536750 research-article2014
HPQ0010.1177/1359105314536750Ginting et al.
Article
Type D personality is associated with health behaviors and perceived social support in individuals with coronary heart disease
Journal of Health Psychology 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314536750 hpq.sagepub.com
Henndy Ginting1,2, Monique van de Ven1, Eni S Becker1 and Gérard Näring1
Abstract This study investigated the role of Type D personality in health behaviors and perceived social support in individuals with coronary heart disease. Different from other related studies, this study assessed a broader range of health behaviors in an eastern population while controlling for anxiety and depression. In all, 386 Indonesian individuals with coronary heart disease completed the measures assessing Type D, perceived social support, depression, anxiety, and health behaviors. Compared with non-Type D, Type D individuals reported more unhealthy behaviors, less healthy behaviors, and perceived less social support. For those identified as Type D, tailored interventions might be considered.
Keywords coronary heart disease, distress, health behavior, social support
Introduction Health behaviors play a vital role in coronary heart disease (CHD) outcomes (Duivis et al., 2011). Nevertheless, many individuals with CHD continue to smoke, eat unhealthy, not exercise, or adhere to their medication (Kotseva et al., 2009). Initially, they may engage in healthier behaviors following non-fatal cardiac events, but once categorized as patients with stable CHD, a significant number of patients eventually return to their unhealthy ways of living (e.g. Teo et al., 2013). The reasons for this relapse are certainly complex, but personality has been found to be an important predictor of health behavior (e.g. Raynor and Levine, 2009). The distressed personality type (Type D) is defined as a combination between negative
affectivity (NA) and social inhibition (SI), and is assessed as a categorical construct (Denollet, 2005). Assessing Type D as a dimensional construct was introduced later (Denollet et al., 2013; Ferguson et al., 2009). Type D has been associated with poor CHD prognosis (Denollet and Pedersen, 2011), and unhealthy behaviors are a possible pathway to explain the association 1Radboud
University Nijmegen, The Netherlands Christian University, Indonesia
2Maranatha
Corresponding author: Henndy Ginting, Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands. Email: [email protected]
Downloaded from hpq.sagepub.com at University of Otago Library on March 16, 2015
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Journal of Health Psychology
between Type D and poor CHD prognosis (e.g. Gilmour and Williams, 2012; Williams et al., 2011). Type D individuals tend to have a pessimistic view of the future, experience negative emotions across time and situations, and experience a number of daily activities as stressful (Denollet, 2005). These tendencies may lead to individuals’ reluctance to change unhealthy behaviors. Several studies among healthy individuals (e.g. Mommersteeg et al., 2010; Williams et al., 2008) employed a comprehensive assessment of health behaviors (including smoking, alcohol use, exercise, and dietary habits) to confirm the relationship between Type D and health-related behaviors. However, studies among individuals with CHD, which tested the relation between Type D and health behaviors, investigated only one particular health behavior (e.g. smoking) and have not included more diverse domains of health behaviors that are specifically relevant for CHD (Svansdottir et al., 2012). Therefore, a study using a broader domain of health behaviors that are specifically recommended for CHD is still needed in order to better understand the association between Type D and health behaviors in individuals with CHD. Studies have also indicated that social support is an important factor in the CHD prognosis. Lack of social support has been associated with increased levels of atherosclerosis (Rozanski et al., 1999), heart disease mortality (Rosengren et al., 2004), myocardial infarction (MI) (Lett et al., 2009), and slower recovery following MI (Frasure-Smith et al., 2000). How individuals with CHD perceive available social support is probably more important than is the actual social support (e.g. McDowell and Serovich, 2007; Sararoudi et al., 2011). Some individuals with stable CHD, especially individuals who have experienced cardiac events, tend to perceive less social support, and such a perception could be maintained over time (ENRICHD Investigators, 2001; Lett et al., 2005). Perceived social support (PSS) is defined as the cognitive appraisal of the recipient (i.e. the individual) regarding the accessibility and
