MARITAL STATUS AND HEALTH OUTCOMES IN A DEVELOPING COUNTRY:

EXPLORING THE CONTEXTUAL EFFECTS OF MARRIAGE, GENDER,

CHILDREN, AND LINEAL TIES ON SUBJECTIVE HEALTH IN GHANA

A Dissertation

Presented to

The Graduate Faculty of The University of Akron

In Partial Fulfillment

of the Requirements for the Degree

Doctor of Philosophy

Enoch Lamptey

August, 2017

MARITAL STATUS AND HEALTH OUTCOMES IN A DEVELOPING COUNTRY:

EXPLORING THE CONTEXTUAL EFFECTS OF MARRIAGE, GENDER,

CHILDREN, AND LINEAL TIES ON SUBJECTIVE HEALTH IN GHAN

Enoch Lamptey

Dissertation

Approved: Accepted:

______Advisor Interim Department Chair Dr. Baffour K. Takyi Dr. William T. Lyons

______Committee Member Interim Dean of the College Dr. Juan Xi Dr. John Green

______Committee Member Interim Dean of the Graduate School Dr. Clare Stacey Dr. Chand Midha

______Committee Member Date Dr. Adrianne M. Frech

______Committee Member Dr. Jun Ye

ii ABSTRACT

A growing body of literature on marriage and health suggest that marriage is beneficial to health-—physical, psychological, behavioral, and longevity. Additionally, there are inconsistencies in the existing literature concerning the effect of gender and children on the association between marital status and health outcomes. However, the vast majority of these studies rely on data from Western developed countries such as

United States of America, Canada, and other developed countries; and they leave open questions with regards to whether the hypothesized relationship between marriage and positive health outcomes are equally applicable or generalizable to other countries, especially less developed countries. The purpose of this dissertation was to contribute to the existing cross-cultural literature on marriage and health. This study also focused on how culturally specific issues such as communalistic cultural values and practices, which are pervasive in the Ghanaian’s society, may improve the wellbeing (health) of never- married Ghanaians.

Using theoretically driven models and nationally representative data from the

2011 Ghana World Value Survey (n = 1552), this study examined marriage and family processes in Ghana, and how they are associated with health. I examined whether there was variation in health among currently, previous, and never married people in Ghana, and how sociocultural practices such as the significant attachment to children influence the association between marital status and health.

iii Findings from the analyses show that in general and contrast to what has been reported in the Western literature, in Ghana, I did not find that the married have better health than their never-married counterparts. The results show that compared to the currently and never married, formerly married Ghanaians reported the worst health.

Gender did not moderate the relationship between marital status and health. The presence of children rather than diminish the health of the married increased their health. Also, I found that among patrilineal ethnic groups in Ghana, married persons experienced better health relative to their unmarried counterparts. On the contrary, among matrilineal ethnic groups in Ghana, there is no variation in self-rated health among the currently, previous, and the never-married. I conclude with some limitations and policy implications of the findings.

iv ACKNOWLEDGEMENTS

There are many people I am must thank for their support, help, and encouragement during the completion of this dissertation. First, I would like to express my sincere gratitude to my advisor and chair of my dissertation committee, Dr. Baffour K

Takyi, for his guidance and support throughout my graduate career. I am so grateful to have the opportunity to work with such a wonderful scholar, advisor, and friend. I would like to thank Dr. Juan Xi for her support, patience, and encouragement throughout the dissertation process and my graduate career as well. Dr. Xi was very instrumental both in my personal and graduate life and nurtured me to be a studious fellow and a great scholar. I appreciate the constant constructive criticisms from her and grateful for her giving me the opportunity to have my first publication as a graduate student.

I would also like to give a special thanks to Dr. Clare Stacey for her profound guidance and providing me with all the necessary tools to excel in my graduate and professional career. I am grateful for her kindness to my family and me. I would like to acknowledge my other committee members. Thanks to Dr. Adrianne Frech and Dr. Jun

Ye for their valuable contribution throughout the dissertation process.

I also want to recognize individuals who took time from their busy schedules to review my dissertation: Dr. Chris Opoku-Agyeman, Department of Public Administration and Urban Studies-The University of Akron, and my colleague, Rachael Pesta,

Department of Sociology, the University of Akron. I would like to thank the following members of the Sociology Department for their guidance, friendship, and support during v my graduate years at The University of Akron: Dr. John Zipp, Dr. Matthew Lee, Dr.

Stacey Nofziger, Dr. Jodi-Ross Hendersen, Dr. Kathryn Feltey, and Dr. Manacy Pai.

My friends in the Sociology Department deserve special thanks, particularly

Nusrat Islam, Corey Stevens, Rania Issa, Kristin Santos, Dr. Will LeSeur, and Dr. Peter

Barr (who are no longer at the department). Your friendship, support, and many emails of encouragement have made my years at the department less stressful. It has been a wonderful experience working and learning with you. To you Dr. LeSeur, thanks for your professional and personal support. I value your friendship and cannot thank you enough for your immense guidance, words of encouragements, and learning statistical methods from you.

In addition to the above-mentioned names, I also wish to acknowledge the moral support of the following persons: Emmanuel Boadi Atta, Daniel Nana Yaw Amponsah,

Belinda Lamptey, Willhemina Lamptey, George Lamptey, Leo Lamptey, and Naa Koshie

Lamptey (Ghana). Thanks for being there for me over the years. I appreciate your support, motivation, and advice. You have made this process so much less stressful. God richly bless you all.

I would like to give a special thanks to my wife, Angela Lamptey, and my two lovely children, Leron and Darryl Lamptey. To you Angela, I am extremely grateful for your support, love, prayers, and encouragement throughout the dissertation process as well as my graduate years in the U.S. You are indeed a wonderful wife and I thank God for your life. I would not have made it without your support, especially taking care of our two wonderful kids when I am away from the family. Thank you, my love.

vi DEDICATION

I will bless the LORD at all times; His praise shall continually be in my mouth

(Psalm 34:1).

First, I want to dedicate all my accomplishments to God for giving me life, knowledge, and supporting my family and me over the years. Second, I dedicate this dissertation to my wife, Angela Lamptey, children (Leron and Darryl Lamptey), my mum, Beatrice Afanu Lamptey, and my late dad, Bismark Lamptey. Daddy, although you are no longer with us today, I know you are proud of me, for what I have accomplished since it has always been your dream to see me succeed academically, and in life. Third, to my siblings (Belinda, Willhemina, and George), Dr. Baffour Takyi, Dr. Juan Xi, and Dr.

Clare Stacey for their tremendous support, guidance, dedication, and mentoring towards my successes and accomplishments. Thank you very much.

vii TABLE OF CONTENTS

Page

LIST OF TABLES ...... xi

LIST OF FIGURES ...... xii

CHAPTER

I. THE RESEARCH CONTEXT: MARRIAGE AND HEALTH ...... 1

1.1 Introduction ...... 1

1.2 The Present Study: Problem Statement and Limited Research ...... 5

1.3 Significance of the Study ...... 13

1.4 Research Objectives ...... 15

1.5 Research Questions ...... 15

1.6 Organization of the Study ...... 16

II. LITERATURE REVIEW ...... 18

2.1 The Theoretical Context on the Links Between Marriage and Health ...... 18

2.2 Why Marriage Is Associated with Health ...... 19

2.3 The Crisis/Stress Theory ...... 26

2.4 The Social Selection Theory ...... 27

2.5 Marriage and Mental Health ...... 29

2.6 Marriage and Physical Health ...... 33

2.7 Marriage and Health Behaviors ...... 37

viii 2.8 Quality of Marital Relationship and the Negative Side of Marriage ...... 39

2.9 The Effect of Gender: Marital Status, Gender, and Health ...... 44

2.10 Summary and Conclusion ...... 49

III. THE SOCIAL SETTING ...... 51

3.1 Background Information and the Socio-Cultural Context of Marriage and Health in Ghana ...... 51

3.2 Marriage and Family Processes in Ghana...... 52

3.3 Bridewealth and Women's Autonomy ...... 58

3.4 Early Marriage ...... 61

3.5 Why Never-Married Ghanaians May Experience Good Health ...... 64

3.6 Marital Dissolution, Widowhood Rites and Negative Cultural Practices ...81

3.7 The Effect of Gender on the Association between Marital Status and Health in Ghana ...... 84

3.8 The Effect of Children: Parenthood, Marriage, and Health in Ghana (Married Only) ...... 89

3.9 Lineage Ties, Marital Status, and Health Outcomes: The Ghanaian Context ...... 98

3.10 Summary and Conclusion ...... 105

IV. DATA AND METHODS ...... 110

4.1 Introduction ...... 110

4.2 Data and Sampling ...... 111

4.3 Dependent Variable: Health Outcomes ...... 113

4.4 Independent Variables ...... 114

4.5 Control Variables ...... 117

4.6 Strategy ...... 121

ix 4.7 Summary and Conclusion ...... 124

V. RESULTS ...... 125

5.1 Introduction ...... 125

5.2 Descriptive Statistics...... 125

5.3 Patrilineal and Matrilineal Comparisons ...... 128

5.4 Bivariate Associations: Health and Marital Status ...... 131

5.5 Multivariate Modeling: Marriage and Health in Ghana ...... 135

5.6 The Moderation Effect of Gender: Marriage, Gender, and Health ...... 141

5.7 The Children Effect: Marriage, Children, and Health in Ghana ...... 144

5.8 Examining the Effect of Lineage Ties, Marital Status, and Health Outcomes ...... 147

5.9 Summary and Conclusion ...... 153

VI. DISCUSSION AND CONCLUSIONS ...... 155

6.1 Marital Status and Health Outcomes in Ghana ...... 155

6.2 The Effect of Children on the Health of Married Ghanaians ...... 165

6.3 Lineage Ties, Marital Status, and Health Outcomes: The Ghanaian Context ...... 168

6.4 Policy Implications and Directions for Future Research ...... 175

6.5 Study Limitations ...... 185

REFERENCES ...... 189

x LIST OF TABLES

Table Page

1 Summary Information on Variables Used in the Study: 2011 Ghana World Value Survey ...... 127

2 Descriptive Characteristics of Patrilineal Ethnic Groups in Ghana ...... 129

3 Descriptive Characteristics of Matrilineal Ethnic Groups in Ghana ...... 131

4 Bivariate Relationship Between SRH and Mediating Variables ...... 135

5 Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated Health, Ghana 2011 (N = 1552) ...... 140

6 Summary of Ordered Logistic Regression Estimates for Variables Predicting the Effect of Gender on Self-Rated Health, Ghana 2011 (N = 1552) ...... 143

7 Summary of Ordered Logistic Regression Estimates for Variables Predicting the Effect of Children on Couples, Ghana 2011 ...... 146

8 Summary of Ordered Logistic Regression Estimates for Variables Predicting Self- Rated Health Among Patrilineal Ethnic Groups, Ghana 2011 ...... 149

9 Summary of Ordered Logistic Regression Estimates for Variables Predicting Self- Rated Health Among Matrilineal Ethnic Groups, Ghana 2011 ...... 152

xi LIST OF FIGURES

Figure Page

1 Modeling the effects of marriage on health outcomes: Is marriage beneficial in Ghana? ...... 108

2 The moderation effect of gender: marriage, gender, and health ...... 109

3 The moderation effect of lineal ties: lineage type, marital status, and health ...... 109

4 Marital status and self-reported health ...... 132

5 Gender, marital status, and self-reported health ...... 133

xii CHAPTER I

THE RESEARCH CONTEXT: MARRIAGE AND HEALTH

1.1 Introduction

Marriage is a healthy state. The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony. (Farr 1858: 223)

A substantial body of research mostly from the Western developed countries continue to document the health benefits associated with marriage (Carr and Springer

2010; Dinour et al. 2012; Wood, Goesling and Avellar 2007; Koball et al. 2010; Manzoli,

Villari, Pirone, and Boccia 2007; Musick and Bumpass 2012; Ryan et al. 2014;

Schoenborn 2004; Waite and Gallagher 2000). Many of these studies have found that the married enjoy better mental and physical health than the unmarried (Ross 1995; Waite and Gallagher 2000; Williams and Umberson 2004) and that they also have a reduced risk of mortality (Chung and Kim 2015; Dupre and Meadows 2007). Overall, these studies have reported that married people, both men and women, tend to have or experience lower mortality rates at every age relative to those who remain unmarried or lose their spouse through such events as widowhood or divorce (Kaplan and Kronic

2006; Kohn and Averette 2014; Liu 2012; Murray 2000).

Though the connection between married life and health outcomes has been studied extensively, something that is true especially in countries in the developed world

1 such as Canada, United States of America, and the United Kingdom (Koball et al. 2010;

McFarland, Hayward, and Brown 2013; Rogers, 1995; Schoenborn 2004; Waite and

Gallagher 2000; Wilson and Oswald 2005; Wood, Goesling, and Avellar 2007), this is not always the case when it comes to countries in the developing world, and especially those in the sub-Saharan African (SSA) region. With special reference to SSA, a review of the literature suggests that very little research, if any, exists that investigates the intersection between health behavior and health outcomes and one’s marital status. It is partly within this context that this dissertation was conceptualized. In this dissertation, I specifically focus attention on health and marital status in a sub-Saharan African environment, specifically Ghana, a country I am more familiar with. I examine whether the hypothesized positive relationship between marriage and health outcomes is also applicable within the Ghanaian society considering the differences in cultural values and systems that characterize that society in comparison to those found in the advanced or

Western societies where most of the previous studies have been conducted to date.

The family is the foundation of every society, and in Ghana and countries around the world, it is regarded as an important institution. Though the family is the cornerstone of many social institutions, it varies from one society to another. Sustained through a series of kinship networks and marriages, the family is acknowledged as the bedrock of all social life. Thus, the family is the epicenter where socialization process, child upbringing, transfer of cultural activities, and knowledge are embedded. Similarly, the functions of the family institution to the individual and society is equivocal. However, the form and functions associated with the family differs remarkably from one society to another.

2 An equally important institution associated with the family which has major influence in the day-to-day activities of the individual is the institution of marriage

(Marks and Lambert 1998; Meadows, McLanahan, and Brooks-Gunn 2008; Ryan et al.

2014; Umberson and Montez 2010).

Marriage is viewed by many as a universal institution through which families are raised and nurtured according to Umberson and Montez (2010). Not only that, it is also the process through which domestic groups are formed, descent groups are interlinked and reproduction of society, biological and social, is achieved (Keesing 1958). Although different scholars have tried to provide definition of marriage, Kessing (1958) contended that marriage can generally be conceptualized to include the following:

 Marriage is characteristically not a relationship between individuals but a

contract between groups. The relationship contractually established in the

marriage may endure despite the death of one partner (or even both).

 Marriage entails a transfer of flows of rights. The exact set of rights passing

from the wife's groups to the husband's (or vice versa) work, services rights,

rights over children, property, and so on varies widely.

Despite the universalistic nature of what constitutes marriage, the type of marriage consummated by a couple often depends on a host of factors, among which are the following: socioeconomic status of the couple (e.g., formal education, occupation, income, wealth, place of residence), family, religion, and ethnic backgrounds.

Throughout Ghana, the laws of the country recognize different forms of marriages: customary law marriages, consensual unions, marriages contracted under Islamic rules, and those contracted under the Ordinance (civil or church).

3 On the issue of marriage and health, a plethora of literature have found marriage to be associated with positive health outcomes (Carr and Springer 2010; Horwitz, White, and Howell-White 1996; Marks and Lambert 1998). The health benefits associated with marriage, scholars argue, is mostly due to the resources that come with being in a marital union. These resources include economic gains (such as increased income, economies of scale), access to social support, and social control (Cherlin 2004; Mastekasa 1992; Soons and Kalmijn 2009; Waite and Gallagher 2000; Wood et al. 2007; Zimmerman and

Easterlin 2006). Married people have been found to experience better mental health than their unmarried counterparts (Meadows, McLanahan, and Brooks-Gunn 2008; Mirowsky and Ross 2003; Waite and Gallagher 2000; Williams, Frech, and Carlson 2010).

Studies have also found that the married enjoy better mental and physical health than the unmarried (e.g., Kim and McKenry 2002; Kiecolt-Glaser and Newton 2001;

Koball et al. 2010; Ross 1995; Ruiz et al. 2006; Waite and Gallagher 2000; Wanic and

Kulik 2011) and that they also have a reduced risk of mortality (e.g., Hu and Goldman

1990; Lillard and Panis 1996; Waite and Gallagher 2000). In general, married individuals consistently report greater health outcomes than never-married individuals, who in turn report greater health and wellbeing than the previously married individuals (i.e., divorced, separated, or widowed) (Kaplan and Kronic 2006; Uchino 2006; Mastekaasa

1994a; Williams and Umberson 2004). Research consistently shows that compared to the unmarried, married people have better mental health (Lindstrom 2009; Wade and Pevalin

2004). This general conclusion applies to a range of outcomes, including depression

(Brown 2000), happiness (Zimmerman and Easterlin 2006), life satisfaction (Williams

2003), psychological wellbeing (Dush and Amato 2005), and mortality from suicide

4 (Rogers 1995). More importantly, this marriage advantage has been observed in a number of countries and regions, including the United States, Australia, New Zealand, Europe and Asia (Diener et al. 2000; Lee and Ono 2012; Soons and Kalmijn 2009).

1.2 The Present Study: Problem Statement and Limited Research

Many of the existing studies agree that marriage has a beneficial effect on health and have provided insights into the mechanisms by which marriage and health behavior may be related. These existing studies which are predominantly from Western developed countries have demonstrated the positive association between marriage and health outcomes (see for example Carr and Springer 2010; Dinour et al. 2012; Koball et al.

2010; Kim and McKenry 2002; Lillard and Panis 1996; Liu, 2012; Ryan et al. 2014;

Schoenborn 2004; Umberson and Montez 2010; Waite and Gallagher 2000; Waite 1995;

Wanic and Kulik 2011; Wood, Goesling and Avellar 2007).

Even though these studies have provided significant insight into how and why marriage may be associated with good health, the focus of most of these studies is on married and non-married people in developed countries. As a result, we know very little about whether marriage is linked to positive health outcomes in developing countries such as those in sub-Saharan Africa.

Such an omission is problematic as it reduces our understanding of the links between marriage and health, especially in the context of sub-Saharan Africa (SSA) where marriage is nearly universal, and cultural norms and expectations about family life are different from those found in many industrialized or Western societies. It is therefore surprising that very little is known about the potential benefits of marriage to health in the lives of married people living in this part of the world. This is surprising considering how

5 important marriage and family life matters to many Ghanaians, and for that matter

Africans in general (Amoateng and Heaton 1989; Nukunya 1999). Moreover, it is possible that the differences in family life, cultural values, and setting could potentially confound our understanding of the links between health and marriage, something that is rarely discussed in the existing literature.

Ghana is not an exception to the overarching influence of family in the lives of the people as throughout SSA, kin ties and family life undergird their social organizations. Family and married life is so central that it has been suggested that people who are unmarried and also childless in many African societies often face significant social pressures and some degree of stigmatization (Oheneba-Sakyi and Takyi 2006). In contrast, married people (especially those with children) are held in high esteem in Ghana and many parts of SSA and are accorded with greater respect and privileges than those who are unmarried. Even married couples without children are stigmatized within the

Ghanaian context. It is therefore not surprising that few Africans remain single throughout their lives as studies have observed, with more than 1 in 10 girls married before their 15th birthday and four in ten married by age 18 (see e.g., Garenne 2014).

Therefore, it is imperative to examine whether this hypothesized relationship between marriage and health which has been theorized predominantly in developed countries is applicable to other developing countries such as Ghana.

Secondly, despite marriage as a universal phenomenon, the form, structure, and processes of marriage and family life differ remarkably from one society to another. That is, the uniqueness of a society's way of life is manifested in their values, norms, behaviors, and other sociocultural processes that distinctively differentiate one from the

6 other. In other words, the institutions of marriage and family are culturally specific and are heavily influenced by the sociocultural setting and the people residing in that particular society. Due to social and cultural differences between developed and developing nations, the institution of marriage/family may operate differently, and this may invariably influence the health benefits associated with the institution of marriage in developing countries such as Ghana. Thus, the realization of the health benefits of marriage in sub-Saharan Africa is most likely to be influenced by certain important factors, such as access to kin-group or extended families, early marriages, high fertility rates, polygamous marriage, bride-wealth/price, premium placed on children, lineage continuity and inheritance, among other related cultural factors. Therefore, it is imperative for sociologists, family and health scholars to situate marriage within the cultural domain of that particular society to consider how the health benefits associated with marital status may vary from one society to another.

For example, early and polygamous marriages are common features of traditional

Ghanaian and African family structures (Cremin et al. 2009; Locoh 2000). Early transition into marriage has been reported to have a negative effect on the health of young girls such as maternal mortality, infant and child mortality, high fertility, abuse, among others (Beegle and Krutikova 2008). Also, some have linked polygamous marriages to be associated with less intimacy and emotional attachment since husbands are less likely to form social bonds with all the wives in the union. Since polygamous marriages are more common in Ghana and SSA, the health benefits associated with marriage may operate differently in the sociocultural context of Ghana.

7 Moreover, as a result of social changes (e.g., structural, economic) occurring in the Global North countries such as the U.S., there is the tendency for married women to decide not to give birth (e.g., voluntary childlessness) but to adopt. This may not attract any form of stigma since changes in the sociocultural values and norms are more prevalent in these Western countries. However, this might not be the situation in the case of Ghana and other countries in sub-Saharan Africa. To the extent that cultural differences exist between developed and developing countries, the health benefits associated with marriage may not be evident, and if they are, may likely operate differently in Ghana. Yet, there is a gap in the existing literature whether the health benefits associated with marriage as found in predominantly in Western developed countries are applicable to those found in less developed countries.

Furthermore, the strength of family ties in Ghana, broadly defined to encompass lineal members provides some justification to re-examine the discourse on marriage and health—especially as pertains to SSA. For example, the belief that married people tend to be healthier than the unmarried is based on a theoretical idea which contends that marriage provides social support and social integration that helps to cushion the married from stress, isolation, and economic support; something often absent among the unmarried (Koball et al. 2010; Waite and Gallagher 2000; Wilson and Oswald 2005).

What makes the never married experience poor health in most Western developed countries (MDCs) is the isolation, loneliness (somehow partly due to individualistic cultural values), and risky behaviors (such as smoking, drinking alcohol, and driving recklessly) that they are likely to engage in. In other words, the relative advantage of married people over the unmarried when it comes to positive health outcomes has to do

8 with access to social support they receive from their spouses (Carr and Springer 2010;

Marks and Lambert 1998; Ryan et al. 2014; Umberson and Montez 2010).

While such an assertion may be true with regard to the MDCs with their strong emphasis on individualism, this may not always be the case in the context of SSA where the larger community is more important than the individual, thus confounding the potential role of marriage to health outcomes. The idea that unmarried people tend to be lonely and less integrated into society as some scholars have alluded to (Koball et al.

2010; Waite and Gallagher 2000) is weak at best in the context of SSA where their norms and values are more communalistic such that unmarried people may still have access to social support just like their married counterparts. Furthermore, the never-married individuals are not a homogeneous group. They are individuals who are educated and employed, as well as those who do not possess such attributes.

More importantly, singles in Western developed countries such as the U.S. may be more predisposed to isolation and loneliness partly due to the individualistic values that characterize these countries (Barrett 2000; Koball et al. 2010). It may be that the relative disadvantage of the unmarried, especially the never-married, compared to their married counterparts may be a reflection of differences in cultural norms and values found in these developed countries as compared to those found in less developed countries. What is missing in the extant literature is how the hypothesized association between marriage and health which has been found predominantly in developed countries may or may not be applicable in developing countries in sub-Saharan Africa. These expectations are based on the following reasons:

9 First, marriages in many parts of sub-Saharan Africa including Ghana are considered as unions between two families and not only the two couples (Mbugua 1992;

Takyi 2001). Indeed, the traditional Ghanaian family, for example, is more than the nuclear (conjugal) unit. Within the socio-cultural terrain of Ghana, the term family is used to refer to both the nuclear unit and the larger extended family as well. This means that both members of the extended families, including kin groups play a critical role in the marriage process. Despite the recent erosion of some of the influence or power of the extended family (due to modernization, migration) in the affairs of members of the conjugal family, elderly relatives, especially the aged, are most respected and they play a significant role in the selection of potential spouses (Apostou 2007).

Because marriages in traditional Ghanaian society are not considered as unions between two individuals, marital breakdowns or dissolutions are frowned upon and often carry a great deal of stigma not only to the couples but the entire families as well (Takyi and Dodoo 2007; Takyi and Brighton 2006). The stigma attached to divorce/separation means that unhappy couples in unhappy marriages may tend to place the interest of children and families (e.g., relatives, community) over their own welfare and aspirations, and as a result are less likely to exit such strained and problematic marital unions. By making it difficult for married persons to exit unhappy, highly volatile and strained marriages due in part to external influences or pressures, these individuals are more likely to experience poor health by staying with their spouses.

Another notable difference between Ghana and many countries in the Western developed nations that may confound the health benefits associated with marriage is the high value or premium attached to childbearing in Ghana and other countries in SSA

10 (Caldwell and Caldwell 1990). Despite the fact that childbearing is a personal decision, the sociocultural context in which such decisions are made cannot be ignored as well.

Parenthood is culturally salient and this is evident by the strong social expectations and attachment associated with it (McQuillan et al. 2003). Existing studies continue to document the deleterious effect of childbearing on the health of parents. The presence of children at home has been found to be negatively associated with physical health. For instance, in a study on married couples in the U.S., Nomaguchi and Bianchi (2004), found that married couples with children at home spent less time in physical or recreational activities, which tend to have a deleterious impact on their health compared with couples without children. Marriage serves as an alliance between families, and as a result, marriage contracts are expected to serve the emotional and financial interests of the larger extended family members rather than the individuals’ romantic ideals (Bleeck

1975; Takyi and Broughton 2006).

A major stress that married couples are most likely to experience unlike their unmarried counterparts is the pressure to procreate. African societies, and for that matter

Ghanaians, value children as the most important purpose and meaning of marriage

(Bongaarts et al. 1984; Caldwell and Caldwell 1990). Because children are the main source of old age support, labor, prestige, and marital stability, scholars such as Takyi

(2001) suggested that it is more problematic if not suicidal for parents to not have fewer children. Despite the rewards or benefits associated with large families in the sociocultural context of Ghana, having too many children can also lead to more economic or financial hardships (Ross, Mirowsky, and Goldsteen 1990). Aside from the fact that having more children (especially toddlers and preschoolers) could lead to more chronic

11 strain especially for married women, the presence of children can also lead to financial hardships for married individuals compared to their unmarried counterparts who may not have such financial responsibilities. Yet, we know little about how the presence of many children (which is culturally desirable but which may be associated with financial strain) may moderate the relationship between marital status and health outcomes in developing countries such as Ghana.

Finally, a distinct feature associated with the marriage and family system in

Ghana and SSA which can influence or mediate the effect of marriage on health is the role of ethnicity or lineage system. Kinship system in Ghana structure how property rights and inheritances are transferred from one generation to the other. Scholars such as

Oppong (1974) and Takyi and Gyimah (2007) contended that marriages among matrilineal ethnic groups are more unstable because women in such ethnic groups are more autonomous and less likely to pull resources together with their married partners compared to women in patrilineal ethnic groups. Also, because among matrilineal groups children born to married couples do not inherit from their paternal or "biological" fathers but belong to the mothers' lineage upon marital dissolution, such marriages are more likely to be characterized by tensions, misunderstanding, and even conflicts. This then means that it is possible that married individuals in matrilineal ethnic groups such as the

Akans of Ghana are more likely to be disadvantaged relative to their never-married counterparts.

A closely related point that draws on research on African families and has the potential also to undermine the cohesion of the family unit and any possibility that they would pool their resources together or not, has to do with the payment of bride wealth to

12 the bride’s family prior to marriage. This practice which is one of the distinctive features of African marriages-—although what is exchanged during such transactions vary from one ethnic group to the other (Meekers 1992)—serves as compensation for the loss of the wife and children’s labor but it can potentially affect marital and gender relations (Takyi

2001). Among the matrilineal Akans of Ghana where the amount exchanged may be minimal or of a token nature, the authority of the husband over the wife may be compromised somewhat, thereby reducing the chances that married couples would pool their resources together, which in turn reduces the marriage benefits that have been linked to joint resources. As a result, the health benefits associated with marriage may not operate in the same way among patrilineal and matrilineal ethnic groups in Ghana.

This dissertation focused on the interconnection between marriage/family processes and health in Ghana. Ghana provides a unique sociocultural and economic context for examining the effect of marriage, gender, children, and lineage system on self-rated health. As aforementioned, the available research on the association between marriage and health solely rely on data from Western developed countries, with less attention on whether this hypothesized relationship is also applicable or generalizable to other less developed countries such as Ghana. Given that context matters in marriage and health research, and the fact that there are cultural differences between Ghana and countries in the Global North, I expected to find that the health of never married

Ghanaians may not be different from that of their married counterparts.

1.3 Significance of the Study

The institution of marriage and family is important in the lives of people especially Ghanaians. In Ghana, probably more than anywhere else, the institution of

13 family and marriage is so important that unmarried persons are more likely to be pressured into marriage or sanctioned for not entering into marriage (Takyi 2001).

Studies conducted in Ghana and other countries in sub-Saharan Africa have highlighted some of the distinct features of Ghanaian marriages (e.g., early and polygamous marriages, payment of bridewealth (Bowman 2003; Cantalupo et al. 2006; Erulkar 2013;

Fuseini and Dodoo 2011)

While family life is the bedrock of many Ghanaians social lives and influences a host of behaviors, less attention has been paid to how marriage affects the health of

Ghanaian men and women. Not only that, we know very little about how marital dissolution impacts the health of formerly married persons compared to currently married individuals.

In Ghana, structural and cultural factors, such as poverty (both at the national and individual level), gender inequality, patriarchal cultural practices, high cost of living, early and polygamous marriages may undermine some of the health benefits associated with marriage (Cantalupo et al. 2006; Fuseini and Dodoo 2011; Takyi and Mann 2006).

Knowing about how these issues affect health is important as some scholars elsewhere have found marriage to be associated with positive health outcomes.

Similarly, formerly married persons (either through death or divorce) are also more likely to disproportionately bear financial responsibilities which could have some negative ramifications on their health. Thus, the consequences of divorce, separation, and widowhood ranging from stigmatization, loneliness (as a result of detachment from family, friends, and community as a whole), and financial strain may become a disadvantage to such individuals; yet studies in Ghana and sub-Saharan Africa have paid

14 less attention to this phenomenon. This study contributes to existing knowledge by examining the mechanisms if any, by which marriage promotes and inhibits health advantages to married persons compared to the non-married in Ghana.

1.4 Research Objectives

Specifically, the study was intended to:

1. Examine the effects of marriage, gender, children, and kinship ties on self-rated health.

2. Explore how sociocultural factors such as living in a communalistic environment (e.g., access to social support from residing with parents), and financial issues influence the relationship between marital status and health in Ghana.

To accomplish these objectives, the study was guided by five research questions.

1.5 Research Questions

1. Are there differences in health outcomes (measured in terms of self-reported

health) between married and unmarried persons in Ghana? If so, how and

why?

2. Do sociocultural factors, such as living with parents, significant attachment or

value attached to childbearing (having more children), and economic factors,

such as financial strain influence the relationship between marriage and health

in Ghana?

3. Are the differences in self-reported health between the married and unmarried

individuals moderated by gender?

15 4. Does having children negatively impact the health of couples with children

compared to those without children?

5. Does the effect of marital status on self-rated health differ by type of kinship

system (matrilineal versus patrilineal)?

1.6 Organization of the Study

This dissertation is organized into six chapters. In Chapter II, empirical research that has been conducted on the relationship between marital status and positive health outcomes is reviewed, heightening the limitations of existing studies and laying the foundation to explore marriage and family processes in Ghana in the next chapter. These scholarly studies predominantly come from Western developed countries. Chapter III examines marriage and family processes in Ghana by theorizing why the health of never married Ghanaians may not be different from that of their married counterparts. This chapter also pays particular attention to some cultural values and practices such as payment of bridewealth and early marriages that characterize the married life of

Ghanaians and which have the tendency to inhibit or obscure some of the health benefits associated with marriage. Chapter III further looks at some of the negative experiences of formerly married persons in Ghana as well as the consequences and the stigma attached to being divorced.

Chapter III also examines how the association between marital status and health is moderated by gender, the presence of children, and lineage/descent system. In a gendered stratified society such as Ghana, to be male is associated with many privileges.

Consequently, the experiences of married women compared to their male counterparts may not be the same, likewise the experiences of formerly married men and women.

