Sense of Coherence: Learning to live with chronic illness through health education

Abstract

Objective:

This study examines people’s experiences of how to live with a chronic disease, their learning needs and their reasons for participating in a health education programme. The aim of the study was to examine if and how a Sense of Coherence (SOC) might guide an understanding of learning processes in health education.

Methods:

This study has a qualitative study design with data collected through five group interviews. Interviews were analysed using qualitative content analysis to identify principal categories of response. Directed content analysis was then used to reference the categories emerging in the first step to the study’s theoretical framework.

Results:

Three main categories were found: (1) the ability to cope with daily life, (2) assets for a better life both in the present and for the future, and (3) the need for knowledge. A synthesis of empirical findings with reference to the first stage of analysis, the three main aspects of learning, and the three dimensions of a SOC revealed that a SOC may be useful in guiding an understanding of learning processes in health education as a life-oriented mastering resource.

Conclusion:

SOC offers a useful framework for informing health education. Research is needed to deepen an understanding of how salutogenic theory can strengthen the development of health education programmes and understanding of participants’ learning.

Keywords

Chronic disease coping health education learning Norway salutogenisis

Introduction

To confront the increasing incidence of chronic disease, Norwegian health authorities have established about 60 local Learning and Mastery Centres. The purpose of these centres is to facilitate learning and mastery for people affected by chronic disease (National Resource Centre for Learning and Mastery, 2011). Learning and Mastery Centres are based on the recognition that medical treatment, training and mastery are equally important in solving health problems, and an active learning approach is emphasised in managing disease. The planning, implementation and evaluation of the courses provided by these centres should be performed jointly by users and professionals, as an assumed equality of professional and lay knowledge is a key principle underpinning the work of the Learning and Mastery Centres.

Health education strategies are often rooted in a biomedical framework (Whitehead, 2003) and have primarily been concerned with knowledge of the effects of risk behaviour (Jensen, 2009). Hoving et al. (2010) claim that there is increasing demand for health education. A systematic literature review conducted by the National Board of Health in Denmark in 2009 (Sundhedsstyrelsen [National Board of Health], 2009) indicates insufficient knowledge about effective and sustainable health educational interventions. The terminology and methodological approaches used in health education are also often confusing (Fitzpatrick and Tinning, 2014) and according to Gard and Leahy (Fitzpatrick and Tinning, 2014) frequently consist of accumulating knowledge and from past and present experiences. The educational aspects of health education are not that well described in research or in patient education (Deccache and Van Ballekom, 2010; Grabowski et al., 2010).

In this paper, using data from group interviews (GIs) with people with chronic disease just about to start a health education course, we analyse if and how a Sense of Coherence (SOC) may guide an understanding of learning processes in health education.

Salutogenesis

Salutogenesis refers to a model of health, the core concept of SOC and, a life orientation (Mittelmark and Bauer, 2017). Salutogenic theory, as introduced by Antonovsky (1987), represented a shift in focus from a disease orientation to a focus on mastering and promoting health (Koelen and Lindström, 2016; Pelikan, 2017; Rootman et al., 2000). According to Antonovsky (1987), the world is a complex place and the normal condition of life is one of chaos and change. A salutogenic approach focuses on the resources for coping with illnesses and learning for health (Antonovsky, 1987). This is in accordance with the aim and the principles of the Learning and Mastery Centres where mastery and successful coping are stressed (Førland and Ringsberg, 2013). A salutogenic approach, with its focus on the origins of health, centres on the identification and use of psychosocial resources for health and well-being (Dietscher et al., 2017; Lillefjell et al., 2017; Lindström and Eriksson, 2010). Its focus is on how people are able to maintain and develop their health, and the factors promoting positive movement in the direction of health (Eriksson, 2017). A salutogenic approach focuses on problem solving, the identification and use of general resistance resources (GRRs),¹ the facilitation of a health-promoting lifestyle and the overall capacity for this engagement in the form of a pervasive SOC.

According to Antonovsky (1987), an individual’s ability to cope with stressful life events depends on his/her SOC, which includes the three dimensions comprehensibility, meaningfulness and manageability. Comprehensibility is the cognitive dimension. It describes the ability to cognitively understand the stimuli one is exposed to and assess their reality. Meaningfulness is the motivational dimension of a SOC. It involves a cognitive and emotional assessment of the value of investing energy and time in the challenges of managing a chronic disease. Manageability is the capacity to cope with a situation, which means that a person has adequate resources to maintain and develop his/her health. According to Antonovsky, SOC occupies a key position within the salutogenic model (Mittelmark and Bauer, 2017).

