Nursing and Health Sciences (2005), 7, 107118

Research Article

Gender differences in health habits and in motivation for

a healthy lifestyle among Swedish university students
Margareta I. K. von Bothmer,1,2 assistant professor, phd, mscn, rnt and Bengt Fridlund1,2,3
professor, phd, rnt
1
School of Social and Health Sciences, Halmstad University, Halmstad, 2Department of Primary Health Care,
Gteborg University, Gteborg and 3Department of Nursing, Lund University, Lund, Sweden

Abstract The aim of the present study was to investigate gender differences in students health habits and
motivation for a healthy lifestyle. The sample of students comprised a probability systematic strat-
ified sample from each department at a small university in the south-west of Sweden (n = 479). A
questionnaire created for this study was used for data collection. Self-rated health was measured
by number of health complaints, where good health was defined as having less than three health
complaints during the last month. A healthy lifestyle index was computed on habits related to
smoking, alcohol consumption, food habits, physical activity and stress. Female students had
healthier habits related to alcohol consumption and nutrition but were more stressed. Male stu-
dents showed a high level of overweight and obesity and were less interested in nutrition advice
and health enhancing activities. The gender differences are discussed in relation to the impact of
stress on female students health, and the risk for male students in having unhealthy nutritional
habits in combination with being physically inactive and drinking too much alcohol.

Key words health habits, motivation, self-rated health, stress, student.

