Social Prescribing: The social cure

With an overburdened primary care system focused on ‘repairing’ broken health, consumer appetite for preventative health care is understandably increasing. We see it as an opportunity to take control, ‘get on the front foot’, to live longer, healthier and more independent lives and avoid the healthcare system and its associated woes.

With investment from the Australian Government lagging behind other countries in preventative health, many of us are doing it for ourselves.

Introduction

For consumers, disease prevention and early intervention health care generally means buying services and products that care for our bodies in a physical sense. As we are learning more and more though, it’s as important, if not more so, to look at the social determinants of health and how they contribute to keeping healthy; to understand that physical illness is often a manifestation of unmet social needs, be those resources like housing and money, or more spiritual, educational, occupational or environmental needs.

It stands to reason that our quest to prevent ill health should include understanding and satisfying our own individual social determinants:
• What matters to me?
• Am I in good shape holistically and if not, what’s getting in the way?
• What can I do to get what I need, not for self indulgence, but because it will benefit my health?

Loneliness

Of all the social determinants of health we can assess, social connections are considered the leading contributor to longevity.

Conversely, loneliness – the gap between the connections a person wants and those they have – is Public Enemy No. 1 in its association with chronic disease.

Now cited as the greatest social issue of our time, because of its impact on our physical and mental health, missing social connections, aka loneliness, are considered to be a leading cause of chronic disease, mental health and suicide. However, to take preventative action means admitting to loneliness something that can be more painful than the illnesses it causes.

Heavily stigmatised, loneliness is associated with being unpopular, a social misfit, a burden and a loser (all survey responses); no wonder it’s hard to acknowledge loneliness in ourselves and almost impossible to share with others in order to seek help.

Trusted and respected, with clinical expertise and community understanding, pharmacy staff are perfectly and almost uniquely positioned to help people recognise and resolve their loneliness as a social need before it escalates to a medical emergency. But first, we need to spot the signs.

Steps in identifying loneliness

One of the first steps in identifying and supporting those who are problematically lonely is to understand the risk factors. Remembering that loneliness exists, like hunger and pain, as an uncomfortable feeling, driving us to seek what we need for survival, everyone is susceptible to temporary loneliness for good reason.

But for almost a third of us, conditions conspire, creating barriers to connecting that lead to chronic loneliness – that’s where the damage is done.

In pharmacies, you will constantly come across people presenting with the symptoms of loneliness, and it helps to know some of the signs. A meta-analysis in 2020 by Feros Care helped to identify 4 key risk factors for loneliness and some of the groups that sat within them – really critical work in targeting the right support for the right people.

Risk factors

1. That’s Life: People in this category face ongoing life barriers to connection that cause loneliness. Think, a permanent carer, a single parent, people living remotely, people with disability or mobility issues, a FIFO or shift worker and people living alone.
2. Life’s Transitions: Our social connections often decline when life changes – uncomfortable but not problematic necessarily. However, if a person is unable to find ways to make new connections, chronic loneliness can set it. Look out for the recently bereaved, military personnel leaving Defence, new parents, people leaving the workforce, new migrants, as a few examples.
3. Structural or environmental loneliness: For some, where and how we live and the things around us can affect the way we connect and can cause loneliness. The most obvious in this category is enforced social isolation as a result of a pandemic, something that catapulted thousands of us into loneliness. However, in this category you can look for seniors excluded from a digitised world, people living in apartment blocks or unsafe areas, places where people are excluded culturally, or transport is poor.
4. People living with mental disability or who are neurologically diverse: Autism, Asperger’s, Tourette’s for example … conditions that can make it difficult to enjoy meaningful connections with others.

The signs of loneliness can be obvious – regular visits to the pharmacy with lingering chats and no particular purpose, health service frequent flyers for example. But loneliness manifests physically too, causing stress on the mind and body that shows up as insomnia, hypertension, obesity, cardiovascular disease, addiction and substance abuse, anxiety and depression. Often ill equipped, under-resourced (or both) to investigate the root cause of such chronic conditions, GPs can reach for the script. Enter the pharmacy, and here’s an opportunity for the community pharmacy to add great value.

So where to start?

Most of us don’t understand the importance of social connections on our health, so kicking off that thinking with a customer is a help in itself. Coupled with the stigma of loneliness, it’s unlikely that customers will instantly recognise or admit to their loneliness, and it may be that the conversation takes place over a series of visits.

Of course, it can’t start with: Do you think you might be lonely? (in fact, using positive language is really important). So, what questions give us some clues?

There are validated tools for assessing loneliness, but their questions sound like a survey and not great to use in a busy pharmacy when you’re trying to build trust: How often do you feel you lack companionship?

How often do you feel left out? How often do you feel isolated from others? (UCLA 3 loneliness scale). These aren’t great questions to open up a conversation.

Instead, try questions such as:
• Have you got anyone to do things with when you feel like it?
• Have you got people around that you can talk to about things that matter?
• How do you feel about your circle of friends? (open-ended questions)
• I know you’ve just moved to the area … how are you finding making new connections? (if you know a little about the person’s circumstances)

Once trust has been established, you’ll be in a position to encourage the person to understand that their social life is worth paying attention to and being open to a social cure.