Rademakers et al. BMC Public Health 2012, 12:577 http://www.biomedcentral.com/1471-2458/12/577 Table 1 13 item Patient Activation Measure1 1 2 3 4 5 6 7 8 9 10 11 12 13 When all is said and done, I am the person who is responsible for managing my health condition Taking an active role in my own health care is the most important factor in determining my health and ability to function I am confident that I can take actions that will help prevent or minimize some symptoms or problems associated with my health condition I know what each of my prescribed medications do I am confident that I can tell when I need to go get medical care and when I can handle a health problem myself I am confident I can tell my health care provider concerns I have even when he or she does not ask I am confident that I can follow through on medical treatments I need to do at home I understand the nature and causes of my health condition(s) I know the different medical treatment options available for my health condition I have been able to maintain the lifestyle changes for my health that I have made I know how to prevent further problems with my health condition I am confident I can figure out solutions when new situations or problems arise with my health condition I am confident that I can maintain lifestyle changes like diet and exercise even during times of stress Page 2 of 7 1 Original version [2]. was examined in relation to a number of health related behaviours and choices [7-9]. Two studies showed that the association between patient activation and measures of health literacy was weak, indicating that these are two distinct concepts [7,8]. The other study distinguished be- tween numeracy, literacy and activation [9]. In this study more activated patients were better able to understand and use comparative health care information, even when they had lower numeracy and literacy skill levels. It was suggested that activation might be a proxy for motiv- ation and can compensate for lower skills. In all three studies, however, health literacy was defined on a func- tional level. The broader definition of health literacy by Nutbeam [10] distinguishes between functional, commu- nicative/interactive and critical literacy. These latter components definitely show conceptual overlap with pa- tient activation. Nutbeam includes aspects such as mo- tivation, personal skills and self-efficacy in his definition of health literacy and acknowledges that ‘different levels of literacy progressively allow for greater autonomy and personal empowerment’ [10]. Knowing a person’s activation level is relevant because it can help providers to effectively communicate with their patients and to tailor health messages and self- management goals [4]. Compared to the regular patient approach, an intervention with tailored messages has proven to lead to greater improvement in the patients’ biometrical clinical indicators, in their adherence to pre- scribed medication regimens and to a reduction in hos- pitalizations and use of the emergency department [11]. Furthermore, patient activation has proven to be a changeable characteristic [6,12]. This makes the concept even more relevant since it can not only be used for cat- egorizing patients and consumers and tailoring support and education, but also for actual improvement of con- sumer participation with respect to health and health care, both on an individual and on a population level. The Patient Activation Measure has been studied ex- tensively in the USA. Since many of the American pro- blems regarding the management of health and chronic diseases also exist in the Netherlands, there is a definite clinical and scientific need for an instrument that can help differentiate patients and consumers into subgroups that require different strategies in health support, infor- mation and communication. An official, validated Dutch version of the PAM would be suitable and relevant for this purpose. Similar initiatives have been taken in Norway and Denmark [13,14]. Therefore, a research project was performed in the Netherlands in order to: ▪ translate the American short form Patient Activation Measure (PAM 13) into a Dutch version; ▪ establish the psychometric properties of the Dutch version of the PAM 13; and ▪ validate the Dutch version of the PAM in a panel of chronically ill patients. For validation purposes, the concept of health literacy was chosen, even though previous studies have shown a weak association between the two [7-9]. Since all these studies were done in the USA, and the Netherlands’ health care system and patients are different to a major extent, the choice for replication was made. Only very recently, health literacy instruments were translated in Dutch [15] and available for clinical practice and re- search. Therefore this is the first opportunity to confirm or reject earlier findings on the relationship between pa- tient activation and health literacy in the Dutch context. Methods Translation and adaptation process For the translation and adaptation of the PAM 13, a sys- tematic approach conform instructions of the WHO was followed [16]. This method includes the following steps: