Project description - Health Values and Changing Society in Russia

Project director: Dr. Pauliina Aarva (School of Public Health, University of Tampere)

Introduction

Health of the Russian population is in crisis, the overall mortality is increasing and the gap between genders in morbidity and mortality grows. A number of Russian and international studies have drawn conclusions on the consequences of the former communist regime, centralised health care system, socialist ideology, and fatalistic attitude of the Russian population towards their deteriorating health and unhealthy lifestyles. High mortality and morbidity in Russia concerns mainly men. The gender gap in morbidity has been explained by several factors, such as social determinants, gender roles and health behaviour.  Behavioural risk factors, such as smoking, high-fat diet, high levels of alcohol consumption and sedentary life style concern in particular men in Russia.

Alcohol consumption in Russia is among the highest in the world. The per capita consumption of pure alcohol was 7.6 litres as registered alcohol by volume of sales and 14,3 litres as an estimate of total consumption in 1999. Binge drinking is common among Russians.  Smoking prevalence among Russian men was 63 % and women 14% in 1996. Compared to the European average - 40 % of men and 28% women being smokers - the figures for men in Russia are very high. Leisure-time physical activity among Russians is less popular than among citizens of the western countries.  In Moscow the proportion of the physically inactive respondents among men was 35 % and among women 41% in 1991. The Russian Longitudinal Monitoring Survey revealed that even 79 % of respondents were inactive.

Despite of significant efforts for explaining the current health crisis on the basis of socio-economic and behavioural factors, there still is lack of knowledge on what cultural factors and processes are related to health and well-being of the population, e.g.,

• how the transition from soviet  to market economy has changed the processes of health policy making: how policy priorities are identified, how the values and priorities among the population and those new societal  problems occurred during the transition have been taken into account
• which kind of norms, values and common-sense-argumentations on health and well-being dominate in the mass media, which  both reflects and influences public opinion and values related to health and well-being today 
• how people perceive and interpret various health risks, how they reason health choices - both individual and those of society, what kind of norms, values and common-sense-argumentations on health and well-being dominate among the population

Studying cultural processes requires outlining of how the ordinary people have experienced the previous transition in the society in terms of individual health changes and health choices, policy decisions and the media publicity.  Even though these experiences and interpretations do not explain the changes themselves during the transition, they "locate" health values and norms of today to a broader, social and historical framework. This allows deeper understanding of the current health mentalities and subcultures among various population groups.

Objectives

The biomedical dominance of health research in Russia today is reflected in the lack of multi-disciplinary public health research and the absence of cultural research on health. Key problems in Russia to be addressed by the cultural studies included in this research project are

• unclear justifications for policy choices, ineffective actions especially outside the health care system to address the health crisis, poor implementation of officially accepted health policy documents   
• lack of information on the Russian mass media  both in reflecting and influencing the changing values and priorities related to health and well-being  in the society
• lack of knowledge on lay perceptions and interpretations on a) health, health risks and their social and behavioural determinants, b)  health priorities set by the policy makers and health professionals and  
  c) ways to promote health and well-being in Russia

This project will facilitate development of multi-disciplinary public health research in Russia. The disciplines represented by the research team are: sociology, social and health policy research, cultural studies, media studies, psychology, medicine and public health. The main aim of the project is to increase the understanding of societal and cultural factors of health in Russia within policy making, media publicity and public opinion.

The project is divided into three components:

• health policy analysis
• mass media analysis
• study on lay perceptions and interpretations on health and well-being

The specific objectives of the project, by components, are:

1. to assess current health policy, key federal health programs and policy processes (policy analysis)
2. to clarify the role of the media in  reflecting and creating values related to health and well-being  (media publicity analysis)
3. to increase the knowledge of dominating health values and norms and  prevailing health culture among the adult Russian population (studies on lay perceptions and discourses)
4. to advance understanding of differences in  health policies, media publicity and health mentalities/cultures between Russia and Finland (comparisons).

Each objective is divided into several more concrete research questions that may be revised during the research process. Key research questions of the project are:

Objective 1: Health Policy analysis

• What are the key features of health policy processes in Russia? 
• How does the burden of CVDs/burden on smoke related diseases/smoking rates/alcohol consumption rates (the themes to be selected by the research team) reflect to the current key health policy documents, programmes and policy processes in Russia?
• What kind of argumentation is used in both defining priorities for health policy and concrete actions? 
• Why does the policy system fail to implement some key policy options in the field of health promotion and disease prevention

Objective 2: Media publicity on health

• Which kind of health discourses are dominant in the major printed media?
• How do the media prioritise health problems?  How these are related to policy priorities? Are there gaps between priorities set by the policy makers, the media and the population?
• How the media maintains and constructs gender in relation to health?

