Medical students’ academic motivation: an analysis from the perspective of the Theory of Self-Determination

Introduction: The principles of the Theory of Self-Determination are relevant to professional education, as the differentiation and expression of the primary types of motivation have implications for the multiple learning outcomes. Objective: To evaluate academic motivation in 4th-year medical students at two teaching institutions and discuss the results from the perspective of the Theory of Self-Determination. Method: The present is a cross-sectional and quantitative study, conducted through a self-answered questionnaire containing 18 sociodemographic questions and the Academic Motivation Scale (AMS). The sample consisted of 147 4th-year medical students from schools with different teaching methodologies: 73 students from Institution A (Problem-based learning PBL) and 74 students from Institution B (traditional methodology). A univariate analysis was conducted using Student’s t test, Analysis of Variance (ANOVA), chi-square test and Pearson’s correlation, followed by Multiple Linear Regression analysis. Results: There was a moderate profile of intrinsic (IM) and extrinsic (EM) motivation in the sample of students, with a higher IM than EM average. High levels of IM were observed in the domains of motivation for achievement and for knowledge, with the satisfaction of increasing one’s knowledge and increasing professional competence being the factors that most positively impacted motivation. In IM, the factor with the lowest score was the university as a place of enjoyment. EM was related to the desire of having a good life in the future, including monetary compensation. It was observed that the variables female gender, age under 23 years, living alone, having attended the entire course at the same institution and school with the PBL methodology had a positive influence on motivation. Conclusion: The students demonstrated higher levels of IM than those of EM, with a lower score attributed to the university as a place of enjoyment. This fact shows an opportunity for future studies, which will be able to verify the factors of the school environment related to the students’ motivation to learn. EM was associated with future life expectations. To know the variables that characterize the self-regulation of learning is crucial to support teaching strategies that contribute to the improvement of the teaching-learning process.


INTRODUCTION
Motivation is a fundamental component of the human performance process 1-3 . Its correlation to the teaching and learning contexts has aroused interest in the literature, as it has predictive power in the school environment, considering that a motivated student is able to transform the acquired knowledge into an incentive for continued learning 4 . Objective or subjective perceptions about the level of personal effectiveness or competence in the academic study environment can affect the intensity or orientation of motivation 5 .
Motivation can be defined as the need or desire linked to the will to meet an expected goal 6 , or as the behavior regulated by the need and instinct to achieve a certain result 7 . According to Pintricch 8,9 , from the academic viewpoint, the motivation to perform a task can be stimulated by three components: (a) a reason or purpose to perform it; (b) the individual's belief in their ability to perform it; and (c) the affective reactions obtained with the performance of the activity.
Two types of motivation can be characterized: the intrinsic motivation, in which something is done for the interest and satisfaction inherent to the action; and extrinsic motivation, in which something is done because of a different consequence or outcome of the action. Extrinsic motivation takes on different forms, which are differentiated by the degree of internalization of values and regulation of conducts, reflecting different levels of autonomy. An autonomous motivation is related to more quality in learning, greater persistence and better learner's psychological adjustment, at any stage of training or schooling 10,11 . That is, extrinsically-motivated behaviors are ruled by the relationship between the prospects of instrumental gains and losses (for instance, incentives), while intrinsicallymotivated behaviors are so for their own good (for instance, the satisfaction of performing the task).
Seeking to understand the motivational determinants and the self-determined forms of motivation, Deci and Ryan 12 proposed what they called the 'Theory of Self-determination' , which differentiates between the distinct levels of motivation: the intrinsic and extrinsic motivation, and the demotivation. The Theory of Self-Determination focuses, particularly, on how one internalizes ideas, values, objectives and intentions under the influence of incorporated social contexts, such as the interaction of the individual with the environment and the context 13 , and it has inspired several studies in the area of education in Brazil [14][15][16][17] .
The principle that learning is established through motivation mechanisms is related to the bases of the Theory of Self-Determination. The latter, in turn, understands human behavior as being encouraged by three primary and universal psychological needs for the development of self-determination: • Autonomy: reflects the desire to participate in activities where the possibility of choice is present; • Capacity: is related to feeling empowered and confident to perform a certain behavior with a certain aptitude; • Social relation: it is the need to realize that the behavior is positively recognized by other people, or that its practice facilitates socialization13 (Figure 1). According to Lozano et al. 25 in a dynamic motivational model, a "motivated student" considers the proposed educational activities to be useful or interesting (perception of an educational activity value), feels able to complete the

Autonomy and satisfaction
Social recognition Feeling of capacity activities for their own satisfaction (perceived self-efficacy) and has the impression of being responsible for the progress of their learning (perception of controllability).
Considering the importance of the motivation construct for the learning process in medical education and its relationship with the Theory of Self-Determination, this study aimed to assess academic motivation in 4th-year medical students at two teaching institutions in the city of Belo Horizonte, state of Minas Gerais (MG), Brazil, and discuss the results from the viewpoint of the Theory of Self-Determination. The results of this study can be used as parameters for the development of interventions that might have an impact on medical students' learning.

