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Do health control beliefs predict behaviour in Russians?
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Preventive Medicine 37 (2003) 73– 81
www.elsevier.com/locate/ypmed
Do health control beliefs predict behaviour in Russians? Francesca Perlman, M.D., MFPHM,a,* Martin Bobak, M.D., Ph.D.,a Andrew Steptoe, Ph.D.,a Richard Rose, Ph.D.,b and Michael Marmot, M.D., Ph.D., FRCPa a
International Centre for Health and Society, University College, London, UK Centre for the Study of Public Policy, Strathclyde University, Glasgow, UK
b
Abstract Background. 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. Method. 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. Results. 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. Conclusions. 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. © 2003 American Health Foundation and Elsevier Science (USA). All rights reserved. Keywords: Russia; Internal– external control; Attitude to health; Health behaviour; Psychological models; Knowledge; Attitudes; Practice
Background Life expectancy at birth for Russian men in 1997 was 12 years shorter than the average in the countries now forming the European Union, and for women it was 6 years shorter. The gap is due to the combination of a long-term stagnation in life expectancy in Russia since the 1960s and the dramatic fluctuations in mortality since the collapse of the communist regime in the early 1990s. Much of this difference is explained by a high mortality from noncommunicable disease in Russia, particularly cardiovascular disease and injuries in middle-aged men [1]. Since these diseases are caused at least partly by risk factors that are health
* Corresponding author. International Centre for Health and Society, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK. Fax: ⫹020-78130280. E-mail address: [email protected] (F. Perlman).
behaviours, it is important to explore the factors which influence these behaviours. Cockerham defines health lifestyles as “collective patterns of health-related behaviour based on choices from options available to people according to their life chances” [2]. This implies that lifestyles are a product of both life choices (self-direction) and life chances (related to the influence of structural factors), both concepts described by Max Weber in 1922, and that choice only exists within a range of social constraint, described as “habitus” [3]. The MONICA study showed a high level of risk factors for CVD (such as smoking, high blood pressure, and obesity) in Russia [4]. Similarly, the prevalence of heavy drinking, an important risk factor for alcohol poisoning, injury, and possibly sudden cardiac death, is high in Russian men [5]. High rates of smoking and binge drinking in the FSU may be related to structural aspects of society [6]. A cultural pattern of male heavy drinking emerged amongst peasants in the 19th century [6] and became more frequent in the
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F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
Soviet Union, as did cigarette smoking, after Word War II. In addition, external factors, such as cheap alcohol and cigarettes and the poor availability of a healthy diet, almost certainly contributed to poor health lifestyles [6]. Adoption of health behaviours by individuals is influenced by knowledge and beliefs in a variety of European populations [7] (for example, smoking is less common amongst those who believe that it is harmful). This knowledge is likely to be almost universal in Western populations but our understanding of its level in Russia is limited. However, there is some awareness of the harmful effects of smoking in the former Soviet Union. In Belarus 76% of people believed that smoking was harmful, and in the Ukraine this figure was 88% [8]. Neither is the prevalence of health control beliefs in Russia known. The Soviet health system was not well suited to managing the increasing burden of chronic disease, and there was little emphasis on individual lifestyle change. The health system was oriented towards communicable disease prevention and towards maintaining the fitness of workers. This was in the context of a culture where the individual was less important than the collective [6]. People with greater perceived control over life have a more favourable risk factor profile [9] and better self-rated health [10,11], although the latter was not shown to have been mediated by health behaviour [12]. Poor health-related sense of control strongly predicts poor self-rated health in Russia [13] and is thought to mediate the effects of deprivation and inequality [10]. Several theoretical models describe the effect of health beliefs on behaviour. The social cognition model [14] describes two beliefs required to adopt a particular health behaviour, firstly that its benefits outweigh its costs and secondly that an individual has the skills and ability to perform the preventive behaviour (self-efficacy). The health locus of control model states that people with an internal locus of control (who believe that their own actions influence their health) are more likely to adopt health promoting behaviours than those with an external locus (who believe that external factors influence health most) [15]. There are two subdivisions of external locus of control, the powerful others locus (influence by the actions of people such as health professionals) and the chance locus. There is little evidence to support this hypothesis [16]; it may be useful in the context of the value that people place on their health [17] but even this has had limited support [18]. Very few studies have examined the locus of control over health in Russia, and it is not known whether the models developed in western societies also apply to Russians. Overall, Russian society is one where heavy smoking and drinking are culturally acceptable, passivity and dependence on the state has been encouraged, and a feeling of powerlessness and alienation is common [19]. In this context, the relationship between health control beliefs and behaviour is of interest. In this paper, we addressed two
specific questions. First, we examined whether Russians believe that they can act to control their health and the distribution of these beliefs in relation to socioeconomic factors. Second, we investigated whether health control beliefs influence health behaviours.
Methods We used face-to-face interview data collected during the 1996 New Russia Barometer (NRB) survey, one of a series of surveys on social, economic, and political attitudes during the transition to democracy (www.cspp.strathclyde. ac.uk). The survey was conducted in a national multistage sample of the Russian population aged 18 years and over [20]. The Russian Federation was first stratified into 22 regions, then to urban and rural areas, and then, for rural areas, into regional centres and other towns. From this framework, 69 urban and rural settlements were randomly selected with a probability equal to their population size, and primary sampling units were randomly drawn within these locations. In each primary sampling unit, households were listed by address. One address was selected randomly as the starting point and interviewers were instructed to seek an interview at every nth house. At each address the interviewer asked for a respondent matching by an age by gender by education grid. Of 3379 households with someone at home, in 965 cases no one met the requirements of the age–sex– education grid. Of the 2414 remaining households, in 470 (20%) the interview was refused; in 271 (11%) the door was not answered; in 63 (3%) the identified individual was unable to answer, and 11 interviews (0.4%) were interrupted. The 1599 completed interviews represent a final response rate of 66%. The distribution of the respondents by age, sex, and education corresponded well with the structure of the Russian population [20]. Beliefs about perceived control over health were measured by agreement with three statements: (i) “Keeping healthy depends on things I can do myself”; (ii) “There are certain things I can do to avoid the risk of a heart attack”; and (iii) “There are certain things I can do for myself to reduce the risk of cancer.” Responses were graded on a 6-point scale: “agree strongly,” “agree some,” “agree a little,” “disagree a little,” “disagree some,” and “disagree strongly.” These questions were adapted from the Whitehall II study [21] and are similar to Lachman and Weaver’s questions on perceived mastery [22]. Crohnbach’s-␣ coefficient was 0.68, and factor analysis showed that all three items loaded onto a single factor with an eigenvalue of 1.17. However, we used the questions separately, rather than combining them into one scale. Data on four cardiovascular risk factors which were either health behaviours or (in the case of obesity) strongly related to health behaviour were collected. These were the current smoking (question “Do you smoke now”—yes/
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
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Table 1 Prevalence of health behaviours and health control beliefs by sex and age group Age group
Male 18–29 30–39 40–49 50–59 60–69 70–79 Total Female 18–29 30–39 40–49 50–59 60–69 70–79 Total a
No. of subjects
Percentage current smokers
Percentage drinking several times a week
Percentage binge drinkinga
Percentage obese (BMI ⬎ 30)
Percentage agreeing that they can do things to “Keep healthy”
“Avoid heart attack”
“Avoid cancer”
183 125 169 130 94 30 731
68.3 71.2 70.1 55.8 45.7 40.0 62.9
26.9 21.2 14.3 5.1 4.3 7.4 13.9
45.0 52.1 59.2 43.6 36.1 19.1 47.4
1.7 5.9 7.9 7.9 13.5 22.2 7.2
77.5 69.6 71.6 64.6 54.3 33.3 67.7
51.1 36.8 42.9 46.9 40.4 43.3 44.3
32.8 28.0 29.6 24.6 29.8 30.0 29.3
157 157 173 159 141 81 868
26.9 21.2 14.3 5.1 4.3 7.4 13.9
3.2 1.9 2.9 1.3 0.0 0.0 1.7
11.8 9.8 13.4 6.0 2.9 7.4 9.36
5.1 12.3 22.3 27.4 30.8 17.4 19.1
77.1 70.7 61.0 56.6 44.0 32.1 59.4
42.0 45.5 42.8 38.0 36.2 32.1 40.2
29.3 36.3 36.4 28.5 24.8 18.5 30.1
Binge drinking is defined here as drinking a minimum of a bottle of wine, a large glass of vodka, or 2 litres of beer on one occasion
smoked in past/never smoked), regular drinking, which we defined as drinking alcohol several times a week (question “Do you sometimes drink alcoholic beverages—several alternatives given), binge drinking, which we defined as an average alcohol consumption in one sitting of more than 80 g (question “If you drink, on average how much do you drink in one go”—measures given in beer wine and vodka), and obesity, which we defined as a self-reported body mass index (weight in kilograms/height squared in metres) of at least 30 (question “What is your weight; what is your height”). The survey also collected information on a range of socioeconomic and psychosocial factors. Total household income was reported in roubles per month. The material deprivation score was computed by adding responses to three questions about how often the participants do without food, heating, or necessary clothes or shoes; the score had values from 0 (low) to 9 (high material deprivation). Educational level was reported on the following scale: elementary, secondary, vocational or technical (had completed secondary education and taken other further training but not completed a university degree), and university. Marital status was categorised into married, single, separated or divorced, and widowed. The availability of informal social networks was assessed by a question about on whom the subjects rely when in trouble; the answers were grouped into self, formal, or informal support. Subjective social status was also measured using the question “There are people in a high position in this society and others who have a low status. What position do you have now.” A scale of 1 to 9 was used. The analytical strategy was as follows. Firstly, we assessed the distribution of health control beliefs and health behaviours by age and sex. Since both beliefs and behav-
iours were associated with age, all subsequent analyses controlled for age (modelled as a continuous variable). Health control beliefs and behaviours differed between the sexes, so data for men and women were analysed separately. Secondly, we examined the relationship between socioeconomic factors and beliefs using logistic regression. For this purpose beliefs were dichotomised by collapsing the responses into “agree” and “disagree.” The odds ratios were first adjusted for age and then for other socioeconomic and psychosocial factors. Thirdly, we investigated whether beliefs were associated with behaviours, again using logistic regression with behaviours dichotomised as above. Again we report odds ratios adjusted for age and for age and socioeconomic and psychosocial factors. All analyses were performed using the Stata 6 statistical programme (Stata Corporation http://www. stata.com).
