Families, Systems, & Health 2014, Vol. 32, No. 2, 186 –197

© 2014 American Psychological Association 1091-7527/14/$12.00 DOI: 10.1037/fsh0000015

Older Couples With and Without Cardiovascular Disease: Testing Associations Between and Among Affective Communication, Marital Satisfaction, Physical and Mental Health Joshua R. Novak, MS, Jonathan G. Sandberg, PhD, and James M. Harper, PhD

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Brigham Young University The American Heart Association (Go et al., 2013) estimated that about 2,150 Americans die each day from cardiovascular disease (CVD). For those 65 years of age or older, the total cost of heart related services in 2009 was $121.2 billion (Go et al., 2013). Many people live with the chronic conditions of cardiovascular disease (Petersen et al., 2005). Researchers have identified the genetic, medical, and lifestyle habits of those with CVD, yet there is a dearth of literature focusing on the relational/social aspects of cardiovascular disease and how such factors are associated with the risk, presentation, and maintenance of cardiovascular illness. Considering that men have a higher lifetime risk for developing CVD than women (51.7% to 39.2%; Roger et al., 2012), the purpose of this study was to compare various aspects of the couple relationship among and between couples with a husband who reports CVD and couples in which neither report CVD. Keywords: couples, older adults, health, cardiovascular disease, affective communication

Couple Relationships, Relationship Quality, and Health

health habits and directly through cardiovascular, immune, neurosensory, endocrine, and other physiological mechanisms.

Physical Health Obesity, physical activity, smoking, and high blood pressure are issues that are linked with the influence of social relationships (Campbell, 2003; House, Landis, & Umberson, 1988). Although these and a number of other health concerns are associated with relationships in general, couple relationships are fundamental for most adults and have a significant influence on health (Sandberg, Miller, Harper, Davey, & Robila, 2009; Kiecolt-Glaser & Newton, 2001; Wickrama, Lorenz, Conger, & Elder, 1997). In meta-analyses of marriage and health studies, Kiecolt-Glaser and Newton (2001) concluded that negative dimensions of marital functioning affect health indirectly through depression and

This article was published Online First January 20, 2014. Joshua R. Novak, M.S., Jonathan G. Sandberg, PhD, and James M. Harper, PhD, School of Family Life, Brigham Young University. Correspondence concerning this article should be addressed to Joshua R. Novak, School of Family Life, 266 TLRB, Brigham Young University, Provo, UT 84602. E-mail: [email protected] 186

Mental Health Not only is physical health affected by the couple relationship, literature has shown that depression is associated with marital discord regardless of gender, culture, and age (Bookwala & Franks, 2005; Fincham, 2003; Fincham & Beach, 1999; Whisman, Whitten, & Whiteford, 2006). The interaction between depression and couple relationships appears to be systemic in nature, with struggling couple relationships increasing depression and higher levels of depression leading to lower couple relationship satisfaction (Fekete et al., 2006; Heene, Buysse, & Van Oost, 2007). Depression has also been shown to alter cardiovascular, immune, and endocrine functioning (Glassman & Shapiro, 1998; Kiecolt-Glaser & Newton, 2001; Simonsick, Wallace, Blazer, & Berkman, 1995). Quality of the Couple Relationship and Health Several studies have focused on health and illness within the context of couple relationship quality. Poor marital quality has been shown to

