Social Science & Medicine 55 (2002) 191–209

Social environment, life challenge, and health among theelderly in Taiwan

Megan Becketta,*, Noreen Goldmanb, Maxine Weinsteinc, I-Fen Lind,Yi-Li Chuange

aRAND, 1700 Main Street, Santa Monica, CA 90401, USAbOffice of Population Research, Princeton University, Wallace Hall, Princeton, NJ 08455-2091, USA

cGraduate School of Arts and Sciences, Georgetown University, P.O. Box 571214, Washington DC 20057-1214, USAdDepartment of Sociology, Bowling Green State University, Bowling Green, OH 43403, USA

eNational Institute of Family Planning, Taichung, Taiwan

Abstract

We use an ongoing longitudinal survey of elderly Taiwanese to examine the linkages among health, the social

environment, and exposure to life challenge. Data from three waves of the survey provide measures of social hierarchy,

social connection, life challenge, and health outcomes. On the basis of multinomial and binomial logistic models, we

explore the effects of social factors and challenge on being unhealthy or deceased at follow-up. The estimates indicate

that poor health status at follow-up is associated with (1) low socioeconomic status, not having any living children,

limited networks of friends, and low participation in social activities; and (2) three life challengesFchronic financial

problems, excessive demands placed by close relatives and friends, and having a spouse in poor health. Respondents

facing several challenges or having multiple negative attributes in their social environment are especially likely to be

unhealthy at follow-up, although negative attributes appear to be counteracted by positive ones. Many findings from

Western societies extend to this Taiwanese population. However, some aspects of social connection and challenge

hypothesized to affect health fail to reveal a significant association. The analysis identifies differences between men and

women in the effects of specific challenges on health, but sex differences in the effects of socioeconomic status and social

connection on health are not significant. r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Social environment; Gender; Elderly; Stress; Socioeconomic status; Taiwan

Introduction

The complex relationships among health, the social

environment, and exposure to stressful experience have

engaged the attention of researchers from a variety of

disciplines. Two aspects of the social environmentFpo-

sition in social hierarchies and integration in social

networksFhave been studied extensively. With regard

to the former, epidemiologists and social scientists have

demonstrated that persons of lower socioeconomic

status (SES)Ffor example, those with less income,

fewer years of education, and lower occupational

classFexperience higher death rates and poorer health

than those of higher SES. These differences exist at every

level of the social hierarchy (i.e., not simply between the

poor and the non-poor) and affect every age group (e.g.,

Feinstein, 1993; Adler, Boyce, Chesney, Folkman, &

Syme, 1993; Adler et al., 1994). With regard to social

networks, researchers have shown that persons who are

less socially integrated have poorer health and survival

outcomes than those with more extensive and stronger

social connections (e.g., House, Landis, & Umberson,

1988). Recent studies focusing on the elderly have

confirmed the importance of social ties and social

support on the health of this segment of the population*Corresponding author. Fax: +1-310-393-4818.

E-mail address: beckett@rand.org (M. Beckett).

0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 6 1 - 7

(e.g., Goldman, Korenman, & Weinstein, 1995; Shye,

Mullooly, Freeborn, & Pope, 1995).

In a second large literature, scientists have demon-

strated that life challenges (such as the loss of a spouse

or friends, retirement, relocation) and chronic strains

(such as financial difficulties and marital problems) are

also associated with poor health status (e.g., Kieclot-

Glaser, Glaser, Gravenstein, Malarkey, & Sheridan,

1996; Thoits, 1995). An experience that is perceived as

stressful causes a chain of physiological reactions that

disrupts normal functioning in various bodily systems,

such as cardiovascular and immune functioning. As a

consequence, life stresses or challenges have been linked

to the development and progression of (1) chronic

diseases, such as diabetes and cardiovascular disease

(Brosschot et al., 1994; McEwen & Stellar, 1993); (2)

psychiatric disorders, such as depression and anxiety

(Dean, Kolody, & Wood, 1990; Glass, Kasl, & Berk-

man, 1997); and (3) cognitive and physical performance,

such as loss of memory (Lupien et al., 1994). The health-

related consequences of exposure to life challenges are

likely to be especially severe for the elderly, because this

segment of the population is particularly vulnerable to

chronic challenges, including loss of job, residence,

friends, and family.

The two sets of linkages described aboveFi.e.,

between the social environment and health and between

life challenge and healthFare unlikely to be indepen-

dent of one another because socioeconomic status

mediates both the exposure to, and the impact of, life

challenges (House et al., 1994). For example, chronic

strains, such as exposure to social aggression and

poverty, are more prevalent among lower socioeconomic

strata than among those who are well off (House et al.,

1994; Thoits, 1995). In addition, because the resources

that can be brought to bear are affected by socio-

economic status and social ties, the social environment

affects the impact of challenge (Cohen, 1988; House

et al., 1994; McLeod & Kessler, 1990). For example,

financial assets can cushion the effect of challenges that

do arise, and education may provide the knowledge and

access to resources that can reduce their impacts. The

presence of social contacts not only reduces the negative

effects of life events and strains, but also affects the

perception and interpretation of events, thereby redu-

cing the physiological response (Cohen & Wills, 1985;

McLeod & Kessler, 1990).

To date, most studies that have examined the

associations among the social environment, life chal-

lenge, and health outcomes have been based on Western

populations. As evidenced by new large-scale studies

among elderly populations in several Asian populations

(e.g., Hermalin, 1998), there is rapidly growing interest

in investigating the generalizability of these linkages to

developing and newly industrialized countries. The

purpose of this study is to estimate the associations

among the social environment, life challenges, and

health and survival in the elderly population of Taiwan,

and to explore whether the resulting patterns are similar

to those found in previous research. Although Taiwan

shares certain demographic characteristics with Western

populations, such as a similar cause-of-death structure,

high life expectancy, and high level of industrialization,

Taiwan provides a striking contrast to American and

European societies in several cultural and social dimen-

sions that affect the life of the elderly.

The analysis is based on a nationally representative

panel sample of elderly Taiwanese: the Study of Health

and Living Status of the Elderly in Taiwan. As described

in more detail below, this survey contains extremely

detailed and high quality data on the social environment

of the elderly that permit us to alleviate the conse-

quences of many of the limitations of previous studies

on this topic. In the following section of the paper, we

describe some aspects of Taiwanese society that may

affect the relationships among social factors, life

challenge, and health. Next, we present out hypotheses

regarding the expected associations among elderly

Taiwanese. Subsequently, we describe the data and

analytic strategy that underlie our analysis. Finally, we

present the results of the statistical analysis and discuss

the findings and their implications.

The Taiwanese setting

As in Western societies, education, occupation, and

income are the leading determinants of position in social

hierarchy in Taiwan. Education, in particular, has held

an important role in Chinese culture dating back at least

as far as the Han dynasty (206 BC) and it has continued

to be an important component of social status and

upward mobility on the island to the present time.

During much of the period when Taiwan was a colony

of Japan (1895–1945), the Taiwanese maintained their

own tradition of family organized education that

focused on the education of sons (Baker, 1979; Fricke,

Chang, & Yang, 1994). The value placed on education

has, if anything, increased in Taiwan since the end of the

Japanese colonial period in 1945 and the influx, in 1949,

of Chinese from the Mainland (Egan, 1994; Smith, 1981;

Fricke et al., 1994). More recent educational changes

have been instituted by the government to facilitate

industrial development by providing a technically

proficient labor force, and sharp increases in enrollment

rates for women have led to reductions in sex

differentials in education (Hermalin, Liu, & Freedman,

1994).

Education has also been an important factor in

determining the traditional Chinese hierarchy of occu-

pations. In the past, four distinct classes of occupations

existed. First, the scholars, who comprised teachers,

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209192

government officials, and soldiers with academic

training; second, the self-employed farmers; third,

artisans and craftsmen; and fourth, merchants

(Grichting, 1971). This association between the most

highly ranked occupations and educational training

persists. In terms of more current occupational

categories, this hierarchy has translated to those in

professional activities enjoying the highest ranks.

Broadly speaking, the remaining three classes have

retained this ordering, although there have been shifts

in the social hierarchy over time (e.g., the high status

affording to the emerging group of business executives).

There are many similarities between the U.S. and

Taiwan in social status associated with different

occupations (Tsai & Chiu, 1991).

During the past few decades, Taiwan has been

transformed from a relatively poor agricultural society

to a prosperous industrialized one (Hermalin, Ofstedal,

& Chang, 1992). Since 1960, mean per capita income in

Taiwan has increased by a factor of more than seven (in

constant dollars) (Shih & Chuang, 1995). These in-

creases have improved the standard of living across all

social strata. Still, in spite of these absolute improve-

ments, and despite the greater equalization that resulted

from land reform on the island (Hermalin et al., 1994),

significant differentials in income persist (Hermalin et al.,

1992).

