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8/6/2019 Coping With Anger Provocation Situations
http://slidepdf.com/reader/full/coping-with-anger-provocation-situations 1/13
Journal of Occupational Health Psychology
2000,Vol. 5. No. 1,191-203
Copyright 2000 by the EducationalPublUhing Foundation
m76-89°8/D(V$5.00 DOI: 10.1037//1076-8998.5.I.191
Coping WithAnger-Provoking Situations, Psychosocial Working
Conditions, and ECG-Detected Signs of Coronary Heart Disease
Annika HarenstamKarolinska Institute
Tores TheorellNational Institute for Psychosocial
Factors and Health
Lennart KaijserKarolinska Institute
This study explored the association among coping, psychosocial work factors, and signs of
coronary heart disease (CHD) among prison staff (777 men,345 women). Electrocardiogram
(ECG) recordings at rest, health examinations, and a questionnaire were used. A high level of
covert coping in men and a low level of open coping in women showed the strongest association
with signs of CHD. Among several traditional biological and lifestyle risk factors, only age and
systolic blood pressure in men and none in the case of women were significantlyassociated with
CHD signs in the final multivariate regression analyses.A coping style of repressed emotions and
actions in anger-provoking situations, independent of traditional risk factors, seems to be
associated with a prevalence of ECG signs in male and female prison staff.
A number of epidemiological studies have sup-
ported the hypothesis that strain-inducing work
conditions have an impact on cardiovascular disease.
A series of investigations have shown that employees
with low control, monotonous tasks, and few
opportunities to learn new things at work show an
increased risk of cardiovascular disease (Johnson,
Hall, & Theorell, 1989; Karasek & Theorell, 1990;
Landsbergis et al., 1993; Netterstr0m, Kristensen,
Damsgaard, Olsen, & SJ01, 1991). However, the
intermediate steps involved remain largely unknown.
Psychosocial factors may worsen adverse health
behavior, for example, increase cigarette smoking.
Psychosocial factors may act as triggering mecha-
Annika Harenstam, Division of Occupational Health,
Department of Public Health Sciences, Karolinska Institute,Stockholm, Sweden; Tores Theorell, National Institute for
Psychosocial Factors and Health, Stockholm, Sweden;
Lennart Kaijser, Department of Medical Laboratory Sci-
ences and Technology, Division of Clinical Physiology,
Karolinska Institute at Huddinge Hospital, Sweden.
The study was supported by grants from the Swedish
Working Life Fund. We are indebted to Previa (formerly
Statshalsan) and personnel at the Swedish Prison Service for
their assistance andcontributions todatacollection, and also
to Erik Soderman, Division of Occupational Health,
Department of Public Health Sciences, Karolinska Institute,
for assistance with the statistical analyses.
Correspondence concerning this article should be ad-
dressed to Annika Harenstam, Division of OccupationalHealth, Department of Public Health Sciences, Karolinska
Institute, SE-171 76 Stockholm, Sweden. Electronic mail
may be sent to [email protected].
nisms for coronary heart disease (CHD). Finally, they
may also play a role in relation to long-term
physiological processes, such as those involving
hypertension and coronary atherosclerosis.When the
coronary arteries have been affected by such long-
termprocesses, changes mayarise in the electrocardio-
gram (ECG) recorded at rest. This physiological
measure has not, to our knowledge, been used as an
outcome variable in epidemiological studies of
cardiovascular disease in relation to psychosocial
factors. In recent years, ECG at rest has seldom been
used in relation to measuring the extent of CHD.
The main physiological reason for expecting a
relationship between psychosocial factors and ECG
changes is that psychosocial processes at work may
induce long-lasting arousal that may accelerate the
progress of coronary atherosclerosis. This has been
discussed in the scientific literature for a long time(see, for instance, Wolf 1969). There are twopossible
mechanisms behind this relationship. First, psychologi-
cal arousal stimulates coagulation, which enhances
atherosclerosis. Small possibility to issue control at
work has been shown,for instance,to be associated—
independent of a number of confounders—with
elevated plasma concentration of fibrinogen that is
essential to coagulation. The association between
psychosocial adversity and plasma fibrinogen has
been stronger for women than for men (Brunner et a].,
1996; Davis, Matthews, Meihan, & Kiss, 1995;
Netterstrom et al., 1991; Tsutsumi, Theorell, Hal-
Iqvist, Reuterwall, & de Faire, 1999). Second,
repeated elevation of blood pressure may induce
191
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192 HARENSTAM, THEORELL, AND KAIJSER
thickening of the artery walls and as a consequence
reduced coronary artery capacity to carry oxygen to
the heart muscle (Schnall, Schwartz, Landsbergis,
Warren, &Pickering, 1992).Thus, along-lasting state
of arousal may contribute to thickening of the coronary
artery wallsaswellas toaccelerated coronary atheroscle-
rosis. These processes may result in ECG changes
that could be visible on ECG recorded at rest.
