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Relationship status and health: Does the use of different relationship indicators matter? a
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Björn Schneider , Ingmar Rapp , Thomas Klein & Jan Eckhard a
Max Weber Institute of Sociology, Heidelberg University, Heidelberg, Germany Published online: 25 Apr 2014.
Click for updates To cite this article: Björn Schneider, Ingmar Rapp, Thomas Klein & Jan Eckhard (2014) Relationship status and health: Does the use of different relationship indicators matter?, Global Public Health: An International Journal for Research, Policy and Practice, 9:5, 528-537, DOI: 10.1080/17441692.2014.904917 To link to this article: http://dx.doi.org/10.1080/17441692.2014.904917
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Global Public Health, 2014 Vol. 9, No. 5, 528–537, http://dx.doi.org/10.1080/17441692.2014.904917
Relationship status and health: Does the use of different relationship indicators matter? Björn Schneider*, Ingmar Rapp, Thomas Klein and Jan Eckhard Max Weber Institute of Sociology, Heidelberg University, Heidelberg, Germany
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(Received 14 March 2013; accepted 9 February 2014) Studies that analyse the association between relationship status and health usually disregard non-marital relationships. The present study examines if the use of different relationship indicators leads to different associations between relationship status and physical and mental health. The database used for this analysis is the Survey of Health and Ageing in Europe, a large population-based survey of Europeans aged 50 and over and their cohabitants. This study combines crosssectional and retrospective data of 13 European countries. The sample size is 9298 men and 11,631 women for grip strength and 9609 men and 12,333 women for depression. Generalised estimating equations are used. For men, the goodness-of-fit measure quasi-likelihood under the independence model criterion indicates that marital status is a better predictor than cohabitation status or partnership status for predicting grip strength. However, for grip strength of women, there are only small differences in the model fit between the different relationship indicators. For both men and women, the partnership status (marriage, cohabitation or dating relationship) shows the best model fit for explaining depression. The results suggest that future health research could benefit from the use of relationship indicators other than marital status, particularly regarding mental health. Keywords: relationship status; depression; grip strength; Europe; SHARE
Introduction The last decades have been characterised by an increasing spread of new living and relationship arrangements in nearly all western countries. The intention to marry is declining, and the divorce rate is increasing in almost all European countries (European Commission, 2011), while cohabitation and dating relationships have become much more common. Several relationships interrupted by time periods without a partner have partially replaced marriage with one lifetime partner (Kiernan, 2001). This development challenges research of relationship effects on health, which usually focuses on the association between marital status and health. Cross-sectional studies usually show better physical and mental health for married people than for unmarried individuals (Hughes & Waite, 2009; Simon, 2002; Williams & Umberson, 2004). Three possible explanations for the association between marriage status and health are discussed in the literature. First, the marital resource model suggests that marriage provides additional resources that have a positive influence on health (Ross, Mirowsky, & Goldsteen, 1990; Waite, 1995): better economic resources, social support from the spouse *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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and the regulation of health behaviour are described in the literature. People who have never been married or who are divorced or widowed cannot benefit from these marital resources and therefore suffer from poorer health outcomes. A second explanation for marital status differences in health is based on the crisis model. Here, marital dissolutions are considered to be associated with higher levels of stress that can lead to deteriorating health (Booth & Amato, 1991). This may not only have short-term effects on health (Brockmann & Klein, 2004), but can also have long-term effects that may persist even if the individuals remarry (Hughes & Waite, 2009). The third explanation is the selection thesis. It is argued that poor health reduces the probability of marrying and also increases the probability of divorce (Cheung, 1998; Mastekaasa, 1992). Longitudinal studies offer evidence for all three explanations (Carr & Springer, 2010; Umberson, Thomeer, & Williams, 2012). However, with recent changes in family and relationship structures, marital status may no longer be an adequate measure for health outcomes related to living arrangements because there are more never-married, divorced and widowed individuals who are living with a partner. Additionally, there is an increasing number of non-cohabiting couples. Therefore, the beneficial health effects of marriage may also apply to non-marital relationships; these relationships also provide additional resources, can be stressful when dissolved, and may also be subject to health-related selection. The findings concerning health differences between different forms of relationships are mixed. A recent review of the existing literature shows that there is very little evidence for a mental health benefit in cohabitation (Umberson et al., 2012). However, other authors conclude that cohabiting couples have better mental and physical health than non-cohabiting couples but poorer health than married people (Carr & Springer, 2010). Fuller (2010) reports that cohabiting individuals tend to have poorer health status and behaviour than both their married and single counterparts. The impact of relationship status on health may vary with the health category that is being assessed. Physical health can often be a result of events and periods that took place earlier in life and that influenced