Steps in Measuring Patient Activation

Thursday, January 14th, 2010
This post was written by Melanie Matthews

Dr. Judith Hibbard, professor of health policy at the University of Oregon and developer of the Patient Activation Measure™ (PAM), answers the question of whether or not patient activation can be measured.

We started out the process of defining activation by first asking whether it is something that we can measure. The first step was to get some clarity on the definition of activation because people use the term loosely. We went through a rigorous process that included reading the literature, holding patient focus groups and having expert consensus panels. For all of those groups we asked the question, what does it take to manage successfully when you have a chronic illness? We did have some consensus in answering that question; however, the definition that emerged was that people need to believe that they have a role to play in self-management, in collaborating with their provider and in taking preventive action. They also need to have some skill and confidence.

We used a process called Rasch analysis for our measurement, which is used when more precise and consistent measurement is important. This process yields a measurement that is stronger, more precise and consistent than most social science-based measures. The analysis consists of short and tall bars that represent the difficulty structure of the measure. There are 13 questions, with each question having a calibration — how hard it is for most people to admit if something is true about them or not. The short bars represent those people who can say that something is true about them and the tall bars represent those people who can’t. This difficulty structure is quite robust. We have had the measures translated into 15 languages. We have evaluated the results of about six of those translations. This difficulty structure is maintained across language and culture.

The other characteristic of the measurement that is important and different is that we seem to be tapping into one underlying idea, even though there are 13 different questions. We think the underlying idea is, “I understand what my job is and I feel able to do it.” That is important because it can allow us to predict how people will behave in different situations. If you can imagine having measurement on someone’s self-esteem, and if you knew their level of self-esteem, you could predict how they might behave in different situations. That is the same with the PAM. It is tapping into an underlying idea that tells us about people’s behaviors.

After looking at the measurement, we were able to see that it looks like people go through different phases or levels on their way to becoming effective self-managers. We have conducted in-depth interviews with people at these different levels and what we see is that people at the low end are discouraged. They have had many experiences with failure. They feel overwhelmed with the job of managing their health. They have low confidence in themselves and they become passive. Some of them may not recognize that their job is to manage their health. At the high end of activation, we have the opposite. People are very proactive and goal-oriented. They also have good problem-solving skills, which is something that the individuals at the low-end do not have.

Imagine someone at the low end of activation, who has a chronic illness, going in to see their clinician. They are told that they have to change many different things about their lifestyle. What happens? They feel overwhelmed. They might try to do it, but they can’t. By not understanding what is going on with that person, the clinician may be helping to keep that person in a low activation state.

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