Elsevier

Social Science & Medicine

Volume 57, Issue 10, November 2003, Pages 1901-1912
Social Science & Medicine

Partner's and own education: does who you live with matter for self-assessed health, smoking and excessive alcohol consumption?

https://doi.org/10.1016/S0277-9536(03)00055-8Get rights and content

Abstract

This study analyses the importance of partner status and partner's education, adjusted for own education, on self-assessed health, smoking and excessive alcohol consumption. The relationship between socio-economic factors and health-related outcomes is traditionally studied from an individual perspective. Recently, applying social–ecological models that include socio-economic factors on various social levels is becoming popular. We argue that partners are an important influence on individual health and health-related behaviour at the household level. Therefore, we include partners in the analysis of educational health inequalities. Using data of almost 40,000 individuals (with almost 15,000 Dutch cohabiting couples), aged 25–74 years, who participated in the Netherlands Health Interview Survey between 1989 and 1996, we test hypotheses on the importance of own and partner's education. We apply advanced logistic regression models that are especially suitable for studying the relative influence of partners’ education. Controlled for own education, partner's education is significantly associated with self-assessed health and smoking, for men and women. Accounting for both partners’ education the social gradient in self-assessed health and smoking is steeper than based on own or partner's education alone. The social gradient in health is underestimated by not considering partner's education, especially for women.

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

References (63)

  • L.F Berkman et al.

    Social epidemiology

    (2000)
  • W Bernasco et al.

    Coupled careersEffects of spouse's resources on occupational attainment in the Netherlands

    European Sociological Review

    (1998)
  • H Bosma et al.

    Educational level of spouses and risk of mortalityThe WHO Kaunas–Rotterdam Intervention Study (KRIS)

    International Journal of Epidemiology

    (1995)
  • P Bourdieu

    DistinctionA social critique of the judgement of taste

    (1984)
  • A.E Cavelaars et al.

    Educational differences in smokingInternational comparison

    British Medical Journal

    (2000)
  • Central Bureau voor de Statistiek (Statitics Netherlands), (1996). Netherlands Health Interview Survey 1981–1995....
  • D.R Cox

    Role of models in statistical analysis

    Statistical Science

    (1990)
  • R.M Crum et al.

    Level of education and alcohol abuse and dependence in adulthoodA further inquiry

    American Journal of Public Health

    (1993)
  • N.D De Graaf et al.

    Husbands’ and wives’ voting behaviour in BritainClass-dependent mutual influence of spouses

    Acta Sociologica

    (1992)
  • N.D De Graaf et al.

    Class mobility and political preferencesIndividual and contextual effects

    American Journal of Sociology

    (1995)
  • J Eckenrode

    The mobilization of social supportsSome individual constraints

    American Journal of Psychology

    (1983)
  • A.M Epstein et al.

    Using proxies to evaluate quality of life. Can they provide valid information about patients' health status and satisfaction with medical care?

    Medical Care

    (1989)
  • R Erikson

    Social class of men, women and families

    Sociology

    (1984)
  • K.F Ferraro et al.

    Utility of health data from social surveysIs there a gold standard for measuring morbidity?

    American Sociological Review

    (2000)
  • A.J Fox et al.

    Social class mortality differentialsArtifact, selection or life circumstances?

    Journal of Epidemiology and Community Health

    (1985)
  • Graham, H. (Ed.) (2000). Understanding health inequalities. Buckingham: Open University...
  • H Graham et al.

    Influences on women's smoking statusThe contribution of socio-economic status in adolescence and adulthood

    European Journal of Public Health

    (1999)
  • J.S House

    Understanding social factors and inequalities in health20th century progress and 21st century prospects

    Journal of Health and Social Behavior

    (2002)
  • H.H Hyman et al.

    The enduring effects of education

    (1976)
  • E.L Idler et al.

    Self-rated health and mortalityA review of twenty-seven community studies

    Journal of Health and Social Behaviour

    (1997)
  • Joung, I. M. A. (1996). Marital status and health. Descriptive and explanatory studies. Erasmus University Rotterdam...
  • Cited by (0)

    View full text