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Psychosomatic Medicine 63:609-618 (2001)
© 2001 American Psychosomatic Society

ORIGINAL ARTICLES

Social Support and Health Behavior in Hostile Black and White Men and Women in CARDIA

Jennifer Allen, BA, Jerome Markovitz, MD, MPH, David R. Jacobs, Jr., PhD and Sarah S. Knox, PhD.

From the Division of Epidemiology and Clinical Applications, National Heart, Lung, and Blood Institute (J.A., S.S.K.), Bethesda, Maryland; and the Division of Preventive Medicine, University of Alabama, Birmingham, Alabama; Division of Epidemiology (J.M.), University of Minnesota, Minneapolis, Minnesota.

Address reprint requests to: Sarah S. Knox, PhD, National Heart, Lung, and Blood Institute, Division of Epidemiology and Clinical Applications, 6701 Rockledge Dr., Bethesda, MD 20892-7936. Email: knoxs{at}nhlbi.nih.gov


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
OBJECTIVE: These cross-sectional analyses of the Coronary Artery Risk Development in Young Adults (CARDIA) data were stimulated by previous CARDIA analyses that showed an adverse association between hostility and several health behaviors: physical activity, cigarette smoking, alcohol consumption, and caloric intake, in both black and white men and women, such that the higher the hostility, the worse the health behavior profile. The current study investigated whether high social support was associated with better health behavior than low social support in individuals with high hostility scores.

METHODS: The subjects were 5115 healthy black and white men and women ranging in age from 18 to 30 years. The hypothesis was that the association between hostility and certain adverse health behaviors would be diminished in the presence of high social support. Race-gender specific median cutpoints of the Cook-Medley Hostility scale and an index of social support defined levels of high and low hostility and social support.

RESULTS: After controlling for age and body mass index (BMI), support was positively associated with more exercise in all groups except black women, but when coupled with high hostility, this positive association between support and exercise remained only in men. White women with high support were less often smokers but this association did not hold when examined only in the high-hostile group. Black men and white women with high support in the presence of high hostility consumed more alcohol, but the amount was moderate.

CONCLUSIONS: We conclude that social support in the presence of high hostility only sometimes reduces the association of hostility to adverse health behaviors and that these effects are complex. Additional research investigating types of social support on health behavior in different race-gender groups is advocated.

Key Words: hostility • social support • health behavior

Abbreviations: ANOVAs = analyses of variance; BMI = body mass index; CARDIA = Coronary Artery Risk Development in Young Adults; CHD = coronary heart disease; MMPI = Minnesota Multiphasic Personality Inventory; METs = metabolic equivalents.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
HOSTILITY/SOCIAL SUPPORT
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
For many years the experience and expression of anger and hostility have been recognized as potential risk factors in the etiology of coronary heart disease (1–3), other cardiovascular-related conditions (4–6), and all-cause mortality (7–11). Research has revealed that there are multiple pathways through which these emotions can lead to poor health: excessive cardiovascular and neuroendocrine responsivity to laboratory challenges (12–13), slow recovery after challenge (14–15), nonacute physiological changes such as platelet activation (16) and lipid concentrations (17–20), and their influence on health behaviors. Concerning health behavior, high hostility has been associated with higher smoking rates (21), salt consumption (22), alcohol consumption (11), and body mass index (23) than low hostility.

Another psychosocial factor, social isolation, has also shown documented associations with increased morbidity and mortality in prospective and cross-sectional epidemiological studies, as well as secondary prevention research (24–30). These studies indicate that the presence of social support can have a protective effect. The mediating mechanisms, like those for hostility, are hypothesized to involve both health behaviors and neuroendocrine pathways (31). Examples of influences on health behaviors are a positive association between social support and exercise (32–33) and significant associations with smoking (34–35). Continued availability of social support has been reported in association with successful attempts at smoking cessation and prevention of relapse (36–37). However, having friends who smoke can be an important predictor of smoking initiation among adolescents, even more so than having parents who smoke (38–39), although this may be more prominent for initiation in white adolescents than in black adolescents (40–42). Some types of social support may also have a negative impact on alcohol consumption. Adolescents who initiated drinking alcohol reported more exposure to parent and friend models than did abstinent youth, perceived higher prevalence of alcohol use among same-age peers, were more likely to have been allowed to have a drink in their home, and were more likely to have best friends offer drinks or pressure them to try (43).

