The unique contribution of key existential factors to the prediction of psychological well-being of older adults following spousal loss

PURPOSE: This study examined the unique contribution of key existential factors to the prediction of psychological well-being of older adults following spousal loss. DESIGN AND METHOD: A number of measures to assess psychological well-being, sociodemographic standing, social resources, and religious and spiritual resources were administered to a volunteer sample of widows and widowers to test the hypothesis that existential factors such as personal meaning, religiosity, and spirituality are more potent predictors of psychological well-being than are previously hypothesized variables of sociodemographic, social support, and physical factors. RESULTS: A hierarchical regression analysis of the data supported the hypothesis that existential factors are major contributors to psychological well-being of older adults following spousal loss. Findings showed that widowers, compared to widows, scored lower on the measure of psychological well-being. IMPLICATIONS: Implications of the findings are discussed for practitioners working with bereaved spouses; suggestions for further research concerning bereavement and psychological well-being are made.     

Impact of spouse vision impairment on partner health and well-being: a longitudinal analysis of couples

OBJECTIVES: The purpose of this study was to assess the impact of older spouses' vision impairment on the health and well-being of their partners and to test for gender differences. METHODS: Participants were 418 older couples from the Alameda County Study. Vision impairment was assessed in 1994 with a 9-point scale assessing difficulty seeing in everyday situations; outcomes were assessed in 1999. Longitudinal analyses included multivariate statistical models adjusting for paired data and partners' own vision impairment, age, gender, chronic conditions, and financial problems. We include results on outcomes for partners' own vision impairment for comparative purposes. We assessed gender differences with interaction tests. RESULTS: Spouse vision impairment negatively impacted partner depression, physical functioning, well-being, social involvement, and marital quality; these effects were not greatly different in magnitude from those associated with partners' own vision impairment. Three of four outcomes with significant gender differences evidenced stronger impacts of husbands' vision impairment on wives' well-being and marital quality than the reverse. DISCUSSION: Spouses do not live in isolation; characteristics of one impact the other. Both treatment and rehabilitation programs should include spouses and other family members of visually impaired patients. Why wives appear more sensitive to their husbands' vision impairment is unclear and warrants further study.     

Moderate hearing loss is related with social frailty in a community-dwelling older adults: The Korean Frailty and Aging Cohort Study (KFACS)

ObjectivesTo determine whether hearing loss is associated with social frailty in older adults.MethodsCross-sectional analysis of cohort study data. Hearing was measured using of Pure-tone audiometry. Hearing loss was determined based on the average of hearing thresholds at 0.5, 1, and 2 kHz in the ear that had better hearing. Social frailty was defined based on the summation of the following 5 social components (1. Neighborhood meeting attendance 2. Talking to friend(s) sometimes 3.Someone gives you love and affection 4. Living alone 5. Meeting someone every day). Participants who had no correspondence to the components were considered non-social frailty; those with 1–2 components were considered social prefrailty; and those having 3 or more components were considered social frailty.ResultsThe prevalence of non-social frailty, social prefrailty, social frailty was 27.6%, 60.7% and 11.7% respectively. Of the five questions, two components (Neighborhood meeting attendance and Presence of someone who shows love and affection to the participants) were associated with hearing loss (p < 0.001). Compared to non-social frailty, the odds ratio of social frailty for hearing loss was 2.24 (95% CI 1.48–3.38) after adjusting for age, residential area, economic status, smoking, depressive disorder and MMSE, and 2.17 (95% CI 1.43–3.30) after further adjustments with physical frailty.ConclusionHearing loss was associated with social frailty even after controlling confounding factors even including physical frailty.     

