Background
Empirical research spanning several decades has demonstrated that married people experience a range of physical and mental health benefits and greater functionality, self-rated health, and longevity as compared to non-married individuals [
1‐
6]. Previous research exploring mechanisms linking marital status and health outcomes has posited several ways that marriage and health are causally associated [
1,
7,
8]. First, marriage may offer economic, social, and psychological benefits, which may promote good health. These mechanisms may include access to sufficient economic resources, social control of behaviors by one’s spouse, or a sense of social support within the marital relationship. Second, transitioning to widowhood may induce significant strain upon a sudden change in resources, a change which leads to negative effects [
9]. Alternatively, assortative mating based on health may occur [
10,
11]. Also, research has found that healthier people tend to get married and stay married while unhealthy people tend to become widowed or divorced [
12‐
16]. Regardless of mechanism, longitudinal studies have provided evidence of links between earlier marital status states and marital transitions to later wellbeing, health-related outcomes, chronic disease and mortality, [
2,
7,
17‐
24] though the direction and strength of associations vary across studies and outcomes. Moreover, associations between marital status and health-related outcomes have remained even after adjusting for various sets of demographic and socioeconomic characteristics.
Widowhood is inherently a gendered and cultured experience as the salience of different mechanisms linking widowhood to health may depend on gender and on local norms [
9]. Much of the formative research on marital status and health associations has been conducted in high-income countries where a substantial number of studies examining gender differences in the widowhood-health relationship have found evidence of worse outcomes for men, [
5,
25‐
29] findings which are posited to be due to the loss of social and psychological support from the wife. However, results are mixed across the literature [
30‐
33]. Moreover, research has provided evidence of variation in the relationships between marital status and health outcomes across cultures [
9,
34‐
44]. Indeed, widowhood may differently affect men and women across contexts due to differences in gender norms and marriage traditions. For example, in some contexts widowhood may lead to increased financial strain for women while it may lead to increased household strain for men [
45]. That relationship may differ in other contexts where roles and responsibilities differ by gender. Moreover, in patriarchal cultures, remarriage may not be a realistic option for women (particularly older women), thus forcing older women to remain widowed and without resources indefinitely [
46]. In contrast, men may easily seek remarriage [
44,
47]. If a woman is widowed from a young age without much ability to remarry due to cultural barriers (particularly if she already has children), then she may be economically disadvantaged for life. Alternatively, older men in some cultures where wives traditionally take care of men may be less able to cope with a loss of a spouse for longer periods whereas the existence of strong family ties (particularly other female familial relationships) may prevent negative effects in the short-term. In places where paternalistic norms are pervasive in everyday life (particularly in patterns of behavior related to economic opportunities, social activities, marriage traditions, and reputations), becoming widowed may severely restrict an individual’s ability to access financial, affective, informational, or physical resources, which in turn might affect health outcomes.
In India, a country with strict gender norms and traditional kinship systems, [
48‐
50] widowhood is considered to be a dreaded phase of life among some groups, particularly for women [
51]. Traditionally, the woman’s main role in India was to care for her husband. Upon losing her husband, the main purpose to life was lost. As she belonged to her husband’s family, in-laws frequent viewed widowed women as a burden. In the past, a traditional Hindu custom (which is the dominant religion in India) called for widows to commit suicide upon the death of their husband, [
52] and although the practice is illegal now, it is still occurs (though obviously with lower frequency). More recently, the ‘city of widows’ in India has been highlighted, which is a holy site that is home to thousands of widowed women who live in dire circumstances and beg for money [
53,
54]. In general, widowhood for women in India is a very tenuous period of life, highlighted by significant poverty, lack of social support, a lack of ability to remarry, and a greater risk of mortality [
46,
55‐
57]. Widowhood for elderly women in India may be a highly stigmatizing and potentially public experience as, according to traditional customs, they may shave their heads, wear only plain or white clothing, eat only two or fewer meals per day, and not be permitted to attend social gatherings or to re-marry [
58‐
60]. Thus, given historical precedent and India’s patriarchal society embodying strict norms, attitudes, and practices that typically affect the social status of the elderly, and women in particular, [
61] widowed older women in India may face significant discrimination (experienced or perceived) as well as a lack of economic resources [
51,
62‐
64]. These issues may in turn affect health outcomes. In this context, widowhood may present substantial disadvantages for women if the transition signifies a loss of resources, particularly in the long-term, though there may be differences by socioeconomic status and other demographic factors, as well as by region [
65‐
67]. In contrast, widowhood may not be associated with health outcomes for men if other women in the family immediately take over the daily household chores and any care the widowed men may need.
