Knowledge of the health impacts of smoking and public attitudes towards tobacco control in the former Soviet Union.

AIMS: To describe levels of knowledge on the harmful effects of tobacco and public support for tobacco control measures in nine countries of the former Soviet Union and to examine the characteristics associated with this knowledge and support. METHODS: Standardised, cross-sectional nationally representative surveys conducted in 2010/2011 with 18 000 men and women aged 18 years and older in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. Respondents were asked a range of questions on their knowledge of the health effects of tobacco and their support for a variety of tobacco control measures. Descriptive analysis was conducted on levels of knowledge and support, along with multivariate logistic regression analysis of characteristics associated with overall knowledge and support scores. RESULTS: Large gaps exist in public understanding of the negative health effects of tobacco use, particularly in Azerbaijan, Kazakhstan, Kyrgyzstan and Moldova. There are also extremely high levels of misunderstanding about the potential effects of 'light' cigarettes. However, there is popular support for tobacco control measures. Over three quarters of the respondents felt that their governments could be more effective in pursuing tobacco control. Higher levels of education, social capital (membership of an organisation) and being a former or never-smoker were associated with higher knowledge on the health effects of tobacco and/or being more supportive of tobacco control measures. CONCLUSIONS: Increasing public awareness of tobacco's health effects is essential for informed decision-making by individuals and for further increasing public support for tobacco control measures.

Micro- and meso-level influences on obesity in the former Soviet Union: a multi-level analysis.

BACKGROUND: Limited evidence exists on obesity in the former Soviet Union (fSU), particularly its micro- and meso-level determinants. The objectives of this study were to determine age- and gender-adjusted prevalence of self-reported overweight and obesity in nine fSU countries; explore the relationship between individual and household (micro-level) factors and obesity; and explore the relationship between features of nutritional and physical environments (meso-level) and obesity. METHODS: Data were collected from 18,000 adults using household surveys and from 333 communities using community profiles in Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2010. Individual- and community-level determinants of self-reported obesity (body mass index ≥ 30 kg/m(2)) were analysed using multi-level random intercept logistic regression models. RESULTS: A total of 13% of the males and 18% of the females were categorized as obese. Factors associated with obesity in males were older age, increasing educational achievement, declining self-reported health, alcohol consumption and automobile ownership. Males who were current smokers, not married and perceived physical activity to be important were less likely to be obese. For females, obesity was associated with older age, completion of secondary-level education, declining self-reported health and average household financial situation. Unmarried women were less likely to be obese. Multi-level analysis indicated that individuals living in communities with higher presence of garbage were more likely to be obese. CONCLUSIONS: This is the first study to examine both micro- and meso-level influences on obesity in fSU using multi-level analysis. Findings indicate a similar obesity risk profile to countries in Western Europe and North America.

Prevalence and psychosocial determinants of nicotine dependence in nine countries of the former Soviet Union.

INTRODUCTION: Despite the high prevalence of smoking in the former Soviet Union (fSU), particularly among men, there is very little information on nicotine dependence in the region. The study aim was to describe the prevalence of nicotine dependence in 9 countries of the fSU and to examine the psychosocial factors associated with nicotine dependence. METHODS: Cross-sectional, nationally representative surveys using multistage random sampling were conducted in 2010 with men and women aged 18 years and over in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine. The main outcome of interest was nicotine dependence using the Fagerström Test for Nicotine Dependence. Multivariate regression analysis was then used to explore the influence of a range of psychosocial factors on higher nicotine dependence. RESULTS: Mean nicotine dependence among men in the region as a whole was 3.96, with high dependence ranging from 17% in Belarus to 40% in Georgia. Among women, mean dependence was 2.96, with a prevalence of high dependence of 11% for the region. Gender (men), younger age of first smoking, lower education level, not being a member of an organization, bad household economic situation, high alcohol dependence, and high psychological distress showed significant associations with higher nicotine dependence. CONCLUSIONS: High nicotine dependence among men was recorded in a number of study countries. Findings highlight the need for tobacco programmes to target early age smokers and less educated and poorer groups and suggest common ground for programmes seeking to reduce nicotine dependence, harmful alcohol use, and psychological distress.

Changes in smoking prevalence in 8 countries of the former Soviet Union between 2001 and 2010.

OBJECTIVES: We sought to present new data on smoking prevalence in 8 countries, analyze prevalence changes between 2001 and 2010, and examine trend variance by age, location, education level, and household economic status. METHODS: We conducted cross-sectional household surveys in 2010 in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine. We compared smoking prevalence with a related 2001 study for the different countries and population subgroups, and also calculated the adjusted prevalence rate ratios of smoking. RESULTS: All-age 2010 smoking prevalence among men ranged from 39% (Moldova) to 59% (Armenia), and among women from 2% (Armenia) to 16% (Russia). There was a significantly lower smoking prevalence among men in 2010 compared with 2001 in Belarus, Kazakhstan, Kyrgyzstan, and Russia, but not for women in any country. For all countries combined, there was a significantly lower smoking prevalence in 2010 than in 2001 for men aged 18 to 39 years and men with a good or average economic situation. CONCLUSIONS: Smoking prevalence appears to have stabilized and may be declining in younger groups, but remains extremely high among men, especially those in lower socioeconomic groups.

Patterns of public support for price increases on alcohol in the former Soviet Union.

AIMS: To measure levels of public support for price increases on beer and spirits in nine former Soviet Union countries and to examine the characteristics influencing such support. METHODS: Cross-sectional surveys were conducted in 2010 with 18,000 respondents aged 18+ in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. Descriptive and multivariate logistic regression analyses were used. RESULTS: The lowest level of support for price increases on beer were in Georgia (men 5%, women 9%) and Armenia (men 5%, women 11%); and the highest were in Kyrgyzstan (men 30%, women 38%), Azerbaijan (men 27%, women 37%) and Russia (men 23%, women 34%). The lowest levels of support for price increases on spirits were Armenia (men 8%, women 14%) and Georgia (men 14%, women 21%); and the highest were in Kyrgyzstan (men 38%, 47% women) and Moldova (men 36%, women 43%). Characteristics associated with supporting price increases included gender (women), higher education, good economic situation, lower alcohol consumption and greater knowledge of harmful alcohol behaviour. CONCLUSION: Alcohol price increases are an effective means to reduce hazardous alcohol use. Despite opposition in some groups, there is evidence of public support for alcohol price increases in the study countries.

The persistence of irregular treatment of hypertension in the former Soviet Union.

BACKGROUND: Hypertension is one of the leading causes of avoidable mortality in the former Soviet Union (fSU). In previous work, the authors described patterns of irregular hypertension treatment in eight countries of the fSU in 2001. This paper presents new data on changes in the use of hypertension treatment in the same countries. METHODS: Using household survey data from 18 420 (2001) and 17 914 (2010) respondents from Armenia, Azerbaijan (2010 only), Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine, the authors describe changes in rates of irregular treatment use (less than daily) between 2001 and 2010. Multivariate logistic regression was also used to analyse the characteristics associated with irregular treatment. RESULTS: Irregular treatment was extremely high at 74% in 2001 and only fell to 68% in 2010 (all countries combined). Irregular treatment remained particularly high in 2010 in Armenia (79%), Kazakhstan (73%) and Moldova (73%). Recurring characteristics associated with irregular treatment included gender (men), younger age, higher fitness levels, and consuming alcohol and tobacco. CONCLUSIONS: Irregular hypertension treatment continues to be a major problem in the countries of the fSU and requires an urgent response.

Changes in household access to water in countries of the former Soviet Union.

BACKGROUND: Evidence from the Early 2000s quantified limited coverage of household water supplies in countries of the former Soviet Union. The study objectives were to measure changes in access to piped household water in seven of these countries between 2001 and 2010 and examine how these varied by household economic status. METHODS: Cross-sectional household sample surveys were conducted in 2010 in Armenia, Belarus, Georgia, Kazakhstan, Moldova, Russia and Ukraine. Data on household piped water were compared with a related 2001 study and descriptive, regression and relative risk analyses applied. RESULTS: Increases in access to piped water in the home between 2001 and 2010 were recorded in urban and rural areas of all countries, except Kazakhstan. Access remains lower in rural areas. The relative risk of urban households not having piped water in 2010 compared with 2001 diminished by one-third for households with a bad/very bad economic situation [rate ratio (RR): 0.66] and by half for wealthier households (RR: 0.48). In rural areas, the declines were 15% for households with a bad/very bad economic situation (RR: 0.85) and 30% for wealthier households (RR: 0.69). CONCLUSIONS: Despite encouraging increases in access to piped water, there remain significant gaps for rural and poorer households.

Health care reform in the former Soviet Union: beyond the transition.

OBJECTIVE: To assess accessibility and affordability of health care in eight countries of the former Soviet Union. DATA SOURCES/STUDY SETTING: Primary data collection conducted in 2010 in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine. STUDY DESIGN: Cross-sectional household survey using multistage stratified random sampling. DATA COLLECTION/EXTRACTION METHODS: Data were collected using standardized questionnaires with subjects aged 18+ on demographic, socioeconomic, and health care access characteristics. Descriptive and multivariate regression analyses were used. PRINCIPAL FINDINGS: Almost half of respondents who had a health problem in the previous month which they viewed as needing care had not sought care. Respondents significantly less likely to seek care included those living in Armenia, Georgia, or Ukraine, in rural areas, aged 35-49, with a poor household economic situation, and high alcohol consumption. Cost was most often cited as the reason for not seeking health care. Most respondents who did obtain care made out-of-pocket payments, with median amounts varying from $13 in Belarus to $100 in Azerbaijan. CONCLUSIONS: Access to health care and within-country inequalities appear to have improved over the past decade. However, considerable problems remain, including out-of-pocket payments and unaffordability despite efforts to improve financial protection.