quality of social support (Burg et al., 2005). Thus, the level of PSS is determined by the individuals’ satisfaction with the support available to them (Zimet et al., 1988). PSS is influenced by individual characteristics (Bowling et al., 2005). Individuals with Type D may feel tense, inhibited, and insecure in the company of others, preferring to keep other people at a distance (Denollet, 2005). Studies have found that Type D individuals with CHD also have higher levels of perceived social alienation from family, friends, and significant others (Sararoudi et al., 2011). Whereas, in the Western countries, Type D has been found to be associated with lower levels of healthy behaviors and PSS among individuals with CHD (e.g. Denollet and Pedersen, 2011; Svansdottir et al., 2012; Williams et al., 2008), studies in Eastern cultures have been limited, with the exception of Sararoudi et al. (2011) who investigated the relation between Type D and PSS in post-MI patients in Iran. Since health behaviors and PSS may be important pathways in the association between Type D and poor clinical outcomes in CHD, further research on the associations of Type D with both health behaviors and PSS in other cultures, such as Indonesia, is warranted (Pedersen and Denollet, 2006). Contrary to other related studies, this study assessed a much broader range of health behaviors, and it was the first study of this kind conducted in Indonesia. Furthermore, previous research on the relationship between Type D and general health behaviors as well as PSS (i.e. Mommersteeg et al., 2010; Williams et al., 2008) has only assessed Type D using the traditional categorical cutoff points (recommended by Denollet, 2005). Ferguson et al. (2009) suggested that Type D may be better represented as a dimensional construct conceptualized as the interaction of NA and SI, but a number of current studies (e.g. Coyne et al., 2011; Molloy et al., 2012) have reported null findings when measuring Type D as a dimensional construct (interaction of NA × SI). Therefore, this study assessed Type D using both the categorical and the dimensional constructs.
Downloaded from hpq.sagepub.com at University of Otago Library on March 16, 2015
3
Ginting et al. Type D individuals with CHD experience symptoms of depression and anxiety (Denollet and Pedersen, 2011). Anxiety and depression have been associated with unhealthy behaviors and PSS (Burg et al., 2005; Strine et al., 2008). Consequently, anxiety and depression may influence possible associations between Type D and health behaviors as well as PSS. The only study on the association of Type D and PSS in Eastern population (Sararoudi et al., 2011) did not control for depression and anxiety. Therefore, this study aims to test the hypothesis that Type D personality (categorical and dimensional) is uniquely related to more unhealthy behaviors, less healthy behaviors, and lower PSS, while controlling for demographic characteristics, depression, and anxiety in Indonesian individuals with CHD.
Methods Participants and procedure This study was conducted in cardiology clinics in three largest hospitals in Bandung, Indonesia. The sample comprised 386 individuals with CHD (271 male and 115 female) aged 36–75 years (M = 58.35, standard deviation (SD) = 8.94). All had been diagnosed by cardiologists as having CHD. Additional inclusion criteria were that the patient was able to give written informed consent, was in a stable physiological condition (e.g. currently not experiencing angina), and was not a psychiatric patient. The Hasan Sadikin General Hospital ethical committee reviewed and approved the study procedures. Table 1 shows demographic and medical characteristics of the participants.
Measures Two qualified translators translated the original version of all English questionnaires used in this study into Bahasa (Indonesian language) and other translators used back-translation procedures to translate the questionnaires from Bahasa back into English (International Test Commission, 2010). A committee of experts in
clinical psychology reviewed the original English versions, English back translations, and Bahasa versions of all questionnaires to finalize the questionnaires. The Type D Scale-14. The Type D Scale-14 (DS14) assesses NA and SI, each measured with seven items on a scale from 0 (false) to 4 (true). The cutoff point for categorical Type D is ≥ 10 on both the NA and SI subscales (Denollet, 2005). The Indonesian version of the DS14 is a valid measure of Type D in Indonesian individuals with CHD (Ginting et al., 2011). The Beck Depression Inventory-II. The Beck Depression Inventory-II (BDI-II) assesses the severity of subjective depressive symptoms with 21 items measured on a scale from 0 (none) to 3 (severe), with total scores ranging from 0 to 63 (Beck et al., 1996). The Indonesian version of the BDI-II is a valid measure of depression in Indonesian individuals with CHD (Ginting et al., 2013). The Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI) (Beck and Steer, 1993) measures the severity of subjective anxiety symptoms with 21 items (α = .86) measured on a scale from 0 (not applicable) to 3 (severe), with total score ranging from 0 to 63. The Multidimensional Scale of PSS. The Multidimensional Scale of PSS (MSPSS) (Zimet et al., 1988) is a 12-item scale measuring PSS from friends (α = .84), family (α = .87), and significant others (α = .84) on a scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Higher scores indicate higher levels of perceived support. The Health Behaviors Inventory. The Health Behaviors Inventory (HBI) was constructed in Bahasa for the purpose of this study to measure health behaviors that have been recommended for individuals with CHD (Chow et al., 2010; Harvard School of Public Health, 2012; McCullough et al., 2002; Wood et al., 1998). The HBI comprises 23 items which are divided
