Social Science & Medicine 53 (2001) 1621–1630

Health behaviour, risk awareness and emotional well-being in

students from Eastern Europe and Western Europe
Andrew Steptoea,*, Jane Wardleb
a
Psychobiology Group, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place,
London WC1E 6BT, UK
b
Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place,
London WC1E 6BT, UK

Abstract

Life expectancy and other indices of health have deteriorated markedly in the former socialist countries of Eastern
Europe over recent decades. The possible roles of lifestyles, knowledge about health and behaviour, emotional well-
being and perceptions of control were assessed in a cross-sectional survey of young adults of similar educational status
in Eastern and Western Europe. As part of the European Health and Behaviour Survey, data were collected in 1989–
1991 from 4170 university students aged 18–30 years from Austria, Belgium, the Federal Republic of Germany, the
Netherlands and Switzerland, and from 2293 students from the German Democratic Republic, Hungary and Poland.
Measures were obtained of health behaviours, awareness of the role of lifestyle factors in health, depression, social
support, health locus of control, and the value placed on health. After adjustment for age and sex, East European
students had less healthy lifestyles than Western Europeans according to a composite index of 11 health behaviours,
with significant differences for seven activities: regular exercise, drinking alcohol, avoiding dietary fat, eating fibre,
adding salt to food, wearing a seat-belt, and using sunscreen protection. East European students were less likely to be
aware of the relationship between lifestyle factors (smoking, exercise, fat and salt consumption) and cardiovascular
disease risk. In addition, they were more depressed (adjusted odds of elevated scores on the Beck Depression Inventory
of 2.46, 95% C.I. 1.95–3.09), reported lower social support, and had higher beliefs in the ‘‘chance’’ and ‘‘powerful
others’’ locus of control. Internal locus of control levels did not differ across regions, and Eastern Europeans placed a
higher valuation on their health. Unhealthy lifestyles associated with lack of information about health and behaviour,
greater beliefs in uncontrollable influences, and diminished emotional well-being, may contribute to poor health status
in Eastern Europe. # 2001 Elsevier Science Ltd. All rights reserved.

Keywords: UK; Health behaviour; Emotional well-being; Risk perception; Eastern Europe; Western Europe

Introduction Costeool, & Mitchell, 1997; Hertzman, Kelly, & Bobak,

The differences in health and rates of premature
mortality between Western Europe and Central and
Eastern Europe are of major concern (Bobadilla,
*Correspondence address: Health Behaviour Unit, Depart-
ment of Epidemiology and Public Health, University College
London, 1-19 Torrington Place, London WC1E 6BT, UK. Tel.:
+44-20-7679-5628; fax: +44-20-7916-8542.
E-mail address: a.steptoe@ucl.ac.uk (A. Steptoe).
1996). Over the past 30 years, there has been a
progressive increase in differences in life expectancy
between the countries of the European Union and the
countries of Central and Eastern Europe (Bobak &
Marmot, 1996). For example, between 1970 and 1991,
there were decreases in male life expectancy at age 15 in
Hungary, Poland, Romania, and Bulgaria, compared
with increases of more than three years in the European
Union. Life expectancy at age 15 increased over the
same period among women in Eastern Europe, but to a

