(Hypertension. 1995;25:554-559.)
© 1995 American Heart Association, Inc.
Articles |
Job Status and High-Effort Coping Influence Work Blood Pressure in Women and Blacks
From the Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill (K.C.L., K.A.B., A.L.H., S.S.G.); the Departments of Pediatrics and Preventive Medicine, University of Tennessee, Memphis (J.R.T.); and the Department of Psychiatry, Duke University, Durham, NC (A.S., N.B.A.).
Correspondence to Kathleen C. Light, CB #7175, Medical Building A, University of North Carolina, Chapel Hill, NC 27599-7175.
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Abstract |
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Abstract Work-related stress has been associated with an increased risk of hypertension and more severe cardiovascular problems in white men but has been less studied in women and black men. To determine whether the trait of high-effort coping (John Henryism) was related to higher blood pressure during work and laboratory challenges, we studied a biracial sample of 72 men and 71 women working full time outside the home who underwent ambulatory blood pressure monitoring for one 8-hour workday. This was followed by laboratory monitoring of blood pressure during resting baseline and five brief stressors. Women who were high-effort copers and had high status jobs had higher diastolic pressures at work and in the lab than other women; their pressure levels did not differ from those of men, but other women had lower pressures than men. In blacks, the same combination of high-effort coping plus high job status was similarly associated with high work and laboratory diastolic pressure, as well as higher work systolic pressure. The trait of high-effort coping was observed in the large majority (71%) of the women and blacks who had achieved high status jobs but was seen in a minority (36%) of white men with high status jobs and was unrelated to increased blood pressure in the latter group.
Key Words: blood pressure, ambulatory • sex • blacks • job adaptation, psychological • stress
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Introduction |
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The pathogenesis of hypertension, and its more severe cardiovascular consequences, is complexly determined, involving both genetic and environmental factors. Among those environmental factors that have been associated with higher blood pressure (BP) and an increased risk of cardiovascular morbidity and mortality is exposure to stress in the workplace.1 2 3 Having a lower status occupation has been shown to be related to higher BP levels and a greater incidence of hypertension in both whites and blacks.4 5 Several recent investigations have underscored the importance of "job strain" (the combination of high psychological demands plus low decision latitude at work) as a determinant of elevated BP at work, at home, and even during sleep in male workers.6 7 8 In contrast to these findings in men, for female workers, job strain as defined above has frequently failed to show a relationship to higher ambulatory BP at home or at work.8 9 10
The absence of the expected relationship between job strain and BP in women indicates that psychosocial factors influencing BP in women are different than in men and encourages further examination of what factors might specifically have a greater effect for female workers. Our prior research using the job strain model8 suggested that having a high status job might not have the same beneficial influence on BP in women as it has been shown to have in men, because a trend was observed for women with high job status to show greater increases in diastolic BP (DBP) from the clinic context to mean levels during a working day. Previous research on the cardiovascular response to laboratory stressors has suggested that behavioral stressors that require a high and sustained level of active coping effort (defined as mental effort directed toward achieving an important outcome) tend to evoke BP increases that are greater and persist longer than those seen when subjects reduce their coping effort.11 12 13 In our society, a smaller proportion of women and black men hold high status jobs, and there is a perception that greater effort and perseverance are required to achieve and retain such jobs for these subgroups than for white men. For example, in 1984, female college graduates earned only 64% of the median income earned by men. Although black female college graduates actually earned 118% of the median income of white female college graduates, black male college graduates earned only 71% of the income of their white male counterparts.14
Thus, it was hypothesized that high job status might be associated with elevated work BP in women and black men with a behavioral predisposition to high-effort coping. Based on the black folk hero John Henry, who refused to quit in an unfair struggle against a machine even at the cost of his life, James et al15 developed the John Henryism Active Coping Scale to assess "the individual's self-perception that he can meet the demands of his environment through hard work and determination" (p 263). These researchers observed that in black men from a rural Southern community, where only 14% of the sample had any education beyond high school, high John Henryism was associated with higher casual stethoscopic BP levels in those who had less than a high school education. Subsequently, James and colleagues16 observed that the prevalence of hypertension was nearly three times as great in black adults who were high in John Henryism if they were low versus high in education, whereas John Henryism did not affect hypertension prevalence in white adults. In the present investigation, we examined the relationship of John Henryism or the trait of high-effort coping to BP during a typical working day and during a laboratory stress session in a sample from the higher end of the socioeconomic spectrum: healthy, young white and black men and women who were all well-educated but differed in terms of job status.
