Galinsky, A.M., & Waite, L.J. (2013). Sexual activity and psychological health as mediators of the relationship between physical health and marital quality. Journals of Gerontology, Series B:
Psychological Sciences and Social Sciences, 69(3), 482–492, doi:10.1093/geronb/gbt165. Advance Access publication January 27, 2014
Sexual Activity and Psychological Health As Mediators
of the Relationship Between Physical Health and Marital
Quality
Adena M. Galinsky1 and Linda J. Waite2
1
Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
2
Department of Sociology, University of Chicago, Illinois.
Objectives. The pathways linking spousal health to marital quality in later life have been little examined at the population level. We develop a conceptual model that links married older adults’ physical health and that of their spouse to positive and negative dimensions of marital quality via psychological well-being of both partners and their sexual activity.
Methods. We use data from 1,464 older adults in 732 marital dyads in the 2010–2011 wave of the National Social
Life Health and Aging Project.
Results. We find that own fair or poor physical health is linked to lower positive and higher negative marital quality, spouse’s health to positive quality, and that own and spouse’s mental health and more frequent sex are associated
with higher positive and lower negative marital quality. Further, we find that (a) sexual activity mediates the association
between own and partner’s physical health and positive marital quality, (b) own mental health mediates the association
between one’s own physical health and both positive and negative marital quality, and (c) partner’s mental health mediates the associations of spouse’s physical health with positive marital quality. These results are robust to alternative
specifications of the model.
Discussion. The results suggest ways to protect marital quality among older adults who are struggling with physical
illness in themselves or their partners.
Key Words: Aging—Marital quality—Marriage—Psychological health—Sexuality.
M
arried people show better health and lower mortality risk than the unmarried (Waite & Gallagher,
2000), but the benefits depend on the quality of the relationship, with poor quality relationships no better and perhaps
worse than no relationship (Umberson, Williams, Powers,
Liu, & Needham, 2006; Williams, 2003). Marital quality
is important across the life span but seems to be particularly important in later life as health tends to decline and the
effects of adversity accumulate (Carstensen, 1992; Henry,
Berg, Smith, & Florsheim, 2007; Umberson et al., 2006).
Marital adversity has been found to accelerate the decline in
physical and mental health with age and to increase the risk
of dying (Birditt & Antonucci, 2008; Coyne et al., 2001;
Hibbard & Pope, 1993; Waite, Luo, & Lewin, 2009). At the
same time, poor health can act as a stressor in the marriage,
leading to declines in marital quality (Booth & Johnson,
1994; Wickrama, Lorenz, Conger, & Elder, 1997).
Most of the research examining the link between physical health and marital quality has investigated how negative
interactions in marriage lead to declines in physical health
(Choi & Marks, 2008; Kiecolt-Glaser & Newton, 2001;
Uchino, Cacioppo, & Kiecolt-Glaser, 1996), with larger
effects at older ages (Umberson et al., 2006). Conversely,
high-quality marriages can help individuals to cope with
482
stressors and thereby maintain good physical health
(Ditzen, Hoppmann, & Klumb, 2008; Warner & KelleyMoore, 2012). However, the causal mechanisms connecting
martial quality and physical health operate in both directions. Indeed, among adults age less than 55, decrements
in health have been associated with deterioration in marital
happiness (Booth & Johnson, 1994; Wickrama et al., 1997).
Furthermore, although decrements in one’s own health have
been linked to modest decrements in marital quality, decrements in one’s partner’s health have been linked to quite
substantial declines in marital quality (Yorgason, Booth, &
Johnson, 2008). This process may be particularly important
in later life, when chronic illness becomes common (Yang,
2008).
The pathways linking poor health with marital quality in
later life have been little examined at the population level,
despite the importance of martial quality to individuals and
society. In this study, we examine one set of hypothesized
pathways. We argue that reduced engagement in sex with
one’s spouse, an enriching marital role, is associated with
worse marital relationship quality among those whose own
health is poor and those whose spouse has physical health
problems. Also, marital relationship quality is worse among
those with the psychological distress that often accompanies
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America.
All rights reserved. For permissions, please e-mail: [email protected].
Received June 12, 2012; Accepted December 8, 2013
Decision Editor: Merril Silverstein, PhD
Linking Health to Marital Quality
poor physical health in either spouse (Blazer, 2009; Bruce,
2000; Hagedoorn et al., 2001).
We develop a conceptual model that links physical
health, couple sexual activity, psychological well-being,
and marital quality. In our model, ongoing sexual activity mediates the association between physical health and
marital quality, as does psychological well-being. We conceptualize sexuality activity and psychological well-being
as mediators because especially at older ages the biggest
challenges to health come from chronic conditions, which
develop slowly over years. In contrast, poor mental health
as reflected, for example, in depression, may alter relatively
quickly in response to the current situation (Hughes &
Waite, 2009; Luo, Hawkley, Waite, & Caccioppo, 2012) as
can sexual behavior (Carpenter, Nathanson, & Kim, 2009).
Note that although we use the term marital quality for convenience, our analysis includes cohabitors as well. We test
a series of hypotheses based on this model using data on
both members of older adults in marital and cohabitational
dyads from the second wave of the nationally representative
National Social Life, Health and Aging Study.
Couple Sexual Activity As a Mediator of the Physical
Health–Marital Quality Association
Poor physical health may be associated with marital quality indirectly through spousal engagement in marital roles.
Poor physical health of one or one’s partner may affect
the roles partners take in a relationship and the interaction
between them in these roles. Hence, in this framework,
poor physical health affects marital happiness through
poor role performance and less positive (or more negative)
interactions.
Sexual Behavior
Health problems have been linked to problems carrying
out social and family roles (Northouse, Mood, Templin,
Mellon, & George, 2000). In particular, the health problems of one or one’s partner can interfere with either partner’s desire for or ability to engage in sexual relations
(DeLamater & Moorman, 2007; Karraker, DeLamater,
& Schwartz, 2011; Laumann, Das, & Waite, 2008). It is
important to note that the physical health problems of men
may be especially important regarding sexual relations
(Lindau et al., 2007). Physical health has been shown to
affect satisfaction with sex in a middle-aged population
(Carpenter et al., 2009). The link between health problems
and sexual activity may help explain the observed association between increased age and decreased engagement
in partnered sexual activity (Call, Sprecher, & Schwartz,
1995; Donnelly, 1993), which has been associated with
low marital satisfaction (Call et al., 1995; DeLamater &
Moorman, 2007; Donnelly, 1993). We hypothesize that
marital quality is lower among those with less engagement
in partnered sex.
483
Physical Health, Psychological Health, and Marital
Quality
The impact of poor physical health on psychological distress has been well documented among individuals and in
relationships. At the individual level, poor physical health,
as indicated by morbidity and frailty, increases the risk
for poor psychological health (Blazer, 2009; Bruce, 2000;
Ormel, Rijsdijk, Sullivan, van Sonderen, & Kempen, 2002).
