2. Theory and Hypotheses
To address the burden of patients’ limited health literacy, healthcare systems should redesign their services to support patients to effectively navigate, understand, and use information to take care of their health [
7,
8,
9]. This transformation can be accomplished by encouraging healthcare providers to embrace patient engagement as a guiding paradigm to foster the patient’s proactivity and autonomy in obtaining and using health information for an effective management of their care. However, to become fully engaged in their healthcare, patients should acquire a “psychological readiness” towards the possibility to take an active and autonomous role in their own healthcare. This psychological maturation is function of the patients’ emotional elaboration of their health condition and of their new role identity (i.e., as a patient). This process has been widely described by the Patient Health Engagement Model (PHE-model) [
10] that points to the role of the patients’ emotional maturation as the main driver of their ability to adjust to the changes required by the new health condition. The psychological process of engagement as described by the PHE-model involves four developmental phases, namely, blackout, arousal, adhesion, and eudaimonic project. The PHE-model theorizes possible psychological trajectories of engagement along a continuum from a position of disengagement (namely, blackout), where patients experience feelings of psychological vulnerability connected to the illness and feel psychologically frozen and feel paralyzed, to a position of full engagement (namely, eudaimonic project) where patients become totally aware of their disease and its implications and have elaborated and accepted their “new identity” of patient and became able to embrace a more positive and satisfactory approach to their life [
11,
12,
13,
14]. In this scenario, to foster the patient’s emotional elaboration, of much relevance is the ability of healthcare professionals to promote a healthcare climate which is supportive of the patient’s autonomy, which has been associated with numerous positive patient outcomes [
15]. Research demonstrated that an autonomy-supportive healthcare climate of mutual understanding, trust, and shared decision-making has been found to improve healthcare outcomes by increasing PHE [
16,
17]. In healthcare encounters, the concept of autonomy support represents a relational climate whereby the healthcare professionals put patients at the center of their care experience, enabling them to become fully engaged along the care journey [
18,
19].
Therefore, the implementation of such model of care oriented to a participatory style in the relationship with patients forces professionals to move back from a disease-centered approach toward a patient-engagement-oriented one which encompasses the key principles of patient-centered care by also implying the consideration of patients as partners. This means building good interpersonal relationships among patients and their health providers by increasing trust, facilitating information exchange, and supporting patients’ autonomy by recognizing and cultivating their own capabilities and self-management skills as individuals who have to reconstruct a “new normality” around the disease condition [
20,
21].
According to self-determination theory, patients’ sense of autonomy represents a critical component of their motivational profile for effective self-care [
18,
22,
23]. In healthcare settings, autonomous motivation is of particular importance to improve health literacy levels [
24,
25,
26], and an autonomy-supportive healthcare climate is, therefore, a crucial strategy for achieving such goal [
27].
Based on the literature above, our first hypothesis posited that:
Hypothesis 1. There is a significant, positive relationship between patient perceptions of autonomy-supportive healthcare climate and health literacy levels.
According to the literature described above, the Patient Health Engagement model refers to the patient’s psychological readiness to play an active role in his/her own healthcare journey as an autonomous actor taking increased responsibility for decision-making regarding his or her health. [
28]. This model is rooted in the concept of patients’ autonomy, and thus it values the importance of supporting patients’ interest in and desire to participate in healthcare decisions. In this vein, PHE is a motivational and psychological-rooted model and does not involve the patient as a passive recipient of information, whose task is the mere comprehension and acceptance of information. In these terms, PHE is a crucial factor for improving patients’ health literacy in terms of collecting, understanding, and using information about their health condition [
1,
29,
30]. Research demonstrated that patients improve their health literacy to a point where they become more involved in healthcare processes (including shared decision-making) [
31]. If patients are not psychologically ready to assume an active role in their healthcare and are not supported in playing an autonomous role in their healthcare, they cannot obtain, process, and understand basic health information that is useful to take care of themselves well or make good decisions on health [
32].
Based on the literature above, we next posit that:
Hypothesis 2. There will be a significant, positive relationship between PHE-model levels and health literacy.
Moreover, previous research has demonstrated how the patient perception of autonomy support from their healthcare providers is related to increasing in the PHE positions [
33,
34,
35]. A healthcare climate oriented to promote the patient ability to take an active and autonomous role in the care management has been pointed out as a predictor of the PHE positions [
36,
37,
38]. The more that patients feel legitimized to be autonomous actors in their care management, the more they increase their psychological readiness to be engaged in their own care.
Based on the literature above, the third hypothesis posited that:
Hypothesis 3. There will be a significant, positive relationship between patient perceptions of patient reported autonomy supportive healthcare climate and PHE positions.
