Study selection
The initial search across three databases produced a total of 1866 articles. In the subsequent phase, 152 duplicates were eliminated, leaving 1714 articles for title and abstract screening. Out of these, 62 articles met the eligibility criteria based on abstract and title screening and advanced to the full-text screening stage. Among these, 47 articles were excluded because their focus was not on PHC settings or individuals with pertinent chronic conditions, and/or they lacked relevant data on social prescription. This led to a final inclusion of 15 articles for this review. The details of the screening and selection process are illustrated in Fig. 1.
Study characteristics and setting
Among the fifteen studies that were included, five were published between 2017 and 2019, six in 2021, two in 2022, and one in 2023. With the exception of one study conducted in Australia [17], all the included studies took place in the United Kingdom. The encompassed studies exhibited a range of research designs, comprising a cohort study [18], cross-sectional study [19], pragmatic study [20], mixed-method studies [8, 17, 21, 22] and qualitative studies [12, 23–29]. Table 1 presents the characteristics of these studies.
Table 1
Characteristics of the included studies
Study | Study objective | Study design | Study setting | Study population/participants | Social referral medium |
Carnes et al., 2017 [8] | i) To assess the effect of service on mental well-being and primary health care resource use and ii) To assess whether the service could be implemented as intended. | Mixed methods approach | 22 primary care general practices in London, UK | 487 patients in GPs who were frequent attenders and, or socially isolated. People were not referred if they were in acute crisis, at risk to self and/or others, had uncontrolled addictions or mental health problems. | GP referred the patients to a social prescribing coordinator. |
Moffatt et al., 2017 [12] | To describe the experiences of patients with long-term conditions involved in the link worker social prescribing programme | Qualitative study | Inner city areas in West Newcastle, UK (Most socioeconomically deprived areas) | 30 patients aged 40–74 years with one or more long term conditions | GP, practice nurse, and healthcare assistants referred to a trained link worker. |
Mistry et al., 2023 [17] | To explore the feasibility and acceptability of involving Bilingual Community Navigators (BCNs) in the general practice setting in Australia. | Mixed-method design | Sydney, Australia | 95 patients attending the general practices; 3 practice staffs; and 3 trained community health workers (BCNs) | GP referred patients to the navigator. |
Wildman & Wildman 2021 [18] | To determine whether a UK’s NHS Community Health Worker social prescribing program was associated with improved HbA1c levels among type 2 diabetes patients | Cohort study | High socioeconomic deprivation areas in Northeast England. | 8086 adults aged 40 to 74 years with type 2 diabetes | Primary care practitioner referred the patient to a link worker(CHW) |
Tierney, Wong & Mahtani 2019 [19] | To explore how 'care navigation' is interpreted and currently implemented by clinical commissioning groups (CCGs) in England | Cross-sectional survey | All clinical commissioning groups England | 147 CCGs who provided info on care navigation | Social referral medium varied and mostly included self-transfers by patients or referrals by healthcare professionals (GPs), and trained receptionists. In some CCGs, multidisciplinary teams like accident & emergencies workers, hospitals, voluntary and community sectors, and others like police, fire brigades, ambulance services, libraries, pop-up clinics in supermarkets, rehabilitation teams, dementia teams, mental health teams, carers and family members made the referrals. |
Kiely et al. 2021 [20] | To test the effectiveness of primary care-based link workers providing social prescribing in improving health outcomes for people with multimorbidity | Pragmatic study | General practices in deprived areas in Ireland. | 12 patients with multimorbidity who attend general practices in deprived areas in Ireland. 6 patients, 1 link worker and 2 GPs included in the evaluation of trial’s acceptability and feasibility. | Patients were referred to the link worker by the GPs. |
Gibson et al., 2021 [21] | To explore the complex social contexts in which social prescribing is delivered. | Qualitative | Ethnically and socially mixed urban area of North of England | Four clients aged between 40 and 74 years with at least one of eight qualifying long-term health conditions from primary care. | Patients were referred by their GPs to Ways to Wellness program. |
Frostick & Bertotti 2021 [22] | To identify the training, skills and experience of social prescribing Link Workers, working with patients with long-term conditions | Qualitative study | Three social prescribing schemes based within London and the southeast of England | 13 experienced link workers actively working on the social prescribing scheme and had been there for six months or more. | Referrals were made by GPs. |
