Social capital, gender and self-rated health. Evidence from the Moscow Health Survey 2004

Abstract

The state of public health in Russia is undoubtedly poor compared with other European countries. The health crisis that has characterised the transition period has been attributed to a number of factors, with an increasing interest being focused on the impact of social capital - or the lack of it. However, there have been relatively few studies of the relation between social capital and health in Russia, and especially in Moscow. The aim of this study is to examine the relationship between social capital and self-rated health in Greater Moscow. The study draws on data from the Moscow Health Survey 2004, where 1190 Muscovites were interviewed. Our results indicate that among women, there is no relationship between any form of social capital and self-rated health. However, an association was detected between social capital outside the family and men's self-rated health. Men who rarely or never visit friends and acquaintances are significantly more likely to report less than good health than those who visit more often. Likewise, men who are not members of any voluntary associations have significantly higher odds of reporting poorer health than those who are, while social capital in the family does not seem to be of importance at all. We suggest that these findings might be due to the different gender roles in Russia, and the different socializing patterns and values embedded in them. In addition, different forms of social capital provide access to different forms of resources, influence, and support. They also imply different obligations. These differences are highly relevant for health outcomes, both in Moscow and elsewhere.

Full text

Social capital, gender and self-rated health. Evidence from the Moscow
Health Survey 2004
q
Sara Ferlander
*
, Ilkka Henrik Ma
¨kinen
Stockholm Centre on Health of Societies in Transition, So
¨derto
¨rn University, Huddinge, Sweden
article info
Article history:
Available online 10 September 2009
Keywords:
Family
Friends
Gender
Moscow
Russia
Self-rated health
Social capital
Social networks
Voluntary associations
abstract
The state of public health in Russia is undoubtedly poor compared with other European countries. The
health crisis that has characterised the transition period has been attributed to a number of factors, with
an increasing interest being focused on the impact of social capital – or the lack of it. However, there have
been relatively few studies of the relation between social capital and health in Russia, and especially in
Moscow. The aim of this study is to examine the relationship between social capital and self-rated health
in Greater Moscow. The study draws on data from the Moscow Health Survey 2004, where 1190
Muscovites were interviewed. Our results indicate that among women, there is no relationship between
any form of social capital and self-rated health. However, an association was detected between social
capital outside the family and men’s self-rated health. Men who rarely or never visit friends and
acquaintances are significantly more likely to report less than good health than those who visit more
often. Likewise, men who are not members of any voluntary associations have significantly higher odds
of reporting poorer health than those who are, while social capital in the family does not seem to be of
importance at all. We suggest that these findings might be due to the different gender roles in Russia, and
the different socializing patterns and values embedded in them. In addition, different forms of social
capital provide access to different forms of resources, influence, and support. They also imply different
obligations. These differences are highly relevant for health outcomes, both in Moscow and elsewhere.
Ó2009 Elsevier Ltd. All rights reserved.
Introduction
The fall of communism in Russia has been followed by
a dramatic deterioration in public health, both as regards mortality
(Brainerd & Cutler, 2005) and self-rated health (Carlson, 2000).
Compared with 1989, life expectancy at birth has declined by 3.8
years for men and 1.3 years for women and the gender gap has
grown by 2.5 years during this period. In 2006, life expectancy at
birth was 60.5 years for men and 73.3 for women. For men and
women combined, it lags 13.6 years behind the average of the EU
countries (European Health for All Database, WHO, 2009). In
a study of 18 countries, based on surveys conducted in 1995–1997,
Carlson (2004) found that Russians and Ukrainians felt least
healthy in Europe, with 72 percent of Russians reporting being in
poor health. In 2000, Rose (2003) found that 63 percent of Russians
reported less than good health. Like mortality, self-ratedhealth also
differs by gender, however, with more women than men reporting
poor health (Bobak, Pikhart, Hertzman, Rose, & Marmot, 1998;
Carlson, 2004).
The average health status also varies between different
regions in Russia. Urban areas have had the largest falls in life
expectancy, and these areas have been heavily exposed to the
effects of the transition, and are characterised by high crime rates
and higher but unequally distributed household incomes (Wa l-
berg, McKee, Shkolnikov, Chenet, & Leon, 1998). Moscow has
been the engine of the Russian transition. It is deeply involved in
the global economy and economically far ahead of the rest of the
country (Medvedkov & Medvedkov, 2005). However, Moscow is
q
We would like to offer our deepest thanks to the interviewers in Moscow, the
1190 Muscovites who kindly agreed to participate in the survey, and to our Russian
colleagues – Dr Olga Kislitsyna, Dr Ludmila Migranova and Professor Natalia
Rimashevskaya – at the Institute of Social and Economic Studies of Population
(ISESP) for their excellent collaborative work on the Moscow Health Survey. We
would also like to thank Associate Professor Per Carlson at the Mid-Sweden
University and Dr Kesi Mahendran at the Open University, UK, as well as our
colleagues from the Stockholm Centre on Health of Societies in Transition at the
So
¨derto
¨rn University – Professor Denny Vågero
¨, Dr Andrew Stickley, PhD-student
Tanya Jukkala, Associate Professor Michael Gentile and Dr Mall Leinsalu – for their
help and valuable comments to earlier versions of this article. Thanks also go to
Judith Black and Professor Duncan Timms for their English corrections. Finally, we
want to thank the anonymous reviewers for their detailed comments. This research
has been funded by the Swedish Foundation for Baltic and East European Studies
and the Royal Swedish Academy of Sciences.
*Corresponding author.
E-mail address: sara.ferlander@sh.se (S. Ferlander).
Contents lists available at ScienceDirect
Social Science & Medicine
journal homepage: www.elsevier.com/locate/socscimed
0277-9536/$ – see front matter Ó2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.socscimed.2009.08.009
Social Science & Medicine 69 (2009) 1323–1332

also characterised by high levels of social and economic
inequality (Goskomstat, 20 03; Kolossov & O’Loughlin, 2004).
