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Cynical Hostility, Socioeconomic Position, Health Behaviors, and Symptom Load: A Cross-Sectional Analysis in a Danish Population-Based Study

From the Department of Social Medicine, Institute of Public Health, University of Copenhagen, Denmark (U.C., R.L., M.T.D., B.E.H., F.D., P.D., J.L.); Department of Biostatistics, Institute of Public Health, University of Copenhagen, Denmark (S.D.); Department of Health, County of Ribe, Denmark (L.I.); Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan (J.L.).

Address correspondence and reprint requests to Ulla Christensen, MA, PhD, Department of Social Medicine, Institute of Public Health, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK 2200 Copenhagen N, Denmark. E-mail: U.Christensen{at}socmed.ku.dk

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION NOTES REFERENCES

 
OBJECTIVE: To analyze the cross-sectional association between cynical hostility and high symptom load in a Danish population-based study. Furthermore, the aim was to investigate to what extent health risk behaviors mediated this association.

METHODS: Data were based on a postal questionnaire in a Danish random sample of 3426 men and 3699 women aged 40 or 50 years. Cynical hostility was measured by the 8-item Cynical Distrust Scale. High symptom load was assessed by physiological and mental symptoms experienced within the last 4 weeks. Confounders were age and socioeconomic position, while potential mediators were alcohol consumption, smoking, physical activity, and BMI.

RESULTS: Higher cynical hostility was associated with self-reported symptom load. Health behaviors did not seem to mediate this effect. Socioeconomic position was a strong confounder for the effect on both health and health behaviors. After adjustment the effects of hostility on health remained with odds ratios of 2.1 (1.7–2.6) for women and 2.3 (1.8–2.8) for men.

CONCLUSION: After adjustment for socioeconomic position, cynical hostility has an effect on self-reported high symptom load, and this effect is not mediated by health behaviors.

Key Words: cynical hostility, • symptom load, • social class, • health risk behaviors.

Abbreviations: BMI = body mass index.

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION NOTES REFERENCES

 
Over the last decade cynical hostility, defined as an enduring, negative attitude toward others involving cognitive, affective, and behavioral components (1), has increasingly been recognized as a psychological characteristic with a negative impact on health (2). Thus, hostility has been associated with cardiovascular reactivity (3–6), with coronary artery calcification in young adults (7), with coronary heart disease (8–10), and with mortality (9–10). It has been suggested that the negative effect of cynical hostility on health may be due to its influence on the body’s resistance or vulnerability to different pathogenic processes (11), and different biological pathways have been suggested (12). The wide impact on health has been supported by a Finnish study among 1077 municipal employees. This study showed that over a period of 4 years, high hostility scores among men predicted a high total of long-term sickness absence (13,14).

High levels of hostility and poor health have been linked with high prevalence of health-damaging behaviors such as smoking, alcohol consumption, lack of physical exercise, and BMI among people who are hostile (2). This increase in risk behaviors has been shown not only among adults (15,16) but also among adolescents and young adults (17–19). This mechanism explaining the association between hostility and health may, however, be confounded by social position (20–22). In a large study among 2125 Finnish men aged 42 to 60 years, Everson et al. (10) showed that high levels of cynical hostility were associated with an increased risk of all-cause and cardiovascular mortality and incident myocardial infarction. Alcohol intake, smoking, and high BMI among the most cynical men were significant mediating factors in explaining these relations between hostility, myocardial infarction, and mortality. However, Everson et al. (10) also emphasized the importance of socioeconomic position in understanding the relationship among hostility, behavioral factors, and mortality.

The strong associations between cynical hostility measured by the Cook-Medley Hostility Scale and variables such as education, income, and occupation have been found among adult men and women (23,24). In a study among 2674 middle-aged Finnish men Lynch et al. (20) found that adult health behaviors and psychosocial dispositions detrimental to health (including cynical hostility) were consistently related to poor childhood conditions, low levels of education, and blue-collar occupation. Furthermore, using data collected in 1965, 1974, and 1983 among a population sample of adults in Alameda County (US), Lynch et al. (25) showed that sustained economic hardship was closely related to a high score of cynical hostility as measured by a fourth survey of the same population sample in 1994. These results have recently been supported in a paper by Harper et al. (26), who demonstrated that high levels of cynical hostility were associated with socioeconomic conditions in both early and later life in a Finnish cohort of 2585 middle-aged men. A recent Dutch cross-sectional study on the role of hostility in the association between educational level and self-rated health among 3494 men and women suggested that a substantial part of the educational gradient in health could be ascribed to the mediating effect of hostility. Only a minor part of the effect of hostility was mediated by health behavior (22).

