The Relationship Between Living Alone and Self-Rated Health Varies by Age: Evidence From the National Health Interview Survey

Abstract

Despite growing attention to the connection between living arrangements and health, less is known about how the health of individuals living alone varies by age. Using data from the 2016 National Health Interview Survey (N = 30,079), we estimated logistic regression models stratified by age group, comparing health by living arrangement and controlling for sociodemographic characteristics. Middle-aged adults living alone had higher odds of poor/fair self-rated health, compared with adults living with others (35-64 years of age: adjusted odds ratio [AOR] = 1.19, p < .05). In contrast, older adults (65 years and older) living alone had significantly lower odds of reporting poor/fair health than their counterparts living with others (AOR = .70, p < .001). The direction of association between self-rated health and other covariates did not differ by age group. The relationship between living alone and health varies by age and policies and programs designed to support the growing population of people living alone should be tailored accordingly.

Keywords

age differences living arrangements self-rated health National Health Interview Survey

Introduction

Loneliness and social isolation are strongly associated with poorer self-rated health, psychological distress, depression, and mortality in later life (Holt-Lunstad, Smith, Baker, Harris, & Stephenson, 2015; Idler & Benyamini, 1997; Nummela, Seppänen, & Uutela, 2011). However, there is variation in the relationship between loneliness and health by sociodemographic characteristics. For example, previous research has shown that older men may benefit more from social relationships compared with older women (Nummela et al., 2011). Other research suggests that high socioeconomic status and wealth may buffer the relationship between social isolation and health outcomes, including self-rated health, in older adults (Henning-Smith, Shippee, & Capistrant, 2018; Lindström, 2009). Some research has also found that social isolation is more strongly associated with poorer health outcomes in adults younger than 65 (Holt-Lunstad et al., 2015).

Living arrangements, especially living alone, are closely related to, albeit distinct concepts from, social isolation and loneliness (Klinenberg, 2016). Social isolation is an objective and quantifiable shortage of social networks (including number of contacts, frequency of interactions, and strength of social relationships), while loneliness is a subjective psychological response to social isolation (Nicholson, 2012). Older adults living alone may be more prone to social isolation and (sometimes) loneliness compared with older adults living with others (Steptoe, Shankar, Demakakos, & Wardle, 2013). Much of the research on the association between living arrangements and health has focused exclusively on older adults. A closer examination of the relationship between living alone and self-rated health across the entire adult life span is needed given the recent rise of mortality and morbidity among middle-aged adults and the increase in living alone across the population (Holt-Lunstad et al., 2015; Klinenberg, 2016). Knowing how the relationship between living alone and health status varies across the life span will inform targeted initiatives to improve population health.

We address this gap in the literature by examining the association between living alone and self-rated health, first for all adults and then for discreet age groups across the adult life span. Not only is self-rated health commonly used in population-based studies on living arrangements, but self-rated health is a well-documented predictor of mortality among older adults (Idler & Benyamini, 1997; Mossey & Shapiro, 1982). In addition, we investigate how the relationship between living alone and self-rated health changes after adjusting for sociodemographic characteristics.

Literature Review

Worsening trends in morbidity, mortality, and life expectancy are a major public health concern in the United States. (Case & Deaton, 2015; Crimmins & Beltran-Sanchez, 2011). The current opioid epidemic may explain some of the rise in morbidity and mortality in recent years (Braden, Edlund, & Sullivan, 2017; McCall Jones, Baldwin, & Compton, 2017), as may a related, but distinct, increase in suicide, especially among White, middle-aged men (Braden et al., 2017; Case & Deaton, 2015). Together, these trends are sometimes referred to as “deaths of despair” (Stein, Gennuso, Ugboaja, & Remington, 2017), and they are closely linked with the phenomenon of social isolation, in which individuals have limited contact with friends, family, and other sources of social support.

