Journal of Affective Disorders 178 (2015) 142–148

Contents lists available at ScienceDirect

Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research report

Urban–rural differences in psychological distress in nine countries

of the former Soviet Union
Andrew Stickley a,b,c,n, Ai Koyanagi d,e, Bayard Roberts a, Martin McKee a
a
ECOHOST—The Centre for Health and Social Change, London School of Hygiene and Tropical Medicine, London, United Kingdom
b
The Stockholm Centre for Health and Social Change (SCOHOST), Södertörn University, Huddinge, Sweden
c
Department of Human Ecology, Graduate School of Medicine, University of Tokyo,Tokyo, Japan
d
Research and Development Unit, Parc Sanitari Sant Joan de Déu, Fundació Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
e
Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Madrid, Spain

art ic l e i nf o a b s t r a c t

Article history: Background: Studies have shown that the prevalence of mental illness can vary between urban and rural
Received 18 February 2015 locations. This study extended research to the countries of the former Soviet Union (fSU) by assessing the
Accepted 19 February 2015 association between settlement type and psychological distress and whether factors associated with
Available online 28 February 2015
psychological distress vary by settlement type.
Keywords: Methods: Data on 18,000 adults aged Z18 years from the Health in Times of Transition (HITT) survey
Former Soviet Union undertaken in Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, and
Psychological distress Ukraine in 2010/11 were analyzed. Settlement types were country capitals, regional capitals, cities/other
Urban urban settlements, and villages. Psychological distress was defined as the country-specific highest
Rural
quintile of a composite score based on 11 questions. Logistic regression analysis with random effects was
HITT survey
used to examine associations.
Results: In a pooled country analysis, living in a smaller urban settlement or village was associated with
significantly higher odds for psychological distress compared to living in the country capital. Lower social
support was a strong correlate of psychological distress in all locations except capital cities.
Limitations: The psychological distress measure has not been formally validated in the study countries.
Conclusions: Lower levels of urbanicity are associated with greater psychological distress in the fSU
countries. As many Western studies have linked greater urbanization to poorer mental health, this highlights
the need for caution in extrapolating findings from one part of the world to others and the importance of
undertaking research on the geographical correlates of mental health in different world regions.
& 2015 Elsevier B.V. All rights reserved.

1. Introduction
During the past 30 years, a growing body of research has shown
that the prevalence of mental ill health varies between urban and
rural areas. This was summarized in a recent meta-analysis of 20
population-based survey studies undertaken in developed countries
between 1985–2008 which showed that the pooled adjusted odds
ratios for the occurrence of mood disorders (odds ratio [OR]: 1.28) and
anxiety disorders (OR: 1.13) were higher in urban compared to rural
areas (Peen et al., 2010). Other research however, has highlighted the
potential complexity of this association. Romans et al. (2011) for
example, found that differences can depend on the type of mental
illness. In their study, rates of depression were higher in urban than in
rural areas of Canada, but there was no difference for agoraphobia,
n
Correspondence to: The Stockholm Centre for Health and Social Change,
(SCOHOST), Södertörn University, 141 89 Huddinge, Sweden. Tel.: þ46 8 608 4689;
fax: þ46 8 608 3040.
E-mail address: andrew.stickley@sh.se (A. Stickley).
social phobia, or panic disorder. Similarly, a recent study from the
United States indicated that using a simple urban–rural dichotomy
might be insufficient as the odds for mental illness (depression and
psychological distress) were highest in intermediate (i.e. small urban
and semi-rural) areas compared to large urban areas (Breslau et al.,
2014). The relationship might also vary between developed and
developing countries. Earlier studies from both Turkey (Oguzturk,
2008) and Pakistan (Mumford et al., 1997, 2000) found higher rates of
anxiety and depression in rural areas.
Greater socioeconomic disadvantage, a poorer physical and social
environment, as well as higher levels of crime are all stressors that
can lead to mental ill health (Galea et al., 2011), and are factors which
might explain, at least in part, urban–rural differences in mental
health outcomes (Paykel et al., 2000). However, to date, few studies
have compared individual predictors of mental health across different
types of location. Those which have showed that although markers of
socioeconomic disadvantage such as low education (Kim et al., 2002)
and financial strain (Abe et al., 2012) are associated with depression
across locations, other factors can vary depending on the specific

