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Role conflict and health behaviors: Moderating effects on psychological distress and somatic complaints
Georgia Pomakiab; Abas Supelib; Chris Verhoevenb a Department of Psychology, University of British Columbia, Vancouver B.C., Canada V6T 1Z4 b Department of Psychology, Leiden University, Leiden, The Netherlands

To cite this Article Pomaki, Georgia , Supeli, Abas and Verhoeven, Chris(2007) 'Role conflict and health behaviors:

Moderating effects on psychological distress and somatic complaints', Psychology & Health, 22: 3, 317 335 To link to this Article: DOI: 10.1080/14768320600774561 URL: http://dx.doi.org/10.1080/14768320600774561

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Psychology and Health April 2007; 22(3): 317335

Role conflict and health behaviors: Moderating effects on psychological distress and somatic complaints
GEORGIA POMAKI1,2, ABAS SUPELI2, & CHRIS VERHOEVEN2
Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver B.C., Canada V6T 1Z4 and 2Department of Psychology, Leiden University, Wassenaarseweg 52, 2300 RB, Leiden, The Netherlands (Received 30 June 2005; in final form 21 April 2006)
Abstract Prior research has shown that role conflict is an important source of strain at the workplace and thus it is important to explore factors that can buffer its deleterious effects. Health behaviors could moderate such stressorstrain relationships by altering both the physiological and psychological responses to stress. The present study examined the direct and moderating roles of health promoting behaviors (HPBs) in a sample of 226 university hospital medical doctors. Results showed that both role conflict and HPBs were directly associated with emotional exhaustion, depressive symptoms, and somatic complaints. Moderation effects were also found, such that doctors who engaged in more HPBs were less affected by high role conflict in relation to emotional exhaustion and depressive symptoms. These findings suggest that HPBs can be beneficial coping strategies.
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Keywords: Role conflict, physicians, health behaviors, psychological distress, coping, work stress

Introduction Role conflict is considered a source of chronic stress and has been documented to have a significant impact on job satisfaction, psychological distress, burnout, and somatic complaints (Fisher & Gitelson, 1983; Glazer & Beehr, 2005; Jackson & Schuler, 1985). Role conflict is here defined as a stressful situation that results from discrepant role expectations and from the inability to resolve those incompatible expectations (Boles, Wood, & Johnson, 2003;
Correspondence: Georgia Pomaki, Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver B.C., Canada V6T 1Z4. E-mail: gpomaki@psych.ubc.ca ISSN 0887-0446 print/ISSN 1476-8321 online 2007 Taylor & Francis DOI: 10.1080/14768320600774561

318 G. Pomaki et al. Tidd & Friedman, 2002). The present study first examines the direct relationship between role conflict on the one hand and emotional exhaustion, depressive symptoms, and somatic complaints on the other. Secondly, we investigated whether health promoting behaviors (HPBs) can have a direct and a buffering effect on the study outcomes. There is theoretical and empirical support for the study of moderators in the role conflictstrain relationship. From a theoretical standpoint, Kahn and Byosiere (1992, p. 622) suggested that properties of the work and the person can moderate or buffer the negative impact of work stressors. Two meta-analyses support this suggestion: Fisher and Gitelson (1983) and Jackson and Schuler (1985) revealed that although role conflict has strong main effects on employees strain outcomes, there is substantial variance left unexplained in these outcomes. According to the results of both meta-analyses, future studies should not only identify direct relationships between role conflict and strain, but also consider variables that can moderate the role conflictstrain relationship. Despite the theoretical support for the study of moderators, empirical evidence has provided mixed results. For example, although in a longitudinal study on call center employees, Jimmieson (2000) found that job control buffered the negative effects of role conflict on job satisfaction, psychological well-being, and somatic complaints, ODriscoll and Beehr (2000) found no moderating effect of control on psychological strain and job satisfaction among employees in accounting firms. Kickul and Posig (2001) found that social support moderated the relationship between role conflict and emotional exhaustion in various occupational groups, but Beehr and Drexler (1986) found no support for the moderating effect of social support in a homogeneous sample of bank employees. Also, personality traits have been examined as potential moderators: organization-based self-esteem (Pierce, Gardner, Dunham, & Cummings, 1993), participation in decision making and tolerance for conflict (Posner & Randolph, 1980), and need for clarity (ODriscoll & Beehr, 2000) have all been found to moderate the effects of role conflict on outcomes such as psychological strain and job satisfaction in various occupational groups. Finally, Perrewe et al. (2004) found that having political skill could ameliorate the negative effects of role conflict on anxiety, somatic complaints, and blood pressure in a sample of employees working at an oil company. However, other studies have not found support for a moderating effect. Time management ( Jex & Elacqua 1999), self-efficacy ( Jimmieson, 2000; Perrewe et al., 2004), understanding, prediction, and control of work-related events (Tetrick & LaRocco, 1987) were not found to moderate the role conflictstrain relationship. One reason for the mixed results has been suggested by Jackson and Schuler (1985): more specific theory is needed for selecting and examining potential moderators of the relationship between role conflict and strain outcomes. Others have suggested that moderators should be salient to the individuals under study in order for them to play a significant buffering role (ODriscoll & Beehr, 2000). Measurement may also play an important role in detecting moderating effects.

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For example, in Jimmiesons (2000) study, the use of a more focused measure of work control may have contributed to the significant findings. Also, Kickul and Posig (2001) and Seers, McGee, Serey and Graen (1983) recommended the use of more specific measures of moderators. In their studies, significant moderating results were partly attributed to the use of an explicit measure of social support (vs. a combined measure of social support). In the present study, we attempted to address these recommendations. Firstly, we selected the moderating variable based on the general stress and coping theory (Lazarus, 1991) and on an explicit model showing that HPBs can act as coping strategies (Ingledew, Hardy, Cooper, & Jemal, 1996). Secondly, HPBs were considerably endorsed by our sample, which gave us some confidence that our moderating variable is salient in our participants lives. Finally, we used a valid and specific indicator of HPBs in an attempt to overcome measurement limitations. Health promoting behaviors as coping strategies To date, mostly job characteristics and personality traits have been examined as potential moderators of the role conflictstrain relationship. Less attention has been devoted to behaviors that could help individuals deal with the pressures of role conflict. Tidd and Friedman (2002) emphasized the need to identify specific behavioral responses that can help employees cope with role conflict since organizational and dispositional changes are not always feasible. In the present study, we suggest that engagement in HPBs has the potential to buffer the negative effects of role conflict on well-being, because HPBs can act as coping strategies. This means that we are not only interested in the main effects of HPBs on psychological well-being, but also in their ability to act as resources that individuals can use when faced with the stressors at work. The HPBs are considered to be activities that individuals undertake in order to maintain good health, are amenable to change and have consistently been found to directly predict physical and psychological health outcomes (Conner & Norman, 1996). Interestingly, social and psychological factors (such as social support and personality traits) are usually seen as resources that the person can draw upon in the face of adversity (DeLongis & Holtzman, 2005), whereas the role of physiologically based factors has been given less attention (Ensel & Lin, 2004). Hence, HPBs are not typically included in measures of coping behavior. Ingledew et al. (1996) proposed a model where HPBs are part of ones coping repertoire. In a study of 256 adults, Ingledew et al. (1996) demonstrated that individuals did in fact engage in HPBs as a response to stressful situations. These HPBs were exercise, eating, and self-care (self-care includes both alcohol use and avoiding unhealthy habits). A reasonable question here is concerned with the mechanism through which HPBs are thought to operate in order to influence the stressorstrain relationship. Steffy, Jones and Noe (1990) suggested that HPBs may affect this relationship by

320 G. Pomaki et al. altering the individuals aroused physiological and psychological state that occurs in response to stressors. In a longitudinal study on male executives Kobasa, Maddi, Puccetti and Zola (1985) found that physical exercise buffered the effects of stressful life events on illness. They proposed that although HPBs reduce the level of experienced strain without altering its causes, regular engagement in HPBs may help develop continued protection against the detrimental effects of stressful events. This protective function has been consistently demonstrated for physical exercise (Shanafelt, Sloan, & Habermann, 2003). Although not directly considered as coping strategies, a few studies have looked at individual HPBs mostly physical exercise and alcohol use and their role in alleviating the effect of stressors in the general population. For example, Ingledew and McDonagh (1998) found that exercise in response to stressful situations was a problem-solving strategy as well as a means to take some time away from the problem. Ensel and Lin (2004) found that physical exercise moderated the relationship between life events on the one hand and depressive and somatic symptoms on the other in the general population. With regard to alcohol use, extensive research has shown that individuals drink as a means to cope with lifes stressors (Cooper, Frone, Russell, & Mudar, 1995). Finally, in a longitudinal study, Salo (1995) reported that engaging in regular exercise appeared to be one of the most effective ways of coping with work stress, whereas the use of alcohol, tobacco, and food were among the most ineffective ways of coping with work stress. It is largely unknown whether these and other HPBs can offer the same buffering role against work-related stressors and more specifically against role conflict at work. In addition, not all existing studies have examined explicit moderating influences of HPBs in the stressorstrain relationship. Health promoting behaviors at work Most of the studies to date have looked at the moderating role of HPBs outside the workplace. One study in 3337 employees from three types of industries reported weak evidence for a moderating effect of HPBs on the relationship between work stressors (such as role overload and role ambiguity) and psychological distress: only 4 out of 54 interactions examined were found to be statistically significant (Steffy et al., 1990). Steffy et al. (1990) suggested that this absence of moderating effects may be attributable to the HPBs measure used in their study. This measure was constructed for their study and assessed the frequency of engaging in two sets of HPBs: one set included lifestyle behaviors (e.g., exercise, diet, sleep, physical examinations, and relaxation) and a second set included intake of substances, such as caffeine, tobacco, and alcohol. The present study used a single, specific, and well-established measure of assessing engagement in HPBs the Alameda 7 which has been shown to strongly influence strain outcomes and more specifically, long-term mortality rates (Breslow & Enstrom, 1980). This measure included most of the health behaviors that were investigated in Steffy et al.s (1990) study. These HPBs included sleeping 78 h a night, not smoking, eating breakfast each day, having no

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more than one or two alcoholic drinks a day, exercising regularly, not snacking between meals, and keeping a good weight. Based on prior recommendations for the use of more specific measures for moderators, we focused on a single composite measure of HPBs that was based on yes/no answers, instead of two composite measures assessing frequency of engaging in HPBs as used by Steffy et al. (1990). The present study In the present study we first examined whether role conflict and HPBs are directly associated with emotional exhaustion, depressive symptoms, and somatic complaints (i.e., main effects) in a sample of university hospital medical doctors. Secondly, we investigated possible interaction effects of role conflict and HPBs on the study outcomes. High prevalence of emotional exhaustion has been found in medical specialists, such as general practitioners (Grassi & Magnani, 2000), practicing surgeons (Campbell, Sonnad, Eckhauser, Campbell, & Greenfield, 2001), psychiatrists (Benbow & Jolley, 2002), and anesthetists (Nyssen, Hansez, Baele, Lamy, & de Keyser, 2003). Medical doctors have also been found to report high levels of depression (Gallery, Whitley, Klonis, Anzinger, & Revicki, 1992; Newbury-Birch & Kamali, 2001) and somatic complaints, such as gastrointestinal symptoms, upper and lower limb musculoskeletal symptoms, cardiovascular symptoms, and nonspecific symptoms (Bergman, Ahmad, & Stewart, 2003). Leiter and Maslach (1988) have suggested that role conflict is expected to have a direct impact on emotional exhaustion. Role conflict has been found to predict emotional exhaustion in various occupational groups (e.g., Elloy, Terpening, & Kohls, 2001; Tummers, Landaweerd, & van Merode, 2002). Role conflict may be particularly pertinent to medical doctors (Campbell et al., 2001) working in a university hospital setting, in view of their multiple work roles: researcher, educator, clinician, and administrator (Harden, 1999; Rutter, Herzberg, & Paice, 2002). Cross-sectional studies show significant relationships between role conflict and various indicators of psychological distress (depersonalization in child life specialists, Holloway & Wallinga, 1990; job stress, depressive symptoms and job satisfaction in emergency medicine residents, Revicki, Whitley, Gallery, & Allison, 1993; job stress in consultant doctors, Deary, Blenkin, Agius, Endler, & Zealley, 1996). In addition, in a study of doctors and other health care employees, Weinberg and Creed (2000) found that conflict arising from various work roles (e.g., clinical vs. managerial) was one of the most important factors differentiating a group with depressive and anxiety disorders from a control group. Longitudinal studies have shown similar results: Bedeian and Armenakis (1981) found that role conflict was associated with high levels of job stress. Peiro, Gonzales-Roma, Tordera and Manas (2001) showed that although role conflict predicted emotional exhaustion cross-sectionally, no longitudinal effects were found. Peiro et al. (2001) concluded that a rather short time lag may be required to detect influences of role conflict on emotional exhaustion.

