Marital status has frequently found to be associated with quality of life and well-being; but it is difficult to attribute causality. It is possible that a third variable, such as a less agreeable personality, confounds the relationship; sophisticated analyses have been performed in psychology and economics to examine this possibility.
3.7.1.1 Family characteristics: Evidence from cross-sectional studies
Studies have found an association between marital status and quality of life (Netuveli et al., 2006; von dem Knesebeck et al., 2007; Ejechi, 2012). In the Irish Longitudinal
Study on Ageing, living with a spouse was associated with better CASP-19 quality of life compared to living alone or living with others (McGee et al., 2011). In a community dwelling sample from Taiwan, participants living alone had lower average quality of life scores than other participants (Wu et al., 2013). In ELSA, living with a partner was positively associated with quality of life for men but not for women (Zaninotto et al., 2009). Interestingly, an analysis of data from ELSA found that married people had substantially higher CASP-19 scores (around five points higher) than individuals with other marital statuses only when they reported receiving high levels of support from their spouse (Demakakos et al., 2010). Adjusting for aspects of social participation and social relationships also removed associations in studies using TILDA and ELSA data (Layte et al., 2013; Netuveli et al., 2006).
3.7.1.2 Family characteristics: Evidence from longitudinal studies
In a study of change in quality of life over four years using ELSA data, becoming widowed was associated with improved quality of life. This may be due to recovery from difficult circumstances preceding the bereavement but might also be due to controlling for a range of other covariates such as changes in depression (Webb et al., 2011). A prospective analysis with continental European SHARE data found that participants who entered a partnership were were less likely than those who left a partnership to experience a decline in CASP-12 quality of life (Wahrendorf and Siegrist, 2010). A prospective analysis of data from ELSA found that neither losing a partner (through death, separation or divorce) nor gaining a partner was associated with any change to CASP-19 quality of life (Emmerson and Muriel, 2008). An analysis using three waves of ELSA found that recent widowhood was associated with lower average quality of life only among the group of individuals who displayed symptoms of depression (defined as non-resilient), a result which highlights variations in individual responses to widowhood (Demakakos et al., 2008). Studies with a sub-sample of the Boyd-Orr cohort suggested that individuals who maintained quality of life following such adversities had managed to draw upon resources such as close ongoing relationships or maintaining previous enjoyable social roles that provided continuity in the face of life changing events (Hildon et al., 2008).
3.7.1.3 Family characteristics: Evidence from life course studies
Family conflict or family fracture by the age of seven years was associated with lower CASP-12 (v2) quality of life in participants aged 50 years from the British National Child Development Study, as was divorce, separation or death of a spouse by age 33 years (Blane et al., 2012). In path analyses, much of the impact upon quality of life at age 50 years of family fracture or family conflict by age of seven seemed to be mediated by current depression.
In a small retrospective study using the British Boyd-Orr cohort, variations in quality of life by different life course relationship statuses were suggestive but not significant. This study examined differences by gender, finding that men who experienced relationship break-up or early widowhood had lower quality of life than those who were continuously
married (Wiggins et al., 2007). In contrast, it was continuously married women who were at a disadvantage compared to other groups of women. However, these differences, particularly for men, are mostly likely due to the lasting effects of the relationship trajectory on current circumstances, in this case current marital status.
In a large prospective study using the British Household Panel Survey, having had children at younger ages was related to lower quality of life among participants aged over 51 years, a relationship which was largely accounted for by pathways through current socio-economic and health disadvantages (Read and Grundy, 2011).
3.7.1.4 Family characteristics: Evidence from the broader subjective well- being literature
Marital status has been found to be one of the strongest correlates of happiness and well-being (Argyle, 1999). Research into changes in marital status have found that divorce or separation can have greater effects than widowhood (Argyle, 1999). It appears that the association between marriage and subjective well-being is causal. This is because, if the association between marriage and well-being were due to happier people marrying sooner, then, as people age, the average happiness of both marrying and never-married people should decline. However, this is not what happens (Myers, 1999). A recent review in economics concluded that stable and secure intimate relationships (whether marriage or cohabitation) are beneficial for subjective well-being and the dissolution of relationships tends to harm well-being (Dolan et al., 2008). Bringing up children has been found to be associated with improved life satisfaction but not with happiness (Dolan et al., 2008).
