Excess mortality among the unmarried: A case study of Japan

Vol.36, No. Printedin Great Britain

Sm. Sci. Med.

4, pp. 533-546,

0277-9536/93

1993

$6.00 + 0.00

PergamonPressLtd

EXCESS MORTALITY AMONG THE UNMARRIED: A CASE STUDY OF JAPAN NOREENGOLDMAN’and YUANRENGHu2 ‘Fellow, Center for Advanced Study in the Behavioral Sciences, Stanford, CA and Professor of Demography and Public Affairs, Princeton University, Princeton, NJ 08544, U.S.A. and 2Statistical Analyst, WESTAT Inc., Rockville, MD 20850, U.S.A. Abstract-Recent research has demonstrated that mortality patterns by marital status in Japan are different from corresponding patterns in other industrialized countries. Most notably, the magnitude of the excess mortality experienced by single Japanese has been staggering. For example, estimates of life expectancy for the mid-1900s indicate that single Japanese men and women had life expectancies between 15 and 20 years lower than their married counterparts. In addition, gender differences among single Japanese have been smaller than elsewhere, while those among divorced persons have been unanticipatedly large; and, the excess mortality of the Japanese single population has been decreasing over the past few decades in contrast to generally increasing differentials elsewhere. In this paper, we use a variety of data sources to explore several explanations for these unique mortality patterns in Japan. Undeniably, the traditional Japanese system of arranged marriages makes the process of selecting a spouse a significant factor. Evidence from anthropological studies and attitudinal surveys indicates that marriage is likely to have been and probably continues to be more selective with regard to underlying health characteristics in Japan than in other industrialized countries. However, causal explanations related to the importance of marriage and the family in Japanese society may also be responsible for the relatively high mortality experienced by singles and by divorced men. Key words-mortality

by marital status, Japanese mortality

INTRODUmION Few demographic issues have been as frequently studied yet remain as poorly understood as does the relationship betweeen marital status and mortality. In literally hundreds of studies in industrialized nations dating as far back as the mid- 1SOOs,researchers have established that single, divorced and widowed men and women have higher mortality risks, and poorer health in general, than their married counterparts. At the same time, relatively little is known about the extent to which these differences result from marriage selection or from causal mechanisms sometimes referred to as marriage protection. In other words, do married people fare better than their unmarried counterparts because mentally and physically healthier persons are more likely to get married in the first place (marriage selection), or because of the presumed social, psychological, economic and environmental benefits associated with having a spouse (marriage protection)? The arguments in support of causal mechanisms are numerous. For example, social scientists claim that the increased social ties and networks that result from marriage facilitate access to medical information and services, constrain risk-taking behavior and encourage healthy behavior, act as a buffering mechanism in stressful situations, substitute for formal health care, and provide additional economic resources that effect the frequency and quality of health care services (e.g. Berkman [l], Blazer [2], Umberson [3] and Weiss [4]). Another variant of the

marriage protection hypothesis derives from the premise that departures from the married state (namely, becoming widowed or divorced) are stressprovoking crises that ultimately lead to higher mortality. While many scholars agree that such causal mechanisms are operative, and some have even gone so far as to advocate marriage as a way to improve health and increase longevity [5], there has been less consensus as to the importance of selection mechanisms in accounting for the better health and longevity of the married. Whether they do so explicitly or implicitly, most researchers ultimately conclude that causal influences are probably more important than selection factors in generating the higher death rates and poorer health among unmarried persons. In effect, many scholars refute the importance of marriage selection mechanisms in producing the observed differences in longevity; and, they do so on the basis of relatively little or non-convincing evidence (e.g. Bernard [6] and Umberson [3]) or through the use of fallacious inferences (e.g. Durkheim [7], see Goldman [8]). A related drawback of much of this earlier research has been the failure to consider whether findings can be generalized across populations. As shown below, a recent comparative study has indicated important variations in the nature and magnitude of differential mortality by marital status across countries and over time. Specifically, patterns in Japan have been distinct from those of most other industrialized countries.

533

534

NOREENGOLDMANand YUANRENGHu

Since the nature of the marriage process also differs substantially

between Japan and the other countries

in the comparative

study, it seems at least plausible

that the importance

of marriage selection in account-

ing for the observed mortality

differentials

varies by

location. In this paper, we begin by reviewing mortality

the Japanese

patterns by marital status and the ways in

which these patterns are distinct from those observed elsewhere. We subsequently consider several possible mechanisms

underlying

the

Japanese

patterns-

errors in the data, as well as selection

and causal explanations. We combine a variety of sources of data-anthropological studies, sample surveys and information on cause-of-death by marital status-in our efforts to demonstrate both the importance of the Japanese marriage selection process and the likely influence of a variety of marriage protection mechanisms in producing the distinct mortality patterns by marital status in Japan. MORTALITY PATTERNS BY MARITAL STATUS A recent analysis, designed to explore the extent to which mortality

patterns by marital status were simi-

lar across 16 industrialized

countries,

revealed

that

patterns in Japan were distinct from those in other populations

in several ways [9]. Most of these differ-

ences pertain to the single (i.e. never-married) lation.

First, the magnitude

experienced (relative

by

Japanese

popu-

of the excess mortality single

men

to their married counterparts)

and

women

far exceeded

that of other countries. As shown in Fig. 1, the death

rate for single persons was at least three times as high as that for married persons in Japan; the corresponding relative mortality ratio (defined as the death rate of the unmarried group divided by the death rate of married persons) in the other countries ranged between 1.3 and 2.2 [lo]. Second, the relative mortality ratios for single women were almost as high as those for single men, a pattern unlike the typically higher ratio experienced by men in most countries. Third, the relative mortality ratios of single persons in Japan declined substantially since the 1950s while the ratios for single persons in most of the other countries were increasing over this time period. And fourth, whereas other countries typically experienced a decline in relative mortality for single persons from middle to old age, single women in Japan maintained high levels of excess mortality throughout the oldest age group [l 11. Yet a fifth distinct pattern was apparent among divorced Japanese: the death rate for divorced men in Japan was more than three times as high as for married men; corresponding ratios for divorced men in other countries were substantially smaller as were the ratios for divorced Japanese women. It is interesting to note that mortality among Japanese widows and widowers was not exceptionaly high in comparison with corresponding levels of relative mortality observed in other industrialized countries.

The most striking characteristic of the mortality risks among unmarried Japanese is the exceptionally high death rates experienced by the never-married. This feature of Japanese mortality is even more apparent when the death rates are translated into life expectancies. In Figs 2(A) and (B) single and married life expectancies for males and females in 1940, 1960 and 1980 are shown for industrialized countries with available data. The life expectancies are calculated for the age range 2&75 [12]. Figures 2(A) and (B) depict both the striking magnitude of the excess mortality of single persons in the past and the enormous improvements in mortality for both single and married persons in Japan relative to the other countries. In 1940, for example, single females in Japan had a life expectancy between 17 and 22 years lower than the values for single women in the U.S.A., Sweden, England and France, and about 17 years lower than comparable life expectancy for married Japanese women! Differentials for unmarried Japanese males were almost as large. By 1960, these differences had declined but remained large: for example, about a lo-year disadvantage for single Japanese women relative to both single women in the other countries and married Japanese women. By 1980, these differentials had decreased substantially, although life expectancy for never-married Japanese remained the lowest of the 12 countries shown and was about 4 years below that for married Japanese women and 7 years below that for married Japanese men. In addition, over this 40-year span, life expectancy among married persons in Japan evolved from the lowest to the highest among the countries shown here. What factors can account for the atypically high mortality experienced by singles and by divorced men in Japan? We begin by briefly exploring the extent to which reporting errors could have resulted in the observed patterns. Subsequently, we consider the roles of the mate selection process and various protective aspects of marriage in generating the mortality advantage of the married population. CAN THE DIFFERENTIALS BE EXPLAINED BY ERRORS IN THE DATA?

Some demographers have argued that the apparently high mortality experienced by unmarried populations may be an artifact of misreporting, including errors in census data (e.g. Sheps [13] and Berkson [14]). For example, to the extent that the census disproportionately undercounts the unmarried population, exposure for the unmarried population will be underestimated and reported death rates exaggerated. For the seven Japanese censuses conducted between 1950 and 1980, estimated total undercounts ranged between 0.5% and 1.5%, with the largest undercounts (5% or less) pertaining to males in their twenties [ 151. Although undercount estimates are not available by marital status, simulations indicate that

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Fig. 1. Relative mortality ratios by country and gender. The country codes are as follows: Austria (AUS), France (FRA), Netherlands West Germany @‘GE), Hungary (HUN), Portugal (POR), Japan (JAP). Taiwan (TAI), Denmark (DEN), Finland (FIN), Norway Sweden @WE), England and Wales (E + w), Scotland (SCO), Canada (CAN) and U.S.A.

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(NET), (NOR),

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536

and YUANRENG Hu

NOREENGOLDMAN

even large differential undercounts between the married and the unmarried populations could not account for the observed mortality differences in Japan [16]. Moreover, given the generally high quality of Japanese census and vital registration data [17], it is difficult to imagine that this problem could affect the Japanese data more than those from the other countries in the study.

THE EFFECT

OF THE MATE SELECTION

PROCESS

A more tenable hypothesis is that the atypically large mortality differentials between never-married and married persons in Japan result from the nature of the mate selection process. There are several aspects of the Japanese marriage process that make such an argument plausible. First is the importance

48

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51

Excess mortality among the unmarried

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53

Fig. 2(B) Fig. 2. (A) Life expectancies (between ages 20 and 75) for single and married men, 1940, 1960 and 1980. (B) Life expectancies (between ages 20 and 75) for single and married women, 1940, 1960 and 1980. Sources: Japan: Vital Statistics, Japan. Ministry of Health and Welfare, Japan, 1940, 1960, 1980. Population Census ofJapan, Vol. 1. Office of the Prime Minister, Bureau of Statistics, Japan, 1940, 1960, 1980. Sweden: Befolknings-Forandringar, Del 3. Hela riket och lanen m m. Statistika Centralbyran, Stockholm, 1940, 1960, 1980. France: Mouvement de la Population. Statistiques AnnwIles, Institute National de la Statistique et des Etudes Economiques, 1940, 1960-1962. Quang Chi D. and Guignon N. La Situation Demographique en 1980. Institute National de la Statistique et des Etudes Ewnomiques. U.S.: Grove R. D. and Hetzel A. M. Vital Statistics. Rates in the United States 1940-1960. National Center for Health Statistics, Washington, DC, 1968. Other countries: United Nations Demographic Yearbook. selected years between 1958 and 1985.

538

NOREENGOLDMANand YUANRENCHu

of the health of the potential spouse as a criterion for mate selection. Second is the inclusion of outsiders in the selection process. And third is the efficiency of the process: before the most recent decade or two, virtually all Japanese eventually married. Each of these characteristics is strongly related to the Japanese system of arranged marriages. Importance

qf health in the marriage process

During the Meiji Restoration, arranged marriages-which had been common among the samurai warriors in pre-modern Japan-spread to most levels of society [ 18, 191. The decision to arrange a marriage usually rested with the head of the family or the household, although the arrangements (as well as the initiation of the match) often involved a mediator or go-between [19,20]. A typical arrangement might involve a series of discussions between the two families, followed by a formal meeting or miai, which involved the eligible young man and woman and members of the two families [21]. If the miai was successful, a formal engagement would follow within a few months; if not, subsequent miai involving other potential spouses would be arranged in the future. In addition to the go-between (nakado) who had formal responsibility for negotiating the marriage, relatives, friends, neighbors and even private detectives were frequently involved in screening potential mates. There is considerable evidence that health had been a very important criterion for Japanese marriages. Vogel [2l] notes that families relied on criteria such as the “family’s status and wealth, the health, life expectancy and strength of the family line” in the selection of a spouse. One of the most important concerns for the Japanese family was to avoid contamination of the blood line with disease, and families were particularly fearful of certain hereditary and psychological diseases [19]. It also seems likely that tuberculosis infection played an important role in the marriage process. Dore [22, p. 661 argues that tuberculosis was the most feared disease in Japan around 1950, in part because of its high prevalence (tuberculosis was the single most important cause of death in Japan from the mid-1930s until 1951 [23]), but also because of the belief that the disease was inherited and “might damage the family’s chances in the marriage market.” Results from several anthropological studies suggest that a variety of persons and procedures were used to screen the mentally and physically disabled from marriage [24]. In rural areas, families relied upon friends and neighbors for information about the potential spouse’s family, while in urban areas private detectives were frequently employed 119,251. In their efforts to glean information about the health status of the potential spouse, a family might request copies of the potential spouse’s family records at the registry offices [26], call the potential spouse’s school or office to check for medical absences, or use private

