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Leisure-time physical activity in university students from 23 countries:
associations with health beliefs, risk awareness, and national
economic development
Anne Haase, Ph.D.,
a
Andrew Steptoe, D.Phil.,
b,
*
James F. Sallis, Ph.D.,
c
and Jane Wardle, Ph.D.
a
a
Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
b
Psychobiology Group, Department of Epidemiology and Public Health, University College London, London WC1E 6BT, UK
c
Department of Psychology, San Diego State University, San Diego, CA 92182, USA
Available online 16 April 2004
Abstract
Background. Physical inactivity has been linked with chronic disease and obesity in most western populations. However, prevalence of
inactivity, health beliefs, and knowledge of the risks of inactivity have rarely been assessed across a wide range of developed and developing
countries.
Methods. A cross-sectional survey was carried out with 19,298 university students from 23 countries varying in culture and level of
economic development. Data concerning leisure-time physical activity, health beliefs, and health knowledge were collected.
Results. The prevalence of inactivity in leisure time varied with cultural and economic developmental factors, averaging 23% (North-
Western Europe and the United States), 30% (Central and Eastern Europe), 39% (Mediterranean), 42% (Pacific Asian), and 44% (developing
countries). The likelihood of leisure-time physical activity was positively associated with the strength of beliefs in the health benefits of
activity and with national economic development (per capita gross domestic product). Knowledge about activity and health was
disappointing, with only 40–60% being aware that physical activity was relevant to risk of heart disease.
Conclusions. Leisure-time physical activity is below recommended levels in a substantial proportion of students, and is related to cultural
factors and stage of national economic development. The relationship between health beliefs and behavior is robust across cultures, but health
knowledge remains deficient.
D2004 The Institute for Cancer Prevention and Elsevier Inc. All rights reserved.
Keywords: Coronary heart disease; Psychosocial; International; Prevalence; Exercise
Introduction
The health benefits of leisure-time physical activity are
widely recognized, as inactivity is associated with increased
risk of coronary heart disease, various cancers, obesity, and
other health problems [1,2]. The recommendation to increase
physical activity is a key element of health-promotion strate-
gies in many countries, and of international initiatives targeted
at developed and developing countries such as the WHO Mega
Country Health Promotion Network [3,4]. Surveys from
individual countries indicate that the prevalence of adequate
physical activity is relatively high in children and adolescents
[5,6] but substantially lower in adults, suggesting that late
adolescence and early adult life may be a critical period of
transition [7,8]. It is important therefore to monitor trends in
physical activity in young adults, and to understand factors
such as attitudes and knowledge of health benefits that may be
associated with activity levels.
International comparisons are valuable from the perspec-
tive of global public health since they help define variations
in physical activity in different cultures, point to common
determinants across countries, suggest countries or regions
in most need of intervention, and highlight good practice in
health promotion. Unfortunately, the measurement of lei-
sure-time physical activity is complex, and surveys using
0091-7435/$ - see front matter D2004 The Institute for Cancer Prevention and Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2004.01.028
* Corresponding author. Department of Epidemiology and Public
Health, University College London, 1-19 Torrington Place, London WC1E
6BT, UK. Fax: +44-20-7916-8542.
E-mail address: a.steptoe@ucl.ac.uk (A. Steptoe).
www.elsevier.com/locate/ypmed
Preventive Medicine 39 (2004) 182 – 190
different methods are difficult to compare [9]. There have
been relatively few substantial international studies of
comparable samples from different countries [5,10– 12],
and these have predominately focused on Europe. Informa-
tion concerning leisure-time physical activity in developing
and Pacific Asian countries is sparse. Consequently, it has
not yet been possible to formulate models of the evolution
of leisure physical activity in relation to levels of national
economic development, as have been proposed for other
health-related behaviors such as smoking [13].
