The transition to widowhood does indeed influence the quality of health care that individuals receive. Past work suggests that the loss of marital benefits and the crisis caused by spousal death may combine to negatively affect individuals’ abilities to maintain contact with health providers, advocate for themselves in the formal medical system, and coordinate formal and informal care (Umberson 1987
; Williams 2004
; Williams and Umberson 2004
Our analyses support the crisis model: the occurrences of quality-of-care indicators experienced significant fluctuation during the months surrounding spousal death. During the time leading up to spousal death, all quality indicators experienced a gradual but significant decline. This decline is likely indicative of the burden of spousal caregiving and/or the loss of marital benefits due to spousal incapacitation. In the month when spousal death occurred, all quality indicators experienced a sharp drop, which may be attributed to acute bereavement and the need to manage the urgent and practical matters associated with the passing of a spouse.
In the months immediately after spousal death, the quality indicators improved, especially the rates of preventive service delivery and diabetic monitoring. At this time, newly widowed individuals intensified their interaction with the formal medical system; the rates and numbers of visits to both primary care physicians and specialists reached the highest point (results not shown). Consistent with the relief model, these trends may reflect a tendency of the newly widowed to compensate for earlier neglect of their health care needs. In addition, spousal death might remind them of their own vulnerability (Walter 2003
). Or they might feel particularly unwell and think that health care providers can offer comfort and help; the physical manifestation of grief might lead the widowed to seek the assistance of medical professionals, who might take the opportunity to perform routine and preventive services (Stroebe et al. 2001
). Regardless of their motives, the newly widowed appear to have had enough resources to sustain a high level of contact with the formal medical system. Spousal death may have freed up household resources, in particular the time of the surviving spouse that used to be devoted to caring for the dying spouse. It is also very likely that during the time following spousal death, the widowed experienced a surge of attention and support from their family and friends (Ha 2008
). Future work will need to explore which of the foregoing mechanisms were operational.
Whether our findings support the argument regarding the positive impact of marriage with respect to interaction with the formal medical system is more ambiguous. First, being widowed proved not to have long-term detrimental effects on individuals’ abilities to obtain preventive services. That is, losing one’s spouse does not have sustained negative effect on one’s abilities to maintain contact with the formal medical system. However, these findings do not imply that there are no marital benefits. It is plausible that internalized values and habituated behaviors acquired during the marriage continued to function without external sanction or motivation after spousal death. These findings also do not preclude the possibility that the marital benefits were partially lost after spousal death but the surviving spouses were able to compensate for the loss and gradually regain their ability to maintain contact with the formal medical system. This scenario is consistent with the trajectory of changes in the likelihood of receiving influenza vaccination; after the precipitous drop at the time of spousal death and a large rise immediately after, the rate of influenza vaccination remained lower than the baseline level but gradually increased and approached the baseline level three years after spousal death. On the other hand, the rates of breast cancer screening and diabetic monitoring rose well above the baseline level following spousal death. In these cases, the depletion of marital benefits, if the depletion took place at all, seems to have been overwhelmed by the intention to seek medical help and the availability of additional resources.
On the other hand, for men, the rates of preventable hospitalizations and early readmissions remained higher than the baseline level three years after spousal death. We suggest that whereas obtaining appropriate preventive services can be achieved through sustained outpatient interaction with the health care providers, more factors are involved in avoiding preventable hospitalizations and early readmissions. Preventable hospitalizations may be headed off with both sustained interaction with health care providers and adequate home and self-care, as well as coordination between the formal and informal care. Early readmissions may be prevented by good communication between the patient and doctor, competent discharge planning, and again adequate home and self-care after discharge. As a result, avoiding these undesirable events may be more sensitive to spousal inputs.