Results Table 1 shows the numbers of men and women and the prevalence of health behaviours and health beliefs by age group and sex. Cigarette smoking and drinking alcohol were significantly more frequent in men (P ⬍ 0.01). Both regular and binge drinking were common in men: almost half the younger male adult population drank at least a bottle of wine or two large glasses of vodka at one sitting. This behaviour was infrequent in women The prevalence of obesity was higher in women (P ⬍ 0.01) and older people of either sex (P ⬍ 0.01). Overall, 63% of the sample agreed that “keeping healthy depends on things I can do myself.” Significantly more men (67%) than women (59%) agreed (P ⫽ 0.02). A smaller
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F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
Table 2 Odds ratios (95% confidence intervals) for health control beliefs by socioeconomic and psychosocial factors in men No. of subjects
Household income (roubles/month) ⱕ500 ⱕ1000 ⱕ1500 ⬎1500 P for trend Source of support Informal ⫾ formal Self only Formal only Education Elementary Completed secondary Vocational/technical University P for trend Marital status Married/cohabiting Single Separated/divorced Widowed Deprivation 1 (Least deprived) 2 3 4 5 (Most deprived) P for trend Self-assessed social status 1 (Highest) 2 3 4 (Lowest) P for trend Age 18–29 30–39 40–49 50–59 60–69 70 and over P for trend
Keeping healthy depends on things I can do myself (agree or disagree)
There are certain things I can do to avoid the risk of a heart attack (agree/disagree)
There are certain things I can do for myself to reduce the risk of cancer (agree/disagree)
Age adjusted
Adjusted for all other factors
Age adjusted
Adjusted for all other factors
Age adjusted
Adjusted for all other factors
208 270 123 130
1 1.89 (1.28–2.79) 1.92 (1.17–3.15) 2.58 (1.53–4.34) ⬍0.001
1 1.90 (1.25–2.87) 1.62 (0.96–2.75) 2.07 (1.17–3.67) 0.017
1 1.15 (0.79–1.67) 1.52 (0.96–2.41) 2.28 (1.44–3.62) ⬍0.001
1 1.23 (0.83–1.84) 1.47 (0.89–2.43) 2.01 (1.20–3.37) 0.019
1 1.14 (0.75–1.74) 1.80 (1.10–2.95) 1.99 (1.22–3.25) 0.003
1 1.20 (0.77–1.87) 1.71 (1.01–2.92) 2.01 (1.16–3.47) 0.007
272 355 94
1 0.87 (0.62–1.23) 0.74 (0.44–1.27)
1 0.80 (0.56–1.15) 0.76 (0.44–1.34)
1 0.70 (0.51–0.96) 0.77 (0.46–1.29)
1 0.64 (0.46–0.89) 0.76 (0.45–1.30)
1 0.81 (0.58–1.14) 0.70 (0.39–1.25)
1 0.80 (0.56–1.13) 0.72 (0.40–1.31)
207 163 242 119
1 1.29 (0.81–2.04) 1.51 (0.98–2.32) 2.22 (1.29–3.84) 0.001
1 1.18 (0.73–1.92) 1.27 (0.81–2.01) 1.75 (0.98–3.12) 0.044
1 1.12 (0.72–1.75) 1.07 (0.71–1.61) 1.95 (1.20–3.16) 0.053
1 1.09 (0.69–1.74) 0.96 (0.62–1.49) 1.63 (0.97–2.73) 0.390
1 1.00 (0.62–1.62) 0.93 (0.59–1.45) 1.25 (0.75–2.08) 0.812
1 0.95 (0.57–1.56) 0.83 (0.51–1.33) 1.06 (0.61–1.83) 0.581
564 116 22 29
1 1.22 (0.69–2.13) 2.17 (0.71–6.65) 0.98 (0.44–2.18)
1 1.19 (0.66–2.15) 2.32 (0.73–7.30) 1.12 (0.49–2.57)
1 0.92 (0.57–1.49) 1.06 (0.45–2.52) 0.67 (0.30–1.51)
1 0.89 (0.53–1.49) 1.28 (0.52–3.18) 0.76 (0.33–1.78)
1 1.30 (0.78–2.17) 1.19 (0.47–2.98) 0.48 (0.17–1.33)
1 1.25 (0.73–2.14) 1.40 (0.54–3.65) 0.54 (0.19–1.52)
224 321 345 407 302
1 0.93 (0.53–1.61) 0.66 (0.39–1.13) 0.62 (0.36–1.07) 0.60 (0.33–1.09) 0.033
1 1.09 (0.61–1.94) 0.75 (0.43–1.32) 0.79 (0.44–1.42) 1.02 (0.53–1.97) 0.660
1 0.57 (0.35–0.92) 0.44 (0.27–0.70) 0.47 (0.29–0.76) 0.50 (0.29–0.87) 0.004
1 0.62 (0.38–1.02) 0.50 (0.30–0.84) 0.61 (0.36–1.03) 0.76 (0.42–1.39) 0.216
1 0.82 (0.49–1.35) 0.84 (0.51–1.38) 0.63 (0.37–1.06) 0.70 (0.39–1.26) 0.212
1 0.91 (0.54–1.54) 0.97 (0.57–1.64) 0.81 (0.46–1.42) 0.98 (0.51–1.88) 0.886
127 315 203 85
1 0.64 (0.39–1.06) 0.52 (0.31–0.87) 0.49 (0.27–0.92) 0.012
1 0.74 (0.44–1.24) 0.63 (0.36–1.08) 0.75 (0.38–1.46) 0.236
1 0.90 (0.59–1.35) 0.52 (0.33–0.82) 0.72 (0.41–1.27) 0.015
1 1.02 (0.65–1.58) 0.64 (0.39–1.03) 0.98 (0.53–1.82) 0.227
1 0.86 (0.56–1.34) 0.70 (0.43–1.15) 0.71 (0.38–1.31) 0.137
1 0.88 (0.55–1.41) 0.78 (0.47–1.30) 0.87 (0.45–1.71) 0.464
183 125 169 130 94 30
1 0.67 (0.40–1.12) 0.73 (0.45–1.19) 0.53 (0.32–0.88) 0.34 (0.20–0.59) 0.15 (0.06–0.34) ⬍0.001
1 0.68 (0.38–1.24) 0.77 (0.44–1.35) 0.56 (0.31–1.02) 0.52 (0.26–1.00) 0.20 (0.08–0.52) 0.008
1 0.56 (0.35–0.89) 0.72 (0.47–1.09) 0.85 (0.54–1.33) 0.65 (0.39–1.08) 0.73 (0.34–1.59) 0.274
1 0.50 (0.29–0.86) 0.73 (0.44–1.20) 0.89 (0.52–1.52) 0.78 (0.41–1.46) 1.02 (0.42–2.46) 0.714
1 0.80 (0.48–1.31) 0.86 (0.55–1.35) 0.67 (0.40–1.11) 0.87 (0.51–1.49) 0.88 (0.38–2.03) 0.331
1 0.83 (0.47–1.48) 0.96 (0.56–1.63) 0.78 (0.43–1.42) 1.20 (0.61–2.37) 1.24 (0.48–3.20) 0.657
proportion agreed that there were things they could do to prevent a heart attack (42%) or cancer (30%), and the prevalence of these beliefs did not differ significantly between men and women. The strength of agreement or disagreement with the health control beliefs is also shown. Fewer people totally or generally agreed with the statements than “agreed a little” or “disagreed some.” Nearly a fifth totally disagreed that they could act to prevent a heart attack, and almost a third that they could do things to prevent cancer. Both health behaviours and beliefs varied with age (Ta-
ble 1). Younger adults smoked more, particularly women, and more younger people believed they could act to influence their health. Individual socioeconomic factors were intercorrelated, but the correlation coefficients were modest, between 0.1 and 0.3. Associations between age, socioeconomic and psychosocial factors, and health control beliefs are shown in Tables 2 (men) and 3 (women). Household income was strongly associated with health control beliefs in men after controlling for socioeconomic factors. In women the association was weaker, and after controlling for age and socio-
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
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Table 3 Odds ratios (95% confidence intervals) for health control beliefs by socioeconomic and psychosocial factors in women No of Keeping healthy depends on subjects things I can do myself (agree or disagree) Age adjusted Household income (roubles/month) ⱕ500 ⱕ1000 ⱕ1500 ⬎1500 P for trend Source of support Informal ⫾ formal Self only Formal only Education Elementary Completed secondary Vocational/technical University P for trend Marital status Married/cohabiting Single Separated/divorced Widowed Deprivation 1 (Least deprived) 2 3 4 5 (Most deprived) P for trend Self-assessed social status 1 (Highest) 2 3 4 (Lowest) P for trend Age 18–29 30–39 40–49 50–59 60–69 70 and over P for trend
Adjusted for all other factors
There are certain things I can do to avoid the risk of a heart attack (agree/disagree)
There are certain things I can do for myself to reduce the risk of cancer (agree/disagree)
Age adjusted
Adjusted for all other factors
Age adjusted
Adjusted for all other factors
1 1.28 (0.90–1.83) 1.69 (0.99–2.88) 1.69 (0.99–2.88) 0.035
1 1.34 (0.94–1.91) 2.18 (1.33–3.57) 2.18 (1.33–3.57) 0.001
1 1.11 (0.76–1.62) 1.54 (0.89–2.66) 1.54 (0.89–2.66) 0.182
334 323 115 96
1 1.52 (1.02–2.11) 1.54 (0.96–2.46) 1.41 (0.85–2.35) 0.051
1 1 1.49 (1.05–2.12) 1.43 (1.03–1.98) 1.44 (0.87–2.38) 1.81 (1.15–2.82) 1.16 (0.65–2.03) 2.32 (1.43–3.75) 0.275 ⬍0.001
401 319 119
1 0.95 (0.70–1.30) 0.50 (0.31–0.81)
1 0.89 (0.65–1.23) 0.49 (0.30–0.81)
1 1 1 1 0.60 (0.44–0.81) 0.56 (0.41–0.77) 0.73 (0.53–1.01) 0.65 (0.46–0.91) 0.81 (0.51–1.29) 0.76 (0.47–1.23) 0.73 (0.44–1.23) 0.69 (0.40–1.18)
301 165 270 132
1 1.27 (0.82–1.96) 0.79 (0.54–1.17) 0.90 (0.56–1.43) 0.268
1 1.07 (0.67–1.70) 0.74 (0.49–1.13) 0.79 (0.47–1.31) 0.178
1 1.01 (0.66–1.55) 1.62 (1.11–2.37) 1.39 (0.88–2.18) 0.018
1 0.84 (0.53–1.33) 1.57 (1.05–2.36) 1.07 (0.66–1.76) 0.078
1 1.06 (0.67–1.68) 1.63 (1.09–2.44) 1.29 (0.79–2.10) 0.019
1 0.99 (0.60–1.62) 1.66 (1.07–2.56) 1.12 (0.66–1.90) 0.071
513 105 93 156
1 1.55 (0.92–2.63) 0.84 (0.53–1.32) 0.66 (0.43–1.02)
1 1.63 (0.94–2.82) 0.99 (0.61–1.62) 0.78 (0.49–1.25)
1 1.71 (1.08–2.71) 0.84 (0.53–1.32) 0.87 (0.55–1.36)
1 1.99 (1.22–3.25) 0.98 (0.60–1.61) 0.98 (0.60–1.58)
1 1.39 (0.86–2.25) 0.55 (0.32–0.92) 0.45 (0.27–0.77)
1 1.54 (0.93–2.56) 0.53 (0.30–0.93) 0.46 (0.27–0.81)
103 158 168 239 200
1 0.66 (0.38–1.16) 0.68 (0.39–1.19) 0.61 (0.36–1.04) 0.55 (0.31–0.95) 0.048
1 0.65 (0.36–1.19) 0.68 (0.37–1.24) 0.67 (0.38–1.18) 0.60 (0.33–1.11) 0.299
1 0.99 (0.60–1.64) 0.54 (0.33–0.90) 0.72 (0.45–1.16) 0.45 (0.27–0.74) 0.001
1 0.99 (0.58–1.69) 0.53 (0.30–0.91) 0.76 (0.45–1.28) 0.49 (0.28–0.86) 0.039
1 0.79 (0.47–1.33) 0.68 (0.41–1.15) 0.63 (0.38–1.04) 0.49 (0.28–0.83) 0.004
1 0.80 (0.46–1.41) 0.73 (0.41–1.28) 0.73 (0.42–1.26) 0.50 (0.28–0.92) 0.119
93 345 275 154
1 0.62 (0.37–1.04) 0.69 (0.41–1.19) 0.53 (0.29–0.95) 0.13
1 0.52 (0.30–0.91) 0.60 (0.33–1.06) 0.47 (0.25–0.88) 0.17
1 0.73 (0.46–1.15) 0.71 (0.44–1.14) 0.59 (0.35–1.02) 0.093
1 0.69 (0.42–1.13) 0.76 (0.45–1.27) 0.68 (0.38–1.22) 0.345
1 0.50 (0.32–0.81) 0.57 (0.35–0.92) 0.42 (0.24–0.75) 0.029
1 0.51 (0.31–0.83) 0.60 (0.35–1.02) 0.53 (0.29–0.98) 0.149
1 1 0.72 (0.43–1.19) 0.97 (0.56–1.71) 0.47 (0.29–0.76) 0.63 (0.37–1.09) 0.39 (0.24–0.63) 0.54 (0.31–0.95) 0.23 (0.14–0.38) 0.35 (0.19–0.65) 0.14 (0.08–0.26) 0.24 (0.12–0.51) ⬍0.001 ⬍0.001
1 1.15 (0.74–1.80) 1.03 (0.67–1.60) 0.84 (0.54–1.33) 0.78 (0.49–1.25) 0.65 (0.37–1.15) 0.020
1 1.55 (0.92–2.60) 1.66 (0.99–2.79) 1.59 (0.92–2.76) 1.57 (0.86–2.87) 1.48 (0.71–3.09) 0.270
1 1.38 (0.86–2.21) 1.38 (0.87–2.19) 0.96 (0.59–1.56) 0.80 (0.48–1.33) 0.55 (0.28–1.06) 0.012
1 1.69 (0.98–2.92) 2.25 (1.30–3.88) 1.87 (1.04–3.38) 1.96 (1.03–3.72) 1.73 (0.76–3.97) 0.060
