Effectiveness and Value of Relationships in Link Worker Social Prescribing Over an 18-month Follow Up Period

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Sharman, Shaun Hayes, David Chua, Catherine Haslam, Tegan Cruwys, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6118230/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in BMC Primary Care → Version 1 posted 4 You are reading this latest preprint version Abstract Background: To make confident referrals to link worker social prescribing (LWSP) programs, GPs and other health providers need evidence of their overall effectiveness and the value of the relationships and social activities that contribute to their outcomes. This research aimed to examine these questions in data collected from participants of a LWSP program over an 18-month follow-up period. Methods: Sixty-four participants ( M age = 53.59) enrolled in the LWSP arm of a controlled trial provided data at three timepoints: baseline (T1, n =64), +8-weeks (T2, n =50) and +18-months (T3, n =30) on group activities, relationship quality with link worker and community group facilitators, and outcomes on loneliness, distress, wellbeing, trust and health. Results: Participants were referred to a diverse range of social group programs, and the number of meaningful social groups increased from a median of 2 groups at T1, to 3 groups at T2 and T3. Loneliness reduced at T2 and T3, and these effects were large. Moderate-to-large effects were also found at 18-months for psychological distress and self-rated health. Participants’ relationships with link workers and group facilitators’ skill in fostering belonging at T2 (but not at T1), were associated with participant improvements at T3. Conclusions: Positive effects of LWSP were found in all outcome measures at 18-months follow-up. There was also evidence that the relational skills of link workers in building interpersonal rapport and community group facilitators in enabling a sense of belonging were key to participants’ positives outcomes. These findings emphasise that social prescribing is a multifaceted and highly relational health pathway. Strong relational and integrated care are important in achieving improved health outcomes. Trial registration: ANZCTR, retrospectively registered on 08/06/2022, https://www.anzctr.org.au/ACTRN12622000801718.aspx Loneliness social prescribing community health wellbeing longer-term outcomes relationship quality Figures Figure 1 Figure 2 Introduction Social prescribing in primary care Social prescribing has emerged as a patient-centred approach in primary care, addressing the social determinants of health by connecting individuals with non-clinical community services. In the holistic model of social prescribing, link workers engage with socially isolated clients to produce bespoke action plans that support client engagement with social activities and services in their local communities [1]. Social prescribing programs are now available in at least 26 countries [2], across a range of settings, and age groups including children and young people [3–5], and older adults [6]. Despite the promise of this approach however, it has been difficult to establish the effectiveness of social prescribing due to the variety of models and referral pathways used, and the diverse activities and services included across programs [7,8]. Indeed, Husk et al. observed that ‘social prescribing is not a single intervention but a pathway and series of relationships, all of which need to function to meet patient need’ [9]. The effects of social prescribing may take time to emerge, as demonstrated in a controlled study of 114 community dwelling adults finding only small effects on loneliness and trust at 8-weeks follow-up [10]. This means that prospective studies with longer-term follow-ups are critical, although few have been published thus far. Some studies have utilised follow-up periods between 6 and 9-months, centring on people experiencing loneliness in the context of mental illness [11, 12] or other long-term health conditions [13–16]. Results have focused primarily on wellbeing outcomes with improvements found on measures of anxiety, depression, and generalised wellbeing. Small reductions in loneliness, [11] and improved quality of life and health status [12, 17] have also been observed in studies with small sample sizes and no comparison group. One long-term comparative study found no differences after 8-months between social prescribing participants and matched controls on quantitative measures of health, wellbeing, anxiety, depression, or active engagement in life [15]. Nevertheless, this study found that social prescribing participants had a reduced number of General Practitioner (GP) appointments and that their prescribed medication stabilised. This lack of long-term data means we are yet to understand the sustainability of attending groups and activities and whether these group memberships continue after the social prescribing period has ended. The longevity of these memberships is important as we know that increases in group memberships for social prescribing clients have been associated with greater feelings of belonging to their local community [13]. Improvements in health outcomes have also been observed, with greater engagement in social groups predicting reduced primary care utilization [13]. Indeed, if these changes are not sustained after leaving social prescribing programs, practitioners may find clients returning to primary care once again seeking medical solutions for their unmet social needs [18]. Not enough research on relationships and social activities in LWSP One possible reason that the benefits of social prescribing may take time to emerge is that there are many relationships involved, and these take time to establish and maintain. These include the person’s integrated relationships with the referrer (usually a GP or other health professional), their Link Worker, and the facilitator and members of the community-based group program(s) that they are referred into as part of social prescribing. To date, most social prescribing evaluations have reported on the health and psychosocial outcomes for participants or costs and benefits for health services. However, there are relatively few studies that focus on the activities and relationships that enable participants to benefit from their involvement in social prescribing programs. In fact, this was one of the 8 recommendations made to guide future social prescribing implementation research in a recent perspective paper [19]. Supporting people to join and sustain new group memberships is critical to the success of social prescribing and several qualitative studies have suggested that the relationship between clients and Link Workers is the key component [13, 20–22]. These studies suggest that client engagement with social prescribing programs stems from the range of person-centred and rapport building strategies that Link Workers use — including those that (a) support clients’ agency to co-develop a social plan, (b) help them to overcome multiple and complex barriers to joining social programs, and (c) create a sense of safety around attending new groups [22]. Although these relationships are clearly important in guiding clients to groups, investigations thus far have not yet examined the next step in the social prescribing pathway: client relationships with facilitators and members of the groups they attend. The shared sense of identity, connection, and comfort among group members (a sense of ‘us-ness’) are critical to forming successful group memberships [23–25]. The development of this group identity is likely partly attributed to the qualities of leadership displayed by social prescribing program facilitators [26], and may help to explain how pathways within the Social Identity Model of Identity Change (SIMIC) are supported. That is, how feelings of belonging are aided when new identities are formed. However, this type of facilitator relationship has primarily been examined within organisational contexts rather than within community and voluntary sector group activities. While there is some existing qualitative research about clients’ relationships with Link Workers [22, 27], these have not been examined quantitatively to date. Furthermore, clients’ relationships with community group facilitators have rarely been examined quantitatively. Thus, there is a need for quantitative research that captures aspects of the social processes through which positive outcomes may be enabled in order to identify the ‘active ingredients’ of social prescribing [7]. Understanding these mechanisms is crucial for optimizing implementation and ensuring long-term impact. The current study This research was designed to address these gaps. It draws upon a controlled evaluation of social prescribing among 114 community dwelling adults who were non-randomly assigned to LWSP or to GP treatment-as-usual in the same locations in South East Queensland [28] Outcomes for this trial at 8 weeks (reported elsewhere [10]) revealed significant large effects relative to control on loneliness and social trust, and small-to-moderate effects on wellbeing, social anxiety, and psychological distress. More specifically, interactions on all these measures reflected the fact that improvements over time was more marked for SP participants than they were for controls. In the current study, we extend upon previous research among social prescribing participants in three key ways: (1) by examining quantitative changes over a relatively long period (18-months) in loneliness, wellbeing, perceived health, psychological distress, and social trust; (2) by assessing participants’ engagement in groups; and (3) by exploring whether relational components of LWSP, such as clients’ relationships with Link Workers and group facilitators, are associated with subsequent psychosocial and health outcomes. Methods The methodology and procedure for SP and data collection at baseline (T1) and 8-week follow up (T2) are described elsewhere [ 10 , 28 ], and registered on the ANZ clinical trials registry, with data collected for this stage of the project from February to June 2023. The 18-month follow-up (T3) was not prospectively planned. However, it became possible late in the period of our evaluation due to resources not used following COVID-19 restrictions at the commencement of the project. We prioritised T3 follow ups for participants in the social prescribing arm as we wanted to explore their longer-term relationships and outcomes. Accordingly, the current study has a within-subjects repeated measures design in which we report results for SP participants who completed surveys at all three time points, with time treated categorically. Participants Of the 63 participants in the LWSP arm at T1, 50 participants completed follow up data collection at T2. Forty-eight of these were contacted again at T3; two were not contacted as one did not want to participate in further research following T2, and a translator could not be sourced in time for the other. From this, 30 participants completed T3 data collection (a 63% response rate at T3). The average follow-up period from T1 to T3 for the 30 participants was approximately 18 months ( M = 552.90 days, SD = 191.99) with 48% retention from T1 (a consort diagram is provided elsewhere for T1 and T2) [ 10 ]. The sample at T3 included 24 women, and 6 men aged between 34 and 81 ( M = 53.59, SD = 12.94). Most (93%) were single or separated. Only 7% were married or cohabiting. In this sample, most were born in Australia (77%), with others born in New Zealand, China, Iran, Vietnam, or the United Kingdom. Overall, 37% of participants reported having a university degree, 