Building self-determination through the lens of the Circle of Courage: a qualitative evaluation of a social prescribing program for children and youth in Canada

Abstract

Background

Social prescribing is gaining traction globally as a means to achieve global goals for health and wellbeing. In 2023, we launched a social prescribing program in a comprehensive, pediatric integrated health and social service hub in an underserved inner city neighbourhood in Ottawa, Ontario, Canada. The program targeted children and youth with poor social health, including social isolation and loneliness. Program participants were paired with a connector, who worked with them to explore their individual needs, strengths, and interests. Together, they created a social prescription for a child and youth-friendly community activity. The connector then provided a supported referral to aid the program participant in successfully completing their social prescription. The program was piloted at the hub over a period of ten months, during which time a program evaluation took place. As part of our program evaluation, we sought to explore the concept of self-determination, which is thought to be one of the guiding principles of social prescribing. While self-determination has been explored in adult social prescribing, it has not yet been examined in child and youth social prescribing. Thus, the aim of this evaluation was to explore the ways in which our social prescribing program may foster self-determination in children and youth.

Methods

A qualitative descriptive design was employed. Between November 2023 and February 2024, semi-structured interviews were conducted with 33 program participants and 30 caregivers at the six-month mark of enrollment in the program. Interview questions centered around program participants’ and caregivers’ experiences of the program. Interviews were audio recorded, transcribed verbatim, and anonymized. Using the Circle of Courage – a child and youth-focused theory on self-determination, we conducted deductive thematic analysis.

Results

The findings indicated that the program may foster self-determination through each component of the Circle of Courage: (1) Independence: The child’s free will is nurtured by increased responsibility; (2) Belonging: The universal longing for human bonds is nurtured by relationships of trust; (3) Mastery: The child’s inborn thirst for learning is nurtured; and (4) Generosity: The child’s character is nurtured by concern for others.

Conclusion

This evaluation has shed light on the ways in which social prescribing may foster self-determination in children and youth. The Circle of Courage may be a useful framework to explore the impact of other child and youth social prescribing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-025-03066-8.

Background

It was almost three centuries ago that Benjamin Franklin famously proclaimed that “an ounce of prevention is worth a pound of cure” [1], and his words still ring true to this day. Across the globe, there is growing realization of the inadequacies of modern health care systems – more accurately described as sick care systems that wait for people to get sick and then treat them rather than trying to stop them from getting sick in the first place, which calls for a shift towards true health care systems that prioritize prevention and health promotion [2]. Social prescribing is gaining traction globally as a particularly powerful way of doing so [3]. Social prescribing is “a means for trusted individuals in clinical and community settings to identify that a person has non-medical, health-related social needs and to subsequently connect them to non-clinical supports and services within the community by co-producing a social prescription – a non-medical prescription, to improve health and wellbeing and to strengthen community connections” [4, p. 9]. Social prescriptions are personalized, in that they are tailored to individual needs, strengths, and interests [5]. Examples include supports for basic needs, physical activity, arts and culture programs, social activities, time in nature, and volunteer opportunities. By shifting the focus from treating illness to promoting wellness, this holistic approach to health and wellbeing aims to advance health equity, enhance both participant and provider experience, reduce costs, and improve population health [3, 6], which comprise the Quintuple Aim – an internationally recognized framework for optimizing health system performance [7].

One of the guiding principles of social prescribing is a concept called self-determination [3]. Self-determination refers to having the ability to make one’s own choices and feeling a sense of control over one’s life [8]. As one of the core dimensions of quality of life [9], self-determination promotes positive outcomes in areas such as health and wellbeing, employment, education, income, and community participation [10]. Self-determination develops throughout the life course [11], but its establishment in childhood and adolescence is particularly important [12]. This is due to the critical role that self-determination plays in positive child and youth development, which ultimately lays the foundation for thriving in adulthood [13].

There are a number of theories that have been used to underpin social prescribing, with Self-Determination Theory (SDT) being one theory that has been used to explain how social prescribing generates positive outcomes [14]. SDT posits that self-determination is associated with optimal motivation and greater health and wellbeing, and that self-determination requires the satisfaction of three psychological needs: 1) Autonomy: The need to feel control over life and decisions; 2) Relatedness: The need to have meaningful relationships and to feel a sense of belonging; and 3) Competence: The ability to influence outcomes and to be capable and effective [15]. Beneficence – the ability to give and to make a positive impact on others, has been proposed as a fourth psychological need [16].

