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http://bmj.com/cgi/content/full/326/7401/1240
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BMJ 2003;326:1240-1242 (7 June)
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 Collections under
which this article appears: Alcohol
Socioeconomic
Determinants of Health |
S L Plavinski, dean1, S I Plavinskaya, leading researcher2, A N Klimov, principal researcher2
1 College of Public Health, Medical Academy for Postgraduate Studies, Saint Petersburg, Russia, 2 Department of Biochemistry, Institute for Experimental Medicine, Saint Petersburg, Russia
Correspondence to: S L Plavinski splavinskij@mail.ru
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionReferences |
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Objective To determine the association between social factors
and the increase in mortality in Russia in the 1990s.
Design Prospective population cohort study.
Setting Saint Petersburg, Russia.
Participants Two cohorts of men aged 40-59 years randomly selected from district voting list: 3907 screened in 1975-7 and 1467 in 1986-8.
Main outcome measures Education, various health related measures, alcohol intake. Mortality in subsequent 10 years.
Results There was no recorded increase in mortality in men with university degrees. The relative risk in the second cohort compared with the first was 0.92 (95% confidence interval 0.67 to 1.24). For participants with only high school education it was significantly higher in the second cohort (1.32, 1.02 to 1.71). The most pronounced differences were found among participants with the lowest level of education, in which the relative risk was 1.75 (1.44 to 2.12). The same pattern held for coronary vascular disease and cancer mortality.
Conclusion In Russia men in the lower socioeconomic groups were most affected by the sharp increases in mortality in the 1990s.
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Introduction |
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The rapid increase in mortality in Russia in the 1990s was a
development previously not reported in any economically developed
country. For men life expectancy decreased from about 64 years in
1990 to 59 years in 1993.1 There is still
controversy as to who suffered most from concurrent economic
breakdown. Several large prospective studies on mortality from
ischaemic heart disease in Russia offer a unique opportunity to
identify subpopulations that were more affected.
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Methods |
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The study sample comprised two cohorts of men living in the
Petrogradsky district of Leningrad (now Saint Petersburg). The first
cohort was 5000 randomly selected men from the 1974 voting list who
were born from 1916 to 1935. The response rate was 78% (3907 men were
screened). The second cohort was selected from the 1985 voting list
(men born from 1927 to 1946). In total 1000 men aged 40-49 and 1000
aged 50-59 were randomly selected for screening. The response rate
was 71% for 40-49 year olds and 76% for 50-59 year olds (total 1467
men screened). The screening procedure has been described in detail
elsewhere2–4 and was the same
for the two groups.
The follow up study began in January 1979. If the state registration organ (ZAGS) indicated that participants were no longer registered at the designated addresses we tried to contact them if they had moved away or contacted their relatives or neighbours if they had died. Overall loss to follow up was 3%. In the second cohort we were unable to get data for 15 men who had died.
The first cohort was followed up for a mean of 18.1 years, and there were 1890 deaths. The second cohort was followed up for a mean of 11.2 years, and there were 323 deaths. The first day of follow up was the day the last participant from this cohort was screened: 6 July 1977 for the first cohort and 21 August 1988 for the second cohort (see webextra figure). We have presented data for the first 10 years of follow up.
We used Kaplan-Meier survival curves and calculated relative risks and confidence intervals from person time data. We used the exact Poisson method to calculate confidence intervals.5 Statistical analysis was performed with SAS system, version 6.12 for Windows (SAS Institutes, Cary, NC).
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Results |
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The two groups screened closely resembled each other in terms of age,
place of residence, structure, behavioural risk factors, and
biological indicators (table 1). The number of people with
education less than high school decreased because the second cohort
included only those born after the Bolshevik revolution, when high
school education became mandatory.