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Methods |
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Subjects
For the present report we used a sample of 143 healthy men and women aged 18 to 49 years, 129 of whom were participants in our previous investigation of job strain effects on ambulatory BP.8 This total included 72 men (40 whites, 32 blacks) and 71 women (35 whites, 36 blacks). Each subject was required to be employed full time outside the home, but no minimum duration of current employment or selection by the nature or status of occupation was used in sample selection. However, subjects represented a highly educated sample, as all volunteers had completed high school and most (65.2%) had a college degree. A wide range of occupations was included, from physicians and executive officers to janitors and factory shift workers, but white-collar workers predominated for both men (71%) and women (72%). Subjects were recruited by notices posted on employee bulletin boards at a number of businesses, hospitals, schools, and colleges in the Raleigh–Durham–Chapel Hill area and by word of mouth. Since it is difficult to recruit full-time workers, especially women and blacks, for extensive testing, all laboratory test sessions were scheduled after work in the evening, and instrumentation for ambulatory monitoring was performed as early as 6 AM so as to minimize subject inconvenience. Also, all subjects received a large monetary incentive ($100) for participating. To ensure similarity of treatment, a pair of lab assistants (one white and one black) worked together to perform recruitment and testing. Each volunteer read a detailed description of the protocol, which was approved by the local review board, and provided written informed consent. Each also underwent a physical examination supervised by a cardiologist and provided medical history information. Exclusionary criteria included (1) DBP greater than 95 mm Hg (or torr in Système International units) or current use of antihypertensive medications at screening exam, (2) any serious cardiovascular, renal, or pulmonary problem, and (3) chronic physical or psychological disorder or substance abuse history. Women were tested during days 3 through 8 of their menstrual cycle, and none was taking oral contraceptives at the time of testing.
Physiological Recording Procedures
BP recording procedures for screening and ambulatory BP have
been described in detail by Light et al.8 Briefly,
subjects first provided screening levels of systolic BP (SBP) and DBP
based on four averaged auscultatory readings obtained in an initial
visit to the university medical center. Then, from 1 to 6 weeks later,
each subject was instrumented for ambulatory BP monitoring with the
Accutracker 103 monitor (Suntech), involving four determinations per
hour made throughout a normal 8-hour working day. Each determination
was accompanied by an entry in a diary in which the subject recorded
current posture, location, recent physical and mental activities, and
mood state, including levels of stress, tension, and anger. At the end
of the workday, subjects returned to the laboratory, where monitors
were removed and the data downloaded into computer files. These data
were subsequently reviewed and edited by an experienced staff member to
exclude artifactual readings, following criteria detailed previously by
Hinderliter et al,17 and then a single mean level of
SBP and DBP at work was calculated by averaging all valid
readings over the work period for each subject.
After the data from monitors were downloaded, the subjects were reinstrumented with the same monitors. Then, SBP and DBP measures were recorded (with rapid cuff inflations manually started by a research assistant) during laboratory resting baseline (15 minutes) followed by a series of five behavioral stressors, each 3 minutes in duration. Cuff pressure and Korotkoff sounds were also displayed on a chart recorder with the use of a special connector cable provided by Suntech to ensure that cuffs inflated to levels above the appearance of Korotkoff sounds and to allow deletion of readings affected by movement or other artifacts. Recovery periods followed each task. These periods were of variable duration, lasting until each subject had demonstrated recovery of both SBP and DBP to within 5 mm Hg of the lowest values observed during the initial resting baseline. The minimum recovery period was 5 minutes, and the maximum was 10 minutes. The five stressors have been described in detail by Light et al.18 Briefly, the stressors included (1) a computerized math task, which continuously adjusted for differences in problem solving ability by increasing or decreasing problem difficulty; (2) a competitive reaction time task, in which paired subjects were instructed to try to press a button faster than a same-race, same-sex competitor; (3) an active speech task, in which subjects prepared and then gave a speech describing how he or she would think, act, and feel during an interpersonal hassle with a vendor (a car dealer who refused to honor the car warranty or a sales clerk who refused to honor an advertised sale price); (4) a passive speech condition, which involved hearing a same-race, same-sex peer give a similar speech that would be compared with his or her own speech for awarding prizes based on communication clarity and interest; and (5) the forehead cold pressor, which involved having a bag of ice and water held firmly across the entire forehead, leading to a cold headache pain sensation. Mean levels of SBP and DBP (obtained once per minute for up to three consecutive readings during key periods) were calculated for minutes 13 through 15 of baseline and minutes 1 through 3 of each stressor.
