Patient engagement is a crucial aspect of the healthcare sector that has been demonstrated to significantly enhance patient satisfaction and medical outcomes, thereby fostering a relationship between patients and healthcare professionals by ensuring that patients are actively involved in decisions about their care. The National Health Insurance Scheme (NHIS) in Ghana is essential for increasing access to healthcare and medical treatment. However, the Ministry of Health of Ghana recently reported (2023) that in 2022 the Greater Accra Region had the lowest penetration rate in the country, with only 40.31 \% of the population in the Greater Accra region enrolled in the NHIS, a 2.1 \% decrease from the previous year. This is in stark contrast to neighbouring areas, which all exceeded a 50 \% enrolment rate. The NHIS has over 16 million active members nationwide, with a coverage rate of 54 \% (Naatogmah, 2022). Consequently, NHIS membership serves as a key access metric, reflecting overall patient engagement and trust in the system.

The global recognition of the benefits of patient engagement, combined with the unique challenges faced in the Ga East Municipality in Ghana, drives this study. World Health Organization (2021) insights indicate that patients who actively participate in their care experience significantly better health outcomes. As Birnhak (2024) reports, patients who are engaged can experience significantly improved health outcomes compared to those who are similarly situated but less engaged.

The NHIS is part of the important structure for achieving Universal Health Coverage (UHC) in Ghana; however, low participation in Greater Accra, particularly in urban areas like the Ga East Municipality, indicates that the strategic goal of increased engagement remains out of reach. The inability to engage leads to lower patient confidence and reduced medical recommendations due to a reluctance to engage with the broader healthcare system. Therefore, by examining local and global studies, this research aims to comprehend what works, and how healthcare providers can enhance patient involvement in their care.

Scientific problem: What factors support patients' engagement, how does the NHIS in Ghana influence this engagement, and what recommendations do patients and providers have to enhance it?

The study aims to identify the key factors influencing patient engagement and, after analysing strategies for patient engagement used worldwide, to assess their suitability for engaging patients in the Ga East Municipality, Ghana.

A qualitative study was undertaken to investigate the factors and strategies influencing patient engagement. Interviews and discussion-based primary research were excluded from this study due to time and resource constraints. Despite this limitation, a thorough review of pertinent secondary data was carried out to provide solid and evidence-informed insights on patient engagement practices and outcomes across various settings. The data collection process relied on a literature review of existing studies from around the globe that employed key terms, such as trust, communication, leadership and shared decision-making, which underpin healthcare delivery, as well as patient engagement and involvement behaviours.

The study was based entirely on secondary data sources, including peer-reviewed articles, policy documents and health system reports published from 2018 to 2024. More than 3,000 initial results were found in the primary search, which we then filtered by the following four selection criteria: (a) the study must have been published in the last ten years; (b) the study must be available through a public database or published in reputable scientific journals; (c) the study must include applied empirical data and models; (d) other researchers must cite the study; and (e) it must be directly tied to patient engagement and health outcomes. After appraising these requirements, the 20 articles and reports deemed most relevant to the study's objectives were selected.

Based on the established research selection criteria, articles published in peer-reviewed scientific journals, such as PubMed, BMJ and Google Scholar, were analysed. Data from the World Health Organization (WHO), Centres for Disease Control and Prevention (CDC), Ghana's Ministry of Health, and case studies of individual health programmes were also drawn on. This review was conducted by formulating an overarching research question that guided the identification of relevant material.

The data from the selected studies for the review were compiled into an empirical table to identify common trends, patterns and challenges across various healthcare contexts. Analysing the disparate data thematically using the central themes facilitated the clarification of the different elements related to understanding what patient engagement is and how it is operationalised in various contexts.

Lastly, the study also included a comparison of patient engagement strategies across regions and healthcare systems. A review of the WHO Community Engagement Framework, the CDC's Patient Activation Framework and the EUPATI Patient Engagement framework was conducted to assess and identify the frameworks that incorporated strategies reflecting how best practices from around the world could be adapted to local contexts. The ethical aspects of the research process were handled with care. All sources were checked for relevance and reliability, and the original authors were duly cited, ensuring that the auditing and credibility of the information used remained trustworthy.

Studies conducted both domestically and internationally demonstrate the similarities and differences among patient engagement programmes. In Ghana, Ankomah et al. (2023) examined patient-public engage-

ment. They report that resource mobilisation was reasonably adequate, but the community needs assessment processes and leadership in areas such as health programmes (e.g. Community Health Planning and Services) and Buruli Ulcer programmes were lacking. The paper addresses current issues such as the return on investment and power imbalance, although Marzban et al. (2022) and Sagen et al. (2022) offer more optimistic perspectives on the prospects for patient engagement worldwide, including improved health, self-care and patient adherence. Ghana's focus on personal protective equipment in community health is more attuned to the local context, whereas all contexts share the importance of stakeholders. From a global well-being perspective, this represents a strategic concern about governance structures, essentially an economically related issue, while local economic assessments are not comparable.