Downloaded from hpq.sagepub.com at University of Otago Library on March 16, 2015
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Journal of Health Psychology
Table 1. Comparison of demographic and medical characteristics, domains of health behaviors, and the three facets of PSS by Type D (N = 386). Characteristics
Type D (n = 108)
Non-Type D (n = 278)
Gender (% female) Mean age (SD) Marital status (% married) Mean length of formal education (SD) Employment status (% retired) CHD diagnosis since less than 3 years (%) Previous myocardial infarction (%) Prior coronary artery bypass graft (%) Prior angioplasty procedure (%) Cardiac medication Antihypertensive (%) Anti-cholesterol (%) Beta-blocker (%) Blood thinner (%) Nitrates (%) Addictive behaviors, mean (SD) Unhealthy foods consumption, mean (SD) Healthy foods consumption, mean (SD) Exercise, mean (SD) Weight control, mean (SD) Medication adherence, mean (SD) PSS from family, mean (SD) PSS from friends, mean (SD) PSS from others, mean (SD)
36 58.39 (8.93) 90 13.98 (2.65) 66 56 35 8 29
27 58.41 (8.96) 91 12.69 (2.78) 64 50 31 9 35
.09 .84 .72 .01 .80 .82 .38 .75 .22
63 54 16 71 10 1.82 (0.89) 2.47 (0.76) 3.02 (0.75) 3.38 (1.15) 2.61 (0.96) 4.31 (0.82) 5.23 (1.17) 4.65 (1.30) 5.28 (1.20)
52 62 15 76 7 1.43 (0.64) 2.09 (0.60) 3.50 (0.74) 3.88 (0.98) 3.18 (0.95) 4.41 (0.79) 6.06 (0.91) 5.43 (1.17) 5.97 (0.92)
.05 .07 .87 .31 .27
HPQ0010.1177/1359105314536750Ginting et al.
Article
Type D personality is associated with health behaviors and perceived social support in individuals with coronary heart disease
Journal of Health Psychology 1–11 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359105314536750 hpq.sagepub.com
Henndy Ginting1,2, Monique van de Ven1, Eni S Becker1 and Gérard Näring1
Abstract This study investigated the role of Type D personality in health behaviors and perceived social support in individuals with coronary heart disease. Different from other related studies, this study assessed a broader range of health behaviors in an eastern population while controlling for anxiety and depression. In all, 386 Indonesian individuals with coronary heart disease completed the measures assessing Type D, perceived social support, depression, anxiety, and health behaviors. Compared with non-Type D, Type D individuals reported more unhealthy behaviors, less healthy behaviors, and perceived less social support. For those identified as Type D, tailored interventions might be considered.
Keywords coronary heart disease, distress, health behavior, social support
Introduction Health behaviors play a vital role in coronary heart disease (CHD) outcomes (Duivis et al., 2011). Nevertheless, many individuals with CHD continue to smoke, eat unhealthy, not exercise, or adhere to their medication (Kotseva et al., 2009). Initially, they may engage in healthier behaviors following non-fatal cardiac events, but once categorized as patients with stable CHD, a significant number of patients eventually return to their unhealthy ways of living (e.g. Teo et al., 2013). The reasons for this relapse are certainly complex, but personality has been found to be an important predictor of health behavior (e.g. Raynor and Levine, 2009). The distressed personality type (Type D) is defined as a combination between negative
affectivity (NA) and social inhibition (SI), and is assessed as a categorical construct (Denollet, 2005). Assessing Type D as a dimensional construct was introduced later (Denollet et al., 2013; Ferguson et al., 2009). Type D has been associated with poor CHD prognosis (Denollet and Pedersen, 2011), and unhealthy behaviors are a possible pathway to explain the association 1Radboud
University Nijmegen, The Netherlands Christian University, Indonesia
2Maranatha
Corresponding author: Henndy Ginting, Behavioural Science Institute, Radboud University Nijmegen, P.O. Box 9104, 6500 HE Nijmegen, The Netherlands. Email: [email protected]
Downloaded from hpq.sagepub.com at University of Otago Library on March 16, 2015
2
Journal of Health Psychology
