Social patterning of ill health in Helsinki and Moscow: results from a comparative survey in 1991

Population norms of health-related quality of life in Moscow, Russia: the EQ-5D-5L-based survey

Purpose

To develop population norms for the EQ-5D-5L questionnaire based on a representative sample of Moscow citizens.

Methods

We used quota sampling accounting for sex, age group and administrative district of residence. Respondents in randomly selected outdoor and indoor locations were surveyed with the official Russian paper-and-pencil version of the EQ-5D-5L questionnaire and a set of socio-demographic questions. We estimated four types of EQ-5D results: the distribution of limitations according to EQ-5D-5L dimensions, the perception of the health-related quality of life (HRQoL) with a visual analogue scale (EQ VAS), the unweighted score for a respondent’s health state (Level Sum Score, LSS) and the Russian health preferences-based weighted score (EQ index). In order to estimate the EQ-5D-5L index, we used a newly developed Russian EQ-5D-3L value set, together with EuroQol Group cross-over methodology.

Results

A total of 1020 respondents (18–93 years old) from the general Moscow adult population completed the EQ-5D-5L questionnaire. HRQoL domains with the largest number of identified health limitations were pain/discomfort (48.6%) and anxiety/depression (44.1%). Two hundred seventy-nine respondents (27.0%) did not report any health restrictions. The mean EQ VAS and EQ-5D-5L index were 74.1 (SD 17.3) and 0.907 (0.106) respectively. Multivariate analysis showed that female sex, advanced age and lack of access to the Internet had a negative influence on HRQoL, whereas residence in certain districts had a positive impact.

Conclusions

The study provides population norms of health-related quality of life in Moscow, measured according to the EQ-5D-5L questionnaire. These reference values can be used to optimise the effectiveness of resource allocation in healthcare.

Electronic supplementary material

The online version of this article (10.1007/s11136-020-02705-0) contains supplementary material, which is available to authorised users.

Infant Mortality in Moscow: the Perils of Progress in Russia's World City

This paper examines changes in infant mortality (IM) in Moscow, Russia's largest and most affluent city. Along with some remarkable improvements in Moscow's health system over the period between 2000 and 2014, the overall IM rate for Moscow's residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow's 125 neighborhoods. Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.

Socioeconomic differences in self-rated health among women: a comparison of St. Petersburg to Estonia and Finland

Introduction

Social determinants of health have not been intensively studied in Russia, even though the health divide has been clearly demonstrated by an increased mortality rate among those with low education. A comparative analysis of social health determinants in countries with different historical and economic backgrounds may provide useful evidence for addressing health inequalities. We aimed to assess socioeconomic determinants of self-rated health in St. Petersburg as compared to Estonia and Finland.

Methods

Data for women aged 18–44 were extracted from existing population-based surveys and analysed. In St. Petersburg the data were originally collected in 2003 (response rate 68%), in Estonia in 2004–2005 (54%), and in Finland in 2000–2001 (86%). The study samples comprised 865 women in St. Petersburg, 2141 in Estonia and 1897 in Finland.

Results

Self-rated health was much poorer in St. Petersburg than in Estonia or Finland. High education was negatively associated with poor self-rated health in all the studied populations; it was (partially) mediated via health behaviour and limiting long-term illness only in Estonia and Finland, but not in St. Petersburg. High personal income and employment did not associate with poor self-rated health among St. Petersburg women, as it did in Estonia and Finland. In St. Petersburg housewives rather than employed women had better self-rated health, unlike the two other areas.

Conclusion

Women’s self-rated health in St. Petersburg varied similarly by education but differently by income and employment as compared to Estonia and Finland. Education is likely the most meaningful dimension of women’s socioeconomic position in St. Petersburg. More research is needed to further clarify the pathways between socioeconomic position and health in Russia.

To what extent do biomarkers account for the large social disparities in health in Moscow?