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322 G. Pomaki et al. Nevertheless, other studies indicate that the relationship between role conflict and psychological distress may be more complex. For example, Rutter et al. (2002) proposed that adding teaching to a medical doctors typical tasks does not necessarily increase stress; it is instead the circumstances that arise from such task enrichment that can influence doctors stress levels. As a consequence, they proposed that more research is needed to understand how role conflict arises. Work by Revicki et al. (1993) suggests that the presence of resources may moderate the role conflictstrain relationship. Medical doctors have been found to use general self-care strategies, such as exercise, adequate sleep, and healthy eating as means to cope with work-related stressors and to promote personal well-being (Quill & Williamson, 1990; Shanafelt et al., 2003; Weiner, Swain, Wolf, & Gottlieb, 2001). Also, empirical evidence provides some support for the relationship between physicians HPBs and their well-being. Bergman et al. (2003) found that health behaviors (i.e., exercise, diet, sleep, perceived physical health, and fatigue after work) were predictive of physical symptoms (including nonspecific symptoms such as headache, chronic tiredness, and poor concentration among others) in male but not in female university hospital medical doctors. Engaging in exercise activities appeared to reduce stress levels among dentists (Newton & Gibbons, 1996). Finally, Firth-Cozens (2003) recently proposed that lack of sleep may explain the relationship between physician stress and medical errors. In the present study, we first sought to examine whether role conflict and HPBs would be directly associated with emotional exhaustion, depressive symptoms (henceforth these two study outcomes together are referred to as psychological distress) and somatic complaints. We predicted that role conflict would have a positive association with the study outcomes, whereas HPBs behaviors would show a negative association. Secondly, we investigated whether engaging in HPBs moderates the relationship between role conflict and psychological distress and somatic complaints. More specifically, we hypothesized that engaging in HPBs would buffer the negative effects of role conflict on the study outcomes. This means that medical doctors characterized by high levels of role conflict but who engaged more in HPBs would report lower levels of psychological distress and fewer somatic complaints compared to those doctors who engaged less in HPBs.

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Method Participants This study was conducted at one of the university hospitals in The Netherlands. The participants were 226 medical doctors (161 men, 65 women). The participants mean age was 44.7 years (SD 7.55). More than half of the participants (54.7%) had worked at the same hospital for more than 10 years

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and almost half of them (47.8%) had worked in their current position for more than 5 years. More than half of the participants (57.5%) worked more than 36 h per week. Procedure All medical doctors of the hospital were invited to participate in this study. Questionnaires were mailed to the respondents home address and returned by prepaid mail. The questionnaires were sent to a total of 441 medical doctors. To increase the response rate, a reminder letter was sent 3 weeks after the initial mailing. The response rate in this study (51.25%) is comparable to that reported in similar surveys of university hospital medical doctors (e.g., Bergman et al., 2003; Holloway & Wallinga, 1990). We compared responders to nonresponders on several parameters, by means of chi-square and t-tests. These comparisons revealed no differences in terms of age, gender, and number of work hours. Measures Role conflict. Role conflict was measured with a set of questions based on the Leiden Quality of Work Questionnaire (LQWQ; Van der Doef & Maes, 1999), which has been extensively used in a variety of populations. The standard role conflict scale in the LQWQ consists of 6 items. By means of focus groups consisting of medical doctors, we adapted those items to fit the study population. More specifically, we excluded three items and added one item. This procedure resulted in role conflict consisting of four-items. Respondents were asked to indicate their degree of agreement with those 4 items on a four-point scale (1 strongly disagree, 4 strongly agree). The items comprising the scale were: I am regularly faced with conflicting demands at work, I know exactly what my colleagues expect of me (reversed), I know exactly which tasks I am responsible for as a doctor (reversed), On a regular basis, I must carry out procedures that I dont entirely support. Higher score indicated higher role conflict. The internal consistency for role conflict was moderate ( 0.64). Health promoting behaviors. Medical doctors HPBs were assessed with the Alameda 7 (Belloc & Breslow, 1972; Breslow & Enstrom, 1980). Seven important HPBs were defined, namely sleeping 78 h a night, not smoking, eating breakfast each day, having no more than one or two alcoholic drinks a day, exercising regularly, not snacking between meals, and keeping a good weight. Respondents were asked to indicate whether they engaged in those seven HPBs (0 no, 1 yes). Keeping a good weight was assessed by means of the body mass index (BMI) that was calculated as weight (kg)/height2 (m). The standard for overweight was set at 25 kg/m2 and higher, according to Hall (2003) (0 overweight, 1 low or average weight). The score for HPBs was constructed by summing over these seven items. Higher scores indicated engagement in more HPBs.

