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Patient Activation Measure

Last Updated

Purpose

The Patient Activation Measure (PAM-13) is a 13-item questionnaire measuring patient activation by assessing knowledge, skills, and confidence with managing one’s own health.

Link to Instrument

https://www.insigniahealth.com/pam/

Acronym PAM-13

Area of Assessment

Assertiveness
Motivation
Self-efficacy

Assessment Type

Patient Reported Outcomes

Cost

Not Free

Cost Description

Variable based on license option. License options include Standard Commercial, Limited Commercial, and Research Licenses, which can be found at https://www.insigniahealth.com/license/. Each option includes a variety of tools including the survey, administration tools, training tools, and intervention programs.

CDE Status

Not a CDE—last searched 3/6/2024.

Populations

Neurological Disorders
Renal Disease
Osteoarthritis
Orthopedic Surgery
Older Adults and Geriatric Care
Non-Specific Patient Population
Multiple Sclerosis
Mixed Populations

Key Descriptions

  • Initially developed as a 22-item survey. A 10-item survey is also available.
  • Unidimensional scale.
  • Scale ranges from 1 (strongly disagree) to 4 (strongly agree).
  • Estimated item response probabilities from Rasch modeling are used to assign activation scores from 0 to 100, with higher scores indicating greater activation. Activation scores are then converted to a PAM level:
    o Level 1: Believing an active role is important (indicated by a score of 0.0-47.0)
    o Level 2: Having confidence and knowledge to take action (47.1-55.1)
    o Level 3: Taking action to maintain or improve health (55.2-72.4)
    o Level 4: Continuing healthy behaviors under stress (72.5-100)

Number of Items

13

Equipment Required

  • Computer with licensed program

Time to Administer

Less than 5 minutes

Required Training

Training Course

Required Training Description

Licensed program includes live and on-demand training courses. Instruction manual is also provided.
https://www.insigniahealth.com/license/

Age Ranges

Adult

19 - 64

years

Elderly Adult

65 - 97

years

Instrument Reviewers

Kaitlin Lillywhite, OTR/L, CSRS, OTD student, Columbia University

Anna Norweg, PhD, MA, OTR, Columbia University

 

ICF Domain

Participation

Measurement Domain

General Health

Considerations

  • Available in over 35 languages
  • Intervention program (Flourish) aims to personalize health education, action steps, health provider support, and extrinsic rewards to increase patient activation based on results of the survey.

 

Non-Specific Patient Population

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Construct Validity

Convergent validity:

Non-Specific Patient Population: (Hibbard et al., 2004; n = 1515; age >= 45; mean age = 55; age range = 45 to 97; female = 958 (63%); reported ≥1 chronic disease, n = 1192 (79%); 22-item PAM administered via telephone survey)

  • Adequate correlation between PAM scores and general health, as measured by the SF-8 (r = 0.38)

 

Discriminant validity:

Non-Specific Patient Population: (Hibbard et al., 2004; n = 1515)

  • Excellent discriminant validity between PAM scores and doctor office visits/emergency room visits/and hospital nights (r = -0.07)

 

Face Validity

“An 80-item pool was constructed by selecting questions from existing instruments and creating new ones were none existed. The items in the pool were categorized under the domains they were intended to measure and were reviewed by a subset of the expert panel for face and content validity. All 80 items were further refined with three rounds of face-to-face cognitive testing with 20 respondents with chronic conditions. Items were evaluated in terms of how well they were understood, the degree to which there was variability in responses, and the adequacy of the response categories (Hibbard et al., 2004, p. 1010-1011).”   

Mixed Populations

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Internal Consistency

Cardiac Rehabilitation Patients and Employees of a Large Health System: (Hibbard et al., 2004; n = 486 (120 cardiac rehabilitation patients via self-administered questionnaire and 366 employees of a large health system in a second community via a web-based version of the survey; 118 (24%) reported no chronic disease)

  • Excellent: Cronbach’s alpha = 0.91*

 

Inpatient Cardiac and Oncology: (Prey et al., 2016; n = 100; mean age (SD) = 64.1 (1.69) years; inpatient population; unplanned admissions n = 50; USA, Dominican Republic, and Puerto Rico samples)

  • Excellent: Cronbach’s alpha = 0.81

 

*Scores higher than 0.9 may indicate redundancy in the scale questions.

