The effects of family position and status on health

Sot. Sci. Med. Vol. 35, NO. 4, pp. 453464, 1992 Printed in Great Britain. All rights reserved

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0277-9536/92 $5.00 + 0.00 I992 Pergamon Press Ltd

SECTION G THE EFFECTS

OF FAMILY POSITION ON HEALTH

AND

STATUS

SALLY MACINTYRE MRC Medical Sociology Unit, 6 Lilybank Gardens, Glasgow G12 SQQ, Scotland Abstract-In the last couple of decades there has been a considerable amount of research, mainly in the U.S.A., on the effects of family position on health. This paper reviews material on (a) the impact of family of origin on health and (b) adult family position and health. Parental divorce is shown to be related to a range of adverse outcomes in childhood, adolescence and adulthood. Marriage and parenthood are associated with longevity and good mental and physical health. This paper argues for more research in other cultural settings, for panel studies, for more direct measures of the roles and processes often inferred from structural variables, and for the use of measures of physical development and functioning. Key words-parental

divorce, family position, marital status

INTRODUCTION Nineteenth century social scientists such as Durkheim, Marx, Comte, Tonnies and Weber paid considerable attention to the role of close social bonds in the regulation of peoples’ lives. The study

of such bonds has come back into fashion during the last couple of decades in relation to research into the determinants of health. The terms may have changed-from gemeinschaft, alienation, anomie and organic solidarity to social support, social networks, and vulnerability-but there is nevertheless some continuity in theoretical approaches. There is also some continuity in empirical work. In 1859 the then Registrar General for England and Wales, William Farr, published an analysis of age-specific death rates for single, married and widowed men and women in France in 1853. He concluded from the figures that “Marriage is a healthy state. The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony” [l]. Also in respect of nineteenth century France, Durkheim was analysing suicide rates and concluding that marriage and parenthood provided elements of obligation and constraint, as well as a sense of meaning and purpose, which tended to lower the risk of suicide [2]. Types of analysis similar to those of Farr and Durkheim have been common in the 1970s and 198Os, particularly in the U.S.A. Although Farr’s observations about marital status and mortality were confirmed by data from France, Russia and Sweden in 1886-1895 [3], until relatively recently most of the research on the relationship between social or family ties and health has tended to focus on mental health, or on deaths from causes 453

such as suicide or liver cirrhosis which could be seen as having social or ‘volitional’ aspects [4]. A study that was influential in re-directing attention to allcause mortality was the Alameda County Study in the U.S.A., which showed the predictive power of variables such as marital status and social networks for mortality over a 9 year follow up period [5]. In a rather different field and tradition, obstetric and paediatric epidemiologists have for some time noted the consistency of associations between a child’s legitimacy, birth order and number of siblings on the one hand, and her/his birthweight, height and other measures of physical development and functioning on the other hand [6,7]. Nevertheless, it is still the case that whether in relation to family of origin or family of orientation, much more attention is directed towards the effect of family position and status on mental health than it is to physical health, specific cause or all cause mortality, or physical development or functioning. (In the case of the influence of family of origin on later development the literature on physical or mental health is indeed swamped by the extremely large body of research on educational, occupational, marital and behavioural outcomes [7-91.) This paper does not set out to provide a comprehensive critical review of all the research pertaining to the effects of family position and status on health. Rather the aim is firstly to describe what on (I priori grounds might be considered as falling within this topic; secondly to give some broad characterisation of the major strands of research and major findings in this field; and thirdly to highlight methodological and substantive issues which might influence future research.

SALLY MACINIYRE

454

HEALTHOUTCOMES

FAMILY POSITION AND STATUS FAMILY

OF ORIGIN Perinatal mortality Birthweight Height Hospitalisation Accidents Health-related behaviours (smoking, drinking etc) Mental health Health rated by parents Self rated health

Birth order Number of siblings Legitimacy Two parent/one parent family Parental divorce or separation Parental death Maternal employment

OWN All cause mortality Specific cause mortality Attempted and completed Morbidity Health service use Hospitalisation Mental health Happiness Acute illness Chronic illness

Marital status Marital history Living alone/with others Parenthood Single parent/two parent family Effects of divorce, separation or widowhood Female employment

suicide

NEXT GENERATION Marital status Marital history Living alone/with others Parenthood Single parent/two parent family Effects of divorce, separation or widowhood Female employment Fig. 1. Topics

FAMILY POSITION

studied

?? little research

in the field of research on family position and health.

AND STATUS: THEIR EFFECT ON HEALTH

There are three ways in which features of family position and status might influence health. Firstly, aspects of one’s family of origin could influence one’s health. Leaving aside the socio-economic position of that family itself, there are a number of variables relating to family of origin which are known to be, or could be hypothesized to be, associated with health; these include birth order, number of siblings, legitimacy, being brought up by one or two parents, and parental death, divorce or remarriage. Secondly, roles and statuses achieved in adult life could influence one’s own health. Possibly important factors include marital, employment and parental statuses and histories. Thirdly, the family position and status of one’s children could influence one’s own health. Again, possibly influential factors here include the marital, employment and parental statuses and histories of one’s children, and in turn of their children. These three possible types of influence on health could operate additively or multiplicatively to influence health. A 50 year old woman’s health chances may be influenced by her family of origin (for example, as the only child of divorced parents,

brought up in a single parent household and now caring for her elderly mother); by her own family position (for example, married and with 6 children); and by her children’s roles and statuses (for example, her widowed 25 year old daughter with three children under 5). Research into family position and health is mainly confined to the first two of these three categories; the research in each category tends to be rather different in methods and approach from research in the other categories; and very few pieces of research examine the interaction between all three. In the space available in this review only the first two categories will be covered. It should be noted that research on family of origin and achieved family position is much more common than research on the effects on health of the family circumstances of the next generation. FAMILY OF ORIGIN