Despite living in the richest city in Russia, many Muscovites
experience severe economic problems (Secor & O’Loughlin,
2005). Registered crime rates have also increased greatly –
almost threefold – since 1990 (Rosstat, 2006), and according to
the World-Wide Quality of Life Survey (2005) Moscow is
considered one of the unsafest cities in the world.
The Russian health crisis has been related to a number of factors,
such as health-related behaviours (Cockerham, 1999), e.g. alcohol
consumption (Leon et al., 2007), crime (Walberg et al., 1998), the
economy (Carlson, 1998), and social factors, such as social capital
(Kennedy, Kawachi, & Brainerd, 1998; Rose, 2000). Kennedy et al.
(1998) found that Russian regions with low average levels of social
capital had lower life expectancies than others, while Rose (2000),
studying individuals, found a positive relationship between the
possession of social capital and self-rated health in Russia.
However, there have been relatively few studies of the relation
between social capital and health in the transition countries of
Eastern Europe including Russia (D’Hombres, Rocco, Suhrcke, &
McKee, in press). To the best of our knowledge there have been no
studies of the relationship between the two in Moscow since
McKeehan (2000) and Palosuo (2000) conducted studies there in
1991, the last year of Soviet rule.
Social capital
Social capital has in recent decades become one of the most
popular issues in the social sciences. The concept is widely used in
sociology, political science, economics, education, and, more
recently, public health. The interest in social capital is often asso-
ciated with the works of Bourdieu (1986), Coleman (1988) and
Putnam (1993). Despite their differences, they all see social capital
as a resource accessed through social relationships. Bourdieu
(1986) defines social capital as ‘‘the actual or potential resources
which are linked to possession of a durable network of more or less
institutionalised relationships of mutual acquaintances and
recognition – or in other words, to membership of a group’’ (p. 248).
Putnam (2000) argues that ‘‘the core idea of social capital is that
social networks have a value.social contacts affect the produc-
tivity of individuals and groups’’ (pp. 18–19).
Two main approaches to social capital can be identified. The
first one focuses on how individuals gain rewards, such as
support and job opportunities, through access to social networks
(Bourdieu, 1986; Coleman, 1988; Granovetter, 1973). However, it
has also been argued that by equating social capital with social
networks and social support one may simply be ‘pouring old
wine into new bottles’ (Kawachi, Kim, Coutts, & Subramanian,
2004). Over time, the concept of social capital has been expanded
and been used at the collective level, including elements such as
generalised social trust (Kennedy et al., 1998; Putnam, 1993).
Portes (1998), however, has argued that social capital as
a collective property is simultaneously both cause and effect.
Woolcook (1998) therefore emphasises that social capital should
be defined by its sources, the social connections, rather than its
effects such as, for example, trust. Nevertheless, disregarding the
debate on whether social capital is a property of individuals or
collectives, many scholars argue that it can be both (Kawachi,
2006). As noted by Lin (2001), social relations can be beneficial
(or harmful) both for the individual and the collective. In this
study, social capital is seen as a resource, individual or
communal, that is accessed via various forms of social network.
However, the concept is measured from an individual perspec-
tive: Muscovites’ personal social contacts are investigated in
relation to their self-rated health.
Different forms of social capital
There are many different forms of social capital. A common
distinction is made between informal and formal social capital
(Ferlander, 2007; Putnam, 20 00; Rose, 1998). Informal social capital
is characterised by casual contacts with family and friends, while
formal social capital comprises rule-bound networks, such as
voluntary associations. Among informal networks, a further
distinction can be made between contacts within and outside the
family (Stone, 2001).
Family relations are often described as the main form of social
capital (Bourdieu, 1994; Coleman, 1991). However, there is some
evidence of a decline in family-based social capital, at least in the
West, and the growing importance of friendship ties (Field, 2008).
Pahl and Spencer (1997) emphasize the significance of friends, as
‘‘they are voluntarily chosen; they are developed not given, and they
help to strengthen our own distinctive individuality’’ (pp. 102–103).
While Bourdieu and Coleman portray ‘strong ties’,
1
and especially
those in the family, as the mainforms of social capital, Putnam (1993),
especially in his early work, has focused on more formal varieties
outside the family, such as the weaker ties accessed through volun-
tary associations. In his more recent work, however, he has included
more informal forms of social capital, within and outside the family,
such as family, friends, and neighbours (Putnam, 2000).
Social capital and gender
Gender has been largely missing from the social capital litera-
ture. It has, for example, been more or less ignored by Bourdieu
(1986), Coleman (1988), and Putnam (1993), the main scholars of
social capital. However, recent studies have investigated the issue
and found gender differences in social capital. Women tend to have
access to more informal and family-based social capital than men
(Caiazza & Gault, 2006; Gidengil, Goodyear-Grant, Nevitte, & Blais,
2006). According to Moore (1990) there is also a gender difference
in the nature of informal networks to the effect that men’s
networks contain more co-workers and friends, while women’s
tend to be more family-oriented. Spending more time on domestic
work and childcare, women may be less involved in socializing
outside the family.
Based on a study of more than fifty countries, Norris and
Inglehart (2006) found that men were more likely than women to
join formal organisations in all types of societies. Lowndes (2006),
however, found that British men and women have similar levels of
associational involvement. In contrast to the question of the level of
involvement, there is more agreement concerning the fact that men
and women belong to different types of organisations. Associations
related to sports and recreation are preferred by men, while women
tend to predominate in associations related to education, religion
and social services, i.e. in organisations related to traditional female
roles (Gidengil & O’Neill, 2006a). Regarding the roles held within
voluntary associations, men are more likely to occupy strategic
positions, such as committee posts, while women tend to dominate
in traditional roles of visiting, befriending, and parental activities
(Lowndes, 2006). Additionally, women’s contacts within voluntary
associations are usually more homogeneous than men’s. There is
a general prevalence of same-gender contacts, but women’s
1
Strong ties are intimate ties among people who are emotionally close to each
other, such as immediate family and close friends. Weak ties, on the other hand,
refer to ties among people who are emotionally distant from each other, such as
acquaintances. For a discussion of strong and weak ties, including their health
effects, see Ferlander (2007). For a further discussion concerning the strength of
weak ties in general, see Granovetter (1973).
