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Marriage, Relationships and Health

Selected Research and Reports

The aims are  to help readers understand the findings of soundly conducted research about what is currently known about this subject, to stimulate additional high quality research to fill in the gaps, and to encourage the design and testing of innovative interventions in health care.  Additional publications and resources will be posted as they come to our attention.
 
We wish to thank the participants in the NHMRC Making Connections Wingspread conference, held in October 2008, for their assistance in compiling and reviewing this collection.

Table of Contents:

Definitions

Research Reviews
Research on Key Topics
Research Linking Relationship Quality and Health
National Health Surveys Data on Marriage and Couple Relationships
MRE Demonstration Projects
MRE Curricula in Programs Focusing on Health Outcomes for:

Prevention Approaches
Conferences on Marriage and Health

Acronyms and Abbreviations Key:
DHHS - Department of Health and Human Services
ACF - Administration for Children and Families, DHHS
OFA - Office of Family Assistance, ACF
NIH - National Institutes of Health, DHHS
CDC - Centers for Disease Control, DHHS
NHMRC - National Healthy Marriage Resource Center
MRE - Marriage and Relationship Education

Definitions

 

What is a Healthy Marriage?

The public debates about marriage emphasize that the goal should be to promote "healthy marriage," not marriage "per se," and that programs should strive to "strengthen marriage."  While healthy marriages can take many different forms, in the following publications researchers identify those key elements that "healthy marriages" share.

Moore, K.A.,  Jekielek, S.M,  Bronte-Tinkew, J.,  Guzman, L.,  Ryan, S,  Redd, Zakia. (2004). What Is "Healthy Marriage"? Defining the Concept. Research Brief, Child Trends. Washington DC. #2003-16.
This brief reviews a large body of research to identify the core characteristics that healthy marriages have in common, and develops a conceptual model that includes the antecedents and consequences of a healthy marriage.

Stanley, S. (2004). Testimony On Healthy Marriage, United States Senate Committee on Finance, Subcommittee on Social Security and Family Policy, May 5, 2004.
The author explains the theory and research upon which he and his colleagues at the Center for Marital Studies believe that sound and healthy marriages are based upon three fundamental types of safety: safety in interaction, personal safety and safety in commitment.

What is Marriage & Relationship Education (MRE)?

These publications describe the little known and rapidly evolving field of marriage and relationship education programs:

Ooms, T. (2005). The New Kid on the Block: What is Marriage Education and Does it Work?
Center for Law and Social Policy (CLASP), Washington DC, 2005.
This brief summarizes the research roots and recent rapid growth of the emerging field of marriage and relationship education both in the private and public sector, and summarizes what is known to date about its effectiveness.

Stanley, S., Markman, H., Jenkins, N (2008) Marriage Education and Government Policy: Helping Couples Who Choose Marriage Achieve Success
In this article the authors respond to commonly asked questions about the research basis for MRE, its goals, and whether it can be effective with low-income populations.

Ooms, T., (2009)  What is the Healthy Marriage Field? What is a Healthy Marriage?
National Healthy Marriage Resource Center Brief
This handout outlines the key findings of the Child Trends and CLASP briefs and the Stanley testimony listed above.

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Research Reviews

Among health researchers there is a growing interest in going beyond the examination of associations between marital status and health outcomes.  New lines of investigation are beginning to measure specific aspects of marital/relationship quality that affect health, and to examine the causal pathways that may connect social support and marital/relationship quality to health outcomes.  The following are comprehensive, balanced, systematic reviews of research across disciplines, with extensive references.

Wood, R., Goesling, B, & Avellar, S. (2007).  The Effects of Marriage on Health: A Synthesis of Recent Research Evidence.  Mathematica Research Institute, Princeton, NJ
Full report available here: http://aspe.hhs.gov/hsp/07/marriageonhealth/index.htm
Brief available here: http://aspe.hhs.gov/hsp/07/marriageonhealth/rb.htm 
Commissioned by the U.S. Department of Health and Human Services this synthesis summarizes the potential protective benefits of marriage in terms of five outcomes: health risk behaviors, health care access, mental health, longevity and physical health of adult partners, and children's health.  It reviews two decades of research on marital status and health outcomes, relying on rigorous studies, with controls for selection of healthier mates as marriage partners, to ensure that outcomes are the result of the protective effects of marriage itself.  The review does not include research on marital quality.

Staton, J. (2009). Making the Connection Between Healthy Marriage and Health Outcomes: What the Research Says. Research Brief, National Healthy Marriage Resource Center. 
This research brief provides an overview of recent research with a specific focus on documenting both positive and negative effects of marital relationship quality on health outcomes, for children, adolescents and young adults, and for adults especially as they age.  Studies which suggest some of the causal pathways are also discussed.

Carr, Deborah, & Springer, Kristen W (2009). Families and Health Research in the 21st Century: Advances in Research and Theory.  Manuscript submitted for publication to the Journal of Marriage and Family. Decade in Review, Special Issue. 
This article is not yet published, but it reviews research in the 1990s on the effects of family structures, transitions, and processes on the physical, mental and social well-being of its members, including children.

Ross, C.E., Mirowsky, J, & Goldstein, K. (1990). The Impact of the Family on Health: The Decade in ReviewJournal of Marriage and Family, 52, 4, 1059-1078.  Available through JSTOR.
This article summarizes research from the 1980's showing that overall, married adults are in better health than the unmarried.  However, many of these studies may not have controlled for selection effects or for socio-economic background variables.

National Healthy Marriage Resource Center (2008) What is the Relationship of Marriage to Physical Health?
This fact sheet provides statistics and data about the connection between healthy marriage and physical health. 

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Research on Key Topics

The research reviews cited above provide numerous research references.  In this section additional key research publications are listed organized by topic.

