Reflections on Health Policy from the 8^th International SDT Conference

BY ARLEN MOLLER, BEN RIGBY, & EMILY OLIVER | DEC 07, 2023
¹Illinois Institute of Technology; ²Newcastle University; ³Durham University

On May 31^st 2023, we hosted a participatory workshop titled “SDT & Health Policy,” at the 8^th International Self-Determination Theory (SDT) Conference in Orlando, Florida ⁽¹⁾. The workshop invited discussion among leading researchers and practitioners in this and related fields, and was structured around three provocations (click here to download the slide-deck):

• Provocation 1: Is SDT philosophically antithetical to health-related mandates?
• Provocation 2: Can a whole-systems approach to public health policy function without alienating individuals (e.g. policymakers or practitioners)?
• Provocation 3: Can researchers preserve their autonomy in health policy arenas?

Here, we present our reflections and key insights gleaned from the workshop discussions.

Overview: As a macro theory of human motivation, SDT posits implications at multiple levels of analysis, from elemental (e.g. neuroscience, within-person, within-context) to system (e.g. cross-cultural, economic, political) levels. SDT research on health policy, specifically, represents an important and actively growing area for scholarship and application ^(2-4). However, in terms of relative empirical attention, to-date, SDT research on more elemental-level aspects of health has far surpassed system-level research on health policy, as the following examples illustrate:

• In the new Oxford Handbook on SDT ⁽⁵⁾, health policy is not extensively covered until the 56^th and final chapter, which is an overarching analysis of economic and political influences on basic psychological needs ⁽⁶⁾. Moreover, there was no specific focus on health policy in the 5-chapter section dedicated to “Clinical and Health Applications.”
• A review of keywords in titles from the 8^th International SDT Conference program revealed 20 instances of the word “health,” but only 2 instances of the phrases “health policy” or “healthcare policy.”
• Leading SDT scholars have stressed the importance of exercising caution when translating behavioral science findings into policy recommendations, introducing a taxonomy of “evidence readiness levels” to be suitable for policy.⁽²⁰⁾

As such, with the help of workshop attendees, we sought to identify key themes for future SDT-guided research on this important topic.

Initial reflection: Clarifying definitions and terminology is critical

One challenge inherent to cross-disciplinary research involves navigating how the same or similar terms are defined and applied across different disciplines. Communication scholars have postulated that such challenges are fueled not only by benign confusion, but also by intentional efforts of political strategists to control, re-define, or even misrepresent the debate.⁽⁷⁾ Through our workshop it became very apparent that the communication challenge is especially acute around SDT and health policy. Drawing on SDT literature and Prof. Rich Ryan’s opening Conference keynote, we present the following definitions of key terms related to health policy in Table 1.

Table 1: Distinguishing between autonomy, structure, freedom and independence.

Key term	SDT-definition
Autonomy	Autonomy is being willingly engaged; one feels self-regulated and volitional, rather than controlled or pressured. Autonomy is prominent in activities that reflect one’s authentic values and interests; it can be assessed at the individual (individual autonomy) or group (collective autonomy) level.
Structure	Structure includes laws, rules, limits and mandates. Autonomy relates to structure as the perceived legitimacy of those laws, rules, limits, mandates. Structure can support satisfaction of the need for competence.
Freedom	Freedom is the absence of requirements or constraints. One can be autonomous in the presence of requirements or constraints.
Independence	Independence is a lack of dependence on other people. One can be autonomously dependent.

What follows is a summary of additional themes raised during the workshop (Table 2), which is accompanied by a series of key SDT-guided implications. These highlight the important contributions that can be made from incorporating SDT research as a lens to understand existing health policy issues and for formulating novel policy responses. The four overarching themes identified by the team of workshop facilitators were: 1) Protecting or policing bodies (from 1^st provocation); 2) Addressing inequalities; 3) Supporting health/policy sector actors (from 2^nd and 3^rd provocations); and 4) Communicating policy to support motivation (from 1^st and 3^rd provocations).

Table 2: Summarizing SDT & Health Policy Themes Raised by Conference Workshop Attendees