30% having completed a certificate or diploma, 17% having completed high school, and 17% not having completed high school. This smaller sample was closely representative of the larger sample of participants reported elsewhere [ 10 ]. Measures Social groups listed and documented elsewhere [ 10 , 28 ], were classified into categories: physical activity; arts and creative; volunteering, work, and educational; social activities or clubs; family and friends; communities such as neighbourhoods or churches; and support groups. Individual groups were summed to assess total number of groups that participants were members of at each time-point. However, participants at T1 and T2 were limited to a maximum of 6 groups, while there was no limitation at T3. Therefore, median values are used to describe comparisons between time points, all other analyses use total groups at T3. Social prescribing relationships were assessed at T1 and T2 using a single item ‘I think my wellbeing coordinator / social connector and I have a strong relationship’ and a single item ‘the group facilitator helps me feel a sense of belonging in the group’, both on a 5-point scale of agreement from 1 = strongly disagree to 5 = strongly agree . At T3, participants were also asked “Did you feel the program was able to help you feel reconnected?”, and “Have you used the skills you gained from your social connector/ link worker to help you join any new groups or activities?” using the same scale. Loneliness was assessed using the 8-item UCLA Loneliness Scale (ULS-8; α T1 = .90, α T2 = .91, α T3 = .91) recorded on a 4-point scale from 1 = never to 4 = often [ 29 ]. Following recommended guidelines [ 30 , 31 ], a direct measure of loneliness was also included; the single item ‘How often do you feel lonely?’, rated on a 5-point scale from 1 = never to 5 = often/always . Wellbeing was measured using the 14-item Warwick Edinburgh Mental Wellbeing Scale (α T1 = .93, α T2 = .94, α T3 = .92) using a 5-point rating scale from 1 = none of the time to 5 = all of the time [ 32 ]. Items asked respondents how often they had experienced various psychological states over the past two weeks (e.g., ‘I’ve been feeling relaxed’). Scores were summed to produce a total score in the range from 14 to 70, with higher scores corresponding to a higher level of mental wellbeing. Psychological distress was assessed using the well-established 6-item scale (K6; α T1 = .93, α T2 = .92, α T3 = .91) that asked respondents to indicate how often they had experienced 3 depression symptoms and 3 anxiety symptoms over the past 30 days, on a scale from 0 = never to 4 = always [ 33 ]. A total score in the range of 0 to 24 is calculated and a score of 13 + is interpreted as clinically elevated [ 34 ]. Trust. Due to a lack of validated measures of general social trust suited to our study, we used an adapted version of the Cognitive Trust in Service Relationships Scale by removing the service relationship components of the items (α T1 = .74, α T2 = .76, α T3 = .85) [ 35 ]. Social trust items such as ‘I feel I can trust others’ advice to me’ were rated from 1 = strongly disagree to 7 = strongly agree . Current health was measured using a single item asking participants to rate their current overall health from 1 = very poor to 5 = excellent . Procedure Participants were asked to complete a survey either online or in-person after providing written informed consent. Participants were reimbursed with $ 40 vouchers at each survey. The T3 survey included fewer measures than T1 and T2. The same primary researcher contacted (or attempted to contact) eligible SP clients who had previously participated in T1 and T2. Results 18-month outcomes Means, standard deviations, and effect sizes (Cohen’s d) for each outcome using repeated measures ANOVAs are reported in Table 1 . There was a significant effect of time on the ULS-8 loneliness scale, F (2, 58) = 10.27, p < .001. Pairwise comparisons with Bonferroni corrections revealed significant differences between T1 and T2 ( p = .045), and T1 and T3 ( p < .001). There was also a significant effect of time on the single-item loneliness scale, F (2, 52) = 10.41, p < .001. Pairwise comparisons showed the same pattern of change between T1 and T2 ( p = .006), T1 and T3 ( p = .003). Psychological distress decreased significantly over time, F (2, 56) = 3.65, p = .032. Pairwise comparisons found a significant difference only between T1 and T3, p = .049. Self-rated health also showed a significant increase across time F (2, 54) = 5.74, p = .006. However, pairwise comparisons only found a significant difference between T1 and T3 ( p = .015). Effect sizes on loneliness, psychological distress, and perceived health outcomes were large (see Table 1 , and Fig. 1 ). In addition, there was a moderate (non-significant) effect of time on wellbeing, F (2, 52) = 2.53, p = .089, and small-to-moderate (non-significant) effect of time on trust F (2, 56) = 1.41, p = .253. Table 1 Descriptive statistics over 18-months follow-up on quantitative outcomes for 30 participants of link worker social prescribing in Queensland Outcome Baseline: T1 M ( SD ) + 8 weeks: T2 M ( SD ) + 18 months: T3 M ( SD ) F p Effect size (time), η p 2 Loneliness scale (ULS) 23.23 (4.93) ab 21.60 (5.36) a 19.97 (6.11) b 10.27 < .001 0.262 Loneliness item 4.07 (1.11) ab 3.52 (1.25) a 3.22 (1.37) b 10.41 < .001 0.286 Wellbeing (WEMBWS) 41.22 (9.99) 43.56 (10.91) 44.89 (10.72) 2.53 .089 0.089 Distress (K6) 11.86 (5.91) a 10.86 (6.05) 9.31 (6.08) b 3.65 .032 0.115 Perceived health item 3.07 (1.02) 3.04 (1.07) a 3.50 (0.92) b 5.74 .006 0.175 Social Trust 3.39 (0.98) 3.74 (1.09) 3.67 (1.52) 1.41 .253 0.048 Note : M = Mean; SD = Standard deviation; η p 2 = partial eta squared (effect size); ab differing superscript identifies a significant difference between time points for an outcome; ULS = 8-item UCLA loneliness scale; WEMWBS = Warwick Edinburgh Mental Wellbeing Scale; K6 = 6-item Kessler psychological distress scale; bold denotes a significant difference at p < .05 Social prescribing relationships and activities Overall, the number of meaningful social groups that participants reported they belonged increased from a median of 2 groups at T1, to 3 groups at T2 and 3 groups at T3. At T3, 39% were still seeing their Link Worker at least some of the time, and 44% of participants were still attending a group that their Link Worker had connected them to. The proportion of different activities and groups engaged in by participants at T1 and T3 are shown in Fig. 2 . This figure shows that participants engaged in similar types of groups and activities as they had at the beginning the program, although there was some change in the specific groups that they attended over time. In addition, 36% reported using the skills they had learned to join new groups or activities without the assistance of their Link Worker. A strong connection with their Link Worker was endorsed by participants at both T1 ( M = 4.00, SD = 0.83) and T2 ( M = 3.7, SD = 1.15). Participants also indicated that activity facilitators had helped them to feel a sense of belonging in the group at T1 ( M = 4.26, SD = .81) and T2 ( M = 4.07, SD = 1.0). At T3, there was general agreement that SP was able to help them feel reconnected ( M = 3.68. SD = 1.16). Correlations between relationship quality and outcomes We examined correlations between relationship variables at each time-point, the number of groups at T3 and their association with health, wellbeing, and trust outcomes at T3 (see Table 2 ). Bivariate correlations revealed no relationships between T1 relationship ratings and T3 psychosocial outcomes. However, higher ratings of Link Worker relationship strength at T2 were related to lower T3 distress ( p = .006), lower loneliness both on the single-item measure ( p = .006) and the ULS-8 ( p < .001), as well as greater wellbeing ( p = .011) and overall health ( p < .001). A greater sense that facilitators fostered a sense of belonging at T2 was also associated with: a greater sense that the SP program helped participants feel connected at T3 ( p = .033), less feelings of loneliness (both on the single-item ( p = .014) and the ULS-8 ( p < .001), less distress ( p = .033), greater wellbeing ( p = .013), greater trust ( p = .005) and better overall health ( p = .01). A sense that the program helped participants to feel reconnected at T3 was also related to lower loneliness scores on the ULS-8 ( p = .003), lower distress ( p = .002), more wellbeing ( p = .024) and greater trust ( p = .005). Being a member of a greater number of groups at T3 was also associated with lower loneliness (single-item p = .02), lower distress ( p = .016), higher wellbeing ( p = .029), and better overall health ( p = .041) at T3. Table 2 Bivariate correlations between relationship variables and + 18-month outcomes Outcome Baseline LW relationship strength Baseline Facilitator belonging 8-week LW relationship strength 8-week Facilitator belonging T3 program reconnection Number of groups at 18-months Number of groups at 18-months -0.077 0.111 0.223 0.346 0.369 1 T3 program reconnection -0.145 -0.085 0.331 .397* 1 Loneliness scale (ULS) 0.109 0.101 − .615** − .604** − .530** -0.38 Loneliness item -0.133 0.198 − .503** − .467* -0.268 − .463* Wellbeing (WEMBWS) -0.094 0.07 .459* .458* .410* .427* Distress (K6) 0.042 0.105 − .487** − .397* − .532** − .468* Perceived health item 0.092 -0.179 .660** .468* 0.21 .404* Social Trust 0.276 0.153 -0.237 − .387* − .502** -0.233 Note : * Significance < .05; ** Significant < .001; ULS = 8-item UCLA loneliness scale; WEMWBS = Warwick Edinburgh Mental Wellbeing Scale; K6 = 6-item Kessler psychological distress scale Discussion The aim of this research was to examine the impact of LWSP, including the value of relationships and social activities, on participants’ psychological and health outcomes over an 18-month period. It was clear from our findings that clients’ relationships with their Link Worker were an important and valuable factor related to improved mental and physical health for participants. Importantly, though, it was the strength of relationship at 8-weeks, not baseline, that was associated with lower loneliness and distress, and higher wellbeing and perceived health at 18-months. This is the first study to show quantitively that the relational aspects of LWSP predict longer-term psychosocial and health outcomes for clients. However, our findings reinforce the conclusions of previous qualitative research that has suggested that the success of social prescribing is dependent on Link Workers’ relationship building with clients and forming the stepping stones to good rapport with group facilitators [ 20 , 22 ]. Merely pointing clients towards activities is less likely to be successful — particularly for those with complex needs [ 36 ]. These findings have important implications for primary care providers (e.g., GPs, practice nurses), who are often the initial point of referral to social prescribing programs. While social prescribing is designed to address social determinants of health, its success relies not just on referral, but on ensuring patients understand the role of Link Workers in providing ongoing relational support. Given that our findings indicate that relationship strength at 8-weeks, rather than baseline, predicts longer-term outcomes, primary care providers could play a role in setting expectations at the point of referral—highlighting the importance of sustained engagement beyond initial contact. Community group activity facilitators also played an important role in social prescribing. At 8-weeks, the extent to which facilitators were perceived to have helped participants feel a sense of belonging was associated