Objective 3: Lay perceptions and discourses on health

• What are the priority health risks defined by the Russian population and why? Which kind of threats for health and well-being people perceive in the Russian society in general and in their own life in particular? How the public opinion considers responsibilities of the government and individual citizens to protect population from disease and promote health?
• How cultural stereotypes, e.g. gender roles are related to health matters among the population (use of medical services, disease prevention, health behaviour, individual responsibilities, attitudes to health information etc.)

Objective 4: Comparisons between Russia and Finland

• How the health policy processes, media publicity and lay perceptions on health differ in two neighbouring countries Finland and Russia? 
•  What kind of differences can be identified between Finnish and Russian "masculine" and "feminine" health cultures"?

Theoretical approach

The project has two basic theoretical approaches to be utilised in the study: the structuralistic-semiotic concept of culture and gender, which is understood as a cultural product and reproduced in social interaction.

The cultural-semiotic approach defines "culture" as a system of symbolic forms (texts, signs) and communication rules (languages, codes). Symbolic representations, such as forms of argumentations, structures of value statements and various metaphors used in the publications or speech are considered as the key components of the culture. Each culture creates its own meta-language, i.e. its own rules, which define the "right" or accepted ways to communicate. This is interesting also in researching various "health languages", such as medical language, health promotion language, alternative-medicine-language, fitness language, anti-health language and others and their role in different societies. 

The culture can be defined in terms of boarders. The culture compares the languages of other cultures with its own grammar, excludes something from its domain and perhaps adopts something new from outside, or something old that was formerly excluded. The redefinition of boarders leads to the cultural shifts, to the formation of new cultures. The interesting questions in researching health cultures are (1) what is it which is outside the boarders, i.e. which things are left outside the dominant health culture and (2) how to understand the cultural shift, redefinition of boarders, i.e. how the new health cultures are emerged.  In order to clarify these questions, the semiotic model of binary oppositions allows to identify the boarders by assessing the sign systems from contrary and contradictory positions. In the analysis process this theoretical model (which is often described as the semiotic square) helps in identifying oppositional differences between value statements and argumentations. By placing the key concepts derived through the discourse analysis of the texts into the model, we are able to make interesting findings about the health culture(s) and mentalities and to make reliable comparisons between various competing cultures and subcultures. The model itself can be regarded as a descriptive semiotic meta-language, which allows to derive "moral" and "rhetoric" qualities, which are implicit, not necessarily explicitly declared.  Using the model, it is possible to reveal from the texts under research clear cultural boarders and thus better understand various subcultures, anti-cultures and ideological micro-universes. This is possible, because the value statements and key arguments identified from the texts are culturally constructed, i.e. they have evolved under "the pressure" and hidden instructions of the collective memory of culture. This is explained by the cultural nature of language itself, as discussed earlier.

Gender as a theory-driven concept. Promoting population's health (through social policy, legislation, education and communication) requires deep knowledge of ways how people experience, perceive, assess and interpret health, health behaviours and risks related to them. Many studies have focused on lay beliefs and interpretations in recent years as well as on content and meaning of "health" in different contexts. Research on health behaviours has to take into account the meanings people give to health and it should be context-bound. Furthermore, some groups of population are not motivated in or are even resistant to any health promotion activities. Understanding of resistance is particularly important in Russia, where level of unhealthy behaviours is high and motivating the people to healthier life-style is according to governmental policy the key issue in improving population's health and well-being.

Although huge gender gap in health in Russia is a well-known fact, there is a lack of studies addressing gender differences from the cultural point of view, i.e. what are the norms, expectations and attributes attached to men and women. Many studies have discussed the gender differences in health behaviours without theorising the concept of gender as a cultural product. As gender is one of the primary axes around which social life is organised, indicators of health behaviour should be analysed together with gender-related norms. As it has been pointed out, behaviour is based on both life choices and life chances. People make life choices according to the chances they feel they have. The chances do not mean just physical possibilities but also knowledge and social norms, i.e. what expected to be acceptable within the social environment the person is living in. In order to understand the differences in health behaviours, gender should not be used merely as a background variable but as a theory-driven concept where norms and cultural expectations to men and women are analysed thoroughly.

