26, 845–854 (1997)
PM970224
PREVENTIVE MEDICINE
ARTICLE NO.
Leisure-Time Physical Exercise: Prevalence, Attitudinal Correlates, and
Behavioral Correlates among Young Europeans from 21 Countries
Andrew Steptoe, D.Sc.,*,1 Jane Wardle, Ph.D.,* Raymond Fuller, Ph.D.,† Arne Holte, Ph.D.,‡
Joao Justo, Ph.D.,§ Robbert Sanderman, Ph.D.,¶ and Lars Wichstrøm, Ph.D.\
*University of London, London, United Kingdom; †Trinity College, Dublin, Republic of Ireland; ‡University of Tromsø, Tromsø, Norway;
§University of Lisbon, Lisbon, Portúgal; ¶University of Groningen, Groningen, The Netherlands; and \Norwegian University of Science
and Technology, Norway
Background. Increasing leisure time physical exercise is a major target of public health programs
throughout the developed world, but few international comparisons of exercise habits among people
from diverse cultures have been published. The objectives of this study were to assess the prevalence of
exercise among young adults from 21 European countries, to analyze associations with health beliefs and
risk awareness, and to investigate relationships
among exercise, other health-related behaviors, and
emotional well-being.
Methods. The European Health and Behaviour Survey, a questionnaire survey of 7,302 male and 9,181
female university students ages 18–30 years from 21
countries, was analyzed.
Results. Age-adjusted prevalence of physical exercise in the past 2 weeks averaged 73.2% among men
and 68.3% among women, but varied markedly from
more than 80% to less than 60% across country
samples. Beliefs in the health benefits of exercise were
consistently associated with physical exercise, as was
desire to lose weight. Awareness of the influence of
exercise on heart disease averaged 52% among men
and 54% among women, but was not strongly associated with engagement in exercise. Associations among
exercise, lack of smoking, and sleep time were observed, but results for alcohol consumption were inconsistent. Social support and depression were independently associated with physical exercise.
Conclusions. Physical exercise levels are highly variable across samples of relatively privileged young Europeans from different countries. Associations with
other health behaviors and with emotional well-being
suggest that regular physical exercise is consistent
with a healthy lifestyle. Links with health beliefs are
consistent despite sociocultural differences, but defi-
1
To whom correspondence should be addressed at Department of
Psychology, St. George’s Hospital Medical School, University of London, Cranmer Terrace, London SW17 ORE, UK. Fax: (44) 181 767
2741.
cient knowledge of the health consequences of a sedentary lifestyle remains a cause for concern. © 1997 Academic Press
Key Words: physical exercise; health beliefs; health
behavior; depression; social support.
INTRODUCTION
Lack of physical activity increases risk of coronary
heart disease [1] and other diseases of major socioeconomic impact [2]. The low prevalence of regular leisure
time physical exercise is a cause for concern in many
countries, and encouragement of more active lifestyles
is an important component of both national and international public health recommendations [3,4]. There
have been few international studies of leisure time
physical exercise. Data collected through surveys in
individual countries are difficult to compare because of
varying time frames and methods of assessment. This
paper describes results from a survey in which young
European students from 21 countries were questioned
about physical activity using identical methods.
We assessed the prevalence of leisure time physical
exercise over previous 2 weeks in well-educated young
adults across Europe. Gender differences have frequently been reported, with young men exercising
more than young women [5], but it is not known whether this pattern is maintained across cultures. Since
physical activity is negatively associated with perceived health status [6], the impact of persistent health
problems was also analyzed.
Three supplementary issues were investigated. The
first concerns the associations among exercise, health
beliefs, and risk awareness. Regular physical activity
is positively correlated with the perceived health benefits of exercise in some [7] but not all studies [8]. Risk
awareness, operationalized here as knowledge of the
influence of exercise on coronary heart disease, is considered a prerequisite of behavior change in many
models of health promotion and disease prevention [9].
International studies provide a unique opportunity to
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0091-7435/97 $25.00
Copyright © 1997 by Academic Press
All rights of reproduction in any form reserved.
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STEPTOE ET AL.
assess the robustness of associations between these
cognitive factors and exercise in different sociocultural
contexts.
