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Abstract
Objective: The aim of this study was to investigate the and SOC were related to good HQL; cynicism, anger-out, and
relationship of hostility and anger expression to sense of coherence anger-in correlated negatively with HQL. Path models revealed
(SOC) and their role as predictors of health-related quality of life that SOC was the strongest predictor of HQL while hostility and
(HQL). It was hypothesised that SOC would mediate the impact of anger lost their direct impact on HQL. Conclusions: Given the
hostility and anger on HQL. Methods: This is a substudy of the significant associations of hostility and anger with SOC, it is con-
Anglo-Scandinavian Cardiac Outcomes Trial, which evaluates cluded that the salutogenic theory of Antonovsky (A. Antonovsky,
different treatment strategies to prevent cardiovascular disease in Health, Stress, and Coping: New Perspectives on Mental Health
hypertensive patients. At baseline, SOC was assessed with a short and Physical Well-Being, Jossey-Bass Inc, San Francisco, 1979)
form measure, and hostility–anger with the Cynical Distrust scale should be extended to include hostility-related constructs. The
and with the Anger Expression scales. HQL was assessed impact of hostility and anger on HQL is, to a great extent,
at 6 months with the RAND-36. The sample comprised of mediated through SOC, which implies that in future studies, the
774 subjects (77.5% men). Results: Results showed that strong role of hostility as a risk factor of ill health should be reconsidered
SOC associates with ability to control expression of anger and with from the SOC theory perspective.
low levels of suppressed or openly expressed anger. Anger control D 2006 Elsevier Inc. All rights reserved.
Keywords: Anger expression; Cardiovascular diseases; Health-related quality of life; Hostility; Sense of coherence
0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2005.12.005
34 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39
ill health, the evidence being especially strong for cardio- This study is part of a substudy of the Anglo-
vascular diseases (see, e.g., Refs. [8,9]). Scandinavian Cardiac Outcomes Trial (ASCOT), which
From that point of view, it is surprising that so little examines prevention of coronary heart disease (CHD) and
research has been devoted to explore the possible relation of vascular events by blood-pressure-lowering and by choles-
these constructs. For example, in the study by Pallant and terol-lowering therapy. Inclusion criteria for the ASCOT
Lae [10], the construct validity of SOC was examined by cohort were elevated blood pressure and three other risk
correlating it with a number of indicators of self-reported indicators of cardiovascular diseases; a more detailed
health and measures of personality and coping, but no description of the inclusion criteria, design, and methods
measure of hostility or anger was included. of the main study have been published elsewhere [15].
So far, there seems to be only one study, which has The present substudy monitored changes in HQL during a
directly focused on the joint impact of hostility and SOC on 2-year follow-up in the Finnish sample in the ASCOT trial,
health [5]. In that longitudinal study, self-rated health and as well as psychosocial risk factors of CHD in long-term
records of sickness absences were used as outcome variables. follow-up [16]. The focus of this part of the substudy was to
The authors concluded that low SOC might be an important establish personality factors related to SOC and, supposedly,
factor partially explaining the adverse effect of hostility on ill to predict HQL 6 months after baseline assessments.
health. The main limitations of this study were that it was Psychological factors and HQL were assessed using a
based on women only, and their measure of hostility was a self-report questionnaire, which was given to participants at
narrow, three-item scale essentially assessing irritability [5]. the screening visit, to be returned in a reply paid envelope.
Thus, there seems to be an obvious paucity of research Follow-up questionnaires to monitor changes in HQL were
into the relation of different facets of hostility and SOC. administered to participants at the 6-month follow-up visit.
Even in Antonovsky’s key text on SOC, the hostility For the present analysis, the 6-month follow-up was chosen
concept is mentioned in only one sentence (Ref. [2], p. 6) because we tried to minimise the common variance
and anger, not even once. Moreover, given that hostility and contamination of hypothesised predictors with the outcome
anger are well-established risk factors of ill health, and high measure likely to occur with self-report methods.
SOC is supposed to be a protective factor, it seems highly At the screening visit, a leaflet and oral information
interesting to explore in detail how these constructs are about the present substudy was given to potential partic-
interrelated and what is their impact on health and health- ipants together with the questionnaire. Concomitantly, it
related quality of life (HQL). was made clear that nonresponse would not in any way
Considering the psychological theories on anger and influence their participation to the main study. Exclusion
hostility together with the SOC construct, it seems logical criteria for this substudy were notable difficulties in under-
to expect that they were related: high SOC would probably standing spoken and/or written Finnish and refusal to
involve ability to control anger and to express it in a participate. The study plan was approved by the ethical
constructive way. At the same time, one could hypothesize committees concerned.
that extreme tendency to openly expressed anger, or excess
inhibition of anger expression regardless of the actual sub- Measures
jective experience of the emotion, would correlate negatively
with strong SOC. Furthermore, the general level of hostile In addition to items covering relevant sociodemographic
tendencies, as expressed by the cognitive component of data (e.g., education and marital status), the following self-
hostility, i.e., by high levels of cynicism, could be expected to report measures were included in this study:
J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39 35
Table 3
Correlations between study variables by gendera
1. 2. 3. 4. 5. 6. 7. 8. 9.
1. Age .12 .04 .2444 .194 .09 .2344 .12 .02
2. Education .1444 .2044 .01 .07 .09 .12 .06 .11
3. Cynical distrust .1344 .1844 .3544 .09 .14 .2244 .09 .2044
4. SOC .07 .01 .2944 .3144 .3944 .3144 .2744 .4944
5. AX-con .02 .03 .08 .3644 .11 .5744 .10 .2444
6. AX-in .05 .084 .1644 .4144 .1744 .06 .03 .14
7. AX-out .084 .04 .1444 .2844 .6344 .2044 .08 .154
8. PCS (6 months) .1744 .2044 .1944 .2344 .1144 .104 .04 .6944
9. MCS (6 months) .04 .04 .2444 .4644 .2344 .2444 .1744 .6444
a
Men (n=600) below diagonal; women (n=174) above diagonal.
4 Pb.05.
44 Pb.01.
confounding factors. In previous studies, these factors have correlation with the mental composite score of HQL; for
also been shown to relate with HQL [21,26]. anger control, the correlation was positive while cynical
distrust; AX-in and AX-out showed negative association
with MCS.
Results
Path analyses
Mean values of the baseline psychological variables and
the 6-month HQL composite scores for men and women are Path analysis was then applied to test the proposed model
presented in Table 2. presented in Fig. 1. It was expected that the impact of
There was a statistically significant gender difference in hostility on HQL would be mediated by SOC. Furthermore,
the mean values for PCS and MCS, showing considerably high level of education, cohabiting, and old age were
lower quality of life scores for women. Comparison with expected to associate positively with SOC, while old age
population-based reference values [21] also indicated that would associate negatively with quality of life.
women in this sample had more limitations in their Due to a strong correlation of AX-out with AX-con
functional capacity than the population sample. Statistically indicative of multicollinearity problems, AX-out was not
significant gender differences were also found in AX-out as included in the models. Separate path analyses were
well as in cynical distrust, indicating that men were higher performed for men and women to establish the predictors
on hostility. of PCS and MCS scores of HQL at 6 months. The final
Zero-order correlations between psychological variables models for men and women are illustrated in Figs. 2
and background variables are presented in Table 3. and 3, respectively, and the fit statistics are summarized
The observed correlations supported all the main in Table 4.
assumptions of the relationships between the study variables Results indicated that the fit of the initial theoretical
as presented in Fig. 1. As expected, all the anger expression models with the data were good or excellent (see Table 4).
variables and cynical distrust had statistically significant No modifications were done for the model of women, and
correlations with SOC. Furthermore, all but one of these the modifications for the model of men were minimal: the
hostility-related variables had a statistically significant statistically significant associations of education on PCS as
Fig. 2. The final path model for men; numbers in figure are standardized Fig. 3. A path model for women; numbers in figure are standardized path
path coefficients; nonsignificant paths are indicated with dotted arrows. coefficients; nonsignificant paths are indicated with dotted arrows. CynDis,
CynDis, cynical distrust; marstat, dichotomised marital status (1=living cynical distrust; marstat, dichotomised marital status (1= living alone;
alone; 2 = cohabiting). 2 = cohabiting).
J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39 37
Table 4 psychosocial risk factors and the need to assess SOC in the
Summary of the goodness of fit indexes of the path models for men
context of other social and psychological factors [6].
and women
Considering the fact that they used different measures for
Chi-square df P NFI CFI AGFI RMSEA
both SOC and hostility, the clear correspondence of their
Model results with the present study is remarkable. Also, Kivim7ki
Men 1 41.12 10 .00 .96 .97 .93 .071
and coworkers [5] found a significant negative relationship
Men 2 16.17 9 .063 .98 .99 .97 .035
Women 16.33 10 .091 .94 .98 .91 .057 of SOC with a short measure of hostility, which was again
Men 1, original theoretical model for men; Men 2, final modified model for
different from our measure as well as from the measure used
men. NFI, normed fit index; CFI, comparative fit index; AGFI, adjusted by Surtees and coworkers. Thus, three independent studies
goodness of fit index; RMSEA, root mean square error of approximation. with large samples and using different indicators of the
hostility construct have found a significant negative associ-
well as the positive impact of cohabiting on SOC were ation of hostility with SOC. Furthermore, our results, based
added in the model 2 for men (see Fig. 2). on three measures of anger expression styles, support and
The main hypotheses were supported, indicating that extend the suggested important role of anger and hostility
high SOC scores were predicted with high anger control and for the SOC theory.
low levels of AX-in and cynicism. A relatively large Considering our theoretical model, one could propose an
proportion of the variance in SOC was explained by the alternative way of constructing it, i.e., to have SOC as a
variables in the model both for men and for women latent variable to explain anger-hostility variables. However,
(R 2=0.33 and 0.37, respectively). from the developmental point of view, SOC is supposed to
For both sexes, SOC scores at baseline predicted emerge and stabilise rather late, not much before 30 years of
statistically significantly both components of HQL at age [2], whereas anger-hostility-related features are usually
6 months; the impact on the psychological aspects (MCS) considered to evolve already during the early years of
of HQL were more pronounced (see Figs. 1 and 2). High childhood and to have, at least partly, a genetic background
level of education (for men) and young age (for women) had [28]. Thus, despite the cross-sectional, simultaneous assess-
a positive impact of PCS. Furthermore, the results did not ment of anger-hostility and SOC in this study, we argue for
show any statistically significant direct links from cynicism the hypothesis that vicissitudes of hostility and aggressive
or anger measures to HQL. behaviour play a part in the development of SOC. It remains
for future longitudinal studies to confirm this argument and
to demonstrate in detail their role and possible interaction as
Discussion risk factors of ill health.
The other key finding in this study, as we see it, is that
Based on the psychological theories of anger and the impact of anger-hostility variables on HQL seems to be
hostility as well as on the salutogenic theory of the SOC mediated by SOC. When hostility, anger, and SOC were
construct, a model was proposed. Our results supported all analysed together, the zero-order significant correlations of
the main hypothesised links in the model. hostility–anger variables with HQL were totally accounted
Firstly, we expected anger-hostility to be related to SOC. for by SOC.
Zero-order correlations (all N0.3 for women, and varying These results are consistent with those reported by
from 0.28–0.41 for men) showed that there would be about Kivim7ki and coworkers [5]. Based on their longitudinal
10–15% shared variance in SOC, with each of the various study on female employees’ sickness absences, they
aspects of anger and hostility included in the proposed concluded that low SOC might be an important factor
model. Furthermore, it is important to note that the items of partially explaining the adverse effect of hostility on ill
SOC include no reference to aggression or hostility, health. Their study, however, examined only women, and
indicating a genuine relationship of these constructs. their measure of hostility was a short, three-item generic
However, because all the constructs were assessed with measure of hostility giving no information of separate
self-report measures, a shared method variance cannot be aspects of anger. In our study, we were able to compare the
completely ruled out. patterns of relations in men and women. Results indicated
To our knowledge, there are only two previous studies that the main pattern of associations were very much alike
that have reported on this issue. The observed zero-order for both genders. Some differences were found in the way
correlations of SOC with hostility are in line with the results sociodemographic variables associated with SOC and HQL.
of the recent population study by Surtees and coworkers [6], For example, for men being married, cohabiting had a
where a graded negative association was found between positive impact on SOC, while for women, no such
SOC and a single dimension measure of hostility both in relationship was found. This finding needs to be confirmed
men and in women. While the psychological implications of by other studies; there might well be cultural or age-
this finding were not extensively discussed in their paper dependent differences in various populations.
focused on establishing a link between SOC and mortality, Moreover, women in the present sample showed sig-
they pointed out the potential importance of clustering of nificantly lower levels of functional capacity, i.e., in HQL.
38 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39
This is probably explained by the inclusion criteria of the perspective, and also, the salutogenic theory of SOC should
main study, which was recruiting subjects at high risk for be extended to include hostility-related constructs.
cardiovascular diseases. Consequently, women were about
3 years older than men, which may partly explain the
difference in mean levels of HQL, at least in PCS. Recently, Acknowledgments
however, Emery and coworkers [14] have reported that
women with cardiac disease experienced significantly lower Data collection and data management of this ASCOT
quality of life, as indicated by the same composite scales of substudy were supported by Finnish Pfizer.
the RAND-36 as in the present study. Thus, a response bias
favouring men could also be a plausible explanation for the
reported gender differences. References
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