Enhancing self-management of patients with inflammatory bowel disease: the role of autonomy support in health goal pursuit

Abstract

Background:

Inflammatory bowel disease (IBD) is a chronic condition that significantly affects patients’ physical, mental, and social health, as well as their overall quality of life. Effective management of the disease demands self-management skills, enabling patients to navigate the daily challenges associated with IBD, such as unpredictable flare-ups, frequent hospitalization, severe symptoms, pain, and physical changes.

Objectives:

This study examines the motivational aspects of self-management for patients with IBD and focuses on the role of autonomy and directive support from healthcare professionals in enhancing their self-concordance and self-efficacy.

Design:

From November 2022 to February 2023, a cross-sectional questionnaire study was conducted at the IBD Center of Internal Medicine Clinic in Szeged, Hungary.

Methods:

A total of 374 adult patients with IBD completed the paper–pencil questionnaire, of whom 241 patients (64.4%) had Crohn’s disease, and 133 patients (35.6%) had ulcerative colitis.

Results:

Based on the findings of the path analysis (χ² (8) = 18.914, p = 0.01, comparative fit index = 0.935, TLI = 0.837, root mean squared error of approximation = 0.06), autonomy support positively predicted self-concordance (β = 0.48) and self-efficacy (β = 0.02), particularly during disease relapse. In addition, self-concordance and self-efficacy predicted more positive (βs = 0.28 and 0.35) and fewer negative emotional experiences (βs = −0.09 and −0.20). The model’s associations varied between the relapse and remission groups, indicating distinct impacts on different states of the disease.

Conclusion:

Overall, autonomy support from healthcare professionals has been shown to enhance self-management in patients with IBD, particularly during disease relapse. Meanwhile, self-concordance and self-efficacy act as positive internal factors, thus reducing negative emotional experiences, especially during remission. In sum, this study underscores the need for further exploration of the motivational aspects of self-management and provides insights into developing interventions that promote the health behaviors of patients with IBD.

Plain language summary

Self-management of inflammatory bowel disease patients

Autonomy support from healthcare professionals has been shown to significantly improve the effectiveness of self-management in patients with inflammatory bowel disease (IBD) (especially during disease relapse), by enhancing their self-concordance and self-efficacy. In this case, the interplay between disease activity, positive and negative emotions, and self-regulatory mechanisms underscores the importance of examining the motivational aspects for developing interventions that promote health behaviors in patients with IBD.

Keywords

autonomy and directive support IBD self-concordance self-efficacy self-management

Introduction

Inflammatory bowel disease (IBD) is a chronic condition that can have a significant impact on an individual’s quality of life. This study explores the health goals of patients with IBD and their adaptation to the lifestyle modifications necessitated by the disease.

Supporting patients’ autonomy in establishing health goals not only enables them to actively participate in disease management, but it also fosters long-term success in coping with the condition. Additionally, increased self-concordance and self-efficacy during health goal pursuit and self-management can contribute to more positive and fewer negative emotional experiences. A unique aspect of our study is to examine the role of autonomy and directive support from healthcare professionals in enhancing the self-concordance and self-efficacy of patients with IBD, taking into account whether the disease is in remission or relapse. In this regard, our study addresses a notable gap in the current understanding of the motivational and self-regulatory factors of IBD self-management. In the following, we summarize the main factors in our study.

Psychological aspects of IBD

IBD refers to a chronic gastrointestinal condition with unclear etiology,^1,2 encompassing two main clinical forms: Crohn’s disease and ulcerative colitis. This disease primarily affects the gastrointestinal tract, causing various symptoms such as diarrhea, abdominal pain, bloody stools, bloating, and weight loss.^3-5 Since IBD is a lifelong condition, with the alternation of relapses and remissions, it can significantly impair patients’ physical, mental, and social conditions, as well as their overall quality of life.⁶ Meanwhile, the unpredictability of relapses, the need for frequent hospitalization, the nature of the symptoms, the severe pain, and the physical transformation caused by the disease can lead to loss of control and autonomy. This may underpin the development of anxiety and depression whose prevalence is higher among patients with IBD.^7-10

In IBD, disease self-management is crucial for maintaining remission and preventing progression. This includes daily behaviors such as adhering to regular medical check-ups, medication, and smoking cessation, as well as following dietary recommendations, participating in sports activities, and reducing stress.^11,12 Effective self-management can also lead to positive health-related outcomes, including the reduction of inflammation, the alleviation of symptoms, better psychological/physical well-being, and improved quality of life.^13-15

Despite the benefits of adapting to lifestyle changes required by the disease, previous research has found that 30%–45% of patients are nonadherent.^16,17 Hence, examining the psychological factors that influence the efficacy of patients’ self-management is important. It can elevate patients’ engagement and improve their adherence to treatment plans, fostering a more comprehensive and patient-centered approach to self-management support.

Autonomy and directive support

Since healthcare professionals play an important role in patients’ social environments and self-management, it is important to address the nature of their support, especially for patients with chronic diseases.¹⁸ Extensive studies have consistently demonstrated the positive impact of social support on self-management behaviors, including medication adherence, dietary modifications, and psychological symptom management.^19,20 For the IBD population, such support can effectively enhance self-management and alleviate various symptoms.^9,21 Thus, we applied the self-determination theory (SDT), according to which social support is categorized into two types: directive and autonomy support. Directive support involves providing reminders, advice, suggestions, and even compliments to potentially persuade individuals to make behavioral changes, whereas autonomy support includes acknowledging personal volition, recognizing negative feelings, and enhancing internal motivation.²² Regarding personal goals, autonomy support refers to the extent to which the social environment fosters an individual’s sense of autonomy, allowing them to feel that their actions are self-chosen and aligned with their own values and interests. Autonomy supportive behavior has proven to be more beneficial, being linked to increased health goal self-concordance and self-efficacy, and contributing to long-term mental well-being.^23,24 Conversely, directive support neither correlates with improved goal internalization nor with better well-being.^21,25,26

