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Making the Connection Between Healthy Marriage and Health Outcomes

Making the Connection
There are no public or privately funded research programs designed to study the connections between marriage and health. However an extensive body of research has accumulated in recent years clearly documenting that married adults are physically and emotionally healthier, live longer than adults that are never married, divorce, separated or widowed, and that their children will be healthier as well. This research is scattered among different disciplines, and has emerged both from analyses of general population health surveys and in research on specific populations and diseases. While these syntheses conclude that the associations between marriage and health are strong, they also make clear that the research is not yet nuanced, or robust enough to identify the causal pathways leading from marriage to health outcomes. Moreover, these reviews rely primarily on analyses of large population surveys that treat all marriages as the same, and include bad, “unhealthy” marriages along with the good, healthy or “good enough” marriages. It is generally acknowledged that unhappy, unhealthy, high-conflict marriages have negative effects on both physical & mental health. We discuss the increasing body of evidence on the protective effects of healthy, higher-quality marriages, as well as the health hazards of lower-quality marriages, especially as adults grow older. And we give examples of some emerging, fascinating clinical and laboratory-based studies that are beginning to identify some of the psycho-physiologic pathways through which marital quality affects health outcomes. It is these studies that suggest efforts to improve marital and relationship quality may be able to positively affect some health outcomes, especially at key points during the various stages of marriage.
The link between Marriage and Health
In the Case for Marriage, Linda Waite and co-author Maggie Gallagher summarized an extensive body of survey research and concluded that getting married and being married is linked to many positive physical and mental health outcomes. In fact, these benefits seem to persist even when factors that affect health outcomes, such as health status prior to marriage, income levels and race/ethnicity are taken into account. Also research suggests that married couples living in poverty have better physical health compared to their low-income peers who are unmarried, divorced or widowed . Research also indicates a man or woman’s marital status at age 48 – that is, whether married, divorced, widowed, or never married — strongly predicts their chances of either surviving to age 65 or dying prematurely. For example, as depicted in the charts below , divorced men have only a 65 percent chance of living to age 65, compared to a 90 percent chance for married men, and a never-married woman has an 80 percent chance of living to age 65, compared to a 95 percent chance for married women). What is it about marriage that has these positive effects on health? Various factors play a role. First, there is the “selection effect.” This refers to the premise that people who are inherently healthier mentally and physically, may be more likely to get married and to stay married, inflating the apparent effects of marriage on health. The “selection effect” may also work to ‘select out’ individuals for divorce who have unhealthy (but undetected behaviors) and mental health traits (such as hostility) that independently affect health outcomes. This can contribute to an over-estimation of the effects of divorce itself on subsequent health. Second, there is the “protection” effect, which asserts that marriage itself changes individual health risk behaviors and encourages behaviors that are more likely to promote and protect health. Third, there is the social support, companionship, caring and care giving that marriage generally brings to individual partners, especially as they grow older . Fourth, there are the additional economic resources that are associated with marriage, such as the fact that married individuals earn more, are more likely to have health insurance and have access to health care. In summary, in previous decades, selection of healthier partners for marriage was thought to be sufficient to explain the health benefits of marriage. The current research consensus is that the health benefits of marriage appear to result from a combination of selection and protection effects, as well as the additional resources and social support that healthy marriage brings over time.

The links between marital quality and health

An increasing number of studies suggest that it is the quality of the marital relationship, rather than simply being married that affects health. The term “marital quality” includes both positive experiences (feeling loved, cared for and satisfied in the relationship), and negative experiences (excessive demands, criticism, emotional withdrawal, marital conflict). Having a marriage with relatively low levels of negative interactions appears to be what leads to lifelong cumulative health benefits. But what is generally meant by the terms a “healthy” or “good enough” marriage? There is no blueprint for a “healthy” marriage but researchers have identified a number of core characteristics that healthy marriages share including effective communication and conflict resolution, commitment over the long haul, and emotional support and companionship. A truly healthy marriage is physically and emotionally safe for both partners and for their children. A marriage in which there is violence is unhealthy by definition— physical and/or emotional abuses within a marriage are clear health risks. Even without physical conflict, marriages that are high in negative distress and discord carry health hazards by creating a high-stress environment that may increase the likelihood of divorce, which is strongly associated with poorer health outcomes for both men and women. A recent national representative survey of adults has demonstrated that an unhappy marriage [reported negativity, distress, lack of support, etc.] eliminates any predicted health benefits for adults. Moreover, even when conflicted marriages end via divorce, symptoms of distress continue as the former spouses spar over financial and custody issues.  In the following sections we discuss some key findings from both representative population surveys and clinical studies. They are organized from a life course perspective and demonstrate the links between marriage and health, highlighting those that focus on marital/relationship quality by stages of the life cycle. For reasons of space we do not discuss the economic resources and access issues at length, and our major focus is on physical health outcomes; however, the same risk and protective factors have been found to affect mental health outcomes as well, especially for depression. We have included only high quality studies, and relied especially on research which controls for other factors affecting health outcomes, such as income, prior health or other health conditions.

