Stress and stress resistance resources among male dentists

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Title:
Stress and stress resistance resources among male dentists
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xii, 188 leaves : ; 28 cm.
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English
Creator:
Klement, Elizabeth Cline, 1952-
Publication Date:

Subjects

Subjects / Keywords:
Dentists -- Job stress -- Florida   ( lcsh )
Stress (Psychology)   ( lcsh )
Adjustment (Psychology)   ( lcsh )
Genre:
bibliography   ( marcgt )
non-fiction   ( marcgt )

Notes

Thesis:
Thesis (Ph. D.)--University of Florida, 1988.
Bibliography:
Includes bibliographical references.
Statement of Responsibility:
by Elizabeth Cline Klement.
General Note:
Typescript.
General Note:
Vita.

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Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
aleph - 001123840
notis - AFM0892
oclc - 20071174
System ID:
AA00002141:00001

Full Text













STRESS


AND STRESS RESISTANCE
AMONG MALE DENTISTS


ELIZABETH


CLINE


RESOURCES


KLEMENT


A DISSERTATION PRESENTED TO
THE UNIVERSITY
IN PARTIAL FULFILLMENT OF T
DEGREE OF DOCTOR


THE GRADUATE S
OF FLORIDA
HE REQUIREMENTS
OF PHILOSOPHY


SCHOOL

FOR


OF

THE



























Copyright


1988


Elizabeth


Cline


Klement




























This


dissertation


have
not

THOMAS


been
for


would


not


possible i
my husband


. KLEMENT,


D.M.D.


to whom


I dedicate


this


work














ACKNLOWLEDGEMENTS


A number


special


people


have


been


an important


part


thi


heartfelt


dissertation


appreciation


experience.


their


I wish


express


contributions,


encourage-


ment,


interest,


and


support.


First,


aid


I would


and


like


support


thank


role


. Roderick


as committee


. McDavi


chairman.


Rod'


guidance,


support,


and


friendship


have


been


invaluable


not


only


as committee


chair


but


also


as my


faculty


advisor


over


a 14-year


period.


I appreciated


his


patience,


respected


judgments,


valued


standards


of excellence,


and


needed


unswerving


belief


that


I would


indeed


complete


thi


degree.


wish


to thank,


also,


the


other


members


committee,


each


of whom


made


special


contributions.


thank


. Paul


. Fitzgerald


, for


encouragement


during


the


tough


times;


. Jane


. Myers


, for


her


diligence


and


constructive


criticisms


in reading


the


manuscript;


and


Wallace


Mealiea,


his


knowledge


of stress


dentists.


I extend


a special


thank


you


to Dr. Peggy


Fong,


S S


w ~ ~ ~ ~ ~ ~ ~~r amr A- I, CI -. 4---l-A .. iet


___ *~


mrrrrk~u,


AF CkA


1-,^-


* I I


CA~









helping


me conceptualize,


operationalize,


and


write


the


research


proposal


was


invaluable.


A number


of other


people


made


important


contributions,


directly


or indirectly,


effort.


I wish


thank


Arnold


White,


Jr.,


his


willingness


write


introductory


letter


to the


mail


survey.


His


contribution


was


especially


significant


because


the


personal


challenges


cancer.


was


thank


suggestions


facing

Marie S


writing


his


timpinsk


the


mail


heroic

i for


battle


her


survey.


helpful


I wish


Sharon


list,


Ross


letters,


her


envelopes,


and


work


the


the


mail


mailing


survey.


appreciated


her


commitment


to get


the


survey


out


on time


and


her


willingness


to work


around


the


clock


to meet


deadline.


I also


want


thank


Sharon'


daughter


Nicole


her


assistance


in stuffing


the


envelopes


also


wish


thank


Adele


Koehler


her


expert


typing


skills


and


her


commitment


to meeting


the


deadline.


thank


Kevin


McKillop


his


consultations


on the


data


analyses.


heartfelt


dear


gratitude


friend


her


Mickie


listening


Miller


ear,


I extend


intellectual


stimulation,


moral


support,


and


knowing


so well


what


like


to write


a dissertation.


Sharing


this


experience


with


her


made


the


difference.


against


tireless


thank


preparing


postcards









Each


of them,


their


own


special


way,


provided


the


special


"mothering"


children


needed


so I could


away


from


them


without


feeling


"too"


guilty.


I wish


express


sincere


appreciation


the


more


than


dentists


the


state


of Florida


who


gave


of their


time


to contribute


to this


attempt


to further


understand


the


stress


they


experience.


I would


like


thank


family


their


innumerable


contributions


this


effort.


thank


parents,


Cranmore


Lucile


Cline,


the


gifts


the


love


of learning


and


pride


educational


achievement


which


have


inspired


this


pursuit


the


Ph.D.


degree.


I deeply


appreciate


the


help


they


provided


me on my


many


trips


back


and


forth


between


Petersburg


and


Gainesville.


am especially


thankful


mother'


assistance


delivering


the


final


drafts


to the


typist,


the


copy


center,


and


the


committee


members.


thank


three


children,


Kristen


Elizabeth


Klement


(5),


Katherine


Victoria


Klement


(3),


and


Robert


Thomas


Klement


(2),


who


have


provided


me the


balance


and


diversity


I needed.


this


They


project


were


first


either


began.


very

I hope


young

that


or as yet

as they g


unborn


row


when


can


inspire


each


them


a dream


the


determination


reach


a high


goal.









dentists.


I appreciated


his


patience


with


almost


total


absorption


this


project


many


months.


thank


him


serving


as a sounding


board


and


providing


much


needed


emotional


occasions


his


support.


many


hours


also


relied


tedious


on him


labor


on numerous


helping


prepare


and


sorting


materials


the


project.


Additionally,


I could


not


have


accomplished


this


without


his


unfailing


sense


of humor,


encouragement,


love,


pride


accomplishments.


has


meant


a great


deal


to have


wonderful


partner


to share


this


endeavor


with


me.


















TABLE OF CONTENTS


Page


ACKNOWLEDGEMENTS......................................







CHAPTERS


I INTRODUCTION..................... ............ ...


Statement of the Problem...
Purpose of the Study.......
Need for the Study.........
Significance of the Study..
Definition of Terms........
Organization of the Study..


.a .a . C .
. C .


. . . .
S a
. .........cCC
.............
.............
.............
.............


........
........
........

........
......g..
* .00*0*C C0
*0C.0*0*06C0
* IOOODO. C
*0a.00000*


REVIEW OF THE LITERATURE........................


Stress...... . ... .....................
Historical Overview....................
Theoretical Models of Stress..........
Measurement Techniques.................
Stress in Dentistry........................
Stressors in the Practice of Dentistry.
Stress Response in Dentists............
Satisfaction...............................
Theories of Satisfaction...............
Career Satisfaction of Dentists........
Mediator Variables in the Stress Process...
Hardiness....*C.... ......... ........ ...
Coping............... .. ..............
Social Support.........................
Health Practices and Exercise..........
Health practices..................
Exercise..........................
Summary....................................


.....











Page


The Index of Well-Being....................
The Dental Stress Inventory.................
The Hardiness Test..........................
Coping Responses............................
The Vulnerability Scale of the Stress Audit.
Demographic Questionnaire...................
Data Collection.................................
Data Analysis.................................
Limitations of the Study.......................


IV RESULTS AND DISCUSSION.......................... 113


Results...e..................
Research Question One....
Research Question Two....
Research Question Three..
Research Question Four...
Career satisfaction.
Life satisfaction...
Intercorrelations...
Research Question Five...
Strain..............
Career satisfaction.
Life satisfaction...
Discussion...................


. . . .
.....0.....00


............ .
. .. .......
.............


. .a. C . C
..........000
.............


. C C . C C C
.............
.............
.............
C .*.CC .C C C
. "


....0


.....




.....
.....
0...0


C CS C


CONCLUSIONS, IMPLICATIONS, SUMMARY, AND
RECOMMENDATIONS................................. 151


Conclusions.............................
Implications............................
Summary......................... .......
Recommendations for Future Research......


.....I.
0000...
.......
..0.000


APPENDICES


A INSTRUMENTS..................................... 160


B COVER LETTERS FOR SURVEY QUESTIONNAIRE.......... 167


REFERENCES............................ ........... ... 170


BIOGRAPHICAL SKETCH................................... 187














LIST


OF TABLES


Table


Page


Frequency and Relative
Demographic Variables.


Frequency


Distributions


Means and
Criterion

Analyses
Meetings


Standard Deviations
Variables..........


of Predictor


Variance of Frequency
Other Variables.......


and


Staff


Analyses
Practice


Variance of Role
Other Variables.


of
. .


Spouse
. ..0 0.


the


Stepwise
Between


Regression
Strain and


Analysis of
the Predictor


the Relationship
Variables.......


Stepwise Regression Analysis
Between Career Satisfaction
Variables...................


of
and


the
the


Relationship
Predictor


Stepwise Regression Analysis
Between Life Satisfaction and
Variables.................. ..


Correlation
Continuous


of the Relationship
the Predictor
. . *


Matrix Intercorrelations Among All
Predictor and Criterion Variables..


Simple Linear
Relationship
Variables and


Simple Linear
Relationship
Variables and

Simple Linear
Relationship
Variables and


Regression Analysis of
Between Stressors With
Strain................


Regression Analysis of
Between Stressors With
Career Satisfaction...

Regression Analysis of
Between Stressors With
Life Satisfaction.....


the
the Mediating


the
the Mediating


the
the Mediating










Abstract
of the U


of Dissertation


university


Requirements


Presented


of Florida


Degree


to the


Partial
of Doctor


Graduate


School


Fulfillment of
of Philosophy


the


STRESS


AND


STRESS


RESISTANCE


RESOURCES


AMONG


Elizabeth


MALE


DENTISTS


Cline


Klement


December


1988


Chairman:


Roderick


. McDavis


Major


Department


Counselor


Education


The


purpose


of thi


study


was


to describe


stress


role


of stress


resistance


resources


in male


dentists.


Specifically,


relative


using


effects


the


transactional


of hardiness,


coping


model

style,


stress


social


the


support,


and


health


practices


the


stressors-strain/satisfaction


relationship


male


dentists


were


explored.


The


sample


included


male


dentists


actively


involved


in practice


randomly


selected


from


the


membership


list


the


Florida


Dental


Association.


Participants


completed


questionnaires


assess


their


levels


of strain,


career


satisfaction,


life


satisfaction,


stressors,


hardiness,


coping


styles,


social


support,


health


practices,


and


demographic


characteristics.


One


finding


study


was


that


the


participants


reported


moderate


levels


of stressors,


strain,


hardiness,


career


sati


sfaction,


moderate


to high


levels


of social









certain d

spouse, d

meetings,


demographic


lays

typ


variables


of continuing

e of practice,


(years


education,

religious


practice,


frequency

preference


role


of staff

, income,


and


marital


status)


and


the


other


measures.


A third


finding


was


that


strain


was


positively


predicted


stressors


and


avoidance


coping


and


negatively


predicted


hardiness,


social


support,


and


role


the


spouse.


A fourth


finding


was


that


career


satisfaction


was


positively


predicted


income,


frequency


staff


meetings,


active-behavioral


coping,


and


hardiness,


and


negatively


predicted


religious


preference.


predicted


contrast,


hardiness,


life


social


satisfaction


support,


was


health


positively

practices,


and


role


the


spouse,


and


negatively


predicted


stressors.


A fifth


finding


was


that


hardiness,


avoidance


coping,


and


stressors


was


the


optimum


subset


predictors


strain


male


dentists.


Hardiness


, social


support,


and


health


practices


served


as mediators


the


stressors-life


satisfaction


relationship


among


male


dentists.
















CHAPTER I
INTRODUCTION


Nowadays, e
stress. Yo
daily conve
radio, in t
increasing
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same way or
definition.
as frustrat
traffic con
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chemical ev
tension. T
every human


everyone seems
u hear about
rsation but a
he newspapers
number of con
courses devot
few people de
even bother
The business
ion or emotion
troller, as a
ist and endoc
ent; and the
his list coul


exp


eri


surprisingly, most
accountants, short
surgeons--consider


stores
that
the c
death
been
the c
(Sely


sful.
ours
avema
from
just
rash
e, 19


Simi
the
s fe
unge
str
the
, P.


ence
peop
-orde
their
rly,
age o
of a
cold
sful
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7)


to b
this
Iso o
, and
feren
ed to
fine
to at
spers
nal t
prob
rinol
athle
d be
r act
e--be
cook
own
ost c


e
t


0


talking about
pic not only


n television
in the eve
ces, center
stress. Y
the concept
tempt a cle
on thinks o
ension; the
lem in conc
ogist, as a
te, as music
extended to
ivity, and,
they chart
s, [dentist


O
o


ccupat
mmenta


i
t


stress," for
tack by wild
or exhaustion
s our fear of


exchange,


n, v
r
s, a
et


a
f

e

u


e


in
ia


nd


in the
rcut
stress
air
ntration
purely
lar
almost
somewhat
red


s,]


on the
ors bel
getting
animals
n must
a world


;


There


are


many


reasons


dentists


experience


stress.


The


training


dentists


receive


competitive


and


long,


and


the


long-term


process


of establishing


and


maintaining


a dental


practice


demanding.


Dentists


often


work


long


hours,


with


anxious


fearful


patients,


who


may


have


a poor


public


or
most
ieve
that
or of
have
d war,


or overpopulation.


I









benefit


professional


social


support


that


other


occupations


enjoy


Since


"stress


a threat


the


quality


life,


and


to physical


and


psychological


well-being"


(Cox,


1978


cited


(albeit


dentists


are


controversial)


a population


statistics


at risk.


confirm


Frequently


that


dentists


have


a higher


than


average


rate


of physical


and


psychological


symptoms


that


are


considered


the


outcomes


high


stress.


Some


these


outcomes


include


coronary


heart


disease


(Russek,


1962),


suicide


(Blachly,


Osterud,


Josslin,


1963)


, divorce,


alcoholism,


and


drug


abuse


(Clarno,


1986)


The


effect


of occupational


stress


in the


development


physical

Calhoun,


and


1980)


mental


The


illness


National


well


established


Institute


(Calhoun


Occupational


Safety


and


Health


(NIOSH)


studied


the


relative


incidence


mental


health


disorders


occupational


categories


(Colligan,


Smith,


& Hurrell


, 1977)


The


study


revealed


that


seven


the


top


27 occupations


were


in the


health


care


field.


A recent


researcher


on high


stress


occupational


groups,


however


, did


not


find


such


a clear


cut


link


between


stress


and


decreased


phys


ical


and


mental


health


(Kobasa,


1979,


1982


Stress

identified


researchers

to be at high


have


examined


risk to


the


occupational


damaging


groups


effects


. v),









controllers


(Rose,


administrators


Jenkins,


(Orpen


& King,


Hurst,

1986) ,


1978) ,


university


commercial


airline


pilots (

General

experien


Sloan


findings

ce a grea


Cooper,


1986),


indicated


deal


that


of job


and


dentists


while

stress


these


(Katz, 1987)

individuals


not


did


them


showed


the


physical


and


psychological


symptoms


thought


to be


outcomes


stress.


Apparently


there


are


differences


ways


that


individuals


respond


to stress.


Some


individuals


become


while


others


show


no debilitating


signs


of stress


and


may


actually


thrive


under


stress


(Kobasa,


1979).


These


differences


can


be explained


through


the


transactional


model


of stress


which


maintains


that


stress


resides


neither


the


situation


nor


the


person


but


the


transaction


between


the


environment


situation)


and


the


person.


The


stress


response


is experienced


the


person


a result


of a stressful


transaction


between


the


person


the


environment


(Matheny


, Aycock,


Pugh,


Curlette,


Cannella,


1986)


The


stress


process


begins


with


demands


made


on the


person.