detectives to assess the likelihood of defective genes in the family line-for example, because of mental illness or the presence of a Hiroshima victim in the family [ 19, 25, 271. Additional evidence for the importance of healthrelated selection criteria comes from a 1983 survey. A total of about 9000 couples under age 65 were asked to assess the relative importance of 17 factors in the mate selection process [28]. ‘Health’ ranked either first or second for husbands and wives of all marriage cohorts. Perhaps more revealing is the fact that about half of the respondents rated ‘relatives’ genetic diseases’ as ‘very important’ or ‘moderately important’. Size of the single population Another aspect of the mate selection process in Japan, which reinforces the use of health-related factors as selection criteria, is the fact that the vast majority of the population marries. For example, between 1940 and 1960, 3% or fewer of Japanese women and men in their forties had never been married, in contrast to comparable estimates for Western European countries averaging to about 10%. Demographers have argued that if marriage is selective on the basis of health characteristics, the relative size of the single population should be negatively related to the magnitude of its mortality rate. That is, the higher the proportion of the population that is married, the higher should be the death rates among those who remain single 129, 301. The 16country study referred to earlier did demonstrate a fairly consistent negative relationship between the size of the single group and the magnitude of its death rate [31]. Hence, it is tempting to attribute the large excess mortality of single Japanese to the selective nature of the Japanese marriage system. However, the size of the single group does not provide sufficient information to justify inferences about the importance of marriage selection, for several reasons. First, size is not always a good predictor of mortality among singles, as indicated by the finding that Taiwan has smaller percentages single than Japan but yet Taiwanese singles experience lower levels of excess mortality than their Japanese counterparts [32]. Second, mathematical simulations demonstrate that, contrary to intuition, marriage selection on the basis of health does not necessarily result in a negative relationship between the relative size of the single group and its mortality rate [8]. In fact, the relationship can be negative, positive, or nonmonotonic, depending, for example, on the extent to which unhealthy individuals are discriminated in the marriage market and the extent to which healthy individuals choose to remain single. And third, a negative relationship between the relative size and the mortality rate of singles could result from causal mechanisms as well as from selection. Sociologists, for example, have argued that role conflicts and high levels of stress associated with being in relatively

Excess mortality among the unmarried small groups result in higher rates of morbidity and mortality [33]. Although it is not legitimate to make statistical inferences about the role of the mate selection process from the sheer size of the single population, evidence from historical and anthropological studies suggests that two characteristics of the Japanese marriage system-high rates of marriage and the selection of future spouses on the basis of characteristics related to health-led to both a small and a relatively unhealthy single population. That is, strong societal pressures to marry meant that virtually all Japanese who could marry did so; and, as indicated by smallscale studies in Suye Mura in the 1930s [34] and Kurotsuchi during the 1970s [19], the few persons who failed to marry were characterized by mental or physical handicaps--either themselves or within their family. Impact of the mate selection process on patterns of excess mortality among singles

The features of the marriage selection process described above-use of health-related criteria, involvement of outsiders in the selection process, and the near universality of marriage-are more distinctive of traditional arranged marriages than of modern ‘love marriages’. Indeed, it seems highly likely that the decline of the rniai during the post-war period and the increasing prevalence of renai (love marriages) at least partly account for the declining magnitude of the excess mortality of Japanese singles over the past few decades. Between the marriage cohort of the late 1940s and that of the late 198Os, the frequency of arranged marriages declined precipitously, from 74 to 24% [35, 361. During the same time period the relative mortality of singles fell substantiallyfor example, by as much as 40% between 1955 and 1980. Although the distinction between arranged and love marriages is often an ill-defined one [37], it is evident that more recent marriage cohorts have had considerably more latitude than earlier ones in the choice of a spouse. It is likely that such freedom of choice reduced the importance of family criteria (including health) for establishing a match [38]. Data from the 1983 survey referred to earlier indicate that more recent marriage cohorts were only half as likely as earlier cohorts to consider ‘relatives’ genetic diseases’ as an important factor in selecting a spouse, and they were considerably more likely to select ‘personality’ or ‘attitude toward life’ as major considerations. This change in the preference profile for future mates was accompanied by another important change over the past few decades in Japan: the replacement of infectious diseases by chronic diseases as the leading causes of death. The precipitous decline in the prevalence of tuberculosis and other respiratory and gastro-intestinal infections (which often occurred at relatively young ages) may simply have made it progressively less feasible for potential SSM 36,&K

539

spouses to be chosen on the basis of observable health limitations. One additional factor may account for the reduction in excess mortality among singles. Modest increases in the size of the single population over the past few decades [39] appear to be partly the result of an increasing propensity for highly educated and professionally-oriented persons (particularly women) to repudiate marriage [36]. Since socioeconomic status is positively related to longevity, these changes are likely to have contributed to the increasing life expectancy among Japanese singles shown earlier in Fig. 2. There is some evidence that health factors were more important for selection of the bride than for the groom since the former was chosen for her presumed ability to bear healthy children [40,41]. Since traditional arranged marriages were more prevalent among earlier marriage cohorts, older female cohorts were more likely than younger ones to have been denied marriage because of health limitations. Hence, differences in marriage arrangements between men and women may have resulted in the unique gender and age patterns of excess mortality observed among Japanese singles-namely, higher than expected mortality among single women, particularly in the older age groups [42]. In summary, the results suggest that marriage is likely to have been (and probably continues to be) more selective with regard to underlying health characteristics in Japan than in other industrialized countries, and that selection was probably more important several decades ago than today. This argument is consistent with the observation that, on average, singles in Japan have experienced higher mortality than formerly married persons [43]. (By contrast, in most other countries, divorced persons typically face the highest mortality risks.) Nevertheless, it is important to recognize that although formerly married persons in Japan ‘passed’ their first marriage selection process, they are exposed to more than one such process. As discussed later, selective remarriage on the basis of health may account for differences in the level of excess mortality between divorced men and women. MORTALITYBYCAUSEOF DEATH Do cause-of-death data support the marriage selection hypotheses presented above? We attempt to answer this question by examining excess mortality among unmarried persons for selected causes of death during the period 1975-1985 (the only years for which cause-of-death data by marital status were available). For completeness, we present estimates below for single, divorced and widowed persons, although we focus on the first two marital groups. Table 1 presents estimated relative mortality ratios for each of 14 causes of death and for all remaining causes (primarily chronic diseases) [44]. The resulting

NOREENGOLDMANand YUANRENGHu

540

Table I. Relative

mortality

ratios’ by cause of death, Japan (1975-1985) Males

-___ Divorced

Females

Cause

Single

Mental disorders Infective and parasitic diseases Homicide Suicide All other external causes Cirrhosis of liver and other chronic liver diseases Diabetes mellitus Hypertensive diseases Cerebrovascular diseases Motor accidents lschemic heart diseases Cancer of digestive organs and peritoneum Leukemia Cancer of respiratory and organs mthrathoracic Remaining causes

