1. Self perceived health in Ukraine: results of a cross sectional survey Dr Anna Gilmore EUROPEAN CENTRE ON HEALTH OF SOCIETIES IN TRANSITION London School of Hygiene and Tropical Medicine

2. UKRAINE

3. Source: WHO HFA database Life expectancy at birth

4. Evidence from Russia Shows: –Fall in LE accounted for by increase in cardiovascular and external causes of death –young and middle aged males in lower educational groups –regions undergoing the most rapid economic change Has led experts to suggest that 3 main factors underpin the fall: –Material factors (impoverishment) –Psychosocial factors (instability, stress of change) –Lifestyle factors (alcohol)

5. We therefore used a cross sectional survey to examine: 1. Distribution of health in Ukraine 2. Determinants of health in Ukraine –Impact of s/e and p/s factors on health –Relative importance of these factors 3.Could control explain socioeconomic or psychosocial differences in health? 4Did social networks buffer the impact of these stressors on health?

6. Survey methodology Cross sectional survey of self perceived health Feb-March 2000 Nationally representative sample of adults18+ Multi-stage random sampling technique with the no. of interviews within each area allocated according to population size. Trained interviewers Quality control: In 10% a supervisor present 1590 interviews completed: Response rate 72%

7. What is self perceived health? –Respondents rate their own health on a 5-point scale –Shown to be a valid and reliable measure of overall health –Predictive of mortality and later disability

8. Results: 1. Distribution of self perceived health, sexes combined

9. 2. Determinants of health: binary logistic regression Variables: Demographic: –age, sex, urban/rural, education, nationality, language Socioeconomic: –Income, material situation, employment Psychosocial: –social position, change in social position, control, –social networks: ability to borrow money from family or friends, family relations, marital status, Communist Party membership, membership of a religion Lifestyle: smoking Analysis: Age, sex adjusted Age, sex, education, urban/rural Multivariable analysis (10 variables)

10. OR for average or worse health : sociodemographic factors Age sex adjustedmultivariable Age group: 18-29 30-39 40-49 50-59 60+ 1.00 2.07 (1.46-2.93) 3.68 (2.50-5.44) 8.11 (4.88-13.48) 15.78 (9.19-27.10) 1.00 2.06 (1.41-3.30) 3.91 (2.39-6.39) 6.72 (3.55-12.71) 11.20 (5.02-24.96) Gender: Male Female 1.00 3.51 (2.64-4.67) 1.00 3.58 (2.50-5.14)

11. OR for average or worse health sociodemographic factors cont’d Age sex adjustedmultivariable Urban/rural: Men City>500K Town Village Women City>500K Town Village 1.00 0.62 (0.40-0.96) 1.06 (0.67-1.69) 1.00 2.30 (1.65-3.92) 2.70 (1.49-4.89) 1.00 0.58 (0.34-.99) 0.65 (0.36-1.16) 1.00 2.00 (0.97-4.11) 3.24 (1.30-8.07) Education Higher Secondary < Secondary 1.00 1.90 (1.33-2.72) 1.70 (1.04-2.78) 1.00 1.36 (0.88-2.10) 1.09 (0.58-2.08)

12. OR for average or worse health : socio-economic factors Age sex adjustedmultivariable Material situation: Average or better Bad Very bad 1.00 1.70 (1.24-2.33) 2.02 (1.4-2.91) 1.00 1.31 (0.88-1.94) 1.64 (1.01-2.67) Employed at present: Yes No 1.00 1.65 (1.16-2.34 ) 1.00 1.13 (0.74-1.72) IncomeNo impact

13. OR for average or worse health : psychosocial factors Age sex adjustedmultivariable Control over life High Medium Low 1.00 1.35 (0.99-1.84) 2.40 (1.62-3.55) 1.00 1.26 (0.86-1.83) 1.89 (1.15-3.11) Current social position High Medium low 1.00 1.38 (0.76-21.51) 2.11 (1.16-3.84) Change in social pos’n Improved/the same Got worse 1.00 1.66 (1.24-2.23) 1.00 1.41 (0.99-2.00)

14. OR for average or worse health : Psychosocial factors cont’d Age sex adjustedmultivariable Family relations Very good Normal Tensions & conflicts 1.00 2.21 (1.51-3.22) 3.44 (1.94-6.10) 1.00 2.21 (1.39-3.50) 3.62 (1.76-7.45) Borrow a weeks wage Definitely Probably Probably not Definitely not 1.00 1.44 (1.02-2.03 1.90 (1.26-2.86) 1.96 (1.28-2.99) 1.00 1.49 (0.96-2.30) 1.49 (0.91-2.46) 1.42 (0.83-2.42) Marital status, CP membership, religion, No impact

15. 3. Does control mediate the effect of material and social position on health?

16. 4. Do social networks buffer impact of s/e and p/s stressors on health? Controlling for: OR for less than good self- perceived health unemployed Deterioration in social pos’n

17. Issues/limitations of this study Power to detect significant differences, particularly in sub-group analyses was limited by sample size. No data on alcohol consumption which is an important health determinant in the former Soviet Union. A cross-sectional survey and hence the time sequence and causality of events is difficult to establish.

18. Conclusions Low levels of self rated health in Ukraine Marked gender and geographic inequalities Socio-economic factors (material situation) and psychosocial factors (control, deterioration in social position) are independent health determinants Control over life accounts for the negative impact of low social position on health Good family relations appear to protect against poor health but unclear how this works

19. Suggest that reduction in material wealth, loss of control and ‘change’ may all have contributed to decline in life expectancy seen with transition.