According


to Lazarus


(1966,


1981) ,


the


principal


spokesman


these


transactional


approaches,


demands


events


calling


adaptation


on the


part


the


person


lead


to two


forms


cognitive


appraisal


primary


appraisal








result


not


only


from


characteristic


ways


appra:


rising


demands


and


resources


but


from


the


individual'


habitual


style


of relating


to events


and


structuring


life


(Matheny


et al., 1986)


The


transactional


model


of stress


represents


a turn


away


and


from


illness


traditional


indicators


stress


were


research


measured


which


and


stress


correlated.


scores


Thi


model


also


signifies


serious


consideration


individual


differences


as well


as the


optimistic


view


that


some


people


do remain


healthy


(Rabkin


& Struening,


1976).


Hence,


researchers


have


proposed


the


idea


that


there


are


moderator


Johnson


or mediating


Sarason,


1979)


variable


or resistance


(Antonovsky,

e resources


1979

that


mediate


life


the


events


connection


the


between


onset


the


physical


occurrence


and


of stressful


psychological


symptoms.


As Johnson


Sarason


(1978),


Kobasa


(1979)


and


other


investigators


debilitated


even


have


though


shown

they 1


, many


ive


persons


quite


are


stressful


not

lives


Stress


res


instance


been


associ


ated


with


a wide


variety


resources


including


personality


characteristics


such


hardiness


1984;


(Kobasa,


Pearlin


(Billings


1979) ,


Schooler,


& Moos,


1981;


coping

1978),


Cobb


styles

perceiv<


, 1976;


(Lazarus

ad social


Schaefer


& Folkman,

support


, Coyne,


Lazarus,


1981;


Thoits,


1986)


health


practi


ces


(Wiebe









Statement


the


Problem


Although


relatively


new,


concept


there


of stress

initial em


resistance


pirical


resources


support


documenting


the


importance


of mediating


or moderator


variables


the


stress-illness


relationship.


Kobasa


(1979)


studied


the


personality


factor


hardiness--characterized


commitment,


control,


and


challenge--as


a conditioner


the

male


effects of stressful

business executives


life

and


events

lawyers


on illness


(Kobasa,


onset


1982


Results


both


studi


indicated


individuals


high


hardiness

individual


Other

hardiness


remained


low


researchers


combination


healthy under

hardiness did


have i

n with


high

not


stress

remain


investigated


other


the


mediating


while

healthy


effects

variable


such


as exercise


(Kobasa,


Maddi


, & Puccetti,


1982


social


support


(Kobasa


& Puccetti,


1983) ,


health


practi


ces


(Wiebe


McCallum,


1982


1986) ,


Katz


and


(1987)


social


found


support


that


and


hardiness


exerci


was


(Kobasa,


more


predictive


both


stress


career


satisfaction


dentists


than


were


any


the


situational


factors


inherent


within


the


practice


of dentistry


Another


investigator


examined


the


relationships


between


stress


and


satisfaction


level


and


hardiness,


social


support,


and


coping


strategies


academic


multinle-role


persons


ammond.


1987)


J- J


.


II


.









and


personality


characteristics


on psychological


symptoms


2300


Chicago


adults.


Results


indicated


the


effective


coping


modes


are


unequally


distributed


society,


with


men,


the


educated,


effective


and


coping


affluent


styles.


making


Billings


greater


and


use


Moos


the


(1984)


most


found


that


coping


and


social


resources


did


not


mediate


the


stress-


psychological


symptoms


relationship


a large


group


clinically


depressed


patients.


Social

mediating v


support


variable


has

and


been


yet


the


the


most


results


frequently


are


researched


inconsistent


whether


mediates,


or serves


as a buffer


between,


stre


ssful


events


psychological


distress.


Several


studies


have


found


that


social


support


significantly


negatively


correlated


with


psychiatric


symptoms


(Eaton,


1978;


Lin,


Ensel,


Simeone,


& Kuo,


1979;


Wilcox


, 1981)


LaRocco,


House,


and


French


(1980)


found


that


social


support


did


buffer


stress


and


mental/physical


health


a large


group


men


from


23 occupations;


however,


did


not


buffer


relationship


between


stress


and


dissatisfaction.


The


opposing


view


reflected


data


gathered


from


middle-aged


sample,


which


did


find


that


social


support


was


beneficial


because


mediated


effects


of stressful


events


(Schaefer


et al.


, 1981).


There


are


also


apparent


differences


the


importance









effects


life


stress


in women,


but


that


did


not


function


as a stress


resistance


factor


for


men.


Instead


work


environment


support


men


appears


(Holahan


to be


& Moos,


a more


1982;


important


Kobasa


source


& Puccetti,


1983).


Wellness


factors


such


as health


practi


ces


and


exerci


also


have


been


proposed


as mediating


variable


, although


ess


frequently


than


the


others


Kobasa


(1982


found


that


exerci


and


social


support


did


not


significantly


affect


degree


of strain


reported


lawyers.


Yet, in


another


study,


executives


high


both


hardiness


and


exercise


remained


more


healthy


than


those


high


in one


or the


other


(Kobasa,


Maddi,


Puccetti,


1982).


Wiebe


and


McCallum


(1986)


found


that


hardy


college


students


may


more


healthy


because


they


maintained


better


health


practices


while


experiencing


stress


than


did


nonhardy


individuals.


In spite


the


fact


that


numerous


artic


have


appeared


the


dental


literature


regarding


the


stressors


experienced


dentists,


have


been


based


on empirical


research.


Only


one


researcher


has


examined


the


effects


any


mediator


variable


on the


stress-illness


relationship


dentists

related


Katz


to lower


(1987)

level


found


hardiness


of stress


and


to be


significantly


psychiatric


symptoms


and


higher


level


career


sati


faction


experienced









years


both


stress


professional


of dentistry


and


and


the


public


purported


literature


inordinately


about


high


incidence


of suicide,


coronary


heart


disease,


alcohol


and


drug


abuse,


divorce,


depression,


and


other


problems


presumed


to be stress


related


among


dentists


(Howard,


Cunningham,


Rechnitzer,


Goode,


1978;


Katz,


1978)


However,


recent


evidence


indicates


that


the


case


high


suicide


rates


among


dentists


may


have


been


overstated


(Temple


University,


1976)


Yet


tion


the


courses,


frequency


and


of articles,


professional


books,


meeting


continuing


presentations


educa-

on the


topic


of stress


among


dentists


reflects


that


the


profession


as a whole


perceives


members


to be highly


stressed


their


work


settings.


Even


dentists


do not


differ


from


others


the


incidence


of stress


related


problems,


the


belief


that


they


do has


at least


reached


the


level


of widely


accepted


folklore


with


the


profession


and,


an increasing


extent,


with


the


general


public.


Purpose


the


Study


The


purpose


this


study


was


to describe


stress


and


the


role


of stress


resistance


resources


male


dentists.


Specifically,


using


the


transactional


model


of stress,


the


relative


mediating


effects


of hardiness,


coping


style,


social


sunnort


and


health


practices


'-.


the


stressors-


.


L


i









Need


the


Study


While


much


has


been


written


about


the


apparent


stress


of dentists,


actual


empirical


research


scant.


The


statistically


based


studies


that


have


been


conducted


suffer


from


serious


shortcomings


both


methodology


and


theoretical


conceptualization


(Howard


et al.,


1976;


O'Shea


et al.,


1984)


To date


there


has


been


only


one


researcher


(Katz,


1987)


who


interpreted


data


within


a theoretical


model


of stress


as a transaction


between


the


person


and


the


environment.


Most


articles


the


professional


and


lay


press


which


promote


the


image


of dentistry


as a highly


stressed


occupation


often


refer


the


"fact"


that


dentists


have


highest


suicide


rate


of all


professionals.


The


data


this


"fact"


come


from


an Oregon


study


(Blachly


et al.,


1963).


The


finding


indicated


that


from


1950


to 1956


dentists'


suicide


rate


was


higher,


about


six


times,


than


that


average


white


male


population


of Oregon


(and


highest


of all


prof


ess


ions


included


the


study).


However,


the


succeeding


five


years,


1957


to 1961


(years


not


included


the


study),


dentists'


suicide


rate


was


about


twice


that


the


general


population


and


about


the


equivalent


of physicians'


and


attorneys'


rates


Aver"


and


Mnrett


(19FR5


stated


that


dentistry


mav


not


*





-10-


dentists


are


not


as vulnerable


to the


negative


aspects


stress


as other


groups.


Money


can


buy


many


resources,


including


time


and


opportunities


exercise


and


vacations,


of which


may


mediate


the


effects


of stress.


The


extent


to which


one


has


control


or perceives


oneself


to have


control


over


potentially


negative


stressors


appears


reduce


the


adverse


consequences


of such


stressors.


These


authors


proposed


that


dentists


have


learned


or have


available


to them


relatively


appropriate


and


effective


means


dealing


with


stressors.


concept,


however,


seemingly


based


transactional


model


of stress


which


views


stress


as the


interaction


between


the


person


and


environment,


needs


to be empirically


tested


in a group


practicing


dentists.


Before


success


intervention


approaches


can


developed


to help


dentists


deal


with


their


professional


stressors,


basic


research


must


conducted


to determine


the


degree t

stressed


o which


their


dental


practitioners


occupational


es.


perceive


themselves


In addition,


attempt


should


be made


to systematically


identify


and


determine


relative


contribution


of the


factors


contributing

The tra


to dentists'


nsactional


strain


model


and


sati


stress


sfaction.


(Lazarus


Folkman,


1984)


has


been


studied


a limited


manner


with


samples






-11-


health.


Empirical


research


does


provide


evidence


about


mediating


effects


of such


stress


resistance


resources


personality


characteristics,


coping


styles


, social


support,


health


practices,


and


exercise.


There


have


been,


however,


no studies


that


have


adequately


investigated


the


effects


of each


of these


mediating


variables


the


same


study


In only


one


study


has


stress


and


accompanying


satisfaction


experienced


dentists


been


investigated


(Katz,


1987)


Clearly,


there


a need


to explore


the


effects


of multiple


moderator


variables


and


to investigate


the


applicability


the


transactional


model


of stress


with


a broader


population.


SiQnificance


the


Study


Information


about


stress


and


satisfaction


dentists


the


joint


mediating


of hardiness,


coping


styles,


social


support,


health


practices


has


significance


number


areas.


the


area


theory,


the


results


study


will


have


implications


the


transactional


theory


stress


investigating


the


joint


effects


of multiple


moderator


variable


es.


In the


area


of research,


the


results


the


study


will


make


a significant


contribution


the


dental


literature


as well


as the


stress


literature.


rnstil ts


lJ. I


the


studv


will


have


far-reachina


vbha






-12-


field.


Finally,


information


the


results


counselors


who


thi

are


study


concern


will p

d with


provide

such


matters


as person-environment


fit,


and


personal


growth


and


wellness


(Matheny


et al.


, 1986)


dentists


experience


high


level


stress


or low


level


sati


sfaction,


some


them


are


likely


to seek


the


help


counselors.


counselors


are


knowledgeable


about


stress


and


sati


faction


dentists


hardiness,


and


the


coping


relative


styles,


importance


social


support,


of mediators


and


such


health


practi


ces


, they


may


be better


prepared


to help


dentists


well


as others


high-stress


occupations.


Definition


Terms


A number


terms


will


be used


throughout


this


study


and


thus


require


further


elaboration


and


definition.


Career


satisfaction


an individual'


attitude


toward


one'


present


career,


essentially


comprised


of feelings


being


actualized


(having


a good


between


career


and


ability


and


interests)


and


feelings


being


successful


(Osherson


& Dill,


1983)


Cognitive


appraisal


denotes


the


way


people


construe


the


significance


of encounters


for


their


well-being,


that


, as


irrelevant


, benign


, harmful,


threatening,


or challenging


annrn l (T


fJ.A SI ratCn


aC raE~


*tLE wA r


Fn __mirr


InLL~u


rlYA


N






-13-


internal


the


demands


resources


that

the


are appraised

person (Lazarus


as taxing c

& Folkman,


r exceeding


1984,


141)


CoDina


style


a person'


general


propensity


to deal


with


stressful


events


a particular


way


Specifically,


cognitive


and


behavioral


reactions


that


are


performed


reduce


or eliminate


psychological


distress


or stressful


conditions


(Billings


& Moos,


1981)


Dentists


thi


study


are


men


actively


involved


the


practice


of dentistry


and


who


are


also


members


the


Florida


Dental


Association.


Hardiness


describes


a constellation


three


personality


characteristic


that


function


as a resistance


resource


encounter


with


stressful


life


events,


including


ability


to feel


deeply


involved


or committed


the


activities


their


lives,


the


belief


that


one


can


control


or influence


the


events


their


experience,


and


the


anticipation


of change


as an exciting


challenge


further


development


(Kobasa,


1979).


Health


practices


refer


a variety


of positive


and


negative


behaviors


related


to dietary


practi


ces


, hygienic


practices,


recklessness,


substance


abuse


, and


exercise


(Wiebe


McCallum,


1986)


Life


satis


faction


denotes


people'


assessment


the





-14-


Mediatinac


variables


are


variables


that


mediate


moderate


the


connection


between


stress


on an individual


and


the


onset


of physical


and


psychological


symptoms


(Johnson


Sarason,


1979)


In this


study,


hardiness


, coping


style,


social


support,


and


health


practices


will


be investigated


mediating


variables.


Sati


sfaction


the


affective


orientation


on the


part


people


toward


they


are


presently


occupying


(Vroom,


1964)


Social


SUDPort


describes


the


extent


to which


individual


support,


believe


information,


that


and


their


needs


feedback


and


are


resources


fulfilled


(Procidano


& Heller,


1983)


Strain


psychological


or physical


consequences


associated


with


stress,


often


referred


to as the


stress


response.


In thi


study,


strain


defined


as a syndrome


physical,

elicited,


behavioral,


varying


cognitive


degrees


, by


symptoms


environmental


that


are


demands


upon


the


individual


(Lefebvre


& Sandford,


1985).


Stress


denotes


the


particular


relationship


between


people


and


the


environment


that


appraised


people


taxing


or exceeding


their


resources


and


endangering


their


well-being


(Lazarus


& Folkman,


1984,


Stressors


are


the


demands


made


on the


person


from


. 19)






-15-


as unequal


resources


and


viewed


as a stressor


(Matheny


al.,


1986).


Organization


the


Study


Chapter


II contains


a review


and


analysis


of the


related


literature


on stress,


stress


dentistry,


satisfaction,

specifically


and


mediating


hardiness,


variables


coping


style,


the


social


stress

support


process,

. and


health


practices.


methodology


the


a description


Chapter

study,


the


includes


including


population


the


a description


research


sample,


the


of the


questions,

instruments,


the


data


collection


procedures,


the


data


analysis,


and


the


limitations

discussion


the


of the


study.

results


In Chapter


are


IV the


presented.


results


Chapter


and


V includes


conclusions,


implications


the


study,


summary,


and


recommendations


future


research.















CHAPTER


REVIEW


OF THE


LITERATURE


In this

literature r


chapter,


relevant


a review


to the


and


areas


synthesis


of stress,


the


stress


dentistry,


satisfaction,


and


stress


mediating


variables


are


presented


Stress


Pioneer


stress


researcher


Hans


Selye


stated


that


"stress


is a scientific


concept


which


suffers


from


the


mixed


essing


of being


too


well


known


and


too


little


understood"


(Selye,


1980,


Although


stress


a difficult


concept


to define,


much


research


has


been


directed


understanding


various


phenomena


associated


with


Thi


section


includes


a historical


overview


the


stress


concept;


theoretical


models


of stress


also


are


reviewed,


along


with


measurement


techniques.


Historical


Overview


Refnre


""irni nrr


ton c'nntemimnorar v


science.


-I- t- -I-


useful






-17-


several


disciplines,


including


physiology,


endocrinology,


medicine,


sociology


, anthropology,


and


psychology.


However,


there


are


two


basic


traditions


which


research


has


thrived.


