Final Report Summary - HITT-2008 (Health in times of transition: Trends in population health and health policies in CIS countries)
Executive summary:
'Health in Times of Transition: Trends in Population Health and Health Policies in CIS Countries' (in short - HITT-CIS) is a large-scale international research effort, primarily supported by the Seventh Framework Program of the European Union (FP7-Health). The project is dedicated to the detailed analysis of the state of health, health care and lifestyles in 9 countries of the former Soviet Union and embraces three main sub-regions of 'post-Soviet space': Eastern Europe (Belarus, Moldova, Russia, Ukraine), Caucasus (Armenia, Azerbaijan, Georgia) and Central Asia (Kazakhstan, Kyrgyzstan).
Many communities across the large post-soviet region suffer from social challenges such as alcoholism, high tobacco consumption and suboptimal nutrition, thus burdening health systems and compromising living standards. In this context, the EU-funded project is researching these issues to help support public health policymaking.
The project is studying long-term trends in population health, including key issues such as diet, nutrition, smoking and alcohol consumption as well as the related societal implications. It is looking at related public policies, examining access to healthcare, identifying strategies to overcome these challenges and supporting the development of more effective policies.
MAJOR THEMATIC AREAS OF THE STUDY:
The following major themes have been addressed by the study in the course of in-depth empirical, statistical and socio-economic research efforts in the countries of NIS region:
-Long-term trends in population health
-Access to health care (in particular, exemplified for diabetes patients)
-Investigation of the social and economic burden of disease
-Dynamics of living conditions, healthy and unhealthy lifestyles
-Diet and nutrition patterns of the population
-Consumption of alcohol and tobacco in NIS countries and relevant official policies
AVAILABILITY OF RESEARCH RESULTS:
Since the commencement of the LLH-HITT research program in 2000, consortium's experts have published hundreds of scientific articles in peer-reviewed journals and mass-media in English, Russian and other languages, prepared several monographs and written numerous chapters in academic and popular books. Most of these publications can be accessed from the project's web-site either as full-text, or links to the publication sources (see http://www.hitt-cis.net/reports/ online).
Project Context and Objectives:
This project HITT-CIS has been designed and implemented under an FP7 topic HEALTH-2007-3.5-1: Epidemiological investigations into long-term trends of population health as a consequence of socio-economic transitions, including life-style induced health problems.
OVERALL AIM AND SPECIFIC OBJECTIVES OF THE PROJECT:
The overall aim of this project was to contribute to the improvement of the health of the populations in the countries concerned, by producing policy-relevant evidence on population health and its socio-economic determinants and communicating these findings to key decision-makers.
DESCRIPTIVE OBJECTIVES:
Describing the health trends, burden of disease, risk factors and social costs of poor health in 9 CIS countries.
A) MEASURE THE BURDEN OF DISEASE AND ITS PROXIMAL AND DISTAL RISK FACTORS
By means of large household surveys (approximately 32,000 respondents in ten CIS countries), we quantify the burden of disease, assessed by self-reported health and validated measures of disease, as well as the prevalence of key risk factors and socio-economic factors. This allows us assessing the social, economic, and cultural patterning of exposure to risk and disease.
B) MEASURE THE COST OF POOR HEALTH
Recognising the low priority that health occupies on the political agenda, we use standard econometric techniques (and building on our earlier work in this region) to assess the economic implications of poor health, through lower labour force participation, lost productivity etc. as well as projections of future growth under various health trajectories.
EXPLANATORY AND ANALYTICAL OBJECTIVES:
Explaining the social, economic and cultural determinants of health-related behaviour of the population alongside with a detailed account of national and regional health care policies in 9 CIS countries
C) IDENTIFY (a) THE SOCIAL; ECONOMIC AND CULTURAL DETERMINANTS OF EXPOSURE TO RISK FACTORS AND (b) HEALTH SEEKING BEHAVIOUR AND ACCESS TO HEALTH CARE
This was done by using standard regression techniques with data from the surveys. This includes a detailed regional analysis in Ukraine, taking advantage of its marked internal diversity. It will also involve comparisons with our earlier surveys to track changes over time.
D) IDENTIFY THE CONSTRAINTS THAT INDIVIDUALS FACE IN MAKING HEALTHY CHOICES
Individuals are not entirely free agents in making decisions about their health. This objective was pursued through (a) the development and application of instruments for community diagnosis that will assess the extent to which communities facilitate or obstruct smoking and hazardous drinking and (b) focus groups (as well as survey data) to assess the knowledge, attitudes and practices in relation to diet.
E) UNDERSTAND THE POLICY ENVIRONMENT IN WHICH PEOPLE MAKE CHOICES
Assessment of official policies on alcohol, tobacco, and nutrition
F) UNDERSTAND THE ECONOMIC FORCES SHAPING HEALTH DECISIONS
In the target countries, a detailed analysis of the tobacco and alcohol sectors has been undertaken, to quantify trends in sales and production, to understand the nature of the market and the positions of key actors, and to identify levers for and barriers to change.
G) IDENTIFY THE BARRIERS FACED IN ACCESSING EFFECTIVE CARE
We have collected and analysed data on people's subjective experiences with health care systems, such as accessibility and quality of the services in order to understand the efficiency of the health system,; using rapid appraisal (including policy analysis, interviews and focus groups with patients and providers), we have identified major barriers to obtaining access to high quality, integrated care.
POLICY-RELATED; DISSEMINATION AND INFORMATION OBJECTIVES:
Facilitation a dialogue with the key stakeholders in the region to improve the situation. Wider regional and international dissemination of project results under a motto Leaving a lasting legacy
H) FOR SELECTED POLICY OPTIONS, IDENTIFY KEY STAKEHOLDERS, THEIR INTER-RELATIONSHIPS, THEIR POSITIONS AND INFLUENCE
I) ENSURE EFFECTIVE DISSEMINATION TO KEY STAKEHOLDERS WITHIN COUNTRIES AND IN THE INTERNATIONAL COMMUNITY
Special procedures for the stakeholder analyses (mainly sociological methods in soft qualitative research) have been used to identify opportunities for change. The outcomes are publicized and discussed in a series of specialized workshops and thematic Policy Briefs.
Building on the team's existing links and strong record of effective dissemination, ensure that the evidence obtained is heard by those who can make a difference
CAPACITY BUILDING OBJECTIVES:
Train the researchers and make project data into a research tool for further studies
J) BUILD CAPACITY FOR QUALITATIVE AND POLICY RESEARCH IN THE COUNTRIES BEING STUDIED
Although the project partners in the CIS have extensive experience undertaking quantitative surveys, skills in qualitative and policy analysis are limited. This project has had a strong training element (a summer school, several instructive training workshops).
K) TO CREATE MULTI - LEVEL DATA SETS FOR OTHER RESEARCHERS
When combined with data from the earlier surveys (32,000 respondents from the 2009 survey in 8 countries and 18,400 respondents from the 2001 survey in 10 countries) our large-scale household survey provide an invaluable resource for those seeking to understand this region.
Project Results:
EMPIRICAL BASE OF THE STUDY:
The project's empirical program included a wide palette of quantitative, qualitative and combined research methods that allowed collecting unique but accurate and verifiable data for the in-depth research on the above themes. The study has applied in particular the following methods:
-secondary critical analysis of available statistical data sets on health, health care, demography and social development and infrastructures in target countries (national and international statistics, governmental reports, experts' data bases);
-two large-scale household surveys in every participating country in 2001 and 2010 (multistage proportional representative samples, random routes, 18 thousand respondents per wave, the sample included 1,800 to 4,000 respondents per country);
-structural observations on communal environment (more than 300 routes and the related community profiles in 9 countries);
-rapid appraisal of the access to health care exemplified for diabetes patients (a complex multi-method empirical effort in five countries);
-series of focus-groups on healthy/unhealthy lifestyles and health-care experiences (more than 40 sessions in urban and rural locations among young and adult men and women in seven countries);
-teenagers' essays on their perception of health, health-care and healthy lifestyles (300 pieces written by high-school students in five countries);
-content-analysis of mass-media revealing the structure of coverage of health-related themes (printed periodicals in four countries, largest national newspapers, coverage of 2010);
-special studies on alcohol and tobacco policies and consumption (stakeholder analysis, analysis of cigarette packaging etc.)
ACCESS TO HEALTH SERVICES AND MEDICINES IN NIS COUNTRIES, PRACTICES OF HEALTH CARE
HEALTH CARE REFORMS IN THE FORMER SOVIET UNION
OBJECTIVE: To assess accessibility and affordability of health care in 8 countries of the former Soviet Union.
METHODS: Using data from the HITT study countries, descriptive and multivariate regression analyses were used on health services.
RESULTS: 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-pockets payments, with median amounts varying from 13 USD 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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22092004
PUBLIC SATISFACTION AS A MEASURE OF HEALTH SYSTEM PERFORMANCE: A STUDY OF NINE COUNTRIES IN THE FORMER SOVIET UNION
BACKGROUND: Measurement of health system performance increasingly includes the views of healthcare users, yet little research has focused on general population satisfaction with health systems.
AIM: To examine public satisfaction with health systems in the former Soviet Union (fSU).
METHODS: Data from the LLH (2001) and HITT (2010) study countries were analysed. The prevalence of health system satisfaction in each country was compared for 2001 and 2010. Patterns of satisfaction were further examined by comparing satisfaction with the health system and other parts of the public sector, and the views of health care users and non-users. Potential determinants of population satisfaction were explored using logistic regression.
RESULTS: For all countries combined, the level of satisfaction with health systems increased from 19.4% in 2001 to 40.6% in 2010, but varied considerably by country. Changes in satisfaction with the health system were similar to changes with the public sector, and non-users of healthcare were slightly more likely to report satisfaction than users. Characteristics associated with higher satisfaction include younger age, lower education, higher economic status, rural residency, better health status, and higher levels of political trust. Our results suggest that satisfaction can provide useful insight into public opinion on health system performance, particularly when used in conjunction with other subjective measures of satisfaction with government performance.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23545269
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. In previous work we described patterns of irregular hypertension treatment in eight countries of the former Soviet Union in 2001.
AIM: To describe changes in the use of hypertension treatment in the HITT countries between 2001 and 2010.
METHODS: Using household survey data from the LLH (2001) and HITT (2010) study countries, we use descriptive analysis to record changes in rates of irregular treatment use (less than daily) between 2001 and 2010;and multivariate logistic regression 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%), 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 former Soviet Union and requires an urgent response.
Web link: http://jech.bmj.com/content/early/2012/03/23/jech-2011-200645.abstract
PREVALENCE AND FACTORS WITH THE USE OF ALTERNATIVE (FOLK) MEDICINE PRACTITIONERS IN 8 COUNTRIES OF THE FORMER SOVIET UNION
BACKGROUND: Research suggests that since the collapse of the Soviet Union there has been a sharp growth in the use of complementary and alternative medicine (CAM) in some former Soviet countries. However, as yet, comparatively little is known about the use of CAM in the countries throughout this region. Against this background, the aim of the current study was to determine the prevalence of using alternative (folk) medicine practitioners in eight countries of the former Soviet Union (fSU) and to examine factors associated with their use.