Within the fields of obstetric and paediatric epidemiology it is well known that characteristics of the family of origin-such as whether it is a two or one parent family and whether there are already children in the family-influence whether a pregnancy is likely

The effects of family position and status on health to result in a healthy live birth, and other important outcomes of pregnancy such as birthweight. Rates of perinatal mortality are consistently higher for illegitimate births or for births to lone mothers [lo], and there is a J shaped curve of perinatal mortality and low birthweight by parity (i.e. first born children have higher risks than second or third borns, and risks increase with increasing parity thereafter) [lO-121. These observations are sufficiently well known for legitimacy and parity to be routinely incorporated into perinatal epidemiology (Ref. [12]). It is also well known that similar characteristics of the family of origin are associated with aspects of physical development such as height; for example, only children in the 1946 British Birth cohort were taller at 7 and 11 than children with sibilings [7]. In the 1958 birth cohort at age 7, for any given number of younger siblings, first born children were 2.8 cm taller than fourth or later children; and for any given birth order, those children with no younger siblings were 1.1 cm taller than those with two or more younger siblings [6]. Perhaps surprisingly, the processes linking family structure and such physical characteristics in the perinatal and childhood periods have been comparatively little researched by social scientists, compared with the processes linking family separation subsequent to birth with a variety of mental health and behavioural outcomes of such separation. With the exception of studies such as those of Illsley and Mitchell [ 121and Oakley and Rajan [ 131,the relationships between family structure and variables such as birthweight, perinatal mortality or height tend to be taken for granted as background information rather than being treated as topics for research in their own right. There is a large and burgeoning literature on the effects of family structure on childhood, adolescent and adult functioning. A wide range of outcomes such as psychological functioning and adjustment, behaviour, educational and occupational achievement, income, crime and delinquency, and marital histories have been studied in relation to family of origin both in the U.K. [14-201, and the U.S.A. [8,9,21]. Such studies consistently show that across a range of such outcomes children born illegitimate and not subsequently adopted, and those from families disrupted by parental divorce, do worse than their counterparts brought up by continuously married parents. In a meta-analysis of 37 different studies of the effects of parental divorce, for example, Amato and Keith found significantly negative effects for psychological adjustment, behaviour/conduct, use of mental health services, social relations, marital quality, separation or divorce, general family quality, one-parent family status, educational attainment, material quality of life, occupational quality, physical health, and ‘other’ outcomes [22]. A striking feature of this body of research is how little of it examines adolescent or adult health as outcomes of family structure, dissolution, or reconstiSSM 35,4--H

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tution. A number of otherwise comprehensive reviews (e.g. Refs [8,9,21]) focus almost entirely on psychological functioning, socio-economic and educational careers and marital histories and give little attention to health, particularly to physical health as measured by physical development and functioning, morbidity, or all-cause or specific cause mortality. This is in marked contrast to research on the relationship between the marital status of adults and their own health, in which morbidity or mortality indicators are more common (see next section). Given evidence from elsewhere [23] that psychological factors in childhood can effect growth trajectories, it is perhaps surprising that the effects of family structure and functioning on height, weight and other physical characteristics are rarely examined. (Although recent work from the 1946 U.K. birth cohort looked at early life determinants of height at 36, birth order and number of siblings were the only family position variables examined [24].) One reason for regretting this is that some other measures of health or illness may be contaminated by reporting biases or biases in referral. Precisely because in most western industrialised societies people worry about the effects of single parenthood single or other ‘anomalous’ family situations, parents, stepfamilies and gate-keepers to services such as family doctors or school teachers may have lower thresholds for observing problems in children from these families. Thus, for example, Wadsworth et al. [25] observed that accidents in pre-school children born in 1970 in the U.K. were more common in stepfamilies than in one parent or two (biological) parent families (52.3%, 47.3% and 42.7% respectively were reported as having one or more accidents). The more striking difference, however, was in hospital admission after an accident; 5.8% among two (biological) parent families, compared to 10.8% and 10.3% among stepfamilies and one parent families respectively. After adjustment for other factors, family type was not significantly associated with the rate of any accidents or of repeated accidents, but for hospital admissions after accidents family type appeared as the most significant factor. This may reflect not the seriousness of the accidents but the vigilance of both parents and gate-keepers with regard to children from ‘anomalous’ families. The same problem of interpretation applies to findings such as those of Dawson, (based on a cross sectional survey in 1988 of a U.S. nationwide sample of 17,000 children under 18) that children living with single mothers, or with mothers and stepfathers, were more likely than those living with both biological parents to have been treated for emotional or behavioural disorders in the year preceding interview [26]. Referral for treatment for such disorders could well have been confounded by knowledge of the family situation. Perhaps more face validity can be attributed to the more specific findings that compared

