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Published on 02.02.17 in Vol 19, No 2 (2017): February

This paper is in the following e-collection/theme issue:

    Original Paper

    Searching for Real-World Effectiveness of Health Care Innovations: Scoping Study of Social Prescribing for Diabetes

    1School of Life Sciences, Faculty of Science and Technology, University of Westminster, London, United Kingdom

    2School of Health Sciences and Social Work, Faculty of Science, University of Portsmouth, Portsmouth, United Kingdom

    3Institute of Transcultural Health Studies, European University Viadrina, Frankfurt, Germany

    Corresponding Author:

    Karen Pilkington, BPharm (Hons), MSc, PhD

    School of Health Sciences and Social Work

    Faculty of Science

    University of Portsmouth

    St Michael's Building

    2 King Richard 1st Road

    Portsmouth, P01 2FR

    United Kingdom

    Phone: 44 123 984 4497

    Email: karen.pilkington@port.ac.uk


    ABSTRACT

    Background: Social prescribing is a process whereby primary care patients are linked or referred to nonmedical sources of support in the community and voluntary sector. It is a concept that has arisen in practice and implemented widely in the United Kingdom and has been evaluated by various organizations.

    Objective: The aim of our study was to characterize, collate, and analyze the evidence from evaluation of social prescribing for type 2 diabetes in the United Kingdom and Ireland, comparing information available on publicly available websites with the published literature.

    Methods: We used a broad, pragmatic definition of social prescribing and conducted Web-based searches for websites of organizations providing potentially relevant services. We also explored linked information. In parallel, we searched Medline, PubMed, Cochrane Library, Google Scholar, and reference lists for relevant studies published in peer-reviewed journals. We extracted the data systematically on the characteristics, any reported evaluation, outcomes measured and results, and terminology used to describe each service.

    Results: We identified 40 UK- or Ireland-based projects that referred people with type 2 diabetes and prediabetes to nonmedical interventions or services provided in the community. We located evaluations of 24 projects; 11 as published papers, 12 as Web-based reports, and 1 as both a paper and a Web-based report. The interventions and services identified included structured group educational programs, exercise referral schemes, and individualized advice and support with signposting of health-related activities in the community. Although specific interventions such as community-based group educational programs and exercise referral have been evaluated in randomized controlled trials, evaluation of individualized social prescribing services involving people with type 2 diabetes has, in most cases, used pre-post and mixed methods approaches. These evaluations report generic improvement in a broad range of outcomes and provide an insight into the criteria for the success of social prescribing services.

    Conclusions: Our study revealed the varied models of social prescribing and nonmedical, community-based services available to people with type 2 diabetes and the extent of evaluation of these, which would not have been achieved by searching databases alone. The findings of this scoping study do not prove that social prescribing is an effective measure for people with type 2 diabetes in the United Kingdom, but can be used to inform future evaluation and contribute to the development of the evidence base for social prescribing. Accessing Web-based information provides a potential method for investigating how specific innovative health concepts, such as social prescribing, have been translated, implemented, and evaluated in practice. Several challenges were encountered including defining the concept, focusing on process plus intervention, and searching diverse, evolving Web-based sources. Further exploration of this approach will inform future research on the application of innovative health care concepts into practice.

    J Med Internet Res 2017;19(2):e20

    doi:10.2196/jmir.6431

    KEYWORDS



    Introduction

    The World Health Organization global report on diabetes revealed that the number of people with diabetes had risen from 108 million in 1980 to 422 million in 2014 [1]. A similarly dramatic increase is anticipated in the future in the United Kingdom, as the number of people with type 2 diabetes is projected to increase by 50% between 2010 and 2030 [2]. Major advances have occurred in diabetes research, showing that lifestyle interventions can delay or prevent the onset of diabetes [3,4], but prevention and good control of diabetes remain elusive for most of the population [5]. The primary care sector represents a potentially important setting in this context, as more than 85% of the population in the United Kingdom visits a general practitioner (GP) at least once a year [6]. Furthermore, to increase the sustainability of general practice, other options for the support and care of patients, particularly those with chronic conditions, are being sought by organizations such as National Health Service (NHS) England [7].

    Social prescribing (or “community referral”) is a relatively new approach in health care, aiming to create referral pathways that enable the GP or a health care practitioner to refer patients with social or practical needs to a local provider of nonclinical services [8,9]. These are often offered by volunteers or the community sector and cover a wide range of interventions including educational sessions, exercise training, dietary advice, creative activities, self-help groups, emotional or social support, and stress management. A current challenge is to systematically collate and evaluate the evidence of the impact of social prescribing on people’s lives, its conceptualization, dissemination, and the way it is operationalized in practice.

    In general, the translation of research into practice encompasses multiple dimensions, with different levels of scientific involvement and routes of publication. It covers projects that analyze selected aspects of the implementation of new treatments or research knowledge into a practical setting to ensure they not only reach the patients for whom they are intended but are also implemented in the most effective manner [10]. The focus in research is frequently on the efficacy and generalizability of public health interventions, whereas there may be equal levels of interest in the local implementation of interventions in a real-world setting, with “scientific” outcomes being of minor interest, resulting in a low priority for publication. As a result, using the standards of and processes for conducting systematic reviews on health care interventions [11,12] may not represent an adequate approach for gathering evidence of translational research including real-world projects. Limited numbers of studies are available in peer-reviewed articles and, therefore, in the major databases for synthesizing data and drawing conclusions. However, although other sources such as evaluations in practice may be available, these may be limited in methodological and reporting quality and difficult to locate.

    Previous reviews of the evidence on social prescribing have been reported [13,14] as have evaluations of schemes such as exercise on referral [15-17], which fit the concept of social prescribing. Innovative care programs have been evaluated, which include elements of social prescribing and encourage commissioning of nontraditional providers to support people with long-term conditions including diabetes [18], as have fitness programs involving various initiatives across the United Kingdom [19]. There has not, however, been an in-depth review focusing on social prescribing for a specific health area such as diabetes in a specific context (the United Kingdom) with a comparison of the data available from formal (published) and informal Web-based (gray literature) sources.

    The aim of this study was to characterize social prescribing, and to then collate and analyze evaluations of social prescribing, by focusing on services or projects for people with type 2 diabetes in the United Kingdom and Ireland. This allowed an examination of how an innovative health care concept has been translated and applied in practice and provided an indication of the evidence that is available. By searching publicly available websites in addition to the published literature, it also allowed a comparison of the information available from formal (published literature) and informal (websites and related Web-based information) sources, and an exploration of the potential value, feasibility, and challenges presented by such an approach to searching for evidence.


    Methods

    Overview

    The overall approach is based on that of a scoping review or study, a framework for which was provided by Arksey and O’Malley [20]. The following elements of the framework, in particular, informed the approach: identifying all literature regardless of study design, redefining search terms as familiarity with the literature increases, and using an iterative process. However, our methods were also guided by our aim to explore information available on websites about real-world projects or services and compare this with the published literature.

    Search Strategies

    Because of the broad scope and varied terminology associated with social prescribing, and the intention to explore the gray literature in additional to conventional databases, we used a range of search strategies and an iterative approach. We searched the Cochrane Library, MEDLINE, PubMed, and Google scholar, and various sources of gray literature (Google, Yahoo, Bing, greylit.org, Opengrey.eu, and specific NHS websites such as NHS Evidence).

    The initial search for published studies combined the following thematic fields to identify social prescribing projects: (1) social prescri* OR refer*; (2) program OR treatment OR management OR education OR support OR physical exercise OR aerobic OR physical activity OR leisure-time OR exercise OR sport OR leisure activit* OR physical fitness OR training OR physical performance OR weight loss OR weight reduction OR BMI OR body weight OR body mass index OR obesity OR overweight OR adiposity OR smoking OR tobacco OR cigarette OR social support OR loneliness; (3) diabetes; (4) primary care OR GP OR general practitioner OR community OR voluntary. In addition, we performed a search on lifestyle intervention trials for type 2 diabetes in MEDLINE and searched the 200 most recent hits for studies on social prescribing to test the effectiveness of our search strategy.

