Premature mortality among lone fathers and childless men
Introduction
Health inequalities among men have been found primarily to be associated with unemployment and occupational class. In health research, men have mainly been considered in terms of their occupational role as main breadwinner, whereas women have usually been treated in terms of their family roles. In analyses of women's health, and its associations with family circumstances, there has been a stress on how family roles intersect with material circumstances and participation in paid employment (Arber, 1991). By contrast, in studies of inequalities in men's health, less attention has been paid to marital or parental functions—either as main variables or as additional roles relevant to the analysis of other structural variables. Studies have shown that marital and parental role characteristics are important factors for women. However, when occasionally examined in relation to men, such factors have failed to indicate health outcomes, and instead unemployment and kind of occupation have seemed to be important (Verbrugge, 1983; Arber, 1991; Hibbard & Pope, 1993).
Studies from a number of Western countries have shown that married people live longer than the unmarried, whether widowed, divorced or never-married (Gove, 1973; Berkman & Syme, 1979; Macintyre, 1992; Koskinen & Martelin, 1994). Studies of physical illness and psychological well-being give a broadly similar picture (Verbrugge, 1978; Arber, 1991; Wyke & Ford, 1992; Hope, Rodgers, & Power, 1999). There have been suggestions that the effects of divorce on health and survival are less pronounced for women than men (Macintyre (1972), Gove (1973)), but it remains unclear whether there are differences between the genders in these respects. Women have been considered to have stronger social ties to friends and relatives than men (and should therefore manage a divorce better), whereas men have been regarded as being more dependent on marriage for their social networks. Women are likely to be more reliant on marriage for their personal finances (Macintyre, 1992). However, it has been suggested that women provide more health benefits to their spouses than do men, with the result that a divorce might have more detrimental consequences for men's health than for women's (Umberson, 1987).
In analyses of 16 developed countries, Hu and Goldman (1990) found that the excess mortality of unmarried men (relative to married men) consistently and greatly exceeded that of unmarried women (relative to married women). However, with regard to self-reported health, Verbrugge (1983) found that men and women benefit from marriage to a similar extent, and also that women are even more sensitive to marital status than men in terms of morbidity, disability and health-services use. A Swedish study found that widowhood was the only state where men had a clearly higher relative mortality ratio than women after a wide range of background variables were controlled for (Hemström, 1996).
The explanations offered for health disadvantages among single people broadly divide into those based on social causation and those related to health selection (Wyke & Ford, 1992). Social-causation theory suggests that marriage has a protective effect, and that the adverse health consequences of being single are due to a lack of material resources, indulgence in risky negative health behaviour, a greater vulnerability to stress, and lack of social support. For previously married people stress suffered during marital break-down also contributes. The health-selection argument is that emotionally unstable and/or physically handicapped persons have lower probabilities of getting married, staying married, and remarrying. Researchers tend to agree that observed differences between the partnered and the single are the product of a combination of selection and behavioural/environmental factors.
It was as early as in 1897 that Durkheim (1951) demonstrated the protective effect of having children in the household, but the parental role (especially of males) has been less extensively examined in relation to health and well-being (Benzeval, 1998). From their review of research conducted during the 1980s, Ross, Mirowsky, and Goldsteen (1990) concluded that having children at home has no effect on psychological well-being, but a small, albeit variable, effect on parents’ physical health (as measured by self-reported numbers of health problems, chronic problems, physical feelings of unease, days of restricted activity, and so on). A later review by Mastekaasa (2000) indicated the same conclusion, with the exception that mortality from suicide was found to be clearly lower among parents. Whereas Kotler and Wingard (1989) found that neither number of children nor presence of a child in the home affected mortality risk among men, Martikainen (1995) reported a clearly lower mortality rate for women with children below 16 regardless of whether they were married and/or in paid employment.
When interaction between marital and parental roles has been analysed, a number of studies point to poorer health and increased mortality among lone than partnered mothers (Kotler & Wingard, 1989; Martikainen, 1995; Benzeval, 1998; Burström, Diderichsen, Shouls, & Whitehead, 1999; Whitehead, Burström, & Diderichsen, 2000; Ringbäck Weitoft, Haglund, & Rosén, 2000). The few attempts made to examine the health among lone fathers, indicate that lone custodial fathers report poorer health than cohabiting fathers but nevertheless, they report better health than lone mothers (Popay & Jones, 1990; Benzeval, 1998). However, in comparison with men living without children, both single and married men over 40 with dependent children reported better health than those without children (Clark, Freeman, Kane, & Lewis, 1987).
This study focuses on male marital and parental roles and their relation to mortality. Lone fathers are of particular interest, especially non-custodial fathers. The situation of this subgroup is not easily captured by routine population-based statistics. This is because it is generally not possible to identify parents who are not recorded in registers alongside their children, which divorced fathers seldom are. Instead, they are merely classified as single, widowed or divorced. Through unique access to population-based registry data covering all known biological relations between children and parents in Sweden, and also the capacity individually to link to other data sources, it was possible to relate non-custodial fatherhood, and also other categories of male family situation, to later mortality outcome. Further, in multivariate analyses, the impacts of household resources and socioeconomic group affiliation were also considered. We controlled for possible health-selection effects by taking into account the previous inpatient history of the males in question.
Section snippets
Material and methods
This study was based on Swedish national registers containing extensive social, economic and health information. Using the unique personal identification number assigned to each Swedish resident it was possible to effect individual record linkage between different data sources and thereby relate the various members of any one household.
All men, aged 29–54 in 1990, registered in the Swedish Population and Housing censuses of both 1985 and 1990 were identified. We needed information from both of
Results
In total, we investigated 682,919 men in five groups, which varied in size according to family situation (see Table 1). These men made up 49% of all the males in the same age range recorded in the Swedish censuses of 1985 and 1990. The males who were not included consisted mainly of fathers of older children only (aged more than 17 in 1990)—a considerable group since men as old as 54 were encompassed by the study. We also excluded fathers only of children younger than 5 in 1990, those who had
Discussion
Our study of almost 700,000 men clearly demonstrates that lone fathers without custody of their young children, in particular, face a major elevated risk of premature mortality in comparison with cohabiting fathers. Closely followed by lone childless men, they are worst off with regard to all-cause mortality, and death from violence, injury, suicide or addiction. The age-adjusted relative risks give a picture of actual differences between groups in society, and some risk increases are of a
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