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324 G. Pomaki et al. Emotional exhaustion. Emotional exhaustion was measured by means of the UBOS (Schaufeli & van Dierendonck, 2000), a validated Dutch version of the original Maslach Burnout Inventory (Maslach & Jackson, 1981, 1986). The UBOS has been shown to have good psychometric properties in two validation studies (Gorter, Albrecht, Hoogstraten, & Eijkman, 1999; Schaufeli & van Dierendonck, 1993). The use of the subscale emotional exhaustion as a valid indicator of professional burnout has been supported in several studies (e.g., Cordes & Dougherty, 1993; Lee & Ashforth, 1996). Eight items of this scale measured emotional exhaustion on a seven-point scale (0 never, 6 always). Higher scores indicated higher emotional exhaustion. Norms for emotional exhaustion (Schaufeli & van Dierendonck, 2000) based on 550 medical doctors working in The Netherlands show a mean score of 13.52, which is identical to the mean score of this studys sample (M 13.02). Emotional exhaustion showed satisfactory reliability ( 0.89). Depressive symptoms and somatic complaints. Depressive symptoms and somatic complaints were assessed with the depression and somatization scales respectively of a validated Dutch version of the SCL-90, a symptom checklist (Arindell & Ettema, 1986; based on Derogatis, 1983). The questionnaire has been widely used among Dutch working samples (Kamphuis & Emmelkamp, 1998; Pomaki, Maes, & ter Doest, 2004). It has also been shown to have good psychometric properties (Derogatis & Cleary, 1977; Schmitz et al., 2000). In particular, the depression subscale has been found to have consistently high internal reliability across different studies (Koeter, 1992; Morgan, Wiederman, & Magnus, 1998). The depression scale consists of 16 items and the somatic complaints scale of 12 items. Respondents were asked to indicate to what extent they had been bothered by each of a variety of symptoms over the past week on a 5-point scale (1 not at all, 5 very much). Higher scores indicated more depressive symptoms and somatic complaints. The norm scores for depressive symptoms and somatic complaints (Arrindell & Ettema, 1986) are based on 432 men and 577 women from a normal population in The Netherlands. The depressive symptoms of this studys sample for males (M 19.32) and females (M 21.33) were average compared to the norm population. For somatic symptoms this sample scored below average compared to the norm group (males M 14.49; females M 15.44). The internal consistencies for both depressive symptoms ( 0.91) and somatic complaints ( 0.73) were very good. Statistical analyses As previous research in medical doctors has provided mixed results for age and gender differences in emotional exhaustion, depressive symptoms, and somatic complaints (Campbell et al., 2001; Kluger, Townend, & Laidlaw, 2003; Lert, Chastang, & Castano, 2001), we controlled for the potential impact of age and gender by entering them in the first step of the regression analyses.

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The next step included the centered scores of role conflict and HPBs. In the last step, the interaction between role conflict and HPBs was entered. When an interaction term was significant, plots were constructed by computing the unstandardized beta values of all variables at values one standard deviation above and below the mean. This helped illustrate the nature of the interaction. We repeated the same analyses controlling for additional participant characteristics (i.e., number of work hours, years employed at the same hospital and years working at current position).

Results
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Descriptive statistics and bivariate correlations The means and standard deviations for all study variables are displayed in Table I. For further analyses, the data were transformed to meet the normal distribution assumption (Tabachnick & Fidel, 2001). Emotional exhaustion data were subjected to a square root transformation. Role conflict data were subjected to a log 10(X C) transformation. Finally, depressive symptoms and somatic complaints data were subjected to an inverse-reflect transformation. The assumptions of parametric statistics were satisfied after the variables were transformed. The correlations for all study variables are presented in Table I. Almost all correlations were significant and were in the expected direction. However, the correlation between role conflict and HPBs was not significant. Age and gender The first step in the regression analyses examined the contribution of age and gender. Age was associated with somatic complaints, with older medical doctors scoring higher on somatic complaints than their younger counterparts. Gender was related to depressive symptoms and to somatic complaints. Women scored higher on depressive symptoms and somatic complaints than did their men counterparts.

Table I.

Means, standard deviations, and intercorrelations (Pearsons r). M SD 1.53 1.18 9.31 6.28 3.49 1 0.02 0.25*** 0.28*** 0.19** 2 0.16* 0.29*** 0.34*** 3 4

1. 2. 3. 4. 5.

