Journal of Psychosomatic Research 52 (2002) 239 – 247

Sense of coherence as a mediator between hostility and health

Seven-year prospective study on female employees
Mika Kivimäkia,b,*, Marko Elovainioc, Jussi Vahterad, Jari-Erik Nurmie, Taru Feldte,
Liisa Keltikangas-Järvinena, Jaana Penttid
a
Department of Psychology, University of Helsinki, PO Box 13, Helsinki 00014, Finland
b
Department of Psychology, Finnish Institute of Occupational Health, Topeliulesenkatu 41 aA, Helsinki 00250, Finland
c
National Research and Development Centre for Welfare and Health, PO Box 220, Helsinki 00531, Finland
d
Turku Regional Institute of Occupational Health, Hämeenkatu 10, Turku 20500, Finland
e
Department of Psychology, University of Jyväskylä, PO Box 35, Jyväskylä 40351, Finland
Received 29 May 2001; accepted 1 November 2001

Abstract

Objective: We proposed and tested a model in which low
sense of coherence (SOC) was hypothesized to underlie the
association between hostility and health problems. Methods:
Structural equation modeling was based on cross-lagged 7-year
follow-up data, relating to five measurement points in 433 female
municipal employees. Results: The mediated model fitted well
with the data. After adjustment for baseline characteristics,
hostility was associated with increased risk of health problems, as
indicated by records of sickness absences and poor self-rated
health. Incorporating SOC into the model attenuated this
association by 33 – 50%, depending on the indicator of health.
The mediated effect of SOC was stronger than that of an
alternative mediator, depressive symptoms. Conclusion: Low
SOC may be a psychological background factor partially
underlying the adverse effect of hostility on ill health. D 2002
Elsevier Science Inc. All rights reserved.

Keywords: Health; Hostility; Personality; Psychosocial factors; Sense of coherence; Sickness absence; Women

Introduction esis, we examined whether SOC mediates the association

Hostile men and women have been found to be at
greater risk of coronary heart disease [1 –6] and other
health problems [7 – 11]. Potential mechanisms through
which hostility is argued to influence health relate to poor
health habits, heightened sympathetic reactivity and low
levels of social support [10]. However, the psychological
background of these behavioral, psycho-physiological and
interpersonal mechanisms is not clear.
On the basis of research on hostility and other vari-
ables that relate to hostility, we hypothesized that an
unhealthy life orientation, as delineated in the theory of
sense of coherence (SOC) [12 – 14], represents such a
psychological background. To empirically test the hypoth-
* Corresponding author. Department of Psychology, Finnish Institute of
Occupational Health, Topeliulesenkatu 41 aA, Helsinki FIN-00250, Finland.
Tel.: +358-9-47471; fax: +358-92414634.
E-mail address: mika.kivimaki@occuphealth.fi (M. Kivimäki).
between hostility and health.
Behavioral, psycho-physiological and interpersonal
mechanisms
At least three inter-related models explaining the
mechanisms through which hostility could influence
health have been proposed. First, the behavioral model
states that hostile individuals engage in high-risk health
behaviors such as heavy alcohol consumption, regular
smoking and a sedentary life style [15 –17].
Second, the psycho-physiological reactivity model
suggests that hostility may create a risk to health
via sympathetic reactions [10,18]. Hostile individuals,
who tend to experience more frequent and intense epi-
sodes of anger, show heightened cardiovascular and/or
neuroendocrine responses to behavioral and psycho-
logical stressors [19 – 21]. These, in turn, are linked to
carotid atherosclerosis and elevated blood pressure and