Research team

Aarva, Pauliina, researcher, project director
Pietilä, Ilkka, researcher, PhD student, project manager
Dvoryanchikova, Aleksandra., researcher, post doc student
Aleksandra Dvoryanchikova, PhD student, researcher
Olga Shek, PhD student, researcher
Elena Taranukhina, research assistant
Scientific advisers: Lehto, Juhani and Jylhä, Marja

Materials

The project will use mainly qualitative materials: individual and group interviews, policy documents and mass media texts.  Since qualitative analysis deals with language, the working language of the analysis is Russian, which ensures the adequate synthesising the analysis results of all components. The project will be implemented in close collaboration with two ongoing (February 2004) projects of the Health Promotion Research Program of the Academy of Finland.

Health Policy.  Key health policy documents related to the selected health policy areas will be identified for the closer analysis. Then federal preventive programs related to this area will be collected and briefly reviewed. Out of these programmes the relevant 1 or 2 programs will be selected for the closer analysis.  This analysis includes three phases:

1. The planned activities of the programs, the division of tasks, the implementation schedule, the budget and the evaluation criteria will be systematically studied and assessed.
2. Based on the study results the interviews with key actors involved in the development and implementation of the policy documents and programmes will be conducted with the focus to gain information about the realisation of the programs (e.g. the real budget instead of the planned one, the real activities implemented, the results achieved according to those interviewed).
3. A discourse analysis of the text of the programme(s) will be conducted to reveal the expressed justifications and argumentations of the programs.

Media publicity.  Mass media texts will be chosen from the key printed media in 2004 and 2005. Two major national level newspapers will be selected on the base of their popularity (mass newspapers) and the profile of readers (no elite papers). All health related materials will be selected from the sample of the published issues in 2004/2005. The content of the collected material will be first described in terms of the health themes of the editorials, articles, items of news, human interest materials and advertisements. The second phase will be to define the smaller amount of the media texts for the discourse analysis, which will reveal the main health statements and arguments in the material. The third phase is the structuring of the revealed statements according to theoretical model (e-g. semiotic model), which allows us to find out the rhetoric dimensions of the health discourses in the media texts.

Lay discourses. The qualitative interview data will be collected in St. Petersburg. Two types of interview materials will be collected: individual interviews and focus group interviews where men and women will form their own groups with some 5 participants in each group.

The interviews will be thematically semi-structured allowing free discussion of each theme. The themes to be discussed will be related to surveys to be conducted within the project but include also broader issues related to health, such as: 

• how "health" is conceptualised and what is the content of the concept?
• what health risks are considered as most important determinants of health and how the threat to an individual is interpreted? How responsibility for health is understood and interpreted? 
• how gender is described in relation to health, health behaviours and risks?

The focus group interviews will discuss the same issues as other interviews. They will be conducted after collection of individual interviews and used for further analyses of conclusions made on the basis of individual interviews.  The interviews will be tape-recorded and transcribed. Method to be used is discourse analysis. The qualitative interviews of men and their analyses will be compared with similar interviews conducted in the research project Values, norms and health promotion cultures 2002-2004 financed by the Academy of Finland (Health Promotion Research Programme) where Finnish men have been interviewed on the same topics. This allows making comparisons between Russian and Finnish cultures.

Expected results

The research project will contribute to the increase of the understanding of societal and cultural determinants of health in Russia and the differences in health cultures between two neighbouring countries. The following results are expected to be reached by the project:

• Information on political decision processes and their main implications in major arenas influencing health in both health care and at the population level.
• Better knowledge about the cultural  (including gender) patterns of health in Russia and deeper understanding of the health priorities and the dominant perceptions of health problems among the Russian population
• Increased knowledge on the role, values  and gender orientations of the media in promoting health and well-being among the Russian population and 
• Information about differences in health policy processes, health cultures/mentalities and media health publicity between Finland and Russia

By the end of 2007 the following outcomes are expected to be achieved:

• articles in international scientific journals,  reports in professional meetings
• articles in publications for professionals and the general public in Russia and in Finland
• workshops to stimulate discussion on cultural aspects of health and health promotion 
• web materials "Health Values and Russian Society - perspectives for the future" 
• the network of  Russian and Finnish researchers working on cultural health studies 

The research results will be disseminated to the Russian regions through publications, web-materials and seminars.