This study assessed leisure-time physical activity in
university students from 23 countries, analyzing the preva-
lence of inactivity and activity at recommended levels of
three or more times a week [14]. We investigated whether
there were systematic differences in physical activity across
countries related to national economic development, and to
geographical, cultural, and political groupings. The strength
of individual attitudes concerning the benefits of physical
activity and knowledge about the role of physical activity in
preventing chronic disease was also evaluated. These psy-
chological variables are relevant for planning health educa-
tion, and may be associated with increased frequency of
leisure-time physical activity [15]. We used multilevel
modeling to assess the associations between leisure-time
physical activity and individual-level factors (attitudes, risk
awareness) and ecological-level factors (national economic
development) simultaneously. Because data were collected
from university students rather than representative samples
of young adults in each country, we cross-validated inter-
national differences in reported activity levels by compari-
son with existing data sets that included several of the
countries sampled [10].
Methods
These analyses were based on data from the International
Health and Behaviour Survey (IHBS), a cross-sectional
questionnaire study of health behaviors and attitudes in
19,298 university students from 23 countries, carried out
between 1999 and 2001. Assessments of physical activity
were identical to those included in the European Health
Behaviour Survey (EHBS), conducted between 1989 and
1991 [12,16]. The study was carried out with a network of
collaborators in participating countries (see Acknowledge-
ments). The countries involved were Belgium, Bulgaria,
Colombia, France, Germany, Greece, Hungary, Iceland,
Ireland, Italy, Japan, South Korea, the Netherlands, Poland,
Portugal, Romania, Slovakia, South Africa, Spain, Thailand,
United Kingdom, United States, and Venezuela. The ques-
tionnaire used for data collection was developed in English,
then translated and back-translated into 17 languages (Bul-
garian, Dutch, Flemish, French, German, Greek, Hungarian,
Icelandic, Italian, Japanese, Korean, Polish, Portuguese,
Romanian, Slovak, Spanish, and Thai). Collaborators col-
lected data from university students aged 17 – 30 years who
were not studying medicine or health-related topics. Be-
tween one and three universities were sampled in each
country. A variety of students were involved, including
those studying physical sciences, engineering, law, social
science, languages, geography, history, and economics. Data
collection was standardized, with the questionnaire being
administered to large groups of students usually at the end
of classes, so participation rates in most countries exceeded
90%. The sample size ranged from 471 to 2,028 respondents
per country. Respondents were told that the survey
concerned activities related to health and that an interna-
tional comparison was being carried out, but no further
details were given. Data from the United Kingdom were
collected in England; the German sample came from uni-
versities in the former Federal Republic (West Germany);
the South African data from a university with predominantly
black students; and the United States’ sample from univer-
sities in California and Colorado.
Two items were used to measure leisure-time physical
activity. The first item asked whether the individual had
taken any exercise (e.g., sport, physically active pastime) in
the past 2 weeks, and the second item asked for the number
of physical activity sessions over that time period. These
items are similar to those used in several behavioral risk
factor surveillance systems, such as the STEPS (Stepwise
Approach to Surveillance of Noncommunicable Disease
Risk Factors) and CARMEN (Conjunto de Acciones para
la Reduccion Multifactorial de Enfermedades No transmi-
sibles) programs [4]. Reliability data for these measures are
published elsewhere [17,18]. Participants were asked what
type of physical activity they carried out. These data are not
detailed in this paper, but the dominant forms of activity
were jogging/running, swimming, football (soccer), and
aerobics. A belief rating was completed of how important
physical activity was for the maintenance of health, ranging
from 1 = not at all important to 10 = very important.
Knowledge about the specific health benefits of physical
activity was assessed in a section of the questionnaire
inquiring about the influence of a range of lifestyle factors
such as smoking and alcohol on specific medical conditions
[19]. We analyzed the proportion of respondents who stated
that physical activity was related to the development of heart
disease. The economic development level of participating
countries was assessed by per capita gross domestic product
(GDP), abstracted from the World Bank development indi-
cators [20].
