Published online: 5 February 2018
International Society of Behavioral Medicine 2018
Purpose This study investigated the relationship between the individual’s self-assessed health status (SAHS) and health-risk
factors (smoking, alcohol consumption and obesity), in 16 European countries. The associations were studied for the individual
and for the country measures—and in particular, for the unexplored aspect of interaction between individual and country levels of
the three risk factors.
Method Data for 47,114 adults, who participated in the Survey of Health Aging and Retirement Europe (SHARE), were
analyzed using Multilevel Regression Analysis. The individual data were complemented by OECD data that provided
country-specific risk measures: percentage of daily smokers, annual per-capita consumption of alcohol (liters), and percentage
of obese individuals.
Results We found that the individual’s SAHS is negatively associated with smoking and with weight-risk factors and is positively
associated with her/his alcohol consumption. The most pronounced associations relate to the weight variables, albeit they are
attenuated in countries with higher percentages of obese individuals. Significant differences across countries were evidenced in
the association between SAHS and smoking and between SAHS and alcohol consumption.
Conclusion Individual health levels are associated with individual risk factors and also with the behaviors in the country.
Significant interactions might indicate that psychological factors are at work.
Keywords Self-assessed health status
Behavioral risk factors
Behavioral risk factors are major contributors to health prob-
lems and costs. In industrialized countries, where chronic
(rather than infectious) diseases lead to morbidity and mortal-
ity, health behaviors are particularly important. There is a long
tradition (starting in the 1960s) of influential work on risks of
tobacco and alcohol, while research on obesity is more recent.
All three risk factors are prevalent, although only obesity has
increased dramatically over the past 30 years [1, 2].
In many areas of health research, the historic focus has been
on person- or individual-level factors that impact health, with
less interest in area characteristics as potential health/disease
determinants . The notion that Bplace^ might be important
for health re-emerged in the 1980s and 1990s, and interest has
increased sharply in recent years. Consequently, journals of
epidemiology and of public health published numerous studies
on Barea^ or Bneighborhood^ effects on health . Picket and
Pearl  reviewed 25 studies, demonstrating that 23 of the
studies reported a statistically significant association between
the environment/location and a health outcome.
While there is some consensus that health variations be-
tween different locations/contexts exist, there is a debate re-
garding the origins and channels of these variations—are they
contextual or compositional? For instance, Blaxter  was
convinced that contextual effects are important and places mat-
ter in their own right. In contrast, Sloggett and Joshi and
* Teresa García-Muñoz
Department of Quantitative Methods, University of Granada,
CELSI, Bratislava, Slovakia
Department of Economics, Bar-Ilan University, Ramat-Gan, Israel
IZA, Bonn, Germany
Hebrew University—Hadassah School of Medicine,
International Journal of Behavioral Medicine (2018) 25:183–197
Behavioral Health Risk Factors: the Interaction of Personal
and Country Effects