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Applying Theory to Make a Difference in Adoption and Adherence

Mears, Jennifer M.A.; Kilpatrick, Marcus Ph.D.

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ACSM's Health & Fitness Journal: January 2008 - Volume 12 - Issue 1 - p 20-26
doi: 10.1249/01.FIT.0000298460.30006.00
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Despite the widely known health benefits associated with physical activity, participation in regular physical activity is well below the goal recommendations set forth by Healthy People 2010 objectives (1). More than half of Americans do not meet the current recommendations, and approximately one fourth are not active at all (2). Current recommendations for physical activity from the Office of the Surgeon General include the accumulation of at least 30 minutes of moderate physical activity on most days of the week (3). This recommendation provides for great flexibility in how this moderate amount of physical activity can be accumulated and suggests that 15 minutes of running, 30 minutes of brisk walking, and 45 minutes of recreational volleyball provide an appropriate stimulus for health promotion and reduction of disease risk. Collectively, current recommendations embrace the notion that there are numerous paths to greater health and that flexible physical activity prescriptions provide choices that may foster enhanced motivation for a physically active lifestyle.



Motivation can be defined as the degree of determination, drive, or desire with which an individual approaches or avoids a behavior (4). One motivational theory that is relatively new to the field of exercise science and health promotion is self-determination theory (SDT) (5). The basic premise of this theory is that not all motivations are created equal. The theory suggests that individuals develop their motivational approach for a given activity based on how well participation in that activity meets their basic psychological needs for autonomy, competence, and relatedness.

Meeting these basic needs results in increased confidence and a more healthy motivational orientation, which facilitates the development of enjoyment, effort, and adherence. Likewise, SDT suggests that people are less likely to adhere to an exercise program if they perceive that their actions are being controlled by others, if they feel unskilled, or if they have minimal or negative social connections associated with their exercise. Self-determination theory also accounts for how the presence or absence of these psychological needs ultimately impacts behavior through a continuum of motivation that ranges from no motivation to intrinsic motivation. A description of the levels of motivation based on SDT is depicted in the Figure and includes amotivation, other-determined extrinsic motivation, self-determined extrinsic motivation, and intrinsic motivation. This aspect of the theory is an important elaboration on traditional views of motivation and behavioral outcomes. Specifically, motivation was originally conceptualized as simply being present or absent, and later, existing motivation was described as being intrinsic or extrinsic. Research and practice now suggest that motivation is more complex and requires significant elaboration that is provided by SDT.

Self-Determination Theory and Exercise Motives.

Amotivation is the least desirable form of motivation along the continuum and is described as the absence of drive or intention to engage in a behavior. An individual with this perspective does not expect that physical activity will result in increases in autonomy, competence, or relatedness. Motivation for these individuals is compromised by bad experiences and/or lack of education regarding the benefits of exercise. Predictably, SDT suggests that those who are amotivated are less likely to participate in regular physical activity.

Other-determined extrinsic motivation exists when people are motivated through outside sources such as rewards, pressure, obligation, fear, or guilt. Each of these sources of motivation has the potential to be potent but is not very desirable because they lack the autonomy and free choice that characterize behaviors that are more likely to be adhered to. Clearly, fear and guilt are not optimal characteristics of successful behavior change. Three examples of other-determined extrinsic motivation include a person who exercises as a result of pressure from their spouse, someone who participates in incentive programs at their worksite fitness center, and someone who fears disease. Although all of these individuals are participating in activity, according to the SDT, long-term adherence is unlikely.

Self-determined extrinsic motivation also exists because of external factors but is characterized more positively because the behavior is chosen autonomously and without the sense of pressure or coercion. This type of motivation exists when individuals participate to obtain a valued outcome such as gains in fitness, improvements in health, relaxation, or social benefits. These valued outcomes are all considered to be desirable and are linked to improved adherence. The differences between self-determined and other-determined motivation can be subtle, but the implications are significant both cognitively and from a behavioral perspective. Motives based on health and social contexts provide useful examples. Motives based on health improvement and fear of disease may seem similar but represent vastly different levels of autonomy. That is, exercising to improve health is associated with a more desirable motivational approach than is exercising because of fear and pressure. Self-determination theory suggests that the primary difference is related to autonomy, whereby autonomy is present in motivations based on health improvement and absent when the motive is pressure and/or fear. Similar distinctions can be made for individuals who exercise because of the positive interactions with others in comparison to those who exercise to be recognized and esteemed by others. The former reflects self-determined extrinsic motivation, and the latter represents other-determined extrinsic motivation. These types of distinctions have important implications for practitioners who want to facilitate a motivational approach that is likely to result in long-term adherence to a physically active lifestyle.


