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. Author manuscript; available in PMC: 2024 Jan 1.
Published in final edited form as: Health Psychol. 2022 Nov 21;42(1):53–62. doi: 10.1037/hea0001255

Expectations of respect and appreciation in daily life and associations with subclinical cardiovascular disease

Jenny M Cundiff 1, Thomas W Kamarck 2, Matthew F Muldoon 2, Anna L Marsland 2, Stephen B Manuck 2
PMCID: PMC9853515  NIHMSID: NIHMS1856466  PMID: 36409101

Abstract

Objective:

To test whether expectations of respect and appreciation from others, assessed in daily life, are associated with preclinical vascular disease.

Method:

Participants were an urban community sample of 483 employed adults (47% male, 17% Black, mean age = 42.8 years). Carotid intima-media thickness (IMT) was measured using B-mode ultrasound. Expectations of being treated with respect and appreciation were measured using the average of hourly assessments over the course of 4 days, and home and work averages were also examined separately.

Results:

Expectations of greater respect and appreciation from others were associated with significantly less carotid IMT even after adjustment for demographic factors, general positivity and negativity of social interactions, neuroticism, optimism, perceived discrimination and concurrent biological risk factors. This association was similar across social contexts of work and home and also when expectations of respect and appreciation were examined separately. Lower expectations of respect and appreciation and more negative social interactions were both independently associated with greater IMT in fully adjusted models and effect sizes were similar to traditional biological risk factors such as BMI.

Conclusions:

Mid-life adults who anticipate greater respect and appreciation from others in everyday life evidence less preclinical vascular disease. Consistent with the literature showing that anticipation of social threats and unfair treatment may increase cardiovascular risk, expectations of being valued and treated with respect by others is associated with decreased risk.

Keywords: respect, agency, intima-media thickness, cardiovascular, ecological momentary assessment

Cardiovascular disease is the leading cause of death in the United States, and the quality of our social interactions and relationships contribute to differences in cardiovascular health. In general, warm and supportive social relationships are associated with better health, and repetitive interpersonal stress and conflict are associated with poorer health (e.g., Cohen, 2004; Holt-Lunstad, Smith, & Layton, 2010; Pietromonico & Collins, 2017; Smith & Weihs, 2019).

Although not yet directly examined in the literature, receiving respect and appreciation from others in everyday life may be associated with better cardiovascular health. A significant literature suggests that being treated unfairly, with less respect and consideration than others, is interpersonally stressful, counter-productive to the development and maintenance of strong social bonds and associated with cardiovascular risk (e.g., Gottman, 1994; Williams et al. 2012). For example, one of the strongest predictors of divorce is the display of contempt during marital interactions, where contempt is defined as harsh displays of disrespect (e.g., disgust; Gottman, 1994). Discriminatory experiences, characterized by disrespectful and unfair interpersonal treatment, and measured using items such as being “treated with less respect or courtesy than other people” or people “acting as if they are better than you,” also contribute to stress and cardiovascular risk (Williams et al. 1997). Although many studies of discrimination and unfair treatment focus on racism as a particularly important form of unfair treatment that may help explain Black-White differences in cardiovascular disease, greater exposure to unfair treatment has been associated with more stress and poorer cardiovascular health in both Black and White Americans (Dolezsar, McGrath, Herzig & Miller, 2014; Lewis, Cogburn & Williams, 2015; Moody et al. 2020; Pascoe & Smart-Richman, 2009; Peterson et al. 2016; Williams et al., 2012).

Experiences of disrespect and unfair treatment may contribute to stress-related wear and tear on the cardiovascular system through repeated exposures to instances of unfair treatment, but chronic vigilance in anticipation of poor treatment may also play a role. Vigilance to social threats appears to increase vascular resistance (Gump & Matthews, 1998; Smith, Ruiz, & Uchino, 2000), which may promote atherogenesis via disruptions of laminar flow (shear stresses) at common sites of lesion development (Davies, 2009; Fukumoto et al. 2008; Malek, Alper & Izumo, 1999). Thus, chronic or sustained vigilance may contribute to risk for atherosclerotic cardiovascular disease, and anticipation of unfair treatment may represent a more chronic and sustained stressor than acute experiences of poor treatment. Consistently, previous research has found that socially vigilant individuals, those who expect and attend more to potential social threats, show increased risk for cardiovascular disease (e.g., Ruiz, Taylor, Uchino et al. 2017). Additionally, a recent paper by Lewis and colleagues (2019) found that greater expectations of unfair treatment on the basis of race, but not actual exposures to racism in the last 12 months, were associated with greater subclinical atherosclerosis as indexed by carotid intima-media thickness (IMT).

