Motivational factors for initiating and maintaining physical activity among adults aged over fifty targeted by a tailored intervention.

Objective: To provide insight into the motivational working mechanisms (i.e. mediators) of an effective physical activity (PA) intervention for adults aged over fifty.Design: The mediation model (N = 822) was investigated in an RCT for the total intervention population, participants who were not norm-active at baseline (targeting PA initiation) and norm-active participants (targeting PA maintenance) separately.Main Outcome Measures: Potential mediators (attitude, self-efficacy, intention, action planning and coping planning) of the effect on PA (6-months) were assessed at baseline, 3 and/or 6 months.Results: The intervention resulted in a decrease in intention (B= -.209; p=.017), and an increase in action planning (B=.214; p=.018) and PA (B=.220; p=.002). Intention and action planning did not mediate the effect on PA. Self-efficacy, although not significantly influenced by the intervention, was found to be the only motivational variable that predicted change in PA (B=.164; p=.007). These results were confirmed among participants initiating PA. Among norm-active participants no significant intervention effects were identified.Conclusion: The motivational factors cannot explain the intervention effect on PA. Most likely, the effect can be explained by an interaction between the motivational factors together. Differences between participants initiating versus maintaining PA, highlight the importance of performing mediation analyses per subgroup.

Modeling Longitudinal Relationships Between Habit and Physical Activity: Two Cross-Lagged Panel Design Studies in Older Adults.

These longitudinal studies in older adults targeted mediated relationships between habit and physical activity (PA). In The Netherlands two independent studies were conducted among 1976 (Study 1: Mage = 63.63, SD = 8.66, 30% functional limitations) and 2140 (Study 2: Mage = 62.75, SD = 8.57, 45% functional limitations) adults aged 50 years or older. Cross-lagged panel designs were applied to examine whether habit mediates the relationship between prior and later PA and whether PA simultaneously mediates the relationship between prior and later habit. Data on habit and PA were collected by means of questionnaires at baseline (t0) and at 6 (t1) and 12 (t2) months after baseline measurement. Results of structural equation modeling analyses were not unambiguous. Indications for the existence of both hypothesized mediation effects were found, but no clear, unequivocal pattern appeared. Somewhat more support was found for the PA-habit-PA path than for the habit-PA-habit path. More research is needed to draw more definitive conclusions.

Long-term health outcomes and cost-effectiveness of a computer-tailored physical activity intervention among people aged over fifty: modelling the results of a randomized controlled trial.

BACKGROUND: Physical inactivity is a significant predictor of several chronic diseases, becoming more prevalent as people age. Since the aging population increases demands on healthcare budgets, effectively stimulating physical activity (PA) against acceptable costs is of major relevance. This study provides insight into long-term health outcomes and cost-effectiveness of a tailored PA intervention among adults aged over fifty. METHODS: Intervention participants (N = 1729) received tailored advice three times within four months, targeting the psychosocial determinants of PA. The intervention was delivered in different conditions (i.e. print-delivered versus Web-based, and with or without additional information on local PA opportunities). In a clustered RCT, the effects of the different intervention conditions were compared to each other and to a control group. Effects on weekly Metabolic Equivalents (MET)-hours of PA obtained one year after the intervention started were extrapolated to long-term outcomes (5-year, 10-year and lifetime horizons) in terms of health effects and quality-adjusted life years (QALYs) and its effect on healthcare costs, using a computer simulation model. Combining the model outcomes with intervention cost estimates, this study provides insight into the long-term cost-effectiveness of the intervention. Incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS: For all extrapolated time horizons, the printed and the Web-based intervention resulted in decreased incidence numbers for diabetes, colon cancer, breast cancer, acute myocardial infarctions, and stroke and increased QALYs as a result of increased PA. Considering a societal Willingness-to-Pay of €20,000/QALY, on a lifetime horizon the printed (ICER = €7,500/QALY) as well as the Web-based interventions (ICER = €10,100/QALY) were cost-effective. On a 5-year time horizon, the Web-based intervention was preferred over the printed intervention. On a 10-year and lifetime horizon, the printed intervention was the preferred intervention condition, since the monetary savings of the Web-based intervention did no longer outweigh its lower effects. Adding environmental information resulted in a lower cost-effectiveness. CONCLUSION: A tailored PA intervention in a printed delivery mode, without environmental information, has the most potential for being cost-effective in adults aged over 50. TRIAL REGISTRATION: The current study was registered at the Dutch Trial Register (NTR2297; April 26th 2010).

Cost-effectiveness and cost-utility of a Web-based or print-delivered tailored intervention to promote physical activity among adults aged over fifty: an economic evaluation of the Active Plus intervention.

