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Type A behavior: Contextual effects within a Southern black community
Sot. Sci. Med. Vol. 36, No. 3, pp. 289-295, 1993 Printed in Great Britain. All rights rcserwd
Copyright 0
0271-9536193 56.00 + 0.00 1993 Pergamon Press Ltd
TYPE A BEHAVIOR: CONTEXTUAL EFFECTS WITHIN A SOUTHERN BLACK COMMUNITY WILLIAM W. DRE~~LER
Department of Behavioral and Community Medicine, University of Alabama School of Medicine, Tuscaloosa Program, Tuscaloosa, AL 35487-0326,U.S.A. Abstract-The
relationships among Type A behavior (assessed by the Framingham Type A scale), reported physical symptoms, and blood pressure were examined in a study of an African-American community in the rural southern U.S.A. The study was designed to determine: (a) if the cultural context of a black community altered the definition of Type A behavior; and (b) if the effects of Type A behavior were modified by this cultural context, as well as by socioeconomic and social structural variables. It was found that the patterning of traits characteristic of Type A behavior was different in the black (vs published studies of the majority) community, and that subscales of Type A behavior in turn had different effects on health variables than those observed in published studies. The health effects of these subscales were also moderated by socioeconomic and social structural variables. Future research should examine more closely how the definition of the Type A behavior pattern, and its effects, are modified by social and cultural context. Key words--Type
A behavior, contextual effects, black community
The Type A behavior pattern (TABP), first described by Friedman and Rosenman [l], is a behavioral syndrome characterized by excessive competitive drive, time urgency, job involvement, hostility, and nonverbal behaviors indicative of hypervigilance. In both the Western Collaborative Group Study [2] and the Framingham Study [3], the TABP was found to increase the risk of clinically apparent coronary artery disease approx. 2-fold, independently from conventional or ‘known’ risk factors (i.e. blood pressure, serum cholesterol, smoking, glucose intolerance). Two recent meta-analyses of the literature on TABP and coronary artery disease indicate that, retrospectively and prospectively, there is a reliable association between the TABP and coronary artery disease, especially in population (as opposed to high-risk clinical) samples [4, 51. There are, however, a sufficient number of negative findings regarding this association that some have begun to question whether the TABP is a useful theoretical construct at all [6], arguing instead that what has been defined as the TABP actually masks some more essential underlying psychological trait, such as hostility. It is probably most reasonable to presume, as Dimsdale [7] does, that there is something important underlying the various observed associations between the TABP and heart disease. The persistent ability of the global Type A construct to predict onset of coronary artery disease, especially when a measure of hostility is simultaneously controlled for, suggests that a continued exploration of the TABP is likely to be fruitful [8]. One approach to such a continued exploration is to move away from the reductionist and essentialist
orientation, in which the attempt is made to break the Type A construct down into smaller-and-smaller discrete psychological traits, and instead to examine how the definition and effect of the TABP varies by social and cultural context. It has been argued [9, lo] that the profile of behaviors associated with the Type A pattern has developed within the specific cultural context of the Western world, and that the effects of that behavior pattern on health can vary in relation to the social context in which it occurs. In several studies, the patterning of items has changed when standard measures of the TABP have been used in groups that diverge from the typical (i.e. North American, white, male) groups studied [l 1, 121. Similarly, social context variables, such as socioeconomic status [3] and discrepancies in educational status between spouses [13], have been found to modify the effect of the TABP. The evidential basis for this expanded sociocultural perspective on the TABP is, however, small. Therefore, a pilot study of the TABP was carried out within a cultural context which diverges considerably from that of the archetypical Type A: an AfricanAmerican community in the rural Southern U.S.A. The examination of the patterning of responses to a standard measure of the TABP and of how those responses are related to psychophysiological and physiological variables within this sociocultural context will help to shed some light on the nature of this phenomenon. THE RESEARCH
SITE
Research was carried out in the black community of a small (pop. 80,000) city in the southern U.S.A. 289
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WILLIAM W. DRFSSLER
A detailed ethnography of this community is available elsewhere [14]. Like most African-American communities, especially in the rural South, this community has undergone substantial social and cultural change over the past 40 years, since the beginnings of the civil rights movement in the U.S.A. There was little internal differentiation in socioeconomic terms prior to the civil rights movement; while there was a small middle class of professionals and businesspersons, the majority of the population was employed as unskilled or semi-skilled laborers for white employers. Educational levels rarely exceeded the primary school level. Since the civil rights movement the fact of change along these dimensions is indisputable, while the degree of change remains a moot point. Nationally, Farley [15] has shown that education, income, and occupational attainment have all increased substantially within the black community; however, disparities between blacks and whites have been diminished little. In the community in which this study was conducted, the inverse correlation between age and occupational attainment (r = -0.21, P < O.Ol), and age and educational level (r = - 0.56, P < O.Ol), attest to the recency of the phenomenon of socioeconomic differentiation in the black community. An important consideration in the study of the TABP is the cultural construction of the concept of the person in the African-American community. A number of authors, observing from what are quite different vantage points, argue that the concept of the ‘individual’ is less discrete and bounded than that seen in typical Euroamerican societies [16-181. Rather, the moral world in which the ideal of the person is socially constructed places a greater emphasis on ‘the-individual-in-society’. The person is defined as extending through space and time in his or her embeddedness within a kin group and the community. In the study community this conception of personhood was expressed most forcefully by individual informants in discussions of the meaning of work. Work was not viewed by these informants as the expression of individual achievement, but rather as a pathway for the contribution of the person to the good of his or her family and community. In this sense, work and achievement in the occupational sphere are an opportunity for the individual to fulfill more completely the ideal of personhood, which is to apply oneself to the larger social good. This, of course, is the traditional cultural ideal, and members of the community, especially older persons, are quick to point out how this ideal emphasis on the-individual-in-society has been diminished in the course of recent social change. It is interesting that older informants invoked the dimension of time, as when one complained that the younger generation 1‘ wanted too much, too soon, too fast.” The ‘too much’ that is wanted refers to an emphasis perceived to be placed on the acquisition of material goods and the adoption of behaviors construed as symbols of
status in the larger society. This perception by itself is indicative of the extent to which traditional conceptions of the person are seen as, if not gone, at least under assault. And the emphasis on wanting to achieve this style of life as quickly as possible points out the urgency with which younger members of the black community are perceived to pursue achievement in lifestyle and upward social mobility. The point here is not to provide an indepth analysis of the cultural construction of identity and the self within this black community; that would be beyond the scope of this paper. Rather, the point is that there are good reasons to suppose that the characteristics of the TABP are construed differently within the black community. Given this supposition, it is in turn useful to examine the nature and effects of an accepted measure of the TABP within this cultural context. METHODS
Sampling
A sample of 186 households was randomly selected from two low income and two middle income neighborhoods in the primary black community of a small southern city. One adult was interviewed per household; this was always either the head of household or the spouse of the household head (when present, choice of head or spouse was made on a random basis). Sampling was restricted to two age groups, 25-39 year olds (n = 110) and 40-55 year olds (n = 76). The nonresponse rate was low (15%). Measurement of dependent variables and covariates
All respondents were interviewed in their homes by same-sex, same-ethnic group interviewers. Two dependent variables were selected for analysis: blood pressure and psychophysiological symptoms. Blood pressure was assessed using the ascultatory technique; three blood pressure measurements were taken over the course of an interview lasting from one to lf hr. Blood pressures were recorded as first (systolic) and fifth (diastolic) phase Korotkoff sounds. The dependent variables employed in the present analysis are the means of the second and third readings. Psychophysiological symptom reports were obtained by asking the respondent how often during the past week he or she had been bothered by the following sensations: (1) having an upset stomach; (2) feeling faint or dizzy; (3) noticing your hands trembling; (4) sweating when not working or overheated; (5) feelings of tightness or tension in the neck or back; (6) having a poor appetite; (7) feeling your heart pound or race when not physically active; (8) having trouble catching your breath; (9) having trouble sleeping or staying asleep; and, (10) feeling low in energy. Each sensation was rated on a 4-point scale of frequency, and final scale scores were arrived at by averaging over the 10 items, so that total scale scores retain the range of 1.O-4.0. The scale exhibits acceptable internal consistency reliability (o! = 0.84).
