Health-Care Self-Determination Theory Questionnaire (HCSDTQ)

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 self- determined, 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 external reasons 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.

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.

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 weight- loss 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 labelled Perceived Autonomy Support: The Climate Questionnaires.