One


has


evolved


from


the


biological


perspective,


based


on research


physiology


and


endocrinology.


The


other


based


on a psychosocial


tradition.


Each


has


made


important


contributions


the


understanding


of stress


(Fleming,


Baum,


& Singer,


1984).


The


biological


tradition


has


roots


the


medical


interest


stress,


which


can


traced


back


to Hippocrates


in ancient


Greece


(Selye,


1985).


Physicians


the


19th


and


20th


centuries


hypothesized


that


stress


and


strain


could


lead t

(cited


o physical


illnesses.


Feuerstein


et al.,


In 1910,

1986) ob


Sir


serve


William

d that


Osler

the


lifestyle


of certain


businessmen


resulted


significant


strain


and


predisposed


them


to angina


pectoris.


Later


the


great


American


physiologist


Walter


Cannon


made


one


the


earliest


contributions


to stress


research.


Cannon


(1932)


used


the


term


stress


to describe


his


research


on the


fight-


or-flight


response,


that


when


an organism


perceives


threat,


the


body


rapidly


aroused


and


motivated


through


the


sympathetic


nervous


system


the


endocrine


system.


There


a concerted


physiological


response


which


mobili


zes


the


organism


to attack


the


threat


or to flee;


hence,





-18-


harmful


because


disrupts


emotional


and


physiological


functioning


and


can


cause


medical


problems


over


time.


Though


Cannon'


(1936)


work


very


important


understanding


stress,


work


Selye


(1956,


1976)


reflects


primary


popular


view


of stress


research


the


biological


community


Although


Selye


(1936)


initially


explored


the


effects


sex


hormones


on physiological


functioning,


he became


interested


the


stressful


impact


interventions.


Accordingly,


Selye


exposed


laboratory


animal


to a variety


of prolonged


stressors--such


as extreme


cold


and


fatigue--and


observed


their


physiological


responses.


To Selye'


surpri


stressors,


regard


ess


type,


produced


essentially


the


same


pattern


physiological


responding.


From


these


observations,


Selye


(1956)


proposed


the


general


adaptation


syndrome


(GAS)


theory,


a three-stage


process


that


describes


how


stress


affects


the


organism.


The


first


stage


process


alarm,


which


the


organism


mobilized


to combat


physical


demands


the


stressor


The


second


stage


is resistance,


which


the


organism


appears


to hold


own


against


the


still


present


threat


The


third


stage


is exhaustion,


which


occurs


the


organism


fail


overcome


threat


and


depletes


physiological


resources


the


process


of trying.


The


organism


seemingly






-19-


enough


to overwhelm


the


organism's


ability


to resist


(Fleming


et al.,


1984).


The


substantial


impact


of Selye'


work


on the


field


stress


continues


to be


felt


today


The


Selye


model


remains


a cornerstone


of the


field


of stress.


One


reason


that


offers


a general


theory


of stress


(Selye,


1976)


with


several


important


implications.


First,


the


implication


thi


theory


that


the


effects


of stress


are


cumulative.


That


, the


damage


produced


stressors


accumulates


over


time.


Second,


Selye


proposed


that


repeated


or prolonged


exhaustion


resources,


the


third


stage


the


syndrome,


was


responsible


the


physiological


damage


that


laid


the


groundwork


disease.


In fact,


prolonged


or repeated


stress


has


been


implicated


orders


such


cardiovascular


disease,


arthriti


, hypertension,


and


immune-


related


deficiencies


(Taylor,


1986)


In addition


the


biological


tradition,


there


psychosocial


, 1984)


perspective


Thi


on the


perspective


study


has


of stress


generated


(Fleming


a stream


research


that


is usually


independent


physiological


studies.


thi


view


,stress


the


reaction


organism


to demands


placed


upon


The


key


focus


within


this r

normal


ather

human


broad

s and


perspective

nonphysical


upon


stressor


healthy,

s. The


usually

emphasis






-20-


only


exists


when


the


person


undergoing


defines


such


A classic


provided


Speisman,


students


research

Lazarus


Lazarus ,


viewed


example


and


Mordkoff


a film


of thi


colleagues (

, & Davison,


of aboriginal


conception


,Lazarus,


1964)


subincis


stress

1966;


College


rites


(adult


circumci


sion


means


of stone


-age


tools)


Before


viewing


the


film,


they


were


exposed


one


four


experimental


conditions.


One


group


listened


intellectual


anthropological


description


the


rites.


second


group


heard


a lecture


that


deemphasized


the


pain


the


initiates


were


experiencing


and


emphasized


their


excitement


over


the


events.


Another


group


heard


a description


that


emphasized


the


pain


and


trauma


that


the


initiates


were


undergoing


The


fourth


group


heard


no sound


track.


Measures


autonomic


arousal


(heart


rate,


skin


conductance)


and


self


-reports


suggested


that


the


first


two


groups


experienced


considerably


ess


stress


than


did


the


group


whose


attention


was


focused


on the


trauma


and


pain.


film


stressor


itself


elicited


no universal


reaction.


Thus,


this


study


illustrates


that


stress


was


not


only


intrinsic


to the


film


itself


but


also


depended


upon


the


viewer'


appraisal


Although


there


are


several


definitions


the


stress






-21-


represent


stimulus


events


or demands


requiring


some


form


adjustment


or adaptation.


responses,


stress


Stressors


response.


usually


The


evoke


circular


a typical


nature


thi


definition


intentional.


believed


that


complex


feedback


system


between


stressor


and


stress


response,


with


each


influencing


the


other.


the


most


basic


level,


one


cannot


assume


with


certainty


that


a particular


stimulus


will


result


a stress


response


for


individual


Actually


the


stress-response-


producing


properties


of a stimulus


may


also


vary


over


time


situations


same


individual.


At a broader


level,


these


observations


suggest


that


a number


of factors


can


mediate


or moderate


the


stressor-stress


response


interaction,


thus


determining


the


ultimate


stress


experience.


These


mediating


factors


are


discussed


detail


a later


Theoretical


section


Models


chapter


Stress


Biobehavioral


scientists


have


created


several


theori


try


to link


environmental


phenomenon


(stressors)


with


psychological


or phys


ical


consequences


(stress


responses)


Currently,


there


are


three


ma3 or


theoretical


model


stress


stimulus-ba


sed,


response-based,


and


interactional


a


a~ ~ ,,,~ -S.- 1--- aa a u a--e a


,1


ni


YI11 r


*


I


1..~


L






-22-


demands


made


on the


person


(Selye,


1956).


Transactional


models


, on the


other


hand,


see


stress


as an


interaction


between


the


person


and


environment


(Coyne


& Lazarus,


1980;


Lazarus,


Kanner,


Folkman,


1980)


The


general


public


usually


thinks


of stress


according


a stimulus-based


engineering


model,


principles.


which


essentially


In considering


this


based


engineering-


oriented


model,


a useful


analogy


has


been


drawn


with


Hooke'


Law


of elasticity


cited


Cox,


1978) ,


which


describes


how


loads


produce


deformation


metals.


The


main


factors


Hooke'


Law


are


that


of "stress,


" the


load


demand)


which


placed


deformation


strain


which


produced


on the


metal,


results.


a given


and


The


that


law


stress


of "strain,


states


falls


that


within


the


" the

the


"elastic


limit"


the


material


, when


the


stress


removed


the


material


will


simply


return


original


condition.


However


, if


the


strain


passes


beyond


the


elastic


limit


then


some

that


permanent


just


damage


as physical


will


systems


result.


have


Thi


analogy


an elasti


suggests


limit,


people


have


some


built-in


resistance


to stress.


to a point


stress


can


tolerated,


but


when


becomes


intolerable


permanent

result.


damage,

There ar


physiological


,pears


and


to be great


psychological


individual


may


variation


resistance


to stress,


level


which


one


finds


easily





-23-


some


environmental


condition


(the


stimulus


or stressor)


an impact

examples


on the


person


of research


that


using


produces


theory


strain.


are


Clear


studi


stressful


occupations


(Rose,


Jenkins,


& Hurst,


1978)


and


life


events


research


(Dohrenwend


& Dohrenwend,


1974)


The


major


task


delineate


the


characteristics


of stressful


situations


Holmes


and


Rahe


(1967)


have


identified


and


classified


divorce,


stressful


change


life


of job,


events


vacation,


, such


etc.,


as death


and


a spouse,


attempted


determine


the


impact


of these


life


events


on individuals


This


approach


postulates


tha


treats s

t stress


tress


as the


the


form


independent


clusterin


variable

a life e


and


vents


results


strain


or tension


which


increases


the


risk


illness.


Response-based


models


emphasize


determination


stress


response


which


reflects


a situation


which


the


person


under


strain


from


a stressor


(Feuerstein


1986)


Studies


investigating


this


model


view


stress


as a


dependent

syndrome


variable.


(GAS)


Selye'


an example


(1956)


the


general


adaptation


response-based


concept


of stress.


Selye


emphasized


that


stress


the


person'


response


the


demands


the


environment


(Cox,


1978)


The


stress


response


a nonspecific,


universal


pattern


of defense





-24-


although


initially


adaptive,


severe


and


prolonged


may


result


disease


states.


way,


a decline


resistance


to stress


below


normal


levels


associated


with


the


development


of disease


and


physical


trauma.


Both


the


stimulus-based


and


the


response-based


models


of stress


focus


only


on one


aspect


of the


stress


experience,


either


the


stimulus


or the


response.


The


stimulus-based


model


has


major


weaknesses


failure


to identify


what


stressful


about


particular


real


-life


situations


and


to explain


individual


differences


(Cox


, 1978)


The


response-based


model


assumes


that


any


stimulus


which


produces


the


stress


response


must


be viewed


as a stressor


Thus,


some


activities


and


phenomena


which


are


not


generally


considered


stressors,


such


as exercise,


emotions,


and


fatigue,


would


be labeled


as such.


Furthermore,


straightforward


relationship


between


the


various


components


of the


stress


response


across


individuals


and


situations


been


defined


(McGrath,


1970).


more


recent


model,


the


transactional


model,


overcomes


some


these


problems.


Transactional


models


beyond


considering


only


stimulus


and


response


aspects


stress.


Stress


seen


an intervening


variable


between


stimulus


and


response


(Cox,


1978).


The


transactional


model


proposes


that


stress


occurs


through


the


relationship,


or interaction,


between


the


person






-25-


transaction


implies


a newly


created


level


abstraction


which


the


separate


person


environment


elements


are


joined


together


form


a new


relational


meaning"


(Lazarus


Folkman,


1984,


. 294)


approach


takes


into


account


characteristics


of the


person


on the


one


hand


and


the


nature


the


environmental


event


on the


other


Stress


viewed


as the


reflection


of a lack


of fit


between


the


person


and


environment.


concept


This


of illness,


view


which


parallels


no longer


the


seen


modern


medical


as caused


ely


an external


organism.


Whether


or not


illness


occurs


depends


also


on the


individual'


susceptability


One

Lazarus


version


and


of the


colleagues


transactional


, Coyne


model


& Lazarus,


is proposed


1980;


Folkman,


1984;


Folkman,


Schaefer,


& Lazarus,


1979;


Lazarus,


1966


1981


Lazarus


Folkman


1984


Lazarus


& Launier,


1978)


It is a cognitively


oriented


theory


of psychological


stress


are


and


viewed


coping


as being


which


dynamic


the


and


person


and


mutually


environment


reciprocal


Stress


is conceptualized


as a relationship


between


the


person


and


environment


that


is appraised


the


person


as taxing


exceeding


one'


resources


and


as endangering


one'


well


being.


The


theory


identify


two


processes


, cognitive


appraisal


and


use


coping


strategies,


as critical


mediators


of stressful


person-environment


relationships


and






-26-


particular


encounter


with


the


environment


relevant


one'


well-being


and,


what


way.


Lazarus


and


Folkman


(1984)


propose


two


kinds


appraisal:


involves


the


primary


and


individual'


secondary.


Primary


determination


appraisal


the


situation


positive,


irrelevant,


or stressful.


Stressful


appraisals


can


take


three


forms:


harm/loss,


where


the


damage


has


already


been


done;


threat,


where


there


potential


harm/loss;

trigger ne


and
*t


Igative


challenge.

emotions


Harm/loss


such


and


as fear


threat


or anger,


appraisals

whereas


challenge


triggers


positive


emotions


such


as excitement


eagerness


(Matheny


et al.,


1986) .


During


this


process


the


individual


appraises


the


level


of demand


of the


situation


(Cox,


1978).


Thus,


demand


based


on the


person'


perception


the


environment.


Demand


may


be external,


coming


from


the


environment


(such


as a work


deadline),


internal,


including


psychological


and


physiological


needs


and


expectations,


such


as the


expectation


that


one


can


everything


well.


In secondary


appraisal,


the


individual


assesses


resources


available


and


what


can


be done


about


the


situation.


Numerous


factors


influence


the


appraisal


process,


including


factors


relating


to the


situation,


the


person,


and


to the


coping


strategies


available


(Lazarus


& Folkman,






-27-


about


personal


control,


expectations


of ability


and


outcome


affect


the


appraisal


process.


Factors


relating


to coping


strategies


available


to the


person


include


problem


solving


skills,


social


skills,


social


support,


and


material


resources.


These


factors


interact


influence


how


individuals


with


appraise


The


the


person'


situation


appraisal


and


then


their


ability


influences


the


to deal


coping


strategies


tried.


The


individual


continually


reappraises


the


situation


and


possibilities


as new


information


from


the


environment

received.


and

How


from


the


the


person


person's


copes


own


reactions


is thought


are


to have


short-


term


and


long-term


consequences


in terms


of social


functioning,


morale


and


well-being,


somatic


health.


The


transactional


model,


as opposed


the


stimulus-


based


and


response-based


models


, has


the


strength


of not


focusing


on either


just


the


stressor


or the


stress


response.


Instead,


focuses


on the


interaction


between


the


person


the


environment


Furthermore,


allows


individual


differences


through


the


inclusion


of perceptions


of demands


and


resources.


It also


proposes


mediating


factors


that


help


explain


why


people


under


stress


do not


experience


effects.


Finally,


considers


positive


outcomes


such


morale


well-being


, rather


than


focusing


only


on negative


outcomes


such


as psychological


symptoms


or physical


illness.






-28-


Measurement


Techniques


Methods


studying


stress


vary


terms


of type


setting,


such


as a laboratory


or natural


environment,


and


mode


of measurement,


such


as physiological,


behavioral,


cognitive


(Feuerstein


et al.,


1986).


This


section


illustrates


stress.


several


First,


current


measurement


techniques


of stressors


measuring


discussed,


followed


the


measurement


of various


aspects


the


stress


response.


Stressors


represent


are


stimulus


demands


events


made


that


on the


require


individual.


some


The


form


adaptation


or adjustment.


Stressors


can


be external


physical


stimuli,


such


as cold,


heat,


loud


noises,


crowding,


or interpersonal


difficulties


with


a loved


one,


or internal


stimuli,


such


as physical


pain


or cognitions


including


thoughts


or feelings.


Stressors


can


be both


positive


negative;


fact,


positive


events


may


require


as much


adaptation


or adjustment


as negative


events.


Stressors


also


vary


considerably


across


individuals,


as well


as across


time


and


situations


the


same


individual.


Several


research


teams


have


worked


identify


and


scale


stressors


that


are


common


to most


people.


The


Social


Readjustment


Rating


Scale


(SRRS)


and


Schedule


of Recent


P __n r_ an


hoan


1coA1


m Acii r-1


nrP cstressr


ttlrft rIal


, C'D\


l 91r





-29-


promotion,


while


the


SRE


measures


the


frequency


these


life


changes


the


last


year


Numerous


studies


relating


life


events


to subsequent


phy


sical


illness


have


established


moderate


correlations


ranging


from


(Schroeder


Costa,


1984).


relationship


Although


has


been


study


very


the


popular


life


events-illness


stress


research;


recently


researchers


have


been


critical


the


ma3or


life


event


scales


and


many


questions


have


been


raised


about


methodological


problems


(Taylor,


1986)


In contrast


the


work


on major


life


events


, Lazarus


and


associates


developed


the


Hassl


and


Uplifts


Scales


(Kanner,


Coyne,


Scahefer


, & Lazarus,


1981)


assess


the


role

and

are


of minor


their

the i


stressful


cumulative


rritating


events


impact


both


on health


, frustrating


negative


and


distre


and


illness.


ssing


deman


positive,

Hassles

ds that


characterize


everyday


transactions


with


environment.