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to children living with both biological parents, children whose parents had divorced experienced a 2&30% higher rate of accidental injury, and those living with a single mother had a 50% higher rate of asthma. Angel and Worabey set out to test the hypothesis that single mothers may view their children’s health “as poorer than it is in reality” [27, p. 411. They analysed data on mothers of children from 6 months to 11 years from two related American surveys, Hispanic HANES (Health and Nutrition Examination Survey) and NHANES2. Children in female headed households were more likely to have been hospitalised, and single mothers reported the greatest number of chronic conditions for their children and were more likely than other mothers to report their children’s health as being good or fair (rather than excellent). In the Hispanic HANES, physicians also rated the children’s health; there were significant disagreements between mothers and physicians in these assessments, with depressed mothers reporting their children to be in poorer health than the physicians or non-depressed mothers. The association between depressed affect in the mother and poorer ratings of children’s health remained when the physicians’ assessments were taken into account. This suggests that it may not be that single motherhood leads to depressed affect which in turn leads to less healthy children, but that single motherhood may lead to maternal depression which may in turn lead to lower perception of children’s health. The authors conclude that “several social and cultural factors, including marital status, acculturation and income, affect the ‘accuracy’ of mothers’ assessments. Medical sociology, epidemiology and health service research in general rely heavily on such proxy reports and on self reports for both children and adults. Our findings, however, indicate that these subjective reports cannot be taken at face value; it is necessary to understand the factors that influence self-perceptions and the reporting of health status if they are to be used in statistical models” 127, p. 491. This is not to ‘explain away’ associations between parental family structure and children’s health and well being, but to point to the interpretational problems arising from reports on children’s health being made by those who may be more likely to be depressed or to worry about theories of the possible harmfulness of single parenthood. Fewer such interpretational problems apply to studies of adults. Cross-sectional studies of adults consistently show a range of negative outcomes associated with parental divorce. In Amato and Keith’s meta analysis of studies examining parental divorce and a range of outcomes in adult offspring the mean effect sizes across these studies were statistically significant and negative across nearly all outcomes adjustment, studied (including psychological measured in 23 studies, and physical health, measured in 11) [22]. However, the authors point out

that the mean effect sizes were significantly stronger in clinical studies than in community samples; and tended to be stronger for whites than for blacks, in earlier rather than more recent studies, and in studies that did not use statistical controls. They also point out that the effect sizes, although consistently negative, are weak (the largest mean effect sizes are in the order of { standard deviation between the groups and many are nearer h). Their conclusions are worth quoting in full: Individuals who experienced parental divorce as children, compared to those whose parents were continuously married, have lower quality of life as adults. However, these differences appear to be small rather than large. Furthermore, studies based on non-clinical samples with controls in place for relevant predivorce variables show weaker effects than do other studies. And studies conducted in the 1980s show weaker effects than do those conducted in earlier decades. In other words, the more sophisticated and recent the study, the more tenuous is the connection between parental divorce and adult well being [22, p. 561. The evidence on the importance of parental death for later mental health has been equivocal but it seems probable than it may have less effect than parental divorce [20], possibly because, as has been shown for the 1946 birth cohort, material disruption and downward social mobility in the remnant family was greater after divorce than after parental death [17]. At age 26 men and women from families broken by divorce or death were more likely to report stomach ulcers and psychiatric illness [28]. At age 36 the loss of a parent before the age of 18 did not have a significantly adverse effect on affective disorder among women, but it did among men and was particularly marked in those who experienced the loss when they were between 5 and 11 years. Parental divorce or separation by contrast had no significant effect on later effective disorder for sons but was associated with higher scores on the Present State Examination (PSE) for women. The highest rate of ‘caseness’ on the PSE occurred in women who experienced parental separation before the age of 5. The associations between early life family circumstances and later affective disorder were, however, weak [20]. Another study of the women from this cohort found that at age 36 women who had experienced parental divorce not only had higher PSE scores than those from intact families; they also reported higher alcohol intake, were more likely to be smokers, and exhibited more signs of vulnerability. Women who had experienced parental death in childhood did not, however, differ significantly on any of these indicators from those with intact families of origin [18]. Findings from this cohort contrast with retrospective obervations of associations between depression in women and early death of a parent [29]. In a short term panel study of adolescents in the U.S., Mechanic and Hansel1 found that higher levels of reported family conflict were associated significantly with prospective increase in depressed mood, anxiety, and physical symptoms. In contrast, divorce,

