Rademakers et al. BMC Public Health 2012, 12:577 http://www.biomedcentral.com/1471-2458/12/577 the Netherlands patient choice and empowerment have become important themes in the past decade, the United States have a longer tradition in patient involvement and focussing on individual responsibilities, also with respect to health and health care. Since the difference with the Danish sample is the greatest, sampling differences will probably play a role as well. Further studies with com- parable samples (e.g. by age, type of chronic disease) are necessary to be able to make more substantiated com- parisons between countries. Self-reported health is the most distinguishing variable with respect to the patient activation scores, both in the Netherlands as in Denmark and the United States. It is not possible in this cross-sectional study to establish cause and effect. It is known that people with low activa- tion scores (level 1 and 2) are more often caught in a cir- cle of negative emotions and low self esteem [3]. This might also influence a more negative assessment of their health status. However, since American studies have demonstrated that a higher score on the PAM positively influences various health related behaviours [3,4], one can expect a positive influence on health by improving the PAM and by helping professionals to tailor their care to the specific needs and possibilities of their patients, which may vary by their activation status. Further stud- ies in this domain in the Netherlands, using the PAM-13 Dutch, are now beginning. Conclusions The PAM-13 Dutch is a reliable instrument to measure patient activation. The level of internal consistency is good (α = 0.88) and item-rest correlations are moderate to strong. The test-retest reliability of the instrument was moderate. Cross-validation with the SBSQ-D, a self report measure on Health literacy, was weak to moder- ate. More research is needed into the validity of the Pa- tient Activation Measure, especially with respect to a more comprehensive measure of Health literacy. Additional files Additional file 1: Dutch version of the PAM-13 (PAM-13-Dutch). Competing interests The authors declare that they have no competing interests. Authors’ contributions JR has contributed with the original idea for the questionnaire translation and the study design. She conducted the focus group (together with JN) and wrote the first draft of the manuscript. JN guided the translation process, conducted the cognitive interviews and performed qualitative and statistical data analysis. LvdH contributed to the general statistical data analyses. MH and MR were responsible for the data collection in the National Panel and assisted in drafting the manuscript. JR, JN and MR participated in the expert panel. 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