Fear of Falling Carries Over into Overprotection in Old Age: A Cross-Lagged Panel Analysis

Fear of falling might result in overprotection by one's social environment. In turn, feeling dependent could increase fear of falling. However, the association between fear of falling and perceived overprotection and its temporal order is unknown. This longitudinal study explores this potential mutual longitudinal association. This study presents secondary analyses from a larger trial. We tested the association between fear of falling and perceived overprotection in a cross-lagged path model controlled for falls, health-related quality of life, age, gender, and trial condition. N = 310 participants (M = 70 years, range: 64-92) completed self-reports at Time 1, 7 (Time 2), and 11 weeks (Time 3) after baseline assessment. We found a positive association from fear of falling to perceived overprotection (β = .12, 95% CI[0.02, 0.21], p = .02; β = .10; [0.01, 0.18], p = .03). The reversed cross-lagged paths were not significant. Findings suggest higher fear of falling translates into perceived overprotection, which may in turn increase loss of independence in old age.

A Stepped Health Services Intervention to Improve Care for Mental and Neurological Diseases: Protocol for a Prospective Cohort Trial

BACKGROUND

Mental and neurological disorders cause a large proportion of morbidity burden and require adequate health care structures. However, deficits in the German health care system like long waiting times for access to specialized care and a lack of coordination between health care providers lead to suboptimal quality of care and elevated health care costs.

OBJECTIVE

To overcome these deficits, we implement and evaluate a unique stepped and coordinated model of care (the Neurologisch-psychiatrische und psychotherapeutische Versorgung [NPPV] program) for patients with mental and neurological diseases.

METHODS

Patients included in the program receive an appropriate treatment according to medical needs in a multiprofessional network of ambulatory health care providers. The therapy is coordinated by a managing physician and complemented by additional therapy modules, such as group therapy, internet-based cognitive behavioral therapy, and a case management. Statutory health insurance (SHI) routine data and data from a longitudinal patient survey will be used to compare the program with regular care and evaluate SHI expenditures and patient-related outcomes. A health care provider survey will evaluate the quality of structure and processes and provider satisfaction. Finally, an analysis of ambulatory claims data and drug prescription data will be used to evaluate if health care providers follow a needs-led approach in therapy. Ethics approval for this trial was obtained from the ethics committee of the chamber of physicians in North Rhine (September 13, 2017, reference No. 2017287).

RESULTS

Patient enrollment of NPPV ended in September 2021. Data analysis has been completed in 2022. The results of this study will be disseminated through scientific publications, academic conferences, and a publicly available report to the German Federal Joint Committee, which is expected to be available in the first half of 2023.

CONCLUSIONS

The NPPV program is the first intervention to implement a stepped model of care for both mental and neurological diseases in Germany. The analysis of several data sources and a large sample size (more than 14,000 patients) enable a comprehensive evaluation of the NPPV program.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00022754; https://tinyurl.com/3mx9pz5z.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37569.

Health sensitivity in the daily lives of younger and older adults: correlates and longer-term change in health

OBJECTIVES

How susceptible older adults' affect is to fluctuations in health (i.e., health sensitivity) indicates how well they adapt to everyday health challenges. Theory and evidence are inconsistent as to whether older adults are more or less health sensitive than younger adults. The role of health burden as correlate and outcome of health sensitivity and age differences therein is also unclear. We thus move the study of health sensitivity ahead from longitudinal inquiry to examine age differences, the role of health burden, and long-term implications of daily life health sensitivitMethods: We use data from COGITO where 101 younger adults (M_age = 25; range = 20-31) and 103 older adults (M_age = 71; range = 65-80) gave daily reports of physical symptoms and positive and negative affect during a ∼100-day micro-longitudinal phase, as well as reports of trait-level health two years before and after.

RESULTS

Extending earlier reports, older age and higher health burden were (independently) associated with lower health sensitivity in positive but not negative affect. Health sensitivity was unrelated to long-term changes in health burden.

CONCLUSION

We take our findings to indicate successful aging (older adults are not more emotionally vulnerable to health issues) and discuss habituation as a process underlying how age and health burden may reduce health sensitivity.

