uplifts, and affect-mood scale each month for the Pmonth academic year from .... Rahe Social Readjustment Rating Scale' was used. It con- tains 63 items that ...
Behavioral Medicine 15:37-45, 1989
Relationship of Hassles, Uplifts, and Life Events to Psychological Wen-Being of Freshman Medical Students Thomas M. Wolf, PhD, Robert C. Elston, PhD, and Grace E. Kissling, PhD
HmIes, uplifts, and lfe events were reluted to psychological well-being with a representative sample of 55 (of 179)fmhman medctrl students, Statdents were sent m m m of hrrssles, upIIfts, and sffecf-moods masures for 9 corwcutive months atid a meawe of ltfe st- at fha beginning and middle of the schod year. The h a w k mmre was found to be a befterpredictor of concurrent and sukquent negative mood than wm the I$e stre= m e n r e , whereas life stwar found to Be a betterpredictor of subsequent positive mood than hassles. On the whole, upl$ts wem unrelated to mood. The relatiomhip between life stress and hmles wm also investigated. The imp/icatiopas of the fmdings for future sf= and health outcume r m m h are discwed. Much m d w a stress research has dealt with major and dramatic environmentd changes or life ,events.' although the assumptions underlying ths approach have some major defect^.^ Practically, in fact, the relationship between life event scores and health outcome is extremely weak,3 and alternative theoretical and methodological approaches for investigating stress and the processes mediating health outcomes are essential. Lazstnrs and Fo1kman2 ,have developed a promising cognitive-phenornenoiogical stress and coping model. They emphasize the cumulative impact of day-to-day events (microstressors) that have personal meaning and significance for the individual (proximal variables) in contrast to major life events (distal variables). Common occurrences are labeled hmsIes (irritating, frustrating, and distressing incidents that occur in one's daily transactions with the environment) and uplifts (pleasurable, happy, and satisfying experiences). by DeLongis et a14 and Kanner et al.' These investigators have shown that hassle scores were more strongly associated with psyDr Wolf ir professor of psychiatiy and Dr Ekfon p m f m r and head of biometry and genet&, Louisiana State iJnivmAly School of Medicine, New Orleans, and Dr Kiding is now wmeiate prof m r of mathematics, University of North Caro-
lina at G m b o r o .
chologid symptoms than were life went scores, but, surprisingly, independent of hassles, uplifts contributed little to health. In more rigorous tests that provided support for this finding, with initid symptom level taken into account, hassles scores were a significant predictor of prospectively assessed psychological symptoms and were a better predictor than major life events.6 Inasmuch as uplifts may serve as emotional buffers against stress disorders by serving as breathers, sustainers, and restorers when physical resources are depleted,' it is of interest to measure hassles and uplifts in tandem because the combination could prove to be a good predictor of h d t h outcome (psychological and physical s y m p toms). Overall, hassles and uplifts were found to be positively reIated to each other. This unexpected finding may reflect a response bias, common variance due to differences in activity level, or the effects of current concerns on &-monitoring and evaluative processes.' Medical students undergo considerable stress during their medical education, and the freshman year is viewed as particularly trying by most students,' a time in which many of the basic psychological needs of the students are stifled9These intense pmsures and demands can have an adverse effect on lifestyle characteristics and heaIth. During the first year, for example, the students' perceptions of their general health decreased signif~wtly,including
HASSLES, UPLIFTS, AND LIFE EVENTS
perceptions of their physical health, p s y c h o l o ~ e m o tional health, control over the things that happen in life, feeling good about thernsehes, maintaining a positive attitude toward life, and making a signifimnt contribution to the lives of others. loInterestingly, the most severe decline was in the area of psycholo~caVemotiondhealth. Because the stress of medical education can M e r e with psychological and physical functioning, it is of theoretical and practical interest to develop measurement instruments that tap the common, everyday hassles and upMts that medical students experience in their transactions with the environment.2 The goal of this research, therefore, was to relate hassles and uplifts, as well as major life events, to psychological well-being on an ongoing basis during the freshman year of medical school. This study differs from previous studies in that medical students were used in contrast to middle-aged persons and special h d e s and uplifts measures had to be developed. Some previously noted problem areas with stress research (eg, Monroe6) are taken into account in the present study. These include the independent predictive relationship of hassles to health outcome {controlling for initial symptom level), the direction of the relationship of hassles and health outcome, and the direction of the relationship of life events to hassles. Based on the previously reviewed research,& we hypothesized that hassles would be a significant predictor of prospectively asses& health outcome and be a better predictor than major life events. We also tentatively hypothesized that uplifts would be a weak predictor of prospectively assessed h d t h outcome.