They i

things


include


annoying


or traffic


jams


practical


and


problems


fortuitous


such


as losing


occurrences


such


inclement


weather,


as well


as arguments,


disappointments,


and


financial


family


concerns.


Uplifts


are


the


pleasant


events


everyday


life


that


may


buffer


people


against


illness;


such


small


joys


as playing


with


one'


child


enjoying


a pleasant


dinner


with


friends.


Several


studies


have


proved


hassles


to be a better


predictor


(than


major






-30-


may


ultimately


emerge


that


the


wear


and


tear


daily


life


that


more


reliably


predicts


illness


and


psychological


well-being


than


more


major


but


rare


life


events.


Another m

identification


ethod


of assessing


of specific


groups


stressors


of individual


the


commonly


exposed


to similar


occupational


stressors.


Thi


assessment


has


defined


and


quantified


these


occupational


stressors.


Two


examples


this


type


approach


are


the


Nursing


Stress


Scale


(Gray-Taft


& Anderson,


1981)


and


the


Dental


Stress


Index


(Katz,


1981)


The


Nursing


Stress


Scale


measures


stressors


nurses


encounter


the


performance


their


duties,


while


the


Dental


Stress


Index


measures


dentists'


perceptions


of stressors


common


the


practice


dentistry.


An assessment


of the


stress


response


can


be made


using


physiological


, behavioral,


or cognitive


measures.


Currently


there


more


variety


types


measures


the


stress


response


than


stressors.


Part


the


reason


that


the


stress


response


often


thought


as the


dependent


variable


in studies


and


, therefore,


must


measured


(Feuerstein


al., 1986)


The

includes


physiological


both


component


psychophysiological


the


and


stress


biochemical


sponse

responses


(Feuerstein


et al


, 1986).


The


electrical


activity






-31-


endorphins


are


some


biochemical


variable


studied.


Physiological


measures


of stress


should


not


be used


as the


sole


indicators


the


stress


response;


they


measure


only


one


aspect


the


stressor-stress


response


and


may


sensitive


to other


factors


as well.


In addition


stressors,


level


of activity,


sex,


age,


and


weight


can


affect


the


physiological


responses


humans.


In general,


assessment


the


behavioral


component


the


stress


response


includes


both


direct


observations


made


an experimenter


and


self-reports


the


subject.


There


are


two


types


of behavioral


servational


methods.


The


first


includes


recording


specific


behaviors


such


as facial


expressions,


movement,


verbal


responses,


or rate


of speech.


The


second


method


involves


observation


of performance


such


areas


as memory,


attention,


visual-motor


skill


, and


problem-solving.


Performance


tasks


are


useful


that


distress,


activation,


or arousal


can


affect


a person'


ability


to perform


decreasing


motivation,


attention,


concentration


which


can


determine


the


quality


of performance


before,


during,


and


after


exposure


to stressors.


Behavioral


self-reports


include


questionnaires,


rating


scal


checklists


used


the


subj ect


indicate


behavior


that


may


be observable


additional


in an experimental


information


on behavior


setting

Activity


or to provide


schedules






-32-


behavioral


self-reports.


Self-report


measures


are


probably


the


most


frequently


used


method


measuring


the


stress


response

The


humans


cognitive


(Baum, Gr

component


unberg,


the


& Singer,

stress re


1982)


tsponse


represents


an important


variable


several


stress


model


Cognitive


assessment


can


refer


a wide


variety


measures


designed


measure


thoughts,


beliefs,


attitudes,


and


mood,


name


a few.


important


emphasize


that


cognitive


processes


do not


only


represent


components


the


stress


response,


but


that


they


can


actually


influence


the


stress


response


, serve


as mediating


variable


concept


transaction


especially

al model


relevant


of stress.


when


considering


Measures


the


the

cognitive


components


stress


response


are


usually


the


form


self-report


questionnaires,


checklists


interviews.


Several


model


of stress


emphasize


the


occurrence


multiple


use


responses


of multimodal


reaction


measurement,


a stressor


including


Therefore


physiological,


behavioral,


cognitive


assessments


of the


stress


response

measure,


1985)


offers


the


the


Strain


assesses


greatest


degree


Questionnaire


three


dimensions


information.


(Lefebvre


using


One


& Sandford,


a self-report


format.


The


transactional


model


of stress


emphasis


zes


the






-33-


factors


(i.e.,


potential


stressors)


may


influence


the


pattern


stressful


of coping


efforts


transaction


and


that


also


are


that


into


coping


motion


may


during


influence


which


environmental


factors


will


be involved


and


what


form


they


will


take


(Coyne


& Lazarus,


1980).


Therefore,


rather


than


a fixed


entity


that


impinges


on the


person,


environmental


stimuli


are


only


potentially


important,


becoming


more


salient


their


interaction


or transaction


with


coping


efforts.


Such


a model


requires


a dynamic


assessment


of the


reciprocal


interactions


of environmental


contexts


(i.e.,


potential


stressors),


cognitive


appraisals


and


coping


behaviors


(i.e


as mediating


variables),


and


their


concomitant


physiological,


behavioral,


and


cognitive


outcomes


(i.e.,


stress


response).


Stress


Dentistry


Several


authors


have


stated


that


dentists


are


very


stressed


group


professionals


(Dunlap


Stewart,


1981).


The


job


a dentist


physically


hard;


moreover,


the


majority


practitioner


dentists,

s, are in


because


evolved


they

the


are


private


long-term


strains


building


a successful


practice.


Jackson


and


Mealiea


(1977)


reported:


ractt itlioner


a nracti ce


the


dental


''n 1nn


:


.I






-34-


sell,


an


service obv
understood
anxieties o
empathize a
effectively
personnel,
inventory,


attempt
iously n


to deliver


needed


or desired;
f patients,


nd


care;


manage


keep
order


yet


the


less


(3) allay
understand


(4) hire,
notoriously


financial


supply


care


and


frequently


the
and


train,


fears


and


support,
and


transient


records,


deal


manage


with


subcontractors


(dental


laboratories),


indeed,


handle


the


work


load


the


not-so-small


businessman;


read
sense
both


the
of


and


journals,
an array


of a clinical


(Jackson


& Mealiea,


) stay
attend


abreast


the


changes


and


of the


meetings


the


sociopolitica


1977,


field,


and


make


profession,
1 nature.


560)


no wonder


then


that


many


dentists


feel


overworked


and


that


they


must


things


to all


people.


Hence,


relatively


easy


over


a period


time


feel


stressed


and


become


emotionally


burned


out.


this


section


the


relevant


literature


reviewed


two


areas:


stressors


inherent


practice


dentistry


and


the


stress


response


dentists.


Stressors


the


Practice


of Dentistry


The


dentistry


vast


have


majority


focused


articles


discussing


on characteristics


stress


the


dental


profession,


or stressors


inherent


the


practice


dentistry,


that


purportedly


are


responsible


for


the


high


levels


stress


that


dentists


are


said


to experience.


Many


factors


inherent


practicing


dentistry


have


been


mentioned


In 4-ha 14 -~~~ a a 4-a enA r1~l a n eb)i14n


En/alrt/ll 1 ^Tt/


C AYI~ CI ~ YIA


* *a


1r Ck +*^A I


nnr^l





-35-


1978) ,

AIDS,


exposure

threat of


infectious


malpractice


diseases


(Phillips,


such a

1982),


is hepatitis


third


and


party


interference


treating


anxious


treatment


and


or fearful


financial


patients


plans


(Katz,


or patients


1986)


having


pain


(Dunlap


& Stewart,


1982),


negative


public


image


of dentists,


lack


of appreciation


or cooperation


from


patients


(O'Shea


al.,

socia


1984),


professional


support


(Nevin


isolation

ampson, 1


(Forrest,


986),


1978) ,


demands


little

managing


staff,


rapidly


changing


technology


and


standards


practice


(for


a recent


review


see


Katz,


1986).


The


personality


characteristics


of dentists


which


contribute


stress


also


have


been


researched.


Several


observations


have


been


made


about


the


personality


style


the


"typical"


dentist


These


characteristics


of personality


are


authoritarian


inflexible


(Heist,


1960) ;


hard-


working,


ambitious,


perfectionistic,


emotionally


controlled (Sword,

competitive, time


1977a);

urgent,


type A personality

extreme impatience;


traits


measuring


accomplishments


terms


of numbers


(Howard


et al


1976);


low


self-esteem,


left


brain


dominated,


and


unrealistic


beliefs,


attitudes,


and


values


(King,


1978).


As interesting


and


informative


as the


published


reports


above


may


appear,


many


are


suggestive


rather


than


definitive,


and


statistical


studies


are


few.


However,






-36-


Dunlap


and


Stewart


(1982)


analyzed


3,700


questionnaires


from


replies


to a magazine


poll


on dentists'


stress.


They


found


the


most


common


dental


stressors


were


perfectionism,


patients


exhibiting


pain


or fear,


pressure


earn


more


money,


situations


where


deci


sions


are


questioned


or others


can


not


do things


right,


feelings


of overwork,


hurry,


and


lack


of appreciation.


The


authors


also


examined


the


overall


report


of stress


demographic


characteristics.


The


results


indicated


the


never-married


group


demonstrated


less


stress


than


did


the


marrieds,


while


the


divorced


respondents


were


the


most


stressed


of all


categories.


Stress,


surprisingly,


was


relatively


low


the


first


year


practice.


Then


the


stress


index


continued


to rise


during


the


first


five


years


of practice,


until


reached


a rather


high


plateau


where


remained


more


or 1


ess


constant


through


the


fourteenth


year


of practice.


After


that,


continued


to decline


through


the


balance


the


dental


career.


Solo


practitioners


reported


higher


stress


than


those


practicing


in a partnership


or group


practice.


Another


interesting


finding


was


the


least


stressed


group


also


was


the


busiest,


with


the


highest


patient


volume.


In a study


participants


at a California


scientific


meeting


(Cooper,


Mallinger,


& Kahn,


1978),


dentists


were


asked


to rate


their


perceived


stressors


in a 15-item






-37-


assistance.


After


relating


each


the


items


physiological


measures


of stress


(blood


pressure,


pulse


rate,


and


ECG


readings),


they


found


that


only


one


item,


the


demands


of building


and


sustaining


a practice,


was


correlated


consistently


with


each


of the


health


criteria


measures.


In another


study


American


dentists,


who


voluntarily


attended


a health


screening


at a national


dental


meeting,


completed


a questionnaire


on sources


of practice


stress


(O'Shea


et al.,


1984).


Results


suggested


that


six


sources


dentists'


stress


were


problems


of patients'


compliance,


pain,


and


anxiety,


interpersonal


relationships,


the


physical


strain


of work,


economic


pressures,


third-party


constraints


, and


strain


of perfectionism


and


seeking


ideal


results.


Among


stressors


lowest


the


composite


ratings


were


isolation


from


fellow


practitioners,


competition,


monotony,


lack


of acceptance


patients


of the


preferred


treatment


plan,


and


lack


of appreciation.


Another


significant


finding


was


three-fourths


those


surveyed


thought


dentistry


was


more


stressful


than


other


occupations,


but


an equally


high


proportion


believed


that


they


were


under


less


stress


than


other


dentists.


Cooper


et al.


(1987)


studied


the


relationship


between


possible


causes


stress


(demographic,


personality,


and






-38-


stress


were


pressures


from


scheduling,


staffing,


income


needs,


and


quality


control.


The


authors


concluded


that


stress


levels


the


profession


were


high,


likely


higher,


and


were


already


showing


effects


with


deteriorating


levels


mental


health


and


job


satisfaction.


Studies


Cooper,


Mallinger,


and


Kahn


(1980)


and


the


follow-up


Mallinger,


Brousseau,


and


Cooper


(1978)


are


significant


that


they


represent


the


first


systematic


attempts


to evaluate


both


personality


and


situational/


environmental


contributions


to the


stressors


experienced


dentists.


One


serious


shortcoming


lack


randomization


selection.


Since


subjects


(150


and


110,


respectively)


were


volunteers


at a health


screening


clinic


dentists,


concern


about


the


representative


nature


of the


sample


should


be noted.


Despite


conceptual


difficulties


regarding


the


selection


of physiological


indices


as the


sole


criterion


stressfulness


(vs.


perceptual


criterion),


these


studies


point


the


way


further


examination


environmental

stressfulness


and

and


of the


personality

satisfaction


interaction


stressors


transaction)


as predictors


dentists.


Based


on the


literature


review


of dental


stressors,


only


one


study


addressed


the


need


that


the


American


Dental


Association


(ADA)


Bureau


Economic


Research


& Statistics






-39-


transactional


model


of stress,


examined


both


the


relative


importance


of personality


factors


and


factors


inherent


the


practice


dentistry


upon


perceived


stress


and


career


satisfaction.


The


personality


factor


hardiness


was


more


predictive


both


stress


and


career


satisfaction


than


were


any


the


practice


stressors.


Hardiness


was


found


to be significantly


related


lower


levels


of stress


and


psychiatric


symptoms


and


higher


levels


career


satisfaction


experienced


the


dentists


the


study.


contrast,


the


practice


stressors


and


outcome


measures


were


significantly


related


only


a few


instances.


Only


income


level


and


frequency


exercise


were


strongly


related


to dentists'


career


sati


sfaction.


Only


specialization


was


strongly


related


to reduced


stress.


Only


the


number


of weeks


away


from


the


office


was


found


to be


significantly


related


to both


reduced


stress


and


increased


career


study


satisfaction


support


(Katz,


position


1987)


that


The


the


findings


sources


this


of stress


dental


practitioners


are


a function


their


personality


and


perceptions


rather


than


their


practice


stressors.


Stress


Response


Dentists


inal-har %n~t7 nV 4+arClrn~r arn*aa4r


ral~~ac!


+-ka


~ t ra ~


Brka V r+


r-^^/^x


TE-~


P






-40-


1977a,

other


1977b).

articles,


Problems

as the c


frequently


consequences


cited,


of stress


these

for d


and


dentists


include


cardiovascular


disease,


depression,


divorce,


alcoholism,


drug


abuse,


and


suicide.


A frequently


cited


study,


published


years


ago


Russek


(1962),


indicated


that


the


prevalence


coronary


heart


disease


(CHD)


among


dentists


more


highly


influenced


relative


level


occupational


stress


than


heredity


or diet.


more


recent


report


(Nielsen


& Polakoff,


1975)


found


that


coronary


heart


disease


and


hypertension


are


more


population.


prevalent


Indeed,


dentists


Steinberg


than


(1977)


the


stated


general


cardiovascular


disease

killing


the


nearly


most

7 out


frequent


of 10,


cause


premature


middle-aged


male


death,

dentists.


Investigators


of maladaptive


behavior


outside


the


dental


office


but


resulting


from


stress


within


the


office


environment--divorce,


alcoholism,


or drug


abuse--suggest


that


stress


at work


could


result


in expressions


of symptoms


personal


life.


Indeed


a high


rate


divorce


among


dentists


frequently


reported


(Sword,


1977a).


However,


American


Research


and


Dental


Association


Statistics


(1977)


(ADA) Bureau

reported that


Economic


a literature


search


found


only


one


article


on this


topic.


This


study


divorce


complaints


filed


California


(Rosow


& Rose,


1972)






-41-


Substance


abuse


frequently


been


linked


to overwork


and


stress.


Clarno


(1986)


stated


that,


based


on the


evidence


available


today,


not


known


whether


dentists


suffer

does a


from


similar


a higher


or a lower


population


sample


incident

within


of alcoholism


society.


than


The


National


Council


on Alcoholism


estimates


that


the


percentage


alcoholics


among


professionals


general


1 1/2


times


greater

Bissell


than

and


that


among


Haberman


nonprofessionals


(1984),


(Forrest,


an important


and


1978).


recent


review


of alcoholism


the


professions


(dentists,


physicians,


women),


nurses,


estimated


attorneys,


that


social


the


workers,


dentists


and


the


college


country


were


alcoholic.


There


also


evidence


that


owing


to the


accessibility


of controlled


substances


in the


practice


dentistry,


dentists


may


have


a slightly


higher


incidence


drug


dependence


than


the


average


population.


this


also


true


in medicine


and


nursing.


However,


one


study


found


that


dentists


reported


less


stress


and


less


drug


use


than


physicians


(Stout-Wiegand


Trent,


1981)


Stress


can


be a significant


problem


dentistry


and


can,


undeniably,


(Shurtz


, Mayhew,


factor


& Cayton,


the


1986).


onset


of depression


In a conceptual


article,


Sword


(1977a)


discussed


the


relationship


of depression


substance


abuse


and


suicide.


The


description


the


pre-






-42-


such


characteristics


are


adaptive


aiding


the


dentist


achieving


life


goals


, the


same


characteristics


may


predispose


the


dentist


to experiencing


a high


level


stress


and


dissatis


faction


when


faced


with


the


limiting


realities


of dental


practice.


Depression


can


result


over


period


time


from


becoming


emotionally


burned


out


(Wiley,


1986)


Thi


turn


can


lead


to seeking


an escape


alcohol,


drugs,


or suicide.


Perhaps


researched


dentists


most


topic


that


frequently


concerning

of suicide


discussed


stress-related


Numerous


and


thoroughly


problems


articles


among


have


appeared


the


dental


literature


about


the


problem


and


how


to combat


(Forrest,


1978)


One


study


(Blachly,


Osterud,


Josslin,


1963)


found


that


dentists


had


the


highest


suicide


rate


among


any


profession.


Despite


methodological


flaws


this


regional


study,


thi


view


of dentists


as having


the


highest


suicide


rate


has


been


perpetuated


the


media


and


become


a popularly


held


belief


among


dentists


and


much


the


general


public


Rose


and


Rosow


(1973)


found


that


dentists


had


a suicide


rate,


comparable


to physicians,


approximately


twice


that


the


white,


male


population


the


United


States.


Orner


(1978)


concluded


that


dentists


have a

whole,


i lower

and t


rate


hat


of suicide


causes


than


of death


does


as the


the


population


result


any


as a

illness





-43-


The


topic


suicide


among


dentists


admittedly


controversial


(Ayer


& Moretti,


1985).


The


American


Dental


Association


(ADA)


expressed


concern


over


the


problem


and


has


sponsored


research


and


national


conferences


to discuss


the


topic


(ADA


News,


1977,


February


21) .


The


ADA


Bureau


Economic


extensive


Research


study


Statistics


conducted


(1977)


Temple


reported


University


on an


School


Dentistry


researchers


(Temple


University,


School


Dentistry,


1976).


The


results


this


study,


which


considered


the


most


extensive


date


both


scope


and


methodology


, concluded


that


dentists


do not


differ


from


the


general


population


suicide


rate


and


have


a death


rate


from


causes


that


less


than


the


general


population


groups.


While


issue


of dental


suicide


may


have


been


minimized


this


report,


issue


of stress


among


dentists


appears


to be


very


much


alive


based


on the


frequency


articles


on the


topic


the


dental


literature.


Many


the


conclusions


about


dental


stress


drawn


from


these


opinion


articles


are


invalid


according


research.


But


the


mythology


of dental


stress


has become


so credible


and


oversold


that


even


many


dentists


cannot


distinguish


between


fact


and


fantasy


(Hark,


1983).





-44-


interchangeably


with


similar


terms


such


as happiness,


quality

Converse


of life,

, and Re


and


,dgers


adjustment.

(9176), sa


According


ltisfaction


to Campbell,


implies


cognitive

external


j judgment

standards


a current


of comparison


situation


such


laid


as "other


against

people


know"


or more


private


level


aspiration.


Thi


may


compared


to happiness,


which


seems


to evoke


chiefly


absolutely


emotional


state


(Campbell


et al.,


1976)


Quality


of life


different


still


that


usually


measured


some


objective


standard,


such


as ownership


of luxury


items,


and


thus


assumes


that


people


who


have


a high


quality


of life


are


satisfied.


Finally,


the


term


adjustment


often


used


similarly


to satisfaction,


especially


the


area


marriage,


even


though


adjustment


refers


more


congruence


between


partners


expectations,


performances,


and


values


(Rhyne,


1981)


This


study


and


the


following


review


literature


Theori


focused



Satis


on satisfaction.


faction


There


are


several


theoretical


explanations


satisfaction.


These


include


Maslow'


(1954)


need


hierarchy,


the


motivation


theory


as proposed


Herzberg


(1966),


theori


that


compare


expectations


and


performance,


and


finally


theories


based


on rewards.






-45-


behavior


until


the


more


potent


are


fulfilled.


The


five


classes


needs


of needs


relating


are


physiological


to belonging,


needs


friendship


, safety


and


love,


needs,


esteem


needs


and


the


need


self-actualization.


The


assumption


that


the


higher


one


gets


the


hierarchy,


the


more


one


satisfied.


Unfortunately,


acceptance


the


theory


largely


an act


of faith,


little


research


has


been


carried


out


to verify


(Cox,


1978).


Herzberg


(1966)


has


developed


a theory


suggesting


that


nature


the


work


performed


itself


an important


factor


in determining


the


level


of satisfaction


experienced.


Individuals


who


find


their


daily


tasks


interesting


challenging


are


likely


experience


more


satisfaction


than


those


who


find


their


work


tasks


tedious


or boring.


Herzberg


(1966)


proposed


the


two-factor,


motivation-hygiene


theory


describe


sati


work


faction


satisfaction.


depends


Herzberg


on motivator


argued


factors,


that


whereas


dissatisfaction


relates


to hygiene


factors.


Good


hygiene,


such


as better


working


conditions


and


more


pay,


are


theorized


to decrease


dissatisfaction,


but


do not


promote


satisfaction.


Motivation


factors


such


as achievement,


recognition,


responsibility,


opportunity


personal


growth


or advancement


will


increase


satisfaction.


Unfortunately,


many


studies


have


failed


to support


this






-46-


performance


achieves


one'


desired


goal


or is


discrepant


from


one's


value


standard,


with


the


former


resulting


higher


satisfaction


the


latter


lower


sati


sfaction.


Similarly,


Locke


(1975)


argued


that


satisfaction


related


to the


amount


of discrepancy


existing


between


how


much


wanted


and


how


much


obtained


Hence,


appears


important


to examine


the


extent


to which


expectations


have


been


realized


to determine


a person'


true


level


satis


faction.


The


expectancy


theory


, developed


Wabah


and


House


(1974),


considers


satisfaction


to be measured


work


motivation.


The


theory


states


that


after


a reasonable


expenditure


of effort,


one'


professional


expectations


are


not


met,


the


result


will


be a lower


level


of professional


motivation


and


satisfaction.


Linsenmeier


and


Brickman


(1980)


sati


propose


faction


a similar

based,


idea.


at least


They


suggest


in part,


that


on the


goals


expectations


performing


the


well


individual.


generally


They


more


add


that,


satisfying


although


than


performing


badly,


the


lower


the


expectations,


the


more


person


will


be satisfied.


They


suggest,


short,


that


people


will


sati


sfied


with


themselves


and


what


they


accomplish


to the


extent


that


their


accomplishment


exceeds


what


they


had


expected


to achieve,


and


disappointed


fails


short





-47-


whereas


those


who


overestimate


themselves


are


apt


surprised


failure.


In effect,


satisfaction


depends


on expectations


regarding


performance


outcomes


as well


as the


performance


outcome


itself.


Vroom


(1964)


defined


satisfaction


as the


affective


orientation


on the


part


individuals


toward


the


roles


they


are


presently


occupying.


Satisfaction


also


a function


of the


attainment


of rewards.


Thus,


the


more


rewards


a role


offers,


the


more


satisfied


a person


will


with


The


theory


research


the


area


satisfaction


has


generally


focused


on satisfaction


within


role.


Such


areas


as job


satisfaction


and


marital


satisfaction


are


common


the


literature.


Thus,


each


role


has


own


specific


theories


assessment


techniques.


However,


there


is a tremendous


amount


of overlap


among


roles


how


satisfaction


conceptualized.


Campbell


et al.


(1976)


proposed


that


job


satisfaction


based


on how


persons


perceive


their


situation.


This


based,


in part,


on objective


characteristics


the


job


and


on characteristics


of the


respondent


which


determine


how


the


person


perceives


characteristics


the


job.


Thus,


one


approach


to assessing


job


satisfaction


to solicit


individuals'


assessments


the


attributes


of their


jobs.


Attributes


that


have


been


found


be important


are


comfort,





-48-


the


between


career


and


abiliti


and


interests,


and


the


degree


to which


they


feel


successful.


This


approach


has


been


taken


Osherson


and


Dill


(1983)


How


sati


sfaction


one


role


affects


satisfaction


other


roles


has


been


the


topic


some


interest


and


investigation.


The


most


commonly


researched


interrelationship


between


the


roles


of life


general


and


work.


Studies


have


generally


found


a positive


relationship


between


work


sati


sfaction


and


satisfaction


with


life


Hulin,


general


1969;


(Campbell


& Barrett,


al.,


1972;


1976;


Greenhaus,


Kornhauser,


1965


1974;


London,


Crandall,


& Seal


1977;


Schmitt


& Mellon,


1980)


Campbell


et al.


sati


(1976)


sfaction


estimate


shared


that

with


20%

work


of the


variance


satisfaction


of life


and


conclude


that


work


sati


sfaction


one


the


most


important


predictors


of life


sati


sfaction.


That


, at least


the


of work


and


general


life,


people


who


are


satisfied


with


one


role


are


likely


to be satis


fied


with


their


other


es.


However,


the


relationship


not


perfect.


There


of the


variance


that


still


unaccounted


for,


using


estimate


of shared


variance


computed


Campbell


et al


(1976)


Thus,


may


be wise


study


career


satisfaction


and


general


life


satisfaction


separately





-49-


profession,


not


much


known


about


factors


contributing


satisfaction


increasingly


with


dentistry.


important


Such


light


information


the


changing


becoming


nature


dental


practice


and


desire


to reduce


unnecessary


stress


(Dunlap,


1977).


The


practice


of dentistry


seems


possess


many


the


characteristics


commonly


associated


with


satisfaction.


offers


prestige,


good


income,


potential


for


personal


development,


a helping


profession.


Indeed,


Bisconti


and


Solmon


(1977)


showed


that


many


the


characteristics


traditional


private


practice,


such


as the


freedom


to design


one's


own


work


and


to fully


use


one'


skills

dental


were


practi


associated

ce rarely


with sa

requires


tisfaction.


working


In addition,

large


organizations


or doing


repetitive


clerical


tasks,


both


which


have


been


associated


with


occupational


dissatisfaction.


Jackson


and


Mealiea


(1977)


claim


other


factors,


such


ability


planning


to control


to avoid


one'


unnecessary


personal


financial


environment


burdens,


and


are


use


related


sati


sfaction


and


can


result


a reduction


stress.


They


also


suggest


that


dentists


who


find


rewarding


interact


professionally


with


peers


experience


a higher


level


of satisfaction.


The


practice


of dentistry


does


fact





-50-


help


others


as well


as creative


and


artistic


challenges.


Although


career


satisfaction


among


dentists


varies


widely,


the


plethora


of reports


describing


their


career


dissatisfaction


supported


(often


empirical


linked


research


high


stress)


investigating


not


the


topic


(King,


1978;


Sword,


1977b).


Hence


dentists'


career


satisfaction,


typically,


has


been


found


the


average


to be


quite


high


(George


& Milone,


1982).


Eccles


and


Powell


(1967)


conducted


a mail


survey


of 231


dentists


practicing


South


Wales.


Some


relevant


findings


were


that


dentists


between


the


ages


of 23-24


and


those


over


were


the


most


satisfied


while


those


the


45-54


age


group


were


the


least


satisfied.


The


greatest


sources


satisfaction


were


related


achievement


and


satisfaction


the


work


itself


, as well


as good


relationships


with


patients.


The


greatest


sources


of dissatisfaction


and


difficulty


external


limitations


imposed


on the


dentist


and


the


pace


work.


Income


and


status


had


little


effect


on job


satisfaction.


Sixty


percent


the


dentists


said


they


liked


their


work


while


stated


that


they


did


not


like


Howard


attributed


et al.


stress


(1976),


as a factor


a previously


the


cited


dissati


study,


faction


dentists.


The


best


predictors


of job


satisfaction


were


the






-51-


experience


of the


dentist.


The


younger


dentists


were


found


to be


the


most


dissatisfied


the


group.


A trio


of studies


on Utah


dentists


yielded


some


interesting


results.


Murray


and


Seggar


(1975)


found


unusually


high


level


of role


satisfaction


(90%)


among


dentists

negligible


practicing

v affected


Utah.

age,


Levels


number


of satisfaction


years


were


practice,


social


participation,


or practice


location.


In 1980,


Murray


compared


results


the


role


satisfaction


of dentists


from


different


cultural


areas.


The


Utah


study


was


essentially


replicated


and


compared


with


a study


of 94


dentists


practicing


Kentucky.


While


the


relationship


between


role


satisfaction


and


age


and


role


satisfaction


and


years


was


practicing


an increase


number


years


was


statistically


satisfaction


practicing


with


the


significant,


an increase


Kentucky


there


in the


group.


Conversely,


the


younger


dentists


the


Utah


sample


tended


to be


more


satisfied


than


their


Kentucky


counterparts.


Schwartz


and


Murray


(1981)


in a secondary


analysis


the


Utah


study


investigated


various


aspects


the


original


data


career


to try


to understand


satisfaction


level


reasons


their


the


respondents.


unusually


One


high


the


findings


was


that


dentists


who


reported


their


fees


were


"too


low"


tended


to be significantly


less


satisfied


than


those





-52-


a low


structure


associated


with


lower


dentist


work


satisfaction.


Lange,


Loupe,


and


Meskin


(1982)


reported


the


results


a longitudinal


study


of University


of Minnesota


School


Dentistry


graduates


entering


their


sixth


year


of practice.


The


researchers


sought


to determine


whether


there


were


any


characteristics


accounted


groups,


the


dentists


differences


14 dentists


each,


sati


or the


sfaction


identified


practice


between


that


two


"satisfied"


and


"dissatisfied.


While


age


was


not


a factor


this


group


young


dentists,


the


overall


results


identified


professional


and


community


involvement


as an important


characteristic


the


more


satisfied


group.


The


most


satisfied


dentists


also


seemed


to be


less


threatened


change


and


hold


a more


positive


view


of the


profession.


Conversely


the


less


satis


fied


dentists


were


as optimistic


as the


most


satisfied


dentists.


Yablon


and


Rosner


(1982)


also


studied


the


relationship


income


three


categories


career


satisfaction.


They


surveyed


1172


graduates


of Columbia


University'


School


of Dentistry


and


Oral


Surgery.


The


three


categories


career


satisfaction


were


intrinsic,


extrinsic,


and


overall


career


satisfaction.


The


results


indicated


a general


trend


toward


increased


overall





-53-


dentists'


satisfaction


increased


with


increasing


income,


but


only


to a point.


Apparently


the


lack


income


was


more


a source


of dissatisfaction


than


existence


of high


income


was


a source


of positive


satisfaction.