Benefits of volunteering on psychological well-being in older adulthood: evidence from a randomized controlled trial

Objectives: Long-term volunteering has been associated with better physical, mental, and cognitive health in correlational studies. Few studies, however, have examined the longitudinal benefits of volunteering with randomized experimental designs (e.g., intervention studies). Even fewer studies have examined whether such benefits can be shown after short-term volunteering. To fill this gap, we conducted four 1-hour volunteering intervention sessions to promote volunteering among a group of older adults with limited volunteering experience and examined the impact of volunteering on depressive symptoms, meaning in life, general self-efficacy, and perceived autonomy.Methods: A total of 384 participants aged 50-96 years were assigned at random to either an intervention group to promote volunteering behaviors or an active control group to promote physical activity. The participants' monthly volunteering minutes, depressive symptoms, meaning in life, general self-efficacy and perceived autonomy were measured at baseline and six weeks, three months, and six months after the intervention.Results: Being in the volunteering intervention condition was not directly associated with depressive symptoms, meaning in life, general self-efficacy, or perceived autonomy at the 6-week, 3-month, or 6-month follow-ups after the intervention. However, there was an indirect effect of the intervention on depressive symptoms: participants in the intervention group, who had increased their volunteering at the 3-month follow-up, reported fewer depressive symptoms at the 6-month follow-up.Discussion: Our randomized controlled trial suggests that short-term volunteering does not reliably lead to short-term changes in psychosocial health measures as correlational studies would suggest. Efforts need to be made to encourage older adults to maintain long-term volunteering.

Changes in views on aging in later adulthood: the role of cardiovascular events

A number of longitudinal studies have pointed to the long-term impact of different views on aging (VoA) on health in later life, whereas the reverse relationship has rarely been examined. Serious cardiovascular events such as myocardial infarction or stroke are life-threatening events which might in turn lead to changes in VoA. The present longitudinal study examined the effect of a cardiovascular event (CVE) on VoA over a three-year period using pooled data from three waves of the German Ageing Survey (2008, 2011, 2014, age range: 40-95 years). In order to account for alternative explanations for changes in VoA, individuals without CVE (n = 200) were matched to individuals who experienced a CVE (n = 202) using a propensity score matching procedure. Compared to individuals without CVE, individuals who experienced a CVE showed adverse changes in three VoA indicators (self-perceptions of aging as associated with physical losses/with ongoing development; subjective age). These results suggest that CVE can in fact change how individuals view their own aging. According to previous studies, this can lead to future health changes and thus become a health-related downward spiral. Health promotion programs could, therefore, profit by adding specific VoA interventions for individuals who experienced a CVE.

Promoting Volunteering Among Older Adults in Hong Kong: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Volunteering has consistently been associated with better mental, physical, and cognitive health in older adulthood. However, the volunteering rate of older adults in Hong Kong is much lower than in Western countries. Few studies have examined whether interventions can be effective in motivating older adults to volunteer in Hong Kong. To fill this gap, we conducted a randomized controlled trial to examine the impact of a theory-based social-cognitive intervention on volunteering.

RESEARCH DESIGN AND METHODS

A total of 264 community-dwelling older adults in Hong Kong (Mage = 69.95 years, SDage = 6.90 years, 81.06% female) were randomly assigned to either an experimental group or an active control group. Participants in the experimental group received 4 weekly 1-hr face-to-face volunteering intervention sessions. Those in the active control group received parallel sessions targeting physical activity instead of volunteering. The time spent on volunteering per month was self-reported and measured at baseline, 6 weeks, 3 months, and 6 months after the intervention. Self-efficacy, intention, action planning, and self-monitoring of volunteering were measured as mediators.

RESULTS

Monthly volunteering minutes increased among participants in the experimental group when compared with the active control group at 6-week, 3-month, and 6-month follow-ups. Self-efficacy, intention, and action planning consistently mediated the effect of the intervention on volunteering minutes.

DISCUSSION AND IMPLICATIONS

The findings demonstrate the effectiveness of the intervention on volunteering behavior in older adults in Hong Kong through well-established behavior change techniques.

Positive Self-perceptions of Aging Promote Healthy Eating Behavior Across the Life Span via Social-Cognitive Processes

OBJECTIVES

Negative self-perceptions of aging (SPA) have been shown to result in lower levels of preventive behavior, health, and longevity. This study focuses on the understudied SPA effects on healthy eating across the life span. Moreover, it aims to provide longitudinal evidence of the psychological mechanisms behind this relationship.

