Journal of Occupational Health Psychology Copyright 2000 by the Educational PublUhing Foundation

2000, Vol. 5. No. 1,191-203 m76-89°8/D(V$5.00 DOI: 10.1037//1076-8998.5.I.191

Coping With Anger-Provoking Situations, Psychosocial Working

Conditions, and ECG-Detected Signs of Coronary Heart Disease

Annika Harenstam Tores Theorell

Karolinska Institute National Institute for Psychosocial
Factors and Health

Lennart Kaijser
Karolinska 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 significantly associated 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 and contributions to data collection, 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 Occupational
Health, Department of Public Health Sciences, Karolinska
Institute, SE-171 76 Stockholm, Sweden. Electronic mail
may be sent to annika.harenstam@smd.sll.se.
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-
term processes, changes may arise 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 two possible
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, a long-lasting state
of arousal may contribute to thickening of the coronary
artery walls as well as to accelerated 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 to explore the
influence of coping processes and psychosocial work
factors, in interaction with traditional risk factors, on
cardiovascular ill health among prison staff in
Sweden. A wide spectrum of organizational, occupa-
tional, and group- and individual-related factors are
characterized as psychosocial. Factors such as
control, skill utilization, demands, and role conflicts
are 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 to health
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 in relation to CHD.
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 by both 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 coping
is 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 of hypertension,
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 to characterize 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 as coping 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, in particular, of coping 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 in prisons.
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 for
guards 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 in Sweden, a total of
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 and
relevance 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, and categorized by 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). It contains
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 alternatives are 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 1 Study
Group, 1993). An abbreviated version of 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)

Men Women
No. of
Index items a n a n

Control 5 .67 1.330 .69 513

Understimulation 7 .74 1,239 .71 476
Psychosocial climate 15 .87 767 .90 273
Management style 7 .72 1,157 .70 422
Job demands 10 .76 1,266 .81 485
Skill discretion 12 .85 1,052 .85 397
Social support 7 .76 1,124 .81 411
Mental strain 3 .65 1,318 .73 519
Insecurity 13 .81 1,214 .77 446
 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. The following 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 you regularly 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 than users of oral snuff.
4. Self-reported symptoms of ill health (symptom scale:
sum score calculated 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 schedule including only night work. Work
schedules defined as shift work in this study include regular
night work as well 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's rest. 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 were as follows: (a) serum
gamma glutamyl transpeptidase (GT; ukatA) used as a proxy
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 blood pressure (mm Hg), (g) blood glucose
mg/lOOml, and (h) heart rate (beats/min).
Mean levels and standard deviations for each of the
biological variables and also p values for gender differences
are presented in Appendix C.
Standard 12-lead ECG 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 356 women). 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 as having 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) was regarded as a "sign of CHD"—the dependent
variable used in the statistical analyses. Sixty-five men (8%)
and 20 women (6%) were classified as CHD cases.
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
or nearly 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, and worse management support
than the men with signs of CHD. Consequently, our
hypothesis 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 CHD reported 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 interaction in
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 = -01 on covert coping and p = .01 on open
coping). 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 those who have.
 COPING AND CORONARY HEART DISEASE L95

On account of these initial analyses on men, we decided to
investigate the risk factors for CHD only in participants 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 19 women (6%) defined as CHD
cases.
The median age of both men and women was approxi-
mately 50 years. Among the CHD cases, 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 CHD cases, 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 a clinically based stratification was 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 Results

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 consulted a physician for 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
To present data comparable with other findings, we
listed prevalence data for the group that have not
consulted a physician for cardiovascular symptoms as
well as for the entire study group (see Table 2). Not
many epidemiological studies have been performed
of the extent of CHD abnormalities using ECG at rest.
The most extensive and reliable study is the so-called
Seven Countries Study (Aravanis et al., 1967), in
which samples of men ages 40-59 were 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 T waves ranged between 1.3%
and 8.6% in the European samples and was between