Most studies examining health-related outcomes as a function of marital status among older adults in India have found worse health to be associated with widowed status as compared to married status [
68‐
73]. These studies, however, adjusted for varying sets of covariates and many of the studies only focused on self-rated health as the outcome. Moreover, few studies have focused on the potential health effects of widowhood for men in India. Yet, as the aging population of India increases in a context where access to and affordability of social services is limited for older individuals, [
74,
75] it is important to identify individuals who are more at risk for worse health outcomes among the general older adult population. Being widowed represents a relatively easy marker.
Thus, assessing whether there is evidence of a direct relationship between widowhood and multiple subjective and objective health-related outcomes and chronic diseases among older adults in India after adjusting for a large set of demographic and socioeconomic factors (such as caste, education, wealth, religion, living with children, rural/urban location, etc.) is warranted. Moreover, examining these associations separately for men and women is critical due to unequal gender norms in India and also because a higher proportion of men in India remarry while an increasing fraction of women remain widows [
70]. Finally, no studies of which we are aware have examined how duration of widowhood is associated with outcomes among older adults in India. Yet, men and women recently widowed may experience worse outcomes than people widowed for much longer. For example, men who are more recently widowed may experience stressful transitions and immediate loss of a known daily support. In the long run, however, they are likely well-cared for by other female relatives. Alternatively, women who have been widowed for a long time may be the worst off due to long-term reduced access to resources and, perhaps, poor treatment by their husband’s family. Previous studies from other countries have revealed a relationship between duration widowhood and self-reported health, psychological wellbeing, or other health outcomes, [
20,
26,
37,
76‐
78] though findings have differed across populations and outcomes.
The current study attempts to address these gaps in the literature by providing empirically descriptive answers to two questions: First, to what extent is widowhood associated with a variety of health-related outcomes and chronic diseases among older men and women, separately, in India, after adjusting for several demographic and socioeconomic indicators? Second, is there evidence that widowhood duration matters in these relationships? We hypothesized that being widowed (without regards to duration) would be associated with worse health outcomes for both men and women, even after adjusting for several indicators of socioeconomic status, living arrangement, and place, though we thought that the strength of the relationship would be greater among women. Moreover, we hypothesized that being widowed for longer would be associated with an even greater risk of poor health outcomes for women given a potential longer period of resource restriction.
Results
Table
1 provides descriptive statistics about the sample and also the average scores of self-reported health, psychological distress, and cognitive ability across sub-categories of socio-demographic characteristics. For context, almost two-thirds of the sample population were within the ages of 60 to 69 years while about 10 % were 80 years or older. In addition, 4 % of men had been widowed for 0–4 years, 4 % for 5–9 years, and 6 % for 10 years or more. Among women, 14 % had been widowed for 0–4 years, 13 % for 5–9 years, and 34 % for 10 years or more. Table
2 provides the prevalence among the sample population of being diagnosed with each of four chronic diseases (hypertension, diabetes, arthritis, and asthma), being diagnosed with at least 1 chronic disease, being in poor health, and having a probable common mental disorder. Among men, 30 % who were currently married vs. 36 % who were widowed for 10 years or more had at least one chronic disease, 49 to 57 % of men in those same groups reported being in poor health, and 24 to 35 % had a probable mental disorder. Among women, the prevalence of being diagnosed with at least 1 chronic disease, being in poor health, and having a probable common mental disorder, separately, was higher among married women than the associated prevalence among women who had been widowed for 5 to 9 years.
