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Development of the Patient Activation Measure (PAM): Conceptualizing and Measuring Activation in Patients and Consumers
Open accessAbstract
Background. Controlling costs and achieving health care quality improvements require the participation of activated and informed consumers and patients. Objectives. We describe a process for conceptualizing and operationalizing what it means to be “activated” and delineate the process we used to develop a measure for assessing “activation,” and the psychometric properties of that measure. Methods. We used the convergence of the findings from a national expert consensus panel and patient focus groups to define the concept and identify the domains of activation. These domains were operationalized by constructing a large item pool. Items were pilot‐tested and initial psychometric analysis performed using Rasch methodology. The third stage refined and extended the measure. The fourth stage used a national probability sample to assess the measure's psychometric performance overall and within different subpopulations. Study Sample. Convenience samples of patients with and without chronic illness, and a national probability sample ( N =1,515) are included at different stages in the research. Conclusions. The Patient Activation Measure is a valid, highly reliable, unidimensional, probabilistic Guttman‐like scale that reflects a developmental model of activation. Activation appears to involve four stages: (1) believing the patient role is important, (2) having the confidence and knowledge necessary to take action, (3) actually taking action to maintain and improve one's health, and (4) staying the course even under stress. The measure has good psychometric properties indicating that it can be used at the individual patient level to tailor intervention and assess changes.
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“Participants also completed the 10-question Patient Activation Measure (PAM), a validated measure of patient activation that includes person’s beliefs, motivation, and actions for self-care at these visits [9,23,24].”
From Effectiveness of Digital Medicines to Improve Clinical Outcomes in Patients with Uncontrolled Hypertension and Type 2 Diabetes: Prospective, Open-Label, Cluster-Randomized Pilot Clinical Trial (2017) · cites this paper as [23]
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BackgroundSelf-citationDevelopment and Validation of the Patient Assessment of Chronic Illness Care (PACIC)
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“The PAM, developed by Hibbard et al. (2004, 2005), is a powerful instrument able to detect the level of activation of patients toward their care management (Hibbard and Mahoney, 2010; Greene and Hibbard, 2012).”
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“Measure (PAM) (56) An interval-level, unidimensional Guttman-like measure”
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“activation can predict health utilization and health outcomes [46].”
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“Participants also completed the 10-question Patient Activation Measure (PAM), a validated measure of patient activation that includes person’s beliefs, motivation, and actions for self-care at these visits [9,23,24].”
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“While self-perceived eHealth literacy refers to individuals’ self-perceived abilities to obtain and utilize Web-based health information for the purpose of self-management [52], patient activation refers to individuals’ self-belief in their behavioral repertoires, abilities, and knowledge pertaining to self-management…”
BackgroundInfluentialPsychometric properties of the patient activation measure among multimorbid older adults.
Skolasky, R., Green, A., Scharfstein, D. O., Boult, C., Reider, L., & Wegener, S. (2011) · Health Services Research · doi:10.1111/j.1475-6773.2010.01210.x · Cited by 201
Skill Set or Mind Set? Associations between Health Literacy, Patient Activation and Health
Smith, S. G., Curtis, L. M., Wardle, J., von Wagner, C., & Wolf, M. S. (2013) · PLoS ONE · doi:10.1371/journal.pone.0074373 · Cited by 204
“Statistical Analyses One-way Analysis of Variance (ANOVA) was used to compare mean performance on the TOFHLA and PAM by participant characteristics.”
BackgroundInfluentialEvaluating Patient Empowerment in Association With eHealth Technology: Scoping Review
Risling, T., Martinez, J., Young, J., & Thorp-Froslie, N. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.7809 · Cited by 191
“The widespread uptake of the Patient Activation Measure (PAM) by Hibbard Stockard [33] as a standard in this area has provided some conceptual stability for patient activation.”