health in a negative or positive manner. In general, physical health changes slowly over time. In contrast, mental health should more strongly reflect current circumstances; therefore, rapid changes in an individual’s mental health status may be observable. It is important to note that the health effects of marriage can be affected by gender. In this regard, the findings in the literature are ambiguous. Some studies find stronger health effects for men than for women (Kaplan & Kronick, 2006; Simon & Barrett, 2010; Umberson, 1992; Williams & Umberson, 2004). However, some authors regard the gender differences as small and negligible (Carr & Springer, 2010; Waite & Gallagher, 2000), while others suggest a stronger relationship effect on health for women than for men (Fuller, 2010). Therefore, gender-separated analyses are appropriate. The present study examines whether the use of different relationship indicators leads to different associations between relationship status and physical and mental health. Three different indicators are used: marital status, cohabiting status (which includes marriage and cohabitation) and partnership status (which includes marriage, cohabitation and dating relationships). The aim is to determine which relationship indicator best explains health status. Methods The database for this study is the Survey of Health and Ageing in Europe (SHARE), a cross-national panel database of individuals from 13 European countries (Austria, Belgium,
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Czech Republic, Denmark, France, Germany, Greece, Italy, the Netherlands, Poland, Spain, Sweden and Switzerland) aged 50 and older and their cohabitants. For the analysis, the second wave (2006–2007) is combined with retrospective questions from the third wave (SHARELIFE, 2008–2009). Retrospective data provide information about the dissolution of marital, cohabitation and dating relationships. This is important as most surveys disregard non-marital relationship history. The second wave of SHARE contains detailed information about health. Dependent variables Both physical and mental health are investigated in this study. Maximum hand grip strength is used as a measure of physical health. The advantages of grip strength as a health measurement are its independence from medical diagnoses as well as its independence from subjective evaluation standards. Grip strength is highly correlated with other health indicators (Hank, Jürges, Schupp, & Wagner, 2009) and can be perceived as a long-term predictor for functional limitations, disability (Rantanen et al., 1999) and mortality (Gale, Martyn, Cooper, & Sayer, 2007; Rantanen et al., 2000). Grip strength was measured during the interviews by means of a hand grip dynamometer. For each hand, two measurements were taken. If the two values for one hand differed by more than 20 kg, both were coded as missing. The maximum grip strength is the maximum of four measurements (if there are valid values for both hands) or the maximum of two measurements (if there are only valid values for one hand). The mean grip strength in the sample is 43.51 kg (STD 10.05) for men and 27.02 kg (STD 7.51) for women. Mental health is operationalised as the existence of depression symptoms. Beliefs, restrictions and attitudes typical for depression are captured by means of the EuroDepression (EURO-D) Scale (Prince, Beekman, et al., 1999; Prince, Reischies, et al., 1999). This indirect measurement has advantages over medical diagnoses because not every person meeting the criteria for depression is diagnosed as such. The EURO-D score (range 0–12) expresses the extent of symptoms. The questions cover 12 dimensions: depression, pessimism, suicidality, guilt, sleep, interest, irritability, appetite, fatigue, concentration, enjoyment and tearfulness. A clinically significant depression is defined as a EURO-D score greater than 3, which is a validated threshold for a number of clinically relevant indicators (Dewey & Prince, 2005). Independent variables Three different systems of dummy variables are used as distinct relationship indicators. The first indicator refers to marriage status only. It contrasts the group of continuously married subjects with currently remarried, previously married (divorced and widowed) and never married individuals. The second relationship indicator focuses on cohabitation status and includes the following categories: ‘Continuously living with a partner (married or cohabitating)’, ‘Currently living with a partner again’, ‘Previously lived with a partner’ and ‘Never lived with a partner’. The third relationship indicator focuses on partnership status and consists of the following groups: ‘Continuously in relationship (married, cohabitating or dating)’, ‘Currently in relationship again’, ‘Previously in relationship’, ‘Never in relationship’. The distribution of these variables in the sample is shown in Table 1. Of note, there is overlap among the groups. For instance, some of the continuously married individuals have never lived with a different partner and therefore also belong to the group of those
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Table 1. Descriptive statistics.
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Men
Marital status Continuously married Currently remarried Previously married Never married Total Cohabitation status Continuously living with partner Currently living with partner again Previously lived with partner Never lived with partner Total Partnership status Continuously in relationship Currently in relationship again Previously in relationship Never in relationship Total Age Years of education
Women
Frequency
Percentage
Frequency
Percentage
7443 664 1068 514 9689
76.82 6.85 11.02 5.30 100
7893 569 3417 547 12,426
63.52 4.58 27.50 4.40 100
7329 959 1063 338 9689
75.64 9.90 10.97 3.49 100
7781 902 3359 384 12,426
62.62 7.26 27.03 3.09 100
6941 1571 905 272 9689
71.64 16.21 9.34 2.81 100
7491 1478 3161 296 12,426
60.28 11.89 25.44 2.38 100
Mean 64.81 10.51 9689
SD 9.30 4.75
Mean 63.61 9.60 12,426
SD 10.24 4.43
Note: The numbers encompass all cases with at least valid information for grip strength or depression and therefore slightly differ from the number of cases in Tables 2 and 3. Source: SHARE (waves 2 and 3), own calculations.