Assessment of Job Status and John Henryism
Job status was assessed by the specific occupational titles
provided by the participants with the use of the classification of
Stevens and Cho,19 which was derived from general economic
norms based on the 1980 national census. A predisposition for
high-effort coping was assessed using the John Henryism Active Coping
12 Scale,16 provided to us by the scale author during
prior collaborative research on BP responses to stressors in white and
black college students.20 This is a 12-item scale with
five response choices per item ranging from completely false to
completely true in regard to how the subjects see themselves. Sample
items include the following: "Hard work has really helped me to get
ahead in life"; "When things don't go the way I want them to,
that just makes me work even harder"; "I don't let my personal
feelings get in the way of doing a job." In the present
investigation, John Henryism or high-effort coping scores were not
correlated with hostility scores and showed a negative correlation with
anger-in score (r=-.24 and -.23 for men and women,
respectively; P<.05), as measured with the Multidimensional
Anger Inventory.21 In the previous collaborative research
with college students, subjects scoring high in John Henryism included
nearly equal proportions of type A and type B
individuals.20 Thus, we conclude that this index does not
overlap substantially with anger, hostility, or type A behavior
pattern.
To create subgroups based on job status, we calculated the mean job
status score for the full sample. Those subjects (66% of our sample)
whose occupations were rated at or below this mean level, regardless of
race or gender, were designated as low job status (n=39 and 55 for men
and women; n=32 and 62 for whites and blacks, respectively), whereas
those above this level (34% of our sample) were designated high job
status (n=34 and 15 for men and women; n=43 and 6 for whites and
blacks, respectively). For John Henryism or high-effort coping,
subgroups high and low in this trait were created by a simple
median split based on the full sample, also independent of ethnicity or
gender. The median John Henryism score was 48, slightly lower than the
median of 53 reported by James et al.16 Possible ethnic
and gender differences in the association between high-effort coping
and having a high status job were tested with the use of
2 analysis (see below). Based on our
hypotheses, the subgroups whose BP levels were expected to be higher
than other subjects were the high-effort copers with high status jobs
among the women independent of ethnic group (n=10, including 7 white
and 3 black subjects) and among the blacks independent of gender (n=5,
including 3 women and 2 men).
Data Analysis
The relationship of job status and high-effort coping score to
mean ambulatory levels of SBP and DBP during the 8-hour working day was
analyzed by repeated-measures ANOVA generated with the Statistical
Analysis System (SAS Institute) programs. Separate analyses were used
to examine the effects of gender versus the effects of ethnic group in
interaction with job status and John Henryism. Laboratory levels of SBP
and DBP during baseline and the five stressors were analyzed using the
same method. Heart rate, stroke volume index, and cardiac index levels
(assessed with impedance cardiography) were obtained during the
laboratory testing, but because these measures failed to yield any
significant group differences relating to job status or high-effort
coping, they are not presented. The level of significance was set
at a value of 
=.05.
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Results |
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Gender Differences in Effects of Job Status and John Henryism
The combination of high-effort coping and a high status job was related to higher BP at work in women but not in men. Initial analysis of mean work DBP indicated a significant interaction of job statusxJohn Henryismxgender [F(3,135)=2.81, P<.043]. Subsequent analyses showed that women who were high-effort copers and had high status jobs had significantly higher work DBP than any of the other female subgroups (P<.05, see Fig 1). In addition, all other female subgroups had work DBP levels that were significantly lower than those of the male subgroups (P<.05). In contrast, high-effort women with high status jobs showed DBP levels at work that were equally as high as those of the men (P=NS). Mean work SBP of these women showed only a nonsignificant tendency to be higher than other women (not shown). Among the men, the high-effort copers did not differ significantly from other men in terms of work SBP or DBP regardless of job status. Independent of coping status, men with low job status tended to have higher work DBP than men with high job status (P<.09, see Fig 1).
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In the laboratory, the same job statusxJohn Henryismxgender interaction was significant for raw DBP levels across baseline and stressor condition [F(3,135)=3.55, P<.017] and was marginally significant for SBP levels across all conditions (P<.056). As depicted in Fig 2, the women with high status jobs who were predisposed to high-effort coping had higher BP values throughout the lab session than other women and in fact showed levels comparable to those of men, whereas other women had significantly lower DBP than men (P<.05). SBP levels showed a similar pattern (not shown). For men, low job status was associated with higher DBP levels during the lab session, particularly at baseline (79.9±1.6 versus 75.6±1.5 mm Hg, P<.05). However, men who scored high versus low in effortful coping did not differ in BP under any condition.
