Socio-economic disadvantage is associated with heavier drinking in high but not middle-income countries participating in the International Alcohol Control Study.

INTRODUCTION AND AIMS: To investigate if socio-economic disadvantage, at the individual- and country-level, is associated with heavier drinking in some middle- and high-income countries. DESIGN AND METHODS: Surveys of drinkers were undertaken in some high- and middle-income countries. Participating countries were Australia, England, New Zealand, Scotland (high-income) and Peru, Thailand and Vietnam (middle-income). Disadvantage at the country-level was defined as per World Bank (categorised as middle-or high-income); individual-level measures were (i) years of education and (ii) whether and individual was under or over the poverty line in each country. Measures of heavier drinking were (i) proportion of drinkers that consumed 8+ drinks and (ii) three drinking risk groups (lower, increasing and higher). Multi-level logistic regression models were used. RESULTS: Individual-level measures of disadvantage, lower education and living in poverty, were associated with heavier drinking, consuming 8+ drinks on a typical occasion or drinking at the higher risk level, when all countries were considered together. Drinkers in the middle-income countries had a higher probability of consuming 8+ drinks on a typical occasion relative to drinkers in the high-income countries. Interactions between country-level income and individual-level disadvantage were undertaken: disadvantaged drinkers in the middle-income countries were less likely to be heavier drinkers relative to those with less disadvantage in the high-income countries. DISCUSSION AND CONCLUSIONS: Associations between socio-economic disadvantage and heavier drinking vary depending on country-level income. These findings highlight the value of exploring cross-country differences in heavier drinking and disadvantage and the importance of including country-level measurements to better elucidate relationships.

Policy-relevant behaviours predict heavier drinking and mediate the relationship with age, gender and education status: Analysis from the International Alcohol Control Study.

INTRODUCTION AND AIMS: To investigate behaviours related to four alcohol policy variables (policy-relevant behaviours) and demographic variables in relation to typical quantities of alcohol consumed on-premise in six International Alcohol Control study countries. DESIGN AND METHODS: General population surveys with drinkers using a comparable survey instrument and data analysed using path analysis in an overall model and for each country. MEASURES: typical quantities per occasion consumed on-premise; gender, age; years of education, prices paid, time of purchase, time to access alcohol and liking for alcohol advertisements. RESULTS: In the overall model younger people, males and those with fewer years of education consumed larger typical quantities. Overall lower prices paid, later time of purchase and liking for alcohol ads predicted consuming larger typical quantities; this was found in the high-income countries, less consistently in the high-middle-income countries and not in the low middle-income country. Three policy-relevant behaviours (prices paid, time of purchase, liking for alcohol ads) mediated the relationships between age, gender, education and consumption in high-income countries. DISCUSSION AND CONCLUSIONS: International Alcohol Control survey data showed a relationship between policy-relevant behaviours and typical quantities consumed and support the likely effect of policy change (trading hours, price and restrictions on marketing) on heavier drinking. The path analysis also revealed policy-relevant behaviours were significant mediating variables between the effect of age, gender and educational status on consumption. However, this relationship is clearest in high-income countries. Further research is required to understand better how circumstances in low-middle-income countries impact effects of policies.

Alcohol taxes' contribution to prices in high and middle-income countries: Data from the International Alcohol Control Study.

INTRODUCTION: Taxation is increasingly being used as an effective means of influencing behaviour in relation to harmful products. In this paper we use data from six participating countries of the International Alcohol Control Study to examine and evaluate their comparative prices and tax regimes. METHODS: We calculate taxes and prices for three high-income and three middle-income countries. The data are drawn from the International Alcohol Control survey and from the Alcohol Environment Protocol. Tax systems are described and then the rates of tax on key products presented. Comparisons are made using the Purchasing Power Parity rates. The price and purchase data from each country's International Alcohol Control survey is then used to calculate the mean percentage of retail price paid in tax weighted by actual consumption. RESULTS: Both ad valorem and specific per unit of alcohol taxation systems are represented among the six countries. The prices differ widely between countries even though presented in terms of Purchasing Power Parity. The percentage of tax in the final price also varies widely but is much lower than the 75% set by the World Health Organization as a goal for tobacco tax. CONCLUSION: There is considerable variation in tax systems and prices across countries. There is scope to increase taxation and this analysis provides comparable data, including the percentage of tax in final price, from some middle and high-income countries for consideration in policy discussion.

Drinker Types, Harm, and Policy-Related Variables: Results from the 2011 International Alcohol Control Study in New Zealand.