Infants & Children
Bramlett, M.D. & Blumberg, S.J., Family Structure and Children's Physical and Mental Health.  Health Affairs, 26, 2, 549-558. Available through Health Affairs website. 
Abstract:  Using the 2003 National Survey of Children's Health, this paper examines the physical and mental health of children by family structure. Children in step, single-mother, or grandparent-only families had poorer health than children living with two biological parents. Adjusting for demographic differences reduced observed disparities, although children living in single-mother or grandparent-only families still had poorer health than children living with two biological parents. Adjusted estimates showed that children in single-father families generally did as well as (for mental health) or better than (for physical health) children living with two biological parents.

Amato, P. R., & Cheadle, J. (2005). The Long Reach of Divorce: Divorce and Child Well-Being Across Three Generations. Journal of Marriage and Family, 67, 191-206.
Abstract:  We used data from the study of Marital Instability Over the Life Course to examine links between divorce in the grandparent generation and outcomes in the grandchild generation (N ¼ 691). Divorce in the first (G1) generation was associated with lower education, more marital discord, weaker ties with mothers, and weaker ties with fathers in the third (G3) generation.  These associations were mediated by family characteristics in the middle (G2) generation, including lower education, more marital discord, more divorce, and greater tension in early parent-child relationships. In supplementary analyses, we found no evidence that the estimated effects of divorce differed by offspring gender or became weaker over time. Our results suggest that divorce has consequences for subsequent generations, including individuals who were not yet born at the time of the original divorce. 

Adolescent Health & Risk Behaviors
Brown, S. L. (2006). Family Structure Transitions and Adolescent Well-Being, Demography, 43, 3, 447-471. Also available here:  http://www.bgsu.edu/downloads/cas/file35404.pdf
Abstract:  Data from waves one and two of the National Longitudinal Study of Adolescent Health (N=11,201) were used to investigate the influence of family instability, including parental cohabitation transitions, on adolescent delinquency, depression, and academic problems. Adolescents who experienced a living arrangement transition between waves reported lower levels of well-being at wave two, on average, than those in stable two biological parent married families. This pattern of findings held regardless of whether the transition was from a two-parent to one-parent family or a one-parent to two-parent family. The effects of transitions into and out of stepfamilies on adolescent well-being were similar for married versus cohabiting stepfamilies. Formalization of a cohabiting stepfamily through marriage did not translate into any appreciable benefits for adolescent well-being.

Kaye, K., Day, R.D., Hair, E.C., Moore, K.A., Hadley, A. M. & Orhner, D.K. Parent Marital Quality and the Parent-Adolescent Relationship: Effects on Sexual Activity Among Adolescents and Youth (2008). Marriage and Family Review, 45, Issue 2/3. See also: http://aspe.hhs.gov/hsp/08/RelationshipStrengths/SexualActivity 
Abstract:  The link between growing up outside of an intact family, and the likelihood of engaging in risky
sexual behaviors as an adolescent has been explored extensively. However, there are fewer studies examining the age of onset of sexual activity and the likelihood of risky sexual behaviors among adolescents within intact families, specifically married-parent families, and what elements of married-parent families seem to function as protective factors for adolescents. This study takes an extensive look at relationship characteristics within married-parent families-that is, the parent marital relationship, the youth-parent relationship, and the interaction of the two-to identify the family context that might influence adolescents sexual activity. Parental marital relationships were characterized both with respect to level of supportive qualities as well as degree of conflict, and the youth's relationship with each parent was characterized as positive or negative.

Adult Health & Well-Being
Bookwala, J. (2005). The Role of Marital Quality in Physical Health during the Mature Years. Journal of Aging and Health, 17, 85-104.  Available through Sage Publications.
Abstract:  This study examined the role of marital quality in the physical health of mature adults. Method: Participants were from the National Survey of Midlife Development in the United States aged 50+ years who were in their first marriage. Five dimensions of marital quality and four indicators of physical health were used. Results: Regression analyses indicated that marital quality indices accounted for a significant amount of explained variance in physical health. Most notably, higher levels of negative spousal behaviors uniquely contributed to physical health, predicting more physical symptoms, chronic health problems, and physical disability, and poorer perceived health.


Hawkins, D., & Booth, A. (2005). Unhappily Ever After: Effects of Long-term, Low-quality Marriages on Well-being. Social Forces, 84, 445-465. Available through JSTOR.
Abstract:  The present study shows that long-term, low-quality marriages have significant negative
effects on overall well-being. We utilizea nationally representative longitudinal study with a multi-item marital quality scale that allows us to track unhappy marriages over a 12-year period and to assess marital happiness along many dimensions.  Remaining unhappily married is associated with significantly lower levels of overall happiness, life satisfaction, self-esteem and overall health along with elevated levels of psychological distress compared to remaining otherwise continuously married. There is also some evidence that staying unhappily married is more detrimental than divorcing, as people in low-quality marriages are less happy than individuals who divorce and remarry. They also have lower levels of life satisfaction, self-esteem and overall health than individuals who divorce and remain
unmarried. Unhappily married people may have greater odds of improving their wellbeing by dissolving their low-quality unions as there is no evidence that they are better off in any aspect of overall well-being than those who divorce.

Hughes, M.E. & Waite, L.J. (2009). Marital Biography and Health at Mid-life. Journal of Health and Social Behavior 50, 344-358.
Abstract:  This article develops a series of hypotheses about the long-term effects of one's
history of marriage, divorce, and widowhood on health, and it tests those hypotheses using data from the Health and Retirement Study. We examine four dimensions of health at mid-life: chronic conditions, mobility limitations, self-rated health, and depressive symptoms. We find that the experience of marital disruption damages health, with the effects still evident years later; among the currently married, those who have ever been divorced show worse health on all dimensions. Both the divorced and widowed who do not remarry show worse health than the currently married on all dimensions. Dimensions of health that seem to develop slowly, such as chronic conditions and mobility limitations, show strong effects of past marital disruption, whereas others, such as depressive symptoms, seem more sensitive to current marital status. Those who spent more years divorced or widowed show more chronic conditions and mobility limitations.