continuously living with a partner. There are also cases in which a person moves from one group to another if the variable system is redefined. For example, individuals who are married for the first time and who had one or more cohabitations before marriage move from ‘continuously married’ to ‘currently living with partner again’. As the examples show, there are respondents who remain in the same category regardless of the relationship definition, whereas other move from one category to another with a redefinition. Age and years of education are included in the analysis as they are potential confounders. Table 1 also shows the distribution of age and years of education. Dummy variables are used to control for country effects. Statistical methods Data from all countries are pooled. Separate analyses by country are not made because the number of cases from individual countries is not sufficient. Cases were deleted if there were missing values for the dependent variable or for one or more independent variables. Furthermore, cases were omitted from the analysis if there were contradictions between the reported relationship biography in wave 3 and the current relationship status in wave 2. After the exclusion of cases as described above, 20,929 cases and 21,942 cases were available for grip strength and depression analysis, respectively. Because of clustering at the country level, standard statistic models such as linear or logistic regression would lead
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to false standard errors and thereby false inferences. To address this problem, generalised estimating equation (GEE) models were used to obtain appropriate inferential statistics for clustered data (Liang & Zeger, 1986). The models for the depression indicator use the logit link function, and the models for grip strength use the identity link function. The working correlation matrix is set as independent. The quasi-likelihood under the independence model criterion (QIC) is applied to compare the non-nested models and determine the relationship indicator that shows the best model fit. Lower QIC scores indicate a better model fit, but there is no test for statistical significance of the differences. All models are calculated separately to capture different effects on men and women. SAS 9.2 via PROC GENMOD was used for model estimation.
Results Table 2 shows the GEE models for the maximum grip strength of men and women. Model 1 presents the coefficients of marital status for men with controls for age, education and country (coefficients not reported). The reference group is comprised of continuously married men. Only the grip strength of the never married men is significantly weaker than the grip strength of the continuously married men. There are no significant differences between the continuously married, currently remarried and previously married men. Model 2 focuses on cohabitation status, whereas Model 3 focuses on partnership status. The results show that also never living with a partner (−2.96) and never being in a relationship (−2.52) is negatively associated with grip strength for men. In addition, Models 2 and 3 show a significant negative association between grip strength and previously living with a partner or previously being in a relationship, respectively. Model 1 indicates the best fit because the QIC value is the lowest of all three models. The results for women are displayed in the last three models of Table 2. As with men, the group of never married women has the lowest maximum grip strength (Model 4). In contrast to men, the currently remarried and previously married women also have a reduced grip strength compared to the continuously married women. The results are similar for cohabitation status (Model 5) and partnership status (Model 6). Women who continuously live with a partner or who are continuously in a relationship have the lowest grip strength. The last model offers the best goodness of fit, but the QIC values are very similar. The results for depression are illustrated in Table 3. For previously married men as well as for never married men, the odds of suffering from depression are significantly higher than in the reference data, while there are no differences between the continuously married and the currently remarried men (Model 1). Model 2 indicates the association between cohabitation status and depression. In contrast to Model 1, there is only a significant difference between men who previously lived with a partner and men who continuously live with a partner. In Model 3, the effects of partnership status are shown. As in Model 2, there is only a significant difference between the group who previously lived with a partner and the group of subjects who continuously live with one. This difference is stronger than the corresponding associations observed in Models 1 and 2. Model 3 (partnership status as indicator) provides the best fit. The results for women are presented in Models 4, 5 and 6. Similar to men, there is a positive association between previously married women and depressive symptoms (Model 4). In contrast to men, the group of currently remarried women also has a higher probability for depression. There is no significant difference between the never married women and the continuously married women.
Table 2. Effects of marriage, cohabitation and relationship history on grip strength (GEE – identity link function). Men
Marital status Continuously married Currently remarried Previously married Never married Cohabitation status Continuously living with partner Currently living with partner again Previously lived with partner Never lived with partner Partnership status Continuously in relationship Currently in relationship again Previously in relationship Never in relationship Age Years of education Constant QIC n
Model 2
Model 3
Ref. −0.22 −0.04 −3.14***
Model 4
Model 6
Ref. −0.82** −0.81*** −1.10** Ref. −0.30 −0.65* −2.96***
−0.56*** 0.15*** 76.53*** 9291.66 9298
Model 5
−0.55*** 0.15*** 76.20*** 9293.36 9298
Note: All models are controlled for country differences; the effects are not depicted. Source: SHARE (waves 2 and 3), own calculations. *p < 0.05; **p < 0.01; ***p < 0.001; two-tailed test.
Ref. −0.64* −0.91*** −1.26** Ref. −0.41 −1.07** −2.52*** −0.55*** 0.16*** 76.12*** 9294.36 9298
−0.32*** 0.12*** 45.35*** 11,626.59 11,631
−0.31*** 0.12*** 45.27*** 11,626.81 11,631
Ref. −0.56* −0.89*** −1.17* −0.31*** 0.12*** 45.30*** 11,626.18 11,631
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Model 1
Women
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Table 3. Effects of marriage, cohabitation and relationship history on depressions (GEE – logit link function).
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Model 1 Marital status Continuously married Currently remarried Previously married Never married Cohabitation status Continuously living with partner Currently living with partner again Previously lived with partner Never lived with partner Partnership status Continuously in relationship Currently in relationship again Previously in relationship Never in relationship Age Years of education Constant QIC n
Model 2
Women Model 3
Ref. 1.06 1.52*** 1.47***
Model 4
Model 6
Ref. 1.37** 1.47*** 1.10 Ref. 1.02 1.66*** 1.23
1.02*** 0.95*** 0.29*** 7882.65 9609
Model 5
1.02*** 0.95*** 0.31*** 7878.55 9609
Note: All models are controlled for country differences; the effects are not depicted. Source: SHARE (waves 2 and 3), own calculations. **p < 0.01; ***p < 0.001; two-tailed test.
