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Psychosomatic Medicine 65:558-563 (2003)
© 2003 American Psychosomatic Society

ORIGINAL ARTICLES

Job Strain and Blood Pressure in Employed Men and Women: A Pooled Analysis of Four Northern Italian Population Samples

Giancarlo Cesana, MD, Roberto Sega, MD, Marco Ferrario, MD, Paolo Chiodini, MSc, Giovanni Corrao, PhD and Giuseppe Mancia, MD

From Department of Clinical Medicine, Prevention and Biotechnology of S. Gerardo Hospital (G.C., R.S., M.F., G.M.); and Department of Statistics, University of Milano Bicocca (P.C., G.C.), Milan, Italy.

Address reprint requests to: Giancarlo Cesana, Research Centre on Chronic Degenerative Diseases, Villa Serena, via Donizetti 106, I-20052 Monza. Email: giancarlo.cesana{at}unimib.it

Received for publication December 14, 2001; revision received September 11, 2002.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: The extent to which psychosocial stress concurs to raise blood pressure is still uncertain. Here the association between job strain and office blood pressure in a pooled analysis of four population samples from northern Italy is assessed.

METHODS: Four surveys assessing prevalence of major coronary risk factors were performed in 1986, 1990, 1991, and 1993 in area "Brianza" (Milan), a World Health Organization-MONItoring cardiovascular disease (WHO-MONICA) Project collaborating center. Ten year age- and gender-stratified independent samples were randomly recruited from the 25- to 64-year-old residents. The methods used to assess coronary risk factors strictly adhered to the MONICA manual, were kept constant, and underwent internal and external quality controls. Job strain was investigated through the administration to employed participants of a questionnaire derived from the Karasek model, assessing job demand/control latitude. Analysis was restricted to 25- to 54-year-old participants, untreated for hypertension (1799 men and 1010 women).

RESULTS: Among men, there was a 3 mm Hg increase of systolic blood pressure (p< .001) moving from low to high strain job categories. This difference was independent from age, education, body mass index, alcohol intake, smoking habits, leisure time physical activity, and survey. No relevant differences among job strain categories were found in women and for diastolic blood pressure in both gender groups.

CONCLUSIONS: These results carried out on a large population-based sample confirm previous findings obtained adopting ambulatory blood pressure measurements in more restricted samples of population or patients. Further research is needed to clarify the relationship between perceived work stress and blood pressure in women.

Key Words: job strain, • blood pressure.

Abbreviations: WHO = World Health Organization;; MONICA = MONItoring cardiovascular diseases;; BMI = body mass index;; MOPSY = MOnica PSYchosocial;; PAMELA = Pressioni AMbulatoriali E Loro Associazioni (ambulatory pressures and their associations);; BP = blood pressure;; SAS = statistical analysis software;; PROCAM = PROspective Cardiovascular Munster study;; JCQ = job content questionnaire.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Among the factors that are believed to contribute to persistent elevations of blood pressure, psychosocial stress appears as the most "enigmatic" (1). It is commonly thought that this factor operates on a background of genetic susceptibility and interacts with other lifestyle determinants of hypertension such as obesity, physical inactivity, and salt and alcohol intake (2, 3). It is also commonly thought that for all those determinants the common pathogenetic mechanism is sympathetic overactivity, which is particularly important in the early stages of the disease, the structural changes in the resistance vessels (also partly accompanied by sympathetic influences) becoming dominant later (4). However, the extent to which psychosocial stress concurs to raise blood pressure is still uncertain. Animal studies have suggested that chronic stress of almost any type can cause a blood pressure increase and epidemiological studies have shown that the prevalence of hypertension is dependent on social and cultural factors, particularly urbanization and education (5, 6) . However, with the Karasek demand-control paradigm (7) (the analysis of job strain), ie, the stress perception resulting from the interaction of the physical-psychological requests imposed to the worker and the liberty he has to respond to them, the "adaptative" aspects of blood pressure have emerged with both more details and questions.

