Enhancing higher education student well-being through social prescribing: a realist evaluation protocol.

INTRODUCTION: UK higher education (HE) student numbers are increasing and students report higher levels of mental health and well-being issues. Social prescribing links individuals to community-based, non-medical support. It is widely implemented throughout the UK, and is supported by the Welsh Government. This protocol presents an evaluation of a new social prescribing service to enhance student well-being, a first for UK HE students. METHODS AND ANALYSIS: A realist evaluation to articulate why, how and to what extent and circumstances social prescribing works for students, using a mixed-methods sequential design of four cycles. Cycle 1 informs the model and programme theory development of how the model works; activities include a Realist Review, Group Concept Mapping and producing bilingual short films about the evaluation and model. Cycle 2 involves secondary analysis of routine service data, and outcome measurements from students receiving a social prescription. Cycle 3 uses reflective diaries and qualitative realist interviews with stakeholders to understand the process and outcome of the model. Cycle 4 concludes with a world café workshop with stakeholders to agree and finalise the framework specification of 'how, why, when and to what extent' the model works. A meta-matrix construction will determine convergence, complementarity or discrepancy across the cycles. An advisory group of key stakeholders informs each cycle. ETHICS AND DISSEMINATION: University of South Wales Life Sciences and Education Ethics Committee and Wrexham Glyndwr University (WGU) Research Ethics Sub-Committee approved secondary data analysis of participant demographics (200 805LRL:USW, id441:WGU), outcome measurement tools (200 902LR:USW, id441:WGU) and qualitative data collection (200 804LR:USW, id449:WGU). The authors will publish findings in peer-reviewed journals, produce an evaluation report to the funder and a short film for dissemination via stakeholders, university networks, United Nations Regional Centre of Expertise in Wales, PRIME Centre Wales, Wales School for Social Prescribing Research, conferences and social media. © Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

The realist method enables the development of a social prescribing model that identifies causal relationships and informs implementation of the model.

An advisory group of HE, student union and third sector staff informs this study and will provide guidance for the evaluation design and its findings so that the explanatory theory and framework are usable and translatable.

The dissemination strategy will allow the transference of principles to other HE settings.

The social prescribing service started in a pandemic and restrictions will impact the method that is, reduced opportunities for recruitment and engagement.

Background

Student well-being

The numbers of students accessing higher education (HE) in the UK is increasing. Current data indicate over 2.3 million HE students, and over half of UK young adults will access tertiary education by the age of 30.1 There is an associated rise in student mental health and well-being issues2 and the number of HE students dropping out with mental health problems has more than doubled in recent years.1 Well-being levels for students are lower than for the general population,3 1:16 students leave before year two.4 Potential issues for new students may include moving to a new area, the shift towards independent learning, increased financial independence and relationship pressures. These are exacerbated for students with a declared disability, mature students and students from Black, Asian or Minority Ethnic backgrounds.1 3–5 While strategies have been developed to ameliorate these challenges,6 effectively supporting student mental health and well-being remains difficult in HE. A range of systems and networks within HE and beyond may be effective in supporting students, but the way in which they are identified, accessed and used remains highly variable.5 Social prescribing may be a productive strategy to connect students to services and increase access to well-being support.

Social prescribing

Social prescribing is an umbrella term to describe ways of linking individuals to community-based, non-medical support. There is no agreed definition,7 but it has been described as enabling, ‘General Practitioners (GPs), nurses and other primary care professionals to refer people to a range of local, non-clinical services to support their health and well-being’.8 In Wales, it is defined as, ‘connecting citizens to community support to better manage their health and well-being’(p 30)’.9 These definitions refer to the process of connecting/referring individuals to community assets that may address a wide range of social, emotional or practice needs to improve health and well-being.10

Social prescribing is prevalent throughout the UK and integral to Welsh Government plans for NHS Wales.11 It is seen as an approach that could make a positive impact on the sustainability of General Practice primary care.12 13 However, there is limited research evidence on social prescribing intervention effectiveness, who benefits from it (if at all) and whether it offers value for money.12 Good quality, robust evidence is needed on what constitutes effective social prescribing practice and its process14 to inform commissioning, and determine how it may affect individuals and in what way. Commissioner and policymaker reliance on outcome evaluation in isolation may stifle other important questions; effect size does not inform implementation (enablers, challenges, processes) or contextual factors that may influence intervention delivery and outcomes.15

The present study

‘Enhancing Student Well-being through social prescribing’ is a unique project where Wrexham Glyndwr University (WGU) and the University of South Wales (USW) are working with local communities to enhance student well-being. It is the first social prescribing project focussing on university students, which is pertinent given the prevalence of mental health and well-being issues among UK HE students. The model aims to enhance student well-being, build resilience through early identification of issues and increase use of timely and appropriate support. It will promote new ways of working using a replicable model of social prescribing cocreated with key partners from the local community to benefit students as part of a whole system approach to well-being.