Type A behavior and contextual effects Covariates included in these analyses are: age in years; sex (male = 1; female = 0); and the Quetelet Index of body mass. Independent variables The 6-item version of the Framingham Type A scale was used in this study. The scale consists of 5 self-descriptors, rated on a 3-point scale assessing how well the statements describe the respondent, and one dichotomous item. The 5 self-descriptors are: (1) usually pressed for time; (2) eating too fast; (3) being hard driving/competitive; (4) being bossy/ dominating; and, (5) having a strong need to be brst in things. The dichotomous item is: “Do you get quite upset if you have to wait for anything?’ These 6 items were scaled using factor analysis, to be described in more detail below. Two additional variables were assessed, to be examined as potential modifiers of the effects of the TABP. ‘Socioeconomic status’ @ES) is a conventional indicator combining information on the occupational class of the head of household, occupational class of the spouse, and educational level of the respondent; these items were weighted, summed, and standardized (this measure is described in detail elsewhere [19]). The second potential social modifier of the TABP is the discrepancy in education between referred to simply as ‘educational disspouses, crepancy.’ If the respondent’s years of education are greater than his or her spouse’s years of education, this variable is coded ‘1;’ if the spouse’s years of education are equal to or less than the respondent’s years of education, this variable is coded ‘0.’ Data analysis Factor analysis and multiple regression analysis will serve as the major data analytic tools here (see below). Because this is an exploratory study, twotailed tests of statistical significance are reported throughout. RESULTS
The first step in the analysis was to scale the FTAS items. Factor analysis, using squared multiple correlation coefficients as initial communality estimates, extracting factors with eigenvalues exceeding unity, and using varimax rotation, was chosen, following the analysis of Houston et af. of the FTAS [20]. The results of this analysis are shown in Table 1. Like Houston et al., two factors were obtained. Two items load the first factor, both of which refer to the hard-driving and achievement-oriented components of the TABP. The remaining four items load the second factor, all of which refer to time urgency. The rank-order of the magnitude of the items loading the time urgency factor shown in Table 1 is very similar to that obtained by Houston et al., although ‘upset when having to wait’ is considerably less salient in the black community. The rank-order of the two itens
291
Table 1. Factor analysis of the Framingham Type A Scale Factor I. 2. 3. 4. 5. 6.
Strong need to be the best in things Being hard driving and competitive Usually feeling pressed for time Eating too fast Being bossy or dominating Getting upset when having to wait for things Eigenvalue % Total variance
I
Factor 2
0.75 0.69 0.05 0.15 0.33
0.12 0.27 0.59 0.44 0.40
0.17
0.36
2.24 37.4
1.06 17.8
loading the hard-driving factor is reversed from that observed by Houston et al. Following those authors, the subscale items were summed to produce unitweighted scales (as opposed to factor scales). Descriptive statistics for all of the variables included in these analyses are shown in Table 2. Two of the principal aims in the remainder of these analyses are: (1) to determine if the FTAS dimensions exhibit associations with dependent variables similar to those observed in majority samples; and (2) to determine if those associations are modified by SES. Both of these aims can be achieved in hierachical multiple regression analyses using psychophysiological symptoms, systolic blood pressure, and diastolic blood pressure as dependent variables. In the first step of the analysis, covariates, SES, and the two FTAS subscales are entered into the regression equation; in the second step of the analysis, crossproduct terms between SES and each of the FTAS subscales are entered (i.e. SES x hard-driving; SES x time urgency). These analyses are shown in Table 3. For psychophysiological symptoms, time urgency is related to more symptoms; this association is, however, modified by SES. As shown in Fig. 1, persons higher in SES do not report symptoms at the same level as persons lower in SES. Results for systolic and diastolic blood pressure are quite similar. Persons who are more time urgent have higher systolic and diastolic blood pressure, while persons who are more hard-driving have lower systolic and diastolic blood pressures. These associations are unmodified by SES. The third goal of this analysis is to examine how, among married persons, discrepancies in education
Table 2. Descriptive statistics for all variables included in the analyses (n = 186) Variable Psychophysiologic symptoms Systolic blood pressure Diastolic blood pressure Age Sex (%male) Body mass index SES Time urgency Hard-driving Spouse educational discrepancy (% discrepant)*
Descriptive statistics l.ZS(iO.35) 121.51 (k 17.33) 82.65 (f 12.16) 38.07 (k9.49) 46.2 3.46(+0.39) 0.00(~1.00) 5.56(+ 1.77) 3.63(+1.43) 53.8
*Note: Calculated on subsample (n = 95) of married persons.
292
WILLIAMW. DRESSLER symptoms, systolic blood pressure, and diastolic blood pressure on predictor variables and interactions (standardized regression coefficients), n = 186
Table 3. Regression
of psychophysiologic
symptoms Step: (1)
Age
0.10
Sex
0.18** -0.14** -0.24*** 0.16** 0.02
Body mass index SES Time urgency Hard-driving SES x time urgency SES x hard driving R= R= =
0.37”’ 0.14
(2) 0.13’ 0.17.’ -0.14” - -0.22*** 0.16” 0.02 _-0.14* 0.04 0.41*** 0.16
Systolic blood pressure
Diastolic blood pressure
Step: (I)
step: (I)
0.28” 0.39*** 0.21”’ - -0.13** 0.13” - -0.16’*
0.52*** 0.27
(2) 0.27*** 0.391.. 0.21*** -0.13** 0.14” -0.16** -0.01 0.02 0.52*** 0.27
0.18** 0.38*** 0.21*** - -0.06 0.13. _-0.16**
0.4.5*** 0.20
(2) 0.17** 0.38*” 0.21*** -0.07 0.141 -0.16” -0.04 0.05 0.45*** 0.20
*P < 0.08; l*P < 0.05; ***P < 0.01; (all 2-tailed)
between spouses might modify the association of FTAS subscales and dependent variables. The same form of analysis described above is used here; these analyses are of course limited to the married subsample (n = 95) and are shown in Table 4. For psychophysiological symptoms, essentially the same results are obtained as before; educational discrepancy between spouses does not alter the association of higher time urgency with more symptom reporting. Again, the results for systolic and diastolic blood pressure are very similar. In each case, the inverse association between the hard-driving subscale and blood pressure is effectively blunted if the respondent has a higher educational level than his or her spouse. Because the pattern of these results is so similar, only the pattern for diastolic blood pressure is shown (in Fig. 2). Finally, in an effort to better understand the FTAS subscales, each was regressed on a set 17 potential correlates, ranging from simple sociodemographic variables (i.e. age, sex), to more complicated social relational variables (e.g. density of an ego-centered kin network). Variables were removed by backward stepwise elimination. Hard-driving had only four correlates retained in the model: sex (b = 0.27, P < 0.01); age (/I = - 0.18, P < 0.01); occupational class (b = 0.21, P < 0.01); and, marital status (/3 = 0.19, P < 0.01). Time urgency was reduced to a single correlate: education (r = 0.25, P < 0.001).
1.75
r
g 1.50 B E $
-------Hlgh SES
1.25 : 1.00 1
I Low
I High
Time urgency Fig. 1. Interaction effect of SES and time urgency to psychophysiologic symptoms.
in relation
All of the analyses described above were replicated including a covariate indicating whether or not the respondent was currently taking anti-hypertensive medication. Inclusion of this covariate made no difference in the results.
DISCUSSION
One aim of this paper was to determine if the TABP, as measured by the FTAS, behaved in a psychometrically similar way within an AfricanAmerican community in the rural South as it has been observed to in majority samples. It was argued that this community diverged socioculturally from the archetypical sociocultural group used to define the TABP. The factor analysis of the FTAS differed subtly, but saliently, from the majority population samples studied by Houston et al. [20]. The time urgency factor was quite similar in the black community and in the Houston et al. sample; however, the loadings of the two items defining the hard-driving factor were reversed. In the black community, ‘having a strong need to excel’ was more important in defining this factor than ‘being hard driving and competitive.’ Again, this is a subtle, but important, difference, as demonstrated by two convergent pieces of evidence. First, the ethnographic data from the study community, summarized briefly above, indicate that there is indeed a strong value placed on being hard-driving within the community, but to what end? The end is not to achieve in an individual and competitive sense, but rather to contribute to the larger good of the family and the community. It is within this cultural understanding of the meaning of achievement and hard work that these items are interpreted by the individual respondent. Second, this interpretation of the results of the factor analysis of the FTAS converges with the results of a factor analytic study of the Jenkins Activity Schedule (JAS) carried out by Waldron et al. [12]. These investigators factored the JAS separately for males and females, and for blacks and whites. In reference to a factor on which the hard-driving and competitive items loaded for the white subsample, these authors observed that for the black subsample
Type A behavior and contextual effects
293
Table 4. Regression of psychophysiologic symptoms, systolic blood pressure, and diastolic blood pressure on predictor variables and interactions, subsample (n = 95) of married couples (standardized regression coefficients) symptoms Steu: (1)
Age Sex
Body mass index SES Spouse education discrepancy Time urgency Hard-driving Discrepancy x time urgency Discrepancy x hard driving R=
RI=
Systolic blood pressure
Diastolic blood pressure Stew (1)
(2)
Steo: (I)
0.191 0.07 -0.07 -0.32”’
0.19. 0.07 -0.04 -0.32***
0.15 0.41*** 0.30*** -0.17*
-0.01 0.20” - 0.03
-0.02 0.14 0.11
-0.06 0.06 -0.19’
-
-0.10
-
0.41” 0.17
0.10 0.43’1 0.18
(2)
0.05 0.37*** 0.2a*** -0.08
0.03 0.39.0. 0.34*** -0.09
0.03 0.17 -0.36**
0.14 0.06 -0.18
0.08 0.17 -0.44*+*
-0.15
0;7*** 0.33
(2)
0.13 0.42*** 0.33”. -0.18’
0.25’ 0.60*** 0.36
0.47*** 0.22
-0.15 0.38*** 0.53*** 0.28
‘P < 0.08; l*P < 0.05; l**P -C0.01; (all 2-tailed).
the content of the factor appeared to be more explicitly related to being ‘hardworking,’ with explicit descriptors of ‘competitiveness’ assuming less importance. Thus, items that are interpreted explicitly as referring to competitive, achievement-oriented striving for the majority community assume less salience for black respondents, while items referring to hard work and excellence are salient and culturally valued within the moral world of African-American culture. This interpretation of the meaning of items of Type A behavior in the black community looms large in the interpretation of the relationships between FTAS subscales and outcome variables. As observed in other studies [20], time urgency was found to be related to more psychophysiological symptoms, but the hard-driving factor showed no association with this variable. More complicated results were obtained in the analyses of systolic and diastolic blood pressure. In these analyses, time urgency was related to higher systolic and diastolic blood pressure, while hard-driving was related to lower systolic and diastolic blood pressure. These latter findings must be interpreted in terms of traditional African-American culture and the
c
95 r 90
85
b 80 75
1
No discrepancy
\
c
701 LOW
High
Hard - driving
Fig. 2. Interaction effect of hard-driving and spouse educational discrepancy in relation to diastolic blood pressure.
changes it has undergone over the past four decades. For an individual in the black community to endorse self-descriptors concerning his or her commitment to hard work is to affirm basic socially-patterned values, values which connect the individual to a community tradition. In this sense, the individual respondent is expressing a self-perception consonant with a cultural ideal. This self-perception, in turn, is associated with lower blood pressure, because there exists little conflict, at least along this dimension, between the individual respondent and socially-constructed ideals of the individual. Time urgency, on the other hand, is not a part of the socially-constructed ideal of the person. Rather, time urgency, expressing as it does the cornmodification of time and its investment in one or another activity, separates the person from the flow of lived social experience. This incongruity between the individual and a socially-constructed ideal is in turn related to higher blood pressure (see Dressler [21] for more discussion of the concept of cultural incongruity). Another major goal of this analysis was to determine how the impact of the FTAS subscales was modified by socioeconomic and social relational variables. With respect to SES, no modification of the FTAS was observed in relation to blood pressure; however, when psychophysiological symptoms were analyzed, SES significantly reduced the impact of time urgency. There is a growing consensus that SES can alter the impact of stressful life events on reported symptoms [ 14,22,23], with one interpretation for the finding being that lower class persons have fewer resources to cope with the occurrence of events. It has been observed by some that the time urgent Type A individual actually does get more done, at least according to certain criteria [24]. This could, however, be a liability for some lower status persons, because often the values implicit in the occupational settings of lower class persons emphasize conformity and time-regulated work, as opposed to the hyperproduction of achieving more in less time, a value more likely to be useful in upper status occupations where individual production and achievement are
294
WILLIAMW. DRESSLER
salient [25]. Therefore, a behavior pattern such as time urgency may create conflict for the individual in lower status occupations, which in turn is related to the experience of psychophysiological symptoms. The final aim in these analyses was to determine how a most immediate social relational context of the individual, as indicated by congruence in educational status between husbands and wives, modified the association of the FTAS subscales and outcome variables. No relationship was observed for psychophysiological symptoms. For systolic and diastolic blood pressure, if a respondent had more education than his or her spouse, the inverse effect of harddriving on blood pressure was blunted. This association is precisely the opposite of what would be anticipated on the basis of prior research. Generally, the health of males has been examined in these studies, with those studies reporting significant effects showing that a male with less education than his wife has higher risk of a variety of health problems, including cardiovascular disease. For women, at least one study found a similar deleterious effect of a wife having lower educational credentials than her husband [26]. When the TABP is included, the effect of Type A has been observed to be exacerbated among men discrepant in education with their wives [I 31. Because of the unusual nature of these findings, and the small sample size, regression diagnostics were examined carefully for all of these analyses [27]. Three influential cases were identified, one of which had a large studentized residual; the other two had large leverage values. If these three cases are deleted from the first set of analyses (Table 3) the magnitude of the effects of the FTAS subscales and their associated significance levels are increased. If these three cases are deleted from the second se! of analyses, the interaction effect between hard-r\ri,/ing and educational discrepancy disappears in the analysis of systolic blood pressure; in the analysis of diastolic blood pressure, that interaction is substantially reduced in significance (P = 0.10) but it does not disappear entirely. Therefore, any interpretation of that effect must proceed with the caveat that only additional studies can indicate if indeed this effect really occurs, much less what it is. In any event, it is useful to provide more detail for this variable in parsing the meaning of the effect. Persons who are coded as discrepant have an average education of 14 years, and their spouses have an average education of 12 years, or, in other words, persons with educations beyond high school are married to persons with high school educations. It seems to me likely that, in the context of the black community, this variable is actually indicative of upward social mobility of a household. Recall that, prior to the civil rights movement, individual educational levels were low; yet, this variable identifies persons with post-secondary educations. This may indicate individuals, and families, whose social status has risen markedly, certainly inter-generationally, and probably intra-