Table 2
Prevalence of Coronary Heart Disease (CHD) Signs

Any sign
(a) Pathological (b) ST segment (c) Negative of CHD3
Group Q waves depression T waves (a, b, or c)

All men >40 years ( « = 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 >40 years (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 of CHD).
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 Q waves 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 all single items related to coping
and signs of CHD were tested by means of chi-square
analyses 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

Variable 1 2 3 4 5 6 7 8 9 10 11
Women (« == 330)
1. Control — .57*** .32*** .40*** -.14* -.30*** _ 40*** 30*** -.35*** -.04 -.03
2. Skill discretion — .60*** .45*** -.12* -.22*** -.65*** .40*** -.22*** -.01 -.01
3. Psychosocial climate — .56*** -.13* -.40*** -.22*** .65*** -.40*** -.01 -.03
4. Management style — -.09 — 27*** -.20*** .54*** -.32*** .01 .00
5. Insecurity 23*** .10 -.08 .25*** -.10 .07
—
6. Mental strain — -.08 -.35*** .87*** .14* -.05
7. Understimulation -.04 -.20*** -.07 .07
—
8. Social support — -.42*** -.04 -.04
9. Job demands .12* .03
—
10. Open coping — -.61***
11. Covert coping —
Men (n = 725)
1. Control — .70*** .41*** 40*** _ 29*** -.29*** -.46*** .28*** -.35*** -.03 -.01
2. Skill discretion — .56*** .44*** -.21*** -.18*** -.70*** .29*** -.14*** -.03 .02
3. Psychosocial climate — .61*** -.13** -.25*** -.29*** .63*** -.26*** -.06 -.03
4. Management style — -.13* -.21*** -.24*** .55*** -,25*** -.07 .00
5. Insecurity — .36*** -.02 -.11** .44*** -.01 .03
6. Mental strain -.09* -^ 32*** .84*** .01 .00
—
7. Understimulation -.09* -.21*** .02 .00
—
8. Social support — -.39*** .00 -.04
9. Job demands -.00 -.01
—
10. Open coping — -.57***
11. Covert coping —