Table 1
Descriptive characteristics of a representative sample of older adults (60 + years) across seven states in India in 2011 (N = 9,171)
Marital Status |
Currently Married | 3698 | 85.5 | 1888 | 39 | 3.4 | 1.0 | 3.5 | 1.0 | 3.4 | 3.9 | 3.1 | 3.6 | 4.6 | 1.7 | 4.3 | 1.6 |
Widowed 0 to 4 years | 189 | 4.4 | 690 | 14.2 | 3.7 | 0.9 | 3.7 | 1.0 | 3.7 | 3.8 | 4.3 | 3.9 | 4.1 | 1.9 | 3.8 | 1.6 |
Widowed 5 to 9 years | 162 | 3.7 | 631 | 13 | 3.4 | 1.0 | 3.5 | 0.9 | 3.9 | 4.2 | 3.5 | 3.9 | 3.9 | 1.6 | 4.2 | 1.6 |
Widowed 10+ years | 277 | 6.4 | 1636 | 33.8 | 3.6 | 1.0 | 3.8 | 1.0 | 3.0 | 3.6 | 4.5 | 3.9 | 3.9 | 1.7 | 3.5 | 1.6 |
Age Group |
60–64 | 1519 | 35.1 | 1716 | 35.4 | 3.2 | 1.0 | 3.4 | 1.0 | 2.6 | 3.4 | 3.0 | 3.5 | 4.9 | 1.6 | 4.4 | 1.6 |
65–69 | 1219 | 28.2 | 1324 | 27.3 | 3.4 | 1.0 | 3.6 | 1.0 | 3.0 | 3.6 | 3.6 | 3.8 | 4.6 | 1.6 | 4.0 | 1.6 |
70–74 | 771 | 17.8 | 819 | 16.9 | 3.4 | 1.1 | 3.7 | 1.0 | 3.5 | 3.7 | 4.4 | 4.0 | 4.3 | 1.6 | 3.7 | 1.5 |
75–79 | 395 | 9.1 | 462 | 9.6 | 3.6 | 1.0 | 3.8 | 1.0 | 3.5 | 3.8 | 4.5 | 3.8 | 4.0 | 1.8 | 3.4 | 1.6 |
80+ years | 422 | 9.8 | 524 | 10.8 | 3.8 | 1.1 | 3.9 | 1.0 | 4.4 | 4.1 | 5.1 | 4.1 | 3.5 | 1.8 | 3.0 | 1.7 |
Living with Children |
No | 1255 | 29 | 1328 | 27.4 | 3.4 | 1.0 | 3.6 | 1.0 | 3.2 | 3.8 | 3.8 | 3.9 | 4.6 | 1.7 | 4.0 | 1.7 |
Yes | 3071 | 71 | 3517 | 72.6 | 3.4 | 1.0 | 3.6 | 1.0 | 3.1 | 3.6 | 3.7 | 3.8 | 4.4 | 1.7 | 3.9 | 1.6 |
Caste |
Scheduled Caste | 850 | 19.6 | 968 | 20 | 3.6 | 1.0 | 3.7 | 1.0 | 3.6 | 3.9 | 4.3 | 4.0 | 4.2 | 1.7 | 3.6 | 1.5 |
Schedule Tribe | 222 | 5.1 | 250 | 5.2 | 3.3 | 0.9 | 3.5 | 0.9 | 4.1 | 3.8 | 4.8 | 4.0 | 4.1 | 1.4 | 3.7 | 1.5 |
Other Backward Caste | 1515 | 35 | 1702 | 35.1 | 3.5 | 1.0 | 3.6 | 1.0 | 3.5 | 3.9 | 4.0 | 3.9 | 4.5 | 1.6 | 4.0 | 1.7 |
None of them | 1739 | 40.2 | 1925 | 39.7 | 3.3 | 1.1 | 3.5 | 1.1 | 2.4 | 3.3 | 3.2 | 3.6 | 4.6 | 1.8 | 4.0 | 1.7 |
Work status (in the last 1 year) |
No | 2759 | 63.8 | 4334 | 89.5 | 3.5 | 1.0 | 3.6 | 1.0 | 3.3 | 3.8 | 3.7 | 3.8 | 4.4 | 1.8 | 3.9 | 1.7 |
Yes | 1567 | 36.2 | 511 | 10.5 | 3.3 | 1.0 | 3.4 | 1.0 | 2.8 | 3.4 | 4.0 | 3.7 | 4.6 | 1.6 | 4.0 | 1.5 |
Education |
None | 1353 | 31.3 | 2940 | 60.7 | 3.6 | 1.0 | 3.7 | 1.0 | 4.3 | 4.0 | 4.4 | 3.9 | 3.9 | 1.5 | 3.6 | 1.5 |
< 5 years | 945 | 21.8 | 966 | 19.9 | 3.5 | 1.0 | 3.6 | 1.1 | 3.6 | 3.7 | 3.4 | 3.6 | 4.1 | 1.6 | 4.0 | 1.6 |
6 to 10 years | 1406 | 32.5 | 723 | 14.9 | 3.3 | 1.0 | 3.4 | 1.0 | 2.2 | 3.2 | 2.1 | 3.0 | 4.9 | 1.6 | 4.8 | 1.6 |
≥ 11 years | 622 | 14.4 | 216 | 4.5 | 3.0 | 1.1 | 3.3 | 1.1 | 1.8 | 2.8 | 1.9 | 3.0 | 5.5 | 1.8 | 5.4 | 1.9 |
Household Wealth Quintile |
Bottom | 779 | 18 | 1000 | 20.6 | 3.7 | 0.9 | 3.8 | 0.9 | 5.0 | 3.7 | 5.4 | 3.8 | 3.9 | 1.4 | 3.6 | 1.5 |
Second | 839 | 19.4 | 1007 | 20.8 | 3.5 | 1.0 | 3.6 | 1.0 | 4.0 | 3.9 | 4.4 | 3.9 | 4.1 | 1.6 | 3.7 | 1.5 |
