Measuring health confidence: benefits to patients, clinicians and healthcare providers

Abstract

Background

Patients need a high level of health confidence to manage their own care with success. However, health confidence is complex and changes throughout life.

Methods

The Health Confidence Score (HCS) is a measure of a patient’s confidence and has four items covering their opinion of their health knowledge, ability to self-care, get help and participate in shared decision-making, plus an aggregate summary score. It is a short, easy-to-use measure with a low reading age.

Data from about 5000 ratings are analysed, coming from anonymised patients living out of hospital.

Results

Findings show a highly significant improvement in health confidence between referral and follow-up after care and treatment. Health confidence is inversely related to the number of medications taken. The highest health confidence is in patients aged between 30 and 49. The lowest health confidence is in patients aged between 50 and 69. No significant difference in health confidence between male and female patients. Health confidence is a different concept from health status and personal well-being.

Conclusion

Integrating HCS into routine care fosters patient-centred healthcare, promotes self-care and can reduce cost of care.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• The Health Confidence Score was originally validated using a convenience sample of the general public.

WHAT THIS STUDY ADDS

• This study provides more detailed validation with almost 5000 patients in southern England.

• It also provides more detail about the underlying concepts, including health literacy, self-efficacy and activation, behaviour change, access to help and shared decision-making.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• A validated measure of patients’ health confidence is needed to support managers and clinicians in the introduction of patient-centred care. If more detailed measures are required, other measures may be used.

Introduction

This study evaluates the Health Confidence Score (HCS) as a tool for enhancing patient-centred care through improved self-management. The HCS is a short, easy-to-read tool designed to measure patients’ health confidence. It covers health literacy, self-efficacy, access to care and shared decision-making (SDM).¹

The HCS helps clinicians tailor treatments to individual patient needs. Improved health confidence has benefits for the patient and the health services, because people with better health confidence may make fewer demands on health services, have better outcomes and cost less.² As healthcare continues to prioritise patient-centred models and digital health tools, health confidence is a cornerstone of effective care.

Health confidence is a patient’s belief in their ability to manage their own health. It is a multidimensional concept shaped by each patient’s abilities and by their clinical support. Health confidence is complex and changes throughout life. Patients with serious diseases have lower confidence in their ability to self-care than those who are well.³ Health confidence is a prerequisite of behaviour change and self-care.

Many healthcare professionals find it hard to change from a paternalistic model towards patient-centred care.⁴ Traditional clinical education provides doctors and nurses with medical information and technical skills,⁵ and only a small part of the curriculum is devoted to the need to boost patients’ health confidence.

This study explores aspects of patient-centred care, which have informed the design and application of the HCS. These include health literacy, self-efficacy, behaviour change, access to help and SDM. The HCS can be integrated into telehealth and digital platforms to support patient engagement and self-management (SNOMED CT and LOINC codes are available). It includes data from a sample of over 5000 ratings from southern England.

Components

Health confidence is a multifaceted concept covering health literacy, self-efficacy and activation, access to help and SDM. Different measures have been developed to measure each of these concepts. The HCS aims to measure the core concept using four short questions answered by patients.

First, we describe Michie’s model of behaviour change (COM-B), which provides a unifying framework.

Behaviour change

The COM-B model is based on the idea that patients need the capability (or means), the opportunity and the motive to do something, which is in their best interests.^{6 7} COM-B provides a way to identify psychological and other barriers that prevent people changing their behaviour in ways that clinicians hope for.

Capability includes the physical and psychological capacity to engage in an activity, including any necessary knowledge, skills and tools. Opportunity includes everything that makes a behaviour possible or which prompts it. If you carry a mobile phone, you have the opportunity to use it, although this may not be acceptable during a theatrical performance. Motivation includes both conscious choices and unconscious habits. Conscious and unconscious motivations are different. Fast unconscious thinking is system 1, while slow conscious thinking is system 2.⁸ You must always be more motivated to do something than not to do it. Clinicians often try to get people to change their behaviour, such as to give up smoking or eat less, but this is hard to do.

Health literacy

Health literacy is the ability of an individual to use knowledge and information about their health. People with high health literacy navigate the health system better when they are ill, but more than 40% of the UK adult population struggle to understand basic healthcare information, even when it is written specifically for them.⁹

Improving patients’ health literacy is a key step to helping them care for their own health.¹⁰ However, clinical language does not help, with many terms based on Latin and Greek roots. Eponyms add to the confusion.

Self-efficacy and activation

Self-efficacy is a general concept affecting all areas of human endeavour.^{11 12} People with high self-efficacy see challenging situations as problems to be mastered, they overcome setbacks and disappointments and develop deeper interest and commitment in their interests and activities. Self-efficacy increases when people solve problems that they have identified themselves. On the other hand, people with poor self-efficacy avoid challenging tasks, thinking that they are beyond their capabilities and quickly lose confidence in what they can do.

