Sot. Sci. Med. Vol. 33, No. 8, pp. 925-936, Printed in Great Britain. All tights reserved
1991 Copyright
0
0277-9536/91 53.00 + 0.00 1991 Pergamon Press plc
THE EUROPEAN HEALTH AND BEHAVIOUR SURVEY: RATIONALE, METHODS AND INITIAL RESULTS FROM THE UNITED KINGDOM JANE WARDLE’ and ANDREW STEPTOE~ ‘Department of Psychology, Institute of Psychiatry, De Crespigny Park, London SES, U.K. and ZDepartment of Psychology, St George’s Hospital Medical School, Cranmer Terrace, London SW17, U.K. Abstract-The aim of this study was to assess a wide range of health-related behaviours, beliefs concerning the importance of behaviours for health, and health knowledge, using a standardized protocol suitable for translation and administration in different countries of Europe. An inventory was developed from previous literature for the assessment of substance use, positive health practices, diet and eating habits, driving behaviour and preventive health care, beliefs concerning the importance of 25 activities for health, and knowledge about the influence of seven factors (including smoking, alcohol and diet) on major diseases. The first phase of the study involved administration of the inventory to approximately 200 male and 200 female university students aged 18-30 in 20 European countries. This report concerns data collected from 419 students in the U.K., together with analyses of short-term response stability. The inventory showed adequate short-term stability. Sex differences were observed in a number of behaviours, including consumption of fats and cholesterol, salt and fibre, dieting, exercise, sun-protection, driving speed, regular dental check-ups, frequency of brushing teeth, access to doctor and blood pressure measurement. Beliefs about the importance of behaviours for health were closely associated with the occurrence or frequency of the behaviours both within and between health behaviour categories. Little relationship was observed between health behaviour and awareness of the role of these same factors in disease. Important gaps in health knowledge were identified. Data concerning the frequency of health-related behaviours is crucial to the planning of health education and primary prevention programmes. The close association between beliefs and behaviour emphasises the importance of cognitive factors, while health knowledge appears to play a less direct role. Key words-health
behaviour, health beliefs, medical knowledge, international
INTRODUCTION
Health behaviour was defined by Kasl and Cobb [l] as “Any activity undertaken by a person believing himself to be healthy for the purpose of preventing disease or detecting it at an asymptomatic stage”. Several limitations to this conceptualization have been recognized over the last two decades, including the omission of lay or self-defined health behaviours [2], and the exclusion of activities carried out by people with recognised illnesses that are directed at self-management, delaying disease progression or improving general well-being. Nevertheless, the significance of behaviour and life style for health and well-being is now widely acknowledged. Studies in Alameda County identified seven features of life style-not smoking, moderate alcohol intake, sleeping 7-8 hr a night, exercising regularly, maintaining a desirable body weight, avoiding snacks and eating breakfast regularly-that were together associated with morbidity and subsequent long-term sutviva1 [3,4]. This pattern has been replicated in independent samples [5,6], although the construction of an additive “health practices index” has been criticised [7l. Research into major causes of morbidity and mortality such as cancer and ischaemic heart disease emphasises the importance, for prevention, of behaviours such as smoking, alcohol consumption, dietary choice, sexual behaviours and physical
exercise [8,9]. Studies of premature death attributable to life style factors also confirm smoking, alcohol consumption and diet as major precursors, together with gaps in primary prevention and screening uptake [lo]. Information concerning health-related behaviour is vital to the planning of health education and primary prevention programmes. Health behaviours have been monitored in several large scale surveys in the United States, including the National Survey of Personal Health Practices and Health Consequences, the Health Promotion and Disease Prevention Section of the National Health Interview Survey, and the Behavioral Risk Factor Surveill: ,nce System [ 111. International comparisons are also being carried out within parrticular fields of health risk, such as the MONICA project on cardiovascular risk factors [12], and surveys of smoking [13] and personal hygiene [14]. A WHO cross-national survey on health behaviour in schoolchildren is currently underway, and is concerned with smoking, physical exercise, eating habits, use of alcohol, oral hygiene and sleeping habits in 11-15 year-olds [15]. In general however, comparisons of health behaviours across countries are made difficult by a lack of uniform protocols for data collection, leading to differences in the definition of health-related activities. International comparisons of health attitudes and knowledge of the links between behaviour and disease are also lacking. 925
JANE WARDLE
926
and
The European Health and Behaviour Survey was therefore initiated within the Medical and Health Research Programme of the European Community. The project has been carried out through the Concerted Action on Breakdown in Human Adaptation: Quantification of Parameters. The aim has been to develop a survey for assessing health-related behaviours, beliefs concerning health and behaviour, and awareness of the influence of behaviour on specific major diseases, using a standard protocol and uniform scoring and data entry procedure, in order to facilitate comparisons across the European populations. There are two important reasons for concentrating on Europe. Firstly, there are large differences in the incidence of major diseases across the continent [16, 171. Although variations in health care availability may be partly responsible [18], differences in life style and behaviour are also significant. Secondly, Europe is entering a phase of greater cultural mobility and integration. The single market within the European Community and the loosening of restrictions on travel between Western and Eastern Europe may lead to widespread movements of people. However, the pattern of health-related habits and beliefs may vary considerably, so that efforts at health promotion and effective health resource utilization in one country may not be appropriate for immigrants from another region. It is essential therefore to develop a database for health behaviours and beliefs across Europe, so that policy decisions can be made on an informed basis, taking regional and cultural factors into account. Twenty countries have participated in the first phase of the study. The present paper outlines a rationale for the European Health and Behaviour Survey, describes the protocol and provides evidence for test-retest stability. In addition, initial results from the first United Kingdom sample are presented concerning the prevalence of health-related practices, sex differences, and links between behaviour, beliefs and knowledge. RATIONALE
In common with other large-scale surveys, it was decided to sample across a range of health-related behaviours, instead of focusing on risk factors for a single disorder. Six major classes of health-related behaviours were assessed, namely: Substance sumption;
use-smoking
and
alcohol
con-
Positive health practices-physical exercise, sleep time, protection during exposure to the sun, and frequency of brushing teeth; Diet and eating habits-the consumption of red meat, fruit, salt, fibre, coffee drinking, the avoidance of fat and cholesterol, number of meals and between-meal snacks, regularity of eating breakfast, and dieting; Driving behaviour-seat belt use, obedience to speed limits, and drinking and driving; Preventive health care-regular access to a doctor and dentist, regular blood pressure checks, breast and testicle self-examination,
ANDREW STEPTOE
professional smears.
breast examination
and cervical
Beliefs concerning behaviour and health
Beliefs concerning health maintenance are of importance both in themselves, and because of their role in determining health behaviour. Several models relating attitudes, beliefs and emotions to health behaviour have been developed. These include the Health Belief Model [19], the Theory of Reasoned Action [20], Subjective Expected Utility models [21], Protection Motivation Theory [22], and Self-Efficacy Theory [23]. Other investigators have taken a dynamic view, considering the different stages involved in the adoption of preventive action [24,25]. The formulation of measures that would adequately assess all the attitudes that have been found relevant, and relate these to each of the classes of behaviour addressed in this survey, would be an immense and unwieldy exercise. It was therefore decided to assess beliefs about the importance of carrying out a range of different activities for health maintenance in general. Such beliefs are considered relevant in almost all of the theoretical models, being described in the Health Belief Model as perceived benefits, and in the Theory of Reasoned Action as “beliefs that behaviours lead to certain outcomes” [20]. Other synonyms or similar concepts include outcome expectations [26], efficacy expectations [27] and perceived efficacy of actions [28]. Beliefs of this kind have been implicated in the maintenance of a range of health-related behaviours, including cigarette smoking [29], alcohol consumption [30], healthy eating [31], exercise [32], dental hygiene [33], drinking and driving [34], seat-belt use [35], breast self-examination [36], testicle selfexamination [37], and participation in screening and vaccination programmes [38,39]. In the present study, overall appraisal of the importance of behaviours to health was selected as the best indicator of the subjects’ attitudes to health preservation. Beliefs about the importance of health habits not only influence behaviour, but are also significant in fashioning attitudes to legislation, social policy decisions and healthy lifestyle promotion programmes. Beliefs concerning seventeen of the activities included in the behaviour section were assessed, together with beliefs about a number of other behaviours that are relevant to health. In order to reduce the possibility of confounding attitude and behaviour measures, behaviours were assessed first, and buffer items were inserted between the two sets of questions [40]. Health knowledge
A major aim of health education is to provide accurate information concerning the relevance of personal habits to health maintenance, in the interests of influencing risk appraisal and ultimately behaviour [41]. Associations between knowledge and positive health behaviour have been found for factors such as diet (421, smoking [43], alcohol intake, exercise and breast self-examination [44], although other studies have found less evidence for consistency in knowledge and behaviour [29]. In the present study, respondents were asked about the relevance of factors such as smoking, alcohol consumption and exercise for
European Health and Behaviour Survey a series of major illnesses, including heart disease, hypertension, lung and breast cancer. Study sample
The first phase of the European Health and Behaviour Survey was carried out with university students from non-medical faculties. A target number of 200 male and 200 female students in the age range 18-30 from each of the 20 participating centres was selected for this phase. Similar sized groups of men and women were required in order to analyze sex differences, since these are pervasive [l.S, 44,451. Concerns are frequently expressed about the value of research conducted with student samples, so the reasons underlying this choice should be outlined. 1. Students represent a relatively homogeneous and easily identifiable group. Since health behaviours have been shown to vary with education, socio-economic status and age, the recruitment of samples with very different profiles in these respects would seriously limit the possibilities for comparisons between national groups [45--48). 2. University students are a relatively healthy group. Health status has an important influence on health habits and practices [46-483, so the inclusion of mixed samples would again complicate international comparisons. 3. In many countries, university students occupy a significant position in public life, and may comprise the opinion leaders of the future. Patterns of health behaviour and beliefs in students may therefore be particularly significant. 4. The administration of the survey to students in classes ensured a high response rate (in many countries loo%), reducing the biases that might arise through selection or non-participation. 5. The prevention of serious illness such as ischaemic heart disease begins early in life, since risk factors can be identified even in childhood that have long-term implications for health [49]. Similarly, non-life threatening conditions such as periodontal disease depend on health behaviours in the early decades of life [50]. While studies of children are important, the young adults included in this survey were leading independent lives, so their habits may not have been simple reflections of family attitudes and practices. METHOD
Subjects 219 male and 200 female students aged 18-30 from the University of London completed the first phase of the U.K. wing of the survey. The participants were studying law, economics, engineering and physical sciences. Test-retest stability was assessed in a separate group of 46 students who filled in the survey twice at an interval of 17 days.
