Health-related lifestyles and alienation in Moscow and Helsinki

Health-related lifestyles and alienation in Moscow and Helsinki

Social Science & Medicine 51 (2000) 1325±1341 www.elsevier.com/locate/socscimed Health-related lifestyles and alienation in Moscow and Helsinki Hann...

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Social Science & Medicine 51 (2000) 1325±1341

www.elsevier.com/locate/socscimed

Health-related lifestyles and alienation in Moscow and Helsinki Hannele Palosuo* Department of Public Health, University of Helsinki, POB 41, FIN-00014 University of Helsinki, Finland

Abstract Health-related lifestyles (smoking, drinking alcohol, exercise and diet) and feelings of alienation (powerlessness and hopelessness) of the citizens of Helsinki and Moscow are examined and discussed in a framework of life chances and life choices. The data were collected by a postal survey of 18±64 yr old citizens of Helsinki (N = 824) and Moscow (N = 545) in 1991. Almost all respondents in both cities used alcohol, but heavy drinking was more frequently reported in Helsinki. Muscovite men were smokers more often and Muscovite women less often than their counterparts in Helsinki. Nearly half of the Muscovites, but less than one-®fth of the Helsinki respondents considered their diet unhealthy or of poor quality. Regular exercise was much more common among the Finns compared to the Muscovites. The sex di€erence in health-related lifestyles was wider in Moscow than in Helsinki, especially concerning health-damaging behaviour. Feelings of alienation were more pronounced in Moscow. In both cities alienation was more clearly associated with socioeconomic life chance factors than with lifestyle factors. In Helsinki feelings of alienation had stronger associations both with health and health related lifestyles, which possibly points to a conventional strati®cation e€ect of a market-based class society. In Moscow, which represents a more traditional community, alienation seemed to be part of a widely felt general discontent. Health was a highly salient value in both cities, especially among women. In Helsinki a high valuation of health was connected with less smoking, more exercise and a healthier diet. Valuing health did not seem to emerge as a distinct healthy lifestyle in Moscow where behavioural choices were limited by many material constraints. 7 2000 Elsevier Science Ltd. All rights reserved. Keywords: Russia; Finland; Lifestyle; Health behaviour; Alienation

Introduction A growing number of studies have found socioeconomic di€erences in mortality and morbidity in Russia

* Tel.: +358-9-191-27544, +358-9-684-5247; fax +358-9191-27540. E-mail address: [email protected] (H. Palosuo).

and other East European countries similar to those found elsewhere (Valkonen, 1987; Kunst, 1997; Shkolnikov, Leon, Adamets, Andreev & Deev, 1998; Watson, 1998; Carlson, 1998; Bobak, Pikhart, Hertzman, Rose & Marmot, 1998). At the same time the question has been raised whether the structural models that emphasise the e€ects of social class on health (WnukLipinski & Illsley, 1990) are as plausible in explaining health di€erences in Russia and other former socialist countries as they are in western societies (Palosuo,

0277-9536/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved. PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 0 9 5 - 2

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Uutela, Zhuravleva & Lakomova, 1998; Watson, 1998). This has to do with the di€erences in the strati®cation structures. Soviet Russia was not a classless society as used to be claimed, neither was it a class society, but rather a system strati®ed by `preclasses' or estates, where material and symbolic rewards were distributed not so much by the market mechanism as by the rules of the centrally planned economy and party oligarchy (see, for example, Piirainen, 1994, 1977; Beliaeva, 1994; Starikov, 1995; Tihonova, 1999). While a process of restructuration of the social hierarchy towards a class society is currently taking place (e.g. Piirainen, 1997; Tihonova, 1999), many `incongruities' originating from the Soviet time seem to persist. An example are those well-educated Russians who have not been able to convert their Soviet time cultural or material `assets' (such as higher education in humanities, engineering skills in the war industries, or social networks essential in managing everyday life) to meet the requirements of the peculiar Russian market of the transition time but have instead fallen into great social and material diculties which would have been unlikely for persons with similar resources in the West (Piirainen, 1997). Because of such incongruities with regard to education, occupation, material rewards and social status, the health consequences of social inequality, including the impact of lifestyles, might in Russia be patterned somewhat di€erently from western countries. Lifestyle and alienation Alcohol and other lifestyle factors have become an important area in the examination of the East±West di€erences in health (Cockerham, 1996, 1999; Bobak & Marmot, 1996; Uitenbroek, Kerekovska & Festchieva, 1996). A healthy way of living has also been acknowledged as a major challenge of preventive public health policy in Soviet and especially present day Russia at least in principle, if not always in practice (see, for example, Kopyt & Sidorov, 1986; Lisicyn, 1989; Towards a Healthy Russia, 1994, 1997). The epidemiological lifestyle approach has, however, also been criticised for being devoid of social context and as such unable to understand the Eastern European trends in health (Makara, 1994). One critical claim has been that the levels of smoking, overall consumption of alcohol or high fat diet have not been substantially higher in the East European populations but sometimes even lower than in the West (Watson, 1995). Instead, Watson (1995) has proposed a psychosocial framework for analysing the health outcomes of the socialist modernisation, or its ¯aws, which were disclosed as high levels of frustration and anomie as well as a growing relative deprivation felt by the East European people in comparison with western people.

This development had resulted in hopelessness concerning future and turning away from the public into the private sphere. The ways to cope with everyday demands were centred and dependent on the family, which under socialism not only retained but even strengthened its position. A family-oriented `neo-traditionalism' or traditionalism in Russia (Piirainen, 1994, 1997) and elsewhere in Eastern Europe may have provided women with better resources to cope with change, which has been suggested as one possible explanation for their better survival as compared to that of men (Watson, 1995). However, psychosocial frameworks are not inconsistent with lifestyle explanations, if lifestyle is understood in a wider social context (e.g. Blaxter, 1990; Abel, 1991; Cockerham, RuÈtten & Abel, 1997). The application of the concept of lifestyle of Max Weber into a health context (Abel, 1991; Cockerham, 1996; Cockerham et al., 1997) gives tools also for comparative purposes. In the Weberian framework two interdependent aspects of lifestyle are distinguished: life chances, which are contingent on structural conditions, and life choices or life conduct, which refer to the personal choices made by individuals. While health-related practices are based on personal choices, they are available to people according to their life chances (Cockerham, 1996). Life chances are conditioned by the structural opportunities embedded in the social positions of the individual, such as sex, age and social class. If values, norms and attitudes are incorporated into the lifestyle approach as suggested by Abel (1991), then cohesion and integration into the society, or its reverse, alienation and anomie, implicated in the psychosocial model (Watson, 1995), can also be included. Values, which are embedded in tradition and steer individual goals, and norms, which regulate behaviour, can obviously have di€erent degrees of cohesive capacity in di€erent societies. The facets of alienation singled out by Seeman (1959) have been useful in empirical research (Ekerwald, 1998; Geyer, 1996). Seeman distinguished between ®ve basic meanings of alienation, as seen from an individuals point of view: powerlessness, meaninglessness, normlessness, isolation and self-estrangement, each of which could be located in and delineated from the classical notions of alienation and anomie. Alienation in the sense of social-psychological powerlessness is related to various concepts of control orientations (see Seeman, 1959). An alienated person is not strongly attached to the goals of society and may not be particularly motivated to follow generally accepted norms (see, for example, Israel, 1994). In the context of health this means that an alienated person may not be interested in keeping ®t or healthy. A society emphasising productivity and competition may estrange those citi-

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zens who cannot keep up with its pace, e.g. because of their poor health. On the other hand, alienation may also be seen as a form of giving up, and as such, an adaptation mechanism in a situation where few active coping mechanisms are available (Manderscheid, 1978). Rapid social change, when the goals and norms are being rede®ned, is likely to evoke high alienation, especially if large segments of the population lose their habitual means of subsistence without ®nding new possibilities to earn their living or to create meaningful ways to exist. In the Marxist view, alienation was to disappear after the alienating capitalistic mode of production was abolished. Therefore alienation was considered neither an appropriate concept nor a suitable topic to study in a socialist country (e.g. Geyer, 1996). Yet by the late 1980s Russian sociologists admitted that alienation was widely experienced in socialist countries, even more so than in capitalist countries (Alienation under Socialism, 1990; Lapin, 1994). They pointed to many indirect indications of alienation expressed in opinion surveys in the Soviet Union, such as high levels of dissatisfaction in di€erent spheres of life and high levels of loneliness. Even in 1991, after some hopeful years of perestroika, opinion surveys revealed growing apathy and disillusionment concerning political activity among the Russians (Levada, 1994). Somewhat later Bobak et al. (1998) found that a low perceived control over life and health, concepts related to alienation, have under the present disruption of social institutions contributed to poor health among the Russians. Context and purpose of the study The purpose of this paper is to examine health-related lifestyles among adult populations in Moscow and Helsinki on the basis of surveys conducted in 1991. At that time Finland was just in the beginning of an economic recession which hit the country harder than the rest of Western Europe, while the Soviet Union had for some six years undergone an accelerating change which lead to the dissolution of the Union that year. At the time of the study Finland could in general terms be characterised as a modern class society based on a market economy, whereas the Soviet Union could in spite of its modern features, such as a high level of industrialisation and education, be seen as a quasimodern or traditional society. Both countries had their own encompassing though qualitatively di€erent welfare structures: Finland a Scandinavian type of welfare system with a national health service (Hermanson, Aro & Bennett, 1994; Health in Finland, 1999), the Soviet Union a socialist welfare system with a free health care which covered the whole population but su€ered from

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serious material de®ciencies (e.g. Lassey, Lassey & Jinks, 1997; Field, 1995; Miljukova & Puuronen, 1999). In spite of the di€erences between the countries there are also cultural and historical similarities which are relevant to health-related lifestyles. Both had undergone a relatively late and rapid industrialisation and urbanisation as compared to most West European countries. Moscow, sometimes called the `big village', had during the forced industrialisation period received masses of migrants, who had taken their countryside habits along and adapted them to the city life, instead of adopting an urban lifestyle. This process has been so slow as to suggest that the `real' urbanisation of Russia is only now underway (see, for example, Piirainen, 1997; also Vishnevskij, 1998). Similarly, Helsinki experienced a doubling of its population in about two decades after the Second World War and is inhabited by rural people. Such histories may be connected to some similarities, e.g. in the heavy drinking habits, typical of northern cultures. However, both Moscow and Helsinki as such belong to the most advanced areas economically and culturally in their own countries and should not be taken as representative of their countries at large. The focus of the present study will be more on Moscow, while Helsinki serves as a `normal' western reference point. This emphasis derives from the fact that very little empirical and comparative research had been done in the Soviet Union and Moscow at that time, whereas health and health behaviour surveys had been carried out routinely for decades in Finland. Drawing on the work of Abel (1991) and Cockerham et al. (1997), lifestyle is here de®ned as a domain of health-related behaviour, manifesting itself as personal, yet collectively and culturally conditioned choices, which are enabled and restricted by structural life chances. Empirically, health-related lifestyle is taken to comprise di€erent habits (smoking, use of alcohol, exercise and dietary habits) and their con®gurations, as well as value orientations such as valuing health and standard of living. The concept `habit' links behaviour to tradition and everyday behaviour; however, `habit', `practice' and `behaviour' will be used synonymously without dwelling on their historical roots in di€erent research traditions. Integration of individuals into society is conceptualised in terms of alienation, which is seen as a mediating mechanism a€ecting people's motivation to lead or not to lead a healthy life. In the lifestyle framework alienation is understood as an expression of the frustration which arises from the lack of possibilities to make choices of whatever chances or opportunities are available. In principle, material constraints should have a stronger e€ect in a class society such as Finland, whereas in a status-ordered society such as Russia, tradition or normative constraints should play a stronger

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role. This can be exempli®ed by the position of alcohol use. In Russia there has been no strict social control on drinking concerning men. Heavy drinking has rather been a tradition of the male culture, but not of the female culture (see, for example, Ryan, 1995; Cockerham, 1996; Simpura & Levin, 1997; Shurygina, 1996). The attitude towards drinking is thus not just a free lifestyle choice but constrained by normative expectations set by tradition. However, at the time of our study the use of alcohol was in Moscow also restricted by material conditions, such as shortage of legally sold alcohol. Tradition is not absent in the western societies either, but for most western people the ways of using alcohol are more likely to be voluntary lifestyle choices of a modern type, conditioned by the class position and including health considerations. There were alienating elements in the rapid economic and cultural changes in both countries at the time of the study, yet it could be expected that alienation would be more strongly felt in Moscow than Helsinki. In this case alienation would contribute to less healthy lifestyles and poorer health in Moscow. The speci®c aims of this study are: 1. To compare health-related lifestyles in Moscow and Helsinki in terms of smoking, use of alcohol, physical exercise and diet by di€erent social strati®cation or life chance factors, such as sex, education, income and occupation. 2. To assess the association of the lifestyles with perceived health, symptoms and illnesses. 3. To study the associations of alienation with healthrelated habits and health. 4. To discuss the meaning and role of the health-related lifestyles in the context of comparative research of communities of a di€erent degree of modernity.