    The search for gray literature (websites and related Web-based material) was based on the combination and iterative modification of the terms “social prescribing,” “social prescription,” ”primary care,” ”diabetes,” ”referral,” and “community services.” For instance, we searched the first 100 hits in the search engines for “social prescribing” and “diabetes.” If we found NHS websites with links or references to other projects of potential relevance, we followed these; otherwise we modified the search terms and repeated the process multiple times. An initial set of searches was conducted in December 2014.

    The aforementioned searches were repeated in October 2016. At this point, further searches were conducted. Three search strategies for databases were developed based on the results of previous searches including further terms for link workers and “social prescribing interventions” and a term for prediabetes based on the rationale that the interventions would be of a similar nature to those for type 2 diabetes. These strategies are presented in Multimedia Appendix 1. The final search was a further Web-based search via the Google.co.uk search engine using the strategy “social prescribing” AND diabetes AND evaluation. The inclusion of evaluation as a term in this search was due to the fact that in the interim since the previous search, the use of the term social prescribing on websites had become much more extensive. Therefore, it was necessary to focus on identifying projects that had been evaluated. Searches for each of the individual projects located on websites were also carried out by searching using the project name on PubMed.

    Selection Criteria

    Various definitions of social prescribing have been proposed, but it is clear that there is still a lack of consensus on its scope and interpretation. Therefore, a broad, pragmatic set of criteria was used to identify studies or projects that were likely to fit within the spectrum of relevant interventions: located in the United Kingdom or Ireland and involving a primary care provider referring patients including those with type 2 diabetes or prediabetes to a third party that is delivering nonmedical services in the community. Studies or evaluations had to include a description of the referral process or be described as a social prescribing service and mention type 2 diabetes or prediabetes either in the inclusion criteria or in the report or publication. In line with the aim of a scoping review, all study designs used in evaluation were included as were all forms of report. There was no formal language restriction, but studies and projects were excluded if they were available only as abstracts, protocols, located outside the United Kingdom or Ireland, or did not provide details regarding the process of referring the patients from primary care to the external health care, community, or voluntary service. The searches were conducted by 2 authors (ML and KP). Initial screening of each set of search results was carried out by 1 author, preliminary selections by each of the 2 authors were then compared to compile a “short-list,” full-texts were consulted, and final selections were made with reference to the third author (MP) where necessary.

    Data Extraction and Analysis

    For each service, data were extracted by 1 of the authors (ML or KP) into a Microsoft Excel spreadsheet, documenting the name of the service, the name of the organization that carried out the service, the type of organization, the location, the criteria for referral, the type of intervention, outcomes, or objectives, the evaluation of the projects and its findings, the type of publications, and the terminology used in the project regarding social prescription. All extracted data was checked by at least one other author (KP, ML, or MP). For those projects that had undergone an evaluation where the relevant published papers or Web-based report was located, details of the evaluation were extracted. As a range of study designs were used in evaluation and because the main aim was to scope the information available, full appraisal was not carried out, as is the usual approach at this stage [21]. To provide an indication of the quality of the evidence on effectiveness, the following items were extracted: study design (including whether randomized and, where relevant, the control interventions employed), sample size, data collection methods, and outcomes measured. For this purpose, the main study or latest evaluation report was accessed. Details of any additional or related studies are discussed in the text.


    Results

    Search Results and Study Characteristics

    A total of 40 projects or services and 24 evaluations were identified through the various searches and sources. A total of 3249 records from databases were screened, and a “shortlist” of 302 potentially relevant studies was compiled. After further screening and exclusion of studies, 29 papers related to 12 projects were selected, which met the inclusion criteria. For the Web-based searches, in addition to iterative searching, 189 documents retrieved by the final Google search were accessed, resulting in a list of 40 possibly relevant projects, of which 11 were excluded (2, not diabetes; 3, only type 1 diabetes; 3, no clear referral from primary care; 3, complex change interventions including but not focused on social prescribing). Twenty-nine projects met the inclusion criteria, with evaluations found for 13 projects (a Web-based report and a published paper were found for 1 project). Three additional project evaluations were located that included people with long-term conditions but, as diabetes was not specifically mentioned, these were not included. The screening process is shown in Figure 1.

    Summaries of the evaluated projects or services focusing on the key study or report in each case are shown in Table 1. Details of the additional projects located on the Internet are presented in Table 2. The references to papers, reports, and websites are included for each project or service.

    Figure 1. Process for the identification, screening, and selection of projects and evaluations.
    View this figure
    Table 1. Evaluated projects or services involving nonmedical community-based interventions.
    View this table
    Table 2. Additional projects or services identified from Web-based searches.
    View this table

    Overview of Projects

    The included projects represented a range of initiatives and interventions and were commissioned by a range of organizations, either solely or in collaboration, including NHS organizations, local government, and charities. Three projects had a national coverage, providing a standardized program (eg, DESMOND) [47] or a service that was locally adopted from an initial version (eg, X-PERT) [79] or a “social prescribing” intervention provided as part of a national program [24]. The remaining projects were limited to a local area, ranging from city districts to counties or regions.

    Locating the Relevant Information

    Although all published studies were located using a standard medical database, information on the projects or services was found from a variety of sources. Much of the information was retrieved from websites of the organizations delivering the projects. However, in order to include information on the prespecified aspects and, where evaluation reports were not available, it was necessary to follow links to other resources or websites and to access presentations, minutes of relevant meetings, and reports. The specific sources used are referenced in Table 2.

    The studies published in peer-reviewed journals met our broad definition of social prescribing as a referral process from primary care to an external provider of nonmedical services in the community. These studies were not, however, described as social prescribing projects. In fact, only 1 study was located on PubMed that referred to social prescribing [107]. It was potentially relevant, as it was focused on long-term conditions. However, diabetes was not mentioned, and therefore it was not included. The descriptions varied considerably across the projects. Some were referred to as educational programs emphasizing the type of intervention, as “diabetes programs” emphasizing the condition, or GP referral programs focusing on the process. Projects or services were also described as a “community prescription,” a community service, a voluntary, community, and social enterprise undertaking, or a social prescribing project.

    The Range of Interventions

    The intervention in the majority of projects (n=16) was a structured group education program that included multiple thematic areas such as disease information, disease management, healthy lifestyle, and health consequences of diabetes. For instance, the DESMOND program is a structured education program over 6 hours on 1 or 2 days [47]. In the X-PERT diabetes program, participants receive a handbook and are taught by trained educators about diabetes, weight management and other lifestyle factors, and diabetic complications [77]. A number of services involved referral or recommendation of exercise; 7 schemes were based solely on exercise (“Exercise on Prescription” schemes), whereas others offered access to exercise classes as part of a “menu” of community activities. For example, 1 service offered free physical activity options (eg, Tai Chi, Zumba, Community Gym) for 12 weeks at maximum or an individually tailored exercise program for 12 weeks in combination with personal support, a final meeting, follow-up contacts, and a report that was sent to the GP [101].

    Of the interventions that did not involve group education or exercise on prescription, 1 involved trained and quality-assured lifestyle facilitators delivering an “individually tailored behavior change intervention” [22]. Another provided individual support to black and minority ethnic people with type 2 diabetes via “Public Health Improvement Teams” [84]. Other interventions included community-based diabetes prevention programs [48,50,60], a lifestyle and weight management program [76], and a social and horticultural project [64]. The remainder were described as “social prescribing.” In one of these, a personalized signposting service was provided by “Social Prescribing Coordinators” to local services provided by a voluntary, community, and social enterprise (VSCE) group [30]. Similar services were provided by Community Health Champions, Community Prescription Navigators, Social Prescribers or Social Prescribing Workers (or VCS Advisors), link workers, and a practice-based health facilitator (or health manager).

    Evidence from the Evaluations

    We identified a variety of types of research and evaluation on the interventions, ranging from local projects with regular audits using questionnaires, to national programs tested using multicenter randomized controlled trials (RCTs). Of the 24 evaluations, 10 involved RCTs of behavioral, education, or exercise interventions. The majority were service evaluations that used a combination of approaches, both qualitative and quantitative. This required collection and analysis of monitoring data, measurement of outcomes using validated measures or self-reporting, cost-effectiveness calculations, and methods for gaining an insight into the perspectives of both providers and users of the services through surveys, interviews, and focus groups.