*p<m. ***r><.001.
 COPING AND CORONARY HEART DISEASE 197

rate, systolic blood pressure in women and men, and Table 4

also diastolic blood pressure in men were highly Logistic Regression With Signs of Coronary Heart
significant. High BMI was associated with greater Disease (CHD) as the Outcome Variable and
prevalence of signs of CHD in men but not in women. Biological, Clinical, Lifestyle, and Psychosocial
Following these univariate analyses, several logis- Variables as Explanatory Factors: Odds Ratios (ORs)
tic-regression models were tested. The first model and Confidence Intervals (Cl)for Men and Women
included only age and the psychosocial dimensions,
Factor OR CI
six in the case of men (control, management style,
Men
psychosocial climate, mental strain, job demands, and
covert coping) and three in the case of women Age 46-54 years 1.83 0.6-5.06
Age 55 or more 2.77 1.06-7.24
(insecurity, job demands, and open coping). Results
Body mass index
for the final model with psychosocial variables
Medium 1.07 0.42-2.68
showed significant associations between low level of High 0.72 0.27-1.85
open coping and signs of CHD in women and high Systolic blood pressure, high 2.51 1.02-6.14
level of covert coping and CHD in men. None of the Diastolic blood pressure, high 1.28 0.57-2.87
Heart rate, high 1.92 0.94-3.87
other psychosocial factors were found to have
Triglycerides 1.81 0.85-3.86
significant associations with signs of CHD. Glucose, high 3.79 0.73-19.50
The next step was to introduce the selected clinical, Regular medication 1.84 0.87-3.86
lifestyle, and biological variables into the models. Control
Many of the clinical and the biological variables, Medium 1.35 0.51-3.56
Low 1.27 0.50-3.18
particularly in the case of women, had to be excluded
Management
because of weak associations in the preceding Medium 1.69 0.62-4.58
univariate analyses. In the case of men, the remaining Low 2.40 0.80-7.18
variables were age, BMI, systolic and diastolic blood Psychosocial climate
Medium 0.58 0.21-1.56
pressure, heart rate, triglycerides, glucose, and regular
Low 0.78 0.28-2.13
medication. For women, they were age, systolic blood Job demands
pressure, heart rate, cholesterol, and smoking. The Medium 0.51 0.16-1.04
multivariate regression analyses did not show any High 0.73 0.21-2.49
significant associations with signs of CHD in either Mental strain
Medium 2.09 0.62-6.95
men or women except for the highest age group of High 2.48 0.56-10.86
men. However, heart rate, systolic blood pressure, Covert coping, high 2.60 1.27-5.32
and smoking in women and heart rate in men showed
Women
odds ratios with tendencies toward significance.
Age 46—53 years 1.80 0.27-11.72
To investigate whether psychosocial factors had
Age 54 or more 3.47 0.60-19.94
some relation to the outcome independent of tradi- Systolic blood pressure, high 2.13 0.37-12.02
tional risk factors, we combined in the final analyses Heart rate, high 2.42 0.72-8.03
(see Table 4) all of the selected variables included in Cholesterol, high 1.31 0.33-5.10
the logistic models. In the analysis for women, only a Smoking 0.23 0.04-1.13
Job demands
low level of open coping showed a significant association
Medium 0.% 0.2CM1.45
with sign of CHD, although there was a tendency for High 1.94 0.46-8.20
smoking to be associated in the opposite direction Insecurity
from that expected. Thus, none of the traditional risk Medium 1.71 0.26-11.15
High 3.53 0.65-19.08
factors for CHD seem to be associated with a high
Open coping, low 9.07 1.11-73.75
prevalence of CHD in women after adjustment for
psychosocial work conditions. In men, however, high Note. For men, the likelihood ratio = 254.17, X2(21,
N= 653) = 41.26, p < .005: for women, the likelihood
systolic blood pressure had a significant association
ratio = 83.43, x 2 (l 1, N = 287) = 26.44, p < .006.
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.
disease mentioned in the introduction, the triggering
Discussion mechanism could not be investigated in the present
study because of the choice of abnormalities in the
Of the three mechanisms involved in the relation ECO at rest as the indicator of cardiovascular ill
between psychosocial factors and cardiovascular health. However, it is possible to comment on the two
 HARENSTAM, THEORELL, AND KAIJSER
other mechanisms in relation to the results. That
psychosocial factors affect health behavior such as
smoking has been discussed in the literature. This has
not been shown in the present study, probably because
of selection and socialization processes in the prisons
affecting behavior and coping strategies particularly
among the female employees, as discussed later.
However, the results support the fact that psychoso-
cial factors may play a role in relation to long-term
physiological processes. The most important finding
