Bridging health and society

C.J., a 17-year-old female patient, attends an appointment at a primary care clinic to discuss her onset of depressive symptoms. Rather than pulling out the prescription pad, the physician employs social prescribing and connects C.J. to a link worker. After learning about what C.J. enjoys, the link worker “prescribes” non-medical resources, including a support group for young adults and dance classes.

Scenes like this might seem to be from a far-flung future yet are being played out daily in places such as Sheffield, UK. ¹ Meanwhile, in Canada, the health care system is in crisis, with unprecedented staffing shortages, long wait times, and increasing barriers to services. As of 2023, an estimated 4 million Canadians lack a primary care provider, with vulnerable populations disproportionately disadvantaged. ^2,3

In cases when primary care access is attainable, efforts might be aimed at treating a person’s disease rather than the whole person, an approach that sometimes disregards the patient’s values, needs, and life circumstances. Yet it embodies the prevailing subscription to medicalization in health care, where conditions and experiences become defined, understood, and managed through medical means. ⁴ Moving toward a more holistic model of care can allow physicians to intervene earlier and address underlying social issues, shifting the paradigm from “What is the matter with you?” to “What matters to you?”

Importance of link workers

While making this shift might seem challenging, there has been substantial movement toward integrating social prescribing into primary care. Through this practice, physicians refer patients to community resources to address critical social factors influencing their health. ^5,6 This process is typically facilitated by link workers (also known as connectors or navigators) who act as the bridge between patients and community supports. ⁶ Link workers require expertise in community resources and can be specially trained professionals; existing professionals such as social workers; community groups; or students. ⁶ Social prescribing has been successfully implemented in more than 20 countries and, as it becomes integrated into Canadian health care, we can expect improvements in chronic disease prevention and recovery and decreased health care costs. ^5,6 The use of link workers, particularly in primary care networks, could also reduce the need for physicians to stay up to date on community resources and social programs, thus lightening their administrative burden—which the College of Family Physicians of Canada identified as a major source of burnout. ⁷ According to the 2021 National Physician Health Survey, 57% of general practitioner respondents experienced burnout, representing an increase of 24 percentage points since 2017. ⁸

Mental health care strategy

Social prescribing is a strategy for addressing mental health concerns, with growing evidence supporting its positive impact. ⁹ One study examined the effect of individuals with mental health problems who participated in community groups, including football teams, reading clubs, and choirs. ⁹ The participants developed increased self-confidence and self-esteem. ⁹ For example, Anna, a participant who struggled with depression and severe isolation, described joining a gardening group as a crucial stepping stone to building the confidence she needed to lead a meaningful life. ⁹ In fact, the self-esteem Anna gained improved her employment-seeking attitude and gave her the confidence to pursue a previously daunting job application. ⁹ A similar case study tells the story of a widowed individual who experienced depression after relocating to a town in rural Canada; she was referred to a community food program by her family physician. ¹⁰ This social prescription and subsequent community support led this person to improved health, companionship, and eventually a role as a peer leader in the community food program. ¹⁰

Managing chronic disease

Awareness of social prescribing and the social determinants of health is particularly relevant to the treatment of chronic medical conditions. For example, a study found that patients living with multiple sclerosis reported lower physical and psychological burden if they had greater social support in the form of mutually beneficial relationships grounded in trust and reciprocity. ¹¹ Interventions addressing the psychosocial dimension of disease proved similarly impactful for people living with type 2 diabetes, where physician-referred community health workers helped patients to manage their disease using lifestyle, self-care, work, volunteering, social relationships, and mental well-being interventions. ¹² Subsequently, these patients saw improvements in their glycemic control. ¹²

Support at any age

Although the term social prescribing has only entered our collective vocabulary in the past decade, grassroots programs that embody its spirit have existed for some time. Arts on Prescription workshops in England, for example, have been helping adolescents at risk of emotional or behavioural problems for the past 30 years. ¹³ While the youth in this program were referred by school staff members rather than physicians, these staff members understood that the mental health challenges these youth faced could be improved through social intervention. ¹³ Adolescents in this program saw marked improvements in their mental well-being and resilience. ¹³ These findings provide credence to social prescribing’s ability to support vulnerable populations, including those with chronic physical and mental health conditions.

Canada’s growing population of older adults might also experience health concerns such as decreased social connection, mental wellness, and physical activity. However, patients living with dementia who were prescribed physical and mental well-being exercise classes once a week experienced statistically significant increases in well-being, as did their caregivers. ¹⁴ Similarly, a prospective cohort survey of older adults with chronic health conditions found that increased community involvement resulted in decreased health care costs and statistically significant improvement in health-related quality of life. ¹⁵ The Come Eat Together project, a community initiative in Durham, UK, addresses social isolation among older adults through food-related activities such as monthly lunch clubs, communal meal preparation, and transportation to the grocery store. ¹⁶ This project has demonstrated effectiveness in reducing loneliness, with 97% of participants building new friendships and widening their social networks. ¹⁶ As such, social prescribing proves to be a feasible option to improve the lives of the aging population, and programs such as Healthy Aging Alberta ¹⁷ and Links2Wellbeing ¹⁸ in Ontario have already successfully piloted this practice.

Successes and challenges

Social prescribing interventions in Canada and globally have demonstrated numerous successes, particularly in addressing mental health issues, chronic disease, and the needs of older adults, but they are not without their challenges. For instance, community projects require resources and infrastructure to continue operating, as well as consistent staffing and project leads. Further, should a primary stakeholder or project lead withdraw, there might not be a suitable backup. Rural communities without gathering spaces, such as community centres, or access to public transportation might face additional challenges to support social programs. Moreover, patients in areas of socioeconomic inequality, despite potentially having the most to gain from such programs, might be more difficult to engage due to barriers such as individuals’ previous negative experiences with public agencies.

Potential solutions to these challenges include recognizing and channeling existing community assets and involving various stakeholders in program design. Other avenues toward sustainable programming include engaging a regular pool of attendees and project leads living in the community of intervention rather than using limited-time or single-day events that might not produce lasting change. Of course, simply reproducing activity formats across different settings might not be viable due to different communities’ requirements and interests. To increase a social prescribing initiative’s likelihood of success, it is necessary to involve the community in the program design and assess resources, needs, and attitudes before implementation.

The issues of family practice time constraints, limited access to family doctors, a lack of the aforementioned link workers, and limited awareness of link workers’ roles should not be underestimated. Healthy Aging Alberta has already developed a simple curriculum to help train new link workers by teaching them about their role in the system, equity-based approaches to care, and how to build community connections to support patients. More than 82% of the workers that have completed the course felt confident in their ability to apply the knowledge and skills from this training into their day-to-day practices as link workers. ¹⁷ Furthermore, as it is not always realistic for family doctors to have access to link or social workers, existing services such as 211, a free, confidential national helpline that seamlessly connects callers to community- and government-based resources and supports, can connect patients directly to services and benefits. Finally, Canadian organizations, such as the Canadian Social Prescribing Student Collective ¹⁹ and the Canadian Institute for Social Prescribing, ²⁰ are working to increase awareness of and promote access to these services. As these groups and others continue to build a nationwide network to support social prescribing practitioners, participants, communities, policy-makers, and researchers, it is expected that our understanding of the social determinants of health will continue to grow and positively impact patient outcomes. ¹¹