    Of the education programs, the DESMOND program, one of the most extensively tested, had undergone a series of clinical trials and other evaluations. These include a large-scale RCT with a subsequent 3-year follow-up study [36,44], a more recent nonrandomized trial comparing health care professional and lay educators [45], and a study on cost-effectiveness [42]. The results revealed that its group education program for patients with newly diagnosed type 2 diabetes was effective at improving some key outcomes but not all. There were positive improvements in illness beliefs, which were still sustained after 3 years, but differences in biomedical or lifestyle outcomes were not apparent after this period [44]. Further research revealed that there was no difference in study outcomes between patients who were referred to 2 health professional educators and those who were referred to a team consisting of a professional educator and a layperson [45]. The cost-effectiveness analysis showed DESMOND to be cost-effective compared with usual care at 12 months [42]. Further studies focused on the facilitators and their skills, and the perspectives of participants in the program, through the use of qualitative approaches [39,46].

    A second education-based intervention, X-PERT, has also been tested in an RCT, and a range of benefits were reported on physiological and behavioral outcomes, including improved glycemic control, BMI, diet, and self-management skills at 14 months [77]. A noncontrolled trial of an adaptation of the program designed for Bangladeshi adults with type 2 diabetes, which did not involve GP referral and therefore is not included in the tables, has also been completed but was underpowered due to low attendance rates [108,109]. A program designed specifically for Muslim diabetics was also assessed by retrospective analysis and reported beneficial effects [65].

    Pre-post questionnaires and physiological measures were used to assess the CODE (Community Oriented Diabetes Education) program with positive trends but not significant changes in physiological measures. However, there was a significant increase in participants’ knowledge scores, coping ability, motivation to change, and making informed decisions about their diabetes [33].

    Other studies investigated the effectiveness of exercise on prescription schemes [26,54,71,75]. Mixed results were reported with effects, if observed, either limited to reduction of anxiety or not maintained over time. One RCT found no difference between an exercise program, instructor-led walking, or advice only [54], while a regression analysis of one scheme explored how the effects of support differed as a function of who provided the support [27]. RCTs were also used to assess the effects of interventions described as behavioral or lifestyle change interventions [22,51,60].

    Internal or external evaluation of services described as social prescribing, either ongoing or completed, was reported on a number of the websites. Of these, evaluation reports were found for 6 “social prescribing” services. In other cases, the results of the evaluations were reported in brief on the website, or in the minutes of relevant meetings or other documents. Some services had been evaluated as part of large projects, whereas in several cases, reports were unavailable or could not be located. One further service had been approved by QISMET (the Quality Institute for Self-Management Education and Training), an independent body developed to support self-management providers and commissioners [98]. In some cases, the collection of data was reported but the results were not located by the searches we performed.

    The type of evaluation ranged in design. Basic numerical data were collected including numbers referred to and accessing the service, and numbers of people reporting changes in various aspects such as increased physical activity or simply completing the program. Questionnaires and more complex designs, for example, mixed approaches using questionnaires combined with interviews or objective outcome data, were also employed in some cases.

    One social prescribing project in inner London that underwent a full evaluation using a mixture of qualitative and quantitative methods also incorporated a matched control group [29]. No significant differences were found between groups based on the quantitative measures, although the qualitative data indicated beneficial effects with positive responses from the participants.

    In the case of the other projects described as social prescribing for which full evaluations were found, a pre-post design was used [24,59,66,73]. Although positive outcomes were reported in, for example, physical activity, weight, blood pressure, mood, and social outcomes, (see Table 1 for the range of outcomes reported), this design did not allow firm conclusions on effectiveness to be drawn. One evaluation reported reduced hospital admissions and improved social outcomes [66]. Several evaluations focused on aspects related to implementing such a project in practice by exploring the perspectives of the patients, the health care providers, the role of the link worker, and the project governance to conclude with recommendations for future social prescribing projects [59].

    While a formal, in-depth systematic appraisal of the methodology was not carried out, a number of issues were encountered when extracting data from the evaluations. It proved difficult in some reports to find the rationale, or occasionally the actual numbers, for the samples used in evaluations. It was also clear that missing data was an issue, particularly where follow-up was at several time points. This is, perhaps, not surprising considering that the aim of social prescribing and related interventions is to direct the patient to the community and voluntary sector rather than encourage follow-up in primary care. However, what was not always clear was how missing data were treated. Finally, as described earlier, referral was often based on psychological, social, or practical needs; this meant that the primary diagnosis was not often reported nor were the results provided by diagnosis.


    Discussion

    Principal Findings

    Our study revealed limited evidence on social prescribing, specifically for type 2 diabetes in the United Kingdom and Ireland in peer-reviewed literature. Only 1 published study referred to social prescribing and that involved people with long-term conditions with no specific mention of type 2 diabetes. Nevertheless, broader Web-based searches demonstrated the existence of numerous “real-world” projects that investigated potentially relevant community-based interventions and had undergone evaluation using a variety of methods. Analysis of these projects also revealed the diverse ways in which the concept of social prescribing has been implemented in practice. The findings of this scoping study do not allow firm conclusions as to the effectiveness of social prescribing for people with type 2 diabetes. The results of the broader searches provide a clearer picture of the potential effects, possible outcomes, and processes involved, and thus inform research in this area. These evaluations also have the potential to provide valuable information for those organizations planning to implement similar services in future. This study has also revealed the different ways in which social prescribing may be described in practice, and this will aid those searching for evidence in future.

    Challenges and Limitations

    The challenges encountered when designing and conducting this study have led to a number of limitations. First, we attempted to identify evaluations of what is effectively a process, the referral of patients from primary care to a nonmedical, community-based activity, program, or service, rather than an intervention per se. In addition, some studies may not have referred specifically to social prescribing and described the intervention using different wording due to the lack of consensus on terminology in this area, thus precluding their identification. We attempted to address these points by using a range of several search strategies and an iterative process whereby we amended the later strategies according to the results of the initial searches. Although we extended the later database searches by including terms for prediabetes and a range of interventions, because of the recent proliferation of websites on the prevention of diabetes, we did not search specifically for diabetes prevention programs on the Web. Such programs, for example, those launched as part of the national Diabetes Prevention Program [110], are likely to use similar models and interventions to the projects included in this review, but further exploration of this aspect would be valuable. The selection of studies also relied on the referral process being reported clearly. The complexity of both identifying and assessing the evidence on social prescribing is demonstrated by the case of the X-PERT project. The RCT on X-PERT was initially excluded from our search because it did not include referral from primary care to an external service provider, whereas in practice, patients are referred from the general practice to the X-PERT educators via social prescribing. A similar situation occurred with later trials of the DESMOND program. Related to this point, it is debatable whether referring patients to a program as part of an RCT is adequately replicating the social prescribing process in practice. A conventional systematic review of published literature might, therefore, not represent a feasible approach to identify the entire literature and assess the effectiveness of the process.

    A second potential limitation was that we limited the search to the United Kingdom and Ireland. The heterogeneity of national health systems, the plethora of diabetes websites, and the varied language used in describing this concept outside the United Kingdom would have proved a considerable challenge, had we attempted to cover the worldwide literature. This does mean that broadly similar projects in other countries were omitted from this review. Third, only information available on the Internet was retrieved and there was no direct contact with those delivering programs or services for further information, confirmation, or clarification. For this reason, it is possible we might have omitted relevant projects or incorrectly interpreted the information we were able to locate. Website information also evolved throughout the course of the study. Finally, by focusing on diabetes and including only those programs or services that specifically referred to people with this condition, we might have omitted relevant services or programs. Conversely, using a broad definition of the intervention resulted in the inclusion of projects and services that, perhaps, do not fit with the original concept of social prescribing as being a mechanism to refer from primary care to the voluntary and community sector. In some cases, the services, although nonmedical and community-based, were still provided by health professionals.

    Nevertheless, our broad searches have demonstrated that social prescribing is prevalent in the United Kingdom, and that information is available that is potentially valuable but not currently in the published literature and therefore difficult to locate and access. At this point, our analysis on the range of projects and services, and the evaluations of these, may prove helpful.