Apart from a small aboriginal population, by far

the overwhelming ancestry of the Taiwanese population

is Chinese, stemming from migrants from the Mainland

who originated from two primary provinces: the

Fukienese majority from Fukien province, and the

Hakka, most of whom came from Kwantung

(Fricke et al., 1994). Both the Fukienese and the Hakka

are referred to as ‘‘Taiwanese’’ in contrast to the

‘‘Mainlanders’’ who constituted a migratory influx when

the Nationalist army came to Taiwan after the Second

World War. The distinction between Mainlanders

and Taiwanese is of particular importance for

this study, first, because the move from the Mainland

itself would have constituted a potentially challenging

event for the migrants, and second, because of

the distinctive demographic and social characteristics

that affect Mainlander access to and participation

in social networks and position in hierarchies.

For example, Mainlanders are overwhelmingly

male, and while the Taiwanese who are not married

are primarily widowed (i.e., virtually all Taiwanese

eventually marry and divorce is uncommon),

the Mainlanders are more likely to be never married

(or divorced or separated). They are among the

‘‘younger’’ elderly, are concentrated in urban areas,

are more likely than the Taiwanese to live alone,

and enjoy higher incomes and education than the

Taiwanese (Hermalin, Chang, Lin, Lee, & Ofstedal,

1990; Hermalin et al., 1992).

From the point of view of this investigation, there are

several potentially important social and cultural char-

acteristics that distinguish Taiwan from Western popu-

lations. First is the presence of extended or

intergenerational households, which constitute the

traditional and frequently preferred living arrangement

for the elderly. In particular, patrilineal norms have led

to coresidence of parents with their adult sons being the

dominant and preferred household structure, an ar-

rangement through which married sons and their wives

have been providing considerable support for elderly

Taiwanese. Second is the role of age and generation in

Chinese culture: respect for the elderly is deeply

embedded in patterns of deference in Taiwan and,

ideally, age has been associated with greater authority,

greater control over decisions, and improved treatment

by children and others. Third is the high level of

stratification by sex in Taiwanese society, which

originated in the traditional, patriarchal Chinese family

system and was maintained during the postwar period

(Greenhalgh, 1985). A fourth noteworthy contrast

between Taiwan and most Western populations has

been the rapidity of social and demographic change. For

example, during the past few decades, Taiwan has

experienced a dramatic drop in fertility to below

replacement levels, and substantial increases in age at

marriage, life expectancy, migration among younger age

groups, levels of education (especially among females),

employment among women, and levels of urbanization.

Many of these trends have been implicated in the

concomitant reduction in the prevalence of intergenera-

tional households, which are gradually being replaced by

an elderly couple or an elderly person living alone. This

increasing Westernization of Taiwanese society is likely

to have important consequences for the social environ-

ment and economic status of the elderly and for the

provision of support and health services to this growing

segment of the population.

Hypotheses

Researchers have lamented the dearth of empirical

observations from non-Western societies concerning the

effects of social factors on the health of the elderly

(Sugisawa, Liang, & Liu, 1994). The few studies that

have been carried out in East Asian societies typically

support the general findings described earlier. For

example, being unmarried and having few social

contracts was found to be associated with higher

mortality in an elderly Chinese cohort in Hong Kong

(Ho, 1991), and older Taiwanese with little or no

schooling were shown to have much higher death rates

than their more educated counterparts (Kramarow &

Yang, 1997). However, some analyses have produced

less consistent results, suggesting that social influences

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 193

on health and survival may be weaker in East Asian

than in Western populations perhaps because of

stronger social cohesion in the former societies (Sugisa-

wa et al., 1994).

As described below, our analyses address six hypoth-

eses pertaining to the influence of social factors and life

challenge on the health and survival of elderly Taiwa-

nese. In light of the vast literature in this area and the

importance of education, occupational position and

intergenerational relations in Taiwan, we anticipate that

the following general associations, found in other,

primarily Western societies, will also be present in this

population:

* We expect that measures of social connection and life

challenge will reveal significant associations with

health and survival among the elderly in Taiwan.* We hypothesize that the social environment will

mediate the effects of life challenges on health. For

example, respondents who experience a disadvan-

taged social environment should be more likely than

their socially advantaged counterparts to experience

poor health and survival outcomes when faced with

adverse life events.* We anticipate that (1) variables reflecting the

social environment and life challenge will be

associated with health in a cumulative fashion; and

(2) that positive aspects of the social environment will

increase the likelihood of health maintenance and

counteract the negative influence of social adversity

on health. Although very few studies, even in

Western populations, have tested this hypothesis

explicitly, recent evidence suggests that the associa-

tions between health and social and economic factors

result from cumulative processes, and that a mean-

ingful representation of the social and economic

environment needs to include both adversity and

advantage (Singer & Ryff, 1999; Power & Matthews,

1998).

At the same time, we hypothesize that, because of

considerable cultural variation between Taiwan and

Western populations, differences will emerge. Although

variability in data and statistical procedures from study

to study make numerical comparisons across popula-

tions impossible, we anticipate that the results for

Taiwan will deviate from patterns identified in the

previous literature in two important ways:

* Whereas one of the most powerful measures of social

support in Western societies is the presence of an

intimate relationship (typically a spouse or lover), we

expect that the presence of, and support from,

childrenFespecially sonsFwill be one of the stron-

gest predictors in Taiwan.* Whereas, the literature for Western populations has

generally found the protective effects of social

connection on health to be stronger for men than

for women1 (e.g., Hu & Goldman, 1990; House,

Landis, & Umberson, 1988), we hypothesize that the

lower autonomy of women may weaken or reverse

this sex differential in Taiwan.2

Finally, we hypothesize that ethnic differences in

health outcomes will be apparent:

* We anticipate that, in the presence of controls for the

social environment, Mainlanders will experience

poorer health outcomes than the Taiwanese because

the move from the Mainland itself would have

constituted a challenging event for the migrants.

However, we recognize that this ‘‘challenge’’ oc-

curred about four decades prior to the start of the

survey and that its effect may not only have

weakened over time (e.g., as more susceptible

individuals have died), but that Mainlanders may

have been protected by their higher socioeconomic

and political status. At the same time, it is plausible

that the influx of Mainlanders may have imposed

political subordination and economic hardship on

the Taiwanese.

Methods

Data and samples

The 1989 study of health and living status of the

elderly in Taiwan consists of face-to-face interviews with

a random sample of 4049 persons aged 60 and over

drawn from the entire elderly population of Taiwan,

including the institutional population. The sampling

plan entailed a three-stage probability sample in which

townships were the primary sampling unit. Only one

respondent was selected from a given household. The

1Although most studies have found that social connection is

more strongly associated with men’s health or longevity than

with women’s, some exceptions have been reported (e.g.,

Berkman & Syme, 1979). Similarly, although analyses of

mortality have demonstrated stronger SES effects for men than

for women (e.g., McDonough, Williams, House, & Duncan,

1999), there are some exceptions (e.g., Martikainen, 1995). In

contrast to the generally consistent findings for social factors

and health, sex differences in the association between life

challenge and health have not been consistent across studies

and appear to depend on the nature of the stressful event

(Thoits, 1995). Women seem to be more susceptible to stressful

events that affect persons in their social networks, whereas men

appear to have greater vulnerability to challenges affecting their

financial and employment status.2An alternative hypothesis is that, in a patriarchal society like

Taiwan, the benefits of social connection may vary by sex

because they may entail greater responsibilities and burdens for

women as compared with men.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209194

response rate was 92 percent (Taiwan Provincial

Institute of Family Planning, & Institute of Gerontology

University of Michigan 1989). As shown in Fig. 1, our

analyses use data from this initial 1989 survey and from

full-length face-to-face reinterviews in 1993 and 1996. (A

subsequent face-to-face reinterview was carried out in

1999, but the data were not yet available at the time of

this writing.) The sample sizes of completed interviews

were 3155 and 2669 at the two reinterviews, respectively,

with response rates of about 90 percent for each. Deaths

reported as having occurred subsequent to baseline were

confirmed through household registration office death

registration forms.

The initial sample for this analysis was selected

randomly from the 1989 sample to comprise two-thirds

of the respondents and the analysis derives from the

subset of these respondents who survived and were

interviewed in 1993 (see Fig. 1). The decision to use a

random subsample of two-thirds of the respondents

rather than the entire sample was carried out as part of a

broader split sample design. The overall objective of this

strategy has been to use the larger (i.e., two-thirds)

subsample to estimate models, as we do in this paper,

and the remaining subsample to appraise the models in

subsequent analyses (Berk, 1981). Although this type of

validation has been widely proposed as an antidote to

excessive model exploration and meaningless signifi-

cance levels, it has rarely been carried out (Picard &

Berk, 1990).