METHODS: Data from the LLH (2001) and HITT (2010) were analysed. Respondents were asked about how they treated 10 symptoms, with options including the use of alternative (folk) medicine practitioners. Multivariate logistic regression analysis was used to determine the factors associated with the treatment of differing symptoms by such practitioners in these countries.
RESULTS: The prevalence of using an alternative (folk) medicine practitioner for symptom treatment varied widely between countries, ranging from 3.5% in Armenia to 25.0% in Kyrgyzstan. For nearly every symptom, respondents living in rural locations were more likely to use an alternative (folk) medicine practitioner than urban residents. Greater wealth was also associated with using these practitioners, while distrust of doctors played a role in the treatment of some symptoms.
CONCLUSIONS: The widespread use of alternative (folk) medicine practitioners in some fSU countries and the growth of this form of health care provision in the post-Soviet period in conditions of variable licensing and regulation, highlights the urgent need for more research on this phenomenon and its potential effects on population health in the countries in this region.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23578173?dopt=Abstract
MULTI - METHOD SYSTEM APPRAISAL OF DIABETES CARE IN THE FORMER SOVIET UNION
OBJECTIVE: To use diabetes as a tracer for health system diagnoses, health outcomes, integration of care, and responsiveness. To explore the perspectives of patients, providers and policy makers on complex systems and interventions in diabetes management, encompassing multiple levels of care, within and outside the health system. To map patient pathways in order to assess the appropriateness, affordability and responsiveness of care and to compare them with policy.
METHODS: The study was conducted in Armenia, Belarus, the Republic of Moldova, the Russian Federation and in Ukraine. It involved a documentary review of legislation, secondary analysis or synthesis of routine data on diabetes and its complications, accompanied by in-depth interviews and focus group discussions, triangulating the perspectives of patients, providers and policy makers.
RESULTS: Specialists dominate diabetes care despite on-going efforts to increase primary diabetes care. The study found poor coordination between different levels of care. Patients emphasise barriers to self-management: they were often not provided with adequate information to effectively manage their disease. Access to drugs and consumables was dependent on patients' time and ability to pay. Despite specialist training, diabetes nurses had a very limited role in diabetes treatment and control. There were gaps in data collection and the registration of diabetes patients, which hampered planning and resource allocation.
CONCLUSIONS: Diabetes management seems to have improved since the break-up of the Soviet Union. Nevertheless, if health systems are to become more responsive and produce better health outcomes, significant improvements will have to be made to accessibility, affordability, acceptability of health systems in the five countries under analysis.
ECONOMICS, DEMOGRAPHY AND HEALTH
THE EFFECT ON HEALTH ON LABOUR SUPPLY IN NINE FORMER SOVIET UNION COUNTRIES
BACKGROUND: There has been very little examination of the impact of poor health on economic productivity in countries in the former Soviet Union.
AIM: To examine the consequences of ill health on labour supply for the nine HITT countries.
MATHODS: We control for a wide range of individual, household, and community factors, using both standard regression techniques and instrumental variable estimation to address potential endogeneity.
RESULTS: We find in our baseline ordinary least squares specification that poor health is associated with a decrease in the probability of working of about 13 %. Controlling for community-level unobserved variables slightly increases the magnitude of this effect, to about 14 %. Controlling for endogeneity with the instrumental variable approach further supports this finding, with the magnitude of the effect ranging from 12 to 35 %.
CONCLUSIONS: Our findings confirm the cost that the still considerable adult health burden in the FSU is imposing on its population, not only in terms of the disease burden itself, but also in terms of individuals' labour market participation, as well as potentially in terms of increased poverty risk. Other things being equal, this would increase the expected ' return on investment' to be had from interventions aimed at improving health in this region.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23292272
REGIONAL VARIATION IN MORTALITY IN UKRAINE
OBJECTIVES: We set out to identify the contribution of various causes of death to regional differences in life expectancy in Ukraine.
METHODS: Mortality data by oblast (province) were obtained from the State Statistical Committee of Ukraine. The contribution of various causes of death to differences in life expectancy between East, West and South Ukraine was estimated using decomposition.
RESULTS: In 2008, life expectancy for men in South (61.8 years) and East Ukraine (61.2 years) was lower than for men in West Ukraine (64.0 years). A similar pattern was observed among women. This was mostly due to deaths from infectious disease and external causes among young adults, and cardio- and cerebro-vascular deaths among older adults. Deaths from TB among young adults contribute most to differences in life expectancy.
CONCLUSIONS: Deaths due to infectious disease, especially TB, play an important role in the gap in life expectancy between regions in Ukraine. These deaths are entirely preventable-further research is needed to identify what has 'protected' individuals in Western Ukraine from the burden of deaths experienced by their Southern and Eastern counterparts.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23525667
ALCOHOL USE AND POLICIES IN NIS COUNTRIES
PATTERNS OF PUBLIC SUPPORT FOR PRICE INCREASES ON ALCOHOL IN THE FORMER SOVIET UNION
AIM: To measure levels of public support for price increases on beer and spirits in nine FSU countries and to examine the characteristics influencing such support.
MATHODS: Cross-sectional surveys were conducted in 2010 with 18000 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.
CONCLUSIONS: 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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22553046
DEMOGRAPHY, TRADE, HEALTH SYSTEMS AND HEALTH
BACKGROUND: This report reviews data for objectives related to: (i) life expectancies; (ii) alcohol and tobacco consumption and trade; diet and nutrition. A fourth objective describing health systems is addressed in separately in the Health Systems in Transition (HiT) profiles produced by the London School of Hygiene and Tropical Medicine.
METHODS: All 15 countries of the former Soviet Union are included in this report. The time period covered in this report is from 1990 to 2008 (or the nearest latest available data). Government and United Nations (UN) databases were the primary data sources used as they provide annual data. Life expectancy data were collected from the World Health Organisation's (WHO) European Health for All Database. Alcohol consumption data were collected from the Food and Agricultural Organisation (FAO) statistics database and the WHO database. Tobacco data were collected from the United States Department for Agriculture, Foreign Agricultural Services database, the ERC Group, and the WHO database.
FINDINGS: Life expectancy at birth for men, women and all has increased since the dramatic decline in the early/mid 1990's. However, 5 countries still had lower life-expectancy in 2008 than in 1990. Importantly these countries included the most populous countries of Russia and Ukraine. As a result, life expectancy at birth overall still remains 1.85 years less than in 1990 for the region as a whole.
ALCOHOL AND TOBACCO MARKET IN RUSSIA
BACKGROUND: This report reviews data on the alcohol and tobacco market in Russia which will be used to support additional deliverables from the HITT project, particularly the stakeholder analysis of alcohol and tobacco markets and policies in Russia and the paper on the price elasticity of demand for alcohol in Russia.
METHODS: The time period covered in this report is from 1990 to 2007/2008. Alcohol consumption data were collected from the Food and Agricultural Organisation (FAO) statistics database and the World Health Organisation European Health for All Database. Tobacco data were collected from the United States Department for Agriculture, Foreign Agricultural Services database, the ERC Group, and the WHO database.
FINDINGS: There has been a dramatic increase in alcohol supply in Russia since the early 1990's. The vast majority of this increase is from domestic production. Alcohol production has increased 171% from 4,952,000 tonnes in 1992 to 13,425,000 tonnes in 2007; while imports have increased 125% from 480,000 tonnes to 1,081,000 tonnes; and exports have increased 248% from 119,000 tonnes to 414,000 tonnes.
ESTIMATING THE CAUSAL EFFECT OF ALCOHOL CONSUMPTION ON WELL-BEING FOR A CROSS-SECTION OF NINE FORMER SOVIET UNION COUNTRIES
BACKGROUND: While the adverse health and economic consequences attributable to alcohol consumption are widely acknowledged, its impact on psychological wellbeing is less well understood.
AIM: To examine the influence of alcohol use on psychological wellbeing while addressing the endogenous relationship between alcohol consumption and individual mental well-being using an instrumental variable (IV) approach.
METHODS: Using HITT data from the nine countries, we employed an instrumental variable approach to identify any causal effects of alcohol consumption on mental well-being. The availability of 24-hour alcohol sales outlets in the neighbourhood of the individuals is used as an instrument, based on theoretical reasoning and statistical testing of its validity.
RESULTS: We find that increased alcohol consumption decreases well-being and that ignoring endogeneity leads to underestimation of this effect. This finding adds a further and previously under-appreciated dimension to the expected benefits that could be achieved with more effective alcohol policy in this region.
Web link: http://www.sciencedirect.com/science/article/pii/S0277953613002372
TOBACCO USE AND POLICIES
CHANGES IN SMOKING PREVALENCE IN EIGHT COUNTRIES OF THE FORMER SOVIET UNION BETWEEN 2001 AND 2010.
OBJECTIVES: To present new data on smoking prevalence in eight countries; analyse prevalence changes between 2001 and 2010; examine trend variance by age, location, education level, and household economic status.
METHODS: Data were analysed from the LLH (2001) and HITT (2010) studies, with smoking prevalence was compared with a related 2001 study for the different countries and population sub-groups, and the adjusted prevalence rate ratios of smoking also calculated.
RESULTS: All-age 2010 male smoking prevalence ranged from 39% (Moldova) to 59% (Armenia), and female prevalence 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.
CONCLUSIONS: Smoking prevalence appears to have stabilised and may be declining in younger groups, but remains extremely high among men, especially those in lower socio-economic groups.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22594739
ANALYZING COMPLIANCE OF CIGARETTE PACKAGING WITH THE FCTC AND NATIONAL LEGISLATION IN EIGHT FORMER SOVIET COUNTRIES
AIM: To analyze compliance of cigarette packets with the Framework Convention on Tobacco Control (FCTC) and national legislation and the policy actions that are required in 8 former Soviet Union countries.
METHODS: We obtained cigarette packets of each of the ten most smoked cigarette brands in each of Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine. The packets were then analysed using a standardized data collection instrument. The analysis included the placing, size and content of health warnings labels and deceptive labels (e.g. 'Lights'). Findings were assessed for compliance with the FCTC and national legislation.
RESULTS: Health warnings were on all packets from all countries and met the FCTC minimum recommendations on size and position except Azerbaijan and Georgia. All countries used a variety of warnings except Azerbaijan. No country had pictorial health warnings, despite them being mandatory in Georgia and Moldova.
CONCLUSIONS: Despite progress in the use of health warning messages, gaps still remain - particularly with the use of deceptive labels. Stronger surveillance and enforcement mechanisms are required to improve compliance with the FCTC and national legislation.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23047889
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, 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 nine countries of the former Soviet Union and to examine the psychosocial factors associated with nicotine dependence.
METHODS: HITT data were analysed. The main outcome of interest was nicotine dependence using the Fagerstrom 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 organisation, 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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22529221
SMOKING CESSATION AND DESIRE TO STOP SMOKING IN NINE COUNTRIES OF THE FORMER SOVIET UNION
INTRODUCTION: Smoking rates and corresponding levels of premature mortality from smoking-related diseases in the former Soviet Union (fSU) are among the highest in the world. To reduce this health burden greater focus on smoking cessation is needed, but little is currently known about rates and characteristics of cessation in the fSU.
METHODS: HITT data were analysed to describe patterns of desire and action taken to stop smoking, quit ratios (former ever-smokers as a % of ever-smokers, with no specified recall period), and help used to stop smoking. Multivariate logistic regression was used to analyse characteristics associated with smoking cessation and desire to stop smoking.