GRRs are essential to the development of a SOC, while a SOC provides the capability to use the GRRs that are available. A person’s ability to comprehend the situation they find themselves in and their capacity to access and use available resources has an impact on his/her coping approach. An individual’s motivation to invest effort and energy in a health-promoting way (meaningfulness) depends on their ability to understand the situation (comprehensibility) and the resources available (GRRs) to meet the challenges (manageability) in their daily lives.

Learning

Learning is a complex phenomenon and can be described from different perspectives (Illeris, 2008). No single learning theory encompasses all the aspects of learning, and in recent years, a multifaceted understanding of learning, including both its cognitive and its socio-cultural perspectives, has emerged (Knowles et al., 2011). According to this approach, learning is best understood as an active process of construction and the individual’s life-world provides the basis for their understanding, thinking and action (Mezirow, 2008). Learning consists of content-related, interaction-related and driving force-related dimensions (Illeris, 2008). The content aspect implies a focus on the relationship between the intended learning content and the participant’s prerequisites for learning. The interaction-related aspect refers to the learner’s opportunities for involvement and engagement. To date, most attention has to be paid to the individual’s driving forces for learning, which means emphasising the participant’s motivation and experiences as a resource for e learning through dialogue (Illeris, 2008). Learning is a meaning-making constructive process involving new or modified interpretations of perceptions and experiences (Mezirow, 2008). The assessment and reformulation of what Mezirow (2008) termed ‘meaning perspectives’ is a core activity in learning. Meaning, knowledge and understanding are created through interaction with people and the environment. Because people’s experiences are a key element in adult learning, learning requires involvement and participation (Knowles et al., 2011).

According to Antonovsky (1987), a SOC is crucial when it comes to the individual’s ability to manage life and promote health. A strong SOC leads to better perceived health and quality of life (Eriksson and Lindström, 2007). However, research exploring salutogenesis in relation to educational settings is sparse. To promote learning related to strengthening a SOC, we need to understand more about how participants’ experiences and learning needs link to a SOC, that is, what participants themselves bring to the concept SOC, when attending a health education programme such as those provided at Learning and Mastery Centres.

Aim of the study

The aim of the study was to examine if and how a SOC may guide an understanding of learning processes in health education.

Methods

Study context and design

The study was conducted at a medium sized Learning and Mastery Centre in Norway offering 25 different courses related to chronic diseases. The majority of these courses were similar in design to those given by Centres in other parts of the country, with course plans sharing a common structure and educational approach.

Courses were of 7 hours duration and were delivered in groups over 2 days. Participants received details of the course in advance. The course plans were constructed around a specific diagnosis, available treatment, possible complications, physical training and the sharing of experiences. Some course plans contained lessons on diet and nutrition, and three course plans included lessons on social security benefits. Practical topics such as injection techniques for people with diabetes were also included.

A qualitative design was used in order to capture participants’ own experiences and perceptions about health, illness, learning and mastery and how to use the Learning and Mastery Centre in this matter (Hsieh and Shannon, 2005). GIs were used in order to generate a wider range of responses, experiences and perceptions than individual interviews might achieve (Cohen et al., 2013).

Data collection

GIs took place with participants from five courses. The interviews were conducted by the first author (G.F.) over a 3-month period during 2006 and took place 2 hours before the participants joined the first day of their course. We chose to interview the participants in advance, as we wanted to elicit their perceptions before they commenced the course. GIs lasted on average of 1.5 hours and were semi-structured and informal in style. The main topics included in the GIs were participants’ experiences and perceptions about health, illness, learning and mastery, and how they thought they could use the Learning and Mastery Centre in this matter. Questions asked were primarily open-ended and included follow-up questions to probe in more detail participants’ perceptions. In particular, participants shared their experiences related to their health condition and their learning needs, as well as their reasons for attending a health education programme. Salutogenesis was not explicit mentioned in the interviews. The focus on a SOC related to the second stage of analysis.

Participants

Participants in the study were selected from courses provided by hospital trusts in all the health regions of Norway. Courses were selected in collaboration with the leader of the Learning and Mastery Centre and were related to the diagnosis of asthma, type 2 diabetes, heart disease, kidney disease and Crohn’s disease. Staff asked for permission to send out written information about the study together with the course plan to people who had expressed an interest in participating in one of the five courses. From a total of 38 people invited to the GIs, 20 persons attended. To protect participant confidentiality, all the names in this article are fictitious. For the principal characteristics of participants, see Table 1.

