- Strong patient health literacy is key for improving patient engagement, but it does not occur in a vacuum. Instead, providers should assess and understand outside variables that affect health literacy, such as practice-wide interventions, policy decisions, and a patient’s environment, according to a report funded by the Agency for Healthcare Research and Quality (AHRQ).
According to the report’s authors, patient health literacy and influencing variables are directly tied to patient engagement.
“Over the past two decades, a link has been established between patients’ literacy skills and health outcomes,” the authors said. “Consequently, health literacy researchers have introduced a critical new variable, health literacy skills, that can be measured and compared.”
“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,” they continued.
To improve patient health literacy, the authors argued that industry professionals should use a social ecological approach.
“The social ecological model expands the lens of health literacy beyond the individual to look at the delivery of health information, the materials and tools provided to the public, the communication skills of public health and healthcare professionals, the attributes of health related institutions, and the health policies that influence the systems in which they work,” the report noted.
According to the researchers, a health literacy social ecological model can lead to longer lasting improvements over time because it builds a web of support for patients. Instead of waiting for the patient to become more health literate on her own or asking her to learn more about her health, social ecological models foster health literacy initiatives using the skills of all stakeholders.
Within the health literacy social ecological framework, the report authors said there are five different strategies, including accumulation, amplification, facilitation, cascade, and convergence strategies.
This strategy states that all interventions designed to improve health literacy can help meet that goal independently. These interventions do not necessarily affect or depend upon one another.
The authors offer the example of the Center for Disease Control’s Act Against AIDs (AAA) health literacy initiative. This program includes several different components, such as health education network building, communication pamphlets, and social media marketing. Each of these interventions can be effective on their own, and pool together toward the same end: better health literacy and patient engagement for individuals at risk for HIV/AIDS.
“Components of AAA also seek to promote a better understanding of HIV treatment among individuals who are living with HIV through materials that apply plain language best practices and clear communication principles to ensure messages are engaging and accessible,” the authors explained. “The consequence of these strategies should lead to the promotion of improved health literacy and patient engagement.”
Amplification is when a healthcare organization uses one intervention to intensify another, smaller intervention. For example, a physician can conduct a health literacy intervention to explain the importance of preventive screenings, and amplify that intervention using a clinic-wide social media marketing campaign.
“This strategy may be useful in instances where social marketing techniques help individuals and community-based organizations to be more responsive to health education and to support group messages,” the authors explained.
Similar to the amplification strategy, facilitation involves interventions that are interdependent. Facilitation programs help move a patient to a desired end by removing obstacles. This strategy requires the patient to be activated in their healthcare, but the individual may still face barriers to better health and engagement.
With breast cancer screenings, for example, a facilitation strategy would change the clinical guidelines for patients ages 40 to 49, allowing them to receive a screening if they have a family history of breast cancer or have certain health preferences.
“The decision to start screening mammography in women prior to age 50 years should be an individual one,” the authors said. “This allows women who place a higher value on the potential benefit than the potential harms may choose to begin biennial screening between the ages of 40 and 49 years.”
This facilitation strategy allowed women well-equipped with health literacy skills to engage in healthier behaviors.
Cascade strategies include a series of interventions that waterfall into the next. They usually begin with policy-level changes that spark organizational and individual interventions.
For example, the Affordable Care Act called for all state insurance exchanges to offer health plan assister programs to educate patients on the various available plans, the authors said. This spurred health plans to create health literacy programs, which gave patients the tools they needed to select their own health plans and gain coverage.
From there, these patients, who may have been previously uninsured, began visiting the doctor, gaining more health literacy skills and potentially becoming more engaged.
Like a set of dominoes, these cascade interventions started with one change that fell into the next, eventually moving toward changes in patient behavior.
Convergence strategy involves a set of separate interventions that work together to meet a common goal. While these interventions are not arranged hierarchically, like in a cascade strategy, they do depend on each other to help patients build better health literacy.
“The convergence strategy implies that interventions at different levels influence an outcome by mutually reinforcing each other and changing interaction patterns,” the authors explained. “The ecological process underlying this effect is referred to as reciprocal interdependence.”
The Alliance to Reduce Diabetes Disparities used a convergence strategy to improve health literacy in its nationwide patient population, the authors said. The organization offered grants to five states to implement health literacy strategies across 47 different clinics.
Although each clinic implemented its own unique programs, each centered on three themes: patient change, clinician change, and system change, all with an emphasis on patient self-management.
Together, each program helped the clinics reach their ultimate goal of improving patient health literacy and eventually patient engagement.
According to the researchers, each of these strategies – accumulation, amplification, facilitation, cascade, and convergence – work to build a social ecological strategy that acknowledges different variables in building patient health literacy.
“The field of health literacy is witnessing a paradigm shift from a focus on individuals' health literacy to a broader health system perspective that brings attention to the accessibility of health materials and tools, the communication skills of health professionals, and the institutional characteristics that support the active engagement of patients and their families,” the authors said.
Healthcare professionals need to identify strategies that incorporate all of these factors and do not simply rely on the patient to build better health literacy, the authors said. These strategies, which culminate into a social ecological model, help achieve that end.
“Each of the five multilevel strategies described above shifts some of the burden of responsibility off the patient and relies on systemic changes to support ease of access and engagement by eliminating barriers,” the authors concluded.