The impact of hearing loss on quality of life in older adults

PURPOSE: The authors investigate the impact of hearing loss on quality of life in a large population of older adults. DESIGN AND METHODS: Data are from the 5-year follow-up Epidemiology of Hearing Loss Study, a population-based longitudinal study of age-related hearing impairment conducted in Beaver Dam, WI. Participants (N = 2,688) were 53-97 years old (mean = 69 years) and 42% were male. Difficulties with communication were assessed by using the Hearing Handicap for the Elderly-Screening version (HHIE-S), with additional questions regarding communication difficulties in specific situations. Health-related quality of life was assessed by using measures of activities of daily living (ADLs), instrumental ADLs (IADLs) and the Short Form 36 Health Survey (SF-36). Hearing loss measured by audiometry was categorized on the basis of the pure-tone average of hearing thresholds at 0.5, 1, 2, and 4 kHz. RESULTS: Of participants, 28% had a mild hearing loss and 24% had a moderate to severe hearing loss. Severity of hearing loss was significantly associated with having a hearing handicap and with self-reported communication difficulties. Individuals with moderate to severe hearing loss were more likely than individuals without hearing loss to have impaired ADLs and IADLs. Severity of hearing loss was significantly associated with decreased function in both the Mental Component Summary score and the Physical Component Summary score of the SF-36 as well as with six of the eight individual domain scores. IMPLICATIONS: Severity of hearing loss is associated with reduced quality of life in older adults.     

Comparative impact of hearing and vision impairment on subsequent functioning

OBJECTIVES: The purpose of this study was to compare independent impacts of two levels of self-reported hearing and vision impairment on subsequent disability, physical functioning, mental health, and social functioning. DESIGN: A 1-year prospective cohort study. SETTING: San Francisco Bay Area, California. PARTICIPANTS: Two thousand four hundred forty-two community-dwelling men and women age 50 to 102 from the Alameda County Study (California). MEASUREMENTS: Hearing and vision impairment were assessed in 1994. Outcomes, measured in 1995, included physical disability (activities of daily living, instrumental activities of daily living, physical performance, mobility, and lack of participation in activities), mental health (self-assessed, major depressive episode), and social functioning (feeling left out, feeling lonely, hard to feel close to others, inability to pay attention). All 1995 outcomes were adjusted for baseline 1994 values. RESULTS: Both impairments had strong independent impacts on subsequent functioning. Vision impairment exerted a more wide-ranging impact on functional status, ranging from physical disability to social functioning. However, the results also highlighted the importance of hearing impairment, even when mild. CONCLUSIONS: These impairments can be partially ameliorated through prevention, assessment, and treatment strategies. Greater attention to sensory impairments by clinicians, patients, public health advocates, and researchers is needed to enhance functioning in older adults.     

Contributions of Psychological Well-Being and Social Support to an Integrative Model of Subjective Health in Later Adulthood

This study examined the contributions of psychological well-being and social support to an integrative model of subjective health among older adults. Structural equation modeling was used to test the proposed model of subjective health which included age, education, physical health problems, functional status, psychological well-being and social support. Partial support for the model was found. Psychological well-being had both a direct effect on subjective health and an indirect effect mediated by physical health problems. Social support had an indirect association with subjective health via its effect on psychological well-being. Functional status had only a weak effect on subjective health. Longitudinal data at a six-year interval revealed the same direct and/or indirect effects of these variables on subjective health. This study sheds light on how psychological and social resources are linked with subjective health in later adulthood.     

Hearing loss is a risk factor of disability in older adults: A systematic review

Background and ObjectivesHearing loss (HL) is a public health problem affecting older adults. HL is not only a health condition but also a complex, dynamic phenomenon related to disability. Previous studies identified associations between HL and undesirable outcomes; however, their correlation remains inconclusive. Hearing loss can have profound impact on daily life in the elderly, and an understanding of how HL contributes to disability is needed. A systematic review was conducted to comprehensively examine current evidence and determine the association between HL and disability regarding impairment, activity and participation in older adults.Research Design and MethodsThe Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines were applied in this systematic review. Quality assessment was conducted using the Newcastle-Ottawa Scale for longitudinal studies and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for cross-sectional studies.ResultsIn this systematic review of 20 studies, HL was associated with mobility limitation, activity limitation and participation restriction. The severity of HL was associated with impaired mobility and physical performance, but the association was only found in persons with severe/major HL. HL was also associated with activities of daily living (ADL) dependency, however these findings were mainly based on cross-sectional studies.Discussion and ImplicationsHL is related to disability by impairment, activity limitations or participation restrictions in older adults. Future studies should include participation restrictions as a mediation factor to better understand this association. Consistent and accurate hearing measurements and hearing loss criteria are also required to determine the impact of HL on disability.     

Cochlear implantation in older adults

Cochlear implants allow individuals with severe to profound hearing loss access to sound and spoken language. The number of older adults in the United States who are potential candidates for cochlear implantation (CI) is approximately 150,000 and will continue to increase with the aging of the population. Should CI be routinely recommended for these older adults, and do these individuals benefit from CI? We reviewed our 12-year experience with CI in adults aged ≥60 years (n = 445) at Johns Hopkins Medical Institutions to investigate the impact of CI on speech understanding and to identify factors associated with speech performance. Complete data on speech outcomes at baseline and 1 year post-CI were available for 83 individuals.Our results demonstrate that CI in adults aged ≥60 years consistently improved speech understanding scores, with a mean increase of 60.0% (SD 24.1) on HINT (Hearing in Noise Test) sentences in quiet. The magnitude of the gain in speech scores was negatively associated with age at implantation, such that for every increasing year of age at CI the gain in speech scores was 1.3 percentage points less (95% confidence interval [95% CI], 0.6-1.9) after adjusting for age at hearing loss onset. Conversely, individuals with higher pre-CI speech scores (HINT scores between 40% and 60%) had significantly greater post-CI speech scores by a mean of 10.0 percentage points (95% CI, 0.4-19.6) than those with lower pre-CI speech scores (HINT <40%) after adjusting for age at CI and age at hearing loss onset.These results suggest that older adult CI candidates who are younger at implantation and with higher preoperative speech scores obtain the highest speech understanding scores after CI, with possible implications for current United States Medicare policy. Finally, we provide an extended discussion of the epidemiology and impact of hearing loss in older adults. Future research of CI in older adults should expand beyond simple speech outcomes to take into account the broad cognitive, social, and physical functioning outcomes that are likely detrimentally affected by hearing loss and may be mitigated by CI. ABBREVIATIONS: 95% CI = 95% confidence interval, CI = cochlear implantation, CMS = Centers for Medicare & Medicaid Services, dB = decibel, GWAS = genome-wide association studies, HINT = Hearing in Noise Test, NHANES = National Health and Nutrition Examination Survey, PTA = pure tone average.     

Spousal characteristics as predictors of well-being in older couples.

This study examined the relations between spousal variables and the psychological well-being of husbands and wives in older couples to determine if spousal characteristics were more important determinants of well-being for wives than for husbands. One hundred-twenty older married men and women completed standardized self-report measures and a short interview. The variables investigated included education, verbal intelligence, personality, physical health, marital adjustment, psychological well-being, as well as response bias to marital defensiveness. Spousal variables significantly predicted wives' well-being (R2 = 29%) with the three most influential predictor variables being the husbands' perception of the marriage, positive dimension of well-being and physical health. In contrast, spousal variables did not significantly predict husbands' well-being. The study supported the hypothesis of differential responsiveness of men and women to spousal variables and highlighted the importance of marital adjustment for the psychological well-being of older wives.     

Informal Social Support and Older Persons’ Psychological Well-Being in Hong Kong

This paper focuses on the importance and the effectiveness of various types of informal support for older persons' psychological well-being. It examines the effects of objective measures of informal support (such as size of social networks and frequency of contact) and subjective measures (such as satisfaction with the support received) on psychological well-being of older occupants in different household circumstances (i.e.,living alone, with spouse or relatives, in old urban areas or new towns, in private or public housing). Data were collected from face-to-face interviews with a sample of 518 older persons (224 males, 294 females) aged 60 and over, systematically drawn from a GIS-derived framework of housing districts in old urban areas and new towns in Hong Kong. The results show that both objective and subjective measures of informal support were related to older persons' psychological well-being, but subjective measures of informal support (specifically satisfaction with support received from family members) were found to be more important predictors of psychological well-being. Furthermore, the effects of size of social network on psychological well-being were stronger for older persons who lived alone than for those who lived with a spouse or relatives. The results also show that persons who lived in the old urban areas received more support than did their counterparts in the new towns and older persons who lived in public housing received more objective informal support than those who lived in private housing. The implications of the findings for policy towards older persons in Hong Kong and similar Asia-Pacific societies are discussed.     

Race and sex differences in age-related hearing loss: the Health, Aging and Body Composition Study

OBJECTIVES: To determine the prevalence of and risk factors for hearing loss in a sample of 2,052 older adults (aged 73-84; 46.9% male, 37.3% black) enrolled in the Health, Aging and Body Composition (Health ABC) Study. DESIGN: Cross-sectional analysis of a longitudinal cohort study. SETTING: Pittsburgh, Pennsylvania, and Memphis, Tennessee, areas. PARTICIPANTS: Random sample of Medicare beneficiary subjects enrolled in the Health ABC program from 1997 to 1998. They included 2,052 individuals: 660 white men (32.2%), 631 white women (30.8%), 310 black men (15.1%), and 451 black women (22.0%). Participants ranged in age from 73 to 84, with a mean age of 77.5. MEASUREMENTS: Hearing sensitivity was measured using pure-tone threshold testing. Hearing loss was defined based on two averages of hearing thresholds: 500, 1,000, and 2,000 Hz greater than 25-decibel (dB) hearing level (HL) (hearing loss); and 2,000, 4,000, and 8,000 Hz greater than 40-dB HL (high-frequency hearing loss). Potential hearing loss correlates, including demographics, medical history, ototoxic medication use, occupational noise exposure, and lifestyle factors, were collected via questionnaire. RESULTS: The prevalence of hearing loss was 59.9%; the prevalence of high-frequency hearing loss was 76.9%. Hearing loss was most common in white men, followed by white women, black men, and black women. Older age, white race, diabetes mellitus, cerebrovascular disease, smoking, poorer cognitive status, occupational noise exposure, and ear surgery were associated with hearing loss after multivariable adjustment. Race- and sex-specific risk factors included higher blood pressure and occupational noise exposure (white men), poorer cognitive status and smoking (black women), and low total hip bone mineral density (black men). Possible protective factors included salicylate use (overall sample, black men) and moderate alcohol intake (black women). CONCLUSION: Hearing loss was extremely common in this population. Because many of the identified hearing loss risk factors are modifiable, some of the burden associated with hearing loss in older people should be preventable.     

Dual sensory loss and social participation in older Europeans

The purpose of the study was to describe the prevalence of hearing difficulties, vision difficulties and dual sensory difficulties in 11 European countries, and to study whether sensory difficulties are associated with social inactivity in older Europeans. This cross-sectional study is based on the 2004 data collection of the Survey of Health, Ageing and Retirement in Europe comprising 27,536 men and women aged 50 years and older. Hearing and vision difficulties, as well as participation in seven different social activities were assessed using a structured computer-assisted personal interview. Logistic regression models were used for analyses. Altogether, 5.9 % of the participants reported both hearing and vision difficulties (dual sensory loss), 10.2 % vision difficulties only, and 13.5 % hearing difficulties only. More than two-thirds (68.6 %) of the participants with dual sensory loss were socially inactive compared to half of those who reported no sensory difficulties. The participants who reported dual sensory loss had 2.18 (95 % CI 1.83–2.59) times higher odds for social inactivity compared to persons without hearing or vision difficulties. In a model adjusted for age, gender, mobility, depressive symptoms, cognition, education and wealth the corresponding odds ratio was 1.21 (95 % CI 1.00–1.47). According to our results, sensory difficulties were associated with social inactivity, but the higher likelihood for social inactivity among persons with sensory difficulties was attenuated by other health and socio-economic indicators. Our results suggest that various preventive and rehabilitative actions targeting older persons’ sensory functions may enhance their social activity.     

Long‐Term Effectiveness of Screening for Hearing Loss: The Screening for Auditory Impairment—Which Hearing Assessment Test (SAI‐WHAT) Randomized Trial

OBJECTIVES: To evaluate the effect of hearing screening on long‐term hearing outcomes in a general population of older veterans. DESIGN: Hearing loss in the elderly is underdetected and undertreated. Routine hearing screening has been proposed, but it is not clear whether screening identifies patients who are sufficiently motivated to adhere to treatment. A four‐arm randomized clinical trial was conducted to compare three screening strategies with no screening in 2,305 older veterans seeking general medical care. SETTING: Veterans Affairs Puget Sound Health Care System. INTERVENTIONS: The screening strategies were a tone‐emitting otoscope, a widely used questionnaire about hearing handicap, and a combination of both tools. MEASUREMENTS: Hearing aid use 1 year after screening. RESULTS: Of participants who underwent screening with the tone‐emitting otoscope, questionnaire, and combined testing, 18.6%, 59.2%, and 63.6%, respectively, screened positive for hearing loss (P<.01 for test of equality across three arms). Patients proceeded to formal audiology evaluation 14.7%, 23.0%, and 26.6% of the time in the same screening arms, compared with 10.8% in the control arm (P<.01 for test of equality across four arms). Hearing aid use 1 year after screening was 6.3%, 4.1%, and 7.4% in the same arms, compared with 3.3% in the control arm (P<.01). Hearing aid users experienced significant improvements in hearing‐related function and communication ability. CONCLUSION: In older veterans, screening for hearing loss led to significantly more hearing aid use. Screening with the tone‐emitting otoscope was more efficient. The results are most applicable to older populations with few cost barriers to hearing aids.     