3.7.2
Social relationships
George (2010), in a recent review, states that the dimension of social relationships most strongly associated with subjective well-being in older people is perceived social support. She defines this as the “perception that high-quality emotional support and instrumental assistance are available if needed” (George, 2010). The nature of the support provided by social relationships can be sub-divided into two types: 1) functional measures of social support such as provision of confiding/emotional support, practical support or negative aspects of close relationships and 2) structural measures such as frequency of contacts, size of a person’s social network or marital status (Stringhini et al., 2012).
3.7.2.1 Social relationships: Evidence from cross-sectional studies
Studies have found that social relationships are important for quality of life, whether this is measured by relationships and contacts with family and friends (Hildon et al., 2010; Howel, 2012; Layte et al., 2013; Netuveli et al., 2006; Webb et al., 2011), loneliness (Layte et al., 2013), network size (Demakakos et al., 2010; Litwin and Stoeckel, 2013a; Wiggins et al., 2004; Zaninotto et al., 2009) or network quality (Litwin and Stoeckel, 2013a; Wiggins et al., 2004). Individuals who felt that they were not receiving positive support from their spouse, children, family, or friends reported lower quality of life (Zaninotto et al., 2009),
although this result could be vulnerable to individual differences affecting evaluations of both social support and quality of life.
Individuals who experienced social detachment (an index made up of people with at least three of: no (i) civic, (ii) social/recreational or (iii) cultural participation; (iv) no emotional support; (v) little contact with others, (vi) no holiday or day trip taken over last year) had lower CASP-19 quality of life scores in ELSA (Tomaszewski and Barnes, 2008).
3.7.2.2 Social relationships: Evidence from longitudinal studies
Improvements in the quality of relationships with family and friends were associated with an improvement in CASP-19 quality of life scores in a prospective study, although, as both measures are self-reported, it is not possible to be sure that a factor such as improved mood is contributing to evaluations of both (Webb et al., 2011). Increased contact with friends was associated with an improvement in quality of life, but increased contact with family was associated with a deterioration in quality of life, perhaps because an increase in contact with family was a result of an increased need to receive or provide emotional or practical support.
3.7.2.3 Social relationships: Evidence from life course studies
Individuals who had experienced longer durations of social detachment (defined in sec- tion 3.7.2.1, above) reported lower quality of life, suggesting either a cumulative effect of social exclusion over time upon quality of life if the relationship with quality of life was causal, or that lengthier periods of social detachment signal individuals who are in greater difficulty (Tomaszewski and Barnes, 2008).
3.7.2.4 Social relationships: Evidence from the broader subjective well-being literature
Myers (1999) reports robust evidence for associations between social support and well- being, including results from quasi-experimental studies which suggest that higher levels of social support promote well-being. There is also evidence that changes in the quality of people’s relationships drive changes in their well-being (Stutzer and Frey, 2012). Socializing with friends and family has been found to be associated with higher well-being, including in later life, although this is not the case when the contact involves provision of care from others (Dolan et al., 2008).
3.7.3
Caring
In France, most care to ill or disabled adults is provided within their household by family members (CNSA, 2011, p. 22). Carers are a heterogeneous group, with a minority of carers providing most of the care (Hirst, 2003, 2005). Many carers do not self-identify as such, instead regarding caring as a normal part of their obligations to other family members (Department of Health, 1999, p. 11); therefore questions inquiring about caring
need to be carefully phrased. Trends over the last 30 years point to an intensification of care, in which more adults are providing longer episodes of more intensive care (Hirst, 2003; Marks et al., 2002).
3.7.3.1 Caring: Evidence from cross-sectional studies
Certain sorts of social relationships can negatively influence quality of life; in cross-sectional analyses in ELSA, participants coming up to the state pension age with caring responsi- bilities reported lower quality of life (Zaninotto et al., 2013), although no relationship was found for people over the state retirement age (McMunn et al., 2009). In cross-sectional analyses of SHARE data from continental Europe, caring for a person was associated with lower quality of life (Litwin and Stoeckel, 2013b; Wahrendorf et al., 2008), a relationship that was weakened but did not entirely disappear when the participant felt that their activity was appreciated (Wahrendorf et al., 2006).