This realist evaluation16 aims to inform the development and refinement of a ‘programme theory’ that articulates why and to what extent social prescribing works for students, how and when they access interventions and what forms they take. This programme theory will inform the development of a WGU social prescribing model that can be applied to USW, before implementation scaling to other Welsh HE Institutions and beyond. The study commenced in March 2020 and will conclude in October 2021.

The study aims to answer the following questions:

What forms of social prescribing interventions are specifically targeted at HE students?

How do HE students access social prescribing interventions aimed at them?

When do HE students access the social prescribing interventions targeted at them?

For whom does the use of social prescribing interventions work?

To what extent does social prescribing work for HE students?

Intervention and study setting

The WGU social prescribing model17 connects students with non-clinical services within and beyond the university to support a range of health and well-being needs. Box 1 summarises the intervention and is illustrated using figure 1.

Figure 1

Wrexham Glyndwr University social prescribing model is a visual representation of the student journey through the pathway. Access to the service is via the online platform Elemental, which is followed by an initial assessment to determine what support is appropriate that is, a social prescription or a referral to another hub. Where a social prescription is required, they are cocreated with the student and referral handler (navigator) before referral to non-clinical services (resources).

Situated in North Wales and established in 2008, WGU has campuses in Wrexham, Northop and St Asaph. In 2019/2020 WGU had 2750 full-time students (1725 females and 1015 males) and 3295 part-time students (1855 females, 1435 males), with 3980 domiciled in Wales.18 It was ranked first for social inclusion in England and Wales19 and had the highest proportion of mature entrants (70.8%) of students receiving disabled students allowance (21.5%) of all Welsh HE.20

The social prescribing intervention aims to enhance student well-being via a ‘whole system’ approach that works collaboratively across community and organisational boundaries to deliver individual and societal benefit.

The service operates using the digital social prescribing platform, Elemental Software.50 The cloud-based platform connects students’ well-being risks to specific interventions in the university or their community, either through a self-referral (for example on the university website) or via the referral agent. The software filters the social prescription option by location, cost, ability and type of support to maximise student engagement.

The model consists of eight ‘hubs’: Counselling, Chaplaincy, Accommodation, Health and Well-being, Funding, General, Careers and Employability and Inclusion.

There are two routes for students to access the social prescribing service: (i) via self-referral, (ii) via referral agents (eg, personal tutors, lecturers, chaplaincy).

When students enter the online portal, referral handlers carry out an assessment with them to determine (i) their need, (ii) whether a social prescription is appropriate and (iii) if a referral to another hub is required to better meet their need.

If a social prescription is deemed appropriate, referral handlers manage the cases and conduct a ‘what matters conversation’ with students to cocreate the social prescription(s). Fully trained staff include a project manager and two referral handlers (project manager with a dual role of referral handler).

Students are referred to non-clinical providers using Elemental Software. This can include university societies and activities, another hub and local community services/groups and groups.

The service began in October 2020. To date n=514 students are registered on Elemental Software, of which n=35 have gone on to receive a social prescription.

Patient and public involvement

Engaging with stakeholders is fundamental to realist evaluation and programme theory development.21 22 A stakeholder advisory group will meet monthly. It will include representatives from WGU and USW Student Unions, strategic and operational staff involved in the model’s design, development and delivery (including the social prescribing service), the evaluation team and third sector and community representation. The advisory group will check the understanding of findings and ensure that the explanatory theory and framework are usable and translatable.