Hanlon et al., 2021 [23] | To explore the utility of self-determination theory in improving well-being by connecting patients to appropriate community resources. | Qualitative study | General practices based on socioeconomically deprived areas of Glasgow, Scotland | 12 patients with physical, psychological, or social problems that the GPs or practice nurse felt might benefit from seeing the Community Link Practitioners (CLPs). | General practitioners or practice nurse referred patients to CLPs. Also, some patients self-referred to CLPs. |
Morris et al., 2022 [24] | To explore how people with LTCs managed their health and well-being under social distancing restrictions and self-isolation during the first wave of the COVID-19 pandemic | Qualitative study | Northeast England (ethnically diverse urban locality including urban fringes) | 44 people with one or more long-term conditions who were already part of a social prescribing intervention evaluation (Wildman et al., 2019, Moffatt et al., 2019 and Gibson et al., 2021). | Patients were referred by their primary care practitioner to Ways to Wellness program and assigned to a trained link worker. |
Morris et al., 2022 [25] | To describe changes to the social prescribing service during the first wave of the COVID-19 pandemic. | Qualitative study | Ethnically diverse urban locality (including urban fringes) in Northeast England | 44 community-dwelling adults aged 40–74 with at least one of the following long-term conditions: diabetes type 1 and 2, heart failure, coronary heart disease, epilepsy, osteoporosis, asthma, and/or chronic obstructive pulmonary disease with or without anxiety and/or depression. Additionally, 5 link workers and 8 service managerial staff | Patients were referred by their GPs to Ways to Wellness program and assigned to a link worker. |
Wildman et al., 2019 [26] | To explore experiences of social prescribing among people with long term conditions | Qualitative study | Socioeconomically deprived area of Northeast England | 24 individual aged 40 to 74 years with long-term conditions who were users of the link worker social prescribing service. | The primary care practitioner referred the patient to a link worker. |
Chng et al., 2021 [27] | To explore the implementation process of social prescription approach involving primary care-based 'link workers'. | Qualitative study | Seven general practices in deprived areas of Glasgow, Scotland over two years period. | Participants were practice staff with responsibility for leading the Link Worker Programme (lead General Practitioners, Community Link Practitioners, and practice managers) and community organisation workers identified by Community Link Practitioners. Number of participants varied in different phases. | Referrals were made by General Practitioners. |
Hazeldine et.al., 2021 [28] | To describe the experiences of early implementation of link worker social prescribing; to assess how this series of relationships functions; and identify the key barriers and facilitators experienced on the ground. | Qualitative study | Southwest of England | 11 link workers, 2 link worker managers and 1 counsellor | GPs referred patients to link workers. |
Wildman et al., 2019 [29] | To explore link workers self-definitions of their roles in social prescribing and self-identified skills and qualities necessary for effective client linkage. | Qualitative study | Social prescribing scheme in a socioeconomically deprived area of Northeast England | 15 participants, aged 40 to 74 years, with long-term conditions who were SP service users participated in FGD. | Patients were referred to the CLP by GPs, practice staff or could self-refer. |
The included studies showcased a wide array of study settings. Most of the studies were conducted within areas marked by socio-economic deprivation [8, 12, 20, 23, 26, 27]. One study was conducted on PHC practices within the National Health Services (NHS) [18], while another study was housed within NHS’s Clinical Commissioning groups in England [19]. The Australian study [17] specifically targeted individuals from culturally and linguistically diverse backgrounds, with a particular emphasis on the Chinese and Samoan communities residing in Sydney. Additionally, three of the studies [21, 24, 25] were executed in ethnically diverse and urban localities, including urban fringes. One study [28] was conducted within marginalized communities, while three other studies [17, 22, 29] occurred in communities displaying diversity in ethnicity, gender, and age.
Operational definition
The term social prescriber used in this study represents diverse titles held within the included studies, such as community link practitioners [23, 27], link workers [8, 12, 18, 20–26], support workers [19], social prescribing coordinator [8] and bilingual community navigators [17].