The effects of family position and status on health current separation from parents and parental death were not associated significantly with changes in any health measures over time [30]. The importance of the prospective approach, usually applied to children or adolescents, is that it can test whether adverse physical or mental health outcomes preceded family separation. Both in the U.S.A. and U.K. it has been shown that poorer mental health and behaviour disorders often predate the parental divorce. For example, Doherty and Needle, on the basis of longitudinal studies of families in the Minneapolis-St Paul area, found that adolescents from disrupted families reported lower psychological well being and more substance abuse, both before and after the divorce, than their counterparts with continuously married families. Girls’ difficulties were occurring prior to the separation and did not change substantially after the divorce, while boys’ difficulties (especially substance abuse) increased subsequent to the divorce [31]. Block, Block and Gjerde showed that young people’s difficulties can predate parental separation by an even longer period; in a follow-up study of 130 children from 3 to 14 years, they found that boys from subsequently divorcing families were ‘uncontrolled’ up to 11 years prior to their parents’ divorce [32]. Similar temporal sequences have been reported in the U.K.; for example, Elliott and Richards found that children whose parents separated when they were between 7 and 16 showed more “unhappy and worried behaviour”, not only at 16 but also at 7, than counterparts whose parents remained married [33]. (This raises the intriguing possibility that parental conflict and divorce may not only be reflected in their children’s behaviour and adjustment fairly early in the process, but may be caused by the children’s behaviour. Maybe couples with more difficult children are more likely to divorce?) Again, this is not to suggest that observed relationships between parental divorce and the psychological well being of the children can be explained away, but to indicate the complexity of the possible causal links and to alert researchers to the possibility of a reverse causal process, i.e. that having sick or disturbed children may put strains on parents that lead to a higher probability of marital stress and separation. If we take a more extreme example and think about the parents of disabled, ill or mentally disturbed children then we can see that such causal reversals are not entirely implausible [3436]. Apart from some general comments about the present state of the art in research on the impact of family of origin and health made in the conclusion to this paper, and often applying in addition to research on family of achievement, a few specific concluding observations can be made. Firstly there is a disjunction between the independent variables of interest in studies of perinatal and childhood health and those of interest in studies of older children, adolescents or adults; characteristics such as birth order, number of siblings and legitimacy are rarely examined in relation

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to later outcomes. Secondly there is a similar disjunction between the dependent variables studied earlier and later; mortality, height and weight tend only to be examined in the perinatal or childhood periods. FAMILY

OF ACHIEVEMENT

It has consistently been shown that married people live longer than people who have never been married or who were formerly married. The Alameda County study, for example, found that women who were unmarried (single, separated, divorced, or widowed) in 1965 had 1.4 times the risk of dying in the next 9 years compared to their married counterparts. Among men the relative risk of death from being unmarried was greater, and higher at younger ages (e.g. at 30-49 years of age the relative risk was nearly 3) [S]. National mortality data for 1971 from England and Wales show that for both men and women mortality rates were higher for the non-married than the married at all ages from 22-87 [3]. More recent national U.K. data show Standardised Mortality Ratios (SMRs) of 96 for married women, 106 for widowed and divorced women, and 131 for single women in 19761981 [37]. National mortality data from the U.S.A. in a slightly earlier period, 196668, show ratios of deaths for non-married compared to married people to be 3.1 at ages 3544, 2.6 at 45-54, 2.1 at 55-64 and 1.3 at 65-74 for men, and 1.9, 1.6, 1.4 and 1.1 for non-married compared to married women in these same age groups [38]. Studies from a range of industrialised countries have shown that among the unmarried, divorced people have the highest rates, while never-married people have rates intermediate between married and divorced people [39]. Studies of physical illness show a broadly similar picture. Data from the British General Household Survey and the American National Health Interview Survey suggest that rates of self-reported morbidity (both acute and long term) are highest among divorced or separated people. Arber computed standardised limiting longstanding illness ratios from the 1985-6 General Household Survey and reported ratios of 96, 99 and 132 for married, single, and formerly married men; and of 91, 103 and 147 for married, single, and formerly married women [40]. American data similarly show that formerly married people are most likely to report limiting chronic conditions, and that married people report the lowest rates. For example, in 1971-2 20.6% single, 15.7% married, 21.7% widowed and 21.7% divorced persons reported limitation due to chronic conditions 1411. Studies of marital status in relation to psychological well-being are even more common than those in relation to mortality and physical morbidity. Several American studies have shown that married people have higher psychological well-being than the nonmarried. Glenn and Weaver for example, using data

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from General Social Surveys conducted in U.S.A. in the 1970s show higher global happiness among married men and women after adjusting for other possible confounding variables such as age, income, education, and employment [42]. As Gove, Hughes, and Briggs Style note: “In the overwhelming majority of the comparisons between the married and the unmarried . . . the married are in better mental health, happier, less inclined to suicide or other forms of death in which psychological factors play a key role, and are less likely to be institutionalised for mental illness or other forms of maladaptive behaviour” [43, p. 1221. There are, however, some contradictory findings. Aneshensel, Frerichs and Clark, for example, found that after controlling for age, education and income in a community survey in Los Angeles, there were no statistically significant effects of marital status on depression among either men or women [44]. Associations between marital status and health may vary between men and women. There have been repeated suggestions that although the married of both sexes do better than their unmarried counterparts, this effect is less marked for women than for men and that marriage may therefore be ‘better’ for men than for women [45]. For example, Gove showed that the disparity in attempted and completed suicide rates between being married and being single, divorced or widowed is greater for men than for women [46]. He also showed that rates of mental illness among married women were higher than those among married men, while rates among single, divorced and widowed women were not higher than those of their male counterparts [47]. Similarly greater advantages of marriage for men than for women have been reported for mortality [5, 38,451. Data from the Alameda County Study, for example, showed that the relative risk of death in the 9 years of follow-up was 1.4 for unmarried compared to married women, while for men it was 2.8 at 30-49,2.1 at 50-59, and 1.2 at 60-69 years of age [S]. Studies of gender differences in health post-divorce are contradictory. Menaghan and Lieberman, in a short term panel study in metropolitan Chicago, found there was no significant sex difference in the impact of divorce on depressive affect [48]. Riessman and Gerstel, however, found that after divorce men experienced more of the severe health outcomes (including death and hospitalisation) while women had more of the less severe health problems (such as restricted activity due to acute or chronic illness). For several morbidity measures, and for depression, separation was associated with worse outcomes for women and divorce with worse outcomes for men [49]. Zick and Smith, using data from the Panel Study of Income Dynamics in the U.S.A., found that men who had been widowed or divorced for three years or more had a significantly higher probability of dying than married men, after adjusting for a range of socio-demographic factors. Males who had recently

