Health-related behaviour in the Netherlands
Why study health-related behaviour?
There are clear differences in the health status of different groups in the Dutch population. Epidemiological research shows that differences in lifestyle are important in explaining these health differences (Mackenbach 2010; Williams 1995). There is, accordingly, great interest in the Netherlands in promoting a healthy lifestyle. Studying different lifestyles can help explain differences in perceived (or subjective) health. However, lifestyle differences are also closely related to objective health aspects, such as the risk of disease and mortality.
There is a clear, extensive and growing interest in these lifestyle behaviours; see also Acknowledgements and sources. Health inequalities can attract a great deal of moral criticism (McCartney et al. 2013). Additionally, governments see tackling health-related behaviours as a clear opportunity for combating inequality. After all, other causes of health inequality across population groups, such as genetic disposition and family background, are much less open to influence through government policy. These policies therefore focus mainly on addressing the behavioural and cultural causes of health inequalities, through public information campaigns, prevention activities, support and various forms of training.
All these measures are essentially aimed at promoting healthy behaviour, increasing knowledge about risky behaviour and nudging cultural preferences towards healthy behaviour. This publication therefore fits into a broader policy context, which prioritises the importance of prevention over cure. An example is the National Prevention Agreement (Nationaal Preventieakkoord) to which a number of civil-society organisations recently agreed on. This Agreement explicitly emphasises behaviour and health, in contrast to the earlier focus on care and disease (see e.g. Council for Public Health and Health Care (RVZ 2010). Other examples are various reports from the Health Council of the Netherlands (Gezondheidsraad)).
Better insight into differences in health-related behaviour between educational groups
A lot is already known about health-related behaviours from numerous national and international studies; see also Acknowledgements and sources. This study seeks to go further by offering more detailed information based on unique comparative data. More specifically, our aim is to provide information for a broad, interested readership. First, we look at inequality in health-related behaviour based on different educational groups; see also Education as a dividing line. This gives us insight into existing differences in the self-reported health of the population.
Second, we study health-related behaviour in a broader perspective, investigating whether there is an accumulation of (un)healthy habits in the same groups in society, and whether the education gap exacerbates this; see also Accumulation of risk factors.
Third, we examine differences in the health-related behaviour of different educational groups in their social and national context. These differences are related not only to family aspects, such as the individual’s household and the origin of their partner, but also to education gaps in health-related behaviour in other European countries; see Family and lifestyle habits and Partner and health-related behaviour. This enables us to say something about the national context and how national policy can influence differences. This international comparison also provides an insight into how cultural and structural country characteristics might explain differences in the education gap between countries; see also The Netherlands in Europe.
Fourth, we look in some detail at the use of Alternative medicine. This is the first time such information has been available in a representative study in a comparative European perspective.
Finally, in describing health-related behaviour we draw on the highly respected data from the European Social Survey ( http://www.europeansocialsurvey.org), which are representative for the Dutch population. This guarantees a valid description of differences in health-related behaviour.
Healthy and unhealthy health-related behaviours
What do we mean by health-related behaviour? First and foremost, it is important to acknowledge that health-related behaviour is not about occasional excess, but about habits which form an integral part of someone’s personal lifestyle. These habits have often developed over many years and become a normal part of a person’s daily life. As a consequence, they can have a substantial impact on an individual’s health over the longer term (Williams 1995). That impact may be harmful to health, or may promote health (Huijts et al. 2017).
In the following cards we study six relevant lifestyle expressions which are presumed to be related to health. The behaviours studied are as follows:
- drinking alcohol regularly (several times per week);
- being overweight;
- consuming vegetables;
- consuming fruit;
- engaging in sufficient physical activity.
Drawing on information from the Health Council of the Netherlands (www.gezondheidsraad.nl), we developed a benchmarking system to determine what can be regarded as healthy and unhealthy. It is important to note that we were constrained in the design of this benchmarking system by the framing of the questions on (un)healthy habits in Round 7 of the European Social Survey (2014/’15); see also Acknowledgements and sources.
What is healthy and unhealthy?
What is healthy?
We studied three healthy behaviours: eating vegetables, eating fruit and engaging in sufficient physical activity. No standardised health benchmarks are available for eating fruit and vegetables. However, the Health Council of the Netherlands (2015) states that eating fruit and vegetables lowers the risk of coronary heart disease, stroke, diabetes and certain forms of cancer. The Council accordingly recommends the consumption of at least 200 grams of vegetables and 200 grams of fruit per day. With regard to consumption of vegetables, we therefore distinguish between people who eat vegetables at least once per day and people who do not. We then look at the regular consumption of fruit, taking as a starting point that eating fruit daily is healthy.
