Health-Care‚ Self-Determination Theory Packet

This packet contains three questionnaires that have been developed to assess constructs contained within Self-Determination Theory (SDT) as the theory relates to health-care behavior (Deci & Ryan‚ 1985; Williams‚ Deci‚ & Ryan‚ 1999). The first is the Treatment Self-Regulation Questionnaire (TSRQ); the second is the Perceived Competence Scale (PCS); and the third is the Health Care Climate Questionnaire (HCCQ). The TSRQ also appears on the page with the other Self-Regulation Questionnaires; the PCS also appears on the page with the other Perceived Competence Questionnaires; and the HCCQ appears on the page with the other Perceived Autonomy Support Questionnaires. We have brought them together here within one packet to make it easier for people who are interested in health care research to have them all together. Further‚ on this page we have four versions of each of the three questionnaire‚ relating to four different health relevant behaviors: namely‚ smoking cessation‚ diet improvement‚ exercising regularly‚ and drinking responsibly.
Treatment Self-Regulation Questionnaire (TSRQ)
The TSRQ is a set of questionnaires concerning why people do or would do some healthy behavior‚ enter treatment for some disease‚ try to change an unhealthy behavior‚ follow a treatment regimen‚ or engage in some other health-relevant behavior. All of the questionnaires have the same purpose‚ to assess the degree to
which a person’s motivation for a particular behavior or set of behaviors is relatively autonomous or selfdetermined‚ but the wording varies somewhat from one version of the questionnaire to another in order to be appropriate for the particular behaviors being investigated. The TSRQ has a slightly different set of responses when applied to why one would engage in a healthy behavior from when it is applied to why one would enter treatment for‚ say‚ alcohol abuse or methadone‚ because‚ when entering some treatments additional externalreasons may be involved (e.g.‚ court mandates)‚ so people’s reasons may be somewhat different for different kinds of behaviors. Still‚ the various reasons that are used in each questionnaire fall along the relative autonomy continuum and thus are theoretically comparable.
There are three subscales to the scale: the autonomous regulatory style; the controlled regulatory style; and amotivation (which refers to being unmotivated). The amotivation subscale has been used in relatively few studies‚ and the amotivation subscale is not included in the versions of the TSRQ that is presented in the section
of the SDT web site with the other Self-Regulation Questionnaires. The autonomous style represents the most self-determined form of motivation and has consistently been associated with maintained behavior change and positive health-care outcomes. This scale is adapted slightly for each situation or behavior. That is‚ the format of the questionnaire asks patients why they do (or would) engage in particular behaviors such as stopping smoking or participating in a weight-loss program. Thus‚ whenever it is used‚ the questionnaire must have the appropriate behavior as part of the questions being considered. The questionnaires presented here can be adapted as needed for studying other behaviors.
The TSRQ utilizes a general approach to assessing autonomous self-regulation developed by Ryan and Connell (1989). The TSRQ was first used for “beha‎ving in a healthy way” in Williams‚ Grow‚ Freedman‚ Ryan‚ and Deci (1996)‚ and has also appeared in Williams‚ Freedman‚ and Deci (1998)‚ Williams‚ Rodin‚ Ryan‚ Grolnick‚ and Deci (1998)‚ Williams‚ Cox‚ Kouides‚ and Deci (1999)‚ and several other studies. The TSRQ has now been widely used in the study of behavior change in health care settings. A validation article of the TSRQ was published by Levesque‚ Williams‚ Elliot‚ Pickering‚ Bodenhamer‚ and Finley (2007). An earlier version of the TSRQ‚ called the Treatment Motivation Questionnaire‚ was first used for “entering treatment” in Ryan‚ Plant‚ and O’Malley (1995)‚ and has subsequently been used in Zeldman‚ Ryan‚ and Fiscella (1999). The scale has also been adapted by Pelletier‚ Tuson‚ and Haddad (1997) for motivation for psychotherapy.