The Russian population continues to face political and economic challenges, has experienced poor general health and high mortality for decades, and has exhibited widening health disparities. The physiological factors underlying links between health and socioeconomic position in the Russian population are therefore an important topic to investigate. We used data from a population-based survey of Moscow residents aged 55 and older (n = 1495), fielded between December 2006 and June 2009, to address two questions. First, are social disparities evident across different clusters of biomarkers? Second, does biological risk mediate the link between socioeconomic status and health? Health outcomes included subscales for general health, physical function, and bodily pain. Socioeconomic status was represented by education and an index of material resources. Biological risk was measured by 20 biomarkers including cardiovascular, inflammatory, and neuroendocrine markers as well as heart rate parameters from 24-h ECG monitoring. For both sexes, the age-adjusted educational disparity in standard cardiovascular risk factors was substantial (men: standardized β = -0.16, 95% CI = -0.23 to -0.09; women: β = -0.25, CI = -0.32 to -0.18). Education differences in inflammation were also evident in both men (β = -0.17, CI = -0.25 to -0.09) and women (β = -0.09, CI = -0.17 to -0.01). Heart rate parameters differed by education only in men (β = -0.10, CI = -0.18 to -0.02). The associations between material resources and biological risk scores were generally weaker than those for education. Social disparities in neuroendocrine markers were negligible for men and women. In terms of mediating effects, biological risk accounted for more of the education gap in general health and physical function (19-36%) than in bodily pain (12-18%). Inclusion of inflammatory markers and heart rate parameters-which were important predictors of health outcomes-may explain how we accounted for more of the social disparities than previous studies.

Gender differences in predictors of self-rated health in Armenia: a population-based study of an economy in transition

INTRODUCTION

Self-rated health is a widely used health outcome measure that strongly correlates with physical and mental health status and predicts mortality. This study identified the set of predictors of fair/poor self-rated health in adult female and male populations of Armenia during a period of long-lasting socio-economic transition to a market economy.

METHODS

Differences in self-rated health were analyzed along three dimensions: socioeconomic, behavioral/attitudinal, and psychosocial. The study utilized data from a 2006 nationwide household health survey that used a multi-stage probability proportional to size cluster sampling with a combination of interviewer-administered and self-administered surveys. Both female and male representatives of a household aged 18 and over completed the self-administered survey. Multivariate odds ratios (OR) for fair/poor self-rated health were calculated for different sets of variables and logistic regression models fitted separately for women and men to identify the determinants of fair/poor self-rated health.

RESULTS

Overall, 2310 women and 462 men participated in the survey. The rate of fair/poor self-rated health was 61.8% among women and 59.7% among men. For women, the set of independent predictors of fair/poor self-rated health included age, unemployment, poverty, low affordability of healthcare, depression, and weak social support. For men, the set included age, lower education, depression, weak social support, and drinking alcohol less than once a week. For both genders, depression and weak social support demonstrated the strongest independent association with fair/poor self-rated health.

CONCLUSIONS

The prevalence of fair/poor self-rated health was similar among men and women in this study, but the sets of independent predictors of perceived health differed somewhat, possibly, reflecting lifestyle differences between men and women in Armenia. Nevertheless, psychosocial variables were the strongest predictors of fair/poor self-rated health for both genders, indicating the importance of improving the country's psychosocial environment through social reforms and poverty reduction.

The intersection of life expectancy and gender in a transitional state: the case of Russia

This paper examines the gender-related features of the health crisis in Russia which has produced the largest gender gap in life expectancy in the world. Stress and negative health lifestyles are the two most likely causes of the long-term adverse longevity pattern in Russia. However, this development cannot be clarified by a simple cause and effect explanation. This is because gender roles and gender-based normative behaviour, along with class influences, intervened to help shape outcomes. Men and women responded to the crisis along gender lines, with stress the best single explanation for a stunted longevity for females and negative health lifestyles accounting for much of the premature mortality among males.

Self-rated health compared with objectively measured health status as a tool for mortality risk screening in older adults: 10-year follow-up of the Bambuí Cohort Study of Aging

Interest in self-rated health (SRH) as a tool for use in disease and mortality risk screening is increasing. The authors assessed the discriminatory ability of baseline SRH to predict 10-year mortality rates compared with objectively measured health status. Principal component analysis was used to create a health score that included systolic blood pressure, presence of diabetes mellitus, body mass index, electrocardiographic parameters, B-type natriuretic peptide, and other biochemical and hematologic measures. From 1997 to 2007, a total of 474 of the 1,388 baseline participants died and 81 were lost to follow-up, yielding 11,833 person-years of observation. The adjusted hazard ratio for death was 1.74 (95% confidence interval (CI): 1.32, 2.29) for persons reporting poor health versus those reporting good health. When combined with age and sex, SRH had a C statistic to predict death equal to 0.69 (95% CI: 0.67, 0.71), which was comparable to that of the inclusive health score (C = 0.69, 95% CI: 0.67, 0.72). The addition of other parameters, such as lifestyle, physical functioning, mental symptoms, and physical symptoms, had little effect on these 2 predictive models (C = 0.71 (95% CI: 0.69, 0.73) and C = 0.71 (95% CI: 0.69, 0.74), respectively). The abilities of the SRH and the health score models to predict death decreased in parallel fashion over time. These results suggest that older adults who report poor health warrant particular attention as persons who have accumulated biologic markers of disease.

