2.1. Study Design

We used a qualitative descriptive approach [25, 26] and conducted online semi-structured one-to-one interviews [26] to gain insights into social prescribing implementation in BC. To ensure methodological rigor, we followed the 32-item consolidated criteria for reporting qualitative research (COREQ) guidelines for designing, conducting, and reporting the study [27]. We obtained ethics approval from the University of BC’s Behavioral Research Ethics Board (H22-01858).

2.2. Study Setting and Participants

We completed this study in the province of BC, located on the west coast of Canada, which has a population of around 5 million people. Notably, most BC social prescribing programs focus on people aged 60 years and older [28]. Many of the programs started in January 2020, before the beginning of the COVID-19 pandemic. At the time we conducted this research, there were approximately 20 sites available across BC, and we included 11 social prescribing community connectors from BC. Using an online search engine, we identified publicly available information for organizations in BC which self-described as providing social prescribing services. For recruitment, we contacted programs using publicly available email addresses. We also sent an ethics-approved email of introduction to a social prescribing organization requesting they share the study details within their network. If participants wanted to take part, they would contact the research study coordinator directly via email. We provided participants with information and a written consent form. Participants agreed to take part in the research by giving verbal consent.

2.3. Data Collection

We conducted interviews over a university-based Zoom platform (Zoom Video Communications Inc., CA) with one (EE) or two authors (EE and MCA). We followed a consistent process, and we turned off the video for interviews and anonymized screen names. We intentionally collected and reported minimal information on participants given the small community of people working in social prescribing in BC. We recorded (with permission) and transcribed the audio verbatim via an external company who signed a confidentiality agreement. Additionally, one interviewer (EE) took written notes to supplement the recordings.

In Table 1, we provide sample interview questions used in this study, which were based on guidance for conducting implementation science research [23, 24, 29, 30]. The predetermined implementation factors included program acceptability, adoption, reach, dose, feasibility, fidelity, and sustainability, and community connectors’ self-efficacy in delivering the program.

2.4. Data Analyses

We used directed content analysis [31], which is a deductive qualitative approach guided by theories or frameworks to extend frameworks and/or to focus research questions [31]. We chose this approach because of the practical nature of social prescribing and our aim to identify implementation factors to consider in future research studies. During the analysis process, two authors (EE and MCA) independently read and reread the interview scripts from the perspective of the predetermined implementation factors (themes) [31] based on published guidance [23, 24], and using NVivo software (QSR International, MA, version 14). While reviewing the interview transcripts, the authors specifically sought to identify how the information provided could be considered an implementation factor, drawing on insights from previous research [23, 24]. The authors (EE and MCA) independently coded information from transcripts and shared their NVivo files. For the first three interviews, the two authors met to discuss the merged codes and then one author (EE) merged codes (from both authors) for the remaining interviews. The second author (MCA) reviewed themes and confirmed the codes met the concept for each implementation theme, as guided by the published literature [23, 24]. To describe participants’ responses to specific questions related to (1) community connectors’ roles and programs, (2) implementation barriers, and (3) perceptions of the future of social prescribing, one author (MCA) synthesized responses, and a second author (EE) confirmed them. We provided quotes (illustrations) to exemplify participants’ perspectives for themes. We randomly assigned participants a number for the purposes of reporting quotes (e.g., the assigned participant number was not based on when the interview occurred temporally) to anonymize findings. We labeled participants’ quotes using the following format: community connectors (CC1 to CC11).

2.5. Research Team Reflexivity and Rigor

Personal characteristics of interviewers: The positionality of the two authors (EE and MCA) who conducted the analysis included the following characteristics: They both lived in BC and worked at a university and had experience with rehabilitation research (EE and MCA) and practice (MCA); both authors had a PhD. One author (EE) was a new investigator while the other author (MCA) was a professor with over 20 years of research experience. Neither of the two authors (EE and MCA) had lived experience with social prescribing, but one author (MCA) previously worked clinically as a physiotherapist with older adults across the continuum of care. The authors did not have a prior relationship with the study participants (community connectors). One author (MCA) had research partnerships with colleagues involved in the dissemination or administration for social prescribing in BC, but these colleagues were not directly involved in this study.