METHOD

We investigated whether SPA (T1) can predict changes in eating behavior (T3) over 1 year in 1,321 participants (T1), aged 18-92 years. The explanatory role of social-cognitive processes (T1, T2) was tested via a two-step mediation analysis with multigroup modeling for different age and education levels.

RESULTS

Baseline positive SPA predicted more healthy eating at T3 (b = 0.68, SE = 0.24, p = .01), controlling for baseline eating (T1), age, education, gender, BMI, and illnesses. Self-efficacy (T1) and intention to eat healthily (T2) serially mediated this effect, indirect effect: b = 0.04, p = .02, 95% CI (0.02, 0.08). SPA had stronger effects in older and less educated participants.

DISCUSSION

This study provides important insights into the mechanisms behind positive SPA fueling successful health behavior change dynamics. Fostering more positive SPA through interventions might be especially important for vulnerable groups. Addressing SPA already in younger ages might help establish health-promoting life-span dynamics.

DO SERIOUS HEALTH EVENTS CHANGE HOW WE VIEW OUR OWN AGING? ON THE ROLE OF CARDIOVASCULAR EVENTS

Several studies have demonstrated beneficial effects of views on aging (VoA) on health, while the reverse relationship is seldom in focus. Serious health events (e.g., myocardial infarction) are life-threatening and remind individuals of the finitude of life possibly changing their VoA. The present study investigates the effect of cardiovascular events (CVE) on longitudinal changes in VoA using pooled data of three waves of the German Ageing Survey (2008, 2011, 2014, age-range: 40-95 years). To account for alternative explanations, individuals without CVE were matched to the individuals with CVE (n = 202) using a propensity-score-matching approach. Individuals who experienced a CVE showed more adverse changes in three VoA indicators (aging associated with physical losses, ongoing development, felt age) than individuals without CVE. Results show that CVE can change how we view our own aging which in turn affects future health changes. Following a CVE people may benefit from promoting positive VoA.

Study protocol of a multi-center RCT testing a social-cognitive intervention to promote volunteering in older adults against an active control

Background

Volunteering could be a win-win opportunity for older adults: Links between volunteering and societal improvements as well as older adults’ own health and longevity are found in several observational studies. RCTs to increase volunteering in older adults are however sparse, leaving the question of causality unanswered. This study protocol describes a theory-based social-cognitive intervention with multiple behavior change techniques to increase volunteering among community-dwelling older adults in Hong Kong.

Methods

In a parallel group, two-arm, randomized controlled trial, an initial N = 360 are assigned to receive either the volunteering intervention or the active control intervention (parallel content targeting physical activity). The primarily outcome measure is self-reported volunteering minutes per month at baseline, six weeks, three months and six months after the intervention. Participants in the treatment group are expected to increase their weekly volunteering minutes over time as compared to participants in the control group. Possible active ingredients of the intervention as well as mental and physical health outcomes of increased volunteering are investigated by means of mediation analyses.

Discussion

Like many industrialized nations, Hong Kong faces a rapid demographic change. An effective psychological intervention to encourage retirees to engage in formal volunteering would alleviate some of the societal challenges a growing proportion of older adults entails.

Trial registration

Primary Registry and Trial Identifying Number ChiCTR-IIC-17010349, secondary CCRB trial number CUHK_CCRB00543, registration date 2016/12/28.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1034-1) contains supplementary material, which is available to authorized users.

Regional Impact of Population Aging on Changes in Individual Self-perceptions of Aging: Findings From the German Ageing Survey

Background and Objectives

The importance of self-perceptions of aging (SPA) for health and longevity is well documented. Comparably little is known about factors that contribute to SPA. Besides individual factors, the context a person lives in may shape SPA. Research has so far focused on country-level differences in age stereotypes, indicating that rapid population aging accompanies more negative age stereotypes. The present study expands previous research by investigating the impact of district-specific population aging within one country on different facets of SPA.

Research Design and Methods

Based on a large representative survey in Germany, the study investigates changes in SPA as ongoing development as well as the SPA of physical loss over a 12-year period in adults aged 40+. The study uses several indicators of population aging (e.g., population development, average age, greying index), to identify four clusters differing in their pace of population aging. Based on three-level latent change models, these clusters were compared in their impact on changes in SPA.