Self-efficacy is context specific. A person can have high self-efficacy in one area, such as playing football, but less in another area, such as singing. It alters throughout life as people acquire new skills, experiences and understanding. Success in mastering a task boosts it, while failure reduces self-efficacy. Seeing other people succeed tends to strengthen it, as does verbal encouragement. Moods, stress and emotional states all impact self-efficacy.¹³

Patient activation is closely related to self-efficacy; it is understanding one’s role in the care process and having the knowledge, skill and confidence to manage one’s health and care.¹⁴ It emphasises patients’ willingness and ability to take their own actions to manage their conditions, to feel confident about managing their own health and to play a more active role in staying healthy. People with high self-efficacy know when to seek help when they need it and make more informed choices. This has been shown to reduce costs, produce better outcomes and improve satisfaction with the care they receive.^{1 15}

The most widely used activation measure is the Patient Activation Measure (PAM-13) with 13 items.¹⁶ The PAM has three scores: first, the raw score is the sum of the item scores, each scored 1 to 4, giving a range from 13 to 52. Second, these scores are then transformed to an individual patient activation score on a 0–100 scale (where high is good). Finally, these are grouped into four activation levels: level 1, disengaged and overwhelmed; level 2, becoming aware but still struggling; level 3, taking action; and level 4, maintaining behaviours and pushing further.

Access to help

Getting the right help from different parts of the health service can be complex for clinicians and even harder for patients. This becomes even worse as people get older and have multiple conditions.¹⁷ Record numbers of patients wait for planned care and treatment; some people who need treatment have difficulties in seeing their GP and then getting a hospital referral. Once in hospital, they often have to wait around too long.¹⁸

Shared decision-making

SDM is collaboration between the patient and their healthcare professionals to reach a joint decision about future care.¹⁹ It lets patients discuss and share their hopes and fears and get a full understanding of the benefits, risks and outcomes of different care or treatment options. This helps them decide what is right for them at that time, such as choosing to change treatment, continue as is, or choose no treatment.

Clinical decisions involve difficult judgements. These involve trade-offs between expected effectiveness, costs, safety and convenience, as well as unfamiliar names of drugs and procedures (see health literacy above). Making SDM work involves sharing, empathy and understanding by both the clinician and the patient.

Methods

The study described here used a cross-sectional design to assess the effectiveness of the HCS. Data came from anonymised telephone interviews in primary care across Southern England’s counties of Hampshire, Surrey and Berkshire and cover a mix of urban, suburban and rural patient populations, with primary care services focused on chronic disease management and routine health monitoring.

Data were collected between 2019 and 2023 at the point of referral and at follow-up about 2 months later. Most patients received individualised health coaching from community nurses or social prescribers between their initial referral and follow-up assessments. Patients who moved out of the study area or passed away during the study period were excluded from the analysis. Incomplete surveys and those missing key demographic data were not included in the final analysis.

The sample size of 5000 patients was selected to provide a robust dataset for evaluating the validity and reliability of the HCS across diverse patient populations and to enable the detection of statistically significant relationships between health confidence and other patient characteristics.

The HCS was originally developed as a concise tool to measure health literacy, self-efficacy, access to care and SDM.¹ We developed the measure to have a low reading age, be as short as possible and encompass the key aspects.

Figure 1 shows the HCS.

Figure 1. Health Confidence Score.

The four items are:

1. I know enough about my health addresses each patient’s health literacy; it is abbreviated to Knowledge.

2. I can look after my health addresses each patient’s self-efficacy and activation; it is abbreviated to Self-Care.

3. I can get the right help when I need it addresses each patient’s access to healthcare; it is abbreviated to Get Help.

4. I am involved in decisions about me addresses shared decision-making as seen by the patient; it is abbreviated to SDM.

Each HCS item is scored from 0 to 3 with an aggregate score ranging from 0 to 12. If any item is missing, no aggregate score is calculated. To calculate population-level scores, individual item scores are multiplied by 100 and divided by 3, yielding a score on a 0–100 scale.

The mean value of the four item scores is then used to generate an aggregate HCS score for the population by multiplying by 100 and dividing by 12. If any item is missing, no summary score is calculated for that rating.²⁰

Reading age was measured using the Flesch-Kincaid Grade (FKG), which approximates to the school year.²¹ The actual reading age is FKG plus 6. Here, FKG is 2.2, so reading age is 8.2 years. The low reading age (8.2 years) makes it accessible to a wide range of patients. The word count is 45 words.

