## Gabriele Doblhammer Jordi Gumà Editors

# A Demographic Perspective on Gender, Family and Health in Europe

A Demographic Perspective on Gender, Family and Health in Europe

Gabriele Doblhammer • Jordi Gumà Editors

# A Demographic Perspective on Gender, Family and Health in Europe

Editors Gabriele Doblhammer Institute for Sociology and Demography University of Rostock Rostock Germany

and

German Center for Neurodegenerative Disease (DZNE) Bonn Germany

and

Rostock Center for the Study of Demographic Change Rostock Germany

Jordi Gumà Department of Political and Social Sciences University Pompeu Fabra Barcelona Spain

ISBN 978-3-319-72355-6 ISBN 978-3-319-72356-3 (eBook) https://doi.org/10.1007/978-3-319-72356-3

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## Contents

## Contributors

Isabella Buber-Ennser Wittgenstein Centre (IIASA, VID/ÖAW, WU), Vienna Institute of Demography/Austrian Academy of Sciences, Vienna, Austria

Giorgio Di Gessa Department of Global Health & Social Medicine, King's College London, London, UK

Gabriele Doblhammer German Center for Neurodegenerative Disease (DZNE), Bonn, Germany; Faculty of Economics and Social Sciences, Institute for Sociology and Demography, University of Rostock, Rostock, Germany; Rostock Center for the Study of Demographic Change, Rostock, Germany; Max Planck Institute for Demographic Research, Rostock, Germany

Viviana Egidi Department of Statistics, Sapienza University of Rome, Rome, Italy

Daniela Georges Institute for Sociology and Demography, University of Rostock, Rostock, Germany; Rostock Center for the Study of Demographic Change, Rostock, Germany

Patrizia Giannantoni La Sapienza University of Rome, Rome, Italy

Jordi Gumà Department of Political and Social Sciences, University Pompeu Fabra, Barcelona, Spain

Doris Hanappi University of California, Berkeley, Berkeley, USA; Austrian Academy of Sciences (ÖAW), Vienna, Austria

Karsten Hank Institute of Sociology and Social Psychology, University of Cologne, Cologne, Germany

Irena E. Kotowska Institute of Statistics and Demography, Warsaw School of Economics, Warsaw, Poland

Daniel Kreft Institute for Sociology and Demography, University of Rostock, Rostock, Germany; Rostock Center for the Study of Demographic Change, Rostock, Germany

Anna Oksuzyan Max Planck Institute for Demographic Research, Rostock, Germany

Livia Sz. Oláh Department of Sociology, Stockholm University, Stockholm, Sweden

Steffen Peters Rostock Center for the Study of Demographic Change, Rostock, Germany

Petra Rattay Robert Koch Institute, Berlin, Germany

Rudolf Richter Department of Sociology, University of Vienna, Vienna, Austria

Debora Rizzuto Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Aging Research Center, Stockholm, Sweden

Anja Steinbach Institute of Sociology, University of Duisburg-Essen, Duisburg, Germany

Cecilia Tomassini Department of Economics, University of Molise, Campobasso, Italy

Elena von der Lippe Robert Koch Institute, Berlin, Germany

Anna-Karin Welmer Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Aging Research Center, Stockholm, Sweden

## Framework

#### Jordi Gumà and Gabriele Doblhammer

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

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

J. Gumà (&)

Department of Political and Social Sciences, University Pompeu Fabra, Barcelona, Spain e-mail<EMAIL_ADDRESS>
G. Doblhammer Institute for Sociology and Demography, University of Rostock, Rostock Germany e-mail<EMAIL_ADDRESS>
<sup>©</sup> The Author(s) 2018

G. Doblhammer and J. Gumà (eds.), A Demographic Perspective on Gender, Family and Health in Europe, https://doi.org/10.1007/978-3-319-72356-3\_1

resources of different natures (economic, knowledge, social ties, etc.) and share these with the other members, thus compensating for or reinforcing existing individual advantages or disadvantages.

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

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

#### The Triangle Between Health, Gender, and Family

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

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

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

#### Different Approaches to the Concept of Family

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

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

#### Individual Level Characteristic

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

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

#### Household Level Characteristics

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

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

#### Different Approaches to the Concept of Health

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

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

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

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

#### The Concept of Sex Versus the Concept of Gender

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

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

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

#### References

Open Access This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

The images or other third party material in this chapter are included in the chapter's Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the chapter's Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder.

## Summary and Research Implications

Gabriele Doblhammer and Jordi Gumà

Despite considerable changes in family forms during the past decades, the influence of family on health is strong and persistent. All over Europe the elderly still live in more traditional family forms related to marriage and their family biographies are closely tied to the civil status of their partnership. On the other hand, new family forms have been emerging among the young, yet the prevalence and acceptance of these forms differs widely between societies. At a young age, the distribution of paid and unpaid work within the household is largely gendered, and in the case of families with children it is centred around the care provision for children; at old age, when paid work has ceased and income is secured by pension systems, the distribution of unpaid work is less of an issue, while the care provision for partners is at the heart of gendered family responsibilities.

Among the young and middle aged adults, where variability in health is low, little is known about new family and partnership forms, their relationship with health, and the pathways through which they act. The young population is heterogonous in terms of their ethnic background, and little is known whether the relationship between family forms and health is universal in a society or dependent on migration background and the respective values and norms. And little is known to what extent advantaged and disadvantaged family forms are universal in different welfare state regimes or whether they depend on the social and cultural context of a society.

Among the old, when different ageing trajectories result in an increasing variability in individual health, the health of the partner becomes even more important; in combination with an individual's own health there might be strong mutual

G. Doblhammer (&)

J. Gumà

#### Department of Political and Social Sciences, University Pompeu Fabra, Barcelona, Spain e-mail<EMAIL_ADDRESS>
Institute for Sociology and Demography, University of Rostock, Rostock, Germany e-mail<EMAIL_ADDRESS>
<sup>©</sup> The Author(s) 2018

G. Doblhammer and J. Gumà (eds.), A Demographic Perspective on Gender, Family and Health in Europe, https://doi.org/10.1007/978-3-319-72356-3\_2

influences. Thus, the present family situation and abrupt changes may become more important for an individual's health when compared to the lifelong family biography. Not much is known about if or how partners advancing in age start to resemble each other more closely in terms of health and how the health of the partner influences an individual's own health. Little is known about how geographical and emotional closeness or distance of family members affects health.

In the following we summarize and discuss the main findings of this book by touching on the issues mentioned above. While all these studies explore novel aspects in the triangle of health, family, and gender, they can provide only some insight into this wide-ranging topic. We will first focus on the relationship between traditional and new family forms and health among the young, then turn to the effect of partnership and parenthood among the old, then discuss some of the possible pathways, and end with future possible research directions. We try to give an encompassing view of all studies in this book but point out that the individual authors discuss their findings and future avenues of research in much more detail.

#### Traditional Family Forms, New Living Arrangements and Health Among the Young and Middle Aged

In all young and middle aged populations studied, the best health is found among the married and those living together with a partner, who have two or more children. This is true for all welfare state regimes (Doblhammer and Gumà) and, in the case of Germany, for both migrant and non-migrant groups (Georges, Kreft, and Doblhammer). This health advantage is larger for women than men and it is generally the case that women's health depends on household characteristics to a larger extent than does men's health (Doblhammer and Gumà).

While for women new family forms are by and large associated with a health disadvantage, the extent of this disadvantage differs between welfare state regimes. Most of the findings described below stem from cross-sectional perspectives; in the Austrian study (Buber-Ennser and Hanappi) they become even stronger in a longitudinal perspective when union dissolution and separation are studied, which generally result in worse health.

#### Consensual Unions and Stepfamilies

In Austria, women living in a stepfamily where at least one partner has a pre-union child, either living in the household or not, have worse health (Buber-Ennser and Hanappi). This finding is supported by the cross-country study for selected European countries where cohabiting women (with or without children) have worse health than the married (Doblhammer and Gumà). These effects seem to be largely the result of financial deprivation, because the inclusion of variables indicating the ability to financially make ends meet partly or fully attenuate the observed relations. Furthermore, poor health in complex stepfamilies is particularly prevalent among people with less education and is absent among the highly educated. In addition to financial aspects, another important influence appears to be a society's value climate towards new family forms. When the value climate is indirectly measured in terms of the proportion of a certain family form, the disadvantage of new family forms is smaller (or even disappears) in societies where they are comparatively more frequent.

Concerning stepfamilies and cohabitation, similar but much weaker health tendencies exist for men, which are statistically not significant. Financial difficulties are a less important mediator, and on the contrary cohabiting men seem to be better off in financial terms. Thus, there is a strongly gendered effect of the household structure on health.

#### Single Parents

Single mothers have worse health than the partnered in all countries studied and this is due largely to financial difficulties. While the negative effects of consensual unions disappear in societies where they are more frequent, this is not true for single mothers (Doblhammer and Gumà). The more frequent they are, the higher the disadvantage in terms of their health. Financial difficulties or deprivation partly explain this disadvantage. Single mothers are more prevalent in the Nordic Dual-Earner welfare states, where partners usually rely on two incomes, which makes it particularly difficult for single mothers to generate sufficient household income. Another important aspect may be the lack of a partner in daily childcare and household chores, a lack of general support by friends, family and society, and the burden of increased or even sole responsibilities for the child.

#### Living Apart Together

Another new living arrangement is living apart together (LAT) which has been studied in the Austrian context (Buber-Ennser and Hanappi). This is the only study among the young which did not confine family to the household and in which information about partners living outside the household was available. Both men and women in a LAT relationship experience better health, but for men the effect is larger than for women and statistically significant. When it comes to health, financial factors do not seem to play an important role.