http://dx.doi.org/10.1016/j.jad.2015.02.020
0165-0327/& 2015 Elsevier B.V. All rights reserved.
 A. Stickley et al. / Journal of Affective Disorders 178 (2015) 142–148
research setting and outcome examined. Studies on late-life depres-
sion in Korea (Kim et al., 2004) and frequent mental distress in the
United States (Rohrer et al., 2005) for example, have linked female sex
to higher odds for worse mental health in (more) urbanized areas
only, while a recent study from Japan found that poorer social support
was associated with elderly depression in rural but not urban areas
(Abe et al., 2012).
Despite the increasing accumulation of knowledge about urban–
rural differences in mental health, there are still regions of the world
where there has been little or no research on the geographical
distribution of mental illness. The countries of the former Soviet
Union (fSU) comprise such a region, even though there are grounds
to believe that this setting might be especially apposite to examine
such differences. Not only has previous research recorded high rates
of mental ill health in the fSU countries (Bobak et al., 2006; Dershem
et al., 1996), possibly linked to the social instability, impoverishment,
and removal of social safety nets (Roberts et al., 2012a) that followed
in the wake of the collapse of communism, but there is also some
evidence that the negative impact of transition might have varied
between urban and rural areas in some countries. There are high
rates of rural (vs. urban) poverty in Kazakhstan and Russia (Macours
and Swinnen, 2008) with evidence that there has been a “ruraliza-
tion” of poverty in the latter in recent years (Gerry et al., 2008).
Comparatively high levels of fatal violence, alcohol-related mortality
and suicide in rural areas in post-Soviet Belarus (Razvodovsky and
Stickley, 2009; Stickley et al., 2009; Stickley and Razvodovsky, 2009)
might also be indicative of worse economic and social conditions. If
socioeconomic change has impacted differently in urban and rural
areas, this might also be reflected in differences in the prevalence of
mental health outcomes, as economic and social marginalization has
been linked to poorer mental health in these countries (Roberts et al.,
2010, 2012a).
The current study will thus examine the association between
settlement type and psychological distress in nine countries of the
fSU. Psychological distress has previously been defined as “a state of
emotional suffering characterized by symptoms of depression and
anxiety” (Drapeau et al., 2011). Although most cases will not reach the
threshold for clinical mental illness (Roberts et al., 2010), it has been
linked to a number of extremely serious health outcomes including
suicide (Ridner, 2004) and an increased risk of premature mortality
(Robinson et al., 2004). In addition, research (from the United States)
has shown that its prevalence can vary between urban and rural areas
(Dhingra et al., 2009). Given this, the main aims of this study were:
(1) to examine whether there were differences in the prevalence of
psychological distress between urban and rural regions in nine
counties of the former Soviet Union; (2) to determine whether there
are differences in the factors associated with psychological distress in
urban and rural areas in these countries.
2. Methods
The data in this study came from the Health in Times of Transition
(HITT) survey. This cross-sectional survey was undertaken in Armenia,
Azerbaijan, Belarus, Georgia, Kazakhstan, Moldova, Russia, and Ukraine
in 2010 but was delayed until early 2011 in Kyrgyzstan because of
political unrest. Multi-stage random sampling with stratification by
region and urban/rural settlement type was conducted in each country
to obtain a nationally representative sample. Random route proce-
dures were used to select households from within primary sampling
units (PSU) (approximately 100–200 per country). Within each
selected household, one person aged 18 or above was randomly
chosen to participate (determined by the nearest birthday). Informa-
tion was obtained from respondents by trained interviewers who
conducted face-to-face interviews in the respondents' homes using a
standard questionnaire. In every country, interviewees had the choice
143
of responding in either their own country language or Russian except
for in Russia and Belarus where only Russian was used. All adults were
eligible for inclusion in the survey except for those that were
institutionalized, hospitalized, homeless, in the military, in prison, or
intoxicated at the time of the survey.
Information was collected from 18,000 respondents. In six coun-
tries, the sample size was 1800 respondents. However, larger samples
were recruited in Russia and Ukraine (3000 persons and 2000
persons, respectively) to take account of their larger and more
regionally diverse populations. Georgia also had a larger sample size
(n¼2200) as a result of a booster survey of 400 additional interviews
that was undertaken towards the end of 2010 to improve represen-
tativeness. Across the countries, response rates varied from 47%
(Kazakhstan) to 83% (Georgia) (Roberts et al., 2013). All respondents
provided informed consent before being included in the survey with
ethical approval for the study being obtained from the ethics
committee at the London School of Hygiene and Tropical Medicine.
The survey was carried out in accordance with the ethical standards
specified in the 1964 Helsinki Declaration.
2.1. Study variables
The dependent variable in this study was psychological distress. It
was measured with a 12-item scale that has been used in several
recent studies of psychological distress in the fSU countries (Goryakin
et al., 2015; Roberts et al., 2010, 2012a). Respondents answered yes/
no to whether they had recently experienced: feelings of stress;
feelings of loneliness; an inability to concentrate; insomnia; feelings
of being under constant strain; feeling an inability to overcome
difficulties; loss of confidence in oneself; nervous shaking or trem-
bling; frightening thoughts coming into their mind; spells of exhaus-
tion or fatigue; feeling that life is too complicated; and feeling that it
was impossible to influence things. As this study also examined locus
of control, the final item was removed. The revised 11-item scale had
a good level of internal consistency (α ¼ 0.79). Respondents in the top
quintile of scores in each country were categorized as suffering from
psychological distress.
The main independent variable was settlement type. Respondents
were categorized as living in one of four types of settlement:
(1) country capital; (2) regional capital; (3) city (but not country or
regional capital)/settlement of an urban type; (4) village. These
entities were categorized according to official state designations based
on population size and other factors (e.g. forms of employment).
Information was also collected on other demographic, economic
and psychosocial variables. Details of respondents' sex and age were
collected, with the latter categorized as 18–29, 30–39, 40–49, 50–59,
and 60 years and above. Marital status was categorized as: married/
cohabiting, single (never married), and divorced/widowed. Educa-
tional level was also divided into three categories, high (complete/
incomplete higher education), middle (completed secondary/second-
ary specialized education), and low (incomplete secondary education
or less). For economic situation, respondents were asked, “How
would you describe the economic situation of your household at
the present time?” with responses categorized as good (very good/
good), average (average), and bad (bad/very bad). Social support was
assessed by asking respondents 5 questions with the introduction, “Is
there anyone”: (1) “who you can really count on to listen to you
when you need to talk?”, (2) “who you can really count on to help
you out in a crisis/in your most difficult moments?”, (3) “who you
can totally be yourself with?”, (4) “who you feel appreciates you as a
person?”, (5) “who can comfort you when you are upset?” These
questions had yes/no responses. The number of affirmative answers
was used to create a scale score running from 0 to 5 with the scores
being then categorized as: high (4/5 yes answers), moderate (2/3),
and low (0/l). To assess the effects of bereavement, respondents were
asked, “During the last months have you experienced the death of
144 A. Stickley et al. / Journal of Affective Disorders 178 (2015) 142–148

Table 1
Characteristics of the study sample by settlement type.

Characteristic Category Country capital Regional capital City or urbana Village P-valueb

n % n % n % n %

Sex Male 1290 43.0 1550 41.6 1787 43.2 3202 44.9 0.009
Female 1712 57.0 2179 58.4 2347 56.8 3933 55.1
Age (years) 18–29 992 33.0 1137 30.5 1161 28.1 1753 24.6 o0.001
30–39 591 19.7 708 19.0 777 18.8 1336 18.7
40–49 538 17.9 645 17.3 740 17.9 1457 20.4
50–59 387 12.9 571 15.3 612 14.8 1185 16.6
Z 60 494 16.5 668 17.9 844 20.4 1404 19.7
Marital status Married/cohabiting 1699 56.9 2169 58.4 2458 59.8 4804 67.4 o0.001
Single 854 28.6 836 22.5 820 19.9 1182 16.6
Divorced/widowed 433 14.5 707 19.1 835 20.3 1139 16.0
Education High 1334 44.6 1265 33.9 1065 25.9 1278 17.9 o0.001
Middle 1493 49.9 2169 58.2 2548 61.9 4459 62.6
Low 163 5.5 293 7.9 503 12.2 1386 19.5
Household Good 827 27.9 847 22.9 846 20.8 1465 20.7 o0.001
Economic situation Average 1585 53.4 2212 59.8 2444 60.1 3955 56.0
Bad 555 18.7 639 17.3 774 19.1 1648 23.3
Social support High 2460 85.4 3223 91.7 3559 91.9 6015 88.9 o0.001
Moderate 271 9.4 178 5.1 197 5.1 460 6.8
Low 150 5.2 112 3.2 116 3.0 290 4.3
Death of close relative No 2496 84.3 3106 83.5 3466 84.3 5724 80.4 o0.001
Yes 464 15.7 612 16.5 648 15.8 1396 19.6
Disability No 2847 94.9 3465 93.1 3811 92.5 6630 93.0 o0.001
Yes 152 5.1 258 6.9 309 7.5 498 7.0
Locus of control High 1143 39.5 1430 39.7 1579 40.1 2422 35.2 o0.001
Middle 982 33.9 1273 35.3 1404 35.6 2536 36.9
Low 771 26.6 900 25.0 957 24.3 1917 27.9

a
Referred to areas which were not country or regional capitals.
b
P-values obtained by Chi-squared tests.

a close relative?” Disability was assessed by asking respondents, “Do
you have a disability?” Finally, information on locus of control was
obtained by asking the respondent to what extent they agreed/
disagreed with the statement, “I feel that what happens in my life is
often determined by factors beyond my control”. Responses were
categorized as high locus of control (disagree/rather disagree),
middle (quite agree), and low (agree).
2.2. Statistical analysis
Chi-squared statistics were used to assess differences in the
characteristics of the study sample across the four types of settlement
(Table 1). Multivariable logistic regression with a two-level random
effects structure, where individuals and PSUs were considered as level
one and two, respectively, was used in two subsequent analyses.
Settlement type was included in the model as a level-two covariate.
For the pooled analyses, country was included in the model as a fixed
effect. First, pooled and individual country analyses were carried out to
examine the association between psychological distress and settle-
ment type while controlling for other demographic, economic, and
psychosocial variables (Table 2). Second, an analysis stratified by
settlement type was conducted to assess whether the factors asso-
ciated with psychological distress differ between settlement types
using the pooled data (Table 3). In order to test whether there was
effect modification in the association between the various control
variables and psychological distress by settlement type, a cross-level
interaction term was included in the model. The statistical analysis
was done with Stata 12.1 (Stata Corp LP, College station, Texas) with
the results presented as odds ratios (OR) with 95% confidence intervals
(CI). The level of statistical significance set at Po0.05.
3. Results
All of the study sample characteristics varied significantly across
settlement types (Table 1). Fewer young people (aged 18–29) lived in
villages and there was a higher percentage of marriages/cohabitation
in that setting. High education was more prevalent in the capitals
while village households were more likely to be in a bad economic
situation. Levels of social support were lower in the country capitals,
and those living in villages were more likely to report the recent
death of a close relative. The level of disability was lowest in the
country capitals, while a high locus of control was least prevalent in
villages.
In a pooled country model there was no difference between living
in the capital city of a country and a regional capital in terms of
psychological distress (Table 2). However, those who lived in smaller
cities/urban settlements were significantly more likely to have a high
level of psychological distress (OR: 1.37, 95% CI: 1.09–1.73) compared
with those who lived in the capital city, as were rural residents
(OR: 1.25, 95% CI: 1.01–1.56).
The power to detect differences within individual countries may
have been limited by small sample sizes for some residential com-
munities. However, in both Armenia (OR: 3.05, 95% CI: 1.25–7.46) and
Moldova (OR: 2.36, 95% CI: 1.09–5.12) living in a village (compared to
the national capital city) increased the risk of experiencing psycholo-
gical distress. In Azerbaijan, living in a smaller city increased the odds
of psychological distress by over 6 times (OR: 6.77, 95% CI: 3.15–14.56).
In Georgia, living in a regional capital was associated with a reduced
risk of experiencing psychological distress compared to living in Tbilisi
(OR: 0.33, 95% CI: 0.15–0.72).
Female sex, being aged 60 or above, having a bad household
economic situation, being disabled and having a low locus of
control were all associated with higher odds for psychological
distress in all of the settlement types (Table 3). Other variables
were associated with higher odds of psychological distress in all
locations except the capital city i.e. being aged 50–59, divorced or
widowed, having a low level of education, social support or a
middle level locus of control. Tests for interaction effects showed
that older age (50 and above) and having less than a high level of
social support were more strongly associated with psychological
 A. Stickley et al. / Journal of Affective Disorders 178 (2015) 142–148 145

Table 2
Association between settlement type and psychological distress in nine countries of the former Soviet Union.