The Effects of Marriage and Marital Quality on Child Health

Studies reviewed by Wood and colleagues in a recent synthesis of research on marriage and health show that marriage also benefits the health of children during their childhood and into their adult years. Children raised to adulthood by married parents live longer, and have better physical health as children and later in life as adults, compared to children raised in other living arrangements. Children living with two biological parents are healthier than children growing up in other family arrangements (e.g., step-parent, single mother, grandparents), regardless of income levels . When these children reach adulthood, surveys show that they will have better physical health and a longer lifespan . Because most research on children’s health (until recently) only measured family structure and did not explore parental lifetime health status or parental marital relationship quality, the association of better children’s health outcomes with marriage factors clearly needs further investigation.
It is well-known that parents’ divorce can negatively affect children’s academic, social and psychological well-being, and can lead to greater incidence of risky behaviors, such as unprotected sexual activity and substance abuse, that will affect their health. If we look specifically at the health outcomes over their life span, children whose parents divorced before they were 17, grow up to have shorter a lifespan (for males) and more acute and chronic health conditions (for both males and females), compared to children whose parents remain married. Additionally, new research supports that marital discord / conflict between parents is a better predictor of illness later in life for their offspring than just measuring the marital status of the parents . More recent studies have pointed to pre-divorce relationship aspects, such as parental conflict, as often-unmeasured factors contributing to the effects of divorce on children’s health . This underlines the potential equivalence of distressed marriages and of divorce on a child’s health & well-being . Interestingly, research has found that children of distressed, highly negative couples have higher levels of stress-related hormones in their system, which is a marker for the presence of chronic physiological stress. One ongoing longitudinal study funded by the Centers for Disease Control (CDC) focuses on the effects of adverse childhood experiences (ACE) on lifetime health outcomes. This study is beginning to demonstrate strong correlations, not just between later life health risk and physical and sexual abuse experiences in childhood, but with a number of other childhood risk factors such as problem drinking, violence against the mother, separation or divorce, emotional abuse or neglect. Many of these in turn are associated with the quality of the marriage relationship. A few studies describe specific, measurable consequences for children’s health of less stable, nurturing, parental relationships, when income levels and other societal factors are taken into account. For example, a child’s chance of being diagnosed with asthma is more likely if the biological parents are unmarried and also not living together, after controlling for income levels, compared with either cohabiting parents and married parents (Harknett, 2005). In this study, the incidence of emergency hospital visits for asthma attacks increases in direct proportion with more tenuous and distant parent relationships, i.e., from married to cohabiting to not living together.

Adolescent Health & Risk Behaviors
Adolescent high risk behaviors—smoking, excessive drinking/drug use, poor diet, risky sexual activities —are of concern because of lifelong health consequences. Risky teen behaviors have long been known to be influenced by family structure (married, cohabiting, stepfamily, single parenting). The presence of two married biological parents who can provide greater parental involvement, monitoring, supervision and closeness provide the best outcomes for teen health and well-being. Now research is showing that the quality of the parents’ relationship with each other can affect (i.e., increase or decrease) an adolescent’s health risk behaviors, and may be more powerful than just marital status. Family structure effects are mediated by the quality of family processes, and by family disruption from separation, divorce or even remarriage. Early and unprotected sexual activity in teens, a known health risk factor, is explained by the presence of marital conflict as well as by the adolescent’s relationship with each parent. This holds particularly true for teenage girls. Adolescents living with married parents are less likely to use illegal drugs, compared to those who live with single parents or are in stepparent families in similar community/SES contexts, and are less likely to have depressive symptoms than young adults in stepfamilies, single parent families, or single parent families with other adults present. Adolescents appear especially vulnerable to family disruptions . Much of this vulnerability is explained by levels of prior marital discord, pointing to low marital quality before and after disruption as a key factor that explains the well-established association of adolescent health risk behaviors with divorce .

