Many individuals do not engage in health-promoting behaviors that would confer important
health benefits despite research that has shown that engaging in a suite of four health
behaviors (physical activity, eating a healthy diet, not smoking, drinking alcohol
in moderation) leads to a 11–14 year delay in all-cause mortality (Khaw et al., 2008;
Ford et al., 2011). Motivating people disinclined to engage in health behavior presents
a significant challenge to public health practitioners. Although there have been advances
in interventions to increase individuals' motivation to engage in health-related behaviors,
gaps in knowledge exist. In particular, effective strategies to promote behavior change
in individuals with little or no motivation to change are relatively scarce.
Most social psychological theories applied to health behavior change tend to assume
a degree of motivation for change and have focused on attempts to promote action by
converting motivation into action. Approaches such as goal-setting (Locke, 1996; Fenner
et al., 2013), self-monitoring (Miller and Thayer, 1988), action planning (Schwarzer,
2014), and implementation intentions (Gollwitzer, 1999; Hagger and Luszczynska, 2014)
focus on harnessing motivation and promoting action in those already likely to be
motivated to change. As a consequence, such approaches are heavily dependent on individuals
having some motivation to change even though they are not actually engaging in the
behavior. These individuals are best characterized as “inclined abstainers” (Orbell
and Sheeran, 1998) or “unsuccessful intenders” (Rhodes and de Bruijn, 2013). The approaches,
however, do not focus on individuals with low or no motivation to change which account
for a substantive proportion of the population. For example, less than 10% of smokers
report wanting to quit (Wewers et al., 2003) and 60% of smokers do not make a quit
attempt during any given year (Centers for Disease Control and Prevention, 2007).
Similarly, up to 30% of individuals express no intention to exercise (Ronda et al.,
2001; Rhodes and de Bruijn, 2013). It is clear, therefore, that a large number of
individuals are not motivated to engage in health-promoting behaviors and tend to
be those most at risk. In this article, we briefly review theoretical perspectives
focusing on individuals who are not motivated to engage in health-promoting behaviors.
We contend that although theories identify low motivation as a state, they do not
provide complete explanations of, and underlying reasons for, the absence of motivation,
nor do they suggest comprehensive strategies that may engage these hard-to-reach individuals.
We offer some theory-derived suggestions on how to engage unmotivated individuals
to increase their participation in health-promoting behaviors.
Two prominent theoretical perspectives offer conceptualizations of “unmotivated” individuals:
self-determination theory and the transtheoretical model. Self-determination theory
(Deci and Ryan, 1985, 2000) distinguishes between different types of motivation or
reasons underlying behavioral engagement (Chatzisarantis et al., 2007, 2008). According
to the theory, the state in which an individual lacks intention to act is termed amotivation
(Vallerand, 2001). Individuals reporting being amotivated toward health behaviors
are unable to identify the reasons why they act, and tend to have low intentions and
poor uptake and adherence to health behaviors (Thøgersen-Ntoumani and Ntoumanis, 2006).
Similarly, the transtheoretical model identifies several stages that characterize
individuals on a continuum of change with respect to health behavior (Prochaska et
al., 2005). Individuals in the precontemplation stage have no apparent interest in
engaging in health behavior. Individuals in this stage do not consider the need of
change and are resistant to suggestions of change. Some theorists have drawn parallels
between the precontemplation stage and amotivated states (Thøgersen-Ntoumani and Ntoumanis,
2006). Both perspectives do not provide explicit solutions to addressing individuals
in amotivated and precontemplative states. For example, interventions based on the
transtheoretical model for precontemplators have tended to be limited to targeting
the experiential processes of consciousness raising and dramatic relief that amounts
to the information provision, both of which have limited effectiveness in changing
behavior in those with low motivation (Foster et al., 2005; Miller and Rollnick, 2013;
Peters et al., 2013). We argue that improving intervention effectiveness for unmotivated
individuals should begin with an analysis of the underlying reasons for being in an
amotivated or precontemplative state when it comes to health behaviors and how these
may be specifically targeted in interventions.
Some research has examined the etiology of amotivation from a self-determination theory
and social-cognitive perspectives (Pelletier et al., 1999; Vlachopoulous and Gigoudi,
2008; Shen et al., 2010). Amotivation may stem from low levels of self-efficacy, outcome
expectancies, effort beliefs, and value beliefs (Vlachopoulous and Gigoudi, 2008;
Shen et al., 2010). Low self-efficacy relates to low confidence and feelings that
the individual lacks the capacity or resources to produce the desired behavior. Low
outcome expectancies relate to beliefs that the costs of the behavior outweigh the
benefits. A lack of effort beliefs is concerned with the recognition of the required
amount of effort or energy needed to change behavior (e.g., perceiving physical activity
as “too hard”), or overcome the perceived barriers and disinhibiting factors (e.g.,
fear of embarrassment, lack of knowledge), and being willing to invest the necessary
effort to achieve the desired outcome. Further, low value beliefs relate to not attaching
sufficient value to the behavior to make it worthwhile pursuing (Wigfield and Eccles,
2000). Low outcome expectancies and value beliefs, therefore, serve as demotivating
factors. These sets of beliefs provide clear direction regarding the conditions that
lead to the development of amotivation and how they could be addressed. Based on these
findings, strategies aiming to reduce amotivation could include confidence-building
strategies, targeting decisional balance and also those that focus on changing effort
and value beliefs. Given that these types of strategies have been used in counseling
approaches to changing behavior, such as motivational interviewing (Miller and Rollnick,
2013), it raises the possibility that these may be viable avenues to resolve unmotivated
states like amotivation.
