Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA. E-mail: matthewska{at}msx.upmc.edu
Contemporary women constitute the majority of college undergraduates and are achieving a higher level of educational attainment than any other previous generation in the US.1 A similar experience is observed in other developed countries.2 Thus, a natural experiment of enormous proportions is occurring, and it is important to ask what is the public health impact of womens increasing educational attainment.
In the present issue, Egeland and colleagues3 take a fresh look at the public health impact of womens education on their husbands. In a cohort of over 20 000 married Norwegian men followed for 12 years, those married to educated women (defined as 11 years) experienced lower risk for coronary heart disease (CHD) mortality than did men married to less educated women. The benefit of wifes education remained apparent after statistical adjustments for mens own educational attainment and was strongest among the most educated men (also defined as
11 years).
Are we to conclude then that an educated wife is never hazardous to her husbands health and perhaps even beneficial? No, we cannot. As the authors note (see ref. 3), major epidemiological studies conducted in the US, including the Framingham Heart Disease Study, Rancho Bernardo Study, Western Electric Study, and Western Collaborative Group Study, report an adverse effect on mens CHD rates of marriage to well educated women.
Shall we conclude that with the exception of the quite fortunate Norwegian men, educated women always have a damaging effect on their partners health? After all, a reasonable explanation has been offered: the greater education of wives relative to their husbands could have induced stress and marital discord, which, in turn, increased mens risk for CHD mortality. However, the data on marriage and health do not yield a simple picture: Being married is indeed beneficial to men, but marital discord has a weaker effect on men than on their wives.4 Furthermore, several excellent studies show that the husbands of less educated women are at elevated risk for CHD mortality.3
At present then it is most reasonable to conclude that sometimes better educated women confer a disadvantage and sometimes they confer an advantage. Such may be an accurate summary of the literature, but it is also unsatisfactory and unsatisfying. The challenge of social epidemiology is to identify a priori the psychobiological processes underlying social constructs and include measures of proposed psychosocial and biological mediators in the study protocol. In this way, well articulated hypotheses and models can be confirmed or disconfirmed.
Taking advantage of existing 1980 census data and a risk factor survey conducted between 1977 and 1983, Egeland et al. did not have the luxury of comprehensive testing of psychosocial and biological processes. In that circumstance a natural response to inconsistent findings is to search for critical differences in study design, health outcomes, statistical power, and sample characteristics and Egeland et al. provide an insightful discussion of such differences. It is also worthwhile speculating what the meaning of being married to educated women may have been in Norway and the US at the time the studies were conducted. Norway is widely considered to be an egalitarian culture. Norwegian women were given the right to vote in 1913. Men born in the cohort studied by Egeland et al. lived through World War II, when their country was occupied by Nazi Germany. Men born at a similar time in the US returned after World War II service to the benefits of higher education through the GI bill. From 1940 through 1970, the rates of mens attending and graduating from college increased dramatically, while the proportion of women attending college declined.1 American men married to educated women were atypical, and perhaps experienced more role conflicts than did their Norwegian counterparts. One might anticipate that as it becomes normative for men to be married to educated women in the US the associated stigma and role conflict may lessen.
Another way to frame the question of the public health consequences of womens increasing educational attainment is to consider whether it leads to families experiencing greater or lesser prestige in society and greater or lesser access to resources. High prestige and good access to resources are the key elements of high socioeconomic status (SES) and high SES is a well-established predictor of longevity and low rates of CHD morbidity.5 In most circumstances, educated wives should contribute to families having greater resources and prestige, especially as better educated women have better health themselves.6 Husbands with less education than their wives may experience an offsetting loss of prestige but this effect is probably highly dependent on the cohort and times. Future studies should consider the framework of SES and the associated psychobiological processes in understanding the health impact of womens education.
In sum, Egeland and her colleagues are to be congratulated for their meaningful contribution to addressing an important public health question: Is an educated wife hazardous to her husbands heart? At present, the answer is sometimes an educated wife is health damaging and sometimes she is health promoting. I suspect that in contemporary cohorts, increasing education of women will lead to their families having greater access to resources and higher prestige, and to better health in both husbands and wives. Time will tell.
References
1 Foster CD, Siegel MA, Jacobs NR. Womens Changing Role. Wylie TX: Information Aids Inc., 1990.
2 The Worlds Women 19701990. Trends and Statistics Social Statistics and Indicators Series K No. 8. New York: United Nations, 1991.
3 Egeland GM, Tverdal A, Meyer HE, Selmer R. A mans heart and a wifes education: A 12-year coronary heart disease mortality follow-up in Norwegian men. Int J Epidemiol 2002;31:799805.
4 Kiecolt-Glaser JK, Newton TL. Marriage and health: His and hers. Psychol Bull 2001;127:472503.[CrossRef][ISI][Medline]
5 Kaplan GA, Keil JE. Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation 1993;88:179398.
6 Matthews KA, Kelsey SF, Meilahn EN et al. Educational attainment and behavioural and biologic risk factors for coronary heart disease in middle-aged women. Am J Epidemiol 1989;129:113244.[Abstract]