Xavier Trudel

Adverse effects of psychosocial work factors on blood pressure: systematic review of studies on demand–control–support and effort–reward imbalance models

OBJECTIVES A growing body of research has investigated the adverse effects of psychosocial work factors on blood pressure (BP) elevation. There is now a clear need for an up-to-date, critical synthesis of reliable findings on this topic. This systematic review aimed to evaluate the adverse effects of psychosocial work factors of both the demand-control-support (DCS) and effort-reward imbalance (ERI) models on BP among men and women, according to the methodological quality of the studies. METHODS To be eligible, studies had to: (i) evaluate at least one psychosocial work factor, (ii) evaluate BP or hypertension, (iii) comprise ≥100 workers, (iv) be written in English or French, and (v) be published in a peer-reviewed journal. RESULT A total of 74 studies were included. Of these, 64 examined the DCS model, and 12 looked at the ERI model, with 2 studies considering both models. Approximately half the studies observed a significant adverse effect of psychosocial work factors on BP. A more consistent effect was observed, however, among men than women. For job strain, a more consistent effect was also observed in studies of higher methodological quality, ie, studies using a prospective design and ambulatory BP measures. CONCLUSIONS A more consistent adverse effect of psychosocial work factors was observed among men than women and in studies of higher methodological quality. These findings contribute to the current effort of primary prevention of cardiovascular disease by documenting the psychosocial etiology of elevated BP, a major cardiovascular risk factor.

Job Strain and Masked Hypertension

Objectives: To determine whether psychosocial work characteristics are associated with the prevalence of masked hypertension in a population of white collar workers. Methods: White-collar workers were recruited from three public organizations. Blood pressure (BP) was measured at the workplace for manual measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of all subsequent readings taken during the working day). Masked hypertension (MH) was defined as manual BP <140/90 mm Hg, and ambulatory BP ≥135/85 mm Hg. Job strain was evaluated, using the quadrant method for exposure assessment, as well as alternative formulations. Results: BP measurements were obtained from 2,357 workers (80% participation, 61% women; mean age, 44 years). For men, being in the active group (high psychological demands and high decision latitude) was associated with MH (adjusted odds ratio, 2.07; 95% confidence interval, 1.30-3.31). No significant association with a higher prevalence of MH was observed in women. Conclusion: MH is associated with job strain in men. Workers in “active” job situations may be more likely to have the condition. MH = masked hypertension; WCHT = white-coat hypertension; MBPM = manual blood pressure monitoring; ABPM = ambulatory blood pressure monitoring; DABP = diastolic ambulatory blood pressure; OBP = office blood pressure; OOBP = out-of-office blood pressure; CBP = casual blood pressure; BMI = body mass index; OR = odds ratio.

Masked hypertension: different blood pressure measurement methodology and risk factors in a working population

Objectives To estimate the prevalence of masked hypertension when the same ambulatory device is used for both manual and ambulatory blood pressure measurements and to measure associations with lifestyle risk factors in a working population. Methods White-collar workers were recruited from three public organizations. Blood pressure was measured at the workplace using Spacelabs 90207 for manual measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of every other reading obtained during the working day). Masked hypertension was defined as manual blood pressure measurement of less than 140/90 mmHg and ambulatory blood pressure measurement of at least 135/85 mmHg. Smoking, alcohol intake, BMI and leisure physical activity were also assessed. Results Blood pressure measurements were obtained from 2370 workers (80% participation, 61% women; mean age = 44 years). Masked hypertension was diagnosed in 15.02% of the participants. The prevalence was higher in men [adjusted odds ratio (OR) = 2.38, 95% confidence interval (CI) = 1.86–3.05]. The prevalence in men increased with age (adjusted OR = 2.08 for 40–49 years, 95% CI = 1.33–3.26 and adjusted OR = 1.91 for ≥50 years, 95% CI = 1.20–3.04) and BMI (adjusted OR = 1.78 for BMI ≥ 27, 95% CI = 1.21–2.64). The prevalence in women increased with BMI (adjusted OR = 1.65 for BMI ≥27, 95% CI = 1.14–2.39) and alcohol intake (adjusted OR = 2.12 for at least six drinks per week, 95% CI = 1.34–3.35). Conclusion Masked hypertension is frequent and still present when blood pressure is measured out of the office, using the same device for manual and ambulatory measurements. Sex, age, BMI and alcohol intake are associated with masked hypertension.