Third | 820 | 19 | 987 | 20.4 | 3.5 | 1.0 | 3.6 | 1.0 | 3.2 | 3.7 | 3.5 | 3.8 | 4.3 | 1.7 | 3.9 | 1.6 |
Fourth | 934 | 21.6 | 904 | 18.7 | 3.3 | 1.0 | 3.5 | 1.0 | 2.3 | 3.4 | 3.0 | 3.7 | 4.8 | 1.7 | 4.2 | 1.7 |
Top | 954 | 22.1 | 947 | 19.6 | 3.2 | 1.1 | 3.5 | 1.1 | 1.5 | 2.6 | 2.5 | 3.2 | 5.1 | 1.8 | 4.4 | 1.8 |
Place |
Urban | 2035 | 47 | 2322 | 47.9 | 3.3 | 1.0 | 3.5 | 1.0 | 2.6 | 3.5 | 3.4 | 3.7 | 4.7 | 1.8 | 4.1 | 1.7 |
Rural | 2291 | 53 | 2523 | 52.1 | 3.5 | 1.0 | 3.7 | 1.0 | 3.6 | 3.8 | 4.1 | 3.9 | 4.3 | 1.6 | 3.8 | 1.5 |
State |
Himachal Pradesh | 727 | 16.8 | 709 | 14.6 | 3.1 | 1.1 | 3.3 | 1.1 | 1.8 | 3.3 | 2.8 | 3.9 | 5.2 | 1.8 | 4.2 | 1.7 |
Punjab | 621 | 14.4 | 696 | 14.4 | 3.6 | 0.9 | 3.8 | 0.9 | 1.5 | 2.8 | 1.9 | 3.0 | 4.4 | 1.6 | 4.2 | 1.6 |
West Bengal | 477 | 11 | 550 | 11.4 | 3.9 | 0.8 | 4.2 | 0.8 | 4.5 | 2.9 | 4.7 | 3.1 | 3.6 | 1.4 | 3.1 | 1.2 |
Orissa | 703 | 16.3 | 713 | 14.7 | 3.3 | 0.9 | 3.4 | 0.9 | 4.3 | 3.6 | 5.1 | 3.7 | 4.1 | 1.5 | 3.7 | 1.5 |
Maharashtra | 624 | 14.4 | 704 | 14.5 | 3.1 | 1.1 | 3.2 | 1.0 | 3.5 | 3.6 | 3.9 | 3.8 | 4.6 | 1.5 | 4.1 | 1.5 |
Kerala | 539 | 12.5 | 736 | 15.2 | 3.7 | 1.2 | 3.9 | 1.1 | 1.9 | 2.9 | 3.2 | 3.6 | 4.0 | 1.9 | 3.7 | 1.9 |
Tamil Nadu | 635 | 14.7 | 737 | 15.2 | 3.4 | 0.7 | 3.5 | 0.8 | 4.5 | 4.5 | 4.8 | 4.3 | 4.9 | 1.6 | 4.4 | 1.5 |
Table 2
Prevalence of chronic disease, poor health, and probable mental disorder among older adults across seven states in India in 2011 (unit = %)
Marital Status |
Currently Married | 18 | 24 | 12 | 11 | 8 | 6 | 23 | 34 | 30 | 37 | 49 | 52 | 24 | 24 |
Widowed 0 to 4 years | 20 | 29 | 16 | 12 | 11 | 7 | 24 | 30 | 31 | 36 | 62 | 65 | 28 | 38 |
Widowed 5 to 9 years | 13 | 18 | 12 | 8 | 6 | 7 | 26 | 28 | 28 | 31 | 51 | 45 | 34 | 30 |
Widowed 10+ years | 18 | 28 | 9 | 11 | 10 | 7 | 31 | 35 | 36 | 40 | 57 | 64 | 35 | 39 |
Age Group |
60–64 | 15 | 21 | 12 | 10 | 5 | 5 | 17 | 28 | 23 | 32 | 41 | 47 | 20 | 24 |
65–69 | 18 | 26 | 11 | 11 | 8 | 7 | 23 | 35 | 29 | 38 | 49 | 55 | 23 | 31 |
70–74 | 20 | 28 | 12 | 11 | 9 | 8 | 28 | 38 | 35 | 43 | 54 | 62 | 27 | 37 |
75–79 | 24 | 31 | 15 | 13 | 10 | 8 | 28 | 31 | 36 | 37 | 61 | 69 | 28 | 37 |
80+ years | 22 | 27 | 11 | 8 | 15 | 9 | 38 | 39 | 45 | 44 | 64 | 74 | 38 | 46 |
Living with Children |
No | 18 | 21 | 13 | 9 | 8 | 7 | 24 | 34 | 30 | 38 | 48 | 56 | 27 | 33 |
Yes | 18 | 27 | 12 | 11 | 8 | 7 | 24 | 33 | 30 | 37 | 51 | 57 | 24 | 31 |
Caste |
Scheduled Caste | 14 | 22 | 7 | 8 | 8 | 5 | 26 | 35 | 31 | 38 | 58 | 61 | 30 | 37 |
Schedule Tribe | 10 | 13 | 5 | 4 | 7 | 8 | 25 | 30 | 28 | 31 | 43 | 47 | 31 | 38 |
Other Backward Caste | 17 | 24 | 12 | 12 | 8 | 7 | 23 | 27 | 29 | 31 | 50 | 57 | 30 | 35 |
None of them | 22 | 30 | 15 | 12 | 9 | 7 | 24 | 38 | 30 | 43 | 47 | 56 | 18 | 26 |