0022-3999/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved.
PII: S 0 0 2 2 - 3 9 9 9 ( 0 1 ) 0 0 3 0 5 - 1
240 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247
play a role in the pathogenesis of coronary heart disease
[22,23].
Finally, as suggested in the psychosocial vulnerability
model and the transactional model, hostile individuals
experience more stressful life events, have smaller social
networks and receive less social support than nonhostile
persons [10,24,25]. Heightened vulnerability to health
problems in hostile individuals may therefore be attributed
to increased exposure to psychosocial risk factors and/or
inability to benefit from the interpersonal resources avail-
able to them [9,24]. The way in which hostile individuals
express anger and their desire to inflict harm is likely to
lead to interpersonal conflicts and cause others to be less
supportive [10,25 – 27].
SOC and hostility – health relationship
The theory of SOC suggests three psychological dimen-
sions that are particularly relevant to the development of
disease [12 – 14,28]. These include appraisals of the world
characterized by (1) lack of meaningfulness (i.e., demands
are interpreted as stressors or threats rather than as mean-
ingful challenges worthy of being taken up); (2) low
manageability (i.e., one perceives oneself as having insuf-
ficient resources to deal with one’s environment); and (3)
incomprehensibility (i.e., environment is not perceived as
structured, predictable and explicable).
We assume that these dimensions may reflect the psy-
chological underpinnings of the behavioral, psycho-physio-
logical and interpersonal models of hostility. First, the
reasons for poor health habits among hostile individuals
may include their low regard for themselves and a high
degree of cynicism and mistrust. Combined, these reduce
the perceived importance of health-enhancing behaviors and
increase the likelihood that health warnings are ignored
[15,27]. Cynicism and mistrust imply a perception of the
environment as nonsupportive, i.e., an appraisal character-
ized by low manageability. In line with this, empirical
studies suggest that hostile perceptions and SOC are indeed
inter-related [29 –34].
Second, stress-eliciting appraisals representing the psy-
chological side of the psycho-physiological reactivity model
may reflect low SOC. Williams et al. [35] suggested that
given their expectation that people cannot be trusted, hostile
individuals are often likely to be in ‘‘a state of vigilant
observation of others’’ (p. 182). Such appraisals and feel-
ings have been correlated with low SOC [31,36].
Third, the interpersonal world of hostile individuals,
described by the combination of multiple stressors and few
buffers in the psychosocial vulnerability and transactional
models, is also a likely source of low SOC. A prospective
relationship for high stress exposure and low support with
decreased SOC has been demonstrated [37 – 39]. Cross-
sectionally, low social support, poor social integration and
low coping resources have been associated with low SOC
[31,36,40,41].
Thus, at the psychological level, the behavioral, psycho-
physiological and interpersonal models of hostility may
share common elements that are attributable to low SOC.
If this is the case, SOC may mediate the relationship
between hostility and health.
The present study
Only indirect evidence is available to support the
hypothesis on the mediated role of SOC. Hostility (as
measured by the Cook and Medley [42] Hostility scale or
the Finnish Twin Study Hostility scale, the FTSH scale)
[2] and low SOC have been associated with mental and
physical health problems, including coronary heart disease
[6,10,11,43– 48]. These findings, combined with evidence
showing that hostility is related to low SOC [29,30,32,33],
are consistent with our hypothesis. However, to justify the
status of SOC as a mediator between hostility and health,
the associations between hostility and health, hostility and
SOC, and SOC and health need to be tested within a single
study [49].
In the present study, we tested the mediation hypo-
thesis by examining longitudinally whether SOC would
mediate between hostility and health. As a part of this
test procedure, we studied depressive symptoms as an
alternative mediator [48]. Taking women as a target
group serves to counterbalance the existing male dom-
inance in populations drawn for hostility research [10].
Method
Participants
In 1990, 841 identifiable full-time female municipal
workers employed by the town of Raisio, in southwestern
Finland, responded to a questionnaire which was designed
to allow for the assessment of hostility, SOC, self-rated
health and potential confounding factors. They repre-
sented 95% of all women employed by the municipality
at that time. Five hundred eighty-two of those who
responded were still working in the same organization
7 years later, in 1997. Of this number, 433 (76%)
responded to the two follow-up surveys, conducted in
1993 and 1997.
It was not possible to assess whether the 44 employees
who did not return the questionnaire in the first survey
differed in terms of hostility or health from those who did.
However, those women who refused to respond to the
follow-up surveys did not differ significantly from the
participants in terms of hostility [c2(1) = 0.03, n.s.], sickness
absence [t(580) value for the difference in logarithmically
transformed number of sick leave days =
0.52, n.s.] or self-
rated health [c2(1) = 0.12, n.s.]. Thus, there is no indication
of confounding factors in the relationship between hostility
and health due to sample attrition.