Data and methods The data were collected by mailed questionnaires from random samples of the 18±64-year-old inhabitants of Helsinki (population 0.5 million) and Moscow (population 8.9 million in 1989). In Helsinki the response rate was 71%, which was normal for a postal survey, in Moscow 29%. Postal surveys were not customary in the Soviet Union and response rates were lower than in western countries (Doktorov, 1986). In this study the rate was additionally a€ected by the fact that the data collection had to be ended with the short-lived coup d'eÁtat in August 1991. By that time only one incomplete reminder round had been made in Moscow compared to two full reminder rounds with new questionnaires in Helsinki (more details in Palo-

suo, Zhuravleva, Uutela, Lakomova & Shilova, 1995; Palosuo, 1998). The two data sets (Helsinki N = 824, Moscow N = 545) had compatible distributions by sex and age, and were close to the sex and age compositions of their cities (reported in Palosuo et al., 1998). There is a bias by education in the Moscow data, in which 46% had a university/college education. This clearly exceeds the level reported by the city statistics, where 32% of the employed work force and 26% of the population over 15 yr had at least college level in 1989 (Moskva v cifrah, 1990 g). In Helsinki 15% had a university degree (about 3%-units less than in the Helsinki population). The quality or content of higher education in Moscow was probably not the same as in Helsinki and the average duration of education among the Muscovite respondents with a degree was two years less than in Helsinki. This is consistent with Finns having to complete 12 years of school before entering higher education compared to 10 years in the Soviet Union. Nonetheless, one has to keep in mind that the Russian sample is not representative of the Muscovites but relates to the more educated strata. Because of this bias, the impact of education will be especially addressed in the analyses by partitioning by education or controlling for its e€ect or using its `direct' e€ect by regression analysis. In addition, the role and signi®cance of education as a strati®cation variable will be discussed in relevant connections in the article. In both cities most women were paid employees almost as often as men (78% of women and 86% of men in Moscow, 69% and 73% respectively in Helsinki). Occupation was in Helsinki measured as an occupational area classi®cation and in Moscow as a mixed occupation and professional status classi®cation (see Table 5; distributions in Palosuo et al., 1995). Respondents were instructed to indicate their former occupation, if they were retired or unemployed. Occupation in the two data sets was thus not fully comparable but will nevertheless be used as an indicator of the social position. Health-related lifestyle components studied here are the usual and most important ones: smoking, use of alcohol, exercise and diet (questions and distributions in Palosuo et al., 1995). They were examined by the life chance factors (i.e. social strati®cation variables): sex, age, education (measured as years of completed schooling), family income (5-point scale) and occupation, using crosstabulations and multiple regression analysis (OLS). The associations of alienation with health-related habits and health, as well as associations of the lifestyle components with value assessments and attributions of success in life, were examined by partial correlation coecients. In analyses with categorical variables (occupation), variance analysis and multiple classi®cation analysis (MCA) were used. The interpret-

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ation of the beta coecient produced by MCA is comparable to the interpretation of standardised beta of the multiple regression analysis. Health-related lifestyles There were marked di€erences in health-related habits between the two cities. Men in Moscow were more often daily smokers (46%) than men in Helsinki (35%), but among women it was vice versa: 25% of women in Helsinki and 16% in Moscow were smokers (Table 1). Regular smoking was more common among the less educated Helsinki women and Moscow men, whereas the association was weaker among Helsinki men, and for Moscow women it was the other way round (Table 2). Family income had no statistically signi®cant e€ect on smoking in either city. Being a smoker was signi®cantly more common among male workers in Moscow, whereas white collar employees and health care workers were more seldom smokers (assessed by variance analysis and multiple classi®cation analysis, ®gures not shown). Among Moscow women there was little variation by occupation, teachers being slightly less prone to smoke than other groups. In Helsinki there was no statistically signi®cant

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association between occupation and smoking, but men and women working in science, art and teaching were somewhat less often smokers, whereas men working in administration and women working in commerce tended to smoke more often. In both cities almost all were users of alcohol (Table 1), but the reported frequencies of use of wine, beer and strong liquors were on a lower level in Moscow (see Palosuo, Uutela, Zhuravleva & Lakomova, 1997). Use of homemade wine and illicit home-distilled spirits were more often reported in Moscow, but this did not compensate for the di€erence between the cities. Heavy drinking was more often reported in Helsinki, and so were its harmful consequences. These were connected with a lower level of education among men in both cities (Table 2; for harmful consequences, see Palosuo et al., 1997). Yet, among women a relatively frequent use of alcohol was associated with more education in both cities. Family income was only weakly associated with the frequency of heavy drinking. Men working in industry, construction or trac as well as those working in administration reported more often heavy drinking in Helsinki (®gures not shown), this was similar in Moscow where male workers had highest frequencies but upper white collar workers the lowest. Among Muscovite women, vari-

Table 1 Prevalences of health-related habits (%) and observance of health-enhancing behaviour (Question `Do you regularly engage in some of the following things to keep up your health or ®tness?' Percent answering `yes', of all respondents including `no', `don't know' and missing values.) Helsinki Men (%) Daily smokers Had alcohol past year Has been intoxicated at least every month last year Subjective appraisal of diet as unhealthy (Helsinki) or of insucient/ low quality (Moscow) Has tried to reduce weight during the past year Has co€ee every day Has tea every day Leisure-time exercise at least once a week once a month less often Health-enhancing behaviour: observes a diet for health exercises for health sleeps and rests avoids abundant use of stimulants (Helsinki)/avoids harmful habits (Moscow) attends preventive check-ups (N )

Moscow Women (%)

Men (%)

Women (%)

35 93 40 18

25 90 22 15

46 95 20 41

16 89 4 48

21 90 37

38 87 48

11 52 95

24 72 95

78 11 12 100

74 14 12 100

42 15 43 100

29 12 59 100

28 65 62 53

41 65 70 70

16 44 24 34

24 28 31 47

18 (359±363)

24 (456±461)

15 (230±245)

16 (289±300)

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ation by occupation was similarly statistically signi®cant: workers, but also health care employees and teachers reported more often intoxication than other upper collar employees. Among Helsinki women, workers of industry, construction and trac but even those working in science and art, reported more frequent intoxication, however, the variation was small and nonsigni®cant. In general, Russian women reported much lower use of di€erent beverages than Finnish women. In both cities table wine was somewhat more popular among women than men (Palosuo et al., 1997). Beer was the favourite among Finnish men, strong liquors among Muscovite men. Although the levels of reported use in Moscow were clearly lower compared to a survey in Moscow in 1994 (Simpura, Levin & Mustonen, 1995, 1997), the patterns were consistent with the latter Moscow survey. A distinct cultural di€erence was seen in the consumption of such popular drinks as tea and co€ee. Almost all Muscovites had tea every day, whereas coffee was as self-evidently part of the daily life in Hel-