A. Social prescription: intended recipients, social prescribers, referral and follow-up pathways
The intended recipients of social referrals displayed variability across the studies, with specific criteria employed to identify individuals who could potentially benefit from the programs. Most of the studies explicitly focused on individuals aged between 40 and 74 years who had chronic conditions [12, 17, 19, 24–26]. The chronic conditions reported encompassed type 2 diabetes, COPD, cardiovascular diseases, chronic liver conditions, respiratory diseases, and multimorbidity.
In all of the studies, the pathways for referral to social prescribers were made by GPs within the PHC setting [8, 12, 17–29]. In two studies [23, 29], individuals either self-referred or were referred by general practice staff. One study [19] under the NHS Clinical Commissioning Groups program employed a diverse range of approaches for social prescription, including self-referral and referrals through trained receptionists, accident and emergency workers, hospitals, volunteers, community members etc.
In terms of follow-up, in four studies [12, 17, 21, 25], social prescribers established connections with individuals by scheduling appointments at GP practices, cafes, community centers, participants' homes, council centers, and sometimes via telephone, email, and text. In one study [24], individuals involved in the social prescription intervention maintained contact with social prescribers through digital platforms and telephones.
B. Existing social prescription initiatives for people living with chronic long-term conditions
Social prescribers played a pivotal role in supporting and directing individuals with chronic conditions towards a variety of programs designed to enhance interactions, motivation for action plans, and access to essential services [8, 17, 21, 23]. These efforts assisted individuals in rediscovering past interests and fostering the formation of groups centered around new shared passions [21, 23]. One illustrative example of such initiatives was connecting individuals with diabetes to local gym facilities, weight management programs, and diverse activity groups like walking, healthy eating, and breathing exercises, effectively promoting a healthy lifestyle [12, 20, 21, 26]. Furthermore, individuals with chronic disease dealing with mental health challenges and social isolation engaged in an array of community-based activities such as gardening, fishing, crafts, and participation in voluntary groups, alongside arts-focused endeavours like choirs and art therapy [12, 21, 26].
Social prescribers aided with medical appointments, paperwork, and offered information about local resources, including social benefits and transportation [17]. They provided emotional support through active listening and empathetic understanding [17]. Diverse strategies were employed to help those facing financial challenges, including providing financial guidance, connecting individuals with charitable and support groups, offering welfare advice, and providing employment assistance [12, 21, 26]. Additionally, social prescribers linked economically disadvantaged individuals with food banks, supplying food vouchers [21]. Amid the COVID-19 pandemic, social prescribers leveraged digital tools, including telephone calls and social media, to distribute exercise resources and coordinate food delivery [24, 25]. In addition to patient-centered work, social prescribers developed referral pathways by actively building networks and collaborating with local organizations and organized shared learning events to strengthen both new and existing community connections [8, 17, 27]. Figure 2 illustrates the social prescription interventions catering to people living with chronic long-term conditions.
C. Opportunities and challenges for implementing social prescribing intervention
The primary outcomes related to the implementation of social prescription interventions in the included studies were categorized into two overarching themes: the opportunities and the challenges of enacting social prescribing initiatives. Each of these themes was further subdivided into distinct subthemes described below.
Within the framework of this review, opportunities refer to the set of circumstances or factors that enabled the implementation and utilisation of social prescriptive initiatives. Similarly, challenges are denoted as the issues or obstacles encountered by stakeholders (including healthcare providers and patients) while implementing and using social prescription initiatives. Figure 3 provides a visual representation of the opportunities and challenges of implementing social prescription interventions, and the subsequent sections delve into comprehensive explanations of each sub-theme.
Opportunities for implementing social prescribing intervention
i. Interpersonal relationships and trust between social prescribers and service users
Establishing a strong and trusted relationship between social prescribers and individuals with chronic conditions is pivotal for effective social prescribing and greater engagement in social prescription initiatives [17, 20, 22]. Social prescribers serve as key advocates, addressing the clinical and non-clinical needs of those with chronic conditions [12, 17, 19, 21, 23–26], motivating and boosting confidence, and promoting referrals to necessary health and well-being services [8, 12, 17, 18, 21, 23–26]. These prescribers adeptly cultivate open and trustworthy bonds with service users, even offering counseling during bereavement [17, 23, 25] and promoting social engagement [21]. Notably, their strong interpersonal skills and attentive listening [17, 26] foster trust with service users, resulting in increased satisfaction and reduced complaints. Key attributes such as face-to-face interactions, interaction quality, trustworthiness, friendliness, empathy, non-judgmental demeanor, motivational support, and clear communication of potential risks and benefits by social prescribers were valuable facilitators of social prescription initiatives [8, 18, 23]. Furthermore, the prompt adaptation of interventions to assist vulnerable populations during the COVID-19 pandemic not only bolstered social prescribers' relationships with patients but also with health care professionals and community organizations [22, 25].