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There were no significant interactions between time periods within the lab session and job status or John Henryism. Thus, these two psychosocial factors were seen to influence raw levels of SBP and DBP but were not associated with reliable differences in reactivity (change from baseline to stressors). To assess whether the higher DBP of female active copers with high status jobs might be associated with higher body mass index or older age, we performed ANOVAs using these measures, but all group differences were nonsignificant (P>.45).
Ethnic Group Differences in Effects of Job Status and John
Henryism
When analyses were repeated using ethnic group instead of gender
as an independent variable, a similar pattern was seen for blacks
as for women. For both mean SBP and DBP during a regular workday,
significant job statusxJohn Henryismxethnic group interactions were
obtained [F(3,135)=5.52 and 6.71, respectively; P<.021].
Blacks with high status jobs who were high-effort copers had higher SBP
and DBP levels at work than other subgroups (P<.05, see
Figs 3 and 4). For raw levels of DBP
throughout the lab session, the same interaction was significant
[F(3,135)=3.53, P<.03]. The same black subjects who were
high in both job status and effortful coping had higher DBP at baseline
and across the stressors compared with other groups (P<.05,
see Fig 5). As with the gender analyses, no reactivity
differences involving ethnic group and John Henryism or job status were
significant. In regard to possible contributions of age and body mass
index, analyses indicated a main effect of ethnic group for body mass
index (whites<blacks, P<.05) but no interaction with job
status and John Henryism for either measure (P>.60).
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Distribution of John Henryism as a Function of Minority Status and
Job Status
We performed a post hoc 2 test to examine
the probability that higher active coping might differentially be
associated with having a high status job in female and black workers
compared with white men, who tend to hold the majority of high status
jobs. This test revealed that there was a significant difference in the
subgroup proportions of high and low active copers among the white men
versus all other subjects who hold high status occupations
[2(1,49)=5.27, P<.023]. Among white
men, only a minority who held high status jobs were high in John
Henryism (36%), whereas among blacks and women combined, the large
majority with high status jobs were high in John Henryism (71%). This
differential pattern suggests that among black and female workers, it
may be more important than it is for white men to be predisposed toward
effortful active coping in order to achieve and retain high status
jobs.
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Discussion |
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The present investigation provides some novel although preliminary observations about the way in which male and female workers differ and in the way white and black workers differ in their BP responses to challenges and stresses associated with the work environment. The present findings suggest that unlike white men, women and black men who are well-educated and employed in high status jobs may tend more often to respond to work and other mentally challenging situations with higher BP levels, particularly if they are predisposed to believe strongly that hard work, personal control, and initiative are the keys to success. One limitation of this study is that the numbers of women and black men who reported having a high status job in this study are relatively small; they made up only approximately one third of the subjects with high status jobs, whereas white men made up the other two thirds. This unequal distribution may in part be due to greater difficulty in recruiting such subjects, but it may also reflect the underrepresentation of women and minorities (especially black men) in high status jobs nationwide. For example, among individuals aged 25 through 64 years in 1980, the percentage in executive, administrative, managerial, or professional specialty occupations was 30% for white men, 15% for black men, 26% for white women, and 19% for black women.14 Nevertheless, the small number of women and blacks with high status jobs who were studied may limit the generalizability of these findings and indicates a need for replication in a larger sample.
Since most of the blacks and women in this study who had achieved a high occupational status were high in this trait of effortful active coping (71%), this meant that most of these minority individuals with the best jobs demonstrated elevated BP levels throughout the working day relative to their less well-employed counterparts or to white men with equivalent jobs. One reasonable interpretation of these findings is that in black and female workers, the trait of high-effort coping may increase the likelihood of their achieving job success when they are educated and trained for a high status job, but it may do so at the cost of BP elevation at work. Increased ambulatory BP at work has been shown to be strongly related to increased left ventricular mass index, which is the strongest known predictor other than age of subsequent cardiovascular morbidity and mortality.22
At first glance, these findings may appear contradictory to the extensive literature indicating that low socioeconomic status (SES, conventionally assessed by job status, education, or income) not high SES is associated with higher BP and a greater incidence of hypertension.4 5 They may also appear contradictory to the original finding of James et al15 showing higher BP in black men high in John Henryism but low in SES as defined by education. The present sample, however, differs from these other investigations in that it did not include any participants from the lowest end of the SES spectrum. Instead, this study focused on a highly educated and therefore high SES population. With no representation of truly low SES subjects, it is not surprising that the results yielded less evidence of the adverse BP effects of low job status; this occurred only in the men, as a trend for higher work DBP and significantly higher laboratory DBP. In regard to John Henryism and its interaction with SES, the most recent research by James and associates23 in a larger, more urban sample of black adults did not obtain a clearly significant difference in hypertension prevalence between low and high SES groups who were high in John Henryism. This was attributed to an effect of higher psychological stress reported by the black subjects with higher status jobs.