Intrinsic motivation exists when the primary reason for engaging in an activity is enjoyment and satisfaction. Although this type of motivation may seem conceptually similar to self-determined extrinsic motivation, intrinsic motivation only exists when the experience of pleasure and satisfaction is separate from the outcomes that the activity provides. That is, being excited about exercise because it allows you to spend time with friends is different from enjoying exercise for its own sake. This distinction is of some functional importance because pure enjoyment of something is a strong predictor of future behavior. However, the practical implications are less pronounced because SDT generally suggests that the key element in behavioral adherence is the presence of autonomy, which is present in both of these healthy types of motivation.

An important aspect of this theory relates to how individuals can move through the continuum of motivation with appropriate education, encouragement, and intervention. It may be that intrinsic motivation for exercise may not be possible for everyone. However, SDT does suggest, and both reason and experience agree, that progression from amotivation to autonomously choosing to be active is realistic and possible (5). The possibility that unmotivated and poorly motivated individuals can make this progression demonstrates why it is important for health fitness professionals to understand a participant's motivation to exercise. Provision of appropriate education and communication represents potential mechanisms for this change that allows clients and participants to move along the continuum of motivation. Therefore, determining current motivation provides valuable information that can facilitate exercise adherence, achievement of goals, and increased self-determination.

Exercise motivation questionnaires developed for use in research are available for use by practitioners who desire to learn more about the motivational orientation of their clients. Several questionnaires based around SDT have been developed by exercise psychologist David Markland and his colleagues (6). Electronic copies along with descriptions and scoring instructions are made available at his academic Web site (6). Two of these questionnaires are the Exercise Motivation Inventory (EMI) and the Behavioral Regulation in Exercise Questionnaire (BREQ) (7,8). The BREQ measures the different forms of motivations described by SDT and depicted in the Figure (i.e., amotivation and intrinsic motivation). In contrast, the EMI measures specific motive for exercise participation (i.e., enjoyment, guilt, and fitness). One recommendation for practitioners is to distribute one of the questionnaires as part of a new member packet. Health and fitness professionals can review the responses and provide tailored physical activity recommendations for the client. Specifically, a new client or participant who suggests that fear of disease is a significant motivation for being physically active would likely benefit from educational materials related to common diseases and the benefits of physical activity in risk reduction and disease management.


One approach that is gaining momentum in various disciplines of health, psychology, and medicine as a way of motivating individuals toward healthy behaviors is motivational interviewing (MI) (9). This approach is client centered and is intended to facilitate autonomy and intrinsic motivation. A primary function of MI is to encourage individuals to explore the origins of their lack of motivation and/or ambivalence toward physical activity behavior change. Within the context of physical activity, ambivalence exists when a sedentary individual simultaneously has positive and negative feelings about becoming more active and fit. Discussing the presence of ambivalence and poorly organized motivation represents the core elements of this technique, which was developed and used in clinical counseling as a method of intervention for addictions. Recently, however, MI has been used in health promotion and physical activity environments and seems to be a very good fit with SDT (10,11) and may have great use in the physical activity domain (12).

The use of MI provides an opportunity for the innate needs described by SDT to be met (10,11). Four core elements of MI that make this attainment of needs possible include the following: showing empathy, rolling with resistance, enhancement of self-efficacy, and developing discrepancies (9). These four elements are used while interviewing and interacting with the individual currently positioned at a lower level of readiness for change (13). These practical principles are summarized in Table 1 and can promote motivation for behavior change.