been divorced (but not men recently widowed) had a significantly higher hazard of dying than males with no recent marital status transitions. The mortality of women who had recently or ever been divorced or widowed was not significantly different from married women [50]. Thus although there is some support from studies of life after divorce for the proposition that marriage is relatively better for men than for women, there is also some conflicting evidence. The picture is rendered even more complex if one adds age, parental status and other social ties into the picture. Kobrin and Hendershott examined mortality in the U.S.A. in 196668 and found that the married have lower rates than the non-married, that this difference was greater for males than for females, and that it falls with increasing age (confirming the above findings for men from the Alameda County Study). They then examined parenting status among married persons, dividing them into those with children under 18 and those without. Death rates were higher for those without children than for those with children, the difference being greater for women than for men and the differentials declining sharply with age. The mortality ratios for non-parents compared to parents were 2.1 for males and 2.4 for females at 3544; 1.3 for males and 1.6 for females at 45-54; and 0.9 for males and 1.l for females at 55-64 [38]. Clark et al. used data from a 1982 survey of access to health care for a hierarchical analysis of health status among people with different domestic positions. They found that both married and single men over 41 with dependent children reported better health than those without dependent children; however, single women at all ages with dependent children reported poorer health than those without. Clark et al. describe this as “the protective effect of children for men or the health burden of children on women” [51, p. 5031. Veevers has argued that much of the variation in suicide rates normally attributed to marital status “may in fact be due to the differential probabilities that individuals will have had children and will have assumed parental roles” [52, p. 1351. Unfortunately, as she herself points out, there are few available data to test this proposition which is largely derived from Durkheim’s work on suicide [2]. Work on ‘happiness’ has tended to show that even if parenthood protects against suicide, it does not necessarily protect one from mental ill-health. Andrews and Withey found that the presence of children seemed to lower feelings of well being for unmarried women, though not for married persons [53]. Glenn and Weaver report that after controlling for other variables such as age and unemployment, there is only a slight negative effect of having children on global happiness [42]. There is other conflicting evidence from the U.S.A. about the role of children. Marcus and Seeman found that women with no children at home have more symptoms that those with children [54]; however, Woods and Hulka found

The effects of family position and status on health a positive relationship between the number of children and health problems [55]. Anson used data from the National Health Interview Survey of 1979 to examine the health status of womem in different living arrangements. After controlling for sociodemographic factors she found that women living with their parents were the healthiest, followed by those in children’s or relatives’ households; women heads of household were the least healthy, just preceded by those living alone; women who live with their husbands or with unrelated persons were intermediate and did not differ from each other [56]. A number of investigators have looked not only at parenting status but also at employment status. Hibbard and Pope conducted a multivariate analysis of morbidity and mortality data from a 15 year follow up of a sample of members of a large HMO studied in 1970-71. They found that for employed women, parental status (having one or more children at home) has either a protective effect (e.g. lowers the risk of ischaemic heart disease) or has no effect. Being unmarried increased the risk of cancer for employed women, whether or not a child is in the home. Neither marital nor parental status was predictive of any of the health outcomes among non-employed women. Parental status was unrelated to any of the morbidity or mortality measures in men [57]. Verbrugge undertook a multivariate analysis on a cross-sectional survey of adults in Detroit, examining the effects of employment, marriage and parenthood on health status and health behaviour. Married parents tended to have the best health profile, while people with the fewest family roles (non-married non-parents) had the poorest health profile. Family ties had similar health effects for men and women, and women with all three roles did not have different health outcomes from men with all three roles. Employment had the strongest positive effect on health, followed by marriage and then employment. The effect of multiple roles seemed to be additive, that is there was no special effect (positive or negative) of combining all three roles [58]. Elliott and Huppert have examined employment and parental status among a British nationwide sample of married women. The most important influence on these women’s mental health was the age of the youngest child; women with children under 5 were likely to show signs of psychological disturbance, women with school age children showed least disturbance, and women with no dependent children were intermediate. The age of the youngest child had no effect on physical health, as measured by the percentage reporting four or more illness symptoms. (There was a significant interaction between employment and social class, such that employment was associated with better health for middle class women but not for working class women [59].) Using the same data-set, Blaxter has shown the disadvantageous effect for women of single parenthood. Standardised illness ratios among women aged