Expectations of disrespectful and unfair treatment may reflect an individual difference in cognitive style, similar to optimism or pessimism. However, these expectations are also likely associated with actual experiences of receiving fair and respectful treatment from others or not and so may differ based on interaction partners and social context. For example, individuals may be more likely to expect respectful and fair treatment at home compared to work. Methodological advances such as Ecological Momentary Assessment (EMA) allow researchers to measure internal experiences, such as expectations of unfair treatment, across contexts and in real time, in order to examine both variation across social context and whether contexts show differential association with outcomes (Shiffman, Stone, & Hufford, 2007). EMA methods are also consistent with conceptualizations of the cumulative burden of stress on disease, which hypothesize that frequency and severity of stress exposures influence health by virtue of their cumulative effects on autonomic, neuroendocrine, and inflammatory processes (Taylor, Repetti, & Seeman, 1997). Repeated exposures perturb the functioning of these regulatory biological systems and, over time, can lead to dysfunction and increase risk of cardiovascular disease.

The current study is an exploratory examination of whether expectations of respect and appreciation during daily life, which likely reduce social vigilance and represent the opposite of unfair or disrespectful treatment, are associated with IMT. We perform secondary data analysis of a large observational data set, and examine whether effects are independent of general positivity and negativity of social interactions during daily life, as well as individual differences (e.g., neuroticism, optimism) and experiences (exposure to discrimination) that may confound associations with cardiovascular risk. We also examine whether associations remain after adjustment for multiple major biological risk factors for increased IMT; whether associations generalize across age, sex, race and SES in the current sample; and, in supplemental analyses, examine whether autonomic, neuroendocrine, and inflammatory biomarkers may help explain observed associations.

Methods

Participants

Participants were drawn from the Adult Health and Behavior Project – Phase 2 (AHAB-II), a healthy sample of working adults. AHAB-II participants were recruited from the community primarily through mass direct mailings of recruitment letters to individuals randomly selected from voter registration lists and other public domain lists. Participants who responded to the recruitment letter were screened for eligibility. To be eligible to participate in AHAB-II, individuals had to be between the ages of 30–54 years and currently working at least 25 hours per week outside of the home. Individuals were excluded from participation if they had a history of cardiovascular disease, schizophrenia or bipolar disorder, chronic hepatitis, renal failure, neurological disorder, lung disease requiring drug treatment, or stage 2 hypertension (SBP/DBP ≥ 160/100). Additionally, individuals who excessively consumed alcohol (≥ 5 portions 3–4 times per week), used fish-oil supplements, or were prescribed any medications with autonomic effects (e.g., cardiovascular, psychotropic, glucocorticoid, lipid-lowering, diabetic, or prescription weight-loss medications) were excluded. Women who were pregnant, shift workers, and those who could not otherwise complete the protocol were also excluded. Participants received compensation up to $410, depending on extent of participation in visits, as well as compliance with the protocol. 494 men and women completed the study between March 2008 and October 2011. 483 of the participants (98%) identified their race as either Black or White. Because these were the two groups most well-represented in the sample, we restricted the sample to only those participants who self-identified their race as either Black or White, allowing us to examine race as a moderator in a clear and parsimonious manner. Of these 483 participants, nine were missing IMT, leaving 474 participants in regression analyses.

Procedure

The study was conducted in compliance with the University of Pittsburgh Institutional Review Board. The study involved seven visits, some of which are not relevant to the current report. Informed consent was obtained at visit 1 along with demographic variables, and personality assessments were administered at visit 3. A carotid artery ultrasound was performed at visit 4. To estimate elapsed time between visits, we calculated the time from first to last visit, then divided by the number of visits attended by each subject minus 1. Subjects’ mean interval between sessions was 13.9 days (SD = 4.6 days).

At visit 2, participants were trained to use a personal device for EMA data collection (Palm Z22, software: Satellite Forms) and practiced responding to questions using the device before entering the field for monitoring. Once in the field, participants completed a practice day of monitoring and received feedback on compliance. After this practice day, participants completed a 4-day monitoring protocol. The monitoring protocol consisted of two 2-day monitoring periods (3 working days and 1 nonworking day), usually one period at the beginning of the workweek and another at the end of the workweek, with at least one non-monitoring day in between. Participants were prompted to answer hourly EMA assessments during waking hours on these 4 days. While in the field, participants received four scheduled telephone calls from study staff, and staff were always available by cell phone for technical support. Compliance with the EMA protocol was defined as full completion of all questions on the hourly assessment. Using the timing of the beginning and end of day assessments, we estimated the number of expected assessments completed (1 per hour) and compared this to the number observed. The average number of hourly assessments missed was 6 reports over the course of 4 monitoring days; on average, participants missed 1 to 2 assessments per day and responded to 54.5 hourly assessments over the 4-day monitoring period (between 13 and 14 per day). Some participants (n = 50 out of 483 participants; 10% of the current sample) completed more than 4 monitoring days at the request of the researchers due to problems with some of their assessments or equipment and these participants completed more hourly interviews on average (mean = 65.7) as a result of this additional monitoring. When these participants are excluded, results indicate that the remaining participants responded to closer to 13 interviews per day on average.

Measures

Demographics.

Participants self-reported age, race/ethnicity, and sex as well as family income, highest level of education completed, and primary job title and responsibilities. Income was divided into fifteen categories, ranging from <$5,000 to ≥$250,000. To render categories more easily interpretable, income was recoded to the midpoint of each of the fifteen categories ($225,000 for the highest category). Education was divided into four categories ranging from high school or GED completion or less to a graduate degree. Job information was assessed during a structured interview and used to classify participants into the following three groups based on Standard Occupation Classification (SOC) codes (US Department of Labor, 2000 SOC System): blue collar, sales and administrative support, and white collar. These groups were converted to an interval scale (e.g., 1, 2, 3). SOC codes can be used to create six job classifications instead of the three used here. The current three group aggregates were used because they parallel occupational categories used in previous studies of SES and health in this dataset and others (e.g., Gallo et al., 2004; Joseph et al., 2016). Results of a principal components analysis including education level, occupational class, and income revealed that all three indices of SES loaded on one common factor (i.e., only one eigenvalue greater than 1, greater than 60% of variance explained, and all loadings greater than .70). Hence, family income, education, and occupational class were standardized and then aggregated to form a composite SES score for each individual, which was then used as a control variable.

Expectations of Respect and Appreciation.

Because the primary aims of the parent study related to occupational stress (Joseph et al., 2016), the assessment of expectations of respect and appreciation were originally included as part of an EMA assessment of the effort-reward model of occupational stress (Siegrist, 1996). Expectations of respect and appreciation were measured at each hourly assessment using two items following the stem, “Think about your mental and physical activity in the past 10 minutes.” Items read: 1) “efforts will be appreciated by others?” and 2) “efforts will be respected by others?” All item responses [NO! No no yes Yes YES!] were converted to a scale from 1 to 6, with 1 being the strongest “No” and 6 being the strongest “Yes.” At the observation level (examining averaged items), the intraclass correlation coefficient was .32 and indicates the percent of variance explained by person (e.g., Merz & Roesch, 2011). Thus 32% of the variance for each hourly observation was attributable to between-person differences.

In order to derive a measure of individual difference, these hourly scores were averaged across observations within person, resulting in one mean score for each study participant. In contrast to the hourly scores, these aggregated measures were reliable measures of individual difference. For example, when we aggregated scores separately across the first two days of monitoring and the second two days of monitoring, mean ratings of expectations of respect only, appreciation only, and their combination were reasonably stable over time (test–retest correlations of .83, .79, and .81, respectively).

General positivity and negativity of social interactions.

At each hourly assessment, the quality of the most recent social interaction was measured using four items, two items that measured negative aspects of social interaction (“someone treated you badly?” and “someone in conflict with you?”), and two items that measured positive aspects of the interaction (“pleasant interaction?” and “agreeable interaction?”). All items were scored on a scale from 1 to 6, with 1 being the strongest “No” and 6 being the strongest “Yes.” Consistent with previous work in this sample (Cundiff, Kamarck, & Manuck, 2016; John-Henderson et al., 2016; Joseph et al., 2014), the two items in each scale were averaged at each hourly observation and then those scale scores were averaged across observations within person, resulting in a mean score for each study participant on each scale. We have previously shown that positive and negative social interaction items were best treated as separate constructs rather than two ends of a continuous dimension (Joseph et al., 2014; John-Henderson et al., 2016).

Neuroticism, Optimism and Exposure to Discrimination.

Participants completed neuroticism items from the self-report version of the NEO-PI-R, the most prominent self-report instrument for lexically-derived trait ratings, which has established internal consistency (Cronbach’s α >.85) and convergent and discriminant validity (Costa & McCrae, 1992). Trait optimism was measured using the LOT-R, which has established validity and test-retest reliability (Carver & Scheier, 2019; Scheier, Carver & Bridges, 1994). Exposure to discrimination was measured using the perceived ethnic discrimination questionnaire (PEDQ), which has shown adequate reliability and construct validity (Contrada et al. 2001), and has been widely used (e.g., Blair et al. 2021).

Carotid Artery IMT.