Suruey Wherever possible, health-related behaviours were assessed using existing measures, particularly those developed for the Health Promotion and Disease Prevention section of the 1985 U.S. National Health Interview Survey [51], and the Health and Lifestyle
927
Survey [52]. Smoking was classified into 8 categories, ranging from never having smoked a single cigarette to smoking more than 20 cigarettes a day. Four categories of alcohol consumption were used: nondrinker, special occasions drinker, occasional and regular drinker. Occasional and regular drinkers were asked on how many days over the past two weeks they had had a drink, and how many drinks they consumed on those days. Physical activity was assessed by questions concerning exercise over the last two weeks, the type of exercise, and the number of sessions carried out. Mode and distance of travel to college were also recorded. Participants were asked if they wished to reduce smoking and alcohol levels, and to increase the amount that they exercised. Average sleep time was reported in hours and minutes. Exposure to the sun was measured by asking subjects whether they sunbathed, and if so, whether they used sunscreen cream or lotion. Frequency of brushing teeth was assessed in four categories ranging from ‘twice or more a day’ to ‘seldom or never’. In the assessment of diet and eating habits, five categories were used to measure the consumption of red meat (beef, pork, sausages, hamburgers etc) and fruit, ranging from ‘at least once a day’ to ‘never’. The addition of salt to meals was classified into four categories ranging from ‘usually’ to ‘never’. Conscious efforts to avoid fat and cholesterol or to eat food high in fibre were measured in a yes/no format, followed by free report of the actual foodstuffs avoided or selected. Coffee drinking was classified into four categories, regularity of eating breakfast into three, while a count of the average number of meals and between-meal snacks was taken. Participants were asked if they were trying to lose weight and were dieting to lose weight, and rated their perceived weight on a five-point scale ranging from ‘very overweight’ to ‘very underweight’. The section on driving behaviour included assessments of seat belt use and driving speed on 4-point scales, and an estimate of how many times over the last year respondents had driven when they felt that they had had too much to drink. Preventive health care items included whether or not they had regular dental examinations, had a regular doctor or clinic to which they could go, and when they had had their blood pressure measured. Women were asked if they knew how to examine their own breasts for lumps, and if so, how frequently they carried out this behaviour. Men were asked the equivalent question for testicle self-examination. Frequency of breast examination by a doctor or nurse was assessed in three categories, and frequency of cervical smears in four categories. In addition to health behaviours, age, height, weight, marital status and number of children were recorded. Participants were asked for details of any persistent health problems, treatments from a doctor or health clinic over the last month, and for use of unprescribed treatments over the last month. Beliefs concerning the importance of behaviours for health were assessed with a series of lo-point scales, where 1 = a low importance to health, and 10 = very great importance to health. The 25 items are listed in Table 3. Knowledge was assessed by presenting a matrix of seven health problems (dia-
928
JANE WARDLE and ANDREW STEPTOE
b&es, heart disease, lung cancer, mental illness, breast cancer, high blood pressure and skin cancer) and nine factors (smoking, alcohol, exercise, stress, heredity, eating animal fat, eating salt, eating fibre, sunbathing). Subjects were asked to tick the appropriate box if they were of the opinion that the health problem was influenced by the factor in question. Procedure
Students completed the survey at the end of lectures and before they left the class. They were told that the survey concerned activities related to health and that an international comparison was being carried out, but no further details were provided. Students were assured of complete anonymity. Administration of the survey in lecture theatres allowed failures of completion to be counted accurately. The protocol was completed by 92-100% of the various classes approached. Analysis
Test-retest stability of categorical responses was assessed using Goodman and Kruskal’s gamma (G) or lambda (L) statistics as appropriate [53]. Stability of parametric data was analyzed using productmoment correlations. Test-retest stability of the knowledge section of the survey was not assessed, on the grounds that exposure to questions on the first occasion might stimulate information seeking and exchange, leading to genuine changes in opinion. In the analysis of the United Kingdom data set, sex differences were analyzed using Students t-test and corrected x2 statistics, while the links between behaviour and beliefs were assessed with analysis of variance. RESULTS
Test-retest stability
Complete agreement between responses given on two occasions was recorded for the following variables: frequency of brushing teeth, regular attendance at the dentist, and breast examination by a doctor or nurse. Highly stable responses were also observed for smoking, alcohol consumption, sunbathing, consumption of red meat, salt, coffee, avoidance of fat and cholesterol, eating of fibre, regularity of breakfast, dieting, perceived weight, seatbelt use, obedience to speed limits, access to doctor, breast and testicle self-examination, cervical smears, persistent health problems, and unprescribed medication (L = 0.60-0.96, G = 0.91-0.99, P 10 times a year
(x2 = 6.06-41.7, P < 0.01). There was no sex difference in the proportion of smokers who wished to cut down or drinkers who wished to reduce, but significantly more women than men wanted to increase their levels of physical exercise. Women were more likely to diet than men (15.2% vs 4.1%, x2= 13.7, P < 0.001). As can be seen from Table 2, only 23% of women stated that they knew how to carry out breast self-examination, while the proportion of men who were familiar with testicle self-examination was 8.0%. The numbers carrying out these examinations with any frequency were minimal. Beliefs concerning behaviour and health
The average ratings given by men and women about the importance of different activities and habits
55.3 15.1 (1.9)
Women
(sex differences) 0.00 I 0.001
75.4 7.9 (0.89) 14.4 1.0 24.6 23.3 83.7 5.5 a.2 2.6 68.9 13.1 18.0
8.0 93.9 I.2 2.3 1.9
for health are shown in Table 3, ranked according to aggregate means. The highest rating (mean 9.58 out of a maximum of 10) was given for not driving after drinking, while the lowest rating was for drinking no alcohol at all. Significant sex differences were found for thirteen items, and in each case bar one, women gave higher ratings than men. Interestingly, these items overlap considerably with the sex differences in health behaviours shown in Table 2; women believed that avoiding direct sunshine, tooth brushing regularly, avoiding animal fat, eating fibre and driving within the speed limit were more important for health than did men. They also thought it more important to use a condom with a partner whose previous experience is unknown, not to eat too much sugar and to avoid food additivies than did men. It is also
Table 3. Beliefs about the importance of behaviours for health (SEM in parentheses) P Men