Although research and clinical practice suggests that an autonomy-supportive healthcare climate may be important to enhance the patients’ psychological readiness to engage and health literacy, no prior study, to the best of our knowledge, has developed and tested comprehensive models for capturing the relationship between these variables that have been included in our proposed theoretical model (see
Figure 1).
For these reasons we added a fourth hypothesis that posited that:
Hypothesis 4. Psychological readiness to engage mediates the relationship between patient reported autonomy supportive healthcare climate which is supportive of patient’s autonomy and health literacy.
To address this literature gap, our objectives were to: (1) examine the association between autonomy-supportive healthcare climate and health literacy levels; (2) examine the association between autonomy-supportive healthcare climate and patients’ readiness to engage measured with the PHE-model; (3) examine the association between PHE-model and health literacy; and (4) use mediation analysis to explore whether patient reported autonomy supportive healthcare climate might contribute to patients’ health literacy by supporting the psychological readiness to engage (PHE-model).
5. Discussion
Since health literacy plays a crucial role in chronic disease management, understanding the relationship between health literacy and the quality of healthcare climate may provide important insights for clinicians who care for such patient populations and may have important implications for the reduction of inequalities in the care of chronic conditions. To date, potential solutions to enhance patients’ health literacy skills have focused on improving the readability and understandability of medical documents or on adopting new technologies as a means to deliver information [
55,
56]. Although these efforts will surely lead to helpful changes in supporting patients in the acquisition of skills to obtain, process, and understand basic health information, our study considered other crucial variables and suggests that patients who are more engaged in their healthcare and are psychologically ready to be active players in the patient–doctor relationship are also more literate.
The major findings of this research are aligned with those of previous studies, highlighting the impacts of autonomy-supportive healthcare climate on patient’s health literacy and patient’s psychological readiness to engagement in the care process [
32,
33,
57]. This study showed that autonomy-supportive healthcare climate has a positive correlation with the patient ability to obtain, understand, and use health information along their healthcare journey; These findings are consistent with the results of previous studies [
7,
58,
59], proposing pathways of the effects of a patient–provider relationship oriented to support the patient’s autonomy on patient’s health literacy. This means that patients who perceive that their healthcare providers are likely to support their autonomy in managing their health have a better understanding of prescription labels, effectively interpret their health values or medication dosing schedules, and extract/criticize health information.
Among a diverse array of potential intervening variables in the relationship between healthcare climate and health literacy, this study found the mediating role of the Patient Health Engagement model (such as the measure of the patients’ psychological readiness to engage) in healthcare in this path. Our analysis demonstrated patient health engagement to be a critical construct. While an indirect pathway between autonomy-supportive climate and health literacy via Patient Health Engagement has been mentioned in the literature [
32,
60], empirical research has not reported on the subject. To our knowledge, the present study is the first to support the presence of an indirect relationship among those variables and to empirically demonstrate the role of patients’ psychological readiness to engage in this interaction. The study model suggests that the Patient Health Engagement model is crucial to the link between a healthcare climate oriented to support patient autonomy and health literacy. This means that the patient’s psychological readiness to play an active role during the healthcare encounters is a key factor in the influence of autonomy-supportive climate on the patients’ health literacy level.
In clinical practice, it is very important to stimulate and promote the patient’s ability to collect, understand and use health information. To achieve this, healthcare professionals should consider adopting relational strategies to support patients in adopting a partnership and autonomous role in the care process through the psychological acceptance of their health condition. For example, empowering the patient’s perceptions of his or her own ability to take control over his or her life regarding the disease and to find a “new normality” may be a useful strategy for improving patients’ health literacy [
61]. For this reason, a healthcare model merely oriented to train healthcare professionals in improving communication skills to foster patient health literacy might be not enough to reach this goal. A medical education program aimed to support healthcare professionals in adopting new models of care oriented to interpret the medical encounter as a partnership setting where both clinicians and patient share all parts of the health decision-making process and play an active role in the care journey is warranted to effectively support individuals in becoming literate about their condition. Our study has a number of limitations. First, one of our main variables was patients’ reports of their physician’s relational and communication processes of care and not direct observations. This could be a source of bias related to social desirability effect. Second, we did not control the model for important confounders that we hypothesized could impact health literacy skills, such as age and educational level. For this reason, it is possible that our findings are a result of residual confounding. Furthermore, potentially confounding variables such as education were not considered in this study due to the fact that these variables were self-reported and very subject to bias. Further study should consider this limitation. Another limitation in this study is its use of a cross-sectional design, which means that, unlike a longitudinal design, causal relationships among study variables could not be determined. Finally, the measurement model of the items we used to assess health literacy was not completely adequate: the low alpha suggests that the measurement of health literacy may have been inaccurate. This could be due to an ineffective adaptation of the items to Italian language or culture. However, the overall goodness-of-fit of our model vouches for its validity. Further studies with more adequate measures should be carried out in order to corroborate the mediation relation found here.