The second objective was to study the relationship
between exercise and other health-related behaviors.
The evidence concerning associations with smoking, alcohol consumption, and sleep patterns is inconclusive
[10,11], and the extent to which active people engage in
other health behaviors in different cultural settings is
not known. Body weight and the desire to lose weight
may also be influential, so they were assessed in this
study. Finally, we studied the associations among exercise, perceived social support, and depressed mood.
Regular physical activity is thought to have a positive
impact on psychological well-being [12] and is negatively associated with depression [13]. Social support is
also protective of depression and is positively related to
adherence to physical activity programs [14]. The issue
of whether associations between physical exercise and
depression are independent of social support was
therefore studied in a subsample of the cohort.
METHOD
These analyses were based on data from the European Health and Behavior Survey, a study of health
behaviors and health beliefs among college students
from 21 European countries carried out between 1989
and 1992 and supported by the Medical and Health
Research Program of the European Commission [15].
The survey instrument has been described elsewhere
[16], and only details relevant to the present report will
be presented.
Data were collected from 7,302 men and 9,181
women ages 18–30 studying non-health-related
courses at universities in the countries listed in Table
1. Data collection was based on a common assessment
protocol that was translated and back-translated into
15 languages, with a standard scoring and data management system. Questionnaires were typically completed in classes, although in some countries (France,
The Netherlands, Sweden) postal surveys and individual recruitment were involved. Administration of
the questionnaire in classes allowed failures of completion to be counted, and response rates varied from 85 to
95% in most countries. No information was available
concerning nonresponders. Participants were told that
they survey concerned activities related to health.
Physical exercise was assessed by responses to the
question ‘‘Over the past 2 weeks have you taken any
exercise (e.g., sport, physically active pastime)?’’ Those
who responded positively were asked what activity
they had carried out and how many times they had
exercised. In subsequent analyses, participants were
divided into those who had exercised one to four times
and those who had exercised five or more times in the
TABLE 1
Age-Adjusted Prevalence of Exercise in the Past 2 Weeks: Proportion of Men and Women Who Were Physically Active,
with 95% Confidence Intervals
Men
Country
N
Austria
Belgium
Denmark
Finland
France
Germany (E)
Germany (W)
Greece
Hungary
Iceland
Ireland
Italy
The Netherlands
Norway
Poland
Portugal
Spain
Sweden
Switzerland
UK England
UK Scotland
368
501
392
242
284
327
386
296
363
391
295
388
246
429
380
313
354
305
235
293
117
Overall
6905
Physically
active
75%
74%
75%
84%
67%
76%
80%
55%
87%
83%
70%
74%
83%
74%
76%
52%
58%
77%
83%
66%
64%
73.2%
Women
95% CI
N
70–79%
70–78%
71–79%
79–90%
62–72%
71–80%
76–85%
50–60%
82–91%
79–87%
65–75%
69–78%
78–89%
70–78%
71–80%
47–56%
54–63%
73–82%
78–89%
61–71%
56–71%
349
606
379
458
354
346
371
343
361
381
458
383
493
733
378
492
412
376
340
394
261
8668
Physically
active
75%
62%
81%
92%
58%
72%
79%
29%
95%
75%
66%
58%
83%
78%
73%
35%
36%
85%
78%
62%
63%
68.3%
95% CI
70–79%
58–65%
76–85%
88–96%
53–62%
67–76%
74–83%
25–43%
90–99%
70–78%
62–70%
54–62%
79–87%
75–81%
69–77%
31–38%
32–40%
80–89%
73–82%
57–65%
57–67%
847
PHYSICAL EXERCISE AMONG YOUNG EUROPEANS
past 2 weeks. Smoking was measured by questions
adapted from the screening instrument used by the
Office of Population Censuses and Surveys in the
United Kingdom [17]. In the present analysis, the
sample was divided into smokers and nonsmokers on
the basis of reporting any current smoking. Sleeping
habits were measured by asking participants how
many hours of sleep they had on average. It was found
in the Alameda County Study that average sleep time
was an independent predictor of morbidity and mortality [18]. Consequently, sleep times were divided into
satisfactory (7–8 hr) and unsatisfactory (less than 7 hr
or more than 9 hr per night). Alcohol consumption was
assessed by requesting participants to classify themselves as nondrinkers, occasional drinkers, or regular
drinkers. Those who drank alcohol indicated how many
days they had consumed alcohol during the previous 2
weeks and how many drinks they had consumed on
average. They were subsequently divided into three
categories: nondrinkers; fewer than one unit per day;
and one or more units per day. Desire to lose weight
was assessed on a yes/no format.
