Supporting autonomy to motivate patients with diabetes for glucose control

OBJECTIVE: We applied the self-determination theory of human motivation to examine whether patient perceptions of autonomy supportiveness (i.e., patient centeredness) from their diabetes care providers related to improved glucose control over a 12-month period. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study of patients with diabetes from a diabetes treatment center at a university-affiliated community hospital. Participants were 128 patients between 18 and 80 years of age who took medication for diabetes, had no other major medical illnesses, and were responsible for monitoring their glucose and taking their medications. The main outcome measure was a change in HbA1c values over the 12 months of the study RESULTS: Patient perception of autonomy support from a health care provider related to a change in HbA1c values at 12 months (P < 0.05). Further analyses showed that perceived autonomy support from the staff related to significant increases in patient autonomous motivation at 12 months (P < 0.05); that increases in autonomous motivation related to significant increases in perceived competence (P < 0.05); and that increases in a patient's perceived competence related to significant reductions in their HbA1c values over 12 months (P < 0.001). CONCLUSIONS: The findings support the prediction of the self-determination theory that patients with diabetes whose health care providers are autonomy supportive will become more motivated to regulate their glucose levels, feel more able to regulate their glucose, and show improvements in their HbA1c values.     

Testing a Self-Determination Theory Process Model for Promoting Glycemic Control Through Diabetes Self-Management.

A longitudinal study tested the self-determination theory (SDT) process model of health behavior change for glycemic control within a randomized trial of patient activation versus passive education. Glycosylated hemoglobin for patients with Type 2 diabetes (n=159) was assessed at baseline, 6 months, and 12 months. Autonomous motivation and perceived competence were assessed at baseline and 6 months, and the autonomy supportiveness of clinical practitioners was assessed at 3 months. Perceptions of autonomy and competence were promoted by perceived autonomy support, and changes in perceptions of autonomy and competence, in turn, predicted change in glycemic control. Self-management behaviors mediated the relation between change in perceived competence and change in glycemic control. The self-determination process model fit the data well. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Testing a self-determination theory intervention for motivating tobacco cessation: Supporting autonomy and competence in a clinical trial.

A longitudinal randomized trial tested the self-determination theory (SDT) intervention and process model of health behavior change for tobacco cessation (N = 1006). Adult smokers were recruited for a study of smokers' health and were assigned to intensive treatment or community care. Participants were relatively poor and undereducated. Intervention patients perceived greater autonomy support and reported greater autonomous and competence motivations than did control patients. They also reported greater medication use and significantly greater abstinence. Structural equation modeling analyses confirmed the SDT process model in which perceived autonomy support led to increases in autonomous and competence motivations, which in turn led to greater cessation. The causal role of autonomy support in the internalization of autonomous motivation, perceived competence, and smoking cessation was supported. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Facilitating autonomous motivation for smoking cessation.

Physicians used either an autonomy-supportive or a controlling interpersonal style to counsel smokers based on National Cancer Institute guidelines. Physician autonomy support was rated from audiotapes, and patients' perceived competence and autonomous motivation for quitting were self-reported on questionnaires. Validated point prevalences for 6, 12, and 30 months and for continuous cessation were examined. The intervention did not have a direct effect on quit rates; however, structural equation modeling supported the self-determination process model of smoking cessation. The model indicated that the autonomy-supportive intervention was rated as more autonomy supportive, that rated autonomy support predicted autonomous motivation, and that autonomous motivation predicted cessation at all points in time. Perceived competence contributed independent variance to cessation only at 6 months. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Does pay for performance increase or decrease perceived self-determination and intrinsic motivation?

Laboratory and field studies examined the relationships of reward for high performance with perceived self-determination and intrinsic motivation. Study 1 found that pay for meeting a performance standard had positive effects on college students' perceived self-determination and competence, expressed task enjoyment, and free time spent performing the task. Furthermore, reward's incremental effect on expressed task enjoyment was mediated by perceived self-determination and competence. Study 2 established that perceived self-determination mediated positive relationships between employees' performance-reward expectancy and perceived organizational support, positive mood at work, and job performance. Study 3 demonstrated that performance-reward expectancy was positively related to employees' expressed interest in daily job activities, with this relationship being greater among employees having a high desire for control. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Teacher motivational strategies and student self-determination in physical education.