    Figure 2. A model of social prescribing including people with type 2 diabetes.
    View this figure

    The Social Prescribing Concept and Terminology Surrounding This Concept

    It is clear from the findings of this review that different models have been implemented in practice, some of which fit more closely with the original concept of “social prescribing.” It is also clear that although the term “social prescribing” is more widely used in practice in the United Kingdom, it is not a concept that is currently recognized in the main medical databases or in other countries. Even within the United Kingdom, the link workers, who are a crucial part of many social prescribing services, are described in different ways. The findings from this scoping review do, however, suggest a preliminary model for social prescribing such as that presented in Figure 2. This will require further development and refinement.

    Translating Research Into Practice

    It has been argued that the term “translational research” does not distinguish between testing of new treatments and research on how to implement new treatments in practice [10]. This is supported by our finding that the process of social prescribing, potentially the crucial step in the implementation process, is neglected in comparison to the intervention itself. A wide range of models of the process were revealed, for example, direct referral by the GP to the community sector, referral to the community via an in-practice link worker, or referral to a link worker based in the voluntary and community sector. Only 1 study attempted to address whether the process of prescribing an intervention had any influence by comparing referral to exercise programs in the community with tailored advice and information on local exercise facilities. None of the evaluations we located investigated, for example, how direct referral by a GP compared with referral via a link worker.

    In general, many barriers exist that hamper the adoption of research into diabetes into clinical care at the level of the patient, primary care, health care system, community, and society [111]. Several countries have developed diabetes prevention programs for clinical care [112], whereas there has been limited translational research in the United Kingdom [113]. The effects of lifestyle programs in real-world primary care for patients with prediabetes or T2DM are small [114] and depend substantially on the program and its implementation [115]. Development, evaluation, and reporting of translational research programs need to be adapted to reflect the context and consider generalizability [116]. In exploring the effectiveness of implementation, various measures of success need to be taken into account and interpreted. For example, although in many cases, qualitative data in the evaluations found in our searches revealed a positive patient experience, this has not yet been supported by quantitative outcomes to the same degree. It is also clear that, in evaluating the effectiveness of these programs, a range of generic outcomes are used and the focus is often not on disease-specific indicators such as hemoglobin A1c. This is because social prescribing grew out of a perceived need to address broader social, behavioral, and practical issues that impact on, and may be caused by, the disease. Thus, the focus is on the person who has diabetes rather than on the disease itself. Interest in social prescribing is increasing, and its effects on specific groups such as those with diabetes are likely to be of interest, making it important to provide guidance on how real-world evaluations should be conducted and reported to ensure that the data collected can be more accurately compared and analyzed. The results of our analysis of real-world project evaluation will inform this guidance, while guidance such as that produced by Diabetes UK on commissioning to involve nontraditional providers in the support of people with long-term conditions is also valuable [117].

    Our review also suggests a need to improve the reporting of implementation research, specifically service evaluations. Social, cultural, legal, demographic, and other factors that are controlled in trials become relevant influences during the process of implementation [118]. Combining these factors with the diversity in settings, methods, and outcomes of the real-world projects indicates that further development of existing reporting guidelines would be beneficial [119]. However, although standardization of reporting of evaluations would allow greater comparison across services and projects, a service evaluation is produced for a specific organization and to meet the specific requirements of that organization. Thus, increasing standardization of reporting, should this be considered feasible, must be balanced with the need to meet these requirements.

    It has been suggested that evidence synthesis plays a pivotal role in developing or refining a framework of translational research [120]. A first step to enable this would be to better understand and define the multiple dimensions of translational research including implementation projects in real-world settings [10]. This might begin with a debate on reporting of different types of translational research, such has been proposed for Web-based health interventions [121]. Additionally, the challenges encountered in identifying relevant projects in this study indicate that it might prove fruitful to develop specific databases or networks to support larger-scale and more rigorous evaluation and comparison of programs and their relative cost-effectiveness.

    Finally, a discussion might be necessary on how the principles of systematic reviews of health interventions can be applied to translational research, as the hierarchical model of evidence-based medicine has been shown valid only for certain questions such as efficacy [122]. It has been suggested that the study design alone may be an inadequate marker of the quality of evidence for interventions that are complex, program based, and dependent on context [123]. Consideration must be given to the evaluation process and its ability to detect effects and distinguish between failure of an intervention and failure of the delivery process. It is clear from this review that approaches incorporating a range of methods are necessary for evaluating the implementation of such complex interventions in practice. Novel approaches to synthesizing the evidence in this field are already underway [124].

    As part of this discussion, it will be worth considering what role service evaluations of real-world projects play in the evidence base, and whether there are minimum standards for conducting such evaluations. Carrying out formal quality appraisal of these is complex, as they involve a range of data collection approaches, and it is unclear how best to accurately assess and compare the methodology used in individual evaluations. Although standardized tools and checklists exist for designs such as RCTs and qualitative studies, similar tools are not widely available for complex designs. As described earlier, there is also a question of how service evaluations may best be identified, as it is clear that the majority remain in the gray literature and would not be located via conventional systematic search techniques.

    Conclusions

    This review revealed the range of models of social prescribing and related nonmedical community-based services, and the extent of evaluation that has been carried out to assess the potential benefits of these, which would not have been achieved by searching databases alone. Although the evidence from these evaluations does not prove that social prescribing is an effective measure for implementing nonmedical interventions for patients with type 2 diabetes in the United Kingdom, there is sufficient to indicate the value of further evaluation and comparison, particularly if focused on real-world settings. The findings of this scoping study may inform future evaluation. Further research is necessary to better understand the communication between primary care and community or voluntary sector and to improve the documentation of the final step of translational research, implementing interventions in real-world settings.

    Accessing Web-based information provides a potential method for investigating how specific innovative health concepts, such as social prescribing for type 2 diabetes, have been implemented in practice and the full extent of the evaluation of such innovations. Several challenges were encountered including defining the concept, focusing on process plus intervention, and systematically searching varied and evolving Web-based sources. Obtaining sufficient relevant information requires searching for and analyzing information from a range of sources. The methods and findings from this study have already informed a broader scoping exercise on the evaluation of social prescribing projects in the United Kingdom, which is underway. Further exploration of this approach will inform future research on the application of health-related concepts into practice.

    Acknowledgments

    This study was partially funded by the Make My Day Better charity as part of an evaluation of a social prescribing service. The charity had no involvement in the preparation, review, or approval of this paper.

    Authors' Contributions

    KP contributed to the design of the study, conducted the follow-up searches, selected papers and websites, extracted data, and contributed to the writing of the manuscript. ML contributed to the design of the study, conducted the initial and iterative searches, selected papers and websites, extracted data, and contributed to the writing of the manuscript. MP contributed to the design of the study, checked the selections and data extraction, and contributed to the writing of the manuscript.

    Conflicts of Interest

    None declared.

    Multimedia Appendix 1

    Search strategies.

