The Quality of Life of Female Faculty Working in the Teacher Education Program - Essay Example

Running Head: RESEARCH PROJECT PROPOSAL Research Project Proposal of INTRODUCTION Introduction of the Problem Quality of life for higher education female faculty working in University Teacher Education programs is impacted by stress on a daily basis. During my three years of service to the University, I have observed the under representation of academic women on the campus. Faculty salary equity, promotion, and tenure are also factors that contribute to the overall quality of life, since more female faculty serves in adjunct positions. These factors have a tendency to increase levels of stress in female faculty working in the University Teacher Education program. Statement of the Problem This study will explore the research about the effects of therapeutic massage on stress and quality of life of female faculty working in the teacher education program at a (Name) University. It will enquire into if there will be some impact on the efficiency and life style of the female faculty staff if they are provided with the massage facility in order to reduce the level of stress in imparting their too heavy pedagogical duties. Purpose of the Problem The purpose of this project is to study the quality of life of female faculty working in the Teacher Education program at a (Name) University to determine what effects massage therapy designed to relax and revitalize the mind, body, and spirit has on stress reduction and overall quality of life. The quantitative and qualitative feedback received from pretest and posttest surveys and massage follow-up questionnaires will be used to determine what if any difference the effects of therapeutic massage designed to relax and revitalize the mind, body and spirit has on stress reduction and management, and overall quality of life. Research Questions The following research questions will be used to guide the study. 1. In what ways does stress impact the quality of life of female faculty working in the Teacher Education program at this (Name) University 2. In what ways are identified stressors of female faculty working in the Teacher Education program at this (Name) University different 3. In what ways does participation in the holistic health alternative practice of therapeutic massage treatments improve the quality of life of female faculty working in the Teacher Education program at this (Name) University Significance of the Study The (Name) University female faculty across schools and departments will benefit from knowing if perceived stress is reduced and quality of life improved as a result of participating in a perceived Quality of Life and Stress survey and three massage therapy treatments designed to relax and revitalize the mind, body, and spirit. The information will be used to increase awareness of the stress female faculty encounter in the Teacher Education program. The findings may result in the development of holistic health programs that improve higher education environments. The information will be shared and published with the Massage Therapy Foundation of the American Massage Therapy Association. REVIEW OF LITERATURE The literature referred to value of life as a qualitative practice that appears from the inside, a mode of concerning to life that twigs from a fresh perceptive and an eternal change in a manner an individual witness life. In order to be familiar with living being and becoming as it communicates to worth of life and transform of the inside out, it was required to examine strain and its consequence on fitness and living being. When the symbols of stress persevere, an entity is in danger for heart infection, cancer, corpulence, hopelessness, obsessive-compulsive, ill treatment, diabetes, and so on. Stress slows down the resistant organism. A destabilized resistant organism effects in ill health. It is necessary to identify the sign of stress and make out what steps should be taken to reduce the stressors that influence physical condition and value of life. Knowing that tension begins when a person observe circumstances as frightening instigated action on the part of the investigator to learn optional health alternatives that aid individuals to deal with trauma and recover value of life on the whole. According to Castleman (2004) the holistic health is a strategy to producing healthiness. It highlights the need for a person to stabilize and assimilate corporal, psychological, poignant, and religious facets of health. It let us for creating reverent, supportive relationships with people and the surroundings, while energetically taking part in ones health judgment and therapeutic procedure. Containing understanding and information of holistic health substitutes sanctions for the amalgamation of conservative and balancing treatments. Stress is a usual reply of the body to certain incentive, and there are numerous mechanisms to strain. Excess of stress can show the way to physiological harms for example heart infection and a destabilized resistant organism. Stress controlling and entertaining trainings can help to minimize the cause of stress and assist in maintaining the body fit. Stress can be activated by a large number of factors. Few of them are physical disturbance, stretched contact to cold, lengthened weighty exercise, illness, upset, dwindled oxygen delivering, sleep deficiency, tenderness, terror, and other disturbing anxieties. (Sagy, 2002) Once the mind has sensed the stressor, a procedure normally termed as the "fight-or-flight response" activates, arranging the body to cope with the stressor. The initial step is the alarm feedback. Hormones are unconfined and the body grows to be more responsive and attentive. Beat and inhalation frequency speed up and physique stressed, assisting the body stimulate handling resources to cope with the trauma. The next phase, resistance, is when the body lessens stress and proceeds to a more usual condition, or continues restless and then trouble start to happen emotionally and physically. The third phase, tiredness, or "suffer exhaustion", is as the body is greatly annoying to handle the stress. Skin or abdomen troubles may take place and an individual might even gyrate to drugs to try to control the stress. Rub downing (massage) is a harmonizing healing process that people consider when implementing the holistic strategy to life. Massage and its different types of handlings or techniques can alleviate ache and, in amalgamation with further health preventive measures, can help make well certain situations. Effectual and fine-trained massage psychotherapist knows methods to lessen ache, and will perform cautiously under what they think accurate to the client. The decisive objective of one massage is to loosen up and rejuvenate the body and strength of mind by plummeting stress and recovering the superiority of life of living beings. (Castleman, 2004) By involving in healthy lifestyle, being excited to study and learn, having trust and optimism in their own character and others, and leasing depart of the strain in life assist us survive lives conducted by good judgment and eventually get familiar with worth of life. Value of life as it links to this research means the extent up to which an individual measure to get pleasure from the main probabilities of her existence. The value of life is not a single dimensional, poignant on being and adoring beings, were make sure that the perception of value of life covers various aspects: political and traditional principles plus more concrete procedures such as existing and instructive standards and independence from ailment. Fletcher limited their investigation to the proportions of value of life that has the latent to be altered by curative circumstances. (Moyer, et. al, 2004) Examination of the research on worth of life illustrates the thoughts selected by the word contentment or its different synonyms in dissimilar speech are the oldest contestants as worldwide indicator of an overall good value of life. Study shows that when public speak about contentment, they are naturally referring to a comparatively eternal, reasonable, fine emotion and approach concerning to life. It comes out that hypothesis of life contentment possibly be construed as a hypothesis of ecstasy, and in common these presumptions would be speculation of individual organism. (Knoop, 1994) METHODOLOGY Population The population for this study will consist of thirty female faculties working in the Teacher Education program at a (Name) University. The group of thirty female faculties will participant in a pretest and posttest Perceived Stress Scale of 10 items. Fifteen female faculty participants, randomly selected from the group of thirty, will receive three therapeutic massages over a six-week period. The massages will be designed to reduce stress, and to relax and revitalize the body, mind, and spirit. The fifteen female faulty participants receiving therapeutic massage will become the experimental group, whereas, the remaining fifteen participants of the original group of thirty will become the control group. The Instruments To acquire the necessary data regarding stress, John D. and Catherine T. MacArthurs' Perceived Stress Scale of 10 items will be administered to thirty female faculties working in the Teacher Education program at a (Name) University. The Perceived Stress Scale is available at http://www.maces.ucsf.edu/research/Psychosocial/notebook/PPS10.html. Permission for use of this scale is not necessary when used for academic research or educational purposes (Appendix B). The components of the survey scale are designed to allow female faculty to report their individual perceptions with respect to quality of life, stress, and knowledge of self. The survey scale is designed to elicit information regarding participant awareness of quality of life, stress, and knowledge of self (Appendix B). In addition to the pretest and posttest, the fifteen members of the experimental group will be asked to complete a Stress Scale indicator survey on the day of the therapeutic massage treatment. The Stress Scale indicator and follow-up comment survey will provide feedback on the effects of the therapeutic massage treatment two days after receiving the massage. Upon completion of the survey instruments and approval by reviewers, copies will be mailed to each participant. The target date for completion of the survey scale is April 15, 2006. The target date for approval by reviewers is February 8, 2006. The target date for mailing the survey pretest is April 1, 2006. Data Collection Approval to conduct the study of quality of life of higher education female faculty working in the Teacher Education program at a (Name) University to determine what if any difference the effects of therapeutic massage designed to relax and revitalize the mind, body, and spirit has on stress reduction and management, and overall quality of life will be sought from the Institutional Review Board (IRB) at Capella University and at Minot State University. Approval from both institutions will allow the primary investigator to conduct the study in fairness and good faith. Return of the surveys will imply consent on the part of respondents to participate in the study. The Secretary of Teacher Education will provide the names and addresses of all thirty women professors and instructors who will complete the Perceived Stress Scale survey between April 1 and April 15, 2006. A cover letter explaining the survey scale and purpose of the study will be attached to the survey instrument (Appendix A). The survey will be mailed from the Office of the Secretary of Teacher Education on the (Name) University campus. The survey will be returned in a pre-addressed, postage paid envelope to (Name), independent investigator, data collector and analyzer. (Name's) office is located in the Math and Computer Science Building on the campus the (Name) University. The independent investigator will code response envelopes to identify respondents for follow-up purposes. Instruments and envelopes will be separated upon receipt by the independent investigator to preserve anonymity of the responses. Codes will not be provided to the primary investigator of the study. Survey responses will be anonymous. The same process will be repeated for the Perceived Stress Scale posttest survey between June 1 and June 13, 2006. Survey responses will be anonymous and posttest survey data will be used to complete the study. All survey data will be retained for six months following the completion of the study and then destroyed using the shredding process. In addition to the pretest and posttest, the fifteen members of the experimental group will be asked to complete a Stress Scale indicator survey on the day of the therapeutic massage treatment. The Stress Scale indicator and follow-up comment survey will provide feedback on the effects of the therapeutic massage treatment two days after receiving the massage. The independent investigator will code response envelopes to identify respondents for follow-up purposes. References Castleman, Michael, Jun/Jul2004, Holistic Health Care Explore the options and choose what's right for you, Mother Earth News, 00271535, Issue 204. Knoop, Robert, Dec94, Relieving Stress Through Value-Rich Work,Journal of Social Psychology, 00224545, Vol. 134, Issue 6. Moyer, Christopher A., Rounds, James, Hannum, James W., January 1, 2004, A Meta-Analysis of Massage Therapy Research,Psychological Bulletin, 00332909, Vol. 130, Issue 1. Sagy, Shifra, Jul2002, Moderating Factors Explaining Stress Reactions: Comparing Chronic-Without-Acute-Stress and Chronic-With-Acute-Stress Situations,Journal of Psychology, 00223980, Vol. 136, Issue 4. APPENDICES APPENDIX A COVER LETTER Dear Colleague, You are invited to participate in a dissertation study designed to determine whether the holistic health alternative practice of therapeutic massage reduces stress and improves the overall quality of life of female faculty member working in the Teacher Education program at our local University. Being a participant in this unique group of thirty female faculty members asks that you complete a pretest and posttest Perceived Stress Scale of 10 items. The completed pretest is to be mailed in the preaddressed, stamped envelope to (Name) by April 15, 2006. The posttest Perceived Stress Scale of 10 items will be completed between June 1 and June 13, 2006, and will be mailed in a preaddressed, stamped envelope to (Name). Upon completion of the pretest Perceived Stress Scale, fifteen female faculty participants will be randomly selected to receive three therapeutic massages over a six-week period. The massages will be designed to reduce stress, and to relax and revitalize the body, mind, and spirit of the fifteen member experimental group. Information gathered from the experimental group and the pre and post Perceived Stress Scale 10 item instruments will be used to answer the questions posed by the study. Participants will receive the results of the study. Thank you for your willingness to assist with my dissertation study. I appreciate. APPENDIX B Example of Quality of Life and Stress Survey Instrument Lickert Survey Items The following questions are the type that might be asked when determining quality of life and levels of perceived stress of higher education women professors and instructors involved in the Teacher Education program at Minot State University. 