Health inequity, treatment compliance, and health literacy at the local level: theoretical and practical aspects
Karen Amlaev

   © Karen Amlaev, 2015
   © Vlad Babayants, translation, 2015

   Created with Ridero

   Foreword by the leader of the WHO Healthy Cities project
   Healthy Cities since its inception 25 years ago has put a strong emphasis on equity and strategies and interventions aimed to support individuals and communities have more control on decisions and developments that affect their health and wellbeing. Health literacy is increasingly recognized as a very promising domain of public health and health promotion. It is an important component in our strategies to promote empowerment and community resilience.
   Translating theory and evidence into local practice can be challenging. Concepts need to be expressed and understood in professional terms that are used locally. Recommendations and frameworks for action need to be adapted to local political and organizational contexts and realities. The support of local academic institution can be vital in such efforts.
   The monograph at hand prepared by Karen Amlaev, Member of the European Advisory Committee, Professor of the Stavropol State University is a good example of an endeavour to address equity and health literacy in Stavropol, linking theory and evidence with situation analyses and action plans.
   I should like to congratulate professor Karen Amlaev for this initiative and his commitment to supporting the Stavropol Healthy Cities project and the work of the Russian Healthy Cities network and beyond.

Dr Agis Tsouros
Director
Division of Policy and Governance for Health and Well-being
World Health Organization’s Regional Office for Europe
Copenhagen

   Introduction
   The project Healthy Cities has been making its contribution to health promotion in the European Region for several decades now. The peculiar feature of it is proper response to the issues arising in public health and healthcare systems in European countries. This is reflected in the topics that are taken as key ones at certain stages of the Healthy Cities project.
   The Russian Federation has been an active member of the European network of Healthy Cities and dozens of Russian cities have joined our movement in the latest years.
   The monograph presented here focuses on relevant issues of modern healthcare – health inequity, low health literacy and treatment compliance.
   Health inequity has become one of the key priorities for the European Strategy 2020. Even though the health status indicators, such as the death rate, are improving all over Europe there are still sharp health differences between countries, inside countries, and even between cities and social groups. Unfortunately, health inequity is increasing the global economic recession being among the key causes here. The growing unemployment and cut budgets on public needs will affect millions of people’s living conditions in Europe, and will have the greatest impact on the health status of the most vulnerable groups. Should there be no timely and proper measures taken this health inequity may only increase.
   The issues of low health literacy and treatment compliance, even though seemingly belonging to a different area, yet are indirectly linked to the issue of health inequity. It is obvious that improving literacy among the population in general and especially among its most vulnerable groups (socially disadvantaged) would add to the local community resilience against the socio-economic negative effects of the crisis, as well as contribute to the reduction of health inequity.
   On the other hand a higher level of health literacy will improve patients” treatment compliance, which allows gaining better results in terms of improving people’s health status with no financial cost. Our research demonstrates that the compliance among the vulnerable groups (low-income and those with a low level of education) is poorer than among other groups. This means that improved health literacy and treatment compliance would also promote reduction of health inequity.
   This entire range of issues with their potential solution is reflected in this monograph. The book offers a theoretical overview of the current state of the issue as well as provides the author’s own findings and the experience of the City of Stavropol gained due to the participation in the Healthy Cities project. This monograph would make a good reading for politicians and specialists representing various professional areas (healthcare, education, etc.) whose activities have an impact on people’s health in any way.

Health inequity

   The current state

   Health inequity: political and social aspects
   Literature will often use the term HEALTH INEQUITY as a synonym to HEALTH INJUSTICE. However, these terms are not similar. Since health inequity is a general term typically used to define differences, changes, and disproportions in the health status of individuals and groups not any health inequity will be unjust. Yet, many types of health inequity are undoubtedly unjust as the concept of health injustice focuses on distribution of resources and other processes that drive certain types of health inequity, i.e. on systematic disparities in terms of health (or in its social determinants) among various social groups enjoying more or less favorable opportunities. In other words it focuses on health inequities that are unjust and unfair.
   Speaking of the English terms “inequality” and “inequity” that are used to define “disparity”: in healthcare the expression social inequalities in health imply the same disparity [just like social inequities in health], which is unfair and unjust” (Whitehead and Dahlgren, 2008).
   Some researchers suggest a definition based on which unfairness in health will be related to those health disparities that are considered avoidable, removable, unfair and unjust (Braveman P. et al, 1996, 2001; Newton K.,1997; Anand S., 2002; Whitehead and Dahlgren, 2008).
   Health inequity is increasing both inside countries and among them. Besides, in all countries there is a large gap in terms of health status dividing various groups irrespective of their income. In high income countries there can be observed a more than 10-year life expectancy gap between various groups depending on such factors as the ethnicity, gender, social & economic status, and the geography of residence. In poor countries all regions show significant difference in child death rate depending on the household welfare.
   Socio-economic conditions (social determinants) have a significant impact people’s health through their entire life-span. People with lower income demonstrate at least twice the likelihood of developing a serious disease or premature death if compared to those with high income. Besides, the social disparities in health status, which could be called the social health gradient, can be observed through all the stages of the social ladder and go beyond the low-income group. In particular, even in the middle class those with lower positions contract diseases and die more often than their colleagues holding higher positions (Whitehead M., Dahlgren G., 2008).
   When viewing the behavioral factors – either positively or negatively affecting health – we shall come across numerous undeniable facts showing that poorer (from socio-economic point of view) groups usually demonstrate poorer nutrition, lower physical activity at their spare time, have a higher level of tobacco use or some other alcohol-related behavior patterns that seriously affect health. Special literature available reflecting the findings received from qualitative research into poorer groups” living conditions and lifestyles, serves evidence that such people have more restricted choices in terms of healthy lifestyles, which is due to the limits on their time, space, and money available to them, and could also be accounted for by the psycho-social mechanisms influencing them. All this is aggravated with the difference in access to goods, conditions and services, which could prevent or reduce the health damage from the socio-economic factors. For instance there are differences about access to the major medical care and their quality when we talk of various groups of the society, where healthier and better-off groups enjoy more of that access. The same holds true both for preventive services and for treatment (Whitehead and Dahlgren, 2008).
   The economic standpoint contains reasons showing that such healthcare disparities result in huge loss and waste of human resource, which could otherwise be used both for individual prosperity and for the society at large.
   Health inequity means that a significant part of the society has no chance to reach their full health potential, and this cuts them from access and a chance to enjoy other basic human rights. The conclusion here implies that the society should be equal and fair in distributing the resources available so that to make these accessible for everyone (Whitehead, M. et al., 2008).
   Socio-economic factors are meaningful factors in health inequity. This assumption is based on the ideas of the mechanisms connecting health and socio-economic inequity. In some cases such mechanisms are rather obvious while in other cases they are more complicated and are not so visible from the surface. Thus, the level of income determines the differences in living standards – the quality and the quantity of the goods and services consumed. This, first of all, affects the nutrition calorie content, food diversity and balance, protective and sanitary-hygiene features of the clothes and footwear, as well as the comfort and convenience of the living micro-environment. Differences in the living conditions develop unequal capacities to adjust and to cope with physical and emotional stress. Inequity in living conditions determines unequal access to efficient ways of coping with health disturbances. Such mechanisms of socio-economic inequity “rubbing off” onto health is linked to the hypothesis stating that the relationship between the health and the socio-economic status could be expressed through the interconnection of “better economic status – better health status”. The health status is subject to the influence of individual behavior – smoking, alcohol, poor or imbalanced nutrition, and lack of physical activity. The differences in health status that are due to lifestyle shall be unfair when the choice of the lifestyle is restricted with socio-economic factors never directly depending on the person himself. For instance, poorer (from the socio-economic viewpoint) groups have been shown to tend to adopt behavior patterns posing potential threat to their health (Тапилина В. C., 2004).
   The findings from a number of European research projects suggest that the death rate among those found at the “lowest” rank of the social ladder is typically 2–3 times as high, while the life expectancy in non-qualified employees is 5 years shorter if compared with qualified personnel; also there is a 9—12-year gap between the poor and the well-off in terms of their life expectancy free from any disabling condition (Anand, 2002; Mackenbach, Kunst, 1997; Marmot, 2004).
   Studying social inequity in health and its change over time is one of the key areas in the modern research into the sociology of health. Such research will help deeper comprehension of social mechanisms in the development of health and how much health inequity is due to economic and social changes that the society faces; this will also bring about the idea of the trends – either increasing or decreasing – in health inequity between different social groups. Such research projects are of great importance in terms of developing a social policy aiming at better public health, as well as of assessing the efficiency of the currently implemented measures (Anand, 2002; Mackenbach, Kunst, 1997; Marmot, 2004). According to the documents of the leading international organizations (World Health Organization, WHO, 1990; Braveman, Pitarino, Creese, and Monash, 1996) the nowadays policy of public healthcare is based on the concept of health as a specific public benefit the access to which should be determined following the principles of social justice. This implies equal opportunities in getting the key health resources for people representing various social groups. The implementation of this requirement would involve special attention towards the groups whose status is less favorable compared to others (Anand, 2002).
   Mention should be made here that a policy aimed at reducing the health-related burden in low-status social groups will not just meet the justice principles, yet it will also contribute to significant improvement in the population’s health in general (Mackenbach, and Kunst, 1997).
   Even though the latest decade has seen measures to reduce inequity taken across Europe, there are still many countries with a growing concern that the disparities and inequities are expanding, which is especially obvious in the Central and Eastern Europe where the phenomena in question have adopted in this century an unprecedented scale if compared with other industrial countries. In some countries (the Russian Federation being one of them) where the worsening general health status in people is a common fact, the increasing inequity and disparities are a dramatic consequence of severe socio-economic shock. However, even countries with a good state of things in healthcare (e.g. Denmark, the Netherlands, and Sweden) also demonstrate significant evidence of retaining and even increasing inequity, which puts them, too, among the top concern objects from the point of view of public healthcare. The differentiated aggravation of women’s health, in particular in those belonging to vulnerable social groups, has become an issue that is attracting more and more attention from policy-makers in those countries. In some countries there is direct evidence of health inequity depending on the ethnicity. The findings received from the United Kingdom as well as from other places suggest that this is largely a result of the poor socio-economic conditions of certain ethnic groups.
   Inequity and injustice are quite different and vary from area to area in different periods of time, which is evidence to the fact that they are not fixed and inevitable and could, actually, be altered. The best results gained or underway in a particular country should become a sample and a guide for other countries in their attempt to reach achievable aims in improving their people’s health.
   Social inequity in health is systematic health disparities in various socio-economic groups. This inequity is socially determined (and, therefore, is changeable) and is unfair. Such a judgment of justice is based on the common principle of human rights. There are facts showing that there is huge (and still increasing) social inequity in Europe nowadays, at least as far as relative criteria are concerned (Whitehead and Dahlgren, 2008).
   The range of socio-economic inequities is wide: gender– and age-related, educational, race-ethnic, professional, power-related, material– and property-related, territorial, etc. And way, socio-economic inequities violate the principle of social justice. In this respect the concept of social justice could be analyzed.
   Social inequity has existed for the entire comprehensible human history. Even though inequity has always been subject to destructive criticism and has never been approved, yet people through history have demonstrated extreme resistance to any “ideal” society based on social equity and absence of suppression among groups.
   There is special concern over social inequity when it comes to children’s health. During that the report on health inequity, including the issues of qualitative assessment of gender, age, geographic, and socio-economic factors influencing health disparities, contains data on the health status of adolescents aged 11, 13, and 15 in 2005–2006 representing 41 countries and the WHO’s European region and North America. The purpose of the report was to detect the actual differences in youngsters” health status, and provision of information that could be useful for the development and implementation of specific programs, also contributing to improving young people’s health at large.
   This research has produced convincing evidence showing that despite the high health status and well-being in young people many of them still have severe issues related to overweight and obesity, low self-esteem, dissatisfaction with their life, and substance abuse (Whitehead M., Dahlgren G., 2008; C. Currie, S. N. Gabhainn, E. Godeau, C. Roberts, R. Smith, D. Currie, W. Picket, M. Richter, A. Morgan, V. Barnekow, 2008).
   The World Health Organization has developed an ambitious program Health for All, which targets at a 25 % reduction of health inequities both inside countries and among them by the beginning of the XXI century (World Health Organization, Targets for Health for All, 1990). However, given the results obtained from numerous research projects the WHO European Bureau once again has defined the European targets for health inequity reduction.
   HEALTH-21: European target 1 – Solidarity for health in the European Region.
   By the year 2020, the present gap in health status between member states of the European region should be reduced by at least one third.
   HEALTH-21: European target 2 – Equity in health.
   By the year 2020, the health gap between socioeconomic groups within countries should be reduced by at least one fourth in all member states, by substantially improving the level of health of disadvantaged groups.
   HEALTH-21: European target 3 – Multisectoral responsibility for health.
   By the year 2020, all sectors should have recognized and accepted their responsibility for health (Whitehead and Dahlgren, 2008).

   Prior to dealing with the prominent health inequity there should be an understanding of its major causes and health inequity manifestations.
   Complete and proper understanding of how inequity develops – be that in terms of income or health – as well as what factors influence the process, how these inequities are related, and finding ways to reduce the inequity down to a socially acceptable level – all these are important premises for the development of an efficient socio-economic policy (Кислицына О. А., 2005).
   The most vulnerable to inequity groups still remain the youth, women, retirees, and low-qualification workers. Along with poverty and beggary (sometimes referred to as deep poverty) there is also disadvantage. This typically affects children, the disabled, retirees, representatives of another race or ethnicity, and the chronically poor.
   A society may eliminate absolute poverty, yet there is always some relative. This is because inequity will inevitably accompany complex societies. Therefore, relative poverty will always be present even if the living standards for all the groups of a society have gone up.
   The relation between the death rate and the income, the likelihood of a shorter life expectancy develops due to long accumulation of negative impacts from financial hardships and the emotional reactions linked to them. An individual’s health status is largely determined by the social group this particular person belongs to. A preliminary analysis of the relation between health inequity and economic status shows that towards various health indicators there is both inverse (higher status – fewer diseases) and direct relation. The position held by an individual in the social hierarchy – no matter how it may be defined – through job, level of education or income is always the determining factor both for the health status, and for the prevalence of behaviors that are destructive for health. The issue of social determination of health has been widely discussed by Russian authors (Назарова И. Б., 2007; Русинова Н. Л., Браун Дж., 1997; Журавлева И. В., 1999, 2006; Русинова Н. Л., Панова Л. В. Сафронов В. В., 2007).
   They showed in their research that people employed in areas with lower status and low income more often demonstrate stress symptoms. Stress can act as an effect modifier. This means that in case of comparable levels of harmful impacts those experiencing stress are more susceptible to diseases and accidents. We should also keep in view the extra effects of behavioral stress manifestations, such as smoking, alcohol abuse or violence.
   An empirical illustration of interrelation between health inequity and income inequity is, for instance, the data on differentiation of the medium number of health deviations in various groups of subjective economic status. The highest number of health issues has been registered in the groups with the lowest economic status, and the number will decrease as the status of the group grows.
   A similar relation between health and the objective economic status can be seen in case of some specific diseases, blood circulation issues in particular. The highest concentration of those who suffered myocardial infarction can be seen among the population with the lowest status, and this number of infarction occurrences goes down as long as the subjective economic status goes up (Blaxter, 1990; Marmot, Stansfeld, Patel, North, Head, White, Brunner, Feeney, Marmot, Smith, 1991; Wilkinson 1992; Adler, Boyce, Chesney, Folkman and Syme, 1993; Marmot, 2004).
   The role of economic factors in health inequity
   The dependence of health from the objective economic status is also an illustration of the type of health issues.
   First, it shows a higher concentration of people with low income among those with high or very high likelihood of health loss: groups of those unable to maintain self-care and suffering from limited physical capacity include the elderly. In other words, inverse relation between the objective economic status and the health status is mostly typical of the elderly and the oldest groups of the population, which supports the hypothesis concerning the fact that the development of a stable negative relation between health and economic status is largely subject to the factor of accumulating the negative impact from financial hardships and their consequences over a long time. Second, there is direct relation between chronic diseases and the economic status. A complementary analysis of the relation in view of the age factor among people with various incomes also shows that the poor have a higher share of those suffering from diagnosed chronic diseases in all age groups, if compared with similar age groups with the maximum income. As for acute communicable diseases both the poor and the rich are equally vulnerable to them, with the middle class demonstrating a lower level of vulnerability.
   The distribution of the different age population suffering from health issues in the groups of the subjective economic status also suggests that in the young age (or in the first part of life) the share of people with detected (diagnosed) issues is growing along with the subjective economic status growth. Yet, there is a tendency seen in those approaching the end of their age: the higher subjective economic status the higher concentration of people with health issues.
   People who are rather well-off have significant material possibilities to get the medical assistance needed and to take care of, and maintain their own health. This could be seen, in particular, in the prevalence of preventive visits to medical institutions. Among the well-off this index is significantly higher, if compared to the disadvantaged, both in general, and within specific age and level-of-education groups (Русинова Н. Л., Панова Л. В. Сафронов В. В., 2007; Падиарова А. Б., 2009).
   Thus, there has been both direct and inverse relation identified between health and the objective and subjective economic status. On the one hand, the higher economic status the more often people visit medical institutions for preventive purposes and the higher the number of those with chronic diseases detected. On the other hand, the higher economic status the lower (on average) the number of people with health issues, the lower the share of people with severe heart diseases (myocardial infarction), and the lower the share of those with significant and stable loss of health. In general the individual findings on health support the conclusions and assumptions concerning the prolonged and ongoing impact of income on health, which were done based on the analysis of socio-economic inequity and territorial differences in people’s health status. There we can see both cumulative effect where “the quantity (of money) shall transfer into quality (of health)” after a certain period of time, and the stimulating role of higher income on the ongoing health monitoring and timely response to its disturbances.
   The relation between the social status and various aspects of mental issues has been of interest for both doctors and researchers since long ago; the findings from a lot of research have demonstrated the meaningfulness of social status in understanding mental diseases and disability. The epidemiological research projects conducted all over the world have shown an inverse relation between mental issues and the social class. There has been consistent data obtained suggesting that mental disturbances are more common for the lower social class (Meltzer et al, 1995). At the same time, lately there have been discovered other channels of the significant impact that inequity has on health. In particular, it has been shown that chronic stresses related to the dissatisfaction with one’s socio-economic status may result in neuro-endocrine and psychological functional alterations thus contributing to the disease likelihood. It has already become a common opinion that a longer feeling of fear, uncertainty, low self-esteem, social isolation, inability to make decisions and be in charge of the situation both at home and at work impact health seriously: this may cause depression, increase susceptibility to communicable diseases, diabetes, high blood cholesterol, and cardio-vascular issues. Low socio-economic position, therefore, impacts health directly through deprivation and financial hardships, and through the subjective vision of one’s “unequal” position in the society and the related judgment, relations, experiences. When studying the influence that the socio-economic status has on health focus should be kept on both the objective and subjective socio-economic status. Therefore, there is an undoubted connection between the financial status and health, which can be seen both from the scientific-theoretical viewpoint, and at the level of common sense (Падиарова, А. Б., 2009).
   Many researchers state that low socio-economic status is associated with high prevalence of mood disorders (Dohrenwend et al, 1992). There was also a suggestion that belonging to a particular social class will influence the nature of psychopathological symptomatology in depression. Patients demonstrating symptoms of somatized and anxiety disorders more often belong to a lower social class. At the same time cognitive symptoms were more often detected in patients from a higher class. The severity of depression in adults, related to financial issues, may depend on age. Mirowsky и Ross (2001) found that it goes down as the age goes up. Financial troubles and poor marital relationships are significant factors contributing to the risk of depression onset and its chronic course (Patel et al, 2002). Just like depression, poverty is typically chronic in its nature, so it usually needs focus both from caregivers and from decision makers.
   If compared to the general population people who attempt suicide more often belong to the social groups where social instability and poverty are typical.
   Gunnell et al. (1995) investigated the relation between suicide, parasuicidal behavior, and socio-economic issues. They identified a connection between suicide and parasuicidal behavior, while negative socio-economic factor offered nearly complete explanation. Besides, these murders and suicides more often happen in densely populated poor areas (Kennedy et al, 1999). Crawford and Prince (1999) also support these findings. They noticed an increase in the suicide rate among young unemployed men living under severe social deprivation. It also true that the frequency of cocaine or opiate overdose cases is associated with poverty (Marzuk et al, 1997).
   Both unemployed men and women demonstrate a higher level of alcohol or substance dependency in case they belong to the unemployed. The social class is a risk factor of death due to alcohol abuse, which is also related to such structural social factors as poverty, disadvantage position and the social class. The rate of alcohol-induced death is higher among men involved in physical labor than among clerks, yet the relative index will depend on the age. Men aged 25–39 and involved in common non-qualified physical labor demonstrate a death rate 10–20 times higher than representatives of the middle class, while among those aged 55–64 the same index is only 2,5–4 times higher if compared to those who are involved in a type of labor requiring special skills (Harrison & Gardiner, 1999).
   The relation between the lower socio-economic status and personality disorders is far from being well-investigated. Low family income and insufficient living conditions are prognostic factors for crime among adolescents and adults (based on official and survey data). However, the connection between poverty and crime is a complex and a continuous one. The interrelation between impetuosity and the neighborhood in connection to criminal activity show that impetuosity is higher among residents of poor areas rather than among those residing in better-off ones (Lynam et al, 2000). A Cambridge research into the development of minor delinquency produced data stating that unstable employment at the age of 18 was an important independent predictor of previous conviction history among young men aged 21–25 (Farrington, 1995).
   The growing number of researches into the relation between poverty and health indicates that low income combined with unfavorable demographic factors and insufficient external support causes stress and life crisis, which serve risk factors for children and may trigger mental disturbances in them. Children from the poorest families show a 3 times higher rate of mental disturbances than children from more prosperous families. Poverty and disadvantaged social status have strongest connection with insufficient skills in children and their poor academic performance (Duncan & Brooks-Gunn, 1997).
   Kaplan G. A. et al, (2001), after studying the socio-economic status in childhood and the cognitive functioning in adulthood, concluded that a higher socio-economic status in childhood and a higher level of education determine a higher level of cognitive functioning in the period of maturity, while both mothers and fathers, independently, contribute to the development of creative cognitive functioning in their children and their cognitive capacity at older age. Obviously, a better socio-economic status in parents and a higher level of education in children may improve cognitive functioning and reduce the risk of dementia at a later stage of life.
   Confused, strict and full of violence upbringing as well as lack of control and poor child-parent attachment will aggravate the poverty effect and worsen other structural factors, when it comes to minor delinquency. A Cambridge research into the evolution of minor criminals poverty was taken as one of the most important predictors for delinquency (Farrington, 1995). It was also shown that, in view of mother’s education and behavior in early childhood, poverty also affected academic performance and delinquency (Pagani et al, 1999). Eyler and Behnke (1999), after studying the effects of most common psychoactive substances in children (on their first and second years of life) who were subjected to that in the prenatal period, concluded that the children living in poverty demonstrated obviously aggravated effects of those substances.
   The materials of the WHO show that social inequities may also have an impact on the level of vulnerability to environmental risks and the severity of these risks” impact on health. There have been 4 of such mechanisms demonstrated:
   ?Mechanism 1. Social determinants correlate with the quality of the environment. Socially disadvantaged groups often live and work under poorer environmental conditions if compared to the general population.
   ?Mechanism 2. The levels of impact are in a certain dependency on the factors related to social inequity (such as level of knowledge and type of behavior in terms of health). Therefore in case of similar environment disadvantaged groups may be subject to a more intense impact than the population in general.
   ?Mechanism 3. Factors related to social inequities (such as health status and biological susceptibility) affect the dependency “impact – response”. Given the same level of impact, disadvantaged groups may reveal a higher level of vulnerability to unfavorable consequences for health, e.g. due to synergy of various risk factors.
   ?Mechanism 4. Social inequities have a direct impact on the end results related to health, which may reveal itself through both environmental and non-environmental mechanisms. However, under similar dependency parameters of “impact – response” disadvantaged groups may reveal a higher level of vulnerability to unfavorable consequences for health due to poorer access to the respective services and reduced capacity to cope with the negative effects. The absolute scale of the consequences can also be higher in disadvantaged groups because of higher prevalence of previously existing health issues (Whitehead and Dahlgren, 2008).
   According to most researches representatives of lower socio-economic groups stand a higher vulnerability to negative environmental factors (Braubach M, Fairburn J., 2010; Bolte G, Tamburlini G, Kohlhuber M., 2010).
   Gender features of health inequity and the family role
   Research conducted all over the world show that gender is another important factor determining health inequity.
   The feature typical of Russia is an extremely high death rate among men and an unprecedented gap between the life expectancy among men and women (12–14 years).
   This attracts more attention to men’s health in modern Russia, which overshadows the fact that, according to medical statistics and opinion polls, women have been consistently showing higher rates of health issues.
   The lower status of health in Russian women – not only compared to Russian men yet also to women in other countries – is also seen from the calculations of the healthy life expectancy. According to the data provided by the leading Russian demographers the huge gap in the healthy life expectancy of the 20-year olds (both Russian men and women) and their Western counterparts (13 years), in men is due to a higher level of death rate (especially in the working age), and in women – due to a lower health status (mostly in the older age) (Масленникова Г. Я., Оганов Р. Г., 2002, 2004).
   Actually, the so-called gender paradox, which could be expressed as “women become ill more often while men die earlier”, which is a global tendency, typical of civilized countries at least, has always been of interest to researchers. For a long time this gender paradox has been explained by medical statistics, supporting the fact that men typically suffer from fatal illnesses and fall prey to illnesses that do not reveal well expressed symptomatology; as for women – they typically suffer from acute and chronic, even though less severe conditions.
   Thus, a number of empirical research projects have shown a significant variability in the scale, and sometimes in the patterns of gender-bound health differences at various stages of life cycle, as well as within different health indicators.
   According to the theory of unequal impact, women demonstrate a higher level of ill health due to their restricted access to material and public resources that would save health, and because of increased stress accounted for by their gender and family role.
   If compared to men women hold different positions: they are more often unemployed, get employment in other areas, and in general they have to enjoy lower income. There are also some gender differences in behavior stereotypes as men are more prone to smoking, alcohol abuse and unbalanced diet, while women are less active physically.
   It has also been proven empirically that women carry a heavier burden of responsibility in fulfilling their social roles. Theу also possess a smaller psychological resource required to cope with stresses. In particular, women have a lower awareness of control over life circumstances. At the same time women, if compared to men, have various sources of obtaining some social support.
   According to the second approach – vulnerability difference – women demonstrate more health issues as they respond differently (compared to men) to financial, behavioral and socio-psychological circumstances that develop health.
   Thus, empirical data shows that full-time employment along with taking care of the family, as well as social support are more important health predictors for women rather than for men.
   Tobacco and alcohol consumption are more meaningful health determinants for men while overweight and low physical activity affects women more. While maturing educated girls create smaller and healthier families. The survival rate in their children is higher, and they stand a higher chance of getting education, if compared to children born to less educated mothers (Expert Group Meeting, United Nations, Division for the Advancement of Women (DAW), World Health Organization (WHO), United Nations Population Fund (UNFPA), Tunisia, 1998).
   The research conducted in Russia has shown that in women the meaningful determinants of physical functioning include the level of education, awareness of personal responsibility for health, as well as a possibility to spend some time taking care of oneself, while men’s physical condition depends more on a balanced diet and preventive measures. Men’s physical health is especially vulnerable to external impacts at a certain stage of their lives, the pre-retirement decade, to be exact (51–60 years. Gender differences are especially obvious in the health developing mechanisms when analyzing the levels of realized welfare (Назарова И. Б., 2007; Русинова Н. Л., Браун Дж., 1997; Журавлева И. В., 1999, 2006; Русинова Н. Л., Панова Л. В. Сафронов В. В., 2007).
   In important issue in healthcare is getting assistance by women in many countries. There is significant evidence showing that women are subject to gender-bound restrictions in terms of getting access to medical assistance, which is true in particular for women from the poorest groups. The obstacles they have to face include lack of culturally adjusted types of assistance, shortage of resources, transportation troubles, suppression, and sometimes even a ban imposed by husband or other family members. Lack of public funding for healthcare affects men as well, yet in view of a limited family budget women’s healthcare needs do not enjoy priority.
   Similar issues remain in relation to identification and measuring abuse, family violence, and sexual abuse. The life expectancy of an American woman will depend on ethnic factors: white women live an average of 82,2 years, while for black women this index is 75,5. The infant death rate (per 1,000 births) among the black population is 13,6, among Chinese the infant death rate in America is only 3,5. The maternal mortality among black women over 35 is 71,0 per 100,000 labors, while among white women it is only 11,4. Hite women have a higher rate of breast cancer; however the survival rate within 5 years following treatment in black women is 15 % lower because the tumor in them is detected at later stages. Latin American women have a cervical carcinoma rate that is double of the rate among white women, and their death rate from this issue is 40 % higher. American Indians get antenatal assistance in 69 % of cases while American Japanese – in 90 % of cases. The HIV and AIDS prevalence (per 100,000 women) is 2,3 among the white, 11,8 among Latin Americans, and 50,0 – among the black population. The death rate for infants born to white mothers with no special education is twice higher if compared to white mothers with a degree in higher education (Expert Group Meeting, United Nations, Division for the Advancement of Women (DAW), World Health Organization (WHO), United Nations Population Fund (UNFPA), Tunisia, 1998).
   Males also have some specific features contributing to the development of health inequities. For instance, men’s mental health is significantly due to the position they have in the society.
   It is interesting to note though that the relation between men’s mental health and the key markers of their social position – education and financial welfare – is inverse. While a high level of prosperity has a positive effect on men’s mental well-being, their mental health clearly deteriorates along with their education level.
   As for women, their realized welfare is largely determined by behavioral factors, mental issues faced in the family environment, and the capacity of their psychological resources allowing them to cope with stress (Expert Group Meeting, United Nations, Division for the Advancement of Women (DAW), World Health Organization (WHO), United Nations Population Fund (UNFPA), Tunisia, 1998).
   A number of research projects carried out in Western Europe stress the importance of family in shaping a certain level of health inequity. The parents” resources alone already have an impact on young children’s life quality and create inequity between children from prosperous and poor families. First, the parents” economic capacity determines where and how the family will live. There is a difference if children live in a small rented apartment located in a disadvantaged urban area or in a large house with a garden in a fashionable neighborhood (Meulemann, 1990). Empirical findings show that different life quality among children from poor and prosperous families does not just matter in itself yet it also serves precondition for further inequities. The level of recognition that children enjoy among their friends depends on their toys, sport gear, pets, fashionable clothes, opportunity to travel, pocket money, the configuration of their own computer (Szydlik, M., 2004).
   At the same time already in the earliest childhood the parents” resources set important milestones for the entire biography and for the position in the social inequity structure. The parents” choice of the residential area has a direct impact on their children’s first friends” social position. Peers, in turn, have a significant impact on children’s and adolescents” secondary socialization – they either increase or suppress the interest in education and culture. This means that parents, be that deliberately or not, through the social groups of their children’s first friends set the framework for the common and desired standards in education, about which their children learn from their closest environment. Of course, it is also important that the residence determines the choice of school and the level of education in the child’s school friends.
   The parents” impact on their children’s education can hardly be overestimated. Education determines the opportunities in life. The individual education has a decisive influence on income, choice of profession, prestige, career, employment opportunities, working conditions, match between the professional background and employment, property, retirement benefit, choice of partner, health and life expectancy. This is why education is a central measure for social stratification. The one with the best education shall get the highest score in all the above-mentioned areas. Each year of school or professional training adds around 6 % to the salary. Better educated people will have less trouble finding an employment and they are fired more seldom. Those with a University degree stand a better chance to find an employment within their area of training (Szydlik М., 1996).
   Parents set important educational standards for their children. This is not only about the decisions concerning education itself but also about the general level of education in the family. The very first years of life lay the basis for future academic and professional success. The decisive role here is rather common – the financial capacity of the parents. Therefore, the family connections reproduce social inequity through the entire life. Especially impressive here is the connection of inter-generation solidarity and social inequity. Solidarity between generations is well expressed not only in relation to minor children who still reside with their parents. This goes on after the children leave the parental home. This solidarity continues for the entire life, thus constantly reproducing social inequity.
   Parents from higher social groups create better conditions for their children not only in childhood and adolescence. When children become independent they still get support through regular money transfers, gifts, property and, finally, inheritance. This is how the support provided by the upper class to their children through their lives will enforce and even increase the social inequity. The youngster who had better chances due to the parents” resources will have obvious advantage in adulthood.
   In general solidarity between generations is well expressed through all the social groups. However, bigger opportunities mean bigger support. Parents without significant resources can never provide such support. This is how families strengthen and increase social inequity. This enhances the chances of children whose parents hold higher social positions thus reducing the opportunities of children from poorer families. Here we must recognize the invaluable service done by the family and assist it in every way. However, an important public and political task is to reduce inequity based on parentage (Szydlik, M., 2004).