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COMMUNICATION IN COUPLES WITH AND WITHOUT CVD

be detrimental to physical health and wellbeing, as well as related to depression, reduced immune system functioning, and even dental problems (Greene & Griffin, 1998; KiecoltGlaser et al., 2005; Kiecolt-Glaser, Marucha, Atkinson, & Glaser, 2001; Marcenes & Sheiham, 1996; McPheters & Sandberg, 2010). Better marital quality has also been linked to fewer illness symptoms, better overall health, and healthier sleep patterns for both genders (Gallo et al., 2003; Prigerson, Maciejewski, & Rosenheck, 1999; Thomas, 1995). In addition, survival rates after congestive heart failure and kidney disease were shown to be improved with better marital quality (Coyne et al., 2001; Kimmel et al., 2000), and higher marital quality was related to lower biopsychosocial risk factors for cardiovascular disease (CVD; Gallo et al., 2003). Marital strain was associated with poorer prognoses of patients with established heart disease (Ortho-Gomér et al., 2000). For men with elevated risk factors of congenital heart disease, marital disruption was associated with increased congenital heart disease incidence (Matthews & Gump, 2002). Couples and CVD Cardiovascular Reactivity and Couple Communication Scholars have recently begun to examine the factors, other than genetics and lifestyle choices, that impact CVD. Pickering (1996) stated that an increase in cardiovascular reactivity leads to hypertension, which increases the risk of CVD. Rankin-Esquer and colleagues (2000) found that couple conflict was related to cardiovascular reactivity and argued that in couples who have difficulty resolving conflicts, the likelihood of repeated events of higher blood pressure and higher heart rates increases. Researchers found that the inability to resolve conflicts in marriage or in families could be associated with the activation of and maintenance of arousal of the sympathetic nervous system of the body, and therefore lead to hypertension and arterial disease (Ewart, Taylor, Kraemer, & Agras, 1991; Gottman, McCoy, Coan, & Collier, 1996). In addition, Ewart et al. (1991) found that couples trained in communication skills experienced reduced blood pressure reactivity to arguments. In summary, the more dif-

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ficulty couples have in navigating and resolving communication issues, the more likely heart and cardiovascular issues may develop. Communication and Physical Health Researchers have identified the impact that married couples’ communication patterns have on marital quality (Frye-Cox & Hesse, 2013; Ledermann, Rudaz, Guy Rudaz, & Bradbury, 2010), and physiological functioning (Denton, Burelson, Hobbs, Von Stein, & Rodriguez, 2001; Kiecolt-Glaser et al., 1996). Poorer marital quality over time is predicted by short-term physiological stress responses, and through repetition, impacts long-term health outcomes (Cacioppo et al., 1998; Coyne et al., 2001; Gallo et al., 2003; Gottman, Coan, Carrere, & Swanson, 1998; Levenson & Gottman, 1983, 1985). Furthermore, the quality of the relationship is influenced by the spouses’ self-reported perceptions of communication (Noller & Guthrie, 1989) and, reciprocally, the perceived quality of the relationship affects physiological arousal during marital interaction (Menchaca & Dehle, 2005). Finally, Heffner and colleagues (2006) identified pursue/withdraw communication and the effects on couples’ neuroendocrinology. They found that older spouses who reported greater wife demand/husband withdraw patterns in their marriage had greater cortisol responses during a conflict discussion. Despite the above findings, literature on different types of communication and physical health (particularly heart health) outcomes have been lacking. Purpose As stated earlier, the purpose of this study project was to compare the relationships of affective communication, marital satisfaction, health satisfaction, and depression among and between structural equation models for two groups: couples in which only the husbands listed CVD as the most problematic health concern and those couples in which neither partner listed CVD as the most problematic health concern. Research Questions The following research questions were examined.

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NOVAK, SANDBERG, AND HARPER How are couples’ perceptions of affective communication patterns related to their physical health satisfaction, mental health (depression), and marital satisfaction?

The remaining 231 couples were the subjects of this study. Demographic information can be seen in Table 1.

How does the relationship among couples’ perceptions of affective communication patterns, physical health, depression, and marital satisfaction differ in couples where the husband lists CVD as the primary health concern compared to couples in which neither report CVD as the primary health concern?

Measures

Method Sample and Procedure A secondary data analysis was performed using data previously collected for Project Couple Retire (for more details regarding the study, see Sandberg & Harper, 1999). Questionnaires were sent to 9,328 addresses that had been purchased from a major marketing firm, the Donnelley Corporation. This firm guaranteed that each of the addresses represented a married couple with at least one partner between the ages of 55–75 that had been selected at random from a sample of couples from each state in the United States. Data collection began in 1994 and was focused on changes induced by retirement and their impact on physical and mental health over time. Of the 9,328 mailed questionnaires, 1,611 were returned. In addition, 591 were returned due to people no longer meeting the inclusion criteria, were no longer living at the address, or were the wrong addresses, and an additional 997 were also returned because one partner responded or because the questionnaires were too incomplete. The overall response rate for the study was 24%, which was calculated by adding the number of responses and bad addresses, then dividing by the number mailed (Dillman, Smyth, & Christian, 2009). This lower response rate is common among studies of older individuals using lengthy, mailed surveys (Kaldenberg, Koenig, & Becker, 1994; Roszkowski & Bean, 1990). This sample has been previously compared to (a) those that were not included because their spouses did not complete the questionnaire, (b) nonrespondents, and (c) U.S. Census information (Harper & Sandberg, 2009). There were no significant differences between this sample and the other three groups mentioned above based on age, length of marriage, number of children, income, employment, and religious preference.

