Social and Psychosocial Determinants of Self-Rated Health in Central and Eastern Europe
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The next strongest predictors in women were weak social support and low affordability of healthcare. Severely poor women were 1.
Again, the strongest association was found for depression OR 3. The next strong predictor among men was education: those with less than secondary education had three times the odds and those with secondary education 2. The final models were checked for multicollinearity and the detected highest value for the Variance Inflating Factor did not exceed 1. However, between gender differences in self-rated health are frequently insignificant [ 2 , 21 , 50 , 51 ].
A recent study from Sweden suggests that gender differences in self-rated health would disappear if women were as secure financially as men and were not treated in a condescending manner to a larger extent than men [ 49 ]. The Armavir study found that material deprivation was the strongest predictor of poor self-rated health, with a clear dose—response relationship [ 35 ].
In this study, the effect of poverty on self-rated health was mediated largely by psychosocial variables.
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A growing body of evidence showed that the association between material conditions and health outcomes intensifies as income inequality increases and that a threshold of income inequality exists beyond which its negative impacts on health begin to emerge [ 38 ]. The importance of psychosocial pathways through which material circumstances affect health indirectly also is well recognized [ 27 ] and can partly explain our findings.
Previous studies well documented the detrimental effect of depression on health [ 7 , 30 , 52 , 53 ]. Similar to this study, a study from Hungary found depression to be a stronger predictor of self-rated health than socio-economic deprivation and mediate between the latter and self-rated morbidity rates, especially among men [ 30 ].
The study authors hypothesized that in suddenly changing societies material deprivation and depressive symptomatology could worsen each other creating a vicious cycle that leads to higher self-rated morbidity rates. Social support was found to be protective of health in many studies [ 7 , 22 , 25 , 53 - 58 ]. Different emotional and instrumental aid pathways through which social support might influence health were suggested, including better coping abilities with stress, higher sense of self-esteem, self-efficacy and coherence, positive feelings of belonging and attachment, more engagement in health-promoting behaviors and refraining from health-damaging ones [ 59 ].
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We found greater impact of weak social support on perceived health for men than for women, a finding consistent with that from the French Gazel cohort study [ 53 ]. For men, education also showed strong independent dose—response association with self-rated health. This is a common finding in many transition countries [ 19 , 29 ].
However, this association in transition countries is weaker than that seen in the west [ 60 ]. The most common explanation for this difference is that the link between education, occupation and material well-being in these countries is not as consistent as in the west [ 2 , 20 , 61 ].
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Thus, in countries like Armenia, better knowledge of health and better copping abilities among educated might play a more important role in the observed positive association between education and health than a secure position in the labor market that higher education usually guarantees in the west [ 2 ]. We found that educational level was independently associated with self-rated health among men, but not among women.
This finding is consistent with other studies, suggesting that educational level has stronger health effect in men than in women [ 22 , 61 ]. Instead, material conditions, affordability of healthcare and employment were found to be independent predictors of self-rated health among women, but not men. These factors are known determinants of self-rated health [ 21 , 23 , 24 , 32 , 38 ]. Together with unemployment that affected women disproportionately more in Armenia [ 33 ], this reality places women in a situation where the influence of household-related factors on their health is perhaps stronger than that of outside factors.
The influence of housing factors supersede the effect of educational attainment on perceived health [ 63 ]. Previous research has repeatedly shown the relation of unemployment with poor health [ 22 , 24 , 26 , 32 ]. Unemployment can influence health through different pathways including reduced income, psychosocial stress and loss of social networks.
In transition periods, however, when unemployment is a widespread phenomenon, the psychosocial stress caused by it becomes less pronounced [ 64 ]. Employment might contribute differently to perceived health status for women in Armenia. Employment allows women partially to trade household duties for greater control over their life, which was shown to be associated with better perceived health [ 2 , 19 , 20 , 28 , 56 ]. Unemployed women, however, are fully dependent on their housing environment. This study revealed a protective effect of moderate drinking on self-rated health among men.