The main objective of this study was toexplore the
influence of coping processes and psychosocial work
factors, in interaction with traditional risk factors, on
cardiovascular ill health among prison staff in
Sweden. Awide spectrum of organizational, occupa-
tional, and group- and individual-related factors are
characterized as psychosocial. Factors such as
control, skill utilization, demands, and role conflictsare often used as indicators of both the setting in
which the individual works and the job content
itself—and have probably been the most commonly
investigated psychosocial factors in relation tohealth
since the late 1970s. Furthermore, there are factors
such as psychosocial climate and social support,
which aim at the description of social relations. In a
study of employees working at institutions requiring
many psychologically demanding personal contacts,
it seemed important to investigate such psychosocial
factors inrelation toCHD.
A third category of psychosocial factors, which are
more individually related than those referred to
above, group around the concept of coping. A
theoretical framework has been developed in which
coping is regarded as important to the development of
stress reactions and disease in various ways: Coping
style is said to have an impact on the duration,
intensity, and frequency of neurochemical reactions;
coping may influence health behavior; and, finally,
certain coping styles may restrain adjustment to
symptoms (see, e.g., Lazarus & Folkman, 1984;
Latack &Havlovic, 1992). Choice of coping strategy
seems to be influenced byboth individual characteris-
tics and organizational and social environmental
factors (Heaney, House, Israel, & Mero, 1995).
Furthermore, Menaghan (1983) has shown that
coping behavior is role specific. In a recent study of
correctional officers, passive coping was associated
with many strain indexes, and workers with high job
strain (according to the demand-control model)
showed significantly less active coping than those
with lower strain jobs (Dollard& Winefield, 1998).
Although there is a general agreement that copingis an important element in the overall stress process,
coping with stressful events has been measured in
many different ways (Dewe, Cox, &Ferguson, 1993;
Harburg et al., 1973; Latack & Havlovic, 1992).
There seems to be a growing recognition that
measures of coping should be specific, that is, try to
capture what a person does or thinks in a particular
encounter or situation (Dewe, 1991; O'Driscoll &
Cooper, 1994; Thoits, 1995).Although coping style is
largely regarded as a rather stable person characteris-
tic, work conditions differ with regard to the
prevalence of anger-provoking situations. Following
Harburg et al.'s epidemiological investigations of
different areas of Detroit (in 1973), we hypothesized
that psychosocial conditions that frequently evoke
anger may facilitate the development ofhypertension,
particularly when anger is not expressed. The same
type of situations might plausibly give rise to
increased risk of CHD.
That prison work is psychologically straining has
been established in many studies. Role conflicts,
meaninglessness, low skill utilization, and insecurity
seem tocharacterize the job (Cheek &Miller, 1983;
Harenstam &Theorell, 1990; Kalimo, 1980; Shamir
&Drory, 1982). Some studies have also indicated that
cardiovascular symptoms are more common among
prison staff than in many other occupational groups
(Harenstam, 1989; Shamir & Drory, 1982; TUchsen,
Andersen, Costa, Filakti, & Marmot, 1996). Studies
on institutions (e.g., hospitals and prisons) indicate
that organizational, relational, and also more indi-
vidual factors such ascoping are associated with each
other and have an important influence on stress and
anxiety among people in this type of work environ-
ment (Dollard & Winefield, 1998; Menzies, 1960).
Accordingly, prison staff seemed to be a suitable
group to consider in studying the impact on CHD of
psychosocial factors and, inparticular, ofcoping with
anger-provoking situations.
Because prison employees may be rather homog-
enous with regard to their work conditions, it is
extremely important to use instruments that arc
adjusted to that particular type of work. Only then is it
possible to differentiate between types of prisons and
also between various occupational groups inprisons.
Because the instruments commonly used in studies of
psychosocial factors and disease were mainly con-
structed for industrial work, il is important to adjust
questionnaire items for human-service tasks, such as
caring and maintaining custody (Ekenvall, Haren-
stam, Karlqvist, Nise, & Vingard, 1993; Harenstam,
1989; Soderfeldt et al., 1996; Theorell, 1992).
