Creating and sustaining enabling systems and communities to address social needs: protocol for a living lab social prescribing study

Creating and sustaining enabling systems and communities to address social needs: protocol for a living lab social prescribing study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Creating and sustaining enabling systems and communities to address social needs: protocol for a living lab social prescribing study Candice Oster, Ashleigh Powell, Claire Hutchinson, Sahar Faghidno, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6461338/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Social needs - such as housing, income, food security, and social connectedness - have a significant effect on health and wellbeing. One way to address social needs is through social prescribing, which involves screening for unmet needs (e.g., during healthcare appointments) and providing referrals to social and community services. For social prescribing to be effective, it must address both individual needs as well as support the social and community services that are required to meet these needs. The objective of this study is to adopt a place-based framework that combines: 1) individual-level referral for social needs, with 2) community and stakeholder engagement to determine community assets, resources, networks, and need to inform model development. Methods The study will be conducted in three-phases across two low-socioeconomic Australian communities, underpinned by the ‘enabling places’ theoretical framework. Phase 1 will involve identifying key elements that enable place-based social prescribing using photovoice methods with health and social care providers and community members. Outcomes will inform co-design workshops to develop a place-based social prescribing model of care that is augmented by technology to facilitate integration across health, social, and community services. In Phase 2, the co-designed model will be implemented in the two communities. Phase 3 will involve a mixed methods approach to the evaluation of the model’s implementation, effectiveness, and social return on investment. Discussion The study aims to foster place-based initiatives and community development, a missing element in much of the social prescribing discourse. It is anticipated that outcomes will contribute to the design and implementation of social prescribing models that are tailor-made for Australian communities, systems, and funding systems. Social prescribing Social determinants of health Participatory research Social support Community referral Social return on investment Living lab Background Social needs such as the lack of housing, income, and food security, as well as loneliness and social isolation, are increasing worldwide, exacerbated by the cost-of-living crisis and the flow-on effects of the COVID-19 pandemic ( 1 ). In Australia, homelessness has increased 5.2% since 2016 ( 2 ), over 5.5 million have experienced food insecurity ( 3 ), over 25% find it difficult to get by on their current income ( 4 ), and around 25% experience loneliness and social isolation ( 5 ). Social needs cause significant distress and hardship ( 6 ). Yet those most in need struggle to access social and community support due to a lack of information, referral pathways, and local services ( 7 ). There is a growing trend where patients present during primary health care appointments, particularly in general practice, with social needs ( 8 ). However, health practitioners are not equipped to address these needs, and this has been shown to lead to clinician burnout, vicarious trauma, and compassion fatigue ( 9 ). At the same time social and community services struggle to link with these ‘invisible populations’ because they are disconnected from services, systems, and communities ( 9 ). One way to address patients’ social needs and reduce health system burden is through better integration across social, health, and community sectors ( 10 ). Social prescribing is an approach to service integration that aims to address patients’ social needs through screening (e.g., during healthcare appointments) and referrals to social and community services. Box 1 provides a detailed definition of social prescribing from an international Delphi study ( 11 ). Box 1. Internationally agreed definition of social prescribing Social prescribing is “a holistic, person-centred and community-based approach to health and well-being that bridges the gap between clinical and nonclinical supports and services. By drawing on the central tenets of health promotion and disease prevention, it offers a way to mitigate the impacts of adverse social determinants of health and health inequities by addressing nonmedical, health-related social needs (e.g. issues with housing, food, employment, income, social support). While it looks different across the globe, it is recognised as being a means for trusted individuals in clinical and community settings to identify that a person has nonmedical, health-related social needs and to subsequently connect them to nonclinical supports and services within the community by co-producing a social prescription—a nonmedical prescription, to improve health and well-being and to strengthen community connections. It requires collective action and collaboration among multiple sectors and stakeholders.” ( 11 , p.9) Social prescribing is relatively advanced in the United Kingdom (UK) and the United States (US), with increasing development and uptake worldwide ( 12 ) and growing evidence of positive effects on wellbeing and cost-effectiveness ( 13 – 15 ). In Australia, social prescribing is in its early stages of development and implementation but is gaining significant momentum ( 7 , 16 – 19 ) and is included in health policy ( 20 ). The challenge for Australia is that its health and social systems are particularly fragmented, with different funding models and governance systems, compared with those of many other countries such as the UK and the US ( 21 ). This means overseas models cannot be simply transposed onto the Australian context. Further, social prescribing programs typically focus on addressing individual social needs, neglecting the community context in which these needs are to be addressed ( 22 ). Without additional investment in social and community supports, the implementation of social prescribing risks creating excessive burden for the social sector, including ‘bottlenecks’ in service access and referrals to non-existent supports (termed the ‘road to nowhere’ problem) ( 9 , 23 ). A further critique of social prescribing is that it risks individualising social determinants of health (referred to as ‘victim blaming’), ignoring the underlying structural, including socio-economic, factors that shape life circumstances ( 23 ). This places responsibility and therefore blame for addressing social determinants on individuals rather than governments and societies ( 23 ). The current Australian study aims to shift the paradigm of social prescribing from an individual level to a community-based response to address social needs arising from social determinants of health. The project adopts a place-based framework that combines: 1) individual-level referral for social needs, with 2) community and stakeholder engagement to determine community assets, resources, networks, and need to inform model development. Specifically, the study aims to: 1. Identify key elements that enable place-based social prescribing in Australia and use these to co-design a technology-enabled social prescribing model. 2. Implement the new social prescribing model in two high-needs communities. 3. Evaluate the model’s implementation, effectiveness, and social return on investment. Methods/Design A living lab approach The project will adopt a living lab approach (also known as a natural experiment) that will blend research and implementation processes in real-life community settings ( 24 ), working closely with Partner Organisations (POs) from health care, social and community services, and local government to co-design, implement, and evaluate solutions systematically. This is consistent with the requirement for “collective action and collaboration among multiple sectors and stakeholders” in the definition of social prescribing definition in Box 1 ( 11 ). The research will leverage the real-life context of the Community Connection Program (CCP), a program that is administered by the Department of Human Services South Australia (DHS; one of the POs). The CCP aims to address social exclusion by linking participants with multiple services within the social sector (e.g., financial assistance, food relief, housing, family relationships). The CCP is an ideal real-world context for the study as it aims to link participants to multiple services to meet their social needs, but as yet lacks referral pathways to/from primary health care. The project will be undertaken in two Local Government Area (LGA) locations covering low socioeconomic communities in South Australia, where CCP is delivered by POs from Non-Government Organisations (NGOs) (PO Anglicare SA on behalf of a consortium of three other NGOs) and the LGAs (POs Onkaparinga and Marion Councils). In this project, CCP referral pathways will be expanded to/from primary health care, with the support of PO Adelaide Primary Health Network, and broader local community services, using a co-designed technology-enabled referral system (building on and adapting pilot software developed by PO Semantic Consulting). General practices will be the starting point, with the focus on the Practice Nurse role, but other primary, allied (e.g., physiotherapy, pharmacy) and holistic (e.g., massage therapists) health settings would also be included. The living lab approach will enable co-designing, testing, and evaluating of the new social prescribing model in the real-life conditions of the two LGAs. The project will be overseen by a steering committee comprising key stakeholder representatives from health care, social care, and community. The theory of ‘enabling places’ The communities and service settings in which social prescribing is implemented