1.In the last month, how often have you been upset because of something that happened unexpectedly Very Often_____ 4 Fairly Often_____ 3 Sometimes_____ 2 Almost Never_____ 1 Never_____ 0 2.In the last month, how often have you found that you could not cope with all the things you had to do Very Often_____ 4 Fairly Often_____ 3 Sometimes_____ 2 Almost Never_____ 1 Never_____ 0 3.In the last month, how often have you felt difficulties were piling up so high that you could not overcome them Very Often_____ 4 Fairly Often_____ 3 Sometimes_____ 2 Almost Never_____ 1 Never_____ 0 4.In the last month, how often have you been able to control irritations in your life Very Often_____ 4 Fairly Often_____ 3 Sometimes_____ 2 Almost Never_____ 1 Never_____ 0 5. In the last month, how often have you had trouble with fatigue Very Often_____ 4 Fairly Often_____ 3 Sometimes_____ 2 Almost Never_____ 1 Never_____ 0 6.In the last month, how often have you felt sad or depressed Very Often_____ 4 Fairly Often_____ 3 Sometimes_____ 2 Almost Never_____ 1 Never_____ 0 John D. and Catherine T. MacArthur have a Perceived Stress Scale - 10 Item available at http://www.maces.ucsf.edu/research/Psychosocial/notebook/PPS10.html. Permission for use of this scale is not necessary when used for academic research or educational purposes. Title: Moderating Factors Explaining Stress Reactions: Comparing Chronic-Without-Acute-Stress and Chronic-With-Acute-Stress Situations , By: Sagy, Shifra, Journal of Psychology, 00223980, Jul2002, Vol. 136, Issue 4 ABSTRACT. On the basis of Herzberg, Mausner, and Snyderman's (1959) motivator-hygiene theory, it was hypothesized that intrinsic but not extrinsic work values would be inversely related to stress. Also investigated was the question of which work values provide the most relief from stress. Elementary school teachers and administrators (N = 607) from nine school boards in southern Ontario completed a survey that included Pines, Aronson, and Kafry's (1981) stress scale and Elizur's (1984) work values scale. Almost all of the 12 intrinsic work values investigated were negatively correlated with stress, but the 4 extrinsic work values studied were not consistently related to stress. Five work values explained 11% of the variance in physical stress, 9 work values explained 22% of the variance in emotional stress, and 6 work values explained 26% of the variance in mental stress. Four work values emerged as meaningful predictors of all three types of stress: being esteemed by others, achieving through work, doing meaningful work, and being able to use one's knowledge and abilities. Although much effort has been expended in identifying the sources and effects of stress at work (Frew & Bruning, 1987; Parasuraman & Alutto, 1984; Schuler, 1980), the literature is rather sparse on suggestions for relief from stress. About half of the stress-coping programs reported concentrate on the individual. They emphasize such responses as modifying behavior, seeking counseling, improving physical fitness, and attending seminars on burnout. The other half of the programs reported propose organizational remedies. These include increased emphasis on participative decision making, management by objectives, job re-design, and role clarification (Ivancevich, Matteson, Freedman, & Phillips, 1990; Knoop, 1986, 1991; Newman & Beehr, 1979). Among the stress-reduction techniques favoring job redesign are job rotation, job enlargement, job enrichment, and self-managed work teams (Griffin, 1991). Prominent within job enrichment is Hackman and Oldham's (1980) job characteristics model, which underscores the importance of what Hackman and Oldham called core job characteristics: skill variety, task identity, task significance, autonomy, and job feedback. Less prominent, but potentially as powerful, is Herzberg, Mausner, and Snyderman's (1959) motivation-hygiene theory. Herzberg et al. (1959) collected a cluster of factors that made people feel good and bad about their jobs. These factors, which Herzberg et al. called job satisfiers and job dissatisfiers, were related, not too successfully, to organizational variables such as productivity and performance (House & Wigdor, 1967). Nevertheless, rather than benefiting only the organization, Herzberg et al.'s factors seemed to be of equal benefit to the individual. Herzberg et al.'s (1959) factors, which are really work values because they are estimates of the worth and importance of aspects of work and job, can also affect stress. Whereas values satisfy or dissatisfy, stress constrains or impels. To some values, one attaches a subjective importance, to others one does not. Generally, the more importance a person gives to a value and the more desirable it appears to be, the more psychological and physical effort that person is willing to expend. This phenomenon may be called positive stress. It follows that the less desirable a value, the less effort a person is likely to give to it. When a person is impelled to exert effort on something he or she does not value, negative stress results. Two hypotheses concerning the relationship between work values and work stress can be deduced from Herzberg et al.'s (1959) motivator-hygiene theory. First, intrinsic work values should have an inverse relationship with stress: the more intrinsic values the job provides--such as achievement, recognition, the value of the work itself, and responsibility--the less stress individuals should experience. Second, because extrinsic factors--such as working conditions, security, and benefits--at best lead to an absence of dissatisfaction, they should not lead to stress reduction. In addition to these two hypotheses, we attempted to determine which set of work values provides the most relief from stress. Method Sample and Procedure The sample consisted of 607 elementary teachers and administrators from nine school boards in southern Ontario. Altogether, 950 questionnaires were distributed by 30 part-time graduate students to educators in their own and neighboring schools (the response rate was 64%). Most of the educators held a bachelor's degree (59%), some held a master's degree (20%), and a minority had merely a teaching certificate (18%). The average age was 40. Most educators (39%) had worked for their board an average of 12 years and had been in their present school for 6 years. A high percentage were women (69%) and married (67%). Administrators (principals, vice-principals, and department heads) accounted for 22% of the sample, and teachers accounted for the remainder (78%). Instruments Two measures were used. Stress was measured with Pines, Aronson, and Kafry's (1981) tedium scale. Respondents were asked to indicate the frequency of 20 experiences (e.g., being tired, feeling anxious) on a 5-point scale ranging from never to always. Stout and Williams (1983) reported favorably on the validity and reliability of this scale, which assesses physical, emotional, and mental exhaustion. Alpha reliabilities in this study were .82 for physical stress, .85 for emotional stress, and .74 for mental stress. The measure of work values was taken from Elizur's (1984) study. Respon-dents were asked to indicate how much of each work value they presently experienced in their job. A 5-point scale was used, with anchors labeled very little and very much. Analysis The items that made up the three stress measures were factor analyzed. The resultant factor loadings were used as item weights. That is, because items loaded to a varying extent on each of the three factors, each item was weighted by its factor loading. For example, the item "feeling hopeless" was included in the computation of physical, mental, and emotional stress, each time with a different factor loading. Because item loadings varied for each stress dimension, the mean scores of the stress dimensions cannot be compared. Total variance accounted for by the three stress dimensions was 60%. Results To determine whether Herzberg et al.'s (1959) theoretical model applied to this sample, we factor analyzed the 16 work values. Three factors emerged--two intrinsic factors and one extrinsic factor. The first intrinsic factor pertained to the work itself and comprised the following values (loadings in parentheses): responsibility (.66), achievement (.70), influence over work (.71), meaningfulness of work (.68), use of abilities and knowledge (.69), independence in work (.60), esteem (.59), job status (.52), and contribution to society (.51). The second intrinsic factor consisted of work outcomes rather than values arising from the work itself: recognition (.72), influence in the organization (.80), and pride in the organization (.68). The extrinsic factor consisted of job characteristics: benefits (.63), hours of work (.73), working conditions (.52), and security (.61). This factor structure is somewhat different from the structure obtained in an earlier study of secondary teachers (Knoop, 1994). The two intrinsic factors were similar in both studies, but in the present study only esteem and status loaded on the work-itself factor rather than the work-outcome factor. However, the loadings for these two items were high on both factors. Another intrinsic value, contribution to society, also loaded highly on the extrinsic dimension. As hypothesized, Pearson correlations between intrinsic values and stress aspects were all negatively correlated (p >. 1) (see Table 1). Results for extrinsic values were mixed. Two values, benefits and convenient hours of work, showed no significant correlations with physical stress or emotional stress. The other two values, working conditions and job security, did have significant but not particularly meaningful correlations. The second hypothesis was therefore only partially confirmed. Generally, the findings suggest that the more these educators perceived themselves to be experiencing job aspects they valued, the less they considered themselves to be under stress. When the work values were entered individually into a regression equation, it was found that the values providing the most relief from stress differed for each dimension. For physical stress, a total of 11% of the variance was explained by five work values (p < .001 in all cases): 7% by achievement and 1% each by influence over work, benefits, security, and esteem. For emotional stress, 22% of the variance was explained by nine values: 11% by meaningfulness of work, 3% by esteem, and 1% each by status, benefits, security, achievement, influence in the organization, recognition, and use of abilities and knowledge. For mental stress, 26% of the variance was explained by six values: 15% by esteem, 6% by use of abilities and knowledge, 2% by achievement, and 1% each by security, benefits, and contribution to society. When the values were entered in groups--two sets of intrinsic and one set of extrinsic values--only the intrinsic work-itself values explained a significant amount of variance for each stress dimension. For physical stress, 7% of the variance was explained by values associated with the work itself; for emotional stress, 15% of the variance was explained by those values; and for mental stress, 22% of the variance was explained. The intrinsic work-outcome values and the extrinsic job-characteristic values did not add to the variance explained. Discussion The results show that if an organization provides people with features they value, stress will be reduced. Upon reflection, this is not a surprising finding. Even so, stress models and research typically ignore values as a remedy for stress, and few organizations consciously build relief from stress into their work structure and culture. The findings in this study imply that the values Herzberg et al. (1959) called motivators and satisfiers are also stress relievers. Why is this How are values and stress connected As referred to earlier, both variables (stress and values) have strong yet divergent theoretical bases. Values are conducive to one's welfare (Locke, 1976). They are subjective, dependent on individual interpretation, accessible only to personal experience, and acquired over time. Work values are those values that individuals seek to attain and act to gain through their job. Stress arises when people interact with the organizational environment. Stress comes about when individuals are confronted with a demand, a constraint, or an opportunity to act that "threatens to exceed the person's capabilities and resources for meeting it" (McGrath, 1976). Resources