Amer i c an and Jap a nese W omen Use Dif fer ent Cop ing ...psych.wisc.edu/Miyamoto/CACL/Morling et al 03.pdf · Amer i c an and Jap a nese W omen Use Dif fer ent Cop ing Str at

10.1177/0146167203256878PER SON AL ITY AND SO CIAL PSY CHOL OGY BUL LE TINMorling et al. / AMER I CAN AND JAP A NESE COP ING STRAT E GIES

Amer i can and Jap a nese Women Use Dif fer ent Cop ing Strat e gies Dur ing Nor mal Pregnancy

Beth MorlingMuhlenberg Col lege

Shinobu KitayamaKyoto Uni ver sity

Yuri MiyamotoUni ver sity of Mich i gan

In this lon gi tu di nal study, preg nant women in Japan and theUnited States reported on three cop ing strat e gies. Two are indi -vid u ally phrased: per sonal influ ence over out comes and accep -tance of out comes. The third, social assur ance, is grounded inrela tion ships, not ing that close oth ers can influ ence out comes. AEuro pean Amer i can sam ple rated accep tance high est as a strat -egy, whereas Jap a nese women rated social assur ance high est. For Amer i cans, accep tance cor re lated with better preg nancy out -comes (less dis tress over time, better pre na tal care, and less weight gain). For Jap a nese women, social assur ance pre dicted a morepos i tive mater nal rela tion ship. Accep tance cor re lated with lessTime 1 dis tress in both sam ples. Sur pris ingly, per sonal influ ence gen er ally did not pre dict pos i tive out comes in either sam ple, per -haps because nor mal preg nancy is a time-lim ited event with apos i tive prog no sis. The find ings are con sis tent with the view that well-being is related to indi vid ual vari ables in the United Statesbut also to features of social relationships in Japan.

Keywords: cul ture; health; preg nancy; pri mary con trol; sec ond arycon trol; lon gi tu di nal study; Japan; United States

Infor mal obser va tions con firm that preg nancy andchild bear ing are dif fer ent around the world. NorthAmer i can women may crave pick led cucum bers; Jap a -nese women may crave pick led plums (umeboshi). MostAmer i can women receive pain med i ca tion in labor; Jap a -nese women are encour aged to avoid it. Despite thesedif fer ences, preg nancy has some uni ver sal fea tures. Inmod ern cul tures, nor mal preg nancy is a health eventthat is antic i pated and enjoyed, usu ally with a pos i tiveout come. As well, preg nancy is a health event dur ingwhich women may expe ri ence life style changes, weightgain, or phys i cal dis com fort and may worry about labor

and deliv ery and the adjust ment to moth er hood. Howdo women han dle the stress ors of nor mal preg nancy?Health psy chol o gists have repeat edly dem on strated thatthe effec tive ness of cop ing strat e gies depends on fea -tures of the event, the cognitions of the peo ple involved,and aspects of the social envi ron ment, includ ing theindi vid ual’s social net work and cul ture. This arti cleaddresses cop ing with nor mal preg nancy and how it mayvary with cul ture (specifically, middle-class, EuropeanAmerican culture and Japanese culture).

VA RI ETY OF COP ING STRAT E GIES

Peo ple have many cop ing strat e gies on which to drawdur ing stress ful health events. Our study inves ti gatedthree, labeled here as per sonal influ ence, accep tance,and social assur ance. These strat e gies vary in their rel a -tive empha sis on the indi vid ual or on social rela tion -ships, and they vary in their the o ret i cal cat e go ri za tion aspri mary versus secondary control.

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Au thors’ Note: The au thors wish to thank the women who par tic i patedand the nurses and mid wives who co or di nated data col lec tion, es pe -cially Ruriko Tokumoto. We also thank Don Dale for sta tis ti cal ad vice;Emilie Ruglis and Maria Nel son for help in data man age ment; andKiyoko Miyauchi, col leagues at the Ehime Col lege of Health Sci ence,and Mayumi Karasawa for help in early stages of the study. We thankJim Averill and Steve Heine for com ments on a pre vi ous ver sion of thisar ti cle. Com ple tion of this re search was sup ported by travel sup portfrom the Na tional Sci ence Foun da tion, from fac ulty de vel op mentgrants from Un ion Col lege and Muhlenberg Col lege, and fromMombusho Grant B-20252398, 07044036. Beth Morling is now at theUni ver sity of Del a ware, Psy chol ogy De part ment, Newark, DE 19716; e-mail: [email protected].

PSPB, Vol. 29 No. X, Month 2003 1-DOI: 10.1177/0146167203256878© 2003 by the So ci ety for Per son al ity and So cial Psy chol ogy, Inc.

Con trol and cop ing. Past research has repeat edly sug -gested that peo ple cope better with ill ness and stresswhen they feel a sense of per sonal influ ence, or con trol,over aspects of it. Such a per cep tion of per sonal influ -ence over aspects of stress ful events has been called pri -mary con trol in some past research (how ever, we use theterm per sonal influ ence in this arti cle because the wordcon trol is not ade quately trans lat able into Jap a nese). Forexam ple, peo ple with can cer who believed they hadsome con trol over aspects of their ill ness reported lessdis tress than those who did not (e.g., Thomp son,Sobolew-Shubin, Galbraith, Schwankovsky, & Cruzen,1993). Sim i lar results are found with men cop ingwith heart attacks (Affleck, Tennen, Croog, & Levine,1987), men with HIV (Reed, Tay lor, & Kemeny, 1993; Thompson, Nanni, & Levine, 1994), peo ple with rheu -ma toid arthri tis (Tennen, Affleck, Urrows, Hig gins, &Mendola, 1992), and peo ple cop ing with changes intheir appear ance as they age (Thompson et al., 1998).

Accord ing to one anal y sis, per sonal influ ence is com -ple mented by an alter na tive response, sec ond ary con -trol (Rothbaum, Weisz, & Snyder, 1982), in which peo ple adjust to or align them selves with aspects of an event.Research has com monly clas si fied two strat e gies as sec -ond ary con trol. One strat egy empha sizes peo ple’s accep -tance of stress ful events. For exam ple, in one study, par -tic i pants reported how much they “feel okay about[stressor] because I accept it and don’t try to change it”(Thomp son, Col lins, New comb, & Hunt, 1996). Sim i -larly, peo ple have reported whether “it is more impor -tant for me to accept [stressor] than to fight it” andwhether they “accept as is” a par tic u lar stressor or out -come (Thomp son et al., 1998). Accep tance as a cop ingstrat egy (“I have accepted the real ity of the fact that thishas hap pened”) has cor re lated with less dis tress amongwomen with breast can cer (Carver et al., 1993). Accep -tance also has been pre dicted, and some times found, tobe help ful when per sonal influ ence is not possible (e.g.,Thompson et al., 1994, 1996, 1998).

Another strat egy that is often clas si fied under sec -ondary con trol is vicar i ous con trol, in which peo plealign with oth ers who may con trol impor tant out comes(Rothbaum et al., 1982). Some research sug gests thatvicar i ous con trol can be help ful, and some sug gests itcan be harm ful or neu tral. For exam ple, among peo plecop ing with can cer, vicar i ous con trol pre dicted bet -ter adjust ment for peo ple with pos i tive prog no ses andpre dicted better adjust ment for women (but not men)( Taylor, Helgeson, Reed, & Skokan, 1991). How ever,AIDS patients who report feel ing that “peo ple or thingsout side [them selves]” have con trol over con di tions of ill -ness were adjust ing more poorly, espe cially those with apoor prog no sis (Reed et al., 1993). In addi tion, rheu ma -toid arthri tis patients who believed health care pro vid ers

con trolled their daily symp toms expe ri enced worsemoods (Affleck, Tennen, Pfeif fer, & Fifield, 1987).Because vicar i ous con trol addresses the inter ven tionand care of other people, we should distinguish it fromsocial support.

