Single mothers’ self-assessment of health: a systematic exploration of the literature E. Rousou1 RN, PhDc, C. Kouta2 M. Karanikola3 RN, PhD
RN, PhD, N.
Middleton2 PhD &
1 Scientific Staff, 2 Assistant Professor, 3 Lecturer, Department of Nursing, School of Health Sciences, Cyprus University of Technology, Limassol, Cyprus
ROUSOU E., KOUTA C., MIDDLETON N. & KARANIKOLA M. (2013) Single mothers’ self-assessment of health: a systematic exploration of the literature. International Nursing Review 60, 425–434 Aim: This study aimed to explore single mothers’ self-assessed level of health status compared to partnered mothers and the relevant factors associated with it. Background: The number of single-mother families is increasing worldwide. A large body of international research reveals that single mothers experience poorer physical and mental health than their married counterparts. An important contributory factor for this health disparity appears to be socio-economic disadvantage. Methods: A systematic search of the literature was conducted using the keywords ‘lone’ or ‘single’ and ‘mother*’ or ‘parent*’ or ‘family structure’ in combination with ‘health’. EMBASE, CINAHL, COCHRANE and PUBMED databas were searched for quantitative research studies published in the past decade. Results: Eleven quantitative research articles with self-assessment of health status in single mothers were identified. Single mothers report lower levels of health status compared to partnered mothers. These inequalities appear to be associated with financial hardship and lack of social support. Both these factors increase single mothers’ susceptibility to stress and illness. Conclusion: Despite the study limitations (e.g. results based mainly on secondary data from household surveys), it provides evidence that single motherhood places women in an adverse social position that is associated with prolonged stress mainly due to unemployment, economic hardship and social exclusion, which affects negatively their health status. These findings can be seen as a challenge for health professionals, especially those working in the community sector and policy makers too, to establish supportive measures for this vulnerable group focused on socio-economic factors. Keywords: Health Professionals, Lone Mothers, Nurses, Poverty, Review, Self-Rated Health, Single Mothers, Social Exclusion
Introduction The increase in the number of families headed by single mothers has been one of the most significant structural changes in society, especially in the developed world (Avison et al. 2008).
Correspondence address: Elena Rousou, 8 Vavilonos, 4007 Mesa Yitonia, Limassol, Cyprus; Tel: +357-99846634; Fax: +357-25002822; E-mail: [email protected].
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As of 2011, 11.7 million families in the USA were headed by a single parent, 85.2% of which were headed by a mother (US Census Bureau 2011). In Europe, statistics show a tremendous rise in divorce rates and births outside marriage, both of which lead to single-parent families mainly headed by a mother. Since 1970, the crude marriage rate in the EU-27 has declined by 38% (from 7.9 per 1000 inhabitants in 1970 to 4.9 in 2007). At the same time, marriages became less stable, as indicated by the
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increase in the divorce rate, from 0.9 per 1000 inhabitants in 1970 to 2.1 in 2007. In parallel, the percentage of births outside marriage rose to 37.4 in 2010, compared to 17.4 in 1990. In Cyprus, despite the fact that single-parent families constitute only a small percentage of all families, there has been a significant increase over the last decades (from 3.6% in 1982 to 7.6% in 2011), of which the majority was headed by a mother (6.7% compared to 0.9% headed by a father) (Eurostat 2012). At the same time, it seems that single motherhood affects negatively single mothers’ health status. A large body of the literature exists concerning this issue, emphasizing single mothers’ need for greater support (Keating-Lefler et al. 2004). This evidence reveals that single motherhood places women in an adverse social position that is associated with prolonged stress due to long hours of work and single-handed child care (Fritzell et al. 2007; Wickrama et al. 2006), which affects negatively their health status as well as their dependents (Waldfogel et al. 2010). The majority of the studies dealing with single mothers’ health status examine the mental health consequences in relation to high levels of stress. Single mothers have been found to experience higher rates of psychological distress (Dziak et al. 2010; Franz et al. 2003), mood disorders (Wade et al. 2011), anxiety disorders (Afifi et al. 2006) and depressive symptoms (Crosier et al. 2007; Wang & Pies 2004). Fewer studies have dealt with the physical aspects of health of single mothers, but those that did demonstrate a vulnerability to specific health conditions such as cardiovascular disease (Young et al. 2005) or increased risk of mortality and morbidity compared to partnered mothers (Weitoft et al. 2002; Wickrama et al. 2006). Exploration of the degree to which single mothers constitute a vulnerable population for physical as well as mental disorders is therefore of high importance. The perception of health as experienced by a person is considered an initial indicator for several health outcomes, and therefore, self-assessment tools [e.g. self-rated health (SRH)] are commonly used as a predictor for assessing health status. SRH is recommended as a health indicator by the World Health Organization (Lundberg et al. 2000) and is considered a good proxy of future morbidity and mortality (Benjamins et al. 2004; Jylha 2009). This exploration of single mothers’ self-assessed levels of health and the associated factors will be useful for health professionals and policy makers for creating and implementing active policies for social protection and for appropriate reform of community nursing services.
Aim This study aimed to explore single mothers’ level of health status as it is reported quantitatively. In particular, the study focuses on the following research questions:
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1 What is the level of single mothers’ self-reported health status compared to partnered mothers? 2 Which factors are associated with single mothers’ selfreported health status?
Method A systematic search was conducted between February and May 2012 in the MEDLINE, PUBMED, CINAHL, EMBASE and COCHRANE databases using the terms ‘single’ or ‘lone’ and ‘mother*’ or ‘parent*’ and ‘health’, in all different combinations. To maximize the amount of relevant literature, the key terms ‘family structure’ and ‘family status’ were used in combination with health. The reference and citation list of selected articles were also screened for potentially relevant articles. The inclusion criteria were as follows: 1 studies with a quantitative research design, 2 reports of single/lone mothers’ or parents’ health status, either as a single group or in comparison to partnered mothers/ parents, 3 articles published in the above databases from 2002 to May 2012; the last decade was only considered, as socioeconomic situations rapidly change over time, and 4 articles to be in English or Greek language, as these are authors’ spoken and written languages. The exclusion criteria were as follows: 1 studies that focused entirely on psychological distress, mental illness or evaluated specific medical diseases, 2 studies using only in-hospital data for evaluating the mortality or the morbidity rates among single mothers, 3 studies that exclusively dealt with single fathers, 4 studies with qualitative design, as the primary aim of this review was not to explore the perceptions beyond the self-rating of health, 5 studies in languages other than English and Greek, and 6 studies that were not researched-based. The same search strategy was adopted in the case of each database and it was carried out independently by members of the research team (E.R., C.K., N.M. and M.K.).
Results The initial search yielded a total of 588 hits. As many as 432 articles were excluded after reading the title, while 34 duplicates were identified. After reading the abstract, a total of 77 articles were further excluded and the remaining 45 articles were retrieved for full examination. Among these, 34 articles focused solely on mental health or specific health conditions and were excluded. Three additional articles were identified from the reference lists of the selected papers, and therefore, a total of 14 articles were forwarded for quality appraisal. The articles were
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quality appraised using a checklist based on Petticrew & Roberts’s (2006) ‘Framework for appraising a survey’. It was considered to be most appropriate for this review as they specifically provide guidance for appraising quantitative studies, with a focus on systematizing the assessment of the reliability and utility of the information presented in the studies. Each member of the research team had to respond positively or negatively, based on his/her judgement, on each of the criteria for considering a study to be methodologically sound. During the quality appraisal process, a total of three studies were excluded as they did not report their findings separately for single and partnered mothers, or were not using a validated instrument (Curtis & Phipps 2004; Weitoft et al. 2002; Eamon & Wu 2011). The final selection included 11 studies, all of which used an SRH question (Fig. 1 provides an overview of the identification process).
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588 titles 432 articles eliminated after reading the title 34 duplicated articles
122 abstracts 77 articles eliminated after reading the abstract
45 full text 34 articles focused entirely on psychological distress, mental illness or specific medic al conditions (e.g. cardiovascular disease)
General description of study characteristics
Six (out of 11) compared single and partnered mothers, two compared single and partnered parents (i.e. included both mothers and fathers), and three studies classified women according to multiple roles (i.e. single or partnered mothers, partnered or single women without children). Eight studies were performed in Europe (Sweden, Great Britain, Italy and Finland), two in the USA and one in South Korea. The characteristics of the 11 studies are summarized in Table 1. The majority of studies investigated self-reported health status of single mothers in relation to specific determinants, such as socio-economic status. Seven studies were crosssectional surveys, four of which were cross-cultural comparative. Seven studies utilized secondary data from large longitudinal studies such as Britain General Household Survey (GHS) and Sweden Survey of Living Conditions (ULF). The remaining four studies were longitudinal surveys with a length of follow-up between 10 and 20 years. Sample sizes varied considerably between the studies, ranging from 375 to 53 292 participants. Studies with particularly large samples were either those which made secondary use of data from large longitudinal surveys and/or those with crossnational comparisons. The data in the longitudinal surveys from where secondary data were extracted were collected via face-to-face interviews and self-complied questionnaires. The secondary data were selected based on the predefined criteria for each research study (9 out of 11). Stratified random sampling and postal questionnaires were used to collect the data for the remaining two studies. Attrition rates varied between 14% and 49.2%, and the response rates mainly between 64% and 85%. The study of Kim et al. (2010) had the highest response rate (95.8%).
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3 articles identified from reference list 14 full text
3 articles not meeting the methodological quality standards (e.g. unspecified sample, not using a validated health indicator)
11 articles for review Fig. 1 Flow diagram for the search process for identifying and including references for the systematic review based on the Center for Reviews and Dissemination for undertaking reviews (CRD, 2009).
In all the studies, the SRH was used with a single question regarding subjective general health, generally based on categorical descriptions such as excellent, very good, good, fair and poor (Goldman et al. 1995). In six of the identified studies, a 5-point scale was used, while in four of the remaining, a 3-point scale, and in one study, a 4 point scale was used. In all studies though, the results were dichotomized into ‘good’ or ‘less than good’
n Sample groups
53 292 Single and partnered mothers
35 047 Single and partnered mothers
6 370 Single and partnered mothers
19 192 Single and partnered mothers
1 589 Single and partnered parents
1 041 Single and partnered parents
Author/s and location of research
Fritzell et al. (2012) Great Britain, Italy, Sweden
Burstrom et al. (2010) Italy, Sweden, Great Britain
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Kim et al. (2010) South Korea
Fritzell et al. (2007) Sweden
Westin & Westerling (2007) Sweden
Westin & Westerling (2006) Sweden
Cross-sectional
Cross-sectional
Aggregate Longitudinal
Cross-sectional
Cross-national Cross-sectional Comparative
Cross-national Cross-sectional Comparative
Design
SRH
SRH
SRH LLI
SRH
SRH LLI
SRH
Health indicators
Instruments
CSI
Predictors
Table 1 Characteristics of quantitative studies evaluating single mothers’ self-assessed general health status
Single motherhood in Britain and Sweden was associated with increased risk of poor health, while in Italy, it did not. Non-employment is significantly associated with a higher risk of poor health in all settings. Single mothers had significantly worse health in all 3 countries, for each of the age groups and in the age-standardized rates, were worse off financially and more likely to suffer material disadvantage, especially in Britain. The gap was smaller in Italy, where single mothers were more likely to be employed. Single mothers had a significantly higher risk of poor/fair health. Subjective economic status explained 28.0% of the excess risk of poor/fair health among women in the single compared to the partnered status. All factors combined (living natural parent, emotional support from siblings, social activities, educational attainment, equivalized household income and subjective economic status) accounted for 41.4% of the excess risk among single mothers. Single mothers reported worse SRH and had higher risks of hospitalization and mortality in all time periods despite changes in social context and policy context. Non-employed mothers and recipients of social assistance had higher risks to report poor health. Less than good health was associated with: single parenthood, female gender and lower education. Social capital was unevenly distributed between single and married mothers and was clearly and positively associated with less than good SRH. When adjusted for financial strain and employment status, emotional support, trust and participation were all independently and positively associated with SRH. Single motherhood was independently associated with less than good SRH, low educational level and financial stress. Despite that, single mothers were more likely to refrain from seeing a physician for a medical problem.
Key findings
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416 Married and divorced mothers
1 171 Childless women Homemakers Single mothers Remarried mothers Intermittent employed married mothers 4 940 Partnered mothers Partnered women with no children Single mothers Non-partnered women 7 758 Partnered mothers Partnered women with no children Divorced mothers Single mothers Single women with no children
Wickrama et al. (2006) USA
McMunn et al. (2006) Britain
Cross-sectional Comparative
Cross-sectional Comparative
Longitudinal Prospective
Longitudinal Prospective
Longitudinal
SRH LLI
SRH
SRH
SRH LLI
SRH
CSI, conditional synergy index; LLI, limited long-standing illness; OR, odds ratio; SRH, self-rated/reported health.
Lahelma et al. (2002) Britain, Finland
Roos et al. (2005) Finland, Sweden
15 546 Single and partnered mothers
Fritzell & Burstrom (2006) Sweden
In both countries, women living in two parent families and having children had better health than women living in other family types or on their own, despite the more generous welfare state and high full-time employment among Finnish women. Adjusting for employment status, education and household income weakened the association between family type and poor SRH. In Britain, the disadvantaged social position of single mothers accounts for a greater proportion of their poor SRH than in Finland.
Single mothers in all socio-demographic categories and especially those between 16 and 24 years reported less than good SRH to a higher extent and this risk had increased in the time period 1990–1998. A polarization in SRH was noted among single mothers, with worsening health in poorer groups and improved health among better off groups. Economic strain had a substantial explanatory value for the excess risk of less than good SRH throughout the period studied. Single parenthood creates financial difficulties for rural mothers. The financial adversity is linked to SRH trajectories that then contribute to change in morbidity during the middle years. Divorced status followed by single parenthood influenced long-term morbidity directly and was associated with higher initial levels of poor mental health, poor physical health and increases the level of family financial strain. Homemakers, single mothers and childless women were significantly more likely to report poor SRH at age 54 than women in the multiple role group. As for single mothers, when adjusted for work quality at age 36, the OR was reduced but remained significant (P = 0.03). When adjusted for work and family stress, the odds for reporting poor health declined but remained significant (P = 0.02) Single mothers and non-partnered women in both countries were more likely to report less than good SRH than partnered mothers The association did not markedly changed when adjusted for income. Employment status was not associated with health in Finland, but strongly associated in Sweden (P = 0.00).
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health. Goldman et al. (1995) reported that SRH, controlling for baseline health and socio-demographic status, is independently associated with change in functional ability over a period of 1–6 years, with an approximately 2.5 times greater risk for decline among those who report their health as fair or poor compared to those with good self-ratings. According to Bowling (2005) and Manor et al. (2001), SRH is appropriate for use in general surveys, has predictive validity for physical disease, changes in functional status, socio-demographic characteristics of respondents, and over time, among persons with or without limiting long-standing illness (Burstrom & Freedlund 2001). Furthermore, it has been shown to be useful for comparisons both within and between countries (Volkers et al. 2007). Specific findings
Differences in study aims, including the different comparison groups, are among the factors that impede presentation of the results obtained in different studies. Thus, specific results are presented based on the following criteria in relation to the selfassessed level of health status: (i) family and/or parental role combinations, (ii) economic strain, (iii) differences in policy regimes, and (iv) social support. Family and/or parental role combinations and self-assessed level of health
In all studies, single mothers assessed their level of health lower than any other group of women, particularly compared to partnered mothers. Therefore, family status was argued as the main reason for this inequality due to the adverse socioeconomic position of single mothers. Under this scope, two studies intended to identify which family combinations are disadvantageous for women’s health. Roos et al. (2005), through a cross-cultural comparative study in Finland and Sweden, found that ‘with partnered’ mothers had the lowest prevalence of ill health in both countries (Finland: 22% vs. 30%; Sweden: 16% vs. 22%). Notably, this association did not markedly change even after adjusting for income in either country. The non-employed reported ill health more often than the employed and a high proportion among them were single mothers. Similar finding are reported by Lahelma et al. (2002) in Britain and Finland. In both countries, partnered mothers reported better health than women living in other family types or on their own. Single mothers were the most disadvantaged group, showing overall worse perceived health, while the observed differences compared to partnered mothers was not dissimilar between those who were divorced [odds ratio (OR = 1.94, confidence interval (CI): 1.54–245] or never married (OR = 2.12, CI: 1.62–2.77). In Finland, despite the
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more generous welfare state and high full-time employment among Finish women, a similar picture was observed (divorced single mothers OR = 1.36, CI: 0.92–2.02; single mothers OR = 1.76, CI: 0.98–3.17). This association was also examined by McMunn et al. (2006) in a prospective study. Their aim was to examine the longitudinal relationships between life course social roles and subjective health among British women in midlife, and to investigate the extent to which indicators of role quality (focused on the concept of agency based on Doyal & Gough’s (1991) theory of human needs) mediate these relationships. Their results also revealed that homemakers and single mothers were statistically significantly more likely to report poor health at age 54 (OR = 2.00, CI: 1.31–3.05; 1.59, CI: 1.10– 2.29, respectively) (P = 0.01). When adjusted for work quality at age 36, the odds of single mothers reporting poor health hardly attenuated (OR = 1.58, CI: 1.09–2.27) but remained statistically significant, while when adjusting for work and family stress, the estimated odds ratio attenuated further but still remained statistically significant (OR = 1.29, CI: 0.88–1.90) (P = 0.02).