Inequalities in health and health service utilisation among reproductive age women in St. Petersburg, Russia: a cross-sectional study

BACKGROUND

Russian society has faced dramatic changes in terms of social stratification since the collapse of the Soviet Union. During this time, extensive reforms have taken place in the organisation of health services, including the development of the private sector. Previous studies in Russia have shown a wide gap in mortality between socioeconomic groups. There are just a few studies on health service utilisation in post-Soviet Russia and data on inequality of health service use are limited. The aim of the present study was to analyse health (self-rated health and self-reported chronic diseases) and health care utilisation patterns by socioeconomic status (SES) among reproductive age women in St. Petersburg.

METHODS

The questionnaire survey was conducted in 2004 (n = 1147), with a response rate of 67%. Education and income were used as dimensions of SES. The association between SES and health and use of health services was assessed by logistic regression, adjusting for age.

RESULTS

As expected low SES was associated with poor self-rated health (education: OR = 1.48; personal income: OR = 1.42: family income: OR = 2.31). University education was associated with use of a wider range of outpatient medical services and increased use of the following examinations: Pap smear (age-adjusted OR = 2.06), gynaecological examinations (age-adjusted OR = 1.62) and mammography among older (more than 40 years) women (age-adjusted OR = 1.98). Personal income had similar correlations, but family income was related only to the use of mammography among older women.

CONCLUSIONS

Our study suggests a considerable inequality in health and utilisation of preventive health service among reproductive age women. Therefore, further studies are needed to identify barriers to health promotion resources.

What is self-rated health and why does it predict mortality? Towards a unified conceptual model

The association of self-rated health with mortality is well established but poorly understood. This paper provides new insights into self-rated health that help integrate information from different disciplines, both social and biological, into one unified conceptual framework. It proposes, first, a model describing the health assessment process to show how self-rated health can reflect the states of the human body and mind. Here, an analytic distinction is made between the different types of information on which people base their health assessments and the contextual frameworks in which this information is evaluated and summarized. The model helps us understand why self-ratings of health may be modified by age or culture, but still be a valid measure of health status. Second, based on the proposed model, the paper examines the association of self-rated health with mortality. The key question is, what do people know and how do they know what they know that makes self-rated health such an inclusive and universal predictor of the most absolute biological event, death. The focus is on the social and biological pathways that mediate information from the human organism to individual consciousness, thus incorporating that information into self-ratings of health. A unique source of information is provided by the bodily sensations that are directly available only to the individual him- or herself. According to recent findings in human biology, these sensations may reflect important physiological dysregulations, such as inflammatory processes. Third, the paper discusses the advantages and limitations of self-rated health as a measure of health in research and clinical practice. Future research should investigate both the logics that govern people's reasoning about their health and the physiological processes that underlie bodily feelings and sensations. Self-rated health lies at the cross-roads of culture and biology, therefore a collaborative effort between different disciplines can only improve our understanding of this key measure of health status.

The specter of post-communism: women and alcohol in eight post-Soviet states

Because men have borne the heaviest burden of premature mortality in the former Soviet Union, women have for the most part been overlooked in studies of the health crisis in this part of the world. A considerable body of research points to alcohol consumption among males as a primary lifestyle cause of premature mortality. However, the extent to which alcohol use has penetrated the female population following the collapse of communism and how this consumption is associated with other social factors is less well-understood. Accordingly, this paper investigates alcohol consumption in eight republics of the former USSR - Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine using data collected in 2001. More specifically, discussion of gender role transformations and the historical experiences of women during the Soviet era emphasize two potentially important social influences examined in this analysis: psychological distress and Soviet political ideology. Findings suggest that distress is only weakly statistically associated with frequent drinking behavior among women, but results for political ideology show that this factor is statistically and significantly associated with drinking behaviors. Alcohol consumption was not particularly common among women under communism, but trends have been changing. Our discussion suggests that, after the collapse of the Soviet state, women are more able to embrace behavioral practices related to alcohol, and many may do so as an overt rejection of traditional Soviet norms and values. Findings are also discussed within the context of current epidemiological trends and future research directions in these eight republics.

Comparison of self-rated health in older people of St. Petersburg, Russia, and Tampere, Finland: how sensitive is SRH to cross-cultural factors?

