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CHAPTER THREE
SALUTOGENIC CONSTRUCTS IN STRESS AND COPING
It matters not how strait the gate, how charged with punishments the scroll, I am the
master of my fate: I am the captain of my soul.
-W.E. Henley, Invictus, 1888.
The previous chapter described the stress process and the most important sources of life
and occupational stress. Various coping resources for example, generalized resistance
resources (GRRs) and internal locus of control were also mentioned. The objective of
this chapter is to conduct a literature review of the salutogenic approach pertaining to
stress and coping. Three salutogenic constructs formulated by Antonovsky, Kobasa and
Rotter will be discussed. Section 3.1 commences with a background to the concept of
salutogenesis, the salutogenic model of health, the sense of coherence construct and a
discussion of sense of coherence, coping and health. Section 3.2 focuses on two other
salutogenic constructs namely hardiness and locus of control.
3.1 THE SALUTOGENIC APPROACH
In 1973 Aaron Antonovsky, a Professor of Medical Sociology at Ben Gurion University
of the Negev in Israel, introduced the concept of salutogenesis (Marais, 1997). The word
salutogenesis is derived from the Latin: salus meaning ‘health’ and the Greek meaning
‘origins’. Antonovsky’s (1987a) describes salutogenesis as the focus on the overall
problem of positive adaptation in stress related situations. Thus the word salutogenesis
refers to the origin of health and relates to how certain individuals cope successfully with
stress whilst others do not and may succumb to disease. In contrast to the concept
salutogenesis is the traditional or medical approach known as pathogenesis.
3.1.1
PATHOGENESIS AND SALUTOGENESIS
Numerous stress specialists cited in the literature (for example Selye, 1976) have focused
primarily on the pathogenic or negative effects of stress, reporting maladaptive coping
56
patterns, stress related illnesses and other adverse consequences.
(Dossey, 1994;
Levenstein, 1994) contend that Antonovsky’s work has encouraged a paradigm shift
from pathogenesis to salutogenesis, changing the biopsychosocial model regarding the
explanation for coping, health and wellness. A distinction between the two approaches is
required.
3.1.1.1 PATHOGENESIS
Pathogenesis is described as the genesis of pathology, expressing the second law of
thermodynamics according to which ‘organized systems’ or symptoms indicate that the
human body may become run down, dysfunctional, chaotic or unwell (Dossey, 1994).
Central to this pathogenic approach is the view that stress causes ill health or disease.
The medical or pathogenic approach tends to categorize individuals as either ‘well’ or
‘unwell’ and focuses primarily on specific areas in the body, for example the malfunction
of an organ and not on the combination of psychological, emotional and physical factors
that may contribute to illness. In evaluating the pathogenic approach, Dossey (1994)
contends that the pathogenic approach tends to be ‘overwhelmingly’ physical and ignores
the view that human consciousness and human choice may influence health and wellness.
Thus the pathogenic approach focuses on the disease and its prevention as opposed to
facilitating active adaptation for the organism to the environment.
3.1.1.2
SALUTOGENESIS
Wolff and Ratner (1999) describe salutogenesis as the ‘antonym’ of pathogenesis, with
salutogenesis emphasizing the promotion of health and the prevention of disease instead
of the origins of disease. In contrast to pathogenesis, the concept of salutogenesis
includes economic, social and environmental factors as determinants in health and illness
(Dossey, 1994). Antonovsky (1979, 1987b) argues that a healthful view or salutogenic
approach should accompany the pathogenic approach and not necessarily replace it.
Central to the salutogenic approach is the view that stressors are omnipresent in human
57
existence and that many individuals cope successfully in spite of being subjected to the
most demanding stressors (Antonovsky, 1987b). Thus the salutogenic approach questions
why some individuals do not succumb to illness when confronted with severe stress or
pathogens.
In response to this question, Antonovsky (1979) developed the salutogenic
model of health and the sense of coherence construct.
3.1.2
THE SALUTOGENIC MODEL OF HEALTH
Antonovsky’s concept of salutogenesis and the subsequent development of the
salutogenic model of
health arose from a study conducted on the sequelae of the
experiences of several women concentration camp survivors twenty eight years after the
Second World War (Antonovsky, 1979; 1987b). Health status was a prime dependent
variable in the study, with data entailing factors relating to wellbeing, coping, role
satisfaction, mood and family relations.
A considerable number of women appeared to
be well adapted in spite of having experienced the horrors of the concentration camps and
displacement in the years that followed the holocaust. In reference to this classical study,
Antonovsky, Maoz, Dowty and Wijsenbeek (1971) asked : what gave these women the
fortitude or strength to function well and be happy at some levels, despite their adverse
experiences?
The salutogenic model of health depicts a cyclical process which explains the
individual’s position on the health ‘ease/dis-ease continuum’. Rather than a dichotomous
approach to health whereby the individual is perceived as well or unwell, individuals may
be found on a continuum between the two extremes. This implies that the individual
could be located on a ‘health ease continuum’ at one stage of his/her life and at another
time be located on a disease continuum or ‘phase’. Being ‘well’ or healthy includes the
emotional, physical, psychological and social characteristics or ‘influences’ that the
individual experiences. Antonovsky (1987b) contends that these characteristics are not
necessarily dependent on each other, in that an individual suffering from a terminal
illness may be psychologically healthier than the individual not presenting any physical
58
illness. In order to cope with stressors, the individual utilizes generalized resistance
resources (GRR’s) as briefly mentioned in the previous chapter. Antonovsky (1979,
1987a, 1987b) further describes the generalized resistance resources as characteristics of
a group, individual, society or subculture that facilitate coping with a wide variety of
stressors. Generalized resistance resources (GRR’s) consist of the following categories:
i)
Artifactual-material
This is described as the situational position that the individual is born into.
The
situational position may consist of access to material resources, education, health,
occupation, geographic location, the physical environment and levels of pollution or
noise.
ii)
Physical and biochemical make-up
A physical resistance resource relates to the individual’s genetic factors and includes
characteristics such as intelligence and the ability of the body’s immune system to
combat disease and adapt to a changing environment.
iii)
Cognitive resistance resources
This includes the individual’s ability to utilize available resources to his or her advantage.
