BACKGROUND: Eastern European countries have some of the highest rates of cardiovascular disease (CVD) mortality, much of which cannot be adequately accounted for by conventional CVD risk factors. Psychosocial and socioeconomic factors may affect risk of CVD, but relatively few studies on this issue have been undertaken in Eastern Europe. We investigated whether various psychosocial factors are associated with CVD mortality independently from each other and whether they can help explain differences in CVD mortality between Eastern European populations. METHODS: Participants were from the Health, Alcohol and Psychological factors in Eastern Europe (HAPIEE) cohort study in Russia, Poland and the Czech Republic, including a total of 20,867 men and women aged 43-74 years and free of CVD at baseline examination during 2002-2005. Participants were followed-up for CVD mortality after linkage to national mortality registries for a median of 7.2 years. RESULTS: During the follow-up, 556 participants died from CVD. After mutual adjustment, six psychosocial and socioeconomic factors were associated with increased risk of CVD death: unemployment, low material amenities, depression, being single, infrequent contacts with friends or relatives. The hazard ratios [HRs] for these six factors ranged between 1.26 [95% confidence interval 1.14-1.40] and 1.81 [95% confidence interval 1.24-2.64], fully adjusted for each other, and conventional cardiovascular risk factors. Population-attributable fractions ranged from 8% [4%-13%] to 22% [11%-31%] for each factor, when measured on average across the three cohorts. However, the prevalence of psychosocial and socioeconomic risk factors and their HRs were similar between the three countries. Altogether, these factors could not explain why participants from Russia had higher CVD mortality when compared to participants from Poland/Czech Republic. Limitations of this study include measurement error that could lead to residual confounding; and the possibilities for reverse causation and/or unmeasured confounding from observational studies to lead to associations that are not causal in nature. CONCLUSIONS: Six psychosocial and socioeconomic factors were associated with cardiovascular mortality, independent of each other. Differences in mortality between cohorts from Russia versus Poland or Check Republic remained unexplained.

Centre for Environmental Health Monitoring National Institute of Public Health Prague Czech Republic

Chair of Epidemiology and Population Studies Institute of Public Health Faculty of Health Sciences Jagiellonian University Krakow Poland

Department of Epidemiology and Public Health University College London London United Kingdom

Institute of Cardiology Lithuanian University of Health Sciences Kaunas Lithuania

Novosibirsk State Medical University Novosibirsk Russia

Research Institute of Internal and Preventive Medicine Branch of the Institute of Cytology and Genetics SB RAS Novosibirsk Russia

See more in PubMed

Berkman LF, Syme SL. Social networks, host resistance, and mortality: a nine-year follow-up study of Alameda County residents. American Journal of Epidemiology. 1979;109(2):186–204. PubMed

Veronesi G, Ferrario MM, Kuulasmaa K, Bobak M, Chambless LE, Salomaa V, et al. Educational class inequalities in the incidence of coronary heart disease in Europe. Heart. 2016;102(12):958–65. 10.1136/heartjnl-2015-308909 PubMed DOI

Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality. Social Science & Medicine. 2011;72(6):840–54. 10.1016/j.socscimed.2011.01.005 PubMed DOI PMC

Barth J, Schneider S, von Känel R. Lack of social support in the etiology and the prognosis of coronary heart disease: a systematic review and meta-analysis. Psychosomatic Medicine. 2010;72(3):229–38. 10.1097/PSY.0b013e3181d01611 PubMed DOI

Van der Kooy K, van Hout H, Marwijk H, Marten H, Stehouwer C, Beekman A. Depression and the risk for cardiovascular diseases: systematic review and meta analysis. International Journal of Geriatric Psychiatry. 2007;22(7):613–26. 10.1002/gps.1723 PubMed DOI

Piepoli MF, Hoes AW, Agewall S, Albus C, Brotons C, Catapano AL, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). European Heart Journal. 2016;37(29):2315–81. 10.1093/eurheartj/ehw106 PubMed DOI PMC

Kuulasmaa K, Tunstall-Pedoe H, Dobson A, Fortmann S, Sans S, Tolonen H, et al. Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations. The Lancet. 2000;355(9205):675–87. 10.1016/S0140-6736(99)11180-2 PubMed DOI

United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects 2017 [Accessed on 20 sept 2017]. Available from: https://esa.un.org/unpd/wpp/DataQuery/.