Never to drive after drinking Use a condom with a new sexual partner Brush teeth regularly Wear a seat belt Not to smoke Cervical smear every 3 years Take regular exercise Dental exam every year Sleep 7-8 hr Drive within speed limit Breast self-examination every month Fire extinguisher in house Smoke detector in the house Eat fibrc Moderate alcohol intake Avoid animal fat Breakfast every day Avoid too much sugar Testicle self-examination every month Control or avoid stress Avoid direct sunshine Avoid food additives Avoid excessive coffee Blood pressure measure every year Drink no alcohol
9.44 (0.10) 8.98 (0.13) 8.68 (0.12) 8.80 (0.13) 8.47 (0.18) 8.29 (0.16) 8.30 (0.13) 7.53 (0.16) 7.43 (0.17) 6.71 (0.18) 7.58 (0.17) 6.94 (0.17) 7.00 (0.17) 6.78 (0.16) 6.52 (0.19) 6.21 (0.17) 6.62 (0.20) 6.08 (0.16) 6.14 (0.22) 6.24 (0.18) 5.42 (0.18) 5.20(0.18) 5.38 (0. IS) 4.43 (0.18) 3.38 (0.21)
Women 9.73 (0.06) 9.52 (0.08) 9.06 (0.09) 8.85 (0.13) 8.80 (0.15) 8.16(0.16) 8.08 (0.12) 7.93 (0.15) 7.48 (0.17) 7.89 (0.13) 6.65(0.17) 7.28 (0.17) 7.17(0.18) 7.29 (0.15) 7.22 (0.16) 7.06 (0.17) 6.54 (0.21) 6.94 (0.15) 6.85(0.18) 6.24(0.19) 6.30 (0.19) 6.18(0.18) 5.92(0.17) 4.77 (0.19) 3.23 (0.18)
(sex difference) 0.025 0.001 0.0 I
0.001 0.001 0.02 0.01 0.001 0.001 0.01 0.001 0.00 I 0.05
European
Health and Behaviour Survey
intriguing to note that women rate testicle self-examination as more important than do men, while men consider breast self-examination to be more important than do women. Both men and women downgrade cancer prevention checks that they have to do themselves, compared with beliefs about what the opposite sex should do. Health knowledge
The proportion of the U.K. sample who were aware of the links between the various factors on the Knowledge section of the survey and health problems is shown in Table 4. Only the more important associations are given, but full details are available from the authors. A number of interesting points are evident in these data. Almost the entire sample was aware that smoking was related to lung cancer, that animal fats were linked with heart disease, and that exposure to the sun was relevant to skin cancer. Other major risk factors, such as smoking for heart disease and alcohol for high blood pressure, were known by a sizeable proportion (60.5 and 62.3%) while only a minority were aware of risk factors for breast cancer such as alcohol consumption and animal fats (6.9 and 5.3% respectively). Stress was widely believed to be relevant to illness, being the most frequently endorsed factor for high blood pressure (78.3%) and mental illness (76.6%) while also being reported prominently for heart disease (64.7%). In general, respondents were more confident about factors relating to cardiovascular disease than cancers or other disorders, as can be seen from the proportions endorsing each item. Among the opinions concerning factors related to illness, it is striking that substantial numbers believe that smoking is directly linked with breast cancer (34.1%) and high blood pressure (47.7%). A number of sex differences were found in these responses, notably for the role of stress and animal fat in heart disease, heredity for lung cancer, smoking, alcohol and heredity for breast cancer, and all seven factors listed in Table 4 for high blood pressure Table 4. Knowledne
of factors
Percentaae Heart disease
High blood pressure
Mental
illness
Lung cancer Breast cancer
Skin cancer
related to illness endorsine:
Eating animal Smoking Stress Alcohol Heredity Exercise Stress Eating salt Alcohol Eating animal Exercise Smoking Heredity Stress Heredity Alcohol Smoking Heredity Smoking Heredity Stress Alcohol Farina animal Sunbithing
fat
fat
fat
items
% 88.5 68.5 64.7 57.5 56.1 55.4 18.3 70.4 62.3 52.3 48.1 47.7 4215 16.6 62.5 42.0 98.6 15.3 34.1 30.5 13.6 6.9 5.3 98.3
931
(x2 = 3.88-18.8, P < 0.05). In each case, more women than men endorsed the items. Links between behaviours, beliefs and knowledge
The associations between each behaviour and beliefs about the importance of that behaviour for health were assessed by comparing belief ratings across behaviour frequency categories. Striking relationships were observed for all the 17 items for which behaviours and corresponding beliefs were recorded, and these are detailed in Table 5. For every item, there is a significant association between the frequency or intensity of carrying out the behaviour and the mean rating of the associated belief. For example, people who brush their teeth twice or more per day believe this behaviour to be more important for health than those who brush their teeth once a day, who in turn believe it to be more important than those who brush their teeth less frequently than once per day. The same relationship holds for every item concerning substance use, positive health practices, diet, driving behaviour and preventive health care for which parallel behaviour and belief measures were obtained. The only item not to reach full significance concerned testicle self-examination; in this case, the small numbers carrying out the behaviour reduced statistical reliability. A relationship can also be observed across behaviours between the prevalence of activities and the mean belief ratings. This association is shown in Fig. 1, where the proportion of the sample carrying out each behaviour is plotted against the mean rating of the associated belief for the entire sample. A positive association between the two parameters is apparent (r = 0.56, P < 0.01). Thus the behaviours that on average were believed to be more important for health were carried out by more individuals than behaviours which were believed to be less important. Points falling above the diagonal refer to activities that were carried out more frequently than might be expected purely on the basis of beliefs concerning relevance to health. One of these items is the use of sunscreen cream or lotion when sunbathing, to which cosmetic reasons might contribute. Points lying below the diagonal represent activities that are carried out less frequently than would be anticipated on the basis of beliefs. It is interesting that the strongest outliers in this category are three preventive health care practices: breast and testicle self-examination, and cervical smear testing. Associations between health-related behaviours and health knowledge were also analyzed. Very few significant relationships were observed. Thus there were no significant differences between non-smokers and smokers of different categories in the proportion who were of the opinion that smoking influenced the seven health problems studied. Nor did smokers who wished or did not wish to reduce smoking levels show differences in knowledge. Similarly, frequency of eating red meat or conscious avoidance of cholesterol were not reliably associated with awareness of the influence of animal fats on illness; frequency of adding salt to food was not linked with awareness of the links between salt and illness; conscious efforts to eat fibre were not associated with knowledge about fibre and illness; and exercise levels were not
932
JANE WARDLE and ANDREW SEPTOE Table 5. Behaviour prevalence and belief ratings Mea” rating of beliefs about importance Cigarette smoking
Importance of not smoking Alcohol consumption
Importance of not drinking at all Importance of drinking moderately Exercise ocer the last 2 weeks
Non-smoker
< I/day
9.1 I
( + pipe, cigar) 7.40
Sleep time
Red meat consumption
Importance of not eating too much animal fat Avoidance of fat and cholesterol
Importance of not eating too much animal fat Dietary Jibre
Importance of eating enough dietary fibre
P 0.0001
7-8 hours 7.86
>8 hours 8.84
P 0.0001
I O/day P
I-IO/day
>2 times 7.60
Yes
NO
8.41
6.16
Within 12 months 5.15 Within 3 years 8.88
Seldom 3.93
> I2 months 4.09 >3 years ago 9.00
P
0.0001 P 0.0001 P 0.0001
Never 3.96 Never 7.90
P 0.0001 P
0.025
Z-10
I-10
10
l-10 a year 7.38
1991 Copyright
0
0277-9536/91 53.00 + 0.00 1991 Pergamon Press plc