    PDF File (Adobe PDF File), 27KB

    References

    1. World Health Organisation (WHO). 2016. Diabetes: Fact sheet   URL: http://www.who.int/mediacentre/factsheets/fs312/en [accessed 2016-07-05] [WebCite Cache]
    2. Holman N, Forouhi NG, Goyder E, Wild SH. The association of public health observatories (APHO) diabetes prevalence model: estimates of total diabetes prevalence for England, 2010-2030. Diabet Med 2011 May;28(5):575-582. [CrossRef] [Medline]
    3. Diabetes Prevention Program Research Group, Knowler WC, Fowler SE, Hamman RF, Christophi CA, Hoffman HJ, et al. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes study. Lancet 2009 Nov 14;374(9702):1677-1686 [FREE Full text] [CrossRef] [Medline]
    4. Schellenberg ES, Dryden DM, Vandermeer B, Ha C, Korownyk C. Lifestyle interventions for patients with and at risk for type 2 diabetes: a systematic review and meta-analysis. Ann Intern Med 2013 Oct 15;159(8):543-551. [CrossRef] [Medline]
    5. Stark CS, Fradkin JE, Saydah SH, Rust KF, Cowie CC. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care 2013 Aug;36(8):2271-2279 [FREE Full text] [CrossRef] [Medline]
    6. Picker Institute Europe. 2007. National survey of local health services 2006   URL: http:/​/webarchive.​nationalarchives.gov.uk/​20130107105354/​http:/​/www.​dh.gov.uk/​en/​Publicationsandstatistics/​Statistics/​StatisticalWorkAreas/​Statisticalhealthcare/​DH_073494 [accessed 2017-01-03] [WebCite Cache]
    7. NHS England. 2014. Five year forward view   URL: https://www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf [accessed 2017-01-03] [WebCite Cache]
    8. South J, Higgins TJ, Woodall J, White SM. Can social prescribing provide the missing link? Prim Health Care Res Dev 2008 Nov 4;9(04):310. [CrossRef]
    9. Brandling J, House W. Social prescribing in general practice: adding meaning to medicine. Br J Gen Pract 2009 Jun;59(563):454-456 [FREE Full text] [CrossRef] [Medline]
    10. Woolf SH. The meaning of translational research and why it matters. J Am Med Assoc 2008 Jan 9;299(2):211-213. [CrossRef] [Medline]
    11. Higgins J, Green S. 2011. Cochrane handbook for systematic reviews of interventions, Version 5   URL: http://handbook.cochrane.org/ [WebCite Cache]
    12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 2009 Jul 21;6(7):e1000100 [FREE Full text] [CrossRef] [Medline]
    13. Centre for Reviews and Dissemination. University of York; 2015. Evidence to inform the commissioning of social prescribing   URL: https://www.york.ac.uk/media/crd/Ev%20briefing_social_prescribing.pdf [accessed 2016-11-05] [WebCite Cache]
    14. Thomson L, Camic PM, Chatterjee H. 2015. Social prescribing: a review of community referral schemes   URL: https://www.ucl.ac.uk/museums/research/museumsonprescription [accessed 2017-01-03] [WebCite Cache]
    15. Campbell F, Holmes M, Everson-Hock E, Davis S, Buckley WH, Anokye N, et al. A systematic review and economic evaluation of exercise referral schemes in primary care: a short report. Health Technol Assess 2015 Jul;19(60):1-110 [FREE Full text] [CrossRef] [Medline]
    16. Murphy S, Raisane L, Moore G, Edwards R, Linck P, Hounsome N, et al. 2010. The evaluation of the national exercise referral scheme in Wales   URL: http://gov.wales/docs/caecd/research/101104nationalexerciseschemeen.pdf [accessed 2016-11-06] [WebCite Cache]
    17. Mental Health Foundation. 2009. Moving on Up   URL: https://www.mentalhealth.org.uk/sites/default/files/moving_on_up_report.pdf [accessed 2016-11-06] [WebCite Cache]
    18. Year of Care. 2011. Year of Care: Report of findings from the pilot programme   URL: http://www.yearofcare.co.uk/sites/default/files/images/YOC_Report%20-%20correct.pdf [accessed 2016-11-06] [WebCite Cache]
    19. Ecorys UK and University of Keele. Fit as a Fiddle Final Evaluation Report   URL: http:/​/www.​ageuk.org.uk/​Documents/​EN-GB/​ID201168_Fit_As_A_Fiddle_Evaluation_Report_FINAL130313_FINAL.​pdf?pdf?true?dtrk=true [accessed 2016-11-06] [WebCite Cache]
    20. Arksey H, O'Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005 Feb;8(1):19-32. [CrossRef]
    21. Pham MT, Rajić A, Greig JD, Sargeant JM, Papadopoulos A, McEwen SA. A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res Synth Methods 2014 Dec;5(4):371-385 [FREE Full text] [CrossRef] [Medline]
    22. Griffin SJ, Simmons RK, Prevost AT, Williams KM, Hardeman W, Sutton S, et al. Multiple behaviour change intervention and outcomes in recently diagnosed type 2 diabetes: the ADDITION-Plus randomised controlled trial. Diabetologia 2014 Jul;57(7):1308-1319 [FREE Full text] [CrossRef] [Medline]
    23. Dambha-Miller H, Cooper AJ, Simmons RK, Kinmonth AL, Griffin SJ. Patient-centred care, health behaviours and cardiovascular risk factor levels in people with recently diagnosed type 2 diabetes: 5-year follow-up of the ADDITION-Plus trial cohort. BMJ Open 2016 Jan 06;6(1):e008931 [FREE Full text] [CrossRef] [Medline]
    24. Wigfield A, Alden S, Kispeter E. 2015. Age UK's fit for the future Social Prescribing extension project Evaluation report   URL: http:/​/www.​ageuk.org.uk/​Documents/​EN-GB/​fit%20as%20a%20fiddle/​fftf%20extension%20project-Final%20Evaluation%20Report%20(July%202015).​docx.​pdf?dtrk=true [accessed 2016-11-28] [WebCite Cache]
    25. Wigfield A, Kispeter E, Alden S, Turner R. 2015. Age UK's Fit for the Future project: Evaluation report   URL: http:/​/www.​ageuk.org.uk/​Documents/​EN-GB/​fit%20as%20a%20fiddle/​fit%20for%20the%20future%20project%20-%20Final%20Evaluation%20Report%20(July%202015).​pdf?dtrk=true [accessed 2016-11-28] [WebCite Cache]
    26. Duda JL, Williams GC, Ntoumanis N, Daley A, Eves FF, Mutrie N, et al. Effects of a standard provision versus an autonomy supportive exercise referral programme on physical activity, quality of life and well-being indicators: a cluster randomised controlled trial. Int J Behav Nutr Phys Act 2014;11:10 [FREE Full text] [CrossRef] [Medline]
    27. Rouse PC, Ntoumanis N, Duda JL, Jolly K, Williams GC. In the beginning: role of autonomy support on the motivation, mental health and intentions of participants entering an exercise referral scheme. Psychol Health 2011 Jun;26(6):729-749. [CrossRef] [Medline]
    28. Birmingham City Council. About Excercise (sic) on Prescription   URL: http:/​/www.​birmingham.gov.uk/​cs/​Satellite?c=Page&childpagename=Exercise-on-Prescription%2FPageLayout&cid=1223237047303&pagename=BCC%2FCommon %2FWrapper%2FWrapper [WebCite Cache]
    29. City and Hackney Clinical Commissioning Group, University of East London. 2014. Shine 2014 final report: Social Prescribing: integrating GP and Community Assets for Health   URL: http://www.health.org.uk/sites/health/files/City%20and%20Hackney%20CCG%20final%20report.pdf [accessed 2017-01-04] [WebCite Cache]
    30. City and Hackney Clinical Commissioning Group. About Us   URL: http://www.cityandhackneyccg.nhs.uk/about-us/ [accessed 2016-07-06] [WebCite Cache]
    31. City and Hackney Clinical Commissioning Group. 2014. Building Health Partnerships: Social prescribing in City and Hackney   URL: http:/​/www.​cityandhackneyccg.nhs.uk/​news/​Building-Health-Partnerships-Social-prescribing-in-City-and-Hackney.​htm [accessed 2016-07-06] [WebCite Cache]
    32. University of East London. Social prescribing: integrating GP and community assets for health   URL: https:/​/www.​uel.ac.uk/​IHHD/​Our-work/​Research-themes-and-projects/​Well-communities-temp/​Health-Foundation-Shrine [accessed 2016-07-06] [WebCite Cache]
