Self reported hypertension among unemployed people in the United States

BMJ 1995;310:568 (4 March)

Papers

Self reported hypertension among unemployed people in the United States

Robert M Brackbill, epidemiologist,^a Paul Z Siegel, medical epidemiologist,^a Susan P Ackermann, statistician ^a

^a Centers for Disease Control and Prevention, Mailstop E-44, Atlanta, GA 30333, USA

Correspondence to: Dr Brackbill.

Higher death rates from cardiovascular diseases have been reportedamong unemployed people in several countries after age, socioeconomicstatus, and marital status have been controlled for. Other studieshave found that blood pressure and serum cholesterol concentrationrise before and after loss of a job. Moreover, unemployed peopleconsult doctors about cardiovascular conditions including hypertension,more often than do employed people.¹ We used data from a crosssectional survey of American adults to estimate the risk ofhypertension among unemployed people after controlling for otherrisk factors.

Subjects, methods, and results

In 1992, 48 states and the District of Columbia participatedin the behavioural risk factor surveillance system, which entailedinterviewing people by telephone who had been contacted by diallingrandom numbers. A total of 96 213 people were interviewed. Themedian percentage of complete interviews for all the stateswas 82%. The percentages of respondents who had had their bloodpressure checked in the past year were similar by demographicgroup. People who had not had their blood pressure checked inthe past year were excluded. This study included people aged30-59 who were available for work outside the home (n=36957).Data for each state were weighted demographically and by selectionprobability.

Subjects were categorised as having hypertension if they hadbeen told more than once by a health care professional thatthey had high blood pressure. Employed people either had anemployer or were self employed (n=34 120). Unemployed respondentshad been out of work for less than a year (n=1314) or a yearor more (n=1523). Rates of unemployment estimated by the behaviouralrisk factor surveillance system were significantly correlatedby state with unemployment rates obtained from the United StatesBureau of Labor Statistics.

We computed prevalence odds ratios by logistic regression² toestimate the relative risk of hypertension among unemployedpeople. These ratios were adjusted for age, body mass, racialor ethnic group, education, and alcohol consumption. The tableshows the results. People who reported having been unemployedfor a year or more had a higher estimated risk of hypertensionthan those who reported having been unemployed less than a year.Unemployed men with less than a high school education had thehighest risk of hypertension (prevalence odds ratio 3.1 (95%confidence interval 2.5 to 4.6)), but men who had graduatedfrom high school and been unemployed for a year or more stillhad an increased risk (table). Women who had been unemployedfor a year or more and had less than a high school educationhad an increased risk of hypertension (table). Age (prevalenceodds ratio e^0.06 (95% confidence interval e^0.059 to e^0.062)),body mass (e^0.13 (e^0.10 to e^0.14)), being black (e^0.42, (e^0.28to e^0.56)), and alcohol consumption (e^0.09 per ounce (28 g)(e^0.05 to e^0.13)) predicted self reported hypertension; sexdid not.

Adjusted prevalence odds ratios (95% confidence intervals) for self
reported hypertension among unemployed Americans aged 30-59, by
length of unemployment, education, and sex*
--------------------------------------------------------------------------------------------------------
                                                           Unemployed
--------------------------------------------------------------------------------------------------------
Education                                           <1 year             >/=1 year
--------------------------------------------------------------------------------------------------------
Whole sample:                                    1.3 (1.0 to 1.6)    1.7 (1.4 to 2.1)
Men:
  Did not graduate from high school              3.0 (2.2 to 4.1)    3.3 (2.1 to 5.2)
  Graduated from high or technical
   school                                        0.8 (0.4 to 1.6)    2.0 (1.3 to 3.2)
  Educated beyond high or technical
   school                                        1.1 (0.6 to 2.0)    1.5 (0.7 to 3.6)
  Total                                          1.3 (0.9 to 1.8)    2.2 (1.7 to 2.9)
Women:
  Did not graduate from high school              1.7 (0.8 to 3.3)    2.4 (1.5 to 3.9)
  Graduated from high or technical
   school                                        1.2 (0.7 to 2.1)    1.3 (0.9 to 2.1)
  Educated beyond high or technical
   school                                        1.3 (0.8 to 2.2)    0.8 (0.5 to 1.3)
  Total                                          1.3 (0.9 to 1.6)    1.7 (1.4 to 2.1)
--------------------------------------------------------------------------------------------------------
*Behavioural risk factor surveillance system, 1992.

Comment

The prevalence of self reported hypertension was increased amongunemployed people in the United States, especially among menwith less education. This is consistent with the associationof lower education with a higher prevalence of hypertension³and the fact that men are more adversely affected by unemploymentthan women.⁴

The recognised limitations of this study are that the subjectscould have misclassified their hypertension and employment statusand that we did not control for health selection bias--thatis, unemployment because of poor health. Other studies haveindicated that self reported hypertension is quite accurateand that people who lose their jobs involuntarily suffer adversehealth consequences. To our knowledge, however, no other populationbased study has shown increased hypertension among unemployedpeople after other risk factors have been controlled for.

Stress with job loss and subsequent unemployment may resultin adverse physical and mental health. Stressful life events,including unemployment, may precede heart disease.⁵ We recommendthat unemployed people receive appropriate screening for andtreatment of hypertension, especially those in poorer socioeconomicgroups.