16 Hence, I look at how gender and children moderate the effect of marital status on self- rated health.

Furthermore, Chapter III of this dissertation examines how the effect of marital status on health operates in both matrilineal and patrilineal ethnic groups in Ghana. Here,

I sought to examine whether marital instability that characterizes matrilineal marriages

(partly due to female autonomy and low or no bride-wealth payment) may be detrimental to the health of married persons among matrilineal ethnic groups compared to their married counterparts in patrilineal ethnic groups since marriages among the latter are more stable.

In Chapter IV I discuss the data, methods of data collection, and research plan, along with the type of analytical strategies or techniques used in the dissertation. In

Chapter V I present the results from the quantitative analyses on the association between marital status and health outcomes in Ghana. In Chapter VI I evaluate the results, draw conclusions, discuss limitations, suggest some policy implications, and make recommendations for future research.

17 CHAPTER II

LITERATURE REVIEW

2.1 The Theoretical Context on the Links Between Marriage and Health

This dissertation explored the intersection between family life, marriage processes, and health outcomes in Ghana. This chapter examined the existing studies that are relevant to the discourse on marriage and health. First, I examine some of the theories on marriage and health. The chapter reviewed the extant literature on marriage and health, and the diverse mechanisms by which marriage affect health outcomes. Here, I specifically discuss how marriage is associated with mental and physical health, as well as healthy behaviors.

Second, I examined how the quality of relationship is linked to health outcomes. I also discussed some of the negative effects of marriage. I argued that although marriage may be associated with better health, being married could also be linked to poor health.

Finally, I reviewed the literature on the moderating effect of gender on the association between marital status and health. The health benefits of marriage have been categorized into mental or psychological health, physical health, and health-related behaviors and are discussed below.

In studying the influence of marriage on mortality in France, William Farr (1858) stated that:

Cretins do not marry; idiots do not marry; idle vagrants herd together, but rarely marry. Criminals by birth and education do not marry to any great extent. . . . The

18 children of families which have been afflicted with lunacy are not probably sought in marriage to a great extent as others; and several hereditary diseases present practically some from matrimony. The beautiful the good, and the healthy are mutually attractive, and their unions are promoted by the parents in France. (Farr 1858: 509 cited by Goldman 1993)

Farr found that mortality among the unmarried was far greater than mortality among the married. Subsequent studies have replicated Farr's findings and concluded that at any given age, married people have lower death rates than unmarried people. Also, among the unmarried, divorced people have the highest rates, while never married people have intermediate rates closer to married people (Shapiro and Keyes 2008; Zheng and

Thomas 2013).

The health benefits associated with marriage, scholars argue, are mostly due to the resources that come with being in a marital union. These resources include economic gains (such as increased income, economies of scale), access to social support, and social control (Cherlin 2004; Hu and Goldman 1990; Mastekasa 1992; Soons and Kalmijn

2009; Waite and Gallagher 2000; Wood et al. 2007; Zimmerman and Easterlin 2006).

Some theoretical explanations have been put forward to explain the hypothesized relationship between marriage and positive health outcomes. They include the following: social causation, the crisis/stress, and the social selection theory.

2.2 Why Marriage Is Associated with Health

The Social Causation Theory

The social causation or marital resource thesis is rooted in the idea that marriage provides social, psychological, and economic resources that in turn promote mental, physical, and longevity (Eng et al. 2005; Lee et al. 2005; Shapiro and Keys 2008;

Williams and Umberson 2004). The social causation theorists contend that indeed there is

19 a direct and causal link between marriage and health outcomes (Kim and Mckenry 2002;

Lillard and Panis 1995; Marks and Lambert 1998; Simon and Marcussen 1999;

Umberson 1992; Waite and Gallagher 2000). To these scholars, the institution of marriage provides an environment for better health outcomes, and these theorists suggest a number of mechanisms through which these occur or translate into improved health outcomes. They include, for example, marriage as an avenue for accumulation or acquisition of economic resources, the social support that comes with marriage, and the fact that marriage serves as an agent of social control (that is a deterrence against unhealthy behavior).

The economic aspect of marriage

From an economic point of view, marriage create an environment for good health because it offers economic advantages that are often absent to unmarried people. These benefits take a variety of forms but can include increased income (pooled income), and the access to a partner's health insurance (Koball et al. 2010; Lillard and Waite 1995; Liu and Umberson 2008; Schoehenborn 2004; Wood et al. 2007). Such a view is consistent with Becker’s (1981) argument that marriage create an environment for increased economic resources; something that occurs through specialization, economies of scale, and the pooling together of resources by marital dyads. Consistent with such an expectation, it is therefore no surprise that studies have pointed out that in general married people tend to have higher household incomes than unmarried people, including the divorced and separated (Holden and Smock 1991; Koball et al. 2010). Existing literature has shown a strong positive relationship between socioeconomic status and health outcomes (Dupre 2008; Link and Phelan 1995; Schnittker 2004). For example,

20 studies show that women who never marry have lower family incomes than those who do, and divorced women experience substantial declines in income (Carr and Springer

2010; Holden and Smock 1991; McLanahan and Sandefur 1994).

The increased household income, according to resource theorists, has a significant effect on health by helping married couples to purchase healthy and nutritional diets that improve their health (Koball et al. 2010). Increased household income provides a context whereby married persons can purchase medical care or other health-enhancing resources in the event of illness. Indeed, increased household income has been found to be associated with increased access to health insurance (Jovanovic, Chyongchiou, and

Chang 2003; Liu and Umberson 2008; Wood et al. 2007). Pearlin and Johnson (1977) contended that marriage "can function as a protective barrier against the distressful consequences of external threats" (p. 717). In other words, while marriage may not prevent social and economic problems from occurring, it can protect individuals from experiencing high levels of psychological distress. One reason why marriage might benefit mental health is that it contributes to the financial stability of families (Mirowsky and Ross 2003; Stack and Eshleman 1998; Waite and Gallagher 2000). Research indicates that married people tend to exhibit higher levels of family income and lower levels of financial hardship (Mandara, Johnston, Murray, and Varner 2008). Waite and

Gallagher (2000) contended that married people have greater access to income from dual earners, lower costs from sharing life expenses, greater savings for family commitments, and lower impulse spending from having to be accountable to another person.

Despite the economic gains associated with marriage, some scholars including

Ross (1995) argued that marriage may limit the autonomy of women. To these scholars,

21 marriage is a trade-off for women. That is, although marriage improves health by increasing economic resources for married couples and the economic gains of marriage, the argument is made by some scholars that this benefits certain individuals (especially women) within the marital union and not both partners (Carr and Springer 2010; Koball et al. 2010; Ross et al. 1990).

Analyzing a prospective panel data of women in the U.S. (the National

Longitudinal Survey of Young Women between the ages of 24-34 year), Waldron,

Hughes, and Brooks (1996) found that the health benefits of marriage gained through economic resources were only limited to married women who were unemployed and those working as part-timers. On the contrary, they found that married women who were full-time employees and those with high socioeconomic status did not substantially have better health relative to their counterparts. Additionally, women who were neither married nor employed had poor health (Waldron et al. 1996). This suggests that the relationship between marriage and health is sensitive to many important factors such as employment status, quality of marital interactions (relationship), how decisions are made at the household level, gender relations.

Marriage as a Form of Social Support and Social Control

Proponents of the social support and social control thesis suggest that marriage benefits health by increasing people's access to social support that may not be available to the unmarried (Nock 2005; Peters and Liefbroer 1997). Social support is defined as "the commitment, caring, advice, and aid provided in personal relationships" (Ross et al.

1990:1062). Social support provided to a spouse can range from emotional to instrumental support. Emotional support is the sense of being cared about, loved, and

22 valued as a person, as well as having someone who cares about you and your problems

(Berkman et al. 2000; Rook and Ituarte 1999; Uchino 2006; Uchino et al. 2012). An intimate relationship offers emotional benefits, such as a sense of connectedness or support (Kiecolt-Glaser and Newton 2001; Kaplan and Kronick 2006; Koball et al. 2010), which may improve both mental and physical health (Brummet et al. 2001; Frasure-

Smith et al. 2000; House, Umberson and Landis 1988; Seeman 1996; Umberson and

Montez 2010; Wood, Goesling, and Avellar 2007).

Overall, the mechanisms by which social support is associated with positive health outcomes include the following: support from a spouse could act as a buffer against stressful events (improving emotional health); by reducing risky behaviors, social support could lead to aiding in early detection and treatment, and by helping recovery from illness through the availability of nursing care (Kiecolt-Glaser and Newton 2001;

Ross et al. 1990; Uchino 2004). Emotional support decreases depression, anxiety, sickness, and other psychological problems (Ross, Mirowsky, and Goldsteen 1990).

Kessler and Essex (1982) contended that marriage protects individuals from life strains and depression because it provides people with a confiding intimate relationship that directly affects their ability to cope.

One unique aspect of the institution of marriage is that it is an integrating force that connects people or romantic partners to one another as well as to friends and relatives. As such, these ties provide the foundation or basis for the provision of social support (Mirowsky and Ross 2003). Research suggests that social support is important in reducing symptoms of psychological distress (Uchino 2004). This is made possible through the creation or enhancement of sense of security and feelings of self-worth. The

23 significance of knowing that one is loved, valued, and cared for makes it easier to lessen any form of stressful events and this reduces the perceptions of one's vulnerability to stressors (Umberson and Montez 2010; Wood, Goesling, and Avellar 2007) and consequently, by reducing one's perception of stressful situations (Mirowsky and Ross

2003; Waite and Gallagher 2000). Thus, low levels of support have been found to be associated with poor mental health (Umberson and Montez 2010).

The second way social support can improve health is by encouraging and reinforcing protective behaviors (Ryan et al. 2014). Because of this reinforcing role, marriage acts as a form of social control (Lillard and Waite 1995; Umberson and

Williams 2005). In this context, marriage may prevent individuals occupying the marital role from indulging in risky behaviors such as smoking, excessive drinking, or driving fast thus reducing the risk of mortality and illness among married individuals. As studies have observed, marriage provides a stable, coherent, regulated environment (August and

Sorkin 2010; Umberson 1987; Williams and Umberson 2004). Compared to single, divorced, and widowed people, for example, the married experience more social control and regulation of their behavior (Umberson 1992). Not surprisingly and in many situations, married people live healthier lifestyles than singles, divorced, or widowed

(Lillard and Waite 1995). Married people are more likely to quit smoking, to eat diets low in cholesterol and high in fruits and vegetables (Carr and Springer 2010; Ross,

Mirowsky, and Goldsteen 1990).

According to Umberson (1992), the social control of people's behaviors occurs through internal and external influences. Internally, this occurs through the internalization of norms, while external pressures such as sanctioning of unconventional or deviant

24 behaviors. Umberson noted that "family relationships may provide social control of health behaviors indirectly by affecting the internalization of norms for healthful behavior, and directly by providing informal sanctions for deviating from behavior conducive to health" (1992:309).

Married persons are more likely to adhere to regulatory norms because should they deviate from these norms, they are more likely to be subjected to criticisms and this may damage their relationships with loved ones (Umberson 1987). These relationships involve rewards and commitment (August and Sorkin 2010; Umberson 1987; Wilson and

Oswald 2005). Norms for healthy behavior may be enforced through regulations and sanctions. For instance, an individual may be reminded to engage in healthy behaviors such as exercising, regular eating, and sleeping. An individual who fails to adhere to norms for healthy behavior may eventually comply because if he or she does not, his or her spouse may threaten to end the relationship (e.g., in the case of excessive drinking).

Several studies show that marriage is associated with healthier drinking practices, including lower rates of heavy drinking, binge drinking, and alcohol dependence

(Horwitz et al. 1996; Waite et al. 2009).

Studies have shown that married persons are most likely to mention their partners as key individuals who attempt to exercise some form of control on them in pursuit of changing their unhealthy lifestyles (Franks et al. 2006; Helgeson, Novak, Lepore, and

Eton 2004; Rook and Ituarte 1999; Umberson 1992). In a study of 1,477 patients with type 2 diabetes from Southern California, August and Sorkin (2010) found that married individuals reported their spouses most frequently as sources of social control, with unmarried women naming children and unmarried men naming friends/neighbors most

25 frequently as sources of social control. In addition, August and Sorkin (2010), found that social control through the use of persuasion was positively associated with better dietary behaviors among married patients (see also Umberson 1992). Married people are more likely to be scrutinized and monitored closely by their spouses; hence they tend to be motivated to reduce any negative behavior partly due to commitment and responsibilities associated with being married. In essence, the social normative expectations associated with the institution of marriage may prevent married persons from indulging in any unhealthy behaviors. In other words, the constant surveillance that the married experienced relative to the unmarried account for a disproportionately lower rate of risky behaviors among the married.

2.3 The Crisis/Stress Theory

The stress thesis focuses more on marital dissolution. According to the crisis model, the strains of marital dissolution undermine the health of the divorced, separated, and the widowed (Williams and Umberson 2004; Liu and Umberson 2010). In this view, the stress of marital dissolution, rather than marriage, per se, is responsible for the health gap between the married and the unmarried. The process of divorce and widowhood creates many stressors, which in turn have psychological and social consequences and this negatively affect health (Aseltine and Kessler 1993; Liu 2012). Once marriage ends and partners separate, many of these health benefits appear to diminish over time (e.g.,

Mastekaasa et a1. 1994).

The extant literature on divorce/separation/widowhood and health shows that, both marital and nonmarital union dissolution on average leads to a reduction in household income especially for women (Andre et al. 2006; Uunk 2004). Not only that, it

26 increases women's risk for poverty (Aassve et al. 2007; Avellar and Smock 2005;

Dewilde 2002; Jenkins 2008). A decreased income may affect health through a number of processes, including stress, reduced access to health care (preventive), cutting down on money spent on healthy food and exercise, worsened housing conditions, and even adverse effects of taking on an extra job or more hours (Koball et al. 2010; Liu 2012). In addition, the loss of a spouse through separation/divorce or bereavement is itself a stressful experience, which can cause poor health outcomes. Studies show that divorce and widow transitions increase chronic illness and mortality (Liu 2012; Pienta, Hayward, and Jenkins 2000; Rohrer et al. 2008) and negatively affect self-rated health (Williams and Umberson 2004). Similarly, Liu (2012) found that, although continuously divorced and widowed men and women exhibited similar health trajectories as the continuously married across age and birth cohorts, transitions to divorce and widowhood had differential effects on self-rated health (see also Ryan et al. 2014).

2.4 The Social Selection Theory

According to the social selection thesis, the healthy are selected into marriage, whereas the unhealthy are selected out (Murray 2000; Stutzer and Frey 2006; Waldron,

Hughes, and Brooks 1996; Zheng and Thomas 2013). In other words, married people do not have better health because they are married; rather, people with better health are the ones who end up in marriage. Therefore, a disproportionate number of healthy individuals are found in marital unions compared with other union statuses. Thus, persons with observably poor health and those with chronic conditions may find it more difficult to attract a spouse than do healthy individuals (Dinour et al. 2013; Goldman 1993; Sobal et al. 2003). Conversely, those in good health may be better able to maintain a marital

27 union and thus have lower marital dissolution rates. From this perspective, both direct and indirect selection processes occur (Goldman 1993; Joung et al. 1998; Manfredini et al. 2010). In the direct process, health status is a criterion both for assortative mating and union dissolution; in the indirect process, health behaviors are criteria (Joung et al. 1998;

Wu and Hart 2002).

Additionally, scholars in favor of social selection thesis argue that persons with physical, emotional, psychological, or mental problems are less likely to marry; and if they do, their marriage is associated with high levels of dissolution (Averett et al. 2008;

Hu and Goldman 1990; Manfredini et al. 2010; Sobal et al. 2003). Utilizing data from many developed countries, Hu and Goldman (1990) found that a selection process operates for single and divorced persons such that the smaller the population in these marital statuses, the higher their death rates in comparison with the married (Lillard and

Panis 1996). Mastekaasa (1992) in a study of 9,000 unmarried persons, found that psychological well-being significantly predicted transition into marriage for women ages

20-39 and for men 26-39. Mastekaasa (1992) found that as levels of psychological well- being increased, the probability of marrying also increased.

Other related studies on social selection show that emotionally and unstable individuals are more likely to be selected out of marriage (Forthofer et al. 1996). This argument is based on the idea that depressed or unhappy individuals may not be particularly motivated to find a partner, and even if they do, in most situations they are less likely to be appealing marital match for others seeking a marriage partner (Uecker

2012). Forthofer et al. (1996) for example studied the effect of psychiatric disorders on the timing of first marriage and found that psychiatric disorders were positively

28 associated with early marriage and negatively associated with on-time and late marriage.

They observed that adolescents with history of any psychiatric disorder were more likely to marry before age 19 than their counterparts without history of disorder.

Despite the lack of consensus with respect to whether marriage is associated with health outcomes (social causation) or whether chronically ill individuals are selected out of marriage (selection effect), scholars such as Murray (2000), Wkye and Ford (1992) contended that both mechanisms operate simultaneously; hence, there is no need to pit one theory against the other. According to Bernard, whether a person chooses not to marry or is selected involuntarily out of marriage: "we are faced with the irrepressible, inevitable, and – most researchers concede – insoluble chicken-and-egg, cause-and-effect question" (1982:18). Thus, it is appropriate to speculate that both social selection and social causation do operate together though it is not within the ambit of this dissertation to elevate one theoretical perspective (social causation) over the other (social selection).

The health benefits of marriage as found in the existing literature can be subdivided into the following; a) mental health, b) physical health, and c) healthy behaviors.

2.5 Marriage and Mental Health

Most of the research studies on the association between marriage and mental health focus exclusively on depression (Frech and Williams 2007; Horwitz, White, and

Howell-White 1996; Wade and Pevalin 2004; Wilson and Oswald 2005). In this literature it has been observed that marriage may reduce depressive symptoms through its effects on social support and intimate connection. Existing research shows that men and women who get and stay married are less depressed than those who remain single (Kim and

29 McKenry 2002; Lamb, Lee, and DeMaris 2003), and those who divorce (Aseltine,

Robert, and Kessler 1993; Horwitz, White, and Howell-White 1996). That is, marital entry is associated with reductions in depressive symptoms, and this result holds whether the comparison group is the continuously married (Kim and McKenry 2002; Marks and

Lambert 1998) or the continuously unmarried (Lamb et al. 2003; Simon 2002; Wilson and Oswald 2005).

In addition, there is evidence that remarriage is less beneficial than first marriage

(Kim and McKenry 2002) and that marriage preceded by cohabitation is also less beneficial (Kim and McKenry 2002; Lamb et al. 2003). It has been observed that people tend to report fewer symptoms of depression immediately after getting married (Uecker

2012). Using fixed effects models, scholars such as Soons and Kalmijn, (2009) and

Zimmerman and Easterlin (2006) found that marriage is associated with better mental health. These scholars found that the mental or psychological state of newly married couples (both men and women) improves drastically when compared to their counterparts who are continuously single and those who have lost their partners through divorce or death (see also Lamb et al. 2003). Studies have shown that entry into marriage significantly improves mental health (e.g., Frech and Williams 2007; Lamb et al. 2003;

Simon 2002; Simon and Marcussen 1999).

In their study on adults in the United States, Lamb and his colleagues found that entry into marriage decreases depression. These scholars found that those who remained unmarried over the five-year period experienced more depressive symptoms than their counterparts who were stably married over the same period. According to Kessler and

Essex (1982) married people are more resilient to emotional damage caused by a variety

30 of strains and frustrations. Kessler and Essex contended that marriage protects individuals from life strains and depression. These scholars argued that this is due to the fact that marriage provides people with a confiding intimate relationship that affects their ability to cope.

Similarly, Pearlin and Johnson (1977) contended that compared to married persons, never-married or unmarried individuals are "doubly disadvantaged" in the sense that they lack economic resources and are more likely to be less integrated (e.g., staying in isolation). These two characteristics of the unmarried makes them more vulnerable to chronic stress than the married. Using a longitudinal design consisting of 1,400 young adults in the U.S., Horwitz and colleagues (1996) found that even after controlling for premarital levels of depression and alcohol problems, married people were less depressed and had fewer alcohol problems than people who remained single over the seven-year period of their investigation. Although the levels of depression and alcohol abuse declined for both singles and those who married later on, the decline was greater for the latter group.

Simon and Marcussen (1999) contended that beliefs about marriage are strongly correlated with mental wellbeing. Simon and Marcussen argued that individuals who value the permanence of marriage and who hold a strong negative belief about divorce, experience more depression when their marriages break down, compared to their married counterparts who do not believe in the permanence of marriage. Even with other factors held constant, they found that marital break-up has a larger effect on depressive symptoms and getting married promotes better mental health. In yet another study, Marks and Lambert (1998) used two-wave panel data from the U.S. National Survey of Families

31 and Households to examine the protective effect of marriage by analyzing the effects of marital history on wellbeing. Marks and Lambert found that compared to those continually married, the continually separated/divorced show significantly lower levels of mental health. Similarly, the widowed had significantly increased chances of depression; the continually singles are less happy and more depressed, but do exhibit higher autonomy and personal growth. Conversely, transition to marriage from being never- married strongly increases all measures of psychological wellbeing.

In a recent study on the relationship between marriage and mental health among young adults in the United States (using data from National Longitudinal Study of

Adolescent Health), Uecker (2012) found that for all three aspects of mental health measures (psychological distress, drunkenness, and life-satisfaction), married adults reported better health outcomes. Compared to never-married and formerly married, married persons reported low psychological distress, little or no alcohol abuse, and higher levels of life satisfaction.

The protective effect of marriage against poor mental health is not only limited to young and middle-aged adults. To demonstrate the significant role marriage plays in the life of elderly married persons (50 years and older) relative to their counterparts who are not married or living alone, Dean and his colleagues (1990) found that elderly persons who live alone have higher levels of depressive symptomatology, and this relationship is independent of the influence of support from friends, undesirable life events, disability, and financial strain. The uniqueness of this study is the ability on the part of the researchers to control for potential confounding measures such as disability, financial strain, and undesirable life events that are mostly associated with old age. Yet, Dean and

32 colleagues found an independent effect of living alone on depressive symptoms. This study provided additional support or confirmation to the protective effect of marriage against poor mental health across different age group. In other words, the health benefit of marriage is not only limited to a specific age group, but rather affects all individuals who are married compared to those who are not married.

2.6 Marriage and Physical Health

Substantial evidence exists suggesting that marriage helps to keep human beings alive (Koball et al. 2010; Lillard and Panis 1996; Manzoli, Villari, Pirone, and Boccia

2007; Murray 2000; Waite 1995; Zhang and Hayward 2006). That is to say, marriage may have some benefits for physical health and longevity (Wilson and Oswald 2005).

Studies increasingly show that married people live longer and enjoy better physical health than unmarried people. People who are divorced or widowed are at a particularly high risk of dying prematurely as these studies have observed. Never married individuals face somewhat lower risks of death in any given moment; however, the married tends to have the lowest risk of all the groups (Lorenz et al. 2006; Prigerson et al. 2000). Interestingly, this relationship has been found for more than 120 years (Coombs 1991; Murray 2000;

Rogers 1995), for both men and women (Kaplan and Kronick 2006), in different countries (Gardner and Oswald 2004; Hu and Goldman 1990; Manzoli et al. 2007), and for a wide range of measures of health and illness (Gore et al. 2005; Krongrad et al.

1996). A study from Bangladesh by Rahman (1993), for example, showed that married persons have significantly lower mortality rates than the never married or divorced.

Using a longitudinal data from Taiwan, Mete (2005) also found evidence to show that

33 being married increases the chances of being alive seven years later by five percent (also see Wilson and Oswald 2005).

Murray (2000) used a longitudinal data (graduates from Amherst College,

Massachusetts, born between 1832-79 and using height and weight measurement for the respondents before they were married) and found that being married accounted for a huge

47 percent reduction in within-period mortality risk compared to an increased risk of mortality for the never married.

Williams and Umberson (2004) also provided a rigorous evidence on the protective effect of marriage on physical health. Using a longitudinal data from the nationally representative Americans' Changing Lives (ACL) to examine the effect of transitions into and out of marriage on the changes in physical health, Williams and

Umberson found that regardless of age and socioeconomic status, marital transition (e.g., from married to divorced/separated/widowed) was associated with poor self-rated health.

Similarly, Prigreson and his colleagues (2004) focused only on the transition out of marriage, and they found that widowhood was associated with increased limitation in physical functioning and an increased number of chronic health conditions. They observed that men and women who lost their spouses through death suffered and had an increased level of chronic stress compared to their counterparts who remained married

(see also Lorenz et al. 2006).

Zhang and Hayward (2006) also examined the effect of marriage on the risk of cardiovascular disease, which is a leading cause of death in the United States for both men and women. Using a nationally representative Health and Retirement Survey data,

Zhang and Hayward found that the risk of cardiovascular disease is about 60 percent

34 higher among divorced women than it is for women in their first marriage, and about 30 percent higher for widows in their first marriage. Lillard and Waite (1995) explored the effect of marital status on mortality as well as how the effect of duration of marital status may affect mortality. Lillard and Waite found that married men have significantly lower mortality risk while married and widowed women have lower mortality than single or divorced/separated women.

Research findings on the physical health benefits of marriage are not only limited to the United States (Goldman et al. 1995; Schoenborn 2004). Manzoli, Villari, Pirone, and Boccia (2007) conducted a meta-analysis of cohort studies by pooling 53 independent comparisons consisting of more than 250,000 elderly respondents (across different countries such as the U.S., Canada, Finland, Australia, Italy, Spain, UK,

Sweden, China, Bangladesh) to examine the relationship between marital status and health. Manzoli and colleagues found that compared to married individuals, the widowed had a relative ratio (RR) of death of 1.11, divorced/separated had 1.16, and never married had 1.11. Out of the 52 countries surveyed, Manzoli and colleagues observed that marriage (e.g., support from a spouse) was a significant predictive of total mortality in 26 countries.

In a similar study, Wu and Hart (2013) examined the effects of marital and nonmarital union transition on health. Utilizing a Canadian longitudinal data, Wu and

Hart found that dissolution of the marital union was associated with a decrease in both physical and mental health, while married persons reported better physical and mental health. A longitudinal study conducted by Orth-Gomer and his colleagues (1993) in

Sweden showed that marriage and social integration are strongly associated with the

35 incidence of coronary heart disease (CHD). Married persons reported the lowest incidence of CHD compared to never-married and formerly married individuals. Another study undertaken by Murphy and his colleagues (2007) in Great Britain which focused only on elderly people in an institutionalized setting revealed that married individuals

(both men and women) in private households reported the lowest rates of functional limitation and long standing illness. On the contrary, Murphy and colleagues (2007) also found that never-married persons especially women showed the highest rates of functional limitation and long-standing illness.

Apart from the physical health benefits associated with marriage, many studies have demonstrated the link between marriage and longevity (Wickrama et al. 1997;

Wilson and Oswald 2005; Wood et al. 2007). For example, studies have documented a robust relationship between marriage and longevity for both men and women in the

United States (Kaplan and Kronick 2006; Waite and Gallagher 2000), as well as in several European countries (Manzoli et al. 2007). Marital status has been found to be associated with mortality for the unmarried compared to married persons (Murray, 2000); and for a wide range of specific causes of death, including, homicides, suicides, accidents, cardiovascular disease, infectious diseases like AIDS (Kaplan and Kronick

2006; Krongard et al. 2006). Using a nationally representative National Health Interview

Survey to examine the effect of marriage on longevity over an eight-year period beginning in 1989, Kaplan and Kronick (2006) found out that the odds of mortality are about 39 percent higher for widows than for married people, 27 percent higher for those divorced or separated, and 58 percent higher for the never married.

36 2.7 Marriage and Health Behaviors

One essential way in which marriage influence a person's health is through its effect on health-related behaviors, such as drug abuse, alcohol consumption, cigarette smoking, diet, and exercise (Carr and Springer 2010; Duncan, Wilkerson, and England

2006; Kiecolt-Glaser and Newton 2001; Ross, Mirowsky, and Goldsteen 1990; Wanic, and Kulik 2011). Marriage benefits health by increasing access to social control and social support (Beggs et al. 1996; Peter and Liefbroer 1997; Ross et al. 1990).

The protective effect of marriage against risky and unhealthy behaviors involves a multiplicity of things. For example, new responsibilities associated with marriage may encourage people to give up certain behaviors which are considered incompatible with married life, such as heavy drinking or drug use. At the same time, marriage has a substantial influence on how adults spend their time, reducing the amount of time spent socializing with friends, for example (Umberson, 1992, 1996). These changes then lead to a reduction in alcohol consumption since married individuals are less likely to go out to social events that may involve drinking. Compared to singles, divorced or separated, and widowed, the married experience more social control and regulation of behavior

(Umberson 1992; Umberson and Montez 2010). Marital status shapes and constrains the behaviors of married individuals. For example, married people are more likely to have access to a confidant (Umberson et al. 1996) and also eat at more frequent and regular intervals (Jeffrey and Rick 2002).

In many situations, married people live a healthier lifestyle than their unmarried counterparts. Behaviors that are associated with being unmarried are associated with poor health (Koball et al. 2010). Existing studies have found that married people are most

37 likely to mention their partners as key individuals who attempt to exercise some form of control on them in pursuit of changing their unhealthy lifestyles (Berkman et al. 2000;

Franks et al. 2006; Helgeson, Novak, Lepore, and Eton 2004; Lewis and Rook 1999;

Rook and Ituarte 1999; Tucker 2002; Umberson 1987).

A number of studies have also found that unmarried adults are more likely to drink, use marijuana, and drive recklessly than married adults (Koball et al. 2010).

Duncan et al. (2006) used a nationally representative sample from the National

Longitudinal Survey of Youth (NLSY) to examine the effect of transition into first marriage on marijuana use and binge drinking. Duncan and his colleagues found that for both men and women, the frequency of binge drinking declined substantially during the

24-month period just before and after first marriage. For men, their likelihood of engaging in binge drinking dropped from 50 to 45 percent. These scholars found a significant reduction in marijuana use following marriage especially for men. Duncan and colleagues found that the likelihood of using marijuana dropped from 19 percent to 12 percent after entry into first marriage.

In addition, Tucker and Mueller (2000) found that strategies of social control such as inviting partners to engage in healthy behaviors together or actually engaging in the behavior together (e.g., prompting the partner to healthier by cooking healthy meals for him or her, prompting the partner to see the doctor by making doctor appointments for him or her) are the most effective ways of improving the psychological, emotional, and behavioral wellbeing of persons who need urgent care. All this research goes to confirm the significant role of a spouse or partner in promoting better health outcomes. The unmarried on the contrary lack access to all these benefits associated with being married

38 as studies have found. However, being married does not necessarily confer health benefits. Recent studies show that the quality of marital relations also influence the association between marriage and positive health outcomes (Kiecolt-Glaser and Newton

2001).

2.8 Quality of Marital Relationship and the Negative Side of Marriage

Despite existing studies that show that marriage is associated with some health benefits, getting married does not necessarily mean married individuals will automatically accumulate such health benefits (Kiecolt-Glaser and Newton 2001; Robles

2014; Whisman et al. 2006). In other words, the mere presence of another adult at the household-level does not explain the relationship between marriage and wellbeing or health (Robles and Kiecolt-Glaser 2003; Ross, Mirowsky, and Goldsteen 1990). It is important to note that, the quality of marriage contributes significantly to overall psychological wellbeing or positive health outcome (Uchino et al. 1996, 2006). Not every marriage is associated with good health. A distressed marriage or marriage characterized by conflicts are a major source of stress, and this can negatively impact on the health of both spouses (Robles 2014; Robles et al. 2014; Mastekaasa 1994; Uchino 2006). Poor marital quality has been associated with compromised immune and endocrine function and depression (Kiecolt-Glaser and Newton 2001; Umberson and Montez 2010). On the contrary, higher levels of positive marital quality, such as marital happiness and supports, have been found to have weaker and sometimes inconsistent relationships with health

(Carr and Springer 2010).

Marital strain also erodes physical health, and the negative effect of marital strain on health becomes more pronounced with advancing age (Umberson et al. 2005).

39 Relationship stress undermines health through behavioral, psychosocial, and physiological pathways (Robles and Kiecolt-Glaser 2003; Umberson and Montez 2010).

Stress contributes to psychological distress and physiological arousal (e.g., increased heart rate and blood pressure) that can damage health through cumulative wear and tear on physiological systems and which may lead to unhealthy or risk behaviors (e.g., food consumption, heavy drinking, smoking) all in an attempt to cope with stress (Umberson and Montez 2010). Glenn and Weaver (1981) found that marital happiness was the most important factor in predicting overall happiness or both men and women. In a 5-year follow-up study of female patients admitted for an acute coronary event from 1991 to

1994 in the U.S., Orth-Gomer et al. (2000) found that marital status was not associated with increased risk of recurrent coronary events (including cardiac death and acute myocardial infarction). However, these researchers found that women who reported moderate to severe marital strain were almost three times more likely to experience a recurrent coronary event, even after controlling for demographic, health behavior, and disease status variables (Robles and Kiecolt-Glaser 2003). Marital conflict is reliably associated with heightened blood pressure and heart rates (Kiecolt-Glaser and Newton

2001).