Several but not all studies using the Karasek model, for the study of job stress perception, have shown a positive relationship with ambulatory blood pressure level, both cross-sectionally and prospectively (4, 8, 9) in men but not in women, and in selected samples of workers or patients. In addition, the diurnal blood pressure pattern in men with high strain jobs evidenced a persistent elevation throughout the day and night, consistent with the hypothesis of job strain as an independent risk factor in the development of human hypertension (10). Other studies using office blood pressure as an outcome measure of occupational stress have found little or no relationship or even inverse associations (11–18). In particular, in a wide population study in Japan (3187 men and 3400 women) job strain was observed to be related to hypertension in males but not in females, although no relationship could be observed with systolic and diastolic blood pressure even in males (19). One of the major shortcomings of all these studies is the lack of precise definitions of blood pressure measurement methods, which result nonstandardized among the studies and often within the same study. In addition, the questionnaires adopted in some of the studies are not based on the Karasek paradigm, making the comparison of the findings more difficult.

In a previous study, we provided the evidence of an association between job strain and ambulatory blood pressure in a male general population sample, although the relationship was found only in normotensives and only for systolic blood pressure (20). The association was unexpectedly confirmed also for clinic blood pressure. This led us to extend the analysis of the relationship between job strain and blood pressure to the four general population samples recruited in a geographically defined area ("Brianza") between 1986 and 1994. The aim of this study is therefore to assess whether the positive results obtained with the relatively sophisticated methods of ambulatory blood pressure measurement can be extended to larger population-based samples of both gender groups, adopting the simple and traditional measurement of blood pressure in the doctor’s office.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Population and Samples
Area Brianza, a WHO-MONICA collaborating center, is located in the Lombardia region of northern Italy, between Milan and the Swiss border. It is characterized by a high level of industrialization and urbanization, with about 1,000,000 inhabitants, and one of the highest average incomes in the country.

Three population surveys (1st, 2nd, and 3rd MONICA) were conducted in Brianza in 1986–1987, 1989–1990, and 1993–1994 to assess coronary risk factor changes over time. In 1991–1992, another population survey, PAMELA, was carried out to investigate the relationships between clinic and ambulatory blood pressure measurements at the population level (21).

In the MONICA surveys, 10-year age- and gender-stratified random samples were selected from the municipality rolls among 25- to 64-year-old residents of five selected towns (of 74 in the area), identified to represent the level of urbanization of the target population. In the PAMELA survey, sampling procedures were the same, but subjects were extracted from the residents of the city of Monza, the largest town in the area (about 150,000 people). Each age-sex stratum was composed of about 200 subjects with overall participation rates of 68.3% in men and 69.3% in women, with small variations among gender-age groups and among surveys (Table 1). People selected in previous surveys were not included in subsequent ones; therefore surveys were independent. All surveys started at the beginning of autumn and continued through midsummer, with an interruption of one month in the winter season (middle of December to middle of January). No seasonal shift in participants’ distributions was detected among surveys. Data analysis was restricted to employed (currently working with a stable job) men and women 25-54 years old, due to the high retirement rates in the last investigated decade (until a few years ago, in Italy, retirement was possible after 30 years of work and most often occurred at around 55 years of age). Hypertensive subjects under treatment were also excluded because of the effect of treatment on the blood pressure values.


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  		TABLE 1. Study Characteristics
 
Coronary Risk Factor Measurements
The methods adopted to measure risk factor prevalence strictly adhered to the WHO-MONICA project procedures, which are extensively described elsewhere (22). Briefly, trained technicians took blood pressure and results underwent satisfactory internal and external quality control assessment (23). Measurements were taken twice, 5 minutes apart on subjects in the sitting position, after 10 minutes of rest, and at least 1 hour from the venipuncture, carried out for the assessment of lipid profile. Standard and periodically calibrated mercury sphygmomanometers were used, recording the first and fifth phase of the Korotkoff sounds for systolic and diastolic blood pressure, respectively. In the initial survey, sphygmomanometers were equipped with only one cuff bladder (13 cm), whereas in the following surveys a larger cuff (17 cm) was also made available, although its use was limited to <2% of the participants in each survey. The average of the two measurements was used as the study variable.

Height and weight were measured on subjects without shoes and wearing light clothing. BMI was computed as weight in kilograms divided by height in squared meters. The gender-specific fourth quintile of BMI was adopted as a relative cutoff point for obesity.

