Introduction

Addressing the social determinants of health and reducing health inequities is a major challenge for health services worldwide, especially for Primary Health Care (PHC). Individuals from lower socioeconomic status tend to have fewer opportunities and resources to adopt healthy lifestyles [1,2]. In addition, social inequalities often translate into disparities in health care access, leading to increased disease burden, higher mortality rates and decreased life expectancy [3–5]. Furthermore, social isolation and loneliness are risk factors for all causes of mortality and result in an increased demand for PHC services [6–10].

Clinical approaches based solely on disease treatment and the biomedical model, have shown to be insufficient to comprehensively meet patients’ needs [11,12]. To achieve better health and well-being, individuals must have their social, economic, and emotional issues addressed [3]. In this regard, complex interventions have been designed and implemented with the purpose of providing holistic and comprehensive care that addresses all dimensions of human well-being [13]. SP is one of the well-known practical models of complex intervention that focuses on addressing individual social, economic and emotional needs, within an integrated and person-centred care approach [14].

This integrative model strengthens the network between the health and social sectors and is operationalized mainly through the patient’s referral process and the collaboration between a healthcare provider and a link worker or community navigator [14]. Link workers carry out detailed assessments of the patient’s needs and an individual care plan is co-created. This plan outlines how to support a person’s needs by using services in the community where the individual lives, considering the specificities of the existing resources [14]. These services are related to e.g. physical activity, language classes, artistic and cultural activities, gardening, financial services, food and housing support, and intend to respond to non-medical needs, such as social isolation, mental health issues, financial difficulties, migrant integration, or functional dependency, among others.

It is important to evaluate the processes of implementation of complex interventions such as SP, including its enablers and barriers, to understand what works and does not work, for whom, and in which circumstances [15]. In particular, understanding the drivers of implementation success and failure related to the intervention context is crucial to inform improvement and design of scalable and sustainable interventions [16,17]. In order to assess the key determinants of the implementation of SP projects it is fundamental to use adequate theoretical frameworks [18]. Several models have been developed to provide a structure for describing the process of putting effective interventions into practice, as well as a subsidy to analyse which factors influence implementation efforts and outcomes [18,19]. The Consolidate Framework for Implementation Research (CFIR) is a key theoretically grounded framework, which serves to systematically guide the assessment of implementation contexts and the identification of multilevel factors influencing the implementation outcomes of an intervention [20].

Using the CFIR, our study aimed to identify enablers and barriers to the implementation of an SP program in Lisbon from the perspectives of stakeholders involved in the program implementation.

Methods

Setting

The SP program was implemented in two Family Health Units (FHUs) in Lisbon, which provide general health care to approximately 29.000 people of all ages. Users of these units include people living in socially and economically vulnerable situations, such as elderly in isolation, recently arrived migrants, unemployed people, many who have low levels of education, and people experiencing homelessness [21]. These FHUs are staffed with family doctors, nurses and clinical secretaries and receive specialized support from social workers, psychologists, physiotherapists, and occupational therapists [22].

SP program. The SP program has been implemented in these FHUs with the aim of responding to users’ socioeconomic and emotional needs through the community assets available, to improve their health, well-being, and quality of life. The project also aims to improve communication and collaboration between health professionals, social workers and community partners operating in the territories covered.

FHUs’ patients of all age groups and with any non-clinical needs are referred to the SP program by their healthcare provider, or voluntarily enter the program. Clinical secretaries also assist in proactive referral to the SP program during their front-desk contacts.

During regular appointments, whenever healthcare providers identify non-clinical needs, they explain the SP program to their patients and ask about their interest in taking part. Upon patient consent, healthcare providers complete a referral form on a dedicated electronic platform, which sends an automatic email to the FHU’s social worker and other involved healthcare providers (e.g., family doctor and family nurse) with the patients’ referral information (e.g. reasons for referral, presence of chronic disease, need for a translator). Patients are then schedule an SP appointment with the social worker. Follow-up of patients who do not schedule this appointment within 2–3 weeks is guaranteed by a clinical secretary.

In this SP program, social workers have taken on the role of SP link workers. In the first SP appointment, the social worker assesses the patient’ needs, their preferences and motivations, and jointly they devise a personalised action plan. The social worker introduces the patient to activities provided by the FHU, such as walking groups and health literacy sessions, and activities offered by partners of the social/voluntary sector in the community.

Following patient’ agreement regarding the most suitable strategies to address the identified individual needs, the social worker refers the patient (by e-mail or telephone) to the appropriate services in the community. The SP program also includes patient follow-up after the referral process, to assess patient’s pathway and achieved outcomes and, if necessary, to schedule new appointments. Throughout the SP program, the social worker updates and shares information with the healthcare provider. For this purpose, instruments were developed and adapted to expedite communication between different stakeholders. The email with referral information could be used to case discussions between social worker and healthcare providers (family doctor, family nurse and professional who made the referral) and for the social worker to give feedback on the patient’s progress. The participation in the SP program is considered complete when the patient has their needs met. If a patient does not attend the scheduled appointments or drops out of agreed activities, then their participation is also ended.