Lorenz, F.O., Wickrama, K.A.S., Conger, R.D. & Elder, G.H. (2006). The Short-term and Decade-long Effects of Divorce on Women's Midlife Health. Journal of Health & Social Behavior, 47. 111-125. Available through JSTOR.
Abstract:  We hypothesize that divorce immediately increases psychological distress and has long-term negative consequences for the physical health of divorced people. In addition, we hypothesize that divorce indirectly causes long-term increases in distress through stressful midlife events. The hypotheses are tested using data from 416 rural Iowa women who were interviewed repeatedly in the early 1990s when they were mothers of adolescent children; the women were interviewed again in 2001. The data support the hypotheses. In the years immediately after their divorce (1991-1994), divorced women reported significantly higher levels of psychological distress than married women but no differences in physical illness. A decade later (in 2001), the divorced women reported significantly higher
levels of illness, even after controlling for age, remarriage, education, income, and prior health. Compared to their married counterparts, divorced women reported higher levels of stressful life events between 1994 and 2000, which led to higher levels of depressive symptoms in 2001.

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.
Abstract:  We work from a life course perspective and identify several reasons to expect age and gender differences in the link between marital quality and health. We present growth curve evidence from a national longitudinal survey to show that marital strain accelerates the typical decline in self-rated health that occurs over time and that this adverse effect is greater at older ages. These findings fit with recent theoretical work on cumulative adversity in that marital strain seems to have a cumulative effect on health over time-an effect that produces increasing vulnerability to marital strain with age. Contrary to expectations, marital quality seems to affect the health of men and women in similar ways across the life course.

Zhang, Zhenmei, and Mark D. Hayward. 2006. Gender, the Marital Life Course & Cardiovascular Health in Late Midlife. Journal of Marriage and the Family, 68, (3), 639-657. Available through Wiley-Blackwell.
Abstract:  Drawing on 5 waves of the Health and Retirement Study, we examine the influence of the
marital life course on the prevalence and incidence of cardiovascular disease among 9,434 middle-aged individuals. Results show that compared to continuously married persons, both men and women with a marital loss have significantly higher prevalence of cardiovascular disease at baseline. Men and women, however, differ in the effects of marital loss on the incidence of cardiovascular disease over the course of the study. Women with a marital loss have a higher risk of cardiovascular disease in late midlife compared to continuously married women, whereas marital loss is not associated with men's risk of cardiovascular disease. Emotional distress and socioeconomic status account for the higher risk of cardiovascular disease among divorced women.

African Americans and the Black Community
Okafor, Martha Okafor.  2007.  A Public Health Perspective on Healthy Marriage.  Prepared for the African American Healthy Marriage Initiative (AAHMI).   

Mortality
Kaplan, Robert M. and Richard G. Kronick. Marital Status and Longevity in the United States Population. Journal of Epidemiology and Community Health, vol. 60, 2006, pp. 760-765.
Abstract: Purpose: To investigate the relation between marital status and survival. Data sources: The US 1989 national health interview survey (NHIS) merged with the 1997 US national death index. Results: Among 1989 NHIS respondents, 5876 (8.77%) died before 1997 and 61 123 (91.23%) were known to be alive. Controlling for demographic and socioeconomic characteristics, the death rate for people who were unmarried was significantly higher than it was for those who were married and living with their spouses. Although the effect was significant for all categories of unmarried, it was strongest for those who had never married. The never married effect was seen for both sexes, and was significantly stronger for men than for women. For the youngest age group (19-44), the predominant causes of early death among adults who had never married were infectious disease (presumably HIV) and external causes. In the middle aged and older men and women, the predominant causes were cardiovascular and other chronic diseases. Conclusion: Current marriage is associated with longer survival. Among the not married categories, having never been married was the strongest predictor of premature mortality. It is difficult to assess the causal effect of marital status from these observational data.

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Research Linking Relationship Quality and Health

An emerging group of research studies focus on the strength of the associations between "marital quality" (defined as the emotional climate and interpersonal interactions between spouses) and the health of both adult partners and children.  The interest in these psychosocial factors is high because relationship dynamics are potentially modifiable through information and education.  

The studies listed below are just a few examples of well-conducted clinical and longitudinal cohort studies, across various disciplines, focusing on different health outcomes in relation to marital or relationship quality.  The examples are studies that took into account background variables affecting health (such as income and race), and some use physiological measures or medical records as well as self-reports of health.

Heart Disease Studies
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. American Journal of Cardiology. 88, 5, 526-529.
Abstract:  Mounting evidence indicates that social support is associated with better outcomes of cardiovascular disease and reduced all-cause mortality. Much less is known about the specific contribution of marital functioning to these outcomes, and the potential prognostic significance of marital quality for congestive heart failure (CHF) has not been explored. Interview and observational measures of marital quality obtained from 189 patients with CHF (139 men and 50 women) and their spouses were examined as predictors of patient survival up to 48 months after assessment and compared with prediction based on illness severity (New York Heart Association [NYHA] class). Four-year survival rates were 52.5% and 68% for male patients and female patients, respectively. In Cox regression analyses, a composite measure of marital quality predicted 4-year survival as well as the patient's concurrent NYHA class did (both p <0.001). Adjusting for CHF severity did not diminish the prognostic significance of marital functioning, and prediction of survival from marital quality appeared stronger for female than for male patients. Thus, when marital quality and NYHA class are considered jointly, they both make independent, statistically significant contributions to the prediction of patient mortality.

