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Marital Status and Health Problems*
Marital Status and Health Problems 653
Not only is marital conflict itself a stressor, but other life stressors can affect marital conflict. For example, greater work demands among air traffic controllers and unemployment in blue-collar workers have been shown to be associated with more negative marital interactions. Stressful events may increase conflict by diminishing the capacity of spouses to provide support to one another, even as it increases their need for support. Such events may also affect marital interactions by giving rise to new conflicts of interest or by exacerbating old ones.
See Also the Following Articles Marital Status and Health Problems; Marriage.
Further Reading Aubry, T., Tefft, B. and Kingsbury, N. (1990). Behavioral and psychological consequences of unemployment in blue-collar couples. Journal of Community Psychology 18, 99–109. Beach, S. R. H., Fincham, F. D. and Katz, J. (1998). Marital therapy in the treatment of depression: toward a third generation of therapy and research. Clinical Psychology Review 18, 635–661. Bradbury, T. N. and Fincham, F. D. (1992). Attributions and behavior in marital interaction. Journal of Personality and Social Psychology 63, 613–628. Burman, B. and Margolin, G. (1992). Analysis of the association between marital relationships and health problems: an interactional perspective. Psychological Bulletin 112, 39–63. Christensen, A. and Heavey, C. L. (1990). Gender and social structure in the demand/withdraw pattern of
marital conflict. Journal of Personality and Social Psychology 59, 73–81. Cummings, E. M. and Davies, P. T. (2002). Effects of marital conflict on children: recent advances and emerging themes in process-oriented research. Journal of Child Psychology and Psychiatry 43, 31–63. Ewart, C. K., Taylor, C. B., Kraemer, H. C., et al. (1991). High blood pressure and marital discord: not being nasty matters more than being nice. Health Psychology 10, 155–163. Gottman, J. M. (1979). Marital interaction: experimental investigations. New York: Academic Press. Grych, J. H. and Fincham, F. D. (1990). Marital conflict and children’s adjustment: a cognitive-contextual framework. Psychological Bulletin 108, 267–290. Halford, W. K. and Markman, H. J. (eds.) (1997). Clinical handbook of marriage and couples intervention. London: John Wiley. Hazan, C. and Shaver, P. R. (1994). Attachment as an organizational framework for research on close relationships. Psychological Inquiry 5, 1–22. Kiecolt-Glaser, J. K., Malarkey, W. B., Chee, M. A., et al. (1993). Negative behavior during marital conflict is associated with immunological down-regulation. Psychosomatic Medicine 55, 395–409. Kiecolt-Glaser, J. K., Glaser, R., Cacioppo, J. T., et al. (1997). Marital conflict in older adults: endocrinological and immunological correlates. Psychosomatic Medicine 59, 339–349. Repetti, R. L. (1989). Effects of daily workload on subsequent behavior during marital interaction: the roles of social withdrawal and spouse support. Journal of Personality and Social Psychology 57, 651–659. Robles, T. F. and Kiecolt-Glaser, J. K. (2003). The physiology of marriage: pathways to health. Physiology and Behavior 79, 409–416.
Marital Status and Health Problems I M A Joung Erasmus University, Rotterdam, Netherlands ã 2007 Elsevier Inc. All rights reserved. This article is reproduced from the previous edition, volume 2, pp 685–691, ã 2000, Elsevier Inc.
Glossary Determinants of health Intermediary factors Unmarried Selection
Health Differences among Marital Status Groups Theories about the Explanation Selection on Health and Determinants of Health Social Causation, Intermediary Factors, and Biological Pathways
Social causation
Factors associated with health and illness, such as socioeconomic status and alcohol consumption. Determinants of health through which marital status affects health outcomes. People who have never been married, are divorced, or are widowed. The theory about health differences between marital status groups in which it is assumed that health affects marital status. The theory about health differences between marital status groups in which it is assumed that marital status affects health.
654 Marital Status and Health Problems
Marital status is associated with all kinds of health outcomes: both subjective health states (illness, e.g., self-perceived health) and objective health states (disease, e.g., clinically diagnosed conditions), both mental and physical health, and both morbidity and mortality. Health differences between marital status groups are generally assumed to result from both an effect of health on marital status (selection) and an effect of marital status on health (social causation). Marital status affects health through several intermediary factors; of these, psychosocial factors, especially psychosocial stress, occupy a central position.
Health Differences among Marital Status Groups The general pattern for health differences among marital status groups is that married people have the fewest health problems, followed by never-married and widowed people, whereas divorced people have the most health problems. This ranking is found both among men and women; however, the differences among the marital status groups are generally larger among men than among women. In most studies in which separated people are distinguished as a separate group, it is found that they have as many as or even more health problems than divorced people. However, in many studies on health differences among marital status groups, separated people have not been treated as a separate marital status category but have been grouped with either divorced or married people. In many Western countries, nonmarital cohabitation is of increasing importance. The few studies that have addressed health differences between married people and people living in consensual unions have found either no health differences or that the health of people in consensual unions compared somewhat unfavorably with that of married people but favorably with that of the unmarried, noncohabitating people. The remainder of this article focuses on health differences among married, never-married, divorced, and widowed people. Mortality
Mortality differences among marital status groups were described in the nineteenth century. For instance, in 1853 William Farr examined age-specific mortality rates for never-married, married, and widowed people living in France. He found that the mortality rates of married men and women compared favorably to those of never-married and widowed men and women. For example, at the ages 40–50 mortality rates were 17.7, 10.3, and 20.1 per 1000 for never-married,married,andwidowedmen,respectively.