of the present study is that coping style in anger-
provoking situations seems to be important in relation
to CHD as they are reflected in ECG abnormalities at
rest. An increased CHD risk in persons who do not
report open coping behavior has also been shown in
other studies (Chan & Ward, 1993). Furthermore, it is
noteworthy that control was not significantly associ-
ated with signs of CHD in the present study, although
there was a tendency for such an association among
men in the univariate analyses. High job strain, as
denned in the Karasek model, has been found to be
associated with increased risk of cardiovascular
disease in several studies (Karasek & Theorell, 1990).
The job-strain model, however, which combines job
demands and decision latitude, was not tested in the
present study because skill discretion and decision
authority showed too low a correlation.
In both women and men, the association between
coping and ECG signs of CHD was more important
than traditional biological, clinical, and lifestyle
factors. When the traditional risk factors were
included in the same model as the psychosocial
factors, the odds ratio for a high level of covert coping
remained significant for men, and the odds ratio for
low level of open coping among women increased.
High levels of reported covert and low levels of open
coping had the highest odds ratios of all variables
tested in the final multivariate logistic regression.
Established risk factors, such as shift work and
family history of CHD, did not show significant
relations with the outcome variable in the present
study. As those having shift work in the present study
rotate between day and night work, with a dominating
proportion of day shifts, it is not likely that shift
workers and day workers differ systematically with
regard to what job tasks they perform and the
character of demands. Still, it is surprising that
working on a rotating shift schedule did not seem to
be a risk factor. Prevalence data in Table 2 do not
support a selection process in working at prisons.
There are no indications of selection out of prison
work either, as the turnover of staff is very low in
prisons (Harenstam, 1989). However, persons with
suspected heart disease were excluded from our
analyses. A selection process may have been in-
volved, that is, persons with symptoms of ill health
may move from shift work to regular day schedule
and stop smoking, although they may not consult a
physician concerning the possibility of cardiovascular
disease. On the basis of the same data, it has been
reported previously that prison officers with day work
more often than others consult a physician for
cardiovascular symptoms and other symptoms of ill
health than officers with shift work (Harenstam,
1989). In the intensive pilot study preceding this
investigation, 24-hr ECG recordings were performed
of 66 employees at work. The results showed that
shift work was significantly associated with ventricu-
lar ectopic beats, especially during night work
(Harenstam, Theorell, Orth-Gomer, Palm, & Unden,
1987). Shift work is a risk factor for cardiovascular
disease, but this was not detectable with the present
study design.
Another explanation might be that not consulting a
physician even when needed might be associated with
a high level of covert coping in men and a low level of
open coping in women. This raises the question
whether a proneness to avoid conflicts at work and to
avoid reporting symptoms of ill health might be
associated with an increased risk of coronary heart
disease. The initial analyses showing larger differ-
ences with regard to coping style among men who
have not consulted a physician indicate that such an
explanation might have some importance. On the
other hand, the inclusion of participants who have
consulted a physician for cardiovascular symptoms
would have created difficulties because associations
in the opposite direction were found in this group.
This indicates that participants who consulted a
physician for cardiovascular disease and had no signs
of CHD constitute a "special" group.
The tendency toward a reversed association
between smoking and ECG signs of CHD in women
should be further investigated in other studies. As
stated earlier, women with no signs of CHD had
almost the same smoking habits as men, but the
proportion of smokers among women with signs of
CHD was less than half that. Women have reported a
less open coping than men in most previous studies as
well as in our own (Theorell et al., 1993). However,
when tested, women who smoke reported open
coping to the same extent as men in our study. It
should be mentioned that female participation in
prison staff, particularly as prison officers, is a rather
new phenomenon. There might be a selection process
involved regarding which women start to work at