Grouping variable: Most problematic health concern. Respondents were asked to indicate which of their health conditions was the most problematic out of a list of health problems. Groups were classified as couples with husbands with a CVD concern if only the husband had listed heart condition, circulation problems, or high blood pressure as a primary health concern and the wife did not, and couples without a CVD concern if neither had listed the above issues as their major health concern. Health satisfaction. Participants were asked to respond to “How satisfied are you with Table 1 Demographic Characteristics of Sample Husbands (n ⫽ 231)

Wives (n ⫽ 231)

Variables

M

SD

M

SD

Age Length of marriage Years of education

65.43 36.76 13.27

4.30 11.34 3.55

62.95 36.74 13.07

5.55 11.35 2.71

Variables

N

%

N

%

0 0 225 2 4

0.0 0.0 97.4 0.9 1.7

0 0 228 3 0

0.0 0.0 98.7 1.3 0.0

20 63 57 33 11 6 11 18

9.1 28.8 26.0 15.1 5.0 2.7 5.0 8.2

61 58 30 15 4 3 3 3

34.5 32.8 16.9 8.5 2.3 1.7 1.7 1.7

45 6 2 154 22

19.5 2.6 0.9 66.7 9.5

46 9 1 150 20

20.4 4.0 0.4 66.4 8.8

72 150

32.4 67.6

63 167

27.3 72.6

Race Asian Black Caucasian Hispanic Other/missing Income Under $9,999 $10,000–19,000 $20,000–29,000 $30,000–39,000 $40,000–49,000 $50,000–59,000 $60,000–69,000 Over $70,000 Religion Catholic Jewish L.D.S. Protestant Other Employed Yes No Note.

L.D.S. ⫽ Latter Day Saints.

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COMMUNICATION IN COUPLES WITH AND WITHOUT CVD

your overall health?” (1 ⫽ extremely dissatisfied; 7 ⫽ extremely satisfied). Studies have demonstrated that single-item measures of selfrated and self-perceived health correlate well with objective outcomes such as mortality (Idler & Benyamini, 1997; Schwarze, Anderson, & Anger, 2000; Helmert, 2003) and have been shown to be reliable (Martikainen et al., 1999) and valid in different ethnic groups (Chandola & Jenkinson, 2000). The higher the score, the more satisfied the individual was with his or her health. Perceptions of affective communication. Perceptions of affective communication were measured by 13 items from the revised Marital Satisfaction Inventory (Snyder, 1997), which is used to measure various aspects of marital interaction from communication to satisfaction with children (Scheer & Snyder, 1984). The 13-item affective communication subscale assesses the dissatisfaction of affect of conversations or how conversations are processed (Duba et al., 2012). Responses are assessed as true or false and include sample questions such as, “It is sometimes easier to confide in a friend than in my partner,” and “There are some things my partner and I just can’t talk about.” Scores were added together and the sum score was used, with higher scores indicating more reported problems in affective communication. The Cronbach Alpha for the affective communication subscale was 0.84. Depression. Depression was measured using the Center for Epidemiological Studies Depression Scale (CES-D), “a short self-report scale designed to measure depressive symptomatology in the general population” (Radloff, 1977, p. 385). The CES-D has consistently demonstrated itself to be reliable and a valid (criterion and discriminant) measure for depressive symptomatology with split-half correlation and Cronbach’s alpha coefficients ranging from .85 to .92 (Clement et al., 1999; Radloff & Teri, 1986). The CES-D has been used with older individuals and evidenced appropriate psychometric properties (Santor et al., 1995). Marital satisfaction. The Kansas Marital Satisfaction Scale (Schumm, Milliken, Poresky, Bollman, & Jurich, 1983; Schumm et al., 1985) was used to measure marital satisfaction. The Kansas Marital Satisfaction Scale consists of three items, all of which use the same stem: “How satisfied are you with . . .” to ask the

