Applying self‐determination theory towards motivational factors of physical activity in people undergoing haemodialyses: A qualitative interview study

Abstract Introduction The level of physical activity of people undergoing haemodialyses is low, so understanding what factors underlie the motivation to be physically active in people undergoing haemodialyses is important. Therefore, this qualitative study aims to explore the different motivation types and corresponding basic psychological needs (BPNs) of people undergoing haemodialyses based on self‐determination theory. Methods We adopted the objective sampling method to select 19 patients with the end‐stage renal disease aged from 28 to 66 years old from a tertiary hospital in Xi'an. They underwent haemodialyses five to six times every 2 weeks for more than 3 months. Then, we conducted semistructured one‐on‐one interviews with 19 people undergoing haemodialyses using qualitative content analysis. All interviews were recorded, transcribed verbatim and analyzed on a thematic analysis. Results We analyzed four motivation types of patients, namely four themes, including entrenching in physical inactivity (Amotivation), breaking physical inactivity (Controlled motivation), finding one's way (Autonomous regulation) and enjoying the positive effects of physical activity (Intrinsic motivation). Each motivation is dominated by one or more BPNs. For example, inadequate Competence such as decreased physical function is the reason why the patient does not perform physical activities. Due to the lack of health education on physical activity, people undergoing haemodialyses often lack the motivation for controlled regulation. The motivation for self‐regulation is generated by the patients' promotion of meeting BPNs, such as normal social interactions. The formation of patients' autonomous motivation can't be separated from the effective understanding felt by other patients, because their situations are similar. Enjoying physical activity promotes the formation of patients' intrinsic motivation and the maintenance of this behaviour. Conclusion Perceived Competence, Relatedness and Autonomous Motivation are important determinants for physical activity in people undergoing haemodialyses. Patients need to internalize the changed values and skills, so as to generate the motivation of self‐regulation, rather than external or controlled forms of motivation regulation, to better maintain behaviour change. Patient or Public Contribution People undergoing haemodialyses were involved in the development of the interview topic guide to ensure all relevant topics were explored.


| INTRODUCTION
Physical activity, including activities and purposeful exercise as part of daily living, decreases as kidney disease progresses, reaching a nadir in people undergoing haemodialyses. 1 The physical activity of people undergoing haemodialyses is significantly lower than that of healthy people of the same age and sex and shows a progressive decline, only reaching 35% of that of sedentary people without kidney disease. 2 It is also associated with poor health-related quality of life and increased mortality. [3][4][5] Meanwhile, people undergoing haemodialyses have severe symptoms and comorbidities 6 that can negatively impact physical functioning 7 and quality of life. 8,9 This also reduces the patient's physical activity, which in turn deepens the limitations of the patient's physical functions, forming a vicious circle. 10 Interestingly, physical inactivity is a major modifiable risk factor for poor health-related quality of life, morbidity and mortality in people undergoing haemodialyses. 11 People undergoing haemodialyses who are more physically active have been shown to have a lower risk of death compared with sedentary patients. 12 The UK Kidney association recommends that people undergoing haemodialyses aim for at least 30 min or moderate intensity of physical activity five times a week, and emphasizes that even small increases in physical activity may provide some benefit. 13 Although the above-mentioned 'people undergoing haemodialyses need more physical activity', this information failed to change the behaviour of people undergoing haemodialyses. To enhance an individual's physical activity, we, therefore, need to understand and explain, so that we can finally intervene in the factors that affect behaviour change. Most of the previous studies used quantitative questionnaires to study the benefits and barriers of physical activity in people undergoing haemodialyses, qualitative research can explore when and how these factors affect physical activity. [14][15][16] Previous studies based on social cognitive theory only considered the number of motivations (i.e., motivated and not motivated) for patients with chronic kidney disease, and only explored the external factors that generated motivation for physical activity, such as the benefits of physical activity to overall health. 17,18 All of these studies, without exception, explained the direction of behaviour, but did not explain how such behaviour was motivated. 19 Self-determination theory (SDT) is an organismic theory about human motivation. Its premise is that human beings have internal needs, and behaviour is not only a response to information or punishment, which provides a useful framework for better understanding the motivation behind patients' participation in sports activities. 20,21 The theory holds that individuals actively pursue three basic psychological needs (BPN): Autonomy, Competence and Relatedness. Autonomy refers to the need for individuals to act, control and support behaviours and make decisions. Competence is the need to feel capable and effective when completing tasks.
Relatedness is the need to experience meaningful connections with others in one's own environment. When patients participate in physical activity and meet their three BPN, their self-determined motivation will develop and enhance. 22 More specifically, patients would enjoy the activity (Intrinsic motivation), integrate it into their lifestyle and realize that physical activity is important because it has related benefits (Autonomous regulation). On the other hand, if the BPN is not satisfied, the patient would get more controlled physical activity or movement. Controlled regulations reflect participation in physical activity with an internal sense of obligation to avoid guilt, or obtain external incentives or avoid punishment. Both Autonomy regulation and Controlled regulations belong to extrinsic motivation.
Amotivation implies a lack of motivation and interest in activities.
Self-motivated behaviours are associated with more favourable physical and mental health outcomes. 23 On the contrary, those social conditions that undermine these psychological needs will lead to more controllable motives, thus causing the pressure of obedience to damage behaviour. SDT emphasizes the importance of motivation HUANG ET AL. | 1369 quality more than motivation quantity because different motivation types will produce different activity states. And motivation quality is self-regulated. 24 The purpose of this study is to explore the different types of motivation and corresponding BPN of patients when they participate in physical activities based on SDT. This will help researchers design future physical activity interventions to promote BPN satisfaction and compliance.