Since then numerous researchers in many countries have looked at mortality differences among marital status groups. A considerable number of studies have been performed on this subject in the last decades. The results from these studies indicate very consistently that married people have lower mortality rates than unmarried people. The sizes of the mortality differences between married and unmarried groups and the rankings of the mortality rates of the three unmarried groups have changed over time. For instance, in the Netherlands in the period of 1869–1872, the differences in total mortality between married and never-married women were rather small, and under the age of 40 never-married women actually had lower mortality rates than married women. This was mainly due to the high childbirth mortality rate among married women. In the following decades, the differences in total mortality between married and never ¼ married women increased as, childbirth mortality rate, among others, decreased. The relationship between marital status and mortality also shows some differences between countries. Hu and Goldman explored mortality differences between marital status groups in 16 industrialized countries for the period of 1950–1980. They found that, for the majority of countries, divorced men experienced the highest mortality rates among men and that, in about half of the countries, the same pattern existed for women. Generally, the mortality rates of divorced men and women were 2–2.5 and 1.5–2 times, respectively, those of their married counterparts. In Japan, however, the mortality rate of nevermarried men was as high as the rate of divorced men and never-married women had much higher mortality rates than divorced women. Also, mortality rate differences between the never married and married in Japan far exceeded the largest mortality rate differences by marital status in the other countries (being more than three times that of the married group). The differences in total mortality rates among marital status groups are more or less mirrored in the differences in rates for specific causes of death. For the majority of causes of death, the largest differences are found between the rates for divorced and married people. In general, never-married and widowed people have higher rates of cause-specific mortality than married people, alternately occupying the position of the group with the second highest mortality rate. In comparison with the differences found for the total mortality rate, the relative size of the differences in the rates of mortality due to cardiovascular diseases and cancer is somewhat smaller, but it is considerably larger for the mortality rates due to external causes of death (e.g., accident and suicide). Table 1 shows the
Marital Status and Health Problems 655
age-adjusted relative risks of divorced men and women compared to married men and women for total mortality and mortality from a number of specific causes of death. Morbidity
More recently, differences in morbidity, short-term disability, and health-care use among marital status groups have been studied. Morbidity differences largely have patterns similar to mortality rate differences: married people have the lowest rates, divorced people have the highest rates, and never-married and widowed people have rates in between. The size of the differences among marital status groups is generally larger for indicators of subjective health (e.g., self-perceived general health and subjective health complaints) than for indicators of objective health (e.g., chronic diseases) and is larger for mental than for physical health. Morbidity differentials are by and large reflected in the patterns for health-care use and short-term
Table 1 Relative risks of divorced men and women compared to their married counterparts in the Netherlands, 1986–1990a
Total mortality Cardiovascular diseases Cancer External causes Infective diseases Cirrhosis of the liver (with mention of alcohol) Diabetes mellitus
Divorced men
Divorced women
1.6 1.5 1.2 3.8 2.2 9.1
1.5b 1.4 1.3 3.0 2.1 6.0
2.2
1.4
a
Source: Statistics Netherlands. For example, a relative risks of 1.5 means that the mortality rate of divorced women is 1.5 times that of married women. b
disability. Widowed and divorced people have higher rates for physician contacts, hospital admissions, and use of medicines and report more bed days and days of restricted activity than married people. Nevermarried people, however, seem to have a lower healthcare use and less bed disability days than married people, despite their higher morbidity rates.
Theories about the Explanation Several explanations have been suggested for the association between marital status and health. First, it has been put forward that the association might be due to data errors and thus be an artifact. Although data errors might explain part of the association between marital status and health found in earlier studies, more recent studies have shown convincingly that there are genuine health differences among marital status groups. Other explanations that have been proposed can be grouped into two main theories: selection theory and social causation theory. According to selection theory, the relatively good health of married people is the result of the selection of healthy people into and unhealthy people out of the married state. According to social causation theory, marriage has a health-promoting or a health-protective effect, whereas the unmarried state has adverse health effects. Thus, in selection theory, health status precedes marital status; in social causation theory, marital status precedes health status. A graphic representation of these explanations is shown in Figure 1. In order to establish whether or to what extent health differences precede differences in marital status or vice versa, longitudinal data are required. Selection theory and social causation theory are not mutually exclusive, and it is generally accepted that a combination of
Psychosocial factors (stress, social support, social control and regulation)
Health behaviors
Marital status
Health
Material circumstances
Figure 1 A representation of the explanations for health differences among marital status groups. !, social causation;
, selection.
656 Marital Status and Health Problems
selective and causal factors are responsible for the observed health patterns in marital status groups.
Selection on Health and Determinants of Health According to selection theory, the relatively good health of married people is the result of the selection of healthy people into and unhealthy people out of the married state, thus increasing the relative amount of unhealthy people in the unmarried states. A distinction can be made between direct selection and indirect selection. In direct selection, health itself is the selection criterion; in indirect selection, the determinants of health are the selection criteria. The process of selection could occur with regard to first marriages as well as other marital transitions (divorce, bereavement, and remarriage) and could cause the health differences by marital status in several ways. Selection in partner choice is the most straightforward mechanism: unhealthy people may be less attractive marriage partners and thus may either not be chosen or, if illness develops during marriage, might be discarded as marriage partners. Selection may also operate through assortive mating, the fact that people generally tend to marry partners with traits that they themselves possess, such as physical attractiveness. Assortive mating could also includes health status and does not so much influence whether a person marries as whom the person marries. If, indeed, unhealthy people are more likely to marry unhealthy others, we could find that unhealthy married people are more likely to become widowed because their unhealthy partner is at greater risk of mortality. In addition, it is conceivable that relationships in which both partners are unhealthy are more stressful and therefore more prone to dissolution. Finally, with regard to the transition from the married to the widowed state, selection may also operate through processes independent of partner choice due to health considerations, for instance, through both spouses developing health problems after marriage for reasons such as a joint unfavorable environment (e.g., shared material deprivation or unhealthy behaviors). In this case, the health differences between married and widowed people are not caused by the conditions of widowhood itself (social causation) but are, instead, based in already existing health differences between those who will become widowed and those who will remain married (selection). Direct Selection
It has been demonstrated in several longitudinal studies that direct selection is operative in marital
transitions. However, the evidence is still partial and sometimes inconsistent. There are indications that the presence of disease decreases the marriage probabilities of never-married people and increases the divorce probabilities of married people. It has also been found that direct selection might be able to explain a considerable part of the health differences among marital status groups. However, other studies have been unable to demonstrate selection effects, and sometimes even evidence for adverse selection was found (i.e., that healthier people were less likely to marry). Indirect Selection
As stated earlier, selection may operate not only through the exclusion of unhealthy people from marriage (direct selection) but also through selection on a wide range of determinants of health (indirect selection). The determinants of health that may operate in this way are, for instance, socioeconomic status, physical appearance (e.g., body length and obesity), and health-related habits (e.g., alcohol consumption). Research has demonstrated that indirect selection is indeed operative in marital transitions and that its direction is mostly, but not always, in accordance with the health differences observed among marital status groups. Adverse selection occurs, for instance, with regard to educational level among women – people with a higher educational level have more favorable health outcomes than those with a lower educational level, but women with a high educational level are overrepresented among never-married and divorced women.