Social isolation poses a direct risk to mortality (Holt-Lunstad et al., 2015), on par with physical inactivity and obesity (Lu, Kao, & Hsieh, 2010). Social isolation and feelings of loneliness are also associated with poorer physical and mental health outcomes, including depression, anxiety, substance use, poorer health behaviors, heart disease, stroke, dementia, and even the common cold (Chou, Liang, & Sareen, 2011; Cohen, Doyle, Skoner, Rabin, & Gwaltney, 1997; Cornwell & Waite, 2009; Holwerda et al., 2014; Locher et al., 2005; Nicholson, 2012). One’s risk of being socially isolated is determined, in part, by one’s living arrangements and daily interactions (or lack thereof) with cohabiting partners, family, friends, and roommates. As a result, living alone is a primary risk factor for social isolation (Holt-Lunstad et al., 2015). Certainly, not everyone who lives alone is socially isolated, and vice versa. However, living alone limits one’s household interactions and places one at a higher risk of social isolation compared with those living with others (Nicholson, 2012).

Living alone is sometimes identified as one of the “least healthy” living arrangements, associated with poorer quality of life, mental health, and physical health outcomes (Gierveld, Dykstra, & Schenk, 2012; Henning-Smith, 2016; Weissman & Russell, 2018). Still, the research on living alone is inconclusive, even though living alone is increasingly common in the United States and globally (Klinenberg, 2012; Ruggles, 2007). While some studies have found negative associations between living alone and health, other studies have found that for some individuals, especially older adults, living alone can have better outcomes, including self-rated health, provided that they have access to necessary economic, social, and material resources (Henning-Smith et al., 2018; Klinenberg, 2012) and instrumental support (Sun et al., 2007; Zunzunegui, Béland, & Otero, 2001). People living alone must rely more heavily on social support and networks outside of the household (Cornwell, 2014; Hawkley & Kocherginsky, 2018); variation in their ability to do so may lead to variation in their associated health outcomes. However, the ability to interact with others outside of the household may be dependent on existing social relationships, health status, access to events and groups, and available time to pursue social activities, all of which may vary by age. More research is needed to fully understand how the relationship between living alone and health varies by age to design policies and programs (e.g., civic engagement, community-driven social events, volunteer organizations and opportunities, adult day care centers, and home-delivered meals) that are responsive to current and future needs of adults of all ages.

Research Questions and Hypotheses

This study adds to the literature on the relationship between living alone and health by examining how self-rated health varies by living arrangement across different age categories. Our specific research questions are as follows:

Research Question 1: Does self-rated health differ for adults living alone versus with others?

Research Question 2: How does the relationship between self-rated health and living alone vary by age?

Research Question 3: What is the relationship between living alone and self-rated health across age groups after adjusting for sociodemographic characteristics?

We hypothesize that living alone may be associated with poorer health, especially for middle-aged adults, where “deaths of despair” and the impact of social isolation are especially prevalent and growing (Stein et al., 2017). Results from this study will be useful for identifying the living arrangements of people in the poorest health at different age groups and for targeting interventions to address the recent rise in mortality and morbidity in the United States. These findings will also provide new evidence about the well-being of older adults currently living alone, as well as about the status of future generations of older adults.

Research Design

Data and Sample

Data for this study come from the 2016 National Health Interview Survey (NHIS), accessed through the University of Minnesota’s Integrated Public Use Microdata Series (IPUMS) Health Surveys Series, a harmonized and publicly available version of the NHIS (Blewett, Drew, Griffin, King, & Williams, 2016). Conducted each year by the National Center for Health Statistics (NCHS) at the CDC, data for the NHIS are collected through in-person household interviews drawn from a random sample of civilian households and noninstitutionalized group quarters. In 2016, the NHIS included data on 97,169 individuals from 25,990 unique households (Division of Health Interview Statistics, NCHS, 2017). The NHIS includes core questions on all household members, plus additional questions on one sampled adult and one sampled child (if applicable) per household. The 2016 NHIS includes data on 33,028 sampled adults, which comprise the sample for the current study. We included all adults with complete data on living arrangements and all covariates, resulting in a final sample size of 30,079 adults.

