Our study's aim was to describe the socioeconomic inequalities in health-related behaviours and in nutritional status of Hungarian and Romanian citizens living on both sides of the border.
Smoking prevalence was at similar level both among Hungarians (33.2%) and Romanians (36.4%) in the present study, which is in agreement with the findings from the most recent Eurobarometer study on tobacco [28
]. According to that survey, the prevalence of smokers (including daily and occasionally smokers) is the highest in Greece (42%), followed by Bulgaria (38%), Latvia (37%), Romania and Hungary (both 36%).
Our study demonstrated an association of smoking with socioeconomic status, such as low education and poorer financial conditions in Hungarians, and only with poor financial conditions in Romanians. Similar associations have been found by other studies, i.e. the risk of smoking is higher in low educated and poorer people [33
]. According to Wardle et al., cigarette smoking is more prevalent in lower social class respondents aged over 35 years [36
]. An investigation on 12 European countries (around 1990) has also revealed that smoking is more prevalent among the lower educated, particularly in Northern European countries [3
]. Socioeconomic inequalities in tobacco smoking are also revealed during the three periods of the Australian National Health Survey, e.g. males with the highest SES have been more likely to be never smokers than those with lower SES [7
]. In a Polish study, men with higher education (aged 18 to 66 years) are less likely to smoke compared to the less educated, whereas among women with higher education smoking is more common [4
]. Health interview surveys in Hungary also demonstrate that cigarette smoking is more prevalent among low educated and poorer people [37
The SES related variations in the prevalence of smoking could be influenced by the actual stage of smoking epidemic in a given country [3
]. Many countries in Eastern Europe such as Romania and Hungary are currently at stage 3 of the tobacco epidemic characterized by a marked downturn in smoking prevalence in men, a more gradual decline in women, especially in those with a higher educational level [3
In our study, the prevalence of unhealthy diet was higher in Romanians than in Hungarians. The low intake of fruits and vegetables was also found in Hungary by the "National Health Interview Survey" [29
]. An overview of the health status of Romanians reports that low fruit and vegetable intake is one of the leading risk factors of non-communicable diseases [23
]. A study in Transylvania has found that vegetable intake is under reference values in females [41
], and another study delivered in 25-65-year old subjects has found higher prevalence of unhealthy diet in men [42
In agreement with other studies, we revealed an association of unhealthy diet with education and financial conditions in both countries. Wardle et al. have also found that low fruit and vegetable intake is more prevalent in lower social class respondents [36
]. Johansson et al. have reported that social status measured by education and aggregates of SES (blue-collar and white-collar workers and income per year) is correlated to indicators of healthy diet (e.g. fruit and vegetable consumption) in men and women aged 16-79 years, e.g. those having at least 13 years of education have higher intakes of fruits, vegetables and fibre than those with less than 13 years of education [13
]. Likewise, in a review paper about food patterns in terms of various socioeconomic indicators across Europe, it is stated that those who are poorer in material or social conditions are likely to follow a less healthy diet, i.e. people with lower SES consume nutrients from a less diverse food base: they eat monotonous diets with little variety [12
In our study, leisure time physical inactivity of the participants was independent of their demographic and socioeconomic data in both countries - the result being in contrast with several reports in the literature. Haenle et al. have highlighted gender and age related differences in German adults aged 18-65 years; males are more likely than females to engage in more intense leisure time physical activity, and females in the youngest age group are the least physically active [43
]. A review of several studies describes that those with higher education levels or the self-employed are more likely to be moderately active in their leisure time [12
]. The Hungarian national survey (2000) has described that higher educated and wealthier people are less likely to be physically inactive in their leisure time and/or at work [32
], while the next survey (2003) has found an association between financial conditions and inactivity only in females [38
]. An Australian survey points at strong socioeconomic inequalities in terms of leisure time physical activity in both males and females [7
], however, no associations have been found between physical activity levels in leisure time and social status indices such as the level of education and annual income in the ATTICA study in Greece among 20-89 years old persons [11
A systematic review on the prevalence of obesity indicates geographic variations with rates being higher in Central, Eastern, and Southern Europe than in Western and Northern Europe. This geographic pattern can be explained, at least partly, by different socioeconomic conditions as well as by lifestyle and nutritional factors, but may also be partly due to ethnic differences [44
]. The percentage of people who are overweight and obese reflects socioeconomic inequalities in Australia [7
]. In a study on males (53-75 years) in Denmark, leisure time physical activity is associated with obesity and social class [45
]. In our study, the prevalence of obesity was higher among Hungarians (22.0%) than Romanians (16.5%). The risk of obesity was higher in older people in both nations, and was associated with medium and low educational levels in Hungarians.