SDT has been used to understand the ways in which social prescribing builds self-determination in adults [8, 17]. However, to our knowledge, self-determination has not yet been explored in social prescribing for children and youth. There is a limited, albeit promising, evidence base around child and youth social prescribing that demonstrates benefits to service user health and wellbeing, healthcare and community resource use and cost, and service user and stakeholder experiences [18]. While self-determination has not been an explicit focus of studies on child and youth social prescribing to date, the concepts that comprise SDT have surfaced in the literature. This calls for purposeful exploration of self-determination in child and youth social prescribing.

As part of our program evaluation of our child and youth social prescribing program, we set out to examine the key concepts that comprise SDT by using an equivalent, child and youth-focused theory, called the Circle of Courage [19–21], to explore this phenomenon in children and youth. The Circle of Courage posits that children and youth have four universal needs:

1. Independence (akin to autonomy in SDT): The child’s free will is nurtured by increased responsibility so that the child can say, “I have power to make decisions”;

2. Belonging (akin to relatedness in SDT): The universal longing for human bonds is nurtured by relationships of trust so that the child can say, “I am loved”;

3. Mastery (akin to competence in SDT): The child’s inborn thirst for learning is nurtured and by learning to cope with the world the child can say, “I can succeed”;

4. Generosity (akin to beneficence in SDT): The child’s character is nurtured by concern for others so that the child can say, “I have a purpose for my life” [19–21].

The Circle of Courage is grounded in the wisdom of Indigenous peoples and modern scientific thought [19–21]. Since time immemorial, Indigenous communities have embraced sophisticated child-rearing strategies that are designed to nurture courageous children. This includes encouraging children to make decisions, solve problems, and show personal responsibility (Independence); treat others as kin (Belonging); respect those with more experience, learn through observation and listening, and value personal growth over competition (Mastery); and unselfishly give to others (Generosity). The Circle of Courage integrates these traditional values with contemporary research on positive child and youth development. By bringing together Indigenous and Western ways of knowing, the Circle of Courage embodies the spirit of two-eyed seeing – a term coined by Mi’kmaw Elder Albert Marshall that refers to “learning to see from one eye with the strengths of Indigenous ways of knowing and from the other eye with the strengths of Western ways of knowing and to using both of these eyes together” [22, p. 335]. Through the combined strength of both knowledge systems, the Circle of Courage offers a useful lens through which to examine self-determination in child and youth social prescribing. Thus, the aim of this evaluation was to explore – through the lens of the Circle of Courage, the ways in which our social prescribing program may foster self-determination in children and youth.

Methods

Design

A qualitative descriptive design was employed [23]. Semi-structured interviews were conducted with program participants and caregivers to gain insights into their experiences of the program.

Setting

The social prescribing program took place in a comprehensive, pediatric integrated health and social service hub that was situated within a community services centre based in Ottawa, Ontario, Canada. The former Vanier Social Pediatric Hub served children and youth who were 0 to 17 years of age, experiencing complex psychosocial issues, and either living or going to school in the Vanier neighbourhood, which is one of the most socioeconomically deprived communities in Ottawa [24]. This richly diverse urban neighbourhood falls in the quintile of highest socioeconomic disadvantage on the socioeconomic index, with a high prevalence of unemployment, low income, housing insecurity, low educational attainment, and crime, as well as a high proportion of Francophone minoritized groups, immigrants and refugees, and ethnic and racial minority groups among its 18,000 residents. The hub embraced the community social pediatrics model that was developed by Montréal pediatrician, Dr. Gilles Julien [25]. Social pediatrics is “a global, holistic, and multidisciplinary approach to child health – it considers the health of the child within the context of their society, environment, school, and family, integrating the physical, mental, and social dimensions of child health and development as well as care, prevention, and promotion of health and quality of life” [26, p. 106].

Program

Under the community social pediatrics model, the hub team was already providing a holistic model of care. However, due to the socioeconomic challenges faced by the families presenting to the hub, the hub team found that they were spending most of their time addressing urgent basic needs of the caregivers like housing instability and food insecurity. The hub team saw the need to augment this crucial work with an offering that was focused on the personal dreams and wishes of the children and youth themselves. This led to the launch of a social prescribing program that was piloted at the hub over a period of ten months (May 2023 to February 2024) with the aim of promoting the health and wellbeing of the children and youth. The program was delivered in both official languages of Canada (English and French). There was a strong health equity focus to the program, with two key features being that the program targeted populations experiencing inequities and mitigated financial barriers such that families did not have to pay out of pocket for the social prescriptions.