Measures

The key dependent variable in this study was self-rated health. Survey respondents were asked whether they would rate their health as “excellent, very good, good, fair, or poor.” For the purposes of this study, we collapsed values of “excellent, very good, and good” into one category and values of “fair or poor” into a second category. Poor/fair self-rated health is a validated and commonly used measure that shares a predictive relationship with health outcomes and mortality (DeSalvo, Bloser, Reynolds, He, & Muntner, 2006; Idler & Benyamini, 1997; Mossey & Shapiro, 1982; Wu et al., 2013). The primary independent variable in this study was living arrangement, or more specifically, whether the sampled adult was living alone or with others (which may include spouses/partners, children, other relatives, friends, or unrelated housemates). This follows prior research on living alone versus with others (Dean, Kolody, Wood, & Matt, 1992; Lu et al., 2010; Zhou et al., 2010).

Both self-rated health and living arrangements are influenced by sociodemographic and health characteristics. Therefore, we examined bivariate differences between living alone and living with others across several confounding variables in our analyses. Sociodemographic characteristics of interest included age; gender; whether the respondent was widowed, divorced, or separated (vs. currently married/partnered or never married); race and ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, and non-Hispanic Asian or other race); educational attainment (less than a high school degree, high school degree, some college, or college degree and higher); employment status (employed vs. not employed); and household income calculated as a percentage of the federal poverty level (FPL; <100%, 100%-199%, 200%-399%, ≥400% FPL). Health characteristics included presence of a disability (defined by the presence of an activity limitation or functional limitation due a chronic health condition) and severe psychological distress, defined as a score of 13 or higher on the 24-point Kessler-6 (K6) scale (Kessler et al., 2002).

Analysis

We compared bivariate differences in self-rated health (poor/fair vs. excellent/very good/good) by sociodemographic characteristics, health, and living arrangements using chi-square tests. We also used chi-square tests to compare differences in self-rated health between adults living alone versus adults living with others within specific age groups (18-24, 25-34, 35-44, 45-54, 55-64, 65-74, 75-84, and 85 and older). Finally, we conducted logistic regression models assessing the relationship between living alone and self-rated health while adjusting for sociodemographic characteristics (age, gender, marital status, race and ethnicity, educational attainment, employment status, poverty status, disability status, and psychological distress). We estimated our regression models for the entire sample and then stratified by age group (young = 18-34, middle = 35-64, and older = 65 and older). All analyses were conducted in Stata using the svy suite of commands to incorporate survey weights that account for the complex sampling design and to approximate nationally representative estimates. This study uses publicly available, de-identified data and was therefore not subject to institutional review board review.

Results

Table 1 reports sample characteristics separately by health status. Adults living alone make up nearly one third of the sample and, on average, have poorer health than adults in other living arrangements (16.7% report poor/fair health, compared with 12.0% of adults living with others.) Fair and poor health was more likely to be reported by older adults (20.5% of those 65 years and older vs. 5.4% of those 18-34, p < .001); females (13.0% vs. 14.0%, p < .05); adults who were widowed/divorced/separated (21.5% vs. 10.7% of married adults and 10.4% of never married adults, p < .001); adults who were non-Hispanic Black or Hispanic (19.3% and 16.5%, respectively, vs. 12.2% of non-Hispanic White adults, p < .001); adults with less than a high school degree (31.7% vs. 5.5% of those with a college degree); adults who were unemployed (23.8% vs. 6.0%, p < .001), and adults living under the poverty line (26.4% vs. 5.8%, p < .001). Adults with a disability (28.0% vs. 3.1%, p < .001) and adult with severe psychological distress (54.8% vs. 11.9%, p < .001) were also more likely to report fair or poor health.

Table 1.

Sample Characteristics for Adults by Health Status.

