Abstract

This research has focused on the role of sense of coherence in perceived quality of life and mental health among adults identified with different levels of depression. The research is grounded in a mental health model stemmed from medical sociology, which focuses on the mass level health and coping mechanisms in diverse populations. In a mass-level study, a survey research design was selected for approaching participants and collecting information from 300 adults having depressive symptoms. More specifically, a cross-sectional design was employed for data collection. About seven months were consumed in compiling this research, out of which major time was spent in data collection. Findings of the study confirmed the anticipated outcomes as a sense of coherence positively predicted perceived quality of life and mental health among adults having depressive symptoms.

Key Words

Depressive Symptoms, Sense of Coherence, Quality of Life, Mental Health

Introduction

Health and illness are two major concerns of all medical professionals. Some give more importance to promoting health, whereas some others focus more on curing illness. In the center, the medical sociologist Antonovsky appeared with unique insights for dealing health-illness continuum from the salutogenesis model. In between health and illness, coping is the vital benefit of this perspective which at the same time ensures health and prevents possible illness. Instead of countering illness, it is more appropriate to promote health well before illness occurs and instead of curing illnesses, it is better to eliminate its causes through coping and careful prevention. These are major insights that the salutogenesis perspective offers for dealing with health and illness. Furthermore, the salutogenesis model of medical care and health promotion introduces the concept of a sense of coherence which is comprised of comprehensibility, manageability, and meaningfulness. Sense of coherence leads towards numerous positive health outcomes among normal groups and mental health patients at the same time. Existing indigenous research merely focused on the normal population instead of mental health patients or at-risk individuals. Even while studying the role of sense of coherence in depression, normal samples were taken for predicting depression through a sense of coherence (Antonovsky, 1979, 1984, 1996). Thus, in order to bridge this gap, the present study focused on the role of sense of coherence in the prediction of quality of life and mental health among depressive symptoms, contrary to the past research which used sense of coherence to predict depression among normal adults. 

In the health-disease, care-cure and prevention-intervention continuum, a sense of coherence focus on health, care and prevention, which ensures long-ranged strategic health gains (Antonovsky, 1979, 1987). A good deal of medical research confirms that a sense of coherence enhances the quality of life and mental health among individuals with different psychiatric disorders and psychological problems (Holmberg et al., 2004; Griffiths, 2008). Thus, enhancing the sense of coherence is linked with a higher quality of life and good mental health, and both of these are essential elements to help adults cope with their depressive symptoms (Fok et al., 2005; Richardson & Ratner, 2005). Thus on the basis of the insights gained from the existing literature, it is anticipated that sense of coherence is likely to positive predict quality of life and mental health among adults having depressive symptoms. World Health Organization (2005) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (p. 19). Sense of coherence is linked with both physical and mental health as well as health-related quality of life (Ware, 2006). However, a sense of coherence is more strongly related to mental or psychological health than physical health. Thus, in this research, the link between a sense of coherence and mental health is investigated. Besides this, researchers attempted to associate a sense of coherence with physical health-related quality of life and mental health-related quality of life. However, it was found to have a more consistent association with mental health-related quality of life (Flensborg-Madsenet al., 2005; Fok et al., 2005).

The concept of sense of coherence is a leading model of mental health which ensures health at a mass level. The facets of this model can be used to ensure well-being and reduce stress. This beyond individual-level interventions for coping with stressors, the sense of coherence is a macro-level mechanism to deal with health in the domain of medical sociology. The ideal integration of the components of the sense of coherence can be used to effectively reduce psychiatric symptoms and strengthen the health of people belonging to normal and clinical samples. Thus the uniqueness of this model is that it makes coping, recovery and ensures good health at the same time. Most models either help in coping or enable good health, but this model is a package to address both of these concerns Antonovsky, 1979, 1984, 1996).. The effectiveness of sense of coherence is proved in diverse populations (Bayard-Bur?eld et al., 2001; Forsga et al., 2000;  Kanhai et al., 2014; Mayer & Krause, 2011; Naaldenberg  et al., 2011; Kivima et al., 2002; Schumann et al., 2003).

