The Ecology of Engagement: Fostering cooperative efforts in health with patients and communities

Abstract Context Patients and community members are engaged in nearly every aspect of health systems. However, the engagement literature remains siloed and fragmented, which makes it difficult to connect engagement efforts with broader goals of health, equity and sustainability. Integrated and inclusive models of engagement are needed to support further transformative efforts. Methods This article describes the Ecology of Engagement, an integrated model of engagement. The model posits that: (1) Health ecosystems include all members of society engaged in health; (2) Engagement is the ‘together’ piece of health and healthcare (e.g., caring for each other, preventing, researching, teaching and building policies together); (3) Health ecosystems and engagement are interdependent from each other, both influencing health, equity, resilience and sustainability. Conclusion The Ecology of Engagement offers a common sketch to foster dialogue on engagement across health ecosystems. The model can drive cooperative efforts with patients and communities on health, equity, resilience and sustainability. Patients and Public Contribution Three of the authors have lived experiences as patients. One has a socially disclosed identity as a patient partner leader with extensive experience in engagement (individual care, education, research, management and policy). Two authors have significant experience as patients and informal caregivers, which were mobilized in descriptive illustrations. A fourth author has experience as an engaged citizen in health policy debates. All authors have professional lived experience in health (manager, researcher, health professional, consultant and educator). Six patient and caregiver partners with lived experience of engagement (other than the authors) contributed important revisions and intellectual content.


| THE NEED FOR AN ECOLOGICAL PERSPECTIVE ON HEALTH COPRODUCTION
Patients and community members are engaged in nearly every aspect of health ecosystems (e.g., self-care, clinical care, research, education, public health and policy). Dozens of models and conceptual frameworks have been published to support engagement with patients and community members. [1][2][3][4] Patient and community engagement tend to assume an intrinsic distinction between care providers (e.g., health professionals) and care receivers (e.g., patients), with patients and citizens being framed as 'end-users', 'beneficiaries' and 'consumers'. 5 Accordingly, engagement is viewed as 'inviting people from outside' into professional health systems. 6 This assumes that professionals are leading the engagement 'intervention' (whom to engage and how) to achieve health systems' goals (e.g., vaccination rates, medication adherence, research uptake and social acceptability of policies). 7 Increased recognition that health is coproduced with patients and communities calls for more reciprocal and integrated models of engagement, acknowledging that leadership and roles can evolve over time. Coproduction refers to the idea that care is produced jointly by 'providers' and 'users', thus blurring the distinction between who gives and receives care. 8 Coproduction of individual care recognizes the role of informal care provided by patients, family members and citizens, emphasizing the fact that professional delivery of healthcare services only represents a fraction of the total care received. 9 From a public health perspective, collective coproduction of health recognizes the influence that communities and civic institutions have on environmental and social determinants of health (e.g., mutual support, education, income distribution, employment, climate change). 10 While the idea of health coproduction has been around for years, 8 its application in practice remains problematic and inequitable.
Engagement practices are still largely characterized by fragmented, short-term initiatives, leaving important segments of health systems uninviting and not interacting with community members. Also, many communities remain excluded from influential decision-making roles, thus perpetuating knowledge and power imbalance that impedes global capacities for system transformation and health coproduction. 11 The International Summit on Patient and Public Partnershipwhich convened over 100 patient, community and health system leaders-highlighted the need to 'assemble the puzzle' and develop a common vision for systemic transformation anchored in a partnership model of health. Participants stressed the need to 'look at the whole elephant, in interaction with its environment'. International leaders recognized the challenge of building an integrated vision of engagement in health coproduction, emphasizing the need to 'broaden the tent' to new ideas and perspectives. 12,13 Inclusive engagement models are therefore needed to push towards health coproduction for all. 14 Other disciplines have faced similar challenges in building integrated views of complex systems. In response, ecological models have been fruitfully developed and used in biology, public health, psychology and sociology to understand dynamic and interdependent relationships across systems' levels. 15 This paper capitalizes on the strengths of ecological models to propose an integrated perspective on engagement in health coproduction.

| Objective
The Ecology of Engagement is a conceptual model focused on understanding, supporting and evaluating engagement relationships across health ecosystems. The goal of this article is to describe the Ecology of Engagement and illustrate its potential implications for practice and research. The article is divided into four sections: 1. After a brief description of our theory-building approach, we sketch an overview of the Ecology of Engagement and offer definitions of key concepts; 2. We then describe the core components of the model: health ecosystems, engagement and the interactions between both; 3. Following the idea that 'there is nothing more practical than a good theory', 16 we illustrate the pragmatic application of the model using international empirical examples; 4. We finally reflect on the strengths and limitations of the model, while outlining a research agenda for the future.

| Theory-building approach
To build the Ecology of Engagement Model, we followed Lynham's interpretive approach to theory-building in applied research. Theorybuilding is understood as 'the purposeful process or recurring cycle by which coherent descriptions, explanations and representations of observed or experienced phenomena are generated, verified and refined'. 17 Interpretive theory-building inquiry focuses on the practical construction of meanings to understand and interpret complex phenomena. Our theory-building goal was to provide engagement practitioners and scientists with a common language to conceptualize engagement across health systems. As such, we did not seek to inductively build new theories (as in grounded theory approaches) nor did we try to build predictive models based on analytical approaches (as in meta-analysis). Instead, we examined the fit between existing theories and actual engagement experiences through practice-totheory dialogue based on two sources of expertize: the practical knowledge of patients, professionals and citizens who experienced engagement, and the theoretical expertize of engagement scientists. the model were discussed with international experts in engagement science, as well as six patients and caregivers with several years of engagement experience. Our collective approach as a diverse writing team was anchored in dialogical traditions of science highlighting the importance of carefully listening, understanding and learning from multiple paradigms and perspectives while thriving on differences and intellectual tensions. 18,19 The resulting model should be considered exploratory and descriptive, seeking to pragmatically support further collaboration among practitioners and scientists. 20

| The Ecology of Engagement model overview
The Ecology of Engagement focuses on understanding, supporting and evaluating engagement relationships in health ecosystems. Ecological systems are 'living systems'. Mechanical systems (e.g., cars, the solar system) operate under constant, predictable rules. Conversely, living systems (e.g., the human body, a forest) are characterized by complexity and emergent properties arising across levels. 21 Individuals are embedded within communities, institutions and societies with emergent properties across levels 22 (e.g., collective ability to shape policy decisions). Engagement among individuals is qualitatively different from collective engagement across communities, institutions and groups, which have emergent properties beyond those of its participating members.
Ecological perspectives emphasize the interdependence and multidirectional influence between individual and collective factors. 15 Central to ecological perspectives are the assumption of mutual interaction and reciprocal causation among levels. The microlevel refers to individuals (e.g., individual patient and professional decision-making). The mesolevel refers to groups and institutions (e.g., patient association, clinical team, community support group and research institution). The macrolevel refers to larger forces within the social systems in which groups and institutions are embedded (e.g., environment, culture, policies and legislation). From an engagement perspective, engagement at the microlevel (e.g., care) can generate knowledge and opportunities for engagement at the meso-(e.g., institution) and macrolevels (e.g., policy).   Health Ecosystem Include all members of society engaged in health-related activities. Health-related activities include caring for self or others, health promotion, research, education, governance and policy. Health ecosystems are broader than professional health systems and incorporate patients, informal caregivers, communities and their environment as integral contributors to individual and population health.
Community system Community members (patients, family members, informal caregivers and citizens) and community groups (patient associations, networks, civic institutions and social movements) who engage in health-related activities.
Professional system Professional members (e.g., clinicians, managers, researchers, policymakers) and institutions (healthcare institutions, public health agencies, government) who engage in health-related activities.

Mesolevel
Groups and institutions in which individuals interact together (e.g., patient association, clinic, research team, training institutions).

Macrolevel
Forces within the larger social system in which groups and institutions are embedded (e.g., culture, policies, values, legislation, environment).

Engagement relationships ('inner dynamic' of the model) Engagement
Dynamic relationships among individuals or groups oriented toward joint health-related activities. Engagement is the 'together' piece of health and healthcare (e.g., caring together, doing research together, teaching together, promoting health together and developing policies together).
Typology of engagement Characterization of engagement relationships according to power and knowledge flow (activism, information, consultation, participation and partnership), at what levels of health ecosystems they operate (micro-, meso-and macrolevels), and among which individuals and groups (e.g., bonding, bridging and linking).

