Research Report

The development of a questionnaire to assess motivation in stroke

survivors: a pilot study
Sarah Hallams
Physiotherapy Honours Student, University of Newcastle Australia
Kerry Baker, BAppSc (Physiotherapy), PhD
Physiotherapy Lecturer, University of Newcastle Australia

ABSTRACT
The aim of this research was to develop a questionnaire to assess motivation in
stroke survivors. A literature review was conducted to determine the factors that
influence motivation and self-determination; these were developed into the
questionnaire items. Expert opinion regarding the relevance of these items was
sought, and additional items added. The questionnaire was then given to three
members of a community stroke group to complete. Cronbachs alpha and Pearson
Product Moment coefficients were calculated for each item to determine internal
reliability. All items scored alpha coefficients of greater than 0.90, suggesting high
homogeneity between items. Pearson Product Moment coefficients ranged from
-0.4813 to 0.9961. Due to the small sample size the reliability of the questionnaire
could not be determined. Further research is needed to demonstrate reliability
and validity of the instrument. Hallams S, Baker K. (2009): The development of a
questionnaire to assess motivation in stroke survivors: a pilot study. New Zealand
Journal of Physiotherapy 37(2): 55-60.
Key Words: Motivation, stroke, questionnaire design, rehabilitation

INTRODUCTION would be described as amotivated. Patients who

The World Health Organisation defines motivation
as a global mental function - a conscious and
unconscious drive - that produces the incentive
to act (W.H.O 2001). Motivation for a particular
behaviour can be described along a continuum
of self-determination first described by Deci and
Ryan (1985) ranging from amotivated behaviour to
intrinsically motivated, self-determined behaviour
(Deci and Ryan 1985). An individual who is
amotivated sees no link between their behaviour
and outcomes (Deci and Ryan 1985, Vallerand
and OConnor 1989). The progression from this
motivational state is to non self-determined,
extrinsically motivated behaviour which is externally
regulated, often by rewards or constraints (Deci
and Ryan 1985, Vallerand and OConnor 1989).
Individuals that are motivated in this way may
undertake a particular behaviour because they feel
pressured to do so or to receive some reward, such
as praise, approval or a tangible object (Mullan et
al 1997).
Extrinsically motivated behaviour may also be
self-determined, where the activity is undertaken
because of its importance or usefulness, as a
means to an end (Deci and Ryan 1985, Mullan et
al 1997, Vallerand and OConnor 1989). In this
case the individual experiences feelings of direction
and purpose rather than obligation and pressure
(Vallerand and OConnor 1989). Behaviour that is
intrinsically motivated is fully self-determined and
is undertaken in the absence of any reward other
than the feelings that accompany or immediately
follow the activity, such as enjoyment or competence
(Deci and Ryan 1985).
This concept of motivation can be applied to
patients who have suffered a stroke. A patient who
sees no link between therapy sessions and recovery
participate in therapy because they feel pressured
to do so by the rehabilitation team or their family
are extrinsically motivated and their behaviour is
not self-determined. Patients who participate in
therapy because they see that it will help them
return home are extrinsically motivated but
display self-determined behaviour. Those patients
who participate in therapy because it makes
them feel competent or because they enjoy the
therapy sessions can be described as intrinsically
motivated.
Motivation is a construct that is referred
to frequently in the field of rehabilitation. It
is commonly accepted that increased levels of
motivation lead to more positive outcomes (Maclean
and Pound 2000). Many health professionals
believe that motivation is the most important
factor in determining functional outcomes of
stroke rehabilitation (Becker and Kaufman 1995).
Several studies have shown a relationship between
motivation and outcome of rehabilitation (Friedrich
et al 1998, Grahn et al 2000, Maclean et al 2002).
However, there is a lack of general consensus as
to what constitutes motivation and which factors
influence it (Maclean and Pound 2000, Maclean et
al 2000, 2002).
Stroke survivors are often categorised as
motivated or unmotivated by health practitioners
based on single factors such as their general
demeanour, compliance with therapy or observed
interest in therapy (Maclean et al 2002). This
approach fails in that it does not acknowledge the
multitude of factors that may influence a patients
level of motivation. These include but are certainly
not limited to: environmental factors, the relevance
of rehabilitation to the patient, the amount of
social support, understanding of the rehabilitation

