Kirill Danishevski

Implementing general practice in Russia: getting beyond the first steps

Russia has been trying to establish a model of primary health care based on integrated general practice. Is it managing to shake off the old attitudes and infrastructures of the Soviet era?

Knowledge of the health impacts of smoking and public attitudes towards tobacco control in the former Soviet Union

Aims To describe levels of knowledge on the harmful effects of tobacco and public support for tobacco control measures in nine countries of the former Soviet Union and to examine the characteristics associated with this knowledge and support. Methods Standardised, cross-sectional nationally representative surveys conducted in 2010/2011 with 18 000 men and women aged 18 years and older in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine. Respondents were asked a range of questions on their knowledge of the health effects of tobacco and their support for a variety of tobacco control measures. Descriptive analysis was conducted on levels of knowledge and support, along with multivariate logistic regression analysis of characteristics associated with overall knowledge and support scores. Results Large gaps exist in public understanding of the negative health effects of tobacco use, particularly in Azerbaijan, Kazakhstan, Kyrgyzstan and Moldova. There are also extremely high levels of misunderstanding about the potential effects of ‘light’ cigarettes. However, there is popular support for tobacco control measures. Over three quarters of the respondents felt that their governments could be more effective in pursuing tobacco control. Higher levels of education, social capital (membership of an organisation) and being a former or never-smoker were associated with higher knowledge on the health effects of tobacco and/or being more supportive of tobacco control measures. Conclusions Increasing public awareness of tobaccos health effects is essential for informed decision-making by individuals and for further increasing public support for tobacco control measures.

Public attitudes towards smoking and tobacco control policy in Russia

Background: Since the political transition in 1991, Russia has been targeted intensively by the transnational tobacco industry. Already high smoking rates among men have increased further; traditionally low rates among women have more than doubled. The tobacco companies have so far faced little opposition as they shape the discourse on smoking in Russia. This paper asks what ordinary Russians really think about possible actions to reduce smoking. Methods: A representative sample of the Russian population (1600 respondents) was interviewed face to face in November 2007. Results: Only 14% of respondents considered tobacco control in Russia adequate, while 37% thought that nothing was being done at all. There was support for prices keeping pace with or even exceeding inflation. Over 70% of all respondents favoured a ban on sales from street kiosks, while 56% believed that existing health warnings (currently 4% of front and back of packs) were inadequate. The current policy of designating a few tables in bars and restaurants as non-smoking was supported by less than 10% of respondents, while almost a third supported a total ban, with 44% supporting provision of equal space for smokers and non-smokers. Older age, non-smoking status and living in a smaller town all emerged as significantly associated with the propensity to support antismoking measures. The tobacco companies were generally viewed as behaving like most other companies in Russia, with three-quarters of respondents believing that these companies definitely or maybe bribe politicians. Knowledge of impact of smoking on health was limited with significant underestimation of dangers and addictive qualities of tobacco. A third believed that light cigarettes are safer than normal cigarettes. Conclusion: The majority of the Russian population would support considerable strengthening of tobacco control policies but there is also a need for effective public education campaigns.

Reforming the Russian health-care system

Across Russia, pensioners are protesting about reforms that will remove many of the benefits they currently enjoy, such as free transport and subsidised accommodation and fuel, replacing them with cash allowances that they consider inadequate compensation for what they will lose. This protest is the most visible manifestation of a wide-ranging programme of reform being undertaken by President Vladmir Putin as he seeks to tackle the deep-seated problems facing the country. These reforms have implications for all areas of government activity, including the health sector.

Variations in obstetric practice in Russia: a story of professional autonomy, isolation and limited evidence.

The Russian health system seeks to ensure consistent models of care through a series of nationwide decrees. Yet patterns of care vary widely, often unrelated to evidence of effectiveness. This study examines care provided by obstetricians in all 19 facilities in a typical Russian region. A first set of structured interviews was conducted with 52 obstetricians, with emerging themes explored in a second set of interviews with 36 of the original interviewees. Accounts were compared with quantitative data on patterns of practice.Obstetricians had little access to information, with only limited use of Russian journals and textbooks and minimal access to international evidence.The decisions made by obstetricians largely determined the overall pattern of care, with midwives, nurses and anaesthetists clearly subordinate. Care was highly medicalized, with many interventions long discarded in the west. There was no obvious reason for widespread variations.Obstetric care in Russia is characterized by widespread use of many harmful or ineffective practices, while many effective ones are not used. Effective policies to tackle these problems will require wide-ranging policies addressing factors ranging from educational policies to the status of professionals but, above all, will have to confront the legacy of Soviet science that prioritized ideology over evidence.