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. 2021 Nov 11;66(3):348–355. doi: 10.1093/annweh/wxab096

Low Social Support at Work and Ambulatory Blood Pressure in a Repeated Cross-sectional Study of White-Collar Workers

Xavier Trudel 1,2,✉, Edwige Tiwa Diffo 1,2, Mahée Gilbert-Ouimet 1,3, Miceline Mésidor 1,2, Denis Talbot 1,2, Alain Milot 1,4, Chantal Brisson 1,2
PMCID: PMC8922192  PMID: 34761261

Abstract

Objectives

Previous studies on the effect of low social support at work on blood pressure showed mixed results. Few previous studies have used ambulatory blood pressure and examined whether the effect of low social support at work vary among men and women. The aim of this study was to examine the association between low social support at work, ambulatory blood pressure means and hypertension prevalence, in a sample of white-collar workers men and women.

Methods

A repeated cross-sectional design was used. Data were collected three times during a 5-year period, among 3919 white-collar women and men. At each time, coworker and supervisor social support at work were measured using validated scales. Ambulatory blood pressure was measured every 15 min during a working day. General estimating equations were used.

Results

In adjusted models, women exposed to low coworker (+0.6 mmHg) and low supervisor social support at work (+0.7 mmHg) had slightly higher diastolic blood pressure means when compared to unexposed women. In men, those with low coworker social support at work had higher diastolic (+0.7 mmHg) blood pressure while those with low supervisor social support had a higher prevalence of hypertension (prevalence ratio = 1.14, 95% CI: 1.04–1.24).

Conclusions

Men with low supervisor social support at work had a higher prevalence of hypertension. Low social support at work was associated with modest increases in diastolic blood pressure among men and women. Workplace prevention strategies aiming to increase social support at work could lead to beneficial effects on worker’s cardiovascular health.

Keywords: ambulatory blood pressure, primary prevention, psychosocial stressors at work, social support, work environment

What’s Important About This Paper?

In this study, conducted among 3919 white collar-workers followed for 5 years, men with low supervisor social support at work had a 14% increase in prevalence of hypertension relative to high support, assessed using ambulatory blood pressure. This association was not observed among women. Low social support at work was associated with modest increases in diastolic blood pressure among men and women. Workplace strategies aiming to improve social support at work could lead to beneficial effects on workers’ cardiovascular health.

Introduction

Hypertension is a leading cause of premature death worldwide (GBD 2017 Risk Factors Collaborators, 2018). It is considered a major global public health problem due to its high prevalence and multi-system complications (Kearney et al., 2004). Hypertension accounts for about half of all strokes and ischemic heart disease events globally (Lawes et al., 2008). According to the recently lowered threshold published in the 2017 ACC/AHA Guideline, nearly half of the working US population aged 45–54 would be hypertensive (Whelton et al., 2017).

Population-based prevention strategies should be promoted to reduce the burden of hypertension (Carey et al., 2018). Population-based strategies aim to reduce the prevalence of modifiable BP risk factors and to downwardly shift the entire distribution of blood pressure (BP). Psychosocial stressors at work are modifiable factors from the work environment and were shown to be associated with the prevalence of hypertension (Landsbergis et al., 2013a; Gilbert-Ouimet et al., 2014). More specifically, the association between job strain, as defined according to the Karasek’s job strain model and high BP has been demonstrated (Landsbergis et al., 2013a; Gilbert-Ouimet et al., 2014). The demand-control model suggests that workers who are simultaneously exposed to high psychosocial demands (PD) and to low decision latitude (DL) are more likely to develop stress-related problems (Karasek, 1979). Low social support from colleagues and from supervisors is a third factor that has been added to the initial model of job strain (Johnson et al., 1989). A low level of social support at work is hypothesized to amplify the negative impact of job strain on cardiovascular health. Previous evidence suggests that low social support at work could also act as an independent cardiovascular disease (CVD) risk factor on its own (Johnson and Hall, 1988; Falk et al., 1992). However, the effect of low social support at work on hypertension is inconsistent in previous studies (Niedhammer et al., 1998; Pelfrene et al., 2002). Two important methodological limitations could explain these mixed findings. First, few studies have examined the effect of low social support using ambulatory blood pressure (ABP) measurement. ABP measures blood pressure automatically during daily activities at home or at work (Hayashi et al., 1996; Landsbergis et al., 2013b). Its superiority has been shown in terms of validity and reliability over clinic BP measurement (O’Brien, 2003; Dolan et al., 2005; Mancia et al., 2007). Second, among studies using ABP, few have examined whether the adverse effect of low social support at work varies among men and women (Karlin et al., 2003).

The aim of this study was to examine the association between low social support at work and hypertension prevalence, assessed using ambulatory blood pressure, in a sample of white-collar workers men and women.

Methods

The study design and population were detailed previously (Trudel et al., 2018). The study relied on a repeated cross-sectional design involving three waves of data collection over a period of 5 years (years 1, 3, and 5). The study population was composed of white-collar men and women working in three public insurance institutions in Quebec City, Canada. Their main professional activities involved organizing and providing insurance services to the general population. Their jobs covered the full range of white-collar occupations, including office workers, technicians, professionals, and middle and senior managers. There was no shift and night workers in this study population. At each data collection, participants were met at their workplace and social support at work was measured using validated scales. All employees were invited to complete a self-administered questionnaire on the work environment and BP risk factors during each data collection phase. The participation rate was 80.1% during the first data collection and reached 85% at both follow-ups. Workers participated in only one (n = 1370), two (n = 1287), or all three (n = 1298) measurements, contributing one observation for each participation. The unit of analysis for the present study was the number of observations. Observations for which women reported being pregnant (N = 59) or with insufficient working time (less than 21 h per week, N = 41) were excluded. The final study sample consisted of 3919 workers and 7738 observations.

Social support

Social support at work was measured using the Job Content Questionnaire (JCQ) using validated scales (Karasek et al., 1998). The consistency, reliability and validity of the JCQ have been demonstrated (Brisson et al., 1998; Larocque et al., 1998). Six items were used to assess coworker social support and five items were used to assess supervisor social support. Participants rated each item on a 4-point Likert-type scale. Responses were summed to obtain a total score for coworker and supervisor social support. Binary variables were created using the sample median split yielding high and low social support.

Ambulatory blood pressure

Spacelabs 90207 device (Spacelabs produit Médicaux Ltée, St-Laurent, Québec Canada) was used in the present study to measure ABP (O’Brien et al., 1991, 2000). The device was installed in a research office at the participant’s workplace on the non-dominant arm if the difference in BP measure between both arms was inferior to 10 mmHg, otherwise it was installed on the arm with the highest BP value. ABP was measured every 15 min during daytime. The participants tasks were mainly achieved in a seating position. In order to minimize motion artefacts, clear instructions were given to participants in case the monitor performed a reading while they were in a standing position (stop working and resting arm at their side). Participants had at least 20 ABP measurements which is in accordance with criteria recently recommended by expert committees (Cloutier et al., 2015). We defined normotension as daytime systolic ABP less than 135 mmHg and daytime diastolic ABP less than 85 mmHg. Hypertension was defined as daytime systolic ABP ≥135 mmHg, or daytime diastolic ABP ≥85 mmHg or being treated for hypertension.

Covariates

Several factors were considered as potential confounders including sociodemographic factors (sex, age, education), lifestyle related risk factors (cigarette smoking, alcohol intake) as well as body mass index (BMI), family history of CVD, medication for hypertension and job strain. Smoking status was defined as a daily consumption of at least one cigarette per day. Three categories were used to measure alcohol intake frequency for the pass year: less than one drink weekly, one to five drinks per week and six or more drinks per week. Body weight and height were measured to determine BMI (kg/m2). Participants were asked if they had a family history of CVD. The latter was defined as a cardiovascular event like angina, myocardial infarction, coronary revascularization or stroke suffered by the participant’ mother, father, brother or sister before the age of 60 years. All the risk factors listed above were evaluated using validated protocols (Daveluy et al., 1994, 2000). Job strain was assessed using a total of eighteen items from the JCQ (Karasek et al., 1998): nine items to assess psychological demand (which reflect quantity of work, level of intellectual effort required and time constraints) and nine items to assess decision latitude (which reflect autonomy, participation in decision-making process and opportunities for learning). Participants were considered as having high psychological demands if the psychological demands score were greater or equal to 24 (the median for the general working population of Quebec) (Daveluy et al., 2000). Workers were classified as having low decision latitude with a decision latitude score of 72 or lower (median for the general working population of Quebec) (Daveluy et al., 2000). Workers with high psychological demands and low decision latitude were defined as having job strain.