Role conflict HPBs Emotional exhaustion Depressive symptoms Somatic complaints

7.86 4.81 13.02 19.90 14.76

0.62*** 0.52***

0.61***

Notes. HPBs denotes health promoting behaviors. *p < 0.05; **p < 0.01; ***p < 0.001.

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Table II. Summary of hierarchical multiple regression analyses for variables predicting emotional exhaustion, depressive symptoms, and somatic complaints. Emotional exhaustion Variable Step 1: Demographic variables Age Gender Step 2: Main effects Role conflict HPBs Step 3: Interaction term Role conflict and HPBs R2 0.02 0.07 0.10 0.08*** 0.23*** 0.17* 0.03* 0.16* 0.02* 0.15* 0.15*** 0.26*** 0.28*** 0.00 0.06  Depressive symptoms R2 0.04* 0.09 0.19** 0.15*** 0.19** 0.34***  Somatic complaints R2 0.04** 0.14* 0.18** 

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Notes. Higher scores on gender denote female doctors. Total Adjusted R2 is 0.10 for emotional exhaustion, 0.19 for depressive symptoms, and 0.17 for somatic complaints. p  0.05; **p  0.01; ***p  0.001.

Main effects The second step in the regression analyses assessed the main effects of role conflict and HPBs on the outcome variables. Together, the two predictor variables explained significant amounts of variance: 8% in emotional exhaustion, 15% in depressive symptoms, and 15% in somatic complaints. As can be seen from the coefficients in Table II, the main effects of role conflict and HPBs were significant for all outcome variables. As expected, role conflict was positively associated with all study outcomes, whereas HPBs showed negative associations. Moderating effects According to the second hypothesis of the study, HPBs were expected to moderate the relationship between role conflict and the outcome variables. In step 3 in Table II, we can see that the interaction between role conflict and HPBs significantly explained 3% of variance in emotional exhaustion and 2% in depressive symptoms. The interaction term was not predictive of somatic complaints. Figures 1 and 2 depict the nature of the significant interaction effects. HPBs seemed to buffer the deleterious effects of high role conflict on emotional exhaustion and depressive symptoms. As role conflict increased, the level of emotional exhaustion and depressive symptoms remained stable as long as doctors engaged more in HPBs. We performed the same analyses controlling for three additional participant characteristics (i.e., number of work hours, years employed at the same hospital, and years working at current position). The results regarding main and interaction effects remained unchanged after controlling for those variables.

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4.5 4 Emotional exhaustion 3.5 3 2.5 2 1.5 1 0.5 0 Low
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Low engagement in HPBs High engagement in HPBs

High Role conflict

Figure 1. Interaction effects of role conflict and health promoting behaviors (HPBs) on emotional exhaustion.

3 2.5 Depressive symptoms 2 1.5 1 0.5 0 Low High Role conflict High engagement in HPBs Low engagement in HPBs

Figure 2. Interaction effects of role conflict and health promoting behaviors (HPBs) on depressive symptoms.

Discussion The objective of the present study was twofold: first, we examined whether role conflict and HPBs would be directly associated to emotional exhaustion, depressive symptoms, and somatic complaints. Then, we investigated whether HPBs play a moderating role in the association between role conflict and strain. In accordance with previous research, we found that role conflict had a positive association with the study outcomes and HPBs had a negative association. Employees who reported more role conflict at work or engaged less in HPBs were