Although gender and ethnic variation in hostility and its effects on health have been the subject of much research, considerably less has been reported on the influence of gender and ethnicity on social support in relation to health behavior. Inasmuch as ethnic and cultural influences play an important role in health-related behaviors both within and between genders, this is an under- investigated area. Black women tend to be less physically active than white women during both adolescence and adulthood (44–46). Black adolescents start smoking later than white adolescents (47–48), smoke at lower rates (49–51), and are less at risk of becoming smokers (40, 52–53). Black adults still smoke fewer cigarettes a day than whites, but black men have higher smoking rates than white men (54). Alcohol consumption is lower among black adolescents than white adults (55), lower among black men than white men (56), and lower among black women than white women (57).

Black women also tend to have less healthy eating habits than white women (58), as well as higher body mass index (59), which may be due to black-white differences in the perception of body image that have been documented in early adolescence (60–62). There are also gender differences within race. In a study comparing black college students, men were significantly more often smokers and reported heavier drinking then women, but women were statistically more likely to view themselves as overweight than men (63).

Unraveling ethnic/gender differences in the influence of social support on health behavior is complicated because the availability of social support also varies. Although it has been reported that men have lower support than women (64), exploration into the sources of support reveal that in general, women have a larger number of close confidants than men (65) but smaller social networks (66–67). Similar complexity emerges when exploring ethnic differences. In a study of a rural southern community, blacks reported lower levels of instrumental and emotional support than whites (68). However, data from a national survey that did not test for regional differences, indicated that blacks were as likely as whites to provide and receive instrumental and emotional support (69).


   HOSTILITY/SOCIAL SUPPORT
TOP
 ABSTRACT
 INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Broadening research to include the interaction between multiple factors is becoming increasingly important in attempting to better understand the complexity of health damaging behaviors in young people. Although hostility and social support are often studied in research relating psychosocial factors and risk for CHD, there are few studies that have looked at the combined influence of hostility and social support on health behaviors. The CARDIA Study, a longitudinal investigation of risk factors in healthy young adults, reported a significant positive association between hostility and cigarette smoking, alcohol consumption, and caloric intake (70), and these associations were consistent across race/gender subgroups. If the association between hostility and poor health behaviors is consistent across race/gender groups although gender and ethnic differences in these behaviors otherwise exist, would the presence of social support modulate this deleterious effect? The purpose of this article on CARDIA participants was to investigate race/gender effects of the presence or absence of social support on health behaviors in high-hostile individuals. The hypothesis was that high hostility in the presence of high social support would be associated with less detrimental health-related behaviors than high hostility without support. The focus of this article is on high-hostile individuals because the behavior of low-hostile people was not at risk.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
 METHODS
RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
The CARDIA Study is an ongoing, prospective epidemiologic study. The baseline examination data were collected in 1985 and 1986. There have subsequently been four follow-up examinations at year 2 (1987–1988), year 5 (1990–1991), year 7 (1992–1993), and year 10 (1995–1996). Although several examinations included measures of hostility, only the baseline exam included measures of both hostility and social support, therefore, this discussion will be restricted to baseline data. A detailed description of the study design and recruitment methods can be found in an earlier publication (71).

Participants
The CARDIA Study was conducted in four urban centers: Minneapolis, Minnesota; Birmingham, Alabama; Chicago, Illinois; and Oakland, California. The total sample consisted of 5115 participants (2787 women and 2328 men) approximately balanced within each center for race, gender, and socioeconomic status. Fifty-five percent were women; 52% were blacks. Participants were no less than 18 and no more than 30 years of age at the initial examination reported in this study. Only those who described themselves as black or white, having a permanent address in the target area, free of long-term disease or disability, and not pregnant at the initial examination were included in the study.

Psychosocial Measures
High- and low-hostility and social support groups were established by means of a median split, which divides the individuals into two equal groups. This was considered to be a better measure than a mean, which is more susceptible to influence by extreme values.

