The results indicate that the shortened 13-item version is both reliable and valid. The shorter version of the PAM will make it more feasible to use activation scores to inform patient care plans. However, for PAM users who are seeking the highest level of measurement precision, the PAM 22 may be more desirable.
PAM scores can provide insight into possible strategies for supporting activation among patients at different points along the continuum. Patients who score at the bottom of the measure may still believe that the doctor will “fix” them. Patients whose scores are somewhat higher, but are still in the bottom half may understand that they must be involved in their care, but still lack the basic knowledge about their conditions and their treatments that is necessary for them to effectively act. Thus, patients scoring in the bottom half of the measure likely need to work on self-awareness of their role in the care process and in gaining the basic knowledge about their conditions.
Patient's whose scores are in the upper half are beginning to gain confidence in their ability to take on self-management behaviors and make lifestyle changes. At this stage experiencing a series of small successes will likely build a sense of self-efficacy and increase activation (Battersby et al. 2003
). Patients scoring near the upper range of the measure are likely to have made changes in their lifestyles but may still have difficulty maintaining them when new situations arise or when they are under stress. Thus, for those patients scoring in the upper half of the PAM, working on developing a sense of self-efficacy for taking on and maintaining behaviors is paramount.
Attaining the basic knowledge and beliefs reflected in early stages of activation are likely necessary for building a sense of efficacy for the self-management tasks involved in the later stages. We hypothesize that patients need to sequentially pass through each of these stages on the way to becoming effective self-managers. These stages have some similarities with the stages of change in the Transtheoretical Model (Prochaska and DiClemente 1983
; Prochaska, Redding, and Evers 1997
), which includes precontemplation, contemplation, preparation, action, and maintenance stages. The Transtheoretical Model emphasizes motivation and readiness and does not explicitly deal with issues of skill and knowledge acquisition. Further the Transtheoretical Model focuses on one behavior at a time and requires the development of a measurement tool specific to that behavior. The idea of tailoring interventions to the patient's stage is similar for both models.
While the PAM has strong psychometric properties, research is still needed to make it fully ready for use in different settings and with different populations. PAM users are beginning to translate the measure into other languages. The degree to which the measure is valid and reliable in these different language translations and among different cultures is unknown and deserves investigation. While early evidence indicates the measure is valid and reliable for different chronic illnesses, this too requires further study. Replication studies of the measure with different populations in different settings are underway and will add to our understanding of these questions.
Research, which tests interventions that are effective in encouraging and supporting patient advancement through the stages, is a high priority. It is very likely that a strategy that will help a patient move from stage one (believing the patient has an active role) to stage two (having the confidence and knowledge to take action) is different from what will help her move into stage 3 (taking action). That is, once a patient score or stage is known, what interventions are efficacious in increasing that patient's activation?
In addition to using the PAM score to inform interactions with patients, an alternative approach has been tried in pilot efforts. Because the items can be ordered by difficulty, it is possible to visually scan patient responses and observe when their answers begin to move away from “strongly agree.” Clinicians can use this as an opportunity to begin a conversation with the patient about the item where responses changed. For example, “I see you are less sure about your medications, let's talk about that.” Using the PAM in this way can sharpen the specificity of the interaction with the patient, increasing the probability that individual barriers and issues can be identified and dealt with. It may be that using both the visual scan and the PAM score or stage may be the most effective use of the measure. If this were the case, it might be advantageous to use the full 22-item PAM to allow for more opportunities to identify problems specific to an individual patient. Just using the “visual scan” approach is the easiest way to use the measure in a clinical encounter, particularly when electronic data collection is not an option. Because there is no scoring involved and no data entry, testing the efficacy of this “low tech” approach is also a priority.
Among the interventions that do increase activation, what effect do they have on patient health outcomes and costs?
Research on the use of the PAM for managing enrolled patient populations is also needed. Would early intervention with patients identified through screening as having both clinical risk factors and low skills (low PAM scores), reduce costs and improve health outcomes?
Using the PAM as a basis for designing care plans and for assessing individual and patient population progress appears to be a viable approach, and one that warrants controlled testing to determine whether patients' whose care plans are informed by PAM scores have better outcomes and require less health care resources than those patients whose care plans are not so informed.