157 157 173 159 141 87
economic factors only the association with the belief that one can act to prevent a heart attack reached statistical significance. In men, a university education was significantly associated with a belief in the ability to act to control health or prevent a heart attack, but the significance disappeared after socioeconomic factors were controlled for, as did the significance of the trend. In women, a vocational or technical education was statistically significantly associated with a belief in the ability to prevent a heart attack or cancer after controlling for age alone, but not after controlling for so-
cioeconomic factors. The reduction of odds ratios in the multivariate models suggests that the associations were partly confounded or mediated by the covariates. However, these changes in odds ratios were small, and the loss of significance could also have been due to loss of statistical power in the multivariate model. Self-reliance or reliance on formal sources of support was associated with less agreement with any of the health control beliefs, although this reached statistical significance in only two instances. Marital status was not significantly associated with health beliefs in men. Single women were
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Table 4 Odds ratios (95% confidence intervals) of health behaviours for different health control beliefs Smoking Age adjusted
Regular drinking Adjusted for other factorsa
Age adjusted
Men Keeping healthy depends on things I can do myself Agree 0.84 (0.60–1.17) 0.90 (0.63–1.28) 0.48 (0.29–0.79) Disagree 1 1 1 There are certain things I can do to avoid the risk of a heart attack Agree 0.80 (0.58–1.09) 0.87 (0.62–1.21) 0.52 (0.31–0.88) Disagree 1 1 1 There are certain things I can do for myself to reduce the risk of cancer Agree 0.66 (0.47–0.92) 0.69 (0.49–0.98) 0.83 (0.48–1.45) Disagree 1 1 1 Women Keeping healthy depends on things I can do myself Agree 1.39 (0.89–2.19) 1.42 (0.87–2.33) 1.33 (0.41–4.29) Disagree 1 1 1 There are certain things I can do to avoid the risk of a heart attack Agree 1.26 (0.84–1.88) 1.26 (0.80–1.97) 0.48 (0.15–1.54) Disagree 1 1 1 There are certain things I can do for myself to reduce the risk of cancer Agree 1.36 (0.89–2.07) 1.44 (0.91–2.28) 0.30 (0.07–1.36) Disagree 1 1 1 a
Binge drinking Adjusted for other factorsa
Age adjusted
Obesity Adjusted for other factorsa
Age adjusted
Adjusted for other factorsa
0.50 (0.29–0.85) 0.86 (0.61–1.22) 0.94 (0.65–1.34) 0.92 (0.50–1.70) 0.87 (0.46–1.64) 1 1 1 1 1 0.47 (0.27–0.83) 0.95 (0.69–1.30) 1.05 (0.76–1.47) 1.04 (0.58–1.88) 0.97 (0.52–1.80) 1 1 1 1 1 0.89 (0.51–1.58) 0.75 (0.53–1.05) 0.80 (0.56–1.13) 0.89 (0.46–1.73) 0.81 (0.40–1.63) 1 1 1 1 1
1.29 (0.37–4.50) 1.16 (0.62–2.18) 0.99 (0.51–1.92) 0.99 (0.69–1.44) 0.87 (0.59–1.28) 1 1 1 1 1 0.40 (0.11–1.54) 1.04 (0.59–1.86) 1.17 (0.62–2.19) 0.81 (0.56–1.17) 0.87 (0.59–1.29) 1 1 1 1 1 0.33 (0.07–1.60) 0.99 (0.54–1.81) 0.99 (0.52–1.89) 0.56 (0.37–0.87) 0.58 (0.37–0.91) 1 1 1 1 1
Age, total household income, degree of destitution, self-rated social position, marital status, education, and sources of support (self, formal, or informal).
significantly more likely than married women to believe that they could act to prevent a heart attack, and separated or divorced women were significantly less likely than married women to believe that they could act to prevent cancer. In men there was a significant association between health control beliefs and material deprivation but the significance was lost after controlling for other socioeconomic factors. In women there was a significantly association with deprivation for all three health control beliefs when controlled for by age alone, but it persisted only for the belief that one can act to prevent a heart attack after adjusting for socioeconomic factors. There were significant trends in subjective social status in men for a general health control belief and for a belief in women that one can act to prevent cancer. Those with lower social status were less likely to hold these beliefs. Again this association was attenuated after controlling for socioeconomic factors. In men and women most health control beliefs were inversely related to age, although some associations were reduced in multivariate models. Table 4 shows the relationships between health control beliefs and health behaviours. In men a belief that one could act to keep healthy generally or to prevent a heart attack was significantly associated with a lower likelihood of drinking alcohol more than once a week and a belief that one could act to reduce the risk of cancer was significantly associated with current nonsmoking status. In women, a belief that one could act to reduce the risk of cancer was significantly associated with a lower risk of obesity. In contrast, however, health beliefs in women were weakly associated with increased rates of smoking and regular drinking, although these associations did not reach statistical significance,
mainly because of the relatively small numbers of female smokers.
Discussion In this study in a national Russian population sample we found that health control beliefs were associated with several socioeconomic and psychosocial variables. In general, a higher socioeconomic position and more favourable psychosocial characteristics were associated with higher levels of health control beliefs. These beliefs predicted some health behaviours, but the associations were weaker and less consistent than might be expected. Limitations of this study Before interpreting the results, the limitations of the study need to be considered. First, this was a cross-sectional study, subject to a possible reporting bias. However, reporting bias would tend to overestimate any inverse relationship between health control beliefs and health behaviours, but is unlikely to explain the relatively weak associations found here or the positive association between health control beliefs and smoking in women. Second, the questions on health control beliefs were not specific. A general belief that one can act to prevent certain diseases does not imply a correct knowledge of how to do so. These different meanings could help explain why some factors strongly predicted one health control belief but not others. We cannot exclude the possibility that these questions may mean something different to Russian respondents
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
than to those in other countries, although we used a forward and back translation to make sure that the meaning of the original questionnaire was preserved in the Russian version. Our questions on perceived control over health relate to the health locus of control model, described in the introduction. Ideally we should have tested concurrent validity with a well-established scale measuring health locus of control, and the lack of this is a limitation. We were unable to conduct a formal validation of the questionnaire but the face validity of our health control questions was good, and our question on control over general health are very similar to items from the health locus of control scale [15]. Further issues relating to theories of health control which we did not explore were the two subdivisions of external locus of control, the powerful others locus (influence by the actions of people such as health professionals) and the chance locus. However, this theory has had only a limited support [16]. Another issue that we did not explore is the value that people place on their health [17]. These are interesting issues in the context of Palosuo’s study, described in the introduction [19] but we were unable to administer a more extensive interview at that time. Third, there are other risk factors for chronic diseases, such as poor diet and lack of exercise, known to be common in Russia [19]. In addition, the definitions of the unhealthy behaviours studied in this paper may vary. Specifically, regular drinking, defined here as drinking alcohol several times a week, may not indicate drinking an excessive amount. However, other data suggest that regular drinking in Russia is often associated with heavy drinking; accordingly, frequent drinking was found to be associated with increased mortality in a cohort study in Russia [23]. Despite these limitations, we believe that this study sheds some light on the determinants of health control beliefs and health behaviours in Russia. Health control beliefs Substantially more people believed that keeping healthy depended on things they could do themselves than that they could reduce their risk of heart attack or cancer. This may indicate that general health means something other than chronic noncommunicable disease to most people. In particular, cancer may indicate untreatable and unpredictable disease, for which there is little scope for prevention. It could also indicate that ability to influence one’s overall health is a fairly general belief, whereas preventing a heart attack or cancer requires more specific knowledge. There was a tendency for responses to cluster around the middle of the scale (“agree a little” or “disagree some”), consistent with an unwillingness to express a strong preference. A similar pattern was observed in responses to questions on self-rated health [13]. Because of lack of directly comparable data, it is difficult to assess whether the proportion with these health beliefs is high or low.
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Younger age is one of the strongest predictors for a belief that keeping healthy depends on one’s own actions in both sexes, even after controlling for socioeconomic factors, including education. Experience of poor health, commoner in older people, could affect health control beliefs. However, an additional adjustment for self-rated health did not change this pattern. Reasons for the age difference in beliefs are unclear. Several “economies” exist in Russia, formal and informal, monetary and nonmonetary [24]. To take this into account, we used different measures of socioeconomic position: income, material deprivation, and self-assessed social status. Interestingly, income predicted health control beliefs most consistently, but this effect was much stronger in men. One possible explanation is that traditionally wages are more important for men and that women may rely more on the informal economy [24]. Material deprivation and self-rated social status were not significantly associated with health control beliefs after controlling for other socioeconomic factors. However, very few people rated themselves as having high self-rated social status, and this could conceal any underlying trend. A higher level of education predicted some of the health control beliefs, but controlling for other socioeconomic factors reduced the strength of these associations. This could be partly a result of reduced power to detect a difference. Education in itself may have a protective effect on health since people of all social backgrounds benefit [25]. This contrasts with the view that education merely perpetuates social inequalities in health since those with higher social status often receive a better education. Even in Soviet Russia children of professionals and intellectuals were more likely to receive a university education [26]. The weak associations with education and health control beliefs are therefore surprising and suggest that if education does have a protective effect in this population it is not through health control beliefs or their influence on behaviour. People who rely only on formal sources of support generally have weaker health control beliefs. It is possible that membership of the informal social networks formed by many ordinary people as part of the “hourglass society” [27] in an attempt to separate themselves from a state which they continue to mistrust [27] could have a relationship with beliefs. We have shown that monetary income is connected with more health control beliefs. In this case informal networks provide nonmonetary sources of income, for example, through favours done for and by friends, and greater informal “incomes” could be associated in a similar way. Secondly, social capital through network membership may influence health and well-being [28] and this could be partly through beliefs and behaviour. This could be a two-way effect though, since individuals with more initiative and a greater sense of control might be expected to be more likely to form such networks.
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Association between beliefs and behaviour Health control beliefs were associated with lower rates of smoking and drinking in men and lower rates of obesity in women, consistent with what we expected. In general, however, beliefs had a relatively weak effect on behaviours. The positive association between health control and smoking in women is of particular concern. Previous data have shown that there is a demographic transition in the smoking pattern in Russia, where this previously male-dominated behaviour is taken up by women [29]. Pressure from advertising and taxation policies for cigarettes could also contribute to this pattern. The relationship between health beliefs and behaviour in Russia has not been studied extensively and international data are rare and, due to differences in methodology, not directly comparable. One study compared residents of Moscow and Helsinki, a typical Western city. Although people in both cities placed a high abstract rank on health, Muscovites adopted a lifestyle characterised as “passive” and “unhealthy.” Valuing health highly did not influence behaviour in Muscovite men, although it influenced Helsinki men, who exercised more frequently, had a healthier diet, and smoked less [19]. Muscovites tended to have a more external locus of health control, blaming life conditions and genetics for poor health, but in contrast, the Finns blamed their own lack of efforts to improve health [19]. The authors state that a lack of perceived control may be related to a feeling of powerlessness, a facet of a feeling of alienation from society which they also showed to be commoner in Moscow than Helsinki [19]. In another international study, Russian adolescents had high levels of perceived control compared to those in other East European countries [30]. This study also looked at students’ awareness of risk factors for heart disease in Eastern and Western Europe. Western European students had a consistently higher level of awareness than Eastern European students, but the relation between control, awareness, and behaviour was not reported. In another study of students across Europe, high internal health control was associated with healthy behaviours in six domains, including different dietary components and exercise, but not to cigarette smoking and alcohol consumption, though alcohol consumption was very low in this group [31]. In Western countries, perceived self-efficacy or health belief indices have been found to be associated with improved compliance with recommendation to visit a doctors in a mass screening campaign [32], lower rates of smoking and heavy drinking, and higher levels of physical activity [33] and other health behaviours [34]. There is less information on health control explicitly but the literature suggests that it is associated with more favourable health behaviours and compliance with treatment [35]. The fact that in our study few people believed they could prevent cancer or a heart attack and that health control beliefs do not often produce behavioural change supports
Palosuo’s finding that an external health locus of control is commoner in Russians than Finns and that unhealthy lifestyles were common in Russia, despite a high abstract valuation of health by many people [19]. One explanation could be a sense of alienation and powerlessness, shown to be more common in Moscow than the West [19]. Another explanation for the lack of behaviour change could also be incorrect health beliefs; for example, the actions which people believe influence heart disease might not include smoking or binge drinking. The perceived environment or “habitus” [3] which may influence health behaviours in Russians consists of structural factors which do not make the choice of a healthy lifestyle easy. These factors may therefore reduce the influence of health beliefs on behaviour. Heavy drinking and smoking, especially in adult males, remains the cultural norm and is exacerbated by the ready availability of cheap cigarettes and alcohol. A need to prioritise more basic survival in a context of continuing stressful social change may have led to a low priority being placed by many on health promoting behaviours. In addition many people have lived most of their lives in a Soviet society which devalued the individual and which may also have created a false sense of security in its function and ability to take care of people [36], leading to passivity and irresponsibility in health lifestyles [37].
Conclusions and implications for policy and research The unhealthy lifestyle of many Russians, with high levels of smoking and alcohol consumption, undoubtedly contributes to the toll of premature mortality and has implications for the future burden of disease and health care needs. There are widespread beliefs, especially amongst younger people, that one can act to control one’s health. However, these beliefs are often not translated into action. Structural factors such as the availability and pricing of alcohol and cigarettes are important in influencing behaviour, but addressing these issues in Russia may be difficult. It was public unpopularity which led to the demise of Gorbachev’s anti alcohol campaign, which was associated with a reduction in mortality in the 1980s [38]. The nature of the “hourglass” society [27], where many people feel alienated from the aims of the state [19], may reduce the effectiveness of interventions at a state level. More success in changing behaviour may be attained by interventions at the level of informal networks, empowering individuals to change their behaviour. Educational interventions may be of value but their effectiveness in Russia is not well researched. These may be complex areas to address in practice, though, bearing in mind the far more fundamental problems the country faces at present. Future research should focus on more specific health beliefs of Russians and identifying why these are not being translated into action.
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Acknowledgments The New Russia Barometer Study was funded by the Paul Lazarsfeld Society in Vienna, the European Union, and the Centre for the Study of Public Policy (CSPP), University of Strathclyde, Glasgow. The analyses were funded by the John D. and Catherine T. MacArthur Foundation. M.M. is supported by a UK MRC Professorship. References [1] WHO. Highlights on health in the Russian Federation. Geneva: WHO; 1999. [2] Cocham WC. The social determinants of the decline of life expectancy in Russia and Eastern Europe: a lifestyle explanation. J Health Soc Behav 1997;38:117–30. [3] Bourdieu P. Outline of a theory of practice. Cambridge: Cambridge Univ. Press; 1977. [4] Bobak M. Determinants of the East-West life-expectancy gap: contribution of lifestyle and behaviour. Evidence from the MONICA Study. In: Hertzman C, Kelly S, Bobak M, editors. East-West life expectancy gap in Europe. Environmental and non-environmental determinants. Dordrecht: Kluwer Academic; 1996, p. 99 –108. [5] Bobak M, McKee M, Rose R, Marmot M. Alcohol consumption in a national sample of the Russian population. Addiction 1999;94:857– 66. [6] Cockerham WC. Health lifestyles in Russia. Soc Sci Med 2000;51(9): 1313–24. [7] Steptoe A, Wardle J. Cognitive predictors of health behaviour in contrasting regions of Europe. Br J Clin Psychol 1992;31(Pt. 4):485– 502. [8] Rose R, McKee M. Smoking and drinking in Russia, Ukraine and Belarus. Glasgow: CSPP Publications, Univ. of Strathclyde; 1998. [9] Bosma H, Stansfeld SA, Marmot MG. Job control, personal characteristics, and heart disease. J Occup Health Psychol 1998;3(4):402– 09. [10] Bobak M, Marmot M, Pikhart H, Rose R, Pajak A, Rywik S, et al. Socioeconomic factors, material inequalities, and perceived control in self-rated health: cross-sectional data from seven Eastern European countries. Proceeding from the Conference on Self-rated Health, Prague, September 1998. In: Nilsson P, Orth-Gomer K, editors. Selfrated health in a European perspective. Stockholm: FRN; 2000, p. 63–76. [11] Carlson P. Self-perceived health in East and West Europe. Another European health divide. Soc Sci Med 1998;46:1355– 66. [12] Bailis DS, Segall A, Mahon MJ, et al. Perceived control in relation to socioeconomic and behavioural resources for health. Soc Sci Med 2001;52:1661–76. [13] Bobak M, Pikhart H, Hertzman C, Rose R, Marmot M. Socioeconomic factors, perceived control and self-reported health in Russia. A cross-sectional survey. Soc Sci Med 1998;47:269 –79. [14] Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall; 1986. [15] Wallston KA, Wallston BS, De Vellis RF. Development of the Multidimensional Health Locus of Control (MHLC) Scale. Health Education Monogr 2002;6:160 –70. [16] Reich JW, Erdal KJ, Zautra AJ. Beliefs about control and health behaviours. In: Gochman DS, editor. Handbook of health behaviour research: I: Personal and social determinants. New York: Plenum; 1997, p. 93–111. [17] Wallston KA. Hocus-pocus, the focus isn’t strictly on the locus: Rotter social learning theory modified for health. Cognitive Ther Res 1992;16:183–99.