m0Ds Parlidpation and Prooedu~ This study derived from a larger study that investigated lifestyle characteristic changes, stress, coping, and health of medical students. Seventy-two medical students from a freshman class of 179 volunteered to participate in this Iongitudinal study. They were asked to complete a hassles, uplifts, and affect-mood scale each month for the Pmonth academic year from September 1983 through May 1984, Only those students who completed a packet of questionnaim for at least 6 of the 9 months (September though May) were- retained for statistical analysis. The final group, therefore, included 55 students, although the Sample sizes varied somewhat from month to month. Those 55 students also completed a life stress measure at the beginning (August), middle (January), and end (June) of the academic year. The data gathered at the end of the year were not included in the statistical analysa because information regarding the length of the rating period was
inadvertently left out of the instructions and students left it blank or f~edin a variety of time intervals. All students enrolled at Louisiana State University School of Medicine in New Orleans must have h e n state residents for a mhhum of one year. T h e curriculum is generally viewed as traditional when compared with that of other schools. The 55 partkipants did not differ significantly from the 124 nonparticipants in the freshman class with regard to age, race, or sex. The mean age of participants was 23.5 {SD = 3.2); 39 were male, and 16 were female. Fifty-one were white, 1 was black, 3 were of other, unspecified race. The mean age of nonparticipants was 23.6 (SD = 3.7); 90 were male, 34 were f e d e ; and 111 were white, 10 were black, 3 were of other, unspecified race. In addition, we noted no significant differences in undergraduate and first-year medical school gradepoint averages between participants and their nonparticipating classmates. The group of 55 students can therefore be considered representative of the entire 1983 freshman class at LSU with respect to these characteristics. The students were sent the &la through intercampus mail toward the end of each month and asked to complete them the following Saturday. They were instructed to return the scales in a self-addressed envelope through intercampus mail the next week. Thus, the instructions and presumably the time of completion at the end of the month were standardized for all students.
instruments Medical Education H&a Scak The Hassles Scale consists of 1M items in the following areas: personal habits, interpersonal relationships, health habits, f~nancialstatus, chores, and viewpoints on the outside world, Taking into account the previous week, each item is rated for frequency and intensity on a 4-point scale: 0 = none, 1 = slightly or littk, 2 = moderately, and 3 = extremely. Examples include fmding a place to study, relating to professors, paying bills, class schedules, and not having enough time with family and friends. The Hassles Scale was developed through extensive pilot testiag with a previous class of medical students. They spontaneously generated the items during group discussions and were asked to complete the scale at home with a view to dweioping a comprehensive, clear, and easily administered instrument. In addition, other scales and the research literature were discussed in developing the scale. It underwent a number of revisions before being developed in its present form. The guiding conceptual framework and method for the development of these new instruments came from the work of Richard S. Lazarus
WOLF ET AL
and his collaborators. It should be pointed out, however, that the Hassles and Uplifts S d e s developed by Lazarus were designed for a middle-aged population and were not appropriate for use with medical students. The following three summary scores were used for later analyses: (1) nurnkr of items endorsed (1, 2, or 3); (2) mean frequency score-total frequency score divided by the number of items endorsed; and (3) mean intensity score--total intensity score divided by the number of items endorsed. These three measures were selected because they were weakly correlated with each other but highly correlated with other possible summary measures that were not included in later analyses. The Hassles Scale has high test-retest (month-tomonth) repeatability. The Pearson correlations ranged from .62 to .86{M = .77) for number of items endorsed, .63 to .81 (M = -72)for frequency, and from .66 to .85 (M= ,751 for intensity.
