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ORIGINAL ARTICLES |
Psychiatry and Behavioral Sciences (M.M.M., G.G.B., R.B.W.), Behavioral Medicine Research Center, Duke University Medical Center, Durham, NC; and Gerontological Research Center (J.J.S., J.F.T.), National Institute on Aging, Baltimore, MD.
Address correspondence and reprint requests to Marcellus M. Merritt, PhD, Research Fellow, NIA/GRC/LPC, 5600 Nathan Shock Drive, Baltimore, MD 21224. E-mail: merrittma{at}grc.nia.nih.gov
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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METHODS: Subjects were 58 normotensive, healthy black men age 23 to 47 years. The procedure included the completion of psychosocial questionnaires and participation in a psychophysiological reactivity protocol. The reactivity protocol involved the following experimental tasks and associated recovery periods: an active speech task and an anger recall task. Measures of systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), and rate pressure product (RPP) were obtained continuously using a Finapres beat-to-beat blood pressure monitor throughout the reactivity protocol.
RESULTS: At high JH, low (compared with high) education level was linked with higher DBP during anger recall and final recovery, higher SBP during final recovery, and higher HR and RPP during speech preparation and final recovery (p < .05). Among subjects with low education, high (vs. low) JH was associated with higher SBP, HR, and RPP during final recovery (p < .05).
CONCLUSIONS: John Henryism may increase the risk of cardiovascular disease among people with low education by increased cardiovascular reactivity and prolonged recovery to stress.
Key Words: coping, • socioeconomic status, • cardiovascular reactivity, • hypertension, • blacks.
Abbreviations: ANOVA = analysis of variance;; BP = blood pressure;; CVR = cardiovascular response;; DBP = diastolic blood pressure;; HR = heart rate;; HRV = heart rate variability;; JH = John Henryism;; JHAC = John Henryism Scale of Active Coping;; JS = job strain;; RPP = rate pressure product;; SBP = systolic blood pressure;; SES = socioeconomic status.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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Whether this heightened response to psychosocial stressors is problematic may depend on the coping style used by the person experiencing the stressful events. Past reactivity studies have indicated that active (vs. passive) modes of coping are linked with maladaptive CVR under certain circumstances (10–12). Many blacks have used the coping style of John Henryism (JH) as a means of dealing with the chronic stressors of daily life (eg, racism or discrimination, financial pressures, and high job strain [JS]) (13). JH has been defined as a firm behavioral tendency to cope in an active and effortful manner with psychosocial stressors (14). Although JH alone may predict CVR for some, it does not explain the entire picture. This high-effort coping response may be maladaptive in people with limited access to both psychosocial and socioeconomic resources (eg, education, income, job status, JS). These people may be at greater risk for cardiovascular disease caused by chronic dysregulation of the autonomic nervous system. This dysregulation may be characterized by increased sympathetic activation (and/or decreased parasympathetic activation) and heightened CVR to mental and physical stressors.
This notion of high levels of JH predicting greater risk of hypertension in people with low but not high socioeconomic status (SES) (13) has been termed the JH hypothesis. This hypothesis has received mixed support in previous research. It has been confirmed almost exclusively in black American populations (14–18), with the exception of one study involving Dutch men (19), but research with more socioeconomically diverse samples suggests no consistent pattern (9,20–31). Although the hypothesis has been confirmed primarily in studies examining blood pressure (BP) levels, no consensus regarding JH and SES effects on CVR exists (9,18).
One weakness of the previous CVR studies has been the use of nonpersonally salient stressors. Personally relevant psychosocial stressors such as racism stressors (for black participants) and anger recall have shown strong cardiovascular effects in recent studies (8,32), mainly because of their deep psychological and affective impact. One mechanism by which these affective responses drive increased CVR may be worry and rumination, or persistent worry about a stimulus event (33). JH is an everyday behavioral mechanism and low SES a contextual mechanism by which such ruminative processes may produce prolonged CVR and delayed cardiovascular recovery. If one has a personality that is rooted in constant engagement with a challenge (JH) despite low odds for success (low SES or high JS), then revisiting challenging anger-provoking stressors may produce prolonged CVR. Such a conceptualization in which the CVR paradigm is broadened to include recovery from stressors may extend the clinical significance and ecological validity of the JH hypothesis.