encompass both physical ‘spaces’ (e.g., a clinic, a community centre) and people’s experiences within these spaces – together, these constitute the ‘places’ of social prescribing. The real-world context of the living lab provides the opportunity for a place-based approach to social prescribing that explicitly acknowledges the importance of place as “a fundamental feature of human experience, deeply implicated in the development of identity and belonging and central to the conduct of everyday life” ( 25 , p.149). There has been extensive research exploring the qualities of place that are generative or enabling of health and wellbeing ( 25 ). The health and wellbeing qualities of natural environments, for example, can be seen in social prescribing programs that focus on nature-based health interventions (green prescribing) ( 26 ). Our project will extend this research beyond an understanding of the health promoting qualities of specific environments to explore the person-place encounter and how this is enabling of wellbeing via social prescribing, drawing on Duff’s theory of ‘enabling places’ ( 25 ). Duff views ‘enabling places’ (places that are supportive or enabling of health and wellbeing) as comprising three classes of enabling resources - social (social networks/ interactions), affective (e.g., feelings of belonging), and material (e.g., objects, physical spaces) ( 25 ). Enabling resources “support the maintenance of health and wellbeing; the mitigation of specific risks and vulnerabilities; and the creation of health promoting or ‘enabling’ places” ( 27 , p.339). Through this lens, wellbeing is understood as a process that “emerges in everyday situations and environments” ( 28 , p.211) rather than as a quality that is intrinsic to individuals, allowing movement beyond an individualistic (potentially victim-blaming) approach to addressing social needs in social prescribing. Drawing on the theory of ‘enabling places’, this project will include “an evaluation of the character of enabling resources” in the two communities of focus and “a determination of the ways these resources might by harnessed” ( 27 , p.343) to better meet the social needs affecting individuals and communities. The theory of ‘enabling places’ will be applied to both develop and evaluate the social prescribing program. The project will be undertaken in three phases over three years. The overarching project logic and theory of change statement, which details the assumptions of the project and how the outcomes will contribute to change ( 29 ), were developed in collaboration with POs and are detailed in Supplementary File 1. Phase 1: Photovoice-informed co-design Photovoice will be used in Phase 1 to explore what constitutes enabling places for social prescribing, drawing on this understanding to co-design technology enabled, place-based social prescribing in the two communities. Photovoice Photovoice is a participatory action research method where people document and reflect on their realities/experiences using photography. Photovoice has three main goals: “( 1 ) to enable people to record and reflect their community's strengths and concerns, ( 2 ) to promote critical dialog and knowledge about important issues through large and small group discussion of photographs, and ( 3 ) to reach policymakers” ( 30 , p.369) by visually showcasing community issues and needs. It is an ideal approach for capturing people’s perceived realities of social needs and community capacity to inform co-design of place-based social prescribing. Visual methodologies like photovoice are able to transcend “cultural and developmental barriers to expression, which are inherent in much linguistically focused research”, providing a greater depth of understanding of people’s experiences than qualitative research interviews alone (31, p.e2216). In this study, photovoice will involve people taking photographs of situations/spaces/objects that help or hinder support for social needs in their communities and for their patients/clients. These photographs will be reflected on by participants in group discussions. This photovoice method will serve the dual purposes of data collection and community engagement, producing unique visual and qualitative data to examine elements of enabling places for social prescribing, and facilitating connections between community members, providers, and researchers. Recruitment: We will recruit both health and social service providers who provide services to the communities and community members themselves (n = 20 in each LGA) using snowball sampling; this sample size is appropriate in photovoice methods ( 31 ). Recruitment will be done via POs’ social media posts, newsletters/flyers, and email distribution lists. Data collection: Participants will be asked to take photographs that reflect their experiences of enablers and barriers to community support and connection over six weeks and share these through communities of practice (one for community members and one for service providers in each community), facilitated through the Discussion Forum feature within the university’s Learning Management System to ensure privacy of discussions. Participants will either use their own phones/cameras or be supplied with a camera as needed. No photographs that identify individuals will be included to protect privacy (e.g., by blurring/pixelating faces and other identifying features in the images). Participants will then come together in a workshop (one per LGA) to explore ‘What does “good” look like?’ for enabling systems and communities that address social needs. Participants will discuss their photographs and experiences in small groups and present these to the larger group for further discussion. Discussions will be audio-recorded and transcribed verbatim. Data analysis: Data in the form of photographs, Discussion Forum posts, and workshop transcriptions will be analysed using theoretical thematic analysis ( 32 ) in NVivo, where themes will be developed through the lens of ‘enabling places’ to identify enabling social, affective, and material resources for social prescribing in the two communities. The initial process will involve familiarisation with the data and generation of codes reflecting the content of the photographs and text. Codes will then be collated into potential themes. This will be followed by interpretive analysis in which the themes will be interrogated in relation to the ‘enabling place’ framework to explore how social, affective, and material resources are produced in the LGAs as enabling (or not) of social prescribing. Outcomes will be presented in a steering-committee workshop to explore barriers and enablers to place-based social prescribing for discussion in the next part of Phase 1: co-design workshops. Photovoice informed co-design Co-design is another participatory method that systematically brings together the expertise and lived experience of all key stakeholders (e.g., service users and providers) to the design of a collective solution ( 33 , 34 ). Four workshops (two in each LGA) will be conducted with health and social-service providers and community members (n = 25 participants in each workshop) to co-design a place-based model of social prescribing within the living lab of the CCP. Co-design will involve designing both the referral pathway and strategies for building community resources and support. Recruitment: Participant recruitment (n = 50 service providers; n = 50 community members) will be supported through PO community and provider networks. Service providers are expected to span general practitioners, practice nurses, allied and holistic health, and social and community services. Community participants will include any community members (aged 18 and over) that would like to take part in a co-design workshop. Data collection: We will follow a 7-step co-design process: resourcing, planning, recruiting, sensitising, facilitating, reflecting, and building for change, adapted from Trischeler et al. ( 33 ) to focus on fostering collaboration across siloed sectors ( 9 ). Resourcing will enable an understanding of the problems to be addressed, in this case how enabling places can be developed and sustained for social prescribing using the outcomes of the photovoice study. Planning and recruiting will be iterative across the workshops with PO support, building on the outcomes of each workshop to plan successive workshop content and recruitment. Sensitising (preparing participants for the design task) will be through a presentation of photovoice outcomes, explanation of the concept of social prescribing, and workbook activities where participants rate the relevance of social prescribing components and processes to their communities. Facilitating will involve the design of ideas for a social prescribing model through small group activities (e.g., participant journey mapping) that are then presented to the larger group for discussion. Reflecting on co-design outcomes and building for change (assessing feasibility and realisation of ideas generated through co-design) will occur in Phase 3. Data analysis and synthesis: Workshop discussions will be audiotaped and transcribed verbatim. Data in the form of workbooks, designs on butcher paper, and transcriptions will be analysed descriptively and synthesised into a draft social prescribing model and presented to the steering committee for reflection and refinement. Social prescribing technology: A workshop will be undertaken with POs to determine how to augment existing technology developed by the technology PO to ensure it is fit for the co-designed model, including integration of a database of community services and resources, integration with existing systems, and reporting processes to inform identification of service gaps and duplication. The outcome of Phase 1 will be a co-designed framework for technology-enabled, place-based social prescribing. Phase 2: Development and implementation of the model The project will be embedded across the two communities to test the generalisability and replicability of the co-designed model. This will involve developing all relevant components of technology-enabled, place-based