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ABSTRACT: BACKGROUND Many Russians experienced difficulty in accessing prescription medication during the widespread health service disruption and rapid socio-economic transition of the 1990s. This paper examines trends and determinants of access in Russia during this period. METHODS Data were from nine rounds (1994-2004) of the Russia Longitudinal Monitoring Survey, a 38-centre household panel survey. Trends were measured in failing to access prescribed medication for the following reasons: unobtainable from a pharmacy, unable to afford and 'other' reasons. Determinants of unaffordability were studied in 1994, 1998 and 2004, using cross-sectional, age-adjusted logistic regression, with further multivariate analyses of unaffordability and failure to access for 'other' reasons in 2004. RESULTS After 1994, reporting of unavailability in pharmacies fell sharply from 25% to 4%. Meanwhile, unaffordability increased to 20% in 1998 but declined to 9% by 2004. In 1994, significant determinants of unaffordability were unemployment and lacking health care insurance in men. By 2004, determinants included low income and material goods in both sexes; rented accommodation and low education in men; and chronic disease and disability-related retirement in women. Not obtaining medicines for 'other' reasons was more likely amongst frequent male drinkers, and low educated or cohabiting women. Regional and gender differences were widest in 1998, coinciding with the Russian financial crisis. CONCLUSIONS Rapid improvements in drug availability in the late 1990s in Russia are a probable consequence of a more liberalized pharmaceutical sector and an improved pharmacy network, whilst later improvements in affordability may relate to expanded health care insurance coverage and economic recovery after the 1998 crash. A significant minority still finds prescription costs problematic, notably poorer and sick individuals, with inequalities apparently widening. Non-monetary determinants of affordability indicate its partly subjective nature, however. Ongoing research into access is needed, due to recent national changes in prescription drug subsidies, and into doctor- and patient-related influences on access and prescribing for individual conditions.
Health Policy and Planning 01/2011; 26(6):453-63. · 2.65 Impact Factor
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ABSTRACT: We used the Russia Longitudinal Monitoring Survey (RLMS) to investigate associations between employment, socioeconomic position, and mortality.
Data were from working-age respondents in 8 rounds (1994-2003) of the RLMS. We measured associations between education, occupation, unemployment, and insecure employment and mortality with Cox proportional hazards analyses.
Of 4465 men and 4158 women who were currently employed, 251 men and 34 women died. A third of employed respondents experienced wage arrears, and 10% experienced compulsory leave and payment in consumer goods. Insecure employment, more common among the less-educated and manual workers, fluctuated with macroeconomic measures. Mortality was significantly associated with payment in consumer goods among men (hazard ratio [HR] = 1.46; 95% confidence interval [CI] = 1.03, 2.07), compulsory unpaid leave among women (HR = 3.79; 95% CI = 1.82, 7.88), and male unemployment (HR = 1.88; 95% CI = 1.38, 2.55). Associations with death within 1 year of entry were generally somewhat stronger than the association with mortality over the whole study period.
Unemployment and job insecurity predicted mortality, suggesting that they contributed to Russia's high mortality during the transition from communism.
American Journal of Public Health 09/2009; 99(10):1818-25. · 3.93 Impact Factor
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ABSTRACT: The break-up of the USSR brought considerable disruption to health services in Russia. The uptake of compulsory health insurance rose rapidly after its introduction in 1993. However, by 2000 coverage was still incomplete, especially amongst the disadvantaged. By this time, however, the state health service had become more stable, and the private sector was growing. This paper describes subsequent trends and determinants of healthcare insurance coverage in Russia, and its relationship with health service utilisation, as well as the role of the private sector.
Data were from the Russia Longitudinal Monitoring Survey, an annual household panel survey (2000-4) from 38 centres across the Russian Federation. Annual trends in insurance coverage were measured (2000-4). Cross-sectional multivariate analyses of the determinants of health insurance and its relationship with health care utilisation were performed in working-age people (18-59 years) using 2004 data.
Between 2000 and 2004, coverage by the compulsory insurance scheme increased from 88% to 94% of adults; however 10% of working-age men remained uninsured. Compulsory health insurance coverage was lower amongst the poor, unemployed, unhealthy and people outside the main cities. The uninsured were less likely to seek medical help for new health problems. 3% of respondents had supplementary (private) insurance, and rising utilisation of private healthcare was greatest amongst the more educated and wealthy.
