**Unni Karin Moksnes 1,2,\* and Geir Arild Espnes <sup>1</sup>**


### Received: 17 March 2020; Accepted: 18 April 2020; Published: 26 April 2020

**Abstract:** This study investigated the associations between sex, age, socio-economic status, stress, sense of coherence (SOC), and health (mental wellbeing, depressive symptoms, self-rated health, and subjective health complaints) in Norwegian adolescents aged 13–19 years. Furthermore, the study investigated the potential protective or compensatory role from SOC on the association between stress and health. *Methods:* The study was based on a cross-sectional sample of 1233 adolescents. Data were analyzed with descriptive, comparative, and multiple linear regression analyses. *Results*: Girls reported significantly higher scores on depressive symptoms and subjective health complaints than boys. Stress was significantly and positively associated with depressive symptoms. SOC associated significantly with all outcome variables; and especially with mental wellbeing and depressive symptoms. Significant interaction effects of sex in combination with stress and SOC were found in association with depression and mental wellbeing. Associations were strongest for girls. *Conclusion:* The findings provided support for the significant role of SOC as a coping resource, especially in relation to adolescents' mental health; weaker associations were found with subjective health complains and self-rated health. The findings also mainly supported a compensatory role of SOC on the association between stress and health during adolescence.

**Keywords:** subjective health complaints; self-rated health; mental health; stress; sense of coherence; salutogenesis; moderator

#### **1. Introduction**

A fair opportunity for every young person to reach their full health potential is a democratic goal for most societies, regardless of demographic, social, economic, educational, and cultural factors [1,2]. Hence, in order to promote positive development in adolescents it is important to investigate how adolescents evaluate their health, and what factors have the greatest impact on their health, as assessed through self-reports. This was also interesting in reference to the fact that young people especially during this period of life experience changes and transitions, which might influence their health and well-being throughout the life course [3,4].

In general, in Norwegian and most other Western societies, children and adolescents growing up today are characterized by good health and a high quality of life. However, self-reported mental health problems have increased in recent years, both globally and nationally and account for a large proportion of negative health outcomes in young people, in all societies [5–7]. In Norway, it is estimated that approximately one in five adolescents have mental health problems affecting their daily life and seven percent have symptoms that meet the requirements for a psychiatric diagnosis [8]. Mental health problems seem to be especially evident in girls, where the proportion of girls aged 15–20 years who are given a psychiatric diagnosis (most common problems are depression, anxiety, eating disorders, and behavioral disorders), has increased from five to seven percent per year, from 2011 to 2016. [8].

Adolescents typically have low rates of serious medical illnesses, but studies show an increase in reports of subjective health complains (SHC), especially among girls, during the adolescent years [9–12]. These complaints refer to mental and physical 'unexplained symptoms', often related to stress experience [9–12]. A well-used indicator to assess the overall perception of health status, is to ask people to self-rate their health (SRH) [13,14]. Previous studies suggest that adolescents' perception of health seem to be relatively stable during the adolescent years [13–16]. However, sex differences in SRH are often reported to increase with age, where especially girls seem to report more negative evaluations of SRH than boys [9–11,17–19]. There is evidence to show that this health deterioration, along with an increase in SHC, relates to a broad spectrum of medical, physical, psychological, and psychosocial factors, where an increased experience of multiple independent and cumulative stressors is recognized as one important factor [10,17,20,21]. Research shows that stress levels increase from preadolescence to adolescence, where girls report higher stressor load and seem to be more vulnerable to the negative psychological effects of stress than boys [4,20]. In order to promote positive functioning, health, and wellbeing in the adolescent population, it is important to gain a better understanding of how stress relates to adolescents' overall experience of health, as well as investigating the role of potential protective factors in this context. The concept of sense of coherence (SOC) is central in the exploration of what coping resources are crucial for the individual's capacity to cope with stressors in daily life and create health (salutogenesis) as a complementary approach to the traditional focus on risks for disease (pathogenesis) [22,23]. SOC is described as a personal coping resource and life orientation, which is recognized as the ability to perceive life as comprehensible, manageable, and meaningful, and the perception of having resources needed to cope with normative and non-normative stressors in daily life [22,23].

SOC is a central resource for the protection and promotion of health [24]. A strong SOC is associated with a positive mental health and subjective well-being and a lower severity of symptoms of anxiety and depression [22,24–26]. Through the last years, a discussion has evolved regarding the weak associations between SOC and physical health [27]. This has been explained by the fact that SOC mainly comprises the individual's mental, social, and spiritual resources for coping with life challenges [24]. Studies in adolescent samples have, however, shown positive associations between SOC and perceived positive health [28–30], and negative associations between SOC and SHC [17,31,32]. Where adolescents have been examined for 'normal' life stressors, such as academic, school, or peer pressure as well as family conflicts, it has been shown that those with stronger SOC report lower stress levels [26,32–34].

It is unclear whether SOC has a compensatory or protective role on the association between perceived stress and health. A compensatory model proposes that SOC operates as a resource, irrespective of stress levels (compensation), while a protective model claims that SOC is activated in the face of adversity (buffer effect). In adult samples, SOC seems to have both a protective and compensatory role in association with different health outcomes [24,35]. Studies conducted in adolescents focusing on daily life stressors have shown that SOC has a weak-to-moderate stress protective role in relation to SHC [21,31,36]. In studies based on Norwegian adolescent samples, support for a stress compensatory role of SOC has mainly been found in relation to both SHC [17], life satisfaction [37], and symptoms of anxiety and depression [26]. These studies have similarities with the present study by investing the role of stress and SOC in relation to mental and physical symptoms. However, the present study extends these studies by investigating the health outcomes more broadly, including subjective-, physical-, and mental health, as well as investigating the potential moderating role of sex and SOC on the association between stress and health in a sample of Norwegian adolescents age 13–19 years in rural areas in mid-Norway. The present study also included socio-economic status that are relevant to investigate in relation to adolescents' health and wellbeing [1,2].

The aims of the study were to investigate in adolescents:

