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Family has been shown to be one of the most relevant socio-demographic factors in understanding health differences among individuals in Western countries. The difference in survival between the married and not married population was stated by William Farr as early as the 19th Century (Farr 1885). However, although the health advantages of those who live with a partner were already well known, the interest in this factor has increased among scholars in the past three decades. This increase has run parallel to two interrelated changes in traditional patterns which are contributing to reshape current European societies: diversification of family forms and the subsequent acceptance of the new forms among individuals; and the increase of female empowerment due to a progressive reduction of the gender gap.

The diversification of family forms has led to a more complex scenario that extends beyond merely comparing married and not-married individuals. At the same time, the traditional gender roles that men and women used to play within the context of the families in the past have also been modified. This family diversification and the process of gender balancing has not occurred with the same intensity and timing in all European countries. It has been stated that both processes have spread from the North and West to the South and East of the Continent (Surkyn and Lesthaeghe 2004). With these changes, family as a social determinant of health has become an ever more important factor of health, one which is rooted at the meso-level and extends beyond individual characteristics at the micro-level. Indeed, when one thinks about family, one figures a context where individuals provide resources of different natures (economic, knowledge, social ties, etc.) and share these with the other members, thus compensating for or reinforcing existing individual advantages or disadvantages.

To understand the complex relationship of this triangle of family, gender, and health, one must understand patterns and trends in each of the three components separately, as well as their interdependencies. This book tries to expand upon the widely observable specialization in demographic research, which usually involves researchers studying either family or fertility processes or focusing on health and mortality. While both topics are commonly explored in the context of gender or sex, it is rare that a deeper understanding of health processes exists among researchers who deal with family processes. At the same time, researchers interested in health and mortality tend to lack insight into the structures of gendered processes in the family and the household. To overcome this lack of knowledge, this book compiles three keynote chapters that provide an overview about (1) the relationship between family and fertility characteristics and health, (2) the changing roles of men and women in the context of families and societies, and (3) sex and gender differences in health.

In addition to these keynote chapters, six country-specific case studies and one comparative study are presented in order to understand how different patterns in social change modify the link between family and health in women and men. The country-specific case studies range from the North of Europe (Sweden), to the Center (Germany and Austria) and the South (Italy). The comparative study explores twelve European countries from the North, Center, East and South of the Continent which are representative of different welfare states, gender models, household and family forms, and health profiles. Because this book’s compilation of studies can provide only a small snapshot, we have tried to select country-specific case studies which focus on populations which have received less attention in the past, while presenting findings for other countries in the keynote chapter on the relationship between family, fertility, and health. We use the two keynote chapters on the new roles of men and women in family and society, and on sex differences in health as the basis for a joint framework, but we have abstained from harmonizing concepts in order to permit the authors to fully explore the data available in their countries. Hence, in the following we will briefly present the three keynote chapters and give a short overview about the different approaches to family, health, and gender that were used in these studies.

The Triangle Between Health, Gender, and Family

The three initial keynote chapters present the reader with a detailed background of the three sides of the triangle of family, health and gender. The first chapter by Hank and Steinbach offers a comprehensive summary of the main findings on the role of family relations in shaping individuals’ health (and vice versa) or, in other words, the study of family as a social determinant of health as well as a source of selection into family transitions. This chapter covers the main literature about the influence of partnership and parenthood on an adult’s health, as well as how a child’s well-being varies according to different family structures and how these family circumstances shape health in later life. The authors extend their review to the link between intergenerational family relations and health, thereby including relations between relatives who likely do not live together in the same household. This chapter provides solid evidence of the relevance of family to shape individuals’ health across the entire life-course: from early childhood, through adulthood, to very old-age.

