Sense of coherence in Crete and Sweden: Key findings and messages from a comparative study

Abstract

Background/objective: The concept of ‘‘sense of coherence’’ (SOC) was introduced in 1987 by Aaron Antonovsky to describe a dispositional orientation, ‘‘a way of seeing the world’’, which is presumed to enhance health. This study reports on the results of the first implementation of SOC in rural Crete and discusses the findings, with a view to the potential impact on primary care delivery in rural Crete. Methods: This study forms part of a follow-up project initially established in 1988 in the rural area of Spili, Crete. All participants of the initial study still living in the area (n = 248) were eligible. Data were obtained from 200 subjects (91 males and 109 females) aged 28-92 years, resulting in a second-phase participation rate of 80.7%. The SOC scales (both the SOC-29 and SOC-13 forms) were recorded for 175 (87.1%) of the participants. Results: Comparing the SOC scores among Cretan males and females, there is a statistically significant difference (p < 0.0001), with men reporting a higher sense of coherence than women, regardless of the form of the questionnaire used. Cretan women seem to score significantly lower than their Swedish counterparts (p < 0.0001), while Cretan men tend to report a higher SOC compared to their matched Swedish reference population (p = 0.07). Discussion: The study introduces other issues worthy of additional research, particularly with regard to the significantly lower SOC scores obtained by Cretan women, compared to Cretan men. These low SOC scores raise the issue of a potential increase of psychiatric morbidity in the area, leading to a high impact on primary care services. Future investigation into the health impact of SOC factors could be of value to primary care physicians located in rural Crete.

• Cardiovascular risk factors
• sense of coherence
• gender
• Crete
• Sweden

Introduction

Following publication of the Seven Countries Study [1], the nutritional habits and lifestyle characteristics of the Mediterranean population have attracted increasing interest from a public health perspective. The study demonstrated a particularly low incidence of coronary heart disease (CHD) among males from southern Europe, with Cretans presenting the lowest morbidity and mortality rates. This finding has been attributed to the Mediterranean diet [2]. Adherence to a diet rich in dietary fibre and monounsaturated fats is associated in the literature with reduced rates of all-cause mortality and positive health effects, even among individuals diagnosed with coronary heart diseases and cancers [3], [4].

A research project in primary healthcare was established in 1988, in the rural area of Spili in Crete, aiming to monitor the health status of the population. The project, mainly targeting cardiovascular disease, has been active over the last 20 years. Originally considered to represent a cardiovascular “low risk” population, Spili surprisingly demonstrated a rather unfavourable risk-factor profile, with a high prevalence of smoking, alcohol intake, and a relatively high prevalence of hypertension, diabetes, obesity, and hypercholesterolaemia [5]. However, CHD prevalence remains impressively low in the area. Aiming to interpret our findings, we formulated a hypothesis stating that other determinants, namely the closely knit social network and social coherence of the local community, may also be cardio-protective [5], [6].

The concept of “sense of coherence” (SOC) was introduced in 1987 by Aaron Antonovsky to describe a dispositional orientation, “a way of seeing the world”, which is presumed to enhance health [7]. Instead of trying to discover why people fall ill, he focused on what keeps them healthy. According to his theory, there are three components within the construct, namely comprehensibility, manageability, and meaningfulness, all of which possess health-promoting effects. Evaluation of SOC is achieved through a guided 29-item (13-item for the short version; referred to as SOC-29 and SOC-13, respectively, in the literature) questionnaire that has proved applicable across cultures and has been successfully translated, validated, and used in more than 30 languages and countries [8]. Higher SOC scores have been associated with reduced risks for overall mortality and cardiovascular disease [9].

Given the above knowledge and the interest that the Cretan population presents, we decided to investigate SOC in a well-defined rural population and compare it to a reference population from northern Europe. This study reports on the results of the first implementation of SOC in rural Crete and discusses the findings, with a view to the potential impact on primary care delivery in rural Crete.

Methods

This study forms part of a follow-up project initially established in 1988 in the rural area of Spili, in Crete. Population characteristics and the scope of the initial study are described elsewhere [5]. During the re-evaluation, we aimed to examine all participants of the initial study still living in the area (n=248). Data were obtained from 200 subjects (91 males and 109 females) aged 28–92 years, resulting in a second-phase participation rate of 80.7%. The SOC scales (both the SOC-29 and SOC-13 forms) were recorded for 175 (87.1%) of the participants. The Greek version of SOC was used [10]. Cretan data were compared to those of a Swedish regional population that were available from a cross-sectional survey covering the 45–69-year-old age group. Aiming to match the two populations in terms of age and sex, we identified the corresponding age group from Spili and found 78 Cretans (28 males and 50 females) to be eligible. Each participant from Spili was randomly, in terms of age and sex, matched with two individuals from the Swedish database, creating a Swedish reference group of 156 subjects (56 males and 100 females). The short form SOC-13 was available in the Swedish cohort, and our comparative study used SOC-13 data.

All data were statistically analysed using SPSS version 13.0 (SPSS Inc., Chicago, IL, USA). Significance of mean differences in SOC was estimated using 95% confidence intervals (CI) and the two-sided analysis of variance (ANOVA) test. A p value less than 0.05 was considered as statistically significant. The study was approved by both the Research Ethics Committee of the University Hospital of Heraklion, Crete, Greece, as well as the Research Ethics Committee at Linköping University, Sweden.

