Background
Patient empowerment is a cornerstone of contemporary medicine and is central to national health care plans [
1]. Individuals are increasingly encouraged, with support from professionals, to manage their own health. For this approach to be effective, a detailed understanding of how patients experience regulating their behaviour when they initiate and attempt to sustain health behaviour change is needed.
Approximately 6% of the adult population in England have diabetes, 90% are cases of Type 2 Diabetes Mellitus (T2DM) and the prevalence of T2DM is rising [
2]. The burden of T2DM on individuals’ health (i.e., increased risk of cardiovascular disease, amputation, kidney disease, retinopathy and depression) and the economy are well documented and preventing, managing and treating diabetes are public health priorities [
2].
The point of diagnosis with T2DM is an opportunity for clinicians to help patients initiate changes in lifestyle behaviours such as physical activity and diet [
3]. Guidelines for the care of adults with T2DM build on a foundation of patient-centred care, and advocate the provision of theory-based patient education at, or soon after diagnosis to create personalised management plans, combining advice on diet, increasing physical activity and losing weight [
3]. It is also suggested that patients try to improve their diet and increase their physical activity for 3 months before starting medication [
4]. Related guidance (e.g., National Institute for Health and Care Excellence) on changing lifestyle behaviours such as physical activity suggests a range of techniques to
motivate and support individual-level change including helping patients understand the consequences of their health-related behaviour, goal setting, and devising coping strategies to prevent relapse [
5]. However, despite this potentially complementary dual focus on patient self-regulation and motivation, current guidelines do not consider the degree to which patients’ motivation for lifestyle change itself is or is not self-regulated.
Recently Fisher et al. [
6] have stated that the efficacy of diabetes-directed interventions “is often dependent upon on how well a clinician is able to support personal engagement and motivation of the person with diabetes to use these new tools and knowledge consistently, and as directed”. Self-determination theory (SDT) [
7] is a psychological framework of motivational self-regulation that has been extensively applied to physical activity [
8], diet [
9], medication adherence [
10] and diabetes control interventions [
11‐
13]. Rather than considering only the
quantity of people’s motivation (i.e., motivated vs. not motivated) as in previous work with patients with T2DM [
14], within SDT, the
quality of motivation is considered based on the extent to which it is self-regulated [
15].
Within SDT (Table
1), the most self-determined form of motivation is
intrinsic motivation, where behaviour is driven by interest, enjoyment or the satisfaction that it brings. Types of motivation that are not intrinsic but based on tangible consequences or outcomes can vary in their level of autonomy/self-regulation. The most autonomous form (
integrated motivation) is where motivation is derived from an alignment of the outcomes of a given behaviour (e.g., healthy eating) with a person’s broader sense of self, values or goals. Less self-determined, but still considered autonomous, is
identified motivation which is based on personally important or valued benefits of an activity (e.g., valued health or social benefits of being active).
Introjected motivation is a form of controlled motivation where self-imposed sanctions such as avoiding guilt or gaining contingent self-esteem drive behaviour whereas
external motivation represents motivation based on a desire to comply with external demands or requests, avoid punishments or to gain rewards. Finally,
amotivation represents an absence of motivation or intention to act. The dynamic process (although not necessarily linear) through which individuals’ progress from less to more self-regulation/autonomous motivation is called
internalisation [
15].
Table 1
Types of motivation along the Self-determination Theory continuum and diet/physical activity examples
| Non-regulation | External Regulation | Introjected Regulation | Identified Regulation | Integrated Regulation | Intrinsic Regulation |
Motivation type description | Lack of motivation or intention to act | Lifestyle behaviour change is to avoid punishment or gain a reward | Lifestyle change aims at avoiding guilt or enhancing self-worth | Lifestyle changes are personally important or valued | Lifestyle behaviours are in harmony with other personal values and goals | Lifestyle behaviours are enjoyable or inherently satisfying to do |
Diet / physical activity example | Not changing one’s lifestyle behaviours or passively going through the motions | Eating less confectionary to avoid being told off by a dietician | Exercising because one feels they should, and will feel guilty if one doesn’t | Maintaining one’s physical fitness is a personally important goal | Eating a healthily is consistent with one’s goals to be physically active | Trying out new healthy recipes is satisfying and fun |
Research amongst people with T2DM has shown that autonomous motivation is positively associated with lifestyle behaviours such as physical activity [
16], dietary self-care [
17,
18], medication adherence [
13], key mediators of behaviour change (e.g., action planning) [
18] and sustained improvement in physical health including diabetes control [
12]. There is also some evidence that controlled motivation (e.g., pressure to comply with advice or change ones behaviour to please others or to suppress feelings of guilt) is associated with improved dietary self-care amongst people with newly-diagnosed T2DM [
19]. Together, this evidence highlights the beneficial outcomes associated with autonomous motivation but also that controlled motivation may play a role in the lifestyle changes of people with newly diagnosed diabetes. This is not surprising given that upon diagnosis, patients commonly receive information (e.g., identifying previous lifestyle behaviours that may have contributed to diabetes, possible future health complications, the lifestyle change needed to manage their symptoms, and weight and blood glucose targets to meet); interactions that have the potential to trigger either autonomous (e.g., identifying personally important reasons for change) or controlled (e.g., feeling guilty or pressured) motivation for change.