0277-9536/01/$ - see front matter # 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 0 ) 0 0 4 4 6 - 9
1622 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630
much lesser extent than among Western Europeans.
Premature death from cardiovascular diseases and
external causes are major contributors to this pattern.
A number of explanations for these trends have been
put forward (Bobak & Marmot, 1996; Cockerham,
1997; 1999). Poor medical care in Central and Eastern
Europe may make a limited contribution, though this is
unlikely to account for more than 10% of the difference
in all-cause mortality (Boys, Forster, & Jozan, 1991).
Environmental pollution may also play a significant
role, particularly in Poland, the former East Germany
and the Czech Republic. However, it has been argued
that health behaviours and psychosocial stress are the
most important factors. Smoking, patterns of alcohol
intake, and dietary factors such as fat and antioxidant
consumption may all contribute, although there is
uncertainty about the magnitude of differences between
Western Europe and the former Communist states of
Eastern Europe (Watson, 1995; Uitenbroek, Kerekovs-
ka, & Festchieva, 1996; Bobak et al., 1999).
The health behaviour explanation implies that Wes-
tern and Eastern Europeans may differ not only in
individual habits, but also in health-related lifestyles. A
healthy lifestyle implies healthy practices across a range
of personal behaviours and activities. Comparisons of a
broad range of health behaviours between regions of
Europe have been limited thus far. In the present study,
we therefore investigated the prevalence of unhealthy
options in twelve health behaviours, so as to obtain
evidence concerning broad lifestyle differences between
Western and Eastern Europe.
We also investigated factors that might be associated
with differences in health behaviour. Cockerham (1997)
has argued that unhealthy lifestyles in Eastern Europe
are determined less by individual choice than by
structural constraints embodied in reduced life chances.
People may lack information about health and beha-
viour, or have little control over provision (limiting
dietary and exercise choices), while living in societies in
which unhealthy lifestyles are normative. These factors
may be associated with a sense of powerlessness
and fatalism engendered by the political system
(Nagorski, 1993). Watson (1995) has emphasised
that Eastern Europeans may experience cumulative
frustration due to a mismatch between personal
aspirations and the means of achieving them, and an
inability to improve the material situation through
exclusion by the state from activity in the public sphere.
Chronic social stress resulting from feelings of dis-
advantage and uncertainty over fundamental shifts in
economic and political organisation may also contri-
bute, leading to a pervasive sense of lack of control.
We address these factors by assessing risk awareness,
locus of control, the valuation of health, social support
and depressive symptoms. If people living in Eastern
Europe lack information about health and behaviour,
then we predict that they will be less aware than their
Western counterparts of the role played by habitual
behaviours in disease risk. We tested this hypothesis by
comparing the levels of awareness of the involvement of
lifestyle factors (fat intake, salt intake, smoking, physical
activity, etc.) in cardiovascular disease (heart disease and
high blood pressure).
The hypothesised sense of powerlessness in East
European citizens was indexed in terms of health locus
of control. Health locus of control is a domain-specific
control construct that indexes beliefs in different types of
means-ends relationship (Skinner, 1996). Since it is
specific to the domain of health, it may not reflect
general perceptions of control. However, it is particu-
larly relevant to the actions people carry out to maintain
health. We have previously shown that health locus of
control is associated with the likelihood of healthy
behavioural choices (Steptoe & Wardle, in press). The
association between low sense of control over life in
general (and health in particular) and self-rated health
has previously been described in a Russian sample
(Bobak, Pikhart, Hertzman, Rose, & Marmot, 1998).
However, the measures of control had poor internal
consistency, and no comparison with other countries
was possible. In the present analysis, we used the well-
established Multidimensional Health Locus of Control
scales that distinguish beliefs in internal control from
beliefs in chance, and beliefs in powerful others
(specifically health professionals). We predicted that
respondents from Eastern Europe would have lower
internal control beliefs and greater beliefs in chance than
Western Europeans. We also hypothesised that Eastern
Europeans would have stronger beliefs in the influence
of powerful others over their health, since the Commu-
nist political system might have engendered greater
dependence on authority than was apparent in Western
Europe.
If differences in healthy lifestyles between Western
and Eastern Europeans do exist, they might also be
related to differences in valuations of health. People who
do not place a high priority on health within their value
systems are less likely to be concerned about carrying
out activities that are hazardous to health in the long
term (Norman & Bennett, 1996). We therefore adminis-
tered a standard measure of the value of health, to assess
whether respondents from Western and Eastern Europe
differed in the importance they placed on health.
Finally, we tested psychosocial explanations for
differences in health between Eastern and Western
Europe by assessing depressive symptoms and social
support. Differences in social stress might be expected to
be translated into higher levels of depressive symptoms
in Eastern Europeans, while greater social fragmenta-
tion could lead to reduced social support. The pre-
valence in depressive symptoms assessed in national
representative surveys in Hungary increased markedly
 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630 1623