NZ Journal of Physiotherapy July 2009, Vol. 37 (2) 55

 process, relationship with the therapist and
importance of recovery to the patient (Holmqvist
and von Koch 2001, Maclean and Pound 2000,
Maclean et al 2000).
Subjectively assessing a patients motivation
risks an incorrect assessment and may result in
a perceived level of motivation that is inconsistent
with reality. In a study of motivation conducted by
Resnick (1996), patients were chosen to participate
after they had been labelled unmotivated by the
rehabilitation team. When interviewed however,
none of these patients considered themselves
unmotivated.
Qualitative research conducted by Maclean and
colleagues (2002) suggested that labelling a patient
as unmotivated may have a negative effect on their
rehabilitation. Some of the health professionals
interviewed as part of their research stated that
they treated unmotivated patients differently,
and found working with them more of a chore
(Maclean et al 2002). Becker and Kaufman (1995)
argued that using motivational labels put too much
responsibility on the patient, which could negatively
effect a patients rehabilitation especially if their
recovery was incomplete.
Given the negative consequences of subjectively
assessing a patients motivation, an objective
measure would prove useful in the stroke
rehabilitation environment. The purpose of this
research was to develop a questionnaire that would
address the varying factors that affect motivation
levels and determine where the patients motivation
lay on the self-determination continuum. Using
such a questionnaire in the rehabilitation setting
should enable health professionals to gain a better
understanding of factors contributing both positively
and negatively to their patients motivation. This
should allow them to then determine more effective
strategies to maximise patient motivation and
thereby improve rehabilitation outcomes.
METHODS
Subjects
Two groups of participants were recruited for this
research: an expert group and a patient group.
Inclusion criteria for experts were current
involvement in stroke rehabilitation and/or
psychology, and at least five years experience in
this field. Experts were known to the authors and
their contact details were available in the public
domain.
Two inclusion criteria for patients were a history
of stroke, and current involvement in a community
stroke group. The patient sample was one of
convenience. Patients were sourced from the Young
Stroke Survivors community group. Informed
consent was obtained from both expert and patient
participants. The study was approved by the
University of Newcastle Human Research Ethics
Committee (approval number: H-514-0307)
56
Questionnaire Development
A literature search was conducted on the Medline
database using the keywords motivation and
rehabilitation. Additional articles were sourced
from hand-searches of the bibliographies of
electronically located articles.
Literature was deemed relevant if it discussed
motivation in the context of rehabilitation, or
discussed motivation in the context of self-
determination theory.
From these articles, two item lists were compiled.
The first included factors that were suggested to
affect motivation in the context of rehabilitation.
Items that duplicated ideas were deleted from
this list. The second listed items that described
the various stages of self-determined behaviour;
amotivation through to intrinsic motivation.
Both lists were formatted to form a two-part
questionnaire. Guidelines for design were taken
from work by Mullin and colleagues (2000), and the
Australian Aphasia Association (2006).
The questionnaire was emailed to expert
participants who were asked to rate the relevance
of each item on a five-point numerical Likert scale.
Items judged to be not relevant at all received
a score of one; those thought to be somewhat
relevant scored a three; and items judged to be
extremely relevant received a score of five. Items
that received a score of less than three from all
experts were removed from the questionnaire.
Expert participants were also asked to state any
additional items which they considered should be
included. Items that were suggested for inclusion
by more than one expert were added to the
questionnaire.
The amended questionnaire was given to the
patient group who were similarly asked to rate each
item in terms of its relevance to their motivation
following their stroke. Patient participants were
also asked to list any additional items that they felt
should be included.
Statistical analysis of both patient and expert
responses was performed using the statistical
program JMP (Version 6.0.0, 2005, SAS Institute
Inc., Cary, NC). Cronbachs alpha values were
computed to estimate internal reliability. The alpha
coefficient is an indication of the correlation among
the items in a questionnaire (Kielhofner 2006).
Higher coefficients indicate increased homogeneity
of the items (Kielhofner 2006). Homogeneity between
items in a questionnaire is desirable as it suggests
that all items are related to the same domain, which
in our case is motivation. Cronbachs alpha values
of above 0.70 were considered acceptable (Nunally
1978). We computed values for each of the thirty-
three items in the questionnaire. These values
give an estimate of how well that particular item
correlates with all other items in the questionnaire.
We also computed a value for the questionnaire
as a whole, which gives an estimate of the overall
homogeneity of the questionnaire.
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
 Pearson Product Moment correlations were
computed to estimate item-total correlations.