In the planning phase of the program, the implementation team adopted a participatory and collaborative approach to plan and develop tools and processes. Stakeholders were invited to participate in the discussions and decisions related to the dedicated platform for referrals and other communication tools, and to help adapt the SP model to the Portuguese context. A key strategy used by the implementation team to engage all stakeholders in SP implementation was to reinforce the communication through monthly meetings with community partners, monthly feedbacks to the health unit teams and frequent publication of newsletters. Specifically, regarding the organization of meetings, different strategies were used for promoting collective participation, including clinical cases discussion, workshops, and holding meetings in different locations.

Overall, the implementation of the SP program involved approximately 20 professionals, from executive directors and health unit coordinators to family doctors, social workers and focal points of community partners. Professionals from the FHUs who were involved in SP implementation redirected approximately four hours per week of their time to develop the program’s activities. No additional funding was provided to run the program. Fig 1 illustrates the intervention strategy.

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Fig 1. Circuit implemented in the SP program in Lisbon.

https://doi.org/10.1371/journal.pone.0306404.g001

Data analysis

Thematic analysis was conducted according to the six steps outlined by Clarke & Braun [25]: I) Familiarising with data; II) Generating initial codes; III) Searching for themes; IV) Reviewing themes; V) Defining and naming themes; VI) Producing the report. A deductive approach was applied, in which the CFIR was used as a framework to orientate the thematic analysis and the codes identified in the data were grouped in according to existing domains and constructs derived from the CFIR. In this analysis, the themes were presented as domains and categories were described as constructs according to CFIR nomenclature [20]. The CFIR is composed of five major domains divided into 39 constructs (Table 1), each of them possibly influencing an intervention’s implementation as a facilitator or a barrier to the implementation of the SP program [20].

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Table 1. Description of CFIR domains and constructs [20].

https://doi.org/10.1371/journal.pone.0306404.t001

Results

For this study, a total of 15 participants were invited to participate, resulting in nine participants enrolled in the study, including two health professional who make referral to SP, two link workers and five focal points of community partners (from local authorities, local associations, and non-governmental organizations). The majority (n = 8) of participants were female, 5 aged between 30–40 years, 5 were social workers and 2 family doctors. Overall, 5 domains and 9 constructs emerged from the interviews narratives referring to both enablers and barriers to the implementation of the SP program (Table 2).

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Table 2. Enablers and barriers according to CFIR.

https://doi.org/10.1371/journal.pone.0306404.t002

Discussion

This study describes the first Social Prescribing project in Portugal, based on evaluation research, enabling us to monitor the implementation process closely and systematically. Conducting an evaluative component in SP projects has been pointed out as a strategy to reduce the evidence gaps in the area [26].

Most evaluation studies on SP focus mainly on the effectiveness of the intervention in terms of patient outcomes, while fewer studies have referred to the implementation process itself [26–28]. Understanding this process from the perspectives of relevant stakeholders allows to identify barriers and enablers, which can help health professionals, managers, policymakers, and other key stakeholders to develop effective projects in this area [28]. Increased knowledge of the SP implementation processes can also assist in the development of improvement strategies [16].

SP has a solid conceptual ground and implementing it seems simple. Still our findings show that, in practice, SP is a complex intervention that involves multiple stakeholders, diverse community responses and is subject to multilevel factors that can highly impact how successful its implementation turns out to be. SP has elements of complexity across several domains: the components and properties of the intervention itself, the implementation processes, the characteristics of the context and the features of the recipient populations [29].

This study allowed to identify several enablers and barriers of implementation of the SP program from the perspective of relevant stakeholders. The holistic approach of SP emerged as a key facilitator for stakeholders’ uptake and engagement in the program. In this study, participants referred to the SP intervention as an opportunity to respond to the non-clinical needs of the population. In fact, SP acknowledges that needs, such as social isolation, mental health issues, lack of physical activity, and poor living conditions, can significantly impact a person’s health condition and well-being [30]. SP is a strategy to put into practice the holistic paradigm of health care and recognizes the importance of addressing the broader determinants of health and well-being beyond traditional medical interventions [31–34]. Rather than solely relying on medication or medical treatment, SP considers the social, emotional, and practical needs of individuals, placing the person at the center of care [33]. The preparation of a personalised action plan within a co-design approach enhances trust between patients and stakeholders and fosters a sense of control, encouraging them to consider non-clinical aspects while actively participating in treatment choices [35]. Accordingly, past studies have reported the importance of adopting a de-medicalization health approach by general practitioners, especially for patients who have social issues as primary causes for their health condition, thus contributing to making the health system more effective and sustainable [32,36]. A facilitating factor of SP implementation that emerged as well was professionals’ positive attitudes toward the intervention, especially the underlying holistic perspective of patients’ health and well-being, and an understanding of the influence of social determinants on health, individual or collective [32–34]. By taking a holistic, patient-centered, approach and considering the individual’s circumstances, SP allows to empower individuals, enhances their social connections, and promotes self-care, thereby improving their overall well-being and promoting more equitable care [33,37]. Furthermore, it enables service users to express their priorities and align their needs and interests with the available resources [38].

