Patient activation: time to think differently about treatments…

It’s self-evident that people who ‘look after themselves’ whether in terms of (for instance) managing diet, activity levels, stress or indeed managing their clinical conditions tend to enjoy better health than those who don’t.

There are numerous drivers of these disparities, including culture, upbringing and deprivation, but one important (and changeable) contributor is the degree to which we as individuals feel capable and confident to manage our health – a concept known as health-related agency or self-efficacy.

The most widely used measure of health-related self-efficacy is the Patient Activation Measure (PAM). It is a patient-reported measure of knowledge, skills and confidence to manage health and is most commonly deployed as a 13-item questionnaire to segment populations of patients into four levels of activation.

Scoring tends to predict:

• The degree to which patients manage their health on a daily basis
• Their engagement in health-related decision-making and with treatment regimes
• Clinical outcomes
• Healthcare utilisation (the higher the score, the lower the use of services – particularly unscheduled services).

The PAM has been validated across numerous patient populations and physical and mental health conditions, and the findings across all groups are roughly comparable; in other words the PAM seems to tap into a core psychological and behavioural characteristic.

There are a variety of interventions that can support patients to improve their level of activation, most notably self-management programmes, peer support and health coaching. All of them aim to improve confidence and capability – with the important secondary effects noted above. This is an important insight; the deployment of the PAM has helped mainstream health systems understand that there are individual psychological drivers of health outcomes and system impact that require our attention.

While there is a relationship between the PAM score and adherence to treatment in the broadest sense, there is only one item in the PAM that is medicine-specific. It follows that if we want to specifically improve treatment engagement, adherence and persistence, we need to deploy a more specific activation measure.

Our research into the mechanisms of adherence tells us that, in parallel with the findings in the field of patient activation, there are individual psychological drivers of treatment engagement, adherence and persistence.

These drivers concern what patients think about treatments, including recommendations for prevention of disease such as vaccination, and there are two main categories:

1. What patients think about pharmaceuticals in general (eg, “All medicines are poisons and are over-prescribed by doctors”)
2. What patients think about a specific treatment that is recommended for them (eg, “Will this medicine really help me or could it do more harm than good?”).

Our 25 years of global research have shown us there are three key elements of activation that determine engagement, adherence and persistence with recommended treatments:

1. Being convinced that it is really necessary
2. Feeling that personal concerns have been addressed
3. Being able to overcome any practical difficulties (eg, cost, access).

We have constructed a number of validated tools that draw on this ‘necessity, concerns, practicalities’ (NCP) framework:

1. The TARA (Treatment Activation and Adherence Risk Assessment) is a segmentation tool that deploys the NCP with regard to medicines
2. The VAM (Vaccine Activation Measure) is a segmentation tool that segments people according to vaccines confidence and likely acceptance/refusal of vaccines.

Like the PAM, these tools provide insights into the primary psychological drivers of engagement with medicines or vaccines, and as with the PAM we have demonstrated that patients fall into four segments from highly sceptical to fully activated.

Finally, (and again, like the PAM), we have demonstrated that focused support (either coaching by a trained professional or a digital intervention) can help patients move from sceptical to engaged, thus improving engagement and adherence to treatment with a concomitant effect on outcomes.

If we are serious about supporting patients to engage with medicines and vaccines, we all need to think differently.

To increase treatment activation we need to identify and help people to overcome the perceptual and practical barriers that impede engagement and adherence. General health activation is important but when dealing with treatments we need to think beyond this to consider the specific perceptions (necessity beliefs and concerns) and practicalities that motivate and enable engagement and adherence.

For more information about our extensive body of work in behavioural medicine and how we support pharmaceutical companies across the functional and drug development phases, please contact Rob Gray, CEO at Personia Health rob.gray@personiahealth.com