Study design

The study is a realist evaluation mixed-methods sequential design21 with four cycles of data collection, analysis and translation/development of principles into a model. Realism is a theory-driven approach to the synthesis of evidence, the goal of which is to build an abstracted model or programme theory that explicates what a programme or intervention is and how it can be expected to work. It is a theory of implementation and causation.23 The realist method is grounded within generative causation; in order to infer a causal relationship between an intervention (I) and outcome (O), one must understand the underpinning mechanism (M) connecting them, as well as the context (C) in which they occur.24 Activities in each cycle may lead to changes in model development. The evaluation will require access to third sector and community organisations who have significant impact on student well-being.

Cycle 1: preparation and understanding the model/theory

Cycle 1 (C1) informs the development of the social prescribing model and underpins the three subsequent evaluation cycles. Preparatory activities include securing ethical permission, project set-up and communication (including a series of short bilingual films about the evaluation process and model).25

Three elements inform the initial model and programme theory of how the model works:

A Realist Review26 (PROSPERO registration: CRD42020193075).

Group Concept Mapping (GCM) with WGU students and staff.27

A series of coproduction workshops hosted by Do Well Ltd.28

Cycle 2: testing evidence of context, mechanism and outcome patterns to the model

Cycle 2 (C2) will assess and analyse the model via secondary analysis of routine data collected from all students as part of service delivery. Referral handlers collect this data using Elemental Software. The type of service data to be included will be determined after study team and advisory group discussion. It may include demographics, referral source, referral reason, numbers of students accessing the service, number and type of social prescribing activity/intervention, re-referrals and number of students dropping out of intervention.

Additional service data will be collected using repeated measures at either two or three time points. Depending on the student’s point of entry into the service this will be baseline (day 0), mid-point (+4 weeks) and end of the intervention (+12 weeks). Outcome measures collected over the course of the intervention will determine the service impact on students. Follow-up measurements will be captured at+3–6 months (depending on the length of the project) to identify whether any changes have been sustained over time. These will be incorporated into the Elemental Software so data may be gathered when students opt for self-referral.

Data will be collected using three validated outcome tools:

The Warwick-Edinburgh Mental Well-being Scale (WEMWBS)29

WEMWBS has 14 items that capture the eudemonic (people’s functioning, social relationships, sense of purpose) and hedonic perspectives on well-being (eg, feelings of happiness),30 for example, ‘I’ve been feeling optimistic about the future’.31 The 5-point Likert scale represents a score for each item from 1 to 5, meaning a total score from 14 to 70, a higher score indicates a higher level of mental well-being.31 WEMWBS has been validated for use with diverse populations of people aged 13–75+ years and shows high levels of internal consistency and reliability against accepted criteria.31 It will allow for longitudinal comparison of this group with a matched Welsh population sample using WEMWBS data collected by the National Survey for Wales.32

ONS433

The Office of National Statistics (ONS) Personal Well-being (PWB) Domain uses four measures (referred to as the ONS4) to capture three types of well-being: evaluative, eudemonic and affective experience.33 Individuals complete the questions on a scale of 0–10, for example, ‘Overall, how satisfied are you with your life these days?’, where 0 is ‘not at all’ and 10 is ‘completely’.33 Scores are grouped as 0–4 (low), 5–6 (medium), 7–8 (high) and 9–10 (very high).33 The What Works Centre for Well-being recommends the ONS4, ‘as accepted and trusted subjective measures from the National Well-being Programme that capture distinct aspects of personal well-being: evaluative, eudemonic and affective experience’ (Benson et al, p. 1).34 While the ONS4 are not fully validated measures,35 social prescribing evaluations have previously reported the ONS4 as showing good internal reliability (Cronbach’s α=0.90).34

The Brief Resilience Scale (BRS)36

BRS assesses an individual’s self-perceived ability to recover from stress and is demonstrated to have good internal consistency and test–retest reliability.36 It has six items on a 5-point Likert scale (score range 1 (low resilience) to 5 (high resilience)) with an equal number of positive and negative worded items to reduce social desirability and positive response bias.36 Statements include ‘I tend to bounce back quickly after hard times’ and ‘I have a hard time making it through stressful events’. Total scores are between 6 and 30 and higher scores indicate higher resilience.36

The three outcome measurements will determine whether the social prescribing service enhances well-being, builds resilience, and achieves its purpose.

Recruitment and sample size

Referral handlers will collect routine demographic service data and outcome measurement data from students who have either self-referred or been referred by a referral agent to the service between 1 October 2020 and 31 May 2021. The estimated total combined number of referrals for this period is approximately n=650. Power calculations for the three measurement tools show that a sample of n=650 would detect a fairly small meaningful difference (MD)/effect size (ES) (eg, WEMWBS, MD=0.89; ONS4 and BRS, ES=0.127) as significant at 5% level with a power of 90%.