#### Generational Household Composition Among Migrants and Non-migrants

While new family forms are negligible among the migrant groups studied in Germany, they differ markedly by their generational composition. Migrants from Turkey and Aussiedler, who primarily stem from countries of the former Soviet Union, more often live in a multi-generational household context than Germans (Georges, Kreft, and Doblhammer). These three groups also differ concerning their individual values, cultural norms, and their social backgrounds. Thus, one might expect differences in the effect of the household structure on individual health by migration background. The study, however, reveals (with few exceptions) a similar relationship in all three groups: individuals living in two generation households with multiple children, i.e. a couple with two or more children, have superior health compared to all other groups, and individuals living in a one generation household have the worst health. Living without a partner is negatively associated with health, and the extent of the effect is similar for all three groups. Furthermore, in all three groups women's health depends to a larger extent on the household form, but most importantly, the effect of a specific household form on health is equally gendered among migrants and native Germans. It is difficult to interpret this finding because it can imply two things. On the one hand, the social structure of German society, in the form of its welfare state, the health system, and the prevailing norms and values may simply overrule any differences in the relationship between household form and health that might result from different cultural backgrounds. On the other hand, Turkish migrants and Aussiedler in Germany, many of whom have spent extended periods in Germany, may have adopted norms and values of the majority populations with regards to family composition and health.

#### The Relationship Between Family and Health Among the Elderly

At young and middle ages the household composition influences women's health in particular and creates a disadvantage for all women who do not follow the traditional family norm of living in a marriage with two or more children. While similar tendencies do exist for men, the effects are much smaller. At old age this gendered response changes, with men's health becoming equally dependent on the household and family composition. Two country studies of Italy (Tomassini, Di Gessa, and Egidi) and Sweden (Doblhammer, Peters, Rizzuto, and Welmer) come to this conclusion, albeit by examining two populations with widely different welfare states, family values, and norms, and by using different health measures and study designs. In addition, a third Italian study (Giannantoni and Egidi) concludes that with advancing age the members of a household become more equal in their health outcome.

#### Children and Health

One of the two Italian studies investigates the relationships between fertility and late life health in a familialistic welfare state system where the family is at the centre of care provision, cohabitation between different generations is more frequent, and gender roles are more traditional (Tomassini, Di Gessa, and Egidi). In this context, the dependency between fertility and later life health for women may be even larger than in other populations for two reasons. First, health selection into fertility might be stronger due to social pressure into marriage and fertility, leaving the "unfit" more often unmarried and/or childless. Second, the negative consequences of having a large number of children might be stronger because the care burden of rearing the children has to be mainly covered by mothers (and grandmothers). On the other hand, large family networks might reduce stress related to child rearing by distributing care work on more (family) shoulders. The selection argument also holds for men, and large numbers of children would create additional pressure on fathers to provide economic resources. However, as this study focuses on elderly women and men, one might not expect such a large difference compared to other welfare state regimes, because the childbearing period of the cohorts observed usually took place before or at the beginning of the second demographic transition, at a time when welfare states, household compositions, and gender roles did not differ to such an extent as they do today.

At a first glance the Italian study reveals similar patterns to what was previously observed in other populations. Namely, health is best for mothers with one or two children; large numbers of children are detrimental to various health domains of mothers and also, to some extent, of fathers and the relationship is generally stronger among women than men. Most interestingly, the detrimental health effect is not modified by the quantity of contacts between mothers and children. Thus close relations with adult children might not be able to buffer the negative consequences of repeated pregnancies. These results are reflected in the Swedish study (Doblhammer, Peters, Rizzuto, and Welmer) insofar that having children is definitely beneficial for men's health but not necessarily for women's health. The Swedish study is set in a welfare state system in which the state is the centre of care provision, but in which more recently the family, and in particular the partner, has become more important in providing care. Cohabitation between old and middle aged generations is not frequent, and gender roles are more equal. While the Swedish study, due to sample size, was not able to look into the relationship by number of children, it was obvious that in terms of health men profited more from fatherhood than women do from motherhood.

In Italy, the childless do not suffer from worse health, which, given that health selection into childlessness does exist, might point towards the possibility that parenthood is also associated with negative social consequences that are avoided by being childless. On the other hand, only the fittest childless individuals might have survived until old age. The Swedish study permitted a somewhat deeper insight by differentiating between being childlessness while living with a partner and being childless without a partner. There it was interesting to see that the childless in partnerships had the fastest deterioration of health, which might be an indication of negative health selection having taken place.

The Italian study showed that social factors are able to modify possible biological effects of fertility on late life health. First, there was no effect of closely spaced children on any of the health domains late in life, which may point towards beneficial and stress reducing effects for parents rearing children in a closely knit family environment. In addition, having a child very early in life was positive for late life health among women in Southern Italy, while it was detrimental in Northern Italy, which may be related to a higher acceptance of early and high fertility in the South. Interestingly, indicators of marital history and early childhood circumstances did not influence the relationship between fertility and health, despite being significant themselves.

#### Partner and Health

In the above mentioned Italian study, present marital status was more predictive of health than the marital biography, and the presently married generally had better health. While the latter result was particularly strong and significant for self-rated health and limitations, it was also a tendency for ADL, IADL, and depressive symptoms. The Swedish study further extends these findings, by showing that in terms of walking speed as an indicator of health, living in a partnership is more beneficial for men than for women; for women it can even be detrimental. For men there is a positive relationship between walking speed and the number of possible resources of help in the family: the childless without a partner have the slowest walking speed, those with children and a partner have the fastest. For women no such relationship exists: children tend to be slightly positively related to walking speed, partners have a negative influence on walking speed.

In conclusion, the two studies provide strong evidence that biological factors partly underlie the relationship between fertility and late life health, particularly among women, but that this relationship is widely responsive to the social environment. In addition, living with a partner at old age can be beneficial, which is mainly seen for men. For women, however, it can also create an additional burden due to care giving which reflects negatively on their own health. Most interestingly, these findings appear to be independent of the welfare state regime.

#### The Effect of the Household Level on Health

The question whether the impact of the household situation on the health of its individual members differs in a familialistic welfare state regime is taken up in a different study (Giannantoni and Egidi). In the special context of Italy, dependent on the health indicator used, about 15–38% of the variability in health can be attributed to joint factors at the household level. These figures fall into the range reported by other studies, which, however, deal primarily with less developed countries. Figures reported for the US are between 9 and 15%. Most interestingly, the study reveals that the health of household members is more homogenous in small families and within couples, and that homogeneity increases with age, despite the fact that the variability in individual health increases with age. The authors attribute this increasing homogeneity not only to similar health determinants within a household, such as nutritional choices or prevention attitudes, but also to mutual influences, which they define in relation to the health outcome itself. In other words the good or poor health of one household member may influence the health outcomes of the other members. Whether this effect is stronger for men or for women cannot be answered based on the cross-sectional data the study uses, because a time reference for the deterioration of the health among partners is missing. Here, again, the Swedish study sheds some more light by showing that living in a partnership is not necessarily beneficial for the health of women, while it is definitely positive for men. Thus, as the authors of the Italian study hypothesize, the "contagion" of poor health from men to women might be stronger than from women to men. At the centre of this "contagion" is certainly the gender specific role of care provision in the context of lower life expectancy and earlier health deterioration among men. While there is strong evidence on the negative effects of the care giver burden, still more research is needed regarding to what extent this burden can be relieved by the health system in particular, the welfare state in general, as well as social attitudes in terms of formal and informal care provision. There is ample evidence that the care giver burden is particularly large when care is provided due to feelings of obligations rather than voluntarily. In addition, it is unclear to what extent the psychological effects of the poor health of a close family member exert a negative influence on the health and well-being of others independent of the burden of care giving.

#### Pathways

All studies in this book show that family type is correlated with social status measured, e.g. in terms of education, occupational status, and income, and that social status explains some of the differences in health by family status. However, much remains unexplained and other important pathways must exist additionally. Two pathways have been explored in detail in the individual country studies: financial difficulties and health behaviour.

### Financial Difficulties

One important factor is financial difficulties measured in terms of the ability to make ends meet. This is a very powerful indicator that explains the disadvantaged health among women living in new family forms such as stepfamilies, consensual unions with or without children, and very importantly, of single mothers (Buber-Ennser and Hanappi). It accounts for many of the significant differences between women living in new family forms and married women with children. Interestingly, this is not the case for men because accounting for the presence of financial difficulties even increases the extent of male health differences by family status. This implies that financial responsibilities partly depress the health of married fathers, less so the health of men living in other family forms.

Financial deprivation is not only an important pathway in populations where new family forms are less frequent, such as the Familialistic and Transition Post-Socialist welfare states, but also in the countries of the Dual-Earner and the General Family Support regimes (Doblhammer and Gumà). However, the types of new family forms sensitive to financial deprivation differ. In the Nordic Dual-Earner welfare states, living in a consensual union has become an alternative to marriage even when children are present. These family types do not necessarily experience financial difficulties, and while women do suffer some disadvantage in health as compared to the married, the difference is rather small. In many of the other countries, however, consensual unions are often a transitory phase to marriage with probably little difference in the health outcome, but often they are also characterised by fragile living arrangements with low household income, instable and changing partnerships, and insufficient social support from family and friends. Women living in these types of consensual unions may indeed be very similar to single mothers, who are among the most disadvantaged groups in all welfare state regimes. Despite the high labour market involvement of single mothers (the latest OECD figures show that in all welfare states their labour participation reaches or even surpasses that of married women) they have a high risk of financial deprivation mainly due to part-time employment and the foregone income of a second adult household member.

#### Life-Style Factors

In addition to social status and financial deprivation, life style factors turn out to be an important pathway of differences in health by family status. Among German young and middle aged adults, those married with children follow better health behaviours in terms of diet, smoking, physical activity and alcohol consumption (von der Lippe and Rattay). Some of these differences, however, appear to be mediated by social status, e.g. the healthier diet of married women and men, while others such as the higher prevalence of smoking among the divorced and widowed are independent of social status. Here it is interesting to note that for both genders children have a genuine effect on better diet starting with the arrival of the first child, and smoking is less prevalent among parents with two or more children independent of social status.

As mentioned previously, single never married and divorced mothers are a particularly vulnerable group with the highest odds of smoking and at-risk alcohol consumption (although they do appear to be physically more active). This group is exposed to reinforcing risk factors of poor health, starting with financial deprivation and lack of social resources and appreciation, to unhealthy behaviour.

The number and ages of children are significant modulators of these associations. Having a higher number of children and living together with pre-school children usually leads to better health behaviour. While the German study is based on cross-sectional data, this finding hints at important life-course changes in health behaviour associated with the family biography.

Healthy behaviour appears to be linked with parenthood more closely among women than men and it has been suggested that this has to do with the social roles occupied by men and women. While the partnership status per se does not have a gendered influence on health behaviour in present day Germany, it did have a gendered impact in the past. One may speculate that this shall have to do with a disappearance of specific gender roles over time, with women being strongly involved in the labour force and men becoming more involved in household chores. However, the arrival of a first, and even more often, of a second child usually results in taking up more traditional social roles leading to gendered health behaviour of parents.

#### Biological Pathways

While the pathways described above are of social origin, some of the studies also pointed towards biological pathways, although we were not able to test these directly. Health selection into partnership status as well as into childlessness is to some extent certainly a biological phenomenon. More important, however, is the finding that among women high fertility may go together with worse health in the long-term. In the Italian study (Tomassini, Di Gessa, and Egidi), none of the indicators included in the partnership biography could explain the increase in poor health by repeated pregnancies, and frequency of contacts with children at old age also could not account for the negative strain. The biological origin of the health disadvantage is further strengthened by the absence of strong health patterns in relation to the number of children among men. The keynote chapter on gender and health discusses hormonal and genetic foundations of health differences between men and women (Oksuzyan, Gumà, and Doblhammer). These biological foundations may also be associated with fertility histories. Still, the societal context may be able to modify possible biological pathways, as pointed out by the keynote chapter on families and health.

#### Future Research Directions

Present research has widely documented the differences in health by family status between different populations at a specific point in time, different groups within population, for the young and middle aged, and the old.

The next step in understanding these differences must overcome the traditional characterization of family status by marital status, partnership status, or parenthood characteristics. Some of the studies in this book have started in this direction, but only first steps have been taken. One way to proceed further is to characterize fragile and non-fragile living arrangements. This categorization cannot only rely on the present family status but also has to include partnership and fertility biographies, in particular frequently changing and unstable partnerships as well as major disruptions such as the birth of a child, and the end of a partnership such as divorce or widowhood. The characterization of fragile family forms is of great importance among the young and middle aged where the new family forms have been emerging. However, they also need to be identified among the old, where it has probably more to do with geographical and emotional closeness or distance among family members not living in the same household.

This characterization could shed more light on the underlying pathways such as the immediate and long-lasting effects of financial deprivation, risky health behaviours, lack of social support, care obligations, etc. These pathways change over the course of family biographies, leading to periods of life with more or less positive health repercussions. These different periods may reinforce or counterbalance each other, and healthy or unhealthy behaviour during specific time periods or at specific family situations may have a particularly positive or negative outcome for immediate or long-lasting health.

When exploring sensible time periods and ages, not only the health of adult but also of child and adolescent members of a household should be investigated. This aspect was briefly touched upon in one of the keynote chapters of the book but was not taken further in the individual studies. Similar to other early-life influences, the question arises whether certain family situations do have an immediate or long-lasting effect on a young individual's health by initiating a certain pathway or by acting at a vulnerable age.

Another important step is to explore changes in health differences by family forms over time. With new family forms developing in the course of the second demographic transition and the emergence of new gender roles, the selection forces into specific family forms have also been changing and will continue to do so in future. Dependent on the social acceptance and, thus, on the social support of new family forms, one would expect a weakening (high acceptance) or strengthening (low acceptance) of the health advantage of the married (with children) with respective changes in gendered health behaviours, financial situation, and the distribution of paid and unpaid work.

In many European societies the baby boomer cohorts are among the forerunners of new family forms. They have been starting to approach young old age in recent years and will continue to do so in the near future. They will be the first cohorts in which new family forms at old age will become more prevalent and much may be learnt in studying their health profile in comparison with previous cohorts at the same age.

Over the last decades European societies have become more diverse due to migrant populations. These populations differ significantly in their family composition within households but also beyond the household. Earlier migrant cohorts are now approaching old age and little is known whether their relationships between family composition and health differ from those of the majority population. Other important migrant specific questions are whether family composition is related to re-migration and whether this is correlated with health, and whether life-course influences, such as age at migration, modify the relationship between family composition and health.

While working on this book it became ever more obvious that family demographers interested in the formation and dissolution of families, as well as the gendered distribution of tasks within families and demographers interested in morbidity and mortality, need to work together more closely. In order to gain a better understanding of the underlying processes in this wide-spread research area we will need to overcome the traditional boundaries in the field of demography.

But also boundaries between disciplines must be overcome to translate research findings into policy recommendations. Among others, demographers, health economists, political scientist and sociologists working on poverty and social inequality need to combine their research efforts to come up with ideas and suggestions for policies which can help battle poor health associated with certain family situations.

We close this summary of findings and ideas by observing that the relationship between health, family, and gender is a perfect example of the paradox that research leads to a better understanding, but even more, to unsolved puzzles. We hope that our contribution in the form of this book provides both new insights and new questions.

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## Part I Keynote Chapters

## Families and Health: A Review

Karsten Hank and Anja Steinbach

#### Introduction

Social scientists interested in individuals' health (and health inequalities) may take two—complementary—general perspectives: a life-course perspective (e.g., Kuh et al. 2003) and a contextual perspective (in which relevant social contexts may be defined at very different levels of aggregation, ranging from personal social networks to welfare states; e.g., Deindl et al. 2016). Arguably, the family context not only constitutes a core element of most individuals' social network structure, it also accompanies the individual across the entire life-course. Understanding the role of family in shaping individuals' health thus seems an important task, one which has received considerable attention in various social science disciplines (for recent reviews see Arránz Becker et al. 2017; Carr et al. 2014; Rapp and Klein 2015).

In this review, we basically follow the World Health Organization's definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity", that is, health is conceptualized as a multidimensional outcome with objective and subjective components. The role of family in health is considered from the adult's perspective [focusing on partnership (Section "Partnership and Adult Health") and parenthood (Section "Parenthood and Adult Health")] as well as from the child's perspective [focusing on the consequences of parental separation and divorce (Section "Family Structure and Child

K. Hank (&)

Institute of Sociology and Social Psychology, University of Cologne, Cologne, Germany e-mail<EMAIL_ADDRESS>
A. Steinbach Institute of Sociology, University of Duisburg-Essen, Duisburg, Germany e-mail<EMAIL_ADDRESS>
© The Author(s) 2018

23

G. Doblhammer and J. Gumà (eds.), A Demographic Perspective on Gender, Family and Health in Europe, https://doi.org/10.1007/978-3-319-72356-3\_3

Well-Being")]. We also review findings from research addressing the association of childhood circumstances (Section "Childhood Circumstances and Later Life Health") and intergenerational family relations (Section "Intergenerational Family Relations and Health") with health. This chapter concludes with a brief outlook on directions for future research (Section "Conclusions and Future Directions"). While our primary interest is on universal relationships between individuals' family context (histories, respectively) and different health outcomes, we are well aware of possible cross-national variations. Because in many cases the empirical evidence available is predominantly based on studies from the United States, we explicitly seek to include an overview of European research.

#### Partnership and Adult Health

Marriage has long been suggested to have a protective effect on health (including survival; for reviews see Koball et al. 2010; Rendall et al. 2011). Such a causal effect is said to result from both economic advantages and social support inherent in a marriage. Men in particular are purported to enjoy health benefits, as they tend to engage in healthier and less risky behaviors once married (e.g. drinking less alcohol and driving more carefully). However, caution is necessary: First, married people may overestimate their health, and the protective effect that marriage accords may diminish at the most severe levels of health (Zheng and Thomas 2013). Second, even more importantly, selection effects are likely to play a role here, as better health may affect one's chances to get (and remain) married. Healthier individuals may be more likely to possess characteristics such as a higher socio-economic status or greater physical attractiveness, making them more desirable (and more stable) marriage partners than those in poor health.

Even if selection is accounted for, a salutary effect of being married for a variety of physical and mental health outcomes has been demonstrated repeatedly (but see Kalmijn 2017). More recently, effects of changes in marital status and the consideration of marital biographies have received growing attention (e.g., Dupre and Meadows 2007; Hughes and Waite 2009). One important finding from this research is that dimensions of health which develop rather slowly, such as chronic conditions or mobility limitations, tend to be more strongly affected by marital history (pointing to the importance of time spent in a specific status), whereas others, such as depressive symptoms, seem to react more sensitively to current marital status.

Divorce has long been suggested to bring about negative short- and long-term effects on health, even among those who remarried (e.g., Lorenz et al. 2006). A recent European study, however, provides evidence for heterogeneous (that is, gendered) effects of union dissolution on self-assessed health: While for men separation more often leads to increases rather than decreases in health, women fare worse more often than well just after union dissolution (Monden and Uunk 2013). Gendered social pathways also seem to exist, if the reverse causal relationship is considered: Karraker and Latham (2015) found that only wives' onset of serious physical illness is associated with an elevated risk of divorce. There appear to be no gender differences, though, if the relationship between widowhood and health (specifically depression) is considered (e.g., Sasson and Umberson 2014; Schaan 2013). Across marital groups, the continuously married are better off compared to the widowed, whereas early (long-term) widowhood is associated with worse outcomes than late widowhood. Moreover, individuals reporting higher marital quality at baseline experience larger increases in the number of symptoms of depression after having entered widowhood than those with lower marital quality (see Walker and Luszcz 2009, for a review).

Along the same lines, Hank and Wagner (2013) found that having a partner does not contribute to greater psychological well-being per se: Only those reporting satisfaction with the extent of reciprocity in their relationship report lower numbers of depression symptoms than their unmarried counterparts. There is also evidence that marital strain accelerates the typical decline in self-rated health occurring over the life-course. This adverse effect has been shown to be similarly strong in men and women and to be greater at older ages (Umberson et al. 2006; also see Xu et al. 2016). Staying unhappily married may even be more detrimental to health than divorcing, as people in low-quality marriages were found to exhibit lower levels of overall well-being, largely independent of whether they remain unmarried or remarry (see Hawkins and Booth 2005).

Effects of marriage (marital history) on mortality have been investigated in the US (e.g., Henretta 2010; Rendall et al. 2011) as well as in a variety of European settings (e.g., Blomgren et al. 2012; Brockmann and Klein 2004). There is a consistent survival advantage of being married over unmarried both for women and—particularly—for men. Little evidence, however, is found for mortality differences between never-married, divorced/separated, and widowed statuses (see Shor et al. 2012a, b, for recent meta-analyses). Into an individual's current status, the marital biography has also been shown to be relevant: For example, multiple transitions into and out of marriage as well as a lower proportion of adult life spent married have been found to be associated with a higher hazard of dying after age 50 (also if current marital status is controlled for), even though the relationship tends to weaken at older ages.

Finally, although there appears to be some universality in the marriage-healthnexus reported above, it still seems important to situate marriage cohorts in their specific historical social contexts (cf. Newton et al. 2014; Schaan 2013). This also includes accounting properly for the growing complexity of relationship histories, that is, considering marriage alone is no longer sufficient to understand how living with (or without) a partner affects health (e.g., Schneider et al. 2014).

## Parenthood and Adult Health<sup>1</sup>

Closely intertwined with individuals' partnership histories (and their association with adult health) is the reproductive history and the parenthood-health-nexus (cf. O'Flaherty et al. 2016; Kravdal et al. 2012). Two causal mechanisms have been suggested to drive the relationship between individuals' fertility and later life health outcomes including survival (see, for example, Grundy and Tomassini 2005; Mirowsky 2005; Henretta 2007). First, there is evidence for biological effects, that is, direct long-term physiological and psychological implications of women's reproductive history on particular diseases. Most notably, breast cancer as well as other cancers of the female reproductive system were shown to be associated with pregnancy, childbirth, and lactation (see Grundy and Kravdal 2010, for a recent analysis).

Second, childbearing has been proposed to be related to a variety of social factors that might have both positive and negative effects on women's and men's health in later years. Specifically, differences in socio-economic status, social relationships, and health behaviors across the life-course have been put forward as being potentially relevant in this regard (e.g., Grundy and Tomassini 2005; Henretta 2007; Kendig et al. 2007). Having children may lead to economic strain, and particularly early as well as non-marital childbearing are likely to be related to lower socio-economic status and poorer family functioning over the life course (cf. Mirowsky and Ross 2002; Koropeckyj-Cox et al. 2007). There also is considerable potential for role overload and stresses related to raising children, particularly among lone parents. This, however, is contrasted by potentially health enhancing aspects of parenthood, such as greater opportunities for community participation and social support by children in later life. Moreover, parenthood may be associated with incentives—and social pressures—to adopt healthier behaviors (e.g., Fletcher 2012; Perales et al. 2015). The net effect of these factors not only varies according to individuals' socio-economic circumstances, but also with particular fertility pathways (e.g. the timing of births).

The relative importance of these biological and social mechanisms in determining the childbearing-health-nexus is still poorly understood (cf. Grundy and Read 2015). Causal analysis is further complicated by a range of possible selection effects, that is, by factors affecting both fertility and health. For example, individuals with a poor initial health endowment may not only be less fecund than their healthier counterparts, but they are also less likely to marry; i.e., their opportunities to become a parent and to enjoy the health benefits of marriage are reduced as well (see Section "Partnership and Adult Health" for details).

Although there is empirical evidence for a differential effect of childbearing (particularly timing of births) on specific physical health outcomes, such as diabetes, cardiovascular disease, or cancer (e.g., Alonzo 2002; Henretta 2007), many studies have used composite health indices or other general health measures, such as individuals' self-rated health (e.g., Hank 2010; Mirowsky 2005; Sudha et al.

<sup>1</sup> This section draws heavily on Hank (2010: 277–278).

2006). Findings suggest that high parity (six or more children), early first birth, and the experience of infant death or pregnancy loss are associated with worse self-reported health at older ages. Early childbearing also bears a clear positive correlation with the prevalence of limitations in activities of daily living, whereas no significant effects of high parity were found. Looking at the presence of limiting long term illness, Grundy and Tomassini (2005) reported higher risks among older women with five or more children and those who had a teenage birth. Controlling for parity, mothers with short birth intervals were more likely to experience long term illness, whereas those who had a late birth (at age 40 or later) exhibited a reduced risk. Mirowsky (2005), however, reported a steep increase in later life general health problems among women who delayed their first birth beyond age 40.

Unlike other major social roles, a clear relationship between parenthood and psychological well-being (depression) could not be identified by previous research (e.g. Evenson and Simon 2005; Hank and Wagner 2013; Kruk and Reinhold 2014). Some studies suggest that older childless men and women exhibit lower levels of depressive symptoms than parents, particularly if they are compared to those who had their first child early (e.g. Henretta et al. 2008) or whose relationship with their offspring is of poor quality (e.g. Koropeckyj-Cox 2002). More recently, however, Huijts et al. (2013) found that being childless is associated with worse psychological well-being for men (but not for women). Also, Grundy et al. (2017) showed that in Eastern, but not Western, European countries childlessness and having one compared with two children were associated with more depressive symptoms.

Studies dealing with individuals' childbearing histories and mortality (for reviews see Högnäs et al. 2017; Hurt et al. 2006) generally suggest that early childbearing tends to be associated with a higher hazard of dying, whereas late children enhance women's longevity (e.g., Doblhammer 2000; Mirowsky 2005; Henretta 2007).2 Grundy and Kravdal (2008), however, reported a positive association between earlier parenthood and later mortality as well as a reverse association with late age at last birth in Norway (with similar results for both men and women). Moreover, the authors found an overall negative association between higher parity and mortality, which is only partially consistent with Doblhammer (2000), for example, who showed for England/Wales and Austria that childless women and those with three or more children experienced excess mortality (also see Grundy and Tomassini 2005). Henretta (2007), however, did not find evidence for an effect of the number of children ever born on mortality. It seems important to keep in mind that even if the influence of reproductive history on longevity is statistically significant, it generally "is small compared to differences in longevity stemming from environmental factors such as level of education or family status" (Doblhammer 2000: 175; also see Hurt et al. 2006).

Recent evidence indicates that the fertility-health-nexus described above might vary across different societal contexts (e.g., Grundy 2009; Grundy and Foverskov 2016; Hank 2010). Along these lines, Grundy and Kravdal (2008) suggested that

<sup>2</sup> See Christiansen (2014) for an investigation of the association between grandparenthood and mortality.

'family friendly' policies—such as generous parental leave regulations (cf. Aitken et al. 2015; also see Guertzgen and Hank 2018)—may have resulted in long-term health benefits for parents.

#### Family Structure and Child Well-Being

In addition to child maltreatment (see Greenfield 2010; Oswald et al. 2010; Prosser and Corso 2007 for reviews), parental separation and divorce have been identified as major family-related threats to children's health or—more generally well-being. Following Moore et al. (2014), four dimensions of child well-being may be distinguished: (a) Physical well-being refers to children's overall physical health. (b) Psychological well-being reflects how children think about themselves, their future, and how they manage their emotions and situational demands. Specific aspects of psychological well-being include internalizing and externalizing behavioral problems, prosocial behavior and depression, perception of stress, self-worth, perceived autonomy, and participation. (c) Social well-being is related to how comfortable children are with social relationships. Of foremost importance are parent-child relationships (involving both biological and step relations), especially positive communication and other elements of good relationship climate. It also includes, however, the quality of peer relations. (d) Cognitive and educational wellbeing encompasses children's learning abilities and their utilization of educational opportunities, which also bear a close association with (long-term) health outcomes. Increasingly, the focus has expanded from a deficit-oriented approach—involving, for example, deprivation, risk behaviors, and the absence of health—to positive quality of life outcomes from the child's perspective.

Empirical studies—primarily from the US—generally indicate that children with separated or divorced parents tend to score worse than children who live with both biological parents on measures of a range of behavioral, emotional, social, or cognitive outcomes (for overviews see Amato 2010; Jeynes 2006; Sweeney 2010) and the resulting inequalities have been shown to—potentially—last through adulthood (Kalmijn 2008, 2013; Klaus et al. 2012; Steinbach 2013). Because the majority of theoretical approaches employed to explain the differences in child well-being among nuclear, single-parent, and separated/divorced families rely at least in part upon concepts of stress, coping, risk and resilience, Amato (2000: 1271) suggested an integrating 'divorce-stress-adjustment perspective'. From this perspective (which can easily be extended to include separation), the parents' divorce is not a singular event but rather a long-term developmental process that begins when the parents are still married and ends usually years after the legal act. In the underlying explanatory model of the divorce-stress-adjustment perspective, the divorce decree itself has minimal direct effects on children's well-being but the stressors und strains that accompany the divorce can indeed increase the likelihood of psychological, behavioral, and health problems for children. However, many factors moderate children's reactions and the speed of their adjustment to parental divorce.

The well-being of children with separated or divorced parents is at threat from stressors affecting parents and children (e.g., Amato 2010). Separated parents may experience stress from a decline of emotional support, increased frequency of conflict with the ex-partner or financial insecurity. Any number of other typical sources of parental stress can arise, such as multiple family transitions after the separation or divorce, a change of domicile, or a new job. For children, the decline of parental support and guidance, the reduction or the loss of contact with one parent, continuing conflicts between parents or economic decline can cause stress that undermines well-being. Other typical sources of post-separation stress also threaten children's well-being: a change of schools, a change of home, loss of friends, or the addition of a new stepparent.