Typically‚ the responses on the autonomous items are averaged to form the reflection of autonomous motivation for the target behavior and the responses on the controlled items are averaged to form the reflection of controlled motivation for the target behavior. In those studies where amotivation has also been assessed‚ the
amotivated responses are also averaged. These three subscale scores can be used separately. However‚ a Relative Autonomous Motivation Index can be formed by subtracting the average for the controlled reasons from the average for the autonomous reasons.
This packet contains four versions of the TSRQ‚ all of which are for four healthy behaviors smoking cessation‚ diet improvement‚ exercising regularly‚ and drinking responsibly.
Perceived Competence Scale (PCS)
(Concerning Feelings about Healthy Beha‎ving)
The Perceived Competence Scale (PCS) concerns feelings about beha‎ving in healthy ways. This is a short 4-item questionnaire that assesses the degree to which participants feel confident about being able to make (or maintain) a change toward a healthy behavior‚ participate in a health-care program‚ or carry out a treatment regimen. Consistently‚ people who feel more competent with regard to a particular behavior have been found to be more likely to make and maintain the change and to evidence positive health care outcomes. As with the TSRQ‚ the PCS can be adapted as needed for studying other behaviors. Items are worded slightly differently for different target behaviors. In this packet‚ there are four versions of the questionnaire concerning the feelings of being able to engage in four healthy behaviors‚ namely not smoking‚ eating a healthy diet‚ exercising regularly‚ and using alcohol responsibly (or not at all).
The alpha reliability for the perceived competence items has always been about 0.90. The scale has been used in several studies. Of note‚ in a study of diabetic patients (Williams‚ Freedman‚ & Deci‚ 1998)‚ perceived competence was predicted by the degree to which the patients experienced the health-care climate in their Diabetes Treatment Center to be autonomy supportive‚ and perceived competence at carrying out the treatment regiment in turn predicted patients glucose control (i.e.‚ HbA1c). It is theoretically important to differentiate perceived autonomy (assessed with the TSRQ) from perceived competence (assessed with the PCS)‚ and the constructs do have discriminative validity.
Health Care Climate Questionnaire (HCCQ)
(Concerning Support for Healthy Beha‎ving)
The original Health-Care Climate Questionnaire (HCCQ) is a 15-item measure that assesses patients’ perceptions of the degree to which they experience their health-care providers (or their physician‚ or their counselor‚ or their health-care program leader) to be autonomy supportive versus controlling in providing general treatment or with respect to a specific health-care issue. It was validated in a study of patients visiting their primary-care physicians and was first used in a published study of obese patients participating in a weightloss program (Williams‚ Grow et al.‚ 1996). It has also been used concerning teenage smoking cessation
(Williams‚ Cox‚ Kouides‚ & Deci‚ 1999)‚ adult smoking cessation (Williams‚ Gagne‚ Ryan‚ & Deci‚ 1999)‚ diet improvement and regular exercise (Williams‚ Freedman‚ & Deci‚ 1998)‚ participating in a methadone treatment program (Zeldman et al.‚ 1999)‚ and adhering to medication prescriptions (Williams‚ Rodin‚ et al.‚ 1998). Alpha reliability for the 15 items has consistently been above .090. In a study of diabetic patients‚ the HCCQ questions referred to “your health-care practitioners” in order to assess participants’ perceptions of their general health-care climate in the Diabetes Treatment Center. In other studies it has referred to physicians. Items are worded differently depending on the provider or context being assessed. Further‚ when it concerns treatment
with respect to a specific issue or behavior‚ the wording is adjusted slightly to refer to the target issue or behavior. The wording of the versions herein presented can be adjusted slightly‚ as needed‚ to refer to different providers or different behaviors. In each case the content of the items is the same except for these minor changes.
There is also a short form of the HCCQ that includes 6 of the 15 items. This has been used in various studies‚ especially when the data were analyzed with Structural Equation Modelling where relatively few indicators of a latent variable are needed. With the 6-item scale the alpha has been about 0.82. In this packet‚ the 6-item short form is presented for the same 4 health behaviors as used for the TSRQ and the PCS. The full 15-item version of the HCCQ can be found in the SDT web site within the questionnaire page labeled Perceived Autonomy Support: The Climate Questionnaires.