 

Construct Validity

Convergent validity:

Inpatient Cardiac and Oncology: (Prey et al., 2016) 

  • Adequate convergent validity  between Patient Activation Measure (PAM) scores and Patient Reported Outcomes Measurement Information System (PROMIS) Global Health scores (r = 0.40)
  • Adequate convergent validity  between PAM scores and PROMIS Physical Health scores (r = .40)
  • Adequate convergent validity between PAM scores and PROMIS* Mental Health scores (r = 0.45)

 

Discriminant validity:

Inpatient Cardiac and Oncology: (Prey et al., 2016) 

  • Significant difference in PAM levels of participants who had planned vs. unplanned admissions
    • 56% of participants with unplanned admissions had low activation compared to 24% of participants with planned admissions (p = 0.001)
    • Patients with unplanned admissions were more likely to have low activation compared to patients with planned admissions, even after controlling for baseline covariates (adjusted OR = 5.7, p = 0.008)

 

 

Osteoarthritis

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Internal Consistency

Osteoarthritis: (Eyles et al., 2020; n = 217; mean age (SD) = 65.5 (10.8) years, mean visual analog pain scale = 4.0 (2.3))

  • Excellent: Cronbach’s alpha = 0.92*

*Scores higher than 0.9 may indicate redundancy in the scale questions.

Construct Validity

Convergent validity:

 Osteoarthritis:  (Eyles et al., 2020; n = 217)

  • Poor convergent validity between PAM and Depression, Anxiety, and Stress Scale (DASS): r = -0.26
  • Adequate convergent validity between PAM and Assessment of Quality of Life (AQoL-6D)  (r = 0.32)

 

Discriminant validity:

Osteoarthritis:  (Eyles et al., 2020; n = 217)

  • Excellent discriminant validity between:
    • PAM and the Knee Injury and Osteoarthritis Outcome Score (KOOS) Pain (r = 0.13)
    • PAM scores and KOOS Activities of Daily Living (KOOS-ADL) (r = 0.15)
    • PAM scores and Hip Disability and Osteoarthritis Outcome Score (HOOS) Pain (r = -0.06)
    • PAM scores and HOOS ADL (r = -0.23)

Renal Disease

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Internal Consistency

Chronic Kidney Disease (CKD) - Not Requiring Dialysis: (Lightfoot et al., 2021; n = 942; mean age (SD) = 66.4 (20.8) years; male = 554 (59%); estimated glomerular filtration rate (SD) = 36 (21) ml/min)

  • Excellent: Cronbach’s alpha = 0.925*, (95% CI = 0.917 – 0.932) 
  • Poor: Average inter-item correlation = 0.502

*Score higher than 0.9 may indicate redundancy in the scale questions.

 

Floor/Ceiling Effects

Chronic Kidney Disease (CKD) - Not Requiring Dialysis: (Lightfoot, et al., 2021)

  • Adequate: Floor effects of 2-5% for all items 
  • Adequate: Ceiling effects of <20% for 6 items
  • Poor: Ceiling effects of >=20% for 7 items

Neurological Disorders

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Internal Consistency

Neurological Conditions: (Packer et al., 2015; n = 722; female = 65%)

  • Excellent: Cronbach’s alpha = 0.87

 

Construct Validity

Convergent validity:

Neurological Conditions: (Packer et al., 2015)

  • Adequate convergent validity  between PAM scores and Health Utility Index (r = 0.32, p < 0.0001)
  • Adequate convergent validity  between PAM scores and the mental health subscale of the Short Form-36 (SF-36) (r = 0.35, p < 0.0001)
  • Poor convergent validity between PAM scores and the physical health subscale of the SF-36 Scale (r = 0.20, p < 0.0001)
  • Poor convergent validity between PAM scores and the Simple Lifestyle Indicator Questionnaire (r = 0.29, p < 0.0001)

 

Older Adults and Geriatric Care

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Internal Consistency

Multi-morbid, Community-Dwelling: (Skolasky et al., 2011; n = 855; mean age (SD) = 77.3 (6.4) years; mean ADL score (SD) = 0.57 (1.10); mean IADL score (SD) = 1.01 (1.37))

  • Excellent: Cronbach’s alpha = 0.87

 

Construct Validity

Convergent validity:

Multi-morbid, Community-Dwelling: (Skolasky et al., 2011)

  • Adequate convergent validity  between PAM scores and the communication subscale of the Primary Care Assessment Survey (PCAS) (r = 0.339)
  • Adequate: Adequate correlation between PAM and the integration subscale of the PCAS (r = 0.304)

 

Discriminant validity:

Multi-morbid, Community-Dwelling: (Skolasky et al., 2011)

  • Excellent discriminant validity between PAM scores and the physical health subscales of the SF-36 (r = 0.215)
  • Excellent discriminant validity between PAM scores and the mental health subscales of the SF-36 (r = 0.193)

Orthopedic Surgery

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Test/Retest Reliability

Elective Lumbar Spine Surgery: (Skolasky et al., 2009; n = 283; mean age (SD) = 59 (15.7) years; female = 158 (56%); subset of 65 participants completed retest within 1 week of initial test)

  • Acceptable test-retest reliability (ICC = 0.84)

Internal Consistency

Elective Lumbar Spine Surgery: (Skolasky et al., 2009; calculated using split-half scores from the baseline PAM and adjusted using the Spearman-Brown formula)

  • Excellent: split-half reliability = 0.92*

*Scores higher than 0.9 may indicate redundancy in the scale questions.