Health-related personal goals

Meanwhile, health-related personal goals are one of the motivational aspects of self-management and play an important role in behavioral changes, emotions, and commitment.^26-30 Specifically, such goals encompass aspirations related to an individual’s appearance, health, and fitness. Hence, setting appropriate health goals can increase an individual’s sense of autonomy and motivate them to become more active.^31,32

Self-concordance

Self-concordance is a micro-theory of the SDT,^24,33 describing the consistency with an individual’s core values, talents, and needs.^34-36 Self-concordant motivation is crucial for the success of health goal pursuit as it can predict greater efforts and more positive emotions, contributing to an individual’s well-being.^35,37-39 In their study on the role of self-concordance in IBD self-management, Horvát et al.⁴⁰ indicated that this psychological factor signifies an internal capacity, leading to lower quality of life through positive and fewer negative emotions during health goal pursuit.

Self-efficacy

Self-efficacy is a psychological function that has been recognized to act as a crucial tool for individuals adjusting to the lifestyle changes brought about by chronic diseases, regardless of disease severity.^41-44 According to Bandura,⁴⁵ self-efficacy represents the belief that an individual can successfully perform certain tasks to achieve the desired outcomes itself. In the context of personal goals, greater self-efficacy can predict better goal progress and long-term commitment.^35,46 Among patients with IBD, previous studies have indicated that self-efficacy is a relevant component in disease management and coping.^47-49

Disease activity and self-management

IBD is characterized by an unpredictable course that fluctuates between remission and relapse.⁵⁰ Specifically, remission indicates a period in which the symptoms of the disease significantly improve or disappear, while relapse is when the inflammatory process in the digestive tract intensifies, leading to the worsening of symptoms.⁵¹ The impact of disease activity on the quality of life is also noteworthy, demonstrating reduced life satisfaction of 18% during relapse, compared to 6.6% during remission.⁵²

The goal of IBD treatment is not only treating active inflammation but also maintaining remission and preventing relapses to improve patients’ overall well-being. Moreover, previous research has mainly focused on the impact of self-management on disease activity, indicating that effective self-management is associated with shorter duration of treatment^18,53 and fewer disease relapses.⁵⁴ However, since it is important to recognize the challenges of patients with IBD, we determine how disease activity can predict self-management.⁸

The present study

In this cross-sectional study, we investigate how healthcare professionals can enhance the self-concordance and self-efficacy of patients with IBD in health goal pursuit by fostering their autonomy. Additionally, we examine the mediating role of positive and negative emotions in the relationship between self-concordance and IBD patients’ quality of life, expanding the research of Horvát et al.,⁴⁰ who investigated the correlation between goal self-concordance, goal self-efficacy, and general anxiety among a sample of patients with IBD.

Overall, the purpose of this study is threefold. First, we explore how autonomy and directive support from healthcare professionals shape self-concordance and self-efficacy during health goal pursuit. In this case, due to previous ambient results, we do not formulate a specific hypothesis on how directive support can predict self-concordance and self-efficacy. Second, we determine whether self-concordance and self-efficacy are linked to positive and negative emotional experiences during health goal pursuit. Third, we assess whether positive and negative emotions during health goal pursuit can predict life satisfaction. All of the variables, except for life satisfaction, were evaluated in connection to health goal pursuit. Figure 1 summarizes the theoretical model. To test our model, we present the following hypotheses:

H1. Individuals with IBD who perceive higher levels of autonomy support from healthcare professionals will experience greater self-concordance and self-efficacy during health goal pursuit.

H2. Self-concordance and self-efficacy will predict positive and negative emotions during health goal pursuit.

H3. Positive emotions will predict greater life satisfaction, whereas negative emotions will predict lower life satisfaction among patients with IBD.

We also formulated the following research question:

Q1. Will individuals with IBD who perceive higher levels of directive support from healthcare professionals experience lower self-concordance and self-efficacy during health goal pursuit?

Moreover, we assess the influence of disease activity by comparing our theoretical model between two groups of patients: (1) those in remission and (2) those experiencing a relapse.

Figure 1.

Model summary.

Materials and methods

Participants

This cross-sectional questionnaire study was conducted at the IBD Center of Internal Medicine Clinic in Szeged, Hungary. The participants were individually contacted during their regular check-ups at the center. Informed consent was collected before they completed the paper-and-pencil questionnaires. Their participation was voluntary; only the patients who agreed to participate, provided answers, and completed the questionnaire were included in the statistical analyses. The inclusion criteria were as follows: (1) aged 18 years or older; (2) an IBD diagnosis according to international criteria; and (3) a statement of consent. Those who are younger than 18 years of age or those currently receiving psychiatric treatment (or have received such treatment over the past year) were excluded from this study.

Ethical considerations

Ethical approval for this study was obtained from the Regional Research Ethics Committee of the Albert Szent-Györgyi Health Center at the University of Szeged. The date of ethics approval is November 11, 2023. This study was carried out according to the Code of Ethics of the World Medical Association (Declaration of Helsinki), and written informed consent was obtained from all the participants.

Procedure

Data collection for the study was conducted from November 2022 to February 2023. Patients were requested to complete a questionnaire, which took 30–40 min. Data collection was conducted with the assistance of psychology students trained in the procedure during their classes at the university. Training was necessary because patients might have raised clarifying questions during the completion of the questionnaires, and the students present were responsible for supervising the process and competently answering any questions. Participants did not receive any specific intervention in the study. The completion of the questionnaires took 30–40 min in average for the participants. Data entry, coding, cleaning, and analysis were performed by members of the research team.