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[18] Bennett P, Norman P, Murphy S, Moore L, Tudor-Smith C. Beliefs about alcohol, health locus of control, value for health and reported consumption in a representative population sample. Health Education Res 1998;13:25–32. [19] Palosuo H. Health-related lifestyles and alienation in Moscow and Helsinki. Soc Sci Med 2000;51(9):1325– 41. [20] Rose R. New Russia Barometer VI: After the presidential election. Centre for the Study of Public Policy: Studies in Public Policy, No. 272. Glasgow: Univ. of Strathclyde; 1996. [21] North FM, Syme SL, Feeney A, Shipley M, Marmot M. Psychosocial work environment and sickness absence among British civil servants: the Whitehall II Study. Am J Public Health 1996;86:332– 40. [22] Lachman ME, Weaver SL. The sense of control as a moderator of social class differences in health and well-being. J Pers Soc Psychol 1998;74:763–73. [23] Malyutina S, Bobak M, Kurilovitch S, Ryizova E, Nikitin Y, Marmot M. Alcohol consumption and binge drinking in Novosibirsk, Russia, 1985–95. Addiction 2001;96:987–95. [24] Rose R, Mishler W, Haerpfer C. “Getting real”: social capital in post-communist societies. Presented on the conference of the Society for Comparative Research: The erosion of confidence in advanced democracies, Brussels, 7–9 November 1996. [25] Reynolds JR, Ross CE. Social stratification and health: education’s benefit beyond economic status and social origins. Soc Problems 2002;45(2):221– 47. [26] World Health Organization. MONICA Psychosocial Optional Study. Suggested measuring instruments. EUR/ICP/NCD 011-5274n. Copenhagen: WHO Regional Office for Europe; 1992. [27] Rose R. Russia as an hour-glass society: a constitution without citizens. EECR 1995;4:34 – 42. [28] Kawachi I, Kennedy BP, Lochner K, Prothrow-Stith D. Social capital, income inequality and mortality. Am J Public Health 1997;87:1491– 98. [29] McKee M, Bobak M, Rose R, Shkolnikov V, Chenet L, Leon D. Patterns of smoking in Russia. Tobacco Control 1998;7:22– 6. [30] Grob A, Little TD, Wanner B, Wearing AJ. Adolescents’ well-being and perceived control across 14 sociocultural contexts. J Personality Soc Psychol 1996;71(4):785–95. [31] Steptoe A, Wardle J. Locus of control and health behaviour revisited: A multivariate analysis of young adults in 18 countries. Br J Psychol 2001;92:659 –72. [32] Guibert R, Leduc N, Fournier P, Tetreault H. What factors determine whether individuals found to have hypercholesterolaemia at mass screening accept advice to visit their physician? Public Health 1999; 113(3):105–10. [33] Troein M, Rastam L, Selander S. Health beliefs and heart disease risk among middle-aged Swedish men. Results from screening in an urban primary care district. Scand J Prim Health Care 1997;15(4):198 –202. [34] Kelly RB, Zyzanski SJ, Alemagno SA. Prediction of motivation and behaviour change following health promotion: role of health beliefs, social support and self-efficacy. Soc Sci Med 1991;32(3):311–20. [35] Droomers M, Schrijvers C, Mackenbach J. Why do lower educated people continue smoking? Explanations from the longitudinal GLOBE study. Health Psychol 2002;21(3):263–72. [36] Shkolnikov V, Mesle F. The Russian mortality crisis as mirrored by mortality. In: DaVanzo J, editor. Russia’s demographic crisis. Santa Monica, CA: Rand; 1996, p. 113– 67. [37] Shkolnikov V, Malkov LP. [Life expectancy in Russia]. Moscow: Center of Demography and Human Ecology; 2000. [38] Shkolnikov VM, Nemtsov A. The anti-alcohol campaign and variations in Russian mortality. In: Bobadilla JL, Costello CA, Mitchell F, editors. Premature death in the New Independent States. Washington, DC: Nat. Acad. Press; 1997, p. 239 – 61.
Preventive Medicine 37 (2003) 73– 81
www.elsevier.com/locate/ypmed
Do health control beliefs predict behaviour in Russians? Francesca Perlman, M.D., MFPHM,a,* Martin Bobak, M.D., Ph.D.,a Andrew Steptoe, Ph.D.,a Richard Rose, Ph.D.,b and Michael Marmot, M.D., Ph.D., FRCPa a
International Centre for Health and Society, University College, London, UK Centre for the Study of Public Policy, Strathclyde University, Glasgow, UK
b
Abstract Background. 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. Method. 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. Results. 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. Conclusions. 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. © 2003 American Health Foundation and Elsevier Science (USA). All rights reserved. Keywords: Russia; Internal– external control; Attitude to health; Health behaviour; Psychological models; Knowledge; Attitudes; Practice
Background Life expectancy at birth for Russian men in 1997 was 12 years shorter than the average in the countries now forming the European Union, and for women it was 6 years shorter. The gap is due to the combination of a long-term stagnation in life expectancy in Russia since the 1960s and the dramatic fluctuations in mortality since the collapse of the communist regime in the early 1990s. Much of this difference is explained by a high mortality from noncommunicable disease in Russia, particularly cardiovascular disease and injuries in middle-aged men [1]. Since these diseases are caused at least partly by risk factors that are health
* Corresponding author. International Centre for Health and Society, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London WC1E 6BT, UK. Fax: ⫹020-78130280. E-mail address: [email protected] (F. Perlman).
behaviours, it is important to explore the factors which influence these behaviours. Cockerham defines health lifestyles as “collective patterns of health-related behaviour based on choices from options available to people according to their life chances” [2]. This implies that lifestyles are a product of both life choices (self-direction) and life chances (related to the influence of structural factors), both concepts described by Max Weber in 1922, and that choice only exists within a range of social constraint, described as “habitus” [3]. The MONICA study showed a high level of risk factors for CVD (such as smoking, high blood pressure, and obesity) in Russia [4]. Similarly, the prevalence of heavy drinking, an important risk factor for alcohol poisoning, injury, and possibly sudden cardiac death, is high in Russian men [5]. High rates of smoking and binge drinking in the FSU may be related to structural aspects of society [6]. A cultural pattern of male heavy drinking emerged amongst peasants in the 19th century [6] and became more frequent in the
0091-7435/03/$ – see front matter © 2003 American Health Foundation and Elsevier Science (USA). All rights reserved. doi:10.1016/S0091-7435(03)00085-9
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Soviet Union, as did cigarette smoking, after Word War II. In addition, external factors, such as cheap alcohol and cigarettes and the poor availability of a healthy diet, almost certainly contributed to poor health lifestyles [6]. Adoption of health behaviours by individuals is influenced by knowledge and beliefs in a variety of European populations [7] (for example, smoking is less common amongst those who believe that it is harmful). This knowledge is likely to be almost universal in Western populations but our understanding of its level in Russia is limited. However, there is some awareness of the harmful effects of smoking in the former Soviet Union. In Belarus 76% of people believed that smoking was harmful, and in the Ukraine this figure was 88% [8]. Neither is the prevalence of health control beliefs in Russia known. The Soviet health system was not well suited to managing the increasing burden of chronic disease, and there was little emphasis on individual lifestyle change. The health system was oriented towards communicable disease prevention and towards maintaining the fitness of workers. This was in the context of a culture where the individual was less important than the collective [6]. People with greater perceived control over life have a more favourable risk factor profile [9] and better self-rated health [10,11], although the latter was not shown to have been mediated by health behaviour [12]. Poor health-related sense of control strongly predicts poor self-rated health in Russia [13] and is thought to mediate the effects of deprivation and inequality [10]. Several theoretical models describe the effect of health beliefs on behaviour. The social cognition model [14] describes two beliefs required to adopt a particular health behaviour, firstly that its benefits outweigh its costs and secondly that an individual has the skills and ability to perform the preventive behaviour (self-efficacy). The health locus of control model states that people with an internal locus of control (who believe that their own actions influence their health) are more likely to adopt health promoting behaviours than those with an external locus (who believe that external factors influence health most) [15]. There are two subdivisions of external locus of control, the powerful others locus (influence by the actions of people such as health professionals) and the chance locus. There is little evidence to support this hypothesis [16]; it may be useful in the context of the value that people place on their health [17] but even this has had limited support [18]. Very few studies have examined the locus of control over health in Russia, and it is not known whether the models developed in western societies also apply to Russians. Overall, Russian society is one where heavy smoking and drinking are culturally acceptable, passivity and dependence on the state has been encouraged, and a feeling of powerlessness and alienation is common [19]. In this context, the relationship between health control beliefs and behaviour is of interest. In this paper, we addressed two
specific questions. First, we examined whether Russians believe that they can act to control their health and the distribution of these beliefs in relation to socioeconomic factors. Second, we investigated whether health control beliefs influence health behaviours.