Birkeland et al. (2022) noted that involving patients, particularly in decision-making, goes beyond their satisfaction with care arrangements, even in the presence of unfavourable clinical outcomes. Miller and Reihlen (2023) take a similar position, highlighting the need for collaboration between the health system, physicians and patients to foster involvement. This study involved initiatives that educated patients, raised awareness and built a digital health environment that supports health literacy. When Pokhilenko et al. (2021) examined the significance of doctors' confidence levels on patient engagement, they found that the effects varied between men and women. The literature review revealed that patient engagement can be enhanced through increased patient trust, active participation in decision-making, leadership, education and financial sustainability (see Fig. 1).

Trust is a crucial factor influencing patient engagement. Evidence from Pokhilenko et al. (2021), Horgan et al. (2020), and O'Neill et al. (2022) suggests that trust plays a vital role in patients' understanding of the type and extent of their engagement with health services. The findings by Pokhilenko et al. (2021) yielded fascinating results regarding trust and engagement in relation to gender. In the study, the researchers explored how healthcare trust led to some level of engagement for women but not for men. Understanding distinctions in the attention of demographic groups to trust and accountability perceptions of the health system is important for patient engagement strategies.

Horgan et al. (2020) stated that the level of trust in citizenship will ultimately determine how willing individuals are to share health information, and subsequently whether they are inclined to engage with their citizen-level health data to effectively learn how and where to make improvements in healthcare, particularly in relation to digitally framed healthcare. O'Neill et al. (2022) also presented their thoughts on how cultural value systems, experiences with healthcare, and community norms may shape trust concerning partners, and what these thoughts might imply for marginalised and underserved populations.

Effective patient engagement relies on collaboration among patients, healthcare providers and other stakeholders within the broader healthcare system. Research shows that Miller and Reihlen (2023), Newman et al. (2021), and Birkeland et al. (2022) asserted that when healthcare delivery is collaborative, both the quality of care and patient satisfaction improve. Engaging patients in these cooperatives involves not only the co-delivery of treatment but also the integration of patients into the planning, decision-making and communication processes of healthcare.

Newman et al. (2021) found that easy-to-use tools, outreach messaging and strong organisational support were all welcome characteristics that could empower patients to engage with their health. Birkeland et al. (2022) concluded that shared decision-making increases patient satisfaction, even when patients are in poor health. Clavel et al. (2021), however, remind us that while many tools have the potential to support engagement, the intersection of organisational engagement tools and practices is often limited by co-development, which can hinder partnerships.

A common thread throughout the papers was the defining role of leadership in further fostering patient engagement. Ankomah et al. (2023), Bombard et al. (2018), and Parr et al. (2020) observed that when practices aimed at engaging patients were implemented, they were often carried out in an unintentional, poorly coordinated manner, due to weak leadership in their medical and hospital organisations, lacking a visible pathway, and proving unsustainable. Ankomah et al. (2023) indicated that while engagement as a vehicle might have mobilised actual resources in the constituent dimensions of patient engagement, the misalignment of leadership meant it was not attuned to the needs of the communities of interest.

Bombard et al. (2018) indicated that although the components of engaging strategies reflected a process that yielded early impact results, they were significantly unsupported and under-resourced, not necessarily due to intention, but rather because of a lack of clarity in leadership roles and the institutional footing required to experiment with anything meaningful to engage patients. Parr et al. (2020) furthered this relationship: they concluded that leadership style influences patient safety and satisfaction, and is also related to employee performance. Patient engagement interventions enable patients to feel that they can engage, but only to the extent that their leader is visible, supportive and empowering.

Education is the cornerstone of promoting active patient participation. According to Sagen et al. (2023), a patient has a better chance of engaging in participatory engagement when they possess sufficient knowledge of their rights, role, and options for service. However, acknowledged constraints on participatory engagement encompass various factors, such as health literacy, changing provider participation conditions alongside increasing expectations for patient involvement, and perceived power imbalances in the provider/patient relationship. Barello et al. (2020) recognised the importance of training for both patients and providers to achieve equitable engagement, while Muscat et al. (2020) emphasised the necessity of addressing health literacy for informed decision-making.

Another important consideration is the actual financial investment in patient engagement. In previous discussions, the authors reflected that when comparing engagement, patient satisfaction and quality of care, many of the economic costs could not be identified and articulated due to metrics and systems not being fully developed. Similarly, Sagen et al. (2023) and Clavel et al. (2021) emphasised the need to create new evaluation forms of engagement to clarify what success can look like in an engagement project.

Two popular theoretical models have been proposed for increasing patient engagement: the Patient Engagement Model (PEM), and the Health Belief Model (HBM). The PEM and HBM offer a foundational understanding of engagement in patient activation, drawing on the health engagement components of the PEM Model and the cognitive appraisal of beliefs. This steers the practitioner towards more tailored consultative strategies to encourage adherence to care and medical advice, thereby improving health outcomes.

The PEM assists in considering patients as they undergo a four-phase dynamic process to explore how patients can nurture and support their health management (Graffigna, Barello, 2018). The four phases are identified as blackout, arousal, adhesion and eudaimonic project. The model describes the emotional and psychological phases of the patient's journey, while simultaneously outlining the role of the health professional in supporting the patient throughout their journey. The HBM describes how beliefs about illness, including disease susceptibility, the seriousness of health conditions, the benefits of behaviours to prioritise health, and barriers to obtaining healthcare, can influence health behaviour (Jose et al., 2021). By acknowledging patient beliefs, health practitioners can be more responsive in their practice to patient beliefs and intentions.