Results

Compared to districts with an average rate of population aging, the study shows that persons living in regions with a fast population aging rate (C1) hold more negative SPA in both facets (ps = .01). Districts with slow population aging (C2) have significantly higher SPA ongoing development (p = .03).

Discussion and Implications

The study underlines the importance for regional differences in population aging on the development of SPA. In particular, societies should be aware that fast population aging may result in more negative SPA.

Response shift in self-rated health after serious health events in old age

OBJECTIVE

Although health generally deteriorates with advancing age, how older adults evaluate their health status (i.e., their self-rated health, SRH) remains rather positive. So far, however, little is known about how SRH in old age may change in the face of an abrupt health decline. Because change/stability in SRH may reflect not only change/stability in health but also changes in the meaning people assign to the concept of "health", response shift effects in SRH for people with and without a serious health event are investigated in the present study in the older general population.

METHOD

Longitudinal data from 1764 participants of the German Ageing Survey aged 65 + assessed at two occasions three years apart was used to investigate changes in SRH and three types of response shift: recalibration (change in standards for good health), reprioritization (change in the importance of different factors for health), and reconceptualization (omission/inclusion of new factors). The so-called "then-test" was used to examine recalibration response shift and path analyses, to examine reprioritization and reconceptualization response shift.

RESULTS

SRH declined between the two measurement occasions. As expected, people who experienced a serious health event indicated stronger declines in SRH. The study found evidence of two types of response shift. Regardless of whether they experienced a serious health event or not, individuals on average retrospectively overestimated their baseline health relative to the concurrent rating (recalibration). Furthermore, the predictive importance of depressive symptoms and optimism for SRH increased for individuals who experienced a serious health event (reprioritization).

CONCLUSION

The results indicate that older adults maintain stable SRH by using two types of response shift: recalibration and, when faced with a serious health event, reprioritization response shift.

The KTx360°-study: a multicenter, multisectoral, multimodal, telemedicine-based follow-up care model to improve care and reduce health-care costs after kidney transplantation in children and adults

Background

Follow-up care after kidney transplantation is performed in transplant centers as well as in local nephrologist’s practices in Germany. However, organized integrated care of these different sectors of the German health care system is missing. This organizational deficit as well as non-adherence of kidney recipients and longterm cardiovascular complications are major reasons for an impaired patient and graft survival.

Methods

The KTx360° study is supported by a grant from the Federal Joint Committee of the Federal Republic of Germany.

The study will include 448 (39 children) incident patients of all ages with KTx after study start in May 2017 and 963 (83 children) prevalent patients with KTx between 2010 and 2016.

The collaboration between transplant centers and nephrologists in private local practices will be supported by internet-based case-files and scheduled virtual visits (patient consultation via video conferencing). At specified points of the care process patients will receive cardiovascular and adherence assessments and respective interventions. Care will be coordinated by an additional case management.

The goals of the study will be evaluated by an independent institute using claims data from the statutory health insurances and data collected from patients and their caregivers during study participation. To model longitudinal changes after transplantation and differences in changes and levels of immunosuppresive therapy after transplantation between study participants and historical data as well as data from control patients who do not participate in KTx360°, adjusted regression analyses, such as mixed models with repeated measures, will be used. Relevant confounders will be controlled in all analyses.

Discussion

The study aims to prolong patient and graft survival, to reduce avoidable hospitalizations, co-morbidities and health care costs, and to enhance quality of life of patients after kidney transplantation.

Trial registration

ISRCTN29416382 (retrospectively registered on 05.05.2017)

Perceived somatic and affective barriers for self-efficacy and physical activity

According to Bandura's social-cognitive theory, perceptions of somatic and affective barriers are sources of self-efficacy. This longitudinal study compares general indicators of health barriers with measures of perceived somatic and affective barriers to predict self-efficacy and accelerometer-assessed physical activity in a subsample of n = 153 (selected at random from N = 310) community-dwelling German older adults. Perceived somatic and affective barriers longitudinally predicted physical activity mediated by self-efficacy, whereas general health barriers did not. Perceived health barriers to physical activity might be more important than more objective health barriers for older adults' physical activity levels.