Protective factors also influence separation and divorce outcomes. The action both of stressors and protective factors helps explain why children's reactions to separation and divorce are highly variable. Moreover, studies often use the selection perspective, which hypothesizes that some individuals carry traits that increase the likelihood that they will end up divorced or as single parents, to augment the divorce-stress-adjustment perspective (e.g., Amato 2000; Sweeney 2010). The well-being of children living in single-parent and stepfamilies is protected by factors that include available resources (individual, interpersonal, structural), the subjective meaning and normative connotation of separation and divorce as well as socio-demographic characteristics including the child's gender, the number of biological and stepsiblings, and the age of the child both at the time of parental separation and at the time when the stepfamily is established (e.g., Booth et al. 2010; Pryor 2008; Rodgers and Rose 2002; Turunen 2013). Other factors, for example a high degree of co-parenting among the adults involved or children's participation in decision making, can also serve to reduce post-separation stress and increase child well-being.

Finally, increasing attention has been paid to residence and custody arrangements among separated families and to the stressors and protective factors associated with them. In many cases, a separation or divorce leads to a significant reduction or loss of father-child contact (e.g., Smyth et al. 2004; Swiss and Le Bourdais 2009). This may reduce stress if it eliminates family conflict. Yet the loss of contact is also associated with a reduction of children's resources. Because paternal involvement in parenting has strongly increased overall during recent years (Williams 2008), fathers now more commonly maintain contact with their children after separation (Westphal et al. 2014). The number of working mothers who divide parenting responsibilities with the father, both before and after separation, has also increased. Together, these trends are leading to an increased number of post-separation, multi-household family structures, which bring about challenges of various kinds for all family members and are thus also likely to affect individuals' health and well-being.

#### Childhood Circumstances and Later Life Health

Next to the effects of family structure on child well-being described in the previous section, various aspects of individuals' childhood circumstances have been suggested to exhibit a lasting impact on adult health. On the one hand, adverse macro-level conditions during childhood, reflected by, for example, high infant mortality rates or economic recession seem to matter for later life health and mortality (e.g., Delaney et al. 2011; van den Berg et al. 2009). On the other hand, micro-level conditions closely related to the individual's family background particularly early health and parental socio-economic status (SES)—have been shown to be important.<sup>3</sup>

These factors may affect later health directly or indirectly. On one hand, early nutritional deprivation, for example, might directly initiate negative health trajectories during the individual's childhood, which may persist or even aggravate during the ageing process, independent of adult SES ('latency model'; e.g., Huang et al. 2011; Zhang et al. 2008). On the other hand, poor health and economic deprivation in childhood might impact later life health indirectly through impaired adult socioeconomic attainment ('pathway model'; e.g., Case et al. 2005; Haas 2008).

Next to showing a consistently negative correlation between low early-life SES and self-rated health in adulthood, studies also revealed a significant relationship between childhood SES and older adults'risk of suffering from functional limitations (e.g., Haas 2008; Huang et al. 2011; Wen and Gu 2011), cognitive impairment (e.g., Wen and Gu 2011; Zhang et al. 2008), as well as chronic conditions and depressive symptoms (e.g., Luo and Waite 2005; Pavela and Latham 2016). Along the same lines, poor childhood health was shown to have long-term negative effects on, for example, individuals' functional status (e.g., Haas 2008; Huang et al. 2011) and chronic health conditions (e.g., Blackwell et al. 2001; Haas 2007). Despite being correlated with each other, early health and SES also appear to bear independent associations with adult health. Research by Case et al. (2005), for example, indicated that even if parents' income, education, and social class are controlled for, adults who suffered from poor childhood health exhibit significantly worse health outcomes than adults who did not experience poor health during their childhood (also see Blackwell et al. 2001; Haas 2007).

#### Intergenerational Family Relations and Health

Intergenerational family relations might impact individuals' health just as health might affect intergenerational relationships in the family. In the following, we consider both causal directions as well as different dimensions of 'intergenerational

<sup>3</sup> See Brandt et al. (2012) for a more comprehensive overview of the related literature and a joint empirical consideration of (contemporary) contextual and life-course (childhood) factors impacting later life health.

solidarity' (e.g., Bengtson and Roberts 1991) and well-being (physical and psychological health); also see Steinbach and Hank (2015).

The family social network constitutes, on the one hand, an important resource to protect individuals' health by, for example, reducing psychosocial stress and increasing one's overall well-being (e.g., Antonucci et al. 2007; Franks et al. 1992). Low relationship quality between parents and adult children (e.g., An and Cooney 2006; Koropeckyj-Cox 2002) or burdens associated with providing care to kin (e.g., Call et al. 1999; Sherwood et al. 2005), on the other hand, have been shown to result in health deterioration, especially if psychological well-being is considered. The individual's trust in the family network as a potential source of support and the emotional stability of family relations appear to be particularly important here. Some evidence suggests that the subjective perception of support might even be more relevant for individuals' health than the actual support one has (or has not) received (e.g., Antonucci 2001).

Whereas emotional closeness and relationship quality strongly influence the well-being of parents and adult children (e.g., Merz et al. 2009a, b), geographic proximity and frequency of contact appear to be unrelated to older parents' life satisfaction—at least if the exchange of instrumental support is controlled for (see Lowenstein et al. 2007). This latter finding underlines the importance of distinguishing between emotional support (including closeness and relationship quality) on the one hand, and instrumental support on the other hand. The former not only seems to be more beneficial for both generations in the family, but receipt of the latter may even reduce one's well-being (e.g., Merz and Consedine 2009; Merz et al. 2009b; also see Bordone 2015). This kind of adverse effect seems most likely in situations characterized by a strong imbalance in the exchange of intergenerational support (e.g., Lowenstein et al. 2007; Pillemer et al. 2007).

A large and growing number of empirical studies assess the impact of family relations on health beyond the parent-child-relationship, taking a three-generational perspective. Their results suggest a positive relationship between caring for one's grandchildren and a variety of physical and psychological health outcomes (Arpino and Bordone 2014; Di Gessa et al. 2016a, b; Hughes et al. 2007; Mahne and Huxhold 2015). Moreover, focusing on the role of the relationship to grandparents in the well-being of adolescent and young adult grandchildren, Ruiz and Silverstein (2007) showed that grandchildren benefit from a close relationship to their grandparents as well, especially if they are living in a non-traditional family context. This result is corroborated by a more general finding suggesting that grandparents are more likely to step in and provide help, if the middle generation's resources are limited, making grandparents support an all the more important resource for (grand-)children's health (e.g., Arránz Becker and Steinbach 2012; McIlvane et al. 2007).

Health, however, is not only affected by characteristics of intergenerational family relations, but is also a determinant of the latter. Good health may be an important resource to provide intergenerational support, whereas poor health might often trigger the need to establish an exchange of instrumental and/or financial support between generations in a family. It is therefore surprising that so far only relatively little empirical research has been conducted yet addressing this causal direction of the intergenerational relations and health nexus. Health outcomes are often merely treated as control variables in multivariate models, without much theoretical or thorough empirical consideration of possible underlying mechanisms. Longitudinal analyses in particular are missing—despite the obvious relevance of the question as to which extent changes in the individual's health status might affect various dimensions of intergenerational relationships.

Cross-sectional findings suggests that good (poor) health in both the parents' and the children's generation is positively (negatively) associated with reports of relationship quality (e.g., Rossi and Rossi 1990; Steinbach and Kopp 2010; Szydlik 2000). A longitudinal study by Merz et al. (2009a) supports the notion that the observed cross-sectional associations indeed reflect a causal effect of health on the intergenerational relationship. Stress has been put forward as a possible explanation for this: Health deterioration causes stress in parents and children, which eventually affects relationship quality in negative ways. Whereas changes in parents' health status appear to be unrelated to the frequency of contact with adult children (Ward et al. 2014), studies have found the expected changes in instrumental support: Those in poorer health—especially parents—are more likely to receive and less likely to provide help (e.g., Chan and Ermisch 2012; also see Ogg and Renaut 2013). Both parents and children are sensitive to the other generation's needs and variations across the life course (cf. Grundy 2005).

#### Conclusions and Future Directions

The evidence reviewed in the previous sections suggests that family matters greatly —and in various ways—for individuals' health across the entire life-course: from early childhood, through adulthood, to very old-age. Our review has also shown that the investigation of the multifaceted family-health-nexus is a flourishing field for empirical research in various social science disciplines (sociology, social epidemiology, demography, etc.). The increasing availability of high-quality international data sets providing detailed information on individuals' social (i.e. family) and health circumstances has spawned a plethora of studies beyond the US context. Even if many of the associations reported above appear to be fairly universal, it is still seems useful to corroborate these findings in a variety of societal settings. Europe—with its diversity of welfare, family, and other kinds of 'regimes'—has been fairly well-covered to date (except for many Eastern European countries) and our knowledge about the interrelationship between families and health in Asia (especially China) is also growing rapidly.

We conclude our review of the current state of the art with a (selective) outlook on what we consider to be some promising—and necessary—issues for future research:

#### References

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## The New Roles of Men and Women and Implications for Families and Societies

Livia Sz. Oláh, Irena E. Kotowska and Rudolf Richter

#### Introduction

The major trends in family structures and their shifts across the industrialized world over the past decades are well known: fertility rates have declined below the level sufficient for the replacement of the population and childbearing occurs later and more often outside marriage. Marriage, too, is being postponed and is more often foregone, and couple relationships—both marital and non-marital ones—have become more fragile. These changes have led to increasingly complex family compositions and to a previously unprecedented diversity of family forms and relationships over the life course. The new family trends and patterns have been paralleled by changes in gender roles, especially an expansion of the female role to an economic provider for a family, and lately also transformation of men's role with more extensive involvement in family responsibilities, mainly care for children. In contemporary family scholarship there is an increasing awareness of gender and family changes being interconnected, and conceptualization of the gender revolution has gained terrain (Goldscheider 1990; Puur et al. 2008; Esping-Andersen 2009; England 2010). Developments related to women's new role are seen as weakening the family and have been attributed to the first phase of the gender

L. Sz.Oláh (&)

R. Richter Department of Sociology, University of Vienna, Vienna, Austria e-mail<EMAIL_ADDRESS>
Department of Sociology, Stockholm University, Stockholm, Sweden e-mail<EMAIL_ADDRESS>
I. E. Kotowska Institute of Statistics and Demography, Warsaw School of Economics, Warsaw, Poland e-mail<EMAIL_ADDRESS>
revolution, while more recent family changes and the emerging caring male role have been linked to the second phase (Goldscheider et al. 2015).