B-mode ultrasound assessments were conducted using an Acuson Sonoline Antares high resolution duplex scanner (Acuson-Siemens, Malvern, PA). Trained, certified sonographers identified the borders of the intima and medial layers of the left and right carotid artery, using the intima-lumen interface and the media-adventitial interface as markers. B-mode images were obtained from the near and far walls of the distal common carotid artery, 1 cm proximal to the carotid bulb; the far walls of the carotid bulb, and from the point where the near and far walls are no longer parallel and extending down to the flow divider; and the internal carotid artery from the flow divider to 1 cm distal from the flow divider (John-Henderson et al., 2016). Studies were read using an automated edge detection algorithm (Artery Measurement System, Goteborg University, Gothenburg, Sweden)(Wendelhag, Liang, Gustavsson, & Wikstrand, 1997). The software generates two lines: one that traverses the lumen-intima interface and one that spans the media-adventitia interface. The distances between the interfaces are measured in 1 cm increments, generating one measurement (in millimeters) per pixel in each region. Mean IMT was computed as the average of all intima-media distance values in millimeters across both carotid arteries. The intraclass correlation coefficient between readers was calculated each year of the study and ranged from 0.89 to 0.97. To reduce the influence of outliers, two extreme outliers were windsorized to three standard deviations above the mean. After windsorizing these two values, scores were normally distributed and skew and kurtosis were both below 1. The windsorized variable was used in analyses.

Biological control variables.

We controlled for a number of biological factors previously shown to be correlated with IMT (Janicki-Deverts, Cohen, Matthews, Jacobs, & Adler, 2011; Joseph et al., 2014). Clinic blood pressure was assessed at visits 2 and 3 by trained research assistants using a manual Baumanometer mercury sphygmomanometer (desk model; W.A. Baum Co Inc, Copiague, NY) and a standard protocol. Two readings were taken at each visit. Clinic systolic blood pressures for each visit were calculated as the average of the two readings, and the mean systolic blood pressure across the two visits was calculated. A standard lipid panel (total cholesterol, high-density lipoprotein, low-density lipoprotein) and fasting serum glucose were assessed. Fasting serum glucose was assayed via standard calorimetry, and waist circumference was measured in inches. Smoking status was indexed by self-report (0=past smoker/non-smoker, 1= current smoker).

Results

Sample characteristics are presented in Table 1; this is a highly educated, employed sample of mostly White (17% Black) men and women. Examination of mean differences in expectations of respect and appreciation by race and gender revealed that both Black (vs White) participants and female (vs. male) participants showed relatively higher expectations of respect and appreciation; t (481)=3.71, p<.001 and t (481)=2.14, p=.03, respectively. IMT was also higher for Black (vs. White) participants and male (vs. female) participants on average; t (472) = 5.31, p<.001 and t (472) = 2.72, p=.007.

Table 1.

Sample Characteristics (N=483)

Variable n (%) Mean (SD)
Race
     White 400 (82.8)
     Black 83 (17.2)
Sex
     Male 228 (47.2)
     Female 255 (52.8)
Education
 High school/GED or less 30 (6.2)
 Some college/associates 110 (22.8)
 Bachelor’s degree 184 (38.1)
 Graduate/professional degree 159 (32.9)
Family Income 78.2 (49.2)
Age 42.7 (7.3)
Resting SBP 115.3 (10.76)
Resting DBP 72.6 (7.87)
BMI 26.98 (5.25)
IMT .64 (.11)
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GED=general educational development test. BMI = body mass index. SBP = systolic blood pressure. DBP= diastolic blood pressure. IMT = intima medial thickness. Family income is represented in US dollars and was divided by 1000.

Partial correlations of the primary study variables controlling for age, sex, and race are shown in Table 2. Greater expectations of respect and appreciation were associated with less negativity and more positivity in social interactions and with lower neuroticism and greater optimism, but were not associated with objective SES or perceived discrimination. Greater expectations of respect and appreciation, less negativity in social interactions, and more positivity in social interactions were each significantly correlated with IMT (associations between IMT and positivity and negativity were originally reported in John-Henderson et al. 2016). Neither objective SES, neuroticism, optimism, nor discrimination were correlated with IMT.

Table 2.

Partial correlations among primary study variables and psychosocial covariates.

1 2 3 4 5 6 7 8
1. Expectations of respect and appreciation −.14* −.18* .41* −.02 −.17* −.01 .21*
2. IMT .16* −.14* −.03 .06 .06 −.04
3. Negativity of Interactions −.68* .01 .25* .21* −.13*
4. Positivity of Interactions −.06 −.24* −.13* .18*
5. SES −.12* −.19* .23*
6. Neuroticism .17* −.53*
7. Discrimination −.19*
8. Optimism
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Values are correlations controlling for age, sex, and race. Expectations of respect and appreciation and negativity and positivity of interactions are based on mean EMA ratings. IMT = intima-media thickness, SES = socioeconomic status.