In order to identify inadequate social environments

and stresses that have persisted over several years, we

use data from two interview dates (1989 and 1993) to

construct the relevant explanatory variables. This is in

contrast to the analytic strategy used in most previous

research, which typically relies on a single cross-

sectional measure. The advantage of measures based

on two or more interviews is that they are more likely to

capture long-term inadequacies and challenges rather

than transient situations and short term discontent (see,

for example, House, Strecher, Metzner, & Robbins,

1986). In order to use both the 1989 and 1993 interviews

to construct explanatory variables, we restrict the

analysis to respondents who were still alive as of the

1993 survey date. Their health and survival are

subsequently assessed as of the 1996 survey date.

A common failing of earlier research has been the

absence of adequate controls for health status at the

baseline. This limitation potentially confounds the

results because of reverse causality: unhealthy persons

may be more likely than their healthier counterparts to

Fig. 1. Diagram of survey design for interviews and split-sample design for analysis (the subset of respondents in this analysis is shown

in gray).

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 195

face disadvantaged social settings or life challenges. In

order to ensure adequate controls for health status at

baseline, we carried out two sets of analyses. First we

analyzed data from the randomly selected sample of

two-thirds of respondents comprising 1983 respondents

who were alive as of the 1993 interview data. Models

based on this sample included two sets of control

variables for health status at baseline. The analysis was

repeated on the subset of these respondents who were

‘‘healthy’’ at the start of the follow-up period (1993).

The ‘‘healthy’’ subgroup included 1358 respondents who

reported no or little difficulty with a set of functional

activities and who assessed their overall health status as

‘‘good’’ or better (as described in more detail in the

subsequent section). While this second strategy has the

advantage of being restricted to a relatively homoge-

neous set of individuals with respect to initial health

status, it too suffers from potential biases. Because the

analysis examines the consequences of social factors

and challenges that existed or occurred prior to 1993,

this sample selectively excludes those whose health

deteriorated most rapidly in response to these variables.

However, given that the two sets of models yielded very

similar estimates, we conclude that our findings are

robust to the use of these alternative samples. Only the

estimates based on the larger sample (i.e., including

persons who are unhealthy at baseline) are presented

here, but noteworthy differences between the two

analyses are described later.

Explanatory variables and outcomes

The variables used in this analysis are presented in

Table 1, along with their distribution for the men and

women in our sample. The selection of variables was

guided primarily by the previous literature related to

social factors, challenges and health, and the appro-

priateness of the variables in the Taiwanese culture.

We include two demographic characteristics in the

model: age and self-identified Mainlander status. As

noted earlier, Mainlander status identifies the approxi-

mately one million Nationalist civilian and military

Table 1

Characteristics of the sample by sex

Total Men Women

Mean (%) s.d. Mean (%) s.d. Mean (%) s.d.

Demographic characteristics

Mean age in 1989 (60–90) 67.1 (5.6) 66.6 (5.5) 67.7 (5.8)

Percent Mainlander 22.1 32.1 8.8

Percent with missing data on Mainlander status 1.4 1.0 1.9

Social hierarchy (1993)

Mean paternal SES indexa 59.6 (4.6) 59.8 (4.9) 59.3 (4.1)

Percent with missing data on paternal SEI index 3.5 3.2 4.0

Respondent’s education

Percent no education and illiterate 39.2 19.6 65.4

Percent 1–6 years education or literate 41.6 51.8 27.9

Percent 7+years education 19.2 28.6 6.7

Social connection (1993)

Mean # friends/neighbors see or talk to weekly (0–50) 3.8 (5.4) 4.0 (5.5) 3.6 (5.1)

Percent with missing data on # friends see or talk to weekly 1.1 1.3 0.8

Mean # social activities (0–6)b 1.4 (1.0) 1.6 (1.0) 1.2 (0.8)

Percent with chronically poor emotional supportc 5.4 5.4 5.4

Percent with missing data on emotional support 1.3 1.4 1.2

Contact with children

Percent without living children 4.8 7.5 1.3

Percent with coresident child or visit child weekly 79.4 75.5 84.6

Percent visit child less than weekly 15.8 17.0 14.1

Life challenge (1993)

Percent lost spouse since 1989d 6.8 5.1 8.9

Percent with chronic financial difficultye 10.4 10.9 9.8

Percent with missing data on chronic financial difficulty 1.8 1.9 1.6

Percent with spouse in poor healthf 4.8 5.5 3.9

Percent with excessive demands made by social tiesg 1.9 2.4 1.2

Percent with missing data on excessive demands 1.3 1.4 1.2

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209196

supporters, largely young men, who migrated to Taiwan

from Mainland China around 1949 and 1950. Table 1

reveals that Mainlanders constitute 22 percent of the

sample, but a much higher percentage of men (32) than

of women (9). As described below, we include a set of

measures of the social environment, life challenge, and

baseline health as additional explanatory variables, and

a set of four outcomes to capture the respondent’s status

as of the 1996 interview.

Measures of the social environment

We measure position in the social hierarchy by

assessing both the respondent’s status and the status of

the respondent’s father. We determine the father’s social

position on the basis of his major lifetime occupation.

We use a socioeconomic index specifically developed for

Taiwan, derived from the prestige, education, and

income associated with Taiwanese occupations (Tsai &

Chiu, 1991). This index is highly correlated with those

based on the Standard International Occupational

Prestige Scale developed by Treiman (1977). We

measure the respondent’s status by his or her level of

education. As can be seen from Table 1, in contrast to

men, the majority of women in our sample (about two-

thirds) are illiterate. This difference is not surprising

given the history of education in Taiwan described

earlier. In early stages of the analysis, we also explored

measures for paternal education and the respondent’s

occupational status (using husband’s occupational

status for female respondents, because many female

respondents were never employed outside of the home),

but neither of these was significantly related to health

outcomes.

We also incorporate measures of social connection in

the statistical models. We considered several variables to

Table 1 (continued)

Total Men Women

Mean (%) s.d. Mean (%) s.d. Mean (%) s.d.

Percent deceased child since 1989 5.0 4.1 6.4

Health status (1993)

Percent with very good or excellent self-rated health 43.8 51.1 34.1

Percent with good self-rated health 33.1 30.4 36.8

Percent with fair or poor self-rated health 23.0 18.5 29.1

Mean # functional limitations (0–6)h 0.39 (1.02) 0.27 (0.90) 0.55 (1.15)

Health outcome (1996)

Percent lost to follow-up 12.8 12.4 13.4

Percent deceased 10.6 11.3 9.7

Percent unhealthyi 31.2 25.6 38.6

Percent healthyj 45.4 50.8 38.4

Number of respondents 1,983 1,133 850

aBased on Tsai and Chiu’s (1991) socioeconomic index for Taiwan based on the prestige, education and income related to 82

occupational titles. Scale ranges from 55.1 for agricultural and animal husbandry workers to 76.1 for physicians, dentists, and

veterinarians.bBased on number of memberships in social organizations (organizations of elderly persons, religious groups, business associations,

political groups, and clan organizations) and participation in any social activity outside of the household (playing games, socializing,

joining group organized activities, going for walks or other physical activities, other hobbies/activities such as watching operas).cDefined as being (1) having below average satisfaction with support from (a) spouse (if available), (b) children, children-in-law,

grandchildren and (c) others in 1989 and (2) not satisfied or very unsatisfied with consideration and care shown by family members,

friends or relatives in 1993.d Includes divorced/separated (9 cases), widowhood (101 cases), and unknown reason for change in marital status (24 cases).eChronic financial difficulty is defined as reporting, on average, (1) some, quite a bit, or a great deal of financial burden imposed

across types of social ties (see footnote c) or some, much or extreme difficulty meeting monthly expenses in 1989 and (2) some, quite a

bit, or a great deal of financial burden imposed by social ties or some, much or extreme difficulty meeting expenses in 1993.fPoor health defined as being in fair or poor health or needing assistance with physical care tasks due to health problems.gDefined as reporting in 1989 and 1993 that social ties make a great deal, quite a bit or some demands on respondent.hNumber of functions (bathing, climbing 2–3 flights of stairs, walking 200–300m, crouching, reaching up over one’s head, using

fingers to grasp or handle) respondent reports more than a little difficulty performing.iUnhealthy defined as reporting fair or poor health or more than a little difficulty with a set of functions (listed in footnote h) at the

1996 interview.jHealthy defined as reporting little or no difficulty with a set of functions (see footnote h) and reporting good, very good, or excellent

health at the 1996 interview.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 197

capture coresidence patterns, proximity of relatives,

frequency of contact with children (distinguishing sons

from daughters), frequency of contact with friends and

neighbors, the number of friends and neighbors with

whom the respondent reported having frequent contact,

and participation in social activities and associations. In

the final models, we retained three variables pertaining

to these aspects of social connection: coresidence/

contact with children, number of friends and neighbors

in frequent contact with the respondent, and number of

social activities and organizations in which the respon-

dent participates. As indicated by the estimates in Table

1, the majority of respondents (particularly women)

have frequent contact with children. Very few women

and only 7.5 percent of men (88 percent of whom are

Mainlanders) have no living children and most respon-

dents (about 84 percent) have at least weekly contact

with a child. Several additional variables not presented

in the tableFthe presence of living sons, the presence of

relatives nearby or in close contact with the respondent,

and coresidence with kin other than children and with

non-relativesFwere not significantly related to health

outcomes.3

We also include a fourth measure of social connection

that identifies respondents who have been receiving

chronically inadequate emotional support. This variable

is obtained from questions asked in 1989 and 1993

pertaining to the respondent’s satisfaction with the

emotional support provided by the respondent’s social

ties. In this and other questions described later that refer

to the provision or receipt of support, social ties

generally include the spouse, family members (i.e.,

usually children and sometimes children-in-law and

grandchildren), and friends, neighbors and other rela-

tives.