Health policy themes	Example areas of health policy focus	Possible policy categories	SDT-guided implications*
Overarching Theme 1: Protecting or policing bodies (from 1st provocation)
Health behavior mandates	Mandates related to health insurance, vaccines, face-masks, social distancing.	Guidelines, Legislation	To the extent individuals’ health behaviors influence others’ health outcomes (networked effects), health-related mandates can result in maximizing group-level autonomy need satisfaction, even while reducing individual-level autonomy need satisfaction for some group members.
Bodily autonomy	Sexual and reproductive rights (e.g. access to birth control, abortion, IVF), or access to gender affirming care (e.g. hormone therapy and surgery).	Guidelines, Regulation, Service provision	To the extent maximizing individuals’ bodily autonomy supports autonomy need satisfaction and does not adversely influence others’ health outcomes (via networked effects), SDT will typically offer support for maximizing bodily autonomy.
End of life care	Advanced care directives, or physician assisted suicide.	Guidelines, Regulation, Service provision	To the extent patients have the capacity to make decisions for themselves, SDT will typically support empowering patients to make informed decisions for themselves with regard to curtailing care (do not resuscitate) or physician assisted suicide (8).
Overarching theme 2: Addressing inequalities
Equity and health	Health related policies that vary by group or status (e.g. for immigrants, those incarcerated, genders, racial or ethnic minorities, physical or mental disabilities).	Any	Such policies may intentionally or inadvertently produce health disparities (e.g. involuntary residential treatments). Inclusion of affected patient groups in policy making process (e.g.participatory policymaking) is one approach to supporting the autonomy of marginalized groups (9).
Poverty and wealth inequality as drivers of health outcomes	Progressive tax policies and social welfare programs as health policies (e.g. universal basic income).	Fiscal measures	Social welfare programs may benefit low-income groups both materially and via support for basic psychological need satisfaction (10). To help fund them, SDT-guided research on whether some progressive taxation policies are experienced as more autonomy supportive than others would be valuable.

Overarching theme 3: Supporting health/policy sector actors (from 2nd and 3rd provocations)
Healthcare workers’ occupational health	Training liaison officers in SDT and motivation science to navigate relations between government and research institutions (e.g. UK Department of Health and Social Care & NIHR Policy Research Unit).	Communication/ marketing, Service provision	SDT-informed system-level policies may prevent large health systems from alienating frontline healthcare workers.
Payment systems and ownership models for healthcare workers	Using fee-for-service vs. performance- or value-based payment models; Healthcare workers as employees vs. owners.	Fiscal measures	Payment systems that are controlling or fail to provide informational feedback (e.g. fee-for-service) negatively impact healthcare workers’ motivation and occupational health. Ownership models that afford healthcare workers shared ownership could help support healthcare workers’ autonomous motivation and occupational health (11, 12).
Whole system approaches	Accounting for complexity in policymaking, and in trying to change health and care systems.	Any	The properties of complex systems (e.g. self-organization and interdependence) can have an alienating and needs thwarting effect on policy actors. Defining clear roles for policy actors (e.g. as policy entrepreneurs) can support relatedness and provides a structure within which competence may be fostered (13).
Overarching theme 4: Communicating policy to support motivation (from 1st and 3rd provocations)
Environment/ climate policy	Aligning values and pro-environmental motivation to bolster voter support for pro-environmental policies.	Environmental/ social planning	Impacts of climate change (e.g. catastrophic weather events, food and water shortages, reduced biodiversity) objectively reduce freedom and population health. However, SDT suggests voters’ attitudes toward climate change likely varies based on perceived causes. Autonomy may be thwarted more where this cause is perceived to be choices made by selfish people (or corporations run by people), as opposed to something impersonal, benevolent, or random (“an act of God”) (14).
Communicating health policies	Encouraging Covid-19 related social distancing using autonomy-supportive vs. controlling communication styles.	Communication/ marketing	SDT-informed implications include: consideration of specific word choices; offering internalizable rationale; perspective taking, acknowledge frustration, empathy; credibility of source/communicator; tone, prosody; avoiding shaming or mocking (15, 16, 17).

Continuing this discussion. We’d like to close with a call for continued discussion and debate among SDT researcher and practitioners on this important topic.

• Which of these themes related to SDT and health policy do you find most pressingly important?
• Are there important themes or aspects of themes above that we neglected?

A moderated comment section below will be actively monitored, and we welcome direct communication from interested colleagues. We hope these ongoing discussions will, for example, allows us to update and expand our table, as well as take one or more of these ideas forward for further in-depth examination.