De Vogli, R., Chandola, T., & Marmot, M. G. (2007). Negative Aspects of Close Relationships and Heart Disease. Archives of Internal Medicine, 167, 1951-1957.
Abstract:  Background: The aims of the study were to (1) analyze the association between negative aspects of close relationships and increased risk for coronary heart disease and (2) examine whether the association is stronger among women and people of lower social position. Methods: Prospective cohort study of 9011 British civil servants (6114 men and 2897 women). Negative aspects of close relationships and other social support measures (confiding/emotional and practical) were assessed with the Close Persons Questionnaire during phase 2 (1989-1990) or phase 1 (1985-1988). Associations between negative aspects of close relationships and incident coronary events were determined during an average follow-up period of 12.2 years. Covariates included sociodemographic characteristics (age, sex, marital status, and employment grade), biological factors (obesity, hypertension, diabetes mellitus, and cholesterol level), psychosocial factors (negative affectivity, depression, and work stress), and health behaviors (smoking, alcohol intake, exercise, and fruit and vegetable consumption). Results: After adjustment for sociodemographic characteristics, biological factors, and other dimensions of social support, individuals who experienced negative aspects of close relationships had a higher risk of incident coronary events (hazard ratio, 1.34; 95% confidence interval, 1.10-1.63). The association was attenuated but remained statistically significant after additional adjustment for negative affectivity and depression (hazard ratio, 1.25; 95% confidence interval, 1.02-1.55). Although women and men in a lower employment grade were more likely to be exposed to negative aspects of close relationships, sex and social position had no statistically significant interaction effects. Confiding/emotional and practical support were not associated with incident coronary events. Conclusion: Adverse close relationships may increase the risk of heart disease.

Immune System Studies
Kiecolt-Glaser, J.K. & Newton, T.L. (2001). Marriage and Health: His and Hers? Psychological Bulletin, 127, 4, 472-503.  Available through PsycNET.
Abstract:  This review focuses on the pathway leading from the marital relationship to physical health. Evidence from 64 articles published in the past decade, particularly marital interaction studies, suggests that marital functioning is consequential for health; negative dimensions of marital functioning have indirect influences on health outcomes through depression and health habits, and direct influences on cardiovascular, endocrine, immune, neurosensory, and other physiological mechanisms. Moreover, individual difference variables such as trait hostility augment the impact of marital processes on biological systems. Emerging themes in the past decade include the importance of differentiating positive and negative dimensions of marital functioning, the explanatory power of behavioral data, and gender differences in the pathways from the marital relationship to physiological functioning. Contemporary models of gender that emphasize self-processes, traits, and roles furnish alternative perspectives on the differential costs and benefits of marriage for men's and women's health.

Kiecolt-Glaser, J.K., Glaser, R., Caccioppo, J.T., Malarkey, W. B. (1998). Marital Stress: Immunologic, Neuroendocrine, and Autonomic Correlates. Annals of the New York Academy of Sciences. 840, 656-663. Available through Wiley InterScience.
Abstract:  Ninety newlywed couples (mean age = 25), selected on the basis of extremely stringent mental and physical health criteria, were admitted to a hospital research unit for 24 hours to provide a detailed assessment of conflict-resolution behaviors and changes in autonomic, endocrine, and immune function. Among these newlyweds, negative or hostile behaviors during marital conflict (coded from videotaped interactions) were associated with increased levels of epinephrine, norepinephrine, growth hormone, and ACTH as well as greater immunological change over the subsequent 24 hours. Wives demonstrated greater and more persistent physiological changes related to marital conflict than husbands. To assess the generalizability of these physiological changes, a similar laboratory paradigm was used with 31 older couples (mean age = 67) who had been married an average of 42 years. Consistent with the data from newlyweds, both endocrinological and immunological data showed significant relationships to negative behavior during marital conflict in these older couples. These findings suggest that abrasive marital interactions have important endocrinological and immunological correlates.

Divorce, Depression Studies
Lorenz, F.O., Wickrama, K.A.S., Conger, R.D. & Elder, G.H. (2006). The Short-term and Decade-long Effects of Divorce on Women's Midlife Health Journal of Health & Social Behavior, 47. 111-125.  Available through JSTOR.
Abstract:  We hypothesize that divorce immediately increases psychological distress and has long-term negative consequences for the physical health of divorced people. In addition, we hypothesize that divorce indirectly causes long-term increases in distress through stressful midlife events. The hypotheses are tested using data from 416 rural Iowa women who were interviewed repeatedly in the early 1990s when they were mothers of adolescent children; the women were interviewed again in 2001. The data support the hypotheses. In the years immediately after their divorce (1991-1994), divorced women reported significantly higher levels of psychological distress than married women but no differences in physical illness. A decade later (in 2001), the divorced women reported significantly higher
levels of illness, even after controlling for age, remarriage, education, income, and prior health. Compared to their married counterparts, divorced women reported higher levels of stressful life events between 1994 and 2000, which led to higher levels of depressive symptoms in 2001.

Amato, P. R., & Cheadle, J. (2005).  The Long Reach of Divorce: Divorce and Child Well-being Across Three Generations. Journal of Marriage and Family, 67, 191-206. Available through Wiley InterScience.
Abstract:  We used data from the study of Marital Instability Over the Life Course to examine links between divorce in the grandparent generation and outcomes in the grandchild generation (N ¼ 691). Divorce in the first (G1) generation was associated with lower education, more marital discord, weaker ties with mothers, and weaker ties with fathers in the third (G3) generation.  These associations were mediated by family characteristics in the middle (G2) generation, including lower education, more marital discord, more divorce, and greater tension in early parent-child relationships. In supplementary analyses, we found no evidence that the estimated effects of divorce differed by offspring gender or became weaker over time. Our results suggest that divorce has consequences for subsequent generations, including individuals who were not yet born at the time of the original divorce. 