Information on full-time years of school education, smoking habits, alcohol consumption, leisure time physical activity, and antihypertensive drug treatments was collected through a standardized interview. Information on smoking habits was categorized in a dichotomous variable, including occasional smokers with current smokers and past smokers with never smokers. The usual daily consumption of wine, beer, and spirits was investigated and converted to units of alcohol (one glass of wine, one medium tankard or can of beer, or one small glass of spirits) consumed every day. In order to refer to the average consumption in the adult Italian population, a dummy variable was used in the analysis with values of <=2 or >2 alcoholic drinks per day. Leisure-time physical activity was investigated by means of the questionnaire proposed by Baecke et al. (24), with separate indexes for sport and recreational activities. For the purpose of the present analysis, where leisure-time physical activity was used as a covariate, a dummy variable was constructed: positive value was attributed to subjects falling into the upper 10th percentile of the distribution of a comprehensive variable, built up as the sum of the recreational activity index plus the double of the sport activity index. Such a positive score corresponds to engaging in sports for two or more times per week or in recreational activities, like cycling or walking, for three or more times per week for at least 1 hour.

Job Strain Assessment and Scores
Each employed participant was asked to fill in the MOPSY Questionnaire, in which a short job-strain scale derived from the Karasek questionnaire was included. The scale (set up at the WHO Regional Office for Europe) was composed of 13 items, of which 6 dealt with decision latitude and 5 with job demand (25). The remaining two items on social support were not considered for the present analysis. The Italian version of the MOPSY questionnaire was validated at the time of the first MONICA survey (26): internal consistency (Cronbach alpha coefficient) resulted 0.72 for decision latitude and 0.6 for perceived job demand; in addition, the two dimensions resulted orthogonal, as foreseen by the model, with a Pearson correlation coefficient varying from 0.01 in men to 0.05 in women. The questionnaire was used with minor modifications in the other two surveys and in the PAMELA study.

Job strain evaluation was obtained through the traditional quadrant term approach (27), using as cutoff points the overall gender-specific sample medians of the two considered scores (decision latitude range of scores was 6–24 in both gender groups and the medians were 18 in men and 17 in women; psychological job demand range was 5–20 and the median 12 in both gender groups). In the high strain group were classified individuals who scored above the sample median of the demand scale and equal or below the median of the decision latitude scale. Similarly, the passive condition was determined by demand and decision scores equal or below the correspondent sample medians; the active condition by scores above the median for both dimensions; and the low strain condition by levels of job demand equal or below the median and decision latitude above the median. In addition, according to the levels of each job strain score, subjects were classified into tertile levels of perceived job demand (cutoff points: males 11 and 13, females 11 and 13) and decision latitude (cutoff points: males 17 and 19, females 16 and 18).

Statistical Analysis
Separate analyses were performed for men and women, and for normotensive (BP < 140/90 mm Hg), high normotensive (130/80 < BP < 140/90) and hypertensive (BP >=140/90 mm Hg) subjects. The systolic and the diastolic blood pressure values were considered as dependent variables in the analysis of covariance, using the SAS general linear model procedure (28), and the perceived job stress scores (job strain-quadrant term, tertiles of job demand and tertiles of decision latitude) were considered as explanatory variables in separate models. In each model these covariates were included as fixed effects: age (as a continuous variable), BMI, alcohol intake, smoking status, level of education, prevalence of leisure time physical activity (one dummy variable each), and year of survey (three dummy variables). Occupational level (job title grouped in five descending classes according to the Erikson-Goldthorpe-Portocarero method) (29) was not included as a covariate because its statistical contribution was irrelevant after education was included. Year of survey was included as a covariate because of possible undetected differences in measurements and because of evidence of decrements in blood pressure mean levels during the observation period (23).

First-order interaction terms were also tested, but no longer kept into the models because neither statistically significant nor relevant improvements in the R2 were detected.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Table 2 shows the characteristics of the general population MONICA samples, 25 to 54 years old, and the final sample sizes of the study after exclusion of unemployed subjects and those for whom questionnaire and employment information were not available. As described in METHODS, participation of invited people in the MONICA survey was around 70% in the entire age range with minor changes among age-gender strata. Missing data were low, with the exception of the first survey due to some organization problems at the start of screening activities. Missing questionnaires were more frequent among women than among men in all surveys. As expected, the percentage of employed men was much greater than that of employed women: 88% vs. 52% for the entire samples. The percentage of missing data on employment was 7% to 8% in both men and women. Final sample sizes were 1799 men and 1010 women, corresponding to 87% and 78% of the employed participants, with the age means of 39.9 (SD 8.28) and 37.1 (SD 7.77), respectively.