There are no data sets describing levels of leisure
physical activity in samples from all the countries included
in this study. The WHO cross-national study of health
behavior in school children aged 11–15 years [5] is not
comparable, because physical activity levels at this age are
strongly determined by school policies [21]. The largest
number of countries are represented in a pan-European
study of adults [10], so prevalence levels from 10 of the
countries in the present study were compared with these
results.
A. Haase et al. / Preventive Medicine 39 (2004) 182–190 183
The statistical analyses involved comparing leisure
physical activity, beliefs, and risk awareness in each
country sample, and in groups of countries defined by
cultural, geographical, and political criteria. Five groups
of countries were created: North-Western Europe and the
United States (Belgium, England, France, Germany, Ice-
land, Ireland, the Netherlands, and the United States), the
former socialist states of Central and Eastern Europe
(Bulgaria, Hungary, Poland, Romania, and Slovakia),
Mediterranean countries (Greece, Italy, Portugal, and
Spain), countries of the Pacific-Asian rim (Japan, Korea,
and Thailand), and developing countries (Colombia,
South Africa, and Venezuela).
Physical activity data were analyzed by dividing the
sample into three groups: inactive, low-frequency activity,
and recommended frequency activity. The ACSM 1990
guideline of exercising three or more times a week (six
times in 2 weeks) was used as a reference for determin-
ing whether people reached recommended levels of
activity [14]. This recommendation was embodied in
Healthy People 2000 [22]. Although public health guide-
lines for physical activity have been revised, this guide-
line is widely supported as identifying levels of physical
activity producing health benefits, and was used in the
analyses of physical activity carried out with the earlier
EHBS [12]. The prevalence of inactivity, low-frequency
activity, and recommended activity was computed for
men and women in each country sample. There were
small differences in average age between countries, so
data are presented as age-adjusted prevalence with 95%
confidence intervals (CI).
The belief ratings were skewed toward positive scores.
These data were therefore analyzed by dichotomizing scores
as 9 or 10 (indicating strong beliefs) or 8 or less (indicating
weaker beliefs). The proportion of respondents in each
country or group of countries who had strong beliefs in
the importance of activity for health was then analyzed.
Awareness of the role of physical activity in heart disease
was analyzed as a binary variable. Associations between
beliefs, health knowledge, national economic development
(GDP), and physical activity were analyzed using multilevel
logistic regressions, assessing the odds of any leisure
physical activity, and the odds of recommended frequency
activity. Gender (with women coded 1 and men coded 0)
and age were included in these models. The multilevel
regressions were carried out using a random intercepts
maximum likelihood logit model in STATA. All analyses
involving groups of countries involved clustered data, so
confidence intervals were adjusted to take account of intra-
cluster effects using STATA.
Results
Prevalence of leisure-time physical activity
The age-adjusted prevalence of physical inactivity is
shown in Fig. 1, and the prevalence of activity at recom-
mended levels in Fig. 2. Overall, more women than men
reported no leisure-time physical activity (38%, CI 37 – 39
vs. 27%, CI 26 – 28, P< 0.0001). The differences were
significant ( P< 0.01 or less) in 16 of the 23 countries, but
were not reliable in Germany, Hungary, Iceland, Ireland,
Japan, the Netherlands, or the United States. The prevalence
of inactivity varied markedly across country samples, rang-
ing from 11% (Belgium) to 41% (Portugal and South
Africa) among men, and from 15% (USA) to 65% (Portu-
gal) among women. Leisure-time physical activity at rec-
ommended levels was more common in men (28%, CI 27 –
29) than women (19%, CI 18 – 20, P< 0.0001), and differed
widely between country samples. The lowest prevalence of
leisure-time physical activity at recommended levels was in
Japan and Germany for men, and Japan for women, while
the highest levels were reported by students from Poland
Fig. 1. Age-adjusted prevalence (%) of physical inactivity in university students from 23 countries. Black bars: men. Shaded bars: women.