328 G. Pomaki et al. more at risk for higher levels of emotional exhaustion, depressive symptoms, and somatic complaints. We also found interesting interaction effects: as role conflict increased, engaging more in HPBs (i.e., exercising, refraining from smoking and excessive drinking, eating healthily, having adequate sleep, and keeping a good weight) was associated with lower emotional exhaustion and depressive symptoms. In other words, we found that HPBs buffered the effects of high role conflict on psychological distress (however no buffering effect was found for somatic complaints). Seen differently, higher role conflict was shown to have a more pronounced deleterious effect for those doctors who reported the least engagement in HPBs. With regard to our main effects, doctors who experienced higher levels of role conflict reported more psychological distress and somatic complaints. Role conflict can be particularly relevant to the medical profession, as medical doctors at university hospitals have to perform administrative, research, teaching, and clinical roles. Although there is extensive empirical evidence that conflict among those roles is associated with psychological distress (e.g., Bedeian & Armenakis, 1981; Deary et al., 1996), some researchers have suggested that the addition of new tasks (e.g., teacher or clinician) to existing ones is not necessarily detrimental to well-being (Rutter et al., 2002). This study adds to the existing evidence in medical doctors and other occupational groups that, conflicting work tasks are strongly associated with strain outcomes. Therefore, further research into factors that can be potentially protective of the deleterious effects of role conflict seems warranted. We also found a direct association between HPBs and psychological distress and somatic complaints. Engaging more in HPBs was associated with less psychological distress and fewer somatic complaints. This result supports previous research where HPBs were found to be predictive of physical (Bergman et al., 2003) and depressive symptoms (Van Gool et al., 2003). Participants in the present study seemed to engage considerably in both health promoting and health compromising behaviors (43% exercised, 13.9% smoked, 45.7% did not have adequate amounts of sleep, and 17.5% had more than two glasses of alcohol per day). The degree of engagement in these HPBs in our sample seems comparable to that of other samples, which may strengthen the generalizability of our findings regarding HPBs. For example, Rathod et al. (2000) reported similar but slightly lower rates of engagement in HPBs for a group of psychiatrists (32% exercised, 9% smoked, 28% did not have adequate amounts of sleep, and 12% made use of alcohol). According to a study by Wynd and Ryan-Wenger (2004), 18 and 24% of active duty army personnel smoked and consumed alcohol respectively, whereas the percentages for civilian army employees were 17 and 21% respectively. Moreover, the majority of our respondents practiced 46 HPBs, whereas 11.9% of our participants reported practicing 13 HPBs (out of total 7 HPBs) and a mere 5.5% practiced all 7 HPBs. These findings may imply that HPBs were salient in our sample, an issue raised

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in previous studies regarding the ability to find significant moderating effects (ODriscoll & Beehr, 2000). Regarding our buffer hypothesis, most existing research on possible moderators of the role conflictstrain relationship has focused on either job characteristics or personality traits, with mixed findings. Specific behavioral responses that can provide employees with the resources to draw upon in the face of role conflict have been largely overlooked (Tidd & Friedman, 2002). This study provides required evidence that behaviors which aim to improve ones health have the potential to buffer the negative effects of work stressors, such as role conflict. Future studies can look at whether HPBs can have this protective effect against other important work stressors and in other occupational groups. One reason for the inconsistent moderation results in previous studies regarding the role conflictstrain relationship is the specificity of measurement in moderator variables ( Jimmieson, 2000; Kickul & Posig, 2001; Seers et al., 1983). We used a well-established composite measure of HPBs namely Alameda 7 that assesses engagement (yes vs. no) in seven different health behaviors. A previous study by Steffy et al. (1990) that has used two different measures of frequency of engagement in health behaviors found no support for a moderating effect. More research regarding the measurement of HPBs could unveil the level of specificity at which this variable can be better assessed. Despite existing evidence that HPBs are influenced by work stressors (Niedhammer et al., 1998; Tsutsumi et al., 2003) and directly influence strain outcomes (Parkes, 1987; Stearns & Moore, 1993), HPBs have not often been looked at as possible moderators of the work stressorstrain relationship. Our study shows that HPBs can be thought of as useful coping strategies that protect against work stressors. Outside the occupational health area, HPBs have been recently conceptualized as coping strategies that can help individuals deal with life stressors (see Ingledew et al., 1996; Ingledew & McDonagh, 1998). The mechanism through which HPBs are thought to affect the stressorstrain relationship includes changing both the psychological and physiological state that occurs when individuals are confronted with taxing stressors. HPBs are not considered to have a direct effect on the stressor but on the ability of the stressor to cause strain (Steffy et al., 1990). Our data support the transactional model of stress (Lazarus, 1991), which states that the effect of stressors on well-being depends on ones ability to cope with those stressors. Interestingly, Kobasa et al. (1985) suggested that engaging in HPBs regularly can offer continuous protection against recurring stressors. HPBs did not affect the relationship between role conflict and somatic complaints. It is possible that a model including only main effects provides a better explanation for somatic complaints than a model including moderation effects.1 In other words, HPBs may not have the potential to buffer the negative effects of role conflict on somatic symptoms although they did buffer these negative effects on psychological distress. Moreover, in a previous study HPBs (such as physical exercise) failed to moderate the relationship between stressful life events and illness in students (Roth, Wiebe, Fillingim, & Shay,