Medical Education Uplifts Scale Constructed in a fashion similar to that of the Hassles Scale, the Uplifis Scale consists of 113 items with the same areas, rating scales, and measures as found with the Hassles Scale. ExampIes include having instructors give good lectures, getting good examination grades, improving one's eating habits, meeting family responsibilities, and being complimented. The month-to-month correlations rangd from -54 to .81 [M = .72)for number of items endorsed, .58 to .73 (M = .& forIfrequency, ) and .67 to -79 (M = .74) for intensity. Life Ewnfs Scale A scale developed by Hough, Fairbank, and Garcia1' that is judged to be an improvement over the Holrnes and Rahe Social Readjustment Rating Scale' was used. It contains 63 items that aie comprehensive in scope and specific and precise in description. It was developed with un-
FIGURE 1 Pictorial Representation of How Each Type of Correlation Was Averaged Month Affects Balance Index was measured Sept Oct Nov Dec Jan Feb Mar Apr May
Sept
Nov Dec
5
Month hassles/uplifis
Jan
.-
Feb
measured :r
:.*
3
Mar
Number of months Affecls Balance Index was measured before hassles/uplifts
Spring 1989
Number of months Arfecls Balnnce Index was measured after hdes/upliCts
HASSLES, UPLIFTS, AND LIFE EVENTS
TABLE 1 Cordations among the Three Summw Mellsarcs for the E h d e s and U p W Scalea J3assles
Number of items endorsed
Uplifts
Number of items endorsed Frequency Intensity
.48* -
.li
Frequency
Intensity
- .18
- .12*
- .12
-
Note: Frequency = total frequency -re score number of itms endorsed. *p < .Ol.
d-
.46*
-34
.38*
.59*
number of ituns endomil; intensity = total intensity
dergraduate students arid
b d on ratio measurement. The scores are based on the slips method, which involves asking students to arrange the slips according to how much change was required and then to assign ratio scores to each event. The slips method was judged to be 'more error-free than a list method that was also used (Hough et al"). The previous 5 months were to be considered in completing the scale.
metrically sound."-'3The Affects Balance Scale is multidimensional, consisting of four positive affects (positive total [+qjoy, contentment, vigor, and affection) and four negative affects (negative total 1- T] anxiety, d s pression, guilt, and hostility). Each dimension has five items, and posible scores range from 0 to 20. The previous week was to be considered in making the rating. The statistical analyses pertained to three summary measures: +T, -T, ABZ.
The scale is a &item, 5-point (0 = never, 1 = rarely, 2 = sometimes, 3 = frequently, 4 = always) adjective checklist designed to measure affective (mood] state by means of the Affects Balance Index a difference score obtained by subtracting negative affect totah from positive affect tot&, which has been shown to be p s y c b
S t a t W d Method
(No,
JnitiaIly, correlations M e e n hassles and uplifts were computed by pooling the data for a l l 9 months as though each month provided an independeat sample of data. Correlations were then mmputed between each of the three Affects BaIance Scale m a s u m and & of the six
TABLE 2 End&
Average CodaUons between Number of
8
7
- .29
.09
Hades endorsed
.37*
with - T Hassle endorsed with ABI
- .40*
Hassles endorsed
and Affects Bmkw S& ( A m
Number of months ABS given prior to hassles 6 5 4 3
.M
-01
- .03
- .OS
.06
.09
-22
-17
.21
.03
- .09
-.I2
-
2
1
-.I0
- -11
with +T
Note: + T = positive total; * p < .05. * p < .01.
-T
-
-11
= negative total, and ABI = Affects B h c e Index [ m t i v e totat
-.I4
-
.23 -
.20
20) - (neg&
.32* - -24
#tal + 20)]
WOLF ET AL
measures of hassles arid uplifts (three of hassies and three of uplifts). Since the measures were taken nine times at monthly intervals, each of these 18 types of correlations could be calculated for each of the 9 x 9 = 81 pairs of time points, resulting in a totd of 1,458 correlations. In order to condense these results, each E& of 81 correlations was reduced to 17 by averagmg the correlations that involve comparable time intervals. For example, we averaged the two correlations in which the Affects Balance Scale was measured 7 months before hassles (Affects Balance Scale measured in September with hassles in ApriI and Affects Balance Scale in October with hassles in My). Similarly, we averaged the three correlations the Affects Balance Scde measures 6 months after hassles. This resulted in 18 sets of 17 average correlations [two of which were "averages" of single correlations). A pictorial representation of how the mrreiations were averaged is shown in Figure 1. Each of the 81 cells contains a set of 18 correlations. The correlations of each type were averaged across each set of cells traversed by a single diagonal line. Numbers along the bottom indicate, for the particulm diagonal line, the number of months the Affects Balance Scale was measured before hassles/uplifts. Numbers along the right side indicate the number of months the Affects Balance Scale was measured after hassles/uplifts. Simple averages are reported, but it was verif~edthat averaging the z transforms yielded results that were never different by more than .01. The significance of the correlations was judged conservatively as follows. For the correlations between hassles and uplifts, which were based on 441 pairs of measurements over all 9 months, in each case the correlation was based on a set of 55 independent pairs (corresponding to one pair of measurements on each of the 55 participants)
Same
and an additional dependent set of 386 pairs. Only the 55 independent pairs were taken into m u n t in determining significance. Thus,correlations stated to be signifxcant at a particular level are in fact signif cant at that level; but correlations for which such a statement is not made may
or may not be signifcant. For the average correlations between the Affects Balance Scale and hassles or uplifts, the average number of pairs on which each of the individual correlations in the average was based was calculated. It was assumed that the average correlation was a simple correlation based on only that number of independent pairs. This is also a very conservative approach, especially when more than two or three correlations have been averaged.