   Role of education in health inequity
   As stressed above, education is one of the major determinants of the economic inequity and its role is increasing year after year.
   The public expenses on education make up about 60 % of the total national educational budget; the part covered by the population is about 30 %, with another 10 % coming from the employers. This ratio of public and non-public funding on education (60/40) is significantly different from what economically developed countries have where the population has a higher level of income in general and, which is equally important, where the differentiation in income is much lower, while the private funding from employers and sponsors is higher. For instance, in 2001 in the USA the public budget for education was 69,2 %, in Germany – 81,4 %, in Great Britain – 84,7 %, in Italy – 90,7 %, in Sweden – 96,8 %, in the Czech Republic – 90,6 %, in Slovakia – 97,1 %.
   The crisis of public funding for education in Russia stimulates paid education and getting fee from the family for various services, which increases inequity in access to education. Selection is more and more based not on the aptitude criteria but on the applicants” parents” financial capacity. A survey conducted in 2005 by the Russian National Center for Public Opinion showed that half of the Russian population (55 %) cannot afford educational services that are paid, while 21 % of Russians can afford it in extreme cases only. Besides, attending an educational institution and graduating from it with the respective degree certificate does not mean having quality education. The growing density of education both in school and in universities is one of the factors for a certain reduction of its quality. This already contributes, and will contribute on, to the growth of inequity.
   However, it is common knowledge that each extra year or education in Russia accounts for a nine-percent death rate reduction in men and a seven-percent death rate reduction in women, while those involved in mental work (especially leaders) demonstrate a higher survival rate than those involved in physical labor (Тапилина В. C., 2004). Researches carried out in St. Petersburg (Russia) showed significant differences in health status esteem depending on the level of education and financial deprivation – in the social groups with limited educational and economic resources the health status was lower (Русинова Н. Л., Браун Дж., 1997; Русинова Н. Л., Панова Л. В., 2003; 2005; Максимова Т. М., 2005; Назарова И. Б, 2007). Foreign authors, too, focused on the issue of social differentiation of health in our country. In order to support the facts mentioned it was shown that the level of financial hardships and education are important predictors of the perceived health (Bobak, Pikhart, Hertzman, Rose and Marmot, 1998; Bobak, Pikhart, Rose, Hertzman, and Michael Marmot, 2000; Carlson, 2000). These works also stated that one of the significant health status determinants is such an indicator of social well-being as the perceived control over the life circumstances.
   The differences in education related, to a certain degree, to income differentiation, may also reveal themselves in the value and behavioral aspect of the way someone treats his/her own health. In particular, education is connected to the specificity of ordinary health conceptualization, the level of personal responsibility for one’s health status, and the differences in people’s awareness of health issues, healthy lifestyle, and medical care. People with a degree in higher education are usually involved in a wider network of interpersonal connections thus standing a better opportunity to get instrumental and emotional support. The level of education has also been repeatedly noticed to have relation to the differences in the prevalence of health destroying behavior patterns (Демьянова А. А., 2005; Cockerham, 2000; Pomerleau, Gilmore, McKee, Rose, and Haerpfer, 2004). For instance, in 1998 in the female part of the city 64 % of the respondents with a level of education below average referred to their health as poor or very poor, while among those with a higher degree of education the same response was obtained from 20 % only. As for men, about 58 % of St. Petersburg residents with no complete secondary education considered their health as unsatisfactory, while in the most educated segment the same response was given only in 10 % of cases. In the same year the share of respondents with poor health in the first (lowest) and the fourth (highest) income quartiles were: for women – 30 % and 13 %, and for men – 21 % and 4 % (Русинова Н. Л., Браун Дж., 1997, 1999; Rusinova and Brown, 2003).
   The economic status is a projection of income inequity, which has direct relation to health inequity. However, the differences in income are also known to reflect the differences in the level of education, the professional background. The educational status in many countries is used as the major indicator of people’s status in the socio-economic inequity hierarchy, while the economic status, in turn, is viewed as the indicator of the return from the investment into the cultural capital. Apart from that education can be considered as an indicator of an increased capacity to take and process information, as well as make decisions allowing taking proper and meaningful approaches to maintaining and caring for one’s own health. There is an obvious relation between income and profession. Low income is typically connected with unqualified heavy physical labor, which, in addition, contains the risk of being injured or maimed.
   A separate issue that requires solution within health inequity is marginalized groups that are to be found in any country and in any society. Unfavorable working conditions that potentially exacerbate the impact of environmental risk factors are mostly typical of marginalized groups, such as refugees and migrants even though they could pose a problem for people with a low level of education. The concept of “unfavorable working conditions” may embrace such types as working with no contract signed, child labor, as well as forced and coerced (as a pay for a debt) labor. Working with no contract signed is the major source of inequity in relation to the environment and health, as well as violation of regulations for national labor safety, working hygiene, and working conditions, which involves various negative effects on the health of the employees.
   In Hungary, for instance, 15 % of Gypsy settlements (Roma) were located within 1 kilometer from illegal dumps, and 11 % – within 1 km from the places for destroying dead animals (Gyorgy et al., 2005). In Serbia similar settlements had a 2–3 times lower water supply and hygienic facilities (Sepkowitz, 2006).
   Therefore health inequity has along historical context; this issue is determined by many factors and is found anywhere regardless of the socio-economic level of development of the country as a whole. Yet, in view of ethical, legal, economic, and medical-social implications this issue requires urgent response at all levels, from local to global.
   Health inequity in Russian Federation: state of things
   The issue of inequity in income distribution in the post-socialist area has been a subject for wide discussion both in our country and abroad. This point has always been the focus of researchers and politicians, from time to time giving raise to acute socio-political debate. Russia is no exception here given the significant changes it has undergone in the latest decade. Quite a tough issue is developing human potential under rapidly progressing market conditions and similarly rapidly disappearing social benefits for the disadvantaged. In view if this, experts define two types of challenges: on the one hand the country is facing typical of poor countries troubles like spread of communicable diseases, regions with stagnating poverty (still present in Russia), undeveloped infrastructure and high death rate. On the other hand the country is suffering from healthcare and education crisis, and such issues are common for advanced post-industrial countries as well.
   Poverty profile in Russia
   Poverty in Russia has a number of typical features. For instance, most vulnerable are families with children and, therefore, children themselves, who are under 16. Note to be made though that this issue is not common for most countries. As for retirees they are under lower risks of being affected by poverty because most of them work and the social benefit system is oriented, first of all, at the elderly.
   Special mention should be made of the fact that working population is the larger part of the poor group even despite of salary growth. In order to reduce the number of poor people among the working population the minimum salary should be at least 150 % of the minimum cost of living. In the April of 2009 25 % or the working population received their salaries below this minimum. 70 % of them had children. 37,4 % of the working population received salaries below 200 % of the minimum cost of living.
   This level of pay for labor is sufficient for meeting the minimum needs of one employee and one child. Therefore, even in a situation where two parents are employed such salaries cannot be enough to support two children at the minimum level.
   The largest share of the poor population is accounted for by the people who are able to work, especially youth. Countrymen are more vulnerable to poverty than urban population. Besides, the maximum poverty risk affects the unemployed population, economically inactive groups, as well as those living on social and disability benefits.
   Level of poverty and inequity
   The dynamics of poverty and inequity is determined by the consumption share for the 20 % of poorest against the total volume of consumption. Up until 2000 this index was about 5,8–6,1 %. Later on the share of the poorest 20 % has gone down, which serves perfect evidence of the fact that the poor have got no access to the results of economic growth.
   (The World Bank in Russia Russian Economic Report, No. 21, March 2010, http://siteresources.worldbank.org/INTRUSSIANFEDERATION/Resources/305499-1245838520910/6238985-1269435660465/RER21rus.pdf).
   The liberal economic reforms went along with a significant fall in the standard of living and an increase in the socio-economic differentiation. The growing economic inequity has become a serious challenge both for the people and for the government. Our country now has significant inequity in terms of health and accessible medical assistance due to polarization of income and opportunities, which means limited and clearly deficient current social policy carried out in our society. The recent research findings have provided quite a clear demonstration of significant differences in people’s opportunities at birth, during the preschool and school period, in terms of getting access to higher education, housing, transportation, shopping, recreation and fun activities, relationships with the state, access to medical services, life expectancy, maintaining health status and healthy lifestyles, religious affiliation, funeral services, inheritance, etc. Just 20–25 years ago when the disproportion was not so extreme some specialists in social hygiene and healthcare arrangement even talked about potential homogenous conditionality of health in our country.
   We must admit that health inequity is a new and, obviously, a long-term issue in Russia. Even though there have always been differences in people’s health status this point never got so much attention. One of the sources of social tension in any country is the gap between people’s welfare, in the level of their prosperity. The level of prosperity is determined by two factors:
   1) the size of (any kind of) property possessed by individuals;
   2) the size of the individuals” income (Дашкевич П. Р., 1995; Денисов П. Р., 1997).
   One of the criteria of civilization in any country’s social sphere is maintaining the respective appropriate living standard for the groups (families) that for some reasons cannot meet even the minimum standards and customs (food, clothing, leisure, etc.). One of the most urgent social issues in Russia that came into being because of economic changes is unprecedented inequity in income. According to the Russian Statistics Agency (Rosstat), by 2006 the income of the most prosperous groups was 16 times the share of the least prosperous ones (Российский статистический ежегодник, Россия в цифрах, 2006). However, if we take into account that the official statistics often underestimates the socio-economic differentiation in Russia not taking into view the shadow economy, then the true gap in question may be much larger. According to the data provided by T. Zaslavskaya (2005) the inequity gap between the 10 % at the extremities is 30–40 times. As noted at the Report on Poverty Evaluation made by the World Bank (2004), this fast growth of income inequity in Russia was close to a record – Russia here is very much different from other countries including Central and East Europe, where they also had a transfer to the market economy. Experts say that socio-economic differentiation similar to Russian should be looked for in Latin America rather than in European societies (Murphy, Bobak, Nicholson, Rose and Marmot, 2006). The social stratification trend in our country that became especially obvious in the 1990-s is still there under the rather long process of economic growth noticed in the recent years – income differentiation was detected in 2007 as well (Щербакова Е. М., 2008).
   The high rate of economic and socio-structural changes in Russia that were ahead of most people’s adjustment capacity brought to many increased levels of chronic stress, loss of control over life circumstances, and resulted in prevalence of behaviors related to health risks, first of all high alcohol consumption (Cockerham, 2000; Bobak, Pikhart, Rose, Hertzman, and Marmot 2000; Cockerham, Hinote, Abbott, 2006).
   All this could not but affect Russian people’s health, which is well seen from the growing death rate and reduced life expectancy.
   As a result, by the early 21 -------
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Century (2000) the death rate brought Russian into one line with African countries located south of Sahara, namely 15 deaths a year per 100 people, which is nearly double the index of developed societies (Римашевская Н. М., Кислицина О. А., 2004).
   The recent years have witnessed quite clear a vicious circle where the national Russian healthcare system has found itself – the more funding is invested into specialized inpatient care and hi-tech clinics the less funding is given to prevention and early detection, which results in an increased number of patients, adds to the severity of their conditions, detection of diseases at later and even very bad untreated stages, and chronization of pathologies, which requires even more funding for tertiary healthcare.
   Therefore, the modern Russian healthcare system could be described with a high level of inequity in distributing health opportunities among individuals and groups of people, as well as with a conflict between the state and the society, with erosion of the aims and objectives in the sphere of healthcare (Сизова И. Л., 2007).
   The impact of social inequity in the Russian society has been especially seen the young generation, whose origin and development came onto the reforms.
   Under the reforms in Russia, apart from traditional disturbances there have come into being new trends in youth’s health: “psychization” and “psychologization” of diseases, increasing social disadaptation, loss of confidence about one’s strength, increased feeling of “social loneliness”. This aspect creates the necessity of a sociological reflection on the changing social conditions and their impact on new deviations in youngsters” health, and the development of new practices in certain classes and social groups.
   Even though we have already discussed poverty as the most important factor of inequity, Vladimir Putin’s words – Russia is a rich country of poor people – make us turn towards the issue again, yet in the context of the Russian reality.
   On the initial stage of the economic reforms in Russia the core group of the poor was traditionally represented by the so-called vulnerable groups including retirees, disabled, large families and one-parent families with children. Nowadays the focus is definitely shifting towards a different risk group – the “working” poor, the part of the society that are able to work and, due to various reasons have low income, which keeps them from supporting themselves and their families properly.
   Quite often poverty has also socio-psychological preconditions. One of them is the “overtaking” poverty. This term could be used to describe a phenomenon implying prestige consumption. It is typical for youth, rather than for older people, to dress well and to look no worse than others. The things that prosperous parents” children have (fashionable and expensive clothes) set up certain example attracting children whose parents cannot afford that. If a prosperous parent can buy something never feeling and financial issue then a poor parent’s budget may be seriously affected by the same purchase. This prestige consumption makes many people live beyond their financial capacity. Those from poor families feel uncomfortable due to their own position and that of their family, which does not allow them live better. This causes a generation conflict where children blame their parents for not wanting or not being able to “make money”, even despite all the morals. As a result poor people’s children find illegal ways to make money, which they need to “catch up” with the rich ones, to live up to the standards imposed on them by the middle or the upper class (Падиарова А. Б., 2008, 2009).
   The poor’s focus is shifted towards negative evaluation of the reality, pessimism, and despair. They are often unable to build proper relations within their families – high voice in the family, mutual reprimands, obscene words and abusive language become a common thing. Such conditions develop a special lifestyle and a value system, which could be described by restraint and voluntary isolation, economic and social dependency, lack of clear behavior role models, separation and political passivity, absence of future plans and self-confidence; increased disposition to conflicts in family relations (rude talks, quarrels between parents and children, frequent divorces) (Кислицина О. А., 2005).
   Other reasons responsible for acute aggravation of health inequity in Russia during the transition period include:
   1. Actual shift in healthcare from caring for health to clinical medicine, i.e. from mass recreational and preventive measures to individual treatment.
   2. Increased share of paid services, development of new relationships with patients, which destroy the basics of medical ethics, and which make it possible to view the patient as another source of income; chronic deficit of funding with a large number of various sources of that, which never contributes to financial transparency.
   3. Sharp increase in inequity in terms of people’s access to medical services, while the majority of these people are socially disadvantaged.
   4. Prominent inequity in doctors” incomes.
   5. Unequal access to medical services for certain groups of people: homeless people, neglected children, migrants, and just financially vulnerable people.
   4. Continuing practice of increasing the share of costly and expensive medicine, a huge gap between the quality and quantity of medical assistance in cities and in the provincial areas, and the gap between the assistance provided to rural and to urban residents is increasing.
   5. Obvious and neglected mismatch between people need for preventive medicine, treatment and rehabilitation, and the funding allocated to the area. All this makes medicine spontaneous, paid, creates new issues and even power abuse, which may result in undermining the entire structure of the system. Since recently, instead of improving medical assistance, managers in healthcare have started talking about lifestyles, thus trying to avoid responsibility for current state of things in medicine and shifting it onto people who abuse tobacco, alcohol, stick to unhealthy diets and just do not take care of their own health, even though, actually, all this is one of the tasks for the system of healthcare.
   6. Overly complexity of the very system of healthcare and, as a result, its poor controllability and efficiency (Комаров Ю. М., 2010).