BACKGROUND: The adverse health effects of insufficient physical activity (PA) result in high costs to society. The economic burden of insufficient PA, which increases in our aging population, stresses the urgency for cost-effective interventions to promote PA among older adults. The current study provides insight in the cost-effectiveness and cost-utility of different versions of a tailored PA intervention (Active Plus) among adults aged over fifty. METHODS: The intervention conditions (i.e. print-delivered basic (PB; N = 439), print-delivered environmental (PE; N = 435), Web-based basic (WB; N = 423), Web-based environmental (WE; N = 432)) and a waiting-list control group were studied in a clustered randomized controlled trial. Intervention costs were registered during the trial. Health care costs, participant costs and productivity losses were identified and compared with the intervention effects on PA (in MET-hours per week) and quality-adjusted life years (QALYs) 12 months after the start of the intervention. Cost-effectiveness ratios (ICERs) and cost-utility ratios (ICURs) were calculated per intervention condition. Non-parametric bootstrapping techniques and sensitivity analyses were performed to account for uncertainty. RESULTS: As a whole (i.e. the four intervention conditions together) the Active Plus intervention was found to be cost-effective. The PB-intervention (ICER = €-55/MET-hour), PE-intervention (ICER = €-94/MET-hour) and the WE-intervention (ICER = €-139/MET-hour) all resulted in higher effects on PA and lower societal costs than the control group. With regard to QALYs, the PB-intervention (ICUR = €38,120/QALY), the PE-intervention (ICUR = €405,892/QALY) and the WE-intervention (ICUR = €-47,293/QALY) were found to be cost-effective when considering a willingness-to-pay threshold of €20,000/QALY. In most cases PE had the highest probability to be cost-effective. CONCLUSIONS: The Active Plus intervention was found to be a cost-effective manner to increase PA in a population aged over fifty when compared to no-intervention. The tailored Active Plus intervention delivered through printed material and with additional environmental information (PE) turned out to be the most cost-effective intervention condition as confirmed by the different sensitivity analyses. By increasing PA at relatively low costs, the Active Plus intervention can contribute to a better public health. TRIAL REGISTRATION: Dutch Trial Register: NTR2297.

Habit as moderator of the intention-physical activity relationship in older adults: a longitudinal study.

This longitudinal study examined whether habit strength moderates the intention-physical activity (PA) relationship in older adults, within the framework of the attitude-social influences-efficacy (ASE) model and the theory of planned behaviour (TPB). A total of 1836 older adults (Mage = 62.95 years, SDage = 8.17) completed a questionnaire on social cognitive constructs and PA habit strength at baseline, and six months later a measure of PA. Three PA habit groups (i.e., low, medium and high) were composed, based on tertiles of the mean index score. Multi-group structural equation modelling analyses showed that intention significantly determined PA behaviour only in participants with a low or medium habit strength towards PA. This result suggests that PA is not intentional at high levels of habit strength and demonstrates the usefulness of incorporating habit in the ASE and TPB models. Results also showed that about half of the participants with a strong PA habit did not meet the recommended PA level. As strong habits may prevent intentional behavioural change and may hinder the receptiveness and openness for informational PA change strategies, additional intervention strategies, such as awareness raising and the use of implementation intentions, are needed for strongly habitual, but insufficiently active older adults.

Development of web-based computer-tailored advice to promote physical activity among people older than 50 years.

BACKGROUND: The Active Plus project is a systematically developed theory- and evidence-based, computer-tailored intervention, which was found to be effective in changing physical activity behavior in people aged over 50 years. The process and effect outcomes of the first version of the Active Plus project were translated into an adapted intervention using the RE-AIM framework. The RE-AIM model is often used to evaluate the potential public health impact of an intervention and distinguishes five dimensions: reach, effectiveness, adoption, implementation, and maintenance. OBJECTIVE: To gain insight into the systematic translation of the first print-delivered version of the Active Plus project into an adapted (Web-based) follow-up project. The focus of this study was on the reach and effectiveness dimensions, since these dimensions are most influenced by the results from the original Active Plus project. METHODS: We optimized the potential reach and effect of the interventions by extending the delivery mode of the print-delivered intervention into an additional Web-based intervention. The interventions were adapted based on results of the process evaluation, analyses of effects within subgroups, and evaluation of the working mechanisms of the original intervention. We pretested the new intervention materials and the Web-based versions of the interventions. Subsequently, the new intervention conditions were implemented in a clustered randomized controlled trial. RESULTS: Adaptations resulted in four improved tailoring interventions: (1) a basic print-delivered intervention, (2) a basic Web-based intervention, (3) a print-delivered intervention with an additional environmental component, and (4) a Web-based version with an additional environmental component. Pretest results with participants showed that all new intervention materials had modest usability and relatively high appreciation, and that filling in an online questionnaire and performing the online tasks was not problematic. We used the pretest results to improve the usability of the different interventions. Implementation of the new interventions in a clustered randomized controlled trial showed that the print-delivered interventions had a higher response rate than the Web-based interventions. Participants of both low and high socioeconomic status were reached by both print-delivered and Web-based interventions. CONCLUSIONS: Translation of the (process) evaluation of an effective intervention into an adapted intervention is challenging and rarely reported. We discuss several major lessons learned from our experience. TRIAL REGISTRATION: Nederlands Trial Register (NTR): 2297; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2297 (Archived by WebCite at http://www.webcitation.org/65TkwoESp).