Physical education teachers can influence students' self-determination through the motivational strategies they use. In this study, the authors examined the relationship between teachers' perceptions of class average self-determination, the teachers' self-determination, and their reported use of 3 motivational strategies: autonomy support, structure, and involvement. They examined the relationship between the 3 motivational strategies, students' perceptions of psychological need satisfaction, and students' self-determination. They also investigated the relationship between teachers' and students' self-determination. Multilevel and standard regression analyses revealed that teachers' perceptions of class average self-determination predicted their reported use of the motivational strategies, and this relationship was mediated by their own self-determination. Student perceptions of the three strategies had a positive effect on their own self-determination, and this relationship was mediated by their reported satisfaction of autonomy and competence. Finally, teachers' self-determination did not predict students' self-determination. The importance of promoting an adaptive motivational climate for both teachers and students is discussed with reference to self-determination theory. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Internalization of biopsychosocial values by medical students: A test of self-determination theory.

Two studies tested self-determination theory with 2nd-year medical students in an interviewing course. Study 1 revealed that (a) individuals with a more autonomous orientation on the General Causality Orientations Scale had higher psychosocial beliefs at the beginning of the course and reported more autonomous reasons for participating in the course, and (b) students who perceived their instructors as more autonomy-supportive became more autonomous in their learning during the 6-month course. Study 2, a 30-month longitudinal study, revealed that students who perceived their instructors as more autonomy-supportive became more autonomous in their learning, which in turn accounted for a significant increase in both perceived competence and psychosocial beliefs over the 20-week period of the course, more autonomy support when interviewing a simulated patient 6 months later, and stronger psychosocial beliefs 2 years later. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can self-determination theory explain what underlies the productive, satisfying learning experiences of collectivistically oriented Korean students?

Recognizing recent criticisms concerning the cross-cultural generalizability of self-determination theory (SDT), the authors tested the SDT view that high school students in collectivistically oriented South Korea benefit from classroom experiences of autonomy support and psychological need satisfaction. In Study 1, experiences of autonomy, competence, and relatedness underlaid Korean students’ most satisfying learning experiences, and experiences of low autonomy and low competence underlaid their least satisfying learning experiences. In Study 2, psychological need satisfaction experiences were associated with productive (achievement and engagement) and satisfying (intrinsic motivation and proneness to negative affect) student outcomes. Study 3 replicated and extended Study 2’s structural equation modeling findings by showing that the hypothesized model explained students’ positive outcomes even after controlling for cultural and parental influences, including the collectivistic value orientation. Study 4 replicated the earlier cross-sectional findings with a semester-long prospective 3-wave design. The authors discuss how the findings support the motivation theory’s cross-cultural generalizability. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Is self-concealment associated with acute and chronic pain?

Objective: Self-concealment is the predisposition to hide negative personal information. The present research examined whether self-concealment was associated with acute and chronic pain. Methods: In Study 1, undergraduate students (N = 44) completed an online questionnaire packet and then completed a cold-pressor task in the laboratory. In Study 2, individuals with chronic pain (N = 85) completed an online survey. Results: Study 1: Trait self-concealment was negatively associated with pain tolerance. Study 2: Self-concealment of chronic pain (hiding aspects of one's chronic pain condition from others) was associated with higher levels of self-reported pain and lower psychological well-being, independent of disclosure of feelings regarding pain. Furthermore, this association was mediated by autonomy and competence needs. Conclusions: Self-concealment was found to be associated with higher levels of pain in both healthy and chronic pain samples. Moreover, the findings also suggest that intervention methods using the self-determination theory framework (i.e., autonomy and competence supportive) might be effective for individuals with chronic pain. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Promoting self-determined motivation for exercise in cardiac rehabilitation: The role of autonomy support.

Objective: Using self-determination theory (SDT), we examined relationships between cardiac rehabilitation (CR) participants’ perceived autonomy support, motivation for exercise, and exercise behavior. Research Method/Design: Male CR outpatients (N = 53; Mage = 62.83 ± 10.78 years). The design was correlational (cross-sectional and prospective), examining relationships between perceived autonomy support and motivation for exercise at Week 4 of CR participation as well as motivation and CR attendance and other indicators of exercise behavior (frequency, duration, total exercise time) at a 1-week follow-up, 10 weeks later. Results: Perceived autonomy support was correlated with self-determined motivation, r(53) = .32, p r(53) = .34, p R2 = .27; β = .52, p     

Patient-centered culturally sensitive health care: Model testing and refinement.