The aim of this study was to examine if there are differences in self-rated health (SRH) between older people in St. Petersburg, Russia, and Tampere, Finland. Two SRH measures were examined: a global measure without any frame of reference, and an age-comparative SRH with an explicitly elicited reference of age peers. The Tampere data, consisting of 737 60-89-year-old respondents, came from the Tampere Longitudinal Study on Ageing (TamELSA) in 1989. The St. Petersburg data, consisting of 1,168 people aged 60-89 years, came from the Planning of Medical and Social Services within Elder Care in St. Petersburg project (IPSE) in 2000. In both cities the data were collected by same structured questionnaire. Self-rated health, both global and comparative, was better in Tampere than in St. Petersburg when symptoms, chronic diseases and functional ability were adjusted for. Also, the association of chronic diseases with global SRH was different in St. Petersburg and Tampere. In addition to the real differences in the prevalence and seriousness of health problems, the differences in SRH may be caused by different ways of evaluating health. Our conclusion is that self-rated health is sensitive to cultural and social factors. Direct comparisons between different countries should be made with caution, and the differences in language use must be taken into account when interpreting the results.

Comparison of health and effective functioning in Russia and the United States

Background:

Global aging may increase the societal burden of providing more resources to augment elders’ disabilities. The implications of functional disabilities can vary depending on the society in which they occur.

Objective:

To determine differences in US and Russian elder citizens’ function.

Research design:

Convenience sample of persons 60 years and older were surveyed and evaluated.

Subjects:

One hundred community dwelling residents, half from Galesburg, Illinois and half from Moscow, Russia.

Measurements:

An interviewer administered questionnaire and functional assessment examination.

Results:

The Russian sample was younger than the American sample with a mean age of 67 years versus 78 years, and less likely to be widowed or living alone. Sixty percent of Russians took no medications compared with 14% of Americans, but Russians reported more cardiovascular disease, angina, and hypertension. Forty-four percent of Russians screened as being depressed and only 4% of the Americans. Self-assessed health was good for 77% of Americans and only 6% of Russians. The Medical Outcomes Study SF-36 Health Survey (MOS) eight health concepts showed favorable results for the Americans except for physical functioning, which indicated no difference.

Conclusions:

Marked health and functional differences exist between our samples. Russians had more cardiovascular disease, took less medication, drank and smoked more and were much more likely to be depressed than the US subjects.

Psychological distress, gender, and health lifestyles in Belarus, Kazakhstan, Russia, and Ukraine

This paper examines the relationship between psychological distress, gender, and health lifestyles in Belarus, Kazakhstan, Russia, and Ukraine. These countries have been subjected to highly stressful and extensive social change associated with the transition out of communism. Data were collected by face-to-face interviews (n = 10,406) in November 2001. Distress was measured by 12 psychological distress symptoms. Health lifestyles focused on measures of alcohol consumption, smoking and diet. We found that females carried a much heavier burden of psychological distress than males, but this distress did not translate into greater alcohol consumption and smoking for these women or for men. The greatest influence of distress on health lifestyle practices was on daily diets in that both less distressed females and males consumed a more balanced diet than more distressed persons. Our findings suggest that it is the normative demands of a particular lifestyle, rather than distress, that principally shapes the pattern of heavy male drinking. This is an important finding as some sources indicate heavy drinking is largely responsible for the health crisis in the former socialist states.

The sociodemographic patterning of health in Estonia, Latvia, Lithuania and Finland

BACKGROUND

Public health problems in the Baltic countries are typical of Eastern European transition economies. A common assumption is that the economic transition has been particularly difficult for previously disadvantaged groups, and comparative research on the health differences between sociodemographic groups in the Baltic countries is therefore needed. This study compared associations of health with gender, age, education, level of urbanization and marital status in three Baltic countries and Finland.

METHODS

The data were gathered from cross-sectional postal surveys conducted in 1994, 1996, 1998 and 2000 on adult populations (aged 20-64 years) in Estonia (n = 5052), Latvia (n = 4290), Lithuania (n = 7945) and Finland (n = 12796). Three self-reported health indicators were used: (i) perceived health, (ii) diagnosed diseases and (iii) symptoms.

RESULTS

The prevalence of less-than-good perceived health (average, rather poor or poor) was higher in the Baltic countries (men 66-56%, women 68-64%) than in Finland (men 35%, women 31%). The odds ratios (with 95% confidence intervals) of less-than-good perceived health among the low educated compared to the highly educated in Estonia, Latvia, Lithuania and Finland were 2.03 (1.49-2.77), 2.00 (1.45-2.76), 2.27 (1.78-2.89) and 1.89 (1.61-2.20) among men, and 3.32 (2.43-4.55), 2.77 (2.04-3.77), 2.07 (1.61-2.66) and 1.89 (1.63-2.20) among women, respectively. Diseases and symptoms were also more common among the lower educated men and women in all four countries. However, urbanization and marital status were not consistently related to the health indicators.