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Table 2 and the figure show our main results. Among participants with university education all cause mortality in both cohorts was almost the same: 12.8 per 1000 person years of observation for the first cohort and 11.7 for the second (relative risk 0.92, 95% confidence interval 0.67 to 1.24). Mortality among men with only high school education was the same in both cohorts for the first six years of follow up (figure), but then diverged and at the end of follow up was significantly higher in the second cohort (1.32, 1.02 to 1.71). The largest differences were in men with the least education (less than high school). All cause mortality was higher almost from the beginning of the follow up, steadily rising with time and reaching 48.6 per 1000 person years for the second cohort at the end of follow up. Ten years before it was 43% lower (27.8 per 1000 person years; 1.75, 1.44 to 2.12). The increase in mortality has been noted for cardiovascular disease and cancer, though it was not significant for coronary heart disease. Increases in mortality from cardiovascular disease and cancer were highest among men with the least education (1.99, 1.49 to 2.63; and 1.78, 1.20 to 2.58, respectively). Surprisingly, there was no significant increase in the rate of accidental/violent deaths.
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We divided participants into two groups: those who drank more than 150 g of alcohol during the week before screening and those who drank less. In both groups mortality increased in the 1990s (see webextra table A). This increase was more pronounced than the increase in mortality associated with increased alcohol consumption within each cohort. Among men with the least education, mortality in the 1990s increased 60-80% compared with 8-22% increase associated with increased alcohol consumption (the relative risk for alcohol related mortality was 1.27, 1.02 to 1.57, in the first cohort and 1.08, 0.73 to 1.57, in the second cohort).
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Discussion |
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In 1980 the Black report first presented evidence to show the links
between the socioeconomic environment and health and wellbeing.6 In the United Kingdom between 1976-81 and 1986-92
the mortality gap between socioeconomic classes I and II and
classes IV and V increased.7 The higher mortality
among people with little education has also been well documented in
Russian epidemiological studies.3
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Our data show that the increase in mortality in the mid-1990s disproportionately affected men with low education, with an increase of almost 75% from the level of the mid-1980s. The reason why social changes have struck mostly the least educated could be that for those sectors of society, breakdown of the socialist state could engender a sense of catastrophe.9 The mediator between stress and mortality could be alcohol. Russian men commonly use alcohol because it "helps them to forget everyday cares and difficulties."10 Also alcohol related problems were more common among the less educated respondents. However, our analysis shows that the increase in mortality in Russia was socially determined, and though alcohol may play a part in this process it is not the sole factor.
A figure showing
details of recruitment and follow up and a table showing alcohol
intake can be found on bmj.com
We thank all those who participated in data collection and follow up of participants: G Ilyina, A Katrushenko, V Khoptiar, I Klenina, V Konstantinov, B Lipovetsky, E Magracheva, T Maslova, G Mirer, N Muchina, N Nikulcheva, N Parfenova, D Shestov, Y Slepenkov, V Tryufanov, L Vassilieva, N Zhukovskaya.
Contributors: SLP proposed the initial hypotheses, analysed the data. and wrote the paper. SIP participated in data collection and analysis, provided expert knowledge of the mortality classification and determinants of mortality, and provided ideas for study execution and analysis. ANK conceived the study, supervised and directed data collection, and is guarantor. All authors commented on the paper. ANK was the principal investigator in the larger project of which this study is part.
Funding: Cohort study was funded partially by NIH grants NO-1HR12243-L/HR/NHLBI, NO-1HV08112/HV/NHLBI and by the Soviet (then Russian) Academy of Medical Sciences. The guarantor accepts full responsibility for the conduct of the study, had access to the data, and controlled the decision to publish.
Competing interests: None declared.
Ethical approval: The USSR Lipid Research Clinics cohort study has been carried out under a government-to-government agreement between the United States and the Union of Soviet Socialist Republics on a joint programme in cardiovascular diseases, signed in 1972.
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References |
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(Accepted April 7, 2003)
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| Collections under
which this article appears:Alcohol
Socioeconomic
Determinants of Health |
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