INTRODUCTION measurement method; one of them is self-rated symp-

toms (Bue Bjorner et al., 1996).
Health-related behavior in early life influences later
The major determinants of health are socioeconomic
risks for lifestyle-related disorders. It is therefore
determinants, lifestyle and physical environment
important to investigate health behaviors among
(World Health Organization [WHO], 2003). Lifestyle
young people. University students represent a major
related risk factors, acknowledged in the report, are
segment of the young adult population (Leslie et al.,
unhealthy nutrition, physical inactivity, tobacco use
1999). It makes sense to focus on them in a study of
and use of alcohol and illicit drugs (WHO, 2003).
associations between health, motivation for a healthy
Macintyre et al. (1996) discussed if women really have
lifestyle and different health habits in order to improve
higher morbidity than men and argued that an impor-
health promotion activities targeting this group. Stu-
tant gender difference was that women suffered more
dents comprise a homogenous and accessible popula-
from psychological distress, and men more from phys-
tion, which is also relatively healthy. This minimizes the
ical ailments, while Lahelma et al. (1999) noticed that
bias related to the influence of illness on health behav-
women showed poorer health but men had more
iors (Steptoe & Wardle, 2001). The way people assess
severe ill-health with increasing age.
their own health has been shown to be a good predictor
The gender differences in health according to Den-
of mortality in many population studies. The predictive
ton et al. (2004) are attributable to differing structural
power of self-rated health is strong, irrespective of
(socioeconomic, age, social support, family arrange-
ment) context and to different exposure to lifestyle
(smoking, drinking, exercise, diet) and psychosocial
(critical life events, stress, psychological resources) fac-
Correspondences address: Margareta von Bothmer, School of Social and
Health Sciences, Halmstad University, PO Box 823, SE-301 18 Halmstad,
tors. Denton et al. (2004) showed that womens health
Sweden. Email: Margareta.von_Bothmer@hos.hh.se was more influenced by structural and psychosocial
Received: 20 April 2004; accepted 4 October 2004 determinants such as stress and lower levels of
108
self-esteem, mastery and sense of coherence, while
mens health was more affected by health behaviors
such as smoking, drinking and physical activity.
To develop health education and health promotion
initiatives targeting students, it is important to have
detailed knowledge about the health of students and
their health related behaviors, and factors that influ-
ence these such as knowledge, attitudes, personal
resources, motivation for a healthy lifestyle and social
support. To our knowledge, few studies have been per-
formed on health and health behavior from a gender
perspective among university students. Three examples
are: a study by Steptoe and Wardle (2001) showed that
students from Western Europe had a healthier lifestyle
than students from Eastern Europe regarding smoking,
alcohol consumption and diet, and that students from
Eastern Europe were more depressed and reported
lower social support than students from Western
Europe, but no gender differences were discussed.
Another study showed that Lithuanian students were
more depressed and reported lower social support than
students from Spain and Germany (Stock et al., 2003).
The gender difference highlighted in the Stock et al.
study was that female students reported more health
complaints, especially psychosomatic complaints, than
male students (Stock et al., 2003). A third study com-
paring leisure-time physical activity in university stu-
dents from 23 countries revealed a gender difference,
with a higher proportion of men (28% versus 19%,
P < 0.001) being physically active at a recommended
level (Haase et al., 2004).
The aim of the present study was to investigate gen-
der differences in students health habits and motiva-
tion for a healthy lifestyle built on the following
research questions: Are there any gender differences in
healthy habits? Are there any gender differences in
motivation for a healthy lifestyle? Are there any gen-
der differences in self-rated health? Does motivation
for a healthy lifestyle have any association with self-
rated health?
METHOD
Design and setting
A descriptive comparative design was used, with ques-
tionnaires as the means of data collection. The study
was carried out in the south-west of Sweden at a small
university with 5000 students.
Sample and selection
The sample of students comprised a probability sys-
tematic stratified sample from each department at the
M. von Bothmer and B. Fridlund
university. Eligible students were those studying on a
full-term basis. Selecting every tenth person on each
class list, starting with a randomly chosen number,
made the systematic sampling. The sample comprised
479 students and the response rate was 69%, ensuing
332 returned questionnaires.
Instrumentation
An instrument was created for this study to cover areas
that are deemed important for studying health and
health habits. Face and content validity of the question-
naire was established through building the question-
naire on literature reviews of issues related to health,
health habits and motivation for a healthy lifestyle. The
instrument comprised questions on sociodemograph-
ics, health complaints, motivation for a healthy life-
style, and on different health habits. The instrument
covered the following areas and number of items
(Table 1):
Sociodemographics: gender, age, height, weight,
family situation (living alone or with partner or parent,
having children or no children), fathers education,
mothers education, department at university, term;
nine questions. Body mass index (BMI, kg/m2) was cal-
culated on self-reported weight and height. Under-
weight was defined as BMI 19.0, normal weight as
BMI 19.124.9, overweight as BMI 25.029.9, and obe-
sity as BMI 30.0 (Lowry et al., 2000).
Health complaints (headache, stomach ache, cold,
flu, symptoms from muscles, back pain, anxiety, cough-
ing, fatigue, sleeplessness, stress, constipation, diar-
rhea, allergy etc.). The question was: Have you, during
the last month, been bothered by any of the following
symptoms? (listed as above); 16 questions. Response
alternatives were yes and no. The yes answers were
computed together for each individual and formed the
composite scale Health complaints, which was then
reversed and presented as self-rated health. Good
health was defined as having less than three symptoms
during the last month, and poor health as having more
than seven symptoms.
Motivation for a healthy lifestyle: comprised
three areas, namely willingness to participate in health
promotion activities, attitudes towards changing life-
style, and recent changes in health related habits. These
formed a motivation for healthy lifestyle index.
Questions related to health habits: tobacco use,
alcohol consumption, food habits, physical activity,
and stress. A healthy lifestyle index was constructed
by summing the number of healthier options for
each individual (Steptoe & Wardle, 2001). Respon-
dents were classified in three categories of healthy
lifestyle; poor (01 healthy habit), medium healthy
Table 1. Overview over the index scales in the Health and Health Habits Instrument (3HI)
Areas
Health complaints (inverted =
self-rated health)
Motivation for a healthy lifestyle
a. Willingness to participate in health
promotion activities (smoke cessation
in a group or individually, weight reduction
in a group or individual nutrition advice,
physical activity in a group or individually,
relaxing strategies in a group or alone,
strengthening your social network,
receiving advice on alcohol consumption
or other drugs, counseling in sexual and
social life)
b. Attitudes towards changing lifestyle
c. Recent changes in health related habits
Health habits
Tobacco use
a. Frequency and amount
b. To smokers how they perceive their
smoking and why they smoke
c. and their reasons for starting
d. To non-smokers why they do not
smoke
Response alternatives Factor analysis and Variable after data procedure
Number of items and scale level Cronbachs alpha and validation
16 questions: headache, Yes/no Yes-answers computed together
stomach ache, cold, flu, and formed the composite
symptoms from muscles, variable Health complaints.
back pain, anxiety, stress, Good health < 3 symptoms,
coughing, fatigue, constipation/ medium health 3 and < 7
diarrhea, allergy, sleeplessness, symptoms, poor health 7
others symptoms
a. 12 questions a. Response alternatives: already a. Not applicable Motivation for healthy lifestyle
Gender differences in health habits and motivation
participating, yes, maybe, no, not index was computed by adding
applicable yes-answers on willingness to
participate in health promotion
activities and positive answers on
attitudes and recently undertaken
changes in health related habits.
The Motivation for healthy
lifestyle index was scaled as
1 = low motivation, 2 = medium
b. Eight questions b. Seven-point semantic b. Two questions loaded on motivation, 3 = high motivation
differential Likert scale with one factor, a = 0.52
end-points strongly disagree and
strongly agree
c. 10 questions c. Yes/no
a. One question a. Seven alternatives where a. Not applicable Computed as never smokers, light
0 = never and 7 = more than 20 cig./ smokers (< 10 cig./day), heavy
day or more than 7 packages (50 smokers (> 10 cig./day). As part
gram) of snuff of the healthy lifestyle index, the
b. Five questions b. c. d. Seven-point semantic b. Not applicable healthy option was defined as not
differential Likert scale with c. Negative opinions about smoking and the unhealthy
c. Two questions end-points strongly disagree and smoking on one factor, option as regular smoking
d. Four questions strongly agree a = 0.76; regardless of amount
positive opinions on smoking
one factor, a = 0.40
109
 110
Table 1. Continued