available to organizations include values--the conscious or unconscious wants and desires that motivate individuals. The findings suggest that just as perceived job situations interact with individuals' values to influence job satisfaction (Smith, Kendall, & Hulin, 1969), situations and values also can interact to bring about relief from stress. If the work situation is bland, that is, if it does not cater to individual values, it is unlikely to motivate and satisfy workers. Indeed, bland and impoverished jobs can lead to stress if what the job offers is perceived to be less than what the job holder demands. Put differently, if job demands are so dull that they do not stimulate the interest of job holders, the required effort can result in stress. Conversely, enriched jobs can lead to an absence or relief of stress because what the job offers is perceived to be equal to or greater than what the person demands of the job. In general, if a job is stimulating and caters to what people seek to attain through work, their efforts can result in two stress conditions. First, for individuals who are not experiencing undue stress, increased effort should not produce such stress. Second, for individuals who are already experiencing undue stress, injecting meaningful stimuli into their jobs can relieve the stress that might result from increased effort. People who have to push themselves to complete work they dislike may perceive additional but meaningful work as stimulating. This leads to the generalization that stressful work may be offset by meaningful work. Values sought and attained alleviate stress resulting from values sought but unattained. Situationally, useful effort-stimulating aspects of a job act as relievers for undue stress-inducing aspects. This implies that not all aspects of a job need to be value-laden to prevent or reduce stress: Those aspects that are value-laden can compensate for those that are not. At any given time, the combination of circumstances arising from the work itself, or surrounding the job, can be such that desired and achieved values will compensate for desired but unachieved values. Stress levels will go up and down as circumstances change. One can postulate that jobs with high autonomy will be more stress equilibrating than jobs with low autonomy. Furthermore, if workers are given autonomy, it is possible that the stress mechanism will be self-regulating. One situation provoking undue stress will induce individuals to seek another situation that promises relief from stress. Both of these interpretations support the well-documented inverted-U relationship between stress and performance: Moderate, sporadic levels of stress stimulate workers and lead to higher performance, whereas moderate, continuous levels of stress can result in lower performance and burnout (Ivancevich & Matteson, 1981). Sporadic levels of stress can be conceived of as situational, continuous levels as universal. Complex and enriched jobs are likely to contain desired situational job features that relieve stress induced by unwanted features. In contrast, simple and dull jobs can contain unwanted universal job features, none of which afford relief from stress. The perceived importance of work values will be the deciding factor in the latter case. Remarkably, almost all work values, even extrinsic values, were negatively related to stress in the present study. This finding indicates that the power of achieved work values to relieve stress may be pervasive. Nevertheless, depending on the individual, some work values will undoubtedly be better stress relievers than others. Unfortunately, individual differences tend to get lost in quantitative analysis. Qualitative research on work values and stress may better explain how these two variables interact within individuals. In this study of Canadian educators, four work values emerged as meaningful predictors for the three dimensions of stress investigated: esteem from others, achievement through work, meaningful work, and the use of one's abilities and knowledge. It makes sense to assume that, for example, meaningful work alleviates such stress symptoms as feeling worthless, trapped, troubled, hopeless, and disillusioned; or that esteem from others makes people feel more optimistic, happy, and energetic; or that a sense of achievement reduces feelings of tiredness, exhaustion, and weariness. All four values are thus phenomenologically justifiable. The total variance explained for each stress dimension is moderate. Undoubtedly, other factors beside work values can relieve stress. Nevertheless, the main stress relievers identified here not only have been repeatedly discussed in the literature (e.g., Hackman & Oldham, 1980; Maslow, 1954; McClelland, 1961), albeit under headings other than stress, but also are cheap to implement. It should be possible to design work that includes what people value in a job. TABLE 1 Means, Standard Deviations, and Pearson Correlations Between Stress and Work Values Legend for Chart: A - Work value B - M C - SD D - Stress, Physical E - Stress, Emotional F - Stress, Mental A B C D E F Work itself Exercising responsibility 3.88 0.87 -.17[**] -.27[**] .34[**] Esteem [being valued as a person] 3.73 0.80 -.27[**] -.35[**] .42[**] Achievement through work 3.80 0.80 -.30[**] -.37[**] .43[**] Influence over work 3.77 0.77 -.28[**] -.32[**] .37[**] Doing meaningful work 4.04 0.74 -.21[**] -.36[**] .40[**] Job status 3.55 0.81 -.22[**] -.30[**] .35[**] Use of abilities and knowledge 3.84 0.91 -.17[**] -.30[**] .41[**] Contribution to society 3.91 0.86 -.17[**] -.29[**] .37[**] Independence in work 3.80 0.86 -.11 -.21[**] .29[**] Work outcomes Recognition for work well done 3.31 0.93 -.19[**] -.28[**] .30[**] Influence in the organization 2.89 0.99 -.08 -.09 .16[**] Pride in working for the organization 3.52 0.92 -.13[*] -.21[**] .30[**] Job characteristics Benefits [pay, vacation, etc.] 3.88 0.94 .04 -.04 .07 Convenient hours of work 3.94 0.89 -.10 -.11 .15[**] Working conditions 3.62 0.88 -.14[*] -.18[**] .24[**] Job security 4.14 0.94 -.16[**] -.26[**]-.27[**] Stress variable Physical 17.76 3.58 Emotional 15.57 4.04 Mental 11.50 2.46 Note. N = 607. *p < .01. **p < .001. REFERENCES Elizur, D. (1984). Facets of work values: A structural analysis of work outcomes. Journal of Applied Psychology, 69, 379-389. Frew, D., & Bruning, N. (1987). Perceived organizational characteristics and personality measures as predictors of stress/strain in the work place, Journal of Management, 13, 633-646. Griffin, R. (1991). Effects of work redesign on employee perceptions, attitudes, and behaviors: A long-term investigation. Academy of Management Journal, 34, 425-435. Hackman, R., & Oldham, G. (1980). Work redesign. Reading, MA: Addison Wesley. Herzberg, F., Mausner, B., & Snyderman, B. (1959). The motivation to work. New York: Wiley. House, R., & Wigdor, L. (1967). Herzberg's dual-factor theory of job satisfaction and motivations: A review of the evidence and criticism. Personnel Psychology, 20, 369-389. Ivancevich, J., & Matteson, M. (1981). Stress and work. Glenview, IL: Scott, Foresman. 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Title: Moderating Factors Explaining Stress Reactions: Comparing Chronic-Without-Acute-Stress and Chronic-With-Acute-Stress Situations , By: Sagy, Shifra, Journal of Psychology, 00223980, Jul2002, Vol. 136, Issue 4 ABSTRACT. The author compared patterns of moderating factors explaining stress reactions during 2 states: chronic-without-acute-stress and chronic-with-acute-stress. She hypothesized that personal dispositions would contribute more to understanding stress reactions during a prolonged stress state than during an acute state. The participants were Israeli Jewish adolescents living in West Bank settlements during the prolonged (chronic-without-acute-stress) state of the intifada (the Palestinian uprising against Israeli occupation) and during the chronic-with-acute-stress state, immediately after the assassination of Prime Minister Rabin. The author examined 5 variables as moderating factors-trait anxiety, sense of coherence, cognitive appraisal of the political situation, family sense of coherence, and sense Of community-and measured 2 stress reactions-state anxiety and psychological distress. Data were collected from 266 8th-grade students during the chronic-without-acute-stress state and 448 students at the same grade level at the chronic-with-acute-stress state. The overall magnitude of variance explanation was different at each state: The author found a relatively high explained variance of state anxiety and psychological distress in the chronic-without-acute-stress situation but not in the chronic-with-acute stress state. These data support the value of developing a model that would recognize the different types of stress situations for moderating the effects of stress. Key words: chronic with acute stress situation, chronic without acute stress situation, moderating factors, stress reactions IN THE FIELD OF STRESS AND ANXIETY, some researchers have evaluated the importance of considering differential stress effects on individual reactions (Folkman & Lazarus, 1985: Magnusson, 1982) with the belief that this approach explains individual reactions in terms of the patterns of cross-situational profile. However, only a few models or theories on the effects of stress deal with differences in types of stress situations (Parkes, 1986). Moreover, only a few models differentiate between chronic strains-the relatively enduring problems, conflicts, and threats that people face in their daily lives-and acute stressors (Timko, Moos, & Michelson, 1993). Although some researchers perceive prolonged or chronic stress as one of the major types of stressful situations that often have more pervasive and potentially detrimental effects (Pearlin, 1989), most psychologists in this field place greater emphasis on studying reactions to acute life events (Garbarino & Kostelny, 1994: Moos, 1992). Moreover, there has been no systematic research regarding the comparative question of the differential determinants or factors explaining stress reactions in chronic versus acute stress situations (Moos: Pearlin). The human condition is stressful, and stresses are ubiquitous (Antonovsky, 1987). Thus, in this study I did not focus only on the comparison between chronic and acute stress situations. Rather, I investigated the prolonged or chronic stress situation in two different states-chronic-without-acute-stress and chronic-with-acute-stress-by comparing stress reactions of adolescents under these divergent environmental circumstances. Specifically, my aim was to study some moderating factors that may serve as buffers in attenuating the potential impact of stressor events (Billings & Moos, 1981). I compared patterns of these moderating effects during a chronic-without-acute-stress situation with patterns of effects in a chronic-with-acute-stress situation. The chronic situation appears to be similar to a normal situation, usually characterized by daily hassles (Elliot & Eisdrofer, 1982). Indeed, research from different parts of the world has confirmed that children exposed to political violence do not inevitably suffer serious psychological consequences (Cairns & Dawes, 1996). In fact, the majority exhibit normal anxiety (Dawes, 1994). Punamaki (1996) even referred to the possibility of habituation to political violence and a threatening environment. If the chronic-without-acute state is habituating, then one might expect that the moderating factors (occurring at higher levels of stress) would have less effect on stress reactions than in the chronic-with-acute state (Baron & Kenny, 1986). In this research, however, I explored a different theoretical framework. Crisis theorists (e.g., Caplan, 1964) have argued that a powerful stressful acute event might minimize or even eliminate individual differences in psychological responses because it initially overwhelms coping resources for those affected. Following this theoretical approach, Gal and Israelshvily (1978) proposed an interaction model of reactions to stress that emphasized the differential influence of situational versus personality factors as determinants of how an individual copes with stress in different states. according to their model, when an individual perceives a threat as acute, his or her behavior is more affected by the characteristics of the situation than by personal factors. As the perceived threat decreases, the contribution of personality factors increases. Sagy and Antonovsky (1986) found empirical support for this model in a longitudinal study with adolescents who were confronting an acute stress situation before the evacuation of Sinai settlements in the framework of the peace treaty with Egypt. Between 2 and 3 weeks before the evacuation, when the stress was acute, none of the moderating variables we examined were significant in explaining the emotional reactions of state anxiety. After the evacuation, when the acuteness of the stress decreased, the situation was similar to one with normal or chronic stress (there were still components of stress in the new situation), the predictors for state anxiety showed a significant impact: The explained variance increased from 0% (acute state) to 38% (chronic state). According to Gal and Israelshvily's (1978) model, moderating factors should have marked effects on the stress reactions in the chronic-without-acute-stress situation. Conversely, in the chronic-with-acute-stress situation, the moderators could have a relatively low explanatory power. Research Background For the present study, I researched Israeli Jewish adolescents living in West Bank settlements[1] in the context of the chronic prolonged stress of the Jewish settlers during the intifada[2] period (during which the Palestinians began to rebel against Israelis) and the acute state immediately after the assassination of Prime Minister Rabin in November 1995. What were the components