Measuring and Improving Patient Self-Efficacy and Informed Choice

David Foster, Senior Director, Analytics and Insight

Healthwise has a deeply held purpose—to empower people to live their healthiest life possible. Our task is to inform people during their care journey. But how do we know whether we are delivering on that purpose?


Earlier this year, a colleague working in a digital health collaborative asked about the various ways of measuring perceived self-efficacy. This sparked a conversation about how to measure this important psychological characteristic that can tell you whether or not someone thinks they can do things that impact their health. The psychologist Albert Bandura’s gift to population health professionals is not only the thesis that perceived self-efficacy can be improved to make an impact on health status, but that it can be measured with the right tools.

Lots of attention is given to all the new ways that consumers can track biometrics and the fact these patient-generated health measurements can be incorporated into care through digital interoperability. It’s important to remember that psychometrics can be paired with biometrics to give a complete picture of how well a person is managing their health. With psychometrics, we are just moving from one part—the feet, let’s say—to another part of the body—the headspace.

The Patient Activation Measure (PAM) and Insignia

Many are familiar with the behavioral scientist Judith Hibbard’s work on the development of the PAM.1 There are hundreds of studies on how this tool helps to quantify the motivational mindset. The National Health Service in the United Kingdom uses the PAM at the clinic and community level to personalize care plans.2

Consider that the PAM allows a clinician to get into the mind of the patient and figure out, “What is their motivation?” You can track this over time and determine how a given treatment plan is working for an individual or a group. Low-activated people at a PAM level 1 or 2 may require more time and attention from care providers before they start taking action. Studies by the NHS show how PAM score and level can be used to guide tailored health coaching.3


Altarum Consumer Engagement (ACE) Measure

Another way to measure self-efficacy is with the Altarum Consumer Engagement (ACE) measure.4 The assessment consists of multiple domains of engagement:

  • Commitment: Confidence and ability to maintain a healthy lifestyle and manage one’s health
  • Informed Choice: Patterns of seeking and using information about health and health care
  • Navigation: Confidence and ability to ask about and participate in treatment decisions

People who are at lowest level of commitment may not be helpable just by boosting engagement. Care professionals may have to address issues higher on the hierarchy of needs—i.e. other issues that are more urgent, like housing and food. Trying to engage a patient in this state may not be effective if other needs are taking up their brain space. In this situation, it might be better to get a social worker involved.

The ACE can be implemented across a large system, like it has been at the University of Pittsburgh Medical Center. This organization uses the ACE regularly on a large number of patients. UPMC has done over 250,000 administrations of the ACE and has measured the same person twice in some cases. It is feasible to use the ACE widely among a large population.

The ACE can also be used to evaluate health interventions. Consider that interventions might lead to improved engagement and outcomes at the same time. Investigators at UCLA find ACE scores increase with diabetes prevention program (DPP) attendance. Stay tuned for future ACE studies from this same investigator team in the future.5


Measuring the Healthwise Mission and Purpose

Healthwise advocates for an increase in “informed choice.” We’d like to see more people spending time with our materials as a part of their care. We’d also like to see more people independently seek out information to help them with their health decisions and behaviors. Using a measure like the PAM or the ACE can help our partners understand where they are making improvements in informed choice that help people live their healthiest lives possible.

What Can You Do?

Consider measuring consumer engagement with tools like the ACE or the PAM.

Incorporate patient health education in your interventions so that people can make informed decisions and increase their perception that they can do something about their health.

Value-based care quality measurement ought to include whether or not patients are informed and involved in their care. These types of measurement tools are one way to show this type of quality. After all, engagement measures track with disease courses. By empowering and informing the consumer, we can reduce disparities in how care is delivered.

1 https://www.insigniahealth.com/products/pam-survey
2 https://www.england.nhs.uk/personalisedcare/supported-self-management/patient-activation/pa-faqs/
3 https://www.england.nhs.uk/wp-content/uploads/2016/07/pa-horsham-mid-sussex-crawley-ccg-cs.pdf
4 https://altarum.org/solution/ace-patient-engagement-measure
5 https://www.sciencedirect.com/science/article/pii/S2211335519301329