Social prescribing during the COVID-19 pandemic: a qualitative study of service providers' and clients' experiences

Understanding How, Why and for Whom Link Work Interventions Promote Access in Community Healthcare Settings in the United Kingdom: A Realist Review

INTRODUCTION

Inequity in access to healthcare in the United Kingdom can have a profound impact on people's ability to manage their health problems. Link work interventions attempt to overcome the socioeconomic and structural barriers that perpetuate health inequalities. Link workers are typically staff members without professional clinical qualifications who support patients to bridge the gap between services. However, little is currently known about how and why link work interventions might be effective. This realist review attempts to understand the contexts and resultant mechanisms by which link work interventions affect access to community healthcare services.

METHODS

The authors completed a systematic search of empirical literature in Embase, CINAHL, Medline, PsychInfo and SocIndex, as well as grey literature and CLUSTER searches. Context, mechanism and outcome (CMO) configurations were generated iteratively in consultation with an expert panel and grouped into theory areas.

RESULTS

Thirty-one eligible manuscripts were identified, resulting in nine CMO configurations within three theory areas. These pertained to adequate time in time-pressured systems; the importance of link workers being embedded across multiple systems; and emotional and practical support for link workers.

CONCLUSION

Although link work interventions are increasingly utilised across community healthcare settings, the contexts in which they operate vary considerably, triggering a range of mechanisms. The findings suggest that careful matching of resources to patient need and complexity is important. It affords link workers the time to develop relationships with patients, embed themselves in local communities and referring teams, and develop knowledge of local challenges.

PATIENT OR PUBLIC CONTRIBUTION

The team included people with lived experience of mental health conditions and a carer who were involved at all stages of the review.

Efficacy of community groups as a social prescription for senior health-insights from a natural experiment during the COVID-19 lockdown

Loneliness and associated physical and cognitive health decline among the aging population is an important medical concern, exacerbated in times of abnormal isolation like the 2020-2021 Covid-19 pandemic lockdown. In this backdrop, recent "social prescribing" based health policy initiatives such as community groups as a support structure for the aging population assumes great importance. In this paper, we evaluate and quantify the impact of such social prescribing policies in combatting loneliness and related health degeneration of the aging population in times of abnormal isolation. To this end, we conduct a natural experiment across a sample of 618 individuals aged 65 and over with varying access to community groups during the Covid-19 lockdown period. Using a random-effects, probit model to compare the differences in health outcomes of participants with access to community groups (target) with those without access (control), we find that the target group was 2.65 times less likely to suffer from loneliness as compared to the control group, along with lower incidences of reported cardiovascular and cognitive health decline. These initial findings provide preliminary support in favor of the interventional power of social prescription tools in mitigating loneliness and its consequent negative health impact on the aging population.

A meta-ethnography of the factors that shape link workers' experiences of social prescribing

BACKGROUND

Social prescribing is gaining traction internationally. It is an approach which seeks to address non-medical and health-related social needs through taking a holistic person-centred and community-based approach. This involves connecting people with and supporting them to access groups and organisations within their local communities. It is hoped that social prescribing might improve health inequities and reduce reliance on healthcare services. In the UK, social prescribing link workers have become core parts of primary care teams. Despite growing literature on the implementation of social prescribing, to date there has been no synthesis that develops a theoretical understanding of the factors that shape link workers' experiences of their role.

METHODS

We undertook a meta-ethnographic evidence synthesis of qualitative literature to develop a novel conceptual framework that explains how link workers experience their roles. We identified studies using a systematic search of key databases, Google alerts, and through scanning reference lists of included studies. We followed the eMERGe guidance when conducting and reporting this meta-ethnography.

RESULTS

Our synthesis included 21 studies and developed a "line of argument" or overarching conceptual framework which highlighted inherent and interacting tensions present at each of the levels that social prescribing operates. These tensions may arise from a mismatch between the policy logic of social prescribing and the material and structural reality, shaped by social, political, and economic forces, into which it is being implemented.

CONCLUSIONS

The tensions highlighted in our review shape link workers' experiences of their role. They may call into question the sustainability of social prescribing and the link worker role as currently implemented, as well as their ability to deliver desired outcomes such as reducing health inequities or healthcare service utilisation. Greater consideration should be given to how the link worker role is defined, deployed, and trained. Furthermore, thought should be given to ensuring that the infrastructure into which social prescribing is being implemented is sufficient to meet needs. Should social prescribing seek to improve outcomes for those experiencing social and economic disadvantage, it may be necessary for social prescribing models to allow for more intensive and longer-term modes of support.

