Katherine Keenan

Alcohol and fatal life trajectories in Russia: understanding narrative accounts of premature male death in the family

BackgroundIn the post-Soviet period, Russian working-age men have suffered unusually high mortality rates. Earlier quantitative work found that part of this is attributable to hazardous and harmful patterns of alcohol consumption, which increased in the period of transition at a time of massive social and economic disruption and uncertainty. However, there has been very little work done to document and understand in detail the downward life trajectories of individual men who died prematurely from alcohol-related conditions. Building on an earlier case-control study, this unique qualitative study investigates the perceived interplay between mens drinking careers, their employment and family history, health and eventual death.MethodsIn-depth interviews were conducted with close relatives (most often the widow) of 19 men who died between 2003 and 2005 aged 25-54 years whose close relatives reported that alcohol contributed to their death. The study was conducted in a typical medium-sized Russian city. The relatives accounts were analysed using thematic content analysis.ResultsThe accounts describe how hazardous drinking both contributed to serious employment, family and health problems, and was simultaneously used as a coping mechanism to deal with life crises and a decline in social status. The interviews highlighted the importance of the workplace and employment status for shaping mens drinking patterns. Common themes emerged around a culture of drinking in the workplace, peer pressure from colleagues to drink, use of alcohol as remuneration, consuming non-beverage alcohols, Russian-specific drinking patterns, attitudes to treatment, and passive attitudes towards health and drinking.ConclusionsThe study provides a unique insight into the personal decline that lies behind the extremely high working-age mortality due to heavy drinking in Russia, and highlights how health status and hazardous drinking are often closely intertwined with economic and social functioning. Descriptions of the development of drinking careers, hazardous drinking patterns and treatment experiences can be used to plan effective interventions relevant in the Russian context.

Alcohol consumption and self-reported (SF12) physical and mental health among working-aged men in a typical Russian city: a cross-sectional study

Aim To investigate the association between patterns of alcohol consumption and self-reported physical and mental health in a population with a high prevalence of hazardous drinking. Design Cross-sectional study of an age-stratified random sample of a population register. Setting The city of Izhevsk, The Russian Federation, 2008–09. Participants A total of 1031 men aged 25–60 years (68% response rate). Measurements Self-reported health was evaluated with the SF12 physical (PCS) and mental (MCS) component summaries. Measures of hazardous drinking (based on frequency of adverse effects of alcohol intake including hangover, excessive drunkenness and extended episodes of intoxication lasting 2 or more days) were used in addition to frequency of alcohol consumption and total volume of beverage ethanol per year. Information on smoking and socio-demographic factors were obtained. Findings Compared with abstainers, those drinking 10–19 litres of beverage ethanol per year had a PCS score 2.66 [95% confidence interval (CI) = 0.76; 4.56] higher. Hazardous beverage drinking was associated with a lower PCS score [mean diff: −2.95 (95% CI = −5.28; −0.62)] and even more strongly with a lower MCS score [mean diff: −4.29 (95% CI = −6.87; −1.70)] compared to non-hazardous drinkers, with frequent non-beverage alcohol drinking being associated with a particularly low MCS score [−7.23 (95% CI = −11.16; −3.29)]. Adjustment for smoking and socio-demographic factors attenuated these associations slightly, but the same patterns persisted. Adjustment for employment status attenuated the associations with PCS considerably. Conclusion Among working-aged male adults in Russia, hazardous patterns of alcohol drinking are associated with poorer self-reported physical health, and even more strongly with poorer self-reported mental health. Physical health appears to be lower in those reporting complete abstinence from alcohol compared with those drinking 10–19 litres per year.

Reproductive history and post-reproductive mortality: A sibling comparison analysis using Swedish register data

A growing body of evidence suggests that reproductive history influences post-reproductive mortality. A potential explanation for this association is confounding by socioeconomic status in the family of origin, as socioeconomic status is related to both fertility behaviours and to long-term health. We examine the relationship between age at first birth, completed parity, and post-reproductive mortality and address the potential confounding role of family of origin. We use Swedish population register data for men and women born 1932-1960, and examine both all-cause and cause-specific mortality. The contributions of our study are the use of a sibling comparison design that minimizes residual confounding from shared family background characteristics and assessment of cause-specific mortality that can shed light on the mechanisms linking reproductive history to mortality. Our results were entirely consistent with previous research on this topic, with teenage first time parents having higher mortality, and the relationship between parity and mortality following a U-shaped pattern where childless men and women and those with five or more children had the highest mortality. These results indicate that selection into specific fertility behaviours based upon socioeconomic status and experiences within the family of origin does not explain the relationship between reproductive history and post-reproductive mortality. Additional analyses where we adjust for other lifecourse factors such as educational attainment, attained socioeconomic status, and post-reproductive marital history do not change the results. Our results add an important new level of robustness to the findings on reproductive history and mortality by showing that the association is robust to confounding by factors shared by siblings. However it is still uncertain whether reproductive history causally influences health, or whether other confounding factors such as childhood health or risk-taking propensity could explain the association.