The effect of economic strain on the self-assessment of health
Economic aspects were a feature in nearly all of the studies. However, a number of studies aimed to examine this link more in-depth. A common finding was that single mothers experience higher levels of financial hardship, mainly due to unemployment, and therefore worse levels of SRH. In Sweden, Westin & Westerling (2006) analysed SRH and health-care utilization with regard to whether respondents were single or partnered parents (including both fathers and mothers). Among single mothers, as many as 51% rated their health as ‘less than good’ compared to 27% among partnered mothers. Despite their higher medical need, single mothers refrained from seeing a physician much more often (OR = 2.07, CI: 1.29–3.32) and this is mainly due to financial hardship (P < 0.01). While they observed similar results among fathers (39.3% vs. 24.7% to report less than good health), the findings were more marked among mothers. In fact, there is evidence to suggest that in some countries the situation has worsened in recent years. In Sweden, the results of a longitudinal study by Fritzell & Burstrom (2006) showed an upward trend in the prevalence of economic strain during the 1990s, in terms of job characteristics and income, and SRH for both single and partnered mothers. A polarization in SRH was noted among single mothers, with worsening health in poorer groups and improved health among better off groups. The prevalence of ‘less than good SRH’ among
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single mothers aged 16–24 years more than doubled during 1990–1998 compared to the first period (36.2% vs. 16.3%, respectively). The longitudinal impact of financial strain on health was also investigated by Wickrama et al. (2006) in a prospective study among rural mothers in the USA. Specifically, they wanted to investigate the extent by which single parenthood following a divorce undermines the long-term physical health in relation to changes in the family’s financial circumstances. They found that single parenthood following a divorce created financial difficulties and that this financial adversity was linked to self-assessed physical health trajectories which contributed to the developmental course of morbidity in the subsequent years. Initial level and rate of change in family financial strain contributed to subsequent morbidity (b = 0.24, t = 2.47 and b = 0.20, t = 4.37, respectively) despite the fact that divorced mothers seemed to experience lower rates of depressive symptoms during the first years after divorce (b = -0.14, t = 2.82). Self-assessed level of health among single mothers in different policy regimes
A series of studies have investigated the impact of specific policy arrangements on the health of single mothers in either longitudinal or cross-cultural research studies. Fritzell et al. (2007), with an aggregate longitudinal study, focused on whether changes in social and policy context during the 1990s in Sweden (i.e. high employment among eligible population) had an adverse effect on the health of single mothers, compared with partnered mothers. They found that despite the changes, single mothers continued to have higher mortality rates and significant excess risk of being hospitalized than couple mothers throughout the study period. More recently, two cross-cultural comparative studies (Burstrom et al. 2010; Fritzell et al. 2012) intended to explore the level of health between single and partnered mothers in relation to welfare state arrangements and social policy in three different environments: Great Britain, Italy and Sweden. Their results were similar, and the researchers concluded that single mothers could be considered a disadvantaged group in all countries as they were more likely to be unemployed and suffer material hardship, irrespective of the policy regime, and they were more prone to ‘less than good health’. Burstrom et al. (2010) pointed out that British and Swedish single mothers were less likely to be employed compared to partnered mothers (Sweden: 77% vs. 84% and Britain: 50.4% vs. 69.4%, respectively) and appeared to be worse off financially and more likely than partnered mothers to suffer material disadvantage, especially in Britain (50.3% vs. 19.1%) and, to a smaller extent, in Sweden (16.1% vs. 9.9%). Therefore, single mothers reported
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significantly worse health in all three countries (Italy: 48.9% vs. 41.0%; Sweden: 31.6% vs. 16.6%; Britain: 42.8% vs. 29.9%). The observed gap appeared smaller in Italy, where single mothers were more likely to be employed compared to partnered mothers (i.e. 58% vs. 44%, respectively), strengthening therefore an association between employment and level of health. Similarly, Fritzell et al. (2012) found that despite the differences in welfare states’ arrangements among these countries, single mothers were more likely to be economically inactive compared to partnered mothers in all settings, and that unemployment was significantly associated with a higher risk of poor health in all three countries (Britain: OR = 1.70, CI: 1.52–1.90; Italy: OR = 1.13, CI: 1.08–1.18; Sweden: OR = 2.22, CI: 1.91– 2.59).
The impact of social support in the self-assessment of single mothers’ health status
Other than socio-economic circumstances, the lack of social support was also identified to be related to higher levels of poor health among single mothers. An issue raised by Kim et al. (2010) in South Korea was whether there is an association between socio-economic status and social support, with SRH between single and partnered mothers. They found that single mothers had significantly higher risk for poor/fair health (60.1% vs. 28.7%; P < 0.01) and these difference persisted, even after adjusting for potential mediating factors: subjective economic status alone explained 28.0% of the excess risk of poor/fair health among single mothers, whereas all factors combined (social support, income, subjective economic status) accounted for 41.4%. Single mothers appeared less likely to experience emotional support from their sibling(s) and participated less in social activities compared to partnered mothers. This association was also assessed in Westin & Westerling (2007) in Sweden. Specifically, they aimed to examine whether social capital, defined as social participation and trust, is a possible mechanism in explaining existing inequalities in health between single and couple. As anticipated, social capital was unevenly distributed between single and couple mothers, and therefore, low levels of social capital were strongly associated with ‘less than good’ SRH. This inequality persisted even after controlling for social support, socio-economic and sociodemographic variables (OR = 2.00, CI: 1.48–2.72 for low levels of trust and OR = 2.44, CI: 1.84–3.25 for low levels of social participation). In addition, there was a differentiation between emotional and instrumental support. Emotional support was found to be associated with perceived health (OR = 1.61, CI:
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1.08–2.38) unlike instrumental, and this positive association still remained even after adjusting for financial strain and employment status.
Discussion A common finding across all studies presented here was that single mothers were assessing their health status to be worse than partnered mothers or women in any other group. According to the results, single mothers had twice or even tripled the chances to report their SRH as ‘less than good’ compared to their married counterparts. The most pronounced difference was observed in the studies by Kim et al. (2010) in South Korea, in Sweden by Roos et al. (2005) and in Britain by Lahelma et al. (2002). Cross-cultural comparisons also revealed that the findings are similar in all countries, despite the differences in family policy models, or the welfare arrangements, social policy and the living conditions. This is mostly emphasized in the studies of Fritzell et al. (2012) and Burstrom et al. (2010), where three different policy regimes were investigated. Single mothers reported significantly worse health in all settings and thus should be considered a disadvantaged group concerning their health status. The smaller gap identified in Italy, where single mothers were more likely to be employed, strongly suggests that unemployment and economic hardship are the main reasons for this inequality. This issue is supported by the majority of the studies, as findings showed that the observed health inequalities were mostly related to socio-economic hardship, either due to unemployment or the lack of welfare arrangements, which potentially increase their susceptibility to stress. Non-employment, according to Eamon & Wu (2011), increases the risk of suffering material hardship and was significantly associated with higher risk of poor health in all settings examined (Fritzell et al. 2012; Lahelma et al. 2002; Roos et al. 2005; Westin & Westerling 2007; Wickrama et al. 2006). This issue is mostly highlighted by Westin & Westerling (2006), where single mothers had double the likelihood to refrain from seeing a physician, even though they assessed their health as ‘less than good’ compared to partnered mothers. Eamon & Wu (2011) emphasized this association, as employment problems seemed to increase the risk of suffering material hardship among single-mother families. Despite Roos et al.’s (2005) findings that employment seemed to benefit social contacts and improve women’s economic independence and well-being, according to Eamon & Wu (2011), many single mothers cannot rely on employment alone to meet their families’ basic needs. On the other hand, employment status does not seem to benefit single mothers’ social contacts or improve their independence and well-being to the same extent as other women
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(Roos et al. 2005). Thus, single mothers cannot rely on employment alone to meet their families’ basic needs and additional socio-economic circumstances should be taken into consideration. Lack of social support was also identified to be related to higher levels of poor health among single mothers. Westin & Westerling (2007) found that social capital was unevenly distributed between single and married mothers and that emotional, but not instrumental, support was associated with single mothers’ lower levels of health status. Similar findings were identified by Kim et al. (2010) in South Korea, where mediating factors, such as emotional support from siblings and social activities, accounted for 41.1% of the excess risk for poorer level of health among single mothers.
