Marital Status, the Economic Benefits of Marriage, and Days of ...

9]. The variation in shared economic resources by marital status may help married persons weather turbulent ... InternationalJournalofPopulationResearchTableofContentsSpecialIssuesInternationalJournalofPopulationResearch/2012/Article/OnthispageAbstractIntroductionResultsDiscussionConclusionAppendixReferencesCopyrightRelatedArticlesResearchArticle|OpenAccessVolume2012|ArticleID568785|https://doi.org/10.1155/2012/568785ShowcitationMaritalStatus,theEconomicBenefitsofMarriage,andDaysofInactivityduetoPoorHealthJimP.Stimpson,1FernandoA.Wilson,2andM.KristenPeek3ShowmoreAcademicEditor:SidneyR.SchulerReceived21Jan2012Revised15Jun2012Accepted03Jul2012Published27Aug2012Purpose.Thisstudyexploredwhethertheeconomicbenefitsofmarriagemediatetheassociationbetweenmarriageandhealthandifthatrelationshipisconditionalonthelevelofsharedeconomicresources.Methods.Pooled,cross-sectionaldatafromNHANES2001–2006wereanalyzedusingmultivariatezero-inflatednegativebinomialregressionforthenumberofdaysofinactivityduetopoorphysicalormentalhealth.Results.Personsthatweredivorced/separatedreportedthehighestaveragenumberofdaysofinactivity(mean = 2.5)withina30dayperiod,andmarriedpersonsreportedthelowestnumberofdaysofinactivity(mean = 1.4).Multivariateresultsindicatedthatwidowedpersonsdidnotreportsignificantlymoredaysofinactivitythanmarriedpersons.Incometopovertyratioreducedthesizeandeliminatedstatisticalsignificanceofthedifferencebetweendivorced/separatedandnevermarriedmaritalstatusescomparedtomarriedpersons.Theinteractioneffectformaritalstatusandincometopovertyratiowasstatisticallysignificantsuggestingthattherelationshipbetweenmaritalstatusandinactivityisconditionalonsharedincome.Conclusion.Marriageconfershealthprotectivebenefitsinpartthroughpooledincomerelativetoothermaritalstatuses.1.IntroductionThereisagrowinginterestinhowthetypesandqualityofsocialtiesinfluenceourmortality,morbidity,andhealthlifestyle[1–4].Oneformofsocialrelationshipsthathasnearunanimoussupportforbeinghealthenhancingismarriage[5–8].Oneviewofthisrelationshipisthathealthierpersonsaremorelikelytogetmarriedandstaymarried,whichisreferredtoastheselectionhypothesis[9,10].Anotherview,thecausationhypothesis,arguesthatmarriageconfersnumeroussocialandeconomicbenefitsthatprotectmarriedpersonsfromillhealthovertime[6].Thesocialbenefitsofmarriageincludesocialsupportduringtimesofstress,whichcanprotecthealthbyreducinginflammationandincreasingserotoninreleasetoelevatemoods,andencouragementtoengageinhealthybehaviors[3,11–14].Economicbenefitsofmarriageincludepooledassets,livinginthesamehousehold,accesstospousalhealthinsurance,andsharedhouseholdlabor[9,15,16].Someofthesebenefitscanalsobegainedbycohabitingwithapartner,whichmaypartiallyexplaintheriseincohabitingunionsoverthepastfewdecades[16–18].Althoughtheseeconomicbenefitsmayenablemarriedandcohabitingpersonstoinvestinhealthpromotingresources,thereisstilllittleresearchdoneonidentifyingwhethertheeconomicbenefitsmediateormoderatetheassociationbetweenmarriageandhealth.Therefore,thisstudywillbuildontheexistingliteraturebydeterminingwhethertheassociationbetweenmarriageandhealthisrelatedtotheeconomicbenefitsofmarriagesuchasimprovedaccesstohealthinsuranceorpooledincome.2.Methodology2.1.DescriptionoftheDataThisstudyusedpubliclyavailabledatacollectedbytheNationalCenterforHealthStatistics(NCHS)from2001–2006.TheNationalHealthandNutritionExaminationSurvey(NHANES)isanationallyrepresentativesurveyofnoninstitutionalizedindividualsintheUnitedStatesonvarioushealthtopicswithparticularemphasisonnutrition.Since1999,theNCHShasconductedNHANESsurveyseverytwoyearswithanoversamplingofolderadults,HispanicsandAfricanAmericanstoensureadequaterepresentation.Eachrespondentcompletesaquestionnaireadministeredbytrainedpersonnelandmayalsobegivenaphysicalexaminationincludingbloodwork[19].Thefinalanalyticalsampleconsistedof13,678respondentswhowere20yearsofageorolderwithcompletedataonallstudyvariables.2.2.MeasuresTheoutcomevariableselectedwasself-reporteddaysofinactivityinthepast30days.Thequestionnaireaskedrespondentsthefollowingquestion:“Duringthepast30days,forabouthowmanydaysdidpoorphysicalormentalhealthkeepyoufromdoingyourusualactivities,suchasself-care,work,schoolorrecreation?”.Responsesrangedfrom0to30days.Anadvantageofthisoutcomevariableisthatthetimeframefortheresponse(past30days)fitswellwiththecross-sectionaldesignofthestudycomparedtohealthoutcomemeasuresthatdevelopoverlongtimehorizons.Maritalstatuswasthemainpredictorvariableinthisstudy.Personsself-reportedthattheywerecurrentlymarried,nevermarried,widowed,cohabiting,ordivorced/separated.Agewascategorizedintothefollowinggroups:20–39,40–64,and65+.Genderwasmeasuredwithabinaryindicator(female=1,male=0).Educationwasmeasuredaslessthanhighschool,highschool,andmorethanhighschool.Race/ethnicityreflectednon-HispanicWhitesasthereferencegroup,comparedtonon-HispanicBlack,Hispanic,andotherethnicities.Healthbehaviorsincludedbinaryindicatorsofanyonecurrentlysmokinginthehouseholdandobesity(>30 kg/m2).Accesstohealthcarewasdefinedashavingausualsourceofcareorcurrentlyhavinganyhealthinsurance.Familyincome-to-povertyratiorangedfrom0to5withlowerscoresindicatinggreaterlevelsofpovertyrelativetoincome.Thisvariablewascategorizedintothefollowinggroups:0–0.99,1–3.99,and4-5.2.3.AnalysisPlanStatisticalanalysespoolthreedifferentcross-sectionsofNHANES:2001-02,2003-04,and2005-06.STATASE/12[STATACorporation,CollegeStation,TX]wasusedtoadjustforsurveyweightingandthecomplexsampledesignofNHANES.Descriptivestatisticswerecalculatedbymaritalstatuscategoriesandadjustedforsampleweightsandcomplexsampledesignfactors.Theoutcomevariableisacountofdaysofinactivity,whichwasoverdispersedandthereforePoissonregressionwasnotappropriate.Zero-inflatednegativebinomialregressionwaschosenbasedontheresultsfromtheVuonglikelihoodratiotest.Rateratioswerecalculatedforthenegativebinomialregressionresults;rateratiosareinterpretedsimilartooddsratioswithvalueshigherthan1.00suggestingahigherrelativeriskofreportinganadditionaldayofinactivity.Thefirststepofthemodelaccountedfordemographiccharacteristicsandhealthbehaviors,whichcouldvarybymaritalstatus[3,11–14].Thenextstepaddedaccesstohealthcare,whichisoneoftheeconomicbenefitsofmarriage[15].Finally,incometopovertyratiowasaddedtothemodels,whichisabenefitforbothmarriedandcohabitingcouples[16].Inadditiontothemainpredictorvariables,allanalysesadjustforyearofthesurveyinterview.Giventhepotentialfortheassociationofmarriageandhealthtovarybytheeconomicbenefitsofmarriage,aninteractioneffectwascalculatedbetweenmaritalstatusandincometopovertyratioaswellasmaritalstatusandhealthinsurance.Sensitivityanalysesinvestigatedtheeffectofageonrelationshipbetweenmaritalstatusandhealthgiventhestrongrelationshipagehaswithbothvariables.Aninteractioneffectwascalculatedbetweenmaritalstatusandageandthestatisticallysignificantresultsindicatethattheeffectofmaritalstatusonhealthdependsonageoftherespondent.Agewasalsostratifiedtoinvestigatetheroleofsocialsupportontherelationshipbetweenmaritalstatusandhealth.NHANESonlycollectedsocialsupportdataforrespondents60yearsofageandolderfrom1999–2002andfrompersons40yearsofageandolderfrom2003–2006.Wecalculatedthemodelusingsocialsupportforpersons65yearsandolder,andtheresultsindicatedthatsocialsupportwasnotastatisticallysignificantmainpredictorfortheoutcomevariable.Theresultsfromthesensitivityanalysesareshownintheappendix.3.ResultsThedescriptivestatisticsforthestudyvariablesbymaritalstatuscategoriesarepresentedinTable1.Overall,59%ofthesamplewasmarriedduringthestudyperiod.Therewasconsiderablevariationamongthestudyvariablesbymartialstatusinlargepartduetotherelationshipbetweenageandmaritalstatus.Amongthosethatweremarried,52%were40–64yearsofage,32%were20–39yearsofage,andtheremaining15%were65andolder.Asimilaragedistributionwasfoundwithinthedivorced/separatedmartialstatus.However,adramaticandoppositedifferenceintheagedistributionwasfoundforthewidowedandnevermarriedmaritalstatuses.Theyoungeragegroupcomprised78%ofthenevermarried;conversely,76%oftheoldestagegroupmadeupthewidowed.Genderwasapproximatelyevenlydistributedamongthemaritalstatuseswiththeexceptionofwidowedstatus,whichwaspredominantlycomprisedofwomen.Othernotabledifferencesinthedistributionofmaritalstatuswerethatnevermarriedandcohabitinghadalowerpercentageaffirmativelyreportingausualsourceofhealthcareoranyhealthinsurancecomparedtoothermaritalstatuses.Marriedpersonsreportedthelowestlevelsofpovertyat7%andthehighestlevelsofincomerelativetothepovertylevelat45%comparedtoothermaritalstatuses.Finally,personsthatweredivorced/separatedreportedthehighestaveragenumberofdaysofinactivity(mean=2.5)withina30dayperiod,andmarriedpersonsreportedthelowestnumberofdaysofinactivity(mean=1.4).Table1 Weightedmeansorpercentagesbymaritalstatus:nationalhealthandnutritionexaminationsurveys,2001–2006.Table2showstheresultsofthemultivariateregression,whichtestswhethertheeconomicbenefitsofmarriagemediatetherelationshipbetweenmaritalstatusanddaysofinactivityduetopoorhealth.Thefirstmodel,withadjustmentsfordemographicandbehavioralfactors,indicatedthatdivorced/separated( R R = 1 . 2 7 ),nevermarried( R R = 1 . 3 3 ),andcohabiting( R R = 1 . 4 7 )maritalstatuseshadsignificantlymoredaysofinactivitycomparedtomarriedpersons.Widowedstatuswasnotstatisticallysignificantindicatingthatmarriedpersonsandwidowedpersonshavesimilardaysofinactivitynetofcontributingfactors.Thesecondmodeladdedadjustmentsforaccesstohealthcare,whichisoneofthebenefitsofmarriage.However,themaineffectforhealthinsurancewasnotastatisticallysignificant,andthecombinationofbothvariablesdidnotappeartoreducethesizeorsignificanceoftherelationshipbetweenmaritalstatusanddaysofinactivity.Thefinalmodeladdedincometopovertyratio,andthemaineffectofthisvariablewasstatisticallysignificant.Furthermore,theadditionofthisvariablereducedthesizeandeliminatedstatisticalsignificanceofthedifferencebetweendivorced/separatedandnevermarriedmaritalstatusescomparedtomarriedpersons.Themagnitudeofthedifferencebetweenmarriedandcohabitingstatuswasreducedinsize( R R = 1 . 