Social sup port and vicar i ous con trol beget social assur ance.Social sup port is asso ci ated with better phys i cal health(Uchino, Cacioppo, & Kiecolt-Glaser, 1996) and helpswomen dur ing preg nancy, too (Dunkel-Schetter,Sagrestano, Feldman, & Killingsworth, 1996). In alargely Latina, eco nom i cally dis ad van taged sam ple,women who received task help and infor ma tion fromoth ers had better birth out comes (Col lins, Dunkel-Schetter, Lobel, & Scrim shaw, 1993). Per ceived sup portalso has been cor re lated with fetal growth (Feldman,Dunkel-Schetter, Sand man, & Wadhwa, 2000). The lackof social sup port (as one of a fam ily of cop ing resources)can put preg nant women at risk for more severe dis tress(Chap man, Hobfoll, & Ritter, 1997; Wells, Hobfoll, &Lavin, 1999). A vari ety of stud ies reviewed by Dunkel-Schetter, Gurung, Lobel, and Wadhwa (2001) sug geststhat social sup port is related to lower rates of stress andanx i ety and occa sion ally to better birth out comes. How -ever, some pop u la tions (e.g., Latinas and Afri can Amer i -cans) may ben e fit from social sup port more than oth ers(e.g., Euro pean Amer i cans), espe cially when thesupport comes from friends and family.

The con struct of social sup port inter sects with thecon trol lit er a ture, we sug gest, in the case of vicar i ouscon trol. Vicar i ous con trol has pre vi ously been mea sured in terms of the influ ence of med i cal experts who may not be close to the indi vid ual (Affleck, Tennen, Pfeif fer,et al., 1987; Reed et al., 1993). But vicar i ous con trol alsocould be con strued as feel ings of trust and an assur anceof receiv ing sym pa thetic help from oth ers, espe ciallywhen the “oth ers” involved include friends and fam ily.Our inter pre ta tion of vicar i ous con trol is inspired by theindig e nous Jap a nese idea of mutual sym pa thy, whichis related to sub jec tive well-being in Japan (Kitayama &Markus, 2000; Uchida & Kitayama, 2001). To cap ture the idea that oth ers are offer ing help (in the form of mak ingdeci sions or exer cis ing agency) on one’s behalf, we spec -ify in the pres ent research that other peo ple can be fam -ily friends and spouses (as well as doc tors). And to dis tin -guish this inter pre ta tion from vicar i ous con trol asfor merly stud ied, we call it social assur ance. Thus, socialassur ance is sim i lar to past mea sures of per ceived avail -able social sup port, but it also retains its con trol rootsbecause it specifies that the individual is aligning herselfwith the influence of others.

In this arti cle, then, we focus on three strat e gies forcop ing with the minor stress ors of nor mal preg nancy:per sonal influ ence (pri mary con trol), accep tance, andsocial assur ance. The last two strat e gies are sub types of

2 PER SON AL ITY AND SO CIAL PSY CHOL OGY BUL LE TIN

the estab lished cat e gory of sec ond ary con trol, but one iscon strued as an indi vid ual act and the other is stated interms of close social rela tion ships.1

COP ING DUR ING NOR MAL

PREG NANCY IN TWO CUL TURES

Cul tures vary con sid er ably in terms of cul tur allyauthen ti cated and shared mod els of the self. These mod -els of self may in turn influ ence the type of cop ing strat e -gies peo ple turn to dur ing health events. The major ity ofresearch on the dif fer ent kinds of cop ing has focused onWhite North Amer i cans, a cul tural group asso ci ated with indi vid u al ism and afflu ence (Hofstede, 2001; Triandis,1989). The U.S. model of the per son is an indepen -dent and unique self, sep a rate from oth ers, with indi vid -ual traits and atti tudes that direct behav ior (Markus &Kitayama, 1991). Dur ing preg nancy, Euro pean Amer i -can women may rely the most on cop ing strat e gies thatfocus on the indi vid ual, in this case, on per son ally influ -enc ing out comes or by (per son ally) accept ing them.Fur ther more, evi dence indi cates that indi vid u allyframed psy cho log i cal phe nom ena are par tic u larlyimpor tant for a Euro pean Amer i can’s well-being. Forexam ple, even though Euro pean Amer i cans feel hap -pier when they per ceive more social sup port, this effectis medi ated by the effect of social sup port on their (indi -vid ual) self-esteem (Uchida, Kitayama, Mesquita, &Reyes, 2002). This con sid er ation sug gests that Amer i canwomen, more than Jap a nese women, may ben e fit from asense of per sonal influ ence, accep tance, or both,because these two strat e gies are framed in terms of theindi vid ual. Thus, despite the fact that preg nancy couldbe con strued as an inter per sonal event involv ing newfam ily rela tion ships, Amer i can women may be morelikely to use coping strategies that are framed in terms oftheir own thoughts and feelings.

In con trast, Jap a nese cul ture empha sizes an inter -dependent model of the per son as a per me able entityenmeshed in human rela tion ships; peo ple’s behav iorchanges and adapts depend ing on con text (Markus &Kitayama, 1991). Dur ing preg nancy, then, Jap a nesewomen may seek to main tain their connectedness withoth ers in rela tion ship. A num ber of stud ies sug gest thatEast Asian women and men may ben e fit from the con -struct we call social assur ance. Sim i lar to our def i ni tion,these stud ies focus on trust, sym pa thy, or con trol on thepart of close oth ers. For exam ple, good feel ings amongJap a nese (but not among Amer i cans) are asso ci ated with socially engaged emo tions and friendly feel ings(Kitayama, Markus, & Kurokawa, 2000). Social sup porthas a direct effect on per sonal hap pi ness in Japan butnot in the United States (Uchida et al., 2002). Thus, Jap a -nese well-being appears to be depend ent, in part, on thehelp peo ple receive from oth ers (Kitayama & Markus,

2000). Sim i larly, among Hong Kong stu dents, sub jec tivewell-being is cor re lated not only with self-esteem (as isthe case in the United States) but equally as strongly withinter per sonal har mony (Kwan, Bond, & Singelis, 1997).Of inter est, some research on preg nancy has shown thatsocial sup port may ben e fit more strongly women fromU.S. sub cul tures that have been described as collectivis -tic, such as Latinas and Afri can Amer i cans, com pared tothose from White, indi vid u al is tic sub cul tures (seeDunkel-Schetter et al., 2001). This vari ety of results leadsus to pre dict that Jap a nese women may benefit relativelymore than Americans from the construct we call socialassurance.

In addi tion to ben e fit ing from social assur ance, cul -tural anal y ses sug gest that Jap a nese women also mayben e fit from accep tance. Accep tance is another way ofadjust ing one self to sit u a tions and real i ties. Accord ingto a clas sic review (Weisz, Rothbaum, & Blackburn,1984) and empir i cal research (Morling, Kitayama, &Miyamoto, 2002), Jap a nese cul ture empha sizes adjust -ing one self to sit u a tions. One way of adjust ing one self isto accept out comes as they are, with out try ing to changethem. Thus, Jap a nese women may ben e fit from two strat -e gies, both of which were orig i nally cat e go rized as sec -ond ary control: social assurance and acceptance.

In short, the cur rent anal y sis sug gests that in cul turesthat are orga nized in terms of the inde pend ent model ofself, mainly the indi vid u ally framed forms of cop ing—accep tance or per sonal influ ence—will be endorsed ascop ing strat e gies and be espe cially ben e fi cial dur ingnor mal preg nancy. In con trast, in cul tures that are orga -nized in terms of the inter de pen dent model of self andthat empha size adjust ing one self to sit u a tions, the sec -ond ary con trol forms of cop ing—social assur ance andaccep tance—are likely to be preferred and beneficial.