CONCLUSIONS

The Baltic countries share a similar sociodemographic patterning of health with most European countries, i.e. the lower educated have worse health. The methodological considerations of this study point out, however, that further research is needed to support public health policies aimed at the most vulnerable population groups.

Determinants of smoking in eight countries of the former Soviet Union: results from the living conditions, lifestyles and health study

AIMS

To provide accurate and timely data on the determinants of smoking in countries of the former Soviet Union in order to facilitate the development of effective tobacco control policies in the region. Such data are urgently needed given the absence of accurate comparative data in the region and the recent changes experienced.

DESIGN

Cross-sectional surveys using standardized methods and representative samples of the adult population in eight former Soviet Union countries conducted as part of the EU-Copernicus Project Living Conditions, Lifestyle, and Health study.

SETTING

Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine.

PARTICIPANTS

A total of 18 428 adults aged 18 plus; response rates 71-88%.

MEASUREMENTS

The association of smoking with demographic and socio-economic factors was investigated using multiple logistic regression analyses, stratifying by gender.

FINDINGS

Age was a strong determinant of smoking in both genders, with elderly individuals being less likely to smoke. Men who were more socially disadvantaged (less educated, poorer economic situation and/or less social support) were more likely to smoke. In women, living in larger urban areas was the strongest predictor of smoking. Divorced, separated or widowed women were also more likely to smoke than married women. Muslim respondents smoked less frequently compared with other respondents.

CONCLUSIONS

Smoking is a major public health issue in the FSU particularly affecting socially vulnerable men and young women living in urbanized areas. These high-risk groups should be targeted in future smoking prevention and cessation strategies in the region.

Health lifestyles in central Asia: the case of Kazakhstan and Kyrgyzstan

There is a growing body of evidence suggesting that negative health lifestyles are the principal social determinants of the mortality crisis in the former socialist states. Little is known, however, about health lifestyles in Central Asia, where the downturn in life expectancy was also experienced. This paper examines health lifestyles in Kazakhstan and Kyrgyzstan in order to fill an important gap in the literature. The data show, consistent with the improved longevity of the Kyrgyz population, that such lifestyles are more positive in Kyrgyzstan despite the somewhat better economic situation in Kazakhstan, where the mortality crisis continues.

Self-reported health in Poland and the United States: a comparative analysis of demographic, family and socioeconomic influences

This study compares the social determinants of individual health between the United States, a capitalist society, and Poland, a 'post-communist' society. The effects of demographic factors, family characteristics and socioeconomic status on self-reported health are estimated with OLS regression using data from the 1994 American and Polish General Social Surveys. The results show lower self-reported health and more rapid declines in health for people over 60 in Poland than in the United States. Also, in Poland, women report worse health than do men while the opposite is found for the United States. The relationships between education, income and health were stronger in the United States than in Poland. Age, gender and SES may operate differently in the two countries because of a gap in social development (e.g. varying living standards and styles, health care systems and cultural attitudes) between the West and the former Eastern Europe.

Changing health inequalities in east and west Germany since unification

The unification of Germany in 1990 brought about substantial social and economic changes in its eastern part, with new uncertainties and, despite increasing overall income, rising inequality. This paper explores the potential impact on health of these changes during the 1990s, looking specifically at income-related health inequalities in east and west Germany and its modulation by psychosocial factors. We used data from the German Socio-Economic Panel (GSOEP) for the years 1992 and 1997, including individuals aged 25+. We investigated changes in self-perceived health in the two parts of Germany and its socio-economic and psychosocial determinants. Analyses estimated odds ratios of less than good health using logistic regression. In 1992, 47% of east Germans rated their health worse than good compared with 54% in the west. By 1997, the east-west gap in self-rated health had disappeared, with the prevalence of poor health increasing to 56% in both parts. Income and education were important determinants of health in east and west, with, in the age-sex-adjusted model, those having available less than 60% of median equivalent income being at increased risk of poor health in 1992 (OR(east) 2.39, 1.45-3.94; OR(west) 2.04, 1.65-2.52). Addition of education reduced the strength of this relationship only slightly. In the west, income-related health inequalities widened between 1992 and 1997 yet the initially stronger gradient declined in the east, despite an overall increase in income inequality (OR(east) 1.63, 1.04-2.56; OR(west) 2.65, 2.19-3.21). The impact of education remained stable. Psychosocial variables were important determinants, mediating the effects of income, with leisure-cultural social involvement exerting the strongest effect in both east and west.The results show that, unlike in the west, the overall increase in income inequality in east Germany between 1992 and 1997 was not accompanied by a simultaneous increase in income-related health inequalities. This suggests that mechanisms involved in the association of socio-economic factors and health possibly behave differently in east and west.