At the relationship level, one’s partner’s poor physical
health, and his or her associated poor psychological health,
predicts poor psychological health in the physically healthy
partner (Hagedoorn et al., 2001).
According to the stress generation model, individuals
experiencing psychological distress cause stressful interactions with spouses, which leads to poor marital quality
(Davila, Bradbury, Cohan, & Tochluk, 1997; Hammen,
1991). Thus, in this framework, poor physical health leads
to stress, which increases the risk of poor psychological
health, which in turn increases chances of negative interactions and ultimately poor marital quality. Evidence for
this theory has been found among older adults at both the
individual and relationship levels. Psychological distress
has been shown to mediate the association between one’s
own and one’s spouse’s poor health and low marital happiness (Yorgason et al., 2008). Psychologically distressed
people have also been shown to have more negative spousal
interactions (Kramer, 1993; Rehman, Gollan, & Mortimer,
2008). Though the association between psychological ill
health and marital distress is found across the life span
(Gierveld, van Groenou, Hoogendoorn, & Smit, 2009;
Hawkins & Booth, 2005; Horwitz, White, & Howell-White,
1996; Ross, 1995), it seems to be stronger in older adults
(Whisman, 2007).
Thus, we hypothesize that psychological health—one’s
own and one’s partner’s—mediates the association between
physical health—one’s own and one’s partner’s—and marital quality.
Dimensions of marital quality.—Marital quality consists
of both positive and negative dimensions, which are distinct
constructs, not merely opposite poles of a single dimension
(Fincham, Beach, & Kemp-Fincham, 1997; Fincham &
Linfield, 1997). Most research to date has focused mainly
on the positive dimension, and on the physical and psychological health correlates of sexual engagement (Carpenter
et al., 2009) or, separately, of marital quality. For this reason, we know little about how physical health, psychological well-being, and the sexual engagement of the couple
operate together to predict both positive and negative marital quality in a population sample.
Conceptual Framework
Our conceptual model of the associations among physical health, partnered sexual behavior, psychological health,
484
Galinsky and Waite
and marital quality is shown in Figure 1. In this model, poor
physical health—either one’s own or one’s partner’s—is
linked to lower levels of both one’s own and one’s partner’s
psychological health and greater likelihood of low levels
of partnered sex. In turn, infrequent partnered sex and poor
psychological health are both associated with poor marital quality. Note that this model reflects one set of hypothesized relationships. We discuss alternative models later in
the article. We test the following hypotheses:
1.We hypothesize frequency of sex with one’s spouse
mediates the association between physical health—
one’s own and one’s partner’s—and marital quality.
2. We hypothesize that psychological health—one’s own
and one’s partner’s—mediates the association between
physical health—one’s own and one’s partner’s—and
marital quality.
Methods
Data and Sample
Data come from the second wave of the National Social
Life Health and Aging Project (NSHAP). The first wave of this
study, conducted in 2005 and 2006, surveyed a national probability sample of 3,005 community-dwelling men and women
ages 57–85 in the United States (O’Muircheartaigh, Eckman,
& Smith, 2009; Smith et al., 2009). The second wave, conducted in 2010 and 2011, reinterviewed as many respondents
from the first wave as could be contacted and were healthy
enough to participate (88.8%), as well as some Wave 1 nonrespondents, and the partners of the Wave 2 respondents, with
an unweighted response rate of 76.1% for referent respondents and 84.5% for partners, yielding an overall response rate
of 78.3%. In both waves, the bulk of the data were collected in
respondents’ homes during a 2-hr interview using a ComputerAssisted Personal Interview questionnaire. Additional data
were collected via a Leave-Behind Questionnaire (LBQ) that
the respondent completed and mailed in after the interviewer
had left. The return rate for the second wave LBQ was 87%.
Of the 2,261 original Wave 1 respondents, 1,961 (86.7%)
were randomly selected for the partner-interview sample.
Of these, 1,075 (54.8%) were married or living with a partner. Of such partners offered an interview, 905 (84.2%)
participated. Of the 161 original Wave 1 non-respondents
who participated in Wave 2, 90 were married or living with
a partner, and of those 90 partners, 48 (53%) participated.
The characteristics of the sample of participating partners
are discussed in O’Muircheartaigh, English, Pedlow, and
Kwok (in press), who point to very little bias. The two
same-sex couples in the sample were included. Thus, the
total number of respondents participating whose spouse or
cohabiting partner also participated was 1,910. The 76.6%
of those 1,910 respondents with complete data on relationship quality and explanatory variables comprise this study’s
sample (N = 1,464). Sample characteristics are shown in
Table 1.
Measures
Marital quality.—Our measures of marriage quality are
derived from nine items. First, respondents were asked
how close they felt their relationship with their spouse
was. Possible responses were not very close, somewhat
close, very close, or extremely close. Respondents were
also asked a set of four questions about their spouse. These
items asked how often the respondent could open up to
their spouse if they needed to talk about their worries, how
often the respondent could rely on their spouse for help if
they had a problem, how often the spouse made too many
demands on the respondent, and how often the spouse
criticized the respondent. Possible responses to each were
hardly ever (or never), rarely, some of the time, or often.
Respondents were also asked how happy their relationship
with their spouse was, with answer options anchored at
1 (very unhappy) and 7 (very happy) and how they liked
to spend their free time—doing things together with their
partner, doing some things together and some separately, or
doing things separately. The respondents were asked how
emotionally satisfying they found their relationship with
Figure 1. Conceptual model of the associations among physical health, sexual activity, psychological health, and marital quality.
485
Linking Health to Marital Quality
Table 1. Sample Characteristics % (N) or mean (SD)
Respondent’s physical health (%)
Excellent
Very good
Good
Poor/fair
Partner’s physical health (%)
Excellent
Very good
Good
Poor/fair
Respondent’s report of sexual
frequency in past year (mean, SD)a
Respondent’s mental health (mean, SD)b
Partner’s mental health (mean, SD)b
Respondent’s gender (male), %
Respondent’s age (%)
<65
65–74
75+
Respondent’s race/ethnicity (%)
White
Black
Other
Respondent’s education (%)
<High school
High school diploma or higher
Respondent’s comorbidity score (%)
0
1
2
3+
Partner’s comorbidity score
0
1
2
3+
Marital duration (%)
<10 years (0)
10–39 years
40+ years
Relationship type (%)
Married
Cohabiting
Table 2. Factor Loadings From the Factor Analysis of Marital
Quality Among Older Adults Factor structure
12.6 (172)
33.3 (461)
33.7 (498)
20.4 (333)
12.4 (173)
31.8 (456)
34.7 (485)
21.2 (350)
1.2 (1.8)
2.7 (1.5)
2.7 (1.5)
49.3 (726)
31.4 (343)
43.9 (674)
24.7 (447)
85.7 (1,131)
4.6 (133)
9.7 (200)
12.6 (233)
87.4 (1,231)
17.8 (223)
22.5 (321)
20.2 (322)
39.5 (598)
17.5 (223)
23.7 (335)
17.8 (288)
41 (618)
10.6 (118)
33.8 (463)
55.6 (883)
95.6 (1,415)
4.4 (49)
Notes. All percentages were weighted to account for differential
probabilities of selection and differential non-response.
a
Sexual frequency was coded as 3 = once a week or more, 2 = two to three
times per month, 1 = less than once per month, and 0 = never.
b
Mental health and partner’s mental health were coded as 4 = excellent,
3 = very good, 2 = good, and 1 = poor/fair.
their current or most recent sexual partner, which for married respondents was assumed to be their spouse. Answer
options were extremely, very, moderately, slightly, or not
at all. Finally, in the LBQ, they were asked how often their
partner got on their nerves. Possible responses were never
or hardly ever, rarely, sometimes, or often.