The long-term efficacy of two computer-tailored physical activity interventions for older adults: main effects and mediators.

OBJECTIVE: Low-cost (e.g., computer-tailored) interventions with sustained effects are needed to increase and maintain physical activity in older adults. This study examined the long-term efficacy of 2 computer-tailored physical activity interventions for older adults and its psychosocial and environmental mediators. METHODS: A clustered randomized controlled trial (N = 1,971) was conducted that included 3 research arms: (a) basic computer-tailored print intervention, targeting psychosocial mediators; (b) environmentally computer-tailored print intervention, targeting psychosocial and environmental mediators; and (c) no-intervention control group. Interventions were developed using the intervention mapping approach and consisted of 3 computer-tailored letters delivered over 4 months. Questionnaires assessed the study outcomes (i.e., total weekly days and total weekly minutes of physical activity) at baseline and 12 months. Potential mediators (i.e., awareness, attitude, self-efficacy, intention, social influence, intrinsic motivation, self-regulation, and perceived environment) were assessed at baseline and at 3 or 6 months. RESULTS: Multilevel regression analyses revealed that both interventions significantly changed total weekly days of physical activity compared with the control group, but only the environmentally computer-tailored print intervention significantly changed weekly minutes of physical activity. Multiple mediation models showed that the effects of both interventions on weekly days of physical activity were mediated by changes in awareness and intention. CONCLUSIONS: Computer-tailored interventions were effective in inducing long-term behavioral changes in physical activity behavior of older adults. Awareness and intention were found to be important mediators of changing daily physical activity and should be included in future computer-tailored intervention studies.

Exploring the efficacy and moderators of two computer-tailored physical activity interventions for older adults: a randomized controlled trial.

BACKGROUND: Important health benefits can be derived when low-cost (e.g., computer-tailored) physical activity interventions for older adults demonstrate sustained effects. PURPOSE: The purpose of the study was to conduct in-depth analysis on the long-term efficacy of two tailored physical activity interventions for older adults. METHODS: A randomized controlled trial (n = 1,971) with two computer-tailored interventions and a no-intervention control group was conducted. The two tailored interventions consisted of three tailored letters, delivered during 4 months. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention additionally targeted environmental determinants, by providing tailored environmental information. Self-reported behaviors (i.e., total physical activity, transport walking and cycling, leisure walking and cycling, and sports) were measured at baseline and 12 months. Additionally, potential personal, health-related, and psychosocial moderators of the intervention effects were examined. RESULTS: The environmentally tailored intervention was effective in changing total physical activity, leisure cycling, and sports compared with the basic intervention and control group. No intervention effects were found for the basic intervention. Moderation analysis revealed that participants with a higher age, lower body mass index, and higher intention were unresponsive to the interventions. CONCLUSIONS: Providing environmental information is an effective intervention strategy for increasing physical activity behaviors among older adults, especially among certain "at-risk" subgroups such as lower educated, overweight, or insufficiently active participants. Moderation analysis was perceived as a promising method for identifying meaningful subgroups that are unaffected by an intervention, which should receive special attention in future interventions.

The working mechanisms of an environmentally tailored physical activity intervention for older adults: a randomized controlled trial.