THE EUROPEAN HEALTH AND BEHAVIOUR SURVEY: RATIONALE, METHODS AND INITIAL RESULTS FROM THE UNITED KINGDOM JANE WARDLE’ and ANDREW STEPTOE~ ‘Department of Psychology, Institute of Psychiatry, De Crespigny Park, London SES, U.K. and ZDepartment of Psychology, St George’s Hospital Medical School, Cranmer Terrace, London SW17, U.K. Abstract-The aim of this study was to assess a wide range of health-related behaviours, beliefs concerning the importance of behaviours for health, and health knowledge, using a standardized protocol suitable for translation and administration in different countries of Europe. An inventory was developed from previous literature for the assessment of substance use, positive health practices, diet and eating habits, driving behaviour and preventive health care, beliefs concerning the importance of 25 activities for health, and knowledge about the influence of seven factors (including smoking, alcohol and diet) on major diseases. The first phase of the study involved administration of the inventory to approximately 200 male and 200 female university students aged 18-30 in 20 European countries. This report concerns data collected from 419 students in the U.K., together with analyses of short-term response stability. The inventory showed adequate short-term stability. Sex differences were observed in a number of behaviours, including consumption of fats and cholesterol, salt and fibre, dieting, exercise, sun-protection, driving speed, regular dental check-ups, frequency of brushing teeth, access to doctor and blood pressure measurement. Beliefs about the importance of behaviours for health were closely associated with the occurrence or frequency of the behaviours both within and between health behaviour categories. Little relationship was observed between health behaviour and awareness of the role of these same factors in disease. Important gaps in health knowledge were identified. Data concerning the frequency of health-related behaviours is crucial to the planning of health education and primary prevention programmes. The close association between beliefs and behaviour emphasises the importance of cognitive factors, while health knowledge appears to play a less direct role. Key words-health
behaviour, health beliefs, medical knowledge, international
INTRODUCTION
Health behaviour was defined by Kasl and Cobb [l] as “Any activity undertaken by a person believing himself to be healthy for the purpose of preventing disease or detecting it at an asymptomatic stage”. Several limitations to this conceptualization have been recognized over the last two decades, including the omission of lay or self-defined health behaviours [2], and the exclusion of activities carried out by people with recognised illnesses that are directed at self-management, delaying disease progression or improving general well-being. Nevertheless, the significance of behaviour and life style for health and well-being is now widely acknowledged. Studies in Alameda County identified seven features of life style-not smoking, moderate alcohol intake, sleeping 7-8 hr a night, exercising regularly, maintaining a desirable body weight, avoiding snacks and eating breakfast regularly-that were together associated with morbidity and subsequent long-term sutviva1 [3,4]. This pattern has been replicated in independent samples [5,6], although the construction of an additive “health practices index” has been criticised [7l. Research into major causes of morbidity and mortality such as cancer and ischaemic heart disease emphasises the importance, for prevention, of behaviours such as smoking, alcohol consumption, dietary choice, sexual behaviours and physical
exercise [8,9]. Studies of premature death attributable to life style factors also confirm smoking, alcohol consumption and diet as major precursors, together with gaps in primary prevention and screening uptake [lo]. Information concerning health-related behaviour is vital to the planning of health education and primary prevention programmes. Health behaviours have been monitored in several large scale surveys in the United States, including the National Survey of Personal Health Practices and Health Consequences, the Health Promotion and Disease Prevention Section of the National Health Interview Survey, and the Behavioral Risk Factor Surveill: ,nce System [ 111. International comparisons are also being carried out within parrticular fields of health risk, such as the MONICA project on cardiovascular risk factors [12], and surveys of smoking [13] and personal hygiene [14]. A WHO cross-national survey on health behaviour in schoolchildren is currently underway, and is concerned with smoking, physical exercise, eating habits, use of alcohol, oral hygiene and sleeping habits in 11-15 year-olds [15]. In general however, comparisons of health behaviours across countries are made difficult by a lack of uniform protocols for data collection, leading to differences in the definition of health-related activities. International comparisons of health attitudes and knowledge of the links between behaviour and disease are also lacking. 925
JANE WARDLE
926
and
The European Health and Behaviour Survey was therefore initiated within the Medical and Health Research Programme of the European Community. The project has been carried out through the Concerted Action on Breakdown in Human Adaptation: Quantification of Parameters. The aim has been to develop a survey for assessing health-related behaviours, beliefs concerning health and behaviour, and awareness of the influence of behaviour on specific major diseases, using a standard protocol and uniform scoring and data entry procedure, in order to facilitate comparisons across the European populations. There are two important reasons for concentrating on Europe. Firstly, there are large differences in the incidence of major diseases across the continent [16, 171. Although variations in health care availability may be partly responsible [18], differences in life style and behaviour are also significant. Secondly, Europe is entering a phase of greater cultural mobility and integration. The single market within the European Community and the loosening of restrictions on travel between Western and Eastern Europe may lead to widespread movements of people. However, the pattern of health-related habits and beliefs may vary considerably, so that efforts at health promotion and effective health resource utilization in one country may not be appropriate for immigrants from another region. It is essential therefore to develop a database for health behaviours and beliefs across Europe, so that policy decisions can be made on an informed basis, taking regional and cultural factors into account. Twenty countries have participated in the first phase of the study. The present paper outlines a rationale for the European Health and Behaviour Survey, describes the protocol and provides evidence for test-retest stability. In addition, initial results from the first United Kingdom sample are presented concerning the prevalence of health-related practices, sex differences, and links between behaviour, beliefs and knowledge. RATIONALE
In common with other large-scale surveys, it was decided to sample across a range of health-related behaviours, instead of focusing on risk factors for a single disorder. Six major classes of health-related behaviours were assessed, namely: Substance sumption;
use-smoking
and
alcohol
con-
Positive health practices-physical exercise, sleep time, protection during exposure to the sun, and frequency of brushing teeth; Diet and eating habits-the consumption of red meat, fruit, salt, fibre, coffee drinking, the avoidance of fat and cholesterol, number of meals and between-meal snacks, regularity of eating breakfast, and dieting; Driving behaviour-seat belt use, obedience to speed limits, and drinking and driving; Preventive health care-regular access to a doctor and dentist, regular blood pressure checks, breast and testicle self-examination,
ANDREW STEPTOE
professional smears.
