A Self Determination Theory Approach to Therapeutic Recreation

Autonomy Support at Diabetes Camp: A Self Determination Theory Approach to Therapeutic Recreation

Hill, Eddie

Adolescents with type 1 diabetes struggle to effectively manage their illness. Failure to take responsibility for regulating glycemic levels can lead to a number of very significant physiological, psychological, and social problems. This study employed a Benefits-Based Programming (BBP) approach and self-determination theory (SDT) to target outcomes through a recreation camp setting. The SDT provided researchers with a theoretical framework that focused on the internalization of diabetes management. The camp setting was chosen because annually diabetes camps serve more than 10,000 adolescents. Empirical evidence supports the use of theory-based camping for therapeutic purposes among adolescents with disabilities and illnesses to increase self-esteem, self-image, and self-determined behaviors (Brannan, Fullerton, Arick, Robb, & Bender, 2002; Mahon, 1994; Marsh, 1999). The results of this theory-based study can be used by recreation therapists and recreation programmers to help increase the effectiveness of other diabetes camps. Results of the regression equations showed perceived autonomy support to be significantly and uniquely related to the predicted outcome variable (e.g., competence for diabetes management).

KEY WORDS: Self-determination theory (SDT), self-management, internalization, type 1 diabetes, Benefits-Based Programming (BBP), summer camp, and motivation.

Purpose of the Study

Physicians assert that people with type 1 diabetes should provide 95% of the behavioral management for their own disease. Existing evidence, however, indicates that adolescents manage less than 20% of their diabetes (Anderson, 1985). Failure to internalize behaviors and take responsibility for regulating glycemic levels can lead to a number of very significant physiological, psychological, and social problems. Poor management of glycemie levels can lead to aggression, antisocial conduct, anxiety, depression, kidney failure, stroke, nontraumatic amputations, and death (Bryden, Peveler, Stein, Neil, Mayou, & Dunger, 2001).

A Benefits-Based Program may lessen adolescents’ poor management of type 1 diabetes. Benefits-Based Programming (BBP) emphasizes the use of a theoretical framework to target outcomes through recreation programs (Hurtes, Alien, Stevens, & Lee, 2000). A key to the success of such programs for adolescents with diabetes is the facilitation, production and execution of recreation experiences that are explicitly designed to help those individuals internalize behaviors for self-management. Benefits-based programming also emphasizes the importance of using intentionality and theoretical frameworks.

Self-determination theory states that behaviors are autonomously motivated to the extent that people experience a true sense of volition and choice (Deci & Ryan, 2000; Williams, Rodin, Ryan, Grolnick, & Deci, 1998). It is unlikely that management of behaviors for adolescents with diabetes will be truly intrinsically motivated. Therefore, addressing extrinsic motivation may be the most effective way to increase internalized behavior (Deci & Ryan, 2000). “At this point [internalization] of the individual’s behavior has been brought into congruence with one’s values and needs” (Deci & Ryan, 2002, p. 201). Internalization, for the purpose of the study, is defined as behaviors that are congruent with one’s own values. Self-determination theory (SDT) provides a framework to explain what is needed for diabetes self-management behaviors to become internalized.

Empirical evidence supports the use of theory-based therapeutic camping for adolescents with disabilities and illnesses to increase selfesteem, self-image, and self-determined behaviors (Brannan, Fullerton, Arick, Robb, & Bender, 2002; Mahon, 1994; Marsh, 1999). Camping programs for people with diabetes serve more than 10,000 adolescents annually (American Diabetes Association, 2003). Therefore, the purposes of this study were to examine both the effects of an intentional, summer camp recreation program on internalization of type 1 diabetes management behaviors among adolescents and the role that autonomy support plays in diabetes management.

Review of Literature

Type 1 Diabetes

An increasing number of adolescents are being diagnosed with type 1 diabetes, but are unable to effectively manage their illness (Byrden et al., 2001). Type 1 diabetes develops when the body’s immune system destroys pancreatic beta cells, the only cells in the body that produce the hormone, insulin. Treatment requires the injection of insulin through a syringe or pump several times a day. Unfortunately, adolescents struggle to make the connection between careful self-management skills practiced in adolescence and the impact on quality of life as an adult. When glycemic control deteriorates from childhood to young adulthood, individuals are at risk of developing short and long-term complications (Byrden et al., 2001; Mann & Johnston, 1982). Shortterm health complications for adolescents with type 1 diabetes can lead to immediate problems at school, home, and in recreation activities.