The present findings may also help explain why job strain does not show a relationship to higher ambulatory BP at work or in other contexts in previous investigations with female workers.8 10 The job strain model developed by Karasek et al3 specifies that high psychological demand by itself is insufficient to relate to elevated BP or increased cardiovascular risk without the second element, low job decision latitude. For women and blacks, one might hypothesize that the challenges of working hard in a high status job may frequently involve sufficient perceived adversity and uncertainty about future job success to have a psychological effect similar to the reduced control associated with low job decision authority and creativity. Recent findings on perceptions of job-related stress in high SES blacks,24 25 female human service supervisors,26 and female college professors27 are consistent with this interpretation.
In laboratory studies of effortful active coping, both self-reported coping effort and BP increases have been shown to be greater and more sustained when that challenge is difficult but not impossible to achieve, when the subject believes that his or her own effort can make a difference in the task outcome, and when there is some uncertainty about eventual success or failure or some intermittent failures mixed with successes.11 12 13 These same characteristics may apply to the perceptions of high job status women and blacks about their performance at work and the effort required to achieve further success and advancement on the job. Certainly, in our sample, only a small proportion of the women and blacks with high status jobs failed to score high in John Henryism. This finding naturally does not make it clear whether higher effort was in fact required to achieve the job status or whether only those minority individuals with this trait sought out such jobs. In either case, however, one may hypothesize that persistent high-effort coping could lead to frequent short-term increases in BP, which may eventually lead to sustained increases. Since the elevation in BP shown by female and black high-effort copers with high status jobs was evident at baseline rest in the lab as well as during work and lab challenges, it suggests that in some of our subjects, long-term increases may already have occurred. Sleep BP levels and BP levels during an extended period of home life after work, which were not obtained, would provide a more robust test of these hypotheses.
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Acknowledgments |
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This work was supported by grants HL-31533, HL-50778, and RR00046 from the National Institutes of Health, Bethesda, Md. We wish to acknowledge the important theoretical contributions of Dr Sherman A. James and the late Dr Paul A. Obrist to the conceptualization of this work.
Received June 28, 1994; first decision September 14, 1994; accepted December 9, 1994.
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 R. Clark Subjective Stress and Coping Resources Interact to Predict Blood Pressure Reactivity in Black College Students Journal of Black Psychology, November 1, 2003; 29(4): 445 - 462. [Abstract] [PDF]
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A. Steptoe, S. Kunz-Ebrecht, N. Owen, P. J. Feldman, G. Willemsen, C. Kirschbaum, and M. Marmot Socioeconomic Status and Stress-Related Biological Responses Over the Working Day Psychosom Med, May 1, 2003; 65(3): 461 - 470. [Abstract] [Full Text] [PDF]
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A. Steptoe, S. Kunz-Ebrecht, N. Owen, P. J. Feldman, A. Rumley, G. D. O. Lowe, and M. Marmot Influence of Socioeconomic Status and Job Control on Plasma Fibrinogen Responses to Acute Mental Stress Psychosom Med, January 1, 2003; 65(1): 137 - 144. [Abstract] [Full Text] [PDF]
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 A. Steptoe and M. Marmot The role of psychobiological pathways in socio-economic inequalities in cardiovascular disease risk Eur. Heart J., January 1, 2002; 23(1): 13 - 25. [Full Text] [PDF]
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C. Brisson, N. Laflamme, J. Moisan, A. Milot, B. Masse, and M. Vezina Effect of Family Responsibilities and Job Strain on Ambulatory Blood Pressure Among White-Collar Women Psychosom Med, March 1, 1999; 61(2): 205 - 213. [Abstract] [Full Text] [PDF]
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