Health beliefs about physical exercise were assessed
by asking subjects to rate their belief in the importance
to health of taking regular exercise on a 10-point scale
from 1 4 low importance to 10 4 very great importance. Risk awareness was assessed as part of a larger
section of the survey concerned with knowledge of a
range of lifestyle factors relevant to health [19].
Subjects were asked on a yes/no format whether they
believed that heart disease was influenced by exercise.
Data were collected in two phases with a 1-year interval. Preliminary analyses indicated no significant
differences between the phases, so the cohorts were
combined. In the second phase of data collection, social
support and depression were assessed in participants
from all countries except Austria, Belgium, Hungary,
and Italy. The short form of the Social Support Questionnaire (SSQ) was administered, from which a measure of social support availability was derived from the
average of the number of people who could be called
upon to support the individual in a range of difficult
situations [20]. A rating of satisfaction with social support was also obtained from the SSQ, but was not included in the analysis since the distribution was highly
skewed. Depression was assessed using the short version of the Beck Depression Inventory (BDI) [21]. This
measure consists of 13 of the 21 items of the full BDI
and correlates highly with the full instrument [22].
Analyses of social support and depression were based
on 5,633 and 5,529 individuals, respectively. Health
status was assessed by asking participants whether
they suffered from any persistent health problems, and
respondents also provided information about height
and weight, from which body mass index (BMI) was
calculated [23].
RESULTS
Prevalence of Physical Exercise among Men
and Women
Data concerning exercise were available from 6,905
men and 8,668 women distributed across countries as
shown in Table 1. The mean age of the sample varied
significantly across countries from 19.1 ± 1.3 years in
Belgium to 23.5 ± 2.60 in West Germany. The prevalence of leisure time physical exercise was therefore
adjusted for age, and the levels in each country sample
are detailed in Table 1. Prevalence varied substantially
across samples with the lowest levels among men and
women being recorded in Greece, Spain, and Portugal
and the highest in Hungary and Finland. The confidence intervals summarized in Table 1 indicate that
prevalence differed from the overall population mean
for men in Finland, West Germany, Hungary, Iceland,
the Netherlands, and Switzerland (with high levels)
and in France, Greece, Portugal, Spain, England, and
Scotland (low levels). Among women, the levels in Austria, Denmark, Finland, West Germany, Hungary, Iceland, the Netherlands, Norway, Poland, Sweden, and
Switzerland were significantly higher than the overall
population mean, while the levels in Belgium, France,
Greece, Italy, Portugal, Spain, England, and Scotland
lay significantly below the population average. These
data suggest a disappointingly low prevalence of leisure time physical exercise among relatively privileged
young adults in many European countries.
Men were more likely than women to have exercised
in the previous 2 weeks, but this difference was significant only in six countries (Belgium, Greece, Iceland,
Italy, Portugal, and Spain). Prevalence was somewhat
higher among women than men in Denmark, Finland,
Hungary, and Sweden, albeit with overlapping confidence intervals. Men were more likely than women to
engage in frequent physical activity. Overall, 35.5% (CI
34.7, 36.9) of men had exercised on five or more occasions during the previous 2 weeks, compared with
29.7% (CI 28.7, 30.6) of women (P < 0.0001). When
country samples were analyzed separately, this trend
was significant in seven cases (Belgium, France,
Greece, Iceland, Italy, Portugal, and Spain). In Finland
alone, the reverse trend was apparent (P < 0.0001),
since 52.7% of women had exercised five or more times
compared with 35.7% of men.
Overall, 17.0% of men and 22.8% of women reported
persistent health problems, the most common being
allergies and skin problems. There was no significant
association between health problems and physical activity among either sex.