Self-Determination Theory

Self-determination theory is a theoretical framework used in recreation (Sibthorp, Paisley, & Hill, 2003) and health care management research (Ryan, Plant, & O’Malley, 1995; Williams, Grow, Freedman, Ryan, & Deci, 1996; Williams et al., 1998). Researchers have demonstated that when patients’ motivation for health care behavioral change is primarily autonomously directed, they are more likely to engage in healthy behaviors (Williams, 2002). Thus, autonomy results from an internalization of regulatory behaviors.

Following the SDT model, enhanced competence, autonomy, and relatedness leads to increased internalization, thereby increasing self-determined behavior (Deci & Ryan, 2000). A feeling of competence results when a person takes on and, in his or her own view, meets optimal challenges. Autonomy refers to the perceived origin or source of one’s own motivation (deCharms, 1968; Deci & Ryan, 1985; Ryan & Connell, 1989). Relatedness refers to the feeling of connection, and the ability to care for and being cared for by others, giving a sense of belongingness with other individuals and with one’s own community (Baumeister & Leary, 1995; Bowlby, 1979; Ryan, Plant, & O’Malley, 1995).

In addition, SDT stresses the importance of satisfying competence, autonomy, and relatedness through autonomy supportive environments. These environments are needed for individuals to take ownership of their behavior (Deci & Flaste, 1995; Deci & Ryan, 2000), and to provide choice, perspective taking, and rationale giving (Sheldon, Williams, & Joiner, 2003). A few selected choices about behavior (at the practitioners’ discretion) offer some ownership to the individual making the decision. Practitioners, physicians, counselors, or educators can offer perspective taking through a paradigm shift. Taking a step back and thinking about things from the participants’ viewpoint offers a sense of understanding and empathy for individuals with diabetes. Giving a rationale for suggestions or requests is important so that the individual does not feel the provider is telling him or her what to do (Deci & Flaste, 1995). Providing a rationale also helps the individual make a well thought-out decision based on the information provided. Sheldon et al. (2003) found that providing an autonomy supportive environment significantly promoted internalization in persons with tobacco dependence, mental health issues, substance abuse, and type 1 diabetes.

Underpinnings of SDT

The SDT in its most basic form addresses motivation. Deci and Ryan emphasize the importance of individuals satisfying their need for competence, autonomy, and relatedness, as well as having an autonomy supportive environment, in order to internalize behavior. These three psychological factors are all interrelated. For example, if an individual is competent, yet is not given choice, he or she may not make an internalized decision. In addition, if the same competent individual does not feel connected to others or that the decisions he or she makes are unsupported by others, he or she is still unlikely to internalize behavior. Researchers indicated that providing an autonomy supportive environment may be the best way to satisfy the three needs, thus leading to internalization (Sheldon, William, & Joiner, 2003).

Figure 1 illustrates the essence of extrinsic motivation based on the SDT. At the far left of the figure behaviors are represented that are externally motivated, and on the far right is intrinsic motivation. Thus, the middle section of the continuum represents various forms of extrinsic motivation. Extrinsic motivation occurs on a continuum (shown in Figure 1) with four levels: external regulation, introjected regulation, identified regulation, and internalization regulation (Deci & Ryan, 2002).

The most self-determined form of extrinsic motivation is integrated regulation or internalization (Deci & Ryan, 2000). “At this point the individual’s behavior has been brought into congruence with one’s values and needs” (Deci & Ryan, 2002, p. 201). This form of regulation is most often associated with positive experiences, and is the most autonomous and internal form of extrinsic motivation (Deci & Ryan, 2000). Even though these types of behaviors appear to be chosen, they are conceptualized as falling under extrinsic motivation. Certain behaviors may never be intrinsically motivated. The behaviors (i.e., self-administering insulin shots) continue to be dependent on extrinsic motivation. It is unlikely giving oneself an injection of insulin will ever be done for the enjoyment itself. However, internalized regulation is the most autonomous form of extrinsic motivation.

Therapeutic Recreation and Diabetes

Many professionals have begun to realize the benefits of Therapeutic Recreation (TR) services that target diabetes management. Caldwell, Finklestein, and Demers (2001) explored how leisure experiences differ between diabetic and non-diabetic adolescents. To our knowledge, this research was the first of its kind to explore this population’s leisure experiences. The differences were not statistically significant and “The youth in the study appeared to have the same levels of parental control in leisure and self-determination in leisure as did the youth in the comparison group” (p. 244). However, the more researchers begin to explore parental influence on a child’s motivation for diabetes management (e.g., at camp), the more parental influence was viewed as an important variable.

