Cross-country evidence on the social determinants of the post-socialist mortality crisis in Europe: a review and performance-based hierarchy of variables.

An unprecedented mortality crisis befell the former socialist countries between 1989 and 1995, representing one of the greatest demographic shocks of the period after the Second World War. While it is likely that country-level variation in the post-socialist mortality crisis in Eastern Europe can be explained by a constellation of political and socio-economic factors, no comprehensive review of the existing scholarly attempts at explaining these factors exists. We review 39 cross-national multi-variable peer reviewed studies of social determinants of mortality in post-socialist Europe in order to assess the social factors behind the post-socialist mortality crisis, determine the gaps in the existing literature and to make suggestions for future research. We propose a novel methodology to determine the relative importance of variables based on the ratio of significant to insignificant findings for each variable. The literature identifies inequality, welfare payments, religious composition, democracy, economic performance and unemployment as the leading factors that have a significant influence on mortality outcomes. Existing cross-country studies fail to establish a definitive connection between mortality and diets, drinking patterns, liberalisation, trust, health expenditure and war. We also point out that the level of analysis is not a neutral methodological choice but might influence the results themselves.

Smoking, alcohol and cancer mortality in Eastern European men: Findings from the PrivMort retrospective cohort study.

Eastern European men have among the highest cancer mortality rates globally. Prevalence of smoking and alcohol intake in this region is also high. The aim of our study was to calculate population attributable risk fraction (PARF) of cancer deaths from smoking and alcohol in Russia, Belarus and Hungary, and to examine the contribution of these lifestyle factors to differences in male cancer mortality in the three countries. Data were collected as part of the PrivMort retrospective cohort study. Randomly selected participants living in mid-size towns in Russia, Belarus and Hungary provided information on smoking habits, alcohol consumption, vital status and cause of death (if applicable) of male relatives (fathers, siblings and partners). PARF of cancer deaths (age 35-79) due to smoking, alcohol consumption and both combined was estimated between 2001 and 2013. Among 72,190 men, 4,702 died of cancer. Age standardized cancer mortality rates were similar to official data in all three countries. The estimated PARF (95% CI) associated with measures of smoking, alcohol consumption, both combined, and overall smoking or drinking were 25% (19-30), 2% (0-4), 29% (19-39), 43% (32-53) in Russia, 18% (8-28), 2% (-1 to 6), 28% (20-35), 38% (25-50) in Belarus and 17% (13-20), 1% (0-3), 25% (20-30), 35% (28-42) in Hungary, respectively. These results suggest that in Eastern Europe, at least one third of cancer deaths in males may have been attributable to smoking and/or alcohol consumption in recent years. Health policies targeting these lifestyle factors can have a major impact on population health.

The gendered effects of foreign investment and prolonged state ownership on mortality in Hungary: an indirect demographic, retrospective cohort study.

BACKGROUND: Research on the health outcomes of globalisation and economic transition has yielded conflicting results, partly due to methodological and data limitations. Specifically, the outcomes of changes in foreign investment and state ownership need to be examined using multilevel data, linking macro-effects and micro-effects. We exploited the natural experiment offered by the Hungarian economic transition by means of a multilevel study designed to address these gaps in the scientific literature. METHODS: For this indirect demographic, retrospective cohort study, we collected multilevel data related to Hungary between 1995 and 2004 from the PrivMort database and other sources at the town, company, and individual level to assess the relation between the dominant company ownership of a town and mortality. We grouped towns into three ownership categories: dominant state, domestic private, and foreign ownership. We did population surveys in these towns to collect data on vital status and other characteristics of survey respondents' relatives. We assessed the relation between dominant ownership and mortality at the individual level. We used discrete-time survival modelling, adjusting for town-level and individual-level confounders, with clustered SEs. FINDINGS: Of 83 eligible towns identified, we randomly selected 52 for inclusion in the analysis and analysed ownership data from 262 companies within these towns. Additionally, between June 16, 2014, and Dec 22, 2014, we collected data on 78 622 individuals from the 52 towns, of whom 27 694 were considered eligible. After multivariable adjustment, we found that women living in towns with prolonged state ownership had significantly lower odds of dying than women living in towns dominated by domestic private ownership (odds ratio [OR] 0·74, 95% CI 0·61-0·90) or by foreign investment (OR 0·80, 0·69-0·92). INTERPRETATION: Prolonged state ownership was associated with protection of life chances during the post-socialist transformation for women. The indirect economic benefits of foreign investment do not translate automatically into better health without appropriate industrial and social policies. FUNDING: The European Research Council.

