Does the Perception That Stress Affects Health Matter? The Association With Health and Mortality

Abstract

Objective:
This study sought to examine the relationship among the amount of stress, the perception that stress affects health, and health and mortality outcomes in a nationally representative sample of U.S. adults.

Methods:
Data from the 1998 National Health Interview Survey were linked to prospective National Death Index mortality data through 2006. Separate logistic regression models were used to examine the factors associated with current health status and psychological distress. Cox proportional hazard models were used to determine the impact of perceiving that stress affects health on all-cause mortality. Each model specifically examined the interaction between the amount of stress and the perception that stress affects health, controlling for sociodemographic, health behavior, and access to health care factors.

Results:
33.7% of nearly 186 million (unweighted n = 28,753) U.S. adults perceived that stress affected their health a lot or to some extent. Both higher levels of reported stress and the perception that stress affects health were independently associated with an increased likelihood of worse health and mental health outcomes. The amount of stress and the perception that stress affects health interacted such that those who reported a lot of stress and that stress impacted their health a lot had a 43% increased risk of premature death (HR = 1.43, 95% CI [1.2, 1.7]).

Conclusions:
High amounts of stress and the perception that stress impacts health are each associated with poor health and mental health. Individuals who perceived that stress affects their health and reported a large amount of stress had an increased risk of premature death.

Full text

Health Psychology
Does the Perception That Stress Affects Health Matter?
The Association With Health and Mortality
Abiola Keller, Kristin Litzelman, Lauren E. Wisk, Torsheika Maddox, Erika Rose Cheng, Paul
D. Creswell, and Whitney P. Witt
Online First Publication, December 26, 2011. doi: 10.1037/a0026743
CITATION
Keller, A., Litzelman, K., Wisk, L. E., Maddox, T., Cheng, E. R., Creswell, P. D., & Witt, W. P.
(2011, December 26). Does the Perception That Stress Affects Health Matter? The
Association With Health and Mortality. Health Psychology. Advance online publication. doi:
10.1037/a0026743

Does the Perception That Stress Affects Health Matter?
The Association With Health and Mortality
Abiola Keller, Kristin Litzelman, Lauren E. Wisk, Torsheika Maddox, Erika Rose Cheng,
Paul D. Creswell, and Whitney P. Witt
University of Wisconsin - Madison
Objective: This study sought to examine the relationship among the amount of stress, the perception that
stress affects health, and health and mortality outcomes in a nationally representative sample of U.S.
adults. Methods: Data from the 1998 National Health Interview Survey were linked to prospective
National Death Index mortality data through 2006. Separate logistic regression models were used to
examine the factors associated with current health status and psychological distress. Cox proportional
hazard models were used to determine the impact of perceiving that stress affects health on all-cause
mortality. Each model specifically examined the interaction between the amount of stress and the
perception that stress affects health, controlling for sociodemographic, health behavior, and access to
health care factors. Results: 33.7% of nearly 186 million (unweighted n⫽28,753) U.S. adults perceived
that stress affected their health a lot or to some extent. Both higher levels of reported stress and the
perception that stress affects health were independently associated with an increased likelihood of worse
health and mental health outcomes. The amount of stress and the perception that stress affects health
interacted such that those who reported a lot of stress and that stress impacted their health a lot had a 43%
increased risk of premature death (HR ⫽1.43, 95% CI [1.2, 1.7]). Conclusions: High amounts of stress
and the perception that stress impacts health are each associated with poor health and mental health.
Individuals who perceived that stress affects their health and reported a large amount of stress had an
increased risk of premature death.
Keywords: United States, stress, perception, National Health Interview Survey (NHIS), mortality
Supplemental materials: http://dx.doi.org/10.1037/a0026743.supp
Stress, broadly defined as a situation “in which environmental
demands, internal demands, or both, tax or exceed the adaptive
resources of an individual, social system, or tissue system” (Monat
& Lazarus, 1991), is pervasive in today’s society, with nearly a
third of Americans rating their average stress levels as extreme (8,
9, or 10 on a 10-point scale where 10 corresponds to “a great deal
of stress”) (APA, 2008). Consequences of prolonged stress include
adverse psychological and physical health effects, as well as an
increased risk of premature mortality (Braveman, Egerter, &
Mockenhaupt, 2011; Lantz, House, Mero, & Williams, 2005;
McEwen, 1998; McEwen & Seeman, 1999; Miller, Cohen, &
Ritchey, 2002). In fact, the effects of stress on well-being are so
well recognized that U.S. Public Health officials have called for a
reduction of stress since the 1970s (USPHS, 1979).