Health Beliefs and Risk Awareness
Mean ratings of beliefs in the importance of taking
regular exercise for health maintenance were high, av-
848
STEPTOE ET AL.
FIG. 1. Health beliefs and physical exercise. Age-adjusted proportion of physically active men and women in the sample of respondents
at each of the 10 points of the scale on which beliefs in the importance of regular exercise for health were rated from 1 4 low importance
to 10 4 very great importance.
eraging 8.14 ± 2.0 among men and 8.19 ± 1.8 among
women. Across country samples, average belief ratings
ranged from 8.96 ± 1.6 (Hungary) to 7.66 ± 2.4 (Poland)
among men and from 9.15 ± 1.3 (Hungary) to 7.73 ± 2.0
(Belgium) among women.
A marked association between physical exercise and
beliefs in the health benefits of exercise was observed
among men and women. This is illustrated in Fig. 1,
which summarizes the proportion of physically active
individuals among people making ratings at each level
of the 10-point belief scale. There was a gradual increase in the prevalence of exercise as beliefs became
stronger.
The proportion of individuals who were aware of the
association between exercise and heart disease in each
country sample is shown in Fig. 2. Overall, 52% of men
and 54% of women were aware of the role of exercise,
with striking country differences. More than 70% were
FIG. 2. Exercise and heart disease. Age-adjusted proportion of men and women aware for the influence of exercise on heart disease in
each country sample. Au, Austria; Be, Belgium; Dk, Denmark; Fi, Finland; Fr, France; eG, former DDR; wG, Germany; Hu, Hungary; Ic,
Iceland; Ir, Republic of Ireland; It, Italy; Nl, The Netherlands; No, Norway; Po, Poland, Pt, Portugal; Sp, Spain; Sw, Sweden; Sz, Switzerland;
Eng, UK–England; and Sc, UK–Scotland.
849
PHYSICAL EXERCISE AMONG YOUNG EUROPEANS
aware of the association in Denmark, Finland,
the Netherlands, and Norway, but fewer than 40% in
Belgium, Greece, Italy, and Poland. No consistent sex
differences were observed. There was a modest association between physical exercise and risk awareness,
in that across all country samples 54.7% of the exercisers compared with 51.0% of sedentary individuals
knew of the link with heart disease (P < 0.0001). However, this association was not significant in any country sample individually and was small in public health
terms.
Multiple logistic regression was carried out to assess
the independent contribution of belief ratings and risk
awareness to participation in physical exercise. Age
and sex were included in the model, which was tested
for each country sample separately. For the purposes of
this analysis, belief ratings were divided into low (1–5)
and high (6–10) categories, and the results are detailed
in Table 2. Findings for beliefs were very consistent. In
each country, the estimated odds of physical exercise
were increased for those with a high as opposed to a
low belief in the importance of exercise for health, adjusted for age, sex, and risk awareness. All the belief
odds ratios were significant (P < 0.025 to P < 0.0001).
By contrast, the odds ratios of physical exercise among
individuals who were aware of the association between
exercise and heart disease were significant in only one
country sample (Portugal, P 4 0.03).
Physical Exercise and Other Health Behaviors
Lack of physical exercise was associated with cigarette smoking among both men and women; 40.7% of
inactive men were smokers, compared with 29.8% of
active individuals (P < 0.0001), and the corresponding
proportions were 34.4 and 26.8% in women (P <
0.0001). The association was significant in nine individual country samples for men and in five samples for
women. The proportion of smokers among respondents
who had exercised one to four times and five or more
times over the previous two weeks was also calculated.
These data are summarized in Fig. 3 and indicate that
among men a consistent trend was present (P <
0.00001), with fewer smokers among those who exercised frequently. The pattern was less striking among
women, although the trend remained statistically significant (P < 0.0001). In individual country samples,
the relationship was significant in seven samples for
men and in two samples for women.