Programs in therapeutic recreation using an intentional and theoretical framework have been shown to be effective (Carruthers & Hood, 2002; Ellis, Braff, & Hutchinson, 2001; Phoenix, 2001), but little research has explored TR services in diabetes camps. Diabetes camps are speculated to be beneficial to participants. These camps provide active contexts for therapeutic recreation programming and allow realistic practice of exercise, glucose, diet, and injection control in an authentic medium without parental influences. The participants’ blood sugar will naturally be affected with increased levels of activity (e.g., running, swimming, and hiking). The camp experience offers teens the opportunities to share common experiences, to meet others with diabetes, and to form meaningful friendships.

During the summer of 2002, a pilot study was conducted to determine the effectiveness of a diabetes camp that targeted self-management skills. The Recreation Opportunities for Adolescents with Diabetes (ROAD) program utilized a Benefits Based Programming (BBP) design. Benefits Based Programming focuses on intentional recreation programming and uses a four step model: 1) identify desired outcomes, 2) program for those specific outcomes, 3) assess the outcomes, and 4) share findings with organizations that can benefit from results. The ROAD program piloted two approaches. One program was wildernessbased and the other program was a camp-plus. Camp-plus was a traditional camp with the addition of intentional components. The campplus program evaluation provided evidence that an intentional recreation program targeting internalized diabetes management was promising. The evidence indicated that the camp-plus setting was the more sustainable model (Sibthorp et al., 2003).

Figure 2 displays the model, based on the SDT principals, of a benefits-based camp to foster competence, autonomy, and relatedness for diabetes management through an autonomy supportive environment. The SDT suggests that individuals meeting these basic psychological needs will internalize behavior and be more self-determined in their behaviors. As individuals begin to meet these three psychological needs, they begin to integrate behavioral regulation and move toward more internalized behaviors. Subsequently, diabetes may become more internalized as they begin to manage their diabetes. Therefore, the following hypotheses were examined:

H^sub 1^: Benefits based camp participants will score significantly higher on measures of competence, autonomy, and relatedness for diabetes management than a comparison group of campers with diabetes not participating in theory-based programs, while controlling for pretest scores of competence, autonomy, and relatedness for diabetes management.

H^sub 2^: At the three month follow-up, benefits based camp participants will score significantly higher on measures of competence, autonomy, and relatedness for diabetes management than the comparison group of campers with diabetes not participating in theory-based programs, while controlling for pretest scores of competence, autonomy, and relatedness for diabetes management.

H^sub 3^: Camper perceptions of an autonomy supportive camp staff will be positively and uniquely related to postcamp perceptions of competence, autonomy, and relatedness for diabetes management, while controlling for pretest scores of competence, autonomy, and relatedness for diabetes management.

Methods

The purpose of this study was to examine the effects of an intentionally programmed camp on intemalization of diabetes management among adolescents with type 1 diabetes. A quasi-experimental (SDT theory-based) study was designed and implemented and compared to an existing program model at another diabetes camp. The experimental camp was a six day intentionally programmed camp grounded in SDT principles. The camp staff of the experimental group attempted to create an autonomy supportive environment while fostering the attainment of the three psychological needs of the SDT: competence, autonomy, and relatedness. Campers attended activities including diabetes education, meal planning assistance, camper led parent training, testing and adjustments, leisure education, camp games and activities, daily runs and exercises, challenge course initiatives, and free time.

Setting

The quasi-experimental study took place at the Foundation for Children and Youth with Diabetes (FCYD) Teen Week’s camp, located at Camp Redcliff near Huntsville, Utah. The FCYD diabetes camp was founded in 1962. Presently, this diabetes camp has increased its membership to include over 1,000 campers and 400 volunteer staff annually, making it the largest volunteer-based diabetes camp in the United States. Teen Week is offered once during the summer. Typically, Teen Week summer camp includes daily education on diabetes management and many recreational opportunities, such as swimming and hiking. Many counselors at FCYD diabetes camp were former campers who now volunteer their time. Students (e.g., medical, dietary, and pharmacy) have also served as counselors. Each session of camp is staffed by physicians, dietitians, nurses, certified diabetes educators, pharmacists, and infirmary staff, all of whom are volunteers.