social prescribing identified through co-design and include how to harness and develop the social, affective, and material resources identified through photovoice. While the specific components and resources are yet to be determined, examples include processes for raising awareness of the concept of social prescribing in the communities and de-stigmatising social needs; identifying people with unmet social needs; triage, referral, engagement, support, and follow-up; processes for understanding and developing community resources and networks. Two site project officers (one per LGA) will be embedded with POs working across the existing CCP delivery sites. They will undertake mapping of local services, develop and maintain databases, coordinate across CCP sites, build relationships with general practices and other relevant settings as determined through co-design, and manage data collection. The team also includes a marketing specialist who will be responsible for devising appealing marketing collateral (digital and hard copy information flyers, etc.) for raising awareness of social prescribing and how to part-take for professionals and members of the community. PO Semantic Consulting will adapt their prototype social prescribing platform based on the outcomes of Phase 1 codesign. The adapted technology will be pre-tested with POs, using the CCP. Additional settings will be four general practices (identified by PO Adelaide Primary Health Network). A range of evidence-based implementation strategies identified using the Expert Recommendations for Implementing Change (ERIC) ( 35 ) will be used, starting with the development of a formal implementation blueprint with POs, and identifying early adopters through PO networks. Staff in implementation settings will be trained in the co-designed social prescribing system and technology. A decision-tree tool will be put in place to help health service providers identify appropriate participants for social prescribing and refer them to the service. Community will be engaged through a purposefully designed and rolled out marketing strategy to address lack of knowledge of social prescribing in Australia, identified in our pilot research ( 9 ). The co-designed strategies for building community resources and support will be implemented, utilising existing community development processes and practices of POs (DHS, Councils, and NGOs). The social prescribing intervention will be implemented in general practice settings and other willing health organisations (e.g., allied health) and the CCP for nine months. Phase 3: Mixed-methods evaluation A mixed-methods evaluation will be undertaken across three levels: i) process evaluation to assess implementation fidelity and quality (qualitative); ii) implementation evaluation to examine broader contextual factors influencing model delivery (qualitative); and iii) outcome evaluation measuring the effectiveness and Social Return on Investment of the model in achieving its intended individual- and system-level outcomes (quantitative). Social return on investment (SROI) is an approach to economic evaluation, used to “identify what changes and what is important for [key stakeholders], giving a much wider measure of value” than standard economic evaluation ( 36 , p.3). SROI is a highly flexible form of cost-benefit analysis that will allow us to capture and express in monetary values social outcomes that are not typically included in traditional forms of economic evaluation ( 37 ). SROI plays a critical role in ‘translating’ social prescribing benefits into the ‘language’ that policymakers can understand, which is important at this early stage of model development and adoption in Australia. Recruitment: Evaluation and SROI participants will be community members (n = 300; ~150 per LGA) who have received support through the social prescribing program. POs have indicated the feasibility of this sample size. A conservative a priori power analysis was conducted (G*Power Version 3.1). For a small effect-size (Cohen’s d), a significance criterion of α = 0.05 and power = 0.95, the minimum sample size needed for pre- and post-comparisons across the two sites is 266. Therefore, aiming for a sample of 300 should balance both feasibility and statistical analysis considerations. Participants in qualitative evaluation (n = 30 social prescribing clients; n = 20 intervention staff) will be recruited via the social prescribing implementation settings. Data collection: Quantitative data will be collected at baseline, at exit from the program (12 weeks post enrolment), and nine months post intervention. Within the context of the living lab approach, quantitative data will include pre- and post-outcome measures routinely collected by POs as part of the CCP, to reduce the burden on service providers and participants. These measures include items developed by the DHS Data and Evaluation team that relate to referrals made, community participation, and satisfaction with care, and a Structural Wellbeing Index. The Structural Wellbeing Index captures participants’ current situation across nine life domains that are considered determinants of a person’s wellbeing (physical wellbeing, emotional wellbeing, financial situation, family and domestic violence, child safety, alcohol and other drugs, housing situation, gambling, social and cultural connections). Supplementing the DHS developed measure of wellbeing is a validated measure of personal wellbeing, the Personal Wellbeing Index (PWI)( 38 ). The PWI is valid and reliable measure that has been extensively used to assess subjective wellbeing across seven life domains, including standard of living, health, achieving in life, personal relationships, safety, community connectedness, and future security. Participants’ loneliness will be measured using the Campaign to End Loneliness Tool (CtELT)( 39 ), which is a valid and reliable three-item scale which was initially developed to assess improvements resulting from community-based programs that aim to address social disconnection. Qualitative data will be collected via individual interviews nine months post intervention and transcribed verbatim. Data analysis: Pre- and post- quantitative outcomes will be analysed using difference-in-differences analysis to compare changes in quantitative outcome measures between those participating in this program and a naturally occurring control group (captured via routine data collection in the CCP in other SA regions without social prescribing). This analytic approach to the comparison of the intervention group to the naturally occurring control group is a robust approach to examining data from this ‘living lab’ as it provides opportunities to examine – and control for – pre-existing differences and explore parallel trends between the groups over time ( 40 , 41 ). Qualitative data will be analysed using theoretical thematic analysis through the ‘enabling places’ framework (as per Phase 1) to explore participant experiences and identify barriers and enablers to place-based social prescribing. Calculating SROI: SROI will be informed by quantitative and qualitative data. Financial proxies will be applied to outcomes that have no market-traded value ( 42 ). Discounts will be applied to avoid overclaiming (e.g., discounts account for other services and supports participants might be accessing). The SROI ratio will be calculated by dividing the discounted, monetised value of outcomes by total investment (data from POs). Robust sensitivity analysis will test assumptions in the SROI Eq. (43). Outcomes will be presented at a PO workshop to explore the sustainability and scalability of the model based on evidence of model performance, derived from the qualitative and quantitative evaluation. Dissemination and knowledge translation will occur via the Australian Social Prescribing Institute of Research and Education, the Think Tank on the Future of Social Prescribing in South Australia (with membership across health care, social care, community and NGOs), and the South Australian Social Prescribing Community of Practice (comprising researchers with an interest/involvement in social prescribing). Ethical principles The study protocol was approved by the Flinders University Human Research Ethics Committee (Project Number 8366), in accordance with National Health and Medical Council of Australia and the Declaration of Helsinki. Discussion Social prescribing is a complex intervention across three disconnected sectors – health care, social care, and community – that aims to address non-medical, social needs that affect health and wellbeing. In addition to providing a referral pathway between sectors, it is important that social prescribing avoids individualising social needs and overwhelming existing resources and capacity in the social and community sectors ( 23 ). This study aims to identify key elements that enable place-based social prescribing and use these to co-design, implement, and evaluate technology-enabled social prescribing in two low-socioeconomic communities. A key strength of the project is the use of a living lab approach in close collaboration with POs across health, social, and community sectors ( 24 ). This will facilitate knowledge translation by meeting the strategic aims of addressing silos across sectors and service fragmentation through system integration and place-based care. A further strength is the use of participatory methods (photovoice and co-design) informed by the theory of ‘enabling places’ ( 25 ) to advance the theoretical understanding of social prescribing ( 44 ). Calculation of the social return on investment will furthermore enable communication of the value of community-based interventions and cross-sector integration via a social prescribing model in a language that Australian public and policymakers can understand to leverage future funding. The main limitation of the study is the short period of time of implementation. Longitudinal data beyond the 9-month period would allow greater understanding of processes and outcomes. The study is furthermore limited to the use of routinely collected data to determine impact. While this aims to reduce participant and practitioner burden and is consistent with a living lab approach, it potentially limits comparison of outcomes with the broader social prescribing literature that uses different outcome measures ( 45 ). Unmet social needs have a significant negative impact on Australians, worsened by fragmentations and the lack of collaboration in these sectors. Addressing systemic fragmentation will bring opportunities for early intervention to improve wellbeing, health, and social connection. The study aims to foster place-based initiatives and community development, a missing element in much of the social prescribing discourse. It is anticipated that outcomes will contribute to the development of social prescribing that is tailor-made for Australian communities, systems, and funding models. Abbreviations CCP: Community Connections Program LGA: Local Government Area NGO: Non-Government Organisation PO: Partner Organisation DHS: Department of Human Services, South Australia United Kingdom: UK United States: US Declarations Ethics approval and consent to participate The study protocol was approved by the Flinders University Human Research Ethics Committee (Project Number 8366), in accordance with National Health and Medical Council of Australia and the Declaration of Helsinki. Informed consent will be obtained from participants. All participants will be provided a detailed Participant Information Sheet and Consent Form, describing: the purpose and benefits of the study, participant involvement and potential risks, withdrawal rights, confidentiality and privacy, data storage, recognition of contribution, study feedback, and information on ethics committee approval and who to contact for any queries or concerns. Individuals who would like to take part in the study will be asked to sign a consent form prior to participating. Consent for publication Not applicable. Availability of data and materials The datasets that will be generated and/or analysed during the study will not be publicly available due privacy concerns but will be available from the corresponding author on reasonable request at completion of the study. Competing interests The authors declare that they have no competing interests. Funding The study is funded by an Australian Research Council Linkage Grant (LP240100242). Authors contributions CO, AP, CH and SB conceived and designed the study. All authors will be involved in data collection and analysis. All authors edited, revised and approved the final manuscript. Acknowledgements We would like to acknowledge the support of Partner Organisations (SA Department of Human Services, Adelaide Primary Health Network, Anglicare SA, Onkaparinga Council, Marion Council, and Semantic Consulting) in the project. References International Monetary Fund. Cost of living crisis https://www.imf.org/external/pubs/ft/ar/2023/in-focus/cost-of-living-crisis/: International Monetary Fund; 2023 [Available from: https://www.imf.org/external/pubs/ft/ar/2023/in-focus/cost-of-living-crisis/. Australian Bureau of Statistics. Estimating homelessness: Census https://www.abs.gov.au/statistics/people/housing/estimating-homelessness-census/latest-release.: ABS; 2021 [ Bowden M. Understanding food insecurity in Australia. 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Health Education & Behavior. 1997;24:369-87. Oster C, Skelton C, Venning A, Fairweather K, Redpath P. A pathway through the uncanny: A phenomenological photovoice study of Australian university students' experieces of physical activity during COVID19. Health & Social Care in the Community. 2022;30:e2214-e25. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3:77-101. Trischeler J, Dietrich T, Rundle-Thiele S. Co-design: From expert- to user-driven ideas in public service design. Public Manag Rev. 2019;21(11):1596-619. Oster C, Powell A, Hutchinson C, Anderson D, Gransbury B, Walton M, et al. Co-designing social prescribing for the Barossa. Australia: Caring Futures Institute and Centre for Social Impact, Flinders University; 2024. Waltz TJ, Powell BJ, Matthieu MM, Damschroder LJ, Chinman MJ, Smith JL, et al. Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: Results from the Expert Recommendations for Implementing Change (ERIC) study. Impl Sci. 2015;10:109. Hopkins G, Winrow E, Davies C, Seddon D. Beyond social prescribing - The use of social return on investment (SROI) analysis in integrated health and social care interventions in England and Wales: A protocol for a systematic review. PLoS ONE. 2023;18(2):e0277386. Hutchinson C, Berndt A, Gilbert-Hunt S, George S, Ratcliffe J. Valuing the impact of health and social care programmes using social return on investment analysis: How have academics advanced the methodology? A protocol for a systematic review of peer-reviewed literature. BMJ Open. 2018;8(12):e022534. International Wellbeing Group. Personal Wellbeing Index Manual: 6th Edition, Version 2, 190626, pp. 1-55. Geelong: Australian Centre on Quality of Life, School of Psychology, Deaking University - Melbourne Campus; 2024. Smith ML, Chen E, Lau CA, Davis D, Simmons JW, Merianos AL. Effectiveness of chronic disease management self-management education (CDSME) programs to reduce loneliness. Chronic Illness. 2023;19(3):646-64. Valentelyte G, Keegan C, Sorensen J. A comparison of four quasi-experimental methods: An analysis of the introduction of activity-based funding in Ireland. BMC Health Serv Res. 2022;22(1):1311. Fredriksson A, de Oliveira GM. Impact evaluation using difference-in-difference. RAUSP Manag J. 2019;54(4):519-32. Nichols J, Lawlor E, Neitzert E, Goodspeed T. A Guide to Social Return on Investment. The SROI Network. 2012. Hutchinson C, Lester L, Coram V, Flatau P, Goodwin-Smith I. A social return on investment analysis of a social enterprise to support open employment for people with disability. Soc Enterprise J. 2024;20(5):951-68. Evers S, Husk K, Napierala H, Wendt L, Gerhardus A. Theories used to develop or evaluate social prescribing in studies: A scoping review. BMC Health Serv Res. 2024;24:140. Ashe MC, dos Santos IK, Alfares H, Chudyk AM, Esfandiari E. Outcomes and instruments used in social prescribing: A modified umbrella review. Health Promotion and Chronic Disease Prevention in Canada. 2024;44(6):244-69. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 22 May, 2025 Reviews received at journal 20 May, 2025 Reviews received at journal 18 May, 2025 Reviewers agreed at journal 11 May, 2025 Reviewers agreed at journal 06 May, 2025 Reviewers invited by journal 05 May, 2025 Editor invited by journal 30 Apr, 2025 Editor assigned by journal 23 Apr, 2025 Submission checks completed at journal 22 Apr, 2025 First submitted to journal 22 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6461338","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":453103366,"identity":"843e3853-0a7c-4dff-9e05-6c0bf9c4a803","order_by":0,"name":"Candice Oster","email":"data:image/png;base64,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","orcid":"","institution":"Flinders University","correspondingAuthor":true,"prefix":"","firstName":"Candice","middleName":"","lastName":"Oster","suffix":""},{"id":453103367,"identity":"fccba620-ece6-423b-baa1-3715c8a4449b","order_by":1,"name":"Ashleigh Powell","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Ashleigh","middleName":"","lastName":"Powell","suffix":""},{"id":453103368,"identity":"ac0719d4-d7f0-439a-90ca-9f1441feefd9","order_by":2,"name":"Claire Hutchinson","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Claire","middleName":"","lastName":"Hutchinson","suffix":""},{"id":453103369,"identity":"94182d61-e272-4331-9e5f-0326aa9c7646","order_by":3,"name":"Sahar Faghidno","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Sahar","middleName":"","lastName":"Faghidno","suffix":""},{"id":453103370,"identity":"de7826c2-b051-4a3b-91e0-cbc0b4d013bd","order_by":4,"name":"Svetlana Bogomolova","email":"","orcid":"","institution":"Flinders University","correspondingAuthor":false,"prefix":"","firstName":"Svetlana","middleName":"","lastName":"Bogomolova","suffix":""}],"badges":[],"createdAt":"2025-04-16 08:38:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6461338/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6461338/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82292569,"identity":"ea662c71-9f0d-41d3-a39b-39e3bf263f92","added_by":"auto","created_at":"2025-05-08 18:20:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":535038,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6461338/v1/ec104bd4-2fc0-4a37-a841-5d61a339f2dc.pdf"},{"id":82292185,"identity":"deb0927b-80aa-4ba6-96ca-c6a87bc675dc","added_by":"auto","created_at":"2025-05-08 18:12:41","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":126959,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6461338/v1/ee37bc50b304827520ef95d9.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Creating and sustaining enabling systems and communities to address social needs: protocol for a living lab social prescribing study","fulltext":[{"header":"Background","content":"\u003cp\u003eSocial needs such as the lack of housing, income, and food security, as well as loneliness and social isolation, are increasing worldwide, exacerbated by the cost-of-living crisis and the flow-on effects of the COVID-19 pandemic (\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e). In Australia, homelessness has increased 5.2% since 2016 (\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e), over 5.5\u0026nbsp;million have experienced food insecurity (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), over 25% find it difficult to get by on their current income (\u003cspan class=\"CitationRef\"\u003e4\u003c/span\u003e), and around 25% experience loneliness and social isolation (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e). Social needs cause significant distress and hardship (\u003cspan class=\"CitationRef\"\u003e6\u003c/span\u003e). Yet those most in need struggle to access social and community support due to a lack of information, referral pathways, and local services (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThere is a growing trend where patients present during primary health care appointments, particularly in general practice, with social needs (\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e). However, health practitioners are not equipped to address these needs, and this has been shown to lead to clinician burnout, vicarious trauma, and compassion fatigue (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). At the same time social and community services struggle to link with these \u0026lsquo;invisible populations\u0026rsquo; because they are disconnected from services, systems, and communities (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e). One way to address patients\u0026rsquo; social needs and reduce health system burden is through better integration across social, health, and community sectors (\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSocial prescribing is an approach to service integration that aims to address patients\u0026rsquo; social needs through screening (e.g., during healthcare appointments) and referrals to social and community services. Box 1 provides a detailed definition of social prescribing from an international Delphi study (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eBox 1. Internationally agreed definition of social prescribing\u003c/h3\u003e\n\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Taba\" border=\"1\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSocial prescribing is \u0026ldquo;a holistic, person-centred and community-based approach to health and well-being that bridges the gap between clinical and nonclinical supports and services. By drawing on the central tenets of health promotion and disease prevention, it offers a way to mitigate the impacts of adverse social determinants of health and health inequities by addressing nonmedical, health-related social needs (e.g. issues with housing, food, employment, income, social support). While it looks different across the globe, it is recognised as being a means for trusted individuals in clinical and community settings to identify that a person has nonmedical, health-related social needs and to subsequently connect them to nonclinical supports and services within the community by co-producing a social prescription\u0026mdash;a nonmedical prescription, to improve health and well-being and to strengthen community connections. It requires collective action and collaboration among multiple sectors and stakeholders.\u0026rdquo; (\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e, p.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eSocial prescribing is relatively advanced in the United Kingdom (UK) and the United States (US), with increasing development and uptake worldwide (\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e) and growing evidence of positive effects on wellbeing and cost-effectiveness (\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e). In Australia, social prescribing is in its early stages of development and implementation but is gaining significant momentum (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e) and is included in health policy (\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e). The challenge for Australia is that its health and social systems are particularly fragmented, with different funding models and governance systems, compared with those of many other countries such as the UK and the US (\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e). This means overseas models cannot be simply transposed onto the Australian context.\u003c/p\u003e\n\u003cp\u003eFurther, social prescribing programs typically focus on addressing individual social needs, neglecting the community context in which these needs are to be addressed (\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e). Without additional investment in social and community supports, the implementation of social prescribing risks creating excessive burden for the social sector, including \u0026lsquo;bottlenecks\u0026rsquo; in service access and referrals to non-existent supports (termed the \u0026lsquo;road to nowhere\u0026rsquo; problem) (\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). A further critique of social prescribing is that it risks individualising social determinants of health (referred to as \u0026lsquo;victim blaming\u0026rsquo;), ignoring the underlying structural, including socio-economic, factors that shape life circumstances (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e). This places responsibility and therefore blame for addressing social determinants on individuals rather than governments and societies (\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe current Australian study aims to shift the paradigm of social prescribing from an individual level to a community-based response to address social needs arising from social determinants of health. The project adopts a place-based framework that combines: 1) individual-level referral for social needs, with 2) community and stakeholder engagement to determine community assets, resources, networks, and need to inform model development. Specifically, the study aims to:\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e1. Identify key elements that enable place-based social prescribing in Australia and use these to co-design a technology-enabled social prescribing model.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e2. Implement the new social prescribing model in two high-needs communities.\u003cbr\u003e\u003c/span\u003e\u003cspan\u003e3. Evaluate the model\u0026rsquo;s implementation, effectiveness, and social return on investment.\u003c/span\u003e\u003c/p\u003e"},{"header":"Methods/Design","content":"\u003ch2\u003eA living lab approach\u003c/h2\u003e\u003cp\u003eThe project will adopt a living lab approach (also known as a natural experiment) that will blend research and implementation processes in real-life community settings (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), working closely with Partner Organisations (POs) from health care, social and community services, and local government to co-design, implement, and evaluate solutions systematically. This is consistent with the requirement for “collective action and collaboration among multiple sectors and stakeholders” in the definition of social prescribing definition in Box 1 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe research will leverage the real-life context of the Community Connection Program (CCP), a program that is administered by the Department of Human Services South Australia (DHS; one of the POs). The CCP aims to address social exclusion by linking participants with multiple services within the social sector (e.g., financial assistance, food relief, housing, family relationships). The CCP is an ideal real-world context for the study as it aims to link participants to multiple services to meet their social needs, but as yet lacks referral pathways to/from primary health care. The project will be undertaken in two Local Government Area (LGA) locations covering low socioeconomic communities in South Australia, where CCP is delivered by POs from Non-Government Organisations (NGOs) (PO Anglicare SA on behalf of a consortium of three other NGOs) and the LGAs (POs Onkaparinga and Marion Councils).\u003c/p\u003e\u003cp\u003eIn this project, CCP referral pathways will be expanded to/from primary health care, with the support of PO Adelaide Primary Health Network, and broader local community services, using a co-designed technology-enabled referral system (building on and adapting pilot software developed by PO Semantic Consulting). General practices will be the starting point, with the focus on the Practice Nurse role, but other primary, allied (e.g., physiotherapy, pharmacy) and holistic (e.g., massage therapists) health settings would also be included. The living lab approach will enable co-designing, testing, and evaluating of the new social prescribing model in the real-life conditions of the two LGAs. The project will be overseen by a steering committee comprising key stakeholder representatives from health care, social care, and community.\u003c/p\u003e\n\u003ch3\u003eThe theory of ‘enabling places’\u003c/h3\u003e\n\u003cp\u003eThe communities and service settings in which social prescribing is implemented encompass both physical \u0026lsquo;spaces\u0026rsquo; (e.g., a clinic, a community centre) and people\u0026rsquo;s experiences within these spaces \u0026ndash; together, these constitute the \u0026lsquo;places\u0026rsquo; of social prescribing. The real-world context of the living lab provides the opportunity for a place-based approach to social prescribing that explicitly acknowledges the importance of place as \u0026ldquo;a fundamental feature of human experience, deeply implicated in the development of identity and belonging and central to the conduct of everyday life\u0026rdquo; (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, p.149).\u003c/p\u003e \u003cp\u003eThere has been extensive research exploring the qualities of place that are generative or enabling of health and wellbeing (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). The health and wellbeing qualities of natural environments, for example, can be seen in social prescribing programs that focus on nature-based health interventions (green prescribing) (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Our project will extend this research beyond an understanding of the health promoting \u003cem\u003equalities\u003c/em\u003e of specific environments to explore the person-place encounter and how this is enabling of wellbeing via social prescribing, drawing on Duff\u0026rsquo;s theory of \u0026lsquo;enabling places\u0026rsquo; (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuff views \u0026lsquo;enabling places\u0026rsquo; (places that are supportive or enabling of health and wellbeing) as comprising three classes of enabling resources - social (social networks/ interactions), affective (e.g., feelings of belonging), and material (e.g., objects, physical spaces) (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Enabling resources \u0026ldquo;support the maintenance of health and wellbeing; the mitigation of specific risks and vulnerabilities; and the creation of health promoting or \u0026lsquo;enabling\u0026rsquo; places\u0026rdquo; (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, p.339). Through this lens, wellbeing is understood as a process that \u0026ldquo;emerges in everyday situations and environments\u0026rdquo; (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, p.211) rather than as a quality that is intrinsic to individuals, allowing movement beyond an individualistic (potentially victim-blaming) approach to addressing social needs in social prescribing.