Ref. 1.46*** 1.46*** 0.99 Ref. 1.12 1.87*** 0.94 1.02** 0.95*** 0.32*** 7867.48 9609
Ref.
1.00 0.95*** 1.55 14,206.94 12,333
1.01 0.95*** 1.47 14,198.24 12,333
1.46*** 1.46*** 0.96 1.01 0.95*** 1.44 14,194.43 12,333
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The results are similar for cohabitation status (Model 5) and partnership status (Model 6). In both cases, depressive symptoms are more prevalent in the group of individuals who previously lived with a partner or who have previously been in a relationship, when compared to the respective continuous groups. The same applies to the group of subjects currently living with a partner again or those who are currently in a relationship again. One more, the last model (partnership status) offers the best fit.
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Discussion For men’s physical health, the goodness-of-fit measure indicates that marital status is the best relationship indicator for the observed data. The concerning QIC values are 9291.66 for marital status, 9293.36 for cohabitation status and 9394.36 for partnership status. For women’s grip strength, there are very little differences in the goodness of fit between the different relationship indicators. The QIC values vary between 11,626.18 for partnership status to 11,626.81 for cohabitation status. There is a difference in grip strength between people who have continuously been in a relationship and those who have never been. Additionally, for men, there is a negative association between men who previously lived with a partner or were previously in a relationship (but not with previously married men) and health. This could indicate negative health effects of relationship dissolutions. For women, there is a difference in grip strength between women who are continuously in a relationship and in a relationship again or who previously were in a relationship, regardless of the relationship indicator used. This result is consistent with the assumption of the long-term effects of relationship dissolutions. It is interesting to note that there seems to be no negative effect of marital dissolutions on grip strength for men, but there is a negative association for women. For both men and women, the goodness-of-fit QIC measure shows that the partnership status (marriage, cohabitation or dating relationship) is the best relationship indicator for analysing depression. For men, the QIC values are 7882.65 for marital status, 7878.55 for cohabitation status and 7867.48 for partnership status. For women, the QIC values are 14,206.94 for marital status, 14,198.24 for cohabitation status and 14,194.43 for partnership status. For men, depression rates are highest for those who were previously in a relationship, regardless of the relationship indicator used. This supports the crisis model that describes a correlation between relationship dissolutions and depression. For marital status, there is a positive association between never married men and depression. This result is an indicator for health selection in favour of marriage for men. For women, there is a correlation between depression and being in a relationship again or having previously been in a relationship, regardless of the applied relationship indicator. This is consistent with the assumption of the long-lasting effects of relationship dissolutions. There is little literature about the impact of non-marital relationships on physical and mental health. The present results suggest that the association between cohabitation and health is weaker than the association between marriage and health or is non-existent (Carr & Springer, 2010; Umberson et al., 2012); however, it is unclear which relationship indicator is the best predictor for health. This study suggests that there are only minor differences in grip strength between the different relationship indicators used here. Nonetheless, for men, marital status seems to be a better predictor for grip strength than cohabitation and partnership status. However, for depression, partnership status (marriage, cohabitation or dating relationship) seems to be a
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better indicator for analysing relationship effects on health than marital or cohabitation status.
Limitations A limitation of this study is that relationship biography relies on retrospective data. Therefore, recall bias is possible. Additionally, there are no longitudinal data for depression and grip strength. Therefore, a distinction between the protection and selection effects is not possible. Because of the small variance in marriage, cohabitation and dating relationship biographies, the data from 13 European countries have been pooled. Despite controlling for fixed country effects and clustering, it is possible that unobserved country-specific heterogeneity leads to a bias. Furthermore, the observed results of the pooled data can be different from results in certain individual countries. The conclusions concerning the best model fit based on the QIC value suffer from the fact that there is no way to test the significance of differences in QIC values. Therefore, it is unclear if these results are generalisable. Finally, this study focuses only on one indicator each for physical and mental health. Future research should examine if the results are reproducible with other indicators for physical and mental health.
Conclusions The results for grip strength suggest that using partnership or cohabitation status instead of marital status does not improve the analysis. However, differences in depression are better explained with partnership status than with marital or cohabitation status. These results suggest that future research on health could benefit from the use of relationship indicators other than marital status, particularly regarding mental health.
Funding This paper was created in the context of the project ‘The effects of the change of the relationship and family biography on health and health behaviour’ (KL 946/13-1) funded by the German Research Foundation (DFG). The paper uses data from SHARELIFE release 1, as of 24 November 2010 and SHARE release 2.5.0, as of 24 May 2011. The SHARE data collection was funded by the European Commission through the 5th framework programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life), through the 6th framework programme (projects SHAREI3, RII-CT-2006-062193, COMPARE, CIT5-CT-2005-028857 and SHARELIFE, CIT4-CT-2006028812) and through the 7th framework programme (SHARE-PREP, 211909 and SHARE-LEAP, 227822). Additional funding from the US National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG-4553-01 and OGHA 04-064, IAG BSR06-11, R21 AG025169) as well as from various national sources is gratefully acknowledged (see http:// www.share-project.org for a full list of funding institutions).