of the prolonged or chronic stress situation First, the settlers in the West Bank were exposed to political violence during the intifada, which began in December 1987 and continued in various forms even after the Oslo Accords between Israel and the Palestinians were signed in 1993. During this time, the settlers' children have faced danger in their daily travels to and from schools, including roadblocks, stone throwing, and gunfire aimed at vehicles. Other elements of stress were introduced by the ambiguity and uncertainty regarding the future as a result of the peace agreements between Israel and Palestine. Shalit (1982) viewed ambiguity-"the inability to clarify what the environment is" (p. 7)-as possessing the highest threat potential in the hierarchy of situational variables. The element of acuteness was introduced to the ongoing chronic stress stale by the assassination of Prime Minister Rabin, which occurred in November 1995-just before we examined the second sample of the study. It was a collective traumatic experience for the whole Israeli society. However, public opinion in Israel was highly aroused against the Zionist religious sector, from which the assassin came-specially because he said that the murder was performed in the name of its ideology. Factors Explaining Stress Reactions In the present study, I focused on two emotional reactions that are commonly used in research as indicators of psychological stress (Lazarus, 1993): anxiety state reaction (Spielberger, 1972) and psychological distress as measured by psychosomatic symptoms (Ben-Sira, 1979). As I mentioned earlier, my main comparative question related to the extent to which personal resources moderated the negative effects of the stressor. These resources included three personal orientations or traits-trait anxiety, sense of coherence (SOC), and cognitive appraisal of the situation-and the sociodemographic parameter of gender. Two environmental resources were represented by the family sense of coherence and sense of community. Current research on anxiety distinguishes between an individual's actual experiences of anxiety in a specific situation (state anxiety) and an individual's predisposition to have anxious experiences or to engage in anxiety-provoking behaviors in stressful situations (trait anxiety). Trait anxiety is a relatively stable condition that represents, among other characteristics, individual differences in the likelihood that, in certain situations, a person will experience state anxiety (Endler & Parker, 1990). In a theoretical model, Antonovsky (1987) sought to explain the successful coping with stressors by SOC. SOC is a global orientation-an enduring tendency to see the world as more or less comprehensible, manageable, and meaningful. The SOC, according to the model, has implications for individual responses in various kinds of stressful situations. The SOC model suggests that an individual with a strong SOC is less likely than one with a weak SOC to perceive many stressful situations as threatening-and, thus, anxiety provoking-and would be more likely to appraise such situations as manageable. Lazarus (1966) introduced the concept of appraisal as the cognitive mediation of stress reactions, viewing it as a universal process in which people evaluate the significance of what is happening for their personal well-being. Phillips and Endler (1982) perceived the implication of this assumption for research on anxiety: Data on participants' perceptions of a situation could provide valuable information regarding the degree to which cognitive appraisals moderate situations and emotional responses. Thus, researchers hypothesized that attitudes regarding government functioning and the complex political situation after the peace agreements were signed would influence emotional responses. Gender is a variable that can affect the ways in which individuals manifest stress outcomes (Pearlin, 1989): Research that shows that teenage girls generally report higher level of anxiety than teenage boys (e.g., Zeidner, Klingman, & Itzkovitz, 1993). The environmental resources I examined in this study were the family and community as perceived by the adolescent. Research on these kinds of variables is still at a stage that does slot permit satisfactory operational translation of complex collective concepts (Walker, 1985). Sagy and Antonovsky (1992) discussed two dichotomous techniques reflecting theoretical approaches-the holistic approach, which is external and objective (e.g., Reiss, 1981)- and the internal and subjective reductionist approach (e.g., McCubbin & Patterson, 1983). In the present study, I adopted the second approach: I did not inquire into the objective cognitive map of the collective group. Instead, I examined the cognitive representations of the individuals involved, as they were seen from the participant's perspective. I found that the family's views and beliefs were crucial resources for its members' adaptation to stressful events (Boss, 1987: Oliveri & Reiss, 1984, Patterson & Garwick, 1994). I examined the impact of the family sense of coherence on the adolescents' state emotions on the assumption that the family is a salient socializing agent influencing patterns of behavior in adolescence (Coleman, 1980), including emotional responses to stress. The coherence of the family refers to the extent to which the participant sees his or her family world view as coherent. The two types of states that I investigated in this study were characterized as complex community stress situations, posing a threat to the entire gamut of communities of settlers in the West Bank. Community characteristics may also contribute to the understanding of emotional reactions in stressful situations. I investigated the community on the basis of the sense of community concept-a personal quality connoting a strong attachment between people and their communities (Davidson & Cotter, 1991). McMillan and Chavis (1986) defined this concept in terms of four elements: membership, influence, integration and fulfillment of needs, and shared emotional connections. Empirical research on the model suggests that these elements are interrelated and make up a relatively cohesive construct (Chavis, Hodge, & McMillan, 1986: Davidson & Cotter, 1991: Pretty, 1990). In sum, my purpose in the present study was to increase knowledge about a variety of moderating factors in two different stress situations. My major hypothesis was that during the chronic-without-acute-stress situation, personal dispositions would contribute more to understanding stress reactions, whereas in a chronic-with-acute-stress situation, these factors would have less explanatory power. Method Participants I carried out the research for the present study from November to December 1994 (chronic-without-acute-stress state) and November to December 1995 (chronic-with-acute-stress state). During the first situation, I collected data in three schools in the West Bank settlements. The sample was composed of 266 eighth-grade students (135 boys and 131 girls). Most of the students (86%) and their parents (57%) of the fathers and 69%) of the mothers) were born in Israel. Most of the parents (81% of the fathers and 86% of the mothers) had more than 11 years of education, and 34% of the students' fathers and 29% of the mothers had University degrees. In the second situation, after Rabin's assassination, I collected data in four schools from 448 eighth-grade students (213 boys and 235 girls). Students who were eighth graders in the first stage of the study were already in high school by the second data-collection period. Therefore, the sample for the chronic-with-acute-stress state was actually a different group, but there were no significant differences in the demographic characteristics between the two groups. Procedure I collected data using self-completion questionnaires administered in classrooms during a normal class period. I invited all the students in the grade to participate. Two master's degree students administered the questionnaires and provided general instructions and explanations relating to the anonymity of the data collected. Measures I assessed state anxiety using the Hebrew version of Spielberger. Gorsuch and Lushene's (1970) State-Trait Anxiety Inventory (STAI). The Hebrew STAI is a translation of the English STAI. It proved to be reliable, valid, and equivalent to the English inventory (Teichman, 1978). I evaluated state anxiety scores using the mean score of the relevant 20-item inventory of the STAI (on a Likert-type scale ranging from 1 to 4). Cronbach's alpha was .84 for the chronic state group, the and .85 for the group in the acute situation. The Scale of Psychological Distress (SPD) is a 6-item psychosomatic symptom scale, referring to frequency of occurrence of familiar psychological symptoms. The scale was developed in Hebrew (Ben-Sira, 1979) and has been used in several studies with satisfactory psychometric properties (Ben-Sira, 1988). Five of the items were culled from Langer's psychological-equilibrium index (Langer, 1962): pounding heart, fainting, insomnia, headache, and sore hands. The scale was elaborated for use in a population of children (Sagy & Dotan, 2001). I modified some of the symptoms for this study (e.g., I used stomachache instead of sore hands), and I deleted 1 item (nervous breakdown). In this format, the questionnaire included 5 items and was scored on a Likert-type scale ranging from 1 to 4; low scores denoted a high level of psychological distress, and high scores indicated a low level of distress. Cronbach's alpha was .66 for the chronic stale group and .61 for the acute state group. I measured the moderator variables using the following inventories: I used the Hebrew version of STAI to assess trait anxiety. Cronbach's alpha was .81 for the chronic state group and .78 for the acute state group. I measured SOC using a series of semantic differential items on a 7-point Likert-type scale, with anchoring phrases at each end. High scores indicated a strong SOC, and low scores indicated a weak SOC. an account of the development of the SOC scale and its psychometric properties, showing it to be a reliable and reasonably valid scale, appears in Antonovsky (1987,1993). I measured SOC using a short-form scale consisting of 13 items and found a high correlation with the original long version (Antonovsky, 1993). Cronbach's alpha was .74 for the chronic state group and .73 for the acute state group. The scale included items such as, "Doing the things you do everyday is"-with answers ranging from (1) a source of pain and boredom to (7) a source of deep pleasure and satisfaction. I measured cognitive appraisal of the political situation using a 5-item questionnaire scored on a 5-point Likert-type scale. The questionnaire included questions on political attitudes, the chances of the peace process succeeding, and the extent of confidence in the government and its ability to function. Cronbach's alpha was .74 for both groups. I measured sense of family coherence (SOFC) using a scale consisting of 12 items on a 7-point Likert-type scale. This scale was an elaborated version (on the family level) of the SOC personal orientation scale (Sagy, 1998). The SOFC score was the mean score of all scale items, with high scores denoting a strong sense of family coherence. The scale included items such as "When your family faces a difficult problem you usually feel that the choice of a solution is," with answers ranging from (1) always confusing and hard to find for the family to (7) always completely clear for the family, and "How much does it seem to you that the family rules are clear to you" with answers ranging from (1) the family rules are not clear at all to (7) the family rules are completely clear. Previous studies showed Cronbach's alpha coefficients of .88 and .76 (Sagy, 1998; Sagy & Dotan, 2001). Cronbach's alpha was .74 for the chronic state group and .77 for the acute state group. I measured sense of community using a scale developed by Davidson and Cotter (1986) and found it to be reliable and valid (Davidson & Cotter, 1986, 1991). The scale consists of 17 questions, scored on a 4-point Likert-type scale and was translated into Hebrew by Sagy, Stern, and Krakover (1996). It includes items such as, "I feel like I belong here" (membership); "It is hard to make friends and meet people in this place" (influence); "It would take a lot for me to move away from this community" (shared emotional connection). Cronbach's alpha was .82 for the chronic state group and .85 for the acute state group. Results Table 1 displays score means, standard deviations, and t test results of the variables in the study. The state anxiety and the SPD scores were at the high end of the scale. Results of t tests showed no significant differences in state anxiety and SPD scores between the two states. Tables 2 and 3 present the results of stepwise multiple regression analyses. The predictor variables I examined were gender, trait anxiety, SOC, SOFC, sense of community, and cognitive appraisal. The main predictor in the two analyses was trait anxiety. This may have been caused by the intercorrelations among some of the moderators (Tabachnick & Fidell, 1983). In the chronic-without-acute-stress state, however, other predictors (cognitive appraisal, SOFC, sense of community, gender) also contributed to the variance, and in the chronic-with-acute-stress state, no other variables entered the equation. The overall magnitude of variance explained was also different for each state: In the chronic-without-acute-stress state, the predictor variables explained 30% of variance of state anxiety but only 17% in the chronic-with-acute-stress state. With regard to SPD, 21% of the variance was accounted for in the chronic-without-acute-stress state but only 9% was accounted for in the chronic-with-acute-stress state. Discussion In the present study, I attempted to examine moderating factors related to stress reactions