 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247
Study design
Measurements were conducted at five points in time.
At Time 1, in 1990, hostility, health habits and self-rated
health status were assessed by a questionnaire survey. At
Time 2, the years 1991– 1993, data on the sick leaves of
the respondents were collected. At Time 3, at the end of
1993, the potential mediators, i.e., SOC and depressive
symptoms, were assessed by a second survey. At Time 4,
data on the sick leaves of the respondents were once
again collected, covering the years 1994– 1996. At Time
5, in 1997, hostility and self-rated health were measured
by a third survey.
Predictive relationships among hostility, SOC, depress-
ive symptoms and ill health were analyzed separately
for the two health indicators — sickness absence and
self-rated health. In the case of sickness absence, the
panel design comprised the measurements taken at all
five points in time. For self-rated health, the study
design consisted of the measurements taken at Times 1,
3 and 5. Both these designs allow for the testing of
whether hostility predicted subsequent health after
adjustment for the effect of health at the baseline
(Time 1 or 2), and also testing the reverse causality,
i.e., whether health at baseline predicted later hostility.
Testing reverse causality is important, and lack of
such testing has been argued to be a drawback in
most longitudinal studies exploring effects between
constructs [51].
Hostility
Hostility was measured at Times 1 and 5 using the
FTSH scale [2]. The items making up this scale —
consisting of self-ratings of proneness to anger, irritabil-
ity and argumentativeness—were as follows: (1) ‘‘Do
you get angry easily?’’; (2) ‘‘Do you get irritated
easily?’’; and (3) ‘‘How often do you get into argu-
ments?’’. Responses to the items were given on a seven-
point Likert-type scale (e.g., 1 = do not get angry easily,
7 = get angry easily).
In other studies, the FTSH scale has shown convergent
validity by significantly correlating with the Trait – Anger
scale [52]; in the study by Romanov et al. [53], for
example, r was .62 for women. The Trait – Anger scale
correlated with the Cook– Medley Hostility scale with
coefficients ranging from .43 to .59 [52]. The FTSH
measure has successfully been used in prospective studies
to predict sickness absence spells, hospitalization, coronary
heart disease and mortality [2,7,9,53,54]. The 9-year Time
1 –Time 2 correlation of r = .57 found by Romanov et al.
[53] indicated highly satisfactory temporal stability for
the scale.
In the sample studied, the internal consistency and
long-term stability of the FTSH scale were satisfactory
(Cronbach’s a= .77, 7-year test – retest reliability, r = .65).
241
Potential mediators
SOC and depressive symptoms were studied as poten-
tial mediators of the relationship between hostility and
health. Both mediators were measured at Time 3.
SOC was assessed by a six-item version of the Ori-
entation to Life Questionnaire (items are numbered 8, 10,
15, 22, 24 and 27 in the longer, 29-item version of this
questionnaire) by Antonovsky [13]. The six-item measure
covers all three aspects of SOC, that is, comprehensibility,
manageability and meaningfulness. The respondents are
asked to check their level of agreement with items on a
seven-point semantic differential scale with two anchoring
phrases (a sample item: ‘‘Does it happen that you have the
feeling that you don’t know exactly what’s about to
happen?’’; 1 = very seldom or never, 7 = very often).
The six-item version corresponded well with the results
derived using the original Orientation to Life Question-
naire. For the six-item version, Cronbach’s a was .76 and
the 3-year follow-up correlation .62. In studies using the
original questionnaire, Cronbach’s a has varied between
.74 and .91 and the test – retest correlations for 12-month
follow-ups between .54 and .78 [28]. In a Swedish study,
the average level of SOC ranged from 4.93 to 5.55 [30]. In
the present sample, the average was 5.09, well within the
limits of the Swedish data.
The scale comprises all the depression items in the 12-item
General Health Questionnaire [55]. These include the fol-
lowing questions (1) ‘‘Have you recently been feeling
unhappy and depressed?’’; (2) ‘‘Have you recently been
losing confidence in yourself?’’; and (3) ‘‘Have you recently
been thinking of yourself as a worthless person?’’. Responses
were given on a four-point scale (e.g., 1 = better than usual,
4 = a lot worse than usual). Cronbach’s a was .80.
Indicating a good convergent validity for the measure, it
has correlated with the original Depression scale of the
long version of the General Health Questionnaire [55] at
the level of r= .96 in other samples [56]. In the present
study, this measure was significantly associated with the
total 12-item General Health Questionnaire score that
assesses nonspecific psychiatric morbidity (r = .86).
Health
Two measures of health used were based on archival data
on sickness absences and self-rated health. We gathered
sickness – absence data from the records of occupational
health care units in Raisio, Finland, covering Time 2
(1991 –1993) and Time 4 (1994 –1996). In accordance with
the situation in other Finnish municipalities, the procedures
for recording sick leave in Raisio are reliable. Each sick-
leave period taken by every employee is recorded, including
the dates when each spell started and ended. In accordance
with regulations, each sick-leave certificate, irrespective of
its place of issue, must be forwarded for recording. Absences
due to caring for a sick child are not recorded as sick leave.