BACKGROUND: The aim was to identify a typology of drinkers in New Zealand based on alcohol consumption, beverage choice, and public versus private drinking locations and investigate the relationship between drinker types, harms experienced, and policy-related variables. METHODS: Model-based cluster analysis of male and female drinkers including volumes of alcohol consumed in the form of beer, wine, spirits, and ready-to-drinks (RTDs) in off- and on-premise settings. Cluster membership was then related to harm measures: alcohol dependence, self-rated health; and to 3 policy-relevant variables: liking for alcohol adverts, price paid for alcohol, and time of purchase. RESULTS: Males and females were analyzed separately. Men fell into 4 and women into 14 clearly discriminated clusters. The male clusters consumed a relatively high proportion of alcohol in the form of beer. Women had a number of small extreme clusters and some consumed mainly spirits-based RTDs, while others drank mainly wine. Those in the higher consuming clusters were more likely to have signs of alcohol dependency, to report lower satisfaction with their health, to like alcohol ads, and to have purchased late at night. CONCLUSIONS: Consumption patterns are sufficiently distinctive to identify typologies of male and female alcohol consumers. Women drinkers are more heterogeneous than men. The clusters relate differently to policy-related variables.

Purchases by heavier drinking young people concentrated in lower priced beverages: Implications for policy.

INTRODUCTION AND AIMS: Alcohol is an increasingly important risk factor in the global burden of disease. The acute harms experienced and persistence of drinking patterns established in adolescence motivate investigating influences on youth drinking. The aim is to examine association between heavier drinking in young people and their choice of beverage type, purchase outlet and price. DESIGN AND METHODS: A nationally representative sample of New Zealand drinkers (N = 1056) aged 16-19 years recruited using random digit dialling was surveyed in 2012 as part of the International Alcohol Control study. Typical quantities consumed and frequency of alcohol consumption categorised respondents into lower, medium and heavier consumption groups. Beverage choice, prices paid and on or off-premise purchase were related to consumption using univariate analysis. Logistic analysis was used to examine multivariate factors predicting membership of consumption groups. RESULTS: Twenty percent of the sample consumed six or more drinks at least once a week, increasing to 1 in 4 for those 18 years and older. Heavier drinkers consumed more alcohol in the form of ready to drinks (RTD) especially high-potency RTDs. Lower consumers drank greater proportion of wine. Heavier drinkers paid less than medium consumers who paid less than lower consumers. High-potency RTDs were cheaper per unit of alcohol than other beverages and chosen by heavier drinkers resulting in lower prices. DISCUSSION AND CONCLUSIONS: Heavy consumption of alcohol remains common in New Zealand young drinkers. Heavier drinkers paid less to purchase alcohol and consumed more alcohol in the form of high-potency RTDs. [Wall M, Casswell S, Yeh L-C. Purchases by heavier drinking young people concentrated in lower priced beverages: Implications for policy. Drug Alcohol Rev 2017;36:352-358].

How the alcohol industry relies on harmful use of alcohol and works to protect its profits.

The alcohol industry have attempted to position themselves as collaborators in alcohol policy making as a way of influencing policies away from a focus on the drivers of the harmful use of alcohol (marketing, over availability and affordability). Their framings of alcohol consumption and harms allow them to argue for ineffective measures, largely targeting heavier consumers, and against population wide measures as the latter will affect moderate drinkers. The goal of their public relations organisations is to 'promote responsible drinking'. However, analysis of data collected in the International Alcohol Control study and used to estimate how much heavier drinking occasions contribute to the alcohol market in five different countries shows the alcohol industry's reliance on the harmful use of alcohol. In higher income countries heavier drinking occasions make up approximately 50% of sales and in middle income countries it is closer to two-thirds. It is this reliance on the harmful use of alcohol which underpins the conflicting interests between the transnational alcohol corporations and public health and which militates against their involvement in the alcohol policy arena. [Caswell S, Callinan S, Chaiyasong S, Cuong PV, Kazantseva E, Bayandorj T, Huckle T, Parker K, Railton R, Wall M. How the alcohol industry relies on harmful use of alcohol and works to protect its profits. Drug Alcohol Rev 2016;35:661-664].

Policy-Relevant Behaviors Predict Heavier Drinking in Both On and Off Premises and Mediate the Relationship Between Heavier Alcohol Consumption and Age, Gender, and Socioeconomic Status-Analysis from the International Alcohol Control Study.

