Living arrangements, health and well-being: A European Perspective UPTAP Meeting 21 st March 2007 Harriet Young and Emily Grundy London School of Hygiene and Tropical Medicine

Background  Demographic changes over the last century have led to older age structures throughout Europe.  Declines in the proportions of older people living with children and increases in proportions living alone.

Background What are the implications for health and well-being ? Research to date: Those living with spouse are the most healthy Those living with spouse are the most healthy Contradictory evidence for those not living with spouse: more healthy living with other relatives or living alone ? Contradictory evidence for those not living with spouse: more healthy living with other relatives or living alone ? Michael et al (2001), Grundy (2001)Michael et al (2001), Grundy (2001) Selection effects Selection effects Effects vary according to cultural and socio- economic context Effects vary according to cultural and socio- economic context

Research Objectives  1 & 2: Analyse associations between living arrangements, health and well-being among older people Across Europe, examining differences between groups of countries Across Europe, examining differences between groups of countries In more detail for England / England and Wales In more detail for England / England and Wales  3: Examine pathways to living arrangements and the effect that allowing for these has on health in England and Wales

Variables  Different outcome variables Scales of happiness scale, satisfaction with life & loneliness Scales of happiness scale, satisfaction with life & loneliness Psychological morbidity – CES-D depression scale Psychological morbidity – CES-D depression scale Self-rated health & limiting long term illness Self-rated health & limiting long term illness Indicators of functional capacity Indicators of functional capacity Mortality Mortality  Explanatory variable Living arrangements: Living arrangements: spouse only,spouse only, spouse and other,spouse and other, Children or others only,Children or others only, AloneAlone

Dataset: European Social Survey (ESS)  Two cross-sectional rounds of data – 2002 and 2004  Using data from 19 countries  Sample size 18,131 people aged 60+

Country groupings NorthWestSouthEast SwedenNorwayFinlandDenmarkGermanyBelgiumUKAustriaNetherlandsPortugalGreeceSpainPolandSloveniaSlovakiaHungaryUkraineEstonia Czech Republic N=3621N=5867N=3857N=4786

Dataset: English Longitudinal Study of Ageing (ELSA)  Two waves of data in 2002 and 2004  Cross-sectional dataset of population aged 60+ in Wave One – 7146 people  Longitudinal dataset of population aged 60+ in Wave One and present at Wave Two – 5443 people

Dataset: Office for National Statistics Longitudinal Study (LS)  A record linkage study of population of England and Wales, with 4 census points linked in, plus census information on household members at each census.  Dataset of population aged 60+ at 2001 Census and present at all 4 census points: 80,937 people.  Dataset of population aged 60+ at 1991 Census and present : 91,155 people

Psychological health and well-being  Associations between living arrangements and…. ESS: Happiness and satisfaction with life scales (0-10): ordinal regression ESS: Happiness and satisfaction with life scales (0-10): ordinal regression ELSA: 8 point CES-Depression score (0-2 compared with 3+): logistic regression ELSA: 8 point CES-Depression score (0-2 compared with 3+): logistic regression ELSA: Loneliness scale (9 item scale from 4 questions): linear regression ELSA: Loneliness scale (9 item scale from 4 questions): linear regression

This model controlled for gender, age, smoking, wealth, housing tenure, contact with relatives, contact with friends, membership of social organisations and self-rated health status ELSA

This model controlled for gender, age, contact with relatives, contact with friends, membership of social organisations, health status at wave one, presence of depression at wave 1 ELSA

Adjusted odds ratios from ordinal regression of living arrangements on happiness compared with those living with a spouse only, 19 European Countries, ESS (lower OR =less happy) Men Odds Ratio Women Spouse only (ref group) Spouse and others Alone0.57***0.54*** With non-spouse others 0.56**0.90 ** P<0.01 *** P<0.001 Models also adjusted for region, age, income, education, feelings about income, social meetings and activities, current widowhood and presence of limiting long term illness. ESS

Table 3: Odds ratios from ordinal logistic regression of living arrangements & other factors on happiness for non-married women, 19 European countries ESS * * Model also controls for age, region, income, education, feelings about income, indicators of social contacts, whether currently widowed, & region for Europe- wide model ** p<0.01 *** p<0.001 Odds Ratio (lower OR= less happy) Living arrangements (living with non-spouse other vv alone) All countries 1.7*** Nordic1.2 West2.1*** South2.0** East1.4 ESS

Self rated health and mortality Associations between living arrangements and:  Self rated health using ELSA (binary variable: poor & fair vv excellent & v good & good health): logistic regression ELSA (binary variable: poor & fair vv excellent & v good & good health): logistic regression ONS LS (binary variable: good & fair health vv poor health): logistic regression ONS LS (binary variable: good & fair health vv poor health): logistic regression ESS (6 level variable): ordinal logistic regression ESS (6 level variable): ordinal logistic regression  ONS LS: death 2001 Census to end 2004: logistic regression

This model controlled for gender, age, smoking, wealth, housing tenure, contact with relatives, contact with friends, membership of social organisations and self-rated health status ELSA

Odds Ratios from logistic regression of poor self-rated health on living arrangement change 1991 and 2001 for people aged 60+. England and Wales, ONS LS. Odds ratio Living arrangement change (ref group: with spouse both points or moved to live with spouse) Alone both 0.93** Non-spouse other both 1.21*** To live alone 0.93** To live with non-spouse others 1.31*** To communal establishment 1.83*** Model also controlled for age, gender, tenure and car access score, region and limiting long term illness in Source: ONS Longitudinal Study, Authors analysis. ONS LS

Odds Ratios from logistic regression of poor self-rated health & death on living arrangement change 1991 and 2001 for people aged 60+. England and Wales, ONS LS. Self rated health 2001 Odds ratio Death Odds ratio Living arrangement change (ref group: with spouse both points or moved to live with spouse) Alone both 0.93**1.10** Non-spouse other both 0.21***1.28*** To live alone 0.93**1.16*** To live with non-spouse others 1.31***1.44*** To communal establishment 1.83***5.69*** ONS LS Model also controlled for age, gender, tenure and car access score, region and limiting long term illness in Source: ONS Longitudinal Study, Authors analysis.

Self rated health and living arrangements: ESS data  No significant associations between self- rated health and living arrangements for all regions combined.  However, living alone was associated with poorer health than those living with a spouse for women in Northern countries and men in Western countries. ESS

Limitations  Comparability of variables between datasets  Proportion of population in institutions differs throughout Europe – exclusion of this group may have biased ESS results.  Longitudinal analysis: 10 yearly interval for change in living arrangements using ONS LS.

Conclusions  Clear association between living alone and higher levels of depression, loneliness and unhappiness (ESS & ELSA).  Contradictory findings on self-rated health.  Differing findings depending on health indicator used

The End Thank you