Contribution of Socioeconomic Status to the Association between Hostility and Cardiovascular Risk Behaviors: A Prospective Cohort Study

Laura Pulkki1, Mika Kivimäki1, Marko Elovainio1, Jorma Viikari2 and Liisa Keltikangas-Järvinen1 

1 Department of Psychology, Division of Applied Psychology, University of Helsinki, Helsinki, Finland.
2 Department of Medicine, Turku University, Turku, Finland.

Received for publication January 24, 2003; accepted for publication May 23, 2003.


    ABSTRACT
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
The authors examined the contribution of childhood and early adulthood socioeconomic status (SES) to the association between adulthood cynical hostility and cardiovascular risk behaviors. Participants from the population-based, prospective Cardiovascular Risk in Young Finns Study were 531 males and 688 females, aged 12–21 years at the baseline in 1983 and 21–30 years at the follow-up in 1992. Cardiovascular risk behaviors comprised the number of cigarettes smoked per day, physical inactivity, the type of fat used in the diet, and the frequency of alcohol consumption. The general linear models showed socioeconomic variation in cynical hostility, butter use in the diet, and smoking. In regression analyses, hostility was positively associated with smoking in men and women (ß coefficients = 0.16 and 0.09; p values = 0.000 and 0.019, respectively) and with frequency of alcohol use (ß coefficients = 0.10 and 0.03; p values = 0.024 and 0.03, respectively). Adding parents’ and participants’ SES to the model marginally attenuated these associations. The authors conclude that the association of cynical hostility with smoking and alcohol use seems to be independent of intergenerational social mobility and childhood and adulthood SES.

cardiovascular system; hostility; risk; social class; social mobility

Abbreviations: Abbreviation: SES, socioeconomic status.


    INTRODUCTION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Editor’s note: An invited commentary on this article appears on page 743.

Cynical hostility, or cynical mistrust, is characterized by suspiciousness, negative attitudes toward the world, and the tendency to interpret others’ actions as reflecting selfish intent (1, 2). Although not entirely consistently (35), evidence from initially healthy populations shows that cynical hostility is associated with cardiovascular morbidity and mortality (1, 2, 6, 7). Hostility may affect cardiovascular risk through stress-induced cardiovascular and neuroendocrine hyperreactivity and health risk behaviors such as smoking, alcohol use, and fat intake, thus subjecting the body to constant "wear and tear" (1, 2, 810). Hostile individuals may also be at risk because they experience a variety of psychosocial adversities, such as a low level of social support and a high level of interpersonal conflicts, as proposed by the psychosocial vulnerability model (1, 2, 11).

Recently, the role of hostility as an independent contributor to cardiovascular risk has been questioned. The neomaterialistic view of health inequalities suggests that the association between psychosocial factors, such as hostility, and cardiovascular risk is confounded by socioeconomic conditions, the hypothesized true factor underlying the disease (1214). Hostility could simply represent a marker of socioeconomic status (SES) or be a part of the process through which material conditions affect cardiovascular risk. These arguments are not without evidence. First, low SES in childhood and adulthood has been associated with high levels of cynical hostility and hopelessness in adulthood (1517). Second, it is well-established that low childhood and adulthood SES is associated with increased cardiovascular risk (18, 19).

The purpose of the present study was to examine the extent to which the relation between cynical hostility and cardiovascular risk behaviors is attributable to childhood SES, adulthood SES, and intergenerational social mobility in a population-based Finnish sample of young adults.


    MATERIALS AND METHODS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Sample selection and participants
This study is part of the ongoing research project entitled Cardiovascular Risk in Young Finns (20). In order to select participants that would represent Finnish children and adolescents in terms of living conditions and socioeconomic and demographic background, Finland was divided into five areas according to the location of the university cities with a medical school. In each area, urban and rural boys and girls were randomly selected on the basis of their personal Social Security number from the Social Insurance Institution’s population register, which covers the whole population of Finland. The study plan was accepted by the ethical committees of all participant universities, and the study protocol of each study phase corresponded to the World Health Organization proposal for a cross-sectional study of atherosclerosis precursors in children (21).