BACKGROUND: Our goal was to investigate the role of behaviors amenable to policy change in mediating the relationship between alcohol consumption in off and on premises, age, and 2 measures of socioeconomic status (education and income). METHODS: A cross-sectional general population survey was analyzed by using Bayesian path analysis to understand direct and mediating pathways. A total of 1,900 drinkers (past 6 months), aged 18 to 65 years, living in households with landline phones participated in the study. Measures were as follows: typical quantities of alcohol consumed per occasion, frequency of drinking, both off and on premise; gender, age groups; and years of education, personal income, prices paid, time of purchase, and liking for alcohol advertisements. RESULTS: Later times of purchase predicted larger quantities consumed (on and off premise) and more frequent drinking (on premise only). Younger people and males purchased later, and this mediated their heavier consumption. Lower prices paid predicted larger quantities consumed (on premise) and higher frequency of drinking (off premise). Younger and male respondents paid lower prices, and this mediated larger quantities consumed on premise and more frequent drinking off premise. Less well educated paid lower prices, and this mediated drinking more frequently off premise among this group. Liking for alcohol ads predicted drinking larger quantities and higher frequency both off and on premise. Younger and male respondents reported greater liking for ads, and this mediated their consumption of larger quantities and more frequent drinking both on and off premise. Those with higher income drank larger amounts on premise and more frequently on and off, but there were no mediating effects from the policy-relevant variables. CONCLUSIONS: Heavier drinking patterns by young people and those less well educated could be ameliorated by attention to alcohol policy.

A multilevel cross-lagged structural equation analysis for reciprocal relationship between social capital and health.

We investigated the reciprocal relationship between individual social capital and perceived mental and physical health in the UK. Using data from the British Household Panel Survey from 1991 to 2008, we fitted cross-lagged structural equation models that include three indicators of social capital vis. social participation, social network, and loneliness. Given that multiple measurement points (level 1) are nested within individuals (level 2), we also applied a multilevel model to allow for residual variation in the outcomes at the occasion and individual levels. Controlling for gender, age, employment status, educational attainment, marital status, household wealth, and region, our analyses suggest that social participation predicts subsequent change in perceived mental health, and vice versa. However, whilst loneliness is found to be significantly related to perceived mental and physical health, reciprocal causality is not found for perceived mental health. Furthermore, we find evidence for reverse effects with both perceived mental and physical health appearing to be the dominant causal factor with respect to the prospective level of social network. Our findings thus shed further light on the importance of social participation and social inclusion in health promotion and aid the development of more effective public health policies in the UK.

International alcohol control study: pricing data and hours of purchase predict heavier drinking.

BACKGROUND: This study reports findings from the International Alcohol Control (IAC) study that assesses the impact of alcohol control policy on consumption and policy-related behaviors. Modeled on the International Tobacco Control study that uses longitudinal surveys with comparison between countries, the baseline survey was carried out in New Zealand. This study reports analysis of the purchasing behavior respondents report separately for on- and off-premise outlets, providing validation data for both alcohol consumption and reported prices. METHODS: New Zealand is a high-income country with an adult per capita alcohol consumption (as of 2011) of 9.5 l. The survey was carried out among a nationally representative sample of drinkers. Interview data on place and time of purchase, amounts purchased, price paid, and consumption (beverage and location specific) was collected. Relationships between policy relevant variables and consumption were modeled taking into account demographic variables. Validation was provided by government data on alcohol available for consumption, aggregate expenditure and prices from the Consumer Price Index. RESULTS: Drinkers paying low prices at on- or off-licensed premises had higher odds of consuming 6+ drinks on a typical occasion, as did drinkers purchasing alcohol at later times. Regarding frequency, drinkers purchasing at later times were more likely to be daily drinkers. Lower price in off licenses but not on licenses predicted daily drinking. The data collected accounted for approximately 96% of alcohol available for consumption and the prices accounted for 98% of aggregate expenditure. CONCLUSIONS: Valid survey data were collected to give an accurate picture of alcohol consumption and prices paid by drinkers. Heavy drinkers were more likely to buy cheaper alcohol and purchase at later times; 2 policy issues under discussion in many settings. This analysis suggests the IAC study that has the potential to provide data to contribute to the debate on appropriate policy responses to reduce alcohol-related harm.

Affordability of alcohol as a key driver of alcohol demand in New Zealand: a co-integration analysis.

AIMS: To investigate whether affordability of alcohol is an important determinant of alcohol consumption along with price. This will inform effective tax policy to influence consumption. DESIGN: Co-integration analysis was used to analyse relationship between real price, affordability and consumption. Changes in retail availability of wine in 1990 and beer in 1999 were also included in the models. The econometric approach taken allows identification of short- and long-term responses. Separate analyses were performed for wine, beer, spirits and ready-to-drinks (spirits based pre-mixed drinks). SETTING: New Zealand 1988-2011. MEASUREMENTS: Quarterly data on price and alcohol available for consumption for wine, beer, spirits and ready-to-drinks. Price data were analysed as: real price (own price of alcohol relative to the price of other goods) and affordability (average earnings relative to own price). FINDINGS: There was strong evidence for co-integration between wine and beer consumption and affordability. There was weaker evidence for co-integration between consumption and real price. CONCLUSIONS: The affordability of alcohol is more important than real price in determining consumption of alcohol. This suggests that affordability needs to be considered by policy makers when determining tax and pricing policies to reduce alcohol-related harm.

The Well London program--a cluster randomized trial of community engagement for improving health behaviors and mental wellbeing: baseline survey results.

BACKGROUND: The Well London program used community engagement, complemented by changes to the physical and social neighborhood environment, to improve physical activity levels, healthy eating, and mental wellbeing in the most deprived communities in London. The effectiveness of Well London is being evaluated in a pair-matched cluster randomized trial (CRT). The baseline survey data are reported here. METHODS: The CRT involved 20 matched pairs of intervention and control communities (defined as UK census lower super output areas (LSOAs); ranked in the 11% most deprived LSOAs in London by the English Indices of Multiple Deprivation) across 20 London boroughs. The primary trial outcomes, sociodemographic information, and environmental neighbourhood characteristics were assessed in three quantitative components within the Well London CRT at baseline: a cross-sectional, interviewer-administered adult household survey; a self-completed, school-based adolescent questionnaire; a fieldworker completed neighborhood environmental audit. Baseline data collection occurred in 2008. Physical activity, healthy eating, and mental wellbeing were assessed using standardized, validated questionnaire tools. Multiple imputation was used to account for missing data in the outcomes and other variables in the adult and adolescent surveys. RESULTS: There were 4,107 adults and 1,214 adolescent respondents in the baseline surveys. The intervention and control areas were broadly comparable with respect to the primary outcomes and key sociodemographic characteristics. The environmental characteristics of the intervention and control neighborhoods were broadly similar. There was greater between-cluster variation in the primary outcomes in the adult population compared to the adolescent population. Levels of healthy eating, smoking, and self-reported anxiety/depression were similar in the Well London adult population and the national Health Survey for England. Levels of physical activity were higher in the Well London adult population but this is likely to be due to the different measurement tools used in the two surveys. CONCLUSIONS: Randomization of social interventions such as Well London is acceptable and feasible and in this study the intervention and control arms are well-balanced with respect to the primary outcomes and key sociodemographic characteristics. The matched design has improved the statistical efficiency of the study amongst adults but less so amongst adolescents. Follow-up data collection will be completed 2012.

The International Alcohol Control (IAC) study-evaluating the impact of alcohol policies.

BACKGROUND: This paper describes a new multicountry collaborative project to assess the impact of alcohol control policy. Longitudinal surveys of drinkers in a number of participating countries and analysis of the policy context allow for the assessment of change over time within countries and comparison between countries. The design of the study is modeled on the International Tobacco Control study and aims to assess the impact of alcohol policies in different cultural contexts on policy-related behaviors and alcohol consumption. A survey instrument and protocol for policy analysis have been developed by the initial participating countries: England, Scotland, Thailand, South Korea, and New Zealand. The first round of data collection is scheduled for 2011-2012. MEASUREMENTS: The survey instrument (International Alcohol Control [IAC] survey) measures key policy relevant behaviors: place and time of purchase, amounts purchased and price paid; ease of access to alcohol purchase; alcohol marketing measures; social supply; perceptions of alcohol affordability and availability and salience of price; perceptions of enforcement; people's experiences with specific alcohol restrictions; support for policy and consumption (typical quantity, frequency using beverage and location-specific measures). The Policy Analysis Protocol (PoLAP) assesses relevant aspects of the policy environment including regulation and implementation. RESULTS: It has proved feasible to design instruments to collect detailed data on behaviors relevant to alcohol policy change and to assess the policy environment in different cultural settings. CONCLUSIONS: In a policy arena in which the interest groups and stakeholders have different perceptions of appropriate policy responses to alcohol-related harm, a robust methodology to assess the impact of policy will contribute to the debate.