PRES ENT RE SEARCH

As noted ear lier, many recent preg nancy stud ies haveexam ined high-risk pop u la tions. This research has dem -on strated that stress pre dicts neg a tive neo na tal out -comes (Dunkel-Schetter et al., 2001; Lobel, Dunkel-Schetter, & Scrim shaw, 1992) and that per sonal re -sources (mea sured by self-esteem, opti mism, and feel -ings of per sonal influ ence and con trol) can be ben e fi cial (e.g., Killingsworth-Rini, Dunkel-Schetter, Wadhwa, &Sand man, 1999). This work has pro vided com pre hen -sive empir i cal knowl edge on the eti ol ogy of neo na talrisk fac tors in vul ner a ble pop u la tions. The pres entresearch, how ever, is explic itly focused on two cul tur allymain stream, mid dle-class groups that are not at risk. Inaddi tion, the pres ent study is the first to com pare pri -mary and secondary control-related strategies duringpregnancy.

Morling et al. / AMER I CAN AND JAP A NESE COP ING STRAT E GIES 3

Spe cif i cally, we con ducted a two-part study of womenin nor mal preg nancy. Dur ing their sec ond tri mes ter,women reported on how they coped with sev eral com -mon con cerns of preg nancy. We asked women (a) if theyfelt that they had per sonal influ ence over these things;(b) if they felt they could accept these com mon con -cerns, no mat ter how they turned out; and (c) if they feltother peo ple (part ner, close friends, or fam ily) couldinflu ence these things on their behalf. Depend ent vari -ables at the pre na tal stage included the women’s dis tress(a com pos ite of stress, anx i ety, and depres sion) and their sub jec tive per cep tions of pre na tal care. Depend ent vari -ables after deliv ery included dis tress, women’s cur rentfeel ings toward their new borns, and neg a tive emo tionsdur ing labor, as well as more objec tive out comes (includ -ing mater nal weight gain, birth weight, and ges ta tionalage). We pre dicted that in the United States, accep tanceor per sonal influ ence would be most fre quent and ben e -fi cial, whereas in Japan, social assur ance and acceptancewould be most frequent and beneficial.

METHOD

Participants

Amer i can women were recruited from four obstet ri -cal offices in the city of Schenectady, New York. Nursesand mid wives at each office were asked to dis trib ute a letter of intro duc tion and an ini tial sur vey (Time 1) towomen at their 4th- or 5th-month pre na tal appoint -ments. Women who chose to par tic i pate mailed theirsur veys to the Amer i can author. Later in the study, toincrease par tic i pa tion, women (N = 16) who par tic i pated in an Internet preg nancy bul le tin board were recruitedto par tic i pate.2 Amer i can women in our sam ple deliv -ered at a num ber of dif fer ent hos pi tals, so about 2 weeksprior to each par tic i pant’s due date, the sec ond sur veywas mailed to each par tic i pant’s home address. If women did not respond to the sec ond sur vey, we con ducted upto three, fol low-up phone calls. After com plet ing bothparts of the sur vey, par tic i pants were mailed $10. Of 62women (59 White) who com pleted the first sur vey, 56women com pleted the Time 2 sur vey; 5 did not becauseof nonresponse and 1 because of lost preg nancy. Amer i -can women completed their surveys an average of 16.4days after delivery.

The Jap a nese women all deliv ered at the same hos pi -tal, so their recruit ment was dif fer ent. Women whoreceived pre na tal care at the Cen ter for Obstet rics at theCen tral Hos pi tal of Ehime Pre fec ture (Ehime KenritsuChuo Byouin) received Time 1 sur veys from nurse- midwives at pre na tal vis its dur ing their sec ond tri mes ter.In addi tion, all women who deliv ered at that hos pi tal(regard less of whether they had par tic i pated in the Time 1 sur vey) received Time 2 sur veys while still recov er ing in

the hos pi tal. Jap a nese par tic i pants mailed com pletedsur veys to the Jap a nese research ers (they com pletedtheir sur veys an aver age of 13.6 days after deliv ery). Atotal of 94 Jap a nese women completed surveys at bothTime 1 and Time 2.

Table 1 sum ma rizes basic demo graphic infor ma tionon each sam ple and dem on strates that the two sam plesdif fered in sev eral impor tant respects. Most impor tant,because of dif fer ences in how nurses inter preted therecruit ing pro cess at Time 1, Amer i can women (M = 5.44 months) were far ther along in their preg nan cies thanJap a nese women (M = 4.06 months). Num ber of monthspreg nant did not cor re late with any of the major studyvari ables (see Table 2); nev er the less, all cul tural dif fer -ences reported here must be inter preted cau tiouslybecause of this poten tial con found. Amer i can womenhad higher lev els of edu ca tion; how ever, both lev els aretyp i cal of women in each cul ture. Amer i can women were paid, whereas Jap a nese women received only a small gift. Despite these dif fer ences, Amer i can and Jap a nesewomen were of the same age, had sim i lar numbers ofliving children, and had similar modal incomes.

Time 1 Measures

Ques tion naire items were devel oped bilin gually. Wewrote items in Eng lish and then imme di ately trans latedthe ques tions into Jap a nese. We made adjust ments toeach item’s word ing as nec es sary for equiv a lence in bothlanguages.

Cop ing strat e gies. Women’s styles of cop ing were mea -sured in terms of the com mon con cerns of preg nancy.Before con struct ing the ques tion naire, we inter viewed asmall sam ple of mid wives and preg nant women in eachcul ture about com mon con cerns dur ing the sec ond tri -mes ter. Women most often reported being con cernedabout the baby’s health and well-being, their rela tion -ship with their part ner, their labor and deliv ery, and theamount of weight they were gaining.

On the ques tion naire, we asked women to report howwor ried each con cern made them: “I am wor ried about__________ [e.g., my labor and deliv ery].” Then weasked three cop ing ques tions for each con cern, one forper sonal influ ence (PI), one for accep tance (AC), andone for social assur ance (SA) (see the appen dix for theactual ques tions). All items used a scale of 1 (not at all) to5 (very much).

In addi tion to assess ing these four actual con cerns, we also assessed reac tions to four hypo thet i cal sit u a tions.Women were asked to imag ine how they would cope if(a) their labor part ner had to be away dur ing their duedate, (b) their baby were breech and they were facedwith a Cae sar ean sec tion, (c) they were forced to care fora rel a tive in their spouse’s fam ily dur ing their 8th month, and (d) they were required to go on bed-rest because of


pre ma ture labor. Women reported how dis tressed eachsit u a tion would make them feel and answered three cop -ing ques tions about each sit u a tion on 5-point scales (seethe appendix for wording).

After inspect ing interitem cor re la tions and fac toranal y ses of these eight sit u a tions, we found that the mostpar si mo ni ous solu tion was to cre ate means across the sit -u a tions for each cop ing strat egy. Three com pos ites mea -sured Time 1 feel ings of (a) per sonal influ ence (U.S. α =.58, Japan α= .78), (b) accep tance (U.S. α = .44, Japan α = .77), and (c) social assur ance (U.S. α = .82, Japan α =.84). The alpha reliabilities for the United States for per -sonal influ ence and accep tance were lower than ideal;how ever, no sin gle item or set of items (sit u a tions) couldbe removed to increase the alpha appre cia bly. In anycase, we still found sig nif i cant regres sion coef fi cients foraccep tance (as noted later); there fore, the low inter nalreli abil ity may only attenuate the true relationships.

Anx i ety, depres sion, and stress (dis tress). We mea suredanx i ety (“dur ing the past week”) using the 20-itemSpielberger State Anx i ety Inven tory (Spielberger, 1983)(U.S. α = .93, Japan α = .93). We mea sured depres sion(“dur ing the past week”) using the first 11 items of theCen ter for Epidemiologic Stud ies Depres sion Scale(CES-D) (Radloff, 1977), as trans lated for research byYatomi, Liang, Krause, and Akiyama (1993) (U.S. α = .79,

Japan α = .80). Anx i ety and depres sion items used 4-point scales. We asked women to report ret ro spec tivelyon the early period of their preg nancy, report ing “howstress ful was that period for you?” with a 7-point scalerang ing from 1 (not at all) to 7 (extremely), which we latercon verted to a 4-point scale.