Work status (in the last 1 year) |
No | 21 | 27 | 14 | 12 | 9 | 7 | 24 | 34 | 31 | 38 | 53 | 58 | 27 | 32 |
Yes | 13 | 14 | 8 | 4 | 6 | 6 | 23 | 28 | 28 | 30 | 44 | 49 | 22 | 34 |
Education |
None | 14 | 22 | 6 | 7 | 9 | 6 | 33 | 37 | 36 | 40 | 59 | 61 | 37 | 39 |
< 5 years | 17 | 32 | 10 | 16 | 10 | 8 | 23 | 27 | 30 | 34 | 56 | 56 | 30 | 26 |
6 to 10 years | 19 | 30 | 14 | 16 | 8 | 7 | 19 | 25 | 26 | 30 | 43 | 42 | 16 | 14 |
≥ 11 years | 29 | 32 | 22 | 19 | 5 | 6 | 16 | 35 | 25 | 41 | 35 | 48 | 12 | 14 |
Household Wealth Quintile |
Bottom | 9 | 13 | 3 | 4 | 8 | 5 | 27 | 31 | 29 | 34 | 60 | 64 | 44 | 49 |
Second | 13 | 18 | 8 | 6 | 9 | 6 | 26 | 34 | 29 | 37 | 53 | 57 | 35 | 40 |
Third | 17 | 28 | 9 | 12 | 9 | 7 | 26 | 31 | 31 | 35 | 49 | 56 | 24 | 29 |
Fourth | 18 | 30 | 13 | 14 | 8 | 8 | 21 | 33 | 29 | 39 | 45 | 52 | 17 | 23 |
Top | 31 | 38 | 24 | 20 | 7 | 8 | 21 | 36 | 32 | 42 | 44 | 55 | 9 | 17 |
Place |
Urban | 20 | 28 | 15 | 13 | 7 | 7 | 21 | 31 | 28 | 36 | 46 | 53 | 20 | 29 |
Rural | 17 | 23 | 9 | 8 | 9 | 7 | 27 | 35 | 32 | 39 | 54 | 60 | 30 | 35 |
State |
Himachal Pradesh | 15 | 22 | 9 | 8 | 9 | 6 | 24 | 43 | 29 | 46 | 38 | 46 | 13 | 22 |
Punjab | 25 | 38 | 13 | 14 | 7 | 6 | 38 | 52 | 44 | 56 | 60 | 68 | 10 | 13 |
West Bengal | 19 | 28 | 9 | 7 | 3 | 2 | 15 | 25 | 25 | 31 | 71 | 80 | 37 | 43 |
Orissa | 15 | 17 | 9 | 5 | 5 | 4 | 22 | 29 | 24 | 30 | 45 | 47 | 36 | 46 |
Maharashtra | 13 | 16 | 9 | 6 | 13 | 11 | 31 | 36 | 33 | 37 | 38 | 41 | 26 | 31 |
Kerala | 35 | 45 | 32 | 28 | 16 | 13 | 13 | 17 | 33 | 30 | 62 | 71 | 11 | 23 |
Tamil Nadu | 9 | 12 | 6 | 6 | 3 | 3 | 20 | 27 | 23 | 30 | 45 | 50 | 42 | 46 |
Table
3 displays the estimated relationships between widowhood and linear health-related outcomes (scores of self-rated health, psychological distress, and cognitive ability, separately), as well as between widowhood and binary health-related outcomes (being in poor health and having a probable mental disorder, separately) and binary indicators of chronic disease (diagnosed with hypertension, diabetes, arthritis, asthma, and 1 or more chronic diseases, separately) for men and women separately. The relationships between widowhood and all outcomes except for diabetes, arthritis, asthma, and having 1 or more chronic diseases were statistically significant in Model 1 for women with widowhood being associated with worse outcomes. The same pattern was found for men, but only for cognitive ability and having a probable common mental disorder. Adjusting for socioeconomic factors in Model 2 attenuated the relationships between widowhood and outcomes though most of the estimates remained statistically significant and in the predicted direction. There was no evidence of widowhood acting as a protective factor for either gender.