with those participants feeling less lonely and distressed, having greater wellbeing and trust, and having better self-rated health. Moreover, this cultivation of a sense of belonging was also associated with agreement that social prescribing had helped participants feel reconnected, a relationship that was not found for client relationships with their Link Worker. This may reflect the particular role that group facilitators play in encouraging participants to develop meaningful group memberships and associated social identities that can counteract loneliness, which are foundational for health [ 25 ]. Elsewhere, social identity researchers have suggested that key actions here include mapping similarities between group members, using inclusive ‘we / our group’ language, encouraging interaction between group members through activities involving shared goals, cooperation, and trust; emphasising similarities between group members, and promoting member reflections on personal achievements that relate to the group’s function [ 23 , 24 ]. To date, though, very little research has explored the skills and strategies that facilitators might employ to build meaningful social connections between group members. Future research on social prescribing would benefit from exploring the importance of these strategies, as recommended by Dingle et al [ 19 ]. Nevertheless, the present findings are broadly consistent with social identity theorising. In particular, the number of groups that participants belonged to at 18-months was associated with less loneliness and distress, and greater wellbeing and perceived health. Interestingly, the types of groups that participants belonged to tended to remain the same over time, despite changes in the specific groups they attended. Moreover, while at T3, 61% of participants no longer attended meetings with their Link Worker, their desire to maintain or rebuild social relationships was reflected in the proportion of participants who anecdotally reported during T3 data collection that they were using the skills they had learned to join new groups or activities — for example, joining social clubs, forming and facilitating new groups, and creating new friendships within their neighbourhoods. This suggests that social prescribing benefits can be sustained beyond the initial period of Link Worker engagement — provided social prescribing is a basis for the development of meaningful group-based relationships. At the same time, though, it suggests that there is a pressing need to understand precisely how clients can be successfully ‘signed off’ to ensure they have the skills needed to maintain such relationships, and thereby ensure that social prescribing services are optimised. Longer-term health and wellbeing benefits Outcomes on the 8-item UCLA loneliness scale and the single-item measure of loneliness showed improvements from baseline at + 8-weeks and + 18-month follow-up, with medium to large effect sizes. This again suggests that group engagement helped to satisfy participants’ social needs. It is also noteworthy in light of the fact that previous studies with shorter follow-up windows have sometimes not observed a significant reduction in loneliness [ 12 ]. Similarly, participants’ perceptions of their health improved from baseline to + 18-months, with a moderate to large effect size, but not between baseline and + 8-weeks. Again, this implies that the benefits of social prescribing are not instantaneous but take time to emerge. This, though, is a conclusion that needs to be interrogated in further research, potentially including other measures of health, such as blood pressure, glucose, immune function tests, and sleep quality [ 8 , 37 , 38 ]. Ratings of trust were relatively stable over time, with non-significant increases (of small-to-medium size) over time that were greater among participants who reported stronger Link Worker and facilitator relationship quality. At the same time, our comparative research across T1 and T2 found that ratings of social trust reduced among TAU participants compared to small increases in ratings among social prescribing participants [ 10 ]. Given that lack of trust has been identified in other research as a correlate of loneliness and a barrier to making social connections [ 39 , 40 ], this too would seem to be an important focus for future research. In particular, more work is needed to understand the activities and strategies that Link Workers and facilitators might employ to help clients feel confident and safe as they set out to forge new social connections and (re)join groups. Strengths, limitations, and future directions Although social prescribing implementation has rapidly increased in recent years, there are still few studies evaluating the longer-term impact of social prescribing on its participants, and even fewer that provide data after 6-months. This is one of the few studies to examine outcomes of social prescribing after 18-months. It is also the first study to quantitatively demonstrate associations between the relationships between clients and Link Workers, and between clients and community social group facilitators, and participant improvements in these health and psychosocial measures. Further, there is currently no single established measure of Link Worker-client relationship quality and satisfaction (although there is a feedback tool available) [ 41 ], our single-item measure was able to provide evidence of the immediate value of the Link Worker to participants. Despite these strengths, this research was limited in its ability to recruit and retain more participants. This was partly due to the nature of the vulnerable population accessing social prescribing and the compounding impact of COVID-19 lockdown regulations that interfered with participant contact. Regardless, the impact and generalisability of these findings are limited by the small size of the sample and the possibility that the participants we did retain were doing well in comparison to those who were not able to be followed up at the final time-point. Future longitudinal investigations into social prescribing would be strengthened by including a control or comparison group. Additionally, our research did not include relational processes with referrers. Future research should explore how primary care providers can optimize their role in the referral process. Previous research with Link Workers and Clients has indicated that clients often attend social prescribing with little to no understanding of what is involved [ 3 , 22 , 42 ]. This could include examinations of how discussions about social prescribing at the point of referral influence patient engagement with Link Workers and subsequent groups. Understanding these dynamics could help refine primary care guidance on referral into social prescribing. Conclusion This study responds to a call for research into the longer-term outcomes of social prescribing and an examination of potential contributions of group activities and relational processes to participant outcomes. Despite the small sample size and lack of comparison sample, we found substantial benefits for participants at 18-months on loneliness, perceived health, mental health, and engagement with meaningful groups. Moreover, the quality of participants’ relationships with Link Workers and group facilitators’ skills in fostering group belonging at 8-weeks were associated with positive 18-month outcomes. These findings emphasise that social prescribing is a multifaceted and highly relational health pathway. Ensuring that patients understand the role of Link Workers within social prescribing and the importance of sustained engagement may be important to maximise the benefits of these interventions. Declarations Ethics approval and consent to participate All participants provided written consent to participate, and the protocol was approved by the University human research ethics committee #2019002287. Consent for publication All participants provided written consent for their information to be used in the research which had potential for publication. Availability of data and materials Data are available by request from the corresponding author. Competing interests JRB is the CEO of a primary care service that employs a social prescribing scheme within their practice. He was not involved in participant recruitment, data collection or analysis. We declare no other conflicts of interest. Funding This study was supported by funding from the Australian Research Council LP180100761. The ARC was not involved in any aspect of the research or decision to submit this manuscript for publication. SH was supported by a PhD stipend from the University of XXX linked to this grant. Authors' contributions LSS led the project management, and was involved in data collection and analysis, and wrote the first draft of the manuscript. GAD, CH, TC, JJ, and NM were involved in project design and funding acquisition. SH was involved in data collection. DC, JRB and TJ facilitated referrals and data collection. All authors read and approved the final manuscript. Acknowledgements The authors are extremely grateful to the participants, members of the project steering group Deb Crompton, Corinne McMillan, and Jim Pollock, to link workers Wendy Blackmon, Elise Marr, Loretta Stumer, and Susan Gilmartin, and to research assistants Dylan Nicholls, Shannon Tyrie and Hana Kermani. References Global Social Prescribing Alliance (GSPA). 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Social Prescribing as ‘Social Cure’: A longitudinal study of the health benefits of social connectedness within a Social Prescribing pathway. J Health Psychol. 2022;27:386–96. Carnes D, Sohanpal R, Frostick C, Hull S, Mathur R, Netuveli G, et al. The impact of a social prescribing service on patients in primary care: a mixed methods evaluation. BMC Health Serv Res. 2017;17:835. Moffatt S, Wildman J, Pollard TM, Gibson K, Wildman JM, O’Brien N, et al. Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study. Public Health Res. 2023;11:1–185. Aggar C, Caruana T, Thomas T, Baker JR. Social prescribing as an intervention for people with work-related injuries and psychosocial difficulties in Australia. Adv Health Behav. 2020;3:101–11. Cruwys T, Wakefield JRH, Sani F, Dingle GA, Jetten J. Social isolation predicts frequent attendance in primary care. Ann Behav Med. 2018. https://doi.org/10.1093/abm/kax054 . Dingle GA, Aggar C, Arslanovski N, Astell-Burt T, Baker JR, Baxter R et al. Australian and UK perspectives on social prescribing implementation research: Theory, measurement, resourcing, and discovery to ensure health equity. Health Soc Care Community. 2025; online https://doi.org/10.1155/hsc/2650302 Payne K, Walton E, Burton C. Steps to benefit from social prescription: a qualitative interview study. Br J Gen Pract. 2020;70:e36–44. Chatterjee HJ, Camic PM, Lockyer B, Thomson LJM. Non-clinical community interventions: a systematised review of social prescribing schemes. Arts Health. 2018;10:97–123. Sharman LS, McNamara N, Hayes S, Dingle GA. Social prescribing link workers—A qualitative Australian perspective. Health Soc Care Community. 2022;30. Robertson AM, Cruwys T, Stevens M, Platow MJ. A social identity approach to facilitating therapy groups. Clin Psychol Sci Pract. 