In the present study, information about parents’ educational level was collected in 1983, when the participants were 12, 15, 18, and 21 years of age. The follow-up measurement 9 years later in 1992 assessed each participant’s socioeconomic status, cynical hostility, and cardiovascular risk behaviors. Complete data were available from 1,219 participants (531 men and 688 women), 62 percent of the participants in 1983. Sample attrition in the Cardiovascular Risk in Young Finns follow-up studies has not been found to be systematic (22).

Measures
Cynical hostility was derived from the Minnesota Multiphasic Personality Inventory questionnaire (the Individual Card Form (23)) through factor analyses of the items on the paranoia and depression scales (24, 25) (sample items: "I think nearly anyone would tell a lie to keep out of trouble," "most people will use somewhat unfair means to gain profit or an advantage rather than to lose it," and "most people inwardly dislike putting themselves out to help other people"). The original true/false response scale was reformatted into a five-point scale ranging from totally disagree (point 1) to totally agree (point 5), because this coding scheme was thought to be more effective in bringing out variance in hostility in this young and healthy study sample. The internal reliability of the scale was 0.73 for men and 0.76 for women (Cronbach’s alpha). The cynical hostility scale used in this study has been shown previously to correlate significantly with scales measuring hostility-related constructs such as paranoia (26) and anger (27, 28), and confirmatory factor analyses have shown that the items of the scale loaded significantly on the same factor (29). This scale has previously been associated with low social support (28), hostile parental child-rearing attitudes (29), child’s difficult temperament (29), and physiologic coronary risk factors (28, 30).

SES was measured as educational level, which was requested from parents at the baseline and from participants at the follow-up. The categories were as follows: high (academic, studying at or graduated from a university); intermediate (secondary education but not academic); and low (comprehensive school as the highest level of education). Information on the parent with a higher educational level was used in the analyses. For assessment of intergenerational social mobility of the participants, SES was dichotomized into high (individuals with secondary or academic education) and low (individuals with comprehensive school as the highest education). Four categories of social mobility were formed: stable high (high parental and high adulthood SES), downwardly mobile (high parental and low adulthood SES), upwardly mobile (low parental and high adulthood SES), and stable low (low parental and low adulthood SES). Additional SES indicators were parents’ and participants’ occupational status and parents’ income. Occupational status was measured for the two oldest age cohorts (n = 188 for men and n = 246 for women), categorized as upper nonmanual, lower nonmanual, manual, and entrepreneur.

Cardiovascular risk behaviors in the follow-up comprised smoking (the number of cigarettes smoked per day); physical inactivity (an index consisting of the product term of frequency, intensity, and duration of exercise) (31); type of fat used in the diet (preference of vegetable oil, margarine, or butter); and alcohol consumption (the average number of occasions per week when alcoholic beverages were consumed). These self-reported measures have been associated with serum lipids, insulin concentrations, and blood pressure in previous studies of the Cardiovascular Risk in Young Finns sample (32).

Statistical analyses
Positive findings in all the following steps were considered to support the hypothesis that SES contributes to the association between hostility and cardiovascular risk behaviors: step 1, SES is significantly associated with cynical hostility and health risk behaviors; step 2, hostility is significantly associated with cardiovascular risk behaviors; and step 3, this association is significantly attenuated after controlling for SES.

In the first step, gender differences in SES levels were tested by chi-square analysis. Gender differences in hostility and cardiovascular risk behaviors were tested by univariate analysis of variance. Because significant gender differences were found, all subsequent analyses were conducted separately for men and women.

In the second step, age-adjusted differences in the mean levels of hostility and cardiovascular risk behaviors between SES categories were tested using analysis of variance. To examine whether the association between parental SES and cardiovascular risk behaviors was independent of participants’ current SES, we controlled for this variable in the model. The possible mediating role of hostility in the significant relations between SES and cardiovascular risk behaviors was examined by adding hostility as a covariate in the model. A mediating effect was considered to be found if the association between SES and cardiovascular risk behaviors was significantly attenuated after controlling for hostility (33).