We com bined anx i ety, depres sion, and stress into asin gle score, weight ing each ele ment accord ing to its fac -tor load ing. All three vari ables loaded on the same fac -tor, but the stress item had a lower weight than the othertwo scales. (In the United States, anx i ety’s weight was .88, depres sion was .89, and stress was .52; in Japan, anx i ety’sweight was .90, depres sion was .92, and stress was .49.)

Pre na tal care. To mea sure women’s sub jec tive impres -sion of doing pos i tive things for their preg nancy, womenreported on 4-point scales the extent to which they feelthey “take care” to do 11 things such as “not have toomuch caf feine” or “keep level of stress low” (U.S. α = .77,Japan α = .83).

Phys i cal symp toms. Women rated the sever ity of theirfirst tri mes ter morn ing sick ness on 5-point scales. Theyrated the extent of their phys i cal symp toms with a sin gleitem from 1 (vir tu ally no phys i cal dis com forts or med i cal prob -lems) to 5 (many severe phys i cal dis com forts or med i cal prob -lems). (The scale means in Table 1 cor re spond to a fewminor dis com forts or med i cal prob lems.)


TA BLE 1: Char ac ter is tics of Each Sam ple

Item United States (n = 64) Ja pan (n = 94) Sig nif i cance

First preg nancy (par ity = 0) 43.5% 50.5%Past lost preg nancy 45.2% 26.3%Ma ter nal age 29.4 29.4Modal in come $30-60,000 5,000,000 yen ($45,000)Modal ed u ca tion Col lege di ploma High school di plomaMonths preg nant at Time 1 5.45 4.06 ***Time 1 stress (7-point scale) 4.05 4.38Time 2 stress 3.63 3.77STAI Time 1 (4-point scale) 1.94 1.91STAI Time 2 1.81 2.05 *CES-D Time 1 (4-point scale) 1.78 1.66CES-D Time 2 1.68 1.69% who smoked (freq) 12.9% (freq 6.9/day) 9.7% (freq 4.4/day)% who drank al co hol (freq) 11.3% (freq .88/wk) 19.1% (freq 1.67/wk)% who ex er cised (freq) 72.6% (freq 2.37/wk) 28.4% (freq 1.97/wk)Sub jec tive pre na tal care (4-point scale) 2.98 2.76Phys i cal symp toms, early preg nancy (5-point scale) 2.16 2.88 **Phys i cal symp toms, en tire preg nancy (5-point scale) 2.25 2.35Prepregnancy weight 66.7 kg 50.8 kg ***Moth ers ideal weight gain (% of orig i nal body weight) 11.4 kg (17.9%) 8.4 kg (17.0%) *** (ns)Ac tual weight gain (%) 16.2 kg (24.8%) 9.6 kg (19.4%) *** (**)La bor neg a tive emo tions (5-point scale) 2.42 2.28Pos i tive feel ings to ward new born (5-point scale) 4.51 4.32 **

NOTE: freq = fre quency, STAI = Spielberger State-Trait Anx i ety In ven tory (State ver sion), CES-D = Cen ter for Epidemiologic Stud ies De pres sion In -ven tory.*p < .05. **p < .01. ***p < .001.

6

TA BLE 2: Cor re la tions Among Ma jor Vari ables

Mospg Age Par itya Educ Inc Care Dist1 PI AC SA Dist2 Posrel Bwt Gest L.emot

United StatesMospgAge .15Par ity .02 .21Educ .08 .30* .14Inc .18 .39* .13 .56*Care .12 .02 .06 .15 .01Dist1 .01 .31* .19 .13 .27* .29*PI.00 .17 .21 .14 .14 .08 .06AC .01 .18 .03 .07 .06 .53* .32* .06SA .16 .15 .12 .03 .01 .12 .03 .50* .25Dist2 .19 .25 .15 .19 .19 .28* .32* .16 .31* .15Posrel .09 .00 .28* .25 .08 .06 .11 .05 .26* .02 .06Bwt .14 .07 .22 .04 .21 .06 .20 .08 .02 .07 .01 .49*Gest .07 .07 .05 .09 .02 .05 .09 .03 .05 .04 .05 .29* .56*L.emot .13 .20 .17 .06 .02 .05 .28* .18 .10 .13 .21 .21 .03 .09

Ja panMospgAge .18Par ity .21 .19Educ .05 .21 .13Inc .09 .17 .01 .23*Care .13 .00 .11 .07 .08Dist1 .03 .17 .05 .03 .16 .18PI.01 .06 .02 .01 .13 .29* .32*AC .01 .00 .14 .08 .03 .26* .38* .71*SA .02 .32* .02 .12 .07 .29* .28* .54* .46*Dist2 .14 .07 .13 .00 .18 .27* .66* .28* .21* .35*Posrel .17 .13 .05 .23* .11 .15 .25* .18 .18 .30* .32*Bwt .09 .07 .14 .13 .22* .08 .05 .10 .21* .08 .11 .14Gest .01 .04 .04 .02 .04 .05 .00 .12 .12 .01 .06 .23* .42*L.emot .09 .07 .29* .07 .01 .10 .37* .11 .15 .19 .51* .36* .01 .02

NOTE: Mospg = months preg nant at Time 1, Educ = ed u ca tion level, Inc = in come level, Care = sub jec tive pre na tal care, Dist1 = dis tress at Time 1, PI = per sonal in flu ence, AC = ac cep tance, SA =so cial as sur ance, Dist2 = dis tress at Time 2, Posrel = pos i tive re la tion ship with new born, Bwt = in fants birth weight, Gest = in fants ges ta tional age, L.emot = neg a tive emo tions dur ing la bor (highscores = more neg a tive).a. Par ity 0 = first child, 1 = later child.*p < .05.

Weight gain. Women reported their prepregnancyweight, their weight on the day they filled out the Time 1sur vey, the amount of weight they ide ally wanted to gain,and the amount of weight their doc tor or mid wife rec -om mended gain ing. Amer i can val ues were later con -verted to kilo grams.

Time 2 Measures

We col lected basic demo graphic infor ma tion at Time2 in addi tion to the fol low ing mea sures.

Anx i ety, depres sion, and stress (dis tress). Womenreported their state anx i ety (U.S. α = .94, Japan α = .73)and depres sion (U.S. α = .83, Japan α = .79) using 4-point scales and the same Time 1 mea sures, this time framed as their feel ings “since the baby was born.” Women used 7-point scales (later con verted to 4 points) to reflect on the last 4 weeks of their preg nancy and the ques tion, “Howstress ful was that period for you?” as well as the course oftheir entire preg nancy and the ques tion, “How stress fulwas this period for you?” (U.S. α = .53, Japan α = .77).Anal o gous to Time 1, we com bined anx i ety, depres sion,and stress into a sin gle score, weight ing each ele mentaccord ing to its fac tor load ing. (In the United States,anx i ety’s weight was .93, depres sion was .92, and stresswas .53; in Japan, anx i ety’s weight was .85, depres sion was .91, and stress was .68.)

Pos i tive feel ings toward new born. To cre ate a rela tion -ship-ori ented mea sure of birth out comes, we cre ated anine-item com pos ite to mea sure women’s rela tion shipwith their new borns by com bin ing women’s feel ings ofwarmth when hold ing the baby, feed ing the baby, andwhen the baby was fussy; women’s feel ings of how sweettheir babies were at these same three times; and theirreports of how easy, com fort able, and sat is fy ing theyfound breast feed ing (U.S. α = .68, Japan α = .73).

Weight gain. Women reported their final weight be -fore deliv ery.

Neg a tive emo tions dur ing labor and birth out comes.Women ret ro spec tively reported four emo tions dur inglabor (anx ious, calm, depressed, angry) on 5-pointscales, later com bined into a sin gle mean (U.S. α = .66,Japan α = .76). We also com puted the baby’s ges ta tionalage and women reported their baby’s birth weight.