in two different states: chronic-without-acute stress and chronic-with-acute-stress. Some of the results indicate a strong similarity between the two situations. First, I found that the stress reactions in the two situations were similar in their intensity. Second, among the personal and environmental resources I examined, anxiety was the main predictor of the emotional reactions in both situations. Although these findings may be explained in methodological terms, they still suggest that the same personality trait has a potential significance for moderating stress reactions in the two states. The similar results between the two states can be explained by the background of the selective situations examined here. Because the normal situation was one of chronic stress (with the background of the intifada), it seems that the element of acuteness, introduced by the assassination of Rabin, had no additional effect. These results, however, reflect only one aspect of the comparison between the two states. The more significant findings of this study reside in the different magnitude of variance explanation at each state: The moderators of stress were more significant in attenuating the reactions of the chronic-without-acute-stress state than of the chronic-with-acute-stress state. The relatively high explained variance of state anxiety and psychological distress that I found in the chronic-without-acute-stress situation did not occur in the acute state. These findings support my hypotheses regarding the explanatory power of moderating factors. As I suggested earlier, a buffering effect may be more likely to occur in acute stress situations-the more acute the state, the less the explanatory power of the moderators. The results of this study show a significant decrease in the explained variance in the chronic-with-acute-stress state and thus support this kind of distinction. I found a similar and even more dramatic tendency in a longitudinal research, mentioned earlier, on adolescents who experienced an acute stress state before the evacuation of Sinai settlements (Sagy & Antonovsky, 1986). In that study, the explained variance increased from 0% in the acute state to 38%) in the chronic situation. In sum, the findings of this study support, first and foremost, the value of developing a model that recognizes the different types of stress situations in the research of moderating factors explaining stress reactions. The findings hint at an important distinction between chronic-with- and without-acute-stress states, that has received little attention in past research. Moreover, these findings support the hypothesis that in a chronic-with-acute-stress situation, the variables of individual psychology have lower explanatory power than in a chronic-without-acute-stress situation. These results suggest that research in the area of stress reactions should not focus only on the personal resources as moderators in an acute stress state. Despite these theoretically suggestive results, the generalizability of this study is limited because of the relatively small samples and the selective and not strictly defined situations examined here. Moreover, causal relationships cannot be inferred from the findings of this report, which is cross-sectional in nature. However, because much stress research still involves students and relatively non-stressed samples, research conducted in the field is of special interest. "An investigator needs only go where the work is, look, listen and record," wrote Kurt Lewin some 5 decades ago (Marrow, 1969, p. 15). To a limited extent, I have attempted to answer this call. Although the results of this study may reflect only the special, unique situations examined here, they raise theoretical issues that should be investigated in a wider spectrum of stress situations. Original manuscript received February 6, 2001 Final revision received September 21, 2001 Manuscript accepted October 12, 2001 1. At the time of this study (1994-1995), the area of the West Bank under Israel's control was populated by approximately 800,000 Palestinians and close to 130,000 Israelis, a large percentage of whom belonged to the Zionist religious sector. Israeli settlements are scattered over a large expanse of territory. Most of the settlements are small, containing up to 1,500 inhabitants, and these were the source of our sample. 2. Intifada is the Arabic word for uprising and refers to the sudden outburst of Palestinian resistance to the Israeli military occupation, which was the outcome of the Six Days War in 1967. TABLE 1 Means, Standard Deviations, and t Test Results, for Each Stress State Legend for Chart: A - Variable B - Chronic-without-acute stress (n = 266): M C - Chronic-without-acute stress (n = 266): SD D - Chronic-with-acute stress (n = 448): M E - Chronic-with-acute stress (n = 448): SD F - t A B C D E F State anxiety 2.24 .57 2.21 .60 .68 Psychological distress 2.18 .53 2.11 .50 1.67 Trait anxiety 2.02 .45 1.97 .41 1.72 Sense of coherence 4.32 .87 4.47 .77 2.27[1] Cognitive appraisal 4.96 1.09 4.84 1.02 .71 Sense of family coherence 4.49 .84 4.76 .80 4.17[3] Sense of community 2.90 .50 3.23 .49 8.61[3] 1 p .05. 3 p .001. TABLE 2 Stepwise Multiple Regression Results for State Anxiety for Each Stress State Legend for Chart: A - Variable B - Chronic-without-acute stress (n = 266): C - Chronic-without-acute stress (n = 266): R change D - Chronic-with-acute stress (n = 448): E - Chronic-with-acute stress (n = 448): R change A B C D E Trait anxiety .39 .24[3] .34 .16[3] Sense of coherence .00 - .05 .01[1] Cognitive appraisal .11 .02[1] .06 - Family coherence .10 .01[1] .01 - Sense of community .13 .02[2] .08 - Gender .09 .01[1] .07 - R - .30 - .17 1 p .05. 2 p .01. 3 p .001. 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The context of adolescents' chronic life stress. American Journal of Community Psychology, 21, 397-420. Walker, A. J. (1985). Reconceptualizing family stress. Journal of Marriage and the Family, 47, 827-837. Zeidner, M., Klingman, A., & Itzkovitz, R. (1993). Anxiety, control, social support and coping under threat of missile attack: A semi-projective assessment. Journal of Personality Assessment, 60, 435-457. By Shifra Sagy, Department of Education Ben-Gurion University of the Negev, Israel Address correspondence to Shifra Sagy, Department of Education, Ben-Gurion University of the Negev, P.O. Box 653, Beer-Sheva 84105, Israel; shifra@bgumail. bgu.ac.il (e-mail). Title: A Meta-Analysis of Massage Therapy Research , By: Moyer, Christopher A., Rounds, James, Hannum, James W., Psychological Bulletin, 00332909, January 1, 2004, Vol. 130, Issue 1 Acknowledgment: We wish to thank Sue Duval, Carol Webber, and the Interlibrary Borrowing Staff at the Illinois Research and Reference Center, University of Illinois at Urbana-Champaign, for their invaluable contributions to this project. Patrick Armstrong and James Wardrop also contributed. Correspondence concerning this article should be addressed to: James Rounds, Department of Educational Psychology, University of Illinois at Urbana-Champaign, 1310 South Sixth Street, Champaign, IL, 61820-6990. Electronic mail may be sent to: jrounds@uiuc.edu Massage therapy (MT), the manual manipulation of soft tissue intended to promote health and well-being, has a history extending back several thousand years. Recorded in writing as far back as 2000 B.C. (Fritz, 2000, p. 13), massage was a part of many ancient cultures including that of the Chinese, Egyptians, Greeks, Hindus, Japanese, and Romans, and was often considered to be a medicinal practice (Elton, Stanley, & Burrows, 1983, p. 275). The Greek physician Hippocrates (460-377 B.C.) advocated rubbing as a treatment for stiffness; later, the physicians Celsus (25 B.C.-A.D. 50) and Galen (A.D. 129-199) wrote extensively on the medicinal and therapeutic value of massage and related techniques such as anointing, bathing, and exercise. However, in Western cultures, the association between massage and medicine eventually diminished as Greco-Roman traditions were abandoned. Although the practice of massage continued as a folk medicine treatment during the Middle Ages, its adoption by the common people served to separate it from the scientific and medical milieu, and in this way, massage fell out of favor with the medical establishment (Fritz, 2000; Salvo, 1999). This schism continued during the early part of the 19th century, during which time Per Henrik Ling developed Swedish massage, the basis of many modern forms of MT. Ling, who was not trained in medicine, applied his ideas and techniques to the treatment of disease, a practice that met opposition from the Swedish medical community. Despite this resistance, Ling gained support from his influential clients and was eventually able to teach his system to physicians, who adopted his techniques and shared them with like-minded colleagues. Soon after, in the later part of the century, the Dutch physician Johann Mezger was successful in reintroducing massage to the scientific community, presenting it to his colleagues as a medical treatment, and codifying some of its elements with terms that are still in use today (Fritz, 2000, pp. 16-17; Salvo, 1999, pp. 9-11). Interest in MT has continued to grow among the scientific community and consumers alike. Currently, in the United States, MT is one of the fastest growing sectors of the expanding complementary and alternative medical therapy movement. Visits to massage therapists increased 36% between 1990 and 1997, with consumers now spending between $4 and $6 billion annually for MT (Eisenberg et al., 1998), in pursuit of benefits such as improved circulation, relaxation, feelings of well-being, and reductions in anxiety and pain, all of which are endorsed as benefits of MT by the American Massage Therapy Association (AMTA, 1999b). At the same time, numerous studies across several fields including psychology, medicine, nursing, and kinesiology support MT's therapeutic value. Field (1998) reviewed the effectiveness of MT in treating symptoms associated with a host of clinical conditions, including pregnancy, labor, burn treatment, postoperative pain, juvenile rheumatoid arthritis, fibromyalgia, back pain, migraine headache, multiple sclerosis, spinal cord injury, autism, attention-deficit/hyperactivity disorder, posttraumatic stress disorder, eating disorders, chronic fatigue, depression, diabetes, asthma, HIV, and breast cancer. In addition to the beneficial outcomes that were unique to these specific conditions, Field proposed a set of common findings by indicating that "across studies, decreases were noted in anxiety, depression, [and] stress hormones (cortisol)" (p. 1278). Even the popular press has picked up on the increase in MT practice and research. A feature in Time suggested that MT is on the rise, in part, because of "people's greater awareness of the effect stress has on health" (Luscombe, 2002, p. 49). It is also reported that the National Institutes of Health have begun funding MT research, and that the White House Commission on Complementary and Alternative Medicine Policy (2002) has called for more research and public education on MT. The Time article concludes by noting that the Commission's chairman, physician James Gordon, indicates that MT is known to be effective in decreasing anxiety, reducing pain, and improving mood (Luscombe, 2002, p. 50). If MT can be effective in the ways indicated by the AMTA, Field, and Gordon, it would represent a therapy of interest to a variety of fields. One can imagine its use expanding beyond the private practices of massage therapists, and extending to places such as hospitals, nursing homes, psychological treatment centers, sports performance clinics, and workplaces. In addition, MT could establish itself as a treatment supported by insurance carriers and health maintenance organizations. These are, in fact, trends that are already occurring in a limited way. Nevertheless, for these trends to continue (indeed, to determine if they even should continue), what is needed is a more rigorous and quantitative examination of MT's effectiveness than that which currently exists. There are three meta-analyses of MT research, but each is very limited in scope. Ottenbacher et al. (1987) quantified 19 studies that examined the effects of tactile stimulation on infants and young children, and found statistically significant beneficial outcomes for five of the six categories examined: motor-reflex, cognitive-language, social-personal, physiological, and overall development. Labyak and Metzger (1997) examined nine studies that sought to measure the effect of effleurage back massage on physiological indicators of relaxation, and concluded that this form of MT was effective in promoting relaxation. However, interpretation of this finding is made problematic by their decision to include within-groups designs in the analysis, leaving open the possibility that the observed effects could be attributable to spontaneous recovery, placebo effect, or statistical regression (Field, 1998, p. 1270), and by the fact that only limited information is provided on the individual studies and their effect sizes. Ernst (1998) reviewed seven studies that assessed the effect of postexercise MT as a treatment for delayed-onset muscle soreness, reaching the tentative conclusion that MT may be a promising treatment, a conclusion that is hampered, like that of Labyak and Metzger, by a lack of sufficient statistics reported in the review itself. No study to date has quantitatively reviewed the range of commonly reported MT effects in physically mature individuals. The present study is intended to address this problem. By means of a more exhaustive literature search than those conducted in previous reviews, we seek to unite the spectrum of MT studies that appear in a range of scientific disciplines including psychology, medicine, nursing, and kinesiology. In addition, by limiting inclusion to studies that use a between-groups