between 1988 and 1995, particularly in lower social Secondly, university students are relatively healthy. It is
status groups (Kopp, Szedmak, & Skrabski, 1998). known that health behaviours are influenced by illness
Direct evidence between East and West are limited thus and disability, so the inclusion of more diverse samples
far. However, it was found in a study of middle-aged would necessitate the collection of complex data
men that Lithuanians reported lower social support at concerning physical health and disability, complicating
work, lower job control, and high levels of depressive international comparisons (Gottlieb & Green, 1984).
symptoms than did Swedish men of the same age Thirdly, university students occupy a significant position
(Kristenson, et al., 1998). in public life. The politicians and policy makers of the
These issues were investigated in the present analysis future have typically been university students, and
using data from the European Health and Behaviour students themselves have played a major role in public
Survey (EHBS), a study of health behaviour, attitudes life and social change in many countries over the past
and knowledge in University students from 21 countries century. The attitudes and behaviours of university
carried out between 1989 and 1991 (Wardle & Steptoe, students are not only important in themselves, but are
1991; Steptoe & Wardle, 1996). The comparison in this also relevant to policies concerning health and preven-
analysis is between students in three East European tion in the future. A fourth advantage of studying
countries (former East Germany, Hungary and Poland) students is that data were typically collected in classes.
and West European student samples. There are im- Although participation was voluntary, response rates
portant variations between regions such as central exceeded 90% in most countries, far higher than is
Europe, Scandinavia and Mediterranean Europe in common when participants are invited individually to
dietary habits and other health-related behaviours complete surveys.
(Steptoe & Wardle, 1992). In order to provide an
appropriate comparison for the three East European
country samples, Western Europe was therefore repre-
sented by five geographically close countries (Austria, Method
Belgium, Netherlands, Switzerland and former West
Germany). The period of data collection was one of Participants
great political and economic change in the three Eastern
European countries. In November 1989, the Berlin wall The methodology and sampling in the EHBS have
was breached, and German reunification officially took been detailed elsewhere (Steptoe & Wardle, 1996). A
place 11 months later. In Hungary, the demise of the target sample of 700–800 male and female university
socialist state led to the election of a non-communist students of non-health subjects aged 18–25 were
government in the spring of 1990, while Poland saw the administered a self-completed structured questionnaire,
collapse of the communist regime at the end of 1989. using a uniform format in all languages. The ques-
This survey of personal health behaviour was not tionnaire was given to students in classes, and response
intended to provide a comparison of representative rates were generally greater than 90%. The test–retest
samples of young adults from different countries. reliability of the survey is satisfactory (Wardle &
University students are generally better educated than Steptoe, 1991). Table 1 summarises the number of
other young adults, and tend to originate from more students in the five Western and three Eastern European
privileged family backgrounds. Educational attainment countries included in this comparison. Separate samples
and other markers of social status are associated with
differences in healthy practices and with knowledge of
the role of behaviour in disease risk (Wardle et al., 1999; Table 1
Wardle, Parmenter, & Waller, 2000). The respondents in Gender and age distribution of participants
the study may therefore have carried out more healthy Total Men Women Age
behaviour and have been better informed about risks sample (mean  SD)
than young adults who had not entered tertiary
education. Nevertheless, there are several advantages Western Europe
to surveying university students. Firstly, it is imperative Austria 810 416 394 21.5  2.6
Belgium 1223 543 680 19.0  1.2
in international studies to compare like with like,
Netherlands 749 247 502 22.2  2.4
otherwise, no conclusions can be drawn about the Switzerland 597 242 355 22.2  2.7
pattern of results in different regions of the world. West Germany 791 400 391 23.5  5.6
University students are an easily identifiable, homo-
genous and accessible sector of the population. By Eastern Europe
restricting the range of respondents in terms of East Germany 738 351 387 22.3  2.2
Hungary 756 377 379 20.9  2.4
education, we were able to reduce differences between
Poland 799 399 400 21.8  2.1
country samples that were due to extraneous factors.
1624 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630
were obtained from West and East Germany, since data
were collected at the time of unification. Within each
country, data were collected in the following centres:
Vienna (Austria), Diepenbeek (Belgium), Leipzig (for-
mer German Democratic Republic), Hamburg and
Wuppertal (Federal Republic of Germany), Budapest
(Hungary), Groningen (the Netherlands), Bytom and
Krakow (Poland), and Lausanne (Switzerland). The
varying numbers of respondents from participating
countries reflects differences in the extent of the survey
in each centre, and not variations in response rate.
Data concerning health behaviours and risk aware-
ness were available from all countries. Data related to
depression, social support, health locus of control and
value of health were collected in two of the three East
European countries (East Germany, Poland) and three
West European countries (Netherlands, Switzerland,
West Germany).
Health behaviours
Twelve health behaviours were investigated in this
analysis. Data were analysed using logistic regression, so
that each behaviour rating was transformed into binary
outcomes, with the ‘‘healthy’’ option being coded 0, and
the ‘‘unhealthy’’ option coded 1.
Cigarette smoking was assessed with standard mea-
sures (Steptoe, et al., 1995). Participants were defined as
regular smokers if they reported smoking more than one
cigarette per day.
Exercise was assessed by asking participants if they
had taken any exercise, or carried out any sport or
physically active pastime over the last two weeks. They
were also asked how many times they had exercised over
the past two weeks. Lack of regular exercise was defined
as exercising four or fewer times over the past two
weeks.
Alcohol consumption was assessed by asking partici-
pants if they were non-drinkers, occasional or regular
drinkers. Those who drank alcohol were also asked on
how many days over the past two weeks they had drunk,
and how many drinks they had consumed on average on
each occasion. The proportion of regular alcohol
drinkers was relatively low in this survey, with only
18.3% drinking an average of one or more drinks per
day. Respondents were therefore categorised according
to whether or not they drank alcohol.
Fat consumption was assessed by asking whether or
not the respondent made a conscious effort to avoid
eating foods that contain fat and cholesterol.
Fibre consumption was assessed by asking whether or
not the respondent made a conscious effort to eat foods
that are high in fibre.
Fruit consumption was assessed in terms of frequency.
Participants were divided according to whether or not
they ate fruit daily.
Salt intake was assessed by asking respondents
whether they added salt to their meals. They were
classified according to whether they usually added salt,
or added salt only sometimes, occasionally or never.