Information
Engagement relationship where knowledge is communicated from engagement leaders to engaged individuals or groups.
Consultation Engagement relationship where knowledge is collected from engaged individuals/groups toward engagement leaders.
Participation Engagement relationship where knowledge is exchanged between engagement leaders and engaged people.
Partnership Engagement relationship where engaged parties colead (governance), cobuild (process) and are coaccountable (results) for a common initiative being carried together.
Activism Engagement relationship where engagement leaders challenge existing power relationships and social structures to change the status quo (including social norms, embedded practices, policies or the dominance of certain social groups).
Bonding Engagement relationships within community or professional systems. Bonding relationships are 'inward looking', reinforcing connections among homogenous groups of people with a shared identity (e.g., self-support group, professional team) Bridging Engagement relationships across community or professional systems. Bridging relationships are 'outward looking', reinforcing connections across a heterogeneous group of people with different identities (e.g., quality improvement committees with patients and health professional members).
Linking Engagement relationships across ecosystem levels. Linking relationships are 'upward looking', reinforcing connections with people across power and authority gradients (e.g., tenants' participation in a social housing management committee, project coleadership between a patient and health authority manager, community development project with citizens and municipal government leaders).

Density
Total number of engagement relationships among individuals and groups. Density quantifies how many engagement relationships are developed and maintained among community members and professionals, each offering opportunities for mutual influence across the whole ecosystem. To unpack this umbrella definition, we propose a typology of engagement relationships according to power and knowledge flow (activism, information, consultation, participation, partnership), at what levels of health ecosystems they operate (micro-, meso-and macrolevels), among which individuals and groups (e.g., bonding, bridging, linking), and their ecological distribution (density, intensity and diversity).

| 'The Loop': Distinguishing engagement based on knowledge and power
Following other authors, 2 we assume that theoretically relevant differences exist between engagement relationship categories. 1-3 A common assumption of existing typologies is that engagement is either led by professionals (e.g., Rowe and Frewer 'typology of public engagement mechanisms' ranging from 'information' to 'participation' 2 ) or led by citizens themselves (e.g., Sherry Arstein's 'ladder of citizen participation' ranging from 'manipulation' to 'citizen control' 1 ).
The preconditions of engagement. 27 Conversely, activism targets the transformation of power relationships and social structures as a potential result of engagement. 28,29 Partnership approaches seek to achieve 'transformation from the inside' (through collaborative

Concept Definition
Intensity Strength of bonding, bridging and linking engagement relationships within the health ecosystem as a whole, allowing sustained connections within and across community and professional systems.

Diversity
Variety of individuals and groups forging engagement relationships within the health ecosystem as a whole. Diversity points to the inclusiveness of engagement relationships, and the potential exclusion of certain individuals and groups with whom knowledge, power and health production capacity may be unequally distributed.
Ecological effects of engagement ('inputs and outputs' of the model) Health coproduction Change in the health of individuals and groups resulting from the joint actions of community members and professionals.

Resilience
Ability of health ecosystems to adapt, evolve and survive as a result of changes and crises.
Resource use Use of human, financial or environmental resources by the health ecosystem.

Equity
Inclusive distribution of knowledge, power and health production capacity among individuals and groups within health ecosystems.
leadership, sharing of expertize and resources and partnership synergy), 27 while activism focuses on changing power relationships and institutional structures 'from the outside' (through critical questioning of discourses and redistribution of resources and power). 30,31 Differences in engagement approaches are reflected in the choice of appropriate evaluation criteria to assess the process and outcomes of engagement. Table 2 illustrates examples of engagement at different health ecosystem levels, along with their potential evaluation criteria.

| Engagement with whom: Bonding, bridging and linking
Drawing from social capital theory, we further distinguish engagement relationships according to who is engaged with whom ( Figure 2)

| Ecosystemic distribution of engagement relationships
Engagement relationships can be studied 'from the inside out', by characterizing the relationships of a focal individual or collective (e.g., bonding and bridging relationships established by a single patient partner) or studied from the 'outside-in', by characterizing the distribution of engagement relationships within a health ecosystem. 36 The ecosystemic distribution of engagement relationships can be characterized based on its density, intensity and diversity: 1. Density refers to the total number of engagement relationships among individuals and groups within an ecosystem. It quantifies The loop (engaging how and under whose leadership). Engagement are dynamic relationships oriented toward joint health-related actions. Engagement can be led by the community (yellow), by professionals (blue), or co-led (green). Engagement is distinguished by knowledge flow (information to, consultation from, participation between) and power (activism to transform power dynamics from the outside, partnering by sharing power from the inside). Engagement relationships evolve over time ('bouncing along the loop'). connections within and across community and professional systems, while weaker ties (e.g., informal contacts among individuals) can play a role in bridging more isolated community and professional groups. 37 3. Diversity refers to the variety of individuals and groups forging engagement relationships within the health ecosystem as a whole.
Diversity points to the inclusiveness of engagement relationships and the potential exclusion of certain individuals and groups with whom knowledge, power and health production capacity may be unequally distributed.

