Partner's and own education: does who you live with matter for self-assessed health, smoking and excessive alcohol consumption?
Introduction
The social gradient in self-assessed health and health-related behaviour, such as smoking and alcohol consumption, on the individual level is nowadays well established (Mackenbach et al., 1997; Pappas, Queen, Hadden, & Fisher, 1993; Marmot & Wilkinson, 1999). Education is one of the major dimensions of the social gradient in health. Lower educated people are less healthy, smoke more often and consume alcohol more excessively than their higher educated counterparts (Cavelaars et al., 2000; Droomers, Schrijvers, Stronks, Van de Mheen, & Mackenbach, 1999; Crum, Helzer, & Anthony, 1993; Lynch, Kaplan, & Salonen, 1997). Whereas there is little need for further empirical proof of these differences, there still is much to be learned in understanding the social determinants of health and health-related behaviour, especially with regard to the role of the social context individuals live in (House, 2002; Marmot et al., 1997).
Questions and theories about the social gradient in health outcomes are usually formulated on the level of individuals and empirical research employs isolated individuals as units of analysis. The dominance of this individualistic approach has been noted before. Regarding health behaviour Rice and colleagues (1998, p. 971) for instance wrote: “the majority of research … has tended to concentrate on the role of the consumer as the basic unit of analysis assuming that behaviour or lifestyle is an independent and self-determining function of individuals without regard for the environment which they inhabit”. The same holds true for other research on health and health-related outcomes. By and large, research has ignored that lifestyles are not purely individual phenomena. Ross and Huber (1985) rightly stated “it is in the household that larger social and economic order impinges on individuals, exposing them to varying degrees of hardship, frustration, and struggle”. Recently, it is acknowledged that health-related outcomes can better be understood by applying social–ecological models that include socio-economic factors over the life course and on various social levels (Berkman & Kawachi, 2000; Robert & House, 2000; Zimmer, Hermalin, & Lin, 2002). For instance, neighbourhood level socio-economic status (SES) affects health outcomes independent of own SES (Pickett & Pearl, 2001). It is likely that socio-economic factors on other levels, such as the household level, are important as well. We argue that partner's SES is such an important factor.
Relatively little research has explicitly studied the importance of partner's SES with regard to health and health behaviour. Previous research has shown that it matters for one's health whether you live with someone (Joung, 1996; Macintyre, 1992; Ross, Mirowsky, & Goldsteen, 1990). However, the question whether it matters who you live with is largely left unanswered. Earlier research on partner's SES and mortality (Bosma, Appels, Sturmans, Grabauskas, & Gostautas, 1995; Suarez & Barret-Conner, 1984; Martikainen, 1995) and health and longstanding illness (Arber, 1997) points at the relevance of partner's socio-economic characteristics for own health-related outcomes. Indirect empirical support for the importance of spouses for health and health behaviour can also be found in the literature on SES indicators (e.g., by using household equivalent income, or the highest occupational status in the household) (Krieger, Williams, & Moss, 1997; Vågerö, 2000), social support (Seeman 2000) and smoking cessation (Monden, De Graaf, & Kraaykamp, 2003; Osler & Prescott, 1998). No previous studies however, investigated explicitly to what extent partner's SES influences self-assessed health, smoking and excessive alcohol consumption independent of own SES.
In this paper, we will first simultaneously address the questions whether it matters if you live with someone and who you live with. Then we will focus on people who cohabit and study whether it matters who you live with, in more detail than done in previous studies. We use education as an indicator of SES. Education is a central stratifying characteristic in modern societies (Berkel van Schaik & Tax, 1990). Moreover, educational attainment is more than a financial or economic resource. The school system affects and socializes everyone. Especially, higher education is associated with a healthier lifestyle, health knowledge and less risk behaviour. Thus, we will answer the following questions: (a) Is there an effect of partner's education on self-assessed health, excessive smoking and alcohol consumption after controlling for own education, and if so to what extent? (b) Are the independent effects of partner's education equal for men and for women? and (c) Are health-related outcomes more associated with the highest educational level than the lowest educational level in a household?
Section snippets
Why partner's education matters for health and health behaviour
Previous research has shown that having a partner has positive effects on one's health and health behaviour, especially for men (Joung, 1996; Macintyre, 1992; Ross, Mirowsky, & Goldsteen, 1990). Explanations are sought in (improved) social support, attachment and economic well-being for married people (Umberson, 1992). In this study, we need to answer the question why partner's education matters for health and health behaviour. The explanations are rather similar to those that explain
Data
We employ data from nine editions (1989–1996) of the annual Netherlands’ Health Interview Survey (NethHIS) from Statistics Netherlands (Centraal Bureau voor de Statistiek, 1996). The NethHIS is a combined face-to-face interview and self-administrated questionnaire among about 8000 respondents (per year) in randomly sampled households and is representative for the Dutch non-institutionalised population. The survey design is cross-sectional. Up to four members in each household were interviewed,
Results
Table 1 shows that in about 57 per cent of the couples partners have mixed educational levels. Although a majority lives with a partner of a different educational level, there is a strong tendency for homogamy (a tendency to live with a partner who has an (almost) equivalent educational level).
In Table 2, we present the percentage of respondents reporting poor health, current smoking and excessive alcohol consumption for all combinations of own and partner's education to illustrate our research
Discussion and conclusion
In this study, we showed that partner's education is significantly associated with reporting less than good health and smoking, even after controlling for one's own education. Having a partner with low educational attainment increases health risks for both men and women, whereas having a higher educated partner decreases them. The effect of partner's education is comparable in size to that of having or not having a partner (partner status). There was no significant association of partner's
Acknowledgements
Preparation of this paper was supported by a grant from the Netherlands Organization for Scientific Research (NWO grant number 425-12-011). Frank van Lenthe is supported by a grant from the Netherlands Organization for Scientific Research (NWO grant number 904-66-104). The manuscript was partly written during a stay at the Department of Public Health at the Erasmus Medical Center Rotterdam. We thank Carola Schrijvers (formerly Erasmus Medical Center Rotterdam) and two anonymous reviewers for
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