References and Articles in which the Health-Care Scales Have Been Used
Deci‚ E. L.‚ & Ryan‚ R.M. (1985). Intrinsic motivation and self-determination in human behavior. New York: Plenum Publishing Co.
Pelletier‚ L. G.‚ Tuson‚ K. M.‚ & Haddad‚ N. K. (1997). Client Motivation for Therapy Scale: A measure of intrinsic motivation‚ extrinsic motivation and amotivation for therapy. Journal of Personality Assessment‚ 68‚ 414-435.
Ryan‚ R. M.‚ & Connell‚ J. P. (1989). Perceived locus of causality and internalization: Examining reasons for acting in two domains. Journal of Personality and Social Psychology‚ 57‚ 749-761.
Ryan‚ R. M.‚ Plant‚ R. W.‚ & O’Malley‚ S. (1995). Initial motivations for alcohol treatment: Relations with patient ch‎aracteristics‚ treatment involvement and dr‎opout. Addictive Behaviors‚ 20‚ 279-297.
Williams‚ G. C.‚ Cox‚ E. M.‚ Kouides‚ R.‚ & Deci‚ E. L. (1999). Presenting the facts about smoking to adolescents: The effects of an autonomy supportive style. Archives of Pediatrics and Adolescent Medicine‚ 153‚ 959-964.
Williams‚ G. C.‚ Deci‚ E. L.‚ & Ryan‚ R. M. (1998). Building Health-Care Partnerships by Supporting Autonomy: Promoting Maintained Behavior Change and Positive Health Outcomes. In A. L. Suchman‚ P. Hinton-Walker‚ & R. Botelho (Eds.) Partnerships in healthcare: Transforming relational process (pp. 67-87). Rochester‚ NY: University of Rochester Press.
Williams‚ G. C.‚ Freedman‚ Z. R.‚ & Deci‚ E. L. (1998). Supporting autonomy to motivate glucose control in patients with diabetes. Diabetes Care‚ 21‚ 1644-1651.
Williams‚ G. C.‚ Gagné‚ M.‚ Ryan‚ R. M.‚ & Deci‚ E. L. (1999). Supporting autonomy to motivate smoking cessation: A test of self-determination theory. Unpublished manuscript‚ University of Rochester.
Williams‚ G. C.‚ Grow‚ V. M.‚ Freedman‚ Z.‚ Ryan‚ R. M.‚ & Deci‚ E. L. (1996). Motivational predictors of weight loss and weight-loss maintenance. Journal of Personality and Social Psychology‚ 70‚115-126.
Williams‚ G. C.‚ Rodin‚ G. C.‚ Ryan‚ R. M.‚ Grolnick‚ W. S.‚ & Deci‚ E. L. (1998). Autonomous regulation and long-term medication adherence in adult outpatients. Health Psychology‚ 17‚ 269-276.
Zeldman‚ A.‚ Ryan‚ R. M.‚ & Fiscella‚ K. (1999). Attitudes‚ beliefs and motives in addiction recovery. Unpublished manuscript‚ University of Rochester.
Levesque‚ C. S.‚ Williams‚ G. C.‚ Elliot D.‚ Pickering‚ M. A.‚ Bodenhamer‚ B.‚ & Finley‚ P. J (2007). Validating the theoretical structure of the treatment self-regulation questionnaire (TSRQ) across three different health behaviors. Health Education Research‚ 21‚ 691-702.
The Scales
Treatment Self-Regulation Questionnaire (TSRQ)
(Concerning Motivation for Healthy Beha‎ving)
Scoring Information. This scale has 15 items: 6 that assess autonomous motivation‚ 6 that assess controlled motivation‚ and 3 that assess amotivation. The autonomous motivation subscale consists of items # 1‚ 3‚ 6‚ 8‚ 11‚ & 13; the controlled motivation subscale consists of items # 2‚ 4‚ 7‚ 9‚ 12‚ & 14; and the amotivation subscale consists of items # 5‚ 10‚ & 15. In some previous studies the TSRQ used only 4 autonomous items‚ 4 controlled items‚ and no amotivation items. The 8 items used in that version of the scale were: 2‚ 3‚ 4‚ 6‚ 7‚ 8‚ 13‚ & 14. The additional items were added to balance across subtle differences within
both autonomous and controlled reasons and to allow the concept of amotivation to be examined when it is relevant to the scientific question being considered. The added items have all been validated in other selfregulation questionnaires based on SDT.