To obtain consistent response categories across all measures, we recoded these measures. The measures of relationship happiness, emotional satisfaction, and relationship
closeness were left skewed, so we collapsed the categories
1 (“Positive
Marital Quality”)
0.52
0.60
−0.01
0.02
−0.37
0.65
0.60
0.64
0.38
2 (“Negative
Marital Quality”)
Questionnaire items
0.03
0.01
0.74
0.58
0.34
−0.05
−0.06
0.06
−0.02
Rely on partner
Open up to partner
Partner criticizes
Partner makes too many demands
Partner gets on nerves
Happiness of marriage
Emotional satisfaction
Feel close to partner
Spend time with partner
Notes. Values in bold are greater than 0.30.
at the low-quality end of the scale. Relationship happiness
was recoded into 1 = Unhappy (1, 2, 3, 4), 2 = Happy (5,
6), and 3 = Very Happy (7) (r = .91 with original measure).
Emotional satisfaction was recoded 1 = not, slightly, or
moderately; 2 = very; and 3 = extremely (r = .95 with original measure). Relationship closeness was recoded 1 = not
very or somewhat, 2 = very, and 3 = extremely (r = .99 with
original measure). For consistency with the other items in
the scale, we collapsed the categories never/hardly ever and
rarely for the opening up, relying on, criticizing, demanding, and getting on nerves items.
To form our scales of negative and positive relationship
quality, we first conducted an exploratory factor analysis
with the principal component method, which suggested
that a two-factor solution would be best. Our main factor
analysis used the iterated principle factor method and an
oblique rotation because we expected that the factors would
be correlated (as they were, r = −.66). We refer to Factor
1 as Positive Marital Quality (alpha = 0.76) and Factor 2
as Negative Marital Quality (alpha = 0.63). The estimated
factor scores, which we calculated following Warner and
Kelley-Moore (2012), are the dependent variables in our
models (Floyd & Widaman, 1995). The final results from
this factor analyses are shown in Table 2.
Our martial quality measures are very similar to those
used by Warner and Kelley-Moore (2012). Our factor
structure differed slightly in that we added the close, gets
on nerves, and emotional satisfaction variables. We made
these changes for three reasons. First, the gets on nerves
item was added in Wave 2 and was not available to Warner
and Kelley-Moore. Second, with only the original items in
the scale, the negative marital quality scale, as derived from
a factor analysis using the Wave 2 sample, had only two
items. Third, the addition of these items increased the reliability of both marital quality factors in our sample. The
changes did not substantively affect the factor solution.
Physical health.—Both measures of physical health are
self-assessments. Respondents rated their own physical
486
Galinsky and Waite
health as excellent, very good, good, fair, or poor. Partner’s
physical health was obtained directly from the respondent’s partner’s interview. Self-rated physical health is a
widely used global measure that seems to reflect some
underlying dimension of health or trajectory of health
that the person perceives. It is quite predictive of later
mortality and has been well validated (Benyamini, Idler,
Leventhal, & Leventhal, 2000; Ferraro & Kelley-Moore,
2001). The poor and fair categories of both measures
were combined for the analysis to ensure adequate cell
size (Smith, 2009). The own and partner’s physical health
measures are correlated: r = .20. Because a person’s
assessment of their physical health can be affected by
their mental health (Mulsant, Ganguli, & Seaberg, 1997),
we include a count of major chronic conditions as a control. The NSHAP comorbidity index is a weighted index,
based on the Charlson comorbidity index, created from
indicators of 15 conditions (Vasilopoulos et al., in press).
The categorical version was coded with four categories:
a score of 0, 1, 2, and 3 or more. As was the case for
the physical and mental health measures, we obtained the
value of “partner’s comorbidity score” variable directly
from the interview with the partner. The partners’ comorbidity indexes were correlated at .10.
Psychological health.—Respondents also rated their
own mental health using the excellent, very good, good,
fair, or poor scale. The question followed immediately after
the question on self-rated physical health and asked: What
about your emotional or mental health? Is it excellent, very
good, good, fair, or poor? This question reflects the individual’s perception and evaluation of their symptoms as significant (Zuvekas & Fleishman, 2008), in contrast to measures
of depressive symptoms or anxiety, which ask about the
symptoms directly. As for the physical health measures,
we obtained the value of “partner’s mental health” variable
directly from the interview with the partner. The poor and
fair categories of this measure were also combined for the
analysis. The own and partner’s mental health measures
were also correlated: r = .20.
Partnered sexual behavior.—We measure frequency of
sex with the spouse using two variables (Galinsky, Waite,
& McClintock, in press). Respondents were first asked
if they had had sex with their spouse in the past year.
Those who answered that they had were then asked about
their sexual frequency: once a month or less, two to three
times a month, once or twice a week, three to six times a
week, or once a day or more. Because this measure was
skewed toward lower frequencies, to ensure adequate
cell size we combined the last three categories into a single category of “once a week or more.” We combined
the answers to these two questions to yield a measure
with four categories: did not have sex with spouse in the
past year, had sex once a month or less, had sex two to
three times a month, and had sex once a week or more
(0 = none to 3 = once a week or more). Each respondent
reported on his or her own perception of engagement in
the sexual frequency role. Partner reports were correlated
at r = .72.
Control measures included gender, age, race/ethnicity,
educational attainment, and relationship type and duration,
factors that have been associated with marital quality. Age
was coded as a categorical variable, with the categories being
younger than 65 years old, 65–74, and 75 or older. Race/
ethnicity was coded as white, black, or other. Educational
attainment was coded as high school diploma or equivalent,
or less than that. Marriage duration was coded as less than
10 years, 10–39 years, and 40 years or more. For cohabiting
couples, this measure was calculated as the length of time
they had been cohabiting. We also included a categorical
measure of morbidity.
Analysis
Our analysis consisted of two steps. First, we estimated
a series of multiple regression models, for both the positive and negative marital quality measures, entering first the
sociodemographic and physical health measures, then adding the partnered sex and psychological health measures.
The physical health measures were entered into the regressions as categorical variables, with the excellent category
as the reference, because preliminary analysis revealed that
the associations between physical health and marital quality were not linear. The sexual behavior and psychological health measures were entered as continuous variables
because preliminary analysis showed that their associations
with marital quality were linear. Second, we tested for mediation by performing Sobel tests with bootstrapping to test
the significance of the indirect effects and to check whether
the effect of physical health on marital quality was significantly reduced when the mediating variables were added to
the model (Preacher & Hayes, 2008). We calculated indirect
effects using the products of coefficients method (Baron &
Kenny, 1986)
All analyses were adjusted for the complex sampling
design and the resulting unequal probability of selection.
All analyses were conducted using Stata Release 11 (Stata
Corporation, College Station, TX).
Results
Physical Health and Marital Quality
To examine the association between physical health and
marital quality, we turn to the first two columns in Table 3.
The first column presents results for the regression of positive marital quality on demographic factors, own and partner’s physical health. The net of sociodemographic controls
and partner’s health reveals that those with lower levels of
own self-rated physical health tend to report lower levels of
487
Linking Health to Marital Quality
Table 3. Coefficients From Ordinary Least Squares Regression of Positive and Negative Marital Quality Own physical health
Excellent
Very good
Good
Fair/poor
Partner’s physical health
Excellent
Very good
Good
Fair/poor
Own report of sexual frequency
Own mental health
Partner’s mental health
Own gender: male
Own age
<65
65–74
75+
Own race/ethnicity
White
Black
Other
Own education
<High school
High school diploma or more
Own comorbidity score
0
1
2
3+
Partner’s comorbidity score
0
1
2
3+
Marital duration
<10 years
10–39 years
40+ years
Relationship type
Married
Cohabiting
F
p
r2
Positive (1)
Negative (1)
Positive (2)
Negative (2)
Positive (3)
Negative (3)
Positive (4)
Negative (4)
Reference
−0.1
−0.14+
−0.37**
Reference
0.11
0.18*
0.25*
Reference
−0.07
−0.08
−0.30*
Reference
0.08
0.12
0.19+
Reference
0.08
0.17*
0.05
Reference
−0.02
−0.05
−0.06
Reference
0.09
0.17*
0.07
Reference
−0.03
−0.05
−0.07
Reference
−0.07
−0.12
−0.40***
Reference
−0.06
−0.07
0.22+
Reference
−0.04
−0.08
−0.33**
0.13***
Reference
−0.08
−0.10
0.15
−0.12***
Reference
−0.01
−0.05
−0.29**
0.12***
0.26***
Reference
−0.11
−0.12
0.12
−0.12***
−0.18***
0.09+
Reference
0.05
0.05
−0.14
0.12***
0.25***
0.11**
0.22***
Reference
−0.15
−0.20*
−0.01
−0.11***
−0.17***
−0.08*
0.08
0.25***
0.05
0.23***
0.07
0.20***
Reference
−0.15+
−0.17*
Reference
0.10+
0.16*
Reference
−0.10
−0.06
Reference
0.06
0.06
Reference
−0.10
−0.07
Reference
0.05
0.07
Reference
−0.10
−0.08
Reference
0.06
0.07
Reference
−0.23+
−0.08
Reference
0.39***
0.04
Reference
−0.24+
−0.12
Reference
0.40***
0.08
Reference
−0.23
−0.14
Reference
0.39***
0.09
Reference
−0.21
−0.14
Reference
0.37**
0.09
Reference
0.07
Reference
0.08
Reference
0.06
Reference
0.10
Reference
0.02
Reference
0.13
Reference
0.02
Reference
0.13
Reference
0.11
0.15
0.08
Reference
0
−0.04
−0.02
Reference
0.12
0.17
0.09
Reference
−0.01
−0.05
−0.03
Reference
0.04
0.08
0.03
Reference
0.04
0.01
0.01
Reference
0.05
0.08
0.04
Reference
0.04
0.01
0.01
Reference
0.04
0.14
0.08
Reference
0.04
−0.14
−0.06
Reference
0.06
0.15+
0.1
Reference
0.02
−0.14
−0.08
Reference
0.06
0.13
0.1
Reference
0.02
−0.13
−0.08
Reference
0.03
0.09
0.08
Reference
0.04
−0.1
−0.06
Reference
0.07
0.10
Reference
−0.09
−0.01
Reference
0.10
0.13
Reference
−0.12
−0.03
Reference
0.02
0.06
Reference
−0.06
0.02
Reference
0.01
0.04
Reference
−0.04
0.03
Reference
−0.28
3.8
0
.09
Reference
0.23
2.65
.01
.05
Reference
−0.33+
4.55
0
.11
Reference
0.28
3.07
0
.08
Reference
−0.35+
8.84
0
.17
Reference
0.3
5.04
0
.11
Reference
−0.33+
8.61
0
.18
Reference
0.28
4.84
0
.11
Notes. All estimates were weighted to account for differential probabilities of selection and differential non-response.
+
p < .1. *p < .05. **p < .01. ***p < .001 (two-tailed tests).
positive marital quality and higher levels of negative marital
quality. Older adults in fair/poor health experience lower
positive marital quality than those in excellent health, and
those in good or fair/poor health experience higher negative
marital quality than those in excellent health. The net of
sociodemographic characteristics and own physical health,
those whose partners are in fair/poor physical health have
lower levels of positive marital quality compared with those
whose partners are in excellent physical health. Partner’s
physical health is not associated with negative marital
quality. Note that the coefficients for fair/poor health are
virtually identical for own health and for partner’s health;
in each case, those with health at the bottom of the scale
or whose partner had health this bad showed levels of positive marital quality that were a third of a standard deviation
lower than those with excellent health or with partners in
excellent health.
Sexual Activity and Marital Quality
To see the association between partnered sexual activity and marital quality, we look at the second column of
Table 3. Lower levels of engagement in partnered sex
488
Galinsky and Waite
in the last year are linked to both lower positive marital
quality and higher negative marital quality. A one-point
increase in the measure of sexual activity, say from reporting no sex at all to reporting sex once a month or less, was
associated with an increase in positive marital quality and
a decrease in negative marital quality of about 0.12 SD in
the respective scale.
Psychological Well-Being and Marital Quality
To see the association between psychological health
and marital quality, we look at the third and fourth sets
of models in Table 3. We find that both one’s own and
one’s partner’s mental health are associated with positive and negative marital quality. The associations are in
the expected directions for both measures: poorer mental health is associated with lower levels of positive and
higher levels of negative marital quality. As we see in
Model 4, these associations hold even after controlling for
the other type of well-being. Note that the coefficient for
own mental health is larger for positive than for negative
marital quality (0.26 vs. −0.18), and it is larger for own
than for partner’s mental health (0.25 vs. 0.11 for positive
and −0.17 vs. −0.08 for negative marital quality).
Evidence of Mediation: Marital Role As Mediator
Based on our first hypothesis, we expected to find that
physical health would predict marital quality, as would
partnered sex, and that the coefficients of physical health
in the marital quality regression would be reduced when
the sexual activity measure was added. We find strong support for this first hypothesis for own physical health, but
only partial support for partner’s physical health, because
partner’s physical health only predicted positive marital
quality. The change in the coefficient for own fair/poor
health in the positive marital quality model, after the
sexual activity variable was added, according to the Sobel
test, was −0.06 with bias-corrected 95% confidence interval (95% CI: −0.12 to −0.02). The corresponding changes
in the negative marital quality model were 0.05 with 95%
CI (0.02–0.10) for own good health and 0.06 with 95%
CI (0.02–0.11) for fair/poor health. The corresponding
change in the coefficient for partner’s fair/poor health in
the positive marital quality model was −0.07 with 95% CI
(−0.12 to −0.04).
A test of mediation using the product of coefficients
method showed that the indirect effect of own physical
health on positive marital quality through sexual engagement was significant (B = −0.15, 95% CI = −0.26 to −0.06,
p < .01), as was the indirect effect of own physical health
on negative marital quality through sexual engagement
(B = 0.14, 95% CI = 0.06–0.28, p < .01), and the indirect
effect of partner’s physical health on positive marital quality through sexual engagement (B = −0.14, 95% CI = −0.26
to −0.05, p < .01).
Evidence of Mediation: Psychological Well-Being As
Mediator
Based on our second hypotheses, we expected to find that
physical health would predict marital quality, as would psychological health, and that the coefficient of the physical
health variables in the marital quality regression would be
reduced in significance and magnitude when the psychological health variables were added. We find complete support
for this hypothesis for own physical health and own mental
health and partial support for partner’s physical health and
partner’s mental health. There is also marginal evidence
that own mental health mediates the association between
partner’s physical health and positive marital quality.
When the own mental health measure was added to the
positive marital quality model, the own physical health
coefficient for fair/poor health was significantly reduced by
−0.36 (95% CI −0.47 to −0.27) and the partner’s physical
health coefficient for fair/poor health was marginally significantly reduced by −0.04 (95% CI −0.11 to 0). When
the own mental health measure was added to the negative
marital quality model, the own physical health coefficient
for good health was significantly reduced by 0.18 (95% CI
0.12–0.26) and the own physical health coefficient for fair/
poor health was significant reduced by 0.25 (95% CI 0.17–
0.35). Partner’s mental health mediated the association
between partner’s physical health and positive marital quality. The effect of partner’s health on positive marital quality was reduced when partner’s mental health was added to
that model—the fair/poor health coefficient was reduced by
−0.18 (95% CI −0.29 to −0.07). Partner’s mental health did
not mediate the association between own physical health
and positive or negative marital quality.
A test of mediation using the product of coefficients
method showed that the indirect effect of own physical health on positive marital quality through own mental
health was significant (B = −0.76, 95% CI = −0.99 to −0.57,
p < .0001), as was the indirect effect of own physical health
on negative marital quality through own mental health
(B = 0.53, 95% CI = 0.37–0.76, p < .0001), the indirect
effect of partner’s physical health on positive marital quality through own mental health (B = −0.11, 95% CI = −0.27
to −0.02, p < .1), and the indirect effect of partner’s physical
health on positive marital quality through partner’s mental
health (B = −0.37, 95% CI = −0.59 to −0.17, p < .01).
Demographic Factors and Marital Quality
Some final results are worth noting. Consistent with
previous research, husbands reported higher positive marital quality than wives (Table 3) (Bulanda, 2011). African
American older adults report higher levels of negative marital quality compared with white older adults (Table 3). This
finding is consistent with previous research that has found
that whites report higher marital happiness than African
Americans (Corra, Carter, Carter, & Knox, 2009).
Linking Health to Marital Quality
Robustness Checks
We repeated the analysis restricting the sample to those
couples who were legally married, dropping those who were
cohabiting. The results were unchanged. We also repeated
the analysis using multiple imputation, such that all of the
married or cohabiting Wave 2 respondents whose partners
participated were included in the analysis sample. Again,
the results were substantially the same. We next repeated
the analysis using a measure of depressive symptoms over
the past week instead of self-reported mental health and the
results were substantially the same. Finally, we repeated
the analysis using a continuous measure of age and alternative categorizations of educational attainment and marriage
duration. Again, the results were substantially the same.
We also reestimated all models dropping from the factor scale the items that loaded at less than 0.4 and found
all results and interpretations of them robust to this change.
Lastly, we estimated models that included caregiving as a
predictor, with the intent of testing it as a mediator between
physical health and marital quality and found that it did not
predict marital quality.
Discussion
The benefits of high-quality relationships, and particularly high-quality marriages, to individuals, families, communities, employers, and society are well known (Bradbury,
Fincham, & Beach, 2000; Fincham & Beach, 2010; Waite &
Gallagher, 2000). Marital quality can be reduced by health
declines in later life (Booth & Johnson, 1994; Yorgason
et al., 2008). However, the pathways linking the health of
each of the spouses to the health of the marriage are not
well understood. This article uses a nationally representative sample of older adult couples to examine how engagement in partnered sex and psychological well-being may
explain the link of the physical health of each of the partners to positive and negative marital quality in later life.
The NSHAP W2 data provide detailed measures of psychological well-being and marital quality, both pointed out as
important gaps in earlier studies (Carpenter et al., 2009).
NSHAP W2 also provides information obtained directly
from both members of marital and cohabiting dyads.
According to our conceptual framework, the poorer
physical health that is often a problem in later life increases
the chances of low engagement in sex with one’s spouse
and of poor psychological well-being. Both of these factors
may themselves be associated with poor marital quality and
we argue that they may mediate the association between
physical health and marital quality.
This conceptual model specifies that poor physical health
affects the psychological well-being of that person and his or
her spouse at the same time that it affects the sexual behavior
of the couple. These, in turn affect marital quality directly
and moderate the effect of physical health on marital quality. This causal order is supported by previous research on
489
some of these links, although reverse causality is possible
and, for some of these relationships, probable. Over the
long run, marital quality may affect physical and emotional
health (Holt-Lunstad & Birmingham, 2008), and psychological well-being may affect sexual function (Carpenter
et al., 2009). Longitudinal data on dyads are needed to test
this more elaborated conceptual framework. Our framework
provides a baseline from which these analyses can be done,
when longitudinal data on these dyads are available.
We find that degree of engagement in partnered sex mediates the association of own and partner’s physical health with
positive marital quality, and own health and negative marital
quality. These results are consistent with our first hypothesis.
Consistent with our second hypothesis, we found that own
mental health mediates the association between own physical health and both positive and negative marital quality, and
between partner’s physical health and positive marital quality. Partner’s mental health mediates the association between
partner’s physical health and positive marital quality.
Our finding that the frequency with which one engages
in partnered sex mediates the physical health–marital quality association is consistent with the literature. Intimacy and
giving and receiving love are important components of the
marital role, these goals are often achieved via sexual interactions, and physical health problems can interfere with sexual activity (DeLamater & Moorman, 2007; Karraker et al.,
2011; Laumann et al., 2008). Our finding that psychological
health mediates the physical health–marital quality association is also consistent with one other study that found such a
mediating effect (Yorgason et al., 2008). Our study improves
upon Yorgason and colleagues (2008), by including a measure of partner’s self-reported physical and mental health. Our
finding that own mental health mediates all three physical
health–marital quality links identified, but partner’s mental
health only mediates one of the three (partner’s physical
health and positive marital quality) might be explained by our
measurement of marital quality. Our outcome is the respondent’s own evaluation of the quality of the marriage. Own
mental health is a lens through which the individual views
both the relationship and the partner, coloring them brighter
or darker. This makes it a powerful mediator. Partner’s mental health, on the other hand, only affects own perceptions of
marital quality to the extent to which it is externalized and
thus affects the partnership.
As individuals age, the means of sexual expression may
change, with less focus on vaginal intercourse and more
frequent sexual touching (Galinsky, 2012). Our measure of
sexual behavior was designed to be quite inclusive; it asks
explicitly about any activities with one’s partner that were
sexually arousing, noting that they did not need to result in
orgasm or include vaginal intercourse. Thus, older adults
who reported no or little partnered sex were saying that they
were quite disengaged from this activity with their spouse.
The men and women in these sexually inactive couples
showed lower levels of marital happiness and higher levels
490
Galinsky and Waite
of dissatisfaction and negative interactions than couples who
maintained their sexual engagement, in some form, as
they aged.
Strengths and Limitations
This study uses recent data, including a measure of sexual
activity with their partner not often available in data sets that
also contain data on physical, psychological, and marital
well-being, to test theory-based hypotheses. We include an
extensive and rich set of measures of both positive and negative dimensions of marital quality. The measures of spouse’s
physical and mental health are obtained directly from that
person and thus are not subject to bias as they would have
been if the respondent reported on his/her spouse’s health.
The results can be generalized to married community-dwelling older adults in the United States. These are the strengths
of the study. The study also has some limitations.
First, this study’s results cannot be generalized to older adults
living in institutions because such people were not included
in the survey sample. Second, because this study uses crosssectional data, we cannot be sure of direction of causality. For
example, poor marital quality probably reduces the likelihood
of and frequency of sex for the couple, as might poor mental
health. And both probably make couple negotiations around
the challenges of declining health more difficult and less often
successful. Own and partner’s physical and mental health are
measured by one question each, and although self-rated physical health has been well validated, the measure of self-rated
mental health is less well known and understood. An extension
of this line of research might explore the relationship of specific
mental health challenges, such as anxiety or depression, and
specific chronic diseases such as diabetes, to sexual functioning
and marital quality. Longitudinal data on both members of the
couple would allow researchers to begin to disentangle causal
connections. Third, selection bias may be at work. Unhappily
married people are more likely to divorce, and probably more
likely to die, and such people would not be in our sample (Waite
et al., 2009). Fourth, the processes we study may differ by race
or ethnicity, by socioeconomic status, and by gender. Future
research might explore these possibilities.
Implications
This study’s results suggest that to protect marital quality in later life, it may be important for older adults to find
ways to stay engaged in sexual activity, even as health problems render familiar forms of sexual interaction difficult
or impossible. Clearly, older adults’ access to high-quality
health care for both physical and emotional issues is key.
The results also suggest that those caring for older adults,
both physicians and family, be alert to physical changes that
may affect mood and emotional state, with implications
for sexual and marital functioning. Medical professionals
who feel ill-equipped to address intimacy issues with their
older patients might refer them to specialists in couples and
sexual therapy. At the same time, providing mental health
services to older adults who are struggling with physical
illness in themselves or their partners may be an important
way to protect marital quality. The results also suggest the
value of relationship education programs for older couples
(Stanley, Markman, & Whitton, 2002).
Funding
This work was supported by funding for MERIT Award R37 AG030481
to L. J. Waite, from the National Institute on Aging, and from the National
Institutes of Health, including the National Institute on Aging, the Office
of Women’s Health Research, the Office of AIDS Research, the Office of
Behavioral and Social Sciences Research, and the National Institute on
Child Health and Human Development for the National Social Life, Health
and Aging Project (NSHAP R01AG021487, R37AG030481), the NSHAP
Wave 2 Partner Project (R01AG033903), the Center on Demography
and Economics of Aging (P30AG012857), the Population Research
Center (R24HD051152), and the Specialized Training Program in the
Demography and Economics of Aging (T32AG000243).
Acknowledgments
Portions of these analyses were presented at the 2012 meeting of the
Population Association of America in San Francisco, CA and the 2012
meeting of the Society for the Scientific Study of Sexuality in Bloomington,
IN. A. M. Galinsky originated the research question, performed all statistical analyses, and wrote the paper. L. J. Waite contributed to the formulation of the research question and the design of the data analysis, supervised
the data analysis and contributed to revising the paper.
Correspondence
Correspondence should be addressed to Adena Galinsky, PhD,
Department of Population, Family and Reproductive Health, Johns
Hopkins Bloomberg School of Public Health, Baltimore, MD 21205.
E-mail: [email protected].
References
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual,
strategic and statistical considerations. Journal of Personality
and Social Psychology, 51, 1173–1182. doi:http://dx.doi.
org/10.1037/0022-3514.51.6.1173
Benyamini, Y., Idler, E. L., Leventhal, H., & Leventhal, E. A. (2000).
Positive affect and function as influences on self-assessments of
health: Expanding our views beyond illness and disability. The
Journals of Gerontology, Series B: Psychological Sciences and
Social Sciences, 55, 107–116. doi:http://dx.doi.org/10.1093/
geronb/55.2.P107
Birditt, K., & Antonucci, T. C. (2008). Life sustaining irritations?
Relationship quality and mortality in the context of chronic illness. Social Science & Medicine, 67, 1291–1299. doi:10.1016/j.
socscimed.2008.06.029
Blazer, D. G. (2009). Depression in late life: Review and commentary. The
Journal of Lifelong Learning in Psychiatry, VII, 118–136. doi:http://
dx.doi.org/10.2307/352716
Booth, A., & Johnson, D. R. (1994). Declining health and marital quality. Journal of Marriage and the Family, 56, 218–223.
doi:10.2307/352716
Bradbury, T. N., Fincham, F. D., & Beach, S. R. H. (2000). Research
on the nature and determinants of marital satisfaction: A decade in review. Journal of Marriage and the Family, 62, 964–980.
doi:10.1111/j.1741-3737.2000.00964.x
Bruce, M. L. (2000). Depression and disability. In G. M. Williams, D. R.