The influence of social capital on health in eight former Soviet countries: why does it differ?

BACKGROUND: Previous research has identified the role of social capital in explaining variations in health in the countries of the former Soviet Union. This study explores whether the benefits of social capital vary among these countries and why. METHODS: The impact of micro social capital (trust, membership and social isolation) on individual health was estimated in each of eight former Soviet republics using instrumental variables to overcome methodological hazards such as endogeneity and reverse causality. Interactions with institutional variables (voice and accountability, effectiveness of the legal system, informal economy) and social protection variables (employment protection, old age and disability benefits, sickness and health benefits) were examined. RESULTS: Most social capital indicators, in most countries, are associated with better health but the magnitude and significance of the impact differ between countries. Some of this variation can be explained by interacting social capital indicators with measures of institutional quality, with membership of organisations bringing greater benefit for health in countries where civil liberties are stronger, whereas social isolation has more adverse consequences where there is a large informal economy. A lesser amount is explained by the interaction of social capital indicators with selected measures of social protection. CONCLUSION: When considering interventions to improve social capital as a means of improving population health, it seems advisable to take into account the influence of macrocontextual variables, in order not to overstate or understate the likely impact of the intervention.

Hazardous alcohol drinking in the former Soviet Union: a cross-sectional study of eight countries.

BACKGROUND: Hazardous consumption of large quantities of alcohol is a major cause of ill-health in the former Soviet Union (fSU). The objective of this study was to describe episodic heavy drinking and other hazardous drinking behaviors in eight countries of the fSU. METHODS: Data from national surveys of adults conducted in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine in 2001 were used (overall sample size 18,428; response rates 71-88%). Heavy episodic drinking, high alcohol intake, drinking alcohol during the working day, and using illegally produced strong spirits were examined. RESULTS: On average, 23% of men and 2% of women were defined as heavy episodic drinkers (> or = 2 l of beer or > or = 750 g bottle of wine or > or = 200 g strong spirits at least once every 2-3 weeks). This was more common in young males, women who are single or who are divorced/separated/widowed, in smokers, and in frequent alcohol drinkers. About half the respondents who drank strong spirits obtained at least some alcohol from private sources. Among drinkers, 11% of males and 7% of women usually took their first drink before the end of working day. CONCLUSIONS: Heavy episodic alcohol drinking is frequent in males throughout the region--although prevalence rates may have been affected by underreporting--but is still relatively rare in women. Alcohol policies in the region should address hazardous drinking patterns and the common use of illegally produced alcohol.

Socioeconomic differences in health, health behaviour and access to health care in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation and Ukraine / by Marc Suhrcke

This publication presents tables summarizing the distribution of health, health behaviour, health care access and social capital by socioeconomic status, gender and residence (urban and rural). The data come from the Living Conditions, Lifestylesand Health (LLH) Project, which conducted representative surveys in eight countries of the former Soviet Union: Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Republic of Moldova, the Russian Federation and Ukraine in October and November 2001. The statistics are descriptive and do not necessarily reflect causal relationships between socioeconomic status and health.

Drinking in the Commonwealth of Independent States--evidence from eight countries.

AIMS: To describe the frequency of alcohol consumption and beverage preferences in eight countries of the Commonwealth of Independent States (CIS). DESIGN: Cross-sectional. SETTING: Populations of Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation and Ukraine. PARTICIPANTS: Representative samples of the adult population of each country (overall sample size 18,428; response rates: 71-88%). MEASUREMENTS: A standardised questionnaire was administered by trained interviewers to examine alcohol consumption frequency and usual intakes of beer, wine and strong spirits. FINDINGS: Between 11 and 34% of males and 26-71% of females reported never drinking alcohol. Abstention was lowest in the Russian Federation and Belarus, two traditional spirits-drinking countries. It was particularly high in Kyrgyzstan and Georgia, two countries with a relatively low frequency of alcohol consumption but large amounts consumed per occasion (particularly Georgia). On the contrary, Moldovan respondents drank frequently, but consumed smaller amounts per occasion. As expected, spirits were consumed in largest amounts in traditional spirits-drinking countries, as well as Armenia and wine in traditional wine-drinking countries. Beer consumption was relatively high in Russia, Belarus, Ukraine and Kazakhstan (males), particularly in young respondents. CONCLUSIONS: Although cross-country comparisons of alcohol intake should be interpreted cautiously, this study suggested that drinking patterns in the countries examined are not entirely typical of usual dry/wet drinking cultures, and confirms that the CIS is very diverse in terms of drinking patterns and beverage preferences. The study provides an important baseline for future comparisons as markets open to new products, as has been the case elsewhere in Europe.