Despite high population insurance coverage, a multiply disadvantaged uninsured minority remains, with low utilisation of health services. Universal insurance could therefore increase access, and potentially contribute to reducing avoidable healthcare-related mortality. Meanwhile, the socioeconomically advantaged are turning increasingly to a growing private sector.
BMC Health Services Research 05/2009; 9:68. · 1.66 Impact Factor
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ABSTRACT: Although Russian women have adequate knowledge of modern contraceptives, their level of use of these methods has been low, and abortion rates remain relatively high.
In 1994-2003, sexually active women aged 18-49 were interviewed about their contraceptive use as part of the Russia Longitudinal Monitoring Survey. Trends in contraceptive use were examined. Multivariate analyses were conducted to identify characteristics associated with reliable contraceptive use (IUD use or consistent oral contraceptive use) in 1994 and 2003.
In each year, about 25% of sexually active women had used no contraceptive method in the past month, and 20% had used traditional methods. Prevalence of barrier method use increased from 9% to 21% between 1994 and 2003, while that of IUD use declined from 34% to 21%. These changes were especially pronounced in Moscow and St. Petersburg, and among younger women. Common reasons for nonuse were irregular sexual relations (cited by 29% of nonusers in 2003), desire for pregnancy (22%), perceived inability to get pregnant (15%), feeling that contraceptives are uncomfortable or unpleasant (15%), health problems (11%) and the availability of abortion (6%). In 1994 and 2003, the odds of reliable contraceptive use were elevated among women with at least a secondary education (odds ratios, 1.5-1.7), and were reduced among smokers (0.6-0.7).
Modern, effective contraceptive use has not increased among sexually active Russian women. Growing use of barrier contraceptives may reflect HIV awareness. Obstacles to effective contraceptive use, such as attitudes and health service factors, need further clarification.
Perspectives on Sexual and Reproductive Health 04/2009; 41(1):40-50. · 1.41 Impact Factor
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ABSTRACT: To study trends in diabetes awareness and care in post-transition Russia, at a time of increased all-cause and diabetic mortality and disrupted health care.
Trends in diabetes awareness (a self-reported doctor diagnosis) and diabetic treatment were recorded over eight rounds (1994-2003) of the Russia Longitudinal Monitoring Survey, a 38 centre panel study, in respondents aged over 18 (over 7000/round). Logistic regression was used in 2 individual years (1994 and 2003) to study the determinants of diagnosis further.
Throughout the study, diabetes awareness was three times more frequent in women (6%) than men (2%). Awareness was lower in rural and less-educated respondents, and these geographic and socioeconomic differences widened during the study. High body mass index predicted diabetes awareness in women, but did not explain gender or socioeconomic differences. More than half those reporting a diabetic diagnosis reported receiving no conventional medical treatment, and insulin use was less frequent than in Western populations.
The prevalence of diabetic awareness was much lower than studies of diabetes prevalence based on biochemical criteria (9%), and there were unexplained gender and socioeconomic variations. Reported treatment rates were low. Unrecognised and undertreated diabetes may underlie a substantial burden of potentially preventable morbidity in Russia.
Diabetes research and clinical practice 06/2008; 80(2):305-13. · 2.16 Impact Factor
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ABSTRACT: To study different socioeconomic determinants of mortality in posttransition Russia and propose potential explanations. Previous research has demonstrated a widening educational mortality gradient, widespread deprivation, and harmful health behaviors.
Data were from seven rounds (1994-2002) of the 38-center Russia Longitudinal Monitoring Survey. We measured associations among education, income, consumer goods, smoking, alcohol consumption, and subsequent death (reported by another household member), using univariate and multivariate Cox proportional hazards analysis.
There were 11,482 adults older than 18 years, 782 deaths, and a mean follow-up of 4.2 years. Study and national mortality rates were comparable (standardized mortality ratio of 0.96 in men and 0.78 in women). Education predicted mortality strongly: the fully adjusted hazard ratios for less than secondary compared with higher education were 1.68 (1.26-2.23) in men and 3.08 (2.25-4.21) in women. Income and material measures did not predict mortality strongly. Smoking and weekly drinking independently doubled the mortality risk; however, like income, they did not explain the educational mortality gradient, of which material measures accounted for one-third in men only.
Education, unlike material advantage, protected strongly against mortality. Education may better reflect lifetime health-related exposures, although other explanations (e.g., psychosocial, cardiovascular risk) deserve further research. Health behaviors exhibited strong, separate effects on mortality.