 COPING AND CORONARY HEART DISEASE
prisons. Another explanation might be that women
have difficulties in adopting the norms of this kind of
work environment and that women who use open
coping as men do have also adopted the habit of
smoking more often than other women. Unfortu-
nately, we do not know for how many years the male
and female smokers in our study group had used
tobacco. We know, however, that the women who
used tobacco smoked less than the men did.
The present study has, of course, all the weak-
nesses of a cross-sectional study. It should also be
pointed out that it is based on a relatively homoge-
neous sample in which variations in objective work
conditions may be small. As reported earlier (Haren-
stam, Palm, & Theorell, 1988), there seem to be
differences in objective work conditions—particu-
larly between prisons with different categories of
inmates. In the third of prisons with the highest
proportions of drug-abusing inmates, staff showed
higher mean levels of cortisol and higher sick-leave
rates, and also reported significantly worse working
conditions. Significant associations between psycho-
social conditions and physiological outcomes were
more often found on the basis of the aggregated data,
that is, when means by prison rather than individual
data were examined (Harenstam, 1989). These results
support the hypothesis that self-reported work condi-
tions do reflect objective work conditions, even
though individual characteristics have an impact on
how employees assess them.
In the present study, coping style did not show
strong associations with psychosocial job factors. In
other studies, however, coping has normally been
found to be associated with psychosocial work factors
(Theorell et al., 1993). Our result might be due to the
method we used for assessing coping, that is, asking
for a choice of the most appropriate alternative rather
than responses to several items. Results from
aggregated analyses of the same data have shown that
coping should not be interpreted solely as an
individual-related factor. Significant differences be-
tween groups of prisons with regard to single
questions regarding coping with problems at work
were found (Harenstam, 1989). In age-adjusted
aggregated analyses based on mean levels for male
and female staff, dealing directly with problems
occurring in work with inmates was found to be
associated with a supportive management style and a
good psychosocial climate. And one of the criteria for
having supportive management style was that the
managers dealt with problems openly. No other
explanations for this result than the influence of
organizational and social environment factors on the
199
individual coping behavior could be found. In a
longitudinal study, it was found that organizational
and social coping resources influence subsequent
coping behavior (Heaney et al., 1995). Previous
studies of prison personnel have found that a
supportive, staff-oriented management style de-
creases conflicts and job-role ambiguity (Hawkins,
1976; Sykes, 1958). In similar vein, House (1971)
stated that a staff-oriented management style is
extremely important for job satisfaction in organiza-
tions characterized by ambiguous goals and high
psychological job demands. And one of the most
important predictors of CHD in the Framingham
study was a nonsupporting boss (La Rosa, 1988).
According to the results of their study on correctional
officers, Bollard and Winefield (1998) proposed that
officers with high-strain jobs learn to use less active
coping style than those with lower strain jobs. Active
coping have many similarities to open coping used in
the present study. Thus, it can be hypothesized that it
might be possible to support and spread a coping style
conducive to preventing cardiovascular disease on a
work site if superiors act as models for the staff with
regard to the methodology of conflict solution.
In the present study, before exclusion of any
participants, the prevalence of pathological Q waves
and ST depression were in the mid-ranges found in
the Seven Countries Study samples. Regarding
negative T waves, prevalences in the present study
were slightly higher than those of the Seven Countries
samples but still comparable. In making these
comparisons, one should remember that more than 20
years have elapsed since the Seven Countries Study
was conducted, and in most of the countries
investigated, mortality from CHD has decreased by at
least 20% (Thorn, 1989). However, it seems reason-
able to suppose that the male prison staff examined—
who had an age distribution similar to the one in the
Seven Countries Study (Aravanis et al., 1967)—had a
prevalence of CHD (according to ECG at rest) when
compared with those of the normal populations of
European countries. On the other hand, men in the