Seat-belt use was assessed by asking respondents
whether they wore a seat-belt when riding or driving in
the front seat of a car, all of the time, some of the time,
or never. Those who responded with all of the time were
regarded as regular seat-belt users. Respondents who
stated that they did not ride in cars were excluded from
this analysis.
Sunscreen use was assessed by asking participants if
they used sun protection, cream or lotion when
sunbathing. Participants who stated that they never
sunbathed were excluded from these analyses.
Tooth brushing was categorised according to whether
or not participants brushed their teeth at least daily.
Breast self-examination for women and testicle self-
examination for men were assessed by asking respon-
dents if they knew how to carry out such examinations,
and if so how frequently they carried them out (for
details, see Wardle et al., 1994, 1995). Respondents were
considered to be carrying out these self-examinations
regularly if they examined themselves ten or more times
per year.
A healthy lifestyle index was constructed by summing
the number of healthier options endorsed by each
individual. This could range from 0 (no healthy
behaviours) to 11 (all healthy behaviours). Respondents
who scored positively on the majority of items (i.e. six or
more) were deemed to have a healthy lifestyle. A second
6-item index was compiled of behaviours that might be
considered most important for health (smoking, alcohol
intake, exercise, fat consumption, fibre consumption and
use of a seat-belt). In this case, a score of four or more
was taken to indicate a healthy lifestyle.
Risk awareness
Awareness of risks associated with different aspects of
lifestyle were assessed by asking participants with simple
yes/no responses whether they were of the opinion that
high blood pressure was influenced (either positively or
negatively) by salt intake, alcohol consumption, and
physical exercise, and whether heart disease was
influenced by smoking, physical exercise and fat
consumption. These items were extracted from a larger
array of risk awareness measures on the grounds that
they had been endorsed in a survey of experienced public
health physicians and epidemiologists in European
universities (Steptoe & Wardle, 1994).
Other measures
Depressive symptoms were assessed with the shortened
Beck depression inventory (BDI, Beck & Beck, 1972).
 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630
This consists of 14 items from the full 21 item BDI, and
is known to correlate well with other measures of
depression (Beck, Steer, & Garbin, 1988). Scores of five
or more were taken to define moderate depressive
symptoms, as recommended by Beck and Beck (1972).
Social Support was assessed using the six-item version
of the Social Support Questionnaire (Sarason, Sarason,
Shearin, & Pierce, 1987). Measures of social support
availability and social support satisfaction were derived
from the Social Support Questionnaire. The social
support availability measure was the average number
of people who could be called upon to support the
individual in the six difficult situations specified.
Participants were classified according to whether or
not they could call upon more than two people for social
support. Satisfaction with support was assessed with a
six point scale ranging from 1=very dissatisfied to
6=very satisfied. A threshold of 4.5 divided participants
with high and low satisfaction.
Health locus of control was assessed using the Multi-
dimensional Health Locus of Control scales devised by
Wallston, Wallston, and De Vellis (1978). This consists
of 18 items, each of which is rated on a six-point scale
from strongly disagree to strongly agree. Six items
contribute to the internal locus of control scale (e.g. ‘‘I
can pretty much stay healthy by taking good care of
myself’’), six to the powerful others scale (e.g. ‘‘following
doctor’s orders to the letter is the best way for me to stay
healthy’’), and six to the chance locus of control scale
(e.g. ‘‘when I become ill, it’s a matter of fate’’). Ratings
were summed, so scores on each scale could range from
6 to 36, with higher scores indicating greater beliefs in
internal, powerful others and chance control over
health. The multidimensional health locus of control
scales have been used extensively in health research, and
have adequate internal consistency (Wallston, Wallston
& DeVellis, 1978; Norman & Bennett, 1996). Health
locus of control scales were analysed by dividing the
sample by median split into low and high scoring
groups.
Value of Health. The value that individuals place on
health as a priority in their lives was assessed with the
Health as a Value scale (Lau, Hartman, & Ware, 1986).
This consists of four items (e.g. ‘‘If you don’t have your
health, you don’t have anything’’), each of which was
rated on the same six point scale as health locus of
control. Ratings were summed, so could range from 4 to
24, with higher scores indicating greater value placed on
health, and analysed after dividing by median split into
low and high groups.
Statistical analysis
Data were analysed using multiple logistic regression
on each behaviour, risk awareness measure, and well-
being and attitudinal measure. Regions (West, East), sex
1625
and age were entered simultaneously into the regression
models. Western Europe was taken as the reference
group. Odds, adjusted for age and sex, for Eastern
European students engaging in ‘‘unhealthy’’ behavioural
options, being aware of links between behaviours and
cardiovascular disease risk, and having depressive
symptoms or low social supports are presented. The
95% confidence intervals for odds ratios and p values
obtained by logistic regression were obtained using Stata
(Stata Corporation, College Station, TX).
Results
Table 1 summarises the study sample. There was a
total of 6463 men and women in the survey, with 4170
from West European and 2293 from East European
countries. There were a greater number of women than
men in the samples from Belgium, Netherlands and
Switzerland, with broadly equal numbers in other
countries.
Health behaviours
The raw frequencies of unhealthy behaviours and the
adjusted odds of unhealthy behaviours in East and West
European samples are shown in Table 2. There were
more regular smokers in West than in East European
samples. For seven of the remaining twelve behaviours,
the odds of unhealthy behaviour were greater in Eastern
than Western Europeans. After adjustment for age and
sex, students from Eastern Europe were significantly
more likely than Western Europeans not to take regular
exercise, to drink alcohol, to make no efforts to avoid
dietary fat and eat fibre, to add salt to their food, not to
wear seat-belts, and not to use sunscreen. There were no
differences for fruit consumption. Regular breast self-
examination and testicle self-examination was infre-
quent in the entire cohort, and were unrelated to
European region. Eastern Europeans were more likely
to brush their teeth daily, but the absolute numbers of
respondents not brushing their teeth regularly was very
small (2.8% versus 1.2%). These analyses indicate that
with the exception of smoking, tooth brushing and self-
examination, fewer East than West European students
engaged in protective health behaviours.
Analysis of the combined healthy lifestyle index
indicated that 47.1% of Eastern Europeans had a
healthy lifestyle, compared with 63.4% of Western
Europeans. Adjusted odds of having a healthy lifestyle
for East European students were 0.52 (C.I. 0.47–0.58,
p50.001). On the more restricted six-item index, 36.1%
of Western Europeans scored four or more, compared
with 23.9% of Eastern Europeans. The adjusted odds of
having a lifestyle score of four or more for East
European students were 0.57 (C.I. 0.50–0.63, p50.001).
1626 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630