Table 1.

Participants in the group interviews (GIs).

Groups	Number of course attendees	Number of GI participants	Gender (men/women)	Age (mean)	Duration of disease (years)
Asthma	10	6	0/6	35–68 (58)	1–30
Diabetes II	9	4	2/2	45–81 (56)	<1–10
Heart disease	12	4	3/1	47–74 (56)	<1–11
Kidney disease	5	2	1/1	48–55 (51)	<1>
Crohn’s disease	10	4	1/3	35–53 (47)	7–30

Analysis

Interviews were tape-recorded and, transcribed verbatim. The analysis took place in two steps. Initially, interviews were analysed using qualitative content analysis with a focus on the latent content of the interviews (Graneheim and Lundman, 2004). The transcripts were read and re-read many times to develop an overview. Elements of text were then extracted and brought together with reference to the topics focused on in the GIs and participants’ experiences related to their condition and their learning needs as well as their reasons for attending a health education programme. Quotations were condensed into meaning units and abstracted into sub-categories and categories (see Table 2 for an example).

Table 2.

An example of the first step of analysis.

Meaning unit	Condensed meaning unit	Sub-category	Category
Magda (Mb Crohn GI): If you’re on a coach trip and they say they’re closing the toilets you feel (laughing as she speaks) that you have to go (the others are in agreement – yes, yes). So you really get in a panic.	Because of the lack of bowel control no access to toilet causes stress	Bodily symptoms influence daily life	Ability to cope with daily life.
Daniel (Diabetes GI): (talking about his knowledge needs) … ‘A bit about how diabetes can develop; in relation to the stage you’re at now and onwards. How rapidly it will develop, for example. Can the condition be limited? … It’s always at the back of my mind (laughs)’.	The development of the diabetes and how the late effects can be limited is always at the back of your mind.	Willingness and capacity to develop coping skills related to promoting health	Assets for a better life in the present and for the future
Lilly (Asthma GI): ‘So I’ve been allergic for quite a long time and it’s their connection with each other (asthma – allergy) that I’d like to know about’.	The need for knowledge about the link between asthma and allergy	Symptom-related knowledge	Need for knowledge

At a second stage of analysis, directed content analysis inspired by Hsieh and Shannon (2005) was used to examine if and how a SOC may facilitate understanding of the learning processes involved in health education. With reference to learning theories, Biesta et al. (2011) claim that there is a need for research that focuses on how theories ‘work’, that is, on what implications the theory may have in practice. A strength of directed content analysis is that through it existing theory can be supported and extended (Hsieh and Shannon, 2005). In this second stage of analysis, the categories emerging at the first step and the theoretical framework with reference to the three main aspects of learning described by Illeris (2008) and the three dimensions of SOC (Antonovsky, 1987) represented the units of analysis.

Trustworthiness

The theoretical framework the analysis built on, as well as the study context and the participants, are carefully described to enhance trustworthiness. G.F. had main responsibility for the analysis. However, all authors contributed to the analysis, the results and the writing in an iterative way. The use of multiple researchers from different backgrounds (education, nursing, social science, health promotion) provided a form of triangulation and added to trustworthiness. To facilitate the reader’s evaluation of the credibility of the findings, quotations from the interviews are provided in the text (Graneheim and Lundman, 2004).

Ethics

The study was conducted in accordance with the ethical procedures of the Declaration of Helsinki (World Medical Association [WMA] Declaration of Helsinki, 2010). Participants received verbal and written information about the study in advance and signed an informed consent form. Participants were informed that their participation in the study was voluntary, and they had the right to withdraw at any time (WMA Declaration of Helsinki, 2010). The study was approved by The Regional Medical Research Ethics Committee of Western Norway (ref. number 197.05). For confidentiality reasons, the participants are assigned pseudonyms in this paper.

Findings

First step of analysis

Findings from the GIs showed how participants expressed their experiences and learning needs emanating from their daily lives. Their need for knowledge was related to their individual symptoms and the characteristics of their particular condition. They expected that the course contents would be linked to the troubles and challenges they faced in daily life. Results are described under three headings: ‘The ability to cope with daily life’, ‘Assets for a better life in the present and for the future’ and ‘The need for knowledge’. Seven sub-categories related to these three major categories are shown in Table 3.

Table 3.

Sub-categories and categories emerging in the first step of the analysis.

