1. 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

2. 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.

3. 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

4. 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

5. 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

6. 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+

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

8. 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

9. 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 1971-1991: 91,155 people

10. 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

11. 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

12. 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

13. Adjusted odds ratios from ordinal regression of living arrangements on happiness compared with those living with a spouse only, 19 European Countries, ESS 20002-4 (lower OR =less happy) Men Odds Ratio Women Spouse only (ref group) 1.01.0 Spouse and others 0.960.98 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

14. Table 3: Odds ratios from ordinal logistic regression of living arrangements & other factors on happiness for non-married women, 19 European countries ESS 2002-4* * 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

15. 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

16. 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

17. 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 1991-2001 (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 1991. Source: ONS Longitudinal Study, Authors analysis. ONS LS

18. 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 2001-2004 Odds ratio Living arrangement change 1991-2001 (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 1991. Source: ONS Longitudinal Study, Authors analysis.

19. 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

20. 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.

21. 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

22. The End Thank you Harriet.Young@lshtm.ac.uk Emily.Grundy@lshtm.ac.uk