Hostility.
Hostility was measured with the 50-item Cook and Medley Hostility subscale of the MMPI (72). For the present analyses, a total hostility score, ranging from 0 to 50 was used. High hostility was defined within each race/gender subgroup as being higher than the median for that group.

Social support.
The 11-item social support measure was a combination of instrumental and emotional support from a scale developed by Seeman and Syme (73) as well as additional questions reflecting network adequacy and social network index. Although longer measures with detailed information on each type of support would have provided more information, that type of scale is almost never possible in biomedical epidemiology, due to the large number of variables and risk of undue patient burden. However, the scale used in this study has been validated in previous studies of coronary heart disease and carotid artery atherosclerosis (74, 75). There were four questions relating to instrumental support (eg, help with household tasks, loan of money), one question relating to emotional support (eg, someone to whom you can turn for help with personal problems), four questions relating to network adequacy (eg, often feel lonely, feel that others care, wish you had more close friends), and two questions concerning the social network (eg, participation in organizations or clubs). The social support score used in this study was calculated using a weighted mean of instrumental support, network adequacy, emotional support, and a social network index. The intent of a total score was to assess the total amount of different types of support available to the individual. Scores above the median cutpoint of the total social support score were defined as high social support.

Health Behaviors
Two types of behaviors were examined: health maintenance behaviors (physical activity and dietary fat consumption), and risk taking behaviors (smoking and alcohol consumption). They are, henceforth, referred to by the term, "health behaviors," to indicate behaviors that either promote or are detrimental to health.

Physical activity.
The score reported here is the total intensity score for physical activity based on a self-report measure assessing participation in different types of leisure-time physical activity including jogging or running; vigorous racket sports; bicycling faster than 10 miles/hour; swimming; vigorous exercise class or vigorous dancing; nonwork activity such as shoveling, weightlifting, and moving heavy objects; vigorous work activity such as lifting, carrying, and or digging; other strenuous sports such as basketball, football, skating, and skiing; nonstrenuous sports such as softball, shooting baskets, volleyball, and ping-pong; taking walks or hikes or walking to work; bowling or golfing; home exercise or calisthenics; and home maintenance and gardening including carpentry, painting, raking, and mowing. For each activity, participants indicated the number of months the activity was performed for at least 1 hour during each of those months and the number of months the activity was performed for at least 2 to 5 hours per week (the cut point for frequent participation varied by activity). The score was calculated taking into account the approximate energy expenditure for each activity ranging from three to eight METs and the level and the number of months of participation in the activity. Additional details on how the activities were scored have been published previously (76). A total intensity score consisting of heavy and moderate activity was used as the physical activity score for these analyses.

Alcohol consumption.
Alcohol consumption was measured with an interviewer-administered questionnaire that assessed the average quantity of different types of alcohol consumed during an average week. One drink was defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of liquor and was converted to give average milliliters of alcohol consumed per day.

Smoking status.
Smoking status was measured by an interviewer-administered questionnaire. For this study, answers were classified as current smoker (smoke at least 5 cigarettes per week, almost every week, for at least 3 months) and nonsmoker (which included people who had never smoked and those who had previously smoked). Values given in Tables 1 to 4 are the percentage of smokers in each group.


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  		Table 1. Means of Hostility, Social Support, Health Behaviors, BMI, and Education
 
Keys score.
The Keys score was a measure of dietary fat consumption calculated by obtaining extensive information concerning food intake during the past month. An interview was conducted by certified nutritionists and coded according to the University of Minnesota’s Nutrition Coding Center Nutrient Data Base (version 10) program, which provided quantification of nutrients, including dietary fats and cholesterol and total caloric intake (77). Also, included were the amount and frequency of food eaten, method of preparation, types of fats used in preparation, and frequency of consumption, condiments, and sauces. These data were then used to calculate the Keys Index score (78) based on saturated and polyunsaturated fat, cholesterol, and calories in the daily diet.

Body Mass Index and Educational Level
Although not health behaviors, BMI and educational level were also analyzed as dependent variables to investigate whether they are indirectly related in a way that might influence health behavior. It has been demonstrated in the CARDIA data that young black men with limited educational levels have the highest hostility (79) and there is higher caloric intake in high-hostile individuals (70), which could lead to higher body mass index.