A. Haase et al. / Preventive Medicine 39 (2004) 182–190184
(men) and Iceland and Ireland (women). Interestingly, there
was no overall difference in the proportion of men and
women active at low frequency (45% CI 44 – 46 for men,
43% CI 42 – 44 for women), indicating that the gender
difference was due to the proportions wholly inactive or
active at recommended levels.
The prevalence of leisure-time physical activity by coun-
try group is shown in Table 1. Significant trends in inactiv-
ity across groups of countries were present for both men and
women. Levels of inactivity were lowest in North-Western
Europe and the United States, and highest in developing
countries. There were less-consistent differences between
groups of countries in activity at recommended levels; in
neither men nor women did the prevalence of recommended
activity differ between North-Western Europe and the Unit-
ed States, Central and Eastern Europe, and Mediterranean
countries. A significant trend across groups of countries was
present in low-frequency activity in women but not men ( P
< 0.001). A higher prevalence of low-frequency physical
activity was reported from North-Western Europe and the
United States than in Mediterranean and developing
countries.
The per capita GDP in 2001 ranged in these countries
from more than $35,000 (USA) to less than $2,000
(Bulgaria, Colombia, South Africa, Thailand). The prev-
alence of leisure-time physical activity at any level was
positively correlated with economic development (r=
0.49, P= 0.02), so activity was more prevalent in more
developed countries.
Comparison with European Union data
The prevalence of leisure-time activity at any level in the
10 countries that participated in the comparison European
Union study was 69%, not significantly different from the
67% reported by Martinez-Gonzalez et al. [10]. In addition,
the prevalence of activity in the present study correlated r=
0.72 ( P= 0.02) with the European Union study, providing
external corroboration for the differences between countries
reported here.
Fig. 2. Age-adjusted prevalence of recommended frequency (six times in the past 2 weeks) leisure-time physical activity in university students from 23
countries. Black bars: men. Shaded bars: women.
Table 1
Prevalence of inactivity, low-frequency leisure-time activity, and recom-
mended frequency activity in five groups of countries
Inactive Low-
frequency
activity
Recommended
frequency
activity
Men
North-Western
Europe + United
States (n= 2617)
21% (16 – 26) 49% (43 – 55) 30% (22 – 39)
Central and Eastern
Europe (n= 1890)
25% (17 – 35) 43% (35 – 52) 32% (25 – 40)
Mediterranean
(n= 1859)
30% (22 – 40) 40% (35 – 45) 30% (19 – 44)
Pacific Asian (n= 827) 34% (33 – 34) 48% (42 – 54) 18% (14 – 24)
Developing countries
(n= 1196)
35% (28 – 42) 43% (35 – 51) 23% (22 – 24)
Pfor trend across
groups of countries
for men
0.05 n.s. n.s.
Women
North-Western
Europe + United
States (n= 3618)
24% (17 – 32) 54% (47 – 60) 22% (17 – 29)
Central and Eastern
Europe (n= 2276)
33% (25 – 43) 47% (39 – 55) 19% (18 – 21)
Mediterranean
(n= 2370)
46% (34 – 59) 32% (26 – 38) 22% (15 – 32)
Pacific Asian
(n= 1257)
47% (36 – 58) 38% (25– 53) 15% (11– 20)
Developing countries
(n= 1148)
53% (47 – 60) 34% (30 – 38) 13% (10 – 15)
Pfor trend across
groups of countries
for women
0.001 0.001 n.s.
Note. Prevalence levels are age-adjusted. Ninety-five percent confidence
intervals are adjusted for intracluster effects.
A. Haase et al. / Preventive Medicine 39 (2004) 182–190 185
Beliefs in the importance of physical activity for health
Strong beliefs (ratings of 9 or 10) about the importance
of physical activity for health were related to behavior in a
dose-dependent fashion ( P< 0.0001). This is illustrated in
Fig. 3, where it is evident that the proportion of respond-
ents with strong beliefs was lowest among inactive stu-
dents, and greatest in those active at recommended levels.
