Toward a theory of patient and consumer activation

https://doi.org/10.1016/j.pec.2009.12.015Get rights and content

Abstract

Objective

The purpose of this study is to begin the process of developing a theory of activation, to inform educational efforts and the design of interventions. Because the experience of positive emotions in daily life, tends to widen the individual's array of behavioral responses and increase their openness to new information, we examine how emotions relate to activation levels.

Methods

A web survey was carried out in 2008 with a National sample of respondents between the ages of 25–75. The study achieved a 63% response rate with a final sample size of 843.

Results

The findings indicate that activation is linked with the experience of positive and negative emotion in daily life. Those low in activation are weighted down by negative affect and negative self-perception.

Conclusions

Bringing about change in activation, likely means breaking this cycle of negative self-perception and emotions.

Practice implications

Experiencing success can start a positive upward cycle, just like failure produces the opposite. By encouraging small steps toward improving health, ones that are realistic, given the individuals level of activation, it is possible to start that positive cycle. Effective educational efforts should focus on improving self-efficacy and the individual's self-concept as a self-manager.

Introduction

Consumer and patient activation refers to the degree to which the individual understands they must play an active role in managing their own health and health care, and the extent to which they feel able to fulfill that role. Specifically, it refers to the individual's knowledge, skill, and confidence for managing his/her own health and health care [1]. The concept has been widely studied using the patient activation measure (PAM). The PAM is a 13-item survey instrument that was developed using qualitative methods, classical test theory, and Rasch analysis. It is an interval level, un-dimensional, Guttman-like measure. Research shows that PAM scores are predictive of most health behaviors [1], [2], [3], [4], [5], [6].

Those who are more activated are more likely to engage in healthy behaviors, such as regular exercise and low fat diet; to engage in disease-specific self-management behaviors, such as monitoring and medication adherence; to obtain preventive care, and to seek and use health use health information [2], [3], [4]. Activation is also predictive of health outcomes and health care utilization [5]. A recent Kaiser Permenante study that followed diabetic patients over a 2-year period found that baseline PAM scores predicted whether or not patients had good glycemic control, were adherent to diabetic testing, and whether or not they had had a hospitalization 2 years later [6]. These findings indicate the construct of activation is stable enough, and the measurement robust enough to predict important health outcomes into the future.

A longitudinal study that followed chronic illness patients over a 6-month period, showed that those who did become more activated, significantly improved multiple health related behaviors. That is, as they apparently began to feel more “in control” of their health, they changed many things about how they took care of themselves [4]. Because most behavioral change theories focus on one behavior at a time, these findings provide a potentially new way to understand how behavioral change can be supported.

Given that activation is linked with the full range of health behaviors and many health outcomes, investigating how people become more or less activated becomes important. The key challenge is to develop effective interventions and educational programs that will support increases in activation among individuals and whole populations. Our purpose here is to further understand factors that underlie activation or are closely linked with it.

The social context shapes perceptions and beliefs and likely plays an important role in how people understand their own role in managing their health. For example, social norms can either support or undermine the idea that people should pro-actively protect and promote their health [7]. The greater the degree to which this particular social norm is articulated and modeled in the social environments and institutions where people live, work, and get their health care, the more likely it is that individuals will adopt it into their belief system. Research indicates environments that support social norms of being an informed and pro-active manager of one's own health, are more likely to have higher activated consumers, than environments that do not support these norms [2], [3].

Gaining confidence in one's own ability to fulfill the role of pro-active self-manager is another important step in becoming activated. Gaining confidence is likely an iterative self-reinforcing process. When individuals see others experiencing success and experience some success with their own efforts, they begin to feel more capable and confident [8]. Gaining confidence and experiencing success can actually lead to more successes. Results from human flourishing studies indicate that when people experience more positive emotions in their daily lives, they tend to widen the array of behavioral responses, to be more open to new information and to adapting new behavioral strategies [9]. Fredrickson's [10], [11] broaden-and-build theory of positive emotions asserts that people's daily experiences of positive emotions compound over time to build a variety of consequential personal resources. Short-term benefits of positive emotions include increased creativity, problem-solving ability, and openness to new experiences and information. These shorter-term benefits can lead to building a person's social, psychological, intellectual, and physical resources over time. That is, in the long term, the effect of positive emotions is to increase resources and resilience for better coping with adversity, increased closeness of personal relationships, and improved immune system functioning [12].

The theory of broaden-and-build has much applicability to the concept of activation. People who experience more positive emotions are more open to new information and experiences and are more likely to adopt new norms, such as the importance of being pro-active about one's own health. Those experiencing more positive emotions are more likely to successfully problem-solve when encountering new problems, and to have the social support of people around them to help them cope.