BMI.
BMI was calculated as weight in kilograms divided by height in meters squared.

Educational level.
Educational level was a self-report of the highest grade of school or university completed.

Statistical Measures
Inasmuch as the objective of the study was to determine whether social support would modulate the effects of hostility on health behaviors, BMI, and educational level in hostile individuals in this young cohort, it was necessary to determine whether cutpoints for high and low hostility should be defined within or across groups. Preliminary analyses of variance revealed that significant differences in hostility and social support levels existed by race and gender, after controlling for age. A mean or a median value established across groups would have resulted in some within group analyses containing almost empty cells. Therefore, it was decided to define high and low hostility and social support scores within each race/gender subgroup and to do separate analyses for each group, so that white women with high hostility were compared with white women with low hostility, etc. A median cut point was chosen so the groups would be of equal size and then avoid the effect of outliers. There is also precedence for a median cut point in the hostility literature (80). ANOVAs were then calculated within each race/gender subgroup to determine whether the level of behavior differed by the level of hostility and social support.

Although the focus of this study was social support in individuals with high hostility, it was important to determine whether a hostility/social support interaction existed across levels of hostility. Therefore, each health behavior, as well as BMI and educational level, were regressed on support (high-low), hostility (high-low), and the hostility-social support interaction. In the final analyses, individuals considered high hostile were divided into two groups: those with high hostility and high social support and those with high hostility and low social support. Analyses in individuals considered low hostile were not calculated because they were at low risk for poor health behavior. The goal was to observe whether high social support was associated with improved health behavior in high-hostile individuals. All analyses were conducted using the SAS statistical software (SAS Institute Inc., Cary, NC) (81).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
 METHODS
 RESULTS
DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Hostility and Social Support in Race-Gender Subgroups
The race/gender means of health behaviors as well as hostility and social support can be seen in Table 1.

As reported earlier (82), men had higher hostility than women and black participants had higher hostility than whites. Post-hoc tests revealed that white women had significantly more social support than the other subgroups and black men had the least support. Differences in social support between white men and black women were not significant. Additional Pearson Product-Moment Correlations (not shown) indicated a significant inverse association between hostility and social support across the entire range of scores in all race-gender subgroups (r=-.11 to -.19; p<.0002 in all groups), such that the higher the hostility, the lower the social support.

Overview of Health Behaviors
Table 1 also shows the means of health behaviors in all race-gender subgroups; black women exercised significantly less than all other subgroups and both black and white men exercised more than white women. There were no significant differences in physical activity between black and white men. Milliliters of alcohol consumed per day in men were twice those of white women and about three times those of black women, respectively. White women drank significantly more alcohol than black women. Differences in mean levels of alcohol between black and white men were not statistically significant. Smoking status also varied by race and gender. There were significantly more black men who were current cigarette smokers compared with the other subgroups and black women were significantly more likely to be current cigarette smokers than both white men and women. Differences in cigarette smoking between white men and women were not significant. There was also significant variation in BMI between subgroups. Black women had the highest mean and white women the lowest. Mean Keys scores were significantly different between all subgroups with black men having the highest score and white women having the lowest. Whites had significantly more education than blacks (approximately 1 to 1.5 years).

Social Support and Health Behavior
A comparison of health behaviors, BMI, and educational level in high and low social support groups can be seen in Table 2. Within group analyses of variance revealed that after controlling for age, black men (p<.04), white men (p<.0001), and white women (0.02) with high social support exercised significantly more than their counterparts with low support. But black women with high support did not exercise more. There were no significant differences in alcohol consumption between the high and low social support groups. Analyses of smoking status revealed that only white women with high social support were significantly less often cigarette smokers (p<.02) than their counterparts with low support. However, there was a tendency in the same direction in black men (p<.09). Body mass index did not vary significantly by level of support in any race-gender subgroup. In all race-gender subgroups, those with high social support had significantly more education than individuals with low support (black men, p<.02; white men, p<.0001; black women, p<.0001; and white women, p<.02).