    33. Clarke A. Effectiveness of a community orientated diabetes education (CODE) programme for people with type 2 diabetes. European Diabetes Nursing 2015 Feb 17;8(3):94-99a. [CrossRef]
    34. Diabetes Federation of Ireland. 2008. Community Orientated Diabetes Education (CODE): A structured education programme for people with diabetes. Evaluation Report 2007   URL: https://www.diabetes.ie/wp-content/uploads/2014/11/CODE_2007_Report_April_2008_rev.pdf [accessed 2017-01-03] [WebCite Cache]
    35. Diabetes Ireland. CODE: Community Orientated Diabetes Education   URL: https://www.indi.ie/images/public_docs/2010_CODE_info_for_INDIx.pdf [accessed 2016-07-27] [WebCite Cache]
    36. Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Diabetes Education and Self Management for Ongoing and Newly Diagnosed Collaborative. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. Br Med J 2008 Mar 1;336(7642):491-495 [FREE Full text] [CrossRef] [Medline]
    37. Skinner TC, Carey ME, Cradock S, Daly H, Davies MJ, Doherty Y, et al. Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND): process modelling of pilot study. Patient Educ Couns 2006 Dec;64(1-3):369-377. [CrossRef] [Medline]
    38. Khunti K, Skinner TC, Heller S, Carey ME, Dallosso HM, Davies MJ. Biomedical, lifestyle and psychosocial characteristics of people newly diagnosed with type 2 diabetes: baseline data from the DESMOND randomized controlled trial. Diabet Med 2008 Dec;25(12):1454-1461. [CrossRef] [Medline]
    39. Ockleford E, Shaw RL, Willars J, Dixon-Woods M. Education and self-management for people newly diagnosed with type 2 diabetes: a qualitative study of patients' views. Chronic Illn 2008 Mar;4(1):28-37. [CrossRef] [Medline]
    40. Skinner TC, Carey ME, Cradock S, Dallosso HM, Daly H, Davies MJ, et al. 'Educator talk' and patient change: some insights from the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) randomized controlled trial. Diabet Med 2008 Sep;25(9):1117-1120. [CrossRef] [Medline]
    41. Skinner TC, Carey ME, Cradock S, Dallosso HM, Daly H, Davies MJ, DESMOND Collaborative. Depressive symptoms in the first year from diagnosis of Type 2 diabetes: results from the DESMOND trial. Diabet Med 2010 Aug;27(8):965-967. [CrossRef] [Medline]
    42. Gillett M, Dallosso HM, Dixon S, Brennan A, Carey ME, Campbell MJ, et al. Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis. Br Med J 2010;341:c4093 [FREE Full text] [Medline]
    43. Skinner TC, Carey ME, Cradock S, Dallosso HM, Daly H, Davies MJ, DESMOND Collaborative. Comparison of illness representations dimensions and illness representation clusters in predicting outcomes in the first year following diagnosis of type 2 diabetes: results from the DESMOND trial. Psychol Health 2011 Mar;26(3):321-335. [CrossRef] [Medline]
    44. Khunti K, Gray LJ, Skinner T, Carey ME, Realf K, Dallosso H, et al. Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. Br Med J 2012;344:e2333 [FREE Full text] [Medline]
    45. Carey ME, Mandalia PK, Daly H, Gray LJ, Hale R, Martin SL, et al. Increasing capacity to deliver diabetes self-management education: results of the DESMOND lay educator non-randomized controlled equivalence trial. Diabet Med 2014 Nov;31(11):1431-1438. [CrossRef] [Medline]
    46. Eborall HC, Dallosso HM, Daly H, Martin-Stacey L, Heller SR. The face of equipoise--delivering a structured education programme within a randomized controlled trial: qualitative study. Trials 2014;15:15 [FREE Full text] [CrossRef] [Medline]
    47. Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) project   URL: http://www.desmond-project.org.uk/index.php [accessed 2016-07-27] [WebCite Cache]
    48. Davies MJ, Gray LJ, Troughton J, Gray A, Tuomilehto J, Farooqi A, Let's Prevent Diabetes Team. A community based primary prevention programme for type 2 diabetes integrating identification and lifestyle intervention for prevention: the Let's Prevent Diabetes cluster randomised controlled trial. Prev Med 2016 Mar;84:48-56. [CrossRef] [Medline]
    49. Gray LJ, Yates T, Troughton J, Khunti K, Davies MJ, Let’s Prevent Diabetes Team. Engagement, retention, and progression to type 2 diabetes: a retrospective analysis of the cluster-randomised “Let's Prevent Diabetes” trial. PLoS Med 2016 Jul;13(7):e1002078 [FREE Full text] [CrossRef] [Medline]
    50. Yates T, Edwardson CL, Henson J, Gray LJ, Ashra NB, Troughton J, et al. Walking away from type 2 diabetes: a cluster randomized controlled trial. Diabet Med 2016 Sep 2:- Epub ahead of print. [CrossRef] [Medline]
    51. Penn L, White M, Oldroyd J, Walker M, Alberti KG, Mathers JC. Prevention of type 2 diabetes in adults with impaired glucose tolerance: the European Diabetes Prevention RCT in Newcastle upon Tyne, UK. BMC Public Health 2009 Sep 16;9:342 [FREE Full text] [CrossRef] [Medline]
    52. Penn L, Moffatt SM, White M. Participants' perspective on maintaining behaviour change: a qualitative study within the European Diabetes Prevention Study. BMC Public Health 2008 Jul 10;8:235 [FREE Full text] [CrossRef] [Medline]
    53. Penn L, White M, Lindström J, den Boer AT, Blaak E, Eriksson JG, et al. Importance of weight loss maintenance and risk prediction in the prevention of type 2 diabetes: analysis of European Diabetes Prevention Study RCT. PLoS One 2013;8(2):e57143 [FREE Full text] [CrossRef] [Medline]
    54. Isaacs AJ, Critchley JA, Tai SS, Buckingham K, Westley D, Harridge SD, et al. Exercise Evaluation Randomised Trial (EXERT): a randomised trial comparing GP referral for leisure centre-based exercise, community-based walking and advice only. Health Technol Assess 2007 Mar;11(10):1-165, iii-iv [FREE Full text] [Medline]
    55. Solomon E, Clifford Z. 2015. Evaluation of the “Living Well, Taking Control” community-based prevention and management of type 2 diabetes programme: a study protocol and presentation of preliminary findings   URL: http://decipher.uk.net/wp-content/uploads/2015/03/F2-Emma-Solomon-Diabetes-prevention.pdf [accessed 2016-11-06] [WebCite Cache]
    56. Health Exchange. 2016. Living Well, Taking Control   URL: https://www.healthexchange.org.uk/corporate/our-partners/living-well-taking-control/ [accessed 2016-11-28] [WebCite Cache]
    57. Jennings E, Greene P, Nasteva G, Mellor D, Cowley P, Harvey J. Evaluation of Initial Structured Group Education in Newly Diagnosed Type 2 Diabetes   URL: http:/​/connect.​qualityincare.org/​__data/​assets/​pdf_file/​0009/​547074/​Evaluation_of_Initial_Structured_Group_Education_in_Newly_Diagnosed_Type_2_Diabetes.​pdf [WebCite Cache]
    58. North Wales NHS Trust. Newly Diagnosed Type 2 Diabetes Dietary Education Group (Type 2 group leaflet)   URL: http://connect.qualityincare.org/__data/assets/pdf_file/0011/547076/Type_2_Group_Leaflet.pdf [accessed 2017-01-03] [WebCite Cache]
    59. HeathWORKS Newcastle. 2013. Newcastle Social Prescribing Project: Final report   URL: http:/​/www.​healthworksnewcastle.org.uk/​2013/​08/​newcastle-social-prescribing-project-final-evaluation/​ [accessed 2017-01-03] [WebCite Cache]
    60. Penn L, Ryan V, White M. Feasibility, acceptability and outcomes at a 12-month follow-up of a novel community-based intervention to prevent type 2 diabetes in adults at high risk: mixed methods pilot study. BMJ Open 2013 Nov 12;3(11):e003585 [FREE Full text] [CrossRef] [Medline]