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subject about their marriage, their relationship with their spouse, and their partner as a spouse. Each question is scored on a 7-point Likert scale, ranging from 1 (extremely dissatisfied) to 7 (extremely satisfied), resulting in a total score ranging from 3–21. The Cronbach’s alpha reliability coefficient in this study was .97 for husbands and .97 for wives. Control variables. Socioeconomic status (SES) remained the only significant control variable in the analyses and was calculated using the household median income range divided by the 2013 federal poverty level for that specified household size (U.S. Department of Health & Human Services, 2013). Statistical Analyses Kashy and Kenny (2000) identified the Actor–Partner Interdependence Model (APIM) which examines the shared influence/interdependence in relationships (i.e., the characteristics of one member of the dyad affects outcomes of the other member in the dyad). In APIM, the actor effect refers to the fact that a person’s outcome is affected by his or her own predictor variable. The partner effect refers to a person’s outcome also being affected by his or her partner’s predictor variable. The following variables were added to the model: husband problematic affective communication, wife problematic affective communication, husband marital satisfaction, wife marital satisfaction, husband health satisfaction, wife health satisfaction, husband depression, and wife depression. Means, standard deviations, and correlations for all variables are reported in Table 2. Multiple group analysis in AMOS (Arbuckle, 2006) was performed, using the above variables for two groups: couples who did not report CVD (N ⫽ 119) as their biggest health concern and couples in which the husbands identified CVD as the biggest health concern (N ⫽ 112). The final model is shown in Figure 1. Results SEM Results In terms of direct actor effects, husband problematic affective communication was negatively related to husband health satisfaction for

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Table 2 Correlations, Means, and Standard Deviations for Couples With Husband With CVD and for Couples With Husband Without CVD

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Variables 1. 2. 3. 4. 5. 6. 7. 8.

Wife affective communication Husband affective communication Wife marital satisfaction Husband marital satisfaction Wife health satisfaction Husband health satisfaction Wife depression Husband depression with CVD SD without CVD SD

1

2

3

4

5

6

7

8

1.0 .48ⴱⴱⴱ ⫺.68ⴱⴱⴱ ⫺.34ⴱⴱⴱ ⫺.12 .01 .37ⴱⴱⴱ .16 3.91 4.01 3.55 3.95

.62ⴱⴱⴱ 1.0 ⫺.44ⴱⴱⴱ ⫺.42ⴱⴱⴱ ⫺.14 ⫺.17 .26ⴱⴱ .46ⴱⴱⴱ 2.55 3.09 2.79 3.30

⫺.66ⴱⴱⴱ ⫺.55ⴱⴱⴱ 1.0 .47ⴱⴱⴱ .16 .13 ⫺.30ⴱⴱⴱ ⫺.07 18.66 3.22 18.65 3.30

⫺.28ⴱⴱⴱ ⫺.47ⴱⴱⴱ .53ⴱⴱⴱ 1.0 .14 .35ⴱⴱⴱ ⫺.05 ⫺.12 18.92 3.50 19.03 3.07

⫺.05 ⫺.01 .08 ⫺.05 1.0 .15 ⫺.28ⴱⴱⴱ ⫺.31ⴱⴱⴱ 5.18 1.50 4.63 1.55

⫺.07 ⫺.19ⴱ .12 .09 .19ⴱ 1.0 ⫺.09 ⫺.34ⴱⴱⴱ 4.95 1.23 4.95 1.35

.36ⴱⴱⴱ .29ⴱⴱⴱ ⫺.36ⴱⴱⴱ ⫺.16 ⫺.35ⴱⴱⴱ ⫺.17 1.0 .35ⴱⴱⴱ 6.01 6.03 8.00 8.10

.31ⴱⴱⴱ .35ⴱⴱⴱ ⫺.32ⴱⴱⴱ ⫺.25ⴱⴱ ⫺.02 ⫺.29ⴱⴱⴱ .30ⴱⴱⴱ 1.0 6.17 6.73 7.23 6.14

Note. Correlations for couples with husband without cardiovascular disease (CVD) are reported above the diagonal; correlations for couples with husband with CVD are reported below the diagonal. ⴱ p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

the non-CVD couples (␤ ⫽ ⫺.25, p ⬍ .05) but not for the husband CVD couples (␤ ⫽ ⫺.11). Husband problematic affective communication was positively related to husband depression for

both the non-CVD group and the husband CVD group (␤ ⫽ .26, p ⬍ 0.01; ␤ ⫽ .53, p ⬍ .001). Wife problematic affective communication was not significantly related to wife depression for