Social Causation, Intermediary Factors, and Biological Pathways According to social causation theory, health depends on marital status. Marital status may, on the one hand, affect the etiology of health problems: the married state may prevent people from becoming ill, whereas the unmarried state may be the cause of a decline in resistance to diseases. Marital status may, on the other hand, once health problems have developed, affect the course and outcome of the disease. Ample evidence from longitudinal studies shows that differences in marital status are associated with subsequent health differences; thus social causation mechanisms explain (part of the) health differences among marital status groups. The effect of marital status on health is not assumed to be a direct effect but to be intermediated by psychosocial factors (e.g., stress and social relationships), material circumstances (e.g., financial situation and housing conditions), and health behaviors (e.g., smoking and alcohol consumption).
Marital Status and Health Problems 657 Psychosocial Factors
Psychosocial stress is related causally to illness and mortality. Lazarus and Folkman defined psychosocial stress as ‘‘a particular relationship between the person and the environment that is appraised by the individual as taxing or exceeding his or her resources and endangering his or her well-being.’’ Psychosocial stress varies among marital status groups. First, bereavement and divorce are stressful life events in themselves. On the social readjustment rating scale of Holmes and Rahe, a scale of 43 life events ordered on the basis of the assumed intensity and length of time necessary to accommodate to the life event, bereavement and divorce rank first and second, respectively. Understandingly, the loss of a beloved person is an important source of stress itself. Feelings of failure, lowered self-esteem, and sense of incompetence, which are often experienced by divorced people, also evoke stress. Furthermore, the many concurrent changes in the lives of bereaved or divorced people, such as lowered income, change in parental responsibilities, forced move to other housing, or the loss of familiar activities and habit systems, also contribute highly to the total amount of stress experienced. Second, the differences in psychosocial stress among marital status groups are also caused by mechanisms other than the stressful character of the event of bereavement or divorce. Negative societal attitudes toward the marital status a person occupies can be a source of stress. Although societal attitudes toward alternatives to marriage have become more liberal in recent years, prejudices and stereotyped images of never-married people and divorced people still exist. Uncertainty about social roles is also a source of stress, and certainty about social roles differs according to marital status. Marriage provides people with clear and socially acceptable roles, whereas divorce lacks clearly defined norms. Other psychosocial factors may also contribute to the effect of marital status on health. Several aspects of social relationships are associated with health status and differ among the marital status groups. First, social integration (the existence and quantity of social relationships) is related directly to health. Psychological and sociobiological theories suggest that the mere presence of, or sense of relatedness with, another organism may promote health through relatively direct motivational, emotional, or neuroendocrinal effects. Married people are, on average, more socially integrated for several reasons: they have at least one social tie in their spouse; their children constitute additional social ties, which most never-married people lack; and their social network is expanded with the social ties of their spouse.
Consequently, the loss of a spouse also means a break in the social network. Second, social support (the functional nature or quality of social relationships) has been found to be related directly and indirectly to health. With regard to the latter, social support is assumed to buffer the negative health effects of stress, thus modifying the relationship between stress and health. In this case, social support has no beneficial effect on the health of people who experience little stress, but the beneficial effects of social support increase with increasing stress. Social support is the aid that is transmitted between social network members. An distinction is often made between emotional and instrumental support. Emotional support includes expressions of affection, admiration, respect, or affirmation; instrumental support is the provision of advice, information, or more practical assistance. The availability and quality of social support differ by marital status. Partner relationships are, in general, more supportive than are other types of relationships. This also means that in cases of bereavement or divorce an important provider of social support is lost. Finally, differences in social relationships among marital status groups result in differences in social regulation and control. Married people experience more social control; wives, in particular, try to influence their spouses’ health behaviors. Furthermore, married people have a more regulated life, which facilitates health-promoting behaviors such as proper sleep, diet, and exercise; the moderate use of alcohol; the adherence to medical regiment; and seeking appropriate medical care. Material Circumstances
Differences in material resources among marital status groups constitute another intermediary of the relationship between marital status and health. People who share a household profit from economies of scale in the purchasing and use of housing and other goods and services. In addition, changes in marital status are often associated with large changes in material resources. Bereavement and divorce are, especially among women, often accompanied by a decline of their financial situation and, consequently, a deterioration in other structural living circumstances (e.g., housing). This is most obvious in situations in which the husband is the sole wage earner. However, even in cases of double incomes the wife is likely to be worse off financially after divorce or bereavement. Women are generally married to men of a higher or equivalent educational level, and in many countries men earn on average more than women of an equivalent educational level earn. The fact that the material
658 Marital Status and Health Problems
situation of women generally deteriorates after a divorce does not necessarily imply that men gain materially from divorce. In a divorce, possessions are divided between the former spouses, the ex-husband might be obliged to pay alimony, and economies of scale are lost. This might put divorced men in a materially disadvantaged position compared to married men. Widowed women are generally better off financially than divorced women, even with comparable levels of household income, because divorced women lose their house and must divide assets with their ex-husband, whereas widowed women more often keep the family home and other financial assets intact. Health Behaviors
Differences in health behaviors among marital status groups are also seen as an intermediary of the association between marital status and health. Marriage often has a deterrent effect on negative health behaviors, such as smoking, excessive alcohol consumption, substance use, and other risk-taking behavior, and marriage promotes an orderly lifestyle. Differences in sexual and reproductive behavior among the marital status groups have been mentioned as explanations for differences in mortality rates from several malignant neoplasms – the excessive mortality rate among never-married women from breast cancer, uterine cancer, and ovarian cancer; the higher mortality rate among divorced women from cervical cancer; and the lower mortality rate among never-married men from prostate cancer. Finally, differences in the use of health services among marital groups have been mentioned (e.g., married people are more inclined to use preventive health services) and in compliance with required prolonged treatment (married people are more willing to undertake the required treatments for diabetes mellitus and tuberculosis). Interrelationships between Intermediary Factors
Psychosocial factors, material circumstances, and health behaviors have been mentioned as possible intermediary factors in the effects of marriage on health. However, the effects of marriage on health through intermediary factors cannot be viewed as three independent pathways. Several interrelationships could exist among the three intermediary factors. In the conceptual model of these interrelationships is shown in Figure 1, marital status is not assumed to have a direct effect on health behavior but to influence health behavior only indirectly through psychosocial factors and material conditions. Psychosocial factors may have direct health effects or may operate through an effect on health behaviors.