Greater burden of care is associated with lower quality of life; there was little difference between the health of non-carers and carers providing under 20 hours a week of care in a survey of English data (Ross et al., 2008, p. 44). Providing help was associated with lower average CASP-19 quality of life scores in ELSA when participants were caring for a partner or spouse, a difference which was accounted for not by lack of satisfaction or appreciation, but rather by the burden of care, expressed in the number of hours of care provided and the sense of obligation carers had (Breeze and Stafford, 2010). Quality of life was similar for both carers and non-carers of a parent or parent-in-law, while participants who reported caring for a grandchild reported higher-than-average quality of life, particularly those who did not spend long hours caring and who did not feel obliged to care (Breeze and Stafford, 2010).
Characteristics of the individual being cared for were also associated with quality of life of the carer. Carers had lower quality of life when the recipients of care had problems with memory, but not when they had pain, difficulties with instrumental activities of daily living or more general cognitive abilities (Ross et al., 2008).
3.7.3.2 Caring: Evidence from longitudinal studies
In a prospective analysis of the second wave of SHARE data, caring for a person was not associated with quality of life in wave two (Siegrist and Wahrendorf, 2009). Beginning or stopping providing care for an adult was not associated with quality of life in a multivariate change analysis of two waves of the SHARE data (Wahrendorf and Siegrist, 2010), although this study included as carers individuals declaring that they provided any care to a sick or disabled adult during the last four weeks, meaning that individuals providing low levels of care were included.
3.7.3.3 Caring: Evidence from the broader subjective well-being literature
A substantial literature, briefly reviewed by Hirst (2005), demonstrates the negative impact of providing informal care on mental and physical health, and that transitions into and
out of care have been associated with changes in carer distress. While the act of helping others might have potentially beneficial impacts (Department of Health, 1999; Marks et al., 2002), the studies that exist indicate that informal caring tends to be associated with poorer well-being, particularly when more intensive care is provided and when the recipient of care is close family (Dolan et al., 2008; Hirst, 2003; OECD, 2011b).
Transitions into caring have been associated with declines in a range of well-being measures (Hirst, 2005; Marks et al., 2002; Pinquart and Sörensen, 2003). Figure 3.2 shows that the decline in mental health associated with gaining informal caring responsibilities is visible only in women who were providing 20 hours or more care per week (similar but less pronounced trends were reported for men) (Hirst, 2005). This result highlights the importance of differentiating the care population, in this case by gender and the intensity of caring; other studies have demonstrated the importance of differentiating carers by factors such as the type of chronic illness and the carer’s relationship to the recipient of care (Marks et al., 2002; Pinquart and Sörensen, 2003; Schoenmakers et al., 2010; van Groenou et al., 2013).
Figure 3.2 also displays higher distress among women who will subsequently provide high levels of care in the year before they actually begin caring. Several explanations are possible, but one is that individuals are already providing some level of emotional or other support to somebody showing early signs of frailty or impairment (Hirst, 2005).
Transitions out of caring have also been associated with poorer well-being, perhaps because this corresponds to the life event of a close family member entering an institution or passing away (Dolan et al., 2008; Hirst, 2005).
Figure 3.2: Prevalence of psychological distress before (c0) and during care episodes (c1–c6) by hours caring per week in the British Household Panel Survey
F F F F F F F KRXUVRUPRUH OHVVWKDQKRXUV
Women only. The vertical axis is the proportion of women reporting high distress scores. The horizontal axis indicates the years of caregiving provided (e.g., c2 means the second successive year of caring). Source: Hirst, M. (2005) Carer distress: A prospective, population-based study. Social Science & Medicine, 61(3), 697–708. With kind permission of Elsevier.
3.7.4
Social participation
A number of studies have examined the relationship between social participation, commonly participation in religious, community activities or in volunteering, and quality of life. However, a particular difficulty with studies examining the associations between social participation and subjective well-being is that it is extremely difficult to assign causality, even in longitudinal studies. It is most likely that any relationships are bi-directional, as people with poorer quality of life for other reasons, such as health difficulties or caring responsibilities, may choose to reduce their levels of participation and that participation in pleasant and sociable activities may contribute to well-being.
3.7.4.1 Social participation: Evidence from cross-sectional studies
A recent Irish study found that social participation is an important factor explaining variation in CASP-19 quality of life (Layte et al., 2013). Cross-sectional associations have been repeatedly found between social participation and quality of life, whether this concerns leisure and social activities (von dem Knesebeck et al., 2007; Wahrendorf and Siegrist, 2010), current or past membership of civil society organizations (Timonen et al., 2011; Blane et al., 2012), religious activities (Levin, 2013) or volunteering (Timonen et al., 2011; Wahrendorf and Siegrist, 2010).