Method

It is survey research conducted using a cross-sectional design (Shaughnessy et al., 2006). This research is carried out on a purposive sample of depressed adults. For this purpose, firstly depression subscale of DASS was administered on students from different universities situated in Islamabad and Haripur. This scale helped in identifying the adults having depressive symptoms and screening the others. Thus, a total of 300 adults with depressive symptoms were selected, and they were given the remaining scales to provide the information. Depressive adults were further divided into two categories of male and female adults. 

Data was collected from depressed adults through three scales. Firstly, the depression subscale of DASS (Lovibond & Lovibond, 1995) was used for screening of adults without depressive symptoms and identification of depressive adults. Thus a 7-items subscale facilitated the screening purpose. 

Specific cut off scores was used to categorize the adults along with different levels of depression. Adults with a mild level of depression were not included in the sample; however, adults with moderate and profound levels of depression were finally selected. Non-dressed adults were dropped at this stage, whereas every depressed adult was further given three scales measuring sense of coherence, quality of life and mental health. The first scale was the 13-items Sense of Coherence Scale (Antonovsky, 1993) with 26 items. World Health Organization Quality of Life Questionnaire (The WHOQOL Group, 1998)The scale scores were taken to measure low and high quality of life with low and high scores on the scale, respectively. The third important instrument in the study was the 12-items General Health Questionnaire (Williams, 1988)which provides information regarding the overall mental health of a depressive adult. Low and high scores on this scale provided information regarding the low and high mental health of adult participants, respectively. 

The research was executed in two cities in Pakistan. From both cities, only university students were targeted. Firstly, the brief introduction of the study and researchers helped in report building with potential participants. After report building, written informed consent was taken from all participants. Initially, DASS was given to each participant, and they were motivated that their level of depression would be communicated to them after the completion of the scale. At this stage, participants were identified with specific levels of depression. Those who were not meeting the specific criteria of depression were excluded from the study at the initial stage. However, as promised, they were informed they are non-depressed, and they do not need any sort of clinical assistance. When the linage of adults reached the desired level of depressed adults, further screening was stopped. Whereas the remaining depressive adults were further given three scales. After completion of the scales, the depressive adults were thanked for their cooperation. 

Results

After collecting the information, data analysis was carried out with SPSS-21. By using enter method of linear regression analysis, sense of coherence predicted quality of life and mental health among depressive adults. Before conducting regression analysis, correlations among variables were computed, and alpha coefficients were obtained in order to ensure the consistency of scale scores. Furthermore, skewness and kurtosis values were computed to confirm the normality of the data.




 

Table 1. Psychometric Properties of Variables

Variables	M(SD)	?	Min-Max	Skewness	Kurtosis	1	2	3	4
1.    Sense of coherence	50.43(9.85	.86	20-66	.25	.89	-	.55***	.44***	-.52***
2.    Quality of life	81.35(10.12)	.92	40-98	.89	.52		-	.47***	-.49***
3.    Mental health	28.69(7.23)	.82	12-55	.51	.26			-	-.50***
4.    Depression	16.74(6.52)	.91	15-21	-.75	.28				-

***p< .001

 




Pearson correlation indicates that sense of coherence is positively correlated with quality of life with r (298) = .55, p< .001 and mental health with r (298) = .44, p< .001 whereas negatively correlated with depression with r (298) = -.52, p< .001. Quality of life has positive correlation with mental health with r (298) = .47, p< .001 whereas negative correlation with depressionr (298) = -.49, p< .001. Mental health has negative correlation with depression with r (298) = -.50, p< .001.