Method
Swedish prisons are small, varying from 10 to 400
employees and ranging from open institutions to closed,
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COPING AND CORONARY HEART DISEASE 193
high-security ones. The number of staff in relation to the
number of inmates is large compared with most other
countries. Prison guards represent the largest occupational
group, and most of them are men, although there are female
prison guards working with the same job tasks as male
guards at all prisons since early 1980s. The daily routine forguards differs somewhat, mainly as a consequence of the
size of prison, the category of inmates, and the activities and
programs for inmates. However, all have both custodial
treatment and service tasks. The population for the present
study consisted of all staff at 67 prisons inSweden, a totalof
just over 5,000 persons. A stratified sample of 2,300 was
drawn for the investigation. Stratification was based on size
of prison and occupational-group affiliation. Large prisons
and the largest occupation (prison officers) were somewhat
underrepresented in the sample, and the dropout rate was
10%. Nearly 1,500 men and 600 women of all staff
categories and of varying ages and lengths of service took
part in the study.
To choose suitable methods and to increase validity andrelevance of the instruments, we preceded the present
investigation with an intensive pilot study at four prisons.
Open-ended personal interviews were conducted with a
stratified random sample of 77 employees (66 men and 11
women). All interviews were tape-recorded, transcribed,
analyzed, andcategorizedby using qualitative methods. The
findings were then used as a basis for constructing single
questionnaire items of validity and relevance in the case of
prison personnel, which generated questions on the dimen-
sions insecurity, understimulation, mental strain, and
management style. Other dimensions were incorporated into
the instrument on the basis of items included in Karasek and
Theorell's (1990) job-strain model and supplemented by
social support (Johnson, 1986).
Following consideration of an earlier factor analysis
(Knox, Theorell, Svensson, & Waller, 1985), a few items
expressing the original dimensions of the demand-control
model were slightly modified, and some items were added in
light of the nature of the study group. For example, the
original control or decision-latitude dimension is con-
structed using two factors, decision authority and skill
discretion. For the present study, however, the difference
between them (according to computed product-moment
correlation coefficients) was sufficiently large to justify
keeping them apart. Accordingly, the combination of control
and demands of the job-strain model was not used for the
present study. Instead, the control dimension used here is a
traditional decision-authority factor. However, in the light of
the qualitative analysis, an item concerning predictability
was added. Internal consistencies of the indexes on
psychosocial job factors were calculated for men and
women separately for the entire study group (see Table 1).
The questionnaire items on coping were based on a
Swedish version of a questionnaire originally developed for
a U.S. study on high blood pressure (Harburg et ah, 1973;
Theorell, Schiildt, Ekholm,& Miche"lsen, 1995). Itcontains
two opening questions dealing with how the participant
usually reacts in a conflict situation at work and with what
the participant would do if unfairly treated in an occupa-
tional context. Different alternativesare presented and have
to be responded to in relation to superiors and colleagues.
The original version had four situational response alterna-
tives (ranging from very often to never). The Swedish
version has recently been extensively tested. The results of a
factor analysis indicated that it was statistically feasible to
construct two sum scores, one describing "open" coping
(e.g., talking to the aggressor either immediately or after
reflection) and one describing "covert" coping (Theorell,
Michelsen, Nordemar, & the Stockholm MUSIC 1Study
Group, 1993).An abbreviated versionof the coping indexes
was used for the present study. Each respondent was
requested to mark the alternatives most suitable for him or
her in two workplace settings—those of being unjustly
treated by superior and colleague. The open coping index
had four, and the covert coping index three alternatives for
the two opening questions. Because the coping indexes
consist of the sum of alternatives that could be regarded as
mutually exclusive, Cronbach's alpha has not been calcu-
lated in the case of open or covert coping. To provide the
reader with some information about the relevance of
combining individual items into composite indexes (of open
and covert coping), we presented the items and the actual
response patterns separately in Appendix A. The frequencies
for marked alternatives were found to be similar regardless
of workplace setting: being unjustly treated by superior or
colleague. Because sum scores were used for both scales
(i.e., in relation to superiors and colleagues), scores on the
open coping index can range from 0 to 8, and on the covert
coping index from 0 to 6.
A high sum score on the open coping dimension means
that relational problems in the workplace are dealt with
directly and communicated openly to the persons involved.