Shaffer, & P. A. Parmelee (Eds.), Physical illness and depression
in older adults: A handbook of theory, research, and practice (pp.
11–29). New York, NY: Kluwer Academic.
Linking Health to Marital Quality
Bulanda, J. R. (2011). Gender, marital power, and marital quality in later
life. Journal of Women & Aging, 23, 3–22. doi:10.1080/08952841.2
011.540481
Call, V., Sprecher, S., & Schwartz, P. (1995). The incidence and frequency
of marital sex in a national sample. Journal of Marriage and the
Family, 57, 639–652. doi:10.2307/353919
Carpenter, L. M., Nathanson, C. A., & Kim, Y. J. (2009). Physical women,
emotional men: Gender and sexual satisfaction in midlife. Archives
of Sexual Behavior, 38, 87–107. doi:http://dx.doi.org/10.1007/
s10508-007-9215-y
Carstensen, L. L. (1992). Social and emotional patterns in adulthood—
Support for socioemotional selectivity theory. Psychology and
Aging, 7, 331–338. doi:10.1037/0882-7974.7.3.331
Choi, H., & Marks, N. F. (2008). Marital conflict, depressive symptoms,
and functional impairment. Journal of Marriage and the Family, 70,
377–390. doi:10.1111/j.1741-3737.2008.00488.x
Corra, M., Carter, S. K., Carter, J. S., & Knox, D. (2009). Trends in marital happiness by gender and race, 1973 to 2006. Journal of Family
Issues, 30, 1379–1404. doi:10.1177/0192513X09336214
Coyne, J. C., Rohrbaugh, M. J., Shoham, V., Sonnega, J. S., Nicklas, J.
M., & Cranford, J. A. (2001). Prognostic importance of marital quality for survival of congestive heart failure. The American Journal of
Cardiology, 88, 526–529. doi:10.1016/S0002-9149(01)01731-3
Davila, J., Bradbury, T. N., Cohan, C. L., & Tochluk, S. (1997). Marital
functioning and depressive symptoms: Evidence for a stress generation model. Journal of Personality and Social Psychology, 73, 849–
861. doi:10.1037/0022-3514.73.4.849
DeLamater, J., & Moorman, S. M. (2007). Sexual behavior in later life. Journal of Aging and Health, 19, 921–945.
doi:10.1177/0898264307308342
Ditzen, B., Hoppmann, C., & Klumb, P. (2008). Positive couple interactions and daily cortisol: On the stress-protecting role of intimacy. Psychosomatic Medicine, 70, 883–889. doi:10.1097/
PSY.0b013e318185c4fc
Donnelly, D. A. (1993). Sexually inactive marriages. Journal of Sex
Research, 30, 171–179. doi:10.1080/00224499309551698
Ferraro, K. F., & Kelley-Moore, J. A. (2001). Self-rated health and mortality among black and white adults: Examining the dynamic evaluation
thesis. The Journals of Gerontology. Series B, Psychological Sciences
and Social Sciences, 56, S195–S205. doi:10.1093/geronb/56.4.S195
Fincham, F., Beach, S., & Kemp-Fincham, S. (1997). Marital quality:
A new theoretical perspective. In R. Sternberg & M. Hojjat (Eds.),
Satisfaction in close relationships (pp. 275–306). New York, NY:
Guilford Press.
Fincham, F. D., & Beach, S. R. H. (2010). Marriage in the new millennium: A decade in review. Journal of Marriage and the Family, 72,
630–649. doi:10.1111/j.1741-3737.2010.00722.x
Fincham, F. D., & Linfield, K. J. (1997). A new look at marital quality: Can spouses feel positive and negative about
their marriage? Journal of Family Psychology, 11, 489–502.
doi:10.1037/0893-3200.11.4.489-502
Floyd, F. J., & Widaman, K. F. (1995). Factor analysis in the development and refinement of clinical assessment instruments.
Psychological Assessment, 7, 286–299. doi:http://dx.doi.
org/10.1037/1040-3590.7.3.286
Galinsky, A. M. (2012). Sexual touching and difficulties with sexual
arousal and orgasm among U.S. older adults. Archives of Sexual
Behavior, 41, 875–890. doi:10.1007/s10508-011-9873-7
Galinsky, A., Waite, L. J., & McClintock, L. M. (in press). Sexual interest and motivation, sexual behavior and physical contact in NSHAP
Wave 2. The Journals of Gerontology, Series B: Psychological
Sciences and Social Sciences.
Gierveld, J. d. e. J., van Groenou, M. B., Hoogendoorn, A. W., & Smit, J. H.
(2009). Quality of marriages in later life and emotional and social loneliness. The Journals of Gerontology. Series B, Psychological Sciences
and Social Sciences, 64, 497–506. doi:10.1093/geronb/gbn043
491
Hagedoorn, M., Sanderman, R., Ranchor, A. V., Brilman, E. I., Kempen,
G. I., & Ormel, J. (2001). Chronic disease in elderly couples: Are
women more responsive to their spouses’ health condition than men?
Journal of Psychosomatic Research, 51, 693–696. doi:10.1016/
S0022-3999(01)00279-3
Hammen, C. (1991). Generation of stress in the course of unipolar depression. Journal of Abnormal Psychology, 100, 555–561.
doi:10.1037/0021-843X.100.4.555
Hawkins, D. N., & Booth, A. (2005). Unhappily ever after: Effects of
long-term, low-quality marriages on well-being. Social Forces, 84,
451–471. doi:10.1353/sof.2005.0103
Henry, N. J. M., Berg, C. A., Smith, T. W., & Florsheim, P. (2007). Positive
and negative characteristics of marital interaction and their association with marital satisfaction in middle-aged and older couples.
Psychology and Aging, 22, 428–441. doi:10.1037/0882.7974.22.3.428
Hibbard, J. H., & Pope, C. R. (1993). The quality of social roles as predictors of morbidity and mortality. Social Science & Medicine, 36,
217–225. doi:10.1016/0277-9536(93)90005-O
Holt-Lunstad, J., & Birmingham, W. (2008). Is there something unique
about marriage? The relative impact of marital status, relationship
quality, and network social support on ambulatory blood pressure
and mental health. Annals of Behavioral Medicine, 35, 239–244.
doi:http://dx.doi.org/10.1007/s12160-008-9018-y
Horwitz, A. V., White, H. R., & Howell-White, S. (1996). Becoming
married and mental health: A longitudinal study of a cohort of
young adults. Journal of Marriage and the Family, 58, 895–907.
doi:10.2307/353978
Hughes, M. E., & Waite, L. J. (2009). Marital biography and health at
midlife. Journal of Health and Social Behavior, 50, 344–358.
doi:10.1177/002214650905000307
Karraker, A., Delamater, J., & Schwartz, C. R. (2011). Sexual frequency
decline from midlife to later life. The Journals of Gerontology.