2023;:No Pagination Specified-No Pagination Specified. Cruwys T, Steffens NK, Haslam SA, Haslam C, Hornsey MJ, McGarty C, et al. Predictors of social identification in group therapy. Psychother Res. 2020;30:348–61. Haslam C, Jetten J, Cruwys T, Alexander Haslam. The New Psychology of Health: Unlocking the Social Cure. New York, NY: Routledge; 2018. Randel AE, Galvin BM, Shore LM, Ehrhart KH, Chung BG, Dean MA, et al. Inclusive leadership: Realizing positive outcomes through belongingness and being valued for uniqueness. Hum Resour Manag Rev. 2018;28:190–203. Hayes S, Sharman LS, McNamara N, Dingle GA. Link workers’ and clients’ perspectives on how social prescribing offers a social cure for loneliness. Under Review. Dingle GA, Sharman LS, Hayes S, Chua D, Baker JR, Haslam C, et al. A controlled evaluation of the effect of social prescribing programs on loneliness for adults in Queensland, Australia (protocol). BMC Public Health. 2022;22:1384. Hays RD, DiMatteo MR. A Short-Form Measure of Loneliness. J Pers Assess. 1987;51:69–81. Ending Loneliness Together. A Guide to Evaluating Loneliness Outcomes for Community Organisations. 2021. What Works Wellbeing. A brief guide to measuring loneliness for charities and social enterprises. 2019. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S, et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes. 2007;5:63. Kessler RC, Andrews G, Colpe LJ, Hiripi E, Mroczek DK, Normand SLT, et al. Short screening scales to monitor population prevalences and trends in non-specific psychological distress. Psychol Med. 2002;32:959–76. Furukawa TA, Kessler RC, Slade T, Andrews G. The performance of the K6 and K10 screening scales for psychological distress in the Australian National Survey of Mental Health and Well-Being. Psychol Med. 2003;33:357–62. Johnson D, Grayson K. Cognitive and affective trust in service relationships. J Bus Res. 2005;58:500–7. Drinkwater C, Polley M. Advice on social prescribing link workers for primary care networks in England from the National Social Prescribing Network. 2019. Cacioppo JT, Hawkley LC, Crawford LE, Ernst JM, Burleson MH, Kowalewski RB, et al. Loneliness and health: potential mechanisms. Psychosom Med. 2002;64:407–17. Marty PK, Novotny P, Benzo RP. Loneliness and ED Visits in Chronic Obstructive Pulmonary Disease. Mayo Clin Proc Innov Qual Outcomes. 2019;3:350–7. Dingle GA, Sharman LS. Social Prescribing: A Review of the Literature. In: Menzies RG, Menzies RE, Dingle GA, editors. Existential Concerns and Cognitive-Behavioral Procedures: An Integrative Approach to Mental Health. Cham: Springer International Publishing; 2022. pp. 135–49. Ingram I, Kelly PJ, Deane FP, Baker AL, Dingle GA. Perceptions of loneliness among people accessing treatment for substance use disorders. Drug Alcohol Rev. 2020;39:484–94. NHS. Workforce development framework: social prescribing link workers. 2023. https://www.england.nhs.uk/publication/workforce-development-framework-social-prescribing-link-workers/ . Accessed 5 Jun 2023. Sharman LS, Jones A, Dingle GA. 1-year evaluation of the social prescribing trial, in Brisbane North. The University of Queensland; 2024. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in BMC Primary Care → Version 1 posted Editorial decision: Revision requested 04 Mar, 2025 Editor assigned by journal 28 Feb, 2025 Submission checks completed at journal 28 Feb, 2025 First submitted to journal 27 Feb, 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-6118230","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":421992157,"identity":"50f568dd-21ab-4078-a03e-d419ab0136ab","order_by":0,"name":"Leah S. Sharman","email":"","orcid":"","institution":"The University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Leah","middleName":"S.","lastName":"Sharman","suffix":""},{"id":421992158,"identity":"a658e9b4-029a-446d-b3f4-c9f419eeed2d","order_by":1,"name":"Shaun Hayes","email":"","orcid":"","institution":"The University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Shaun","middleName":"","lastName":"Hayes","suffix":""},{"id":421992159,"identity":"bd767ae0-b38f-45d7-ae10-4f427f9e950b","order_by":2,"name":"David Chua","email":"","orcid":"","institution":"The University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Chua","suffix":""},{"id":421992160,"identity":"86c78882-85a1-4549-ab1e-a5c65cca76c1","order_by":3,"name":"Catherine Haslam","email":"","orcid":"","institution":"The University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Catherine","middleName":"","lastName":"Haslam","suffix":""},{"id":421992162,"identity":"a687a69e-5a04-4dc7-93e8-f714c7766672","order_by":4,"name":"Tegan Cruwys","email":"","orcid":"","institution":"Australian National University","correspondingAuthor":false,"prefix":"","firstName":"Tegan","middleName":"","lastName":"Cruwys","suffix":""},{"id":421992164,"identity":"ac891591-72ec-4eb7-b192-cbf03dc7995e","order_by":5,"name":"Jolanda Jetten","email":"","orcid":"","institution":"The University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"Jolanda","middleName":"","lastName":"Jetten","suffix":""},{"id":421992167,"identity":"3e7085c1-b146-4db1-a980-96b6b9e4edfa","order_by":6,"name":"S. Alexander Haslam","email":"","orcid":"","institution":"The University of Queensland","correspondingAuthor":false,"prefix":"","firstName":"S.","middleName":"Alexander","lastName":"Haslam","suffix":""},{"id":421992170,"identity":"46616467-f2f4-4eff-aac9-05164cf41d5c","order_by":7,"name":"Niamh McNamara","email":"","orcid":"","institution":"Nottingham Trent University","correspondingAuthor":false,"prefix":"","firstName":"Niamh","middleName":"","lastName":"McNamara","suffix":""},{"id":421992174,"identity":"60c82ae0-ef0f-4538-b98a-f7371d6c6d13","order_by":8,"name":"James R. Baker","email":"","orcid":"","institution":"Southern Cross University","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"R.","lastName":"Baker","suffix":""},{"id":421992177,"identity":"4d221d72-2ed9-4840-a5bf-1c471503a62c","order_by":9,"name":"Tracey Johnson","email":"","orcid":"","institution":"Inala Primary Care","correspondingAuthor":false,"prefix":"","firstName":"Tracey","middleName":"","lastName":"Johnson","suffix":""},{"id":421992180,"identity":"6b6176f6-ad63-4798-8f17-ea4a4f51cdd3","order_by":10,"name":"Genevieve A. Dingle","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/UlEQVRIiWNgGAWjYHACgwMMDBYM/AiBBKK0SDBINpCihQGkBaSROC3yDswbDxf8kpAzvt3+TIKxzZqBnz3HgOFnG24thgfYCg7P7JMwNrtzxgyoJZ1BsueNAWMvPi0NPAaHeXskErfdyGEDajnMYHADaAsvEVrqN89IfwbWYg/UwvgXjxZ5BqAWnh8SCQYSCWYQWyRyDJjx2WLADPQLb4OE4Yw7Z4wtEs6l80iceVZwWOYcHlvamzd/5vljI88/u/3hjQ9l1nL87ckbH74pw2PLYSDBCHKGBAOLRAIDMw9I9ABuDUBbGkDkH7AW5g8MDMz4FI+CUTAKRsEIBQDjEU07/qtYHgAAAABJRU5ErkJggg==","orcid":"","institution":"The University of Queensland","correspondingAuthor":true,"prefix":"","firstName":"Genevieve","middleName":"A.","lastName":"Dingle","suffix":""}],"badges":[],"createdAt":"2025-02-27 06:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6118230/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6118230/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12875-025-03084-6","type":"published","date":"2025-11-24T15:58:39+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77565507,"identity":"09a95110-cdab-4a86-82c6-ca00d54381f9","added_by":"auto","created_at":"2025-03-03 07:33:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":323815,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eChanges for self-rated loneliness, distress, and health at baseline (T1), 8-weeks (T2), and 18 months (T3).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6118230/v1/40cb5b377d85c86af634c57d.png"},{"id":77565276,"identity":"1c0200dc-2ee0-4881-a2ed-cc963cb3b33c","added_by":"auto","created_at":"2025-03-03 07:25:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":464101,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTypes of activities and groups participants engaged in, at Time 1 (inner-circle) and Time 2 (outer-circle) after engaging in social prescribing.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6118230/v1/e7274ed955c5e163efe1f8ca.png"},{"id":97179574,"identity":"e8cffd96-5578-4cfb-ae47-a6fd2aea8286","added_by":"auto","created_at":"2025-12-01 16:16:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1772789,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6118230/v1/73ac3357-61b2-4f47-a6ac-8e15ee3869d0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eEffectiveness and Value of Relationships in Link Worker Social Prescribing Over an 18-month Follow Up Period\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003e\u003cstrong\u003eSocial prescribing in primary care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSocial prescribing has emerged as a patient-centred approach in primary care, addressing the social determinants of health by connecting individuals with non-clinical community services. In the holistic model of social prescribing, link workers engage with socially isolated clients to produce bespoke action plans that support client engagement with social activities and services in their local communities\u0026nbsp;[1]. Social prescribing programs are now available in at least 26 countries\u0026nbsp;[2], across a range of settings, and age groups including children and young people\u0026nbsp;[3\u0026ndash;5], and older adults\u0026nbsp;[6]. Despite the promise of this approach however, it has been difficult to establish the effectiveness of social prescribing due to the variety of models and referral pathways used, and the diverse activities and services included across programs [7,8]. Indeed, Husk et al. observed that \u0026lsquo;social prescribing is not a single intervention but a pathway and series of relationships, all of which need to function to meet patient need\u0026rsquo;\u0026nbsp;[9].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe effects of social prescribing may take time to emerge, as demonstrated in a controlled study of 114 community dwelling adults finding only small effects on loneliness and trust at 8-weeks follow-up [10]. This means that prospective studies with longer-term follow-ups are critical, although few have been published thus far. Some studies have utilised follow-up periods between 6 and 9-months, centring on people experiencing loneliness in the context of mental illness [11, 12] or other long-term health conditions [13\u0026ndash;16]. Results have focused primarily on wellbeing outcomes with improvements found on measures of anxiety, depression, and generalised wellbeing. Small reductions in loneliness, [11] and improved quality of life and health status [12, 17] have also been observed in studies with small sample sizes and no comparison group.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eOne long-term comparative study found no differences after 8-months between social prescribing participants and matched controls on quantitative measures of health, wellbeing, anxiety, depression, or active engagement in life [15]. Nevertheless, this study found that social prescribing participants had a reduced number of General Practitioner (GP) appointments and that their prescribed medication stabilised.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis\u0026nbsp;lack of long-term data means we are yet to understand the sustainability of attending groups and activities and whether these group memberships continue after the social prescribing period has ended. The longevity of these memberships is important as we know that increases in group memberships for social prescribing clients have been associated with greater feelings of belonging to their local community [13]. Improvements in health outcomes have also been observed, with greater engagement in social groups predicting reduced primary care utilization [13]. Indeed, if these changes are not sustained after leaving social prescribing programs, practitioners may find clients returning to primary care once again seeking medical solutions for their unmet social needs [18]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNot enough research on relationships and social activities in LWSP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne possible reason that the benefits of social prescribing may take time to emerge is that there are many relationships involved, and these take time to establish and maintain. \u0026nbsp;These include the person\u0026rsquo;s integrated relationships with the referrer (usually a GP or other health professional), their Link Worker, and the facilitator and members of the community-based group program(s) that they are referred into as part of social prescribing. To date, most social prescribing evaluations have reported on the health and psychosocial outcomes for participants or costs and benefits for health services. However, there are relatively few studies that focus on the activities and relationships that enable participants to benefit from their involvement in social prescribing programs. In fact, this was one of the 8 recommendations made to guide future social prescribing implementation research in a recent perspective paper\u0026nbsp;[19].\u0026nbsp;Supporting people to join and sustain new group memberships is critical to the success of social prescribing and several qualitative studies have suggested that the relationship between clients and Link Workers is the key component [13, 20\u0026ndash;22]. These studies suggest that client engagement with social prescribing programs stems from the range of person-centred and rapport building strategies that Link Workers use \u0026mdash; including those that (a) support clients\u0026rsquo; agency to co-develop a social plan, (b) help them to overcome multiple and complex barriers to joining social programs, and (c) create a sense of safety around attending new groups [22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough these relationships are clearly important in guiding clients to groups, investigations thus far have not yet examined the next step in the social prescribing pathway: client relationships with facilitators and members of the groups they attend. The shared sense of identity, connection, and comfort among group members (a sense of \u0026lsquo;us-ness\u0026rsquo;) are critical to forming successful group memberships [23\u0026ndash;25]. The development of this group identity is likely partly attributed to the qualities of leadership displayed by social prescribing program facilitators [26], and may help to explain how pathways within the Social Identity Model of Identity Change (SIMIC) are supported. That is, how feelings of belonging are aided when new identities are formed. However, this type of facilitator relationship has primarily been examined within organisational contexts rather than within community and voluntary sector group activities. While there is some existing qualitative research about clients\u0026rsquo; relationships with Link Workers [22, 27], these have not been examined quantitatively to date. Furthermore, clients\u0026rsquo; relationships with community group facilitators have rarely been examined quantitatively. Thus, there is a need for quantitative research that captures aspects of the social processes through which positive outcomes may be enabled in order to identify the \u0026lsquo;active ingredients\u0026rsquo; of social prescribing [7]. Understanding these mechanisms is crucial for optimizing implementation and ensuring long-term impact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe current study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was designed to address these gaps. It draws upon a controlled evaluation of social prescribing among 114 community dwelling adults who were non-randomly assigned to LWSP or to GP treatment-as-usual in the same locations in South East Queensland [28] Outcomes for this trial at 8 weeks (reported elsewhere [10]) revealed significant large effects relative to control on loneliness and social trust, and small-to-moderate effects on wellbeing, social anxiety, and psychological distress. More specifically, interactions on all these measures reflected the fact that improvements over time was more marked for SP participants than they were for controls. In the current study, we extend upon previous research among social prescribing participants in three key ways: (1) by examining quantitative changes over a relatively long period (18-months) in loneliness, wellbeing, perceived health, psychological distress, and social trust; (2) by assessing participants\u0026rsquo; engagement in groups; and (3) by exploring whether relational components of LWSP, such as clients\u0026rsquo; relationships with Link Workers and group facilitators, are associated with subsequent psychosocial and health outcomes. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe methodology and procedure for SP and data collection at baseline (T1) and 8-week follow up (T2) are described elsewhere [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], and registered on the ANZ clinical trials registry, with data collected for this stage of the project from February to June 2023. The 18-month follow-up (T3) was not prospectively planned. However, it became possible late in the period of our evaluation due to resources not used following COVID-19 restrictions at the commencement of the project. We prioritised T3 follow ups for participants in the social prescribing arm as we wanted to explore their longer-term relationships and outcomes. Accordingly, the current study has a within-subjects repeated measures design in which we report results for SP participants who completed surveys at all three time points, with time treated categorically.\u003c/p\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eOf the 63 participants in the LWSP arm at T1, 50 participants completed follow up data collection at T2. Forty-eight of these were contacted again at T3; two were not contacted as one did not want to participate in further research following T2, and a translator could not be sourced in time for the other. From this, 30 participants completed T3 data collection (a 63% response rate at T3). The average follow-up period from T1 to T3 for the 30 participants was approximately 18 months (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;552.90 days, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;191.99) with 48% retention from T1 (a consort diagram is provided elsewhere for T1 and T2) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe sample at T3 included 24 women, and 6 men aged between 34 and 81 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;53.59, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;12.94). Most (93%) were single or separated. Only 7% were married or cohabiting. In this sample, most were born in Australia (77%), with others born in New Zealand, China, Iran, Vietnam, or the United Kingdom. Overall, 37% of participants reported having a university degree, 30% having completed a certificate or diploma, 17% having completed high school, and 17% not having completed high school. This smaller sample was closely representative of the larger sample of participants reported elsewhere [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eSocial groups\u003c/b\u003e listed and documented elsewhere [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], were classified into categories: physical activity; arts and creative; volunteering, work, and educational; social activities or clubs; family and friends; communities such as neighbourhoods or churches; and support groups. Individual groups were summed to assess total number of groups that participants were members of at each time-point. However, participants at T1 and T2 were limited to a maximum of 6 groups, while there was no limitation at T3. Therefore, median values are used to describe comparisons between time points, all other analyses use total groups at T3.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSocial prescribing relationships\u003c/b\u003e were assessed at T1 and T2 using a single item \u0026lsquo;I think my wellbeing coordinator / social connector and I have a strong relationship\u0026rsquo; and a single item \u0026lsquo;the group facilitator helps me feel a sense of belonging in the group\u0026rsquo;, both on a 5-point scale of agreement from 1\u0026thinsp;=\u0026thinsp;\u003cem\u003estrongly disagree\u003c/em\u003e to 5\u0026thinsp;=\u0026thinsp;\u003cem\u003estrongly agree\u003c/em\u003e. At T3, participants were also asked \u0026ldquo;Did you feel the program was able to help you feel reconnected?\u0026rdquo;, and \u0026ldquo;Have you used the skills you gained from your social connector/ link worker to help you join any new groups or activities?\u0026rdquo; using the same scale.\u003c/p\u003e \u003cp\u003e\u003cb\u003eLoneliness\u003c/b\u003e was assessed using the 8-item UCLA Loneliness Scale (ULS-8; α\u003csub\u003eT1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.90, α\u003csub\u003eT2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.91, α\u003csub\u003eT3\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.91) recorded on a 4-point scale from 1\u0026thinsp;=\u0026thinsp;\u003cem\u003enever\u003c/em\u003e to 4\u0026thinsp;=\u0026thinsp;\u003cem\u003eoften\u003c/em\u003e [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Following recommended guidelines [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], a direct measure of loneliness was also included; the single item \u0026lsquo;How often do you feel lonely?\u0026rsquo;, rated on a 5-point scale from 1\u0026thinsp;=\u0026thinsp;\u003cem\u003enever\u003c/em\u003e to 5\u0026thinsp;=\u0026thinsp;\u003cem\u003eoften/always\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWellbeing\u003c/b\u003e was measured using the 14-item Warwick Edinburgh Mental Wellbeing Scale (α\u003csub\u003eT1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.93, α\u003csub\u003eT2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.94, α\u003csub\u003eT3\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.92) using a 5-point rating scale from 1\u0026thinsp;=\u0026thinsp;\u003cem\u003enone of the time\u003c/em\u003e to 5\u0026thinsp;=\u0026thinsp;\u003cem\u003eall of the time\u003c/em\u003e [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Items asked respondents how often they had experienced various psychological states over the past two weeks (e.g., \u0026lsquo;I\u0026rsquo;ve been feeling relaxed\u0026rsquo;). Scores were summed to produce a total score in the range from 14 to 70, with higher scores corresponding to a higher level of mental wellbeing.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePsychological distress\u003c/b\u003e was assessed using the well-established 6-item scale (K6; α\u003csub\u003eT1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.93, α\u003csub\u003eT2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.92, α\u003csub\u003eT3\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.91) that asked respondents to indicate how often they had experienced 3 depression symptoms and 3 anxiety symptoms over the past 30 days, on a scale from 0\u0026thinsp;=\u0026thinsp;\u003cem\u003enever\u003c/em\u003e to 4\u0026thinsp;=\u0026thinsp;\u003cem\u003ealways\u003c/em\u003e [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A total score in the range of 0 to 24 is calculated and a score of 13\u0026thinsp;+\u0026thinsp;is interpreted as clinically elevated [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cb\u003eTrust.