The fact that the association between socioeconomic position and health relates both to cynical hostility and health risk behaviors makes it important to further examine their mutual contribution to poor health. We must also broaden our perspective to include health indicators other than cardiovascular and coronary heart diseases. Thus, the aim of the present study is to analyze the cross-sectional association between cynical hostility and high symptom load in a Danish population study. Furthermore, the aim is to investigate the extent to which health risk behaviors mediate this association and the confounding role of socioeconomic position.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION NOTES REFERENCES

 
Study Population
The population for this cross-sectional study includes a random sample of Danish adults aged 40 and 50 years by October 1, 1999. It is part of the Danish Longitudinal Study on Work, Unemployment and Health. The sample is drawn from the AKF Longitudinal Register at the Statistics Denmark (AKF, Amternes og Kommunernes Forskningsinstitut/ Institute of Local Government Studies in Denmark), which comprises information on a 10% random sample of the Danish population aged 15 years or older (N = 408,000). The register includes data on demography, household information, housing conditions, migration, employment status, education, income, capital assets, and transfer incomes.

The present data are based on a postal survey carried out in the spring 2000. The questionnaire comprised variables on physical and mental health, demographic and socioeconomic factors, occupational environment, social relations, health behaviors, and psychological factors such as coping, hopelessness, self-efficacy, and hostility.

The response rate was 69% (N = 7588). Data on nonparticipants were derived from the AKF Longitudinal Registers and showed that nonparticipants included a significantly lower proportion of women, of native-born Danes, of employed persons, and a significantly higher proportion of nontrained or semiskilled persons. We found no significant differences in number of contacts with general practitioner between participants and nonparticipants. Information on social class was not obtained for 463 of the participants, so the present analyses were based on a population of 3426 men and 3699 women.

Measurements
Health was measured by symptom load based on 13 items measuring physical and mental symptoms experienced within the last 4 weeks. The symptoms recorded were musculoskeletal symptoms, headache, rapid palpitation, nervousness/restlessness/anxiety, sleeping problems, tiredness, stomach ache, indigestion, diarrhea/constipation, eczema/skin rash/itching, coughing, breathing difficulties, and impairment of memory. Response options were not at all, a little of the time, most of the time, all the time. This short self-report inventory has been used in the Danish nationwide health and morbidity surveys, which have been conducted in 1987, 1994, and 2000 (including 22,500 persons aged 16 years or more) (27,28). In a study of validity of an almost identical inventory used in female populations, Krantz and Östergren (29) found that the items of the short inventory scale were widely dispersed among the factors represented by the main Symptom Check List 90 subscales and consequently the short scale assessed a single entity. Such an entity represented a proxy for general distress in women. On the basis of a study among 2111 adult men and women Foppa et al. (30) also concluded that a short scale consisting of 11 severe function symptoms similar to those used in our study constituted a distinct and general dimension of ill-health. We scored number of symptoms experienced most of the time or all the time with a range from 0 to 13. Two different preliminary analyses were conducted using all symptoms in 1 index (symptom load) and each individual symptom as separate outcome measures. As hostility was independently associated with each of the symptoms; as we found no major change in the results between the 2 kinds of outcome measure (the combined index or each separate symptom), we chose to present all the analyses in this paper using the combined index of symptom load. Sensitivity analyses (not shown) were performed, and our results were robust to several different dichotomizing cut points on the symptom index. For the final analyses, the top quintile of symptom load was chosen (scoring 3 or more symptoms).

Cynical hostility was measured by the 8-item Cynical Distrust Scale, derived from the Cook-Medley Hostility Scale, originally based on the items from the Minnesota Teacher Attitude Inventory (31). The Cynical Distrust Scale that measured the cognitive component of hostility was factor-analytically derived form the Cook-Medley Scale by Greenglass and Julkunen (32). In 2 separate samples of Canadian and Finnish students, they demonstrated that the Cynical Distrust Scale is a sufficiently valid, reliable, and specific measure of cynicism and distrust when compared with the full Cook-Medley Scale (33,34). In the present study, we used the 8 items as presented in English by Everson et al. (10); wording is presented in Figure 1. We translated the items into Danish and adjusted the wording after a back-translation into English. The Danish version was tested in a large-scale pilot study of the entire questionnaire among a study population (N = 993) drawn from the same sampling frame as the main survey. Response options were completely agree, somewhat agree, somewhat disagree, completely disagree. In the analyses, the items were summed to obtain a Cynical Distrust Scale score with a range of 0 to 24. In order to define the cutoff for exposure dichotomy, the association between the score and the symptom load was tested both by visual inspection of graphs and by trying several different dichotomies of the scale. We found a graded increase in the association between cynical hostility and symptom load. A cut point was made with a third of the population scoring high on hostility; so the scale was dichotomized into low (scoring 0–8) and high hostility (scoring 9+).