Response alternatives Factor analysis and Variable after data procedure

Areas Number of items and scale level Cronbachs alpha and validation

Alcohol consumption
a. Frequency and amount at a time
b. Reasons for drinking and attitudes
toward drinking
a. Two questions a. Frequency item with seven
alternatives from 0 = never, to
7 = more than 5 times/week.
Amount alternatives from 1 unit/
time to 7 or more units/time
(unit = 1 can of beer or a glass of
wine)
b. Six questions b. Seven-point semantic
differential Likert scale with
end-points strongly disagree and
strongly agree
Factor on alcohol attitudes,
a = 0.70
as healthy
Level of alcohol
consumption calculated as
frequency units/occasions
(u/w, 1 unit = 1 can of beer/1 glass
of wine). Low level: < 7,
moderate: 710; high: > 10 m/w. In
the healthy lifestyle index, a high
level was defined as unhealthy,
low and moderate consumption

Nutritional habits
a. Food habits related to fat, fiber and
fruit/vegetable consumption
b. Reasons for why not practicing healthy
nutritional habits
a. Five questions a. + b. Seven-point semantic a. Five questions loaded on The Food habit index comprised
differential Likert scale with end- one factor, a = 0.63 five questions and each of them
points strongly disagree and was dichotomized, the healthy
strongly agree options were summarized. Less
b. Six questions healthy habits (01), medium
healthy (23) and healthy
nutritional habits (45)

Physical activity (PA)

a. Regular physical activity 23 a. One question a. Above described Not applicable (a) Dichotomized and the
times/week seven-point Likert scale healthy part of it was computed
b. Willingness to participate in PA, b. Two questions b. Yes/no/already participating together with
already participating regularly in PA either (b) already participating and
individually or in a group c. Yes/no (c) started to exercise, forming a
c. Recently undertaken changes in health c. One question physical activity index, scaled in
related habits, exercising more d. Seven-point Likert scale three levels (0, 1, 23). In the
d. Reasons for not being active d. Two questions healthy lifestyle index, 1 was
defined as healthy level of PA

Stress
Questions on experienced stress last year;
finding study life stressful; difficulties in
managing time; non-balance between
work, leisure time, sleep and rest; stress
awareness and coping with stress
Seven questions Seven-point semantic differential
Likert scale with end-points
strongly disagree and strongly
agree
Five questions loading on
one factor, stress, a = 0.79;
Two questions loading on
one factor, stress
awareness, a = 0.40
The stress factor items were
computed and formed the stress
index, where low level of
experienced stress was defined as
01, medium as 23, and > 3 as
high level

Social network and social support

Questions reflecting affect, affirmation,
confidence, social cohesion, getting help,
social support availability and social
support satisfaction
10 questions Seven-point semantic differential
Likert scale with end-points
strongly disagree and strongly
agree
Seven questions loaded on
one factor, social support/
network, a = 0.74; two
questions loaded on concern
for relatives, a = 0.72
The social support factor items
were computed and the index was
scaled in three degrees: low,
medium and high level of social
support and network
M. von Bothmer and B. Fridlund
Gender differences in health habits and motivation 111