Entry into the social prescribing pathway began at regular hub appointments, wherein children and youth presented to the hub with their caregivers for assessment of their medical and social needs with the hub team. Those who were identified as having poor social health were eligible to participate in the social prescribing program. Once the hub team obtained consent from the caregiver and assent (ages 4–11)/consent (ages 12–17) from their child to participate in both the social prescribing program and the program evaluation, a referral was made to the program. The following reasons for referral were accepted for entry into the program: (1) Feeling socially isolated; (2) Feeling lonely; (3) Lack of social skills; (4) Lack of involvement in social activities; (5) Lack of participation in opportunities in the community; (6) Experiencing financial and/or transportation barriers to community engagement; and (7) Poor sense of community belonging. Upon being referred to the program, the child was assigned to a connector. The program had three connectors, all of whom were hub staff. The child-connector dyad met within one to two weeks and then every few weeks thereafter, either at the hub, over the phone, in the home, or in the community – wherever the family preferred. Each session was up to one hour in length. As a key part of the sessions, the connector worked with the child to explore their individual needs, strengths, and interests. By using the information that was gathered through this process to inform decision-making, the child-connector dyad co-produced a social prescription for a child and youth-friendly community activity. There were six different types of social prescriptions: (1) Arts and Culture; (2) Physical Activity; (3) Time in Nature; (4) Career Exploration; (5) Practical Skills; and (6) Entertainment and Leisure. Social prescriptions were written on a social prescription pad, and after being signed by both the child and connector, they were handed to the child in the same way that a medical prescription would be. The connector provided a supported referral and met with the child on an ongoing basis to offer encouragement and motivation, build rapport, monitor progress, and co-produce additional social prescriptions as needed. Through a feedback loop, the connector reported back to the rest of the hub team. Everything was documented in the electronic medical record, including referrals, sessions, and social prescriptions. The program is described in greater detail elsewhere [27].

Participants

This evaluation consisted of a convenience sample of families involved in the social prescribing program. All program participants and caregivers were eligible to participate.

Recruitment

Hub staff contacted families by phone to inform them about the opportunity to participate and to schedule an interview date and time for those who wished to participate.

Data collection

At the time of enrollment in the program, caregivers completed an intake form on behalf of their child. Sociodemographic information collected through the form included age, gender identity, mother tongue, official language preference, country of birth, newcomer status, ethnicity/race, disability status, annual household income, and household composition.

Between November 2023 and February 2024, semi-structured interviews were conducted with program participants and caregivers at the six-month mark of enrollment in the program. To mitigate the risk of interviewer bias and response bias, the interviews were conducted by medical trainees (VD, ES, IF, AB) who were not involved in the clinical care of the program participants nor the program development or implementation except for the work they did behind the scenes to assist the connectors in arranging the social prescriptions. Given the wide age range and developmental diversity of program participants, two interview guides were developed – one for 4 to 7-year-olds (Supplementary Material 1) and one for 8 to 17-year-olds (Supplementary Material 2), with discretion given to the interviewers to select the most appropriate interview guide based on age and developmental ability. The interview guide for 4 to 7-year-olds had a corresponding interview activity (Supplementary Material 3). The interview activity was a drawing exercise, whereby the child was asked to draw pictures of their connector and any social prescriptions they participated in. The drawings were used as an elicitation tool, as drawing is known to support memory performance and facilitate communication in interviews with children [28], particularly young children [29]. A separate interview guide was developed for caregivers (Supplementary Material 4). The development of the interview guides was informed by the Common Understanding of Social Prescribing (CUSP) conceptual framework [4] and child and youth-centered resources, including a report from the Social Prescribing Youth Network on what to assess in child and youth social prescribing [30] and a collection of sample interview questions from YouthREX (Youth Research and Evaluation eXchange) [31]. Interview questions centered around program participants’ and caregivers’ experiences of the program. Interviews were conducted in either English or French and occurred either in person at the hub or over the phone. Family members were interviewed one at a time, while remaining together in the same room or on the same phone call. Each interview took approximately 20 min. Interviews were audio recorded, transcribed verbatim, and anonymized.

Data analysis

Sociodemographic data were analyzed using Microsoft Excel. Following the approach set out by Braun and Clarke [32], qualitative data were thematically analyzed, with data management supported by NVivo. This involved taking the following six steps: (1) Familiarizing oneself with the data; (2) Generating codes; (3) Searching for themes; (4) Reviewing themes; (5) Defining and naming themes; and (6) Producing a report [32]. A deductive thematic analysis approach was employed, which is characterized by Braun and Clarke [32] as a top-down, theory-driven approach that involves using a pre-existing theoretical framework to guide coding and theme development. In this case, the Circle of Courage [19–21] was used as a framework to map the data, meaning the four concepts that make up this theory – independence, belonging, mastery, and generosity, were used to examine the data. The lead investigator (CM) analyzed the data and presented the findings to the senior investigator (SB) to verify the accuracy of the analysis.

Ethical considerations

The evaluation was conducted in accordance with the Declaration of Helsinki. Since this work was conducted as part of a program evaluation, it was deemed to be a non-research activity and was therefore exempt from ethics approval by the Children’s Hospital of Eastern Ontario (CHEO) Research Ethics Board. Informed consent, both written and verbal, was obtained from the families involved in this evaluation. Families received a $25 CAD gift card as a token of appreciation for their time.

Results

Semi-structured interviews were conducted with 30 families, including 33 program participants and 30 caregivers. There were 33 families and 43 program participants in the pilot, meaning the recruitment rate for this evaluation was 91% and 77%, respectively. There were no notable differences between those who participated in the evaluation and those who did not. As outlined in Table 1, 67% of program participants were 8–12 years of age (average = 10 years of age), 55% were male, 33% had a mother tongue that was not one of the official languages of Canada (English and French), 30% were Francophone minoritized groups, 39% were born outside of North America, 30% were newcomers (immigrant or refugee in Canada < 5 years), 85% were ethnic and racial minority groups, and 73% had a disability (e.g., attention deficit hyperactivity disorder, autism spectrum disorder). As outlined in Table 2, program participants came from families facing multiple socioeconomic challenges, with 60% of families reporting an annual household income of $39,999 CAD or less and 53% classifying themselves as a single caregiver household. As shown in Fig. 1, qualitative data analysis revealed the ways in which the experiences of the families in the social prescribing program linked to each component of the Circle of Courage.

Table 1.

Program participant characteristics (N = 33)

Characteristic	N	%
Age
4–7	3	9.1
8–12	22	66.7
13–17	8	24.2
Gender identity
Male	18	54.5
Female	15	45.5
Mother tongue
Arabic	4	12.1
English	13	39.4
French	9	27.3
Other	7	21.2
Official language preference
English	21	63.6
French	10	30.3
Both	2	6.1
Region of birth
Africa	4	12.1
North America	20	60.6
Middle East	9	27.3
Newcomer status
Yes	10	30.3
No	23	69.7
Ethnicity/race
Asian	4	12.1
Black	14	33.3
Middle Eastern	6	18.2
White	5	15.2
Other	4	12.1
Disability status
Developmental Disability	13	39.4
Learning Disability	4	12.1
Mental Disability	4	12.1
Physical Disability	3	9.1
None	9	27.3

Table 2.

Family characteristics (N = 30)

Characteristic	N	%
Annual household income (CAD)
$0–19,999	10	33.3
$20,000–39,999	8	26.7
$40,000+	5	16.7
No response	7	23.3
Household composition
Single caregiver	16	53.3
Multiple caregivers	14	46.7

Fig. 1.

Key themes identified with the Circle of Courage [19–21]

Independence

The findings indicated that the social prescribing program may foster independence in program participants. This pertains to the first component of the Circle of Courage, whereby the child’s free will is nurtured by increased responsibility so that the child can say, “I have power to make decisions” [19–21]. Families shared experiences of independence and how it was cultivated through the child’s engagement with their connector and their social prescription.

With respect to the connector, independence was promoted through the ‘what matters to you’ conversation and the co-production of the social prescription – both hallmarks of social prescribing. Program participants shared what this looked like and how much they enjoyed it.

“[My connector and I] had a nice sit down to talk about what could interest me, and we talked about like what things could be done with each thing, and we kind of looked at it together to decide what to do.” – Participant (age 14).

Program participants spoke positively about the fact that their connector gave them the power to make decisions. One participant (age 14) shared, “I felt like I was really like heard, and it was good like talking about what different options were within my interest that I could do.” Caregivers also spoke about this. A caregiver of an 8-year-old child remarked, “It was just [my child] that said what she wanted, and [the connector] allowed her to make the decisions.” Caregivers appreciated the fact that it was their child’s voice, not their own, that was heard.