Low SES (assessed as education, job status, or income) is associated with increased risk for hypertension, especially among African Americans (34–36). Educational attainment is an especially powerful predictor given that it influences job status, which in turn influences income. Education provides access to coping resources such as social and career networks, impressive credentials, and knowledge of health-promoting behaviors that may help buffer the chronic autonomic and sympathetic responses linked with atypical efforts to overcome taxing environmental stressors. The interaction of low education and high JH in particular has shown predictive effects on high blood pressure levels among black Americans (13–17,26).
Job strain is an indirect and more ecological measure of SES resources (37). It could be argued that such a context-based measure of SES may strengthen the validity of the JH hypothesis by providing supplemental information regarding socioeconomic resources (in addition to that found for traditional measures of SES). Given that JS is predictive of elevated BP levels and CVR (38–40), JH and JS may have powerful additive effects on CVR to psychosocial stress.
Based on the foregoing review, JH should not differentially affect CVR to active speech and anger recall for black males with adequate access to resources (ie, education, low JS), whereas high-JH people with inadequate resources will display greater CVR and delayed cardiovascular recovery. This study extends previous studies by testing the moderating role of the JH hypothesis in CVR and cardiovascular recovery to personally relevant psychosocial stressors in an adult working population.
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METHODS |
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Procedure
Screening
An experimenter took approximately 5 minutes to ask prospective subjects questions about sociodemographic factors, psychosocial factors, health behaviors, and physical health status and medical history. Exclusions included racial group membership not including African American or black American background; diagnoses of any major, chronic medical conditions; or present or past use of antihypertensive medication. The study was limited to black men to investigate further the unique role that certain psychosocial factors have had for the cardiovascular health of African American men in past studies. Future research will investigate the role of low SES, JH, and exposure to psychosocial stress on CVR in black and white men and women.
Laboratory Visit
The 90-minute laboratory visit included the following procedures. First, the subject read and signed an informed consent form that had been approved by the Duke University Medical Center Internal Review Board. Next, the subject completed a battery of questionnaires related to social and psychological factors. Then the experimenter measured casual (seated) BP and heart rate (HR) four times with a Dinamap BP monitor. Subjects who were classified as hypertensive (casual systolic BP="?‘ 
140 mm Hg and/or casual diastolic BP 90 mm Hg) did not qualify for the experimental protocol.
Next, the subject participated in three mental tasks interspersed with four resting periods. First, the experimenter asked the subject to rest for 5 minutes. Then the subject read a short neutral passage (instructions for washing clothes) out loud in his normal speaking voice. The purposes of this task were to collect a baseline measure of speaking BP and HR and to introduce subjects to the BP recording equipment. Subsequent to the reading task, the subject rested for 3 minutes.
The second mental task included a 10-minute active speech task with a 2-minute audiotaped overt racist or a nonracist scenario (subjects assigned randomly). The nonracist stressor described unfair treatment in a shopping scenario that was not explicitly rooted in racial discrimination, whereas the overt racist stressor described unfair treatment in the same shopping scenario that was explicitly rooted in racial discrimination. Before listening to the scenario, the experimenter asked the subject to listen to the tape and then to take 5 minutes to prepare a 5-minute presentation of his thoughts and feelings about the scenario and how he would respond to the situation if he were the target of the unfair treatment. After listening to the audiotape, the subject took 5 minutes to prepare his presentation. During the presentation period, the subject discussed his thoughts and feelings about the situation, and the experimenter asked a set of standardized questions about preferred emotional and behavioral coping responses to the scenario. After the active speech task, the subject rested for 10 minutes.