Measures of life challenge

The models include several measures of challenge that

have been shown to predict poor health outcomes in

previous studies. These challenges refer to either a loss

between the 1989 and 1993 interview dates or the

presence of a strain at both times. The specific challenges

consist of: (1) loss of a spouse (owing to either

widowhood or divorce, primarily the former) in the

period between 1989 and 1993; (2) difficulty meeting

expenses in both 1989 and 1993; (3) spouse in poor

health in 1993; (4) excessive demands placed on the

respondent by social ties in 1989 and 1993; and (5) loss

of a child between 1989 and 1993. As shown in Table 1,

the prevalence of these challenges varies considerably

from fewer than 2 percent of the respondents facing

excess demands from their social ties to more than 10

percent experiencing chronic financial problems. The

low proportion reporting excessive demands may reflect

reluctance on the part of elderly Taiwanese to acknowl-

edge dissatisfaction with their own lives and their

relationships with others.4

Indexes of social connection and life challenge

In this analysis, the effects of social connection and

life challenge on health are explored not only in terms of

the specific variables shown in Table 1, but also in terms

of cumulative measures (or indexes) of social connection

and life challenge. The variables that comprise these

indexes, and their distribution, are shown for men and

women in Table 2. The index of life challenge is simply a

count of the number of challenges faced by the

respondent, based on the five life challenges listed in

Table 1. As shown in the final panel of the table, no

respondent faced more than four of these challenges,

and about one-quarter of respondents faced at least one.

Two indexes are constructed to describe the adequacy

of the respondent’s social connections. The first of these

is a count of the number of negative attributes of social

connection faced by the respondent, derived from five

variablesFfour of which are based on variables

identical or similar to those presented in Table 1. In

three of these cases the variables in Table 1 have been

transformed to identify respondents with very low levels

of social connection. Thus, for example, rather than

using the average number of friends or neighbors in

weekly contact with the respondent, the index is based

on a dichotomous variable that denotes whether the

respondent has no friends or neighbors in weekly contact

(shown as a proportion for the sample in the first panel

of Table 2). This index also incorporates an additional

variable not depicted in Table 1Fwhether or not the

respondent has at least two detrimental characteristics

associated with their social tiesFand is derived from

questions related to the level of criticism given to the

respondent by relatives and friends, satisfaction with

care when the respondent is ill, availability of persons to

listen to the respondents, amount of love and considera-

tion shown to the respondents, and quality of the

spousal relationship (see the footnotes to Table 2 for

details). Although each of the corresponding variables

might be expected to have only a weak association with

subsequent health, particularly since relatively few

3We also considered including a variable to denote marital

status, but, because few Taiwanese remain single or become

divorced, the resulting variable was highly correlated with loss

of a spouse.

4Other attitudinal measures, such as respondents’ assess-

ments of their financial difficulties and receipt of emotional

support, may also be subject to these social desirability biases.

However, the proportion of respondents reporting excessive

demands is considerably smaller than corresponding values for

other variables.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209198

Table 2

Distribution of the social connection and life challenge indices and component variables measured in 1993 by sexa

Men Women

Mean (%) s.d. Mean (%) s.d.

Components of negative attributes index of social connection

Percent with chronically poor emotional support 5.4 5.6

Percent with no friends/neighbors see or talk to weekly 28.3 28.4

Percent without living children 7.3 1.4

Percent participating in no social activities 10.3 18.3

Percent with two or more negative aspects of social tiesb 8.8 8.7

Distribution of negative attributes indexc

0 55.9 54.5

1 26.9 27.5

2 8.5 11.0

3 2.6 2.9

4 0.9 0.3

Missing information 5.2 3.9

Mean score 0.55 (0.83) 0.59 (0.82)

Components of positive attributes index of social connection

Percent with chronically strong emotional support 7.1 4.6

Percent with ten or more friends/neighbors see or talk with weekly 14.9 13.2

Percent participating in three or more social activities 16.5 6.9

Percent with two or more positive aspects of social tiesd 54.3 53.7

Distribution of net index (positive minus negative attributes)

�4 0.9 0.3

�3 2.4 2.7

�2 7.0 9.4

�1 18.9 21.5

0 32.3 34.4

+1 21.0 19.8

+2 9.6 6.8

+3 2.3 1.1

+4 0.4 0.1

Missing information 5.2 3.9

Mean net score 0.05 (1.30) �0.12 (1.21)

Distribution of life challenge indexe

0 75.3 72.8

1 19.1 22.4

2 3.5 3.3

3 0.2 0.1

4 0.1 0.0

Missing information 1.7 1.4

Mean number of challenges 0.27 (0.54) 0.29 (0.53)

Number of respondents 993 736

aCases that were lost to follow-up in 1996 are excluded.bNegative aspects of social ties are: (1) reporting excessive criticism by social ties (spouse, relatives, and neighbors and friends) in

1989 and 1993; (2) dissatisfaction with care received from social ties when ill; (3) dissatisfaction with care and consideration shown; (4)

no one listens much to respondent; and (5) at least two of the following negative aspects of spousal relationship; (a) makes excessive

demands, (b) does not listen, (c) does not show love and consideration, (d) does not provide adequate emotional support, and (e) is too

critical.cProportions may not sum to one because of rounding error.dPositive aspects of social ties are: (1) social ties (spouse, relatives, neighbors and friends) excessively criticize ‘‘not at all’’; (2) highly

satisfied with care received from social ties when ill; (3) highly satisfied with care and consideration shown; (4) always someone there to

listen to respondent when needed; and at least three of the following positive aspects of spousal relationship; (a) does not make

excessive demands; (b) willing to listen a great deal; (c) shows great deal of love and consideration; (d) provides great deal of emotional

support; and (e) is ‘‘not at all’’ too critical.eThe life challenge index is the sum of the five challenge variables shown in Table 1 (chronic financial difficulty, loss of spouse,

spouse in poor health, excessive demands, and deceased child).

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 199

respondents acknowledge having any particular limita-

tion in their relationships, the combination of these

distinct variables is likely to offer a more robust measure

of the quality of the respondent’s relation with their

friends and relatives.

As shown in the first panel of Table 2, about 9 percent

of men and women face two or more of the measured

negative aspects of their social ties and a similar

proportion do not participate in any of the mentioned

social activities. More than one-quarter of respondents

do not have weekly contact with friends or neighbors,

and, as presented in the next panel, as many as 45

percent of respondents experience at least one of the five

overall negative attributes of social connection. Inter-

estingly, although research in the U.S. indicates large

differences between men and women in the nature of

social networks (Antonucci & Akiyama, 1987; Belle,

1987), the descriptive statistics presented here indicate

generally modest differences. Two notable discrepancies

by sex pertain to the percentages not participating in

social activities and having no children.

The second index of social connection incorporates

positive as well as negative attributes. The four5 positive

attributes shown in the table reflect the high end of the

distribution of the variables incorporated in the previous

index: e.g., persons with many friends and neighbors in

weekly contact, persons participating in at least a few

social activities, persons with positive aspects of their

social ties, and persons receiving strong emotional

support from these ties. This index is constructed by

cumulating the number of positive attributes and

subtracting the number of negative ones; the mean score

is close to zero.

Measures of health status

For analyses based on the total (as opposed to the

healthy) sample at baseline (1993), we introduce two

control variables that capture health status at this time

point. The first of these measures is based on a question

in which respondents are asked to evaluate their health

at the time of the interview in terms of five ratings:

excellent, very good, good, fair and poor. This type of

information has been included in numerous health

interview surveys worldwide, for several reasons. First,

self-assessed health status is highly correlated with

measures of disability and chronic illness (Ferraro,

1980; Rakowski & Cryan, 1990). Second, it appears

tap distinct dimensions of wellbeing (such as psycholo-

gical health) that are not captured by more ‘‘objective’’

measures (Tessler & Mechanic, 1978). And third, it is

highly predictive of subsequent mortality, even in the

presence of other measures of illness and disability,

including physicians’ assessments (Idler & Benyamini,

1997).