generationally. In the process of upward mobility, the meaning attached to values such as being hard working may change, losing the connotation of the moral sense of work associated with traditional AfricanAmerican culture. The beneficial cardiovascular effect of regarding oneself in those terms would then also be lost. Regardless of the specific interpretation of any single finding reported here. in general the pattern of results indicates that the meaning and the effects of the TABP, as measured by the FTAS, vary when they are examined within a sociocultural group different from that group on which the pattern was first defined. Furthermore. these results are all consistent with the idea [9, lo] that the TABP. as a syndrome, is socially produced within the particular institutional structures collectively referred to as ‘modern, western’ society. That the syndrome is socially ‘produced’ receives support from one particular finding generated in the current study. The best predictor of time urgency, the pathogenic component of the TABP for this sample, was education. As shown in the old studies of psychological modernity [28], educational experience of the sort referred to in the west as ‘formal’ is the socializer par excellence for ‘modern’ beliefs and attitudes. With respect to the TABP, formal education is certainly an institutional setting in which time is learned to be a commodity, to be parcelled and invested so as to gain a return on that use of it. In the black community, it is also the dimension of the TABP consistently related to poor health. On the other hand, the dimension of the TABP indicative of hard work, consistent with the socially-constructed meaning of work in the community, is related to better health, except where it is blunted by a factor which might be indicative of upward social mobility. In short, all of these analyses are consistent with the notion that the TABP is interpreted in the specific context of culture, and in turn has distinctive effects. But this pilot study can only be regarded as a prelude to more intensive and sophisticated research designs. In addition to a more systematic model which can generate more precise hypotheses, future research should include multiple measures of the TABP, including especially the structured interview. Similarly, this future research should be carried out in the context of prevalence and incidence studies of coronary heart disease. Finally, multiple comparison groups varying in ethnicity and culture should be included. Ultimately, however, the utility of the present work may be to indicate that research on the Type A behavior pattern has been hampered by a lack of theory development with respect to the social and cultural bases and the contextual effects of the behavior pattern, with a few notable exceptions 19, 10,29, 301. Future work in this area may substantially advance our understanding of the cardiopathic effects of this pattern of behavior.
Type A behavior and contextual effects Acknowledgements-This
research was supported by research grants MH33943 and MH42553 from NIMH, and by a BRSG grant from the Graduate School, The University of Alabama.
REFERENCES
1. Friedman M. and Rosenman R. N. Tvne A Behavior and Your Heart. Alfred A. Knopf, New York, 1974. 2. Rosenman R. H.. Brand R. J.. Jenkins C. D., Friedman M., Straus R. and Wurm M. Coronary heart disease in the Western Collaborative Group Study: Final followUDexoerience of 8-l/2 years. JAMA 233. 872. 1975. 3. Hay&s S. G., Feinleid M. and Kannel W.. B. The relationship of psychosocial factors to coronary heart disease in the Framingham Study III. Am. J. Epidemiol. 111, 37 1980. 4. Booth-Kewley S. and Friedman
predictors
H. S. Psychological of heart disease: A quantitative review.
Psycho/. Bull. 101, 343, 1987. 5. Matthews K. A. Coronary heart disease and Type A
behaviors: Update on and alternative to the BoothKewley and Friedman (1987) quantitative review. Psychol. Bull. 104, 373, 1988. 6. Williams R. B. Psychological factors in coronary artery disease: Epidemiologic evidence. Circulation 76, 117
Suppl., 1987. 7. Dimsdale J. E. A perspective on Type A behavior and coronary disease. NEJM 318, 110, 1988. 8. Hecker M. H. L., Chesney M. A., Black G. W. and
Frautschi N. Coronary-prone behaviors in the Western Collaborative Grout) Studv. Psvchosam. Med. 50. 153. 9. Helman C. G. Heart disease and the cu!tural construction of time. Sot. Sci. Med. 25. 969. lY87. 10. Dressier W. W. Type A behavior and the social production of cardiovascular disease. J. Nerv. Men. Dis. 177, 181, 1989.
11. Cohen J. B., Syme S. L., Jenkins C. D., Kagan A. and Zyzanski S. J. Cultural context of Type A behavior and risk for CHD: a study of Japanise American males. J. Behav. Med. 2, 375, 1979. 12. Waldron I., Zyzanski S., Shekelle R. B., Jenkins C. D. and Tannebaum S. The coronary prone behavior pattern in employed men and women. J. Hum. Stress 3, 2, 1977.
13. Eaker E. D, Haynes S. G. and Feinleib M. Spouse behavior and coronary heart disease in men: prospective
295
results from the Framingham heart study. Am. J. Epidemiol. 118, 23, 1983. 14. Dressier W. W. Stress and Adaptation in the Context of Culture: Depression in a Southern Black Community. State University of New York Press, Albany, NY, 1991. 15. Farley R. Three steps forward and two back? Recent changes in the social and economic status of blacks. Ethnic Racial Stud. 8, 4, 1985.
16. Herskovits M. J. The Myth of the Negro Past. Beacon Press, Boston, 1958. 17. Jackson J. S., McCullough W. R. and Gurin G. Group identity development within black families. In Btack Families (Edited by McAdoo H. P.), pp. 252. Sage Beverly Hills, CA, 1981. 18. Nobles W. W. Africanity: Its role in black families. The Black Scholar 6, 10, 1974. 19. Dressler W. W. Social support, lifestyle incongruity, and arterial blood pressure in a southern black community. Psychosom. Med. 53, 608, 1991. 20. Houston B. K., Smith T. W. and Zurawski R. M. Principal dimensions of the Framingham Type A scale: Differential relationships to cardiovascular reactivity and anxiety. J. Hum. Stress 12, 105, 1986. 21. Dressler W. W. Hypertension and perceived stress: A St Lucian example. Ethos 12, 265, 1984. 22. McLeod J. D. and Kessler R. C. Socioeconomic status differences in vulnerabililty to undesirable life events. J. Hlth sot. Behav. 31, 162, 1990. 23. Ulbrich P. M., Warheit G. J. and Zimmerman R. S. Race, socioeconomic status, and psychological distress: An examination of differential vulnerability. J. Hlth sot. Behau. 30, 131, 1989.
24. Matthews K. A., Helmreich R. L., Beane W. E. and Lucker G. Pattern A, achievement striving, and scientific merit. J. Person. sot. Psychol. 39, 962, 1980. 25. Kohn M. L. Social class and parent-child relationships: An interpretation. Am. J. Social. 68, 471, 1963. 26. Vernon S. W. and Buffler P. A. The status of status inconsistency. Epidemiol. Rev. 10, 65, 1988. 27. Bollen K. A. and Jackman R. W. Regression diagnostics: An expository treatment of outlines and influential cases. Social. Meth. Res. 13, 510, 1985. 28. Inkeles A. and Smith D. H. Becoming Modern. Harvard University Press, Cambridge, MA, 1974. 29. Appels A. Culture and disease. Sot. Sci. Med. 23, 477, 1986. 30. Van Egeren L. F. A “success trap” theory of Type A behavior: Historical background. J. sot. Behav. Person. 5, 45, 1990.