The majority of previous research has studied motivation amongst people with T2DM using quantitative questionnaires and existing qualitative research has only identified motivational factors such as weight management and physical and mental well-being as motivating physical activity among people at risk of diabetes [
20]. Despite calls from researchers [
21], the
quality of the motivation of people who are in early phases of initiating behaviour change following a diagnosis of diabetes has not been studied from the patients’ perspective. It is important to address this gap because understanding people’s motivational experiences at critical times of behaviour change can inform the design of patient-centred lifestyle interventions or care.
The present study aimed to: (1) qualitatively explore how people newly diagnosed with T2DM articulate and experience motivation for lifestyle change as proposed in SDT, and (2) to examine qualitative evidence for patients’ motivational internalisation over time (i.e., transition from controlled to autonomous motivation).
Discussion
This study is the first qualitative examination of the types of motivation for lifestyle change articulated in SDT amongst people newly diagnosed with T2DM. As the participants were involved in a lifestyle intervention, it could be argued that almost all had some motivation to change, but despite this, the findings highlight the diversity in motivation quality both between and within participants. The prospective data facilitated an analysis of motivation transitions.
Diagnosis with T2DM provokes a range of emotional responses [
26], close scrutiny of patients’ lifestyle, threats to people’s social and personal identity and the need to construct a new identity representations [
27]. It is not surprising therefore that many participants’ motivation for change was controlled, or not self-regulated. External motivation for diet or physical activity change was experienced as participants complying with what they perceived to be restrictive dietary advice and through fear of non-compliance (i.e., “lapses”) being identified in appointments or assessments. On the SDT continuum (Table
1) external and introjected motivation are located adjacently and in the theory, motivation is viewed as dynamic rather than static [
15]. This was supported in our findings as participants often experienced these motivations concurrently, by complying with recommendations and labelling themselves as “good” or “naughty” and their behaviour as “right” or “wrong” based on the extent to which their behaviour change was successful. Consistent with previous research with exercisers pursuing extrinsic (relatively controlling) goals [
28], participants whose motivation was relatively controlled experienced frustrating slow progress towards rigidly defined end point goals (e.g., weight loss). These experiences of controlled motivation amongst people with newly diagnosed T2DM are a source of internal conflict and potential barriers to their development of self-regulation.
Previous work has shown that autonomous motivation is associated with physical activity and healthy eating [
8,
9]. Identified motivation (i.e., personally important valuing of a behaviour) mainly stemmed from the value participants placed on health, quality of life and family responsibilities which they understood to be compromised by uncontrolled diabetes. Improved health is an intrinsic goal [
29] which, relative to extrinsic goals, such as improved appearance, is associated with autonomous motivation and physical activity behaviour [
30,
31]. The results add experiential support to this finding as for some participants health-based reasons for change, prompted by their T2DM diagnosis, were more motivating than their previous extrinsic appearance-based weight loss goals. Diabetes diagnosis may offer an opportunity to help individuals identify meaningful intrinsic goals (e.g., health or family time) which will likely underpin autonomous motivation.
Despite the participants being relatively newly diagnosed with T2DM some reported integrated motivation (i.e., physical activity or healthy eating being part of their identity), which plays an important role in motivating diet [
9] and physical activity [
32]. Having internalised early controlled motivations (i.e., moved from controlled to autonomous motivation), participants’ new lifestyle had become a pattern or a way of life which was robust to challenges. Integrated motivation developed over time and internalisation was supported by personal factors such as a positive attitude, resilience to barriers (e.g., bad weather), persistence and practitioners who encouraged gradual change.