Annals of Epidemiology 03/2008; 18(2):92-100. · 3.21 Impact Factor
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ABSTRACT: Research into Russia's health crisis during the 1990s includes studies of both mortality and self-rated health, assuming that the determinants of the two are the same. In this paper, we tested this assumption, using data from a single study on both outcomes and socioeconomic, lifestyle and psychological predictor variables.
We analysed data from 7 rounds (1994-2001) of the Russia Longitudinal Monitoring Survey, a panel study of a general population sample (11,482 adults aged over 18 living in households of 2 or more people). Self-rated health was measured on a 5 point scale and dichotomised by combining responses "very poor" and "poor" into poor health. Deaths (n = 782) during a mean follow up of 4.1 years were reported by another household member. Associations between several predictor variables and poor or very poor self-rated health and mortality were measured using logistic regression and Cox proportional hazards analysis respectively.
Poor self-rated health was significantly associated with mortality; hazard ratios, compared with very good, good or average health, were 1.69 (1.36-2.10) in men and 1.74 (1.38-2.20) in women. Low education predicted both mortality and poor self-rated health, but income predicted subjective health more strongly. Smoking doubled the risk of death but was unrelated to subjective wellbeing. Frequent drinkers experienced greater mortality than occasional drinkers, despite reporting better health. In contrast, dissatisfaction with life predicted poor self-rated health, but not mortality.
Differences between the predictors of subjective health and mortality, even though these outcomes were strongly associated, suggest that influences on subjective health are not restricted to serious disease. These findings also suggest the presence of risk factors for relatively sudden deaths in apparently well people, although further research is required. Meanwhile, caution is required when using studies of self-rated health in Russia to understand the determinants of mortality.
International Journal for Equity in Health 01/2008; 7:19. · 1.71 Impact Factor
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ABSTRACT: Changes in smoking, particularly an increase in women, were predicted to follow the aggressive campaigns of multinational tobacco companies in transitional Russia. However, such changes have not yet been demonstrated unequivocally.
To examine smoking trends by gender, education and area of residence.
Data from 10 rounds of the Russia Longitudinal Monitoring Survey (1992-2003), consisting of more than 3000 men and 4000 women in each round, were used. The mean reported ages of first smoking in current smokers were compared between 10-year birth cohorts.
Between 1992 and 2003, smoking prevalence doubled among women from 6.9% (95% CI 6.3% to 7.6%) to 14.8% (13.9% to 15.7%) and increased among men from 57.4% (95% CI 56.0% to 58.8%) to 62.6% (61.1% to 64.1%). In both sexes, the rise was significantly greater in the least educated, markedly so in women (a doubling vs a 1.5-fold rise in the most educated). Although prevalence of smoking among women was considerably higher in Moscow and St Petersburg than in rural areas, the dramatic threefold increase in prevalence in rural women was significantly greater than in the main cities (36%, p<0.001). The mean age of first smoking was significantly lower in women born after 1960, but in men it was stable between cohorts.
For the first time, it has been shown unequivocally that smoking among women increased markedly during the transition to a market economy in Russia. The already high prevalence of smoking among men has continued to rise. These changes are likely to reflect the activity of the tobacco industry and provide further evidence of the harms of privatisation. Effective tobacco control policies are urgently needed.
Tobacco control 11/2007; 16(5):299-305. · 3.85 Impact Factor
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ABSTRACT: Unhealthy lifestyles contribute substantially to Russia's high mortality. Health control beliefs influence lifestyles to some extent in the West but this relationship is not well studied in Russia.
Data from a 1996 cross-sectional interview study in a multistage random Russian population sample (n=1599, response rate 66%) were analysed. These were belief in the ability to influence general health, risk of heart attack, or cancer; the prevalence of smoking, drinking alcohol several times weekly, binge drinking (>80 g alcohol per occasion), and obesity (self-reported body mass index >30); and several social characteristics.
Believing one could influence one's health (prevalence 63%) and reduce the risk of a heart attack (42%) and cancer (30%) was associated with younger age, male sex, and higher income after controlling for other socioeconomic factors. Associations between health control beliefs and behaviours were generally weak and inconsistent. Men believing they could influence their general health were somewhat less likely to smoke or drink regularly. Fewer women who believed that they could reduce their risk of cancer were obese.
Health control beliefs, commoner in younger and better off Russians, were weakly related to behaviours. This has implications for designing interventions to change health behaviours in Russia.
Preventive Medicine 09/2003; 37(2):73-81. · 3.22 Impact Factor