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330 G. Pomaki et al. 1989). The restricted time frame (namely one month) that was used in that study helped explain the absence of moderating effects. In addition, Kelloway and Barling (1991) suggested that work-related well-being may mediate the relationship between work stressors and general well-being. Longitudinal research using a longer time frame and work-related well-being may help future studies better examine moderating effects of HPBs on somatic complaints. We also found a few significant associations between age and gender and the study outcomes. Age was positively associated with somatic complaints, with older employees reporting more somatic complaints. However, other studies report no association between age and somatic symptoms (e.g., Bergman et al., 2003; Pomaki et al., 2004). Furthermore, we did not find an association between age and psychological distress, a finding that contradicts previous findings. Younger doctors (i.e., under 30 years old) have been previously reported to have more emotional exhaustion and higher stress levels than their older counterparts (Bohle, Baumgartel, Gotz, Muller, & Jocham, 2001; Campbell et al., 2001; Nyssen et al., 2003). It is noteworthy that in our study 92.9% of the participants were 35 years or older. This means that our sample did not include many junior doctors. Gender was significantly related to depressive symptoms and somatic complaints, but not to emotional exhaustion. This finding is in line with previous studies (Bergman et al., 2003; Newbury-Birch & Kamali, 2001), where women physicians reported higher levels of depression and physical symptoms than men physicians. Furthermore, the finding that gender was not a significant predictor of emotional exhaustion is also in line with other studies that showed high prevalence of emotional exhaustion in medical specialists to be independent of gender (Benbow & Jolley, 2002; Campbell et al., 2001; Nyssen et al., 2003). From a practical point of view, our findings can have implications for health promotion programs. Compared to other moderators of the stressorstrain relationship, such as personality traits and work conditions, HPBs are more likely to be under the persons control. Both individuals and their environments could support HPBs that may then provide protection against stressors. From an organizational point of view, university hospitals can provide exercise facilities (on site or outside the hospital), professional nutritional advice, and motivational programs to help their employees engage in HPBs. The present study showed that engaging more in HPBs has an independent association with lower emotional exhaustion, depressive symptoms, and somatic complaints, which may mean that a healthy lifestyle could have a stable positive effect on well-being. In addition, for employees who experience high role conflict engaging more in HPBs seems to be especially beneficial. This study is one of the few studies that have examined the moderating effect of HPBs on the work stressorstrain relationship. However, the present study has its own limitations. First, this study relied on cross-sectional data, so no causal relationships could be examined. It would be interesting for future studies to investigate whether HPBs have long-term moderating effects on the role conflict psychological distress relationship. Longitudinal studies can also help

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show whether role conflict is an antecedent versus correlate of distress (Boles, Dean, Ricks, Short, & Wang, 2000). Secondly, this study used only self-report measures. Although we did not address this limitation in our research design, according to Podsakoff, MacKenzie, Lee and Podsakoff (2003) our use of different scale anchors in our measures and simply worded items may have helped reduce possible common method variance effects. Third, this study did not take into account the conflict arising from explicit roles (i.e., teacher, clinician, researcher, and administrator roles). Future research could identify the roles that are more likely to impose incongruent requirements. Finally, like previous studies on medical doctors (Deary et al., 1996) the present study did not differentiate among groups of medical specialists. Future studies could examine whether certain specialist groups are more likely to experience high role conflict. It would also be interesting to further investigate whether engaging in HPBs is a beneficial coping strategy for the most burdened groups of specialists. However, previous studies have reported no differences among specialist groups in terms of job satisfaction and psychological distress (Ramirez, Graham, Richards, Cull, & Gregory, 1996; Zuger, 2004). Further research can also look into how specific HPBs may alter the detrimental effects of work stressors. In addition, other potential moderating variables could be examined. Hall, Hall and Abaci (1997) found that medical doctors who followed a course in human relations reported lower levels of work-related stress. Although there is evidence that HPBs buffer the effects of life stressors on well-being (e.g., Brown, 1991), there is little evidence on whether this applies to work-related stressors. Our findings add to the much needed research on the moderating effects of HPBs in the work stressorstrain relationship. The present results suggest that it is important to consider HPBs as possible ways of reducing the effect of role conflict on psychological distress. Acknowledgments The authors would like to thank Susan Holtzman, Eli Puterman, and Laura ter Doest for their useful comments on an earlier version of this manuscript. GP is supported by a Marie Curie Fellowship (509343) and a Michael Smith Fellowship [ST-PDF 334(03-1)POP].

Note
[1] We thank an anonymous reviewer for this comment.

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