   Thus, we believe that in order to reduce the urgency of health inequity it takes comprehensive intersectoral measures, which should be initiated by the public health sector, while all the municipal agencies and public groups should be involved as equal partners.
   Measures for reducing health inequity
   Health inequity determinants lie within areas of public life other than healthcare alone; then it is obvious that there is a need for a policy in all these areas aiming at assessing their impact on health, especially on the health of the most vulnerable groups, which would allow coordinating the policy respectively.
   From the viewpoint of social policy, first of all there is a need to realize the scale of the issue. This is why the top aim for a social policy in this area should be activity for, at least, limiting the impact of poverty and income inequity on people’s health.
   The Committee for socio-economic determinants recommends the following
   – to carry out a quantitative assessment of potential effects on the health of different groups of the population due to particular risk factors;
   – to detect the risk factors (including social determinants) whose effect could be prevented;
   – to carry out a differentiated analysis of the impact on health that competing risk factors have, e.g. such as tobacco smoking and diet;
   – to detect and carry out a deeper analysis of the cumulative effect of multiple impacts;
   – to investigate additional and synergetic (or, which is less likely, antagonistic) interaction between socio-economic factors and the negative environmental factors;
   – to get to deeper understanding of the nature and gender differences in the vulnerability of children, older people and the elderly to negative environmental effects (CSDH, 2009).
   The countries looking for counter-measures in order to reduce social and environmental inequities should take into account their driving forces and the underlying reasons. No doubt, there are no easy ways to eliminate the inequities, proof to that being the social processes that have been going on in the latest decades. The key to success of the strategies that are being implemented is a clear division between short– and long-term objectives, and reducing socially determined environmental issues takes various approaches.
   ?In the long-term outlook disadvantaged groups will gain the maximum benefit from interventions aiming at creating a safer environment just because these groups are more often subject to negative environmental impact.
   ?The long-term measures that should be part of the local, national, and international agenda must include special events and campaigns aiming at serving the groups with the detected risk of the most serious or specific unfavorable effects of environmental inequity.
   Since poverty is one of the key factors determining health inequity, this inequity cannot be resolved unless this key issue is resolved.
   The major stream in overcoming absolute poverty is ensuring productive employment, increasing labor efficiency, creating conditions allowing the working population earning more thus supporting themselves and their families.
   In this case the size of the salary comes out as the major guarantee against poverty. The role of the state here implies establishing market conditions for increased competitive capacity in the national economy through increased competitive capacity of the Russian enterprises – implementing the required industrial policy, proper adjustment of the system for staff training, introducing measures for supporting the national manufacturer.
   Higher selectivity in offering social assistance, application-based priority, and individual social benefits – all these make up an efficient way of eliminating poverty.
   When selecting socially vulnerable groups there is a need to match the officially established poverty line with their income, the officially established minimum property standard with the property that they possess. Special attention should be paid here to the issue of homelessness, neglected children, and children in crisis families.
   An important task for social policy is detecting the obstacles on the way to obtaining social support and benefits.
   The current system for revealing and supporting poor families and people providing them with various benefits, advantages, sand other types of assistance is far from being perfect and needs adjustment to market economy. The funding allocated nowadays to provide social support to the poor is not efficiently distributed and will often go to the families that are poor indeed. As a result the truly poorest population remains even in worse condition.
   The international practice includes the following measures to combat poverty:
   – Redistribution of income.
   First of all there should be measures for the development of an efficient labor market. This issue implies resolving two key tasks:
   – Measures for reducing the number of low-paid employees;
   In the major measures aiming at the reduction of the number of low-paid employees the following can be defined:
   – Increased salaries for public employees through bringing up the expenses for remuneration of labor;
   – Implementing a policy aiming at reducing illegal types of labor remuneration, which contributes to impoverishment of the working population (delayed pay, payment in kind). Such a policy must include economic and administrative measures targeting, first of all, the employer;
   – Encouraging employment for those who want and can work, new workplace establishment. To ensure prompt the establishment of new workplaces takes stimulating the priority in the development of the economic areas that can provide new workplaces with minimum investment. This is, first of all, small– and middle-scale business.
   – measures for reducing income inequity at the expense of social transfers and increased minimum guarantees in social security sphere;
   – introducing a progressive income tax for individuals. Officially the gap between the 10 % of the poorest and the richest is 15 times (CSDH, 2009).
   No doubt, apart from solving general healthcare issues, the measures for reforming the national healthcare system should also contribute to reducing health inequity in Russia. Such organizational measures include:
   1. A multifunctional network of healthcare institutions with its internal and external connections, which would allow calling this network a healthcare system.
   2. A rather branchy system of medical examinations, check-ups and measures. There should be extensive work to offer general public training in self-help in certain cases (in case of trauma, bleeding, etc.) and self-examination (regular examination and palpation of breast, taking the pulse, blood pressure, etc.); this will take circulation of special literature.
   Besides, the tasks for healthcare both in general and locally (by health criteria) include:
   – bringing closer to densely populated areas shopping malls offering everyday goods, pharmacies, institutions for primary medical assistance, recreational institutions, schools and preschool institutions, places of everyday use, public transport, etc.;
   – Improved facilities, reduced environment pollution, improved quality of water, air, and soil;
   – Improved local environment, planting of greenery, establishing recreational areas;
   – Improved structure and quality of food, efficient control of food safety;
   – Increased level of culture and education, encouraging involvement of children and adolescents into activities based on their interests, organizing their spare time and creating conditions for public physical activities (stadia, swimming pools, skating rinks, skiing paths, sport gyms, etc.);
   – Strengthening the value of family, crime prevention;
   – Activating the movement for health and mobile lifestyles;
   – Eliminating drug abuse, tobacco smoking, alcohol consumption, preventive work with children, youth and adolescents;
   – Sanitary education of the general public, increasing the level of sanitary literacy and culture, teaching simplest ways of primary self-help and mutual assistance;
   – Combating prostitution, STDs, and AIDS;
   – Vaccination and immunization;
   – Establishing paramedical and nurse respite service, integrated medical support at home (day-time or day-and-night), establishment of municipal or neighborhood nursing homes or hospices;
   – Health and working capacity recovery, establishment of rehabilitation centers;
   – Conducting preventive, special periodic medical check-ups, early diseases detection, primary medical assistance;
   – Detecting socially vulnerable groups and providing them with the individual required support;
   – Working and living conditions. Since health inequity is often related to unequal living or working conditions then reducing the inequities should imply eliminating the underlying causes. Some public policies aiming at the establishment of proper and safe residence, increased standards of professional health and accident prevention, even though they were developed to help people in general, still may prove most efficient for those employed and living under the worst conditions, through increasing their physical and social environment standards;
   – Choice of lifestyle. The state policy here should be aiming at offering people equal opportunities in choosing healthy lifestyles. Recreational institutions and sport facilities, for instance, should be accessible both by their location and price, while shopping mall chains should guarantee cheap and nutritional food supplies. At the same time the advertisement and promotion of products that have a negative effect on health should be restricted (Комаров Ю. М., 2010).
   The areas of social policy that could have the most efficient contribution into improving people’s health include the following ones (CSDH, 2009; Final report by Commission on Social Determinants, WHO, 2010):
   – Intervention into early life.
   More and more research support the role of the environment where a child lives in the early childhood, which has an impact on the child’s future behavior, academic performance, and health for his/her entire life. People whose childhood included residing in families suffering from financial issues were more prone to various diseases in adulthood. Therefore, offering equal opportunities requires the earliest intervention possible. It is common knowledge that mother’s nutrition during pregnancy will impact not only the child’s health in the first year, yet for the entire life. Therefore, a woman’s weight prior to pregnancy is a good predictor of the child’s weight at birth; a lower weight, in turn, is related to a higher risk of coronary heart disease, hypertension, and diabetes in the future life. This means that investing into policies reducing negative early effects may prove profitable not only in the present, yet in the future generations as well (Gilmore. G., 2009).
   The role of the population in the system is extremely important and may reveal itself in municipal volunteers and activists involved in all the aspects of healthcare and in solving all the issues. It is becoming more and more popular to join patients in groups of self-training (with some professionals involved as well), teaching them how to make the best of their living and working with some particular chronic disease or after overcoming some dependency (alcohol, tobacco, drugs). Here we can also mention the currently popular in Russia so-called schools of people with diabetes, hypertension, asthma, osteochondrosis, osteoarthrosis, etc., anonymous alcoholics groups and so on. Involving people from the most disadvantaged groups into common work will give them a chance to become part of political processes and define measures for inequity reduction, which would allow better detection and elimination of the most relevant inequities. Based on the data analyzed we can make a preliminary conclusion that breaking the vicious circle of increasing poverty and poor health, even under scarce resources, is mostly about their mobilization in three areas: successful employment (improved conditions based on involvement that may bring satisfaction); strengthening social connections, development of a stable communication circle for people who are related and who share similar ideas; consistent and economical disease prevention, which includes a wide range of issues (proper nutrition, absence of negative behaviors, general activity, maintaining social connections, positive emotions, etc.). (Комаров Ю. М., 2010).
   While running a policy for reducing inequity it is important to conduct monitoring of differences in the efficiency of the measures and policies implemented towards various groups of people, and to ensure more precise match between the measures taken and the respective needs.
   We cannot assume that all measures and interventions designed for improving health would be equally efficient for all social groups. These ideas concerning policies and activities can be easily illustrated through anti-tobacco campaigns.
   Foreign research shows that when budgetary-financial policy is used to regulate cigarette prices then it mostly affects smoking among adolescent and youngsters under 20 rather than the adult population. Besides, according to the same research findings tobacco prices typically have a larger impact on adults with low income, and, as a result, it is poor smokers, and not rich ones, who are likely to be among the first ones to reduce smoking after a rise in prices. And, vice versa, anti-tobacco advertisement very often proves most efficient with the more prosperous groups, and least efficient – with groups suffering from various troubles in life and experiencing economic hardships (The WHO Regional Office for Europe, 2010).
   Thus, we can see that, according to the data offered by literature, health inequity is a serious medical-social issue for most countries including Russia. The urgency of this issue in our country not only ever went down, yet it has increased. However, nowadays there are opportunities for its systemic resolution. In the literature that was available to us we found only general recommendations on the issue in question; at the same time we never found any information concerning health inequity reducing technologies tested in any Russian city. Therefore, the development of a technology aiming at health inequity reduction in a particular Russian city, based on the strength of the determining factors, seems to be an important scientific task.

   Investigation into health inequity: City of Stavropol (K. R. Amlaev, 2010)
   In order to avoid any average data and to receive representative information about the life quality of the most vulnerable groups of Stavropolities there was a sociological survey conducted (questionnaires) for representative sample. The total bulk of respondents was 600 people following the calculation formula for representative sample. The major purpose of the survey is to investigate issues related to health inequity.
   Samples were developed by the following principle: every third visitor of the local social services was interrogated. The design of questionnaire implied the Ostfold list (Norway) for life quality evaluation, which included the following blocks
   § Assessment of one’s own health
   § Respondents” lifestyles
   § Respondents” socialactivity
   § Trust towards various authorities and social services
   § Satisfaction with the neighborhood of residence and with the living conditions
   § Respondents” socio-demographic description
   The questionnaire was designed at the institutes for public health of Sweden and Norway as part of the European project Health Profile (HePro), (translated into Russian and adjustment to the purpose of the research – K. Amlaev, 2005).
   The sample bulk included both representatives of vulnerable groups and other groups as well. The filed study (71 persons) was conducted in the October of 2009. The work with large database of primary information determined the choice of methods, implementing which was possible based on the statistical software package SPSS.
   Description of sample bulk
   The major poll included 529 people +71 from the field study. 32,1 % of them were men, 67,9 % – women. The age distribution was the following way: Stavropolities under 20 – 8,4 %, 20–29 – 22,1 %, 30–39 – 21,0 %, 40–49 – 16,7 %, 50–59 – 15,6 %, 60–69 – 9,9 %, over 69 – 6,3 %.
   More than half of the respondents have stable employment (51,0 %). 17,0 % of the bulk are unemployed retirees. Occasional employment have 7,8 % of the respondents, and temporarily employed are 6,3 %. 5,7 % are undergoing professional training, officially registered as jobless are 2,1 %, 1,1 % are supported by their parents or some other people; 1,3 % are involved in other activities.
   44,5 % of the respondents have a higher education degrees, 27,4 % have secondary professional degrees, 5,0 % are with initial professional training. 11,4 % finished 11-year schooling; 6,9 % graduated after 9 years of schooling. 4,8 % of the respondents have just elementary education.
   44,4 % of the respondents are officially married; 9,7 % live with their partners; 25,3 % are single; 11,0 % are divorced; 9,5 % are widow (er) s. 11,0 % live alone; 23,9 % live with just one person at home; 28,3 % – with two persons at home, 19,0 % – with three, 10,5 % – with four. 4,7 % of the respondents have families of six, 1,4 % – of seven, 0,7 % – 8, and only 0,5 % of them reside with a family of 9.
   18,4 % of the respondents have no children. Most of them (38,0 %) have only 1 child. One third of the respondents have 2 children, while the share of those raising 3 children is 9,6 %, 4 children – 0,8 %, and 5 children – 0,3 %.
   50,0 % live in a separate apartment (in apartment blocks), and 28,5 % live in cottage-type houses; 8,2 % rent an apartment or a room; 5,7 % have a room in a dormitory; 3,6 % dwell in communal apartments, 1,9 % live in cottages; other types of housing have 21 % of the respondents. 75,2 % of them are owners of their dwellings.
   The most common source of income among respondents is their salaries at the major employment (67,6 %). 34,1 % have their retirement benefits as their source of income. Relatives help to 23,0 %, while 21,7 % get social benefits and advantages; 17,4 % have extra employment. 10,7 % also grow products in their garden, which is their extra income. 9,4 % have scholarship in their income structure. 7,1 % have income from entrepreneur activities, and 1,1 % have income from bank deposits, shares, and bonds; other types of income are common for 4,4 % of the respondents.
   22,6 % spend less than half of their income on food; 38,4 % spend on food about half of their income, and 39,0 % of the respondents spend on food over 50 % of their income. 32,7 % of the respondents often do not have enough money to buy the most essential products. 41,9 % cannot afford buying things for longer use; 19,8 % do afford expensive things for longer use, yet on a loan only and not all at the same time. Those who cannot buy only an apartment or an expensive car account for 4,7 %, and 1 % of the respondents do not restrict themselves in anything.
   Here and below we provide only statistically meaningful results of the research (sample tolerance – no more than 2,0, p <0,05, Pearson’s chi-square> 20,0)!
   Health and lifestyle
   31,0 % of the respondents described their health as pretty good. 40,2 % out of them were under 50, and 11,6 % – over 50.
   Those spending less than half of their income on food (conditionally well-off) in 21,1 % of the cases described their own health as excellent; 36,9 % of the respondents mentioned they experience frequents stresses.
   Among those with stable employment 35,8 % experience stress, while among the unemployed this share was in 54,5 of the respondents.
   Most often various diseases affect people over 50 and unemployed retirees (83,4 % and 89,7 % respectively). Especially indicative is the difference between those with elementary education and those holding a higher education degree – 76,0 % vs 48,3 %.
   85,5 % of widow (er) s and 45,9 % of single respondents suffer from some chronic illnesses, traumas, disability, etc.
   It has been found that 20,0 % of those supported by their parents mentioned they constantly suffer from physical and emotional issues, while among the unemployed the same answer gave 9,1 % of the respondents. From among those with elementary education 68,0 % experience negative impact of their physical and emotional state on their social activities, while those holding a higher education degree fewer people depend on physical and emotional troubles. Most often emotional issues were mentioned by the unemployed group and unemployed retirees (65,9 % and 72,7 %). Respondents with elementary education more often suffer from the impact of their mental-emotional state – 80,0 %.
   Least time on physical activity spend migrants (40 %) and the unemployed.
   39,5 % of men and 71,3 % of women accounted for non-smokers. And there were more smokers among respondents with elementary education rather than among those with higher education. Only 20 % of the respondents with elementary education referred to themselves as non-smokers while among those with a higher education degree the same was true for 66,5 %. 42,1 % of single and 25,9%o of those officially married smoke. Never smoked 20,0 % of the respondents with elementary education and 54,7 % with higher education.
   23,7 % of the respondents who work occasionally tried alcohol-containing liquids that are non-consumable; unlike them those with stable employment tried similar liquids in 14,7 % of cases only.
   Single people more often non-consumable alcohols (23,5 %) while among those married officially only 9,1 % tried such alcohols.
   Social aspects
   It is interesting to note that only 4,9 % of those with stable employment do not count on somebody’s support and assistance. At the same time 41,5 % of the respondents with only occasional jobs, and 40,0 % of dependent respondents do not expect any support. Those who are employed expect somebody’s support in 81,9 % of cases. People taking care of a disabled child expect some support in 50,0 % of cases, while only 20,0 % of migrants believe someone will provide them with such support.
   The research has shown that the respondents” social activity also depends on their belonging to a particular social group. It has been noted that the most politically active part of the population includes people with stable employment as only 17,9 % of them do not go to the elections; however, if we speak about the dependent population and housewives, on the contrary, remain more indifferent toward elections giving negative answer to the respective question in 60,0 % and 39,5 % of cases.
   Migrants have proven to be the least politically active group – 80,0 % of them do not attend election. The most active group is retirees – only 14,2 % of them gave a negative answer.
   More than half of the respondents trust the system of healthcare – 53,1 %; in terms of the system of education this number was – 52,7 %; social services – 54,9 %, the police – 22,1 %. About 50,0 % of the respondents trust job placement service – 44,3 %, while over 30 % of the respondents trust social insurance services – 30,9 %.
   The highest level of trust towards the police demonstrate war veterans – 57,2 %, while among the employed population the police enjoys trust from 27,7 % only; as for migrants none of them trust the police.
   23 % of the respondents trust insurance companies; the prosecution office and Court have trust from 21 % of the respondents.
   A little over 20 % of the respondents trust law-making authorities and about one third trust Head of the City Administration. Over one third of the respondents trust the media.
   45,9 % of the respondents absolutely agree or agree rather than not that nothing depends on them. 86,4 % of those with elementary education completely agree, or quite agree that nothing depends on them. Among those with a higher education degree the same answer gave 41,7 % of the respondents.
   Quality of medical assistance and its availability
   60 % of the respondents are satisfied with the district doctor’s working hours. The cost of treatment was acceptable for 36,5 % of the respondents. Half of the respondents were happy with the attitude towards patients. 34,7 % of the respondents found the quality of the treatment good.
   The cost of the administered treatment was unacceptable for 50,0 % of the disabled, 20,0 % of migrants, 17,1 % of retirees in general, and for 13,9 % of those employed. 34,0 % of the respondents noted that being hospitalized in-patiently is easy or rather easy. People with temporary employment said so only in 21,0 % of cases. Dependents in 100 % cases believe that hospitalization in the in-patient department is difficult or rather difficult. 80,0 % of migrants mentioned that it was rather difficult or difficult to be hospitalized in the in-patient ward, while among war veterans only 12,5 % mentioned the same.
   Social and daily-life conditions
   Over 50,0 % of all respondents are happy with the service offered at most shops, post offices, personal service places, etc.
   40,0 % of the respondents consider sufficient the cultural opportunities (libraries, movie houses, theaters, dance clubs). A little over one third of the respondents expressed satisfaction with active leisure opportunities (stadia, swimming pools, gyms), and over 40,0 % of the respondents were happy with the public transport.
   20,0 % of dependent respondents are happy with the service they can get at most shops, post offices, personal service places, etc.
   25 % of dependent respondents consider acceptable the opportunities for cultural life (libraries, movie houses, theaters, dance clubs), while 100 % of this group of respondents found active leisure opportunities (stadia, swimming pools, gyms) insufficient.
   The level of daily service was found poor by 60,0 % of migrants, 50,0 % of the disabled, and 35,7 % of the employed respondents.
   War veterans and Labor veterans are unhappy with the daily service offered at their neighborhood in 16,1 % and 12,5 % of cases respectively.
   Insufficient the local opportunities for cultural life were found among migrants, the disabled, retirees, and the employed – 60,0 %, 50,0 %, 43,8 %, and 39,6 % respectively. War veterans consider cultural opportunities insufficient in 14,3 % of cases only.

   Conclusion
   The survey has proven that poverty among Stavropolities is rather high, while the crisis only exacerbated the issue. According to our findings over 39 % of the respondents spend more than half of their income on food. This correlates with percentage of those who lack money to meet their basic needs – 32,7 %.
   Our research has shown that people’s assessment of their own health depends on their marital status, income, and place of residence; it is lower in widow (er) s, low-income groups, and those residing in the “depressed” neighborhoods.
   A high level of stress has been found in the unemployed, widowers and those residing in overpopulated areas, which, as we think, is due to lack of stability, insufficient socio-psychological support, and dense population (high level of noise, traffic jams, etc.).
   The unemployed and migrants pay the least attention to physical activity. An independent risk factor for tobacco and alcohol dependency is a low level of education; the same category of people demonstrates the highest level of alcohol consumption.
   Dependent people, temporarily employed, and migrants have the lowest expectation of getting support from anyone.
   The electoral activity of Stavropolities depends on their income and duration of residence in the area – low-income groups and migrants are infrequent visitors at elections. Another factor reducing electoral activity is the area of residence.
   The social service that enjoys the highest demand from the residents of Stavropol is the district medical service. This service, along with the system of education, and social assistance services, enjoys most trust. A low level of trust has been found towards the police (3,7 % among the disabled and 0 % – among migrants).
   The level of trust to the Head of City is 27,8 %, which is higher than the level of trust to law-makers, prosecutors, Court, and insurance companies. The lowest trust to various bodies has been found among the dependent, migrants, and those residing in the “depressive” neighborhoods of Stavropol.
   The disabled and migrants demonstrate a lower level of satisfaction with the district medical service. A low level of satisfaction with doctors” attitude has been found among the disabled and migrants, which could be attributed to deontological issues. Troubles with hospitalization experience those who are dependent, who have temporary employment, and migrants. Various types of discrimination (according to the respondents” opinion) experience people with a low level of education and those residing in communal apartments. The lowest assessment to their neighborhood of residence was given by dependents, which is due to low mobility access for this group of respondents, and residents of the “depressive” areas, which is likely to be linked to lack of an efficient transport system and a low level of social and cultural infrastructure in these areas.
   Thus, despite the measures aiming at providing support to socially vulnerable groups this work proves not efficient enough.
   The research has demonstrated an uneven effect and quality of the socio-economic health determinants in various groups of Stavropol’s residents. The correlations detected between the impact of such determinants and the lifestyles, personal assessment of health, and the respondents” social activity, may serve a basis for making governance decisions. There has also been an intersectoral action plan developed to obtain positive results and to reduce health inequities in the residents of Stavropol.
   Intersectoral Plan for Reducing Health Inequity in Stavropol
   Basic provisions on plan development for reducing health inequity
   The plan has been developed in view of its major purpose – reduced health inequity among Stavropolities based on intersectoral municipal policy for health; some key approaches were used as well.
   An important task was defined as the development of a dialogue with various sectors in terms of improving the life quality for the vulnerable groups of residents. In the course of the plan development both horizontal and vertical approaches were employed. On the one hand there were key parties defined: municipal authorities, the individual, communities and interested organizations; medical service (horizontal lines); on the other hand there were issues of equity, communication, monitoring and evaluation determined as the major parts for any activity within the program (vertical lines). The specific measures have been integrated into this logic and naturally interconnected
   The major areas of the plan implementation include:
   – a municipal policy for improving health and intersectoral cooperation in terms of reducing health inequity, eliminating risk factors contributing to inequity, partnership for health at various levels of the society, improving preventive activities carried out in medical institutions;
   – reduced inequity and positive effect on the socio-economic health determinants, communication for health, monitoring and evaluation of the efficiency of the measures carried out.
   People’s health status depends not so much on the capacity of the healthcare system as on the condition of the socio-economic health determinants.
   This is why a significant role is attributed to the municipal government, where we are talking about the efficiency and impact of the political decisions on the lifestyles and health of the local residents.
   Up until now the work on improving health was viewed as the responsibility of healthcare professionals. One of the conditions for successful implementation of public healthcare policy is establishing with other sectors a dialogue on how they cold contribute to improved public health and benefit from that.
   The municipal authorities are responsible for developing a policy taking into view public healthcare issues, and for taking proper measures in all the respective sectors.
   Therefore the key role of the municipal administration is to improve law-making, as well as to coordinate and provide resources for implementing the program.
   Nowadays one of the crucial elements is proper funding. The progress in this area is indispensable for successful implementation of the principles envisaged in the plan.
   There are inevitable connections between health, poverty, and social solidarity, and therefore reforms and development of interconnection in healthcare will play an important role in implementing the tasks determined by the program.
   The healthcare department, which acting as an advocate for health interests, ensures strategic planning in terms of the policy that impacts people’s health and its determinants.
   In general the public health strategy implementation should be based on the following key principles:
   1. The municipal government’s adoption of health interests and values, and inclusion of these into its activities and the activities of all sectors of the local city community at all levels of public management.
   2. Bringing down the risk of diseases related to lifestyles and the development of skills and opportunities for living healthier life in general.
   3. Building partnership for reducing health inequity.
   People’s health develops in a particular social environment – daily life, and depends not only on the public governance and medical service, yet also on the availability and activities of NGOs, religious organizations, private sector, the media, local authorities, and the local community.
   Well-coordinated activities by healthcare specialists are crucial. The international experience has shown that health improvement and disease prevention in daily life and at the local level is much more efficient than measures taken at the individual level.
   Multipartnership contributes to social activity and adds to people’s and communities” ability to resolve their own issues. It is possible to mobilize all public capacity at the local level and to enforce the democratic approach, which is always positive.
   Local self-government authorities are also key parties in the program. When this plan was developed it was related to the already existing Strategy for the Development of Stavropol. The development and enforcement of intersectoral interaction between the public sector, NGOs, and local self-government will allow more efficient and comprehensive resolution of health inequity issues.
   Working with the local community is a key element in health improvement and inequity reduction. The inevitable condition here is activating and involving people. This is aiming at empowering the local population to influence health determinants at individual and social levels, taking into account the environment. Such methods contribute to the involvement of the local community into defining and resolving issues they have to face in their daily routine. Running activities for resolving these issues increases the likelihood of maintaining stable changes inside the community.
   4. Introduction of program for health improving as a priority in the healthcare policy on the way to integration and development of an independent service for improving health.
   5. Development of a wide comprehensive communication system for the benefit of health.
   The three major areas of communication are:
   – communication with various groups of the population;
   – professional communication with medical employees;
   – communication with other sectors and partners.
   6. Monitoring, evaluation, and efficiency of the activities carried out.
   Monitoring and evaluation include several difficulties. Improving health is a long-term investment where the results of epidemiological impact are not likely to be seen even in mid-term period, but only 10 years after. This is why measuring the efficiency and success of the program should be done using the following indicators: change in lifestyles, development of skills and knowledge, organizational and legal development (organizations, communities, etc.).
   In case of successful implementation of the plan the expected results will include:
   Health will be an important element in daily political thinking and a major argument in decision-making at all levels of public governance.
   An increased role of public healthcare and preventive trend in the healthcare system.
   Improved public funding for healthcare services, introduction of new methods, e.g. attracting resources from taxes.
   An increased number of partners (religious organizations, NGOs, the media, private sector, etc.) involved into health-improving measures. Increasing the role of the communities as partners for the system of healthcare, and enhancing their control and influence upon factors deteriorating their health. Positive changes in turning the society towards the meaning of health as the major element in the value of daily activities. The development of positive lifestyle elements (healthy diet, sport activities in leisure time), reduction of health-affecting behaviors and of the socio-economic damage wrought by such behaviors, especially in the youth.