Previous studies have found a U-shaped relation between alcohol consumption and health: heavy drinkers and those with past history of alcohol abuse usually reported poor health, while those consuming small to moderate amounts of alcohol were more likely to report better health than abstainers [ 3 , 14 , 48 , 65 ]. The positive effect of moderate alcohol consumption on health was attributed to its ability to reduce the risk of cardiovascular and cerebrovascular adverse health events [ 65 ]. However, in cross-sectional studies, a reverse causation is also a possibility, when poor health prevents drinking.
In a study in Russia, frequent drinking was linked to better self-rated health but was also predictive for higher mortality [ 48 ]. These results are consistent with previous studies, which also have shown that behavioral factors usually explain only a small portion of the socioeconomic differences in self-rated health [ 66 , 67 ]. The refusal rate in this household health survey The characteristics of those who refused to participate are unknown, but it is unlikely that response bias could affect the results.
Although the sampled households were representative for each marz , the respondents were selected to preferably include married women or those having children less than 18 years and their husbands. This method could have resulted in an under-representation of older age groups. In the male sample, younger men under 29 were slightly underrepresented, while older men 65 and over were slightly overrepresented. However, age-adjusted logistic regression analysis of the whole sample not shown did not indicate significant between-gender differences in self-rated health.
However, the set of factors independently associated with self-rated health in this study largely mirrors those identified by a number of longitudinal studies as determinants of ill health [ 7 , 14 , 24 , 38 , 53 , 54 , 65 ]. As the study was based on the secondary analysis of previously collected data, our choice of independent variables was limited to what these data could provide.
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Hence, several important potential predictors of self-rated health like perceived life control, details of employment and household labor were left out from this study. In western societies, causes of health inequalities are generally similar for both genders [ 51 ]. In Armenia, however, the lifestyles of women and men are more different than in the west.
Household-related duties are more dominant for women, while men are more engaged in activities outside the household.
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Most probably, the identified between-gender differences in the sets of predictors of perceived health reflect these realities. Nevertheless, this study found no such differences in terms of the strongest predictors of perceived health — psychosocial variables. This study showed that since the Armavir study in [ 44 ], the set of factors independently associated with self-rated health have changed. The role of material deprivation decreased while the influence of psychosocial factors on perceived health became dominant.
The economic growth in Armenia during — could partially explain this change, as it resulted in some reduction of poverty. Another explanation is that in the situation, when poverty became less severe, material circumstances affected health indirectly through psychosocial pathways. The findings of this study emphasize the importance of social reforms to further reduce poverty, ensure universal access to basic healthcare services and improve the psychosocial environment in Armenia. All authors participated in conceptualizing the original assessment and designing the survey instrument.
Demirchyan conceptualized the specific research questions, performed the analysis and drafted the manuscript. Petrosyan and M.
Psychoanalysis / Modern Psychoanalysis
Thompson substantially contributed to the interpretation of data and critically revised the manuscript. All authors read and approved the final manuscript. National Center for Biotechnology Information , U.
Life expectancy in countries of Central and Eastern Europe is substantially shorter than in Western Europe, and a similar divide exists in self-rated health. Read Social and Psychosocial Determinants of Self-Rated Health in Central and Eastern Europe book reviews & author details and more at giuliettasprint.konfer.eu
Int J Equity Health. Published online Nov Author information Article notes Copyright and License information Disclaimer. Corresponding author. Anahit Demirchyan: ma. Received Aug 7; Accepted Nov This article has been cited by other articles in PMC. Abstract Introduction Self-rated health is a widely used health outcome measure that strongly correlates with physical and mental health status and predicts mortality. Results Overall, women and men participated in the survey. Introduction Self-rated health is widely used in cross-sectional studies as a single-item health outcome measure that strongly correlates with objective physical and mental health status [ 1 - 5 ].
Variables Most variables were dichotomized to enhance the interpretability of the logistic regression coefficients.
Statistical analyses The sets of determinants of self-rated health could vary among women and men [ 43 ], thus, this analyses was stratified by gender. Results The mean age of female respondents Open in a separate window. Study limitations The refusal rate in this household health survey Competing interests The authors declare that they have no competing interests.