To understand the everyday realities of modern societies we need to recognize that the family is a dynamic entity, characterized by growing complexity with respect to decision-making processes regarding transitions over the family life course and organization of family life. Indeed, the family can no longer be described simply as a set of well-defined roles; it is negotiated on a daily basis, constructed by interactions between partners at the micro-level (Morgan 2011), and influenced by macro structures of the political and economic spheres. Work and family lives are increasingly influencing each other as both women and men engage in earning as well as caring activities, often reinforced by the labour market developments with specific skill demands, together with increasing employment instability and precariousness. Gender relations and related values and attitudes have become more fluid, changing dynamically over the life course in the context of blurring boundaries of family and work life. Also, different policy contexts affect new constructions of gender in doing family in various ways, impeding convergence to a singular pattern of family life courses across countries.

In this chapter we seek to shed more light on these complex developments in the European context. First we present the changes in family patterns over the past fifty years, before addressing the transition of gender roles and views on their interplay with the demographic developments. Next, we discuss new challenges related to transitions in and organizations of contemporary family life based on an overview of theoretical as well as empirical advances of research. A brief conclusion ends this chapter.

#### Increasingly Diverse Family Biographies

Family patterns in Europe have undergone extensive changes in the past half century. The early to mid-1960s marked the end of the "Golden Age of the Family" (Skolnick 1978; Sobotka 2011), with high marriage and birth rates at relatively young ages, few divorces, and a low prevalence of non-traditional family forms. By the late 20th century, fertility rates had declined well below the replacement level of 2.1 children per woman on average, while marriage and parenthood had been delayed to more mature ages, new forms of couple relationships emerged while the propensity to marry decreased, and family dissolution became quite frequent even among couples with children (Frejka et al. 2008). People are increasingly refraining from long-term commitments in respect of partnership formation and childbearing, which indicates a de-standardization of the family life course (Bruckner and Mayer 2005; Elzinga and Liefbroer 2007), but in the long run may lead to a re-standardization of family patterns (Huinink 2013). In any case, there is a considerable diversity in the extent of and the pace at which these new patterns emerged across Europe (Neyer 2013).

Acknowledging the importance of the social context for family dynamics as suggested in the literature (see e.g. Frejka et al. 2008; OECD 2011), we display the trends by welfare regime/policy configuration types (Esping-Andersen 1990; Korpi 2000), highlighting the details of changes in family patterns. We distinguish among the Dual-Earner policy configuration type or Social Democratic welfare regime with extensive policy provisions facilitating a work-life balance for both women and men; the Liberal or Market-Oriented regime with limited and usually means-tested state support to families and the dominance of market-based solutions regarding welfare provision; the General Family Support policy configuration type or Conservative welfare regime in which men's primacy in the labour market has not really been questioned while the range of state support to families and to women to combine paid work and family responsibilities varies greatly across countries; the Familialistic or Mediterranean welfare regime with nearly no or extremely limited policy provisions to families and pronounced gender role differentiation; and the Transition Post-Socialist cluster which represents a hybrid model and is also rather heterogeneous in terms of state support to families and to women to combine labour market participation and family life (Hobson and Oláh 2006; Saraceno 2008; Cerami and Vanhuysse 2009; Neyer 2013).

The de-standardization of the family life course in Europe that has led to increasingly diverse family biographies started with the decline in childbearing (Van de Kaa 1987; Lesthaeghe 2010). As shown in Fig. 1, the baby boom of the 1950s-early 1960s was followed by a dramatic decrease of period fertility rates, below the level necessary for the simple reproduction of a population. This occurred first in the Dual-Earner and the General Family Support clusters, in the early 1970s. Countries of the Familialistic regime entered the low fertility path in the early 1980s, followed by the Liberal regime and the Transition Post-Socialist cluster in the same decade. Fertility rates continued to decline in all but the Dual-Earner and the Liberal regimes to and even below the so-called critical level of low fertility, i.e., 1.5 children per woman on average, known to accelerate population ageing if sustained for a longer period (McDonald 2006). The German-speaking countries in the General Family Support policy configuration type also have shown very low levels of childbearing, though more or less counterbalanced by reasonably high fertility rates in other countries of that cluster. In the first years of the 21st century, the trends turned slightly upwards, generating hopes for a fertility recovery, but the increase has stopped and/or reversed in recent years, with childbearing at or somewhat below the critical level in the majority of European countries.

Period rates are, however, not seen as an optimal measure of fertility, as they are highly influenced by variations in timing and spacing of births (Sobotka and Lutz 2010); cohort fertility or completed family size is considered to be more reliable. As seen in Fig. 2, cohort fertility varies across countries as well as over female birth cohorts, that is, women born in the mid-1930s, 1940s, 1950s, 1960s and 1970s (the latter based on predicted cohort fertility). In all countries we find higher fertility levels for the older cohorts, in line with the decline seen for period fertility rates. Focusing on women born in the second half of the 20th century, the picture is more diverse. For the mid-1960 and -70 cohorts, fertility did not decline for countries of

Fig. 1 Period total fertility rates (average number of children per woman) in different welfare regimes/policy configuration types, 1960–2013.

Source INED (2013) for the years 1960–2008; Eurostat (2015) for the years 2009–2013.

Note Means for each group. Countries are grouped as follows: Dual-Earner: Denmark, Finland, Iceland, Norway, and Sweden; Liberal: United Kingdom, Ireland, and Switzerland; General Family Support: Austria, Belgium, France, Germany [for the years 1960–1989 West Germany only], Luxembourg, and the Netherlands; Familialistic: Greece, Italy, Portugal, and Spain; Transition Post-Socialist: Bulgaria, Czech Republic, Estonia, East-Germany (1960–1989); Hungary, Latvia, Lithuania, Poland, Romania, Slovakia, and Slovenia

the Dual-Earner cluster, nor for France, Belgium, or the UK, where even the youngest cohorts display fertility levels of about two children per woman on average, unlike in other countries and clusters. In contrast, we see completed family sizes at or slightly above 1.5 for the 1965 and 1975 cohorts for Switzerland and the German-speaking countries, and for the 1975 cohort for the Familialistic cluster, along with Bulgaria, Poland, and Romania, and only somewhat higher levels for other countries in the Transition Post-Socialist cluster. Taken together, Figs. 1 and 2 thus indicate that the European policy agenda should continue to be concerned about demographic sustainability given these low fertility levels (see also Oláh and Fahlén 2013, for a more detailed discussion).

The decline of period fertility rates has been accompanied by the ageing of fertility, that is, a rising mean age at first birth (Frejka et al. 2008). In the 1960s and 1970s, women in Europe had their first child in their early to mid-twenties, with the youngest first-time mothers in the Transition Post-Socialist cluster and the oldest ones in the Familialistic cluster. The postponement of first births started during the 1980s in all but the Transition Post-Socialist policy configuration type, where such a trend first emerged in the early/mid-1990s. In the beginning of the 21st century, motherhood is entered at around age thirty in Liberal regime countries and at the late twenties in other clusters. Ages of first fatherhood are a few years above that of first motherhood, because men start their family careers later than women. In any case, as Figs. 1 and 2 suggest, early entry into parenthood, as in the Transition

Fig. 2 Total completed cohort fertility (average number of children per woman) of selected birth cohorts.

Source INED (2013) for cohorts: 1935–1965; Myrskylä et al. (2013) for cohort 1975. Note For Belgium the cohort 1960 is displayed instead of 1965, for Lithuania the cohort 1940 is displayed instead of 1935; for Poland the cohorts 1950 and 1960 are displayed instead of 1955 and 1965

Post-Socialist cluster, is not necessarily accompanied by high fertility levels, whereas a late start of childbearing may not be a hindrance for achieving reasonably high fertility rates, the latter seen in the Dual-Earner and the Liberal regimes.

When discussing changes in fertility behavior, an important dimension to be addressed is the upsurge of extramarital childbearing in connection with new partnership patterns. Indeed, marriage had nearly ceased to be the dominant form of couple relationships in the Dual-Earner, the General Family Support, and the Liberal clusters by the late 1970s, as non-marital cohabitation has become increasingly prevalent. The Familialistic regime joined the trend in the early 1980s, and the Transition Post-Socialist cluster followed from the early 1990s. In these latter groups, the decline in marriage rates was suggested to be strongly related to growing economic uncertainty and housing shortages (Sardon 1993; Philipov and Dorbritz 2003).

Independent of the cause, marriage formation has been increasingly postponed from the early-/mid-1980s in most regime types, and since the mid-1990s even in the Transition Post-Socialist cluster (Frejka et al. 2008). By the early 21st century, first marriage is entered around age thirty by women, but somewhat earlier in the Post-Socialist cluster. In fact, the mean age at first marriage has been above that offirst parenthood in the past decades in the Dual-Earner policy configuration type as couples entered marriage after the birth of their first or second child. A similar pattern has also emerged lately in the Liberal and the General Family Support clusters.

As the propensity to marry declined, births have increasingly occurred in consensual relationships. In the early 1960s, when marriage rates were still high, the proportion of out-of-wedlock births was around 10% or less in European countries. This share has increased rapidly in the Dual-Earner cluster since the 1970s, currently accounting for about half of all births there. Other clusters displayed moderate levels of non-marital childbearing up until the late 1980s. Since then, the share of such births has nearly doubled. The Familialistic regime joined the increasing trend during the early 2000s. In recent years, nearly one-third of births occurred out-of-wedlock even in these countries. However, we do find quite large variations across countries in the different clusters with respect to non-marital childbearing, and the association with fertility levels is also far from clear-cut (Oláh 2015).

