Welcome to the project "Living Conditions, Lifestyle and Health". This EU-Copernikus project aims to study the relationship between living standards, lifestyle and health of the populations of 8 former Soviet countries.
- Institute for Advanced Studies (IHS), Austria
- Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Ukraine
- About the Project
Objectives, expected benefits and overall approach of the project
- To study the relationship between living standards, lifestyle and health of the populations of 8 former Soviet countries: Russia, Belarus, Ukraine, Moldova, Kazakhstan, Kyrgyzstan, Armenia, and Georgia. These countries represent a large part of the former Soviet Union but also provide ethnic, cultural and religious variations
- To investigate how tobacco and alcohol consumption, including their social and cultural context, is related to cardiovascular disease in these 8 countries
- To investigate how socio-economic conditions including conditions of employment, unemployment, housing, income and social group are related to health outcomes
- To investigate how social capital and social networks, including informal versus formal provision of care and the way in which health services are used by individuals, affects health outcomes
- To investigate how psycho-social factors such as feelings of control over one's life can affect health outcomes
- To investigate how culture and lifestyle, including ethnic and regional differences, can affect health outcomes
- To investigate the impact of environmental factors such as employment, region and nuclear and other pollution
- To produce new empirical knowledge going well beyond existing epidemiological data about life styles, living conditions and health of individual adults in eight former CIS countries
- To analyse which of the above factors are most important. Using complex multivariate statistics to understand under what circumstances and to what extent differences in individual choice of life styles, socio-economic status, ethnic behaviour, national health provision and aggregate national resources lead to differences in health
- To support the development of a pluralistic scientific system with research excellence by working with national teams of senior researchers in eight different CIS states
- To create multi-level data sets bringing together aggregated health and environmental statistics with original survey data (18500 respondents) and qualitative sub-regional studies including Delphi-style feed back mechanisms
- To use these results to determine the causes of declining health
- To disseminate within each CIS country where research is conducted, through the WWW and other publicaly available resources a clear statement of the evidence, and policy implications in the relevant national languages. The results of the research would also be made available to EU policymakers and researchers at an international level
- To spell out the policy implications of these issues and to raise awaremess about health issues based upon informed research
Institute for Advanced Studies (IHS), Austria-Co-ordinators
- Prof. Christian Haerpfer
- Prof. Claire Wallace
- Dr. Alexander Chvorostov
- Sergei Nagaev
State Engineering University of Armenia, Armenia
- Dr. Edik Kyureghyan
The Ceter of Sociological and Political Studies, Belarus
- Prof. David Rotman
Centre for Social Studies, Georgia
- Tamara Berekashvili
- Marina Muskhelishvili
The International Centre for Sociological and Political Research, Kyrgyzstan
- Prof. Kussein Isaev
Center for Study of Public Opinion, Kazakhstan
- Dr. Baurzhan Zusupoiv
Opinia-Independent Service of Sociology and Information, Moldova
- Tudor Danii
- Mariana Mascautanu
The Center for Sociological Studies at the Moscow Lomonosov State University (CSS), Russian Federation
- Dr Sergei Tumanov
- Dr Alexander Gasparishvili,
- Dr Alexander Ionov
East Ukrainian Foundation for Social Research, Ukraine
- Prof. V.S. Bakirov
- Dr V.N. Nikolayevskiy
- Dr A. I. Navrotskiy
- Dr A. I. Kizilov
- Y.V. Akmurzin
Whilst the dramatic fall in life expectancy and its association with cardiovascular disease and with accidental death and poisoning are well known, what is less well known are the causes for this in a peace time situation in the former Soviet countries (Eberstadt 1999). Alcohol and tobacco consumption are important but given that consumption of these two have always been high in the Soviet Union, why the dramatic fall in health over the last ten years? Explanations put forward by Russian authors tend to emphasise political and economic problems such as widening socio-economic inequalities (people cannot afford good food and medicaments) rising unemployment or the deterioration of the health services (Breev 1998, Shevaldina 1997). Others point to high levels of pollution or the particular climactic conditions in some parts of Russia, especially the North (Morozova 1994, Potapov, Ustyushin and Shushkova 1994, Feshbach and Friendly 1992). Others point to psycho-social factors such as depression and lack of control over one's life and inability to have or to fulfil life plans (Shilova 1994, Bobak et al 1998). Yet others are more likely to emphasise lifestyle habits such as heavy use of alcohol and tobacco, diet and especially binge drinking (Cockerham 1999, Eberstadt 1999). However, recent studies have emphasized that it is the way these things are combined through lifestyle, culture and "habitus" which is important (Cockerham 1999). This would also reflect current thinking about health inequalities and society more generally (Wilkinson 1999). This study would put together a range of sources of information at an individual and aggregate level in order to better understand the relative importance of these different factors and provide a better explanation of health outcomes.