design with random assignment of participants, the present study more accurately measures MT's true effects than reviews that have included other designs that are open to bias and do not permit strong causal claims. Overview of MT In modern practice, MT is not a single technique, or even a single set of techniques. Rather, it is a broad heading for a range of approaches that share common characteristics, a fact that is evident in definitions provided by the AMTA. The AMTA defines massage as "manual soft tissue manipulation [that] includes holding, causing movement, and/or applying pressure to the body," and massage therapy as "a profession in which the practitioner applies manual techniques, and may apply adjunctive therapies, with the intention of positively affecting the health and well-being of the client" (AMTA, 1999a). Clearly, these definitions provide latitude for a variety of approaches to exist under the rubric of MT. In one instance, MT may consist of a treatment lasting an hour or more, with long, firm strokes applied to numerous sites of the client's body, while that client lies partially disrobed on a specially designed table in a private clinic. In another instance, an MT client may receive a 10-min treatment of kneading focused on the shoulders while seated fully clothed in a specially designed chair, in a public space such as a shopping mall or workplace. Duration of treatment, types of touch and strokes administered, the sites of the body where treatment is applied, the apparatus used to facilitate treatment, and where that treatment takes place can all vary considerably. In addition, there is also considerable variability in the explanatory mechanisms that massage therapists (and recipients) subscribe to. Finally, the outcomes being pursued may vary widely; whereas one client may undergo MT in the hopes of obtaining relief from backache, another may receive MT to reduce emotional tension. In the present study, we define MT as the manual manipulation of soft tissue intended to promote health and well-being, a definition that encompasses the diverse nature of this form of treatment. Though MT can take a variety of forms, the common element that allows these forms to be grouped together is their use of interpersonal touch in the form of soft tissue manipulation. This element forms the basis for the predominant theories encountered in MT research that are concerned with how it may provide the benefits of reductions in anxiety, depression, stress hormones, and pain. In several of these theories, the pressure applied to the body by means of MT is thought to trigger certain physiological responses that ultimately result in beneficial outcomes. It should be noted, however, that the pressure required by these theories has not been quantified, nor do existing clinical studies of MT routinely report on the amount of pressure administered in a way that would permit precise replication. Although at least one study utilizing infants as subjects observed differential effects in terms of weight gain for firm versus light strokes (Scafidi et al., 1986), no study to date has examined pressure as an independent variable with a sample of physically mature participants. MT Theories Unfortunately, there has been little emphasis on theory in the MT literature, with many researchers choosing to emphasize their predictions and results without testing, or in some cases even discussing, possible explanatory mechanisms. In other instances, theories are offered, but important details are omitted. Researchers have rarely specified such things as whether a theory explains immediate versus lasting effects, or if activation of a theoretical mechanism requires a course of treatment as opposed to a single application. For the theories that follow, we suggest that only the first one, the gate control theory of pain reduction, is logically limited to providing an immediate effect. Each of the remaining theories, to various degrees, could potentially offer immediate or lasting effects, or provide benefits that accumulate over a course of treatment. However, it must be noted that these are strictly suppositions and have not yet been tested. The order in which these theories are presented reflects their frequency in the literature. Those that appear first are most frequently cited. Gate Control Theory of Pain Reduction Melzack and Wall (1965) theorized that the experience of pain can be reduced by competing stimuli such as pressure or cold, because of the fact that these stimuli travel along faster nervous system pathways than pain. In this way, MT performed with sufficient pressure would create a stimulus that interferes with the transmission of the pain stimuli to the brain, effectively "closing the gate" to the reception of pain before it can be processed (e.g., Barbour, McGuire, & Kirchhoff, 1986; Field, 1998; Malkin, 1994). This notion, that MT may have an analgesic effect consistent with gate control theory, appears in the literature more than any other theory pertaining to MT. Promotion of Parasympathetic Activity MT may provide its benefits by shifting the autonomic nervous system (ANS) from a state of sympathetic response to a state of parasympathetic response. A sympathetic response of the ANS occurs as an individual's body prepares to mobilize or defend itself when faced with a threat or challenge, and is associated with increased cardiovascular activity, an increase in stress hormones, and feelings of tension. Conversely, the parasympathetic response occurs when an individual's body is at rest and not faced with a threat, or is recovering from a threat that has since passed, and is associated with decreased cardiovascular activity, a decrease in stress hormones, and feelings of calmness and well-being (Sarafino, 2002, p. 40). The pressure applied during MT may stimulate vagal activity (Field, 1998, pp. 1273, 1276-1277), which in turn leads to a reduction of stress hormones and physiological arousal, and a subsequent parasympathetic response of the ANS (e.g., Ferrell-Torry & Glick, 1993; Hulme, Waterman, & Hillier, 1999; Schachner, Field, Hernandez-Reif, Duarte, & Krasnegor, 1998). By stimulating a parasympathetic response through physiological means, MT may promote reductions in anxiety, depression, and pain that are consistent with a state of calmness. This same mechanism may also be responsible for several condition-specific benefits resulting from MT, such as increased immune system response in HIV-positive individuals (Diego et al., 2001), or improved functioning during a test of mental performance, in which study participants receiving MT also displayed changes in electroencephalograph pattern consistent with increased relaxation and alertness (Field, Ironson, et al., 1996). However, support for this theory is not universal, and it has even been suggested that MT may promote a sympathetic response of the ANS (e.g., Barr & Taslitz, 1970). Influence on Body Chemistry Two studies have linked MT with increased levels of serotonin (Field, Grizzle, Scafidi, & Schanberg, 1996; Ironson et al., 1996), which "may inhibit the transmission of noxious nerve signals to the brain" (Field, 1998, p. 1274). Others have suggested that manipulations such as rubbing, or applying pressure, may stimulate a release of endorphins into the bloodstream (Andersson & Lundeberg, 1995; Oumeish, 1998). In these ways, MT may provide pain relief or feelings of well-being by influencing the body chemistry of the recipient. Mechanical Effects Articles concerned with sports performance, exercise recovery, and injury management highlight the possibility that MT may speed healing and reduce pain by mechanical means. The manipulations and pressure of MT may break down subcutaneous adhesions and prevent fibrosis (Donnelly & Wilton, 2002, p. 5) and promote circulation of blood and lymph (Fritz, 2000, pp. 475-478), processes that may lead to reductions in pain associated with injury or strenuous exercise. However, as a group, studies concerned with measuring MT's effect on circulation have generated inconsistent results (Tiidus, 1999). Promotion of Restorative Sleep Individuals deprived of deep sleep may experience changes in body chemistry that lead to increases in pain. In the absence of deep sleep, levels of substance P increase and levels of somatostatin decrease, and both of these changes have been linked with the experience of pain (Sunshine et al., 1996). Sunshine et al. (1996) concluded that MT may have promoted deeper, less disturbed sleep in a sample of fibromyalgia sufferers who experienced a reduction in pain during the course of treatment. Chen, Lin, Wu, and Lin (1999) reached the conclusion that acupressure treatment may have been effective in improving sleep quality in a sample of elderly residents at an assisted-living facility. In this way, MT may reduce pain indirectly by promoting restorative sleep. Interpersonal Attention The five theories previously described, the majority of which attempt to explain the role MT may play in reducing pain, are the only ones that appear consistently in the scientific literature. However, the element of interpersonal attention that may be present in MT must also be considered. It is occasionally noted that some portion of MT effects may result from the interpersonal attention that the recipient experiences, as opposed to resulting entirely from the activation of physiological mechanisms (Field, 1998, p. 1270; Malkin, 1994). However, although this possible effect of interpersonal attention is acknowledged in the research literature, it is almost universally treated as a nuisance variable, and comparison treatments are selected in such a way that different groups receive the same amount of attention. In this way it is believed that any benefits demonstrated by the MT group that exceed those of the comparison group can be attributed to a specific ingredient of MT, specifically interpersonal touch in the form of soft tissue manipulation. Although many studies, including all of those in the present analysis, attempt to control for interpersonal attention, no study to date has examined it as an independent variable. As such, the role that interpersonal attention may play in MT effects is not well understood. Effects The present study examines both psychological and physiological effects resulting from MT. The psychological effects correspond with those suggested by Field and Gordon and endorsed by the AMTA, and are also of interest because MT can be considered a novel way of treating these conditions, which are more routinely addressed by means of psychotherapy or pharmaceuticals. The physiological effects nominate themselves because MT is a physical therapy. We contend that MT effects can also be divided into single-dose effects and multiple-dose effects. Single-dose effects include MT's influence on states, either psychological or physiological, that are transient in nature and that might reasonably be expected to be influenced by a single session of MT. These include state anxiety, negative mood, pain assessed immediately following treatment, heart rate, blood pressure, and cortisol level. Multiple-dose effects are restricted to MT's influence on variables that are typically considered to be more enduring, or that would likely be influenced only by a series of MT sessions performed over a period of time, as opposed to a single dose. These variables include trait anxiety and depression, as well as pain when it is assessed at a time considerably after treatment has ended. Frequently, researchers elect to examine both single-dose effects and multiple-dose effects within the same study. Diego et al. (2001) is one such study, in which treatment group participants received MT twice weekly for a period of 12 weeks, and comparison group participants engaged in progressive muscle relaxation (PMR) according to the same schedule. Assessments of state anxiety were made immediately prior to, and immediately following, both the first and last sessions of MT or PMR in the study. Depression, a condition expected to be more resistant to change, was assessed prior to the first session of MT or PMR, and not again until after the 24th and last sessions of either treatment. Many studies, particularly those conducted by the Touch Research Institute, use such a design in order to examine both single- and multiple-dose effects. It must be noted that the terms single-dose effect and multiple-dose effect are not yet in common usage. Research into MT generated by the Touch Research Institute typically uses the terms short-term effect and long-term effect to make a similar distinction, but no consistent terminology has been used among other MT researchers. The decision to use this terminology is motivated by the desire to prevent any confusion that may arise with regard to how long an effect may last following the termination of treatment. Very few studies have attempted to examine whether any MT effects may last beyond the final day on which a participant receives treatment, making the use of the term long-term effect potentially confusing. All effects in the present study, with the exception of one outcome variable, were assessed on the same day that a treatment took place. The exception is MT's effect on delayed assessment of pain, for which assessments took place at various time periods significantly after treatment had been discontinued. Presently, pain appears to be the only variable in the MT literature that has been assessed in this way; the possibility that MT may have enduring effects on other variables has gone essentially unaddressed. Single-Dose Effects State anxiety State anxiety is a momentary emotional reaction consisting of apprehension, tension, worry, and heightened ANS activity. Because state anxiety can be understood as a reaction to one's condition or environment, the intensity and duration of such a state is determined by an individual's perception of a situation as threatening (Spielberger, 1972, p. 489). Many