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Marital status, gender, and depression: Analysis of the baseline survey of the Korean Longitudinal Study of Ageing (KLoSA)
Social Science & Medicine 69 (2009) 1608–1615
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Marital status, gender, and depression: Analysis of the baseline survey of the Korean Longitudinal Study of Ageing (KLoSA)q Soong-Nang Jang a, Ichiro Kawachi a, *, Jiyeun Chang b, Kachung Boo b, Hyun-Gu Shin b, Hyejung Lee b, Sung-il Cho c a b c
Harvard School of Public Health, Boston, MA, United States Korea Labor Institute, Republic of Korea Seoul National University, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 12 October 2009
Marital status is a robust predictor of health outcomes in Western populations. However, data from Asian cultures remain sparse, and some studies suggest marked gender differences in the health benefits of marriage among Asian populations. We investigated the influence of marital status on depressive symptoms in older adult Koreans. Data were obtained from a sample of adults aged 45 to 85 years (4016 men, 5003 women) who participated in the 2006 cross-sectional baseline survey of the Korean Longitudinal Study of Ageing. Depressive symptoms were measured by the 10-item Center for Epidemiological Studies–Depression scale. A multiple regression model was used to examine the association between marital status and depressive symptoms, controlling for socioeconomic status, living arrangement, disability, and number of chronic diseases. In women aged 75 to 85 years, no significant differences were found between women who were married versus those who were widowed, divorced, or separated with regard to depressive symptoms. These findings were driven by increasing depressive symptoms among married women with age. Whereas divorced and widowed men in the sample reported higher rates of depressive symptoms than did married men, the difference between married vs. widowed/divorced women converged as they aged. This pattern of depressive symptoms by gender and life stage may reflect the distinctive influence of the Asian context on relations between men and women, such as traditional gender roles and patriarchal norms for older generation. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Depressive symptoms Marital status Korea Ageing Gender
Introduction Numerous empirical studies have provided evidence for the protective effects of marriage on health; that is, married individuals are more likely to be healthier than are widowed, divorced, separated, or never-married individuals (Manzoli, Villari, Pirone, & Boccia, 2007; Turner, Lloyd, & Roszell, 1999; Williams, 2004). Married individuals live longer than do unmarried individuals, and this protective effect cannot be entirely explained by the selection of healthy individuals into marriage (Lillard & Panis, 1996). The benefits of marriage also extend to factors other than survival;
q This work was supported by a Korea Research Foundation Grant (KRF -2007321-B00096) funded by the Korean Government (MOEHRD). Kawachi is supported in part by the MacArthur Network on SES and Health. * Corresponding author. Harvard School of Public Health, Department of Health and Social Behavior, 677 Huntingdon Avenue, Boston, MA 02115, United States. Tel.: þ1 617 432 0235; fax: þ1 617 432 3123. E-mail address: [email protected] (I. Kawachi). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.09.007
married individuals reportedly experience lower rates of depression (Afifi, Cox, & Enns, 2006; Holt-Lunstad, Birmingham, & Jones, 2008; Inaba et al., 2005; Weissman et al., 1996; Williams, 2004). The health benefits of marriage may be mediated by a variety of mechanisms, including access to economic resources (economies of scale in household consumption, financial security, as well as the so-called ‘‘marriage premium’’ by which married individuals command higher wages in the labor market) (Waite, 1995); the exchange of social support (House, Landis, & Umberson, 1988); and the beneficial influence of spouses on marital partners’ health behaviors (Eng, Kawachi, Fitzmaurice, & Rimm, 2005; Lee et al., 2005). According to the social support theory of marriage, the loss of one’s spouse is often associated with increased risk of depression due to loss of financial, emotional, physical, and instrumental support (Levenson, Carstensen, & Gottman, 1993; Lopata, 1978; Mineau, Smith, & Bean, 2002; Ross, Mirowsky, & Goldstein, 1990; Umberson, Wortman, & Kessler, 1992). In contrast, Nagata, Takatsuka, and Shimizu (2003) suggested that widowhood does not have
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an important effect on the mental health of elders because the normative nature of losing one’s spouse at an advanced age might mitigate the consequences of widowhood on mental health (Nagata et al., 2003). Although many studies have reported similar mental health benefits of marriage among men and women (Arber, 2004; House et al., 1988; Manzoli et al., 2007; Seeman & Crimmins, 2001), several studies have reported gender differences with regard to the mental strain deriving from widowhood. For men, widowhood may lead to a weakening of family contacts, and older widowers might suffer more than older widows do from a lack of social support due to smaller networks of friends and more distant relationships with children and other family members (Davidson, 2000; Wenger, Davies, Shahtahmasebi, & Scott, 1996). Moen (1996) observed that the death of one’s spouse might have a more deleterious emotional impact on men, in that they derive more social and emotional support from marriage. The differential emotional impact of widowhood on men and women may be explained using a life course perspective: widowhood is an anticipated life event for women after a certain age, thus they are more likely than are older men to be prepared and to have a support group of peers and family members. For older women, widowhood may represent freedom from the care-giving role, as well as an opportunity to develop closeness with their children by living with them (Carr, 2004; Lee, DeMaris, Bavin, & Sullivan, 2001). In addition, several studies have emphasized the ability of the widowed to recover from grief and depression. Ferraro (1989) suggested that these factors provide some measure of compensation for widowed older women. Older widows seem to have a high degree of emotional resilience (Mastekaasa, 1994). The bulk of this evidence about the associations among marital status, health, and gender is based on Western populations. Fewer studies have been conducted in Asian cultures, where the patterns of associations have differed from the results obtained from Western societies. For example, Ikeda et al. (2007) examined the association between marital status and mortality in a 10-year prospective cohort of 94,062 middle-aged Japanese men and women and found that widowhood and divorce increased the risk of all-cause and cause-specific mortality by 1.5 to 2.0 fold in Japanese men, but no survival advantage was observed for married women (Ikeda et al., 2007). A study conducted in Beijing and Shanghai reported that the rate of depressive symptoms among men (50–70 years) without a spouse was 2.6 times higher than rates for married men, but marital status was not significantly associated with depression among women (Pan et al., 2008). These gender differences in the health benefit of marriage in Asian societies may stem from the social and cultural environment, which includes strictly demarcated gender roles deriving from patriarchal and Confucian norms. As a result of industrialization and urbanization during recent decades, Korean families have become more similar to Westernized nuclear families with spouse-centered structures. However, the patriarchal ideology persists in Korean families, especially in older couples (Cha, 2007). In recent decades, increasing life expectancy in Asia has resulted in marriages of increased duration. The period of time following the departure of children has lengthened dramatically, as reflected in higher rates of married individuals living together without children in the home. In 2005, 55.4% of Korean aged 65 years and older were married, an increase of 3.4% over this rate in 2000 (Korean National Statistics, 2006). Moreover, the prevalence of losing a spouse declined by 4.1% in this population during this period. These increases in the number of married elders, including increased rates of re-marriage among older individuals (Korean National Statistics, 2006), have reduced the traditional dependence on children, leading to lives that are increasingly
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focused on the couple in later life. Behind these gradual trends, however, conflict remains with regard to family members’ roles and norms. Women’s labor market participation has grown rapidly in Korea, and consequently, the traditional child bearing and particularly care-giving roles have been filled by older women in the family. In addition, the rapid rise in dual-earner couples has resulted in increased need for childcare arrangements and elder care support, as well as informal care support in Korea. Rapid structural change and traditional ideology can create conflict in older couples because wives may want to adopt modern flexible gender roles, whereas husbands might resist change and find it difficult to accept a new role later in life (Kim & Jun, 1997). Given these conditions, the traditional social support provided by marriage may not apply to Korean older women. Instead, these women might experience high levels of stress and depressive symptoms in later life due to marital conflict and the cumulative impact of gender role expectations. This, in turn,, may result in increased care-giving burdens for their husbands, children, and grandchildren. In the present study, we sought to examine the effect of marriage on the mental health of Korean men and women. We assessed the depressive symptoms among married, divorced/ separated, widowed Koreans across different age groups using a representative sample of middle-aged and older adults drawn from the Korean Longitudinal Study of Ageing (KLoSA). The Korean Longitudinal Study of Ageing (KLoSA), based on a nationally representative sample of Koreans aged 45 years or older, was launched in 2006. Funded by the Ministry of Labor, KLoSA is the first national survey of Koreans that measures depressive symptoms and is available to the public. KLoSA was also designed to compile information on various aspects of ageing for use as basic statistical data in interdisciplinary research on the social, economic, physical and psychological aspects of ageing. We hypothesized that marital status would have different influences on depressive symptoms depending on gender and age group. We assessed age in 10-year categories to reflect stages in an individual’s life course. For example, men and women between the ages of 45 and 54 are still tied to parental, social, and occupational roles. Men and women between the ages of 55 and 64 often go through the processes of retirement and subsequent reconnection with their spouses. Men and women between 65 and 74 years of age are adapting to new roles as grandparents or caregivers for sick spouses or grandchildren. Men and women aged 75 years or older are more likely to experience spousal death, health problems, and diminished levels of functioning. In addition, age cohorts separated by 10-year intervals have experienced different social environments during youth and adulthood because Korea has experienced rapid economic development and modernization during the past 50 years. Individuals currently aged 75 years or older have been immersed since childhood in Confucian attitudes about strictly demarcated gender roles. Thus, married older Korean women are burdened with the role of family caregiver for sick spouses and young grandchildren, substituting for working daughters or daughters-in-law with regard to the latter. The burdens of these roles might lead to depressive symptoms among the oldest Korean married women. Methods Study design and data The Korean Longitudinal Study of Ageing (KLoSA) focused on Koreans aged 45 and older living in households selected by multistage stratified probability sampling (based on geographical area) to be representative of the nation. A total of 10,254 individuals
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completed interviews conducted by a trained interviewer. The household response rate was 70.7%, and the individual response rate within households was 75.4%. We limited our analysis to the population of 3813 men and 4827 women aged 45 to 85 years drawn from the baseline survey of the 2006 KLoSA. The average age ( SD) of our sample was 60.69 (10.39) years; this was slightly lower than that of the full panel of respondents. Weights were assigned to the Enumerated District (ED) to estimate parameters, reflecting the sampling process, the survey process, and accuracy of external data. Computation of KLoSA weight involved a sequence of three steps: 1) the design weight based on two-staged sampling probability; 2) the non-response-adjusted weight to reduce the impact of non-responses; and 3) the benchmark weight reflecting changes in the general distribution of population using demographic changes in census, residence registration records or other large-scale surveys. CES-D 10 depression The short-form (10-item) Center for Epidemiological Studies dDepression (CES-D10) scale served as the outcome variable. The CES-D10 is a brief screening instrument that assesses depressive symptoms experienced during the most recent week: the 10 items are divided into two that are positively phrased (feel pretty good, generally satisfied) and eight that are negatively phrased (loss of interest, trouble concentrating, feeling depressed, feeling tired or low in energy, feeling afraid, trouble falling asleep, feeling alone, and hard to get going) (Irwin, Artin, & Oxman, 1999; Kohout, Berkman, Evans, & Cornoni-Huntley, 1993). The responses for each item ranged from 0 to 3; 0 signified very rarely or less than once a day; 1 signified sometimes or 1–2 days during the past week; 2 signified often or 3–4 days during the past week; and 3 signified almost always or 5–7 days during the past week. The summed scores of the 10 items, with scores reversed for the positively phrased items, served as the outcome measure. Higher scores indicated greater distress. The alpha coefficient for the CES-D10 was 0.79, which was comparable to the 0.80 obtained in previous reliability studies (Irwin et al., 1999). The criterion validity of the CES-D 10 was also acceptable for our data because the association between self rated health was significant for CES-D 10 (R ¼ 0.44 for self-rated health). Explanatory variables Respondents reported their marital status as ‘‘married or living with partner,’’ ‘‘separated,’’ ‘‘divorced,’’ ‘‘widowed,’’ or ‘‘never married.’’ We classified these responses into four categories: ‘‘married,’’ ‘‘widowed,’’ ‘‘divorced or separated,’’ and ‘‘never married.’’ Analyses excluded never-married men and women due to the small sample size (N ¼ 89). In order to assess the net effect of marital status within each age and gender group, we considered possible covariates according to the results of previous population-based studies of depressive symptoms: living arrangement, employment status, educational level, income, and chronic disease, and disability (An, An, O’Connor, & Wexler, 2008; Holzer et al., 1986; Jeon, Jang, Rhee, Kawachi, & Cho, 2007; Pearlin, Morton, Menaghan, & Mullan, 1981; Weissman et al., 1996; Yoo, 1997). Living arrangement was dichotomized into living with children or children’s family (1) or other (0). Living alone and living with spouse only were the only living arrangement categories to be highly correlated with marital status in our sample, because marital status partially defined these living arrangements. Thus, we used living with children or children’s family as a covariate.
Most studies show that those with less education, lower income or lower occupational prestige have higher rates of depressive disorders and/or depressive symptoms than those in more advantaged socioeconomic positions. The employment status of respondents was assessed, beginning with a question about whether subjects participated in the labor market. We divided respondents into two groups: employed (1) and not employed (0). The educational levels of respondents were categorized as elementary school or less (1), middle school graduate (2), high school graduate (3), and college graduate and beyond (4). Household-equivalent income was calculated as the total household income divided by the square root of the number of household members; these scores were then divided into quartiles. The number of chronic diseases reflects self-reported histories of having been diagnosed by a physician with one or more of eight conditions: hypertension, diabetes, cancer, lung disease, heart problems, stroke, arthritis, and gastrointestinal disease. Functional status was measured using the 10-item Korean Instrumental Activities of Daily Living (K-IADL) scale, which includes personal grooming, going out for short distances, using transportation, making/receiving phone calls, managing money, doing household chores, preparing meals, shopping, taking medications, and doing the laundry. This measure is widely used and validated with high internal consistency (a ¼ 0.85) (Won et al., 2002). If respondents were dependent with regard to one or more activities, they were categorized as having a disability (1); if they were dependent with regard to none of the IADL items, they were classified as having no disability (0). Analysis We calculated the frequencies, weighted proportions, and means ( SDs) of demographic characteristics by gender and age groups. We used chi-square tests and t-tests to compare the distributions of marital status, and demographic characteristics by gender. We calculated means (SDs) of CES-D scores in men and women according to four age groups: 45–54, 55–64, 65–74, and 75–85 years old. Separate analyses of covariance were performed to assess associations between CES-D10 responses and marital status (excluding ‘‘never married’’), and the results are presented as leastsquares means of the CES-D10. A multiple linear regression model was used to evaluate the influence of marital status on score measuring depressive symptoms by gender and age. The model included marital status (excluding ‘‘never married’’), age in 1-year intervals, education, income, current job status, living arrangement, disability, and number of chronic diseases. We also examined the interaction of gender and marital status. We conducted separate analyses of trends in the associations between age and depressive symptoms with regard to marital status (married, divorced/separated, and widowed) by gender using multiple linear regression. Finally, we conducted statistical tests to compare regression coefficients between men and women across age groups within each marital status. A contrast analysis of a general linear model (Littell, Stroup, & Freund, 2002) was used to test the null hypothesis that the regression coefficients for men and women were equal within each marital status. Results The proportion of married men (92.3%) in the sample was greater than the corresponding proportion for women (73.8%) (Table 1). As expected, women were more likely to be widowed (22.3%) than were men (3.1%). Men tended to be more highly educated than women, and over half the women in the survey
S.-N. Jang et al. / Social Science & Medicine 69 (2009) 1608–1615 Table 1 General characteristics of Korean men and women aged 45–85 years old.
Sample number Marital status* Married Widowed Divorced, separated Never married Age** (mean, SD) 45–54 years old 55–64 years old 65–74 years old 75–85 years old Living with children* Yes No Education* Elementary school or less Middle school High school College or more Household monthly income* (won, mean, SD) Equivalent incomea, ** 1Q (Lowest) 2Q 3Q 4Q (Highest)
Men
Women
4016
5003
92.34% 3.14% 3.07% 1.45% 60.58 (10.13) 33.72% 29.18% 27.09% 10.01%
73.81% 22.30% 3.18% 0.71% 60.77(10.59) 34.40% 27.90% 25.18% 12.51%
51.20% 48.80%
49.03% 50.97%
24.77% 18.63% 36.66% 19.94% 2052.29 (2503.33)
52.06% 18.45% 24.14% 5.36% 1761.20 (2499.46)
21.69 23.80 26.99 27.51
27.02 25.84 24.55 22.59
Job status* Employed 65.35% Retired 18.95% Not employed or home makers 15.7% Number of chronic disease* (mean, SD) 0.66 (0.91) 14.35% Any disability*
28.74% 14.62% 56.64% 0.79 (0.98) 8.81%
*p < 0.05, ** p < 0.01 by chi-square test or t-test. a . Monthly household income divided by the square root of the number of household members. Household equivalized income was categorized into quartiles.
(52.1%) were placed into the least-educated category. Approximately half of both men and women were living with their children. Men reported higher average annual family incomes than did women. The majority of men were employed (65.4%), whereas more than half of the women (56.6%) were homemakers or not employed. Women reported more chronic diseases, whereas men were more likely to report disability (14.4% for men, 8.8% for women). Table 2 lists distribution by marital status and unadjusted CES-D scores means (SD) by age and gender groups. The greatest difference between men and women with regard to marital status occurred in the 75–85 year age group, in which 73.2% of women but only 12.1% of men were widowed. Nearly all the men were married, ranging from 87.2% of men aged 75–85 to 93.5% of men aged 55–64. Mean CES-D 10 scores increased with age among both men and women who were married, whereas widowed men and women had similar scores across age groups. For men aged 45–54 and 55– 64 years, widowed status was associated with a higher CES-D score (8.10) than was any other marital status; however, among those aged 65 years or older, divorced/separated men scored higher than did other groups. Among women, those who were divorced or separated had the highest CES-D scores across all ages. We next examined the association between marital status and depression. Marital status was related to depression in both men and women (Table 3). Individuals who were divorced/separated or widowed scored higher for depression than did married men (least squares mean of CES-D 10 ¼ 5.6), and this correlation was stronger among men than among women. Compared to married women (least squares mean ¼ 5.2), divorced/separated, and widowed women reported significantly higher levels of depressive
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symptoms. The relationship between gender and marital status was significant (p < 0.001), indicating a gender difference in the correlation of marital status with depressive symptoms. Education, income, employment status, number of chronic diseases, and disability were also significant correlates of CES-D 10 in both men and women. Educational attainment and household income were both significantly associated with lower depressive symptom scores for both men and women. Employment status was more strongly correlated with lower depression scores in men than in women (beta coefficient -1.21 in men vs. -0.38 in women). As expected, the number of chronic diseases and the presence of a disability were both associated with increased depression symptom scores. Table 4 presents the results from multiple linear regression models to assess the association of marital status with depressive symptoms by age group and by gender. Separate models were constructed for CES-D10 scores, adjusting for all covariates. None of the models was rejected for multicollinearity, based on the variance inflation factor test. Divorced/separated and widowed men reported higher levels of depressive symptoms than did married men across all age groups. However, this result was not replicated among women. The difference in depressive symptoms according to marital status disappeared among older women (aged 75 years or older), including divorced or separated and widowed women. In particular, the standardized coefficient for widowed women decreased from 1.8 for ages 45–54 to 1.0 for ages 75–85 (not significantly different from depressive symptoms scores for married women; least squares mean ¼ 8.8). The CES-D10 scores for widowed and divorced/separated women in the oldest groups were indistinguishable from those of married women. Among those aged 45–54 years old, widowed men had higher coefficients than did those with other marital statuses (ß ¼ 4.1), whereas divorced/separated women showed the highest coefficients (ß ¼ 2.6). In almost all age groups, with the exception of the oldest group of women, divorced/ separated women had higher CES-D coefficients than did widowed women, compared to married women. Widowed men, however, showed higher coefficients than did divorced/separated men, with the exception of men aged 65–74 years. These results were adjusted for socioeconomic status, living with children, as well as health status. Fig. 1 presents the gender differences among the average depressive symptoms scores (least square means) of married, widowed, and divorced or separated adults across age groups. The trend lines for the CES-D10 scores for married men and women (Fig. 1a) were not parallel within the groups from 45–54 through 75–85 years of age. A divergence between the trend lines of men and women was observed across age groups as a result of rising CES-D 10 scores among older married women. In contrast, average CES-D 10 scores for divorced/separated men and women (Fig. 1b) were divergent at the age of 65–74, but the confidence intervals of them were too wide to confirm the significant gender difference. Depression scores for widowed men and women (Fig. 1c) were constant across age groups (i.e., the lines for men and women were roughly parallel). Table 5 presents differences in age and gender groups in terms of associations between marital status and depressive symptoms. Being married was associated with lower rates of depressive symptoms in middle-aged women, but not in older women. For married women, depressive symptoms increased as age increased (ß ¼ 0.02, p ¼ 0.043). Gender differences in depressive symptoms by age were significant when married men were compared to married women (F ¼ 5.8, p ¼ 0.016). No age trend was found for divorced/separated and widowed men and women. Regression coefficients did not differ significantly with regard to being
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Table 2 Distribution of marital status by age group and unadjusted CES-D scores in Korean men and women aged 45–85 years old. Age groups
Men
Women
45–54
55–64
65–74
75–85
45–54
55–64
65–74
75–85
Sample N(Weighted%) Married 1208 (91.55) Widowed 14 (1.06) Divorced/separated 56 (4.28) Never married 41 (3.11) Total 1320 (100)
1088 33 34 9 1163
(93.52) (2.82) (2.84) (0.82) (100)
1006 70 19 2 1095
(91.89) (6.40) (1.62) (0.08) (100)
382 51 4 1 483
(87.21) (12.08) (0.55) (0.15) (100)
1450 89 88 21 1648
(87.99) (5.41) (5.38) (1.22) (100)
1062 240 32 8 1341
(79.16) (17.93) (2.35) (0.56) (100)
748 533 21 4 1306
(57.31) (40.82) (1.57) (0.30) (100)
181 518 6 3 708
CES-D 10 mean (SD) Married Widowed Divorced/separated Never married Total
5.38 8.66 7.79 12.16 5.56
(4.28) (6.48) (6.87) (6.95) (4.49)
6.31 9.16 14.47 15.00 6.61
(4.56) (6.41) (6.80) (0.00) (4.86)
(5.58) (6.97) (6.44) (0.00) (5.82)
5.25 8.13 8.31 7.73 5.58
(3.99) (4.98) (5.40) (5.37) (4.29)
6.19 7.58 8.85 6.48 6.45
(4.67) (5.77) (6.52) (3.54) (4.94)
7.80 9.11 11.06 7.29 8.30
(5.19) (5.70) (6.48) (5.21) (5.49)
4.67 11.83 8.75 7.32 4.99
(3.52) (8.10) (6.14) (4.35) (3.89)
7.88 10.70 14.63 13.00 8.06
divorced/separated or widowed and age according to gender (F ¼ 2.9, p ¼ 0.089 for divorced/separated individuals and F ¼ 0.7, p ¼ 0.408 for widowed individuals). These results reveal no gender differences in depressive symptoms by age among divorced/separated or widowed Koreans who are middle aged or older. Discussion At younger ages, married Korean women exhibited lower depressive symptom scores compared to their unmarried counterparts. However, this gap narrowed and eventually disappeared due to an age-related increase in depressive symptoms among married Korean women. In contrast, the relationship between marital status and depression remained fairly consistent and stable for Korean men of all ages. Our findings contradict those obtained from Western populations, which did not reveal increased rates of depression among married women as a function of age. In general, as the demands of child-rearing and occupational roles decrease in older age, traditional distinctions between male and female roles may become obscured, influencing the marital relationship in later life (Anderson & McCulloch, 1993). It has been well established that marriage provides an important source of social support to men and women in later life (Arber, 2004; Wenger et al., 1996). However, this benefit does not extend to older Korean women, who may only rarely obtain positive social support from their husbands. The experiences of Korean elders, who have highly stereotyped gender roles, may explain this finding. Changes in gender roles may
9.34 9.79 11.60 11.37 9.64
(25.61) (73.20) (0.81) (0.38) (100) (6.31) (6.22) (5.15) (2.24) (6.24)
induce marital stress among older generations, in particular, due to their lack of familiarity with more flexible gender roles because of their earlier immersion in the traditional patriarchal culture (Jeon et al., 2007). Unlike women in Western countries, most older Korean women (70%) reported that they were responsible for most domestic chores (including care of grandchildren, care of spouse or ageing relatives, and other household chores), which they rarely shared with husbands (Kim & Han, 1996). Patriarchal and Confucian cultures strictly define circumscribed gender roles in which wives are responsible for caretaking and household chores. Korean men who tend to place greater emphasis on their work roles may depend or intrude on their wives to a greater extent after retirement (Lee & Shehan, 1989). This pattern may precipitate marital conflicts between older men and women. Because men have been more likely than women to adhere to traditional attitudes toward gender roles, women have tended to oppose patriarchal norms and men have tended to conform to traditional roles (Lee & Lee, 1999; Scanzoni & Synder, 1980; Tomeh, 1978). Previous studies on the stress and instability of Korean older couples (Kim & Jun, 1997; Lee & Lee, 1999; Seo & Kim, 2000) have reported that wives perceive greater stress than do husbands, and husbands perceive higher level of spousal support than do wives. These previous studies concluded that husbands receive more emotional and physical support from wives than wives receive from husbands in older married couples. In the context of this discrepancy, gender differences in the social support received from marriage may contribute to the differential associations of depressive symptoms found for married men and women.