\u003c/b\u003e Due to a lack of validated measures of general social trust suited to our study, we used an adapted version of the Cognitive Trust in Service Relationships Scale by removing the service relationship components of the items (α\u003csub\u003eT1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.74, α\u003csub\u003eT2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.76, α\u003csub\u003eT3\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;.85) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Social trust items such as \u0026lsquo;I feel I can trust others\u0026rsquo; advice to me\u0026rsquo; were rated from 1\u0026thinsp;=\u0026thinsp;\u003cem\u003estrongly disagree\u003c/em\u003e to 7\u0026thinsp;=\u0026thinsp;\u003cem\u003estrongly agree\u003c/em\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eCurrent health\u003c/b\u003e was measured using a single item asking participants to rate their current overall health from 1\u0026thinsp;=\u0026thinsp;\u003cem\u003every poor\u003c/em\u003e to 5\u0026thinsp;=\u0026thinsp;\u003cem\u003eexcellent\u003c/em\u003e.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003e Participants were asked to complete a survey either online or in-person after providing written informed consent. Participants were reimbursed with \u003cspan\u003e$\u003c/span\u003e40 vouchers at each survey. The T3 survey included fewer measures than T1 and T2. The same primary researcher contacted (or attempted to contact) eligible SP clients who had previously participated in T1 and T2.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e18-month outcomes\u003c/h2\u003e \u003cp\u003eMeans, standard deviations, and effect sizes (Cohen\u0026rsquo;s d) for each outcome using repeated measures ANOVAs are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There was a significant effect of time on the ULS-8 loneliness scale, \u003cem\u003eF\u003c/em\u003e(2, 58)\u0026thinsp;=\u0026thinsp;10.27, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Pairwise comparisons with Bonferroni corrections revealed significant differences between T1 and T2 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.045), and T1 and T3 (\u003cem\u003ep\u0026thinsp;\u0026lt;\u003c/em\u003e\u0026thinsp;.001). There was also a significant effect of time on the single-item loneliness scale, \u003cem\u003eF\u003c/em\u003e(2, 52)\u0026thinsp;=\u0026thinsp;10.41, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001. Pairwise comparisons showed the same pattern of change between T1 and T2 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006), T1 and T3 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003). Psychological distress decreased significantly over time, \u003cem\u003eF\u003c/em\u003e(2, 56)\u0026thinsp;=\u0026thinsp;3.65, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.032. Pairwise comparisons found a significant difference only between T1 and T3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.049. Self-rated health also showed a significant increase across time \u003cem\u003eF\u003c/em\u003e(2, 54)\u0026thinsp;=\u0026thinsp;5.74, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006. However, pairwise comparisons only found a significant difference between T1 and T3 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.015). Effect sizes on loneliness, psychological distress, and perceived health outcomes were large (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In addition, there was a moderate (non-significant) effect of time on wellbeing, \u003cem\u003eF\u003c/em\u003e(2, 52)\u0026thinsp;=\u0026thinsp;2.53, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.089, and small-to-moderate (non-significant) effect of time on trust \u003cem\u003eF\u003c/em\u003e(2, 56)\u0026thinsp;=\u0026thinsp;1.41, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.253.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eDescriptive statistics over 18-months follow-up on quantitative outcomes for 30 participants of link worker social prescribing in Queensland\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline: T1\u003c/p\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e+\u0026thinsp;8 weeks: T2\u003c/p\u003e \u003cp\u003e\u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;18 months: T3 \u003cem\u003eM\u003c/em\u003e (\u003cem\u003eSD\u003c/em\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEffect size (time), η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoneliness scale (ULS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.23 (4.93)\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.60 (5.36)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.97 (6.11)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.262\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoneliness item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.07 (1.11)\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.52 (1.25)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.22 (1.37)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWellbeing (WEMBWS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41.22 (9.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.56 (10.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44.89 (10.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistress (K6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.86 (5.91)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.86 (6.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.31 (6.08)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived health item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.07 (1.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.04 (1.07)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.50 (0.92)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Trust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.39 (0.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.74 (1.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.67 (1.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.048\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote\u003c/em\u003e: M\u0026thinsp;=\u0026thinsp;Mean; SD\u0026thinsp;=\u0026thinsp;Standard deviation; η\u003csub\u003ep\u003c/sub\u003e\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;partial eta squared (effect size); \u003csup\u003eab\u003c/sup\u003e differing superscript identifies a significant difference between time points for an outcome; ULS\u0026thinsp;=\u0026thinsp;8-item UCLA loneliness scale; WEMWBS\u0026thinsp;=\u0026thinsp;Warwick Edinburgh Mental Wellbeing Scale; K6\u0026thinsp;=\u0026thinsp;6-item Kessler psychological distress scale; bold denotes a significant difference at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSocial prescribing relationships and activities\u003c/h3\u003e\n\u003cp\u003eOverall, the number of meaningful social groups that participants reported they belonged increased from a median of 2 groups at T1, to 3 groups at T2 and 3 groups at T3. At T3, 39% were still seeing their Link Worker at least some of the time, and 44% of participants were still attending a group that their Link Worker had connected them to. The proportion of different activities and groups engaged in by participants at T1 and T3 are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. This figure shows that participants engaged in similar types of groups and activities as they had at the beginning the program, although there was some change in the specific groups that they attended over time. In addition, 36% reported using the skills they had learned to join new groups or activities without the assistance of their Link Worker. A strong connection with their Link Worker was endorsed by participants at both T1 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.00, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.83) and T2 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.7, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.15). Participants also indicated that activity facilitators had helped them to feel a sense of belonging in the group at T1 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.26, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.81) and T2 (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.07, \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.0). At T3, there was general agreement that SP was able to help them feel reconnected (\u003cem\u003eM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.68. \u003cem\u003eSD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.16).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCorrelations between relationship quality and outcomes\u003c/h2\u003e \u003cp\u003eWe examined correlations between relationship variables at each time-point, the number of groups at T3 and their association with health, wellbeing, and trust outcomes at T3 (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Bivariate correlations revealed no relationships between T1 relationship ratings and T3 psychosocial outcomes. However, higher ratings of Link Worker relationship strength at T2 were related to lower T3 distress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006), lower loneliness both on the single-item measure (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.006) and the ULS-8 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), as well as greater wellbeing (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.011) and overall health (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). A greater sense that facilitators fostered a sense of belonging at T2 was also associated with: a greater sense that the SP program helped participants feel connected at T3 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.033), less feelings of loneliness (both on the single-item (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.014) and the ULS-8 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), less distress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.033), greater wellbeing (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.013), greater trust (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005) and better overall health (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.01). A sense that the program helped participants to feel reconnected at T3 was also related to lower loneliness scores on the ULS-8 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003), lower distress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002), more wellbeing (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.024) and greater trust (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.005). Being a member of a greater number of groups at T3 was also associated with lower loneliness (single-item \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.02), lower distress (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.016), higher wellbeing (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.029), and better overall health (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.041) at T3.