title: Distal and proximal factors of health behaviors and their associations with health in children and adolescents.
abstract: OBJECTIVE
  The aim of the present paper was to analyze factors affecting distal and proximal health behavior within a biopsychosocial model for examining their interactions and associations with respect to health.
  
  
  METHODS
  Path analysis was based on the nationwide, cross-sectional German Health Interview and Examination Survey for Children and Adolescents (2003 to 2006). The data was collected from 4,529 participants with an average age of 9.45 years (SD = 4.01). Socio-demographic data, psychosocial factors and health behavior were assessed via questionnaire. Participants also underwent physical fitness tests and a medical examination.
  
  
  RESULTS
  Over the five levels of the model analyzed with socioeconomic status, immigration background, and rural-urban differences on the first level; physical activity of relatives and peers, intrinsic motivation, and quality of life on the second level; eating patterns, sedentary behavior, and physical activity on the third level; physical fitness and objective health on the fourth level; and health complaints and subjective health on the fifth level; direct, moderation, and mediation effects could be shown.
  
  
  CONCLUSIONS
  Several distal and proximal factors are needed to take account of the multivariate complexity of health: e.g., immigration background affected health behaviors only indirectly and the effect of physical activity on objective health was mediated by physical fitness.
authors.affiliation: Technische Universität München, Georg-Brauchle-Ring 60/62, München 80992, Germany. lena.lämmle@tum.de
authors.forename: Lena
authors.initials: L
authors.lastname: Lämmle
authors.forename: Alexander
authors.initials: A
authors.lastname: Woll
authors.forename: Gert B M
authors.initials: GB
authors.lastname: Mensink
authors.forename: Klaus
authors.initials: K
authors.lastname: Bös
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior; D002648:Child; D002652:Child Behavior; D004641:Emigration and Immigration; D005247:Feeding Behavior; D005260:Female; D005858:Germany; D015438:Health Behavior; D006304:Health Status; D006801:Humans; D008297:Male; D008962:Models, Theoretical; D009042:Motivation; D009043:Motor Activity; D010809:Physical Fitness; D011788:Quality of Life; D012424:Rural Population; D057185:Sedentary Behavior; D012923:Social Class; D014505:Urban Population