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  		TABLE 2. Sample Characteristics and Restrictions of Participants in Study, 25–54 Yr Old
 
The distribution of job titles, according to the first digit of the International Standard Classification of Occupation 88 Code, is reported in Table 3. As expected, because the samples were population based, a wide variety of classes of occupation has been recruited.


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  		TABLE 3. Type of Jobs
 
In Table 4 the age-adjusted prevalence of major blood pressure covariates in job strain categories is reported. Among both men and women, passive followed by high strain grouping resulted as the more prevalent categories. No differences in both sexes were observed for prevalence of current smokers, excess of alcohol intake and the index of obesity among job strain groups. Prevalence of regular leisure time physical activity was found higher in active and low-strain men and women. Untreated hypertension resulted more prevalent in passive men, but no differences were found in women among job strain categories.


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  		TABLE 4. Distribution (%) of Major BP Covariates Among Job Strain Categories and {chi}2 Age Adjusted
 
Table 5 reports blood pressure means in job strain categories and tertile groupings of decision latitude and psychological job demand, resulting from the pooled analysis, adjusted for age, BMI, alcohol intake, smoking status, education level, regular leisure time physical activity and survey. Among men there was a significant progressive increasing gradient of 3 mm Hg (p< .001) of systolic blood pressure mean values from the low strain to the high strain job category. This increase was associated with a statistically significant decrease of systolic blood pressure values for tertiles of job control. Similar differences were not observed in women and for the demand dimension in both sexes. Job strain categories did not show any significant relationship with diastolic blood pressure. These results did not change when the analysis was carried out on hypertensive and high normotensive subjects separately.


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  		TABLE 5. Mean Clinical Blood Pressure in Pooled MONICA-Brianza Samples of Currently Employed Men and Women
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The aim of our investigation was to check, in several samples of workers representative of general population, the association between job strain and clinical systolic blood pressure that we unexpectedly observed in a study mainly focused on ambulatory blood pressure. It is very difficult to perform more than descriptive studies on the association between psychosocial factors and biological response (30). Our study had the advantage that several surveys were performed over a rather long time span. Furthermore, the procedures through which data were collected were sound. First, the methodology for blood pressure measurement and job strain assessment was consistent throughout. Second, the blood pressure measurements were accurate because of adoption of a meticulous internal and external quality control. Third, participation resulted around 70% in each surveyed sample and age-sex stratum (23, 31), which is satisfactory for subjects randomly extracted from general population (32), and phone interviews of nonparticipants about their social condition, antihypertensive drug assumption and blood pressure status showed no differences vs. participants (31). Fourth, with the exception of the first survey, in males, missing data were only 1% to 2% on employment status, and about 10% on job strain, the latter ranging from 6.9% in more educated people to 14% in less educated; however, the analysis of the first survey data gave results that were similar to those of the subsequent surveys). Fifth, although there are always many problems in the comparison between subjective reports and biological data, the job-strain scale here used was approved in an international cooperative study and refers to the most-accepted and long-lasting paradigm in this kind of research. Finally, although the greater number of missing data on the job-strain questionnaire in women might have influenced the statistical analysis, job strain showed no relationship with blood pressure in this gender as in the majority of previous reports (4, 10, 33, 34).

The results of the study show that in males systolic blood pressure was greater in the passive and high job-strain groups, ie, in the groups characterized by a decreased control of the jobs. They confirm previous findings obtained by ambulatory blood pressure in more restricted samples of population or patients (10, 35), and offer a large database to the conclusion that in the population job strain is accompanied by an increase in blood pressure.