of the samples used in MT research are drawn from populations experiencing serious and chronic health problems that can lead to feelings of anxiety (Hughes, 1987; Popkin, Callies, Lentz, Cohen & Sutherland, 1988). If MT is effective in reducing state anxiety, it may be doubly valuable to such patient populations, in that it could both improve subjective well-being and promote physical health. In physically healthy populations, the improvement in subjective well-being alone may be the primary benefit of a reduction in state anxiety. Negative mood Some studies have examined the effect of MT on mood, which may be defined as "transient episodes of feeling or affect" (Watson, 2000, p. 4). Although the primary studies do not specify a model for mood, virtually all the studies appear to be concerned with MT's ability to bring about a reduction of negative affect rather than an increase in positive affect. Pain Several studies have examined MT's immediate effect on pain, the unpleasant emotional and sensory experience that is associated with actual or potential tissue damage (Merskey et al., 1979). The sources of pain in the primary studies are diverse, and include conditions such as headache (Hernandez-Reif, Dieter, Field, Swerdlow, & Diego, 1998), backache (Hernandez-Reif, Field, Krasnegor, & Theakston, 2001), and labor pain (Hemenway, 1993) among others. Cortisol Some MT studies have attempted to measure a change in participants' cortisol levels. Cortisol is a stress hormone associated with the sympathetic response of the ANS (Field, 1998). MT, a therapy commonly thought of as relaxing, is expected to reduce cortisol levels, a finding that would be consistent with facilitating a parasympathetic response of the ANS (e.g., Field et al., 1992; Ironson et al., 1996). Blood pressure A handful of studies have examined MT's effect on blood pressure. Although predictions are not always offered, most commonly MT is expected to reduce blood pressure consistent with a parasympathetic response of the ANS (Hernandez-Reif, Field, et al., 2000; Okvat, Oz, Ting, & Namerow, 2002). Heart rate A few studies examining MT have attempted to measure its physiological effects in terms of heart rate. Researchers have not always offered clear predictions for this variable (Barr & Taslitz, 1970), but in cases where a prediction is evident, most often a decrease in heart rate is predicted, consistent with a parasympathetic response of the ANS (Cottingham, Porges, & Richmond, 1988; Okvat et al., 2002). Nevertheless, some researchers have noted that the opposite effect could be observed in cases in which MT was a novel experience for research participants (Reed & Held, 1988, p. 1232). Multiple-Dose Effects Trait anxiety Several studies have examined MT's potential to reduce trait anxiety, the "relatively stable individual differences in anxiety proneness as a personality trait" (Spielberger, 1972, p. 482). In contrast with the transient and situation-specific nature of state anxiety, trait anxiety is a dispositional, internalized proneness to be anxious (Phillips, Martin, & Meyers, 1972, p. 412). Persons with high levels of trait anxiety tend to perceive the world as more dangerous or threatening, and experience anxiety states more frequently and with greater intensity than those with lower levels of trait anxiety (Spielberger, 1972, p. 482). Depression Ingram and Siegle (2002) noted that, in the course of research, the concept of depression has been defined many different ways, including as a mood state, a symptom, a syndrome, a mood disorder, and a disease. In the current meta-analysis, studies included in this category have been chosen on the basis of their utilization of a measure believed to capture something beyond "ordinary unhappiness" or a "sad mood," symptoms that would more accurately belong to the previously discussed category of negative mood. Subclinical depression, likely the best description of the type of depression most often assessed in MT research, consists of the aforementioned symptoms combined with symptoms such as mild to moderate levels of motivational and cognitive deficits, vegetative signs, and disruptions in interpersonal relationships (Ingram & Siegle, 2002, p. 90). Delayed assessment of pain A few studies have assessed participants' experience of pain at one or more time points significantly after a course of treatment has ended. The majority of these studies have done so at intervals that range from a few days to 6 weeks (Cen, 2000; Dyson-Hudson, Shiflett, Kirshblum, Bowen, & Druin, 2001; Preyde, 2000; Shulman & Jones, 1996), although one study included an assessment that took place 42 weeks after treatment ended (Cherkin et al., 2001). Because of the small number of studies, and the range of times at which delayed assessments were made, it is not expected that the present study will be able to determine precisely how long an analgesic effect resulting from MT lasts, or the rate at which such an effect decays; rather, the aim is simply to examine whether or not MT may have a lasting analgesic effect. Moderators A number of potentially interesting moderator variables have gone unexamined in MT research. Primary studies, for instance, have neglected to examine whether the length of MT sessions, or characteristics of the therapist and the recipient, influence the magnitude of MT effects. Similarly, only a few studies have used more than one comparison group, making it difficult to determine whether the type of treatment to which MT is compared may moderate its effects. Although within-study examinations of such moderators would permit stronger inferences to be made, their importance can be explored in the present study by means of between-study comparisons. In addition, the present study also examines a potential moderator that cannot be examined within an individual study, that of a laboratory effect. Minutes of MT per session It is common for treatment studies in medicine (e.g., Bollini, Pampallona, Tibaldi, Kupelnick, & Munizza, 1999; Yyldyz & Sachs, 2001) and in psychotherapy (e.g., Bierenbaum, Nichols, & Schwartz, 1976; Turner, Valtierra, Talken, Miller, & DeAnda, 1996) to examine dosage as an independent variable. However, no studies concerned with MT have done so. It is not known whether there is a minimal amount, in terms of minutes of MT administered per session, required to produce benefits, nor is it known whether there is an optimal amount of MT that produces benefits most efficiently. Fortunately, the studies that exist vary considerably in the amount of MT administered to participants in each session, from as little as 5 min (Fraser & Kerr, 1993; Wendler, 1999) to as much as an hour (Levin, 1990). By examining the relationship between the magnitude of effects generated and the amount of MT administered per session, the present study aims to determine whether there are minimum or optimum dosages of MT. Mean age of participants Although MT research has been performed on samples with a variety of age ranges, no study has sought to determine whether MT offers effects of differing magnitude to participants who differ in age. The present study examines whether there is a relationship between the mean age of the participants in a study and the magnitude of effects. Gender of participants Only one study to date, using a very small sample, has examined whether MT effects might vary according to the gender of the recipients (Weinrich & Weinrich, 1990). The present study more powerfully examines the possibility that the gender of the recipient might moderate MT effects by examining whether study outcomes vary according to gender. Type of comparison treatment In discussing the research findings for a different treatment modality (psychotherapy), Wampold (2001) noted that there is a distinction that must be made between absolute and relative efficacy. Absolute efficacy "refers to the effects of treatment vis--vis no treatment and accordingly is best addressed by a research design where treated participants are contrasted with untreated participants" (Wampold, 2001, p. 59). By contrast, relative efficacy "is typically investigated by comparing the outcomes of two treatments" when one wishes to determine which, if either, is superior (Wampold, 2001, p. 73). Clearly, the type of efficacy one wishes to measure plays an important part in determining what will be an appropriate choice for a comparison, as a study designed to measure one does not necessarily measure the other. This issue of distinguishing absolute efficacy (does MT work better than no treatment at all) from relative efficacy (does MT work better than a specific alternative treatment, such as PMR) has not been made explicit enough in MT research. However, a wide variety of comparison treatments have been used in MT research, some of which resemble a wait-list (no treatment) condition, whereas others use active treatments (such as the aforementioned PMR, or chiropractic care) as a point of comparison, or placebo-type comparison treatments that are meant to account for the effect of receiving attention (such as transcutaneous electrical stimulation performed with a machine that is not delivering any current to the participant). Logically, if MT has any effect whatsoever, we expect the MT effects that result from comparison with a no-treatment condition would be larger than those that result from comparing MT to any treatment condition, including so-called placebo conditions in which the participants receive no viable treatment. Combining the results of such different studies without attempting to account for these different comparison points could be problematic. For this reason, we have divided the comparison treatments in the primary studies, when possible, as belonging to either wait-list equivalent or active/placebo categories. The wait-list equivalent category consists of comparison treatments that most closely resemble having received no treatment, and includes wait-list controls, standard care (in studies where all participants had a medical condition and continued to receive care for that condition regardless of group assignment), rest, reading, or a work break. The active/placebo category consists of all other comparison treatments, which are grouped according to the expectation that each could reasonably be expected to have some effect, including the possibility of a placebo effect. These include treatments such as PMR, acupuncture, chiropractic care, and various forms of attention, among others. Studies that used multiple comparison groups that could not be included together within a single category were not included in either category. Therapist training Treatment research in fields such as psychology (Pinquart & Soerensen, 2001; Weisz, Weiss, Alicke, & Klotz, 1987) and medicine (Lin et al., 1997; Tiemens et al., 1999) sometimes examines the existence of training effects to determine whether practitioners with greater amounts of training provide greater benefit to those being treated. No MT research, however, has examined the training of the massage therapist as an independent variable. However, the studies that do exist vary in regard to who performs MT on participants. The majority of studies use one or more fully trained and licensed massage therapists. Others utilize a layperson with only minimal training in providing massage, usually just enough to facilitate the study (e.g., Fischer, Bianculli, Sehdev, & Hediger, 2000; Weinrich & Weinrich, 1990; Wendler, 1999). By contrasting the results of studies that used a fully trained massage therapist with those that used a layperson to provide treatment, the present meta-analysis may be able to determine whether a therapist's training plays an important role in providing MT benefits. Laboratory effect Much of the research in this area, and especially the most recent research, is the product of a single laboratory, the Touch Research Institute (Field, 1998). Because this one source is responsible for a large proportion of MT studies, it is important to determine whether the results coming from this research group differ in a significant way from those of other researchers. If a difference is found, it would be important to examine more closely what factors contribute to that difference. Predictions MT is expected to promote significant and desirable reductions for each of the following variables, consistent with the existing explanatory theories outlined above: state anxiety, negative mood, pain (immediate and delayed assessment), cortisol, heart rate, blood pressure, trait anxiety, and depression. It is expected that greater reductions in these variables will be associated with higher doses of MT, in the form of minutes of MT administered per session, a relationship one would expect to observe if MT is a viable treatment. MT effects are not expected to vary according to the age or gender of participants. It is expected that MT effects generated from studies using wait-list equivalent comparison treatments will be larger than those generated from studies with active/placebo comparison treatments. Finally, no prediction is made concerning therapist training, or the existence of a laboratory effect. Method Literature Search and Criteria for Inclusion A literature search was performed by Christopher A. Moyer and a graduate student in library and information sciences hired as a research assistant. The PsycINFO, MEDLINE, CINAHL, SPORT Discus, and Dissertation Abstracts International databases were searched using the following key words: massage, massotherapy, acupressure (and accupressure), applied kinesiology, bodywork, musculoskeletal manipulation, reflexology, relaxation techniques, Rolfing, Touch Research Institute, and Trager. Author searches were conducted within the same databases for the following authors associated with MT research: Burman, I.; Field, T.; Hart, S.; Hernandez-Reif, M.; Kuhn, C.; Peck, M.; Quintino, O.; Schanberg, S.; Taylor, S.; Theakston, H.; Weinrich, M.; and Weinrich, S. The