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Validation of the Patient Activation Measure (PAM-13) among adults with cardiac conditions in Singapore



The Patient Activation Measure (PAM-13) measures patients’ knowledge, skill, and confidence in chronic condition self-management. The purpose of this study was to assess the validity of PAM-13 (English version) among English-speaking adults with cardiac conditions in Singapore.


A cross-sectional study was conducted in a convenient sample of 270 heart clinic patients. Using the unitary concept of validity, evidence of (1) internal structure via data quality, unidimensionality, differential item functioning, and internal consistency, (2) response process through item difficulty and item fit using Rasch modeling, and (3) relationship to other variables via correlations with depression and self-efficacy were examined.


The item response was high with only one missing answer. All items had a small floor effect, but nine out of 13 items had a ceiling effect larger than 15 %. Cronbach’s α was 0.86, and average inter-item correlations was 0.324. Results suggested unidimensionality; however, differences in item difficulty ranking were found. A low, negative correlation was found with depression, while a moderate, positive correlation was found with self-efficacy.


Evidence in all three areas of validity were mixed. Caution should be exercised when using categorical activation “level” to inform clinical decisions.

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This study was funded by a research grant awarded by the Singapore Association of Occupational Therapists (Grant Number SAOT/RG01/2015).

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Corresponding author

Correspondence to Bi Xia Ngooi.

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Conflict of interest

Bi Xia Ngooi received the above-mentioned research grant from the Singapore Association of Occupational Therapists. Tanya Packer, Grace Warner, George Kephart, Karen Koh, Raymond Wong, and Serene Lim declared that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Singapore’s National Healthcare Group Domain Specific Review Board and Canada’s Dalhousie University Health Sciences Research Ethics Board, and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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Ngooi, B.X., Packer, T.L., Kephart, G. et al. Validation of the Patient Activation Measure (PAM-13) among adults with cardiac conditions in Singapore. Qual Life Res 26, 1071–1080 (2017).

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  • Patient Activation Measure
  • Cardiac
  • Singapore
  • Chronic disease
  • Self-management
  • Validation