Materials

The questionnaire consisted of three sections. In the first part, they were asked about socio-demographic factors, followed by information regarding their disease history and treatment (e.g. type of disease, treatment method, disease activity, year of diagnosis, surgery, medication, and presence of complications). The second part of the questionnaire covered questions on general health and life satisfaction, based on the Satisfaction with Life Scale. The third part of the questionnaire focused on personal health goals, based on the personal project analysis (PPA) method. In this case, such goals were assessed according to the following characteristics: autonomy and directive support from healthcare professionals, goal self-concordance, goal self-efficacy, and positive and negative emotions.

The questionnaires used in the study were administered in Hungarian and were adapted from previous studies conducted in Hungarian. Below, we refer to the original English and Hungarian publications, wherever it is appropriate. The exact Hungarian wording of the questions can be found in the Supplemental Materials under “Questionnaires.”

IBD-specific questions

Self-reported questions about the disease, including diagnosis, type, and condition.

Health goal assessment

In this study, we applied the modified PPA method^32,55,56 to examine the participants’ health-related goals. Specifically, the participants were asked to list their latest health-related goals, after being prompted by the statement “The health-related goals that you are actively pursuing.” In this case, goals included weight management, sports participation, eating habits, smoking cessation, mental health, and sleeping. Then, they were asked to select the most relevant goal and rate it with respect to autonomy and directive support, self-concordance, self-efficacy, and positive and negative emotions, the details of which are as follows.

Autonomy and directive support

The questionnaire assessed the participants’ perceptions of the support from the healthcare professionals for their health-related goals.⁵⁵ This assessment consisted of two subscales with three items each, namely: autonomy support (e.g. “My doctor understands how I see things with respect to this goal”) and directive support (e.g. “My doctor repeatedly reminds me of this goal”). The responses were scored on a 7-point Likert-type scale ranging from 1 (not at all true) to 7 (very true). The internal consistency of the items for autonomy support demonstrated a Cronbach’s α of 0.878, while that for directive support included a Cronbach’s α of 0.910.

Goal self-concordance

The term “goal self-concordance” refers to the extent to which an individual has internalized the goal.^35,57 In this regard, we asked the participants to rate the extent to which they are pursuing their health-related goals based on four reasons, that is, external, introjected, identified, and intrinsic, representing a continuum of perceived locus of causality for action.³⁶ Additionally, an organismic integration variable was calculated from the subtraction of two items of controlled (external) regulation (e.g. “You are pursuing this goal because someone else wants you to”) and introjected regulation (e.g. “You are pursuing this goal because you would feel ashamed, guilty, or anxious if you did not”), and two items of autonomous motivation (identified) regulation (e.g. “You are pursuing this goal because you really believe that it is an important goal to have”) and intrinsic regulation (e.g. “You are pursuing this goal because of the fun and enjoyment that the goal will provide”). Due to the composite nature of the index, the standard reliability estimate of alpha was not applicable.

Goal self-efficacy

The term “goal self-efficacy” refers to an individual’s belief in his/her ability to achieve the goal.^58,59 This four-item questionnaire includes a 7-point Likert scale for each response (e.g. “I can usually handle the situations that come with achieving this goal”). Internal consistency of the four items was excellent, with a Cronbach’s α of 0.846.

Positive and negative emotions

A total of six items were employed to assess emotional experiences during the goal implementation process.^56,57 To measure positive emotions, three items were utilized (e.g. “How often do you experience positive emotions, such as joy and happiness, about this goal”?). Conversely, three items were dedicated to measuring negative emotions (e.g. “How often do you experience negative emotions, such as stress, worry, and anxiety, about this goal”?). Both subscales utilized a 7-point Likert scale, ranging from 1 (Not at all true for me) to 7 (Very true for me). The internal consistency of the items for positive emotions demonstrated a Cronbach’s α of 0.881, while that for negative emotions included a Cronbach’s α of 0.869.

Satisfaction with Life Scale

A total of five items were employed to measure the patients’ satisfaction with life (e.g. “In most respects, my life is almost ideal”).^37,60 The responses were based on a 5-point Likert scale, ranging from 1 (totally agree) to 5 (I do not agree at all). The internal consistency of the items demonstrated a Cronbach’s α of 0.837.

Statistical analyses

In this study, we used JASP software (Version 0.18.3, University of Amsterdam) to manage the data and calculate the statistics. We estimated the necessary sample size to detect an absolute value of 0.15 for correlation coefficients with at least 80% power (beta level = 0.2) and p = 0.05 alpha level. The correlation coefficient of r = 0.15 was considered a minimally interpretable effect size of a bivariate association. The calculation resulted in a minimum of 347 participants, which we considered the minimum sample size for the whole sample.

We tested path analytic models to estimate a system of equations that can specify possible causal linkages and identify the most significant pathways in predicting certain outcomes.⁶¹ Meanwhile, we assessed the model’s goodness of fit through multiple goodness-of-fit indices. Along with the χ² values test, we used the root mean squared error of approximation (RMSEA), the normed fit index (NFI), the comparative fit index (CFI), and the incremental fit index (IFI). In this case, the criteria were that the values for the NFI, CFI, and IFI should be greater than 0.90 and that the RMSEA should be 0.05–0.10, indicating a fair fit.⁶² As for error estimation, it was conducted via the robust method, while the invariance between the two groups (i.e. those in remission and in relapse, respectively) was examined through multiple-group analyses. In this case, we used the CFI to define the invariance with a threshold of change below 0.01. Finally, we included more constrained models and individually assessed their model fit.