RE SULTS

The pri mary inde pend ent vari ables in this study werecoun try and the three cop ing styles: per sonal influ ence(PI), accep tance (AC), and social assur ance (SA), allassessed at Time 1. The pri mary depend ent vari ableswere dis tress and pre na tal care at Time 1 as well as distress, pos i tive feel ings toward the new born, labor

emo tions, weight gain, and objec tive birth outcomes atTime 2.

Birth Outcomes

Phys i cal out comes sug gest that this sam ple rep re -sented largely nor mal, healthy preg nan cies. Three(5.6%) of the United States and nine (9.7%) of the Jap a -nese women had babies that would be clas si fied as lowbirth weight (LBW) (≤ 2,500 grams in both coun tries).National reports indi cate that Amer i can new bornsweigh more, on aver age, than Jap a nese babies (3,370grams com pared to 3,130 grams) and the new borns inour sam ple resem ble these fig ures, at 3,388 and 3,031grams, respec tively. Three (5.3%) of the U.S. and 5(5.4%) of the Jap a nese women had preterm deliv er ies(PTD) ( 37 weeks ges ta tion). In the United States, ratesof LBW are 11% and rates of PTD are 7% (National Cen -ter for Health Sta tis tics, 1993). In Japan, rates of LBW are 6.2% and rates of PTD are 5% (Japan Min is try of Healthand Wel fare, 1990). Thus, the Jap a nese sam ple had aslightly higher rate of LBW than the Jap a nese nationalrate, although they had an aver age rate of PTD. Rates ofCae sar ean sec tion were sim i larly low in the two sam ples(14.3% in the United States and 12.6% in Japan).

What Worries Women

We ana lyzed womens rat ings of how much each of thefour com mon con cerns of preg nancy wor ried themusing a 4 (com mon con cern, within-sub jects) 2 (coun -try, between-sub jects) 2 (par ity, between-sub jects) multi -variate ANOVA with months preg nant at Time 1 as a co -variate. Women from both coun tries were wor ried aboutsim i lar things (Coun try Con cern inter ac tion was ns),although U.S. moth ers more wor ried in gen eral, F(1,149) = 4.34, p < .05, par tial η2 = .028. First-time moth erswere more wor ried in gen eral, F(1, 149) = 7.28, p < .01,par tial η2 = .047, espe cially about their labor and deliv -ery, whereas expe ri enced moth ers were more wor riedabout their own weight gain, inter ac tion F(3, 147) = 5.24, p < .01, par tial η2 = .097. All women were least wor riedabout their rela tion ships with their part ners. This pat -tern of results sug gests that cul tural dif fer ences in cop -ing styles (dis cussed next) can not be attrib uted to cul -tural dif fer ences in the con tent of preg nancy worry.

Overall Coping Styles

To test our pre dic tion that the high est rated cop ingresponses would dif fer between the two cul tures, we analyzed mean dif fer ences in the three cop ing stylesunder inves ti ga tion using the com pos ite cop ing mea -sures (means are pre sented in Fig ure 1). We employeda 3 (cop ing style: per sonal influ ence, accep tance, andsocial assur ance, within-sub jects) 2 (coun try, between- subjects) 2 (par ity, between-sub jects) multivariate


ANOVA. Jap a nese women (M = 3.67) rated the cop ingmea sures higher than did Amer i cans did, M = 3.35, F(1,153) = 15.33, p .001, par tial η2 = .091, per haps becauseof cul tur ally dif fer ent response sets (Chen, Lee, &Stevenson, 1995). There fore, the most rel e vant com par i -sons are among the three cop ing styles within each cul -ture (Heine, Lehman, Peng, & Greenholz, 2002). Infact, the Cop ing Style Coun try inter ac tion was sig nif i -cant, F(2, 306) = 28.59, p < .001, par tial η2 = .157. Themeans are pre sented in Fig ure 1. As we pre dicted, Amer -i can women rated indi vid u ally framed forms of cop inghigh est: The high est rated cop ing style was accep tance,which was sig nif i cantly higher than PI, t(60) = 4.44, p <.01, which was in turn sig nif i cantly higher than SA, t(60)= 3.12, p < .01. In con trast, for Jap a nese women, the high -est rated cop ing style was social assur ance, which was sig -nif i cantly higher than AC, t(92) = 2.65, p < .01. AC wasnot rated sig nif i cantly higher than PI, t(92) = 1.63, ns.Thus, as pre dicted, women from dif fer ent cul tures re -ported rely ing on dif fer ent cop ing strat e gies dur ingpreg nancy. We also noted a main effect for cop ing style,F(2, 306) = 11.68, p < .000, par tial η2 = .071, but its inter -pre ta tion is sub sumed in its inter ac tion with coun try.3

Relationships of Coping Styles to Pregnancy Outcomes

Ana lytic Strat egy. We used hier ar chi cal regres sions totest rela tion ships between the dif fer ent cop ing strat e gies and the depend ent vari ables. We entered main effectsfor cop ing strat e gies and coun try on a first step andCoun try Cop ing Style inter ac tions (cod ing UnitedStates = 0, Japan = 1) on a sec ond step. We inter pretedCoun try Cop ing style inter ac tions by inter pret ing theunstan dard ized betas (bs) asso ci ated with the rel e vantmain effect in the inter ac tion model (i.e., the U.S. b is the slope asso ci ated with the rel e vant cop ing style maineffect in the inter ac tion model and the Jap a nese b is theslope asso ci ated with the main effect in the inter ac tionmodel when the coun try dummy vari able is reversed sothat Japan = 0 and United States = 1) (Aiken & West,1991).

Demo graphic vari ables (mater nal age, par ity, num -ber of months preg nant at Time 1, edu ca tion, andincome) could poten tially medi ate the rela tion ships wetested. To medi ate rela tion ships, such demo graph icsmust be cor re lated with both the inde pend ent vari ables(i.e., the three cop ing strat e gies) and the depend entvari able (e.g., dis tress). No demo graphic vari able wascor re lated with both ele ments of an anal y sis using a cri te -rion of p ≥ .10 (see Table 2); there fore, to con serve power in our rel a tively small sam ples, we chose not to includedemo graph ics as con trol vari ables. One excep tion ismater nal age, which was related to Time 2 dis tress (at p =.07) and to accep tance (at p = .02) in American womenand is included in that analysis.

Pre dict ing dis tress. First, we pre dicted Time 1 dis tressfrom the Time 1 cop ing vari ables (a cross-sec tional anal -y sis). These anal y ses showed a main effect for AC, b = 0.65 (SE = .16), p < .001, R2 = .13, p < .001, such that accep tance at Time 1 was asso ci ated with less dis tress at Time 1. Nointer ac tions were observed.

Next, we pre dicted Time 2 dis tress from the Time 1cop ing vari ables, con trol ling for Time 1 dis tress andmater nal age (a lon gi tu di nal anal y sis). These anal y sesshowed a main effect for coun try, b = 0.65 (SE = .19), p <.001 (Jap a nese women had higher Time 2 dis tress), andfor Time 1 dis tress, b = 0.57 (SE = .09), p .001. We alsonoted a mar ginal main effect for SA, b = 0.25 (SE = .15),p= .09 (main effects R2 = .34, p .001). The inter ac tion step revealed an AC Coun try inter ac tion, b = 0.83 (SE = .38),p= .03, R2 change on inter ac tion step = .07, p = .006. ACpre dicted rel a tively less Time 2 dis tress among Amer i can women, b = 0.43 (SE = .29), p = .15, but sur pris ingly, rel a -tively more Time 2 dis tress among Jap a nese women, b =0.41 (SE =.24), p = .09. (This pos i tive rela tion ship is onlypres ent when Time 1 dis tress is con trolled; the sim plecor re la tion between AC and Time 2 dis tress isnonsignificant and negativesee Table 2). We also notedan inter ac tion of Time 1 Dis tress Coun try, b = 0.61 (SE =.17), p .001. Time 1 dis tress was more strongly relatedto Time 2 dis tress in Japan than in the United States, U.S. b = .20 (SE =.13), p = .10, Japan b = 0.81 (SE = .11), p < .01.