Data collection

Data will be collected at three time points between 1 October 2020 and 8 March 2021 (day 0, week 4, week 12). For students accessing the service between 9 March and 3 May 2021, data will be collected at day 0 and week 4.

Students receive an evaluation participation pack containing an information sheet, and consent form to return if they are willing to participate. Consent will confirm their agreement for the research team to analyse their retrospective data collected at the ‘what matters’ conversation together with service data captured at 4 and 12 weeks (see figure 2).

Figure 2

Data collection with students entering the Wrexham Glyndwr University social prescribing service illustrates the process for data collection with students. At each time point (day 0, 4 weeks and 12 weeks), the referral handler will conduct a ‘what matters’ conversation and capture data using three measurement tools, the WEMWBS, the ONS PWB domain and the BRS. BRS, Brief Resilience Scale; ONS PWB, Office of National Statistics Personal Well-being; WEMWBS, Warwick-Edinburgh Mental Well-being Scale.

Day 0: referral handler meets student for a ‘what matters’ conversation and collects WEMWBS, ONS4, and BRS.

4 Weeks: another service meeting takes place between the student and referral handler to revisit the WEMWBS, ONS4 and BRS. Referral handler checks on student progression and whether the social prescription needs to be revised.

12 weeks: the student completes the final WEMWBS, ONS4 and BRS.

Data analysis

Data analysis is iterative and occurs within and at the end of each cycle. C2 secondary data analysis examines routine service data collected by the referral handler using Elemental Software; it will not contain personal/identifiable data. The project manager will share data with the evaluation team through encrypted email. Data will be cleaned, entered into a spreadsheet and analysed using descriptive and inferential statistics (eg, repeated measures analysis of variance, internal consistency and construct validity) using SPSS V.28.37

Cycle 3: testing and refining theories

Cycle 3 (C3) aims to understand the process and impact (including cultural change) of the new model. Qualitative data will be collected with stakeholders to understand their experiences of:

Service design, development and implementation

Service management and delivery

Receiving the social prescribing service

C3 will use a mixed sampling strategy to recruit participants including purposive (expert, case and maximum variation sampling) and snowballing to identify participants38 (eg, self-refer students). Purposive sampling identifies and selects individuals or groups who have in-depth knowledge and/or experience of the phenomenon of interest.39 Information is sought from ‘key informants’ who are best placed to provide it that is, WGU stakeholders who can highlight key characteristic patterns of the service under evaluation.38

C3 recruits will include (1) students accessing/referred to the service, (2) people involved in the service design, development and delivery for example, project manager, referral agents, referral handlers, Student Union Representatives, senior WGU managers and (3) external partners for example, Elemental Software Team, Do Well Ltd team and community organisations receiving referrals.

C3 will use reflective diaries (n=5) and qualitative realist interviews (n=35–45) (individuals/small groups) with stakeholders.40 All prospective participants will receive an information sheet, and consent form to sign and return. Topic schedules will be informed by C1 activities (eg, Realist Review), and developed with the advisory group. Qualitative data will be audiorecorded and transcribed. WGU staff involved in the design, development, implementation, management and delivery of the model will complete written or audiorecorded reflective diaries. Diary voice recordings will be shared via an encrypted email. Recordings will be transcribed prior to analysis. Reflective diaries will be collated and anonymised by the WGU social prescribing project manager before sharing with the evaluation team for analysis. C3 data collection will conclude on 30 June 2021.

Qualitative data will be imported into NVivo V.1241 for coding and a realist logic of data analysis framework16 will be used in an embedded interpretative content and applied thematic analysis.42 This involves considering data relevance, meaning interpretation, judgments about Context-Mechanism-Outcome-Configurations (CMOCs), programme theory and data rigour.

The realist programme theory of social prescribing, developed in C1, will be tested against reflective diary content and realist qualitative interviews with stakeholders, and interrogated to build CMOCs to confirm, refine or refute the emerging programme theory. An abstracted theory of causation and implementation will be built, articulating how and why the model works, for whom, to what extent, and in what circumstances.43

Multiperspective case studies (n=8) will be constructed to support meaningful analysis and contextualisation. They will give voice and detail of how the project impacted on students’, staff and key stakeholders’ lives. These stories might be digitised in various forms offering a further evaluation dimension.