breast examination
and cervical
Beliefs concerning behaviour and health
Beliefs concerning health maintenance are of importance both in themselves, and because of their role in determining health behaviour. Several models relating attitudes, beliefs and emotions to health behaviour have been developed. These include the Health Belief Model [19], the Theory of Reasoned Action [20], Subjective Expected Utility models [21], Protection Motivation Theory [22], and Self-Efficacy Theory [23]. Other investigators have taken a dynamic view, considering the different stages involved in the adoption of preventive action [24,25]. The formulation of measures that would adequately assess all the attitudes that have been found relevant, and relate these to each of the classes of behaviour addressed in this survey, would be an immense and unwieldy exercise. It was therefore decided to assess beliefs about the importance of carrying out a range of different activities for health maintenance in general. Such beliefs are considered relevant in almost all of the theoretical models, being described in the Health Belief Model as perceived benefits, and in the Theory of Reasoned Action as “beliefs that behaviours lead to certain outcomes” [20]. Other synonyms or similar concepts include outcome expectations [26], efficacy expectations [27] and perceived efficacy of actions [28]. Beliefs of this kind have been implicated in the maintenance of a range of health-related behaviours, including cigarette smoking [29], alcohol consumption [30], healthy eating [31], exercise [32], dental hygiene [33], drinking and driving [34], seat-belt use [35], breast self-examination [36], testicle selfexamination [37], and participation in screening and vaccination programmes [38,39]. In the present study, overall appraisal of the importance of behaviours to health was selected as the best indicator of the subjects’ attitudes to health preservation. Beliefs about the importance of health habits not only influence behaviour, but are also significant in fashioning attitudes to legislation, social policy decisions and healthy lifestyle promotion programmes. Beliefs concerning seventeen of the activities included in the behaviour section were assessed, together with beliefs about a number of other behaviours that are relevant to health. In order to reduce the possibility of confounding attitude and behaviour measures, behaviours were assessed first, and buffer items were inserted between the two sets of questions [40]. Health knowledge
A major aim of health education is to provide accurate information concerning the relevance of personal habits to health maintenance, in the interests of influencing risk appraisal and ultimately behaviour [41]. Associations between knowledge and positive health behaviour have been found for factors such as diet (421, smoking [43], alcohol intake, exercise and breast self-examination [44], although other studies have found less evidence for consistency in knowledge and behaviour [29]. In the present study, respondents were asked about the relevance of factors such as smoking, alcohol consumption and exercise for
European Health and Behaviour Survey a series of major illnesses, including heart disease, hypertension, lung and breast cancer. Study sample
The first phase of the European Health and Behaviour Survey was carried out with university students from non-medical faculties. A target number of 200 male and 200 female students in the age range 18-30 from each of the 20 participating centres was selected for this phase. Similar sized groups of men and women were required in order to analyze sex differences, since these are pervasive [l.S, 44,451. Concerns are frequently expressed about the value of research conducted with student samples, so the reasons underlying this choice should be outlined. 1. Students represent a relatively homogeneous and easily identifiable group. Since health behaviours have been shown to vary with education, socio-economic status and age, the recruitment of samples with very different profiles in these respects would seriously limit the possibilities for comparisons between national groups [45--48). 2. University students are a relatively healthy group. Health status has an important influence on health habits and practices [46-483, so the inclusion of mixed samples would again complicate international comparisons. 3. In many countries, university students occupy a significant position in public life, and may comprise the opinion leaders of the future. Patterns of health behaviour and beliefs in students may therefore be particularly significant. 4. The administration of the survey to students in classes ensured a high response rate (in many countries loo%), reducing the biases that might arise through selection or non-participation. 5. The prevention of serious illness such as ischaemic heart disease begins early in life, since risk factors can be identified even in childhood that have long-term implications for health [49]. Similarly, non-life threatening conditions such as periodontal disease depend on health behaviours in the early decades of life [50]. While studies of children are important, the young adults included in this survey were leading independent lives, so their habits may not have been simple reflections of family attitudes and practices. METHOD
Subjects 219 male and 200 female students aged 18-30 from the University of London completed the first phase of the U.K. wing of the survey. The participants were studying law, economics, engineering and physical sciences. Test-retest stability was assessed in a separate group of 46 students who filled in the survey twice at an interval of 17 days.