BackgroundSchmittdiel, J. A., Mosen, D. M., Glasgow, R. E., Hibbard, J. H., Remmers, C., & Bellows, J. (2007) · Journal of General Internal Medicine · doi:10.1007/s11606-007-0452-5 · Cited by 191
“We adapted 4 self-management behavioral items from Hibbard et al.12 and asked patients to rate these using a 4-point Likert scale (1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree): (1) consuming 5 servings of fruits and vegetables, (2) doing tasks needed to manage their chronic condition, (3) following a re…”
MethodSelf-citationMobile-Web App to Self-Manage Low Back Pain: Randomized Controlled Trial
Irvine, A. B., Russell, H., Manocchia, M., Mino, D. E., Glassen, T. C., Morgan, R. L., Gau, J. M., Birney, A. J., & Ary, D. V. (2015) · Journal of Medical Internet Research · doi:10.2196/jmir.3130 · Cited by 208
“Other Constructs Patient Activation Measure The Patient Activation Measure (PAM) is a reliable probabilistic scale that assesses activation of patients to take responsibility for their own health [58,59].”
Promise of and potential for patient-facing technologies to enable meaningful use
Ahern, D. K., Woods, S. S., Lightowler, M. C., Finley, S. W., & Houston, T. K. (2011) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2011.01.005 · Cited by 189
eHealth for improving quality of life in breast cancer patients: A systematic review
Triberti, S., Savioni, L., Sebri, V., & Pravettoni, G. (2019) · Cancer Treatment Reviews · doi:10.1016/j.ctrv.2019.01.003 · Cited by 184
Kim, J. Y., Wineinger, N. E., & Steinhubl, S. R. (2016) · Journal of Medical Internet Research · doi:10.2196/jmir.5429 · Cited by 186
“The Patient Activation Measure (PAM) is one of the tools for measuring an individual’s skills, confidence, and knowledge in managing his or her own health [8,9].”
The Care Transitions Intervention
Voss, R. (2011) · Archives of Internal Medicine · doi:10.1001/archinternmed.2011.278 · Cited by 181
Patient Activation and Adherence to Physical Therapy in Persons Undergoing Spine Surgery
Skolasky, R. L., MacKenzie, E. J., Wegener, S. T., & Riley, L. H. (2008) · Spine · doi:10.1097/brs.0b013e31818027f1 · Cited by 178
“easily changed (immutable) and those that could be changed (mutable).(6) Immutable psychological factors in-”
BackgroundMethodInfluentialSimmons, L. A., Wolever, R. Q., Bechard, E. M., & D, R. S. M. (2014) · Genome Medicine · doi:10.1186/gm533 · Cited by 177
“0%) measured the knowledge, confidence, and skills components of patient engagement using the Patient Activation Measure (PAM) [41], a well-validated instrument.”
BackgroundMethodInfluentialPilot study of a cell phone-based exercise persistence intervention post-rehabilitation for COPD
Nguyen, H. (2009) · International Journal of Chronic Obstructive Pulmonary Disease · doi:10.2147/copd.s6643 · Cited by 165
Motivational interviewing‐based health coaching as a chronic care intervention
Linden, A., Butterworth, S. W., & Prochaska, J. O. (2010) · Journal of Evaluation in Clinical Practice · doi:10.1111/j.1365-2753.2009.01300.x · Cited by 174
“The non-participant group showed a non-statistically significant increase of 1.17 points on their PAM scores (scored from 0 to 100, with a higher score indicating better patient activation), while the participant group improved by 4.57 points (P = 0.02).”
InfluentialSolomon, M. P., Wagner, S. L., & Goes, J. B. (2012) · Journal of Medical Internet Research · doi:10.2196/jmir.1924 · Cited by 171
“Activated patients strive to understand their conditions, viewing problems as challenges with the confidence that they can be solved [8,19].”
Consumer Competencies and the Use of Comparative Quality Information
Hibbard, J. H., Peters, E. M., Dixon, A., & Tusler, M. (2007) · Medical Care Research and Review · doi:10.1177/1077558707301630 · Cited by 166
“The 13-item measure was created using Rasch methodology (Smith 1996), and it is a unidimensional, interval level, Guttman-like measure (Hibbard et al. 2004, 2005).”