TSRQ (Smoking)
The following question relates to the reasons why you would either stop smoking or continue not smoking.
Different people have different reasons for doing that‚ and we want to know how true each of the following reasons is for you. All 15 response are to the same question.
Please indicate the extent to which each reason is true for you‚ using the following 7-point scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
The reason I would not smoke is:
1. Because I feel that I want to take responsibility for my own health.
2. Because I would feel guilty or ashamed of myself if I smoked.
3. Because I personally believe it is the best thing for my health.
4. Because others would be upset with me if I smoked.
5. I really don’t think about it.
6. Because I have carefully thought about it and believe it is very important for many aspects of my life.
7. Because I would feel bad about myself if I smoked.
8. Because it is an important choice I really want to make.
9. Because I feel pressure from others to not smoke.
10. Because it is easier to do what I am told than think about it.
11. Because it is consistent with my life goals.
12. Because I want others to approve of me.
13. Because it is very important for being as healthy as possible.
14. Because I want others to see I can do it.
15. I don’t really know why.
TSRQ (Diet)
The following question relates to the reasons why you would either start eating a healthier diet or continue to do so. Different people have different reasons for doing that‚ and we want to know how true each of the following reasons is for you. All 15 response are to the same question.
Please indicate the extent to which each reason is true for you‚ using the following 7-point scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
The reason I would eat a healthy diet is:
1. Because I feel that I want to take responsibility for my own health.
2. Because I would feel guilty or ashamed of myself if I did not eat a healthy diet.
3. Because I personally believe it is the best thing for my health.
4. Because others would be upset with me if I did not.
5. I really don’t think about it.
6. Because I have carefully thought about it and believe it is very important for many aspects of my life.
7. Because I would feel bad about myself if I did not eat a healthy diet.
8. Because it is an important choice I really want to make.
9. Because I feel pressure from others to do so.
10. Because it is easier to do what I am told than think about it.
11. Because it is consistent with my life goals.
12. Because I want others to approve of me.
13. Because it is very important for being as healthy as possible.
14. Because I want others to see I can do it.
15. I don’t really know why.
TSRQ (exercise)
The following question relates to the reasons why you would either start to exercise regularly or continue to do so. Different people have different reasons for doing that‚ and we want to know how true each of the following reasons is for you. All 15 response are to the one question.
Please indicate the extent to which each reason is true for you‚ using the following 7-point scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
The reason I would exercise regularly is:
1. Because I feel that I want to take responsibility for my own health.
2. Because I would feel guilty or ashamed of myself if I did not exercise regularly.
3. Because I personally believe it is the best thing for my health.
4. Because others would be upset with me if I did not.
5. I really don’t think about it.
6. Because I have carefully thought about it and believe it is very important for many aspects of my life.
7. Because I would feel bad about myself if I did not exercise regularly.
8. Because it is an important choice I really want to make.
9. Because I feel pressure from others to do so.
10. Because it is easier to do what I am told than think about it.
11. Because it is consistent with my life goals.
12. Because I want others to approve of me.
13. Because it is very important for being as healthy as possible.
14. Because I want others to see I can do it.
15. I don’t really know why.
TSRQ (alcohol)
The following question relates to the reasons why you would control your use of alcohol. Different people have different reasons for doing that‚ and we want to know how true each of the following reasons is for you. All 15 response are to the one question.