*

p<.05. Sample size for all correlations was 449.

In hierarchical regression analyses with additional controls, we examine multiple forms of the independent variable; greater expectations of respect and appreciation across all momentary measurements, at home only, at work only, expectations of respect only, and expectations of appreciation only (Table 3). Expectations of respect and appreciation were lower at home than at work on average; t (467) =15.06, p<.001. After controlling for demographic variables (step 2), greater expectations of respect and appreciation were significantly and similarly associated with lower IMT across items (respect vs. appreciation) and social contexts (home vs. work), consistently accounting for an additional 1% of the variance in IMT. Further controlling for general positivity and negativity of social interactions in step 3 did not significantly alter the association between greater expectations of respect and appreciation and lower IMT, with the exception that expectations of respect and appreciation at work showed a smaller and now nonsignificant association with IMT1. Similarly, expectations of respect only across all ratings showed a slightly smaller and now marginally significant association with IMT. Both expectations of respect and appreciation and general negativity of social interactions were independently associated with IMT, though in opposite directions. These associations did not change after additional controls for neuroticism, optimism, and discrimination in step 4 (Table 3).

Table 3.

Results of Regression Analyses Predicting IMT from Expectations of Respect and Appreciation controlling for social and psychological variables

Mean respect and appreciation across all ratings Mean respect and appreciation at home Mean respect and appreciation at work Mean respect across all ratings Mean appreciation across all ratings
Step Predictors ∆R² b [95%CI] β ∆R² b [95%CI] β ∆R² b [95%CI] β ∆R² b [95%CI] β ∆R² b [95%CI] β
1 .36* .36* .36* .36* .36*
Sex −.05 [−.07, −.04] −.23* −.05 [−.07, −.04] −.23* −.05 [−.07, −.04] −.23* −.05 [−.07, −.04] −.23* −.05 [−.07, −.04] −.23*
Age .008* [.007, .010] .54* .008 [.007, .010] .54* .008 [.007, .010] .54* .008 [.007, .010] .54* .008 [.007, .010] .54*
Race −.06 [−.08, −.04] −.20* −.06 [−.08, −.04] −.20* −.06 [−.08, −.04] −.20* −.06 [−.08, −.04] −.20* −.06 [−.08, −.04] −.20*
SES −.001 [−.005, .003] −.02 −.001 [−.005, .003] −.02 −.001 [−.005, .003] −.02 −.001 [−.005, .003] −.02 −.001 [−.005, .003] −.02
2 0.01* .01* .01* .01* .01*
Respect & Appreciation −.02 [−.03, −.01] −.11* −.01 [−.01, −.002] −.10* −.01 [−.01, −.002] −.10* −.01 [−.03, −.003] −.10* −.02 [−.03, −.01] −.12*
3 0.01* .01* .01* .01* .01*
Respect & Appreciation −.01 [−.03, −.001] −.09* −.01 [−.01, −.001] −.09* −.005 [−.01, .001] −.07 −.01 [−.02, .001] −.08↑ −.02 [−.03, −.003] −.10*
Intx Pos .001 [−.02, .02] .01 −.002 [−.02, .02] −.01 −.003 [−.03, .02] −.02 .00 [−.02, .02] .00 .00 [−.02, .02] .01
Intx Neg .02 [.003, .036] .12* .02 [.002, .036] .11* .02 [.000, .033] .10↑ .02 [.002, .036] .12* .02 [.003, .036] .12*
4 .00 .00 .00 .00 .00
Respect & Appreciation −.02 [−.03, −.002] −.10* −.01 [−.01, −.001] −.09* −.005 [−.01, .001] −.07 −.01↑ [−.02, .001] −.08↑ −.02 [−.03, −.004] −.11*
Intx Pos .001 [−.02, .02] .01 −.002 [−.02, .02] −.01 −.003 [−.03, .02] −.02 .00 [−.02, .02] .00 .00 [−.02, .02] .01
Intx Neg .02 [.001, .036] .11* .02 [.001, .036] .11* .02 [.−002, .033] .09 .02 [.001, .036] .11* .02 [.001, .036] .11*
Neuroticism .00 [.00, .00] .01 .00 [.00, −.00] .01 .00 [.00, .00] .01 .00 [.00, .00] .01 .00 [.00, .00] .01
Discrimination .00 [−.001, .002] .03 .00 [−.001, .002] .02 .00 [−.001, .002] .03 .00 [−.001, .002] .03 .00 [−.001, .002] .03
Optimism .00 [−.002, .002] .02 .00 [−.002, .003] .02 .00 [−.002, .002] .00 .00 [−.002, .002] .01 .00 [−.002, .002] .02
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b = unstandardized beta, β = standardized beta.