Wang H, Naghavi M, Allen C, Barber RM, Zulfiquar AB, Carter A, et al. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet. 2016;388(10053):1459–544. 10.1016/S0140-6736(16)31012-1 PubMed DOI PMC

Bobak M, Marmot M. East-West mortality divide and its potential explanations: proposed research agenda. BMJ. 1996; 312:421 10.1136/bmj.312.7028.421 PubMed DOI PMC

Hajdu P, Mckee M, Bojan F. Changes in premature mortality differentials by marital status in Hungary and in England and Wales. The European Journal of Public Health. 1995;5(4):259–64. 10.1093/eurpub/5.4.259 DOI

Shkolnikov VM, Leon DA, Adamets S, Andreev E, Deev A. Educational level and adult mortality in Russia: an analysis of routine data 1979 to 1994. Social Science & Medicine. 1998;47(3):357–69. 10.1016/S0277-9536(98)00096-3 PubMed DOI

Peasey A, Bobak M, Kubinova R, Malyutina S, Pajak A, Tamosiunas A, et al. Determinants of cardiovascular disease and other non-communicable diseases in Central and Eastern Europe: rationale and design of the HAPIEE study. BMC Public Health. 2006;6:255 10.1186/1471-2458-6-255 PubMed DOI PMC

Stefler D, Pikhart H, Jankovic N, Kubinova R, Pajak A, Malyutina S, et al. Healthy diet indicator and mortality in Eastern European populations: prospective evidence from the HAPIEE cohort. European Journal of Clinical Nutrition. 2014;68(12):1346 10.1038/ejcn.2014.134 PubMed DOI PMC

Bobak M, Malyutina S, Horvat P, Pajak A, Tamosiunas A, Kubinova R, et al. Alcohol, drinking pattern and all-cause, cardiovascular and alcohol-related mortality in Eastern Europe. European Journal of Epidemiology. 2016;31(1):21–30. 10.1007/s10654-015-0092-8 PubMed DOI PMC

Vandenheede H, Vikhireva O, Pikhart H, Kubinova R, Malyutina S, Pajak A, et al. Socioeconomic inequalities in all-cause mortality in the Czech Republic, Russia, Poland and Lithuania in the 2000s: findings from the HAPIEE Study. Journal of Epidemiology and Community Health. 2014;68(4):297–303. 10.1136/jech-2013-203057 PubMed DOI PMC

Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement. 1977;1(3):385–401. 10.1177/014662167700100306 DOI

Bobak M, Pikhart H, Hertzman C, Rose R, Marmot M. Socioeconomic factors, perceived control and self-reported health in Russia. A cross-sectional survey. Social Science & Medicine. 1998;47(2):269–79. 10.1016/S0277-9536(98)00095-1 PubMed DOI

Collaboration PS. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. The Lancet. 2002;360(9349):1903–13. 10.1016/S0140-6736(02)11911-8 PubMed DOI

Rehm J. Measuring quantity, frequency, and volume of drinking. Alcoholism: Clinical and Experimental Research. 1998;22(S2). PubMed

Lane PW, Nelder JA. Analysis of covariance and standardization as instances of prediction. Biometrics. 1982:613–21. PubMed

Marmot MG, Bosma H, Hemingway H, Brunner E, Stansfeld S. Contribution of job control and other risk factors to social variations in coronary heart disease incidence. The Lancet. 1997;350(9073):235–9. 10.1016/S0140-6736(97)04244-X PubMed DOI

Nabi H, Singh-Manoux A, Shipley M, Gimeno D, Marmot MG, Kivimaki M. Do psychological factors affect inflammation and incident coronary heart disease. Arteriosclerosis, Thrombosis, and Vascular Biology. 2008;28(7):1398–406. 10.1161/ATVBAHA.108.167239 PubMed DOI

Kivimäki M, Nyberg ST, Batty GD, Fransson EI, Heikkilä K, Alfredsson L, et al. Job strain as a risk factor for coronary heart disease: a collaborative meta-analysis of individual participant data. The Lancet. 2012;380(9852):1491–7. 10.1016/S0140-6736(12)60994-5 PubMed DOI PMC

Moons KG, Altman DG, Reitsma JB, Ioannidis JP, Macaskill P, Steyerberg EW, et al. Transparent Reporting of a multivariable prediction model for individual Prognosis or diagnosis (TRIPOD): Explanation and Elaboration. Annals of Internal Medicine. 2015;162(1):W1–W73. 10.7326/M14-0698 PubMed DOI

Filakti H, Fox J. Differences in mortality by housing tenure and by car access from the OPCS Longitudinal Study. Population Trends. 1995;(81):27–30. PubMed