Previous research exploring the relationship between stress and
health outcomes, including mortality, has focused on specific
stressors—such as negative life events (Lantz et al., 2005) or
chronic work stress (Matthews & Gump, 2002)—and is often
limited to cause-specific mortality, such as cardiovascular disease
(Burazeri, Goda, Sulo, Stefa, & Kark, 2008; Greenwood, Muir,
Packham, & Madeley, 1996). While studies exploring the relation-
ship between chronic or perceived stress and all-cause mortality
exist (Krueger & Chang, 2008; Lantz et al., 2005), no study has
examined the relationship between an individual’s perception that
stress affects their health and health outcomes.
The perception that stress affects one’s health is conceptually
distinct from the amount of stress an individual experiences;
indeed, one could report experiencing very little stress but still
believe it to have a great impact on their health. Additionally, the
perception of stress affecting health may impact health outcomes
differently than the amount or the severity of stress. Theoretical
work supports the concept that the perception that stress affects
one’s health may impact future health outcomes. Notably, the
transactional model of stress and coping provides critical insight
into the appraisal of stress and the available resources for stress
Abiola Keller, Kristin Litzelman, Lauren E. Wisk, Torsheika Maddox,
Erika Rose Cheng, Paul D. Creswell, and Whitney P. Witt, Department of
Population Health Sciences, University of Wisconsin – Madison.
We would like to acknowledge the generous funding that supported this
research. LEW and PDC were supported by a pre-doctoral NRSA Training
Grant (T32 HS00083; PI: Smith). TM was supported by grants from the
Center for Demography and Ecology (R24 HD047873; PI: Walker), Center
for Demography of Health and Aging (P30 AG17266; PI: Hauser), and a
NIA Training Grant (T32 AG00129; PI: Walker). We would also like to
thank the Editorial Office of the journal Health Psychology and the three
anonymous reviewers for their helpful comments.
Correspondence concerning this article should be addressed to Whitney
P. Witt, Department of Population Health Sciences, School of Medicine
and Public Health, University of Wisconsin-Madison 610 North Walnut
Street, WARF Office 503, Madison, WI 53726. E-mail: wwitt@wisc.edu
Health Psychology © 2012 American Psychological Association
2012, Vol. ●●, No. ●, 000– 000 0278-6133/12/$12.00 DOI: 10.1037/a0026743
1

management (Lazarus & Folkman, 1984; Wenzel, Glanz, & Ler-
man, 2002). According to the model, the impact of a stressor is
mediated by a person’s appraisal of the stressor. Primary appraisal
is mainly determined by perceptions of susceptibility to the event
as well as perceptions of the event’s severity. Whereas appraisals
of personal risk often lead to the initiation of coping mechanisms,
a heightened perception of risk has been associated with increased
psychological distress (Schwartz, Lerman, Miller, Daly, & Masny,
1995) and may be related to other adverse health outcomes. Based
on this theoretical work, it is hypothesized that a heightened
perception of the health risks associated with stress (as indicated
by perceiving that stress impacts one’s health) may be a key factor
in determining or predicting future outcomes.
This is believed to be the first study to examine the relationship
among the amount of stress individuals experience, whether or not
they perceive that stress affects their health, and subsequent health
and mortality outcomes in a nationally representative sample of
U.S. adults. This study aims to examine the relationship between
the perception that stress affects health and current health, mental
health, and mortality. Specifically, it is hypothesized that there will
be a synergistic relationship between the amount of stress and an
individual’s perception that stress affects health, such that those
with the highest amount of stress and the perception that it impacts
their health will experience the worst health outcomes.
This study is unique in that it not only identifies individuals who
report experiencing stress, but also those individuals who perceive
that stress affects their health. Understanding this perception is
critical for advancing knowledge of the health effects of stress and
could have far-reaching implications for future research and for
designing interventions aimed at reducing the negative health
consequences of stress.
Method
Data Source and Study Design
The data originate from the 1998 National Health Interview
Survey (NHIS), a household survey conducted by the National
Center for Health Statistics (NCHS, 2000). The NHIS over-
sampled underrepresented populations, including Hispanics and
African Americans, and used a multistage stratified probability
design to yield nationally representative estimates. The 1998 NHIS
was used for this study because of its specific questions on per-
ceived stress, stress management, and the perceived impact of
stress on health. It appears that such data do not exist in other
recent surveys. All results are based on weighted counts.