The regional comparisons were adjusted for age and
sex, as the latter two factors were also related to health
behaviours. Although not the topic of this report, it
should be noted that overall, women were less likely
than men to be regular smokers or alcohol drinkers, and
were more likely to avoid fat, eat fibre, eat fruit, use a
seat-belt, use sunscreen and brush their teeth daily. Men
on the other hand, were more likely to exercise regularly
and to avoid adding salt to their food. Older participants
were more likely than younger individuals to be
smokers, alcohol drinkers, not to eat fruit daily, and
to add salt to their food. But on the positive side, older
respondents were more likely to avoid fat, eat fibre, use
seat-belts, sunscreen, brush their teeth regularly, and to
carry out regular breast and testicle self-examination.
Risk awareness
Table 3 summarises the proportion of students from
Eastern and Western Europe who were aware of links
between lifestyle factors and high blood pressure or
heart disease. Odds ratios above one indicate a greater
awareness of the links between lifestyle and health in
East compared with West European students. Students
in the West European countries were more likely to be
aware of links between high blood pressure and salt
intake, high blood pressure and alcohol consumption,
and high blood pressure and exercise. They were also
more likely to be aware of the associations between
heart disease and smoking, heart disease and exercise,
and heart disease and fat consumption. All these effects
were significant after adjusting for age and sex; they
indicate lower risk awareness among East European
students.
Emotional well-being, social support, and locus of control
A rather consistent pattern of differences between
West and East European students emerged from these
measures. Eastern Europeans were substantially more
likely to have depressive symptoms and to report low
social support than Western Europeans. The unadjusted
proportion of respondents with depressive symptoms
above threshold was 43.2% in East and 23.5% in West
European country samples. East European students
were more than twice as likely to have few sources of
social support, and to be dissatisfied with social support.