Methods We used face-to-face interview data collected during the 1996 New Russia Barometer (NRB) survey, one of a series of surveys on social, economic, and political attitudes during the transition to democracy (www.cspp.strathclyde. ac.uk). The survey was conducted in a national multistage sample of the Russian population aged 18 years and over [20]. The Russian Federation was first stratified into 22 regions, then to urban and rural areas, and then, for rural areas, into regional centres and other towns. From this framework, 69 urban and rural settlements were randomly selected with a probability equal to their population size, and primary sampling units were randomly drawn within these locations. In each primary sampling unit, households were listed by address. One address was selected randomly as the starting point and interviewers were instructed to seek an interview at every nth house. At each address the interviewer asked for a respondent matching by an age by gender by education grid. Of 3379 households with someone at home, in 965 cases no one met the requirements of the age–sex– education grid. Of the 2414 remaining households, in 470 (20%) the interview was refused; in 271 (11%) the door was not answered; in 63 (3%) the identified individual was unable to answer, and 11 interviews (0.4%) were interrupted. The 1599 completed interviews represent a final response rate of 66%. The distribution of the respondents by age, sex, and education corresponded well with the structure of the Russian population [20]. Beliefs about perceived control over health were measured by agreement with three statements: (i) “Keeping healthy depends on things I can do myself”; (ii) “There are certain things I can do to avoid the risk of a heart attack”; and (iii) “There are certain things I can do for myself to reduce the risk of cancer.” Responses were graded on a 6-point scale: “agree strongly,” “agree some,” “agree a little,” “disagree a little,” “disagree some,” and “disagree strongly.” These questions were adapted from the Whitehall II study [21] and are similar to Lachman and Weaver’s questions on perceived mastery [22]. Crohnbach’s-␣ coefficient was 0.68, and factor analysis showed that all three items loaded onto a single factor with an eigenvalue of 1.17. However, we used the questions separately, rather than combining them into one scale. Data on four cardiovascular risk factors which were either health behaviours or (in the case of obesity) strongly related to health behaviour were collected. These were the current smoking (question “Do you smoke now”—yes/
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
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Table 1 Prevalence of health behaviours and health control beliefs by sex and age group Age group
Male 18–29 30–39 40–49 50–59 60–69 70–79 Total Female 18–29 30–39 40–49 50–59 60–69 70–79 Total a
No. of subjects
Percentage current smokers
Percentage drinking several times a week
Percentage binge drinkinga
Percentage obese (BMI ⬎ 30)
Percentage agreeing that they can do things to “Keep healthy”
“Avoid heart attack”
“Avoid cancer”
183 125 169 130 94 30 731
68.3 71.2 70.1 55.8 45.7 40.0 62.9
26.9 21.2 14.3 5.1 4.3 7.4 13.9
45.0 52.1 59.2 43.6 36.1 19.1 47.4
1.7 5.9 7.9 7.9 13.5 22.2 7.2
77.5 69.6 71.6 64.6 54.3 33.3 67.7
51.1 36.8 42.9 46.9 40.4 43.3 44.3
32.8 28.0 29.6 24.6 29.8 30.0 29.3
157 157 173 159 141 81 868
26.9 21.2 14.3 5.1 4.3 7.4 13.9
3.2 1.9 2.9 1.3 0.0 0.0 1.7
11.8 9.8 13.4 6.0 2.9 7.4 9.36
5.1 12.3 22.3 27.4 30.8 17.4 19.1
77.1 70.7 61.0 56.6 44.0 32.1 59.4
42.0 45.5 42.8 38.0 36.2 32.1 40.2
29.3 36.3 36.4 28.5 24.8 18.5 30.1
Binge drinking is defined here as drinking a minimum of a bottle of wine, a large glass of vodka, or 2 litres of beer on one occasion
smoked in past/never smoked), regular drinking, which we defined as drinking alcohol several times a week (question “Do you sometimes drink alcoholic beverages—several alternatives given), binge drinking, which we defined as an average alcohol consumption in one sitting of more than 80 g (question “If you drink, on average how much do you drink in one go”—measures given in beer wine and vodka), and obesity, which we defined as a self-reported body mass index (weight in kilograms/height squared in metres) of at least 30 (question “What is your weight; what is your height”). The survey also collected information on a range of socioeconomic and psychosocial factors. Total household income was reported in roubles per month. The material deprivation score was computed by adding responses to three questions about how often the participants do without food, heating, or necessary clothes or shoes; the score had values from 0 (low) to 9 (high material deprivation). Educational level was reported on the following scale: elementary, secondary, vocational or technical (had completed secondary education and taken other further training but not completed a university degree), and university. Marital status was categorised into married, single, separated or divorced, and widowed. The availability of informal social networks was assessed by a question about on whom the subjects rely when in trouble; the answers were grouped into self, formal, or informal support. Subjective social status was also measured using the question “There are people in a high position in this society and others who have a low status. What position do you have now.” A scale of 1 to 9 was used. The analytical strategy was as follows. Firstly, we assessed the distribution of health control beliefs and health behaviours by age and sex. Since both beliefs and behav-
iours were associated with age, all subsequent analyses controlled for age (modelled as a continuous variable). Health control beliefs and behaviours differed between the sexes, so data for men and women were analysed separately. Secondly, we examined the relationship between socioeconomic factors and beliefs using logistic regression. For this purpose beliefs were dichotomised by collapsing the responses into “agree” and “disagree.” The odds ratios were first adjusted for age and then for other socioeconomic and psychosocial factors. Thirdly, we investigated whether beliefs were associated with behaviours, again using logistic regression with behaviours dichotomised as above. Again we report odds ratios adjusted for age and for age and socioeconomic and psychosocial factors. All analyses were performed using the Stata 6 statistical programme (Stata Corporation http://www. stata.com).
Results Table 1 shows the numbers of men and women and the prevalence of health behaviours and health beliefs by age group and sex. Cigarette smoking and drinking alcohol were significantly more frequent in men (P ⬍ 0.01). Both regular and binge drinking were common in men: almost half the younger male adult population drank at least a bottle of wine or two large glasses of vodka at one sitting. This behaviour was infrequent in women The prevalence of obesity was higher in women (P ⬍ 0.01) and older people of either sex (P ⬍ 0.01). Overall, 63% of the sample agreed that “keeping healthy depends on things I can do myself.” Significantly more men (67%) than women (59%) agreed (P ⫽ 0.02). A smaller
76
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
Table 2 Odds ratios (95% confidence intervals) for health control beliefs by socioeconomic and psychosocial factors in men No. of subjects
Household income (roubles/month) ⱕ500 ⱕ1000 ⱕ1500 ⬎1500 P for trend Source of support Informal ⫾ formal Self only Formal only Education Elementary Completed secondary Vocational/technical University P for trend Marital status Married/cohabiting Single Separated/divorced Widowed Deprivation 1 (Least deprived) 2 3 4 5 (Most deprived) P for trend Self-assessed social status 1 (Highest) 2 3 4 (Lowest) P for trend Age 18–29 30–39 40–49 50–59 60–69 70 and over P for trend
Keeping healthy depends on things I can do myself (agree or disagree)
There are certain things I can do to avoid the risk of a heart attack (agree/disagree)
There are certain things I can do for myself to reduce the risk of cancer (agree/disagree)
Age adjusted
Adjusted for all other factors
Age adjusted
Adjusted for all other factors
Age adjusted
Adjusted for all other factors
208 270 123 130
1 1.89 (1.28–2.79) 1.92 (1.17–3.15) 2.58 (1.53–4.34) ⬍0.001
1 1.90 (1.25–2.87) 1.62 (0.96–2.75) 2.07 (1.17–3.67) 0.017
1 1.15 (0.79–1.67) 1.52 (0.96–2.41) 2.28 (1.44–3.62) ⬍0.001
1 1.23 (0.83–1.84) 1.47 (0.89–2.43) 2.01 (1.20–3.37) 0.019
1 1.14 (0.75–1.74) 1.80 (1.10–2.95) 1.99 (1.22–3.25) 0.003
1 1.20 (0.77–1.87) 1.71 (1.01–2.92) 2.01 (1.16–3.47) 0.007
272 355 94
1 0.87 (0.62–1.23) 0.74 (0.44–1.27)
1 0.80 (0.56–1.15) 0.76 (0.44–1.34)
1 0.70 (0.51–0.96) 0.77 (0.46–1.29)
1 0.64 (0.46–0.89) 0.76 (0.45–1.30)
1 0.81 (0.58–1.14) 0.70 (0.39–1.25)
1 0.80 (0.56–1.13) 0.72 (0.40–1.31)
207 163 242 119
1 1.29 (0.81–2.04) 1.51 (0.98–2.32) 2.22 (1.29–3.84) 0.001
1 1.18 (0.73–1.92) 1.27 (0.81–2.01) 1.75 (0.98–3.12) 0.044
1 1.12 (0.72–1.75) 1.07 (0.71–1.61) 1.95 (1.20–3.16) 0.053
1 1.09 (0.69–1.74) 0.96 (0.62–1.49) 1.63 (0.97–2.73) 0.390
1 1.00 (0.62–1.62) 0.93 (0.59–1.45) 1.25 (0.75–2.08) 0.812
1 0.95 (0.57–1.56) 0.83 (0.51–1.33) 1.06 (0.61–1.83) 0.581
564 116 22 29
1 1.22 (0.69–2.13) 2.17 (0.71–6.65) 0.98 (0.44–2.18)
1 1.19 (0.66–2.15) 2.32 (0.73–7.30) 1.12 (0.49–2.57)
1 0.92 (0.57–1.49) 1.06 (0.45–2.52) 0.67 (0.30–1.51)
1 0.89 (0.53–1.49) 1.28 (0.52–3.18) 0.76 (0.33–1.78)
1 1.30 (0.78–2.17) 1.19 (0.47–2.98) 0.48 (0.17–1.33)
1 1.25 (0.73–2.14) 1.40 (0.54–3.65) 0.54 (0.19–1.52)
224 321 345 407 302
1 0.93 (0.53–1.61) 0.66 (0.39–1.13) 0.62 (0.36–1.07) 0.60 (0.33–1.09) 0.033
1 1.09 (0.61–1.94) 0.75 (0.43–1.32) 0.79 (0.44–1.42) 1.02 (0.53–1.97) 0.660
1 0.57 (0.35–0.92) 0.44 (0.27–0.70) 0.47 (0.29–0.76) 0.50 (0.29–0.87) 0.004
1 0.62 (0.38–1.02) 0.50 (0.30–0.84) 0.61 (0.36–1.03) 0.76 (0.42–1.39) 0.216
1 0.82 (0.49–1.35) 0.84 (0.51–1.38) 0.63 (0.37–1.06) 0.70 (0.39–1.26) 0.212
1 0.91 (0.54–1.54) 0.97 (0.57–1.64) 0.81 (0.46–1.42) 0.98 (0.51–1.88) 0.886
127 315 203 85
1 0.64 (0.39–1.06) 0.52 (0.31–0.87) 0.49 (0.27–0.92) 0.012
1 0.74 (0.44–1.24) 0.63 (0.36–1.08) 0.75 (0.38–1.46) 0.236
1 0.90 (0.59–1.35) 0.52 (0.33–0.82) 0.72 (0.41–1.27) 0.015
1 1.02 (0.65–1.58) 0.64 (0.39–1.03) 0.98 (0.53–1.82) 0.227
1 0.86 (0.56–1.34) 0.70 (0.43–1.15) 0.71 (0.38–1.31) 0.137
1 0.88 (0.55–1.41) 0.78 (0.47–1.30) 0.87 (0.45–1.71) 0.464
183 125 169 130 94 30
1 0.67 (0.40–1.12) 0.73 (0.45–1.19) 0.53 (0.32–0.88) 0.34 (0.20–0.59) 0.15 (0.06–0.34) ⬍0.001