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Global Public Health: An International Journal for Research, Policy and Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rgph20
Relationship status and health: Does the use of different relationship indicators matter? a
a
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Björn Schneider , Ingmar Rapp , Thomas Klein & Jan Eckhard a
Max Weber Institute of Sociology, Heidelberg University, Heidelberg, Germany Published online: 25 Apr 2014.
Click for updates To cite this article: Björn Schneider, Ingmar Rapp, Thomas Klein & Jan Eckhard (2014) Relationship status and health: Does the use of different relationship indicators matter?, Global Public Health: An International Journal for Research, Policy and Practice, 9:5, 528-537, DOI: 10.1080/17441692.2014.904917 To link to this article: http://dx.doi.org/10.1080/17441692.2014.904917
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Global Public Health, 2014 Vol. 9, No. 5, 528–537, http://dx.doi.org/10.1080/17441692.2014.904917
Relationship status and health: Does the use of different relationship indicators matter? Björn Schneider*, Ingmar Rapp, Thomas Klein and Jan Eckhard Max Weber Institute of Sociology, Heidelberg University, Heidelberg, Germany
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(Received 14 March 2013; accepted 9 February 2014) Studies that analyse the association between relationship status and health usually disregard non-marital relationships. The present study examines if the use of different relationship indicators leads to different associations between relationship status and physical and mental health. The database used for this analysis is the Survey of Health and Ageing in Europe, a large population-based survey of Europeans aged 50 and over and their cohabitants. This study combines crosssectional and retrospective data of 13 European countries. The sample size is 9298 men and 11,631 women for grip strength and 9609 men and 12,333 women for depression. Generalised estimating equations are used. For men, the goodness-of-fit measure quasi-likelihood under the independence model criterion indicates that marital status is a better predictor than cohabitation status or partnership status for predicting grip strength. However, for grip strength of women, there are only small differences in the model fit between the different relationship indicators. For both men and women, the partnership status (marriage, cohabitation or dating relationship) shows the best model fit for explaining depression. The results suggest that future health research could benefit from the use of relationship indicators other than marital status, particularly regarding mental health. Keywords: relationship status; depression; grip strength; Europe; SHARE
Introduction The last decades have been characterised by an increasing spread of new living and relationship arrangements in nearly all western countries. The intention to marry is declining, and the divorce rate is increasing in almost all European countries (European Commission, 2011), while cohabitation and dating relationships have become much more common. Several relationships interrupted by time periods without a partner have partially replaced marriage with one lifetime partner (Kiernan, 2001). This development challenges research of relationship effects on health, which usually focuses on the association between marital status and health. Cross-sectional studies usually show better physical and mental health for married people than for unmarried individuals (Hughes & Waite, 2009; Simon, 2002; Williams & Umberson, 2004). Three possible explanations for the association between marriage status and health are discussed in the literature. First, the marital resource model suggests that marriage provides additional resources that have a positive influence on health (Ross, Mirowsky, & Goldsteen, 1990; Waite, 1995): better economic resources, social support from the spouse *Corresponding author. Email: [email protected] © 2014 Taylor & Francis
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and the regulation of health behaviour are described in the literature. People who have never been married or who are divorced or widowed cannot benefit from these marital resources and therefore suffer from poorer health outcomes. A second explanation for marital status differences in health is based on the crisis model. Here, marital dissolutions are considered to be associated with higher levels of stress that can lead to deteriorating health (Booth & Amato, 1991). This may not only have short-term effects on health (Brockmann & Klein, 2004), but can also have long-term effects that may persist even if the individuals remarry (Hughes & Waite, 2009). The third explanation is the selection thesis. It is argued that poor health reduces the probability of marrying and also increases the probability of divorce (Cheung, 1998; Mastekaasa, 1992). Longitudinal studies offer evidence for all three explanations (Carr & Springer, 2010; Umberson, Thomeer, & Williams, 2012). However, with recent changes in family and relationship structures, marital status may no longer be an adequate measure for health outcomes related to living arrangements because there are more never-married, divorced and widowed individuals who are living with a partner. Additionally, there is an increasing number of non-cohabiting couples. Therefore, the beneficial health effects of marriage may also apply to non-marital relationships; these relationships also provide additional resources, can be stressful when dissolved, and may also be subject to health-related selection. The findings concerning health differences between different forms of relationships are mixed. A recent review of the existing literature shows that there is very little evidence for a mental health benefit in cohabitation (Umberson et al., 2012). However, other authors conclude that cohabiting couples have better mental and physical health than non-cohabiting couples but poorer health than married people (Carr & Springer, 2010). Fuller (2010) reports that cohabiting individuals tend to have poorer health status and behaviour than both their married and single counterparts. The impact of relationship status on health may vary with the health category that is being assessed. Physical health can often be a