Triangulation

C1, C2 and C3 findings will be triangulated against the evaluation questions stated earlier. Quantitative and qualitative findings are combined in triangulation using various datasets to explain differing aspects of a phenomenon of interest.39 44 Each cycle’s findings will be used to build a meta-matrix45 to determine agreement, offer complementary information on the same issue or contradiction.46 Triangulation findings are used to produce a rounded understanding of the study topic, will form part of the funder evaluation report, and will be written up for peer-review publication. C3 will conclude with building a framework of key principles and lessons learnt.

Cycle 4: inalising a framework of key principles and lessons learned

The study will end with a student and stakeholder World Café workshop47 to share findings, agree and finalise the framework specification of ‘how, why, when and to what extent’ it may be used across HE in Wales. The World Café workshop comprises seven integrated principles47 48: set the context, create a hospitable space, explore questions that matter, encourage everyone’s contribution, connect diverse perspectives, listen together for patterns and insights and ‘the harvest’ sharing collective discoveries. Given COVID-19 restrictions, the workshop will be facilitated using online software. Participants will move around the virtual space to facilitated virtual tables to shape the framework specification and how it will be actioned.

Analysis throughout the World Café workshop is iterative. The content of each part of the framework specification is built at the tables within the room. The table ‘host’ collates the written responses to individual questions set at each table. These are presented back to the participants at the workshop end.

Ethics and dissemination

Ethical approval was granted by USW and WGU ethics committees, which approved secondary data analysis of participant demographics and outcome measurement tools, and qualitative data collection. Data will be stored securely on encrypted and password-protected USW systems for 5 years after the evaluation has ended, after which time it will be securely destroyed. Study findings and outputs will be disseminated to academic, HE and public audiences. The dissemination strategy for this study was developed with the advisory group and informed by the student perspective. Bilingual Welsh/English promotional films with user-friendly graphics and student voice-overs have been created (C1) with subtitles to maximise inclusivity. Study findings will align to the RAMESES reporting standards for realist evaluations23 and will be published in peer-reviewed journals, a report to the funder, presented at conferences and through a short film for stakeholders for dissemination via a range of channels.

The refined programme theory developed within this realist evaluation will explore the potential benefits for social prescribing on university students—articulating why, how and in what circumstances the pathway works. This abstracted model of both causation and implementation23 will support the development of social prescribing pathways within HE in Wales the UK. General principles may be applicable in wider contexts and have transferability beyond the UK; however, further research is required to discern the degree to which this may be practicable.

Summary

This study will use mixed-methods to undertake a realist evaluation of a new HE social prescribing model. It is the first realist evaluation of a HE social prescribing service in the UK and internationally. The rise in number of HE students reporting mental health and well-being issues highlights the study’s importance. Existing student support systems and how they are identified, accessed and used remains varied.5 This study will address gaps in knowledge and generate understanding of why, and to what extent, social prescribing works for students, how they access interventions, what forms interventions take and when they are accessed. It will capture the outcomes, and stakeholders’ views and experiences across the course of the service via three data collection cycles complemented by triangulation across the datasets and finalised with a World Café workshop (C4).

C1 will underpin this study by informing the model and programme theory of how the model works. It includes a Realist Review, a GCM study with WGU students and staff and a series of coproduction workshops with stakeholders. The advisory group is integral to the realist approach and it will function as an equal partner throughout all cycles coproducing the final explanatory theory and framework, and ensuring it is usable and translatable.

C2 will collect quantitative data via routine service data captured using Elemental Software. Three outcome measurements will be collected from students receiving a social prescription that will help determine intervention outcomes. A digital platform and directory used in primary care is being used for the first time in HE to support the study.

C3 qualitative data will explore topics such as service design, implementation, management and experiences of delivering and receiving the service from multiple stakeholder perspectives. There has been considerable interest in the model development from stakeholders as WGU is a key partner in the North Wales 2025 Movement, which has, ‘a collective vision to tackle avoidable health and housing inequalities by 2025’.49

C4 triangulated data from all three cycles will support a rounded understanding of the intervention. Finally, the World Café workshop will share findings, agree and finalise the framework specification of ‘how, why, when and to what extent’ for use across HE in Wales.