Characteristic Category Overall Armenia Azerbaijan Belarus Georgia Kazakhstan Kyrgyzstan Moldova Russia Ukraine

Settlement type Country capital Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Regional capital 1.05 2.37 0.65 0.86 0.33b 1.13 2.34 1.31 1.22 0.54
[0.83,1.34] [0.97,5.80] [0.26,1.65] [0.47,1.55] [0.15,0.72] [0.42,3.02] [0.96,5.73] [0.49,3.50] [0.56,2.67] [0.21,1.36]
City or smaller 1.37b 1.85 6.77c 0.95 0.88 0.71 1.36 2.63 1.18 0.50
urban [1.09,1.73] [0.66,5.20] [3.15,14.56] [0.57,1.58] [0.44,1.77] [0.25,2.01] [0.61,3.03] [0.88,7.81] [0.55,2.55] [0.20,1.27]
Village 1.25a 3.05a 0.58 0.89 0.82 1.16 1.41 2.36a 1.74 0.85
[1.01,1.56] [1.25,7.46] [0.28,1.19] [0.52,1.54] [0.50,1.34] [0.44,3.09] [0.73,2.75] [1.09,5.12] [0.79,3.81] [0.33,2.15]
Sex Female vs. Male 1.96c 1.69b 2.12c 1.99c 2.49c 1.43a 2.12c 2.53c 1.73c 2.54c
[1.76,2.18] [1.16,2.46] [1.46,3.07] [1.45,2.72] [1.75,3.56] [1.06,1.92] [1.51,2.97] [1.67,3.82] [1.28,2.32] [1.78,3.62]
Age (years) 18–29 Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
30–39 1.30b 0.94 1.04 1.14 2.68b 1.08 2.35b 1.56 1.01 1.11
[1.09,1.56] [0.52,1.71] [0.58,1.87] [0.68,1.90] [1.36,5.25] [0.67,1.73] [1.40,3.95] [0.69,3.51] [0.59,1.75] [0.58,2.13]
40–49 1.51c 1.06 1.65 1.38 3.30c 1.08 2.07b 1.48 1.23 1.78
[1.26,1.81] [0.58,1.95] [0.95,2.87] [0.81,2.35] [1.71,6.39] [0.65,1.81] [1.19,3.57] [0.64,3.43] [0.71,2.14] [0.98,3.26]
50–59 2.06c 2.07a 2.15a 1.16 4.84c 1.36 3.03c 3.16b 2.32b 1.62
[1.71,2.47] [1.08,3.99] [1.15,4.00] [0.66,2.04] [2.52,9.31] [0.81,2.27] [1.71,5.38] [1.42,7.01] [1.38,3.89] [0.86,3.04]
Z 60 2.20c 2.09a 2.84b 1.18 4.04c 1.72a 3.46c 4.32c 2.13b 2.86c
[1.82,2.65] [1.05,4.16] [1.38,5.83] [0.66,2.11] [2.10,7.75] [1.01,2.92] [1.90,6.32] [1.94,9.65] [1.24,3.63] [1.56,5.25]
Marital status Married/ Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
cohabiting
Single 1.08 0.41b 0.86 1.21 1.17 0.66 1.26 1.22 1.59 1.82a
[0.91,1.28] [0.23,0.74] [0.49,1.48] [0.76,1.94] [0.71,1.93] [0.41,1.08] [0.72,2.20] [0.52,2.85] [0.97,2.60] [1.03,3.22]
Divorced/widowed 1.55c 2.03a 1.72 1.55a 1.63a 1.87b 2.14c 1.07 1.22 1.31
[1.36,1.77] [1.12,3.67] [0.93,3.18] [1.05,2.27] [1.12,2.38] [1.26,2.77] [1.36,3.37] [0.67,1.71] [0.88,1.71] [0.89,1.94]
Education High Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Middle 1.09 0.86 1.07 0.89 1.67b 1.19 1.32 1.15 1.31 1.25
[0.96,1.24] [0.55,1.34] [0.66,1.71] [0.63,1.27] [1.16,2.40] [0.83,1.71] [0.85,2.05] [0.67,2.00] [0.90,1.92] [0.86,1.82]
Low 1.42c 0.74 1.32 1.20 2.85c 1.35 1.91a 1.23 1.61 1.64
[1.19,1.70] [0.36,1.52] [0.61,2.84] [0.63,2.29] [1.61,5.04] [0.80,2.27] [1.13,3.22] [0.67,2.26] [0.96,2.70] [0.93,2.90]
Household Good Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Economic situation Average 1.48c 1.24 2.19b 1.70a 1.21 1.28 0.88 2.72b 1.34 1.31
[1.28,1.71] [0.77,2.01] [1.30,3.69] [1.13,2.58] [0.41,3.59] [0.90,1.83] [0.60,1.30] [1.41,5.26] [0.87,2.06] [0.80,2.13]
Bad 3.53c 2.66b 6.28c 3.45c 3.85a 3.59c 2.47b 9.11c 2.58c 3.36c
[2.97,4.19] [1.45,4.85] [3.50,11.28] [2.02,5.89] [1.31,11.30] [2.06,6.27] [1.41,4.32] [4.54,18.29] [1.56,4.26] [1.93,5.84]
Social support High Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Moderate 1.56c 1.36 1.14 1.91a 2.10 1.43 2.00a 2.88c 2.09b 1.98
[1.30,1.87] [0.78,2.35] [0.60,2.17] [1.09,3.38] [0.96,4.60] [0.84,2.45] [1.15,3.48] [1.54,5.41] [1.21,3.60] [0.99,3.96]
Low 2.13c 2.28a 2.54a 2.09 2.66a 4.03b 3.12a 2.00a 2.79b 2.96b
[1.70,2.67] [1.09,4.77] [1.11,5.82] [0.96,4.55] [1.01,6.99] [1.60,10.14] [1.25,7.78] [1.13,3.55] [1.49,5.23] [1.45,6.08]
Death of close Yes vs. No 1.34c 1.17 1.23 1.53a 1.18 1.31 1.34 1.05 1.59a 1.69b
relative [1.18,1.52] [0.75,1.81] [0.78,1.96] [1.01,2.31] [0.87,1.62] [0.91,1.90] [0.87,2.08] [0.66,1.67] [1.11,2.27] [1.14,2.49]
Disability Yes vs. No 3.55c 4.88c 5.33c 2.68c 3.44c 3.24c 5.10c 5.43c 3.45c 2.41c
[3.00,4.19] [2.48,9.57] [2.57,11.05] [1.53,4.69] [2.16,5.49] [1.84,5.72] [2.90,8.96] [3.00,9.83] [2.35,5.06] [1.46,3.99]
Locus of control High Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref. Ref.
Middle 1.74c 1.46 2.07b 2.24c 1.13 1.21 1.66a 1.71a 2.61c 1.60a
[1.53,1.97] [0.92,2.33] [1.30,3.27] [1.58,3.18] [0.75,1.68] [0.85,1.73] [1.05,2.63] [1.03,2.85] [1.86,3.67] [1.09,2.34]
Low 2.49c 2.29b 2.35c 2.30c 1.77b 2.00c 2.94c 3.55c 3.81c 2.52c
[2.18,2.84] [1.39,3.76] [1.45,3.81] [1.54,3.43] [1.16,2.71] [1.39,2.86] [1.89,4.56] [2.12,5.92] [2.68,5.41] [1.67,3.80]