This pattern did not differ by gender. Nor were there
differences in the prevalence of strong beliefs about the
importance of physical activity for health across groups of
countries. The correlation between economic development
and prevalence of strong beliefs was not significant (r=
0.19, P= 0.41).
Knowledge of health benefits
The proportion of male and female students who were
aware of the association between heart disease and physical
activity is shown in Fig. 4. In general, the levels of
knowledge were disappointing; even in Western developed
countries with established traditions of health education,
only 40–60% of students were aware that physical activity
was relevant to risk of heart disease. Overall, the proportion
of men (43%, CI 42 – 44) and women (45% (CI 44 – 46)
aware of the association was similar, with no marked
differences in any country sample. The proportions of
men and women in each country aware of the association
between physical activity and heart disease was strongly
correlated (r= 0.97, P< 0.0001).
Levels of knowledge of health benefits varied consider-
ably between country samples, with high levels in the
Netherlands, Slovakia, Greece, and Japan, and poor levels
of knowledge in Romania, Thailand, and South Africa. The
levels of knowledge in the five groups of countries com-
pared in this study are summarized in Table 2. With the
exception of the low levels of awareness in developing
countries, there were no systematic variations across the
other groups of countries. This suggests that knowledge
Fig. 3. Proportion of students with strong beliefs in the importance of
physical activity for health, in relation to reported frequency of leisure-
time physical activity—Inactive: no leisure-time physical activity in the
past 2 weeks. Low freq PA: five or fewer episodes in the past 2 weeks.
Recommended PA: six or more episodes in the past 2 weeks. Black
bars: men. Shaded bars: women. Error bars are standard errors of the
mean.
Fig. 4. Age-adjusted proportion of university students from each country who knew of the association between physical activity and heart disease. Black bars:
men. Shaded bars: women.
Table 2
Knowledge of the influence of physical inactivity on heart disease in five
groups of countries
Men Women
North-Western Europe + United States 48% (42 – 54) 52% (47– 57)
Central and Eastern Europe 43% (22 – 67) 43% (24– 65)
Mediterranean 44% (33 – 56) 45% (36– 54)
Pacific Asian 46% (24 – 70) 44% (21– 70)
Developing countries 30% (16 – 48) 26% (12– 47)
Note. Prevalence levels are age-adjusted. Ninety-five percent confidence
intervals are adjusted for intracluster effects.
A. Haase et al. / Preventive Medicine 39 (2004) 182–190186
about the specific health benefits of physical activity is more
strongly associated with economic development than with
cultural and political factors. This impression was confirmed
by the positive correlations across countries between prev-
alence of health knowledge and economic development (r=
0.50, P= 0.019).
Associations between physical activity, beliefs, health
knowledge, and economic development
The multilevel regression analyses on any leisure-time
physical activity, and on physical activity at recommended
frequency, are summarized in Table 3. The likelihood of
being physically active at any level was greater in men than
women, in those with stronger health beliefs (odds ratio
2.82, CI 2.62–3.03), and in respondents from more eco-
nomically developed nations (odds ratio 1.38, CI 1.33 –
1.43). A similar pattern emerged in the analyses of leisure-
time physical activity at recommended levels. Gender,
health beliefs, and national economic development were
significantly associated with activity, while age and knowl-
edge of links between physical activity and heart disease
were not.
Discussion
Analysis of the prevalence of physical activity confirmed
our expectation that there would be wide variations between
country samples. Similar variations in Europe have been
observed in other studies [10 – 12]. We used two overlapping
strategies to try to understand the pattern across countries.