Statistical analysis

Generalized estimating equations (GEE) were used to examine the association between low social support at work, ABP means and hypertension prevalence. GEE take into account within-subject correlation resulting from pooling observations reported by the same individual. All employees at each measurement time were included in the analyses. Systolic and diastolic ABP means were estimated, according to exposure assessed at the same measurement time. Mean ABP and their 95% confidence intervals (CI) were modelled using linear regression. Prevalence ratios (PR) of hypertension was modelled using robust Poisson regression along with their 95% CI (Knol et al., 2012). It should be noted that lifestyle risk factors might act as mediating variables, i.e. intervene in the causal pathway linking psychosocial stressors at work to BP (Kivimaki et al., 2006). Two adjusted models were therefore computed: the first was adjusted for age, education, family history of CVD and, in the case of ABP means, medication for hypertension; the second was additionally adjusted for smoking, BMI, alcohol intake and job strain. The potential modifying effect of job strain was examined and was not statistically significant. Previous studies have suggested that the effect of psychosocial stressors at work on blood pressure and hypertension differed by sex (Gilbert-Ouimet et al., 2014). Therefore, we examined the potential modifying effect of sex using multiplicative interaction terms. The results were statistically significant for both coworker and supervisor social support (results not shown). All analyses were conducted separately in men and women. To handle with missing values, we performed 12 multiple imputations using the Multiple Imputation (MI) procedure. To improve the validity of imputations, we imputed data by sex and time of measurement. Rubin’s rule was used to combine the 12 imputed estimates. We performed three sensitivity analyses. First, we restricted the analysis to the first measurement for all participants. Second, we stratified the analysis for ABP means according to hypertension medication. Finally, social support at work was categorized into tertiles to enhance contrast between groups.

SAS V.9.4 software was used to perform all analysis. This study was approved by the ethical review board of the CHU de Québec-Université Laval research center (# F9-49432). All participants signed a consent form describing the study and were free to withdraw at any time.

Results

Table 1 summarizes the participants’ characteristics. Of the 7738 observations, 39.4% were from men and 60.6% from women. The mean age was 45.6 (SD 9.1) for men and 44.4 (SD 8.3) years for women. Men were generally more educated than women, had high BMI and consumed more alcohol while women were more likely to smoke and have a known history of CVD. Women were also more likely to be exposed to job strain than men (21.7% versus 16.9%). Mean ABP was 129.2/82.4 mmHg (SD 10.3/7.7) in men and 121.7/77.8 mmHg (SD 10.3/7.5) in women.

Table 1.

Description of the study population.

Participants’ characteristics No of observations (%)
Men (N = 3047) Women (N = 4691)
Age (years)a 45.6 (9.1) 44.4 (8.3)
Body mass index (kg/m2)a 27.0 (4.2) 25.9 (6.5)
Education
 Less than college 414 (13.6) 1402 (29.9)
 College 915 (30.0) 1563 (33.3)
 University 1718 (56.4) 1725 (36.8)
Family history of CVD
 No 2008 (67.6) 2855 (63.1)
 Yes 961 (32.4) 1672 (36.9)
Alcohol intake
 <1 drink/week 836 (27.5) 1757 (37.5)
 1–5 drink/week 1153 (37.9) 2008 (42.9)
 ≥6 drink/week 1054 (34.6) 919 (19.6)
Smoking status
 No 2730 (89.7) 4074 (87.0)
 Yes 313 (10.3) 611 (13.0)
Job strain
 No 2513 (83.1) 3653 (78.3)
 Yes 512 (16.9) 1015 (21.7)
Ambulatory blood pressure (mmHg)a
 Systolic 129.2 (10.3) 121.7 (10.3)
 Diastolic 82.4 (7.7) 77.8 (7.5)
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aValues expressed as mean (standard deviation, SD).

Table 2 presents ABP means according to coworker and supervisor social support. After adjustment for age, sex, family history of CVD and medication of hypertension, men with low coworker social support had slightly higher systolic (+0.9 mmHg) and diastolic (+0.8 mmHg) ABP means compared to men with high coworker social support. Mean systolic (+0.7 mmHg) and diastolic (+0.6 mmHg) ABP was also slightly higher in men with low supervisor social support. These estimates were attenuated following additional adjustment for lifestyle-related risk factors and job strain. Among women, those with low coworker social support (+0.6 mmHg) and those with low supervisor social support (+0.7 mmHg) had higher diastolic ABP means when compared with those with high social support, in the fully adjusted models.

Table 2.

Mean ambulatory blood pressure according to coworker and supervisor social support among men and women.