*

p <.05.

↑

p <.06.

Intx Neg = interaction negativity as measured by mean EMA ratings. Intx Pos = interaction positivity as measured by mean EMA ratings.

Additional Biological Controls

Lastly, we retained demographic variables and general negativity of interactions as controls, and examined whether associations persisted after additional adjustment for common biological correlates of IMT (Table 4). Greater expectations of respect and appreciation continued to provide significant independent predictive utility for IMT across items (respect vs. appreciation) and social contexts (home vs. work), though again the effect in the context of work was slightly smaller and only marginally significant with control for negativity of interactions. We standardized all predictors in the fully adjusted model so that standardized betas could be used to compare effect sizes among predictors. The effect size for expectations of respect and appreciation across contexts was β = −.08 and the effect size for BMI and smoking were β = .08 and .04, respectively, indicating that the magnitude of the effect is similar to or larger than these well-established cardiovascular risk factors in this healthy sample.

Table 4.

Results of Regression Analyses Predicting IMT from Expectations of Respect and Appreciation controlling for biological risk factors and smoking

Mean respect and appreciation across all ratings Mean respect and appreciation at home Mean respect and appreciation at work Mean respect across all ratings Mean appreciation across all ratings
Predictors R² b [95%CI] β R² b [95%CI] β R² b [95%CI] β R² b [95%CI] β R² b [95%CI] β
.46* .46* .46* .46* .46*
Respect & Appreciation −.01 [−.02, −.001] −.08* −.005 [−.01, −.001] −.08* −.005 [−.01, .000] −.07↑ −.01 [−.02, .000] −.07* −.01 [−.0, −.003] −.09*
Intx Neg .02 [.003, .026] .09* .02 [.004, .028] .10* .01 [.002, .025] .08* .02 [.004, .027] .09* .01 [.003, .026] .09*
LDL .001 [.000, .001] .10* .001 [.000, .001] .10* .001 [.000, .001] .11* .001 [.000, .001] .11* .001 [.000, .001] .11*
HDL −.001 [−.002, .000] −.13* −.001 [−.002, .000] −.13* −.001 [−.002, .000] −.13* −.001 [−.002, .000] −.13* −.001 [−.002, .000] −.13*
Glucose .00 [−.001, .001] .01 .00 [−.001, .001] .01 .00 [−.001, .001] .01 .00 [−.001, .001] .01 .00 [−.001, .001] .01
Triglycerides .00 [.00, .00] −.02 .00 [.00, .00] −.02 .00 [.00, .00] −.02 .00 [.00, .00] −.02 .00 [.00, .00] −.02
Clinic SBP .002 [.001, .003] .19* .002 [.001, .003] .19* .002 [.001, .003] .19* .002 [.001, .003] .19* .002 [.001, .003] .20*
BMI .002 [.000, .004] .08↑ .002 [.000, .004] .08↑ .002 [.000, .004] .08↑ .002 [.000, .004] .08↑ .002 [.000, .004] .08↑
Smoker .004 [−.003, .010] .04 .004 [−.003, .011] .04 .005 [−.002, .011] .05 .004 [−.002, .011] .05 .004 [−.003, .010] .04
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All analyses control for sex, age, race, and SES; estimates can be seen in Table 3. b = unstandardized beta, β = standardized beta.

*

p <.05.

↑

p <.07.

Intx Neg = interaction negativity as measured by mean EMA ratings. Intx Pos = interaction positivity as measured by mean EMA ratings.

Do demographic variables moderate the association between respect and IMT?

In addition to simply controlling for race, sex, age, and SES, we also examined whether these demographic factors moderated the relationship between daily expectations of respect and appreciation and IMT. No demographic factor modified this association (all p > .10).

Controlling for Effort

Expectations of respect and appreciation related to effort could be associated with the degree of effort or activity expended by participants; participants could report low expectations of respect and appreciation for their efforts, because little effort has been put forth and putting forth little effort may also be associated with poorer cardiovascular health. To examine this possible confound, we aggregated two EMA items that assessed whether participants’ activity in the last ten minutes had “required working hard” or “required working fast.” These items were administered in the same manner and time interval and rated on the same 6-item response scale as expectations of respect and appreciation described above. In a model including demographic controls (age, race, sex, SES), this effort variable was not significantly associated with IMT (B=.02, p=.644), and the association between expectations of respect and appreciation and IMT was unchanged when controlling for effort (before control: B=−.11, p=.004 vs. after control: B= −.12, p=.004).