Another facilitator described by the participants in our study was the close proximity of the social workers to the community and their physical presence in the Health Units. In fact, a good relationship between the link workers and the other healthcare parties involved in SP has been documented in previous research as important as it facilitates the implementation and delivery of SP programs [16]. Accordingly, staff of integrated care services referred that working together in the same building in a collaborative manner improved the quality and frequency of communication, and the agility in solving patients’ problems [39]. Furthermore, structured and regular contact between link workers and health professionals was shown to serve as a reminder about the SP program, encouraging a higher number of referrals [16].

Effective communication was identified as a facilitator, particularly when frequent and close intersectoral communication is adopted. Such communication between health professionals, link workers, and social partners is essential for the success of SP projects [40], by promoting a more collaborative work environment and improving information sharing about patients’ needs [19,33]. Interpersonal relationships between link workers and different healthcare professionals and collaborative work through e.g. shared learning sessions and team meetings can be a facilitator of implementing SP [41].

Other contextual factors influencing the implementation of the SP program relate to the link workers, such as the number of link workers, their time availability, and the complexity of their role. The link worker plays a central role within an SP program and their competence lies in their ability to effectively engage, exhibit empathy, actively listen, empower, and motivate individuals [42]. According to some interviewees in the present study, the link workers´ high workload for the time available often leads to long waiting times for SP consultations. Consequently, this can increase the risk of non-engagement of patients and hinder the effective performance of SP services [28,33,43,44]. Similarly, the involvement of link workers was observed to be influenced by various factors. Such as, the timing of link workers’ engagement in the planning and execution of SP initiatives, particularly their early involvement, has been observed to enhance their motivation and commitment to the project considerably [45], whereas substantial workloads and time constraints have been identified as the main factors deterring link workers from engaging in SP initiatives [46]. A context of limited resources may lead link workers to respond primarily to immediate and urgent demands, reducing their capacity to develop community involvement initiatives or even to follow up with patients with complex needs [33]. In this sense, it is important to understand the complexity, responsibilities and skills inherent to the link worker role, and set boundaries on what is part of its functions [46,47]. According to Hayes et al. 2023 [48], link workers, particularly those overseeing multiple sites, expressed challenges in their interactions with clinical teams, highlighting a sense of disconnectedness. Social prescribers often find themselves operating separately from the healthcare system, which impedes collaboration, hampers patient contact and receiving referrals [48]. Some link workers feel forgotten and struggle with the process, which ultimately impacts referral flow and desired outcomes [48]. The visible presence of the link worker, the feedback from link workers regarding the progress of people they had referred into the scheme and the closely work with health colleagues are strategies that promote early collaboration and greater involvement in the SP process of allied stakeholder buy-in [49].

Indeed, communication was also identified as a barrier in this study when there was a lack of well-established communication channels. Similarly, in a previous study, a clearly defined channel for conveying information about patients’ needs was not explicitly established; instead, there was a prevailing dependence on informal monitoring of implementation, as opposed to formal mechanisms [41]. To tackle this issue, the implementation of computerized communication strategies, such as IT systems and team meetings, seems to facilitate the communication between stakeholders and enable the discussion of complex cases [32,34].

The readiness of the context to implement SP, including, for instance, the community structure, human resources, and patients’ acceptability, is key to achieving successful implementation [23,50], and the findings of our study demonstrate this. Most interviewees referred that the reduced local community resources currently available was, in fact, a hindering factor to the progress of the program. Namely, they mentioned the limited amount and variety of existing local responses, as well as the lack of funding for the design and development of complementing social responses. Lack of resources has been previously identified a challenge associated with the absence of support for services from regional governing bodies, as well as difficulties in securing grants and alternative sources of funding, along with the recruitment and retention of volunteers [38,51]. As documented elsewhere, limited resources, especially low financing for supporting services, can constitute barriers to engaging community partners [16]. A strong and comprehensive community sector is vital for a successful SP intervention, which requires adequate funding and appropriate infrastructure [52,53]. Simultaneously, the resources in the community need to be fully aligned with patients’ needs and accessible; otherwise, the SP activities may be overcrowded or less responsive [33]. A strong, integrated, and comprehensive voluntary and community sector is vital for a successful SP intervention, which requires adequate funding and appropriate infrastructure [52,53].