Table 2 Health-related habits by years of education (controlling for age). Regression coecients (b) and standardised regression coecients (beta) of education, signi®cance of the t-test (sig t ) and multiple correlation coecient squared of the model with education+age (age by 5-yr classes, coecients not shown) b

beta

sig t

R2

Smoking (1=no, 2=sometimes, 3=daily) Moscow men ÿ0.05 ÿ0.16 0.016 0.046 Moscow women 0.02 0.09 0.121 0.027 Helsinki men ÿ0.01 ÿ0.07 0.227 0.032 Helsinki women ÿ0.04 ÿ0.19 0.000 0.069 Frequency of intoxication (from 1=never to 5=weekly) Moscow men ÿ0.04 ÿ0.15 0.017 0.068 Moscow women ÿ0.02 ÿ0.08 0.139 0.121 Helsinki men ÿ0.04 ÿ0.14 0.006 0.108 Helsinki women 0.00 0.02 0.734 0.182 Leisure-time exercise (from 1=weekly to 5=seldom or never) Moscow men ÿ0.06 ÿ0.12 0.076 0.016 Moscow women ÿ0.01 ÿ0.01 0.852 0.006 Helsinki men 0.01 0.04 0.522 0.002 Helsinki women 0.00 0.01 0.818 0.000 Diet (from 1=very healthy, high quality to 5=very unhealthy/of low quality) Moscow men 0.01 0.04 0.555 0.002 Moscow women 0.05 0.16 0.007 0.030 Helsinki men ÿ0.01 ÿ0.07 0.233 0.009 Helsinki women ÿ0.04 ÿ0.16 0.001 0.032

sinki (Table 1). In Moscow especially the well educated women had adopted co€ee drinking much more often than men had. Among Helsinki women abundant consumption of co€ee had a negative correlation with education; instead, having tea was connected with more years of education. Income was not associated with the consumption of these beverages. The consumption of various foodstu€s such as meat, ®sh, milk and their products as well as fruits and vegetables had started to decrease in Russia well before our study in the 1980s (Braithwaite, 1997). The further decline in the study year was probably not so much due to a decrease of the real income which was rather small compared to the following years (e.g. UNICEF, 1993; Klugman & Braithwaite, 1997), as to the obvious distribution problems which were visible as empty shelves in the state food shops. Because of the irritation caused by this development, a detailed assessment of dietary habits in a postal survey in Moscow was considered too risky, and the diet could be addressed by just one question concerning the quality (Moscow) or healthiness (Helsinki) of the diet. The Muscovites reported having a poor diet much more often than the respondents in Helsinki. Finnish women with more years of schooling tended to consider their diet healthy, whereas in Moscow women with more education gave a poor appraisal of their diet (Table 2). Men showed similar though not statistically signi®cant associations at both sites. Family income had only a weak e€ect on this evaluation. The variation by occupation among women in both cities was statistically signi®cant: in Moscow female workers considered their diet more often of good quality than upper white collar workers; in Helsinki diet was considered the healthiest among those working in science and art as well as health and social care (data not shown). Among men the e€ect of occupation was not statistically signi®cant. Leisure-time physical exercise was on a remarkably low level in Moscow. This has been found also in other studies on Russia and Eastern European countries (Towards a Healthy Russia, 1994; Zhuravleva, Shilova, Lakomova & Borzunova, 1993; Cockerham, 1996, 1999; Kauppinen, Yasnaya & Kandolin, 1996; Uitenbroek et al., 1996). While only 12% of the Finnish respondents exercised less frequently than at least once a month, in Moscow 43% of men and 59% of women were on this very low level, or had no exercise at all. Exercise was not statistically signi®cantly associated with education except nearly so among Muscovite men (more exercise with more education; Table 2). Of the occupational groups in Moscow, workers were least prone to exercise among both sexes, whereas teachers and lower white-collar employees tended to be somewhat more active although the associations were not statistically signi®cant in either city.

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Another way to assess health-related lifestyles was by asking whether the respondents practised various habits especially with intent to promote health. These (given in Table 1) were in line with the other indicators described above. Clusters of habits Although some unhealthy habits tend to accumulate, health-related habits do not form unidimensional healthy lifestyles (e.g. Kronenfeld et al., 1988; Blaxter, 1990; Abel, 1991). Summing up behaviours may produce ambiguous indices; yet, the extreme ends of summary indices can be meaningful from a health risk perspective, even if the subjective meaning or cultural context of the practices varies. The proportions of those with `all healthy' habits (no smoking, at least 1± 3 times exercise weekly, healthy/good quality diet, few or no intoxications in a year) were much higher in Helsinki (39% of women, 29% of men) than in Moscow (6% and 7%, respectively). It was very rare to have an `all bad' lifestyle (smoking, intoxication at least every month, exercise less than weekly and a diet of less than good quality). The highest rate was among Muscovite men (5%), but only a few Muscovite women and 2% of the Helsinki respondents were in this group. Similar low prevalences of the aggregation of the same unhealthy habits have been found in other Finnish studies (Karisto, PraÈttaÈlaÈ & Berg, 1993). Smoking and heavy drinking can be considered `active' practices in the sense that they require at least some voluntary consuming. In Helsinki 26% of men reported engaging in both of these injurious habits, but fewer men in Moscow (14%), women in Helsinki being close (13%) and women in Moscow far below (3%). The most common combination of two unhealthy habits among the Muscovites was, on the other hand, having a less than good diet and infrequent or no exercise (37% of men and 52% of women). This is perhaps a rather passive choice and possibly greatly due to restrictions in the life conditions. This combination was quite rare in Helsinki (8% and 9%), whereas the active combination, exercising and a healthy diet, was quite common (61±62%). Altogether, it seems that the Finnish respondents were more active not only in their health enhancing habits, but also health damaging behaviour, whereas it was more common to have rather passive or habitual choices in Moscow. This would speak for a greater role of choice in terms of lifestyle in Helsinki. In Moscow various structural constraints seemed to limit seriously lifestyle choices, while it may be assumed that at the same time cultural constraints in the form of tradition and custom, i.e. social habit (as de®ned by von Wright, 1963) restricted behavioural choices (such

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as lack of a culture of physical activity and traditional norms on male and female drinking). Individual habits had somewhat variable associations with health (Table 3). Among Muscovite men exercise, and among women a good diet, were conducive to good perceived health, whereas among Finnish men all habits correlated statistically signi®cantly with perceived health as expected, among women all but drinking. Chronic diseases were more distant from everyday habits, yet they were associated with a poor diet among men in both cities, as well as with insucient exercise and smoking among Helsinki women. In Moscow women with chronic illnesses were slightly more prone to exercise. Heavy drinking was associated with experiencing symptoms in Helsinki, but less so in Moscow. In Helsinki a healthy diet was connected with ®tness and lighter body weight, whereas in Moscow a good diet tended to lead to more weight. Alienation Alienation was measured by two items: frustration about reaching one's goals, which is close to the dimension of powerlessness, and hopelessness concerning future, which is close the dimension of meaninglessness by Seeman (1959; items borrowed from Prunnila, Puska & RimpelaÈ, 1974). As expected, in both questions the Muscovites expressed greater alienation. In Moscow one-third felt frustrated about their chances to achieve their goal, but a considerable proportion (36±42%) expressed uncertainty about this. By contrast, in Helsinki two-thirds were quite con®dent about their possibilities to achieve their goals, even if this was less common in older age groups. Also in Moscow the oldest men (over 50 yr) felt most powerless, among women this age limit was 40 years. Hopelessness concerning future is a more encompassing feeling of alienation and was expressed less frequently (22% of men and 28% of women in Moscow saw no hope in the future, in Helsinki 8% and 11%, respectively). In Helsinki hopelessness clearly increased by age, in Moscow the variation by age was small. Alienation was connected with life chance indicators. There was more frustration and hopelessness among the less educated respondents in Helsinki, in Moscow the association with education was similar but weaker. Income (Table 4) and occupation (Table 5) were also associated with hopelessness and powerlessness in both cities. Higher levels of discomfort were found in Moscow also on other measures of well-being sometimes linked to alienation (Alienation under Socialism, 1994). It was somewhat more common to have no good friends and feel lonely in Moscow than in Helsinki, in ad-