“I like that I wasn’t really a part of it. So that it was [my child’s] voice completely that was heard. I was there just to say yes though, like, and then I was a part of communicating logistics and emails went through me, but what her interests were and stuff I liked that it was done without me in the room, so that it was just not my two cents getting in there, it was just on, on [my child] sharing completely and I liked that.” – Caregiver of 14-year-old child.

Caregivers pointed out the importance of the sense of autonomy that was nurtured in their child through the program, emphasizing that this was unlike what they experienced in everyday life, where they had no control. They noted the significance of their child having autonomy.

“[My child] loves coming here. You know why? People listen. They listen to his story. They listen to him. I think that’s a big part of it. Listening. The children have a voice. That’s the thing. They have their reign. Cause you know children in [my child’s] situation never have control over anything. So when they can have that control, even if it’s only in one place, it’s good. It’s good for them. At least they can have control of that.” – Caregiver of 15-year-old child.

For program participants, this experience came as a pleasant surprise. They spoke of how unexpected it was and how much they appreciated it. One participant (age 12) shared, “I really liked that [my connector] actually did what I actually wanted. I was not expecting that.”

Besides the connector, families perceived that independence was cultivated through the child’s social prescription, which helped to create healthy boundaries between child and caregiver. Caregivers spoke of how their child’s social prescription helped both child and caregiver get out of their comfort zone by putting them in a situation where they had to be without one another.

“[My child] was having a bit of anxiety at first, but [the dance teachers] were so welcoming. And the first day I was able to stay with her the whole class, but then they said, ‘No mommies allowed’, so that helped with her like separation anxiety from me. Because she’s super close to me. I’m her comfort, I’m her safe zone, and she really sticks to that. Our rope is very close, and we’re just trying to make it a little longer.” – Caregiver of 8-year-old child.

Looking at the bigger picture, caregivers also highlighted that the beneficial impacts of the program on their child’s independence extended beyond the program itself to everyday life. They spoke of how their child was doing more on their own at school and at home.

“I feel like [my child] is actually participating more in school…[my child] went from having her educational assistant helping her writing everything down and like doing everything for her to [my child] actually doing her work and asking for help when she needs help…I feel like [the social prescribing program] is helping a lot. Even at home she’s becoming a bit more independent. I used to have to do everything for her, and now she’s finally doing her own things.” – Caregiver of 8-year-old child.

Belonging

The findings also indicated that the social prescribing program may foster belonging in program participants. This pertains to the second component of the Circle of Courage, whereby the universal longing for human bonds is nurtured by relationships of trust so that the child can say, “I am loved” [19–21]. Families shared experiences of belonging and how it was cultivated through the child’s engagement with their connector and their social prescription.

Firstly, families perceived that belonging was fostered through the child’s development of a trusting relationship with their connector. A caregiver of a 15-year-old child shared, “We feel like [the connector] is family…[my child] likes the relationship between each other.” Program participants spoke of what exactly it was that they liked about their relationship with their connector. When asked what they liked about their connector, one participant (age 7) remarked, “I liked playing together”, while another participant (age 11) shared, “I liked having someone to talk with.”

Secondly, there were the friendships that the child developed with other children through their social prescription. Caregivers noted the friendships that were made. A caregiver of an 8-year-old child remarked, “[Social prescribing] really improves [my child’s] social behaviour as well. They made a lot of friends.” When asked what they liked about their social prescription, program participants spoke fondly about the friendships they made.

“I liked [playing on the soccer team] because I saw my friends. I made other friends too. It was very fun. It was a good environment. Everyone was happy, like there was no one sad, and yeah they were all friendly matches, like there was also no bullying.” – Participant (age 9).

Thirdly, there was the child’s relationship with the adults who were delivering their social prescription. Program participants spoke of the support and mentorship they received from these individuals. One participant (age 15) shared, “[The art class teachers] help us with anything. Like if you’re struggling and don’t know what to do, they help you. They’re really kind.” Caregivers also spoke about this. A caregiver of a 13-year-old child remarked, “I could overhear kind of [my child’s] conversations, and [the guitar instructor] kind of treated him like a buddy.”

Fourthly, there was the child’s relationship with their family. Program participants spoke of how their social prescription created meaningful opportunities to bond with family members. One participant (age 9) noted, “[The social prescribing program] helped me get closer to my family.”

Lastly, there was the child’s relationship with their community. Caregivers spoke of how their child’s social prescription helped them to integrate into their community. A caregiver of an 8-year-old child shared, “[My child] learn to integrate in the community because we came from, we were from different community…so [the social prescribing program] makes them to integrate easily with the community.” Program participants also spoke of how their social prescription made them feel more connected to and supported by their community.