Our second measure of baseline health status is

derived from respondents’ reports on the amount of

difficulty they encounter in performing the following six

functions: bathing, climbing two to three flights of stairs,

walking 200 to 300 meters, crouching, reaching up over

one’s head, and using fingers to grasp or handle items.

Since their development about 40 years ago (e.g., Katz,

Ford, & Moskowitz, 1963), measures of self-reported

functional health status have been widely used to assess

physical functioning, especially among the elderly.

Recent studies have demonstrated the consistency of

these measures over short time intervals (Rathouz et al.,

1998) and their concurrent validity with performance

measures in diverse elderly populations (Ferrucci et al.,

1998). Measures of self-assessed health status and self-

reported functional status have been evaluated not only

in Western populations but also in East Asian popula-

tions, including Taiwan (Leung, Tang, & Lue, 1997;

Sugisawa, Liang, & Liu, 1994; Yu, Kean, Slymen, Liu,

Zhang, & Katzman, 1998; Liu, Liang, & Gu, 1995).

As shown in Table 1, the baseline measure of self-

assessed health status used in this analysis consists of

three categories: very good or excellent; good; fair or

poor. The measure of physical functioning is represented

by a continuous variable denoting the number of

functions (ranging from 0 to 6 of the functions described

above) for which the respondent reports more than a

little difficulty performing. The distributions shown in

the table indicate that a large proportion of respondents

in 1993 report their health as very good or excellent and

that the mean number of functional limitations is low (0.4).

Health outcome

The outcome variable, shown in the last panel in

Table 1, distinguishes among respondents who were (1)

lost to follow-up, (2) deceased, (3) unhealthy, and (4)

healthy as of the 1996 interview date. Consistent with

the control variables for baseline health status, a healthy

outcome is defined as (1) reporting little or no difficulty

with the set of six functions described earlier; and (2)

assessing one’s own health as good, very good or

excellent. The complementary group of respondents is

considered to be unhealthy.6 As shown in Table 1,

almost half of the sample was healthy at follow-up and

about 11 percent died during the period between

5There are only four rather than five variables reflecting

positive attributes because the fifth variable (whether the

respondent has a large number of living children) is not

hypothesized to have a positive effect on health (e.g., as

compared with whether the respondent has several living

children).

6Among the 625 respondents who are unhealthy at baseline,

41 percent report themselves to be in poor or fair health and 27

percent report at least one functional limitation.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209200

interviews. Survival status was ascertained from death

registration records. About 13 percent of the 1993

respondents were presumed to be alive7 in 1996 but did

not supply interviews at that time. Half of these persons

(6.5 percent) were interviewed by a proxy, but, because

proxies did not collect information on health status in

1996, we treat all non-interviewed individuals as LFU in

this analysis.

Analytical strategy

Our analysis proceeds in three stages. We begin by

considering the effects of the explanatory variables

shown in Table 1 on health. In this model, we

distinguish among four outcomes: healthy, unhealthy,

dead, and loss to follow-up. Unlike most analyses of

longitudinal surveys that ignore loss-to-follow up (LFU)

by simply excluding the relevant respondents from the

sample, we include LFU in the initial stage of the

analysis because LFU is generally non-random and

hence likely to introduce bias into the analysis (Gold-

man et al., 1995). In order to explore the effects of social

and challenge variables on health and assess the extent

to which LFU is associated with these factors, we use a

multinomial logistic model based on the four outcomes;

the healthy group comprises the base category. Because

a substantial prior literature indicates that the

health-related impacts of the social environment and

life challenge frequently vary by sex, we fit separate

multinomial models for men and for women.

In order to obtain a simpler model and increase

statistical power (because of the small sample of

deceased persons), we estimate a second model based

on two outcomes. In the resulting (binomial) logistic

model, the outcomes of unhealthy and dead are

combined and respondents classified as LFU are

excluded. As shown in the next section, because the

pattern of relationships between the predictor variables

and the outcome variable are generally consistent

whether we use the dichotomous or the four-category

outcome variable, we employ the dichotomous outcome

variable for the remaining models. To facilitate statis-

tical testing of differences by sex, this (and subsequent)

logic models include all interaction terms with sex.8

However, for simplicity of presentation, the resulting

coefficients are presented separately for males and

females.

In the third stage of the analysis, we estimate a set of

logistic models in which the individual variables depict-

ing social connection and life challenge are replaced with

their respective indexes. As noted above, we explore

three types of indexes, which represent counts of (1)

negative attributes of social connection; (2) positive

minus negative attributes of social connection (i.e., net

scores); and (3) life challenge. These indexes allow us to

estimate the cumulative effects of social adversity and

challenge on health and to examine whether social

advantage counteracts the impact of social adversity, as

hypothesized. In addition, because many distinct vari-

ables have been reduced to only two measures in this

stage of the analysis, we use the interaction between the

index of social connection and the index of challenge to

explore whether social connection mediates the impact

of life challenge.

Results

The results are presented in the form of estimated

coefficients from a multinomial (polytomous) logistic

model in Table 3 and from binomial logistic models in

Tables 4 and 5. In the case of the multinomial model, the

exponentiated coefficients denote a relative risk ratio

(for a one unit change in a continuous variable or

relative to an omitted category for a categorical

variable), where risk is measured relative to the

probability of being healthy (the base category).

The results in Table 3 support the hypothesized

relationships between measures of the social hierarchy

and health: higher values of the paternal socioeconomic

status index (for men) and higher levels of education (for

men and especially women) are associated with lower

relative risks of being unhealthy or dying (relative to

being healthy).

Estimates for the social connection variables reveal

that infrequent contact with friends is significantly

associated with poor health status for both sexes; a

low level of participation in social activities is signifi-

cantly associated with poor health status for women (but

not men); and the absence of living children is

significantly associated with poor health status for men

(but not women).9 Surprisingly, the presence of living

sons, the presence of relatives nearby or in close contact

with the respondent, and coresidence with kin other

than children and with non-relatives – were not

7 In most of these cases, the respondents were known to be

alive. This category includes respondents who were reported as

too ill to respond or respondents for whom a family member

refused the interview. A small proportion of respondents had

unknown or invalid addresses; their survival status was

subsequently checked against death registration records.8The model including all interaction terms with sex yields

identical estimates to those resulting from separate models for

men and women. However, because the former strategy

involves only one error term whereas the latter involves two

error terms, the two approaches yield slight differences in the t-

statistics or p-values associated with the coefficients.

9The absence of a significant association for women may be

largely the consequence of so few women having no living

children.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 201

Table 3

Estimated coefficients (b) and standard errors (s) from the multinomial logistic model of the probability of being loss to follow-up (LFU), deceased or unhealthy in 1996 by sex

Men Women

LFU Deceased Unhealthy LFU Deceased Unhealthy

b s b s b s b s b s b s

Demographic characteristics

Age 0.064** (0.019) 0.103** (0.019) 0.014 (0.017) 0.111** (0.022) 0.133** (0.026) 0.042** (0.018)

Mainlander status

Mainlandera 0.556* (0.225) �0.261 (0.312) 0.368* (0.206) 0.151 (0.406) �0.589 (0.794) �0.436 (0.353)

Taiwanese

Social hierarchy

Paternal SES indexb

Lowest tercile

Intermediate and highest terciles �0.573** (0.225) �0.511* (0.240) �0.369* (0.081) 0.242 (0.268) �0.174 (0.297) 0.034 (0.189)

Respondent’s education

No education and illiterate

1–6 years education or literate �0.395 (0.263) 0.147 (0.288) �0.226 (0.215) 0.011 (0.277) �0.571 (0.373) �0.433* (0.200)

7+years education �0.467 (0.319) �0.219 (0.375) �0.715** (0.265) �0.008 (0.500) c �0.827* (0.423)

Social connection

No. friends/neighbors see or talk to weekly �0.094** (0.029) �0.057* (0.027) �0.011 (0.016) �0.102** (0.035) �0.017 (0.033) �0.036* (0.018)

No. Social activities �0.151 (0.111) 0.056 (0.118) �0.118 (0.087) �0.315* (0.153) �0.715** (0.202) �0.189* (0.108)

Chronically poor emotional support 0.210 (0.482) 0.585 (0.473) 0.327 (0.337) 0.065 (0.581) 0.677 (0.585) 0.404 (0.415)

Contact with children

Without living children 0.833* (0.416) 1.642** (0.446) 1.107** (0.335) 0.129 (1.229) c 0.799 (0.796)

Any coresident child or visit child weekly

Visit child less than weekly 0.145 (0.269) �0.029 (0.317) 0.199 (0.216) �0.298 (0.352) �0.600 (0.457) �0.196 (0.257)