Pre dict ing sub jec tive pre na tal care. We pre dicted Time 1sub jec tive reports of pre na tal care (how much womenreported tak ing care to do a num ber of pos i tive health


Fig ure 1 Time 1 cop ing rat ings of Amer i can and Jap a nese women.

behav iors). The anal y sis returned a sig nif i cant maineffect for AC, b = 0.30 (SE = .08), p < .01; main effects R2 =.17, p < .001. We also observed a sig nif i cant AC Coun tryinter ac tion, b = 0.43 (SE = .17), p = .01, R2 change oninter ac tion step = .04, p = .07, such that AC was asso ci -ated with better pre na tal care in the United States, b =0.52 (SE = .13), p .001, but not in Japan, b = 0.09 (SE =.11), p = .45.

Pre dict ing pos i tive feel ings toward new born. In this anal y -sis, we obtained a main effect for coun try, b = 0.25 (SE =.08), p = .004, main effects R2 = .10, p = .005, such that Jap -a nese women rated this vari able lower than Amer i canwomen. We also noted a mar ginal main effect for AC, b =0.13 (SE = .07), p = .07, such that more Time 1 accep tance tended to pre dict more a pos i tive rela tion ship. Theinter ac tion step indi cated an SA Coun try inter ac tion, b = 0.26 (SE = .12), p = .04, R2 change on the inter ac tion step= .03, p = .17. SA was asso ci ated with more pos i tive feel -ings toward the new born in Japan, b = 0.19 (SE = .08), p =.02, but not in the United States, b = .06 (SE = .09), p = .49.

Pre dict ing weight gain. As seen in Table 1, Amer i canwomen weighed more to begin with, but women fromboth cul tures ide ally wanted to gain sim i lar amounts ofweight at Time 1about 17% of their orig i nal body weight. How ever, Amer i can women on aver age gained 5.46 kilo -grams more than they wanted to, whereas Jap a nesewomen gained 3.87 kilo grams more than they wanted to, t(145) = 3.61, p < .01.

Hier ar chi cal regres sions pre dicted preg nancy weightgain from the sin gle Time 1 cop ing items related only toweight gain. These sin gle cop ing items are more the o ret -i cally mean ing ful than using the cop ing com pos itescores to pre dict weight gain, but the results may be lesssta ble than those asso ci ated with the com pos ite scores.The depend ent vari able was actual weight gain: Time 2report of prebirth weight minus the Time 1 report ofprepregnancy weight. We entered sev eral con trol vari -ables: par ity, weight before preg nancy, weight gain so farat Time 1, and the Time 1 report of how much weight awoman wanted to ide ally gain. We entered the three cop -ing items related to weight gain on the first step (alongwith the con trol vari ables) and inter ac tion terms on asec ond step. This over all anal y sis showed main effectsfor three con trol vari ables: amount of weight gainedalready at Time 1, b = 1.01 (SE = .13), p < .001; goal forideal gain, b = 0.26 (SE = .13), p = .04; and num ber ofmonths preg nant at Time 1, b = 1.72 (SE = .38), p < .001,main effect R2 = .62, p .001. We also observed a sig nif i -cant AC Coun try inter ac tion, b = 2.69 (SE = .79), p < .001,R2 change on inter ac tion step = .04, p = .005, such thatAmer i can women who felt at Time 1 that they couldaccept my weight gain, no mat ter how much or lit tle itmay be actu ally gained less weight over all, b = 1.94 (SE =

.57), p = .001; this rela tion ship was pos i tive in Japan, b =0.75 (SE = .54), p = .16.

Pre dict ing neg a tive emo tions dur ing labor. Finally, we used the three Time 1 antic i pated labor cop ing styles (thetheo retically rel e vant sin gle items) to pre dict womensrecalled emo tions dur ing labor. This emo tion com pos ite con sisted of womens recalled feel ings of anx i ety, calm(reversed), anger, and sad ness dur ing their labor anddeliv ery (mea sured at Time 2). In a first step of a hier ar -chi cal regres sion, we con trolled for the babys ges ta tional age and weight in grams, the use of pain med i ca tion dur -ing labor, and whether women had a Cae sar ean sec tionand entered the three sin gle-item mea sures of cop ingwith labor and deliv ery (not the cop ing com pos itescores). On a sec ond step, we entered the Cop ing Strat -egy Coun try inter ac tions. We observed a mar gin ally sig -nif i cant main effect for womens antic i pated per sonalinflu ence over labor, b = .14 (SE = .08), p = .06, but noneof the Cop ing Strat egy Coun try inter ac tions were sta tis -ti cally sig nif i cant. The find ing that women pro spec tivelybene fited from feel ing in con trol of labor is con sis tentwith past research show ing that con trol-ori ented strat e -gies are cor re lated with less labor pain in Israeli andEuro pean American women (e.g., Manning & Wright,1983; Shiloh, Mahlev, Dar, & Ben-Rafael, 1998).

Sum mary. Table 3 sum ma rizes the sig nif i cant maineffects and inter ac tions for each of the major depend entvari ables. Unlike pre vi ous stud ies of ill ness, feel ings ofper sonal influ ence were not uni formly, inde pend entlyrelated to better psy cho log i cal out comes dur ing preg -nancy. PI was related only to less neg a tive emo tions dur -ing labor (mar gin ally). How ever, strat e gies that could beclas si fied as sec ond ary con trol (either accep tance orsocial assur ance), more than pri mary con trol, wererelated to better out comes. Accep tance was related toless Time 1 dis tress in both sam ples. Social assur ance wasmar gin ally related to less Time 2 dis tress in both sam -ples. In addi tion, we noted some cul tural dif fer ences.Accep tance pre dicted less Time 2 dis tress only in theUnited States (it pre dicted, sur pris ingly, more Time 2dis tress in Japan when Time 1 dis tress was con trolled).Accep tance also pre dicted better pre na tal care and lessweight gain in the United States, but not Japan. Socialassur ance was related to more pos i tive feelings towardthe baby for Japanese women, but not for Americanwomen.

Physical Outcomes

When pre dict ing phys i cal out comes from these cop -ing com pos ites we found no sig nif i cant effects pre dict -ing phys i cal symp toms at Time 1 or Time 2, the babysbirth weight or the babys ges ta tional age, or sever ity ofmorn ing sick ness (with the excep tion of a small, neg a -


tive cor re la tion in Japan between AC and birthweight).There fore, the results of the cop ing mea sures seem tobe lim ited to psy cho log i cal, not phys i cal, out comes. Per -haps such phys i cal out comes would be evi dent withmore power to detect dif fer ences. A related pos si bil ity isthat in this uni formly healthy sam ple, there is less vari -ance to explain with cop ing mea sures. In addi tion, thecop ing vari ables did not pre dict womens fre quency ofsmok ing and drink ing alco hol, probably because therewere so few women who did so.

Do Influence and Acceptance Interact?

Past research has tested the inter ac tion between pri -mary con trol and sec ond ary con trol to exam ine, forexam ple, whether sec ond ary con trol is more effec tivewhen pri mary con trol is low. We tested this hypoth e sis byhier ar chi cally add ing the inter ac tion (based on cen -tered scores) of PI and AC, as well as the inter ac tion of PIand SA, for each of the depend ent vari ables. None of theinter ac tion steps was sig nif i cant. Per haps past resultsshow ing that sec ond ary con trol is more effec tive foradjust ment when pri mary con trol is low are lim ited to sit -u a tions with neg a tive prog no ses (e.g., cop ing with HIVin prison or cop ing with phys i cal aging), a possibility wedevelop further in the Discussion.