A cognitive resistance resource entails the individual’s ability to rationalize, be flexible
and to comprehend and have insight into the norms and codes of society.
iv)
Emotional resistance resources
An emotional resistance resource relates to the individual’s ego identity, role
identification and stability of the personality.
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v)
Valuative-attitudinal
This consists of clusters or groups of coping strategies when confronted with challenging
stimuli or stressors. It includes the ability to avoid potentially stressful situations, the use
of appropriate problem solving strategies and the rationalization of an emotive situation.
vi)
Interpersonal-relational
Interpersonal-relational resistance resources include the individual’s social support
network. For example the support gained from a spouse, friend, colleague or the church.
vii)
Macro-socio-cultural
This category relates to where the individual fits into his or her social environment. It
includes the individual’s culture, belief system, language, norms and the extent to which
the individual or group is committed to the society. The extent of the individual’s
commitment to society gives meaning to his or her existence.
The generalized resistance resources thus emphasize the influence of emotional, physical,
psychological and social characteristics in coping with stress and how they impact on the
individual’s health and wellbeing.
Antonovsky
(1979,1991) contends that the
combination of the individual’s regular use of generalized resistance resources (GRR’s)
and experiences gained from his or her environment, determine how he or she perceives
the world as either incoherent or coherent. This ‘concept of perception’ or personality
construct is referred to as the sense of coherence. The sense of coherence is a central
construct of the salutogenic model and is also referred to as the ‘sense of control’ (Wolff
& Ratner, 1999).
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3.1.2.1 THE SENSE OF COHERENCE CONSTRUCT
Antonovsky (1987b) defines a sense of coherence (SOC) as a ‘global orientation’ that
reveals to what extent the individual perceives the stimuli from his/her internal or
external environments during his/her lifetime as being foreseeable, organized,
comprehensible and capable of being explained. Furthermore, the individual expresses
the conviction that there are sufficient resources available to deal with the demands of the
stressors or stimuli and that the energy invested in dealing with the stressors or
‘challenges’ is perceived as worthwhile and meaningful.
The sense of coherence is thus developed through the progressive understanding of life
experiences and is forged in the sociocultural and historical context of the individual’s
life-span. Coherence refers to a way of perceiving life experience that allows for the
formation of adaptive human responses (Antonovsky, 1993; England & Artenian, 1996).
A social structure may enhance or prevent a strong sense of coherence and where society
experiences social upheaval and rapid change the individual’s sense of coherence may be
undermined (Marais, 1997). Bowman (1997) describes the sense of coherence as the
foundation in the development of coping strategies rather than a coping style.
Antonovsky (1987a,1987b) posits that the sense of coherence is an important determinant
in maintaining the individual’s position on the health ease/disease continuum. In order to
test the core hypothesis that the sense of coherence is causally related to the individual’s
health status, Antonovsky (1987b) developed a questionnaire to measure the sense of
coherence. The questionnaire consists of a 29 item scale, with a 13 item short form. The
Sense of Coherence Questionnaire also referred to as the orientation to life questionnaire,
determines how an individual perceives and interacts with the world, the coping strategies
utilized and how successfully he or she copes with stressors (Antonovsky, 1987b).
Studies in the literature (for example, Strumpfer, 1997) support the validity of the Sense
of Coherence Scale as a measure of Antonovsky’s salutogenic construct. The sense of
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coherence
construct
consists
of
three
components
namely,
comprehensibility,meaningfulness and manageability.
Comprehensibility
Antonovsky (1979,1987b,1991) refers to comprehensibility as the extent to which the
individual perceives stressors or stimuli confronting him or her from internal or external
environments as information that makes cognitive sense and that is clear and structured
rather than stimuli that is chaotic or inexplicable. Information or stimuli that is conveyed
in the form of messages that are perceived as unclear, disordered or chaotic are referred
to as ‘noise’ (Antonovsky, 1991). The individual who obtains high scores on the sense of
comprehensibility views stimuli to be ‘predictable’ in their outcome in similar future
situations. Thus the individual is able to make sense from devastating events like death,
war, failure and so forth. It may be described as a positive capacity to evaluate reality
with adverse events being judged as experiences that the individual can cope with.
Manageability
Antonovsky (1987b) defines this component as the perception of resources that are
available to the individual and to what extent the resources are suitable in order to cope
with the stressors or stimuli. Resources at one’s disposal could refer to the resources that
are controlled by the individual, for example his or her finances. Other resources
controlled by ‘legitimate others’ refers to social support, God, or an individual that can be
‘counted on’. Manageability ensures that the individual does not feel victimized by
adverse events and does to feel the need to mourn the negative event for a great length of
time.
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Meaningfulness
The component meaningfulness entails a motivational element and pertains to events that
the individual with a high score in meaningfulness, views as challenging and worthy of
commitment and emotional investment. Meaningfulness entails the feeling that life makes
sense emotionally it is thus the emotional counterpart to comprehensibility (Antonovsky,
1984). Individuals with high scores on meaningfulness view unhappy experiences as
challenges that entail reasons or ‘meaning’ in their existence. These individuals feel the
need to make an effort in order to overcome negative experiences with dignity.
Antonovsky (1987b) states that the three components are interrelated but that there could
be situations where an individual’s experiences could result in scores being low in one
component and high in another. For example, having a high score on comprehensibility
does not necessarily mean that the individual believes that he or she can manage the
situation well and thus he or she may obtain a low score on manageability (Antonovsky,
1987b).
A low score on the Sense of Coherence Questionnaire reflects a weak self-identity.
Antonovsky (1987b) emphasizes that individuals with a low score would have a ‘rigid’
sense of coherence whereby they expect things to go wrong, often feeling that their lives
are at the mercy of fate. Typically, they tend to give up when faced with an adverse
situation resulting in a loss of self-esteem, a decrease in motivation and feelings of
helplessness. There is also the tendency to blame external factors for their fate or
alternatively resort to self recrimination.