RESULTS: Quit ratios varied from 10.5% in Azerbaijan to 37.6% in Belarus. Desire to stop smoking was generally high (67.2%) while the proportion that had taken action to try to stop was slightly lower (64.9%). The use of help to quit was extremely low (12.6%). Characteristics associated with cessation included being female, over 60, with higher education, poorer health, lower alcohol dependency, higher knowledge of tobacco's health effects and support for tobacco control.
CONCLUSIONS: Quit ratios are low in the fSU but there is widespread desire to stop smoking. Stronger tobacco control and cessation support are urgently required to reduce smoking prevalence and associated premature mortality.
Web link: http://ntr.oxfordjournals.org/content/early/2013/04/02/ntr.ntt034.abstract
KNOWLEDGE OF THE HEALTH IMPACTS OF SMOKING AND PUBLIC ATTITUDES TOWARDS TOBACCO CONTROL IN THE FORMER SOVIET UNION
AIM: 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: HITT data were analysed on respondents' 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.
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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22705600
DIET AND OBESITY
CHANGING PATTERNS OF FRUIT AND VEGETABLE INTAKE IN COUNTRIES OF THE FORMER SOVIET UNION
OBJECTIVE: To assess how the frequency of low fruit and vegetable consumption has changed in the countries of the former Soviet Union (fSU) between 2001 and 2010 and to identify factors associated with their consumption.
DESIGN: Cross-sectional surveys. A standard questionnaire was administered at both time points to examine fruit and vegetable consumption frequency. Logistical regression analysis was used to examine the relationship between demographic, socioeconomic and health behavioral variables and low fruit and vegetable consumption in 2010.
SETTING: Nationally representative population samples from Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine.
Subjects: Adults aged 18 years and older.
RESULTS: Between 2001 and 2010 notable changes occurred in fruit and vegetable consumption in many countries resulting in a slight overall deterioration in diet. By 2010 in 6 countries around 40% of the population was eating fruit once a week or less often, while for vegetables the corresponding figure was in excess of 20% in every country except Azerbaijan.
CONCLUSIONS: International dietary guidelines emphasise the importance of fruit and vegetable consumption. The scale of inadequate consumption of these food groups among much of the population in many fSU countries and its link to socioeconomic disadvantage are deeply worrying. This highlights the urgent need for a greater focus to be placed on population nutrition policies to avoid nutrition-related diseases in the fSU countries.
Web link: http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8926006
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.
OBJECTIVE: 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; 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 (BMI greater than or equal 30 kg/m2) were analyzed using multi-level random intercept logistic regression models.
RESULTS: 13% of males and 18% 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.
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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22645239
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: Data on household piped water from the LLH and HITT studies were compared 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).
CONCLUSIONS: Despite encouraging increases in access to piped water, there remain significant gaps for rural and poorer households.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22267289
ISSUES OF PUBLIC MENTAL HEALTH IN NIS REGION (psychological distress, social capital and other aspects)
CHANGES IN THE LEVELS OF PSYCHOLOGICAL DISTRESS IN EIGHT COUNTRIES OF THE FORMER SOVIET UNION.
BACKGROUND: The collapse of the Soviet Union created considerable stress for many of its inhabitants and, even now, post Soviet societies continue to be characterized by many established risk-factors for poor mental health. The objectives of this study were to compare levels of psychological distress in 2001 and 2010 in eight countries of the former Soviet Union and to explore how these changes vary for different population groups.
METHODS: Data from the LLH (2010) and HITT (2010) were analyzed. Psychological distress was measured using a 12 item instrument, with scores of 10-12 used to indicate high psychological distress. Changes in the levels of psychological distress between 2001 and 2010 were described by country, gender and age group; and then for sub-populations of gender, age group, educational level, disability status, personal support and household economic status using adjusted prevalence rate ratios.
RESULTS: Levels of high psychological distress decreased from 8.7% in 2001 to 4.9% in 2010 (P less than 0.01) for the whole study region (4.5% to 2.8% men; 12.0% to 6.5% for women). All the study countries recorded decreases in high psychological distress.
CONCLUSIONS: The study shows decreases in levels of high psychological distress in the former Soviet Union, but that decreases were less for socially and economically marginalised populations. Despite decreases of psychological distress among women, they continue to bear a significantly higher burden than men. The findings highlight the continued need to break the cycle of poverty, social exclusion and poor mental health in the region.
Web link: http://www.emeraldinsight.com/journals.htm?articleid=17053906
THE COMORBIDITY OF HYPERTENSION AND PSYCHOLOGICAL DISTRESS: A STUDY OF NINE COUNTRIES IN THE FORMER SOVIET UNION
BACKGROUND: Mental health problems in those with physical ailments are often overlooked, especially in the former Soviet Union (fSU) where this comorbidity has received little attention. Our study examines the comorbidity of psychological distress and hypertension in the fSU.
METHODS: Data from the LLH (2001) and HITT (2010) studies nationally representative household survey data from Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2001 and 2010 were analysed to compare the levels of psychological distress in people with and without self-reported hypertension.
RESULTS: There were significantly higher levels of psychological distress among hypertensive respondents (9.9%) than in the general population (4.9%), and a significant association between the two conditions [odds ratio (OR) = 2.27 (1.91; 2.70)].
CONCLUSIONS: There is a significant association between psychological distress and hypertension in the region.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23480878
SOCIAL CAPITAL AND SELF-REPORTED GENERAL AND MENTAL HEALTH IN NINE FORMER SOVIET UNION COUNTRIES
BACKGROUND: Social capital has been proposed as a potentially important contributor to health, yet most of the existing research tends to ignore the challenge of assessing causality in this relationship.
METHODS: We analysed the HITT study data and use various instrumental variable estimation techniques.
FINDINGS: Our results confirm that there appears to be a causal association running from several dimensions of individual social capital to general and mental health. Individual trust appears to be more strongly related to general health, while social isolation- to mental health. In addition, social support and trust seem to be more important determinants of health than the social capital dimensions that facilitate solidarity and collective action. Our findings are remarkably robust to a range of different specifications, including the use of instrumental variables.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23506911
SOCIAL IMPACTS ON HEALTH: THE INTERPLAY OF LIFESTYLES AND SOCIO-ECONOMIC FACTORS
Several components of the empirical program of the HITT-CIS study were dedicated to in-depth qualitative research of the perceptions and practice of healthy and unhealthy lifestyles.
SOCIO-ECONOMIC INFLUENCES ON HEALTH IN THE COMMONWEALTH OF INDEPENDENT STATES
Despite the evidence that poor health lifestyles are a major contributor to life expectancy in the studied post-soviet countries (as in other developed economies) the major factors explain inequalities in health are social and economic ones. Indeed after controlling for demographic, social and economic variables health lifestyle variables (alcoholic consumption and eating a healthy diet) make little contribution to explaining the variance in self-reported health.
FROM PROJECT'S POLICY BRIEF ON SOCIAL AND ECONOMIC IMPACTS OF POOR HEALTH IN THE FORMER SOVIET UNION
Health outcomes in adults living in the former Soviet Union, particularly males, are often well below those expected given their level of economic development. In Russia, life expectancy is much lower than that of countries with a similar GDP, and the likelihood of dying prematurely, between the ages of 15 and 60, is considerably higher. Health is a vital national investment: inequalities in health are estimated to result in a 1.4% loss of GDP every year.
KEY FINDINGS
POORER HEALTH MEANS A LOWER CHANCE OF WORKING
Self-reporting poor health is associated with about a 13-15 % lower probability of working in the countries studied. This is a particularly worrying finding as a high proportion of the population reported having poor health. Almost half of women in Georgia, and over 1 in 4 in Moldova and Ukraine reported their health to be poor or very poor. In almost every country, more than 1 in 10 men reported poor or very poor health.
RELATIONSHIP BETWEEN POVERTY AND ILL HEALTH
People who had to limit their consumption of basic food in the last 12 months were 8% more likely to report poor health. Those who had to limit their access to medical care were 11% more likely to report poor health; high out of pocket payments for health care in the region are likely to push families into poverty when faced with a chronic illness.
RELATIONSHIP BETWEEN POOR HEALTH AND PSYCHOLOGICAL DISTRESS
People with hypertension were twice as likely to suffer with psychological distress. Being unable to access medical drugs was strongly associated with psychological distress in people with hypertension. The results suggest that people who are prescribed unobtainable or unaffordable treatment to control hypertension may experience anxiety and distress. This can have severe psychosocial impacts on the countries in this region.
POLICY RECOMMENDATIONS
Poor health in the former Soviet Union has negative impacts on the labour supply as ill people have a lower likelihood of working. This research also finds a relationship between ill health and poverty, and psychosocial measures of distress. These social and economic impacts of poor health need to be addressed.
INVESTING IN HEALTH
Health is a vital national investment, and governments must raise health expenditure to address the national economic impacts of poor health. Revenue can be raised by raising taxes for high-income groups, introducing new taxes on health-harming products such as tobacco and alcohol, improving collection of existing taxes, or shifting public funding from other sectors to place higher priority on health.
IMPROVE AFFORDABILITY OF PHARMACEUTICALS
The high price of pharmaceuticals in these countries can push people with ill health into poverty, and can results in psychosocial problems such as heightened levels of psychological distress. Access to drugs can be improved by regulating medicine prices, regulating mark-ups in the supply chain, training providers in rational prescribing, and promoting generic drugs to providers and the public.
REDUCE INFORMAL PAYMENTS
To protect those with poor health from slipping into poverty, the financial barriers to accessing care must be removed. Informal payments are a leading financial barrier, which can be addressed by clearer communication with the public about the price of services, and raising official salaries of health care workers. To increase efficiency, payment should be shifted from salaries to performance-related pay, which is linked to quality of work.
FOCUS GROUP DISCUSSIONS ON HEALTHY AND UNHEALTHY LIFESTYLES (QUALITATIVE SUB-STUDY)
RESEARCH OBJECTIVE: This sub-study was designed and implemented to complement the findings from the large-scale survey and structured observations by providing a more nuanced understanding of how people take responsibility for their health in their daily lives. It was also designed to enable us comparing health lifestyles across countries and to compare the findings with those from research carried out in Belarus, Russia and Ukraine in 2002 as part of the Living Conditions, lifestyles and Health Research (LLH) (see http://www.llh.at online). The healthy lifestyles qualitative research was designed to provide information on how people understand health and illness in their daily lives, their construction of what it is to be healthy and what it means to be ill. It enables us to understand, how much control people think they have over health and illness and what they do to remain healthy.
DESIGN OF THE RESEARCH: The research was qualitative and involved focus group discussions with a purposive sample of informants in each of the countries. An agenda, agreed by the team carrying out the qualitative fieldwork, was used to stimulate discussion around the key topics. It was designed to get informants to talk about their understanding of what it is to be healthy, what they think they can do to look after their health, who is responsible for their health and their experiences of using the health services. The aide memoire was informed by the findings from the qualitative research we had done in 2002. It was drafted in English and translated by the teams in each country into the local language.