Aside the fact that marital conflicts negatively affect the health of married persons, some scholars have found marriage to be associated with high body mass index

(BMI) and obesity (Averett, Sikora, and Argys 2008; Brown 2000; Lee et al. 2005; Ross

1995; Sobal, Rauschenbach, and Frongillo 1992; Sobal et al. 2003; Wilson 2012).

Although marriage is associated with positive health outcomes, being married is also associated with many responsibilities, such as caring for one's spouse, children, and other

40 domestic household chores (Nomaguchi and Bianchi 2004). Married women are most likely to spend a greater proportion of their time on unpaid domestic activities. According to Sobal et al. (2003), because married women take more household responsibilities, married women are most likely to prioritize the needs of family members first, and this may lead to less attention for their own needs. As a result, married women are more likely to gain more weight or obesity because maintaining one's weight becomes less of a priority.

Another mechanism by which marriage affects the body weight/BMI of married individuals is through its influence on social support. Marital support can lead to obesity through diet, activity, and social values (Sobal et al. 2003). The lifestyle of persons in the marital role leads to more stable eating patterns. That is, the time commitment of marital role expectations does not allow much time for recreational or sporting activities for married people compared to those who are not married. Using data from the 1995

National Health Interview Survey, Nomaguchi and Bianchi (2004) found that married adults spent less on exercising than unmarried adults. Therefore, transition or entering into marriage is associated with weight gain, and exit from marriage (marital dissolution) is associated with weight loss (Sobal, Rauschenbach, and Frongillo 1992, 2003). In a study of 3,025 adults aged 24-64 years in the United States, Sobal et al. (2003) found that currently married men had higher BMI and were obese compared to men who never married. On the contrary, marital status was not associated with fatness or obesity among women when other variables were controlled. Thus, Sobal and colleagues contended that the marital role tends to influence fatness and obesity among married couples, especially for men.

41 A related issue concerning the negative effect of marriage has to do with the tendency for married individuals to influence one another to engage in risky and unhealthy behaviors such as smoking. Umberson and Montez (2010) termed this as

"social contagion" of negative behaviors (also see Christakis and Fowler 2007; Crosnoe et al. 2004; Smith and Christakis, 2008). Sharing a life means sharing a variety of risk factors which might be detrimental to health. According to Homisha and Leonard (2005), romantic partners are often quite similar to one another, and this similarity may include a wide variety of health and behavioral characteristics. A spouse's smoking status can also affect a partner's cessation or continuation of such habit or lifestyle.

Monden, de Graaf and Kraaykamp (2003) found that individuals living with a current smoker, compared to those living with someone who never smoked or an ex- smoker were least likely to quit smoking. In a study on spousal influence on smoking behaviors in a U.S. community, Homisha and Leonard (2005) observed that married partners who smoked were most likely to influence their non-smoking partners with increased years of marital duration. Similarly, Leonard and Mudar (2004) found that husbands' pre-marital drinking was predictive of wives' drinking at the couples' first anniversary, and wives' drinking at the first anniversary predicted husbands' drinking at the second anniversary. These studies demonstrate that there is the tendency for married couples to influence each other in a way that might be detrimental to their health.

Another negative aspect of marriage is the tendency to cause psychological distress through its effect on social control. Although social control attempts are geared towards reforming a person's unhealthy behaviors by fostering healthy lifestyle habits, they may have emotional and psychological costs associated with them (Franks et al.

42 2006; Helgeson et al. 2004; Rook and Ituarte 1999). This is also known as the "dual effects of social control". Hughes and Gove (1981) contended that others' efforts to restrict harmful behaviors may reduce the occurrence of those behaviors but, at the same time, may arouse distress. They found that people who lived with others reported lower rates of alcohol and drug usage but also reported more psychological distress (Rook et al.

2011).

Rooks and colleagues (1990) contended that social control may have dual effects of improving health behavior while also arousing psychological distress. In other words, social control may be experienced as intrusive, provoking feelings of irritation and resentment (Rook et al. 2011). In addition, social control also may convey to recipients that they are not competent or adequately managing their health behavior on their own, thereby arousing feelings of guilt or shame (Rook et al. 2011; Lewis and Rook, 1999;

Tucker 2002; Tucker and Mueller 2000). In an interview with 80 married men with prostate cancer, Helgeson et al. (2004) found that social control from one’s spouse was not associated with health-enhancing behaviors. Rather, spousal social control was associated with greater psychological distress, especially health-restorative and health- compromising social control. Rook and colleagues (2011) found that chronically ill individuals who do not expect their partners to be involved in their disease management did perceive social control to be intrusive and demeaning.

Scholars such as Ross (1991) perceived marriage as a union that can also limit autonomy of married persons. Unlike married individuals, singles, divorced, separated, and widowed persons are more likely to be autonomous with fewer constraints on their behaviors. That is, nonmarried people are likely to be more independent than married

43 individuals. Compared to nonmarried, being married may decrease people's sense of personal control (Ross 1991). Similarly, marriage can be an avenue for unequal power distribution. To the degree that marriage embodies an unequal distribution of power, with one spouse dominating the other, married men or husbands are more likely to control their wives, leaving them powerless (Ross 1991). Ross contended that marriage is a trade-off for women's sense of control. On one hand marriage increases their sense of control by way of increased household income (through their spouses-husbands), but on the other hand it decreases it by way of decreased autonomy.

2.9 The Effect of Gender: Marital Status, Gender, and Health

It has been established that women live longer than men, yet they have higher morbidity rates (Arber and Cooper 1999; Reiker and Bird 2005). Men experience more life-threatening chronic diseases and die younger, whiles women live longer but have more nonfatal acute and chronic conditions and disability (Rieker and Bird 2005). This is what is termed as the "gender health paradox" (Bird and Reiker 2008).

One of the recurrent debates in the existing literature has been the role of gender in moderating the effect of marital status on health (Kiecolt-Glaser and Newton 2001;

Rogers 1995; Umberson 1992). The association between gender, health, and marital status is a complex one, in the sense that there are inconsistencies and contradictory findings (Gove et al. 1983; Simon 2002; Williams and Umberson 2004; Zhang and

Hayward 2006). Whereas scholars such as Bernard (1972) and Gove et al. (1983) contended that marriage is harmful when it comes to the health of women (women suffer more than their male counterparts), others such as Simon (2002) contended that there is no gender difference with respect to the effect of marriage on health. According to Ross,

44 Mirowsky, and Goldsteen (1990), nonmarried men have about 250 percent greater mortality than married men, and nonmarried women have 50 percent greater mortality than married women. Research suggested that compared to women, men obtain greater health benefits from social relationships/integration such as marriage (Bernard 1972;

Gove, Hughes, and Style 1983; Lillard and Waite 1995; Rogers 1995; Umberson 1992).

The health benefits of marriage for men were first articulated by Durkheim (1951).

Durkheim stated that:

Generally speaking, we now have the cause of that antagonism of the sexes which presents marriage favoring them equally their interests are contrary; one needs restraint and the other liberty. . . . Women can suffer more from marriage if it is unfavorable to her than she can benefit by it if it conforms to her interest. This is because she has less need of it (1951: 274-275).

According to Gove (1972), this protective effect of marriage on men can be attributed to the marriage role. Gove argued that marriage leads to high rates of mental illness for women. This is due to the fact that married women have only one major social role to occupy upon marriage, which is being a housewife; whereas men generally occupy two major roles, being a household head and a worker. That is, married men tend to have two major sources of gratification, family and work/employment. Therefore, should a married man experience dissatisfaction with one of one of his roles, he is more likely to refocus or channel his interest and concern onto the other role. However, if a married woman finds her family role unsatisfactory, she has no major alternative source of gratification. In addition, the role of housewife is unstructured, invisible, frustrating, and does not require a great deal of skill. The tasks of raising children and keeping house carry little prestige and are boring as well. Providing nurturance for others reduces

45 married women’s ability to provide good care for themselves (Reissman and Gersiel

1985).

Another reason why men may benefit more from marriage than their female counterparts has to do with monitoring and social control mechanisms that the former enjoys. According to Finch and Mason (1993), married men often do not form emotionally close supportive relationships with friends, and their wives provide a key supportive role in this respect. When individuals are asked about the person to whom they feel most emotionally "close" or can confide in, married men more often nominate the marital partner as the “closest” person than by married women (Arber 2004; Fuhrer et al. 1999; Umberson 1992). Similarly, scholars such as Ross (1995) and Umberson (1987,

1992) contended that marriage provides individuals, especially men, with someone who monitors their health, health-related behaviors, and who encourages self-regulation. Thus, wives have been found to exert more health-related social control on their husbands than vice versa (e.g., Umberson 1992). In addition, spousal control efforts have been found to be more effective for men compared to women (e.g., Westmaas, Wild, and Ferrence

2002). Studies have found that married men benefit more from their marriage because their behaviors are regulated and monitored more by women (Umberson 1992). Thus, the social support and control provided by women may be the main source of men's health benefits from marriage.

On the contrary, scholars such as Waldron, Hughes, and Brooks (1996), Ross

(1991), and Zick and Smith (1991) contended that the benefits associated with marriage operate in diverse ways to promote positive health outcomes for both married men and women. That is, married women may benefit from marriage through increased financial

46 or material well-being, which affords them the opportunity to live a healthy lifestyle, afford necessities of life, and ability to afford or purchase health insurance (Lillard and

Waite 1995). This will then improve their health. For married men, the ability to have someone, as in a spouse, to provide care and social support improves health. It is from this perspective that Lillard and Panis (1996) contended that both married men and women benefit equally from marriage. Although married women seem to benefit from marriage because of increased material/financial well-being, Waldron, Hughes, and

Brooks (1996) argued that not all married women benefit financially from marriage.

Rather, part-time and nonemployed married women benefit economically from marriage.

However, full-time employed married women do not benefit from the protective aspect of marriage. Thus, the protective effect or benefit of marriage does vary by employment status of married women.

Similarly, gender differences in health (e.g., psychological distress, depression, or mortality) following marital dissolution have long been debated in the literature with some studies showing more adverse effects for men and others for women (Johnson and

Wu 2002). Several studies further suggested that men and women respond to marital dissolution differently. Umberson and Williams (2004) contended that gender differences in the effects of marital dissolution (e.g., divorced or widowhood) are inconsistent across studies. Whereas scholars such as Aseltine and Kessler (1993) reported that women's mental health is more adversely affected by marital dissolution than men's, Booth and

Amato (1991) found no gender difference in mental health effects of marital dissolution.

The dissolution of marriage has some gendered implications. Since it is especially women who lose financially after union dissolution, the economic explanation of the

47 dissolution effect postulates that women’s health suffers in the face of union dissolution.

Waldron et al. (1996) found this to be the case only for nonemployed women).

However, scholars such as Phillipson (1997), Johnson and Wu (2002) contended that since men benefit emotionally from marital relationships, the loss of a spouse who serves as a source of social control and who provides emotional support and takes care of domestic activities (such as caring for children, taking care of household chores, etc.) is most likely to have a major detrimental effect on divorced and widowed men than their female counterparts. Though both bereavement and divorce contribute to poorer health and increased mortality, marital disruption appears to be more detrimental for men than for women (House et al. 1988). That is, men suffer a decrease in social contacts and social support after union dissolution and report an increase in loneliness (Kalmijn and

Broese van Groenou 2005).

Women's social contacts tend to increase after union dissolution, especially regarding contacts with friends. Some investigators have found that it is worse for women's psychological wellbeing and life satisfaction (Wade and Pevalin 2004), and others have found no overall gender differences in reported wellbeing or health (Horwitz et al. 1996b; Simon 2002). In analyzing the gendered mental health outcomes of marital transitions, for example, Simon (2002) found that transition out of marriage is associated with higher rates of alcohol consumption for men and higher rates of depression for women (see also Horwitz, White, and Howell-White 1996b). Thus, there are inconsistencies in the extant literature with respect to the effect of gender in the association between marital status and health outcomes.

48 2.10 Summary and Conclusion

This literature review presented a background on the relationship between marriage and heath. In this chapter, I have examined the plethora of research that links marriage to positive health outcomes. I have summarized some of the existing studies that have found marital quality to be a determinant factor of health. In addition, this chapter has reviewed the lack of consensus on the effect of gender in the association between marital status and health.

Despite a large body of studies have shown that marriage has a beneficial effect on health and have provided insights into the mechanisms by which marriage and health behaviors may be related, the focus of most of these studies is on married and nonmarried people in the more developed countries (Carr and Springer 2010; Dupre and Meadow

2007; Hughes and Waite 2009; Johnson et al. 2010; Meadows et al. 2008; Waite and

Gallagher 2000; Williams and Umberson 2004). As a result of this, we know very little about the extent to which marital status affects the health of people in the developing countries (LDCs) such as those in sub-Saharan Africa. Thus, would the health benefits associated with marriage as found in Western developed countries such as the U.S. be applicable in an African setting where marriage is nearly universal, and cultural norms and expectations about family life are different from those found in many industrialized or Western societies? This is what the dissertation attempted to find out using Ghana, a

West African country, as the social setting for the study.

In the next chapter, I provide the social setting for the study and examine how differences in cultural values such as communalistic values and practices (e.g., access to social support, integration, and social control), payment of bridewealth, the significant

49 attachment to childbearing, and lineage ties that characterize the Ghanaian society influence the association between marital status and health, thereby promoting better health outcomes for unmarried Ghanaians, especially the never married.

50 CHAPTER III

THE SOCIAL SETTING

3.1 Background Information and the Socio-Cultural Context of Marriage and Health

in Ghana

In the previous chapter, I reviewed existing studies on the association between marital status and health outcomes. I also discussed how the relationship between marital status and health is influenced by gender. In addition, I discussed some of the negative aspects of the institution of marriage as some studies have found. I argued that, although these studies have found marriage to be beneficial to health, most of these studies are from Western developed countries. Because of this, we know very little about whether these findings are applicable to married people living in developing countries such as

Ghana considering differences in cultural values and practices.

In this chapter, I first examine the distinct nature of marriage and family processes in Ghana, with particular attention to payment of bridewealth and early marriages in

Ghana, and situating the discussion in the context of health. Second, I examine marriage and health in Ghana and suggest the mechanisms by which marriage may or may not influence health or healthy behaviors. I specifically discuss in this chapter why and how the condition of never married Ghanaians may not be detrimental to their health unlike their counterparts in developed countries. Third, considering the significant attachment

51 associated with childbearing in Ghana, I examine whether having many children influences some of the health benefits associated with marriage. In addition, I examine the ways that gender relations will affect the relationship between marital status and health in Ghana. Finally, I examine how the effect of marriage on health may operate differently among patrilineal and matrilineal ethnic groups in Ghana, considering how kinship/lineage ties influence the lives of people in Ghana and sub-Saharan Africa in general.

3.2 Marriage and Family Processes in Ghana

A former British colony that gained independence in 1957, Ghana is located in the

West African sub-region and has an estimated population of about 25 million people per its 2010 population and housing census, with females comprising 51 percent of the total population and males making up 49 percent (Ghana Statistical Service 2012). The capital of Ghana Accra, situated on the Atlantic Ocean and the second largest city, is Kumasi, the former capital of the Ashanti Tribal Empire (Hollingsworth 2012). According to the

2010 population census, there are over 75 ethnic groupings in Ghana indicating ethnic diversity. Among the various ethnic groups are Akans, Moshi-Dagbani, Ewe, Ga, and

Mande-Busanga. Akans are the most populous, making up 47.5 percent (Ghana Statistical

Service 2012).

In Ghana, the various ethnic groups are contained within ten administrative regions (Gocking 2005). While there are some similarities among these ethnic groups in terms of norms, customs, and traditions, there are distinct cultural practices that differentiate one ethnic group from the other; this is predominantly based on kinship system (Nukunya 2003). Whereas the ten regions make up the political and

52 administrative structure of the country, matrilineal and patrilineal kinship ties are often the foundation of what are considered appropriate behaviors, and form the basis of

Ghanaian social mores as well as determining inheritance rights for most Ghanaians

(Takyi and Gyimah 2007).

Since gaining its political independence, it has had a checkered political and economic history. Politically, it has gone through political upheavals, alternating between military and civilian administration over the past couple of decades. Since the early 1990s though, civilians using democratic principles have ruled it. On the economic front, Ghana has gone through some challenges, especially during the 1970s and 80s. Though its economy has improved significantly since the 1990s, and the number of middle class

Ghanaians have increased significantly (46% compared to a continent-wide average of

34.3%) as a recent African Development Bank (AfDB) data shows (African Development

Bank 2011), still many Ghanaians report that they are not satisfied with their wellbeing

(Addai, Opoku-Agyeman, and Amanfu 2015).

The peculiar nature of the Ghanaian culture is evident in their way of life depicted in marriage and family relationships, legal systems, religious, economic, and political structures (Nukunya 2003). The uniqueness of traditional Ghanaian family system is the reliance and attachment to extended family members or relatives. Despite scholars such as Heaton and Darkwah (2011), and Takyi (2001) who have argued that modernization and urbanization have eroded some of the functions of the extended family, some scholars continue to argue that members of the extended family still play a significant role in the lives of Ghanaians (Tsai and Dzorgbo 2012).

53 In Ghana, unlike countries in the Global North, the idea of a family extends beyond its conjugal members. The extended family system serves as the basic family structure in almost all African cultures since time memorial. Even though the term may be interpreted in different ways, it is usually used in the Ghanaian context to refer to families which extend well beyond the nuclear model, comprising of grandparents, parents and their siblings, siblings and their children, wife and children, grandchildren, cousins and their children, and a number of other relatives referred to as distant relations

(Wusu and Isiugo-Abanihe 2006). The family is not only the basis of Ghanaian social organizations, but it is also the main source of social security in old age (emotionally and financially). An important institution associated with the family is the marriage institution.

The institution of marriage matters a lot in the lives of Ghanaians. According to

Bledsoe:

African marriage is often a long, ambiguous process rather than a unitary event. It may extend over a period of months or even years, as partners and their families work cautiously toward more stable conjugal relationships. For instance, a young lady with permission of her family may test out potential relationships with several young men before establishing a more permanent one. (1990: 118)

According to Takyi and Dodoo (2005), not only are Ghanaians expected to marry but also it is unthinkable for married couples to be childless except for health-related issues.

Marriage in Ghana is nearly universal.

Studies conducted in Ghana and other countries in this part of the region indicate that within the whole region, men and women are expected to marry (Assimeng 1999;

Borngarts 2006; Nukunya 2003). Married life is important to many Africans, including

Ghanaians, because it is the basis for assigning reproductive, economic, and

54 noneconomic roles to individuals. The practice of voluntary celibacy, which is predominant in the Global North (e.g., United States), is quite rare in traditional African societies such as Ghana. The pro-family and marriage ideology that characterize

Ghanaian way of life have some implications for social relations. Among the various ethnic groups in Ghana, unmarried people especially women are often viewed differently from the married (Takyi and Oheneba-Sakyi 1994). The institution of marriage is so important in the lives of Ghanaians to the extent that persons who find prospective spouses and settle down as married couples are more respected in the community and the society as a whole compared to their counterparts who are unmarried (van de Walle and

Meekers 1994). This partly explain why a significant proportion of women in Ghana get married by age twenty (Cohen 1998).

Marriage is the most recognized institution for the establishment and maintenance of family life all over the world (Adjei 2012). In the Ghanaian context and other countries in SSA, marriage is regarded as a sacred institution, which is perceived to be ordained and ordered by God. The theological origin or the religious aspect of marriage can be traced back to the Bible (Genesis 2:24) where it states that a man will leave his father and mother and be united to his wife, and the two will become one flesh (Adjei 2012).

Despite marriage being a union between a man and a woman (popular notion and common practice in most Western developed countries), marriage among Ghanaians is mainly a group affair-between families instead of individuals. That is, in Ghana, marriage is seen as more than just a union between two individuals. Rather, it is viewed as the union between two extended families (Nukunya 2003). In Ghana, marriage is an important institution that establishes and extends kinship ties. Marriage solidifies

55 relationships that enrich communities. Marriage in Ghana as a whole is seen as a cherished and most celebrated norm and rite of passage for male and female members of society (Bigombe and Khadiagala 2003) and a fulfillment of parental obligations.

Marriage contracts serve the needs of the larger extended family members. As such, the selection of a prospective marriage partner is not left entirely in the hands of the individual (Nukunya 2003). The family's involvement in the marriage negotiations and decision making is aimed at establishing a series of networks that were viewed as essential to the stability of the relationship (Oheneba-Sakyi and Takyi 2006). This perspective of Ghanaian marriage underscores the reason for involvement of families and sometimes the entire community in the marriage processes of any intending couple. It then becomes obligatory for members of both families to ensure that the marriage is successful (Nukunya 2003; Takyi 2001). In some situations, elderly individuals try as much as possible to support the married couple, and they at times serve as consultants or mediators when marital disputes arise. The involvement of the extended family and other relatives in the affairs of the married makes it difficult for divorce to be initiated even when married couples are unhappy with their marriage.

However, there are limited studies on marriage and family processes in Ghana.

Research shows that about 42.9 percent of Ghanaians aged 12 years and above were married in 2005 compared to 42 percent of those who have never entered into marital union (Ghana Statistical Service 2009). In addition, 10.2 percent of Ghanaians at the time of the census were separated, widowed, or divorced. Furthermore, there are variations with respect to gender and marital status in Ghana. A study conducted by the Ghana

Health Survey (2009) showed that a higher proportion of men (48.9%) had never been

56 married compared to only about 35.6% of women who had never entered into any marital union. Conversely, the study revealed that the proportion of Ghanaian women who were married at the time of the study outweighed (43.9%) that of their male counterparts who were also married (41.7%). In addition, there were some notable regional variations in the marital status of Ghanaians. For instance, the study found that both Greater Accra and

Ashanti (46.7% and 44.2% respectively) have higher proportions of people who have never been married. On the other hand, Northern region recorded the highest proportion

(54.3%) of people who are married (Ghana Statistical Service 2009).

Even though most Ghanaians cherish marriage, there are different ways of contracting marriage in Ghana. They include customary marriage, religious marriage, and marriage under the law or ordinance. Although national-level data on type of marriage are not readily available, evidence from small-scale surveys conducted indicate that most marriages in Ghana are the traditional type (Ardayfio-Schandorf 1995; Awusabo-Asare

1990). Customary law marriages derive their legitimacy from a section of Part 2 and 3 of the Marriage Act 1884-1985 (Adjei 2012). Under this Act, marriage is defined as a union between a man's family and the woman's family, but it is also a contract between two people – the man and the woman.

Marriage under the Ordinance could be either civil marriage where the parties involved with their relatives and witnesses are required to register the marriage with a civil authority at the Registrar General's Department of the Office of the City Council or a church marriage (Adjei 2012). The main feature of a Common Law or Ordinance marriage is that it is monogamous. It is the union of one man and one woman to the exclusion of all others (Awedoba 2005). Church marriages are performed by legally

57 recognized churches on behalf of civil authority (Nukunya 2003). Church marriage, which falls under the umbrella of religious marriage, involves the administration of the marital union by a priest, religious minister or imam. A religious marriage is viewed more as a spiritual bond and holy vow as commanded by God (or deity) in which a man and a woman come together to create a unified relationship according to God’s laws and commandment (Adjei 2012).

Two distinct socio-cultural practices commonly associated with marriage and family life in Ghana and other countries in SSA, and which may have some negative consequences or mitigate some of the health benefits associated with marriage include payment of bride-wealth and early transition to marriage.

3.3 Bridewealth and Women's Autonomy

One major cultural practice associated with most marriages in Ghana is the payment of some form of bridewealth popularly called tiri nsa.1 According to Fuseini

(2013), bridewealth is an integral part of marriage procedures in Ghana, and it involves the transfer of wealth from the bridegroom's family to his bride's relatives at the inception of the marriage (Fuseini 2013; Fuseini and Dodoo 2011; Goody and Tambiah 1973;

Meekers 1992; Mizinga 2000). Fuseini and Dodoo (2011) contended that in many occasions bridewealth is either paid in full before the marriage or the goods may be transferred by installment over a period of time because of the "substantial" amount of goods that are to be transferred as bridewealth.

According to Nukunya,

1 This refers to drinks, money, and other gifts presented by a man and his family to his prospective bride and family at a traditional marriage ceremony. 58 traditional marriage payments in Ghana differ from society to society and sometimes within the same ethnic group, local differences are found. Among the Ashanti, drinks and money constitute the payment. The formal establishment of marriage results from the payment by the groom and his people (lineage head and parents) of the tiri nasa (lit. head wine) which the Ashanti describe as aseda, a thanking gift. This usually consists of two bottles of gin and an agreed equivalent in cash. (2003: 42)

Marriage is mostly recognized only after the bridewealth has been paid although this may vary from one ethnic group or country to the other (Fuseini 2013). For instance, in Botswana, the absence of bridewealth does not prevent unions, but they are considered inferior types of union, which do not transfer paternal rights to the man, nor guarantee stability or durable access to the land (e.g., if widowed) to the woman. Overall, the payment of bridewealth secures right over the woman to the man and his family with respect to her household labor, sexual, and reproductive rights (Goody and Tambiah

1973).

Despite the importance of bridewealth in legitimizing marriages in Ghana, some scholars continue to argue that the payment of bridewealth diminishes the autonomy of married women and symbolizes gender inequality, which could further lead to negative consequences such as the exploitation of these women (Fuseini and Dodoo 2011;

Jejeebhoy and Sathar 2001; Mawamwenda and Monyooe 1997). In a recent study in

Ghana by Fuseini and Dodoo (2011), these scholars found some interesting findings concerning the relationship between bridewealth and loss of women's autonomy. Fuseini and Dodoo found that the payment of bridewealth undermines women's reproductive autonomy as well as other aspects of their personal life (such as personal business). These findings are consistent with what Bawah et al. (1999) reported that once bridewealth has been paid, the most important responsibility for a woman was to give birth. In addition,

59 Fuseini and Dodoo (2011) contended that the payment of bridewealth whether paid in full or partially determines the extent to which these married women exercise their autonomy.

Fuseini and Dodoo's study revealed that married women whose bridewealth has not been paid fully, partial, or not paid at all tend to exercise more autonomy compared to their married counterparts whose husbands have paid their bridewealth in full. Thus, payment of bridewealth (whether full or partial) is highly correlated with women's sense of autonomy and control at the household level.

In another study on married women and men in Zimbabwe, Mawere (2010) found that the majority of respondents in the study indicated that the payment of bridewealth was associated with gender inequality by giving more power to men and placing women in a subordinate position (Kambarami 2006; Wagner 1999). Thus, the tradition of

"lobola" (payment of bridewealth) lowers female agency by creating a sense of male ownership that leaves the wife subject to her husband's demands (Fuseini and Dodoo

2011; Kambarami 2006).

Another negative effect of bridewealth payment has to do with preventing married women in abusive relationships from annulling their marital unions (Kamabarami 2006).

The return of bridewealth symbolizes the annulment of the marriage. However, in most situations the woman and her family members may have used the bridewealth. The possibility of a refund of the bridewealth may be difficult if not impossible, especially if the woman's family are poor. This means that these married women have to stay in such abusive relationships. Living in an unhappy marriage with less autonomy makes it difficult especially for married women to enjoy or benefit from such marital unions.

Because of this, bridewealth payment can undermine some of the health benefits

60 associated with marital unions since unhappiness, abuse, lack of autonomy, and stress are deleterious to a person's health. Moreover, such a view reflects the argument made by

Ross (1991) that although being married could lead to economic gains for women, it might be counter-reactive. In other words, marriage may increase women's financial status but at the same time, it can reduce their autonomy or sense of mastery.

3.4 Early Marriage

In Ghana and other countries in sub-Saharan Africa, there is a high value attached to the institution of marriage (Adjei 2012; Nukunya 2003). Due to this, most people in the region marry at an early age (Makinwa-Adebusoye 2013). While more women are marrying later in Western developed countries due to personal, social, and economic factors (e.g., the need for economic independence), overall, 20 to 50 percent of women are married by the age of 18 in the developing world with the highest percentages in West

African (Maware 2010). Age at first marriage is very important (especially for women) because it is associated with early birth, high fertility rates (larger families), risk of marital dissolution, increased risk of sexually transmitted diseases, and adverse health outcomes (Nour 2006). An early marriage is any marriage carried out below the age of 18 years, and although it applies to both young boys and girls, it is mostly girls who are mostly affected (Chae 2013; Clark 2004).

Approximately 40% of girls in sub-Saharan Africa are married before the age of

18, thus resulting in early marriage being largely sub-Saharan African phenomena

(UNICEF 2014). Within sub-Saharan Africa, age at marriage is comparatively high in

Central Africa and highest in West Africa with 40% and 49% of girls under 19 years in unions, respectively (Walker 2012). This compares to 20% for Northern and Southern

61 Africa and 27% in East Africa. Within Central Africa, the Democratic Republic of Congo stands out with 74% of all girls in unions by 19 years. Cameroon trails behind with 52% of girls 20-24 years married by age 18 years (Walker 2012). West African countries reporting the highest rates of women aged 20-24 who were first married or in a union by age 15 years are Niger, Chad, Mali. Ghana has one of the highest child marriage prevalence rates in the world, showing that on average, one out of four girls will be married before their 18th birthday (Walker 2012).

Within Ghana itself, a recent study showed that about 25% of the women aged

20-24 were married or were in union before age 18, implying a decline of 11% since

2003 (also see UNICEF 2013). At the regional level in Ghana, previous surveys showed that the prevalence of early marriage is highest in Upper East (50%), followed by Upper

West (39%), Northern (36%), Volta (33%), Brong-Ahafo (33%), Central (28%), Ashanti

(23%), Western (18%), Eastern (18%), and Greater Accra (11%) (UNICEF 2013).

However, studies have found early marriages to be associated with some health implications (Ramjee and Daniels 2013).

The negative consequences of early marriage range from exposure to HIV/AIDS

(as well as other related STIs), cervical cancer, emotional and psychological health problems, child, infant, and maternal mortality, curtailment of educational opportunities, spousal abuse, and among other related problems (Ramjee and Daniels 2013). The low status of women in Ghana means that in some situations, married women may not be in a position to negotiate safe sex. The big differential age gap between these married young girls and their husbands (mostly elderly men) makes it even more difficult for them to practice safe sex. A study conducted by Clark (2004) on the prevalence of high HIV

62 infection among married girls in Kenya and Zambia revealed that, because these young girls were under intense pressure to prove their fertility, they had unprotected sexual intercourse. The study also found that husbands were substantially older (5–14 years) than their wives and were 30% more likely than boyfriends of single girls to be HIV infected.

Studies on harmful effects of early marriage on girls’ health have revealed that girls who are married off before the age of 18, experience earlier sexual début, give birth to more children and lose more children to neonatal and childhood diseases (Erulkar

2013). Studies have shown a strong positive correlation between an early median age of first marriage and an early age of first birth (Ryan 2012). This account explains in part the high maternal mortality and morbidity reported among this population. There are many studies that continue to show how early marriage damages the mental, physical wellbeing and life chances of young girls (Forthofer et al. 1996; Uecker 2012). For example, using the National Longitudinal Study of Adolescent Health, Harris and colleagues (2010) found that early marriage was associated with binge drinking for

African Americans, high BMI for both African Americans and Whites, and depression for African American men.

The adverse health effects of early transition to marriage is not only limited to young girls; adolescent boys are also affected. From a life course perspective, the timing of transitions is likely to influence individual wellbeing (Dupre et al. 2009). Life course theory suggests that the disruption of early life processes, such as education, may have a negative effect on health later in life (Elder 1995). Studies have found early marriages to

63 be associated with poor health and depressive symptoms (see Dupre and Meadows 2007;

Uecker 2012).

In a related study by Garfield and his colleagues (2014), these scholars found that early transition to fatherhood was significantly associated with depression. Depressive symptoms increased on average by about 68 percent over the first five years of fatherhood for the young men in their study (Garfield et al. 2014). Moreover, Garfield and colleagues found that the state of depressive symptoms experienced by these young fathers varied by living arrangements. That is, young fathers who did not live with their children did not experience such a dramatic increase in depressive symptom scores in early fatherhood. Nonresidential fathers' depression symptom scores were elevated prior to fatherhood but started to decrease during early fatherhood (Garfield et al. 2014). On the contrary, young fathers who lived with their spouses and children experienced an elevated and the highest level of depressive symptoms (Garfield et al. 2014). All these research findings demonstrated the deleterious effects of early transition on health irrespective of one's gender.

Given that some Ghanaians marry at an early age, it is plausible to speculate that such a cultural practice can attenuate the marriage-health benefits that have been reported in the literature (predominantly found in Western developed countries).