Please indicate the extent to which each reason is true for you‚ using the following 7-point scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
The reason I would use alcohol responsibly is:
1. Because I feel that I want to take responsibility for my own health.
2. Because I would feel guilty or ashamed of myself if I did not use alcohol responsibly.
3. Because I personally believe it is the best thing for my health.
4. Because others would be upset with me if I did not.
5. I really don’t think about it.
6. Because I have carefully thought about it and believe it is very important for many aspects of my life.
7. Because I would feel bad about myself if I did use alcohol responsibly.
8. Because it is an important choice I really want to make.
9. Because I feel pressure from others to do so.
10. Because it is easier to do what I am told than think about it.
11. Because it is consistent with my life goals.
12. Because I want others to approve of me.
13. Because it is very important for being as healthy as possible.
14. Because I want others to see I can do it.
15. I don’t really know why.
* * * * * * * * * * * * * * * * *
Perceived Competence Scales (PCS)
Scoring Information. This scale has 4 items‚ and an individual’s score is simply the average of his or her responses on the 4 items. When the PCS is used along with the TSRQ‚ the PCS items have sometimes been interspersed with the TSRQ items.
Perceived Competence (Not Smoking)
Please indicate the extent to which each statement is true for you‚ assuming that you were intending either to permanently quit smoking now or to remain permanently abstinent from smoking. Use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel confident in my ability to not smoke.
2. I now feel capable of not smoking.
3. I am able to not smoke anymore.
4. I am able to meet the challenge of not smoking.
Perceived Competence (Maintaining a Healthy Diet)
Please indicate the extent to which each statement is true for you‚ assuming that you were intending either to permanently improve your diet now or to maintain a healthy diet. Use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel confident in my ability to maintain a healthy diet.
2. I now feel capable of maintaining a healthy diet.
3. I am able to maintain a healthy diet permanently.
4. I am able to meet the challenge of maintaining a healthy diet.
Perceived Competence (Exercising Regularly)
Please indicate the extent to which each statement is true for you‚ assuming that you were intending either to begin now a permanent regimen of exercising regularly or to permanently maintain your regular exercise regimen. Use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel confident in my ability to exercise regularly.
2. I now feel capable of exercising regularly.
3. I am able to exercise regularly over the long term.
4. I am able to meet the challenge of exercising regularly.
Perceived Competence (Using Alcohol Responsibly)
Please indicate the extent to which each statement is true for you‚ assuming that you were intending either to begin now permanently abstaining from alcohol use‚ to begin permanently using alcohol responsibly‚ or to permanently maintain your current abstinence or responsible use of alcohol. Use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel confident in my ability to use alcohol responsibly.
2. I now feel capable of using alcohol responsibly.
3. I am able to use alcohol responsibly over the long term.
4. I am able to meet the challenge of using alcohol responsibly.
* * * * * * * * * * * *
Health Care Climate Questionnaire (HCCQ)
Scoring Information. The version of the HCCQ presented here is the 6-item short form‚ concerning the 4 health behaviors. The items have been explicitly written for the target behaviors‚ whereas the general HCCQ typically does not specify particular behaviors. An individual’s score on this scale is simply the average of his or her responses on the 6 items. The long 15-item form of the HCCQ can be found in the SDT web site within the questionnaire page labelled Perceived Autonomy Support: The Climate Questionnaires.
HCCQ (Not Smoking)
This questionnaire contains items that are related to your visits with a health-care practitioner (or group of practitioners) in which your smoking was discussed in any way. Health-care practitioners (doctors‚ nurses‚ counselors‚ etc.) have different styles in dealing with patients‚ and we would like to know very specifically about your experience of your provider(s) in any encounters when your smoking was discussed. Your responses will be kept confidential‚ so none of your practitioners will know about your responses. Please be honest and candid. In some cases‚ you may have met with only your physician; in other cases you may have discussed your smoking with several people. If you have met only with your physician‚ please respond with respect to him or her; if you have met with several practitioners concerning this issue‚ please answer in terms of your experience of all these practitioners together.
In answering the questions‚ please use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel that my health-care practitioners have provided me with choices and options about smoking (including not quitting).