\u003c/p\u003e \u003cp\u003eDrawing on the theory of \u0026lsquo;enabling places\u0026rsquo;, this project will include \u0026ldquo;an evaluation of the character of enabling resources\u0026rdquo; in the two communities of focus and \u0026ldquo;a determination of the ways these resources might by harnessed\u0026rdquo; (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, p.343) to better meet the social needs affecting individuals and communities. The theory of \u0026lsquo;enabling places\u0026rsquo; will be applied to both develop and evaluate the social prescribing program.\u003c/p\u003e \u003cp\u003eThe project will be undertaken in three phases over three years. The overarching project logic and theory of change statement, which details the assumptions of the project and how the outcomes will contribute to change (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), were developed in collaboration with POs and are detailed in Supplementary File 1.\u003c/p\u003e"},{"header":"Phase 1: Photovoice-informed co-design","content":"\u003cp\u003ePhotovoice will be used in Phase 1 to explore what constitutes enabling places for social prescribing, drawing on this understanding to co-design technology enabled, place-based social prescribing in the two communities.\u003c/p\u003e\n\u003ch3\u003ePhotovoice\u003c/h3\u003e\n\u003cp\u003ePhotovoice is a participatory action research method where people document and reflect on their realities/experiences using photography. Photovoice has three main goals: \u0026ldquo;(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) to enable people to record and reflect their community's strengths and concerns, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) to promote critical dialog and knowledge about important issues through large and small group discussion of photographs, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) to reach policymakers\u0026rdquo; (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, p.369) by visually showcasing community issues and needs. It is an ideal approach for capturing people\u0026rsquo;s perceived realities of social needs and community capacity to inform co-design of place-based social prescribing. Visual methodologies like photovoice are able to transcend \u0026ldquo;cultural and developmental barriers to expression, which are inherent in much linguistically focused research\u0026rdquo;, providing a greater depth of understanding of people\u0026rsquo;s experiences than qualitative research interviews alone (31, p.e2216).\u003c/p\u003e \u003cp\u003eIn this study, photovoice will involve people taking photographs of situations/spaces/objects that help or hinder support for social needs in their communities and for their patients/clients. These photographs will be reflected on by participants in group discussions. This photovoice method will serve the dual purposes of data collection and community engagement, producing unique visual and qualitative data to examine elements of enabling places for social prescribing, and facilitating connections between community members, providers, and researchers.\u003c/p\u003e \u003cp\u003eRecruitment: We will recruit both health and social service providers who provide services to the communities and community members themselves (n\u0026thinsp;=\u0026thinsp;20 in each LGA) using snowball sampling; this sample size is appropriate in photovoice methods (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Recruitment will be done via POs\u0026rsquo; social media posts, newsletters/flyers, and email distribution lists.\u003c/p\u003e \u003cp\u003eData collection: Participants will be asked to take photographs that reflect their experiences of enablers and barriers to community support and connection over six weeks and share these through communities of practice (one for community members and one for service providers in each community), facilitated through the Discussion Forum feature within the university\u0026rsquo;s Learning Management System to ensure privacy of discussions. Participants will either use their own phones/cameras or be supplied with a camera as needed. No photographs that identify individuals will be included to protect privacy (e.g., by blurring/pixelating faces and other identifying features in the images). Participants will then come together in a workshop (one per LGA) to explore \u0026lsquo;What does \u0026ldquo;good\u0026rdquo; look like?\u0026rsquo; for enabling systems and communities that address social needs. Participants will discuss their photographs and experiences in small groups and present these to the larger group for further discussion. Discussions will be audio-recorded and transcribed verbatim.\u003c/p\u003e \u003cp\u003eData analysis: Data in the form of photographs, Discussion Forum posts, and workshop transcriptions will be analysed using theoretical thematic analysis (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) in NVivo, where themes will be developed through the lens of \u0026lsquo;enabling places\u0026rsquo; to identify enabling social, affective, and material resources for social prescribing in the two communities. The initial process will involve familiarisation with the data and generation of codes reflecting the content of the photographs and text. Codes will then be collated into potential themes. This will be followed by interpretive analysis in which the themes will be interrogated in relation to the \u0026lsquo;enabling place\u0026rsquo; framework to explore how social, affective, and material resources are produced in the LGAs as enabling (or not) of social prescribing. Outcomes will be presented in a steering-committee workshop to explore barriers and enablers to place-based social prescribing for discussion in the next part of Phase 1: co-design workshops.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePhotovoice informed co-design\u003c/h2\u003e \u003cp\u003eCo-design is another participatory method that systematically brings together the expertise and lived experience of all key stakeholders (e.g., service users and providers) to the design of a collective solution (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Four workshops (two in each LGA) will be conducted with health and social-service providers and community members (n\u0026thinsp;=\u0026thinsp;25 participants in each workshop) to co-design a place-based model of social prescribing within the living lab of the CCP. Co-design will involve designing both the referral pathway and strategies for building community resources and support.\u003c/p\u003e \u003cp\u003eRecruitment: Participant recruitment (n\u0026thinsp;=\u0026thinsp;50 service providers; n\u0026thinsp;=\u0026thinsp;50 community members) will be supported through PO community and provider networks. Service providers are expected to span general practitioners, practice nurses, allied and holistic health, and social and community services. Community participants will include any community members (aged 18 and over) that would like to take part in a co-design workshop.\u003c/p\u003e \u003cp\u003eData collection: We will follow a 7-step co-design process: resourcing, planning, recruiting, sensitising, facilitating, reflecting, and building for change, adapted from Trischeler et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) to focus on fostering collaboration across siloed sectors (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Resourcing will enable an understanding of the problems to be addressed, in this case how enabling places can be developed and sustained for social prescribing using the outcomes of the photovoice study. Planning and recruiting will be iterative across the workshops with PO support, building on the outcomes of each workshop to plan successive workshop content and recruitment. Sensitising (preparing participants for the design task) will be through a presentation of photovoice outcomes, explanation of the concept of social prescribing, and workbook activities where participants rate the relevance of social prescribing components and processes to their communities. Facilitating will involve the design of ideas for a social prescribing model through small group activities (e.g., participant journey mapping) that are then presented to the larger group for discussion. Reflecting on co-design outcomes and building for change (assessing feasibility and realisation of ideas generated through co-design) will occur in Phase 3.\u003c/p\u003e \u003cp\u003eData analysis and synthesis: Workshop discussions will be audiotaped and transcribed verbatim. Data in the form of workbooks, designs on butcher paper, and transcriptions will be analysed descriptively and synthesised into a draft social prescribing model and presented to the steering committee for reflection and refinement.\u003c/p\u003e \u003cp\u003eSocial prescribing technology: A workshop will be undertaken with POs to determine how to augment existing technology developed by the technology PO to ensure it is fit for the co-designed model, including integration of a database of community services and resources, integration with existing systems, and reporting processes to inform identification of service gaps and duplication.\u003c/p\u003e \u003cp\u003eThe outcome of Phase 1 will be a co-designed framework for technology-enabled, place-based social prescribing.\u003c/p\u003e \u003c/div\u003e"},{"header":"Phase 2: Development and implementation of the model","content":"\u003cp\u003eThe project will be embedded across the two communities to test the generalisability and replicability of the co-designed model. This will involve developing all relevant components of technology-enabled, place-based social prescribing identified through co-design and include how to harness and develop the social, affective, and material resources identified through photovoice. While the specific components and resources are yet to be determined, examples include processes for raising awareness of the concept of social prescribing in the communities and de-stigmatising social needs; identifying people with unmet social needs; triage, referral, engagement, support, and follow-up; processes for understanding and developing community resources and networks. Two site project officers (one per LGA) will be embedded with POs working across the existing CCP delivery sites. They will undertake mapping of local services, develop and maintain databases, coordinate across CCP sites, build relationships with general practices and other relevant settings as determined through co-design, and manage data collection. The team also includes a marketing specialist who will be responsible for devising appealing marketing collateral (digital and hard copy information flyers, etc.) for raising awareness of social prescribing and how to part-take for professionals and members of the community.\u003c/p\u003e \u003cp\u003ePO Semantic Consulting will adapt their prototype social prescribing platform based on the outcomes of Phase 1 codesign. The adapted technology will be pre-tested with POs, using the CCP. Additional settings will be four general practices (identified by PO Adelaide Primary Health Network).\u003c/p\u003e \u003cp\u003eA range of evidence-based implementation strategies identified using the Expert Recommendations for Implementing Change (ERIC) (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) will be used, starting with the development of a formal implementation blueprint with POs, and identifying early adopters through PO networks. Staff in implementation settings will be trained in the co-designed social prescribing system and technology. A decision-tree tool will be put in place to help health service providers identify appropriate participants for social prescribing and refer them to the service. Community will be engaged through a purposefully designed and rolled out marketing strategy to address lack of knowledge of social prescribing in Australia, identified in our pilot research (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The co-designed strategies for building community resources and support will be implemented, utilising existing community development processes and practices of POs (DHS, Councils, and NGOs). The social prescribing intervention will be implemented in general practice settings and other willing health organisations (e.g., allied health) and the CCP for nine months.\u003c/p\u003e"},{"header":"Phase 3: Mixed-methods evaluation","content":"\u003cp\u003eA mixed-methods evaluation will be undertaken across three levels: i) process evaluation to assess implementation fidelity and quality (qualitative); ii) implementation evaluation to examine broader contextual factors influencing model delivery (qualitative); and iii) outcome evaluation measuring the effectiveness and Social Return on Investment of the model in achieving its intended individual- and system-level outcomes (quantitative).\u003c/p\u003e \u003cp\u003eSocial return on investment (SROI) is an approach to economic evaluation, used to \u0026ldquo;identify what changes and what is important for [key stakeholders], giving a much wider measure of value\u0026rdquo; than standard economic evaluation (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, p.3). SROI is a highly flexible form of cost-benefit analysis that will allow us to capture and express in monetary values social outcomes that are not typically included in traditional forms of economic evaluation (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). SROI plays a critical role in \u0026lsquo;translating\u0026rsquo; social prescribing benefits into the \u0026lsquo;language\u0026rsquo; that policymakers can understand, which is important at this early stage of model development and adoption in Australia.\u003c/p\u003e \u003cp\u003e Recruitment: Evaluation and SROI participants will be community members (n\u0026thinsp;=\u0026thinsp;300; ~150 per LGA) who have received support through the social prescribing program. POs have indicated the feasibility of this sample size. A conservative \u003cem\u003ea priori\u003c/em\u003e power analysis was conducted (G*Power Version 3.1). For a small effect-size (Cohen\u0026rsquo;s d), a significance criterion of α\u0026thinsp;=\u0026thinsp;0.05 and power\u0026thinsp;=\u0026thinsp;0.95, the minimum sample size needed for pre- and post-comparisons across the two sites is 266. Therefore, aiming for a sample of 300 should balance both feasibility and statistical analysis considerations. Participants in qualitative evaluation (n\u0026thinsp;=\u0026thinsp;30 social prescribing clients; n\u0026thinsp;=\u0026thinsp;20 intervention staff) will be recruited via the social prescribing implementation settings.\u003c/p\u003e \u003cp\u003eData collection: Quantitative data will be collected at baseline, at exit from the program (12 weeks post enrolment), and nine months post intervention. Within the context of the living lab approach, quantitative data will include pre- and post-outcome measures routinely collected by POs as part of the CCP, to reduce the burden on service providers and participants. These measures include items developed by the DHS Data and Evaluation team that relate to referrals made, community participation, and satisfaction with care, and a Structural Wellbeing Index. The Structural Wellbeing Index captures participants\u0026rsquo; current situation across nine life domains that are considered determinants of a person\u0026rsquo;s wellbeing (physical wellbeing, emotional wellbeing, financial situation, family and domestic violence, child safety, alcohol and other drugs, housing situation, gambling, social and cultural connections). Supplementing the DHS developed measure of wellbeing is a validated measure of personal wellbeing, the Personal Wellbeing Index (PWI)(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). The PWI is valid and reliable measure that has been extensively used to assess subjective wellbeing across seven life domains, including standard of living, health, achieving in life, personal relationships, safety, community connectedness, and future security. Participants\u0026rsquo; loneliness will be measured using the Campaign to End Loneliness Tool (CtELT)(\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e), which is a valid and reliable three-item scale which was initially developed to assess improvements resulting from community-based programs that aim to address social disconnection. Qualitative data will be collected via individual interviews nine months post intervention and transcribed verbatim.\u003c/p\u003e \u003cp\u003eData analysis: Pre- and post- quantitative outcomes will be analysed using difference-in-differences analysis to compare changes in quantitative outcome measures between those participating in this program and a naturally occurring control group (captured via routine data collection in the CCP in other SA regions without social prescribing). This analytic approach to the comparison of the intervention group to the naturally occurring control group is a robust approach to examining data from this \u0026lsquo;living lab\u0026rsquo; as it provides opportunities to examine \u0026ndash; and control for \u0026ndash; pre-existing differences and explore parallel trends between the groups over time (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Qualitative data will be analysed using theoretical thematic analysis through the \u0026lsquo;enabling places\u0026rsquo; framework (as per Phase 1) to explore participant experiences and identify barriers and enablers to place-based social prescribing.\u003c/p\u003e \u003cp\u003eCalculating SROI: SROI will be informed by quantitative and qualitative data. Financial proxies will be applied to outcomes that have no market-traded value (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Discounts will be applied to avoid overclaiming (e.g., discounts account for other services and supports participants might be accessing). The SROI ratio will be calculated by dividing the discounted, monetised value of outcomes by total investment (data from POs). Robust sensitivity analysis will test assumptions in the SROI Eq.\u0026nbsp;(43).\u003c/p\u003e \u003cp\u003eOutcomes will be presented at a PO workshop to explore the sustainability and scalability of the model based on evidence of model performance, derived from the qualitative and quantitative evaluation. Dissemination and knowledge translation will occur via the Australian Social Prescribing Institute of Research and Education, the Think Tank on the Future of Social Prescribing in South Australia (with membership across health care, social care, community and NGOs), and the South Australian Social Prescribing Community of Practice (comprising researchers with an interest/involvement in social prescribing).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eEthical principles\u003c/h2\u003e \u003cp\u003e The study protocol was approved by the Flinders University Human Research Ethics Committee (Project Number 8366), in accordance with National Health and Medical Council of Australia and the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSocial prescribing is a complex intervention across three disconnected sectors \u0026ndash; health care, social care, and community \u0026ndash; that aims to address non-medical, social needs that affect health and wellbeing. In addition to providing a referral pathway between sectors, it is important that social prescribing avoids individualising social needs and overwhelming existing resources and capacity in the social and community sectors (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This study aims to identify key elements that enable place-based social prescribing and use these to co-design, implement, and evaluate technology-enabled social prescribing in two low-socioeconomic communities.