| Design
A basic qualitative design was used to complete interviews with patients. 25 Patients were interviewed using individual semistructured interviews suitable for exploring individuals' experiences and opinions.

| Study setting and participants
The study was conducted in the haemodialyses ward of a tertiary hospital in Xi'an, China, from March to June 2022. Patients who met the inclusion and exclusion criteria were contacted after a clinical consultation and obtained a patient information form. Participants with end-stage renal disease, receiving five or six haemodialyses every 2 weeks and more than 3 months met the inclusion criteria for this study. Participants with cognitive impairment who couldn't cooperate with the interviews; and patients with severe physical limitations to activity were excluded. Purposeful sampling methods were then used to ensure that the sample was differentially representative in terms of sex, age and frequency of haemodialyses.
All participants who meet the inclusion and exclusion criteria have signed the informed consent form. The researcher obtained the patient information form from the medical staff, so as to contact the patient after the interview. This study was approved by the Ethics Committee of Xi'an Jiaotong University (No. 20211575).

| Data collection
All patients were interviewed face-to-face in the haemodialyses unit, which lasted 30-45 min. The interview was conducted by M. H., a researcher who systematically studied the relevant theories of qualitative research and repeatedly practiced and confirmed that she has mastered the skills of a qualitative interviews. Interviews followed a semistructured format that was developed based on research objectives, previous research and clinical observations (Supporting Information: Table 1). Before using the interview topic guide, we selected 2-4 people undergoing haemodialyses for preinterview, and further modified and deleted the interview topic guide according to the effect of the preinterview to determine the final version of the interview topic guide. All interviews were recorded digitally, anonymously and verbatim by professionals. Read transcripts while listening to audio files to ensure accuracy. The verified transcript is returned to the patient for examination to ensure accuracy. All audio files and scripts were imported into NVivo 11 (QSR International NVivo 11 Pro). Demographic and clinical data were extracted from medical records.

| Data analysis
Data collection and analysis for this study were conducted concurrently to explore new concepts in the remaining interviews.
Data were analyzed using qualitative content analysis. 26  The code for each interview has been revised and reviewed and divided into categories and subcategories. Emerging categories and subcategories were edited to avoid overlap between categories and excessive heterogeneity within individual categories. 27 The research team stopped the inclusion of research subjects when no new information appeared, and finally, 19 research subjects participated in the interview, meeting the principle of data saturation.

| RESULTS
Nineteen people undergoing haemodialyses were invited to take part in the study. The demographic characteristics of each participant are illustrated in Table 1.

| Entrenching in physical inactivity (Amotivation)
Exemplar quotations for this category are presented in Table 2.
Some participants were reluctant to change due to insufficient Competence, lack of experience of relevance and lack of conditions, so they are usually in a state of physical inactivity.

| Lack of support from family and friends (Relatedness)
Failed physical activity experiences created fear of activity in the patient and, more importantly, were the strong reason for the family to discourage the patient from being active. Going out with friends or colleagues was a good opportunity for patient activity. However, the excessive sense of responsibility of friends was worried that going out will cause secondary harm to the patients, which gradually reduced the opportunities for the patients to participate in activities.
At the same time, it also damaged the social interaction of patients, and the concept of 'patients are sick and different from normal people' was deeply rooted in the patients' mind.
Although nephrologists regularly see patients, they have poor health education on physical activities for patients. Some patients said that they never learned this from the staff of the nephrology department, and thought that the staff was too busy to explain the physical activity to patients. At the same time, the patient felt that the staff did not mention physical activity, indicating that it was not important.

| Lack of external conditions (Autonomy)
Patients described in detail how severe weather hindered their plans to travel outside.
T A B L E 2 Entrenching in physical inactivity (Amotivation) exemplar quotations.

| Breaking physical inactivity (Controlled regulation)
The patients dominated by Controlled motivation also began to perform physical activities, but their execution and persistence were poor. Exemplar quotations for this category are presented in Table 3.

| In preparation for kidney transplantation (Competence)
Overweight patients usually lose weight through physical activity to successfully obtain additional rewards, that is, to reach the standard of kidney transplantation.