In the third step, linear regression analysis was used to study the associations between cynical hostility and cardiovascular risk behaviors, hierarchically adjusted for age, parents’ SES, participants’ SES, and intergenerational social mobility. This step was replicated using parents’ and participants’ occupational level and parents’ income as SES indicators.


    RESULTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
Table 1 shows characteristics of the cohort. Men had significantly higher hostility scores, consumed more cigarettes, and used alcohol more often than women did.


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TABLE 1. Characteristics of the study group, Cardiovascular Risk in Young Finns Study, 1983–1992*
 
Men and women with low parental SES had higher levels of cynical hostility and a higher preference for butter compared with men and women with high parental SES (table 2). Adjustment for participants’ SES changed the association between parental SES and cynical hostility from significant to nonsignificant in women (p value changed from 0.003 to 0.052; the change in hostility scores was –0.09 for low-SES women and 0.62 unit for high-SES women).


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TABLE 2. Age-adjusted means and standard errors for cynical hostility and cardiovascular risk behaviors in young adulthood by parents’ and participants’ socioeconomic status, Cardiovascular Risk in Young Finns Study, 1983–1992
 
Irrespective of sex, participants’ SES was inversely associated with cynical hostility, the number of cigarettes smoked per day, and butter use in the diet. In women, there was also an inverse association between participants’ SES and physical inactivity. Male and female participants with low childhood SES (both the upwardly mobile group and the stable low group) consumed butter as their principal source of fat more often than did participants with a high childhood SES. Of the different combinations of childhood and adult SES, women who had always stayed in the low SES group had the highest hostility level. In men, those who had drifted downward in socioeconomic status consumed alcohol more often than other men did.

The significant associations between SES and cardiovascular risk behaviors displayed in table 2 remained significant when cynical hostility was added as a possible mediator to the model (table available from the first author on request). There was a slight change in the association between participants’ SES and the type of fat used in the diets of women, where the p value changed from 0.011 to 0.022 (change in means, ±0.01).

Table 3 shows the contribution of SES to the relation between cynical hostility and cardiovascular risk behaviors. In the unadjusted models, cynical hostility was positively associated with the number of cigarettes smoked per day and with weekly frequency of alcohol use in men (standardized ß coefficients = 0.16 and 0.10; p values = 0.000 and 0.024, respectively) and in women (standardized ß coefficients = 0.09 and 0.03; p values = 0.019 and 0.017, respectively). After particpants’ education was added to the model, the association between cynical hostility and smoking in women decreased from borderline significance to nonsignificance (change in p values from 0.019 to 0.103). Adding parental SES and intergenerational social mobility to the model did not attenuate the association of cynical hostility with smoking and alcohol use. A replication of this step using parents’ and participants’ occupational status and parents’ income as the SES indicator instead of educational status led to similar attenuations (table available from the first author on request).


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TABLE 3. Standardized regression coefficients of cynical hostility on cardiovascular risk behaviors, hierarchically adjusted for age, parents’ SES,* participants’ SES, and intergenerational social mobility, Cardiovascular Risk in Young Finns Study, 1983–1992
 

    DISCUSSION
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
We found a robust association of cynical hostility with smoking and frequency of alcohol use, which has also been shown in previous research (810). However, our study was one of the few to demonstrate this association in a population-based sample of young and healthy men and women. In men, participants’ SES, parents’ SES, or intergenerational social mobility did not contribute to any of the associations among hostility, smoking, and alcohol use. In women, participants’ SES contributed marginally to the association between hostility and smoking, but no effect was found for the other indicators of SES. We found no support for the hypothesis that hostility is a linking factor between SES and cardiovascular risk behaviors. This finding was contrary to a Dutch study showing that the association between educational level and perceived general health could be largely ascribed to the intermediate effect of hostility (34). In summary, our study is unable to support the neomaterialistic view of health that suggests that the association between hostility and cardiovascular risk is solely due to socioeconomic factors (1214).