Discussion

Unfair and disrespectful treatment, expectations of such treatment, and general vigilance to social threats have been previously associated with cardiovascular risk. In exploratory analyses, we examined whether expectations of respect and appreciation in everyday life may thus be associated with lesser cardiovascular risk. In this large community sample, individuals who report greater expectations of respect and appreciation from others evidence less preclinical vascular disease as indexed by carotid IMT. These associations were generally independent of demographic characteristics (age, sex, race, socioeconomic status), general negativity and positivity of daily social interactions, neuroticism, optimism, exposure to discrimination, and standard biological risk factors for cardiovascular disease (e.g., BMI, cholesterol). Associations with IMT remained similar when examining mean expectations at home and work separately, and when examining expectations of respect and appreciation separately. However, expectations of respect and appreciation at work were no longer significantly associated with IMT after controlling for general positivity and negativity of interactions, and analyses examining expectations of respect only (not appreciation) were also marginal. Additional adjustment for reported effort also did not change the association between expectations of respect and appreciation on IMT. Additionally, associations were not moderated by demographic factors. Hence, greater expectations of respect and appreciation at home were most consistently associated with less subclinical vascular disease when considering additional controls, and similar associations were found in both Black and White participants, men and women, across socioeconomic strata, and across the age range, suggesting that this association may be robust to a number of demographic characteristics associated with cardiovascular health.

Findings here are consistent with recent work showing that cognitive expectancies of social threat may be a significant influence on cardiovascular risk. Further, the specific outcome examined is consistent with the hypothesis that exposure to and anticipation of social threats contribute to the development of atherosclerotic plaque through shear stress, as the outcome here was a measure of atherosclerosis in the carotid arteries (e.g., Malek, Alper & Izumo, 1999; Smith, Ruiz, & Uchino, 2000). We also extend previous findings to a larger and more diverse sample and positively framed social expectancies (e.g., being respected) rather than negative ones (e.g., being disrespected). For example, Lewis and colleagues (2019) found associations between IMT and expectations of unfair treatment on the basis of race in a smaller sample of 52 Black women, and the construct of social vigilance, which has been previously associated with cardiovascular risk, focuses on anticipation of social threats rather than social rewards (e.g., Ruiz, Taylor, Uchino et al., 2017).

The positive wording of the items in this study may also have broader implications. For example, whether the default functioning of human psychophysiology is one of safety (which is then perturbed by signals of threat) or threat (which is then calmed by signals of safety) is a current point of debate (Brosschot, Verkuil & Thayer, 2018). Historically, models have been based on the idea that acute and chronic stress perturb an otherwise homeostatic system, but new theoretical frameworks such as the generalized unsafety theory of stress propose that chronic stress responses that damage the heart could be due to a generalized sense of lack of safety rather than repetitive exposure to discrete stressors (Brosschot, Verkuil & Thayer, 2016; Brosschot, Verkuil & Thayer, 2017; cf., Huskey, Taylor & Friedman, 2022). Individual differences in expectations of respect and appreciation may signify a general sense of safety in the social environment, rather than a relative lack of repeated exposure to interpersonal stress. While these two experiences are likely correlated (e.g, individuals’ expectations of respect and appreciation are likely associated with actual experiences of receiving respect and appreciation), the current study cannot disentangle participants’ expectations from actual behavioral exposures in the social environment as received respect and appreciation was not assessed.

Many groups who experience poorer cardiovascular health, such as Black men and women in America and Americans with fewer socioeconomic resources, also report being treated with less respect in day-to-day life (APA Workgroup on Stress and Health Disparities, 2017). Questions to this effect are included on well-researched discrimination scales, and social stigma is defined by devaluation of persons (Krieger, Smith, Naishadham et al. 2005; Major & O’Brien, 2005). Respecting and appreciating others is arguably the opposite of devaluation, and it is possible that differences in expectations of being appreciated and treated with respect are a particularly important component of stigma and discrimination with respect to cardiovascular risk. However, both Black (vs. White) participants and female (vs. male) participants showed relatively higher expectations of respect and appreciation. This was surprising. Although experiences of unfair treatment and discrimination have been shown to be higher in Black (vs. White) Americans on average (e.g., Peterson et al. 2016), expectations of being treated with respect and appreciation were not highly correlated with a global rating of discrimination in this sample. Further, although race has been associated with more discrete instances of unfair treatment, most measures of discrimination and unfair treatment assess experiences with strangers, whereas the primary independent variable examined here is heavily influenced by others with whom participants interact most frequently. It is possible that Black Americans and women, being aware of racism and sexism, are more likely to frequent social contexts and relationships in which there is a low threat of discrimination and a general expectation of respect. Given research showing that individuals tend to “prune” stressful social connections as they age, this shaping of daily social interactions may also be more likely in adulthood and older adulthood, consistent with the current study population (Carstensen, 2021).

