(Un)healthy lifestylesEducation as a dividing line

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Acknowledgements and sources

Authors: Stéfanie André, Roza Meuleman and Gerbert Kraaykamp

In creating this card stack, we drew on data from the seventh round of the European Social Survey (ESS, www.europeansocialsurvey.org), a representative survey conducted in 2014/15 and containing a rotating module on health and health-related behaviour (Eikemo et al. 2017). The ESS is an international comparative questionnaire-based survey which is conducted among persons aged 15 years and older living in independent households, regardless of nationality or language. Interviews in the Netherlands are conducted in person (face-to-face) by trained interviewers in the respondent’s home.

Respondent selection and response

Respondents were selected for this study who were aged between 25 and 70 years at the time of the survey. This therefore means that young people (explicitly including students) were excluded from the sample. People aged over 70 were also excluded, because health problems are more common in this group and may cause them to adapt their health-related behaviour.

For our analyses it was also important that information was available on essential characteristics such as the sex and educational level of the respondent and their parents; respondents for whom this information was missing were therefore excluded. Where we only lacked information on the educational level of a respondent’s parents (a total of 62 respondents), multiple imputation was used to assign values to 46 persons. In the remaining 16 cases this was not possible due to inadequate information; these respondents were also excluded. As a result of these selections, the same group of respondents was studied for all cards (with the exception of the ‘neighbourhood’ card) (n = 1,415).

In the Dutch section of the European Social Survey, persons living at 3,452 addresses were approached with a request to participate; a total of 1,919 respondents ultimately took part in the survey. After exclusion of the unavailable addresses (business premises, derelict properties, uninhabited), the response rate was 59% (ESS 7 Data Documentation Report 3 January 2014). The data presented for this card stack were weighted using the post-stratification weights prescribed by the ESS. This corrects for the sample design used in a country and for selective nonresponse (for example because young people less often take part in surveys than older people).

The measurement instruments

Education was divided into four categories:

  • low-educated (primary education (lo), new-style primary education (bao), lower secondary education (lbo), lower secondary education (mulo), junior general secondary education (mavo), preparatory secondary vocational education (vmbo), short senior secondary vocational courses (kmbo), senior secondary vocational education, level 1 (mbo 1))
  • higher secondary education (senior general secondary education, levels 2-4 (mbo 2-4), secondary school for girls (mms), senior general secondary education (havo), pre-university education (vwo), modern grammar school (hbs), short higher professional education (kort hbo), enhanced senior secondary vocational education (‘mbo-plus’) (mbo+), university foundation course (propedeuse wo))
  • higher professional (hbo) (Bachelor's and Master’s)
  • research university (Bachelor’s and Master's, kandidaats and doctoraal)

For specific cards, it was decided in some cases to merge categories; where this was done, this is stated.

All outcomes described in the cards are based on answers given by respondents to survey questions about their behaviour. This self-reported behaviour may deviate from actual behaviour for all kinds of reasons, for example due to social desirability or forgetfulness. It is assumed in this study that the difference between self-reported behaviour and actual behaviour is no different for people with a low educational level and people with a high educational level.

For four of the six measurements of health-related behaviour in the ESS, ‘show cards’ were used as a means of showing respondents prescribed standardised response categories. The content of the show cards as shown to respondents can be viewed by clicking on the show card. The question formulations are also reproduced below.


Let’s now talk about smoking cigarettes. Which of the statements on this card comes closest to describing your smoking behaviour?

  • I smoke every day.
  • I smoke, but not every day.
  • I don’t smoke now, but I used to smoke in the past.
  • I’ve only smoked a couple of times.
  • I have never smoked.

The first two categories are classified as ‘smoking’, because smoking regularly but not daily is also unhealthy; the other categories are coded as ‘not smoking’.


How often have you drunk alcohol over the last 12 months, in other words since [day, month, year]? For example, wine, beer, spirits or other alcoholic drinks.

  • every day
  • several times per week
  • once per week
  • two or three times per month
  • once a month.
  • less than once a month
  • never

The first two categories were combined as ‘regular drinking’.


Two measures were used to calculate overweight, namely the respondent’s height and weight. The questions asked were as follows:

  1. How tall are you without shoes on?
  2. How much do you weigh without shoes on?

A person’s BMI was calculated using the formula weight (kg) / (height in metres x height in metres). A BMI above 25 indicates overweight, while a BMI above 30 indicates obesity.

Eating fruit

Using this card, can you say how often you eat fruit? Drinking fruit juice does not count.

  • three times a day or more
  • twice per day
  • once per day
  • less than once per day, but at least four times per week
  • less than four times per week, but at least once per week
  • less than once per week
  • never

(We coded the first three answers as ‘at least once per day’; the other answers were coded as ‘less than once per day’).

