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In this blog, Steven Markham, research fellow at the Centre for Evidence-Based Medicine, University of Oxford, reflects on experiences of designing health promotion interventions to inform current and future policy.

Serious young female doctor meeting with elderly patient in office, listening to woman health problems complaints, typing on laptop, keeping electronic database on computer. Geriatric medic care. © Shutterstock

Steven is currently working on the link worker implementation in primary care study.

My background

I started my career in health, designing interventions to support people to keep healthy and well. I was part of a team of Health Promotion Specialists focused on holistic health and wellness: mental health, emotional health, and physical health including sexual health, physical activity and healthier eating; across demographics of the population: children and young people, young adults, families, men, and older people.

The largest intervention I co-designed was a 'walking for health' programme; developing a series of weekly, group-based health walks at community venues across the local region where I worked. These group-led walks were carefully designed to occur every week, at the same time, starting and finishing at the same venue, with varied routes to keep regular attendees interested. With the help of some wonderful volunteers, we managed to deliver a walk every day of the week across a small region, with some walkers (and volunteer walk leaders) participating four or five times a week. The project was supported by a Public Health department. After the transfer of Public Health departments to local authorities, and despite funding cuts, nearly two decades later, some of these weekly walks continue today.

Challenges with community projects

As all researchers, evaluators and people with an interest in social interventions will know, no project receives 100% positive feedback. There were problems to address around the suitability of the walks for slow walkers, people using wheelchairs and for people with learning difficulties who needed the support of a carer. These issues relate to contentious questions regarding what socially based health interventions are developed in communities and who are they designed for?

Careful planning went into designing the health walk intervention, to use venues close to local bus routes and to enable people to safely store bicycles and belongings. We had to hire venues capable of accommodating the numbers of people attending to enjoy a well-deserved post-walk cup of tea. Some walks attracted more than 80 people which was challenging to manage. Groups of this size had to be split into smaller sets, requiring more volunteer walk leaders, with first aid training, to lead and back-mark manageable group sizes.

To engage walkers and retain their interest and enthusiasm, some of the walks were on terrain through fields and woods which were not accessible for people using wheelchairs. Some walks involved crossing busy roads and all participants needed to take care of, and be responsible for, themselves. Additionally, to adhere to the brisk pace benefits of ‘health walks’, we could not accommodate people unable to keep-up with the speed of the main group of walkers. However, splitting 80 walkers into four groups had the advantage of being able to accommodate differences in the pace and stamina of walkers.

Although we had a fantastic group of volunteers to lead and back-mark the health walks, few volunteers were prepared or trained to be specialised carers. They had enough responsibilities, planning routes and providing sustenance for post-walk socials. Moreover, being required to alter routes for wheelchair access was not always possible. As such, the difficult decision was made to advertise walks as only appropriate for people who could take responsibility for themselves and be able to walk at a brisk pace for 30-minutes. We had to limit newcomers to only taking part in a 30-minute health walk as some initial attendees, whilst convinced they could manage to keep up with other walkers for an hour, struggled to take part for 20 minutes.

Men’s sheds

The need for consideration, adaption and flexibility are not specific to walking groups. For example, my recent research found tensions within the men’s shed movement. “Men’s sheds” are venues with tools and materials for small woodwork projects; with men working on their own projects or contributing to projects for community benefit. Sheds tend to limit their membership to men because the workshop environments attract men to take part and, in the company of other men, they are more likely to talk shoulder-to-shoulder. These conversations include concerns about health and wellbeing that men tend not to share in other environments or with other people. Academics have written about the men’s shed movement and benefits of men’s shed participation.

When I first learnt about these community groups with subsidiary health and wellbeing benefits, I had to ask myself, is it not sexist to have an intervention just for men? I wrestled with this tension for some time, but with rates of social isolation, loneliness and impacts on mental health and wellbeing there are clear needs for interventions specifically designed for this target population. Health interventions that are sensitive to an individual’s needs and preferences align with NHS England's Comprehensive Model of Personalised Care, of which social prescribing forms a key component.

Social prescribing and variation of local support

My reason for sharing these experiences is that link workers need a range of suitable, socially-based interventions to accommodate people and their different interests and abilities. These interventions need appropriate long-term funding to help build capacity even when the interventions are predominantly delivered by willing volunteers. The range of activities available for referrals could make a distinct difference to the successes, failures, and various eventualities in between, of a social prescribing programme. Patients need to feel that any prescribed social intervention is appropriate to their needs, whilst prescribers need to carefully match what is prescribed and who is referred.

Three men’s sheds from my recent research all experienced referrals from services to their community groups. Some of the referrals were appropriate and I met men who experienced acute stress, social isolation, mild to moderate anxiety and/or depression who benefitted from interaction with shed activities and fellow men. There were also some inappropriate referrals of people with learning difficulties without the support of a carer causing problems for groups leaders and their participants.

Recently, the Department of Transport has pledged circa £1m in multi-year funding to eleven local authorities to offer walking and cycling on prescription. I hope that trial projects will clearly define what abilities they are suitable for and tailor at least some interventions to the type of clients that link workers support. Forethought regarding these issues may prevent inappropriate referrals and maximise the success of social prescribing in these eleven local authority areas.  

Steven is working on a study that is funded by a grant from the National Institute for Health and Care Research (NIHR130247). The views expressed are those of the author and not necessarily those of the NIHR, the Department of Health and Social Care, or the author’s host institution.