Unravelling the potential of social prescribing in individual-level type 2 diabetes prevention: a mixed-methods realist evaluation

Abstract

Background: Social prescribing (SP) usually involves linking patients in primary care with services provided by the voluntary and community sector. Preliminary evidence suggests that SP may offer a means of connecting patients with community-based health promotion activities, potentially contributing to the prevention of long-term conditions, such as type 2 diabetes (T2D).

Methods: Using mixed-methods realist evaluation, we explored the possible contribution of SP to individual-level prevention of T2D in a multi-ethnic, socio-economically deprived population in London, UK. We made comparisons with an existing prevention programme (NHS Diabetes Prevention Programme (NDPP)) where relevant and possible. Anonymised primary care electronic health record data of 447,360 people 18+ with an active GP registration between December 2016 and February 2022 were analysed using quantitative methods. Qualitative data (interviews with 11 primary care clinicians, 11 social prescribers, 13 community organisations and 8 SP users at high risk of T2D; 36 hours of ethnographic observations of SP and NDPP sessions; and relevant documents) were analysed thematically. Data were integrated using visual means and realist methods.

Results: People at high risk of T2D were four times more likely to be referred into SP than the eligible general population (RR 4.31 (95% CI 4.17-4.46)), with adjustment for socio-demographic variables resulting in attenuation (RR 1.33 (95% CI 1.27-1.39)). More people at risk of T2D were referred to SP than to NDPP, which could be explained by the broad referral criteria for SP and highly supportive (proactive, welcoming) environments. Holistic and sustained SP allowed acknowledgement of patients' wider socio-economic constraints and provision of long-term personalised care. The fact that SP was embedded within the local community and primary care infrastructure facilitated the timely exchange of information and cross-referrals across providers, resulting in enhanced service responsiveness.

Conclusions: Our study suggests that SP may offer an opportunity for individual-level T2D prevention to shift away from standardised, targeted and short-term strategies to approaches that are increasingly personalised, inclusive and long-term. Primary care-based SP seems most ideally placed to deliver such approaches where practitioners, providers and commissioners work collectively to achieve holistic, accessible, sustained and integrated services.

Keywords: Diabetes prevention; Health promotion; Primary care; Social prescribing.

Fig. 1

Overview of study data sources and analysis. Legend: SP Social Prescribing; NDPP NHS Diabetes Prevention Programme; T2D Type 2 Diabetes; VCS Voluntary and Community Sector

Fig. 2

Distribution of clinical features and their association with referral into SP among the total study population, cohort study 1. Legend: T2D Type 2 Diabetes. Cardiovascular disease includes Ischemic Heart Disease, Peripheral Arterial Disease, and/or Stroke and Transient Ischemic Attack. Respiratory condition includes Asthma and/or COPD. See Additional File 1: Table S2 for information on the variables included in each adjusted model

Fig. 3

Distribution of clinical features and their association with referral into SP among people at high risk of T2D, cohort study 2. Legend: See Additional File 1: Table S3 for information on the variables included in each adjusted model

Fig. 4

Distribution of clinical features and their association with referral into SP amongst people eligible for NDPP, cross-sectional study. Legend: See Additional File 1: Table S6 for information on the variables included in each adjusted model

Fig. 5

Synthesis of study findings. How SP operates to deliver T2D prevention