| HEALTH ECOSYSTEMS AND ENGAGEMENT ARE INTERDEPENDENT
The Ecology of Engagement assumes a bidirectional influence between engagement and health ecosystems: engagement transforms ecosystems and is shaped by its ecological context. Engagement relationships have systemic effects on the equilibrium between health, resilience, equity and sustainability ( Figure 3). This section illustrates the interdependence between engagement and health ecosystems.

| Engagement transforms health ecosystems
A growing empirical literature has documented how the engagement of patients, professionals and communities can transform its ecological context by shaping policies, social determinants of health, research, health institutions, education programmes and direct care. [38][39][40][41][42][43][44] Similarly, several ecological factors (e.g., culture, institutions, policies) influence the process and outcomes of engagement. [45][46][47][48] These influences can operate 'upstream' (micro-to macrolevels), 'downstream' (macro-to microlevels) or 'laterally' (across a single level). 'coconstruction' or 'coproduction' are best classified in the partnership category when leadership is shared between parties. However, they are best classified in the information, consultation or participation category when leadership is held by a single party (e.g.,

| Engaging communities and professionals in health coproduction
Health ecosystems can move back and forth between communityled, professionally led or co-led health production systems as a result of historical, technological, political and cultural forces. For example, low-income countries tend to rely heavily on community health production systems (e.g., informal care by family and community members). Community structures tend to be marginalized with technological progress and the professionalization of care. 48,52 Conversely, extreme professionalization of care tends to be limited by its high resource use and inability to reach certain underserved communities, which creates counter-balancing forces towards coproduction models built on the synergy between community and professional resources.
Bridging engagement relationships between professionals and community members can also support health coproduction dynamics. 26 For example, peer-support workers foster health coproduction through their ability to build trustful relationships across professionals and community systems. This bridge can operate from the clinic to the community (e.g., peer-mentors connecting chronic disease patients living in poverty with community organizations offering housing and food support), 52 or from the community to the clinic (e.g., peer-support workers helping to reconnect people experiencing homelessness with professional healthcare services or harm-reduction strategies aligned with people's own goal and values). 49 Community members can also foster bonding (e.g., introduction to mutual support group) and linking relationships (e.g., advocating for service delivery adaptation).

| Engagement influences resilience, equity and sustainability
Engagement relationships have potential effects on health ecosystems' resource use (entropy), adaptation to change and crisis (resilience) and disparities (equity).
An ecological perspective suggests that the diversity and intensity of engagement relationships influence health ecosystems' sustainability (use of human, financial and environmental resources). 50 Several initiatives mobilizing patients, citizens and communities as care partners have shown comparable or improved outcomes compared to professionally led models of care, 51,53 with lower use of resource-intensive services (e.g., emergency room visits and hospitalizations) and overall costs of care. [54][55][56] The environmental impacts of different health production systems further illustrate the relationships between engagement and sustainability. Climate change has significant impacts on global health and the healthcare sector is a direct contributor to climate change. 57,58 Professional health production systems tend to produce higher (environmental) effects than community-based or health coproduction systems. Large urban hospitals tend to have a high carbon footprint because of direct energy use, disposable technologies and transportation. 58 Conversely, community-based care focused on people empowerment and self-management has greater potential for low carbon footprint healthcare. 57 Engagement relationships can also influence the entropic effects of health on the environment, through professional and citizen mobilization efforts. 59,60 Equity is also influenced by engagement. Despite its massive investment in healthcare ( We present the Ecology of Engagement model with humility, acknowledging that the model is building on the work of many others.
The integrative nature of the Ecology of Engagement seeks to connect engagement theories that are often disconnected from each other while offering a common language to support further dialogue.
This does not imply that the model offers a comprehensive theory of engagement in health. It is merely offered as a pragmatic sketch to build upon.
Drawing from multiple scientific and epistemic traditions can create paradoxes that are difficult to reconcile (e.g., postpositivist views of entropy coexisting alongside constructivist views of social identities), and is influenced by the perspectives of experts involved in theory-building. 76 Such internal tensions are intrinsic to transdisciplinary undertaking and should inform further research and practice dialogue.
The idea that patients, professionals and communities can be engaged at the micro-, meso-and macrolevels has been proposed elsewhere 34

CONFLICT OF INTEREST
The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
The data availability statement does not apply.