(23 healthy habits) and healthy (45 healthy
habits).
Weight concern: three questions; satisfied with
actual weight, ought to weigh less, and ought to weigh
more.
Sexual life: two questions; satisfied with sexual
life and having access to satisfying sexual life. Answers
from these two questions were computed and formed a
three-level satisfaction with sexual life scale (low,
medium and highly satisfied).
Social network and social support: seven ques-
tions, reflecting social support availability, social sup-
port satisfaction and social support. The answers were
computed and the social support index was scaled in
low, medium and high level of social support/network.
All questions, if not otherwise noted, were put on a
seven-point semantic differential scale with endpoints:
strongly disagree and strongly agree.
The questionnaire was tested with a pilot study on 50
nursing students and some revisions were made, that is,
the exclusion of 34 superfluous questions and the addi-
tion of three response options on health complaints
and 10 options for recent changes in health related
habits instead of one open question. The internal con-
sistency was tested with Cronbachs alpha reliability
coefficient and was acceptable at 0.73. The instrument
is hereafter called the Health and Health Habits
Instrument (3HI).
Data collection
Permission was obtained from the Vice Chancellor of
the university, as the university did not have a separate
ethical committee. Before permission was given, the
Vice Chancellor requested information about the
research aims, procedures and reporting of results, and
then gave permission on condition that the students
did not have any objections. All respondents were
informed about confidentiality, freedom to participate
and the right to withdraw from the study at any point.
The information sheet also informed participants
about the aim of the study, the use of code numbers
and the researchers.
The address list was acquired from the student
union. The questionnaire was successfully sent by post
with a stamped envelope attached to 479 students and
332 responded, four of them with blank questionnaires.
To encourage quick and full answers, students who
returned the first 100 completed questionnaires were
offered a small incentive (lottery ticket). All question-
naires were sent back to the researchers with anonym-
ity preserved. Code numbers were used to facilitate
reminders. Reminders were sent to 225 students after
2 weeks and resulted in 60 additional responses. No
further reminder was sent as it was at the end of the
term, and it was considered unlikely that the students
would respond later.
Data analysis
All analysis was carried out using the Statistical Pack-
age for Social Sciences, version 10.0 (SPSS, Chicago,
IL, USA). Descriptive statistics were used to illustrate
the preliminary information. Chi-squared statistic was
used as a test of independence between groups, and
Phi-coefficient or Cramrs V index was used as a mea-
sure of association to quantify the strengths of the rela-
tionships (Norusis, 1998). Statistical significance was
denoted by P < 0.05.
RESULTS
Description of the sample
The sample comprised 49% women and 51% men
(Table 2). Seventy-one percent were younger than

Table 2. Sociodemographic information among female and male university students

Women Men P-value Total

n = 160 49% n = 168 51% (Phi-index) n = 328 Percentage

Age (years)
30 106 66 127 76 NS 233 71
30 54 34 41 24 95 29
Civil status
Living alone 77 48 115 69 *** 192 59
Co-habitant 82 52 53 31 (0.20) 135 41
Children
Without children 110 69 140 83 ** 250 77
With children 49 31 28 17 (0.17) 77 23

**P < 0.01; ***P < 0. 001. Phi-index used as a measure of magnitude in associations. NS, non-significant.
112 M. von Bothmer and B. Fridlund

30 years of age and the majority (59%) lived by them-
selves. Seventy-six percent did not have children.
More women than men had a partner and had
children.
Self-rated health
The most common reported symptoms among the stu-
dents were stress (60%), tiredness (57%), headache
(52%) and pain in the back and neck (51%) (Table 3).
Female students reported stress, tiredness and head-
ache more than male students did. No significant dif-
ferences in self-rated health were found between
younger and older students, or between students with
or without children.
Health-related lifestyle
Female students showed a higher degree of healthy
habits (P < 0.001, Cramers V: 0.23) (Table 4). The
mean smoking rate was 22% (20% for female students,
24% for male students). There was an association
between smoking and alcohol use (P < 0. 01; Cramers
V: 0.24) in the male population. There was a difference
in attitudes towards smoking among female and male
students, in that female smokers who smoked more
than 10 cigarettes/day thought they smoked too much
(P < 0.05, Cramers V: 0.42).
There was a significant difference between alcohol
use by female and male students (P < 0.001, Cramers
V: 0.59). The overall mean alcohol intake per occasion
was four drinks per occasion and the mean frequency

Table 3. Health complaints among female and male university students

Women Men P-value Total

Health complaint Response n = 160 49% n = 168 51% (Phi-index) n = 328 Percentage

Stress Yes 105 71 78 49 *** (0.23) 183 60

No 42 29 81 51
Tiredness Yes 94 65 79 50 ** (0.15) 173 57
No 51 35 80 50
Headache Yes 95 63 64 41 *** (0.22) 159 52
No 56 37 94 59
Pain in the back Yes 88 59 68 44 ** (0.15) 156 51
and neck No 61 41 87 56
Common cold Yes 55 38 74 47 NS 129 43
No 90 62 83 53
Muscle pain Yes 56 39 64 41 NS 120 40
No 86 61 92 59
Stomach pain Yes 64 44 39 25 *** (0.20) 103 34
No 81 56 118 75
Allergy Yes 40 28 46 29 NS 86 28
No 105 72 112 71
Anxiety Yes 42 29 36 23 NS 78 26
No 101 71 120 77
Sleeping Yes 30 21 36 23 NS 66 22
problems No 113 79 121 77
Coughing Yes 28 20 36 23 NS 64 22
No 115 80 119 77
Sprained muscle Yes 23 16 28 18 NS 51 17
No 117 84 127 82
Constipation/ Yes 26 18 13 8 ** (0.15) 39 13
diarrhea No 116 82 143 92
Other Yes 10 14 10 12 NS 20 13
No 62 86 70 88
Depression Yes 14 10 20 13 NS 34 11
No 127 90 136 87
Influenza Yes 6 4 9 6 NS 15 5
No 132 96 147 94