   Plan for reducing health Inequity in Stavropol till 2010 (excerpts)
   General aim:
   To encourage health inequity reduction through efficient social policy based on a dialogue between the civil society, the authorities, business circles and the media.
   Objectives:
   · Increased quality and accessibility of medical assistance;
   · Increased quality, accessibility and individual nature of social services;
   · Establishing environmental stability and reduced inequity based on the territorial principle;
   · Establishing conditions for healthy lifestyle, maintaining and improving health for people in general;
   · Encouragement of poverty and health inequity reduction;
   · Increased awareness of health inequity, encouraging the healthiest decisions taking into account the inequity issue;
   · Improved legal basis on health inequity.

   Partners:
   Stavropol City Administration, Stavropol City Parliament, Committee for Finance and Committee for Budget, Committee for Economic Development and Trade, Committee for Information Policy, Administrations of Stavropol neighborhoods, Department for Healthcare, Department for Culture, Department for Physical Education and Sport, local neighborhood Departments for Labor and Social Welfare, Department for Labor and Social Support in Special Public Affairs, Department for Youth Affairs, Public Institution Job Placement Center of Stavropol, scientists representing higher educational institutions of Stavropol, Russian Institute for Industrial Foods, local and regional NGOs.

   Events within the Plan for Reducing Health Inequity in Stavropol till 2010
   1. Aim: increased quality and accessibility of medical assistance.
   Challenges:
   · Low health status in socially disadvantaged families;
   · Poor access in low-mobility groups (disabled, lonely retirees, elderly) to palliative medical assistance;
   · Poor access in low-mobility groups (disabled, lonely retirees, elderly) to medical counseling;
   · Poor access for the homeless to regular medical assistance;
   · Lack of vital medicines supplied to low-income groups;
   · Lack of healthcare institutions in remote neighborhoods, areas and newly built districts.

   Objectives:
   § Reduction of health inequity by 20 % by 2020 (based on a survey among vulnerable groups);
   § Development of rehabilitation and palliative support, including establishing hospices, hospitals and wards for nurse care, involving the respective ministries and departments, as well as international organizations and NGOs, sponsors, private investors, religious organizations;
   § Establishing new healthcare institutions;
   § Computerization of municipal healthcare system;
   § Establishing GP offices in apartment blocks or next to them in various neighborhoods across the city;
   § Technical adjustment of medical institutions to the needs of low-mobility groups;
   § Establishing a nursing department at Municipal Healthcare Institution CLINICAL HOSPITAL 2;
   § Establishing a shelter house for homeless people;
   § Conducting medical examinations for the marginal groups of people (the homeless, etc.);
   § Supplying vital medicines to those who need them.

   Expected outcomes:
   · Increased temporal and territorial accessibility of healthcare institutions (standard: up to 30 minutes in case of using public transport and transport accessibility – up to 5 kilometers);
   · Increased availability of out-patient municipal healthcare institutions with up to 174,8 visits per 10,000 of the population;
   · Reduced number of detected first tuberculosis (TB) episodes in its bad condition, down to single cases;
   · Reduced number of non-specialized use (by social indications) of beds in healthcare institutions, down to 5 %;
   · Increased (by 10 %) number of detected cases of socially meaningful diseases among the homeless;
   · Increased (by 25 %) number of people who are treatment-compliant due to increased accessibility of medical assistance;
   · Reduced (by 5 %) death rate from vascular diseases;
   · Accessibility of psychological support for the elderly and low-income groups.

   2. Aim: increased quality, accessibility and individual nature of social services
   Challenges:
   · Lack of individually targeted social support for families with children;
   · Lack of access to social infrastructure for disabled people (insufficient public transport system adjusted for carrying low-mobile people, lack of ramps at public organizations, companies, and outside;
   · Isolation of the disabled from the society and lack of skills for communication with peers;
   · Limited opportunities for developing personal creative potential;
   · Lack of access for disabled children to educational institutions;
   · Limited access for disabled children to educational and informational resources;
   · Lack of socio-psychological assistance to disabled children through their entire process of education;
   · Lack of resources for renovating the housing occupied by war veterans;
   · Low level of social activity among the disabled;
   · Lack of public bodies” involvement into activities for social rehabilitation of socially disadvantaged families;
   · Lack of self-care and daily activities skills in low-mobility groups;
   · Low access to psychological assistance for low-mobility groups;
   · Poor social care and support to single mothers.

   Objectives:
   § Development of suggestions for improved social policy in healthcare based on the respective analysis (surveys, feedback from the locals);
   § Encouragement and implementation of programs and measures aiming at financial support, medical and social rehabilitation for low-income groups, the unemployed, those who need support, the disabled, and other people who, due to their physical or intellectual limitations suffer troubles in terms of exercising their legal rights and interests; to start transition to targeted support under social contracts where one of the conditions for providing the family with benefit and social support would be involvement of this family’s capable members into employment and training programs;
   § Increased basic social benefits guaranteed by the legislation, first of all aiming to support children, mothers, family, students, and retirees;
   § Secured income – salaries, retirement benefits, allowances, scholarships;
   § Conducting a questionnaire survey among socially vulnerable minors and families registered at the local database in order to define the families” needs;
   § Support to initiatives aiming at recreation of socially disadvantaged minors in sanatoria, countryside camps, special camps sponsored by social welfare and educational institutions;
   § Investment into children: programs for development in early age, catering in schools, benefits for large families, special policies for neglected and homeless children, programs for combating marginalization (vagrancy, panhandling, drug abuse, delinquency);
   § Support to programs aiming at placing minors from socially vulnerable families to preschool institutions, schools, and higher educational institutions on a free basis; support in placing minors in instituti0on for complementary education;
   § Referring minors” parents to be treated from alcohol dependency;
   § Eliminating obstacles keeping the disabled from gaining access to the social infrastructure (lack of specially adjusted transport, lack of ramps at various places and outside).
   Expected outcomes:
   · Increased access, quality, and individually targeted social support;
   · Increased level of welfare for low-income families;
   · Increase access to secondary education for children with limited capacity;
   · Increased number of children from socially disadvantaged families prepared for placement, and placed in educational institution;
   · Improved work on interaction between the educational institutions of Stavropol and the social-psychological services;
   · Purchase (at the expanse of the regional budget) of 35 sets of equipment as part of the initiative for the Development of Distance Learning for Disabled Children with Limited Capacity within the national project EDUCATION (in 2011); this would allow 35 children with limited capacity to reach a higher level of quality and accessibility of education, and to pursue their training on a continuous basis;
   · Establishment of conditions for smooth integration of children with limited capacity into the educational environment;
   · Expanded activities at the department for musical rehabilitation at the Municipal educational institution CHILD ARTS SCHOOL would result in an increased number of disabled children attending the school, which, in turn, would lead to their better adjustment in the society;
   · Creative activity will be a factor for improved health status in the disabled, a way to create better emotional moods, which will result in recovery or improved performance of the damaged functions (thinking, attention span, imagination, fine motor skills);
   · Development of active life outlook and responsibility towards one’s health among the elderly – at least 10,000 of elderly people participating in local cultural events;
   · Involvement of students and post-graduates from local law schools to provide legal counseling services to at least 500 elderly people per year;
   · Social-pedagogic and correctional psychological assistance coverage of up to 40 % of socially disadvantaged families and children;
   · Targeted and efficient use of the city budget would allow offering at least 2800 sets of social services per year for the disabled;
   · Technical equipment for rehabilitation, equipping bus-stops with smooth ramps and information screens;
   · Stable functioning of a comprehensive rehabilitation and integration system for the disabled in Stavropol would allow at least 4,600 disabled people join the local events each year;
   · Obtaining relevant information concerning the socio-economic status of families with children will allow making timely and proper decisions thus imposing order on the budget allocated to the respective social support;
   · Public recognition of disabled people’s achievements would contribute to the social activity of those with limited capacity;
   · Up to 700war veterans will have their housing conditions improved;
   · Reduced number of extremely poor families by 15 %.

   3. Aim: Establishing environmental stability and reduced inequity based on the territorial principle
   Challenges:
   · Lack of transport access to socially meaningful objects;
   · Poor roads in remote areas of the city;
   · Increased crime rate in the depressive areas;
   · Poor living conditions and the conditions of daily activities.
   Objectives:
   § Establishing stability in the surrounding environment;
   § Introducing the principles of stable development into the city development strategy and programs, prevention of natural resources loss;
   § Improved transportation and environmental conditions;
   § Affordable prices for socially important daily services;
   § Supply of clear drinking water to residents of the remote neighborhoods;
   § Investment into the poor (remote) neighborhoods of the city: basic supplies (natural gas, water, power, sewage treatment system, etc.);
   § Developing a social infrastructure map for the city neighborhoods;
   § Improving living conditions for the population.
   Expected outcomes:
   · The social infrastructure map would improve the quality of the strategic decisions adopted;
   · Street lighting in the evening and night time would help reducing trauma accidents by 10 % and bringing down the crime rate by 15 %;
   · Increased number of transport vehicles and improved circulation routes would improve the accessibility of socially important infrastructure;
   · Increased accessibility of the city environment for low-mobility groups (purchase of special lifts, installation of universal toilets at leisure and recreational zones);
   · Natural gas, power, and water supply for the residents of the remote neighborhoods would go up by 20 %, which would be an improvement of their life quality.
   4. Aim: Establishing conditions encouraging the development of mass physical activities and healthy lifestyle
   Challenges:
   · Low availability of sport constructions;
   · Worsening health status in the younger generation and lack of desire to take care of their own health;
   · Poor arrangement of adolescents” leisure activities in summer time;
   · Social isolation of the elderly;
   · Low supplies of cheap and affordable basic food products to low-mobility groups;
   · Lack of a well-developed infrastructure (shopping areas, recreational zones, etc.) in all the neighborhoods of the city.
   Objectives:
   § Offering equal opportunities in making choice of lifestyles (leisure-time places and sport facilities must be both accessible and affordable);
   § Establishing conditions for preserving and improving health of the elderly population;
   § Offering equal opportunities from the earliest age, and creating a motivation mechanism for healthy lifestyle (healthy diet, physical activity and sports, etc/.), assistance in overcoming dependencies (tobacco, alcohol, drugs);
   § Restricted advertisement and promotion of products that have a negative effect on health;
   § Supplying enriched nutrition (vitamins, microelements) to the vulnerable groups;
   § Ensuring accessibility and affordability of leisure-time activities for the youth;
   § Involving minors and their parents to active participation in local recreational and leisure activities and events.
   Expected outcomes:
   · Construction of new sport facilities in Stavropol would allow increasing by 10 % the number of minors, adolescents (including those experiencing life troubles), and students;
   · Increased outreach for children and adolescents involving them into organized activities, which would result in reduced minor delinquency, alcohol, drug, and substance abuse, as well as smoking by 20 %;
   · Organized leisure-time activities for the youth would result in a 10 % decrease in psychoactive substance;
   · 100 new workplaces would be established;
   · Improved health in pregnant and breastfeeding women.
   5. Aim: poverty and economic inequity reduction
   Challenges:
   · Lack of prestige in relation to blue-collar jobs and low pay;
   · Inactive position taken by public bodies in relation to working adjustment of the disabled;
   · Lack of access to socially meaningful services for low-mobility groups;
   · Low socio-economic status of families and minors who are in socially dangerous situations;
   · Troubles that adolescents face trying to find employment for summer-time;
   · Low financial security of the young generation.
   Objectives:
   § Elimination of extreme poverty among non-marginal groups;
   § Establishing interaction of the job placement center with the neighborhood administration and the local companies (enterprises) located in the area in order to circulate information on the availability of vacancies and facilitating adolescents employment for summer-time;
   § Establishing an efficient policy at the labor market and public support to employment: reduction of low-paid jobs, creating new high-paid and secure workplaces;
   § Encouragement to establishing workplaces for those who need social support as well as encouraging their training, re-training, and employment;
   § Training and re-training within integrated professions;
   § Establishing temporary employment for the unemployed and those experiencing troubles finding employment;
   § Organizing public activities for the disabled;
   § Promotion and quota-allocation of blue-collar jobs;
   § Offering employment to the disabled at common-type enterprises through adjusting some workplaces and changing the working schedule;
   § Establishing financial systems offering services to poor population (the major type of service is small loans, which would allow people starting small business activity (to support themselves and their family));
   § To promote recognition of the homeless (vagrants, panhandlers, etc.) as full members of the society and encourage their potential integration through social support networks.
   Expected outcomes:
   · Proper and timely career guidance, temporary and seasonal employment for the youth; establishing new workplaces through contracts may result in a 20 % reduction of unemployment;
   · An increased (by 20 %) number of people enjoying benefits in retail networks;
   · Increased mobility for the local residents and a reduced number of barriers in the urban environment;
   · Promoting employment and getting an extra source of income for retirees – at least 300 retirees will participate in local trade fairs and exhibitions;
   · Preferential services for certain groups of people in Stavropol would increase access for the disadvantaged to companies offering daily services;
   · Individual service enterprises would offer discounted services to certain groups of people;
   · Each month certain groups of people would save over 500 Rubles (taken in prices for 2010).

   6. Aim: Increased awareness of health inequity, encouraging the healthiest decisions taking into account the inequity issue
   Objectives:
   § Establishing a communication arena for members of the movement against health inequity;
   § Wide use of the media to promote healthy lifestyle, prevent diseases, and providing coverage to health inequity;
   § Informing people and NGOs and involving them into decision-making in social policy development;
   § Lobbying suggestions on eliminating inequity at the municipal level:
   · Establishing efficient mechanisms for involving local residents into decision-making in social policy development;
   · Increased awareness of public authorities concerning the real state of things around health inequity and drawing authorities” attention to the issue;
   § Involving volunteers from among NGO members and students (Stavropol State Medical Academy, humanitarian Universities) to conduct preventive-educational activities;
   § Involving into general activities people from various social groups thus helping them to express their civil potential and to develop due measures against health inequity.
   Expected outcomes:
   · Increased awareness of health inequity among various groups of people;
   · Contributing to decision-making in view of inequity issues;
   · Wide use of the media to cover health inequity issues.

   7. Aim: Improved legal basis on health inequity
   Challenges:
   · Low access to legal support for low-mobility groups;
   · Long waiting list to preschool institutions;
   · Lack of land lots available for building social infrastructure objects.

   Objectives:
   § Improving legal acts aimed to establishing individual preventive work with marginal families and minors;
   §Encouraging protection of constitutional rights and legal interest, enforcing the mechanisms of exercising these rights and interests;
   §Improving the level of legal awareness, culture, and eliminating legal nihilism and pessimism; encouraging the development of civil activity in people;
   §Assistance people in exercising their rights to get medical support;
   §Encouraging the development of the range of free legal services offered to people in the area of administrative, financial, civil, criminal, housing, entrepreneur, family, international, labor, and other types of law;
   § Improving municipal legal acts developed in order to offer social support to families raising children;
   § Improving municipal legal acts developed in order to offer social support to the disabled;
   § Referring parents to local higher educational institutions to get free legal services;
   § Providing local residents with social infrastructure objects, conducting an inventory of the land allocated for building social objects, and developing measures in order to keep such land for (future) constructing the objects in question.
   Expected outcomes:
   · Wider range of free legal services offered to people in the area of administrative, financial, civil, criminal, housing, entrepreneur, family, international, labor, and other types of law;
   · Increased level of legal awareness among parents, due to free legal services offered to them;
   · Keeping land for constructing social infrastructure would allow (in case of budget available) developing the infrastructure of the city and constructing the required objects within “walking distance” from the residence and following the standards;
   · Reduced tension in the area of social infrastructure and services available.

   Conclusion
   1. The conducted analysis of Russian and foreign literature shows that positive results in health inequity cannot be reached without resolving such issues as poverty, better access to quality education, improved measures on environmental well-being, proper land use and development, and fair allocation of resources and powers.
   2. The experience of the work conducted shows that despite the implemented measures on social support health inequity issue is still there and is even increasing, which requires targeted policy aiming at reducing health inequity at all levels, including the municipal one.
   3. The sociological survey has shown that the level of economic poverty is still high in the society. The share of those who lack funding on the basic items is rather high – 32,7 %. The questionnaire survey has shown that low socio-economic status, belonging to certain social groups and place of residence have an impact on the self-assessment of one’s own health status.
   4. The leading factors determining the lifestyles of the respondents include the level of education and employment. The meaningful causes affecting the respondents” social and electoral activity could be described as their economic status, area of residence, and the quality of the socio-economic infrastructure of that area. The least active groups here are migrants. The services that enjoy most trust from the respondents are the district medical service, the system of education, and the social welfare service, which show the need to enforce these services and carry out the local social policy through them. The low level of trust to all types of authorities and the media shows a need for transparency in these areas, better performance in view of developing targeted and efficient economic and social policy at the local level.
   5. Involving local authorities and people into activities on health inequity reduction is not possible without providing them with relevant information concerning the social determinants in their territories of residence, including the qualitative and quantitative features of such determinants in certain social groups. For this purpose there should be periodical issue of City Health Profile established (or some other document), which would be the basis for making decisions in health policy development, as well would serve a tool for “open monitoring” of the efficiency of the decisions adopted.
   6. An important element of learning the needs is a sociological survey, which allows making the assessment more precise due to exclusion of the average (summarizing) indices. This allow studying the situation in relation to various groups of people and, first of all, in relation to the socially vulnerable ones. For instance, the lowest evaluation of their neighborhood has been given by dependent people, which could be explained with poor access of various objects of infrastructure for this group of respondents. The lowest evaluation score to their place of residence was obtained from those residing in “depressive” areas, which, obviously, can be accounted for by a low level of social-cultural infrastructure development in these places.
   7. The methodology for implementing municipal policy aimed at health inequity elimination should be based on the analysis of the quantitative dynamics taken over a certain period of time within certain accepted indicators (criteria) of the city’s performance. This allows defining the inequity gradient by socio-economic determinants of health, as well as conducting comparison, both diachronically, and in relation to other areas.
   8. The Intersectoral Plan for Reducing Health Inequity is aimed at the entire gradient of inequity; obtaining a higher level of health; ensuring common availability of medical service; mutual support for the local residents; development of awareness and involvement into the life of the city; meeting the basic needs of every resident such as food, water, housing; establishing a sufficient level of income, safety, wider opportunities and contacts, information exchange; stabilization of the economic system, as well as active participation of the resident in the local life.
   Recommendations
   · When implementing systemic healthcare measures at the municipal level it is important to keep in mind the already existing health inequity, which potentially allows reducing negative social, medical, and economic effects in the public healthcare system at large.
   · To ensure making the most efficient decisions in healthcare it is important to carry out studies into the socio-economic health determinants taking into account the socio-economic groups.
   · The following activity streamlines for health inequity elimination in Stavropol could be defined:
   1) Bringing the “depressive” areas up to a level closer to the more successful ones;
   2) Improved medical-psychological assistance to dependent people and the disabled;
   3) Increased accessibility (territorial, mobility) and affordability of socio-cultural infrastructure for dependent people;
   4) Developing special programs for social assistance to low-income groups;
   5) Increased accessibility, transparency, reduced bureaucracy in administration bodies and authorities;
   6) Developing programs to help adjustment of migrants;
   7) Establishing local counseling offices for vulnerable groups of people, where they could get legal and psychological support on a free basis;
   8) Developing general and special plans for reducing health inequity and increasing the quality and accessibility of the services offered to vulnerable groups of people.

   · The development of the Plan for Reducing Health Inequity in Stavropol should go through several stages. First, a survey conducted in order to detect the life quality among the vulnerable groups; second, defining the major issues and conducting an analysis of the activities run by the local administrative bodies, with a general report on the health inequity in the city and its further discussion at the local city forum; third, the development and release of the Health profile for the most vulnerable groups; fourth, publishing the Plan and getting residents” feedback as specific ideas; fifth, an analysis of the amendments and approval of the Plan by the Executive committee after a comprehensive discussion; sixth, publishing the final version of the Plan. The Plan shall contain a specified plan for establishing intersectoral municipal programs or introducing amendments into the programs that have already been adopted.
   · As a core for the development of the City Plan on health inequity reduction based on intersectoral cooperation, the municipal areas should develop such a document as Health profile for the vulnerable groups of people, which would contain comprehensive information the life quality and city performance in relation to impact on health.
   · The Plan on health inequity reduction based on intersectoral cooperation, as well as measures and local projects aiming at implementing the plan (Social Guide) should become everyday practice for all the community sectors at the municipal level.
   · The tested and adjusted during the research (in view of one specific Russian city) approaches described in the global strategy HEALTH FOR EVERYONE IN 21 -------
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CENTURY and in the international project HEALTHY CITIES have allowed developing a database, which could be used in other Russian cities involved in carrying out healthcare strategies, especially during the implementation of the priority national projects.