Unmarried people experience higher levels of psychosocial stress. Cigarette smoking and alcohol consumption are palliative coping responses to psychosocial stress. In addition, social support is important in health behavior changes; partner support, for instance, is beneficial to smoking-cessation maintenance. Finally, the more regulated life of married people facilitates healthy behaviors, and married people attempt to influence the health behaviors of their spouses. Also, the material circumstances associated with marital status may have direct health effects, increase psychosocial stress, or operate through changes in health behaviors. With regard to the latter, unhealthy eating habits and a lack of recreation possibilities could, in part, be determined by an individual’s financial position. Evidence from several studies shows that psychosocial factors, material circumstances, and health behaviors act separately as intermediary factors in the relationship between marital status and health. The relative importance of these three groups of intermediary factors has been addressed only recently. Tentative results suggest that psychosocial factors are the most important intermediary factor in health differences between marital status groups among men, whereas material circumstances constitute the major intermediary factor of health differences among women. Pathways of Intermediary Factors to Health
The effects of health behaviors such as smoking, alcohol consumption, obesity, and lack of physical activity on health are relatively well known. For instance, smoking is, in the long term, associated with cardiovascular diseases, chronic obstructive lung diseases, and many malignant neoplasms such as cancer of the lung, bronchus, trachea, larynx, pancreas, and bladder. Excessive alcohol consumption is associated with diseases of the liver, stomach, and central nervous system and is related to external causes of death, such as traffic accidents and suicide. Obesity and lack of physical exercise are both associated with cardiovascular diseases and conditions of the locomotor system; obesity is also associated with the development of non-insulin-dependent diabetes mellitus. There is also a considerable amount of research on the relationship between psychosocial stress and health. Stress may cause direct physiological changes in the endocrine, immune, and autonomic nervous systems. Evidence shows that these physiological changes increase susceptibility to infectious diseases, cancer, and cardiovascular diseases. It has also been suggested that marital status, mediated by psychosocial stress, enhances susceptibility to diseases in
Marital Status and Health Problems 659
general rather than having specific etiological effects. This theory of generalized susceptibility might explain why marital status is associated with many apparently different causes of disease and death. The direct links between social relationships and health are more speculative. Evidence suggests that biological and psychological mechanisms are involved. A variety of studies of animals and humans suggest that the mere presence of, and especially affectionate physical contact with, another similar or nonthreatening organism reduces cardiovascular and other forms of physiological reactivity. The psychological mechanisms are related to, but partially independent of, the biological mechanisms and might, for instance, be affective in nature (if there is a basic human need for relationships or attachments, people will feel better psychologically when that need is fulfilled, with physiological consequences). The direct health effects of material circumstances (i.e., health effects not mediated by psychosocial stress or health behaviors) are also of a more speculative nature. In previous centuries, poverty might have been the cause of starvation, death from hypothermia, or increased susceptibility to infectious diseases because of undernourishment. However, the contribution of these causes of death to overall mortality are minimal in current Western societies. However, it is conceivable that unfavorable material circumstances still increase risks for respiratory infections or the transmission of infectious agents through effects on living conditions (damp houses, presence of fungal mold, and crowding). The results of studies on this subject are inconclusive, however. The health effects of material circumstances are presumably mediated mainly by changes in psychosocial stress and, to a lesser extent, by changes in health behaviors. A final comment with regard to the social causation theory is that we should keep in mind that marital relationships are not always health enhancing. Marital relationships may also have negative health effects,
whereas divorce may have positive health effects. Marital problems are a source of stress, and social control in an environment in which hazardous health behaviors are valued could have unfavorable consequences. With regard to the positive health effects of divorce, it has, for instance, been found that people improve their health after divorce, depending on the stress of the marriage. In addition, several studies have reported that unhappily married people are less healthy than divorced people and happy married people. On the average, however, marriage is associated favorably with intermediary factors and with health.
See Also the Following Articles Bereavement; Economic Factors and Stress; Familial Patterns of Stress; Gender and Stress; Marital Conflict; Psychosocial Factors and Stress; Social Support.
Further Reading Burman, B. and Margolin, G. (1992). Analysis of the association between marital relationships and health problems: an interactional perspective. Psychological Bulletin 112, 39–63. Joung, I. M. A. (1996). Marital status and health: descriptive and explanatory studies. Alblasserdam, Netherlands: Haveka. Joung, J. M. A., van de Mheen, H., Stronks, K., et al. (1998). A longitudinal study of health selection in marital transitions. Social Science & Medicine 46, 425–435. Joung, I. M. A., Stronks, K., van de Mheen, H., et al. (1997). Contribution of psychosocial factors, material circumstances and health behaviours to marital status differences in self-reported health. Journal of Marriage and the Family 59, 476–490. Stroebe, W. and Stroebe, M. S. (1987). Bereavement and health. New York: Cambridge University Press. Waldron, I., Weis, C. C. and Hughes, M. E. (1997). Marital status effects on health: are there differences between never married women and divorced and separated women? Social Science & Medicine 45, 1387–1397.
Not only is marital conflict itself a stressor, but other life stressors can affect marital conflict. For example, greater work demands among air traffic controllers and unemployment in blue-collar workers have been shown to be associated with more negative marital interactions. Stressful events may increase conflict by diminishing the capacity of spouses to provide support to one another, even as it increases their need for support. Such events may also affect marital interactions by giving rise to new conflicts of interest or by exacerbating old ones.
See Also the Following Articles Marital Status and Health Problems; Marriage.
Further Reading Aubry, T., Tefft, B. and Kingsbury, N. (1990). Behavioral and psychological consequences of unemployment in blue-collar couples. Journal of Community Psychology 18, 99–109. Beach, S. R. H., Fincham, F. D. and Katz, J. (1998). Marital therapy in the treatment of depression: toward a third generation of therapy and research. Clinical Psychology Review 18, 635–661. Bradbury, T. N. and Fincham, F. D. (1992). Attributions and behavior in marital interaction. Journal of Personality and Social Psychology 63, 613–628. Burman, B. and Margolin, G. (1992). Analysis of the association between marital relationships and health problems: an interactional perspective. Psychological Bulletin 112, 39–63. Christensen, A. and Heavey, C. L. (1990). Gender and social structure in the demand/withdraw pattern of
marital conflict. Journal of Personality and Social Psychology 59, 73–81. Cummings, E. M. and Davies, P. T. (2002). Effects of marital conflict on children: recent advances and emerging themes in process-oriented research. Journal of Child Psychology and Psychiatry 43, 31–63. Ewart, C. K., Taylor, C. B., Kraemer, H. C., et al. (1991). High blood pressure and marital discord: not being nasty matters more than being nice. Health Psychology 10, 155–163. Gottman, J. M. (1979). Marital interaction: experimental investigations. New York: Academic Press. Grych, J. H. and Fincham, F. D. (1990). Marital conflict and children’s adjustment: a cognitive-contextual framework. Psychological Bulletin 108, 267–290. Halford, W. K. and Markman, H. J. (eds.) (1997). Clinical handbook of marriage and couples intervention. London: John Wiley. Hazan, C. and Shaver, P. R. (1994). Attachment as an organizational framework for research on close relationships. Psychological Inquiry 5, 1–22. Kiecolt-Glaser, J. K., Malarkey, W. B., Chee, M. A., et al. (1993). Negative behavior during marital conflict is associated with immunological down-regulation. Psychosomatic Medicine 55, 395–409. Kiecolt-Glaser, J. K., Glaser, R., Cacioppo, J. T., et al. (1997). Marital conflict in older adults: endocrinological and immunological correlates. Psychosomatic Medicine 59, 339–349. Repetti, R. L. (1989). Effects of daily workload on subsequent behavior during marital interaction: the roles of social withdrawal and spouse support. Journal of Personality and Social Psychology 57, 651–659. Robles, T. F. and Kiecolt-Glaser, J. K. (2003). The physiology of marriage: pathways to health. Physiology and Behavior 79, 409–416.
Marital Status and Health Problems I M A Joung Erasmus University, Rotterdam, Netherlands ã 2007 Elsevier Inc. All rights reserved. This article is reproduced from the previous edition, volume 2, pp 685–691, ã 2000, Elsevier Inc.
Glossary Determinants of health Intermediary factors Unmarried Selection
Health Differences among Marital Status Groups Theories about the Explanation Selection on Health and Determinants of Health Social Causation, Intermediary Factors, and Biological Pathways
Social causation
Factors associated with health and illness, such as socioeconomic status and alcohol consumption. Determinants of health through which marital status affects health outcomes. People who have never been married, are divorced, or are widowed. The theory about health differences between marital status groups in which it is assumed that health affects marital status. The theory about health differences between marital status groups in which it is assumed that marital status affects health.
654 Marital Status and Health Problems
Marital status is associated with all kinds of health outcomes: both subjective health states (illness, e.g., self-perceived health) and objective health states (disease, e.g., clinically diagnosed conditions), both mental and physical health, and both morbidity and mortality. Health differences between marital status groups are generally assumed to result from both an effect of health on marital status (selection) and an effect of marital status on health (social causation). Marital status affects health through several intermediary factors; of these, psychosocial factors, especially psychosocial stress, occupy a central position.
Health Differences among Marital Status Groups The general pattern for health differences among marital status groups is that married people have the fewest health problems, followed by never-married and widowed people, whereas divorced people have the most health problems. This ranking is found both among men and women; however, the differences among the marital status groups are generally larger among men than among women. In most studies in which separated people are distinguished as a separate group, it is found that they have as many as or even more health problems than divorced people. However, in many studies on health differences among marital status groups, separated people have not been treated as a separate marital status category but have been grouped with either divorced or married people. In many Western countries, nonmarital cohabitation is of increasing importance. The few studies that have addressed health differences between married people and people living in consensual unions have found either no health differences or that the health of people in consensual unions compared somewhat unfavorably with that of married people but favorably with that of the unmarried, noncohabitating people. The remainder of this article focuses on health differences among married, never-married, divorced, and widowed people. Mortality
Mortality differences among marital status groups were described in the nineteenth century. For instance, in 1853 William Farr examined age-specific mortality rates for never-married, married, and widowed people living in France. He found that the mortality rates of married men and women compared favorably to those of never-married and widowed men and women. For example, at the ages 40–50 mortality rates were 17.7, 10.3, and 20.1 per 1000 for never-married,married,andwidowedmen,respectively.