Suruey Wherever possible, health-related behaviours were assessed using existing measures, particularly those developed for the Health Promotion and Disease Prevention section of the 1985 U.S. National Health Interview Survey [51], and the Health and Lifestyle
927
Survey [52]. Smoking was classified into 8 categories, ranging from never having smoked a single cigarette to smoking more than 20 cigarettes a day. Four categories of alcohol consumption were used: nondrinker, special occasions drinker, occasional and regular drinker. Occasional and regular drinkers were asked on how many days over the past two weeks they had had a drink, and how many drinks they consumed on those days. Physical activity was assessed by questions concerning exercise over the last two weeks, the type of exercise, and the number of sessions carried out. Mode and distance of travel to college were also recorded. Participants were asked if they wished to reduce smoking and alcohol levels, and to increase the amount that they exercised. Average sleep time was reported in hours and minutes. Exposure to the sun was measured by asking subjects whether they sunbathed, and if so, whether they used sunscreen cream or lotion. Frequency of brushing teeth was assessed in four categories ranging from ‘twice or more a day’ to ‘seldom or never’. In the assessment of diet and eating habits, five categories were used to measure the consumption of red meat (beef, pork, sausages, hamburgers etc) and fruit, ranging from ‘at least once a day’ to ‘never’. The addition of salt to meals was classified into four categories ranging from ‘usually’ to ‘never’. Conscious efforts to avoid fat and cholesterol or to eat food high in fibre were measured in a yes/no format, followed by free report of the actual foodstuffs avoided or selected. Coffee drinking was classified into four categories, regularity of eating breakfast into three, while a count of the average number of meals and between-meal snacks was taken. Participants were asked if they were trying to lose weight and were dieting to lose weight, and rated their perceived weight on a five-point scale ranging from ‘very overweight’ to ‘very underweight’. The section on driving behaviour included assessments of seat belt use and driving speed on 4-point scales, and an estimate of how many times over the last year respondents had driven when they felt that they had had too much to drink. Preventive health care items included whether or not they had regular dental examinations, had a regular doctor or clinic to which they could go, and when they had had their blood pressure measured. Women were asked if they knew how to examine their own breasts for lumps, and if so, how frequently they carried out this behaviour. Men were asked the equivalent question for testicle self-examination. Frequency of breast examination by a doctor or nurse was assessed in three categories, and frequency of cervical smears in four categories. In addition to health behaviours, age, height, weight, marital status and number of children were recorded. Participants were asked for details of any persistent health problems, treatments from a doctor or health clinic over the last month, and for use of unprescribed treatments over the last month. Beliefs concerning the importance of behaviours for health were assessed with a series of lo-point scales, where 1 = a low importance to health, and 10 = very great importance to health. The 25 items are listed in Table 3. Knowledge was assessed by presenting a matrix of seven health problems (dia-
928
JANE WARDLE and ANDREW STEPTOE
b&es, heart disease, lung cancer, mental illness, breast cancer, high blood pressure and skin cancer) and nine factors (smoking, alcohol, exercise, stress, heredity, eating animal fat, eating salt, eating fibre, sunbathing). Subjects were asked to tick the appropriate box if they were of the opinion that the health problem was influenced by the factor in question. Procedure
Students completed the survey at the end of lectures and before they left the class. They were told that the survey concerned activities related to health and that an international comparison was being carried out, but no further details were provided. Students were assured of complete anonymity. Administration of the survey in lecture theatres allowed failures of completion to be counted accurately. The protocol was completed by 92-100% of the various classes approached. Analysis
Test-retest stability of categorical responses was assessed using Goodman and Kruskal’s gamma (G) or lambda (L) statistics as appropriate [53]. Stability of parametric data was analyzed using productmoment correlations. Test-retest stability of the knowledge section of the survey was not assessed, on the grounds that exposure to questions on the first occasion might stimulate information seeking and exchange, leading to genuine changes in opinion. In the analysis of the United Kingdom data set, sex differences were analyzed using Students t-test and corrected x2 statistics, while the links between behaviour and beliefs were assessed with analysis of variance. RESULTS
Test-retest stability
Complete agreement between responses given on two occasions was recorded for the following variables: frequency of brushing teeth, regular attendance at the dentist, and breast examination by a doctor or nurse. Highly stable responses were also observed for smoking, alcohol consumption, sunbathing, consumption of red meat, salt, coffee, avoidance of fat and cholesterol, eating of fibre, regularity of breakfast, dieting, perceived weight, seatbelt use, obedience to speed limits, access to doctor, breast and testicle self-examination, cervical smears, persistent health problems, and unprescribed medication (L = 0.60-0.96, G = 0.91-0.99, P 10 times a year
(x2 = 6.06-41.7, P < 0.01). There was no sex difference in the proportion of smokers who wished to cut down or drinkers who wished to reduce, but significantly more women than men wanted to increase their levels of physical exercise. Women were more likely to diet than men (15.2% vs 4.1%, x2= 13.7, P < 0.001). As can be seen from Table 2, only 23% of women stated that they knew how to carry out breast self-examination, while the proportion of men who were familiar with testicle self-examination was 8.0%. The numbers carrying out these examinations with any frequency were minimal. Beliefs concerning behaviour and health
The average ratings given by men and women about the importance of different activities and habits
55.3 15.1 (1.9)
Women
(sex differences) 0.00 I 0.001
75.4 7.9 (0.89) 14.4 1.0 24.6 23.3 83.7 5.5 a.2 2.6 68.9 13.1 18.0
8.0 93.9 I.2 2.3 1.9
for health are shown in Table 3, ranked according to aggregate means. The highest rating (mean 9.58 out of a maximum of 10) was given for not driving after drinking, while the lowest rating was for drinking no alcohol at all. Significant sex differences were found for thirteen items, and in each case bar one, women gave higher ratings than men. Interestingly, these items overlap considerably with the sex differences in health behaviours shown in Table 2; women believed that avoiding direct sunshine, tooth brushing regularly, avoiding animal fat, eating fibre and driving within the speed limit were more important for health than did men. They also thought it more important to use a condom with a partner whose previous experience is unknown, not to eat too much sugar and to avoid food additivies than did men. It is also
Table 3. Beliefs about the importance of behaviours for health (SEM in parentheses) P Men