In our study, patient adherence was pointed out exclusively as a barrier to implementation. The patient attrition throughout the project was a frequent difficulty referred by the interviewees. According to participants, decreased patient participation occurs through non-booking or missing SP appointments and non-adherence to the proposed activities. Generally, the low engagement of patients is cited as one of the biggest barriers to the implementation and delivery of SP services [16]. Factors affecting patient engagement in SP projects have been identified, including high waiting time, misperception about the health-promoting role of primary health care, misalignment between patient expectations and the SP model of care, lack of interest in SP, skepticism around its potential benefit, and lack of economic support (e.g. for project activities and transportation to SP-related services) [16,17,28]. Strategies to increase patient adherence to SP have been recommended, such as developing activities free of charge, in-person visits, making telephone contacts with first-time referred patients, or even accompanying individuals to their initial session and promoting patients confidence and motivation, while engaging them in health literacy promotion [17,43,54,55]. Offering peer support, peer mentors or buddy systems in understanding health information and interacting with healthcare professionals could also prove advantageous [56].

When introducing SP as a crucial component of patient-centered care, the level and nature of support provided should be tailored to align with the individual needs, motivation and willingness of patients to collaborate with other healthcare providers [35]. Also, there appears to be a certain level of motivation that patients must reach before they are willing to participate in SP, highlighting the importance of finding ways to support patients in overcoming both the initial sign-up and the subsequent visits barriers [36]. Another key patient-related consideration pertains to their perception of care. Some patients are used to and prefer the biomedical model of care, wherein they favor a more passive role, and refrain from active involvement in the decision-making and, by extension, in interventions addressing non-medical determinants of health [17,32,57]. Moreover, patients’ adherence to innovative interventions and autonomy in decision-making may depend on their sociocultural background [58,59]. In addition to readiness of the context, it is essential that SP programs are also adapted to the context in which they are being implemented. The level of flexibility of an intervention or its components is one of the main ingredients of a complex intervention [60]. Flexibility in intervention delivery allows for variation in how, where, and by whom interventions are delivered and received [60]. SP is an intervention that needs to be adapted to the local context, namely the needs of the individuals, the culture, the community structure, the health system and the setting of practice [61]. In the present study, elements such as the construction of tools tailored to the local context and the reliance on the existing social service organizational structure demonstrated the flexibility of SP implementation and were identified as facilitating factors. As previously reported, SP could benefit from engagement from various healthcare professionals and macro-level approaches that establish well-defined strategic, tactical, and operational planning within the health system [32]. Hence, an absence of endorsed national policies and guidance from healthcare providers involved can pose an obstacle to active participation in SP initiatives [45].

As the implementation of a new intervention can be affected by its context, a new intervention may also, in turn, change aspects of the context in which it is delivered [23]. In this sense, interventions can be conceptualized as temporally restricted sequences of events, novel activity settings, and technologies with the capacity to catalyze transformative changes within a system through their dynamic interaction with the contextual factors and the competencies engendered by this interaction [50]. Indeed, an intervention can be viewed as a critical occurrence within the history of a system, leading to the evolution of new structures of interaction and new shared meanings [62]. Interventions affect evolving networks of person-time-place interaction, changing relationships, displacing existing activities and redistributing and transforming resources [62]. Exploring the mechanisms through which interventions bring about change is essential to understanding how the specific intervention’s effects occurred and how these effects might be replicated in similar future interventions [23].

Conclusions

There is currently a boost of SP initiatives in diverse contexts worldwide, but evidence gaps still remain about the implementation process of this complex intervention, i.e. what works, how and why in order to improve project scalability and sustainability. This study assessed the implementation of a pioneer SP program, providing valuable insights on the challenges of implementation in real-world contexts, which can contribute to the development of implementation science. Findings from this study may assist to design and implement future SP projects and to develop strategies that improve acceptability among patients and stakeholders, as well as intervention’s efficacy.

The findings of this study illustrate the influence of the context’ readiness for SP throughout the development of the program, demonstrate that implementation depends on the flexibility of the intervention and reinforces that the changes caused by the intervention can potentially reach a systemic level. Future investment in human resources and the development of partnerships to strengthen community responses can help improve and sustain SP interventions. Our findings suggest that it is imperative to develop strategies to promote patient health literacy, motivation, and confidence in SP and to manage their own health and well-being. Factors influencing patient adherence should be explored in future studies and may be used to guide tailored implementation improvements and delivery of SP interventions elsewhere.

Acknowledgments

We sincerely thank all participants for their time and valuable contributions to this study.