METHOD
The present is a cross-sectional and quantitative study conducted through a self-answered questionnaire, aiming to assess medical students' motivation. The sample consisted of  The items shown in Tables 1 to 3 were analyzed through the scores obtained using the Likert scale, with a score ranging from 1 to 7. Therefore, adapted from the study by Azevedo et al. 27 , the following cutoff points were used: ≤ 3.0 (low

RESULTS
The study involved 147 students who were attending the fourth year of medical school at two educational institutions located in Belo Horizonte-MG. Overall, these were the characteristics of the participants: most were females (70%); age group 19 to 30 years, predominance of family income higher than R$ 10,000.00 (63%); not having a relative who was a physician (69%), being single (96%), not having paid work (97%), not having a health problem (80%); not using antidepressant medication (82%) or for chronic diseases (82%), not being a smoker (97%), not having changed educational institutions during the medical course (85%); having an extracurricular activity (82%) and be regularly attending the course (94%).
The analysis of the academic motivation scores of the 147 students showed an average intrinsic motivation score higher than that observed for extrinsic motivation (Table 1).
In the individual assessment of the items that constitute the AMS, in relation to intrinsic motivation, it was observed that the domain of "intrinsic motivation for achievement" obtained the highest average score; while the items that received the highest score were those related to the perception that university education better prepares someone for the career one has chosen and increases professional competence, the item that received the lowest score was the one about the influence of the university on the choice of professional orientation. In the domain of "intrinsic motivation to know", the item with the highest score was the satisfaction of increasing knowledge on attractive subjects and the one with the lowest score was the joy of discovering new things. The domain of "intrinsic motivation to experience stimulation" was the one with the lowest average score, and in this, the item related to reading interesting subjects was the one with highest score, while the item that considers the university a joy showed the lowest score.
Regarding extrinsic motivation, the domain of "extrinsic motivation for external control" obtained the highest average score, with the highest scores for the items related to having a good life and a good remuneration in the future, while having a prestigious career received the lowest score. In the domain of  EM ones. It is noteworthy that high levels of intrinsic motivation were observed in the domains of motivation for achievement and knowledge, with the satisfaction of increasing knowledge on attractive topics and increasing professional competence being the factors that most positively impacted the analyzed students' motivation. However, low scores were observed in the item attending the university for one's enjoyment. The extrinsic motivation was related to the desire to have a good life and a