Intrinsic motivation (i.e., being motivated by enjoyment, interest and satisfaction) was articulated least frequently, although some participants enjoyed their exercise and diet changes and this was commonly supported by integrated motivation. It is to be expected that new physical activity and eating behaviours may not yet be intrinsically motivated in a sample such as ours, and it is possible that for some patients, or for some behaviours (e.g., cutting down on high sugar foods) which patients find enjoyable, identified motivation for change (i.e., identifying a health-based value) may be a more realistic and adequate motivational target. Indeed it is suggested that maintenance of lifestyle behaviours, such as exercise, is most likely when a person has a combination of intrinsic, identified and integrated motivation types [
33]. Collectively, the findings suggest that if T2DM patients can be supported to internalise their motivation to the point of identifying a personal benefit, or integrate changes as part of an enjoyable way of life, such changes may be more sustainable and resilient to common challenges to behaviour change (e.g., lack of time, periods of holiday, & changes in routine).
Recent quantitative research using SDT has sought to identify how different types of motivation for physical activity commonly cluster within individuals [
21,
32,
34]. Amongst adults with T2DM, Gourlan et al. [
21] identified a “self-determined” profile (high scores on autonomous motivation types), a “moderate” profile (all motivation types moderately endorsed), and a “high combined” profile (all motivation types strongly endorsed plus moderate amotivation). Our findings add further experiential evidence to support the existence of these multifaceted motivation profiles which commonly include both autonomous and controlled motivation. For example, amongst patients who reported largely identified and intrinsic motivation, low-level controlled motivation (often introjected) supported their maintenance of behaviour change at times. Together, the findings support calls for future research to take a theory-driven person- rather than variable-centred approach to understanding motivation [
35] and indicate that mixed-methods approaches may be particularly illuminating.
Largely regardless of their dominant motivation, participants articulated a need for structure in their care, commonly through provision of expert guidance and support. However, the nature of the structure sought differed depending on participants’ motivation. Specifically, participants mainly motivated by autonomous reasons sought support for their ongoing self-regulation (with particular interest in ongoing assessment of health outcomes), whereas participants mainly motivated by controlled reasons sought more continuous provision of motivation (i.e., being pushed or prompted) by a practitioner, family member or friend with references to paternalistic perspectives (e.g., “
like a little boy”). The provision of structure is a cornerstone of autonomy-supportive clinical/interpersonal interactions, which aim to facilitate patients’ autonomous motivation and competence [
36]. This study highlights the importance of considering the long term provision of support/structure for people newly diagnosed with T2DM for two reasons; first, the transition from controlled to autonomous motivation can take time, and ongoing continuity in expert support can create a space to facilitate patients’ internalisation, and second, it is clear that even participants who were relatively self-regulated did not want to be left on their own, rather they wanted professional support to “
keep on track”. Our findings therefore support the distinction drawn in SDT between the provision of autonomy-support (i.e., support for self-regulation) and independence (i.e., being left to fend for oneself).
The findings of this study suggest that to achieve the patient empowerment aspirations of current national health care plans [
1], clinicians would do well to consider the quality not just quantity of their patients’ motivation. Research suggests that physicians may not know whether their T2DM patients are motivated to change or not and recommend the regular measurement of patient motivation [
14]. While our findings support a greater focus on patient motivation, we would argue that considering the
quality of motivation is of primary importance. Our findings complement a recent framework for supporting engagement and motivation for behaviour change in people with diabetes which draws on multiple patient-centred approaches including SDT [
6]. This framework provides clinicians with a pragmatic, three-step approach to building a supportive clinician-patient relationship. Our findings support this work by documenting patient motivational experiences in line with the framework’s underpinning theory that clinicians will likely experience in conversations with patients about behaviour change. Previous work has identified how concepts from SDT could be integrated into medical training [
37] which would help clinicians become attuned to patients’ motivation quality and support patients’ motivational needs.
Strengths and limitations
The qualitative data provided a rich person-centred resource with which we were able to extend previous variable-centred quantitative literature. The sample size was relatively large and the initial interviews were extensive. The repeated interviews helped us hear personal experiences of the dynamic nature of behaviour change and motivation. Despite these strengths, the follow-up interviews were shorter (although the transcripts suggested that discussions were detailed) and although there can be strength in not basing interviews on theory, more theory-driven follow up interviews would have allowed a more in-depth analysis of motivation change. Finally, while we have reported our secondary analysis methods transparently and used researcher triangulation to agree our interpretations, due to the lapse between data collection and the analysis, it was not possible to use other strategies, such as member checking.