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18-29 were 125 for single parents, 97 for women married or cohabiting with children, and 98 for women married and cohabiting without children. (Comparable figures for women aged 30-45 were 105, 96 and 95.) The relative disadvantage for single mothers was even greater for psychosocial health-at 3@45 the ratios were 142 for single mothers, 97 for those married or cohabiting with children and 99 for those married or cohabiting without children. (No comparable analysis was presented for men [60].) Arber has also examined self reported morbidity among men and women in Britain, using data on limiting longstanding illness in the 1985 and 1986 General Household Surveys. Unlike many of the American studies she found a greater differential by marital status for women than for men. Previously married women had a standardised limiting longstanding illness ratio of 147, while the ratio for previously married men was 132, i.e. the excess was 47% for women compared with 32% for men. The ratios for married and single women were 91 and 103, and for equivalent men they were 86 and 99. In multivariate models including social class, employment status, age, housing tenure and car ownership, parental and marital status were not significantly related to illness among men, but they were among women. For women with children under five years old the odds of reporting limiting longstanding illness were 0.58 compared to women with no children, and for previously married women the odds were 1.55 compared to married women. There were significant interactions between employment and marital and parental status among women; there were only slightly higher odds of limiting longstanding illness for previously married women who are employed (1.3 1) compared to married employed women (1 .OO), but previously married housewives have twice as high odds of limiting longstanding illness (3.49) as married housewives (1.78). Parental status was not related to health among employed women, but among unemployed women and housewives, having children under 5 years was associated with less reported illness [401. Using a slightly different focus, Beatson-Herd et al. also examined data from the U.K. General Household Survey for 1983 and 1984, looking at selfreported longstanding and acute conditions, and at use of health services, among women with dependent children. After adjusting for other explanatory variables (age, age of children, employment, housing tenure) only the separated and divorced mothers were found to have a significantly high odds ratio for acute illness (1.71) compared with married mothers, and for longstanding illness and three health service use variables there were no significant differences by marital status. The chief determinants of health and health service use among mothers of dependent children were housing tenure, employment status and the age of the youngest child. The authors point out that the characteristics of this sample of mothers varied

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greatly by marital status, and that after allowing for these different characteristics (age, age of children etc.) the residual effect of marital status per se on health and health service use is lowered [61]. In contrast, Berkman reports from the Alameda County Study in California that although several environmental and psychological stresses impinge more on spouseless than married mothers, differences in physical health between these groups persist even after adjusting for these factors. Married mothers had significantly lower (age adjusted) rates of chronic conditions, functional disabilities, being ‘seriously bothered’ by a health problem, and reporting health as fair or poor, compared to spouseless mothers. Differences between the groups persist after controlling for factors such as socioeconomic status, race, and morale which are associated with spouseless motherhood. Berkman suggests an additive model whereby spouseless mothers are more vulnerable to these stresses [62]. Popay and Jones also examined data from the U.K. GHS, looking at acute and longstanding illness and general perception of health over the last year. Both lone mothers and lone fathers are more likely to report longstanding illness, limiting longstanding illness, recent restricting illness, and poor health in the last 12 months than men and women in two parent families. They examined health by variables such as age, marital history, income, employment status, housing tenure, and suggest that the reasons for gender differences in the health of lone parents lay in differences in their marital histories, in their socioeconomic circumstances, and in the nature of their roles as parents [63]. Some writers have sought to explore whether it is something to do with the marital relationship itself, or simply something to do with not living alone, which influences health positively. Anson examined data on women of working age in the 1979 National Health Interview Survey in the U.S.A. She found that, adjusting for other socio-demographic variables, the presence of a proximate adult was significantly related to the reporting of acute conditions, but not the reporting of chronic conditions or self rated health. Differences in acute and chronic morbidity between the divorced/separated category and the married disappeared when the presence of a proximate adult was taken into account. For measures of illness behaviour, adjustment for the presence of a proximate adult removes the excess illness behaviours of the formerly married women. (Adult children were not included as proximate adults, so this is a rather cautious analysis of the impact on health of living with other people [64].) Kurdek undertook an analysis of reported well being, divorce history and availability of a proximate adult using a sample of households from the National Survey of Families and Households in the U.S.A. Controlling for demographic variables, he found that married persons reported greater happiness and less

depression than persons not currently married, and that cohabiting persons reporting greater well being than persons living without another adult but less well being than married persons. Reported well-being was also related to divorce history, those with no history of divorce reporting greater well being than those who are divorced who in turn reported more well being than those with a history of serial divorce

K51. These findings conflict with those of Hughes and Gove based on a sample of adults in the U.S.A. in 1974-5. They found that among the unmarried, those living alone were not consistently worse off than those living with others across a range of mental health measures. There was a slight tendency for living alone to be worse for the never married than for the widowed, and worse for the widowed than for the divorced. Taking all marital statuses together and controlling for a range of socio-demographic variables, on a majority of the mental health scales those living alone are either better off than the married or closer to the married than those who do not live on their own. Hughes and Gove conclude that “for the vast majority of persons who live alone, living arrangement is not a particularly problematic condition” [66, p. 661. Another issue raised in the American literature is whether it is marriage per se or the quality of marital relations which is protective of health. Berkman and Breslow reported from the Alameda County Study that a marital adjustment scale was not significantly related to mortality in the subsequent 9 years [5]. Looking at mental health as an outcome however, Gove, Hughes and Briggs Style conclude that it is the quality of a marriage and not marriage per se that links marriage to positive mental health. Respondents who reported their marriages as being ‘not too happy’ or as being ‘not at all happy with their marriages’ were in poorer mental health than respondents in any of the unmarried categories in their national (U.S.) probability sample of adults [43]. Studies from the U.S.A. and Britain have thus shown that married persons are likely to live longer and to have better physical and mental health than previously married people, with never married persons being intermediate between the married and divorced. There have been consistent suggestions that in this regard marriage is ‘better’ for men than for women. Parents tend to have better health than non parents, though parents of young children and single mothers often have poorer mental health. Whether it is something to do with the marital relationship or something to do with living with other adults which is protective of health has been examined, with equivocal results. In the space available here I have covered the descriptive rather than analytical or theoretical findings from the studies on family position and health. This should not be taken as suggesting that this body of work is not theory driven. Much of the American