It has been argued that low control is typical of jobs characterized by poor content and less remuneration which are common among people of low socioeconomic status (36). This might be interpreted as to mean that low job control does not reflect only on unsatisfactory organization and interpersonal relationship at work, but is rather an index of a more complex social discomfort produced by the interplay of work with variables like education, income, housing, and others. This may be supported by the observation that in United States and northern European countries blood pressure is inversely related to the socioeconomic status because of the greater prevalence of poor living conditions, uncorrected dangerous life habits, and poorer treatment of hypertension in inferior classes (37–39). However, this does not seem to be the case in Italy, where no significant differences in blood pressure were observed among classes with different socioeconomic status (40).

Furthermore, the results reported in the present study were adjusted for education, which is a major determinant of the socioeconomic status (36). Thus the perception of low control at work seems to be a specific and independent variable associated to the increase in blood pressure. Interestingly, Marmot et al. (41) reached the same conclusion for the risk of a coronary event in the cohorts of the Whiteall study.

Another explanative suggestion may come from the consideration that there are not substantial differences between the passive and the high strain group, whereas the group which shows lower systolic blood pressure is the low strain. This may indicate that the association between job strain and blood pressure is stronger in the low end of a continuum and that it is protective to have a good control and no excessive demand. Thus what is usually considered as a pathogenic effect may be conversely regarded as salutogenic.

Several other findings of our study deserve to be mentioned. First, no association between stressful jobs and blood pressure was seen in women. This finding is common to other studies. It may suggest that women are protected from the sympathetic influences of stress, particularly when they are in the premenopausal age, the prevalent condition in our Italian working samples (42).

Second, smoking, excess of alcohol consumption and obesity did not evidence a different distribution among job strain groups, despite the common opinion that they are dangerous behaviors induced by environmental stress. Instead regular leisure time physical activity was more frequent among low strained and active individuals, enforcing the recognized importance of its coping effect (1, 2), which is probably better understood by more educated people. Noticeable is the higher prevalence of hypertension among high strain and particularly passive males, confirming previous findings (19) and heralding the association between stress perception and increase in blood pressure in this gender.

Third, in our study there was no relationship between job strain and diastolic blood pressure. In the male component of our population, there was a 3-mm Hg difference in systolic blood pressure between the best work condition, ie, low strain, and the worst, ie, high strain. This may seem to be a small difference, difficult to replicate and to evaluate for the prediction of unhealthy outcomes. It should be emphasized, however, that in general population samples, including those of the MONICA, such a difference in systolic blood pressure allows to clearly discriminate between favorable or unfavorable trends (43). Furthermore, systolic blood pressure is directly and continuously related to the risk of stroke or coronary event, even when values are below the limit conventionally established for hypertension. For this reason systolic blood pressure values are included in the widely used PROCAM and Framingham algorithms predicting the occurrence of cardiovascular disease (44).

The results obtained in our research suggest that the study of systolic blood pressure should be promoted, at least in males, as a biological index of the perception of emotional and organizational troubles: a kind of biological exposure index, using a typical terminology of occupational toxicology. This is the case also when only office values are collected, provided that measurements are accurate as in the MONICA Project. Additional research is needed to clarify the relationship between perceived work stress and blood pressure in women. This is the case also for hypertensive individuals in whom more complex psychophysiological mechanisms may be operative (45).


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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 Occup. Environ. Med.Home page
S Radi, T Lang, V Lauwers-Cances, E Diene, G Chatellier, L Larabi, R De Gaudemaris, and for the IHPAF group
Job constraints and arterial hypertension: different effects in men and women: the IHPAF II case control study
Occup. Environ. Med., October 1, 2005; 62(10): 711 - 717.
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 Am J EpidemiolHome page
D. De Bacquer, E. Pelfrene, E. Clays, R. Mak, M. Moreau, P. de Smet, M. Kornitzer, and G. De Backer
Perceived Job Stress and Incidence of Coronary Events: 3-Year Follow-up of the Belgian Job Stress Project Cohort
Am. J. Epidemiol., March 1, 2005; 161(5): 434 - 441.
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 HypertensionHome page
K. S. Thomas, R. A. Nelesen, M. G. Ziegler, W. A. Bardwell, and J. E. Dimsdale
Job Strain, Ethnicity, and Sympathetic Nervous System Activity
Hypertension, December 1, 2004; 44(6): 891 - 896.
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 BMJHome page
Minerva
BMJ, August 9, 2003; 327(7410): 350 - 350.
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