Never to drive after drinking Use a condom with a new sexual partner Brush teeth regularly Wear a seat belt Not to smoke Cervical smear every 3 years Take regular exercise Dental exam every year Sleep 7-8 hr Drive within speed limit Breast self-examination every month Fire extinguisher in house Smoke detector in the house Eat fibrc Moderate alcohol intake Avoid animal fat Breakfast every day Avoid too much sugar Testicle self-examination every month Control or avoid stress Avoid direct sunshine Avoid food additives Avoid excessive coffee Blood pressure measure every year Drink no alcohol
9.44 (0.10) 8.98 (0.13) 8.68 (0.12) 8.80 (0.13) 8.47 (0.18) 8.29 (0.16) 8.30 (0.13) 7.53 (0.16) 7.43 (0.17) 6.71 (0.18) 7.58 (0.17) 6.94 (0.17) 7.00 (0.17) 6.78 (0.16) 6.52 (0.19) 6.21 (0.17) 6.62 (0.20) 6.08 (0.16) 6.14 (0.22) 6.24 (0.18) 5.42 (0.18) 5.20(0.18) 5.38 (0. IS) 4.43 (0.18) 3.38 (0.21)
Women 9.73 (0.06) 9.52 (0.08) 9.06 (0.09) 8.85 (0.13) 8.80 (0.15) 8.16(0.16) 8.08 (0.12) 7.93 (0.15) 7.48 (0.17) 7.89 (0.13) 6.65(0.17) 7.28 (0.17) 7.17(0.18) 7.29 (0.15) 7.22 (0.16) 7.06 (0.17) 6.54 (0.21) 6.94 (0.15) 6.85(0.18) 6.24(0.19) 6.30 (0.19) 6.18(0.18) 5.92(0.17) 4.77 (0.19) 3.23 (0.18)
(sex difference) 0.025 0.001 0.0 I
0.001 0.001 0.02 0.01 0.001 0.001 0.01 0.001 0.00 I 0.05
European
Health and Behaviour Survey
intriguing to note that women rate testicle self-examination as more important than do men, while men consider breast self-examination to be more important than do women. Both men and women downgrade cancer prevention checks that they have to do themselves, compared with beliefs about what the opposite sex should do. Health knowledge
The proportion of the U.K. sample who were aware of the links between the various factors on the Knowledge section of the survey and health problems is shown in Table 4. Only the more important associations are given, but full details are available from the authors. A number of interesting points are evident in these data. Almost the entire sample was aware that smoking was related to lung cancer, that animal fats were linked with heart disease, and that exposure to the sun was relevant to skin cancer. Other major risk factors, such as smoking for heart disease and alcohol for high blood pressure, were known by a sizeable proportion (60.5 and 62.3%) while only a minority were aware of risk factors for breast cancer such as alcohol consumption and animal fats (6.9 and 5.3% respectively). Stress was widely believed to be relevant to illness, being the most frequently endorsed factor for high blood pressure (78.3%) and mental illness (76.6%) while also being reported prominently for heart disease (64.7%). In general, respondents were more confident about factors relating to cardiovascular disease than cancers or other disorders, as can be seen from the proportions endorsing each item. Among the opinions concerning factors related to illness, it is striking that substantial numbers believe that smoking is directly linked with breast cancer (34.1%) and high blood pressure (47.7%). A number of sex differences were found in these responses, notably for the role of stress and animal fat in heart disease, heredity for lung cancer, smoking, alcohol and heredity for breast cancer, and all seven factors listed in Table 4 for high blood pressure Table 4. Knowledne
of factors
Percentaae Heart disease
High blood pressure
Mental
illness
Lung cancer Breast cancer
Skin cancer
related to illness endorsine:
Eating animal Smoking Stress Alcohol Heredity Exercise Stress Eating salt Alcohol Eating animal Exercise Smoking Heredity Stress Heredity Alcohol Smoking Heredity Smoking Heredity Stress Alcohol Farina animal Sunbithing
fat
fat
fat
items
% 88.5 68.5 64.7 57.5 56.1 55.4 18.3 70.4 62.3 52.3 48.1 47.7 4215 16.6 62.5 42.0 98.6 15.3 34.1 30.5 13.6 6.9 5.3 98.3
931
(x2 = 3.88-18.8, P < 0.05). In each case, more women than men endorsed the items. Links between behaviours, beliefs and knowledge
The associations between each behaviour and beliefs about the importance of that behaviour for health were assessed by comparing belief ratings across behaviour frequency categories. Striking relationships were observed for all the 17 items for which behaviours and corresponding beliefs were recorded, and these are detailed in Table 5. For every item, there is a significant association between the frequency or intensity of carrying out the behaviour and the mean rating of the associated belief. For example, people who brush their teeth twice or more per day believe this behaviour to be more important for health than those who brush their teeth once a day, who in turn believe it to be more important than those who brush their teeth less frequently than once per day. The same relationship holds for every item concerning substance use, positive health practices, diet, driving behaviour and preventive health care for which parallel behaviour and belief measures were obtained. The only item not to reach full significance concerned testicle self-examination; in this case, the small numbers carrying out the behaviour reduced statistical reliability. A relationship can also be observed across behaviours between the prevalence of activities and the mean belief ratings. This association is shown in Fig. 1, where the proportion of the sample carrying out each behaviour is plotted against the mean rating of the associated belief for the entire sample. A positive association between the two parameters is apparent (r = 0.56, P < 0.01). Thus the behaviours that on average were believed to be more important for health were carried out by more individuals than behaviours which were believed to be less important. Points falling above the diagonal refer to activities that were carried out more frequently than might be expected purely on the basis of beliefs concerning relevance to health. One of these items is the use of sunscreen cream or lotion when sunbathing, to which cosmetic reasons might contribute. Points lying below the diagonal represent activities that are carried out less frequently than would be anticipated on the basis of beliefs. It is interesting that the strongest outliers in this category are three preventive health care practices: breast and testicle self-examination, and cervical smear testing. Associations between health-related behaviours and health knowledge were also analyzed. Very few significant relationships were observed. Thus there were no significant differences between non-smokers and smokers of different categories in the proportion who were of the opinion that smoking influenced the seven health problems studied. Nor did smokers who wished or did not wish to reduce smoking levels show differences in knowledge. Similarly, frequency of eating red meat or conscious avoidance of cholesterol were not reliably associated with awareness of the influence of animal fats on illness; frequency of adding salt to food was not linked with awareness of the links between salt and illness; conscious efforts to eat fibre were not associated with knowledge about fibre and illness; and exercise levels were not
932
JANE WARDLE and ANDREW SEPTOE Table 5. Behaviour prevalence and belief ratings Mea” rating of beliefs about importance Cigarette smoking
Importance of not smoking Alcohol consumption
Importance of not drinking at all Importance of drinking moderately Exercise ocer the last 2 weeks
Non-smoker
< I/day
9.1 I
( + pipe, cigar) 7.40
Sleep time
Red meat consumption
Importance of not eating too much animal fat Avoidance of fat and cholesterol
Importance of not eating too much animal fat Dietary Jibre
Importance of eating enough dietary fibre
P 0.0001
7-8 hours 7.86
>8 hours 8.84
P 0.0001
I O/day P
I-IO/day
>2 times 7.60
Yes
NO
8.41
6.16
Within 12 months 5.15 Within 3 years 8.88
Seldom 3.93
> I2 months 4.09 >3 years ago 9.00
P
0.0001 P 0.0001 P 0.0001
Never 3.96 Never 7.90
P 0.0001 P
0.025
Z-10
I-10
10
l-10 a year 7.38