SAMPLING OF INFORMANTS: The sample was purposive. Two communities were selected in each country from amongst those included in the HITT survey where structured observations had also been carried out. One was in a poor rural area and one in a more affluent urban area in the capital city. This was designed to provide a contrast between those likely to have the poorest opportunity for looking after their health and those likely to have the greatest opportunity to do so.
ETHICS
Ethical approval for the research was given by the London School of Hygiene and Tropical Medicine that required that ethical approval was obtained by the approved means in each of the participating countries. All participants in FGDs were asked to give verbal consent to participation and advised that they could leave at any time if they so wished. Participants were assured of anonymity and asked to respect the confidentiality of what was discussed.
TRAINING: The facilitators of the FGDs were experienced researchers that had been specifically trained specifically trained for this project. The aim of the training was to ensure that there was a shared understanding of the aims of the research and how it was to be carried out. This was important to ensure that comparable data was collected across the countries and same topics covered.
FOCUS GROUP DISCUSSIONS: The FGDs were held in the preferred language of the participants. They were facilitated by a trained researcher and notes were taken by a research assistant. The FGDs were also recoded. The agenda was used an aide memoire with the facilitators encouraging discussion and ensuring that key points were followed up. Following the FGDs the notes and recording were used to draw up a full transcript in the local language and an edited version in English.
QUALITY ASSURANCE: There were three elements of quality assurance. In each country two FGDs were observed by an independent senior researcher that had participated in the development of the qualitative research. The transcripts in Russian/the local language were independently reviewed and in most countries two FGDs were videoed.
CONTENT-ANALYSIS OF PRINTED MASS-MEDIA (NEWSPAPERS)
RESEARCH OBJECTIVE: finding out the quantity of publications on the issues related with formation of healthy attitudes and healthy lifestyle among the population in the newspaper with the largest circulation.
SUBJECT OF RESEARCH: a leading daily newspaper having the largest circulation in every country under study -project-participant country (six newspapers in total), the region where the newspaper is distributed is the whole country.
GEOGRAPHY OF THE STUDY: Belarus, Georgia, Kazakhstan, Moldova, Russia, Ukraine.
UNIT OF ANALYSIS: in this study - an article, considering the text of the publication in whole.
CONCLUSIONS:
The outcomes of content-analysis of publications covering the issues of healthy lifestyle and health and the problems related with them by the most popular periodicals of Belarus, Georgia, Kazakhstan, Moldova, Russia, Ukraine enable us to make the following main conclusions:
The largest number of publications on the topic of healthy lifestyle and health are recorded in the periodicals 'Segodnya' (Ukraine) and 'SB. Belarus Segodnya' (Belarus) - more than a half of issues of these newspapers had two or more materials on the indicated topic during the period under study. The least number of publications is counted in the Georgian periodical 'Rezonansi', i.e. less than a half copies of this newspaper had materials about healthy lifestyle and health.
The materials about healthcare services prevail among all the publications in the studied periodicals. Little attention is paid to the topics of sexual behaviour and regular visits to the doctors.
Materials of informational character prevail in the analyzed newspapers, and their authors are mainly journalists.
ESSAYS OF HIGH-SCHOOL STUDENT ON HEALTHY AND UNHEALTHY LIFESTYLES (ROTMAN to check)
This empirical sub-study was implemented in Belarus, Georgia, Moldova, Russia and Ukraine during the spring months 2012. Altogether, 376 essays have been written by school-age teenagers (14-18 years) at their classrooms during one lesson (45 minutes). The suggested title of free-shaped essays was defined 'Health and healthy lifestyle'. A sample of 159 of most informative essays was selected for in-depth analysis under the guidance of prof/ David Rotman (BSU-SIMST).
The structural content-analysis of these essays has revealed the following facts and attitudes of respondents:
VALUE OF HEALTH
Virtually all the young people, who participated in the study, believe that health is a necessary condition for a happy, successful life both at present, and in future.
-the majority of the young people are adherent to healthy lifestyle, understand that success in life depends, amongst other factors, on person's health and perceive health as the one of the main value of life.
-the students are well informed about the matters that promote health, and what ruins them. Only very few essays present opinions that keeping healthy is not so important, is unpopular among teenagers and adults.
DEFINITIONS OF HEALTH, HEALTHY LIFESTYLE
-Defining what, actually, health is, students give some-times naïve, sometimes incomplete definitions, often quoting proverbs and popular sayings.
-None of these children's definitions given in their essays contradict the definition of health given by the World Health Organisation.
ATTITUDE TO ONE'S HEALTH, MODELS OF BEHAVIOUR
-The respondents are clearly aware, that people should care about their health by themselves. Many essays note that quite a lot of people do not care about their health nowadays, or using their slang: 'a lot of people do not give a damn to their health'.
-Based on the factual canvas of the essays, one can reconstruct sad and grey-coloured picture of every-day lives of teenagers (their 'uninteresting', passive and unhealthy lifestyle). E.g. 'Most often we are pushed to bad actions by our friends ' or 'It is hard to overcome herd instinct, I know it from my own experience'. However, in their meta-narrative, the respondents try presenting information about themselves more positively. In spite of the popular references to disadvantageous social environments, the respondents tend blaming themselves for their own irresponsibility and laziness.
-Judging by the essay texts, virtually all the students are very well informed about the ways how to keep healthy, about what is right, what is good or what is bad. The overwhelming majority remark, that they adhere to or try to adhere to healthy lifestyle, they do not drink, do not smoke, try to have a healthy diet and do sports. Along with that, the same senior pupils write in their essays, that 'everyone around drinks, smokes and does not care about his health at all'. In fact, this narration is constructed by the principle 'everyone around, but not me', along with that it is possible to see a crowd of smoking teenagers during a break behind school). Thus, one can conclude that teenagers' presentations about their adherence to healthy life-style principles are a little overestimated.
-Quite often schoolchildren express stereotypes and clichés widespread in the society and in mass consciousness by their essays, and also some stereotyped judgments typical for adults, as a rule. These sentences reflect a high level of students' information awareness, but does not guarantee that they understand thorough and thorough what they have written about, and believe in it furthermore.
HITT-CIS HOUSEHOLDS SURVEY
The geographical coverage of the survey includes 9 former Soviet republics in the European region (Russia, Belarus, Ukraine, Moldova), the Southern Caucasus (Armenia, Azerbaijan, Georgia) and Central Asia (Kazakhstan, Kyrgyzstan). Thus, they represent a large part of the former Soviet Union and encompass considerable ethnic, cultural, religious and political diversity that offers scope for investigating key health trends in the region. With the exception of Georgia, these countries are members of the Common Wealth of Independent States (CIS).
SAMPLE DESIGN
Sampling design was developed according to the good practices established in the HITT-CIS Survey Manual. Following the approach outlined in this document, the sample in each country was designed using the multistage proportional representation method with random route as the method of selecting households and the 'nearest birthday' approach as the method of selecting respondents within households.
National survey agencies developed sampling design according to the country peculiarities (geographical and administrative division, size of urban and rural settlements, etc.). Each Sociological agency decided individually about the necessity of division of the territory into the groups of administrative entities. The following compulsory principles in sampling design were set out for survey agencies and were stipulated in Survey Manual:
-Stratification of the country population into strata according to size and types of settlements.
-Sample is allocated to strata proportionately to the number of persons living there.
-Random selection of sampling points after stratification by the distribution of the national, resident population in terms of size and type of settlements, i.e. proportional to the population size (for a total coverage of the country) and to the population density.
-Households are chosen systematically using standard random route procedures, beginning with an initial address selected at random.
-Not more than 10 interviews can be conducted on each route.
-In order to achieve a representative sample and reliable data, the survey is desirable to carry out in working days from 16:00 to 21:00, and on weekends - from 10:00 to 21:00.
-Target respondent is the person with the 'nearest birthday' among the adult household members, who are resident within private households, regardless of nationality and citizenship, language or legal status. There is only one interview per household.
-The only mode of contact and interviewing with selected person is face-to-face.
-In order to increase response rate, at least two recalls are made after the initial visit before 'dropping' the address. One of those contact attempts needed to fall in a weekend, one on an evening and they needed to be spread over a period of time.
-Replacement of enumerated households is possible, provided that at least two recalls after the initial contact has been carried out, or the unit explicitly refused participation in the survey.
-Homeless and institutional populations were not included in HITT-CIS survey.
-The sampling design adopted in each country was evaluated by Survey Executive Committee before the start of the survey. There were assessed the accuracy of the stratification, adequate representation of the population, and size and distribution of the selected clusters.
METHODOLOGICAL FOREGROUND (project's data bases):
Extensive collection of primary empirical data constitutes an intellectual property of the whole HITT-CIS consortium and their usage is regulated through the Consortium Agreement. Individual data collections can be accessed in cooperation with any project partner.
Potential Impact:
Potential as well as actual impact of the complex HITT-CIS study has several dimensions.
ADDRESSING THE PRINCIPAL TARGET USERS
At the beginning of the project team members defined the target groups and stakeholders for which the dissemination activities would be most appropriate according to the interest level of the topic and geographical scope. The target users include governments, international agencies, NGOs and the wider public. Dissemination of the results of this project is facilitated by the strong links that the researchers have with both governments in the region and international agencies.
DISSEMINATION OF PROJECT RESULTS
Throughout the whole life of the project, special emphasis was laid upon the crucial dimension of the practical consequences of the research process. At all levels of dissemination the issue of practical activities to improve public health in all nine target countries was in the foreground of debate and all interactions with potential or active actors in the field of public health.
MEMBERS OF THE HITT-CIS CONSORTIUM TEAM (extended project teams)
This target group consists of more than 200 academics, professional and support staff in the United Kingdom, Austria, Canada, Russia, Belarus, Ukraine, Moldova, Armenia, Georgia, Azerbaijan, Kyrghyzstan, Kazakhstan and Uzbekistan.
SCIENTIFIC AND ACADEMIC COMMUNITIES
The academic dissemination takes place through conferences, seminars, workshops, journal articles and book chapters. In addition to specific topics being covered in these presentations and publications, there will be final volumes bringing together the main themes and topics as a few books. The academic dissemination takes place through individual outputs, but the project coordinator encourages joint publications, especially joint articles or books of EU and CIS partners in order to provide a synthesis of vision and in order to help CIS partners become more visible on the international stage.
GENERAL AND INTERESTED PUBLIC, INCLUDING NGO'S, CIVIL SOCIETY AND GLOBAL PUBLIC
This general public dissemination takes place mainly through the project web site, which serves as the easiest and fastest tool to present the project to the interested public. All projects informational material is available in form of a PDF and open to download on the homepage, where can also be found a list of publications in various journals and books with links, to access them via internet. The webpage was also used as an announcement board for the upcoming and past events where we uploaded invitations as well as summaries, to assure the most efficient and fastest possible communication to the public. Additionally we compiled an extensive mailing list which was used to invite interested society to all public events.
MAIN DISSEMINATION TOOLS
The first and the most frequently updated tool was naturally the HITT-CIS project homepage. The open part of the website has the task of publication and information of research results and events during the life-time of the project and, in a sustainable format, after the formal termination of the project. This fast access within the project consortium ensures that all results were available immediately to all members of the consortium. To ensure speed and easy access for the consortium, the main content of the HITT Website was published in English as well as in Russian language.