We aimed to ensure study rigor in the following ways. First, we developed and followed a detailed study protocol to promote consistency in data collection [32]. Two authors (EE and MCA) independently created and merged codes (confirmability) to represent multiple concepts, and we supported credibility by actively seeking negative cases [33]. The two authors (EE and MCA) had iterative reflexive discussions, including challenging assumptions (reflexivity) [34]. We determined data sufficiency when successive interviews generated no new information related to our questions [35].

3.1. Programs and Participants

Most participants, who worked as a community connector, had health- and social care–related educational backgrounds and/or experience. They reported the composition of social prescribing teams varied Six participants reported programs were coordinated by one person, while other programs had two or more team members. Participants reported they called people who received social prescribing either clients, participants, older adults, or seniors, and the terms varied across sites. Eight participants reported that volunteers were part of their program, and their roles included calling clients (social or wellness calls), home visits, dropping off/delivering items (e.g., food), teaching technology skills, and driving/accompanying people to events.

3.2. Perceived Program Barriers

Participants highlighted several implementation challenges, when specifically asked about program barriers. Four participants reported challenges with locating available resources. Some clients’ needs, such as hoarding support or services for people with dementia, were not adequately addressed by existing programs, posing challenges for social prescribing. One participant shared: “[There are] huge systemic gaps that you get referrals for people and then… how do you meet that need? It would be simple if you had programs for everything, but there isn’t.” [CC4]. Participants also emphasized the need for regular updates on available community resources and a platform for sharing knowledge and information, potentially through online meetings or guest speakers from relevant health authorities.

Other potential barriers identified included challenges for some older clients living on low income who may not be able to afford access to community programs (identified by three participants), and defining the scope of the social prescribing program or community connector role (identified by three participants).

3.3. Implementation Factors—Themes

We organized participants’ responses based on a priori identified implementation factors [23, 24]. Below, we provide a description of the factors, which we used to create the interview guide, including acceptability, adoption, reach, dose, feasibility, fidelity, self-efficacy, and sustainability (Table 2). The information shared by participants included factors or determinants which could impact on program implementation. For example, training and engagement of community connectors can impact on program adoption, and/or how the referral system can impact program reach.

Acceptability of the program: “Satisfaction with various aspects of the innovation” [36] p. 68.

Participants spoke very highly about the acceptability of the social prescribing program: “It’s a great program. It should have been there before” [CC6]. They emphasized the need for social prescribing: “I think there definitely is a need for it and there is room for it to have a little more support.” [CC1], and its potential impact: “I think that more and more in different facets of our life we’re seeing that the social connections benefit us and that being engaged in community is good for us.” [CC9]. They further expressed a desire for social prescribing programs to expand to other locations. “I think it is something that should not only continue but expand.” [CC5].

Preparing community connectors for program adoption: “uptake; utilization; initial implementation; intention to try” [36] p. 68.

The term adoption refers to an organization or setting-level outcome [36] of the number of sites and providers who take up an innovation [37]. However, in BC, the provincial programs already existed when we conducted interviews. Other work identified the need to have guidelines and resources to help providers adopt a new intervention [37], and therefore, here we discuss factors related to community connectors’ preparation for their new role and program.

Most of the social prescribing programs in BC started in January 2020. They quickly transitioned to an online delivery mode due to the start of the COVID-19 pandemic, which could have had implications given not all older adults have (i) computer literacy [39] and (ii) access to hardware (smartphones or computers), possibly due to costs [40]. Furthermore, access to only remote delivery of social prescribing for community connectors could have posed some challenges, such as defining the best mode to connect with clients and/or developing rapport and building trust without meeting in person (especially relevant during a pandemic) [41].

Participants noted they received some on the job training, but others suggested specific training may be useful in the role of a community connector, such as active listening, conflict management, critical thinking, goal-setting, information on cultural diversity or cultural humility training, and motivational interviewing. Several participants commented on the knowledge and skills which would be beneficial in their community connector role (e.g., awareness of available resources): “And you have to be aware of your community and the resources it has to offer and how to counsel and work with people. So, that’s the knowledge that I think you need to have.” [CC1]. Another participant noted “I would say not necessarily training but it’s kind of like health systems navigation or how can we work better in partnership with the healthcare providers.” [CC3] and “You have to be personable. You have to have good communication with people, ability to listen, knowledge of local resources or ability to learn. Good researching skills I think is important. Networking ability is also quite vital.” [CC4]. One participant highlighted the importance of providing printed materials for older adults who may have lower digital literacy or confidence, and/or who may have limited access to online resources. “You have to have the ability to print [program materials] because older adults don’t—a lot of them don’t go online.” [CC4]. Finally, one participant commented: “I think at the end of the day it’s being able to make those meaningful connections with seniors and gaining their trust and being able to work with other people, hooking them up for programs.” [CC8].

Reach: Program Referrals: “The absolute number, proportion, and representativeness of individuals who are willing to participate in a given initiative, intervention, or program.” [37] p. 3.

Although reach refers to an individual-level implementation factor, others have noted reach is the “extent to which implementation (specifically recruitment) activities result in equitable reach among different subgroups” [42] p. 6. In our study, participants shared information on referral sources, which can have an impact on who is referred to social prescribing. Specifically, there were a number of diverse sources of referrals to the program, such as healthcare providers affiliated with a health authority, community services, family physicians, and community living organizations. Other pathways for entry into the program included self-referrals, referrals from community members, and even referrals from neighbors or friends. However, some participants reported challenges with engaging providers to refer patients to the program “…the referral process is not an easy one within the healthcare system at times.” [CC7]. Furthermore, not all referrals resulted in program participation, sometimes due to factors such as clients′ lack of understanding of the program (which may result in a hesitation to engage in the program) and/or the need for multiple contacts to establish the initial connection: “a lot of the time I get referrals and I make a phone call and sometimes [it] takes multiple phone calls to make the first initial connection.” [CC10]. Consequently, some people may have missed out on social prescribing due to challenges with establishing contact.

Tailoring the program’s dose: “amount of program delivered” [36] p. 70.

Program dose varied across clients and required tailoring of program delivery. Specifically, there were variations in the length of time a client may receive social prescribing (and specific services) because of individual needs. Some clients had straightforward needs, while others required more in-depth assessment and support. Furthermore, participants reported variability in workload and resource availability. Thus, program delivery and dose could be influenced by clients’ needs and available resources. “[The program] varies because sometimes some people really just need a quick connection to certain services. Like say, the housekeeping or transportation…” [CC4]. Participants also described the need to tailor the social prescription to clients′ needs, which can change over time. “We have three levels: high needs, medium needs, and low needs. And based on that, we kind of design [the prescription]” [CC11].

This aligns well with the aims of behavior change theory [43, 44] and behavior change techniques (BCTs) [45] which posits strategies are needed to support people in adopting and sustaining new behaviors. Ideally, this is done from the perspective of person-centered care [46] and coproduction of the prescription [7].

Feasibility of the program: “suitability for everyday use; practicability” [36] p. 68.

Overall, participants described the social prescribing program as feasible to deliver but identified areas for improvement. One participant noted the program was manageable to plan their time and appointments. “It’s quite easy. Quite easy, actually… I can plot my time myself in terms of one day making phone calls, the next day setting up [those] appointments… [and] introducing people to the community. It’s not that challenging, no.” [CC5]. While another participant acknowledged feasibility of the program but also noted: “I think there’s room for improvement to make it more feasible, but it is feasible.” [CC9]. Resource availability was emphasized to enhance feasibility. “It all comes down to the programs and resources that are available to the staff… very feasible.” [CC8]. One participant reported: “[The program] requires time management… It’s a learning process, but it’s doable.” [CC10]. While another participant noted “there’s just not enough resources for things that we need. But for actually conducting the program, yeah, there’s no—I don’t see there being any problems with [conducting the program]” [CC1]. Thus, managing the program workload could vary according to the specific clients’ needs and resources available.

Program fidelity: “delivered as intended” [36] p. 68.

Participants raised issues related to program fidelity including the dose or amount of involvement with social prescribing depending on the unmet needs, communication, and program features. They discussed the practicalities of social prescribing, which was context dependent on the ability to access resources. “…we have clients who are here for housing who are experiencing financial crisis. And some clients are experiencing domestic violence, and some just want some simple community resources navigation. So, it can be, like, very different from client to client.” [CC3]. A recurring topic was challenges related to navigation and accessing necessary resources, such as transportation, housing, and medical equipment. This presented a barrier to the fidelity of implementing the program as intended. “… Resources… [like transportation, housing, medical equipment, hearing aids…] things like that need funding or a place where I could easily access to get help from. I don’t have that. And that becomes a little challenging.” [CC10].