Most studies have concentrated upon one or two countries, and the main concern has been with Russia. This study, by contrast, would compare several different post-Soviet countries in order to understand how ethnic, cultural, religious and other variations may have different health outcomes. By creating a pooled, multi-national data set, it would be possible to compare between country as well as within country differences according to socio-economic, demographic (gender, age), regional and psycho-social factors as well as behaviour. The project will be innovative in creating survey data with a variety of measures of life-styles. Instead of assuming that drinking or smoking is in itself a sufficient indicator of life-style characteristics, multivariate statistics will be used to determine whether or not it is part of a syndrome of attributes which are associated with below or above average health in different population, gender or lifestyle groups.
Most studies have tried to explain the deterioration in health. Yet this has not affected everyone in the same way. Women are not affected to the same extent as men. Indeed, in some of the countries that we are considering, health may have actually improved (see Table 1 page 6) and some have attributed this to widening ethnic differences leading Southern countries to leave vodka in favour of wine (Gerner 1995). Increased national pride in those countries who sought liberation in contrast to the general sense of post-imperial defeat in countries like Russia may play some part in this (Field 1995). This study would consider differences between countries and their association with other political and social indicators. It would consider what prevents bad health as well as what causes it.
While studies of the prevalence of smoking and drinking have been conducted in the countries concerned, this research will be distinctive as it will draw on recent insights into the relationship between risk factors and health and on new developments in international health policy. There is now an extensive body of evidence linking changes in alcohol consumption in the countries of the former Soviet Union to the large fluctuations in mortality since the mid 1980s (Leon et al, 1997). The apparent relationship between changes in alcohol consumption and cardiovascular deaths is, however, much more problematic and some have claimed that alcohol can even be cardioprotective. The vast majority of research on the link between cardiovascular disease and alcohol had failed to take account of the pattern of drinking and that, in those few studies that had done so, there was a clearly increased risk of, frequently sudden, cardiac death among those who drank in binges (McKee et al, 1998, Chenet et al, 1998a, McKee & Britton, 1998, Bobak et al, 1999). Although the pattern of drinking is important in determining mortality, the social context of drinking also plays a part. To take the example of death from injury, it is not sufficient for someone to get drunk. They must do so in a setting in which they are exposed to hazardous circumstances and where protective mechanisms are absent. There is a need to understand these issues much better. Finally, it is apparent that there are major socio-economic and gender differences in deaths from alcohol-related causes in the former Soviet Union although the mechanisms underlying these differences are not yet fully elucidated (Chenet et al, 1998b). They are, however, likely to reflect a complex mixture of health related knowledge, attitudes and practices - in other words, lifestyle.
New research is now required that will go beyond the traditional questions about weekly consumption levels at a population level and which will examine pattern of drinking, the social context of drinking (including the extent and nature of problem drinking), and the social determinants of knowledge and attitudes as well as behaviour. Tobacco is also an important determinant of the high burden of disease in the former Soviet Union (Pudule et al, 1999, Shkolnikov et al, 1999). Research on tobacco consumption is especially timely because of the work by the World Health Organisation to develop a Framework Convention on tobacco Control (WHO, 1998). Action to reduce smoking will require information on knowledge and attitudes as well as on practices which form part of living conditions and lifestyles more generally.
A major theoretical innovation is bridging the divide between epidemiological and sociological research that draws inferences about individuals from data about national populations and social structure, as against clinical researchers and micro-economists, who focus on individual-level attributes such as drinking or income. The project will analyse individuals in social contexts using applications of social capital which has been shown to influence physical and emotional health (cf. Kennedy et al., 1998; Bobak 1998). Its conclusions will be more robust because it will use multivariate statistics to test the combined influence of micro-level, network and large-scale contexts as well as health beliefs and behaviour collected at an individual level. It would therefore be able to identify which of the many factors described here might be most important in explaining health outcomes and thus offer better scope for intervention.
The project compares 8 former Soviet countries with considerable variations in life-expectancy, culture, religion and lifestyle. It includes some more European, some more Asiatic countries and Christian as well as Muslim populations. While the evidence of poor and deteriorating health in the population of the Russian Federation with 250 million people is incontrovertible, aggregate evidence cannot answer the question: Why are some former Soviet citizens healthier than others?
Table 1 indicates that on average middle-aged Russian and Ukrainian males are almost twice as likely to die than in Armenia or Georgia. Furthermore, whatever the national mean, there are wide variations in longevity in every country.
The project would enable us to address the issue: why are there variations of this kind between countries and within countries between regions? What factors have lead health in some countries to improve since independence, whilst it has declined dramatically in others?
TABLE 1: CHANGES IN MALE MORTALITY, AGE 40-59 IN POST-COMMUNIST COUNTRIES (countries in project proposal) deaths per 1000 relevant population
1990 1996 Change Georgia 9.86 7.47 -2.39* Armenia 9.38 8.48 -0.90 Moldova 12.76 14.72 +1.96 Belarus 13.02 16.49 +3.47 Kyrgyzstan 12.32 16.12 +3.80 Russia 14.35 19.69 +5.34 Ukraine 13.10 19.11 +6.01 Kazakhstan 13.02 19.05 +6.03
*not fully comparable
Source: UNICEF, Regional Monitoring Reports No. 5 (Florence: International Children Development
Centre, 1998) Table 4.6 Data for Kazakhstan and Kyrgyzstan for 1995.
The project combines a number of different data sources for each country. In the first stage of the project, aggregate statistics will be collected at a national and regional level in order to calculate standardised mortality, infant mortality and other trends over time. In the first stage of the project, surveys will be conducted using standardised formats of 2000 individuals in each country, but 4000 in Russia and 2500 in Ukraine to reflect the size and diversity of those countries. The survey will enable the collection of information about living conditions (housing, health, education, income), about alcohol and tobacco use, about psycho-social attitudes including locus of control and optimism/pessimism, use of health services both formally and informally, social capital and religion along with a range of lifestyle variables which would enable the identification and differentiation of lifestyle groups.
These surveys would be produced in the first instance as national level reports which can be disseminated in the relevant countries in the relevant languages. These surveys would later be combined in Stage 3 in to a multi-national data file from which it would be possible to look at differences between countries in a comparative way and from which it would be possible to build a multi-level causal model to establish which factors are most important for health outcomes.
In Stage 2 of the project, a series of intensive regional studies would be carried out. These studies would take place in only three of the selected countries - the largest three exhibiting some of the worst health problems: Russia, Ukraine and Kazakhstan. Three regions would be chosen in each country based upon the analysis of the aggregate health statistics carried out in Stage 1: a region with good health, one with poor health and one with average health. In each of these sub-regions there would be in-depth interviews with 50 respondents about their health and lifestyle behaviour. Medical history and health checks would be provided for these respondents. There would also be 3 focus groups carried out in each region with targeted population groups such as men aged 40-59, women responsible for family health care and so on. The focus group profiles would be identified in the course of the project. In these regions there would also be expert interviews with health professionals at different levels of the health system including practitioners at the interface with the public. The results of the surveys and the statistical data would be discussed with these local level experts in order to take into account their responses. These regional studies would incorporate local information about the nature of the labour market, pollution levels and other environmental factor that could contribute to health outcomes. In addition, during Stage 2, there would be a special study of the Chernobyl region, replicating a study undertaken there in 1990 by the Belarusian partner. The Chernobyl study spans three of the countries under investigation: Ukraine, Belarus and Russia.
The data collection during Stages 1 and 2 of the project would be mainly the responsibility of the NIS partners but under the leadership and with the central co-ordination from Partner 1 in order to ensure quality comparability and consistency.
In Stage 3 of the project, the data from the regional studies as well as the statistical data would be brought together in multi-national data sets enabling comparisons between countries as well as within countries. At this stage, a series of reports would be produced with the help of the three Western European partners which would address in a comparative and comprehensive way the main objectives of the study. Hence, there would be one report on tobacco and alcohol consumption, one about the consequesnces of socio-economic changes (employment, unemployment, income differences), one report concentrating upon social capital and use of the health services, one report about psycho-social factors affecting health and one report about the consequences of culture and lifestyle for health in different settings. There would be a report by the co-ordinator using multi-level causal modelling in order to indicate which of the factors identified might be the most important in which context. The final outcome of the research programme will be eight national reports and a final comparative report. The results of the project would be presented at both national and international.
The project would use a variety of different sources of data in order to build as complete a picture as possible in the different countries and sub-regions. This is because of the dangers of using only one data source where information may be incomplete. Each source of data has both advantages and risks associated with it.