Participant (age 9): “I only gained more confidence…”.

Interviewer: “What does confidence mean to you?”

Participant: “Confidence means like the community around you like believes in you. They take care of you. Like nobody doesn’t believe in you. Everyone believes in you. They take good care, and they like help you gain your goal. That’s what’s confidence for me.”

Mastery

The findings also indicated that the social prescribing program may foster mastery in program participants. This pertains to the third component of the Circle of Courage, whereby the child’s inborn thirst for learning is nurtured and by learning to cope with the world the child can say, “I can succeed” [19–21]. Families shared experiences of mastery and how it was cultivated through the child’s social prescription.

Program participants spoke of how they went into the program with a desire to learn and crafted their social prescription with this goal in mind. They expressed that they thought of their social prescription as a learning opportunity. One participant (age 14) shared, “I wanted to learn something new, so [my connector and I] found some like courses, like things that helped me learn a new skill.” Caregivers spoke of how their child thought of their social prescription as much more than just an opportunity to have fun. A caregiver of an 8-year-old child noted, “The swimming [my child] enjoyed because she wanted to show she can swim. Yeah, so she was eager to go every time. Yeah, I think it’s not about wanting to swim, it’s knowing the skills. She was really eager to progress to the next level.” While program participants did not always go into the program with a desire to learn, caregivers spoke of how their child’s social prescription deepened their interest in a topic and motivated them to enhance their knowledge and skills in that area.

“It was nice to see [my child] practice something. He seemed to take a greater interest, cause he had a guitar here and he took a greater interest in it. Like he was playing it almost every day, so I think [guitar lessons] motivated him.” – Caregiver of 13-year-old child.

Caregivers also spoke of how their child’s social prescription allowed them to discover new interests and prompted them to develop their knowledge and skills in that area.

Caregiver of 10-year-old child: “[My child] likes to have his own plants.”

Interviewer: “Okay wow. So he’s like taking care of his own plants at home?”

Caregiver: “Well, they’ve sadly passed, but he tries. Maybe not the greenest plants, but the interest is there.”

Interviewer: “Okay that’s awesome. And that was after nature camp?”

Caregiver: “Yeah.”

Through their social prescription, program participants acquired new knowledge and skills. Program participants shared what they learned, including both hard and soft skills. One participant (age 14) noted, “I did learn some good new things. Like how to thread the sewing machine and how to set it up and stuff.” Program participants shared that they were drawing on the knowledge and skills they acquired in everyday life. One participant (age 13) remarked, “[Social prescribing] was very helpful for me cause you know it’s very easy for me to like express myself now in like different art forms.” Caregivers also spoke about this. A caregiver of a 7-year-old child shared, “[My child] is still practicing whatever was taught [at Little Medical School]. So he knows that we need to have bandaids at home, and he uses the stethoscope to check my chest – even his friends when they come over.”

Through the acquisition of new knowledge, skills, and interests, program participants developed a greater sense of competence and confidence. When asked if participating in the social prescribing program changed how they felt, one participant (age 9) remarked, “No…the only thing that it made me feel was get more confidence that I can achieve my dreams.” Program participants felt that the social prescribing program helped them to get out of their comfort zone to try new things and meet new people. One participant (age 14) shared, “I think [the social prescribing program] made [the way I feel] a lot better. Especially like with just getting out and doing things I’m not a 100% sure I know how to do, that really helped.” Another participant (age 13) noted, “I’m pretty sure [the social prescribing program] made me more happier and made me more, you know, confident in myself to be actually like talking in public and like, you know…talking to new people and making new friends.” Caregivers also spoke of their child’s increased sense of competence and confidence.

“These [social prescriptions] have contributed to [my child] gaining more positive outlook and more confidence on the things that she can do, because I know she has all these talents already in her, it’s just that because of the circumstances that has been happening in the past few years, it kind of buried it, and then now with all this exploration that has been going on, all these activities that she’s been enjoying, kind of this is coming back.” – Caregiver of 8-year-old child.

Generosity

The findings also indicated that the social prescribing program may foster generosity in program participants. This pertains to the fourth and final component of the Circle of Courage, whereby the child’s character is nurtured by concern for others so that the child can say, “I have a purpose for my life” [19–21]. Families shared experiences of generosity and how it was cultivated through the child’s social prescription.