Table 3 Multiple regression model of depressive symptoms by marital statusa, gender. Men
Women
ß Married (Least squares meansb) Divorced or separated Widowed Living with children (1,0) Age (1 year interval) Education Equivalent income (quartiles) Employed (1,0) Number of chronic diseases Any disability (1,0) Women Marital status a gender N R2 a b
Reference (5.60) 3.83 2.81 0.18 0.01 0.39 0.40 1.21 0.77 1.29
3069 0.16
Excluded never married persons. Least square means were calculated by analysis of covariance.
Total
P
ß
P
<0.001 <0.001 0.216 0.112 <0.001 <0.001 <0.001 <0.001 <0.001
Reference (6.57) 2.56 1.32 0.06 0.01 0.48 0.58 0.38 0.94 1.69
4970 0.17
<0.001 <0.001 0.700 0.177 <0.001 <0.001 0.0216 <0.001 <0.001
ß Reference (5.67) 5.17 4.02 0.12 0.003 0.43 0.51 0.66 0.88 1.51 1.54 1.26 8940 0.17
P <0.001 <0.001 0.246 0.587 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
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generations, have resulted in the transfer of traditionally female gender roles to older family members. In the context of the persistence of traditional norms in the older generation and the concurrent dramatic social changes in the younger generation, older Korean adults who have performed care-giving duties may find the effects of these rapid social changes undesirable. Marriage constitutes a prerequisite for certain living arrangements. For example, living alone and living only with a spouse were highly correlated with marital status; none of the married individuals was living alone and none of widowed individuals was living with a spouse in our sample. Thus, the effect of marital status on mental health may derive from differences in living arrangement. A recent study of older Korean adults (Jeon et al., 2007) found that living alone appeared detrimental to men, whereas living alone appeared beneficial to women in comparison to living with one’s children. A study in Japan found that women in a multigenerational family had a higher risk of coronary heart disease, probably due to stress deriving from multiple family roles, such as caring for a sick parent and/or young grandchildren (Ikeda et al., in press). These results might be understood in the context of expectations that older women provide support and care for their households while their daughters or daughters-in-law work outside the home. In our analysis, the higher rate of depressive symptoms among married older women than among younger married women remained even after adjusting for living situation (i.e., living with children). Thus, we can conclude that marriage does not have a beneficial effect on the mental health of older Korean women, irrespective of whether multiple generations are included in the living arrangement. In middle age, widowhood was more detrimental to the mental health of men than divorce or separation, whereas divorce or separation was more detrimental than widowhood to mental health of women. Bennett (2005) suggested that widowhood is associated with declines in social engagement and in morale in general. Many widows lack a social support system, i.e., emotional support, service support, economic support, and physical support (Lopata, 1978). However, social support differs by gender after
Table 4 Multiple regression model of depressive symptoms by marital statusa according to gender and age group. Men
Age group
Married (Least squares means)b Divorced or separated Widowed Living with children (1,0) Education Equivalent income (quartiles) Employed (1,0) Number of chronic diseases Any disability (1,0) R2 N Women Married (Least squares means) Divorced or separated Widowed Living with children (1,0) Education Equivalent income (quartiles) Employed (1,0) Number of chronic diseases Any disability (1,0) R2 N
Ref (4.80) Ref (5.30) Ref (6.91) Ref (7.55) 2.78*** 2.61*** 8.04*** 2.21* 4.06** 2.73*** 2.80*** 2.29** 0.87** 0.08 0.08 0.08 0.07 0.32** 0.57*** 0.67** 0.40*** 0.42*** 0.39** 0.55* 2.32*** 1.45*** 0.70* 0.43 0.82*** 0.78*** 0.72*** 0.83*** 0.28 1.04** 1.34*** 2.59*** 0.16 0.13 0.15 0.14 1279 1153 1094 437
45–54
55–64
65–74
75–85
Ref(5.31) Ref (6.15) Ref (7.84) Ref (8.81) 2.58*** 2.01* 3.29** 0.55 1.75*** 1.10*** 1.12* 1.03 0.50* 0.08 0.55 1.02* 0.28* 0.61*** 0.94*** 0.64 0.51*** 0.50*** 0.73*** 0.83*** 0.43** 0.45 0.10 2.32 1.35*** 0.95*** 0.91*** 0.68** 1.95** 2.23*** 1.79*** 1.83*** 0.12 0.11 0.12 0.10 1628 1333 1302 705
Note: Standardized coefficients are reported. *p < 0.05; **p < 0.01; ***p < 0.001. a Excluded never married persons. b Least square means were calculated by analysis of covariance.
In recent years, traditional Korean family patterns of caring for disabled family members or children have changed rapidly. For example, the care-giving role of the daughter or daughter-in-law for disabled elders (Sugiura, Ito, Kutsumi, & Mikami, in press) has diminished in importance; major responsibility for care has shifted to older adults, primarily spouses. Rapid social changes, such as the dramatic increase in women’s participation in the labor market and the transition to a Westernized family culture among younger
Married men and women
16
16
Men 12
Separated/divorced men and women
b CES-D 10 mean
CES-D 10 mean
a
Women
8
1613
Men Women
12 8 4
4
0
0 45-54
55-64
65-74
45-54
75-85
55-64
75-85
Widowed men and women
c 16
CES-D 10 mean
65-74
Age
Age
Men Women
12 8 4 0 45-54
55-64
65-74
75-85
Age
Fig. 1. Least-squares means of CES-D10 scores for married(a), divorced or separated(b), and widowed(c) Koreans by gender and age group.
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Table 5 Age trend of depressive symptoms by marital status among men and women, and the difference in the regression coefficients for age between gender in each marital statusa. Men
ßb Married Divorced or separated Widowed
0.01 0.02 0.07
Women
P-trend 0.359 0.740 0.258
ß 0.02 0.03 0.001
Difference in coefficients (Men vs. Women) P-trend 0.043 0.578 0.935
*
Fc
Pr > F
5.76 2.91 0.69
0.016* 0.089 0.408
*p < 0.05; **p < 0.01; ***p < 0.001. a Excluded never married persons. b Standardized coefficients adjusted for education, living arrangement, income, disability, number of chronic disease are reported. c F-values were calculated by the contrast test in general linear model for each marital status.
widowhood; the majority of female widows are very independent and are involved in a complex support systems or highly dependent upon their children for all areas of support except financial. Friends tend to appear as companions in social activities. In contrast, losing a partner and remaining unmarried influences the rates of depressive symptoms among men. Indeed, men are more likely to identify their wife as a confidante with whom they exchange support and connection, whereas women are more likely to identify someone outside the home such as a friend as a confidant (Kim & Jun, 1997). In addition, Korean cultural norms among older generations treat remarriage after widowhood as normal for men, but as immoral for women. A survey of Korean adults (Kim & Han, 1996) revealed that fewer than 20% of widowed women wanted to remarry, but more than 70% of older men hoped to remarry. In 2006, around 3.03 per 1000 widowed men aged 65 years or older remarried, whereas only 0.10 per 1000 widowed older women aged 65 or older remarried (Korean Statistics, 2006). Both older men and women believe that the chastity of widowed women represents a virtue; thus remaining widowed without remarrying is perceived as natural, not detrimental for older widows (Kim & Han, 1996; Lee & Lee, 1999). The limitations of this study and alternative explanations of the results should also be considered. First, the analysis relied on crosssectional data and consequently the possibility of an endogeneity bias with respect to depression and marital status cannot be ruled out. This problem occurs when an outcome variable influences the predictor variables such that the causal direction ascribed for estimated effects may be incorrectly inferred. In our analysis, this might have occurred if depressed individuals were predisposed to particular marital statuses. Second, the depressive effects of bereavement may also gradually dissipate as widows adapt to their new stage of life, but the present study did not directly address time since widowhood. Moreover, the age variable represents the combination of the life course of an individual and differences among cohorts. One approach to untangling this complexity would consist of analyzing each model according to marital status by gender, age, time since widowhood, husband’s age, and any other relevant variables. Conclusions The gender-specific pattern characterizing the effect of marital status on depression among older Koreans can be explained in terms of the possible cohort effects associated with traditional norms about gender roles. Our results suggest that wives in older Korean couples may commonly experience situations associated with
depressive symptoms. More flexible attitudes toward gender roles and shared familial roles and social activities, instead of adherence to traditional gender roles, are necessary to reduce conflict between husbands and wives and to enable both members of an older couple to receive equal mental health benefits from marriage. Given that the older population is now expected to live longer following child rearing than was previously the case, it is especially important to understand the effects of age, gender, and marital status on the mental health of this population. The circumstances and life courses of married elders tend to vary cross-culturally and may also have differential influences on mental health.