Overall, reported sleep time was outside the 7- to
8-hr ‘‘satisfactory’’ category among 18.4% of men and
16.1% of women. A significantly larger number of exercisers than sedentary individuals were categorized
as having satisfactory sleep levels among both men
(83.0% vs 77.7%, P < 0.00001) and women (85.0% vs
81.4%, P < 0.0001). In the analysis of individual country samples, effects were significant in only two cases
TABLE 2
Predictors of Exercise Behavior: Estimated Odds Ratios (OR) and 95% Confidence Intervals (CI) of Likelihood of Exercise for
Participants with High vs Low Beliefs in the Importance of Regular Exercise, and High vs Low Awareness of the Influence
of Exercise on Heart Disease, Controlling for Sex and Age
Belief in the importance of regular
exercise for health
Risk awareness
(exercise and heart disease)
Country
OR
95% CI
OR
95% CI
Austria
Belgium
Denmark
Finland
France
Germany (East)
Germany (West)
Greece
Hungary
Iceland
Ireland
Italy
The Netherlands
Norway
Poland
Portugal
Spain
Sweden
Switzerland
UK
England
Scotland
6.46
5.04
7.99
6.06
7.89
9.78
4.00
3.74
8.53
3.81
4.50
2.54
6.11
6.20
2.75
6.00
5.93
9.90
4.56
(3.82, 10.9)
(3.59, 7.08)
(5.39, 11.9)
(2.60, 14.2)
(4.62, 13.5)
(6.00, 15.0)
(2.39, 6.66)
(1.99, 7.04)
(3.70, 19.6)
(2.25, 6.45)
(2.67, 7.60)
(1.12, 5.76)
(2.83, 13.2)
(4.25, 9.04)
(1.82, 4.17)
(2.81, 12.8)
(3.03, 11.6)
(5.60, 17.5)
(2.62, 7.95)
1.07
1.08
1.09
1.14
1.14
0.85
0.96
0.99
0.82
1.04
0.92
0.93
1.09
1.00
0.82
1.18
0.96
0.99
0.83
(0.899, 1.28)
(0.936, 1.25)
(0.863, 1.37)
(0.875, 1.50)
(0.962, 1.36)
(0.699, 1.02)
(0.941, 1.01)
(0.833, 1.17)
(0.651, 1.11)
(0.861, 1.27)
(0.786, 1.08)
(0.782, 1.10)
(0.876, 1.35)
(0.857, 1.17)
(0.673, 1.01)
(1.02, 1.36)
(0.825, 1.14)
(0.812, 1.21)
(0.668, 1.03)
5.54
18.25
(3.26, 9.41)
(6.27, 53.2)
0.93
0.84
(0.771, 1.12)
(0.699, 1.06)
850
STEPTOE ET AL.
for each sex, but the small proportion of unsatisfactory
sleep times gave these analyses limited power. There
were no clear associations with the frequency of physical exercise.
Alcohol consumption levels were typically low: only
27.3% of men and 12.5% of women drank an average of
one or more units per day while 34.5% of men and
49.2% of women were nondrinkers. There was a significant association between exercise and alcohol consumption among women in five country samples (Hungary, Ireland, Poland, Portugal, and Scotland). In each
case, exercisers were less likely to drink alcohol than
sedentary women. This association was not consistent
among men and was statistically significant in only one
country sample (Poland).
Overall, the BMI of men was significantly greater
than that of women (means 22.4 ± 2.5 vs 20.8 ± 2.4, P
< 0.0001). Associations with physical exercise were
analyzed by dividing participants into low (BMI <20),
average (BMI 20–25), and high (BMI > 25) categories.
There was no association with physical activity among
women, since similar proportions of women in each cat-
egory exercised. An association was observed among
men, with an average of 75.6% (CI 77.4, 76.7) of those
in the average weight category being physically active,
compared with 70.4% (CI 67.3, 73.5) of the high BMI
group and 64.2% (CI 61.2, 67.3) of the low BMI group.
This association was significant in 8 of the 21 country
samples of men when analyzed separately.
A desire to lose weight was reported among 17.4% of
men and 44.1% of women. Across the entire cohort
there were strong associations between physical exercise and desire to lose weight among both sexes as can
be seen in Fig. 3 (P < 0.0001). The association was
significant in seven of individual country samples for
women but only in one case for men.