Camp Hodia (comparison group) is Idaho’s only camp for children with diabetes. Their Teen Camp is maintained and operated by a staff of volunteers, including physicians, registered nurses, registered dietitians, counselors, and assistants. The camp is located near Alturas Lake in the Sawtooth Mountains north of Sun Valley, Idaho. Hodia’s unique name was created from the last two letters of Idaho “Ho” and from the beginning of diabetes “dia.” Campers at Hodia took part in very similar activities to the FCYD group. Camp activities included diabetes education, rock climbing, water events, and other camp activities. Teen camp presented a mixture of adventure programs, in-depth discussion groups about diabetes management, and time to socialize. Camp offered teens the opportunities to share common experiences, to meet others with diabetes, and to form meaningful friendships.

Participants

This was a convenience sample and consisted of 60 participants from FCYD and 74 participants from Hodia who had pre-registered for camp. The participants’ ages ranged from 13 to 18 years and included both males and females. Permission to participate was granted by the adolescent and the parent. All participants had been diagnosed with type 1 diabetes. The non-diabetic campers who attended camp (i.e., siblings) were excluded from the data collection process. All participants were enrolled in a diabetes camp in the summer of 2003.

Measurement

The measured dependent variables were competence for diabetes management; autonomy for diabetes management in diet, exercise, injections, and glucose; relatedness for diabetes management; and perception of autonomy support from camp staff. These items were scored on a six-point Likert scale, with 6 indicating the participant strongly agreed with the response. At the end of the questionnaire, the campers were asked to include their age and the last four digits of their phone number for coding.

The Perceived Competence Scale is a four item questionnaire. The items are typically written to be specific to the relevant behavior or domain being studied (William, Freedman, & Deci, 1998). The alpha reliability for the perceived competence items in this study was .89. In a study by Williams et al. (1998) the factor loaded cleanly and showed evidence of face validity. An example question is, “I feel confident in my ability to manage my diabetes.”

The 32-item Treatment Self-Regulation Questionnaire was used to measure the degree of autonomy perceived in four areas of diabetes management: diet, exercise, glucose monitoring, and injections/bolus. The Cronbach’s alpha for this study was .95. Researchers using the TSRQ have demonstrated its content validity (Williams et al., 1998). An example question is “the reason I would monitor my diet and exercise is because I feel that I want to take responsibility for my own health.”

The three item Basic Psychological Needs Scale was used to determine the level of relatedness/social connectedness to others as it pertains to diabetes management. The Cronbach’s alpha for this study was .71. Researchers using this scale have determined evidence of face validity in the context of SDT (LaGuardia, Ryan, Couchman, & Deci, 2000). A modified version of the three relatedness items from this scale was used. One item on the original instrument read, “While managing my diabetes, I feel a lot of closeness.” When piloting the instrument, however, camp counselors who were diagnosed with diabetes, as well as campers found the question to be unclear. The question was then modified to read, “While managing my diabetes, I feel a lot of closeness from others.”

The Health-Care Climate Questionnaire measured campers’ perceptions of the degree of autonomy support offered by camp staff. The four item version from this scale was used and had an alpha reliability of .88 for these data. An example question is “I feel that diabetes camp staff has provided me choices and options about managing my diabetes.”

Procedures

The intervention, a six day benefits-based camp, was grounded in SDT. Many aspects of the experimental camp supported campers’ autonomy while meeting the three psychological needs adopted from the SDT: competence, autonomy and relatedness for diabetes management. The following are examples of techniques used by staff in the experimental group.

Satisfying Competence, Autonomy and Relatedness for Diabetes Management

Satisfying competence for diabetes management was targeted through camp experiences that instilled knowledge of diabetes management. Activities included, but were not limited to, diabetes education, leisure education, challenge course initiatives, swim tests, and the ALAST [a parent training led by adolescents]. Adolescents were encouraged to self monitor and regulate glucose, and take part in leisure education. Diabetes education was a primary example of how competence was targeted and fostered during camp. During diabetes education sessions, campers shared their current knowledge of diabetes and asked questions about areas that were pertinent to their daily life. This allowed campers to learn information that was both important and essential for better management (e.g., How can I eat fast food with my friends and manage my blood sugar?).

Autonomy for diabetes management was targeted through a camp experience that fostered choice and a sense of self-controlled behavior. The types of activities that targeted autonomy included the choice of diabetes education, food selection and amount, testing and adjusting, leisure education, and free time. Food selection and meal planning were examples of how autonomy was targeted. The participants were given cue cards during meal times. Cue cards that indicated the number of carbohydrates for that particular meal (i.e., one grape = one gram of carbohydrate) were placed on each table. This gave the participants a sense of choice: they could eat what they wanted, but depending on their choice, insulin or exercise was needed to manage their blood sugar.