**P < 0.01; ***P < 0. 001. Phi-index used as a measure of magnitude in associations. NS, non-significant.
Gender differences in health habits and motivation 113

Table 4. Health habits and self-rated health among university students

Women Men P-value Total

n = 160 49% n = 168 Percentage (Cramers V) n = 328 Percentage

Self-rated health
Poor (713 symptoms) 39 24 37 22 NS 76 23
Medium (36 symptoms) 83 52 72 43 155 47
Good (02 symptoms) 38 24 59 35 97 30
Level of health promoting activities
Low (01) 18 11 41 24 *** 59 18
Medium (25) 96 60 104 62 200 61
High (612) 46 29 23 14 (0.23) 69 21
Motivation for a healthy lifestyle
Low level 28 17 64 38 *** 92 28
Medium level 76 48 76 46 152 47
High level 55 35 27 16 (0.27) 82 25
Tobacco use
None 127 80 126 76 NS 253 78
Low level ( 10/day) 18 11 19 11 37 11
High level (> 10/day) 14 9 21 13 35 11
Alcohol use
Low < 7 m/w 146 95 122 75 268 85
Moderate 710 m/w 4 2.5 20 12 *** 24 7.5
High ( 10 units/week) 4 2.5 20 12 (0.27) 24 7.5
Nutritional habits
Less healthy (01) 44 28 88 52 *** 132 40
Medium healthy (23) 82 51 63 38 145 44
Healthy (45) 34 21 17 10 (0.26) 51 16
Physical activity
No regular exercise (0) 46 29 49 29 NS 95 29
Low level of exercise (1) 48 30 67 40 115 35
High level of exercise (23) 66 41 52 31 118 36
Healthy lifestyle index
Few healthy habits (01) 9 6 22 13 *** 31 10
Medium healthy (23) 90 56 114 68 (0.23) 204 62
Healthy habits (45) 61 38 32 19 93 28
Level of stress
Low level (01) 45 28 74 44 ** 119 36
Medium level (23) 63 39 59 35 122 37
High level (45) 52 33 35 21 (0.18) 87 27
Social support
Low level 25 16 30 18 * 55 17
Medium level 90 56 110 66 200 61
High level 44 28 27 16 (0.14) 71 22
Sex life
Low satisfaction 28 18 61 36.5 *** 89 27
Medium satisfied 53 33 61 36.5 114 35
Highly satisfied 78 49 45 27 (0.26) 123 38

*P < 0. 05; **P < 0.01; ***P < 0. 001. Figures in parenthesis are number of health promoting activities; healthy nutritional
habits (range 05); physical activities in the PA index; healthy habits (range 05); and level of experienced stress on the stress
index. Cramers V-index used as a measure of magnitude in associations. NS, non-significant.

