Improving low health literacy and patient engagement: A social ecological approach

Highlights

• Patient engagement is facilitated by supportive environments at the institutional, community and policy levels.

• Adopting a “health literacy social ecological model (HLSEM)” may improve health literacy and patient engagement.

• Five structured strategies for developing patient engagement interventions using the HLSEM are proposed.

Abstract

Objective

This article posits four principal objectives related to the overarching goal of broadening the conceptualization of health literacy. We propose a social ecological approach to health literacy and patient engagement by illustrating how this multilevel approach offers an array of strategic options for interventions.

Discussion

A social ecological approach supports a broader understanding of health literacy that aligns with increased patient engagement. The ecological model highlights the importance of context, demonstrates how health literacy and patient engagement are inextricably connected, and gives rise to strategies to enhance them both. We illustrate the five multilevel intervention strategies for addressing low health literacy and promoting patient engagement: accumulation, amplification, facilitation, cascade, and convergence strategies. In addition, we provide a theoretical foundation to facilitate the development of interventions to enhance health literacy and ultimately increase patient engagement.

Conclusions

The practice implications of adopting a broader social ecological perspective to address low health literacy shifts the field from thinking about individual educational interventions to how individual interventions may be augmented or supported by interventions at additional levels of influence. The potential benefit of adopting a multilevel intervention approach is that combining interventions could produce synergies that are greater than interventions that only utilize one level of influence.

Introduction

Health literacy is now a key consideration for health research and for program design to enhance efficacious change. Over the past two decades, a link has been established between patients’ literacy skills and health outcomes [1], [2]. Consequently, health literacy researchers have introduced a critical new variable, health literacy skills, that can be measured and compared. However, other key strategic variables, such as difficulty of texts, skills of communicators, and complexity of health systems, have not been considered concomitantly. Our assumption is that increasing health literacy skills will help facilitate more effective patient engagement and that the relationship between the two is positive and bidirectional.

Recent recommendations for advancing health literacy are shifting the focus of health literacy research from examining patient-level skills and deficits to more in-depth and cross-cutting studies that include individuals and populations as well as health professionals and health systems [3]. This broader perspective is not entirely new. In 2003, the U.S. Department of Health and Human Service’s action plan Healthy People 2010 objectives highlighted the complex health literacy phenomenon involving patients, providers, and organizations [4]. In 2004, the U.S. Institute of Medicine’s seminal report Health Literacy: A Prescription to End Confusion called for increased attention to health literacy as an interaction between the skills of individuals and the demands of health systems [5]. In 2010, the U.S. Department of Health and Human Services’ National Action Plan to Improve Health Literacy [6] articulated aims to engage multiple players at the macro and micro levels to improve health literacy and achieve the objectives outlined in Healthy People 2020 [7]. Other federal agencies, including the Centers for Disease Control and Prevention and the Agency for Healthcare Research Quality, along with a growing number of researchers and practitioners endorsed these efforts to bring broader health literacy issues into the public debate and health policy discussions.

Despite these calls for a broader perspective, there have been no systematic attempts to expand the conceptualization of health literacy and to incorporate workable approaches to address low health literacy and increase patient engagement. Additionally, definitions and conceptualizations of patient engagement vary widely [8], [9], increasing the need for clarity around its meaning. Our view of patient engagement is broader than simply what patients are expected to do to receive benefit from the healthcare system. We see patient engagement as including a range of two-way interactions that patients and their representatives, such as family members and caregivers, have with members of the healthcare system [9] as they partner to optimize health.

This article posits four principal objectives related to the overarching goal of broadening the conceptualization of health literacy. First, we propose a social ecological approach to health literacy and patient engagement (Fig. 1). Second, we illustrate how this multilevel approach and model offers an array of strategic options for interventions and efficacious change. Third, we discuss how a social ecological approach and a broader understanding of health literacy supports and aligns with increased patient engagement. Finally, we propose that the ecological model highlights the importance of context, demonstrates how health literacy and patient engagement are inextricably connected, and gives rise to strategies to enhance them both.