Weight satisfaction and self-esteem among teenagers in Helsinki, Moscow and Tallinn

OBJECTIVE

Information on weight satisfaction in Eastern Europe is limited. This study compares relative weight, weight satisfaction and self-esteem of teenagers living in two post-Soviet capitals, Moscow and Tallinn, and a western capital Helsinki.

METHOD

Classroom surveys including data about weight and height, weight satisfaction and self-4 esteem among 15-18-year-old girls (n = 911) and boys (n = 650) collected in 1994-95.

RESULTS

Body mass index and self-esteem were highest in Helsinki. Nevertheless, feelings of over-weight were most common among Tallinn girls and feelings of over- and underweight among Muscovite girls. Boys were mostly satisfied with their current weight with no differences between cities. Low self-esteem was associated with feelings of overweight among girls and underweight among boys.

DISCUSSION

Somewhat unexpectedly, girls grown in non-western cultures were more dissatisfied with their weight than girls in Helsinki. These findings may partly be attributable to rapid economic and cultural transformations that were occurring in these countries during the study period.

Determinants of and inequalities in self-perceived health in Ukraine

Ukraine is the second most populous of the former Soviet Republics and since transition its economy has fared even more poorly than Russia. Although the impact of the collapse of the former Soviet Union on health in Russia has been investigated, little is known of its impact in other post-Soviet republics. We report a cross-sectional study undertaken in Ukraine in March 2000. A multi-stage random sampling technique was used and 1600 interviews completed (72% response rate) with a representative national sample of Ukrainian adults. We investigated socioeconomic and psychosocial determinants of self-perceived health, which has been shown to be a valid and reliable measure of overall health and predictive of mortality. Odds ratios for less than good physical health were calculated using logistic regression. The self-rated health of Ukrainians was poor, 25% of men and 43% of women rated their health as poor or very poor. This is worse than levels recorded in Russia and considerably worse than levels seen in western Europe. Marked gender, geographical and socioeconomic inequalities in health were recorded. Women are at increased risk of poor self-rated health compared with men (OR 3.58, 2.50-5.14) as are women living in villages compared with those in cities (OR 3.24, 1.30-8.07). Socioeconomic factors including poor material situation (OR 1.64, 1.01-2.67), and psychosocial factors including low control over life (OR 1.89, 1.15-3.11) were identified as independent health determinants. Control over life was found to account for the negative impact of low social position on health. Good family relations protected against poor health. The findings suggest that a decrease in control, arising from an increasingly uncertain political and economic environment, a reduction in material wealth and the stress of change may all have contributed to the decline in life expectancy seen with transition.

Prevalence and determinants of smoking in Belarus: a national household survey, 2000

A clear, up-to-date picture of smoking prevalence and its determinants is needed to inform the development of effective tobacco control policy in Belarus and other parts of the former Soviet Union. It is particularly important in view of the way the tobacco industry has targeted this region since transition. A nationally representative household survey designed to explore smoking behaviour and its determinants was undertaken in Belarus in April 2000. Data were available on 1090 individuals aged 18 years and over (response rate 53.4%). Respondents were similar demographically to the population of Belarus. Fifty three percent of men and 9% of women are current smokers and an additional 18% and 7% respectively are ex-smokers. Differences in smoking habits between successive generations were identified. These included a ninefold higher rate of ever-smoking amongst 18-29 years old women compared with those aged over 60 years (p < 0.0001) and a higher proportion of current smokers starting in childhood amongst those aged 18-29 years compared with older smokers (p = 0.0005). Smoking in public places, particularly the workplace where 65% smoke, is common. Smokers are more likely than non-smokers to have positive beliefs about the health impact of active and passive smoking (p < 0.0001). Amongst women the odds of smoking is 13 times higher in those living in large cities compared with those living in villages. In men, disadvantage and a positive attitude to the west appear to increase the likelihood of smoking. To date policy responses have been inadequate. Unless effective tobacco control policies are introduced, tobacco will continue to make an increasingly large contribution to premature morbidity and mortality in Belarus.