By contrast, a high sum score on the covert coping
dimension means that no emotional reactions in provoking
Table 1
Cronbach's Alphas for Men (n = 1,498) and Women (n = 578)
Index
Control
Understimulation
Psychosocial climate
Management style
Jobdemands
Skill discretionSocial support
Mental strain
Insecurity
No. of
items
5
7
15
7
10
127
3
13
Men
a
.67
.74
.87
.72
.76
.85
.76
.65
.81
n
1.330
1,239
767
1,157
1,266
1,0521,124
1,318
1,214
Women
a
.69
.71
.90
.70
.81
.85
.81
.73
.77
n
513
476
273
422
485
397411
519
446
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HARENSTAM, THEORELL, AND KAIJSER
situations are displayed (at least not at work). Only about
25% of the study group chose one or more of the "covert
coping" alternatives (see Appendix B).
Procedure
The following dimensions on the psychosocial job
questionnaire were calculated: control, skill discretion,
psychosocial climate, management style, insecurity, mental
strain, understimulation, social support, job demands, and
covert and open coping. Means and standard deviations for
women and men and also p values generated by (tests on
gender differences are presented in Appendix B. Women
reported better working conditions than did the men in most
of the variables tested.
A health questionnaire, constructed and validated by the
Swedish Foundation for Occupational Health, Research and
Development, was also used.Thefollowing items concerned
with clinical and lifestyle factors were used in the present
study:
1. Self-reports of family history of CHD: Do you have a
close relative who suffered heart disease or hypertension
before 60 years of age? (Yes or No)
2. Do youregularly use any kind of medication? (Yes or
No).
3.Use of tobacco (Yes or No). This factor was constructed
by combining three questions on smoking as well as snuff
habits. Those who smoked and/or used snuff daily, and had
done so for more than 6 months, were counted as using
tobacco. Ex-smokers (who had abstained for at least 6
months) were defined as nonusers. The factor is called
smoking in the tables because most of the participants were
smokers rather thanusersoforal snuff.
4. Self-reported symptoms of ill health (symptom scale:
sumscorecalculated from the health questionnaire).
5. Shift work: Several response alternatives on type of
shift schedules were used and later classified as shift work or
not. Most guards had a shift schedule rotating between day
and night work in a 2- or 3-week period. Number of night
shift varied between two to six night shifts in such a period.
None had a shift scheduleincluding only night work. Work
schedules defined as shift work in this study include regular
night workaswell as day work.
Means and standard deviations for the continuous
variables, percentages for the dichotomized variables, and
also p values for gender differences are presented in
Appendix C.Health examinations were performed by trained nurses at
occupational health care centers. Several physiological
measurements were taken. Blood pressure was measured in
the supine position after 10 min rest tor all participants,and
blood samples were taken in the morning after a regular
night'srest. The study participants were instructed not to eat,
drink, or smoke within 12 hr and not to consume alcohol
within 24 hr before the blood tests. The biological risk
factors tested in the present study wereas follows: (a) serum
gamma glutamyl transpeptidase (GT; ukatA) usedas aproxy
indicator of alcohol consumption, (b) body mass index
(BM1), (c) serum cholesterol and triglycerides (m mol/1), (d)
plasma cortisol (n mol/1), (e) systolic blood pressure (mm
Hg), (0 diastolic bloodpressure (mmHg), (g) blood glucosemg/lOOml, and (h) heart rate (beats/min).
Mean levels and standard deviations for each of the
biological variablesand alsop values for gender differences
are presented in Appendix C.
Standard 12-leadECG was recorded for 15 min at rest.As
a very low prevalence of ECG, signs of CHD was expected
in younger ages; for economic reasons, ECG recordings
were performed only for staff 40 years of age or older (862
men and 356women). Abnormalities, especially those with
regard to CHD, were classified in detail according to the
Minnesota Code (Rose & Blackburn, 1968) by an ECG
reader extensively trained in using the code.After measures
have been standardized, abnormal Q waves, and also ST
segment depression and negative T waves, are reliable
indicators of CHD. Accordingly, for the present study, any
participant for whom at least one of the mentioned changes
was found was operationally defined ashaving CHD.
In the study group, we found that 19% of the men and
12% of the women had codable ECG abnormalities of some
kind. The presence of Q waves (Code 1.1.1-1.3.6), negative
T waves (Code 5.1-5.3), or ST segment depression (Code
4.1 .̂4) wasregarded as a "sign of CHD"—the dependent
variable used in the statistical analyses. Sixty-five men (8%)and 20 women (6%) were classified as CHDcases.
When self-reported psychosocial conditions are investi-
gated in relation to diseases, there might be a recall bias.