Figure 1. Results for group comparisons in structural equation modeling with standardized betas and R squared values reported. Standardized regression weights: couples with no CVD (couples with husbands with CVD). Fit indices for couples with no CVD model: (CVD), ␹2 ⫽ 10.357, df ⫽ 9, p ⫽ .322, comparative fit index (CFI) ⫽ .993, Tucker-Lews index (TLI) ⫽ .973, root mean square error of approximation (RMSEA) ⫽ .037. Fit indices for couples with husbands with CVD model: ␹2 ⫽ 9.762, df ⫽ 7, p ⫽ .202, CFI ⫽ .988, TLI ⫽ .963, RMSEA ⫽ .058. Multiple group full model fit indices: ␹2 ⫽ 26.41, df ⫽ 14, p ⫽ .24, CFI ⫽ .989, TLI ⫽ .971, RMSEA ⫽ .027. ⴱ p ⬍ .05. ⴱⴱⴱ p ⬍ .001.

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COMMUNICATION IN COUPLES WITH AND WITHOUT CVD

the non-CVD group (␤ ⫽ .12) but was positively related for the husband CVD group (␤ ⫽ .28, p ⬍ .05). One partner effect was statistically significant. Wife problematic affective communication was positively related to husband health satisfaction for the couples with husbands reporting CVD concerns (␤ ⫽ .20, p ⬍ .05) but not for couples without CVD concerns (␤ ⫽ .10). Therefore, a suppression effect existed in the couples with husbands with CVD concerns, as the bivariate correlation between the two variables was negative. Significant indirect effects existed from wife problematic affective communication to wife marital satisfaction (␤ ⫽ .53, p ⬍ .001) and wife marital satisfaction to wife depression for the non-CVD group (␤ ⫽ ⫺.26, p ⬍ .05; Sobel ⫽ 1.88 for, two-tailed p ⬍ .05) (Sobel, 1982), showing that for wives whose husbands do not have CVD, one process through which their problematic affective communication is related to their depression is through their marital satisfaction. For the couples where the husband reported CVD, husband problematic affective communication was related to husband marital satisfaction (␤ ⫽ ⫺.42, p ⬍ .001), which was related to husband health satisfaction (␤ ⫽ .36, p ⬍ .001; Sobel ⫽ ⫺2.68, p ⬍ .001), showing that husband problematic affective communication affects husband health satisfaction indirectly through husband marital satisfaction. Wife problematic affective communication was related to wife marital satisfaction (␤ ⫽ ⫺.55, p ⬍ .001) and wife marital satisfaction

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was related to husband depression (␤ ⫽ .18, p ⬍ .05) for couples where the husbands reported CVD (Sobel ⫽ ⫺2.007, two-tailed p ⬍ .05), indicating that for wives whose husbands have CVD, wives’ marital satisfaction fully mediates the relationship between wives problematic affective communication and husbands depression. Table 3 shows the decomposition of direct, indirect, and total effects for both groups. Other significant paths included husband problematic affective communication to husband marital satisfaction for both groups (nonCVD: ␤ ⫽ ⫺.49, p ⬍ .001; husband CVD: ␤ ⫽ ⫺.42, p ⬍ .001), husband problematic affective communication to wife marital satisfaction for both groups (non-CVD: ␤ ⫽ ⫺.25, p ⬍ .01; husband CVD: ␤ ⫽ ⫺.18, p ⬍ .05). Comparison of Paths Between Couples With CVD and Couples Without A fully unconstrained model where all paths in the models were free to vary was compared against a fully constrained model in which paths in the two models were constrained to be equal. A ␹2difference test showed that the constrained and unconstrained models were not significantly different from each other (␹2 difference ⫽ 15.98, df difference ⫽ 10, p ⫽ .29). We then proceeded to sequentially constrain each path in the model until we arrived at the model with the best fit (␹2 ⫽ 26.41, df ⫽ 14, p ⫽ .24, comparative fit index ⫽ .989, TuckerLewis index ⫽ .971, root mean square error of

Table 3 Decomposition of Standardized Direct, Indirect, and Total Effects: Couples Without Husband With CVD (Couples With Husbands With CVD) Predictor variable Wife affective communication

Husband affective communication

Wife marital satisfactionⴱ Husband marital satisfactionⴱ Note.