Physical Exercise, Social Support, and Depression
The SSQ was completed by 2,042 men and 3,591
women, while BDI scores were available from 2,091
men and 3,438 women. The analysis of these instruments was limited to the combined sample, since the
individual country samples were not large enough for
FIG. 3. Proportion of current cigarette smokers (top left), individuals wanting to lose weight (bottom left), people enjoying high social
support (top right), and those with depression ratings >4 (bottom right) among inactive respondents (None), people exercising between one
and four times in the past 2 weeks (1–4), and five or more times (5+). Age-adjusted means and 95% confidence intervals. m, men; d, women.
PHYSICAL EXERCISE AMONG YOUNG EUROPEANS
separate analysis. The number of supportive individuals averaged 3.01 ± 1.83 among men and 3.73 ± 1.78
among women. For the purposes of analysis, the population was divided into those who reported 0–2 supports (low support) and >3 (high support). Figure 3
shows the significant association between physical exercise and social support, with physically active individuals being more likely to enjoy high social support
(P < 0.00001).
Scores on the BDI were skewed toward low values,
averaging 3.7 ± 4.4 among men and 3.9 ± 4.3 among
women. The population was divided into those with low
(0–4) and moderate or high (>4) BDI ratings for analysis. Associations with exercise are summarized in Fig.
3. It is apparent that among both men and women, the
frequency of moderate depression scores declined with
increasing levels of physical exercise (P < 0.0001).
Among men, 24.1% of those exercising five or more
times had moderate or high depression scores, compared with 33.6% of inactive males. The corresponding
proportions for women were 28.0% vs 42.2%.
Social support and depression were negatively correlated among men and women (r 4 −0.222 and
−0.202, respectively, P < 0.0001). Logistic regression
was therefore carried out to assess whether the associations with physical exercise were independent of one
another. Age and sex were included in the model. This
analysis revealed significant independent associations
for both variables with exercise, with the estimated
odds adjusted for age, sex, and depression of high vs
low social support being 1.37 (CI 1.29, 1.46) and the
odds of exercise for low vs moderate or high depression
being 1.19 (CI 1.12, 1.27).
DISCUSSION
International comparisons of behaviors relevant to
health are important for a number of reasons. First,
there are wide variations in Europe in the incidence of
premature morbidity and mortality from coronary
heart disease and other disorders [24], and it is valuable to determine the extent to which these are
matched by lifestyle factors. Knowledge about health
behaviors and their correlates is essential to the planning of services and preventive programs. The issue is
particularly pertinent to Europe, where the Single European Community Act has reduced barriers to population mobility. Proposals to extend the European
Union to Eastern European countries where the pattern of morbidity is very different from that in Western
Europe [25] further emphasizes the need for international data.
The European Health and Behavior Survey was carried out with university students. The data cannot of
course be considered representative for each country,
since university students are typically healthier and
better educated than other sectors of society [26]. Although students of health-related topics were ex-
851
cluded, the national samples may vary considerably in
other characteristics.Nevertheless, the sample has distinct advantages for international comparisons. University students are a relatively homogeneous group in
terms of education and socioeconomic status, and
physical activity is positively associated with both factors [27]. The use of student samples limits the variance in physical activity associated with illness and
disability [28]. Furthermore, university students form
a privileged sector of society, and social diffusion processes may operate by which their behavior and attitudes are gradually transmitted to less advantaged
groups.
The response rate to this survey was high, averaging
about 80% in the different country samples. Unfortunately, we were not able to collect information about
nonresponders. It is unlikely that students who refused to participate had any particular orientation in
relation to physical exercise, since exercise was only
one of many issues addressed in the survey. However,
since the study was introduced to potential participants as a survey of activities related to health, it is
possible that nonresponders had less interest than responders in health issues. Inasmuch as university students associate physical exercise with health, the data
may therefore by biased toward more favorable attitudes to exercise.
The results concerning age-adjusted prevalence of
physical exercise over the previous 2 weeks showed
wide variations across country samples (Table 1).
There was a marked similarity in the proportion of
men and women who were physically active in each
country sample, since the correlation between ageadjusted percentages was high (r 4 0.92, P < 0.001).