In another


article


about


the


same


study,


Yablon


and


Mayhew


(1984)


reported


on nonchairside


factors


that


contributed


results


to the


indicated


career


that


sati


dentists


faction

whose


of dentists.


background


The


and


personal


characteristics


promoted


life


stability


and


who


were


in the


mainstream


the


professional


community


tended


to be


more


satisfied.


These


characteristics


were


exemplified


a more


religious


orientation,


being


married


rather


than


single,


continuing


education


involvement,


and


higher


social


class


background


measured


educational


attainment


parents)


a survey


of 224


practicing


North


Carolina


dentists,


George


and


Milone


(1982)


found


dentists'


sati


faction


depended


financially


largely


on income.


successful


Dentists


practices


tended


the most

to be younger,


employ


more


auxiliaries,


see


more


patients


per


day,


have


more


patients


education,


and


on their


more


recall


lists,


satisfied


with


take m

their


ore


continuing


careers.


These


findings


were


supported


a more


recent


study


on dental


stress


satisfaction.


Katz


(1987)


concluded


that


the





-54-


Mediator


Variables


the


Stress


Process


A large


body


of literature


(life


events


research)


has


demonstrated


onset


that


physical


stress


and


plays


a precipitating


psychological


disturbance.


the


The


literature


also


has


documented


that


the


relationship


between


stressful


life


events


and


future


(physical


or psychological)


illness


, although


statistically


significant,


relatively


small


magnitude


(Dohrenwend


& Dohrenwend,


1974)


Given


the


very


large


sample


zes


characteristic


of life


events


research,


even


very


small


correlations


no practical


utility


may


pass


tests


of statistical


significance


(Rabkin


Streuning,


1976)


When


reports


of obtained


correlation


coefficients


are


included


the


reports,


they


are


typically


below


(accounting


at best


of the


variance


and


typically


-4%).


The


standard


deviations


these


associations


also


are


quite


extreme


suggesting


considerable


variability


across


individuals


the


degree


which


stress


associated


with


illness


(Feuerstein,


Labbe,


Kuczmierczyk,


1986)


Thus


researchers


have


been


sea


rching


factors


that


may


as mediators,


moderators,


buffers,


or resistance


stress


stress


resources


(Antonovsky,


are


against


1979)


identified,


the


Hence


measured


adverse


as the


reliably,


effects


mediators


and


of life


life


included


rToan red


incrsvassd


nredictiveness


likely


da nnin .


.


..


L-V





-55-


Bernstein,


1977);


having


a high


rather


than


a low


income


(Luborsky,


Todd,


& Katchen,


1973)


physiological


constitutional


strengths


such


as a well


-functioning


immunological


system


(Marshall,


1977) ,


family


medical


histories


diseases

health D


that


are


(Kobasa,


practices


free


Maddi,

(Wiebe


of certain


& Courington,


& McCallum,


genetically


1981;


1986) ,


and


linked


Weiner,


1977),


exercise


(Cooper,


Gallman,


& McDonald,


1986;


Kobasa,


Maddi,


Puccetti,


1982);


social


resources


such


as being


married


rather


than


single


(Myers,


Lindenthal,


& Pepper,


1974) ,


perceived


soc


support


(Billings


Moos,


1981;


Cobb,


1976


Schaefe:

styles


Coyne,


(Lazarus


& Lazarus,

Folkman,


1981;

1984;


Thoits,

Pearl in


1986)


coping


& Schooler,


1978);


certain


personality


characteristics


such


as the


absence


of Type


A behavior


patterns


(Chesney


, Black,


Chadwick,


Rosenman,

of control


Scheier,


1981


Friedman


(Johnson


Weintraub,


& Rosenman,


& Sarason,

& Carver,


1978),


1986)


1974),

dispo

and h


internal


sitional

ardiness


locus

optimism

(Kobasa,


1979).


The


mediator


variables


included


this


study,


and


reviewed


this


section,


are


hardiness,


coping


style,


social


support,


and


health


practices.


Hardiness


In a novel


anvroach


the


problem


correlations


I


w m


__


YV


S






-56-


needed


was


a scrutiny


the


factors


which


differentiated


between


highly


stressed


people


who


did


and


did


not


get


sick.


Kobasa


(1979)


studied


middle-


and


upper-level


business


executive


a large


public


utility


a major


metropolitan


area,


see


which


ones


did


and


did


not


develop


illness


as a consequence


their


stressful


lifestyle.


First,


Kobasa


divided


the


group


into


executives


who


had


experienced


a lot


of stress


during


the


previous


three


years


and


those


who


had


experienced


ess


stress,


using


the


Schedule


of Recent


Life


Events


(SRE)


and


the


Social


Readjustment


Rating


Scale


(SRRS)


(Holmes


& Rahe,


1967)


Then,


selected


looking


items


only

from


the


the


high-stress


Seriousness


executives,


of Illness


using


Survey


(Wyler,


Masuda,


& Holmes,


1968),


Kobasa


compared


those


who


had


had


a lot


illnesses


with


those


who


had


had


relatively


illnesses


see


what


stinguished


them.


the


final


sample


of 200


mal


Kobasa


found


that


the


highly


stressed


but


healthy


(high


stores


low


illness)


executives


were


distinguished


a multifaceted


personality


style


Kobasa


termed


hardiness.


The


hardy


personality


composed


of three


characteristic


CS.


The


first


a sense


of commitment,


or a


generalized

expressed a


sense


purpose


s a tendency


or meaningfulness


to involve


oneself


that


deeply






-57-


control


one'


environment.


The


third


component


challenge,


a perception


of change,


not


as a threat


but,


as a


normal


part


of life


that


provides


opportunities


growth


and


development.


As a result


their


sense


of commitment,


control,


and


challenge,


hardy


individuals


may


appraise


potentially


stressful


life


events


more


optimistically


than


would


individuals


who


are


so hardy.


Therefore,


they


may


take


more


direct


action


to find


out


about


these


events,


incorporate


them


into


their


lives,


and


to learn


from


them


what


may


be of value


the


future.


Consequently,


important


way


which


the


hardy


individual


avoids


illness


that


potentially


stressful


events


can


cause


is by


transforming


these


events


into


less


stressful


ones.


Although the h

measurement grounds


ardiness

(e.g.,


concept

Ganellen


has been

& Blaney,


criticized

1984),


Kobasa'


work


significant


several


reasons.


First


, it


identifies


a personality


factor,


hardiness,


that


appears


buffer


against


stress


see


also


Kobasa,


Maddi,


& Courington,


1981;


Kobasa,


Maddi,


& Puccetti,


1982).


Second,


clearly


illustrates


that


this


factor


can


moderate


the


relationship


between


stress


and


illness.


Third,


illustration


an important


method


of studying


stress,


namely,


focusing


attention


on the


people


who


do not


succumb


to stress


rather


than


the


ones


who


do become


debilitated


stress.


This






-58-


In the


initial


study


, hardiness


was


measured


various


sca


les covering


three


components


of hardiness.


They


included


the


Internal-External


Locus


Control


Scale


(Rotter


, Seeman,


& Liverant,


1962),


nine


scal


from


the


Alienation


Test,


including


the


Adventurousness


versus


Responsibility


scale,


the


Powerlessness


versus


Personal


Control


scale,


the


Nihilism


versus


Meaningfulness


scale,


Alienation


from


Self,


Work,


Interpersonal


Relationships,


Family


and


Friends


sca


and


the


Vegetative


versus


Vigorousness


scale


(Maddi,


Kobasa,


& Hoover,


1979)


the


Achievement


scale,


Need


Cognitive


Structure


scale,


and


Need


Endurance


sca


the


Personality


Research


Form


(Jackson,


1974),


as well


as the


Preference


Interesting


Experiences


scal


the


Security


Orientation


sca


the


California


Life


Goals


Evaluation


Schedule


(Hahn,


1966)


A discriminant


function


analysis


, identifying


the


best


combination


of variables


explaining


differences


between


groups,


explained


the


total


variance


between


the


groups


leaving


only


unexplained


(Kobasa,


Hilker,


Maddi,


1979)


Results


indicated


that


high


stress


/low


illness

external


subj ects

locus o


scored


f control,


significantly


lower


powerlessness


on nihilism,


alienation


from


self,


vegetativeness


than


did


high


stress/high


illness






-59-


socioeconomic


level


failed


to discriminate


between


the


two


groups.


There


have


been


longitudinal


studi


with


subjects


drawn


from


the


original


population.


Kobasa,


Maddi,


and


Kahn


(1982),


using


a prospective


research


design


with


subjects,


tested


the


effects


of hardiness


on the


stress-


illness


link


over


a two-year


follow-up


period.


Stress


and


illness


were


measured


same


way


the


earlier


investigation


(Kobasa,


1979).


Six


instruments


were


used


assess


hardine


SS.


They


included


two


tests


commitment,


the

from


Alienation


the


from


Alienation


Self

Test


and


Alienation


(Maddi


from


, 1979)


Work

, two


sca


tests


control,


the


External


Locus


of Control


Scale


(Rotter


et al


1962)


and


the


Powerlessness


sca


le of


the


Alienation


Test


(Maddi


Security


et al


, 1979),


Scal


the


two


tests


California


Life


of challenge,


Goal


the


Evaluation


Schedul


(Hahn,


1966)


and


the


Cognitive


Structure


Scale


the


Personality


Research


form


(Jackson,


1974)


Subjects


filled


out


stress


and


illness


que


stionnaires


once


a year


three


years.


The


hardiness


questionnai


res


were


completed


only


first


year.


As part


the


data


analysis


, Kobasa,


Maddi,


and


Kahn


(198


first


examined


intercorrelations


among


the


six


scal


used


measure


hardiness.


Because


cognitive


structure


did





-60-


analyses


the


data


using


an analysis


covariance


with


prior


illness


illness


(measured


(measured


the


the


sec


first


and


year)


third


as the


years)


covariate,


as the


dependent


variable,


and


hardiness


(measured


the


first


year),


and


stress


(measured


the


second


and


third


years)


independent


variables


indicated


that


stressful


life


events


were


associated


with


increased


illness


and


that


hardiness


decreased


likelihood


of symptom


onset.


Furthermore,


events,


hardy


hardiness


indicating


one


interacted


that


experiencing


with


especially

intensely


stressful


important


stressful


life


to be


life


events.


More


joint


recently,


influence


other


studi


of hardiness


and


have


other


investigated

mediating va


the


riables


such


as constitutional


strength,


exercise,


social


resources,


and


Type


A behavior


pattern.


Kobasa,


Maddi,


and


Courington


(1981)


, using


the


same


business


executive


sample


and


the


refined


five


subtest


measure


of hardiness


, operationalized


constitutional


predisposition


as parents'


illness.


With


prior


illness


statistically


controlled


for,


stress


life


events


, hardiness,


and


constitutional


predisposition


had


main


effects


on later


illness.


Hardiness


and


constitutional


predisposition


were


not


significantly


correlated


with


one


another,


indicating


that


they


were


not


just


measuring


the






-61-


have


an additive


stressful


life


effect


events


with


regard


increasing


to illness,


illness


and


with


a healthy


constitutional


predisposition


and


high


hardiness


decreasing


illness.


Kobasa,


effects


Maddi,


of hardiness


and

and


Puccetti


exerci


(1982


investigated


as buffers


the


the

stress-


illness


relationship.


Using


the


same


sample


and


measures,


hardiness


and


exerci


were


not


found


to be


related


one


another,


but


both


were


related


illness.


Furthermore,


both


interacted


with


stressful


life


events,


indicating


that


they


may


be most


helpful


under


high


stress


conditions.


Kobasa


and


Puccetti


(1983)


investigated


Soc


resources

executive


as well as

population,


hardiness.


they


Using


measured


the


social


same


business


resources


on the


home


and


work


subscal


the


Environment


Scal


developed


Moos


his


colleagues


(Moos


, 1976;


Moos,


Insel,


Humphrey,


1974)


and


the


Social


Assets


Scale


developed


Luborsky,


Todd,


and


Katcher


(1973)


Along


with


the


main


effects


hardiness


and


stressful


life


events


on illness,


boss-support


interacted


with


stressful


life


events


in such


way


that


boss-support


reduced


illness


more


high


stress


executives.


Stressful


life


events,


hardiness,


and


family


support


interacted


such


that


those


who


were


high


stressful


life


events


, high


in perceived


family


support,


and






-62-


Kobasa,


Maddi,


and


Zola


(1983),


using


the


same


male


business


executive


population,


examined


the


relationship


between


Type


A behavior


pattern


and


personality


hardiness


and


stress


and


illness


subjects.


Type


and


hardiness


were


found


to be conceptually


different


personality


orientations


and


empirically


independent


factors.


Type


A and


hardiness


emerged


from


this


study


bases


extrinsic


and


intrinsic


motivation,


respectively


The


results


confirmed


prediction


an interaction


between


the


two


variables


that


influenced


illness


onset.


Under


high


stressful


life


events,


male


executives


who


were


high


the


Type


greatest


but


simultaneously


deterioration


low


of general


hardiness,


health


the


showed


face


mounting


stressful


life


events.


Kobasa


(1980),


establishing


relevance


of hardiness


to stress-resistance


other


occupational


groups


, compared


the


executives


previously


studied


to lawyers


and


career


army


officers


In addition


illness


as an outcome,


measured


the


presence


or absence


of psychiatric


symptoms.


With


army


officers,


a high


correlation


was


found


between


stressful


life


events


both


physical


illness


and


psychiatric


symptoms.


The


personality


variable


challenge,


commitment,


and


control


were


significant


such


that


the


officer


with


a low


commitment,


high


interest





-63-


show


a significant


diagnosable


physical


correlation

1 illness (


between


Kobasa,


stress

1982).


scores and

There was,


however,


a significant


relationship


between


lawyers'


stress


experience


and


their


complaints


of strain


thi


case


physical


and


mental


symptoms


assoc


iated


with


the


stress


response)


Thi


relationship


was


mediated


two


stre


ss-


resistance


resources:


commitment


regressive


coping


techniques.


However,


two


other


stress


resistance


resources,


social


support


, and


exerci


were


not


found


to significantly


affect


the


degree


of strain


reported.


Kobasa


various


ideology"


explained


professions


the


on the


respective


diffe

basi


rences


between


the


groups


see


"profess


Katz,


outcomes


ional


1981)


According


there


to Kobasa


a belief


(1982),


that


within


stress


the


what


legal


makes


profes


the


sion,


profession


stimulating


and


challenging


Whereas,


the


business


executive


and


army


officer


exist


very


different


ideological


contexts.


Within


business,


and


especially


executive


ranks,


destructive.


The


there

army


is a strong


officer


belief


(Kobasa,


that


1980)


stress

presents


somewhat


system


different


which


situation.


officer


The


rigid


functions


authoritarian


requires


giving


high


degree


of control


to others.


Many


officers


find


themselves


functioning


the


modern


army


^





-64-


commitment


the


goals


and


purposes


the


systems


which


they


operate.


The


result


of such


conflicts


between


"subj ective


role


perception


and


objective


role


definition"


(Katz,


1981)


leads


the


more


destructive


stress


related


outcomes


which


the


officers


experience.


interesting


to note


that


the


published


research


on hardiness


Kobasa


and


associates,


the


Chicago


Stress


Project,


has


been


with


mal


only


and


primarily


with


business


executives.


More


recently


other


researchers


have


extended


the


investigation


hardiness


to other


populations.


Ganellan


and


Blaney


(1984)


as well


as Wiebe


McCallum


hardiness


witi


(1986) s

h social


tudied t

support


he


joint


and


mediating


health


practi


effects

ces,


respectively,


college


students


Katz


(1987)


examined


the


effect


of hardiness


on stress


and


satisfaction


dentists.


While


Hammond


(1987)


investigated


the


relative


mediating


effects


stress


hardiness


and


, social


satisfaction


support,


academic


and


coping


multiple


role


style


persons.


These


last


two


reports


are


reviewed


other


sections


chapter.


Ganellan


and


Blaney


(1984)


investigated


the


effects


hardiness


and


social


support


on illness.


The


presence


stressful


life


events


was


measured


the


Life


Experiences


Survey


Sarason,


Johnson,


& Siegal,


1978)


Illness


was





-65-


Internal


subscale


the


Levenson


Locus


Control


Scale


(Levenson,


1974),


and


the


Power


essness


, Vegetativeness,


Nihilism,


Adventurousness,


and


Alienation


from


Self


subscal


of the


Alienation


Test


(Maddi


et al.,


1979)


Social


support


was


measured


the


Social


Perception


Questionnaire


developed


the


authors


(Ganellen


& Blaney,


1984)


Using


a sample


of 83


female


undergraduates,


the


results


first


indicated


that


the


tests


measuring


commitment


and


challenge

In analyze


were


both


the


strongly


relationship


associated

s among ha


with


rdines


social

S, SOC


support.


support,


stressful


life


events,


and


depression,


depression


was


found


to be related


to stressful


life


events,


social


support,


and


the


alienation


from


self and


vegetativeness


subscales


of hardiness.


Only


Alienation


from


Self


subscale


interacted


with


stressful


life


events


significantly


affect


depression.


Ganellen


and


Blaney


(1984)


concluded


reiterating


the


effect


of social


support


on dep


ress


and


questioning


how


interrelated


are


the


three


dimensions


of hardiness.


must


be noted,


however


, that


Ganellen


and


Blaney


used


different


instruments


measure


life


events,


illness,


and


hardiness


than


did


Kobasa


and


colleagues.


Thus,


may


not


be appropriate


to generalize


the


results


obtained






-66-


Two


stress


and


illness


model


that


included


the


mediating

tested pr


effects


ospectively


health

over a


practices


two-month


and


hardiness


period


Wieb


were

e and


McCallum

students


(1986).

completed


Sixty

the


female


and


hardiness


26 mal


test


undergraduate


as described


Kobasa


(198


Stress,


health


practi


ces,


and


illness


the


prior


month


were


assessed


as well


as one


and


two


months


later


Health


practices


were


measured


the


Self


Care


Inventory


(Pardine


, Napoli,


& Dytell


, 1983)


Illness


was


measured


the


first


model


the


severity


of physical


symptoms


reported


on the


Seriousness


Illness


Rating


Secal


(Wyler,


Masuda,


Holmes,


1968);


whereas


in the


second


model


, it


was


measured


the


number


of physical


symptoms


reported.


Path


impact


analyses


stress


both


on illness


model


revealed


diminished


when


that


other


direct


variable


were


included.


Hardiness


exerted


effects


on illness


directly


as well


as indirectly


impact


on health


practices.


The


results


indicated


that


hardiness


did


not


appear


to have


a stress


buffering


effect


on illness


rather


appeared


to mediate


the


impact


stress


on health


practices.


Therefore,


could


be mi


leading


view


hardiness


as a stress


-res


instance


resource.


The


authors


concluded

health pr


that


actice


hardy

s while


individuals


experlenci


appeared

ng stress


to maintain


than


better


do nonhardy






-67-


Several


differences


between


this


study


and


prior


studies


on hardiness


may


contribute


the


contrasting


results.


First,


population


this


study


included


large


number


of females,


was


younger,


and


was


exposed


different


types


stressors


than


the


middle-aged,


male


executives


previous


studies.


Secondly,


this


prospective


study


used


a shorter


time


period


(three


months)


than


prior


studies


which


used


several


years.


Conina


The


impact


any


potentially


stressful


event


substantially


influenced


how


a person


copes


with


Recall


that


according


to the


transactional


model


of stress


(Lazarus


& Folkman,


1984),


cognitive


appraisal,


evaluation,


potentially


stressful


events


mediates


psychologically


between


the


individual


and


the


environment


when


the


individual


encounters


a stressful


event.


Any


new


event


make


event.


or change


a primary


An event


the


appraisal


can


environment


about


be appraised


prompts


significance


as benian


individual


the


(positive),


irrelevant


(neutral),


or stressful


(negative).


an event


judged


to be stress


ful,


will


further


be judged


terms


the


harm


or loss


that


has


already


been


done,


the


- ----- .8- t ~~~~8- --- a awe--


e.L1


a -


. .


- -


,,c,. -,- ,l4 .


,..,YL


'I


CL


I.. L....,,





-68-


Once


these


primary


appraisals


are


made,


the


individual


makes


a secondary


appraisal.


Secondary


appraisal


the


continuous


evaluation


of one'


coping


resources


and


options


to determine


whether


they


will


be sufficient


overcome


the


harm


and


threat


that


event


represents.


The


extent


which


an individual


experiences


psychological


stress,


then,


determined


the


evaluation


both


what


is at


stake


(primary


appraisal)


and


what


coping


resources


are


available


(secondary


appraisal)


It is


important


to define


operationally


what


meant


coping.


Coping,


according


to Lazarus


and


colleagues


(Lazarus


& Folkman,


1984),


defined


as the


cognitive


and


behavioral


efforts


manage


environmental


and


internal


demands


and


conflicts


among


them.


These


cognitive


behavioral

tolerating,


actions, c

reducing,


ir efforts,

and/or mi


are


directed


.nimizing


at mastering,


environmental


and


internal


demands


or exceeding


the


conflicts


resources


that


the


are


person.


appraised


Although


as taxing


coping


is commonly


conceptualized


as occurring


in reaction


stressful


situations,


also


can


occur


before


a stressful


confrontation.


This


form


of coping


anticipatory


coping.


Coping


also


refers


to the


efforts


manage


demands,


regardless


of the


success


those


efforts.


The


effectiveness


any


given


coping


strategy


not


inherent






-69-


terms


the


method


of coping,


the


individual


can


utilize


either


an active


response


to resolve


the


stressful


event


choose

of the


to avoi

coping


the


respon


stressor

se may b


(avoidance


e directed


coping).


at the


The


problem


focus

itself


(problem-focused)


stressor


or the


(emotion-focused


emotional c

) (Folkman,


consequencess

Schaefer,


of the

& Lazarus,


1979;


efforts


Pearlin


are


& Schooler,


attempts


1978) .


something


Problem-focused


constructive


coping


about


stressful


conditions


that


are


harming,


threatening,


challenging


individual.


Emotion-focused


coping


involves


efforts t

stressful 1


o regulate

event.


the


emotional


Sometimes


consequences


problem-solving


the


efforts


and


emotional


regulation


work


together.


However,


problem-


solving


efforts


and


emotional


regulation


also


may


work


cross


purposes.


There


are


literally


hundreds


coping


strategies


individual


might


use


in confronting


a stressful


event.


Some


will


problem-focused


emotional


regulation.


and


The


others


same


will


person


be oriented


may


toward


engage


intrapsychic


coping


efforts,


information


seeking,


direct


actions,


turning


to others,


and


inhibition


of action


(Cohen


& Lazarus,


1979)


at different


points


coping


with


the


same


event.

part c


Which


>n the


coping


nature


responses


the


will


stressor


be used


itself


depends


and


large


the






-70-


are


people


who


become


nearly


hysterical


the


smallest


stressor,


huge


whereas


amounts


other


of stress


people


and


seem


remain


to be able


nearly


to confront


unflappable


(Taylor,


1986)


Thi


is an example


of difference


coping


style.


Although


a variety


coping


styles


exists,


only


have


received


systematic


study.


Pearlin


and


Schooler


(1978)


studied


normative


coping


responses


to normative


life


problems


a large


sample


2300


adults


(ages


18-65)


Chicago.


Through


a structured


interview


format


information


was


gathered


about


life


strains


and


the


coping


repertoires


people


used


these


strains


each


of four


role


areas--occupation,


household


economic


marriage,


and


parenting.


The


researchers


examined


the


emotional


stresses,


depression,


and


anxiety


response


the


strains.


Coping


responses


represented


some


the


things


that


people


their


concrete


efforts


to deal


with


life


strains


encountered


their


different


roles.


Coping


resources


referred


not


to what


people


but


to what


was


available


to them


developing


their


coping


repertoires.


Social


resources


represented


the


interpersonal


networks


which


were


a potential


source


support:


family,


friends,


co-workers,


neighbors,


etc.


Psychological


resources


represented


some


the


things


people


are,


the


personality


characteristic


that


people


draw


upon


to help


them


withstand






-71-


the


situation


(the


most


direct


method);


responses


that


function


to perceptually


control


the


meaning


the


problem


(e.g.,


positive


comparisons,


selective


ignoring,


and


substitution


rewards);


and


responses


that


attempt


minimize


the


discomforts


engendered


the


problems,


but


are


not


directed


at the


problems


themselves.


The


efficacy


of 17 concrete


coping


behaviors


representing


these


three


functions


was


evaluated.


Results


indicated


that


individuals'


coping


interventions


were


most


effective


when


dealing


with


problems


within


the


close


interpersonal


area


of marriage,


and


to a lesser


extent


parenting,


and


least


effective


when


dealing


with


the


more


impersonal


problems


found


occupation.


The


most


effective


coping


responses


were


unequally


distributed


in society,


with


men,


the


educated,


and


affluent


making


greater


use


efficacious


mechanisms.


Pearl in


and


Schooler


(1978)


also


found


that


using


a particular


coping


response


was


less


important,


the


effects


of stress,


than


using


a variety


coping


responses.


Using


the


same


data


from


random


sample


of 2300


adults


(Pearlin


& Schooler,


1978),


Fleishman


(1984)


examined


the


relationships


between


coping


and


general


personality


variables


mastery,


self-esteem


self-denial,


and


nondisclosure


of problems.


Findings


indicated


that


both






-72-


affected


use


emotion-focused


coping,


and


nondisclosure


reduced


advice-seeking


whereas


mastery


and


self-esteem


had


weaker


effects.


The


author


concluded


that


coping


depended


upon


whether


problems


occurred


either


an interpersonal


impersonal


context


on whether


one


preferred


to act


independently


or seek


aid


from


others.


Billings


and


Moos


(1981)


explored


the


nature


individual


and


social


resources


as intervening


processes


mediating


the


effect


of life


events


on psychological


and


physical


distress.


Pearlin


and


Schooler


(1978),


their


analyses


focused


on two


approaches


to classifying


coping


responses,


method


coping


and


focus


coping,


and


their


roles


moderating


the


effects


stress.


The


method


of coping


classification


divided


coping


attempts


into


three


categories


Active-cognitive


coping


included


attempts


manage


one's


appraisal


the


stressfulness


the


event.


Active-behavioral


coping


referred


to overt


behavioral


attempts


to deal


directly


with


the


problem


and


effects.


Avoidance


coping


referred


to attempts


to avoid


actively


confronting

emotional t


the


problem


ension


such


or to indirectly


behavior


reduce


as eating


the


or smoking


more.


The


second


classification,


focus


coping,


was


composed


two


categories:


problem-focused


and


emotion-


focused


coping


(Antonovsky,


1979;


Lazarus,


1980)


Problem-






-73-


whose


primary


function


was


manage


the


emotional


consequences


of stressors


and


to help


maintain


one'


emotional


equilibrium.


Billings


and


Moos


(1981)


created


19-item


questionnaire


assess


the


use


of the


three


methods


of coping


categories


and


the


two


foci


coping


categories.


Results


were


presented


a representative


community


sample


two-parent


families


the


San


Francisco


Bay


Area.


Small


but


significant


gender


and


contextual


differences


in coping


were


identified.


Women


were


more


likely


use


avoidance


coping,


which


was


associated


with


greater


impairment


of functioning


Persons


with


more


education


and


income


also


were


more


likely


use


more


effective


coping


was


consistent


with


the


findings


Pearlin


and


Schooler


(1978)


The


predictive


value


of social


support


also


was


ess


salient


among


men


than


among


women.


The


conclusion


was


that


measures


coping


and


social


resources


life


did


events


mediate


and


the


personal


relationship

functioning (


between


Billings


stressful

& Moos,


1981)


More


recently,


Billings


Moos


(1984)


explored


of stress,


social


resources,


coping


among


men


women


entering


treatment


depression.


Stressors,


social


resources,


and


coping


were


additively


predictive


patients'


functioning


However,


coping


and


social


resources





-74-


work


effects


on factors


of life


that


buffer


stress.


potentially


survey


was


negative


used


health


measure


personality


characteristics,


coping


strategies,


and


family


support


with


a representative


community


sample


of 267


two-


parent


families.


comparison


Respondents


groups


the


were


Kobasa


divided


(1979)


into


two


hardiness


study),


high


stress/high


distress


and


high


stress/low


distress.


Findings


demonstrated


that


those


who


adapted


to life


stress


with


little


physical


or psychological


strain


were


more


easy-


going


and


less


inclined


use


avoidance


coping


than


individuals


who


became


under


stress.


In addition,


stress


resistant


group,


men


were


more


self-confident


and


women


had


better


family


support


than


their


counterparts


distressed


group.


Folkman


and


Lazarus


(1980)


analyzed


ways


community


stressful


residing


events


men


of daily


women,


living


aged


during


45-64,


one


coped


year.


with


The


item


Ways


Coping


checklist


was


developed


the


authors


measure


coping


this


study.


Results


indicated


that


work


situations


favored


the


use


of problem-focused


coping,


and


health


contexts


favored


emotion-focused


coping.


Situations


constructive


which

could


the


person


be done


thought


or that


were


something

appraised


requiring


more


information


favored


problem-focused


coping,





-75-


1978) ,


gender


differences


emerged


only


problem-


focused


coping.


Men


used


more


problem-focused


coping


than


women


at work


and


situations


having


accepted


and


requiring I

stereotype,


Iore


information.


there


were


Contrary


no gender


to the


differences


cultural


emotion-


focused


coping.


In keeping


with


transactional


perspective


which


emphasis


zes


situational


determinants


coping


efforts,


McCrae

assess


(1984)


the


reported


influence


on two


of losses,


studies


that


threats,


attempted


and


challenges


the


choice


coping


responses.


Analysis


of the


use


of 28


coping


mechanisms


showed


that,


across


both


studies,


type


stressor


had


a consistent


and


significant


effect


on the


choice


coping


mechanisms.


Faith,


fatalism,


and


expression


of feelings


were


used


especially


when


subjects


had


experienced


a loss;


while


wishful


thinking,


faith,


and


fatalism


were


used


subjects


facing


a threat.


A number


mechanisms


were


used


more


under


conditions


of challenge,


including


rational


action,


perseverance,


positive


thinking,


intellectual


denial,


restraint,


self-adaptation,


drawing


strength


from


adversity,


and


humor.


Another


study


Lazarus


and


colleagues


(Folkman,


Lazarus,


Gruen,


& DeLongis,


1986)


examined


the


relationship


between pe


!rsonality


factors,


primary


appraisal,


secondary






-76-


coping


processes


were


assessed


five


different


stressful


situations


that


subjects


experienced


their


day-to-day


lives.


The


results


indicated


that


personality


variable


and


aggregated


appraisal


coping


processes


had


a significant


relation


to psychological


symptoms.


The


more


subj ects


had


stake


(primary


appraisal)


over


diverse


encounters,


the


more


they


were


likely


to experience


psychological


symptoms.


Problem-focused

psychological s


coping


symptoms,


was


negatively


whereas


correlated


confrontive


copin


with

g was


positively


correlated.


These

(Folkman,


which


relations

Lazarus, D


a single


parallel


unkel


stressful


those


-Schetter,


encounter


found


DeLongis


and


another study

, & Gruen, 1986)


immediate


outcome


was


unit


of analysis


The


relations


among


cognitive


appraisal,


coping


, and


the


immediate


outcomes


stressful


encounters


were


examined.


An intraindividual


analysis


was


used


compare


the


same


person'


stre


ssful


encounters


order


to understand


the


functional


relations


among


these


variable


es.


The


findings


indicated


that


coping


was


related


and


appraisal


was


not


related


to the


quality


encounter


outcomes.