The correlation coefficient generated also gives
an estimate of the homogeneity of the scale, but
examines it from a different point of view (Kielhofner
2006). This statistical test gives an estimate of how
well each item in the questionnaire correlates to
the total score; whereas Cronbachs alpha looks
at the relationship between the items themselves.
The scores for items that are related to the domain
of the questionnaire should correlate highly with
the total score of the questionnaire. Correlations
above 0.70 were considered acceptable (Streiner
and Norman 1995). We did not test for statistical
significance in this pilot study, as the small sample
size does not allow adequate power for that purpose.
We acknowledge that there is no validity in doing
a statistical test with so few data; however the
results provided us with a general picture of the
questionnaires internal reliability and homogeneity
which may be useful for future research.
RESULTS
Literature Search
Thirteen studies from the literature were deemed
to be relevant for this research, the details of which
are presented in Appendix 1.
From these studies a list of nineteen factors
that affect motivation was compiled. These were
subdivided into three categories: social factors
(six items), environmental factors (five items) and
personal factors (eight factors). A second list of
a further eleven items describing the motivation
continuum from amotivation to intrinsic motivation
was compiled: amotivation (one item), non self-
determined extrinsic motivation (three items), self-
determined extrinsic motivation (four items), and
intrinsic motivation (three items).
These lists were formatted to create the
questionnaire, which was then emailed to the
expert participants. Seven experts were emailed;
one neurologist, two psychologists and four
physiotherapists. Of these, one expert (female
physiotherapist, fourteen years experience)
completed the questionnaire as asked. Two others
(male neurologist, female psychologist) replied
with suggestions for additional items but did not
complete the questionnaire. The other four experts
did not reply to our email.
None of the items were given a rating below
three, so all were kept for the amended version.
Based on unanimous response from the expert
respondents an additional three items were added
to the questionnaire: social factors (one item), non
self-determined extrinsic motivation (one item), and
self-determined extrinsic motivation (one item). The
finalised list of items is outlined in Table 1.
Six members of the Young Survivors Stroke Group
were present on the day of our visit. Of these, two
declined to participate. One patient consented to
participate but due to time constraints was unable
to complete the questionnaire. The three patients
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
who were able to complete the questionnaire were
all male, with a mean age of 56.33 years (54-60
years). Mean time since stroke was 2.5 years (2-3
years). Two of the participating patients were unable
to read as a result of their stroke. The author read
the questionnaire to these patients. No guidance
was given in regard to responses.
Cronbachs alpha values were computed for each
of the thirty-three items in the questionnaire and
for the questionnaire as a whole. The individual
values ranged from 0.9090 to 0.9451. Specific
values for each item are listed in Table 1. The
Cronbachs alpha value for the questionnaire as
a whole was 0.9195. Pearson Product moment
correlations were computed for each of the thirty
three items, estimating the relationship between
the score for each individual item and that of the
entire questionnaire. Values ranged from -0.4813
to 0.9961. Specific values for each item are outlined
in Table 1.
DISCUSSION
Following an extensive literature search and
feedback from expert and patient participants, a
questionnaire was developed to assess motivation
in stroke survivors.
This pilot study was conducted for the purpose
of stage one of instrument development. It was not
intended to test the usefulness of the instrument
in a clinical population; more research must
be conducted before it can be used clinically.
Cronbachs alpha and Pearson Product Moment
correlations were calculated to assess the internal
reliability of the scale.
There are some limitations to this research
which affect the validity of the conclusions drawn.
The sample was smaller than intended due to
circumstances beyond the authors control. This
limited the statistical significance of the results and
meant it was not possible to determine the reliability
and validity of the instrument.
There were several opportunities for bias in this
study. Two of the participants were unable to read
and had their questionnaire read to them by one
of the authors. This may have introduced response
bias but was unavoidable as the group convenors
were busy and unable to assist. The patients
were not offered any guidance in answering the
questions.
Further opportunity for bias is due to the two
years which had elapsed since the stroke for all
participants. This introduced the possibility of
recall bias. Furthermore, the participants were not
representative of the acute and sub-acute hospital
patients for whom this questionnaire is designed,
affecting the generalisability of the results.
Every item on the scale scored a Cronbachs
alpha coefficient of greater than 0.90, suggesting
high internal reliability and homogeneity between
items. However, these results could have been
greatly affected by the small sample size of this
study.
57
 Table 1: Questionnaire items with associated Cronbachs A and Pearson Product Moment correlation coefficients