Relatedness for diabetes management was targeted through a camp experience that fostered a sense of belonging among others combating the same illness. Activities addressing relatedness included diabetes education, identification with the guest speakers, set-up for meals, and general social experiences with diabetic peers at camp. Relatedness was targeted by the use of guest speakers for talks and education sessions. Some of the speakers had excellent diabetes management and some had poor diabetes management. see Table 9 for a list of [therapeutic recreation-type] activities used at both camps to satisfy the three needs of SDT.

Autonomy Supportive Camp Staff

The camp staff sought to be autonomy supportive in many ways. Staff provided an environment for choice, took the perspective of the individual, and gave a rationale for suggestions. Camp staff provided exercise leaders each morning and the option to swim, jog, or walk for a method of managing blood sugars. Campers did not have to participate, but they were encouraged. Many camp counselors, dieticians, and other staff had been diagnosed with type 1 diabetes. Some were diagnosed early in life, thus giving them the ability to take a similar perspective to the campers. This similarity was crucial to rapport building and establishing a sense of relatedness with camp staff who would be making requests of the campers. The staffs experiences also allowed them to provide a full rationale for suggestions. This technique was used to provide the campers with information on “why” a suggestion was being offered. While offering a rationale did not ensure that the campers would follow through, it was intended to be sincere and choice-oriented.

The Adolescent Led Autonomy Support Training (ALAST) worksheet was a unique camp intervention and was consistent with the framework of an autonomy supportive environment. This part of the camp involved campers completing a worksheet with open-ended questions. Questions and statements addressed such things as what was learned at camp, how those skills might be useful after camp, and changes the participants would like to make for better diabetes management. This supported SDT theory in that the adolescents’ parents learned behaviors the campers would like to “take home.”

On the last day of camp, parents arrived in the morning to participate in the ALAST session. Using the ALAST worksheets, small cabin group discussions were facilitated to provide an intimate setting. Participants, counselors, and parents gathered to share knowledge, questions, comments about camp, and potential changes in the campers’ diabetes management. The ALAST processing time provided the campers with a chance to educate parents on “what they want to do, why and how parents can support this” to better manage their diabetes. This component of camp also provided a forum for listening and learning from one another.

Camp Counselor Training

The camp counselors at the Utah Teen Camp attended a half-day training for camp preparation and a session on autonomy support and its application. This session involved exploring SDT in practical terminology. The SDT training included the use of didactic and experiential teaching techniques. At the end of each evening at camp, the researchers, program coordinators, and other camp staff met to discuss needs or problems. During this time, the researchers checked in with counselors to give and receive feedback (if needed) or address other concerns about making SDT practical at diabetes camp.

Manipulation Check

A two-day visit was used to identify programmatic differences between the Utah and Idaho camps. Researchers interviewed campers and staff. The age and sex of the camp counselors were similar. Further, both camps involved sessions on diabetes education and recreational activities. The two camps’ programs were not as different as intended. The Idaho camp, currently and historically, allowed a great deal of freedom for their campers (i.e., paralleling being autonomy supportive). Both camps were offered choices not only in daily activities but also in diabetes management. As a manipulation check, the two camps were compared using an Independent t-test to determine if they were significantly different from one another with regard to perceptions of autonomy support. The two camps were not statistically different based on campers’ perception of an autonomy supportive camp staff, t (2, 85) = .40, p = .69.

Data Analysis

Analysis of covariance was used to test the statistical significance of the first hypothesis, i.e., the group receiving the benefits based camp experience would have higher posttest mean scores of competence, autonomy and relatedness for diabetes management than a comparison group of campers not participating in a theory-based program, while controlling for pretest scores (of competence, autonomy and relatedness for diabetes management). Due to initial group differences, the pretest was used as a covariate. Analysis of covariance repeated measures was used to test hypothesis two, i.e., at the 3-month follow-up, the group receiving the intervention would maintain higher scores of competence, autonomy and relatedness for diabetes management than the comparison group of campers not participating in a theory-based program.