The keynote chapter by Oláh, Richter, and Kotowska covers the second side of the triangle, the relationship between family and gender roles. Changes in family patterns have run parallel to the process of balancing gender inequalities (e.g. educational expansion of women, increase in female labour force participation, etc.). Therefore, family diversification cannot be understood completely without regarding the rise of female empowerment in Western societies. This keynote chapter first describes the increase in the diversity of family biographies. Second, linked to this higher family diversity, the authors describe the evolution of the main factors which help us understand the change of gender roles. Once both changes into family trajectories and gender roles are explained, the authors pinpoint the close bidirectional link between these two phenomena. The authors also discuss the recent research outcomes of family dynamics, especially regarding partnership transitions and parenthood and the organization of family life, and their association with changing gender roles.

The third keynote chapter by Oksuzyan, Gumà, and Doblhammer closes the triangle by revisiting the origins of health differences between men and women. First, the authors provide ample evidence of the existence of the sex gap in health, distinguishing between those which have been found based on objective and subjective measures of health. For objective measures the authors consider medical diagnoses, while subjective health measures are based on an individual’s self-perception. Second, the authors provide a detailed literature review of the explanations for sex differences in health, dividing the section according to the nature of these explanations: biological, lifestyle behaviors, and social factors. The authors point out that, in the future, research in the social sciences cannot discard the biological root of the health differences between men and women, while health sciences cannot ignore the importance of the social context.

Different Approaches to the Concept of Family

Family can be conceptualized either in terms of ties between relatives who live together in the same household or independently of whether the individual members live together. In the first case, family is a synonym for household, e.g. the number of children refers to number of children living in the household, and partners are defined as living together. Depending on the survey design, the sample unit is either the individual or the household. If the individual is the sample unit, one usually has information about the characteristics of the respondent but not of the other members of the household. Many current surveys, however, take households as sample units and compile information on all their members. This permits researchers to address the study of family and health from two different viewpoints: individual characteristics and/or overall family characteristics and arrangements. In the second case, the notion of family extends beyond the household, most importantly when the number of children refers to ever born children. Sometimes information about the geographical distance between parents and children, and the frequency and quality of contacts is given, but there is rarely more information on the family member outside the survey household. Also, new forms of partnerships extend beyond the household such as living apart together (LAT).

This book provides examples of both approaches to the study of family, namely family confined to the household as well as family extending beyond the household. In addition, depending on the sample design, the studies explore the family effect based on individual information alone or, in the case of household samples, on characteristics of both the individual and the household.

Individual Level Characteristic

On the individual level, five case-studies explore the relationship between partnership, parenthood, and an individual’s position within the household, as defined by the relationship of the household members, on health. The idea behind defining an individual’s household position is to compile information about the partnership situation (married, consensual union, not partnered) with the information about children in the household and the relationship with the family nucleus. This approach allows us to study not only family arrangements but also the different levels of responsibilities related with being member of a household.

Doblhammer and Gumà apply the concept of household position in a comparative study of European countries representing different welfare state regimes. Buber-Ennser and Hanappi extend the basic concept of household position to include stepfamilies and new living arrangements such as LAT. The other studies use the categorizations of individuals according to their legal family status (von der Lippe and Rattay; Tomassini, Di Gessa, and Egidi) and partnership status (Doblhammer, Peters, and Welmer), to parenthood (children ever born yes/no, Doblhammer, Peters, and Welmer), fertility histories (Tomassini, Di Gessa, and Egidi), and children in the household (von der Lippe and Rattay).

Household Level Characteristics

Regarding the household level, two studies explore the impact of the household characteristics in addition to the individual characteristics. The study of Georges, Kreft, and Doblhammer explores the effect of the general household structure focusing on the composition of generations within the household. The rationale behind this approach is that in ethnically diverse populations the propensity to live in single-, one-, or multi-generational households as well as the number of children is stratified by ethnicity, which is also true for health. The other example is the study by Giannantoni and Egidi, who approach family from different characteristics at the household level such as socio-economic status, housing conditions, household size, and structure. Both chapters use multilevel methods in their analyses, with individuals as the first level, household as the second level, and, in the case of Giannantoni and Egidi, region as the third level.