1. Collection of aggregate level statistics on mortality and infant mortality
These offer information in general about patterns of health in the region, although their method of collection may differ and they may not be very accurate. For example, there are different ways of recording death and these may vary by region or by country. Some data may be missing altogether. The project would combine and standardize aggregate level data to provide a general picture of health. Mortality statistics complement the data about life styles obtained from respondents who will have, at the time of interview, a greater or shorter life expectancy. They offer census type comprehensive information about causes of death, thus avoiding sampling error although still subject to other types of error, especially for trend analysis starting in Soviet times. If we conceive of mortality statistics as registering the end health state of all respondents over a period extending beyond the year 2060, then there are good a priori reasons to expect current behaviours of the living to produce future changes in mortality statistics whether for better or for worse. By interviewing the living, we are able to come to anticipate this "final" statistics hic et nunc.
2. Survey information about living conditions, lifestyles and health.
To fully answer the question of what lifestyle factors might be influencing mortality and morbidity we need individual level data. A sample of 4000 is envisaged in russia, 2500 in Ukraine and 2000 in each of the other countries. This would provide adequate representation of different population groups. Normally, there is a problem of finding reliable survey organisations in some of these countries. However, the project co-ordination team have had many years of experience of conducting surveys in post-communist countries including some of the research partners and has consulted a variety of other organisations carrying out international surveys, such as the United States Information Agency. The project co-ordinator has been developing and testing these links through a series of conferences, which took place between March 1998 and August 1999 bringing together relevant survey partners and questioning them about the feasibility of the research and the methods of research. In this way a team as reliable as possible has been developed covering a wide range of countries. However, in some countries, despite considerable investigation, it was decided that research partners could not be found who could adequately provide reliable results. This is why some countries have been excluded from the research.
The survey data would be collected using standardised random techniques (multi-stage clustered sampling) and face-to-face interviews so that a representative sample of the population can be drawn. The survey data would be analysed using the SPSS statistical software package, with which all teams are familiar. The database would be developed in each country using a standardised "mask" so that the same data with the same variable names is produced and these would then be pooled into a combined data set for comparative analysis. The consortium members have developed expertise since the early 1990s in doing this.
However, rigorously conducted survey information can only collect information according to pre-set questions and tells us only a certain amount about how lifestyle and culture mediate health. For this reason a qualitative part to the project has also been designed.
3. The qualitative in-depth interviews and focus groups
These would provide subjective details about lifestyles and health which would complement the survey. However, their numbers are necessarily smaller than those covered in the survey and this is why we have concentrated upon particular regions in particular countries. The usual problem with qualitative research is the fact that it is difficult to incorporate inductive insights (i.e. insights derived from the data collection and interpretation) in a systematic way and to compare qualitative results cross-nationally. This is why we have developed the "framework" analysis using WinMax software to enable collection, recording and analysis of these interviews in a standardised form. The in-depth interviews would be used also as a way of collecting medical data via health checks and medical histories using the assistance of the interface-level health practitioners interviewed in another part of the research.
4. Interviews with health professionals and collection of environmental data
There are too many examples in the post-Communist world of unrealistic policy prescriptions proposed by flown-in Western "experts" who fly out again without evaluating the consequences of their advice. We would seek to avoid such mistakes. In order to incorporate the views of the producers as well as the consumers of services, we are proposing interviews in the 10 selected sub-regions (3 sub-regions in Russia, Ukraine and Kazakhstan plus Chernobyl region) with people at different levels of the health system and to discuss with them the aggregate level and survey data. This incorporates a "Delphi" style element to the project and provides feedback from users of the project at an early stage (see Gibson 1998, Normand et al. 1998 for uses of the Delphi method in health contexts). This is also an element in the dissemination strategy. It is important to produce recommendations for policy which are relevant and sensitive to the real issues facing interface level practitioners. This would be combined with the collection of environmental data about the region including pollution and types of employment as relevant factors shaping health outcomes in interaction with other factors. The study would thus seek to forge links between scientists and health professionals at a local level.
5. Multi-method, multi-level analysis
Relying only upon aggregate level data or only upon survey data or only upon qualitative interviews can lead to erroneous conclusions. Most studies are married to a particular method which can provide only a partial and limited view of health problems. Given that health issues are tied to economic, lifestyle, environmental, gender and other factors in complex ways, such perspectives can only be partial. This project aims to link a variety of different data sources and variety of sources of expertise amongst its partners in order to provide a view of the issues from many different angles.
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- Social-economic Demographic and Health Situation in the Republic of Armenia (1999-2002). Working Paper (2003) (English) pdf
- Invitation to a Workshop Meeting and Agenda "Living Conditions and Health of the RA Population" Leaflet (2003) (English) pdf
- Haerpfer, C W (2002) Living Conditions and Well-Being within the CIS 2rd Annual LLH Project Conference, Vienna. (English) pdf