Gender and psychological distress among middle- and older-aged colorectal cancer patients and their spouses: an unexpected outcome

The population in the western world has been aging while the cancer survival rates have been systematically increasing. Knowledge is lacking about psychological processes and effects of gender difference among middle-aged cancer patients and their healthy spouses. This study assesses psychological distress, coping and social support among middle-aged couples, where one of the partners was diagnosed with colon cancer. A repeated-measure MANOVA and Pearson's correlation coefficient were used to assess the relationships between the variables. Levels of social support were found to be negatively correlated to levels of psychological distress among all of the participants. Surprisingly, men (healthy or sick) were found to be more distressed than their wives (p<0.0001). Men also reported receiving more support from their wives than did the female spouses (p<0.0005). The gender differences found in our study imply that men (healthy or sick) tend to receive more support than they give to their wives. It also implies that men do not use the support they receive as effectively as their wives. Thus, although men report higher levels of support from their spouses, they also report higher levels of psychological distress. Practical implications are discussed.     

Reason or Result? Subjective Well-Being of the Elderly in Urban Beijing: A Cross-Lagged Panel Regression Analysis

Subjective well being (SWB) is an important index to assess the mental life quality of older adults. The purpose of present study is to investigate the casual relationship between the SWB and related factors by a 20-month follow up study. Seven potential factors were chosen from 2 taxonomies of resources—internal vs. external and physical vs. psychological predictors of subjective well-being in older adults. 170 old people in Beijing were assessed at Time 1 and Time 2. Multivariable cross-lagged panel regression analysis base on SWB, perceived social support, health status and general self-efficacy showed that: no variable at Time 1 can predict SWB at Time 2; on the contrary, SWB at Time 1 can predict the general self-efficacy and perceived social support at Time 2. This finding suggests that subjective well-being perhaps was not a result of related factors but a variable that can predict other mental variables of old adults in the future.     

Is there a risk to safety when working in the New South Wales underground coal‐mining industry while having binaural noise‐induced hearing loss?

BACKGROUND: Underground coal-mine workers suffer noise-induced hearing loss and continue working in the industry while having varying degrees of deafness. Few studies have researched the risk to safety arising from the loss of hearing. AIMS: This study is designed to investigate the possible association between hearing loss and accidents in the New South Wales underground coal-mining industry. METHODS: A study was conducted, gathering data over a 10-year period from 1994 to 2003, which identified 97 cases that have had accidents and 983 controls that have had no accidents. Hearing loss levels were noted and compared in the cases and controls. Multiple logistic regression was used to determine whether the variables were significant risk factors in the occurrence of accidents. RESULTS: Hearing loss levels in the total cohort varied from 0 to 54%. The proportion of cases with hearing loss appeared to be significantly higher in the young age group of <29 years than in the controls, but was not significantly different in the older age groups. CONCLUSIONS: This study indicates that workers who have lost up to 54% binaural high tone hearing and are older than 29 years do not appear to have an increased risk to safety when compared with workers who do not have hearing loss. However, workers in the young age group of <29 years who have high tone hearing loss may be at an increased risk of accident.     