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Table 3 Health-related habits and health. Partial correlation coecients (controlling for age). (Perceived health 1=very good 5=very bad; morbidity past year sum 0±8; symptoms past month sum of 17 somatic and psychosomatic symptoms; ®tness 1=walk 500 m, 2=run 100 m, 3=run 500 m; BMI from low to high) Perceived health (4poor) Moscow men (N = 236±242) Smoking (3=daily) ÿ0.06 Heavy drinking (5=weekly) ÿ0.01 Exercise (5=seldom/never) 0.22a Diet (5=low quality) 0.01 Moscow women (N = 286±297) Smoking (4daily) 0.04 Heavy drinking (4weekly) ÿ0.01 Exercise (4seldom/never) 0.06 Diet (4low quality) 0.12 Helsinki men (N = 354±359) Smoking (4daily) 0.11 Heavy drinking (4weekly) 0.13 Exercise (4seldom/never) 0.21 Diet (4unhealthy) 0.33 Helsinki women (N = 451±457) Smoking (4daily) 0.09 Heavy drinking (4weekly) 0.07 Exercise (4seldom/never) 0.13 Diet (4unhealthy) 0.18 a

p < 0.05,



p < 0.01,



Morbidity (4ill)

Symptoms (4many)

Fitness (4®t)

BMI (4high)

ÿ0.06 ÿ0.08 0.01 0.12

ÿ0.05 0.11 0.12 0.11

ÿ0.05 ÿ0.05 ÿ0.16 0.01

ÿ0.01 ÿ0.04 0.08 ÿ0.07

ÿ0.03 ÿ0.08 ÿ0.10 0.06

0.00 ÿ0.03 0.01 0.05

0.03 0.06 ÿ0.09 ÿ0.00

ÿ0.16 ÿ0.08 0.14 ÿ0.18

ÿ0.00 0.08 0.07 0.17

0.12 0.22 0.09 0.25

ÿ0.16 ÿ0.06 ÿ0.16 ÿ0.11

ÿ0.01 0.14 0.05 0.26

0.09 0.05 0.11 0.07

0.08 0.24 0.14 0.08

ÿ0.09 0.03 ÿ0.26 ÿ0.13

ÿ0.10 0.03 0.04 0.17

p < 0.001.

dition the Muscovites expressed much more dissatisfaction with important spheres of life, such as work, economic situation, family life, friendships and health, than respondents in Helsinki (Palosuo et al., 1995). Discontent may, however, re¯ect a relatively close attachment to societal values, and not alienation. In a rating of 20 value domains, the Muscovite respondents

of this study gave lower ratings to such areas as public activity/possibility to develop society, and work, but higher ratings to such domains as the standard of living, religion, family and children. Thus, the Muscovites valued the private sphere of life more than people in Helsinki, who appreciated public activities more. These results are in line with claims of a weak or shallow

Table 4 Life chance factors and feelings of alienation. Partial correlations of alienation with years of education and family income (5 classes), age controlled for

Table 5 Beta coecients for the association between occupationa and feelings of alienation produced by Multiple Classi®cation Analysis and tested by variance analysis, controlling for age

Moscow Men Education (4low) Powerlessness (yes) 0.08 Hopelessness (yes) 0.13 (N )

Moscow

Women

Men

Women

0.12a 0.04

0.13 0.17

0.22 0.12

(238,239) (283,286) (349,350) (444,447)

Income (4low) Powerlessness (yes) 0.03 Hopelessness (yes) 0.19 (N ) a

Helsinki

0.24 0.12

0.27 0.18

0.20 0.26

(225,226) (270,273 (349,350) (435,438) p < 0.05,



p < 0.01,



p < 0.001.

Helsinki

Occupation

Men b

Women b

Men b

Women b

Powerlessness Hopelessness

0.21 0.23

0.23b 0.13

0.17 0.21

0.16 0.13

a Occupation in Helsinki in ®ve classes (scienti®c, technical and art work, health and social care, administration, commercial work, transport, industry and construction, excluding students, retired persons and `others'), in Moscow six classes for men (teachers and scienti®c work, health care employees, upper white collar employees, clerical employees, workers, militia, military and police, `others' excluded) ®ve classes for women (same as men without militia, military and police). b p < 0.05, p < 0.01, p < 0.001.

H. Palosuo / Social Science & Medicine 51 (2000) 1325±1341

civil society in Russia (Alapuro, 1993; PatomaÈki & Pursiainen, 1998) and a weaker integration and reliance on abstract social institutions. They also comply with the (neo)traditionalist claims stressing the importance of the family (Watson, 1995; Piirainen, 1997). It is noteworthy that health was one of the top values as often in Helsinki (84% of men and 93% of women rated it as quite or very important) as in Moscow (83% of men, 86% of women). Feelings of alienation had no signi®cant connections with valuing health except among Muscovite men, of whom those who felt powerless tended to value health more highly than those who did not (data not shown). Thus, health seems to be a very strongly held value, independent of the social turmoil, cultural change or motivational basis. Health was also highly salient as an instrumental value among the Muscovites. This came out in a question concerning attributions of success in life, in which health was one out of 10 possible causes in a list (of which three choices were allowed). For Muscovite women the most popular attributions of success were health, material resources and talent, for men the same in di€erent order: material resources, talent and health (tables in Palosuo et al., 1995). In Helsinki it was more common to rely on talent, strength of character and education; yet, among the lower educated Finns, health also rose to the top attributions. It is worth noticing that while education was the third attribution of success for the respondents in Helsinki, it was one of the least chosen among the Muscovites, who believed more in luck than education. Moreover, in Moscow success was attributed to luck more often by the better educated, while in Helsinki this was the other way round. Merton (1964) has claimed that a belief in luck can be bred by an anomic situation, which apparently prevailed in Moscow to a greater extent than in Helsinki. Other possible interpretations for a belief in luck suggested by Merton (1964) are a mystical position or even modesty: those who have been successful may attribute their success rather to luck than their own e€ort. In Moscow, however, it is plausible that the respondents based their choices on a realistic appraisal of their conditions, in which education had not been an unquestionably positive resource leading to a stable position and good salary. On the contrary academic professions were discriminated against in salaries and continue to be so (e.g. Pirogov & Pronin, 1999). Thus, relying on luck in Moscow may have been an alienated, yet a rational position. For Finns, on the other hand, it has been fully rational to rely on education, which has been the main vehicle of upward mobility until recent times. The Muscovites did, however, attribute success in life also to fate more often than the Finnish respondents, for whom this was the least preferred alternative