Women's risk of repeat abortions is strongly associated with alcohol consumption: a longitudinal analysis of a Russian national panel study, 1994-2009.

Abortion rates in Russia, particularly repeat abortions, are among the highest in the world, and abortion complications make a substantial contribution to the countrys high maternal mortality rate. Russia also has a very high rate of hazardous alcohol use. However, the association between alcohol use and abortion in Russia remains unexplored. We investigated the longitudinal predictors of first and repeat abortion, focussing on womens alcohol use as a risk factor. Follow-up data from 2,623 women of reproductive age (16–44 years) was extracted from 14 waves of the Russian Longitudinal Monitoring Survey (RLMS), a nationally representative panel study covering the period 1994–2009. We used discrete time hazard models to estimate the probability of having a first and repeat abortion by social, demographic and health characteristics at the preceding study wave. Having a first abortion was associated with demographic factors such as age and parity, whereas repeat abortions were associated with low education and alcohol use. After adjustment for demographic and socioeconomic factors, the risk of having a repeat abortion increased significantly as womens drinking frequency increased (P<0.001), and binge drinking women were significantly more likely to have a repeat abortion than non-drinkers (OR 2.28, 95% CI 1.62–3.20). This association was not accounted for by contraceptive use or a higher risk of pregnancy. Therefore the determinants of first and repeat abortion in Russia between 1994–2009 were different. Women who had repeat abortions were distinguished by their heavier and more frequent alcohol use. The mechanism for the association is not well understood but could be explained by unmeasured personality factors, such as risk taking, or social non-conformity increasing the risk of unplanned pregnancy. Heavy or frequent drinkers constitute a particularly high risk group for repeat abortion, who could be targeted in prevention efforts.

The impact of alcohol consumption on patterns of union formation in Russia 1998–2010: An assessment using longitudinal data

Using data from the Russian Longitudinal Monitoring Survey, 1998–2010, we investigated the extent to which patterns of alcohol consumption in Russia are associated with the subsequent likelihood of entry into cohabitation and marriage. Using discrete-time event history analysis we estimated for 16–50 year olds the extent to which the probabilities of entry into the two types of union were affected by the amount of alcohol drunk and the pattern of drinking, adjusted to allow for social and demographic factors including income, employment, and health. The results show that individuals who did not drink alcohol were less likely to embark on either cohabitation or marriage, that frequent consumption of alcohol was associated with a greater chance of entering unmarried cohabitation than of entering into a marriage, and that heavy drinkers were less likely to convert their relationship from cohabitation to marriage.

Number of children, partnership status and later-life depression in Eastern and Western Europe

Abstract Objectives To investigate associations between number of children and partnership with depressive symptoms among older Europeans and assess whether associations are greater in Eastern than Western countries. We further analyze whether associations are mediated by provision and receipt of emotional and financial support. Methods Using cross-sectional data for five Eastern (Bulgaria, Czech Republic, Georgia, Romania, and Russia) and four Western European countries (Belgium, France, Norway, and Sweden) (n = 15,352), we investigated variation in depressive symptoms using linear regression. We fitted conditional change score models for depressive symptoms using longitudinal data for four countries (Bulgaria, Czech Republic, Georgia, and France) (n = 3,978). Results Unpartnered women and men had more depressive symptoms than the partnered. In Eastern, but not Western, European countries childlessness and having one compared with two children were associated with more depressive symptoms. Formal tests indicated that partnership and number of children were more strongly associated with depressive symptoms in Eastern than Western Europe. Discussion Availability of close family is more strongly associated with older people’s depressive symptoms in Eastern than Western Europe. The collapse of previous state supports and greater economic stress in Eastern Europe may mean that having a partner and children has a greater psychological impact than in Western countries.

Longitudinal Prediction of Divorce in Russia: The Role of Individual and Couple Drinking Patterns

Aims: The aim of the study was to explore associations between dimensions of alcohol use in married couples and subsequent divorce in Russia using longitudinal data. Methods: Follow-up data on 7157 married couples were extracted from 14 consecutive annual rounds (1994–2010) of the Russian Longitudinal Monitoring Survey, a national population-based panel study. Discrete-time hazard models were fitted to estimate the probability of divorce among married couples by drinking patterns reported in the previous survey wave. Results: In adjusted models, increased odds of divorce were associated with greater frequency of husband and wife drinking (test for trend P = 0.005, and P = 0.05, respectively), wifes binge drinking (P = 0.05) and husbands heavy vodka drinking (P = 0.005). Couples in whom the wife drank more frequently than the husband were more likely to divorce (OR 2.86, 95% CI 1.52–5.36), compared with other combinations of drinking. The association between drinking and divorce was stronger in regions outside Moscow or St. Petersburg. Conclusion: This study adds to the sparse literature on the topic and suggests that in Russia heavy and frequent drinking of both husbands and wives put couples at greater risk of future divorce, with some variation by region and aspect of alcohol use.