United States in the 1960s had a higher prevalence of
pathological Q waves than men in the present study,
and also a higher prevalence of such changes than the
European men in the Seven Countries Study.
The most important previous study with regard to
comparing men and women is probably the Framing-
ham study (LaCroix & Haynes 1987). In that study,
the CHD outcome largely considered was defined as
angina pectoris. Although its findings are not directly
comparable with ours, it is interesting to note some
similarities between the findings of the studies. In the
 HARENSTAM, THEORELL, AND KAUSER
Framingham study, it was found that suppressed
hostility was one of the most important predictors of
CHD in women (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
analyses chosen 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 to
long-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.
References
Aravanis, C., Blackburn, H. W., van Buchem, F. S. P.,
Buzina, R., Djordjevic, B. S., Donlas, A. S., Fidanza, P.,
Karvonen, M. J., Kimura, N., Lekos, D., Monti, M.,
Puddu, V., & Taylor, H. (1967). Epidemiological studies
related to coronary heart disease: Characteristics of men
aged 40-59 in seven countries. Acta Medico Scaruli-
navica, 460(Suppl.).
Astrand, I.(1960). Aerobic capacity in men and women with
special reference to age. Acta Physiologica Scandinavica,
49(Suppl.), 169.
Brunner, E., Davey Smith, G., Marmot, M., Canner, R.,
Beksinska, M., & O'Brien, J. (1996). Childhood social
circumstances and psychosocial and behavioural factors
as determinants of plasma nbrinogen. Lancet, 347.1008-
1013.
Chan, T.-H., & Ward, S. (1993). Coping process theory: A
tool to reduce stress and cardiovascular disease. AAOHN
Journal, 10, 499-503.
Cheek, F., & Miller, S. (1983). The experience of stress for
correction officers: A double-bind theory of correctional
stress. Journal of Criminal Justice, II, 105-120.
Davis, M. C., Matthews, K. A., Meihan, E. N., & Kiss, J. E.
(1995). Are job characteristics related to fibrinogen levels
in middle-aged women? Health Psychology, 14, 310-
318.
Dewe, P. (1991). Primary appraisal, secondary appraisal and
coping: Their role in stressful work encounters. Journal
of Occupational Psychology, 64, 331-351.
Dewe, P., Cox, T., & Ferguson, E. (1993). Individual
strategies for coping with stress at work: A review. Work
andStress, 7, 5-15.
Dollard, F. M., & Winefield, A. H. (1998). A test of the
demand—control/support model of work stress in correc-
tional officers. Journal of Occupational Health Psychol-
ogy, 3, 243-264.
Ekenvall, L., Harenstam, A., Karlqvist, L., Nise, G., &
Vingard, E. (1993). Kvinnan i den vetenskapliga studien,
finns hon? [The woman in the scientific study—does she
exist). Lakartidningen, 43, 3773-3776.
Harburg, E., Erfurt, I.. Havenstein, L. S., Chape, C., Schull,
W. ]., & Schoch, M. A. (1973). Socio-ecological stress,
suppressed hostility, skin color and black-white blood
pressure: Detroit. Psychosomatic Medicine, 35, 276-286.
Harenstam, A. (1989). Prison personnel: Working condi-
tions, stress and health—a study of 2000 prison
employees in Sweden. Doctoral dissertation, Karolinska
Institute, Stockholm, Sweden.
Harenstam, A., Palm, U. -fl., & Theorell, T. (1988). Stress,
health and the working environment of Swedish prison
staff. Work and Stress, 4, 281-290.
Harenstam, A., & Theorell, T.(1990). Cortisol elevation and
serum gamma-glutamyl transpeptidase in response to
adverse job conditions: How are they interrelated?
Biological Psychology. 31, 157-171.
Harenstam, A., Theorell, T., Orth-Gomer, K., Palm, U. -B.,
& Unden, A. -L. (1987). Shift work, decision latitude and
ventricular ectopic activity: A study of 24-hour electrocar-
diograms in Swedish prison personnel. Work and Stress,
4, 341-350.
Hawkins, G. (1976). The prison: Policy and practice.
Chicago: University of Chicago Press.
Heaney, C. A., House, J. S., Israel, B. A., & Mero, R. P.
(1995). The relationship of organizational and social
coping resources to employee coping behaviour. A
longitudinal analysis. Work and Stress, 9, 416-431.
House, R. J. (1971). A path-goal theory of leader
effectiveness. Administrative Science Quarterly, 16,
321-338.
Johnson, J. (1986). The impact of workplace social support,
job demands and work control upon cardiovascular
disease in Sweden. Doctoral dissertation, University of
Stockholm, Division of Environmental and Organiza-
tional Psychology, Department of Psychology.
Johnson, J., Hall, E., & Theorell, T. (1989). Combined
effects of job strain and social isolation on cardiovascular
disease morbidity and mortality in a random sample of
the Swedish male working population. Scandinavian
Journal of Work Environment and Health, 15, 271-279.
Kalimo, R. (1980). Stress in work. Scandinavian Journal of
