Treatment motivation

Motivation can be seen as a control process, altering the parameters of the cognitive

system so as to execute responses most efficiently. Individual differences reflect higher

order rates of change in these parameter settings (see also Sanders, 1983,1986).

Motivation can be referred as a desire for change" (Hong Cheng, Hwang, Lee, &

Chang, 2009). It is said that motivation is dependent upon the individual and the

situation" (Strombeck, & Wakefield, 2008). Motivation is generally viewed as a process

through which an individual's needs and desires are set in motion" (Rakes, & Dunn,

2010)."Motivation is the process whereby goal‐directed activity is instigated and

sustained" (Pintrich, & Schunk, 1996).Motivation level can increase or decrease as it is

said that motivation is a continuous process" (Khuntia, 2010).

Although the concept of treatment motivation is generally regarded as highly

relevant, it has since long been surrounded by conceptual confusion, resulting in

miscommunication, ambiguous measures, and contradictory conclusions of

research. (Klaus HDrieschneraSylvia M.MLammersbCees P.Fvan der Staakb). Motivation

is a key determinant of psychosocial treatment outcome and thus is increasingly being

recognized as an important target for behavioral interventions

Motivational states can be categorized in several different ways. Conventionally,

it has been useful to distinguish between the affective direction and the energetic

intensity of motivation (Humphreys & Revelle, 1984). More recent work on affective

states, however, has suggested that direction may subdivided into positive and negative
components (Watson & Tellegen, 1985) and that intensity should be considered in terms

of energetic and tense arousal (Thayer, 1989). Motivation may be explained as the degree

to which individuals commit effort to achieve goals that they perceive as being

meaningful and worthwhile" "Johnson, & Johnson, 2003).

Components of motivation

Motivation is dependent on four dynamic perceptual components: attention,

relevance, confidence and satisfaction" (Huang, Huang, & Tschopp, 2010).

Categories of motivation

Motivation is not one size fits all. Royale Scuderi (best name ever) wrote a piece

for Life hacker that I’ve shared with pretty much everyone I know. In it, she outlines

six “motivation types.”

 Rewards / incentives – “I want to get [specific reward], so I’m going to do

[action].”

 Fear of consequences – “I want to avoid [bad thing], so I’m going to do [action].”

 Achievement – “I want to achieve [triumph, milestone, award, public

recognition], so I’m going to do [action].”

 Growth – “I want to feel like I am continually improving, progressing, moving

forward, so I’m going to do [action].”

 Power – “I want to feel strong, powerful and influential, so I’m going to do

[action].”
  Social factors – “I want to feel a sense of belonging, like I am part of a tribe,

coven or community, so I’m going to do [action].”

Types of motivation

There are two primary types of motivation... Intrinsic and Extrinsic motivation.

Both are opposite to each other.

Extrinsic motivation

Extrinsic Motivation is geared toward external rewards and reinforcer's.It is

external or towards the environment. Some examples of external rewards are money,

praise, awards, etc. Some examples of external reinforcer's are policy and procedures,

disciplinary action, speeding tickets, boundary-setting, etc. Extrinsic Motivation is said to

be less effective because it comes from outside the person. External reinforcer's, for

instance, are usually in the form of control. People don't usually like to feel controlled.

It's an invitation to rebel, or dig in our heels, or become defiant. Most of us prefer to use

our own map of the world and may not have to conform to someone else's ideas about

how it should be. We need to explore our blocks to success and how we may be

sabotaging ourselves.

According to Herzberg's Two-Factor Theory many external rewards (e.g, salary,

job security, and benefits) don't really motivate but if they're not there the person can

become de-motivated. Herzberg calls these "hygiene factors".

Intrinsic motivation

Intrinsic Motivation is geared toward internal rewards and reinforcer's. We can

celebrate our success when we do well and we can beat ourselves up when we don't.

Some examples of internal rewards are enjoyment, achievement, a sense of competence.

Some examples of internal reinforcer's are should, musts, & ought, a guilty conscience,

and shame. Internal rewards are associated with high academic and occupational

achievement. It seems motivation is strongest when we do it for the fun of it or for the

feeling of accomplishment. Maybe it's a hobby, or a career path, or our purpose in life.

Theories on motivation

Social Cognitive Theory

Conceptually, early works considered motivation to be primarily a function of

cognition (Rosenstock, 1974; Bandura, 1977). Social Cognitive Theory (SCT) advocates

that the emotive component, self-efficacy, is the primary mediator of the change in

behavior and this is mediated through cognition (Bandura, 1977). Cognition is seen as

mediating an initial change from which evolves success and subsequent self-efficacy.

Further mastery promotes repeat performance in SCT. This classic work advocates that

motivation is concerned with initiation as well as maintenance of a behavior. Recent tests

support the theory (McAuley et al., 1994; Taylor et al., 1999). Furthermore, self-efficacy

is defined as confidence (DiClemente et al., 1985) and is a good predictor of intention

(Bandura, 1977). Tests of the Relapse Prevention Model, derived from SCT, have found

that relapsers have fewer strategies for program continuation (Simkin and Gross, 1994).

The Health Belief Model

The Health Belief Model (HBM) involves primarily the motivational and

attitudinal components of perceived susceptibility and severity of a disease, as well as the

costs and benefits of the directed action (Becker et al., 1972). Subsequent derivations of

the HBM have evolved. Protection Motivation Theory is a hybrid model inclusive of the

motivational and attitudinal components of the HBM as well as self-efficacy derived

from SCT. This theory, which includes perceived severity of threat, vulnerability to threat

and effectiveness of intervention at controlling threat (Rogers, 1975), was utilized in an

earlier study without consistent results (Wurtele and Maddux, 1987).

Herzberg's theory

Herzberg's theory of motivators and hygiene factors Herzberg (1959) constructed

a two-dimensional paradigm of factors affecting people's attitudes about work. He

concluded that such factors as company policy, supervision, interpersonal relations,

working conditions, and salary are hygiene factors rather than motivators. According to

the theory, the absence of hygiene factors can create job dissatisfaction, but their

presence does not motivate or create satisfaction. In contrast, he determined from the data

that the motivators were elements that enriched a person's job; he found five factors in
particular that were strong determiners of job satisfaction: achievement, recognition, the

work itself, responsibility, and advancement. These motivators (satisfiers) were

associated with long-term positive effects in job performance while the hygienic

factors(dissatisfies)consistently produced only short-term changes in job attitudes and

performance, which quickly fell back to its previous level. In summary, satisfiers

describe a person’s relationship with what she or he does, many related to the tasks bei

The two-factor theory (also known as Herzberg's motivation-hygiene theory and

dual-factor theory) states that there are certain factors in the workplace that cause job

satisfaction, while a separate set of factors cause dissatisfaction.

Vroom’s Expectancy Theory

Expectancy Theory proposes that people will choose how to behave depending on

the outcomes they expect as a result of their behavior. In other words, we decide what to

do based on what we expect the outcome to be. At work, it might be that we work longer

hours because we expect a pay rise. However, expectancy theory also suggests that the

process by which we decide our behaviors is also influenced by how likely we perceive

those rewards to be. In this instance, workers may be more likely to work harder if they

had been promised a pay rise (and thus perceived that outcome as very likely) than if they

had only assumed they might get one (and perceived the outcome as possible but not

likely) Expectancy Theory is based on three elements:

1. Expectancy – the belief that your effort will result in your desired goal. This is based

on your past experience, your self confidence and how difficult you think the goal is to

achieve.

2. Instrumentality – the belief that you will receive a reward if you meet performance

expectations.

3. Valence – the value you place on the reward.

Therefore, according to Expectancy Theory, people are most motivated if they believe

that they will receive a desired reward if they hit an achievable target. They are least

motivated if they don’t want the reward or they don’t believe that their efforts will result

in the reward.

Three-Dimensional Theory of Attribution

Attribution Theory explains how we attach meaning to our own, and other people,

behaviors. There are a number of theories about attribution.

Bernard Weiner’s Three-Dimensional theory of attribution assumes that people

try to determine why we do what we do. According to Weiner, the reasons we attribute to

our behavior can influence how we behave in the future. For example, a student who fails

an exam could attribute their failure to a number of factors and it’s this attribution that

will affect their motivation in the future. Weiner theorized that specific attributions (e.g.

bad luck, not studying hard enough) were less important than the characteristics of that

attribution. According to Weiner, there are three main characteristics of attributions that

can affect future motivation.

1. Stability – how stable is the attribution? For example, if the student believes they

failed the exam because they weren’t smart enough, this is a stable factor. An unstable

factor is less permanent, such as being ill. According to Weiner, stable attributions for

successful achievements, such as passing exams, can lead to positive expectations, and

thus higher motivation, for success in the future. However, in negative situations, such as

failing the exam, stable attributions can lead to lower expectations in the future.

2. Locus of control – was the event caused by an internal or an external factor?

For example, if the student believes it’s their own fault they failed the exam, because they

are innately not smart enough (an internal cause), they may be less motivated in the

future. If they believed an external factor was to blame, such as poor teaching, they may

not experience such a drop in motivation.

3. Controllability – how controllable was the situation? If an individual believes they

could have performed better, they may be less motivated to try again in the future than

someone who believes they failed because of factors outside of their control.