In order to assess the third hypothesis, role of autonomy support on the three dependent variables, three sequential regressions were run with the posttest of each variable as the dependent variable in the regression equation. The pretest of the associated outcome variable was entered in the first of two blocks as a covariate. The second block included the campers’ perceptions of an autonomy supportive staff and the group by autonomy supportive camp staff interaction term. The intention was to determine if this perception of autonomy support was uniquely related to the post-test scores of competence, autonomy and relatedness for diabetes management and if the importance of autonomy support varied by camp after statistically controlling for the pre-tests.

Results

The data were entered, cleaned, and screened for univariate outliers through SPSS. Twelve participants were removed from the experimental group due to missing data or an inability to match pre- and posttests. Thirty-five participants were deleted from the comparison group due to missing data or an inability to match data sets. Thus, a usable data set of N = 87 was used for subsequent analyses. The experimental group had 41 matched cases and the comparison group had 46 matched cases. The final sample was 50% female.

The outcome variables for this study included competence, autonomy, and relatedness for diabetes management, and perceptions of an autonomy supportive camp staff. Descriptive statistics of the first three variables for camp participants can be seen in Tables 1 and 2 (Table 2 contains follow-up data, and thus had a limited number of respondents). Table 3 contains correlation coefficients between the three dependent variables. Although all three dependent variables were significantly correlated, the values based on the Pearson statistic are low to moderate, so the three variables can be considered discrete.

Analysis of covariance was used to determine if there was a significant mean difference between the two camps. Three ANCOVAs, with the pretest as a covariate, were used to test the first hypothesis. The ANCOVA analyses revealed significance only for relatedness for diabetes management F (1, 87) = 4.40, p = .03, η^sup 2^ = .05 (Table 4). Eta squared is the proportion of the total variance that is attributed to an effect, and a larger value indicates a stronger relationship. This result suggests that the treatment camp group reported a stronger sense of relatedness than the comparison camp group.

Analysis of covariance for repeated measures was used to test the statistical significance of hypothesis two. This repeated measures was employed to test for significant mean differences over time. Three months after the conclusion of camp, the experimental group returned 31 questionnaires. Of those, 19 pre- and posttest questionnaires were matched. After three months, the comparison camp returned 20 questionnaires. Of those, 17 pre- and posttest questionnaires were matched.

No significant differences between the two groups on competence for diabetes management were found at the 3-month follow up, F (1, 36) = 2.68, p = .60, η^sup 2^ = .01. Using the pretest as a covariate, the ANCOVA of competence for diabetes management revealed significance over time F (1, 36) = 4.80, p = .03, η^sup 2^ = .11. However, the time by group interaction term was not significant F (1, 36) = .03, p = .85, η^sup 2^ = .01. These results indicate that the treatment group was no different than the comparison group in their competence for diabetes management three months after camp ended. The means of both groups decreased from pretest to posttest.

For the analysis of autonomy for diabetes management, the groups were statistically significantly different, F (1, 34) = 6.49, p = .015, η^sup 2^ = .16. This was due to a greater increase in autonomy for diabetes management in the comparison group over that of the experimental group. ANCOVA results revealed that the autonomy for diabetes management over time factor was significant F (1, 34) = 31.16, p = .01, η^sup 2^ = .47. Counter to the hypothesis, the comparison group increased and the experimental group decreased over time. The time by group interaction was not significant F (1, 34) = 2.54, p = .12, η^sup 2^ = .07.

Hypothesis two included the follow-up of relatedness for diabetes management with the pretest of relatedness for diabetes management as a covariate. No significant differences between groups resulted, F (1, 35) = .04, p = .83, η^sup 2^ = .01. Analysis of covariance revealed no significance over time F (1, 35) = .205, p = .65, η^sup 2^ = .01 or time by group F (1, 35) = .06, p = .79, η^sup 2^ = .01. These results indicate that the groups were not statistically different three months after camp ended.

In support of the third hypothesis, all three of the regressions showed perceived autonomy support to be significantly and uniquely related to each of the outcome variables. Campers in both groups who reported higher levels of autonomy support from the camp staff also reported higher post camp levels of competence, autonomy, and relatedness for diabetes management. The regression equations and changes in R^sup 2^ are reported in Tables 5-7. The lack of significant interaction terms for competence, autonomy, and relatedness for diabetes management indicate that autonomy support played a similar role in both the experimental and comparison camps.