The final mental task was a 5-minute anger recall task in which the experimenter asked the subject to recall and discuss a previous experience that made him angry. The experimenter added prompts about the aspect of the experience that induced the most anger and preferred coping responses. After the anger recall task, the subject rested for 3 minutes. The order of tasks was set up such that the reading task would orient subjects to the laboratory setting and the active speech task would uncover how a proposed racist vs. nonracist stressor influences CVR to subsequent anger 1
Finally, the experimenter debriefed the subject. Subjects received $30 on completion of the study and a BP reading card with follow-up recommendations.
Cardiovascular Measures
Measures of systolic blood pressure (SBP) and diastolic blood pressure (DBP) and HR in beats per minute were collected continuously throughout the experimental session using an Ohmeda 2300 Finapres BP monitoring device with the cuff placed on the middle finger of the left hand at heart level. The measures for each rest period and task were averaged. Rate pressure product (RPP), a measure of myocardial oxygen demand (41), was assessed for each period by multiplying mean HR by mean SBP and then dividing by 100.
Psychosocial Measures
The present study focused primarily on JH and educational attainment and JS (as measures of SES).2 The education item asked subjects to note their highest level of education in years from 1 to 21, with 21 years denoting the highest possible level of educational attainment.3 JS was measured with a revised 11-item version of the Job Content questionnaire (37). Five items assessed job demands, and six items measured job control. The JS score was computed as the sum of the job demands items and reverse-coded job control items with a higher score indicating higher JS. Other psychological measures such as anger expression (42) and religiosity (43) were also obtained, and results relevant to these variables and CVR will be reported elsewhere.
Assessment of John Henryism
The John Henryism Scale of Active Coping (JHAC) is a 12-item Likert response scale that assesses (1) exceptional mental and physical energy, (2) a focused resolve to realize one’s goals, and (3) a persevering engagement with hard work (13). Five response options for each item extend from completely true (coded as 1) to completely false (coded as 5). Because each item has high-effort content, each item for each subject was reverse-coded and then summed to derive a total JH score that could range from 12 to 60 points (high scores represent high JH). This coding procedure is consistent with other studies testing the JH hypothesis and CVR (9,18). The JHAC has shown acceptable internal consistency with white and black adult and adolescent samples (14,18,44). Adult samples (white and African American men and women) tend to score near the high end of the JHAC. It is important to note that the median cut-off approach for JH tells us something special about high-effort coping in populations at risk for heart disease (13,44).
Reactivity Scores
Analysis comparing the two baselines and the reading period indicated that CVR increased for the reading task, whereas the baselines did not differ from each other (p < .05). Past research has found that speaking by itself produces increases in CVR (45). Therefore, we adopted a conservative approach to calculating reactivity scores (task - baseline) and used the values from the reading task for each dependent variable as the baseline. Reactivity scores were constructed for speech preparation, presentation, postspeech recovery, anger recall, and final recovery. The present study used a 2 (JH: low/high) x 2 (SES factor: low/high) repeated-measures analysis of variance (ANOVA) generated with SPSS-PC software. A 2 (JH: low/high) x 2 (JS: low/high) repeated-measures ANOVA was also tested. All omnibus tests were corrected for violations of sphericity (46). Pair-wise tests (based on unequal variances) were performed to find the location of significant omnibus tests based on a priori expectations of particular cell means for high JH and low SES people (two-tailed t test).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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= 0.70). Although the mean educational attainment score was somewhat high (14.8 ± 2.6 years), there was an acceptable range of scores, from nine to 21 years of education. JS scores were normally distributed (mean = 21 ± 3.24), with a range of scores from 12 to 31. The JS scale showed very good internal consistency (Cronbach = 0.97). JH was positively correlated with educational attainment (r[58] = 0.25, p = .05). Educational attainment was positively correlated with job status (r[54] = 0.73, p = .0001) and income level (r[58] = 0.37, p = .004). JS was inversely correlated with JH (r[54] = -0.35, p = .01). For the repeated measures ANOVAs, JH, education, and JS were measured as dichotomous variables by means of median split. The median score of 50 for the continuous measure of JH is consistent with findings from a previous study of the same population (9). Twenty-seven subjects were classified as low JH and 31 as high JH. Based on mean educational attainment score, education level was assessed as a dichotomous variable by means of a cut-off at 13 years of education. Subjects at or below the cut-off were grouped as low education (N = 20) and those above as high education (N = 38).