Il.06 5.69 5.3 I 3.99 3.53

2.66 1.70 4.58 3.21 1.91

II.99 4.1 I 16.30 7.06 4.74

IO.61 4.29 2.22 2.96 3.79

2.10 1.53 2.71 1.72 I .67

3.90 2.05 7.08 2.83 2.38

3.43 2.96 2.82 2.27 2.24 2.08

1.64 1.31 I .66 I .45 1.70 I .39

5.43 3.1 I I .94 I.89 3.72 I .X4

2.76 2.44 3.26 2.40 1.85 2.85

1.34 I.31 I .67 1.39 I .45 I .44

2.00 I .27 I .44 I.20 17 I .42

1.34 1.21

I.18 I .07

1.44 1.18

I .67 I.?h

1.20 I.12

.I6 .08

1.17 3.23

1.16 I s7

1.31 2.32

2.40 3.29

I .25 I .49

.46 .54

I .48

2.40

2.73

1.41

I .45

ALL CAUSES

Widowed

2.65

‘These estimates

are based on an additive

log-linear

model that includes

estimates indicate that the ratios are greater than one for each cause, range dramatically across the causes (e.g. from 1.I to 16.3), and, among singles, are highest for mental disorders [45] and infectious and parasitic diseases. Indeed, such results are entirely consistent with the notion that the marriage process involved careful screening against mental disorders as well as against infectious diseases such as tuberculosis. There are several problems, however, in using these data to support hypotheses about the role of the marriage selection process in producing the excess mortality of the unmarried. One problem stems from the fact that some of the causes with the highest relative mortality ratios are relatively uncommon. Thus, for example, although single men are 11 times as likely to die from mental disorders than married men and divorced men are 16 times as apt to die from homicide, relatively few Japanese die from either of these causes. In order to evaluate the contribution from particular causes of death to the Table 2. Hypothetical

relative mortality

Sinale

Single

Suicide Cerebrovascular diseases All other external causes Cirrhosis of liver and other chronic liver diseases Infective and parasitic diseases Motor accidents Ischemic heart diseases Cancer of digestive organs and peritoneum Mental disorders Diabetes mellitus Hypertensive diseases Homicide Cancer of respiratory and intrathoracic organs Leukemia Remaining causes ALL CAUSES ‘These estimates

overall differential between unmarried and married persons, we developed an alternative measure which we have labelled the ‘hypothetical relative mortality ratio’ (HRMR). The HRMR for a particular cause quantifies the amount by which mortality among the unmarried would be higher than that among the married, if the death rate for this cause were the only one to d@er between the unmarried and the married. These estimates can be readily converted into the contributions of each of the specified causes to the overall excess mortality of the unmarried group ([46], see Hu [32] for details). The resulting HRMRs, presented in Table 2, confirm our suspicion that some of the causes with the highest RMRs have relatively little effect on the mortality differential. However, suicide, a cause undoubtedly related to mental disorders, is the single most important cause in explaining the excess mortality of single (and divorced) men and the second most important cause for single women. For ratios’ by cause of death, Japan (197>1985)

Widowed

Females Divorced

Single

Widowed

Divorced

1.25 1.20 I.15

1.02 I.11 I .ot

I.18 I.18 I.11

1.14 1.27 I .05

I .02 1.10 1.01

I .06 1.04 I .02

1.09 1.08 I .07 I .05

I.01 1.01 1.oo I .03

1.16 1.06 I .05 I .06

I .03 I .06 I.01 I .08

I.01 I.01 1.00 I .03

I .02 I.01 1.01 I .02

I.05 I .03 1.01 1.01 1.01

I .03 1.oo 1.00 1.02 1.00

1.08 1.03 1.02 I.01 I.01

1.11 1.02 1.02 I .03 1.00

1.03 I .oo I.01 I .02 I .oo

1.03 1.01 1.00 I.01 1.oo

I .oo I .oo 1.63

1.01 1.00 1.21

1.02 1.00 1.41

I .03 I .oo 1.85

I.01 1.00 I.18

I.01 1.00 1.20

I .48

2.40

2.73

I.41

2.65 are based on an additive

Divorced

year. age group and manta1 Status 132).

Males Cause

Widowed

log-linear

model that includes

year, age group and marital

I .45 status ]32].

541

Excess mortality among the unmarried example, according to the estimates in Table 2, if suicide were the only cause to differ in frequency between the single and the married population, the mortality of single men would be 25% higher than that of married men (i.e. the RMR would be 1.25). Stroke is the leading source of excess mortality among single women and is numerically important among single and divorced men as well [47]. Other major sources of the mortality differential include other external causes [48] and cirrhosis of the liver among single and divorced men and cancer of the digestive system among single women [49]. Note, however, that since the HRMRs for most single causes are small in comparison with the overall RMR, no single cause, or even a combination of several causes, can explain the majority of excess mortality. The estimates in Table 2 reveal the ultimate difficulty of drawing inferences about the importance of selection factors from cause-of-death data. Most of the excess mortality of the single population derives from causes which could be identified with either selection or with causal hypotheses. For example, the higher rate of suicide among singles may result from the marriage selection process-namely, the reduced likelihood of marriage among emotionally unstable or mentally disabled men and women. However, as discussed in more detail below, it is also plausible that the lower suicide death rates among the married are a consequence of emotional and other psychological and social benefits of having a spouse, or of the stress faced by single individuals as a consequence of the stigmas associated with their failure to marry. Similar competing explanations would apply to cirrhosis of the liver-an important source of the excess mortality among single men that is strongly related to the prevalence of alcoholism. Social scientists have frequently argued that to the extent that marital status differentials are large for causes related to one’s psychological state or to diseases for which the sick person could potentially benefit from informal social support, the differentials probably result from the protective aspects of marital roles [SO, 511. However, as suggested above, it is important to recognize that a large differential for almost any cause of death could be attributed to either a selection or protection mechanism. Even differentials for causes that are primarily genetic in nature and frequently appear prior to marriageable age (e.g. diabetes) could be associated with protection mechanisms since marriage offers increased social networks, better economic well-being, and more likely compliance with recommended medical regimes-factors which are likely to extend the longevity of a person with the disease. Moreover, since many of the causes which are important in accounting for the excess mortality of unmarried Japanese are also leading causes of death for the entire population (e.g. stroke and cancer) and are associated with a large number of potential risk

factors related to diet, lifestyle and stress, many plausible selection mechanisms that mately lead to the observed differences specific mortality between the married and populations in Japan. THE POTENTIAL