S. Ferlander, I.H. Ma
¨kinen / Social Science & Medicine 69 (2009) 1323–13321324

contacts are also demographically less diverse than men’s, possibly
due to men’s more strategic positions in many social spheres
(Gidengil et al., 2006). Thus, women’s ties are less likely than men’s
to be diverse and rich in information (Popielarz, 1999).
Social capital may not be equally beneficial for men and women.
It has been suggested that men utilise their contacts to their
advantage better than women do, e.g. in terms of job prospects,
career advancement, or access to diverse information. It has, for
instance, been found that men, possessing similar levels of social
capital to women, tend to possess more political knowledge
(Gidengil et al., 2006). According to Gidengil and O’Neill (2006b),
women disproportionately bear the cost of creating social capital,
while deriving fewer of its benefits than men. Their friendships
focus on intimacy and disclosure, while men’s tend to emphasize
sociability and activity (Shye, Mullooly, Freeborn, & Pope, 1995).
Studies have also shown that women both provide and receive
more support from their networks than do men (Antonucci &
Akiyama, 1987). Whereas women tend to emphasize values like
care-taking, empathy, sacrifice, and cooperation, men generally
focus on values such as rationalism, competition, and objectivity
(Caiazza & Gault, 2006). To sum up, it has been argued that for
women social capital tends to be an asset for ‘getting by’, whereas
for men it is an asset for ‘getting ahead’ (Lowndes, 2006).
Social capital and health
Analysis at both the individual (Rose, 2000) and societal levels
(Wilkinson, 1996) shows that social capital and health are associ-
ated. Social capital has been empirically linked to both mortality
(Brainerd & Cutler, 2005) and self-rated health status (Carlson,
2000; D’Hombres et al., in press). In their systematic literature
review, Kim, Subramanian, and Kawachi (2008) found consistent
evidence of a relationship between social capital and physical
health, especially self-rated health. However, a few studies have
found no relationship between the two (Subramanian, Kim, &
Kawachi, 2002; Veenstra, 2000). Although there are numerous
empirical studies of the association between social capital and
health, not many have investigated the mechanisms underlying the
relationship between the two. Social influence and various forms of
social support have often been described as the potential mecha-
nisms, affecting health through behavioural and psychological
pathways, such as healthy behaviours, stress reduction, promotion
of personal control and a sense of belonging (Berkman & Glass,
2000; Ferlander, 2007).
Different forms of social capital and health
In relation to health, social capital has mainly been considered
as being constituted of informal, strong social ties, such as
connections with family and close friends, which have been
thought to be beneficial for health (Furstenberg & Kaplan, 2004;
Lynch, Due, Muntaner, & Smith, 2000). In their classic work, Brown
and Harris (1978) found that women who have a close confidant
during traumatic life events are less likely to become depressed.
Marriage, one of the most intimate bonds between people, is the
type of social tie that has been most studied in relation to mortality
(Shye et al., 1995). A number of studies in Western countries have
shown that unmarried people, especially men, have higher
mortality rates than those who are married (Rosengren, Wedel, &
Wilhelmsen, 1989). However, Carlson (2004) found no association
between marital status and self-rated health in his study of Euro-
pean countries.
In general, informal family connections may be good for one’s
health because they can provide sources of emotional and instru-
mental support, such as having someone to talk to about personal
problems and/or borrow money from. These forms of support
mechanisms may affect health positively through stress reduction
and by providing a sense of belonging (Berkman & Glass, 2000;
Ferlander, 2007; Wellman & Frank, 2001). However, strong
informal ties can in some cases also be a source of strain, leading to
conflict, disappointment, and poor health (Due, Holstein, Lund,
Modvig, & Avlund, 1999). They can, for instance, create excessive
demands as regards providing support for others, resulting in
feelings of obligation and distress, and to expectations of confor-
mity, resulting in restrictions on individual freedom (Ferlander,
2007; Portes, 1998). Moreover, closed networks with few external
links and high levels of social influence can also promote unhealthy
behaviours, such as tobacco and alcohol consumption (Berkman,
Glass, Brissette, & Seeman, 2000). Jukkala, Ma
¨kinen, Kislitsyna,
Ferlander, and Vågero
¨(2008) have recently found a positive rela-
tionship between contacts with friends and hard drinking among
women in Moscow.
Empirical evidence concerning the relationship between
participation in formal associations and health is mixed. For
instance, Hyyppa
¨and Ma
¨ki (2001) found a positive relationship
between membership of religious associations and self-rated
health in Finland, while Veenstra (2000) found no association
between participation in voluntary associations and the same in
Canada. In their study of eight transition countries, D’Hombres et al.
(in press) found no significant relation between membership of
organisations and self-rated health. Likewise, in Russia, Rose (2000)
found no association between membership of voluntary associa-
tions and self-rated health, while Carlson (2001) did find a positive
relationship between membership of formal organisations and
Russians’ self-rated health.
Formal ties outside the family tend to build up civic skills and
give access to formal support, such as medical services. Putnam
(1993) argues that voluntary associations create an ‘equivalent
status and power’ among their members, which facilitates coop-
eration and also the creation and maintenance of social capital.
According to Prestby, Wandersman, and Florin (1990), membership
in voluntary associations provides benefits such as information,
company, status, and group identity. Information exchange and the
so-called ‘opportunity-based mechanisms’ are important features
within these networks, since they may have indirect health benefits
by, for instance, facilitating access to career opportunities (Fer-
lander, 2007). They may also promote healthy norms of behaviour.
Weitzman and Kawachi (2000) found that participation in volun-
tary activities had a preventive effect on binge drinking in the
American college setting, while Lindstro
¨m and Isacsson (2002)
have found a positive relationship between participation in asso-
ciations and smoking cessation.