3.5 Why Never-Married Ghanaians May Experience Good Health

Loneliness, social isolation, and emotional alienation have become an almost permanent way of life to millions of North Americans; the single, divorced, adolescents, housewives, and the scores of people who call suicide prevention centers and hotlines. (Rokach, 2004: 28)

64 Extensive literature on the relationship between marital status and positive health outcomes have shown that compared to the never-married, married persons experience better health (Carr and Springer 2010; Koball et al. 2010; Waite and Gallagher, 2000).

These benefits experienced by married individuals have been attributed to the protective effect or resources associated with marriage including provision of social support, social control, increase in income, among others (Schoenborn 2004; Wade and Pevalin 2004;

Waldron et al. 1996). Although these mechanisms may concurrently confer better health to married persons compared to the unmarried (which have been found predominantly in

Western literature among developed countries), these same processes coupled with differences in cultural values and practices may operate differently within the Ghanaian context.

Using the same arguments put forward to explain the protective effect of marriage

(marital resource thesis) which include the following: (a) married individuals enjoy economies of scale, specialization, and increased income relative to their unmarried counterparts; and (b) the social support and control that married persons enjoy. I argue that these resources which are associated with marriage are also available to never- married individuals in Ghana and SSA in general. For example, with respect to social support, the communalistic and collectivistic cultural values and practices that characterize Ghanaian culture means that being single does not necessarily mean that these individuals lack social support, social networking, or integration. Rather, the collectivistic social relationships and reciprocity in Ghana mean that never-married

Ghanaians may still be well integrated into their social groupings and may still be monitored or supervised by their immediate and distant relatives thereby benefiting from

65 such social relationships. As a result, the status of the never-married may not be that different from their married counterparts. Thus, the hypothesized relationship between marital status and health (where the married experienced better health compared to the unmarried) which have been found in the Western literature may indirectly or implicitly underscore the relevance of individualistic cultural values and practices that characterize these Western developed countries.

The status of never-married persons in the Ghanaian context may not necessary lead to or cause poor health unlike their never-married counterparts in Western developed countries. This is due to the following reasons: a) collectivistic and communalistic cultural norms and practices (social support and integration); and b) Less financial stress or economic hardship due to minimal financial obligations.

Collectivistic and Communalistic Cultural Norms and Practices (social support)

Man is a social animal who is motivated to escape his loneliness, by reaching out to other humans. (Rokach, 2004: 36)

A substantial number of sociological and epidemiological studies, particularly those examining the association between social relationships and health outcomes have indicated that access to social relationships (such as social support, social integration, and social networks) affect mental health, health behaviors, physical health, and mortality risk

(Brummett et al. 2001; Ertel, Glymour, and Berkman 2009; Frasure-Smith et al. 2000;

Uchino 2004; Umberson, Crosnoe, and Reczek 2010; Umberson and Montez 2010).

These studies consistently showed that individuals with the lowest level of involvement in social relationships are more likely to experience poor health than those with greater involvement (House, Landis, and Umberson 1988). People who are more socially connected to one another are more likely to be healthier and live longer than those who

66 live in isolation. Social isolation has been associated with poor health outcomes (Cohen

2004).

Social isolation can be a stressor because it increases negative affect by causing a sense of alienation, loneliness, and stress while decreasing one's feelings of control and self-esteem (Cohen 2004; Cornwell and Waite 2009). Social isolation or loneliness is very detrimental to the health of the individual. Loneliness has been linked to depression, anxiety (Cornwell and Waite 2009), to drug and alcohol abuse, an increased vulnerability to health problems, and to suicide (Rokach 2004). Furthermore, social isolation has been found to be associated with self-destructive behaviors such as recklessness, excessive eating, and drug and alcohol abuse (Rokach 1990, 2004). Conversely, interacting with others is associated with emotional regulation thereby increasing positive health outcomes and limiting the intensity and duration of negative psychological state (Rokach

1998). Interacting with others, engaging and participating in social activities especially within one's own community reinforces meaningful social roles which provide a sense of value, belonging, and attachments (Berkman et al. 2000; Cohen 1988; House 2001).

As discussed in the previous chapter, one of the major health benefits associated with marriage has to do with the provision of social support and social control for married persons. Social support and social control are two interpersonal mechanisms that have been identified as having positive effects on the health behaviors of married individuals compared to the unmarried (Berkman et al. 2000; Helgeson, Novak, Lepore, and Eton 2004). The institution of marriage serves as an integrating force that connects romantic partners to one another and to friends and relatives, and these ties provide the structural basis for greater social support (Mirowsky and Ross 2003). Studies have shown

67 that marriage is associated with higher levels of social integration and social support

(Kim and McKenry 2002; Koball et al. 2010; Manzoli et al. 2007).

Despite these important resources (social support, social integration, and social control) mostly associated with marriage thereby conferring positive health outcomes to married individuals compared to the unmarried, I argue that within the Ghanaian context, never-married Ghanaians may also have access to these resources. Thus, the relative advantage of the married compared to the unmarried as found in Western literature is predominantly attributed to differences in cultural norms and values. For example, it may be that Western social and philosophical ideologies that place much emphasis on individualism may account for why never-married persons in these countries are more likely to be predisposed to loneliness, which may negatively affect their health.

Engaging in risky behaviors, less access to social ties, and social isolation/ loneliness on the part of the never-married may be due in part to the individualistic values and norms that characterize the cultures of Western developed countries. It is possible that the status of the never-married individuals in the Global North countries is precarious due to loneliness and social isolation. As such, it is reasonable to speculate that the institution of marriage plays a significant role in the lives of the married since it provides some form of companionship and social support for married persons. Thus, the health of the unmarried in the Global North countries may be negatively affected due to the absence of social support and other forms of regulatory mechanisms. This can lead to social isolation/loneliness and subsequently, they engage in unhealthy and risky behaviors such as excessive drinking, recklessness, eating fatty foods, and abusing drugs and alcohol.

68 For example, scholars such as Rokach (2004) contended that countries in the

Global North (especially North American societies) are preoccupied with success, achievement, and individualism. These scholars further argued that social isolation or loneliness is prevalent and even encouraged by the North American culture. According to

Rokach (2004), the culture of North American societies emphasizes individual achievement, competitiveness, and impersonal social relations. These cultural values may then give rise to social isolation or loneliness since people living in the Global North may be more concerned about their own wellbeing than caring about their next-door neighbor.

Marriage then becomes the main source of social support for people who get married in the Global North.

A multiplicity of factors such as individualistic values, respect for individuals' privacy, and lack or low social capital (see Putnam 2000) which characterize many developed countries may account for the detrimental or adverse effects associated with being single. For example, it is very common that people who stays in close proximity or the same neighborhood may not necessarily know their next-door neighbor (see Kawachi and Berkman 2001; Leigh and Putnam 2002). Such a situation is more common in

Western developed countries because of issues pertaining to privacy and individualistic cultural values. Doing otherwise may be perceived as encroaching or overstepping one's boundary. Because of this, the status of individuals who are single may be detrimental to their health because one may not have the benefit associated with social ties since they are less likely to be integrated or participate in community gathering, thereby experiencing the adverse effect of loneliness. Thus, the relative advantage of the married

69 over their unmarried counterparts, which have been found in Western developed countries may be due to individualistic cultural values that characterize these countries.

Moreover, the institution of marriage may not be the only avenue or source of social support and control as found in the existing literature. Friends and members of one's family also play an important role in providing some form of social support for unmarried persons. That is, unmarried individuals may also have close network members who may try to influence their health behaviors (Umberson 1992). However, the effect that these social networks (e.g., friends, relatives) play in monitoring the behaviors of the unmarried may be weak or limited especially in Western developed countries. In a study conducted in the United States, Umberson (1992) found that social control efforts are more effective among the married because of commitments and responsibilities to others compared to their unmarried counterparts.

On the contrary, in a more collectivistic society such as Ghana, members of one's extended family and to a large extent friends do play a significant role in the lives of the unmarried. An attempt by a relative to influence or regulate the lifestyle of the unmarried may not be perceived as an invasion of privacy. Such behaviors are even welcomed and perceived to be appropriate. Thus, it is important to consider not only how married individuals influence their partners’ health through the use of social control, but also the extent to which never-married individuals may experience some form of social support and control in a collectivistic environment.

In the Ghanaian context, structural and cultural factors such as communalistic values and reciprocal relationship mean that persons who are not even married may still benefit from their immediate families. It is not uncommon for an unmarried person to be

70 cared for and supported by his/her relatives, thereby benefiting from such social relations

(Assimeng 1999; Nukunya 2003). The strong emphasis on collectivism and the significant role of kinship/extended relations means that even unmarried individuals are well cared for compared to never-married individuals in advanced countries (Nukunya

2003; Tsai and Dzorgbo 2012). Living with either family relatives, parents, or adults may also be beneficial to never-married Ghanaians. Ghana is still a developing country with stronger family and relative ties. The availability and dependence of one's relatives, friends, and family within the Ghanaian's setting may mitigate some of the negative effects associated with being single. In a recent study conducted in Turkey by Kaya and

Yurtseven (2016), these researchers found that unmarried people (especially single individuals) in Turkey were immune to the negative effects from being single on health issues such as loneliness and lack of social control. These scholars found that the presence of friends and family members as well as stronger familial ties that characterize

Turkey makes it possible for never-married individuals to have access to social support and social control.

In Ghana, people place much emphasis on social relationships. Most Ghanaian and African cultural values can be said to revolve around social relationships. Thus, from birth people are integrated into strong and cohesive in-groups which tend to continue throughout their lifetime (Hofstede 2001). This collectivistic orientation underscores strong concern for the wellbeing of others. In a communal society such as Ghana, people are embedded in a context of social relationships and interdependence and are taught from infancy to never see themselves as isolated beings (Mbiti 1992). In other words, within the sociocultural context of Ghana, people are socialized to think about themselves

71 in relation to their relatives or others (both nuclear and extended family members), and as such, they are required to seek the welfare or wellbeing and harmony of the family

(Gyekye 1996; Wiredu and Gyekye 1992). This means that each member of the family is expected to provide and receive some form of support, and this goes a long way to reiterate the importance of social relations in the Ghanaian society (Etta et al. 2016). The notions of "ubuntu" and communalism in the Ghanaian and African community demonstrate that there is a high estimation of the community at the expense of the single individual unlike what pertains in the Global North countries (Etta et al. 2016; Gyekye

1996). That is, a person is perceived to be a person only through others in the community.

This implies a culture of mutual help, reciprocity, of caring for each other, and sharing with each other.

The effect of living in a communalistic society such as Ghana is central to the discourse on marital status and health in the sense that, although never-married

Ghanaians may not have entered into any marital union, these individuals may still have access to some form of social support unlike their never-married counterparts in developed countries such as those in the U.S. In other words, the health benefits associated with being married (social support and social control) as argued by scholars such as Waite and Gallagher (2000) may not necessarily be limited to married individuals only. People who have not entered into marital unions but are still living with family members and other relatives are also likely to benefit from such social relationships and networks. Never-married Ghanaians may still reap the health benefits associated with such social ties even though they are not married. One way by which never-married

72 individuals in the Ghanaian context could benefit from social relationships although not marred is by residing with others such as relatives, parents, or friends.

Living with someone especially one’s kin or relatives is far more common in

Ghana and countries in this part of the region. That is, living with one's parent is a common practice in the Ghanaian context, which is not normally associated with any form of stigma. Unlike their never-married counterparts in Western developed countries where single adults living with their parents may be stigmatized, this may not be the case in the Ghanaian context. By living with parents, for example, these single adults continue to receive social support (whether emotional, instrumental, or informational) which can help buffer against stress and at the same time can promote positive health outcomes.

Adult children who reside with their parents are more likely to be supervised, and as a result, are less likely to engage in any unhealthy and risky behaviors such as drinking, smoking, and eating unhealthy foods.

Moreover, one distinct cultural value in Ghana is the respect accorded to elderly individuals and the perception that the elderly are always right especially when dealing with young adults (Van der Geest 1998, 2002). The essence of this cultural value manifests itself in terms of how elderly people in Ghana exercise more control over young adults by regulating their behaviors, such as sanctioning behaviors that contradicts societal norms, compared to the kind of relationship that exists between older people and young adults in Western developed countries (Apt 1996). Furthermore, the collectivistic and communalistic cultural values that characterize Ghanaian society make it possible and appropriate for unmarried adults' behaviors to be monitored and regulated not only by their own biological parents but also by members of their extended families and even

73 close friends. Thus, it is not considered an intrusion of privacy should a relative or friend reprimand a young adult on his or her behaviors. However, this same action performed or exhibited in Western developed countries such as the United States of America is more likely to be perceived as an invasion of one's privacy due to the prevalence of individualistic cultural values in the U.S.

The implication of the above explanation is that in Ghana, never-married adults tend to benefit wholesomely in terms of having access to social support and networking which promote good health unlike their never-married counterparts in Western developed countries. In other words, although not being married has been found to be detrimental to the health of the unmarried, never-married persons in the Ghanaian context may not necessarily be disadvantaged since they are more likely to experience some of the health benefits associated with marriage (e.g., access to social support, social control, and integration).

In a study by Liu and Umberson (2008) over a 32-year-period in the U.S, these scholars found that the relative advantage of the married over the never-married decreased substantially for men. This was due to never-married persons now having more access to social resources (potential friends and support networks). Thus, it is possible that the health benefits associated with being married compared to never-married (not formerly married) may not operate the same way in Ghana. Since social relationships

(such as social support, social integration, and social networks) have been found to be beneficial to health and never-married Ghanaians may have access to some form of social support due in part to communalistic cultural values that characterize Ghanaian society, it

74 is appropriate to reason or hypothesize that being single may not negatively affect the health of never-married Ghanaians.

Economic Conditions and Financial Responsibilities in Ghana

The second argument under the marital resource hypothesis that makes it possible for married individuals to have better health relative to their unmarried counterparts has to do with increased household income (Koball et al. 2010; Lillard and Panis 1996;

Schoenborn 2004). The economic resources hypothesis suggests that the dual-earnings of married individuals may provide access to health care and alleviate the stress associated with economic hardship (Schoenborn 2004). Economic resources enhance health by providing care in case of illness, ability to afford better nutrition, and allowing purchase of medical care or other health enhancing resources (Lillard and Panis 1996), whereas economic hardship is detrimental to health by increasing stress (Mirowsky and Ross

2003).

However, I argue that in the Ghanaian setting, the status of the never-married will be associated with some benefits such as less economic/financial stress and other familial obligations that married people may experience. In other words, the collectivistic relationships that characterize the Ghanaian's culture mean that married Ghanaians may experience more financial stress since they are expected to fulfill certain familial obligations such as attending to the needs of their extended family or relatives in addition to their own (conjugal) needs. Never married Ghanaians may not be predisposed to this type of financial stress. Considering the fact that the economy of Ghana is not stable

(e.g., high inflation and unemployment rates), I contend that never-married people in the

Ghanaian context may be better off financially.

75 Ghana, a developing country in sub-Saharan Africa, is relatively endowed with natural resources such as gold, timber, diamonds, manganese, bauxite, and rubber (Ghana

Statistical Service 2014). Ghana's economy is predominantly agricultural, with about 60 percent of the population engaged in subsistence agriculture (Ghana Statistical Service

2014; World Bank 2016). The real sector of Ghana's economy centers on the production of goods and services, mostly comprised of the agricultural sector, industrial sector, and the services sector (Osei-Boateng and Ampratwum 2011). Agricultural products which include cocoa, rice, coffee, cassava, peanuts, corn, and bananas are widely grown and cultivated in Ghana, and these cash crops constitute about 21.5 percent of the country's

GDP in 2014 (World Bank 2016). The major industries in Ghana are mining, lumbering, light manufacturing, cocoa and other food processing, and shipbuilding (Osei-Boateng and Ampratwum 2011). The major exports are gold and other minerals, cocoa, timber, and tuna. Imports include capital equipment, petroleum, and the industrial sector which account for about 28.7 percent of Ghana's GDP (Ghana Statistical Service 2014). The services sector accounts for 50% of GDP. Gold, timber, and cocoa production are the major sources of foreign exchange. For example, in 2011 the cocoa subsector alone earned Ghana about $2.87 billion (World Bank 2016).

Despite the gains and contribution of these three sectors toward the development and growth of Ghana's economy, there have been some major challenges facing the country. These include the decline in employment opportunities, high unemployment, stagnation of the economy, high inflation, macro-economic mismanagement, and rising poverty rates in recent years (Apaloo 2003; World Bank 2016). For instance, the agricultural sector, which contributes a large percentage toward the country’s GDP and

76 employs about 60% of the labor force, continues to face a number of challenges including inadequate capital, lack of access to loans, and lack of market for local famers (The

World Fact-Book 2016). Annual inflation rate in Ghana accelerated to 19.2 percent in

March 2016 from 18.5 percent in the previous month (Ghana Statistical Service 2016).

This is the highest figure since August, 2009 according to Ghana Statistical Service

(2016). Unemployment rate in Ghana averaged 8.8 percent from 2001 until 2013 reaching an all-time high of 12.9 percent in 2005 (Ghana Statistical Service 2014).

Poverty is usually measured either as extreme (absolute) or moderate (relative).

The World Bank has set the international poverty standard as living on less than $1.25 a day for extreme poverty and $2.00 per day for moderate poverty (see Cooke et al. 2016).

Ghana has about 30 percent of its population still living below the poverty line, which estimates their income at less than $1.25 U.S. per day (Cooke et al. 2016). A recent report from the Ghana Statistical Service (2014) found that about 24.2 percent of

Ghana's population are living below the poverty line. This percentage corresponds to about 6.4 million people who are classified as poor.

The incidence of poverty and poverty gap are not evenly distributed among the ten administrative regions in Ghana. Thus, Greater Accra has a very low level (5.6%) of poverty incidence, while the three northern regions of Ghana record the highest level of poverty (e.g. 70.7% in Upper West, 44.4% in Upper East) (Cooke et al. 2016). Similarly, between 2007 and 2011, it was reported that about 40 percent of Ghanaian's share of household income constitute the poorest, while only 20 percent of Ghanaian's share of household income are the richest (Ghana Statistical Service 2015). In addition, the Gini index, which measures the level or state of social and economic inequality in a given

77 country, showed that inequality is more pronounced in Ghana (Cooke et al. 2016). A society that scores 0.0 has perfect equality of income distribution, while a score of 1.0 indicates total inequality. Currently, the Gini Index in Ghana is approximately 0.40

(Cooke et al. 2016).

One way by which never-married people in Ghana will experience relatively good health has to do with less financial stress. Within the sociocultural context of Ghana, the family institution is one of the most important socioeconomic institutions. The strong family ties that characterize the Ghanaian's family system mean that there is more reliance on the family as an economic unit. That is, the communalistic values that pervade Ghanaian's culture implies that there is high interdependency for economic support among family members irrespective of one's marital status (Kutsoati and Morck

2012). However, married people in Ghana may be vulnerable to more financial stress compared to their unmarried counterparts due to the former having many financial obligations. Although studies have found that marriage increases economies of scale and household income, being married also comes with some responsibilities such as taking care of one's family through the provision of shelter, clothing, food, enrolling children in schools, among others.

In addition, because marriage in Ghana is not only considered as a union between a man and a woman but rather considered as a union between two extended families means that members of the conjugal union (married couples) hold certain obligations towards their in-laws (Nukunya 2003). It is a common practice in Ghana, for instance, for a married man to provide financial support to his in-laws (e.g., spouse's relatives). Thus, in addition to meeting the needs and obligations of his own nuclear family, a married man

78 must attend to the needs of his own extended family (e.g., mother, father, and siblings) and that of his spouse's family (e.g., mother-in-law, father-in-law) since in Ghana when a person marries he or she marries not only the spouse but the entire family. Taking care of one's own immediate or nuclear family may be burdensome and strenuous by adding other responsibilities (e.g., supporting other family relatives) within the current economic conditions in Ghana (such as high inflation, high cost of living, unemployment, high poverty rates) which may lead to more financial stress for the married. On the contrary, young adults in Ghana who have not entered into any marital union are less likely to experience this type of financial strain since they do not have to meet any financial obligations towards a spouse, children, or any in-laws that come with being married. In other words, comparing the married and the never-married in Ghana, the former is more likely to experience stress from financial obligations and as such less likely to be financially satisfied with their household income unlike their never-married counterparts.

Since never-married people in the Ghanaian context may hold fewer financial obligations and at the same time have access to some form of social support (e.g., from relatives, friends), they are more likely to report higher levels of wellbeing than those who are married. Having too many financial responsibilities may lead to more strain and this may cause low levels of wellbeing, and subsequently poor health among the currently married. Both macro/structural factors (such as poverty, high unemployment rates, inflation, etc.), and sociocultural values (such as collectivism, reciprocity, and responsibilities towards family members) mean that the effect of financial burden will weigh more on married people compared to the never-married, and this is likely to cause low levels of subjective wellbeing among the former-married.

79 A related issue that could account for the high financial stress experienced by married people in Ghana has to do with the lack of financial programs and support system to poor families. Ghana is not a welfare state. Some studies have shown that living in a welfare state helps to promote wellbeing, which can cause positive health outcomes (Lapinski et al. 1998). According to Di Tella and colleagues (2003), living in a welfare state is positively associated with wellbeing. In the sense that since welfare states provide financial/economic assistance, such as unemployment benefits especially to families living below the poverty line and those with children at home, this helps the cushion the harmful effect of economic hardship.

In a study by Eikemo and colleagues (2008), these researchers found that individuals living in Scandinavian and Anglo-Saxon welfare states tend to have higher levels of wellbeing and self-reported health in comparison to those living in southern and eastern European welfare states. In the case of Ghana, the absence of a welfare system or financial assistance in the country means that an individual may not have any access to financial support that could help mitigate economic hardships. There are no financial aids for unemployed persons in Ghana, and having a family without access to any type of financial assistance means that although the subjective wellbeing of unemployed individuals are most likely to be affected, married people are more likely to be affected the most. Therefore, I argue that financial satisfaction at the household level will mediate the relationship between marital status and self-reported health with never-married less likely to experience such financial stress.

80 3.6 Marital Dissolution, Widowhood Rites and Negative Cultural Practices

The death of a spouse as argued above is rated among the most stressful life events that humans experience (Utz, Caserta, and Lund 2012). A substantial body of evidence indicates that widowhood is associated with declines in health and increases in mortality risk for surviving spouses (Carr and Utz 2001; Stroebe and Schut 2010;

Umberson et al. 1992). A range of mechanisms may account for this association. They include the loss of social support, the stress of bereavement, and adjustments to managing a household alone (Stroebe and Schut 2010). Other researchers also argued that the loss of a spouse means that surviving spouses must cope with grief following the loss of a partner who once provided social and emotional support (Utz et al. 2002).

In Ghana, the status of widowhood is further compounded due to discriminatory and androcentric cultural traditions that exacerbate the already existing situation of surviving spouses, thereby affecting their state of health and living conditions.

Widowhood rites (including widow inheritance and cleansing) and property grabbing/property rights violations (in the absence of formal or a written will) are among some of the contributing factors that put widows/widowers in disadvantageous positions

(Chen 2000; Eboh and Boye 2005).

In Ghana, many widows are expected to go through several widowhood rites.

Despite the fact that the practice is not gender biased, it is usually women who are asked to go through these practices (Agot et al. 2010; Idialu 2012). In the unlikely event where a man has to go through them, the conditions are usually different and less severe for men.

81 This practice is observed by almost every traditional society though the nature of the practice may differ from one society to another. Some of the widowhood rituals include bathing outside the compound, cooking on rubbish dumps, eating from a calabash and using it as a pillow, walking naked to the riverside to have a bath, and being forced to constantly stay in the same room with the deceased husband before burial (Nwalutu

2012; Peterman 2012). Studies show that in Ghana, widows are sometimes subjected to dehumanizing cultural practices such as shaving of head (sometimes with a broken bottle or razor), confining widow into a room for many days, and forcing them to drink concoctions prepared with leaves, hairs, and finger nails of their late husbands (Nwalutu

2012; Tei-Ahontu 2008). Failure to undergo such rituals means that the widow is likely to be perceived as having a hand in the death of her husband, and in turn stigmatized as possessing evil spirits (such as being called a witch).

Apart from these rituals, some ethnic groups in Ghana do practice widowhood inheritance where the widow is expected to marry an elder brother of her late husband

(Afolayan 2011). Widow cleansing and widow inheritance are cultural practices observed in many communities in sub-Saharan Africa (Ntozi 1997). In countries such as Malawi,

Kenya, Zambia, and Botswana, it is widely believed that a widow becomes unclean after her late husband’s burial ceremonies (Ramjee and Daniels 2013). In cleansing rituals, an unprotected sexual act is believed to purify the recipient through the semen entering the woman’s body. Community elders identify a man with whom the widow has to have sex with, someone who has often had several sexual partners in the process of cleansing others. These practices often put widowed women at greater risk for HIV and other STI infections.

82 In addition, in many situations, it is not uncommon for relatives of the deceased person to confiscate properties and wealth formerly owned by the deceased without leaving anything for the surviving widow and her children (Tei-Ahontu 2008). In certain parts of Ghana and countries in SSA, widows may lose access to their own properties, especially where their husbands died without a written will. Sometimes the widow is forced to abandon the marital home and all of her belongings. In communities that allow property grabbing, it is not uncommon for women to be left destitute after the death of a husband (Tei-Ahontu 2008). In some instances, some widows are labeled as witches-for killing their husbands (Peterman 2012). Such widows are ostracized and driven into isolation.

In the preceding paragraphs in this chapter, I have demonstrated the processes by which the conditions of never-married Ghanaians may not be detrimental to their health due to their access to social support, integration, and less financial responsibilities unlike their unmarried counterparts in the developed nations. Similarly, I have highlighted how marital dissolution especially through death affect the health of the formerly married due to negative cultural practices such as widowhood rites. Based on these arguments, I have developed the following hypotheses:

(1) Compared to the currently married, the never-married will experience better

health similar or better health

(2) Compared to the formerly married (including divorced, separated, and

widowed), currently married persons will report better health.

(3) Financial satisfaction at the household level will mediate the relationship

between marital status and self-reported health with never-married persons

83 experiencing higher levels of financial satisfaction compared to the currently

and formerly married individuals.

(4) Living with parent and the presence of children will moderate the relationship

between marital status and self-reported health with never-married persons.

3.7 The Effect of Gender on the Association between Marital Status and Health in Ghana

The Married

As argued in Chapter II, one of the recurrent debates in the existing literature has been the role of gender in moderating the relationship between marital status and health.

There is no consensus on how gender moderates the relationship between marital status and health. Thus, if marriage is beneficial to health and being unmarried is harmful to one's health, who benefits or experiences poor health? Do men benefit more from marriage than women do? Does the dissolution of marriage affect men more than women? I examined how the association between marital status and health in Ghana is moderated by gender.

In a stratified society like Ghana, where the majority of men control resources and are regarded as financial providers or breadwinners of their families and women are considered as homemakers and attending to household chores such as cooking, washing, child and elderly care, this legitimizes power structure among married couples (Takyi and

Mann 2006). In a typical traditional Ghanaian marital relationship, the gendered division of labor at the household level means that married women are more likely to disproportionately bear most of the household responsibilities by cleaning, shopping for groceries, fetching water, washing, cooking, caring for children, among other related domestic chores (Blackden and Wodon 2006). Unlike women in Western countries, the

84 majority of Ghanaian women view themselves as responsible for domestic chores

(McFerson 2010).

A popular depiction of the gendered relationship that characterizes conjugal relationships in Ghana is a mother carrying a baby on her back at the same-time carrying heavy loads on her head, while her husband walks behind her holding nothing and not assisting the wife (Falola and Amponsah 2013). Thus, there is a strong acceptance to strict gender roles within the Ghanaian setting to the extent that deviating from such expectations is met with negative sanctioning (Falola and Amponsah 2013). This gendered inequality means that married women's health may be negatively affected. In a recent qualitative study in Ghana, Annor (2014) found that married women were more involved in household chores and childcare relative to their male partners. All the women interviewed in the study mentioned household chores as their sole responsibilities. For instance, a woman made the remark that "I don't have house help; I'm alone and the children are young. So I have to do most of the things on my own because my husband doesn't help me" (Annor 2014:24).

As previously mentioned, some of these married women may end up providing care not just to their immediate conjugal family but also to members of their extended families such as their own parents and siblings. Therefore, providing care within the

Ghanaian context may be a major chronic stress for these married women. Conversely, the financial responsibilities that come with being married within the Ghanaian context may also be a chronic stressor for married men compared to their female partners. The majority of Ghanaians tend to perceive men as financial providers of their respective families due to patriarchal cultural values and practices. Considering the current

85 economic conditions in Ghana coupled with attending to the needs of one's immediate and extended family, married men are more likely to experience financial burdens and this may attenuate the gendered health benefits associated with marriage. This then implies that the health benefits associated with marriage, if any, may not differ by gender.

The Never-Married

For never-married individuals in Ghana, although studies have shown that men are more likely to be negatively affected by being single due to their less access to social support and social control, this may not be the case in Ghana. As argued in this chapter, the collectivistic nature of Ghanaian's culture may inhibit the negative effect of being single among never-married individuals in Ghana. Yet, the status of being single in the

Ghanaian setting will be beneficial to never-married men more than their female counterparts due to the reasons below.

First, the patriarchal cultural values and practices in Ghana and sub-Saharan

Africa mean that on average the socioeconomic status of men will be relatively higher than that of their female counterparts (Blackden and Wodon 2006; McFerson 2010).

Since men are more likely to control economic resources, they are less likely to experience economic hardship compared to their female counterparts. Gender is strongly related to socioeconomic position in Ghana. Due to patriarchal practices, gender discrimination, and marginalization of women, on average women are more likely to live in poverty and work within the service industry (a sector generally characterized by higher levels of part-time work, lower rates of unionization, lower wages, and poorer working conditions). This places women at a disadvantaged position relative to men. In other words, the higher socioeconomic status of never-married men coupled with their

86 access to social support means that never-married men will experience better health compared to their unmarried female counterparts.

Second, though both never-married men and women in Ghana may benefit from having access to social support, men may benefit more than women due to pressure from family members to settle down (Nukunya 2003). That is, in the sociocultural context of

Ghana, women are mostly perceived to be child-bearers, nurturing, and who are mostly socialized to aspire to be mothers. Since the institution of marriage is cherished and held in high esteem among the people of Ghana, women who have not entered into any marital union are likely to be stigmatized and pressured by their relatives to get married. In some situations, even when these women are wealthy, not being married may diminish the respect friends and family members may accord them.

Gender inequality, gendered socialization, and patriarchal in Ghana places women in a far more precarious position. For example, it is acceptable for men to be single, but for women being single is associated with negative sanctions. Because never-married women may tend to measure themselves by the standards in Ghana (such as the definition of womanhood is only attainable when women get married and bear children) as well as facing intense pressure from friends and relatives unlike their male counterparts, this may diminish the health returns associated with being single. Thus, the health benefits associated with being single may vary by gender, with never-married men reporting higher levels of health than their female counterparts.

The Formerly Married

In Ghana, the adverse effect of marital dissolution whether by divorce or death will affect the health of both formerly married men and women equally. In other words,

87 there is no gender variation with respect to the effect of marital instability among formerly married men and women in Ghana. For example, because marital dissolution by divorce is highly stigmatized in Ghana, both men and women who dissolve their marriages are more likely to be stigmatized by their friends, relatives, and largely the entire community (Asante et al. 2014). When there is a marital conflict among married couples, friends and relatives expect the couples to work through their problems and solve it even in domestic violence cases (Clark and Brauner-Otto 2015). In a study conducted by Cantalupo et al. (2006) in Ghana, an interviewee made a personal observation concerning a married woman who had been abused by her husband and wanted to end the relationship but was prevented by family members. He made the assertion that:

A man was living with a woman. He was always beating her, to the point where she had lost all her teeth. She did not want to see the man. The mere sound of his voice put her off. She went to her parents time and time again. They always told her, that is your husband. Go back to him. You have children. (Cantalupo et al. 2006: 114)

This comment epitomized the extent to which Ghana as a society prohibits divorce. Therefore, persons who successfully dissolve their marriage may experience many strains, which could negatively affect their health.

Furthermore, marital dissolution is a strenuous experience, which is more likely to be a chronic stressor and affect the health of both formerly married men and women in

Ghana. Losing a spouse through divorce or death is associated with emotional, psychological, and financial stress, and formerly married Ghanaians are no different.

Divorce may leave both women and men women with financial hardships, loose emotional ties (less integration and social support), and stigmatization which ultimately

88 affect their health. Finally, marital dissolution especially from death is associated with additional burdens on the health of the surviving spouse in Ghana because among many ethnic groups in Ghana, there are outrageous widowhood rites such as widowhood inheritance (marrying the brother of the deceased), eating from a calabash and using it as pillow, walking naked to the riverside to have a bath, and being forced to constantly stay in the same room with the deceased husband before burial (Nwalutu 2012; Peterman

2012). These outrageous cultural practices/rituals that these widows are subjected to worsen their already tenuous condition.

Based on these arguments and perspectives, I have developed the following hypotheses:

(5) Never-married men will experience better health than their female

counterparts.

(6) The dissolution of marriage will negatively affect both men and women

equally. Both formerly married men and women will report poor health (no

gender variation).

3.8 The Effect of Children: Parenthood, Marriage, and Health in Ghana (Married Only)

The existing literature on the association between parenthood and health was inconclusive. Whereas some studies found that parenthood increases wellbeing

(Myrskylä and Margolis 2014), others found that it has a negative effect (Evenson and

Simon 2005; Umberson et al. 2010). Parenthood is a transformative experience because it is a unique status which is comprised of rewards and constraints for individuals who occupy such positions (Nomguchi and Milkie 2003; Umberson, Pudruvski, and Reczek

89 2010). Despite the fact that having a child is a personal decision, the sociocultural context in which such decisions are made cannot be neglected.

Parenthood is culturally salient and this is evident by the strong social expectations and attachment associated with it (McQuillan et al. 2003). Without children, women especially are said to feel empty, lonely, and demoralized (McQuillan et al.

2003). The presence of children is associated with life satisfaction (Roeters et al. 2016).

Studies have found that children induce positive emotions (such as love and affection), a sense of meaning or purpose, and an experience of psychological growth (Nelson et al.

2014; Nomaguchi and Milkie 2003).

Social context shapes the meaning, experience, and consequences of childlessness in ways that may undermine wellbeing and health for some select groups (e.g., young women facing infertility and older unmarried men). Generally, childless young adults especially married women are more likely to experience poor health compared to their counterparts with children (Nomaguchi and Milkie 2003). Parenthood is not a monolithic experience that affects every individual the same way. The strong social and cultural attachment associated with childbearing can be seen partly in the fact that over 90 percent of all married persons eventually have children (Ross, Mirowsky, and Goldsteen 1990).

In Ghana, the value attached to childbearing greatly influences the worldview and cultural outlook of most Ghanaians. Children play an important role in the life of

Ghanaians. According to Nsamenang (1992), children are seen as serving a spiritual function by way of strengthening the link between the living and the dead. Thus, in the cosmology of Ghanaian and African societies, children represent a connection to the ancestors and their birth represents a continuation of the family not only in physical but

90 also in religious terms. Because of the significant role of childbearing in Ghana and

Africa in general, parenthood is also held in high esteem. In his study in Northern Ghana,

Fortes made the assertion that "the achievement of parenthood is regarded as a sine qua non for the attainment of the full development as a complete person to which all aspire"

(1978: 125). Fortes contended that parenthood is a fulfillment of fundamental kinship, religious, and political obligations to the community. In Ghana, it is not only marriage but parenthood is the primary value associated with the family system. According to

Takyi (2001), Ghanaians are not only expected to get married, but rather it is unthinkable for married couples to be childless. Throughout Ghana, and sub-Saharan Africa, failure to bear a child is mostly associated with divorce or men marrying additional wives (Tabong and Adongo 2013; Takyi 2001).

It is in this regard that the fertility rates in Ghana and sub-Saharan Africa tend to be high compared to Western developed countries. According to Caldwell and Caldwell

(1990), the reason behind high fertility rates in sub-Saharan Africa is rooted in the cultural background, which is centered on a traditional religious belief system that upholds lineage continuation and the succession of generations. High fertility rate is viewed as a medium of increasing the chances of precluding lineage extinction especially in the face of high infant mortality rates, as well as a means of raising the survival rate of the lineage (Makinwa-Adebusoye 2001). In other words, the locus of high fertility is perceived as a means of prolonging the lineage with the replacement of older members with new ones. The country’s population is currently estimated at 25 million, making it the second largest in West Africa (Ghana Statistical Service 2012). Although total fertility rate declined from 6.4 in 1988 to 4.6 in 1998, the total fertility rate in rural

91 Ghana, where 60% of the population lives is 4.9, while that of urban Ghana is 3.1 (see

Teye 2013). In their study in Nigeria, a West African country, Caldwell and Caldwell

(1987:413) contended that “women who had as much as twelve children and still had the desire to give birth to more children.”

In the socio-cultural context of Ghana, high fertility is perceived as a source of joy (Caldwell and Caldwell 1987). Other reasons associated with childbearing in Ghana include: 1) as social security in which children are seen as necessary for families' survival and for the support of aging parents; 2) social power desires in which children are considered a valuable power resource, especially for women in patriarchal social relations; and 3) social perpetuity desires in which children fulfill the need to continue group structure (Makinwa-Adebusoye 2001). Decision making pertaining to childbearing to a considerable extent lies on family status and concerns surrounding the preservation of the lineage and respect for ancestors (Ekane 2013). According to Makinwa-Adebusoye

(2001), this mode of reasoning rests on the belief that ancestors are reincarnated through the birth of additional children.

Sam (2001) differentiated between three values of children in Ghana. They are economic, psychological, and social. Economic value of children refers to the economic gains or support that parent derives from having a child such as being taken care when one is old or reciprocity (Sam 2001). Psychological value of children, on the other hand, refers to the happiness, joy, and companionship that come with being a parent. Social value of children refers to the expected social advantage of having children (e.g., social approval and social status when a married couple has a child and continuation of the family line especially among patrilineal ethnic groups).

92 With respect to the economic value of children, in Ghana and other countries in sub-Saharan Africa, children are security for old age. It is a common practice in Ghana whereby children at an earlier age contribute to household economy (Tolnay and Glynn,

1994). In a mixed-method study on a fishing community in Ghana, Teye (2013) found that the demand for labor, expectations of long-term security, and gendered power relations contributed to the high fertility rates in Ghana. Some of the men in Teye’s study preferred to have more children so that the children can take care of them when they grow old. For example, a male interviewee in Teye’s study made the assertion that, “I had six children with Aku [the first wife]. . . . When I realized that all of Aku’s children would soon leave my house to start their own families, I married Momo so that she could also give me some children to help me with the work. Now Momo also has two children”

(Nyumu, cited in Teye 2013). These statements underscore the significant role that children play not only among rural dwellers but also among the Ghanaian society as a whole.

Relative to the psychological and social value of children, studies have shown that in Ghana and Africa, children are a source of joy, power, pride, and act as a potential source of emotional support for their parents (Chimbatata and Malimba 2016). Life without children was perceived not worth living, as there would be no one to inherit the properties of the deceased (Dyer 2007). In their study on infertility in sub-Saharan Africa,

Chimbatata and Malimba (2016) contended that because of the strong attachment

Africans associate with childbearing, married people experience pressure from their friends and relatives to procreate, and failure to do so may come at a high cost. A male participant in Chimbatata and Malimba (2016) made the assertion that:

93 Children are the ones who sustain the generation and they inherit property. . . . We live on earth just because of them and they make you feel great; it is great success on earth. . . . People are given respect in this society because of children specifically male children.

In the Ghanaian context, having a child may fulfill the need to improve marital life in order to be accepted as a man or woman. This means that the absence of a child can lead to marital conflicts. As a result, married women without children are sometimes considered as witches and not complete women (Tabong and Adongo 2013). Married couples with one child or without children are more often than not pressured by members of their extended families to procreate. It is in this regard that childless couples especially women within the Ghanaian society do face social stigma, shame, a sense of guilt, and worthlessness. Women, in most cases, face economic deprivation, isolation, risk of polygamy, and domestic violence. In some situations, elderly people without children are more likely to miss important rituals and their funerals do not have the needed attention they deserve as compared to those with children (see Chimbatata and Malimba 2016).

Given the value placed on children in Ghana and sub-Saharan Africa, infertile couples mostly experience difficult marital relations, which more often than not result in separation/divorce or domestic violence (Chimbatata and Malimba 2016).

Not only are children valued in Ghana and other parts of Africa, but also the sociocultural context within which children are socialized and trained makes it possible for couples to give birth to many children. According to Boakye-Boaten (2010), there is a reciprocal rights and responsibilities with children and adult individuals living in this part of the region. Thus, children are socialized to acquire the cultural behaviors of the society. Within the sociocultural context of Ghana and Africa, there is a popular proverb that says, “it takes an individual (woman) to give birth, it takes the entire community to

94 raise the child” (Healey 2017). In other words, regardless of a child’s biological parent(s) its upbringing belongs to the community. It is the responsibility of the society to ensure the protection and proper socialization of children (Boakye-Boaten 2010). The communalistic cultural values and practices that pervade Ghana’s culture mean that children are supposed or expected to be cared for and raised by the entire community and members of one’s family. Because of this, child-rearing responsibilities are shared together by both the conjugal family and members of the extended families. This may help ease some of the financial/economic and social costs associated with children.

However, structural changes such as industrialization, urbanization, globalization, education, and migration that Ghana and other countries in sub-Saharan Africa are experiencing, have tremendously altered the involvement of members of the extended families in raising of children (Oheneba-Sakyi and Takyi 2006). According to Ekane

(2013), the advent of modernity has inherently transformed African family organization and is marked by the drift from larger family size to small size households. That is, the trend toward modernity can be seen in the gradual transformations of Ghanaian marriage and family organizations away from corporate kinship and extended families toward nuclear households (Boakye-Boaten 2010). Thus, whereas in the past, the care of a child was most likely shared by relatives and members of one’s extended family, due to urbanization, migration, and economic changes, the bulk of child-rearing responsibilities and the relative cost of raising children now falls on the conjugal couples (such as the husband and the wife) and not the extended family.

According to Boakye-Boaten (2010), changes in the economic institution of many indigenous societies have invariably affected the economic roles of children. Children

95 were considered as economic assets for a family since it was an economic incentive to have many children. However, with the current economic conditions in Ghana, children have now become an economic and social liability for their families. In other words, although childbearing has social, cultural, and religious significance within the Ghanaian context (e.g., giving birth to many children may bring joy and happiness to the couple because it is a much desired thing in Ghana), the issue is that having more children could lead to economic or financial pressure on married couples. Having a child comes with many responsibilities and this has the tendency to affect the health of married couples.

Numerous studies have shown that the presence of children at home is negatively associated with physical health (Nomaguchi and Bianchi 2004; Umberson et al. 2010). In a study on married couples in the U.S., Nomaguchi and Bianchi (2004) found that married couples with children at home spent less time in physical or recreational activities, which tended to have a deleterious impact on their health compared with couples without children. With respect to emotional or psychological wellbeing, the extant literature showed that children do not generally improve the psychological wellbeing of parents (Evenson and Simon 2005; Umberson et al. 2010). Children at home have been found to be associated with increased depression of parents (Umberson et al.

2010). The three main mechanisms by which the presence of children affect parental health outcomes include (1) economic/ financial hardship, (2) the demands of child care, and (3) social support.

First, children increase economic strain on the family, especially for mothers and this increases depression (Ross, Mirowsky, and Goldsteen 1990; Ross and van Willigen

1996). With the same family income, a family with children feels more economic

96 pressure than one without children. The chronic strain of struggling to pay the bills and to feed and clothe the children takes a great toll on feelings of depression. In some situations, the birth of a child means that the mother must either cutback from full-time employment (take part-time job in order to combine both paid work and taking care of children) or be exclusively a housewife. Financial or economic hardship can create a condition of constant stress for such married individuals and this can be detrimental to the health of these individuals (especially mothers).

Second, the presence of children in the household means that parents, especially mothers, have to assume more domestic duties which can negatively affect their health in the absence of supportive partners. In other words, the demand for child care and household responsibilities is disproportionately undertaken by mothers compared to fathers. Inequality in the distribution of housework and child care is the primary means by which gender inequality is perpetuated in the home (Ross and van Willigen 1996)2.

Additionally, children at home tend to decrease the quality of marriage and the amount of support spouses get from each other. Ross and her colleagues (1990) contended that emotional support and satisfaction with marriage decrease with the birth of the first child and do not return to pre-parenthood levels until all the children have left home. Similarly, husbands and wives spend less time together when they have children, and the time they spend together is often focused on the child (Nomaguchi and Bianchi 2004; Umberson et al. 2010). Deriving less satisfaction from marriage due to lack of social support may

2 Multiple roles performed by women such as caregiving of young children, elderly parents, and ill-spouses creates a major strain on women's health. According to the role strain hypothesis, combining competing demands and expectations associated with the roles of mother, partner, and employee lead to a role strain and are detrimental to women's health (Chandola et al. 2004). 97 induce unhappiness, and this may lead to poor health outcomes especially for married women with children.

From this perspective, it is reasonable to assume that married couples in Ghana with many children are more likely to experience poor health compared to their counterparts with fewer children. I developed the hypothesis that

(7) Currently married couples having many children will be negatively associated

with poor health.

3.9 Lineage Ties, Marital Status, and Health Outcomes: The Ghanaian Context

In the previous sections, I examined marriage and family life in Ghana by exploring some of the cultural practices such as payment of bridewealth, early marriages, and widowhood rites that distinguish Ghanaian culture from Western developed countries. Additionally, I have demonstrated how the status of the never-married

Ghanaians may not be detrimental to their health unlike their unmarried counterparts in the Global North countries due to differences in cultural values (e.g., communalistic cultural practice and fewer financial responsibilities). I also examined how the association between marital status and health is moderated by gender within the Ghanaian setting. Additionally, I looked at the effect of children on the health of currently married individuals in Ghana. In this section, I focused on whether the association between marital status and health outcomes operate differently or the same way among matrilineal and patrilineal groups in Ghana.

In Ghana and many countries in Africa, kinship and lineage ties play a significant role in the lives of the people (Takyi and Dodoo 2005). Researchers have observed that kinship norms and kin ties determine a wide range of behavior – from marriage to

98 inheritance rights (Oheneba-Sakyi and Takyi 2006). According to Awusoba-Asare

(1990), kinship system determines inheritance rights and access to property. In addition, it has been reported that lineage systems strongly influence personal and public behavior

(Takyi 2001). For example, spousal selection is strongly influenced by kinship type with members of one’s relations encouraging individuals to marry people of their own ethnic group.

In Ghana, kin ties can be traced through the father or the mother's own allegiance or descent, the matrilineal and the patrilineal family systems. However, there are few people who trace their descent from both mother and father side (bilateral). In general, among the matrilineal Akans of Ghana, a person's immediate family include his or her mother, his or her own brothers and sisters, the children of his or her sisters (maternal nephews and nieces), and his or her mother's brothers and sisters (maternal uncles and aunts) (Awusoba-Asare 1990). Under the matrilineal kinship system, children belong to the mother and her family. Furthermore, in matrilineal succession, women often inherit properties, titles, and lands from their mothers and pass them down to their children, especially females.

On the contrary, among patrilineal ethnic groups, descent is traced only through the male line. Under patrilineal inheritance or succession, females do not inherit properties unless there are no male heirs. Though this study is about health and marital status, arguably it is fair to suggest that lineage/kinship ties may have something to do with the health situation of married and unmarried alike in Ghana. The reasons for such an expectation include the following:

99 First, the type of lineage system whether patrilineal or matrilineal is likely to influence the relationship between marriage and health through its effect on the autonomy of matrilineal women in Ghana3. Existing studies have found that female autonomy is higher among matrilineal ethnic groups compared to women in patrilineal ethnic groups

(Takyi and Broughton 2006). Among matrilineal ethnic groups, descent is traced through the mother and maternal ancestors. As a result of this lineage system, children belong to their mother's lineage, which in most cases involve the inheritance of property (Nukunya

2003).

According to Takyi and Dodoo (2005) because men hold considerable power especially among patrilineal ethnic groups, issues concerning sexual and reproductive decisions are mostly made by men without involving women. Thus, studies have shown lineage differences in gender power relations in Ghana (Takyi and Dodoo 2005). For example, and with respect to the use of contraception, studies have shown that matrilineal women are more likely to implement their fertility preferences than non-matrilineal women (Takyi and Dodoo 2005). Using the 2008 Ghana Demographic and Health Survey data, Fuseini and Kalule-Sabiti (2016) found that unlike patrilineal women, matrilineal women are more autonomous when it comes to making decisions on the number of children to have, when to seek health care services, and freedom of movement.

Additionally, the autonomy of matrilineal women also stems from their ability to inherit from their lineage and improvement in the socioeconomic status of these women unlike

3 Autonomy is defined as "the degree of women's access to (and control over) material resources (including food, income, and other forms of wealth) and to social resources (such as power, prestige, and knowledge) within the family, in the community, and in the society at large" (Dixon, 1978:6). 100 their patrilineal female counterparts who have to depend on their male partners. In other words, the improvement in female economic status of matrilineal women improves their bargaining position at the household level (Fuseini and Dodoo 2011) relative to women in patrilineal ethnic groups.

Despite the fact that matrilineal women are more likely to be autonomous than patrilineal women, being autonomous comes with certain problems such as possible marital conflicts. These may, in turn, negatively affect the health of matrilineal married couples. In other words, the autonomy that women enjoy for being a member of matrilineal ethnic groups may come at a cost due to the patriarchal cultural practices that are pervasive in Ghana. Because male dominance and control is highly prevalent in

Ghana and sub-Saharan Africa as a whole, men still exercise authority over their spouses

(Koenig et al. 2003). Although women's lack of education and low socioeconomic status make them more vulnerable to violence among heterosexual couples, studies have shown that in sub-Saharan Africa, women with high SES are also predisposed to intimate partner violence (Koenig et al. 2003). This is partly due to male insecurity as studies have found

(Tenkorang et al. 2013). Since matrilineal cultures are still shrouded in patriarchal cultures, male dominance may still persist. For instance, married men in matrilineal ethnic groups may tend to perceive the autonomy of their wives as a form of disrespect which could lead to marital conflict. Therefore, so far as marital conflict has been found to be associated with poor health outcomes (Horwitz and White 1991), marriages among matrilineal ethnic groups in Ghana may not confer any advantage to the married couples.

Another important issue associated with lineage system in Ghana, which has the tendency to compromise the health benefits associated with marriage is marital instability

101 that characterizes matrilineal marriages. Research has shown that women from patrilineal societies have lower divorce risk than their matrilineal counterparts (Takyi and Gyimah

2007). According to Goody and Tambiah (1973), matrilineal societies have high divorce rates, and this is somehow due to increased women's autonomy that these women enjoy.

Additionally, one practice of the Akans of Ghana (matrilineal ethnic group) which is believed to weaken their marital union has to do with the token or amount of bridewealth demanded by the woman's family during marriage. These include two bottles of gin and a token of money. These items according to Mizinga (2000) are easier to refund by members of the family in case the marriage ends. Unlike the patrilineal type of marriages where the bridewealth is quite substantial (e.g., the Tallensi of the Upper East region of

Ghana demand a cow as dowry), refunding or returning such dowry can cost the family a great fortune; therefore, members of such group would ensure the stability of their marriages.

Marriages among patrilineal ethnic groups involve permanent incorporation of women to their husbands' lineage and a complete transfer of women's reproductive power to their husbands through payment of bridewealth (Nukunya 2003). As a result, marital dissolution through divorce or separation is more difficult because the bride price would have to be returned in many cases (Fuseini and Dodoo 2011; Nukunya 199, 2003).

Marriages among matrilineal ethnic groups are characterized by absence of or low bridewealth payments. Therefore, divorce is more common among matrilineal ethnic groups than patrilineal (Takyi and Broughton 2006).

A closely related point that draws on research on Ghanaian and African families which has the potential to undermine the cohesion of the family unit is the lack of

102 economic corporation (that is pooling resources together). Takyi and Gyimah (2007) observed that spouses in Akan marriages do not pool resources together. That is, both spouses keep separate account of their income. Takyi and Gyimah (2007) argued that among the matrilineal Akans, reproductive partners tend to have different budgets, resources, and goals. Oppong (1983) has suggested the practice of separate household resources among married dyads has something to do with the Akan belief that men and women should give priority to their own matrilineal kin over their spouses. However, because marriages among patrilineal ethnic groups incorporate both children and married women into the husband’s patrilineal kin, married couples tend to perceive themselves as one conjugal unit and corporate together. Thus, unlike their matrilineal counterparts, patrilineal women are more likely to pool resources together with their spouses and are more likely to function as a unit. What are the implications of ethnicity/lineage type on the association between marital status and health?

Given the above observations, kinship or lineage type may influence the hypothesized relationship between marital status and health. First, it is reasonable to speculate that the effect of marital status on health may differ by lineage type. Lineage type or system will moderate the relationship between marital status and health outcomes among Ghanaians in the sense that the health of married Ghanaians among patrilineal ethnic groups will be better than their unmarried counterparts, whereas the health of married Ghanaians among matrilineal ethnic groups will be worse off than their never- married counterparts. Thus, the high rate of marital instability (divorce and separation) or unstable marriages that characterize matrilineal ethnic groups in Ghana (e.g., will diminish the health benefits associated with marriage among matrilineal ethnic groups)

103 means that married people would be disadvantaged relative to their unmarried counterparts especially when compared to their never-married counterparts (Nukunya,

1999). As a result, marital dissolution through divorce or separation is more difficult because the bride price would have to be returned in many cases (Fuseini and Dodoo

2011). Marriages among matrilineal ethnic groups are characterized by absence of or low bridewealth payments. Therefore, divorce is more common among matrilineal ethnic groups than patrilineal (Takyi and Broughton 2006).

A closely related point that draws on research on Ghanaian and African families which has the potential to undermine the cohesion of the family unit is the lack of economic corporation (that is pooling resources together (Takyi and Gyimah 2007).

As previously argued, marriages characterized by constant conflicts may have a detrimental effect on the health of married couples (Umberson and Montez 2010). The quality of marriage contributes significantly to the overall psychological wellbeing or positive health outcome. A distressed marriage undermines the health benefits associated with marriage (Mastekaasa 1994; Robles and Kiecolt-Glaser 2003). To the effect that matrilineal marriages are unstable and with never-married having access to social support and not vulnerable to any form of marital strain that their married counterparts experience, the never-married will experience better health than their currently and formerly married counterparts.

The stability of marital unions that has been found among patrilineal ethnic groups may indicate that members of the conjugal family are more likely to experience some of the health benefits associated with such marriages. However, there is the possibility that social selection process may operate more among patrilineal groups than

104 among matrilineal ethnic groups. This is primarily because the expensive nature of the bridewealth payment among patrilineal ethnic groups may act as a barrier or prevent low socioeconomic individuals from entering into marriage. In other words, since payment of bridewealth among patrilineal ethnic groups is more expensive compared to the amount of bridewealth presented in matrilineal societies (in some situations bridewealth is not required), some unmarried people among the former group may experience stress stemming from their inability to get married.

The expensive nature of bridewealth among patrilineal ethnic group makes it difficult for single individuals who are willing and ready to settle down to abandon such plans since they may not have the necessary resources needed for the marriage process. It is possible to argue that some single individuals among patrilineal groups may experience some form of stress as a result of their inability to enter into marriage, an institution which is honored and cherished within the Ghanaian setting. Thus, not being able to get married may lead to stress which could negatively affect the health of the never-married.

In addition, the stigma associated with being unmarried may compound the conditions of the unmarried even though they may still have access to social support. Therefore, I argued that among patrilineal ethnic groups in Ghana, married people will experience better health compared to their never and currently unmarried counterparts. Furthermore,

I contended that the situation of the formerly married in both patrilineal and matrilineal groups will be detrimental when compared to those who are married.

3.10 Summary and Conclusion

In this chapter, I examined some of the distinctive cultural practices that characterize marriage and family life in Ghana (e.g., early marriages and payment of

105 bridewealth), and how these cultural values and practices make it necessary for unmarried Ghanaians to experience better health relative to their unmarried counterparts in Western developed countries. Thus, the communalistic values and practices make it possible for never-married people in the Ghanaian setting to still have access to social support, thereby benefiting from such social relationships. Furthermore, the cultural expectations and financial obligations that currently married people in Ghana have to fulfill place them in stressful situations and which may diminish some of the health benefits associated with marriage. I also argued that, within the sociocultural context of

Ghana, marital dissolution is a stressful experience since divorce is highly stigmatized and formerly married individuals are more likely to be criticized and ostracized by friends and relatives. For widows in Ghana, aside from the fact that losing a spouse is detrimental to their health, many widows are even subjected to outrageous cultural practices such as widowhood rituals. Additionally, many widows face extreme poverty and are more likely to be deprived of social support. All these issues compound and worsen the health situations of widows in Ghana.

I have discussed in the previous sections how the presence of children and gender influence the association between marital status and health. The patriarchal cultural values and practices that characterize the Ghanaian society means that the relationship between marital status and health outcomes will be moderated by gender. Similarly, I argued that, although having more children is desirable and encouraged within the

Ghanaian setting, such a practice may lead to poor health since having many children comes with many financial and social obligations. This causes married couples with

106 many children to have poor health compared to their other married counterparts with fewer children.

Finally, I examined how the association between marital status and health operates differently among patrilineal and matrilineal ethnic groups in Ghana. Existing studies found marriages among matrilineal ethnic groups in Ghana and sub-Saharan

Africa to be more unstable compared to patrilineal marriages. In addition, members of the conjugal family among matrilineal ethnic groups have been found not to pool resources together unlike their patrilineal counterparts. To the effect that married couples among matrilineal societies do not pool resources together and their marriages are unstable, it is reasonable to speculate that these couples, compared to their patrilineal counterparts, may not realize the health benefits associated with marriages. Based on the above discussions,

I have developed the following hypotheses:

Hypotheses

(1) Compared to the currently married, the never married will experience better

health similar or better health

(2) Compared to the formerly married (including divorced, separated, and

widowed), currently married persons will report better health.

(3) Financial satisfaction at the household level will mediate the relationship

between marital status and self-reported health with never-married persons

experiencing higher levels of financial satisfaction compared to the currently

and formerly married individuals.

(4) Living with parent and the presence of children will moderate the relationship

between marital status and self-reported health with never-married persons.

107 (5) Never-married men will experience better health than their female

counterparts.

(6) The dissolution of marriage will negatively affect both men and women

equally. Both formerly married men and women will report poor health (no

gender variation).

(7) Among the currently married couples having many children will be negatively

associated with poor health.

(8) Among matrilineal ethnic groups in Ghana, never married persons may

experience better health compared to currently married persons.

(9) Among patrilineal ethnic groups in Ghana, currently married persons will

experience better health when compared to their unmarried counterparts.

(10) The health of formerly married Ghanaians in both patrilineal and matrilineal

ethnic groups will be worse or lower than the health of currently and never

married Ghanaians.

Financial Satisfaction

Marital Status Health

Living with Parents

Children

Figure 1. Modeling the effects of marriage on health outcomes: Is marriage beneficial in Ghana? 108

Marital Status Health

Gender

Fig. 2. The moderation effect of gender: marriage, gender, and health.

Marital Status Health

Lineage Type

(Matrilineal/Patrilineal)

CHAPTER IV

Fig 3. The moderation effect of lineal ties: lineage type, marital status, and health.

109 CHAPTER IV

DATA AND METHODS

4.1 Introduction

This dissertation examined the relationship between marriage and family processes and health outcomes in Ghana. The study focus was on Ghana, a country in sub-Saharan Africa, where marriage and family is central to the people, yet it is not clear whether the pro-family ideology that prevails is linked to good health. Moreover, less attention has been given to whether the health benefits that are associated with marriage are also present or applicable in the context of developing countries bearing in mind cultural diversities between Western industrialized countries and developing countries such as Ghana.

In addressing these questions, this dissertation examined whether married people in Ghana are better off health wise than their unmarried counterparts. Second, the study assessed whether the relationship between marital status and the health of Ghanaians, if any, is moderated by gender. Here, the emphasis was on whether married men derive more health benefits from marriage than married women. Similarly, I intended to discover whether the status of the unmarried affect the health of men more than their female counterparts.

Third, the study sought to examine whether among the currently married, having children is negatively associated with poor health outcomes. Finally, the study examined

110 whether the association between marital status and health operates differently among matrilineal and patrilineal ethnic groups in Ghana.

4.2 Data and Sampling

The data for this study were drawn from the Ghanaian component of the 2011

World Value Surveys (www.worldvaluesurvey.org). The World Value Surveys (WVS) are conducted in many countries across the globe. The World Value Survey is a nationally representative survey conducted in almost 100 countries, which contain almost

90 percent of the world's population, using a questionnaire (WVS, 2016). The World

Values Survey Association is a nonprofit organization funded by various scientific foundations. WVS covers a wide variety of topic areas in any given survey, including questions on family relationships, gender, religion, quality of life, social networks, social values, economics, work, politics and government, the environment, health, social inequality, basic demographics, and many more. The surveys are coordinated by WVS

Executive Committee and funded by the Bank of Sweden Tercentennary Foundation.

Previous partners for the survey include several major international development agencies (including International IDEA), bilateral donors, government ministries in several countries, nonprofit foundations (the institute for Future Studies, Sweden), scientific research projects, as well as scientific foundations such as the National Science

Foundation and the German Science Foundation.

The usefulness of these data for this study is that it has detailed information on issues pertaining to health, religious beliefs and affiliations, marital status, socioeconomic class indicators (e.g., educational attainment, occupational class, proxy income), life satisfaction and happiness, gender inequality indicators, ethnic groups and regions in

111 Ghana, among other important measures. The 2011 Ghana WVS is the most recent and the second of such surveys in Ghana. The uniqueness about the World Value Survey

(WVS) dataset is that the survey uses a standard set of questions to solicit essential information from respondents across selected countries in Africa, Europe, Asia, North and South America. The major advantage in the use of standardized questionnaires is that it enables researchers to track and compare within and between variations among countries in sub-Saharan Africa and other countries in the world. Furthermore, these surveys have very high response rates. Based on the 2000 Ghana Population and Housing

Census, the 2011 Ghana WVS sampled 1,552 households (ages ranging from 18 and above) with a response rate of 90%. The nonresponse rate was attributed to frequent absences of respondents from their dwelling units. The WVS in Ghana used a clustered, stratified, multistage probability sampling design to select a representative sample of

Ghanaians aged 18 and over.

In the first stage, a random selection of sampling points was made based on the regional and district divisions. The approach of stratification of households by the regions of Ghana was used as a result of ensuring representation of all heterogeneity of objective social, economic, cultural, and other characteristics of the sampling units located in different geographic areas/regions of the country. At the same time, it ensured internal homogeneity of the aforementioned characteristics within each stratum. There are ten regions in Ghana, hence, the survey was first stratified by these ten regions. Within each region, the district/s in which the survey was conducted was selected by circular sampling

(PPS: Probability Proportion to Size). At the first stage of sampling procedure, clusters of households formed based on the sample frame were selected using SRS (simple random

112 sampling) method. Mostly, equal sized clusters of households were selected in each stratum. At the second stage of the sampling procedure, the secondary sampling unit, households in each already selected cluster, using the SRS method. In each selected household, the respondent was selected using the recent birthday method. In addition, the selection of respondents in each household unit was further stratified by gender. Only individuals who were 18 years or above were selected for the survey. The mode of data collection for Ghana WVS was face-to-face interview method. Interviews were conducted in English, Twi, Ga, Hausa, and Ewe. After the collection of the survey, the data were weighted to reflect the population distribution of Ghana.

4.3 Dependent Variable: Health Outcomes

Existing literature suggested that health is a multidimensional concept.

Researchers have defined health in a number of ways to include, for example the following: functional limitation, mortality, morbidity, depressive symptoms, unhealthy and risky behaviors such as smoking, alcohol consumption, obesity, and among others

(Carr and Springer 2010; Koball et al. 2010; Linda and Waite 2000; Manzoli et al. 2007).

While the use of multiple indicators of health is recommended, and arguably strengthens the findings of a research, the World Values Survey did not collect other objective (e.g.,

BMI, morbidity) health measures besides self-reported health. Hence, self-rated health is the key dependent variable used in the study. Although the use of self-reported health as a measure comes at a cost, such as possible response bias, findings from this study can advance our understanding about the association between marital status and health in

Ghana. I acknowledge that it did not capture all the dimensions of health that have been

113 alluded to in the literature (Manzoli et al. 2007; Rogers 1996). Unfortunately, I am constrained by the health measures available in the data.

Despite the limitations associated with the use of a single measure of health-for a concept that is multidimensional, use of this measure was relevant for several reasons.

First, prior research found some evidence that self-reported, especially self-rated health, is a powerful predictor of major health outcomes, such as functional limitations and mortality. Second, it has been observed that self-reported health would be particularly useful if respondents suffer from sub-health condition (i.e., a state between health and disease) or contested illnesses (i.e., claimed illnesses that are not recognized or acknowledged by physicians) (Schnittker and Bacak 2014).

In the WVS data, respondents were asked to rate their health on a four-point scale as follows: very good = 1, good = 2, fair = 3, and poor = 4. Responses to this question were reverse coded with the higher score implying better health.

4.4 Independent Variables

Measures of Marital Status

The main explanatory variable of interest in this research was the marital status of the respondents. Marital status was assessed with the question that asked the respondents to indicate their current marital status. In GWVS, respondents were asked to indicate their marital status: 1) married; 2) single/never married; 3) divorced/separated; and 4) widowed. Using these responses, I recoded them into three categories; (1) currently married; (2) never married, and (3) formerly married (comprised of divorced, separated and widowed), with currently married persons being the reference group. The small number of widows and divorced/separated respondents in the dataset coupled with the

114 fact that studies have shown that these groups of individuals have similar sociodemographic characteristics and also experience the effect of marital dissolution in a similar way (for more review see Amato 2000, Amato et al. 2005).

Mediating and Moderating Measures

The association between marital status and health outcomes within the Ghanaian setting as argued in the preceding chapters is likely to be influenced by cultural practices such as communalistic values, age at first marriage, and type of marital union

(monogamous or polygamous marriage). However, these measures were not present in the GWVS data. Therefore, I was unable to examine these contextual factors. The absence of these measures in the dataset by no means affect the outcomes of the study in any major way. Other relevant contextual measures such as ethnicity/lineage, significant attachment to childbearing, religiosity/religion, and attitude towards gender equality were present in the dataset.

(A) Living with parent at home:

To capture access to social support, integration, and other health benefits associated with living in a communalistic society such as Ghana, I used a variable in the

GWS data: living with parent at home. To the extent that the presence of elderly individuals or adults at the household was crucial in terms of providing social support, preventing against risky behaviors such as alcohol usage; using this measure was important since living with parents especially among the never-married in Ghana is not stigmatized as compared to their never-married counterparts in the Western developed countries. Respondents were asked to indicate whether they live with their parents or not.

A dummy variable was created of 1 = not living with parent and 2 = living with parent.

115 (B) Children:

Despite the fact that childbearing is not context specific, the socio-cultural context within which married couples make decisions concerning how many children to have are culturally determined. Since having children, especially many children, is associated with stress such as diminishing couples' state of happiness, increases in financial responsibilities of married couples, and domestic activities, I used this variable to capture how the presence of children will mediate the relationship between marital status and self-reported health.

Respondents were asked: "Have you had any children?" The responses to this question ranges from 0 = no children, 1 = 1 child, 2 = 2 children, 3 = 3 children, 4 = 4 children, 5 = 5 children, 6 = 6 children, 7 = 7 children, and 8 = 8 or more children. This measure was treated as a continuous variable.

(C) Satisfaction with household financial situation:

Considering how structural factors such as high unemployment rates, inflation, and high cost of living may affect the lives of Ghanaians in diverse ways (e.g., married versus unmarried), I attempted to use a variable to measure the extent to which people are satisfied with their financial situation. In other words, to capture how financial stress or economic hardship mediate the relationship between marital status and health of some individuals in Ghana, I used a variable in the dataset which asked respondents to answer the question: "How satisfied are you with the financial situation of your household?" The response to this question ranges from 1 = completely dissatisfied to 10= completely satisfied. For this question, I dichotomized the responses to determine whether respondents were either satisfied with their household financial situation or not. I did

116 reverse coding by assigning 1 = not satisfied with financial household situation and 2 = satisfied with financial household situation.

(D) Lineage/kinship type

With respect to lineage type, respondents were asked to indicate the ethnic group that they belong to. Although in Ghana, there are many ethnic groups, descent or lineal ties are traced mostly traced through the father (patrilineal) or the mother (matrilineal) line. The predominant kinship systems in Ghana are two – matrilineal and patrilineal. The main matrilineal ethnic group in Ghana are the Akans, whereas patrilineal ethnic groups include Ga, Ewe, Guans, Frafra and Krobos. A couple of ethnic groups representing 3.1% in the data set were discarded and set as missing because they were not categorized as either matrilineal or patrilineal. Excluding these from the analyses did not alter the results. Hence, kinship/lineage tie was categorized into 1 = matrilineal, 2 = patrilineal.

(E) Gender

Existing literature showed that gender influences the relationship between marital status and health. In a stratified and patriarchal society such as Ghana, examining how gender moderated the association between marital status and self-rated health was important and contributed toward a better understanding of gendered relations in the country. Gender is coded as "1" indicating female and "2" male.

4.5 Control Variables

(F) Socio-economic status indicators

In examining the relationship between marital status and health in Ghana, other theoretically relevant measures that have been found in previous studies to be associated

117 with health outcomes were also included in the analysis. They included socioeconomic status indicators such as education, subjective social class, and employment status.

With respect to education, respondents were asked to indicate the highest level of education they have attained. Responses range from 1 = No formal education, 2 =

Incomplete primary school, 3 = Complete primary school, 4 = Incomplete secondary school: technical/vocational type, 5 = Complete secondary school: technical/vocational type, 6 = Incomplete secondary school: university preparatory type, 7 = Complete secondary school: university preparatory type, 8 = some university level education- without degree, and 9 = University level-education with degree. The responses were recoded into four categories 0 = No education, 1 = Primary/elementary education

(combining "incomplete and complete primary" education), 2 = Secondary/High School

(combining "incomplete, complete secondary school: technical/vocational type" and

"incomplete and complete secondary school) and, and 3 = Post-secondary/college education (combining "some university level education-without degree and university level-education with degree").

Social class was operationalized as the subjective class status of the respondent.

The specific question asked: "People sometimes describe themselves as belonging to the working class, the middle class, or the upper or lower class. Would you describe yourself as belonging to any of the following: 1 = Upper class, 2 = Upper middle class, 3 = Lower middle class, 4 = Working class, and 5 = Lower class. This was recoded into four categories: 0 = Lower class, 1 =Upper class, 2 = Middle class (combining "upper middle and lower middle" class), and 3 = Working class.

118 Regarding employment status, respondents were asked to indicate their current employment status. Initial responses include the following: 1 = Full-time, 2 = Part-time,

3 = Self-employed, 4 = Retired, 5 = Housewife, 6 = Students, 7 = Unemployed, and 8 = other. I reassigned these responses into two main categories: 1 = not employed and 2 = employed with the latter constituting the combination of full-time, part-time, and self- employed, and the former comprising retired, housewife, students, unemployed, and other.

The age of respondents was treated as a continuous variable ranging from 18 to 82 years. To measure happiness, respondents were asked to respond to this question:

"Taking all things together, would you say you are: 1 = Very happy to 4 = Not all happy?" Responses to the original question was recoded into a binary value with: 1 = Not happy (including happy and rather happy) and 2 = happy (including not happy and not happy at all).

Other control variables used in the analysis include attendance to religious services, support for egalitarian beliefs, feeling secured at the community or neighborhood level, and ethnicity/kinship ties. With respect to religiosity, respondents were asked to indicate how often they attend religious services. The response to this question varies from 1 = More than once a week, 2 = Once a week, 3 = Once a month, 4

= Only on special holidays, 5 = Once a year, 6 = Less often, and 7 = Never. These seven responses were recoded into three categories: 1 = Regular attendance (combining more than once a week), 2 = Once a week, and 3 = Occasionally (combining once a month, only on special occasion, once a year, and less often).

119 Regarding attitude towards egalitarian beliefs, an index was constructed from the summation of five-item questions. Respondents were asked the following questions: 1 =

When a mother works for pay, the children suffer; 2 = On the whole, men make better political leaders than women do; 3 = A university education is more important for a boy than for a girl; 4 = On the whole, men make better business executives than women do, and 5 = Being a housewife is just fulfilling as working for pay. The responses to each of these questions include; 1 = Strongly Agree, 2 = Agree, 3 = Disagree and 4 = Strongly

Disagree. For each question item, I recoded the four responses into a dummy with 1 = support egalitarian beliefs (by combining "strongly disagree and disagree" responses) and 2 = do not support egalitarian beliefs (by combining "strongly agree and agree" responses).

Using the responses to these five question items, a conventional simple summed- score approach was used to create an index of supporting egalitarian beliefs. The result from the index is a continuous variable with a range of minimum and maximum values.

By this approach, higher values mean more support for egalitarian beliefs and vice-versa.

Cronbach's alpha reliability test were used to assess structural validity and internal consistency of items and how closely they are related when combined together. The reported 0.60 score observed was slightly lower than the minimum of 0.70 necessary to assess internal consistency or reliability of an item (Tavakol and Dennick 2013)

To measure respondents' perception of feeling security at the community level, they were asked: "Could you tell me how secure do you feel these days in your neighborhood"? The responses to the question ranges from 1 = Very secure, 2 = Quite secure, 3 = Not very secure, and 4 = Not at all secure. Here also, I recoded these four

120 response categories into a dummy with: 1 = Not feeling very secure (combining very secure and quiet secure) and 2 = Feeling secured (combining not very secure and not secure at all).

4.6 Strategy

In the first stage of the analysis, descriptive statistics were used to provide some summary information about the measures used in the analyses. Bivariate analysis was then performed to examine the association between self-rated health and marital status.

Additionally, in the bivariate analysis I employed a nonparametric method (Chi-square) to examine the relationship between marriage and self-reported health. This test (Chi- square) was used to examine whether there is a relationship between the dependent variable (in this case SRH) and key independent variables such as marital status, financial satisfaction, and living with parent.

Given that the dependent variable has ordered outcomes, in the third level of analysis, I employed a cumulative logit model for the third level of analysis. The cumulative logit model rests on the assumption that the ordinal-level variable being analyzed is the observed form of the latent variable that is actually continuous (Warner

2013). The uniqueness of this analytical strategy has to do with the fact that instead of considering the probability of an individual even (such as in the case of binary logistic regression), it estimates the probability of that event and all events that are ordered before it (Agresti and Finlay 2009; Warner 2013). I estimated the odds of a respondent reporting being in the higher categories of self-rated health (better health) than being in the lower categories of self-rated health (poor health). Thus, the model helped to estimate the influence of being married on self-rated health while simultaneously controlling for other

121 measurable factors associated with health. The specific equations estimated take the following form:

ln (pi/(1-pi) = β0 + β1X1 + β2X2 + ...... + βkXk where pi is the estimated probability of a particular event happening to an individual with a given set of characteristics X1; β0 is a constant that defines the probability pi for an individual with all X1 parameters set to zero; β are the estimated coefficients (Addai et al.

2015). The ratio pi/[1-pi] is the odds of respondents with a given characteristics reporting better versus worse subjective wellbeing, measured through self-rated health. The estimate of βi for a particular covariate X1 is interpreted as the difference in the predicted log odds between those who fall within that category of characteristics and those who fall within the reference group or omitted characteristic (Addai et al. 2015). If each estimated bi is exponentiated (Exp[bi]), the result can be interpreted as giving the relative odds of having better self-rated health for those individuals with characteristic Xi, relative to those individuals in the reference group.

In the first level of analysis, five separate models were estimated. The first examined the effect of marital status (total effect) alone on self-rated health. In the second, third, and fourth model, each of the three mediating variables (financial satisfaction-model 2, children-model 3, and living with parent-model 4) were added separately to determine whether the introduction of these variables diminishes/minimizes or changes the association between marital status and self-rated health. In the final model

5, I controlled for other variables. Using the same data, the second set of analyses examined the moderating effect of gender. In this multivariate analysis, three models were estimated. The first model examined the effect of marital status on self-rated health

122 and gender. In the second equation, I added the interaction terms (gender and marital status) to examine whether the effect of marriage on self-rated health vary by gender or not. In the final model, I controlled for other relevant variables.

The second level of analysis was restricted to only currently married individuals.

The reason for restricting the data to married respondents was to examine how the presence of children (especially having many children) affected the health of married persons considering the cultural significance of children in Ghana as well as the economic issues associated with raising children. Thus, are married persons with fewer children better off in terms of self-rated health compared to their counterparts with many children? Four separate analyses were estimated. In the first model, I estimated the effect of children on self-rated health among married respondents. In the second and third models, financial satisfaction and gender were introduced into the equation. In the fourth model, I controlled for all other variables.

For the final analysis, respondents were categorized into either belonging to matrilineal or patrilineal descent based on their ethnic affiliation. Separate analyses were conducted for patrilineal and matrilineal ethnic groups in Ghana, respectively, to ascertain the extent to which the effect of marital status and health varied by lineage/kinship type. In each set of analyses, two models/equations were estimated. In the first mode, I estimated the effect of marital status on self-rated health, and in the final model I controlled for all other variables. Alpha was set at 0.05 level.

Before the analyses, preliminary diagnostic runs were conducted. For example, missing data and outliers were examined prior to the analysis, and it showed that the dataset did not have any outliers that may have influenced the findings. In addition, the

123 number of missing cases in the data was very minimal and insignificant. Finally, multi- collinearity was carefully explored. To assess the tolerance levels of the variables used in the models as appropriate (tolerance >.2), I carefully examined multi-collinearity.

Interestingly, none of the independent variables was highly related or correlated with one another.

4.7 Summary and Conclusion

This chapter described the dataset and methodological strategies used in this dissertation. As indicated earlier, the data came from the 2011 Ghana component of the

World Value Survey (WVS 2016), a well-known survey that has been conducted in about

100 countries all over the world since 1981.

The Ghana survey is a nationally representative sample which relied on a clustered, stratified, multistage probability sampling design to select those sampled-adults aged 18 and over. The variables used in this study were measured to capture some salient cultural values and practices in Ghana. Also, special emphasis was placed on some mediating/moderating variables such as financial satisfaction, presence of children, living with parents at home, and other equally important variables. The final section of this chapter was devoted to statistical and analytical strategies including descriptive distribution tables, Chi-square test, and cumulative logit models. The next chapter discusses the results obtained from applying the statistical strategies.

124 CHAPTER V

RESULTS

5.1 Introduction

This chapter presents the results from the analyses on marital status and health outcomes in Ghana. The chapter is organized into three section. First, I provide descriptive analyses about the variables used in the study. Second, I present findings from the bivariate analyses. Finally, multivariate models, specifically cumulative logit model techniques are used to examine the interconnection between marital status and health in

Ghana.

5.2 Descriptive Statistics

Table 1 presents descriptive statistics on the characteristics of the respondents by their marital status. As can be seen, equal numbers of men (50.3%) and women (49.7%) were surveyed. However, Table 1 also shows that in contrast to their married counterparts, the never-married respondents tended to be more men (60.1%) than women

(39.9%). Conversely, the results on Table 1 shows that Ghanaian women were more likely to be married (57.4%) compared to their male counterparts (42.6%). Also, the currently (37 years) and formerly married (46 years) respondents tended to be older than the never-married (24 years). Furthermore, it appears there are some socioeconomic differences among the different marital statuses. Regarding their educational attainment, it is evident that the never-married reported higher levels of education than their married

125 counterparts. For example, while 16.7% of the never-married reported a postsecondary education, only 6.9% and 3.9% of currently and the formerly married reported a postsecondary education.

In terms of their class status, 6.4% of the unmarried respondents self-identified as upper class, compared to the 2.9% for the currently married, and 1% for the formerly married. Also, nearly half (49%) of the never-married self-identified as middle class. In contrast, only 43% and 37.3% of current and formerly married respondents said they were in the middle class, respectively. Also, compared to the never-married (18.7%) who self-identified as belonging to lower class, majority of formerly married (30.4%) and currently married (23%) respondents said they were in the lower class.

Considering the mediating variables, the majority of never-married respondents

(46%) indicated they were financially satisfied with their household income compared to only 30% of formerly and 37% of currently married respondents. Table 1 also shows that both currently formerly married (12.7%) and married respondents (17%) were least likely to stay with their parents unlike their never-married counterparts (64.5%). As expected, formerly married (98%) and currently married (85%) of Ghanaians indicated they have at least a child. Regarding their sense of safety at the community level and feelings of happiness, four out of every five – regardless of their marital status – said they were happy of their situation. The respondents were generally happy with their lives as Table 1 shows. Similarly, very few differences existed among the groups regarding regular church attendance. Over a sizable proportion of those surveyed belonged to matrilineal

(60.3%) societies, with the married (current and previous) more likely to identify as such than their never-married counterparts.

126 Table 1

Summary Information on Variables Used in the Study: 2011 Ghana World Value Survey

Table 1: Summary Information on Variables Used in the Study: 2011 Ghana World Value Survey MARITAL STATUS Currently Never Formerly Married Married Married All Gender Male 42.6 60.1 29.4 50.3 Female 57.4 39.9 70.6 49.7 Age 36.6 23.6 45.5 30.9 Educational Status of Respondents No Education 11.8 1.5 14.7 7 Primary 48.1 27.9 51 38.5 Secondary 33.2 53.9 30.4 43.1 Post-Secondary 6.9 16.7 3.9 11.5 Subjective Social Class of Respondents Upper-Class 2.9 6.4 1 4.4 Middle-Class 43 48.9 37.3 45.5 Working-Class 31.1 26.1 31.4 28.7 Lower-Class 23 18.7 30.4 21.4 Employed (1=Yes) 74.5 45.3 72.5 60.2 Chronic Stress/Strain Financially Satisfied (1=Yes) 37.8 46 29.4 41.2 Having one or more children at home 84.9 14 98 51.6 Live with Parent 17.1 64.5 12.7 39.9 Feeling of Happiness (1=Yes) 80.4 84.4 83.3 82.5 Sources of Social Support Attendance to Religious Services Regular 49 47.6 47.1 48.2 Once a week 30.4 31.7 32.4 31.2 Occasionally 20.6 20.6 20.6 20.6 Feeling Secured at the Community level (1=Yes) 86 86.1 87.3 86.1 Not Subscribing to gender inequality beliefs (1=Yes) 92.4 93.6 95.1 93.2 Ethnicity Matrilineal 60.5 63.4 53.5 61.4 Patrilineal 39.5 36.6 46.5 38.6

127 5.3 Patrilineal and Matrilineal Comparisons

Table 2 presents descriptive statistics on the characteristics of patrilineal ethnic group respondents by their marital status. Table 2 shows that a disproportionate number of men are single (65%) compared to 36% reported for women. Also, a disproportionate number of women have either divorced or lost their partner through death (75%) compared to 25% of their male counterparts. With respect to educational attainment of respondents, almost 22% of never-married respondents have post-secondary or college education unlike their currently married (8%) and formerly married (2.1%). Similarly, a higher proportion of never-married respondents have some form of secondary education.

Regarding respondents' class status, 41% of the never-married self-identified as middle class, compared to the 36% for the currently married, and 30% for the formerly married.

In addition, compared to the never-married (23%) who self-identified as belonging to lower class, majority of formerly married (30%) and currently married (27%) respondents said they were in the lower class. Furthermore, the majority of never-married respondents

(46%) indicated they were financially satisfied with their household income compared to only 34% of formerly and 38% of currently married respondents. Table 2 also shows that currently formerly married (21%) and married respondents (20%) were least likely to stay with their parents unlike their never-married counterparts (68%).

128 Table 2

Descriptive Characteristics of Patrilineal Ethnic Groups in Ghana

Table 2: Descriptive Characteristics of Patrilineal Ethnic Groups in Ghana Currently Never Formerly Married Married Married N Gender Male 42.8 65.4 25.5 301 Female 57.2 34.6 74.5 279 Age 37.5 23.6 43 580 Educational Status of Respondents No Education 19.7 3 10.6 65 Primary 45.8 27.1 53.2 219 Secondary 25.8 48 34 213 Post-Secondary 8.7 21.9 2.1 83 Subjective Social Class of Respondents Upper-Class 3.4 4.1 0 20 Middle-Class 36 41.3 29.8 220 Working-Class 33.7 32 40.4 194 Lower-Class 26.9 22.7 29.8 146 Employed (1=Yes) 70.1 44.2 59.6 332 Chronic Stress/Strain Financially Satisfied (1=Yes) 37.5 45.7 34 238 Having one or more children at home 84.5 0 97.9 269 Live with Parent 20.5 68 21.3 247 Feeling of Happiness (1=Yes) 83 85.1 87.2 489 Sources of Social Support Attendance to Religious Services Regular 45.8 50 46.8 274 Once a week 22.1 29.5 319 151 Occasionally 32.1 20.5 21.3 148 Feeling Secured at the Community level (1=Yes) 87.5 85.9 85.1 502 Not Subcribing to gender inequality beliefs (1=Yes) 97.3 95.5 93.6 558 Total 264 269 47 580

Similar to Table 2, Table 3 shows some characteristics of matrilineal ethnic groups in Ghana. It can be seen from Table 3 that a disproportionate number of men reported being single (57%) similar to the results among patrilineal ethnic groups. For 129 women, the comparative figure is 43%. Similarly, a higher proportion of women have divorced or lost their spouse through death (69%). Almost half of the respondents (50%) who are currently and formerly married have primary education compared to only 28% of their never-married counterparts. On the contrary, about 57% of never-married respondents have secondary education compared to 28% of formerly and 37% of currently married respondents.

With respect to social class, about 7% of never-married respondents self- identified as upper class compared to 2% of formerly and 2.7% of currently married. In addition, about 48% of currently married identify themselves as belonging to the middle class compared to 54% of their never-married counterparts. Similarly, a high proportion of formerly married respondents (32%) belong to the lower class compared to 19% of currently and 17% of never-married counterparts. For employment status, about 83% of formerly married respondents are employed compared to 78% of currently married.

Furthermore, about 46% of never-married respondents claimed to be satisfied with their financial situation compared to 39% of currently and 26% of formerly married counterparts.

130 Table 3

Descriptive Characteristics of Matrilineal Ethnic Groups in Ghana

Table 3 Descriptive Characteristics of Matrilineal Ethnic Groups in Ghana Currently Never Formerly Married Married Married N Gender Male 41.7 56.8 31.5 450 Female 58.3 43.2 68.5 474 Age 36.3 23.7 47.6 924 Educational Status of Respondents No Education 6.4 0.6 16.7 38 Primary 50.4 28.2 50 362 Secondary 37.3 57.2 27.8 432 Post-Secondary 5.9 14 5.6 92 Subjective Social Class of Respondents Upper-Class 2.7 7.3 1.9 46 Middle-Class 48.1 54 42.6 469 Working-Class 29.9 22.2 24.1 237 Lower-Class 19.3 16.6 31.5 172 Chronic Stress/Strain Financially Satisfied (1=Yes) 38.5 46 25.9 384 Having one or more children at home 85.9 0 98.1 401 Live with Parent 14.1 63 5.6 353 Feeling of Happiness (1=Yes) 79.3 84.5 79.6 757 Sources of Social Support Attendance to Religious Services Regular 50.9 45.1 46.3 433 Once a week 36 33.7 33.3 315 Occasionally 13.1 21.2 20.4 160 Feeling Secured at the Community level (1=Yes) 85.2 86.2 88.9 794 Not Subscribing to gender inequality beliefs (1=Yes)89.4 92.9 96.3 846 Total 405 465 54 924

5.4 Bivariate Associations: Health and Marital Status

Figure 4 reports variations in self-reported health across the three marital statuses.

As can be seen from Figure 4, there is a significant association between marital status and

131 self-reported health (p < .001) as the existing literature suggested. However, and in contrast to what has been observed with data from mostly the developed world such as the United States, it was the never-married respondents in Ghana who reported good health rather than their married counterparts. For example, while 58.5% of the never- married respondents rated their health as very good, the comparative figures for the currently and formerly married were 48.8% and 34.5%, respectively. Also, the proportion of never-married Ghanaians who reported their health as poor was lower (1.6%) than currently married (2.6%) and formerly married (6.9%) counterparts. The same pattern is discernible when I combined the results for those who reported good and very good health.

Figure 4. Marital status and self-reported health.

132 Despite the fact that Figure 4 shows an association between marital status and health, some previous studies have suggested that the observed health benefits of marriage varies by gender. In Figure 5, I examined the effect of marital status on one hand and gender on the other on self-reported health.

Consistent with the previous findings in Figure 4, once more I observed that the respondents who reported good health tended to be the unmarried, especially the never- married men (93.2%). This figure includes those who reported good and very good rather than the currently married men (88.5%), or the formerly married (80%). Similar to the findings on men, the number of never-married women who viewed their health as quite good (88.7%) was higher than those reported by the currently (86.5%), and the formerly married (77.8%) women. Comparing the formerly married men and women to their currently married counterparts (both males and females), though, I found the currently married to report higher levels of good health.

Figure 5: Gender, Marital Status and Self Reported Health 100% 80% 60% 40% 20% 0%

Poor Fair Good Very Good

Figure 5. Gender, marital status, and self-reported health.

133 Table 4 shows bivariate associations between self-rated health and the three mediating variables namely financial satisfaction at the household level, living with parent, and presence of children. The results do show a strong association between self- rated health and some of the mediating variables. For example, the data reveal that a higher percentage of respondents who indicated that they were satisfied with their financial situation reported having very good health (58.4%) compared to their counterparts who were not satisfied with their financial situation (48.5%). There is a gap of almost 10% between respondents who are financially satisfied with their income and those who are not with respect to self-rated health. At the same time, a lower proportion of Ghanaians who were financially satisfied with their household income reported poor health (1.4%) compared to 3.1% of those who were not satisfied with their financial situation. Similarly, a higher percentage of respondents who stay with their parents at home indicated having very good health (56.4%) as compared to those who do not live their parents (50.1%). In addition, a comparatively lower percentage of respondents with children reported having very good health (47.1%). On the contrary, a higher percentage of respondents who do not have children reported very good health (58.5%).

134 Table 4

Bivariate Relationship Between SRH and Mediating Variables

Table 4: Bivariate Relationship between SRH and Mediating Variables Self-Rated Health Variables Poor Fair Good Very Good x2 (df) P value n Satisfied with financial Situation Yes 1.40% 5.20% 35% 58.40% 28.96 (3) 0.001 1552 No 3.10% 11.50% 37% 48.50%

Live with Parent Yes 1.50% 7.60% 34.60% 56.40% 9.23 (3) 0.023 1552 No 3.00% 9.80% 37.20% 50.10%

Have Children Yes 3.10% 11.20% 38.60% 47.10% 26.27 (3) 0.001 1552 No 1.60% 6.40% 33.60% 58.50% Sample Size (n=1552) *** p < .001, ** p < .01, *p<.05, + p<.10

5.5 Multivariate Modeling: Marriage and Health in Ghana

After examining the bivariate association between marital status and self-reported health, I now examined the relative contributions of marital status and relevant controls in our understanding of self-reported health in Ghana. Using a series of multiple logistic regression models, the results are reported in Tables 5-9. Table 5 shows a summary of the findings from the various regression models of the relationship between marriage, gender, children, lineage, and health among Ghanaians. The first model estimates the baseline model which examined the total effect of marital status on self-reported health

(Model 1) alone. I then added the mediating variables one after the other to examine the relative effect of financial satisfaction at the household level, presence of children, and living with parents on the association between marital status and health outcomes. After that, I included all other relevant covariates in the models (Model 5).

135 Consistent with the previous observations, Table 5 (Model 1) shows that the odds of reporting better health are 1.49 times higher among never-married respondents compared to their married counterparts. This is statistically significant at 0.05 level (OR

= 1.49; p = .001). This means that compared to the currently married, the never-married tend to report better health without controlling for other variables.

While the never-married were more likely to experience good health in comparison to the currently married, this is not the case for formerly married respondents. Thus, the odds of reporting better self-rated health are 47 percent lower among formerly married Ghanaians compared to their currently married counterparts (OR

= 0.53, p = .001). Such a finding implies that the currently married respondents are more likely to experience higher levels of good health when compared to their formerly married counterparts, an observation that is consistent with what has been found in the existing literature.

The introduction of financial satisfaction (a mediating variable) in Model 2 slightly altered the association between marital status and health. For instance, controlling for financial satisfaction at the household level, the odds of experiencing better health are 45 percent higher among the never-married compared to the currently married (Model 2; OR = 1.45, p = .001). Conversely, the odds of reporting better health are 45 percent lower among the never-married compared to their currently married counterparts (OR = 0.55, p= .001). Also, the likelihood of having better health is 35% lower among people who are not satisfied with their financial situation (OR = 0.65, p =

.001). This result shows that financial or economic issues partly mediate the relationship between marital status and self-rated health among Ghanaians as I suggested above.

136 Similarly, the introduction of another mediating variable (presence of children) in

Model 3 showed some interesting findings. Controlling for children, the odds of experiencing better health instead of poor health are 1.2 times higher among never - married respondents compared to their never-married counterparts (OR = 1.22, p = .09).

The magnitude or strength of the relationship between the currently and never-married with respect to self-rated health decreased for the latter group. Thus, the presence of children improves the health of the currently married relative to their never-married counterparts. Additionally, compared to the currently married, the odds of reporting better health are 41 percent lower among formerly married respondents (OR = 0.59, p =

.04). However, the results also show that having many children (Model 3) decreases the odds of reporting better self-rated health (OR = 0.93, p = .03). Financial satisfaction at the household level was still strongly associated with self-rated health with respondents who are not satisfied with their financial situation having lower (34%) odds of reporting better health.

The introduction of the third mediating variable (living with parent) slightly changed the effect of marital status on self-rated health as found in the earlier Model 3.

Contrary to the bivariate analyses that showed that living with parent is associated with self-rated health, living with parent was not predictive of health in the cumulative logit analyses. Although the odds of experiencing better health are 1% lower among individuals who do not live with their parents, this was not statistically significant at 0.05 level (OR = 0.99, p = .917). The relative advantage of the currently married over the formerly married is still statistically significant at 0.05 level. Thus, the odds of reporting better health are 43 percent lower among the formerly married when compared to their

137 currently married counterparts (OR = 0.57, p = .04). In Model 4, both financial satisfaction and having many children are associated with self-rated health with

Ghanaians who are satisfied with their financial situation than those having less number of children reporting better self-rated health.

Findings from the full model (Model 5) that include the other covariates reveal some interesting findings. Controlling for factors such as state of happiness, age, gender, support for egalitarian beliefs, socio-economic status, feeling secured at the community level, and kinship ties, I found that the effect of marriage on self-reported health is still significant and positive only between married and formerly married and not for never- married persons. For example, compared to the currently married, the odds of reporting better are 30 percent lower among the formerly married (OR = 0.70, p =. 10). This suggests that controlling for other important variables, the currently married reported better health than the formerly married. However, there were no significant differences between currently married and the never-married with respect to self-reported health.

These results confirm my hypotheses that (1) there is no difference between currently and never-married people with respect to self-rated health, and (2) currently married people will report better health compared to their formerly married counterparts.

A surprising finding is the net effect of children on the subjective health of

Ghanaians. Whereas in the previous models, presence of children was negatively associated with poor health, this negative relationship was reversed in the final model when other variables were controlled. The data show that the odds of experiencing better health are 1.1 times higher among individuals with many children (OR = 1.09, p = .04).

This finding underscores the benefits of having many children in the sociocultural context

138 of Ghana irrespective of the financial cost associated with children as found in the

Western literature. The result also means that the relevant control variables reveal the true effect of children on self-rated health.

Besides the main effect of marriage, other variables that were strongly linked to positive health outcomes include employment status, educational attainment, age, feeling of happiness, sense of safety at the community level, not subscribing to gender inequality beliefs, and the respondent’s ethnic ties (patrilineal or matrilineal). Regarding employment status, for instance, the odds of being in the higher categories of self-rated health are 34 percent lower among unemployed respondents compared to those who are employed (OR = 0.66, p = .001). Ghanaians who professed not to be happy are about

67% less likely to report better health compared to those who are happy. Furthermore, the probability of experiencing better self-rated health is approximately 1.1 times higher for

Ghanaians who support egalitarian beliefs (OR = 1.12, p = .004). The data reveal that ethnicity or lineage ties are strongly associated with self-rated health. For instance,

Ghanaians who identified themselves as belonging to matrilineal ethnic group (e.g.,

Akans) are 1.5 times more likely to report better self-rated health compared to their counterparts who are patrilineal (OR = 1.48, p = .001). Finally, age was also strongly and negatively associated with self-rated health. For example, the odds of experiencing better self-rated decrease by about 4% as age increases (OR = 0.96, p = .001).