Sex, drugs and economic behaviour in Russia: a study of socio-economic characteristics of high risk populations.

BACKGROUND: Russia faces a worsening IDU/HIV epidemic. This paper examines the social and economic characteristics of injecting drug users in two cities in Russia and compares this with the general population to explore their social and economic needs and the wider implications of the epidemic for the economy and society. METHODS: A cross sectional survey of 711 IDUs in two Russian cities (Volgograd and Barnaul) recruited by a modified chain referral sampling method. Respondents were asked about their education, work, living conditions, expenditure on goods and services and livelihoods. Their characteristics were compared with a random sample of the general population. RESULTS: There are a number of characteristics, in which IDUs do not differ systematically from the general population. They have general education; live in the towns where they were born; and their monthly income is comparable with the Russian average. However, IDUs are more likely to have a vocational qualification than a university degree; less likely to have a permanent job; and those employed are skilled manual rather than professional workers. IDUs are less likely to be officially married and more likely to be living with their parents or on their own. The majority rely on financial help from relatives or friends; and much of their income is from illegal or semi-legal activities. CONCLUSION: IDUs are not atypical or marginal to the Russian economy and society. However, their drug-dependency and related life-style make them particularly vulnerable to the impact of poverty, violence and social insecurity. A failure to effectively control the dual IDU/HIV epidemic can have a significant negative impact on the Russian labour force, health and social costs and overall economy.

Why do health systems matter? Exploring links between health systems and HIV response: a case study from Russia.

INTRODUCTION: Studies on the relevance of stronger health systems to the success of vertical programmes has focused mainly on developing countries with fragile infrastructures and limited human resources. Research in middle-income, and particularly post-Soviet, settings has been scarce. This article examines the relationships between health system characteristics and the HIV response in Russia, the country which towards the end of the Soviet period had the world's highest ratios of doctors and hospital beds to population and yet struggled to address the growing threat of HIV/AIDS. METHODS: The study is based on semi-structured qualitative interviews with policy-makers and senior health care managers in two Russian regions, and a review of published and unpublished sources on health systems and HIV in Russia. FINDINGS: We identified a number of factors associated with the system's failure to address the epidemic. We argue that these factors are not unique to HIV/AIDS. The features of the wider health system within which the HIV response was set up influenced the structure and capacities of the programme, particularly its regulatory and clinical orientation; the discrepancy between formal commitments and implementation; the focus on screening services; and problems with scaling up interventions targeting high-risk groups. DISCUSSION: The system-programme interplay is as important in middle-income countries as in poorer settings. An advanced health care infrastructure cannot protect health systems from potential failures in the delivery of vertical programmes. The HIV response cannot be effective, efficient and responsive to the needs of the population if the broader health system does not adhere to the same principles. Strengthening HIV responses in post-Soviet societies will require improvements in their wider health systems, namely advocacy of prevention for high-risk populations, reallocation of resources from curative towards preventive services, building decision-making capacities at the local level, and developing better working environments for health care staff.

Evaluation of community level interventions to address social and structural determinants of health: a cluster randomised controlled trial.

BACKGROUND: In London and the rest of the UK, diseases associated with poor diet, inadequate physical activity and mental illness account for a large proportion of area based health inequality. There is a lack of evidence on interventions promoting healthier behaviours especially in marginalised populations, at a structural or ecological level and utilising a community development approach.The Well London project financed by the Big Lottery 'Wellbeing' Fund and implemented by a consortium of London based agencies led by the Greater London Authority and the London Health Commission is implementing a set of complex interventions across 20 deprived areas of London. The interventions focus on healthy eating, healthy physical activity and mental health and wellbeing and are designed and executed with community participation complementing existing facilities and services. METHODS/DESIGN: The programme will be evaluated through a cluster randomised controlled trial. Forty areas across London were chosen based on deprivation scores. Areas were characterised by high proportion of Black and Minority Ethnic residents, worklessness, ill-health and poor physical environments. Twenty areas were randomly assigned to the intervention arm of Well London project and twenty 'matched' areas assigned as controls. Measures of physical activity, diet and mental health are collected at start and end of the project and compared to assess impact.The quantitative element will be complemented by a longitudinal qualitative study elucidating pathways of influence between intervention activities and health outcomes. A related element of the study investigates the health-related aspects of the structural and ecological characteristics of the project areas. The project 'process' will also be evaluated. DISCUSSION: The size of the project and the fact that the interventions are 'complex' in the sense that firstly, there are a number of interacting components with a wide range of groups and organisational levels targeted by the intervention, and secondly, a degree of flexibility or tailoring of the intervention, makes this trial potentially very useful in providing evidence of the types of activities that can be used to address chronic health problems in communities suffering from multiple deprivation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN68175121.