Table 2
Odds of unhealthy behaviours in students from Eastern and Western Europe

Western Eastern Odds adjusted for age Significant

Europe (%) Europe (%) and sex [95% CI]

Regular smoking (>1/day) 22.9 19.8 0.79 [0.69–0.90] 0.001

Lack of regular exercise 63.8 70.3 1.37 [1.22–1.53] 0.001
Alcohol consumption 86.6 89.4 1.22 [1.04–1.44] 0.018
No avoidance of dietary fat 58.3 63.1 1.20 [1.07–1.34] 0.001
No effort to eat fibre 56.8 69.3 1.74 [1.55–1.94] 0.001
Eating fruit less than daily 45.7 47.3 1.01 [0.91–1.12] ns
Usually adding salt to food 31.0 45.9 1.88 [1.69–2.08] 0.001
Not always using a seat-belt 18.4 42.4 3.29 [2.93–3.80] 0.001
Not using sunscreen when sunbathing 21.9 32.6 1.68 [1.48–1.90] 0.001
Not brushing teeth daily 2.8 1.2 0.41 [0.27–0.62] 0.001
Not carrying out breast self-examination regularly 90.5 89.0 0.91 [0.71–1.16] ns
Not carrying out testicle self-examination regularly 96.2 97.0 1.26 [0.82–1.94] ns

Table 3
Awareness of risk of links between lifestyle and health: proportions of Eastern and Western students, and adjusted odds

Western Eastern Odds adjusted for age Significance

Europe (%) Europe (%) and sex [95% CI]