	Overall frequency (%)	Fair or poor health (%)	p Value
Living arrangement			<.001
Live alone	32.3	16.7
Live with others	67.7	12.0
Age group			<.001
Young adults (18-34)	27.7	5.4
Middle-aged adults (35-64)	49.0	14.9
Older adults (65 and older)	23.3	20.5
Gender			.022
Female	53.7	14.0
Male	46.3	13.0
Marital status			<.001
Married	44.4	10.7
Never married	28.7	10.4
Widowed, divorced, or separated	26.9	21.5
Race and ethnicity			<.001
Non-Hispanic White	68.2	12.2
Non-Hispanic Black	12.3	19.3
Hispanic	13.2	16.5
Non-Hispanic Asian/Other	6.3	10.3
Educational attainment			<.001
Less than high school	9.4	31.7
High school degree	25.9	17.9
Some college	31.7	12.9
College degree	33.0	5.5
Employment status			<.001
Employed	42.3	6.0
Not employed	57.7	23.8
Household income			<0.001
<100% of FPL	15.0	26.4
100%-199% of FPL	18.4	22.3
200%-399% of FPL	27.6	11.9
400%+ of FPL	39.1	5.8
Disability status			<.001
Has a disability	41.7	28.0
No disability	58.3	3.1
Psychological distress			<.001
Has severe psychological distress	3.8	54.8
No severe psychological distress	96.2	11.9

Source. 2016 National Health Interview Survey.

Note. N = 30,079 adults age 18+; p value represents differences in self-rated health by category. FPL = federal poverty level.

Older adults (age 65 and older) were significantly more likely than younger and middle-aged adults to live alone (46.0%) or with a spouse only (38.9%), as shown in Figure 1. Still, living alone was the most common arragnement for middle-aged adults (age 35-64; 28.4%) and the second most common for younger adults (age 18-34; 27.7%), just after living with unrelated others (e.g., roommates) or with other relatives (28.7%). The least common living arrangement across all age groups was living with one’s own minor children only (as in a single-parent household), with 7.2% of younger adults, 6.6% of middle-aged adults, and 0.4% of older adults falling into that category.

Figure 2 reports the overall distribution of living arrangements as well as the percentage of adults reporting poor/fair self-rated health by living arrangement. Adults living alone comprised the largest group (32%), compared with 25% who lived with a spouse/partner only, 21% who lived with relatives or unrelated adults, 16% who lived with a spouse/partner and minor children, and 5% who lived with minor children only. Adults living alone were most likely to report poor/fair health (16.6%), followed by adults living with relatives or unrelated adults (15.8%), and adults living with minor children only (14.4%).

Figure 3 shows the percentage of adults reporting poor/fair health by whether they lived alone or with others within each age group. There was no significant difference in health for younger adults (<35 years) by living arrangement, and the vast majority (>90%) of younger adults reported good, very good, or excellent health. Starting at age 35, however, the percentage of adults reporting poor/fair health increased, and did so more dramatically, among adults living alone until 65 years of age. Among 55- to 64-year-olds, 24.6% of adults living alone reported poor/fair health compared with only 14.5% of adults living with others (p < .001). After age 65, adults living with others were more likely to report poor/fair health versus adults living alone. Among adults aged 85 and older, 31.5% of those living with others reported poor/fair health, compared with 21.8% of those living alone (p < .01).

Table 2 presents results from the logistic regression models. After controlling for sociodemographic and health characteristics, living alone was not associated with self-reported health for the full sample. However, being older than 34; widowed/separated/divorced; non-Hispanic Black, Hispanic, and Asian or other race or ethnicity (vs. White); having less than a high school education; living below the poverty threshold; and having a disability or psychological distress were all associated with higher odds of poor/fair health, with the strongest association for middle age (adjusted odds ratio [AOR] = 2.04, p < .001), presence of a disability (AOR = 7.37, p < .001), and severe psychological distress (AOR = 4.02, p < .001). In models stratified by age group, living alone was associated with significantly higher odds of reporting poor/fair health among adults aged 35 to 64 (AOR = 1.19, p < .05). Among adults aged 65 and older, living alone was associated with lower odds of reporting poor/fair health, compared with living with others (AOR = 0.70, p < .001). Living alone did not have a significant association with health status for younger adults (ages 18-34). With the exception of some college, where the association was not significant for younger adults, the direction of association was the same for all other covariates across age groups.