Discussion

It appears that perceptions of relatedness may be enhanced by intentionality and an autonomy supportive approach. The camp setting often brings adolescents together and, in this study, campers in the experimental camp were encouraged to rely on one another in order to cope with diabetes. Adolescents are social agents and SDT posits that a sense of relatedness must be satisfied as a basic human need. Through observations of campers during this study, socializing with old friends and meeting new friends were important to the campers. As individuals began to feel more supported by a social environment, they were more likely to internalize behaviors and act responsibly (Deci & Flaste, 1995). The literature indicates that the more individuals internalize behavior that is supported by a positive environment, the more likely they are to behave in a healthy way (Deci & Flaste, 1995).

The lack of significant differences in perceived competence and autonomy for diabetes management between camps may be attributable to the similarity between the two camps. The comparison Idaho camp’s approach was already very “choice oriented.” Although the camp was not explicitly based on a theoretical framework, many of the camp’s approaches paralleled that of the experimental camp in Utah. As a result, the campers in both settings perceived that staff created autonomy supportive environments.

One of the more surprising results was the apparent decline in perceived competence for diabetes management over the course of both one week camps. Much of diabetes camp is fun, but a significant portion is devoted to education. Many adolescents may have had a false initial perception of their diabetes knowledge base. After receiving formal diabetes education, campers may have realized they knew less about certain areas of diabetes management than they had originally perceived. Such a shift of the internal metric in measurement is commonly referred to as a “responseshift bias” and may be evident in this data (cf. Howard, 1980). A decrease in scores may have hindered the move toward internalization.

Hypothesis two focused on the long term maintenance of changes in competence, autonomy, and relatedness for diabetes management. The ANCOVA revealed no overall significance of time by group. This suggests that the groups were similar in competence, autonomy, and relatedness at the 3-month follow up. However, significant main effects over time were present for both competence and autonomy for diabetes management, indicating that participants felt more competent and autonomous from post camp to follow-up. While some of this might possibly be attributed to camp, it is impossible to distinguish the camps’ impact from the general impact of maturation in the participants over three months. The literature indicates that an opportunity is often needed for an individual to exercise his or her competence. After camp, these adolescents may have been given a choice to demonstrate their knowledge. In return, a sense of self-competence may have increased.

Intentional camp models have been effective in fostering interpersonal relationships (Brannan et al., 2002) and a sense of connectedness with other campers (Sibthorp et al., 2003). Therefore, follow-up result that relatedness scores decreased over time is perhaps not surprising. After departing from camp, adolescents had to reintegrate into a community that may not have been as supportive as diabetes camp. Thus, the decrease in perceptions of relatedness for diabetes management at follow-up could indicate that these adolescents felt less connected to nondiabetic peers while at school, home, and during other daily engagements. The literature emphasizes the need for individuals to feel a sense of connectedness to others. Although diagnosis of type 1 diabetes among adolescents is on the rise, they are currently in the minority of cases, as compared to their non-diabetic peers. Therefore, it is likely that the decrease in scores of relatedness is attributed to a less supportive environment beyond camp. Given the poor response rate for the follow-up analysis, statistical power was low and interpretations warrant considerable caution.

The regression equations for H^sub 3^ showed that campers who felt higher levels of autonomy support from the camp staff also perceived themselves as more competent and autonomous, and experienced a greater sense of relatedness for diabetes management. Despite the fact that differences were not found between the camps, it does appear that specific camp staff behaviors, including providing choices, rational provisions, and perspective taking, may be important factors in developing competence, autonomy, and relatedness for diabetes management. If the proponents of SDT are correct, meeting these basic psychological needs related to diabetes management should lead to more self-determined diabetes management behaviors.

This finding is especially interesting because SDT offers practitioners specific behavioral suggestions that can be implemented in a variety of therapeutic recreation contexts where the target is increasing more self-determined behaviors. For example, practitioners could provide “choices” about exercise and diet versus “telling” campers what to do. This could also include minimizing the use of controlling language by making conscious efforts to provide semantic choice. As the literature indicates, an autonomy supportive environment is crucial in leading to internalization. Yet, even prior to internalization, autonomy supportive environments should increase perceptions of competence, autonomy, and relatedness. These results mirror the literature in that aspect. The amount of autonomy support received at camp was predictive of how competent, autonomous, and related in their diabetes management campers would feel at the conclusion of camp.