Table 3
Linear and logistic regression estimates of the association between widowhood and health among older adults in India
Linear Outcome | | b | (95 % CI) | b | (95 % CI) | b | (95 % CI) | b | (95 % CI) |
Self-Rated Health (higher = worse) | Widowed (vs. married) | 0.06 | (−0.03, 0.14) | 0.003 | (−0.08, 0.08) | 0.11*** | (0.06, 0.17) | 0.08** | (0.02, 0.14) |
Psychological Distress (higher = worse) | Widowed (vs. married) | 0.22 | (−0.06, 0.50) | 0.01 | (−0.26, 0.29) | 0.48*** | (0.26, 0.69) | 0.33** | (0.12, 0.55) |
Cognitive Ability (higher = better) | Widowed (vs. married) | −0.30*** | (−0.43, −0.16) | −0.18** | (−0.31, −0.05) | −0.22*** | (−0.31, −0.13) | −0.11* | (−0.20, −0.02) |
Binary Outcome | | AOR | (95 % CI) | AOR | (95 % CI) | AOR | (95 % CI) | AOR | (95 % CI) |
Being in Poor Health | Widowed (vs. married) | 1.14 | (0.94, 1.39) | 1.02 | (0.84, 1.25) | 1.17* | (1.01, 1.35) | 1.08 | (0.93, 1.25) |
Having a Probable Mental Disorder | Widowed (vs. married) | 1.33* | (1.07, 1.66) | 1.17 | (0.93, 1.46) | 1.38* | (1.18, 1.61) | 1.25* | (1.07, 1.48) |
Diagnosed with Hypertension | Widowed (vs. married) | 0.86 | (0.67, 1.10) | 0.86 | (0.67, 1.11) | 1.21* | (1.04, 1.42) | 1.29* | (1.10, 1.52) |
Diagnosed with Diabetes | Widowed (vs. married) | 1.15 | (0.87, 1.54) | 1.21 | (0.90, 1.63) | 1.03 | (0.83, 1.28) | 1.14 | (0.91, 1.42) |
Diagnosed with Asthma | Widowed (vs. married) | 1.02 | (0.74, 1.40) | 0.96 | (0.70, 1.32) | 1.18 | (0.90,1.54) | 1.20 | (0.92, 1.57) |
Diagnosed with Arthritis | Widowed (vs. married) | 0.93 | (0.75, 1.16) | 0.89 | (0.72, 1.11) | 1.07 | (0.92,1.23) | 1.07 | (0.92, 1.24) |
Diagnosed with at least 1 chronic disease | Widowed (vs. married) | 0.88 | (0.72, 1.08) | 0.85 | (0.70, 1.05) | 1.11 | (0.97, 1.28) | 1.12 | (0.97, 1.29) |
When the widowhood category of marital status was re-categorized by taking into account widowhood duration, estimates from Model 3 indicated that only some categories of widowhood were significantly different in terms of outcomes as compared to married individuals (Table
4). Among men, diabetes, cognitive ability, and having a probable common mental disorder, were associated with widowhood, but only for widowers of certain duration. For example, men who were widowed within 0–4 years were more likely to have been diagnosed with diabetes (AOR = 1.64, 95 % CI = 1.06 to 2.54); men who were widowed for 5–9 years were more likely to recall fewer words (b = −0.24, 95 % CI = −0.47 to −0.01) and, men who had been widowed for 10+ years were more likely to have a probable common mental disorder (AOR = 1.38, 95 % CI = 1.01 to 1.88).
