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Marriage Education and Health Care Reform: What’s the Connection? Workshop #320. Smart Marriages Conference, 2009 Jana Staton, Ph.D., LCPC Marriage Works Learning Center Patty Howell, Ed.M., A.G.C. California Healthy Marriages Coalition Lara Rezzarday, MPA

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Marriage Education and Health Care Reform: What’s the Connection? Workshop #320

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    1. Marriage Education and Health Care Reform: What’s the Connection?Workshop #320 Smart Marriages Conference, 2009 Jana Staton, Ph.D., LCPC Marriage Works Learning Center Patty Howell, Ed.M., A.G.C. California Healthy Marriages Coalition Lara Rezzarday, MPA National Multiple Sclerosis Society

    2. Overview of Presentation • To articulate the alignment between Healthy Marriages and Health • Why emphasize Prevention? • Relevance: Marriage Education/Relationship Education is essential to health care reform • Relationship Education in practice • Making the case to national and local leaders

    3. “Healthy Marriage” Definition Often Misunderstood from Definition: Consequences for Adults, Children • Healthy Marriage/ Relationships • Safety • Satisfaction • Communication • Interaction/time together • Commitment to the couple • Intimacy/emotional • support • Healthy conflict resolution • Fidelity • Commitment to the • children • Duration over time • Adult Well Being • Physical longevity • Better mental • health • Wealth • Social Support • Satisfaction & • happiness • Less risk-taking • (substance abuse, • illegal activities • Child Well-being • Positive socio- • emotional outcomes • Cognitive attainment • and educational • achievement • Good health and safety • Positive attitudes/ • values towards • marriage & children • Confident dating • behavior, sexual • activity,relationship • skills • Marital stability in • adulthood

    4. Marital/Family Breakdown is a Health Care Issue with Hidden Cost • US divorce rate continues at close to 40% • 1 million+ US divorces each year • Impacts approx. 1,500,000 more kids each year • Fewer couples are marrying—instead cohabiting & having children • Estimated 2.4 million children in cohabiting families • Estimated that half of cohabiting families will break up over time America’s Families & Living Arrangements, US Census Estimates, 2008.

    5. Direct Economic Costs of Divorce & Family Fragmentation • David Schramm—Journal of Family & Economic Issues • Social Services burden on State and Federal coffers = $30,000 per divorce • Ben Scafidi—The Taxpayer Costs of Divorce and Unwed Childbearing • $112 Billion/yearfor US taxpayers • State-level estimates are included in report at Institute for American Values:

    6. Working UPSTREAM to Reduce (Hidden) DOWNSTREAM Costs

    7. Argument for Linking ME/REto Health & Well-being Framework: ME/RE = A preventive intervention to reduce chronic illness and promote well-being in families & couples. • ME/RE has a well-documented connection to healthier children AND healthier adults.

    8. Argument for Linking ME/REto Health & Well-being, cont. • ME/RE enables health care institutions to invest in prevention = • Enormous benefits for their patients • Enormous PR value as caring institution • Enormous PR value as socially responsible institution • Enormous PR value as cutting edge institution—part of the “solution” to U.S. health care problems • Great cost-effectiveness • positive

    9. Benefits of Healthy Marriages for Health Promotion • Key points for Health Care Reform: • Children: health & well-being depends on safe, stable, nurturing parents, and especially on two biological parent families • Adults: health depends on healthy immune system functioning, low chronic stress, adherence to health care regimens, which in turn depend on social relationships & support.

    10. Research Summaries to Support ME/RE in Health Care Reform

    11. Research on the Connection between Marital Outcomes & Health Outcomes — Healthy and Unhealthy Top 8 Findings

    12. #1 Healthy Lifetime RelationshipsBenefit Both Partners’ Health • Marriage has positive lifetime health benefits for men –reduces risky behaviors, increases social support. (Wood, 2007) • Marriage has positive lifetime health benefits for women – increasing with duration and quality (Lillard & Waite, 1995) • Even low-income married couples have better health than unmarried peers (Schoenborn, 2004 US Census).

    13. Waite, L. (2005).“Marital biography and health.” Plenary address, Smart Marriages and Happy Families Conference, Dallas, TX: Coalition for Marriage, Family and Couples Education. Charts used by permission of the author., based on Lillard, L.A. & Waite, L.J(1995). ‘Till death do us part: Marital disruption and mortality. American Journal of Sociology, 100, 1131-1156.

    14. Children are healthiest growing up with 2 biological parents, compared to other family arrangements(Bramlett & Blumberg, 2003). • Children of divorce have more acute & chronic illness as adults (Maier & Lachman, 2000). • Young children in high-conflict families have high levels of stress hormones, a marker of chronic stress (Gottman & Katz, 1989). • Conflictual marriages AND divorce are both associated with poorer health outcomes for children & teens (Furstenberg & Kiernan, 2001; Kaye et al., 2009). • More ER asthma visits for children of unstable unmarried co-parents (Harknett, 2005). #2 Kids are Healthier

    15. Marital quality, not marital status, explains health benefits - and risks - of marriage for both children & adults: • Negative interactions– criticism, demands, emotional withdrawal – are the biggest risks for poor health. • Frequency of reported positive or supportive behaviors shows little association with better health!(Bookwala, 2005; Umberson 2006; De Vogli, 2007) • Poor marital quality wipes out impact of other health benefits of marriage.(Umberson et al., 2005; Bookwala, 2005) • Couples in very unhappy, distressed marriages have worse health outcomes over 12 years than do equally unhappy couples who divorce in that period (Hawkins & Booth, 2005). #3 Marital Quality is Key

    16. Health & Retirement Survey (HRS)(Waite & Hughes, 2009) • Do you and your spouse/partner like to do things together, or do things apart? • How enjoyable is it for you to spend time together with your partner? • Midlife in the US (MIDUS);funded by Nat’l Institute on Aging • Positive spousal/partner behaviors -- How much: • Does your spouse care for you? • Does your spouse understand the way you feel? • Does your spouse appreciate what you do? • Negative spousal behaviors – How often does: • Your spouse make too many demands on you? • Your spouse make you feel tense? • Your spouse criticize you? How Does Research Measure “Marital Quality”?

    17. #4 Marital Quality and Teen Risk Behaviors • Marital conflict, family disruptions directly affect teen health risk behaviors. (Brown, 2006; Feinberg, et al., 2007) • Teen & later adult health is directly linked to risky health behaviors: smoking, drugs, early sexual activity, delinquency. (Healthy Marriages, Healthy Lives, 2008)

    18. Epigenetics: Why Healthy Families and Healthy Marriages Matter Epigenetics: The study of gene-environment interactions Healthy family processes suppress the expression of genetic tendencies such as aggression, early sexual activity, substance abuse(Halpern, et al., 2007;Guo, Roettger, Cai, 2008). Families that eat together suppress the expression of gene variants (MAOA & DRD2) associated with delinquent/violent adolescent behavior (BOTH male & female) Guo, Roettiger, Cai, 2008).

    19. # 5 Heart Disease Links toMarriage & Marital Quality Married men & women are less likely to die from heart attacks, more likely to return to health (Zhang & Hayward, 2006; Johnson, et al., 2000). Men and women in ‘high-quality’ marriages live longer with CVD, independent of severity of illness, than do those in ‘low quality’ marriages (Coyne, et al., 2001; Rohrbaugh, et al., 2006). Women are more likely to develop early signs of heart disease (metabolic syndrome) if they are in less satisfying relationships (Gallo, et al., 2003).

    20. #6 Marital Quality & Aging • Marital quality has MUCH more impact on adult health as we age:(Umberson, et al., 2006) • Poor health in older adults is directly correlated with negative spousal interactions.(Bookwala, 2005) • Remarriage brings health benefits, making up for negative impacts of divorce.(Sbarra, 2008, Waite, 2005) • Having a spouse in old age reduces nursing home & hospital admissions & protects against loss of ADL.(Schoenborn, 2004)

    21. #7 Partner Support Blocks Stress Support from husband (holding a hand) blocks pain and lowers stress response in happily married wives undergoing experimental electric shocks.(Coan, et al., 2006) “Warm Partner Support” in stressful experimental conditions lowers blood pressure and heart rate, and increases oxytocin, protecting the cardiovascular and immune system. (Grewen, et al., 2003-2005), Light, et al., 2005)

    22. #8 Potential Pathway from Marital Quality to Adult Chronic Illness The big finding! Marital Adults Chronic Major Conflict Chronic inflammatory chronic & Distress Stress response illnesses (immune system) Many Other Sources of Stress Based on Dr. Janice Kiecolt-Glaser presentation “Families & Health: Inflammation as a Central Pathway.” Families & Health Conference, NCMR/NIH, June 2, 2009 Accessed online at

    23. Chronic Illness and Relationship Education in Practice National Multiple Sclerosis Society: Relationship Matters

    24. Risk Factors for a Marriage Living with Chronic Illness • Ongoing unpredictability • Expectations about the relationship are challenged • Strained resources (financially and emotionally) • Symptoms interfere with sexuality, communication and intimacy

    25. How NMSS Relationship Matters Program Addresses the Problems • Allows couples to “normalize” the problem and offer examples, solutions (“we aren’t alone”). • Teaches tools for consistent communication, despite unpredictability. • Encourages couples to embrace adaptations and being open to change (sexuality, having fun, etc.).