Copyright 0
0271-9536193 56.00 + 0.00 1993 Pergamon Press Ltd
TYPE A BEHAVIOR: CONTEXTUAL EFFECTS WITHIN A SOUTHERN BLACK COMMUNITY WILLIAM W. DRE~~LER
Department of Behavioral and Community Medicine, University of Alabama School of Medicine, Tuscaloosa Program, Tuscaloosa, AL 35487-0326,U.S.A. Abstract-The
relationships among Type A behavior (assessed by the Framingham Type A scale), reported physical symptoms, and blood pressure were examined in a study of an African-American community in the rural southern U.S.A. The study was designed to determine: (a) if the cultural context of a black community altered the definition of Type A behavior; and (b) if the effects of Type A behavior were modified by this cultural context, as well as by socioeconomic and social structural variables. It was found that the patterning of traits characteristic of Type A behavior was different in the black (vs published studies of the majority) community, and that subscales of Type A behavior in turn had different effects on health variables than those observed in published studies. The health effects of these subscales were also moderated by socioeconomic and social structural variables. Future research should examine more closely how the definition of the Type A behavior pattern, and its effects, are modified by social and cultural context. Key words--Type
A behavior, contextual effects, black community
The Type A behavior pattern (TABP), first described by Friedman and Rosenman [l], is a behavioral syndrome characterized by excessive competitive drive, time urgency, job involvement, hostility, and nonverbal behaviors indicative of hypervigilance. In both the Western Collaborative Group Study [2] and the Framingham Study [3], the TABP was found to increase the risk of clinically apparent coronary artery disease approx. 2-fold, independently from conventional or ‘known’ risk factors (i.e. blood pressure, serum cholesterol, smoking, glucose intolerance). Two recent meta-analyses of the literature on TABP and coronary artery disease indicate that, retrospectively and prospectively, there is a reliable association between the TABP and coronary artery disease, especially in population (as opposed to high-risk clinical) samples [4, 51. There are, however, a sufficient number of negative findings regarding this association that some have begun to question whether the TABP is a useful theoretical construct at all [6], arguing instead that what has been defined as the TABP actually masks some more essential underlying psychological trait, such as hostility. It is probably most reasonable to presume, as Dimsdale [7] does, that there is something important underlying the various observed associations between the TABP and heart disease. The persistent ability of the global Type A construct to predict onset of coronary artery disease, especially when a measure of hostility is simultaneously controlled for, suggests that a continued exploration of the TABP is likely to be fruitful [8]. One approach to such a continued exploration is to move away from the reductionist and essentialist
orientation, in which the attempt is made to break the Type A construct down into smaller-and-smaller discrete psychological traits, and instead to examine how the definition and effect of the TABP varies by social and cultural context. It has been argued [9, lo] that the profile of behaviors associated with the Type A pattern has developed within the specific cultural context of the Western world, and that the effects of that behavior pattern on health can vary in relation to the social context in which it occurs. In several studies, the patterning of items has changed when standard measures of the TABP have been used in groups that diverge from the typical (i.e. North American, white, male) groups studied [l 1, 121. Similarly, social context variables, such as socioeconomic status [3] and discrepancies in educational status between spouses [13], have been found to modify the effect of the TABP. The evidential basis for this expanded sociocultural perspective on the TABP is, however, small. Therefore, a pilot study of the TABP was carried out within a cultural context which diverges considerably from that of the archetypical Type A: an AfricanAmerican community in the rural Southern U.S.A. The examination of the patterning of responses to a standard measure of the TABP and of how those responses are related to psychophysiological and physiological variables within this sociocultural context will help to shed some light on the nature of this phenomenon. THE RESEARCH
SITE
Research was carried out in the black community of a small (pop. 80,000) city in the southern U.S.A. 289
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WILLIAM W. DRFSSLER
A detailed ethnography of this community is available elsewhere [14]. Like most African-American communities, especially in the rural South, this community has undergone substantial social and cultural change over the past 40 years, since the beginnings of the civil rights movement in the U.S.A. There was little internal differentiation in socioeconomic terms prior to the civil rights movement; while there was a small middle class of professionals and businesspersons, the majority of the population was employed as unskilled or semi-skilled laborers for white employers. Educational levels rarely exceeded the primary school level. Since the civil rights movement the fact of change along these dimensions is indisputable, while the degree of change remains a moot point. Nationally, Farley [15] has shown that education, income, and occupational attainment have all increased substantially within the black community; however, disparities between blacks and whites have been diminished little. In the community in which this study was conducted, the inverse correlation between age and occupational attainment (r = -0.21, P < O.Ol), and age and educational level (r = - 0.56, P < O.Ol), attest to the recency of the phenomenon of socioeconomic differentiation in the black community. An important consideration in the study of the TABP is the cultural construction of the concept of the person in the African-American community. A number of authors, observing from what are quite different vantage points, argue that the concept of the ‘individual’ is less discrete and bounded than that seen in typical Euroamerican societies [16-181. Rather, the moral world in which the ideal of the person is socially constructed places a greater emphasis on ‘the-individual-in-society’. The person is defined as extending through space and time in his or her embeddedness within a kin group and the community. In the study community this conception of personhood was expressed most forcefully by individual informants in discussions of the meaning of work. Work was not viewed by these informants as the expression of individual achievement, but rather as a pathway for the contribution of the person to the good of his or her family and community. In this sense, work and achievement in the occupational sphere are an opportunity for the individual to fulfill more completely the ideal of personhood, which is to apply oneself to the larger social good. This, of course, is the traditional cultural ideal, and members of the community, especially older persons, are quick to point out how this ideal emphasis on the-individual-in-society has been diminished in the course of recent social change. It is interesting that older informants invoked the dimension of time, as when one complained that the younger generation 1‘ wanted too much, too soon, too fast.” The ‘too much’ that is wanted refers to an emphasis perceived to be placed on the acquisition of material goods and the adoption of behaviors construed as symbols of
status in the larger society. This perception by itself is indicative of the extent to which traditional conceptions of the person are seen as, if not gone, at least under assault. And the emphasis on wanting to achieve this style of life as quickly as possible points out the urgency with which younger members of the black community are perceived to pursue achievement in lifestyle and upward social mobility. The point here is not to provide an indepth analysis of the cultural construction of identity and the self within this black community; that would be beyond the scope of this paper. Rather, the point is that there are good reasons to suppose that the characteristics of the TABP are construed differently within the black community. Given this supposition, it is in turn useful to examine the nature and effects of an accepted measure of the TABP within this cultural context. METHODS
Sampling
A sample of 186 households was randomly selected from two low income and two middle income neighborhoods in the primary black community of a small southern city. One adult was interviewed per household; this was always either the head of household or the spouse of the household head (when present, choice of head or spouse was made on a random basis). Sampling was restricted to two age groups, 25-39 year olds (n = 110) and 40-55 year olds (n = 76). The nonresponse rate was low (15%). Measurement of dependent variables and covariates
All respondents were interviewed in their homes by same-sex, same-ethnic group interviewers. Two dependent variables were selected for analysis: blood pressure and psychophysiological symptoms. Blood pressure was assessed using the ascultatory technique; three blood pressure measurements were taken over the course of an interview lasting from one to lf hr. Blood pressures were recorded as first (systolic) and fifth (diastolic) phase Korotkoff sounds. The dependent variables employed in the present analysis are the means of the second and third readings. Psychophysiological symptom reports were obtained by asking the respondent how often during the past week he or she had been bothered by the following sensations: (1) having an upset stomach; (2) feeling faint or dizzy; (3) noticing your hands trembling; (4) sweating when not working or overheated; (5) feelings of tightness or tension in the neck or back; (6) having a poor appetite; (7) feeling your heart pound or race when not physically active; (8) having trouble catching your breath; (9) having trouble sleeping or staying asleep; and, (10) feeling low in energy. Each sensation was rated on a 4-point scale of frequency, and final scale scores were arrived at by averaging over the 10 items, so that total scale scores retain the range of 1.O-4.0. The scale exhibits acceptable internal consistency reliability (o! = 0.84).