Systolic ABP (mmHg) Diastolic ABP (mmHg)
N Crude Adjusteda Adjustedb Crude Adjusteda Adjustedb
Men
 Coworker
  High 1464 128.6 128.8 128.9 81.8 82.0 82.0
  Low 1583 +1.2 (0.4, 2.1) +0.9 (0.0, 1.7) +0.7 (−0.2, 1.5) +1.2 (0.6, 1.9) +0.8 (0.2, 1.5) +0.7 (0.1, 1.4)
 Supervisor
  High 1441 128.7 128.9 129.1 81.9 82.1 82.2
  Low 1606 +1.1 (0.3. 1.9) +0.7 (−0.1, 1.5) +0.4 (−0.4, 1.16) +1.0 (0.4, 1.6) +0.6 (−0.0, 1.2) +0.4 (−0.2, 1.0)
Women
 Coworker
  High 2323 121.3 121.5 121.5 77.4 77.4 77.5
  Low 2368 +0.9 (0.2, 1.6) +0.6 (−0.1, 1.2) +0.5 (−0.2, 1.1) +0.8 (0.3, 1.3) +0.7 (0.3, 1.2) +0.6 (0.1, 1.1)
 Supervisor
  High 2168 121.4 121.5 121.6 77.4 77.4 77.4
  Low 2523 +0.8 (0.1, 1.4) +0.5 (−0.1, 1.2) +0.4 (−0.2, 1.0) +0.9 (0.4, 1.3) +0.8 (0.3, 1.3) +0.7 (0.2, 1.2)
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aAdjusted for age, education, family history of CVD and medication for hypertension.

bAdditionally adjusted for smoking, BMI, alcohol intake and job strain.

Table 3 presents the prevalence ratio of hypertension associated with a low social support at work. In the fully adjusted model, men with low supervisor social support had a 14% increase in the prevalence of hypertension (PR = 1.14, 95% CI: 1.04–1.24) compared to men with high supervisor social support. There was a slightly increased prevalence of hypertension in men with low coworker social support in the crude model, but the association was reduced and no longer statistically significant in the fully adjusted model (PR = 1.06, 95% CI: 0.97–1.16). Exposure to low social support at work was not associated with hypertension among women. Sensitivity analyses using the first measurement for all participants and categorizing exposure in tertiles yielded similar results (Supplementary File, available at Annals of Work Exposures and Health online). In the analyses stratified by medication use, no significant associations were found between low social support at work and systolic ABP among untreated and treated subjects. Mean diastolic ABP was significantly higher in treated men with low coworker social support at work compared to men with high coworker social support at work, whereas this association was not statistically significant among untreated participants. The results were different for women. Untreated women with low coworker social support and low supervisor social support had higher systolic and diastolic ABP compared to those with higher support (Supplementary File, available at Annals of Work Exposures and Health online).

Table 3.

Prevalence ratio for low social support at work and hypertension among men and women.

N Crude prevalence ratio
(95% CI)		 Adjusted prevalence ratioa
(95% CI)		 Adjusted prevalence ratiob
(95% CI)
Men
 Coworker social support
  High 1464 1.00 1.00 1.00
  Low 1583 1.16 (1.06, 1.27) 1.08 (0.98, 1.18) 1.06 (0.97, 1.16)
 Supervisor social support
  High 1441 1.00 1.00 1.00
  Low 1606 1.26 (1.15, 1.37) 1.17 (1.07, 1.28) 1.14 (1.04, 1.24)
Women
 Coworker social support
  High 2323 1.00 1.00 1.00
  Low 2368 1.16 (1.04, 1.30) 1.07 (0.96, 1.20) 1.06 (0.95, 1.18)
 Supervisor social support
  High 2168 1.00 1.00 1.00
  Low 2523 1.11 (0.99, 1.24) 1.04 (0.93, 1.16) 1.02 (0.91, 1.13)
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aAdjusted for age, education, family history of CVD and medication for hypertension.

bAdditionally adjusted for smoking, BMI, alcohol intake and job strain.

Discussion

In this present study, low supervisor social support at work was associated with an increased prevalence of hypertension in men after adjusting for age, sex, education, family history of cardiovascular disease, BMI, alcohol consumption and job strain. The associations between low social support at work and ABP means among men and women were of modest magnitude.