Limitations
All studies presented in this review used SRH as an indicator for evaluating mother’s level of general health in relation to socioeconomic factors. However, the evaluation of health status is multidimensional. While SRH has been shown to capture symptoms or diseases as yet undiagnosed, which may be present in prodromal or pre-clinical stages (Idler & Benyamini 1997), the level of health can be assessed in various ways and with different psychometric tools. To some extent, this can be viewed as a result of the fact that there is limited research based on population samples as the majority of the studies reviewed here were based on secondary analyses of available data from longitudinal household surveys. Four out of the twelve studies made secondary use of data from general household surveys in cross-national comparisons. These cross-national studies had the advantage of gathering large and therefore representative samples. However, even though the data used in the cross-country comparative studies were collected in similar ways and this enabled comparisons across populations, Fritzell et al. (2012) argues that data compatibility is a potential pitfall in all cross-national research, and therefore, issues concerning sample frame and country-specific variables can limit compatibility. Furthermore, the crosssectional nature of these data does not allow for conclusions on the causality of the observed associations. However, all the studies suggested potential explanations for the poor health among single mothers, related to either the economic strain and/or the lack of social support networks. The results from the longitudinal studies (Fritzell & Burstrom 2006; Fritzell et al. 2007; McMunn et al. 2006; Wickrama et al. 2006) strengthen these findings and introduce more detailed explanations on the issues concerning the associations of family combinations, work, stress, and social class and SRH.
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Additionally, an issue concerning the cross-country comparative studies is that reporting SRH may be culturally specific. According to Jylha (2009), these differences may reflect real differences in subjective health status, or they may also reflect differences in health-related knowledge and subjective evaluations of health status. Finally, while the response rates in the majority of the studies were generally high, according to Lorant et al. (2007), those in lower socio-economic position and/or in poor health status are less likely to participate in surveys. This issue is mostly emphasized in a study by Johner et al. (2007), which included only single mothers, and the sample was selected through stratified random selection; the response rate was only 19%. Therefore, taking into consideration that single mothers compose a vulnerable group with regard to their socio-economic position, it is likely that excess risk of ‘less than good’ health among non-employed single mothers reported in these studies is still underestimated.
Implications for practice This review gives a descriptive account of the literature on the self-assessed health status of single mothers, and it will benefit both health professionals, especially those working in the community, and policy makers. Despite the similarities in the findings of the studies, there are still many unresolved issues with regard to the health inequality experienced by single mothers. An important limitation concerning the methodological issues among the identified studies is that only single-item SRH is used as a tool for assessing the level of health status. This is mainly due to the fact that the majority of the studies were based on secondary analysis of available data, and there is limited research based on population samples. Therefore, there is a need for research that will focus on population-based surveys with the use of different psychometric scales that would assess the general perception of health status in relation to different dimensions (e.g. well-being, life satisfaction). In the existing literature, it appears that these associations are mainly correlated with the psychological health rather than SRH. In addition, as can be observed in the cross-cultural studies, to some extent, the political and social arrangements, as well as the economic environments, might be the determining factors for the magnitude of these inequalities. Despite the fact that the results were similar in all settings examined, with single mothers scoring worse their self-assessed level of health, it was noted that in countries where single mothers were more likely to be employed, for example, Italy (Burstrom et al. 2010; Fritzell et al. 2012), the gap was smaller. Therefore, local research with a focus on the possible association of the existing inequalities
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with the in-country political and social circumstances should be encouraged, enabling the possible welfare or social arrangements to be targeted.
Conclusion Single motherhood, economic strain and social disadvantage seem to be in a dynamic state. Unemployment and the increased obligations of single motherhood appear to result in both economic hardship and social exclusion, which eventually increases chronic stress and lowers the levels of SRH. From a public health perspective, this makes the poor health of single mothers all the more important, as it affects all the more women, their children and eventually the whole community. It is important to monitor future trends in the associations between women’s health, employment status and family type, as women-friendly policies are under increasing pressure from international competition and economic downturns. Adverse economic developments and a reversal of women-friendly policies are likely to hit hardest at the social position and living conditions, as well as the health and well-being, of the most vulnerable groups in society, including single mothers.
Conflict of interest None.
Author contributions ER: Conception and design, acquisition, analysis and interpretation of data, and drafting of the article. CK, NM and MK: Critical revision for important intellectual content.
References Afifi, T.O., Cox, B.J. & Enns, M.W. (2006) Mental health profiles among married, never-married, and separated/divorced mothers in a nationally representative sample. Social Psychiatry and Psychiatric Epidemiology, 41, 122–129. Avison, W.R., Davies, L., Willson, A.E. & Shuey, K.M. (2008) Family structure and mother’s mental health: a life course perspective on stability and change. Advances in Life Course Research, 13, 233–255. Benjamins, M.R., Hummer, R.R., Eberstein, I.W. & Nam, C.B. (2004) Selfreported health and adult mortality risk: an analysis of cause-specific mortality. Social Science and Medicine, 59 (6), 1297–1306. Bowling, A. (2005) Just one question: if one question works, why ask several? Journal of Epidemiology and Community Health, 59, 342–345. Burstrom, B. & Freedlund, P. (2001) Self rated health: is it a good prediction of subsequent mortality among adults in lower as well as in higher social classes? Journal of Epidemiology and Community Health, 55, 836– 840. Burstrom, B., et al. (2010) Health inequalities between lone and couple mothers and policy under different welfare regimes – the example of Italy, Sweden and Britain. Social Science and Medicine, 70, 912–920.
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CRD (2009) Systematic Reviews. CRD, York. Crosier, T., Butterworth, P. & Rodgers, B. (2007) Mental health problems among single and partnered mothers. The role of financial hardship and social support. Social Psychiatry and Psychiatric Epidemiology, 42, 6–13. Curtis, L. & Phipps, S. (2004) Social transfers and the health status of mothers in Norway and Canada. Social Science and Medicine, 58, 2499– 2507. Doyal, L. & Gough, I. (1991) A Theory of Human Needs. Macmilan Press Ltd, London. Dziak, E., Janzen, B.L. & Muhajarine, N. (2010) Inequalities in the psychological well-being of employed, single and partnered mothers: the role of psychosocial work quality and work-family conflict. International Journal for Equity in Health, 9 (6), 1–8. Eamon, M.K. & Wu, C.F. (2011) Effects of unemployment and underemployment on maternal hardship in single-mother families. Children and Youth Services Review, 33, 233–241. Eurostat (2012) Marriage and Divorce Statistics. (accessed 23 December 2012). Franz, M., Lensche, H. & Schmitz, N. (2003) Psychological distress and socioeconomic status in single mothers and their children in a German city. Social Psychiatry and Psychiatric Epidemiology, 38, 59–68. Fritzell, S. & Burstrom, B. (2006) Economic strain and self reported health among lone and couple mothers in Sweden during the 1990s compared to the 1980s. Health Policy, 79, 253–264. Fritzell, S., Weitoft, G.R., Fritzell, J. & Burstrom, B. (2007) From macro to micro: the health of Swedish lone mothers during changing economic and social circumstances. Social Science and Medicine, 65, 2474–2488. Fritzell, S., et al. (2012) Does unemployment contribute to the health disadvantage among lone mothers in Britain, Italy and Sweden? Synergy effects and the meaning of family policy. Health and Place, 18, 199–208. Goldman, N., Korenman, S. & Weinstein, R. (1995) Marital status and health among the elderly. Social Science and Medicine, 40, 1717–1730. Idler, E.L. & Benyamini, Y. (1997) Self-rated health and mortality: a review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21–37. Johner, R., Maslany, G., Jeffry, B. & Gingrich, R. (2007) Exploring links between perceived health, social exclusion & social assistance recipiency in Saskatchewan single mothers. Women’s Health and Urban Life, 8 (2), 21–63. Jylha, M. (2009) What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Social Science and Medicine, 69, 307–316. Keating-Lefler, R., et al. (2004) Needs, concerns, and social support of single, low-income mothers. Issues in Mental Health Nursing, 25, 381– 401. Kim, D.-S., Jeon, G.-S. & Jang, S.-N. (2010) Socioeconomic status, social support and self-rated health among lone mothers in South Korea. International Journal of Public Health, 55, 551–559.