An exploratory randomised trial investigating feasibility, potential impact and cost effectiveness of link workers for people living with multimorbidity attending general practices in deprived urban communities

BACKGROUND

Social prescribing link workers are non-health or social care professionals who connect people with psychosocial needs to non-clinical community supports. They are being implemented widely, but there is limited evidence for appropriate target populations or cost effectiveness. This study aimed to explore the feasibility, potential impact on health outcomes and cost effectiveness of practice-based link workers for people with multimorbidity living in deprived urban communities.

METHODS

A pragmatic exploratory randomised trial with wait-list usual care control and blinding at analysis was conducted during the COVID 19 pandemic (July 2020 to January 2021). Participants had two or more ongoing health conditions, attended a general practitioner (GP) serving a deprived urban community who felt they may benefit from a one-month practice-based social prescribing link worker intervention.. Feasibility measures were recruitment and retention of participants, practices and link workers, and completion of outcome data. Primary outcomes at one month were health-related quality of life (EQ-5D-5L) and mental health (HADS). Potential cost effectiveness from the health service perspective was evaluated using quality adjusted life years (QALYs), based on conversion of the EQ-5D-5L and ICECAP-A capability index to utility scoring.

RESULTS

From a target of 600, 251 patients were recruited across 13 general practices. Randomisation to intervention (n = 123) and control (n = 117) was after baseline data collection. Participant retention at one month was 80%. All practices and link workers (n = 10) were retained for the trial period. Data completion for primary outcomes was 75%. There were no significant differences identified using mixed effects regression analysis in EQ-5D-5L (MD 0.01, 95% CI -0.07 to 0.09) or HADS (MD 0.05, 95% CI -0.63 to 0.73), and no cost effectiveness advantages. A sensitivity analysis that considered link workers operating at full capacity in a non-pandemic setting, indicated the probability of effectiveness at the €45,000 ICER threshold value for Ireland was 0.787 using the ICECAP-A capability index.

CONCLUSIONS

While the trial under-recruited participants mainly due to COVID-19 restrictions, it demonstrates that robust evaluations and cost utility analyses are possible. Further evaluations are required to establish cost effectiveness and should consider using the ICE-CAP-A wellbeing measure for cost utility analysis.

REGISTRATION

This trial is registered on ISRCTN.

TITLE

Use of link workers to provide social prescribing and health and social care coordination for people with complex multimorbidity in socially deprived areas.

TRIAL ID

ISRCTN10287737. Date registered 10/12/2019. Link: https://www.isrctn.com/ISRCTN10287737.

What does social prescribing look like in practice? A qualitative case study informed by practice theory

Social prescribing (SP) typically involves linking patients in primary care with a range of local, community-based, non-clinical services. While there is a growing body of literature investigating the effectiveness of SP in improving healthcare outcomes, questions remain about how such outcomes are achieved within the everyday complexity of community health systems. This qualitative case study, informed by practice theory, aimed to investigate how SP practices relevant to people at high risk of type 2 diabetes (T2D) were enacted in a primary care and community setting serving a multi-ethnic, socioeconomically deprived population. We collected different types of qualitative data, including 35 semi-structured interviews with primary care clinicians, link workers and SP organisations; 30 hours of ethnographic observations of community-based SP activities and meetings; and relevant documents. Data analysis drew on theories of social practice, including Feldman's (2000) notion of the organisational routine, which emphasises the creative and emergent nature of routines in practice. We identified different, overlapping ways of practising SP: from highly creative, reflective and adaptive ('I do what it takes'), to more constrained ('I do what I can') or compliant ('I do as I'm told') approaches. Different types of practices were in tension and showed varying degrees of potential to support patients at high risk of T2D. Opportunities to adapt, try, negotiate, and ultimately reinvent SP to suit patients' own needs facilitated successful SP adoption and implementation, but required specific individual, relational, organisational, and institutional resources and conditions. Feldman, M.S., 2000. Organizational Routines as a Source of Continuous Change. Organ. Sci. 11, 611-629.

Estimating the effectiveness of an enhanced 'Improving Access to Psychological Therapies' (IAPT) service addressing the wider determinants of mental health: a real-world evaluation

BACKGROUND

Addressing the wider determinants of mental health alongside psychological therapy could improve mental health service outcomes and population mental health.

OBJECTIVES

To estimate the effectiveness of an enhanced 'Improving Access to Psychological Therapies' (IAPT) mental health service compared with traditional IAPT in England. Alongside traditional therapy treatment, the enhanced service included well-being support and community service links.

DESIGN

A real-world evaluation using IAPT's electronic health records.

SETTING

Three National Health Service IAPT services in England.