Motivational interviewing (Miller and Rollnick, 2013) is a counseling approach to
behavior change. It is well suited to those unmotivated to change as it focused on
building motivation for, and reducing resistance to, behavior change (Hardcastle et
al., 2008, 2013). The interpersonal style and behavior of the practitioner are central
to motivational interviewing (Hagger and Hardcastle, 2014). Few approaches are explicit
about the importance and impact of the relational style in which interventions are
delivered, particularly for those who are not motivated to engage in health behavior.
The specific relational motivational interviewing techniques that may be useful when
working with those less motivated to change include: reframing, overshooting, coming
alongside, shifting focus, and emphasizing autonomy. The content-related techniques
that could be adopted are those that seek to elicit “change talk” (arguments for change)
and reduce “sustain talk” (the person's own arguments for not changing). These techniques
include “running head start,” “looking forward,” and “values exploration.” “Running
head start” is used to elicit client motivational talk through the counselor first
asking open questions to explore the pros of the status quo, in order to then query
the cons of the status quo. The client is also asked about the cons of changing followed
by the pros of changing their behavior. “Looking forward” is a strategy to build motivation
by the counselor prompting the client to envision two possible futures and deemed
to be very useful in a physical activity intervention (Hardcastle et al., 2012). The
first future is if they continue on the same path without any changes. The second
future is if they decide to make a change and prompting them to consider “what that
future may be like: if you did decide that now is not the time to change and we meet
up in five years from now, what would things be like for you? What about that concerns
you the most?” And “If you were to change, what would life be like in the future?
How would you feel? How would things be different?” “Values exploration” is a strategy
for evoking motivation by having clients describe their most important life goals
and values (Miller and Rollnick, 2013). Example questions include: what things are
most important to you?” or “what do you want most in life?” and “how does your (behavior)
fit in with your goals and values?” Focusing on discrepancies between ideal life conditions
and actual conditions may induce a desire to “recalibrate” daily behaviors to be more
congruent with deeply-held, amotivated beliefs. Focusing on ideals can help decrease
clients' defensiveness and foster motivation for change by transferring the focus
away from “bad” behaviors or lifestyle, toward a focus on a more deeply satisfying
lifestyle that can be pursued and enjoyed. The values exploration technique does not
appear to have been adopted in motivational interviewing interventions outside of
the substance abuse field and only one study was located that specifically explored
the effectiveness of a values exploration technique in a weight loss intervention
(e.g., Webber et al., 2008).
Other perspectives on changing behavior in individuals that are unmotivated to engage
in health behaviors come from dual-process theories of action. According to this perspective,
behavior is driven by two processes: conscious consideration of the pros and cons
or expectancies of the value of engaging in the behavior relative to potential costs
of doing so, and non-conscious processes that are spontaneous, impulsive, and occur
with little deliberative thought (e.g., Strack and Deutsch, 2004; Hagger and Chatzisarantis,
2014, 2015 Hagger et al., 2015). Many unhealthy behaviors including unhealthy eating,
smoking, and drinking excess alcohol have been conditioned by cues in the environment
paired with the concomitant reward-based outcome, usually determined by dopaminergic
pathways in the brain which serve as powerful reinforcers of the cued-up behavior
(Rebar et al., 2015). As such, exerting conscious control to override these strong
neural relations between cue and action is difficult and requires considerable cognitive
resources and motivation (Hagger, 2010, 2014; Loftus et al., 2015; Rebar et al., 2015).
By implication, low resources and motivation to engage in conscious effort to resist
the powerful cue-driven urges makes behavior change extremely difficult. This means
that individuals that are unmotivated to engage in health-related behaviors are unlikely
to change because they are not motivated to invest effort in overriding the highly-automated
non-conscious cue-driven processes that drive their behavior. In such circumstances,
researchers have indicated that it may be important to structure individuals' environments
so as to make engaging in the undesired behavior much more difficult (Sallis et al.,
2012). Examples of environmental solutions that may change behavior among the unmotivated
without engaging in costly persuasive techniques include: bans on smoking in public
places and the workplace, employers locating car parks a distance from workplaces
so employees walk a given distance to work each day, and limiting the number of alcoholic
beverages that can be served in bars. Such legislation requires considerable will
among policymakers and is not necessarily a universal solution. For example, banning
smoking in public places and workplaces is unlikely to affect smoking at home. Environmental
strategies may form part of a comprehensive package of solutions to changing behavior
in the unmotivated.
To conclude, we contend that current theoretical perspectives on behavior change do
elaborate sufficiently on how to approach individuals with low motivation to participate
in health behavior. We have proposed some possible suggestions for future research
on how to potentially engage individuals who are unmotivated to participate in health-promoting
behaviors. These strategies outlined include the targeting of self-efficacy, outcome
expectancies, effort and value beliefs; motivational interviewing techniques including
strategies like running head start, looking forward, and values exploration, and we
recommend their use in health behavior interventions that target those unmotivated
to change. We also recognize that environmental interventions have a crucial role
to play in promoting health behavior change among the unmotivated. It is important
to note that these strategies may assist in increasing motivation among individuals
to initiate a health related behavior. Increasing motivation is an important first
step among amotivated or precontemplative individuals who do not engage in any health
behaviors. Further strategies, however, may be needed to assist in the enactment of
the behavior (e.g., planning, volitional strategies) and maintain it over the longer
term (e.g., self-monitoring and self-reinforcement).
Author contributions
SH took the lead role in conceiving and developing the ideas presented in the article
and drafting the article; MH assisted in the conception of the article and took a
lead role in editing and drafting the article; JH, AH, CM, and CT assisted in providing
ideas for the article and assisted in drafting the article.
Conflict of interest statement
The authors declare that the research was conducted in the absence of any commercial
or financial relationships that could be construed as a potential conflict of interest.