Social capital and health – gender differences
Like other benefits, it has been argued that women do not
always get the same health benefits from their social networks as
men (Antonucci & Akiyama, 1987). Some studies have found that
social capital is related to health and mortality for men, but not for
women. While studying a number of European countries, Carlson
(2004) found that men with no organisational activity showed
higher odds of reporting less than good health than men who were
active in voluntary associations. In their Finnish study, Kaplan et al.
(1988) found a strong relation between social connections, both
informal and formal, and men’s mortality from all causes, including
both cardiovascular disease and ischaemic heart disease. Men with
few connections had an increased mortality risk compared with
those who had many. House, Robbins, and Metzner (1982) found
that American men who reported having more social relationships
and undertaking more activities were less likely to die. No
S. Ferlander, I.H. Ma
¨kinen / Social Science & Medicine 69 (2009) 1323–1332 1325

significant associations were found for women in any of these
exemplified studies.
Given women’s greater emotional involvement, their care-
giving and supportive roles in networks may be a strain on their
health. Social relationships may sometimes constitute an emotional
burden, especially for the support provider, who is often a woman
(Antonucci & Akiyama, 1987). It has been found that women are
often highly involved in the stress of others, and thus experience
more stress than men (Sarason, Sarason, & Gurung, 1997; Shye
et al., 1995).
Social capital in the Soviet era and in contemporary Russia
During the Soviet era, one of the distinctive features of Russian
society was a lack of civil society (Evans, 2006). Ordinary citizens
developed strategies to deal with this by investing in informal
social capital as a ‘currency’ (Busse, 2001), so-called ‘blat’, defined
as ‘‘the use of personal networks and informal contacts to obtain
goods and services in short supply and to find a way around formal
procedures’’ (Ledeneva, 1998, p. 1). Rose (1995) compared Soviet
society to an ‘hour-glass’ where informal networks constitute the
base and the formal institutions the top, with few links between
them.
Although the Soviet regime has collapsed, some maintain that
contemporary Russia still lacks a civil society (Marsh, 2000).
However, although a number of Soviet monopoly social organisa-
tions constructed by the state still exist, new non-governmental
organisations (NGOs) are emerging in Russia, especially in cities
(Evans, Henry, & McIntosh Sundstrom, 2006). In January 2005,
more than 145,000 registered organisations existed in the country
(Russian Statistical Yearbook, 2006). According to Twigg (2003),
Moscow has the highest number of NGOs in Russia. Nevertheless,
the level of trust in formal institutions, social and political, is
extremely low among Muscovites (Stickley, Ferlander, Jukkala,
Carlson, Kislitsyna & Ma
¨kinen, 2009). Moreover, Russians are
generally reluctant to participate in formal organisations (Evans
et al., 2006). Carlson (2004) found that only 15 percent of the
population were active in voluntary organisations in 1995–1997,
compared to 31 percent in the countries of Central and Eastern
Europe and 52 percent in Western Europe. The low membership
figures of 1995–1997 fell still further by 1999 (Howard, 2003).
Based on a study in 2000, Rose (2003) argued that 90 percent of
Russians do not belong to any organisations. A year later, D’Hom-
bres et al. (in press) found that only seven percent of Russians
belonged to any formal organisations.
It has been argued that many Russians today continue to use
informal social networks, which to some degree substitute for
formal organisations (Evans et al., 2006; Rose, 1998; Twigg &
Schecter, 2003). Marsh (2000) argues that ‘blat’ networks may still
be a ‘‘distinctive Russian form of social capital’’ (p. 187). Russians
continue to turn to their family, friends and acquaintances for
support and favours. Ledeneva (1998) has found that there is even
more of a tendency to rely on family members than on friends. It
has been argued that the importance of the family has persisted in
post-Soviet Russia (Piirainen, 1997), especially in rural areas
(Wegren, 2006). Also, as elsewhere (Moore, 1990), the family may
be more important for Russian women than for men. Domestic
gender roles are highly traditional in Russia, with women under-
taking the overwhelming majority of domestic work and child-
caring duties (Ashwin & Lytkina, 20 04; Vannoy et al., 1999). Despite
some changes in social roles generated by social change, the
patriarchal type of family relationship remains dominant and has
even increased (Rimashevskaya, 2003).
Regardless of the suggested importance of the family in Russia,
there has been a clear trend toward smaller families akin to that
found in many European countries, accompanied by decreasing
marriage rates and increasing divorce rates (Rimashevskaya, 2003).
This might be detrimental, as the most vulnerable groups in
a society with a lack of civic structures are those who lack informal
contacts (Kennedy et al., 1998). This notion is supported by Bobak
et al. (1998), who found that Russians without access to informal
structures also report poorer health than others. However, in
contrast to many studies in the West, it is worth noting that
marriage has not been found to be a statistically significant
predictor of self-rated health in Russia (Bobak et al., 1998; Cock-
erham, 1999).
Aim of the study
The current study aims to examine the relationship between
social capital and self-rated health in Greater Moscow. The role of
gender differences in the relationship between the two will also be
examined. More specifically, the interest here lies in the association
between different forms of social capital, informal and formal social
capital on the one hand, family-based social capital and social
capital outside the family on the other, and their relationship with
the self-rated health of Muscovites. The hypotheses to be exam-
ined, based on the previous literature, can be summarised as
follows:
1. Informal family-based social capital can be expected to be
mainly positively related to self-rated health due to both social
support mechanisms (emotional and instrumental support)
and psychological pathways, such as stress reduction and
a sense of belonging.
2. However, a gender difference in this relationship may also be
expected. Informal family-based social capital may be less
positively (or even negatively) related to self-rated health
among women due to the embedded obligation of providing
support, the decrease in personal control, and feelings of
distress.
3. For men at least, both formal and informal social capital outside
the family can be expected to be positively related to self-rated
health mainly through social support and opportunity-based
mechanisms, such as social companionship and information
exchange, and psychological pathways, such as stress reduc-
tion, promotion of personal control, and a sense of belonging.
Data and methods
The Moscow Health Survey 2004 is the result of a collaborative
project between the Stockholm Centre on Health of Societies in
Transition (SCOHOST) at So
¨derto
¨rn University and the Institute of
Social and Economic Studies of Population (ISESP) at the Russian
Academy of Sciences in Moscow. During the spring of 2004, face-to-
face interviews were conducted by 30 trained local interviewers
using a structured questionnaire. The survey contains approxi-
mately 100 questions divided into five subject areas: demo-
graphics, living standard, health, lifestyle, and social capital. Most
questions have been used before in previous surveys, such as the
World Values Survey of 1995–1997 (Carlson, 2004) and the
Taganrog Survey of 1998 (Rimashevskaya, 2001; Vågero
¨& Kislit-
syna, 2005). The study was carried out in accordance with the
Helsinki Declaration and local ethical guidelines. It was approved
by the Institute of Socio-Economic Studies of Population (ISESP)
under the Russian Academy of Sciences.
The target population of Greater Moscow encompasses around
8,540,000 individuals aged 18 or over. The sampling frame con-
sisted of 125 municipal districts (raiony) divided into 10 city
S. Ferlander, I.H. Ma
¨kinen / Social Science & Medicine 69 (2009) 1323–13321326

administrative districts (okruga). Stratified random sampling was
used. The aim was to carry out a specific number of interviews with
a specific age and gender distribution in each municipal district in
order to best mirror the distribution of the target population. Non-
respondents were replaced with new subjects, randomly drawn
from a reserve list of the same target population. Thus, where there
was no contact, or if nobody matched the age/gender criteria, a new
address, from the reserve list in the same municipal district, was
visited. Somewhat more than 2500 addresses were visited to obtain
a total of 1200 questionnaires, ten of which had to be rejected due
to poor quality.
The final sample contains 1190 individuals, where the primary
response rate was 47 percent. The average age in the sample is 47
years, and 57 percent of the respondents are women. 53 percent
have a high level of education, and only 19 percent low level of
education. 36 percent reported having experienced several types of
economic problem during the previous twelve months. According
to an analysis of non-responses, based on the first 1200 attempted
interviews, the sample is generally representative of the Moscow
population, with the exception of an overrepresentation of those
with a higher education. For more details, see Vågero
¨, Kislitsyna,
Ferlander, Migranova, Carlson & Rimashevskaya (20 08).
Variables
Self-rated health, the dependent variable in this study, was
measured on a five-point scale by the following question: ‘How
would you generally describe your present state of health? Would you
say it is: very good, good, satisfactory, poor or very poor?’ For the
analysis, and following previous categorizations of self-rated health
in Russia (Carlson, 2004), these categories were split into good
(‘very good’ and ‘good’) and less than good (‘satisfactory’, ‘poor’ and
‘very poor’) health.
Four indicators of social capital were employed as independent
variables. The first three measured informal social capital: the
respondent’s marital status, his/her contact with relatives, and the
contact with friends and acquaintances. Marital status was divided
into two groups: married (or cohabiting) and non-married
(divorced, widowed or single). The other variables indicating
informal social capital were measured by the following questions:
‘Do you tend to visit relatives?’ (family-based social capital) and ‘Do
you tend to visit friends and acquaintances?’ (social capital outside
the family). The answers were divided into two categories: regular
(‘often’) and little (‘rarely/never’) contact.
The measure of the more formal type of social capital was
membership of a voluntary association, which is one of the most
common indicators of social capital overall (e.g. Kawachi , Kennedy,
Lochner & Prothrow-Smith, 1997;Kawachi, Kennedy, & Glass,1999;
Putnam, 1993; Rose, 20 00). It was operationalised by the question:
‘Are you a member of any of the following organisations or associa-
tions: a) sports club, b) environmental organisation, c) cultural,
musical, dance or theatre society, d) women’s organisation,
e) temperance organisation, f) local action group, g) political party,
h) trade union, i) business or employer’s organisation j) religious
organisation, k) other club or association’. There were three response
categories: ‘yes, active member’, ‘yes, ordinary member’ and ‘no’.
These were recoded into: member (active or ordinary member of at
least one voluntary association) and non-member.
Key demographic (age and gender) and socio-economic
(educational level and economic situation) variables were included
in the analysis as controls for the effects of social capital. Educa-
tional level was divided into three groups: high (higher or incom-
plete higher), medium (specialised secondary or vocational
technical school) and low (common secondary or less). Since
income has been shown to be a poor indicator of material wealth in
Russia (Rose & McAllister, 1996; Vågero
¨& Kislitsyna, 2005), a more
consumption-based measure was employed. The respondents were
asked whether during the previous twelve months their family:
Had to rely on outside help to pay regular expenses on time (for
example rent)? Could not have meat or fish more than once or twice
a week? Had to refrain from purchasing necessary clothes or footwear
(for adults or children in the family)?Involuntarily had to refrain from
taking part in social or cultural activities, like going to a restaurant,
cinema, theatre etc.? The answers were then added up, giving a scale
of 0–4, which was further divided into two categories: those
experiencing few (no or one) and those experiencing many (two or
more) kinds of economic problem. Finally, the following question
was included: Do health problems limit your socializing with friends
and families? The response categories ‘no’, ‘yes, my circle of friends
has diminished significantly’ and ‘yes, I have been totally excluded
from my circle of friends and relatives’, were divided into two
groups: yes and no.
Results
Table 1 shows the distribution of Muscovites according to their
health status. 71 percent report less than good (i.e. satisfactory,
poor or very poor) health. There is a statistically significant gender
difference as 63 percent of men report less than good health,
compared with 76 percent of women.
Table 2 presents the distribution of various forms of social
capital. More than half of the sample (57%) are married or cohab-
iting. More than two-fifths state that they visit relatives (42%) or
friends and acquaintances (48%) regularly. A quarter of the
respondents (25%) are members of at least one voluntary associa-
tion, of which the trade unions and sports clubs are the most
popular. Only seven percent of the respondents state that they are
active members in their associations.
Table 2 also reveals statistically significant differences between
men and women regarding social capital. Two thirds of the men in
the sample are married, compared with half of the women.
Nevertheless, there are no statistically significant gender differ-
ences with regard to visiting relatives. However, 52 percent of men
maintain regular contact with their friends, while 46 percent of
women do. Almost a third (30%) of the men are members of some
form of voluntary association, compared with 22 percent of
women. Both of these differences are statistically significant.
However, no gender differences were found in relation to the type
of organisations men and women belong to, with the exception of
sports clubs, where significantly more men (8%) than women (4%)
are members.
Due to the overrepresentation of the highly educated in the
sample, the distributions of responses to the dependent variable and
the independent variables in Tables 1 and 2 were compared, with the
help of chi-square tests, to ones that could have been expected if the
educational distribution in the sample had been the same as the one
in the Moscow population according to the All-Russia Population
Census of 2002. No significant differences were found.
Table 3 shows, via logistic regressions, the odds ratios for the
probability of reporting less than good health in relation to the
Table 1
Self-rated health amongrespondentsaged 18 and overin Moscow, 2004, bygender (%).
Self-rated health Men (n¼510) Women (n¼680) Total (n¼1190) p
Very good 6 3 4 0.000
Good 31 21 25
Satisfactory 51 55 53
Poor 10 18 15
Very poor 2 3 3
S. Ferlander, I.H. Ma
¨kinen / Social Science & Medicine 69 (2009) 1323–1332 1327

independent variables and the control variables, separatelyfor men
and women. As expected, age is statistically significantly associated
with self-rated health. The probability of reporting less than good
health rises with increasing age. In addition, both education and
economic situation, analysed separately, show significant rela-
tionships with self-rated health for both men and women. Having
a low education and experiencing many economic problems
increases the odds of reporting less than good health. When the
variables are mutually adjusted, both associations remain statisti-
cally significant among women. Among men, the strong and
significant positive association between economic situation and
self-rated health persists when all variables are controlled for, but
the relation between education and health loses its significance.
A difference between men and women was found in the rela-
tionship between social capital and self-rated health. There is no
statistically significant relationship between any form of social
capital and self-rated health among women. However, men who
rarely or never visit friends and acquaintances are significantly
more likely (odds ratio: 1.69) to report less than good health than
those who visit more often. Likewise, men who are not members of
any voluntary associations have significantly higher odds (odds
ratio: 1.95) of reporting poorer health than those who are. The
gender gap in self-rated health is greater in the relationships
involving formal (membership in voluntary associations) than
informal (contacts with friends and acquaintances) type of social
capital. In short, social capital outside the family is positively
related to men’s self-rated health in Moscow, while family-based
social capital (marital status or contact with relatives) is not asso-
ciated with Muscovites’ – men’s or women’s – self-rated health in
any way. In order to check whether this lack of association could
depend on the quality of the marital relationship, an additional
analysis was performed taking this
2
into account. However, the
results were not altered.
Discussion
Data and method
Our study has a relatively small sample in relation to the
analyses performed. The highly educated (53%) were also over-
represented in the sample compared with the results from the
All-Russia Population Census 2002 (39%). However, since no
statistically significant differences were found between the
education-standardised and unstandardised figures in the analysis
this did not seem to affect the results. Moreover, the observed
relationship between social capital and self-rated health in the
regression analysis should not have been affected by this over-
representation since education was controlled for.
In social research, measurement error is always a possibility. In
this study, the questions considered are, for the most part, not
difficult to answer, and the presence of a professional interviewer
helped in interpreting their meaning. As to the question of health, it
is intentionally subjective and the answer should depict the indi-
vidual’s state of health such as s/he feels it to be at that moment.
Nevertheless, it is also worth noting that longitudinal studies have
shown that self-rated health is a good predictor of mortality
(Kaplan et al., 1996). Measurement problems are more likely to
arise in the two questions concerning the regularity in visiting
relatives and friends, which is always a matter of subjective inter-
pretation of language.
Being a cross-sectional study, it is difficult to determine the
direction of the causality in the relationship between social capital
and self-rated health. It could be argued that poor health leads to
low levels of social capital instead of the reverse. However,
although not disentangling the problem with causality, it is worth
mentioning that 91 percent of the respondents said that their state
of health had not affected their social networks. Further, a cross-
sectional study is also vulnerable to specification errors in terms of
relevant variables possibly having been missed in the analysis.
Before the analysis of the relationship between social capital and
self-rated health, gender, age, economic situation and education
level were controlled for. However, these do not exhaust the
potential number of confounders.
Self-rated health and gender
A large majority of Muscovites do not perceive themselves as
being in good health: 71 percent reported less than good health in
2004. This figure is substantially higher than in Western pop-
ulations, but rather similar to those previously obtained for the
whole of Russia (Carlson, 2004). However, in comparison with
a more recent Russian study (Rose, 2003), Muscovites perceive
themselves as being more unhealthy than Russians in general.
Substantial gender differences were also found. In line with earlier
studies in Russia (Bobak et al., 1998), women (76%) report poorer
health more often than men (63%). The gender gap is larger in
Moscow than elsewhere in Europe (Carlson, 2004).
Access to social capital
It has been argued that Russian social capital is mainly based on
informal connections and family ties (Evans et al., 2006; Kennedy
et al., 1998; Piirainen, 1997). The more formal types of social capital
outside the family, such as membership of voluntary associations,
are thought to be less important (D’Hombres et al., in press; Rose,
2003). In Moscow, however, we found that a sizeable proportion of
citizens seem to be involved in both informal and formal social-
izing, within and outside the family. Almost half of the Muscovites
in our sample state that they visit family and friends on a regular
basis and a quarter of them are also members of at least one
voluntary association (although only seven percent of them report
being active members). The level of civic involvement in Moscow is
low compared with other European populations (Carlson, 2004),
but not so low as to support the claims that a civil society is absent
(Marsh, 2000).
We found statistically significant differences between men and
women in their access to social capital. Men visit friends more often
than women, a finding that supports some previous studies (Moore,
Table 2
Social capital among respondents aged 18 and over in Moscow, 2004, by gender (%).
Social capital Men (n¼510) Women (n¼680) Total (n¼1190) p
Marital status
Married/cohabiting 66 50 57 0.000
Non-married 34 50 43
Contact with relatives
Regular 42 43 42 0.906
Little 58 57 58
Contact with friends
Regular 52 46 48 0.040
Little 48 54 52
Voluntary associations
Member 30 22 25 0.002
Non-member 70 78 75
2
Familial relationship quality was measured by the following question: ‘Please
try and evaluate the interrelations between members of your family’. There were
four response categories: ‘1) good, friendly, 2) normal, peaceful, 3) tense, edgy,
4) frequent rows, conflicts’.
S. Ferlander, I.H. Ma
¨kinen / Social Science & Medicine 69 (2009) 1323–13321328

1990) but contradicts others (Gidengil et al., 2006). Further, also in
accordance with some earlier studies (Norris & Inglehart, 2006),
but in contrast to others (Lowndes, 2006), more men than women
are members of voluntary associations. Women’s traditional roles
in the Russian family (Ashwin & Lytkina, 2004), including domestic
and child-care duties (Vannoy et al., 1999), may be a reason for their
having fewer contacts outside the family (Norris & Inglehart, 2006).
Social capital and self-rated health – gender differences
A marked gender difference was observed in the relationship
between social capital and self-rated health. No statistically
significant association was found between any form of social
capital and self-rated health among women, while a relationship
between certain forms of social capital and self-rated health did
exist among men. Men who rarely or never visit friends and
acquaintances have higher odds – 1.7 times – of reporting poorer
health than those who visit them more often. Likewise, men who
are not members of any voluntary association are nearly twice as
likely to report less than good health than those who are. These
results lend support to some studies in the West (Carlson, 2004;
Hyyppa
¨&Ma
¨ki, 2001) and an earlier study in Russia by Carlson
(2001), while contradicting the findings by Rose (2000). In sum,
our results support previous studies (Antonucci & Akiyama, 1987;
Carlson, 2004; House et al., 1982; Kaplan et al., 1988), which
suggest that women may not derive the same health benefits from
social capital as men.
Social companionship and the opportunities offered by it may
explain the positive relationship between social capital and men’s
self-rated health. Socializing with friends and acquaintances,
within and outside of formal organisations, may provide
entertainment and relaxation, leading to a reduction of stress. The
diverse connections accessed through voluntary associations, for
example, may also assist men in establishing the right kind of useful
contacts by providing access to various opportunities, such as good
advice, career prospects and new (health) information (Ferlander,
2007). It has been found that members of wide networks tend to be
generally well-informed about health issues (Erickson, 2003).
Information exchange regarding various health issues, such as
shared experiences about doctors, medicine, diet and exercise, may
play a significant role for health.
If these benefits have accrued for men then it is necessary to ask
why women’s social capital is not related to their self-rated health
in Moscow. This might be explained by the different gender roles,
which are pronounced in Russia (Ashwin & Lytkina, 2004; Rima-
shevskaya, 2003; Vannoy et al., 1999), and the different socializing
patterns and values embedded in them. Men tend to be involved in
socializing and information exchange in diverse networks, while
women focus on disclosure and exchange of support in more
homogeneous and less information-rich networks (Popielarz, 1999;
Shye et al., 1995). Women tend to look out for others beyond
personal interest, and this may create fewer opportunities,
including less health benefits. Women’s supportive roles may foster
feelings of emotional stress, putting a strain on their health (Fer-
lander, 2007; Portes, 1998; Sarason et al., 1997). The competing
demands of home and work probably put a further strain on their
health due to a decreased sense of control and increased feelings of
being burdened and experiencing emotional stress. In the present
Russian context, this may be especially the case for women who,
since the collapse of the Soviet Union, have lost access to societal
support, such as day-care centres and cheap dry-cleaning services
(Rimashevskaya, 2003).
Table 3
‘Less than good’ self-rated health among respondents aged 18 and over in Moscow, 2004, by gender. Odds ratios (OR) with 95% confidence limits (CI), estimated from binary
logistic regressions.
Variable Men Women
Model 1
a
Model 2
b
Model 1
a
Model 2
b
OR 95% CI OR 95% CI OR 95% CI OR 95% CI
Age 1.05 1.04–1.06*** 1.04 1.03–1.06*** 1.06 1.05–1.08*** 1.06 1.04–1.07***
Educational level
High 1.00 1.00 1.00 1.00
Medium 1.12 0.70–1.78 0.87 0.53–1.43 1.29 0.84–1.99 1.24 0.79–1.93
Low 1.92 1.12–3.27* 1.69 0.97–2.94 2.13 1.11–4.09* 2.01 1.04–3.90*
Economic problems
Few 1.00 1.00 1.00 1.00
Many 2.02 1.26–3.23** 1.98 1.23–3.21** 1.54 1.03–2.30* 1.53 1.02–2.31*
Marital status
Married 1.00 1.00 1.00 1.00
Non-married 1.04 0.68–1.61 1.11 0.70–1.75 1.34 0.90–1.97 1.34 0.90–2.01
Contact relatives
Regular 1.00 1.00 1.00 1.00
Little 1.25 0.85–1.85 1.05 0.68–1.61 1.31 0.89–1.93 1.11 0.72–1.71
Contact friends
Regular 1.00 1.00 1.00 1.00
Little 1.76 1.16–2.67* 1.69 1.08–2.64* 1.43 0.95–2.13 1.35 0.86–2.10
Voluntary associations
Member 1.00 1.00 1.00 1.00
Non-member 2.17 1.40–3.21*** 1.95 1.26–3.00** 1.27 0.81–2.00 1.18 0.75–1.87
Sample size 507 678
Log likelihood 572.57 616.92
Pseudo R
2
(Nagelkerke) 0.231 0.248
*p0.05; **p0.005; ***p0.001.
a
Age-adjusted effects.
b
Mutually adjusted effects.