Abbreviation: Ref. reference category.

Data are odds ratios and 95% confidence intervals.
Multivariable models were mutually adjusted for all covariates shown in the table. The overall model including all nine countries was also adjusted for country.
a
P o0.05.
b
Po 0.01.
c
Po 0.001.

distress in villages than in the capital city, while the same
association was seen for less than high social support and a low
locus of control in regional capitals compared to the national
capital.
4. Discussion
This study examined whether there were differences in psycho-
logical distress in urban and rural settlements in nine countries of the
fSU. It showed that living in a smaller city/urban-type location or
village was associated with higher odds for psychological distress
when compared to living in the capital city. In the individual
countries, living in a village increased the odds for psychological
distress in Armenia and Moldova, while in Azerbaijan increased odds
were observed among those living in a smaller city/urban type
settlement. Although many of the variables associated with psycho-
logical distress were the same across settlement types in all of the
countries, an interaction test revealed that older age (50 or above)
was associated with significantly higher odds for psychological
distress in rural areas compared to in the capital city. In addition,
lower levels of social support outside capital cities also increased the
risk for psychological distress, while less than a high locus of control
was associated with significantly higher odds for psychological
distress in regional capitals and smaller urban settlements when
compared to capital cities.
The finding of a statistically significant, if modest association,
between living in smaller urban or rural settlements and having
increased odds for psychological distress in the fSU countries con-
flicts with the notion that urbanization per se is associated with
psychiatric (mood and anxiety) disorders (Peen et al., 2010) but
accords with the results from several earlier studies undertaken in
146 A. Stickley et al. / Journal of Affective Disorders 178 (2015) 142–148

Table 3
Predictors of psychological distress by settlement type in nine countries of the former Soviet Union, pooled data.

Characteristic Category Country capital Regional capital City or smaller urban Village