    61. Penn L, Dombrowski SU, Sniehotta FF, White M. Participants' perspectives on making and maintaining behavioural changes in a lifestyle intervention for type 2 diabetes prevention: a qualitative study using the theory domain framework. BMJ Open 2013 Jun 28;3(6):pii: e002949 [FREE Full text] [CrossRef] [Medline]
    62. Penn L, Dombrowski SU, Sniehotta FF, White M. Perspectives of UK Pakistani women on their behaviour change to prevent type 2 diabetes: qualitative study using the theory domain framework. BMJ Open 2014 Jul 08;4(7):e004530 [FREE Full text] [CrossRef] [Medline]
    63. Middlesbrough Environment City (Mevcity). New Life New You: Preventing Type 2 diabetes in BME communities in Middlesbrough   URL: http://www.menvcity.org.uk/nlny/ [accessed 2016-11-06] [WebCite Cache]
    64. Clift S, Cunningham L, Winczewska N. PoLLeN People, Life, Landscape and Nature: An evaluation 2012-2013. Canterbury: Canterbury Christ Church University; 2013.
    65. Bravis V, Hui E, Salih S, Mehar S, Hassanein M, Devendra D. Ramadan Education and Awareness in Diabetes (READ) programme for Muslims with type 2 diabetes who fast during Ramadan. Diabet Med 2010 Mar;27(3):327-331. [CrossRef] [Medline]
    66. Dayson C, Bashir N. 2014. The social and economic impact of the Rotherham Social Prescribing Pilot Main Evaluation Report   URL: http://www4.shu.ac.uk/research/cresr/sites/shu.ac.uk/files/social-economic-impact-rotherham.pdf [WebCite Cache]
    67. Dayson C, Bashir N, Pearson S. 2013. From dependence to independenc: emerging lessons from the Rotherham Social Prescribing Pilot Summary Report   URL: http:/​/www4.​shu.ac.uk/​research/​cresr/​sites/​shu.ac.uk/​files/​social-economic-impact-rotherham-summary.​pdf [WebCite Cache]
    68. Voluntary Action Rotherham. Social Prescribing service   URL: http://www.varotherham.org.uk/social-prescribing-service/ [accessed 2016-07-27] [WebCite Cache]
    69. Warwickshire Health and Wellbeing. Connect WELL: Social Prescribing Pilot Project in Rugby   URL: http://hwb.warwickshire.gov.uk/2015/03/06/connect-well-social-prescribing-pilot-project-in-rugby/ [accessed 2017-01-04] [WebCite Cache]
    70. White J, Coan S. 2016. Sadee Smile Evaluation Final report   URL: http:/​/www.​touchstonesupport.org.uk/​wp-content/​uploads/​2016/​08/​Sadee-Smile-Evaluation-Full-Report.​pdf [accessed 2016-11-06] [WebCite Cache]
    71. Flannery O, Loughren E, Baker C, Crone D. 2014. Exercise on Prescription Evaluation Report for South Gloucestershire   URL: http://eprints.glos.ac.uk/2379/ [accessed 2016-11-06] [WebCite Cache]
    72. South Gloucestershire Council. Exercise on prescription   URL: http:/​/www.​southglos.gov.uk/​health-and-social-care/​staying-healthy/​getting-active/​exercise-on-prescription/​ [accessed 2016-07-27] [WebCite Cache]
    73. Jones M, Kimberlee R, Deave T. 2009. South West Well-being Programme Evaluation Report   URL: http://www.cles.org.uk/wp-content/uploads/2011/03/SWWB-Report-March-2009.pdf [accessed 2016-11-30] [WebCite Cache]
    74. Kimberlee R. 2013. Developing a social prescribing approach for Bristol Project Report   URL: http://eprints.uwe.ac.uk/23221/ [accessed 2016-07-27] [WebCite Cache]
    75. Harrison RA, Roberts C, Elton PJ. Does primary care referral to an exercise programme increase physical activity one year later? A randomized controlled trial. J Public Health (Oxf) 2005 Mar;27(1):25-32 [FREE Full text] [CrossRef] [Medline]
    76. NHS Wirral.: University of Liverpool Wirral PCT Lifestyle and Weight Management Programme: A preliminary report by the Health Economics Unit University of Liverpool Management School   URL: http://info.wirral.nhs.uk/intelligencehub/healtheconomicsandvalueformoney.html [accessed 2017-01-04] [WebCite Cache]
    77. Deakin TA, Cade JE, Williams R, Greenwood DC. Structured patient education: the diabetes X-PERT Programme makes a difference. Diabet Med 2006 Sep;23(9):944-954. [CrossRef] [Medline]
    78. X-PERT Health. Welcome to X-PERT Health: Diabetes Programme   URL: http://www.xperthealth.org.uk/ [accessed 2017-01-04] [WebCite Cache]
    79. X-PERT Health. People with diabetes   URL: http://www.xperthealth.org.uk/people-with-diabetes/x-pert-diabetes [accessed 2016-07-27] [WebCite Cache]
    80. Altogether Better. Altogether Better Diabetes   URL: http://www.altogetherbetter.org.uk/altogether-better-diabetes [accessed 2016-11-06] [WebCite Cache]
    81. Altogether Better. 2015. Altogether Better Working Together to Create Healthier People and Communities   URL: http://www.altogetherbetter.org.uk/evidence-and-resources [accessed 2016-11-07] [WebCite Cache]
    82. Birmingham City Council. Be active plus   URL: http://www.birmingham.gov.uk/beactiveplus [accessed 2016-07-06] [WebCite Cache]
    83. Be Active Birmingham. 2016. Information for surgeries   URL: http://beactivebirmingham.co.uk/be-active-plus/information-for-surgeries [accessed 2016-07-06] [WebCite Cache]
    84. Building Health Partnerships--No. 8: Improving access to targeted services for BME diabetics in Bristol   URL: http:/​/www.​socialenterprise.org.uk/​public/​uploads/​editor/​files/​Health_Partnership_Bristol_08_final.​pdf [accessed 2016-07-05] [WebCite Cache]
    85. Camden. 2016. Camden Exercise Referral   URL: http:/​/www.​camden.gov.uk/​ccm/​content/​leisure/​sports-and-activities/​activities-for-over-50s/​active-health-classes.​en [accessed 2016-07-06] [WebCite Cache]
    86. Camden and Islington Exercise Referral & Adult weight management service: Inclusion and Exclusion criteria   URL: https:/​/gps.​camdenccg.nhs.uk/​cdn/​serve/​service-downloads/​1458746654-2b49340edaa91f835b545c5a92c75a4a.​pdf [accessed 2017-01-04] [WebCite Cache]
    87. Stathi A, Milton K, Riddoch C. 2006. Evaluation of the London Borough of Camden Exercise Referral Scheme   URL: http://opus.bath.ac.uk/48825/ [accessed 2017-01-06] [WebCite Cache]
    88. Kent Community Health NHS Foundation Trust. Diabetes Education and Revision in East Kent (DEREK)   URL: http://www.kentcht.nhs.uk/wp-content/uploads/2016/03/DEREK-programme-00408.pdf [accessed 2017-01-04] [WebCite Cache]
    89. Berkshire Healthcare NHS Foundation Trust. Diabetes   URL: http://www.berkshirehealthcare.nhs.uk/page.asp?fldArea=1&fldMenu=12&fldSubMenu=0&fldKey=138 [WebCite Cache]
    90. Positive Step. Positive step (Go4life): Supporting wellness in North Somerset   URL: http://positivestep.org.uk/ [accessed 2016-07-27] [WebCite Cache]
    91. North Somerset Council. Go4life: Active directory and publications   URL: http://www.n-somerset.gov.uk/my-services/leisure/sport/getting-active/go4life/ [accessed 2016-07-27] [WebCite Cache]
    92. North Somerset Pathways. Healthy Lifestyles   URL: http://www.northsomersetpathways.co.uk/healthy_lifestyles.php [accessed 2017-01-04] [WebCite Cache]
    93. Your Diabetes. Your diabetes. Structured education (Good2go)   URL: http://www.yourdiabetes.org.uk/health_professionals/structured_education/ [accessed 2017-01-04] [WebCite Cache]
    94. North Yorkshire County Council. Diabetes   URL: http://www.northyorks.gov.uk/article/27407/Diabetes [accessed 2016-07-27] [WebCite Cache]
    95. Harrogate and District NHS Foundation Trust. Diabetes service   URL: https://www.hdft.nhs.uk/services/endocrinology/diabetes-service/ [accessed 2016-07-27] [WebCite Cache]
    96. Nottingham University Hospitals NHS Trust. Structured education for type 2 diabetes (Juggle)   URL: http:/​/www.​nuh.nhs.uk/​our-services/​services/​diabetes/​clinics-and-services/​structured-education-for-type-2-diabetes/​ [accessed 2017-01-04] [WebCite Cache]