The social prescriptions served as an opportunity for program participants to learn how to show generosity. When asked what they learned from their social prescription, one participant (age 8) shared, “How to be kind and how to help.” The social prescriptions also served as an opportunity for program participants to engage in acts of generosity. One participant (age 14) remarked, “I wanted to like share the things, like I shared my baking and I showed mommy like some of the sewing machine stuff.” Caregivers also spoke about this. A caregiver of a 14-year-old child noted, “I think [my child] enjoyed sharing [the museum tickets] with her family.” The social prescriptions also served to widen program participants’ notions of how they can serve their community. Caregivers spoke of how their child’s social prescription exposed them to new opportunities that instilled in them a sense of purpose to contribute to their community, both now and in the future. A caregiver of a 9-year-old child remarked, “After [the police station visit], [my child] talking about how he can serve his community, how he can protect. He really, really love to become a police officer”, while a caregiver of a 14-year-old child shared, “Now that [my child] has done the babysitting course, she can say, ‘I can babysit in my community. I can help look after them’.”

Discussion

This evaluation examined the ways in which our social prescribing program may foster self-determination in children and youth. Using the Circle of Courage as a framework, the findings suggested that the program had positive impacts on decision making, sense of autonomy, development of trusting relationships, sense of belonging, knowledge and skill acquisition, sense of competence and confidence, prosocial behaviour, and sense of purpose, which link to independence, belonging, mastery, and generosity. Our findings not only indicated that the Circle of Courage served as a useful lens through which to examine our social prescribing program but also that there may be several positive impacts of our program. Firstly, families perceived that the program generated a greater sense of autonomy in program participants, both through the ‘what matters to you’ conversation and the co-production of the social prescription with their connector, and through the establishment of healthy boundaries with their caregiver (independence). Secondly, families perceived that trusting relationships were nurtured through the program, whereby program participants developed a greater sense of belonging through trusting relationships with their connector, the other children who participated in their social prescription, the adults who delivered their social prescription, their family, and their community (belonging). Thirdly, families perceived that the program fostered a greater sense of competence and confidence in program participants through the acquisition of new knowledge, skills, and interests (mastery). Lastly, families perceived that beneficence was instilled through the program, whereby program participants learned how to show generosity, engaged in acts of generosity, and developed a sense of purpose to serve their community, both now and in the future (generosity).

This evaluation builds on the work of Bhatti et al. [8] and Hanlon et al. [17], who examined the concept of self-determination in adult social prescribing. Using SDT as a framework, they found that social prescribing may build self-determination in adults by fostering autonomy, relatedness, competence, and beneficence. By using an equivalent, child and youth-focused theory to explore this phenomenon in children and youth, our findings indicated that our social prescribing program may foster self-determination in the same ways, namely by fostering independence (akin to autonomy in SDT), belonging (akin to relatedness in SDT), mastery (akin to competence in SDT), and generosity (akin to beneficence in SDT). Similarly, Bhatti et al. [8] and Hanlon et al. [17] found that participants developed a greater sense of autonomy through their interactions with their connector, who focused on what matters to them and shared decision-making power with them. They also reported that participants developed a greater sense of belonging through trusting relationships with their connector, those they met through their social prescription, and their community. Bhatti et al. [8] and Hanlon et al. [17] also found that participants developed a greater sense of competence and confidence through the acquisition of new knowledge, skills, and interests. Finally, they shared that participants developed a sense of purpose by having the opportunity to make a positive impact on others and meaningfully contribute to their community.

It is also important to consider our findings in relation to existing literature on child and youth social prescribing. While self-determination has not been an explicit focus of studies on child and youth social prescribing to date, the concepts that comprise the Circle of Courage have surfaced in the literature. Hayes et al. [33] explored the barriers and facilitators to social prescribing in supporting child and youth mental health. They found that social prescribing puts children and youth in the driving seat of their journey (independence), supports them to make connections with peers who share similar interests and build a trusting relationship with their connector (belonging), and empowers them to navigate the world (mastery). Building on this work, Steffen et al. [34] sought to identify the active ingredients of social prescribing in supporting child and youth mental health. They found that social prescribing gives children and youth the opportunity to exercise agency in their journey and offers a holistic approach that is tailored to what matters to them (independence). They also found that social prescribing gives children and youth the opportunity to develop a supportive relationship with a skilled adult and creates a safe space to discuss their needs (belonging). These components of the Circle of Courage have also surfaced in evaluations of child and youth social prescribing, where children and youth have reported experiencing an increased sense of autonomy (independence), connectedness (belonging), and confidence (mastery) [35–39]. Beyond peer-reviewed studies, these concepts are also highlighted in non-empirical sources. In their commentary on child and youth social prescribing, Bertotti et al. [40] outlined two core mechanisms of social prescribing – the act of connecting the service user to community supports and services through a collaborative process of shared decision making (independence) and the development of a trusting relationship between the connector and service user (belonging) [40]. More recently, the National Children’s Bureau released a good practice guide for child and youth social prescribing [41]. In it, they highlight that social prescribing serves as an opportunity for children and youth to be listened to, valued, and engaged in shared decision making (independence), supported to make connections and build trusting relationships (belonging), empowered and equipped with confidence and resilience (mastery), and enabled to give back through volunteer opportunities (generosity), the benefits of which are not only felt at the individual level – where these features serve as protective factors for health and wellbeing across the life course, but also at the population level – where they contribute to the development of vibrant, thriving, and resilient communities.