Sex Female vs. Male 2.17c 1.80c 1.67c 2.23c

[1.64,2.88] [1.41,2.31] [1.32,2.10] [1.88,2.64]
Age (years) 18–29 Ref. Ref. Ref. Ref.
30–39 0.91 1.58a 1.10 1.54b
[0.59,1.41] [1.06,2.35] [0.73,1.64] [1.15,2.08]
40–49 1.12 1.46 1.54a 1.86c
[0.72,1.74] [0.96,2.21] [1.02,2.31] [1.38,2.49]
50–59 1.32 1.64a 2.60c 2.65c†
[0.83,2.12] [1.08,2.49] [1.72,3.92] [1.96,3.58]
Z 60 1.61a 2.31c 2.44c 2.64c†
[1.01,2.55] [1.51,3.52] [1.60,3.72] [1.93,3.61]
Marital status Married/cohabiting Ref. Ref. Ref. Ref.
Single 0.86 0.98 1.27 1.03
[0.59,1.25] [0.68,1.43] [0.87,1.85] [0.77,1.38]
Divorced/widowed 1.22 1.41a 1.89c 1.52c
[0.84,1.76] [1.05,1.90] [1.43,2.50] [1.22,1.88]
Education High Ref. Ref. Ref. Ref.
Middle 1.07 1.43b 1.06 1.17
[0.81,1.40] [1.09,1.88] [0.81,1.39] [0.92,1.47]
Low 1.20 1.71a 1.61a 1.44a
[0.68,2.14] [1.10,2.66] [1.09,2.38] [1.08,1.92]
Household Good Ref. Ref. Ref. Ref.
economic situation Average 1.59a 1.26 1.16 1.49b
[1.11,2.27] [0.91,1.74] [0.85,1.58] [1.17,1.89]
Bad 3.93c 3.22c 3.67c 3.43c
[2.55,6.05] [2.18,4.75] [2.51,5.37] [2.59,4.54]
Social support High Ref. Ref. Ref. Ref.
Moderate 1.06 2.27c† 1.26† 1.69c†
[0.67,1.67] [1.48,3.48] [0.81,1.96] [1.27,2.25]
Low 1.31 3.49c† 2.04a 2.53c†
[0.75,2.28] [2.05,5.95] [1.19,3.52] [1.76,3.66]
Death of close relative Yes vs. No 1.65b 1.22 1.35a 1.29b
[1.20,2.29] [0.91,1.64] [1.01,1.81] [1.07,1.56]
Disability Yes vs. No 3.59c 3.40c 2.48c 4.37c
[2.27,5.66] [2.35,4.90] [1.72,3.58] [3.35,5.72]
Locus of control High Ref. Ref. Ref. Ref.
Middle 1.31 1.79c 2.00c† 1.75c
[0.95,1.81] [1.33,2.39] [1.52,2.63] [1.42,2.15]
Low 1.84c 3.06c† 2.79c 2.45c
[1.33,2.55] [2.27,4.12] [2.08,3.73] [1.98,3.04]

Abbreviation: Ref. reference category.

Data are odds ratios and 95% confidence intervals.
Models were mutually adjusted for all covariates shown in the table and country.
a
P o0.05.
b
Po 0.01.
c
Po 0.001.
†
Significant interaction for that category compared to country capital (Po 0.05).