3.7.4.2 Social participation: Evidence from longitudinal studies
It is likely that people with a positive outlook on life will tend to report both higher quality of life and more reciprocal interactions with others. Controlling for baseline quality of life in a prospective change analysis will deal with this confounder, if it is a permanent characteristic of individuals. In such prospective studies using the SHARE or ELSA surveys, and which controlled for baseline quality of life, volunteering was associated with higher quality of life, but only among those who reported reciprocity in the interaction (Siegrist and Wahrendorf, 2009; Nazroo and Matthews, 2012) or only among those who were retired (Potočnik and Sonnentag, 2013). Nazroo and Matthews (2012) additionally found that higher frequencies of volunteering and participation in a wider range of activities were associated with higher quality of life. People volunteering in three or more activities reported four-point higher CASP-19 quality of life scores than non-volunteers.
A prospective study with ELSA found that dropping organizational membership was associated with a two-point reduction in CASP-19 scores (Gjonça et al., 2010). Similarly, a prospective survey using the SHARE study found that older people who took up or maintained voluntary activities had a lower chance of experiencing a decline in CASP-12 quality of life (Wahrendorf and Siegrist, 2010). These results were robust for controlling for functional limitation, socio-economic position and living with a partner, all factors which might affect both quality of life and volunteering.
3.7.4.3 Social participation: Evidence from the broader subjective well-being literature
A recent review of the literature in psychology, sociology and gerontology concluded that both religious participation and volunteering seemed to promote subjective well- being (George, 2010) although another review voiced caution concerning the evidence for volunteering (Dolan et al., 2008). It is likely that one of ways in which participating in religious and voluntary activities increases happiness is through the social support and socializing that occurs (Argyle, 1999; Stutzer and Frey, 2012). However, there is evidence that performing volunteering work is rewarding in itself (Stutzer and Frey, 2012).
3.7.5
Neighbourhood
3.7.5.1 Neighbourhood: Evidence from cross-sectional studies
Cross-sectional associations have been found between quality of life and neighbourhood quality (Netuveli et al., 2006; Wiggins et al., 2004). In a cross-sectional study of ELSA participants, higher CASP-19 quality of life was associated with higher quality of the neighbourhood measured with a nine-item scale including elements such as presence of vandalism, a sense of belonging, and participants’ perceptions of trust and support (Netuveli et al., 2006). Again, in the ELSA survey, difficulty in accessing services and amenities such as a bank, local shops or opticians was associated with lower quality of life (Ross et al., 2008, p. 46); quality of life was even lower if individuals struggled to access multiple services (Demakakos et al., 2010). Higher quality of life was associated with greater attachment to the local area and lower area deprivation measured with the index of multiple deprivation (Gilleard et al., 2007). Having high compared to low fear of crime was associated with CASP-19 quality of life scores that were lower by two points (Stafford et al., 2007) in a study using data from the occupational Whitehall II cohort.
3.7.5.2 Neighbourhood: Evidence from longitudinal studies
In a prospective analysis with English data, higher initial neighbourhood quality and improvements in the perceived quality of the neighbourhood were associated with improved quality of life (Webb et al., 2011). An intervention study of individuals aged over 65 years living in British urban neighbourhoods found cross-sectional associations between quality of life and neighbourhood characteristics such as: barriers and nuisance in local open space and neighbourhood; ease of getting out and about; and good paths and cycleways (Thompson et al., 2012). Residential street improvements were not associated with improved quality of life at the standard 95% level of statistical significance, but this may be a consequence of the small sample size (36 people) limiting power. A cross-sectional study of extra care housing schemes for older people found associations between quality of life and elements of the building design such as security and accessibility (Orrell et al., 2013).
3.7.5.3 Neighbourhood: Evidence from the broader subjective well-being literature
Studies have indicated that living in a deprived or unsafe area may worsen life satisfaction, but these studies may have been vulnerable to confounding by socio-economic posi- tion (Dolan et al., 2008). A recent study which controlled for a range of socio-demographic characteristics reported the importance of neighbourhood belonging for greater sense of mastery, an aspect of mental well-being (Nyqvist et al., 2013). Quality of life ratings in older people in a British survey were associated with characteristics of the neighbourhood such as: quality of local facilities, perceived safety of area and degree of neighbourliness of the area (Bowling et al., 2002).
3.8
Socio-economic position
A person’s socio-economic position describes their location within the economic and social