result of events and periods that took place earlier in life and that influenced health in a negative or positive manner. In general, physical health changes slowly over time. In contrast, mental health should more strongly reflect current circumstances; therefore, rapid changes in an individual’s mental health status may be observable. It is important to note that the health effects of marriage can be affected by gender. In this regard, the findings in the literature are ambiguous. Some studies find stronger health effects for men than for women (Kaplan & Kronick, 2006; Simon & Barrett, 2010; Umberson, 1992; Williams & Umberson, 2004). However, some authors regard the gender differences as small and negligible (Carr & Springer, 2010; Waite & Gallagher, 2000), while others suggest a stronger relationship effect on health for women than for men (Fuller, 2010). Therefore, gender-separated analyses are appropriate. The present study examines whether the use of different relationship indicators leads to different associations between relationship status and physical and mental health. Three different indicators are used: marital status, cohabiting status (which includes marriage and cohabitation) and partnership status (which includes marriage, cohabitation and dating relationships). The aim is to determine which relationship indicator best explains health status. Methods The database for this study is the Survey of Health and Ageing in Europe (SHARE), a cross-national panel database of individuals from 13 European countries (Austria, Belgium,
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Czech Republic, Denmark, France, Germany, Greece, Italy, the Netherlands, Poland, Spain, Sweden and Switzerland) aged 50 and older and their cohabitants. For the analysis, the second wave (2006–2007) is combined with retrospective questions from the third wave (SHARELIFE, 2008–2009). Retrospective data provide information about the dissolution of marital, cohabitation and dating relationships. This is important as most surveys disregard non-marital relationship history. The second wave of SHARE contains detailed information about health. Dependent variables Both physical and mental health are investigated in this study. Maximum hand grip strength is used as a measure of physical health. The advantages of grip strength as a health measurement are its independence from medical diagnoses as well as its independence from subjective evaluation standards. Grip strength is highly correlated with other health indicators (Hank, Jürges, Schupp, & Wagner, 2009) and can be perceived as a long-term predictor for functional limitations, disability (Rantanen et al., 1999) and mortality (Gale, Martyn, Cooper, & Sayer, 2007; Rantanen et al., 2000). Grip strength was measured during the interviews by means of a hand grip dynamometer. For each hand, two measurements were taken. If the two values for one hand differed by more than 20 kg, both were coded as missing. The maximum grip strength is the maximum of four measurements (if there are valid values for both hands) or the maximum of two measurements (if there are only valid values for one hand). The mean grip strength in the sample is 43.51 kg (STD 10.05) for men and 27.02 kg (STD 7.51) for women. Mental health is operationalised as the existence of depression symptoms. Beliefs, restrictions and attitudes typical for depression are captured by means of the EuroDepression (EURO-D) Scale (Prince, Beekman, et al., 1999; Prince, Reischies, et al., 1999). This indirect measurement has advantages over medical diagnoses because not every person meeting the criteria for depression is diagnosed as such. The EURO-D score (range 0–12) expresses the extent of symptoms. The questions cover 12 dimensions: depression, pessimism, suicidality, guilt, sleep, interest, irritability, appetite, fatigue, concentration, enjoyment and tearfulness. A clinically significant depression is defined as a EURO-D score greater than 3, which is a validated threshold for a number of clinically relevant indicators (Dewey & Prince, 2005). Independent variables Three different systems of dummy variables are used as distinct relationship indicators. The first indicator refers to marriage status only. It contrasts the group of continuously married subjects with currently remarried, previously married (divorced and widowed) and never married individuals. The second relationship indicator focuses on cohabitation status and includes the following categories: ‘Continuously living with a partner (married or cohabitating)’, ‘Currently living with a partner again’, ‘Previously lived with a partner’ and ‘Never lived with a partner’. The third relationship indicator focuses on partnership status and consists of the following groups: ‘Continuously in relationship (married, cohabitating or dating)’, ‘Currently in relationship again’, ‘Previously in relationship’, ‘Never in relationship’. The distribution of these variables in the sample is shown in Table 1. Of note, there is overlap among the groups. For instance, some of the continuously married individuals have never lived with a different partner and therefore also belong to the group of those
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Table 1. Descriptive statistics.
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Men
Marital status Continuously married Currently remarried Previously married Never married Total Cohabitation status Continuously living with partner Currently living with partner again Previously lived with partner Never lived with partner Total Partnership status Continuously in relationship Currently in relationship again Previously in relationship Never in relationship Total Age Years of education
Women
Frequency
Percentage
Frequency
Percentage
7443 664 1068 514 9689
76.82 6.85 11.02 5.30 100
7893 569 3417 547 12,426
63.52 4.58 27.50 4.40 100
7329 959 1063 338 9689
75.64 9.90 10.97 3.49 100
7781 902 3359 384 12,426
62.62 7.26 27.03 3.09 100
6941 1571 905 272 9689
71.64 16.21 9.34 2.81 100
7491 1478 3161 296 12,426
60.28 11.89 25.44 2.38 100
Mean 64.81 10.51 9689
SD 9.30 4.75
Mean 63.61 9.60 12,426
SD 10.24 4.43
Note: The numbers encompass all cases with at least valid information for grip strength or depression and therefore slightly differ from the number of cases in Tables 2 and 3. Source: SHARE (waves 2 and 3), own calculations.