DISCUSSION
The aim of this study was to evaluate the academic motivation of students attending the 4th year of medical school at two educational institutions in Belo Horizonte, state of MG, Brazil, and to discuss the results from the perspective of the Theory of Self-Determination. The results obtained by the Academic Motivation Scale disclosed moderate levels of intrinsic and extrinsic motivation, with the IM averages being higher than the good remuneration in the future. The intrinsic motivation predominance reveals that what motivates students the most is the enjoyment of the activity in itself. The data obtained in the present study are in line with the results of previous studies regarding the predominance of intrinsic motivation in university students, both in the medical course 15 and in other courses in the biological, human and exact sciences areas 14,28,29 .
The fact that intrinsic motivation predominates in the group of assessed students is an expected and positive fact in both institutions that were part of this study, because according to the Theory of Self-determination, human beings are naturally inclined towards personal development, seeking to internalize psychological and social elements that favor the construction of a sense of self 30 , with the intrinsic motivation being the phenomenon that best represents the positive potential of human nature, configuring itself as a natural tendency to exercise their own capacities, seeking innovations and challenges.
It refers to involvement in a given activity for its own sake, because it is interesting, engaging or somehow generating satisfaction, promoting students' greater interest in learning and confidence in their own capacities and attributes 16,31 . Thus, intrinsic motivation represents the best type of motivation, as it is autonomous or self-determined. The students' curiosity and personal interest in the learning material lead to knowledge that is characterized by a sense of psychological freedom and an internal locus of causality 31 , which can be demonstrated in this study by the high average scores observed in the domains of intrinsic motivation for achievement (which refers to the interaction with the environment and the feeling of competence to create) and in the domain of motivation for knowledge (which is related to exploration, curiosity and objectives).
Intrinsic motivation leads to the creation of internal goals, called learning objectives 32 , unlike the external or performance goals that guide extrinsic motivation, aiming at receiving rewards or the absence of punishment 32  An interesting evidence observed in this study is that among the components of intrinsic motivation, the one that obtained the lowest score in the students' self-perception of motivation was the item associating the university to a place of enjoyment. The literature points out several factors related to the school environment capable of influencing the motivation for learning, and among them, one of the most important is what occurs in the classroom, from the didactic materials used, the teaching methodology employed and the affective factors seen in teacher-student relationship 33,34 . The classroom should be an pleasant place, providing the student with a sense of belonging, with motivation being mediated by the teacher, the classroom environment and the school culture 31 .
Since motivation is influenced by the interaction of intrinsic and extrinsic components 34 , the possibility of awakening the student's motivation by the university, associating it as a place of enjoyment, is an important contribution identified in this study, which highlights the opportunity for teachers and managers to plan methodological, training actions and those related to the educational environment itself, which provide stimulating experiences for students.
Despite the predominance of the intrinsic motivation in the assessed students, the extrinsic component, regulated by rewards and restrictions, was also present. According to Boruchovitch 28 and Ryan and Deci 33 , the presence of the extrinsic orientation, related to behaviors that are used as a means to an end and not by themselves, can also produce good results in learning when accompanied by the intrinsic motivation.
In the domain of extrinsic motivation, the highest scores were observed in items related to future life expectations, including remuneration and those related to the satisfaction of surpassing oneself for personal achievements, and the lowest ones for difficult and academic activities and obtaining a prestigious job. It can be observed, therefore, that the items that most mobilize the extrinsic motivation are those related to the satisfaction of personal desires, the achievement of autonomy and those that arouse the student's interest more for the identification than for the obligation to do something.
After all, human motivation is guided by the need for selfaccomplishment, which considers the meeting of basic needs, including security and esteem 35 . Our data showed that students recognize the university as the best means of preparation for their chosen career, which confirms the proposition that the need for academic training is a reflection of the desire to develop as an individual 35 .
It is important to point out that although the extrinsic component of motivation is relevant for learning, it must be used with the aim of awakening the intrinsic motivation, which is associated with a high degree of academic performance and student satisfaction 36 ; the use of extrinsic rewards without planning can promote a reduction in intrinsic motivation, as it does not awaken in the student the satisfaction of learning for learning's sake 37 .
Knowledge of the students' motivational goals and orientations is important, as they support the motivational sequence triggered when they are faced with a task to be performed, with an impact on learning 28 . The type of motivational orientation of students has been associated with differences In line with what was observed by other researchers 16,24,41,42 , the results of the present study showed that female students had higher average motivation scores when compared to male students. Regarding age, it was observed that younger students had a higher score in extrinsic motivation, which does not corroborate the findings of the literature, since some studies did not find an association between age and motivation, while in others, older students showed a more autonomous profile [43][44][45] .
Unlike the results obtained by Azevedo 27 , it was observed that students who lived without their parents had higher levels of motivation. In an attempt to explain this fact, one can infer that the new social reality experienced by students who are far from their families stimulates the development of autonomy, which is one of the bases of the Theory of Self-Determination. Another important finding was the absence of a relationship between academic performance and the degree of motivation, which reinforces the assessed students' self-determined motivation.
Finally, it was observed that the students attending the institution that adopts the PBL methodology had higher mean AMS scores in comparison to those attending the school using the traditional methodology. This fact can be explained in the light of the Theory of Self-Determination, which establishes autonomy, competence and relationship as pillars of motivation 10 , aspects favored by the PBL methodology 39,46 .
According to the conception developed by Ryan and Deci 33 , the academic environment is preponderant, since it can facilitate or inhibit the intrinsic motivation, due to the support or obstruction of the psychological needs of the students' competence and autonomy. According to Reeve 47 , students who perceive themselves as autonomous in their school interactions show positive results in relation to motivation, commitment, development, learning, performance improvement and psychological status. Thus, a context that encourages autonomy is beneficial to learning and performance, with an effect on motivation, the internalization of values and rules, which will provide people with greater self-determination. However, it is not possible to state, based on these data, that the PBL methodology would be able to individually influence the students' motivation, since this study did not aim to compare the two educational institutions regarding the different variables related to students' motivation.
Despite the natural tendency that students have for personal development, it is important to note that external factors can make it difficult for intrinsic motivation to fully manifest 30

CONCLUSION
This study showed that fourth-year medical students had a moderate profile of intrinsic and extrinsic motivation, with higher averages of intrinsic motivation than the extrinsic ones. The high levels of intrinsic motivation were observed in the domains of motivation for achievement and knowledge, with the satisfaction of increasing knowledge and professional competence being the factors that most positively impacted the students' motivation. Among the factors of intrinsic motivation, the one that received the lowest score was the university as a place of enjoyment. This fact presents an opportunity for future studies, which will be able to verify the factors of the school environment that are associated to the students' motivation to learn. Extrinsic motivation showed to be highly associated with the desire to have a good life in the future, including good remuneration. Academic motivation was influenced by the following factors: female gender, living alone and studying at an institution that applied the PBL methodology. Knowing the variables that characterize the self-regulation of learning is essential to support teaching strategies that contribute to the improvement of the teaching-learning process.