In addition to influencing fertility, the new partnership patterns have had implications for family stability. Couple relationships have become less stable over time as consensual unions, which are more fragile than marriages, have spread and divorce rates increased. The propensity to divorce doubled between the early 1960s and the late 1990s, and divorce rates remained modest only in the Familialistic regime cluster, where it has increased mainly during the last decade (Spijker and Solsona 2012). Declining relationship stability can also affect childbearing. On the one hand, it can reduce fertility as the time people spend in couple relationships shortens, and as women and men may choose to have fewer children because of the prospect of either having to raise their children alone or not being able to be involved with the children because of separation or divorce (Lillard and Waite 1993). On the other hand, high rates of family dissolution can raise fertility rates as second and higher-order partnerships are increasingly formed during the reproductive ages, and couples may opt for joint offspring even if they already have children from previous relationships (Thomson 2004). In any case, the high and/or rising instability of partnerships contributes to the increasing diversity of family biographies in Europe.

#### Changing Gender Roles

The changes in family patterns outlined in the previous section, especially the decline of fertility rates to (far) below the replacement level, have been paralleled by a substantial increase in female labour force participation over time (Bernhardt 1993; OECD 2012). In Central-East European countries (i.e. the Transition Post-Socialist cluster), high female and maternal employment levels were common in the state-socialist period. In Western Europe, the upsurge of female economic activity and mothers' employment occurred first in the Nordic countries (i.e. the Dual-Earner cluster), where the new family patterns emerged first. These countries were also the first to experience a change in women's employment aspirations resulting in the new female work pattern, according to which women do not withdraw from the labour market upon marriage or motherhood, but remain employed until reaching retirement age (Gornick and Meyers 2003; Oláh and Fahlén 2013). Countries of the Liberal and the General Family Support clusters joined the trend during the late 1980s, followed by the Familialistic cluster in the mid-/late 1990s. Anomalously, the end of the state-socialist era brought a substantial decline in female labour force participation in the Transition Post-Socialist cluster imposed by the economic restructuring, followed by some increase in female economic activity as the countries' economic performance gradually improved. Nevertheless, cuts in family policy provisions, especially regarding childcare for the very youngest (i.e. children below age three), along with rigid labour market structures increased the difficulties with respect to work-family reconciliation (Matysiak 2011).

In any case, by the early 21st century gender differences in labour force participation in Europe had greatly diminished (see Fig. 3). The gender gap is rather small in the Dual-Earner cluster and has been quite limited in the Transition Post-Socialist regimes, even though there are lower activity rates for both men and women. More recently, the gender gap has also diminished greatly in the Liberal and the General Family Support regimes. The Familialistic cluster has been characterized by the largest activity gap, as gender role differentiation has been most pronounced there and traditional gender norms have had a strong hold (Lewis 2006; Plantenga et al. 2009). Women's increasing economic activities have also boosted their engagement in higher education (Blossfeld 1995). By the mid-1990s, female educational attainment surpassed that of men in the main childbearing ages in all regime clusters, and it reached the same level as men in the broader working age population (Oláh 2015). The new female educational advantage has been most

Fig. 3 Gender differences in labour market activity [women's activity rate in proportion of men's rate; ages 20–64] in different welfare regimes/policy configuration types, 1992–2014. Source Eurostat (2016).

Note Means for each group. Countries are grouped as follows (years for missing data listed in brackets): Dual-Earner: Denmark, Finland, Iceland (1992–2002), Norway (1992–1999), and Sweden; Liberal: United Kingdom, Ireland, and Switzerland (1992–1995); General Family Support: Austria (1992–1993), Belgium, France, Germany, Luxembourg, and the Netherlands; Familialistic: Greece, Italy (1992), Portugal, and Spain; Transition Post-Socialist: Bulgaria (1992– 1998), Czech Republic (1992–1997), Estonia (1992–1997), Hungary (1992–1995), Latvia (1992– 1997), Lithuania (1992–1997), Poland (1992–1996), Romania (1992–1996), Slovakia (1992– 1997), and Slovenia (1992–1995)

pronounced for the Familialistic cluster, despite female employment rates being lowest there.

The substantially reduced gender employment gap notwithstanding, women earn on average 16% less than men, and this difference is even larger among top earners, about 21% (OECD 2012). The female wage disadvantage is strongly related to their weaker position in the labour market, as women have continued to bear a disproportionately large share of family responsibilities despite their growing involvement in paid work. Hence, part-time work is much more common among women than men and is increasingly used. Currently, about 45% of employed women work part-time in the Liberal and the General Family Support clusters, and one-third in the Dual-Earner cluster, compared to 20 and 10% in the Familialistic regime and the Transition Post-Socialist countries, respectively (Oláh 2015), given more rigid labour market structures in the latter clusters. The share of male part-time work varies between 5 and 15% across regime types.

Gender differences are more modest for unemployment levels, which vary between 5 and 20%, with the highest rates displayed in the Familialistic and the Transition Post-Socialist clusters where economic problems have been pronounced since long before the recent economic crisis. Youth unemployment levels have been much higher though, which can hamper family building, especially among the less educated, men and women alike (Mills et al. 2005; Oláh and Fratczak 2013).

Taken together the trends suggest that the new female gender role has increasingly incorporated dimensions of economic independence and support responsibilities that until quite recently belonged to the male domain, and has promoted a redistribution of responsibilities for the economic provision to a family between men and women. However, this transformation has hardly been accompanied by new patterns in the gender distribution of housework and care, given the rather limited changes in sharing unpaid work among women and men in most countries (Bianchi et al. 2000; Anxo et al. 2011). Much of the decrease in the gender gap for unpaid work is due to women investing less time in domestic duties because of their greater involvement in paid work, than due to a substantial increase in men's household- and/or care work contribution (Sayer et al. 2004; Craig and Mullan 2011). It has resulted in a double burden for women and increasing tensions between work and family life.

Among younger cohorts, more and more fathers seem to embrace the idea of active parenting (Seward et al. 2006; Hobson and Fahlén 2009; Smith Koslowski 2011). Their efforts have received increasing policy support at both the national and European levels (Hobson 2002; Moss 2014). However, the company level, especially employers' and co-workers' attitude towards active fathers, is likely to be of particular importance for the transformation of the male gender role (Brandt and Kvande 2002; Haas and Hwang 2009; Behnke and Meuser 2012). Moreover, mothers need to accept fathers as their equals when it comes to parental care for children in order for the new male role to become established (Allen and Hawkins 1999). Until men's contribution to domestic tasks and care work can match that of women in paid work, the gender revolution will remain incomplete (Esping-Andersen 2009; Goldscheider et al. 2010).

#### Making Sense of the Interplay Between Family Complexity and Gender Role Changes

Contemporary scholarship of economics, demography, sociology, and gender studies has recognized for a long time that new family patterns and evolving gender roles are interlinked. Given declining fertility and nuptiality, increasing instability of couple relationships and a nearly simultaneous growth of female labour force participation, women's increasing economic independence has been seen as a main cause of family changes in economic theorizing, which identifies gender role specialization as one of its main paradigms (see Becker 1991). Labour market developments in the 1980s and 1990s, especially rising educational demands and greater flexibility along with higher levels of job uncertainty, made this paradigm increasingly contested. An influential argument, presented by Oppenheimer (1994, 1997), pointed out the benefits of collaboration among spouses/partners with respect to economic contributions to the family, as by pooling resources couples can better adapt to new challenges in the labour market. As women's educational attainment approaches that of men, they are also better prepared to share with their male partner the responsibilities of providing for the family (Blossfeld 1995; Blossfeld and Drobnic 2001).

In sociology in contrast, it has been argued that ideational changes, such as the spread of individualism and thus the greater emphasis on self-realization, together with changing aspirations for paid work, are the main driving forces behind the postponement of family formation (both marriage and childbearing) and the increasing fragility of couple relationships in modern societies (Bengtson et al. 2005; Steel et al. 2012). In this respect, the Second Demographic Transition (SDT) theory is of particular importance (Van de Kaa 1994; Lesthaeghe 2010). According to the SDT theory, the weakening of normative constraints in advanced societies in combination with access to effective contraception led to fundamental changes in sexual relations, loosening the links between marriage and childbearing. This in turn resulted in delayed marriage and births, rising childlessness, non-marital cohabitation, and partnership instability. Critics pointed out that even though the SDT conceptual framework included structural components of market economy and improving living conditions, labour market developments and the related increase in economic uncertainties were largely ignored when explaining family changes (Perelli-Harris et al. 2010). Moreover, the SDT lacks an explicit gender perspective, notwithstanding its acknowledgement of women's increasing educational attainment and economic activity as part of societal changes (Bernhardt 2004). These latter aspects seem to be crucial for contesting the explanatory power of the SDT framework, especially with respect to family changes of the last decades and their interplay with labour market developments, in particular women's employment.

Indeed, in more recent studies increasing attention has been paid to gender equality in the public sphere and gender equity with respect to family life seen as the main drivers of family change (McDonald 2000, 2006; Esping-Andersen 2009, Neyer et al. 2013), linking back to the hypothesis on work-family incompatibility (Liefbroer and Corijn 1999; Brewster and Rindfuss 2000). These dimensions have been synthesized in new theoretical frameworks on multiple equilibrium (Esping-Andersen and Billari 2015) and the gender revolution (Goldscheider et al. 2015) aimed at explaining past trends as well as recent family changes from the point of view of the ongoing transformation of gender roles. Both concepts focus on the interplay between family related behaviour and shifts in women's and men's social roles reflected in their gendered responsibilities for economic provision and care in a family.