BENEFITS

there are could ultiin causeunmarried

OF MARRIAGE

In spite of the likely importance of the spouse selection process in producing the observed mortality differences, there are many characteristics of Japanese society that lend support to marriage protection theories. Such hypotheses relate the increased social ties, interpersonal relationships and psychological and physical support that result from marriage to generally healthier life styles, greater psychological well-being, and fewer risk-taking behaviors. Since marriage is generally viewed as the normative state for adults, similar arguments associate failure to enter or maintain a marriage with psychological distress and role conflicts (e.g. Gove [50]). The undeniable importance in Japanese society of social interactions in general and of marriage and the family in particular make such causal hypotheses entirely plausible. Marriage in Japan is viewed as an essential stage in the transition toward adulthood and is considered necessary for maintenance of the fundamental institution called ie (roughly translated as ‘family’ or ‘household’) and for procreation. Failure to marry carries severe implications of immaturity and lack of moral responsibilities and indicates an inability to achieve full human status [52, 531. The importance of marriage appears to be especially strong for women, who receive preparation for marriage starting in childhood. Women’s lives are considered meaningless without marriage (and the presence of children), they are under enormous pressure to marry when they reach the appropriate age, and their personal and economic security is dependent on marriage. Although the life of a married woman can be quite demanding, particularly for women today who assume the dual roles of housewife and career person, few women in the past have opted for single life. Lebra [53] claims that aversions to single life result not so much from a desire to marry, but from fear of stigma. Marriage is clearly important for men as well. As a result of strong sex role differentiation, the general dependence of Japanese men on their wives is staggering. It extends beyond simple domestic duties to one of the wife’s subordination of her needs to her husband’s and provision of all of the ‘backstage work’ so that the married man can wholeheartedly devote himself to his career. The Japanese woman is virtually the sole caretaker of children, husband and, frequently, in-laws [27,53]. According to Edwards [52], the complementary social deficiencies of Japanese men and women render marriage necessary for both. In addition, the importance in Japanese culture of group membership and

542

NOREENGOLDMANand YUANRENGHu

the concomitant pressure for conformity to group norms [54] must subject the unmarried Japanese man and woman to repeated sources of stress, role conflict, and discrimination. Since marriage and the family are such integral components of Japanese society, it is important to consider how differences in the social and economic environment of single and married persons could account for the observed differentials in mortality. For example, do the better employment prospects faced by married men account for their longer lifetimes? The better economic situation faced by married Japanese men is incontrovertible: for example, data from the 1955 and 1965 censuses indicate that about one-third of single men aged 35-50 were not employed, in contrast to a comparable figure of about 3% for married men! In addition, estimated life tables by occupational status for men indicate that, in 1980, unemployed men had a life expectancy about 15 years lower than corresponding values associated with most occupational classifications [55]. Unfortunately, it is virtually impossible to use such cross-sectional data to disentangle selection from causal explanations, It seems highly probable that health-related criteria which affect marriage prospects also determine employment prospects-that is, very unhealthy persons are less likely to marry and to find regular employment. Arguments relating differences in socio-economic status between the single and the married to differences in mortality are even more problematic for women. Unlike men, single women are considerably more likely to be employed (and to hold professional and technical positions, for example) than are married women. Indeed, this finding is not unexpected given the fact that Japanese women (especially mothers) have been expected to stay at home, raise the family and let the husband serve as breadwinner. What is perhaps surprising is the virtual absence of a gender difference in the relative mortality of singles: whereras most industrialized countries have substantially greater excess mortality among unmarried men-a pattern typically attributed to women providing more health benefits to their spouses than do men-the gender difference among Japanese singles is small. Thus, in comparison with other countries, single women in Japan face poorer mortality prospects than single males (as compared with their respective married counterparts). One source of the higher than expected mortality among single females is suicide. Compared with values in other industrialized countries, female suicide rates in Japan are high relative to those of men, particularly in the prime marriageable ages [56] and in older ages [57,58]. Other sources of the excess mortality among single females are various forms of cancer (including cancers of the respiratory and digestive systems), which are associated with higher ratios among single females than among either single males or other unmarried females (Tables 1 and 2).

These results are consistent with those from a recent study of cancer incidence in Aichi Prefecture [59]. Kato found significantly higher than expected incidence rates for about 40% of cancer types among single women, but for only a small percentage of cancer types among women or men of other marital statuses [60]. The data in Tables 1 and 2 also suggest particularly high mortality among single women from hypertensive disease and ischemic heart diseases. Discrimination against single women in social interactions and in the labor market could be at least partly responsible for these gender differences [61]. In particular. Headley [57] notes that high suicide rates among unmarried Japanese women reflect their disadvantaged economic and social position [62]. The recent increase in overall excess mortality among single women (but not among single men) from several causes associated with stress (i.e. stroke, heart disease and hypertension) [63] could also result from the increasing tensions Japanese women face at a time when their participation in the labor force is increasing, but when gender discrimination remains relatively strong. There are at least two other hypotheses that relate aspects of married life in Japan to lower risks of mortality. First is the responsibility of the Japanese family (the mother in particular) for the health of its members. Kiefer [64] notes that the Japanese health care system has left considerable responsibility for care of the sick and elderly with the family. Providing this care may be onerous, but it is accepted out of personal convictions or community pressures. In spite of a loosening of family ties in Japan in recent years, about two-thirds of Japan’s aged were living with one of their children in 1985 [65]. Since illegitimate births are rare in contemporary Japan [36], elderly singles are considerably less likely to receive such care than are divorced or widowed persons [66]. Because of the general availability of family support in Japan, certain health care options, such as long-term care facilities, are scarce [67]. A second potential mechanism leading to the observed differences in longevity is less healthy diets and life-style behaviors among the unmarried. Data on the prevalence of smoking and heavy drinking (for Aichi Prefecture) indicate substantially higher values among the single (and divorced) than among the married, for both men and women [59]. Our analysis of mortality by cause of death also suggests that alcohol consumption is considerably greater among the unmarried, and the importance of stroke and cancer of the digestive system in explaining the higher mortality of singles indicates that other dietary factors (such as high salt intake, the popularity of pickled foods and underconsumption of vegetables and fish) may also be significant [68,69]. We noted earlier that, whereas single men and single women in Japan experience similar levels of excess mortality, divorced men experience substantially higher excess mortality than divorced women.

Excess

mortality among the unmarried

What mechanisms can account for such a large gender difference among the divorced? One likely part of the explanation is selective remarriage on the basis of health. Although anecdotal evidence suggests that divorced men remarry while divorced women do not [70], the available data indicate only modestly higher remarriage rates among divorced men than women [71]. A second possible mechanism for the relatively low death rates among divorced women is the presence of children and other potential family ties; studies elsewhere have demonstrated that parenting (and other familial relationships) results in better health and lower risks of dying, in part by encouraging healthy life styles and inhibiting risk-taking behavior (e.g. Kobrin and Hendershot [72] and Umberson [3]). Divorced men in Japan are less likely to obtain custody of their children than women [73] (or even to have contact with their children) and undoubtedly suffer further from a total absence of domestic skills. Yet a third hypothesis is that women who obtain a divorce in Japan are of higher socioeconomic status than the general population [56], and, hence, are healthier or better able to cope with health problems than single women. CONCLUSIONS