The primary outcome measure for this study was the aggregate HCS. Secondary outcome measures included the howRu Health Status questionnaire²² and the Personal Wellbeing Score (PWS),²³ which were used to assess the overall health status and mental well-being of patients. Other data included referral/follow-up, sex (M/F), age group (under 30, 30–49, 50–69, 70–89, over 90) and number of medications taken (0, 1–2, 3–5, 6–9, over 10).

Statistical analyses were conducted using JASP (V.0.18.3).²⁴ Descriptive statistics, independent t-tests and Pearson correlation matrices were used to assess the relationships between HCS scores and other variables, such as age, sex and medication use. Principal component analysis (PCA) was conducted to assess the distinctiveness of the HCS in relation to Health Status (howRu) and PWS. Promax rotation was used to identify underlying dimensions in the dataset, ensuring that the HCS measured unique aspects of health confidence.

Results

Overall

The study analysed data from about 5000 anonymous patients, ranging in age from under 30 to over 90, who were treated in community and GP services in Southern England. The population was predominantly older, with an average age of 75, and most came from a relatively affluent socioeconomic background.

Table 1 provides a detailed breakdown of the distribution of responses across the four HCS items, showing a moderate level of health confidence within this population.

Table 1. Overall distribution of HCS items, showing a broad spread.

HCS item	N	Strongly agree	Agree	Neutral	Disagree	Mean score	SD
I know enough about my health	4961	19.9%	52.2%	16.2%	4.6%	64.8	25.5
I can look after my health	4948	17.0%	50.1%	19.4%	6.6%	61.6	26.6
I can get the right help when I need it	4939	22.7%	50.8%	14.8%	4.1%	66.7	25.6
I am involved in decisions about me	4918	32.8%	48.0%	9.4%	1.9%	73.9	23.5

HCS, Health Confidence Score.

The average aggregate HCS score across all patients was 66.9 (SD = 21.8),

The correlation matrix between the items is shown in table 2.

Table 2. Pearson correlation matrix between HCS items, showing strong inter-item correlations.

Item	Knowledge	SelfCare	GetHelp	SDM
I know enough about my health (Knowledge)	–
I can look after my health (Self-Care)	0.76	–
I can get the right help when I need it (Get Help)	0.65	0.68	–
I am involved in decisions about me (SDM)	0.61	0.57	0.70	–
HCS summary score	0.88	0.88	0.88	0.83

HCS, Health Confidence Score; SDM, shared decision-making.

• Inter-item correlations ranged from r = 0.57 to r=0.76 (all p<0.001).

• The strongest correlation observed between Knowledge and Self-Care (r = 0.76).

• The weakest correlation was between Self-Care and Shared Decision-Making (r = 0.57).

This is as expected because it needs considerable knowledge to look after your own health (Self-Care), while Shared Decision-Making is less closely related to Self-Care. This indicates that the HCS items are related but measure different aspects of health confidence.

The HCS demonstrates strong internal reliability with a Cronbach’s alpha of 0.89. Dropping any of the individual items results in only a slight decrease in alpha (range: 0.85–0.87), indicating that all four items contribute equally to the overall reliability of the scale.²⁵

Referral and follow-up

Figure 2 shows the differences between scores on referral and at follow-up for each item and the HCS summary score. Independent t-tests show significant improvements across all HCS items from referral to Follow-up (p<0.001), with notable increases in:

Figure 2. Mean scores for referrals and at follow-up for each item and the HCS summary score, showing large improvements.

• Knowledge (11.3 points)

• Self-Care (11.9 points)

• Get Help (14.8 points)

• Shared Decision-Making (10.6 points)

• HCS summary score (12.2 points)

In a subset of 902 matched patients (with both Referral and Follow-up data), the mean HCS score increased by 12.2 points (the same as the larger sample), demonstrating a consistent improvement in health confidence after receiving care.

Differences by sex

No significant differences were found between men and women in overall HCS scores or any of the individual items (p>0.05 for all comparisons), indicating that health confidence levels are comparable between genders.

Age group differences

The mean age of patients in this study was approximately 75 years, with the largest age group being 70–89 years (n=3057), reflecting the focus on older populations with multiple chronic conditions. Figure 3 shows the mean HCS score by age group and sex. HCS scores peak between ages 30–49 (mean=73.2) and decline after age 50 (mean=65.2), reflecting lower patients' confidence in managing their own health due to increased prevalence of chronic conditions.

Figure 3. Mean HCS score by age group and sex. HCS, Health Confidence Score.

Impact of medication use

We found a statistically significant inverse correlation between the number of daily medications and HCS scores (p<0.001), suggesting (as expected) that patients managing more complex medication regimens were less confident in their ability to care for their health.