BACKGROUND: The aim of this study was to explore the working mechanisms of a computer tailored physical activity intervention for older adults with environmental information compared to a basic tailored intervention without environmental information. METHOD: A clustered randomized controlled trial with two computer tailored interventions and a no-intervention control group was conducted among 1971 adults aged >/= 50. The two tailored interventions were developed using Intervention Mapping and consisted of three tailored letters delivered over a four-month period. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention additionally targeted environmental determinants, by providing tailored environmental information. Study outcomes were collected with questionnaires at baseline, three and six months and comprised total physical activity (days/week), walking (min/week), cycling (min/week), sports (min/week), environmental perceptions and use and appreciation of the interventions. RESULTS: Mediation analyses showed that changes in cycling, sports and total physical activity behaviour induced by the environmentally tailored intervention were mediated by changes in environmental perceptions. Changes in environmental perceptions did not mediate the effect of the basic tailored intervention on behaviour. Compared with the basic tailored intervention, the environmentally tailored intervention significantly improved cycling behaviour (tau = 30.2). Additionally, the tailored letters of the environmentally tailored intervention were better appreciated and used, although these differences did not mediate the intervention effect. DISCUSSION: This study gave some first indications of the relevance of environmental perceptions as a determinant of changing physical activity behaviours and the potential effectiveness of providing environmental information as an intervention strategy aimed at enhancing physical activity behaviour among older adults.

Efficacy of two tailored interventions promoting physical activity in older adults.

BACKGROUND: Important health benefits can be obtained if effective low-cost interventions promoting physical activity, especially among older adults, are developed. DESIGN: This RCT investigated the efficacy of two tailored physical activity interventions in promoting awareness, initiation, and maintenance of physical activity among older adults compared to a wait-list control group. Data were collected in 2007. Analyses were conducted in 2008. SETTING/PARTICIPANTS: In total, 1971 Dutch older adults (mean age=64 years, 57% women) participated. INTERVENTION: Two tailored physical activity interventions, consisting of three tailored letters delivered during 4 months, were systematically developed. The basic tailored intervention targeted psychosocial determinants alone, while the environmentally tailored intervention (intervention-plus) additionally targeted environmental determinants. MAIN OUTCOME MEASURES: Awareness of personal physical activity behavior, self-reported level of physical activity, and compliance with the physical activity guideline were assessed at baseline, 3 months, and 6 months. RESULTS: Intervention participants became more aware of their personal physical activity level at 6 months (OR(Ibasic)=1.7, OR(Iplus)=1.6) and were significantly more physically active at 3 (EffectSize[ES](Ibasic)=0.20, ES(Iplus)=0.20) and 6 months (ES(Ibasic)=0.30, ES(Iplus)=0.35) when compared to control participants. Moderation analyses showed that the interventions enhanced physical activity initiation at 3 (ES(Ibasic)=0.26, ES(Iplus)=0.21) and 6 months (ES(Ibasic)=0.32, ES(Iplus)=0.27) among participants insufficiently active at baseline, and induced maintenance at 6 months among participants sufficiently active at baseline (ES(Ibasic)=0.33, ES(Iplus)=0.34) when compared to the control condition. No differences between the intervention arms were found. CONCLUSIONS: The results indicate that tailoring can be an effective tool in attaining and enhancing awareness, initiation, and maintenance of physical activity among older adults. Targeting environmental determinants in addition to psychosocial determinants, however, did not result in an additional increase in physical activity behavior. TRIAL REGISTRATION: This study was registered with the Dutch Trial Register NTR 920.

The Active plus protocol: systematic development of two theory- and evidence-based tailored physical activity interventions for the over-fifties.

BACKGROUND: Limited data are available on the development, implementation and evaluation processes of physical activity promotion programmes among older adults. More integrative insights into interventions describing the planned systematic development, implementation and evaluation are needed. METHODS AND DESIGN: The purpose of this study is to give an integrative insight into the development of the Active plus programme applying the six-step Intervention Mapping protocol. The Active plus programme consisted of two theory- and evidence-based tailored physical activity promotion interventions, both comprising three tailored letters delivered over four months and aimed at raising awareness of insufficient physical activity, and stimulating physical activity initiation and maintenance among the over-fifties. The first intervention, the basic tailored intervention, provided tailored letters that intervened on the psychosocial determinants of physical activity. The second intervention, the intervention plus, provided the same tailored information but additionally provided tailored information about physical activity opportunities in the specific environment in which the older adults lived. This environment-based component also provided access to a forum and e-buddy system on a website. A plan for implementation and evaluation is also described. DISCUSSION: The planned development of the Active plus programme resulted in two theory- and evidence-based tailored physical activity interventions targeted at the over-fifties. TRIAL REGISTRATION: Dutch Trial Register NTR 920.

Bystanding an abused child: testing the applicability of the stages of change construct.

A minority of child abuse cases is recognized by professionals, making the role of non-professional bystanders essential. The stages of change construct, as proposed by the Transtheoretical Model, may provide a useful approach to explain non-professional helping behavior. The objective of this study was to test the applicability of the stages of change construct by (i) assessing whether cognitive determinants distinguish between the stages, (ii) testing the predictive value of the stages for future helping behavior and (iii) examining the mediating role of the stages in the relation between previous and future helping behavior. Data of 126 adult non-professional bystanders were analyzed. Respondents were questioned by telephone or via an Internet questionnaire, at baseline and after a follow-up of about two months later. Attitude toward helping was significantly less positive in pre-contemplation than in the other stages, and self-efficacy expectations were significantly higher in preparation compared with the other stages. Moreover, baseline preparators were more likely to conduct future helping behavior than those in the two earlier stages. Finally, the stages of change mediated the relation between previous and future helping behavior. Initial support was found for the applicability of the stages of change construct for helping behavior by non-professional bystanders.

Effect of recruitment method and setting on the composition of samples consisting of adult smokers.

OBJECTIVE: This study aims to determine differences in samples of adult smokers recruited by passive or active recruitment in community pharmacy (PP and AP) or passive recruitment in general practice setting (PG), then comparing these samples to an unrecruited cohort of Dutch smokers. METHODS: The three recruited samples were compared on demographics, smoking behaviour, motivational determinants, stage of change and intention to use specific action plans when quitting using multinomial logistic regression analyses; this method was also used to assess whether recruitment affected the acquired samples concerning demographic variables compared with the cohort. PP, AP and PG response rates were compared with Tukey post hoc tests. RESULTS: Significant differences were found for both AP and PG smokers, compared with PP smokers. Most important results include a higher rate of pre-contemplators in the AP sample and a lower educational level in the PG sample. All recruited samples appeared to be significantly different from the cohort sample. CONCLUSION: Recruitment method and primary care setting does influence the sample recruited, this should be taken into consideration when recruiting a specific sub-sample. PRACTICE IMPLICATIONS: These results are valuable for researchers contemplating recruitment in a primary care setting.

Psychosocial factors related with smoking behaviour in Portuguese adolescents.

Few studies describe the factors associated with smoking behaviour in Portuguese adolescents. Hence, smoking prevention activities are not based on research findings. This study analyses the differences between smokers and nonsmokers and factors associated with smoking behaviour in a sample of Portuguese adolescents. A questionnaire was administrated to seventh grade students of 25 schools from five municipalities near Lisbon (n=3064). The majority of them were never smokers (71.3%), 21.9% smoked less than monthly, 2.1% monthly and 4.7% weekly or more frequently. Smokers were older, had lower school achievement, had more money available to spend, preferred less to be together with nonsmoking people and were more likely to be allowed to smoke at home, to use alcohol and to perform various risky behaviours. Nonsmokers were less convinced of the advantages and more convinced of the disadvantages of smoking, encountered more social norms against smoking, perceived less smoking in others, felt less pressure to smoke from peers, were more confident to refuse cigarettes and had a lower intention to smoke next year. Intention to smoke, self-efficacy expectations to refuse smoking, social influence and alcohol consumption were the most relevant variables associated with smoking behaviour. Consequently, Portuguese smoking prevention programmes should include activities aimed to help adolescents to deal with pressure to smoke from peers and to improve self-efficacy expectations to refuse cigarettes. Our findings also confirm the link between smoking and alcohol use suggesting that the prevention of these two behaviours should be complementary.

Intention to adopt a smoking cessation expert system within a self-selected sample of Dutch general practitioners.

To investigate intention to adopt a new smoking cessation expert system as well as outline perceived barriers by general practitioners (GPs) to adopt this expert system, a written questionnaire was sent to 771 registered GPs. Respondents, representing 34.8% of the registered GPs, were classified as adopters (34.2%), doubters (36.2%) or non-adopters (29.2%). Adopters and doubters were less negative about the time investment for the GP when adopting the expert system than non-adopters. Adopters expected a more positive reaction from their patients than non-adopters. Smoking cessation was mostly considered to be a task for the practice assistant. The authors discuss the relevance of barriers mentioned not to implement the expert system and give recommendations for further steps into implementing primary prevention activities in Dutch general practice.

Unplanned smoking initiation: new insights and implications for interventions.

Despite intensive efforts, most smoking prevention interventions have had disappointing results. In the present paper, the assumption underlying these efforts that smoking initiation is the result of a rational decision or plan, is questioned. The process of adolescent smoking initiation is described, based on a recently conducted series of studies. It is argued that smoking initiation among adolescents is unplanned behaviour. Therefore, interventions regarding smoking initiation should not only include a focus on smoking-specific cognitions. Models that incorporate both conscious and unconscious processes need to be used in mapping smoking prevention efforts. Further, programmes that help adolescents to quit smoking need more attention. Finally, it is argued that smoking prevention interventions should aim at influencing the image of nonsmoking by using mass media interventions and restrictive policies.