Treatment compliance

Despite the abundance of research in this area, most authors used the term

“compliance,” but did not define it. The researchers were urged to make this a priority in

the 1970s. The fact that how people with chronic condition act in accordance with

prescribed treatment was at first introduced as compliance. Compliance was defined by

Sackett and Haynes (1976) as “the extent to which a person's behavior in terms of taking
medications, following diets or executing lifestyle changes coincides with medical or

health advice.” However, not all researchers agreed with this definition used in their

research. McGann (1999) quoted the definition, but continues it with this expression,

“this definition fails to notice the ways in which a recommended advice influences

patients’ life and gives the healthcare professional the role of master.”

Compliance means that the patient has to follow the instructions of therapist

which indicates a relation between therapist - patient where the patient is the receiver of

instructions(Ingram T2009L& Delamater 2006). Anon (2005) argues that this also

includes the sense of 'punishment'. Failure to comply with the therapeutic regimen can be

viewed as 'disobedience' of the patient (J clin pharm 2001). According to Delamater

(2006), non-compliance means that patients disobey the advice of their health care

providers. The term of 'compliance' has been criticized because of the negative dimension

that suggests in relation between therapist-patient (J Adv Nurs. 2008).

The term ‘adherence’ is synonymous with ‘compliance’(Cramer JA, Roy

A, Burrell A,e t a l .2008) will hereafter be used as it has a more positive

connotation – an active decision by the patient to take a certain action rather than

a passive one to obey the provider. Adherence refers to how closely the patient’s

actual pill-taking behaviour comes to the recommendations made by the provider

with respect to timing, dosage and frequency of medication taking and is usually

expressed as a percentage. The general field of medication adherence research has

 found patient non-adherence (missed doses) in a multitude of medical conditions,

such as diabetes, hypertension, arthritis, pulmonary diseases and others.

(Mahwah, 2006).

Attributes of compliance

The attributes of compliance included patient obedience, ability to implement

medical advice, flexibility, responsibility, collaboration, participation, and persistence in

implementing the advices. Antecedents are organized into two interacting categories:

Internal factors refer to the patient, disease, and treatment characteristics and external

factors refer to the healthcare professionals, healthcare system, and socioeconomic

factors. Compliance may lead to desirable and undesirable consequences. of treatment

compliance.( Forough Rafii,1 Naima Seyed Fatemi,1 Ella Danielson,2 Christina Melin

Johansson,2 and Mahnaz Modanloo,2014).

Medication adherence

Medication adherence is defined by the World Health Organization as "the degree

to which the person’s behavior corresponds with the agreed recommendations from a

health care provider."(Dobbels F, Van Damme-Lombaert R, Vanhaecke J, De Geest

S.2005). Though the terms adherence and compliance are synonymously used adherence

differs from compliance. Compliance is the extent to which a patient’s behavior matches

the prescriber’s advice.( Chest 2006). Compliance implies patient obedience to the
physician’s authority, (Br J Rheumatol 1998) whereas adherence signifies that the patient

and physician collaborate to improve the patient’s health by integrating the physician’s

medical opinion and the patient’s lifestyle, values and preferences for care( J Clin

Gastroenterol 2001.).

There are several types of non adherence but most often the categorization is

indisputable, and there is a degree of overlap. The first is known as primary non

adherence, in which providers write prescription but the medication is never filled or

initiated. This type is commonly called non fulfillment adherence.( Gellad WF, Grenard

J, McGlynn EA 2009,2010).

A second type of non adherence is called non persistence in which patients decide

to stop taking a medication after starting it, without being advised by a health

professional to do so. Non persistence is rarely intentional and happens when patients and

providers miscommunication about therapeutic plans. Unintentional non adherence arises

from capacity and resource limitations that prevent patients from implementing their

decisions to follow treatment recommendations (e.g. problems of accessing prescriptions,

cost, competing demands etc) and sometimes involves individual constraints (e.g. poor

inhaler technique, problems remembering doses etc). Whilst intentional non adherence

arises from the beliefs, attitudes and expectations that influence patients’ motivation to

begin and persist with the treatment regimen (Horne R, Weinman J, Barber N, Elliott RA,

Morgan M. Concordance, 2005).

 A third type of non adherence is known as non conforming, this type includes a

variety of ways in which medication are not taken as prescribed, this behavior can range

from skipping doses, to taking medications at incorrect times or at incorrect doses, to

even taking more than prescribed.

The National Institutes of Health Consensus Statement on the Management of

Hepatitis C of 2002 states that ‘patient adherence is critical to the success’ of Hepatitis C

treatment, and advises physicians to help patients maximize adherence by adopting an

individualized approach in which side effects, depression and substance abuse are

managed. Many patients who need HCV treatment, and are eligible, often have numerous

risk factors that have been found to be markers of nonadherence in HIV patients,

including depression, neurocognitive impairment and current substance use.( Wagner GJ,

Ryan GW, 2005).

Theories on treatment compliance

The theory of planned behavior

A theory that attempts to link health beliefs directly to behavior is Ajzen’s theory of

planned behavior (Ajzen & Madden,1986; Fishbein & Ajzen, 1975).