Addressing the feedback received from individuals with chronic conditions emerged as a pivotal factor in constructing trust and nurturing a value-centered relationship between social prescribers and service users [22]. Community-based connections and local familiarity played a crucial role in boosting social capital and encouraging proactive engagement in activities, thereby motivating commitment towards investing in health [21]. A study from Australia [17] highlighted the importance of recruiting and involving social prescribers from the local community to cultivate patient trust.
ii. Adopting a holistic approach to provide support
Participants noted that social prescribers tailored services to their individual needs [12, 18, 21, 23–26], resulting in feelings of satisfaction, enjoyment, and motivation from engaging in social prescription interventions [17, 18, 23, 26]. Moreover, offering motivation, encouragement, and support to access specialized health services fortified individuals' confidence and ability to manage their health issues [17, 26]. For those with diabetes, prescribers fostered confidence through consistent engagement in gym and walking groups, blood sugar management via food choices and healthy eating advice, leading to physical health improvement [12, 21, 23]. Furthermore, a systematic approach involving needs assessment, motivational interviewing, connection to local preventive health services (e.g., local physical activity groups, specialized dieticians, etc.) and action planning proved effective in enhancing healthy lifestyles and self-care among patients [12, 17, 20, 25].
During COVID-19, the provision of food bank vouchers from social prescribers increased the access to government financial support, aiding the maintenance of a healthy lifestyle [24]. Additionally, social and emotional support, bereavement counselling, addressing traumatic disruptions, and health condition follow-ups by social prescribers played a crucial role in prioritizing health during the pandemic [17, 25]. Similarly, social prescribers offered referrals to diverse community initiatives such as welfare rights, employment support, housing advice, and health and lifestyle support, potentially elevating people's living standards [17, 18, 26]. In Australia, social prescribers guided individuals with chronic conditions in understanding the Australian health system, booking appointments, preparing for attendance, and ensuring necessary follow-ups [17]. A study underscored how favourable economic positions of individuals with chronic conditions facilitated engagement in interventions, allowing more time for managing chronic conditions [21].
iii. Application of digital technology
Using digital platforms and social media, such as telephone, email, and text services, social prescribers facilitated social prescribing programs [12, 24]. For example, people employed digital and social media for exercise by following DVD instructions [24]. Amid the COVID-19 pandemic, service users connected with social prescribers via phone, email, or social media, often having video chats to discuss their needs. This depicts the important role of social prescribers in offering emotional support via digital platforms, especially for those grappling with complex health issues during challenging times [17, 23, 25].
iv. Competency of social prescribers
Social prescribers underwent training aimed at establishing connections and networks, with variations in training type and duration across studies. In one study, social prescribers received training in behaviour change methods to deliver personalised services based on patient goals and priorities, using a holistic well-being approach [12]. Other approaches included individual assessment, motivational interviews, action plans, facilitating access to community services, fostering trust-based bonds, promoting behavioural change for a healthy lifestyle, and imparting techniques for decision-making [8, 12, 17, 20, 22, 26, 29]. Training also encompassed mental health first aid and motivational interviewing to support chronic disease individuals with psychological issues [22] as well as arranging specialized appointments [17, 19]. Additionally, support for social prescribers included monthly manager supervision, interactive learning sessions, logbook maintenance, informal knowledge sharing, and peer discussions for knowledge updates and upkeep of the community directory of activities and resources [17, 28]. Social prescribers' previous work experience with the community facilitated program implementation in some instances [17, 28]. Two studies mentioned about the use of social needs screening proprietary tool “Well-being Star” on various domains such as lifestyle, self-care, symptom management, work and volunteering, money, living conditions, social relationships, and mental well-being by social prescribers [18, 26].