Both negativity of social interactions and expectations of respect and appreciation were independently associated with IMT. This finding may highlight the potential importance of assessing aspects of our social lives relevant to agency (respect, competence, efficacy) or “getting ahead,” in addition to more commonly measured social experiences relevant to warmth (support, connection) or “getting along” in the study of social relationships and cardiovascular health (Hogan, 1983; Smith & Cundiff, 2011). The finding may also suggest the importance of assessing both positive and negative aspects of our social environment, but we note that positivity of social interactions was not independently associated with IMT, so the content of the questions (e.g., being liked vs. being respected) may offer unique information beyond their difference in valence.

Limitations

Although we had a large community sample, participants were from an urban and limited geographic region (Southwestern PA). Additionally, study participants were physically healthy, employed, and generally well-educated and findings may not generalize to other populations. Expectations of respect and appreciation in this study were also assessed in response to “efforts”, and expectations for something individuals do (e.g., effort) may differ from more general expectations of being respected and appreciated as an individual. Although expectations of respect and appreciation were measured on an hourly basis, we computed a mean individual difference variable from these ratings. It is possible this construct may be more simply measured using a general one-time assessment, but we did not have such an assessment in the current study. Additionally, because constructs measured at the trait-level are typically thought to reflect individual differences in habitual patterns of thinking, feeling, and/or behaving that occur with greater or lesser frequency or intensity over time in everyday life, the method of assessment here is not inconsistent with the concept of traits (e.g., Roberts, 2009; Sullivan, 1953). Further, IMT is a between-person variable, so within-person effects could not be examined here with respect to our primary outcome variable. Although individual difference factors may influence self-reports of expectations of respect and appreciation, the fact that significant associations remain after accounting for trait neuroticism, optimism, positivity and negativity of social interactions, and perceived discrimination strongly suggests that self-report bias does not fully explain the association between daily expectations of respect and appreciation and IMT. Lastly, the design of the current study is correlational and so can only establish that expectations of respect and appreciation tend to occur less frequently in individuals who have greater IMT. It does not establish, for example, that if we could change an individual’s perceptions or social context to increase expectations of respect and appreciation, we could reduce his or her cardiovascular risk.

Conclusions

Current findings in this large community sample indicate that mid-life adults who anticipate greater respect and appreciation from others in everyday life evidence less preclinical vascular disease even after adjustment for multiple potentially confounding psychosocial factors as well as standard biological risk factors. Consistent with the literature showing that unfair treatment and anticipatory vigilance to social threats may increase cardiovascular risk though the development of atherosclerosis, expectations of being respected and appreciated by others appears to be associated with decreased markers of atherosclerotic plaque in the carotid arteries. This study was exploratory. Future studies are needed to replicate these findings and studies that include a global (one-time) measure of expectations of respect and appreciation would further our understanding of the construct measured herein. Studies that are also able to distinguish between social expectancies (cognitions) and actual interpersonal experience (others’ behavior) would allow researchers to examine whether similar or disparate psychophysiological pathways connect social experiences and social expectations to cardiovascular health.

Acknowledgements:

This work was supported by HL040962 and HL007560. We thank Mark Thomas for his role in the development of and preliminary evaluation of the urinary catecholamine measurement methods used here.

Footnotes

1

The possibility was raised that respect and appreciation at home may be more reliably associated with IMT, because not receiving respect and appreciation for efforts at home is counter to cultural norms (e.g., we generally expect respect and appreciation at home but perhaps less so at work). To examine the possibility that there is more variability in these expectations at work than home, we calculated a standard deviation for each participant on ratings of expectations of respect at home and at work and ratings of expectations of appreciation at home and at work. Variability in participants’ expectations of both respect and appreciation were greater at home compared to at work (t=6.1 and 7.5, respectively, both p<.001). Thus, whether participants expected their efforts would be appreciated and respected was actually less consistent at home than at work. We further tested whether individual variability in expectations of respect and appreciation are associated with IMT above and beyond mean levels of these expectations (the primary IV in this study). When tested, we find that individual variability (operationalized as the standard deviation) in expectations of respect and appreciation at home are significantly associated with IMT, whereas variability in these same expectations at work are not associated with IMT. Thus, both mean levels and variability in expectations of respect and appreciation at home may be more reliably associated with IMT than these same expectations at work.

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