 

Table 2. Linear Regression Analysis

	Outcome: Quality of life		Outcome: Mental health
Predictor	Model B	95%CI LL, UL	Model B	95%CI LL, UL
(constant)	61.71***	[58.84, 68.59]	20.04***	[15.58, 24.51]
Sense of coherence	.91***	[.75, 1.07]	.44***	[.31, .54]
R2	.55		.44
F	130.65		72.82***

***p< .001

 




Table 2 shows sense of coherence positively predicted quality of life F (1, 298) = 130.65, p< .001and mental health F (1, 298) = 72.82, p< .001 by explaining 10% and 15% variance respectively.  

Discussion

The study is inspired by the positive mental health movement, which emerged due to the rise of positive psychology in the current decades (Vazquez et al., 2009). Thus, instead of medical interventions for major depression, the study deals with positive measures for the depressive adults who have depressive symptoms but are not yet diagnosed with a major depressive disorder that requires rigorous prolonged treatment procedures once diagnosed. Thus, the study employed a sense of coherence that provides effective coping mechanisms for countering stressors and enhancing well-being (Nosheen, 2013) for the adults targeted in this research who have solely depressive symptoms at present but still have vulnerability for major depressive disorder. In this regard, a sense of coherence is a psychological shield that enhances health and buffers the negative impacts of stressors (Antonovsky, 1979, 1985, 1998). 

The findings share rich insights required for dealing with at-risk adults. It was hypothesized earlier that sense of coherence is likely to positively predict the quality of life among depressed adults. This anticipation is supported by the findings of the research. Thus, it is important to note that if the level of stress-buffer sense of coherence is enhanced among depressive adults, the perception of quality of life can be improved (Soderman et al., 2001). Perceived quality deficits in life are linked with the vulnerability of depressive symptoms at initial stages and major depressive at later stages if no measures are taken to enhance the perceived quality of life. In this scenario, a sense of coherence can be used as a superior coping facility which not only enhances the perceived quality of life (Eriksson et al., 2007) rather it also increases existing levels of mental health (Flensborg-Madsen et al., 2005). 

Likewise, the anticipation that a sense of coherence is likely to positively predict the mental health of depressive adults is proved by the findings (Ann et al., 2013). Rationally, the absence of mental health or the failure of the mechanism’s essentials for mental health leads to depression. If mental health is ensured, adults are less likely to suffer from depressive symptoms. Thus, instead of countering depressive symptoms through short-term interventions, it is more appropriate to eliminate the factors that lead to depression. Such preventive measures provide long-ranged benefits instead of tactical advantages. In this regard, a sense of coherence appears as a superlative predictor of mental health, which is considered an essential element for reducing the levels of depression among adults (Qudsia, 2014).

The existing body of scientific knowledge is evident on the role of low levels of perceived quality of life and low mental health in enhancing depression and vice versa. Sense of coherence enhances both of these factors essential for reducing depressive symptoms. Thus, according to the insights of the present study, a sense of coherence predicts high levels of quality of life and mental health, which in the long provides strategic benefits of dealing with adults with depressive symptoms who are at risk of major depression. Sense of coherence serves dual functions simultaneously, i.e. reducing stress and enhancing well-being through coping mechanisms (Richardson & Ratner, 2005). It offers positive preventions instead of interventions. Sense of coherence facilitates coping over cure, prevention over intervention and boosts health over countering disorders (Antonovsky, 1979). 

Although this research is a unique contribution to the existing body of scientific knowledge still the response biases, common method variance, and cross-sectional design with low internal validity are potential limitations in this study that can be addressed in future investigations. In future research, the inclusion of other at-risk groups can be valuable. Besides all these limitations, it is applied research that shares practical insights that can be used for dealing with at risk adults. More specifically, professionals from medical, health care, therapy and counselling are encouraged to focus on the sense of coherence as an integral part of their preventions and interventions for ensuring mental health and good quality of life. 

Conclusion

The insights that stemmed from the findings ensured that by enhancing the sense of coherence that instils stress-coping mechanisms, depressive adults’ perception of quality of life could be enhanced, and their mental health could be improved.

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