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Lahelma, E., Arber, S., Kivela, K. & Roos, E. (2002) Multiple roles and health among British and Finnish women: the influence of socioeconomic circumstances. Social Science and Medicine, 54, 727–740. Lorant, V., Demarest, S., Miermans, P.-J. & Van Oyen, H. (2007) Survey error in measuring socio-economic risk factors in health status: a comparison of a survey and a census. International Journal of Epidemiology, 36 (6), 1292–1299. Lundberg, O., Manderbacka, K. & Martikainen, P. (2000) Health measures in a comparative perspective. In Self-Rated Health in A European Perspective (Nilsson, P.M. & Orth-Gomer, K., eds). Forskningsradsmanmden (FRN), Stockholm, pp. 103–112. (2000:2). Manor, O., Matthews, S. & Power, C. (2001) Self rated health and limiting long standing illness: inter-relationships with morbidity in early adulthood. International Journal of Epidemiology, 30 (3), 600–607. McMunn, A., Bartley, M. & Kuh, D. (2006) Women’s health in mid-life: life course social roles and agency as quality. Social Science and Medicine, 63, 1561–1572. Petticrew, M. & Roberts, H. (2006) Systematic Reviews in the Social Sciences: A Practical Guide. Blackwell Publishing Ltd, Oxford, UK. Roos, E., Burstrom, B., Saastamoinen, P. & Lahelma, E. (2005) A comparative study of the pattering of women’s health by family status and employment status in Finland and Sweden. Social Science and Medicine, 60, 2443–2451. US Census Bureau (2011) Table FG10. Family Groups. Volkers, A.C., Westert, G.P. & Schellevis, F.G. (2007) Health disparities by occupation, modified by education: a cross-sectional population study. BMC Public Health, 7, 196–222. Wade, J.T., Veldhuizen, S. & Cairney, J. (2011) Prevalence of psychiatric disorder in lone fathers and mothers: examining the intersection of gender and family structure on mental health. Canadian Journal of Psychiatry, 56 (9), 567–573. Waldfogel, J., Graigie, T. & Brooks-Gunn, J. (2010) Fragile families and child wellbeing. The Future of Children, 20 (2), 87–112. Wang, C.C. & Pies, C.A. (2004) Family, maternal, and child health through photovoice. Maternal and Child Health Journal, 8 (2), 95–102. Weitoft, G.R., Haglund, B., Hjern, A. & Rosen, M. (2002) Mortality, severe morbidity and injury among long-term lone mothers in Sweden. International Journal of Epidemiology, 31, 573–580. Westin, M. & Westerling, R. (2006) Health and healthcare utilization among single mothers and single fathers in Sweden. Scandinavian Journal of Public Health, 34, 182–189. Westin, M. & Westerling, R. (2007) Social capital and inequality in health between single and couple parents in Sweden. Scandinavian Journal of Public Health, 35, 609–617. Wickrama, K.A.S., et al. (2006) Changes in family financial circumstances and the physical health of married and recently divorced mothers. Social Science and Medicine, 63, 123–136. Young, L.E., Cunningham, S.L. & Buist, D.S.M. (2005) Lone mothers are at higher risk for cardiovascular disease compared with partnered mothers. Data from the National Health and Nutrition Examination Survey III (NHANES III). Health Care for Women International, 26, 604–621.
RN, PhD, N.
Middleton2 PhD &
1 Scientific Staff, 2 Assistant Professor, 3 Lecturer, Department of Nursing, School of Health Sciences, Cyprus University of Technology, Limassol, Cyprus
ROUSOU E., KOUTA C., MIDDLETON N. & KARANIKOLA M. (2013) Single mothers’ self-assessment of health: a systematic exploration of the literature. International Nursing Review 60, 425–434 Aim: This study aimed to explore single mothers’ self-assessed level of health status compared to partnered mothers and the relevant factors associated with it. Background: The number of single-mother families is increasing worldwide. A large body of international research reveals that single mothers experience poorer physical and mental health than their married counterparts. An important contributory factor for this health disparity appears to be socio-economic disadvantage. Methods: A systematic search of the literature was conducted using the keywords ‘lone’ or ‘single’ and ‘mother*’ or ‘parent*’ or ‘family structure’ in combination with ‘health’. EMBASE, CINAHL, COCHRANE and PUBMED databas were searched for quantitative research studies published in the past decade. Results: Eleven quantitative research articles with self-assessment of health status in single mothers were identified. Single mothers report lower levels of health status compared to partnered mothers. These inequalities appear to be associated with financial hardship and lack of social support. Both these factors increase single mothers’ susceptibility to stress and illness. Conclusion: Despite the study limitations (e.g. results based mainly on secondary data from household surveys), it provides evidence that single motherhood places women in an adverse social position that is associated with prolonged stress mainly due to unemployment, economic hardship and social exclusion, which affects negatively their health status. These findings can be seen as a challenge for health professionals, especially those working in the community sector and policy makers too, to establish supportive measures for this vulnerable group focused on socio-economic factors. Keywords: Health Professionals, Lone Mothers, Nurses, Poverty, Review, Self-Rated Health, Single Mothers, Social Exclusion
Introduction The increase in the number of families headed by single mothers has been one of the most significant structural changes in society, especially in the developed world (Avison et al. 2008).
Correspondence address: Elena Rousou, 8 Vavilonos, 4007 Mesa Yitonia, Limassol, Cyprus; Tel: +357-99846634; Fax: +357-25002822; E-mail: [email protected].
© 2013 International Council of Nurses
As of 2011, 11.7 million families in the USA were headed by a single parent, 85.2% of which were headed by a mother (US Census Bureau 2011). In Europe, statistics show a tremendous rise in divorce rates and births outside marriage, both of which lead to single-parent families mainly headed by a mother. Since 1970, the crude marriage rate in the EU-27 has declined by 38% (from 7.9 per 1000 inhabitants in 1970 to 4.9 in 2007). At the same time, marriages became less stable, as indicated by the
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increase in the divorce rate, from 0.9 per 1000 inhabitants in 1970 to 2.1 in 2007. In parallel, the percentage of births outside marriage rose to 37.4 in 2010, compared to 17.4 in 1990. In Cyprus, despite the fact that single-parent families constitute only a small percentage of all families, there has been a significant increase over the last decades (from 3.6% in 1982 to 7.6% in 2011), of which the majority was headed by a mother (6.7% compared to 0.9% headed by a father) (Eurostat 2012). At the same time, it seems that single motherhood affects negatively single mothers’ health status. A large body of the literature exists concerning this issue, emphasizing single mothers’ need for greater support (Keating-Lefler et al. 2004). This evidence reveals that single motherhood places women in an adverse social position that is associated with prolonged stress due to long hours of work and single-handed child care (Fritzell et al. 2007; Wickrama et al. 2006), which affects negatively their health status as well as their dependents (Waldfogel et al. 2010). The majority of the studies dealing with single mothers’ health status examine the mental health consequences in relation to high levels of stress. Single mothers have been found to experience higher rates of psychological distress (Dziak et al. 2010; Franz et al. 2003), mood disorders (Wade et al. 2011), anxiety disorders (Afifi et al. 2006) and depressive symptoms (Crosier et al. 2007; Wang & Pies 2004). Fewer studies have dealt with the physical aspects of health of single mothers, but those that did demonstrate a vulnerability to specific health conditions such as cardiovascular disease (Young et al. 2005) or increased risk of mortality and morbidity compared to partnered mothers (Weitoft et al. 2002; Wickrama et al. 2006). Exploration of the degree to which single mothers constitute a vulnerable population for physical as well as mental disorders is therefore of high importance. The perception of health as experienced by a person is considered an initial indicator for several health outcomes, and therefore, self-assessment tools [e.g. self-rated health (SRH)] are commonly used as a predictor for assessing health status. SRH is recommended as a health indicator by the World Health Organization (Lundberg et al. 2000) and is considered a good proxy of future morbidity and mortality (Benjamins et al. 2004; Jylha 2009). This exploration of single mothers’ self-assessed levels of health and the associated factors will be useful for health professionals and policy makers for creating and implementing active policies for social protection and for appropriate reform of community nursing services.