List of Websites:
http://www.hitt-cis.net
http://www.ihs.ac.at
'Health in Times of Transition: Trends in Population Health and Health Policies in CIS Countries' (in short - HITT-CIS) is a large-scale international research effort, primarily supported by the Seventh Framework Program of the European Union (FP7-Health). The project is dedicated to the detailed analysis of the state of health, health care and lifestyles in 9 countries of the former Soviet Union and embraces three main sub-regions of 'post-Soviet space': Eastern Europe (Belarus, Moldova, Russia, Ukraine), Caucasus (Armenia, Azerbaijan, Georgia) and Central Asia (Kazakhstan, Kyrgyzstan).
Many communities across the large post-soviet region suffer from social challenges such as alcoholism, high tobacco consumption and suboptimal nutrition, thus burdening health systems and compromising living standards. In this context, the EU-funded project is researching these issues to help support public health policymaking.
The project is studying long-term trends in population health, including key issues such as diet, nutrition, smoking and alcohol consumption as well as the related societal implications. It is looking at related public policies, examining access to healthcare, identifying strategies to overcome these challenges and supporting the development of more effective policies.
MAJOR THEMATIC AREAS OF THE STUDY:
The following major themes have been addressed by the study in the course of in-depth empirical, statistical and socio-economic research efforts in the countries of NIS region:
-Long-term trends in population health
-Access to health care (in particular, exemplified for diabetes patients)
-Investigation of the social and economic burden of disease
-Dynamics of living conditions, healthy and unhealthy lifestyles
-Diet and nutrition patterns of the population
-Consumption of alcohol and tobacco in NIS countries and relevant official policies
AVAILABILITY OF RESEARCH RESULTS:
Since the commencement of the LLH-HITT research program in 2000, consortium's experts have published hundreds of scientific articles in peer-reviewed journals and mass-media in English, Russian and other languages, prepared several monographs and written numerous chapters in academic and popular books. Most of these publications can be accessed from the project's web-site either as full-text, or links to the publication sources (see http://www.hitt-cis.net/reports/ online).
Project Context and Objectives:
This project HITT-CIS has been designed and implemented under an FP7 topic HEALTH-2007-3.5-1: Epidemiological investigations into long-term trends of population health as a consequence of socio-economic transitions, including life-style induced health problems.
OVERALL AIM AND SPECIFIC OBJECTIVES OF THE PROJECT:
The overall aim of this project was to contribute to the improvement of the health of the populations in the countries concerned, by producing policy-relevant evidence on population health and its socio-economic determinants and communicating these findings to key decision-makers.
DESCRIPTIVE OBJECTIVES:
Describing the health trends, burden of disease, risk factors and social costs of poor health in 9 CIS countries.
A) MEASURE THE BURDEN OF DISEASE AND ITS PROXIMAL AND DISTAL RISK FACTORS
By means of large household surveys (approximately 32,000 respondents in ten CIS countries), we quantify the burden of disease, assessed by self-reported health and validated measures of disease, as well as the prevalence of key risk factors and socio-economic factors. This allows us assessing the social, economic, and cultural patterning of exposure to risk and disease.
B) MEASURE THE COST OF POOR HEALTH
Recognising the low priority that health occupies on the political agenda, we use standard econometric techniques (and building on our earlier work in this region) to assess the economic implications of poor health, through lower labour force participation, lost productivity etc. as well as projections of future growth under various health trajectories.
EXPLANATORY AND ANALYTICAL OBJECTIVES:
Explaining the social, economic and cultural determinants of health-related behaviour of the population alongside with a detailed account of national and regional health care policies in 9 CIS countries
C) IDENTIFY (a) THE SOCIAL; ECONOMIC AND CULTURAL DETERMINANTS OF EXPOSURE TO RISK FACTORS AND (b) HEALTH SEEKING BEHAVIOUR AND ACCESS TO HEALTH CARE
This was done by using standard regression techniques with data from the surveys. This includes a detailed regional analysis in Ukraine, taking advantage of its marked internal diversity. It will also involve comparisons with our earlier surveys to track changes over time.
D) IDENTIFY THE CONSTRAINTS THAT INDIVIDUALS FACE IN MAKING HEALTHY CHOICES
Individuals are not entirely free agents in making decisions about their health. This objective was pursued through (a) the development and application of instruments for community diagnosis that will assess the extent to which communities facilitate or obstruct smoking and hazardous drinking and (b) focus groups (as well as survey data) to assess the knowledge, attitudes and practices in relation to diet.
E) UNDERSTAND THE POLICY ENVIRONMENT IN WHICH PEOPLE MAKE CHOICES
Assessment of official policies on alcohol, tobacco, and nutrition
F) UNDERSTAND THE ECONOMIC FORCES SHAPING HEALTH DECISIONS
In the target countries, a detailed analysis of the tobacco and alcohol sectors has been undertaken, to quantify trends in sales and production, to understand the nature of the market and the positions of key actors, and to identify levers for and barriers to change.
G) IDENTIFY THE BARRIERS FACED IN ACCESSING EFFECTIVE CARE
We have collected and analysed data on people's subjective experiences with health care systems, such as accessibility and quality of the services in order to understand the efficiency of the health system,; using rapid appraisal (including policy analysis, interviews and focus groups with patients and providers), we have identified major barriers to obtaining access to high quality, integrated care.
POLICY-RELATED; DISSEMINATION AND INFORMATION OBJECTIVES:
Facilitation a dialogue with the key stakeholders in the region to improve the situation. Wider regional and international dissemination of project results under a motto Leaving a lasting legacy
H) FOR SELECTED POLICY OPTIONS, IDENTIFY KEY STAKEHOLDERS, THEIR INTER-RELATIONSHIPS, THEIR POSITIONS AND INFLUENCE
I) ENSURE EFFECTIVE DISSEMINATION TO KEY STAKEHOLDERS WITHIN COUNTRIES AND IN THE INTERNATIONAL COMMUNITY
Special procedures for the stakeholder analyses (mainly sociological methods in soft qualitative research) have been used to identify opportunities for change. The outcomes are publicized and discussed in a series of specialized workshops and thematic Policy Briefs.
Building on the team's existing links and strong record of effective dissemination, ensure that the evidence obtained is heard by those who can make a difference
CAPACITY BUILDING OBJECTIVES:
Train the researchers and make project data into a research tool for further studies
J) BUILD CAPACITY FOR QUALITATIVE AND POLICY RESEARCH IN THE COUNTRIES BEING STUDIED
Although the project partners in the CIS have extensive experience undertaking quantitative surveys, skills in qualitative and policy analysis are limited. This project has had a strong training element (a summer school, several instructive training workshops).
K) TO CREATE MULTI - LEVEL DATA SETS FOR OTHER RESEARCHERS
When combined with data from the earlier surveys (32,000 respondents from the 2009 survey in 8 countries and 18,400 respondents from the 2001 survey in 10 countries) our large-scale household survey provide an invaluable resource for those seeking to understand this region.
Project Results:
EMPIRICAL BASE OF THE STUDY:
The project's empirical program included a wide palette of quantitative, qualitative and combined research methods that allowed collecting unique but accurate and verifiable data for the in-depth research on the above themes. The study has applied in particular the following methods:
-secondary critical analysis of available statistical data sets on health, health care, demography and social development and infrastructures in target countries (national and international statistics, governmental reports, experts' data bases);
-two large-scale household surveys in every participating country in 2001 and 2010 (multistage proportional representative samples, random routes, 18 thousand respondents per wave, the sample included 1,800 to 4,000 respondents per country);
-structural observations on communal environment (more than 300 routes and the related community profiles in 9 countries);
-rapid appraisal of the access to health care exemplified for diabetes patients (a complex multi-method empirical effort in five countries);
-series of focus-groups on healthy/unhealthy lifestyles and health-care experiences (more than 40 sessions in urban and rural locations among young and adult men and women in seven countries);
-teenagers' essays on their perception of health, health-care and healthy lifestyles (300 pieces written by high-school students in five countries);
-content-analysis of mass-media revealing the structure of coverage of health-related themes (printed periodicals in four countries, largest national newspapers, coverage of 2010);
-special studies on alcohol and tobacco policies and consumption (stakeholder analysis, analysis of cigarette packaging etc.)
ACCESS TO HEALTH SERVICES AND MEDICINES IN NIS COUNTRIES, PRACTICES OF HEALTH CARE
HEALTH CARE REFORMS IN THE FORMER SOVIET UNION
OBJECTIVE: To assess accessibility and affordability of health care in 8 countries of the former Soviet Union.
METHODS: Using data from the HITT study countries, descriptive and multivariate regression analyses were used on health services.
RESULTS: 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-pockets payments, with median amounts varying from 13 USD 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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22092004
PUBLIC SATISFACTION AS A MEASURE OF HEALTH SYSTEM PERFORMANCE: A STUDY OF NINE COUNTRIES IN THE FORMER SOVIET UNION
BACKGROUND: Measurement of health system performance increasingly includes the views of healthcare users, yet little research has focused on general population satisfaction with health systems.
AIM: To examine public satisfaction with health systems in the former Soviet Union (fSU).
METHODS: Data from the LLH (2001) and HITT (2010) study countries were analysed. The prevalence of health system satisfaction in each country was compared for 2001 and 2010. Patterns of satisfaction were further examined by comparing satisfaction with the health system and other parts of the public sector, and the views of health care users and non-users. Potential determinants of population satisfaction were explored using logistic regression.
RESULTS: For all countries combined, the level of satisfaction with health systems increased from 19.4% in 2001 to 40.6% in 2010, but varied considerably by country. Changes in satisfaction with the health system were similar to changes with the public sector, and non-users of healthcare were slightly more likely to report satisfaction than users. Characteristics associated with higher satisfaction include younger age, lower education, higher economic status, rural residency, better health status, and higher levels of political trust. Our results suggest that satisfaction can provide useful insight into public opinion on health system performance, particularly when used in conjunction with other subjective measures of satisfaction with government performance.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23545269
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. In previous work we described patterns of irregular hypertension treatment in eight countries of the former Soviet Union in 2001.
AIM: To describe changes in the use of hypertension treatment in the HITT countries between 2001 and 2010.
METHODS: Using household survey data from the LLH (2001) and HITT (2010) study countries, we use descriptive analysis to record changes in rates of irregular treatment use (less than daily) between 2001 and 2010;and multivariate logistic regression 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%), 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 former Soviet Union and requires an urgent response.
Web link: http://jech.bmj.com/content/early/2012/03/23/jech-2011-200645.abstract
PREVALENCE AND FACTORS WITH THE USE OF ALTERNATIVE (FOLK) MEDICINE PRACTITIONERS IN 8 COUNTRIES OF THE FORMER SOVIET UNION
BACKGROUND: Research suggests that since the collapse of the Soviet Union there has been a sharp growth in the use of complementary and alternative medicine (CAM) in some former Soviet countries. However, as yet, comparatively little is known about the use of CAM in the countries throughout this region. Against this background, the aim of the current study was to determine the prevalence of using alternative (folk) medicine practitioners in eight countries of the former Soviet Union (fSU) and to examine factors associated with their use.
METHODS: Data from the LLH (2001) and HITT (2010) were analysed. Respondents were asked about how they treated 10 symptoms, with options including the use of alternative (folk) medicine practitioners. Multivariate logistic regression analysis was used to determine the factors associated with the treatment of differing symptoms by such practitioners in these countries.