A high score on the Sense of Coherence Questionnaire indicates a strong self-identity, a
commitment or feeling of involvement regarding work and relationships, an endeavour to
find a balance between rules and strategies and the confidence that new information can
be well comprehended. The individual with a high score on the sense of coherence
questionnaire perceives the environment as stable, predictable and comprehensible, where
63
stimuli are expected to be meaningful and any great change is viewed within a bigger
context of order and structure (Antonovsky, 1987b).
The abundance of generalized resistance resources impacts on the emergence of a strong
sense of coherence affecting the individual’s health and well being (Antonovsky, 1987b;
Strumpfer, 1995). Strumpfer (1990) emphasizes that central to Antonovsky’s hypothesis
is the idea that the stronger an individual’s sense of coherence, the greater the likelihood
that he or she will be able to sustain his or her position on the health ease/dis-ease
continuum. The following section examines the personality characteristics that contribute
to coping and wellness.
3.1.2.2.
SENSE OF COHERENCE, COPING AND WELLNESS
Regarding Antonovsky’s hypothesis that the individual with a strong sense of coherence
is more likely to maintain his or her health, the question arises: What characteristics and
personality traits do these individuals present in order to remain healthy and to cope with
stress? Strumpfer, Viviers and Gouws (1998) contend that the sense of coherence is a
cognitive and emotional appraisal style associated with health-enhancing behaviour and
coping. Antonovsky (1987b) states that the individual with a strong sense of coherence
is able to understand the nature of chronic stressors and is more likely to avoid health
endangering situations preferring to engage in health promoting activities. Geyer (1997)
reports that the sense of coherence is a stable disposition of personality that functions as
an important coping resource for the preservation of health.
Several well known stress theorists in the literature (for example Friedman & Rosenman,
1974; Selye, 1976) have linked personality factors and stress-related emotions such as
anxiety and anger with an increased susceptibility to disease. Antonovsky (1987b) posits
that in appraising the stressor the individual either perceives the stimulus as
happy/challenging or dangerous/threatening. Is the individual with a weak sense of
64
coherence more susceptible to illness due to negative management of emotions in a
stress- related situation? In the classical work of Lazarus (1966) anxiety is referred to as
the stress emotion. Thus a strong sense of coherence could include the ‘management’ or
‘control’ of anxiety when confronted by stressors.
Antonovsky (1987b) contends that
individuals with a strong sense of coherence do not allow negative emotions to dominate
their responses to stressors. This would suggest that by controlling the perception of the
stressor, the physiological response to stress (for example an increased heartbeat) is also
controlled, reducing the risk of disease or illness.
The following salutogenic study conducted by Gibson and Cook (1996) supports that
personality variables, a strong sense of coherence and emotions play a vital role in
general health and the management of stress. Gibson and Cook (1996) hypothesized that
individuals displaying maladjustment and neuroticism on various personality tests would
present low scores on the Sense of Coherence Questionnaire. A sample consisting of 95
students were tested. The following questionnaires were given to the respondents: the
Sense of Coherence Questionnaire, the Eysenck Personality Inventory, the General
Health Questionnaire and the revised Dispositional Resilience Scale.
The findings revealed that the Sense of Coherence Questionnaire and the revised
Dispositional Resilience Scale indirectly measure neuroticism. The results of the study
support the current literature that health questionnaires may indirectly measure
neuroticism and that personality variables for example emotional instability, play an
important role in health and well-being (Gibson & Cook, 1996).
The results also
indicate that individuals who are emotionally labile are more likely to have low scores on
the Sense of Coherence Questionnaire. A limitation of the Gibson and Cook (1996) study
was that the sample of 95 students consisted predominantly of females (76%). This may
have influenced or biased the results in that the literature (for example Strongman, 1987)
indicates that women tend to present themselves as more anxious and emotional than
men.
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Antonovsky and Sagy (1985) examined the impact of the sense of coherence on
emotional responses to stress-related situations. Although the study did not specifically
explore the link between health and the sense of coherence, the findings support that
individuals with a strong sense of coherence present healthier emotional responses to
stress than individuals reporting to have a weak sense of coherence. The study examined
factors conducive to the development of a strong or weak sense of coherence in
adolescents. A sample consisting of 418 adolescents was selected for the study. Of the
418 adolescents, 78 were soon to be evacuated from their homes due to political unrest.
These 78 subjects comprised the study group. The comparison group were the remaining
340 pupils who lived in other communities in Israel. Emotional responses of the study
group were measured one week before and six weeks after evacuation. The following
measurement instruments were used: The Sense of Coherence Questionnaire, the
Spielberger State-Trait Anxiety Inventory and the Antonovsky parent-adolescent
relationship questionnaire.
The findings reported that the boys had significantly higher sense of coherence scores
than did the girls. The hypothesis regarding the relationship between the sense of
coherence and A-trait was well supported, indicating that the stronger the sense of
coherence, the less the inclination to react with ‘unhealthy’ anxiety to stressors. It was
also found that the stability of the community, age and gender were related to the
development of the sense of coherence in adolescents.
In evaluating the study, Antonovsky and Sagy (1985) concede that the measures used
were inadequate. A suggestion for further research could be the inclusion of a health
status questionnaire in order to establish whether ‘less anxious’ individuals not only have
a stronger sense of coherence but whether they enjoy better health than individuals
presenting low sense of coherence scores. Antonovsky and Sagy (1985) also recommend
that future research of a similar nature should focus more on personal and family
experiences conducive to the development of a strong sense of coherence.
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The aforementioned studies demonstrate that certain personality characteristics for
example the management of emotions may contribute to positive coping methods and
well-being.