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eBivariate correlations between relationship variables and +\u0026thinsp;18-month outcomes\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline LW relationship strength\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline Facilitator belonging\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8-week LW relationship strength\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8-week Facilitator belonging\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eT3 program reconnection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNumber of groups at 18-months\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of groups at 18-months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.077\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.369\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eT3 program reconnection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.145\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.085\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.397*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoneliness scale (ULS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.615**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.604**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.530**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLoneliness item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.133\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.503**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.467*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.463*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWellbeing (WEMBWS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.459*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.458*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e.410*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e.427*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistress (K6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.105\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.487**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.397*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.532**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.468*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerceived health item\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-0.179\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e.660**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e.468*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e.404*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Trust\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.276\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.387*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.502**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-0.233\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote\u003c/em\u003e: * Significance\u0026thinsp;\u0026lt;\u0026thinsp;.05; ** Significant\u0026thinsp;\u0026lt;\u0026thinsp;.001; ULS\u0026thinsp;=\u0026thinsp;8-item UCLA loneliness scale; WEMWBS\u0026thinsp;=\u0026thinsp;Warwick Edinburgh Mental Wellbeing Scale; K6\u0026thinsp;=\u0026thinsp;6-item Kessler psychological distress scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe aim of this research was to examine the impact of LWSP, including the value of relationships and social activities, on participants\u0026rsquo; psychological and health outcomes over an 18-month period. It was clear from our findings that clients\u0026rsquo; relationships with their Link Worker were an important and valuable factor related to improved mental and physical health for participants. Importantly, though, it was the strength of relationship at 8-weeks, not baseline, that was associated with lower loneliness and distress, and higher wellbeing and perceived health at 18-months. This is the first study to show quantitively that the relational aspects of LWSP predict longer-term psychosocial and health outcomes for clients. However, our findings reinforce the conclusions of previous qualitative research that has suggested that the success of social prescribing is dependent on Link Workers\u0026rsquo; relationship building with clients and forming the stepping stones to good rapport with group facilitators [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Merely pointing clients towards activities is less likely to be successful \u0026mdash; particularly for those with complex needs [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese findings have important implications for primary care providers (e.g., GPs, practice nurses), who are often the initial point of referral to social prescribing programs. While social prescribing is designed to address social determinants of health, its success relies not just on referral, but on ensuring patients understand the role of Link Workers in providing ongoing relational support. Given that our findings indicate that relationship strength at 8-weeks, rather than baseline, predicts longer-term outcomes, primary care providers could play a role in setting expectations at the point of referral\u0026mdash;highlighting the importance of sustained engagement beyond initial contact.\u003c/p\u003e \u003cp\u003eCommunity group activity facilitators also played an important role in social prescribing. At 8-weeks, the extent to which facilitators were perceived to have helped participants feel a sense of belonging was associated with those participants feeling less lonely and distressed, having greater wellbeing and trust, and having better self-rated health. Moreover, this cultivation of a sense of belonging was also associated with agreement that social prescribing had helped participants feel reconnected, a relationship that was not found for client relationships with their Link Worker. This may reflect the particular role that group facilitators play in encouraging participants to develop meaningful group memberships and associated social identities that can counteract loneliness, which are foundational for health [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Elsewhere, social identity researchers have suggested that key actions here include mapping similarities between group members, using inclusive \u0026lsquo;we / our group\u0026rsquo; language, encouraging interaction between group members through activities involving shared goals, cooperation, and trust; emphasising similarities between group members, and promoting member reflections on personal achievements that relate to the group\u0026rsquo;s function [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. To date, though, very little research has explored the skills and strategies that facilitators might employ to build meaningful social connections between group members. Future research on social prescribing would benefit from exploring the importance of these strategies, as recommended by Dingle et al [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNevertheless, the present findings are broadly consistent with social identity theorising. In particular, the number of groups that participants belonged to at 18-months was associated with less loneliness and distress, and greater wellbeing and perceived health. Interestingly, the types of groups that participants belonged to tended to remain the same over time, despite changes in the specific groups they attended. Moreover, while at T3, 61% of participants no longer attended meetings with their Link Worker, their desire to maintain or rebuild social relationships was reflected in the proportion of participants who anecdotally reported during T3 data collection that they were using the skills they had learned to join new groups or activities \u0026mdash; for example, joining social clubs, forming and facilitating new groups, and creating new friendships within their neighbourhoods. This suggests that social prescribing benefits can be sustained beyond the initial period of Link Worker engagement \u0026mdash; provided social prescribing is a basis for the development of meaningful group-based relationships. At the same time, though, it suggests that there is a pressing need to understand precisely how clients can be successfully \u0026lsquo;signed off\u0026rsquo; to ensure they have the skills needed to maintain such relationships, and thereby ensure that social prescribing services are optimised.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLonger-term health and wellbeing benefits\u003c/h2\u003e \u003cp\u003eOutcomes on the 8-item UCLA loneliness scale and the single-item measure of loneliness showed improvements from baseline at +\u0026thinsp;8-weeks and +\u0026thinsp;18-month follow-up, with medium to large effect sizes. This again suggests that group engagement helped to satisfy participants\u0026rsquo; social needs. It is also noteworthy in light of the fact that previous studies with shorter follow-up windows have sometimes not observed a significant reduction in loneliness [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Similarly, participants\u0026rsquo; perceptions of their health improved from baseline to +\u0026thinsp;18-months, with a moderate to large effect size, but not between baseline and +\u0026thinsp;8-weeks. Again, this implies that the benefits of social prescribing are not instantaneous but take time to emerge. This, though, is a conclusion that needs to be interrogated in further research, potentially including other measures of health, such as blood pressure, glucose, immune function tests, and sleep quality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e Ratings of trust were relatively stable over time, with non-significant increases (of small-to-medium size) over time that were greater among participants who reported stronger Link Worker and facilitator relationship quality. At the same time, our comparative research across T1 and T2 found that ratings of social trust reduced among TAU participants compared to small increases in ratings among social prescribing participants [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Given that lack of trust has been identified in other research as a correlate of loneliness and a barrier to making social connections [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], this too would seem to be an important focus for future research. In particular, more work is needed to understand the activities and strategies that Link Workers and facilitators might employ to help clients feel confident and safe as they set out to forge new social connections and (re)join groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStrengths, limitations, and future directions\u003c/h2\u003e \u003cp\u003eAlthough social prescribing implementation has rapidly increased in recent years, there are still few studies evaluating the longer-term impact of social prescribing on its participants, and even fewer that provide data after 6-months. This is one of the few studies to examine outcomes of social prescribing after 18-months. It is also the first study to quantitatively demonstrate associations between the relationships between clients and Link Workers, and between clients and community social group facilitators, and participant improvements in these health and psychosocial measures. Further, there is currently no single established measure of Link Worker-client relationship quality and satisfaction (although there is a feedback tool available) [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], our single-item measure was able to provide evidence of the immediate value of the Link Worker to participants.\u003c/p\u003e \u003cp\u003eDespite these strengths, this research was limited in its ability to recruit and retain more participants. This was partly due to the nature of the vulnerable population accessing social prescribing and the compounding impact of COVID-19 lockdown regulations that interfered with participant contact. Regardless, the impact and generalisability of these findings are limited by the small size of the sample and the possibility that the participants we did retain were doing well in comparison to those who were not able to be followed up at the final time-point. Future longitudinal investigations into social prescribing would be strengthened by including a control or comparison group.\u003c/p\u003e \u003cp\u003eAdditionally, our research did not include relational processes with referrers. Future research should explore how primary care providers can optimize their role in the referral process. Previous research with Link Workers and Clients has indicated that clients often attend social prescribing with little to no understanding of what is involved [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. This could include examinations of how discussions about social prescribing at the point of referral influence patient engagement with Link Workers and subsequent groups. Understanding these dynamics could help refine primary care guidance on referral into social prescribing.