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Treatment compliance issues: causes and effects

   Treatment compliance: causes and effects. How to change the situation?
   Literature offers various definitions for COMPLIANCE and ADHERENCE, which are not full synonyms. In English “compliance” means the patient’s yielding readily to the prescribed treatment plan and procedure, and it includes three elements: the behavior, the degree of compliance, and the degree of the patient’s determination. [Leppik I. E., 1988]. Here the behavior implies medication intake, the regularity of the visits to the hospital, and following other recommendations issued by the doctor. In a narrower sense the lack of compliance could be described the following way: the patient takes an incorrect dosage of the medication (too much or too little), does not follow the regularity and the duration of the medication course or uses other (not recommended by the doctor) medications [Leppik I. E., 1988].
   The term ADHERENCE TO THERAPY means following “the doctor’s advice”. Despite insignificant differences, this term is close to “compliance”, and is often used as its substitute in clinical practice [Jin J., Sklar G. E., Oh M. N. S, Li S. C., 2008].
   “Therapy compliance” is typically defined as a treatment-related behavior feature (e.g. medication intake, sticking to a diet, change in the lifestyle, visiting the doctor) and its conformity with the doctor’s recommendations [Paschal A. M., Hawley S. R., Romain T. S. et al. 2008]. The degree of compliance may vary from a patient who will follow all the recommendations coming from the doctor to a patient who never follows those [Leppik I. E., 1988]. Of course, in most patients the degree of compliance will be found in between the two extremities.
   According to American doctors 125,000 die annually due to low compliance. Ignoring the doctor’s instructions accounts for 10 % of all hospitalizations. A significant share of the expenses related to in-patient treatment is also explained by poor compliance. It is not possible to legally oblige the patient to go through regular preventive check-ups or to follow the doctor’s advice as this would run contrary to the “Basics of Russian Legislation on Healthcare” and the Constitution itself. Therefore developing the culture of taking medical service and shaping a responsible attitude towards treatment in patients is a relevant issue in Ethics, Psychology, preventive medical and sanitary activities. This is an important part of the doctor-patient relation where the leading role belongs to medical specialists, while the efficiency of their work largely depends on the patient’s compliance and the doctor’s effort applied to encourage it.
   As a rule, it is hard for a doctor to assess a patient’s compliance degree. The assessment methods here could include:
   pharmacological (making sure the medication is taken duly can be done through measuring the concentration in the biological substances);
   clinical (compliance will be proven by visiting the doctor as appointed, the patient’s improved condition – incase of hypertension – stable blood pressure);
   physical (registered resupply of the medication – empty packs, counting the remaining pills, information from the drugstore on the purchase, etc.).
   Each of the methods mentioned above has both advantages and disadvantages, so a reliable assessment of compliance (for clinical surveys, for instance) would take a combination of those. The Morisky-Green test is a common practice. According to the test compliant patients are those giving more than 3 negative answers to the following questions (scoring over 3 points):
   (1) Have you ever forgotten to take your medicine? (No/Yes)
   (2) Are you sometimes neglectful in regard to your medicine hours? (No/Yes)
   (3) Do you skip your medicine hours when you are feeling well? (No/Yes)
   (4) When you feel badly due to the medicine, do you skip it? (No/Yes) [Morisky DE, Green LW, Levine DM, 1986].
   Despite quite controversial opinions expressed, many researchers believe that a compliant patient is someone who actually takes the prescribed medicine in the dosage of 80—120 % of that administered by the doctor [Jin J., Sklar G. E., Oh M. N. S, Li S. C., 2008]. There are several; methods for compliance assessment: 1) data analysis (diary analysis); 2) pills counting remaining by the next visit to the doctor; 3) measuring the medication concentration in blood (or urine) [Rudd P., 1995].
   If the patient is rather open in a conversation or definitely objects the treatment conducted then compliance can be easily evaluated through a direct interview. However, there will be no objective information obtained in case the patient has a reason to conceal the neglect of the doctor’s advice concerning the medication administered. Such reasons most often include the patient’s desire to demonstrate the inefficiency of the treatment. In this case there no sense asking directly and it would take more objective compliance assessment methods. Besides, the patient may conceal interruptions in treatment and other cases of neglecting the doctor’s advice in order not to make the latter disappointed or upset, which may also cause lack of true answers concerning compliance. This type of behavior could be illustrated with the so-called “toothbrush phenomenon” where patients will only observe their doctors” recommendations before the appointment, just like we always brush our teeth before visiting the dentist [Конради А. О., 2007].
   The most reliable way of compliance assessing is to measure the medicine concentration. One research focusing on medicine concentration in patients with arterial hypertension measured through the fluorescence method showed a 100 % level of compliance in 59 % of the patients (i.e. 100 % of the tests showed the presence of the medicine in the body); 23 % of the patient showed a compliance of over 50 %, while in 18 % за the patients the compliance was below 18 % [LuscherT. F., VetterH., SiegenthalerW. Etal., 1985]. Besides, the AH was higher in those with poor compliance.
   The easiest and most available in the clinical practice method of compliance assessment is counting the pills, which will take about 1–2 minutes of the doctor’s time. The following criteria are used for compliance: optimal – 90 %-100 % of the drugs taken from the prescribed amount of medicine; satisfactory – 70–90 %, partial – 40–70 %, poor – below 40 %. Taking less than 75 % of the prescribed medicine will ensure control over the AH in 37 % of cases only, while a 75 % level of compliance will guarantee effect in 81 % of cases. It is important not only to mention the number of the pills taken yet also skipping the next dosage and failure to observe the interval between the intakes [Rudd P., 1995].
   Some other research focusing on compliance showed that in case 17 % of patients changed their treatment with no reason the share of 1 to 3 side effect went up to 29, 41 and 58 % respectively [Wallenius SH, Vainio KK, Korhonen MJ et al. 1995].
   A voluntary refusal to follow the treatment is a common occasion in case of side effects. This was once again confirmed during a research in Britain where 322 (34 %) patients out of 948 demonstrated side effects in the course of treatment. Only 78 % of them reported them to their doctors” while others stopped taking the medication [Lip GY, Beevers GD, Doctors, 1997]. Also, side effects affect 36%of patients while in 17 % of patients they remain along with the treatment going on [Benson J, Britten N., 2003].
   Electronic medication control gadgets have provided very detailed information about medication-related behaviors. Most violations of the medication plan include skipping the intake (more often than taking an extra dosage). Patients” behavior related to medication improves 5 days before and after visiting the doctor compared to 30 days after the visit. This is a phenomenon known as the “white collar compliance”.
   Research projects employing such monitors revealed six types of behavior in patients who are prescribed medication due to chronic illnesses. About one sixth of patients are close to the ideal compliance level; one sixth of patients take nearly all the dosages yet with some irregularity in time; one sixth of them sometimes will miss a dosage and take medication somewhat irregularly; one sixth make “holidays” several times a day skipping dosages to be taken 3–4 times a day; a sixth of patients will make such “holidays” each month or more often frequently skipping the dosages, and another sixth will take their medicines only occasionally or will not take them at all making an impression of good treatment compliance [Сидоренко Т. В., 2009]. These results serve evidence that quite often the information on the patient’s condition may be insufficient to assess the treatment results if it is based exclusively on the on the viewpoint of the doctor who summarizes laboratory-instrumental data.
   Improving treatment compliance takes defining the factors determining it.
   Treatment compliance depends on a range of issues:
   · gender and age (in men, the elderly> 65, and young patients <35, treatment compliance is lower);
   · the patients” personal features, their level of education (denying the illness, poor memory span, impatience, weak character, low level of education and intellect, etc.);
   · the illness course (refractoriness to treatment);
   · the right choice of the medicine – its rather prompt and high efficiency (the patient may be unhappy with the longer hypotensive effect) and good tolerance;
   · the treatment plan, in particular – the amount of the medicine prescribed and the frequency of intakes per day (a complicated plan shall be a trouble for a patient who is employed; polypragmasy will lead to poor compliance);
   · availability of the prescribed medicine in the pharmacy [Ощепкова Е. В., 2003].

   Socio-economic issues also play an important role in compliance. The impact such factors have on treatment compliance varies significantly depending on the country and the healthcare funding. In countries where the cost of medicine is completely covered by patients, which is largely the case with Russia, the cost of treatment will play an important role in determining the following treatment compliance.
   The data obtained in St. Petersburg, following a 1-year follow-up of patients after selecting anti-hypertension therapy and reaching the desired AH index, showed that 62 % of patients refuse following the treatment due to the cost while overshadowing such compliance worsening factors like side effect [Эйдельман С. Е. 2003].
   Patients” refusal to follow the treatment not only does not the cost of anti-hypertension therapy yet makes it more expensive. This can be accounted for by the fact that the costs on AH depend not as much on the medication therapy as on visiting the doctor, hospitalization, loss of working capacity, disability, etc. At the same time the cost of treatment for a patient with a change of therapy is 20 % higher if compared to the cases where the initially administered efficient therapy is followed [Moser M., 2002].
   In order to assess the role of appointments frequency in compliance there was a randomized comparative survey conducted in Canada, where the visiting modes of patients with AH were put against each other – every 3 months and every 6 months. The results of observing the 609 patients involved showed no difference in terms of treatment compliance and achieving the desired AH depending on the number of visits, while 20 % of the patients in both groups remained non-compliant [Birtwistle RV, 2004].
   Mention should be made that the awareness of poor treatment compliance varies significantly among both doctors and patients. Thus, per 70 % of doctors believing that inefficient therapy is due to poor compliance there are only 16 % of patients sharing the same idea [Menard J, Chatellier G., 1995].
   One of the major conditions for patients following the therapy plan is the doctor’s professionalism. It has been found out that 50 % of inefficient therapy is explained y improper use of that [Мосолов С. Н., 2002]. The most common mistakes, apart from untimely start of treatment and failure to follow the clinical indications and counter-indications, include conducting routine (taking into account no individual feature) therapy with low dosage or, on the contrary, frequent change – “juggling” medications observing no duration or premature stop of therapy. A significant factor contributing to minimizing breach of treatment recommendation is still trust and proper contact with the doctor interested in involving the patient into the therapeutic process. It is important to create a so-called therapeutic alliance, maintaining which is a significant indicator of the doctor’s professionalism and a precursor of successful therapy [Незнанов Н. Г., 2004].
   We cannot but take into account the big role that the doctor’s authority plays in compliance. People tend to follow the recommendations of those whose authority they never doubt, so doctors should demonstrate patients their various certificates and diplomas. This has been confirmed through a research carried out in Britain. This showed that the real improvement in the patient’s condition makes them take the prescribed medication in 50 % of cases only [Benson J, Britten N., 2003]. Given that 92 % of patients take their medication regularly because they trust their doctors and expect good results in the future [Benson J, Britten N., 2003], which is directly linked to the doctor’s competence.
   Another socio-demographic factor that may have an impact on treatment compliance is the patient’s marital status: absence of family increases the risk of rejecting the treatment while the presence of a spouse, on the contrary, will bring this risk down. Support from a relative (parent, spouse) is a statistically significant factor increasing the patient’s treatment compliance. Besides, support from relatives increases trust towards the doctor, while lack of such support has a negative impact on this trust. Trust to the doctor, in turn, contributes to treatment compliance in patients with long-treated disseminated sclerosis. The level of education, namely the presence of lack of a higher education degree, does not have a direct effect on the risk of rejecting the treatment. However, among patients holding a degree there are more people with an employment. This could be due to higher education giving a chance to be involved in “intellectual work” even with a significant degree of disability [Сидоренко Т. В., 2009].
   A research into treatment compliance in ophthalmology showed that low compliance may be due to anxiety. A psychological testing showed that most patients in ophthalmology have an anxious type of attitude towards the illness (73 %). A simple observation and interview method showed in them:
   · constant anxiety over complication risk (64 %);
   · suspiciousness over negative illness course (58 %);
   · desire to get treated combines with lack of belief concerning the success of the treatment (37 %);
   · the requirement to go through thorough examination combines with the fear of painful procedures (41 %).
   At the same time most patients (68 %) prefer so-called “empathic” doctors [Ушаков С. А., 2008].
   Doctors believe that the reasons for non-compliance in dentistry include fear (expectation of pain) of medical intervention; underestimated level of the pathology; improper sanitary and cultural level of the patient; the costs related to treatment; lack of out-patient monitoring and mandatory examinations especially in “risk groups” (children, adolescents, the elderly, people employed in hazardous jobs). Both patients and doctors agree over such non-compliance reason as conflicts in dental practice, which are due to
   · Unplanned costs – 19,1%
   · Complications after treatment – 26%
   · Quality of the assistance provided – 33,3%
   · Violation of medical ethics – 34,5%
   · Incomplete information – 42,8 % [Фирсова И. В., 2009].
   Especially urgent compliance issue is in arterial hypertension therapy. There is evidence that nowadays the prevalence of arterial hypertension (AH) among Russian women is 40,1 %, among men – 37,2 %. Specialists forecast that the number of people suffering from AH will go up constantly, and by 2025 the number of those with AH in developing countries will reach 1.5 bln, with another 413 mln people affected in developed countries. The extent of the illness and a chance of preventing such complications as stroke and myocardial infarction require responsibility in terms of observing AH therapy as a reduction of the AH level by 10 % will result in a 45 % decrease in death rate from cardio-vascular issues [Оганов Р. Г., Гиляревский С. Р., Агеев Ф. Т. и др., 2008].
   Contemporary research has shown that active involvement of patients into regular treatment and control of blood pressure (BP) will result in a 48 % reduction in cerebral infarction. Mention to be made here that AH remains a risk factor both after a stroke and/or transient ischemic attack. Several researches show that proper BP control reduces the risk of stroke relapse by 28 %. According to the data released by the State Scientific-Research Center for preventive medicine the latest years have seen an increase in the number of people with AH who are aware of the illness (among men this number has gone up from 37 to 75 % in 2005, and among women – from 58 to 80 %). Even though patients get treatment more often yet the efficiency of therapy still remains poor. Proper control of BP is registered in 9,4 % of men and 13 % of women only. Lately the joint effort of scientists, doctors, and healthcare managers has brought some change into the frequency of using various classes of medication – in 1999 in Russia 37 % за patients were treated with low-efficiency drugs, while in 2008 66 % of patients were given ACE inhibitors, 30 % – β– adrenoceptor blocking drugs, 12 % – calcium channel inhibitors, 40,4 % – diuretics [Оганов Р. Г., Гиляревский С. Р., Агеев Ф. Т. и др., 2008].
   The compliance issue becomes even more relevant when it comes to treating the elderly and old patients. The respective data shows that only 39,2 % of patients follow the therapy as prescribed, while the major part of these patients are the elderly – 69,2 %.
   It has been revealed that 40,1 % of patients at least once changed voluntarily, in part or in full, the prescribed dosage of anti-hypertension drugs; 36,7 % of patients periodically stopped taking their medication while there was no significant difference among the groups of the elderly and old patients and only the explanation of this behavior was special – the elderly said they stopped taking the AH therapy due to lack of effect and the presence of side effects (55,1 %) – coughing, getting dropsical, bradycardia, tachycardia, etc., while old patients mostly referred to social and financial issues such as lack of the drug in drugstores (73,7 %), exclusion of the medication from the list of drugs available “over the counter” (39,4 %), abolition of social services in medication supplies (14,0 %). Besides, the two major groups mentioned administering too many anti-hypertension drugs as a reason for their full or partial refusal to follow the therapy. In a way this is a valid reason because according to the pharmacoepidemiological analysis of treatment records of those involved into the survey, the number of anti-hypertension drugs was 4.3 among the elderly and 4.9 – among old patients; however, the total number of drugs prescribed by all doctors was 6.9 and 7.7 respectively. It is interesting to note that part of the patients mentioned in their questionnaires that they would like to use as many drugs as possible for treatment (including for AH), and to get prescriptions for the same illness from several doctors (GP, Cardiologist, Neurologist, etc.), which, of course, will result in polypragmasy. Among other reasons for full or partial refusal to take the medication 26,1 % of patients mentioned troubles getting the medicine ready for intake – taking it out of the pack, breaking the pill into parts, i.e. these were the patients who, along with AH had another pathology – affected hand joints, rigid-shaking type of the Parkinson’s, etc.; these patients were mostly old; in 6,5 % of cases the reason was due to a poor pack of the medicine (the instruction sheet, the pack design, etc.), which caused troubles in the patients who had some pathology in the visual analyzer [Давыдов Е. Л., Харьков Е. И., 2011].
   In the general population of people with AH the following reasons for poor compliance to hypotension therapy among the risk group could be defined:
   · A big number of the medicines prescribed (55,1 %);
   · Inefficient control over BP (30,8 %);
   · High probability or the presence of side effects (29,7 %);
   · Lack of symptoms of high BP (24,7 %);
   · Insufficient awareness of the need to take the medication regularly (16,6 %);
   · High price of the medicines (4,2 %). [Оганов Р. Г., Гиляревский С. Р., Агеев Ф. Т. и др., 2008].
   One of the obstacles towards successful treatment of AH is still insufficient adherence to the current standards among doctors. Even though the clinical researches mentioned above demonstrated a possibility to achieve the targeted BP index in a large share of patients with AH, including the elderly (68 % of the targeted BP in the ALLHAT research) [The major outcomes …, 2002] doctors still remain skeptical about successful outcome in such patients [Waeber B, Burnier M, Brunner HR, 2000]. According to the NHANES III [Murlow PJ., 1998] 2/3 of patients with a normal level of diastolic BP still have a higher level of systolic pressure. Doctors often refuse to intensify medication therapy influenced by their patients” stories of worsening condition in case of BP decrease, which is not always a valid explanation [Hosie J, Wiklund I, 1995]. Monitoring doctors” behavior has shown that BP is taken repeatedly, as a rule, in case of higher BP index due to subjective desire to detect lower levels [Mashru M, Lant A., 1997]. A number of such reasons result in the fact that doctors – for reasons that have not been well investigated yet – may contribute to worsening their patients” compliance over time and they are not always persistent in their attempts to reach the targeted BP index.
   Lack of the doctor’s preparedness for intensifying the therapy (fear of side effects, complications, higher cost of treatment, as well as lack of subjective conviction that this particular patient should have his BP reduced) leads to poorer compliance in patients as well [Neutel J, Smith D., 2003]. Compliance is in inverse proportion with prevalence of side effects (SE) in hypotension medications. A questionnaire survey among doctors in various countries has shown that patients” non-compliance (about 70 %) accounts for the largest share of the reasons for improper BP control, while only a small part of such reasons are due to SE (no more than 30 %) and insufficient efficiency (around 25 %). A survey among patients has shown that their compliance is 81 % [Hosie J, Wiklund I., 1995]. As patients themselves think SE are the most common reason driving them to refuse treatment (over 50 %) [Леонова М. В., Мясоедова Н. В., 2003]. The most important negative factors determining the further willingness to get treated are the attitude towards the illness viewed as a hopeless state; anxiety due to frequent BP check-ups; and frustration over reaching the set goal of controlling the BP [Jokasalo E, Enlund H, Halonen P et al, 2009].
   An equally tough issue is treatment compliance in children and adolescents. This is especially important as the skills trained in childhood will impact the patient’s attitude to therapy during adulthood as well. There are age-related differences that affect the child’s treatment compliance. For instance, schoolers have troubles taking drugs in school as this might reveal their HIV-status. Taking pills and liquids that are far from being tasty may have a negative effect on treatment compliance in people of any age, yet this is especially relevant to children. Sometimes it is possible to disguise the poor taste, for instance when a pill can be dissolved in water, mixed with milk or jam; such medications may also be produced in the form of syrups [Osterberg L, Blaschke T., 2005]. Research data show that older age in adolescents is often accompanied with poorer treatment compliance (Jenkins T. M., Xanthakos S. A., Zeller M. H. и др., 2011).
   To improve the compliance among pediatric patients there have been various means used, yet they have been a limited success. Mostly there have been behavioral interventions employed or their combination with some other measures. The most common is encouragement implying motivation for regular medication intake through certain signs or other reward. Special signs could be used to allow some privilege, access to certain activities or other benefits. Behavioral strategies will often need resources and trained staff, yet simple encouragement systems can be easily used by parents and other caring persons. In order to improve the attitude towards the treatment some effect was obtained through making tastier medications. Involving family, school, and other types of social support are valuable strategies for achieving the maximum disposition towards treatment [Osterberg L, Blaschke T., 2005].
   Experts believe that in order to improve the efficiency of child medicine due to better compliance it is important that doctors should talk about drugs and intake modes with the children themselves and not only discuss such relevant issues with their parents or careers alone. A research has shown that children aged 6 and above already can develop their own opinion on drugs while many of such opinions remain through adulthood. It is important to understand how children accept medicines, their fears, and how they view medicine efficiency and side effects. Such knowledge might help doctors establish better communication with children when telling them about medicines [De Maria C, Lussier MT, Bajcar J., 2011].
   Another important group where treatment compliance is quire relevant is patients with psychiatric disorders. They typically have troubles following the treatment plan yet they could benefit most from being treatment-compliant. There is literature stating that the rate of non-compliance to anti-psychotic medications varies between 11 % and 80 %. There are reports saying that 48 % of patients do not follow medical recommendations within the 1 -------
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year of therapy, and 74 % of patients do not do that within the first two years. Even during hospitalization, although the nursing staff will regularly give patients their medicines, up to 19 % of mental patients do not take their medicine regularly [Weinden P. J.,1986; Незнанов Н. Г.,2004]. Half of patients suffering from depression who get anti-depressants administered stop taking the medicines as soon as three months after the start of the therapy. The compliance level among patients with schizophrenia is 50–60 % while this indicator in bipolar affective patients is 35 %.
   The average disposition towards treatment in mental patients was assessed 76 % (ranging between 40 and 90 %), in psychotic patients – 58 % (24–90 %), in patients with depression – 65 % (58–90 %). [Бабин С. М., Шлафер А. М., Сергеева Н. А… 2011].
   A number of research projects focused on interventions aiming at improving treatment compliance in mental patients. Success was found in combining educational measures (involving the patient and his/her family), cognitive-support interventions, and periodic use of reinforcement methods. Educational activities are most efficient when employed along with behavioral methods. Reinforcement implies a number of methods, namely some material stimulation (voucher), frequent contact with the patient, and other types of personalized reminders. Unfortunately these interventions require the involvement of trained staff and repeated sessions in order to maintain the positive attitude towards treatment, which will go down otherwise.
   The newer generation of anti-depressants and anti-psychotic drugs generally has fewer side effects rather than the “older” medications. Therefore their use comes along with a smaller rate of quitting treatment. Newer drugs should enjoy preference for a number of reasons yet such factors as cost and efficiency may prove the most meaningful for some patients in terms of ensuring optimal treatment compliance. Depot neuroleptics make a frequent choice in patients with schizophrenia in case of low treatment compliance to per oral drugs [Бабин С. М., Шлафер А. М., Сергеева Н. А… 2011].
   There are various methods employed to improve treatment compliance among patients, and such methods include psycho-educational work, family therapy, behavioral therapy, psycho-pedagogic, and purely didactic approaches [Незнанов Н. Г., 2004].
   There is a lot of belief nowadays in compliance-therapy. When developing it from the method of motivational interviewing there were such techniques used as encouraging asking, active listening, regular use of open questions, summarizing, avoidance of blaming, reasoning pros and cons for alternative actions, encouragement and support, as well as development and reinforcement of adaptive patterns and behaviors. как побуждающее расспрашивание, активное выслушивание, регулярное использование открытых вопросов, резюмирование, избегание обвинений, доводы “за” и “против” альтернативного образа действий, поощрение и поддержка, а также формирование и подкрепление адаптивных установок и форм поведения. Intervention always implied encouraging the patient’s independence, which would be closest to the behavior of an ideal one. Compliance therapy is a short-term psychotherapy performed in three stages each of them involving meetings with a duration of up to 1 hour twice a week 3, 6, and 12 months after there are additional individual psychotherapy sessions offered [Кемп Р., 2000].
   The advantage of compliance-therapy is that it takes a short time while it is an efficient and rather easy-to-do in a clinical setting intervention. The emphasis on cooperation within the therapeutic alliance is in concordance with the growing concern over patients” rights and empowering mental health users. A simple dosage (one pill per day) may result in the maximum compliance especially when combined with frequent visits. Despite this the dosage proves insufficient to 10–40 % of patients who follow this simple treatment plan. A large systematic review of 76 surveys using electronic monitors showed an inverse relation between compliance and the frequency of the medicine intake. In case of 4 times a day intake the average compliance was around 50 % (ranging 31 through 71 %) [Кемп Р., 2000].
   Quite often doctors have to come across patients” disapproval of the treatment, which takes developing methodological approaches to overcome the attitude and control the process of compliance. There are five conceptual models to be viewed to this effect.
   The first model is basic, with a bio-medical approach focusing the patient’s attention on various aspects of medication intake and possible side effects. Another model is behavioral, with an emphasis on reward in case of agreement established. A third model is educational the purpose of that being improved understanding between the doctor and the patient with the latter’s better level of knowledge about the illness. A fourth model dwells on the benefit the treatment gives to the patient’s health. A fifth model focuses its goals on the threat that the patient’s condition may get worse in case of lack of acceptance of the treatment, analyzing also the patient’s cognitive and emotional responses. The process of approval control involves three components – understanding the need for taking medication, control over following the doctor’s recommendations, and the patient’s independence, taking into view that full autonomy of the patient can be seldom achieved yet it remains an ideal result. Identifying the reasons for disapproval and developing methodological approaches for overcoming it relate, first of all, to primary disapproval, i.e. disapproval arising prior to starting the therapy and linked with denying the fact there is a need for that. This issue is most common in treating patients who have no critical attitude towards their own illness. A third area of investigating treatment approval is overcoming secondary disapproval, which can be seen after the start of medication therapy. The reason behind it is, first of all, in new symptoms appearing. At the same time, the more intact the patient’s personality is the more of requirements he/she will impose on the therapy, especially in terms of minimizing undesired effects affecting their routine life and impeding various social activities [Елфимова Е. В., 2009]. The factors improving treatment approval in dentistry also include those mostly related to the doctor – establishing trust with the patient, duration of their conversation, the doctor’s interest in getting the patient’s approval and recovery, the doctor’s enthusiasm, and his/her age (the older the doctor the higher the likelihood approval will be obtained); and those that mostly concern the patient – his/her awareness of the illness gravity and possibility to control it through treatment, inclusion of medication therapy into the lifestyle, support from the family. The factors reducing treatment approval include those related to the illness manifestation (e.g. lack of manifestation of the illness symptoms, lack of criticism towards one’s own condition), medical assistance (duration of the therapy, complexity of the treatment mode, side effects), the patient’s features (young age, male, urban citizens, high level of aggression). When assessing the positive and negative factors affecting approval and treatment it is stressed that the relevant approval determinants are often kaleidoscopic and may change depending on the situation and time.
   The development of patient compliance very much depends not only on the doctor’s high professional competence yet on his personal features as well – tactfulness (100 % of responses), orderliness (94,2 %), sociability (75,0 %), creative approach to work (73,8 %). Fewer patients are attracted by such features in their doctors as practicality (58,3 %), conformity (41,6 %) and straightforwardness (22,6 %). The efficiency of the “doctor-patient” interaction is subject to the impact of the dentist’s professional adjustment and the arrangement of his personal qualities that develop him/her as a competent specialist.
   The major motivation driving patients to seek dentists” assistance is acute pain, which has been confirmed by 67,2 % of rural residents and 50,7 % residents of urban areas; the most common reason for delaying an appointment with the dentist is fear (or expectation of painful manipulation) – 50,3 % of responses [Фирсова И. В., 2009].
   The measures that may improve treatment compliance could include general public activities, changing public awareness, as well as change in the funding system. Improved global compliance can be achieved through establishing training for cardiological patients and optimized “doctor-patient” contact. It should be borne in mind that the doctor’s attitude to compliance, the respective interviewing of the patient and its assessment in dynamics also contributes to its improving.
   The data obtained from “schools for patients” demonstrate a high level of training efficiency in terms of improving regularity of therapy, self-control, BP, and following recommendations on changing lifestyle. 70 % of patients (out of 214) started taking anti-hypertension medications regularly after the training, while initially this figure was 47 %, and within 6 months of follow-up this index remained rather high.
   Treatment compliance can be improved significantly due to simplifying the treatment scheme itself and introduction of special methods helping the patient to avoid missing another intake of the medication [Конради А. О., 2007].
   Methods for improving treatment compliance in patients
   Informing the patient on the illness and treatment.
   Assessing the patient’s awareness and acceptance of the illness, his/her expectations concerning longer monitoring and treatment.
   Discussing the existing doubts and clarifying the uncertainties.
   Informing the patient on the level of his/her lipids.
   Agreeing with the patient on the targeted levels of lipids.
   Informing the patient on the recommended changes in the lifestyle, therapy, and providing him/her with written information on the prescriptions.
   Detecting the issues that make the patient concerned; offering the patient a chance to develop behavior strategy for following the recommendations.
   Stressing the need for longer treatment despite obtaining the targeted levels of lipids.
   Selecting an individual therapy mode.
   Involving the patient into decision-making.
   Defining, along with the patient, realistic short-term goals related to changing lifestyle and treatment.
   Including the patient’s lifestyle into the therapy.
   Discussing potential side effects with the patient.
   Encouraging self-control.
   Minimizing the cost of the therapy.
   Securing the results obtained.
   Discussing with the patient his/her level of lipids at each appointment.
   Monitoring the patient’s observance of the recommendations at each appointment; telling the patient about it.
   Encouraging behavior aimed at gaining control over lipids.
   Making sure the patient has understood the recommendations concerning the therapy mode.
   Making the next appointment before the patient leaves the office.
   Using reminders, remind the patient of the next visit by phone or via E-Mail.
   Planning more frequent visits for non-compliant patients.
   Contacting patients who missed appointments.
   Ensuring social support.
   In case of the patient’s approval, training his/her family in order to ensure everyday support in lipid control.
   Organizing groups of patients for improving mutual support and motivation.
   Efficient strategies for improving patient compliance.
   Establishing “doctor-patient” relations based on trust, respect and mutual understanding will undoubtedly contribute to the patient’s satisfaction, treatment compliance, and health. It is an open secret patients will often evaluate the doctor’s competence based on their service and not clinical skills.
   Training patients
   It is important to remember the following principles for training patients:
   · Adult people will be trained easier in case they understand the benefit of the new knowledge;
   · The information should be offered following the “simple to complex” principle;
   · It is important to encourage the patient’s attempt to employ the newly acquired skills in reality;
   · The information learnt previously should be repeated;
   · At the end of each class it is important to get feedback and to answer the questions that may arise;
   · Speak a common language with the patient, following his/her socio-cultural level and using phrases earlier heard from other patients;
   · Establish good trust with the patient in order to better understand the issue; use more questions that require open answers;
   · Try to support and not to blame the patient while communicating [Конради А. О., 2007; [Кобалава Ж. Д., Виллевальде С. В., 2011].