Construct Validity

Convergent validity:

Elective Lumbar Spine Surgery: (Skolasky et al., 2009)

  • Excellent convergent validity between PAM scores and optimism, as measured by the Life Orientation Test-Revised (r = 0.754)
  • Excellent convergent validity PAM scores and Trait Hope Scale (r = 0.731)
  • Excellent convergent validity between PAM scores and Arthritis Self-Efficacy Scale (r = 0.650)
  • Excellent convergent validity between PAM scores and Multidimensional Health Locus of Control Scale (Internal): (r = 0.659)

 

Discriminant validity:

Elective Lumbar Spine Surgery: (Skolasky et al., 2009)

  • Excellent discriminant validity between PAM scores and depression PRIME-MD (r = -0.128)
  • Excellent discriminant validity between PAM scores and Charlson Comorbidity Index (r = 0.007)

 

Multiple Sclerosis

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Internal Consistency

Multiple Sclerosis: (Stepleman et al., 2010; n = 199; female = 163 (82%); mean age (SD) = 46.24 (10.83) years; mean years since diagnosis (SD) = 8.3 (6.84) years; type of MS: relapse remitting = 131 (69%), progressive = 8 (4%), secondary progressive = 15 (8%), unsure = 37 (19%); respondents recruited from a regional Multiple Sclerosis Center affiliated with an academic medical center in southeastern U.S.)

  • Excellent: Cronbach’s alpha = 0.88

Construct Validity

Convergent validity:

Multiple Sclerosis Clinic:(Stepleman et al., 2010)

  • Adequate convergent validity between PAM scores and Multiple Sclerosis Self-Efficacy Scale (r = 0.50)
  • Adequate convergent validity between PAM scores and Beck’s Depression Inventory (r = -0.43)
  • Poor convergent validity between PAM scores and self-reported frequency of missing disease-modifying therapy injections (r = -0.04)

Bibliography

Eyles, J. P., Ferreira, M., Mills, K., Lucas, B. R., Robbins, S. R., Williams, M., Lee, H., Appleton, S., & Hunter, D. J. (2020). Is the Patient Activation Measure a valid measure of osteoarthritis self-management attitudes and capabilities? Results of a Rasch analysis. Health and Quality of Life Outcomes, 18(1), 121. https://doi.org/10.1186/s12955-020-01364-6

Hibbard, J. H., Mahoney, E. R., Stockard, J., & Tusler, M. (2005). Development and testing of a short form of the patient activation measure. Health Services Research, 40(6 Pt 1), 1918–1930. https://doi.org/10.1111/j.1475-6773.2005.00438.x

Hibbard, J. H., Stockard, J., Mahoney, E. R., & Tusler, M. (2004). Development of the Patient Activation Measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39(4 Pt 1), 1005–1026. https://doi.org/10.1111/j.1475-6773.2004.00269.x

Lightfoot, C. J., Wilkinson, T. J., Memory, K. E., Palmer, J., & Smith, A. C. (2021). Reliability and Validity of the Patient Activation Measure in Kidney Disease: Results of Rasch Analysis. Clinical Journal of the American Society of Nephrology: CJASN, 16(6), 880–888. https://doi.org/10.2215/CJN.19611220

Packer, T. L., Kephart, G., Ghahari, S., Audulv, Å., Versnel, J., & Warner, G. (2015). The Patient Activation Measure: A validation study in a neurological population. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 24(7), 1587–1596. https://doi.org/10.1007/s11136-014-0908-0

Prey, J. E., Qian, M., Restaino, S., Hibbard, J., Bakken, S., Schnall, R., Rothenberg, G., Vawdrey, D. K., & Masterson Creber, R. (2016). Reliability and validity of the patient activation measure in hospitalized patients. Patient Education and Counseling, 99(12), 2026–2033. https://doi.org/10.1016/j.pec.2016.06.029

PubMed. (n.d.). Psychometric assessment of the patient activation measure short form (PAM-13) in rural settings. Retrieved April 9, 2023, from https://pubmed-ncbi-nlm-nih-gov.ezproxy.cul.columbia.edu/22466721/

Skolasky, R. L., Green, A. F., Scharfstein, D., Boult, C., Reider, L., & Wegener, S. T. (2011). Psychometric properties of the patient activation measure among multimorbid older adults. Health Services Research, 46(2), 457–478. https://doi.org/10.1111/j.1475-6773.2010.01210.x

Skolasky, R. L., Mackenzie, E. J., Riley, L. H., & Wegener, S. T. (2009). Psychometric properties of the Patient Activation Measure among individuals presenting for elective lumbar spine surgery. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation, 18(10), 1357–1366. https://doi.org/10.1007/s11136-009-9549-0

Stepleman, L., Rutter, M.-C., Hibbard, J., Johns, L., Wright, D., & Hughes, M. (2010). Validation of the patient activation measure in a multiple sclerosis clinic sample and implications for care. Disability and Rehabilitation, 32(19), 1558–1567. https://doi.org/10.3109/09638280903567885

 

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