Improving low health literacy and patient engagement: A social ecological approach
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.
Section snippets
A social ecological health literacy perspective
Urie Brofenbrenner [10], the architect of the social ecological model for social sciences, focuses on the fact that individuals are influenced by interlocking external factors related to the physical and social environments. This environment is subdivided into five levels: the intimate microsystem that includes friends and family as well as neighborhood organizations and characteristics, a mesosystem that fosters interactions among various microsystems in the larger society, an exosystem that
Strategies emerging from a social ecological health literacy model
Although applying social ecological models in conjunction with multilevel interventions has demonstrated benefit, interventions typically still target only one or two levels of influence [15]. A lack of theoretical guidance about how to design multilevel interventions – especially how different levels can be combined to lead to stronger effects – may be impeding progress [16]. Weiner et al. [16] described five different strategies for combining intervention levels that are relevant to
Implications for patient engagement
The social ecological model emphasizes the importance of considering multiple levels of influence on individuals as a result of their physical and social environments. We advocate for a mindset that considers a “health literacy social ecological model (HLSEM)” when developing interventions to promote health literacy and patient engagement. We believe that such interventions – those that consider these multiple levels of influences – are more likely to impact attainment of health literacy skills
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
Acknowledgments
The authors would like to acknowledge the important editorial and plain language contributions of Jeffrey Novey, MPH, and the word processing skills of Ms. Loraine Monroe. Their invaluable contributions made this manuscript a stronger contribution.
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