Study sample. To obtain the sample, participants were se-
lected from the Sample Adult Core (SAC) component of the NHIS
and linked to the Prevention Adult component of the Prevention
Module, a supplemental questionnaire on prevention for selected
topics of interest to the public health community (NHIS, 1998).
Participants with missing values on covariates or outcome mea-
sures were not included in the study sample (6.7%). Additionally,
sample records that could not be linked to the National Death
Index (NDI) as a result of missing information on matching
characteristics (4.5%) were eliminated from the study sample,
yielding a final sample of 28,753 respondents, of whom 2,960
(10.3%) had died.
Measures
Stress measures.
Amount of stress. To determine the amount of stress experi-
enced in the last 12 months, respondents were asked, “During the
past 12 months, would you say that you experienced a lot of stress,
a moderate amount of stress, relatively little stress, or almost no
stress at all?” This variable was modeled using the original Likert
format.
Perception of stress affecting health. To determine the per-
ceived impact of stress on health respondents were asked, “During
the past 12 months, how much effect has stress had on your
health—a lot, some, hardly any, or none?” This variable was
modeled using the original three-point Likert format.
Stress reduction. To ascertain whether or not individuals had
attempted to reduce their amount of stress, participants were asked,
“During the past 12 months, have you taken any steps to control or
reduce stress in your life?” Responses to this question were mod-
eled using a dichotomous (i.e., yes/no) format.
Outcomes.
Health status. Health status was assessed through self-report
by asking respondents to rate their health as excellent, very good,
good, fair, or poor. A dichotomous variable was used in the
analyses, comparing those in excellent, very good, or good self-
reported health to those in fair or poor self-reported health (here-
after referred to as “poor health”) (Zahran et al., 2005).
Psychological distress. Current psychological distress was
measured using the six-item version of the Kessler Psychological
Distress Scale (K6), included in the Sample Adult Core component of
the NHIS. The K6, a truncated form of a previously developed
10-question psychological distress scale (K10), asks participants to
report the frequency of six emotions (i.e., feeling nervous, hopeless,
fidgety, depressed to the extent that nothing could cheer them up,
worthless, and that everything was an effort) over the past 30 days
(Furukawa, Kessler, Slade, & Andrews, 2003). High levels of the K6
have been shown to have a strong, positive correlation with DSM–IV
diagnoses (Kessler et al., 2003) and common mental disorders (Gill,
Butterworth, Rodgers, & Mackinnon, 2007). It has also been found to
have highly acceptable psychometric properties as demonstrated by
an internal consistency, measured by Cronbach’s alpha, of 0.89 and
discrimination, evaluated by assessing the area under the Receiver
Operating Characteristic (ROC) curve, of 0.86 (Kessler et al., 2003).
Each of the six items in the K6 were coded on a five-point scale
(none of the time, a little of the time, some of the time, most of the
time, or all of the time). The response codes were then summed for
a potential total score range of 0 –24, with higher scores indicating
worse levels of psychological distress. A score of 7 or more was
used to indicate mild to moderate psychological distress. Psycho-
logical distress has been operationalized in a similar fashion in
previous studies (Witt et al., 2006; Witt et al., 2009) and is
consistent with norm-based scoring developed for the K6 in com-
munity and epidemiological samples and classification of scores
developed and normalized in the 1997 NHIS (Kessler et al., 2002).
Mortality. Mortality was measured as death from any cause
between the respondents’ 1998 interview quarter and December
31, 2006. Information on deaths among participants was obtained
from the NDI. Data from the 1998 NHIS were linked to prospec-
tive NDI mortality data by the NCHS. The matching methodology
included matching respondent characteristics (Social Security
2KELLER ET AL.

number; first and last name; middle initial; race; gender; marital
status; father’s surname; day, month, and year of birth; state of
birth and residence) to death records (NCHS, 2009). The NHIS
public-use ID was then used to link respondents in the Prevention
Adult component of the Prevention Module to mortality informa-
tion in the NDI public-use files.
Independent variables.
Sociodemographic characteristics. The following demo-
graphic characteristics were included in the analyses because of
their known relationships with the outcomes of interest: gender,
race/ethnicity (Hispanic, white [non-Hispanic], black [non-
Hispanic], and other [non-Hispanic]), age (17–24, 25–34, 35– 44,
45–54, 55– 64, and 65⫹), level of education (some high school or
less, high school graduate, some college, college graduate or
beyond, and unknown), participation in the paid workforce (had
job in the past week, had no job in the past week but had a job in
the past 12 months, and had no job in the past week or in the past
12 months), marital status (married or living with partner, wid-
owed, divorced/separated, never married, and unknown), urbanic-
ity (urban vs. rural as defined by metropolitan statistical area
status), and household income, as a percentage of the poverty
threshold level (below 100%, 100 –199%, 200 –399%, 400% and
higher, and unknown). A sensitivity analysis was performed dis-
aggregating the number of children in the household to reflect
different family sizes. No significant trend was found; therefore, a
dichotomous variable of “no children” or “1 ⫹child(ren)” was
used in the analysis.
Health and health behavior factors. Respondents were clas-
sified as having a chronic condition if they reported having ever
been told by a doctor or other health professional that they had one
or more of a number of chronic conditions, including hypertension,
coronary heart disease, angina, heart attack, any other heart con-
dition or heart disease, stroke, cancer, ulcer, asthma, emphysema,
or diabetes.
For smoking, participants were categorized as “never smokers”
(had not smoked more than 100 cigarettes in their life), “current
smokers” (smoked more than 100 cigarettes in their life and
currently smoked some days or every day), or “former smokers”
(smoked more than 100 cigarettes in their life but reported that
they now smoke not at all).
To determine physical activity level, respondents were ques-
tioned about 23 physical activities and asked to provide informa-
tion regarding the frequency of these activities, the number of
minutes spent doing the activity, and the change in their heart rate
or breathing as a result of the activity. A summary measure
indicating activity level for each participant in terms of kilocalo-
ries per kilogram of body weight (kcal/kg/day) was calculated
using an algorithm based on published work by Stephens and
Craig (1989) as well as the 1981 Canada Fitness Survey (Stephens
& Craig, 1989). Individuals expending 3.0 or more kcal/kg/day
were classified as “very active,” those expending 1.5–2.9 kcal/kg/
day as “moderately active,” and those expending 0.0 –1.4 kcal/kg/
day as “sedentary” (NHIS, 1998).
Access to health care factors.
Health insurance. Respondents who had health insurance
coverage from any source were considered to be insured. Those
who reported not having any health insurance were categorized as
being uninsured.
Usual source of care. To ascertain whether they had an
appropriate usual source of care (USC), respondents were asked
the following questions: “Is there a place that you usually go to
when you are sick or need advice about your health?” and if yes,
“What kind of place is it—a clinic, doctor’s office, emergency
room, or some other place?” Individuals who responded that they
did not have a USC, or reported the emergency room as their USC,
were classified as not having a USC.
Analytic Approach
Analyses presented in Tables 1 and 2 were generated using
SUDAAN (RTI, 2001) to correct for the complex sample design of
the NHIS. Separate multivariate logistic regression models exam-
Table 1
Frequency of Stress, Perceived Health Impact, and Stress Reduction Among U.S. Adults,
1998 National Health Interview Survey
TOTAL: Weighted n [in thousands]
(unweighted n) %
185,983 (28,753) 100%
Frequency of stress
Amount of stress experienced by U.S. adults in the last 12 months
A lot 37,628 (6,026) 20.2%
Moderate 65,627 (9,663) 35.3%
A little 44,642 (6,871) 24.0%
Almost none 38,087 (6,193) 20.5%
Perceived health impact
How much did stress affect your health?
A lot 14,500 (2,468) 7.8%
Some 48,176 (7,522) 25.9%
Hardly any, or none 123,306 (18,763) 66.3%
Stress reduction
(During the past 12 months), have you taken any steps to control or
reduce stress in your life?
Yes 61,193 (9,489) 32.9%
No 124,790 (19,264) 67.1%
3
THE ASSOCIATION WITH HEALTH AND MORTALITY

ined the factors associated with current health status and psycho-
logical distress. These models specifically examined the interac-
tion between an individual’s amount of stress and their perception
that stress affected their health, controlling for sociodemographic,
health behavior, access to health care factors, and attempts at stress
reduction.
Cox proportional hazard models were used to examine the
impact of the amount of stress experienced and perceiving that
stress affects health on all-cause mortality, controlling for sociode-
mographic, health behavior, and access to health care factors, as
well as attempts at stress reduction. Time of death attributable to
any cause, determined using the quarter and year of death from
NDI data, was used as the end point. Individuals who were still
living (hence not matched to NDI data) were right-censored using
the date of December 31, 2006. The start time for all individuals
was the beginning of the quarter in which they were interviewed
for the 1998 NHIS. Postestimation statistics used to test the pro-
portional hazards assumption found no significant violations of the
assumptions of the model. Stata/SE 11.0 for Windows (StataCorp,
2009) was used to perform all mortality analyses. The Wald and
the Likelihood Ratio Chi-Squared Tests (LRT) were used to test
the significance of the interaction between the amount of stress
experienced and the perception that stress affects health and the
health outcomes.
The “predict” command in Stata/SE 11.0 (StataCorp, 2009)
was used to estimate cumulative hazards from the Cox propor-
tional hazard model for each of the 12 subgroups created from
the interaction of the amount of stress and the perception that
stress affects health, averaged across all other covariates. The
hazards were applied to the weighted number of individuals
who reported a lot of stress and the perception that stress affects
health a lot, and the difference was taken to determine the
number of deaths attributable to endorsing both of these factors
during the study period.
The full tables for the current health status, psychological dis-
tress, and all-cause mortality outcomes are also available as sup-
plemental materials (Supplemental Tables A and B).
Additional Analysis Included in Supplemental
Materials
In addition to the above analyses, chi-squared analyses and
regression models were conducted to examine the frequency dis-
tributions and the odds of the amount of stress and perceiving that
stress affects health (Supplemental Tables C and D). Chi-square
analyses were used to test for differences in sociodemographic
characteristics of adults and the amount of stress experienced.
Sociodemographic, health behavior, and access to health care
factors were examined in multinomial multivariate logistic regres-
sion models for the amount of stress experienced (see Supplemen-
tal Table A). The same approach was used to examine the outcome
of perceiving that stress affects health (see Supplemental Table B).
Results
Overall, 35.3% and 20.2% of this sample of U.S. adults reported
experiencing a moderate amount or a lot of stress in the past year,
respectively, and 32.9% had taken steps to control or reduce stress
in their lives (see Table 1). Additionally, 7.8% and 25.9% of this
Table 2
Logistic Regression Analysis of Current Health and Mental Health Among U.S. Adults, 1998
National Health Interview Survey
Poor health status Psychological distress
OR 95% CI OR 95% CI
Amount of stress in last 12 months
Almost none 1.00 reference 1.00 reference
A little 1.16 1.0 1.4 1.81 1.5 2.2
Moderate 1.36 1.2 1.6 2.86 2.3 3.5
A lot 1.75 1.5 2.1 7.35 6.0 9.1
Perception that stress affects health
Hardly any, or None 1.00 reference 1.00 reference
Some 1.80 1.6 2.1 2.55 2.2 2.9
A lot 4.26 3.6 5.1 5.10 4.3 6.0
Tried to reduce stress in last 12 months
Yes 0.92
†
0.8 1.0 1.07§ 1.0 1.2
No 1.00 reference 1.00 reference
Note. Controlling for gender, race/ethnicity, age, education level, work status, marital status, children in the
household, ratio of family income to poverty threshold, metropolitan statistical area, smoking status, physical
activity level, chronic condition, health insurance, and usual source of care. Interpretation of significance at the
95% level was based on CI limits before rounding. OR ⫽odds ratio; CI ⫽confidence interval; MSA ⫽
metropolitan statistical area.
†
Borderline significance, OR⫽.92, 95% CI [0.82–1.03].
§
Not statistically significant, OR ⫽1.07, 95% CI
[0.96 –1.20].
4KELLER ET AL.

sample perceived that stress had affected their health a lot or to
some extent during the same time period, respectively.
Stress and Health Outcomes
Table 2 presents the results of the separate logistic regression
models examining the factors associated with current health status
and psychological distress. These models tested the interaction
between an individual’s amount of stress and their perception that
stress affected their health, controlling for sociodemographic,
health behavior, access to health care factors, and attempts at stress
reduction; however, statistical testing for the presence of an inter-
action using the LRT was not significant for either outcome. As
such, Table 2 presents the results from the main effects models.
Current Health Status
As seen in Table 2, the analysis of current health status revealed
that higher levels of reported stress were associated with an in-
creased likelihood of reporting poor health. Specifically, adults
who reported a little, a moderate amount, or a lot of stress were
more likely to report being in poor health (odds ratio [OR] ⫽1.16,
95% confidence interval [CI] [1.0, 1.4]; OR ⫽1.36, 95% CI [1.2,
1.6]; and OR ⫽1.75, 95% CI [1.5, 2.1] respectively) compared
with those who reported experiencing almost no stress in the last
12 months. Additionally, reporting the perception that stress af-
fects health was also associated with an increased likelihood of
reporting poor health. Compared with those who reported hardly
any or no perceptions of stress affecting health, those who reported
perceiving that stress affected health “some” or “a lot” were about
two times (OR ⫽1.80, 95% CI [1.6, 2.1]) and four times (OR ⫽
4.26, 95% CI [3.6, 5.1]) more likely to report being in poor health,
respectively. Adults who reported making attempts to reduce their
stress in the last 12 months were less likely to report being in poor
health (OR ⫽0.92, 95% CI [0.82, 1.03]).
Psychological Distress
The analysis of psychological distress revealed that adults who
reported higher levels of stress were also more likely to report
being in psychological distress. Compared with those reporting
almost no stress in the last 12 months, those who reported a little
stress, a moderate amount of stress, or a lot of stress were more
likely to report being in psychological distress (OR ⫽1.81, 95%
CI [1.5, 2.2]; OR ⫽2.86, 95% CI [2.3, 3.5]; and OR ⫽7.35, 95%
CI [6.0, 9.1], respectively). Moreover, reporting the perception that
stress affects health was associated with an increased likelihood of
reporting psychological distress. Specifically, those who reported
perceiving that stress had affected their health “some” or “a lot”
were more than two times (OR ⫽2.55, 95% CI [2.2, 2.9]) and five
times (OR ⫽5.10, 95% CI [4.3, 6.0]) more likely to report being
in psychological distress, as compared with those who reported
hardly any or no perception that stress affected their health. Adults
who reported making attempts to reduce their stress in the last 12
months were no less likely to report psychological distress than
their counterparts who did not take any steps to reduce their stress
(OR ⫽1.07, 95% CI [0.96, 1.20]).
Premature Mortality
Table 3 reports results from the proportional hazard model
estimating the risk of death among this sample of U.S. adults.
Table 3
Cox Proportional Hazards for All-Cause Mortality Among U.S. Adults, 1998 National Health
Interview Survey
All-cause mortality
HR 95% CI
Almost no stress in last 12 months
Hardly any, or No perception that stress affects health 1.00 reference
Some perception that stress affects health 0.96 0.6 1.5
Perception that stress affects health a lot 1.04 0.3 3.7
Little stress in last 12 months
Hardly any, or No perception that stress affects health 1.00 0.9 1.1
Some perception that stress affects health 0.90 0.7 1.1
Perception that stress affects health a lot 1.10 0.3 3.5
Moderate stress in last 12 months
Hardly any, or No perception that stress affects health 1.00 0.9 1.1
Some perception that stress affects health 1.15 1.0 1.3
Perception that stress affects health a lot 0.85 0.6 1.2
A lot of stress in last 12 months
Hardly any, or No perception that stress affects health 0.83 0.6 1.1
Some perception that stress affects health 0.91 0.7 1.1
Perception that stress affects health a lot 1.43 1.2 1.7
Note. Controlling for gender, race/ethnicity, age, education level, work status, marital status, children in the
household, ratio of family income to poverty threshold, metropolitan statistical area, smoking status, physical
activity level, chronic condition, health insurance, usual source of care, and whether the individual took measures
to reduce stress. Interpretation of significance at the 95% level was based on CI limits before rounding. The Wald
test for the interaction significant (p⬍.05).
HR ⫽hazard ratio; CI ⫽confidence interval; MSA ⫽metropolitan statistical area.
5
THE ASSOCIATION WITH HEALTH AND MORTALITY

Neither the amount of stress nor the perception that stress affects
health independently predicted premature mortality. However, the
interaction between the amount of stress reported and the percep-
tion that stress affects health was statistically significant (using the
Wald test [p⬍.05]) such that reporting a lot of stress and
perceiving that stress affects health a lot increased the risk of death
by 43% (Hazard Ratio [HR] ⫽1.43, 95% CI [1.2, 1.7]). This
represents an increase in the predicted cumulative hazard of death
attributable to the stress interaction from 3.5% to 5.1% for those
who reported a lot of stress in the past 12 months and the percep-
tion that stress affects health a lot compared with those who did not
report either. Using these cumulative hazards at the end of the
study follow-up period under the assumption of causality, it was
estimated that the excess deaths attributable to this combination of
stress measures over the study period was 182,079 (controlling for
all other covariates), or about 20,231 deaths per year (over 9
years).
