Jessie Meis

Changing lifestyle is a challenge, especially for chronically ill who suffer from fatigue, dyspnea, anxiety and feelings of shame. Lifestyle interventions guide people in changing their habits, and many of them have been proven to be effective. After finishing the lifestyle intervention, it is a challenge to maintain the changes. Some will manage, others will relapse into old habits. Therefore, it is crucial to gain knowledge into the characteristics of people who succeed in behavior maintenance, opposed to those who relapse. With enhanced knowledge into the determinants of behavior maintenance, more effective maintenance programs can be developed. Based on this need, the studies in the present thesis were developed.

In health psychology, many theories exist that explain or predict behavior. The studies in the present thesis were based on Self-Determination Theory (SDT), because this theory is particularly applied to understand motivational determinants of behavior maintenance. Motivation, and environmental and personal factors that influence motivation, are central concepts in SDT. Motivation is regarded as a qualitative construct. SDT does not refer to the amount of motivation, it rather distinguishes six different types of motivation. One can experience amotivation: not being motivated to change the behavior. Controlled motivation is characterized by feelings of pressure and lack of choice, either emanating from factors situated outside the person (e.g. punishment, deadlines: external regulation), or from inside factors (e.g. guilt, shame, eager for approval: introjected regulation). Controlled types of motivation might help you getting started, but these types of motivation usually do not lead to sustained changes. As soon as the extrinsic motivating factor is no longer present, one will quit performing the behavior. Autonomous motivation is characterized by experiencing a sense of freedom in one’s choices and is driven by feelings of personal relevance (e.g. exercise is important to you because it’s good for your health: identified regulation), personal identity (e.g. I am a sporty type: integrated regulation) or enjoyment (intrinsic motivation). SDT has been applied in lots of different domains, and systematic reviews have demonstrated that autonomous motivation is associated with more favorable outcomes in the long term. Healthcare professionals have a major contributing role in stimulating autonomous motivation by enhancing feelings of autonomy, competence and relatedness.

Different study populations who all made intervention-induced lifestyle changes have been studied in the present thesis. Chapter 2 described which underlying motivations were associated with participating in a tv-program called ‘Netherlands on the Move!’. Chapter 3 and 4 focused on physical activity behavior change and maintenance among COPD patients and healthcare professionals during pulmonary rehabilitation (PR). In chapter 3, COPD patients’ experiences during an in-patient pulmonary rehabilitation program were studied, while in chapter 4 we interviewed patients in the maintenance phase of an out-patient pulmonary rehabilitation program. We assessed differences between patients who did and did not show an objectively assessed long-term response to the PR program, by looking at their motivational regulations and satisfaction of basic psychological needs. Chapter 5 and 6 reported on studies on the quantity versus quality of overweight/obese adults’ motivation regarding physical activity and healthy eating, and changes in their motivational profiles.

Among these three study populations, autonomous types of motivation appeared to be the best predictors of behavior maintenance. Chapter 2 showed that participants who enjoyed taking part in the exercises of ‘Netherlands on the Move!’ (intrinsic motivation), participated more frequently opposed to those who had lower scores in perceived enjoyment. A crucial determinant positively influencing intrinsic motivation is perceived competence. The more competent participants felt in performing the exercises, the more often they watched and participated.

The interviews in the studies described in chapters 3 and 4 revealed that COPD-patients at the start of the PR program were often extrinsically motivated because they were referred to the PR program by a healthcare professional. Feelings of autonomy, competence and relatedness however increased among patients who were able to maintain their improved exercise capacity after the PR program. These patients mentioned to have become more confident in exercising, some of them even began to like it. Seeing fellow patients struggle with similar problems, and tailored counselling by healthcare professionals, helped them to overcome barriers and set achievable goals. Many patients expressed a desire to self-regulate their lives. For most patients being active became more important to them because they experienced and valued the results of being more active. On the other hand, the results of chapter 4 were not completely in line with SDT assumptions. According to SDT, autonomous motivation is the best predictor of sustained behavior change, however responders in chapter 4 also showed controlled motivations, next to autonomous motivations. A hypothesis generated in the present thesis is that chronically ill patients are used to be intensively guided by healthcare professionals and therefore we assume that controlled regulations keep on playing an important facilitating role for them in staying physically active. Among chronically ill patients, it can be recommended to stimulate autonomous motivation, but healthcare professionals do not necessarily need to discourage controlled motivation. The mixed-methods study design of chapter 4 created valuable insights by exploring the motivational regulations and underlying goals people express, by analyzing their own words rather than predefining expressions in a quantitative questionnaire study. This guided the understanding of the results that seemed to deviate SDT assumptions.

SDT questionnaires measure the six types of motivation and each person acquires a score on all six types of motivation. Applying a ‘person-centered approach’, motivational profiles can be constructed, showing by which type(s) of motivation the person is driven. Someone with a ‘high quantity motivational profile’ is driven by both controlled and autonomous motivations, someone with a ‘high quality motivational profile’ is mainly motivated by internal, autonomous sources, not by extrinsic factors. Previous studies showed contradictory results when studying associations between the motivational profiles and physical activity behaviors. Some studies showed that people with a high quantity profile were most active, while other studies revealed the high quality profile was the most active group. In chapter 6 participants of the BeweegKuur lifestyle intervention completed questionnaires at the start of the intervention, and one year later. During baseline assessment, both the high quantity as well as the high quality motivational profiles seemed optimal, however in the long term, the high quality cluster showed the best results. Therefore we concluded that the behavioral change phase the person is in is important to take into account when drawing conclusions about which motivational profile is associated with better outcomes: controlled + autonomous motivation helps to get you started, but in the end purely autonomous motivation (the high quality motivational profile) gives the best results when aiming for maintenance of lifestyle changes.

A second conclusion regarding motivation quantity resulted from chapter 5. Participants of lifestyle interventions often express their motivation in a quantitative way: ‘I am very motivated’. In chapter 5 we measured quantity of motivation as ‘an individual's behavioral intention’ suggested by the Theory of Planned Behavior (TPB), and among the same study population we also measured quality of motivation - like SDT proposes - in six motivational regulations. Additionally, these motivational measures have been associated with physical activity behavior. Results showed that quantity and quality of motivation were conceptually different. A high quantity of motivation seemed to be associated with different motivational regulations, including both ‘good’ and ‘poor’ types of motivation. Variability was large, which implies that among people who are all ‘highly’ motivated (TPB), the quality of their motivation still varies substantially. It thus seems that not all quantitatively expressed motivation will lead to sustained outcomes. Healthcare professionals usually focus on the quantity of motivation at the intake of a lifestyle intervention, but they can be advised not to be misled by expressions of high quantity of motivation by the participant (e.g. ‘I am very motivated’). Instead, they should assess the quality of the participants’ motivation at the intake of a lifestyle intervention and from there on try to stimulate autonomous motivational regulations in order to achieve long-term behavior change. Therefore, it can be recommended to healthcare professionals to apply autonomy supportive coaching and conversation skills, such as asking open ended questions, in order to gain insight in the personal values and preferences of the patient. Avoid phrases like ‘you should …’ or ‘it would be better if you …’. Meanwhile, invite patients to come up with their own ideas and initiatives. In order to guide patients, healthcare professionals can provide options that they know might be effective, and available to the patient.

Finally, chapter 3 and 4 provided suggestions for optimization of maintenance programs after pulmonary rehabilitation. Many COPD-patients at the end of the PR program anticipated that the maintenance period in which they incorporate physical activity into their usual daily routines at home would be tough. Once PR is completed, it is recommended that all patients continue to exercise regularly, otherwise the benefits gained during PR will decline. At the end of the PR program, healthcare professionals can be advised to guide patients into maintenance by setting achievable goals, counter false perceptions, and anticipate barriers and relapses.

The effects of current maintenance programs after PR have been variable. To date, the holy grail for maintaining the benefits of PR has not been found. Therefore, it is likely that no “one size fits all” solution can be found. Therefore, recent studies propose to develop more individually adapted maintenance programs. In the present thesis we suggest a trained lifestyle coach to carry out such an individually tailored PR maintenance program. Combined lifestyle interventions like CooL, HealthyLIFE, BeweegKuur, and SLIMMER for overweight people might inspire the development of PR maintenance programs. The goal of these combined lifestyle interventions is to help people achieve a sustained healthier lifestyle.

The lifestyle coach encourages patients to set realistic, achievable goals, and explores preferences of the patient regarding type of activities and setting. Next to this coaching role, the lifestyle coach also has a brokering role. By collaborating with a health broker (e.g. a care-sport connector) the lifestyle coach can get a better picture of the ‘social map’ of services and opportunities in the public domain and professionals in the network. In this way, the lifestyle coach can offer the patient local exercise opportunities. Since perceived competence is an important determinant of behavior maintenance, and people might need to gain confidence in their new exercise environment, COPD-patients might start a brief exercise program like the one being applied in HealthyLIFE. After enhancing feelings of competence, people can continue exercising by themselves. Furthermore, it is important that the lifestyle coach together with the patient monitors progress and teaches the patient how to cope with barriers and relapses. When necessary, the lifestyle coach refers the patient to other healthcare professionals such as occupational therapists, nutritionists, or health psychologists. So, besides coaching skills, lifestyle coaches also have an important brokering role in connecting healthcare and the public domain. This will enhance the chances of sustained long term outcomes. If we focus more on prevention, and effects of rehabilitation programs and combined lifestyle interventions are sustained, this will lead to a reduction in healthcare costs. Stakeholders are recommended to develop new maintenance programs for COPD patients, or integrate the COPD population and their needs into already existing CLIs like CooL / HealthyLIFE, together with health insurance companies (healthcare domain) and municipalities (public sports domain).