RESULTS: The prevalence of using an alternative (folk) medicine practitioner for symptom treatment varied widely between countries, ranging from 3.5% in Armenia to 25.0% in Kyrgyzstan. For nearly every symptom, respondents living in rural locations were more likely to use an alternative (folk) medicine practitioner than urban residents. Greater wealth was also associated with using these practitioners, while distrust of doctors played a role in the treatment of some symptoms.
CONCLUSIONS: The widespread use of alternative (folk) medicine practitioners in some fSU countries and the growth of this form of health care provision in the post-Soviet period in conditions of variable licensing and regulation, highlights the urgent need for more research on this phenomenon and its potential effects on population health in the countries in this region.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23578173?dopt=Abstract
MULTI - METHOD SYSTEM APPRAISAL OF DIABETES CARE IN THE FORMER SOVIET UNION
OBJECTIVE: To use diabetes as a tracer for health system diagnoses, health outcomes, integration of care, and responsiveness. To explore the perspectives of patients, providers and policy makers on complex systems and interventions in diabetes management, encompassing multiple levels of care, within and outside the health system. To map patient pathways in order to assess the appropriateness, affordability and responsiveness of care and to compare them with policy.
METHODS: The study was conducted in Armenia, Belarus, the Republic of Moldova, the Russian Federation and in Ukraine. It involved a documentary review of legislation, secondary analysis or synthesis of routine data on diabetes and its complications, accompanied by in-depth interviews and focus group discussions, triangulating the perspectives of patients, providers and policy makers.
RESULTS: Specialists dominate diabetes care despite on-going efforts to increase primary diabetes care. The study found poor coordination between different levels of care. Patients emphasise barriers to self-management: they were often not provided with adequate information to effectively manage their disease. Access to drugs and consumables was dependent on patients' time and ability to pay. Despite specialist training, diabetes nurses had a very limited role in diabetes treatment and control. There were gaps in data collection and the registration of diabetes patients, which hampered planning and resource allocation.
CONCLUSIONS: Diabetes management seems to have improved since the break-up of the Soviet Union. Nevertheless, if health systems are to become more responsive and produce better health outcomes, significant improvements will have to be made to accessibility, affordability, acceptability of health systems in the five countries under analysis.
ECONOMICS, DEMOGRAPHY AND HEALTH
THE EFFECT ON HEALTH ON LABOUR SUPPLY IN NINE FORMER SOVIET UNION COUNTRIES
BACKGROUND: There has been very little examination of the impact of poor health on economic productivity in countries in the former Soviet Union.
AIM: To examine the consequences of ill health on labour supply for the nine HITT countries.
MATHODS: We control for a wide range of individual, household, and community factors, using both standard regression techniques and instrumental variable estimation to address potential endogeneity.
RESULTS: We find in our baseline ordinary least squares specification that poor health is associated with a decrease in the probability of working of about 13 %. Controlling for community-level unobserved variables slightly increases the magnitude of this effect, to about 14 %. Controlling for endogeneity with the instrumental variable approach further supports this finding, with the magnitude of the effect ranging from 12 to 35 %.
CONCLUSIONS: Our findings confirm the cost that the still considerable adult health burden in the FSU is imposing on its population, not only in terms of the disease burden itself, but also in terms of individuals' labour market participation, as well as potentially in terms of increased poverty risk. Other things being equal, this would increase the expected ' return on investment' to be had from interventions aimed at improving health in this region.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23292272
REGIONAL VARIATION IN MORTALITY IN UKRAINE
OBJECTIVES: We set out to identify the contribution of various causes of death to regional differences in life expectancy in Ukraine.
METHODS: Mortality data by oblast (province) were obtained from the State Statistical Committee of Ukraine. The contribution of various causes of death to differences in life expectancy between East, West and South Ukraine was estimated using decomposition.
RESULTS: In 2008, life expectancy for men in South (61.8 years) and East Ukraine (61.2 years) was lower than for men in West Ukraine (64.0 years). A similar pattern was observed among women. This was mostly due to deaths from infectious disease and external causes among young adults, and cardio- and cerebro-vascular deaths among older adults. Deaths from TB among young adults contribute most to differences in life expectancy.
CONCLUSIONS: Deaths due to infectious disease, especially TB, play an important role in the gap in life expectancy between regions in Ukraine. These deaths are entirely preventable-further research is needed to identify what has 'protected' individuals in Western Ukraine from the burden of deaths experienced by their Southern and Eastern counterparts.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23525667
ALCOHOL USE AND POLICIES IN NIS COUNTRIES
PATTERNS OF PUBLIC SUPPORT FOR PRICE INCREASES ON ALCOHOL IN THE FORMER SOVIET UNION
AIM: To measure levels of public support for price increases on beer and spirits in nine FSU countries and to examine the characteristics influencing such support.
MATHODS: Cross-sectional surveys were conducted in 2010 with 18000 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.
CONCLUSIONS: 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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22553046
DEMOGRAPHY, TRADE, HEALTH SYSTEMS AND HEALTH
BACKGROUND: This report reviews data for objectives related to: (i) life expectancies; (ii) alcohol and tobacco consumption and trade; diet and nutrition. A fourth objective describing health systems is addressed in separately in the Health Systems in Transition (HiT) profiles produced by the London School of Hygiene and Tropical Medicine.
METHODS: All 15 countries of the former Soviet Union are included in this report. The time period covered in this report is from 1990 to 2008 (or the nearest latest available data). Government and United Nations (UN) databases were the primary data sources used as they provide annual data. Life expectancy data were collected from the World Health Organisation's (WHO) European Health for All Database. Alcohol consumption data were collected from the Food and Agricultural Organisation (FAO) statistics database and the WHO database. Tobacco data were collected from the United States Department for Agriculture, Foreign Agricultural Services database, the ERC Group, and the WHO database.
FINDINGS: Life expectancy at birth for men, women and all has increased since the dramatic decline in the early/mid 1990's. However, 5 countries still had lower life-expectancy in 2008 than in 1990. Importantly these countries included the most populous countries of Russia and Ukraine. As a result, life expectancy at birth overall still remains 1.85 years less than in 1990 for the region as a whole.
ALCOHOL AND TOBACCO MARKET IN RUSSIA
BACKGROUND: This report reviews data on the alcohol and tobacco market in Russia which will be used to support additional deliverables from the HITT project, particularly the stakeholder analysis of alcohol and tobacco markets and policies in Russia and the paper on the price elasticity of demand for alcohol in Russia.
METHODS: The time period covered in this report is from 1990 to 2007/2008. Alcohol consumption data were collected from the Food and Agricultural Organisation (FAO) statistics database and the World Health Organisation European Health for All Database. Tobacco data were collected from the United States Department for Agriculture, Foreign Agricultural Services database, the ERC Group, and the WHO database.
FINDINGS: There has been a dramatic increase in alcohol supply in Russia since the early 1990's. The vast majority of this increase is from domestic production. Alcohol production has increased 171% from 4,952,000 tonnes in 1992 to 13,425,000 tonnes in 2007; while imports have increased 125% from 480,000 tonnes to 1,081,000 tonnes; and exports have increased 248% from 119,000 tonnes to 414,000 tonnes.
ESTIMATING THE CAUSAL EFFECT OF ALCOHOL CONSUMPTION ON WELL-BEING FOR A CROSS-SECTION OF NINE FORMER SOVIET UNION COUNTRIES
BACKGROUND: While the adverse health and economic consequences attributable to alcohol consumption are widely acknowledged, its impact on psychological wellbeing is less well understood.
AIM: To examine the influence of alcohol use on psychological wellbeing while addressing the endogenous relationship between alcohol consumption and individual mental well-being using an instrumental variable (IV) approach.
METHODS: Using HITT data from the nine countries, we employed an instrumental variable approach to identify any causal effects of alcohol consumption on mental well-being. The availability of 24-hour alcohol sales outlets in the neighbourhood of the individuals is used as an instrument, based on theoretical reasoning and statistical testing of its validity.
RESULTS: We find that increased alcohol consumption decreases well-being and that ignoring endogeneity leads to underestimation of this effect. This finding adds a further and previously under-appreciated dimension to the expected benefits that could be achieved with more effective alcohol policy in this region.
Web link: http://www.sciencedirect.com/science/article/pii/S0277953613002372
TOBACCO USE AND POLICIES
CHANGES IN SMOKING PREVALENCE IN EIGHT COUNTRIES OF THE FORMER SOVIET UNION BETWEEN 2001 AND 2010.
OBJECTIVES: To present new data on smoking prevalence in eight countries; analyse prevalence changes between 2001 and 2010; examine trend variance by age, location, education level, and household economic status.
METHODS: Data were analysed from the LLH (2001) and HITT (2010) studies, with smoking prevalence was compared with a related 2001 study for the different countries and population sub-groups, and the adjusted prevalence rate ratios of smoking also calculated.
RESULTS: All-age 2010 male smoking prevalence ranged from 39% (Moldova) to 59% (Armenia), and female prevalence 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.
CONCLUSIONS: Smoking prevalence appears to have stabilised and may be declining in younger groups, but remains extremely high among men, especially those in lower socio-economic groups.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22594739
ANALYZING COMPLIANCE OF CIGARETTE PACKAGING WITH THE FCTC AND NATIONAL LEGISLATION IN EIGHT FORMER SOVIET COUNTRIES
AIM: To analyze compliance of cigarette packets with the Framework Convention on Tobacco Control (FCTC) and national legislation and the policy actions that are required in 8 former Soviet Union countries.
METHODS: We obtained cigarette packets of each of the ten most smoked cigarette brands in each of Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine. The packets were then analysed using a standardized data collection instrument. The analysis included the placing, size and content of health warnings labels and deceptive labels (e.g. 'Lights'). Findings were assessed for compliance with the FCTC and national legislation.
RESULTS: Health warnings were on all packets from all countries and met the FCTC minimum recommendations on size and position except Azerbaijan and Georgia. All countries used a variety of warnings except Azerbaijan. No country had pictorial health warnings, despite them being mandatory in Georgia and Moldova.
CONCLUSIONS: Despite progress in the use of health warning messages, gaps still remain - particularly with the use of deceptive labels. Stronger surveillance and enforcement mechanisms are required to improve compliance with the FCTC and national legislation.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23047889
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, 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 nine countries of the former Soviet Union and to examine the psychosocial factors associated with nicotine dependence.
METHODS: HITT data were analysed. The main outcome of interest was nicotine dependence using the Fagerstrom 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 organisation, 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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22529221
SMOKING CESSATION AND DESIRE TO STOP SMOKING IN NINE COUNTRIES OF THE FORMER SOVIET UNION
INTRODUCTION: Smoking rates and corresponding levels of premature mortality from smoking-related diseases in the former Soviet Union (fSU) are among the highest in the world. To reduce this health burden greater focus on smoking cessation is needed, but little is currently known about rates and characteristics of cessation in the fSU.
METHODS: HITT data were analysed to describe patterns of desire and action taken to stop smoking, quit ratios (former ever-smokers as a % of ever-smokers, with no specified recall period), and help used to stop smoking. Multivariate logistic regression was used to analyse characteristics associated with smoking cessation and desire to stop smoking.