Low levels of physical exercise were recorded in the
southern European countries, with Portugal, Spain,
and Greece having especially low prevalence among
both men and women. A high prevalence was more
common in Scandinavia, notably in Finland and Sweden. These differences do not reflect seasonal effects,
since data were collected over several months in each
country. High levels of physical exercise were recorded
in Eastern European countries (particularly in Hungary), reflecting a tradition of sport and exercise participation in this part of the world. Levels in England
and Scotland were disappointing in view of the efforts
that have been made to publicize the value of physical
activity [29].
Direct comparisons with other data sets cannot be
made with confidence. The closest comparison is with
the WHO cross-national study of health behaviors in
school-age children, which assessed physical activity
among 15-year-olds in 11 countries [30]. The highest
prevalence of exercise out of school was recorded in
Austria, Hungary, and Norway, with low levels in
Spain and Poland. However, 15-year-olds are more
constrained by school activities and family habits than
852
STEPTOE ET AL.
are independent university students. Other international comparisons have been confined to elderly populations [31].
Leisure time physical exercise is one of the few
health-related behaviors that are typically more prevalent among men than women. Our results endorse this
pattern, but suggest that the difference is not universal. In four country samples, the age-adjusted prevalence was higher among women than men, indicating
that cultural factors may influence these differences.
Discussion of the types of physical exercise carried out
is beyond the scope of this paper, but the most frequently reported activities in most countries were running or jogging, football, aerobics, and swimming. The
higher prevalence among men may in part reflect a
greater involvement in college-based sports.
The association between beliefs in the health benefits of regular exercise and physical activity was very
reliable, with a consistent trend of increasing participation with stronger beliefs (Fig. 2). Beliefs in the
health benefits of exercise predicted physical exercise
in every country sample, independently of age, sex, and
risk awareness (Table 2). These associations confirmed
the relationships that have been observed for a wide
range of behaviors and beliefs in the European Health
and Behavior Survey [15] and in other studies [32]. The
result is notable for two reasons. First, robust associations between health beliefs and behaviors were maintained across a range of diverse cultures, with the
prevalence of the behavior varying from 35 to 95%. The
correlation with health beliefs does not therefore depend on physical exercise exceeding any particular
prevalence threshold. Second, health does not rank
high among the motives for exercise among young
people. Factors such as having fun (30), leading an exciting life [33], appearance, and socializing [34] are endorsed more frequently as reasons for exercise than
health benefits. A causal interpretation of the association between health beliefs and exercise cannot be
made from this cross-sectional survey. Nevertheless, in
a follow-up on a subgroup of participants, we have
found that beliefs in health benefits predicted changes
in physical exercise over a 12-month period [35]. Consequently, health beliefs may be a legitimate target for
intervention.
By contrast, the association between awareness of
the health consequences of inactivity and behavior was
weak. Health knowledge was assessed in this analysis
by awareness that physical exercise influences risk of
heart disease, since this association is well established
in longitudinal studies [1]. The results show a disappointing level of awareness among this cohort of educated young Europeans. Fewer than 60% of men and
women were aware of the influence of exercise in the
majority of country samples, and even in the most
knowledgeable sample (Denmark) some 20% were evidently unaware of the link (Fig. 2). These data high-
light a serious shortfall in knowledge about basic
health risks associated with a sedentary lifestyle. The
result is of particular concern in that data were obtained from a well-educated sector of the population.
At the same time, it should be noted that the association between risk awareness and engagement in physical exercise is modest and not statistically significant
in the majority of country samples (Table 2). These
findings suggest that although there is room for substantial improvement in knowledge about the specific
hazards of inactivity, deficient knowledge is not in itself a major determinant of physical exercise among
young adults.
Observations concerning the associations between
physical exercise and other health behaviors have been
mixed. For example, many studies have shown that
exercise is inversely associated with cigarette smoking
[10,36], but this was not confirmed in the U.S. National
Adult Fitness Survey [37] and other surveys [38,39].
Associations between exercise and smoking may be
confounded by socioeconomic status, since occupational
activity is greater among lower status groups in which
smoking is also more prevalent. The relationship between exercise and alcohol consumption is variable
across studies and between sexes [11,40]. Many authorities have emphasized that there are distinct dimensions of health behavior and that physical activity
does not load on the same factor as smoking, alcohol
consumption, or sleep time [41–43]. In the present
study, regular physical exercise was associated with a
lower likelihood of smoking and with sleeping 7–8 hr
per night. Physical exercise was also negatively related
to alcohol consumption among women but not men.