Persistence and Progression of Masked Hypertension: A 5-Year Prospective Study

Objectives. To examine masked hypertension persistence over 5 years. Methods. White-collar workers were recruited from three public organizations. Blood pressure (BP) was measured using Spacelabs 90207. Manually operated BP was defined as the mean of the first three readings taken at rest. Ambulatory BP was defined as the mean of the next readings taken every 15 minutes and recorded during working hours. BP was assessed three times over 5 years. Masked hypertension was defined as manually operated BP less than 140 and less than 90 mmHg and ambulatory BP at least 135 or at least 85 mmHg. Sustained hypertension was defined as manually operated BP at least 140 or at least 90 mmHg and ambulatory BP at least 135 or at least 85 mmHg or being treated for hypertension. Results. BP measurements were obtained from 1669 participants from whom 232 had masked hypertension at baseline. Persistence of masked hypertension was 38% and 18.5%, after 3 and 5 years, respectively. Progression to sustained hypertension was 26% and 37%, after 3 and 5 years, respectively. Conclusion. Among baseline masked hypertensives, one-third progressed to sustained hypertension and about one out of five remained masked after 5 years, potentially delaying diagnosis and treatment.

Adverse psychosocial work factors, blood pressure and hypertension incidence: repeated exposure in a 5-year prospective cohort study

Background Two main theoretical models have been used to assess the impact of psychosocial work factors on blood pressure (BP): the demand–control (DC) model and the effort–reward imbalance (ERI) model. Previous studies have mostly used a single time point exposure to examine this association. Objective To examine the effect of repeated job strain and ERI exposure on (1) ambulatory BP (ABP) evolution over 5 years and (2) hypertension incidence over 5 years. Method The design is a prospective cohort study. The study population was composed of 1394 white-collar workers (568 men and 826 women). They were assessed three times during a 5-year period (years 1, 3 and 5). At each time, psychosocial work factors were measured using validated scales and ABP was measured every 15 min during a working day. Results Men who were chronically exposed over 5 years to an active job had a higher cumulative incidence of hypertension (RR=2.05, 95% CI 1.36 to 3.09), compared with never-exposed men. In women, ERI exposure onset was associated with higher increases in systolic ABP (+2.5 mm Hg). No association was found between chronic high-strain exposure and ABP. Conclusions Chronic exposure to active jobs in men led to a higher risk of hypertension and ERI exposure onset in women led to increases in systolic ABP. Results from the present study highlight the need to consider chronic exposure in order to fully capture the deleterious effect of adverse psychosocial work stressors on cardiovascular health.

Psychosocial work environment and ambulatory blood pressure: independent and combined effect of demand-control and effort-reward imbalance models

Background Two main theoretical models have been used to assess the impact of psychosocial work factors on blood pressure (BP): the demand-control model (DC) and the effort-reward imbalance (ERI) model. Little is known about their independent and combined effect. Objective To examine the independent and combined effect of the DC and ERI models on ambulatory BP (ABP). Method Data were collected three times over 7 years from 3395 white-collar women and men using a repeated cross-sectional design. On each occasion, psychosocial work factors were measured using validated scales. ABP was measured every 15 min during a working day. Systolic and diastolic ABP means were examined in relation to contemporaneous and past exposure. Both models were mutually adjusted. A combined exposure variable was computed. Results In men, high strain, and active, passive and ERI exposure were associated with ABP using contemporaneous exposure. However, the high strain/ABP association was not significant after adjustment for ERI. In women, no association was found with the DC model, while women exposed to ERI had higher ABP. Use of past exposure showed a stronger association between ABP and active exposure in men, while ERI associations were attenuated. Combined exposure to active jobs and to ERI was associated with ABP in both genders. Conclusions In men, associations with the DC model were mixed. Associations between high job strain and ABP were not independent of ERI exposure while both DC intermediate groups were independently associated with ABP. In women, no association was found with the DC model. ERI exposure was independently associated with ABP using contemporaneous exposure, but not using past exposure. Combined active and ERI exposure was also associated with ABP.

Masked hypertension and effort-reward imbalance at work among 2369 white-collar workers

Hypertension is an important risk factor of cardiovascular diseases, the leading cause of death worldwide. Adverse effects of psychosocial factors at work might increase the risk of masked hypertension, but evidences are still scarce. The objective of this study is then to determine whether adverse psychosocial work factors from the effort-reward imbalance (ERI) model are associated with the prevalence of masked hypertension in a population of white-collar workers. White-collar workers were recruited from three public organizations. Blood pressure was measured at the workplace for manually operated measurements (mean of the first three readings taken by a trained assistant) followed by ambulatory measurements (mean of all subsequent readings taken during the working day). Masked hypertension was defined as manually operated BP<140/90 mm Hg and ambulatory BP ⩾135/85 mm Hg. ERI exposure at work was measured using Siegrist’s validated questionnaire. Blood pressure readings were obtained from 2369 workers (participation proportion: 85%). ERI exposure (OR: 1.53 (95% CI: 1.16–2.02) and high efforts at work (OR: 1.61 (95% CI: 1.13–1.29) were associated with masked hypertension, after adjusting for sociodemographic and cardiovascular risk factors. Workers exposed to an imbalance between efforts spent at work and reward had a higher prevalence of masked hypertension. High efforts at work might be of particular importance in explaining this association. Future studies should be designed to investigate how clinicians can include questions on psychosocial work factors to screen for masked hypertension and how workplace interventions can decrease adverse psychosocial exposures to lower BP.