As shown in another Finnish sample (35), smoking was strongly related to participants’ current SES, while dietary habits (as measured by the type of fat consumed) were largely influenced by childhood socioeconomic background, independently of adult SES. In terms of social mobility, the results seem contradictory at first glance: upward social mobility was associated with butter use in both genders, while downward social mobility was associated with alcohol use in men. It seems that once unhealthy dietary habits are learned in childhood, they are difficult to change in adulthood. Thus, upward social mobility as such may not lead to an unhealthy diet, but instead an unhealthy diet may be a "relic" of poor childhood socioeconomic conditions that are not totally compensated for by adulthood SES. Increased alcohol use by downwardly mobile males has also been reported previously (36, 37). However, the cause-effect link may also be such that heavy users of alcohol tend to drift downward in social status, as suggested by the indirect health selection hypothesis (36, 38). All in all, intergenerational social mobility did not have a major impact on health risk behaviors. This is in line with a vast body of evidence suggesting that social mobility has only a minor role in creating inequalities in health or health-related behaviors, and that the cumulative effects of socioeconomic circumstances, starting already in childhood, are the key factor in understanding health inequalities (39, 40).

Hostility was largely influenced by present socioeconomic status. Cynical hostility was highest in participants with low current SES, independently of whether one had always been in low SES or drifted there. Further, participants’ adult SES partially mediated the association between parental SES and cynical hostility; that is, parents’ SES seems to influence hostility through its impact on participants’ SES. It has been shown that low SES predisposes to adverse socioeconomic conditions, such as poor material resources, disrupted interpersonal relationships, and chronic life stress, and that these adversities may lead to pessimistic and cynical life orientations (1517).

Nonenvironmental determinants of cynical hostility may explain why SES did not significantly attenuate the association between hostility and cardiovascular risk behaviors. Studies comparing mono- and dizygotic twins suggest a heritable component in cynicism (41) that is not accounted for by shared family environment or similarities in educational level (42). Interindividual differences in hostility and aggression may also stem from the central nervous system’s serotonergic and dopaminergic functions (43).

We used educational level as the SES indicator because most participants were in the process of entering the labor market and did not have an established occupational position. Education may be considered a reliable indicator of SES, since it is the primary mechanism through which occupational status is achieved in Finland (35, 37). In contrast with several studies using only the father’s SES, we used educational level of the more highly educated parent. We consider this a strength, especially in Finland where women’s participation in the labor force is one of the highest in the world. A replication of the analyses using income and occupational status as SES indicators instead of education showed similar minimal attenuations in the hostility-cardiovascular risk behaviors relation.

The associations between cynical hostility and risk behaviors were cross-sectional, and thus it is not self-evident that hostility precedes cardiovascular risk behaviors. It is also possible that adverse health risk behaviors lead to hostility over time, as suggested by the health selection hypothesis (44). However, longitudinal studies of initially healthy (6, 7) and of high-risk (45) subjects have shown that hostility predicts the development of cardiovascular disease.

In conclusion, this study shows that hostility is associated with smoking and the frequency of alcohol use and that this association is not attributable to socioeconomic confounding. Further research is needed to test whether other potential confounders may be responsible for the association between hostility and cardiovascular risk behaviors.


    ACKNOWLEDGMENTS
 TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 
This study was supported by the Academy of Finland (project nos. 50907 (L. K-J.) and 44968 (M. K.)) and by the Signe and Ane Gyllenberg Foundation.


    NOTES
 
Correspondence to Liisa Keltikangas-Järvinen, Department of Psychology, University of Helsinki, P.O. Box 9, Helsinki 00014, Finland (e-mail: liisa.keltikangas-jarvinen{at}helsinki.fi). Back


    REFERENCES
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 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 ACKNOWLEDGMENTS
 REFERENCES
 

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Invited Commentary: Socioeconomic Status, Hostility, and Health Behaviors—Does It Matter Which Comes First?
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