Series B, Psychological Sciences and Social Sciences, 66, 502–512.
doi:10.1093/geronb/gbr058
Kiecolt-Glaser, J. K., & Newton, T. L. (2001). Marriage and
health: His and hers. Psychological Bulletin, 127, 472–503.
doi:10.1037//0033-2909.127.4.472
Kramer, P. D. (1993). Listening to Prozac. New York, NY: Viking.
Laumann, E. O., Das, A., & Waite, L. J. (2008). Sexual dysfunction
among older adults: Prevalence and risk factors from a nationally
representative U.S. probability sample of men and women 57 to
85 years of age. The Journal of Sexual Medicine, 5, 2300–2311.
doi:10.1111/j.1743-6109.2008.00974.x
Lindau, S., Schumm, P., Laumann, E. O., Levinson, W., O’Muircheataigh,
C. A., & Waite, L. J. (2007). A national study of sexuality and
health among older adults in the United States. New England
Journal of Medicine, 357, 762–774. doi:http://dx.doi.org/10.1056/
NEJMoa067423
Luo, Y., Hawkley, L. C., Waite, L., & Caccioppo, J. T. (2012). Loneliness,
health, and mortality in old age: A national longitudinal study. Social
Science & Medicine, 74, 907–914. doi:http://dx.doi.org/10.1016/j.
socscimed.2011.11.028
Mulsant, B. H., Ganguli, M., & Seaberg, E. C. (1997). The relationship
between self-rated health and depressive symptoms in an epidemiological sample of community-dwelling older adults. Journal of the
American Geriatrics Society, 45, 954–958.
Northouse, L. L., Mood, D., Templin, T., Mellon, S., & George, T. (2000).
Couples’ patterns of adjustment to colon cancer. Social Science &
Medicine, 50, 271–284. doi:10.1016/S0277-9536(99)00281-6
O’Muircheartaigh, C., Eckman, S., & Smith, S. (2009). Statistical design
and estimation for the National Social life, Health, and Aging Project.
The Journals of Gerontology, Series B: Psychological Sciences and
Social Sciences, 64(Suppl. 1), i12–i19. doi:10.1093/geronb/gbp045
O’Muircheartaigh, C., English, N., Pedlow, S., & Kwok, P. K. (in press).
Sample design, sample augmentation, and estimation for Wave II
of the National Social Life, Health and Aging Project (NSHAP).
492
Galinsky and Waite
The Journals of Gerontology, Series B: Psychological Sciences and
Social Sciences.
Ormel, J., Rijsdijk, F. V., Sullivan, M., van Sonderen, E., & Kempen, G.
I. J. M. (2002). Temporal and reciprocal relationship between IADL/
ADL disability and depressive symptoms in late life. The Journals of
Gerontology, Series B: Psychological Sciences and Social Sciences,
57, 338–347. doi:10.1093/geronb/57.4.P338
Preacher, K. J., & Hayes, A. F. (2008). Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods, 40, 879–891. doi:10.3758/
BRM.40.3.879
Rehman, U. S., Gollan, J., & Mortimer, A. R. (2008). The marital context
of depression: Research, limitations, and new directions. Clinical
Psychology Review, 28, 179–198. doi:10.1016/j.cpr.2007.04.007
Ross, C. E. (1995). Reconceptualizing marital-status as a continuum of
social attachment. Journal of Marriage and the Family, 57, 129–140.
doi:10.2307/353822
Smith, J. P. (2009). Reconstructing childhood health histories.
Demography, 46, 387–403. doi:10.1353/dem.0.0058
Smith, S., Jaszczak, A., Graber, J., Lundeen, K., Leitsch, S., Wargo, E.,
& O’Muircheartaigh, C. (2009). Instrument development, study
design implementation, and survey conduct for the national social
life, health, and aging project. The Journals of Gerontology, Series B:
Psychological Sciences and Social Sciences, 64(Suppl. 1), i20–i29.
doi:10.1093/geronb/gbn013
Stanley, S. M., Markman, H. J., & Whitton, S. W. (2002). Communication,
conflict, and commitment: Insights on the foundations of relationship success from a national survey. Family Process, 41, 659–675.
doi:10.1111/j.1545-5300.2002.00659.x
Uchino, B. N., Cacioppo, J. T., & Kiecolt-Glaser, J. K. (1996). The
relationship between social support and physiological processes: A review with emphasis on underlying mechanisms and
implications for health. Psychological Bulletin, 119, 488–531.
doi:10.1037/0033-2909.119.3.488
Umberson, D., Williams, K., Powers, D. A., Liu, H., & Needham, B.
(2006). You make me sick: Marital quality and health over the
life course. Journal of Health and Social Behavior, 47, 1–16.
doi:10.1177/002214650604700101
Vasilopoulos, T., Kotwal, A., Huisingh-Scheetz, M., Waite, L., McClintock,
M. K., & Dale, W. (in press). Comorbidity and chronic conditions in
the National Social Life, Health, and Aging Project (NSHAP), Wave
2. The Journals of Gerontology, Series B: Psychological Sciences
and Social Sciences.
Waite, L. J., & Gallagher, M. (2000). The case for marriage: Why married
people are happier, healthier, and better off financially. New York,
NY: Broadway Books.
Waite, L. J., Luo, Y., & Lewin, A. C. (2009). Marital happiness
and marital stability: Consequences for psychological wellbeing. Social Science Research, 38, 201–212. doi:10.1016/j.
ssresearch.2008.07.001
Warner, D., & Kelley-Moore, J. (2012). The social context of disablement among older adults: Does marital quality matter for loneliness?
Journal of Health and Social Behavior, 53, 50–66. doi:http://dx.doi.
org/10.1177/0022146512439540
Whisman, M. A. (2007). Marital distress and DSM-IV psychiatric disorders in a population-based national survey. Journal of Abnormal
Psychology, 116, 638–643. doi:10.1037/0021-843X.116.3.638
Wickrama, K. A. S., Lorenz, F. O., Conger, R. D., & Elder, G. H.
(1997). Marital quality and physical illness: A latent growth
curve analysis. Journal of Marriage and the Family, 59, 143–155.
doi:10.2307/353668
Williams, K. (2003). Has the future of marriage arrived? A contemporary examination of gender, marriage, and psychological wellbeing. Journal of Health and Social Behavior, 44, 470–487.
doi:10.2307/1519794
Yang, Y. (2008). Trends in U.S. adult chronic disease mortality, 19601999: Age, period, and cohort variations. Demography, 45, 387–416.
doi:10.1353/dem.0.0000
Yorgason, J. B., Booth, A., & Johnson, D. (2008). Health, disability, and marital quality is the association different for
younger versus older cohorts? Research on Aging, 30, 623–648.
doi:10.1177/0164027508322570
Zuvekas, S. H., & Fleishman, J. A. (2008). Self-rated mental health
and racial/ethnic disparities in mental health service use.
Medical Care, 46, 915–923. doi:http://dx.doi.org/10.1097/MLR.
0b013e31817919e5