Type A behavior and contextual effects Covariates included in these analyses are: age in years; sex (male = 1; female = 0); and the Quetelet Index of body mass. Independent variables The 6-item version of the Framingham Type A scale was used in this study. The scale consists of 5 self-descriptors, rated on a 3-point scale assessing how well the statements describe the respondent, and one dichotomous item. The 5 self-descriptors are: (1) usually pressed for time; (2) eating too fast; (3) being hard driving/competitive; (4) being bossy/ dominating; and, (5) having a strong need to be brst in things. The dichotomous item is: “Do you get quite upset if you have to wait for anything?’ These 6 items were scaled using factor analysis, to be described in more detail below. Two additional variables were assessed, to be examined as potential modifiers of the effects of the TABP. ‘Socioeconomic status’ @ES) is a conventional indicator combining information on the occupational class of the head of household, occupational class of the spouse, and educational level of the respondent; these items were weighted, summed, and standardized (this measure is described in detail elsewhere [19]). The second potential social modifier of the TABP is the discrepancy in education between referred to simply as ‘educational disspouses, crepancy.’ If the respondent’s years of education are greater than his or her spouse’s years of education, this variable is coded ‘1;’ if the spouse’s years of education are equal to or less than the respondent’s years of education, this variable is coded ‘0.’ Data analysis Factor analysis and multiple regression analysis will serve as the major data analytic tools here (see below). Because this is an exploratory study, twotailed tests of statistical significance are reported throughout. RESULTS
The first step in the analysis was to scale the FTAS items. Factor analysis, using squared multiple correlation coefficients as initial communality estimates, extracting factors with eigenvalues exceeding unity, and using varimax rotation, was chosen, following the analysis of Houston et af. of the FTAS [20]. The results of this analysis are shown in Table 1. Like Houston et al., two factors were obtained. Two items load the first factor, both of which refer to the hard-driving and achievement-oriented components of the TABP. The remaining four items load the second factor, all of which refer to time urgency. The rank-order of the magnitude of the items loading the time urgency factor shown in Table 1 is very similar to that obtained by Houston et al., although ‘upset when having to wait’ is considerably less salient in the black community. The rank-order of the two itens
291
Table 1. Factor analysis of the Framingham Type A Scale Factor I. 2. 3. 4. 5. 6.
Strong need to be the best in things Being hard driving and competitive Usually feeling pressed for time Eating too fast Being bossy or dominating Getting upset when having to wait for things Eigenvalue % Total variance
I
Factor 2
0.75 0.69 0.05 0.15 0.33
0.12 0.27 0.59 0.44 0.40
0.17
0.36
2.24 37.4
1.06 17.8
loading the hard-driving factor is reversed from that observed by Houston et al. Following those authors, the subscale items were summed to produce unitweighted scales (as opposed to factor scales). Descriptive statistics for all of the variables included in these analyses are shown in Table 2. Two of the principal aims in the remainder of these analyses are: (1) to determine if the FTAS dimensions exhibit associations with dependent variables similar to those observed in majority samples; and (2) to determine if those associations are modified by SES. Both of these aims can be achieved in hierachical multiple regression analyses using psychophysiological symptoms, systolic blood pressure, and diastolic blood pressure as dependent variables. In the first step of the analysis, covariates, SES, and the two FTAS subscales are entered into the regression equation; in the second step of the analysis, crossproduct terms between SES and each of the FTAS subscales are entered (i.e. SES x hard-driving; SES x time urgency). These analyses are shown in Table 3. For psychophysiological symptoms, time urgency is related to more symptoms; this association is, however, modified by SES. As shown in Fig. 1, persons higher in SES do not report symptoms at the same level as persons lower in SES. Results for systolic and diastolic blood pressure are quite similar. Persons who are more time urgent have higher systolic and diastolic blood pressure, while persons who are more hard-driving have lower systolic and diastolic blood pressures. These associations are unmodified by SES. The third goal of this analysis is to examine how, among married persons, discrepancies in education
Table 2. Descriptive statistics for all variables included in the analyses (n = 186) Variable Psychophysiologic symptoms Systolic blood pressure Diastolic blood pressure Age Sex (%male) Body mass index SES Time urgency Hard-driving Spouse educational discrepancy (% discrepant)*
Descriptive statistics l.ZS(iO.35) 121.51 (k 17.33) 82.65 (f 12.16) 38.07 (k9.49) 46.2 3.46(+0.39) 0.00(~1.00) 5.56(+ 1.77) 3.63(+1.43) 53.8
*Note: Calculated on subsample (n = 95) of married persons.
292
WILLIAMW. DRESSLER symptoms, systolic blood pressure, and diastolic blood pressure on predictor variables and interactions (standardized regression coefficients), n = 186
Table 3. Regression
of psychophysiologic
symptoms Step: (1)
Age
0.10
Sex
0.18** -0.14** -0.24*** 0.16** 0.02
Body mass index SES Time urgency Hard-driving SES x time urgency SES x hard driving R= R= =
0.37”’ 0.14
(2) 0.13’ 0.17.’ -0.14” - -0.22*** 0.16” 0.02 _-0.14* 0.04 0.41*** 0.16
Systolic blood pressure
Diastolic blood pressure
Step: (I)
step: (I)
0.28” 0.39*** 0.21”’ - -0.13** 0.13” - -0.16’*
0.52*** 0.27
(2) 0.27*** 0.391.. 0.21*** -0.13** 0.14” -0.16** -0.01 0.02 0.52*** 0.27
0.18** 0.38*** 0.21*** - -0.06 0.13. _-0.16**
0.4.5*** 0.20
(2) 0.17** 0.38*” 0.21*** -0.07 0.141 -0.16” -0.04 0.05 0.45*** 0.20
*P < 0.08; l*P < 0.05; ***P < 0.01; (all 2-tailed)
between spouses might modify the association of FTAS subscales and dependent variables. The same form of analysis described above is used here; these analyses are of course limited to the married subsample (n = 95) and are shown in Table 4. For psychophysiological symptoms, essentially the same results are obtained as before; educational discrepancy between spouses does not alter the association of higher time urgency with more symptom reporting. Again, the results for systolic and diastolic blood pressure are very similar. In each case, the inverse association between the hard-driving subscale and blood pressure is effectively blunted if the respondent has a higher educational level than his or her spouse. Because the pattern of these results is so similar, only the pattern for diastolic blood pressure is shown (in Fig. 2). Finally, in an effort to better understand the FTAS subscales, each was regressed on a set 17 potential correlates, ranging from simple sociodemographic variables (i.e. age, sex), to more complicated social relational variables (e.g. density of an ego-centered kin network). Variables were removed by backward stepwise elimination. Hard-driving had only four correlates retained in the model: sex (b = 0.27, P < 0.01); age (/I = - 0.18, P < 0.01); occupational class (b = 0.21, P < 0.01); and, marital status (/3 = 0.19, P < 0.01). Time urgency was reduced to a single correlate: education (r = 0.25, P < 0.001).