Results

The mean values of the sense-of-coherence measurements (SOC-29 and SOC-13), as well as the 95% CI, for the Spili group are presented in Table I. Table I provides cumulative statistics for the whole population examined in the period 2000–2001. Comparing the SOC scores among males and females, there is a statistically significant difference (p<0.0001), with men reporting a higher sense of coherence than women, regardless of the form of the questionnaire used (SOC-29 or SOC-13).

Table I.  SOC scores (mean values and 95% confidence intervals) for males and females in the village of Spili in Crete.

	SOC-29 (mean, 95% CI)	SOC-13 (mean, 95% CI)
Total (n=175)	140.5	63.2
Males (n=78)	150.1 (145.5–154.7)	68.4 (65.8–71.0)
Females (n=97)	132.7 (128.6–136.8)	59.0 (56.8–61.1)
P value	<0.0001	<0.0001

SOC: sense of coherence; CI: confidence intervals.

The mean age and the standard deviation (SD) for both the Cretan and Swedish group was 57.9±7.6 years, comprising 35.9% males and 64.1% females. Table II presents a comparison of the SOC-13 scores recorded in the Cretan and the Swedish populations. It should be noted that only data referring to the 45–69-year-old age group were recorded in this table. Cretan women seem to score significantly lower than their Swedish counterparts (p<0.0001), while Cretan men tend to report a higher SOC compared to their matched Swedish reference population (p=0.07).

Table II.  Comparison of SOC-13 scores (mean values and 95% confidence intervals) for two matched, in terms of age and sex, populations in Spili, Crete, and Sweden.

	SOC-13
	Mean score	95% CI	P value
Spili (total, n=78)	61.5	58.5–64.5	0.001
Sweden (total, n=156)	67.5	65.6–69.4
Spili males (n=28)	71.0	66.0–76.0	0.07
Sweden males (n=56)	66.1	63.1–69.0
Spili females (n=50)	56.2	53.3–59.1	<0.0001
Sweden females (n=100)	68.3	65.9–70.8

SOC: sense of coherence; CI: confidence intervals.

No statistical differences in the SOC scores recorded were observed for the Swedish reference population, among males and females (data not shown in tables).

Discussion

The study highlights a significant difference in the recorded SOC scores among men and women of this particular rural area in Crete. It also demonstrates a discrepancy compared to data from northern Europe, with men reporting a higher (although not statistically significant) SOC compared to their Swedish counterparts, whereas Cretan women demonstrate a weaker SOC in comparison to both their spouses and to Swedish women.

Gender differences in SOC scores, with males demonstrating a higher SOC, have been reported in the literature before, although the gender effect seems to be small in most of the studies [8]. However, no such differences were observed for the Swedish reference population, and this is in accordance with other reports from northern Europe [11]. Therefore, the striking difference between the two genders, in SOC scores recorded in Cretans, raises an issue for further discussion.

SOC has been extensively used in research, mainly in northern and western European countries, and its predictive validity is well discussed. In a study by Eriksson and Lundin [12], a stronger SOC was associated with a reduced risk of developing post-traumatic stress symptoms in survivors of a major disaster. It has also predicted a better outcome following major surgical procedures such as those performed in patients with morbid obesity [13] or multiple orthopaedic injuries [14]. The validity of SOC has been documented among drug-users, identifying the need for additional life-saving psychological support [15]. Moreover, a large study performed in the UK, which followed general practice patients for a period of 6 years, revealed that a strong SOC was associated with a 30% reduction in mortality from all causes, cardiovascular disease and cancer, independent of age, sex, and prevalent chronic disease [9].

The current descriptive study is unable to determine the extent to which SOC may be a predicting factor in the low prevalence of CHD amongst Cretan males. As such, the study does not lead to any inferential conclusions. However, given the higher SOC in Cretan males (although non-significant) compared to Swedish males, further research into this issue could prove valuable. The involvement of a larger population sample may be beneficial to the further exploration of SOC findings in relation to coronary artery disease in rural populations.

Furthermore, the study introduces other issues worthy of additional research, particularly with regard to the significantly lower SOC scores obtained by Cretan women, compared to Cretan men. In recent years, Cretan women have become more actively involved in employment while retaining the demanding role of raising children and taking care of the household. The combination of a modern, western, post-industrial lifestyle along with expectations of preserving Cretan culture and traditions may be reflected in the low SOC scores reported by this particular group. SOC may be further depleted by the inadequate supportive network in Greece (lack of day-care centres, insufficient legislation for employed mothers).

The low SOC scores recorded from Cretan women also raise the issue of a potential increase of psychiatric morbidity in the area, leading to a high impact on primary care services, which implies changes to the local healthcare system and in the professional continuous training of local general practitioners. Although the ability of SOC to drive an individual towards the health end of a health/disease continuum is not well documented, its effect on psychiatric morbidity is more efficiently supported [16], [17].

In conclusion, although this study is inconclusive concerning the relationship of SOC to the prevalence of CHD, the higher scores achieved by Cretan men indicate that this issue is worthy of further research. Future investigation into the health impact of SOC, together with exploration of various cultural/traditional factors not covered by this measure could be of value to primary care physicians located in rural Crete. Furthermore, the study introduced certain issues of further research with regard to the low SOC scores achieved by Cretan women. This finding could have implications for primary care settings, in terms of addressing wellbeing and psychosocial issues in women living in rural Crete. Issues concerning the extent to which health assets such as high sense of coherence, tight social networks, and social coherence in the local community, even in rural societies undergoing social changes, could be explored in well-designed inferential studies.

Acknowledgements

We would like to thank Dr. Sue Shea, Collaborating Scientist with the Clinic of Social and Family Medicine of the School of Medicine, University of Crete, for her comments and feedback on the final draft of the manuscript. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.