the United States, Taiwan, and Canada (Quebec), which have respec-
tively linked residence in smaller urban (Breslau et al., 2014), rural
(Cheng, 1989), and non-metropolitan areas (Mechakra-Tahiri et al.,
2009) to depression. It also supports research findings from Russia
which have shown that there are high levels of depression in rural
areas (Dershem et al., 1996; O'Brien et al., 2011).
The fact that psychological distress was still higher in villages
than in capital cities in our pooled country sample and in some
individual countries, after adjusting for various demographic,
economic, and psychosocial variables suggests that other factors
are also important. It is possible, for example, that the quality of
life in rural areas might also be affecting mental health. Rural
infrastructure remains comparatively underdeveloped in these
countries (McKee et al., 2006; Roberts et al., 2012b), there is less
provision and use of medical services in rural areas (Balabanova
et al., 2012), while other important aspects of daily life, such as
access to a healthy diet are also worse in rural areas (Abe et al.,
2013). Taken together, such factors might be important, especially
as earlier research in rural areas in this region found a strong
association between satisfaction with life in general and depres-
sion (Dershem et al., 1996). Cultural factors may also be important.
The higher odds for psychological distress observed in Armenian
villages might be linked, for example, to the great social stigma
attached to mental illness in the country (von Schoen-Angerer,
2004; van Baelen et al., 2005), as well as a failure to be able to
guarantee patient confidentiality in rural areas (van Baelen et al.,
2005) which might be affecting help-seeking behavior for those
with mental health problems.
In the pooled analysis, living in smaller cities and settlements of
an urban type compared to the national capital was also associated
with significantly higher odds for psychological distress. In a study
recently undertaken in another former Soviet country―Latvia―rates
of depression were also higher in urban areas outside of the capital
city (i.e. smaller urban areas) although in comparison to those in
rural areas (Rancans et al., 2014). In the current study, the odds ratio
was exceptionally high in Azerbaijan, which might be underpinned
by several factors specific to that country. The country's capital,
Baku, has been experiencing a rapid expansion in recent years using
funds generated from the extraction of oil and gas resources (Grant,
2014). Not only has this led to a large population influx, but also to
the economic domination of the city, which was responsible for
nearly 71% of the country's GDP in 2011 (Valiyev, 2013). Smaller
 A. Stickley et al. / Journal of Affective Disorders 178 (2015) 142–148
urban areas have fared much worse however―even in comparison
with rural areas. Such areas have experienced industrial decline,
with rates of unemployment being twice as high in urban than in
rural areas (Habibov, 2012). This situation might have been further
exacerbated by the low levels of social protection provided by the
state in the presence of widespread poverty (Habibov and Fan,
2007). Moreover, while Baku has acted as a magnet for some parts
of the population, the land reform act in 1996 helped pull people in
the opposite direction and resulted in a “ruralization trend” in the
economy as people migrated from urban to rural areas in search
of work. The fact that greater poverty reduction subsequently
occurred among the rural population (Habibov, 2012) also suggests
that life in the country's smaller urban locations might be especially
difficult and be the source of high levels of psychological distress.
Previous research in these countries has linked factors such
as female sex, being aged 60 or above, having a bad household
economic situation and disability to higher odds for psychological
distress (Roberts et al., 2010) and these associations were also
observed in the current study across all settlement types (Table 3).
Further research will be needed however, to determine why certain
factors were significantly more likely to be linked to psychological
distress in locations outside the capital cities, although some
mechanisms can be speculated on. The comparatively higher odds
among older rural residents for instance, might be linked to the
difficulty of daily life in conjunction with a higher possibility of
illness. This might be especially problematic as not only are medical
services concentrated in the largest urban centers in these countries
(Jowett and Danielyan, 2010), but there is also an increasing need to
pay “under the table fees” for such services which has resulted in
many rural residents not obtaining treatment when ill (von Schoen-
Angerer, 2004). Similarly, lacking social support might be especially
detrimental for mental health where there is a comparative lack of
infrastructure available (Abe et al., 2012).
There are several limitations to this study. Although the scale
that we used to assess psychological distress had a good level of
internal consistency, and has been used before in the countries in
this region, it has not been formally validated in the study
countries (Roberts et al., 2010). However, the fact that similar
factors were linked to psychological distress in this study that have
been associated with depression in urban and rural regions of the
fSU when using conventional scales (Bobak et al., 2006; Dershem
et al., 1996) does give us some confidence in the results we
obtained. We also had no information for some variables that
might have been important for understanding these associations.
For example, we had no data on how long respondents had lived
in their respective settlements or if they had been born there or
migrated there more recently. This might have been a problem as
recent research has found that migration between rural and urban
areas is associated with worse mental health (Lu, 2010). Future
research in these countries should examine such factors to see if
they are important for explaining differences in psychological
distress between settlement types. Finally, it is possible that by
excluding groups such as the institutionalized and homeless we
might have underestimated the extent of psychological distress
and introduced bias into the study if these groups varied by
settlement type within and/or between countries.
5. Conclusions
This study has highlighted the importance of examining psycho-
logical distress in different types of settlement and shown that the
relationship between residential location and mental health varies
within and between countries in the fSU, even though many of the
factors associated with psychological distress are similar across
settlement types. It has also shown that the higher rates of poorer
147
mental health seen in urban locations in developed western coun-
tries are not found in the transition countries in the fSU where living
in smaller urban locations and villages is, overall, associated with
higher odds for greater psychological distress.
Role of funding source
This work was supported by the European Union's 7th Framework Programme,
project HEALTH-F2-2009-223344. The European Commission cannot accept any
responsibility for any information provided or views expressed. AK's work was
supported by the Miguel Servet contract financed by the CP13/00150 project,
integrated into the National Rþ DþI and funded by the ISCIII-General Branch
Evaluation and Promotion of Health Research-and the European Regional Devel-
opment Fund (ERDF). The sponsors played no role in the study design, in the