Sub-categories	Categories
Bodily symptoms’ influence on daily living The influence of climate on daily life	Ability to cope with daily life.
Willingness and capacity to develop coping skills related to bodily symptoms Willingness and capacity to develop coping skills related to social coping Willingness and capacity to develop coping skills related to promoting health	Assets for a better life in the present and the future
Symptom-related knowledge Practical knowledge	Need for knowledge

The ability to cope with daily life

Findings show that participants experienced varying ways of coping in their daily lives, as different conditions invoked different relationships between stimuli and symptoms. Lack of control was associated with bodily symptoms especially in chronic disease, asthma and kidney disease, as well as limitations in daily life related to climatic conditions.

Bodily symptoms’ influence on daily living

Some participants indicated how bodily symptoms’ had an influence on daily living, thus making life unpredictable. Participants with Crohn’s disease experienced the symptom of lack of bowel control as if they were losing control of their lives. Having the urgent need to go to the toilet and not being in control was perceived as especially stressful:

If you’re on a coach trip and they say they’re closing the toilets you feel (laughing as she speaks) that you have to go (the others are in agreement – yes, yes). So, you really get in a panic. (Magda, Crohn’s disease GI)

Participants with Crohn’s disease also noted how taboos around a lack of bowel control could lead to embarrassing situations. The general strategy was to avoid social settings, with social isolation as a consequence:

The thing is we can’t control Crohn’s disease. (Marit, Crohn’s disease GI). (The others nod their heads in agreement). – It controls our daily lives. (Mona, Crohn’s disease GI)

Both participants in the kidney disease GI discussed fatigue and low energy as symptoms of kidney failure. One participant also felt that the disease was controlling much of her life:

Yes, much of it. But I can joke about it and make it go away (laughs) sort of humorously. But it does: day-to-day life. Yes, it does. … I fancy doing other things; like not just living for this disease really. (Nina, Kidney GI)

Asthma GI participants’ ability to cope with daily life was influenced by their lack of understanding of the connection between asthma and allergies. When this connection was not known, the symptoms were not understood. They referred to coping as being able to use their knowledge of the triggers of their allergic reactions and having appropriate medications to engage in risk management. This level of control allowed participants to decrease their limitations and increase their ability to cope:

I control the asthma. I do what I want. … I’m now allergic to cats, but I now have a cat because it’s nice. I’m ill regardless. (Line, Asthma GI)

The influence of climate on daily life

Participants discussed the challenges of managing their health when climate conditions influenced their daily life by setting limitations, particularly in the winter. Activity was important for people with diabetes and heart disease, but was limited by icy roads during the winter:

But this winter I haven’t been all that good at going for walks because of the weather, the weather and wind, so. (Dina, Diabetes GI)

I feel resigned to still being set back a lot, so I’ve had an extreme reaction and don’t risk anything. I can’t deal with the cold. (Harry, Heart GI)

Persons with asthma also often reacted to moisture and cold air:

We’re living in entirely the wrong place. Here in Western Norway is the worst place to live for asthma. (Lise, Asthma GI)

Assets for a better life in the present and the future

Results showed that the motivation for attending a course was closely associated to accessing the resources needed to master symptoms and developing coping skills.

Willingness and capacity to develop coping skills related to bodily symptoms

Participants with asthma expressed the belief that by knowing the triggers for their allergic reactions they would be able to minimise their exposure to symptom-causing factors and optimise their medication. This would in turn contribute to their capacity to find more appropriate strategies for coping with daily life and adopt a health-promoting lifestyle. In contrast to this, participants in the kidney diseases GI perceived that they had little influence on their situation. They seemed somewhat exasperated with the fact and had put their lives on hold. Nina’s coping skills to combat bodily symptoms were closely linked to the hope for a possible future transplant:

So maybe afterwards I can have a better life. But I find it (pause) a bit scary, really, what I’ll (hmm) have to go through. Still, they say it’ll be mostly fine. (Nina, Kidney GI)

Willingness and capacity to develop skills related to social coping

Participants with Crohn’s disease focused on social mastery and the ability to understand physical symptoms, as this would provide them with fewer limitations in everyday life:

Mastering daily life, daring to go out, daring to mingle socially and thereby crossing barriers. Not shutting yourself in and not going round chronically frightened of everything that’s happening in your body; that something may be amiss or dangerous, or this or that. (Marit, Crohn’s disease GI)

Willingness and capacity to develop coping skills related to promoting health

Participants also focused on their health condition related to prospects for the future. For example, participants with heart disease considered living healthily in the present to be an investment in the future. Hallvard summed it up like this:

Getting some good advice so that you can live a few extra years. (Hallvard, Heart GI)

Participants with diabetes were concerned about controlling their blood sugar levels so as to prevent long-term damage. Awareness that managing diabetes in the present has effects in the future was a motivating factor in keeping blood sugar within normal levels:

(talking about his knowledge needs) … A bit about how diabetes can develop; in relation to the stage you’re at now and onwards. How rapidly it will develop, for example. Can the condition be limited? … It’s always at the back of my mind (laughs). (Daniel (Diabetes GI))

The need for knowledge

Study results showed that participants were in need of knowledge relating to their individual symptoms and the characteristics of their particular condition.

Symptom-related knowledge

Participants with asthma needed knowledge related to their symptoms as well as how asthma and allergies link together:

So I’ve been allergic for quite a long time and it’s their connection with each other that I’d like to know about. (Lilly, Asthma GI)

Participants also expressed the need for knowledge about bodily signs. Both participants with Crohn’s disease and participants with heart disease were concerned with the need to understand bodily symptoms in order to reduce their anxiety:

I can also think a bit, you know, in medical and anatomical terms and I … that you know what’s happening in your body … So when your stomach swells up, you’re not running around thinking, ‘Yikes, I’m bursting!’ you see? Sure, it’s dangerous; I’ve got volvulus now. So you don’t get needlessly anxious. (Marit, Crohn’s disease GI)

Participants with heart disease were concerned about being able to distinguish the symptoms caused by heart disease from other more benign bodily signs:

However, if you have a good relationship with what it is, if you sort of get a bit of information that it isn’t unnatural to feel the odd twinge and so on. If you don’t know that and you get a twinge then it just makes you anxious because you know it’s a serious disease. (Hallgeir, Heart GI)

Practical knowledge

Interviews also highlighted participants’ need for practical knowledge related to the mastery of daily life. Participants in the diabetes group mainly expressed the need for practical knowledge of food preparation, meals and exercise in relation to blood sugar levels:

Doris:

How much activity you really need in order to keep it down a bit. But you know, it’s like Daniel says – about diet.

Daniel:

Yes and of course how often food should be taken relative to the level of activity.

Dag:

And above all, which food?

Second step of analysis

The empirical findings in the form of the three main categories emerging in the first analysis and the three main aspects of learning described by Illeris (2008) were used to explore if and how the three dimensions of SOC (Antonovsky, 1987) might guide the understanding of learning processes in health education (Table 4).

Table 4.

Second step of analysis. Categories from the first step of analysis and how they relate to main aspects of learning and to a sense of coherence.

Sense of coherence (Antonovsky, 1987)	Manageability	Meaningfulness	Comprehensibility
Aspects of Learning (Illeris, 2008)	Interaction	Driving forces	Content
Categories emerging in the first step of analysis	Ability to cope with daily life.	Assets for a better life in the present and for the future	Need for knowledge

SOC – a guide to understanding health education as a life-oriented mastery resource

The category ‘Ability to cope with daily life’ indicates that the participants’ ability to manage was influenced by their experienced bodily symptoms and climatic conditions. The interaction-related aspect of learning (Illeris, 2008) refers to the learner’s opportunities for involvement and engagement. From a salutogenic perspective, opportunities for involvement and engagement depend on the individual’s capability to use the GRRs that are available, that is, the resources within themselves and their environment to manage daily life. Facilitating a salutogenic approach to learning implies a focus on GRRs and elucidating the GRRs available. Learning is an adaptive process in the sense that people actively try to adapt to the situation (Knoop, 2008). Although it is difficult to do anything about a factor such as climatic conditions, it is important to focus on how to adapt to these in an optimal way.

The category ‘Assets for a better life in the present and the future’ indicates that participants adopted an approach to health education comprising something more than the driving forces for learning according to Illeris (2008). When Antonovsky (1987) talked about meaningfulness and driving forces, he was referring to the driving forces for life. According to Saugstad (2003), the most important aspect of people’s general action-oriented competence is their attitude to life, the ability to act and the belief that doing so actually helps. Participants’ attitudes to life in this study, that is, their dispositional orientation to life and SOC have an influence on how they adapt to their chronic disease condition and how they develop their own learning abilities. This aspect is included in the definition of health promotion proposed by Eriksson (2007: 943), which stresses the importance of integrating the contribution of a SOC for a positive health development and for health promotion.