As We Grow Older
As married partners reach middle age, it appears that the effects of both marital status and marital relationship quality on adult health become more powerful. Growing older increases the psychological importance of having and engaging in intimate relationships, and this in turn amplifies the potential stress the elderly may experience from any negative marital interactions or from transitions out of marriage through divorce or death of a spouse. Elderly persons who are still married are likely to be healthier. That is, 76 percent report being in good or excellent health, significantly higher percentages than their peers, who are widowed, divorced, living with a partner, or never married. Also, marriage appears to protect the elderly from the onset of physical limitations in carrying out their daily living activities. For example, three times as many widowed adults over 65 reported having limitations in daily activities, compared to their married peers. Research found that physical limitations for divorced or never-married elderly were somewhere in between the married and widowed rates. Many longitudinal studies are documenting the relationship of marital quality and health over time. A three-year community study of roughly 400 married couples, reported declines in marital quality (e.g., reported satisfaction, happiness & commitment) were associated with increased symptoms of physical illness later in life for both men and women. In contrast, increases in marital quality were associated with improvements in physical health later in life, in studies able to control for other factors influencing health such as education, income, income changes, and job difficulties. Two large representative studies of middle-aged and older married adults (50+) found that those who reported higher levels of negative spousal behaviors, such as experiencing criticism, arguments, and demands, had poorer health over time. This was indicated by their general health status, list of physical symptoms, presence of specific chronic health problems, or report of limitations in activities of daily living (ADLs). One study using data from the National Survey of Midlife Development in the U.S. (MIDUS), found that the association of negative marital functioning with poorer health outcomes was as strong for older men as it was for older women. Interestingly, the study also found that negative spousal behaviors were only associated with changes in general health status and no association could be found with the frequency of positive, caring, or helpful behaviors. These studies show that over an eight-year period, the relationship between negative marital quality and health declines was strongest for the oldest subjects (aged 70+ years). Younger adults did not report declines in health even when reporting negative marital quality, thus underscoring the increasing impact of marital quality on physical health in growing older. Heart Disease. The effects of negative marital quality on health have been strikingly captured in studies of heart disease, which is a disease typically associated with aging. The following presents some noteworthy findings from these research studies:
• Overall, married men and women have a lower risk for death from heart attacks, compared to other marital status categories; and married couples enjoy a better chance of returning to health when they receive a diagnosis of cardiovascular disease.
• Women over the age of 50 may have a higher risk of developing cardiovascular disease than men if they are divorced, remarried, or widowed. Between the ages of 50 and 60, the risk of cardiovascular disease for women was about 60 percent higher for divorced women and 30 percent higher for widows, compared to married women.
• A Swedish study showed that marital stress for women increased the risk of having a reoccurrence of a cardiovascular event such as angina, a heart attack, surgery for blocked arteries, or death. Work stress was not associated with an increased reoccurrence for women, unlike the known outcome of work stress on men. The increased risk of reoccurrence persisted after adjusting for other health factors and severity of initial diagnosis.
• Higher marital relationship quality predicted long-term survival (i.e., defined as over 4 years) in a study of 189 heart disease patients, independent of other known risk factors including initial severity of the diagnosis. The most seriously ill patients in satisfied, low-conflict marriages lived significantly longer than much healthier patients in less-satisfying marriages. Over eight years, the quality of the marital relationship continued to predict prolonged survival for the women in this study, but not for the men. Marital quality was a better predictor of survival than individual patient characteristics, such as hostility, optimism, and emotional support from others in general. Over half of women in the high quality marriages were still alive after eight years.
• A recent study of 9,000 British subjects found that negative close relationships significantly increased the risk of coronary events over a 12-year period, independent of socio-demographic characteristics, biological health factors (obesity, hypertension, diabetes, cholesterol level), psychosocial factors (depression, work stress), and health risk behaviors (smoking, drinking, exercise, diet). In contrast, and like Bookwala’s findings (2005), emotional and practical support (positive quality) was not associated with reduced risk of heart disease. The independence of the effect of negative relationship quality from gender and from social position, both known to affect incident coronary disease, is especially striking.
Care giving & Health in the Later Years. Spousal care giving in later years can be both a health benefit for the ill spouse and a health risk for the caregiver. On the benefit side, married persons are known to be less likely to enter a nursing home or pay for costly long-term care, because they can turn to their spouse for care giving. Care and support are thought to be particularly beneficial to married men as they age. Correspondingly, older cohabiting women may feel less call to provide care giving, and thus older cohabiting men may gain fewer health benefits. On the health cost, or health risk side, the physiological impact of extended pre-loss care giving by a spouse, and the neglect of one’s own health concerns, takes a toll on the caregiver’s health.

In summary a good-enough, or healthy marriage – one that is low in negativity – will provide cumulative, lifelong protection against chronic illness and premature death for both men and women, as well as greatly increasing the chances that their children will grow up healthy. These benefits seem only to increase as couples grow old together.