139 Table 5

Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated

Health, Ghana 2011 (N = 1552)

Table 5: Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated Health, Ghana 2011 (N=1552) Model 1 Model 2 Model 3 Model 4 Model 5 Coef. OR Coef. OR Coef. OR Coef. OR Coef. OR Marital Status Never Married 0.40 1.49 *** 0.37 1.45 *** 0.20 1.22 + 0.19 1.21 0.02 1.02 Formerly Married -0.63 0.53 *** -0.60 0.55 *** -0.53 0.59 ** -0.56 0.57 ** -0.35 0.70 + Ref: (Currently Married)

Socio-economic Status Not financially satisfied (Yes=1) -0.43 0.65 *** -0.42 0.66 *** -0.42 0.66 *** -0.19 0.83 + Ref: (Financially satisfied) Employment status (Not employed=1) -0.41 0.66 *** Ref: (Employed)

Subjective Social Class Upper Class 0.45 1.57 Middle Class 0.23 1.26 + Working Class 0.24 1.27 Ref: (Lower Class)

Educational Attainment Primary Education 0.17 1.19 Secondary Education 0.33 1.39 Post-Secondary/College 0.53 1.70 * Ref: (No Formal Education)

Chronic Strain/Stress Children -0.07 0.93 * -0.07 0.93 * 0.09 1.09 * Not living with parent (Yes=1) -0.01 0.99 -0.03 0.97 Ref: (Living with Parent)

Socio-demographics Female -0.22 0.80 * Age -0 0.96 ***

Sources of Social Support Attendance to Religious Services Regular 0.05 1.05 Once a Week -0.03 0.97 Ref: (Occasional)

Not feeling secured at the community level (Yes=1) -0.28 0.76 * Ref: (Feeling secured) Not Subscribing to gender inequality beliefs 0.11 1.12 **

Happiness (Not feeling happy; Yes=1) -1.11 0.33 *** Ref: (Feeling happy) Ethnicity Matrilineal 0.39 1.48 *** Ref: (Patrilineal)

Intercept 1 -3.37 *** -3.65 *** -3.71 *** -3.72 *** -6.35 *** Intercept 2 -1.71 *** -1.99 *** -2.04 *** -2.04 *** -4.62 *** Intercept 3 0.28 .020 -0.03 -0.03 -2.43 ***

Cox and Snell 0.022 .033 .036 0.036 0.132

*** p < .001, ** p < .01, *p<.05, + p<.10

140 5.6 The Moderation Effect of Gender: Marriage, Gender, and Health

Given the assertion that the benefits of marriage on health vary by gender, Table 6 shows the moderating effect of gender on the relationship between marriage and self- rated health. As can be seen from Table 6 Model-1, marital status is associated with self- rate health as previously found in the earlier analyses. However, gender is not a predictor of health at least in the first model. The odds of reporting better health are 54 percent high among the never-married compared to the currently married. This is statistically significant at the 0.05 level (OR = 1.46, p = 0.001). For gender, although the odds of reporting better health are 14 percent lower among women compared to men, this association was not statistically significant at 0.05 level (OR = 0.86, p = .141). Model 2

(Table 6) shows the effect of gender, marital status, and the interaction terms (marital status X gender) on self-rated health. The data show that the effect of marital status on health did not vary by gender. For instance, although the odds of being in the higher categories of self-rated health are 22 percent lower among never-married women compared to never-married men, this is not statistically significant at 0.05 level (OR =

0.78, p = .228). Similarly, the odds of reporting better health are 21% lower among formerly married women compared to their male counterparts. This association is not statistically significant at 0.05 level (OR = 0.79, p = .597).

The introduction of other covariates in the final Model 3 (Table 6) such as demographic characteristics, socio-economic status, state of happiness, support for egalitarian beliefs, and lineage type shows that marriage is somewhat beneficial to health especially when the health of the formerly married is compared to the health of the currently married (OR = 0.68, p = 0.08). Furthermore, controlling for these covariates did

141 not improve or change the effect of the interaction terms (marital X gender). Thus, there is no significant difference between formerly married men and women with respect to the detrimental effect of marital dissolution. Such an observation supports my hypothesis that marital instability or dissolution of marriage may affect both men and women the same way. However, the hypothesis that never-married Ghanaians will experience poor self- rated health when compared to their male counterparts was not supported.

Other relevant variables which are related to self-rated health include age, employment status, educational attainment, support for egalitarian beliefs, presence of children, lineage ties, and among others. For instance, the odds of experiencing better health are 1.7 times higher among respondents with college education compared to those with no formal education (OR = 1.73, p = .04). The odds of reporting better self-rated health are 25 percent lower among Ghanaians who do not feel secured at their community compared to those who feel more secured (OR = 0.75, p = 0.05).

142 Table 6

Summary of Ordered Logistic Regression Estimates for Variables Predicting the Effect of

Gender on Self-Rated Health, Ghana 2011 (N = 1552)

Table 6: Summary of Ordered Logistic Regression Estimates for Variables Predicting the effect of Gender on Self-Rated Health, Ghana 2011 (N=1552) Model 1 Model 2 Model 3 Coef. OR Coef. OR Coef. OR Marital Status Never Married 0.38 1.46 *** 0.22 1.25 ** 0.11 1.12 Formerly Married -0.61 0.54 *** -0.65 0.52 ** -0.39 0.68 + Ref: (Currently Married) Female -0.15 0.86 -0.02 0.98 -0.09 0.91 Interaction Effect Female X Never Married -0.25 0.78 -0.25 0.78 Female X Formerly Married -0.23 0.79 -0.07 0.93 Socio-economic Status Not financially satisfied (Yes=1) -0.43 0.65 *** -0.19 0.83 + Ref: (Financially satisfied) Employment status (Not employed=1) -0.41 0.66 *** Subjective Social Class Upper Class 0.44 1.55 Middle Class 0.23 1.26 Working Class 0.24 1.27 Ref: (Lower Class) Educational Attainment Primary Education 0.18 1.19 Secondary Education 0.35 1.42 Post-Secondary/College 0.55 1.73 * Ref: (No Formal Education) Chronic Strain/Stress Children 0.09 1.10 * Not Living with parent (Yes=1) -0.04 0.96 Ref: (living with parent) Age -0.04 0.96 *** Sources of Social Support Attendance to Religious Services Regular 0.05 1.05 Once a Week -0.03 0.97 Ref: (Occasional) Not feeling secured at the community level (Yes=1) -0.29 0.75 * Ref: (feeling secured) Not Subscribing to gender inequality beliefs 0.11 1.12 ** Happiness (Not happy=1) -1.11 0.33 *** Ref: (feeing happy) Ethnicity Matrilineal 0.39 1.48 *** Intercept 1 -3.45 *** -3.65 *** -3.71 *** Intercept 2 -1.79 *** -1.99 *** -2.04 *** Intercept 3 0.20 .020 -0.03 Cox and Snell 0.023 .024 .036 *** p < .001, ** p < .01, *p<.05, + p<.10

143 5.7 The Children Effect: Marriage, Children, and Health in Ghana

Table 7 gives a summary of findings after carrying out multiple regression analyses in the association between children and self-rated health among currently married people only. The table (Model 1) shows that having more children lowers the odds of reporting better health by about 6 percent (OR = 0.94, p = .09). In other words, as the number of children increases, the health of parents diminishes. In Model-2 (Table 7), the results show that controlling for financial satisfaction, the odds of reporting better health decrease by about 6 percent as the number of children increases (OR = 0.94, p =

.09). With regards to financial satisfaction, the data indicate that the odds of experiencing better health are 34 percent lower among married people who are not satisfied with their financial situation (OR = 0.66, p = .01).

The results on Table 7 (Model 3) show that gender is not predictive of self-rated health among Ghanaians who are married (OR = 0.96, p = .77). Thus, although the odds of reporting better health are 4 percent lower among married women, this relationship was not statistically significant at 0.05 level (OR = 0.96, p = .98). Also, controlling for gender did not alter the effect of children on the health of married Ghanaians. For example, the odds of experiencing better self-rate health decrease by about 6 percent as the number of children increases (OR = 0.94, p = .08). The effect of children on the health of currently married respondents in Model-3 is equivalent to the effect of children in Model-2.

Model 4 (Table 7) provides the results for the full model where other relevant variables were controlled. The results are somehow consistent with the output provided in

Table 5. The analyses show that the control variables in Model 4 (Table 7) suppressed or

144 revealed the actual effect of children on the health of married Ghanaians.4 Whereas the effect of children in the previous models showed a negative effect on self-rated health, when other important covariates were controlled, the negative effect changed to positive.

That is, in Model 4 (Table 7), the odds of experiencing better self-rated health are 1.1 times higher as the number of children increases (OR = 1.09, p = .05). This finding implies that as the presence of children increases, the health of their parent increases as well. This result contradicts existing studies that are mostly from Western industrialized countries (Ross et al. 19990). This may signify the significant attachment that children have in the lives of Ghanaians and people living in sub-Saharan Africa as a whole. Other important variables, which are associated with positive self-rated health among currently married Ghanaians include support for egalitarian beliefs, educational attainment, feeling of happiness, age, and feeling secured at the community level. For example, the odds of reporting better are 2.2 times higher among married people with college education compared to those without formal education (OR = 2.20, p = .04). Currently married respondents who professed not to be happy are about 31 percent less likely to report better health compared to those who are happy (OR = 0.31, p = .001). In this analysis, age was also strongly associated with self-rated health with the odds of reporting better health decreasing by about 3 percent as respondents' age increases (OR = 0.97, p = .001).

4 The true strength or relationship between presence of children and self-rated health becomes more apparent only when the suppressing variables (e.g., age, SES) are controlled for (see Warner 2013). 145 Table 7

Summary of Ordered Logistic Regression Estimates for Variables Predicting the Effect of

Children on Couples, Ghana 2011

Table 7: Summary of Ordered Logistic Regression Estimates for Variables Predicting the effect of Children on Couples, Ghana 2011 Model 1 Model 2 Model 3 Model 4 Coef. OR Coef. OR Coef. OR Coef. OR

Children -0.06 0.94 + -0.06 0.94 + -0.06 0.94 + 0.09 1.09 * Female -0.04 0.96 -0.07 0.93 Socio-economic Status Not financial satisfaction (Yes=1) -0.41 0.66 ** -0.41 0.66 *** -0.19 0.83 Ref: (Financially satisfied) Employment status (Not employed; Yes=1) -0.23 0.79 Ref: (Employed) Subjective Social Class Upper Class 0.29 1.34 Middle Class 0.25 1.28 Working Class 0.19 1.21 Ref: (Lower Class) Educational Attainment Primary Education 0.24 1.27 Secondary Education 0.44 1.55 Post-Secondary/College 0.79 2.20 * Ref: (No Formal Education)

Chronic Strain/Stress Not living with parent (Yes=1) -0.05 0.95 Ref: (living with parent) Age -0.03 0.97 *** Sources of Social Support Attendance to Religious Services Regular 0.06 1.06 Once a Week 0.26 1.29 Ref: (Occasional)

Not feeling secured at the community level (Yes=1) -0.39 0.68 + Ref: (feeling secured) Not Subscribing to gender inequality beliefs 0.14 1.15 * Happiness (Not feeling happy; Yes=1) -1.16 0.31 *** Ref: (feeling happy) Ethnicity Matrilineal 0.15 1.16 Ref: (Patrilineal)

Intercept 1 -3.80 *** -4.06 *** -4.09 *** -6.86 *** Intercept 2 -2.10 *** -2.35 *** -2.38 *** -5.12 *** Intercept 3 -0.11 -.350 * -0.38 * -2.93 *** Cox and Snell 0.004 0.015 .015 0.124 *** p < .001, ** p < .01, *p<.05, + p<.10

146 5.8 Examining the Effect of Lineage Ties, Marital Status, and Health Outcomes

Table 8 provides a summary of findings on the association between marital status and self-rated health among patrilineal ethnic groups in Ghana. The analyses indicate that there is a significant difference between Ghanaians who are married and those who are single with respect to self-rated health. From Table 8 (Model1), the results show that the odds of reporting better health are 1.2 times higher among never-married respondents compared to their currently married counterparts. This relationship is statistically significant (OR = 1.23, p = .05). Conversely and consistent with the hypothesis that among patrilineal ethnic groups in Ghana, formerly married individuals will experience poor health relative to their currently married counterparts. The data in Table 8 Model 1 show that the odds of experiencing better health are 39 percent lower among formerly married respondents compared to the currently married (OR = 0.61, p = .08).

In the final Model 2 (Table 8), the results indicate that the odds of experiencing better health are 37 percent lower among never-married respondents compared to their currently married counterparts (OR = 0.63, p = .05). The controlled variables suppressed the effect of marital status on health especially with respect to currently and never- married individuals. This finding supports my hypothesis that among patrilineal ethnic groups, married people experience better health compared to the never-married.

However, it may also mean that marriage is selective of people among patrilineal ethnic groups, and this may be due to the expensive nature of bridewealth payment. The data also show that odds of reporting better health are 29 percent lower among the formerly married compared to the currently married (OR = 0.71, p = .09).

147 Besides the main effect of marital status on self-rated health among patrilineal ethnic groups in Ghana, other variables that were strongly linked to positive health outcomes included gender, employment status, , educational attainment, age, feeling of happiness, and not subscribing to gender inequality beliefs. Age is still negatively associated with self-rated health. Also, the odds of experiencing better health are 1.6 times higher among persons with secondary education compared to their counterparts with no formal education (OR = 1.67, p = 0.5). Furthermore, among the patrilineal ethnic group, the results show that the odds of reporting better health are 34 percent lower among women compared to men (OR = 0.66, p = .05).

148 Table 8

Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated

Health among Patrilineal Ethnic Groups, Ghana 2011

Table 8: Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated Health among Patrilineal Ethnic Groups, Ghana 2011 Model 1 Model 2 Coef. OR Coef. OR Marital Status Never Married 0.19 1.21 * -0.47 0.63 * Formerly Married -0.49 0.61 + -0.34 0.71 + Ref: (Currently Married) Socio-economic Status Not financially satisfied (Yes=1) -0.28 0.76 Ref: (Financially satisfied) Employment status (Employed; Yes=1) -0.65 0.53 *** Ref: (Not Employed) Subjective Social Class Upper Class -0.16 0.85 Middle Class -0.41 0.66 * Working Class -0.21 0.81 Ref: (Lower Class) Educational Attainment Primary Education 0.24 1.27 Secondary Education 0.51 1.67 * Post-Secondary/College 0.66 1.93 + Ref: (No Formal Education) Chronic Strain/Stress Children 0.01 1.01 Not living with parent (Yes=1) -0.26 0.77 Socio-demographics Female -0.41 0.66 * Age -0.03 0.97 *** Sources of Social Support Attendance to Religious Services Regular -0.31 0.73 Once a Week -0.35 0.70 Ref: (Occasional) Not feeling secured at the community level (Yes=1) -0.37 0.69 Not Subscribing to gender inequality beliefs 0.21 1.23 ** Happiness (Not feeling happy;Yes=1) -1.23 0.29 *** Ref: (feeling happy) Intercept 1 -2.94 *** -5.37 *** Intercept 2 -1.52 *** -3.78 *** Intercept 3 0.50 -1.49 + Cox and Snell 0.010 .145 *** p < .001, ** p < .01, *p<.05, + p<.10

Table 9 provides a summary of findings on the association between marital status and self-rated health among matrilineal ethnic groups (specifically the Akans) in Ghana.

149 The results show that among matrilineal ethnic groups (especially the Akans), the odds of reporting better health are 1.7 times higher among the never-married compared to their never-married counterparts (OR = 1.70, p = .001). This result underscore how marriage instability that predominantly characterizes matrilineal ethnic groups may contribute immensely towards poor health outcomes (see Takyi and Dodoo 2005). Similarly, formerly married people reported poor better health when compared to the currently married (OR = 0.49, p = .01).

In the final model, the effect of marital status was attenuated when other relevant covariates especially age was controlled for. Whereas in the previous analyses, never married respondents among matrilineal ethnic groups reported better health than their married counterparts, this association was no longer statistically significant in the final model. Controlling for all other variables, the odds of reporting better health are 35 percent higher among the never-married compared to the currently married. However, this association is not statistically significant at 0.05 level (OR = 1.35, p = .18). This result does not confirm my hypothesis which stated that never-married persons in matrilineal ethnic groups will experience better health compared to their counterparts who are unmarried. Similarly, there is no significant difference between the formerly and currently married with respect to health among matrilineal ethnic group (OR = 0.67, p =

.19). The controlled variables in the final model made the association between marital status and health among the matrilineal ethnic group spurious.

Other variables which are associated with self-rated health include age, gender, children, socio-economic status, and feeling of happiness. Although there are similarities in terms of the effect of some of these covariates among both patrilineal and matrilineal

150 ethnic groups in Ghana such as the effect of age on health, there are some differences as well. For example, in all the analyses age is associated with self-rated health with health decreasing as respondent ages. One notable difference between patrilineal and matrilineal ethnic group is the effect of children and gender in predicting health. While the odds of reporting better health are lower among patrilineal women when compared to their male counterparts, this is not the situation for matrilineal women. In fact, there is no significant difference between men and women in matrilineal ethnic groups. This result may signify some benefits or advantages such as female autonomy, higher socioeconomic status that matrilineal women enjoy. Furthermore, whereas the effect of children was not associated with health outcomes among patrilineal respondents in Ghana, this was not the case among their matrilineal counterparts. Rather, the presence of children is positively associated with good health among matrilineal ethnic groups in Ghana. For example, the odds of experiencing better health increases by about 17 percent as the number of children increases (OR = 1.17, p = .01).

Finally, among patrilineal ethnic group, the effect of socioeconomic status on health is only significant for middle class respondents when compared to their lower class counterparts. In other words, there is no significant difference between upper and working class when compared to lower working class respondents with respect to self- rated health. On the contrary, among matrilineal ethnic group, there is a significant difference between upper, working, and lower class with respect to health. The findings from these analyses show the complex ways that ethnicity/lineage ties operate differentially among matrilineal and patrilineal ethnic groups in Ghana.

151 Table 9

Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated

Health among Matrilineal Ethnic Groups, Ghana 2011

Table 9: Summary of Ordered Logistic Regression Estimates for Variables Predicting Self-Rated Health among Matrilineal Ethnic Groups, Ghana 2011 Model 1 Model 2 Coef. OR Coef. OR Marital Status Never Married 0.53 1.70 *** 0.30 1.35 Formerly Married -0.72 0.49 ** -0.40 0.67 Ref: (Currently Married) Socio-economic Status No financially satisfied (Yes=1) -0.16 0.85 Ref: (Financially satisfied) Employment status (Employed;Yes=1) -0.24 0.79 Ref: (Employed) Subjective Social Class Upper Class 0.85 2.34 * Middle Class 0.65 1.92 *** Working Class 0.53 1.69 ** Ref: (Lower Class) Educational Attainment Primary Education 0.08 1.08 Secondary Education 0.19 1.21 Post-Secondary/College 0.47 1.59 Ref: (No Formal Education) Chronic Strain/Stress Children 0.16 1.17 ** Not live with parent (Yes=1) 0.11 1.12 Socio-demographics Female -0.15 0.86 Age -0.05 0.95 *** Sources of Social Support Attendance to Religious Services Regular -0.31 0.73 Once a Week -0.21 0.81 Ref: (Occasional) Not feeling secured at the community level (Yes=1) -0.24 0.79 Not Subscribing to gender inequality beliefs 0.07 1.07 Happiness (Not feeling happy; Yes=1) -1.07 0.34 *** Ref: (feeling happy) Intercept 1 -3.69 *** -7.39 *** Intercept 2 -1.85 *** -5.44 *** Intercept 3 0.14 -3.25 *** Cox and Snell 0.031 .139 *** p < .001, ** p < .01, *p<.05, + p<.10

152

5.9 Summary and Conclusion

In this chapter, I presented the results of the quantitative analyses on the relationship between marriage/family processes and health outcomes in Ghana. Bivariate models were used to examine self-rated health and its links to marital status, gender, and some of the mediating variables such as financial satisfaction, children, and living with parents. The Chi- square statistic results showed that never-married persons are more likely to report higher levels of self-rated health. A higher percentage of formerly married respondents reported poor or fair health. This result varied by the gender of the respondents with single men reporting good or very good health compared to their currently and never-married female counterparts. Additionally, financial satisfaction and living with parents were positively associated with better health.

Multivariate models, specifically cumulative logit models were used to examine the effect of marital status, gender, financial satisfaction, children, and living with parents on self-rated health together with other relevant variables. Overall, some of my hypotheses were fully and partially supported, whereas others were not supported by the data. First, I found that there is no difference between never- and currently married respondents with respect to positive health outcomes. This finding somehow contradicts studies that have found health advantage that married persons enjoy relative to their unmarried counterparts. Second, the results showed that marital dissolution have a detrimental effect on the health of respondents. Contrary to the results from the bivariate analyses, the association between marital status and health did not vary by gender.

Third, the results indicated that financial satisfaction and the presence of children partially mediates the association between marital status and health. For example, having

153 more children was positively associated with health, a finding that contradicts what had been found in Western industrialized countries. Fourth, the effect of marital status on health differed by the lineage system. Whereas among the patrilineal ethnic group, the currently married reported better health relative to their currently married counterparts, there is no significant difference between currently and never-married people among the matrilineal group with respect to positive health outcomes. The results showed that, compared to the formerly married, currently married people in patrilineal ethnic groups’ experienced better health. On the contrary, for matrilineal ethnic group, there is no significant difference between formerly and currently married persons with respect to self-rated health.

Finally, other variables that were strongly linked to positive health outcomes include employment status, educational attainment, age, feeling of happiness, sense of safety at the community level, and not subscribing to gender inequality beliefs. In the next chapter I summarize the results from the analyses chapter, discussing the importance and implications of the findings.

154 CHAPTER VI

DISCUSSION AND CONCLUSIONS

6.1 Marital Status and Health Outcomes in Ghana

Past research suggests that marriage improves health outcomes. Many of these existing studies agree that marriage has a beneficial effect on health and have provided insights into the mechanisms by which marriage and health behavior may be related

(Meadows, McLanahan, and Brooks-Gunn 2008; Mirowsky and Ross 2003; Waite and

Gallagher 2000). Many of these studies have found that the married enjoy better mental and physical health than the unmarried (Ross 1995; Waite and Gallagher 2000) and that they also have a reduced risk of mortality (Lillard and Waite 1995).

However, the focus of most of these studies was on married and unmarried people in the more developed countries; hence, we know very little about the extent to which marital status affects the health of people in the developing countries (LDCs) such as those in sub-Saharan Africa. Such an omission reduces our understanding of the links between marriage and health, especially in the context of sub-Saharan Africa (SSA) where marriage is nearly universal, and cultural norms and expectations about family life are different from those found in many Western societies. Surprisingly, very little is known about the potential benefits of marriage to health in the context of the less developing countries (LDCs) such as Ghana (Takyi and Gyimah 2007; Tsai and Dzorgbo

2012).

155 This study used African data to test whether this hypothesized relationship between marital status and health as found in the existing literature can also be applied to married people within the Ghanaian society. I also examined how the presence of children and gender influenced the association between marital status and health.

Moreover, I examined whether the effect of marriage on health operate differently among matrilineal and patrilineal ethnic groups in Ghana respectively. This study proposed that the resources associated with marriage which are responsible for promoting health may be available to never-married persons in Ghana. Hence, the health of never-married in the

Ghanaian context may not be different from that of married counterparts. This chapter discusses the main findings from my analyses on SSA data on marriage and health.

One of the general findings from the analyses is that among the Ghanaian society, rather than reporting poor health, actually the never-married respondents were more likely to self-rate their health as better or equal to that of their married counterparts. This observation is true both in both bivariate and some of the multivariate models. This finding challenged in some ways some of the popular assumptions about marriage and its associated health benefits, especially when we look at SSA societies.

One key finding from the existing literature on marriage and health was the idea that the never-married are less likely to be healthier than their married counterparts

(Lamb et al. 2003; Rogers 1995; Wade and Pevalin 2004). This observation was based on the argument that the never-married in many MDCs have fewer meaningful relationships that cushion them against unhealthy healthy behavior. Equally important was the idea that the neve-married have fewer social ties and economic support, which can be beneficial to health behavior and outcomes (Schoenborn 2004; Umberson et al. 2006;

156 Umberson 1992; Waldron et al. 1996; Waite and Gallagher 2000). Yet in my analysis of

Ghanaian's data, I found that there is no significant difference between married and never-married people.

This finding reaffirmed my argument that the comparative advantage that currently married people benefit or enjoy relative to their unmarried counterparts (e.g., among never-married) may not be applicable especially in a developing country such as

Ghana where the latter still benefit from some form of social support. I contend that in

Ghana, the nev-married still "reap" the benefit (if any) from their access to social support

(from kin members, etc.). Unlike their never-married counterparts in developed countries who may be more prone to depression and are thus more likely to engage in risky unhealthy behavior due to their lack social support/integration, the never-married in

Ghana and other countries in SSA may still have access to some kind of social support which bestow meaningful relationships (Gyekye 1996; Wiredu and Gyekye 1992).

The resources that are associated with marriage and which confer positive health outcomes to married persons are also available to never-married Ghanaians (Van der

Geest 1998). For example, with respect to social support, the communalistic and collectivistic cultural values and practices that characterize Ghanaian culture mean that never-married Ghanaians still have access to some form of social support, network, and are well integrated (Gyekye 1996). The collectivistic cultural values and reciprocal relationships that iare predominant among the Ghanaian society mean that never-married

Ghanaians may still be well integrated into their social groupings and may still be controlled by their immediate and distant relatives, thereby benefiting from such social relationships. The strong emphasis on collectivism and the significant role of

157 kinship/extended relations mean that even unmarried individuals are well cared for compared to never-married individuals in advanced countries (Nukunya 2003; Tsai and

Dzorgbo 2012). This is one of the reasons why never-married Ghanaians may not be vulnerable or experience poor health.

Using a measure such as “living with parents” to capture access to social support, the analysis showed that many unmarried Ghanaians, especially the never-married were more likely to live with their parents at home. Not only that, findings from the bivariate analysis also revealed that a higher number of Ghanaians who stay with their parents experienced higher levels of good health relative to their counterparts who do not live with their parents.

It is not uncommon for an unmarried person to be cared and supported by his/her relatives thereby benefiting from social relations (Nukunya 2003). It is uncharacteristic for single adult persons in developed countries to still live with their parents. That is, living with parents among the never-married in most developed nations such as the U.S. may be associated with stigma. Young adults are expected to move from their parents’ houses which is often perceived as sign of maturity and independency. Therefore, elderly single adults who are still living with their parents at home may face some stigma and pressure from friends and family members. On the contrary, due to communalistic and collectivistic cultural values in Ghana and other countries in this part of the region, never- married individuals can still live with their parents without experiencing any form of social stigma. Living with either family relatives, parents, or adults may generate benefits for never-married Ghanaians. Ghana is still a developing country with stronger family and relative ties.

158 The availability and dependence of one's relatives, friends, and family within the

Ghanaian's setting may mitigate some of the negative effects associated with being single

(Wiredu and Gyekye 1992). In a study conducted in Turkey by Kaya and Yurtseven

(2016), these scholars found that never-married persons in Turkey were more immune to the negative effects from being single such as loneliness and lack of social control. These scholars found that the presence of friends and family members as well as stronger familial ties that predominate Turkey’s culture makes it possible for single individuals to experience better health. It is because never-married persons living in countries characterized by individualistic value (mostly Western developed countries), find it difficult to have any form of social support. In the absence of social support and other forms of regulatory mechanisms, unmarried persons residing in these countries are then more prone to social isolation and loneliness.

Another equally important factor that has been found to promote good health among the married is their access to economic resources (Waite and Gallagher 2000).

The dual earnings of married individuals provides them with access to health care and helps alleviate the stress associated with economic hardship (Koball et al. 2010).

Economic resources enhance health by providing care in case of illness, ability to afford better nutrition, and allowing purchase of medical care or other health-enhancing resources (Lillard and Panis 1996). In contrast, economic hardship may operate the other way around and may be detrimental to the health of the married in the Ghanaian context due to many financial obligations that married people are predisposed to unlike their unmarried counterparts.

159 Despite the fact that studies have found the institution of marriage to be associated with increased household income, being married especially within the

Ghanaian context does come with many familial responsibilities, such as taking care of one's family through the provision of shelter, clothing, food, enrolling children in schools, among others. All these obligations may lead to financial stress, thereby affecting the health of currently married Ghanaians negatively. Within the Ghanaian setting, not being married may benefit the unmarried in the sense that they are less likely to experience some of the financial stressors that their married counterparts go through. It is within this regard that I argued that economic or financial hardship will partially mediate the relationship between marital status and health.

Findings from the analyses indicate that compared to both formerly and currently married, never-married Ghanaians are more satisfied with their financial situation. In addition, results from the bivariate and cumulative logit models show that Ghanaians who are satisfied with their financial situations are more likely to rate their health as better.

Similarly, when I controlled for financial satisfaction, the initial or total effect of marital status on self-rated health changes with never married Ghanaians gaining more health advantage compared to their formerly and currently married counterparts. This result partially explains why financial responsibilities on the part of married Ghanaians may exacerbate the situation of those who are married. Considering the fact that Ghana is a developing country coupled with its recent economic problems such as high unemployment rates, poverty, and high cost of living, the effect of all these factors may affect married Ghanaians especially those with low socioeconomic status as some people have reported (see for example, Ghana Statistical Service 2014)

160 Since marriages in Ghana are not only considered as unions between the spouses, but rather between two extended families, the communalistic cultural values that pervade

Ghanaian society mean that members of the conjugal union (married couples) hold certain obligations towards their in-laws (Nukunya 2003). It is a common practice in

Ghana, for instance, for married persons especially men to provide financial support to their in-laws (e.g., spouse's relatives). In addition to meeting the needs and obligations of the conjugal family, married individuals may also be expected or obligated to attend to the needs of their respective extended family (e.g., mother, father, and siblings). This is partly due to the general cultural expectation that when one marries, he or she marries an entire family and not their spouses alone. Taking care of one's immediate or nuclear family may be burdensome and strenuous and adding other responsibilities (e.g., supporting other family relatives) within the current economic condition or situation in

Ghana (such as high inflation, high cost of living, unemployment, high poverty rates) may lead to more financial stress for the married.

On the contrary, never-married Ghanaians are less likely to experience this type of financial strain since they may not have to fulfill these types of financial and cultural obligations such as providing shelter, food, clothing, and other responsibilities to spouse, children, or in-laws. Hence, the less financial stress that unmarried Ghanaians experience partially mediate the association between marital status and self-rated health.

A major finding from this study which supports and confirms existing research has to do with the detrimental effect of marital dissolution on the health of the formerly married. Existing research showed that the loss of a spouse through separation/divorce or bereavement is a stressful experience and which is associated with poor health outcomes

161 (Aseltine and Kessler 1993; Carr and Utz 2001; Pienta, Hayward, and Jenkins 2000;

Stroebe and Schut 2010; Umberson et al. 1992). That is, marital dissolution undermines the health of the formerly married (Pienta, Hayward, and Jenkins 2000; Wade and

Pevalin 2004). The result from the study indicates that compared to formerly married

Ghanaians, married Ghanaians experienced better self-rated health even when other relevant covariates were controlled. Marital dissolution either through divorce or loss of a spouse is one of the major life events with substantial negative impact on individual lives

(Aseltine and Kessler 1993; Booth and Amato 1991; Williams and Umberson 2004). The process of divorce and widowhood creates many stressors, which in turn have psychological and social consequences, and thus can negatively affect the health of the formerly married (Aseltine and Kessler 1993; Booth and Amato 1991).

The association between gender, health, and marital status is also a complex one in the sense that there are inconsistencies and contradictory findings about the moderating effect of gender (Simon 2002; Zhang and Hayward 2006). While scholars such as Gove et al. (1983) contended that marriage is harmful to women, others such as Simon (2002) contended that there is no gender difference with respect to the effect of marriage on health. In addressing this question, I conducted supplementary analyses that focused on the effect of gender in moderating the association between marital status and health. The results indicate that there is no gender difference in the effect of marriage on the health of

Ghanaians.

For unmarried people, studies show that never-married men are more disadvantaged compared to their female counterparts (Umberson 1992). Thus, compared to single men, single women are more likely to form connections and social bonds.

162 Women are apt to receive more intimate, interactive aspects of relationships, compared to never-married men (Umberson and Montez 2010). That is, men are more prone to engage in unhealthy and risky behaviors such as reckless driving, alcohol and drug abuse than women. In other words, the state of being single is more detrimental to men than women

(Courtenay 2000; Courtenay et al. 2002).

Within the Ghanaian context, I argued that due to the collectivistic and communalistic values, never-married Ghanaians may still have access to social support, hence. benefiting from social integration and also not engaging in any form of unhealthy and risky behaviors. In addition, due to patriarchal cultural practices, men tend to occupy high socioeconomic positions and possess more economic resources relative to their female counterparts. On the contrary, single women may face some pressures from family members to get married. Since in Ghana and many parts of Africa, women are perceived to be child-bearers and nurturing, most women are socialized from early stage to aspire to be mothers. Also, since the institution of marriage is cherished and held in high esteem in Ghana, unmarried women are more likely to be stigmatized and pressured by their relatives to get married (Tabong and Adongo 2013). That is, it is reasonable for men to be single, but for women being single is associated with negative sanctions. Based on this expectation, I hypothesized that gender differences may exist among never- married Ghanaians with respect to self-rated health. However, findings from the analyses indicate that there is no gender difference among never-married Ghanaians with respect to health. This result implies that the social stigma attached to women who are single in

Ghana may be on the decline. Thus, the normative expectations for Ghanaian women to marry, bear children, be in charge of domestic activities are now changing. It is now

163 becoming a norm in Ghana for women to aspire for greater achievements by placing education and self-empowerment (such as employment) ahead of other things. This may partly explain why there is no gender difference among never-married Ghanaians with respect to health.