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Contents lists available at ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Marital status, gender, and depression: Analysis of the baseline survey of the Korean Longitudinal Study of Ageing (KLoSA)q Soong-Nang Jang a, Ichiro Kawachi a, *, Jiyeun Chang b, Kachung Boo b, Hyun-Gu Shin b, Hyejung Lee b, Sung-il Cho c a b c
Harvard School of Public Health, Boston, MA, United States Korea Labor Institute, Republic of Korea Seoul National University, Republic of Korea
a r t i c l e i n f o
a b s t r a c t
Article history: Available online 12 October 2009
Marital status is a robust predictor of health outcomes in Western populations. However, data from Asian cultures remain sparse, and some studies suggest marked gender differences in the health benefits of marriage among Asian populations. We investigated the influence of marital status on depressive symptoms in older adult Koreans. Data were obtained from a sample of adults aged 45 to 85 years (4016 men, 5003 women) who participated in the 2006 cross-sectional baseline survey of the Korean Longitudinal Study of Ageing. Depressive symptoms were measured by the 10-item Center for Epidemiological Studies–Depression scale. A multiple regression model was used to examine the association between marital status and depressive symptoms, controlling for socioeconomic status, living arrangement, disability, and number of chronic diseases. In women aged 75 to 85 years, no significant differences were found between women who were married versus those who were widowed, divorced, or separated with regard to depressive symptoms. These findings were driven by increasing depressive symptoms among married women with age. Whereas divorced and widowed men in the sample reported higher rates of depressive symptoms than did married men, the difference between married vs. widowed/divorced women converged as they aged. This pattern of depressive symptoms by gender and life stage may reflect the distinctive influence of the Asian context on relations between men and women, such as traditional gender roles and patriarchal norms for older generation. Ó 2009 Elsevier Ltd. All rights reserved.
Keywords: Depressive symptoms Marital status Korea Ageing Gender
Introduction Numerous empirical studies have provided evidence for the protective effects of marriage on health; that is, married individuals are more likely to be healthier than are widowed, divorced, separated, or never-married individuals (Manzoli, Villari, Pirone, & Boccia, 2007; Turner, Lloyd, & Roszell, 1999; Williams, 2004). Married individuals live longer than do unmarried individuals, and this protective effect cannot be entirely explained by the selection of healthy individuals into marriage (Lillard & Panis, 1996). The benefits of marriage also extend to factors other than survival;
q This work was supported by a Korea Research Foundation Grant (KRF -2007321-B00096) funded by the Korean Government (MOEHRD). Kawachi is supported in part by the MacArthur Network on SES and Health. * Corresponding author. Harvard School of Public Health, Department of Health and Social Behavior, 677 Huntingdon Avenue, Boston, MA 02115, United States. Tel.: þ1 617 432 0235; fax: þ1 617 432 3123. E-mail address: [email protected] (I. Kawachi). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.09.007
married individuals reportedly experience lower rates of depression (Afifi, Cox, & Enns, 2006; Holt-Lunstad, Birmingham, & Jones, 2008; Inaba et al., 2005; Weissman et al., 1996; Williams, 2004). The health benefits of marriage may be mediated by a variety of mechanisms, including access to economic resources (economies of scale in household consumption, financial security, as well as the so-called ‘‘marriage premium’’ by which married individuals command higher wages in the labor market) (Waite, 1995); the exchange of social support (House, Landis, & Umberson, 1988); and the beneficial influence of spouses on marital partners’ health behaviors (Eng, Kawachi, Fitzmaurice, & Rimm, 2005; Lee et al., 2005). According to the social support theory of marriage, the loss of one’s spouse is often associated with increased risk of depression due to loss of financial, emotional, physical, and instrumental support (Levenson, Carstensen, & Gottman, 1993; Lopata, 1978; Mineau, Smith, & Bean, 2002; Ross, Mirowsky, & Goldstein, 1990; Umberson, Wortman, & Kessler, 1992). In contrast, Nagata, Takatsuka, and Shimizu (2003) suggested that widowhood does not have
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an important effect on the mental health of elders because the normative nature of losing one’s spouse at an advanced age might mitigate the consequences of widowhood on mental health (Nagata et al., 2003). Although many studies have reported similar mental health benefits of marriage among men and women (Arber, 2004; House et al., 1988; Manzoli et al., 2007; Seeman & Crimmins, 2001), several studies have reported gender differences with regard to the mental strain deriving from widowhood. For men, widowhood may lead to a weakening of family contacts, and older widowers might suffer more than older widows do from a lack of social support due to smaller networks of friends and more distant relationships with children and other family members (Davidson, 2000; Wenger, Davies, Shahtahmasebi, & Scott, 1996). Moen (1996) observed that the death of one’s spouse might have a more deleterious emotional impact on men, in that they derive more social and emotional support from marriage. The differential emotional impact of widowhood on men and women may be explained using a life course perspective: widowhood is an anticipated life event for women after a certain age, thus they are more likely than are older men to be prepared and to have a support group of peers and family members. For older women, widowhood may represent freedom from the care-giving role, as well as an opportunity to develop closeness with their children by living with them (Carr, 2004; Lee, DeMaris, Bavin, & Sullivan, 2001). In addition, several studies have emphasized the ability of the widowed to recover from grief and depression. Ferraro (1989) suggested that these factors provide some measure of compensation for widowed older women. Older widows seem to have a high degree of emotional resilience (Mastekaasa, 1994). The bulk of this evidence about the associations among marital status, health, and gender is based on Western populations. Fewer studies have been conducted in Asian cultures, where the patterns of associations have differed from the results obtained from Western societies. For example, Ikeda et al. (2007) examined the association between marital status and mortality in a 10-year prospective cohort of 94,062 middle-aged Japanese men and women and found that widowhood and divorce increased the risk of all-cause and cause-specific mortality by 1.5 to 2.0 fold in Japanese men, but no survival advantage was observed for married women (Ikeda et al., 2007). A study conducted in Beijing and Shanghai reported that the rate of depressive symptoms among men (50–70 years) without a spouse was 2.6 times higher than rates for married men, but marital status was not significantly associated with depression among women (Pan et al., 2008). These gender differences in the health benefit of marriage in Asian societies may stem from the social and cultural environment, which includes strictly demarcated gender roles deriving from patriarchal and Confucian norms. As a result of industrialization and urbanization during recent decades, Korean families have become more similar to Westernized nuclear families with spouse-centered structures. However, the patriarchal ideology persists in Korean families, especially in older couples (Cha, 2007). In recent decades, increasing life expectancy in Asia has resulted in marriages of increased duration. The period of time following the departure of children has lengthened dramatically, as reflected in higher rates of married individuals living together without children in the home. In 2005, 55.4% of Korean aged 65 years and older were married, an increase of 3.4% over this rate in 2000 (Korean National Statistics, 2006). Moreover, the prevalence of losing a spouse declined by 4.1% in this population during this period. These increases in the number of married elders, including increased rates of re-marriage among older individuals (Korean National Statistics, 2006), have reduced the traditional dependence on children, leading to lives that are increasingly
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focused on the couple in later life. Behind these gradual trends, however, conflict remains with regard to family members’ roles and norms. Women’s labor market participation has grown rapidly in Korea, and consequently, the traditional child bearing and particularly care-giving roles have been filled by older women in the family. In addition, the rapid rise in dual-earner couples has resulted in increased need for childcare arrangements and elder care support, as well as informal care support in Korea. Rapid structural change and traditional ideology can create conflict in older couples because wives may want to adopt modern flexible gender roles, whereas husbands might resist change and find it difficult to accept a new role later in life (Kim & Jun, 1997). Given these conditions, the traditional social support provided by marriage may not apply to Korean older women. Instead, these women might experience high levels of stress and depressive symptoms in later life due to marital conflict and the cumulative impact of gender role expectations. This, in turn,, may result in increased care-giving burdens for their husbands, children, and grandchildren. In the present study, we sought to examine the effect of marriage on the mental health of Korean men and women. We assessed the depressive symptoms among married, divorced/ separated, widowed Koreans across different age groups using a representative sample of middle-aged and older adults drawn from the Korean Longitudinal Study of Ageing (KLoSA). The Korean Longitudinal Study of Ageing (KLoSA), based on a nationally representative sample of Koreans aged 45 years or older, was launched in 2006. Funded by the Ministry of Labor, KLoSA is the first national survey of Koreans that measures depressive symptoms