PARTICIPANTS

Data from 17 642 service users classified as having a case of depression and/or anxiety at baseline.

INTERVENTION

We compared the enhanced IAPT service (intervention) to an IAPT service in a different region providing traditional treatment only (geographical control), and the IAPT service with traditional treatment before additional support was introduced (historical control).

PRIMARY OUTCOME MEASURES

Patient Health Questionnaire-9 (PHQ-9) Depression Scale (score range: 0-27) and Generalised Anxiety Disorder-7 (GAD-7) Anxiety Scale (score range: 0-21); for both, lower scores indicate better mental health. Propensity scores were used to estimate inverse probability of treatment weights, subsequently used in mixed effects regression models.

RESULTS

Small improvements (mean, 95% CI) were observed for PHQ-9 (depression) (-0.21 to -0.32 to -0.09) and GAD-7 (anxiety) (-0.23 to -0.34 to -0.13) scores in the intervention group compared with the historical control. There was little evidence of statistically significant differences between intervention control and geographical control.

CONCLUSIONS

Embedding additional health and well-being (H&W) support into standard IAPT services may lead to improved mental health outcomes. However, the lack of improved outcomes compared with the geographical control may instead reflect a more general improvement to the intervention IAPT service. It is not clear from our findings whether an IAPT service with additional H&W support is clinically superior to traditional IAPT models.

A rapid review of opportunities and challenges in the implementation of social prescription interventions for addressing the unmet needs of individuals living with long-term chronic conditions

BACKGROUND

People with long-term chronic conditions often struggle to access and navigate complex health and social services. Social prescription (SP) interventions, a patient-centred approach, help individuals identify their holistic needs and increase access to non-clinical resources, thus leading to improved health and well-being. This review explores existing SP interventions for people with long-term chronic conditions and identifies the opportunities and challenges of implementing them in primary healthcare settings.

METHODS

This rapid review followed the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines and searched relevant articles in three databases (PubMed/MEDLINE, EMBASE, and Web of Science) by using subject headings and keywords combined with Boolean operators. The search encompassed articles published between January 2010 and June 2023. Two authors independently conducted study screening and data abstraction using predefined criteria. A descriptive synthesis process using content analysis was performed to summarise the literature.

RESULTS

Fifteen studies were included, with all but one conducted in the United Kingdom, and revealed that social prescribers help guide patients with long-term chronic conditions to various local initiatives related to health and social needs. Effective implementation of SP interventions relies on building strong relationships between social prescribers and patients, characterised by trust, empathy, and effective communication. A holistic approach to addressing the unmet needs of people with long-term chronic conditions, digital technology utilisation, competent social prescribers, collaborative healthcare partnerships, clinical leadership, and access to local resources are all vital components of successful SP intervention. However, the implementation of SP interventions faces numerous challenges, including accessibility and utilisation barriers, communication gaps, staffing issues, an unsupportive work environment, inadequate training, lack of awareness, time management struggles, coordination and collaboration difficulties, and resource constraints.

CONCLUSION

The present review emphasises the importance of addressing the holistic needs of people with long-term chronic conditions through collaboration and coordination, training of social prescribers, community connections, availability of local resources, and primary care leadership to ensure successful interventions, ultimately leading to improved patient health and well-being outcomes. This study calls for the need to develop or utilise appropriate tools that can capture people's holistic needs, as well as an implementation framework to guide future contextual SP interventions.

"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study

BACKGROUND

The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector.

METHODS

As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021.

FINDINGS

Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience.

CONCLUSIONS

While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

Implementation and impact of a social prescribing intervention: an ethnographic exploration

BACKGROUND

Social prescribing involves referral of patients from primary care to link workers, who work with them to access appropriate local voluntary and community sector services.

AIM

To explore how a social prescribing intervention was delivered by link workers and the experiences of those referred to the intervention.

DESIGN AND SETTING

The study used ethnographic methods to conduct a process evaluation of a social prescribing intervention delivered to support those living with long-term conditions in an economically deprived urban area of the North of England.

METHOD

Participant observation, shadowing, interviews, and focus groups were used to examine the experiences and practices of 20 link workers and 19 clients over a period of 19 months.

RESULTS

Social prescribing provided significant help for some people living with long-term health conditions. However, link workers experienced challenges in embedding social prescribing in an established primary care and voluntary sector landscape. The organisations providing social prescribing drew on broader social discourses emphasising personal responsibility for health, which encouraged a drift towards an approach that emphasised empowerment for lifestyle change more than intensive support. Pressures to complete assessments, required for funding, also encouraged a drift to this lighter-touch approach. A focus on individual responsibility was helpful for some clients but had limited capacity to improve the circumstances or health of those living in the most disadvantaged circumstances.