Work Environment and Health, 6(Suppl. 3), 124.
Karasek, R., & Theorell, T.(1990). Healthy work—stress,
productivity, and the reconstruction of working life. New
York: Basic Books.
 COPING AND CORONARY HEART DISEASE
Knox, S., Theorell, T., Svensson, J., & Waller, D. (1985).
The relation of social support and working environment
to medical variables associated with elevated blood
pressure in young males: A structural model. Social
Science and Medicine, 21, 525-531.
LaCroix, A. Z., & Haynes, S. G. (1987). Gender differences
in the health effects of work place roles. In R. C. Barnett,
L. Biener, & G. K. Baruch (Eds.), Gender and stress (pp.
96-121). London: Free Press.
Landsbergis, P., Schurman, S., Israel, B., Schnall, P.,
Hugentobler, M, Cahill, J., &Baker, D. (1993). Job stress
and heart disease. New Solutions, 4, 42-58.
La Rosa, J. H. (1988). Women, work and health:
Employment as a risk factor for coronary heart disease.
American Journal of Obstetrics and Gynecology, 6,
1597-1602.
Latsck, J. C., & Havlovic, S. J. (1992). Coping with job
stress: A conceptual evaluation framework for coping
measures. Journal of Organizational Behaviour, 13,
479-508.
Lazarus, R. S., & Folkman, S. (1984). Stress, coping and
adaption. New York: Springer.
Menaghan, E. G. (1983). Individual coping efforts: Modera-
tors of the relationship between life stress and mental
health outcomes. In H. B. Kaplan (Ed.), Psyche-social
stress (pp. 157-191). New York: Academic Press.
Menzies, 1. E. P. (1960). A case study in the functioning of
social systems as a defense against anxiety. Human
Relations, 13, 95-121.
Netterstr0m, B., Kristensen, T. S., Damsgaard, M. T., Olsen,
O., & SJ01, A. (1991). Jobstrain and cardiovascular risk
factors: A cross sectional study of employed Danish men
and women. British Journal of Industrial Medicine, 48,
684-689.
O'Driscoll, M., & Cooper. C. (1994). Coping with work-related
stress: A critique of existing measures and proposal for an
alternative methodology. Journal of Occupational and
Organizational Psychology, 67, 343-354.
Rose, G. A., & Blackburn, H. (1968). Classification of the
electrocardiogram "Minnesota Code." In G. A. Rose &
H. Blackburn (Eds.), Cardiovascular survey methods:
World health Organization monograph series (Vol. 56,
pp. 98-154). Geneva: World Health Organization.
Schnall, P., Schwartz, J. E., Landsbergis, P. A., Warren, K.,
& Pickering, T. G. (1992). Relation between job strain,
alcohol and ambulatory blood pressure. Hypertension 19,
488-494.
(Appendixes follow on next page]
201
Shamir, B., & Drory, A. (1982). Occupational tedium among
prison officers. Criminal Justice, 9, 72-79.
Soderfeldt, B., Soderfeldt, M., Muntaner, C., O'Campo, P.,
Warg, L. -E., & Ohlson, C. -G. (1996). Psychosocial work
environment in human service organizations: A concep-
tual analysis and development of the demand-control
model. Social Science and Medicine, 42, 1217-1226.
Sykes, G. (1958). The society of captives: A study of
maximum security prison. Princeton, NJ: Princeton
University Press.
Theorell, T. (1992). On the psychosocial environment in
care. In M. Hagberg, E Hofmann, U. Stoessel, & G.
Westlander (Eds.), Occupational health for health care
workers: International Congress on Occupational Health
(pp. 387-393). Freiburg, Germany: Ecomed.
Theorell, T., Michelsen, H., Nordemar, R., & the Stockholm
MUSIC I Study Group. (1993). Validitetsprovning au
psykosociala indexbildningar [Validity tests of psychoso-
cial indexes]. In M. Hagberg & C. Hogstedt (Eds.),
Stockholmsundersokningen I [The Stockholm Study 1
Survey] (pp. 163-189). Stockholm, Sweden: MUSIC
Books.
Theorell, T., Schilldt, K., Ekholm, I., & Michelsen, H.
(1995). Physical strength and endurance in relation to
perceived psychosocial work environment, sleep distur-
bance and coping strategies in men. Scandinavian
Journal of Rehabilitation Medicine, 27, 67-71.
Thoits, P. (1995). Stress, coping, and social support
processes: Where are we? What next? Journal of Health
and Social Behavior [Extra issue], 53-79.
Thorn, T. J. (1989). International mortality from heart
disease: Rates and trends. International Journal of
Epidemiology, /SfSuppl. 1), 20-28.
Tsutsumi, A., Theorell, T., Hallqvist, I., Reuterwall, C., & de
Faire, U. (1999). The association between job characteris-
tics and plasma fibrinogen in referents of the SHEEP
study. Journal of Epidemiology and Community Medi-
cine, 53. 348-354.
Tuchsen, P., Andersen, O., Costa, G., Filakti, H., & Marmot,
M. (1996). Occupation and ischemic heart disease in the
European Community: A comparative study of occupa-
tions at potential high risk. American Journal of
Industrial Medicine, 30, 407-414.
Wolf, S. (1969). Psychosocial forces in myocardial infaction
and sudden death. Circulation, 4(Suppl. 4), 74-84.
202 HARENSTAM, THEORELL, AND KAI3SER