Health lifestyles in Ukraine.

OBJECTIVES: Several studies have identified negative health lifestyles as a primary determinant of the mortality crisis in Europe's post-communist states, but little is known about Ukraine. In order to address this gap in the literature, this paper provides data on Ukrainian health lifestyles. METHODS: Data were collected by face-to-face interviews in the households (N = 2 400) of a random sample of respondents in Ukraine in November, 2001. The sample was selected using multi-stage random sampling with stratification by region and area (urban/rural). Data were analyzed using logistic regression. RESULTS: Male gender was found to be the most powerful single predictor of negative health lifestyles as shown in the results for frequent drinking, heavy vodka use at one occasion, smoking, and diet. Males rated their health status better than females, but over one-third of the males and one-half of the females rated their health status as rather bad or bad. CONCLUSIONS: Gender and class differences in health lifestyle practices appear to be key variables, with working-class males showing the most negative practices. The results for health status suggest that the overall level of health in Ukraine is not good.

Prevalence of smoking in 8 countries of the former Soviet Union: results from the living conditions, lifestyles and health study.

OBJECTIVES: We sought to provide comparative data on smoking habits in countries of the former Soviet Union. METHODS: We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older. RESULTS: Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%-6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%-15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent. CONCLUSIONS: Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.

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 service utilization in the former soviet union: evidence from eight countries.

BACKGROUND: In the past decade, the countries that emerged from the Soviet Union have experienced major changes in the inherited Soviet model of health care, which was centrally planned and provided universal, free access to basic care. The underlying principle of universality remains, but coexists with new funding and delivery systems and growing out-of-pocket payments. OBJECTIVE: To examine patterns and determinants of health care utilization, the extent of payment for health care, and the settings in which care is obtained in Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and Ukraine. METHODS: Data were derived from cross-sectional surveys, representative of adults aged 18 and over in each country, conducted in 2001. Multistage random sample of 18,428 individuals, stratified by region and area, was obtained. Instrument contained extensive data on demographic, economic, and social characteristics, administered face-to-face. The analysis explored the health seeking behavior of users and nonusers (those reporting an episode of illness but not consulting). RESULTS: In the preceding year, over half of all respondents visited a medical professional, ranging from 65.7 percent in Belarus to 24.4 percent in Georgia, mostly at local primary care facilities. Of those reporting an illness, 20.7 percent of all did not consult although they felt they should have done so, varying from 9.4 percent in Belarus to 42.4 percent in Armenia and 49 percent in Georgia. The main reason for not seeking care was lack of money to pay for treatment (45.2 percent), self-treatment with home-produced remedies (32.9 percent), and purchase of nonprescribed medicine (21.8 percent). There are marked differences between countries; unaffordability was a particularly common factor in Armenia, Georgia, and Moldova (78 percent, 70 percent, 54 percent), and much lower in Belarus and Russia. In Georgia and Armenia, 65 percent and 56 percent of those who had consulted paid out-of-pocket, in the form of money, gifts, or both; these figures were 8 percent and 19 percent in Belarus and Russia respectively and 31.2 percent overall. The probability of not consulting a health professional when seriously ill was significantly higher among those over age 65, and with lower education. Use of health care was markedly lower among those with fewer household assets or a shortage of money, and those dissatisfied with their material resources, factors that explained some of the effects of age. A lack of social support (formal and informal) decreases further the probability of not consulting, adding to the consequences of poor financial status. The probability of seeking care for common conditions varies widely among countries (persistent fever: 56 percent in Belarus; 16 percent in Armenia) and home remedies, alcohol, and direct purchase of pharmaceuticals are commonly used. Informal coping strategies, such as use of connections (36.7 percent) or offering money to health professionals (28.5 percent) are seen as acceptable. CONCLUSIONS: This article provides the first comparative assessment of inequalities in access to health care in multiple countries of the former Soviet Union, using rigorous methodology. The emerging model across the region is extremely diverse. Some countries (Belarus, Russia) have managed to maintain access for most people, while in others the situation is near collapse (Armenia, Georgia). Access is most problematic in health systems characterized by high levels of payment for care and a breakdown of gate-keeping, although these are seen in countries facing major problems such as economic collapse and, in some, a legacy of civil war. There are substantial inequalities within each country and even where access remains adequate there are concerns about its sustainability.

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.