DIS CUS SION

Our results sup port the idea, fre quently acknowl -edged in health psy chol ogy, that the effec tive ness of cop -ing strat e gies depends on the health sit u a tion, the per -son, and cul ture. Spe cif i cally, the results sug gested thatAmer i can and Jap a nese women worry about sim i larthings dur ing nor mal preg nancy and, in some cases, they cope with these con cerns in sim i lar ways. Both sam plesbene fited from accep tance in terms of less Time 1 dis -tress and warmer feel ings toward their new borns at Time 2. But cop ing also dif fered by cul ture: Amer i can womenranked accep tance sig nif i cantly higher than per sonalinflu ence and social assur ance as a way to cope with com -mon con cerns of nor mal preg nancy. In addi tion, Amer i -cans, but not Jap a nese, bene fited from accep tance interms of less Time 2 dis tress, better self-rated pre na talcare, and more on-tar get weight gain. In con trast, Japanese women ranked social assur ance sig nif i cantlyhigher than either accep tance or per sonal influ ence as away to cope with com mon con cerns of nor mal preg -nancy. Jap a nese, but not Amer i cans, bene fited fromsocial assurance in terms of having warmer feelingstoward their babies at Time 2.


TA BLE 3: Sum mary of Main Ef fects and In ter ac tions From Re gres sion Anal y ses

Main Ef fects In ter ac tions

De pend ent Vari able Per sonal In flu ence Ac cep tance So cial As sur ance Coun try PI Coun try AC Coun try SA

Time 1 distress AC predicts lessdistress*

Time 2 distress SA predicts lessdistress

United States: ACpredicts lessdistress; Japan:AC predicts more distress*

Prenatal care AC predicts bettercare*

United States: ACpredicts bettercare; Japan: norelationship*

Positive newbornrelationship

AC predicts betterrelationship

United States: norelationship;Japan: SApredicts betterrelationship*

Weight gain United States: ACpredicts lessweight gain;Japan: norelationship*

Negative laboremotions

NOTE: Ad di tional con trol vari ables are in cluded in some anal y ses (see text). PI = per sonal in flu ence, AC = ac cep tance, SA = so cial as sur ance.p = .09. p ≤ .07. *p .05.

Culture and Coping

These results are unique for two rea sons. For one, thisis one of the first stud ies of how cul ture shapes peo plesresponses to a health-related event. Although women inthe United States and Japan have sim i lar wor ries andcon cerns dur ing preg nancy, these data sug gest that theymay some times cope with their con cerns in dif fer entways. Cul tural empha ses on auton omy (for Amer i cans)and close social rela tion ships (for Jap a nese) may trans -late into how women con strue cop ing strat e gies. Euro -pean Amer i can women, liv ing in an indi vid u al is tic cul -tural con text, may pre fer and ben e fit from a cop ingstrat egy that is framed in indi vid ual terms, that is, anaccep tance of the out comes of preg nancy. In con trast,Jap a nese women, whose cul ture empha sizes the indi vid -u als embeddedness in mutu ally sym pa thetic social rela -tion ships, rated the assur ance of social sup port mosthighly, and they may benefitin one case, sig nif i cantlymore than Americansfrom this strat egy. Jap a nesewomen, sim i lar to Amer i can women, also bene fitedfrom accep tance in terms of less Time 1 dis tress. How -ever, over time, their accep tance actu ally pre dicted more Time 2 dis tress. This pat tern was puz zling: Per haps overtime, accep tance leads to more dis tress because this viewis at odds with the Jap a nese value on being self-criticaland self-improving (Heine, Lehman, Markus, &Kitayama, 1999).

Our study rep li cates past research on cul tural dif fer -ences in gen eral sub jec tive well-being (see Diener &Suh, 2000, for a review), this time in a very spe cific health con text. In the United States, ante ced ents to well-beingappear to be indi vid u ally framed; spe cif i cally, as self-esteem in past research and as accep tance in the cur rentstudy. In Japan, ante ced ents to well-being appear to beboth indi vid u ally and socially framed; spe cif i cally, as self-esteem, har mony, and sym pa thy in past research andaccep tance and social assur ance here (Kwan et al., 1997;Uchida et al., 2002). Taken together, this recent evi -dence sug gests that for peo ple from East Asian cul tures,for mer mod els of health that focus only on indi vid ualconstruals of self-esteem or con trol are insuf fi cient. Topre dict a full sense of well-being in such cul tures,research ers also need to empha size the impor tance ofvari ables that iden tify sig nif i cant social rela tion ships.Nota bly, the depend ent vari able of warm feel ings toward the baby could be viewed as an inter de pen dent out -come, sug gest ing that future cross-cul tural health re -search ers might focus on out come vari ables that arephrased in terms of the individual-in-relationship.

Personal Influence May Not Be Beneficial in Normal Pregnancy

A sec ond unique con tri bu tion of the pres ent research is the some what sur pris ing find ing that feel ings of per -

sonal influ ence did not inde pend ently pre dict betterpsy cho log i cal adjust ment dur ing preg nancy, above theother two cop ing strat e gies we mea sured (with the ex -ception of labor and deliv ery). This result may sug gestthat nor mal preg nancy is a health con text in which per -sonal influ ence (pri mary con trol) is not inde pend entlyrelated to better adjust ment. At first glance, this find ingcon trasts past research, in which pri mary con trol isalmost always ben e fi cial in stress ful sit u a tions and sec -ond ary con trol was ben e fi cial mainly when pri mary con -trol is low (e.g., Heckhausen & Shultz, 1999; Thomp sonet al., 1994, 1998). Most past research on Amer i cansshows that per sonal influ ence is usu ally adap tive instress ful sit u a tions, even when the situations areobjectively uncontrollable (Thompson et al., 1993).

In review ing clas sic and recent lit er a ture on con trol,how ever, we find that research on cop ing has almostalways been in con texts that are time unlim ited, have aneg a tive prog no sis, or that qual ify as true ill nesses, suchas aging, HIV, can cer, and rheu ma toid arthri tis. Evenpast preg nancy research has focused on high-risk sam -ples (see Dunkel-Schetter et al., 2001, for a review). Nor -mal preg nancy is very dif fer ent because preg nancy is notan ill ness. In fact, it is typ i cally antic i pated as a pos i tiveevent, and nor mal preg nan cies have an over whelm inglypos i tive prog no sis (Dunkel-Schetter et al., 2001). Inaddi tion, all preg nan cies have an end point. Under suchpos i tive con di tions, when there is a high prob a bil ity of apos i tive out come inde pend ent of per sonal agency, . . .per sonal agency might not harm the per son, but it isunlikely to con fer ben e fits (Folkman & Tedlie-Moskowitz, 2000, p. 151). In sup port of this idea, Carverand col leagues (2000) dem on strated that can cerpatients who expected a pos i tive out come were adjust ing better, and their feel ings of con trol did not pre dict dis -tress. Nor mal preg nancy is a phe nom e non that may besim i lar to the psy cho log i cal expe ri ence of opti mismbecause it is an event for which women may rea son ablyexpect a pos i tive out come. There fore, in nor mal preg -nancy, per sonal influ ence may not hurt but it may actu -ally not pre dict better out comes. Instead, preg nantwomen may find it more effec tive to rely on accep tanceor social assur ance when they face con cerns. Sim i larresults might occur for other health events that are timelim ited and have very pos i tive prog no ses. For example,personal influence also may be less relevant for copingwith routine surgeries or the common cold.

Of inter est, the one depend ent vari able that was(mar gin ally) related to feel ings of per sonal influ encewas the expe ri ence of neg a tive emo tions dur ing labor.Women might well expe ri ence labor and deliv ery as anevent sep a rate from the preg nancy itself. Labor is poten -tially the most neg a tive aspect of the preg nancy expe ri -ence, and women may want to inter vene to man age its


accom pa ny ing pain, com pli ca tions, or exhaus tion. Assuch, this excep tion may prove the rule that the moreneg a tive an event is, the more rel e vant per sonal influ -ence is for cop ing with the events stress ors. Of course,future research should explic itly test this pre dic tion bycom par ing events with similar stressors but differentprognoses.