v. Collaborative partnership with primary health care
A shared understanding of the roles of social prescribers among GPs and service staff helped social prescribers to effectively connect those with chronic conditions to non-clinical services [17, 27]. Pre-existing supportive informal networks and healthy team relationships among practice staff motivated social prescribers, fostering efficient collaborative work [17, 27]. Many practices often allocated dedicated spaces (practice rooms, waiting rooms for patients, and logistical arrangements) for social prescribers within their practice and invited prescribers to staff meetings, further enhancing effective collaborative work [17, 20–22, 28]. In many studies, GPs' high commitment to identifying and connecting needy patients with social prescribers was crucial for the success of social prescription [17, 20]. This commitment significantly shaped the team culture within practices, integrating social prescribers effectively into the practice team. Notably, one study highlighted that providing social prescribers access to client management databases enabled them to gather patient-related information and prepare to offer support [20].
vi. Clinical leadership
Social prescribers and health care providers highlighted that supportive leadership from general practice managers and commissioners had an impact on the delivery of social prescribing. These leaders contributed to aspects like recruiting social prescribers and establishing referral pathways for social prescribing initiatives [12, 23, 26, 28].
vii. Availability of local community resources and partner organizations
In every study, researchers acknowledged the significance of accessibility to local community resources and the importance of partner organizations in delivering social prescription services [8, 12, 17–29]. In a few studies, the practice of monthly primary care meetings involving social prescribers facilitated exchange of valuable information regarding existing resources and services, aiding social prescribers in compiling a comprehensive list of available resources/services [17, 20].
Challenges for implementing social prescribing intervention
i. Accessibility and utilisation barriers
Barriers such as adverse economic conditions, travel-related time and costs [18], limited internet access [25], and minimal digital literacy [25] impeded the accessibility and utilization of social prescriber services [8, 21]. Additionally, short intervention periods [12], unsafe intervention environments [18], unavailability of desired services [23, 25], strict schedules and inconvenient timing [18] were all identified as barriers. Engagement in social prescription programs was also challenged due to the unavailability of programs tailored to specific ages and genders, as young participants were directed to interventions designed for older individuals, and there was a scarcity of gender-specific exercise sessions [26]. Similarly, language barriers hindered service use for the black and minority ethnic groups. Culturally inappropriate services were also noted as a barrier, with participants facing challenges in adapting their diets and lifestyles to Westernised healthy eating practices [26].
ii. Ineffective communication and lack of shared understanding
Communication gaps, including irregular or absent contact with social prescribers [24–26], a lack of understanding of social prescription services among health care providers, social prescribers, and patients [8, 17, 22], and insufficient communication from the council regarding interventions [24] hampered the utilization of social prescription services. Participants also emphasized the significance of in-person interactions as more enjoyable than remote communication via phones or text, the latter leading to decreased motivation for engagement in the interventions [25]. Social prescribers noted that referred patients often lacked awareness of the reasons for seeing a social prescriber [17] and faced challenges in building rapport and practicing therapeutic skills remotely [25]. In three studies [17, 22, 28], social prescribers expressed dissatisfaction with unclear information received from GPs, potentially leading to inappropriate referrals and decreased effectiveness of the intervention. One study [17] highlighted the importance of GPs conducting more thorough patient screenings in relation to required services before making referrals to social prescribers to prevent overwhelming workloads and increased waiting times for services.
iii. Impact of staff shortage and turnover
The continuity of individuals' participation in programs was disrupted by the replacement of older social prescribers with new ones [24, 26]. Those with chronic conditions faced challenges in maintaining their health and well-being due to interruptions in support from exiting prescribers and establishing communication with new ones [25, 26, 28]. Apprehension about reaching out to new social prescribers hindered smooth progression in the program [24]. Moreover, inconsistent intervention delivery approaches among social prescribers also impeded service utilization [25]. One study [28] pointed out that short-staffing, stemming from staff allocations to various ongoing programs within the organizations, impacted social prescription delivery, and the scarcity of resources made recruiting new staff challenging.
iv. Unsupportive working environment and burnout
Social prescribers noted an unsupportive working environment, insufficient support from practice staff, limited unity in the leadership, strained team relationships, and fewer learning opportunities as barriers to effective intervention delivery [27, 28]. Furthermore, they conveyed that GPs frequently misunderstood the scope of their roles and responsibilities, leading to an additional workload being shouldered by them [22]. This is echoed in several studies that also identified burnout issues among social prescribers [17, 27, 28].