View larger version (20K): [in this window] [in a new window]   Figure 1. The 8 items included in the Cynical Distrust Scale

Confounders
These included age, sex, cohabitation status, school education, vocational training, and socioeconomic position. Socioeconomic position was measured by occupation and coded into social class I-V in accordance with the standards of the Danish National Institute of Social Research, which is similar to the British Registrar General’s Classification I-V. We added social class VI representing people on transfer income, including sickness benefits and disability pension. In this group, 35% were unemployed, 39% were on disability pension, and 8% were on sickness benefits. The rest (18%) were depending on various social benefits. School education, vocational training, and cohabitation status turned out not to confound the effect of hostility and health behaviors.

Statistical Analyses
The first step included gender-specific bivariate cross-tabulations of the association between social class and symptom load, hostility, and health risk behaviors. The second step was a logistic regression (SAS version 6.12) of health risk behavior against hostility adjusted for age. The third step was a series of logistic regression analyses with high symptom load against cynical hostility stratified for sex. Model 1 was adjusted for age only, and model 2 also was adjusted for the confounding effect of social class, school education, vocational training, and cohabitation status. Model 3 included health risk behaviors to test their potential mediating role. Smoking, alcohol intake, BMI, and physical activity were included both one by one and simultaneously in the final analyses to study their effect on the association between cynical hostility and symptoms. All analyses were repeated with cynical hostility as a continuous variable and the observed associations were essentially the same (data not shown).

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION NOTES REFERENCES

 
Table 1 shows that scores of cynical hostility for both men and women showed a graded increase along the 6 social classes. The prevalence of high cynical hostility in social class VI (transfer income) was nearly 4 times as high as in social class I among both men and women. A much higher prevalence of high symptom load was reported in social class VI compared with the other social classes, reflecting the fact that this group includes a large proportion on transfer incomes due to sickness. All risk behaviors followed a more or less clear social gradient for both men and women. Social class is therefore an obvious and potentially strong confounder for the effect of hostility on both health behavior and symptom load. Thus, the effect of hostility on all health behaviors was attenuated when adjusting for social class in the analyses (Table 2). This was most pronounced for the effect on physical activity, which showed a reduction of odds ratio for men from 2.8 (1.8–4.3) to 1.8 (1.1–3.0) and for women from 3.9 (2.6–6.1) to 2.6 (1.6–4.3).

View this table: [in this window] [in a new window]   TABLE 2. Odds Ratios (95% CI) for Health Risk Behaviors by Cynical Hostility Adjusted; 40- and 50-year-old Danish Men and Women Scoring 8 on the Cynical Distrust Scale is Reference

	DISCUSSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION NOTES REFERENCES

We found a higher rate of health risk behaviors among hostile people, which has also been demonstrated in other studies (15–19). However, the hypothesis that health risk behaviors mediate the effect of cynical hostility on symptom load was not supported by the analyses. The effect of hostility on health risk behaviors was reduced by social class. Furthermore, the effect of hostility on symptom load attenuated after inclusion of social class in the model. This is consistent with other studies (20,21), including the Dutch population study by Schrijvers et al. (22), which used perceived general health as the outcome. On the other hand, this independent, negative effect of cynical hostility on health does not correspond with the results found by Everson et al. (10) in the population study among middle-aged Finnish men. One possible explanation of this divergence is that the population included in our study is relatively young. Consequently, the health-damaging effects of the health risk behaviors recorded had not yet expressed themselves in measurable health outcomes in our population sample of 40- and 50-year-olds. Another explanation lies in the difference between the health outcomes used in the studies. The outcomes used in the study by Everson et al. were objective register-based information on all-cause and cardiovascular mortality and incident myocardial infarction. In the present study, we used self-reported symptoms experienced within the last 4 weeks, which may have a variety of different determinants and less clear associations with health risk behaviors than coronary heart disease or mortality. Still, our study suggests that cynical hostility is associated with common health problems that manifest themselves in a high symptom load. The symptoms used in our study are the kind of discomforts experienced by a large proportion of the Danish population (27,28); consequently, they should be considered a public health problem in their own right as they lead to overmedication, sickness absence (35), and depleted life quality.