Some participants further noted program features which could support its delivery. For example, “having a clear expectation for the people who are making the referral [to] the social prescribing program, also have a clear expectation, like, for the client” [CC3]; and “continuous funding and have better standardized promotional material…” [CC3]. Another participant noted the need for “…program materials that are standardized across the province so that we all have access to the same things [to] have less variability.” [CC4], and “we’re working on those materials right now. Manuals and how to coordinate this program effectively and efficiently.” [CC10]. One participant noted the importance of continuous follow-up with clients. “We do follow up to see if everything is going well. If things have gotten better ever since they started using our program or things have gotten worse or if there is anything else that we can assist them with.” [CC2].

Community connector self-efficacy: Belief in one’s abilities [38].

All participants who implemented the program expressed a high degree of confidence and comfort in delivering the program. “We are pretty confident of—about the program and delivering it.” [CC6]. One participant noted: “Social prescribing [here] is quite different than when it started. And that’s due to the situation changing and me learning about the community and what powers that I actually have…” [CC10]. The participant highlighted the significance of the initial conversations, which provided reassurance to clients. They noted that these interactions contributed to calmness and purpose among clients, even when immediate solutions might not be provided, “I feel like that first conversation I have with most of my client[s] is so reassuring… I feel that part gives them a sense of calm, a little bit, knowing there’s somebody that wants to work with them.” [CC10].

Finally, a participant expressed confidence in their abilities, however noted challenges with identifying community resources: “Very confident. Very confident…even though I’m not always confident about some resources, there’s always [a] waitlist…” [CC10].

Sustaining the program: “maintenance; continuation” [36] p. 68.

Participants discussed the development of the social prescribing program, from its early days just before the start of the COVID-19 pandemic to its evolution over three years. They suggested the sustainability of social prescribing programs in BC was tied to its ability to adapt to changing circumstances, engage volunteers, and build relationships with community and healthcare partners. Participants expressed a strong belief in the program’s potential and were invested in its continued success.

The involvement of volunteers and community collaborations were factors in sustaining the program. Volunteers played a role in program delivery (e.g., calls, delivering items, transportation), alleviating some of the community connectors’ workload, and supporting clients. Some volunteers were officially enrolled under the social prescribing program (i.e., they were affiliated with the program), while others were recruited from different sources, such as community agencies (i.e., others offered to provide volunteers from their organization to the social prescribing program). One participant shared, “So I have one volunteer… awesome volunteer…been with me for about 6 months now. But I hope to grow that team, like, have more volunteers…” [CC10]. Furthermore, “volunteers and recruiting university students or high-school students to… [work] for us in the future…” [CC10].

Collaborations with other nonprofit agencies in the community contributed to the program’s sustainability. For example, partnering with a community organization that provided volunteers fostered the expansion of the program’s reach and capacity. These collaborations enabled the program to access additional resources and support. “So, another idea that I came up with is partnering with another agency that would solely …provide me with volunteers.” [CC10].

Several participants suggested sustainability involved greater integration of the program into the healthcare system and partnerships with community organizations to provide support and funding support for clients: “…more partnerships like with [recreation], parks, city, to actually provide different types of subsidies for our older adults.” [CC11]. Furthermore, some participants highlighted the importance of education and raising awareness about the program among service providers and the community. Expansion and sustainability could be achieved through a better understanding of social prescribing and its benefits.

3.4. Social Prescribing: Looking Back and Moving Forward

Some comments discussed expanding the programs: “I strongly feel it will just grow and grow and grow.” [CC6] which could lead to benefits for people and the community: “so having those connectors just to inform people of what’s in their neighborhood even, I think, is a really valuable asset to the community.” [CC9]. While another participant stated: “…what I would love is that when people go to their doctors, and they have these diet-related illnesses, then they would receive some kind of [“prescription”]… [CC7]. Furthermore, another participant spoke specifically to scaling up the model across the province “I would like to see funding for a community connector and social prescribing for each community.” [CC8]

One participant spoke about cultivating collaborations: “And the future is, I feel like, more community environment, like, more volunteers, skilled volunteers, more intake from—buy-in from the healthcare providers and, you know, more streamlined referral and also more holistic approach.” [CC11]. This was similar to comments about having meaningful connections to support older people: “…meaningful [community] partnerships then we would actually be all involved to the health and wellbeing of our older adults.” [CC11]. One novel perspective was to encourage more reciprocal collaboration between community connectors and health and social care providers: “It’s not just the healthcare provider referring their clients to us, but hopefully there’s a two-way support where there’s that feedback loop in between the social prescribing manager and the healthcare providers…” [CC11].