2 4 ),butremainedmarginallystatisticallysignificantsuggestingthatcohabitingpersonsreportmoredaysofinactivityrelativetomarriedpersonsnetofcontributingfactorsincludingtheeconomicbenefitsofmarriage.Table2 Rateratiosfornumberofdaysofinactivityduetopoorphysicalormentalhealthfromzero-inflatednegativebinomialregression:NationalHealthandNutritionExaminationSurveys,2001–2006, 𝑁 = 1 3 , 6 7 8 .Thelastresearchquestionwaswhethertherelationshipbetweenmaritalstatusandpoorhealthwasconditionalontheeconomicbenefitsofmarriage.Therefore,interactioneffectsareshowninTable3formaritalstatus,incometopovertyratio,andhealthinsurance.Theinteractioneffectformaritalstatusandhealthinsurancewasnotstatisticallysignificant.However,theinteractioneffectformaritalstatusandincometopovertyratiowasstatisticallysignificantsuggestingthattherelationshipbetweenmaritalstatusandinactivityisconditionalonsharedincome.Specifically,comparedtounmarried,verypoorpersons,marriedpersonsregardlessofincomeandunmarriedpersonswithhigherincomesreportedfewerdaysofinactivity.Table3 Rateratiosforinteractioneffectsfromzero-inflatednegativebinomialregression:NationalHealthandNutritionExaminationSurveys,2001–2006, 𝑁 = 1 3 , 6 7 8 .4.DiscussionTheprimaryfindingofthisstudywasthatpooledincomemediatedandmoderatedtheassociationbetweenmarriageanddaysofinactivityduetopoorhealth.Evenwhenfindingsindicatedthatothermaritalstatuseshadequivalentriskofpoorhealthasmarriedpersons,particularlyafteradjustingforrelevantfactors,therewasnoindicationthatmarriedpersonshadahigherriskofpoorhealth,whichisconsistentwiththeliterature[5–9].Thevariationinsharedeconomicresourcesbymaritalstatusmayhelpmarriedpersonsweatherturbulenteconomictimesbetterthanunmarriedpersons.Whenyoulivewithapartner,youbenefitfromaneconomyofscalebysharingthesamehousehold.Forexample,bylivinginthesamehousehold,notonlydocouplesshareinthecostofthelivingspacebutalsosharemanyhouseholdproducts.Thesesavingsfromsharedlivingquartersdifferentiallybenefitmarriedandcohabitingpersonsrelativetowidowed,divorced/separatedandnevermarriedpersons.Further,sharedresourceshelpdiversifyeconomicrisk.Ifonebecomesunemployed,thenmarriedpersonsmayhaveanotherpersons’assetsandincometosurviveuntilnewemploymentisfound,whereaspersonsthatarewidowed,divorced/separated,andsingledonothaveanotherincometorelyonduringunemploymentorunderemployment.Anotherexampleofthebenefitofsharedeconomicresourcesistheabilityofmarriedandpotentiallycohabitingpersonstoadvancetheireconomicpositions.Forexample,goingtoschoolfulltimetogetadegreethatwouldenableonetoadvancetheircareermayonlybepossiblebyreducinghoursatworkorquittingone’sjob.Personsthataresharingahouseholdandincomemaybeinabetterfinancialpositiontoenableonepartnertopursueadegreewhiletheotherpartnersuppliesincomeandpotentiallyhealthinsurance.However,onedistinguishingfactorbetweenbeingmarriedandcohabitingisthatpartnersmaynotcompletelyshareeconomicresources.Cohabitingpartnersareunlikelytosharehealthinsuranceplans,dependingonlocaloremployerrules.Also,cohabitingpartnersmaybelesslikelythanmarriedpartnerstohaveajointbankaccount,orjointinvestments,sharehealthinsurance,ornamethepartnerasthebeneficiaryoffinancialassetssuchaslifeinsuranceandretirementaccounts[16].Thismayinpartexplainthefindingthatcohabitersreportedmoredaysofinactivityevenafteradjustmentsforthebenefitsofmarriage.Anotherfindingthatshouldbenotedwasthatwidowedpersonsdidnotreportsignificantlymoredaysofinactivitythanmarriedpersons.Thisfindingwasrelatedtoageandsexadjustment,bothofwhichwerebothstronglyassociatedwithwidowedstatus.Forexample,thedescriptivetableindicatedthat76%ofthewidowedwere65yearsandolder,andthat82%ofthewidowedwerefemale.Otherresearchhasdemonstratedasubstantialgenderdifferenceinhealthoutcomeswithinwidowedstatus,evenafteraccountingforage[20].4.1.LimitationsItshouldbenotedthathouseholdincomeisanimperfectmeasureofhousehold’spooledeconomicresourcesfortworeasons.First,variationinannualincomeovertimewilltypicallybelargerthanvariationinhouseholdnetworth.However,dataonhouseholdnetwealthwerenotcollectedbyNHANES.Second,householdmemberincomesmaynotbeequallydistributedtoeachmember,affectingindividualbenefitsfrompoolinghouseholdincome.Alackofincomepoolingwithinhouseholdswoulddecreasethesignificanceofhouseholdincomeinimprovinghealthstatus.Anotherlimitationofexaminingincomeandhealthisthattherelationshipisreciprocal,andonlyprospectivedatacanunravelwhetherincomeisresponsibleforimprovinghealthorwhetherpoorhealthislimitingincome[21].However,annualhouseholdincomewilltendtobepositivelycorrelatedwithnetwealthand,thus,useofhouseholdincomeintheanalysesisnotexpectedtobeasubstantiallimitation.Ourstudyresultsadjustedincomerelativetopoverty,andthismeasurewasahighlysignificantpredictordespitethislimitation.Socialsupportisanimportantmechanismintherelationshipbetweenmaritalstatusandhealththatcanbufferstress[3,4].Notonlydopersonsgainintimatesocialsupportfromthemaritalorcohabitingpartner,butone’ssocialnetworkalsogrowsasoneinheritsthepartner’sfamilyandfriends.Ofcourse,personsthatarenevermarrieddonothavethissocialbenefit,butalsopersonsthatdivorce/separateloseatleastsomeofthesocialnetworkgains,andwidowedanddivorcedpersonsspecificallylosethesupportofthespouse[20].Itisexpectedthataccountingforthedifferentiallevelsofsocialsupport,particularlyperceivedrelationshipquality,acrossmaritalstatusthatmayhelptobufferstresswouldfurtherreduceorpotentiallyeliminatetheassociationbetweenmaritalstatusandhealth.Wewereabletoadjustforsocialsupportamongpersons65yearsandolder(seetheappendixforresults),butfuturestudiesmayhavebetteraccesstomeasuresofsocialsupportacrossawideragerange,particularlyyoungerages.5.ConclusionThisstudyexploredwhethersharedeconomicresourcesofmarriagemediateandmoderatethepurportedhealthbenefitsofmarriage.Thefindingssuggestedthatnotonlyincomerelativetopovertynotonlymediatestheassociationbetweenmarriageanddaysofinactivitybutthattheassociationmayalsobeconditionalonthelevelofincome.Personsthatwerepoorandunmarriedreportedthemostdaysofinactivity.Thefindingssupportthetheorythatmarriagemayconferhealthprotectivebenefitsinpartthroughsharedeconomicresourcesrelativetoothermaritalstatuses.AppendixA.TechnicalAppendix 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