We argue that the elevated risks for these undesirable outcomes suffered by men after they became widowed signal the loss of marital benefits provided by the wives. What kind of marital benefits are lost? Our data do not allow us to tease out precisely whether the loss was tied to the wives’ role in helping to maintain contact with the formal medical system, supporting self-care and providing informal care at home, or helping coordinate formal and informal care. However, we observed that men did not differ from women in obtaining preventive services after becoming widowed. This suggests that when men became widowed, they lost help with self-care and informal care as well as help with coordinating care needs; possibly, they may have had to substitute that loss with formal care provided in the institutional settings of the health care system. The loss of marital benefits probably does not lie in promoting contact with the formal medical system, but in spouses’ role as advocates, caregivers, and coordinators of health care. These gender differences highlight women’s centrality in the household production of health (di Leonardo 1987
; Powers and Bultena 1976
). These findings may have practical implications since they identify important points of intervention for friends, family, and social services in optimizing men’s adjustment to widowhood.
The trajectories of changes in preventive service delivery generally suggest that there is little decline in the likelihood of obtaining these services after spousal death. But the long-term effects of being widowed on the rates of obtaining different preventive services did vary, which merits further consideration. Although vaccination, cancer screening, and diabetic monitoring are subsumed under the heading of preventive services, they serve different functions, and patients and doctors may attach different salience and urgency to different services. For example, practices of diabetic monitoring are associated with a chronic disease that has already occurred; they are preventive in the sense that they may slow the progression of the disease and prevent acute symptoms. Patients with diabetes may have adopted diabetic monitoring as a routine practice, and this routine may be reinforced by interactions with their doctors. The routine nature of diabetic monitoring could explain why, after the shock and aftermath of spousal death, the rates of diabetic monitoring stabilized at a level close to that before the onset of the process of transitioning to widowhood.
Cancer screening may become particularly salient to the widowed who were made acutely aware of their own mortality with the experience of spousal death (Walter 2003
:15); we may therefore observe an increase in the occurrence of post-widowhood mammograms. As a sensitivity analysis, we examined the trajectory of prostate cancer screening during the transition to widowhood for men between ages 65 and 74 and similarly observed an upward trend in the occurrence of prostate cancer screening after spousal death (results not shown).9
The idiosyncrasy of the mammogram trajectory therefore cannot be attributed to female gender. Among the preventive services under examination, only influenza vaccinations are generally applicable to both spouses. The fact that influenza vaccinations are actually relevant to both spouses might add to the importance of having a spouse to obtaining influenza vaccinations; for example, spouses may obtain these shots together. This may explain why the rates of influenza vaccination lingered slightly below the baseline level long after spousal death.10
We offer the foregoing explanations for why the long-term effects of being widowed varied across different measures of preventive service delivery. However, our ability to use the available data to test the validity of these explanations is limited. More measures of different types of quality indicators would help differentiate the effects of being widowed from the nature of measures under examination.
Our second goal here was to examine whether the changes in quality of health care surrounding the transition to widowhood mediate the much-documented relationship between widowhood and elevated mortality risks. Although we found that quality of care fluctuated around spousal death and that the quality indicators were predictive of the mortality risk of the surviving spouse, our analysis did not detect any mediating effects of health care quality on the widowhood effect on mortality. This finding does not conform to the speculation in the literature about the detrimental effect of a decline in the quality of health care due to widowhood. However, this study first shows that the pattern of changes in quality of health care surrounding spousal death is more complicated than that of a simple decline. Quality of care did experience a decline prior to and at the time of spousal death. But some quality indicators, in particular the use of preventive services, quickly recovered in the months following spousal death; in the long run, being widowed did not exert a strong negative influence on these indicators. Conceptually, this relatively short-term fluctuation in quality of care due to spousal death may still harm the health and survival of the surviving spouse. Empirical examination, however, suggests that this is not the case. Indeed, the mechanism of the widowhood effect may be a fundamentally biosocial one that transcends the mere access to health care.
To our knowledge, this article provides the most complete evidence regarding whether and how marriage confers a survival advantage by promoting quality of health care. However, quality of care is a multidimensional concept, and our study is limited by the number and types of quality-of-care indicators in the available data. Further studies using measures of other dimensions of quality of health care are needed to confirm and extend the findings of this study. Nevertheless, the measures we used are known to be markers of health care quality more generally and, as such, should be taken as markers. We therefore conclude that changes in quality of health care during the transition to widowhood, as we measure it, do not have discernible impact on the elevated mortality suffered by the widowed.