Societal characteristics and health in the former communist countries of Central and Eastern Europe and the former Soviet Union: a multilevel analysis

Objectives: To examine whether, in former communist countries that have undergone profound social and economic transformation, health status is associated with income inequality and other societal characteristics, and whether this represents something more than the association of health status with individual socioeconomic circumstances. Design: Multilevel analysis of cross- sectional data. Setting: 13 Countries from Central and Eastern Europe and the former Soviet Union. Participants: Population samples aged 18+ years ( a total of 15 331 respondents). Mean outcome measures: Poor self- rated health. Results: There were marked differences among participating countries in rates of poor health ( a greater than twofold difference between the countries with the highest and lowest rates of poor health), gross domestic product per capita adjusted for purchasing power parity ( a greater than threefold difference), the Gini coefficient of income inequality ( twofold difference), corruption index ( twofold difference) and homicide rates ( 20- fold difference). Ecologically, the age- and sex- standardised prevalence of poor self- rated health correlated strongly with life expectancy at age 15 ( r = -0.73). In multilevel analyses, societal ( country- level) measures of income inequality were not associated with poor health. Corruption and gross domestic product per capita were associated with poor health after controlling for individuals' socioeconomic circumstances ( education, household income, marital status and ownership of household items); the odds ratios were 1.15 ( 95% confidence interval 1.03 to 1.29) per 1 unit ( on a 10- point scale) increase in the corruption index and 0.79 ( 95% confidence interval 0.68 to 0.93) per $ 5000 increase in gross domestic product per capita. The effects of gross domestic product and corruption were virtually identical in people whose household income was below and above the median. Conclusion: Societal measures of prosperity and corruption, but not income inequalities, were associated with health independently of individual- level socioeconomic characteristics. The finding that these effects were similar in persons with lower and higher income suggests that these factors do not operate exclusively through poverty.