1.75
r
g 1.50 B E $
-------Hlgh SES
1.25 : 1.00 1
I Low
I High
Time urgency Fig. 1. Interaction effect of SES and time urgency to psychophysiologic symptoms.
in relation
All of the analyses described above were replicated including a covariate indicating whether or not the respondent was currently taking anti-hypertensive medication. Inclusion of this covariate made no difference in the results.
DISCUSSION
One aim of this paper was to determine if the TABP, as measured by the FTAS, behaved in a psychometrically similar way within an AfricanAmerican community in the rural South as it has been observed to in majority samples. It was argued that this community diverged socioculturally from the archetypical sociocultural group used to define the TABP. The factor analysis of the FTAS differed subtly, but saliently, from the majority population samples studied by Houston et al. [20]. The time urgency factor was quite similar in the black community and in the Houston et al. sample; however, the loadings of the two items defining the hard-driving factor were reversed. In the black community, ‘having a strong need to excel’ was more important in defining this factor than ‘being hard driving and competitive.’ Again, this is a subtle, but important, difference, as demonstrated by two convergent pieces of evidence. First, the ethnographic data from the study community, summarized briefly above, indicate that there is indeed a strong value placed on being hard-driving within the community, but to what end? The end is not to achieve in an individual and competitive sense, but rather to contribute to the larger good of the family and the community. It is within this cultural understanding of the meaning of achievement and hard work that these items are interpreted by the individual respondent. Second, this interpretation of the results of the factor analysis of the FTAS converges with the results of a factor analytic study of the Jenkins Activity Schedule (JAS) carried out by Waldron et al. [12]. These investigators factored the JAS separately for males and females, and for blacks and whites. In reference to a factor on which the hard-driving and competitive items loaded for the white subsample, these authors observed that for the black subsample
Type A behavior and contextual effects
293
Table 4. Regression of psychophysiologic symptoms, systolic blood pressure, and diastolic blood pressure on predictor variables and interactions, subsample (n = 95) of married couples (standardized regression coefficients) symptoms Steu: (1)
Age Sex
Body mass index SES Spouse education discrepancy Time urgency Hard-driving Discrepancy x time urgency Discrepancy x hard driving R=
RI=
Systolic blood pressure
Diastolic blood pressure Stew (1)
(2)
Steo: (I)
0.191 0.07 -0.07 -0.32”’
0.19. 0.07 -0.04 -0.32***
0.15 0.41*** 0.30*** -0.17*
-0.01 0.20” - 0.03
-0.02 0.14 0.11
-0.06 0.06 -0.19’
-
-0.10
-
0.41” 0.17
0.10 0.43’1 0.18
(2)
0.05 0.37*** 0.2a*** -0.08
0.03 0.39.0. 0.34*** -0.09
0.03 0.17 -0.36**
0.14 0.06 -0.18
0.08 0.17 -0.44*+*
-0.15
0;7*** 0.33
(2)
0.13 0.42*** 0.33”. -0.18’
0.25’ 0.60*** 0.36
0.47*** 0.22
-0.15 0.38*** 0.53*** 0.28
‘P < 0.08; l*P < 0.05; l**P -C0.01; (all 2-tailed).
the content of the factor appeared to be more explicitly related to being ‘hardworking,’ with explicit descriptors of ‘competitiveness’ assuming less importance. Thus, items that are interpreted explicitly as referring to competitive, achievement-oriented striving for the majority community assume less salience for black respondents, while items referring to hard work and excellence are salient and culturally valued within the moral world of African-American culture. This interpretation of the meaning of items of Type A behavior in the black community looms large in the interpretation of the relationships between FTAS subscales and outcome variables. As observed in other studies [20], time urgency was found to be related to more psychophysiological symptoms, but the hard-driving factor showed no association with this variable. More complicated results were obtained in the analyses of systolic and diastolic blood pressure. In these analyses, time urgency was related to higher systolic and diastolic blood pressure, while hard-driving was related to lower systolic and diastolic blood pressure. These latter findings must be interpreted in terms of traditional African-American culture and the
c
95 r 90
85
b 80 75
1
No discrepancy
\
c
701 LOW
High
Hard - driving
Fig. 2. Interaction effect of hard-driving and spouse educational discrepancy in relation to diastolic blood pressure.
changes it has undergone over the past four decades. For an individual in the black community to endorse self-descriptors concerning his or her commitment to hard work is to affirm basic socially-patterned values, values which connect the individual to a community tradition. In this sense, the individual respondent is expressing a self-perception consonant with a cultural ideal. This self-perception, in turn, is associated with lower blood pressure, because there exists little conflict, at least along this dimension, between the individual respondent and socially-constructed ideals of the individual. Time urgency, on the other hand, is not a part of the socially-constructed ideal of the person. Rather, time urgency, expressing as it does the cornmodification of time and its investment in one or another activity, separates the person from the flow of lived social experience. This incongruity between the individual and a socially-constructed ideal is in turn related to higher blood pressure (see Dressler [21] for more discussion of the concept of cultural incongruity). Another major goal of this analysis was to determine how the impact of the FTAS subscales was modified by socioeconomic and social relational variables. With respect to SES, no modification of the FTAS was observed in relation to blood pressure; however, when psychophysiological symptoms were analyzed, SES significantly reduced the impact of time urgency. There is a growing consensus that SES can alter the impact of stressful life events on reported symptoms [ 14,22,23], with one interpretation for the finding being that lower class persons have fewer resources to cope with the occurrence of events. It has been observed by some that the time urgent Type A individual actually does get more done, at least according to certain criteria [24]. This could, however, be a liability for some lower status persons, because often the values implicit in the occupational settings of lower class persons emphasize conformity and time-regulated work, as opposed to the hyperproduction of achieving more in less time, a value more likely to be useful in upper status occupations where individual production and achievement are
294
WILLIAMW. DRESSLER
salient [25]. Therefore, a behavior pattern such as time urgency may create conflict for the individual in lower status occupations, which in turn is related to the experience of psychophysiological symptoms. The final aim in these analyses was to determine how a most immediate social relational context of the individual, as indicated by congruence in educational status between husbands and wives, modified the association of the FTAS subscales and outcome variables. No relationship was observed for psychophysiological symptoms. For systolic and diastolic blood pressure, if a respondent had more education than his or her spouse, the inverse effect of harddriving on blood pressure was blunted. This association is precisely the opposite of what would be anticipated on the basis of prior research. Generally, the health of males has been examined in these studies, with those studies reporting significant effects showing that a male with less education than his wife has higher risk of a variety of health problems, including cardiovascular disease. For women, at least one study found a similar deleterious effect of a wife having lower educational credentials than her husband [26]. When the TABP is included, the effect of Type A has been observed to be exacerbated among men discrepant in education with their wives [I 31. Because of the unusual nature of these findings, and the small sample size, regression diagnostics were examined carefully for all of these analyses [27]. Three influential cases were identified, one of which had a large studentized residual; the other two had large leverage values. If these three cases are deleted from the first set of analyses (Table 3) the magnitude of the effects of the FTAS subscales and their associated significance levels are increased. If these three cases are deleted from the second se! of analyses, the interaction effect between hard-r\ri,/ing and educational discrepancy disappears in the analysis of systolic blood pressure; in the analysis of diastolic blood pressure, that interaction is substantially reduced in significance (P = 0.10) but it does not disappear entirely. Therefore, any interpretation of that effect must proceed with the caveat that only additional studies can indicate if indeed this effect really occurs, much less what it is. In any event, it is useful to provide more detail for this variable in parsing the meaning of the effect. Persons who are coded as discrepant have an average education of 14 years, and their spouses have an average education of 12 years, or, in other words, persons with educations beyond high school are married to persons with high school educations. It seems to me likely that, in the context of the black community, this variable is actually indicative of upward social mobility of a household. Recall that, prior to the civil rights movement, individual educational levels were low; yet, this variable identifies persons with post-secondary educations. This may indicate individuals, and families, whose social status has risen markedly, certainly inter-generationally, and probably intra-