Table 2.

Adjusted Odds of Poor/Fair Health by Living Alone and Age Group.

	Full sample	Younger adults (18-34)	Middle-aged adults (35-64)	Older adults (65 and older)
	OR	OR	OR	OR
	(95% CI)	(95% CI)	(95% CI)	(95% CI)
Age category (ref: 18-34)
35-64	2.04*** [1.75, 2.39]
65 and older	1.42*** [1.19, 1.69]
Live alone	0.97[0.86, 1.08]	0.99[0.72, 1.37]	1.19* [1.02, 1.39]	0.70*** [0.57, 0.85]
Female	0.75*** [0.69, 0.83]	0.89[0.69, 1.15]	0.75*** [0.66, 0.85]	0.76*** [0.65, 0.88]
Widowed, divorced, or separated	1.26*** [1.13, 1.41]	1.35[0.89, 2.05]	1.25** [1.08, 1.45]	1.35** [1.10, 1.66]
Race and ethnicity (ref: Non-Hispanic White)
Non-Hispanic Black	1.74*** [1.53, 1.98]	1.95*** [1.38, 2.75]	1.59*** [1.33, 1.90]	1.80*** [1.44, 2.25]
Hispanic	1.65*** [1.43, 1.91]	1.68** [1.19, 2.39]	1.51*** [1.23, 1.84]	1.84*** [1.39, 2.43]
Non-Hispanic Asian/Other	1.28* [1.03, 1.60]	1.81* [1.13, 2.90]	1.18[0.86, 1.61]	1.17[0.80, 1.71]
Educational attainment (ref: High school degree)
Less than high school	1.45*** [1.27, 1.66]	1.16[0.73, 1.82]	1.48*** [1.21, 1.82]	1.46*** [1.19, 1.80]
Some college	0.85** [0.76, 0.95]	1.04[0.77, 1.40]	0.83* [0.71, 0.97]	0.79* [0.66, 0.95]
College degree	0.47*** [0.41, 0.54]	0.37*** [0.23, 0.58]	0.51*** [0.42, 0.61]	0.43*** [0.35, 0.54]
Employed	0.40*** [0.36, 0.45]	0.67** [0.51, 0.89]	0.35*** [0.31, 0.40]	0.41*** [0.31, 0.55]
Below the poverty threshold	1.63*** [1.44, 1.84]	1.11[0.83, 1.49]	1.69*** [1.44, 2.00]	1.95*** [1.55, 2.46]
Has a disability	7.37*** [6.54, 8.32]	7.86*** [6.00, 10.30]	6.96*** [5.94, 8.16]	7.31*** [5.64, 9.47]
Has severe psychological distress	4.02*** [3.40, 4.75]	4.30*** [2.92, 6.33]	3.67*** [2.97, 4.53]	4.52*** [3.06, 6.67]
N	30,079	7,532	14,757	7,790

Source. 2016 National Health Interview Survey.

Note. OR = odds ratio; CI = confidence interval.

p < .05. **p < .01. ***p < .001.

Discussion

Our study builds on prior research examining the relationship between living alone and self-rated health, which may be more nuanced than previously reported. We found that middle-aged adults (ages 35-64) living alone reported significantly worse health than their counterparts living with others, younger adults (≤34 years) had no difference in health by living arrangements, and older adults (≥65 years) living alone actually had better health than their counterparts living with others. These findings may indicate reverse causality. Middle-aged adults in poor health may be less likely to marry or cohabitate and older adults in poor health may be more likely to have live-in caregivers who provide assistance and support (National Alliance for Caregiving & AARP Public Policy Institute, 2015; Robards, Evandrou, Falkingham, & Vlachantoni, 2012). Furthermore, older adults living alone may actually represent some of the healthiest members of their cohort—potentially due to survival bias. Indeed, prior research on older adults living alone has found that they do sometimes have better health than those living with others, but that that is only true for the most socioeconomically advantaged older adults who may live alone by choice with ample access to assistance and resources to help them do so (Henning-Smith et al., 2018). Future research should continue to examine heterogeneity in health and health outcomes for older adults living alone, based on socioeconomic status and other demographic characteristics, to target home and community-based services and supports to those who need it most.