Marital Quality & Health Over the Lifespan

Carr, D, & Springer, K. (2010). Advances in Families and Health Research in the 21st Century.  Journal of Marriage and Family (Decade in Review Special Issue) 72: 744-762.
Abstract: We review research on families and health published between 2000 and 2009 and highlight key themes and findings from innovative, methodologically rigorous studies. Whereas research in prior decades focused primarily on whether family structure affects child and adult health, contemporary research examines the contextual and processual factors that shape for whom, for which outcomes, and under what conditions families affect mental and physical health. We discuss how family structure, transitions, and processes within families of origin affect children's health over the life course. We then examine the effects of marital status, transitions, and quality for adult health. We point out limitations in current research, discuss implications of recent findings for policy, and highlight theoretical and methodological directions for future research.

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.
Abstract:  We work from a life course perspective and identify several reasons to expect age and gender differences in the link between marital quality and health. We present growth curve evidence from a national longitudinal survey to show that marital strain accelerates the typical decline in self-rated health that occurs over time and that this adverse effect is greater at older ages. These findings fit with recent theoretical work on cumulative adversity in that marital strain seems to have a cumulative effect on health over time-an effect that produces increasing vulnerability to marital strain with age. Contrary to expectations, marital quality seems to affect the health of men and women in similar ways across the life course.

Hawkins, D., & Booth, A. (2005). Unhappily Ever After: Effects of Long-term, Low-quality Marriages on Well-being. Social Forces, 84, 445-465. Available through JSTOR.
Abstract:  The present study shows that long-term, low-quality marriages have significant negative
effects on overall well-being. We utilizea nationally representative longitudinal study with a multi-item marital quality scale that allows us to track unhappy marriages over a 12-year period and to assess marital happiness along many dimensions.  Remaining unhappily married is associated with significantly lower levels of overall happiness, life satisfaction, self-esteem and overall health along with elevated levels of psychological distress compared to remaining otherwise continuously married. There is also some evidence that staying unhappily married is more detrimental than divorcing, as people in low-quality marriages are less happy than individuals who divorce and remarry. They also have lower levels of life satisfaction, self-esteem and overall health than individuals who divorce and remain
unmarried. Unhappily married people may have greater odds of improving their wellbeing by dissolving their low-quality unions as there is no evidence that they are better off in any aspect of overall well-being than those who divorce.

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National Health Surveys Data on Marriage and Couple Relationships

Listed here are several large federally-funded, longitudinal health surveys which also collect some information on marriage and partner relationships, and provide a few examples of published studies that illustrate the potential of these surveys for examining the marriage/health connections.  

Fragile Families and Child Well-Being Study
http://www.fragilefamilies.princeton.edu/
This study followed a cohort of nearly 5000 children born in US cities between 1998 and 2000, three-quarters born to unmarried parents.  Baseline data was collected from both fathers and mothers at birth and repeated when the children were ages one, three and five, In-home assessments were conducted of the children at ages three and five years included physical and mental health measures.  A follow-up study for 2007-2009 is underway.

Sample publications include:
Dush, C.M.K., & Adkins, K.S. (2009). The Mental Health of Mothers and Fathers Before and After Cohabitation and Marital Dissolution. Center for Research on Child Wellbeing. Working Paper #2009-03-FF. Also available at: http://crcw.princeton.edu/publications/publications.asp.

Harknett, K. (2005).  Children's Elevated Risk of Asthma in Unmarried Families Underlying Structural and Behavioral Mechanisms. Working Paper 2005-01-FF.  Also available at: http://crcw.princeton.edu/publications/publications.asp.

Meadows, S.(2007).  Family Structure & Fathers' Well-being: Trajectories of Physical & Mental Health. Working Paper 2007-19-FF.  Also available at:  http://crcw.princeton.edu/publications/publications.asp

Adverse Childhood Experiences Study (ACE)   
http://www.acestudy.org  and at: http://www.cdc.gov/NCCDPHP/ACE
The Center for Disease Control (CDC)-funded Adverse Childhood Experiences Study is following 17,000 middle-class adults in order to study the association between 10 adverse life experiences during childhood or adolescence, and later well-being, health risks, disease, social functioning, medical care costs and mortality experienced in adulthood.

National Children's Study
http://www.nationalchildrensstudy.gov/Pages/default.aspx
The new 20-year National Children's Study, launched in 2009, will examine the effects of physical, biological, familial, psychosocial and environmental influences on the health and development of 100,000 children across the United States, following them from before birth until age 21.

National Longitudinal Study of Adolescent Health http://www.cpc.unc.edu/projects/addhealth/projects/addhealth
The National Longitudinal Study of Adolescent Health followed a nationally representative sample of 90,000 adolescents from grades 7-12 in 1994-95 into young adulthood. Add Health combines longitudinal survey data on respondents' social, economic, psychological and physical well-being with contextual data on the family, neighborhood, community, school, friendships, peer groups, and romantic relationships.

Sample publications include:
Brown, S. L. (2006). Family Structure Transitions and Adolescent Well-Being, Demography, 43, 3, 447-471. Also available here:  http://www.bgsu.edu/downloads/cas/file35404.pdf
Abstract:  Data from waves one and two of the National Longitudinal Study of Adolescent Health (N=11,201) were used to investigate the influence of family instability, including parental cohabitation transitions, on adolescent delinquency, depression, and academic problems. Adolescents who experienced a living arrangement transition between waves reported lower levels of well-being at wave two, on average, than those in stable two biological parent married families. This pattern of findings held regardless of whether the transition was from a two-parent to one-parent family or a one-parent to two-parent family. The effects of transitions into and out of stepfamilies on adolescent well-being were similar for married versus cohabiting stepfamilies. Formalization of a cohabiting stepfamily through marriage did not translate into any appreciable benefits for adolescent well-being.