Other measures

In addition to HCS, health status (howRu) and PWS were collected as secondary outcome measures.

The average health status (howRu) summary score was 64, indicating moderate overall health status. PWS scores were lower (mean PWS=52), highlighting the importance of addressing emotional and psychological factors in patient care.

PCA reveals that health confidence (HCS), health status (howRu) and personal well-being (PWS) each form a distinct domain. The first component, representing health confidence, accounted for 40% of the variance, while health status and personal well-being were captured by separate components, indicating that HCS measures unique aspects of patient self-management (table 3). The howRu distress item is more closely linked to personal well-being than to the other health status items. The Pearson correlations between the summary scores for HCS with howRu is r=0.43 and with PWS is r=0.53.

Table 3. Number of patients, mean scores and principal component analysis of HCS, howRu and PWS, showing three main components.

	N	Mean score	Component 1	Component 2	Component 3
Knowledge	4900	65	0.85
Self-Care	4894	62	0.78
Get Help	4864	67	0.81
SDM	4887	74	0.90
HCS	4813	67	0.96
Pain	4913	73		0.80
Distress	4905	64		0.42	0.59
Disability	4912	58		0.86
Dependence	4889	60		0.83
howRu score	4835	64		0.95
Satisfaction	4894	52			0.87
Worthwhile	4887	53			0.82
Happy	4886	53			0.95
Not anxious	4876	50			0.93
PWS	4804	52			0.98

HCS, Health Confidence Score; PWS, personal well-being score; SDM, shared decision-making.

Discussion

The past 50 years have seen large changes in both healthcare costs and improvements in health. Costs and clinical specialisation have increased. On the other hand, health has also improved—life expectancy at birth in the UK has risen by 9 years (from 72 to 81 years) and globally by 16 years (from 56 to 72 years).²⁶

Most causes of improvement increase costs, such as new pharmaceuticals, medical and surgical methods. The HCS and similar tools to promote patient-centred care may be an exception. The HCS could play a key role in empowering patients to take control of their health, lowering costs and improving overall healthcare efficiency and effectiveness. By integrating the HCS into routine assessments, healthcare providers could align clinical care with patients’ needs.

HCS is a reliable and valid tool for measuring health confidence. Substantial improvements have been observed after clinical interventions. The HCS is sensitive to differences in age, medication use, health status and personal well-being, offering insights for clinicians to tailor care and support patient self-management. Health confidence can help the shift towards more patient-centred care, where patients not only understand medical information but also actively participate in SDM and self-management. This may be expected to lead to reduced healthcare costs and improved long-term health outcomes.

The HCS has been shown to be valuable in various clinical settings out of hospital, from general practice to community health services. It allows clinicians to quickly assess and address gaps in patients’ health confidence, which facilitates personalised consultations, improves patient engagement and fosters self-care.

The HCS is one of the shortest measures of generic health confidence available, with a low reading age. It is suitable for patients who live with a wide range of conditions, including multiple conditions. It identifies problems and provides an indication of what each problem is. As healthcare systems move towards patient-centred models, tools such as the HCS can play a vital role in empowering patients to take control of their health.

In this population, the HCS is independent of sex, although younger women have slightly higher health confidence than men of the same age, but this is reversed in older men. There is a dip after the age of 50.

The inverse correlation between medication use and health confidence suggests that patients with more complex medical regimens are less confident in managing their health independently. HCS is higher when patients are well and lower when they have multiple conditions.

There are moderate correlations between HCS and Health Status (howRu) and PWS. PCA shows that these are distinct concepts.

Compared with tools like the PAM-13,¹⁶ the HCS offers a more comprehensive approach by incorporating health literacy, access to care and SDM alongside self-efficacy and activation. This wider scope makes it particularly useful for capturing multiple dimensions of health confidence in a single, short easy-to-read measure.

Where more information is needed, R-Outcomes has developed more detailed measures of behaviour change²⁷ and SDM.²⁸

Limitations

The data used in this study come from secondary analysis of an older, predominantly affluent population in primary care across Southern England. Information was not collected about the education level of the cohort. Future research should investigate whether these findings hold true in younger, more socioeconomically diverse populations and in regions with different healthcare systems. While the data suggest long-term benefits, such as reduced hospital readmissions and healthcare costs, further studies are needed to confirm these results.

Conclusions

The HCS is a short generic measure of health confidence, with a low reading age. The HCS may help collaboration between patients and clinicians and align care delivery with patient-centred goals. This study shows that the HCS changes throughout life but is sensitive to treatment in primary care. It is inversely related to the number of medications taken and is independent of patients’ sex.

Data availability statement

Data are available upon reasonable request.