Aim This study aimed to explore single mothers’ level of health status as it is reported quantitatively. In particular, the study focuses on the following research questions:
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1 What is the level of single mothers’ self-reported health status compared to partnered mothers? 2 Which factors are associated with single mothers’ selfreported health status?
Method A systematic search was conducted between February and May 2012 in the MEDLINE, PUBMED, CINAHL, EMBASE and COCHRANE databases using the terms ‘single’ or ‘lone’ and ‘mother*’ or ‘parent*’ and ‘health’, in all different combinations. To maximize the amount of relevant literature, the key terms ‘family structure’ and ‘family status’ were used in combination with health. The reference and citation list of selected articles were also screened for potentially relevant articles. The inclusion criteria were as follows: 1 studies with a quantitative research design, 2 reports of single/lone mothers’ or parents’ health status, either as a single group or in comparison to partnered mothers/ parents, 3 articles published in the above databases from 2002 to May 2012; the last decade was only considered, as socioeconomic situations rapidly change over time, and 4 articles to be in English or Greek language, as these are authors’ spoken and written languages. The exclusion criteria were as follows: 1 studies that focused entirely on psychological distress, mental illness or evaluated specific medical diseases, 2 studies using only in-hospital data for evaluating the mortality or the morbidity rates among single mothers, 3 studies that exclusively dealt with single fathers, 4 studies with qualitative design, as the primary aim of this review was not to explore the perceptions beyond the self-rating of health, 5 studies in languages other than English and Greek, and 6 studies that were not researched-based. The same search strategy was adopted in the case of each database and it was carried out independently by members of the research team (E.R., C.K., N.M. and M.K.).
Results The initial search yielded a total of 588 hits. As many as 432 articles were excluded after reading the title, while 34 duplicates were identified. After reading the abstract, a total of 77 articles were further excluded and the remaining 45 articles were retrieved for full examination. Among these, 34 articles focused solely on mental health or specific health conditions and were excluded. Three additional articles were identified from the reference lists of the selected papers, and therefore, a total of 14 articles were forwarded for quality appraisal. The articles were
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quality appraised using a checklist based on Petticrew & Roberts’s (2006) ‘Framework for appraising a survey’. It was considered to be most appropriate for this review as they specifically provide guidance for appraising quantitative studies, with a focus on systematizing the assessment of the reliability and utility of the information presented in the studies. Each member of the research team had to respond positively or negatively, based on his/her judgement, on each of the criteria for considering a study to be methodologically sound. During the quality appraisal process, a total of three studies were excluded as they did not report their findings separately for single and partnered mothers, or were not using a validated instrument (Curtis & Phipps 2004; Weitoft et al. 2002; Eamon & Wu 2011). The final selection included 11 studies, all of which used an SRH question (Fig. 1 provides an overview of the identification process).
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588 titles 432 articles eliminated after reading the title 34 duplicated articles
122 abstracts 77 articles eliminated after reading the abstract
45 full text 34 articles focused entirely on psychological distress, mental illness or specific medic al conditions (e.g. cardiovascular disease)
General description of study characteristics
Six (out of 11) compared single and partnered mothers, two compared single and partnered parents (i.e. included both mothers and fathers), and three studies classified women according to multiple roles (i.e. single or partnered mothers, partnered or single women without children). Eight studies were performed in Europe (Sweden, Great Britain, Italy and Finland), two in the USA and one in South Korea. The characteristics of the 11 studies are summarized in Table 1. The majority of studies investigated self-reported health status of single mothers in relation to specific determinants, such as socio-economic status. Seven studies were crosssectional surveys, four of which were cross-cultural comparative. Seven studies utilized secondary data from large longitudinal studies such as Britain General Household Survey (GHS) and Sweden Survey of Living Conditions (ULF). The remaining four studies were longitudinal surveys with a length of follow-up between 10 and 20 years. Sample sizes varied considerably between the studies, ranging from 375 to 53 292 participants. Studies with particularly large samples were either those which made secondary use of data from large longitudinal surveys and/or those with crossnational comparisons. The data in the longitudinal surveys from where secondary data were extracted were collected via face-to-face interviews and self-complied questionnaires. The secondary data were selected based on the predefined criteria for each research study (9 out of 11). Stratified random sampling and postal questionnaires were used to collect the data for the remaining two studies. Attrition rates varied between 14% and 49.2%, and the response rates mainly between 64% and 85%. The study of Kim et al. (2010) had the highest response rate (95.8%).
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3 articles identified from reference list 14 full text
3 articles not meeting the methodological quality standards (e.g. unspecified sample, not using a validated health indicator)
11 articles for review Fig. 1 Flow diagram for the search process for identifying and including references for the systematic review based on the Center for Reviews and Dissemination for undertaking reviews (CRD, 2009).
In all the studies, the SRH was used with a single question regarding subjective general health, generally based on categorical descriptions such as excellent, very good, good, fair and poor (Goldman et al. 1995). In six of the identified studies, a 5-point scale was used, while in four of the remaining, a 3-point scale, and in one study, a 4 point scale was used. In all studies though, the results were dichotomized into ‘good’ or ‘less than good’
n Sample groups
53 292 Single and partnered mothers
35 047 Single and partnered mothers
6 370 Single and partnered mothers
19 192 Single and partnered mothers
1 589 Single and partnered parents
1 041 Single and partnered parents
Author/s and location of research
Fritzell et al. (2012) Great Britain, Italy, Sweden
Burstrom et al. (2010) Italy, Sweden, Great Britain
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Kim et al. (2010) South Korea
Fritzell et al. (2007) Sweden
Westin & Westerling (2007) Sweden
Westin & Westerling (2006) Sweden
Cross-sectional
Cross-sectional
Aggregate Longitudinal
Cross-sectional
Cross-national Cross-sectional Comparative
Cross-national Cross-sectional Comparative
Design
SRH
SRH
SRH LLI
SRH
SRH LLI
SRH
Health indicators
Instruments
CSI
Predictors
Table 1 Characteristics of quantitative studies evaluating single mothers’ self-assessed general health status
Single motherhood in Britain and Sweden was associated with increased risk of poor health, while in Italy, it did not. Non-employment is significantly associated with a higher risk of poor health in all settings. Single mothers had significantly worse health in all 3 countries, for each of the age groups and in the age-standardized rates, were worse off financially and more likely to suffer material disadvantage, especially in Britain. The gap was smaller in Italy, where single mothers were more likely to be employed. Single mothers had a significantly higher risk of poor/fair health. Subjective economic status explained 28.0% of the excess risk of poor/fair health among women in the single compared to the partnered status. All factors combined (living natural parent, emotional support from siblings, social activities, educational attainment, equivalized household income and subjective economic status) accounted for 41.4% of the excess risk among single mothers. Single mothers reported worse SRH and had higher risks of hospitalization and mortality in all time periods despite changes in social context and policy context. Non-employed mothers and recipients of social assistance had higher risks to report poor health. Less than good health was associated with: single parenthood, female gender and lower education. Social capital was unevenly distributed between single and married mothers and was clearly and positively associated with less than good SRH. When adjusted for financial strain and employment status, emotional support, trust and participation were all independently and positively associated with SRH. Single motherhood was independently associated with less than good SRH, low educational level and financial stress. Despite that, single mothers were more likely to refrain from seeing a physician for a medical problem.
Key findings
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416 Married and divorced mothers
1 171 Childless women Homemakers Single mothers Remarried mothers Intermittent employed married mothers 4 940 Partnered mothers Partnered women with no children Single mothers Non-partnered women 7 758 Partnered mothers Partnered women with no children Divorced mothers Single mothers Single women with no children
Wickrama et al. (2006) USA
McMunn et al. (2006) Britain
Cross-sectional Comparative
Cross-sectional Comparative
Longitudinal Prospective
Longitudinal Prospective
Longitudinal
SRH LLI
SRH
SRH
SRH LLI
SRH
CSI, conditional synergy index; LLI, limited long-standing illness; OR, odds ratio; SRH, self-rated/reported health.
Lahelma et al. (2002) Britain, Finland
Roos et al. (2005) Finland, Sweden
15 546 Single and partnered mothers
Fritzell & Burstrom (2006) Sweden
In both countries, women living in two parent families and having children had better health than women living in other family types or on their own, despite the more generous welfare state and high full-time employment among Finnish women. Adjusting for employment status, education and household income weakened the association between family type and poor SRH. In Britain, the disadvantaged social position of single mothers accounts for a greater proportion of their poor SRH than in Finland.