between Type D and poor CHD prognosis (e.g. Gilmour and Williams, 2012; Williams et al., 2011). Type D individuals tend to have a pessimistic view of the future, experience negative emotions across time and situations, and experience a number of daily activities as stressful (Denollet, 2005). These tendencies may lead to individuals’ reluctance to change unhealthy behaviors. Several studies among healthy individuals (e.g. Mommersteeg et al., 2010; Williams et al., 2008) employed a comprehensive assessment of health behaviors (including smoking, alcohol use, exercise, and dietary habits) to confirm the relationship between Type D and health-related behaviors. However, studies among individuals with CHD, which tested the relation between Type D and health behaviors, investigated only one particular health behavior (e.g. smoking) and have not included more diverse domains of health behaviors that are specifically relevant for CHD (Svansdottir et al., 2012). Therefore, a study using a broader domain of health behaviors that are specifically recommended for CHD is still needed in order to better understand the association between Type D and health behaviors in individuals with CHD. Studies have also indicated that social support is an important factor in the CHD prognosis. Lack of social support has been associated with increased levels of atherosclerosis (Rozanski et al., 1999), heart disease mortality (Rosengren et al., 2004), myocardial infarction (MI) (Lett et al., 2009), and slower recovery following MI (Frasure-Smith et al., 2000). How individuals with CHD perceive available social support is probably more important than is the actual social support (e.g. McDowell and Serovich, 2007; Sararoudi et al., 2011). Some individuals with stable CHD, especially individuals who have experienced cardiac events, tend to perceive less social support, and such a perception could be maintained over time (ENRICHD Investigators, 2001; Lett et al., 2005). Perceived social support (PSS) is defined as the cognitive appraisal of the recipient (i.e. the individual) regarding the accessibility and
quality of social support (Burg et al., 2005). Thus, the level of PSS is determined by the individuals’ satisfaction with the support available to them (Zimet et al., 1988). PSS is influenced by individual characteristics (Bowling et al., 2005). Individuals with Type D may feel tense, inhibited, and insecure in the company of others, preferring to keep other people at a distance (Denollet, 2005). Studies have found that Type D individuals with CHD also have higher levels of perceived social alienation from family, friends, and significant others (Sararoudi et al., 2011). Whereas, in the Western countries, Type D has been found to be associated with lower levels of healthy behaviors and PSS among individuals with CHD (e.g. Denollet and Pedersen, 2011; Svansdottir et al., 2012; Williams et al., 2008), studies in Eastern cultures have been limited, with the exception of Sararoudi et al. (2011) who investigated the relation between Type D and PSS in post-MI patients in Iran. Since health behaviors and PSS may be important pathways in the association between Type D and poor clinical outcomes in CHD, further research on the associations of Type D with both health behaviors and PSS in other cultures, such as Indonesia, is warranted (Pedersen and Denollet, 2006). Contrary to other related studies, this study assessed a much broader range of health behaviors, and it was the first study of this kind conducted in Indonesia. Furthermore, previous research on the relationship between Type D and general health behaviors as well as PSS (i.e. Mommersteeg et al., 2010; Williams et al., 2008) has only assessed Type D using the traditional categorical cutoff points (recommended by Denollet, 2005). Ferguson et al. (2009) suggested that Type D may be better represented as a dimensional construct conceptualized as the interaction of NA and SI, but a number of current studies (e.g. Coyne et al., 2011; Molloy et al., 2012) have reported null findings when measuring Type D as a dimensional construct (interaction of NA × SI). Therefore, this study assessed Type D using both the categorical and the dimensional constructs.
Downloaded from hpq.sagepub.com at University of Otago Library on March 16, 2015
3
Ginting et al. Type D individuals with CHD experience symptoms of depression and anxiety (Denollet and Pedersen, 2011). Anxiety and depression have been associated with unhealthy behaviors and PSS (Burg et al., 2005; Strine et al., 2008). Consequently, anxiety and depression may influence possible associations between Type D and health behaviors as well as PSS. The only study on the association of Type D and PSS in Eastern population (Sararoudi et al., 2011) did not control for depression and anxiety. Therefore, this study aims to test the hypothesis that Type D personality (categorical and dimensional) is uniquely related to more unhealthy behaviors, less healthy behaviors, and lower PSS, while controlling for demographic characteristics, depression, and anxiety in Indonesian individuals with CHD.