Since then numerous researchers in many countries have looked at mortality differences among marital status groups. A considerable number of studies have been performed on this subject in the last decades. The results from these studies indicate very consistently that married people have lower mortality rates than unmarried people. The sizes of the mortality differences between married and unmarried groups and the rankings of the mortality rates of the three unmarried groups have changed over time. For instance, in the Netherlands in the period of 1869–1872, the differences in total mortality between married and never-married women were rather small, and under the age of 40 never-married women actually had lower mortality rates than married women. This was mainly due to the high childbirth mortality rate among married women. In the following decades, the differences in total mortality between married and never ¼ married women increased as, childbirth mortality rate, among others, decreased. The relationship between marital status and mortality also shows some differences between countries. Hu and Goldman explored mortality differences between marital status groups in 16 industrialized countries for the period of 1950–1980. They found that, for the majority of countries, divorced men experienced the highest mortality rates among men and that, in about half of the countries, the same pattern existed for women. Generally, the mortality rates of divorced men and women were 2–2.5 and 1.5–2 times, respectively, those of their married counterparts. In Japan, however, the mortality rate of nevermarried men was as high as the rate of divorced men and never-married women had much higher mortality rates than divorced women. Also, mortality rate differences between the never married and married in Japan far exceeded the largest mortality rate differences by marital status in the other countries (being more than three times that of the married group). The differences in total mortality rates among marital status groups are more or less mirrored in the differences in rates for specific causes of death. For the majority of causes of death, the largest differences are found between the rates for divorced and married people. In general, never-married and widowed people have higher rates of cause-specific mortality than married people, alternately occupying the position of the group with the second highest mortality rate. In comparison with the differences found for the total mortality rate, the relative size of the differences in the rates of mortality due to cardiovascular diseases and cancer is somewhat smaller, but it is considerably larger for the mortality rates due to external causes of death (e.g., accident and suicide). Table 1 shows the
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age-adjusted relative risks of divorced men and women compared to married men and women for total mortality and mortality from a number of specific causes of death. Morbidity
More recently, differences in morbidity, short-term disability, and health-care use among marital status groups have been studied. Morbidity differences largely have patterns similar to mortality rate differences: married people have the lowest rates, divorced people have the highest rates, and never-married and widowed people have rates in between. The size of the differences among marital status groups is generally larger for indicators of subjective health (e.g., self-perceived general health and subjective health complaints) than for indicators of objective health (e.g., chronic diseases) and is larger for mental than for physical health. Morbidity differentials are by and large reflected in the patterns for health-care use and short-term
Table 1 Relative risks of divorced men and women compared to their married counterparts in the Netherlands, 1986–1990a
Total mortality Cardiovascular diseases Cancer External causes Infective diseases Cirrhosis of the liver (with mention of alcohol) Diabetes mellitus
Divorced men
Divorced women
1.6 1.5 1.2 3.8 2.2 9.1
1.5b 1.4 1.3 3.0 2.1 6.0
2.2
1.4
a
Source: Statistics Netherlands. For example, a relative risks of 1.5 means that the mortality rate of divorced women is 1.5 times that of married women. b
disability. Widowed and divorced people have higher rates for physician contacts, hospital admissions, and use of medicines and report more bed days and days of restricted activity than married people. Nevermarried people, however, seem to have a lower healthcare use and less bed disability days than married people, despite their higher morbidity rates.
Theories about the Explanation Several explanations have been suggested for the association between marital status and health. First, it has been put forward that the association might be due to data errors and thus be an artifact. Although data errors might explain part of the association between marital status and health found in earlier studies, more recent studies have shown convincingly that there are genuine health differences among marital status groups. Other explanations that have been proposed can be grouped into two main theories: selection theory and social causation theory. According to selection theory, the relatively good health of married people is the result of the selection of healthy people into and unhealthy people out of the married state. According to social causation theory, marriage has a health-promoting or a health-protective effect, whereas the unmarried state has adverse health effects. Thus, in selection theory, health status precedes marital status; in social causation theory, marital status precedes health status. A graphic representation of these explanations is shown in Figure 1. In order to establish whether or to what extent health differences precede differences in marital status or vice versa, longitudinal data are required. Selection theory and social causation theory are not mutually exclusive, and it is generally accepted that a combination of
Psychosocial factors (stress, social support, social control and regulation)
Health behaviors
Marital status
Health
Material circumstances
Figure 1 A representation of the explanations for health differences among marital status groups. !, social causation;
, selection.
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selective and causal factors are responsible for the observed health patterns in marital status groups.
Selection on Health and Determinants of Health According to selection theory, the relatively good health of married people is the result of the selection of healthy people into and unhealthy people out of the married state, thus increasing the relative amount of unhealthy people in the unmarried states. A distinction can be made between direct selection and indirect selection. In direct selection, health itself is the selection criterion; in indirect selection, the determinants of health are the selection criteria. The process of selection could occur with regard to first marriages as well as other marital transitions (divorce, bereavement, and remarriage) and could cause the health differences by marital status in several ways. Selection in partner choice is the most straightforward mechanism: unhealthy people may be less attractive marriage partners and thus may either not be chosen or, if illness develops during marriage, might be discarded as marriage partners. Selection may also operate through assortive mating, the fact that people generally tend to marry partners with traits that they themselves possess, such as physical attractiveness. Assortive mating could also includes health status and does not so much influence whether a person marries as whom the person marries. If, indeed, unhealthy people are more likely to marry unhealthy others, we could find that unhealthy married people are more likely to become widowed because their unhealthy partner is at greater risk of mortality. In addition, it is conceivable that relationships in which both partners are unhealthy are more stressful and therefore more prone to dissolution. Finally, with regard to the transition from the married to the widowed state, selection may also operate through processes independent of partner choice due to health considerations, for instance, through both spouses developing health problems after marriage for reasons such as a joint unfavorable environment (e.g., shared material deprivation or unhealthy behaviors). In this case, the health differences between married and widowed people are not caused by the conditions of widowhood itself (social causation) but are, instead, based in already existing health differences between those who will become widowed and those who will remain married (selection). Direct Selection
It has been demonstrated in several longitudinal studies that direct selection is operative in marital
transitions. However, the evidence is still partial and sometimes inconsistent. There are indications that the presence of disease decreases the marriage probabilities of never-married people and increases the divorce probabilities of married people. It has also been found that direct selection might be able to explain a considerable part of the health differences among marital status groups. However, other studies have been unable to demonstrate selection effects, and sometimes even evidence for adverse selection was found (i.e., that healthier people were less likely to marry). Indirect Selection
As stated earlier, selection may operate not only through the exclusion of unhealthy people from marriage (direct selection) but also through selection on a wide range of determinants of health (indirect selection). The determinants of health that may operate in this way are, for instance, socioeconomic status, physical appearance (e.g., body length and obesity), and health-related habits (e.g., alcohol consumption). Research has demonstrated that indirect selection is indeed operative in marital transitions and that its direction is mostly, but not always, in accordance with the health differences observed among marital status groups. Adverse selection occurs, for instance, with regard to educational level among women – people with a higher educational level have more favorable health outcomes than those with a lower educational level, but women with a high educational level are overrepresented among never-married and divorced women.