CONCLUSION

Careful consideration of how social prescribing is implemented within primary care is required if it is to provide the support needed by those living in disadvantaged circumstances.

Use of community resources as health assets for rehabilitation of people with Long COVID in northeastern Spain two years after the outbreak of the COVID-19 pandemic: qualitative study

INTRODUCTION

The epidemiology of Post COVID Condition is not yet known. There are different treatment options, but they are not recommended or suitable for all those affected. For this reason and due to the lack of health treatment, many of these patients have tried to carry out their own rehabilitation through the use of community resources.

OBJECTIVE

The objective of this study is to deepen into the understanding about the use of community resources as assets for health and rehabilitation by people with Long COVID and their utility.

METHODOLOGY

A qualitative design was carried out with the participation of 35 Long COVID patients, of which 17 subjects were interviewed individually and 18 of them were part of two focus groups. The participating patients were recruited in November and December 2021 from the Primary Health Care centers and through the Association of Long COVID patients of Aragon. The research topics were the use of community resources, before and after their infection by COVID-19, rehabilitation through their use, as well as barriers and strengths for their employment. All analyses were performed iteratively using NVivo software.

RESULTS

Long COVID patients who have used community resources for rehabilitation have seen an improvement in their physical and mental health. Most of them, specifically those affected, have used green spaces, public facilities, physical or cultural activities and associations. The main barriers identified have been the symptoms themselves and the fear of reinfection, with the main advantage of these activities being the perceived health benefits.

CONCLUSION

The use of community resources seems to be beneficial in the recovery process of Long COVID patients, so it is necessary to continue delving into this topic and promote the formal use of the Recommendation of Health Assets from Primary healthcare.

Constituting link working through choice and care: An ethnographic account of front-line social prescribing

Link worker social prescribing has become a prominent part of NHS England's personalisation agenda. However, approaches to social prescribing vary, with multiple discourses emerging about the potential of social prescribing and different interpretations of personalisation. The transformational promise of social prescribing is the subject of ongoing debate, whilst the factors that shape the nature of front-line link working practices remain unclear. Based on 11 months of in-depth ethnographic research with link workers delivering social prescribing, we show how link workers' practices were shaped by the context of the intervention and how individual link workers navigated varied understandings of social prescribing. Following the work of Mol, we show how link workers drew differentially on the interacting logics of choice and care and trace a multiplicity in front-line link working practices within a single intervention. However, over time, it appeared that a logic of choice was becoming increasingly dominant, making it harder to deliver practices that aligned with a logic of care. We conclude that interpreting personalisation through a logic of choice could potentially undermine link working practices that privilege care whilst obscuring the need for wider investment in health care systems and the social determinants of health.

The emotional well-being of Long COVID patients in relation to their symptoms, social support and stigmatization in social and health services: a qualitative study

BACKGROUND

Long COVID patients have experienced a decline in their quality of life due to, in part but not wholly, its negative emotional impact. Some of the most prevalent mental health symptoms presented by long COVID patients are anxiety, depression, and sleep disorders. As such, the need has arisen to analyze the personal experiences of these patients to understand how they are managing their daily lives while dealing with the condition. The objective of this study is to increase understanding about the emotional well-being of people diagnosed with long COVID.

METHODS

A qualitative design was created and carried out using 35 patients, with 17 participants being interviewed individually and 18 of them taking part in two focus groups. The participating patients were recruited in November and December 2021 from Primary Health Care (PHC) centers in the city of Zaragoza (Northern Spain) and from the Association of Long COVID Patients in Aragon. The study topics were emotional well-being, social support networks, and experience of discrimination. All an inductive thematic content analyses were performed iteratively using NVivo software.

RESULTS

The Long COVID patients identified low levels of self-perceived well-being due to their persistent symptoms, as well as limitations in their daily lives that had been persistent for many months. Suicidal thoughts were also mentioned by several patients. They referred to anguish and anxiety about the future as well as a fear of reinfection or relapse and returning to work. Many of the participants reported that they have sought the help of a mental health professional. Most participants identified discriminatory situations in health care.

CONCLUSIONS

It is necessary to continue researching the impact that Long COVID has had on mental health, as well as to provide Primary Health Care professionals with evidence that can guide the emotional treatment of these patients.

Social prescribing for older people and the role of the cultural sector during the COVID-19 pandemic: What are link workers' views and experiences?