Key Elements of MI

Showing empathy involves listening carefully to client concerns, being careful to acknowledge client feelings and not take the position of authoritarian, or being judgmental. This skill differs from sympathy because empathy is provided when the professional indicates that they understand and can identify with client perspectives. In contrast, sympathy denotes agreement with the client and the sharing of emotions, which can reduce the capacity to effectively listen and assist. Empathy is based around mutual respect and a genuine desire to help the client reach their personal goals rather than impose goals. One example of expressing empathy pertains to barriers to exercise. The professional must listen carefully to the individual's barriers with understanding and display an attitude of acceptance rather than fault before the process of change can occur. This type of interaction satisfies the need for relatedness and will facilitate enhanced motivation for change.

Rolling with resistance requires acknowledgement that the client has some resistance to behavior change. The decision on the part of the client to seek professional guidance is evidence of a desire to change and a need for assistance. Therefore, the professional must be supportive of the efforts to change and should avoid specifically arguing with or challenging the client. The professional should instead be creative and resourceful in efforts to help the client determine their next step. One example of rolling with resistance is provided by a discussion related to exercise barriers. The goal of the professional in this circumstance is to be patient and flexible as the client provides various reasons for not being more active. Appropriately responding during a time of resistance to change will allow the client to be in a better position to make a more significant and personal commitment to change, which helps satisfy the need for autonomy.

Supporting self-efficacy requires that the professional take advantage of every opportunity to increase client confidence and belief in self regarding behavior change. This effort involves providing encouragement when the client sets realistic goals and instilling confidence that the client will be able to successfully cope with behavioral lapses and setbacks. It is expected that clients struggling with lifestyle choices will sometimes make negative comments about themselves, and the professional needs to provide encouragement so as to avoid the development of a defeatist attitude. Collectively, these efforts should increase self-efficacy and satisfy the need for competence.

Developing discrepancies involves helping the client develop a clear picture of the difference between the current and desired behavior. A clear depiction of this difference in a supportive nonjudgmental manner should facilitate the development of clarity in regard to personal values and goals. It is important that this interaction with the client progress in a way that allows the client to reach his or her own conclusions about how to proceed. The professional can educate the client on barriers to exercise, but it is up to the client to establish the reasons to change and intentions to change without coercion from the professional. Facilitation of autonomy is an important goal and outcome for this element of MI.

Collectively, these four elements of MI facilitate the development of intention and motivation that increase the likelihood of success in behavior change efforts. This approach was originally developed for use in the treatment of substance abuse problems but, more recently, has been recommended for use in other health domains such as physical activity (12). Additionally, MI was initially used almost exclusively in clinical settings by clinical psychologists. However, the developers of MI have pointed out that the general approach is not restricted to formal clinical counseling and that suggestions like those previously provided can be useful to all practitioners who are grounded in the spirit of MI (14). Therefore, health fitness professionals interested in using the MI approach must make themselves aware of the training options made available to them. The most basic approach to gaining additional training would include self-study, and this can be accomplished by additional reading on the subject (9-12,14). A more rigorous plan of action would include formal training that is available through participation in seminars and workshops available through the organization affiliated with the developers of MI or other training services (15,16). Practitioners should note that formal training and supervised practice of the techniques should result in more rapid skill acquisition, but self-study and practice can result in adequate competency over time. Additionally, some practitioners will find the principles of MI quite intuitive, whereas others will not, and this type of individual difference will greatly impact how readily the approach is adopted and used effectively. Practitioners are encouraged to explore the resources provided here and elsewhere and to experiment with the basic principles in their interactions with clients as a way of guiding the decision on how to proceed with future training plans.



The usefulness of SDT and MI will ultimately be measured by its effectiveness in facilitating behavior change and adherence to physical activity programs. The following section provides practical applications of these two approaches that fitness professionals can use on a daily basis. Some recommendations are variations on standard practice, and others are more novel. Regardless, each is based on the conceptual framework presented in this article. A summary of these recommendations is provided in Table 2.

Practical Recommendations

Provide rationale

Clients generally want and need to know the rationale and basis for the activities they are asked to participate in. Providing this background involves educating the client regarding the role of physical activity in health and fitness. This provision increases knowledge and appreciation for the activity and facilitates perceptions of empowerment, control, and autonomy.