continuously living with a partner. There are also cases in which a person moves from one group to another if the variable system is redefined. For example, individuals who are married for the first time and who had one or more cohabitations before marriage move from ‘continuously married’ to ‘currently living with partner again’. As the examples show, there are respondents who remain in the same category regardless of the relationship definition, whereas other move from one category to another with a redefinition. Age and years of education are included in the analysis as they are potential confounders. Table 1 also shows the distribution of age and years of education. Dummy variables are used to control for country effects. Statistical methods Data from all countries are pooled. Separate analyses by country are not made because the number of cases from individual countries is not sufficient. Cases were deleted if there were missing values for the dependent variable or for one or more independent variables. Furthermore, cases were omitted from the analysis if there were contradictions between the reported relationship biography in wave 3 and the current relationship status in wave 2. After the exclusion of cases as described above, 20,929 cases and 21,942 cases were available for grip strength and depression analysis, respectively. Because of clustering at the country level, standard statistic models such as linear or logistic regression would lead
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to false standard errors and thereby false inferences. To address this problem, generalised estimating equation (GEE) models were used to obtain appropriate inferential statistics for clustered data (Liang & Zeger, 1986). The models for the depression indicator use the logit link function, and the models for grip strength use the identity link function. The working correlation matrix is set as independent. The quasi-likelihood under the independence model criterion (QIC) is applied to compare the non-nested models and determine the relationship indicator that shows the best model fit. Lower QIC scores indicate a better model fit, but there is no test for statistical significance of the differences. All models are calculated separately to capture different effects on men and women. SAS 9.2 via PROC GENMOD was used for model estimation.
Results Table 2 shows the GEE models for the maximum grip strength of men and women. Model 1 presents the coefficients of marital status for men with controls for age, education and country (coefficients not reported). The reference group is comprised of continuously married men. Only the grip strength of the never married men is significantly weaker than the grip strength of the continuously married men. There are no significant differences between the continuously married, currently remarried and previously married men. Model 2 focuses on cohabitation status, whereas Model 3 focuses on partnership status. The results show that also never living with a partner (−2.96) and never being in a relationship (−2.52) is negatively associated with grip strength for men. In addition, Models 2 and 3 show a significant negative association between grip strength and previously living with a partner or previously being in a relationship, respectively. Model 1 indicates the best fit because the QIC value is the lowest of all three models. The results for women are displayed in the last three models of Table 2. As with men, the group of never married women has the lowest maximum grip strength (Model 4). In contrast to men, the currently remarried and previously married women also have a reduced grip strength compared to the continuously married women. The results are similar for cohabitation status (Model 5) and partnership status (Model 6). Women who continuously live with a partner or who are continuously in a relationship have the lowest grip strength. The last model offers the best goodness of fit, but the QIC values are very similar. The results for depression are illustrated in Table 3. For previously married men as well as for never married men, the odds of suffering from depression are significantly higher than in the reference data, while there are no differences between the continuously married and the currently remarried men (Model 1). Model 2 indicates the association between cohabitation status and depression. In contrast to Model 1, there is only a significant difference between men who previously lived with a partner and men who continuously live with a partner. In Model 3, the effects of partnership status are shown. As in Model 2, there is only a significant difference between the group who previously lived with a partner and the group of subjects who continuously live with one. This difference is stronger than the corresponding associations observed in Models 1 and 2. Model 3 (partnership status as indicator) provides the best fit. The results for women are presented in Models 4, 5 and 6. Similar to men, there is a positive association between previously married women and depressive symptoms (Model 4). In contrast to men, the group of currently remarried women also has a higher probability for depression. There is no significant difference between the never married women and the continuously married women.
Table 2. Effects of marriage, cohabitation and relationship history on grip strength (GEE – identity link function). Men
Marital status Continuously married Currently remarried Previously married Never married Cohabitation status Continuously living with partner Currently living with partner again Previously lived with partner Never lived with partner Partnership status Continuously in relationship Currently in relationship again Previously in relationship Never in relationship Age Years of education Constant QIC n
Model 2
Model 3
Ref. −0.22 −0.04 −3.14***
Model 4
Model 6
Ref. −0.82** −0.81*** −1.10** Ref. −0.30 −0.65* −2.96***
−0.56*** 0.15*** 76.53*** 9291.66 9298
Model 5
−0.55*** 0.15*** 76.20*** 9293.36 9298
Note: All models are controlled for country differences; the effects are not depicted. Source: SHARE (waves 2 and 3), own calculations. *p < 0.05; **p < 0.01; ***p < 0.001; two-tailed test.
Ref. −0.64* −0.91*** −1.26** Ref. −0.41 −1.07** −2.52*** −0.55*** 0.16*** 76.12*** 9294.36 9298
−0.32*** 0.12*** 45.35*** 11,626.59 11,631
−0.31*** 0.12*** 45.27*** 11,626.81 11,631
Ref. −0.56* −0.89*** −1.17* −0.31*** 0.12*** 45.30*** 11,626.18 11,631
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Model 1
Women
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Table 3. Effects of marriage, cohabitation and relationship history on depressions (GEE – logit link function).
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Model 1 Marital status Continuously married Currently remarried Previously married Never married Cohabitation status Continuously living with partner Currently living with partner again Previously lived with partner Never lived with partner Partnership status Continuously in relationship Currently in relationship again Previously in relationship Never in relationship Age Years of education Constant QIC n
Model 2
Women Model 3
Ref. 1.06 1.52*** 1.47***
Model 4
Model 6
Ref. 1.37** 1.47*** 1.10 Ref. 1.02 1.66*** 1.23
1.02*** 0.95*** 0.29*** 7882.65 9609
Model 5
1.02*** 0.95*** 0.31*** 7878.55 9609
Note: All models are controlled for country differences; the effects are not depicted. Source: SHARE (waves 2 and 3), own calculations. **p < 0.01; ***p < 0.001; two-tailed test.