Single mothers in all socio-demographic categories and especially those between 16 and 24 years reported less than good SRH to a higher extent and this risk had increased in the time period 1990–1998. A polarization in SRH was noted among single mothers, with worsening health in poorer groups and improved health among better off groups. Economic strain had a substantial explanatory value for the excess risk of less than good SRH throughout the period studied. Single parenthood creates financial difficulties for rural mothers. The financial adversity is linked to SRH trajectories that then contribute to change in morbidity during the middle years. Divorced status followed by single parenthood influenced long-term morbidity directly and was associated with higher initial levels of poor mental health, poor physical health and increases the level of family financial strain. Homemakers, single mothers and childless women were significantly more likely to report poor SRH at age 54 than women in the multiple role group. As for single mothers, when adjusted for work quality at age 36, the OR was reduced but remained significant (P = 0.03). When adjusted for work and family stress, the odds for reporting poor health declined but remained significant (P = 0.02) Single mothers and non-partnered women in both countries were more likely to report less than good SRH than partnered mothers The association did not markedly changed when adjusted for income. Employment status was not associated with health in Finland, but strongly associated in Sweden (P = 0.00).
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health. Goldman et al. (1995) reported that SRH, controlling for baseline health and socio-demographic status, is independently associated with change in functional ability over a period of 1–6 years, with an approximately 2.5 times greater risk for decline among those who report their health as fair or poor compared to those with good self-ratings. According to Bowling (2005) and Manor et al. (2001), SRH is appropriate for use in general surveys, has predictive validity for physical disease, changes in functional status, socio-demographic characteristics of respondents, and over time, among persons with or without limiting long-standing illness (Burstrom & Freedlund 2001). Furthermore, it has been shown to be useful for comparisons both within and between countries (Volkers et al. 2007). Specific findings
Differences in study aims, including the different comparison groups, are among the factors that impede presentation of the results obtained in different studies. Thus, specific results are presented based on the following criteria in relation to the selfassessed level of health status: (i) family and/or parental role combinations, (ii) economic strain, (iii) differences in policy regimes, and (iv) social support. Family and/or parental role combinations and self-assessed level of health
In all studies, single mothers assessed their level of health lower than any other group of women, particularly compared to partnered mothers. Therefore, family status was argued as the main reason for this inequality due to the adverse socioeconomic position of single mothers. Under this scope, two studies intended to identify which family combinations are disadvantageous for women’s health. Roos et al. (2005), through a cross-cultural comparative study in Finland and Sweden, found that ‘with partnered’ mothers had the lowest prevalence of ill health in both countries (Finland: 22% vs. 30%; Sweden: 16% vs. 22%). Notably, this association did not markedly change even after adjusting for income in either country. The non-employed reported ill health more often than the employed and a high proportion among them were single mothers. Similar finding are reported by Lahelma et al. (2002) in Britain and Finland. In both countries, partnered mothers reported better health than women living in other family types or on their own. Single mothers were the most disadvantaged group, showing overall worse perceived health, while the observed differences compared to partnered mothers was not dissimilar between those who were divorced [odds ratio (OR = 1.94, confidence interval (CI): 1.54–245] or never married (OR = 2.12, CI: 1.62–2.77). In Finland, despite the
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more generous welfare state and high full-time employment among Finish women, a similar picture was observed (divorced single mothers OR = 1.36, CI: 0.92–2.02; single mothers OR = 1.76, CI: 0.98–3.17). This association was also examined by McMunn et al. (2006) in a prospective study. Their aim was to examine the longitudinal relationships between life course social roles and subjective health among British women in midlife, and to investigate the extent to which indicators of role quality (focused on the concept of agency based on Doyal & Gough’s (1991) theory of human needs) mediate these relationships. Their results also revealed that homemakers and single mothers were statistically significantly more likely to report poor health at age 54 (OR = 2.00, CI: 1.31–3.05; 1.59, CI: 1.10– 2.29, respectively) (P = 0.01). When adjusted for work quality at age 36, the odds of single mothers reporting poor health hardly attenuated (OR = 1.58, CI: 1.09–2.27) but remained statistically significant, while when adjusting for work and family stress, the estimated odds ratio attenuated further but still remained statistically significant (OR = 1.29, CI: 0.88–1.90) (P = 0.02).
The effect of economic strain on the self-assessment of health
Economic aspects were a feature in nearly all of the studies. However, a number of studies aimed to examine this link more in-depth. A common finding was that single mothers experience higher levels of financial hardship, mainly due to unemployment, and therefore worse levels of SRH. In Sweden, Westin & Westerling (2006) analysed SRH and health-care utilization with regard to whether respondents were single or partnered parents (including both fathers and mothers). Among single mothers, as many as 51% rated their health as ‘less than good’ compared to 27% among partnered mothers. Despite their higher medical need, single mothers refrained from seeing a physician much more often (OR = 2.07, CI: 1.29–3.32) and this is mainly due to financial hardship (P < 0.01). While they observed similar results among fathers (39.3% vs. 24.7% to report less than good health), the findings were more marked among mothers. In fact, there is evidence to suggest that in some countries the situation has worsened in recent years. In Sweden, the results of a longitudinal study by Fritzell & Burstrom (2006) showed an upward trend in the prevalence of economic strain during the 1990s, in terms of job characteristics and income, and SRH for both single and partnered mothers. A polarization in SRH was noted among single mothers, with worsening health in poorer groups and improved health among better off groups. The prevalence of ‘less than good SRH’ among
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single mothers aged 16–24 years more than doubled during 1990–1998 compared to the first period (36.2% vs. 16.3%, respectively). The longitudinal impact of financial strain on health was also investigated by Wickrama et al. (2006) in a prospective study among rural mothers in the USA. Specifically, they wanted to investigate the extent by which single parenthood following a divorce undermines the long-term physical health in relation to changes in the family’s financial circumstances. They found that single parenthood following a divorce created financial difficulties and that this financial adversity was linked to self-assessed physical health trajectories which contributed to the developmental course of morbidity in the subsequent years. Initial level and rate of change in family financial strain contributed to subsequent morbidity (b = 0.24, t = 2.47 and b = 0.20, t = 4.37, respectively) despite the fact that divorced mothers seemed to experience lower rates of depressive symptoms during the first years after divorce (b = -0.14, t = 2.82). Self-assessed level of health among single mothers in different policy regimes
A series of studies have investigated the impact of specific policy arrangements on the health of single mothers in either longitudinal or cross-cultural research studies. Fritzell et al. (2007), with an aggregate longitudinal study, focused on whether changes in social and policy context during the 1990s in Sweden (i.e. high employment among eligible population) had an adverse effect on the health of single mothers, compared with partnered mothers. They found that despite the changes, single mothers continued to have higher mortality rates and significant excess risk of being hospitalized than couple mothers throughout the study period. More recently, two cross-cultural comparative studies (Burstrom et al. 2010; Fritzell et al. 2012) intended to explore the level of health between single and partnered mothers in relation to welfare state arrangements and social policy in three different environments: Great Britain, Italy and Sweden. Their results were similar, and the researchers concluded that single mothers could be considered a disadvantaged group in all countries as they were more likely to be unemployed and suffer material hardship, irrespective of the policy regime, and they were more prone to ‘less than good health’. Burstrom et al. (2010) pointed out that British and Swedish single mothers were less likely to be employed compared to partnered mothers (Sweden: 77% vs. 84% and Britain: 50.4% vs. 69.4%, respectively) and appeared to be worse off financially and more likely than partnered mothers to suffer material disadvantage, especially in Britain (50.3% vs. 19.1%) and, to a smaller extent, in Sweden (16.1% vs. 9.9%). Therefore, single mothers reported
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significantly worse health in all three countries (Italy: 48.9% vs. 41.0%; Sweden: 31.6% vs. 16.6%; Britain: 42.8% vs. 29.9%). The observed gap appeared smaller in Italy, where single mothers were more likely to be employed compared to partnered mothers (i.e. 58% vs. 44%, respectively), strengthening therefore an association between employment and level of health. Similarly, Fritzell et al. (2012) found that despite the differences in welfare states’ arrangements among these countries, single mothers were more likely to be economically inactive compared to partnered mothers in all settings, and that unemployment was significantly associated with a higher risk of poor health in all three countries (Britain: OR = 1.70, CI: 1.52–1.90; Italy: OR = 1.13, CI: 1.08–1.18; Sweden: OR = 2.22, CI: 1.91– 2.59).