1 0.68 (0.38–1.24) 0.77 (0.44–1.35) 0.56 (0.31–1.02) 0.52 (0.26–1.00) 0.20 (0.08–0.52) 0.008
1 0.56 (0.35–0.89) 0.72 (0.47–1.09) 0.85 (0.54–1.33) 0.65 (0.39–1.08) 0.73 (0.34–1.59) 0.274
1 0.50 (0.29–0.86) 0.73 (0.44–1.20) 0.89 (0.52–1.52) 0.78 (0.41–1.46) 1.02 (0.42–2.46) 0.714
1 0.80 (0.48–1.31) 0.86 (0.55–1.35) 0.67 (0.40–1.11) 0.87 (0.51–1.49) 0.88 (0.38–2.03) 0.331
1 0.83 (0.47–1.48) 0.96 (0.56–1.63) 0.78 (0.43–1.42) 1.20 (0.61–2.37) 1.24 (0.48–3.20) 0.657
proportion agreed that there were things they could do to prevent a heart attack (42%) or cancer (30%), and the prevalence of these beliefs did not differ significantly between men and women. The strength of agreement or disagreement with the health control beliefs is also shown. Fewer people totally or generally agreed with the statements than “agreed a little” or “disagreed some.” Nearly a fifth totally disagreed that they could act to prevent a heart attack, and almost a third that they could do things to prevent cancer. Both health behaviours and beliefs varied with age (Ta-
ble 1). Younger adults smoked more, particularly women, and more younger people believed they could act to influence their health. Individual socioeconomic factors were intercorrelated, but the correlation coefficients were modest, between 0.1 and 0.3. Associations between age, socioeconomic and psychosocial factors, and health control beliefs are shown in Tables 2 (men) and 3 (women). Household income was strongly associated with health control beliefs in men after controlling for socioeconomic factors. In women the association was weaker, and after controlling for age and socio-
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
77
Table 3 Odds ratios (95% confidence intervals) for health control beliefs by socioeconomic and psychosocial factors in women No of Keeping healthy depends on subjects things I can do myself (agree or disagree) Age adjusted Household income (roubles/month) ⱕ500 ⱕ1000 ⱕ1500 ⬎1500 P for trend Source of support Informal ⫾ formal Self only Formal only Education Elementary Completed secondary Vocational/technical University P for trend Marital status Married/cohabiting Single Separated/divorced Widowed Deprivation 1 (Least deprived) 2 3 4 5 (Most deprived) P for trend Self-assessed social status 1 (Highest) 2 3 4 (Lowest) P for trend Age 18–29 30–39 40–49 50–59 60–69 70 and over P for trend
Adjusted for all other factors
There are certain things I can do to avoid the risk of a heart attack (agree/disagree)
There are certain things I can do for myself to reduce the risk of cancer (agree/disagree)
Age adjusted
Adjusted for all other factors
Age adjusted
Adjusted for all other factors
1 1.28 (0.90–1.83) 1.69 (0.99–2.88) 1.69 (0.99–2.88) 0.035
1 1.34 (0.94–1.91) 2.18 (1.33–3.57) 2.18 (1.33–3.57) 0.001
1 1.11 (0.76–1.62) 1.54 (0.89–2.66) 1.54 (0.89–2.66) 0.182
334 323 115 96
1 1.52 (1.02–2.11) 1.54 (0.96–2.46) 1.41 (0.85–2.35) 0.051
1 1 1.49 (1.05–2.12) 1.43 (1.03–1.98) 1.44 (0.87–2.38) 1.81 (1.15–2.82) 1.16 (0.65–2.03) 2.32 (1.43–3.75) 0.275 ⬍0.001
401 319 119
1 0.95 (0.70–1.30) 0.50 (0.31–0.81)
1 0.89 (0.65–1.23) 0.49 (0.30–0.81)
1 1 1 1 0.60 (0.44–0.81) 0.56 (0.41–0.77) 0.73 (0.53–1.01) 0.65 (0.46–0.91) 0.81 (0.51–1.29) 0.76 (0.47–1.23) 0.73 (0.44–1.23) 0.69 (0.40–1.18)
301 165 270 132
1 1.27 (0.82–1.96) 0.79 (0.54–1.17) 0.90 (0.56–1.43) 0.268
1 1.07 (0.67–1.70) 0.74 (0.49–1.13) 0.79 (0.47–1.31) 0.178
1 1.01 (0.66–1.55) 1.62 (1.11–2.37) 1.39 (0.88–2.18) 0.018
1 0.84 (0.53–1.33) 1.57 (1.05–2.36) 1.07 (0.66–1.76) 0.078
1 1.06 (0.67–1.68) 1.63 (1.09–2.44) 1.29 (0.79–2.10) 0.019
1 0.99 (0.60–1.62) 1.66 (1.07–2.56) 1.12 (0.66–1.90) 0.071
513 105 93 156
1 1.55 (0.92–2.63) 0.84 (0.53–1.32) 0.66 (0.43–1.02)
1 1.63 (0.94–2.82) 0.99 (0.61–1.62) 0.78 (0.49–1.25)
1 1.71 (1.08–2.71) 0.84 (0.53–1.32) 0.87 (0.55–1.36)
1 1.99 (1.22–3.25) 0.98 (0.60–1.61) 0.98 (0.60–1.58)
1 1.39 (0.86–2.25) 0.55 (0.32–0.92) 0.45 (0.27–0.77)
1 1.54 (0.93–2.56) 0.53 (0.30–0.93) 0.46 (0.27–0.81)
103 158 168 239 200
1 0.66 (0.38–1.16) 0.68 (0.39–1.19) 0.61 (0.36–1.04) 0.55 (0.31–0.95) 0.048
1 0.65 (0.36–1.19) 0.68 (0.37–1.24) 0.67 (0.38–1.18) 0.60 (0.33–1.11) 0.299
1 0.99 (0.60–1.64) 0.54 (0.33–0.90) 0.72 (0.45–1.16) 0.45 (0.27–0.74) 0.001
1 0.99 (0.58–1.69) 0.53 (0.30–0.91) 0.76 (0.45–1.28) 0.49 (0.28–0.86) 0.039
1 0.79 (0.47–1.33) 0.68 (0.41–1.15) 0.63 (0.38–1.04) 0.49 (0.28–0.83) 0.004
1 0.80 (0.46–1.41) 0.73 (0.41–1.28) 0.73 (0.42–1.26) 0.50 (0.28–0.92) 0.119
93 345 275 154
1 0.62 (0.37–1.04) 0.69 (0.41–1.19) 0.53 (0.29–0.95) 0.13
1 0.52 (0.30–0.91) 0.60 (0.33–1.06) 0.47 (0.25–0.88) 0.17
1 0.73 (0.46–1.15) 0.71 (0.44–1.14) 0.59 (0.35–1.02) 0.093
1 0.69 (0.42–1.13) 0.76 (0.45–1.27) 0.68 (0.38–1.22) 0.345
1 0.50 (0.32–0.81) 0.57 (0.35–0.92) 0.42 (0.24–0.75) 0.029
1 0.51 (0.31–0.83) 0.60 (0.35–1.02) 0.53 (0.29–0.98) 0.149
1 1 0.72 (0.43–1.19) 0.97 (0.56–1.71) 0.47 (0.29–0.76) 0.63 (0.37–1.09) 0.39 (0.24–0.63) 0.54 (0.31–0.95) 0.23 (0.14–0.38) 0.35 (0.19–0.65) 0.14 (0.08–0.26) 0.24 (0.12–0.51) ⬍0.001 ⬍0.001
1 1.15 (0.74–1.80) 1.03 (0.67–1.60) 0.84 (0.54–1.33) 0.78 (0.49–1.25) 0.65 (0.37–1.15) 0.020
1 1.55 (0.92–2.60) 1.66 (0.99–2.79) 1.59 (0.92–2.76) 1.57 (0.86–2.87) 1.48 (0.71–3.09) 0.270
1 1.38 (0.86–2.21) 1.38 (0.87–2.19) 0.96 (0.59–1.56) 0.80 (0.48–1.33) 0.55 (0.28–1.06) 0.012
1 1.69 (0.98–2.92) 2.25 (1.30–3.88) 1.87 (1.04–3.38) 1.96 (1.03–3.72) 1.73 (0.76–3.97) 0.060
157 157 173 159 141 87
economic factors only the association with the belief that one can act to prevent a heart attack reached statistical significance. In men, a university education was significantly associated with a belief in the ability to act to control health or prevent a heart attack, but the significance disappeared after socioeconomic factors were controlled for, as did the significance of the trend. In women, a vocational or technical education was statistically significantly associated with a belief in the ability to prevent a heart attack or cancer after controlling for age alone, but not after controlling for so-
cioeconomic factors. The reduction of odds ratios in the multivariate models suggests that the associations were partly confounded or mediated by the covariates. However, these changes in odds ratios were small, and the loss of significance could also have been due to loss of statistical power in the multivariate model. Self-reliance or reliance on formal sources of support was associated with less agreement with any of the health control beliefs, although this reached statistical significance in only two instances. Marital status was not significantly associated with health beliefs in men. Single women were
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F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
Table 4 Odds ratios (95% confidence intervals) of health behaviours for different health control beliefs Smoking Age adjusted
Regular drinking Adjusted for other factorsa
Age adjusted
Men Keeping healthy depends on things I can do myself Agree 0.84 (0.60–1.17) 0.90 (0.63–1.28) 0.48 (0.29–0.79) Disagree 1 1 1 There are certain things I can do to avoid the risk of a heart attack Agree 0.80 (0.58–1.09) 0.87 (0.62–1.21) 0.52 (0.31–0.88) Disagree 1 1 1 There are certain things I can do for myself to reduce the risk of cancer Agree 0.66 (0.47–0.92) 0.69 (0.49–0.98) 0.83 (0.48–1.45) Disagree 1 1 1 Women Keeping healthy depends on things I can do myself Agree 1.39 (0.89–2.19) 1.42 (0.87–2.33) 1.33 (0.41–4.29) Disagree 1 1 1 There are certain things I can do to avoid the risk of a heart attack Agree 1.26 (0.84–1.88) 1.26 (0.80–1.97) 0.48 (0.15–1.54) Disagree 1 1 1 There are certain things I can do for myself to reduce the risk of cancer Agree 1.36 (0.89–2.07) 1.44 (0.91–2.28) 0.30 (0.07–1.36) Disagree 1 1 1 a
Binge drinking Adjusted for other factorsa
Age adjusted
Obesity Adjusted for other factorsa
Age adjusted
Adjusted for other factorsa
0.50 (0.29–0.85) 0.86 (0.61–1.22) 0.94 (0.65–1.34) 0.92 (0.50–1.70) 0.87 (0.46–1.64) 1 1 1 1 1 0.47 (0.27–0.83) 0.95 (0.69–1.30) 1.05 (0.76–1.47) 1.04 (0.58–1.88) 0.97 (0.52–1.80) 1 1 1 1 1 0.89 (0.51–1.58) 0.75 (0.53–1.05) 0.80 (0.56–1.13) 0.89 (0.46–1.73) 0.81 (0.40–1.63) 1 1 1 1 1
1.29 (0.37–4.50) 1.16 (0.62–2.18) 0.99 (0.51–1.92) 0.99 (0.69–1.44) 0.87 (0.59–1.28) 1 1 1 1 1 0.40 (0.11–1.54) 1.04 (0.59–1.86) 1.17 (0.62–2.19) 0.81 (0.56–1.17) 0.87 (0.59–1.29) 1 1 1 1 1 0.33 (0.07–1.60) 0.99 (0.54–1.81) 0.99 (0.52–1.89) 0.56 (0.37–0.87) 0.58 (0.37–0.91) 1 1 1 1 1
Age, total household income, degree of destitution, self-rated social position, marital status, education, and sources of support (self, formal, or informal).
significantly more likely than married women to believe that they could act to prevent a heart attack, and separated or divorced women were significantly less likely than married women to believe that they could act to prevent cancer. In men there was a significant association between health control beliefs and material deprivation but the significance was lost after controlling for other socioeconomic factors. In women there was a significantly association with deprivation for all three health control beliefs when controlled for by age alone, but it persisted only for the belief that one can act to prevent a heart attack after adjusting for socioeconomic factors. There were significant trends in subjective social status in men for a general health control belief and for a belief in women that one can act to prevent cancer. Those with lower social status were less likely to hold these beliefs. Again this association was attenuated after controlling for socioeconomic factors. In men and women most health control beliefs were inversely related to age, although some associations were reduced in multivariate models. Table 4 shows the relationships between health control beliefs and health behaviours. In men a belief that one could act to keep healthy generally or to prevent a heart attack was significantly associated with a lower likelihood of drinking alcohol more than once a week and a belief that one could act to reduce the risk of cancer was significantly associated with current nonsmoking status. In women, a belief that one could act to reduce the risk of cancer was significantly associated with a lower risk of obesity. In contrast, however, health beliefs in women were weakly associated with increased rates of smoking and regular drinking, although these associations did not reach statistical significance,
mainly because of the relatively small numbers of female smokers.