Ethnic disparities in coronary heart disease management and pay for performance in the UK.

BACKGROUND: Few pay for performance schemes have been subject to rigorous evaluation, and their impact on disparities in chronic disease management is uncertain. OBJECTIVE: To examine disparities in coronary heart disease management and intermediate clinical outcomes within a multiethnic population before and after the introduction of a major pay for performance initiative in April 2004. DESIGN: Comparison of two cross-sectional surveys using electronic general practice records. SETTING: Thirty-two family practices in south London, United Kingdom (UK). PATIENTS: Two thousand eight hundred and ninety-one individuals with coronary heart disease registered with participating practices in 2003 and 3,101 in 2005. MEASUREMENTS: Percentage achievement by ethnic group of quality indicators in the management of coronary heart disease RESULTS: The proportion of patients reaching national treatment targets increased significantly for blood pressure (51.2% to 58.9%) and total cholesterol (65.7% to 73.8%) after the implementation of a major pay for performance initiative in April 2004. Improvements in blood pressure control were greater in the black group compared to whites, with disparities evident at baseline being attenuated (black 54.8% vs. white 58.3% reaching target in 2005). Lower recording of blood pressure in the south Asian group evident in 2003 was attenuated in 2005. Statin prescribing remained significantly lower (p < 0.001) in the black group compared with the south Asian and white groups after the implementation of pay for performance (black 74.8%, south Asian 83.8%, white 80.2% in 2005). CONCLUSIONS: The introduction of pay for performance incentives in UK primary care has been associated with better and more equitable management of coronary heart disease across ethnic groups.

Methods to recruit hard-to-reach groups: comparing two chain referral sampling methods of recruiting injecting drug users across nine studies in Russia and Estonia.

Evidence suggests rapid diffusion of injecting drug use and associated outbreaks of HIV among injecting drug users (IDUs) in the Russian Federation and Eastern Europe. There remains a need for research among non-treatment and community-recruited samples of IDUs to better estimate the dynamics of HIV transmission and to improve treatment and health services access. We compare two sampling methodologies "respondent-driven sampling" (RDS) and chain referral sampling using "indigenous field workers" (IFS) to investigate the relative effectiveness of RDS to reach more marginal and hard-to-reach groups and perhaps to include those with the riskiest behaviour around HIV transmission. We evaluate the relative efficiency of RDS to recruit a lower cost sample in comparison to IFS. We also provide a theoretical comparison of the two approaches. We draw upon nine community-recruited surveys of IDUs undertaken in the Russian Federation and Estonia between 2001 and 2005 that used either IFS or RDS. Sampling effects on the demographic composition and injecting risk behaviours of the samples generated are compared using multivariate analysis. Our findings suggest that RDS does not appear to recruit more marginalised sections of the IDU community nor those engaging in riskier injecting behaviours in comparison with IFS. RDS appears to have practical advantages over IFS in the implementation of fieldwork in terms of greater recruitment efficiency and safety of field workers, but at a greater cost. Further research is needed to assess how the practicalities of implementing RDS in the field compromises the requirements mandated by the theoretical guidelines of RDS for adjusting the sample estimates to obtain estimates of the wider IDU population.

Sexual behaviour in Russia: who exhibits a higher risk? Evidence from longitudinal data.

The object of the paper is to assess the social and economic determinants of 'risky' sexual behaviour in Russia. We used secondary data from a nationally representative survey of 6168 persons between the ages of 14 and 49 years conducted in 2001 and 2003. Sexual risk is defined as having had unprotected (without a condom) penetrative sexual intercourse with two or more partners in the 12 months preceding the survey. The analysis uses a multivariate random effects model. There was a significant reduction in sexually risky behaviour between 2001 and 2003. Men and those employed exhibited significantly greater risk as did those between the ages of 25 and 44 years. Those who considered themselves economically secure also were significantly more likely to have had risky sexual contacts in the year before the survey. Those with only a basic education were significantly less likely to exhibit such behaviour. Those at highest risk in Russia of contracting sexually transmitted diseases (STDs) including HIV are not in marginal or socially excluded groups but instead are part of the core economically active population.