The WHO Community Engagement Framework suggests that trust and relationships extend beyond communication, as care has multidimensional aspects: trust and relationships with care providers are crucial to positively impacting health outcomes in the Ga East Municipality (WHO, n.d.). Furthermore, the US Centres for Disease Control (CDC) and Prevention (2024) defines Patient Activation as the knowledge, skills and confidence individuals possess for managing their health, which addresses the difficulties discussed in this study. Regardless of potential improvements in health, when considering low enrolment in the NHIS, the absence of patient activity, and the need for education and empowerment strategies to engage and activate patients, this approach continues to have the potential to provide an improved outcome and satisfaction.

Alongside the WHO and CDC frameworks, other global and regional frameworks exemplify a commitment to engaging patients and communities in fostering improved health outcomes. These frameworks emerge from various parts of the world, and endorse different strategies for involving patients, such as utilising digital technology, training local community members as leaders, and delivering education at the household level. Summary Table 2 outlines the origins of the frameworks, their purpose, implementation methods and any reported outcomes. This comparison facilitates an understanding of which strategies may be most effective in local contexts such as the Ga East Municipality in the Republic of Ghana.

Table 2 presents various frameworks from different global regions that promote patient and community engagement across multiple areas of healthcare. Each framework reflects the unique interests, capacities and needs of its region. For instance, in Europe the EUPATI Patient Engagement Framework and the Patient Engagement and Evaluation Framework both provide structured support through formal training, tools and evaluation.

Concerning Sub-Saharan Africa, particularly Ghana, the CHPS and PPE initiatives have engaged community leaders, volunteers and community-based organisations to reach the population, especially in rural and underserved areas. Although these programmes may not have implemented as many technological options or formal tracking systems, they highlighted some pertinent examples of the development of trust, accessibility and community engagement.

As noted, challenges such as poor NHIS enrolment, a lack of trust and weak leadership align with emerging global frameworks. In this way, the global strategies refer to the same principle expressed in this study, that patient engagement can improve access and outcomes in healthcare, whether through digital means, education at the household level, or community engagement, by effectively adapting to the local context with strong support systems and capacity.

These global strategies have provided valuable insights, but they rely on existing local systems for engagement, such as Ghana's NHIS. Therefore, it is vital to consider the NHIS in detail, as it plays a crucial role in the health access of the country's inhabitants. A significant case in point is the low NHIS enrolment in the Ga East Municipality. According to Adjei-Tutu (2021), people in this area lack access to any health system, let alone a newer district office and services, including childhood cancer therapy and family planning.

Engagement is influenced by several mitigating factors, such as poverty, poor service and waiting times, and mechanisms including slow reimbursement processes, abandonment and discouragement factors for reengagement. Gender factors are significant, as women have historically enrolled more, owing to their exemption from maternal health episodes, while men have consistently enrolled less (Antabe et al., 2025). This disparity will persist in an environment of reduced access, high out-of-pocket payments, and low confidence in the system, leading at best to disconnection, and at worst importunation.

The financial stresses that healthcare service providers are experiencing, particularly regarding payment delays, contribute to negative public trust and an ambivalence towards registering or renewing their interest in the NHIS (Classfmonline, 2025). More interestingly, a correlation exists between low NHIS enrolment and further disengagement from the health system, providing significant policy insights. As the findings illustrate, NHIS enrolment will not be enhanced without greater accessibility to services, quality of service and timely reimbursement, all of which are crucial to instilling patient trust and engagement, as well as promoting health equity within and beyond the Ga East Municipality.

The literature review provided a valuable framework for identifying patterns, similarities and challenges across healthcare settings. It was also advantageous in understanding the broader context of patient engagement both globally and locally.

The research suggests that patient engagement is a vital factor in achieving improved healthcare outcomes. By reviewing the evidence derived from studies and established frameworks, it is evident that when patients are viewed as active participants in their care, they experience improved outcomes and greater satisfaction.

Studies indicate that engaging patients necessitates effective leadership and communication from both healthcare providers and participants, fostering an environment that maximises patient involvement in their care. To enhance patient engagement in the Ga East Municipality in Ghana, it is proposed to analyse two primary models, namely the Patient Engagement Model (PEM) and the Health Belief Model (HBM).

For healthcare leaders in the Ga East Municipality, one of the most effective ways to enhance the engagement capability within their healthcare organisations would be to develop a servant leadership model that adopts accountability and responsiveness, promoting involvement and engagement in the patient's own care. This includes hiring a patient engagement point person with a clearly defined job description, and institutionalising patient engagement into the everyday operations of all organisations.

Education should be a vital component in facilitating a smooth transition towards enhanced patient engagement. By addressing the educational gaps, participation will occur more naturally and with greater respect and effectiveness from both parties. Healthcare organisations should integrate systems that promote patient engagement, dismantle communication barriers, and foster activity-based collaborations.