Another hypothesis is that there might be a selection out of
the most straining working conditions if symptoms of ill
health are known. Thus, men and women in our study who
have consulted a physician for cardiovascular symptoms
might describe the working conditions as more unsatisfac-
tory than the others, or they might actually have and also
report less straining conditions. If any or both these
hypotheses are correct, the associations between psychoso-
cial working conditions and signs of CHD would be difficult
to detect. As a basis for a decision of including or excluding
persons who have consulted a physician for cardiovascular
disease, both hypotheses were investigated by two-way
analyses of variance. Only 1 woman with signs of CHD had
consulted a physician for cardiovascular disease. Conse-
quently, these analyses were performed only on men, as 17
of the 65 men with signs of CHD had consulted a physician.
These analyses showed some interaction effects (significant
ornearly so;p < .07) of self-reported psychosocial working
conditions between having consulted a physician and signs
of CHD. All analyses showed the same pattern. For example,
among the men who have consulted a physician, those not
having signs of CHD reported higher job demands, less
control, more psychic strain, andworse management support
than the men with signs of CHD. Consequently, ourhypothesis that participants report worse conditions when
they know they have signs of CHD was not confirmed.
However, the other hypothesis, that known cardiovascular
symptoms might lead to less straining working conditions,
seems to have more support as the opposite pattern was
found among the men who have not consulted a physician.
The 48 men with signs of CHDreported worse psychosocial
working conditions than the men with no signs of CHD.
Furthermore, consulting a physician for cardiovascular
symptoms and signs of CHD did not show any interactionin
their statistical associations with die two coping indexes.
The pattern was the same between those having or not
having consulted a physician. However, combined effects
were found (p =-0 1
on covert coping and p = .01 onopencoping). The differences between those with and those
without CHD signs in means of open and covert coping were
much greater among those who have not consulted a
physician than among thosewho have.
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COPING AND CORONARY HEART DISEASE L95
On account of theseinitial analyses on men, we decided to
investigate the risk factors for CHD only inparticipants who
have not consulted a physician for cardiovascular symp-
toms. The others were excluded in the main analyses. The
final study group consisted of 777 men and 345 women,
including 48 men (6%) and 19women (6%) defined as CHD
cases.
The median age of both men and women was approxi-
mately 50 years. Among the CHDcases, 20% of the men and
30% of the women were between 60 and 65 years of age.
Among men and women with no signs of CHD, 12% of the
men and 8% of the women were more than 60 years of age.
Approximately 66% of the study group were prison officers,
whereas the rest were work supervisors or administrative,
management, or treatment staff. Signs of CHD were found in
all occupational groups (except among the very small
number of female work supervisors). There was no
significant difference between the groups with regard to
signs of CHD. Among the CHDcases, 42% of the men and
16% of the women used tobacco daily; and among the
participants with no signs of CHD, 49% were men and 36%
were women.
outcome variable. Variable reduction was effected on the
basis of the age-adjusted gender-specific univariate analy-
ses, using a p value higher than .15 as the principle for
excluding variables from the multivariate analyses. Accord-
ingly, the three separate analyses of women and men
presented did not cover the same variables. For these
multivariate logistic-regression models, all continuous
variables were classified. Tertiles were used for classifying
all psychosocial indexes except the two on coping, because
U-formed associations with sign of CHD might be found.
The coping indexes were dichotomized as they showed
skewed distribution. BMI and age were categorized into
three classes. The other biological variables (except blood
pressure, for which aclinically based stratificationwas used)
were stratified into two classes with the median as the cutoff
point. All classifications were made for each gender
separately. The first multivariate regression incorporated age
and the selected psychosocial variables; the second incorpo-
rated age and both the biological and clinical/lifestyle
variables. The final model combined ah" of the selected
variables in the same logistic regression. Men and women
were analyzed separately.
Statistical Analyses
First, prevalences for each of the three Minnesota Code
categories used as signs of CHD were calculated for the
entire study group and also for the group that has not
consulted a physician for cardiovascular symptoms. All
other analyses were performed only on the group from
which persons who had consulteda physicianfor cardiovas-
cular symptoms had been excluded (i.e., 777 men and 345
women).