242 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247
As most employees tend to exhibit little or no absence
while a few exhibit a great number absences, the distri-
bution number of days the participants were absent due to
sickness was logarithmically transformed [57]. Sickness
absence is assumed to serve as a measure of health in the
working population when health is understood as a com-
bination of social, psychological and physiological func-
tioning [7,58 – 61].
At Times 1 and 5, the respondents gave an overall
assessment of their health on a five-point scale (1 = poor,
5 = excellent). This measure is widely used in medical,
epidemiological and health psychological research and has
been a powerful predictor of mortality and morbidity
[62 – 64].
Potential confounding factors
The potential confounding factors studied were age,
socio-economic status (SES) and health habits, all measured
at Time 1. Information on age and occupational titles was
obtained from the employer’s registers. Using the classifica-
tion of occupations by Statistics Finland, occupational titles
were classified into the following SES categories: 1 = blue-
collar (e.g., cleaners, kitchen workers, waiters), 2 = lower
white-collar (e.g., office workers, nurses, secretaries) and
3 = upper white-collar (e.g., managers, teachers, physicians).
The measures of health habits included alcohol consumption
(number of grams of absolute alcohol per week), smoking
status (current smoker versus not) and physical activity
(a sedentary life style, corresponding to under half an hour
of fast walking per week, versus not) (for a more detailed
description of the measures, see Refs. [61,65,66]).
Statistical analysis
Structural equation modeling is recommended when
estimating mediated effects and antecedent– consequence
relationships [51,67,68]. Thus, we used such models and
performed the statistical analyses with the LISREL 8
program [69]. The goodness-of-fit of each model was
judged by using (a) the c2 test (a higher P value indicates
better fit with the data), (b) the comparative fit index (CFI)
(values > 0.90 indicate an acceptable model), and (c) the
standardized root mean squared residuals (SRMR) value
(values 0.05 or less indicate a good fit).
In comparing the goodness-of-fit between the alternative
models, we examined changes in c2 values and degrees of
freedom. A statistically significant improvement in the c2
value indicated that the model had a better fit.
Results
Table 1 presents the means, standard deviations and
intercorrelations for the variables. Age and SES were related
to self-rated health. The former was also related to hostility
and the latter to sickness absence. Hostility had correlations
with potential mediators, SOC and depression, smoking
status, alcohol consumption and health problems. The
potential mediators showed a correlation with each other
and also with the indicators of health. Smoking and seden-
tary life style were related to self-rated health. Smoking was
also related to sickness absence.
Predictive relationships between hostility and health
As a preliminary step, we specified and tested a full
model which included all of the constructs (i.e., age, SES,
smoking, alcohol consumption, sedentary life style, hostil-
ity, SOC, depressive symptoms, sickness absence, self-
rated health) and related observed variables. The fit of
this model was satisfactory [c2(126) = 203.92, P = .00,
CFI = 0.97, SRMR = 0.04] and significantly better com-
pared to the null model [c2(252) = 2628.24, P = .00,
CFI = 0.66, SRMR = 0.12]. Thus, the operationalization of
the constructs was acceptable.
The predictive relationships between hostility and health
were tested by nested structural equation models. To do this,
we first compared the no-effect model (no causal relationship
between hostility and health) to the trait model (hostility
predicts health) and then to the reversed-causality model
(health predicts hostility) (Fig. 1). In all models, we con-
trolled for the confounding effects of age and SES by
incorporating paths from age to hostility and self-rated health
and from SES to sickness absence and self-rated health.
The fit of the trait model with the data was significantly
better than the fit of the no-effect model (Table 2). The
cross-lagged coefficients from hostility at Time 1 to sickness
absence at Times 2 and 4 were .10 and .12, respectively
(Fig. 1). Both these coefficients are statistically significant,
supporting the hypothesis that hostility predicts health. The
fit of the reversed-causality model was not significantly
better than that of the no-effect model (Fig. 1, Table 2).
We then applied the same testing procedure in relation to
self-rated health. The results of structural modeling repli-
cated the findings obtained by the sickness absence measure:
the fit of the trait model, but not that of the reversed-
causality model, was significantly better than the fit of the
no-effect model with the data (Table 2). The cross-lagged
coefficient from hostility at Time 1 to self-rated health at
Time 5 was
.13 (Fig. 1).
As a conclusion of these analyses, the hostility measure
was found to be stable and to predict later health. No
support was obtained for the reversed-causality hypothesis
that health problems induce hostility.
Structural models on mediators
To test whether SOC or depressive symptoms mediated
the relationships between hostility and sickness absence,
these variables were separately entered into the earlier trait
model (Fig. 1) as mediators (Fig. 2). The criteria for a
 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247 243