England and Artinian (1996) applied a salutogenic nursing approach
reporting that it facilitates recovery by improving the patient’s situational sense of
coherence. Thus where an individual displays negative characteristics, for example
apathy or depression regarding his or her illness, he or she may be instructed how to
become more proactive in the healing process. The approach includes mentoring patients
in how to create situational environments for healing for example, the use of home health
care interventions. The patient also learns how to change his or her perception of illness
and thus learns how to manage negative emotions associated with ill health.
England and Artinian (1996) state that the salutogenic nursing approach thus aims to
improve the patient’s situational sense of coherence by teaching him or her a) how to use
available resources to meet the demands of the illness (manageability) b) to understand
and make cognitive sense of the situational environment for example, the hospital
(comprehensibility)
c) to view the demands made by the illness as worthy of
commitment (meaningfulness). The work of England and Artinian (1996) indicates that
certain characteristics associated with a strong sense of coherence, can be taught to
individuals not only to facilitate healing but also to prevent the recurrence of ill health or
disease. England and Artinian (1996) emphasize that the salutogenic approach has
implications not only for nursing practice but for global health care in general.
The
salutogenic health care and nursing approach is thus an example of how the
salutogenic approach has gained a measure of acceptance in a typically medical or
pathogenic environment. Levenstein (1994) states that Antonovsky could be described as
one of the fathers of the wellness movement. Several authors in the literature (for
example Dossey,1994; Gordon, 1994; Gruman, 1994) compare the salutogenic approach
with the wellness movement or “wellbeing” movement. Central to the wellness concept
is the belief that the individual actively controls his or her own healing process and that
the individual’s consciousness plays a vital role in his or her health (Dossey, 1994).
67
Antonovsky (1994) challenges the core belief of the wellness movement and argues that
the wellness or mind-body studies place undue attention on the ‘self’ and the personality
and do not include the social and environmental determinants in health and disease.
In conclusion, some of the essential characteristics associated with a strong sense of
coherence, is a positive perception and understanding of chronic stressors, effective
management of stress-related emotions and avoidance of health endangering activities.
Several studies found in the literature (for example Gibson and Cook, 1996; Lundberg,
1997) support Antonovsky’s hypothesis that the individual with a strong sense of
coherence is likely to control or manage stress-related emotions and thus be healthier than
the individual with a weak sense of coherence. There is also evidence in the literature (for
example England & Artinian, 1996) that the sense of coherence can be strengthened to
promote recovery from illness.
Antonovsky’s work created a paradigm shift from pathogenesis toward salutogenesis
affording a new perspective of stress and wellness. Lenderking (1995) emphasizes that
one of Antonovsky’s greatest contributions in the ‘mind/body’ approach to health, is the
formulation of the sense of coherence construct which explains how the individual may
remain physically and emotionally healthy despite the many sociopolitical and
psychological stressors he or she may be exposed to over a lifetime.
In further addressing the mind/body approach to health, the literature (for example
Cilliers, Viviers & Marais, 1998; Geyer, 1997; Sullivan, 1993) support that certain
theoretical concepts like hardiness and self-efficacy strengthen the plausibility of the
salutogenic approach. Antonovsky (1987b, 1991) identified the salutogenic constructs of
hardiness, self-efficacy, learned resourcefulness and locus of control as comparable to the
sense of coherence construct. The constructs of hardiness and locus of control are
pertinent to the present study and will be discussed in the following section.
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3.2
HARDINESS AND LOCUS OF CONTROL CONSTRUCTS
Antonovsky (1991) emphasizes that what each of the four salutogenic constructs have in
common is the focus on coping with stressors and the maintenance or return to health.
Kobasa and Puccetti (1983a) state that although there are differences between the
concepts of sense of coherence and hardiness the similarity between the two concepts is
striking. Strumpfer (1995) refers to the salutogenic constructs as having an inherent
methaphor of strength namely, ‘fortigenesis’ or psychological strength in coping with
stress. Section 3.2.1 commences with the hardiness construct and Section 3.2.2 discusses
the locus of control construct.
3.2.1
HARDINESS
The concept of the ‘hardy personality’ was developed by Suzanne Kobasa and her
colleagues at the University of Chicago and is believed to be the salutogenic construct
best known to psychologists (Strumpfer, 1990). Section 3.2.1.1 examines the earlier
research conducted by Kobasa and her colleagues revealing how the hardiness construct
came to be formulated. The three components of the construct are then fully discussed in
Section 3.2.1.2.
Finally, Section 3.2.1.3 provides an evaluation of the hardiness
construct.
3.2.1.1 THE DEVELOPMENT OF THE HARDINESS CONSTRUCT
During the 1960’s and 1970’s a great deal of research focused on the relation between
occupational stress and illness (Pines, 1980). It was during this time that Kobasa began
her research regarding the link between stressful events, personality and illness.
In her classical study, Kobasa (1979) examined the link between stressful life events,
personality and health. The proposition of the study was that individuals who experience
69
high levels of stress without becoming ill, have a personality structure different to
individuals who become ill when confronted with stress. The study included two groups
of middle and upper level executives who had experienced high degrees of stressful life
events over a 3 year period. The stressful life events were measured by the Holmes and
Rahe Schedule of Recent Life Events Questionnaire. The health of the subjects was
determined by the responses received from the Wyler, Masuda, and Holmes Seriousness
of Illness Survey.
The subjects also completed personality questionnaires which
measured three dimensions namely control, commitment and orientation to challenge.
The results reported that one group of executives (n=86) had suffered a great deal of
stress but had not succumbed to illness, whereas the other group (n=75) reported that they
became ill after experiencing certain stressful life events. The results also indicated that
the subjects with high stress and low illness levels had a stronger commitment to self, an
attitude of vigorousness toward the environment, an internal locus of control and a sense
of meaningfulness. Kobasa (1979) referred to the individuals with high stress and low
illness levels as ‘hardy personalities’. The outcome of the study suggested that
personality may be an important determining factor in staying healthy.
In evaluating the study, Kobasa (1979) indicates that the research relied on the honesty of
the subjects and that possible distortions in the data may have occurred especially
regarding the health status of the subjects. Medical or physiological examinations could
have accompanied the use of self-report measures of illness in order to ensure more
certainty regarding the health status of the subjects. Individuals presenting high stress
scores and a recent history of illness may have presented negative responses on the
personality questionnaire due to the psychologically debilitating effects of their illness
(Kobasa, 1979).