Macleod J, Smith GD, Metcalfe C, Hart C. Is subjective social status a more important determinant of health than objective social status? Evidence from a prospective observational study of Scottish men. Social Science & Medicine. 2005;61(9):1916–29. 10.1016/j.socscimed.2005.04.009 PubMed DOI

van Oort FV, van Lenthe FJ, Mackenbach JP. Material, psychosocial, and behavioural factors in the explanation of educational inequalities in mortality in The Netherlands. Journal of Epidemiology and Community Health. 2005;59(3):214–20. 10.1136/jech.2003.016493 PubMed DOI PMC

Perlman F, Bobak M. Socioeconomic and behavioral determinants of mortality in posttransition Russia: a prospective population study. Annals of Epidemiology. 2008;18(2):92–100. 10.1016/j.annepidem.2007.07.093 PubMed DOI

Stringhini S, Sabia S, Shipley M, Brunner E, Nabi H, Kivimaki M, et al. Association of socioeconomic position with health behaviors and mortality. JAMA. 2010;303(12):1159–66. 10.1001/jama.2010.297 PubMed DOI PMC

Kershaw KN, Droomers M, Robinson WR, Carnethon MR, Daviglus ML, Verschuren WM. Quantifying the contributions of behavioral and biological risk factors to socioeconomic disparities in coronary heart disease incidence: the MORGEN study. European Journal of Epidemiology. 2013;28(10):807–14. 10.1007/s10654-013-9847-2 PubMed DOI PMC

Fiscella K, Franks P. Does psychological distress contribute to racial and socioeconomic disparities in mortality? Social Science & Medicine. 1997;45(12):1805–9. 10.1016/S0277-9536(97)00111-1 PubMed DOI

Hintsa T, Shipley MJ, Gimeno D, Elovainio M, Chandola T, Jokela M, et al. Do pre-employment influences explain the association between psychosocial factors at work and coronary heart disease? The Whitehall II study. Occupational and Environmental Medicine. 2010;67(5):330–4. 10.1136/oem.2009.048470 PubMed DOI PMC

Leon DA, Saburova L, Tomkins S, Andreev E, Kiryanov N, McKee M, et al. Hazardous alcohol drinking and premature mortality in Russia: a population based case-control study. The Lancet. 2007;369(9578):2001–9. 10.1016/S0140-6736(07)60941-6 PubMed DOI

Zaridze D, Lewington S, Boroda A, Scélo G, Karpov R, Lazarev A, et al. Alcohol and mortality in Russia: prospective observational study of 151 000 adults. The Lancet. 2014;383(9927):1465–73. 10.1016/S0140-6736(13)62247-3 PubMed DOI PMC

Watson P. Explaining rising mortality among men in Eastern Europe. Social Science & Medicine. 1995;41(7):923–34. 10.1016/0277-9536(94)00405-I PubMed DOI

Jokela M, Batty GD, Nyberg ST, Virtanen M, Nabi H, Singh-Manoux A, et al. Personality and all-cause mortality: individual-participant meta-analysis of 3,947 deaths in 76,150 adults. American Journal of Epidemiology. 2013;178(5):667–75. 10.1093/aje/kwt170 PubMed DOI PMC

Jokela M, Pulkki-Råback L, Elovainio M, Kivimäki M. Personality traits as risk factors for stroke and coronary heart disease mortality: pooled analysis of three cohort studies. Journal of Behavioral Medicine. 2014;37(5):881–9. 10.1007/s10865-013-9548-z PubMed DOI

Blakely T, McKenzie S, Carter K. Misclassification of the mediator matters when estimating indirect effects. Journal of Epidemiology and Community Health. 2013;67(5):458–66. 10.1136/jech-2012-201813 PubMed DOI

Hafeman DM. Confounding of indirect effects: a sensitivity analysis exploring the range of bias due to a cause common to both the mediator and the outcome. American Journal of Eepidemiology. 2011;174(6):710–7. 10.1093/aje/kwr173 PubMed DOI

Tillmann T, Vaucher J, Okbay A, Pikhart H, Peasey A, Kubinova R, et al. Education and coronary heart disease: mendelian randomisation study. BMJ. 2017;358:j3542 10.1136/bmj.j3542 PubMed DOI PMC

Martikainen PT, Valkonen T. Excess mortality of unemployed men and women during a period of rapidly increasing unemployment. The Lancet. 1996;348(9032):909–12. 10.1016/S0140-6736(96)03291-6 PubMed DOI

The Relationship between Epigenetic Age and Myocardial Infarction/Acute Coronary Syndrome in a Population-Based Nested Case-Control Study

Perspectives of cardiovascular research in Central and Eastern Europe (letter)

Cardiovascular Diseases in Central and Eastern Europe: A Call for More Surveillance and Evidence-Based Health Promotion

Czech Brain Aging Study (CBAS): prospective multicentre cohort study on risk and protective factors for dementia in the Czech Republic