Results

Descriptive statistics

A total of 377 adult patients with IBD responded to our cross-sectional questionnaire study, of whom 241 patients (64.4%) had Crohn’s disease and 133 patients (35.6%) had ulcerative colitis. In addition, 44.3% were men, the average age was 41.8 ± 12.1 years, and the average disease duration was 14.7 ± 9.34 years. Detailed descriptions of the demographic characteristics are presented in Table 1. Data from complete respondents were analyzed.

Table 1.

Demographic factors of IBD patients (N = 377).

Sociodemographic characteristics	N	Valid percentage (%)
Gender
Male	167	44.3
Female	210	55.7
Education
Elementary	12	4.1
High school	272	91.9
College or university studies	113	4.4
Marital status
Single	67	17.8
In relationship	310	82.2
Economic activity
Active	286	77.1
Inactive	72	19.4
Student	13	3.5
Disease type
CD	241	61.6
UC	133	34.0
US	5	1.3
Disease activity
Remission	289	77.9
Relapse	82	22.1
Intestinal complication
Stenosis	137	56.2
Fistula	107	43.9
Operation
Yes	159	42.2
No	218	57.8
Hospitalization within 1 year
Yes	76	20.2
No	301	79.8

CD, Crohn’s disease; IBD, inflammatory bowel disease; UC, Ulcerative Colitis; US, Unclassified type of IBD.

Bivariate associations

Since the sample size was large (N = 370), according to the central limit theory, we assumed that the sample distributions satisfy normal distribution assumptions and conducted parametric tests. To test our hypotheses, we ran a series of bivariate Pearson correlations for the study variables. The results of the correlation analyses and the average scores of the questionnaires are summarized in Table 2. Regarding autonomy support, it is significantly and positively linked to self-concordance, self-efficacy, positive emotions, and satisfaction with life, whereas it is negatively linked to negative emotions. As for directive support, it is only significantly and positively linked to self-efficacy. Meanwhile, the scores in the remission group remarkably differ from those in the relapse group. Specifically, the scores for self-concordance, self-efficacy, and satisfaction with life are significantly higher in the remission group, whereas the levels of negative emotions are significantly lower in this group.

Table 2.

Correlation matrix and the characteristics and average scores of the questionnaires (N = 370).

Variable		Disease activity
		Remission		Relapse		T test
		M	SD	M	SD	p	Range	1	2	3	4	5	6	7
1	Autonomy support	4.37	0.79	4.25	0.78	0.23	1–5	–
2	Directive support	3.83	1.10	3.92	0.99	0.54	1–5	0.65***	–
3	Self-concordance	1.92	1.28	1.37	1.23	<0.001	−2 to 4	0.07	0.01	–
4	Self-efficacy	3.65	0.85	3.28	0.77	<0.001	1–5	0.23***	0.135**	0.235***	–
5	Positive emotions	3.29	0.96	3.08	1.02	0.103	1–5	0.15**	0.04	0.31***	0.25***	–
6	Negative emotions	1.71	0.93	2.40	1.14	<0.001	1–5	−0.12*	−0.04	−0.33***	−0.22***	−0.11*	–
7	SWLS	3.69	0.74	3.43	0.82	0.007	1–5	0.13*	0.07	0.15**	0.28***	0.21***	−0.21***	–

N_remission = 282, N_relapse = 82.

p < 0.05. **p < 0.01. ***p < 0.001 denote significant values.

Path model fit

In this study, the fit indices for the hypothesized model indicated an appropriate fit to the data: χ² (8) = 18.914, p = 0.01, CFI = 0.935, TLI = 0.837, RMSEA = 0.06. The results of the path analysis are presented on Figure 2.

Figure 2.

Path model.

Multigroup analysis

To examine the possible differences between the patients in different stages of the disease (i.e. remission or relapse), we tested the multiple-group path analytic models. To examine the model invariance between the patients in remission and relapse, the following steps were performed. First, the unconstrained model (i.e. the model in which the paths are free to vary between groups) was estimated, and the differences in significant pathways between the groups were analyzed: (χ² = 41.422, df = 24, p = 0.01), NFI = 0.81, IFI = 0.91, CFI = 0.89, and RMSEA = 0.07, with a confidence interval CI = 0.03–0.12. Next, the model fit for the constrained model (i.e. the model in which the means are constrained to be equal across the groups) was assessed. In this case, the unconstrained and constrained models were compared using the CFI values. In addition, we tested additional constrained models (means and regression coefficients). We stopped testing when the model with restricted regression coefficients began to significantly deteriorate.

Overall, the fit indices for the constrained model were as follows: NFI = 0.68, IFI = 0.85, CFI = 0.83, and RMSEA = 0.07, CI = 0.04–0.12. According to the CFI values, there is no difference between the groups according to the means, but there is a difference between the groups in regression coefficients. Thus, by separately testing the model in the remission and relapse groups, we found differences in the pathways. According to the results in Table 3, autonomy and directive support only predict self-concordance among the patients in relapse, while self-efficacy and self-concordance only significantly predict negative emotions among the patients in remission. Moreover, positive emotions only significantly predict satisfaction with life in the remission group. Results of the multiple-group analysis between patients with IBD in remission and relapse are presented in Table 4. The standardized estimates for the pathways in the remission and relapse groups are presented in Table 5.

Table 3.

Standardized parameter estimates of direct effects for the study model.

Predictor variable	Predicted variable	Estimate	p	z
AS	SC	0.22	0.001	3.28
DS	SC	0.002	0.97	0.04
AS	SE	0.13	0.05	1.90
DS	SE	−0.10	0.05	−1.38
SC	PE	0.25	<0.001	4.96
SC	NE	−0.29	<0.001	−5.23
SE	PE	0.26	<0.001	5.19
SE	NE	−0.17	<0.001	−3.28
PE	SWLS	0.23	<0.001	3.93
NE	SWLS	−0.19	<0.001	−3.71

The values in the table are the standardized coefficients.