The third healthy behaviour is engaging in sufficient physical activity. The Dutch physical activity guidelines (Nederlandse Norm Gezond Bewegen – NNGB) assume that a minimal amount of physical activity is necessary in order to maintain health. The guidelines suggest at least 2.5 hours of moderately intensive activity per week, spread over several days. Here we define sufficient activity as engaging in intensive physical activity for more than 30 minutes on at least one day per week. For more information on the questions and the response categories, see Acknowledgements and sources.
What is unhealthy?
We look at three types of unhealthy behaviour: smoking, drinking alcohol and being overweight. Smoking has a major impact on illness and health; smokers in the Netherlands die an average of 4.1 years earlier and spend 4.6 years fewer in good health than non-smokers. Here we draw a distinction between non-smokers and people who smoke on a daily or regular basis.
We also regard regular consumption of alcohol as an unhealthy behaviour. The Health Council of the:Netherlands (2015) gives the following advice: ‘Do not drink alcohol, and in any event no more than one glass per day.’ Regular alcohol consumption not only has consequences for health, but also has secondary consequences such as reduced labour productivity, domestic violence and road traffic accidents. Our definition of drinking alcohol regularly is consuming alcohol several times per week.
Finally, we look at having an unhealthy body weight (Body Mass Index – BMI). We draw a distinction here between people with a BMI above 30 (obesity), persons with a BMI higher than 25 (overweight) and persons with a BMI below this threshold. Although the health risks of (moderate) overweight are less clear, the Health Council of the Netherlands (2003) states that the health risks of obesity are reasonably well documented. The morbidity associated with obesity leads for example to more medical treatments, more incapacity for work and higher costs for the healthcare system.
How common is (un)healthy behaviour in the Netherlands and Europe?
Figure 1.1 shows the prevalence of the six health-related behaviours in the Dutch population in 2014.
- It shows that 26% of all persons aged between 25 and 70 years are regular or intensive smokers. Smoking is thus a bad habit which affects roughly a quarter of the Dutch population.
- Regular alcohol consumption is much more common: 40% of the Dutch public report that they consume alcohol several times a week.
- More than half the population (51.6%) are overweight.
- Eating fruit and vegetables every day (70.4% and 77.9%, respectively) is a common aspect of a healthy lifestyle in the Netherlands.
- The majority of Dutch citizens (81.6%) report that they engage in intensive physical activity for more than 30 minutes at least once per week. This need not mean sport, but can also involve activities such as brisk walking or gardening.
Source:European Social Survey Netherlands, Round 7, 2014-2015 (N=1,415)
Source:European Social Survey Netherlands, Round 7, 2014-2015 (n=25,538)
On average, smoking is just as prevalent in the Netherlands as in the rest of Europe (26% in the Netherlands, 27% in Europe). However, the Netherlands is in the top group when it comes to regular alcohol consumption (40% versus 24% in Europe). Regular alcohol consumption is evidently more widespread and more broadly accepted in the Netherlands than in other European countries.
Although the above figure provides information on the incidence and prevalence of health-related behaviour in the population as a whole, we need to investigate which social groups most commonly engage in risky behaviours and health-promoting activities. This will provide specific information on the possible causes of existing health inequality between population groups. Cards 2 to 10 therefore focus on the importance of educational differences in the above six health-related behaviours; see also Education as a dividing line. In the section on Alternative medicine we investigate the popularity of alternative medicine as a special form of health-related behaviour.
Gezondheidsraad (2015). Richtlijnen goede voeding 2015. Accessible (in Dutch) at https://www.gezondheidsraad.nl/sites/default/files/201524_richtlijnen_goede_voeding_2015.pdf.
Huijts, T., A. Gkiouleka, N. Reibling, K.H. Thomson, T.A. Eikemo & C. Bambra (2017). Educational inequalities in risky health behaviours in 21 European countries: findings from the European social survey (2014) special module on the social determinants of health. In: The European Journal of Public Health, vol. 27, suppl_1, pp. 63-72. 63-72.
Mackenbach, J. (2010). Ziekte in Nederland. Volksgezondheid tussen biologie en politiek. Amsterdam: Mouria and Elsevier gezondheidszorg.
McCartney, G., C. Collins & M. Mackenzie (2013). What (or who) causes health inequalities: theories, evidence and implications? In: Health Policy, vol. 113, nr. 3, p. 221-227.
Raad voor de Volksgezondheid en Zorg (2010). Van zz naar gg. Acht debatten, een sprekend verhaal, The Hague.
Williams, S.J. (1995). Theorising class, health and lifestyles: can Bourdieu help us? In: Sociology of Health & Illness, vol. 17, nr. 5, p. 577-604.