Promote moderately difficult goals

A desirable outcome of goal setting is hard work and achievement. Good work ethic is supported when goals are moderately difficult rather than too easy or extremely difficult. Goals that are too easy tend to undermine motivation, whereas self-efficacy is jeopardized by goals perceived as overwhelming. It is the participant's responsibility to establish the goals, and the professional is there to supervise and assist. The professional should meet with the client and have them write down the goals to be met, what steps will be taken to achieve the goal, and a specific date to be achieved. This approach allows the client to develop self-efficacy and mastery.


Provide choices

One important function of fitness professionals is the provision of options to clients regarding how they might be able to meet their goals. Involving the client allows the decision to ultimately rest in the hands of the individual desiring behavior change. This process places the client in a position of control, which is superior when compared with a client feeling controlled or manipulated. Although many clients simply want to be told what to do, fitness professionals should seek to allow the client to make their own decisions because client-generated decisions enhance autonomy.

Promote social aspects

The importance of social elements is obvious both within and outside physical activity. Building relationships with individuals within an exercise context provides the opportunity for positive support of a physically active and healthy lifestyle. These social connections might include developing relationships with exercise leaders and group exercise participants or participating in a sport or recreational club. This social link provides the opportunity for encouragement and accountability and develops a sense of relatedness on the part of the client that is striving for health and fitness.

Provide positive feedback

This classic principle is most readily related to the psychological development of children but also is applicable for adult populations. It is important to never underestimate the power of positive and negative words on the thoughts, attitudes, and motivations of individuals engaged in efforts to initiate or maintain an exercise program. Negative feedback can result in a decreased sense of competence, leading to lack of interest and participation. In contrast, positive feedback functions to build self-confidence and perceptions of mastery and success.

The above list of recommendations is not meant to be exhaustive because many other concepts could clearly be incorporated into an effective professional approach. Additionally, these recommendations are not presented as groundbreaking in terms of providing an entirely novel set of guidelines for assisting individuals desiring to initiate or maintain a fitness program. These recommendations do, however, present a framework based on contemporary theory and practice that should allow the fitness professional to create an approach and environment that is conducive to developing lifelong physical activity patterns in their clients.


One great privilege afforded health and fitness professionals is the opportunity to make a difference in the health and lives of the individuals we serve. Our profession is filled with individuals who love their jobs and the people they work with. The purpose of this article is to provide a framework for making a difference. Combining the strong theoretical underpinnings of SDT and the strong clinical base of MI should allow for much progress in developing the kind of motivation required to initiate and maintain a fitness program over the long term. Self-determination theory suggests that we are born with psychological needs that cause us to engage our world, so that these needs might be met. Furthermore, it seems as though many forms of physical activity have the capacity to meet these innate needs, and the task of the fitness professional is to facilitate the use of physical activity as a means of achieving physical and mental wellness. One effective tool available to those in our profession to facilitate the development of healthier intentions and motivations for physical activity is MI. These relatively simple and straightforward principles can be incorporated into existing approaches currently used by professionals who desire to improve their effectiveness. These approaches do not promise to solve all of the many and varied challenges related to health and physical activity facing our culture and profession, but they do offer a fresh approach worthy of full consideration.

Basic Human Needs According to Self-determination Theory

Autonomy is characterized by a feeling that we are in control and make our own choices.

Competence is characterized by a sense of mastery and confidence that we are adequate and effective.

Relatedness is characterized by a sense of belonging and satisfaction in the social aspects of living.


The health and fitness profession is faced with the challenge of improving the health and fitness of our clients, members, and participants. A healthy approach to motivation is essential for exercise adoption and adherence. Combining SDT and MI should allow for progress in developing the kind of motivation required to initiate and maintain a fitness program over the long term. Making even a small difference in this area could have vast implications for disease prevention and management. Understanding our client's level of motivation helps health and fitness professionals provide guidance that facilitates better health behaviors.


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Self-determination Theory; Motivational Interviewing; Autonomy; Competence; Relatedness

© 2008 American College of Sports Medicine