Exploring Contextual Factors and Patient Activation

Patient Characteristics

The literature shows that patient activation varies by patients’ demographic and socioeconomic characteristics (Cunningham et al., 2011; Hibbard et al., 2008). Racial and ethnic minorities, immigrants, people with lower income, less educational attainment, and worse self-reported health are less active compared to their counterparts (Hibbard et al., 2007; Hibbard et al., 2008). Health insurance coverage is also related to patient activation. Hibbard et al. (2008) showed that patients with Medicaid were less likely to be activated compared to patients covered by private health insurance. These factors related to patient activation are categorized by predisposing (demographic factors), need (health status), and enabling factors (income, education, health insurance, and other socioeconomic factors) according to the Andersen behavioral model (1968, 1995).

Contextual Factors

Davidson, Andersen, Wyn, and Brown (2004) improved the Andersen behavioral model by adding contextual factors. Jerant et al. (2011) also modeled contextual factors as critical attributes to patient activation. Contextual factors are defined as the environment in which patients receive health care (Cook et al., 2013). Specifically, we focus on two types of contextual factors (Hibbard et al., 2008): site of usual source of care and community characteristics. Site of usual source of care, such as a physician’s office or hospital emergency department (ED), reflects the relationship between physicians and patients, the major impact on patient activation (Alexander et al., 2012).

A continuous relationship with a physician is critical to sustaining a patient’s activation and involvement in their care (Haggerty et al., 2003). The primary health care setting, where health care is regularly delivered and illness is usually diagnosed, may relate to higher patient activation, compared to EDs and other sites of care, for a variety of reasons. Primary health care provides a better environment to improve patient–physician communication, cultivate patients’ trust, and sustain patients’ activation in their health care (Alexander et al., 2012). In addition, primary health care also plays a critical role in continuity of care, as well as care coordination, such as referring the patients to specialist visits or other appropriate health care services. The integrated mental health care model, advocating coordinated primary care and specialty care for mental health treatment, has been considered a core clinical feature to improve mental health care (Agency for Healthcare Research and Quality, 2013; SAMHSA-HRSA Center for Integrated Health Solutions [SAMHSA-HRSA], 2013). Our study provides national-level evidence of patient activation in the primary care setting.

The second contextual factor is the characteristics of the community. Hibbard (2009) noted the importance of improving patient activation at the community level. Community characteristics have been shown to be a critical component of people’s health (White, Haas, & Williams, 2009; Williams et al., 2012). Community health care resources and population characteristics are significantly associated with health care access and utilization (Benjamins, Kirby, & Bond Huie, 2004; Davidson et al., 2004; Dinwiddie, Gaskin, Chan, Norrington, & McCleary, 2013; Gaskin, Dinwiddie, Chan, & McCleary, 2012a, 2012b; Ludwig et al., 2012; Ory et al., 2003), including mental health care (Cook et al., 2013; Lee, 2009) and health care disparities (Gaskin et al., 2012a, 2012b; Kim et al., 2013).

Data

The data for this analysis are from the Center for Studying Health System Change 2007 Health Tracking Household Survey (Hibbard et al., 2008; Strouse, Carlson, Hall, & Cybulski, 2009). The Health Tracking Household Survey is the first large, nationally representative survey to include patient activation measures to assess the level of activation in the civilian, noninstitutionalized U.S. population. The survey includes a 13-item patient activation measure in the consumer engagement section, composed of self-reported responses to questions regarding patients’ self-management of their own health. In addition to the activation questions, the survey also provides detailed data on demographics and socioeconomic status of the respondents, as well as their health care access, insurance coverage, and perception of their patient–physician relationship.

To estimate the association between community characteristics and patient activation, we link the Health Tracking Household Survey data with county-level data from the Area Health Resource File. The Area Health Resource File is a county-based data file and has more than 6,000 data elements for all counties in the United States, including number of physicians, community centers, and population demographic components within a particular county.

Analyses

We first summarize the sample characteristics and present the contextual factor measures by different levels of patient activation. Multivariable linear regressions are used to estimate the association between contextual factors and the patient activation index, controlling for all the listed covariates. Model 1 controls for the site of care; Model 2 controls for community characteristics; and Model 3 controls for both site of care and community characteristics. Our analyses use survey weights to generate nationally representative estimates. The survey weights adjust for the nonresponse rates based on age, gender, race and ethnicity, and education (Strouse et al., 2009). Detailed survey-weights calculations are discussed in the methodological report of the survey (Strouse et al., 2009).