Eating vegetables

Using this card, can you say how often you eat vegetables or salads? Eating potatoes does not count.

  • three times a day or more
  • twice per day
  • once per day
  • less than once per day, but at least four times per week
  • less than four times per week, but at least once per week
  • less than once per week
  • never

(We coded the first three answers as ‘at least once per day’; the other answers were coded as ‘less than once per day’).

Physical activity

On how many of the last seven days have you walked at a brisk pace, played sport or engaged in other physical activity for 30 minutes or longer? (Information for the interviewer: the physical activity need not have been continuous in order to be counted).

The distribution of the responses shows that the question was interpreted in different ways by different respondents. As we are concerned with general physical activity and not doing sports, we decided to include everyone who had undertaken any ‘vigorous’ physical activity on at least one day per week in the category ‘physical activity’, and to place all other respondents in the category ‘no physical activity’.

The European charts

In compiling interactive charts for European countries, the same measurements and selections were used as for the Netherlands. Respondents were selected from the group aged 25-70 years who were not students and for whom the educational level of the respondent themselves and their parents was known. In all European countries, the parental educational level of 8% of respondents was unknown. This information was imputed for 890 respondents; the remaining 1,352 respondents (5.2% of the total) were excluded from the survey. This meant that we used information on a total of 25,832 respondents in Europe for the interactive comparative maps.

Two countries from the ESS were left out of consideration: Hungary, due to insufficient information about the educational level of respondents and their parents, and Israel, because its geographical location means it was not regarded as a European country.


Educational differences were tested using a χ² test. All effects of education presented are statistically significant. Where this is not the case, this is stated and only a description is given, not a comparison.

Where we looked at individual educational categories, differences were tested using Anova with Tuckey's post-hoc tests. Where there were two variables (e.g. education of parents and education of respondent), the interaction between the two categories was tested using a two-way Anova.

Supplementary information from Dutch-language and international websites

As this study focuses on the education gap in health-related behaviour and draws on representative European comparative research, it is possible to relate the picture for the Dutch population to that in other countries. We have also attempted to present the results in the most accessible way possible in order to enhance their appeal for a broad interested readership. Although this means that our study contains a number of innovations, it naturally builds on earlier research on lifestyle habits. A number of Internet links where supplementary information can be found are presented below.

  1. The National Institute for Public Health and the Environment (RIVM) produces the Lifestyle Monitor. This Monitor mainly focuses on unhealthy habits among young people, and draws on the Health Survey and data from the Health Behaviour in School-aged Children survey (HBSC). Educational differences are not a central focus.
  2. In StatLine, published by Statistics Netherlands (CBS), users are able to create their own tables for various lifestyle indicators. Data from the annual Dutch Health Survey are generally used for this. Trends in the prevalence of lifestyle behaviours can also be consulted. Lifestyle and sex differences are often a central focus in CBS publications, but analysis based on education is also possible.
  3. The Municipal Health Service (GGD) provides information on a great many lifestyle indicators on the website https://www.gezondheidinsociaaldomein.nl/, making it possible to compare different municipalities. This is primarily descriptive information.
  4. The Health Council of the Netherlands publishes a register of health-related research as well as more specific guidelines on healthy behaviour with regard to smoking, drinking, physical activity and diet.
  5. The World Health Organization (WHO) publishes fact sheets covering various aspects of health, including lifestyle aspects. These contain the most up-to-date knowledge and information on the topic, including its relevance and context. An interesting infographic on smoking can also be found on the WHO site.
  6. Finally, the Centre for Healthy Living contains a policy-rich inventory of lifestyle interventions based on various criteria such as target group, setting or theme.

The translation of this cardstack was made possible by the ESS-SUSTAIN program. The authors would like to thank the reading committee at SCP, consisting of Ineke Stoop, Frieke Vonk, Sander Steijnand Sjoerd Kooikerfor their constructive comments on earlier versions of this publication. Naturally, the content of this publication fully remains the responsibility of the authors.


Eikemo, T.A., C. Bambra, T. Huijts & R. Fitzgerald (2017). The first pan-European sociological health inequalities survey of the general population: the European Social Survey rotating module on the social determinants of health. In: European Sociological Review, vol. 33, nr. 1, p. 137-153.

European Social Survey (2015). ESS7 data documentation report 2014. Accessible at https://www.europeansocialsurvey.org/docs/round7/survey/ESS7_data_documentation_report_e03_1.pdf

Cite this card

André, S., R. Meuleman and G. Kraaykamp (2018). Acknowledgements and sources. In: (Un)healthy lifestyles: Education as a dividing line. Retrieved [datum vandaag] from https://digital.scp.nl/lifestyles/acknowledgements-and-sources.

Information notes

E.g. for unequal inclusion probabilities, chance sample errors.