Analogous partial correlations for hassles and mood were computed, wntrolling for initial symptom level.
Similar correlations were also calculated between life stress and mood, except that Iife stress was measured at only two time points. To determine the relative contributions of Life stress and hassles to the three mood m u r a s , a series of 24 multiple regression analyses was computed. In each case, the dependent variabt was one of the three mood indicators measured in a single month between October and May. The independent variables were life stress (the closest measure preceding the month in which the mood measure was administered-life stress in August for mood in September through January, and life stress in January for mood in February through May) and the average value of number of h d e s endorsed over all preceding months (eg, for mood in October, it was hassles in September only). However, the original value of the mood variable was controlled for by also including, as an independent variable, the average mood value for all pre-
Numkr of months ABS given after hassles
month
Spring 1989
HASSLES, UPLIFTS, AND LIFE EVENTS
ceding months. To apportion the relative contributions of life stress and hassles, the sums of squares due to these two variables were summed over aII months.
hassles endorsed was signifmtIy positively correlated with the - T (concurrently and subsequently for all eight monthly intervals) and significantly negatively with the ABI (concurrently and subsequently for 2, 5-, 6, and 8-month intern&], The - T was signif~cantlypositively correlated with subsequent number of hassIes endord for the 1- and &month intervals, and the ABI was significantly negatively correlated with the number of hassles endorsed for the 8-month internal. It should be emphasized that the 8-monthinterval is based on only one correlation, so that these latter results have less support. Table 2 contains 153 entries, so that one or two WIT& lations rmght be expected to be significarit at the I % level by chance alone (ignoring the conm-dve nature of the
RESULTS Correlations of hassles with uplifts are shown in Table 1. T h e number of items endorxd, frequency, and intensity were significantly positively correlated with the corresponding uplifts measures. The results of the correlations between the Affects Balance Scale and the number of hassles endorsed are shown in Table 2. Hassles frequency and intensity were not strongly related to the Affects Balance Scale, and the carrelations are therefore not presented. The number of
TABLE 3
Aversge Correlations between Life Stme= md Affects b h c e Scale (ABS)
8
9
Life stress
+
'
with T Life stress with -T Life stress with ABI
- .14
.W -
-
.I0
7
.15
- .09
.13
- .02
.28
-
-13
.03
- .19
.19
.00
.07
-09
- .W
-25
Note: +T = positive total; -T + 20) - (negative tatd + 20)] *p < .OS. **p < .01.
Number of months ABS ~ v e nafter life stress 6 5 4 3
=
negative total; and ABI
=
-
.21
-
.37* .21
- .33*
Affects Balance Index [(positive total
TABLE 4
Aversge Correlation8 between w e s and Life Stress Nurnber of months hassles given after life stress 9 Life stress with hassles endorsed Life stress with hassles frequency Life stress with Wiles intensity
.36*
8
.33*
- -01
-05
-11
.02 ..
.31*
.05
-..
.-. ..
4
3
.37**
.38**
.44* *
- -02
.UI
.03
.07
-10
.12
.14
.13
.37**
- .O1
..... .
5
6
7
..-
-.
- -.-
.
.
.- -.-. .
--- - -.-
Note: Hassles frequency = total frequency score + number of items e n d o d , hassles intensity = toast intensity scare inumber of items endorsed. *p < .05. **p < -01.
BehmioruI Medicine
WOLF ET AL
tests performed).
and ABI). The number of hassks endorsed was significantIy positively correlated with subsequent -T for the next three monthly intervals: 5-month r = .33, p < -05; &month r = .37, p < .05; and %month r = .31, p