The content aspect of learning implies a focus on the relationship between the intended learning content and the participant’s prerequisites for learning (Illeris, 2008). The category ‘Need for knowledge’ shows that participants who attend the same course share common challenges, but does not imply that participants share similar competencies in coping with these challenges. Barriers to healthy coping vary between individuals because GRRs are unequally distributed (Antonovsky, 1987). Furthermore, health is created in everyday life and therefore includes all aspects of living (Potvin and McQueen, 2007). An educational challenge is therefore how to make the course contents relevant for the group as well as for different individual learning processes, that is, how best to make the connection between the thematic content of the course and participants’ individual ‘life-world’.

Discussion

The aim of this study was to examine if and how a SOC may guide the understanding of learning processes in health education. The three categories emerging in the first stage of analysis captured participants’ experiences and perceptions of their learning needs. Our synthesis of the empirical findings from the first analysis and the three main aspects of learning described by Illeris (2008) and the three dimensions of SOC (Antonovsky, 1987), showed that a SOC can guide understanding of learning processes in health education as a life-oriented mastering resource.

Findings showed that participants were able to express their experiences and learning needs emanating from their daily life. Facilitating learning based on a salutogenic approach implies inviting learners to reflect on their own driving forces for learning and what the consequences of their own ‘meaning schemes’ are. A focus on learners’ driving forces related to meaningfulness and elucidating their resources concerning GRRs, should influence the learning content in an action oriented way. The ability to cope with daily life (action competence) depends on an individual’s meaning perspectives (comprehensibility) on the topic and the ability to use the internal and external resources available, that is, the learner’s experienced opportunities for involvement and engagement (manageability). According to Simovska (2007), a pedagogical approach based on an understanding of learning as a process that seeks to construct meaning and see a phenomenon from a different perspective would provide more health-promoting effects in the long run.

The aspects of learning (Illeris, 2008) and learning understood as a ‘meaning making construction process’ (Mezirow, 2008), are central elements of a SOC. Findings in this study suggest that meaningfulness comprises more than the driving forces for learning described by Illeris (2008). Crucially, a SOC should be understood as a existential orientation to life with a meaning broader than the three aspects of learning described by Illeris (2008). Antonovsky (1987) claimed that the individual’s real life experiences, mindset and social position have to be changed if a move in the direction of a stronger SOC is to take place. A health education programme organised according to meaningful learning and a SOC would probably have the potential to enhance peoples’ ability to learn and put knowledge into practice.

In a learning context, the most significant dimension of a SOC will depend a learner’s perception of their learning needs. The learner’s perspective determines what they learn (Biggs and Tang, 2007) and much learning involves a degree of relearning (Kolb and Kolb, 2005). Successful coping depends on a dynamic interrelatedness between the different dimensions contributing to a SOC (Antonovsky, 1987). Study findings showed that participants sometimes referred to health and life (i.e. used a health logic) and sometimes to disease and illness (i.e. a pathogenic logic). SOC can be learned and strengthened by interventions (Lindström and Eriksson, 2011).

Learning processes in health education informed by the notion of a SOC imply the use of a life-oriented approach that cannot be reduced to a set of skills. This has implications for the health professional’s own education and role (Lillefjell et al., 2017). A salutogenic approach to health education requires capacity building among professionals with respect to the nature (ontology, epistemology and methodology) of salutogenesis (Førland, 2014). The ontology associated with salutogenesis reflects a positive view in which people are seen as equal and mutually dependent, interacting with their environment (Antonovsky, 1987), and daily life is viewed as constantly changing (Antonovsky, 1987; Eriksson, 2017). This calls for a constructivist perspective of knowledge and learning – understood as an active construction process in which the individual’s life-world is understood as providing the basis for understanding, thinking and action (Eriksson, 2017).

Conclusion

Study findings suggest that a SOC offers a useful framework for guiding health education. A salutogenic approach to health education is a life-oriented approach, which builds upon participants’ experiences and their perceptions of learning. A salutogenic approach to health education implies promoting a greater SOC by focusing on participants’ generalised resistant resources as well as utilising resources within themselves and in their environment to develop their own health. As a SOC is so central to the individual’s ability to maintain and promote health, a salutogenic approach to health education should aim to strengthen a SOC and promote learning simultaneously, so that they mutually reinforce one another.

Footnotes

Acknowledgements

The authors wish to thank participants in the study.

Authors’ contribution

The first author was the moderator of the group interviews and had the main responsibility for the analysis. All authors continually discussed the analysis and the results and were involved in the writing.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

Notes

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