   Apart from the above-mentioned techniques there are other ways of resolving non-compliance issue: (1) side effect of therapy – using low dosages; (2) complexity of dosages – using medications that should be taken once a day; (3) rebound syndrome due to missing therapy (treatment) – using long-term action medications; (4) duration of therapy selection – early use of combined therapy; (5) polypragmasy – using fixed combinations; (6) high cost of the therapy – using generic medications and fizxed combinations [Конради А. О., Полуничева Е. В., 2004].
   There are a number of methodological techniques to be used to improve compliance when the failure is due to the patient’s “absent-mindedness”. You can recommend the patient he/she should link the drug intake to a certain action that is common in the daily routine, for instance shaving or brushing teeth, etc. Reminding by phone or via E-Mail may prove extremely efficient. Quite efficient is special packaging in blisters indicating days of the week, which will always attract the patient’s attention should he/she miss a dosage. Nowadays there are also special boxes for medications that are widely used (in Europe); these boxes have several pockets for different days of the week and are colored different colors, which makes it possible to take several medications following the plan without failure even for elderly patients. Automatic telephone control systems are also becoming part of the clinical practice. It is also important that the way a medication looks and its organoleptic properties play a significant role in compliance [Конради А. О., Полуничева Е. В., 2004]. Offering patients educational literature on AH issues, involving family into treatment to ensure the patient sticks to a low-salt and low-calorie diet, following the “work and rest” plan, doing physical exercises and observing the medication plan, involving a nurse to monitor the compliance – all these are simple yet, as experience shows, efficient measures contributing to improved treatment compliance. Besides, as one research has shown, medication therapy combined with a 10-minute talk with the doctor prior to the treatment, involvement of the family and group work on informing concerning the hazard of AH resulted in normalized BP in 69 % of patients after 5 years, also leading to reduced death rate from all causes by 57,3 %. The comparison group has not produced similar results [Ощепкова Е. В., 2003].
   The major strategies for optimizing the patient’s ability to follow the treatment mode:
   · Identifying poor compliance. Looking for unfavorable attitude markers – missing appointments, lack of response to treatment, lack of newer prescriptions. Asking, in a non-confrontation way, about the obstacles to compliance.
   · Stressing the meaning and effect of following the treatment mode.
   · Evaluating the patient’s attitude towards his/her ability to observe the treatment mode and, if needed, employing the respective methods to improve the attitude.
   · Giving simple and clear instructions and simplifying the treatment plan as much as possible.
   · Encouraging the patient’s development of a scheme for medication intake.
   · Listening to the patient and ensuring the treatment plan fits the patient’s needs.
   · Getting support from other family members and friends and, if needed, from social welfare services.
   · Encouraging the desired behavior and stressing the results obtained, if needed.
   · If ensuring treatment compliance is not very likely, then investigating the possibility of using medications whose effect will not suffer in case a dosage is missed or delayed, i.e. medications with a long half-life period, depot forms (sustained release), transdermal medications.
   · Authority. “Should the expert say this is true it must be so”. People tend to follow the recommendations of those whom they regard a definite authority (show certificates, diplomas, etc. belonging to the people who give recommendations to the patient, including the doctor’s awards).
   · Longing for a rarity. “I cannot have this yet I want it even more”. People tend to overestimate the meaning of rare things or things that are not readily available (mention that failure to follow the doctor’s advice may result in the loss of a rare chance).
   · Consensus. “This is the treatment way that most patients in the civilized world prefer”. People tend to watch others” behavior when making their own decisions (demonstrate that other patients under similar conditions reached significant results following the same recommendations).
   · Relationships “Give and take”. People feel obliged if they have been given something in advance (use the concession system to encourage the patient to follow the recommendation; pay a compliment, use a reward system to motivate treatment compliance).
   · Consistency and persistence. “Start with something easy and then ask for more”. People should feel some pressure to be consistent in their actions (better if patients assume some obligation related to their health status).
   Loyalty and sympathy. “Make friends with someone you want to convert into your belief”. People will accept the terms more easily from those they like (demonstrate your loyalty to work with the patient through the entire treatment course). [Сиренко Ю., 2006].

   Compliance issues in HIV-infected patients
   · HIV and antiretroviral therapy (ART) are singled out of the general line of illnesses where compliance of 80 % is viewed as rather high. The minimum compliance required to efficient ART is 90–95 % [Paterson DL, Swindells S, Mohr J et al., 2000; Casado JL, Sabido R, Perez-Elias MJ et al., 1999; McNabb J, Ross JW, Abriola K et al., 2001].
   · These high demands to ART compliance are explained through the special features of the human immunodeficiency virus (HIV), and first of all – its unusual tendency to mutate. Each dosage missed by the patient creates favorable environment for the virus to develop resistance against the therapy received. For many modern ART medications the resistance threshold is 4–6 mutations, while for some of them this level is just 1 mutation. This means that chances are that missing just one single dosage the patient may lose the possibility to use the medication further because it may be inefficient and the HIV could reproduce in its presence. Another issue is that the HIV strain may be transmitted from person to person. The so-called primary resistance – when a person is initially infected with a stable virus strain, is typical in 10 % of cases in the EU countries, for instance, and there is a tendency for this figure to go up [Wensing AM, van de Vijver DA, Angarano G et al., 2005]. Form this viewpoint the HIV resistance to ART is very much similar to that of TB. The spread of primarily-stable strains increases the cost of treatment significantly and reduces the survvival rate among patients [ZaccarelliM, TozziV, LorenziniPetal.,2005].
   · Therefore, the major effects of such low treatment compliance include: low therapy efficiency and increased cost of treating the spreading ART-resistant HIV strains.

   The following high compliance prediction factors can be identiufied:
   · Psycho-emotional and practical support.
   · The patient’s ability to make medication intake part of the routine activities in everyday life.
   · Awareness of the fact that poor treatment compliance will result in the virus resistance to the medication.
   · Understanding the importance of taking all the dosages prescribed.
   · Absence of uncomfortable feeling having to take medication in the presence of others.
   · Regular visits to the clinic.
   ART at the initial stage of the treatment depends on
   · The patient’s stress level and the efficiency of overcoming it.
   · Belief in the therapy efficiency.
   · Balance between the therapy benefit realized and the limitations imposed by it.
   · Socio-psychological support.
   The ways to improve ART compliance are
   · To develop readiness to take the medications prior administering ART.
   · To discuss the treatment strategy that is clear to the patient and which he will follow.
   · To inform the patient on the specific feature of the treatment explaining the aims of the treatment and the need to comply with the plan administered; this should be done with no haste, after the initial meetings (usually takes 2–3 appointments).
   · If possible, to choose a treatment plan with a low frequency of intakes and number of pills (capsules).
   · Treatment plans with simpler diet requirements are more preferable.
   · To avoid negative interaction between different medications, both administered and taken by the patient beyond the HAART plan.
   · To develop a specific plan for a specific treatment scheme, relation to meals, daily routine, side effects.
   · To inform the patient on the side effects, to be prepared to see them and to treat them.
   · To offer a written scheme for medication intake; to provide (if possible) leaflets illustrating the medications, special boxes for pills designed for a daily or weekly dosage, to recommend using special alarm clock or pagers.
   · To gain support from the patient’s family and friends regarding the treatment plan.
   · To establish compliance support groups or to include these issues into the regular working plans for the support group.
   · To establish link with the local NGOs/Non-Profit NGOs (HIV-service organizations, organizations offering services to people living with HIV/AIDS /PLHA/) regarding ART compliance conducting informational sessions and discussing the practical strategy.
   · A medical institution and an ART maintenance group make a way to improve treatment compliance.
   · To establish a psychotherapeutic environment – trust, openness, confidentiality.
   · The doctor shall be a source of information offering support and conducting.
   · To provide the patient with his/her doctor’s phone number so that contact with the doctor should not be interrupted in between the visits in case the patient needs something related to the issue.
   · To conduct constant monitoring of the patient’s treatment compliance; to intensify work when the compliance goes down (e.g. due to more frequent visits to the doctor, employing the family/friends” resource, referring to the narcological service).
   · To analyze the impact the new diagnoses have on the patient’s compliance (here we are talking about depression, liver illnesses, weight loss, relapse of drug abuse) and to include compliance-related intervention into the treatment of such patients.
   · To establish ART maintenance groups for all patients, for “hard” patients, for patients with special needs (e.g. involving counselors from among the peers for adolescents or people belonging to the same group, for instance, for injection drug users /IDU/).
   · To implement training programs for nurses, counselors from among the community members, administrators, counselors on issues related to drugs, the doctor’s assistants, volunteers, research lab specialists, in order to maintain the information related to compliance.
   · To offer the support training on ART compliance issues.
   · To establish cooperation with HIV-service organizations, with support groups for HIV-infected people, with organizations serving PLHA; to improve access to such organizations through better contacts or joint activities between NGOs/NNGOs and the medical institution.
   · HIV-service organizations, support groups for people with HIV, organizations for PLHA should develop the activity areas related to increased ART compliance including training, informational support, counseling based on the peer-to-peer principle, psychological and emotional support, establishing ART support groups (including groups for people with specific needs: IDU, MSM, adolescents, etc.), informational-counseling phone service, respite service, social support, palliative assistance (home-based and in hospices) thus ensuring consistence in caring for the patient.

Treatment compliance survey in Stavropol (Amlaev K. R., 2012)

   We have studied treatment compliance in onco-urological and urological. The sampling (700 persons) is total, involving all the patients undergoing treatment (since July through September, 2012) in the urology departments of the regional Oncological Center and the Regional Center for specialized assistance.
   The research method implied individual questionnaire. Each questionnaire came along with several options with all the right answers to be chosen. The statistical processing was done with the SPSS-12 version of software. Here below we offer only statistically meaningful results of the research (sample tolerance – no more than 2,0, p <0,05, Pearson’s chi-square> 20,0)!
   The respondent group included 2 equal subgroups – patients with onco-urological pathology – 46,3 % and urological patients – 53,7 %. A detailed analysis of the nosological forms showed that 40,9 % of the patients had oncological issues of the 2 -------
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clinical group; 24 % had benign tumors (prostate adenomas); 29,9 % had inflammatory issues in the urogenital system, and 5,2 % had other urological issues.
   The age distribution want the following way: under 26 лет – 1,3 %; 26–35 – 4 %; 36–45 – 10,3 %; 46–55 – 10,3 %; 56–65 – 33,5 %; above 65–25,6 %.
   A look at the level of education showed that the most numerous were respondents with specialized secondary education – 43,1 % and those with higher education – 27,9 %.
   According to the marital status the subgroups looked the following way: single – 7 %; officially married – 59,8 %; living with a partner – 11,2 %; divorced -11,5 %; widow (er) s – 10,5 %.
   The respondents” prosperity was assessed based on two criteria. First – part of the income they spend on food; second – a more detailed personal assessment of their income. The first criteria showed the following distribution of the subgroups: spending less than half of their income on food (“well-to-do”) – 15,3 %; spending on food half of their income (“average prosperity”) – 37,3 %; spending on the same item over half of their income (“needy”) – 30,1 %; 17,3 % of the respondents experienced difficulties answering the question.
   45,6 % of the respondents mentioned they were believers; believers rather than not – 23,8 %; atheists – 21,1 %; atheists rather than not – 9,4 %.
   The respondents mostly resided in the rural areas of the Stavropol Region – 33,9 %; in the urban areas of the region – 31,9 %; in Stavropol – 20,1 %; from other areas – 16,9 %.
   Health and quality of life
   The respondents mostly revealed negative assessment of their own health. 3,6 % referred to their health as to “very poor”; 34,3 % assessed their health status as “poor”; the response “neither good nor poor” was given by 48,1 % of the respondents; “rather good” – 12,2 %; “excellent” – 1,8 %.
   At the same time 29,1 % of the respondents cannot do whatever they want while 51 % of the respondents experience some limitations due to health status. Besides 77,4 % of the respondents mentioned that their illness impedes their daily activities.
   The respondents noted that the quality of their life: went down sharply – 26,9 %; worsened slightly – 43,4 %; did not change – 17,8 %.
   Among the symptoms of worsening life quality they mentioned constant fatigue – 49,9 %; bad moos – 39,3 %; reduced working capacity – 49,2 %; worsening sexual life – 29,9 %; worsening nutrition – 12 %; reduced income – 12,5 %; troubles in the family relations – 0,5 %.
   Emotional issues in the latest four weeks impeded social activities in 28,4 % of the respondents. 60,7 % of the respondents always or often felt discouraged in the latest weeks (Fig. 20).
   During the same period 52,4 % of them always or often felt collapsed. 45,1 % of the respondents were stable smokers, with another 4,3 % of them smoking occasionally. Those who were not smoking at the moment yet had smoked previously had a share of 46,8 % out of the total number of the respondents. 27 % of the respondents experienced better relations in the family while in 2,5 % of cases the relations became worse.
   Over a third of the respondents would like to attend the Health School (37,3 %). 32,5 % of the respondents trust the official medicine; 49,8 % of them rather trust than not; 1,6 % of the respondents do not trust medicine and another 5,7 % of the respondents trust it in part.
   31,6 % of the respondents need psychological support while another 20,1 % of them responded they need such assistance rather than not. Given that 38,9 % of the respondents would like to get such assistance from a professional psychologist; 9,3 % – from a priest; 8,6 % – from patients who learnt coping the same disease; 29,4 % – from the doctor.

   Quality and availability of medical assistance
   When choosing a doctor respondents rely on the opinion expressed by their friends, colleagues, relatives – 37,5 %; personal opinion – 27,8 %; the opinion of a medical specialist who is their acquaintance – 26,9 %; the scientific degree and position of the doctor – 18,1 %. At the same time 36,8 % do not choose a doctor yet follow the referral.
   The doctor’s qualities as rated by patients look the following way: experience (professional skills) – 84,6 %; knowledge – 65,1 %; ability to find an approach to the patient – 49,7 %; unselfishness – 42 %; being easy-going and accessible – 40,8 %.
   Not all the respondents were happy with their district doctor. 20,1 % of them were unhappy with the working hours; 21,7 % – with the cost of treatment; 13,9 % – with the attitude towards patients, while the quality of treatment made unhappy 15,1 % of the respondents.
   While talking with the patient and their family the doctor told about the treatment mode – 67 % of the respondents; about the risk factors – 52,4 %; about the need to live healthy lifestyle – 32,1 %; given that the doctor told none of the above-mentioned to 12,3 % of patients.
   46,5 % of the respondents are completely satisfied with the amount of the information provided by the doctor; partially satisfied – 38 %; not satisfied and unsatisfied rather than vice versa – 15,5 %. When choosing a medical institution the most important criteria for patients is the specialists employed there – 47,8 %; offering services mostly by the insurance policy – 28,4 %; reputation of the institution – 27 %; close location to home/work/school – 11 %; acquaintances employed in the institution – 4,6 %.
   Most often there is no choice of medical institution demonstrated by the respondents belonging to the group of “have not enough money to cover the basic needs” – 42,5 % and “cannot afford buying things of longer service-life” – 42 %. At the same time 0 % of those belonging to the group of “have no financial limits” gave the same answer.
   The patients evaluated the quality of the in-patient department the following way: unsatisfied and unsatisfied rather than satisfied with the cost of treatment – 18,1 %; attitude towards patients – 9,7 %; quality of treatment – 5,9 %.
   The higher the patient’s level of prosperity the easier it is for them to get hospitalized. The response “easily” was obtained from 31,3 % of the respondents belonging to those “spending half of their income on food”; 16,4 % – from the group “spending around half of the income on food”, and 14,3 % of the respondents “spending over half of their income on food”.
   Nearly 20 % of the respondents mentioned that it was “hard” or “rather hard” for them to find placement in the in-patient ward.
   The respondents believe that only the patient should be informed about his/her oncological illness in 24,9 % of cases; closest family members should be informed -16,9 %; the patients and his/her closest family – 43,6 %, while 14,6 % of them have no personal opinion on the issue.
   In terms of who should be informed about the oncological illness in the patient there was a dependency revealed between the responses and the respondent’s level of prosperity. Most of those belonging to the “conditionally prosperous patients” believe that it is the patient him/herself who should be informed – 30,3 %; close relatives should be informed – 21,2 %; both – 39,45, and there was also a low share of those who could not answer the question – 9,1 %. As the level of prosperity goes down the number of those with no personal opinion goes up – 11,4 % in the group of the “relatively average-income”; 22 % – in the “relatively low-income” group.
   Treatment compliance
   66,3 % of the patients follow all the instructions coming from the doctor; partially compliant are 30 %; non-compliant – 3,7 % of the respondents.
   Among the reasons for refusal to start treatment or for its premature cease the leading one is the high cost of the treatment – 23,6 %; further comes complicated treatment plan – 14 %; fear of pain or treatment – 9,6 %; lack of time for the treatment – 9,3 %; conflict with medical specialists – 1,4 %.
   The high cost of the treatment as a factor for premature cease of the treatment was most common in the subgroup of the most needy respondents – 36,3 %; in the other subgroups the share of those who stopped taking the treatment for the same reason was significantly lower.
   A complicated treatment plan as a reason for stopping the treatment is also more typical of the subgroup “conditionally low-income” – 18,7 % rather than of the other subgroups.
   The reasons for delayed seeking of medical assistance included “I thought it would just pass by itself” – 28,6 %; improper diagnosis given by the doctors – 12,4 %; “was afraid to find out about a serious disease” – 10,3 %; “could not leave my work/studies” – 7,5 %; “thought I would have to pay for the treatment” – 6,8 %.
   The idea that the disease would pass by itself, which explained the delayed referral, is not typical of the low-income subgroups, for instance those who do not have enough to meet the basic needs – 21,2 % of cases, which is twice lower than in other subgroups.
   Conclusion
   1. There is a low level of health competence in patients belonging to the urological and onco-urological profile.
   2. A significant share of patients need psychological assistance.
   3. There are many factors influencing the patient’s choice of the doctor, including the opinion expressed by relatives, friends, colleagues, etc. Important here is the doctor’s experience, knowledge, tactfulness, etc.
   4. The doctor’s communication with patients and their families may play a significant role in improving treatment compliance. At the same time medical specialists do not pay due attention to this aspect.
   5. Compliance level among the respondents made up 66,3 %, which is an average level compared to patients of other medical profiles.
   6. The leading reasons for rejecting treatment include high cost of the therapy and complicated treatment plan. The first reason is especially relevant to low-income groups of patients.
   7. The level of welfare is a factor that increases the availability of hospitalization. The higher it is the more available in-patient care is.

   References

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Healthy literacy issues

   Prevalence of noncommunicable diseases in Russia
   Noncommunicable diseases (ND) are a significant issue in terms of public health. This is due to the increasing share of these diseases against the total number of diseases and death rate.
   In 2008 the death rate from ND was 36 mln out of 57 deaths all over the world. At the same time 29 % of deaths from ND can be seen in countries with low and middle level of income. Given that 80 % of premature deaths from heart issues, stroke, and diabetes could have been prevented with an efficient impact on the risk factors.
   The situation in different countries varies significantly. For instance, the death rate from ND among men in Russia is about 3 times as high as that in Finland, while among females – the gap is 2 times. The comparative data can be seen in the Table below (Table 1)

   Table 1. Standartized by age index of death from ND per 100.000 (WHO, 2008)

   It should be noted that this tendency remains in the following years. The current situation with the death rate in Russia will not allow keeping up the population growth (Federal Service of State Statistics, 2011).
   Tables 2 and 3 offer an analysis of death causes in Russia.

Table 2. Death in Russia by major cause groups

   Table 3. Death in Russia by major cause groups (thous. people)

   The data show that blood circulation, tumors, and external causes keep the lead among the death causes (Federal Service of State Statistics, 2011).
   The WHO data says that Finland is one of the leaders in terms of healthcare.

   Table 4 provides a comparison of healthcare features in Russia and in Finland (WHO, 2012).