F statistics and p values forbetween-group and within-group omnibus tests are shown in Table 1. There were no significant main effects for JH or education level. There were significant period effects for DBP, SBP, HR, and RPP reactivity, with post hoc tests showing significant increases during active speech and anger recall4
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Diastolic Blood Pressure
The education by JH effect (Table 1) showed that at the low education level, high (compared with low) JH was associated with higher DBP reactivity (12.3 mm Hg vs. 3.6 mm Hg). The period by education effect (Table 1) showed that low (compared with high) education level was linked with higher DBP reactivity during final recovery. The period by education by JH effect (Table 1) showed that at high JH, low (compared with high) education level was linked with higher DBP reactivity during anger recall and final recovery (Figure 1,A).5
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Heart Rate
Although the period by JH effect for HR reactivity was significant (Table 1), post hoc tests showed no significant differences in HR reactivity for high and low JH groups. Although the period by education by JH effect was not significant for HR reactivity (Table 1), preplanned analyses indicated that at the low education level, high (compared with low) JH was linked with higher HR reactivity during final recovery (Figure 1,C). At high JH, low (compared with high) education level was linked with higher HR reactivity during speech preparation and final recovery.
Rate Pressure Product
There was a significant education by JH interaction for RPP reactivity (Table 1). At the low education level, high (compared with low) JH was associated with higher RPP reactivity (6.7 mm Hg/min vs. -7.5 mm Hg/min). Although the period by education by JH effect was not significant for RPP reactivity (Table 1), preplanned analyses indicated that at the low education level, high (compared with low) JH was linked with higher RPP reactivity during final recovery (Figure 1,D). At high JH, low (compared with high) education level was linked with higher RPP reactivity during speech preparation and final recovery. Low (compared with high) education level was linked with marginally higher RPP reactivity during postspeech recovery (t[29] = 1.83; p = .07) and anger recall (t[29] = 1.78; p = .08) among high JH people.
John Henryism by Job Strain Effects
There were no significant independent or two-way interactive effects for JH and JS on CVR. The period by JH by JS effect was significant for HR reactivity (F[4,200] = 3.21; p = .03) and RPP reactivity (F[4,200] = 4.68; p = .004). At high JH, high (compared with low) JS was associated with lower HR reactivity during final recovery (t[25] = 2.68; p = .01; -12.3 bpm vs. -5.2 bpm). At low JH, low (compared with high) JS was associated with higher RPP reactivity during presentation (t[25] = 2.11; p = .04; -0.2 mm Hg/min vs. -12.0 mm Hg/min).
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DISCUSSION |
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It is notable that the strongest effects for JH and education were found while participants were simply sitting quietly after the mental stress tasks (ie, while ruminating about the audiotaped shopping scenario and after the anger recall task). This makes high JH and low SES potential key players in ruminative processes and reduced cardiovascular recovery to mental stress. Even stronger CVR may result if subjects are not given a chance to respond to the audiotaped stressor. Previous research has found that not allowing subjects to express their negative affect toward those who have unfairly treated them leads to reduced cardiovascular recovery (47,48). Thus, the experimental protocol can be revised so that subjects are randomly assigned either to participate in the presentation task or simply to sit quietly during this period. The latter group (especially people with high JH and low education) may show higher CVR and reduced cardiovascular recovery given the inhibition of negative affect and active coping and their respective links with increased CVR.