AS, autonomy support; DS, directive support; NE, negative emotions; PE, positive emotions; SC, self-concordance; SE, self-efficacy; SWLS, Satisfaction with Life Scale.

Table 4.

Results of the multiple-group analysis between patients with IBD in remission and relapse.

Model	χ²	df	χ²/df	p	CFI (ΔCFI)
M0 (unconstrained)	41.422	24	1.73	0.01	0.89
M1 (means)	41.422	24	1.73	0.01	0.89 (0)
M2 (means and regression)	70.387	44	1.60	0.007	0.83 (0.07)

CFI, comparative fit index; IBD, inflammatory bowel disease.

Table 5.

Standardized estimates for defined pathways in remission and relapse group.

Predictor variable	Predicted variable	Disease remission		Disease relapse
Predictor variable	Predicted variable	Standardized estimate	p	Standardized estimate	p
AS	SC	0.03	0.73	0.48	0.002
DS	SC	−0.004	0.96	−0.47	0.002
AS	SE	0.18	0.02	0.35	0.02
DS	SE	−0.004	0.96	−0.05	0.75
SC	PE	0.27	<0.001	0.28	0.009
SC	NE	−0.28	<0.001	−0.09	0.45
SE	PE	0.21	<0.001	0.35	<0.001
SE	NE	−0.12	0.04	−0.20	0.09
PE	SWLS	0.23	0.006	0.10	0.35
NE	SWLS	−0.10	0.12	−0.40	<0.001

Values indicating a significant difference between the two groups are highlighted in bold.

AS, autonomy support; DS, directive support; NE, negative emotions; PE, positive emotions; SC, self-concordance; SE, self-efficacy; SWLS, Satisfaction with Life Scale.

Discussion

A novel aspect of this study was the examination of the motivational aspects of self-management for patients with IBD and focused on the role of autonomy and directive support from healthcare professionals in enhancing their self-concordance and self-efficacy of adopting lifestyle changes dictated by the disease. Additional strength of our approach was the inclusion of a multigroup analysis that considered disease activity as a crucial factor of IBD patients’ self-management.

First, the autonomy-supportive behavior of the healthcare professionals had a positive impact on both self-concordance and self-efficacy during health goal pursuit. This indicates the potential to facilitate the internalization of self-management activities, which are essential for managing the disease. Conversely, the same impact was not observed for the directive-supportive behavior of the healthcare professionals. Meanwhile, emotions played a distinct mediating role among self-concordance, self-efficacy, and life satisfaction, varying with disease activity. These results highlight the need for further investigations into the motivational, self-regulatory, and emotional experiences linked to individual health goals within the IBD population since these factors have a significant impact on overall well-being.

As stated earlier, the purpose of this study was threefold. The first objective was to explore the roles of two types of social support (i.e. autonomy and directive) received from healthcare professionals during health-related activities. The significance of social support in enhancing self-management among individuals with chronic diseases, including IBD, has been well-established in the literature.^19,63 However, based on SDT, there is a notable gap in the literature regarding the examination of social support in IBD patients’ self-management, with one research being an exception.⁶⁴

In our study, within the IBD sample, autonomy support significantly and positively predicted both self-concordance and self-efficacy during health goal pursuit. Yet, distinctions emerged when we individually examined the remission and relapse groups, indicating the influence of disease activity on the efficacy of autonomy support from the healthcare professionals. Specifically, as disease symptoms intensify, autonomy support tends to function more as a positive resource, predicting higher self-concordance during relapse. Conversely, the negative impact of directive support becomes more pronounced during relapse, predicting lower self-concordance. In addition, autonomy support was beneficial for self-efficacy, in the relapse and remission groups, while directive support did not have a significant impact on self-efficacy in either group. These results underscore the significance of the supportive role of healthcare professionals in the health behavior change of patients with IBD. In sum, recognizing patients’ autonomy and personal volition, and acknowledging negative emotions can boost their internal motivation and belief that the health behavior change will be carried out. On the contrary, providing reminders, guidance, and explicit recommendations can hinder the success of health behavior change.⁵⁵

The second objective of our study was to determine whether self-concordance and self-efficacy are linked to positive and negative emotional experiences during health goal pursuit. Based on the findings, autonomous motivation was identified as a core component of health behavior change.⁶⁵ In this regard, goal self-concordance represented an aspect of autonomous motivation, reflecting the extent of self-integration, encompassing internal interests and identity, and forming a connection with positive attitudes and behaviors.³⁵ Our path analysis also affirmed the influence of self-concordance on enhancing positive emotions and mitigating negative emotions during health goal pursuit. Previous research has shown that the level of self-concordance in health-related goals indicates the extent to which self-management activities are integrated into the self and internalized as intrinsic values.^34,35 Our findings align with a recent study on patients with IBD, which found that acceptance of the disease is associated with the activation of psychological resources and more effective disease management.⁶⁶ Moreover, in our IBD sample, self-concordance was a predictor of reduced negative emotions. However, when considering disease activity, this association was only significant during remission. This implies that, during remission, self-concordance acts as a protective factor against negative emotions, reducing adverse experiences during health goal pursuit. Conversely, during relapse, this protective function appears to be overshadowed. A possible explanation is that during this period patients may prioritize efforts to manage physical symptoms, diverting attention from their motivation for health-promoting activities.