Table 4
Linear and logistic regression estimates of the association between widowhood accounting for duration and health among older adults in India
Linear Outcome | | b | (95 % CI) | b | (95 % CI) |
Self-Rated Health | Widowed 0 to 4 years | 0.1 | (−0.04, 0.23) | 0.14** | (0.06, 0.22) |
Widowed 5 to 9 years | −0.12 | (−0.26, 0.03) | −0.01 | (−0.09, 0.08) |
Widowed 10+ years | 0.01 | (−0.11, 0.12) | 0.09* | (0.02, 0.15) |
Psychological Distress | Widowed 0 to 4 years | −0.22 | (−0.67, 0.24) | 0.51** | (0.21, 0.80) |
Widowed 5 to 9 years | −0.09 | (−0.58, 0.40) | 0.06 | (−0.26, 0.37) |
Widowed 10+ years | 0.23 | (−0.16, 0.61) | 0.37** | (0.12, 0.62) |
Cognitive Ability | Widowed 0 to 4 years | −0.13 | (−0.34, 0.09) | −0.13* | (−0.26, −0.01) |
Widowed 5 to 9 years | −0.24* | (−0.47, −0.01) | −0.01 | (−0.14, 0.13) |
Widowed 10+ years | −0.18 | (−0.37, 0.001) | −0.15** | (−0.25, −0.04) |
Binary Outcome | | AOR | (95 % CI) | AOR | (95 % CI) |
Poor Health | Widowed 0 to 4 years | 1.32 | (0.94, 1.87) | 1.40** | (1.13, 1.72) |
Widowed 5 to 9 years | 0.82 | (0.57, 1.17) | 0.77* | (0.62, 0.95) |
Widowed 10+ years | 0.99 | (0.75, 1.31) | 1.11 | (0.93, 1.31) |
Probable Mental Disorder | Widowed 0 to 4 years | 0.92 | (0.62, 1.36) | 1.43** | (1.14, 1.78) |
Widowed 5 to 9 years | 1.13 | (0.76, 1.67) | 1.09 | (0.86, 1.38) |
Widowed 10+ years | 1.38* | (1.01, 1.88) | 1.25* | (1.04, 1.50) |
Hypertension | Widowed 0 to 4 years | 0.93 | (0.62, 1.38) | 1.52*** | (1.22, 1.90) |
Widowed 5 to 9 years | 0.7 | (0.43, 1.14) | 0.86 | (0.67, 1.11) |
Widowed 10+ years | 0.92 | (0.65, 1.29) | 1.39*** | (1.16, 1.67) |
Diabetes | Widowed 0 to 4 years | 1.64** | (1.06, 2.54) | 1.15 | (0.85, 1.56) |
Widowed 5 to 9 years | 1.36 | (0.81, 2.30) | 0.93 | (0.66, 1.32) |
Widowed 10+ years | 0.86 | (0.54, 1.36) | 1.23 | (0.95, 1.58) |
Arthritis | Widowed 0 to 4 years | 0.73 | (0.50, 1.07) | 1.01 | (0.82, 1.25) |
Widowed 5 to 9 years | 0.97 | (0.66, 1.44) | 0.95 | (0.76, 1.19) |
Widowed 10+ years | 0.96 | (0.71, 1.29) | 1.15 | (0.97, 1.36) |
Asthma | Widowed 0 to 4 years | 1.23 | (0.75, 2.02) | 1.32 | (0.91, 1.90) |
Widowed 5 to 9 years | 0.70 | (0.36, 1.37) | 1.37 | (0.94, 2.00) |
Widowed 10+ years | 0.93 | (0.60, 1.45) | 1.07 | (0.79, 1.46) |
Diagnosed with at least 1 chronic disease | Widowed 0 to 4 years | 0.8 | (0.56, 1.13) | 1.12 | (0.92, 1.37) |
Widowed 5 to 9 years | 0.78 | (0.54, 1.15) | 0.95 | (0.77, 1.18) |
Widowed 10+ years | 0.93 | (0.70, 1.23) | 1.20* | (1.02, 1.41) |
Among women, there was evidence of a role for duration for most outcomes (except for diabetes, and again arthritis and asthma). For example, women widowed for 4 years or less or for more than 10 years were more likely to report worse self-rated health (b = 0.14, 95 % CI = 0.06 to 0.22, and b = 0.09, 95 % CI = 0.02 to 0.15, respectively), and worse psychological distress (b = 0.51, 95 % CI = 0.21 to 0.80, and b = 0.37, 95 % CI = 0.12 to 0.62, respectively), as well as recall fewer words (b = −0.13, 95 % CI = −0.26 to −0.01, and b = −0.15, 95 % CI = −0.25 to −0.04, respectively) than married women, separately. In addition, hypertension was more likely among women who were recently widowed or who were widowed for a long time (AOR = 1.52, 95 % CI = 1.22 to 1.90, and AOR = 1.39, 95 % CI - 1.16 to 1.67, respectively). Overall, results indicated that mostly recently widowed women and long-term widowed women were at risk for worse health outcomes compared to married women whereas women who were widowed for 5–9 years were no different than women who were married.
Additional file
1: Tables S1–S4 provide the estimates for the relationships between the other explanatory variables and outcomes. Age was a strong predictor for all outcomes for both genders except for diabetes. Men and women with higher education and higher wealth status were more likely to have better health-related outcomes and lower odds of experiencing chronic disease. Wealth status showed no association with arthritis, asthma, or having one or more chronic diseases. Living with children was not associated with any of the outcomes for either men or women (Additional file
1: Tables S1-S4).