Much less is known about why middle-aged adults living alone report worse health than their counterparts living with others. However, this is the group that has experienced recent rises in mortality attributed to “deaths of despair,” such as those deaths attributable to suicide and substance abuse (Case & Deaton, 2015; Garcia et al., 2017). The fact that nearly one quarter of adults between the ages of 55 and 64 living alone reported poor/fair health should raise additional alarm. Much more research, policy, and programmatic attention should focus on improving health and social connectedness among adults in this age group. For instance, attention should focus on access to services and supports for various living arrangements that facilitate social integration. Furthermore, our findings that poor health was related to lower socioeconomic status, above and beyond living arrangement or age group, should serve as a reminder that policy and programmatic interventions should be designed with particular concern for individuals with less education or income. The results of this study suggest that the combination of living alone in middle age with fewer resources may be particularly bad for health, but additional research should investigate the consistency and underlying mechanisms for these patterns.

In this study, we found that nearly one third of adults live alone. Other research has also shown a steady increase in the prevalence of one-person households over the past several decades (Klinenberg, 2012; Vespa, Lewis, & Kreider, 2013). Given the relationship between living alone and the risk of social isolation, as well as the known risk of poor mental and physical health related to social isolation (Holt-Lunstad et al., 2015), more attention is urgently needed on the health and sociodemographic profiles of individuals living alone across the life span. Consistent with other research on adults living alone (Holt-Lunstad et al., 2015), we found that adults living alone had the highest prevalence of reporting poor/fair health. Approximately, 17% of adults living alone reported poor/fair health compared with only 12% who were living with a spouse/partner and 6% who were living with a spouse and minor children. Yet, our finding that the relationship between health and living alone varied by age calls for nuanced policy and programmatic responses, which might vary by age and cohort.

For all other sociodemographic covariates with a significant association with self-rated health in fully adjusted models, the direction of association was the same across age groups (e.g., having more education, being employed, and being female were associated with better self-rated health across age groups; belonging to a racial or ethnic minority group, having a disability, and having psychological distress were associated with poorer self-rated health across age groups). This makes living arrangements—especially living alone—unique among sociodemographic characteristics in helping to identify characteristics of those in the worst health at different ages. Policy makers, social service agencies, and health care providers can use these findings to deliver support to middle-aged adults living alone, who are in worse health than their peers living with others. Such efforts might include civic and community programming (e.g., neighborhood planning committees and homeowner associations), employment and training programs (e.g., networking with local trade and industry organizations), volunteer opportunities (e.g., Rotary Club, Kiwanis International, Habitat for Humanity, mentoring programs), and accessible and integrated models of health care delivery that address the whole person (e.g., coordinating medical and behavioral health with social services as needed). For older adults, the focus on improving health might be more appropriately spent on those living with others, where resources could target caregivers with respite care, including older adults providing care and older adults receiving care from those they live with. Still, across age groups, efforts should be made to support and integrate individuals living alone to mitigate the risk of loneliness and isolation (Holt-Lunstad et al., 2010).

