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.

Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study.

Background: Link worker social prescribing enables health-care professionals to address patients' non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking. Objectives: To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement. Data sources: Quality Outcomes Framework and Secondary Services Use data. Design: Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April-July 2020). Study population and setting: Community-dwelling adults aged 40-74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK. Intervention: Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions. Participants: (1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients. Main outcome measures: The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score. Results: Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (-1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to -£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval -0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems. Limitations: The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise. Conclusions: This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances. Future work: To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts. Trial registration: This trial is registered as ISRCTN13880272. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.

Social prescribing happens when health-care staff refer patients to a link worker. Link workers support and help patients to access community services to improve their health and well-being. Social prescribing is popular within the NHS, but there is little evidence that it works. We looked at a social prescribing model being delivered in a disadvantaged area in north-east England.

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.

Negotiating acquired spinal conditions: Recovery with/in bodily materiality and fluids.

The paper explores the concept of recovery; the unexpected material changes that occur to, and within bodies following acquired spinal conditions. The phrase 'acquired spinal conditions' is used as a collective name for the four accounts of recovery that emerged using Participatory Action Research in the north east of England (2010-11). Using two qualitative methods, Photovoice and participatory diagramming, the empirical material examines the role of physiological changes as a way to enrich understandings of disability and the bodily experience of impairment. Three themes, bodily materiality, material objects and fluids became significant during one-to-one and small group interactions with participants. The paper is situated in wider debates in geographies of disability and impairment, focusing on the interplay between different physiological states of being and the bodily changes experienced through recovery. It argues that recovery is the process of negotiating, adapting and adjusting to changes, from the way bodily materiality shifts and fluctuates following accidents and medical interventions, settling over time as participants become aware of bodily changes, to the role of material objects and the fluids that pass back and forth changing bodily interiors. The paper closes with a call for geographies of affect to explore the individual and collective feelings associated with fluids, and the human-animal relations affecting recovery and bodily interiors.

Chronic Disease Risk Typologies among Young Adults in Community College.

OBJECTIVES: To address chronic disease risk holistically from a behavioral perspective, insights are needed to refine understanding of the covariance of key health behaviors. This study aims to identify distinct typologies of young adults based on 4 modifiable risk factors of chronic disease using a latent class analysis approach, and to describe patterns of class membership based on demographic characteristics, living arrangements, and weight. METHODS: Overall, 441 young adults aged 18-35 attending community colleges in the Minnesota Twin Cities area completed a baseline questionnaire for the Choosing Healthy Options in College Environments and Settings study, a RCT. Behavioral items were used to create indicators for latent classes, and individuals were classified using maximum-probability assignment. RESULTS: Three latent classes were identified: 'active, binge-drinkers with a healthy dietary intake' (13.1%); 'non-active, moderate-smokers and non-drinkers with poor dietary intake' (38.2%); 'moderately active, non-smokers and non-drinkers with moderately healthy dietary intake' (48.7%). Classes exhibited unique demographic and weight-related profiles. CONCLUSIONS: This study may contribute to the literature on health behaviors among young adults and provides evidence that there are weight and age differences among subgroups. Understanding how behaviors cluster is important for identifying groups for targeted interventions in community colleges.

Store-directed price promotions and communications strategies improve healthier food supply and demand: impact results from a randomized controlled, Baltimore City store-intervention trial.