Our data set includes 2,044 patients with self-reported depression. Among these respondents, 1,686 have valid measures of patient activation. We exclude respondents who reported “not applicable,” “don’t know,” or “refused” on more than 7 (out of 13) patient activation questions, and respondents who replied “strongly agree” or “strongly disagree” on all 13 patient activation questions (Hibbard & Cunningham, 2008). After dropping observations with missing values of other covariates, our final sample includes 1,670 adults age 18 years and older with a diagnosis of depression. Approval for the study was obtained from the institutional review board.

Contextual Factor: Site of Care

Depressed patients who report a physician’s office or community clinic as their usual source of care have higher activation measures compared to those who report hospital outpatient clinics or the ED. Maintaining a continuous relationship with a regular physician is associated with patients’ willingness to share their concerns with their physicians and patients’ knowledge of their health conditions. Continuity provides an environment that improves communication, trust, and a sustained sense of responsibility (Haggerty et al., 2003). Additionally, primary health care can also coordinate health care in a cost effective approach (SAMHSA-HRSA, 2013).

Our results also show that patient activation in a community health center setting is comparable to that of a physician’s office. Community health centers usually serve as a safety net for vulnerable populations in the United States, such as low-income racial and ethnic minorities (Shi, Stevens, Wulu, Politzer, & Xu, 2004). Since minority patients report significantly lower activation, community health centers face challenges to maintain quality care and encourage patient activation. On the other hand, these centers are more likely to provide culturally competent care for underserved populations, and patients may be more likely to be engaged (Forrest & Whelan, 2000). Our finding is consistent with the literature that the quality of care received for treatment of chronic conditions in community health centers is comparable to that received in a physician’s office.

Contextual Factors: Community Characteristics

Community characteristics are significantly associated with patient activation. Our results show evidence that patient activation should be highly encouraged in communities with high ratios of foreign-born individuals. This finding is consistent with previous evidence of lower patient activation among immigrants (Cunningham et al., 2011). Policy should target these communities and design culturally competent health care to engage immigrants in their own health. These policies are critical given the rapid population growth rates of immigrants. Educational programs advocating patient activation among these groups might be effective (Hibbard et al., 2008). Results also show that average income of the neighborhood is positively associated with patient activation. This finding is consistent with evidence showing that neighborhood income has a positive effect on residents’ long-term well-being (Chow, Jaffee, & Snowden, 2003; Greenberg et al., 2013; Gresenz, Stockdale, & Wells, 2000).

The role of the place is critical in health care. Health care resources are considered a “community-level enabling variable” (Phillips, Morrison, Andersen, & Aday, 1998), a critical component of health care utilization (Dinwiddie et al., 2013; Gaskin et al., 2012a, 2012b). We find that the number of community mental institutions positively relates to higher patient activation. This finding may suggest that the community and primary care are critical to engage patients with mental disorders in their own health and health care. Our results also suggest that policy interventions targeting specific regions are needed, and such strategies can be effective to improve patient activation. The insignificant relationship of the supply of psychiatrists is consistent with the literature, which shows a weak relationship between the density of psychiatrists and psychologists on mental health care utilization (Gresenz et al., 2000; Stockdale, Tang, Zhang, Belin, & Wells, 2007).

It is worth noting the role of place in mental health care disparities (Gaskin et al., 2012a, 2012b). Residential segregation, for example, has been shown as a critical predictor for health services utilization (Gaskin et al., 2012a, 2012b; Lee, 2009; Park & Iceland, 2011; White et al., 2012; Williams et al., 2012). Although our study does not focus on residential segregation due to data limitations, future research should explore whether segregation relates to racial and ethnic disparities in activation.

Our study has several limitations. First, our study uses a cross-sectional design, which limits analysis of the causal relationship of contextual factors with the patient activation. Although we have tried to control as many factors associated with patient activation as shown in the literature and are available in our data set, unobserved factors related to patient activation, such as the availability of mental health care institutions, might have been omitted. Second, our results only apply to patients who have been diagnosed with depression. Since depression is highly underdiagnosed and undertreated, the activation levels among patients already diagnosed may have been overestimated. Third, since most of the respondents are interviewed in English, our study cannot accurately estimate the association between English proficiency and activation. Fourth, contextual factors are measured at the county level given the restrictions of our data set. It is likely that zip code or other sub-county level measures can reflect better community characteristics.