   Table 4. Some indices describing healthcare in Russia and Finland

   The analysis of certain figures describing public healthcare in Finland and Russia shows that Russia is lagging far behind in terms of TB, HIV prevalence, and expected life span even despite a high share of elderly population in Finland. Such a significant gap can be explained by huge “scissors” in healthcare funding in the two countries, both taken per capita and by the share in the GDP.
   Similar results we can obtain comparing the data on Russia and Norway. Thus, the expected life span in Russia in 2009 was 62 for men and 74 for women, making an average of 68. In Norway the same indicators are 79, 83, and 81 respectively. The death rate including both men and women (per 1.000) is 269; women – 144, men – 391.
   The analysis of the data offered shows that the demographic situation in Russia requires measures aimed at improved healthcare and efficient preventive activities are among such measures. We should also mention that the Russian Government and Ministry of Healthcare have been taking the respective measures in the latest decade. There are significant positive changes caused by the National Project HEALTH. Efficient have also proven such measures as clinical examination, establishing health centers, implementing a program on improving medical assistance to patients with vascular diseases, etc.
   Medical preventive activities take on special relevance as there has been a misbalance in healthcare drawing towards unipolar and mostly treatment-diagnostic types of assistance (specialized assistance, especially in-patient), which is done at the expense of preventive care. There should be a cardinal change in the attitude towards healthcare, which must become just as important as the development of hi-tech and expensive assistance. This would take a modern model of functioning and development for medical prevention, which could combine the economic interests of the state, the specific field, and the individual. Such a model should be based on the contemporary economic realities and be some kind of a directive for executive authorities to be followed locally (Стародубов В. И., Сковердяк JI. A., Соболева И. П., 2005).
   There is some hope that positive changes around public healthcare can be expected, which is due to the European Strategy for the Prevention and Control of Noncommunicable Diseases (WHO, 2006), which is offering an integrated approach including simultaneously:
   · Prevention program and improving people’s health;
   · Determining risk groups and developing measures;
   · Maximum efficient treatment offered to the population;
   · Eliminating inequity in healthcare services.
   The aim of this strategy is to avoid premature death and reduce significantly the expenses due to temporary loss working capacity, which is caused by noncommunicable diseases; to improve the life quality and approach the European healthcare standards. The objectives here include combining actions aiming at eliminating risk factors and their causes with improvements in the healthcare system and prevention of noncommunicable diseases.
   Investment into noncommunicable disease prevention will have a significant positive impact on people’s health in many countries with low and middle income. For instance, in the former Soviet Union and East European countries the adult death rate was reduced down to the EU level through paying due attention to noncommunicable diseases and external causes that affect the birth rate significantly.
   There is a huge potential for improved health in a global strategy that contributes to people’s health and offers prevention programs embracing groups of people or individuals, at the same time increasing to the maximum the outreach of treatment and care.
   Noncommunicable diseases risk factors (RF)
   Long-term prospective researches involving representative groups of the population have shown a development link between progressing chronic noncommunicable diseases (CND) and premature death from them, and the factors determined by the lifestyle, environment, and genetic features that are called risk factors (RF) of CND (Оганов Р. Г., Деев А. Д., Жуковский Г. С., Шальнова С. А.,1998; Шальнова С. А., Деев А. Д., Оганов Р. Г. 2005, Kannel W. B. 1996; Jackson P. R., 2000; Conroy R. M., Pyorala K., Fitzgerald A. P. et al., 2003;).
   The RF concept is the scientific basis for CND prevention. Most RF can be corrected (modifiable) and are of the greatest interest in terms of CND prevention (Оганов Р. Г., Масленникова Г. Я., Шальнова С. А., Деев А. Д.,2002). Other RF (age, gender, and genetic features) cannot be corrected (non-modifiable), yet they are used for evaluation and prediction of individual, group, and population risk of CND. The leading factor determining people’s health status is the lifestyle.
   This shows that risk factors are potentially hazardous factors of behavioral, biological, genetic, environmental, and social nature, pertaining to the surrounding or working environment that increase the likelihood of a disease, its progress and unfavorable outcome.
   The existing nowadays classification for risk factors, i.e. potentially hazardous factors of behavioral, biological, genetic, environmental, and social nature increasing increase the likelihood of a disease, includes the following groups:
   · Socio-economic factors (working conditions, prosperity, living conditions, etc.);
   · Socio-biological factors (parents” age, gender, antenatal care, etc.);
   · Organizational and medical factors (quality and accessibility of medical & social assistance, etc.);
   · Environmental and nature-climate factors.
   All the factors mentioned above interact with one another, change over time, and have some regional peculiarities. The extent of their impact is also changing through the life course. For instance, the major impact a child experiences in the early age is from socio-biological factors. As we grow their role goes down giving way to socio-economic issues, namely – living conditions and lifestyle (Иванова Н. Л., 2007).
   In Russia the share of blood circulation diseases is 57 %, malignant tumors – 13 %, gastrointestinal issues – 4 %, and respiratory issues – 4 %. The total toll on noncomunicable diseases is 78 %. By the Russian regions the standardized death rate figures – both total and from the major noncommunicable diseases – vary greatly with the minimum registered in the South Federal District and the maximum – in the Far East (1246.0 and 1599.8 per 100.000 respectively – in the total death rate; 725.0 and 899.6 – from blood system issues; 164.8 and 198.4 – from malignant tumors) (Оганов Р. Г., 2011).
   Four major risk factors have taken on special importance in Russia – high blood pressure, high level of cholesterol, tobacco smoking and alcohol abuse; the “contribution” from these four in the total death rate is 87,5 % while in the number of years with loss of the working capacity it is 58,5 %. Alcohol abuse is on the top of the impact on the years with loss of the working capacity – 16,5 %. Experts say that in the latest six years the relative figures have not changed significantly (Healthcare concept till 2020).
   Among the adult population (over 15) there are 60 % of smoking men and 15,5 % of women; about 40 % of them have high blood pressure. 17–21 % of men abuse alcohol (alcohol consumption calculated as pure ethanol ≥ 168 g. per week) and 3–4 % of women (alcohol consumption calculated as pure ethanol ≥ 84 g. per week). Single alcohol consumption among men and women exceeds the safe levels 5 and 2 times respectively.
   After the collapse of the Soviet Union psycho-social stress has been having a significant impact on the population’s health. A research conducted in 35 Russian cities has shown that depressive disorders taken as indicators psycho-social stress are common in an average of 46 % patients seeing primary care doctors for various reasons (Оганов Р. Г., 2011).
   In reality one person will often demonstrate 2–3, and more RF at the same time. Thus, among men aged 35–64 (representative sampling among the residents of one Moscow neighborhood) only 18,2 % have 1 RF; 2 RF – 29,2 %, 3 and more RF – 45,5 % (Мартынчик Е. А., Константинов В. В., Тимофеева Т. Н. и др., 2002). RF can have combined effect or they can strengthen one another’s impact on the development, progress, and the unfavorable outcome of a CND. The five leading RF of CND (AH, alcohol abuse, smoking, hypercholesterolemia, overweight) account for 67,2 % of all the healthy years (Global Programme on Evidence for Health Policy; WHO, World Health Report, 2002). This is why nowadays there has been a decision made to evaluate individual, group, and population death risk from CND in view of several RF – the so-called summary or global risk.
   An analysis of RF prevalence in Russia taken in 2008 showed that 57,8 % of Russians have overweight, while 18,4 % of men and 29,8 % of women are obese; diabetes affected 10,6 % of the Russian population, and AH – 43,8 %. Also, a risk factor like increased cholesterol was found in 50,6 % of Russians, while in people in Burkina Faso this issue is common to 17,7 %, and to 21,9 % of Afghans.
   It is only preventive measures, which have proven efficient, that can change the situation in the Russian public healthcare.
   There is every reason to believe that large-scale inter-sectoral activities aiming at prevention and correction of RF will result in a significant decrease of death rate from CND. Proof to that is the experience of many countries where the latest 30 years have seen a sharp reduction of CND RF, which later resulted in reduced the death rate from these issues (Оганов Р. Г., Масленникова Г. Я., Шальнова С. А., Деев А. Д., 2005).
   These risk factors are leading in all the epidemiological European regions and in most European countries even though the order may be different. In 37 out of 52 WHO member-countries the leading factor is high blood pressure; in 31 – smoking. Alcohol is a cause of working capacity loss and premature death among the youth in Europe. These factors are due to certain living conditions. Each of the leading seven risk factors is associated to some standard of living. Besides, in vulnerable social groups these factors mutually enforce and complement one another (WHO, 2006).
   Obviously the efficiency of medical activities (including preventive ones) will depend on the population’s literacy (competence) in terms of health. For this reason the issue of increasing people’s health literacy has been mentioned by the WHO as one of the most relevant issues of public healthcare.

   Health literacy development. What does work here?
   From time to time everyone has to make important decisions, which have a significant impact on his/her health status. This is why strategies for increasing patients” health literacy and involving them into decision-making should be among the key points in healthcare policy. Besides, patients may play a big role in understanding the causes of the disease, in taking care of their own health, and in selecting the optimal treatment, in particular, in case of acute illnesses and chronic diseases. These roles should be always recognized and encouraged in every way.
   When implementing strategies for encouraging patient involvement it is important to pay due attention to their health literacy, common responsibility for decisions, and self-control in maintaining their own health. Health literacy (awareness, competence) represents the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.
   Health literacy implies the achievement of a level of knowledge, personal skills and confidence to take action to improve personal and community health by changing personal lifestyles and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment, i.e. providing or obtaining true possibility, power, capacity. Health literacy is itself dependent upon more general levels of literacy. Poor literacy can affect people’s health directly by limiting their personal, social and cultural development, as well as hindering the development of health literacy. (Health promotion glossary//WHO, – 1998. http://whqlibdoc.who.int/hq/1998/WHO_HPR_HEP_98.1_rus.pdf).