Cronbachs A Item-Total
Item value Correlation
(p-value)
Part 1: I participate in rehabilitation because:

Amotivation:
I dont know 0.9910 0.9961 (0.0039)

Non self-determined extrinsic motivation:

Im told to do so 0.9265 -0.4813 (0.5187)*
I want to make others happy 0.9164 0.6982 (0.3018)*
I feel pushed to do so 0.9170 0.7127 (0.2873)
I worry about what might happen if I dont 0.9234 0.4160 (0.5840)*

Self-determined extrinsic motivation:

I can see that rehabilitation will help me get to my goals 0.9150 0.9091 (0.0909)
The amount of effort that rehabilitation requires is worth it 0.9150 -0.0652 (0.9348)*
Taking part in rehabilitation makes me feel better about myself 0.9129 0.4813 (0.5187)*
I want to get home to be with my family 0.9090 0.9271 (0.2446)
Getting better is important to me 0.9113 0.9091 (0.0909)

Intrinsic Motivation:
I want to take part 0.9150 0.8733 (0.1267)
I enjoy rehabilitation 0.9451 -0.6002 (0.3998)*
Rehabilitation itself is important to me 0.9150 0.9091 (0.0909)

PART 2:

Social Factors:
My family/friends/carers support me too much 0.9133 0.8334 (0.1666)
My family/friends/carers support me too little 0.9207 0.5226 (0.4774)*
My family should look after me 0.9095 0.9130 (0.2676)
I have a good relationship with the rehabilitation team 0.9158 0.8645 (0.1355)
I receive mixed messages from the rehabilitation team 0.9186 0.5679 (0.4321)*
Seeing other patients improve encourages me 0.9207 0.3705 (0.6295)*
Seeing other patients improve discourages me 0.9265 0.3088 (0.6912)*

Environmental Factors:
My surrounding environment is stimulating 0.9170 0.6075 (0.3925)*
I take part in the goal setting process 0.9150 0.9091 (0.0909)
I receive enough encouragement 0.9150 0.8645 (0.1355)
I receive enough information about strokes 0.9129 0.4160 (0.5840)*
I receive enough information about the rehabilitation process 0.9234 0.8645 (0.1355)

Personal Factors:
I feel positive about my recovery 0.9158 0.9091 (0.0909)
I feel positive about life in general 0.9150 0.9091 (0.0909)
I can cope with my life at the moment 0.9113 0.6796 (0.3204)*
I have a good understanding of the rehabilitation process 0.9113 0.9961 (0.0039)
I have a good understanding of strokes 0.9110 0.8645 (0.1355)
I have the time and energy for rehabilitation 0.9158 0.9091 (0.0909)
Rehabilitation challenges me enough 0.9150 0.9091 (0.0909)
I find rehabilitation too difficult 0.9113 0.9091 (0.0909)
*Indicates P.P.M coefficient below acceptable.
Indicates significant p-value

Thirteen items scored a Pearson Product Moment
coefficient of less than 0.70. Given the lack of
validity of these results due to small sample size
no items were deleted from the questionnaire. More
data are necessary to determine whether or not this
questionnaire is reliable.
To determine the items to be included in the
questionnaire, an extensive literature review was
conducted and opinion sought from both experts
and patients. This procedure follows guidelines for
determining content validity, which refers to how
adequately an instrument captures all aspects of
the construct it aims to measure (Kielhofner 2006,
Nunally 1978).
To determine criterion validity, an instrument
needs to be compared to another instrument that
is known to measure the same construct, preferably
one that is considered to be the gold-standard
(Fayers and Machin 2000). As there is currently no
method or instrument available to assess motivation
this was unable to be determined.
Construct validity requires several studies
to produce cumulative evidence and so could
not be determined by this research (Fayers and
Machin 2000, Kielhofner 2006). One aspect of
construct validity is homogeneity, which has been
demonstrated by the Cronbachs alpha results
discussed earlier. However, the validity of these
results is also affected by the small sample size
mentioned previously.
The first section of this questionnaire assesses
the current stage of self-determination of an
individual patient. This is clinically useful as it can
help determine strategies that will best suit the
patient in their current stage and will help them
progress to more self-determined behaviour. The
second section of the questionnaire becomes useful
at this point as it allows the health practitioner to