To reduce the variables in the logistic-regression models,
we performed a number of descriptive and investigatory
analyses. Product-moment correlation coefficients between
all psychosocial dimensions were calculated. Associations
between single items in the coping indexes and signs of
CHD were subjected to chi-square tests to facilitate
interpretation of the results of forthcoming logistic-
regression modeling. Each of the possible risk factors was
first investigated separately. The independent, continuous
variables in these analyses were not classified; that is, mean
scores on the indexes were used, although they were
standardized on the same scale. Furthermore, several steps
in the multivariate logistic regressions were performed (by
means of the SPSS procedure) using sign of CHD as the
Results
Topresent data comparable with other findings, we
listed prevalence data for the group that have not
consulted a physician for cardiovascularsymptoms as
well as for the entire study group (see Table 2). Not
many epidemiological studies have been performed
of the extent of CHDabnormalities usingECG at rest.
The most extensive and reliable study is the so-called
Seven Countries Study (Aravanis et al., 1967), in
which samples of menages 40-59were studied in the
United States, several European countries, and Japan.
In the European samples, prevalence of pathological
Q waves ranged between 1.8% and 3.5%, whereas
prevalence in the U.S. samples was between 3.4% and
5.2%. Prevalence of ST segment depression varied
between 1.0%and 3.3% in the European samples and
between 1.2% and 3.2% in the U.S. samples. Finally,
prevalence of negative Twaves ranged between 1.3%
and 8.6% in the European samples and was between
Table 2
Prevalence of Coronary Heart Disease (CHD) Signs
(a) Pathological
Group Q waves
(b) ST segment
depression
(c) Negative
T waves
Any sign
of CHD3
(a, b, or c)
All men >40years («=862) 22 (3%) 16 (2%) 43 (5%) 65 (8%)
Men >40 years without known heart disease
(n=776) 13 (2%) 12 (2%) 33 (4%) 48 (6%)
All women >40years (n = 356) 5 (1%) 11 (3%) 9 (3%) 20 (6%)
Women >40 years without known heart disease(n = 345) 5 (2%) 10(3%) 9 (3%) 19(6%)
a Some cases had more than one sign of CHD. Accordingly, the sum of (a), (b), and (c) may be higher than prevalence data
presented in this column (i.e., for those having any sign ofCHD).
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196 HARENSTAM, THEORELL, AND KAIJSER
3.6% and 4.7% in the U.S. samples. No similar
studies of women are available. As expected, we
found that the prevalence of Qwaves and negative T
waves was lower among women than men.On the
other hand, it has been known for a long time that ST
segment depression is more frequent among women
than among men, and this was confirmed by the
present study. ST segment depression of the so-called
sympathicotonic type may also be more common in
women than in men (Astrand, 1960).
Most of the psychosocial dimensions showed
rather strong mutual correlations (see Table 3).
However, the two coping indexes were only weakly
correlated with the other psychosocial indexes. The
associations between allsingle items related tocoping
and signs of CHDwere tested by means of chi-squareanalyses because both the outcome and the indepen-
dent variables were categorical (0 or 1). The
associations were found to be in the expected
direction with regard to signs of CHD, although only
some of these associations were significant. However,
there were some gender differences with regard to
which items had significant relations. Associations
between single items on coping and signs of CHD
were more frequent in horizontal relations (i.e., with
colleagues) among women and in vertical relations
(with superiors) among men.
The analyses conducted with one psychosocial risk
factor at a time showed that women reporting a high
level of insecurity at work had a significantly higher
prevalence of signs of CHD compared with other
women. Furthermore, open coping tended to be
negatively associated with signs of CHD in women.
That is, women who infrequently deal openly with a
conflict and who seldom show any emotions when
being unjustly treated seem to have a higher
prevalence of signs of CHD. In men,covert coping
showed a rather strong association with signs of
CHD. It seemed important therefore to include coping
in the logistic regressions despite the different coping
indexes for women and men.Few associations with traditional CHD risk factors
were found. In the separate analyses of men and
women, no significant association between shift work
and signs of CHD was found for either gender.
Although not significant, use of tobacco was found,
surprisingly, to be negatively associated with signs of
CHD among the women. Family history of CHD was
not associated with signs of CHD in this study.
Among the biological factors, the odds ratios for heart
Table 3
Product—Moment Correlations for Women and Men
1 .
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
1.
2.
3.
4.
5.
6.
7.
8.
9.10.
11.
Variable 1 2 3
Control — .57*** .32***
Skill discretion — .60***
Psychosocial climate —
Management style
Insecurity
Mental strain
Understimulation
Social support
Job demands
Open coping
Covert coping
Control — .70*** .41***
Skill discretion — .56***
Psychosocial climate —
Management style
Insecurity
Mental strain
Understimulation
Social support
Job demandsOpen coping
Covert coping
4 5
Women (« =
.40*** -.14*
.45*** -.12*
.56*** -.13*
— -.09
—
Men (n =
40*** _ 29***
.44*** -.21***
.61*** -.13**
— -.13*
—
6
= 330)
-.30***
-.22***
-.40***
— 27***23***
—
725)
-.29***
-.18***
-.25***
-.21***
.36***
—
7
_ 40***
-.65***
-.22***
-.20***
.10
-.08
—
-.46***
-.70***
-.29***
-.24***
-.02
-.09*
—
8
30***
.40***
.65***
.54***
-.08
-.35***
-.04
—
.28***
.29***
.63***
.55***
-.11**
-^ 32***
-.09*
—
9
-.35***
-.22***
-.40***
-.32***
.25***
.87***
-.20***
-.42***
—
-.35***
-.14***
-.26***
-,25***
.44***
.84***
-.21***
-.39***
—
10
-.04
-.01
-.01
.01
-.10
.14*
-.07
-.04
.12*
—
-.03
-.03
-.06
-.07
-.01
.01
.02
.00
-.00
—
11
-.03
-.01
-.03
.00
.07
-.05
.07
-.04
.03
-.61***
—
-.01
.02
-.03
.00
.03
.00
.00
-.04
-.01
-.57***
—
*p<m. ***r><.001.
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COPING AND CORONARY HEART DISEASE 197
rate, systolic blood pressure in women and men,and
also diastolic blood pressure in men were highly
significant. High BMI was associated with greater
prevalence of signs of CHD in men but not in women.
Following these univariate analyses, several logis-tic-regression models were tested. The first model
included only age and the psychosocial dimensions,
six in the case of men (control, management style,
psychosocial climate, mental strain,job demands, and
covert coping) and three in the case of women
(insecurity, job demands, and open coping). Results
for the final model with psychosocial variables
showed significant associations between low level of
open coping and signs of CHD in women and high
level of covert coping and CHD in men. None of the
other psychosocial factors were found to have
significant associations with signs of CHD.
The next step was to introduce the selected clinical,
lifestyle, and biological variables into the models.
Many of the clinical and the biological variables,
particularly in the case of women, had to be excluded
because of weak associations in the preceding
univariate analyses. In the case of men, the remaining
variables were age, BMI, systolic and diastolic blood
pressure, heart rate, triglycerides, glucose, and regular
medication. For women, they were age, systolic blood
pressure, heart rate, cholesterol, and smoking. The
multivariate regression analyses did not show anysignificant associations with signs of CHD in either
men or women except for the highest age group of
men. However, heart rate, systolic blood pressure,
and smoking in women and heart rate in men showed
odds ratios with tendencies toward significance.
To investigate whether psychosocial factors had
some relation to the outcome independent of tradi-
tional risk factors, we combined in the final analyses
(see Table 4) all of the selected variables included in
the logistic models. In the analysis for women, only a
low level ofopen coping showed asignificant association
with sign of CHD, although there was a tendency for
smoking to be associated in the opposite direction
from that expected. Thus, none of the traditional risk
factors for CHD seem to be associated with a high
prevalence of CHD in women after adjustment for
psychosocial work conditions. In men, however, high
systolic blood pressure had a significant association
with sign of CHD after adjustment, while the odds
ratios for a high level of reported covert coping and
the highest age group remained significant.
Discussion
Of the three mechanisms involved in the relation
between psychosocial factors and cardiovascular
Table 4
Logistic Regression With Signs of Coronary Heart
Disease (CHD) as the Outcome Variable and
Biological, Clinical, Lifestyle, and Psychosocial
Variables as Explanatory Factors: Odds Ratios (ORs)and Confidence Intervals (Cl)for Men and Women
Factor
Men
Age46-54 years
Age 55 or more
Body mass index
Medium
High
Systolic blood pressure,high
Diastolic blood pressure, high
Heart rate, high
TriglyceridesGlucose, high
Regular medication
Control
Medium
Low
Management
Medium
Low
Psychosocial climate
Medium
Low
Job demands
Medium
High
Mental strain
Medium
High
Covert coping, high
Women
Age 46—53 years
Age 54 or more
Systolic blood pressure, high
Heart rate, high
Cholesterol, high
Smoking
Job demands
Medium
High
Insecurity
Medium
High
Open coping, low
OR
1.83
2.77
1.07
0.72
2.51
1.28
1.92
1.813.79
1.84
1.35
1.27
1.69
2.40
0.58
0.78
0.51
0.73
2.09
2.48
2.60
1.80
3.47
2.13
2.42
1.31
0.23
0.%
1.94
1.71
3.53
9.07
CI
0.6-5.06
1.06-7.24
0.42-2.68
0.27-1.85
1.02-6.14
0.57-2.87
0.94-3.87
0.85-3.860.73-19.50
0.87-3.86
0.51-3.56
0.50-3.18
0.62-4.58
0.80-7.18
0.21-1.56
0.28-2.13
0.16-1.04
0.21-2.49
0.62-6.95
0.56-10.86
1.27-5.32
0.27-11.72
0.60-19.94
0.37-12.02
0.72-8.03
0.33-5.10
0.04-1.13
0.2CM1.450.46-8.20
0.26-11.15
0.65-19.08
1.11-73.75
Note. For men, the likelihood ratio = 254.17, X2(21,
N= 653) = 41.26, p < .005: for women, the likelihood
ratio = 83.43, x2(l1, N = 287) = 26.44,p <.006.
