More than one in five U.S. adults at lower activation levels

Those who are activated in their health are more apt to stay current on their medications, more engaged during medical encounters, seek out health information, and more likely to eat healthy foods, exercise, and get preventive care.

With that information as a backdrop, a recent Center for Studying Health System Change (HSC) research brief showed that fewer than half of U.S. adults are activated in their health, which can affect chronic care programs such as disease management and benefit designs such as consumer-driven healthcare.

“When you add it all up, [activation level] can have a pretty big impact,” says Judith H. Hibbard, DrPH, professor of health policy at the University of Oregon’s department of planning, public policy, and management and coauthor of the research brief How Engaged Are Consumers in Their Health and Health Care, and Why Does It Matter? with HSC senior fellow Peter J. Cunningham, PhD.

For the research brief, the authors used data from HSC’s 2007 Health Tracking Household Survey, in which 17,800 people were interviewed about their health. The survey found that slightly more than 41% of U.S. adults were at the highest level of activation (Level 4), whereas more than one out of every five was at either of the two lowest activation levels. Activation is gauged by a person’s ability and willingness to manage his or her health and healthcare. (See Figure 19 on p. 17.)

Hibbard designed the patient activation measure (PAM) to assess a person’s “knowledge, skill, and confidence in managing their health,” according to the research brief. (See “Four levels of activation” at left.)

Higher activation levels are associated with “much fewer problems with access to care, even when controlling for insurance coverage and income, which may reflect greater resourcefulness among more highly activated people in navigating the complexities of the health care system and overcoming barriers,” the authors wrote.

A person’s income or education level can play a role in activation but are not sufficient to identify a person’s activation level.

“[Socioeconomic status] certainly is related, but there are people who are quite activated who have lower income, lower education, even lower literacy skills, who are very motivated and focused on doing a good job in managing their health ... There are examples on the other end of the economic ladder where they are not focused on taking care of their health,” Hibbard says.

Those who are at the lower end of activation are discouraged, possibly because they have failed at bettering their health or don’t see a positive effect on their health, Hibbard says.

This discouragement is evident for those with chronic illnesses. Doctors often ask patients who are battling chronic disease to change their lifestyles, which is difficult and scary for many patients. “When they aren’t able to do that, they throw up their hands and do nothing and they feel discouraged,” says Hibbard.

The survey also found a connection between those more activated and those who receive greater support from their providers. Nearly 84% of respondents at Level 4 reported that a provider helped them set goals to improve their diet, compared to slightly less than half of people at Level 1. (See Figure 20 on p. 17.)

Although more than 20% of those surveyed are in the bottom two levels of activation, there is good news—an individual’s activation levels fluctuate. This means that healthcare professionals need to engage a person during those times when he or she is ready.

Physicians can stimulate patient activation

More highly activated patients have more positive and supportive healthcare experiences, the survey found. The authors added that the findings could show that support from physicians stimulates patient activation.

“If this is correct, then encouraging this type of phy-sician support may be a productive pathway for increasing activation. This may be particularly important for those at lower levels of activation, who not only engage in fewer health-promoting behaviors, but also tend to be passive with regard to their health care,” the authors wrote.

These findings show how a positive relationship between patients and their doctors creates more engaged patients and high-quality healthcare, Anne F. Weiss, MPP, senior program officer and team leader of quality/equality strategy at the Robert Wood Johnson Foundation, said in a statement.

“Doctors need to talk with their patients about setting goals for their health and how to monitor their conditions. And since we know that activated patients fare better and ultimately cost less, policymakers should consider encouraging health systems to find ways to activate their patients,” Weiss said.

CDHPs and activation

Activation level plays a role in whether patients have a regular source of care, whether there is an unmet medical need, and whether people delay care or don’t fill prescriptions, according to the survey (See Figure 21 on p. 18.)

Although the theory behind consumer-driven healthcare is that placing more financial responsibility on individuals will drive them to choose healthcare wisely and not overuse services, the researchers wrote that “cost sensitivity by itself may be a necessary but not sufficient condition for greater consumer engagement.”

Increased cost sensitivity is a manifestation of a more activated consumer who seeks information on cost and quality, but lower activation levels can create invisible barriers between the consumer and information.

With states looking at ways to cut Medicaid costs, policymakers have begun implementing consumer-driven healthcare at the Medicaid level. This could present a problem because many in Medicaid are in the lower activation levels. This means the move to consumer-driven health plans (CDHP) may not empower Medicaid beneficiaries to make better healthcare decisions and, ultimately, may not save money in the long run.

“People enrolled in Medicaid are among the least-activated patients among all insurance groups, which reflects both lower educational levels and lower socioeconomic status. The findings suggest that efforts to increase patient responsibility in the Medicaid program will only succeed if they are accompanied by vigorous efforts to educate enrollees and increase their levels of activation,” the survey authors wrote.

Chronic disease differences

Those with chronic conditions are more likely to fall in the lower levels of activation, but activation levels vary by chronic condition. (See Figure 22 on p. 18.)

For example, people with depression are least activated, but those with cancer are more engaged. Those with multiple chronic conditions who are in fair or poor health and are obese are less activated than those with a single condition or who have better health indicators.

All of this points to the need to teach these patients self-management skills to show them how to monitor their health, according to the authors.

Engaging the least activated

Inspiring those at the lower end of activation is difficult, but Hibbard says there are two ways to help those not feeling engaged:

Find out what the person wants to work on first, which will help him or her feel a degree of control.

Break down life changes into easy-to-accomplish, smaller tasks initially so the person can succeed. For example, ask a person who needs to improve his or her diet to start by eating one high-fiber, low-fat meal once per week.

Accomplishing one of those smaller tasks will spark people’s belief in themselves. “That is how a person gets a sense of confidence in experiencing some level of success,” says Hibbard.

Patient activation science

Hibbard says healthcare is still learning about patient activation science. “I think that we’re just on the edge of really learning how to use this kind of information to really tailor and personalize care in ways that we have never done before. Healthcare has been a little slow in coming to this, but I think this will open the door on this topic,” she says.

Sander Domaszewicz, principal at consulting firm Mercer in Newport Beach, CA, says these findings show there is a need for programs that help people down the activation path. Domaszewicz believes more population health companies will see the need to add services that go beyond support and information and provide teachers and trainers to help people gain a better understanding of their ability to affect their health, outcomes, and costs. These services will help people link their behavior to their health and show that improved lifestyles can affect health and spark activation, Domaszewicz says.

Four levels of activation

The patient activation measure (PAM) includes a 13-item scale that asks respondents about their beliefs, knowledge, and confidence in several health behaviors. Based on their responses, they are assigned an activation score. A person’s activation level reflects whether they obtain preventive care, maintain good diet and exercise practices, use self-management behaviors, and seek out health information, according to a research brief by the Center for Studying Health System Change.

PAM’s four activation levels are:

  • Level 1 (lowest level): People are passive and may not feel confident enough to play an active role in their health
  • Level 2: People may lack basic knowledge and confidence in their ability to manage their health
  • Level 3: People appear to take some action but may still lack confidence and skill to support necessary behaviors
  • Level 4: People support their health but may not be able to maintain support because of life stressors




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