was 23 times a month, which matched up to 2.22 units/ heavy quantities, and 40 out of 48 were men. Students
week for female students and 4.79 units/week for male who drank more often also consumed larger quantities
students. Abstainers comprised 4% of the student pop- at each occasion (women: P < 0.01, Cramrs V: 0.28;
ulation. Fifteen percent of the students used alcohol in men: P < 0.001, Cramrs V: 0.29). Men used alcohol
114
more often than women did (P < 0.01, Cramrs V:
0.24) and in higher quantities (P < 0.001, Cramrs V:
0.50). The heavy consumers were found among stu-
dents who were single and without children. Ten out of
18 male students with heavy alcohol consumption
reported stomach pain (P < 0.01, Cramrs V: 0.27) and
eight out of 19 reported sleeping problems (P < 0.01,
Cramrs V: 0.26). It was more common among male
students to have the opinion that drinking is a part of
student life (P < 0.01, Cramrs V: 0.20) and that use
of alcohol makes it easier to socialize (P < 0.001,
Cramrs V: 0.22). There was no significant association
between reported anxiety and alcohol consumption.
Female students had healthier nutritional habits
than male students (P < 0.001, Cramrs V: 0.26)
(Table 4). There was no association between students
nutritional habits and their knowledge of healthy food.
Male students had poorer knowledge than female stu-
dents about healthy food (P < 0.01, Cramrs V: 0.34).
Male students were more overweight and obese than
female students (P < 0.001; Cramrs V: 0.27), with
30% being overweight and obese compared to 13%
among female students. Male students mean BMI was
significantly greater than that of female students
(23.84 2.61 vs 22.27 2.67, P < 0.001, Cramrs V:
0.27). Sixty-one percent among overweight and obese
male students were satisfied with their own weight.
Among the students with normal BMI, 64% of female
students (n = 79) and 76% of male students (n = 87)
were dissatisfied with their weight, with women want-
ing to weigh less.
Seventy-one percent of the students exercised regu-
larly; there was no difference between female and male
students (Table 4). Of 65 female students with a high
level of physical activity, 91% (n = 59) were non-
smokers (P < 0.01, Cramrs V: 0.24). Male students
experiencing low social support did exercise at a low
level (P < 0.05, Cramrs V: 0.22). Co-habiting female
students who were satisfied with their social support
did physical exercise at a higher level than those who
did not experience social support (P < 0.01, Cramrs
V: 0.37). The level of physical activity was associated
with access to good facilities for exercising (female stu-
dents: P < 0.01, Cramrs V: 0.25; male students
P < 0.001, Cramrs V: 0.37).
Twenty-seven percent of the student population
showed high stress, with female students showing more
stress than men (P < 0.01, Cramrs V: 0.18). There was
an association between perceived stress and number
of health complaints (P < 0.001, Cramrs V: 0.32 for
women; 0.35 for men). Male students were more dis-
satisfied with sexual life than female students
(P < 0.001; Cramrs V: 0.26) (Table 4). There was an
association among men between healthy lifestyle index
M. von Bothmer and B. Fridlund
and number of health complaints (P < 0.001, Cramrs
V: 0.29); a healthier lifestyle was associated with fewer
health complaints, but this association was not found
among women, where instead those with a healthy lif-
estyle had more health complaints. Perceived social
support was associated with fewer symptoms for
women (P < 0.01, Cramers V: 0.28).
Motivation for a healthy lifestyle
Women participated more in health activities than men
did (P < 0.001, Cramrs V: 0.23). There were signifi-
cant differences between male and female students in
interest in health promoting activities. Female students
were more interested than male students in changing
their dietary habits, levels of physical activity and prac-
ticing relaxation (P < 0.001, Cramrs V: approximately
0.23). Very few students (between 2% and 4%) were
interested in smoking cessation activities or in getting
advice on alcohol consumption. The Motivation for
healthy lifestyle index showed that female students
were more motivated for a healthy lifestyle than male
students (P < 0.001, Cramrs V: 0.27).
The Motivation for healthy lifestyle index did not
show statistically significant associations with smoking,
alcohol consumption or food habits, but had a positive
association with physical activity (P < 0.01, Cramrs V:
0.28 for female students, and P < 0.001, Cramrs V:
0.36 for male students). A high level of stress among
female students was associated with a high level of
motivation (P < 0.01, Cramrs V: 0.27).
There was an association for female students
between self-rated health and motivation for a healthy
lifestyle in that higher motivation was associated with
more health complaints (P < 0.01, Cramrs V: 0.25).
Closely related to the motivation index is number of
health activities, which, among women, showed a neg-
ative association with self-rated health (P < 0.01,
Cramrs V: 0.24). Women reporting a high degree of
health improving activities suffered more than men
from headache (P < 0.05, Cramrs V: 0.23), stomach
pain (P < 0.01, Cramrs V: 0.25) and stress (P < 0. 05,
Cramrs V: 0.26).
DISCUSSION
Methodological issues
The technique of sampling and data collection is
deemed to be applicable to the aim of the study. The
sample was of a large enough size, and was equal in size
between genders. The attrition rate was an acceptable
31%. The sample is not population representative as it
comprised university students, and therefore caution in
Gender differences in health habits and motivation
generalization of the results is necessary. University
students are better educated than a population-based
sample and also younger, and lifestyle behaviors in
terms of smoking, drinking alcohol, eating poorly and
being physically inactive do not show up their effects
on health in a short time perspective. As students prob-
ably will be the leaders of tomorrow, their health
related activities are of particular interest. Being well-
educated and rather healthy, students comprise a
suitable sample for investigating health habits, as the
variability due to ill health and education is minimized.
The results would be able to generalize to other stu-
dent populations, at least in Sweden, according to the
stratified and systematic sampling procedure. As the
study is cross-sectional no conclusions can be drawn on
trends in health behaviors among university students