Bidirectional Associations Between Self-Perceptions of Aging and Processing Speed Across 3 Years

Abstract. Background: Previous studies point to a potential relationship between self-perceptions of aging (SPA) and cognitive performance. However, most of these studies are limited by their experimental design. Previous longitudinal studies looked solely at memory as an outcome variable without examining the directionality of effects. The present study examines the direction of effects between two domains of SPA (personal growth and physical losses) and processing speed (PS). Methods: The sample consists of 8,198 participants of the German Ageing Survey (DEAS), aged between 40 and 93 years. A cross-lagged path model was estimated to examine directions of relationships across 3 years via chi-squared difference tests for each domain of SPA. Results: In the unconstrained models, the effect of SPA domain personal growth in 2008 on PS in 2011 and vice versa were marginally significant. For SPA domain physical losses, the effect of SPA on PS was significant, whereas the other direction of the effect did not reach significance. However, the cross-lagged paths of both domains of SPA on PS and vice versa could be set equal without a significant loss of model fit. The resulting associations indicate a significant bidirectional relationship between both domains of SPA and PS. Discussion and conclusion: This study provides initial evidence that SPA can influence trajectories of cognitive decline and vice versa. The results emphasize the detrimental and beneficial effects that stereotypes can have on individuals and add further evidence to the theory of stereotype embodiment.

Short-Term Buffers, but Long-Term Suffers? Differential Effects of Negative Self-Perceptions of Aging Following Serious Health Events

Objectives

Large longitudinal studies show that negative self-perceptions of aging can be detrimental for health outcomes. However, negative self-perceptions of aging (i.e., associating aging with physical losses) might be adaptive because they prepare individuals for serious health events (SHEs), resulting in short-term positive effects as opposed to long-term negative effects on well-being and health.

Method

Longitudinal data from 309 older adults (aged 65 and older) were analyzed. Short-term (6 months) and long-term (2.5 years) effects after a SHE of negative self-perceptions of aging on functional limitations (FLs) and negative affect (NA) were investigated.

Results

Results show that in the case of a SHE, individuals with more negative self-perceptions of aging reported less NA after 6 months but more FLs after 2.5 years. In contrast, individuals with less negative self-perceptions of aging reported more NA in the short-run but less FLs later on.

Discussion

People with more negative self-perceptions of aging may be mentally prepared for health events or may have habituated to health declines. Individuals with more positive self-perceptions, in contrast, may invest a lot in coping efforts immediately after the health event. Similarities to research on unrealistic optimism are discussed.

Relations between views on ageing and perceived age discrimination: a domain-specific perspective

This study investigates the relation between age stereotypes and perceived age discrimination. Existing evidence for such a relation is notoriously ambiguous with regard to its direction-age stereotypes can predict (perceived) discrimination, but experiencing discrimination may also change views on ageing-which is why we used a dataset with two waves to disentangle the direction of the associations. Considering research on the multi-dimensionality of views on ageing and perceived age discrimination, we addressed this question from a domain- and age group-specific perspective. Drawing on data from two measurement points of the German Ageing Survey (DEAS; t1: 2008, t2: 2011; age range at t1: 40-93 years, n = 6092 participants at t1), we examined reciprocal relations between views on ageing and perceived age discrimination. Cross-lagged models revealed that domain-specific views on ageing predict subsequent changes in perceived discrimination in corresponding domains: Negative views on ageing regarding personal competence, physical decline, and social interactions were associated with increases in perceived discrimination in the domains of work, medical care, and social life, respectively. However, we did not find evidence for a reciprocal effect of perceived age discrimination on views on ageing. In sum, results indicate that negative views on ageing act as self-fulfilling prophecies by predisposing people to categorize other people's behaviour as age discrimination or to act themselves in a way that might elicit ageist behaviour in others.

Revisiting self-regulatory techniques to promote physical activity in older adults: null-findings from a randomised controlled trial

OBJECTIVE

A randomised controlled trial (RCT) was conducted to evaluate a three-hour face-to-face physical activity (PA) intervention in community-dwelling older German adults with four groups: The intervention group (IG) received behaviour change techniques (BCTs) based on the health action process approach plus a views-on-ageing component to increase PA. The second intervention group 'planning' (IGpl) contained the same BCTs, only substituted the views-on-ageing component against an additional planning task. An active control group received the same BCTs, however, targeting volunteering instead of PA. A passive control group (PCG) received no intervention.