Women's health status in Poland in the transition to a market economy

Since 1989 Poland has been experiencing large-scale social and economic changes as a result of the reforms associated with the transition to a market economy. This study uses a 1996 Health Survey of over 20,000 women to examine the impact of the new socio-economic situation and of women's multiple roles on their health at the early stage of transition. We investigated the importance of selected economic, socio-demographic and cultural determinants in explaining differences in women's health status in Poland, focusing on education level, (un)employment, living conditions, marital status, smoking and life style. There are health inequalities between men and women in Poland based on life expectancy, chronic diseases and health self-assessment. Some of these, especially the large differences between life expectancy at working ages, may be attributed to the difficult socio-economic situation. The multivariate analysis of women's self-assessed health and morbidity from selected chronic diseases indicated substantial inequalities in health. Together with the behavioural and cultural risk factors recognized by medicine, such as obesity, lack of physical exercise and smoking, the paper shows the crucial role of economic factors in influencing Polish women's health. Women whose financial position is poor are more likely to assess their health as less than good, to suffer from respiratory and circulatory systems' diseases and report neurotic problems. Other factors, strongly connected with the transition process in Poland, which contribute to health problems are lack of employment and low educational level, particularly for younger women. Women's marital and parental status are also important predictors of some categories of health problems; however, their influence varies for women of different ages. Our survey also supports the thesis that loneliness in old age, defined on the basis of living in a one-person household, may be negatively correlated with health status.

Family effects on self-reported health among Russian wives and husbands

Alcohol abuse and a transition to the market economy are often blamed for high mortality and low life expectancy in Russia, but little is known about proximate influences on individual health. This study estimates family influences on the self-reported health of Russian wives and husbands. Predicting gender differences in the determinants of health status, hypotheses are presented for the effects on spouses' self-reported health of five family characteristics: economic status, household division of labor, family decision-making, presence of young children, and housing conditions. Controls are included for age, education, sensitivity, alcohol use, job-related time, and urban-rural location. Data from a 1996 sample of couples (n = 925) from Moscow and two rural regions of Russia are analyzed using logistic regression. The findings provide mixed support for the hypotheses, though they do show the important role of family characteristics on spouses' health. Family economic standing is important to both spouses' self-reported health, though young children in the home is not. Family decision-making does influence spouses' health: when Russian wives are the primary decision makers in the family, their own health suffers, though their husbands' health is better. And support is found for the combined effects of job-related time and household labor but only for wives' health. When wife's household labor is low, the probability of her having poor health increases, the more time she devotes to her job. However, when she does substantially more domestic labor than her husband, her job-related time has the opposite effect, reducing the chances of poor health, the more time she spends on job activities. This study is important both in helping to account for poor health of Russians during the current economic and social transition and in identifying aspects of family life that affect men's and women's health cross-nationally.

Epidemiology of smoking in Ukraine, 2000

BACKGROUND

A clear, up-to-date picture of smoking prevalence and its determinants is needed to inform the development of an effective tobacco control policy in Ukraine, particularly given the way in which the tobacco industry has targeted post-Soviet countries since transition.

METHODS

A nationally representative household survey was undertaken in Ukraine in February 2000.

RESULTS

Data were available on 1,590 individuals (response rate 72%). Fifty-seven percent of men and 10% of women were current smokers and an additional 21 and 7%, respectively, were ex-smokers. Smoking behavior has changed considerably over successive generations, with an increase in the proportion of women smoking and a reduction in the mean age at first smoking. Factors associated with smoking include young age, urban residence (among women), and material hardship, particularly unemployment. Involvement in social networks appears to reduce the probability of smoking. Smoking commonly occurs in public places and smokers differ from nonsmokers in their health beliefs about smoking.

CONCLUSIONS

Levels of smoking among men are already high and among young women are increasing rapidly. Unless an effective tobacco policy response is developed to address the issues identified, tobacco will continue to make an increasingly large contribution to premature morbidity and mortality in Ukraine.

Health lifestyles in Russia

Utilizing data from the nationwide Russian Longitudinal Monitoring Survey (RLMS), this paper analyzes health lifestyles in Russia. Heavy alcohol use and smoking, a high-fat diet, and lack of leisure-time exercise are the principal culprits in fostering high rates of heart disease and other causes of premature mortality. This is especially the situation for middle-age, working-class males whose mortality is greater than any other segment of society. This paper focuses on alcohol use as a particularly lethal component of male lifestyles and presents a theoretical argument, grounded in the work of Weber and especially Bourdieu, that poor health lifestyles practices are largely the outcome of structural conditions (life chances) rather than agency (life choices). Societal and group norms and routine practices can adversely affect longevity and this is the case for Russian male blue-collar workers in the middle period of their life course.

