RESPECT: Realist Evaluation of Social PrEscribing with time CrediTs
Research type
Research Study
Full title
Time Credits as a Social Prescription: The Co-production of a Conceptual Framework, Programme Evaluation and Social Return on Investment
IRAS ID
268253
Contact name
Sarah L Brand
Contact email
Sponsor organisation
Cardiff University
Duration of Study in the UK
2 years, 6 months, 30 days
Research summary
Research Summary
Proposed Study
The study is a feasibility study with three interlinked work packages: 1. a formative realist evaluation, 2. feasibility testing for future trial, and 3. a social return on investment evaluation.
The first work package is a formative realist evaluation. This work package aims to develop and refine a programme theory of how Social Prescribing and Time Credits (SP+TC) works, for which patients, and under which circumstances, and to formatively test and refine the intervention in light of the developing theory.
The ‘feasibility for future trial’ work-package aims to justify a future trial through: exploring potential effectiveness in a limited way to establish likelihood of finding an overall effect in a future Randomised Control Trial (RCT); feasibility and acceptability of evaluation study design, including outcomes and outcome measures; and identify and test the feasibility and acceptability of trial processes, including recruitment and retention and nature of referrals (representativeness of the sample and reach of the intervention, who patients are, how they are referred, why they are referred); acceptability of SP+TC as an intervention.
The social return on investment work package will identify potential return on investment and savings of this SP+TC intervention and wider economic benefits to the community
The feasibility study has four stages in which each of the work packages has a different role. Stage 1 (months 8-12): develop initial theory and intervention; Stage 2 (months 11-14): formative evaluation of SP+TC; Stage 3 (months 24-26): final analysis; Stage 4 (month 27): expert steering group decision to progress to study and bid for future study.Summary of Results
Background: Wales has some of the highest rates of long-term limiting illness and mental ill-health in the UK. Poor health remains linked to social and economic disadvantage resulting in health inequalities. Increased levels of community participation can have a positive impact on health behaviours, physical and mental health outcomes especially among disadvantaged populations. Through linking patients with non-medical sources of support within the community Social Prescribing (SP) can help patients self-manage long-term chronic conditions. Time Credits (TC), an adaptation of the time banking model is a framework for giving and receiving services in exchange for units of time. In the SP+TC intervention patients are identified and referred to the Social Prescriber by the GP. Using motivational interviewing goal setting techniques, the social prescriber helps identify issues future goals. The patient is ‘prescribed’ a small number of TC to use on activities of interest and in return pledges their time to earn in the future by volunteering.
Aim of research: How can a SP+TC intervention works to improve psychological wellbeing, for which patients, and under which circumstances.
Methods: This study is a realist evaluation exploring how combining SP+TC works, for which patients, and under which circumstances to reduce social isolation and improve psychological wellbeing. An SP+TC intervention developed through pilot work and was implemented across 3 GP practices in Wales. An initial programme theory about how it would work was co-developed from the evaluation and with stakeholder group (n=9) of GPs, social prescribers and patient representatives and primary data collected to test this understanding. A midpoint stakeholder consultation was convened to review the programme theory (n=5) of GP’s, practice managers, TC organisation and patient representative. Post intervention interviews were conducted with patients who took part in the intervention (n=6), and those involved in delivery (n=6) and a patient representative (n=1). A final stakeholder event was convened with intervention participant and the social prescriber (n= 8) the group discussions were used to inform, adapt and add nuance to the theory by sharing experiences and exploring any health and wellbeing outcomes. The final If-then statements were analysed using Framework Analysis. A programme theory of how SP+TC works to improve patient psychological wellbeing is presented.
Main findings
Interviews were analysed using C-M-O framework (Pawson & Tilly, 1997) first by developing a set of ‘if then’ statements and then further development into C-M-O configurations. Interview and stakeholder transcripts were coded by one researcher (JH) and these C-M-O coding were checked by a second researcher (CJ); comparisons were made to determine how causal mechanisms ‘fired’ in different contexts and produced different outcomes. Analysis was iterative, going ‘back-and-forth’ between the initial programme theory and the C-M-O statements developed from the interviews. This allowed the refinement of the C-M-O statements.Results
1. C-M-O GPs’ ease of referral to the intervention
C - GPs have very little time with individual patients and are pushed for time when making referrals; M - If there are multiple modes of referral, if GPs know where they are referring the individual and they receive positive feedback from the intervention, then:
O - Patients who will benefit from the intervention will be referred
2. C-M-O Patients’ willingness to engage with the intervention
C - People with long-term mental health issues can be reluctant to engage having tried a number of interventions before that haven’t worked M - If they have information about social prescribing from a trusted source (i.e. friends/relatives), if they have time to think through the intervention, and if they are ready in themselves to try something new, then; O - They will engage with social prescribing and attend the first appointment
3. C-M-O Time credits creates an opportunity to make new friends and volunteer and give back
C - The time credits network is embedded in the local community M - This creates the opportunity to volunteer to help others, make friends and builds links within the community then this motivates O - The patient to volunteer and give back
4. A person centred, flexible approach by social prescriber enables continued engagement
C - If the social prescriber takes time and goes at the pace set by the patient using a flexible approach M - Then the patient will feel supported and genuinely cared for O - And continue to engage with social prescribing
5. Goals set need to be meaningful and achievable in order to motivate patients
C - If the social prescriber takes an individual, person centred approach setting goals that are meaningful, incremental and achievable M - Then patients will feel valued and motivated to achieve the goals O - And when goals are achieved this will reinforce the positive behaviour change
6. Continued improvements noticed by the patients and friends and family lead to better self-esteem and psychological wellbeing
C - If the patient and their patient’s family start to see the change in themselves and this is ongoing M - Then they will value the intervention and continue to engage O - Leading to improvements in mood, self-esteem and psychological wellbeing Conclusions Results from the realist evaluation, indicate key to engagement and continued engagement is that patients are provided with information about SP and TC from a trusted source and they are allowed to engage with the intervention at their own place. The social prescriber needs to take a person-centred flexible approach with goals that are set with the patient. Once the patient has engaged combing SP with TC has a number of benefits including, increased social connections, motivation to volunteer and give back to the community and increased patient activation and self-efficacy in being able to manage their own conditions and achieve their goals. This in turn has a ripple effect and improves mood and psychological wellbeing which is noticed by friends and family creating a positive reinforcing effect on continued behaviour change. One key mechanism to the success of a social prescribing intervention is the engagement of GPs in referring to the intervention. For future interventions attention needs to be paid to engaging with GPs as the ‘gate keepers’ of referrals in order for these interventions to be successfully implemented and sustained.REC name
Wales REC 3
REC reference
20/WA/0020
Date of REC Opinion
26 Feb 2020
REC opinion
Further Information Favourable Opinion