Similarly, the effect of marital dissolution has been found to be gendered. Gender differences in health following marital dissolution have long been debated in the literature, with some studies showing more adverse effects for men and others for women

(Johnson and Wu 2002). In this study, I found that both formerly married men and women in Ghana reported poor health. This observation appeared to contradict studies that have found marital dissolution to affect only the health of one gender. Additionally, it gave much credence to existing studies that have found both men and women to experience negative health outcomes following the dissolution of their marriages (Simon and Marcussen 1999).

Scholars such as Simon (2002), Simon and Marcussen (1999) have argued that marital dissolution affects both men and women but in different ways, and as such, there is the need to examine the complex mechanisms by which marital instability affect both men and women. For instance, whereas men may suffer emotionally and may lack social support after the breakdown of their marriage (since their health is more dependent on their spouse monitoring their behaviors and providing care), women on the other hand may experience poor health due to lack of economic or financial support. Furthermore, whereas formerly married women may experience depression after marital dissolution, formerly married men are also more likely to cope with depressive symptoms by smoking

164 and using drugs (Simon and Marcussen 1999). Thus, the findings support studies that show both men and women are affected by marital dissolution.

6.2 The Effect of Children on the Health of Married Ghanaians

Studies have shown that the presence of children at home is negatively associated with physical health (Nomaguchi and Bianchi 2004; Umberson et al. 2010). For example, research has found that the presence of children in a home is associated with increased depression state of parents, and increased economic/financial strain on the family which negatively affect the health of parents (Ross, Mirowsky, and Goldsteen 1990; Umberson et al. 2010). This is due to the fact that with the same family income, a family with children feels more economic pressure than one without children. The strain of struggling to pay the bills, shelter, and clothe children may take a great toll on health of parents. In some situations, the birth of a child means that the mother may either cut back from full- time employment, take part-time job in order to combine both paid work and taking care of children, or be exclusively a housewife. Financial or economic hardship can create a condition of constant stress for such married individuals and this can be detrimental to the health of these individuals, especially mothers.

Accordingly, due to structural changes such as industrialization, high cost of living, globalization, urbanization, and high rate of unemployment in Ghana in sub-

Saharan Africa, scholars such as Ekane (2013) and Boakye-Boaten (2010) contended that these structural processes are transforming family structures in Ghana. For example,

Ekane (2013) argued that there is major shift from larger family size to small size households. The trend toward modernity can be seen in the gradual transformation of

Ghanaian marriage and family organizations away from corporate kinship and extended

165 families toward nuclear households (Boakye-Boaten 2010). According to Boakye-Boaten

(2010), changes in the economic institution of many indigenous societies have invariably affected the economic roles of children. Children were considered as economic assets for a family since it was an economic incentive to have many children (Boakye-Boeten

2010).

Based on the above arguments, I hypothesized that among the currently married in Ghana, couples with many children will experience poor self-rated health compared to their counterparts with fewer children. However, the findings from the analyses show the opposite. Indeed, the presence of more children was positively associated with better self- rated health among married Ghanaians. This finding suggests that the presence of children rather than diminishing the health of their parents as found in Western literature

(Ross, Mirowsky, and Goldsteen 1990; Umberson et al. 2010), children improve the wellbeing and health of Ghanaians who are married. This result contradicts other studies predominantly conducted in Western developed countries that have found not just the presence of children but also the number of children born to married couples to be negatively associated with poor health outcomes (Ross et al. 1990).

The evidence from the present study suggests that having many children increases the health of currently married Ghanaians. This may be related to the significant attachment that children have in the lives of Ghanaians and people living in sub-Saharan

Africa. In Ghana and many parts of Africa, children serve many important functions to parents ranging from economic to social benefits (Sam 2001). The birth of a child brings joy and happiness for married Ghanaians, and there is a sense of worth that comes with being a parent to many Ghanaians. Children also have economic value to their parents as

166 they are a source of social security for old age. Despite structural changes such as modernization, urbanization, and nucleation of the family, members of the extended family may still play an important role in caring for children born to married couples in

Ghana. This may cushion some of the stresses associated with raising children in Ghana.

In addition, having many children could be advantageous in the sense that elderly children can assist their parents economically (such as insurance for old age, providing and care for their elderly parents when they are old and are not able to work), and may also take care of younger siblings. In his study on a fishing community in Ghana, Teye

(2013) found that the demand for labor and expectations of long-term security influenced couples’ decision to give birth to many children especially among men.

The findings from this study demonstrate that, although globalization, urbanization, and migrations have transformed the organization of family structures in

Ghana, children still play a significant role in the lives of Ghanaians. Additionally, the sociocultural context of Ghana makes it possible for friends, relatives, and members of one’s extended family to provide support and care for children. That is, the communalistic cultural values and practices that pervade Ghana’s culture mean that children are still cared for by both the nuclear and extended family. Childrearing responsibilities are shared together by both the conjugal family and members of the extended families (Teye 2013). This can help ease some of the financial/economic and social costs associated with children. Given the value placed on children in Ghana and sub-Saharan Africa, infertile couples mostly experience difficult marital relations which more often than not results in separation/divorce or domestic violence (Chimbatata and

Malimba 2016). This means that the absence of a child can lead to marital conflicts. As a

167 result, married women without children are sometimes considered as witches and not complete women (Tabong and Adongo 2013). It is in this regard that childless couples especially women, within the Ghanaian society do face social stigma, shame, a sense of guilt, and worthlessness (Chimbatata and Malimba 2016).

It is important to note that, although this study shows that the presence of children is positively associated with self-rated health, I was unable to examine whether it is just having children or a specific age group of children influence the effect of children on health. This is important considering the fact that studies show that it is not only the presence of children that causes poor health among parents, but specific groups of children such as toddlers and preschoolers and not adult children that negatively affect the health of their parents (Umberson et al. 2010). Children at home especially toddlers and preschoolers have been found to decrease the quality of marriage and the amount of support spouses get from each other (Ross et al. 1990). Additionally, caring for young children (e.g., toddlers) is time consuming and associated with intensive care and support unlike adult children. However, due to data limitation, I was unable to explore whether specific age groups of children or just the presence of children affect the health of currently married Ghanaians.

6.3 Lineage Ties, Marital Status, and Health Outcomes: The Ghanaian Context

In Ghana and Africa in general, lineage or kinship ties strongly influence both personal and public behaviors of people. Indeed, ethnicity which is associated with kinship systems determines in many cases inheritance rights and access to property

(Oheneba-Sakyi and Takyi 2006). Inheritances are transferred from one generation to the other. Because of the different way matrilineal and patrilineal ethnic groups treat their

168 members in Ghana, I argued that the effect of marriage on the health of Ghanaians may operate differently among these ethnic groups. For example, because marriages among patrilineal ethnic groups in Ghana such as the Gas and the Ewes involve permanent incorporation of women to their husbands' lineage, and also a complete transfer of women's reproductive rights to their husbands through the payment of bridewealth, marital dissolution through divorce or separation has been found to be relatively low among them compared to their matrilineal counterparts (Mizinga 2000).

Furthermore, studies have shown that marriages are quite early among patrilineal ethnic groups (Mizinga 2000). This means that never-married Ghanaians in patrilineal societies may be stigmatized for not getting married. In addition, the expensive nature of bridewealth paid by the potential bridegroom to the woman's family means that not everyone, especially poor men, can afford to marry though they may want to do so. Thus, among the patrilineal ethnic groups in Ghana, people are selected into marriage.

Following these expectations, I hypothesized that among patrilineal ethnic groups, there will be no health variation among never- and currently married Ghanaians.

The finding confirmed my hypothesis, in the sense that among patrilineal ethnic groups in Ghana, the currently married reported better health than their formerly and never-married counterparts. Another possible reason for why currently married

Ghanaians among patrilineal ethnic groups may experience better than their unmarried counterparts may be due to marital stability which has been found to be associated with patrilineal ethnic groups (Goode 1993; Mizinga 2000; Takyi and Broughton 2006). Also, the pooling of resources together by married men and women may lead to increased household income unlike what pertains among matrilineal ethnic marriages (Oppong

169 1983; Takyi and Gyimah 2007). Additionally, because items needed for marital rites are expensive and coupled with the fact that bridewealth are also expensive, individuals who end up getting married may not have the resources needed for such marital processes. In other words, among patrilineal ethnic groups, marriages may be selective of persons entering into such marital unions.

The effect of marital status on self-rated health operated differently among matrilineal ethnic groups in Ghana. The results from the analysis show among matrilineal ethnic groups in Ghana (predominantly the Akans in this study), the never-married reported better health compared to their currently married counterparts (without controlling for other variables). In the final model where other important covariates were controlled, the never-married among the matrilineal ethnic group still reported better self- rated health than their currently married although this association was not statistically significant. This finding was expected considering the fact that matrilineal marriages unlike patrilineal marriage are more unstable (Takyi and Gyimah 2007). In Ghana, marital instability is higher among matrilineal ethnic groups such as the Akans of Ghana as these studies have found.

According to Goody and Tambiah (1973), matrilineal societies are associated with high divorce systems because they increase women's autonomy and lower the costs of divorce for women. One reason why divorce is high among matrilineal ethnic groups has to do with the amount of bridewealth given to the bride and her family prior to the initiation of the marriage. Bridewealth is given to the bride and her family to compensate them for the loss of their daughter's economic services. It also consolidates friendly

170 relations between the man and woman and provides a material pledge that the woman and her children will be well treated.

Among certain communities in Ghana and sub-Saharan Africa (especially patrilineal ethnic societies), marriages that do not include payment of bridewealth are not considered as legal marriages. Hence, bridewealth is culturally, socially, and traditionally significant. However, in many matrilineal ethnic groups, marriages can be contracted without the payment of bridewealth. Even when bridewealth is paid to the bride and her family, most often, the items provided are not that expensive and could be returned at any given time. Based on these factors, it is much easier for matrilineal women to exit their marriages should they feel unhappy (Takyi and Gyimah 2007). On the contrary, the hefty and expensive nature of bridewealth exchanged among patrilineal marriages makes it difficult for these women to renounce their vows.

Additionally, matrilineal women have been found to be more independent unlike patrilineal women (Takyi and Dodoo 2005). The autonomy of matrilineal women may stem from their ability to inherit from their lineage as well as improvement in the socioeconomic status of these women compared to women from patrilineal ethnic groups who to a large extent have to depend on their male partners (Takyi and Gyimah 2007).

The improvement in female economic status of matrilineal women improves their bargaining position at the household level relative to women in patrilineal ethnic groups.

Nonetheless, the autonomy of matrilineal women may come at a cost and could lead to marital conflicts and intimate partner violence. This is due to the fact that patriarchal values and practices are still pervasive in Ghana, and Ghanaian men in general

(especially those married) will still want to exercise control. Because male dominance

171 and control is highly prevalent in Ghana and sub-Saharan Africa as a whole, men still exercise authority over their spouses (Koenig et al. 2003).

Although women's lack of education and low SES makes them more vulnerable to violence among heterosexual couples, studies have shown that in sub-Saharan Africa, women with high SES are also predisposed to intimate partner violence. This is partly due to male insecurity. Since matrilineal cultures are still shrouded in patriarchal cultures, male dominance may still persist. For instance, married men in matrilineal ethnic groups may tend to perceive the autonomy of their wives as a form of disrespect and this could lead to marital conflict. In their study on the relationship between kinship ties and intimate partner violence in Ghana, Sedziafa and colleagues (2016) found that although patrilineal women were more subjected to physical and sexual violence, matrilineal women experienced more emotional and sexual violence.

Scholars such as Takyi and Gyimah (2007) and Oppong (1983) argued that spouses in Akan marriages do not pool resources together. In other words, both spouses keep separate account of their income, a closely related point that draws on research on

Ghanaian and African families and which has the potential to undermine the cohesion of the family unit, and any possibility that they would pool their resources together. Oppong

(1983) believed the practice of separate household resources among married dyads has something to do with the Akan idea that men and women should give priority to their own matrilineal kin over their spouses. However, because marriages among patrilineal ethnic groups incorporate both children and married women into the husbands' patrilineal kin, married couples tend to perceive themselves as one conjugal unit and corporate together. Thus, unlike their matrilineal counterparts, patrilineal women are more likely to

172 pool resources together with their spouses and are more likely to function as a unit. All these factors may attenuate the health benefits associated with matrilineal marriages compared to patrilineal marriages.

A surprising finding from the study has to do with the health of formerly married persons among matrilineal ethnic groups in Ghana. The analysis revealed that although compared to formerly married respondents, married respondents reported better health.

This association was not statistically significant. This result contradicts my hypothesis as well as existing literature that found formerly married individuals to have poor health compared to their married counterparts. This finding is surprising considering the fact that formerly married persons are more likely to experience more chronic stress after the dissolution of their marriages. However, recent studies show that although marital dissolution is detrimental to the health of formerly married, the duration of marital dissolution must be considered since it may moderate the effect of marital instability on health (Hetherington and Stanley-Hagan 1999).

In other words, although divorce may usually be viewed as a stressful event, it may also present a new chance for adults to pursue more harmonious, fulfilling relationships, individuation, and well-being in a new family situation (Hetherington and

Stanley-Hagan 1999; Yu et al. 2010). Thus, the effect of divorce or widowhood on health may not be permanent. Existing studies show that formerly married people, especially men who re-marry shortly after divorce, may later on experience better health relative to their counterparts who are still divorced (Noda et al. 2009). For example, a U.S. study by

Noda and colleagues (2009) showed that remarriage after bereavement or divorce was associated with significantly decreased risk of chronic obstructive pulmonary disease.

173 Similarly, Martikainen and Valkonen (1996) found that although divorce/bereavement was associated with mortality, excess mortality was higher for respondents whose duration of bereavement was shorter compared to those with longer duration.

One notable difference between patrilineal and matrilineal ethnic groups is the effect of children and gender in predicting health outcomes. Whereas among patrilineal ethnic groups in Ghana such as the Gas, men reported better health relative to their female counterparts, there was no gender variation among matrilineal ethnic groups with respect to positive health outcomes. With respect to the effect of children, having children did not predict health among patrilineal ethnic groups. On the contrary and among matrilineal groups, having children, especially more children, was associated with good health.

Besides the main effect of marriage, some of the most important determinants of self-rated health in Ghana include among others the respondents' employment status, financial satisfaction, educational attainment, age, feeling of happiness, sense of security at the community level, not subscribing to gender inequality beliefs, and subjective social class. Feelings of happiness was also found to be strongly associated with self-rated health. People who report not being happy experienced poor health compared to those who indicated they were happy. Regarding employment status for instance, Ghanaians who are unemployed reported poor health compared to their counterparts who are gainfully employed. In addition, age was also strongly and negatively associated with self-rated health.

In conclusion, this study has examined how marriage and family life in a developing country such as Ghana differ remarkably from what pertains in more

174 developed countries. In the study, I found that the health of the never-married is not that different from that of their married counterparts. Cultural differences such as communalistic values and less financial obligations on the part of the never-married did account for this health advantage of the never-married. On the contrary, I did find that the health of the formerly married is worse compared to their currently married counterparts.

Similarly, the presence of children was found to improve the health of Ghanaians.

Finally, the study also showed that the association between marital status and health operated differently among patrilineal and matrilineal ethic groups in Ghana.

6.4 Policy Implications and Directions for Future Research

A review of the literature revealed that compared to the unmarried, married persons are more likely to have better health. Nonetheless, the bulk of these studies were from Western developed countries with less attention on the health benefits of marriage in developing countries such as Ghana (Carr and Springer 2010; Kaplan and Kronick

2006; Kim and McKenry 2002; Koball et al. 2010; Lillard and Panis 1996; Rogers 1995;

Schoenborn 2004; Umberson et al. 2006; Umberson 1992; Waite and Gallagher 2000;

Waldron et al. 1996; Wilson and Oswald 2005; Wood, Goesling and Avellar 2007).

Arguably, it is plausible to suggest that the universalistic nature of marriage does not necessarily mean the effect of marriage on the wellbeing of people is also universal. The findings from this dissertation demonstrate the need for sociologists, family scholars, and researchers to contextualize the mechanisms by which marriage affects the health of people in diverse contexts. The study is unique in the sense that it adds to existing cross- cultural literature on marriage and health and broadens our knowledge about how

175 marriage, family, and health processes occur in different countries, especially those in the developing world such as Ghana.

Among the key findings from the study is the observation that never-married

Ghanaians either reported better health than their married counterparts or there was no difference between being married and being single in relation to reporting good health.

This finding although surprising was expected considering how contextual cultural factors such as communalism and collectivism may cushion the harmful effect of being single. In a related study, Addai, Opoku-Agyeman, and Amanfu (2015) found that compared to the unmarried, married Ghanaians reported low levels of subjective well- being (e.g., happiness and satisfaction with life). These researchers attributed their findings to cultural and socioeconomic factors associated with poor or developing countries where wellbeing and health are determined by economic factors. The relative disadvantaged of the married compared to the never-married is quiet alarming considering the fact that marriage is associated with better health outcomes.

One reason could be that married individuals or members of the conjugal unit in the Ghanaian context are more likely to be predisposed to many economic pressures from members of their immediate and extended families. As previously argued, married persons within the Ghanaian society are more likely to have many financial obligations.

However, considering the fact that Ghana is a developing country with recent economic crises such as inflation and high unemployment rates, meeting the financial needs of both the conjugal and extended family may be a major stress for married Ghanaians. A related factor may be that because Ghana is not a welfare state, married couples with children may find it difficult meeting the needs and demands of their respective families. In this

176 regard, there is the urgent need for government and nongovernmental organizations to provide infrastructural support such as financial assistance, subsidized housing, and schooling that could assist married persons in Ghana.

Another important reason that may explain the health status of married Ghanaians relative to their unmarried counterparts is quality of marriage and age at first marriage.

The mere presence of another adult in the household does not automatically confer health benefits on the currently married. The quality of marriage matters a lot since distressed marriages or marriages characterized by conflicts are a major source of stress, and this can negatively impact on the health of married individuals (Kiecolt-Glaser and Newton

2001). Aside the financial stress that married men may experience within the Ghanaian context that may compromise their health, married women may also be prone to some unrealistic cultural and social pressures (Addai, Agyeman, and Amanfu 2015). For example, the need to have children to satisfy family members and coupled with the need to attend to many needs such as domestic household chores may undermine the health of married women. More importantly, married women may have to juggle their own "wifely duties" such as cooking, caring, washing, and among other related activities of their immediate family and in addition, take on other domestic duties should they live with their own parents or in-laws. Since some married women may be gainfully employed, juggling between paid work and domestic chores may be detrimental to their health. In addition, some marriages within the Ghanaian context have been found to be associated with high rate of intimate partner violence (Takyi 2006). All these issues highlighted here may attenuate the health benefits associated with marriage. In order to alleviate some of

177 these issues, it is important for the state to issue legislation with regards to granting paid- leave for employed mothers.

Furthermore, due to discriminatory and patriarchal cultural practices, women who are employed risk losing their jobs especially when they get pregnant. Such unfriendly and punitive policies will negatively affect married women. Companies and employers must establish laws and policies that are favorable to women especially employed mothers such as maternity and paternity leaves. Husbands should also be encouraged to assist their wives in taking care of household chores. Additionally, with respect to domestic violence against married women, laws must be passed that criminalize domestic violence and perpetrators must be prosecuted. Thus, there is the urgent need for the government, stakeholders, and other nongovernmental organizations to do more in combating against the prevalence of female victimization in Ghana. There should be public awareness through dissemination of information especially in the rural areas in

Ghana about the harmful effect of domestic violence. The government of Ghana has made some improvement by passing the Domestic Violence Act in 2007, yet more work is needed to make this bill a success.

Although I did not control for age at first marriage due to data limitations, it is possible to speculate that early transition to marriage may have minimized some of the health benefits associated with marriage. While more women are marrying in their thirties in Western developed countries, early marriages are far more common in Ghana and other countries in sub-Saharan Africa. Child or early marriages are more predominant in West Africa (Maware 2010). Age at first marriage is very important, especially for women, because it is associated with early birth, high fertility rates (larger

178 families), risk of marital dissolution, increased risk of sexually transmitted diseases and adverse health outcomes (Lecoh 2000).

Furthermore, transition from unmarried status to married is crucial since young adults who marry much earlier are more likely to experience marital conflicts which could be caused by financial issues (e.g., due to their inability to complete their education). Also, for women, early transition to marriage may lead to lack of employment opportunities, increased child-bearing, and economically depending on their spouses.

This could lead to exploitations of women such as domestic abuse, thereby not benefiting from their marriage. One reason behind this practice is poverty. For many poor families, marrying their daughters at an early age is a strategy for economic survival, meaning one less person to feed, clothe, and educate (Chae 2013; UNICEF 2014). Globally, forced child marriage is much more common in poorer countries and regions, and within those countries, it tends to be concentrated among the poorest households. For example, a girl from a poor household is more likely to marry as a child than a girl from a rich household

(UNICEF 2014). One way to stop early child marriage is to raise awareness among communities about the consequences of child marriage. Also, formulating laws and enforcing them is another way to put an end to this social issue.

Another observation from the study has to do with the poor health status of formerly married Ghanaians relative to their married and never-married counterparts. A multiplicity of factors especially within the Ghanaian context may be responsible for this situation. First, because of the stronghold of religion and traditional customary practices, divorce is strongly prohibited. Those who end their marriages may face stigma from their friends, family members, and even community. Negative sanctioning such as insults, and

179 ostracism are some of the negative experiences these individuals may face. This may worsen the already precarious situation of formerly married Ghanaians.

Also, aside from the strain that comes with losing a loved one either through divorce or death, it is not uncommon for the formerly married to experience financial hardship sometimes due to confiscation of properties by the deceased families especially in situations that the deceased died without a will. Even when marriage is dissolved through divorce, women, especially single mothers, are more likely to face economic hardships. Furthermore, in Ghana when a married person loses his or her spouse through death, there are traditional widowhood rites that must be performed for the living partner.

Some of these practices include bathing outside the compound, cooking on rubbish dumps, eating from a calabash and using it as pillow, walking naked to the riverside to have a bath, and being forced to constantly stay in the same room with the deceased husbands before burial (Nwalutu 2012; Peterman 2011). Failure to undergo such rituals means that the widow in most cases is blamed or held responsible for the death of her partner.

In order to improve the health conditions of formerly married Ghanaians, it is imperative for people to be aware about the harmful effects of staying in an abusive marriage. Ghanaians are nonreceptive to marital dissolution through divorce. In many situations, the married woman is required to stay in her matrimonial home and encouraged to "fix" her problems marital problems even when being abused by the husband. Staying in an unhealthy marriage is detrimental to women's health. Therefore, educating people about the need to be receptive about divorce especially when all avenues have been explored in an attempt to make the marriage work. Second, there is

180 the need for policy makers to make laws that protect formerly married people, especially with respect to property inheritance. By not protecting the rights of these individuals, members of the deceased family are more likely to confiscate properties meant for the surviving spouse and children, and this may place the conjugal family in a far worse situation. Also, although traditional rites are part of Ghanaian culture, negative customary practices such as widowhood rites must be abandoned. It is necessary that stakeholders and nongovernmental organization make people aware about the negative repercussions of these cultural practices.

Another finding from the study deals with the significant role of children in

Ghana. The presence of children was positively associated with self-rated health.

However, this finding must be interpreted with caution since I was unable to examine how the age of children could influence the association between marital status and health.

This is due to the fact that toddlers and preschoolers, and not adult children, have been found to negatively affect the health of their parents (Umberson et al. 2010). Nonetheless, children still serve many important functions in the sociocultural context of Ghana. The birth of a child brings joy and happiness for married Ghanaians. There is a sense of worth that comes with being a parent. Children also have economic value to their parents. That is, children are a source of social security for old age. The significant role of children among Ghanaians is both a curse and blessing. On the positive side, childbearing increases the status of married couple especially for women.

In addition, the presence of children could serve economic purposes such as working on the farm or security for old age. On the contrary, married persons without children are more likely to be stigmatized. Thus, because childbearing is so important in

181 the lives of Ghanaians, married couples without a child or more children are highly stigmatized, ridiculed in the community (e.g., witchcraft accusation especially for women who cannot bear a child), sometimes marriages may end in a divorce. In addition, the need for children within the Ghanaian society may be responsible for high fertility rates in Ghana and sub-Saharan Africa. Although at the individual level giving birth to more children may be desirable, at the macro level, Ghana is likely to have an age-dependency population where the majority of its population are children and the elderly. A country with more aged and children, with less able-bodied or working population may face many structural economic issues such as lower tax revenues, lower pension funds, pressure to raise retirement age, among others (Lindh and Malmberg 1999). Moreover, there is the tendency for child abuse/labor to occur since children will be needed to work on farms or engage in other trade instead of attending schools to better their lives and that of their respective families. To solve the problem of high fertility rates in Ghana, the government must endeavor to educate people about the effect of having many children. Parents should be able to give birth to the number of children that they can adequately care for or provide for. Conversely, married women who are barren or infertile should not be stigmatized. Rather, services must be provided to these women to minimize or reduce their stressful experiences. Also, negative attitude towards child adoption should be changed and childless couples should be able to adopt without any difficulties.

Another key finding from this study is the relative importance of socioeconomic status in promoting positive health outcomes. It was observed that Ghanaians with high socioeconomic status such as those in the upper and middle class, high levels of education, employed, and those satisfied with their financial situation reported better

182 health. These findings confirm existing studies that have found a strong association between SES and health (see Link and Phelan 1995; Schnittker 2004). This observation underscores the need for improving the low socioeconomic status of many Ghanaians so as to promote better health. Ghana, a developing country in sub-Saharan Africa which is trying to attain the Millennium Challenge Goal (UNDP-MCG, 2015) which include eradication or minimization of poverty, achieving universal primary education, promoting gender equality and empowering women still have a long way to go.

Economic mismanagement, unstable economy, high inflation, and unemployment in

Ghana are impacting the lives of Ghanaians which is affecting their wellbeing and health.

Providing infrastructural supports such as employment opportunities and access to education may help alleviate the poor state of majority of Ghanaians especially those in the rural areas. Feeling of happiness was also found to be associated with better self-rated health. People’s socioeconomic status influences their assessment of subjective wellbeing such as state of happiness. By improving the living conditions of many Ghanaians through job creation, the subjective wellbeing or individual's level of happiness will inadvertently increase thereby promoting positive health outcomes.

Two significant observations from the research show that social capital and age are strongly associated with better health among Ghanaians. Feeling secured in the community which is a proxy for social capital demonstrates the need for civic and community engagement. The data lend credibility to the importance of feeling safe or secured in one's community or neighborhood. This finding means that when people feel safe in their community, they are willing to come together and be involved in activities within their neighborhood. Social capital and community engagement have been found to

183 be associated with good health (Kawachi and Berkman 2001; Putnam 2000). Although feeling secured at the community level may be due to collectivistic cultural values and practice in Ghana, there is the need to create more avenues to encourage social gathering at the community level. Hence, policy makers should put in place some policies and programs that will encourage community participation and ensuring trust among people.

Also, studies have shown that age has a curvilinear relationship with health

(Carlson 2011). That is, as people get older their health deteriorates gradually. Although the leading causes of death in Ghana include malaria, HIV/AID, stroke, influenza, and pneumonia, many Ghanaians are now experiencing chronic illness later in life (CDC

2013). It is, therefore, important for the government to restructure and revitalize the

National Health Insurance Program so that elderly Ghanaians can take advantage of this scheme. Policies and strategies that may help educate and encourage people to seek health care services are equally important.

Gender is also related to socioeconomic position. One major finding from the study is the relative advantage of men over their female counterparts among patrilineal ethnic groups in Ghana. This was not the situation among matrilineal ethnic groups in

Ghana. This is due to patriarchal practices and discriminatory practices against women that disenfranchise women. This places a woman at a disadvantage compared to their male counterparts, and this may negatively affect their health. In order to improve the health condition of women, it is important to improve the socioeconomic situation of women in Ghana through access to education, employment opportunities, and eradicating all forms of gender discriminatory practices. Improving the condition of women in Ghana will inadvertently improve the decision making of married women in general.

184 6.5 Study Limitations

This study has examined the relationship between marital status and self-reported health in Ghana. Although this study contributes to the discourse of health and marriage, some limitations need to be pointed out about the research. First, due to data limitations, I was unable to use specific health measures in this study. Health is a multi-dimensional concept as existing studies have pointed out. My use of a subjective single measure of health limits our understanding of the links between marriage and health. Future scholars may consider using multiple variables to measure health such as functional limitations, chronic or acute limitations, disability, morbidity, and smoking since this can help future studies to document/elucidate the diverse ways that marital status influences health outcomes.

Second, although the use of self-reported health is a subjective feeling or measure of health, the use of objective health measures (e.g., BMI, hypertension, diabetes, cardiovascular diseases) is more recommendable. For example, Wu and Hart (2013) found that married people are more likely to overestimate their health status (e.g., especially when using self-reported health as a measure). Also, although the dissolution of marriage negatively affected both men and women in the study, I was unable to determine the specific ways that this affects their health. Marital instability may affect both men and women in a different way, affecting women through experiencing depression, and engaging in risky behaviors such as drug and alcohol abuse for men.

However, I was unable to measure this due to only one measure of health (self-rated health). Future researchers should make use of multiple specific health measures.

Third, future research examining the association between marital status and health in developing countries especially those in sub-Saharan Africa should try to explore how 185 age at first marriage and type of marital union are related to health. This is very important because transition from unmarried status to married is crucial, and young adults who marry much earlier are more likely to experience marital conflicts (e.g., due to financial problems) compared to their counterparts who marry late. Early transition to marriage may lead to dropping out of school, lack of employment opportunities, increased childbearing, and economically depending on their spouses (Ramjee and Daniels 2013).

This could lead to exploitations such as domestic abuse, thereby not benefiting health- wise from their marriage. Thus, by separating adults who married later in life from those who married much earlier, future studies can demonstrate whether the former marital union type confers or inhibits positive health outcomes compared to the latter union.

A related limitation of this study with respect to age has to do with my inability to model the mechanism by which age may influence the association between marital status and health. Throughout the entire analyses, age was strongly and negatively associated with health. Yet, I only controlled for age instead of examining the complex mechanisms by which the age of the respondents suppresses the effect of marriage on health. Future researchers must attempt to critically explore the extent to which the association between marital status and health is moderated by age. One way to do this is by splitting or categorizing age into three groups such as young, middle, and old age, and examining how the relationship between marital status and health operates within these age categories.

Another notable area for future research has to do with separating monogamous from polygamous marriages and exploring how the health benefits associated with marriage vary by the types of union. While such an assessment offers some unique

186 perspective, I was unable to test that in this study because of data limitation. This is important because polygamous marriages are quite prevalent in Ghana and other countries in SSA, and there is scanty information/knowledge on how the health benefits associated with marriage may vary by union type in SSA. Buve et al. (2002) contended that polygymous marriages are associated with loose emotional ties and lack of communication between spouses. This is crucial considering the fact that the one of the health benefits of marriage, especially for men in Western developed countries, has to do with social support (relationship, social integration and control) that spouses derive from marital unions.

A fourth limitation of this study has to do with my inability to examine the mechanism by which children influence the health of their parents. This issue has something to do with my inability to have more information on children from the data.

For example, whereas the data collected indicated number of children, the data did not provide other valuable information such as ages of children and whether these children are still living with their parents at home or not. This is important considering the fact that the effect of elderly children and that of preschoolers on parental health may not be the same. Also, the presence of children at home may affect the health of their parent in a different manner compared to children who do not stay together at home with their parents. Future research must attempt to collect and provide detailed information on children.

A fifth limitation of this dissertation is the lack of contextual variables that accurately measure social and cultural constructs in Ghana. This is a limitation of the study since the main argument of the dissertation was to examine how marriage and

187 family processes in Ghana operate differently as a function of differences in social and cultural values. For instance, although I argued that the communalistic values that predominate Ghanaian’s society makes it possible for single individuals to still have access to social support, I did not find any cultural specific variable that could accurately capture some of these cultural differences such as collectivistic values. It is important for future researchers to consider cultural specific variables.

Finally, since the data are cross-sectional, I could not make causal inference between marital status and health. One major limitation of the use of cross-sectional data in health studies has to do with lack of causal inference. Also, with cross-sectional data I was unable to systematically and simultaneously distinguish the effects of cohort, age, and time/period. Since the significance of marriage and people perceptions or attitudes about marriage may vary across time (e.g., social and cultural changes), it is imperative to examine how the association between marital status and health differs across different cohort groups or generations in Ghana. In order to solve this problem, future researchers should consider using longitudinal data. Such an analysis would further extend our understanding of marriage, family, and health processes in developing countries.

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