Sensitivity Analysis
Given the strong relationship between stress and health and the
well-established relationship between self-reported health and
mortality, we examined the potential mediating role of self-
reported health on stress and mortality. Analyses revealed that the
inclusion of self-reported health mediated the relationship between
the stress interaction term and mortality such that the highest
interaction category (reported experiencing a lot of stress and
perceiving that stress impacts their health a lot) was attenuated
from HR of 1.43 to HR of 1.18 and was of borderline significance
(p⫽.076).
Discussion
This study indicates that individuals reporting both a high
amount of stress and the perception that stress affects their health
may be at a greater risk of premature mortality, over and above
those who report high stress or perceived health effects of stress
alone. These findings have significant implications for theories of
stress and health. The hypotheses and results support the notion
that stress appraisal is critical in determining outcomes (Lazarus &
Folkman, 1984). This study provides a key contribution to the
theoretical literature by building on this notion, in testing whether
or not the perception that stress affects one’s health is associated
with adverse health outcomes. The results suggest that the ap-
praisal of both the amount of stress and its impact on health may
work together synergistically to increase the risk of premature
death. These findings provide new insights into the pathways by
which stress may impact health outcomes and suggest new ways of
understanding the linkages among stress, coping, and health.
In this study, the perception that stress affects health was found
to act synergistically with amount of stress to predict an increased
risk of premature death. Specifically, reporting a lot of stress and
perceiving that stress affected one’s health a lot increased the risk
of premature death by 43%. To capture the potential clinical and
public health significance of this finding, the cumulative hazards
models were used to estimate the number of excess deaths attrib-
utable to this combination of stress measures. If this were in fact
a causal relationship, 20,231 deaths each year would be attribut-
able to having a lot of stress and perceiving that stress affects
health a lot. Based on the 2006 Centers for Disease Control and
Prevention (CDC) rankings, this would coincide with the number
of deaths attributable to essential hypertension and hypertensive
renal disease (the 13th leading cause of death in the U.S) and
Parkinson’s disease (the 14th leading cause of death) (CDC, 2011).
While this study is unable to establish a causal relationship, these
results highlight the necessity for further research into the rela-
tionship between the perception that stress affects health and
current health, mental health, and mortality.
Possible explanations for the synergistic effect seen between the
amount of stress and the perceived impact of stress on health
include a person’s negative expectancies, resiliency, and locus of
control regarding health. An individual’s perception of health
plays an important role in determining health outcomes. Studies
have shown that having negative (i.e., pessimistic) expectations of
life events is predictive of poor physical and mental health and
increased use of the health care system (Geers, Kosbab, Helfer,
Weiland, & Wellman, 2007; Maruta, Colligan, Malinchoc, &
Offord, 2002). Furthermore, individuals with negative expecta-
tions are even more likely to exhibit negative health symptoms,
even when given placebo treatments (Geers et al., 2007). In light
of this finding, a possible explanation of the results could be that
the perception that stress affects one’s health is a proxy for
negative expectations; therefore, those with this perception will
subsequently report their health as poor (i.e., self-fulfilling proph-
ecy).
Resiliency is an important and often overlooked resource for
coping with stress. Individuals who have experienced a moderate
amount of adversity in the past exhibit more resilience to recent
adversity (Seery, Holman, & Silver, 2010), suggesting that previ-
ous experiences with stress may help individuals cope with current
stress. Resilient individuals, therefore, may not perceive that stress
affects their health or experience negative health outcomes even
when faced with a lot of stress. Research is needed to evaluate the
relationship between resiliency and the perception that stress im-
pacts one’s health to further determine whether resiliency-
development interventions could improve health outcomes among
those with high stress.
An individual’s health locus of control, defined as their beliefs
in the control they have over their own health (Wallston, Stein, &
Smith, 1994), may also contribute to a heightened perception of
the health implications of stress. Those who perceive that stress
affects their health may have an external locus of control, believing
that their health is not in their control, but attributable to external
circumstances. Studies have indicated that individuals who have a
high external locus of control experience worse outcomes than
those who feel that their health is within their control (Heath,
Saliba, Mahmassani, Major, & Khoury, 2008; Preau et al., 2005).
Although much of this research has focused on those with an
illness, the present study suggests that health-related locus of
control (as seen in a greater perceived impact of stress on health)
may also contribute to outcomes in healthy populations. As such,
encouraging active attempts at problem solving and increasing an
individual’s sense of control over their stress levels and health may
potentially lead to better health outcomes by allowing individuals
to better use coping resources (Thoits, 1995).
In addition, reverse causality may partially explain the findings
in this study. Adults who reported poor health may have been more
likely to report that stress impacts their health simply because of
6KELLER ET AL.