Discussion In this study in a national Russian population sample we found that health control beliefs were associated with several socioeconomic and psychosocial variables. In general, a higher socioeconomic position and more favourable psychosocial characteristics were associated with higher levels of health control beliefs. These beliefs predicted some health behaviours, but the associations were weaker and less consistent than might be expected. Limitations of this study Before interpreting the results, the limitations of the study need to be considered. First, this was a cross-sectional study, subject to a possible reporting bias. However, reporting bias would tend to overestimate any inverse relationship between health control beliefs and health behaviours, but is unlikely to explain the relatively weak associations found here or the positive association between health control beliefs and smoking in women. Second, the questions on health control beliefs were not specific. A general belief that one can act to prevent certain diseases does not imply a correct knowledge of how to do so. These different meanings could help explain why some factors strongly predicted one health control belief but not others. We cannot exclude the possibility that these questions may mean something different to Russian respondents
F. Perlman et al. / Preventive Medicine 37 (2003) 73– 81
than to those in other countries, although we used a forward and back translation to make sure that the meaning of the original questionnaire was preserved in the Russian version. Our questions on perceived control over health relate to the health locus of control model, described in the introduction. Ideally we should have tested concurrent validity with a well-established scale measuring health locus of control, and the lack of this is a limitation. We were unable to conduct a formal validation of the questionnaire but the face validity of our health control questions was good, and our question on control over general health are very similar to items from the health locus of control scale [15]. Further issues relating to theories of health control which we did not explore were the two subdivisions of external locus of control, the powerful others locus (influence by the actions of people such as health professionals) and the chance locus. However, this theory has had only a limited support [16]. Another issue that we did not explore is the value that people place on their health [17]. These are interesting issues in the context of Palosuo’s study, described in the introduction [19] but we were unable to administer a more extensive interview at that time. Third, there are other risk factors for chronic diseases, such as poor diet and lack of exercise, known to be common in Russia [19]. In addition, the definitions of the unhealthy behaviours studied in this paper may vary. Specifically, regular drinking, defined here as drinking alcohol several times a week, may not indicate drinking an excessive amount. However, other data suggest that regular drinking in Russia is often associated with heavy drinking; accordingly, frequent drinking was found to be associated with increased mortality in a cohort study in Russia [23]. Despite these limitations, we believe that this study sheds some light on the determinants of health control beliefs and health behaviours in Russia. Health control beliefs Substantially more people believed that keeping healthy depended on things they could do themselves than that they could reduce their risk of heart attack or cancer. This may indicate that general health means something other than chronic noncommunicable disease to most people. In particular, cancer may indicate untreatable and unpredictable disease, for which there is little scope for prevention. It could also indicate that ability to influence one’s overall health is a fairly general belief, whereas preventing a heart attack or cancer requires more specific knowledge. There was a tendency for responses to cluster around the middle of the scale (“agree a little” or “disagree some”), consistent with an unwillingness to express a strong preference. A similar pattern was observed in responses to questions on self-rated health [13]. Because of lack of directly comparable data, it is difficult to assess whether the proportion with these health beliefs is high or low.
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Younger age is one of the strongest predictors for a belief that keeping healthy depends on one’s own actions in both sexes, even after controlling for socioeconomic factors, including education. Experience of poor health, commoner in older people, could affect health control beliefs. However, an additional adjustment for self-rated health did not change this pattern. Reasons for the age difference in beliefs are unclear. Several “economies” exist in Russia, formal and informal, monetary and nonmonetary [24]. To take this into account, we used different measures of socioeconomic position: income, material deprivation, and self-assessed social status. Interestingly, income predicted health control beliefs most consistently, but this effect was much stronger in men. One possible explanation is that traditionally wages are more important for men and that women may rely more on the informal economy [24]. Material deprivation and self-rated social status were not significantly associated with health control beliefs after controlling for other socioeconomic factors. However, very few people rated themselves as having high self-rated social status, and this could conceal any underlying trend. A higher level of education predicted some of the health control beliefs, but controlling for other socioeconomic factors reduced the strength of these associations. This could be partly a result of reduced power to detect a difference. Education in itself may have a protective effect on health since people of all social backgrounds benefit [25]. This contrasts with the view that education merely perpetuates social inequalities in health since those with higher social status often receive a better education. Even in Soviet Russia children of professionals and intellectuals were more likely to receive a university education [26]. The weak associations with education and health control beliefs are therefore surprising and suggest that if education does have a protective effect in this population it is not through health control beliefs or their influence on behaviour. People who rely only on formal sources of support generally have weaker health control beliefs. It is possible that membership of the informal social networks formed by many ordinary people as part of the “hourglass society” [27] in an attempt to separate themselves from a state which they continue to mistrust [27] could have a relationship with beliefs. We have shown that monetary income is connected with more health control beliefs. In this case informal networks provide nonmonetary sources of income, for example, through favours done for and by friends, and greater informal “incomes” could be associated in a similar way. Secondly, social capital through network membership may influence health and well-being [28] and this could be partly through beliefs and behaviour. This could be a two-way effect though, since individuals with more initiative and a greater sense of control might be expected to be more likely to form such networks.
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Association between beliefs and behaviour Health control beliefs were associated with lower rates of smoking and drinking in men and lower rates of obesity in women, consistent with what we expected. In general, however, beliefs had a relatively weak effect on behaviours. The positive association between health control and smoking in women is of particular concern. Previous data have shown that there is a demographic transition in the smoking pattern in Russia, where this previously male-dominated behaviour is taken up by women [29]. Pressure from advertising and taxation policies for cigarettes could also contribute to this pattern. The relationship between health beliefs and behaviour in Russia has not been studied extensively and international data are rare and, due to differences in methodology, not directly comparable. One study compared residents of Moscow and Helsinki, a typical Western city. Although people in both cities placed a high abstract rank on health, Muscovites adopted a lifestyle characterised as “passive” and “unhealthy.” Valuing health highly did not influence behaviour in Muscovite men, although it influenced Helsinki men, who exercised more frequently, had a healthier diet, and smoked less [19]. Muscovites tended to have a more external locus of health control, blaming life conditions and genetics for poor health, but in contrast, the Finns blamed their own lack of efforts to improve health [19]. The authors state that a lack of perceived control may be related to a feeling of powerlessness, a facet of a feeling of alienation from society which they also showed to be commoner in Moscow than Helsinki [19]. In another international study, Russian adolescents had high levels of perceived control compared to those in other East European countries [30]. This study also looked at students’ awareness of risk factors for heart disease in Eastern and Western Europe. Western European students had a consistently higher level of awareness than Eastern European students, but the relation between control, awareness, and behaviour was not reported. In another study of students across Europe, high internal health control was associated with healthy behaviours in six domains, including different dietary components and exercise, but not to cigarette smoking and alcohol consumption, though alcohol consumption was very low in this group [31]. In Western countries, perceived self-efficacy or health belief indices have been found to be associated with improved compliance with recommendation to visit a doctors in a mass screening campaign [32], lower rates of smoking and heavy drinking, and higher levels of physical activity [33] and other health behaviours [34]. There is less information on health control explicitly but the literature suggests that it is associated with more favourable health behaviours and compliance with treatment [35]. The fact that in our study few people believed they could prevent cancer or a heart attack and that health control beliefs do not often produce behavioural change supports
Palosuo’s finding that an external health locus of control is commoner in Russians than Finns and that unhealthy lifestyles were common in Russia, despite a high abstract valuation of health by many people [19]. One explanation could be a sense of alienation and powerlessness, shown to be more common in Moscow than the West [19]. Another explanation for the lack of behaviour change could also be incorrect health beliefs; for example, the actions which people believe influence heart disease might not include smoking or binge drinking. The perceived environment or “habitus” [3] which may influence health behaviours in Russians consists of structural factors which do not make the choice of a healthy lifestyle easy. These factors may therefore reduce the influence of health beliefs on behaviour. Heavy drinking and smoking, especially in adult males, remains the cultural norm and is exacerbated by the ready availability of cheap cigarettes and alcohol. A need to prioritise more basic survival in a context of continuing stressful social change may have led to a low priority being placed by many on health promoting behaviours. In addition many people have lived most of their lives in a Soviet society which devalued the individual and which may also have created a false sense of security in its function and ability to take care of people [36], leading to passivity and irresponsibility in health lifestyles [37].
Conclusions and implications for policy and research The unhealthy lifestyle of many Russians, with high levels of smoking and alcohol consumption, undoubtedly contributes to the toll of premature mortality and has implications for the future burden of disease and health care needs. There are widespread beliefs, especially amongst younger people, that one can act to control one’s health. However, these beliefs are often not translated into action. Structural factors such as the availability and pricing of alcohol and cigarettes are important in influencing behaviour, but addressing these issues in Russia may be difficult. It was public unpopularity which led to the demise of Gorbachev’s anti alcohol campaign, which was associated with a reduction in mortality in the 1980s [38]. The nature of the “hourglass” society [27], where many people feel alienated from the aims of the state [19], may reduce the effectiveness of interventions at a state level. More success in changing behaviour may be attained by interventions at the level of informal networks, empowering individuals to change their behaviour. Educational interventions may be of value but their effectiveness in Russia is not well researched. These may be complex areas to address in practice, though, bearing in mind the far more fundamental problems the country faces at present. Future research should focus on more specific health beliefs of Russians and identifying why these are not being translated into action.
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