and is available to the public. KLoSA was also designed to compile information on various aspects of ageing for use as basic statistical data in interdisciplinary research on the social, economic, physical and psychological aspects of ageing. We hypothesized that marital status would have different influences on depressive symptoms depending on gender and age group. We assessed age in 10-year categories to reflect stages in an individual’s life course. For example, men and women between the ages of 45 and 54 are still tied to parental, social, and occupational roles. Men and women between the ages of 55 and 64 often go through the processes of retirement and subsequent reconnection with their spouses. Men and women between 65 and 74 years of age are adapting to new roles as grandparents or caregivers for sick spouses or grandchildren. Men and women aged 75 years or older are more likely to experience spousal death, health problems, and diminished levels of functioning. In addition, age cohorts separated by 10-year intervals have experienced different social environments during youth and adulthood because Korea has experienced rapid economic development and modernization during the past 50 years. Individuals currently aged 75 years or older have been immersed since childhood in Confucian attitudes about strictly demarcated gender roles. Thus, married older Korean women are burdened with the role of family caregiver for sick spouses and young grandchildren, substituting for working daughters or daughters-in-law with regard to the latter. The burdens of these roles might lead to depressive symptoms among the oldest Korean married women. Methods Study design and data The Korean Longitudinal Study of Ageing (KLoSA) focused on Koreans aged 45 and older living in households selected by multistage stratified probability sampling (based on geographical area) to be representative of the nation. A total of 10,254 individuals
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completed interviews conducted by a trained interviewer. The household response rate was 70.7%, and the individual response rate within households was 75.4%. We limited our analysis to the population of 3813 men and 4827 women aged 45 to 85 years drawn from the baseline survey of the 2006 KLoSA. The average age ( SD) of our sample was 60.69 (10.39) years; this was slightly lower than that of the full panel of respondents. Weights were assigned to the Enumerated District (ED) to estimate parameters, reflecting the sampling process, the survey process, and accuracy of external data. Computation of KLoSA weight involved a sequence of three steps: 1) the design weight based on two-staged sampling probability; 2) the non-response-adjusted weight to reduce the impact of non-responses; and 3) the benchmark weight reflecting changes in the general distribution of population using demographic changes in census, residence registration records or other large-scale surveys. CES-D 10 depression The short-form (10-item) Center for Epidemiological Studies dDepression (CES-D10) scale served as the outcome variable. The CES-D10 is a brief screening instrument that assesses depressive symptoms experienced during the most recent week: the 10 items are divided into two that are positively phrased (feel pretty good, generally satisfied) and eight that are negatively phrased (loss of interest, trouble concentrating, feeling depressed, feeling tired or low in energy, feeling afraid, trouble falling asleep, feeling alone, and hard to get going) (Irwin, Artin, & Oxman, 1999; Kohout, Berkman, Evans, & Cornoni-Huntley, 1993). The responses for each item ranged from 0 to 3; 0 signified very rarely or less than once a day; 1 signified sometimes or 1–2 days during the past week; 2 signified often or 3–4 days during the past week; and 3 signified almost always or 5–7 days during the past week. The summed scores of the 10 items, with scores reversed for the positively phrased items, served as the outcome measure. Higher scores indicated greater distress. The alpha coefficient for the CES-D10 was 0.79, which was comparable to the 0.80 obtained in previous reliability studies (Irwin et al., 1999). The criterion validity of the CES-D 10 was also acceptable for our data because the association between self rated health was significant for CES-D 10 (R ¼ 0.44 for self-rated health). Explanatory variables Respondents reported their marital status as ‘‘married or living with partner,’’ ‘‘separated,’’ ‘‘divorced,’’ ‘‘widowed,’’ or ‘‘never married.’’ We classified these responses into four categories: ‘‘married,’’ ‘‘widowed,’’ ‘‘divorced or separated,’’ and ‘‘never married.’’ Analyses excluded never-married men and women due to the small sample size (N ¼ 89). In order to assess the net effect of marital status within each age and gender group, we considered possible covariates according to the results of previous population-based studies of depressive symptoms: living arrangement, employment status, educational level, income, and chronic disease, and disability (An, An, O’Connor, & Wexler, 2008; Holzer et al., 1986; Jeon, Jang, Rhee, Kawachi, & Cho, 2007; Pearlin, Morton, Menaghan, & Mullan, 1981; Weissman et al., 1996; Yoo, 1997). Living arrangement was dichotomized into living with children or children’s family (1) or other (0). Living alone and living with spouse only were the only living arrangement categories to be highly correlated with marital status in our sample, because marital status partially defined these living arrangements. Thus, we used living with children or children’s family as a covariate.
Most studies show that those with less education, lower income or lower occupational prestige have higher rates of depressive disorders and/or depressive symptoms than those in more advantaged socioeconomic positions. The employment status of respondents was assessed, beginning with a question about whether subjects participated in the labor market. We divided respondents into two groups: employed (1) and not employed (0). The educational levels of respondents were categorized as elementary school or less (1), middle school graduate (2), high school graduate (3), and college graduate and beyond (4). Household-equivalent income was calculated as the total household income divided by the square root of the number of household members; these scores were then divided into quartiles. The number of chronic diseases reflects self-reported histories of having been diagnosed by a physician with one or more of eight conditions: hypertension, diabetes, cancer, lung disease, heart problems, stroke, arthritis, and gastrointestinal disease. Functional status was measured using the 10-item Korean Instrumental Activities of Daily Living (K-IADL) scale, which includes personal grooming, going out for short distances, using transportation, making/receiving phone calls, managing money, doing household chores, preparing meals, shopping, taking medications, and doing the laundry. This measure is widely used and validated with high internal consistency (a ¼ 0.85) (Won et al., 2002). If respondents were dependent with regard to one or more activities, they were categorized as having a disability (1); if they were dependent with regard to none of the IADL items, they were classified as having no disability (0). Analysis We calculated the frequencies, weighted proportions, and means ( SDs) of demographic characteristics by gender and age groups. We used chi-square tests and t-tests to compare the distributions of marital status, and demographic characteristics by gender. We calculated means (SDs) of CES-D scores in men and women according to four age groups: 45–54, 55–64, 65–74, and 75–85 years old. Separate analyses of covariance were performed to assess associations between CES-D10 responses and marital status (excluding ‘‘never married’’), and the results are presented as leastsquares means of the CES-D10. A multiple linear regression model was used to evaluate the influence of marital status on score measuring depressive symptoms by gender and age. The model included marital status (excluding ‘‘never married’’), age in 1-year intervals, education, income, current job status, living arrangement, disability, and number of chronic diseases. We also examined the interaction of gender and marital status. We conducted separate analyses of trends in the associations between age and depressive symptoms with regard to marital status (married, divorced/separated, and widowed) by gender using multiple linear regression. Finally, we conducted statistical tests to compare regression coefficients between men and women across age groups within each marital status. A contrast analysis of a general linear model (Littell, Stroup, & Freund, 2002) was used to test the null hypothesis that the regression coefficients for men and women were equal within each marital status. Results The proportion of married men (92.3%) in the sample was greater than the corresponding proportion for women (73.8%) (Table 1). As expected, women were more likely to be widowed (22.3%) than were men (3.1%). Men tended to be more highly educated than women, and over half the women in the survey
S.-N. Jang et al. / Social Science & Medicine 69 (2009) 1608–1615 Table 1 General characteristics of Korean men and women aged 45–85 years old.
Sample number Marital status* Married Widowed Divorced, separated Never married Age** (mean, SD) 45–54 years old 55–64 years old 65–74 years old 75–85 years old Living with children* Yes No Education* Elementary school or less Middle school High school College or more Household monthly income* (won, mean, SD) Equivalent incomea, ** 1Q (Lowest) 2Q 3Q 4Q (Highest)
Men
Women
4016
5003
92.34% 3.14% 3.07% 1.45% 60.58 (10.13) 33.72% 29.18% 27.09% 10.01%
73.81% 22.30% 3.18% 0.71% 60.77(10.59) 34.40% 27.90% 25.18% 12.51%
51.20% 48.80%
49.03% 50.97%
24.77% 18.63% 36.66% 19.94% 2052.29 (2503.33)
52.06% 18.45% 24.14% 5.36% 1761.20 (2499.46)
21.69 23.80 26.99 27.51
27.02 25.84 24.55 22.59
Job status* Employed 65.35% Retired 18.95% Not employed or home makers 15.7% Number of chronic disease* (mean, SD) 0.66 (0.91) 14.35% Any disability*
28.74% 14.62% 56.64% 0.79 (0.98) 8.81%
*p < 0.05, ** p < 0.01 by chi-square test or t-test. a . Monthly household income divided by the square root of the number of household members. Household equivalized income was categorized into quartiles.