OBJECTIVE: Small food store interventions show promise to increase healthy food access in under-resourced areas. However, none have tested the impact of price discounts on healthy food supply and demand. We tested the impact of store-directed price discounts and communications strategies, separately and combined, on the stocking, sales and prices of healthier foods and on storeowner psychosocial factors. DESIGN: Factorial design randomized controlled trial. SETTING: Twenty-four corner stores in low-income neighbourhoods of Baltimore City, MD, USA. SUBJECTS: Stores were randomized to pricing intervention, communications intervention, combined pricing and communications intervention, or control. Stores that received the pricing intervention were given a 10-30 % price discount by wholesalers on selected healthier food items during the 6-month trial. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests and refrigerators. RESULTS: All interventions showed significantly increased stock of promoted foods v. CONTROL: There was a significant treatment effect for daily unit sales of healthy snacks (ß=6·4, 95 % CI 0·9, 11·9) and prices of healthy staple foods (ß=-0·49, 95 % CI -0·90, -0·03) for the combined group v. control, but not for other intervention groups. There were no significant intervention effects on storeowner psychosocial factors. CONCLUSIONS: All interventions led to increased stock of healthier foods. The combined intervention was effective in increasing sales of healthier snacks, even though discounts on snacks were not passed to the consumer. Experimental research in small stores is needed to understand the mechanisms by which store-directed price promotions can increase healthy food supply and demand.

Understanding and Changing Food Consumption Behavior Among Children: The Comprehensive Child Consumption Patterns Model.

Current theoretical models attempting to explain diet-related weight status among children center around three individual-level theories. Alone, these theories fail to explain why children are engaging or not engaging in health-promoting eating behaviors. Our Comprehensive Child Consumption Patterns model takes a comprehensive approach and was developed specifically to help explain child food consumption behavior and addresses many of the theoretical gaps found in previous models, including integration of the life course trajectory, key influencers, perceived behavioral control, and self-regulation. Comprehensive Child Consumption Patterns model highlights multiple levels of the socioecological model to explain child food consumption, illustrating how negative influence at multiple levels can lead to caloric imbalance and contribute to child overweight and obesity. Recognizing the necessity for multi-level and system-based interventions, this model serves as a template for holistic, integrated interventions to improve child eating behavior, ultimately impacting life course health development.

Rural adults' perspectives on school food in a North Carolina county.

INTRODUCTION: To address alarming rates of youth obesity, multiple stakeholder perspectives must be understood and considered when developing nutrition interventions. The purpose of this qualitative study was to examine adults' perceptions of school food in rural North Carolina and their opinions about potential changes to encourage students to eat more fruits and vegetables in school meals. METHODS: We conducted semistructured key informant interviews by telephone from February through March 2013 to determine adult opinions regarding elementary school food and child health. Participants included parents, teachers, school administrators, and a cafeteria staff member. Interview transcripts were thematically analyzed using Dedoose qualitative analysis software. RESULTS: Four themes emerged from key informant interviews regarding school meals and increasing fruit and vegetable consumption: 1) schools are an appropriate place for nutritious food, 2) current school food is bland and unappealing, 3) school cafeterias can use simple strategies to increase fruit and vegetable intake, and 4) federal school meal guidelines are perceived as barriers to increased fruit and vegetable intake during school meals. CONCLUSION: Study findings suggest that training and support for cafeteria staff on healthy food preparation and presentation are critical and that there should be a "meeting in the middle" between child appeal and health. Nutritious and appealing school food options may have the potential to greatly increase fruit and vegetable consumption in rural elementary schools in North Carolina.

B'More Healthy: Retail Rewards--design of a multi-level communications and pricing intervention to improve the food environment in Baltimore City.