S. Ferlander, I.H. Ma
¨kinen / Social Science & Medicine 69 (2009) 1323–1332 1329

Different forms of social capital and self-rated health
Contrary to our first hypothesis, but partly supporting the
second one, no statistically significant relationship was found
between marital status, or one’s contact with relatives, and self-
rated health. On the other hand, and in line with hypothesis
three, contacts with friends and membership in voluntary
associations are positively related to men’s self-rated health,
with the latter having a stronger effect than the former. In short,
it appears that social capital – both informal and formal –
outside the family sphere is more important for self-rated
health than family-based social capital in Moscow. This
contradicts the theories that highlight family relations as a vital
form of social capital in Russia (Ledeneva, 1998; Piirainen, 1997;
Wegren, 2 006),orforhealthingeneral(Lynch et al., 2000;
Rosengren et al., 1989). However, our findings support previous
studies, in Russia and elsewhere, which have not found any
relationship between marital status and health (Bobak et al.,
1998; Carlson, 2004; Cockerham, 1999). Reasons behind these
findings have been little discussed, and no clear explanation has
been provided (Cubbins & Szaflarski, 2001).
One reason for the absence of a relation between family-based
social capital and self-rated health in Moscow may pertain to the
fact that one’s family is not voluntarily chosen (Pahl & Spencer,
1997). Family relations can sometimes constitute a burden for the
individual as they may involve conflicts, disappointments, feelings
of obligation, and distress. Therefore, the quality of family relations
has been focused upon in some studies (Carlson, 2000). In this
study, however, taking the perceived quality of family relations into
account did not alter the results. The absence of a link between
family-based social capital and self-rated health is not likely to be
due to low-quality marriages.
Another possible explanation could be the unequal and less
friendship-based relations that usually exist in patriarchal families,
even when the marital relationship as such may be relatively
harmonious. Equal interaction is, according to Putnam (1993),
crucial for collaboration and the creation of social capital. Thirdly,
family networks can also lead to expectations of conformity,
restricting individual freedom and the access to contacts and
information from other sources (Due et al., 1999; Ferlander, 2007;
Portes, 1998). In such circumstances family members may be
unable to reflect on or compare their views against those from
outside their immediate network, leading to – or confirming
existing – unhealthy behaviours and poor health.
Socio-economic position and self-rated health
Both the respondents’ economic situation and their educa-
tional level show a strong connection with their self-rated health.
The failure to be able to meet one’s basic needs and having a low
level of education increase the odds of reporting less than good
health significantly. A lack of money may, for example, result in
difficulties in heating one’s flat or buying food, increasing the risk
of malnutrition and poor health (Carlson, 2004). Besides material
deprivation, financial problems can also be a source of anxiety
and psychological distress (Wilkinson, 1996). It has also often
been found that groups with a lower level of education are more
likely to be involved in unhealthy behaviours (Blaxter, 1990). In
addition, they are more often exposed to stressful events
generally (Stronks, Van de Mheen, Looman, & Mackenbach, 1997).
However, despite the importance of education and economy for
self-rated health, social capital outside the family sphere is
statistically significantly related to men’s health in Moscow over
and above its association with their level of education and
material situation.
Conclusions
The main finding of our study was a clear gender difference
concerning the relation between social capital and self-rated
health. A significant relationship between these could be discerned
among men, but not among women. Apparently, men and women
in Moscow live very different lives, whichalso has consequences for
their health. However, such differences may not only be confined to
this particular city. Earlier studies in the US, Finland, and other
European countries indicate similar gender differences in the
relationship between different kinds of social contacts and health
(Carlson, 2004; House et al., 1982; Kaplan et al., 1988), but without
establishing definitive explanations for them.
Due to the generally strong differences in Russian gender roles,
women and men in Moscow may have different reasons for
maintaining their social relationships (obligation vs. activity), and
these may occupy different places in their social life (necessity vs.
entertainment). Their essential content (care-taking vs. relaxation)
and consequences (support and/or distress vs. information and
opportunities) may also be different. Whereas men might derive
more benefits from their social networks, it is possible that the
traditional female role as a ‘kin-keeper’ or ‘administrator’ of social
relations tends to flavour women’s social relations both within and
outside the family sphere in a manner that makes them less
favourable for their health. Future studies should continue to focus
on gender aspects in order to better understand the complex
relationship between social capital and health.
A second important finding was the lack of association between
family-based social capital and self-rated health in Moscow. It
might be argued that Moscow is more similar to Western counties,
where the role of family-based social capital is declining and
friendship ties are gaining in importance. Families are generally
becoming smaller throughout Russia (Rimashevskaya, 2003), but
there are more single people in Moscow than in the rest of the
country (All-Russia Population Census, 2002). Moscow also has the
highest number of registered voluntary associations in the country
(Twigg, 2003). Consequently, although family-based social capital
is not important for self-rated health in Moscow, it is possible that
elsewhere in the country Russians may still rely on kinship ties.
Despite frequent overlaps, it is important to continue dis-
tinguishing between different types of social capital, theoretically
and empirically, as they imply different kinds of resources, influ-
ence, support, and obligations. These are also relevant for health
outcomes. A family-based network tends to provide emotional and
instrumental support, beneficial for health, but it may also, espe-
cially in a patriarchal type of family, involve obligations, feelings of
inequality and emotional distress, leading to negative health
consequences. Family networks may also, due to their particularist
nature, restrict access to wider contacts and information that is
important for health. Extra-familial relationships, on the other
hand, may be sources of diverse contacts, especially for men, and
influence their health positively through opportunity-based
mechanisms, such as facilitating access to health information and
to important work contacts.
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