Kobasa, Maddi and Kahn (1982) tested the hypothesis that hardiness, consisting of the
three personality dimensions commitment, control and challenge function to decrease the
70
effect of stressful life events in causing illness. Kobasa and her colleagues asked the
question – what personality dispositions play a role in mitigating the effects of stress?
The subjects consisted of 259 middle and upper level management personnel of a large
utility company. They were given a stress questionnaire devised by Homes and Rahe
(1967) and the Seriousness of Illness Survey to complete. The questionnaires measured
stressful life events and the symptoms of illness that may have been experienced in the
previous 3 years. The subjects were asked to complete a questionnaire that measured the
personality dispositions of commitment, control and challenge. Included in the initial
questionnaires were demographic items regarding age, education, job level, length of
time in job level and marital status.
Kobasa et al. (1982) report that hardy individuals engage conscientiously in positive
health routines in contrast to individuals low in hardiness that may engage in poor health
practices. Hardy individuals were also shown to use a cognitive appraisal method of
rendering stressful life events as less overwhelming, in this way reducing the illnessprovoking biological state of ‘adaptational exhaustion’ as advocated by Selye (1976).
The results support that hardiness functions as a resistance resource in buffering the
effects of stressful situations. In analyzing the results Kobasa et al. (1982), hypothesized
that hardiness influences the extent of the manner in which social supports are used in
the coping and management of stressful situations. A study testing this hypothesis was
conducted one year later.
Kobasa and Puccetti (1983) examined how personality and perceived social support
functioned as moderators of the effects of stressful life events and the onset of illness.
Kobasa and Puccetti (1983) compared the generalized resistance resources of
Antonovsky (1979), with particular emphasis on the interpersonal-relational and
macrosociocultural generalized resistance resources as being similar to various
characteristics that contribute to hardiness. Hardiness refers to a ‘generalized ability’
namely, the use of available environmental and personal resources in order to cope
effectively with stressful events (Kobasa & Puccetti, 1983). Thus the study tested the
71
hypothesis that hardy individuals should not only be healthier but utilize more social
resources than individuals presenting low hardiness/high illness scores.
The research method included a sample of 170 middle and senior management executives
who completed the adaptation of the (Holmes & Rahe, 1967) Schedule of Recent Events
questionnaire, the Seriousness of Illness Survey, a hardiness questionnaire and an
Environment Scale that measured social support. Kobasa and Puccetti (1983) developed a
hardiness questionnaire consisting of five scales combined to form a composite score.
The five scales consisted of the alienation from self, alienation from work, powerlessness
scales of the Alienation Test, a Life Goals Evaluation Schedule and a Locus of Control
Scale.
After statistical analysis, the results reported that only certain areas of social support
served to buffer individuals from illness. It was found that the perception of support from
the ‘boss’ buffered the illness-provoking effects of high stress conditions in occupational
settings. The results also indicated that personality and social support do not fully explain
how individuals maintain their health in the face of stressful events. In a similar study,
Ganellen and Blaney (1984b) examined the link between hardiness and social support as
moderators of stress. The results reported a strong relation between social support and
hardiness.
In evaluating the study, Kobasa and Puccetti (1983) posit that apart from social support,
many other resistance resources for example, diet, exercise and family medical history
need to be included in the link between stress-resistance resources and health status. A
limitation of the study was that the subjects were exclusively males. The literature (for
example Barnett, Biener & Baruch, 1987) frequently reports that women rely more
heavily on social support when confronted with stressful events. The findings of the
Kobasa and Puccetti (1983) investigation may have reported different results if both men
and women had been equally represented in the sample of the study.
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Following the various studies conducted by Kobasa and her colleagues, the construct of
hardiness became recognized in the literature as consisting of three components namely,
commitment, control and challenge.
3.2.1.2 THE HARDINESS CONSTRUCT
Kobasa (1979, 1982) described hardiness as a global personality construct consisting of
the following three components:
Commitment
Commitment reveals the tendency to become fully involved in many situations in life.
These situations include work, family, interpersonal relationships and social institutions.
There is an overall sense of purpose in the individual’s approach to life.
Individuals with high scores in Commitment tend to involve themselves in whatever they
are occupied with, rather than experiencing a form of alienation from life’s encounters or
tasks. Individuals with high scores in Commitment are generally interested in activities
and people. Committed individuals have a generalized sense of purpose and
meaningfulness that is expressed as a tendency to partake actively in life events (Ganellen
& Blaney, 1984a).
Low scores in Commitment reveals a general sense of
meaninglessness, apathy and detachment regarding most aspects in the individual’s life.
In Kobasa’s (1983) Hardiness questionnaire, the operational measure of Commitment
consists of eighteen alienation items, all of which are negatively keyed, with half relating
to alienation from work and the other half to alienation from the self.
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Control
According to (Antonovsky, 1987b; Sullivan, 1993) Kobasa’s use of the term ‘control’ is
implied in the same way as that used in Rotter’s (1966) theory of internal and external
locus of control. In terms of coping, a sense of control results in actions aimed at
changing events into situations that are consistent with the individual’s life plans. Control
also enhances stress resistance, thus reducing the likelihood of becoming ill (Kobasa,
Maddi & Kahn, 1982).
In contrast to individuals with low Control scores, individuals with high scores in Control
believe that they can influence life events and do not feel helpless when faced with
adversity. Individuals with high Control scores also try to find explanations for the events
in their lives by attributing situations not as arising from the actions of others, but arising
from their own actions and capabilities. Individuals with high scores in Control thus
reject the notion that chance or luck determine their destiny and believe that they
themselves can influence life events.
Challenge
Challenge suggests that negative or positive life events are perceived as stimulating rather
than threatening. There is an expectation that change, rather than stability, is normal and
that life changes offer a chance for personal development, opportunity and growth
(Strumpfer, 1990).