BACKGROUND: Low-income black residents of Baltimore City have disproportionately higher rates of obesity and chronic disease than other Maryland residents. Increasing the availability and affordability of healthy food are key strategies to improve the food environment and can lead to healthier diets. This paper describes B'More Healthy: Retail Rewards (BHRR), an intervention that tests the effectiveness of performance-based pricing discounts and health communications, separately and combined, on healthy food purchasing and consumption among low-income small store customers. METHODS/DESIGN: BHRR is 2x2 factorial design randomized controlled trial. Fifteen regular customers recruited from each of 24 participating corner stores in Baltimore City were enrolled. Food stores were randomized to 1) pricing intervention, 2) communications intervention, 3) combined intervention, or 4) control. Pricing stores were given a 10-30% price discount on selected healthier food items, such as fresh fruits, frozen vegetables, and baked chips, at the point of purchase from two food wholesale stores during the 6-month trial. Storeowners agreed to pass on the discount to the consumer to increase demand for healthy food. Communications stores received visual and interactive materials to promote healthy items, including signage, taste tests, and refrigerators. Primary outcome measures include consumer food purchasing and associated psychosocial variables. Secondary outcome measures include consumer food consumption, store sales, and associated storeowner psychosocial factors. Process evaluation was monitored throughout the trial at wholesaler, small store, and consumer levels. DISCUSSION: This is the first study to test the impact of performance-based pricing and communications incentives in small food stores, an innovative strategy to encourage local wholesalers and storeowners to share responsibility in creating a healthier food supply by stocking, promoting, and reducing costs of healthier foods in their stores. Local food wholesalers were involved in a top-down, participatory approach to develop and implement an effective and sustainable program. This study will provide evidence on the effectiveness of price incentives and health communications, separately and combined, among a low-income urban U.S. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02279849 (2/18/2014).

Development and implementation of the Baltimore healthy carry-outs feasibility trial: process evaluation results.

BACKGROUND: Prepared food sources, including fast food restaurants and carry-outs, are common in low-income urban areas. These establishments provide foods high in calories, sugar, fat, and sodium. The aims of the study were to (1) describe the development and implementation of a carry-out intervention to provide and promote healthy food choices in prepared food sources, and (2) to assess its feasibility through a process evaluation. METHODS: To promote healthy eating in this setting, a culturally appropriate intervention was developed based on formative research from direct observation, interviews and focus groups. We implemented a 7-month feasibility trial in 8 carry-outs (4 intervention and 4 comparison) in low-income neighborhoods in Baltimore, MD. The trial included three phases: 1) Improving menu boards and labeling to promote healthier items; 2) Promoting healthy sides and beverages and introducing new items; and 3) Introducing affordable healthier combo meals and improving food preparation methods. A process evaluation was conducted to assess intervention reach, dose received, and fidelity using sales receipts, carry-out visit observations, and an intervention exposure assessment. RESULTS: On average, Baltimore Healthy Carry-outs (BHC) increased customer reach at intervention carry-outs; purchases increased by 36.8% at the end of the study compared to baseline. Additionally, menu boards and labels were seen by 100.0% and 84.2% of individuals (n = 101), respectively, at study completion compared to baseline. Customers reported purchasing specific foods due to the presence of a photo on the menu board (65.3%) or menu labeling (42.6%), suggesting moderate to high dose received. Promoted entrée availability and revised menu and poster presence all demonstrated high fidelity and feasibility. CONCLUSIONS: The results suggest that BHC is a culturally acceptable intervention. The program was also immediately adopted by the Baltimore City Food Policy Initiative as a city-wide intervention in its public markets.

Preferences for healthy carryout meals in low-income neighborhoods of Baltimore city.

CONTEXT: The nutrition environment is associated with risk of obesity and other diet-related chronic diseases. In Baltimore's low-income areas, carryouts (locally prepared-food sources that offer food "to go") are a common source of food, but they lack a variety of healthy options for purchase. OBJECTIVE: To evaluate individuals' preferences of healthy combination meals sold at carryouts and to identify successful intervention methods to promote healthier foods in carryouts in low-income communities in Baltimore. METHOD: The study estimated the relationship between combinations of healthier entrées (turkey club, grilled chicken), beverages (diet coke, bottled water), side dishes (watermelon, side salad), price points ($5.00, $7.50), and labeling on consumers' combination meal decisions using a forced-choice conjoint analysis. Logistic regression analysis was used to determine how individuals value different features in combination meals sold in carryouts. RESULTS: There was a statistically significant difference between customer preference for the two entrées, with a turkey club sandwich being preferred over a grilled chicken sandwich (p = .02). Carryout customers (n = 50) preferred water to diet soda (p < .00). CONCLUSION: Results suggested specific foods to improve the bundling of healthy combination meals. The selection of preferred promotion foods is important in the success of environmental nutrition interventions.