Previous studies have examined the effect of social support on BP means and showed inconsistent findings. Among studies using ABP measurements, one previous cross-sectional study, conducted among male (N = 36) and female (N = 34) US Traffic Enforcement Agents showed that low coworker social support was associated with workday systolic ABP among men while low supervisor social support was associated with workday systolic ABP among women (Karlin et al., 2003). Results from the present study do not support a clear distinctive pattern of ABP increases among men and women, both types of low social support being associated with modest increases in ABP among both sexes. In a study conducted among 167 working men and women from the BELSTRESS cohort, nondipping nocturnal ABP was not associated with low social support at work although variations according to social support subtypes and sex differences were not examined (Clays et al., 2012). A study conducted among 55 care employees, mostly women (N = 51), showed that negatively perceived supervisory interactions were associated with higher systolic ABP at work and at home (Wong and Kelloway, 2016). To our knowledge, other previous studies on low social support at work and ABP were conducted among sex-specific samples. A study conducted among 262 male workers in the USA showed a buffering effect of social support at work on the association between job strain and ABP while no independent effect of social support was observed (Landsbergis et al., 1994). A study conducted among 108 women showed an association between low social support at work and systolic ABP (Gallo et al., 2004), while another study, conducted among 149 men from a BP screening program, showed no association (Rau et al., 2001). Some previous studies on low social support and clinical BP examined women and men separately allowing to examine potential differences (Niedhammer et al., 1998; Pelfrene et al., 2002). One of these studies observed no associations (Pelfrene et al., 2002) while the other observed a small but non-significant association in both women and men (Niedhammer et al., 1998). In these studies, low participation proportion (48% and 45%, respectively) could have led to a healthy worker selection effect and a bias toward the null, which could partly explain the absence of associations.

The present study was conducted among a sizable population of workers and examined the adverse effect of low social support on both ABP means and hypertension prevalence. Using hypertension as an additional and distinctive outcome provided additional insights as to how low social support at work is linked with BP on the severity continuum. Our findings suggest that low social support at work is associated with slight increases in ABP among both men and women, while the association with hypertension is only observed for low social support from the supervisor, among men. The absence of association for hypertension in women could be explained by sex differences in the onset on cardiovascular alteration. Women’s biological attributes place them at a reduced risk until menopause (except for pregnancy periods) compared to men. Indeed, it is well documented that cardiovascular events tend to occur approximately 10 years later in women (Arnold et al., 2005). In post hoc analyses, we have examined whether the effect of low social support vary according to age among women and found no evidence of such effect modification (not shown). However, this hypothesis should be examined more thoroughly in future studies.

Our study has limitations. First, despite the usefulness of the repeated cross-sectional design to increase precision, it was not possible to examine the longitudinal relationship linking low social support, blood pressure evolution and the risk of subsequent hypertension. Second, our measure of ABP was collected at work only. Therefore, some relevant aspect of the relationship could not be investigated. For example, social support at work was shown to be associated with dipping status at night, which investigation would have required nighttime BP measurements. Finally, our study population was composed of white-collar workers. It raises the issue of generalizability to other types of occupations. Nonetheless, it was previously suggested that associations between risk factors and CVD incidence among white-collar workers are of comparable magnitude to those observed in the general population (Batty et al., 2014). It is also of note that the service industry represents a sizable and increasing proportion of the general working population in industrialized countries which also factors generalization.

Our study has strengths including the sizable sample of men and women. Social support at work was assessed using validated scales and BP was assessed using ambulatory measurements, reducing the potential for information bias. Moreover, a high participation proportion, above 80% at each measurement time, was achieved, limiting section bias. We adjusted our models for a large number of potential confounders, including sociodemographic, lifestyle related risk factors and job strain. Finally, the use of a repeated cross-sectional design increased study power and allowed an examination of the differential effect of low social support among men and women.

In the present study, low supervisor social support at work was associated with a higher prevalence of hypertension among men, after accounting for sociodemographic, lifestyle-related risk factors and job strain. Low coworker and low supervisor social support were associated with modest increases in ABP among men and women. Our findings suggest that primary prevention strategies in workplaces aiming to improve coworker and supervisor social support could lead to beneficial effects on worker’s cardiovascular health. Organizational-level interventions that include preventive actions aiming to improve social support at work could contribute to reduce the critical burden of hypertension.

Supplementary Material

wxab096_suppl_Supplementary_Files
Click here for additional data file. (58.7KB, docx)

Acknowledgements

This work was performed at the CHU de Québec-Université Laval Research Center, Quebec City, Canada.

Funding

This work was supported by a grant from the Canadian Institutes for Health Research (# 57750).

Conflict of interest

None declared.

Disclaimer

Its contents, including any opinions and/or conclusions expressed, are solely those of the authors.

Data availability

The data underlying this article will be shared on reasonable request to the corresponding author.

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Associated Data

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Supplementary Materials

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Data Availability Statement

The data underlying this article will be shared on reasonable request to the corresponding author.

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