The first was to group countries by political, cultural, and
geographical criteria. The countries included in the North-
Western European and the United States category are all
mature democracies and market economies. The five Central
and Eastern European countries are emerging market econ-
omies that were socialist states until the collapse of com-
munism. The countries of the Mediterranean region share
cultural characteristics in terms of diet and lifestyle. The
countries allocated to the Pacific Asian group were more
heterogeneous, including Japan (an economically advanced
country with high per capita GDP), less affluent Thailand,
and intermediate Korea. The remaining three countries from
Africa and South America were classified as being at a
relatively early stage of economic development. This group-
ing of countries proved to have explanatory power in
relation to the prevalence of inactivity (Table 1). Inactivity
was least prevalent in both men and women from North-
Western Europe and the United States, increasing progres-
sively across country groups, so that inactivity was most
prevalent in the developing country group.
The second method of classifying countries was by using
an index of economic development. The two strategies
overlapped, since the countries of North-Western Europe
and the United States were the most affluent, while the
developing countries were by definition least affluent. But
the other countries in this survey were differently ranked
from their position in the five country grouping. For
example, economic development in terms of per capita
GDP was low in Central and Eastern European participating
countries, while being high in Mediterranean countries. The
classification of countries in terms of economic develop-
ment also showed significant associations with the preva-
lence of physical inactivity among students, independently
of age, gender, and health beliefs.
These findings suggest that there is a broad association
between the economic development stage of countries and
leisure-time physical activity, coupled with specific cultural
and geopolitical determinants. Levels of leisure physical
activity in young adults are generally higher in more
economically developed countries, with the exception of
Mediterranean countries. However, an interesting result is
that this pattern applied more strongly to the presence or
absence of any leisure physical activity, rather than to
physical activity at recommended levels. In the regression
analyses (Table 3), the odds associated with higher GDP
were reduced by 45% in the analysis of recommended
frequency GDP compared with any physical activity. Thus,
cultural and economic factors are less relevant to the
likelihood that university students exercise at a high fre-
quency. It may be that this behavior is more strongly
influenced by other factors (such as involvement in sports)
apart from broad economic and cultural influences.
Exercising three or more times a week was used as the
criterion for attaining recommended levels of activity. This
criterion established by the ACSM in 1990 has been
superseded in countries such as the United States with
public health recommendations based on the accumulation
of 30-min, moderate-intensity physical activity on most
days of the week [1,23]. This level is more difficult to
quantify in surveys of the type used here, and the recom-
mendation has not currently been adopted in many
countries, so the older criterion was applied.
Table 3
Logistic regressions on leisure-time physical activity
Odds of any activity
(vs. inactivity)
Odds of activity at
recommended frequency
(vs. inactivity)
Odds ratio
(95% CI)
POdds ratio
(95% CI)
P
Age 0.99 (0.98 – 1.001) 0.088 0.99 (0.99 – 1.00) 0.88
Gender 0.57 (0.53 – 0.61) 0.001 0.58 (0.53 – 0.63) 0.001
Beliefs in
health
benefits
2.82 (2.62 – 3.03) 0.001 3.07 (2.83 – 3.34) 0.001
Knowledge
of physical
activity/heart
disease link
1.07 (0.99 – 1.15) 0.055 1.04 (0.96 – 1.13) 0.30
Per capita GDP 1.38 (1.33 – 1.43) 0.001 1.21 (1.15 – 1.27) 0.001
The reference category for odds ratios was inactivity in both analyses.
A. Haase et al. / Preventive Medicine 39 (2004) 182–190 187
There were strong associations between reported leisure
physical activity and the strength of beliefs in health
benefits, which emerged both in bivariate (Fig. 3) and
multivariate (Table 3) analyses, consistent with previous
findings with adults [15]. The causal sequence cannot be
determined in this study. Beliefs in health benefits may
stimulate physical activity, but might also emerge in people
who are currently active. The positive relationship was
evident in a wide range of cultural groups, climatic con-
ditions, and political settings, though it is interesting that the
associations were greater in North-Western Europe and the
United States than in other groups of countries. However,
the proportion of participants with strong beliefs in health
benefits did not vary by gender or across country samples.