Outcome variable ⴱ

Wife marital satisfaction Wife depression Husband depression Husband health satisfaction Wife marital satisfactionⴱ Husband marital satisfactionⴱ Wife depression Husband depression Husband health satisfaction Wife depression Husband depression Husband health satisfaction

The asterisk (ⴱ) indicates a mediating variable in the model.

Direct

Indirect

Total

⫺.52 (⫺.57) .21 (.29) 0 (0) .10 (.19) ⫺.23 (⫺.17) ⫺.5 (⫺.42) 0 (0) .26 (.53) ⫺.25 (⫺.11) ⫺.22 (⫺.10) ⫺.16 (.17) ⫺.01 (.36)

0 (0) .12 (.06) .08 (⫺.10) 0 (0) 0 (0) 0 (0) .05 (.02) .04 (⫺.03) .01 (⫺.15) 0 (0) 0 (0) 0 (0)

⫺.52 (⫺.57) .32 (.35) .08 (⫺.10) .10 (.19) ⫺.23 (⫺.17) ⫺.5 (⫺.42) .05 (.02) .30 (.50) ⫺.25 (⫺.26) ⫺.22 (⫺.10) ⫺.16 (.17) ⫺.01 (.36)

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approximation ⫽ .027). In that model, the groups were significantly different on three paths: the path between husband problematic affective communication to husband depression was significantly higher for couples with husbands with CVD concerns; the path between husband marital satisfaction and husband health satisfaction was significantly higher for the couples with husbands with CVD concerns group; and the path between wife marital satisfaction to husband depression was significantly higher for couples with husbands with CVD concerns. Finally, a significant inverse relationship was found for the impact of SES on the wife’s depression only in the couples without CVD group and significant inverse relationships were found for SES on both the husband and wife’s marital satisfaction only in the couples with husbands with heart disease group. Discussion The results for the first research question showed that for husbands, more problematic affective (emotional) communication was associated with lower satisfaction with physical health and higher depression, and lower marital satisfaction was associated with lower health satisfaction and higher depression. These findings are aligned with published studies showing that married couples’ communication patterns impact their marital quality (Menchaca & Dehle, 2005; Weiss & Heyman, 1990) and physiological functioning of partners (Denton et al., 2001; Kiecolt-Glaser et al., 1996). In addition, both the wives’ and the husbands’ problematic affective communication accounted for about 52% of the variance in the wives’ satisfaction with her marriage, which is supported by the literature that identifies a stronger link between marital interaction and marital satisfaction for women than men (Schmitt, Kliegel, & Shapiro, 2007). An unexpected finding was an inverse relationship between higher problematic affective communication scores for the wives and higher husband health satisfaction. It may be that the affective communication of wives as she encourages a healthier lifestyle, though perceived as unpleasant for her (lower marital satisfaction and higher psychological distress), is actually effective at improving husbands’ health satisfaction (often labeled health-related social con-

trol or “nagging”) can be related to improved health behaviors (Tucker, 2002). A final unexpected partner effect was that higher marital satisfaction for wives was related to reports of higher depression for husbands. This finding contradicts years of previous research (Beach & Whisman, 2012) that has shown that marital conflict and depression are highly correlated. However, this study used data from a community sample with lower levels of depression. In addition, it may be that there is some aspect of marital satisfaction that is enhanced when a husband is depressed. Perhaps the closeness a wife experiences as she reaches out to a depressed husband can yield temporary marital satisfaction, even if the pattern would not be sustainable over time (Feldman, 1976; Price, 1991). For the second research question, when neither partner reported CVD as their main health concern, problematic affective communication for the husbands directly affected the husband’s health satisfaction. However, for the couples in which the husband reported CVD as their main health concern, problematic affective communication affected their health satisfaction through their marital satisfaction. It appears that some aspect of marital satisfaction is different for those couples dealing with heart disease as a major health issue. When examining the interdependent partner effects, higher problematic affective communication in the husbands was associated with lower marital satisfaction for their wives. Regardless of if their husbands have CVD or not, wives’ frustration with her partner’s inability to communicate on an emotional level affects her satisfaction with her marriage. This finding supports previous research that has clearly established this association (Weiss & Heyman, 1990). Greater problematic affective communication for the wife was also associated with higher depression in the wife and higher health satisfaction in the husband only when her husband had reported CVD as his main health concern. This finding suggests that wives’ reports of problematic communication result in higher depression for the wife when her husband has CVD. It may be that wives’ hold back on sharing emotions with a husband who has heart disease; the resultant disconnection may contribute in some way to depressive symptoms. It