generationally. In the process of upward mobility, the meaning attached to values such as being hard working may change, losing the connotation of the moral sense of work associated with traditional AfricanAmerican culture. The beneficial cardiovascular effect of regarding oneself in those terms would then also be lost. Regardless of the specific interpretation of any single finding reported here. in general the pattern of results indicates that the meaning and the effects of the TABP, as measured by the FTAS, vary when they are examined within a sociocultural group different from that group on which the pattern was first defined. Furthermore. these results are all consistent with the idea [9, lo] that the TABP. as a syndrome, is socially produced within the particular institutional structures collectively referred to as ‘modern, western’ society. That the syndrome is socially ‘produced’ receives support from one particular finding generated in the current study. The best predictor of time urgency, the pathogenic component of the TABP for this sample, was education. As shown in the old studies of psychological modernity [28], educational experience of the sort referred to in the west as ‘formal’ is the socializer par excellence for ‘modern’ beliefs and attitudes. With respect to the TABP, formal education is certainly an institutional setting in which time is learned to be a commodity, to be parcelled and invested so as to gain a return on that use of it. In the black community, it is also the dimension of the TABP consistently related to poor health. On the other hand, the dimension of the TABP indicative of hard work, consistent with the socially-constructed meaning of work in the community, is related to better health, except where it is blunted by a factor which might be indicative of upward social mobility. In short, all of these analyses are consistent with the notion that the TABP is interpreted in the specific context of culture, and in turn has distinctive effects. But this pilot study can only be regarded as a prelude to more intensive and sophisticated research designs. In addition to a more systematic model which can generate more precise hypotheses, future research should include multiple measures of the TABP, including especially the structured interview. Similarly, this future research should be carried out in the context of prevalence and incidence studies of coronary heart disease. Finally, multiple comparison groups varying in ethnicity and culture should be included. Ultimately, however, the utility of the present work may be to indicate that research on the Type A behavior pattern has been hampered by a lack of theory development with respect to the social and cultural bases and the contextual effects of the behavior pattern, with a few notable exceptions 19, 10,29, 301. Future work in this area may substantially advance our understanding of the cardiopathic effects of this pattern of behavior.
Type A behavior and contextual effects Acknowledgements-This
research was supported by research grants MH33943 and MH42553 from NIMH, and by a BRSG grant from the Graduate School, The University of Alabama.
REFERENCES
1. Friedman M. and Rosenman R. N. Tvne A Behavior and Your Heart. Alfred A. Knopf, New York, 1974. 2. Rosenman R. H.. Brand R. J.. Jenkins C. D., Friedman M., Straus R. and Wurm M. Coronary heart disease in the Western Collaborative Group Study: Final followUDexoerience of 8-l/2 years. JAMA 233. 872. 1975. 3. Hay&s S. G., Feinleid M. and Kannel W.. B. The relationship of psychosocial factors to coronary heart disease in the Framingham Study III. Am. J. Epidemiol. 111, 37 1980. 4. Booth-Kewley S. and Friedman
predictors
H. S. Psychological of heart disease: A quantitative review.
Psycho/. Bull. 101, 343, 1987. 5. Matthews K. A. Coronary heart disease and Type A
behaviors: Update on and alternative to the BoothKewley and Friedman (1987) quantitative review. Psychol. Bull. 104, 373, 1988. 6. Williams R. B. Psychological factors in coronary artery disease: Epidemiologic evidence. Circulation 76, 117
Suppl., 1987. 7. Dimsdale J. E. A perspective on Type A behavior and coronary disease. NEJM 318, 110, 1988. 8. Hecker M. H. L., Chesney M. A., Black G. W. and
Frautschi N. Coronary-prone behaviors in the Western Collaborative Grout) Studv. Psvchosam. Med. 50. 153. 9. Helman C. G. Heart disease and the cu!tural construction of time. Sot. Sci. Med. 25. 969. lY87. 10. Dressier W. W. Type A behavior and the social production of cardiovascular disease. J. Nerv. Men. Dis. 177, 181, 1989.
11. Cohen J. B., Syme S. L., Jenkins C. D., Kagan A. and Zyzanski S. J. Cultural context of Type A behavior and risk for CHD: a study of Japanise American males. J. Behav. Med. 2, 375, 1979. 12. Waldron I., Zyzanski S., Shekelle R. B., Jenkins C. D. and Tannebaum S. The coronary prone behavior pattern in employed men and women. J. Hum. Stress 3, 2, 1977.
13. Eaker E. D, Haynes S. G. and Feinleib M. Spouse behavior and coronary heart disease in men: prospective
295
results from the Framingham heart study. Am. J. Epidemiol. 118, 23, 1983. 14. Dressier W. W. Stress and Adaptation in the Context of Culture: Depression in a Southern Black Community. State University of New York Press, Albany, NY, 1991. 15. Farley R. Three steps forward and two back? Recent changes in the social and economic status of blacks. Ethnic Racial Stud. 8, 4, 1985.
16. Herskovits M. J. The Myth of the Negro Past. Beacon Press, Boston, 1958. 17. Jackson J. S., McCullough W. R. and Gurin G. Group identity development within black families. In Btack Families (Edited by McAdoo H. P.), pp. 252. Sage Beverly Hills, CA, 1981. 18. Nobles W. W. Africanity: Its role in black families. The Black Scholar 6, 10, 1974. 19. Dressler W. W. Social support, lifestyle incongruity, and arterial blood pressure in a southern black community. Psychosom. Med. 53, 608, 1991. 20. Houston B. K., Smith T. W. and Zurawski R. M. Principal dimensions of the Framingham Type A scale: Differential relationships to cardiovascular reactivity and anxiety. J. Hum. Stress 12, 105, 1986. 21. Dressler W. W. Hypertension and perceived stress: A St Lucian example. Ethos 12, 265, 1984. 22. McLeod J. D. and Kessler R. C. Socioeconomic status differences in vulnerabililty to undesirable life events. J. Hlth sot. Behav. 31, 162, 1990. 23. Ulbrich P. M., Warheit G. J. and Zimmerman R. S. Race, socioeconomic status, and psychological distress: An examination of differential vulnerability. J. Hlth sot. Behau. 30, 131, 1989.
24. Matthews K. A., Helmreich R. L., Beane W. E. and Lucker G. Pattern A, achievement striving, and scientific merit. J. Person. sot. Psychol. 39, 962, 1980. 25. Kohn M. L. Social class and parent-child relationships: An interpretation. Am. J. Social. 68, 471, 1963. 26. Vernon S. W. and Buffler P. A. The status of status inconsistency. Epidemiol. Rev. 10, 65, 1988. 27. Bollen K. A. and Jackman R. W. Regression diagnostics: An expository treatment of outlines and influential cases. Social. Meth. Res. 13, 510, 1985. 28. Inkeles A. and Smith D. H. Becoming Modern. Harvard University Press, Cambridge, MA, 1974. 29. Appels A. Culture and disease. Sot. Sci. Med. 23, 477, 1986. 30. Van Egeren L. F. A “success trap” theory of Type A behavior: Historical background. J. sot. Behav. Person. 5, 45, 1990.