Thus, it was not the case that students from the developed
countries such as the United States, Japan, and North-
Western Europe held stronger beliefs in health benefits on
average. It may be therefore that other motives apart from
health benefits determine the higher prevalence of leisure
physical activity in economically developed countries. Fac-
tors such as enjoyment, social support, and trying to lose
weight have been identified as correlates of leisure-time
physical activity in different samples [24,25], so it would be
valuable to evaluate a broader range of physical activity
correlates in future international studies. Increasing the
proportion of young people with strong beliefs in health
benefits might be a valuable component of international
health promotion.
A cornerstone of health education is transmitting infor-
mation about the diseases associated with lifestyle choices,
and this was indexed in the present study by knowledge of
the connection between physical activity and heart disease.
The levels of knowledge of links with heart disease were not
high in the study (Fig. 4), and exceeded 50% of both men
and women in only 8 of 23 country samples. In an analysis
of a subset of countries in this study, we have shown that
levels of knowledge changed little between 1990 and 2000
[16], so the penetration of health education remains limited.
Higher levels of knowledge were not related to the country
grouping (Table 2), but were associated with greater eco-
nomic development. More economically developed
countries may expend greater resources on health education,
while access to mass media is also broader. Nonetheless,
knowledge was not associated with behavior. As shown in
Table 3, knowledge of the relationship between physical
activity and heart disease was not associated with leisure-
time physical activity. These null findings are consistent
with previous research [15]. Thus, although national eco-
nomic development may relate to health knowledge, this
does not translate at an individual level into participation in
leisure-time physical activity. Improving knowledge about
health effects should not be expected to be an effective
physical activity promotion strategy, even in less developed
countries.
The explanation for the gradient in physical activity
across students from countries varying in economic devel-
opment and cultural background is not certain. The pattern
is unlikely to be due to compensatory differences in non-
leisure physical activity since all the participants in this
sample were university students and not engaged in physical
labor. We investigated the issue in detail in a previous study
[12], and found that the contribution to the overall level of
physical activity of walking or bicycling for the purposes of
transportation amongst students was very small. Several
other factors might be relevant. Engaging in leisure-time
physical activity for health reasons in young people is
predicated on a desire to increase longevity in middle and
old age. Less economically developed countries have lower
overall life expectancies than affluent countries, so motiva-
tion for actions that extend life in older age may still be
limited. It can be argued that leisure-time physical activity is
strongly influenced by the cultural significance of inactivity;
in countries in which manual labor remains common,
inactivity may be a marker of prestige. Health promotion
targeted at chronic noncommunicable diseases has until
recently been a low priority in developing countries [4],
resulting in less encouragement of leisure-time physical
activity. The facilities for leisure-time physical activity
may be more limited in universities from less affluent
countries, leading to environmental constraints on partici-
pation. Students at universities in less economically devel-
oped countries may place greater value on academic
achievement, and may commit less time in nonacademic
leisure pursuits than individuals from more privileged
societies. There are probably wide cultural variations in
interest in sport and in sport participation that have yet to be
quantified systematically, but which may also contribute to
the differences across country samples reported here.
This survey was not carried out with representative
samples of young adults from the countries involved.
University students are better educated and generally health-
ier than other sectors of society [26]. University educated
men and women engage in more leisure-time physical
activity then less well educated individuals in many
countries [27]. Levels of leisure physical activity are there-
fore likely to have been higher than would have been
reported from the population in general. There were several
reasons for carrying out the IHBS with this methodology
[19]. When making comparisons across countries, it is
necessary to compare like with like, and university students
are an easily identifiable, accessible, and homogenous
group. Students represent a significant sector of young
adults, and there is considerable concern about their health
behavior [25,28]. In most societies, graduates from univer-
sity take up more prestigious professional and managerial
occupations than less well-educated individuals, so are
likely to hold influential positions in education and policy
making in the future. In addition, conducting the study in
classes meant that response rates were high.