Confrontive


coping


and


distancing


were


ass


ociated


with


unsati


factory


outcomes,


and


problem


solving


positive


reappraisal


were


assoc


iated


with


sati


factory


outcomes.






-77-


Overall,


seems


that


coping


styles


which


focus


on problem


solving,


self-reliance,


and


cognitive


reappraisals


are


related


ignoring


to 1


the


ess


distress


problem


more


seems


satisfaction.


related


to higher


Avoiding


distress.


There


also


seems


to be


some


indication


that


the


role


sphere


which


coping


occurs


may


important.


This


supported


Lazarus


and


Folkman


(1984),


who


assert


that


coping


strategies


are


not


inherently


good


or bad.


strategy


that


effective


in one


situation


may


not


effective


another


Therefore,


the


effectiveness


coping


style


depends


on the


extent


to which


appropriate


the


demands


the


situation.


Social


SuDDort


Research


repeatedly


substantiated


that


people


ages


with


strong


supportive


relationships


and


meaningful


ties


with


others


are


able


cope


better


with


the


store


sses


their


environment


(Christen,


1986)


The


growing


evidence


that


the


presence


, and


contact


with,


others


may


enable


people


cope


better


with


stressors


has


resulted


increased


attention


being


given


during


recent


years


the


mediating


variable


of social


support


(Henderson,


1977;


Johnson


& Sarason,


1979)


Car., a


all nnnr+


lina


Haota


Af^pn f Q


caxrannrn 1


- e a -0


a-a:


Sif~.ia a ifr


1 Wr


|





-78-


the


form


of relationships,


on which


they


can


rely,


especially


These


time


resources


of need,


might


but


include


at other


spouse,


times


family,


as well.


friends,


neighbors,


coworkers,


and


members


the


larger


community


(Lin,


Ensel,


Simeone,


Kuo,


1979)


Cobb


(1976)


has


defined


Soc


support


more


specifically


information


that


leads


individuals


believe


that


they


are


cared


and


loved,


esteemed


and


valued,


and


belong


to a network


of communication


and


mutual


obligation.


Social


support


has


been


defined


somewhat


different


terms


Cassel


(1973),


and


Mechanic


(1974),


who


have


observed


that


social


networks


serve


multiple


functions


helping


one


adjust


demands


the


environment.


Caplan


(1974)


argued


that


times


of psychological


need,


social


support


can


provide


emotional


sustenance,


informational


guidance,


and


tangible


assistance.


Dean


and


Lin


(1977)


suggest


that


social


support


may


viewed


as being


organized


around


two


systems:


the


instrumental


system,


which


geared


the


fulfillment


tasks,


and


the


expressive


system,


which


geared


the


satisfaction


of individual


needs


and


the


maintenance


social


solidarity.


Schaefer,


Coyne,


and


Lazarus


(1981)


identified


three


dimensions


social


support:


emotional


support,


which


involves


intimacy


and


receiving


reassurance;






-79-


concerning


solutions


to one's


problems


and


feedback


about


one'


behavior.


this


time,


no single


conception


of social


support


has


received


consensual


acceptance,


though


Cobb


(1976)


and


Schaefer


et al.


(1981)


seem


to incorporate


the


important


elements


other


definitions.


There


are


two


other


important


aspects


these


authors'


conceptualizations


social

kind o


support.


f social


Cobb

support


(1976)


more


emphasizes


important


that

than


the

the


quality or

quantity.


While,


Schaefer


et al.


(1981),


distinguishing


quantity


versus


quality


of social


support,


recommend


using


the


terms


social


The


network


lack


and


consensus


perceived


social


concerning


the


support,


definition


respectively.


of social


support


also


reflected


ambiguities


measurement.


For


example,


several


studies


have


regarded


marital


status


the


sole


indicator


of social


support,


a practice


that


clearly


simplistic


light


any


the


foregoing


definitions.


The


view


that


social


support


important


to a person'


health


well-being


not


new.


In fact


some


of the


most


persuasive


evidence


power


social


support


factors


influencing


an individual'


susceptibility


to physical


illness


mortality


comes


from


animal


studies


(Bell,


LeRoy,


Stephenson,


1982).


Under


conditions


of laboratory-






-80-


heart


disease


rabbits


(Nerem,


Levesque,


& Cornhill,


1980) ,


hypertension


(Henry


& Cassel,


1969) ,


gastric


ulcer


formation


in rats


(Conger,


awrey,


& Turrell,


1958),


and


experimental


neurosis


a goat


(Liddell,


1950)


Studies


on mortality


rates


humans


have


provided


evidence


the


effects


of social


support


on illness.


the


1950s,


Kraus


and


Lillienfield


(1959)


concluded


from


existing


medical


evidence


that


married


people


experienced


lower


mortality


rate


from


causes


than


did


single


persons,


the


widowed,


and


the


divorced


for


every


age


group


regardless


gender


and


race.


Interestingly,


widowers


were


found


to have


a death


rate


three


to five


times


higher


than


that


married


men


of the


same


age


causes


death.


The


relationship


between


social


support


and


subsequent


mortality


was


replicated


Berkman


and


Syme


(1979).


Almost


7000


people


were


studied


and


their


mortality


rate


was


tracked


over


a 9-year


period.


The


results


confirmed


that


people


who


had


social


support


were


more


likely


to die


than


were


people


with


high


social


support.


They


addressed


social


support


the


broader


term


social


integration


reflected


marital


status,


contacts


with


close


friends


and


relatives,


Although


marital


church


membership,


status


related


or group


associations.


to mortality


within






-81-


Numerous


studies


have


demonstrated


links


between


social


support


and


physical


health


and


illness.


Lynch


(1977)


found


personal


relationships


were


significantly


associated


with


lower


rates


of all


types


of heart


disease.


Social


support


also


has


been


found


interact


with


life


stress


to reduce


the


negative


Cassel,


and


impact


Kaplan


of stress


(197


on physical


health


a well-designed


Nuckolls,


study,


showed


that


the


pregnancy


complication


rate


was


much


higher


those


women


who


experienced


many


life


events


but


had


low


support


scores


measured


quality


of marital


relationship,


interactions


with


extended


family,


and


adjustment


within


the


community)


than


those


who


also


experienced


many


life


events


but


scored


high


on the


social


support scale.

indicated that


Gore's


strain


(1978)


the


study

form o


of unemployed


f elevated


men


cholesterol


level


increased


depression,


and


more


frequent


illness


was


considerably


lessened


among


those


with


supportive


marital


relations


and


ties


the


extended


family


and


peer


groups.


Social


support


only


has


a beneficial


effect


mortality


and


physical


disease,


but


there


also


is a growing


body


distress


evidence

and dis


linking


order.


social


Brown


support


and


with


colleagues


psychological

(Brown,


Bhrolchain,


& Harris,


1975;


Brown


& Harri


1978)


examined






-82-


relationship,


developed


depre


ssion


compared


to only


women


with


such


a confiding


relationship.


Similarly


Eaton


(1978) ,


a new


analysis


another


data


set


(Myers,


Lindenthal,


Pepper,


1975)


found


the


relationship


between


life


stress


and


psychiatric


symptoms


was


greater


for


unmarried


persons


and


those


living


alone


than


individuals


and


Tausig,


who


their


& Ensel,


were


married


associates


1980;


or not


(Dean


Lin,


Lin,


Simeone,


living


1977


Ensel,


alone.


Dean,


& Kuo,


Dean


Lin,


1979)


observed


a significant


psychological


relationship


distress.


one


between


analysis,


social


Lin,


support


Someone,


Ensel,


and


Kuo


(1979)


examined


effects


social


support


and


stressors


on psychiatric


symptoms.


Their


findings


showed,


as expected,


that


stressors


were


positively


related


the


incidence


psychiatric


symptoms,


and


social


support


was


more


significantly


(and


negatively)


related


psychiatric


symptoms.


These


the


studies


likelihood


indicate


illness


social


and


support


to speed


appears


recovery


to lower

illness


when


does


occur


Apparently


people


with


high


levels


social

first


support

place.


may

Socia


be less 1

1 support


ikely

does


to develop


seem


illness


to enhance


in the


the


prospects


recovery


people


who


are


already


(Wallston,


Alagna,


DeVelli


& DeVellis


, 1983)


People


with






-83-


socia

have


support


failed


(Cobb,


to find


1979).


However,


differences


a number


illness


rates


studies


among


people


with


high


versus


low


levels


social


support


(Wallston


et al.,


1983),


may


that


social


support


more


effective


reducing


stress


than


actually


preventing


illness.


What,


exactly,


the


role


social


support


moderating


been


the


extensively


effects


of stress?


explored.


The


Two


first


possibilities

hypothesis, fr


have


equently


labeled


the


"direct


effects"


or "main


effects"


hypothesis


maintains


that


social


support


has


a direct


beneficial


effect


regardless


of the


level


stress.


A number


of studies


report


finding


primarily


main


effects


(Bell


et al.,


1982


Schaefer


Hewson, and

life stress,


et al., 1981)


Vaillant

social


One


(1978)

support,


study


examined


and


Andrews,


the


coping


Tennant,


contributions


style


psychological


impairment.


They


found


that


both


social


support


and


stress


were


independently


(rather


than


interactively)


related


to psychological


impairment


additive


fashion.


The


second


hypothesis,


often


called


the


buffering,


mediating,


or interaction


hypothesis,


proposes


that


social


support


operates


an interactive


fashion


with


level


stress


to modify


the


effects


stress


on health


outcomes.






-84-


found


that


the


relation


between


lack


social


support


and


psychological


distress


increased


as a function


the


level


life


stress


the


individual


had


experienced.


Under


this


hypothesis


the


health


mental


health


benefits


of social


support


when


are


there


chiefly


little


evident


stress


during


social


periods


support


of high


may


stress;


have


physical


or mental


health


benefits.


According


this


hypothesis,


what


social


support


does


act


as a reserve


and


resource


that


individual


blunts


cope


effects


with


stress


stress


more


or enables


effectively


the


when


at high


levels


or when


individual


needs


most.


LaRocco,


House,


French


(1980)


found


that


social


support


did


buffer


the


effects


stress


on mental


and


physical


health.


However,


Soc


support


did


not


buffer


the


effect


of stress


on job-related


strains


(job


dissati


sfac-


tion).

equally


Apparently


well


not


buffered


manifestations


social


support.


of stress


For


are


example,


study


res


idents


near


Three


Mile


Island


following


the


nuclear


accident,


people


with


high


levels


of social


support


showed


less


distress


fewer


behavioral


problems


than


did


people


with


low


levels


of social


support;


however,


physiological


indicators


stress


(arousal)


were


unaffected


social


support


(Fleming,


Baum,


Gisriel,


& Gatchel,


1982).


Interestingly,


while


the


mediating


role


of social






-85-


found


no significant


stress


buffering


effects


of social


support


on physiological


or psychological


strain


(Andrews,


Tennant,


Hewson,


& Vaillant,


1978;


Billings


& Moos,


1984;


Kobasa,


1982;


Schaefer


et al.,


1981).


It has


been


difficult


to determine


whether


the


effect


of social


support


direct,


a buffering


effect,


or the


result


a third


(unknown)


factor.


For


instance,


an issue


often


raised


stressor.


that


Persons


loss


who


live


social


alone


support


and


have


can


be itself


social


contacts


often


report


degrees


of symptomology


even


when


experiencing


stressors.


Perception


of the


need


social


support


and


type


support


needed,


along


with


availability,


accessibility,


and


whether


or not


such


support


used,


are


influenced


developmental


or life


cycle


changes.


Bruhn


Philips


(1984)


proposed


that


individual'


availability


perception


and


the


accessibility,


need


and


Soc


whether


support,


or not


used


are


related


to changes


social


roles


and


life


events


throughout


life


cycle.


Social


support


tends


to be at


peak,


both


terms


need


and


availability,


during


middle


age,


while


lower


levels


are


apparent


during


earlier


and


later


years.


There


are


a small


number


studies


that


have


found


different


results


the


role


social


support






-86-


important


source


of support


men


than


women,


and


that


family


environment


was


an especially


important


source


support


unemployed


women.


Billings


and


Moos


(1984)


generated


similar


results


with


males


and


females


entering


treatment


depression.


Social


support


was


more


strongly


related


to functioning


women,


while


different


sources


of support,


from


coworkers


and


supervisors


work

men's


environment,

adjustment.


were


thought


Holahan


and


to be

Moos


more

(1985)


important


found


stress


resistant


women


had


better


family


support


than


women


in the


distressed


group.


These


authors


suggested


that


these


gender-related


differences


social


support


were


function


of conventional


patterns


sex


role


behavior


in our


society.


In a study


of 102


male


and


female


academic


multiple


role


persons,


Hammond


(1987)


found


no differences


gender


on levels


social


support


perceived


from


families.


However,


women


perceived


significantly


more


social


support


from


friends


than


men.


Several


authors


have


suggested


that


Kobasa'


(1982)


failure


to find


that


social


support


operated


as a stress


resistance


factor,


the


sample


of all


male


lawyers,


was


because


these


observed


gender


differences


the


role


of social


support.






-87-


illness


relationship.


Although


health


practices


and


exercise have

of stress, the


been mentioned

y have been, a


frequently


s of yet,


as possible


only


buffers


minimally


researched.


A thorough


literature


search


generated


fewer


empirical


studies


examining


the


relationship


of health


practices


or exercise


moderating


the


effects


of stress.


Health


practices


a broad


term


and


includes


such


factors


as nutrition,


exercise,


sleep,


smoking,


and


alcohol


and


substance


abuse.


As previously


mentioned


the


cumulative


effect


stressful


life


can


take


toll


on the


body.


People


who


are


stressful 1


situations


may


themselves


eating,


drinking,


or smoking


excess


ively.


Heart


disea


arteriosclerosis,


known


to be


affected


stress.


Yet


number


of other


diseases


are


also


believed


to have


significant


stress


component.


Cancer


one


these


disea


ses,


with


some


fascinating


research


currently


being


done


an effort


identify


cancer-prone


personality


types.


It has


long


been


hypothesized


that


unhealthy


emotions


can


weaken


the


body'


defense


mechanisms


whose


to interfere


with


growth


and


proliferation


abnormal


cells.


Distress


and


emotions


also


seem


to be


important


contributing


factors


hypertension,


asthma,


allergies,


ulcers,


ulcerative


colitis,


and


migraine





-88-


established


as a variable


affecting


health


(Coyne


Holroyd,


1982).


example,


workers


physically


strenuous


occupations


were


found


to have


lower


incidence


rates


myocardial


infarction


(Karvonen,


Rautaharju,


Orma,


Punsar,


Takkunen,


1961)


and


a lower


risk


coronary


heart


mortality


(Paffenberger


& Hale,


1975)


compared


demographically


similar


workers


less


strenuous


occupations.


Assessing


life


style


more


globally,


Pratt


(1971)


found


that


a higher


quality of

nutrition,


Personal


health


elimination,


practices


dental


hygiene,


(e.g.,


sleep,


smoking,


exercise,


and


alcohol


use)


was


related


to a higher


subjective


level


of health


to fewer


health


problems.


Results


such


as these


have


investigators


to suggest


that


the


costly


toll


many


health


problems


exercise,


can


reduced


proper


sleep


through


rest


a healthy


habits,


diet,


restraint


regular


from


smoking


and


alcohol


or substance


abuse,


and


reduced


risk-


taking


behavior


(Matarazzo,


1982;


Pratt,


1971).


Health


practices


influencing


health


status


also


may


modified


stress.


Langlie


(1977)


found


that


subjects


with


many


demands


on their


time


reported


feeling


a lack


control


practices


perceived


as high.


costs


more


of maintaining


direct


support,


good


Weisman


health

(1956)


reported


that


peptic


ulcer


sufferers


aggravate


their


disease


increasing


alcohol


consumption


response


to work


- a


I


qk *


ft


1