Although the roles of marriage selection and protection mechanisms in accounting for the excess mortality of unmarried men and women can never be adequately quantified, this study has helped to identify plausible explanations for the high mortality risks experienced by single Japanese. It seems probable that both selection and protection have operated in the past and continue to do so today, but that mate selection was relatively more important and potentially very significant in the past. The arranged marriage process, which relied explicitly on family criteria including health for the selection of a spouse, appears to have generated a single population characterized by exceptionally high mortality risks. Moreover, changes in the marriage process over the past few decades, combined with gender differences in the mate selection process, are probably responsible for some of the unique patterns of excess mortality among single Japanese. There are, however, alternative credible explanations related to the strength of marriage and the family in Japanese society that are consistent with unexpectedly high mortality among never-married persons, particularly women. One could also argue that a set of social and economic factors, including the weakening of family ties in recent years and the creation of a universal health coverage program in the early 1960s have rendered the life-style of unmarried Japanese progressively closer to that of their married counterparts and have resulted in declining relative mortality ratios over recent decades. Clearly, much remains to be learned about marital status differentials in mortality in Japan. Some of the

543

issues raised here can be properly addressed only with data from a longitudinal survey that follows men and women from relatively young ages through marriageable ages and the remainder of the life cycle. Such a study would need to collect detailed information on health status, lifestyles, living arrangements, and the social and economic environment of individuals. In spite of the difficulty of collecting and analyzing such data, the questions posed here warrant such attention. The size of the unmarried population in Japan is likely to increase in the near future for several reasons. First, age at marriage has been increasing steadily since the post-war period, with current mean ages at first marriage higher than 28 for men and about 26 for women [74]. Second, there is some indication that an increasing fraction of young persons, especially women, would prefer never to marry at all [75, 761. And third, divorce rates have been continuing their slow but steady increase of the past two decades: the most recent estimates indicate that nearly one-fifth of marriages will end in divorce if current divorce rates persist [77]. Although the level of excess mortality among unmarried Japanese has been declining for several decades, the continued presence of large mortality differences in the country with the world’s highest life expectancy merits further attention. Acknowledgements-This research was supported in part by research grants from the National Institute of Child Health and Development (ROI HD22414). the National Science Foundation (BNS-8700864) and the Japan Foundation. We would like to thank Shigemi Kono, Linda Martin, Anne Pebley, Tatsuya Itoh, Zenji Nanjo, Tsugoyoshi Suzuki, Norio Azumi and Kathleen Much for their comments on earlier versions of the manuscript. We are extremely grateful to Drs Shigemi Kono and Kyo Hanada of the Institute of Population Problems, Japan, for providing us with unpublished cause-of-death tabulations prepared for their own research on Japanese mortality. REFERENCES

1. Berkman L. F. Assessing the physical effects of social networks and social support. A. Rev. pub/. Hlrh 5, 413-432, 1984. 2. Blazer D. G. Social support and mortality in an elderly community population. Am. J. Epidemiol. 115, 684-694, 1982. 3. Umberson D. Family status and health behaviors: social control as a dimension of social integration. J. Hlth sot. Behnv. 28, 306-319, 1987. 4. Weiss N. S. Marital status and risk factors for coronary heart disease: The United States Health Examination Survey of Adults. Br. J. prevent. sot. Med. 27, 41-43, 1973. 5. Christensen B. J. The costly retreat from marriage. The Publ. Interest 91, 59-66, 1988. 6. Bernard J. The Future of Marriage. Yale University Press, New Haven, 1982.‘ E. Suicide. The Free Press, Glencoe, IL, 7. Durkheim 1951. 8. Goldman N. Marriage selection and mortality patterns: inferences and fallacies. Unpublished manuscript, 1992. 9. Hu Y. and Goldman N. Mortality differentials by marital status: an international comparison. Demogruphy 21, 233-250, 1990.

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NOREEN GOLDMAN and YUANRENG Hu

10. These estimates

Il.

12.

13. 14.

15.

16.

17.

18. 19. 20. 21.

22. 23.

24.

25.

26.

are derived from a multivariate model of the death rate which controls for age, time period and marital status. The model was fit to data on reported numbers of deaths and persons for males and females in the following 16 countries: Austria, Canada, Denmark, England and Wales, Finland, France, Hungary, Japan, Netherlands, Norway, Portugal, Scotland, Sweden, Taiwan, West Germany and the U.S. The estimated ratios presented above are aggregate figures, adjusted for age (typically for ages between 20 and 64) and time period (approx. 1950-1980). See Hu and Goldman [9] for details. Data at the older ages were not available for many of the 16 countries in the study. Hence, this comparison is restricted to Sweden, the United States and France. The life expectancy calculations are bounded above since people who continue to be married (rather than become widows) at ages over 75 are a progressively more select group among survivors of similar ages. Sheps M. C. Marriage and mortality. Am. J. puhl. Hlth 51, 547-565, 1961. Berkson J. Mortality and marital status: reflections on the derivation of etiology from statistics. Am. J. publ. Hlth 52, 1318-1329, 1962. Atoh M., Itoh T., Takahashi S. and Ishikawa A. Re-estimation of the population by age and sex and vital rates in postwar Japan. J. Pop. Problems (Jinko Mondui Kenkyu) 176, 1-17. 1985. For example, under the extreme assumption that all missing persons below age 65 are single, the relative mortality ratio for the age group 20-65 would be reduced substantially (by about one-quarter). but would remain higher than that for any other country in the study. More realistic assignments of missing persons to marital status groups lead to considerably smaller reductions in the relative mortality ratios. Some scholars speculated that delays in marriage registration, which are still common in Japan, may have biased the resulting data. However, it seems unlikely that reports of marital status in the censuses (which form the basis of the denominators of our rates) would be greatly affected by marriage registration delays. Moreover, if census reports were affected, the result would be an overreporting of unmarried persons and hence an underestimate of the mortality rate among the unmarried. Befu H. Japan: An Anthropological Introduction. Chandler, San Francisco, 1971. Hendry J. Marriage in Changing Japan: Community and Society. St Martin’s Press, New York, 1981. Taeuber I. B. The Population of Japan. Princeton University Press, Princeton, NJ, 1958. Vogel E. F. The Japanese family. In Comparafive Fumily Systems (Edited by Nimkoff M. F.), Chap. 14. Houghton Mifflin, Boston, 1965. Dore R. P. City Life in Japan. University of California Press, Berkeley, CA, 1958. Ministry of Health and Welfare, Japan. Vital Stafistics, Japan, pp. 1288129. Statistics and Information Department, Tokyo, 1989. The mentally or physically unfit were not necessarily relegated to the single life. For example, Hendry [19] and Cornell [Cornell L. L. Spinsters. J. Fam. History 9, 326-339, 19841 argue that the near universality of marriage implied that some handicapped individuals were forced to marry similarly disadvantaged mates. Vogel E. The go-between in a developing society: the case of the Japanese marriage arranger. Hum. Organ. 20, 112-120, 1961. Such records contain information on deaths in the family, as well as on previous divorces, and illegitimacy of births. In the past, the records also contained infor-

27. 28.