Finally, comments from participants on the future of social prescribing were related to funding and referrals “…continuous funding and have a better standardized promotional material…” [CC3]; developing the evidence base for social prescribing “So, I hope that physicians and [changemakers] get the evidence and…research … that [social prescribing is] important.” [CC9] and leadership, “Definitely a lot of potential with this program, and I really think that whoever is leading the program is shaping the program.” [CC11].

4.1. Community Resources

The variability of people’s unmet social needs and available resources can impact on social prescribing implementation [42], and challenges noted within the BC experience were present in other global locations [18, 47–52]. Delivering an intervention as planned (fidelity) may be framed with the concepts function and form. Function is considered the proposed purpose (and has been called the fixed components of an intervention or program [53]), while form relates to how the intervention is delivered (e.g., the process factors such as providers, material, and dose) [42, 53–55]. That is, despite the differences in people’s unmet needs and local contexts, there are core functions in social prescribing which lend themselves to developing a systems approach (based on core or fixed functions) with room for flexibility and adaptation (form) within the context of local communities. Future work would benefit from including theory when developing and evaluating social prescribing interventions [56] and to support the identification of its core functions and “active ingredients” [57].

Lack of access to community resources was a consistent finding throughout this work and mentioned across many of the themes. It is possible resources were available, but they were hard to find, and community connectors’ knowledge of existing community assets was essential for effective care navigation [49]. Alternatively, some communities may lack essential services, impacting negatively on social determinants of health—the social and economic factors which can affect people’s lives. Others have noted social prescribing is dependent on resources such as infrastructure, activities, and transportation [48], and in particular, community assets could be considered as “frontline resources in the battle against loneliness” [58] p.1311. The sustainability of social prescribing may rely on dependable community services to which providers were confident in making referrals [59]. In addition, several studies previously discussed the challenges with longer term sustainability of community resources (e.g., the “prescriptions”) without funding in place to support them [17, 47, 50, 51].

Social prescribing aims to address the downstream manifestations of people’s environments, for example, unmet needs [13]. However, for social prescribing to reach its full potential, there is the need to consider community and structural barriers which could impact people’s social determinants of health. Or, as Hart wrote in 1971 in an article titled the “Inverse Care Law”: “The availability of good [medical care] tends to vary inversely with the need for it in the population served.” [60] p. 7696. In other words, if the lack of available resources (identified in social prescribing) is attributable to structural/environment challenges, the problems, which may lead to the need for social prescribing, may limit the ability of social prescribing to support people in need. Fixing the short-term problems (with social prescribing) without addressing the structural issues may lead to further challenges to address health inequities [15, 61]. Furthermore, even if resources exist, there can be challenges to support people to take up and continue with the social prescriptions, as we [5] and others [62] noted previously.

4.2. Communication and Relationships in Social Prescribing

Study participants identified communication to promote social prescribing program adoption, reach, fidelity, and sustainability, a finding consistent in other work [18, 63]. At the level of adoption and reach, consistent communication on the scope of social prescribing can support appropriate referrals and building relationships. Previous work suggests communication (in general) about the scope of social prescribing may help clarify the care model and the role of community connectors [64] for people who may refer to the program. Of note, a recent synthesis of evidence on community connectors’ (link workers’) role [17] discussed the need to balance between lack of or an evolving role definition and scope, alongside the flexibility with the new role. Communication between people and groups or organizations may also impact on the sustainability of social prescribing [63]. Furthermore, communication between community connectors and people working in the community sector can support program implementation and encourage partnerships [18].