Team sporting events are frequently followed by drinking in the bar, and this may offset any salutagenic effects of exercise.
Overweight individuals are more likely to drop out of
exercise programs and are less responsive to public
health interventions than others [14,44]. In the present study, no simple association between body mass
index and physical exercise was observed. Among
women, body mass index was not related to physical
exercise; instead desire to lose weight was a strong
predictor (Fig. 3). Weight control has previously been
identified as a common motive for physical activity
among young women [34] and is not confined to those
who are overweight by objective criteria. Among men, a
curvilinear association emerged between body mass index and physical exercise, with higher levels of engagement among individuals with a BMI in the average
range (20–25). The lower prevalence of exercise in subjects with high BMI may reflect the pattern documented in earlier studies. Men with low BMI may be
less active because they are less likely to become involved in team sport than others.
The final set of analyses confirmed the association
between lack of physical exercise and depressed mood
PHYSICAL EXERCISE AMONG YOUNG EUROPEANS
documented in other studies (Fig. 3). We also found
that this was independent of the influence of social
support. The latter observation is significant, since social isolation may heighten depressed mood while also
reducing the likelihood of regular vigorous activity.
Unfortunately, the limited numbers completing this
part of the survey prevented separate analysis of country samples, so it is not possible to draw conclusions
about the consistency of this finding across cultures.
The result is consistent with longitudinal studies
showing that regular physical activity may enhance
emotional well-being [45].
The limitations of this study should be noted [15].
The cross-sectional design precludes any causal inferences from being drawn. The results are based on selfreport, and the physical exercise measure included a
range of sports and recreations that vary in their energy demands. Sampling was restricted to a privileged
sector of young adults and to two or three centers
within each country. It is possible that differences in
the type of student included in each country sample
contributed to the pattern of results. Nevertheless, the
results point to wide variations between sociocultural
groups that are a cause of concern and that merit fuller
investigation. The associations with health-related behaviors and emotional well-being suggest that regular
physical exercise is a behavior that is consistent with a
healthy lifestyle across cultures. The consistency of associations between physical exercise and health beliefs
further justifies attention to attitude change in preventive programs.
ACKNOWLEDGMENTS
This research was carried out within the Concerted Action on
Breakdown in Human Adaptation: Quantification of Parameters,
part of the Commission of the European Communities Biomedical
and Health Research Programme. Statistical analysis was supported
with a grant from the Economic and Social Research Council, UK.
The following colleagues contributed to the European Health and
Behavior Survey: Austria, Professor Margit Koller and Professor Elisabeth Groll-Knapp (Vienna); Belgium, Professor Jan Vinck (Diepenbeek); Denmark, Dr. Donald Smith (Århus); Finland, Dr. Martti
Tuomisto (Tampere) and Dr. Raimo Lappalainen (Kuopio); France,
Dr. France Bellisle and Dr. Marie-Odile Monneuse (Paris); East Germany, Dr. Konrad Reschke (Leipzig); West Germany, Dr. Thomas
Kohler (Hamburg), Professor Gudrun Sartory (Wuppertal) and Dr.
Claus Vögele (Marburg); Greece, Professor Nicola Paritsis (Iraklion)
and Dr. Bettina Davou (Ioánina); Hungary, Professor Maria Kopp
and Dr. Árpad Skrabskı́ (Budapest); Iceland, Professor Erlendur
Haraldsson (Reykjavik); Italy, Dr. Anna Maria Zotti and Dr. Giorgio
Bertolotti (Veruno); Poland, Dr. Zbigniew Zarczynski (Krakow) and
Professor Andrzej Brodziak (Bytom); Spain, Professor Jaime Vila
(Granada); Sweden, Professor Mats Fredrikson (Uppsala); Switzerland, Professor Ruth Burckhardt and Dr. Laurent Rossier (Lausanne). We are also grateful for the assistance of Heather Smith in
the analysis of these data.
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