High blood pressure and salt intake 65.5 56.2 0.66 [0.59 to 0.73] 0.001
High blood pressure and alcohol consumption 58.6 52.7 0.77 [0.70 to 0.86] 0.001
High blood pressure and exercise 45.4 42.8 0.88 [0.79 to 0.98] 0.017
Heart disease and smoking 65.2 57.1 0.69 [0.62 to 0.76] 0.001
Heart disease and exercise 53.0 42.7 0.70 [0.63 to 0.77] 0.001
Heart disease and fat consumption 73.8 66.4 0.68 [0.61 to 0.76] 0.001
 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630
There was no difference in internal health locus of
control. However, Eastern Europeans reported signifi-
cantly higher beliefs in powerful others and higher
beliefs in chance locus of control. They therefore had a
greater external health locus of control orientation than
Western Europeans. Contrary to our prediction, East
European students placed a higher value on their health
than West European students.
These analyses were carried out using logistic
methods, dividing scores according to somewhat arbi-
trary thresholds. However, a similar pattern of results
emerged from analyses of variance of the depression,
social support, locus of control and health value scores,
covarying for age and sex.
Discussion
The results of these analyses indicate that the sample
of university students from Eastern Europe report that
they have relatively less healthy lifestyles than Western
European students do. They were also less knowledge-
able about the health risks associated with various
aspects of lifestyle, more depressed, reported lower
social support, and had higher external health locus
control beliefs. Because the study was restricted to
university students, the prevalence of health behaviours
and other factors are not representative of the countries
involved. The profiles come from comparatively healthy,
well-informed and educated sectors of the young
population. Nevertheless, there is no reason to think
that the kinds of differences between West and East
recorded here would not be observed in the entire
population.
Direct comparisons with patterns of health behaviour
recorded in wider samples are not possible, since we are
not aware of other studies that have collected data using
uniform coding systems in similar sectors of the
population in these countries. One striking discrepancy
is between the analyses of regular smoking and
consumption of tobacco in West and East European
countries. As noted in Table 2, the prevalence of regular
smoking was lower among East than West European
student samples. East European countries have among
the highest rates in the world of premature death
attributable to smoking in both men and women (Peto,
Lopez, Boreham, Thun, & Health, 1994). The World
Health Organization (1997) estimated that in 1990–1992,
Poland ranked the highest of 111 countries in terms of
annual per capita consumption of cigarettes. Hungary
was third, with Switzerland ranked fifth, the Nether-
lands eighth, and the three other countries in this study
lower down. However, these figures are averages across
the entire adult population of all ages and levels of
education. A similar prevalence of smoking to the one
we observed has been reported in a survey of medical
1627
students in Hungary (Piko, 1996). It is likely that the
diffusion of healthier smoking habits would commence
in young, educated sectors of the population. The recent
WHO cross-national survey of health-related behaviour
in national representative samples of 15-year olds
showed that daily smoking averaged 21% in the Western
European and 21.3% in the Eastern European countries
studied here (Currie, Hurrelmann, Settertobulte, Smith,
& Todd, 2000).
The differences between West and East European
samples in other health behaviours were similar to those
that have been described elsewhere. For example, the
higher level of regular exercise in West European
students is similar to the pattern observed in 15-year
olds, where 65.2% of Western Europeans exercised more
than 2 h a week, compared with 52.3% of Eastern
Europeans (Currie et al., 2000). The East European
students in the present study were less likely to make
efforts to avoid fat and to eat fibre than their Western
counterparts. In the WHO cross-national study, 11% of
15-year olds from Eastern Europe ate chips or fried
potatoes every day, compared with 3% of Western
Europeans, and daily consumption of chocolate and
other sweets was reported in 52.3% versus 39%. At the
national level, the estimated number of calories per day
derived from animal fat in 1990 averaged 309 in the five
West European countries studied here, compared with
423 in Hungary and Poland (Food and Agriculture
Organization, 1999). By contrast, the proportion of total
energy derived from fat, fruit and vegetables was 6% in
West European and 4% in East European countries.
The higher prevalence of alcohol consumption in East
European students replicates findings in other surveys
(Cockerham, 1999).
Our observation that East European students were
less likely to use seat-belts when driving in the front seat
of a car is particularly interesting in the light of the
excess mortality from external causes such as accidents
that has been described in former socialist states (Bobak
& Marmot, 1996). The lower levels of sunscreen use
might place the East European sample at raised risk for
skin cancers as well. There were no differences between
European regions in the two behaviours carried out
exclusively for detecting cancer: breast self-examination
and testicle self-examination. However, the frequency of
these behaviours was very low, so variance was
restricted (Wardle et al., 1994, 1995).
We would argue that the pattern of less healthy
lifestyles observed among Eastern European students is
not simply a product of individual choice and disregard
for health. Indeed, the data indicate that the East
European sample placed a higher value on their health
than did Western Europeans (Table 4). Rather, the
pattern arises from structural factors leading to lower
provision of health information and greater dependence
on external forces for health maintenance. The analyses
1628 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630
Table 4
Emotional well-being, social support and locus of control in students from Eastern and Western Europe
Western
Europe (%)
Depression 23.5
Social support: low number of supports 13.9
Social support: low satisfaction 15.7
Low internal health locus of control 35.3