Life challenge

Lost spouse since 1989 0.468 (0.407) �0.064 (0.493) �0.065 (0.384) 0.352 (0.409) 0.139 (0.493) 0.506 (0.318)

Chronic financial difficulty 0.369 (0.353) 0.561 (0.366) 0.645** (0.275) �0.288 (0.461) 0.086 (0.473) �0.158 (0.313)

Spouse in poor health 0.534 (0.426) 0.468 (0.451) 0.615* (0.343) 1.492* (0.696) 0.984 (0.926) 1.802** (0.558)

Excessive demands made by social ties 0.105 (0.757) 0.239 (0.786) 0.953* (0.536) 1.397 (1.089) c 1.228 (0.915)

Deceased child since 1989 �0.433 (0.529) �0.031 (0.500) �0.354 (0.424) 0.767* (0.455) 0.705 (0.529) 0.309 (0.394)

M.Beck

ettet

al./Socia

lScien

ce&

Medicin

e55(2002)191–209

202

Health status in 1993

Self-rated health

Very good or excellent

Good 0.529* (0.233) 0.906** (0.262) 0.770** (0.185) 0.370 (0.273) 1.022** (0.386) 0.803** (0.205)

Fair or poor 1.115** (0.317) 1.842** (0.321) 1.848** (0.247) 0.561 (0.349) 1.584** (0.423) 1.469** (0.248)

No. functional limitations (0–6) 1.031** (0.228) 1.160** (0.225) 0.972** (0.220) 0.622** (0.165) 0.807** (0.162) 0.547** (0.146)

Number of respondents 1.133 850

Log likelihood �1151.4 �876.4Pseudo R2 0.152 0.162

Note: Italics indicate reference categories. The base group consists of healthy respondents.aVariables missing 10 or fewer cases are assigned the modal value. When the number of missing cases exceeds 10, we introduce a dummy variable into the model, but do not

present the coefficients. These variables represent respondents with missing information on Mainlander status, paternal SEI, number of friends/neighbors, poor emotional support,

chronic financial difficulty, and excessive demands.bSee footnotes in Table 1 for definition of explanatory variables.cThese coefficients could not be estimated because of empty cells.npo0.05 based on one-tail Z-test.nnpo0.01.

M.Beck

ettet

al./Socia

lScien

ce&

Medicin

e55(2002)191–209

203

Table 4

Estimated coefficients (b) and standard errors (s) from the logistic model of the probability of being unhealthy or deceased in 1996 by

sexa

Men Women

b s b s

Demographic characteristics

Age 0.040** (0.015) 0.058** (0.017)

Mainlander status

Mainlanderb 0.218 (0.196) �0.591 (0.351)w

Taiwanese

Social hierarchy

Paternal SES indexc

Lowest tercile

Intermediate and highest terciles �0.412** (0.171) �0.022 (0.187)

Respondent’s education

No education and illiterate

1–6 years education or literate �0.133 (0.203) �0.466** (0.198)

7+years education �0.638** (0.248) �0.943* (0.413)

Social connection

No. friends/neighbors see or talk to weekly �0.022 (0.015) �0.035* (0.018)

No. social activities �0.078 (0.080) �0.273** (0.109)

Chronically poor emotional support 0.336 (0.365) �0.432 (0.412)

Contact with children

Without living children 1.200** (0.325) 0.563 (0.836)

Any coresident child or visit child weekly

Visit child less than weekly 0.158 (0.206) �0.304 (0.257)

Life challenge

Lost spouse since 1989 �0.206 (0.374) 0.353 (0.318)

Chronic financial difficulty 0.691** (0.263) �0.076 (0.307)

Spouse in poor health 0.515 (0.331) 1.874** (0.577)w

Excessive demands made by social ties 0.799 (0.541) 1.270 (0.929)

Deceased child since 1989 �0.205 (0.388) 0.369 (0.398)

Health status in 1993

Self-rated health

Very good or excellent

Good 0.822** (0.169) 0.801** (0.200)

Fair or poor 1.851** (0.235) 1.460** (0.244)

No. functional limitations (scale 0–6) 1.051** (0.220) 0.630** (0.145)

Number of respondents 993 736

Log likelihood �526.8 �398.0Pseudo R2 0.221 0.213

Note: Italics indicate reference categories.aCases that were lost to follow-up in 1996 are excluded.bVariables missing 10 or fewer cases are assigned the modal value. When the number of missing cases exceeds 10, we introduce a

dummy variable into the model, but do not present the coefficients. These variables represent respondents with missing information on

Mainlander status, paternal SEI, number of friends/neighbors, poor emotional support, chronic financial difficulty, and excessive

demands.cSee footnotes in Table 1 for variable definitions.npo.05 based on one-tail Z-test.nnpo.01.wpo0.05 based on two-tail Z-test for interaction term between sex and a specific variable in a fully-interacted model applied to

pooled male and female sample.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209204

significantly related to health outcomes (data not

shown).

Three of the five variables representing challenges are

significantly associated with at least one of the health

outcomes: chronic financial difficulty (for men), spouse

in poor health (for both sexes, but an especially large

coefficient for women), and excessive demands made by

social ties (for men). Contrary to expectation, loss of a

spouse or loss of a child in the four-year period prior to

baseline had no significant associations with health

outcomes, although the relevant coefficients for women

are sizeable.10

The estimated coefficients for LFU reveal strong

associations with social hierarchy, social connection,

life challenge, initial health status and age. In general,

persons of lower SES, few social ties, those who are

in poor health and those who have a spouse in

poor health face the highest risk of being lost to

follow-up. The positive association for Mainlander

men is consistent with findings that Mainlanders

are more likely than Taiwanese to rely on formal

mechanisms of support and to move into institutional

facilities when they become frail (Hermalin et al., 1992;

Lee, Lin, & Chang, 1995). Because persons lost to

follow-up are selected for poor health and for many of

the same explanatory variables that are associated with

poor health outcomes, the existence of LFU most likely

results in conservative estimates of the association

between the explanatory variables and the health out-

comes of interest in this analysis. That is, coefficients in

Table 5

Estimated coefficients (b) and standard errors (s) from the logistic model of the probability of being unhealthy or deceased in 1996,

incorporating indices of social connection or life challenge by sexa

Men Women

b s b s

Negative attributes of social connection

Categorical

No negative attributes

1 negative attribute 0.242 (0.176) 0.297 (0.201)

2–4 negative attributes 0.433* (0.257) 0.765** (0.286)

Linear 0.203* (0.101) 0.330** (0.118)

Net score (positive minus negative attributes) of social connectionb

Categorical

�4 to �2 net score

�1 to +1 net score �0.385 (0.269) �0.665* (0.296)

+2 to +4 net score �0.438 (0.341) �1.005** (0.424)

Linear �0.139* (0.063) �0.245** (0.078)

Life challenge indexc

Categorical

Zero challenges

1 challenge 0.335* (0.194) 0.406* (0.212)

2–4 challenges 0.918** (0.391) 0.914 (0.575)

Linear 0.384** (1.142) 0.425** (0.175)

Number of respondents 993 736

Note: Italics indicate reference categories.aCases that were lost to follow-up in 1996 are excluded.bModels also include demographic characteristics, social hierarchy, life challenge, and 1993 health status shown in Table 4, and

variables for respondents with missing information.cModels also include demographic characteristics, social hierarchy, social connection, and 1993 health status shown in Table 4 and

variables for respondents with missing information.npo.05 based on one-tail Z-test.nnpo.01.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 205

this table and subsequent tables (which omit LFU) are

likely to be underestimated.

The estimates in Tables 3 and 4 are derived from a

(binomial) logistic model in which the outcomes of

unhealthy and deceased are combined; persons LFU are

excluded. Overall, the results confirm the findings in the

previous table with regard to the importance of position

in the social hierarchy, social connection and life

challenge for poor health. Our tests for interactions

with sex show that very few of the estimated coefficients

are significantly different by sex (as indicated by the

daggers at the right of the table). The most notable

gender differences relate to the presence of an ill spouse,

which has a very large effect for women (i.e., a relative

risk ratio of exp (1.875) or 6.5) and a modest one for

men, and chronic financial difficulties, which is sizeable

for men and virtually zero for women. Surprisingly, in

the presence of controls for the social environment and

life challenge (and baseline health status), Mainlander

women are more likely to be healthy than their

Taiwanese counterparts, although this is not the case

for Mainlander men.

The estimates in Table 5 derive from the same logistic

models as in Table 4 with one exception: in any given

model, the set of variables pertaining to social connec-

tion or to life challenge is replaced by the corresponding

index. Each substitution results in a separate set of

estimates for all coefficients, but only the coefficients

pertaining to the index are presented in the table. For

both parameterizations of the index (linear and catego-

rical) there is a significant association with poor health;

the lack of high values on these scores prevents us from

identifying whether there are notable departures from

linearity in the behavior of these indexes.