Limitations

Based on discussions with camp staff, Utah’s Teen Week has been less “choice oriented” than that of the Idaho Teen Week (comparison), with the exception of the 2003 intervention. This resulted in the two camps being more similar than different. The idea of “folk” theory (e.g., Bertram, 2003) likely explains the similarities between Utah and Idaho Teen Camps. Folk theory refers to an explanation of a behavior due to practical experiences or what appeared to work. For this study, the Utah Teen Camp had an intentional and theoretical program implemented that was different than what had historically taken place at camp. In the past, the Utah camp had included more structure and less choice. During the study, Utah camp staff provided an autonomy supportive camp environment and choice. The Idaho camp had moved from a more structured to a more choice-oriented camp (a few years ago) to what they felt worked. Due to other demands of camp, the Utah based camp staff had only a short timeframe for staff training in the theoretical application of SDT.

The researchers were unable to match many data sets. If the data were better matched (i.e., were not missing phone numbers for coding) the sample size could have been larger. The follow-up data collection was also limited. A more effective approach for collecting follow-up data needs to be pursued. Follow up data were collected by mail for both groups, however, the return rate was less than desired (41%). With the high use of adolescents accessing the internet, an online follow-up survey may have been more effective.

Implications for Research and Practice

Diabetes camps can benefit from recreation therapists and recreation programmers to help increase the effectiveness of the programs offered. Recreational professionals are educated to intentionally design, implement, and evaluate recreation programs. Autonomy supportive techniques and approaches can be fostered through training. The importance of fostering an autonomy supportive environment in this study indicates that such training could be beneficial for diabetes camp staff and, ultimately, for adolescents with diabetes.

These findings support the idea that an autonomy supportive camp staff is uniquely related to camper internalization. That is, campers who felt higher levels of autonomy support from the camp staff also perceived themselves as more competent, more autonomous, and had a greater sense of relatedness for diabetes management. Future research should examine the specific mechanisms that camps use to effectively foster perceptions of autonomy support. As mentioned previously, specific attempts should also be made to develop a training program to produce camp staff that support campers’ autonomy.

Practitioners could make an effort to allow participants to evaluate their own performances. This may be as simple as offering a perceived choice, for example, asking, “what is your blood sugar and how do you feel” versus telling a participant, “check your blood sugar and you need insulin or sugar.” In addition, practitioners could provide education sessions with information to which campers may not have access. For example, this research found that campers wanted information (i.e., counting carbohydrates) for fast food eateries. Lastly, when practitioners do offer suggestions, they could attempt to include rationales for behavioral changes in a way that makes sense to the camper.

Conclusion

Diabetes camps need to be more benefitsbased. These adolescents not only have the inherent and existing challenges of teenage development, they have the need for selfmanagement of diabetes. The literature indicates a need for more theory-based programming that addresses specific outcomes. In addition, recent research continues to support the use of a self-determination theoretical framework (Assor, Roth, & Deci, 2004; Levesque, Zuehlke, Stanek, & Ryan, 2004). With current research supporting the use of SDT in clinical, home, and camp settings, the researchers of this study speculate that a refined camp program grounded in SDT could demonstrate significant findings similar to studies done in other contexts.

As more professionals from the field of recreation get involved with this population (e.g., Cadwell et al., 2001; Sibthorp et al., 2003) better programming, implementation and program efficacy is inevitable. With further research, practitioners and researchers can design intentional recreational programs for adolescents with diabetes to provide an opportunity for more internalized diabetes management, hopefully allowing adolescents to minimize their complications due to their illness. Currently, there is no cure for type 1 diabetes. While some disciplines work to find a cure, other disciplines, like therapeutic recreation, should focus on helping adolescents cope with this life-threatening disease by developing internalized self-management skills.

1 This research was partially supported with funds provided by the Association of Diabetes Educators of Utah. This project could not have happened without the commitment and cooperation of the Foundation for Children and Youth with Diabetes and Camp Hodia. The authors would also like to thank David Donaldson, M.D., for initiating this project.

1 Due to an oversight during the instrument printing, the pretest scale for RDM contained only one item. The error was corrected before the posttest was administered. However, as we intended to use the pretest as a covariate, the single item indicator was used in this capacity

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Eddie Hill, Ph.D. is an Assistant Professor in the Exercise Science, Sport, Physical Education and Recreation Department at Old Dominion University. Recreation & Tourism Studies Program, Health and Physical Education Bldg. Rm. 133, Norfolk, VA 23529-0196, 757-683-4881 ehill@odu.edu. Jim Sibthorp, Ph.D. is an Assistant Professor in the Parks, Recreation, & Tourism Department at the University of Utah. 250 S. 1850 E. Room 200, Salt Lake City, UT 84112-0920, 801-581-5940 jim.sibthorp@health.utah.edu

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