RESULTS: Quit ratios varied from 10.5% in Azerbaijan to 37.6% in Belarus. Desire to stop smoking was generally high (67.2%) while the proportion that had taken action to try to stop was slightly lower (64.9%). The use of help to quit was extremely low (12.6%). Characteristics associated with cessation included being female, over 60, with higher education, poorer health, lower alcohol dependency, higher knowledge of tobacco's health effects and support for tobacco control.
CONCLUSIONS: Quit ratios are low in the fSU but there is widespread desire to stop smoking. Stronger tobacco control and cessation support are urgently required to reduce smoking prevalence and associated premature mortality.
Web link: http://ntr.oxfordjournals.org/content/early/2013/04/02/ntr.ntt034.abstract
KNOWLEDGE OF THE HEALTH IMPACTS OF SMOKING AND PUBLIC ATTITUDES TOWARDS TOBACCO CONTROL IN THE FORMER SOVIET UNION
AIM: 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: HITT data were analysed on respondents' 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.
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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22705600
DIET AND OBESITY
CHANGING PATTERNS OF FRUIT AND VEGETABLE INTAKE IN COUNTRIES OF THE FORMER SOVIET UNION
OBJECTIVE: To assess how the frequency of low fruit and vegetable consumption has changed in the countries of the former Soviet Union (fSU) between 2001 and 2010 and to identify factors associated with their consumption.
DESIGN: Cross-sectional surveys. A standard questionnaire was administered at both time points to examine fruit and vegetable consumption frequency. Logistical regression analysis was used to examine the relationship between demographic, socioeconomic and health behavioral variables and low fruit and vegetable consumption in 2010.
SETTING: Nationally representative population samples from Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine.
Subjects: Adults aged 18 years and older.
RESULTS: Between 2001 and 2010 notable changes occurred in fruit and vegetable consumption in many countries resulting in a slight overall deterioration in diet. By 2010 in 6 countries around 40% of the population was eating fruit once a week or less often, while for vegetables the corresponding figure was in excess of 20% in every country except Azerbaijan.
CONCLUSIONS: International dietary guidelines emphasise the importance of fruit and vegetable consumption. The scale of inadequate consumption of these food groups among much of the population in many fSU countries and its link to socioeconomic disadvantage are deeply worrying. This highlights the urgent need for a greater focus to be placed on population nutrition policies to avoid nutrition-related diseases in the fSU countries.
Web link: http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=8926006
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.
OBJECTIVE: 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; 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 (BMI greater than or equal 30 kg/m2) were analyzed using multi-level random intercept logistic regression models.
RESULTS: 13% of males and 18% 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.
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.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22645239
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: Data on household piped water from the LLH and HITT studies were compared 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).
CONCLUSIONS: Despite encouraging increases in access to piped water, there remain significant gaps for rural and poorer households.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/22267289
ISSUES OF PUBLIC MENTAL HEALTH IN NIS REGION (psychological distress, social capital and other aspects)
CHANGES IN THE LEVELS OF PSYCHOLOGICAL DISTRESS IN EIGHT COUNTRIES OF THE FORMER SOVIET UNION.
BACKGROUND: The collapse of the Soviet Union created considerable stress for many of its inhabitants and, even now, post Soviet societies continue to be characterized by many established risk-factors for poor mental health. The objectives of this study were to compare levels of psychological distress in 2001 and 2010 in eight countries of the former Soviet Union and to explore how these changes vary for different population groups.
METHODS: Data from the LLH (2010) and HITT (2010) were analyzed. Psychological distress was measured using a 12 item instrument, with scores of 10-12 used to indicate high psychological distress. Changes in the levels of psychological distress between 2001 and 2010 were described by country, gender and age group; and then for sub-populations of gender, age group, educational level, disability status, personal support and household economic status using adjusted prevalence rate ratios.
RESULTS: Levels of high psychological distress decreased from 8.7% in 2001 to 4.9% in 2010 (P less than 0.01) for the whole study region (4.5% to 2.8% men; 12.0% to 6.5% for women). All the study countries recorded decreases in high psychological distress.
CONCLUSIONS: The study shows decreases in levels of high psychological distress in the former Soviet Union, but that decreases were less for socially and economically marginalised populations. Despite decreases of psychological distress among women, they continue to bear a significantly higher burden than men. The findings highlight the continued need to break the cycle of poverty, social exclusion and poor mental health in the region.
Web link: http://www.emeraldinsight.com/journals.htm?articleid=17053906
THE COMORBIDITY OF HYPERTENSION AND PSYCHOLOGICAL DISTRESS: A STUDY OF NINE COUNTRIES IN THE FORMER SOVIET UNION
BACKGROUND: Mental health problems in those with physical ailments are often overlooked, especially in the former Soviet Union (fSU) where this comorbidity has received little attention. Our study examines the comorbidity of psychological distress and hypertension in the fSU.
METHODS: Data from the LLH (2001) and HITT (2010) studies nationally representative household survey data from Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine in 2001 and 2010 were analysed to compare the levels of psychological distress in people with and without self-reported hypertension.
RESULTS: There were significantly higher levels of psychological distress among hypertensive respondents (9.9%) than in the general population (4.9%), and a significant association between the two conditions [odds ratio (OR) = 2.27 (1.91; 2.70)].
CONCLUSIONS: There is a significant association between psychological distress and hypertension in the region.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23480878
SOCIAL CAPITAL AND SELF-REPORTED GENERAL AND MENTAL HEALTH IN NINE FORMER SOVIET UNION COUNTRIES
BACKGROUND: Social capital has been proposed as a potentially important contributor to health, yet most of the existing research tends to ignore the challenge of assessing causality in this relationship.
METHODS: We analysed the HITT study data and use various instrumental variable estimation techniques.
FINDINGS: Our results confirm that there appears to be a causal association running from several dimensions of individual social capital to general and mental health. Individual trust appears to be more strongly related to general health, while social isolation- to mental health. In addition, social support and trust seem to be more important determinants of health than the social capital dimensions that facilitate solidarity and collective action. Our findings are remarkably robust to a range of different specifications, including the use of instrumental variables.
Web link: http://www.ncbi.nlm.nih.gov/pubmed/23506911
SOCIAL IMPACTS ON HEALTH: THE INTERPLAY OF LIFESTYLES AND SOCIO-ECONOMIC FACTORS
Several components of the empirical program of the HITT-CIS study were dedicated to in-depth qualitative research of the perceptions and practice of healthy and unhealthy lifestyles.
SOCIO-ECONOMIC INFLUENCES ON HEALTH IN THE COMMONWEALTH OF INDEPENDENT STATES
Despite the evidence that poor health lifestyles are a major contributor to life expectancy in the studied post-soviet countries (as in other developed economies) the major factors explain inequalities in health are social and economic ones. Indeed after controlling for demographic, social and economic variables health lifestyle variables (alcoholic consumption and eating a healthy diet) make little contribution to explaining the variance in self-reported health.
FROM PROJECT'S POLICY BRIEF ON SOCIAL AND ECONOMIC IMPACTS OF POOR HEALTH IN THE FORMER SOVIET UNION
Health outcomes in adults living in the former Soviet Union, particularly males, are often well below those expected given their level of economic development. In Russia, life expectancy is much lower than that of countries with a similar GDP, and the likelihood of dying prematurely, between the ages of 15 and 60, is considerably higher. Health is a vital national investment: inequalities in health are estimated to result in a 1.4% loss of GDP every year.
KEY FINDINGS
POORER HEALTH MEANS A LOWER CHANCE OF WORKING
Self-reporting poor health is associated with about a 13-15 % lower probability of working in the countries studied. This is a particularly worrying finding as a high proportion of the population reported having poor health. Almost half of women in Georgia, and over 1 in 4 in Moldova and Ukraine reported their health to be poor or very poor. In almost every country, more than 1 in 10 men reported poor or very poor health.
RELATIONSHIP BETWEEN POVERTY AND ILL HEALTH
People who had to limit their consumption of basic food in the last 12 months were 8% more likely to report poor health. Those who had to limit their access to medical care were 11% more likely to report poor health; high out of pocket payments for health care in the region are likely to push families into poverty when faced with a chronic illness.
RELATIONSHIP BETWEEN POOR HEALTH AND PSYCHOLOGICAL DISTRESS
People with hypertension were twice as likely to suffer with psychological distress. Being unable to access medical drugs was strongly associated with psychological distress in people with hypertension. The results suggest that people who are prescribed unobtainable or unaffordable treatment to control hypertension may experience anxiety and distress. This can have severe psychosocial impacts on the countries in this region.
POLICY RECOMMENDATIONS
Poor health in the former Soviet Union has negative impacts on the labour supply as ill people have a lower likelihood of working. This research also finds a relationship between ill health and poverty, and psychosocial measures of distress. These social and economic impacts of poor health need to be addressed.
INVESTING IN HEALTH
Health is a vital national investment, and governments must raise health expenditure to address the national economic impacts of poor health. Revenue can be raised by raising taxes for high-income groups, introducing new taxes on health-harming products such as tobacco and alcohol, improving collection of existing taxes, or shifting public funding from other sectors to place higher priority on health.
IMPROVE AFFORDABILITY OF PHARMACEUTICALS
The high price of pharmaceuticals in these countries can push people with ill health into poverty, and can results in psychosocial problems such as heightened levels of psychological distress. Access to drugs can be improved by regulating medicine prices, regulating mark-ups in the supply chain, training providers in rational prescribing, and promoting generic drugs to providers and the public.
REDUCE INFORMAL PAYMENTS
To protect those with poor health from slipping into poverty, the financial barriers to accessing care must be removed. Informal payments are a leading financial barrier, which can be addressed by clearer communication with the public about the price of services, and raising official salaries of health care workers. To increase efficiency, payment should be shifted from salaries to performance-related pay, which is linked to quality of work.
FOCUS GROUP DISCUSSIONS ON HEALTHY AND UNHEALTHY LIFESTYLES (QUALITATIVE SUB-STUDY)
RESEARCH OBJECTIVE: This sub-study was designed and implemented to complement the findings from the large-scale survey and structured observations by providing a more nuanced understanding of how people take responsibility for their health in their daily lives. It was also designed to enable us comparing health lifestyles across countries and to compare the findings with those from research carried out in Belarus, Russia and Ukraine in 2002 as part of the Living Conditions, lifestyles and Health Research (LLH) (see http://www.llh.at online). The healthy lifestyles qualitative research was designed to provide information on how people understand health and illness in their daily lives, their construction of what it is to be healthy and what it means to be ill. It enables us to understand, how much control people think they have over health and illness and what they do to remain healthy.
DESIGN OF THE RESEARCH: The research was qualitative and involved focus group discussions with a purposive sample of informants in each of the countries. An agenda, agreed by the team carrying out the qualitative fieldwork, was used to stimulate discussion around the key topics. It was designed to get informants to talk about their understanding of what it is to be healthy, what they think they can do to look after their health, who is responsible for their health and their experiences of using the health services. The aide memoire was informed by the findings from the qualitative research we had done in 2002. It was drafted in English and translated by the teams in each country into the local language.