Objectives: This article presents the results of an empirical test of a literature-based Patient-Centered Culturally Sensitive Health Care Model. The model was developed to explain and improve health care for ethnically diverse patients seen in community-based primary care clinics. Design: Samples of predominantly low-income African American (n = 110) and non-Hispanic White American (n = 119) patients were recruited to complete questionnaires about their perceived health care provider cultural sensitivity and adherence to their provider's treatment regimen recommendations. Main Outcome Measures: Patients completed written measures of their perceived provider cultural sensitivity, trust in provider, interpersonal control, satisfaction with their health care provider, physical stress, and adherence to provider-recommended treatment regimen variables (i.e., engagement in a health promoting lifestyle, and dietary and medication adherence). Results: Two-group path analyses revealed significant links between patient-perceived provider cultural sensitivity and adherence to provider treatment regimen recommendations, with some differences in associations emerging by race/ethnicity. Conclusion: The findings provide empirical support for the potential usefulness of the Patient-Centered Culturally Sensitive Health Care Model for explaining the linkage between the provision of patient-centered, culturally sensitive health care, and the health behaviors and outcomes of patients who experience such care. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Couple-Focused Group Intervention for Women With Early Stage Breast Cancer.

This study examined the efficacy of a couple-focused group intervention on psychological adaptation of women with early stage breast cancer and evaluated whether perceived partner unsupportive behavior or patient functional impairment moderated intervention effects. Two hundred thirty-eight women were randomly assigned to receive either 6 sessions of a couple-focused group intervention or usual care. Intent-to-treat growth curve analyses indicated that participants assigned to the couples' group reported lower depressive symptoms. Women rating their partners as more unsupportive benefited more from the intervention than did women with less unsupportive partners, and women with more physical impairment benefited more from the intervention group than did women with less impairment. Subgroup analyses comparing women attending the couple-focused group intervention with women not attending groups and with usual care participants indicated that women attending sessions reported significantly less distress than did women receiving usual care and women who dropped out of the intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Autonomy and Competence in German and American University Students: A Comparative Study Based on Self-Determination Theory.

According to self-determination theory (R. M. Ryan & E. L. Deci, 2000), supports for autonomy and competence are essential for growth and well-being in any learning environment. Educational contexts differ in their relative support for these 2 needs. The authors examined the role of autonomy and competence in 2 German and 2 American university settings, as they were predicted to differ in terms of their relative emphasis on competence versus autonomy. Invariance analyses supported the construct comparability of the measures and demonstrated that German students felt significantly more autonomous and less competent than American students. Perceived pressures and positive informational feedback were modeled as antecedents of autonomy and competence, and well-being was examined as a consequence. The hypothesized model was generally supported across the 4 samples. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Glycemic control among Latinos with type 2 diabetes: The role of social-environmental support resources.

Objective: Although active diabetes self-management is required to achieve glycemic control, adherence is poor among ethnic minorities, especially Latinos. Research shows that individuals who report greater social-environmental support resources for disease management manage their diabetes more effectively than those with fewer support resources. Methods: Path analysis was conducted to investigate the value of a multiple-mediator model in explaining how support resources for disease management influence hemoglobin A1c (HbA1c) levels in a sample of 208 Latinos with Type 2 diabetes recruited from low-income serving community clinics in San Diego County. We hypothesized that the relationship between support resources for disease-management and HbA1c would be mediated by diabetes self-management and/or depression. Results: Participants who perceived greater support resources for disease-management reported better diabetes self-management (β = .40, p     

Patient preference for and reports of provider behavior: Impact of symmetry on patient outcomes.

