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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
AFRICA
371
Discussion
We assessed longitudinal associations between BP levels,
depression and coping strategies in a bi-ethnic cohort of
South African teachers. The main findings revealed higher
cardiovascular risk and chronic depression, mostly in blacks.
Indeed, blacks showed increasing defensiveness and ritual- and
spiritual-centred coping over the three years in an attempt to
combat chronic depression. Increasing defensiveness seems
to be costly, as reflected by their chronic hypertensive status.
Whites showed consistent spiritual-centred coping while utilising
avoidance or loss-of-control coping, with a trend of seeking less
social support.
Cultural coping
Individual well-being among blacks andwhites seemed dependent
on each individual cohort member’s ability, or inability, to make
use of healthy coping strategies, i.e. spiritual-centred coping or
seeking social support.
13,25-27
We have shown novel findings in
Africa that there are significant cultural differences in coping
patterns of blacks and whites, and herewith support the notion
of similar studies that suggested that culture has a significant
effect on coping with stress.
26,28
The impact of coping disability will inevitably have an impact
on susceptibility to CVD. From a neuro-theological perspective,
it is interesting to note that this research may also reflect what
is found in other literature, such as the Christian Bible, where
the apostle Paul describes in 1 Corinthians 12:14–20
27
how the
different functioning parts of the body depend on each other
[touch/tactile (palms of hands and soles of feet), the ear, the eye
and smell]. It may symbolise interdependency of functioning
parts of the body as well as interdependency of human beings to
function effectively as a community, with Christ as head of the
church. The pericope in 1 Corinthians 12 is remarkably similar
to awareness in the senses and functioning of the body during the
fight-or-flight response or defensive coping.
High-risk cardiovascular profile among urban-
dwelling blacks
Current findings in blacks demonstrated significantly higher
cardiovascular risk compared to whites, with increased alcohol
consumption and hypertensive status, as well as increases in SBP
over time. Previous studies support the fact that high alcohol
intake increases risk of hypertension, particularly in blacks.
29
In
our study, chronic stress in blacks was observed and is supported
by other studies.
4,13
If combined with chronic higher alcohol
consumption, circulatory disturbances such as vasospasms or
ischaemic heart disease may ensue.
30-34
Indeed, recent findings in
the SABPA cohort showed that habitual utilisation of DefS was
often accompanied by alcohol abuse and a profile of reduced
coronary perfusion.
33
Chronic defensiveness and over-exposure to psychosocial
stress may explain why the current urban-dwelling black teachers
are more vulnerable to CVD than their white cohort counterparts.
Black teachers reported a greater dependency on social support
than white teachers, but interestingly, the follow-up data showed
that seeking social support decreased among blacks, with no
increases among whites over a three-year period. The African
culture is traditionally collectivistic and interdependent, and
individualism during urbanisation induced more psychosocial
stress.
15
Therefore we cautiously suggest that blacks not seeking
social support may rather reflect denial or loss-of-control coping
styles.
In the current study, blacks reported increased use of DefS,
avoidance coping, and ritual- and spiritual-centred coping
coupled with increased SBP levels. Studies also showed that risk
of elevated BP might be the result of habitual defensiveness
during chronic stress caused by a demanding individualistic
urban environment, especially for blacks who are inherently
collectivistically orientated, which could lead to physiological
loss-of-control responses.
13,16,17,34
Our black cohort reported a willingness to try and consume
less alcohol, but the follow-up
γ
-GT levels indicated continued
high levels of alcohol consumption among blacks. These findings
could suggest that alcohol abuse is more frequently used as a
defensive coping strategy among blacks, and that chronic DefS
may contribute to blacks’ susceptibility to CVD risk.
High-risk cardiovascular profile among urban-
dwelling white teachers
The white teachers reported increasing habitual use of
avoidance or loss-of-control coping. They also reported the
use of collectivistic-centred or group-activity coping, which
are preferred strategies under stressful situations and which
may reflect a fraught situation.
14
They did not seek more social
support, but if they were using avoidance or loss-of-control
coping, a lack of support from society, family and friends may
have increased susceptibility to chronic depression.
35
When corporal punishment was abolished in all South
African schools, the impact on teachers’ morale included loss of
control, which may also support the increase in avoidance coping
in this teachers’ cohort.
4,13,36
Current findings also reflected
psychological and cardiovascular vulnerability in the cohort
of white teachers, who used consistent spiritual-centred, social
support and DefS coping to combat stress.
Chronic depression
Recent studies have reinforced the notion that depression can be
a significant risk factor for hypertension and may explain how
different coping strategies could reflect hypertension risk in ethnic
groups with differing cultural backgrounds.
37,38
Psychological
trajectories in white teachers however did not predict depression
or hypertension. They reported avoidance coping or using group
activities, which may seem to be a way to cope with stressful
demands but which can be an additional source of stress itself.
In black teachers, chronic depressive symptoms were
accompanied by 24-hour SBP hypertension. Alcohol
consumption trajectories as a dysfunctional lifestyle factor
were often used to cope with stress. Alcohol consumption or
abuse may further increase depression, since alcohol is a central
nervous system depressant and increases subsequent CVD
risk.
39
Recently, a hypertensive state has been associated with
vasoconstrictive as well as cardio-toxic effects of alcohol.
30
Prior studies have presented data where chronic higher
alcohol consumption/abuse was associated with delayed electrical
conduction in the heart, accompanied by left ventricular
hypertrophy as seen on ECG, silent ischaemic events, and