Social Causation, Intermediary Factors, and Biological Pathways According to social causation theory, health depends on marital status. Marital status may, on the one hand, affect the etiology of health problems: the married state may prevent people from becoming ill, whereas the unmarried state may be the cause of a decline in resistance to diseases. Marital status may, on the other hand, once health problems have developed, affect the course and outcome of the disease. Ample evidence from longitudinal studies shows that differences in marital status are associated with subsequent health differences; thus social causation mechanisms explain (part of the) health differences among marital status groups. The effect of marital status on health is not assumed to be a direct effect but to be intermediated by psychosocial factors (e.g., stress and social relationships), material circumstances (e.g., financial situation and housing conditions), and health behaviors (e.g., smoking and alcohol consumption).
Marital Status and Health Problems 657 Psychosocial Factors
Psychosocial stress is related causally to illness and mortality. Lazarus and Folkman defined psychosocial stress as ‘‘a particular relationship between the person and the environment that is appraised by the individual as taxing or exceeding his or her resources and endangering his or her well-being.’’ Psychosocial stress varies among marital status groups. First, bereavement and divorce are stressful life events in themselves. On the social readjustment rating scale of Holmes and Rahe, a scale of 43 life events ordered on the basis of the assumed intensity and length of time necessary to accommodate to the life event, bereavement and divorce rank first and second, respectively. Understandingly, the loss of a beloved person is an important source of stress itself. Feelings of failure, lowered self-esteem, and sense of incompetence, which are often experienced by divorced people, also evoke stress. Furthermore, the many concurrent changes in the lives of bereaved or divorced people, such as lowered income, change in parental responsibilities, forced move to other housing, or the loss of familiar activities and habit systems, also contribute highly to the total amount of stress experienced. Second, the differences in psychosocial stress among marital status groups are also caused by mechanisms other than the stressful character of the event of bereavement or divorce. Negative societal attitudes toward the marital status a person occupies can be a source of stress. Although societal attitudes toward alternatives to marriage have become more liberal in recent years, prejudices and stereotyped images of never-married people and divorced people still exist. Uncertainty about social roles is also a source of stress, and certainty about social roles differs according to marital status. Marriage provides people with clear and socially acceptable roles, whereas divorce lacks clearly defined norms. Other psychosocial factors may also contribute to the effect of marital status on health. Several aspects of social relationships are associated with health status and differ among the marital status groups. First, social integration (the existence and quantity of social relationships) is related directly to health. Psychological and sociobiological theories suggest that the mere presence of, or sense of relatedness with, another organism may promote health through relatively direct motivational, emotional, or neuroendocrinal effects. Married people are, on average, more socially integrated for several reasons: they have at least one social tie in their spouse; their children constitute additional social ties, which most never-married people lack; and their social network is expanded with the social ties of their spouse.
Consequently, the loss of a spouse also means a break in the social network. Second, social support (the functional nature or quality of social relationships) has been found to be related directly and indirectly to health. With regard to the latter, social support is assumed to buffer the negative health effects of stress, thus modifying the relationship between stress and health. In this case, social support has no beneficial effect on the health of people who experience little stress, but the beneficial effects of social support increase with increasing stress. Social support is the aid that is transmitted between social network members. An distinction is often made between emotional and instrumental support. Emotional support includes expressions of affection, admiration, respect, or affirmation; instrumental support is the provision of advice, information, or more practical assistance. The availability and quality of social support differ by marital status. Partner relationships are, in general, more supportive than are other types of relationships. This also means that in cases of bereavement or divorce an important provider of social support is lost. Finally, differences in social relationships among marital status groups result in differences in social regulation and control. Married people experience more social control; wives, in particular, try to influence their spouses’ health behaviors. Furthermore, married people have a more regulated life, which facilitates health-promoting behaviors such as proper sleep, diet, and exercise; the moderate use of alcohol; the adherence to medical regiment; and seeking appropriate medical care. Material Circumstances
Differences in material resources among marital status groups constitute another intermediary of the relationship between marital status and health. People who share a household profit from economies of scale in the purchasing and use of housing and other goods and services. In addition, changes in marital status are often associated with large changes in material resources. Bereavement and divorce are, especially among women, often accompanied by a decline of their financial situation and, consequently, a deterioration in other structural living circumstances (e.g., housing). This is most obvious in situations in which the husband is the sole wage earner. However, even in cases of double incomes the wife is likely to be worse off financially after divorce or bereavement. Women are generally married to men of a higher or equivalent educational level, and in many countries men earn on average more than women of an equivalent educational level earn. The fact that the material
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situation of women generally deteriorates after a divorce does not necessarily imply that men gain materially from divorce. In a divorce, possessions are divided between the former spouses, the ex-husband might be obliged to pay alimony, and economies of scale are lost. This might put divorced men in a materially disadvantaged position compared to married men. Widowed women are generally better off financially than divorced women, even with comparable levels of household income, because divorced women lose their house and must divide assets with their ex-husband, whereas widowed women more often keep the family home and other financial assets intact. Health Behaviors
Differences in health behaviors among marital status groups are also seen as an intermediary of the association between marital status and health. Marriage often has a deterrent effect on negative health behaviors, such as smoking, excessive alcohol consumption, substance use, and other risk-taking behavior, and marriage promotes an orderly lifestyle. Differences in sexual and reproductive behavior among the marital status groups have been mentioned as explanations for differences in mortality rates from several malignant neoplasms – the excessive mortality rate among never-married women from breast cancer, uterine cancer, and ovarian cancer; the higher mortality rate among divorced women from cervical cancer; and the lower mortality rate among never-married men from prostate cancer. Finally, differences in the use of health services among marital groups have been mentioned (e.g., married people are more inclined to use preventive health services) and in compliance with required prolonged treatment (married people are more willing to undertake the required treatments for diabetes mellitus and tuberculosis). Interrelationships between Intermediary Factors
Psychosocial factors, material circumstances, and health behaviors have been mentioned as possible intermediary factors in the effects of marriage on health. However, the effects of marriage on health through intermediary factors cannot be viewed as three independent pathways. Several interrelationships could exist among the three intermediary factors. In the conceptual model of these interrelationships is shown in Figure 1, marital status is not assumed to have a direct effect on health behavior but to influence health behavior only indirectly through psychosocial factors and material conditions. Psychosocial factors may have direct health effects or may operate through an effect on health behaviors.