The effect of rapid privatisation on mortality in mono-industrial towns in post-Soviet Russia: a retrospective cohort study.

BACKGROUND: Population-level data suggest that economic disruptions in the early 1990s increased working-age male mortality in post-Soviet countries. This study uses individual-level data, using an indirect estimation method, to test the hypothesis that fast privatisation increased mortality in Russia. METHODS: In this retrospective cohort study, we surveyed surviving relatives of individuals who lived through the post-communist transition to retrieve demographic and socioeconomic characteristics of their parents, siblings, and male partners. The survey was done within the framework of the European Research Council (ERC) project PrivMort (The Impact of Privatization on the Mortality Crisis in Eastern Europe). We surveyed relatives in 20 mono-industrial towns in the European part of Russia (ie, the landmass to the west of the Urals). We compared ten fast-privatised and ten slow-privatised towns selected using propensity score matching. In the selected towns, population surveys were done in which respondents provided information about vital status, sociodemographic and socioeconomic characteristics and health-related behaviours of their parents, two eldest siblings (if eligible), and first husbands or long-term partners. We calculated indirect age-standardised mortality rates in fast and slow privatised towns and then, in multivariate analyses, calculated Poisson proportional incidence rate ratios to estimate the effect of rapid privatisation on all-cause mortality risk. FINDINGS: Between November, 2014, and March, 2015, 21 494 households were identified in 20 towns. Overall, 13 932 valid interviews were done (with information collected for 38 339 relatives [21 634 men and 16 705 women]). Fast privatisation was strongly associated with higher working-age male mortality rates both between 1992 and 1998 (age-standardised mortality ratio in men aged 20-69 years in fast vs slow privatised towns: 1·13, SMR 0·83, 95% CI 0·77-0·88 vs 0·73, 0·69-0·77, respectively) and from 1999 to 2006 (1·15, 0·91, 0·86-0·97 vs 0·79, 0·75-0·84). After adjusting for age, marital status, material deprivation history, smoking, drinking and socioeconomic status, working-age men in fast-privatised towns experienced 13% higher mortality than in slow-privatised towns (95% CI 1-26). INTERPRETATION: The rapid pace of privatisation was a significant factor in the marked increase in working-age male mortality in post-Soviet Russia. By providing compelling evidence in support of the health benefits of a slower pace of privatisation, this study can assist policy makers in making informed decisions about the speed and scope of government interventions. FUNDING: The European Research Council.

Mortality in Transition: Study Protocol of the PrivMort Project, a multilevel convenience cohort study.

BACKGROUND: Previous research using routine data identified rapid mass privatisation as an important driver of mortality crisis following the collapse of Communism in Central and Eastern Europe. However, existing studies on the mortality crisis relying on individual level or routine data cannot assess both distal (societal) and proximal (individual) causes of mortality simultaneously. The aim of the PrivMort Project is to overcome these limitations and to investigate the role of societal factors (particularly rapid mass privatisation) and individual-level factors (e.g. alcohol consumption) in the mortality changes in post-communist countries. METHODS: The PrivMort conducts large-sample surveys in Russia, Belarus and Hungary. The approach is unique in comparing towns that have undergone rapid privatisation of their key industrial enterprises with those that experienced more gradual forms of privatisation, employing a multi-level retrospective cohort design that combines data on the industrial characteristics of the towns, socio-economic descriptions of the communities, settlement-level data, individual socio-economic characteristics, and individuals' health behaviour. It then incorporates data on mortality of different types of relatives of survey respondents, employing a retrospective demographic approach, which enables linkage of historical patterns of mortality to exposures, based on experiences of family members. By May 2016, 63,073 respondents provided information on themselves and 205,607 relatives, of whom 102,971 had died. The settlement-level dataset contains information on 539 settlements and 12,082 enterprises in these settlements in Russia, 96 settlements and 271 enterprises in Belarus, and 52 settlement and 148 enterprises in Hungary. DISCUSSION: In addition to reinforcing existing evidence linking smoking, hazardous drinking and unemployment to mortality, the PrivMort dataset will investigate the variation in transition experiences for individual respondents and their families across settlements characterized by differing contextual factors, including industrial characteristics, simultaneously providing information about how excess mortality is distributed across settlements with various privatization strategies.