Limitations

As with any study, these results should be considered in light of their potential limitations. We rely on secondary analysis of cross-sectional data, which cannot address issues of reverse causality. However, we build on other research showing a relationship between living alone and worse health, and we add complexity by exploring the relationship between living arrangements and health and how it varies by age. We are also not able to follow people over time with the NHIS data. Certainly, many people move in and out of different types of living arrangements over the life span. The fact remains, however, that nearly one third of the adult population lives alone at any given time and our findings indicate that they have unique health profiles that require targeted attention depending on their age. Still, we are not able to disentangle age, period, and cohort effects in this article; it is possible that our findings are related to generational differences in the relationship between living alone and health, rather than to differences purely by age. If that were true, that should raise concern about the future health of middle-aged adults living alone today. Finally, this is a study on the association between living alone and health. We cannot use it to draw broader conclusions about social isolation and loneliness—but living alone certainly reduces the number, frequency, and strength of social interactions an individual experiences in a given day.

More research is needed to tease these issues and causal mechanisms apart. For instance, quantitative research with longitudinal data should be used to explore how changing living arrangements may influence health status across the life span. Meanwhile, qualitative research should be used to conduct in-depth examinations to identify the causes and health consequences of living alone during middle adulthood. Knowing the causes of poor health for middle-aged adults living alone will inform community-based and clinical interventions that address the needs of this vulnerable population. As the percentage of adults living alone continues to rise, public health researchers and practitioners should be aware of the associated health outcomes for this growing population. We also recommend additional research on the relationship between living alone and health outcomes (e.g., mental and physical health, access to care, and health services utilization) across the life span, using other methods unavailable in the NHIS such as social network analysis.

Conclusion

Living arrangements—particularly whether one lives alone or with others—may affect health differently across the life span. On average, living alone is associated with worse health in middle age and better health in older age. A growing number of public health studies have reported increased mortality and morbidity for middle-aged adults, and our study adds another layer into the understanding of health in middle-aged adults. Public health research and policy should continue to explore the role of living arrangements, social isolation, and connectedness among middle-aged adults, who form the future generation of older adults. If these factors explain poor health in middle age, attention should be given toward supporting adults who live alone by promoting social integration through local and community-level interventions (e.g., community health promotion events, career and professional development, and social events targeted for middle-aged adults). Such efforts should seek to bolster social networks, but may also rely on health care providers and other professionals to provide synthetic social support to address the most pressing needs (Gale, Kenyon, MacArthur, Jolly, & Hope, 2018). Health care providers should also be mindful and ask about living arrangements for middle-aged patients when providing care and designing treatment plans, including future plans for long-term care (Henning-Smith & Shippee, 2015). Furthermore, medical and nursing schools should begin to train future health care professionals to identify risk factors for loneliness and best practices for improving health outcomes among groups at risk of social isolation and adverse health, such as middle-aged adults living alone.

Life events in middle age may predispose older adults to living alone, or not, in later years (Hays & George, 2002; Shaw, Fors, Fritzell, Lennartsoon, & Agahi, 2018), so particular attention should be paid to middle-aged adults when considering living arrangements and health. Meanwhile, other public health research should explore and learn more about poor health in older adults living with others, some of whom may provide care to or receive care from spouses and adult children, and others who might be living with unrelated roommates or extended family for economic reasons. In all of this research, attention should be paid to other social determinants of health, such as race, ethnicity, gender, educational status, employment, and income, as potential mediators of the relationship between living arrangements and health.

Poor health and increased mortality among middle-aged adults related to “deaths of despair” have received considerable research and media attention in recent years (Braden et al., 2017; Case & Deaton, 2015; Crimmins & Beltran-Sanchez, 2011; McCall Jones et al., 2017; Stein et al., 2017). These trends are alarming and provide a moral and economic imperative for public health practitioners and policy makers to intervene. This study provides one potential mechanism for doing so, by focusing on the health and well-being of adults living alone. Addressing the poorer health of middle-aged adults living alone may require addressing the social and economic needs of adults currently living alone as well as considering the risk factors for why individuals become isolated or live alone in the first place. This study also provides evidence to refute the notion that living alone is synonymous with worse health; in fact, for older adults, living alone was associated with better health. While those findings may derive from adverse selection out of living alone in younger and older adulthood, they demonstrate that living alone can be positive. More work is needed to understand changing trends in who is living alone and how doing so may differ by life stage.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Carrie Henning-Smith

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