Older people's well-being can be bolstered by engaging with cultural activities and venues. They may be encouraged to try cultural offers by a link worker as part of social prescribing. However, the cultural sector, like all parts of life, was affected by the COVID-19 pandemic; this has had implications for cultural offers available to link workers. A study was conducted to explore the views and experiences of link workers in using the cultural sector within social prescribing, particularly for older people (aged 60+) during the pandemic. An online questionnaire was distributed to and completed by link workers in the UK. Data were analysed mainly using descriptive statistics. Open text responses were clustered into similar ideas to create key concepts. Useable responses were received from 148 link workers. They highlighted a general lack of interaction between link workers and the cultural sector about how the latter could support social prescribing. Results suggested that personal familiarity with cultural offers might prompt link workers to refer to them. Some respondents proposed that cultural offers were regarded as elitist, which deterred them from referring there. However, there was a general acknowledgement that the cultural sector could contribute to social prescribing. Link workers need to regard the cultural sector as accessible, appropriate, adequate, affordable and available before referring older people to cultural offers as part of social prescribing. Link workers may benefit from becoming more familiar with cultural sector staff and offers, including online resources, so they can then propose them to patients with confidence.

Effect of social prescribing link workers on health outcomes and costs for adults in primary care and community settings: a systematic review

OBJECTIVES

To establish the evidence base for the effects on health outcomes and costs of social prescribing link workers (non-health or social care professionals who connect people to community resources) for people in community settings focusing on people experiencing multimorbidity and social deprivation.

DESIGN

Systematic review and narrative synthesis using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach.

DATA SOURCES

Cochrane Database, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, EU Clinical Trials Register, CINAHL, Embase, Global Health, PubMed/MEDLINE, PsycInfo, LILACS, Web of Science and grey literature were searched up to 31 July 2021. A forward citation search was completed on 9 June 2022.

ELIGIBILITY CRITERIA

Controlled trials meeting the Cochrane Effectiveness of Practice and Organisation of Care (EPOC) guidance on eligible study designs assessing the effect of social prescribing link workers for adults in community settings on any outcomes. No language restrictions were applied.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, evaluated study quality using the Cochrane EPOC risk of bias tool and judged certainty of the evidence. Results were synthesised narratively.

RESULTS

Eight studies (n=6500 participants), with five randomised controlled trials at low risk of bias and three controlled before-after studies at high risk of bias, were included. Four included participants experiencing multimorbidity and social deprivation. Four (n=2186) reported no impact on health-related quality of life (HRQoL). Four (n=1924) reported mental health outcomes with three reporting no impact. Two US studies found improved ratings of high-quality care and reduced hospitalisations for people with multimorbidity experiencing deprivation. No cost-effectiveness analyses were identified. The certainty of the evidence was low or very low.

CONCLUSIONS

There is an absence of evidence for social prescribing link workers. Policymakers should note this and support evaluation of current programmes before mainstreaming.

PROSPERO REGISTRATION NUMBER

CRD42019134737.

Tailoring cultural offers to meet the needs of older people during uncertain times: a rapid realist review

BACKGROUND

Non-medical issues (e.g. loneliness, financial concerns, housing problems) can shape how people feel physically and psychologically. This has been emphasised during the Covid-19 pandemic, especially for older people. Social prescribing is proposed as a means of addressing non-medical issues, which can include drawing on support offered by the cultural sector.

METHOD

A rapid realist review was conducted to explore how the cultural sector (in particular public/curated gardens, libraries and museums), as part of social prescribing, can support the holistic well-being of older people under conditions imposed by the pandemic. An initial programme theory was developed from our existing knowledge and discussions with cultural sector staff. It informed searches on databases and within the grey literature for relevant documents, which were screened against the review's inclusion criteria. Data were extracted from these documents to develop context-mechanism-outcome configurations (CMOCs). We used the CMOCs to refine our initial programme theory.

RESULTS

Data were extracted from 42 documents. CMOCs developed from these documents highlighted the importance of tailoring-shaping support available through the cultural sector to the needs and expectations of older people-through messaging, matching, monitoring and partnerships. Tailoring can help to secure benefits that older people may derive from engaging with a cultural offer-being distracted (absorbed in an activity) or psychologically held, making connections or transforming through self-growth. We explored the idea of tailoring in more detail by considering it in relation to Social Exchange Theory.

CONCLUSIONS

Tailoring cultural offers to the variety of conditions and circumstances encountered in later life, and to changes in social circumstances (e.g. a global pandemic), is central to social prescribing for older people involving the cultural sector. Adaptations should be directed towards achieving key benefits for older people who have reported feeling lonely, anxious and unwell during the pandemic and recovery from it.