BackgroundMethodInfluentialSelf-citationEneriz-Wiemer, M., Sanders, L., Barr, D. A., & Mendoza, F. (2014) · Academic Pediatrics · doi:10.1016/j.acap.2013.10.003 · Cited by 167
Brenk-Franz, K., Hibbard, J. H., Herrmann, W., Freund, T., Szécsényi, J., Djalali, S., Steurer-Stey, C. A., Sönnichsen, A. C., Tiesler, F., Storch, M., et al. (2013) · PLoS ONE · doi:10.1371/journal.pone.0074786 · Cited by 170
“The Patient Activation Measure (PAM) is a reliable and valid questionnaire that measures patient activation [8].”
BackgroundSelf-citationChronic disease self-management: A hybrid concept analysis
Miller, W. R., Lasiter, S., Ellis, R. J. B., & Buelow, J. M. (2014) · Nursing Outlook · doi:10.1016/j.outlook.2014.07.005 · Cited by 169
Breckenridge, K., Bekker, H. L., Gibbons, E., van der Veer, S. N., Abbott, D., Briançon, S., Cullen, R., Garneata, L., Jager, K., Lønning, K., et al. (2015) · Nephrology, Dialysis and Transplantation · doi:10.1093/ndt/gfv209 · Cited by 150
“• Measures reflecting aspects of patient involvement in their health care, including patient activation [11] and informed and shared decision-making [12].”
BackgroundKumar, P. S., Dwivedi, Y. K., & Anand, A. (2021) · Information Systems Frontiers · doi:10.1007/s10796-021-10136-6 · Cited by 189
Rivet Amico, K. (2011) · Journal of Health Psychology · doi:10.1177/1359105311398727 · Cited by 149
“Focused inquiries on global patient engagement in care, operationalized as timely enrollment, ongoing clinic attendance, frequency of service use, and/or adherence to other aspects of treatment such as medication, diet, and exercise, contribute to a growing recognition that supporting and promoting patient engagement…”
BackgroundGeng, E. H., Odeny, T., Lyamuya, R., Nakiwogga-Muwanga, A., Diero, L. O., Bwana, M., Braitstein, P. K. A., Somi, G. R., Kambugu, A. D., Bukusi, E. A., et al. (2015) · Clinical Infectious Diseases · doi:10.1093/cid/civ1004 · Cited by 162
“Such interventions may also promote potential critical mediators of retention such as treatment literacy and “patient activation” [34, 35].”
BackgroundThe Situation-Specific Theory of Heart Failure Self-care
Riegel, B. J., Dickson, V. V., & Vellone, E. (2022) · The Journal of Cardiovascular Nursing · doi:10.1097/jcn.0000000000000919 · Cited by 176
“98 When studies on patient activation were synthesized in a systematic review of randomized controlled trials, interventions that improved patient activation significantly improved self-care in a variety of other chronic conditions 99 and for a variety of intermediate outcomes such as depression,…”
Public health literacy in America
Gazmararian, J. A., Curran, J. W., Parker, R. M., Bernhardt, J. M., & DeBuono, B. A. (2005) · American Journal of Preventive Medicine · doi:10.1016/j.amepre.2004.11.004 · Cited by 160
Alegría, M., Sribney, W., Pérez, D., Laderman, M., & Keefe, K. (2009) · Journal of general internal medicine · doi:10.1007/s11606-009-1074-x · Cited by 167
Patient Activation and 30-Day Post-Discharge Hospital Utilization
Mitchell, S. E., Gardiner, P. M., Sadikova, E., Martin, J. M., Jack, B. W., Hibbard, J. H., & Paasche‐Orlow, M. K. (2013) · Journal of General Internal Medicine · doi:10.1007/s11606-013-2647-2 · Cited by 158
“02 Retired 12 (18) 12 (10) 23 (12) 43 (14) 90 (13) Unemployed 17 (26) 36 (30) 54 (29) 70 (23) 177 (26) Employed (Part or Full Time) 11 (17) 35 (29) 58 (31) 122 (39) 226 (33) Been homeless Yes 14 (21) 17 (14) 30 (16) 33 (11) 94 (14) 0.”
Self-citationPatient centered primary care is associated with patient hypertension medication adherence
Roumie, C. L., Greevy, R. A., Wallston, K. A., Elasy, T. A., Kaltenbach, L. A., Kotter, K., Dittus, R. S., & Speroff, T. (2010) · Journal of Behavioral Medicine · doi:10.1007/s10865-010-9304-6 · Cited by 157
“The PAM has high reliability estimates (Cronbach’s a = 0.91) which are stable across health status, gender and age.”