The estimates in the first two panels indicate that the

risks of being unhealthy or dead increase with increasing

numbers of negative attributes of social connection and

that positive characteristics counteract negative ones.

The deleterious effects of inadequate social connection

and the beneficial ones associated with positive attri-

butes appear to be greater for women than for men,

although the sex difference is not statistically significant.

The estimates for the life challenge index indicate that

the higher the number of challenges the greater the

relative risk of being unhealthy or dead. The relative

risks for respondents facing 2–4 recent challenges are

largeFabout exp (0.9) or 2.5Ffor both men and

women compared with respondents facing no challenges.

In models not presented here, we included interaction

terms between indexes of social ties and those of life

challenge. Contrary to our hypothesis that challenges

are more likely to lead to negative outcomes in the

absence of strong social connections, the interaction

terms are not statistically significant.

As noted earlier, the analysis described above was

repeated for the subsample of respondents who were

healthy at the time of the 1993 interview. This subsample

differs from the larger sample with respect to the

explanatory variables: e.g., the healthy subgroup is

more educated, has more social ties and faces fewer life

challenges. However, estimates obtained for the healthy

subsample for the models presented in Tables 3–5 are

similar to those shown here with only one exception in

terms of statistically significant results: the effect of the

number of social activities on health is significantly

different between women and men (with women having

the stronger effect).10

Discussion

This study has identified several important aspects of

the social environment linked to the future health status

of the elderly in Taiwan: socioeconomic status, presence

of any living children, size of networks of friends, and

degree of participation in social activities. In addition,

three life challengesFchronic financial problems, ex-

cessive demands placed by close relatives and friends,

and having a spouse in poor healthFare significantly

associated with poor health outcomes for men and/or

women. These findings are generally consistent with our

hypotheses derived from a review of studies based on

Western populations and do not provide evidence for

the argument that East Asian populations are less likely

than Westerners to suffer from poor socioeconomic

environments. Our failure to find any evidence that

social ties buffer the physical-health impact of life

challenges remains baffling.

To our knowledge, there have been few studies

focusing on sex differences in the relationship between

social factors and health in East Asian populations. This

study does not find significantly different patterns by sex

in the association between social factors and health

(with the exception of one social connection variable

when estimates are restricted to the healthy sample).

These results support our hypothesis that sex differences

are likely to be more modest in this population than in

the West, but it also plausible that some of the estimated

sex differentials fail to reach statistical significance

because of insufficient statistical power.

Consistent with the previous literature, this study also

demonstrates that, in terms of physical health, (1) both

10Because we observe the sample only at intervals of several

years, we may not fully capture the health consequences of

these challenges, particularly if the negative effects on health are

concentrated at short durations of the events. For example, we

are likely to be underestimating the bereavement effect (i.e., the

negative health consequences experienced during the first few

years of widowhood) because the discrete time models used in

this analysis do not permit us to consider health outcomes

within the period from 1989 to 1993.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209206

men and women are vulnerable to life challenges,

particularly in the presence of multiple stressful events;

and (2) there are important sex differences that depend

on the particular challenge. A particularly striking result

is the large detrimental effect of an ill spouse on women,

a finding that suggests that the consequences for women

imposed by the burden of caring for an unhealthy

husband are enormous. Although it is possible that

some of the association results from the sharing of risk

factors and illness between spouses, this explanation in

and of itself would have led to equally large coefficients

for men who have a sick wife. The much smaller

coefficient for men suggests that other family members

or friends are likely to assist with the care of an

unhealthy wife.

What is surprising is the lack of significance in the

Taiwanese setting of several aspects of the social

environment and life challenge, such as the degree of

contact with relatives (other than children), having sons,

and the recent loss of a spouse or children. Despite the

traditional importance of extended family, and in

particular sons, we speculate that in Taiwan, as in some

Western population which are facing declines in the

availability of potential kin to provide support (e.g.,

Wachter, 1997), the Taiwanese elderly are reaching out

to daughters, friends, and more general social activities

to supplement traditional ties.

Another unanticipated result is that, among women,

Mainlanders are more likely to be healthy than

Taiwanese. This finding contradicts our hypothesis and

may reflect not only uncontrolled aspects of socio-

economic status, but also the benefits associated with

political dominance enjoyed by Mainlanders until the

present time (although it is not clear why these factors

should not benefit Mainlander men as well).

The present analysis has gone beyond most previous

studies in several important methodological and sub-

stantive dimensions. Inclusion of LFU in the multi-

nomial model demonstrated that the presence of this

type of non-response probably results in conservative-

Frather than exaggeratedFestimates of the effects of

the explanatory variables of interest. The availability of

in-depth current and retrospective information on the

social environment allowed us to introduce detailed

controls for baseline health status, to define explanatory

variables based on information collected at two inter-

view dates, and to create indexes capturing diverse

aspects of social adversity, social advantage, and life

challenge.

Our results based on these indexes demonstrate the

large negative health impact of multiple social deficits

and of exposure to repeated stressful situations. The

implications of these findings for Taiwan may be

especially important in the near future for at least two

reasons. One is that the Taiwanese population is

currently facing several new and unanticipated chal-

lenges: the physical and emotional consequences of large

and devastating earthquakes in the fall of 1999 that

resulted in a series of aftershocks; political tensions with

Mainland China that may be escalating with the current

political regime; and increased rates of crimeFincluding

violent crimeFduring the past decade. Second is a series

of major demographic changes that have led to

reductions in the number of children available for

support and to fewer elderly parents residing with or

living close to their adult children. How the Taiwanese

population will adapt to these changes, in terms of both

their social networks and their physiological responses,

has yet to be determined.

The availability of future waves of this survey, along

with data on physiological measurements that were

collected for a subsample of about 1000 respondents

during the year 2000 (Weinstein & Willis, 2000) will

provide new insights into this question and will enable

researchers to begin to identify the pathways relating

social variables and challenge to mental and physical

health outcomes.

Acknowledgements

This work has been supported by the Demography

and Epidemiology Unit of the Behavioral and Social

Research Program, NIA under grant numbers R01

AG14521-0151, R01-AG16661, R01-AG16790, R03

AG15202-01, 5P30HD/AG32030 and 1 T32 AG00244-

03. We would like to thank Jim House, Anne Pebley,

two anonymous reviewers, and the editor for comments

on earlier drafts of the manuscript.

References

Adler, N. E., Boyce, T., Chesney, M. A., Cohen, S., Folkman,

S., Kahn, R. L., & Syme, S. L. (1994). Socioeconomic status

and health: The challenge of the gradient. American Journal

of Psychology, 49, 15–24.

Adler, N. E., Boyce, T., Chesney, M. A., Folkman, S., & Syme,

S. L. (1993). Socioeconomic inequalities in health. No easy

solution. Journal of the American Medical Association, 269,

3140–3145.

Antonucci, T. C., & Akiyama, H. (1987). An examination of

sex differences in social support among older men and

women. Sex Roles, 17, 737–749.

Baker, H. D. R. (1979). Chinese family and kinship. New York:

Columbia University press.

Belle, D. (1987). Gender differences in the social moderators of

stress. In R. C. Barnett, L. Biener, & G. K. Baruch (Eds.),

Gender and stress. New York: Free Press.

Berk, R.A. (1981). Toward a methodology for mere mortals,

sociological methodology. Washington: American Socio-

logical Association.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 207

Berkman, L. F., & Syme, S. L. (1979). Social networks, host

resistance, and mortality: A nine-year follow-up study of

Alameda County residents. American Journal of Epidemiol-

ogy, 109, 186–204.

Brosschot, J. F., Benschop, R. J., Godaert, G. L. R., Olff, M.,

De Smet, M., Heijnen, C. J., & Ballieux, R. E. (1994).

Influence of life stress of immunological reactivity to

mild psychological stress. Psychosomatic Medicine, 56,

216–224.

Cohen, S. (1988). Psychosocial models of the role of social

support in the etiology of physical disease. Health Psychol-

ogy, 7, 269–697.

Cohen, S., & Wills, T. A. (1985). Stress, social support

and the buffering hypothesis. Psychological Bulletin, 98,

310–357.

Dean, A., Kolody, B., & Wood, P. (1990). Effects of social

support from various sources on depression in elderly

persons. Journal of Health and Social Behavior, 31, 148–161.

Egan, R. C. (1994). Image and deed in the life of Su Shi.

Cambridge: Harvard University Press.

Feinstein, J. (1993). The relationship between socioeconomic

status and health: A review of the literature. Milbank

Quarterly, 71, 279–322.

Ferraro, K. F. (1980). Self-ratings of health among the old and

the old–old. Journal of Health and Social Behavior, 21, 377–

383.