The effects of family position and status on health work in particular is using empirical data to test sociological propositions about the operation of social roles and processes, for example nurturant role obligations [56], multiple roles [58], regulation of behaviour through mechanisms of social constraint, obligation and responsibility [66], high family role demands [44], and role accumulation versus role overload [40]. Health outcomes are thus used to test hypotheses about the experience of such roles and processes, and the literature can be characterised as having considerable intellectual vigour and an engagement both with fundamental sociological issues and with contemporary policy issues. The quality of the available data-sets does not, however, always match up to the conceptual sophistication of the hypotheses to be tested, since much of the empirical health data (for example, the General Household Survey in the U.K.) have been collected for other purposes and may not be ideal for the purposes at hand. GENERAL

CONSIDERATIONS

There is a large body of research on the effect of family position and health. There is insufficient space here adequately to review all the literature in this field; the preceding sections have merely outlined some of the major studies. In this concluding section I will highlight certain general features of this body of work. Firstly, much of its comes from the U.S.A. Although within the American literature some attention is given to ethnic or subcultural variations in the effects of family position and health within American society, very little comparison is made with other cultures. It is thus difficult to know how far the findings are generalisable to other cultures. The U.S.A. centred focus is also apparent in some of the assumptions that are made about the roles and activities associated with structural positions. For example, there are many more studies of the effects of parenthood or employment on women’s health than there are on men’s health, presumably at least in part because being employed and a father are seen as normative and unproblematic. The question arises as to why this field is so dominated by American research. The answer that it is because there are many U.S. journals in this area (i.e. Journal of Health and Social Behaviour, Journal of Marriage and the Family) simply begs the question of why it is that the U.S. can support such journals while other countries cannot. Secondly and relatedly, it is noticeable that in the U.K. the ‘big questions’ for the last decade have concerned socio-economic inequalities in health, whereas in the U.S. they seem to have concernend social support and health. Thus in the U.K. many studies focus on differences in health between socioeconomic groups, controlling for other possible spurious or intervening variables including marital

461

status, structure of family of origin, or parenthood [40,67]. In the U.S. by contrast many studies focus on the effects of marital status or parenthood, controlling for socio-economic factors such as income or employment. As a result of these different foci, the U.S.A. and U.K. research studies do not often speak directly to each other, and often follow parallel rather than convergent tracks. Thirdly and also relating to the dominance of American writers, there is very little, in the Anglophone literature at least, on the effects on health of family position and statuses in non-western nonindustrialised societies; in the segments of those societies with different cultural traditions and family forms; or in Eastern Europe. This is a large and regrettable gap. What are the relationships between family position and health in China, Africa, India or the Middle East? In Islamic, Hindu or Buddhist cultures? In Catholic or Buddhist cultures in which becoming a monk or nun is an available option? In polygamous societies? In the formerly communist countries of Eastern Europe? In kibbutzes? None of these issues were raised in the literature scanned for the production of this paper; perhaps they are addressed in anthropological or other journals, but they do not appear very often in easily accessible mainstream medical sociology journals (including Social Science & Medicine). Yet surely such questions are crucial to a broadening of our understanding of the processes connecting human health with family statuses and position. Fourthly, as in the field of research into unemployment and health, there is little need for more crosssectional studies; only panel studies can adequately answer questions about causal directions and processes. The authors of papers describing crosssectional studies often make valiant attempts to explain why, for example, associations between not being married and being less healthy cannot be attributed to selective processes; but the only true test is prospective observations. In studies of the effects of divorce on children, for example, it is now clear that many of the apparent ill effects observable in crosssectional studies might have been present prior to the parental separation or divorce. (Kiernan has also reported from a U.K. longitudinal study that teenage brides whose marriages broke down were on average significantly more unstable, even before they married, than teenage brides whose marriages remained intact [16].) It is therefore difficult to justify setting up cross-sectional studies as a vehicle for unravelling causal processes, since they can often offer no guidance as to temporal or causal ordering. Fifthly, much research uses structural variables such as marital status as proxies for roles or processes which are the true focus of interest. Yet sometimes the inferential link from structural position to actual circumstances is extremely tenuous. For example, Afron was interested in adult social support and nurturant responsibilities, and in how these might