Table 1
Means, standard deviations and zero-order correlations among variables
Variable M SD 1 2 3 4 5 6 7 8 9 10 11 12
Time 1
(1) Age 39.94 7.47
(2) SES 2.09 0.69 .01
(3) Smoking 0.19 0.39
.19***
.12*
(4) Alcohol consumption 86.7 82.2 .03 .20*** .11*
(5) Sedentary life style 0.08 0.26 .07
.04 .07 .07
(6) Hostility 9.63 4.01
.18*** .08 .17*** .11* .03
(7) Self-rated health 4.17 0.81
.25*** .20***
.08
.03
.23***
.11*

Time 2
(8) Sickness absencea 2.28 1.53
.04
.22*** .13** .00 .05 .09*
.31***

Time 3
(9) SOC 5.09 0.81 .08 .09*
.06 .04
.09
.20*** .17***
.17***
(10) Depressive symptoms 1.94 0.68
.04 .02 .03 .07 .09 .21***
.18*** .12**
.42***

Time 4
(11) Sickness absencea 2.54 1.59 .01
.23*** .11*
.02 .08 .13**
.24*** .48***
.21*** .16***

Time 5
(12) Hostility 8.60 3.75
.14** .05 .08 .11* .03 .65***
.10* .03
.24*** .20*** .12**
(13) Self-rated health 3.86 0.95
.24*** .20***
.11*
.05
.18***
.11* .53***
.35*** .29***
.26***
.36***
.14**
a
Logarithmically transformed.
* P < .05.
** P < .01.
*** P < .001.

Fig. 1. Prospective relationships between hostility and health problems.

244 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247

Table 2
Tests of alternative predictive relationships between hostility and health
Model c2 df CFI SRMR Dc2 Ddf P for difference
Health measure: sickness absence
No-effect model 48.35 30 0.99 0.05
Trait model (hostility ! health) 37.78 28 0.99 0.03 10.57 2 < .01
Reversed-causality model (health ! hostility) 45.28 28 0.99 0.05 3.07 2 n.s.

Health measure: self-rated health

No-effect model 50.78 27 0.98 0.04
Trait model (hostility ! health) 44.71 26 0.99 0.03 6.07 1 < .05
Reversed-causality model (health ! hostility) 50.73 26 0.98 0.04 0.05 1 n.s.
CFI = comparative fit index, SRMR = standardized root mean squared residuals.

mediated effect were: a good fit for the complete model,
significant parameter estimates from hostility to the medi-
ator and from the mediator to health, and a decrease in the
parameter estimate from hostility to health compared to that
in the trait model [50].
In the model with SOC as a mediator, hostility at Time 1
predicted SOC at Time 3, which, in turn, predicted sickness
absence at Time 4. The direct coefficient of .08 between
hostility at Time 1 and absence at Time 4 was nonsignificant
and decreased by 33% compared with that in the trait model
(cf. Figs. 1 and 2).
The alternative mediator model, where SOC was replaced
with depressive symptoms, also fitted with the data
[c2(56) = 79.29, P = .02, CFI = 0.99, SRMR = 0.04]. The
structural coefficient between hostility at Time 1 and
depressive symptoms at Time 3 was .28. The coefficient
between depressive symptoms at Time 3 and sickness
absence at Time 4 was .10. The direct coefficient between
hostility at Time 1 and absence at Time 4 was .10, and thus
only 16% lower than that observed in the trait model. The
decrease in this coefficient was less than half of that found in
relation to SOC, suggesting that depressive symptoms did
not mediate between hostility and sickness absence as
strongly as SOC.[49]
Analogous mediator models were tested for self-rated
health. The model with SOC as a mediator fitted the data
well (Fig. 2). There were significant relationships between
hostility at Time 1 and SOC at Time 3 and between SOC at
Time 3 and self-rated health at Time 5. The coefficient
between hostility and self-rated health was nonsignificant
(
.06) and 50% lower than that in the trait model.

Fig. 3. SOC and health habits as mediators between hostility and

Fig. 2. SOC as a mediator between hostility and health. sickness absence.
 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247
Fig. 4. SOC and health habits as mediators between hostility and self-
rated health.
In the alternative mediator model where SOC was
replaced by depressive symptoms [c2(54) = 102.24, P = .00,
CFI = 0.98, SRMR = 0.05], hostility at Time 1 predicted
depressive symptoms at Time 3 (.26), and depressive symp-
toms predicted self-rated health at Time 5 (
.17). However,
the direct coefficient between hostility and absence was

.09, only 25% lower than in the trait model. Thus,
depressive symptoms were not as strong a mediator between
hostility and self-rated health as SOC.
Finally, we incorporated paths from hostility to health
habits and from health habits to sickness absence and self-
rated health. As shown in Figs. 3 and 4, this did not affect
the mediating role of SOC.
Discussion
The link between hostility and health observed in the
present study is in line with several previous studies using
health indices alternative to those used by ourselves [1– 6].
The presently obtained parameter estimates of .10 –.13
between hostility and health problems also correspond to
a recent meta-analysis reporting weighted average corre-
lations of r = .07– .16 across prospective studies in men
and women on self-reported hostility and physical health
[10]. These values indicate significant, albeit relatively
small, effect sizes. This is to be expected from a theo-
retical point of view since multiple factors influence
245
health (e.g., inherited characteristics, various other per-
sonality traits, working conditions and features of living
circumstances [51]).
Although the mechanisms underlying the hostility –
health link have been under intensive scrutiny in the
research, psychological mediators have received only lim-
ited attention. For the first time, this study explored SOC as
a potential psychological mediator of the effects of hostility
on ill health. As expected, low SOC was more usual in
hostile individuals. This, in turn, significantly explained the
influence of hostility on health problems across the two
different indicators of health and the three different health
measurement follow-ups (i.e., 1 – 3, 4 –6 and 7 years after
the assessment of hostility) used.
Low SOC does not, by definition, imply a depressive
mood, but it has been associated with depression in empir-
ical studies [70]. Depression is a more established health
risk factor than SOC [71,72]. For these reasons, it should be
considered whether, in fact, the present findings are spuri-
ous, reflecting exclusively the operation of depression. Such
a bias is not likely since the mediated effect of low SOC was
stronger than that of depressive symptoms. As a further
indication of the independent role of SOC as a mediator, the
results remained unchanged after the effects of poor health
habits were controlled for. Thus, we found support for the
hypothesis on the role of low SOC as an underlying factor in
the association between hostility and health.
The majority of hostility researches are based on the
Cook– Medley Hostility scale, whereas the present findings
related to the FTSH scale, which is a less frequently used
and shorter measure of hostility indicating anger proneness,
irritability and argumentativeness. This measure seemed to
tap a relatively stable personality trait. The 7-year test –
retest correlation of .65 is well within the range of the 7- to
10-year test – retest reliabilities (r = .52– .81) reported for
well-established self-report inventories of personality,
including the Minnesota Multiple Personality Inventory
(MMPI), the Sixteen Personality Factor Questionnaire
(16-PF) and the California Psychological Inventory (CPI)
[73]. The estimate of .77 obtained from structural equation
modeling is assumed to be an error-free indicator of the
stability and thus provides further support for the trait-like
character of hostility.
Consistent with the evidence on the behavioral model
and findings on the Cook – Medley Hostility scale (e.g.,
Refs. [15 – 17]), FTSH hostility related to a higher preva-
lence of smoking and increased alcohol consumption. The
links observed between hostility, on one hand, and depres-
sive symptoms and SOC, on the other, replicated results
reported in previous studies, including those which used the
Cook– Medley Hostility scale [29,30,32,33,74,75].
Limitations
In interpreting the findings, at least two limitations
should be taken into account. First, we measured hostility
246 M. Kivimäki et al. / Journal of Psychosomatic Research 52 (2002) 239–247
by the FTSH scale [2], which is the shortest major hostility
questionnaire used in this research area. A replication using
the Cook – Medley [42] Hostility scale may provide an
interesting comparison to the present results.
Second, a nonstandardized measure of depressive symp-
toms was used. This measure has been found to correlate
strongly with the depression scale in the General Health
Questionnaire (r = .96) [55]. In spite of this, a more direct
measurement of depression, such as the Beck’s Depression
Inventory [76], is recommended for further clarifications of
the role of depression in the processes underlying hostility
and health.
Conclusions
Research on the interplay among hostility, SOC and
health is only beginning to emerge. This is the first study
to propose and test the hypothesis that low SOC may be a
psychological background factor partially underlying the
adverse effects of hostility on ill health. Our evidence from
longitudinal data on female employees and structural equa-
tion modeling supports this hypothesis.
Acknowledgments
This study was supported by grants from the Academy of
Finland (project 44968) and the Finnish Environment Fund.
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