1333

(although for the Muscovites also the third last). Altogether, these di€erences in beliefs lend support to the view that the structural life chance factors such as education and material resources have a di€erent meaning and position in Moscow as compared to the Finnish context. Alienation, health and health-related habits Feelings of alienation had statistically signi®cant correlations with most health variables in both cities, but in Helsinki the correlations were stronger especially with perceived health and psychosomatic symptoms (Table 6). The number of chronic diseases had also slightly stronger correlations among Finnish women compared to Muscovite women. Obviously the causality could be both ways in these connections, if alienation is understood in its social psychological meaning rather than as a structural factor. Powerlessness and hopelessness were associated with health-related habits mainly in Helsinki and among men, both concerning self-reported `deliberate' healthenhancing lifestyles (such as observing a diet, exercising, observing rest and avoiding abundant use of stimulants, all to keep up health) and `actual' habits (reported smoking, intoxicant drinking, exercise and diet). As expected, those who did not feel alienated tended to behave in a more healthy way. This was to a lesser degree so in Moscow, where exercise, smoking and heavy drinking were to some extent associated with powerlessness among men, but among women only exercise, while hopelessness was correlated only to diet among women, when age and education were controlled for (Table 7). In Helsinki in almost all cases men had higher correlations than women. This seems to indicate that in Helsinki women do not try to cope with their frustrations by an unhealthy or negligent lifestyle to the same extent as men. In Moscow this pattern is less clear. The rather weak correlations among the Muscovites can perhaps be read in terms of their life chance constraints: possibilities to lead a healthy life, such as having a healthy diet, was not just a free choice. From this point of view, the connection with physical exercise, which does not necessarily require any extra equipment, can still support the basic hypothesis that alienation undermines motivation to take care of one's health, even in Moscow. In Helsinki alienation had stronger correlations also with related indicators of detachment and discomfort such as loneliness, not being married, and dissatisfaction with di€erent spheres of life (®gures not shown). Valuing health as assessed in the value ratings described above had some correlations with health-related habits, again more clearly in Helsinki, where men

1334

H. Palosuo / Social Science & Medicine 51 (2000) 1325±1341

Table 6 Feelings of alienation and health. Partial correlations with perceived health, prevalence of symptoms (sum of 17 symptoms) and chronic morbidity (sum 0±8), controlling for age Men

Moscow Perceived health (poor) Symptoms (many) Morbidity (ill) (N ) Helsinki Perceived health (poor) Symptoms (many) Morbidity (ill) (N ) a

p < 0.05,



p < 0.01,

Feeling powerless

Hopeless

Feeling powerless

Hopeless

0.19a 0.17 0.11

0.10 0.09 0.15

0.18 0.20 0.09

0.16 0.21 0.20

0.28 0.27 0.10

0.25 0.23 0.13

0.27 0.30 0.10 

Women

(234±239)

(355±357)

(284±291)

(451±455)

0.29 0.33 0.23

p < 0.001.

Table 7 Partial correlation coecients of feelings of alienation with health-related and health-enhancing habits, controlling for age and education Men

Women

Feeling powerless Moscow Health-related habits Frequency of free-time exercise (5=seldom) Regular smoking (3=daily) Frequency of intoxication (5=weekly) Diet (5=low quality) Health enhancing habits Observe a diet (1=yes, 2=no/dicult to say/no answer) Exercise (yes/no) Sleep and rest (yes/no) Avoid stimulants (yes/no) Preventive medical check-ups (yes/no) (N ) Helsinki Health-related habits Frequency of free-time exercise (5=seldom) Regular smoking (3=daily) Frequency of intoxication (5=weekly) Diet (5=unhealthy) Health enhancing habits Observe a diet (yes/no) Exercise (yes/no) Sleep and rest (yes/no) Avoid stimulants (yes/no) Preventive medical check-ups (yes/no) (N ) a

p < 0.05,



p < 0.01,



p < 0.001.

0.11 0.13 0.12 0.08 ÿ0.03 0.10 0.04 0.05 0.09

(235±238)

Hopeless

Feeling powerless

Hopeless

ÿ0.01 0.01 0.05 0.10

0.12a 0.01 ÿ0.03 0.14

0.07 0.05 ÿ0.03 0.23

ÿ0.01 0.10 ÿ0.04 0.04 0.01

0.06 0.05 0.02 0.05 ÿ0.05

0.05 0.10 0.09 0.01 ÿ0.01

(276±285)

0.14 0.10 0.13 0.23

0.12 0.10 0.14 0.17

0.10 0.02 0.09 0.10

0.12 0.02 0.12 0.05

0.13 0.20 0.16 0.17 0.08

0.19 0.11 0.13 0.18 0.13

0.07 0.07 0.12 0.08 0.05

0.05 0.06 0.13 0.09 0.04

(345±349)

(441±446)

H. Palosuo / Social Science & Medicine 51 (2000) 1325±1341

who valued health highly tended to exercise frequently, have a healthy diet, not to smoke, and avoid harmful substances for health reasons. Drinking alcohol was not related to valuing health. Among Finnish women the correlations were similar. Among Moscow men, valuing health was slightly correlated with assessing the diet as poor and observing rest and sleep. Summary and discussion In comparative research the question of equivalency is crucial in interpreting ®ndings. Seemingly identical variables may have quite di€erent meanings if their contexts are dissimilar, even in the case of basic demographic variables such as sex and age. Finland and the Soviet Union of 1991 had some common cultural features, yet the economic, social, and political structures were markedly di€erent. If the characterisation of Finland as a modern class society and the Soviet Union as a quasimodern or even traditional society ordered by estates is accepted, this would mean that the basic variables describing strati®cation such as occupation, education and income, as well the indicators of the lifestyle, had quite di€erent contents, connotations and implications in the two countries. Also alienation in societies with a di€erent pace and phase of transition is likely to have a di€erent content: Russia, still the largest country in the world, was the centre of a highly integrated union falling apart, whereas Finland, a relatively small country, was in quite a contrary process of integrating into the enlarging European Union. In addition the changes that took place in Russia during the study year were of di€erent magnitude compared to those experienced in Finland, especially considering that the e€ects of the deepening recession were not yet fully visible in Finland. In any case, the theoretical framework of lifestyles within a life chance context need not be con®ned only to a modern `stable' society (see, for example, Piirainen, 1997). Thus, a dual interpretation of the basic concepts seems possible. It has been reported earlier of this data that the Muscovites, particularly women, had poorer perceived health and were more worried about and dissatis®ed with their health than their counterparts in Helsinki (Palosuo et al., 1998). Sex di€erences in self-reported health were generally larger in Moscow than in Helsinki. Similar results of a poorer self-reported health among Russian women compared to men (Vella, 1997; Bobak et al., 1998) as well as to other European women (Carlson, 1998) have been reported. The results on health and health-related habits in Helsinki were fairly well in line with other Finnish studies from that time. Comparisons which were possible with the Muscovite data lent support to its overall credibility as well, for example concerning smoking,