29.

30. 31.

mation on social class. Japanese are now prohibited from seeing family records except for their own [19]. Condon J. A Half Step Behind: Japanese Women of the 8Os, Dodd, Mead and Company, New York, 1985. Imaizumi Y. and Kaneko R. Trends of mate selection in Japan. J. Pop. Problems (Jinko Mondai Kenkyu) 173, l-21, 1985. Livi-Bacci M. Selectivity of marriage and mortality: notes for future research. In Population and Biology (Edited bv Kevfitz N.). no. 99-108. Ordina Editions. Liege, BeIgium~ 1985. .. Kisker E. E. and Goldman N. Perils of single life and benefits of marriage. Sec. Bioi. 34, 1355152, 1987. Controlling for age and period effects, this study found that in 28 out of the 32 country-gender samples (including those for Japan), the smaller the percentage of persons single, the higher the death rate of the single

group [91. 32. Hu Y. Mortality differentials by marital status: a comparative analysis. Doctoral dissertation, Princeton University, 1990. 33. Dodge D. L. and Martin W. T. Social Stress and Chronic Illness. University of Notre Dame Press, Notre Dame, IN, 1970. 34. Embree J. F. Suye Mura. A Japanese Village. University of Chicago Press, Chicago. IL, 1939. 35. Long S. 0. Family Change and the Ltfe Course in Japan. The Cornell East Asia Papers, Cornell University, Ithaca, NY, 1987. 36. Atoh M. Attitude toward marriage among the youth. In Summary of Twentieth National Survey on Family Planning, Chap. VII. The Population Problems Research Council, The Mainichi Shimbum, Tokyo, 1990. betweeen love marriages and arranged 37. The distinction marriages is often unclear, since many marriages classified as the former involve parents, go-betweens and friends at various stages of the mate selection process and marriage decisions among young persons continue to be made jointly with family members [19; United Nations Population of Japan. Country Monograph Series No. 1 I, New York, 1984; Lebra T. S. Japanese Women: Constraint and FulJillment. University of Hawaii Press, Honolulu, 19841. 38. Vogel [21] notes that families today are most likely to rely on education or quality of the school as criteria for the selection of a spouse. Spouse selection on the basis of socio-economic attributes should have less impact on subsequent relative mortality ratios than direct healthrelated selection criteria. of Japanese men and women in their 39. The percentage forties remaining single increased from about 3% in the mid-1900s to about 4 or 5% in 1980 (Office of the Prime Minister, Japan Population Census of Japan. Bureau of Statistics, various years). 40. Benedict R. The Chrysanthemum and the Sword. Patterns of Japanese Culture. Houghton Mifflin Company. Boston, 1946. 41. Blood R. 0. Jr Love Match and Arranged Marriage. A Tokyo-Detroit Comparison, Free Press, New York, 1967. 42. That is, the atypical age pattern of RMRs for a given period could result from changes over time (i.e. over cohorts) in the mate selection process. An examination of age patterns of RMRs by birth cohort for men and women does indeed reveal declining ratios from middle to old age, as well as large declines in the ratios across cohort (particularly among the cohorts born in the early 1900s). 43. One could reasonably argue that single Japanese Americans should experience lower relative mortality than single nersons in Japan, since it is unlikely that such an extensive mate selection process operates among Japanese in the U.S. Calculations based on the 1980

Excess mortality among the unmarried

545

U.S. Census and death registration data for 1979-1981 indicate that single Japanese American men and women generally do have lower RMRs than their counterparts in Japan. It is interesting to note that the RMRs for single Japanese Americans are notably higher than those for all Americans. Unfortunately, the estimates for Japanese Americans suffer from large sampling errors. 44. The classification of causes of death is based on the 8th and 9th revisions of the International Classification of Diseases. The 14 categories presented in this analysis account for about 70% of deaths. The causes are listed in the tables in descending order of the value of the ratio for single men. The estimates are based on log-linear models that consider death rates as a function of age, period and marital status for each country, gender and cause-of-death combination; the resulting parameter estimates are converted into relative mortality ratios

ford University Press, Stanford, CA, 1989. 53. Lebra T. S. Japanese Women: Constraint and Fulfillment. University of Hawaii Press, Honolulu, 1984. 54. Lebra T. S. Japanese Patterns of Behavior. The University Press of Hawaii, Honolulu. 1976. 55. Ishikawa A. Occupational differences in life expectancy for males: 1980. J. Pop. Problems (Jinko Mondai

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Kenkyu) 173, 6472, 1985. 56. For example, in 1971, suicide was the leading cause of

from mental disorders includes such diagnoses as senility, schizophrenia, drug and alcohol dependence and personality disorders. It does not include suicide. 46. The following approximate relationship holds between the estimated RMR (for all causes combined) and the estimated HRMRs by cause (HRMR’): (RMR - 1) x 100 u 5 (HRMR’ - 1) x 100 ,=I Note that the quantity (RMR - 1) denotes the overaN excess mortality of the unmarried group and (HRMR’ - 1) denotes the excess mortality accountedfor

causes, such as cancer of the digestive system, cancer of the respiratory system, and ischemic heart disease become increasingly important at older ages; cancer of the digestive system is one of the three most important causes for singles over age 50 [32]. 50. Gove W. R. Sex, marital status and mortality. Am. J. Social. 79, 45-67, 1973. 51. Litwak E. ef al. Organizational theory, social supports and mortality rates: a theoretical convergence. Am. Social. Rev. 54, 49-66, 1989. 52. Edwards W. Modern Japan Through its Weddings. Stan-

57.

by the ith cause. 41.

It is interesting to note that whereas stroke is one of the leading sources of the excess mortality among single Japanese, ischemic heart disease is one of the major sources among single Americans [32]. The latter finding reflects the general difference between Japan and the U.S. in the prevalence of the two diseases: stroke has been the single most important cause of death in Japan over the period 1950 to 1980, while ischemic heart disease has been the leading cause of death in the U.S. [National Center for Health Statistics Viral Statistics of the United States, Vol. 2. Mortality: 1985. Tokyo, 1985; Ministry of Health and Welfare, Japan Vital Statistics, Japan. Statistics and Information Department, 19851. Several studies based on long-term follow-ups of cohorts of Japanese men living in Japan and in Hawaii have attributed the ‘paradox’ of high risks of stroke concomitant with low rates of coronary heart disease in Japan to high alcohol intake, certain aspects of a traditional Oriental diet (such as low intake of food from animal sources and possibly high salt intake), and low serum cholesterol. Viewed differently, the high levels of animal fat and protein in the American diet appear to have an inhibitory effect on the incidence of stroke, but contribute to heart disease [Takeya Y. et al. Epidemiologic studies of coronary heart disease and stroke in Japanese men living in Japan, Hawaii and California: incidence of stroke in Japan and Hawaii. Stroke 15. 15-23. 1984; Reed D. M. The paradox of high risk ‘of stroke in’populations with low risk of coronary heart disease. Am. J. Epidemioi. 131,5?9-588, 19901.