Recent findings suggest that rumination is associated with decreased recovery (33,48). People who score higher on measures of trait rumination are more likely to show slow recovery after being angered (49,50). As a result of experienced negative affect, rumination about anger-provoking situations lengthens the blood pressure elevation (50–52). Antirumination strategies such as distraction have been associated with enhanced recovery and reduced rumination. For instance, Neumann et al. (33) found in a sample of healthy young women that trait rumination was associated with lower levels of HR, pre-ejection period, and cardiac index and higher levels of log-transformed low-frequency HR variability (HRV) during recovery from an anger recall task. On the other hand, subjects who were distracted during recovery showed increases in normalized high-frequency HRV and decreases in log-transformed and normalized low-frequency HRV and low-to-high frequency HRV. Thus, rumination about recall of a personally stressful event predicted increased CVR, but only in those who were not thinking about something else after the recall. This result is related to our findings in that the people with high JH and low SES may have been ruminating about the anger recall but did not have the opportunity to use distraction coping strategies associated with reduced CVR. Thus, they showed reduced recovery in the form of increased BP, HR, and RPP. The present study did not include data on rumination, but future studies will incorporate it as a potential moderator of JH and SES effects on CVR.
The findings suggest something unique about educational attainment, coping, and hypertension risk. Educational resources may buffer the chronic autonomic and sympathetic responses linked with atypical efforts to overcome taxing environmental stressors. The sympathetic and autonomic nervous systems of people with low education and high JH may be preadjusted as a result of previous experience with stress to hyperrespond to social stressors such as those presented in our protocol. Recent research shows that high BP variability or chronically high BP and low HRV may be predictors of cardiovascular disease and subsequent mortality (47,53,54). The present study examined acute physiological responses to a hypothetical social stressor and recall of an anger-inducing personal experience and found notable and sustained elevations in CVR as a function of high JH and low SES. Thus, exposure to real-life stressors over a period of years may produce even more chronically elevated CVR among people with high JH in low SES contexts. The present findings suggest that the impact of JH to produce hypertension in low SES people could result from repeated acute hyperreactive CVR to stress with delayed recovery.
Further research that incorporates representative samples of black and white men and women may shed light on the potentially hypertensive effects of JH and SES in the context of psychosocial stress. The health implications of JH and SES in CVR to stress may not be the same for black men and women (22). It also is vital to resolve whether these effects are specific to blacks or apply to whites and blacks alike. However, the findings in the current study shed light on JH, SES, and CVR for a subpopulation that has been underrepresented in previous studies.
In summary, high SES in the form of high educational attainment appears to protect black males from the impact of JH on the adverse cardiovascular effects of mental stress. For black subjects with high SES, JH may be an adaptive and arguably necessary coping style to manage everyday psychosocial demands. Because of historical and socioeconomic forces, however, engaging in mainstream coping strategies such as JH can have adverse cardiovascular health consequences for black males who lack the resources to cope with such circumstances.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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NOTES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONNOTESACKNOWLEDGMENTSREFERENCES |
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2. Measures of job status and household income were tested as moderators of JH effects on CVR. However, neither job status nor income interacted with JH to predict CVR scores (p > .05). A composite index of SES with a combination of education and income was also used; however, neither this measure nor its interaction with JH significantly predicted CVR (p > .05). Effects for the composite index, job status, and income will not be discussed further.
3. Years 9 to 12 were bracketed by the term "High Sch." so that 12 years of education represents three years of high school education. Years 13 to 16 were bracketed by "College or Trade Sch.," indicating at least some posthigh school educational attainment. Any value equal to or greater than 17 years represents at least some graduate or professional training.
4. The effects of JH and education on mean arterial pressure were also tested with results mirroring those of DBP. Pulse pressure, a potential marker of arterial compliance, was also tested but did not provide significant results.
5. Post hoc tests showed that at the high education level, low (vs. high) JH was associated with higher DBP, SBP, and RPP reactivity during speech preparation. Although these effects were statistically significant, they had limited clinical significance compared with high JH by low education effects for final recovery. CVR during recovery in the low education and high JH group was four to five times greater than the anticipatory response of the high education and low JH group. Thus, the combination of a high-effort coping disposition and low resources (consistent with the JH hypothesis) appears to have the most deleterious effects on cardiovascular functioning.
Received for publication May 2, 2002.
Revision received August 15, 2003.
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