1335

patterns of use of alcohol, exercise and morbidity (see Palosuo et al., 1995, 1997, 1998). However, because of the limitations of the sample, most notably the educational bias, the observed levels of the various practices must be read with caution, especially those concerning Muscovite men. These limitations are more serious with regard to the levels than the associations and their patterning. The habits of the Muscovites were partly less and partly more healthy than those of Finns. As in other studies (Cepaitis, Korhonen & Vartiainen, 1988; Zaridze, Dvoirin, Kobljakov & Pisklov, 1986; Towards a Healthy Russia, 1994; Vella, 1997; McKee, Bobak, Rose, Shkolnikov, Chenet & Leon, 1998; Cockerham, 1999), a high level of daily smoking among men and a relatively low level among women was noted in Moscow. Among Muscovite men smoking was more common among the less educated, while for women rather the reverse was true. Because of the sample bias, the rate of smoking among Moscow men might be an underestimation. Indeed, in a survey of 1996, a higher rate was reported of male smoking in Moscow, but the same applied also to female smoking (McKee et al., 1998). In Finland the prevalence of smoking among men but not women is low by international comparisons, and was so here too. In Helsinki smoking was connected with a lower level of education, notably among men. Although there are cultural di€erences in the use of alcohol in the two countries (Simpura & Levin, 1997), alcohol seemed to have a fairly similar position among men in both cities, with heavy drinking and subsequent harms accumulating on the less educated men. Here the sample bias by education has apparently led to a greater underestimation of the use of alcohol among Muscovite men than would be the `normal' underestimation in all surveys on alcohol. This seems likely also in view of the role attributed to alcohol in recent studies on mortality in Russia (Ryan, 1995, Leon et al., 1997, Walberg, McKee, Shkolnikov, Chenet & Leon, 1998; Notzon, Komarov, Ermakov, Sempos, Marks & Sempos, 1998; Leon & Shkolnikov, 1998). Muscovite women were more traditional in their infrequent and moderate use of alcohol (also Simpura et al., 1997). Even lower use than in our study has been reported on Russian women in a countrywide survey (Bobak, McKee, Rose & Marmot, 1999). Health considerations in connection with the use of alcohol have probably not been a high concern for the Russians compared to its ritual and social uses (Simpura et al., 1997; Levin, 1997). Dietary habits could be assessed only indirectly as a valuation of the healthiness or quality of the diet. The diet was considered poorer in quality in Moscow than in Helsinki. This may re¯ect real di€erences in the wholesomeness of the diet between the cities, although

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H. Palosuo / Social Science & Medicine 51 (2000) 1325±1341

by our rough measurement it is not certain. Perhaps the wordings of the questions (`healthy' vs `of good/ poor quality', `kachestvennyj') had di€erent connotations, especially as the concept of healthiness was not considered a plausible attribute of diet in Russian. By the relative weight index (BMI), which is an outcome indicator of the diet and energy consumption, there were more obese men in Helsinki than in Moscow, but more obese women in Moscow than Helsinki (Palosuo et al., 1995). The norm of `too much weight' was stricter in Helsinki, which was also seen in fewer attempts by the Muscovites to reduce weight. Perhaps the quality of the diet was understood more in terms of the standard of living than health in Moscow, even if it did not correlate to valuing the living standard. In spite of the reductions in the consumption of many foodstu€s such as meat, ®sh, milk and fruit found in Russian Family Budget Surveys since the 1980s, and continuing in 1991 (but especially in subsequent years), it seems that obesity was still a greater problem than undernutrition among Russian adults (UNICEF, 1993; Braithwaite, 1997; Vella, 1997). Yet, some population groups such as children of poor families and, according to some studies, some of the elderly, have especially after the collapse of the Soviet Union apparently su€ered from nutritional deprivation and inadequate nutrition such as lack of micronutrients (UNICEF, 1993; Popkin, Zohoori & Baturin, 1996; Rush & Welch, 1992; Tulchinsky & Varavikova, 1996; Vella, 1997). A very distinct di€erence was found for leisure-time exercise. The majority of the Muscovites did not exercise at all or much less than recommended by common western health advice. Similar observations of a low level of exercise are available from other East European countries (see Cockerham, 1999). Exercise is possibly more closely linked to a `modern' lifestyle in Moscow than other habits. It was slightly more common among the highly educated Muscovite men, but was not in¯uenced by such material prerequisites as family income. In principle, it is possible to exercise regardless of material conditions or constraints, e.g. one can take walks and do gymnastics without special equipment in Moscow as well as in Helsinki. On the other hand, the higher living density and smaller ¯ats in Moscow as compared to Helsinki may have restricted even home gymnastics. Indeed, when asked about the main cause of not taking suciently care of one's health, the Russians had the option `no appropriate conditions', which was chosen by a ®fth of the Russian respondents. In Helsinki this alternative was not o€ered at all as it was considered too ambiguous, so the Finns blamed their lack of will power for their negligent health-behaviour. Yet, Muscovite women also chose this internal attribution most frequently (Palosuo et al., 1995). In Helsinki leisure-time exercise

was common among both sexes and was not particularly restricted or enhanced by such resources as education or income. The sex di€erences were generally wider in Moscow, especially concerning smoking, heavy drinking and exercise. This was also true of most summary measures. In Helsinki women and men were more egalitarian in their habits and only smoking together with heavy drinking was clearly more typical of men. In the combinations in which an actively unhealthy behaviour was implicated, Muscovite men were more often unhealthy than women. A more passive unhealthy combination, e.g. little exercise and a poor diet, however, was more common among women. On the health promoting side, active combinations were also slightly more common among Muscovite men compared to Muscovite women, mainly because of their more frequent exercise. Muscovite women were better in avoiding harmful habits. While some of the di€erences found in the levels may be due to material constraints limiting consumption in Moscow, they may also point to a cultural transition, which had been underway for a longer period than the rapid transformations around the break-up of the Soviet Union. The urban Soviet population has been characterised as relatively equal in terms of material resources and to comprise a rather well educated large middle stratum (e.g. Beliaeva, 1994; Piirainen, 1994). Yet the lack of a middle class in a western sense has been noted many times. Middle class is the carrier of the modern health lifestyle (Cockerham et al., 1997). No doubt modern middle class lifestyle prerequisites were more prevalent in Helsinki. However, some of the well-educated men in Moscow were perhaps on the threshold of entering an urban modern lifestyle with exercise, less smoking and moderate drinking. Women were more traditional in drinking less and avoiding such `masculine' activities as sports (see Kauppinen et al., 1996). Partly they were in an earlier phase of a lifestyle transition, e.g. smoking was somewhat more common among educated women, which foretells increase in female smoking (as is perhaps manifested in the higher rate reported by McKee et al., 1998), at the same time as their double work and heavy household duties established in other studies (e.g. Haavio-Mannila & Kauppinen, 1994) may have by constraints on time and energy kept them from engaging in sports, for example. From the point of view of the Weberian based lifestyle concepts, health-related lifestyles should have varied more by the structural life chance variables in Helsinki, which is here taken to represent a marketbased class society, than in Moscow, representing a status-ordered society. This should especially be so if the Muscovites are taken to comprise a relatively undi€erentiated middle stratum (almost like one cultu-