Manning, W. D., & Lamb, K. A. (2003).  Adolescent Well-Being in Cohabiting, Married, and Single-Parent Families. Journal of Marriage and the Family, 65(4), 876-893.  Available through JSTOR.
Abstract:  Cohabitation is a family form that increasingly includes children. We use the National Longitudinal Study of Adolescent Health to assess the well-being of adolescents in cohabiting parent
stepfamilies (N ! 13,231). Teens living with cohabiting stepparents often fare worse than teens living with two biological married parents. Adolescents living in cohabiting stepfamilies experience greater disadvantage than teens living in married stepfamilies. Most of these differences, however, are explained by socioeconomic circumstances. Teenagers living with single unmarried mothers are similar to teens living with cohabiting stepparents; exceptions include greater delinquency and lower grade point  averages experienced by teens living with cohabiting stepparents. Yet mother's marital history explains these differences. Our results contribute to our understanding of cohabitation and debates about the importance of marriage for children.

Blum, R. W., Beuhring, T., Shew, M. L., Bearinger, L. H., Sieving, R. E., & Resnick, M. D. (2000). The Effects of Race/Ethnicity, Income, and Family Structure on Adolescent Risk Behaviors. American Journal of Public Health, 90(12), 1879-84.
Abstract:  The study examined the unique and combined contributions of race/ethnicity, income, and family structure to adolescent cigarette smoking, alcohol use, involvement with violence, suicidal thoughts or attempts, and sexual intercourse. Methods: Analyses were based on the National Longitudinal Study of Adolescent Health. A nationally representative sample of 7th to 12th graders participated in in-home interviews, as did a resident parent for 85.6% of the adolescent subjects. The final sample included 10,803 White, Black, and Hispanic 7th to 12th graders. Results: White adolescents were more likely to smoke cigarettes, drink alcohol, and attempt suicide in the younger years than were Black and Hispanic youths. Black youths were more likely to have had sexual intercourse; both Black and Hispanic youths were more likely than White teens to engage in violence. Controlling for gender, race/ethnicity, income, and family structure together explained no more than 10% of the variance in each of the 5 risk behaviors among younger adolescents and no more than 7% among older youths. Conclusions: Findings suggest that when taken together, race/ethnicity, income, and family structure provide only limited understanding of adolescent risk behaviors.

National Longitudinal Survey of Youth (NLSY)
http://www.bls.gov/nls
The National Longitudinal Survey of Youth 1997 (NLSY97) is a survey of a cohort of 9000 young men and women born in the years 1980-84. The respondents were ages 12-17 at first interview and are being followed into adulthood with annual interviews, including relationship quality of youth/young adult relationship; First year interviews included parents' marital status and relationship quality; later data collection includes quality of young adult intimate relationships.

Sample publication:
Kaye, K., Day, R.D., Hair, E.C., Moore, K.A., Hadley, A. M. & Orhner, D.K. (2008). Parent Marital Quality and the Parent-Adolescent Relationship: Effects on Sexual Activity Among Adolescents and Youth. Marriage and Family Review, 45, Issue 2/3. Also available at: http://aspe.hhs.gov/hsp/08/RelationshipStrengths/SexualActivity

National Survey of MidLife in the US (MIDUS)
http://midus.wisc.edu/midus2/
The MIDUS survey, which began in 1995, is a national longitudinal study of 7,000 individuals age 25 to 80 plus.  It investigates participants behavioral, social, psychological, biological, and neurological factors that jointly influence health and well-being as people get older.  Outcomes include onset of aging, health problems, disabilities and mortality rates.  The second wave, MIDUS II is adding comprehensive bio-markers (direct physiological measures) and neuroscience assessments, as well as more focus on relationship quality, in order to provide a more complete picture of the physiological pathways from psychosocial factors to health outcomes.

Sample publications include: 
Bookwala, J. (2005). The Role of Marital Quality in Physical Health during the Mature Years. Journal of Aging and Health, 17, 85-104.  Available through Sage Publications.
Abstract:  This study examined the role of marital quality in the physical health of mature adults. Method: Participants were from the National Survey of Midlife Development in the United States aged 50+ years who were in their first marriage. Five dimensions of marital quality and four indicators of physical health were used. Results: Regression analyses indicated that marital quality indices accounted for a significant amount of explained variance in physical health. Most notably, higher levels of negative spousal behaviors uniquely contributed to physical health, predicting more physical symptoms, chronic health problems, and physical disability, and poorer perceived health.

Maier, E.H. & Lachman, M.E. (2000). Consequences of Early Parental Loss and Separation for Health and Well-being in Midlife. International Journal of Behavioral Development, 24, 2, 183-89. Available through Sage Publications.
Abstract:  We examined the impact of parental death and divorce prior to age 17 on physical and mental wellbeing in a national probability sample of middle-aged adults. The results suggest that, for men, parental divorce was associated with less positive relations with others, less self-acceptance, lower environmental mastery, and greater depression. Parental divorce predicted higher levels of physical health problems for both men and women. This relationship was mediated by income, education, drug use, and family support and was greater for men than women. Parental death predicted more autonomy for men and a higher likelihood of depression for women. The results contribute to understanding the developmental pathways involved in linking early life experiences to adulthood outcomes.

Health & Retirement Survey (HRS)
http://hrsonline.isr.umich.edu
The Health and Retirement Study (HRS) surveys cohorts of more than 22,000 Americans over the age of 50 every two years, and adds a new cohort every 6 years. HRS studies physical and mental health, insurance coverage, financial status, family support systems, labor market status, and retirement planning.

Sample publication:
Zhang, Zhenmei, and Mark D. Hayward. 2006. Gender, the Marital Life Course & Cardiovascular Health in Late Midlife. Journal of Marriage and the Family, 68, (3), 639-657.  Available through Wiley InterScience.
Abstract:  Drawing on 5 waves of the Health and Retirement Study, we examine the influence of the marital life course on the prevalence and incidence of cardiovascular disease among 9,434 middle-aged individuals. Results show that compared to continuously married persons, both men and women with a marital loss have significantly higher prevalence of cardiovascular disease at baseline. Men and women, however, differ in the effects of marital loss on the incidence of cardiovascular disease over the course of the study. Women with a marital loss have a higher risk of cardiovascular disease in late midlife compared to continuously married women, whereas marital loss is not associated with men's risk of cardiovascular disease. Emotional distress and socioeconomic status account for the higher risk of cardiovascular disease among divorced women.

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MRE Demonstration Projects

Described below are three rigorously designed government funded MRE demonstration projects using the "gold standard" of evaluation - randomly assigning couples to experimental or control treatments, and following the couples over time.  Although health outcomes were not the main focus of these programs, most of the evaluations collect some health outcome data, as described here.

Federal Experiments  The Office of Policy Research and Evaluation in the Administration for Children and Families at the U.S. Department of Health and Human Services has funded two large-scale, multi-site longitudinal evaluations of healthy marriage education services targeted on low income unmarried and married parents which are ongoing.  Both programs are including some measures of adult health-related outcomes, including general health rating, mental health (e.g., depressive symptoms), substance use, and health insurance coverage.  Measures of child well-being include birth weight, measures of socio-emotional development, general health rating, presence and severity of asthma, and health insurance coverage.

Building Strong Families (BSF) The purpose of this project is to evaluate MRE and related services for romantically involved, low-income, unwed parents around the time of the birth of a child in seven sites.  Contractor: Mathematica Policy Research, Inc. www.buildingstrongfamilies.info

Supporting Healthy Marriage (SHM)  In response to research indicating that lower-income couples separate and divorce at higher rates than higher-income couples, the SHM study will evaluate MRE and related services designed to help lower-income married couples strengthen and maintain their marriage in eight sites. Contractor: Manpower Demonstration Research Corporation (MDRC), www.supportinghealthymarriage.org  

Supporting Father Involvement Preventive Intervention Study http://supportingfatherinvolvement.org/cowans.html  The California Department of Social Services, Child Abuse Prevention Office funded a randomized clinical trial of the effects of two types of parental education program on child behavior, marital satisfaction and communication.  The sample included 289 low-income couples who were expecting or had children up to age 7.  A majority of them were Mexican American, including married, cohabiting and co-parenting couples.  Participants were randomly assigned to a 16-week fathers' group, 16-week couples' group, or 1-time control group "information" meeting.  Participants in couple groups showed more consistent, longer-term positive effects at the one-year follow up than those in father-only groups.   

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MRE Curricula & Programs Focusing on Health Outcomes

We include here a selection of MRE curricula and programs which are integrated into existing health programs in order to learn whether they improve health outcomes such as healthy birth and infant development, prevention of maternal post-natal depression, reduction of risky adolescent sexual behavior, prevention of child abuse, and improve the management and hence the course of adult chronic disease.

For New Parents / Young Parents

Becoming Parents Program (BPP) BPP demonstration being implemented in Seattle, Washington provides expectant couples with specific knowledge and skills for taking care of their relationship and themselves, to understand and interact effectively with their baby, and deal with the ways a new baby will impact their lives. BPP is also being used in one of the sites in the Supporting Healthy Marriages demonstration program evaluation. http://www.becomingparents.com

Bringing Baby Home Bringing Baby Home teaches skills for strengthening the couple relationship when the baby comes home. It includes modules for nurturing and fostering the baby's development. Bringing Baby Home is being adapted and used by five program sites in the Building Strong Families evaluation ( & renamed, Loving Couples, Loving Children) http://www.bbhonline.org/aboutrri.aspx   

Enhanced Nurse-Family Partnership Study, Portland State University This version of the Olds' Nurse-Family Partnership (NFP) is nurse-delivered home visitation program that targets high-risk first-time mothers-to-be.  Services are continued until the child is two years of age and include components addressing safety, and the relationship between the parents.  Principal Investigator: Lynette Feder Ph.D, lfeder@pdx.edu    

Family Foundations Developed and researched by Mark Feinberg, Ph.D., Family Foundations is the result of years of his work as a clinical psychologist, family therapist, and prevention scientist at Penn State University. http://www.famfound.net/

Love's Cradle RE Love's Cradle targets unmarried, low-income co-parenting couples. The curriculum is being used at one site in the Building Strong Families program. http://www.skillswork.org  

New Home Visiting Demonstrations with Healthy Marriage Components The Children's Bureau has funded three home visiting programs based on the Nurse-Family Partnership (NFP) model which include strong marriage / relationship education components.  One program also has a father involvement component.   

For Adolescents / Youth

New research-based relationship education curricula designed for use in public middle and high school classes, help teens acquire the concepts and practical skills for forming emotionally healthy, mature and ethically-sound relationships, and avoid early, risky sexual activity that has long term negative health consequences.  The following are examples of several research-based and evaluated curricula for teens whose development and dissemination is sponsored by The Dibble Institute.