Hearing loss and depressive symptoms in elderly patients

Aims: Hearing loss is a common disability that has a profound impact on communication and daily functioning in the elderly. The present study assesses the effects of hearing aids on mood, quality of life and caregiver burden when hearing loss, comorbidity and depressive symptoms coexist in the elderly. Methods: A total of 15 patients aged older than 70 years suffering from hearing loss and depressive mood were recruited. Comorbidity was evaluated by the Cumulative Illness Rating Scale, functional ability by the Activities of Daily Living scale and the Lawton Instrumental Activities of Daily Living scale, cognitive capacity by the Mini‐mental State Examination and the Clock Drawing Test, psychological status by the Center for Epidemiological Studies‐Depression scale, and quality of life by the Short Form (36) Health Survey. Caregiver burden was appraised by the Caregiver Burden Inventory. Testing was carried out at baseline and at 1‐, 3‐ and 6‐month intervals, assessing the use of binaural digital and programmable hearing aids. Results: Reduction in depressive symptoms and improved quality of life at statistically significant levels were observed early on with the use of hearing aids. In particular, general health (P < 0.02), vitality (P < 0.03), social functioning (P < 0.05), emotional stability (P < 0.05) and mental health (P < 0.03) all changed for the better, and were maintained for the study duration. The degree of caregiver burden also declined, remaining low throughout the study. Conclusions: The benefits of digital hearing aids in relation to depressive symptoms, general health and social interactivity, but also in the caregiver – patient relationship, were clearly shown in the study. The elderly without cognitive decline and no substantial functional deficits should be encouraged to use hearing aids to improve their quality of life. Geriatr Gerontol Int 2012; 12: 440–445.     

Influence of companion animals on the physical and psychological health of older people: an analysis of a one-year longitudinal study

OBJECTIVE: To examine whether companion animals or attachment to a companion animal was associated with changes in physical and psychological health in older people and whether the relationships between physical and psychological health and human social networks were modified by the presence or absence of a companion animal. DESIGN: A 1-year longitudinal study with standardized telephone interview data collected at baseline and repeated at 1-year SETTING: Wellington County, Ontario, Canada PARTICIPANTS: An age- and sex stratified random sample (baseline n = 1054; follow-up n = 995) of noninstitutionalized adults aged 65 and older (mean age = 73, SD +/- 6.3) MEASUREMENTS: Social Network Activity was measured using a family and non-family social support scale, participation in an organized social group, involvement in the affairs of the social group, the practice of confiding in others, feelings of loneliness, and the perceived presence of support in a crisis situation. Chronic conditions were measured as the current number of selected health problems. Pet ownership was assessed by the report of owning a dog or a cat and the Lexington Attachment to Pets Scale score. Physical health was assessed as the ability to perform Activities of Daily Living (ADLs). Psychological health was measured as a summed score comprising the level of satisfaction regarding one's health, family and friend relationships, job, finances, life in general, overall happiness, and perceived mental health. Sociodemographic variables assessed include subject age, sex, marital status, living arrangements, education, household income, and major life events. RESULTS: Pet owners were younger, currently married or living with someone, and more physically active than non-pet owners. The ADL level of respondents who did not currently own pets deteriorated more on average (beta = -.270, P = .040) than that of respondents who currently owned pets after adjusting for other variables during the 1-year period. No statistically significant direct association was observed between pet ownership and change in psychological well-being (P > .100). However, pet ownership significantly modified the relationship between social support and the change in psychological well-being (P = .001) over a 1-year period. CONCLUSIONS: The results demonstrate the benefits of pet ownership in maintaining or slightly enhancing ADL levels of older people. However, a more complex relationship was observed between pet ownership and an older person's well-being.     

Well-being in older Mexican American spouses

PURPOSE: There is a strong connection between marriage and well-being, with evidence suggesting that the well-being of one spouse is closely correlated with that of the other. However, among older Mexican Americans, there is little information about this phenomenon. To address this, we explore two research questions: Does one spouse's well-being predict the other spouse's well-being? Are there gender differences in these effects? DESIGN AND METHODS: We assess information from 553 couples who participated in Wave 1 (1993-1994) of the Hispanic Established Populations for the Epidemiologic Studies of the Elderly. Using structural equation models, we examined three aspects of well-being among older Mexican American couples: depressive symptoms, life satisfaction, and self-rated health. RESULTS: The findings revealed evidence of an association between the well-being of one spouse and that of the other. Specifically, the self-rated health of husbands and wives predicts that of their partners. However, there is evidence that husbands' depressive symptoms and life satisfaction influence wives' well-being, but not the reverse. IMPLICATIONS: The findings from this study are important because they add to the literature on the connection of well-being among spouses, point to important gender differences, focus on an understudied minority group with unique cultural characteristics, and have implications for the examination of well-being within a marriage framework.