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COMMUNICATION IN COUPLES WITH AND WITHOUT CVD

is also important to note that older couples may be better at recognizing their partner’s triggers, and thus steer clear of them. This could be due to perceiving rigid communication patterns, and a “that’s just the way they are” type of mentality, as couples in long-term marriages as a group seem to have developed an ability to control the emergence of negative affect (Carstensen et al., 1995). Finally, it was found that SES only affects the wife’s depression when her partner does not report CVD as a major concern. This suggests that when her husband is suffering from a lifethreatening illness, finances are not as important as her husband’s health, but in couples without CVD concerns, her depression is a result of lower marital satisfaction and lower SES. Higher SES was associated with lower marital quality for both partners when husband’s report CVD as a major concern, suggesting that the effort to obtain a higher socioeconomic class may mean more time working, less time interacting as a couple in positive ways, and more interaction in negative ways, thus contributing to CVD issues. Likewise, SES was not a significant predictor of marital satisfaction in couples in which neither report CVD issues, which may suggest marital satisfaction is more dependent on other variables (i.e., time spent together, higher affective communication, etc.) and also explains the association between higher marital satisfaction and lower risk for CVD issues (Gallo et al., 2003). Clinical Implications This study shows the importance of developing affective communication skills with couples. Because problematic and conflictual communication tend to raise stress levels and negatively affect the cardiovascular system (Pickering, 1996; Rankin-Esquer, Deeter, & Taylor, 2000), clinicians should focus on helping couples uncover, express, and experience their own emotions while helping each individual to process their partner’s emotions. Such therapies that focus on these processes include emotionfocused therapy (EFT; Johnson, 2004), Gottman’s sound marital house theory (Gottman, 1999), and Integrated behavioral couple therapy (Christensen, Jacobson, & Babcock, 1995). In couples where this becomes the normal and healthy communicative pattern, positive experi-

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ences of the marital relationship form (Cutrona, 1996; Schmitt, Kliegel, & Shapiro, 2007) and results in numerous physical and mental health benefits (Coan et al., 2006; Sandberg et al., 2009). Limitations and Future Directions This study has a number of limitations. First, the construct of health satisfaction, while shown to be correlated with actual health, is a subjective report. Clearly, future research would be strengthened by an objective report of health status or bio markers. Furthermore, to more clearly understand the impact of different patterns of communication, interactional coding of couples during communication would shed greater light on the effects of negative communication on physiology and physical health. As discussed by Smith and Glazer (2006), researchers could combine the two by conducting medical tests while recording couple interaction, allowing for real time interaction of couple communication and health data. Future researchers must work to ensure the sample is more representative of racial diversity that is found in the general population of older adults, as the findings of this study can only be generalized to older White Americans because the sample in this study was predominantly Caucasian. Finally, longitudinal research that focuses on following younger couples through the years and tracking the communication patterns and marital satisfaction with respect to a wide variety of health outcomes will greatly help understand the causal interaction between marital processes and health. Conclusion In conclusion, this study highlights the importance for professionals to recognize the role that marital processes have in affecting health. By working on these marital processes earlier in a couples’ relationship, health outcomes may be subsequently improved later on. Particularly, this study makes a case for working on the emotional communication between partners, as cardiovascular reactivity and heightened blood pressure result from cycles of dysfunctional communication.

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NOVAK, SANDBERG, AND HARPER

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Older couples with and without cardiovascular disease: testing associations between and among affective communication, marital satisfaction, physical and mental health.

The American Heart Association (Go et al., 2013) estimated that about 2,150 Americans die each day from cardiovascular disease (CVD). For those 65 yea...
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