Some research suggests social prescribing is not a single complex intervention rather it consists of many people and relationships all working together to support people and their unmet social needs [65]. Thus, communication is an important element within the delivery of social prescribing [49]. In another study, clients highlighted the important role of community connectors, and in particular their communication style which made clients feel supported [66]. Other work suggests collaborative relationships across sectors are a “key ingredient” for implementing social prescribing [67, 68], and in particular, the important role of community connectors to act as a bridge between people receiving and referring to social prescribing, and community organizations [68].

Recent work [61] highlights a communication style for community connectors which aim to be more responsive to client’s needs—similar to a participant in this study who spoke of an approach which was flexible and person-centered. From a different stand point, but similarly, other work noted lack of time and communication were barriers to follow-up with social prescribing clients [64]. Specifically, language barriers were noted by participants in this study and reported in previous work [69–71].

Of note, there was a suggestion to increase communication between community connectors and health providers. Communication is a significant aspect of care delivery, but it depends on clients′ willingness to share certain aspects of their lives with all team members. Some clients may hesitate to disclose symptoms and/or diagnoses due to the perceived stigma linked to specific chronic conditions [72, 73]. This area requires further exploration, and as noted previously, working with people and communities to advance social prescribing programs aligns well with the growing literature of cocreation or coproduction [74, 75] of public health initiatives.

4.3. Social Prescribing and Volunteers

Participants (8 of 11) in this study highlighted volunteers as team members who took on a variety of supportive roles in the implementation of social prescribing, such as providing social calls and attending home visits or appointments. Volunteers play an important role to society and the economy through engagement in unpaid nonprofit activity [76]. Overall, Canadian volunteers engaged in more than two billion hours of activities in 2017 with an estimated contribution of CAD$55.9 billion [77]. Although volunteers support people and communities, less information is available for volunteering in the context of social prescribing, and when available, the information is described as a “prescription” for people to engage in rather than a service [78, 79].

4.4. To the Future

The findings from this work generate research ideas for future discovery. First, this study highlights common features of social prescribing which could translate into the development of its “core functions” underpinned by the flexibility of “form” to address the nuances of different contexts (e.g., a systems approach based on theory) [57]. Future studies are needed to create social prescribing core functions which may help identify its “active ingredients” [53], while considering the-often changing temporal nature of people’s unmet needs and “issues with delivering care according to a model which is underpinned by a unilinear timeline.” [80] p. 1162. Furthermore, there is a need to support research study design to evaluate the effectiveness and impact of social prescribing without the need to “standardize” all contextual factors [53]. Future work could also explore the presence of resources and/or ways to optimize identification and wayfinding for community connectors and other health and social providers. For example, access to online (searchable) databases of resources available in local communities and/or development of community asset maps to visually display locations of resources when communicating with people who are receiving social prescribing. At the societal level, this suggests the need to better understand availability and funding for the community assets, which may be “prescribed.” This work further highlights the role of communication to disseminate the program (to enhance referrals and possible program reach) and to bring together people and organizations working in different sectors—to breakdown silos and to create a more streamlined process to connect people with unmet needs to communities, people, and resources. Finally, these findings underscore the need to look closely at the role of volunteers in social prescribing, in addition to ascertaining strategies to engage and retain them.

4.5. Study Limitations

This study is the first in Canada to provide insights into participants’ roles as community connectors and the development and sustainability of social prescribing in BC. However, our work is not without limitations. For example, this study only included participants working in social prescribing for older adults, because at present, this is the main focus for the program in the province. While we interviewed community connectors from almost half of the 19 sites available within the province (when we conducted the interviews), it is also possible the people who did not take part in the study had different perspectives for delivering social prescribing. Third, we used directed content analysis, which may have some inherent bias [31], as data were coded deductively with a predetermined set of implementation themes. Fourth, we only interviewed people delivering (but not receiving) social prescribing. Although social prescribing emphasizes the agency of clients and communities, our study focused only on community connectors. Furthermore, the timing of this study is significant and provides insights into how the programs evolved and were sustained during the COVID-19 pandemic. However, if we repeated a similar study in the province, we might have different findings either due to the growth and evolution of the program and/or the context in which social prescribing is now being delivered. Finally, we only interviewed community connectors from one province in Canada, where there are unique healthcare systems and contextual factors to impact on delivery mechanisms. Despite this, the implementation themes we observed based on the perceptions of community connectors were similar to studies from other countries.