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Kilpi, Fanny; Martikainen, Pekka; Konttinen, Hanna; Silventoinen, Karri; Torssander, Jenny; Kawachi, Ichiro

doi: 10.1097/EDE.0000000000000831
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Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland, MRC Integrative Epidemiology Unit at the University of Bristol, Bristol, United Kingdom, fanny.kilpi@bristol.ac.uk

Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland, Laboratory of Population Health, Max Planck Institute for Demographic Research, Rostock, Germany, Centre for Health Equity Studies (CHESS), Stockholm University and Karolinska Institutet, Stockholm, Sweden

Social Psychology, Department of Social Research, University of Helsinki, Helsinki, Finland

Population Research Unit, Department of Social Research, University of Helsinki, Helsinki, Finland

Swedish Institute for Social Research, Stockholm University, Stockholm, Sweden

Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA

The authors report no conflicts of interest.

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To the Editor:

We thank Oude Groeniger and van Lenthe1 for their interest in our article and for drawing important attention to the health of those living without a partner. Although the focus of the study was on the possible spillover effects of partner’s education on myocardial infarction, we kept the individuals living without a partner as a category in our analyses, because they often experience more disadvantage than the married or cohabiting. Yet, as Oude Groeniger and van Lenthe recognize, those without a partner are not a homogeneous group but include individuals who are divorced or widowed and those who have never married. Moreover, these groups may each show sex-specific and socioeconomic status-specific effects on health.

We decided to treat spousal education and living arrangements as time-varying, because the follow-up time in the study was quite long and these covariates may well change over time. Nevertheless, a sensitivity analysis with these social variables measured only at baseline showed only slightly attenuated results for all three myocardial infarction outcomes compared with our time-varying analyses (results available from the authors).

Heterogeneity is, of course, present in the married or cohabiting population as well, with increasingly many having previously experienced union dissolution, while the possible beneficial effects of a marital or cohabiting partnership may accumulate with the relationship duration. Most previous studies show the continuously married to have the best health and lowest mortality, while the divorced are often found to have the greatest health problems or highest mortality (at least in the short term),2 but the findings may be contingent on marital relationship quality. The health of the never-married is usually not far behind that of the divorced, and the widowed have been shown to experience a heightened risk of ill health and mortality mainly in the period immediately before and after their spouses death.3 Previous literature also indicates that marital history may have an independent association with cardiovascular health,4 but there is still scope for research to establish under which conditions the selection explanations are important and when, in contrast, social causation explanations prevail, preferably using stronger causal inference frameworks. Excessive alcohol consumption, stress, and financial difficulties may certainly increase divorce risk, but, equally, the stress of divorce or loss of spouse and the possible accompanying financial difficulties are also likely to influence cardiovascular risk.

Fanny Kilpi

Population Research Unit

Department of Social Research

University of Helsinki

Helsinki, Finland

MRC Integrative Epidemiology Unit at the University of Bristol

Bristol, United Kingdom

fanny.kilpi@bristol.ac.uk

Pekka Martikainen

Population Research Unit

Department of Social Research

University of Helsinki

Helsinki, Finland

Laboratory of Population Health

Max Planck Institute for Demographic Research

Rostock, Germany

Centre for Health Equity Studies (CHESS)

Stockholm University and Karolinska Institutet

Stockholm, Sweden

Hanna Konttinen

Social Psychology

Department of Social Research

University of Helsinki

Helsinki, Finland

Karri Silventoinen

Population Research Unit

Department of Social Research

University of Helsinki

Helsinki, Finland

Jenny Torssander

Swedish Institute for Social Research

Stockholm University

Stockholm, Sweden

Ichiro Kawachi

Department of Social and Behavioral Sciences

Harvard T.H. Chan School of Public Health

Boston, MA

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REFERENCES

1. Oude Groeniger J, van Lenthe FJRe: the spillover influence of partner’s education on myocardial infarction incidence and survival (letter). Epidemiology 2018;29:e34e35.
2. Manzoli L, Villari P, M Pirone G, Boccia AMarital status and mortality in the elderly: a systematic review and meta-analysis. Soc Sci Med. 2007;64:77–94.
3. Einiö E, Moustgaard H, Martikainen P, Leinonen TDoes the risk of hospitalisation for ischaemic heart disease rise already before widowhood? J Epidemiol Community Health. 2017;71:599–605.
4. Zhang Z, Hayward MDGender, the marital life course, and cardiovascular disease in late midlife. J Marriage Fam. 2006;68:639–657.
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