The concept of health also includes mental and social wellbeing. However, all too often health services and facilities only look at the physical care of patients.
Some advice from WHO for creating salutogenic contexts and building communities.
The pandemic highlighted the fragility and limitations of health systems and of the more traditional biomedical approaches to tackling increasingly complex health challenges (Filip, Roxana et al., 2022): starting from mental wellbeing and connections to the social and environmental context (Adisasmito, Wiku B. et al., 2022) in a scenario where inequalities, instead of decreasing, are on the rise (Bambra, Clare et al., 2020), what’s the best way to mobilise community resources to create salutogenic contexts? The answer is: focusing on the things that generate wellbeing, quality of life and social quality, and working on social determinants of health i.e. “the conditions in which people are born, grow, work, live, and age” (WHO, Health Promotion Glossary of Terms, 2021).
Social prescribing: community care
The loneliness and invisibility that a growing proportion of the population is suffering from are often at the root of the discontent felt and the difficulties in managing disease outcomes. Feeling part of a community improves the ability of individuals and their carers, whether family members or professionals, to respond and, by creating relationships, reduces stigma.
For two decades, English-speaking countries, in particular the UK and USA, have found a response in “Social Prescribing”, a system that allows healthcare professionals to use non-health resources in the community to respond to the needs of their patients.
By means of local partnerships between health, cultural and social services, this approach makes it possible, alongside traditional treatments, to prescribe patients with participation in a number of physical or artistic activities, employment or voluntary work, and offers support in exercising social rights as well as access to credit and housing.
Scientific findings show general improvements in terms of mental health (Cooper, Matthew et al., 2022), a reduction in loneliness and an increase in a sense of social connection (Wakefield, Juliet Ruth Helen et al., 2022). A recent study by the University of Westminster shows how participation in social prescribing pathways reduces the demand for GP services and A&E attendances by 28% and 24%, respectively, compared to patients that don’t participate. As a result, the economic impact on the healthcare system also improves. The assessment study conducted in Rotherham, where over 4,000 social prescribing pathways were activated, estimated savings in healthcare costs of £500,000 between 2012 and 2015. A recent study by the World Health Organization indicated that every pound invested in Art on Prescription has a positive impact of £2.30.
Creating a salutogenic system
The strength of this measure is starting from the person and putting them centre-stage to respond to that individual’s physical, mental and social needs. The model moves away from a “repair” view towards a salutogenic system, which helps build and promote health: not only involving patients with needs, but, above all, people with resources to share with the community. This approach is recognised by the World Health Organization which, in 2022, published, in partnership with the "Social Prescription Alliance, A toolkit on how to implement social prescribing”. Much more than a guide, it is a vision which, with the right tools, can support healthcare, social and education policymakers, organisations and healthcare workers in creating contexts that enable social prescribing.
Everyone can benefit from a social prescribing pathway, but WHO states that is the most fragile people that can benefit the most, especially people with chronic conditions, alone or socially isolated, at high risk of mental disorders, and vulnerable people in general – for example, due to their age or financial situation. Consider the potential in terms of wellbeing, supported by evidence, of a walk in the park, listening to music, looking at art, spending time in nature or in cities making new discoveries, and of reading. We are social animals and these experiences have a greater impact if done with others. Think about singing in a choir, dancing or a sewing group in a local library. These are community resources to be harnessed, recognising their therapeutic potential, as a cognitive resource with an impact on different biological systems, from the immune system to the endocrine system.
The work of WHO recognises its value and presents the main evidence of the effectiveness of this type of measure, clarifying the mechanisms of effective implementation and providing guidance on how to achieve it. The most common model involves the primary care health professional putting the patient in contact with a provider that acts as a liaison between the health service and community services. This provider, together with the patient, draws up a personal wellbeing plan based on the treatment recommendations and patient preferences
WHO toolkit
WHO suggests seven steps to take to introduce social prescribing into new contexts, including:
- start at a local level, involving as many local partners as possible to create a map of the services and resources in the community
- activate a co-design process together with the community, in which all groups, including the most vulnerable, must be involved and connected to each other and to the healthcare context, as well as financially supported
- identify link workers that connect the various system players, strengthening the multidisciplinary teams, including general practitioners. Their recruitment should take place based on their interpersonal, communication and empathy skills so that they can listen to and direct the patients to the most appropriate services.
- the design and construction of prescribing pathways should be shared with patients and with the community, who must be active players in these processes.
- the building of professional skills for link workers, with clinical supervision. Furthermore, commitment and clinical involvement should be encouraged, allowing care professionals to access training opportunities relating to the potential of social prescribing.
An impact assessment culture is central to collecting and disseminating evidence that can support the spread and replicability of measures. This approach responds to the need for the sustainability of actions, representing a practical interpretation of the local community model that promotes sustainable wellbeing as outlined in the latest update of the Health Promotion Glossary of Terms. Indeed, social prescribing creates connections to activate collaboration networks between organisations and resources that already exist in communities, overcoming their separate nature and enhancing their value. As already shown, it also reduces the economic impact on the healthcare system, relieving congestion in hospitals and strengthening primary care in the local area, as indicated by the recommendations for the reorientation of health services.
Projects and hopes for the future
There are many projects based on these principles in various countries such as initiatives for people with Alzheimer’s and early reading programmes. However, as highlighted by WHO, these are limited to individual projects, some with outstanding results, which run out of funds after the trial phase. What is missing is a widespread knowledge and culture of social prescribing, with training courses and defined and recognised professional figures, as well as protocols adopted within the healthcare context so that social prescribing can be left not to the initiative of individual operators, but to effective coordination capable of utilising and maximising resources.
An example of social prescribing is the Music and Motherhood project, a multinational study of choir singing programmes to combat postnatal depression coordinated by WHO.
In order to convey the message and promote the adoption of social prescribing in Italy, the manual was recently translated into Italian by a network of players committed to spreading wellbeing in a variety of contexts: the Cultural Welfare Center in collaboration with ISS-Istituto Superiore di Sanità (Italian Institute of Health), DorS Regione Piemonte (Piedmont Region Healthcare Documentation Centre), Centro BACH (Biobehavioral Arts & Culture for Health, Sustainability and Social Cohesion) at the University of Chieti and Pescara, Centro per la Salute del Bambino (Centre for Child Healthcare) and Fondazione Medicina a Misura di Donna (Women’s Medicine Foundation). Translations were carried out in various languages to interpret it according to the different cultures in different parts of the world.
By Catterina Seia and Marta Reichlin (PhD, Cultural Welfare Center (CCW), Research Area)