Obesity, associated with lifestyle and characterized by unbalanced diets high in calories and also by inadequate physical activity, is considered as a risk factor for numerous diseases [46
]. In our study, a positive association was found between leisure time physical inactivity and obesity in Hungarians, whereas a negative association was revealed in Romanians. The association between physical inactivity and obesity in Hungarians was in agreement with the results of FINRISK cross-sectional studies in the 25-64-years old population: leisure-time physical activity was inversely associated with obesity both in men and women [15
]. The negative association between leisure time physical inactivity and obesity in Romanians was inconsistent with most of the previous results. The findings of a prospective cohort study suggests, however, that high BMI is a determinant of sedentary lifestyle, but it has failed to provide unambiguous evidence for an effect of sedentary lifestyle on weight gain [47
]. This seemingly ambiguous result might be due to the fact that we examined only leisure time physical activity and did not cover activity during work. Those being engaged in strenuous physical activity during work are more probably inactive in their leisure time than those having a sedentary occupation. It should also be mentioned that the comparison of our physical activity related results with the findings of previous studies was slightly limited because the measurement for leisure time physical activity has not been previously validated.
In Romanians, unhealthy diet was associated with the risk of obesity, though no association was found in Hungarians. Our findings in Romanians are also in line with the results of FINRISK studies showing that obese subjects appear to consume less fruits and vegetables [15
], and with the results of a cross-sectional study delivered in Romanian primary care settings in Iasi where obesity is more prevalent in case of unhealthy diet in males [42
No association was found between smoking and obesity in our study that is in contrast with several other reports. The study delivered in Iasi (Romania) has described higher rates of obesity among male smokers [42
]. The FINRISK study has highlighted that ex-smokers are heavier than non-smokers both among men and women [15
]. The Copenhagen male study reveals that leisure time physical activity and smoking habits are associated with obesity [45
]. The results of a cross-sectional study in 18-75 years show that smoking status, educational level, time spent in health related sport activities and sedentary behaviour are associated with the likelihood of being overweight [16
A healthy lifestyle, with its behavioural emphasis might not depend only on the individuals' decisions. Individuals can make choices in a social context [48
], and helping individuals to change unhealthy behaviour should always be part of the health promotion. Our study may call the attention to the inequalities in smoking and dietary habits in relation to the socioeconomic status: the occurrence of health-damaging behaviours was more common among the less educated people in both countries. Concerning obesity, we found different situations in the two countries: the effect of dietary habits was detected only in Romanians, and the role of the physical inactivity was dissimilar.
The fact that the emerging health and health-related problems on both sides of the border and their socioeconomic background have common characteristics may draw our attention to the importance of seeking for mutual solutions. These might be realised in the framework of cross-border community based health promotion programmes that would be supported by the European Union, thus, the common problems occurring in the regions near the border could be solved together. Our study may provide some practical implications for formulating programmes that are aimed at improving the healthy behaviour in Hungarians and Romanians. Our results may point out the need for developing interventional strategies, focusing more on people in lower socioeconomic status, in order to reduce the existing inequalities in health and health-related behaviours.
In interpreting our results, it might be important to keep in mind the study's limitations. Our data were obtained in cross-sectional surveys where socioeconomic characteristics were asked simultaneously with the health-related behaviours. Strict causal interpretations should therefore be avoided. Data from self-reports tend to be inaccurate in some instances, e.g. self-reported weight and height may underestimate the prevalence of obesity. Socioeconomic status was measured according to the educational level and self-perceived financial condition, similarly to but not by the same measures that have been used in other studies. Health-related behaviours were measured by simple questions. One part of the measures, such as the measurement of leisure time physical activity was used primarily. One of the limitations of our study was the crude assessment of leisure time physical activity by questions without previous validation with the risk of misclassification. Our categories indexing the physical activity should be regarded as reflecting on common patterns of leisure time physical activity through one year, rather than precise measures of levels. They mainly inform us rather about the prevalence of leisure time physical inactivity than the measure of the level of activity. Another limitation of our study concerning the results on physical activity was that we examined only leisure time physical activity and not activity during work. However, the questions concerning diet and smoking were used according to previous Hungarian and international research in population based epidemiological studies (see the Methods), thus, results can be compared with data published by other researchers and can also be generalized. It may be that the applied measures seem to be too general, but it allows for the feasible involvement of people with various ages, educational levels, etc. Despite these limitations, this study might provide a relevant picture on the prevalence of health-related behaviours and obesity in relation to socioeconomic factors both in Hungarians and Romanians.