Internet Web sites of the AMTA (www.amtamassage.org), the AMTA Foundation (www.amtafoundation.org), and the Touch Research Institute (http://www.miami.edu/touch-research/) were inspected for references, and the Touch Research Institute was also contacted directly to request unpublished data. The reference lists of all studies located by these means were then manually searched to yield additional studies. All studies were inspected to ensure that they examined a form of MT consistent with the present study's operational definition, in which MT is defined as the manual manipulation of soft tissue intended to promote health and well-being. Studies were limited to those that administered MT to human participants other than infants, and that reported results in English. Studies concerned with chiropractic, heat therapy, hydrotherapy, passive motion, or progressive relaxation treatments were not included, unless the study also included an MT group. Studies examining therapeutic touch, a nursing intervention distinct from MT (in that it does not actually require physical contact to occur), were also excluded unless they also had an MT group. Several studies used more than two groups; in these cases, study results were combined in order to yield a between-groups comparison of all subjects receiving MT versus all subjects receiving non-MT treatments. Studies concerned with ice massage, participants performing self-massage, or massage performed with the aid of mechanical devices were excluded, as were studies that only included MT as part of a combination treatment (e.g., MT combined with exercise and movement therapy). MT administered with scented oil or MT administered with background music were not considered to be combination treatments, as these are common elements of MT in clinical practice, and studies using such treatment were included. Studies that did not explicitly label a treatment as "massage" or as "massage therapy," but used a treatment that fit the authors' operational definition of MT, were included. These criteria yielded 144 studies concerned with outcomes of MT. Each study was reviewed independently by Christopher A. Moyer and James Rounds for possible inclusion in the meta-analysis. Studies were examined to ensure that they (a) compared an MT group with one or more non-MT control groups, (b) used random assignment to groups, and (c) reported sufficient data for a between-groups effect size to be generated on at least one dependent variable of interest. These three criteria accounted for approximately equal proportions of excluded studies. The first two inclusion criteria were necessary to ensure that effects were a result of treatment. When participants in MT research serve as their own controls (e.g., Bauer & Dracup, 1987; Fakouri & Jones, 1987) there is no way to know whether effects are attributable to treatment or are instead the result of spontaneous recovery, placebo effect, or statistical regression (Field, 1998, p. 1270). Similarly, random assignment of participants to groups is necessary to control for the possibility of selection effects. Glaser (1990) is an example of a study that is threatened in this way. Because treatment participants were previously enrolled in an MT program, and were compared with a group of participants who were not enrolled, it is likely that these groups differed in their predisposition toward MT in a way that could affect results. When studies met all criteria apart from reporting sufficient data for calculating between-groups effects, and contact information was available, study authors were contacted in an attempt to obtain the necessary data. Specifically, there were seven studies from the Touch Research Institute for which this was the case (Field et al., 1999; Field et al., 2000; Field, Peck, et al., 1998; Field, Quintino, Henteleff, Wells-Keife, & Delvecchio-Feinberg, 1997; Field, Schanberg, et al., 1998; Field, Sunshine, et al., 1997; Sunshine et al., 1996). Upon our request, we were informed that the data needed from these studies (standard deviations) were no longer available. For this reason, these studies could not be included in the meta-analysis. Interrater agreement for the inclusion process was 93%. The 10 studies for which there was initial disagreement, which occurred most frequently as a result of uncertainty regarding random assignment, were then reviewed jointly, with the subsequent decision made to exclude 8 of these. This resulted in a total of 37 studies meeting the inclusion criteria. Variables and Measures The nine variables for which effect sizes were calculated, and the instruments used to assess them, are as follows: State anxiety Fifteen of the 21 studies examining MT's effect on anxiety used the state anxiety portion of the State-Trait Anxiety Inventory (Spielberger, 1983). Five studies used a visual analogue scale, and one study used an investigator-constructed measure. Negative mood Seven of eight studies assessing negative mood used the Profile of Mood States (McNair, Lorr, & Droppleman, 1971). The remaining study used a visual analogue scale. Immediate assessment of pain Eight of the 15 studies assessing pain immediately following treatment used visual analogue scales alone. Two studies used a visual analogue scale in conjunction with either the Short-Form McGill Pain Questionnaire (Melzack, 1987) or the Menstrual Distress Questionnaire (Moos, 1968). Two studies used investigator-constructed measures, and the remaining studies relied on the Neck Pain Questionnaire (Leak et al., 1994), the revised Oswestry Low Back Pain Questionnaire (Hudson-Cook, Tomes-Nicholson, & Breen, 1989), or behavioral observation. Cortisol Of the seven studies that assessed cortisol levels, four relied on salivary samples, two on urinary samples, and one on a blood sample. In each case, samples were collected 20 min after the application of MT, to account for the fact that bodily cortisol levels are indicative of responses occurring 20 min prior to sampling (Field, Hernandez-Reif, Quintino, Schanberg, & Kuhn, 1998, p. 233). Blood pressure Five studies offer data pertaining to participants' blood pressure, assessed by means of a sphygmomanometer. Measures of diastolic and systolic blood pressure were combined into one effect size, because only a few studies report on this variable, and differ in regard to which values they report. Heart rate Of the six studies that assessed the effect of MT on heart rate, four used some type of automatic monitoring device, and one study indicated that pulse was assessed manually. One study did not specify the means by which heart rate was assessed. Trait anxiety Three studies of the seven assessing trait anxiety used the Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1983). One study combined the Conners Teacher Rating Scale (Conners, 1969) and the Revised Children's Manifest Anxiety Scale (Reynolds & Richmond, 1985). The three remaining studies used either the Beck Anxiety Inventory (Beck, Brown, Epstein, & Steer, 1988), the trait portion of the State-Trait Anxiety Inventory (Spielberger, 1983), or an investigator-constructed measure. Depression Five of the 10 studies assessing depression utilized the Center for Epidemiological Studies-Depression Scale (CES-D; Radloff, 1977). Two used the SCL-90-R, and one combined the CES-D and the SCL-90-R. The remaining studies used either the Children's Depression Inventory-Short Form (Kovacs, 1992) or an investigator-constructed measure. Delayed assessment of pain The five studies assessing pain at a time significantly after treatment ended relied on five different instruments. These were the Neck Pain Questionnaire (Leak et al., 1994), the Wheelchair User's Shoulder Pain Index (Curtis et al., 1995), the McGill Pain Questionnaire (Melzack, 1975), a visual analogue scale, and an investigator-constructed measure. Statistical Analysis Effect sizes Between-groups comparisons on variables of interest were converted to Hedges's g effect size. Hedges's g, calculated as (Group Mean 1 - Group Mean 2) pooled standard deviation, estimates the number of standard deviations by which the average member of a treatment group differs from the average member of a comparison group for a given outcome. In cases where a study used more than one measure to examine the same outcome variable, results of multiple measures were standardized and then averaged in order to result in one effect size per variable for any study. Similarly, if a study examined the immediate effects of more than one application of treatment, or examined the treatment effect on delayed assessments of pain at more than one time point, the results of the multiple applications or assessments were standardized and then averaged in order to calculate a single effect size for that study. Effect sizes were coded such that positive values, for any variable, indicate a more desirable outcome (e.g., a reduction in anxiety) for the participants who received MT. This process was done independently by both the first and second authors for the entire set of effect sizes; these initial results were then compared in order to determine agreement and eliminate errors. Agreement rate (AR) of initial calculations for the entire set of 84 effect sizes was 88%. Within outcome categories, the initial rates of agreement were as follows: state anxiety, AR = 86% (n = 21); negative mood, AR = 88% (n = 8); immediate assessment of pain, AR = 87% (n = 15); cortisol, AR = 86% (n = 7); blood pressure, AR = 60% (n = 5); heart rate, AR = 100% (n = 6); trait anxiety, AR = 86% (n = 7); depression, AR = 90% (n = 10); and delayed assessment of pain, AR = 60% (n = 5). When discrepancies were observed, calculations were reviewed jointly to correct errors, and a consensus was reached. Individual study effect sizes were then subjected to a correction for small sample bias, then weighted by their inverse variance and averaged to generate a mean effect size for each outcome variable (Lipsey & Wilson, 2001). An overall, nonspecific effect size was also calculated by averaging all effects within each study, and then calculating a weighted overall effect from these effect sizes. All effect sizes were calculated according to a random effects model of error estimation. Statistical significance of the mean effect sizes was assessed by calculating the 95% confidence interval (CI) for the population parameter. A significance level of.05 or better is inferred when zero is not contained within the CI. For effect sizes reaching statistical significance, the likelihood and possible influence of publication bias-the possibility that studies retrieved for the meta-analysis may not be a random sample of all studies actually conducted (Rosenthal, 1998)-was assessed by means of a trim and fill procedure (Duval & Tweedie, 2000), a nonparametric statistical technique of examining the symmetry and distribution of effect sizes plotted by inverse variance. This technique first estimates the number of studies that may be missing as a result of publication bias, and then allows a new, attenuated effect size to be calculated on the basis of the influence such studies would have if they were included in the analysis. The trim and fill procedure was performed with the Division of Vector-Borne Infectious Diseases library using the statistical computing program S-PLUS (Biggerstaff, 2000), which generates results for the three estimators of missing studies (L0, R0, and Q0) described by Duval and Tweedie (2000). Per the suggestion of these authors, the number of missing studies resulting from each estimator was considered before the eventual decision was made to report results according to the L0 andR0 estimators, which are considered preferable for most situations (Duval & Tweedie, 2000). Moderators As with effect sizes, moderator variable data were also coded independently by both the first and second authors. Agreement rate for initial coding of all moderator data across categories was 97% (n = 158). Within moderator variable categories, initial agreement rates were as follows: minutes per session, AR = 100% (n = 34); mean age, AR = 100% (n = 25); comparison type, AR = 97% (n = 34); training, AR = 87% (n = 31); and laboratory effect, AR = 100% (n = 34); proportion of female participants was coded only by the first author. The influence of moderator variables was assessed by performing a weighted regression analysis (Lipsey & Wilson, 2001) on the set of overall, nonspecific effect sizes for all studies. Results Table 1 lists the effect sizes (Hedges's g) for each study by outcome variable, as well as important study characteristics. The 37 studies included in the meta-analysis used a total of 1,802 participants, including 795 who received MT. Of the 1,007 participants who received a comparison treatment, 49% received one of the five treatments categorized as wait-list equivalent, and the remaining 51% received a treatment categorized as active/placebo. The mean number of participants for a study was 48.7 (SD = 49.0), and mean age of all participants was 40.6 years (SD = 13.9). Participants received an average of 21.7 min (SD = 14.0) of MT per application of treatment. Sixty-five percent of studies reported using a trained massage therapist (or therapists), 22% reported using a minimally trained person (or persons) to deliver treatment, and 14% did not indicate the level of training of the person (or persons) administering MT. Thirty-two percent of studies were conducted by the Touch Research Institute. Individual Study Characteristics and Effect Sizes (g) by Outcome Variable Table 2 graphically represents the distribution of overall study effect sizes by means of a stem and leaf plot. Table 3 lists the mean effect size for each outcome variable, as well as the number of studies contributing to the effect size, its 95% CI, and the results of trim and fill procedures applied to statistically significant effects. The nonspecific, overall mean effect was statistically significant (g = 0.34, p Read More