High powerful others health locus of control 44.4
High chance health locus of control 40.0
Low value of health 52.0
of risk awareness indicated that East European students
were less likely than Western students to know that
heart disease was related to smoking, exercise or fat
intake, and were also less aware of links between high
blood pressure and salt intake, exercise and alcohol
consumption. Data from other comparative studies are
not available, but there is evidence that only a small
minority of Polish adults with high blood pressure
attempt to limit salt intake and dietary fat (Krupa-
Wojciechowska, Narkiewicz, & Rynkiewicz, 1996). If
people are less knowledgeable about the role of lifestyle
factors in the avoidance of disease, then health motives
for lifestyle change may be diminished.
There were striking differences between West and East
European samples in depressed mood and perceptions of
social support. Depression has been recognised as a
major health problem among students (Allgöwer, 2000).
Nearly twice as many Eastern than Western Europeans
had scores above the criterion for moderate depression,
suggesting that the problem was widespread. There is
limited evidence for similar differences between Eastern
and Western Europe in working populations (Kristen-
son et al., 1998). The difference in social support is also
important in the light of the protective role that social
relationships play in coping with stress and maintaining
health and well-being (Cohen & Syme, 1985).
It is not possible from this cross-sectional survey to
conclude that differences in depression or social support
contribute to the less healthy patterns of personal
behaviour reported by respondents from Eastern Eur-
ope. We have previously shown in the larger survey,
from which the present data set was derived, that
depression is associated with a range of less healthy
behaviours, while social support has the reverse effect
(Allgöwer, Wardle, & Steptoe, in press). It is plausible
both that depressed mood leads to patterns such as
sedentary behaviour, alcohol consumption and lack of
care about seat-belt use, and that behaviours such as
physical exercise contribute to improved mood states.
The results of this analysis suggest that negative
moods and low social support are accompanied by more
Eastern Odds adjusted for age Significance
Europe (%) and sex [95% C.I.]
43.2 2.46 [1.95–3.09] 0.001
36.9 3.44 [2.61–4.52] 0.001
31.6 2.31 [1.76–3.04] 0.001
31.4 0.86 [0.71–1.04] ns
63.1 2.19 [1.83–2.64] 0.001
50.2 1.53 [1.28–1.83] 0.001
42.1 0.68 [0.56–0.83] 0.001
external health control beliefs in Eastern Europeans. It
has previously been suggested that internal and chance
health locus of control beliefs are predictive of health
behaviour in healthy populations, while powerful other
ratings are more relevant to people suffering from
chronic illness (Furnham & Steele, 1993). Against
prediction, there were no differences in internal health
locus of control beliefs, but both aspects of external
control (beliefs in chance and beliefs in powerful others)
were higher in the East European sample. The greater
belief in powerful others may be a residue of dependence
on a centralised state and reliance on authority for
health advice and health maintenance. However, the
higher ratings of belief in the role of chance in health
suggest that fatalistic attitudes and a sense of pessimism
may prevail among these young adults.
A number of limitations to these analyses should be
recognised. The survey was cross-sectional and based on
self-report, so causal conclusions linking health beha-
viours with risk awareness, mood and beliefs cannot be
drawn. Data were self-reported, and patterns were not
verified objectively. Perceptions of control were indexed
by health locus of control, and not by a general measure
of sense of control or powerlessness. Differences
between countries in access to higher education could
have influenced the comparisons made here. The sample
collected was not large enough to allow reliable
comparisons to be made between individual countries.
At the time of data collection, the East European
countries were experiencing considerable turmoil result-
ing from political change, and the dismantling of the
collective welfare system which included (however
ineffectively) free health and education services, sub-
sidised accommodation, and job security for many
(Millard, 1992; Szalai & Oronsz, 1992). In the period
immediately following data collection, the economic
output fell substantially in Poland and Hungary, while
unemployment increased (Monee Project, 1999). The
results may therefore reflect the specific conditions
prevailing in 1989 and 1990. On the other hand, recent
surveys suggest that health practices may continue to
 A. Steptoe, J. Wardle / Social Science & Medicine 53 (2001) 1621–1630
deteriorate in Eastern Europe. For example, the
prevalence of cigarette smoking among secondary
school students aged 15–18 years in Budapest increased
from 36% in 1995 to 46% in 1999 (CDC, 2000). We are
currently collecting further data from similar samples in
Western and Eastern Europe, in order to establish
whether differences are stable or have changed over the
past decade in this sector of the population.
Our results suggest that lifestyle factors may con-
tribute to differences in health and well-being between
Western and Eastern Europe, and that these differences
are associated with poorer health knowledge, a greater
sense of powerlessness over health, social isolation and
depressed mood in educated young adults in East
European countries.
Acknowledgements
The authors are most grateful to Martin Bobak for
his comments on these analyses and earlier drafts of
the manuscript. The EHBS was supported in part
by the European Commission BIOMED program,
and by the Economic and Social Research Council,
UK.
The following colleagues participated in data collec-
tion: Austria: Prof. Margit Koller and Prof. Elisabeth
Groll-Knapp (Vienna); Belgium: Prof. Jan Vinck
(Diepenbeek); East Germany: Dr. Konrad Reschke
(Leipzig); West Germany: Dr. Claus Vögele (Marburg)
and Prof. Gudrun Sartory (Wuppertal); Hungary: Prof.
Maria Kopp and Dr. Árpad Skrabskı́ (Budapest); The
Netherlands: Prof. Robbert Sanderman (Groningen);
Poland: Dr. Zbigniew Zarczynski (Krakow) and Prof.
Andrzej Brodziak (Bytom); Switzerland: Prof. Ruth
Burckhardt and Dr. Laurent Rossier (Lausanne).
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