Our confidence in the accuracy of the differences in
leisure-time physical activity between country samples was
strengthened by the positive correlation (r= 0.72) between
A. Haase et al. / Preventive Medicine 39 (2004) 182–190188
levels reported in this survey and the representative samples
assessed by Martinez-Gonzalez et al. [10]. The differences
between countries were also similar to those reported in the
smaller selection of countries assessed by Stahl et al. [11].
Thus, although the overall levels of leisure physical activity
may not be representative, the relative levels reported by
different country samples appear reliable. In a previous
analysis, we have found that levels of physical activity
remained rather stable in students assessed in the EHBS
between 1989 and 1991 and this study in 1999–2001 in 13
countries included in both studies [16]. In that comparison,
the prevalence of physical activity at any level in each
country correlated r= 0.72 in men and r= 0.89 in women
(both P< 0.001) across the 10-year period.
Other limitations to this study should also be acknowl-
edged. The study was cross-sectional and based on self-
report measures, and causal conclusions cannot be drawn.
The universities involved in this study were not selected at
random, and there may be important variations within
countries in physical activity levels relating to geographical
location and the culture of the university. Physical activity
was assessed with simple items that did not discriminate
variations in the intensity or duration of each bout of
activity. Some individuals may have carried out activity at
a modest intensity for a short time, while others could have
been active at high intensities for long periods. Only simple
health beliefs were measured in this study, but many
different cognitive and attitudinal factors are known to
correlate with physical activity, and examining a broader
range of psychosocial variables may help explain the
variation in frequency of leisure-time physical activity
across countries. The measure of health knowledge was
also limited, and more comprehensive assessments may be
informative [29]. Nevertheless, the present study indicates
that between one fifth and one half of university students do
not engage in leisure physical activity, and that knowledge
of health beliefs is limited. Further investigation of interna-
tional differences may highlight particular mediators of
physical activity that could be targeted by health promotion
in less economically developed countries, to help these
states avoid the high levels of obesity and chronic non-
communicable disease prevalent in the most affluent
countries of the world.
Acknowledgments
This research was supported by Cancer Research UK and
by the Economic and Social Research Council, UK. The
following colleagues participated in data collection for the
International Study of Health and Behaviour—Diepenbeek,
Belgium: Jan Vinck; Sophia, Bulgaria: Irina Todorova;
Bogota
´, Colombia: Pablo Sanabria-Ferrand and Diana
Urrego; Paris, France: France Bellisle and Anne Marie
Dalix; Wuppertal and Marburg, Germany: Claus Vo¨gele and
Gudrun Sartory; Athens, Greece: Bettina Davou and
Antonis Armenakis; Budapest, Hungary: Maria Kopp and
Reka Baranyai; Reykjavik, Iceland: Sigurlina Davidsdottir;
Dublin, Ireland: Ray Fuller; Kurume, Japan: Akira Tsuda;
Turin, Italy: Anna Maria Zotti, Gabriella Pravettoni and
Massimo Miglioretti; Groningen, The Netherlands: Robbert
Sanderman; Poznan, Poland: Helena Sı
`k and Micha
3
Ziarko;
Lisbon, Portugal: Joao Justo; Cluj-Napoca, Romania:
Adriana Baban; Bratislava, Slovakia: Gabriel Gulis
ˇ;
Sovenga, South Africa: Karl Peltzer; Granada, Spain: Jaime
Vila, Nieves Perez, Humbelina Robles, Nieves Vera
Guerrero; Bangkok, Thailand: Kiriboon Jongwutiwes and
Maream Nillapun; San Diego, CA and Greeley, CO, USA:
Kelli Glass and Sacha Pampalone; Caracas, Venezuela: Nuri
Bages.
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