   Many actions have been shown to be efficient in improving people’s health literacy, involving patients into decision-making on treatment, and in training patients to take a more active position in health self-control in case of chronic diseases. The examples of such actions include:
   · Written information complementary to the clinical counseling.
   · Information found in the Internet and from other electronic sources.
   · Personal computerized information and virtual support.
   · Communication skills training in medical specialists.
   · Training patients and prompt answers to questions that may arise.
   · Helping patients in decision-making.
   · Self-control training programs.
   Poor health literacy is associated with unequal access to healthcare, so those with a low level of the literacy usually have a lower health status and a higher risk of hospitalization.
   The events for increasing health literacy pursue tree major objectives – to offer information and training; to promote better and more efficient use of medical-sanitary resources, and to eliminate inequity in access to medical assistance. Such events may be run in different ways each of them having its advantages (Angela Coulter, Suzanne Parsons Janet Askham. Brief Analytical Review – healthcare Systems and Policies // WHO, – 2008.
   http://www.euro.who.int/__data/assets/pdf_file/0008/76436/E93419R.pdf)
   We have conducted an analysis of the evidence-based facts on the issue. Methodology – search in the Medline system through the PubMed interface in the latest 10 years: (“health literacy”[MeSH Terms] OR (“health”[All Fields] AND “literacy”[All Fields]) OR “health literacy”[All Fields]) OR (“health education”[MeSH Terms] OR (“health”[All Fields] AND “education”[All Fields]) OR “health education”[All Fields]) AND (“humans”[MeSH Terms] AND (Clinical Trial [ptyp] OR Editorial [ptyp] OR Meta-Analysis [ptyp] OR Practice Guideline [ptyp]) AND (English [lang] OR French [lang] OR German [lang] OR Italian [lang] OR Japanese [lang] OR Russian [lang] OR Spanish [lang]) AND “2001/10/10”[PDat]: “2011/10/07”[PDat].
   15705 references were obtained. Since processing this number of references was not possible we decided to conduct a search for systematic reviews with 586 of them found, which made the basis for the work.
   Up to 90 million Americans have troubles understanding medical information. This epidemic in health literacy is more and more often recognized as an issue affecting health and quality medical assistance, as well as its cost. Yet many doctors do тещ see the state of things as an issue. Wallace and Lennon looked at the educational materials of the American Academy of Family Doctors released for patients and available in the Internet. They found that three out of four distribution sets were designed for a level above the average literacy level of Americans. Chu et al. offered an alternative to the existing tests for evaluating medical examination literacy asking three questions aiming at detecting health illiteracy. In their articles they state the need for improved methods of increasing health literacy under clinical conditions [Дэвис Т. С., Вольф M. S., 2004].
   There are research findings showing that it is important to take into account gender differences when training patients. Thus, with a training intensity of 4 times a week female patients were much more responsible never missing classes, which was not the case with men [Janevic M. R., Janz N. K., Dodge J. A. at al., 2003.].
   It is obvious that during training the doctor should employ the following techniques:
   Explanation
   A frequent issue is to provide the patient with the information on the disease doing it in the right way. The logical approach used for training students or colleagues cannot be used for patients because it does not take into view their experience and ability to understand. In order to find out how correct is the patient’s understanding and acceptance of the doctor’s message it is necessary6 to let him/her express their thoughts, fears, and ideas of the disease and the treatment before the doctor gives the patient another piece of information.
   Active listening and reformulating
   To show to the patient that he/she has been heard and understood it is important to be able to reformulate what has been said by the patient. Reformulating is reproduction of the previously heard message with similar stresses and accuracy yet using other words. Through this the patient will recognize his/her own thought and feel that the idea has been got the right way. Being an active listener the doctor conveys to the patient that his/her complaints have been heard and doubts understood. In response the doctor can express sympathy repeating the patient’s complaint so that to suggest a solution at the same. Reformulating is one of the major counseling strategies. This cannot be an improvisation and it takes special training and experience to turn it into a skill.
   Avoid using professional terms
   Quite often doctors experience telling their patients about their illnesses in simple words. This is due to the fact that in their everyday practice doctors operate special medical terms talking their “incomprehensible” language. However, if we are trying to reach understanding and compliance it is important to remember that medical terminology will often make the patient scared thus impeding establishing trust during the treatment. The ability to speak a common language with the patient is a matter of experience yet it requires an active creative approach from the doctor.
   Using questions that require full answers
   This allows getting new detailed information from the patient, which is virtually impossible in case of using closed questions that can be answered with a YES or a NO.
   Hypertension and health literacy
   Hypertension is the most common pathology where the patients” literacy regarding their illness, lifestyle change, treatment and prevention of serious complications is especially important. However, despite the huge number of research findings there is still no convincing evidence of which type of medical assistance and way of offering them would be optimal for patients with arterial hypertension.
   A systematic review of randomized controlled experiments assessed the following interventions: (1) independent monitoring over arterial pressure; (2) training programs specially designed for patients; (3) educational programs specially designed for doctors; (4) interventions involving medical specialists (nurses and pharmaceutists) into work with people suffering from hypertension; (5) organizational events aiming at improved medical services offered to patients; (6) reminding systems for patients.
   Independent monitoring allowed some reduction in the diastolic pressure by – 2.03 mm. Mercury with a 95 % confidence interval. Educational programs for doctors resulted in an insignificant reduction of the systolic pressure – 2.0 mm. Mercury with a 95 % confidence interval, and of the diastolic pressure – 0.4 mm Mercury. The results allowed the researchers conclude that the clinics employing both practices should have a monitoring system for patients with hypertension. Anti-hypertension therapy should be used through vigorous “step-by-step” treatment in cases where there is no chance to reach the targeted blood pressure level [Fahey T., Schroeder K., Ebrahim S., 2005; Glynn L. G., Murphy A. W., Smith S. M., Schroeder K., Fahey T., 2010]. Primary prevention programs for reducing the morbidity and the death rate from cardio-vascular issues through modifying risk factors are being run in many countries. Interventions aiming at modifying multi-factor risks (such as counseling and patient training) are considered efficient, including from the point of view of the cost-efficiency ratio, which means they should be made popular. However the recent surveys into modifying risk factors have caused a lot of doubt concerning the efficiency of such interventions. The authors of the systematic review conclude that the joint effect of such interventions has no impact on the death rate. Yet, a small but potentially important result of therapy (about a 10 % reduction of cardiovascular death rate) could have been missed. Interventions employing personal or family counseling and/or training, with or without medication therapy have proven more efficient in terms of reducing the prominence of risk factors followed by reduced death rate among the population of patients suffering from hypertension and diabetes with a high risk of cardio-vascular issues. However such interventions are far less efficient in the general population of those with hypertension and diabetes [Ebrahim S/, Beswick A., Burke M., Davey Smith G., 2006]. Another systematic review focused on evaluating the efficiency of the impact that various interventions have on arterial pressure in people with hypertension. Training patients in issues related to the medications they use resulted in reduced average BP (-8.75/-3.60 mm Mercury). Other strategies that were highly efficient in terms of their impact on the SBP (systolic BP) included pharmaceutists” recommendations on treatment (-9,30 mm Mercury), nurse involvement (-4,80 mm Mercury), as well as using the treatment algorithm (-4,00 mm Mercury). There has been a conclusion made here stating that instructing hypertonic patients in groups results in better BP control. Therefore, when implementing new treatment principles for hypertonic patients it is important to view the changes in the healthcare organizational structure in order to establish a team monitoring patients at home [Peterson A. M., Takiya L., Finley R. б 2003; Carter B. L., Rogers M., Daly J., Zheng S., James P. A., 2009].
   Coronary heart disease and health literacy
   Stroke and myocardial infarction are serious complications of hypertension. These conditions usually require urgent assistance and even a smallest delay in providing help in case of acute myocardial infarction may play a big role in terms of reducing the death rate. The media could play a big role as well, yet interventions aiming at reducing the delay in calling the ambulance were a limited success. To achieve the aim it is not enough that the media increase the awareness of the issue; future interventions must address high risk audience involving a dialogue established between patients who had infarction and people belonging to the high risk group talking discussing the importance of eliminating delays in calling the ambulance. Also it is important to provide gender-specific training stressing the importance of evaluating the symptoms, solving the issue, and developing decision-making skills [Caldwell M. A, Miaskowski C., 2002].
   Stroke and health literacy
   Stroke is also one of the leading issues causing deaths all over the world. Being aware of the respective risk factors and knowing the warning symptoms is of big importance for preventing strike and seeking help.
   Numerous research projects show that in general better knowledge of stroke was observed in women, if compared to men, even though both genders demonstrate lack of knowledge here. Four out of eighteen research projects showed better knowledge of risk factors, and eight out of fifteen surveys demonstrated better knowledge of stroke signs among women rather than in men. Knowledge concerning stroke and its signs also proved related to the country of residence and training, age, education, and history of the disease. Patients who had a history of life-threatening events (myocardial infarction or stroke) experienced a short delay in calling emergency medical aid, which was not the case with those did not have that kind of history [Nieuwenhuis M. M., Jaarsma T., van Veldhuisen D. J., van der Wal M. H., 2011].
   It hasbeen stressedrepeatedly that time matters a lot in treating acute stroke. A lot of time is wasted beyond hospital, due to troubles identifying stroke symptoms, because of delay informing the ward or as a resultof transportation problems. The total number of research surveys analyzed was 182. It has shown that the factors related to a shorter delay in calling the ambulance included more severe stroke symptoms, such as hemiparesis or speech disturbances. Only 25–56 % of patients recognized their own symptoms as stroke. It has been shown that education about stroke improves the knowledge of the wraning signs. There is a gap between the existing theoretical knowledge about stroke and the patient’s actions in an acute situation. The behavior depends more on the way the severity of the symptoms is accepted rather than on the knowledge of them. Family members play an important role in making the decision about whether or not the ambulance should be called, and they should be part of the training program. Patient training should be efficient and adjusted to the culture of the trainees and represented in the social context. It is still not clear what educational concepts are best in terms of increasing awareness of symptoms in an acute situation involving stroke, especially in view of the gap between knowing the warning signs and urgent actions, for instance calling the emergency. [Teuschl Y., Brainin M., 2010; Stroebele N., Müller-Riemenschneider F., Nolte C. H., Müller-Nordhorn J, Bockelbrink A, Willich S. N., 2011]. At the same time research findings show that patients who suffered stroke and their family members are not satisfied with the information they have been offered and have poor understanding of stroke issue. There is evidence proving that informing patients and caring person in issues related to stroke will improve patients” satisfaction and will objectively reduce the manifestation of depression in them. However, the reduced manifestation of depression was not clinically significant. Even though it is not clear yet how to better arrange informing there are facts demonstrating that the strategies that involve active participation of patients and their families and implying planned explanation activities, have a significant effect on patients” moods [Smith J., Forster A., House A., Knapp P., Wright J., Young J., 2008].
   Diabetes and health literacy
   Educational programs are also positive in improving patients” knowledge about diabetes and in terms of some self-controlled behavior changes in patients receiving dialysis or patients with microalbuminuria [Li T., Wu H. M., Wang F., Huang C. Q., Yang M., Dong B. R., Liu G. J., 2011].
   Elderly and health literacy
   The elderly represent a specific group that needs various medical-social interventions. Research shows that medical-social interventions conducted in the elderly groups should aim at encouraging moderate activity, include self-monitoring, and promote such groups functioning at specialized centers. There is data showing that that the elderly populations are especially sensitive to interventions stimulating various activities [Conn VS, Valentine JC, Cooper H. M., 2002].
   Surveys among the elderly show that interventions oriented at married couples have a slight effect, which could be enforced through applying the partner’s effort to changing the patient’s behavior and a focus on couples with a high risk of conflict due to the disease of one of them, as well as on those with a low suport from the partner or poor marital relations in general. [Martire L. M., Schulz R., Helgeson V. S., Small B. J., Saghafi E. M., 2010].
   Interactive Health Communication Applications (IHCAs) has become rather popular lately, which is oriented towards using PCs, often the Internet, information packages for patients, where the information on healyth issues is combined with at least one type of social aid, support in decision-making or in lifestyle change.
   A survey investigating the efficiency of this technology involving 3739 chronic patients has shown a significant positive effect on the users who have become bettrer informed, could feel social support, and have demonstrated improvemenq\tsin their lifestyles and in the clinical course of the disease, if compared to those who did not join the program [Murray E., Burns J., See T. S., Lai R., Nazareth I., 2005]. Mesaures for preventing falling incidence are rather relevant for the elderly. Preventive measures taken here are efficient both for reduicing falling risk and for reducing the number of falling incidents within one month [ChangJ. T., Morton S. C., Rubinshtein L. Z., et al., 2004]. At the same time training patients with rheumatoid arthritis will be only of small short-term effect in relation to incapacity for work, general evaluation of patients” condition, the psychological status and depression [Riemsma R. P., Kirwan J. R., Taal E., Rasker J. J., 2003]. It has been also revealed that a low level of education among the elderly increases the risk of involutional depression [Chang-Quan H, Zheng-Rong W, Yong-Hong L, Yi-Zhou X, Qing-Xiu L., 2010].
   Oncological patients and health literacy
   The issue of training oncological patients still remains urgent, especially in view of the forecast stating that this will only increase due to ageing of population. Patients diagnosed with cancer need training as they come across the need of making hard decisions. Of course the central item in training them is the pain therapy. There are barriers to pain management related to cancer that exist both in patients themselves and in professionals. Training offered by public healthcare services to professionals improves their knowledge yet this does not always result in better treatment results in patients. However special measures that change professional behavior prove efficient. Systematic reviews show serve evidence that in general training oriented at patients or specialists may result in a significant clinical effect similar to some analgesics. Therefore, educational interventions should be part of routine clinical practice along with painkilling therapy [Gysels M., Higginson I. J., 2007; Bennett M. I., Flemming K., Closs S. J., 2011].
   Children and health literacy
   The highest return from educational interventions should be expected from working with child population in various areas. For instance, training of safety skills at home, especially if done along with using safety devices, is efficient in relation to thermal injuries in children [Kendrick D., Smith S., Sutton A. J., Mulvaney C., Watson M., Coupland C., Mason-Jones A., 2009]. There are many approaches to resolving issues in child behavior including medication and psychological therapy directed both at the child and at the family. Behavioral or cognitive-behavioral therapy proved efficient indeed yet they are not very much available due to high cost and being time-consuming. Offering information in booklets or in a media mode may reduce the cost and increase access to preventive programs. There were research projects reviewed with 943 participants. The authors conclude that interventions based on the media-format in some cases may be sufficient to gain clinically significant changes in child behavior, which will contribute to reducing the number of employees taking direct care of them. Besides, such interventions may be viewed as the first step into a multi-stage prevention process. Further this may result in an increased number of families that could benefit from such technologies giving specialists spare time to be used for more complicated cases. Thus, media-therapy has both clinical and therapeutic effects in relation to children with behavior issues [Mytton J., DiGuiseppi C., Gough D., Taylor R., Logan S., 2006].
   Aggressive behavior in early childhood is a risk factor for violent or criminal behavior pattern in adulthood. Despite the 20-year experience of employing violence prevention programs there are still questions concerning the efficiency of various preventive interventions related to children demonstrating aggression. Secondary prevention programs run in schools demonstrate more of effect than expected in view of improved behavior. Positive effects can be obtained both in primary and in elementary and in middle school. An analysis of subgroups has shown that measures aimed at improving relationships or developing social skills may be more efficient than training programs for controlling response to provocative situations. Similar results were observed when comparing elementary school with middle school, and mixed classes with those including boys alone [Montgomery P., Bjornstad G., Dennis J., 2006].
   Interesting to note that parents” perception of child issues is different from the objective picture. Several surveys investigated parent view of child obesity in Great Britain, Australia, Italy, and the US. It was noted that parents were likely not to have proper perception of their children’s weight. This was especially relevant to parents who themselves had overweight. Obviously if the parents do not recognize their child’s overweight or the risk of that they cannot interfere to reduce the risk factors and the related complications [Duperrex O., Blackhall K., Burri M., Jeannot E., 2009].
   Along with that in case of some nosologies the parents” and child’s training can offer extra advantage in treatment. It has been proven that training patients with asthma resulted in better functioning of their lungs, as well as in a reduced number of classes skived off, number of days with limited activity and number of visits to the emergency ward. There were also a lower number of night asthma attacks. The highest impact on the disease was noted in programs based on individual training and in involving patients with severe course of asthma. The authors of the systemic review conclude that training programs should be regarded as part of everyday therapy for young people suffering from asthma [Guevara J. P., Wolf F. M., Grum C. M., Clark N. M., 2003].
   In developing countries training parents is of special importance as it concerns not just their children’s health status but sometimes even survival. A number of works show that provision of proper nutrition, whether with or without training of mothers, and pure counseling offered to mothers on nutrition issues may result in significant weight gain in children aged 6—24 months. These events may reduce significantly the risk of delayed growth in developing countries [Imdad A., Yakoob M. Y., Bhutta Z. A.,2001].
   In most countries child sexual abuse is also a serious issue that requires efficient preventive measures. Unfortunately different surveys provide different conclusions regarding the efficiency of such interventions, which demands additional investigation 3—12 months after the intervention is over, taking into account the time needed for assessing the survival of the knowledge acquired [Zwi K. J., Woolfenden S. R., Wheeler D. M., O’Brien T. A., Tait P., Williams K. W., 2007].
   Tobacco smoking and health literacy
   Tobacco epidemic still remains an urgent issue in public healthcare, so it important to employ preventive technologies that have proven efficient. A big role in this process is given to professional healthcare services and here the attitude from future doctors – medical students – to the issue matters a lot. One of the latest surveys studying the attitude towards smoking among dentistry senior students (98,9 % of respondents provided their answers) showed that in total 93,9 % of the respondents advice their smoker-patients that they should quit it, yet only 46,1 % of them really tell their patients how to do it. Sixty percent of the respondents knew about the nicotine replacement therapy but only 36,1 % about the role of anti-depressants in smoking cessation. Most of them (87,2 %) approved a ban on selling cigarettes to adolescents; 73,9 % stated cigarettes should not be advertized; 81,1 % – approved the idea of banning smoking in public places, and 2,8 % would allow smoking in their dentist office [Ehizele A. O., Azodo C. C., Ezeja E. B., Ehigiator O.,2011].
   Eliminating smoking during pregnancy is one of the few ways to prevent complications, low weight at birth, and premature labor. This has serious consequences for the health of both women and children. Smoking during pregnancy is going down in countries with high income and is on the up in low-income countries; it is well associated with poverty, low level of education, poor social support and psychological issues in women.
   Numerous studies have demonstrated that anti-smoking interventions conducted in the first trimester of pregnancy reduce the number of smoking women at later terms and reduce the rate of premature labor and low weight at birth. Due to this the recommendation is to employ such interventions wherever there can be pregnant women; at the same time it is important to offer these women social support [Lumley J., Chamberlain C., Dowswell T., Oliver S., Oakley L., Watson L., 2009]. A significant place where changed attitude to smoking may give positive result is the workplace because this is a place for longer stay. As proven, the presence of absolutely smoking-free workplaces reduced the number of smokers in the average by 3,8 %, also reducing the number of cigarettes smoked per day by 3,1 %, yet with the status of a smoker remaining with the latter. To obtain a similar effect it would take increasing smoking tax from 0.76$ to 3.05$ (0.78 Euros to 3.14 Euros) in the USA, and from 3.44 £ to 6.59 £ (5.32 Euros to 10.20 Euros) in Great Britain. Should all workplaces become smoking-free then the total population of smokers would go down by 4,5 % in the USA and by 7.6 % in Great Britain, which would lead to the tobacco industry losses estimated at 1.7 bln US Dollars and 310 mln Pound Sterling in Great Britain.
   Smoking-free workplaces do not just protect against passive smoking but also encourage smokers to quit smoking or to reduce it [Fichtenberg C. M., Glantz S. A., 2002]. Given that a number of surveys demonstrate that, despite the efficiency of interventions against smoking at workplace, this efficiency is going down over time and is nearly never registered 12 months after the intervention. The maximum efficiency is observed in the first six months after the start of the intervention [Smedslund G., Fisher K. J., Boles S. M., Lichtenstein E., 2004]. Here quire relevant remains the question of what interventions have the maximum efficiency. Randomized studies, controlled studies with no randomization, which assessed the efficiency of campaigns held through the media (defined as communication channels, such as TV, radio, newspapers, posters, leaflets or booklets aiming at reaching a large number of people and which do not depend on person-to-person contact) have shown that these technologies have an impact on the smoking behavior (both objectively and through self-esteem) on young people aged under 25. [Brinn M. P., Carson K. V., Esterman A. J., Chang A. B., Smith B. J., 2010].
   Cannabis smoking is directly linked to tobacco. To get an answer about the efficiency of preventive school programs for reducing cannabis smoking among youngsters aged 12 to 19 there was a summary conducted embracing finding from 15 studies published in scientific journals since 1999. This study of the results has shown that such school programs have a positive effect on reducing the number of students smoking cannabis, if compared to the control groups. It has been demonstrated that programs including elements of several preventive models were much more efficient rather than those based on the model of social impact exclusively. The programs with longer duration (≥ 15 sessions) and run involving other people rather than the coach alone were more efficient when using interactive forms [Porath-Waller A. J., Beasley E., Beirness D. J., 2010].
   Alcohol and health literacy
   Excessive alcohol consumption is a serious social and economic issue. This why search for efficient preventive strategies remains rather urgent. There were 22 surveys analyzed, which focused on alcohol abuse prevention (7,275 participants-students).
   The authors concluded that interventions based on the Internet technologies with feedback, as well as on the face-to-face technologies, are efficient in this respect. It was also noted that Internet-technology based interventions are less expensive, this making them a preferable choice. The maximum effect was noticed in the nearest term after the start of the interventions (3 months). As for technologies employing group feedback or feedback via mail, as well as campaigns based on social norm marketing, such interventions are far less efficient and therefore cannot be recommended. [Moreira M. T., Smith L. A., Foxcroft D., 2009]. This is also confirmed through other surveys. For instance, interventions based on the Internet technologies reduced both the intensity and the amount of the alcohol consumed by college students. These technologies were equivalent in their efficiency to alternative interventions [Carey K. B., Scott-Sheldon L. A., Elliott J. C., Bolles J. R., Carey M. P., 2009]. An economic analysis of such media-campaigns has shown that the positive effect for the public were above the cost of the campaign. As a rule the media campaigns are well planned, performed, and reach a large audience, being implemented along with other current types of prevention. There is substantial evidence confirming that mass campaigns in the media are efficient in terms of prevention of HIV and alcohol-related car accidents [Elder R. W., Shults R. A., Sleet D. A., Nichols J. L., Thompson R. S., Rajab W., 2004].
   Car accidents kill over a million of people all over the world each year, leaving about a dozen of millions disabled for the rest of their lives. In many countries once people get a driving license they also are driving-trained, which is a strategy for reducing accidents. However, the efficiency of that extra training has not been proven yet. The conducted systematic review has shown no proof of the fact that this post-license training is an efficient means of reducing the number of traffic accidents and traumas. Yet such surveys did register a slightly reduced number of traffic rules violation [Ker., Roberts I., Collier T., Beyer F., Bunn F., Frost C., 2005].
   Sexual behavior, HIV, and health literacy
   Improving sexual health is one of the key issues in public healthcare, and there is a huge potential for health improving through various technologies including
   1) minimum intervention (conventional practice or a leaflet);
   2) face-to-face technologies;
   3) various designs of the Internet technologies, e.g. cognitive, behavioral, biological.
   The Internet technologies have been found to be the most efficient means to obtain information about sexual health as well as to achieve the maximum effect in relation to self-esteem, motivation, and sexual behavior [Bailey J. V., Murray E., Rait G., Mercer C. H., Morris R. W., Peacock R., Cassell J., Nazareth I., 2010]. The mass-media are considered to be one of the most important strategies changing the HIV/AIDS-related behavior. The media are used in order to promote voluntary counseling and HIV testing.
   There was an assessment of the effect that the media-based mass interventions have on people in general, as well as on specific targeted groups due to the changed scale of HIV testing, compared to the control groups. For this purpose 35 studies were analyzed. The authors conclude that interventions based on the mass-media have an immediate general effect on all groups of people. No long-term effect was registered unfortunately [Vidanapathirana J., Abramson M. J., Forbes A., Fairley C., 2005].
   A systematic review analyzed any behavior interventions aiming at reduction of sexually transmitted HIV in children aged 11–19. Compared to the control group there was success achieved in reducing the number of STDs, increasing the number of cases using condoms, reducing the frequency of, or delaying “penetrating sex”, and improving the skills for discussing safe sex with the partner. There was evidence obtained showing that comprehensive behavior interventions reduce risky sexual behavior and prevent STD cases. The more intensive and comprehensive the interventions the more efficient they are [Johnson B. T., Scott-Sheldon L. A., Huedo-Medina T. B., Carey M. P.,2011]. At the same time a meta-analysis has shown that training programs in developing countries were moderately efficient in terms of improving youngsters” behavior yet they showed no significant impact on the biological results. It will take further research to determine the factors maximizing the likelihood of success from running such programs [Medley A., Kennedy C., O’Reilly K., Sweat M., 2009]. The success criteria for interventions here include adjustment of an intervention to the culture of the ethnic or socio-economic groups for whom this intervention has been designed; employing peer-to-peer technologies while this concerns not only adolescent yet also other groups of population; training the skills for proper use of condoms and for communicating with the partner on the issues related to safe sex, as well as practical training of the same skills.
   For instance interventions aiming at heterosexual African-Americans proved efficient in reducing HIV-risky sexual behavior. This is due to the fact that all the above-mentioned criteria were taken into account in these interventions [Darbes L, Crepaz N, Lyles C, Kennedy G, Rutherford G., 2008].
   Unwanted pregnancy among adolescents is an urgent issue in the public healthcare both in developing and developed countries. In order to resolve the issue there have been numerous preventive measures and strategies tried all over the world, including sanitary education, training respective skills, and improving access to contraception. However, there is still uncertainty about the consequences such interventions may have and, therefore, the evidence body should be reviewed.
   A combination of training programs and teaching the methods of adolescent contraception, obviously, reduces the risk of unwanted adolescent pregnancy [Oringanje C., Meremikwu M. M., Eko H., Esu E., Meremikwu A., Ehiri J. E., 2009]. There have been studies held in order to investigate the efficiency of primary prevention strategies aiming at the delay of the beginning of sexual life, better pregnancy control, and reduced number of unwanted pregnancies among adolescents. Four programs for promoting abstinence and one program for sexual education in school showed an increase in the unwanted pregnancies among girls who were partners to the boys attending the program. At the same time there was a significant decrease in the number of unwanted pregnancies among the girls attending the comprehensive programs. Therefore, the existing primary prevention programs that have been assessed by experts do not lead to delayed start of sexual life yet they improve pregnancy control by girls and boys, and reduce the number of unwanted pregnancies [Di Censo A., Guyatt G., Willan A., Griffith L., 2002]. There have been new findings obtained deomnstrating the fact that some insufficiently used interventions and ways of presenting antiretroviral therapy proved significant help in overcoming the obstacles on the way ot the maximum effect of antiretroviral therapy. These interventions included antiretroviral therapy along with opioid replacement therapy. There is special interest in a combination of HIV treatment programs with a comprehensive approach that also includes programs for “harm reduction”. Enhancement and promotion of evidence-based HIV-treatment and injected drug prevention programs will require rewspective political will both from the local authoritiesa and from the international healthcare agencies [Wood E., Kerr T., Tyndall M. W., Montaner J. S., 2008].
   Nutrition and health literacy
   Certain aspects of human nutrition behavior may matter in terms of determining efficient treatment and prevention measures for such diseases as obesity, diabetes or metabolic syndrome, which depend largely on nutrition factors. Physiological factors determine the feeling of hunger, satiety and saturation, and the biological mechanism maintains purchase of food following the principle “like” or “don’t like”. The paradigm for the development of “conditional aversion to food” is related to a strong aversion reaction after a meal, which was followed with an upset stomach. Sensory factors are important determinants of appetite and the choice of foods from birth to the oldest age. Newborns demonstrate an inborn feature of accepting or rejecting food based on its taste. The progressing changes in the sensory functions related to ageing affect appetite and the joy we get from food. Food-related behavior is under the influence of many individual psychological features. These include, for instance, chronic restrictions in the diet. These psychological features can be assessed objectively using reliable psychometric methods. Various stimulators found in the external reality affect people’s nutrition behavior. The portion size is a powerful factor determining how much someone eats irrespective of hunger. The general tendency to increase the meal size that has been observed in the North America in the latest decades could have played an important role in the rapid growth of obesity cases. Socio-economic factors are also something that determines the choice of foods and food consumption in the human society. Such factors as the level of education and income determine the choice of foods and behavior so that they influence the risk of obesity. Behavioral sciences have offered a deeper understanding of many cause-and-effect relations that affect nutrition and health. Therefore, doctors and dieticians cannot neglect this important area if they really want to introduce an efficient change into the typical food of certain patients or population at large [Bellisle F., 2003]. The precursors of obesity among children are expanding with a threatening rapidity. Many local authorities have adopted policies aiming at increased physical activities in schools as a way to combat child obesity. There has been a systematic review and a meta-analysis conducted in order to determine the influence of school interventions involving physical activities on the Body Mass Index (BMI) in children. It has been shown that these interventions had no impact on the BMI despite other positive effects on health [Harris K. C., Kuramoto L. K., Schulzer M., Retallack J. E., 2009]. An average campaign in healthcare aiming at the society will make a change not more than by 5 percentage points. Besides, campaigns on healthy diet promoting fruit and vegetable consumption, avoidance of fats, and breastfeeding proved, on the average, somewhat more successful that campaign on other healthcare issues. The factors affecting efficiency are still being discussed. Therefore, the campaigns promoting healthy diet that draw people’s attention to specific behavior interventions, target groups, communication and channels, key messages, and the ways of presenting the program, feedback methods, and assessment possibility, can change human nutrition behavior [Snyder LB., 2007].
   Efficiency of programs for enhancing health literacy
   The need for educating patients and the general public in disease control causes no doubt; however there is no clear idea of the strategies for such education. These include nowadays traditional lectures, discussions, role plays, computer technologies, written material, audio-visual sources, verbal reminders, remonstrations, and model games. Educational strategies increasing the level of knowledge, reducing the level of anxiety and improving satisfaction included the use of computer technologies, audio– and video records, printed materials and demonstrations. Various educational strategies employing combinations of methods proved successful, too. Moreover, training structured in view of a specific patient’s cultural features proved to be more efficient rather than special education or just common education for everyone [Friedman A. J., Cosby R., Boyko S., Hatton-Bauer J., Turnbull G., 2011]. This also confirmed through a systematic review focusing on the efficiency of educational programs for patients with bronchial asthma. It has been proven that culture-specific programs for adults and children from minority groups, who suffer from bronchial asthma, are more efficient rather than general programs on improving life quality, knowledge of the illness, reduced acute conditions, and control of bronchial asthma [Bailey E. J., Cates C. J., Kruske S. G., Morris P. S., Brown N., Chang A. B., 2009]. This is especially relevant to ethnic minorities because the latest studies have shown that ethnic minorities with mid-higher level of income typically have a higher prevalence of Type 2 diabetes if compared to the rest of the population. Diabetic patients education adjusted in view of their cultural features has a short-term effect both on the glucose level control and on the level of the knowledge about diabetes and healthy lifestyles [Hawthorne K, Robles Y, Cannings-John R, Edwards AG., 2008]. Summarizing the systematic reviews and meta-analyses mentioned above the following conclusions can be made:
   Health literacy is among the most urgent tasks for healthcare services; efficient activities in this area will improve patients” life quality, and in some cases it also efficient in terms of preventing socially meaningful phenomena, namely alcohol abuse, tobacco smoking, HIV. All this can produce a significant socio-economic effect.
   The Internet-oriented prevention strategies are getting more and more popularity especially among youngsters.
   For the maximum efficiency preventive education technologies should be adjusted to the cultural and socio-economic features of the group, and in some cases they should be designed in view of personal features of the individual.
   Health literacy study. Stavropol example (Amlaev K. R., 2012)
   We have conducted a sociological study (questionnaire) among primary healthcare physicians.
   The doctors were offered a questionnaire. Each question came along with several answers with all the right ones to be chosen. The questionnaire forms were given to all doctors who are employed (581 specialists) within the physician profile in the healthcare institutions of the city of Stavropol. Parts of the doctors were on holidays and on sabbaticals, so only 500 of the questionnaires came back. So, 500 doctors participated (86,1 % out of the entire number of doctors employed in the physician area).
   According to the doctors” opinion they inform their patients about the illness in 91,6 % + of cases. At the same time 97,2 % of doctors inform their patients about the treatment mode, 93,2 % – about the risk factors, 87,5 % – about the importance of healthy lifestyle.
   Ss far as the informing the family was concerned, the responses came the following way: 56,4 % of doctors inform relatives about any illness the patient has if there is a chance to do so; 24,8 % of the respondents inform relatives only in case of a severe disease; 12,3 % – in case of a fatal illness; 11,4 % find informing the patient’s relatives something not required. At the same time the message provided mostly includes information on the treatment mode – 84,9 %; risk factors – 79,3 %; importance of healthy lifestyle – 60,3 %.
   89 % of doctors pay a lot of attention to shaping their patients” healthy lifestyle. However only 46,9 % of the doctors live healthy life themselves; 45 % of the respondents stick to healthy lifestyles only partially, while 6,7 % do not observe it at all.
   Most of the doctors believe they do not need information on the medical prevention and healthy lifestyle – 51,5 %, while those who need such information would like to get it from special medical literature – 66,3 %; from specialists – 52,1 %; from the Internet – 50,1 %.
   While seeing patients in the medical institution and when visiting them at home doctors take interest in their patients” lifestyles: often – 69,1 %; sometimes – 29,2 %; never – 1,7 %.
   However doctors do not give everyone individually tailored recommendations on healthy lifestyle. Only 36,7 % of the doctors offer advice to every single patient; 34,4 % of the doctors provide such information only to those who need it; 17,5 % – to those who will listen to that, another 17,5 % – to the patients only who will reveal interest; 3,3 % of the doctors give no recommendation at all.
   An important element in medical prevention is conducting medical screening. Yet 56 % of the doctors only observe the standard rules of screening, while 20,6 % of them refer to medical screening not following the standards; 18 % refer to that seldom due to lack of referrals for examination, and 1,1 % do not do that because of lack of time.
   Significant support in improving people’s health literacy and therapeutic process can be found in educational schools for patients. 23,1 % of the doctors believe that such schools do excellent or good work; 8,9 % of the respondents assessed that work as satisfactory, while 11,3 % of the doctors gave those schools a poor score; 56,7 % of the respondents could not give an answer.
   A set of questions determining the knowledge in medical prevention allowed detecting “white spots” in the doctors” awareness. It has been demonstrated that 71,8 % of them only know the order to define the Body Mass Index. Only 45 % of the respondents are aware of the age when the cholesterol level should be observed and of the frequency to do so. When asked about the frequency and the age to start test for hidden blood in the stool only 33,1 % of the doctors gave the right answer. In view of the medical-social importance of vaccination against the flu the respondents were asked respective questions on this issue. Interesting to note that only 62,9 % of the doctors do recommend the vaccination to their patients and get vaccinated themselves; 20,2 % of them recommend it to patients yet do not follow the advice themselves; 11,2 % of the doctors neither get vaccinated nor recommend it to their patients; 5,6 % do not trust the flu vaccination at all.
   One of the requirements in medical prevention is medical counseling for certain groups of people in case they would like to practice intensive physical activities. Only 63,1 % of the doctors agreed with the idea. As for the contemporary methods of treating tobacco dependency only 52,9 % are aware of them.
   All in all the respondents were given 7 questions. 0,6 % of the doctors answered all of them correctly; 6 correct answers were obtained from 7,5 % of the respondents; 5 – 24,4 %; 4 – 25,8 %; 3 – 28,3 %, 2 – 11,1 %; 2,2 % of the respondents gave no correct answer.
   · Most doctors recommend their patients should stick to healthy lifestyle (89 %), yet 46,9 % of the doctors follow that type of lifestyle.
   · At the same time the doctors do not reveal enough interest in their patients” lifestyles (69,1 %), while only 36,7 % of them offer patients individual recommendations on healthy lifestyle.
   · The quality of collecting anamnesis data should be improved – 22 % of the doctors admitted they collect just superficial data and only 56 % of the respondents follow the rules of medical screening observing the standards.
   · Patient schools are not functioning efficiently enough – 23,1 % of the doctors mentioned such work as excellent or good.
   · The quality of the knowledge of medical prevention should be brought up as only 0,6 % of the doctors demonstrated a 100 % level of awareness in this respect. However most of the doctors believe they need no information on medical prevention and healthy lifestyle (51,5 %). Those who do need it use such sources of information as lectures, special literature, and the Internet.
   Health literacy study among young Stavropolities aged 18–25 (Amlaev K. R., 2012).
   There was a survey conducted among 700 young people studying at the specialized vocational schools and higher educational institutions of Stavropol, with a specially designed questionnaire used. This was a single-stage quantitative study and a structured interview (independent filling in the questionnaire forms). The questionnaire offered the respondent one out of several answers. The young people were explained the aim of the study and offered participation. The statistics processing was done with the SPSS 12 software.
   The gender distribution among the respondents was the following way: 51,6 % – boys, 48,4 % – girls. Their age varied from 15 (3,9 %) to 25 (0,3 %). Most of the respondents belonged to the age groups of 17, 18, 19, 20 (18 %, 17,4 %, 20 %, 14,9 % respectively).
   The young people were mostly university students – 57,3 % and attended technical schools – 31,9 %; the smallest share of them were students of professional vocational schools – 6,7 %. Over half of them viewed themselves as believers – 52,2 % and “rather believers” – 31,6 %; most of them were Christians – 76,7 %. Half of them live in single-parent families – 49,6 %, while only 31 % of the respondents have both parents. Most of the young people are not indigenous to Stavropol (30,9 % of locals only), while about half of them come from rural areas of the Stavropol Region – 47 %, urban residents – 24,1 %; from other regions – 28,8 %.
   The importance of healthy lifestyle was admitted among 60 % of the respondents; 36,3 % of the respondents said it is better to live healthy lifestyle. 40,3 % of the youngsters do live that lifestyle wit h another 43,5 % trying to stick to it, and 16,2 % pay no attention to the issue. Those who believe that healthy lifestyle is important are mostly boys – 67,6 % the share of girls sticking to the same opinion being 52 %. However there are also more boys who believe healthy lifestyle does not matter – 4,3 % vs. 2,9 % among the girls.
   Believers were prevailing both among those who see the importance of health lifestyle (66,5 %) and among those who do not view it is important. Also, the highest number of those who think they should live healthy lifestyle is in the group who are Islam believers – 79,4 %.
   Boys are more “passionate” about healthy lifestyle (50,8 % against 29,3 % among girls). Girls were prevailing among those who “live healthy lifestyle rather than don’t” (53,4 % against 34,2 % of boys).
   In reality the youth do not tend to stick to healthy lifestyle as much as they claim. For instance, 47,4 % of the believing respondents fully follow healthy lifestyle while 66,5 % of the respondents claimed so. Besides, this gap between the claim and the real state of things is common for all confessions.
   The share of those who want to obtain information on healthy lifestyle from TV or radio programs is the highest among university students – 21,1 %; the second line is held by technical school students – 10,9 %; even fewer students from professional vocational schools want to learn about healthy lifestyle – 4,8 %. Girls are more prone to getting information from specialists than boys – 51,1 % and 30,3 % respectively.
   Most of the respondents believe they do not need information about healthy lifestyle (77,4 %); these exceed 3 times the number of those who want to get such information – 22,6 %. Given that the respondents mostly would like to obtain the respective information from specialists and the Internet 41 % and 37,8 % respectively.
   About half of the respondents mentioned that doctors never ask them about healthy lifestyle and prevention of socially meaningful illnesses – 43 %, while 32,4 % of the respondents said their doctors do that very seldom. Most of the respondents (65,3 %) stated they had never been given any recommendation on healthy lifestyle from doctors; 6,7 % had got such recommendations, while 15,7 % had been given general recommendations only with no details provided.
   Only 52,4 % of the young people receive annual vaccination against the flu wit h the smallest number of them being among university students – 44,7 %; in technical and professioanl scholls this index is higher – 65,9 % and 60,3 % respectively.
   Most of the respondents (63,4 %) do not know how to calculate their Body Mass Index. Less than a third of the young people know how much time should be devoted to physical activities. During that the respondents mention a time period higher than required for such activities. A significant number of the respondents have improper ideas of the flu vaccination frequency, where 17,6 % of them believe vaccination is to be taken biennially, and another 12,6 % think vaccination is to be done every three years. Only 36,3 % of the young people know what probiotics are and where they are used.
   The respondents were baffled with a question about the allowable dosage of alcohol. Over 40 % of them stated there is no such a dosage; 36,6 % could not answer and only 5,2 % of the young people provided the right answer.
   Only 37,7 % of the students could answer the questions about what colitis is. Only 38,9 % of the respondents are aware of the normal pulse rate. 33,3 % of the young people visited health centers. Yet 61,4 % of the respondents gave the right answer to the question about the aim of establishing such centers.
   More correct answers to questions related to medicine were obtained from girls; there were many more girls in the subgroups of those who answered 5, 6 or 7 questions correctly (out of eight).
   Conclusion
   · Over half of the young people believe that sticking to healthy lifestyle is important yet the number of those who do that in reality is 1,5 times as low.
   · Boys are more detailed in following healthylifestyle rules than girls. The preferred sources of information concerning healyty lifestyle for both sexes are medical specialists and the Internet. At the same time boys are not as interested as girls in getting information about healthy lifestyle from specialists.
   · The number of those who want to obtain information on healthy lifestyle from all the sources does not exceed a quarter of the respondents. Besides, doctors seldom ask yung patients about their lifestyle, and over 65 % of the respondents hever got from their doctors any recommendation on healthy lifestyle.
   · The share of the flu-vaccinated students in the educational institutions of Stavropol is above 50 %, the smallest part of that represnting universities.
   · The level of health literacy among young people is not high enough, which could be seen from the respondents” answers to medicine-related questions, including questions regarding the BMI, safe alcohol consumption, frequency of the flu-vaccination, the required level of physical activities, etc.

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Health inequity, treatment compliance, and health literacy at the local level: theoretical and practical aspects Karen Amlaev

Health inequity

Treatment compliance issues: causes and effects

Treatment compliance survey in Stavropol (Amlaev K. R., 2012)

Healthy literacy issues

Health inequity, treatment compliance, and health literacy at the local level: theoretical and practical aspects
Karen Amlaev