Unmarried people experience higher levels of psychosocial stress. Cigarette smoking and alcohol consumption are palliative coping responses to psychosocial stress. In addition, social support is important in health behavior changes; partner support, for instance, is beneficial to smoking-cessation maintenance. Finally, the more regulated life of married people facilitates healthy behaviors, and married people attempt to influence the health behaviors of their spouses. Also, the material circumstances associated with marital status may have direct health effects, increase psychosocial stress, or operate through changes in health behaviors. With regard to the latter, unhealthy eating habits and a lack of recreation possibilities could, in part, be determined by an individual’s financial position. Evidence from several studies shows that psychosocial factors, material circumstances, and health behaviors act separately as intermediary factors in the relationship between marital status and health. The relative importance of these three groups of intermediary factors has been addressed only recently. Tentative results suggest that psychosocial factors are the most important intermediary factor in health differences between marital status groups among men, whereas material circumstances constitute the major intermediary factor of health differences among women. Pathways of Intermediary Factors to Health
The effects of health behaviors such as smoking, alcohol consumption, obesity, and lack of physical activity on health are relatively well known. For instance, smoking is, in the long term, associated with cardiovascular diseases, chronic obstructive lung diseases, and many malignant neoplasms such as cancer of the lung, bronchus, trachea, larynx, pancreas, and bladder. Excessive alcohol consumption is associated with diseases of the liver, stomach, and central nervous system and is related to external causes of death, such as traffic accidents and suicide. Obesity and lack of physical exercise are both associated with cardiovascular diseases and conditions of the locomotor system; obesity is also associated with the development of non-insulin-dependent diabetes mellitus. There is also a considerable amount of research on the relationship between psychosocial stress and health. Stress may cause direct physiological changes in the endocrine, immune, and autonomic nervous systems. Evidence shows that these physiological changes increase susceptibility to infectious diseases, cancer, and cardiovascular diseases. It has also been suggested that marital status, mediated by psychosocial stress, enhances susceptibility to diseases in
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general rather than having specific etiological effects. This theory of generalized susceptibility might explain why marital status is associated with many apparently different causes of disease and death. The direct links between social relationships and health are more speculative. Evidence suggests that biological and psychological mechanisms are involved. A variety of studies of animals and humans suggest that the mere presence of, and especially affectionate physical contact with, another similar or nonthreatening organism reduces cardiovascular and other forms of physiological reactivity. The psychological mechanisms are related to, but partially independent of, the biological mechanisms and might, for instance, be affective in nature (if there is a basic human need for relationships or attachments, people will feel better psychologically when that need is fulfilled, with physiological consequences). The direct health effects of material circumstances (i.e., health effects not mediated by psychosocial stress or health behaviors) are also of a more speculative nature. In previous centuries, poverty might have been the cause of starvation, death from hypothermia, or increased susceptibility to infectious diseases because of undernourishment. However, the contribution of these causes of death to overall mortality are minimal in current Western societies. However, it is conceivable that unfavorable material circumstances still increase risks for respiratory infections or the transmission of infectious agents through effects on living conditions (damp houses, presence of fungal mold, and crowding). The results of studies on this subject are inconclusive, however. The health effects of material circumstances are presumably mediated mainly by changes in psychosocial stress and, to a lesser extent, by changes in health behaviors. A final comment with regard to the social causation theory is that we should keep in mind that marital relationships are not always health enhancing. Marital relationships may also have negative health effects,
whereas divorce may have positive health effects. Marital problems are a source of stress, and social control in an environment in which hazardous health behaviors are valued could have unfavorable consequences. With regard to the positive health effects of divorce, it has, for instance, been found that people improve their health after divorce, depending on the stress of the marriage. In addition, several studies have reported that unhappily married people are less healthy than divorced people and happy married people. On the average, however, marriage is associated favorably with intermediary factors and with health.
See Also the Following Articles Bereavement; Economic Factors and Stress; Familial Patterns of Stress; Gender and Stress; Marital Conflict; Psychosocial Factors and Stress; Social Support.
Further Reading Burman, B. and Margolin, G. (1992). Analysis of the association between marital relationships and health problems: an interactional perspective. Psychological Bulletin 112, 39–63. Joung, I. M. A. (1996). Marital status and health: descriptive and explanatory studies. Alblasserdam, Netherlands: Haveka. Joung, J. M. A., van de Mheen, H., Stronks, K., et al. (1998). A longitudinal study of health selection in marital transitions. Social Science & Medicine 46, 425–435. Joung, I. M. A., Stronks, K., van de Mheen, H., et al. (1997). Contribution of psychosocial factors, material circumstances and health behaviours to marital status differences in self-reported health. Journal of Marriage and the Family 59, 476–490. Stroebe, W. and Stroebe, M. S. (1987). Bereavement and health. New York: Cambridge University Press. Waldron, I., Weis, C. C. and Hughes, M. E. (1997). Marital status effects on health: are there differences between never married women and divorced and separated women? Social Science & Medicine 45, 1387–1397.