Our study has several potential limitations. First, the issue of reverse causation, via the mechanism that perceived symptoms (ie, poor health) generate hostility, cannot be completely excluded (36). Unfortunately, we had no information on medical history; consequently, this variable could not be added to our multivariate models. Still, longitudinal studies have confirmed the associations between hostility on health that are unlikely to be accounted for by negative health selection (37), and we find it less plausible that a major part of the effect found in this study can be explained by reverse causation. Our study included social class VI, which in Denmark is a heterogeneous group consisting of both people on short-term unemployment benefits, various social security benefits (such as housing subsidy, economic support for heating, child benefit, etc.), and long-term disability pension and sickness benefits. Health status has a reversed effect on social class; as social class VI in our study included a large proportion of people who are sick (in this case 47% of the group), the confounding effect of social class might therefore be overestimated. However, we repeated all analyses excluding social class VI and this did not substantively change the results.

The cross-sectional design also creates a potential bias because symptoms, health risk behaviors, and hostility might be interdependently misclassified (ie, that the way people answer the hostility and behavior questions might be influenced by their current health status and vice versa). The reporting might also be influenced by some third factor such as personality traits. In the present study, we checked this inherent risk of reporting bias by repeating all analyses using nonfatal heart disease in 2000 as outcome (International Classification of Diseases, 10th revision, ICD-10, diagnosis codes I20-I52). For the sake of power in the analyses, we included gender in the 3 models and ran model 3 separately for each behavioral variable. Compared with model 1, the effect of hostility remained nearly unchanged when each of the 4 health behavior variables were included. Odds ratios were 2.4 (1.4–4.3) in model 1, 2.3 (1.2–4.3) in model 2, and ranging from 2.1 (1.1–4.0) for BMI to 2.6 (1.4–5.0) for alcohol in model 3. Information on hospital admissions was obtained from the National Patient Register, which covers all admissions to hospitals in Denmark with less than 1% of all hospital beds being private. Thus, the results found in these analyses make it unlikely that any bias due to response style would seriously limit our main results.

Using self-reported data on health behaviors may introduce the risk of measurement error in the behavioral variables included and affect their ability to mediate. Moreover, the health risk behaviors included in our study are only measured at 1 point in time, which may lead to an overstating of the independent effect of Cynical Hostility. However, all 4 behavioral variables included in the analyses maintained their predictable effect on the outcome throughout every step of the logistic regression models performed. In addition, we do not think that reports of health behaviors are much influenced by the respondents’ general psychological disposition.

Socioeconomic position was a strong confounder for the effect on health behavior. The 2 studies, by Harper et al. (26) and by Lynch et al. (25), have shown that the accumulation of adverse socioeconomic conditions over the life course influences the level of cynical hostility and so residual confounding should be considered in the analyses (38, 39). Including vocational training in the model did not change the estimated effects of hostility, but accumulated social exposures over the life course might involve some residual confounding.

Confidence limits for especially the health behavior variables did in many cases include 1.0, but the estimate for cynical hostility was almost not affected by the inclusion of health risk behaviors into the model. The fact that the effect of socioeconomic position on high symptom load was insignificant for social class II and III (males) is most likely a result of power. We did test trend across categories of social class, which showed p < 0.0001. Finally, we decided to let our conclusions depend on effect sizes and effect patterns, which were graded when social class was included in our models.

Our study is 1 of the very few population studies on cynical hostility and health, which includes a large sample of women. The lower response rate among people with less education and lower employment rate may have influenced the association between cynical hostility and symptom load. We expect a higher level of cynical hostility and symptom load among the nonparticipants, which suggests that the analyses underestimate this association. The very high prevalence of cynical hostility in the lowest social class found in this study is in accordance with other studies (20,23,24,40) and may be explained by the adverse circumstances, negative life events, and psychosocial stress experienced by people with low socioeconomic position (25,41–44).

Further studies on the effect of cynical hostility on self-reported health should focus on this strong and simultaneous association between low socioeconomic position and cynical hostility.

	NOTES

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION NOTES REFERENCES

 
Supported by The Danish Research Councils (j.nr. 9801268).

Received for publication January 24, 2003.

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