Health-related lifestyles and alienation in Moscow and Helsinki

Health-related lifestyles (smoking, drinking alcohol, exercise and diet) and feelings of alienation (powerlessness and hopelessness) of the citizens of Helsinki and Moscow are examined and discussed in a framework of life chances and life choices. The data were collected by a postal survey of 18-64 yr old citizens of Helsinki (N = 824) and Moscow (N = 545) in 1991. Almost all respondents in both cities used alcohol, but heavy drinking was more frequently reported in Helsinki. Muscovite men were smokers more often and Muscovite women less often than their counterparts in Helsinki. Nearly half of the Muscovites, but less than one-fifth of the Helsinki respondents considered their diet unhealthy or of poor quality. Regular exercise was much more common among the Finns compared to the Muscovites. The sex difference in health-related lifestyles was wider in Moscow than in Helsinki, especially concerning health-damaging behaviour. Feelings of alienation were more pronounced in Moscow. In both cities alienation was more clearly associated with socioeconomic life chance factors than with lifestyle factors. In Helsinki feelings of alienation had stronger associations both with health and health related lifestyles, which possibly points to a conventional stratification effect of a market-based class society. In Moscow, which represents a more traditional community, alienation seemed to be part of a widely felt general discontent. Health was a highly salient value in both cities, especially among women. In Helsinki a high valuation of health was connected with less smoking, more exercise and a healthier diet. Valuing health did not seem to emerge as a distinct healthy lifestyle in Moscow where behavioural choices were limited by many material constraints.

A multilevel city health profile of Moscow

This report describes a multilevel city-wide profile of physical health in Moscow, examining individual and urban level factors. Objectives of the paper were to: (1) identify macro and micro risk factors for poor physical health in Moscow;(2) assess the effect of two dimensions of micro determinants--personal health habits and social connectivity, such as social cohesion, social support, and social networks; (3) examine the hypothesis that relative social inequality is a significant structural condition at the community level which influences the physical health of individuals, as a main and as a joint effect with psychosocial behaviors. A random sample of Moscow adults, with household telephones (N = 2000), was collected 17-19 September, 1991, and had a completed interview rate of 81.8%. The questionnaire replicated items from the California Alameda Study and the US Health Interview Survey. Respondents' urban area of residence was linked to macro measures of inequality derived from the Moscow census. This report describes the baseline survey of a prospective study design. Results of this study demonstrate that the social context in a community affects the health of people living there independently from the effects of individual health lifestyle or social connectivity. The structural conditions in Moscow which significantly increased the vulnerability of specific social groups for poor physical health were identified in a hierarchical linear regression: relative social inequality in the form of income inequality; urban area poverty risks; and mean level of alcohol consumption in urban areas. The psychosocial conditions included poor diet, lack of social cohesion and social support, involvement in formal social networks in the form of professional groups. A multilevel theoretical perspective is important for defining the targets of preventive health policy by identifying the structural conditions which increase the health disadvantage of some social groups. Further research is needed in refining the concept of relative social inequality, as well as investigating whether psychosocial factors, such as social cohesion, are mediating links between sick societies and their sick citizens.

Income inequality, social cohesion, and class relations: a critique of Wilkinson's neo-Durkheimian research program

Wilkinson's "income inequality and social cohesion" model has emerged as a leading research program in social epidemiology. Public health scholars and activists working toward the elimination of social inequalities in health can find several appealing features in Wilkinson's research. In particular, it provides a sociological alternative to former models that emphasize poverty, health behaviors, or the cultural aspects of social relations as determinants of population health. Wilkinson's model calls for social explanations, avoids the subjectivist legacy of U.S. functionalist sociology that is evident in "status" approaches to understanding social inequalities in health, and calls for broad policies of income redistribution. Nevertheless, Wilkinson's research program has characteristics that limit its explanatory power and its ability to inform social policies directed toward reducing social inequalities in health. The model ignores class relations, an approach that might help explain how income inequalities are generated and account for both relative and absolute deprivation. Furthermore, Wilkinson's model implies that social cohesion rather than political change is the major determinant of population health. Historical evidence suggests that class formation could determine both reductions in social inequalities and increases in social cohesion. Drawing on recent examples, the authors argue that an emphasis on social cohesion can be used to render communities responsible for their mortality and morbidity rates: a community-level version of "blaming the victim." Such use of social cohesion is related to current policy initiatives in the United States and Britain under the New Democrat and New Labor governments.