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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



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,



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



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.



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).



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.




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



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]




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 •

coping with anger provocation situations

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