BackgroundMethodInfluentialIrizarry, T., Shoemake, J. D., Nilsen, M. L., Czaja, S. J., Beach, S. R., & Dabbs, A. D. (2017) · Journal of Medical Internet Research · doi:10.2196/jmir.7099 · Cited by 175
“The raw score is then converted to an overall score ranging from 0-100 using the table provided in PAM licensing materials [25].”
Graffigna, G., Barello, S., & Bonanomi, A. G. (2017) · PLoS ONE · doi:10.1371/journal.pone.0179865 · Cited by 156
Engaging patients through open notes: an evaluation using mixed methods
Esch, T., Mejilla, R., Anselmo, M. K., Podtschaske, B. V., Delbanco, T., & Walker, J. (2016) · BMJ Open · doi:10.1136/bmjopen-2015-010034 · Cited by 162
“on engagement and self-care, and each patient completed the patient activation measure (PAM-13) survey.(68) 69 All interviews were conducted in 2014 (February–March) in Greater Boston and were recorded and transcribed verbatim using a transcription service.”
MethodDeen, D., Lu, W.-H., Rothstein, D., Santana, L., & Gold, M. R. (2010) · Patient Education and Counseling · doi:10.1016/j.pec.2010.07.026 · Cited by 152
Kinney, R. L., Lemon, S. C., Person, S. D., Pagoto, S., & Saczynski, J. S. (2015) · Patient Education and Counseling · doi:10.1016/j.pec.2015.02.005 · Cited by 152
“Currently, the Patient Activation Measure (PAM) is the only validated instrument that comprehensively measures the degree to which patients are activated to manage their own health care [22] The PAM, which was developed and refined by Hibbard et al.”
BackgroundHealthcare Task Difficulty Among Older Adults With Multimorbidity
Boyd, C. M., Wolff, J. L., Giovannetti, E. R., Reider, L. M., Weiss, C., Xue, Q., Leff, B. A., Boult, C., Hughes, T. B., & Rand, C. (2014) · Medical Care · doi:10.1097/mlr.0b013e3182a977da · Cited by 150
“HCTD may be addressed in part through targeting patient activation, defined as patients’ knowledge, skills, and confidence for self-management.(13,14) As described in the Chronic Care Model, patient-centered chronic illness care is particularly important when considering complex treatment plans in older adults with mu…”
BackgroundMethod
Metadata
- Authors
- Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M.
- Affiliations
- University of Oregon (US)
- Corresponding author
- Hibbard, Judith H.
- Venue
- Health Services Research
- Publisher
- Wiley
- Published
- 2004-06-28
- Volume
- 39
- Issue
- 4p1
- Pages
- 1005-1026
- ISSN
- 0017-9124 (ISSN-L)
- 1475-6773
- PMC
- PMC1361049
- OpenAlex
- W1926404136
- Cited by
- 2,748
- References
- 36
- Citations by year
- 2026: 136 · 2025: 217 · 2024: 227 · 2023: 203 · 2022: 233 · 2021: 235 · 2020: 184 · 2019: 182 · 2018: 186 · 2017: 172 · 2016: 172 · 2015: 147 · 2014: 114 · 2013: 88 · 2012: 65
- FWCI
- 18.98
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Health Services Research (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Scholars' Bank (University of Oregon) (submittedVersion)
- Topics
- Social Sciences › Decision Sciences › Management Science and Operations Research › Psychometric Methodologies and Testing
- Health Sciences › Nursing › Research and Theory › Health Education and Validation
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Keywords
- Patient Activation Measure, patient activation, psychometric validation, Rasch analysis, scale development, chronic disease, health behavior change, healthcare quality improvement
- MeSH terms
- Adult, Aged, Aged, 80 and over, Chronic Disease, Female, Humans, Health Knowledge, Attitudes, Practice, Male, Middle Aged, Outcome and Process Assessment, Health Care, Patient Education as Topic, Patient Participation, Pilot Projects, Primary Prevention, Psychometrics, Surveys and Questionnaires, Time Factors, United States, Reproducibility of Results
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