    26. Marriage Education Curriculum Designed for Couples Living With MS • Program offers three ways to learn: in-person, teleclasses and online. • Focuses on couple relationship, not caregiving or the person with MS • Offers additional resources through National MS Society (counseling, support groups, financial assistance)

    27. (Data as of 7/2009)

    28. Data as of 7/2009

    29. (As of 7/2009)

    30. Connecting Marriage & Relationship Education to Health Care Reform ME/RE Education More safe, stable healthy marriages • Fewer health risk behaviors • Less chronic stress • Chronic illness prevention • Lower costs for treating physical & mental illnesses (social support, adherence)

    31. Effectiveness of Marriage Education/Relationship Education Several meta-analyses: • 100+ studies: “Clear evidence that Marriage Education programs work— to reduce strife, improve communication, increase parenting skills, increase stability, and enhance marital happiness.” Researchers concluded that “…Marriages can do more than merely survive: They can also thrive when couples learn the skills to make their relationships work.” • Fagan, Patterson & Rector. “Marriage and Welfare Reform: The Overwhelming Evidence that Marriage Education Works.” The Heritage Foundation: Backgrounder #1606.

    32. Effectiveness of ME/RE, cont. Other meta-analyses: • Giblin, Sprenkle, Sheenan, 1985. • Butler & Wampler, 1999. • Markman, et al., 1993. • Carroll & Doherty, 2003. • Hawkins, Blanchard, Baldwin & Fawcett, 2008. • Blanchard, Hawkins, Baldwin & Fawcett, 2009.

    33. Effectiveness of ME/RE, cont. • “Preliminary research shows that marriage education workshops can make a real difference in helping married couples stay together and in encouraging unmarried couples who are living together to form a more lasting bond. Expanding access to such services.. Should be something everybody can agree on…” • Barack Obama, 2006. The Audacity of Hope. New York: Three Rivers Press, p. 334.

    34. 2008 Wingspread Conference Recommendations – Where Marriage Educators Can Start • Look for Health Care Allies: • In ‘patient-centered care’ & Medical Home Model. • Life course transitions in primary health care - dating, new baby, empty nesters. • Lifestyle programs for chronic illness--heart, diabetes, multiple sclerosis. • Early childhood intervention – Head Start, Olds Nurse-Family Partnership. • Education & Continuing Education for medical residents, physicians, nurses.

    35. Words that Open Health Care and Community Agency Doors “Innovative approach to addressing health care problems in the U.S.” “SAFE, stable, healthy families” “Healthy Marriages” “Evidence-based practice” (PREP is listed in SAMHSA NREPP for mental health) “Marital quality”—directly affects adult health “Prevention” of family breakdown

    36. WHY talk about “Marital & Relationship Quality”? Health now recognized as being created through an ongoing interrelationship between bio-psycho-social factors Therefore, the family is a primary place where health is created, or health is damaged The quality of the marital relationship is key to the quality of health created within the family context

    37. Unique Factors about Bio-Health Care & Public Policymakers Inclusiveness for all couples is REQUIRED in health care. Skeptical about marriage: many have been through distressed, low-quality marriage and divorce. Many don’t know the research connecting marital/relationship quality to health outcomes, esp. adult physical health. They cannot afford to be wrong.

    38. YES WE CAN! BE VERY SPECIFIC: ME/RE TEACHES: • Healthy Mate Choice • Safety • Effective Communication & Conflict Resolution Skills • Commitment • Ways to Protecting Friendship & Intimacy

    39. YES WE CAN!, cont. ME/RE targets negative interactions linked to poorer physical & mental health; These targets are difficult and expensive to address downstream and much easier and less costly to address upstream; ME/RE Works; ME/RE is a timely and innovative approach for addressing numerous health care problems; ME/RE helps couples provide long-term and effective social support associated with numerous health outcomes.

    40. SUMMARY • ME/RE can support and increase # of healthy, lifelong marriages; • ME/RE can help reduce enormous social service burden associated with family breakdown; • ME/RE can reduce health care costs resulting from marital distress & family breakdown; • Opportunity and importance for us to communicate this message of alignment.

    41. Full Citations in Notes & on Handout Blanchard , Hawkins, et al, 2009 Bookwala, 2005 Brown, 2006 Butler & Wampler, 1999 Carroll & Doherty, 2003 Coan et al, 2006 Coyne et al, 2001 De Vogli et al, 2007 Fagan et al, 2002 Feinberg et al, 2007 Felitti & Anda, 2008 Furstenberg & Kiernan, 2001 Gallo et al, 2003 Giblin, Sprenkle, Sheenan, 1985 Gottman & Katz, 1989 Grewen et al, 2003-2005 Guo, Roettger & Cai, 2008 Halpern et al, 2007 Harknett, 2005 Hawkins et al, 2008 Hawkins & Booth, 2000 Johnson et al,2000 Kaye et al, 2009 Kiecolt-Glaser, 2009 Light et al, 2005 Lillard & Waite, 1995 Maier & Lachman, 2000 Markman et al, 1993 Rohrbaugh, Schoham & Coyne,2006 Sbarr, 2008 Scafid, 2008 Schoenborn, 2004 Schramm, 2006 Umberson & Williams, 2005 Umberson et al, 2006 Waite, 2005 Wood et al, 2007 Zhang & Hayward, 2006 42

    42. Thank you for being involved in this with us! • Jana Staton • • Patty Howell • • Lara Rezzarday •

    43. We Have a Great Opportunity to Contribute