SAMPLING OF INFORMANTS: The sample was purposive. Two communities were selected in each country from amongst those included in the HITT survey where structured observations had also been carried out. One was in a poor rural area and one in a more affluent urban area in the capital city. This was designed to provide a contrast between those likely to have the poorest opportunity for looking after their health and those likely to have the greatest opportunity to do so.
ETHICS
Ethical approval for the research was given by the London School of Hygiene and Tropical Medicine that required that ethical approval was obtained by the approved means in each of the participating countries. All participants in FGDs were asked to give verbal consent to participation and advised that they could leave at any time if they so wished. Participants were assured of anonymity and asked to respect the confidentiality of what was discussed.
TRAINING: The facilitators of the FGDs were experienced researchers that had been specifically trained specifically trained for this project. The aim of the training was to ensure that there was a shared understanding of the aims of the research and how it was to be carried out. This was important to ensure that comparable data was collected across the countries and same topics covered.
FOCUS GROUP DISCUSSIONS: The FGDs were held in the preferred language of the participants. They were facilitated by a trained researcher and notes were taken by a research assistant. The FGDs were also recoded. The agenda was used an aide memoire with the facilitators encouraging discussion and ensuring that key points were followed up. Following the FGDs the notes and recording were used to draw up a full transcript in the local language and an edited version in English.
QUALITY ASSURANCE: There were three elements of quality assurance. In each country two FGDs were observed by an independent senior researcher that had participated in the development of the qualitative research. The transcripts in Russian/the local language were independently reviewed and in most countries two FGDs were videoed.
CONTENT-ANALYSIS OF PRINTED MASS-MEDIA (NEWSPAPERS)
RESEARCH OBJECTIVE: finding out the quantity of publications on the issues related with formation of healthy attitudes and healthy lifestyle among the population in the newspaper with the largest circulation.
SUBJECT OF RESEARCH: a leading daily newspaper having the largest circulation in every country under study -project-participant country (six newspapers in total), the region where the newspaper is distributed is the whole country.
GEOGRAPHY OF THE STUDY: Belarus, Georgia, Kazakhstan, Moldova, Russia, Ukraine.
UNIT OF ANALYSIS: in this study - an article, considering the text of the publication in whole.
CONCLUSIONS:
The outcomes of content-analysis of publications covering the issues of healthy lifestyle and health and the problems related with them by the most popular periodicals of Belarus, Georgia, Kazakhstan, Moldova, Russia, Ukraine enable us to make the following main conclusions:
The largest number of publications on the topic of healthy lifestyle and health are recorded in the periodicals 'Segodnya' (Ukraine) and 'SB. Belarus Segodnya' (Belarus) - more than a half of issues of these newspapers had two or more materials on the indicated topic during the period under study. The least number of publications is counted in the Georgian periodical 'Rezonansi', i.e. less than a half copies of this newspaper had materials about healthy lifestyle and health.
The materials about healthcare services prevail among all the publications in the studied periodicals. Little attention is paid to the topics of sexual behaviour and regular visits to the doctors.
Materials of informational character prevail in the analyzed newspapers, and their authors are mainly journalists.
ESSAYS OF HIGH-SCHOOL STUDENT ON HEALTHY AND UNHEALTHY LIFESTYLES (ROTMAN to check)
This empirical sub-study was implemented in Belarus, Georgia, Moldova, Russia and Ukraine during the spring months 2012. Altogether, 376 essays have been written by school-age teenagers (14-18 years) at their classrooms during one lesson (45 minutes). The suggested title of free-shaped essays was defined 'Health and healthy lifestyle'. A sample of 159 of most informative essays was selected for in-depth analysis under the guidance of prof/ David Rotman (BSU-SIMST).
The structural content-analysis of these essays has revealed the following facts and attitudes of respondents:
VALUE OF HEALTH
Virtually all the young people, who participated in the study, believe that health is a necessary condition for a happy, successful life both at present, and in future.
-the majority of the young people are adherent to healthy lifestyle, understand that success in life depends, amongst other factors, on person's health and perceive health as the one of the main value of life.
-the students are well informed about the matters that promote health, and what ruins them. Only very few essays present opinions that keeping healthy is not so important, is unpopular among teenagers and adults.
DEFINITIONS OF HEALTH, HEALTHY LIFESTYLE
-Defining what, actually, health is, students give some-times naïve, sometimes incomplete definitions, often quoting proverbs and popular sayings.
-None of these children's definitions given in their essays contradict the definition of health given by the World Health Organisation.
ATTITUDE TO ONE'S HEALTH, MODELS OF BEHAVIOUR
-The respondents are clearly aware, that people should care about their health by themselves. Many essays note that quite a lot of people do not care about their health nowadays, or using their slang: 'a lot of people do not give a damn to their health'.
-Based on the factual canvas of the essays, one can reconstruct sad and grey-coloured picture of every-day lives of teenagers (their 'uninteresting', passive and unhealthy lifestyle). E.g. 'Most often we are pushed to bad actions by our friends ' or 'It is hard to overcome herd instinct, I know it from my own experience'. However, in their meta-narrative, the respondents try presenting information about themselves more positively. In spite of the popular references to disadvantageous social environments, the respondents tend blaming themselves for their own irresponsibility and laziness.
-Judging by the essay texts, virtually all the students are very well informed about the ways how to keep healthy, about what is right, what is good or what is bad. The overwhelming majority remark, that they adhere to or try to adhere to healthy lifestyle, they do not drink, do not smoke, try to have a healthy diet and do sports. Along with that, the same senior pupils write in their essays, that 'everyone around drinks, smokes and does not care about his health at all'. In fact, this narration is constructed by the principle 'everyone around, but not me', along with that it is possible to see a crowd of smoking teenagers during a break behind school). Thus, one can conclude that teenagers' presentations about their adherence to healthy life-style principles are a little overestimated.
-Quite often schoolchildren express stereotypes and clichés widespread in the society and in mass consciousness by their essays, and also some stereotyped judgments typical for adults, as a rule. These sentences reflect a high level of students' information awareness, but does not guarantee that they understand thorough and thorough what they have written about, and believe in it furthermore.
HITT-CIS HOUSEHOLDS SURVEY
The geographical coverage of the survey includes 9 former Soviet republics in the European region (Russia, Belarus, Ukraine, Moldova), the Southern Caucasus (Armenia, Azerbaijan, Georgia) and Central Asia (Kazakhstan, Kyrgyzstan). Thus, they represent a large part of the former Soviet Union and encompass considerable ethnic, cultural, religious and political diversity that offers scope for investigating key health trends in the region. With the exception of Georgia, these countries are members of the Common Wealth of Independent States (CIS).
SAMPLE DESIGN
Sampling design was developed according to the good practices established in the HITT-CIS Survey Manual. Following the approach outlined in this document, the sample in each country was designed using the multistage proportional representation method with random route as the method of selecting households and the 'nearest birthday' approach as the method of selecting respondents within households.
National survey agencies developed sampling design according to the country peculiarities (geographical and administrative division, size of urban and rural settlements, etc.). Each Sociological agency decided individually about the necessity of division of the territory into the groups of administrative entities. The following compulsory principles in sampling design were set out for survey agencies and were stipulated in Survey Manual:
-Stratification of the country population into strata according to size and types of settlements.
-Sample is allocated to strata proportionately to the number of persons living there.
-Random selection of sampling points after stratification by the distribution of the national, resident population in terms of size and type of settlements, i.e. proportional to the population size (for a total coverage of the country) and to the population density.
-Households are chosen systematically using standard random route procedures, beginning with an initial address selected at random.
-Not more than 10 interviews can be conducted on each route.
-In order to achieve a representative sample and reliable data, the survey is desirable to carry out in working days from 16:00 to 21:00, and on weekends - from 10:00 to 21:00.
-Target respondent is the person with the 'nearest birthday' among the adult household members, who are resident within private households, regardless of nationality and citizenship, language or legal status. There is only one interview per household.
-The only mode of contact and interviewing with selected person is face-to-face.
-In order to increase response rate, at least two recalls are made after the initial visit before 'dropping' the address. One of those contact attempts needed to fall in a weekend, one on an evening and they needed to be spread over a period of time.
-Replacement of enumerated households is possible, provided that at least two recalls after the initial contact has been carried out, or the unit explicitly refused participation in the survey.
-Homeless and institutional populations were not included in HITT-CIS survey.
-The sampling design adopted in each country was evaluated by Survey Executive Committee before the start of the survey. There were assessed the accuracy of the stratification, adequate representation of the population, and size and distribution of the selected clusters.
METHODOLOGICAL FOREGROUND (project's data bases):
Extensive collection of primary empirical data constitutes an intellectual property of the whole HITT-CIS consortium and their usage is regulated through the Consortium Agreement. Individual data collections can be accessed in cooperation with any project partner.
Potential Impact:
Potential as well as actual impact of the complex HITT-CIS study has several dimensions.
ADDRESSING THE PRINCIPAL TARGET USERS
At the beginning of the project team members defined the target groups and stakeholders for which the dissemination activities would be most appropriate according to the interest level of the topic and geographical scope. The target users include governments, international agencies, NGOs and the wider public. Dissemination of the results of this project is facilitated by the strong links that the researchers have with both governments in the region and international agencies.
DISSEMINATION OF PROJECT RESULTS
Throughout the whole life of the project, special emphasis was laid upon the crucial dimension of the practical consequences of the research process. At all levels of dissemination the issue of practical activities to improve public health in all nine target countries was in the foreground of debate and all interactions with potential or active actors in the field of public health.
MEMBERS OF THE HITT-CIS CONSORTIUM TEAM (extended project teams)
This target group consists of more than 200 academics, professional and support staff in the United Kingdom, Austria, Canada, Russia, Belarus, Ukraine, Moldova, Armenia, Georgia, Azerbaijan, Kyrghyzstan, Kazakhstan and Uzbekistan.
SCIENTIFIC AND ACADEMIC COMMUNITIES
The academic dissemination takes place through conferences, seminars, workshops, journal articles and book chapters. In addition to specific topics being covered in these presentations and publications, there will be final volumes bringing together the main themes and topics as a few books. The academic dissemination takes place through individual outputs, but the project coordinator encourages joint publications, especially joint articles or books of EU and CIS partners in order to provide a synthesis of vision and in order to help CIS partners become more visible on the international stage.
GENERAL AND INTERESTED PUBLIC, INCLUDING NGO'S, CIVIL SOCIETY AND GLOBAL PUBLIC
This general public dissemination takes place mainly through the project web site, which serves as the easiest and fastest tool to present the project to the interested public. All projects informational material is available in form of a PDF and open to download on the homepage, where can also be found a list of publications in various journals and books with links, to access them via internet. The webpage was also used as an announcement board for the upcoming and past events where we uploaded invitations as well as summaries, to assure the most efficient and fastest possible communication to the public. Additionally we compiled an extensive mailing list which was used to invite interested society to all public events.
MAIN DISSEMINATION TOOLS
The first and the most frequently updated tool was naturally the HITT-CIS project homepage. The open part of the website has the task of publication and information of research results and events during the life-time of the project and, in a sustainable format, after the formal termination of the project. This fast access within the project consortium ensures that all results were available immediately to all members of the consortium. To ensure speed and easy access for the consortium, the main content of the HITT Website was published in English as well as in Russian language.
List of Websites:
http://www.hitt-cis.net
http://www.ihs.ac.at