Major themes Minor themes Exemplar quotations
Keeping healthy is an important personal goal (Competence) Fear of rapid decline of physical condition I was afraid that I would not be able to walk. These patients who have come here for more than ten years will be in wheelchairs. What should I do? I am afraid of this….There is a dialysis aunt here, who is over 60 and in good spirits. She always looks after her daughter. She walks two or three kilometers every day, and she deliberately goes to this distant vegetable market to buy vegetables. She has been through it for decades. I think she is in good spirits. (

| Enjoying the positive effects of physical activity (Intrinsic motivation)
When patients enjoy physical activity, they will insist on physical activity all the time. Exemplar quotations for this category are presented in Table 5.

| DISCUSSION
According to SDT, the results describe the four motivation types of physical activity and the corresponding BPN of people undergoing haemodialyses. It can be seen that when three BPNs are not satisfied, the patient has no motivation to do physical activities. When the three BPNs are satisfied, the patient will adjust motivation autonomously, which is beneficial to maintain physical activity.
When people undergoing haemodialyses have no motivation for physical activity, it shows that they are in a state of low physical activity. The patient's Competence, Relatedness and Autonomy are unmet in this motivation type. Amongst them, patient's physical function is decreased, that is, Competence, which is insufficient to T A B L E 5 Enjoying positive effects of physical activity (Intrinsic motivation) exemplar quotations.

Major themes Minor themes Exemplar quotations
Physiological and psychological effects (Competence) Physical function improvement I think doing regular physical activity is also very powerful. In the past ten years, I have never had this flu, and I have not taken cold medicine once in more than ten years. I think this is an encouragement to me. (Q30, I) Full of energy and vitality I don't have the energy if I don't walk. If I walk more often now, I will feel better. (Q31, L) Reduced restrictions on basic needs I can't drink water if I'm not active. Because as soon as I drink water, the weight will increase, and then the amount of hemodialysis will increase. If the amount of hemodialysis is increased, I will suffer. I walk more every day; I can sweat and drink more water. (Q32, R) Enjoyment (Autonomy) Sense of achievement I think it's still useful to go out and walk around every day. The doctors all said, 'You see this old lady is still doing well'. I think this sentence gave me a lot of encouragement. (Q33, I) Enjoying being active Last year on National Day, even though it was cold and rainy, I ran. I was running hot, sweating, and feeling very comfortable. Now I enjoy running more and more. (Q34, O) I was physically active every day. Even though I was a little uncomfortable that day and did not want to run, I would still walk, taking a 20 minute, nearly 30 minutes path. (Q35, P) support patients to participate in physical activity. Patients also use external conditions as an excuse to reduce their Autonomy, such as bad weather.
Nephrology staff are the best candidates to teach physical activity knowledge to people undergoing haemodialyses. However, unlike mass exercise rehabilitation for cardiopulmonary disease, physical activity has not become a healthcare priority for nephrology staff. 28 This is related to the lack of detailed and clear guidelines. 29 Moreover, the lack of formal referral channels for the rehabilitation of people undergoing haemodialyses may lead to nonstandard patient counselling provided by nephrology staff. 30 49 This is because over time, the effects of physical activity are fully realized and the patient gradually enjoys the process, and then the extrinsic motivation becomes more internalized, promoting the maintenance of physical activity. 43 Moreover, their BPN has been met, and patients are more likely to show initiative during physical activity. 33 In fact, some people believe that when a person has an intrinsic and determined motivation, the lifestyle behaviour of maintaining physical activity is most likely, and can better cope with the common challenges of behaviour change (such as time shortage, holidays and daily changes). Extensive research showed the importance of self-motivated physical activity participation forms, because compared with behaviours based on external motivation and less internal motivation, autonomous and voluntary behaviours will bring greater participation and durability.
Although this study provides new insights into the determinants of the transition from physical inactivity to physical activity in people undergoing haemodialyses, there are some limitations. The participants screened in this study may be a group of people undergoing haemodialyses interested in physical activity. The sedentary patient may have refused our interview, and we do not fully understand their lack of motivation. Interestingly, the reasons for the decline in interview participants were also factors that affected physical activity levels. Therefore, the results may not cover all potential barriers.
Future research will benefit from capturing more sedentary patients.
In addition, we did not have the dynamic change process of physical activity behaviour motivation of patients from receiving haemodialyses treatment, nor did we provide strong evidence for the motivation continuum in SDT.

| CONCLUSION
The results of this study suggest that clinicians should consider the quality of patients' motivation, not just the quantity. BPN plays an important role in the change of patients' motivation. For example, the most basic thing is that patients want to be able to participate in activities of daily living, they also need to receive health education from nephrology staff, and the understanding and support of families can promote their self-regulation motivation. Moreover, health services should actively support the physical activity of people undergoing haemodialyses and provide regular physical activity counselling. Employees also may need to have the skills to engage (motivational interviewing) and motivate patients through dialogue. As for patients, they need to internalize the changed values and skills, so as to generate the motivation of self-regulation, rather than external or controlled forms of motivation regulation, to better maintain behaviour change.