v. Inadequate training and capacity building of social prescribers
Social prescribers have recognised their inadequate training to assess comprehensive needs and the referral process, which restricts their ability to address broader determinants of health [28, 29]. Inadequate supervision, both insufficient and ad hoc, was noted by coordinators, link workers, and service delivery personnel, which impeded effective service delivery [27, 28]. Moreover, the limited capacity of social prescribers to identify suitable services and the challenges in maintaining connections with community organizations have hindered the successful implementation of social prescription interventions [17, 28]. In certain studies, participants expressed that some social prescribers had limited or no healthcare background and lacked familiarity with culturally specific services to assist patients [17, 25]. Many studies highlighted the importance of developing the skills and capacity of social prescribers to effectively address patients' intricate physical and mental health issues, as well as to identify contextual changes in their lives that influence their well-being [21, 22, 25].
vi. Unaware of the existence and benefits of social prescribing initiatives
Individuals with chronic conditions felt overwhelmed by referrals, citing concerns about their appropriateness and time commitments [8, 25]. In two separate studies [8, 25], certain participants with chronic conditions were unaware of the existence and benefits of social prescribing initiatives. In another study, many of the referred individuals didn't receive the necessary support due to conflicting priorities and the considerable distances to service centers. In one study [20], patients misunderstood the term "prescribing" as medication-related, causing confusion.
vii. Time management struggles
Social prescribers have indicated that balancing their social prescribing responsibilities with other tasks, such as devising strategic plans for individuals with special needs and complex health conditions, proves to be time-consuming [17, 20, 22, 27]. This complexity hampers their ability to stay visible to GPs and raise awareness of the service's existence among practice staffs [22]. Furthermore, individuals grappling with issues such as anxiety, depression, and family bereavement demand specialized plans, further stretching the time allocation for social prescribers and presenting an additional challenge [21]. Additionally, the task of mapping local services and establishing connections with service providers, essential for addressing individuals' health and social needs, requires a significant investment of time and resources [20].
viii. Engagement challenges for individuals with multiple chronic conditions
Among individuals dealing with multiple chronic conditions and compromised mental well-being, reasons for disengagement were frequently observed [12, 18, 26]. This group faced a range of challenges, including communication-related anxiety [18, 23], lacked confidence [18, 26], faced social isolation [12, 23, 26, 28], and a perceived sense of dependence on social prescribers. For those with multiple chronic conditions, maintaining consistent participation in activities posed a considerable challenge, resulting in increased absenteeism and higher dropout rates [12].
ix. Coordination and collaboration challenges
Studies show that insufficient collaboration and coordination among service providers, link workers, and clients have hindered the successful implementation of social prescribing initiatives [17, 18, 26]. Chng, et al.'s study emphasized problematic team dynamics, especially between administrative and GP staff, along with difficulties in maintaining connections with community organisations, impacting the effectiveness of social prescribing programs [27]. GPs also noted a lack of coordination between administration and health professionals, including social prescribers, impeding the development of a contextually suitable strategic framework [27].
x. Lack of application of need assessment tools
In general, a lack of clarity regarding screening tools for evaluating social needs and guiding appropriate social referrals was observed across the majority of studies. A solitary study from Australia [17] made a reference to the utilization of needs assessment/problem identification by social prescribers; however, the specific types of needs assessed in this context remained unclear. The struggle of social prescribers to effectively refer service users to activities and resources stemmed from limited information about local options [17]. Multiple studies also emphasised the need for a clear implementation plan and process indicators, facilitating the effective delivery and evaluation of social prescribing initiatives [17, 19, 27, 28].
xi. Funding and resource constraints
A predominant issue revealed by most studies is the insufficiency and instability of funding, which emerges as a major barrier to the effective execution of social prescription programs. This scarcity of resources or funds further obstructs the recruitment and retention of skilled social prescribers. Moreover, GPs voiced concerns regarding the existence of unstructured programs constrained by limited time and funding. One study noted the impact of these challenges on the roles of both GPs and social prescribers in fulfilling their respective responsibilities [17].