Appendix A

Questionnaire Items on Covert and Open Coping: Percentage Frequencies of the Chosen
Alternatives for Women/Men
A. How do you usually react when having a conflict with (a) a superior and (b) a colleague: Please mark with X the alter-
native which is most appropriate for you for (a) and (b).
(a) Superior (b) Colleague Index

1. Let it pass without saying anything 10/6 10/4 Covert coping

2. Protest directly 10/14 10/14 Open coping
3. Take it up with the person involved directly 51/65 57/69 Open coping

B. When (a) a superior or (b) a colleague treats you unjustly at your workplace, you get: Please mark the alternative with
an X which is most appropriate tor you for (a) and (b):
(a) Superior (b) Colleague Index

1. Angry and show it directly 18/36 22/35 Open coping

2. Discontent, irritated, or sad and show it 37/30 39/31 Open coping
3. Discontent, irritated, or sad and do not show it 18/9 15/9 Covert coping
4. Neither angry nor discontent/irritated" 2/7 3/7 Covert coping
a
Two more alternatives were included in the first question and one more in the second question. These are not included,
according to a factor analysis performed earlier. Thus, the sum of frequencies is lower than 100%.

Appendix B

Descriptive Statistics for Psychosocial Indexes and Results of Gender Differences

Men Women
No. of
Index items M SD n M SD n P'
Control 5 2.83 0.55 723 3.01 0.53 329 .00
Understimulation 7 2.34 0.42 724 2.26 0.41 330 .00
Psychosocial climate 15 2.93 0.49 717 2.97 0.51 325 ns
Management style 7 2.93 0.53 724 3.05 0.51 330 .00
Job demands 10 2.28 0.50 725 2.15 0.52 329 .00
Skill discretion 12 2.68 0.52 725 2.87 0.49 330 ,00
Social support 7 3.00 0.57 721 3.03 0.59 326 ns
Mental strain 3 2.14 0.77 723 1.96 0.81 326 .00
Insecurity 14 1.74 0.49 685 1.57 0.41 304 .00
Open coping 2X4 2.20 0.51 710 2.03 0.55 308 .00
Covert coping 2X3 1.23 0.46 710 1.33 0.55 308 .01

Note. Most items have four response alternatives, and the rest have been transformed to the same scale (i.e., from 1 to 4).
Sum scores and mean levels have been calculated. All dimensions are in the same direction (i.e., high score = high reported
level of control, etc.).
a
Analyses of variance of gender differences. The/? values were computed using Student's t test.
 COPING AND CORONARY HEART DISEASE 203

Appendix C

Descriptive Statistics for Clinical and Lifestyle Factors and Biological Variables
and Results of Gender Differences
Men Women

Factor M SB/range n M SB/range n P"

Clinical and lifestyle factors

Shift work (0-1) 0.41 777 0.14 345 .00

Symptom scale (serf-reported) 3.87 3.59 767 3.82 3.46 344 ns
Regular medication (1-0) 0.23 761 0.36 339 .00
Smoking or snufl'(O-l) 0.48 773 0.38 343 .00
Family history of CHD (1-0) 0.27 753 0.43 339 .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.

" For clinical and lifestyle factors, the p value for symptom scale is computed using Student's t test; the remaining p values are
computed using Fisher's exact test, double-sided. For biological variables, the p value for glucose and age are computed
using Fisher's exact 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 •