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interact to influence women’s health. But these concepts were operationalised in terms of 6 types of living arrangements; living alone, living with unrelated individuals, living with husbands, heading their own households, living in their children’s or relatives households, or living with their parents. These living arrangements are assumed to be related to adult social support and nurturant obligations, e.g. “women in cell C, who live with parents or in children’s/relatives households, enjoy steady adult support but have only slight nurturant obligations. They have less responsibility for the smooth functioning of the household and can be relieved from nurturant tasks” [56, p. 2021. But ‘living with parents’ could include a wide range of degrees of adult social support and nurturant obligations, including running the household for elderly or dementing parents; if the interest is in adult social support and nurturant role obligations then it might be better to measure these directly. Aneshensel, Frerichs and Clark note in relation to their community study in Los Angeles that “assumptions about the lack of familial obligations and intimate relationships among the unmarried appear unwarranted. Among the unmarried, only 55.5% actually live alone; 35.2% live with relatives and 9.2% with non relatives” [44, p. 3861. As Dawson notes in relation to the research on later outcomes of parental structure: “Most researchers agree that family structure per se is esentially a proxy for related processes that affect children’s health and well being. Family structure is not a perfect proxy for these processes variables, since an intact marriage is no guarantee of an emotionally healthy, well supervised home environment” [26, p. 5741. However, even if it is true that most researchers agree with that proposition, it is also true that many nevertheless infer the processes from the structural variables. Similarly, unwarranted assumptions may be made about the social and affective meanings of particular roles, statuses or events. Divorce, for example, tends to be viewed as a negative event. Mechanic and Hansel1 found in their panel study of adolescents however that 25% of those reporting a parental divorce rated it as a positive event, and 33% rated it as neither good nor bad [30]. Such findings provide an additional reason for restraining the tendency to impute roles to structural positions, and meanings to events. Sixthly, it sometimes appears that the mathematical sophistication offered by multivariate statistical techniques has run ahead of researchers’ abilities to create simple causal models. The conceptual underpinning of some of the statistical controls used in multivariate analysis is on occasion unclear. In particular there is a general failure to distinguish between ‘explaining away’ an observed association between family position and health (looking for spurious associations) and ‘explaining’ such an association (looking for intervening relationships). Controls for a

number of socio-demographic variables are sometimes rather indiscriminately chosen, and combine those that predate and those that postdate the family position and health measure in question. For example, it might be reasonable to control for age when comparing widows with married or nevermarried women, since women who are widowed are likely to be on average older than married or nevermarried women, and therefore in poorer health by virtue of their age quite independently of widowhood. But controlling for income or type of housing might be to control for circumstances consequent on widowhood which might explain some of the ways in which widowhood reduces health. A similar point is put clearly by Dawson in describing how her controls give a conservative estimate of the association between parental divorce and children’s health and well being: “These models may underestimate the true effects of family structure on children’s health and behaviour by statistically controlling for some of the indirect or intermediate paths through which divorce and single parenthood adversely affect children. Specifically, the processes by which children are affected may include the reduction in income after divorce, and this may increase the likelihood of maternal unemployment. Even the odds of being an only child may be increased by parental divorce if, as is likely, the divorced mother is less likely to have another child than her married counterpart” [26, p. 5771. Seventhly, analysis by age often confounds ageing and cohort effects. In studies with a large age span (e.g. the Alameda County study in the U.S., or the General Household or Health and Lifestyle Surveys in the U.K.), differences between age groups in the association between family position and health may be difficult to interpret. They tend to be attributed to ageing effects, but may actually be due to cohort effects; for example, the relationship between widowhood and health may be quite different among the generation who were married before the Second World War compared with later generations. Eighthly, in some of the literature there is a tendency to take self reports or proxy reports of health at face value, without considering how they may be confounded by the family position or status in question. It is not just social researchers who have theories about the possibly health-damaging effects of certain living arrangements; these theories are often shared by members of the public and by gate-keepers to services, and may influence their judgements. Even apparently ‘hard’ measures such as hospitalisation rates may be influenced, not only by the level of illness displayed by the individual, but also by the capacity or perceived capacity of her or his carers to look after her or him. There is therefore a need to use measures which will not be biased by reporting or referral effects. In this connection it is interesting how few of the studies of the effects of parental death or divorce have used measures of physical development

The effects of family position and status on health

463

1.

Mostly from the USA.

2.

Focus in the UK on socio-economic inequalities, in the USA on family variables.

3.

Few studies in non-western forms.

4.

Need for more longitudinal approaches to disentangle causal processes.

5.

Structural variables often used (unwarrantably)

6.

Lack of conceptual clarity in choice of control variables.

non-industrialised

societies or societies with different

family

as proxies for process variables.

Failure to distinguish ageing and cohort effects.

8.

Possible contamination of health measures by family position.

9.

New developments in physiological studies.

Fig. 2. General features of research in the last two decades on family position and status and health.

or functioning, physical health, or mortality. We thus do not know whether there are differences in the height, weight, blood pressure, lung function, incidence of cancer or cardiovascular disease, deaths from specific causes, and overall longevity according to many characteristics of the family of origin. There have been interesting recent attempts to examine the physiological correlates of marital changes and social networks; Kiecolt Glaser et al., for example, examined immune function among married and separated/divorced women, and found that women who had been separated one year or less had significantly poorer immune function than sociodemographically matched counterparts [68]. This sort of research seems promising not only because it can relate marital changes to measures unaffected by self-report bias but also because it may help to explain the mechanisms by which family position or changes in status may increase the likelihood of morbidity or mortality. (Work by Seeman and Syme on the relationship between social networks and directly measured coronary atherosclerosis should also be noted here [69]; see also the overview article by Calebrese et al. on alterations in immunocompetence during stress, bereavement and depression [70].) In conclusion I would argue that in this area of research there is a need to broaden the research agenda to include other cultural settings; to use panel rather than cross sectional designs; to measure social roles or processes directly where possible (rather than inferring them from structural variables); to use measures of physical development and functioning; and to examine the physiological pathways by which family position may influence health. am grateful to Kath Kiernan, Di Kuh, Jean Leiper, Martin-Richards, Anne Sooman and Hazel Williamson for their assistance in the _preparation of _ this paper. Acknowledgemenrs-I

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