Influencing factors of patient activation in chronic diseases: A systematic review using the Social Ecological Model

Objective To systematically identify, categorize, and synthesize the influencing factors of patient activation among people with chronic conditions from a Social Ecological Model (SEM) perspective. Methods A systematic review was conducted following JBI methodology. Six databases (PubMed, EMBASE, Web of Science, ProQuest Health & Medical Collection, The Cochrane Library, and EBSCOhost) were searched from 2002 to 2025. Studies investigating factors associated with patient activation in chronic disease populations were included. Study selection, data extraction, and quality assessment were performed by two reviewers independently. Extracted factors were categorized into individual, interpersonal, organizational, community, and policy levels using the Social Ecological Model framework. Narrative synthesis and meta-analysis (for conflicting factors) were applied. Results A total of 55 studies (51 cross-sectional, 4 longitudinal/cohort) were included. The majority (92.7%) were cross-sectional. Factors were predominantly identified at the individual level, including demographic (e.g., older age [-]), psychological (e.g., depression [-], self-efficacy [+]), health status (e.g., better self-rated health [+]), socioeconomic (e.g., higher education [+]), and health knowledge/behavioral factors (e.g., health literacy [+]). Interpersonal factors included social support [+] and living situation (e.g., living alone [mixed]). Organizational factors involved healthcare support [+] and utilization (e.g., emergency visits [-]). Community (e.g., social risk [-]) and policy-level factors (e.g., private insurance [+]) were understudied. Meta-analysis on gender and living alone yielded non-significant pooled estimates but highlighted substantial heterogeneity. Conclusion Patient activation in chronic conditions is influenced by a multi-level spectrum of factors, with the individual level being most researched. Evidence at community and policy levels is limited. The findings provide a structured, ecological framework for developing multi-level interventions. Future research should employ longitudinal designs, explore macro-level determinants, and address heterogeneity through culturally adapted measures. Reporting Method: The study’s reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 checklist.