their poor health status; moreover poor health status could also
have influenced the amount of stress reported. The cross-sectional
nature of these data precludes us from examining the direction of
causality among the amount of stress, the perception that stress
affects health, and health outcomes.
While this study is unable to investigate the biological processes
responsible for the findings in this study, allostasis—the process of
achieving homeostasis through adjustments to the biological sys-
tem in response to stress (McEwen, 1998)—may be one potential
mechanism. Although protective in the short term, increased levels
of hormonal mediators associated with the human stress response
can be deleterious to the individual if repeated or prolonged (Lantz
et al., 2005; McEwen & Seeman, 1999). Moreover, increased
allostatic load has been associated with worse physical and cog-
nitive function and an increased risk of mortality (Seeman, Mc-
Ewen, Rowe, & Singer, 2001). Individuals who report a lot of
stress and the perception that stress affects their health may be
experiencing the negative health consequences of increased allo-
static load, where the individual’s stress response system has been
taxed to the point of inciting negative physiological and psycho-
logical responses.
Although this study did not find any significant relationship
between attempts at reducing the amount of stress and the psycho-
logical distress and mortality outcomes, it did find that the asso-
ciation between attempting to reduce the amount of stress experi-
enced and the likelihood of reporting being in poor physical health
to be of borderline significance. The lack of significant evidence of
a clear relationship between attempts at stress reduction and health
outcomes could be attributable to selection issues, as it is possible
that adults who attempt to reduce the amount of stress they
experience may be different than those who do not. Further ex-
perimental research is needed to understand the relationship be-
tween attempts at stress reduction and health outcomes.
The findings in this study may have important implications for
shaping future research aimed at furthering the understanding of
the effects of stress on health. Future work may benefit from
incorporating measurements of the perceived impact of stress on
health in addition to measures of specific stressors and perceived
stress. While the role, if any, of these findings in health improve-
ment interventions focusing on overall stress reduction is unclear,
the study findings indicate that this area merits future exploration.
This study has several limitations. First, all data used for these
analyses except mortality were cross-sectional and thus limited the
ability to assess the temporality of stress and health outcomes.
However, despite the fact that the questions ascertaining the
amount of stress and the perceived effects of stress on health were
asked at the same time as those used to operationalize health and
mental health status, the reference time period differed. The stress
measures referred to the past 12 months, the mental health status
questions to the past 30 days, and the health status question to the
respondent’s health at the time of the interview. To account for the
possibility that prior health status may have influenced individu-
als’ perceptions of how stress affected their health, a flag for
chronic conditions was included in the model. This did not appear
to change the findings for the physical or mental health outcomes;
however, this measure may not have adequately captured prior
health status. Second, the cross-sectional nature of the data limits
the ability to explore possible mechanisms for the findings of the
study related to 1) the health and psychological distress outcomes
and 2) the potential mediating role of self-rated health on stress
and mortality. The available data also limit the ability to fully
determine the independent nature of the stress variables used in the
analysis. However, this study demonstrates that the perceived
impact of stress on health deserves further exploration. Future
research will need to explore these relationships over time. Third,
information about the amount of stress and the perception that
stress affects health was obtained through self-report using a sole
reporter. This may have resulted in misclassification of some
respondents. In addition, the health behavior measures used, par-
ticularly physical activity level, are based on self-report and may
be prone to errors in reporting, as research indicates that respon-
dents typically overreport their physical activity level (Duncan,
Sydeman, Perri, Limacher, & Martin, 2001; Troiano et al., 2008).
Finally, this study was unable to address the role of factors that
may be associated with perceptions of stress and health outcomes
such as personality (e.g., neuroticism).
This study has important strengths. First, the results are based on
national, population-based data, providing insight into the individ-
ual and family level sociodemographic, health-behavior, and
health care factors associated with the perception of stress affect-
ing the health of U.S. adults. Because of the large sample size of
the NHIS, several key predictors of perceiving that stress affects
one’s health could be examined together in one model, allowing
for adjusted estimates of the contributing effect of each character-
istic. Additionally, the study incorporated a large number of deaths
over a nine-year follow-up period.
This study extends previous research on the relationship be-
tween stress and health by examining the perception of stress
affecting health in a nationally representative population-based
sample of adults. The findings show that individuals who reported
the perception that stress affected their health and reported a large
amount of stress have an increased risk of premature death. Further
research focused on the relationships between the perception of
stress affecting health and morbidity and mortality outcomes will
be essential to understanding the health effects of stress.
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