    97. Norfolk Community Health and Care NHS Trust. Diabetes Type 2 education programme: Overview   URL: http:/​/www.​norfolkcommunityhealthandcare.nhs.uk/​The-care-we-offer/​Service-search/​diabetes-type-2-education-programme.​htm [accessed 2016-07-27] [WebCite Cache]
    98. Buckinghamshire Healthcare NHS Trust. About Us: National recognition for diabetes education service (Life and health with diabetes) 2013   URL: http://www.buckshealthcare.nhs.uk/About/national-recognition-for-diabetes-education-services.htm [accessed 2016-07-27] [WebCite Cache]
    99. Buckinghamshire Healthcare NHS Trust. Buckinghamshire Formulary: Management of type 2 diabetes   URL: http://www.bucksformulary.nhs.uk/docs/Guideline_667FM.pdf [accessed 2017-01-04] [WebCite Cache]
    100. Bristol Community Health. Living with diabetes   URL: http://briscomhealth.org.uk/diabetes-education-courses/ [accessed 2017-01-04] [WebCite Cache]
    101. Newham Clinical Commissioning Group. Newham Community Prescription - what's it all about?   URL: http://www.newhamccg.nhs.uk/GetInvolved/newham-community-prescription.htm [accessed 2016-07-27] [WebCite Cache]
    102. Newham Community Prescription   URL: http://cohnewham.org/projects/newham-community-prescription/ [accessed 2017-01-04] [WebCite Cache]
    103. Herbert N, Pilkington K, Ridge D, Dixon M, King D, Polley M. Feasibility of using facilitated social prescription to improve the health outcomes for those with Type 2 Diabetes and those at risk of diabetes. Eur J Integr Med 2015;7(6):688. [CrossRef]
    104. College Surgery. Health facilitator   URL: http://www.collegesurgery.org.uk/health_facilitator_p6619.html?a=0 [accessed 2016-07-27] [WebCite Cache]
    105. Cambridge City Council. Fitness for adults with medical conditions (Start-Up exercise referral scheme)   URL: https://www.cambridge.gov.uk/fitness-for-adults-with-medical-conditions [accessed 2017-01-04] [WebCite Cache]
    106. Cambridge City Council. Cambridge City Council's Exercise Referral Schemes Annual Report 2014-15   URL: https://www.cambridge.gov.uk/sites/default/files/cambridge-exercise-referral-report-14-15-v2a.pdf [accessed 2017-01-04] [WebCite Cache]
    107. Whitelaw S, Thirlwall C, Morrison A, Osborne J, Tattum L, Walker S. Developing and implementing a social prescribing initiative in primary care: insights into the possibility of normalisation and sustainability from a UK case study. Prim Health Care Res Dev 2016 Jun 8:1-10. [CrossRef] [Medline]
    108. Choudhury S, Brophy S, Fareedi MA, Zaman B, Ahmed P, Williams DR. Intervention, recruitment and evaluation challenges in the Bangladeshi community: experience from a peer lead educational course. BMC Med Res Methodol 2008;8:64 [FREE Full text] [CrossRef] [Medline]
    109. Choudhury SM, Brophy S, Fareedi MA, Zaman B, Ahmed P, Williams R. Examining the effectiveness of a peer-led education programme for Type 2 diabetes and cardiovascular disease in a Bangladeshi population. Diabet Med 2009 Jan;26(1):40-44. [CrossRef] [Medline]
    110. NHS England. NHS Diabetes Prevention Programme (NHS DPP)   URL: https://www.england.nhs.uk/ourwork/qual-clin-lead/diabetes-prevention/ [accessed 2016-12-02] [WebCite Cache]
    111. Hiss RG. The concept of diabetes translation: addressing barriers to widespread adoption of new science into clinical care. Diabetes Care 2001 Jul;24(7):1293-1296. [Medline]
    112. Yates T, Davies M, Khunti K. Preventing type 2 diabetes: can we make the evidence work? Postgrad Med J 2009 Sep;85(1007):475-480. [CrossRef] [Medline]
    113. Yates T, Davies MJ, Henson J, Troughton J, Edwardson C, Gray LJ, et al. Walking away from type 2 diabetes: trial protocol of a cluster randomised controlled trial evaluating a structured education programme in those at high risk of developing type 2 diabetes. BMC Fam Pract 2012;13:46 [FREE Full text] [CrossRef] [Medline]
    114. Linmans JJ, Spigt MG, Deneer L, Lucas AE, de Bakker M, Gidding LG, et al. Effect of lifestyle intervention for people with diabetes or prediabetes in real-world primary care: propensity score analysis. BMC Fam Pract 2011;12:95 [FREE Full text] [CrossRef] [Medline]
    115. Dunkley AJ, Bodicoat DH, Greaves CJ, Russell C, Yates T, Davies MJ, et al. Diabetes prevention in the real world: effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations: a systematic review and meta-analysis. Diabetes Care 2014 Apr;37(4):922-933. [CrossRef] [Medline]
    116. Glasgow RE, Emmons KM. How can we increase translation of research into practice? Types of evidence needed. Annu Rev Public Health 2007;28:413-433. [CrossRef] [Medline]
    117. Year of Care. Thanks for the Petunias: a guide to developing and commissioning non-traditional providers to support the self management of people with long term conditions 2011   URL: http://www.yearofcare.co.uk/sites/default/files/pdfs/Thanks%20for%20the%20Petunias.pdf [accessed 2016-11-07] [WebCite Cache]
    118. Peters DH, Adam T, Alonge O, Agyepong IA, Tran N. Republished research: implementation research: what it is and how to do it: implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it. Br J Sports Med 2014 Apr;48(8):731-736. [CrossRef] [Medline]
    119. Davidoff F, Batalden P, Stevens D, Ogrinc G, Mooney S, SQUIRE Development Group. Publication guidelines for quality improvement in health care: evolution of the SQUIRE project. Qual Saf Health Care 2008 Oct;17(Suppl 1):i3-i9 [FREE Full text] [CrossRef] [Medline]
    120. Ogilvie D, Craig P, Griffin S, Macintyre S, Wareham NJ. A translational framework for public health research. BMC Public Health 2009;9:116 [FREE Full text] [CrossRef] [Medline]
    121. Eysenbach G, CONSORT-EHEALTH Group. CONSORT-EHEALTH: improving and standardizing evaluation reports of Web-based and mobile health interventions. J Med Internet Res 2011;13(4):e126 [FREE Full text] [CrossRef] [Medline]
    122. Walach H, Falkenberg T, Fønnebø V, Lewith G, Jonas WB. Circular instead of hierarchical: methodological principles for the evaluation of complex interventions. BMC Med Res Methodol 2006;6:29 [FREE Full text] [CrossRef] [Medline]
    123. Rychetnik L, Frommer M, Hawe P, Shiell A. Criteria for evaluating evidence on public health interventions. J Epidemiol Community Health 2002 Feb;56(2):119-127 [FREE Full text] [Medline]
    124. Husk K, Blockley K, Lovell R, Bethel A, Bloomfield D, Warber S, et al. What approaches to social prescribing work, for whom, and in what circumstances? A protocol for a realist review. Syst Rev 2016;5(1):93 [FREE Full text] [CrossRef] [Medline]


    Abbreviations

    BMI: body mass index
    BP: blood pressure
    CHD: coronary heart disease
    GP: general practitioner
    HbA1c: Hemoglobin A1c
    HCP: health care practitioners
    LTC: long-term conditions
    PP: published journal paper
    RCT: randomized controlled trial
    RR: risk ratio
    (S)WEMWBS: (Short) Warwick Edinburgh Mental Wellbeing Scale
    T2DM: type 2 diabetes
    WR: Web-based report


    Edited by G Eysenbach; submitted 02.08.16; peer-reviewed by R Simmons, MC Portillo; comments to author 08.09.16; revised version received 07.11.16; accepted 23.11.16; published 02.02.17

    ©Karen Pilkington, Martin Loef, Marie Polley. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.02.2017.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.