Ferrucci, L., Guralnik, J. M., Cecchi, F., Marchionni, N.,

Salani, B., Kasper, J., Celli, R., Giardini, S., Heikkinen, E.,

Jylha, M., & Baroni, A. (1998). Constant hierarchic patterns

of physical functioning across seven populations in five

countries. The Gerontologist, 38, 286–294.

Fricke, T., Chang, J.-S., & Yang, L.-S. (1994). Historical and

ethnographic perspectives on the Chinese family. In A.

Thornton (Ed.), Social change and the family in Taiwan.

Chicago: University of Chicago Press.

Glass, T. A., Kasl, S. V., & Berkman, L. F. (1997). Stressful life

events and depressive symptoms among the elderly.

Evidence from a prospective community study. Journal of

Aging and Health, 9, 70–89.

Goldman, N., Korenman, S., & Weinstein, R. (1995). Martial

status and health among the elderly. Social Science &

Medicine, 40, 1717–1730.

Greenhalgh, S. (1985). Sexual stratification: The other side of

‘‘Growth with Equity’’ in East Asia. Population and

Development Review, 11(2), 265–313.

Grichting, W. L. (1971). Occupational prestige structure in

Taiwan. National Taiwan University Journal of Sociology,

67–78.

Hermalin, A. I. (1998). Setting the Agenda for Research on

Aging in Developing Countries. Elderly in Asia Research

Report 98–51: Population Studies Center, University of

Michigan.

Hermalin, A. I. Chang, M.-C., Lin, H.-S., Lee, M.-L., &

Ofstedal, M. B. (1990). Patterns of support among the

Elderly in Taiwan and their Policy Implications. Research

Reports 90-4: Population Studies Center, University of

Michigan.

Hermalin, A. I. Liu, P. K. C., & Freedman, D. (1994). The

social and economic transformation of Taiwan. In A.

Thornton. & H.-S. Lin (Eds.), Social change and the family

in Taiwan. Chicago: University of Chicago Press.

Hermalin, A. I., Ofstedal, M. B., & Chang, M.-C. (1992). Types

of Supports for the Aged and Their Providers in Taiwan.

Research Report 92-14: Population Studies Center, Uni-

versity of Michigan.

Ho, S. C. (1991). Health and social predictors of mortality in an

elderly Chinese cohort. American Journal of Epidemiology,

133, 907–921.

House, J. S., Landis, K. R., & Umberson, D. (1988). Social

relationships and health. Science, 241, 540–545.

House, J. S., Lepkowski, J. M., Kinney, A. M., Mero, R. P.,

Kessler, R. C., & Herzog, A. R. (1994). The social

stratification of aging and health. Journal of Health and

Social Behavior, 35, 213–234.

House, J. S., Strecher, V., Metzner, H. L., & Robbins, C. A.

(1986). Occupational stress and health among men and

women in the Tecumseh Community Health Study. Journal

of Health and Social Behavior, 27, 62–77.

Hu, Y., & Goldman, N. (1990). Mortality differentials by

marital status: An international comparison. Demography,

27, 233–250.

Idler, E., & Benyamini, Y. (1997). Self-rated health and

mortality: A review of twenty seven community studies.

Journal of Health and Social Behavior, 38, 21–37.

Katz, S., Ford, A. B., & Moskowitz, R. W. (1963).

Studies of illness in the aged: The index of ADL: A

standardized measure of biological and psychological

function. Journal of the American Medical Association,

185, 914–921.

Kiecolt-Glaser, J. K., Glaser, R., Gravenstein, S., Malarkey,

W. B., & Sheridan, J. (1996). Chronic stress alters the

immune response to influenza virus vaccine in older

adults. Proceedings of National Academy of Sciences, 93,

3043–3047.

Kramarow, E. A., & Yang, W. S. (1997). Educational

Differentials in Mortality: An Examination of Taiwanese

Data, Comparative Study of the Elderly in Asia Research

Report. Research Report 97-40: Population Studies Center:

University of Michigan.

Lee, M., Lin, H., & Chang, M. (1995). Living arrangements of

the elderly in Taiwan: Qualitative evidence. Journal of

Cross-Cultural Gerontology, 10, 53–78.

Leung, K. K., Tang, L. Y., & Lue, B. H. (1997). Self-rated

health and mortality in Chinese institutional elderly

persons. Journal of Clinical Epidemiology, 50, 1107–1116.

Liu, X., Liang, J., & Gu, S. (1995). Flows of social support and

health status among older persons in China. Social Science

& Medicine, 41, 1175–1184.

Lupien, S., Lecours, A. R., Lussier, I., Schwartz, G., Nair, N.

P., & Meaney, M. J. (1994). Basal cortisol levels and

cognitive deficits in human aging. Journal of Neuroscience,

14, 2893–2903.

Martikainen, P. (1995). Women’s employment, marriage,

motherhood and mortality: A test of the multiple role and

role accumulation hypotheses. Social Science & Medicine,

40, 199–212.

McDonough, P., Williams, D. R., House, J. S., & Duncan, G. J.

(1999). Gender and the socioeconomic gradient in mortality.

Journal of Health and Social Behavior, 40, 17–31.

McEwen, B. S., & Stellar, E. (1993). Stress and the individual:

Mechanisms leading to disease. Archives of Internal

Medicine, 153, 2093–2101.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209208

McLeod, J. D., & Kessler, R. C. (1990). Socioeconomic status

differences in vulnerability to undesirable life events. Journal

of Health and Social Behavior, 31, 162–172.

Picard, R. R., & Berk, K. N. (1990). Data splitting. The

American Statistician, 44, 140–147.

Power, C. & Matthews, S. (1998). Accumulation of health risks

across social groups in a national longitudinal study. In S. S.

Strickland & P. S. Shetty (Eds.), Human biology and social

inequality. Cambridge: Cambridge University Press.

Rakowski, W., & Cryan, C. D. (1990). Associations among

health perceptions and health status within three age

groups. Journal of Aging and Health, 2, 58–80.

Rathouz, P. J., Kasper, J. D., Zeger, S. L., Ferrucci, L.,

Bandeen-Roche, K., Miglioretti, D. L., & Fried, L. P.

(1998). Short-term consistency in self-reported physical

functioning among elderly women. American Journal of

Epidemiology, 147, 746–773.

Shih, S. R., & Chuang, Y.-L. (1995). Opportunities and

Constraints for Older Workers in Taiwan. Research Reports,

95-30, Population Studies Center, University of Michigan.

Shye, D., Mullooly, J. P., Freeborn, D. K., & Pope, C. R.

(1995). Gender differences in the relationship between social

network support and mortality: A longitudinal study on an

elderly cohort. Social Science & Medicine, 41, 935–947.

Singer, B., & Ryff, C. D. (1999). Hierarchies of life histories and

associated health risks. Annals of New York Academy of

Science, 896, 96–115.

Smith. (1981). An island of learning: Academiocracy in Taiwan.

Taipei: Pacific Cultural Foundation.

Sugisawa, H., Liang, J., & Liu, X. (1994). Social networks,

social support and mortality among older people in Japan.

Journal of Gerontology: Social Sciences, 49, S3–S13.

Taiwan Provincial Institute of Family Planning, & Institute of

Gerontology University of Michigan. (1989). 1989 Survey of

Health and Living Status of the Elderly in Taiwan:

Questionnaire and Survey Design. Comparative Study of

the Elderly in Four Asian Countries Research Report 1.

Tessler, R., & Mechanic, D. (1978). Psychological distress and

perceived health status. Journal of Health and Social

Behavior,, 19, 254–262.

Thoits, P. A. (1995). Stress, coping, and social support

processes: Where are we? What next? Journal of Health

and Social Behavior (Extra Issue), 53–79.

Treiman, D. J. (1977). Occupational prestige in comparative

perspective. New York: Academic Press.

Tsai, S.-L., & Chiu, H.-Y. (1991). Constructing occupational

scales for Taiwan. Research in Social Stratification and

Mobility, 10, 2229–2253.

Wachter, K. W. (1997). Kinship resources for the elderly.

Philosophical Transactions of the Royal Society of London,

Series B, 352, 1811–1817.

Weinstein, M., & Willis, R. (2000). Stretching social surveys to

include bioindicators: Possibilities for the health and

retirement study, experience from the Taiwan study of the

elderly. In C. E. Finch, J. W. Vaupel., & K. Kinsella (Eds.),

Cells and surveys: Should biological markers be included in

social science research? Washington, DC: National Acad-

emy Press.

Yu, E. S. H., Kean, Y. M., Slymen, D. J., Liu, W. T., Zhang,

M., & Katzman, R. (1998). Self-perceived health and 5-year

mortality risks among the elderly in Shanghai, China.

American Journal of Epidemiology, 147, 880–890.

M. Beckett et al. / Social Science & Medicine 55 (2002) 191–209 209