(52.1%) were placed into the least-educated category. Approximately half of both men and women were living with their children. Men reported higher average annual family incomes than did women. The majority of men were employed (65.4%), whereas more than half of the women (56.6%) were homemakers or not employed. Women reported more chronic diseases, whereas men were more likely to report disability (14.4% for men, 8.8% for women). Table 2 lists distribution by marital status and unadjusted CES-D scores means (SD) by age and gender groups. The greatest difference between men and women with regard to marital status occurred in the 75–85 year age group, in which 73.2% of women but only 12.1% of men were widowed. Nearly all the men were married, ranging from 87.2% of men aged 75–85 to 93.5% of men aged 55–64. Mean CES-D 10 scores increased with age among both men and women who were married, whereas widowed men and women had similar scores across age groups. For men aged 45–54 and 55– 64 years, widowed status was associated with a higher CES-D score (8.10) than was any other marital status; however, among those aged 65 years or older, divorced/separated men scored higher than did other groups. Among women, those who were divorced or separated had the highest CES-D scores across all ages. We next examined the association between marital status and depression. Marital status was related to depression in both men and women (Table 3). Individuals who were divorced/separated or widowed scored higher for depression than did married men (least squares mean of CES-D 10 ¼ 5.6), and this correlation was stronger among men than among women. Compared to married women (least squares mean ¼ 5.2), divorced/separated, and widowed women reported significantly higher levels of depressive
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symptoms. The relationship between gender and marital status was significant (p < 0.001), indicating a gender difference in the correlation of marital status with depressive symptoms. Education, income, employment status, number of chronic diseases, and disability were also significant correlates of CES-D 10 in both men and women. Educational attainment and household income were both significantly associated with lower depressive symptom scores for both men and women. Employment status was more strongly correlated with lower depression scores in men than in women (beta coefficient -1.21 in men vs. -0.38 in women). As expected, the number of chronic diseases and the presence of a disability were both associated with increased depression symptom scores. Table 4 presents the results from multiple linear regression models to assess the association of marital status with depressive symptoms by age group and by gender. Separate models were constructed for CES-D10 scores, adjusting for all covariates. None of the models was rejected for multicollinearity, based on the variance inflation factor test. Divorced/separated and widowed men reported higher levels of depressive symptoms than did married men across all age groups. However, this result was not replicated among women. The difference in depressive symptoms according to marital status disappeared among older women (aged 75 years or older), including divorced or separated and widowed women. In particular, the standardized coefficient for widowed women decreased from 1.8 for ages 45–54 to 1.0 for ages 75–85 (not significantly different from depressive symptoms scores for married women; least squares mean ¼ 8.8). The CES-D10 scores for widowed and divorced/separated women in the oldest groups were indistinguishable from those of married women. Among those aged 45–54 years old, widowed men had higher coefficients than did those with other marital statuses (ß ¼ 4.1), whereas divorced/separated women showed the highest coefficients (ß ¼ 2.6). In almost all age groups, with the exception of the oldest group of women, divorced/ separated women had higher CES-D coefficients than did widowed women, compared to married women. Widowed men, however, showed higher coefficients than did divorced/separated men, with the exception of men aged 65–74 years. These results were adjusted for socioeconomic status, living with children, as well as health status. Fig. 1 presents the gender differences among the average depressive symptoms scores (least square means) of married, widowed, and divorced or separated adults across age groups. The trend lines for the CES-D10 scores for married men and women (Fig. 1a) were not parallel within the groups from 45–54 through 75–85 years of age. A divergence between the trend lines of men and women was observed across age groups as a result of rising CES-D 10 scores among older married women. In contrast, average CES-D 10 scores for divorced/separated men and women (Fig. 1b) were divergent at the age of 65–74, but the confidence intervals of them were too wide to confirm the significant gender difference. Depression scores for widowed men and women (Fig. 1c) were constant across age groups (i.e., the lines for men and women were roughly parallel). Table 5 presents differences in age and gender groups in terms of associations between marital status and depressive symptoms. Being married was associated with lower rates of depressive symptoms in middle-aged women, but not in older women. For married women, depressive symptoms increased as age increased (ß ¼ 0.02, p ¼ 0.043). Gender differences in depressive symptoms by age were significant when married men were compared to married women (F ¼ 5.8, p ¼ 0.016). No age trend was found for divorced/separated and widowed men and women. Regression coefficients did not differ significantly with regard to being
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Table 2 Distribution of marital status by age group and unadjusted CES-D scores in Korean men and women aged 45–85 years old. Age groups
Men
Women
45–54
55–64
65–74
75–85
45–54
55–64
65–74
75–85
Sample N(Weighted%) Married 1208 (91.55) Widowed 14 (1.06) Divorced/separated 56 (4.28) Never married 41 (3.11) Total 1320 (100)
1088 33 34 9 1163
(93.52) (2.82) (2.84) (0.82) (100)
1006 70 19 2 1095
(91.89) (6.40) (1.62) (0.08) (100)
382 51 4 1 483
(87.21) (12.08) (0.55) (0.15) (100)
1450 89 88 21 1648
(87.99) (5.41) (5.38) (1.22) (100)
1062 240 32 8 1341
(79.16) (17.93) (2.35) (0.56) (100)
748 533 21 4 1306
(57.31) (40.82) (1.57) (0.30) (100)
181 518 6 3 708
CES-D 10 mean (SD) Married Widowed Divorced/separated Never married Total
5.38 8.66 7.79 12.16 5.56
(4.28) (6.48) (6.87) (6.95) (4.49)
6.31 9.16 14.47 15.00 6.61
(4.56) (6.41) (6.80) (0.00) (4.86)
(5.58) (6.97) (6.44) (0.00) (5.82)
5.25 8.13 8.31 7.73 5.58
(3.99) (4.98) (5.40) (5.37) (4.29)
6.19 7.58 8.85 6.48 6.45
(4.67) (5.77) (6.52) (3.54) (4.94)
7.80 9.11 11.06 7.29 8.30
(5.19) (5.70) (6.48) (5.21) (5.49)
4.67 11.83 8.75 7.32 4.99
(3.52) (8.10) (6.14) (4.35) (3.89)
7.88 10.70 14.63 13.00 8.06
divorced/separated or widowed and age according to gender (F ¼ 2.9, p ¼ 0.089 for divorced/separated individuals and F ¼ 0.7, p ¼ 0.408 for widowed individuals). These results reveal no gender differences in depressive symptoms by age among divorced/separated or widowed Koreans who are middle aged or older. Discussion At younger ages, married Korean women exhibited lower depressive symptom scores compared to their unmarried counterparts. However, this gap narrowed and eventually disappeared due to an age-related increase in depressive symptoms among married Korean women. In contrast, the relationship between marital status and depression remained fairly consistent and stable for Korean men of all ages. Our findings contradict those obtained from Western populations, which did not reveal increased rates of depression among married women as a function of age. In general, as the demands of child-rearing and occupational roles decrease in older age, traditional distinctions between male and female roles may become obscured, influencing the marital relationship in later life (Anderson & McCulloch, 1993). It has been well established that marriage provides an important source of social support to men and women in later life (Arber, 2004; Wenger et al., 1996). However, this benefit does not extend to older Korean women, who may only rarely obtain positive social support from their husbands. The experiences of Korean elders, who have highly stereotyped gender roles, may explain this finding. Changes in gender roles may
9.34 9.79 11.60 11.37 9.64
(25.61) (73.20) (0.81) (0.38) (100) (6.31) (6.22) (5.15) (2.24) (6.24)
induce marital stress among older generations, in particular, due to their lack of familiarity with more flexible gender roles because of their earlier immersion in the traditional patriarchal culture (Jeon et al., 2007). Unlike women in Western countries, most older Korean women (70%) reported that they were responsible for most domestic chores (including care of grandchildren, care of spouse or ageing relatives, and other household chores), which they rarely shared with husbands (Kim & Han, 1996). Patriarchal and Confucian cultures strictly define circumscribed gender roles in which wives are responsible for caretaking and household chores. Korean men who tend to place greater emphasis on their work roles may depend or intrude on their wives to a greater extent after retirement (Lee & Shehan, 1989). This pattern may precipitate marital conflicts between older men and women. Because men have been more likely than women to adhere to traditional attitudes toward gender roles, women have tended to oppose patriarchal norms and men have tended to conform to traditional roles (Lee & Lee, 1999; Scanzoni & Synder, 1980; Tomeh, 1978). Previous studies on the stress and instability of Korean older couples (Kim & Jun, 1997; Lee & Lee, 1999; Seo & Kim, 2000) have reported that wives perceive greater stress than do husbands, and husbands perceive higher level of spousal support than do wives. These previous studies concluded that husbands receive more emotional and physical support from wives than wives receive from husbands in older married couples. In the context of this discrepancy, gender differences in the social support received from marriage may contribute to the differential associations of depressive symptoms found for married men and women.