over time, such as Steptoe et al. (2002) have shown, but
the results can indicate important areas for further
research and practice in student health promotion
activities.
A limitation of the present study could be that health
was measured only by self reports. Conversely, it has
been convincingly shown that self-rated health predicts
mortality and that reporting of symptoms is a valid
method in assessing self-rated health (Bue Bjorner
et al., 1996).
The reliability of self-reported health habits could be
questioned, but self report measures are looked upon
as both practical and ethical means to gather data,
although biases due to social desirability and poor
recall are possible (Christiansen et al., 2002). The abso-
lute intake of alcohol is generally underestimated by
using questionnaires, but this kind of measure may be
reliable for ranking purposes (Townshend & Duka,
2002). The estimated alcohol consumption in this study
is probably too low, but probably correct in ranking
individuals to high versus low consumption groups.
The internal consistency of this newly established
instrument showed a moderately good accuracy (Ker-
linger, 1986) and the instrument (3HI) merits a further
development by being used and validated in future
research on similar and dissimilar populations.
To denote the importance of statistically significant
results, they were reported together with Cramrs V
or Phi (for two-dimensional tables) as a measure of the
magnitude in association, although chi-squared based
measures are difficult to interpret (Norusis, 1998).
According to Kerlinger (1986), a correlation between
0.20 and 0.30 could be of interest when n is larger than
100. Because the sample comprised more than 300 stu-
dents, and such big samples easily give statistically sig-
nificant results, these are only reported if they are
combined with a magnitude estimate 0.20 (with some
exemption).
115
Result issues
There were no statistically significant differences in
level of self-rated health among female and male stu-
dents. Stress was negatively related to self-rated health
both for women and men, but women reported more
stress-related symptoms than men, such as headache,
tiredness and pain in the back and neck. This is in line
with other studies (Macintyre et al., 1996; Stock et al.,
2003) and so is the excess in perceived stress by women
(McDonough & Walters, 2001), who found that
womens greater exposure to stress accounted only for
a small proportion of the gender disparity in health.
Female students had healthier habits than their male
counterparts in relation to alcohol consumption and
nutrition and were also more motivated for a healthy
lifestyle, but this does not seem to have influenced their
self-rated health. This could depend on their higher
stress levels, which may override the benefits of a
healthy lifestyle, or it could be interpreted in line with
Carter and Kulbok (2002), who questioned the impact
of motivation for health behaviors, depending on poor
measurements of the construct. The multimodal influ-
ences on health behavior are still poorly understood
(Meillier et al., 1997; Baumann et al., 2002) and there is
a need to develop theories that can increase our knowl-
edge and understanding of specific behaviors.
The healthy lifestyle index indicated that 28% of the
students had a healthy lifestyle, which is not in line with
Steptoe and Wardles study (2001). The interrelation-
ships between different health habits which is docu-
mented in other studies (Burke et al., 1997; Baumann
et al., 2002) was found only between smoking and alco-
hol consumption for male students. This could depend
on too small a sample in relation to the low levels of
smoking and alcohol consumption in the sample, or on
measurement bias, or it could be that clustering of
unhealthy behaviors does not exist in this sample.
The prevalence of smoking is low compared to the
prevalence among university students in many Euro-
pean countries (Steptoe et al., 2002). The gender dif-
ferences in alcohol consumption and heavy alcohol
consumption are found in other student populations
(Webb et al., 1996; Burke et al., 1997; Demers et al.,
2002) and also that heavy consumption is related to
cultural norms among students which describe drink-
ing as a normal part of student life (Demers et al.,
2002). The level of alcohol consumption in this sample
is far below the level reported in other studies (Gill,
2002) and so is the percentage of abstainers. In UK,
pleasure was the most commonly reported reason for
drinking (Webb et al., 1996), while in this study making
it easier to socialize might reflect different cultural
norms. As this reason was more common among men it
116
could also be interpreted as means of building social
confidence and coping with stress, as men interviewed
in Davies et al.s study (2000) suggested.
A noteworthy gender difference was in the preva-
lence of overweight and obesity, with 30% of the male
students being overweight or obese compared to 13%
of female students. The prevalence of obesity is much
less than in American studies (Lowry et al., 2000)
where 35% of students were found to be overweight or
obese. However, the figures are noteworthy even in a
Swedish setting, because the prevalence of obesity in
Europe is estimated to be 15%, although the figures
are quickly rising (Conference on Obesity, 2002; van
der Wilk & Jansen, 2004). As in other studies (Steptoe
et al., 1997; Lowry et al., 2000) females were more
likely to perceive themselves as being slightly over-
weight, but in this study it was the male students who
were more overweight but at the same time more sat-
isfied with their current weight. Together with their
unhealthy nutritional habits, relative disinterest in
nutritional advice and low level of physical activity, this
gives rise to concern about the future health for these
men. This should be important to follow up in future
studies.
The male students in this study showed lower levels
of physical activity compared to students in 13 other
European countries, whereas female students showed
higher levels than half of the female populations in
Steptoe et al.s study (2002), although comparison may
be biased by different classifications and measure-
ments. Many studies have found that a social support-
ive environment is crucial for being physically active
(Leslie et al., 1999; Sthl et al., 2001; de Bourdeaudhuij
& Sallis, 2002; Plotnikoff et al., 2004) as well as cultural
norms and national economic development (Haase
et al., 2004). The correlation between social support