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  		Table 2. Means of Health Behaviors, BMI, and Education by Level of Social Supporta
 
Hostility and Health Behavior
A comparison of health behaviors, BMI, and educational level in high- and low-hostile groups can be seen in Table 3. The only significant differences in physical activity after controlling for age, were seen in white women where the high-hostility group exercised more (p<.03). High-hostile individuals in all race-gender subgroups drank considerably more alcohol than low-hostile individuals (p<=.001) and all race-gender subgroups with high hostility were significantly more likely to be current cigarette smokers than those with low hostility (p<.0001 in all subgroups). Analyses of body mass index showed that only among white men was high hostility associated with significantly higher BMI (p<.03) than in those with low hostility. The only notable difference in Keys scores between the high- and low-hostile groups was in white men, where high hostility was associated with higher BMI. With respect to educational level, high hostility was associated with significantly lower educational level (p<.0001 in all subgroups).


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  		Table 3. Means of Health Behaviors, BMI, and Education by Hostility Levela
 
Hostility/Social Support Interaction
Tests of interaction between levels of hostility and social support were calculated by regressing each health behavior on main effects of hostility and social support as well as on a support-hostility interaction term. There was only one significant interaction and that was for physical activity in white women. Therefore, the effect of social support on all other health behaviors did not differ significantly by the level of hostility and there is no statistical reason for limiting our analyses to high-hostile individuals. However, tests of significance for interaction terms have lower power to detect differences than main effects tests, due to greater variance (82). For this reason and because a positive effect of social support in the high-hostile (more at risk) individuals would have greater impact on clinical risk, we examined the effect of high and low social support in high-hostile individuals.

High Hostility and High or Low Social Support
A comparison of health behaviors, BMI, and educational level in high-hostile, high support and high-hostile, low support groups by race-gender can be seen in Table 4. High-hostile men exercised more (p<.03 in black men; p<.003 in white men) if they had high support than if they had low support; although not significant, the finding was in the same direction in women. However, high-hostile black men (p<.10) and white women (p=.03) with high support also consumed more alcohol than their high-hostile counterparts with low support. There were no significant differences in the number of smokers, level of BMI, or Keys scores between the high-hostile, high-support and high-hostile, low support groups. For education, only white men with high social support in the presence of high hostility had significantly higher education (p<.005) than those with high hostility and low social support.


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  		Table 4. Means of Health Behaviors in Hostile Individuals with High/Low Social Supporta
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
 METHODS
 RESULTS
 DISCUSSION
ACKNOWLEDGMENTS
 REFERENCES
 
The rationale for investigating the effect of high social support in high-hostile individuals was two-fold: the well-documented association between hostility and unhealthy behavior; and the accumulating evidence of a protective effect of social support on health, part of which is presumed to be mediated by an influence on health behaviors. The hypothesis was that high hostility in the presence of high social support would be associated with less detrimental health-related behaviors than high hostility without support. The data from this study indicate that the associations are complex. Support was positively associated with more exercise in all groups except black women but when it was coupled with high hostility, the significant effect on exercise remained in men but was only a trend in white women (p=.06). Consistent with this pattern, high support when examined alone was associated with higher educational level after controlling for age in all groups, but when examined in the presence of high hostility this positive association remained only in white men. These data suggest that the positive influence of high social support is sometimes outweighed by the negative effect of hostility, when both are present simultaneously.

The results concerning alcohol consumption are less straightforward. Examined by itself, social support showed no association with alcohol consumption, but in the presence of high hostility, support tended to be associated with more, rather than less drinking in black men (p<.10) and white women (p<.04). However, if the amount of alcohol in a glass of wine is approximated at 21 ml, then the average amount of alcohol, even in the highest group (black men) was only slightly higher than one drink a day. According to an American Heart Association Advisory Committee, consumption of one or two drinks per day is associated with a reduction in CHD risk of approximately 30% to 50% (83, 84). A summary of data on alcohol and stroke also shows a protective effect for ischemic stroke (85). Seen from this perspective, the slight increases in the high support groups in high-hostile individuals would be positive rather than negative.

A national survey of black and non-black adolescents reported that exposure to friends as drinking models was a major predictor of the frequency and quantity of alcohol consumption (55). However, students with high social support during exam stress have been shown to decrease alcohol consumption (86). Together these data may indicate that young people socialize with alcohol, but when they are not socializing (eg, exam time) support from peers contributes to a decrease in drinking.