Psychosocial work factors and social inequalities in psychological distress: a population-based study

BackgroundMental health problems (MHP) are the leading cause of disability worldwide. The inverse association between socioeconomic position (SEP) and MHP has been well documented. There is prospective evidence that factors from the work environment, including adverse psychosocial work factors, could contribute to the development of MHP including psychological distress. However, the contribution of psychosocial work factors to social inequalities in MHP remains unclear. This study evaluates the contribution of psychosocial work factors from two highly supported models, the Demand-Control-Support (DCS) and the Effort-Reward Imbalance (ERI) models to SEP inequalities of psychological distress in men and women from a population-based sample of Quebec workers.MethodsData were collected during a survey on working conditions, health and safety at work. SEP was evaluated using education, occupation and household income. Psychosocial work factors and psychological distress were assessed using validated instruments. Mean differences (MD) in the score of psychological distress were estimated separately for men and women.ResultsLow education level and low household income were associated with psychological distress among men (MD, 0.56 (95% CI 0.06; 1.05) and 1.26 (95% CI 0.79; 1.73) respectively). In men, the contribution of psychosocial work factors from the DCS and the ERI models to the association between household income and psychological distress ranged from 9% to 24%. No clear inequalities were observed among women.ConclusionsThese results suggest that psychosocial work factors from the DCS and the ERI models contribute to explain a part of social inequalities in psychological distress among men. Psychosocial factors at work are frequent and modifiable. The present study supports the relevance of targeting these factors for the primary prevention of MHP and for health policies aiming to reduce social inequalities in mental health.

Workplace Interventions Aiming to Improve Psychosocial Work Factors and Related Health

Workplace interventions aiming to improve work environment characteristics, including psychosocial work factors, have been widely recommended to improve workers’ health. This chapter presents: (i) evidences regarding the effects of interventions aiming to reduce adverse psychosocial work factors and related health problems, (ii) quality criteria required to conduct solid intervention research in this area, (iii) three psychosocial workplace intervention studies meeting most of these quality criteria, and (iv) public health policies aiming to help reduce adverse psychosocial work factors. Overall, psychosocial workplace intervention studies have led to inconsistent findings. However, a better understanding of the methodological quality, content and context of these interventions could contribute to explain their varying effectiveness. The three high quality psychosocial workplace intervention studies presented in this chapter observed improvements of both psychosocial work factors and health outcomes. Solid psychosocial workplace interventions appear to be promising approaches and could lead to significant health benefits.

THE 22-YEAR PROSPECTIVE QUEBEC (PROQ) STUDY ON WORK AND HEALTH CONDUCTED AMONG 9000 WHITE-COLLAR WORKERS

Objective: Cardiovascular diseases (CVD) are the leading cause of mortality worldwide accounting for 17.7 million deaths per year. Mental health problems (MHP) are the first cause of disability worldwide. Their prevalence, long duration and high risk of recurrence place a considerable burden on health and social care systems and important productivity losses for employers. The PROspective Quebec (PROQ) Study on Work and Health is a prospective cohort initiated in 1991-93 to further extend our comprehension of the effect of work stressors on cardiovascular and mental health outcomes. Design and method: At baseline (1991–1993), the study population involved 9,189 white-collar workers aged 18 to 65 years-old employed by 19 specific public organizations in Quebec City. At the first follow-up, 8 years later (1999–2001), 8,121 workers agreed to participate again corresponding to 89% of the initial sample. The 22-year follow-up (2015–18) is currently ongoing. This second follow-up includes measurements at later life of a large number of cardiovascular and mental health outcomes as well as their major risk factors, including blood pressure. Results: Data collection procedures are a self-reported questionnaire, an interview, biological variables and medico-administrative databases extractions. This prospective cohort will fill important research gaps related to: 1) the pathways by which adverse psychosocial work stressors cumulated over the working life could lead to higher risk of cardiovascular diseases (CVD) and mental health problems (MHP) at older ages, 2) the effects of psychosocial work stressors on novel subclinical markers of disease risk (aortic stiffness, inflammatory markers, telomere length, cognitive function) and 3) the costs of CVD and mental health problems attributable to work stressors. Conclusions: This cohort is one of the most rigorous and extensive occupational cohorts in the world. The results will contribute substantially to the primary prevention of CVD and MHP.