LoveU2  is a comprehensive, developmentally appropriate curriculum that guides teens in building healthy relationships and making wise relationship choices.  An adaptation of LoveU2 for high-risk youth called Love Notes: Making Relationships Work for Young Adults and Young Parents, funded by the Annie E Casey Foundation is now being field-tested in several Youth Build sites.  Developer: Marline Pearson

Relationships Smarts Plus is another adaptation of Love U2 being offered in several high schools in Alabama and evaluated by researchers at Auburn University.   More Information.

Connections is a nationally evaluated relationship and marriage program for teens with two versions: Dating and Emotions for middle school, and Relationships and Marriage for high school

Healthy Choices, Healthy Relationships - Character and Consequences.  This new version of Connections for ninth graders, which combines material from the empirically tested PREP program, is now being piloted in Oklahoma high school health classes as a part of the Oklahoma Marriage Initiative. Developer:  Charlene R. Kamper

For Adults

A few relationship education programs for couples facing chronic illness are now being developed and evaluated.  They generally have the twin goals of helping couples protect their relationship from the multiple and prolonged stresses of coping with the disease, and also potentially improving patient health outcomes by increasing social support and adherence to medical regimens.

Relationship Matters, National Multiple Sclerosis Society
Relationship Matters helps couples deal with the effects of multiple sclerosis on their relationship. It features cutting-edge on-demand, learn at home programs through the Internet or by teleconference, to overcome the challenges of accessibility, fatigue, and mobility impairment for couples with MS which can make it difficult for them to participate in community based programs.  This program was intentionally designed as a model for use with couples coping with other chronic illnesses and disabilities.  This program was funded for five years by the Office of Family Assitance in the Administration for Children and Families at the U.S. Department of Health and Human Services.   

Coping Skills Training for Type 2 Diabetes with Immigrant Chinese Families
This behavioral diabetes education and research program addresses specific family and cultural factors in immigrant Chinese patients with diabetes which exert substantial effects on Type 2 diabetes (T2DM) outcomes, including family emotional processes, support and conflict management.  Funded by THe National Institute of Nursing Research, NIH.  University of California, San Francisco, Principal Investigator: Catherine Chesla.  

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Public Health Prevention Strategies

Two general types of public health primary prevention approaches, based on the research linking marital and relationship quality to health, are beginning to emerge.  Others can be expected to be developed in the future.  These are (1) Training health care and other professionals on how to recognize and appropriately address relationship issues in the course of their work; and (2) Providing the public with general information about how couple relationships can affect and in turn be affected by physical and mental health. The following are examples of both types.

The Brief Encounters Program
Brief Encounters® was developed in Great Britain by the non-profit organization One Plus One to help frontline primary health care providers make timely and effective brief relationship interventions with the families they encounter routinely.   More Information.

Hawkins, A. & Ooms, T. (2010). What Works in Relationship and Marriage Education?: A Review of Lessons Learned with a Focus on Low-Income Couples.  National Healthy Marriage Resource Center Research Report.
This report reviews and synthesizes the lessons emerging from evaluation research and practitioner experience to address two related questions: (a) What have we learned about the design and implementation of government-sponsored MRE programs? and (b) What do we know about the effects of these programs on participants, especially low-income populations? It begins with a summary of the key lessons that have emerged from implementation studies of MRE programs currently in the field. Next, it summarizes and synthesizes the evidence on program effects from strong evaluations conducted on the first generation of MRE programs (i.e., from the mid-seventies to the early 2000s, prior to substantial public funding). Results are then presented from a new meta-analysis of 15 evaluation studies, including three randomized control trials (many of them funded by the federal government), of second generation MRE programs serving low-income populations. The Report briefly mentions the Building Strong Families multi-site experiment which released its interim impact findings in May 2010. The conclusion summarizes the overall results to date and ends with a list of recommendations for future research.

Healthy Marriages, Healthy Lives. (2008)
Healthy Marriages, Healthy Children.  (2009)
Howell, P. Editor, California Healthy Marriages Coalition
Two brochures provide brief descriptions of numerous selected studies that show evidence of positive associations between marriage and health outcomes for adults and children.

Tips for Sustaining a Healthy Marriage in Families with Children with Special Needs. (2009). National Healthy Marriage Resource Center.

Depression and Marriage.  (2007). National Healthy Marriage Resource Center.

Nakazawa, D. J.  How a Marriage Survives When One Partner Gets Sick  More Magazine, August 2009
The popular press is beginning to write about the effects of chronic illness on marital satisfaction;
this article presents a thoughtful discussion and includes a reference to the National Multiple
Sclerosis Society's Relationship Matters program, the first national effort to provide relationshp
education for couples facing chronic illness.

Sheehy, G.  Why Marriage is Good Medicine for Men. Parade Magazine, Sept. 8, 2008.

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Conferences on Marriage and Health

"Making Connections" - Effects of Couple Relationships on Health Outcomes of Infants, Teens & Older Adults.
October 20-2, 2008, Wingspread Conference Center, Racine WI, sponsored by the National Healthy Marriage Resource Center (NHMRC).  The NHMRC invited 35 experts in health research, health care policy and healthy marriage & relationship education to participate in this two-day conference.  The aim was to critically examine the research findings on the relationship between marital status, relationship quality, and health outcomes and discuss implications for research, programs and practice.  This collection on marriage and health is one product of the conference.  A summary report presenting highlights of the conference discussion and recommendations is forthcoming.

NHMRC Webinar Marriage & Health: There Is a Connection!
January 21, 2009.  Presenters:  Jana Staton, Ph.D. and William Doherty, Ph.D.

Families and Health: New Directions in Research & Theory
June 1-2, 2009.  Sponsored by the National Center for Marriage Research, National Institutes of Health Bethesda, MD.  See: Conference Agenda.  Click on View Session 1, 2, etc. for Webcast of each of the six panel sessions. Presentation powerpoint slides are posted as a link at each author's name (there will be no papers).