Table 3 Multiple regression model of depressive symptoms by marital statusa, gender. Men
Women
ß Married (Least squares meansb) Divorced or separated Widowed Living with children (1,0) Age (1 year interval) Education Equivalent income (quartiles) Employed (1,0) Number of chronic diseases Any disability (1,0) Women Marital status a gender N R2 a b
Reference (5.60) 3.83 2.81 0.18 0.01 0.39 0.40 1.21 0.77 1.29
3069 0.16
Excluded never married persons. Least square means were calculated by analysis of covariance.
Total
P
ß
P
<0.001 <0.001 0.216 0.112 <0.001 <0.001 <0.001 <0.001 <0.001
Reference (6.57) 2.56 1.32 0.06 0.01 0.48 0.58 0.38 0.94 1.69
4970 0.17
<0.001 <0.001 0.700 0.177 <0.001 <0.001 0.0216 <0.001 <0.001
ß Reference (5.67) 5.17 4.02 0.12 0.003 0.43 0.51 0.66 0.88 1.51 1.54 1.26 8940 0.17
P <0.001 <0.001 0.246 0.587 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
S.-N. Jang et al. / Social Science & Medicine 69 (2009) 1608–1615
generations, have resulted in the transfer of traditionally female gender roles to older family members. In the context of the persistence of traditional norms in the older generation and the concurrent dramatic social changes in the younger generation, older Korean adults who have performed care-giving duties may find the effects of these rapid social changes undesirable. Marriage constitutes a prerequisite for certain living arrangements. For example, living alone and living only with a spouse were highly correlated with marital status; none of the married individuals was living alone and none of widowed individuals was living with a spouse in our sample. Thus, the effect of marital status on mental health may derive from differences in living arrangement. A recent study of older Korean adults (Jeon et al., 2007) found that living alone appeared detrimental to men, whereas living alone appeared beneficial to women in comparison to living with one’s children. A study in Japan found that women in a multigenerational family had a higher risk of coronary heart disease, probably due to stress deriving from multiple family roles, such as caring for a sick parent and/or young grandchildren (Ikeda et al., in press). These results might be understood in the context of expectations that older women provide support and care for their households while their daughters or daughters-in-law work outside the home. In our analysis, the higher rate of depressive symptoms among married older women than among younger married women remained even after adjusting for living situation (i.e., living with children). Thus, we can conclude that marriage does not have a beneficial effect on the mental health of older Korean women, irrespective of whether multiple generations are included in the living arrangement. In middle age, widowhood was more detrimental to the mental health of men than divorce or separation, whereas divorce or separation was more detrimental than widowhood to mental health of women. Bennett (2005) suggested that widowhood is associated with declines in social engagement and in morale in general. Many widows lack a social support system, i.e., emotional support, service support, economic support, and physical support (Lopata, 1978). However, social support differs by gender after
Table 4 Multiple regression model of depressive symptoms by marital statusa according to gender and age group. Men
Age group
Married (Least squares means)b Divorced or separated Widowed Living with children (1,0) Education Equivalent income (quartiles) Employed (1,0) Number of chronic diseases Any disability (1,0) R2 N Women Married (Least squares means) Divorced or separated Widowed Living with children (1,0) Education Equivalent income (quartiles) Employed (1,0) Number of chronic diseases Any disability (1,0) R2 N
Ref (4.80) Ref (5.30) Ref (6.91) Ref (7.55) 2.78*** 2.61*** 8.04*** 2.21* 4.06** 2.73*** 2.80*** 2.29** 0.87** 0.08 0.08 0.08 0.07 0.32** 0.57*** 0.67** 0.40*** 0.42*** 0.39** 0.55* 2.32*** 1.45*** 0.70* 0.43 0.82*** 0.78*** 0.72*** 0.83*** 0.28 1.04** 1.34*** 2.59*** 0.16 0.13 0.15 0.14 1279 1153 1094 437
45–54
55–64
65–74
75–85
Ref(5.31) Ref (6.15) Ref (7.84) Ref (8.81) 2.58*** 2.01* 3.29** 0.55 1.75*** 1.10*** 1.12* 1.03 0.50* 0.08 0.55 1.02* 0.28* 0.61*** 0.94*** 0.64 0.51*** 0.50*** 0.73*** 0.83*** 0.43** 0.45 0.10 2.32 1.35*** 0.95*** 0.91*** 0.68** 1.95** 2.23*** 1.79*** 1.83*** 0.12 0.11 0.12 0.10 1628 1333 1302 705
Note: Standardized coefficients are reported. *p < 0.05; **p < 0.01; ***p < 0.001. a Excluded never married persons. b Least square means were calculated by analysis of covariance.
In recent years, traditional Korean family patterns of caring for disabled family members or children have changed rapidly. For example, the care-giving role of the daughter or daughter-in-law for disabled elders (Sugiura, Ito, Kutsumi, & Mikami, in press) has diminished in importance; major responsibility for care has shifted to older adults, primarily spouses. Rapid social changes, such as the dramatic increase in women’s participation in the labor market and the transition to a Westernized family culture among younger
Married men and women
16
16
Men 12
Separated/divorced men and women
b CES-D 10 mean
CES-D 10 mean
a
Women
8
1613
Men Women
12 8 4
4
0
0 45-54
55-64
65-74
45-54
75-85
55-64
75-85
Widowed men and women
c 16
CES-D 10 mean
65-74
Age
Age
Men Women
12 8 4 0 45-54
55-64
65-74
75-85
Age
Fig. 1. Least-squares means of CES-D10 scores for married(a), divorced or separated(b), and widowed(c) Koreans by gender and age group.
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Table 5 Age trend of depressive symptoms by marital status among men and women, and the difference in the regression coefficients for age between gender in each marital statusa. Men
ßb Married Divorced or separated Widowed
0.01 0.02 0.07
Women
P-trend 0.359 0.740 0.258
ß 0.02 0.03 0.001
Difference in coefficients (Men vs. Women) P-trend 0.043 0.578 0.935
*
Fc
Pr > F
5.76 2.91 0.69
0.016* 0.089 0.408
*p < 0.05; **p < 0.01; ***p < 0.001. a Excluded never married persons. b Standardized coefficients adjusted for education, living arrangement, income, disability, number of chronic disease are reported. c F-values were calculated by the contrast test in general linear model for each marital status.
widowhood; the majority of female widows are very independent and are involved in a complex support systems or highly dependent upon their children for all areas of support except financial. Friends tend to appear as companions in social activities. In contrast, losing a partner and remaining unmarried influences the rates of depressive symptoms among men. Indeed, men are more likely to identify their wife as a confidante with whom they exchange support and connection, whereas women are more likely to identify someone outside the home such as a friend as a confidant (Kim & Jun, 1997). In addition, Korean cultural norms among older generations treat remarriage after widowhood as normal for men, but as immoral for women. A survey of Korean adults (Kim & Han, 1996) revealed that fewer than 20% of widowed women wanted to remarry, but more than 70% of older men hoped to remarry. In 2006, around 3.03 per 1000 widowed men aged 65 years or older remarried, whereas only 0.10 per 1000 widowed older women aged 65 or older remarried (Korean Statistics, 2006). Both older men and women believe that the chastity of widowed women represents a virtue; thus remaining widowed without remarrying is perceived as natural, not detrimental for older widows (Kim & Han, 1996; Lee & Lee, 1999). The limitations of this study and alternative explanations of the results should also be considered. First, the analysis relied on crosssectional data and consequently the possibility of an endogeneity bias with respect to depression and marital status cannot be ruled out. This problem occurs when an outcome variable influences the predictor variables such that the causal direction ascribed for estimated effects may be incorrectly inferred. In our analysis, this might have occurred if depressed individuals were predisposed to particular marital statuses. Second, the depressive effects of bereavement may also gradually dissipate as widows adapt to their new stage of life, but the present study did not directly address time since widowhood. Moreover, the age variable represents the combination of the life course of an individual and differences among cohorts. One approach to untangling this complexity would consist of analyzing each model according to marital status by gender, age, time since widowhood, husband’s age, and any other relevant variables. Conclusions The gender-specific pattern characterizing the effect of marital status on depression among older Koreans can be explained in terms of the possible cohort effects associated with traditional norms about gender roles. Our results suggest that wives in older Korean couples may commonly experience situations associated with
depressive symptoms. More flexible attitudes toward gender roles and shared familial roles and social activities, instead of adherence to traditional gender roles, are necessary to reduce conflict between husbands and wives and to enable both members of an older couple to receive equal mental health benefits from marriage. Given that the older population is now expected to live longer following child rearing than was previously the case, it is especially important to understand the effects of age, gender, and marital status on the mental health of this population. The circumstances and life courses of married elders tend to vary cross-culturally and may also have differential influences on mental health.
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