Self determination theory

 Self-determination theory (SDT), a theory that also guides health behavior

modification, builds on the idea that people are actively motivated to pursue their goals

(Deci & Ryan, 1985; Ryan &Deci, 2000). The theory targets the two important

components. People are autonomous motivation and perceived competence. People are

autonomously motivated when they experience free will and choice when making

decisions. Competence refers to the belief that one is capable of making the health

behavior change.

Accordingly, if a women changes her diet because her physician tells her to, she

may not experience sense of autonomy and instead may experience her actions as under

another’s control. This may undermine her commitment to behavior change. However, if

her dietary change is autonomously chosen, she will be intrinsically motivated persist.

SDT has given rise to intervention that target these beliefs, namely autonomous

motivation and competence, and have shown some success in changing behavior

including smoking to alcohol use (e.g., Williams, McGregor, Sharp, Levesque, et al.,

2006).A meta analysis of 184 studies indicates support for self-determination theory and

the importance of autonomous motivation for changing health behaviors (Ng et al., 2012)
Social Support

Gottlieb (2000) formed social support more generally’’the procedure of

communication in relationships which enhance coping, esteem, capabilities and

belonging through concrete or perceived exchanges of physical or psychosocial

resources”.

Albrecht and Adelman (1987)

Social Support is the information that leads an individual to feel valued, loved and

belonging to mutually obliged network (Cobbo, 1976 as cited in Sarason, Sarason, &

Pierce, 1990). Shumaker and Brownell (1984) described social support as an exchange of

resources between at least 2 individuals perceived by the provider or the recipient to be

intended to enhance the well-being of the recipient. Social support reffered to an

interaction, person, or relationship (Veiel & Bauman, 1992).

Classification

Lepore (1998) classified social support manipulation into two types, active

support and passive support. Active support refers to the active supportive comments or

geastures of an observer. This type of support, in Lepore’s concept, is an unambiguous

emotional and esteem support that may minimize the doubts about the intention of

supporters. Assive support offers more ambiguous gestures to the recipients, with a lack

of interaction between support providers and recipients, which may reduce the support

potential of the providers and for this reason, may not provide consistent results.
There are a few different kinds of social support:

 Emotional — like when someone shows empathy, concern, or affection

 Instrumental — like when someone gives you a ride or cooks you a meal

 Informational — like when someone offers advice or guidance

 Companionship — like when someone spends time with you or shares your interests

Health benefits of social support

Social support not only help us cope with challenges, it also lead to improved

health , including physical health , psychological health and overall well-being . This

means that having access to adequate social support is essential to a healthy life.(Albrecht

and Goldsmith, 2003) Some of the many health outcome of social support include; I

psychological adjustment 2 Improved efficacy 3 Better coping with upsetting events 4

Resistance to disease 5 Recovery from diseases.

THEORIES on social suppot

Relational regulation theory

Relational regulation theory (RRT) (Lakey, B.; Orehek, E. 2011) is another

theory, which is designed to explain main effects (the direct effects hypothesis) between

perceived support and mental health. As mentioned previously, perceived support has

been found to have both buffering and direct effects on mental health.[99] RRT was

proposed in order to explain perceived support’s main effects on mental health which
cannot be explained by the stress and coping theory.( Lakey, B.; Orehek, E.

(2011). ) RRT hypothesizes that the link between perceived support and mental health

comes from people regulating their emotions through ordinary conversations and shared

activities rather than through conversations on how to cope with stress. This regulation is

relational in that the support providers, conversation topics and activities that help

regulate emotion are primarily a matter of personal taste. This is supported by previous

work showing that the largest part of perceived support is relational in nature (Lakey, B.

(2010). )

Life span theory

Life-span theory (Uchino, B. (2009).) is another theory to explain the links of

social support and health, which emphasizes the differences between perceived and

received support. According to this theory, social support develops throughout the life

span, but especially in childhood attachment with parents. Social support develops along

with adaptive personality traits such as low hostility, low neuroticism, high optimism, as

well as social and coping skills. Together, support and other aspects of personality

influence health largely by promoting health practices (e.g., exercise and weight

management) and by preventing health-related stressors (e.g., job loss, divorce).

Evidence for life-span theory includes that a portion of perceived support is trait-like

(Lakey, B. (2010) and that perceived support is linked to adaptive personality

characteristics and attachment experiences (Uchino, B. 2009).

Models
 The stress-buffering model says that social support can help people cope with a

stressful situation by protecting (or buffering) them from the bad health effects linked

to stress. According to this model, social support is most helpful during stressful

times.

 The direct effects model says that social support has a positive effect on health

overall. For example, the social support people get through ordinary interactions

enables them to keep their emotions in check, thereby improving their mental health.