48. The category ‘all other external causes’ shown in Tables 1 and 2 consists primarily of accidents other than motor accidents. 49. Separate analyses of cause-specific contributions to marital status differentials in mortality were undertaken for each age group. The results indicate that some causes-notably suicide, stroke, and external causesare important in accounting for the high mortality of single and divorced Japanese in most age groups. Other

58.

59.

60.

61.

death for females in their twenties. A frequent reason for suicide among unmarried females was problems associated with ‘love affairs’, including premarital pregnancy. Iga [Iga M. The Thorn in the Chrysanthemum: Suicide and Economic Success in Modern Japan. University of California Press, Berkeley, CA, 19861 suggests that strong sexism is the primary cause of traditional female suicides in Japan. Headley [Headley L. A. Suicide in Asia and the Near East. University of California Press, Berkeley, CA, 19831 speculates that older unmarried women today have lower status than in earlier times; they may also have less economic security. As of 1990, older Japanese women had higher death rates from suicide than older women in most other developed countries with available data [Metropolitan Life International. Comparison of mortality from suicide. Stat. Bull. 71, 22-28, 19901. Kato I., Tominaga S. and Terao C. An epidemiological study on marital status and cancer incidence. Jap. J. Cancer Res. 80, 306-311, 1989. Kato et al. [59] found that the incidence rate for lung cancer was considerably higher among single as compared with divorced women, even though the prevalence of smoking was lower among singles. Many scholars discuss issues related to gender inequality in the Japanese labor market (e.g. Smith R. J. Gender inequality in contemporary Japan. J. Jap. Stud. 13, l-25, 1987; Osako M. M. Dilemmas of Japanese professional women. Sot. Problems 26, 15-25, 1978; Cook A. H. and Hayashi H. Working Women Reform.

in

Japan:

Discrimination,

Resistance

and

Cornell University Press, Ithaca, NY, 1980), but few distinguish between unmarried and married women. 62. Unlike in Western cultures, suicide rates in Japan are positively related to poverty and unemployment [Iga M., Yamamoto J., Noguchi T. and Koshinaga J. Suicide in Japan. Sot. Sci. Med. 12A, 507-516, 1978; Motohashi Y. Effects of socioeconomic factors on secular trends in suicide in Japan, 1953-1986. J. Biosoc. Sci. 23, 221-227, 19911. Since poverty and unemployment are considerably more prevalent among the unmarried, economic differentials by marital status could partly explain their relatively high suicide rates. 63. An analysis of time trends in cause of death data indicates that, for single males, the overall decline in the RMR over the decade from 1975 to 1985 resulted from declines in 13 of the 14 cause-specific RMRs (the exception is motor accidents). For females, on the other hand, about half of the cause-specific ratios showed an increase (including stroke, ischemic heart disease, hypertension and cancers of the digestive and

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respiratory systems); the largest decrease was associated with suicide [32]. 64. Kiefer C. W. Care of the aged in Japan. In He&h, Illness and Medical Care in Japan (Edited by Norbeck and Lock), pp. 899109. University of Hawaii Press, Honolulu, 1987. 65. Martin L. G. The graying of Japan. Pop. Bull. 44, (2).

gender difference arises from higher remarriage rates among divorced women below age 30 combined with consistently higher remarriage rates among divorced men for all age groups over 30 [Hirosima K. and Yamamoto M. Nuptiality trends in Japan: 1988-1989. J. Pop. Problems (Jinko Mondai 19911. Survey data on intentions

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however, does not account for the 66. This explanation, much higher relative mortality risks of single females over age 75 compared with single men. aging, socioeconomic structure 67. Ogawa N. Population and family organization in Japan. Unpublished manuscript, 1991. The establishment of institutions for long-term care of the elderly was not officially approved by the government until 1983. The reliance on long hospital stays for the elderly in lieu of special homes for the aged stems in part from the stigma attached to institutionalization [65]. 68. Miller D. G. Cancer prevention: steps you can take. In The American Cancer Society Cancer Book (Edited by Holleb A. I.). Chap. 2. Doubleday, Garden City, NY. 1986. T. L@ Sty/e and Mortality. A Large-Scale 69. Hirayama Census-Based Cohort Study in Japan. Contributions to Epidemiology and Biostatistics Vol. 6. Karger, Basel. Switzerland, 1990. after 70. Cornell L. L. Gender differences in remarriage divorce in Japan and the United States. J. Marriage Fam. 51, 457

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71. In 1968, the remarriage rate for divorced men was 1.28 times that for women. Data on the sex ratio of remarrying divorced persons suggest a decrease in the differential in recent years [United Nations Population ofJapan. Country Monograph Series No. I I, New York. 19843. Estimated remarriage rates among divorced men and women for 1980 indicate only slightly higher total remarriage rates among men. However, this small

YUANRENGHu

76

Kenkyu)

46,

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to remarry indicate that, in 1978, divorced Japanese men were almost twice as likely to express a desire to remarry in the future (52%) as were their female counterparts (29%) [Kumagai F. Changing divorce in Japan. J. Fam. History 8, (l), 855107, 1983). Kobrin F. E. and Hendershot G. E. Do family ties reduce mortality? Evidence from the United States, 196661968. J. Marriage Fam. 39, 733-745, 1977. Over the period from 1950 to 1980, women became increasingly more likely to be awarded custody of their children. In 1980, wives were about three times as likely to be awarded custody of a child in a divorce settlement as were husbands [Ministry of Health and Welfare, Japan. Vital Statistics Japan. Statistics and Information Department, Tokyo, 19881. Health and Welfare Statistics Association. Health and Welfare Statistics in Japan. Tokyo, 1991. Sato Y. Work and life of single women of the post-war generation. In Proceedings of the 1983 Tokyo Symposium on Women: Women and Work (Edited by the International Group for the Study of Women, Tokyo). Asian and Pacific Development Center, Kuala Lumpur, 1983. Tsuya Noriko 0. Changing Attitudes toward Marriage and the Family in Japan. Paper presented at the Nihon University International Symposium on the Family and the Contemporary Japanese Culture: An International Perspective, Tokyo, Japan, 1991.

77. Hirosima K. and Bando R. Divorce rate of Japan: 1980&1988. J. Pop. Problems (Jinko Mondai Kenk_w) 46, 55564,

1990.