In addition to exploring characteristics at the individual and meso-level, two of the studies also explore longitudinal information. Buber-Ennser and Hanappi use two waves of the Austrian Gender and Generation Study to analyze health among young and middle aged adults, while Doblhammer, Peters, Rizzuto and Welmer focus on the elderly using three waves of the Swedish National Study of Ageing and Care in Kungsholmen.

Different Approaches to the Concept of Health

The World Health Organization defined the concept of health in the preamble of its Constitution in 1946 as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. This holistic definition implies that it is almost impossible to summarize health in a single indicator and that it must be addressed by different approaches. Indeed, some of the studies chose more than one health indicator (e.g. Giannantoni and Egidi, and Tomassini, Di Gessa, and Egidi).

In this book, the most frequently studied health indicator is self-perceived (also called self-assessed) health, which compiles information about how individuals perceive their general health on a scale from very poor to very good. Apart from the capacity of this indicator to summarize the different dimensions of an individual’s health in a single indicator, it can also inform us about how individuals perceive their evolution of health (Idler and Benyamini 1997). A more general health indicator explored in this book is derived from the question “Have you been ill or had an accidental injury within the last four weeks before the interview?” This indicator compiles information about long-lasting illnesses. The third health indicator analyzed which can be considered a measure of general health is functional limitations and personal independence through questions about Activities of Daily Living (ADL) (Katz et al. 1963) and the Instrumental Activities of Daily Living (IADL) scales (Lawton and Brody 1969).

Looking at more specific health indicators, mental health was analyzed through two different indicators, the depression score and the Mental Component Summary derived from the Short Form-12 Health Survey. Basically, both are synthetic indicators based on answers to a set of items related with depressive symptoms, such as feeling guilty or being irritable. In the case of physical performance, the indicators are walking speed and the Physical Component Summary derived from SF-12 Health Survey. The former is an objectively measured indicator which focuses on one aspect of physical performance, namely the speed of walking, although previous research has found a strong association with other health indicators and mortality. On the other hand, the physical component from SF-12 is another synthetic indicator derived from a set of questions about physical capacities of respondents.

Finally, healthy life-style is also analyzed based on smoking, alcohol consumption, diet, and physical activity. Exploring healthy-life style offers us a better understanding of the relationship between family and health because it is one of the intermediary behaviors that link family characteristics to health.

The Concept of Sex Versus the Concept of Gender

The book addresses the sometimes unclear difference between the concepts of sex differences and gender inequalities. It is relevant to make a distinction between the two concepts because their nature or origin is different. When talking about sex differences, one simply refers to differences in results between men and women that might have a diverse origin, whereas when talking about gender inequalities one refers to psychological, social, and cultural differences between males and females (e.g. distribution of roles within the household, different social behaviors assumed for men and women, etc.) (Giddens 2009). We can find a good example of this distinction in the keynote chapter about sex and health, in which the authors distinguish between biological sources of differences between men and women and social factors which originate in situations of gender inequality that affect an individual’s health.

The use of the word “gender” in academic disciplines such as epidemiology and sociology also contributes to the confusion. The former generally employs this word to refer to studies where results of both sexes are compared, whereas the latter usually uses this concept to address differences rooted in social inequalities between men and women. In all the empirical chapters the authors compare male and female profiles and base their research questions, as well as their proposed explanations, on factors related to gender inequalities. In this direction, four of the chapters (Georges, Kreft, and Doblhammer; Doblhammer and Gumà; Buber-Ennser and Hanappi; Tomassini, Di Gessa, and Egidi) give a high relevance to the gendered distribution of roles within the context of the household, which are presented in detail in Oláh, Richter, and Kotowska.

Another argument related to gender inequalities is introduced by von der Lippe and Rattay and addresses the unequal level of social control to which men and women are exposed. This is also mentioned in the chapter of Oksuzyan, Gumà, and Doblhammer, and points to the fact that women bear a higher social control in terms of their life-style, which on the one hand protects them from unhealthy behaviors (i.e. smoking, drinking, etc.) though on the other hand exposes them to higher social sanctions in comparison with men in case of not avoiding these unhealthy behaviors.