Thus, gaining confidence, experiencing success, and the resulting positive emotions can be an upward spiral that is self-reinforcing. The accumulation of these positive experiences, in turn, increases the chances for experiencing further successes and ultimately leads to effective self-management.

The reverse is also likely true. Experiencing multiple failures in attempting to manage a chronic illness or adopt a healthy behavior, is likely to result in feelings of being overwhelmed, disempowered, discouraged, and ultimately in taking a passive approach to health [13]. Such experiences increase overall negative affect, which in turn reduces one's capacity for problem solving and using new information [9]. Once people internalize the knowledge that they can, or cannot, be in control of their health and functioning through their own actions, this knowledge appears to be relatively stable. That is, this belief about their ability to manage their health becomes part of the individual's self-concept. This is consistent with the symbolic interactionism framework in social psychology, where the individual ascribes meaning to behaviors, objects, events, or even themselves [14]. Level of activation, then may be a reflection of how people view themselves as managers of their own health. The PAM items are 13 declarative statements about oneself (that the respondent agrees or disagrees with). Thus, one could say that the PAM, is a measure of self-management self-concept.

If emotions are key underpinnings of activation, then this is critical to understand, and to use these insights to inform interventions designed to support greater activation. Further, if activation is a reflection of self-management self-concept, then part of the task with the low activated, is to explicitly work on changing that self-concept.

In this study we examine how emotions relate to activation level. If successful experiences, build confidence and other positive emotions, and failures increase feelings of discouragement negative emotions, then we would expect to observe more positive affect among the highly activated. Similarly, we would expect that those who are low in activation, to report more negative affect and to be more discouraged and overwhelmed with the task of managing their health. Finally, because having specific health goals for oneself is an indicator of being pro-active about one's health, we would expect those higher in activation to more often have personal health goals. In this analysis we examine these questions:

  • Do people at different levels of activation experience a different balance of positive and negative affect or emotions in their everyday life?

  • Do people at different levels of activation experience a different balance of positive and negative emotions when managing their health?

  • What are the specific emotions that predominate at each level of activation?

  • Does activation level predict whether people have specific health goals?

Section snippets

Study design

The study utilizes a cross-sectional design to examine the relationship among variables at one point in time. A web survey was carried out in September 2008 with respondents between the ages of 25 and 75. The survey was conducted using the Knowledge Networks on-line national panel.

Knowledge Networks (KN) has an online research panel based on probability sampling that covers both the online and offline populations in the U.S. The panel members are randomly recruited by telephone and households

Results

Table 1 shows the characteristics of the study sample. Respondents ranged in age from 25 to 75 with a mean age of 54. Slightly more than half the sample was female. Almost 44% of respondents had a high school education or less. Twenty-one percent rated their own health as only fair or poor. Thirty-four percent scored in the lowest two levels on the activation measure.

To answer the research questions we examined the average number of positive and average number of negative emotions people at

Discussion

Previous findings show that activation level is predictive of a wide range of health behaviors [1], [2], [3], [4], [5], [6]. The findings from this study indicate that individuals at different levels of activation also experience different emotions in their day-to-day life, and when managing their health. Our goal in examining emotions, is to create a deeper understanding about what it means to be at these different levels of activation, understand the factors shaping behavior, and therefore,

Funding

None.

Conflict of interest

Judith Hibbard and Eldon Mahoney both are consultants to and have an ownership interest in Insignia Health, LLC. Insignia Health holds the licensing rights to the patient activation measure (PAM).

References (15)

  • J. Fowles et al.

    Measuring self-management of patients’ and employees’ health: Further validation of the patient activation measure (PAM) based on its relation to employee characteristics

    Patient Educ Couns

    (2009)
  • J.H. Hibbard et al.

    Development and testing of a short form of the patient activation measure

    Health Serv Res

    (2005)
  • E. Becker et al.

    Translating primary care practice climate into patient activation: the role of patient trust in physician

    Med Care

    (2008)
  • J.H. Hibbard et al.

    Do increases in patient activation result in improved self-management behaviors?

    Health Serv Res

    (2007)
  • D. Mosen et al.

    Is patient activation associated with outcomes of care for adults with chronic conditions?

    J Ambul Care Manage

    (2007)
  • C. Remmers et al.

    Is patient activation associated with future health outcomes and healthcare utilization among patients with diabetes?

    J Ambul Care Manage

    (2009)
  • D.T. Gilbert et al.

    The handbook of social psychology

    (1998)
There are more references available in the full text version of this article.

Cited by (173)

View all citing articles on Scopus
View full text