H. Palosuo / Social Science & Medicine 51 (2000) 1325±1341

rally homogenous `estate'). This, however, was not really caught in this study when analysing separate health-related habits: family income as measured here was a weak predictor of the habits altogether, and some associations with education and occupation were signi®cant in Moscow and others in Helsinki. Sex di€erences were clearer. Sex obviously has a dual role in the life chance framework: it can be considered a life chance factor among other structural factors, but at the same time it represents an ascribed status. Sex had a clearer impact on both individual health-related habits and most summary measures in Moscow. This speaks for a greater role of tradition in Moscow and is in line with the theoretical assumptions of the lifestyle framework. Alienation was measured only by two items. Feelings of alienation were more common in Moscow than in Helsinki. Similar results on health, dissatisfaction and lack of control have been obtained in other studies on Russia in the 1990s (Carlson, 1998; Bobak et al., 1998). Income and occupation had similar or even stronger associations with alienation in Moscow. Even if income and social class were not likely to have the same hierarchical qualities in Moscow as in Helsinki, the salience of material conditions is clear (also Kivinen, 1994; Piirainen, 1997; Bobak et al., 1998). This was seen both in the value assessments and causal attributions of success, in which the standard of living and material resources were more valued in Moscow than in Helsinki. It is also reasonable to conclude from the lesser value given to education in causal attributions of success that its role as a life chance factor indeed was dissimilar in comparison to Helsinki. The connections between alienation and perceived health, health-related habits and other measures of well-being were usually weaker in Moscow than in Helsinki. The stronger associations in Helsinki can perhaps be interpreted as indicative of a higher degree of relative marginalisation and a `normal' strati®cation e€ect typical of Western market economies. Alienation, poor health and poor health-related habits were in Helsinki generally more clearly concentrated into the poorly faring segment of the population such as the older and the less educated, especially among men. However, it is possible that the mostly weak associations in the Russian data were due to the educational bias, which may have wiped out real variance (e.g. more marginalised or other kinds of groups could have emerged among the Muscovites with a more representative sample), or also due to a weaker reliability of the Muscovite data. A better measurement of alienation with more items on its di€erent aspects might have revealed clearer and di€erent patterns of alienation especially in Moscow. Health propaganda and education were not absent in the Soviet Union (see, for example, Sobolevskij,

1337

1984). A healthy way of life was considered a central characteristic of the communist way of life as well as of the development of a harmonious personality (e.g. Kucenko & Novikov, 1987). Yet, the idea of primary prevention of diseases by means of a healthy lifestyle was not widely adopted even by the health care personnel let alone the population (see, for example, Remennick & Ottenstein-Eisen, 1998; Tulchinsky & Varavikova, 1996). In our study this was also corroborated by some questions concerning the possibilities of prevention: for instance, the Helsinki respondents believed more often than the Russians that heart diseases can be prevented by healthy habits, whereas the Muscovites believed more often that this was possible concerning cancers. In Helsinki almost all agreed that it always pays to stop smoking whereas in Moscow especially men were more reluctant to comply with such a view. There were also other indications of a more external locus of control among the Muscovites: they attributed ill-health more often to genetics and life conditions than Finns who blamed more often personal e€ort such as indi€erence to one's own health, or stress. In addition, Helsinki respondents had more reliance on social institutions and were much more often of the opinion that their health behaviour had been in¯uenced by education at home and school, as well as by the health education distributed in the mass media or given by health professionals (Palosuo et al., 1995). In spite of all these di€erences, health as an abstract value was as highly appraised in both cities, but its instrumental salience was more pronounced in Moscow, even if it did not ®nd an expression in a more healthy lifestyle. From the viewpoint of health policy, being alienated can be seen as a characteristic of a `risk group', indicating passivity and indi€erence to lead a healthy life. However, in Moscow alienation seemed to be an expression of a relatively common general discomfort, connected to self-reported health in a similar way as in Helsinki, but because of the di€erent social context, without a consistent pattern in relation to health behaviour, and without clear connotations to a risk group. On the contrary, the high prevalence of the passive unhealthy lifestyle combinations seems to disperse the risks quite widely. Since the time of this study, there have been no great changes in the health of the Finnish population in spite of the recession, mass unemployment and other major structural changes, which were and are taking place (Lahelma, Rahkonen & Huuhka, 1997a). In a somewhat longer perspective, since the late 1970s, the health status of the adult population has slightly improved (Lahelma et al., 1997a), as well as some indicators of health-related lifestyles (more exercise, less fat in food, reduction in male smoking), though not all (slight increase in drinking and women's smoking;

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H. Palosuo / Social Science & Medicine 51 (2000) 1325±1341

Lahelma et al., 1997b; Karisto et al., 1993). In terms of mortality the overall development has been quite clear and life expectancy in Finland has grown (Health in Finland, 1999). In these years Russia has plunged into an unparalleled economic and social turbulence, which has since the dissolution of the Soviet Union manifested itself not just in the decline of the life expectancy and increase of all kinds of morbidity, including infectious diseases (Towards a Healthy Russia, 1994; Glukhovyets & Semyonova, 1994; UNDP, 1997; Naselenie Rossii 1998, 1999), but also in a rapid decrease in the real wages, increase in income di€erences and growth of poverty (e.g. Klugman & Braithwaite, 1997). After the liberalisation of sales and prices in 1992, the de®cit of consumption goods typical of the Soviet period disappeared, kiosks selling alcohol indiscriminately day and night mushroomed in every street corner and subway (Levin, 1997), and western cigarettes, available everywhere as well, were shamelessly advertised as vehicles of happiness. Thus the distribution of life chances and options for life choices have dramatically changed. Moscow, however, remains a privileged area with far better material chances and less poverty than most other parts of Russia (Braithwaite, 1997). Yet, in spite of the revolutionary changes in the Russian society in the past 10 years, there is much continuity and even strengthening of some traditions from the Soviet and perhaps earlier times, which in many ways a€ect people's everyday lives and lifestyles (see, for example, Piirainen, 1997; Watson, 1995). Alienation is likely to be connected to these processes both in general and context-bound ways and perhaps have new qualities that would require new methods of enquiry (see, for example, Gergen, 1996). On the basis of this study it seems that alienation as a part of social marginalisation in Finland or alienation as widely spread general discomfort in Russia may have quite di€erent implications on people's health-related lifestyles and on subsequent demands on social and health policy. Acknowledgements This paper is based on a joint research project initiated by Irina Zhuravleva from the Institute of Sociology, Russian Academy of Science, Moscow, who was in charge of collecting the Russian data. Other members of the study group are Nina Lakomova and Lyudmila Shilova from that Institute, and Antti Uutela from the National Public Health Institute in Helsinki. Their help during many years of the project is gratefully acknowledged. I would also like to thank Professor Tapani Valkonen and Professor Thomas Abel for their helpful comments on an earlier draft of

the manuscript, and Professor Eero Lahelma for his assistance not only in the form of constructive comments on several drafts but also organising possibilities for carrying out the study. The Academy of Finland has supported the project.

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