Objective: Research has suggested that congruence between patient characteristics and contextual characteristics is a more robust predictor of outcomes than either patient or context characteristics alone. The goal of the present study was to examine the degree of congruence between patient preferences for the clinical encounter and reports of analogous dimensions of provider behavior and the effects of this congruence on patient outcomes. Design: Two hundred eighteen patients with diabetes (predominately Type II) completed measures of preference for and ratings of perceived provider behavior in three domains (1) information sharing, (2) behavioral involvement, and (3) socioemotional support. Main Outcome Measures: Patient satisfaction, self-reported adherence, and a clinical marker of diabetic control (hemoglobin A1c) were the outcomes of interest. Results: Congruence in information sharing and congruence in behavioral involvement were predictive of glycemic control and self-reported adherence, respectively. Congruence in behavioral involvement and congruence in socioemotional support were predictive of greater patient satisfaction. Conclusion: These findings provide further support for the importance of congruence between patient characteristics and contextual characteristics in predicting patient outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Benefit finding, affective reactions to diabetes stress, and diabetes management among early adolescents.

Objective: To examine whether benefit finding was associated with better adjustment among adolescents with diabetes by buffering negative affective reactions to diabetes stress and by promoting positive affective reactions. Design: Early adolescents aged 10–14 with Type 1 diabetes (n = 252) described recent diabetes stressors, affective reactions, and perceived coping effectiveness. They also completed measures of benefit finding, depressive symptoms, and adherence. Metabolic control (i.e., HbA1c) was obtained from medical records. Main Outcome Measures: The main outcome measures were perceived coping effectiveness, depressive symptoms, adherence, and HbA1c. Results: Benefit finding was associated with lower depressive symptoms, higher perceived coping effectiveness and better adherence, and with higher positive as well as negative affective reactions to diabetes stress. Benefit finding interacted with negative affective reactions to predict depressive symptoms and HbA1c. Negative affective reactions to stress were associated with poorer adjustment among those with low benefit finding, but were unrelated or more weakly related to poor adjustment among those with high benefit finding. Positive affective reactions did not mediate associations between benefit finding and any outcome. Conclusions: Consistent with a stress-buffering process, benefit finding may be a resource that buffers the disruptive aspects of negative affective reactions to stress for adolescents' diabetes management. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Perceptions of Parental Involvement and Support as Predictors of College Students' Persistence in a Science Curriculum.

As technological and scientific skills are increasingly needed, finding that science students encounter significant problems in their academic program causes serious concern. The authors examined how perceived parental involvement and support predict college students' persistence in science based on J. P. Connell and J. G. Wellborn's (1991) theoretical model: Perceived parental involvement and support should foster student persistence by promoting students' competence, autonomy, and relatedness. Results suggest that perceived parental autonomy supports predicted scientific persistence partly through students' autonomy. Perceived parental involvement, although unrelated to persistence, was a significant predictor of autonomy and relatedness. Results suggest that perceived parental involvement and support have specific roles in predicting student self-processes and achievement, highlighting the importance of sustaining parents' contribution for college students. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in social support as mediators of the impact of a psychosocial intervention for spouse caregivers of persons with Alzheimer's disease.

The spouse caregivers of 406 patients with Alzheimer's disease were randomly assigned to an enhanced counseling and support intervention or to a usual care control condition. Structured interviews were conducted to assess changes in social support and psychosocial outcomes for the 312 caregivers who provided care in the home for at least 1 year. The number of support persons, satisfaction with the support network, and support persons' assistance with caregiving all increased significantly as a function of the intervention. Structural equation models indicated increased satisfaction with the social support network mediated a significant proportion of the intervention's impact on caregiver depression. A portion of this mediated effect was further mediated by changes in caregiver stress appraisals. Implications for strengthening intervention programs for spouse caregivers of individuals with Alzheimer's disease are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A motivational model of rural students' intentions to persist in, versus drop out of, high school.

Using self-determination theory, the authors tested a motivational model to explain the conditions under which rural students formulate their intentions to persist in, versus drop out of, high school. The model argues that motivational variables underlie students' intentions to drop out and that students' motivation can be either supported in the classroom by autonomy-supportive teachers or frustrated by controlling teachers. LISREL analyses of questionnaire data from 483 rural high school students showed that the provision of autonomy support within classrooms predicted students' self-determined motivation and perceived competence. These motivational resources, in turn, predicted students' intentions to persist, versus drop out, and they did so even after controlling for the effect of achievement. (PsycINFO Database Record (c) 2010 APA, all rights reserved)