The findings of a positive association between social support and exercise in the current study are consistent with those in other studies (45, 87, 88). In addition, our results show that support is associated differentially with exercise in high-hostile men and women. High-hostile men but not women exercised significantly more if they had high support than if they had low support. Consistent with other literature, young black women in this cohort had significantly lower physical activity levels (45, 46, 89) and higher BMI (59, 90) than other groups. Although the reasons for this discrepancy are unclear, it has been shown that black women do not experience the same social pressure to lose weight or the dissatisfaction with body image that white women do (61, 91, 92).

The hypothesis of a positive influence of social support on smoking behavior was not substantiated by these data. Because other studies indicate that peer influence may be more important than that of parents, the lack of an association may be a result of our not being able to discriminate whether support was coming from smoking or nonsmoking peers. If there were a positive influence from nonsmoking peers on one set of individuals, it could have been masked by a negative influence on other probands whose supportive others do smoke. Because smoking is such an important factor in cardiopulmonary health, the potential biphasic effect of peer support on smoking behavior would be worth investigating in future studies.

Although we could not ascertain the smoking status of people in the support system, we did have information pertaining to type of support (instrumental or emotional). The number of questions was really not sufficient to create robust subscales, but we did exploratory analyses with the hopes that the resulting descriptive data would give us some indication for future research. Black men in this cohort with high instrumental or emotional support were less likely to smoke, but this did not hold in the presence of high hostility (p<.03). Black women with high network adequacy were significantly less often current smokers (p<.04) than those with low network adequacy, even in the presence of high hostility (p=.005). It is possible that community, family, and cultural factors may influence smoking behavior in African Americans in ways that are different from whites. Interestingly, white women who showed no main effect of type of support on smoking status, smoked significantly less if they were high hostile with high network adequacy as opposed to high hostile with low network adequacy. Due to the nature of the scales, these findings are only preliminary but suggest that properly examining smoking and type of available support available may be a fruitful line of research.

The Keys score was included in this study because dietary fat consumption is such an important health behavior with respect to cardiovascular disease risk. However, the only significant finding was that of a higher Keys score in high-hostile white men, suggesting that dietary fat consumption is probably not very influenced by these psychosocial factors.

Although educational level and BMI are not health behaviors, they were included in these analyses because they are often used as control variables in studies of psychosocial factors and health end points. Despite this rather common methodology, there are scant data to indicate whether they are confounders or are involved in the causal pathway (ie, as mediators). Therefore, we wanted some additional information that might shed light on the issue. The results show that only educational level varied consistently by level of social support and by level of hostility. Although this does not give us information about the direction of causality, it does raise the possibility that educational level may be part of the pathway linking social support and hostility to health outcome. If high social support helps people attain an education, then the knowledge gained may result in more healthful behaviors. Higher education also tends to be associated with higher socioeconomic status, increased decision latitude (less stress), and better access to health care. Obviously, more research is needed before we will know whether social support causes higher education or higher education results in more social support. But the same type of reasoning relates to the association of hostility to education. The negative neuroendocrine correlates of hostility are well-documented. Lower levels of hostility in more highly educated people may be a marker for lower chronic sympathetic arousal, and a better cardiovascular profile. If this is the case, then controlling for education when analyzing the effect of social support and hostility on health end points may eliminate some of the variance under investigation.

In conclusion, findings from this study do not support a general ameliorating effect of social support on adverse health behaviors in high-hostile individuals. The fact that level of social support did not seem to elicit protective effects on health behavior in the presence of high hostility (except with respect to physical activity) in this young cohort, suggests that the negative effects of hostility are robust. These data also suggest that hostility and social support may interact in a complex manner that needs to be further investigated. Social support is a multifaceted construct and its influence depends on the behavioral and cultural context through which it is experienced.


   ACKNOWLEDGMENTS
TOP
 ABSTRACT
 INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
REFERENCES
 
This research was supported by Grants N01-HC-48047 through -48050 and N01-HC-95095 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.

Received for publication March 16, 2000.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 HOSTILITY/SOCIAL SUPPORT
 METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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