Medical abortion provision by pharmacies and drug sellers in low-and middle-income countries : a systematic review

Abstract We undertook a systematic review to assess 1) the level and quality of pharmacy and drug shop provision of medical abortion (MA) in low‐ and middle‐income countries (LMICs) and 2) interventions to improve quality of provision. We used standardized terms to search six databases for peer‐reviewed and grey literature. We double‐extracted data using a standardized template, and double‐graded studies for methodological quality. We identified 22 studies from 16 countries reporting on level and quality of MA provision through pharmacies and drug sellers, and three intervention studies. Despite widespread awareness and provision of MA drugs, even in legally restricted contexts, most studies found that pharmacy workers and drug sellers had poor knowledge of effective regimens. Evidence on interventions to improve pharmacy and drug shop provision of MA was limited and generally low quality, but indicated that training could be effective in improving knowledge. Programmatic attention should focus on the development and rigorous evaluation of innovative interventions to improve womens access to information about MA self‐management in low‐and middle‐income countries.

Social factors influencing Russian male alcohol use over the life course: a qualitative study investigating age based social norms, masculinity, and workplace context

The massive fluctuations occurring in Russian alcohol-related mortality since the mid-1980s cannot be seen outside of the context of great social and economic change. There is a dearth of qualitative studies about Russian male drinking and especially needed are those that address social processes and individual changes in drinking. Conducted as part of a longitudinal study on men’s alcohol consumption in Izhevsk, this qualitative study uses 25 semi-structured biographical interviews with men aged 33–60 years to explore life course variation in drinking. The dominant pattern was decreasing binge and frequent drinking as men reached middle age which was precipitated by family building, reductions in drinking with work colleagues, and health concerns. A minority of men described chaotic drinking histories with periods of abstinence and heavy drinking. The results highlight the importance of the blue-collar work environment for conditioning male heavy drinking in young adulthood through a variety of social, normative and structural mechanisms. Post-Soviet changes had a structural influence on the propensity for workplace drinking but the important social function of male drinking sessions remained. Bonding with workmates through heavy drinking was seen as an unavoidable and essential part of young men’s social life. With age peer pressure to drink decreased and the need to perform the role of responsible breadwinner put different behavioural demands on men. For some resisting social pressure to drink became an important site of self-determination and a mark of masculine maturity. Over the lifetime the place where masculine identity was asserted shifted from the workplace to the home, which commonly resulted in a reduction in drinking. We contribute to existing theories of Russian male drinking by showing that the performance of age-related social roles influences Russian men’s drinking patterns, drinking contexts and their attitudes. Further research should be conducted investigating drinking trajectories in Russian men.

Commentary: Alcohol, child development and harm to others: a ‘hard’ problem

In epidemiology and public health, as in any other area of science, not all interesting and potentially important questions are equally easy to address. Some are tough and refractory, resisting repeated attempts to answer them convincingly. The impact of breastfeeding on child growth and development is at the hard end of this spectrum. Observational studies are fraught with difficulties, as breastfeeding in many countries is highly socially patterned and strongly linked to a range of maternal characteristics, all of which could confound any of the observed associations. In addition, the risk of reverse causality is substantial (a sick infant will be fed differently). Nevertheless, there remains considerable scientific, policy and public interest in the potential benefits of breastfeeding on reduced risk of obesity, improved neurocognitive performance and cardiovascular risk profile in childhood and later life, to name but a few outcomes. One of the most important recent contributions to this research area has been the PROBIT trial set up in 1996–97 in Belarus. 1 Taking advantage of the newly found openness resulting from the then recent break-up of the Soviet Union (1991–92), this study used an ingenious and pragmatic clusterrandomized design, in which maternity units were allocated to provide either enhanced breastfeeding support or usual practice. During the past few years, this large trial has provided some of the most convincing evidence to date that extended breastfeeding is associated with increased childhood cognition, 2 but appears not to increase stature or reduce blood pressure or adiposity or obesity in childhood. 3,4 This study is now being exploited to see what it can tell us about the impact of parental behaviours and family circumstances on child development. In this issue of the IJE, Yang and Kramer report the results of their analyses of parental drinking and family break-up on childhood cognition and behaviour at 6.5 years of age. 5 Like the impact of breastfeeding,