58 NZ Journal of Physiotherapy July 2009, Vol. 37 (2)

 determine which factors are helping or hindering
the patients motivation. For example, a patient
who indicates they have non self-determined
motivation for rehabilitation may also reveal that
they have a poor understanding of strokes or the
rehabilitation process. In such a case, the patient
may benefit from education about the rehabilitation
process and how it will help them achieve their
goals. Having a clearer perception of the path their
rehabilitation will follow and the gains that can be
made may assist the patient to progress to more
self-determined behaviour.
The questionnaire is not intended to provide
health practitioners with a score to rate a patients
motivation. As outlined previously, labelling
patients as motivated or unmotivated can have
a negative effect on the rehabilitation process
(Becker and Kaufman 1995, Maclean et al 2002).
It is the authors concern that similar effects
could be experienced if too much focus is placed
on a numerical score. Instead, the instrument is
intended to provide information for clinicians to
form a holistic view of a patients motivation.
It is also important to consider the responses to
this questionnaire in conjunction with other factors.
Many patients experience depression, emotional or
behavioural impairments or disruptions in cognitive
function following a stroke (Linden et al 2007,
Zinn et al 2007). These factors would also affect
the rehabilitation process, and some may affect
the way the patient answers the questionnaire.
The questionnaire is designed to be used as part
of a multi-faceted assessment process, and the
results should be interpreted with these additional
factors in mind. The addition of an instrument to
specifically assess motivation may improve the
rehabilitation environment for an individual.
Future research, conducted on a larger sample
of patients who are in the acute to sub-acute period
following a stroke would allow the validity and
reliability of this instrument to be determined. The
instrument must not be used in clinical care until
such research has been completed.
CONCLUSION
Following a review of the literature and consultation
with both experts and patients, a questionnaire to
assess motivation following stroke was developed.
The instrument is designed to determine the
patients stage of self-determination as well as
positive or negative factors affecting their motivation.
This will provide health practitioners with a broader
understanding of the many factors influencing their
patients rehabilitation, and enable them to develop
strategies to best suit each individual. By gaining
a better understanding of the factors affecting a
patients motivation, health practitioners will be able
to facilitate self-determined behaviour and this may
lead to improved rehabilitation outcomes. Further
research is needed to determine the validity and
reliability of this questionnaire before it can be used
in clinical care.
NZ Journal of Physiotherapy July 2009, Vol. 37 (2)
Key Points
! Motivation is an important part of the
rehabilitation process and effects functional
outcomes.
! Several factors influence motivation, all of which
should be considered in order to provide an
optimal rehabilitation environment.
A questionnaire composed of the various factors
that influence motivation was developed
to assess motivation and self-determination
following stroke.
! Further research is needed to determine the
reliability and validity of this instrument.
The evidence from this pilot study is insufficient to
recommend the clinical use of the instrument.
ACKNOWLEDGEMENTS
The authors would like to thank the members of the Young
Stroke Survivors community stroke group for their assistance with
this project and the clinicians who reviewed the questionnaire.
ADDRESS FOR CORRESPONDENCE
Sarah Hallams, 4/47 Todman Avenue, Kensington, NSW 2032,
Email: s_hallams@hotmail.com
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Appendix 1: Details of relevant studies retrieved by literature search:

Study Details Type of Research Items gained from research

Becker and Kaufman (1995) Qualitative Social, Environmental, Personal
Deci and Ryan (1987) Literature review Self-determination
Holmqvist and von Koch (2001) Literature review Environmental
Maclean and Pound (2000) Literature review Social, Environmental, Personal
Maclean et al (2000) Qualitative Social, Environmental, Personal
Maclean et al (2002) Qualitative Social, Environmental, Personal
Merrill (1994) Literature review Social, Personal
Mullen et al (1997) Quantitative Self-determination
Pelletier et al (1995) Quantitative Self-determination
Resnick (1996) Qualitative Social, Personal
Siegert and Taylor (2004) Literature review Social, Environmental, Personal
Vallerand and Bissonnette (1992) Quantitative Self-determination
Vallerand and OConnor (1989) Qualitative Self-determination

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60 NZ Journal of Physiotherapy July 2009, Vol. 37 (2)