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The Relationship Between Competence and Health Behaviors: An Empirical Analysis

According to Self-Determination Theory (SDT; see Deci & Ryan, 2008), health-related

behavior change will be better maintained, if a patient’s need for competence is satisfied

(Ryan, Patrick, Deci, & Williams, 2008). When people feel competent in regulating their

health behavior, they have an ability to understand the rationale behind this and an ability to

enact it (Deci & Ryan, 2000). My aim was to review evidence for the role of competence in

predicting health behaviors.

Method

Empirical studies were searched via Google Scholar and Web of Science, using “self-

determination”, “competence”, and “health” as keywords. Results were limited to articles in

English and published in peer-reviewed journals. Abstracts were read, and potentially

relevant articles were retrieved. Studies were excluded which did not discuss competence

specifically. Reference lists of reviews and meta-analyses were reviewed, finding additional

articles that had not been identified in the previous steps. Of these, some were theoretical in

nature or not directly examining health behaviors, but were included due to their relevance.

Satisfying the Need for Competence in Health Contexts

Health-related behaviors, such as smoking cessation or taking medication, can be challenging

to maintain because they can be unenjoyable or uninteresting and thus not intrinsically

motivated. Therefore, health practitioners have a role in facilitating the internalization of

extrinsically motivated behaviors by providing a need-supportive environment (Ryan et al.,

2008).

The literature suggests a wide range of ways in which practitioners can support their

patients’ competence. These include structure and goal-setting (Podlog & Brown, 2016);
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modelling and skill-development (Halvari & Halvari, 2006); feedback and optimal challenges

(Fransen, Boen, Vansteenkiste, Mertens, & Vande Broek, 2018); and strategies and limits

(Curran, Hill & Niemiec, 2013). Because of this diversity, Ryan et al. (2008) and Ng et al.

(2012) call for additional research to clarify the exact active components in practitioner

support that facilitate effective change. However, this is difficult, because many studies rely

on measuring need satisfaction via self-report. Sheldon and Filak (2008) suggest that the

three needs should be experimentally manipulated to examine causal effects. Fransen et al.

(2018) examined competence support in a sport context by manipulating the extent to which

coaches provide motivational feedback. This could perhaps be replicated with health

practitioners instead of coaches.

Are Competence, Autonomy and Relatedness Equal? The Relationship Between the

Three Needs in Health Behavior Regulation

According to Deci and Ryan (2000), competence alone is not enough; the needs of

relatedness and autonomy must also be satisfied for positive behaviors to be maintained.

SDT postulates that gaining competence is facilitated by autonomy: people can only learn

and apply new strategies if they are volitionally engaged (Markland, Ryan, Tobin, &

Rollnick, 2005). It is difficult to develop competence without engagement; conversely, it is

difficult to engage in an activity without the necessary competence. Halvari, Halvari,

Bjørnebekk and Deci (2012) found evidence for this bidirectional link: autonomous

motivation positively predicted perceived dental competence, which was related to the health

outcomes. However, Teixeira et al. (2006) found that that competence affected change in

motivation and behavior first, whereas autonomy affected change in the longer-term.

Williams, Gagne, Ryan and Deci (2002) found that competence only contributed to smoking

cessation in the short-term, whereas autonomous motivation predicted cessation at all points
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in the time. Supporting this, Silva et al. (2011) found that once patients have internalised the

skills and means to maintain health behaviors, they no longer need the help of health

professionals in promoting their competence. In the long-term, they are competent enough to

rely on their own autonomous motivation.

Halvari and Halvari (2006) found that the effect of perceived dental competence was

stronger than the relation between the intervention and autonomous motivation for dental

health. This suggests that the need for competence could be more important than the need for

autonomy. Indeed, Halvari et al. (2012) suggest that future dental treatments should focus on

facilitating perceived competence. In addition, Neubauer, Schilling and Wahl (2015) found

that only competence, not autonomy, predicted intraindividual variability in wellbeing in

older adults. They suggest that competence needs vary throughout the lifespan.

There is evidence that the effect of competence in health behavior maintenance is

facilitated by relatedness: Williams et al. (2009) report that people with a mutually caring

relationship with health professionals are more likely to perceive the health behavior as

personally important, which then improves their competence. Bruzzese, Idalski-Carcone,

Lam, Ellis and Naar-King (2014) found that family routines and patients’ competence in

managing their asthma were correlated; they suggest that the shared experience of health care

helps develop greater competence in asthma management.

Limitations

Phillips and Guarnaccia (2017) reviewed SDT-based interventions for obesity and diabetes;

they found that competence was not always used rigorously as an SDT construct. I found this

to be the case in other studies as well, and found competence often defined as “similar to self-

efficacy” (e.g. Williams et al., 2006). Sweet, Fortier, Strachan and Blanchard (2012)

integrated competence and self-efficacy into a new variable “confidence”. However,

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Rodgers, Markland, Selzler, Murray and Wilson (2014) carried out a factor analysis showing

that self-efficacy and competence are different constructs. Therefore, using these terms

interchangeably could affect the generalizability of the studies.

Conclusion

The literature suggests that successful health behavior maintenance can be facilitated in a

need-supportive context. However, further research is needed to determine the specific

factors that support competence.

There is evidence that competence need satisfaction on its own does not lead to

behavioral changes. Rather, it is likely that all three needs must be satisfied. However, it is

not clear whether competence, autonomy and relatedness are equally important in

determining health behaviors.

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