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study responds to a call for research into the longer-term outcomes of social prescribing and an examination of potential contributions of group activities and relational processes to participant outcomes. Despite the small sample size and lack of comparison sample, we found substantial benefits for participants at 18-months on loneliness, perceived health, mental health, and engagement with meaningful groups. Moreover, the quality of participants\u0026rsquo; relationships with Link Workers and group facilitators\u0026rsquo; skills in fostering group belonging at 8-weeks were associated with positive 18-month outcomes. These findings emphasise that social prescribing is a multifaceted and highly relational health pathway. Ensuring that patients understand the role of Link Workers within social prescribing and the importance of sustained engagement may be important to maximise the benefits of these interventions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written consent to participate, and the protocol was approved by the University human research ethics committee #2019002287.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants provided written consent for their information to be used in the research which had potential for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are available by request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJRB is the CEO of a primary care service that employs a social prescribing scheme within their practice. He was not involved in participant recruitment, data collection or analysis. We declare no other conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by funding from the Australian Research Council LP180100761. The ARC was not involved in any aspect of the research or decision to submit this manuscript for publication. SH was supported by a PhD stipend from the University of XXX linked to this grant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLSS led the project management, and was involved in data collection and analysis, and wrote the first draft of the manuscript. GAD, CH, TC, JJ, and NM were involved in project design and funding acquisition. SH was involved in data collection. DC, JRB and TJ facilitated referrals and data collection. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are extremely grateful to the participants, members of the project steering group Deb Crompton, Corinne McMillan, and Jim Pollock, to link workers Wendy Blackmon, Elise Marr, Loretta Stumer, and Susan Gilmartin, and to research assistants Dylan Nicholls, Shannon Tyrie and Hana Kermani.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGlobal Social Prescribing Alliance (GSPA). Global Social Prescribing Alliance: International playbook. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuhl C, Mulligan K, Bayoumi I, Ashcroft R, Godfrey C. Establishing internationally accepted conceptual and operational definitions of social prescribing through expert consensus: a Delphi study. 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Social prescribing as an intervention for people with work-related injuries and psychosocial difficulties in Australia. Adv Health Behav. 2020;3:101\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCruwys T, Wakefield JRH, Sani F, Dingle GA, Jetten J. Social isolation predicts frequent attendance in primary care. Ann Behav Med. 2018. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/abm/kax054\u003c/span\u003e\u003cspan address=\"10.1093/abm/kax054\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDingle GA, Aggar C, Arslanovski N, Astell-Burt T, Baker JR, Baxter R et al. Australian and UK perspectives on social prescribing implementation research: Theory, measurement, resourcing, and discovery to ensure health equity. Health Soc Care Community. 2025; online \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1155/hsc/2650302\u003c/span\u003e\u003cspan address=\"10.1155/hsc/2650302\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePayne K, Walton E, Burton C. Steps to benefit from social prescription: a qualitative interview study. Br J Gen Pract. 2020;70:e36\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChatterjee HJ, Camic PM, Lockyer B, Thomson LJM. Non-clinical community interventions: a systematised review of social prescribing schemes. Arts Health. 2018;10:97\u0026ndash;123.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharman LS, McNamara N, Hayes S, Dingle GA. Social prescribing link workers\u0026mdash;A qualitative Australian perspective. 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Hum Resour Manag Rev. 2018;28:190\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHayes S, Sharman LS, McNamara N, Dingle GA. Link workers\u0026rsquo; and clients\u0026rsquo; perspectives on how social prescribing offers a social cure for loneliness. Under Review.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDingle GA, Sharman LS, Hayes S, Chua D, Baker JR, Haslam C, et al. A controlled evaluation of the effect of social prescribing programs on loneliness for adults in Queensland, Australia (protocol). BMC Public Health. 2022;22:1384.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHays RD, DiMatteo MR. A Short-Form Measure of Loneliness. J Pers Assess. 1987;51:69\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEnding Loneliness Together. A Guide to Evaluating Loneliness Outcomes for Community Organisations. 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhat Works Wellbeing. 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Cognitive and affective trust in service relationships. J Bus Res. 2005;58:500\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDrinkwater C, Polley M. Advice on social prescribing link workers for primary care networks in England from the National Social Prescribing Network. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCacioppo JT, Hawkley LC, Crawford LE, Ernst JM, Burleson MH, Kowalewski RB, et al. Loneliness and health: potential mechanisms. Psychosom Med. 2002;64:407\u0026ndash;17.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarty PK, Novotny P, Benzo RP. Loneliness and ED Visits in Chronic Obstructive Pulmonary Disease. Mayo Clin Proc Innov Qual Outcomes. 2019;3:350\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDingle GA, Sharman LS. Social Prescribing: A Review of the Literature. In: Menzies RG, Menzies RE, Dingle GA, editors. Existential Concerns and Cognitive-Behavioral Procedures: An Integrative Approach to Mental Health. Cham: Springer International Publishing; 2022. pp. 135\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIngram I, Kelly PJ, Deane FP, Baker AL, Dingle GA. Perceptions of loneliness among people accessing treatment for substance use disorders. Drug Alcohol Rev. 2020;39:484\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS. Workforce development framework: social prescribing link workers. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.england.nhs.uk/publication/workforce-development-framework-social-prescribing-link-workers/\u003c/span\u003e\u003cspan address=\"https://www.england.nhs.uk/publication/workforce-development-framework-social-prescribing-link-workers/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 5 Jun 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharman LS, Jones A, Dingle GA. 1-year evaluation of the social prescribing trial, in Brisbane North. The University of Queensland; 2024.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"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":"Loneliness, social prescribing, community, health, wellbeing, longer-term outcomes, relationship quality","lastPublishedDoi":"10.21203/rs.3.rs-6118230/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6118230/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e To make confident referrals to link worker social prescribing (LWSP) programs, GPs and other health providers need evidence of their overall effectiveness and the value of the relationships and social activities that contribute to their outcomes. This research aimed to examine these questions in data collected from participants of a LWSP program over an 18-month follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Sixty-four participants (\u003cem\u003eM\u003c/em\u003e\u003csub\u003e\u003cem\u003eage\u003c/em\u003e\u003c/sub\u003e = 53.59) enrolled in the LWSP arm of a controlled trial provided data at three timepoints: baseline (T1, \u003cem\u003en\u003c/em\u003e=64), +8-weeks (T2, \u003cem\u003en\u003c/em\u003e=50) and +18-months (T3, \u003cem\u003en\u003c/em\u003e=30) on group activities, relationship quality with link worker and community group facilitators, and outcomes on loneliness, distress, wellbeing, trust and health.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Participants were referred to a diverse range of social group programs, and the number of meaningful social groups increased from a median of 2 groups at T1, to 3 groups at T2 and T3. Loneliness reduced at T2 and T3, and these effects were large. Moderate-to-large effects were also found at 18-months for psychological distress and self-rated health. Participants’ relationships with link workers and group facilitators’ skill in fostering belonging at T2 (but not at T1), were associated with participant improvements at T3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Positive effects of LWSP were found in all outcome measures at 18-months follow-up. There was also evidence that the relational skills of link workers in building interpersonal rapport and community group facilitators in enabling a sense of belonging were key to participants’ positives outcomes. These findings emphasise that social prescribing is a multifaceted and highly relational health pathway. Strong relational and integrated care are important in achieving improved health outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e ANZCTR, retrospectively registered on 08/06/2022,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ehttps://www.anzctr.org.au/ACTRN12622000801718.aspx\u003c/p\u003e","manuscriptTitle":"Effectiveness and Value of Relationships in Link Worker Social Prescribing Over an 18-month Follow Up Period","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-03 07:25:14","doi":"10.21203/rs.3.rs-6118230/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-04T10:40:22+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-28T15:10:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-28T08:54:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Primary Care","date":"2025-02-27T06:49:22+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":"0f600212-c005-4c77-81a3-d703c1319064","owner":[],"postedDate":"March 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:12:08+00:00","versionOfRecord":{"articleIdentity":"rs-6118230","link":"https://doi.org/10.1186/s12875-025-03084-6","journal":{"identity":"bmc-primary-care","isVorOnly":false,"title":"BMC Primary Care"},"publishedOn":"2025-11-24 15:58:39","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-03-03 07:25:14","video":"","vorDoi":"10.1186/s12875-025-03084-6","vorDoiUrl":"https://doi.org/10.1186/s12875-025-03084-6","workflowStages":[]},"version":"v1","identity":"rs-6118230","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6118230","identity":"rs-6118230","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}