As for self-efficacy, it emerged as a predictor of positive emotions in both the relapse and remission groups. Similar to self-concordance, it forecasted fewer negative emotions, but this association was only observed during remission. According to related research, the role of self-efficacy in determining health outcomes for individuals with IBD is vital since it is a significant factor that influences the initiation and execution of health behaviors related to the disease.⁴⁵ Our observed positive impact of self-efficacy during health goal pursuit aligns with prior research, which found a positive correlation between self-efficacy and self-esteem, health-related quality of life, and improved mental well-being in patients with IBD.⁴¹

The third objective of our study was to investigate the relationship between emotional experiences during health goal pursuit and overall life satisfaction, by specifically determining whether emotions play a mediating role between self-concordance, self-efficacy, and life satisfaction in patients with IBD. The results of the path analysis indicated that, in our IBD sample, life satisfaction was influenced by both positive and negative emotions. However, upon considering disease activity, positive emotions only predicted higher life satisfaction in the remission group, while negative emotions only predicted lower life satisfaction in the relapse group.

Being the inaugural exploration into the role of health goal-related experiences in the life satisfaction of patients with IBD, these findings suggest that emotions during health behaviors linked to disease self-management can significantly influence patients’ quality of life. Meanwhile, negative emotions have a more noticeable impact on psychological functioning, especially during relapse, whereas the protective effect of positive emotions is diminished. Conversely, during remission, the protective function of positive emotions is more evident, while the impact of negative emotions on patients’ quality of life is attenuated.

In evaluating the results, a potentially valuable framework is the conservation resources theory,⁶⁷ which proposes that resources have psychological significance, serving as a safeguard against threatening situations. They also play an important role in enabling individuals to effectively manage stress and maintain positive self-esteem. In this regard, the primary objective is to conserve and enhance these resources. However, stressors, such as a chronic disease, can diminish the capacity to safeguard and generate resilience. It can also be inferred that the escalation of physical symptoms provides a modified context to protecting and generating resources, inhibiting self-regulatory mechanisms or the capacity for self-concordant and self-efficacious goal pursuit. This, in turn, can have an impact on emotional outcomes. Since this was the first study to comprehensively explore the complex interplay between disease activity and positive internal resources, including self-concordance and self-efficacy during health goal pursuit, and their associations with emotions and satisfaction with life, further research is essential for confirming the reliability of the results.

Limitations

In this study, we examined a linear model with a primary focus on autonomy support, as a predictor of self-concordance and self-efficacy. However, it is conceivable that autonomy support and internal resources may influence life satisfaction not only through emotional experiences but also through direct pathways. The intricate interplay of these factors in shaping the quality of life for individuals with IBD necessitates further research. The reliability of the data on disease status may have been compromised by relying only on self-reported data from patients instead of medical data. Additionally, due to the cross-sectional nature of this study, our models were not suitable for exploring causal relationships, highlighting the need for longitudinal research that focuses on causation.

Conclusion

Based on the findings of this study, if patients with IBD experience autonomy support from healthcare professionals, then they can become more effective in self-management, through their enhanced capacity for self-concordant and self-efficacious health goal pursuit. This association is particularly pronounced during disease relapse. Moreover, self-concordance and self-efficacy can serve as positive psychological factors, mitigating the negative emotional experiences during health goal pursuit, especially during remission. However, the observed interplay among disease activity, emotions, and self-regulatory mechanisms underscores the need for further exploration of the motivational aspects of IBD self-management. Overall, these findings provide valuable insights into developing interventions that promote the health behaviors of patients with IBD.

Supplemental Material

sj-odt-1-tag-10.1177_17562848241275315 – Supplemental material for Enhancing self-management of patients with inflammatory bowel disease: the role of autonomy support in health goal pursuit

Supplemental material, sj-odt-1-tag-10.1177_17562848241275315 for Enhancing self-management of patients with inflammatory bowel disease: the role of autonomy support in health goal pursuit by Barbara Horvát, Kata Orbán, Anett Dávid, Viola Sallay, Beatrix Rafael, Sanela Njers, Tamás Molnár, Márta Csabai, Georgina Csordás and Tamás Martos in Therapeutic Advances in Gastroenterology

Footnotes

Acknowledgements

We express gratitude to the research team for data collection and to patients with IBD who dedicated their time to completing the forms. Appreciation is also extended to colleagues who provided personal assistance, contributing to the realization of this study. The written support was financially supported by Klebelsberg Library, University of Szeged.

Declarations

ORCID iDs

Barbara Horvát

Tamás Molnár

Supplemental material

Supplemental material for this article is available online.

References

Podolsky

. Inflammatory bowel disease. N Engl J Med 2002; 347(6): 417–429.

Sartor

. Mechanisms of disease: pathogenesis of Crohn’s disease and ulcerative colitis. Nat Clin Pract Gastroenterol Hepatol 2006; 3(7): 390–407.

Devlen

Beusterien

Yen

, et al. The burden of inflammatory bowel disease: a patient-reported qualitative analysis and development of a conceptual model. Inflamm Bowel Dis 2014; 20(3): 545–552.

Dibley

Norton

. Experiences of fecal incontinence in people with inflammatory bowel disease: self-reported experiences among a community sample. Inflamm Bowel Dis 2013; 19(7): 1450–1462.

Park

Ehrlich

Allen

, et al. The cost of inflammatory bowel disease: an initiative from the Crohn’s & Colitis Foundation. Inflamm Bowel Dis 2020; 26(1): 1–10.

Knowles

Graff

Wilding

, et al. Quality of life in inflammatory bowel disease: a systematic review and meta-analyses—Part I. Inflamm Bowel Dis 2018; 24(4): 742–751.

Byrne

Rosenfeld

Leung

, et al. Prevalence of anxiety and depression in patients with inflammatory bowel disease. Can J Gastroenterol Hepatol 2017; 2017: e6496727.