The impact of social support in the self-assessment of single mothers’ health status
Other than socio-economic circumstances, the lack of social support was also identified to be related to higher levels of poor health among single mothers. An issue raised by Kim et al. (2010) in South Korea was whether there is an association between socio-economic status and social support, with SRH between single and partnered mothers. They found that single mothers had significantly higher risk for poor/fair health (60.1% vs. 28.7%; P < 0.01) and these difference persisted, even after adjusting for potential mediating factors: subjective economic status alone explained 28.0% of the excess risk of poor/fair health among single mothers, whereas all factors combined (social support, income, subjective economic status) accounted for 41.4%. Single mothers appeared less likely to experience emotional support from their sibling(s) and participated less in social activities compared to partnered mothers. This association was also assessed in Westin & Westerling (2007) in Sweden. Specifically, they aimed to examine whether social capital, defined as social participation and trust, is a possible mechanism in explaining existing inequalities in health between single and couple. As anticipated, social capital was unevenly distributed between single and couple mothers, and therefore, low levels of social capital were strongly associated with ‘less than good’ SRH. This inequality persisted even after controlling for social support, socio-economic and sociodemographic variables (OR = 2.00, CI: 1.48–2.72 for low levels of trust and OR = 2.44, CI: 1.84–3.25 for low levels of social participation). In addition, there was a differentiation between emotional and instrumental support. Emotional support was found to be associated with perceived health (OR = 1.61, CI:
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1.08–2.38) unlike instrumental, and this positive association still remained even after adjusting for financial strain and employment status.
Discussion A common finding across all studies presented here was that single mothers were assessing their health status to be worse than partnered mothers or women in any other group. According to the results, single mothers had twice or even tripled the chances to report their SRH as ‘less than good’ compared to their married counterparts. The most pronounced difference was observed in the studies by Kim et al. (2010) in South Korea, in Sweden by Roos et al. (2005) and in Britain by Lahelma et al. (2002). Cross-cultural comparisons also revealed that the findings are similar in all countries, despite the differences in family policy models, or the welfare arrangements, social policy and the living conditions. This is mostly emphasized in the studies of Fritzell et al. (2012) and Burstrom et al. (2010), where three different policy regimes were investigated. Single mothers reported significantly worse health in all settings and thus should be considered a disadvantaged group concerning their health status. The smaller gap identified in Italy, where single mothers were more likely to be employed, strongly suggests that unemployment and economic hardship are the main reasons for this inequality. This issue is supported by the majority of the studies, as findings showed that the observed health inequalities were mostly related to socio-economic hardship, either due to unemployment or the lack of welfare arrangements, which potentially increase their susceptibility to stress. Non-employment, according to Eamon & Wu (2011), increases the risk of suffering material hardship and was significantly associated with higher risk of poor health in all settings examined (Fritzell et al. 2012; Lahelma et al. 2002; Roos et al. 2005; Westin & Westerling 2007; Wickrama et al. 2006). This issue is mostly highlighted by Westin & Westerling (2006), where single mothers had double the likelihood to refrain from seeing a physician, even though they assessed their health as ‘less than good’ compared to partnered mothers. Eamon & Wu (2011) emphasized this association, as employment problems seemed to increase the risk of suffering material hardship among single-mother families. Despite Roos et al.’s (2005) findings that employment seemed to benefit social contacts and improve women’s economic independence and well-being, according to Eamon & Wu (2011), many single mothers cannot rely on employment alone to meet their families’ basic needs. On the other hand, employment status does not seem to benefit single mothers’ social contacts or improve their independence and well-being to the same extent as other women
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(Roos et al. 2005). Thus, single mothers cannot rely on employment alone to meet their families’ basic needs and additional socio-economic circumstances should be taken into consideration. Lack of social support was also identified to be related to higher levels of poor health among single mothers. Westin & Westerling (2007) found that social capital was unevenly distributed between single and married mothers and that emotional, but not instrumental, support was associated with single mothers’ lower levels of health status. Similar findings were identified by Kim et al. (2010) in South Korea, where mediating factors, such as emotional support from siblings and social activities, accounted for 41.1% of the excess risk for poorer level of health among single mothers.
Limitations
All studies presented in this review used SRH as an indicator for evaluating mother’s level of general health in relation to socioeconomic factors. However, the evaluation of health status is multidimensional. While SRH has been shown to capture symptoms or diseases as yet undiagnosed, which may be present in prodromal or pre-clinical stages (Idler & Benyamini 1997), the level of health can be assessed in various ways and with different psychometric tools. To some extent, this can be viewed as a result of the fact that there is limited research based on population samples as the majority of the studies reviewed here were based on secondary analyses of available data from longitudinal household surveys. Four out of the twelve studies made secondary use of data from general household surveys in cross-national comparisons. These cross-national studies had the advantage of gathering large and therefore representative samples. However, even though the data used in the cross-country comparative studies were collected in similar ways and this enabled comparisons across populations, Fritzell et al. (2012) argues that data compatibility is a potential pitfall in all cross-national research, and therefore, issues concerning sample frame and country-specific variables can limit compatibility. Furthermore, the crosssectional nature of these data does not allow for conclusions on the causality of the observed associations. However, all the studies suggested potential explanations for the poor health among single mothers, related to either the economic strain and/or the lack of social support networks. The results from the longitudinal studies (Fritzell & Burstrom 2006; Fritzell et al. 2007; McMunn et al. 2006; Wickrama et al. 2006) strengthen these findings and introduce more detailed explanations on the issues concerning the associations of family combinations, work, stress, and social class and SRH.
Single mothers’ health
Additionally, an issue concerning the cross-country comparative studies is that reporting SRH may be culturally specific. According to Jylha (2009), these differences may reflect real differences in subjective health status, or they may also reflect differences in health-related knowledge and subjective evaluations of health status. Finally, while the response rates in the majority of the studies were generally high, according to Lorant et al. (2007), those in lower socio-economic position and/or in poor health status are less likely to participate in surveys. This issue is mostly emphasized in a study by Johner et al. (2007), which included only single mothers, and the sample was selected through stratified random selection; the response rate was only 19%. Therefore, taking into consideration that single mothers compose a vulnerable group with regard to their socio-economic position, it is likely that excess risk of ‘less than good’ health among non-employed single mothers reported in these studies is still underestimated.
Implications for practice This review gives a descriptive account of the literature on the self-assessed health status of single mothers, and it will benefit both health professionals, especially those working in the community, and policy makers. Despite the similarities in the findings of the studies, there are still many unresolved issues with regard to the health inequality experienced by single mothers. An important limitation concerning the methodological issues among the identified studies is that only single-item SRH is used as a tool for assessing the level of health status. This is mainly due to the fact that the majority of the studies were based on secondary analysis of available data, and there is limited research based on population samples. Therefore, there is a need for research that will focus on population-based surveys with the use of different psychometric scales that would assess the general perception of health status in relation to different dimensions (e.g. well-being, life satisfaction). In the existing literature, it appears that these associations are mainly correlated with the psychological health rather than SRH. In addition, as can be observed in the cross-cultural studies, to some extent, the political and social arrangements, as well as the economic environments, might be the determining factors for the magnitude of these inequalities. Despite the fact that the results were similar in all settings examined, with single mothers scoring worse their self-assessed level of health, it was noted that in countries where single mothers were more likely to be employed, for example, Italy (Burstrom et al. 2010; Fritzell et al. 2012), the gap was smaller. Therefore, local research with a focus on the possible association of the existing inequalities
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with the in-country political and social circumstances should be encouraged, enabling the possible welfare or social arrangements to be targeted.
Conclusion Single motherhood, economic strain and social disadvantage seem to be in a dynamic state. Unemployment and the increased obligations of single motherhood appear to result in both economic hardship and social exclusion, which eventually increases chronic stress and lowers the levels of SRH. From a public health perspective, this makes the poor health of single mothers all the more important, as it affects all the more women, their children and eventually the whole community. It is important to monitor future trends in the associations between women’s health, employment status and family type, as women-friendly policies are under increasing pressure from international competition and economic downturns. Adverse economic developments and a reversal of women-friendly policies are likely to hit hardest at the social position and living conditions, as well as the health and well-being, of the most vulnerable groups in society, including single mothers.
Conflict of interest None.
Author contributions ER: Conception and design, acquisition, analysis and interpretation of data, and drafting of the article. CK, NM and MK: Critical revision for important intellectual content.
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