2. I feel my health-care providers understand how I see things with respect to my smoking.
3. My health-care providers convey confidence in my ability to make changes regarding my smoking
4. My health care practitioners listen to how I would like to do things regarding my smoking.
5. My health-care practitioners encourage me to ask questions about my smoking.
6. My health-care practitioners try to understand how I see my smoking before suggesting any changes.
HCCQ (Healthy Diet)
This questionnaire contains items that are related to your visits with a health-care practitioner (or group of practitioners) in which your diet was discussed in any way. Health-care practitioners (doctors‚ nurses‚ counselors‚ etc.) have different styles in dealing with patients‚ and we would like to know very specifically about your experience of your provider(s) in any encounters when your diet was discussed. Your responses will be kept confidential‚ so none of your practitioners will know about your responses. Please be honest and candid. In some cases‚ you may have met with only your physician; in other cases you may have discussed your diet with several people. If you have met only with your physician‚ please respond with respect to him or her; if you have met with several practitioners concerning this issue‚ please answer in terms of your experience of all these practitioners together.
In answering the questions‚ please use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel that my health-care practitioners have provided me with choices and options about changing my diet (including not changing).
2. I feel my health-care providers understand how I see things with respect to my diet.
3. My health-care providers convey confidence in my ability to make changes regarding my diet.
4. My health care practitioners listen to how I would like to do things regarding my diet.
5. My health-care practitioners encourage me to ask questions about my diet.
6. My health-care practitioners try to understand how I see my diet before suggesting any changes.
HCCQ (Exercising Regularly)
This questionnaire contains items that are related to your visits with a health-care practitioner (or group of practitioners) in which your exercising was discussed in any way. Health-care practitioners (doctors‚ nurses‚ counselors‚ etc.) have different styles in dealing with patients‚ and we would like to know very specifically about your experience of your provider(s) in any encounters when your exercising was discussed. Your responses will be kept confidential‚ so none of your practitioners will know about your responses. Please be honest and candid. In some cases‚ you may have met with only your physician; in other cases you may have discussed your diet with several people. If you have met only with your physician‚ please respond with respect to him or her; if you have met with several practitioners concerning this issue‚ please answer in terms of your experience of all these practitioners together.
In answering the questions‚ please use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel that my health-care practitioners have provided me with choices and options about exercising regularly (including not exercising regularly).
2. I feel my health-care providers understand how I see things with respect to my exercising regularly.
3. My health-care providers convey confidence in my ability to make changes regarding my exercising regularly
4. My health care practitioners listen to how I would like to do things regarding my exercise.
5. My health-care practitioners encourage me to ask questions about my exercising.
6. My health-care practitioners try to understand how I see my exercising before suggesting any changes.
HCCQ (Using Alcohol Responsibly)
This questionnaire contains items that are related to your visits with a health-care practitioner (or group of practitioners) in which your use of alcohol was discussed in any way. Health-care practitioners (doctors‚ nurses‚ counselors‚ etc.) have different styles in dealing with patients‚ and we would like to know very specifically about your experience of your provider(s) in any encounters when your alcohol use was discussed.
Your responses will be kept confidential‚ so none of your practitioners will know about your responses. Please be honest and candid. In some cases‚ you may have met with only your physician; in other cases you may have discussed your alcohol use with several people. If you have met only with your physician‚ please respond with respect to him or her; if you have met with several practitioners concerning this issue‚ please answer in terms of your experience of all these practitioners together.
In answering the questions‚ please use the following scale:
1
2
3
4
5
6
7
not at all
true
somewhat
true
very
true
1. I feel that my health-care practitioners have provided me with choices and options about using alcohol responsibly (including not changing my drinking).
2. I feel my health-care providers understand how I see things with respect to my using alcohol responsibly.
3. My health-care providers convey confidence in my ability to make changes regarding my use of alcohol
4. My health care practitioners listen to how I would like to do things regarding my responsible use of alcohol.
5. My health-care practitioners encourage me to ask questions about my alcohol use.
6. My health-care practitioners try to understand how I see my use of alcohol before suggesting any changes.