during the previous 12 months) on self-reported health status , we are unaware of any other study that has reported a comprehensive test of the hypothesis that SOC is a marker of social stress adaptive capacity with which to compare findings. However, our results may be seen to contribute to recent debates concerning individual differences in the human capacity to cope with adverse experience. In particular, these include issues arising from resilience research [9,18,34], from the study of positive (change or) adaptation to trauma [35,36], from wisdom research [35,37,38], and from tests of set-point theory . With differing degrees of emphasis, these interrelated research areas have focused on identifying and extending understanding of individual differences (or contexts) that differentiate the process of human adaptation to adversity. For example, research has suggested that higher mental ability assessed in childhood is inversely associated with adult mortality [40,41], with speculation that the association may, at least in part, implicate psychometric intelligence as a significant influence on effective health self-care . Other recent work has shown a strong SOC to be associated with improved health biomarkers [43,44] and with the adoption of health-promoting dietary habits . The results of this study may therefore stimulate investigation of the joint association between SOC and wisdom-related measures. Future evaluation of set-point theory may also benefit through consideration of interrelationships with SOC. Recent tests, based upon assessment of progressive adaptation following marital status changes, including death of partner  and following unemployment , noted substantial individual differences in the capacity of individuals to adapt to these experiences, and that these were probably influenced by personality. Collectively, therefore, our findings strengthen the rationale underlying these research areas, underpin other evidence concerning the human capacity for resilience, show SOC powerfully to distinguish social stress adaptive capacity, and
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Appendix. Derivation of indices of event impact (I-Impact) and adaptation (I-Adapt) Indices of event impact (I-Impact) and adaptation (IAdapt) were derived to take account of variations by event type and (for adaptation) by event timing. For each event reported, responses to the impact and adaptation questions were assigned numerical values on a scale from 1 to 4 (for impact: not at all=1, a little=2, moderately=3, extremely=4;
and for adaptation: completely=1, mostly=2, a little=3, not at all=4). Impact scores were centered according to event type (through subtraction of the sample mean impact score for all reported events of the same event type), and adaptation scores were centered according to event type and the elapsed time since event occurrence (through subtraction of the sample mean adaptation score for all events of the same type reported in the same year relative to questionnaire completion). For each individual, I-Impact and I-Adapt were derived as the mean centered impact and adaptation scores for all events reported by that individual. Where no events were reported (for 412 and 969 participants, respectively), these indices could not be calculated. In addition, the S.D.’s of I-Impact and I-Adapt were greater for participants who reported fewer events (where the number of event experiences on which I-Impact and IAdapt were based varied from 1 to 18 and 1 to 15, respectively). Finally, therefore, I-Impact and I-Adapt were standardized, first, such that their S.D.’s were constant according to the number of events experienced, and second, to have mean=0 and S.D.=1. A positive I-Impact score represents a higher impact of adverse events experienced than the sample mean, and a positive I-Adapt score represents slower adaptation to the adverse effects of the adverse events experienced than the sample mean.
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