Graff

Walker

Lix

, et al. The relationship of inflammatory bowel disease type and activity to psychological functioning and quality of life. Clin Gastroenterol Hepatol 2006; 4(12): 1491–1501.

Kovács

Depressive and anxiety symptoms, dysfunctional attitudes and social aspects in irritable bowel syndrome and inflammatory bowel disease. Int J Psychiatry Med 2007; 37(3): 245–255.

10.

Robertson

Ray

Diamond

, et al. Personality profile and affective state of patients with inflammatory bowel disease. Gut 1989; 30(5): 623–626.

11.

Grady

Gough

. Self-management: a comprehensive approach to management of chronic conditions. Am J Public Health 2014; 104(8): e25–e31.

12.

Plevinsky

Greenley

Fishman

LN.

Self-management in patients with inflammatory bowel disease: strategies, outcomes, and integration into clinical care.Clin Exp Gastroenterol 2016; 9: 259–267.

13.

Kamat

Pai

Rajan

, et al. Cost of illness in inflammatory bowel disease. Dig Dis Sci 2017; 62(9): 2318–2326.

14.

Lamers

Roos

DNM

Heerink

, et al. Lower impact of disease on daily life and less fatigue in patients with inflammatory bowel disease following a lifestyle intervention. Inflamm Bowel Dis 2022; 28(12): 1791–1799.

15.

Schlee

Uecker

Bauer

, et al. Multimodal stress reduction and lifestyle modification program for patients with ulcerative colitis: a qualitative study. BMC Complement Med Ther 2022; 22(1): 60.

16.

Chan

Chen

Tiao

, et al. Medication adherence in inflammatory bowel disease. Intest Res 2017; 15(4): 434–445.

17.

Wagoner

Kavookjian

. The influence of motivational interviewing on patients with inflammatory bowel disease: a systematic review of the literature. J Clin Med Res 2017; 9(8): 659–666.

18.

Elkjaer

Shuhaibar

Burisch

, et al. E-health empowers patients with ulcerative colitis: a randomised controlled trial of the web-guided “Constant-care” approach. Gut 2010; 59(12): 1652–1661.

19.

DiMatteo

MR.

Social support and patient adherence to medical treatment: a meta-analysis. Health Psychol 2004; 23(2): 207–218.

20.

Gariépy

Honkaniemi

Quesnel-Vallée

. Social support and protection from depression: systematic review of current findings in Western countries. Br J Psychiatry 2014; 209(4): 284–293.

21.

Carbonneau

Martos

Sallay

, et al. Examining the associations of autonomy and directive support given and received with relationship satisfaction in the context of goals that romantic partners have for one another. Motiv Emot 2019; 43(6): 874–882.

22.

Koestner

Powers

Carbonneau

, et al. Distinguishing autonomous and directive forms of goal support: their effects on goal progress, relationship quality, and subjective well-being. Pers Soc Psychol Bull 2012; 38(12): 1609–1620.

23.

Patrick

Knee

Canevello

, et al. The role of need fulfillment in relationship functioning and well-being: a self-determination theory perspective. J Pers Soc Psychol 2007; 92(3): 434–457.

24.

Ryan

Deci

EL.

Self-determination theory: basic psychological needs in motivation, development, and wellness. New York: Guilford Publications, 2017.

25.

Csuka

Désfalvi

Thege

, et al. Relationship satisfaction and self-esteem in patients with breast cancer and healthy women: the role of expected and actual personal projects support from the partner. BMC Womens Health 2023; 23(1): 426.

26.

Ryan

Deci

. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 2000; 55: 68–78.

27.

Austin

Vancouver

JB.

Goal constructs in psychology: structure, process, and content. Psychol Bull 1996; 120(3): 338–375.

28.

Liversage

Wissing

Schutte

. Promotion of well-being in work and interpersonal relationships: a scoping review of goals and meaning interventions. Int J Wellbeing 2023; 13(3): 94–110.

29.

Martos

Konkolÿ Thege

Kopp

Csak az egészség meglegyen? Egészséggel kapcsolatos életcélok fontossága a „Hungarostudy Egészség Panel” 2006 felmérés alapján [All you need is health? The importance of health related life goals in the Hungarostudy Epidemiological Panel 2006 survey]. Pszichológia

2010; 30: 161–173.

30.

Peterman

Lecci

. Personal projects in health and illness. In: Little

Salmela-Aro

Phillips

(eds) Personal project pursuit: goals, action, and human flourishing. Mahwah, NJ: Lawrence Erlbaum Associates, 2007, pp. 329–353.

31.

Mann

Ridder

Fujita

. Self-regulation of health behavior: social psychological approaches to goal setting and goal striving. Health Psychol 2013; 32: 487–498.

32.

Martos

Sallay

Désfalvi

, et al. Psychometric characteristics of the Hungarian version of the Satisfaction with Life Scale (SWLS-H). Mentálhig Pszichoszomatika 2014; 15(3): 289–303.

33.

Ryan

Deci

EL.

Overview of self-determination theory: an organismic-dialectical perspective. In: Deci

Ryan

(eds) Handbook of self-determination research. USA: University of Rochester Press, 2002, pp. 3–33.

34.

Judge

Bono

Erez

, et al. Core self-evaluations and job and life satisfaction: the role of self-concordance and goal attainment. J Appl Psychol 2005; 90(2): 257–268.

35.

Sheldon

Elliot

. Goal striving, need satisfaction, and longitudinal well-being: the self-concordance model. J Pers Soc Psychol 1999; 76: 482–497.

36.

Sheldon

Kasser

Pursuing personal goals: skills enable progress, but not all progress is beneficial. Pers Soc Psychol Bull 1998; 24: 1319–1331.