Strengths and limitations

There are several strengths and limitations of this evaluation. One of the strengths is the number of participants, with 33 program participants and 30 caregivers, as well as a high recruitment rate of 91% of families and 77% of program participants from the pilot, making this one of the largest qualitative evaluations of child and youth social prescribing to date. Another strength is the fact that there was significant diversity and representation from populations experiencing inequities. Taken together, the number and type of participants involved in this evaluation allows for a rich understanding of the phenomenon of interest. Additionally, with growing criticism surrounding the lack of theoretical underpinning for social prescribing [42], a strength of this work is the use of the Circle of Courage as a lens through which to examine our social prescribing program.

With this being a program evaluation based in a community organization, this work was shaped by pragmatic needs and resource realities. There are associated limitations to note, including the overlapping roles and responsibilities of our team across program development, implementation, and evaluation, the focus on short-term effects of the program, and the use of single coding for data analysis. These limitations reflect the real-world conditions under which this work was conducted. There are additional limitations to note. Firstly, while all program participants and caregivers were invited to participate in this evaluation, not all of them agreed to, which may have introduced bias into the evaluation since those who agreed to participate may have had more meaningful experiences than those who did not. Secondly, the use of deductive thematic analysis precluded the discovery of insights that did not fit into the pre-existing framework that was used. Despite these limitations, the findings of this evaluation offer valuable insights into the ways in which our social prescribing program may foster self-determination in children and youth.

Implications for research and practice

With limited evidence on social prescribing for children and youth [18], this evaluation adds to the evidence base. To our knowledge, this is the first evaluation to examine the ways in which social prescribing may foster self-determination in children and youth. While previous studies have explored the concept of self-determination in adults [8, 17], this evaluation specifically focused on children and youth, thereby contributing to the development of a more complete understanding of how social prescribing may build self-determination across the life course.

Our findings offer insights for research and practice. Firstly, the Circle of Courage served as a helpful lens through which to examine our program, meaning it may be a useful framework to explore the impact of other child and youth social prescribing programs. Secondly, this evaluation has shed light on the ways in which social prescribing may foster self-determination in children and youth, which warrants further exploration of this phenomenon – and with social prescribing being an umbrella term under which many different models fit, this includes developing an understanding of what works, for whom, and in what circumstances.

Conclusion

In this evaluation, we examined the ways in which our social prescribing program may foster self-determination in children and youth. Using the Circle of Courage as a framework, the findings indicated that social prescribing may foster independence, belonging, mastery, and generosity in children and youth.

Abbreviations

SDT

Self-Determination Theory

Author contributions

Conceptualization, CM and SB; methodology, CM and SB; investigation, CM; VD; ES; IF; AB; SB; data curation, CM; VD; ES; IF; AB; SB; quantitative analysis, CM; qualitative analysis, CM and SB; writing – original draft preparation, CM; writing – review and editing, CM; VD; ES; IF; AB; SK; NR; SB; supervision, CM and SB; project administration, CM and SB; funding acquisition, SB. All authors read and approved the final manuscript.

Funding

This project was funded by the Public Health Agency of Canada (PHAC) Mental Health Promotion Innovation Fund (MHP-IF). The views expressed in this publication are those of the authors and not necessarily those of the Public Health Agency of Canada.

Data availability

The datasets that were generated and analyzed in this evaluation are not publicly available but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This evaluation was conducted in accordance with the Declaration of Helsinki. Since this work was conducted as part of a program evaluation, it was deemed to be a non-research activity and was therefore exempt from ethics approval by the Children’s Hospital of Eastern Ontario (CHEO) Research Ethics Board. Informed consent, both written and verbal, was obtained from the families involved in this evaluation.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.