Individuals with high scores in Challenge, perceive demanding or difficult life events as
opportunities rather than threats. Kobasa and Puccetti (1983) describe the individual with
a high score on Challenge as being open, revealing cognitive flexibility and having a
tolerance for ambiguity.
In summary, earlier studies conducted by Kobasa and her colleagues indicated that the
personality components of commitment, control and challenge served to buffer
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individuals against the effects of stress and illness. Individuals presenting high scores in
these three personality components are referred to as hardy individuals. Although the
hardiness construct is well documented and supported in the literature, some studies have
failed to show the expected relationship between hardiness and health.
3.2.1.3 AN EVALUATION OF THE HARDINESS CONSTRUCT
A considerable body of evidence supports Kobasa’s proposed relationship between
hardiness and health. However, some studies in the literature (for example Funk &
Houston, 1987; Hull, Van Treuren & Virnelli, 1987, Strumpfer, 1990) posit that Kobasa’s
(1979,1982) research including her work with her colleagues namely, Kobasa, Maddi and
Zola (1983) may contain certain shortcomings.
A possible shortcoming in the studies conducted by Kobasa and her colleagues, is the
lack of female representation in the research samples. In discussing the methodology used
in their studies (Kobasa, 1979, 1982; Kobasa & Puccetti, 1983) indicate that the
executive subjects tested were ‘exclusively white and male’.
In reviewing Kobasa’s
earlier research, Pines (1980) states that Kobasa’s studies were conducted mainly on
male subjects. A more recent study (Sheppard & Kashani, 1991) revealed that the
components of Control and Commitment predicted health outcomes for males but not for
females. This finding indicates that gender differences may exist regarding the
relationship between hardiness and health.
Sheppard and Kashani (1991) studied the relationship between psychological hardiness
and the experience of a variety of dysfunctional symptoms in male and female
adolescents. Gender was included as a variable to explore possible gender differences in
the influence of the three hardiness components. The sample consisted of 150
adolescents, namely 75 males and 75 females. The subjects were administered the
Hardiness Scale and the Diagnostic Interview for Children and Adolescents test which
served to measure dysfunctional symptoms as well as stress levels. Stress levels were
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measured by 14 items in the Diagnostic Interview for Children and Adolescents test. The
dysfunctional symptoms consisted of anxiety symptoms, eating disorder symptoms,
psychotic symptoms and delusional symptoms.
The results reported that the hardiness component of Commitment appears to play a
different role in the stress/illness relationship for males and females. For males, high
Commitment scores were associated with fewer somatic problems under extremely
stressful conditions. For females, high Commitment scores were associated with fewer
somatic problems under less stressful conditions. In support of gender differences
regarding hardiness and health, Schmied and Lawler (1986) suggest that hardiness may
be related to health outcomes among males but not among females. However, Rhodewalt
and Zone (1989) found that hardiness predicted both physical and mental health among
women.
In evaluating the study, Sheppard and Kashani (1991) state that most hardiness studies
have relied on self-report instruments to assess health status rather than utilizing
physiological measures. Sheppard and Kashani (1991) state that there is evidence that
self-report measures of illness reflect negative affectivity and are not related to long-term
health status, bringing into question previous studies (for example Kobasa, 1979,1982)
regarding hardiness. After analyzing the three hardiness components used in (Kobasa,
1979; Kobasa et al. 1982; Kobasa & Puccetti, 1983), Hull et al. (1987) contend that
hardiness is not a unitary phenomenon in that the sub-scale of Challenge appears to have
very little explanatory power in health outcomes.
Funk and Houston (1987) tested the hardiness hypothesis by replicating previous studies
(for example Kobasa & Pucetti, 1983) conducted by Kobasa and her colleagues. The
subjects consisted of 120 male students. The reason for choosing only male subjects was
to ensure consistency with previous studies on hardiness and stressful life events. The
measurement instruments consisted of The Life Experiences Survey (measuring stressful
life events), the Hardiness questionnaire (Kobasa & Puccetti, 1983), and two measures of
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maladjustment, namely the College Maladjustment Scale and the General Maladjustment
Scale. Health status was measured by using the Health Problems Questionnaire and the
Health Record Form. A Beck Depression Inventory test was used to measure the degree
of depression. A factor analysis was conducted on the hardiness sub-scales.
The results reported significant correlations between the hardiness and maladjustment
measures suggesting that the concept of hardiness in not well operationalized on the
Hardiness Scale used by Kobasa, (1982) and Kobasa and Puccetti (1983). Strumpfer
(1991) states that the Hardiness Scale only provides negative indicators, namely
alienation from self and work, need for security, powerlessness and external locus of
control. These negative indicators may have influenced the finding that significant
relationships were found between hardiness and the two measures of maladjustment used
in the study. The results also suggest that hardiness may not be a unique dimension of
personality but another expression of maladjustment.
Funk and Houston (1987) recommend that future research focus on specific components,
namely Commitment, Challenge or Control and place less emphasis on the overall
hardiness scores. Funk and Houston (1987) postulate that previous hardiness research
contains insufficient empirical support for the hypothesis that hardiness buffers the
effects of stressful events.
In conclusion, hardiness research provides an important basis for understanding how
individuals who are confronted by stress can remain healthy (Marais, 1997). Although
some studies have failed to provide support for the buffering role of hardiness (for
example, Funk & Houston, 1987), it remains difficult to adequately compare these studies
due to some of the differences in the measurement instruments that the studies utilized
(Strumpfer, 1990).
Sheppard and Kashani (1991) recommend that future hardiness
research include gender as a variable and that physiological or medical tests should
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accompany self-report measures of health status. Despite some of the equivocal findings
in the literature, the hardiness construct is still widely recognized as part of the
salutogenic paradigm but its operationalization remains a concern (Strumpfer, 1991).
The following section discusses another salutogenic construct that has received a great
deal of attention in the literature namely, that of Rotter’s internal and external locus of
control.
3.2.2
LOCUS OF CONTROL
In one of his earlier works, Rotter (1954) introduced social learning theory which
provided the foundation for the development of the locus of control construct. After
extensive research regarding the social learning theory concepts namely, the role of
reinforcement, regard and gratification, the locus of control construct was developed by
Rotter (1966) at the University of Connecticut. Section 3.2.2.1 commences with a
definition of internal-external locus of control and discusses the locus of control
construct. Section 3.2.2.2 examines the role of locus of control in stress and coping.
3.2.2.1 THE LOCUS OF CONTROL CONSTRUCT
In his classical work, Rotter (1966) states that individuals who perceive that a
reinforcement in not contingent upon their own actions but as a result of luck, fate or
chance have an external locus of control. Individuals who perceive that reinforcements
are contingent upon their own actions or behaviour have an internal locus of control.
Locus of control thus refers to the beliefs concerning the control over reinforcements
(Bothma & Schepers, 1997). Brunas-Wagstaff (1998) describes locus of control as a
cognitive style, with reliance on external or internal cues resulting in attributional
judgements relating to the causation of events. According to De Wet (1990) locus of
control is not an expectation regarding a certain type of reinforcement but a generalized
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expectancy of ‘problem solving’. Hammerschlag (1984) states that the concept of locus
of control relates to expectancies concerning the outcome of actions.
Bothma and Schepers (1997) contend that the most frequently used locus of control
measurement is the Rotter International Internal-External Control Scale devised by Rotter
(1966). However, many alternative measures have been created that relate to the original
locus of control construct. Ashkanasy (1985) indicates that an important issue in locus of
control literature concerns the generalizability of locus of control expectancies.
Generalizability refers to the universality of the expectancies measured by the Rotter
(1966) Scale. Thus a locus of control measure could be formulated and used to reveal
perceptions of control in specific areas for example, measures of Marital Locus of
Control, Health Locus of Control and Weight Loss Locus of Control (Mayer & Sutton,
1996).
The Bothma and Schepers (1997) study is an example of how the locus of control
construct can be applied in a specific area, namely in an occupational setting. The
objective of the study was to predict the work performance of Black managers. An
alternative to the Rotter International Internal-External Control Scale was used, namely
the Locus of Control Inventory devised by Schepers (1995). The other two instruments
used were the Achievement Motivation Questionnaire (Pottas, Erewee, Boshoff &
Lessing, 1988) and the Performance Appraisal Questionnaire (Schepers, 1994).
A
sample comprising of 102 Black male employees in junior or middle management
positions completed the three questionnaires.
After statistical analysis, results indicated that managers with high internal Locus of
Control scores are found to be better performers, however the evidence that internal
control can be associated with more effective performance in managers is not conclusive.
Future replications of the study could include a larger sample to cross validate the
findings of the study (Bothma & Schepers, 1997).
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Several authors in the literature (for example Erwee et al, 1982; Pratt, 1987; Saleh &
Desai, 1990; Venkataphathy, 1984) not only reveal how the Locus of Control construct
can be applied to measure areas like work performance and achievement, but contend that
a strong internal Locus of Control reduces the negative effects of job stressors.
The
literature also provides evidence that locus of control acts as a mediator influencing the
relation between life stressors, coping and health (Parkes, 1984).
3.2.2.2 LOCUS OF CONTROL, STRESS, COPING AND ILLNESS
The locus of control construct has often been compared to Antonovsky’s (1987b) sense
of coherence construct, in that both constructs pertain to the individual’s perception of his
or her external and internal environment (Kalimo & Vuori, 1990; Sullivan, 1995).
Antonovsky (1991) emphasizes that although the locus of control construct was not
originally intended to measure coping resources, it has frequently been used in studies
regarding stress-related coping, health and well-being.
What role does locus of control play in coping with stress and the maintenance of health?
Levenson (1981) states that the concept of locus of control is particularly pertinent to
health behaviours. Burger (1992) provides an example of ‘health behaviour’ by stating
that individuals with an internal locus of control exhibit the need to control by taking
action when confronted with stress. Even if the action is ineffective, there is a feeling of
being able to cope or deal with the problem rather than becoming resigned and helpless
(Burger, 1992). The classical work of Strickland (1978) entailed a review of previous
studies on internal-external locus of control expectancies and health behaviours and
attitudes.
It was reported that individuals with an internal locus of control are more
likely than individuals with an external locus of control to engage in information seeking
regarding disease and health maintenance when relevant to their own wellbeing. These
behaviours were classified as problem focused within the theoretical framework of stress
and coping.
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Peacock and Wong (1996) examined locus of control beliefs and optimism as predictors
of control appraisals and coping associated with various anticipatory stressful events.
The sample consisted of 118 undergraduates who completed measures of locus of control
(Rotter I-E), optimism (Life Orientation Test) and control appraisals using the Stress
Appraisal Measure. Regression analyses revealed that optimism and locus of control were
relatively independent predictors of control appraisals. It was also found that control
appraisals were better predictors of coping than optimism or locus of control. Peacock
and Wong (1996) indicate that a limitation of the study was that the stressful events
presented to the subjects were hypothetical and may not have resulted in an accurate
reflection of how the subjects would have reacted in real stress-related situations.
Parkes (1984) studied locus of control and coping processes in relation to certain stress
related events reported by 171 female student nurses. The measurement instruments
included the General Coping Questionnaire, the Direct Coping and Suppression
Questionnaire and the Rotter (1966) Locus of Control Scale. The subjects had to recall
previous stressful events and record their coping responses and behaviours on the answer
sheets.
The results reported significant interactions between locus of control and appraisal for
each of the measures. The results further showed that patterns of coping for subjects with
high internal locus of control scores were potentially more adaptive in relation to
appraisal styles of subjects with high external locus of control scores. The results are thus
consistent with the view that locus of control acts as a mediator between stress and
mental and physical health status and is derived mainly from the different ways that
individuals with high internal or high external scores perceive the stressors that they
encounter (Parkes, 1984). A limitation of the study is that the sample did not contain male
subjects, resulting in a lack of clarification as to whether males and females would have
responded in the same manner regarding the locus of control scores.