disease mentioned in the introduction, the triggering
mechanism could not be investigated in the present
study because of the choice of abnormalities in the
ECO at rest as the indicator of cardiovascular ill
health. However, it ispossible tocomment on the two
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HARENSTAM, THEORELL, AND KAUSER
Framingham study, it was found that suppressed
hostility was one of the most important predictors of
CHD inwomen (La Rosa, 1988). In the present study,
a low level on open coping might be interpreted as
involving the repression of negative emotions.We have tried to avoid spurious secondary
associations with CHD by only considering persons
with untreated cardiovascular symptoms. But there is
still the problem of a small number of cases. This
means that some of the odds ratios are high and the
confidence intervals wide. A logistic model may
easily explain all variation if too many exposure
variables in relation to number of cases are included
in that model. However, because our aim was to
investigate whether coping with anger-provoking
situations and psychosocial work factors had an
independent relation to outcome, many exposure
variables had to be included in the analyses.
Furthermore, because the study did not attempt to
explain causes of CHD, the forms of statistical
analyseschosen were regarded as appropriate (i.e., in
the light of the study being cross-sectional). Given all
of these limitations, it can still be concluded that
coping style is likely to have an independent
association with CHD signs (as measured by ECG
recordings) among both women and men. Thus, the
hypothesis that psychosocial factors, in this case,
coping strategies, have an important role in relation tolong-term physiological processes is supported.
Furthermore, although the two coping indexes seem
to have different importance for women and men,
interpretation of the results is similar for both the
genders. Reporting that no reactions are shown (men)
and acts toward the aggressor are seldom or never
performed (women) were both found to be associated
with high prevalence of CHD in the present study.
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(Appendixes follow on next page]
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COPING AND CORONARY HEART DISEASE 203
AppendixC
Descriptive Statistics for Clinical and Lifestyle Factors and Biological Variables
and Results of Gender Differences
Factor M
Men
SB/range n M
Women
SB/range n P"
Clinical and lifestyle factors
Shift work (0-1)
Symptomscale (serf-reported)
Regular medication (1-0)
Smoking or snufl'(O-l)
Family history of CHD (1-0)
0.41
3.87
0.23
0.48
0.27
3.59
777
767
761
773
753
0.14
3.82
0.36
0.38
0.43
3.46
345
344
339
343
339
.00
ns
.00
.00
.00
Biological variables
Age 50.31 40-65 776 49.40 4O-66 345 .04
Body mass index (kg/m2) 26.16 3.29 775 24.54 3.87 344 .00
Systolic blood pressure 136.53 17.01 776 130.15 17.00 344 .00
Diastolic blood pressure 86.33 10.37 776 81.98 9.80 344 .00
Heart rate 68.46 10.57 762 71.57 10.58 339 .00
Cortisol 495.03 143.54 713 515.49 179.60 320 .05
Triglycerides 1.87 1.35 729 1.34 0.59 324 .00
Cholesterol 6.65 1.21 729 6.50 1.24 324 .07
Gamma GT 0.63 0.60 732 0.35 0.48 324 .00
Glucose (0-1) 0.02 772 0.03 337 ns
Note. CHD = coronary heart disease; GT=ghjtamy! rranspeptidase.
" Forclinical and lifestyle factors, thep value for symptom scale is computed using Student's t test; the remainingp values are
computed using Fisher's exact test, double-sided. For biological variables, the p value for glucose and age are computed
using Fisher'sexact test, double-sided; all the others are computed using Student's / test.
Received December 8,1998
Revision received March 25,1999
Accepted June 8,1999 •