Limitations

There are a num ber of lim i ta tions to this set of datathat sug gest it be inter preted with cau tion. First, the sam -ple size is small. To max i mize power, we kept the num ber of inde pend ent vari ables as small as pos si ble and choseto use regres sion anal y ses (rather than struc tural equa -tion mod el ing). Per haps because of small sam ple sizes,the results were not always con ven tion ally sig nif i cant;there fore, all results deserve to be treated with cau tion.The sur pris ing null result for per sonal influ ence is espe -cially impor tant to rep li cate in a more pow er ful sam plein a future study. In addi tion, although our cross-cul tural sam ple of preg nant women is quite unique, con di tionspre cluded hav ing access to med i cal record details thatwould have quan ti fied the degree to which our sam plewas low risk, which would be impor tant to con firm thatour women expe ri enced nor mal preg nan cies. Althoughour women came from nor mal (not high risk) obstet ri -cal clin ics, and reported hav ing only a few minor med i cal symp toms or con cerns, it would be better to assess rec -ords, as in past research (e.g., Collins et al., 1993).

Our data showed that Amer i can women did notendorse or ben e fit from a sense of social assur ance, afind ing that seems to con tra dict a study in which womenwith can cer bene fited from vicar i ous con trol (Tay loret al., 1991). How ever, our mea sure of social assur ancespec i fied ties with closer friends and fam ily, whereas paststud ies asked about vicar i ous con trol through med i calexperts. In addi tion, the fact that our Amer i can womendid not ben e fit from social assur ance should not be seenas a chal lenge for past research on the ben e fits of socialsup port, includ ing its ben e fits for preg nant Euro peanAmer i can women (e.g., Feldman et al., 2000). Past mea -sures of social sup port have stud ied emo tional, instru -men tal, or even affir ma tion support but not help withdecisions or influence.

Finally, our result that accep tance can pre dict bettercop ing may be restricted to this unique health event ofnor mal preg nancy. In other research, accep tance as acop ing strat egy has had mixed results. As noted, accep -tance has pre dicted less dis tress among women withbreast can cer (Carver et al., 1993); how ever, real is ticaccep tance of dis ease in a sam ple of men diag nosed withAIDS pre dicted decreased sur vival time (Reed, Kemeny,Tay lor, Wang, & Visscher, 1994). In another sam ple,accep tance pre dicted more dis tress among HIV-pos i tive

men who had low lev els of pri mary con trol (Thomp sonet al., 1996). Thus, accep tance as a cop ing strat egy doesnot help for all pop u la tions, per haps depend ing on theprog no sis of a dis ease, the pop u la tion under inves ti ga -tion, and how ques tions about accep tance are phrased.Sim i larly, social assur ance would not be expected toimprove cop ing dur ing all ill nesses (as reviewed earlier), even among interdependent cultural groups.

Conclusion

Our study focused on three cop ing strat e gies: per -sonal influ ence, accep tance, and social assur ance. Wehave sug gested two the o ret i cally inter est ing ways to cat e -go rize them. One dis tinc tion may be made between per -sonal influ ence, as a form of pri mary con trol, and theother two, as forms of sec ond ary con trol. Here, the sur -pris ing but inter est ing result is that strat e gies tra di tion -ally cat e go rized as sec ond ary con trol may be related topos i tive out comes dur ing stress ful events, inde pend entof the level of per sonal influ ence. We have argued thatthis find ing is attrib ut able to the unique event of nor malpreg nancy, which is char ac ter ized both by a num ber ofstress ful con cerns and by a pos i tive prog no sis. Parsed inthis way, our study adds to the lit er a ture on con trol andcop ing with stress (see Carver et al., 2000; Thompson &Spacapan, 1991).

A sec ond dis tinc tion may be made between indi vid -ual-cen tered forms of cop ing (per sonal influ ence andaccep tance) and an inter de pen dent, har mo ni ous form(social assur ance). Addressed from this angle, our datasug gest that Amer i can women ben e fit from a cop ingstrat egy that is described in terms of the indi vid ual viaaccep tance of out comes. Jap a nese women pre fer, andalso may ben e fit from, a cop ing strat egy that asserts thatoth ers will help them or exert influ ence on their behalf.Parsed this way, our study rep li cates and extends a num -ber of recent stud ies that dem on strate cul tural dif fer -ences between East-Asian and North Amer i can cul turesin terms of cor re lates of well-being (Diener & Suh,2000), as well as con trol in gen eral (Morling et al., 2002). In con cert with this past research, our study allows us tocon clude that cul tures may shape the strat e gies that peo -ple ben e fit from, not only for their gen eral well-beingbut also in specific health contexts such as pregnancy.

AP PEN DIXTime 1 Mea sures of Cop ing Strat e gies

Personal Influence

I think I can influ ence things related to my babys healthand well-being, make deci sions about those things, orchange them accord ing to my own wishes.


I think I can in flu ence things re lated to my re la tion shipwith my part ner, make de ci sions about those things, orchange them ac cord ing to my own wishes.

I think I can in flu ence my la bor and de liv ery, make de ci -sions about the ex pe ri ence, or change it ac cord ing to myown wishes.

I think I can influ ence things related to the amount ofweight I gain, make deci sions about those things, orchange them accord ing to my own wishes.

And in re sponse to each of four hy po thet i cal stress ors (seetext), women re sponded to the fol low ing:

I think I would try to per son ally influ ence peo ple orthings in the sit u a tion, make my own deci sions, orchange the sit u a tion as I wish.

Acceptance

I think I can accept my devel op ing babys health and well- being, how ever it turns out.

I think I can accept my rela tion ship with my part ner,how ever it may be.

I think I can accept my labor and deliv ery, how ever itmay go.

I think I can accept the amount of weight I gain dur ingpreg nancy, how ever much or lit tle it may be.


I think I would accept this sit u a tion, as it is.

So cial Assurance

I think that other peo ple (e.g., friends, fam ily, doc tors,etc.) can influ ence, change, or help me make deci sionsabout things related to my babys health and well-being.

I think that other peo ple (e.g., my part ner, friends, fam -ily) can influ ence, change, or help me make deci sionsabout things related to my rela tion ship with my part ner.

I think that other peo ple (e.g., friends, fam ily, doc tors,etc.) can influ ence, change, or help me make deci sionsabout the expe ri ence of my labor and deliv ery.

I think that other peo ple (e.g., friends, fam ily, doc tors,etc.) can influ ence, change, or help me make deci sionsabout things related to the amount of weight I gain.


I think that peo ple close to me (friends, fam ily, doc tors,etc.) would try to influ ence the sit u a tion and change thesit u a tion for me.

NOTE: In the ac tual sur vey, items were grouped by stressor, not by strategy.

NOTES

1. In hind sight, we might have filled out the implied 2 2 (of Influ -ence vs. Accep tance Indi vid ual vs. Social) and asked par tic i pantswhether they believed impor tant, close oth ers could accept cer tain out -comes related to their preg nancy. This vari able did not occur to us inthe plan ning stages of this research, prob a bly because past research oncop ing has never asked ques tions even close to it. How ever, future stud -ies might find this vari able of inter est as a psy cho log i cal vari able reflect -ing the person-in-relationship.

2. t tests com par ing the Internet sam ple with the other Amer i canwomen revealed no sig nif i cant dif fer ences in demo graphic vari ables or in the major inde pend ent and depend ent vari ables. In one excep tion,the Internet sam ple reported mar gin ally higher lev els of edu ca tion,t(60) = 1.78, p = .08.

3. If one does not accept the argu ment that Jap a nese and Amer i -cans used the response scales dif fer ently, then the inter pre ta tion of theCoun try Cop ing style inter ac tion would be only that social assur ance ishigher in Japan than in the United States.

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