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Many authors in the literature (for example Holahan & Moos, 1985; Singh, 1999) support
that individuals presenting an internal locus of control utilize resources more effectively
in order to cope with stress. Individuals with a strong internal locus of control are not
only more likely to seek social support when dealing with stress, but are more effective in
attaining social support since they tend to be more socially aware, are better at problem
solving and display the ability to interpret social cues (Mayer & Sutton, 1996).
The aforementioned research indicates that individuals with an internal locus of control
adapt and cope better with stressors, but are they healthier than individuals with an
external locus of control? Mayer and Sutton (1996) state that given the research findings,
there is little doubt that individuals with an external locus of control are more likely to
suffer from depression. Ganellen and Blaney (1984) found that individuals with strong
beliefs in chance and who exhibited high levels of stress revealed the greatest
vulnerability to depression. Everly (1990) states that stress, bereavement and depression
have been revealed to be clinically significant immunosuppressors. The ability to exert a
sense of control over the stressor has shown to mitigate immunosuppression
(Everly,1990; Singh, 1999).
Singh (1999) investigated whether women with breast cancer experienced stressful life
events preceding the onset of the disease and whether the same individuals exhibited a
low internal locus of control orientation. The results confirmed the hypothesis that
individuals with breast cancer had experienced a significantly higher frequency of
cumulative life events and high stress ratings, including a lower internal health locus of
control. The study supports the view that internal locus of control is associated with more
adaptive coping, also mitigating the effects of stress. This finding emphasizes the
‘holistic’ care of patients whereby both pathogenic and salutogenic approaches could be
combined as a source of etiology, prevention and treatment.
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Although the aforementioned authors contend that having control in adverse situations is
stress reducing, Folkman (1984) states that the obverse could be true. This has been
found in patients with coronary-prone Type A behaviour who were counselled to control
their behaviour by becoming less driven and competitive in order to reduce the risk of
illness. However, to do so the individual needed to act against his or her values thus
leading to a loss of self-esteem, increased distress levels and decline in job productivity
(Folkman, 1984; Mills & Kranz, 1979).
Antonovsky (1991) also emphasizes that the
individual’s values and beliefs can influence locus of control, positing that although an
internal locus of control is considered a salutogenic strength, it should also be considered
in the context of its sociocultural sources. Arab cultures for example, may be influenced
by religious convictions that a higher power or fate determines their existence and thus
have a greater tendency to present an external locus of control (Antonovsky, 1991).
To conclude, locus of control is best viewed as a cognitive mediator of a stressful
transaction with the outcome being largely dependant upon the individual’s adaptation to
the situation. Studies in the literature (for example Folkman, 1984; Furnam, 1983) report
that perceptions of control may be shaped by generalized values, cultural beliefs or by
situational contingencies and should be considered in the context of a specific stressful
situation.
External locus of control has been associated with depression, anxiety and physical
illness. An internal locus of control has been referred to as a salutogenic strength due to
its association with positive coping resources and a greater resilience to illness. The locus
of control construct is thus recognized in the literature as a measure of coping resources
and has frequently been used in studies regarding stress, health and well-being.
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3.3
CHAPTER SUMMARY
The objective of this chapter was to conduct a literature review of the salutogenic
approach to stress and coping. Included in the salutogenic approach were three
salutogenic constructs known as sense of coherence, locus of control and hardiness. The
first section of the chapter dealt with Antonovsky’s (1987b) concept of salutogenesis
which refers to the origin of health and relates to how certain individuals cope
successfully with stress. The salutogenic model of health revealed how the individual
may be located on a ‘health dis/ease continuum’ depending on how he or she utilizes
generalized resistance resources which facilitate coping with a wide variety of stressors.
The sense of coherence construct and its three components namely, Comprehensibility,
Manageability and Meaningfulness were discussed and Antonovsky’s hypothesis
suggesting that the individual with a strong sense of coherence is likely to be healthier
was examined by referring to various studies in the literature.
In discussing the hardiness construct, Kobasa’s earlier research was analyzed providing a
background as to how the hardiness construct came to be formulated. The three
components of the hardiness construct, namely Commitment, Control and Challenge
were examined. The hardiness construct was then critically evaluated by reviewing
various studies in the literature. A few studies in the literature (for example, Funk &
Houson, 1987) failed to show the expected relationship between hardiness and health. It
was found that most of Kobasa’s (Kobasa, 1979; Kobasa et al. 1982; Kobasa & Puccetti,
1983) earlier works included only male participants. Various studies (for example
Sheppard & Kashani, 1991) report that gender differences may exist regarding the
relationship between hardiness and health. Future research pertaining to hardiness and
coping should include gender as a variable (Sheppard & Kashani, 1991).
The locus of control construct mentioned in Rotter’s (1966) classical work, has been
widely used in personality research.
A strong internal locus of control has been
associated with the positive coping in stress and illness, whilst a strong external locus of
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control is frequently associated with maladaptive coping patterns, namely depression,
anxiety and physical illness. The locus of control construct has been used to reveal
different perceptions of control, for example measures of Marital Locus of Control and
Health Locus of Control. Many authors in the literature (for example Holahan & Moos,
1985; Singh,1999) support that individuals with an internal locus of control use resources
for effectively to cope with stress.
Strumpfer (1990) posits that with the similarities in the salutogenic constructs, the
emergence of a new paradigm appears to be valid. The integration of all the salutogenic
constructs and the resulting research has revealed that a complimentary union of social
science and medicine is feasible, notwithstanding the disparate philosophical roots of
both disciplines. This exemplifies the growing awareness that stress related diseases and
maladaptive coping styles need to be treated from both the psychological and
physiological perspectives. Certain studies (for example Sheppard & Kashani, 1991)
mentioned in this chapter revealed that there may be differences in the way that men and
women cope with stress.
The following chapter compares various coping resources used by men and women.