\u003c/p\u003e \u003cp\u003eA key strength of the project is the use of a living lab approach in close collaboration with POs across health, social, and community sectors (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). This will facilitate knowledge translation by meeting the strategic aims of addressing silos across sectors and service fragmentation through system integration and place-based care. A further strength is the use of participatory methods (photovoice and co-design) informed by the theory of \u0026lsquo;enabling places\u0026rsquo; (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) to advance the theoretical understanding of social prescribing (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Calculation of the social return on investment will furthermore enable communication of the \u003cem\u003evalue\u003c/em\u003e of community-based interventions and cross-sector integration via a social prescribing model in a language that Australian public and policymakers can understand to leverage future funding.\u003c/p\u003e \u003cp\u003eThe main limitation of the study is the short period of time of implementation. Longitudinal data beyond the 9-month period would allow greater understanding of processes and outcomes. The study is furthermore limited to the use of routinely collected data to determine impact. While this aims to reduce participant and practitioner burden and is consistent with a living lab approach, it potentially limits comparison of outcomes with the broader social prescribing literature that uses different outcome measures (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnmet social needs have a significant negative impact on Australians, worsened by fragmentations and the lack of collaboration in these sectors. Addressing systemic fragmentation will bring opportunities for early intervention to improve wellbeing, health, and social connection. The study aims to foster place-based initiatives and community development, a missing element in much of the social prescribing discourse. It is anticipated that outcomes will contribute to the development of social prescribing that is tailor-made for Australian communities, systems, and funding models.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCCP: Community Connections Program\u003c/p\u003e\n\u003cp\u003eLGA: Local Government Area\u003c/p\u003e\n\u003cp\u003eNGO: Non-Government Organisation\u003c/p\u003e\n\u003cp\u003ePO: Partner Organisation\u003c/p\u003e\n\u003cp\u003eDHS: Department of Human Services, South Australia\u003c/p\u003e\n\u003cp\u003eUnited Kingdom: UK\u003c/p\u003e\n\u003cp\u003eUnited States: US\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Flinders University Human Research Ethics Committee (Project Number 8366), in accordance with National Health and Medical Council of Australia and the Declaration of Helsinki. Informed consent will be obtained from participants. All participants will be provided a detailed Participant Information Sheet and Consent Form, describing: the purpose and benefits of the study, participant involvement and potential risks, withdrawal rights, confidentiality and privacy, data storage, recognition of contribution, study feedback, and information on ethics committee approval and who to contact for any queries or concerns. Individuals who would like to take part in the study will be asked to sign a consent form prior to participating.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets that will be generated and/or analysed during the study will not be publicly available due privacy concerns but will be available from the corresponding author on reasonable request at completion of the study.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study is funded by an Australian Research Council Linkage Grant (LP240100242).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors contributions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCO, AP, CH and SB conceived and designed the study. All authors will be involved in data collection and analysis. All authors edited, revised and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the support of Partner Organisations (SA Department of Human Services, Adelaide Primary Health Network, Anglicare SA, Onkaparinga Council, Marion Council, and Semantic Consulting) in the project.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eInternational Monetary Fund. Cost of living crisis https://www.imf.org/external/pubs/ft/ar/2023/in-focus/cost-of-living-crisis/: International Monetary Fund; 2023 [Available from: https://www.imf.org/external/pubs/ft/ar/2023/in-focus/cost-of-living-crisis/.\u003c/li\u003e\n\u003cli\u003eAustralian Bureau of Statistics. 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A comparison of four quasi-experimental methods: An analysis of the introduction of activity-based funding in Ireland. BMC Health Serv Res. 2022;22(1):1311.\u003c/li\u003e\n\u003cli\u003eFredriksson A, de Oliveira GM. Impact evaluation using difference-in-difference. RAUSP Manag J. 2019;54(4):519-32.\u003c/li\u003e\n\u003cli\u003eNichols J, Lawlor E, Neitzert E, Goodspeed T. A Guide to Social Return on Investment. The SROI Network. 2012.\u003c/li\u003e\n\u003cli\u003eHutchinson C, Lester L, Coram V, Flatau P, Goodwin-Smith I. A social return on investment analysis of a social enterprise to support open employment for people with disability. Soc Enterprise J. 2024;20(5):951-68.\u003c/li\u003e\n\u003cli\u003eEvers S, Husk K, Napierala H, Wendt L, Gerhardus A. Theories used to develop or evaluate social prescribing in studies: A scoping review. BMC Health Serv Res. 2024;24:140.\u003c/li\u003e\n\u003cli\u003eAshe MC, dos Santos IK, Alfares H, Chudyk AM, Esfandiari E. Outcomes and instruments used in social prescribing: A modified umbrella review. Health Promotion and Chronic Disease Prevention in Canada. 2024;44(6):244-69.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Social prescribing, Social determinants of health, Participatory research, Social support, Community referral, Social return on investment, Living lab","lastPublishedDoi":"10.21203/rs.3.rs-6461338/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6461338/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSocial needs - such as housing, income, food security, and social connectedness - have a significant effect on health and wellbeing. One way to address social needs is through social prescribing, which involves screening for unmet needs (e.g., during healthcare appointments) and providing referrals to social and community services. For social prescribing to be effective, it must address both individual needs as well as support the social and community services that are required to meet these needs. The objective of this study is to adopt a place-based framework that combines: 1) individual-level referral for social needs, with 2) community and stakeholder engagement to determine community assets, resources, networks, and need to inform model development.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe study will be conducted in three-phases across two low-socioeconomic Australian communities, underpinned by the \u0026lsquo;enabling places\u0026rsquo; theoretical framework. Phase 1 will involve identifying key elements that enable place-based social prescribing using photovoice methods with health and social care providers and community members. Outcomes will inform co-design workshops to develop a place-based social prescribing model of care that is augmented by technology to facilitate integration across health, social, and community services. In Phase 2, the co-designed model will be implemented in the two communities. Phase 3 will involve a mixed methods approach to the evaluation of the model\u0026rsquo;s implementation, effectiveness, and social return on investment.\u003c/p\u003e\u003ch2\u003eDiscussion\u003c/h2\u003e \u003cp\u003eThe study aims to foster place-based initiatives and community development, a missing element in much of the social prescribing discourse. It is anticipated that outcomes will contribute to the design and implementation of social prescribing models that are tailor-made for Australian communities, systems, and funding systems.\u003c/p\u003e","manuscriptTitle":"Creating and sustaining enabling systems and communities to address social needs: protocol for a living lab social prescribing study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-08 18:12:36","doi":"10.21203/rs.3.rs-6461338/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-22T04:42:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-20T16:19:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-18T11:46:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199198828382894426830530596240948545277","date":"2025-05-11T08:51:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"45672705095671017588680404797018702081","date":"2025-05-06T09:34:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-05T22:08:40+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-30T19:51:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-23T07:47:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-23T01:50:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-04-23T01:48:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-primary-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"famp","sideBox":"Learn more about [BMC Primary Care](https://bmcprimcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12875","title":"BMC Primary Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e22eaffa-6247-4472-8558-ab12ca6e6d20","owner":[],"postedDate":"May 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-15T11:23:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-08 18:12:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6461338","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6461338","identity":"rs-6461338","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}