DESIGN

The RCT comprised 5 time-points over 14 months in N = 310 participants aged 64+.

MAIN OUTCOME MEASURES

Self-reported as well as accelerometer-assessed PA.

RESULTS

Neither PA measure increased in the IG as compared to the other groups at any point in time. Bayes analyses supported these null-effects.

CONCLUSION

A possible explanation for this null-finding in line with a recent meta-analysis is that some self-regulatory BCTs may be ineffective or even negatively associated with PA in interventions for older adults as they are assumed to be less acceptable for older adults. This interpretation was supported by observed reluctance to participate in self-regulatory BCTs in the current study.

Regional resources buffer the impact of functional limitations on perceived autonomy in older adults with multiple illnesses

Retaining perceptions of autonomy is a key component of successful aging. Perceived autonomy refers to the capacity to make and enact self-directed decisions. These perceptions are often threatened in older adults with multiple illnesses, when functional limitations resulting from these illnesses impede the enactment of self-directed decisions. Regional resources (in Germany specifically at the level of administrative districts) might counteract these impediments of autonomy. Economically stronger districts can provide more-concrete support resources for older adults, buffering the negative effect of functional limitations on self-perceived autonomy. This study assessed participants aged over 65 with 2 or more chronic conditions. In total, N = 287 provided data (Mage = 73.3, SD = 5.07), and n = 97 were women. Gross domestic product (GDP) per capita was used as a proxy measure of administrative district wealth in Germany. Hierarchical multilevel regression analyses with cross-level interactions were conducted. Results suggest that the detrimental effect of functional limitations on perceived autonomy is less pronounced for participants residing in higher GDP districts. Conversely, for participants in lower GDP districts, the effect is exacerbated. This finding suggests that districts with greater financial resources might be better able to invest in supports that promote and facilitate autonomy and, thus, provide a buffer against threats to individual perceived autonomy.

Sources of self-efficacy for physical activity

OBJECTIVE

The effects of self-efficacy beliefs on physical activity are well documented, but much less is known about the origins of self-efficacy beliefs. This article proposes scales to assess the sources of self-efficacy for physical activity aims and to comparatively test their predictive power for physical activity via self-efficacy over time to detect the principal sources of self-efficacy beliefs for physical activity.

METHOD

A study of 1,406 German adults aged 16-90 years was conducted to construct scales to assess the sources of self-efficacy for physical activity (Study 1). In Study 2, the scales' predictive validity for self-efficacy and physical activity was tested in a sample of 310 older German adults.

RESULTS

Short, reliable and valid instruments to measure six sources of self-efficacy for physical activity were developed that enable researchers to comparatively test the predictive value of the sources of self-efficacy.

CONCLUSION

The results suggest that mastery experience, self-persuasion, and reduction in negative affective states are the most important predictors of self-efficacy for physical activity in community-dwelling older adults.

Contextual and individual predictors of physical activity: Interactions between environmental factors and health cognitions

OBJECTIVE

Although health behavior theories assume a role of the context in health behavior self-regulation, this role is often weakly specified and rarely examined. The two studies in this article test whether properties of the environment (districts) affect if and how health-related cognitions are translated into physical activity.

METHODS

Multilevel modeling was used to examine the assumed cross-level interactions. Study 1 is a large-scale survey representative of the German adult population (N = 6,201). Gross domestic product (GDP) on the level of administrative districts was used to indicate environmental opportunities and barriers. Study 2 examined cross-level interactions of proximal predictors of physical activity (intentions, action planning, and coping planning) in older adults with multiple illnesses (N = 309), a high-risk group for health deteriorations.

RESULTS

Study 1 showed that on the individual level, health attitudes (B = .11) and education (B = .71) were significantly associated with physical activity. GDP moderated the attitudes-behavior relation (B = .01), with higher attitude-behavior relations in districts with higher GDP. Study 2 finds that intention (B = .16), action planning (B = .17), and coping planning (B = .13) significantly predict activity. In addition, district-level GDP significantly moderated the relations between action planning and coping planning, but not intention, on physical activity.

CONCLUSIONS

Results suggest that the effects of health attitudes and planning on physical activity are moderated by environmental factors. Districts with higher GDP provide better contextual opportunities for the enactment of concrete if-then plans for physical activity. This has implications for both theory and health promotion.