The multiple equilibrium framework addresses the evolution of the family from the male breadwinner model to the dual-earner—dual-carer model with special focus on the female revolution, following the transformation of gender roles on the path towards gender egalitarianism. Family related demographic behaviours are seen as strictly associated with transitions across family equilibria, aiming for consistency between people's evolving preferences and behaviours (Esping-Andersen and Billari 2015). In contrast, Goldscheider et al. (2015) distinguish between two phases of the transformation of gender roles. The first phase of the gender revolution is characterised by a strong rise in women's labor force participation and a gradual adaptation of the public sphere to this change towards increasing gender equality, while gender roles within the family remain unchanged. This stage includes transitions from the male breadwinner model to the modernised male breadwinner or dual earnerwomen's double burden model. The second phase of the gender revolution starts with increasing involvement of men in the family chores, marking the transition towards the dual-earner—dual-carer model. Both conceptual frameworks highlight the relevance of the transformation of gender roles outside and within the family, in line with McDonald's views on the importance of gender equality and gender equity for fertility change (McDonald 2000, 2006). In addition, they call for attention to men's situation, which until relatively recently has been quite neglected (for exceptions see Goldscheider and Kaufman 1996; Puur et al. 2008; Goldscheider et al. 2010), even though the decline in male wages and men's labour force activity along with growing labour market uncertainty have been recognized (Oppenheimer et al. 1997; Booth et al. 1999; Mills et al. 2005).

The role of social context in the interplay of gender and family changes has been addressed in the Capabilities approach, originated in Amartya Sen's (1993) framework of capabilities and their relation to the institutional environment. The approach has been applied focusing on gendered agency and capabilities to form and maintain stable relationships and have and care for children (Hobson and Oláh 2006; Hobson 2011). Studies on fertility and partnership changes and women's increasing labor market activities frequently rely on the policy regime framework, first presented by Esping-Andersen (1990), addressing the constraints and opportunities for individuals and families that affect the organization of paid and unpaid work and family formation. More recent welfare regime typologies (Lewis 2009; Thévenon 2011) and policy configuration approaches (Korpi 2000; Korpi et al. 2013) also highlight the linkages between variations of family, fertility and reconciliation policies.

In addition to theorizing about transitions over the family life course and their interlinkages with gender role changes, another major topic of scholarly attention has been the organization of family life. Studies of families and the division of work within households show that family members do gender as they do housework and childcare (Berk 1985; West and Fenstermaker 1995). Acts are performative in the sense that they construct, corroborate, and reconstruct identities in relation to jointly agreed-upon definitions. The performativity makes it possible to create and maintain an illusion of two essential and polar gender identities, at the same time enabling the reconstructions of gender (Butler 1990). This 'doing gender' approach emphasizes that we are assessed by and held accountable for based on gender in nearly everything we do (West and Zimmerman 1987; Jurczyk et al. 2014). This accountability, in turn, influences the social constructions of roles such as husbands and wives, mothers and fathers. Rooted in the concept of doing gender, the 'doing family' approach, looking at practices resulting in gender differences (Morgan 1999, 2011; Smart 2000; Nelson 2006), takes into account the fact that social habits are reproduced through everyday interactions. It argues that family life is not a given per se, but rather a social construction, because families embed their everyday family lives in internal daily routines, practices, and external social activities interlinked with changes in gender roles and family relationships.

Following upon the logic of the interplay between demographic changes and transformation of gender roles as outlined above, we will now address both transitions as well as the organization of family life. These are interpreted in the context of the de-standardized family life course and the growing complexity of family forms and relationships. In our overview of research, we focus first on women's new role and its implications for family dynamics, considering both women and men as main actors. Next we turn to the topic of gendered transition to parenthood, a borderline issue between family transitions and family life organization. The latter aspect is more thoroughly addressed in the discussion of new gender roles in doing families. Finally, we focus on coping strategies in family and work reconciliation under conditions of uncertainty and precariousness, an issue of growing importance for understanding transitions in family life.

#### New Challenges of Transitions in and Organization of Family Life

In this section we discuss recent research outcomes of family dynamics in a comparative perspective, especially regarding partnership transitions and parenthood and the organization of family life, and their association with changing gender roles. The results we present here refer to the main outcomes of Work Package 3 of the FamiliesAndSocieties project: The new roles of men and women and implications for families and societies. First, we focus on the reversal of the gender gap in education, a main driver of the transformation of gender roles, and its impacts on family patterns, especially on couple formation and fertility. New conceptual approaches are needed in order to study these processes. It is important to take into account both the more diverse ways of starting a family in modern societies compared to that of previous decades and the education-specific mating squeeze, resulting from the expansion of higher education, affecting women in particular. Next, we focus on the gendered transition to parenthood in Sweden, Switzerland, and Austria, countries with different institutional and gender systems and advancements in transformation of the family regarding economic provision and caring duties.

Men's involvement in family life can also be approached from the perspective of its organization. To illustrate how evolving gender roles are reflected in doing family, outcomes of two comparative studies are discussed addressing time spent by fathers with children and the gender gap in household work in different family types across Europe. Finally, coping strategies in family and work reconciliation under conditions of uncertainty and precariousness will be discussed.

#### Women's New Role and Its Implications for Family Dynamics

Women's new social role is closely connected to their educational attainment. Aggregated data show that women have outperformed men in formal education in the past decades, and consequently they now have increasingly as much or more education as their partners, unlike in the past. The reversal of the gender gap in education has far-reaching implications for family dynamics and needs to be taken into account not only in studying behaviours relevant for demographic development and social relations but also in applying an adequate analytical approach. Moreover, to account for the increasing importance of non-marital cohabitation as well as a growing proportion of children born in consensual unions instead of marriage, the conventional concept of the "marriage squeeze" should be extended to include this partnership type. Van Bavel (2012) proposed to address imbalances on the "mating market" instead of the "marriage market" only, and to pay attention to education accounting for an education-specific mating squeeze. Relying on data from the European Labour Force Survey (LFS) and Eurostat official statistics on population, his co-authored study demonstrates the importance of the mating squeeze for family formation in modern societies (De Hauw et al. 2014).

Indeed, the expansion of higher education among women and resulting patterns of assortative mating affect family formation, fertility, and divorce (Schwartz and Han 2014; Grow and Van Bavel 2015). Contrary to expectations, highly educated women are not more likely to remain single. Rather, they appear to partner more often with men with less education than themselves. How exactly this is related to the timing instead of the likelihood of partnership formation is, however, still an open question (De Hauw and Van Bavel 2016). The reversal of gender inequality has also resulted in remarkable shifts in educational pairing: educational hypergamy (women marrying up) is declining while homogamy and hypogamy (women marrying down) are becoming more prevalent (Esteve et al. 2012). In a study of Klesment and Van Bavel (2015), based on EU-SILC data, educationally homogamous couples constitute more than half of the sample and the share of hypogamous couples exceeds that of hypergamous couples (except for Austria, Germany, the Czech Republic, and Romania). Between 2007 and 2011 the proportion of highly educated homogamous couples increased similarly to the share of hypogamous partnerships with highly educated woman.

New patterns of educational pairings affect the decision-making processes related to fertility, as a comparative study based on the EU-SILC panel data on 17 countries reveals (Nitsche et al. 2015). Homogamous highly educated couples show a distinct childbearing behaviour in most societies studied. They tend to postpone the first birth longest, while transition rates to subsequent (second and third) births are highest for them compared to other educational pairings, especially to couples with a highly educated woman and a lower educated man. This suggests that homogamous highly educated couples recuperate their postponed transition to the first birth by progressing to second and/or third births faster. Moreover, differences in childbearing behaviour within the group of highly educated men are in contrast to what may be expected based on the conventional economic models of the family. Hypergamous couples with a highly educated man and a lower educated woman display significantly lower second and third birth transition rates than homogamous highly educated couples across the majority of countries. There is no country in which second or third birth transitions rates among this type of couples are higher than rates of homogamous highly educated couples. These findings are in line with Oppenheimer's (1994) hypothesis on pooling resources in a couple instead of Becker's (1991) economic model.

#### The Gendered Transition to Parenthood

In our research on the gendered transition to parenthood, country-specific studies based on both qualitative and quantitative approaches provide in-depth insights into combining parenthood with working careers. Leaves for child care are considered a crucial policy measure to support reconciliation of work and caring responsibilities. Especially fathers' entitlements and use of leave play an important role in reversing the asymmetry in the gendered impacts of parenthood on work performance of men and women. When becoming a father, men tend to strengthen their economic provision to the family, also by increasing their working hours, while women take leave from employment to care for a child and quite often either stay at home or switch to part-time work until the child starts day care. Below we discuss two country specific studies on leave practices in Sweden and Switzerland, countries with contrasting leave systems, different stages of family change and transformation of gender roles.

The study on Sweden, a Dual-Earner cluster country, explores how both men's and women's "new" roles are related to their time spent in paid work and in care, taking into account children-parents ties (Evertsson et al. 2015). By combining analyses of quantitative survey data (YAPS—Young Adult Panel Study, Sweden) and qualitative interviews conducted with middle-class first-time parents, new insights into the division of parental leave in Sweden are provided. The findings suggest that fathers' family orientation and willingness to share caring responsibilities are the main determinants of longer leaves of fathers. Reasons for couple's unequal leave use vary from mothers' preferences to stay home for a long period, and fathers' refusal to take leave, or work-related reasons, to the economic situation of the family. Father's work conditions are more important for his leave duration than the work conditions of mother for her leave length; and income difference is sometimes used as a motive for a father to take a short leave irrespective of who earns the most. In any case, the duration of the father's parental leave significantly affects his contribution to child care even when both parents resume paid work, i.e. the longer the father's leave, the more likely child care is to be equally divided in the long-term. These qualitative findings indicate that traditional norms and ideals about the mother as primary care taker hinder an equal sharing of the leave during the child's first year, despite ideals of gender equality and equal parenting being highly regarded by the parents interviewed. Thus family income and factors related to the parents' work conditions seem to interact with norms and ideals, and they produce different outcomes across couples. The study also suggests several mechanisms through which fathers' parental leave uptake may causally influence the share of care between parents when a child is older. Fathers' parental leave uptake is linked to a closer relationship between the father and the child and also contributes to a greater understanding between the parents, both when it comes to sharing home tasks when a child is small and to combining paid work with unpaid work, including care.