Methods Participants and procedure This study was conducted in cardiology clinics in three largest hospitals in Bandung, Indonesia. The sample comprised 386 individuals with CHD (271 male and 115 female) aged 36–75 years (M = 58.35, standard deviation (SD) = 8.94). All had been diagnosed by cardiologists as having CHD. Additional inclusion criteria were that the patient was able to give written informed consent, was in a stable physiological condition (e.g. currently not experiencing angina), and was not a psychiatric patient. The Hasan Sadikin General Hospital ethical committee reviewed and approved the study procedures. Table 1 shows demographic and medical characteristics of the participants.
Measures Two qualified translators translated the original version of all English questionnaires used in this study into Bahasa (Indonesian language) and other translators used back-translation procedures to translate the questionnaires from Bahasa back into English (International Test Commission, 2010). A committee of experts in
clinical psychology reviewed the original English versions, English back translations, and Bahasa versions of all questionnaires to finalize the questionnaires. The Type D Scale-14. The Type D Scale-14 (DS14) assesses NA and SI, each measured with seven items on a scale from 0 (false) to 4 (true). The cutoff point for categorical Type D is ≥ 10 on both the NA and SI subscales (Denollet, 2005). The Indonesian version of the DS14 is a valid measure of Type D in Indonesian individuals with CHD (Ginting et al., 2011). The Beck Depression Inventory-II. The Beck Depression Inventory-II (BDI-II) assesses the severity of subjective depressive symptoms with 21 items measured on a scale from 0 (none) to 3 (severe), with total scores ranging from 0 to 63 (Beck et al., 1996). The Indonesian version of the BDI-II is a valid measure of depression in Indonesian individuals with CHD (Ginting et al., 2013). The Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI) (Beck and Steer, 1993) measures the severity of subjective anxiety symptoms with 21 items (α = .86) measured on a scale from 0 (not applicable) to 3 (severe), with total score ranging from 0 to 63. The Multidimensional Scale of PSS. The Multidimensional Scale of PSS (MSPSS) (Zimet et al., 1988) is a 12-item scale measuring PSS from friends (α = .84), family (α = .87), and significant others (α = .84) on a scale ranging from 1 (very strongly disagree) to 7 (very strongly agree). Higher scores indicate higher levels of perceived support. The Health Behaviors Inventory. The Health Behaviors Inventory (HBI) was constructed in Bahasa for the purpose of this study to measure health behaviors that have been recommended for individuals with CHD (Chow et al., 2010; Harvard School of Public Health, 2012; McCullough et al., 2002; Wood et al., 1998). The HBI comprises 23 items which are divided
Downloaded from hpq.sagepub.com at University of Otago Library on March 16, 2015
4
Journal of Health Psychology
Table 1. Comparison of demographic and medical characteristics, domains of health behaviors, and the three facets of PSS by Type D (N = 386). Characteristics
Type D (n = 108)
Non-Type D (n = 278)
Gender (% female) Mean age (SD) Marital status (% married) Mean length of formal education (SD) Employment status (% retired) CHD diagnosis since less than 3 years (%) Previous myocardial infarction (%) Prior coronary artery bypass graft (%) Prior angioplasty procedure (%) Cardiac medication Antihypertensive (%) Anti-cholesterol (%) Beta-blocker (%) Blood thinner (%) Nitrates (%) Addictive behaviors, mean (SD) Unhealthy foods consumption, mean (SD) Healthy foods consumption, mean (SD) Exercise, mean (SD) Weight control, mean (SD) Medication adherence, mean (SD) PSS from family, mean (SD) PSS from friends, mean (SD) PSS from others, mean (SD)
36 58.39 (8.93) 90 13.98 (2.65) 66 56 35 8 29
27 58.41 (8.96) 91 12.69 (2.78) 64 50 31 9 35
.09 .84 .72 .01 .80 .82 .38 .75 .22
63 54 16 71 10 1.82 (0.89) 2.47 (0.76) 3.02 (0.75) 3.38 (1.15) 2.61 (0.96) 4.31 (0.82) 5.23 (1.17) 4.65 (1.30) 5.28 (1.20)
52 62 15 76 7 1.43 (0.64) 2.09 (0.60) 3.50 (0.74) 3.88 (0.98) 3.18 (0.95) 4.41 (0.79) 6.06 (0.91) 5.43 (1.17) 5.97 (0.92)
.05 .07 .87 .31 .27