and physical activity shown in other studies (Sthl
et al., 2001; de Bourdeaudhuij & Sallis, 2002) could be
confirmed in that male students experiencing low
social support had lower levels of physical activity,
while female students with high social support did
exercise at a higher level. The association between
physical activity and perceived access to these activi-
ties might be explained such as Sthl et al. (2001) sug-
gest, namely that active people make themselves
aware of local opportunities for activities. A feasible
way of promoting health in relation to physical activ-
ity would be as Plotnikoff et al. (2004) suggested,
strengthening participation with others in physical
activity.
The association among women between social sup-
port and self-rated health is in line with other studies
(Broadhead et al., 1983; Denton & Walters, 1999; Den-
ton et al., 2004). Surprisingly, few associations were
M. von Bothmer and B. Fridlund
found between social support and health, and
between social support and health habits. This may
reflect poor measurements of social support although
it was assessed to cover the complexity of the con-
struct (Broadhead et al., 1983; Denton & Walters,
1999).
A negative association was found among women
between the level of health activities, level of healthy
lifestyle habits and self-rated health, and this is surpris-
ing. What we do not know is the direction of the asso-
ciation. It could be that more health activities lead to
more symptoms, or conversely, that more symptoms
lead you to engage in more health activities. Women
who were more engaged in health activities also more
frequently reported headache, stomach pain and stress.
It could be hypothesized that a high level of involve-
ment in health activities acts as an additional stressor
for female university students, in a situation which is
perhaps already perceived as stressful.
The association in the female population between
high motivation and a high level of health complaints
tells nothing about the direction. It could be inter-
preted as ill health fuels the motivation, or that factors
other than motivation are influencing health related
behaviors. One part of the motivation for a healthy lif-
estyle index was interest in participating in different
health promoting activities, and female students were
significantly more interested than men. This could
relate to men experiencing more barriers in seeking
health services due to their need to conceal vulnerabil-
ity and need to be independent, as suggested by Davies
et al. (2000). Motivation may be an influencing factor
on health behavior, but Carter and Kulbok (2002)
found that motivation did not have a significant effect
in over half of the studies in the review, and they dis-
cussed if this may depend on poor measurement of the
motivation construct or that motivation in fact is not an
essential determinant of health behaviors. The sugges-
tion from Carter and Kulbok (2002) to develop the
motivation concept and its measurement in future
research in order to determine the meaning and scope
of motivation for health behaviors is sustained by the
findings in this study.
A limitation of this study is that it only describes the
association between self-rated health and individual
health habits and not social and environmental health
determinants. It is easier to change health related
behaviors when you also experience changes in social
life (Meillier et al., 1997), thus student health organiza-
tions could take advantage of this knowledge in tar-
geting motivational initiatives for health promotion
among students in relation to smoking, physical activ-
ity, nutrition, alcohol consumption and coping with
stress.
Gender differences in health habits and motivation
CONCLUSIONS AND
RECOMMENDATIONS
This study showed no gender differences in overall
self-rated health, but female students reported more
stress, headache and tiredness than male students did.
The factors that most influenced self-rated health
among male students were stress, alcohol consumption
and nutritional habits; among female students it was
stress. An unexpected finding was that healthy habits
and a high motivation for a healthy lifestyle were asso-
ciated with poorer health among female students. The
cause of the association is not known. That health
problems lead to greater engagement in health enhanc-
ing activities is as probable an explanation as that too
high involvement in health activities can act as a stres-
sor and thereby induce health problems. This finding
needs to be investigated further, preferably in prospec-
tive, longitudinal studies.
The university students in this study were practicing
healthy habits around the same level as students in
other Western European countries. They showed
healthier behaviors related to smoking and alcohol use
than other students, but their nutritional habits were
poor. Especially alarming is that male students tend to
be overweight or obese and at the same time wanting
to weigh more even when the BMI was normal, and not
interested in getting nutritional advice. This gives
concerns for the future. Being physically active was
strongly associated with access to facilities for exercis-
ing. One way to promote students health would be to
create facilities for sporting and calisthenics at univer-
sity campuses, which could also increase communal
physical activity.
Not many associations between self-rated health and
other health determinants than stress were found. Per-
ceived social support was beneficial for female stu-
dents health, while a high level of physical activity was
associated with more health complaints. Motivation for
a healthy lifestyle was, in this study, not an important
factor for practicing healthy behaviors. The concept of
motivation needs further development.
Ideally, the research should use large, community-
based samples rather than university students, and have
prospective and longitudinal designs to make causal
conclusions possible. This cross-sectional study gives
some ideas for future research on factors influencing
health among university students, especially how stress
and motivation influence health and healthy habits.
ACKNOWLEDGMENTS
Financial support is gratefully acknowledged from the
Faculty of Medicine, Lund University, Lund; the Asso-
117
ciation Nurses Home of Southern Sweden, Lund;
School of Social and Health Sciences, Halmstad Uni-
versity, Halmstad; and Department of Primary Health
Care, Gteborg University, Gteborg, Sweden.
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