Ref. 1.46*** 1.46*** 0.99 Ref. 1.12 1.87*** 0.94 1.02** 0.95*** 0.32*** 7867.48 9609
Ref.
1.00 0.95*** 1.55 14,206.94 12,333
1.01 0.95*** 1.47 14,198.24 12,333
1.46*** 1.46*** 0.96 1.01 0.95*** 1.44 14,194.43 12,333
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The results are similar for cohabitation status (Model 5) and partnership status (Model 6). In both cases, depressive symptoms are more prevalent in the group of individuals who previously lived with a partner or who have previously been in a relationship, when compared to the respective continuous groups. The same applies to the group of subjects currently living with a partner again or those who are currently in a relationship again. One more, the last model (partnership status) offers the best fit.
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Discussion For men’s physical health, the goodness-of-fit measure indicates that marital status is the best relationship indicator for the observed data. The concerning QIC values are 9291.66 for marital status, 9293.36 for cohabitation status and 9394.36 for partnership status. For women’s grip strength, there are very little differences in the goodness of fit between the different relationship indicators. The QIC values vary between 11,626.18 for partnership status to 11,626.81 for cohabitation status. There is a difference in grip strength between people who have continuously been in a relationship and those who have never been. Additionally, for men, there is a negative association between men who previously lived with a partner or were previously in a relationship (but not with previously married men) and health. This could indicate negative health effects of relationship dissolutions. For women, there is a difference in grip strength between women who are continuously in a relationship and in a relationship again or who previously were in a relationship, regardless of the relationship indicator used. This result is consistent with the assumption of the long-term effects of relationship dissolutions. It is interesting to note that there seems to be no negative effect of marital dissolutions on grip strength for men, but there is a negative association for women. For both men and women, the goodness-of-fit QIC measure shows that the partnership status (marriage, cohabitation or dating relationship) is the best relationship indicator for analysing depression. For men, the QIC values are 7882.65 for marital status, 7878.55 for cohabitation status and 7867.48 for partnership status. For women, the QIC values are 14,206.94 for marital status, 14,198.24 for cohabitation status and 14,194.43 for partnership status. For men, depression rates are highest for those who were previously in a relationship, regardless of the relationship indicator used. This supports the crisis model that describes a correlation between relationship dissolutions and depression. For marital status, there is a positive association between never married men and depression. This result is an indicator for health selection in favour of marriage for men. For women, there is a correlation between depression and being in a relationship again or having previously been in a relationship, regardless of the applied relationship indicator. This is consistent with the assumption of the long-lasting effects of relationship dissolutions. There is little literature about the impact of non-marital relationships on physical and mental health. The present results suggest that the association between cohabitation and health is weaker than the association between marriage and health or is non-existent (Carr & Springer, 2010; Umberson et al., 2012); however, it is unclear which relationship indicator is the best predictor for health. This study suggests that there are only minor differences in grip strength between the different relationship indicators used here. Nonetheless, for men, marital status seems to be a better predictor for grip strength than cohabitation and partnership status. However, for depression, partnership status (marriage, cohabitation or dating relationship) seems to be a
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better indicator for analysing relationship effects on health than marital or cohabitation status.
Limitations A limitation of this study is that relationship biography relies on retrospective data. Therefore, recall bias is possible. Additionally, there are no longitudinal data for depression and grip strength. Therefore, a distinction between the protection and selection effects is not possible. Because of the small variance in marriage, cohabitation and dating relationship biographies, the data from 13 European countries have been pooled. Despite controlling for fixed country effects and clustering, it is possible that unobserved country-specific heterogeneity leads to a bias. Furthermore, the observed results of the pooled data can be different from results in certain individual countries. The conclusions concerning the best model fit based on the QIC value suffer from the fact that there is no way to test the significance of differences in QIC values. Therefore, it is unclear if these results are generalisable. Finally, this study focuses only on one indicator each for physical and mental health. Future research should examine if the results are reproducible with other indicators for physical and mental health.
Conclusions The results for grip strength suggest that using partnership or cohabitation status instead of marital status does not improve the analysis. However, differences in depression are better explained with partnership status than with marital or cohabitation status. These results suggest that future research on health could benefit from the use of relationship indicators other than marital status, particularly regarding mental health.
Funding This paper was created in the context of the project ‘The effects of the change of the relationship and family biography on health and health behaviour’ (KL 946/13-1) funded by the German Research Foundation (DFG). The paper uses data from SHARELIFE release 1, as of 24 November 2010 and SHARE release 2.5.0, as of 24 May 2011. The SHARE data collection was funded by the European Commission through the 5th framework programme (project QLK6-CT-2001-00360 in the thematic programme Quality of Life), through the 6th framework programme (projects SHAREI3, RII-CT-2006-062193, COMPARE, CIT5-CT-2005-028857 and SHARELIFE, CIT4-CT-2006028812) and through the 7th framework programme (SHARE-PREP, 211909 and SHARE-LEAP, 227822). Additional funding from the US National Institute on Aging (U01 AG09740-13S2, P01 AG005842, P01 AG08291, P30 AG12815, Y1-AG-4553-01 and OGHA 04-064, IAG BSR06-11, R21 AG025169) as well as from various national sources is gratefully acknowledged (see http:// www.share-project.org for a full list of funding institutions).
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