37.

Bailis

Fleming

Segall

Self-determination and functional persuasion to encourage physical activity. Psychol Health 2005; 20(6): 691–708.

38.

Sheldon

Lyubomirsky

. How to increase and sustain positive emotion: the effects of expressing gratitude and visualizing best possible selves. J Posit Psychol 2006; 1(2): 73–82.

39.

Smyth

APJ

Werner

Milyavskaya

, et al. Do mindful people set better goals? Investigating the relation between trait mindfulness, self-concordance, and goal progress. J Res Pers 2020; 88: 104015.

40.

Horvát

Dávid

Sallay

, et al. Improving disease management of patients with inflammatory bowel disease: the potential role of self-concordant health goals. Front Psychol 2023; 14: 1115160.

41.

Izaguirre

Keefer

. Development of a self-efficacy scale for adolescents and young adults with inflammatory bowel disease. J Pediatr Gastroenterol Nutr 2014; 59: 29–32.

42.

Lorig

Sobel

Ritter

, et al. Effect of a self-management program on patients with chronic disease. Eff Clin Pract 2001; 4(6): 256–262.

43.

McAuley

. Self-efficacy and the maintenance of exercise participation in older adults. J Behav Med 1993; 16: 103–113.

44.

Strecher

DeVellis

Becker

, et al. The role of self-efficacy in achieving health behavior change. Health Educ Q 1986; 13(1): 73–92.

45.

Bandura

. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev 1977; 84(2): 191–215.

46.

Koestner

. Reaching one’s personal goals: a motivational perspective focused on autonomy. Can Psychol 2008; 49(1): 60–67

47.

Eindor-Abarbanel

Naftali

Ruhimovich

, et al. Important relation between self-efficacy, sense of coherence, illness perceptions, depression and anxiety in patients with inflammatory bowel disease. Frontline Gastroenterol 2021; 12(7): 601–607.

48.

Graff

Walker

Lix

, et al. The relationship of inflammatory bowel disease type and activity to psychological functioning and quality of life. Clin Gastroenterol Hepatol 2006; 4(12): 1491–1501.

49.

Sheehan

Greene-Higgs

Swanson

, et al. Self-efficacy and the impact of inflammatory bowel disease on patients’ daily lives. Clin Transl Gastroenterol 2023; 14(6): e00577.

50.

Cosnes

Gower-Rousseau

Seksik

, et al. Epidemiology and natural history of inflammatory bowel diseases. Gastroenterology 2011; 140(6): 1785–1794.

51.

Prantera

Korelitz

BI.

Crohn’s disease. Florida: CRC Press, 1996.

52.

Rowse

Hollobone

Afhim

, et al. Factors associated with life satisfaction in people with Crohn’s disease and ulcerative colitis: results from the national 2018 Crohn’s and Colitis UK Inflammatory Bowel Disease Quality of Life Survey. J Crohns Colitis 2019; 13(Suppl. 1): S042–S043.

53.

Robinson

Thompson

Wilkin

, et al. Guided self-management and patient-directed follow-up of ulcerative colitis: a randomised trial. Lancet 2001; 358(9286): 976–981.

54.

Kennedy

Nelson

Reeves

, et al. A randomised controlled trial to assess the effectiveness and cost of a patient orientated self management approach to chronic inflammatory bowel disease. Gut 2004; 53(11): 1639–1645.

55.

Koestner

Powers

Carbonneau

56.

Little

. Personal projects and the distributed self: aspects of a conative psychology. In: Suls

(ed.) The self in social perspective: psychological perspectives on the self. Mahwah: Lawrence Erlbaum Associates, 1993, pp. 157–185.

57.

Martos

Kézdy

Horváth-Szabó

. Religious motivations for everyday goals: their religious context and potential consequences. Motiv Emot 2011; 35: 75–88.

58.

Rózsa

Réthelyi

Stauder

, et al. A Hungarostudy 2002 országos reprezentatív felmérés általános módszertana és a felhasznált tesztbattéria pszichometriai jellemzői. Psychiatr Hung 2003; 18: 83–94.

59.

Schwarzer

Jerusalem

. General self-efficacy scale [dataset]. APA PsycTests. https://doi.org/10.1037/t00393-000

60.

Diener

Emmons

Larsen

, et al. The satisfaction with life scale. J Pers Assess 1985; 49(1): 71–75.

61.

Lleras

Path analysis. In: Kempf-Leonard

(ed.) Encyclopedia of social measurement. Elsevier, 2005, pp. 25–30.

62.

MacCallum

Browne

Sugawara

. Power analysis and determination of sample size for covariance structure modeling. Psychol Methods 1996; 1(2): 130–149.

63.

Katz

Tripp

Ropeleski

, et al. Mechanisms of quality of life and social support in inflammatory bowel disease. J Clin Psychol Med Settings 2016; 23(1): 88–98.

64.

Dasharathy

Long

Lackner

, et al. Psychological factors associated with adherence to oral treatment in ulcerative colitis. Inflamm Bowel Dis 2023; 29(1): 97–102.

65.

Knittle

De Gucht

Hurkmans

, et al. Targeting motivation and self-regulation to increase physical activity among patients with rheumatoid arthritis: a randomised controlled trial. Clin Rheumatol 2015; 34(2): 231–238.

66.

Peters

Brown

. The relationship between illness identity and the self-management of inflammatory bowel disease. Br J Health Psychol 2022; 27(3): 956–970.

67.

Hobfoll

Halbesleben

Neveu

J-P

, et al. Conservation of resources in the organizational context: the reality of resources and their consequences. Annu Rev Organ Psychol Organ Behav 2018; 5(1): 103–128.

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