Discussion
This analysis of marital status and health-related outcomes and chronic diseases among older adults across India suggests that, for women, widowhood (as opposed to being married) may be a risk factor for poor self-rated health, psychological distress and reduced cognitive ability, as well as having a probable common mental disorder and being diagnosed with hypertension, separately. There is no evidence of these associations among men except for with cognitive ability and having a probable common mental disorder. Results did not substantively change for men or women even after adjusting for several demographic and socioeconomic factors. Moreover, examining these associations through a widowhood duration lens provides evidence that the relationship between widowhood and health outcomes may be more nuanced than a simple binary effect (widowed vs. not widowed). For women, being widowed for a short amount of time or for the long-term seemed to be worse for many health outcomes as compared to married women. In contrast, the relevance of widowhood duration varied across health outcomes for men though the health of married men was, for the most part, no different than the health of widowed men regardless of widowhood duration.
More recently widowed older women in India may struggle to cope with new substantial losses in access to financial resources and a new (often diminished) social role within their in-laws or son’s household, which may negatively affect their health. Not only may women lose regular economic support when transitioning to widowhood, they may also be deprived of any inheritance rights and lose overall purpose within the household. In contrast, the health of women widowed for an intermediate amount of time (e.g. 5 to 9 years) may not differ from the health of married women because these widowed women have been able to cope (at least temporarily) with the passing of their spouse, have settled into a new household context, and are not yet facing the psychological prospect of having to live for many years without a new spouse nor having to yet address the long-term issues of not having access to resources that a spouse would provide. Perhaps they have found a way to survive by building new social ties or have taken on new responsibilities within their husband’s or son’s family. In addition, survival selection could be playing a role; women who survived to be widowed 5 to 9 years may, on average, be healthier than the same cohort of women when they had only been widowed 4 years or less as the unhealthiest women in that cohort may have died by the time this cohort of women became widowed for 5 to 9 years. Finally, the health of women who have been widowed for 10 or more years may have once again simply deteriorated in contrast to married women perhaps because they have both psychologically and physically remained without resources and spousal support for a decade, a situation which would likely continue until they pass away (as they are not likely to remarry). Critically, regardless of duration, older widowed Indian women may face an interwoven set of losses and challenges that affect their health outcomes [
88].
Among men, the situation appears much more varied. For the most part in India, men’s access to resources does not change when they become widowed. Instead of marital status or duration of widowhood, marital quality might be a better predictor of health outcomes for men. Interestingly, however, more recently widowed men may be susceptible to diabetes-related risk factors, such as a change in diet as wives in India are typically responsible for household chores, including cooking. The death of a wife might lead to a worse diet and onset of diabetes at the beginning before another woman takes over regular preparation of food for the newly widowed man. In contrast, men who would have remained widowed for a long time might have already died or remarried (due to finding it too difficult) whereas the men who remain single long after being widowed are perhaps the most resilient. Importantly, the pathways through which health outcomes are affected at different points during widowhood for both men and women warrant further exploration.
Our findings about self-rated health are similar to previous studies in China and India [
37,
70,
73]. In addition, our findings suggesting reduced cognitive ability among widowed men are similar to a study conducted in three countries in Europe [
17]. However, the present results indicating a negative relationship between widowhood and a number of health outcomes for women and a lack of a relationship between widowhood and most health outcomes for widowed men are inconsistent with many studies from high-income countries, which have typically found a marriage benefit for men and none for women or for both men and women [
1,
2,
4,
9]. The results may be dissimilar in some cases if different mechanisms are operating to link widowhood and health outcomes across contexts. When comparing India and high-income countries like the United States, the United Kingdom, and the Netherlands, there are significant differences in gender norms, economic mobility, marriage traditions, inheritance traditions, and the extent to which government takes care of certain groups within its citizenry (e.g. the widowed, the aged, the poor, etc.). Our result indicating no relationship between psychological distress and marital status for men was the opposite of the results from a study of older adults from Korea [
35]. The findings may between these two countries due to potential differences in gender norms, treatment of wives, and response to the loss of social support.
An important limitation of this study was our inability to examine objective markers of health and disease. Therefore, there are likely undiagnosed cases of mental distress and chronic disease in our sample. Moreover, we were unable to adjust for pre-widowhood disease status, which is likely very important for assessing determinants of health outcomes after widowhood [
27]. In addition, this study does not capture the effect of widowhood and widowhood duration on overall health as indicated by mortality. Critical to acknowledge in the interpretation of these results is that the widowed may be more likely to die than non-widowed. It could be that the men in this study are overall a much healthier population than they would be if the widowed men who had already died were still alive. Although the same could be said of the women, men are more likely to die earlier. Thus, this issue might more strongly bias the findings about men than the findings about women. Finally, given the cross-sectional nature of the data, we cannot infer causality from our associational estimates. Future studies may clarify the relevance of marital status to health outcomes among older widowed men and women in India by collecting longitudinal data and biomarkers as well as information on the quality of marital relationships and information about gender norms and sex roles within the household.