collection, analysis and interpretation of data; in the writing of the manuscript, or
in the decision to submit it for publication.
Conflict of interest
The authors declare that they have no conflicts of interest.
Acknowledgments
We are grateful to all members of the HITT Study teams who participated in the
co-ordination, organization and collection of the data.
References
Abe, S.K., Stickley, A., Roberts, B., Richardson, E., Abbott, P., Rotman, D., et al., 2013.
Changing patterns of fruit and vegetable intake in countries of the former
Soviet Union. Public Health Nutr. 16, 1924–1932.
Abe, Y., Fujise, N., Fukunaga, R., Nakagawa, Y., Ikeda, M., 2012. Comparisons of the
prevalence of and risk factors for elderly depression between urban and rural
populations in Japan. Int. Psychogeriatr. 24, 1235–1241.
Balabanova, D., Roberts, B., Richardson, E., Haerpfer, C., McKee, M., 2012. Health
care reform in the former Soviet Union: beyond the transition. Health Serv. Res.
47, 840–864.
Bobak, M., Pikhart, H., Pajak, A., Kubinova, R., Malyutina, S., Sebakova, H., et al.,
2006. Depressive symptoms in urban population samples in Russia, Poland and
the Czech Republic. Br. J. Psychiatry 188, 359–365.
Breslau, J., Marshall, G.N., Pincus, H.A., Brown, R.A., 2014. Are mental disorders
more common in urban than rural areas of the United States? J. Psychiatr. Res.
56, 50–55.
Cheng, T.A., 1989. Urbanisation and minor psychiatric morbidity. Soc. Psychiatry
Psychiatr. Epidemiol. 24, 309–316.
Dershem, L.D., Patsiorkovski, V.V., O'Brien, D.J., 1996. The use of the CES-D for
measuring symptoms of depression in three rural Russian villages. Soc. Indic.
Res. 39, 89–108.
Dhingra, S.S., Strine, T.W., Holt, J.B., Berry, J.T., Mokdad, A.H., 2009. Rural–urban
variations in psychological distress: findings from the behavioral risk factor
surveillance system, 2007. Int. J. Public Health 54 (Suppl 1), S16–S22.
Drapeau, A., Marchand, A., Beaulieu-Prévost, D., 2011. Epidemiology of psycholo-
gical distress. In: L'Abate, L. (Ed.), Mental illness. Understanding, prediction and
control. InTech Open Access Publisher, Croatia, pp. 105–134.
Galea, S., Uddin, M., Koenen, K., 2011. The urban environment and mental
disorders: epigenetic links. Epigenetics 6, 400–404.
Gerry, C.J., Nivorozhkin, E., Rigg, J.A., 2008. The great divide: ‘ruralisation’ of poverty
in Russia. Camb. J. Econ. 32, 593–607.
Goryakin, Y., Suhrcke, M., Roberts, B., McKee, M., 2015. Mental health inequalities in
9 former Soviet Union countries: evidence from the previous decade. Soc. Sci.
Med. 124, 142–151.
Grant, B., 2014. The edifice complex: architecture and the political life of surplus in
the new Baku. Public Cult. 26, 501–528.
Habibov, N., 2012. How and why determinants of household welfare changed in
Azerbaijan during the transition: lessons from national surveys. Probl. Econ.
Transit. 54, 3–52.
Habibov, N., Fan, L., 2007. Social protection and poverty in Azerbaijan, a low-
income country in transition: implications of a household survey. Int. Soc.
Secur. Rev 60, 47–68.
Jowett, M., Danielyan, E., 2010. Is there a role for user charges? Thoughts on health
system reform in Armenia. Bull. World Health Organ. 88, 472–473.
Kim, J.M., Shin, I.S., Yoon, J.S., Stewart, R., 2002. Prevalence and correlates of late-life
depression compared between urban and rural populations in Korea. Int. J.
Geriatr. Psychiatry 17, 409–415.
Kim, J.M., Stewart, R., Shin, I.S., Yoon, J.S., Lee, H.Y., 2004. Lifetime urban-rural
residence, social support and late-life depression in Korea. Int. J. Geriatr.
Psychiatry 19, 843–851.
Lu, Y., 2010. Rural–urban migration and health: evidence from longitudinal data in
Indonesia. Soc. Sci. Med. 70, 412–419.
Macours, K., Swinnen, J.F.M., 2008. Rural–urban poverty differences in transition
countries. World Dev. 36, 2170–2187.
148 A. Stickley et al. / Journal of Affective Disorders 178 (2015) 142–148
McKee, M., Balabanova, D., Akingbade, K., Pomerleau, J., Stickley, A., Rose, R., et al.,
2006. Access to water in the countries of the former Soviet Union. Public Health
120, 364–372.
Mechakra-Tahiri, S., Zunzunegui, M.V., Préville, M., Dubé, M., 2009. Social relation-
ships and depression among people 65 years and over living in rural and urban
areas of Quebec. Int. J. Geriatr. Psychiatry 24, 1226–1236.
Mumford, D.B., Minhas, F.A., Akhtar, I., Akhter, S., Mubbashar, M.H., 2000. Stress
and psychiatric disorder in urban Rawalpindi. Community survey. Br. J.
Psychiatry 177, 557–562.
Mumford, D.B., Saeed, K., Ahmad, I., Latif, S., Mubbashar, M.H., 1997. Stress and
psychiatric disorder in rural Punjab. A community survey. Br. J. Psychiatry 170,
473–478.
O'Brien, D.J., Wegren, S.K., Patsiorkovsky, V.V., 2011. Poverty, inequality and
subjective quality of life in rural Russia during the transition to a market
economy: 1991–2006. Poverty Public Policy 3, 1–26.
Oguzturk, O., 2008. Differences in quality of life in rural and urban populations.
Clin. Investig. Med. 31, E346–E350.
Paykel, E.S., Abbott, R., Jenkins, R., Brugha, T.S., Meltzer, H., 2000. Urban–rural
mental health differences in Great Britain: findings from the national morbidity
survey. Psychol. Med. 30, 269–280.
Peen, J., Schoevers, R.A., Beekman, A.T., Dekker, J., 2010. The current status of
urban–rural differences in psychiatric disorders. Acta. Psychiatr. Scand. 121,
84–93.
Rancans, E., Vrublevska, J., Snikere, S., Koroleva, I., Trapencieris, M., 2014. The point
prevalence of depression and associated sociodemographic correlates in the
general population of Latvia. J. Affect. Disord. 156, 104–110.
Razvodovsky, Y., Stickley, A., 2009. Suicide in urban and rural regions of Belarus,
1990–2005. Public Health 123, 27–31.
Ridner, S.H., 2004. Psychological distress: concept analysis. J. Adv. Nurs. 45,
536–545.
Roberts, B., Abbott, P., McKee, M., 2010. Levels and determinants of psychological
distress in eight countries of the former Soviet Union. J. Public Ment. Health 9,
17–26.
Roberts, B., Abbott, P., McKee, M., 2012a. Changes in the levels of psychological
distress in eight countries of the former Soviet Union. J. Public Ment. Health 11,
141–152.
Roberts, B., Stickley, A., Gasparishvili, A., Haerpfer, C., McKee, M., 2012b. Changes in
household access to water in countries of the former Soviet Union. J. Public
Health 34, 352–359.
Roberts, B, Stickley, A, Gilmore, A.B., Danishevski, K, Kizilova, K, Bryden, A, et al.,
2013. Knowledge of the health impacts of smoking and public attitudes
towards tobacco control in the former Soviet Union. Tob. Control 22, e12.
Robinson, K.L., McBeth, J., Macfarlane, G.J., 2004. Psychological distress and
premature mortality in the general population: a prospective study. Ann.
Epidemiol. 14, 467–472.
Rohrer, J.E., Borders, T.F., Blanton, J., 2005. Rural residence is not a risk factor for
frequent mental distress: a behavioral risk factor surveillance survey. BMC
Public Health 5, 46.
Romans, S., Cohen, M., Forte, T., 2011. Rates of depression and anxiety in urban and
rural Canada. Soc. Psychiatry Psychiatr. Epidemiol. 46, 567–575.
Stickley, A., Leinsalu, M., Razvodovsky, Y.E., 2009. Homicide in post-Soviet Belarus:
urban-rural trends. Eur. J. Public Health 19, 117–120.
Stickley, A., Razvodovsky, Y., 2009. Alcohol poisoning in Belarus: a comparison of
urban–rural trends, 1990–2005. Alcohol Alcohol. 44, 326–331.
van Baelen, L., Theocharopoulos, Y., Hargreaves, S., 2005. Mental health problems in
Armenia: low demand, high needs. Br. J. Gen. Pract. 55, 64–65.
Valiyev, A., 2013. Baku. Cities 31, 625–640.
von Schoen-Angerer, T., 2004. Understanding health care in the south Caucasus:
examples from Armenia. BMJ 329, 562–565.