Suggested Reading

1. Oliver, E., Moller, A. C., Rigby, B. (May 2023). Workshop: Self-Determination Theory and Health Policy. 8th International Self-Determination Theory Conference, May 31-June 3, 2023, Orlando, FL.
2. Moller, A. C., Ryan, R. M., & Deci, E. L. (2006). Self-determination theory and public policy: Improving the quality of consumer decisions without using coercion. Journal of Public Policy & Marketing, 25(1), 104-116.
3. Ng, J. Y., Ntoumanis, N., Thøgersen-Ntoumani, C., Deci, E. L., Ryan, R. M., Duda, J. L., & Williams, G. C. (2012). Self-determination theory applied to health contexts: A meta-analysis. Perspectives on Psychological Science, 7(4), 325-340.
4. Smith, G. P., & Williams, T. M. (2017). You can lead a horse to water … what Self-Determination Theory can contribute to our understanding of clinical policy implementation. Journal of Health Services Research & Policy, 22(1):37-44. doi:10.1177/1355819616652922
5. Ryan, R. M. (2023). The Oxford Handbook of Self-Determination Theory (First Edition). Oxford University Press. New York, New York.
6. Ryan, R. M., & DeHaan, C. R. (2023). The Social Conditions for Human Flourishing: Economic and Political Influences on Basic Psychological Needs (Chapter 56). In Ryan, R.M. (Ed.), The Oxford Handbook of Self-Determination Theory (1^st ed, pp.1149-1172). Oxford University Press.
7. Lakoff, G. (2006). Whose freedom?: The battle over America’s most important idea. Farrar, Straus and Giroux.
8. Duberstein, P. R., Conwell, Y., Cox, C., Podgorski, C. A., Glazer, R. S., & Caine, E. D. (1995). Attitudes Toward Self-Determined Death: A Survey of Primary Care Physicians. Journal of the American Geriatrics Society, 43(4), 395–400. https://doi.org/10.1111/j.1532-5415.1995.tb05814.x
9. Thomas K., Wilson J. L., Bedell P., Morse D. S. (2019). “They didn’t give up on me”: A women’s transitions clinic from the perspective of re-entering women. Addiction Science & Clinical Practice, 14, Article 12. https://doi.org/10.1186/s13722-019-0142-8
10. Oishi, S., Schimmack, U., & Diener, E. (2012). Progressive Taxation and the Subjective Well-Being of Nations. Psychological Science, 23(1), 86–92. https://doi.org/10.1177/0956797611420882
11. Legate, N., & Weinstein, N. (2022). Can We Communicate Autonomy Support and a Mandate? How Motivating Messages Relate to Motivation for Staying at Home across Time during the COVID-19 Pandemic. Health Communication, 37(14), 1842–1849. https://doi.org/10.1080/10410236.2021.1921907   
12. Moller, A. C., Olafsen, A. H., Jager, A. J., Kao, A. C., & Williams, G. C. (2022). Motivational mechanisms underlying physicians’ occupational health: a self-determination theory perspective. Medical Care Research and Review, 79(2), 255-266.
13. Rigby, B.P., Dodd-Reynolds, C.J. and Oliver, E.J., 2022. The understanding, application and influence of complexity in national physical activity policy-making. Health Research Policy and Systems, 20(1), p.59.
14. Legault, L. (2023). The “What” and the “Why” of Pro-Environmental Deeds: How Values and Self-Determined Motivation Interact to Predict Environmentally Protective Behavior (Chapter 55). In Ryan, R.M. (Ed.), The Oxford Handbook of Self-Determination Theory (1^st ed, pp. 1130-1148). Oxford University Press.
15. Morbée, S., Vansteenkiste, M., Waterschoot, J., Klein, O., Luminet, O., Schmitz, M., Van den Bergh, O., Van Oost, P., & Yzerbyt, V. (2022). The Role of Communication Style and External Motivators in Predicting Vaccination Experiences and Intentions: An Experimental Vignette Study. Health Communication, 1–10. https://doi.org/10.1080/10410236.2022.2125012
16. Legate, N., Ngyuen, T. V., Weinstein, N., Moller, A., Legault, L., Vally, Z., … & Ogbonnaya, C. E. (2022). A global experiment on motivating social distancing during the COVID-19 pandemic. Proceedings of the National Academy of Sciences, 119(22).
17. Offodile II, A. C., Cerullo, M., Bindal, M., Rauh-Hain, J. A., & Ho, V. (2021). Private Equity Investments In Health Care: An Overview Of Hospital And Health System Leveraged Buyouts, 2003–17. Health Affairs, 40(5), 719–726. https://doi.org/10.1377/hlthaff.2020.01535
18. Fabian, M., & Dold, M. (2022). Agentic preferences: A foundation for nudging when preferences are endogenous. Behavioural Public Policy, 1-21.https://doi:10.1017/bpp.2022.17
19. Ryan, R. M. & Brown, K. W. (2005). Legislating competence: high-stakes testing policies and their relations with psychological theories and research. In Andrew J. Elliot & Carol S. Dweck (eds). Handbook of competence and motivation. Guilford Press.
20. IJzerman, H., Lewis Jr, N. A., Przybylski, A. K., Weinstein, N., DeBruine, L., Ritchie, S. J., Vazire, S., Forscher, P.S., Morey, R.D., Ivory, J.D., & Anvari, F. (2020). Use caution when applying behavioural science to policy. Nature Human Behaviour, 4(11), 1092-1094.

Acknowledgements: We thank Jacques Forest and Dan Laitsch for their thoughtful feedback on earlier drafts of this Blog Post.

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