YOGA ON SOCIAL PRESCRIPTION
Results from Yoga in Healthcare Alliance Research
In an attempt to help relieve pressure on the NHS, an increasing number of doctors are offering ‘social prescriptions’ rather than medication, in order to treat people throughout the UK.
Recognising that health is often determined by a complex range of social, economic and environmental factors, social prescribing is the process where GPs, nurses and other primary care professionals can refer people to a range of activities. These often include befriending, group learning, gardening, volunteering, arts activities, cookery, healthy eating advice and yoga.
Social prescribing seeks to address people’s needs in a holistic way, and the hope is that it will not only empower people to take greater control of their health, but will enable them to live happier, healthier lives. One review of studies on social prescribing showed that on average, it was associated with:
28% fall in visits to a GP
24% drop in attendance at emergency wards
Tackling the epidemic of lifestyle-related disease and the social determinants of health lie at the heart of social prescribing. One common prescription is for more exercise, and the other is for mental health – and yoga is increasingly being viewed as a viable social prescription that can address both physical and mental wellbeing.
Given the accumulating evidence that demonstrates yoga effectiveness in tackling a variety of conditions – from lower back pain to diabetes, depression and stress – The Yoga in Healthcare Alliance recently carried out a survey asking members in the Social Prescribing Network for their views on the role of yoga in social prescribing.
A fifth described themselves as belonging to the third sector, and the rest reflected a diverse group, including a general practitioner, practice nurse/manager, pharmacist, commissioner, yoga teacher/researcher/therapist, evaluator of social prescribing projects, project coordinator, nurse community team leader, occupational therapist, and public health professional.
These individuals also represented a broad cross section of Clinical Commissioning Groups (CCGs), including Crawley, East Sussex and Kent (‘Let’s Get Working’ project), Kernow (St. Austell Healthcare Hub), Newcastle Gateshead and Hammersmith and Fulham, and groups like Telford & Wrekin Council, Zest Social Prescribing Service (Sheffield), Bromley by Bow Centre (Macmillan Social Prescribing) and CoolTan Arts.
While 56% of respondents said their practice/community/CCG offers some form of social prescribing, 39% replied that they didn’t know. Of this 56% who do offer social prescribing, 32% offer yoga as part of this, 27% do not, and 42% do not know.
The cost savings
However when exploring confidence levels relating to yoga’s health benefits for specific conditions, responses were mixed:
Reducing low back pain:
43% were “somewhat confident” and 34% were “very confident”. Compared with 9% “not confident” or 13% “somewhat lacking in confidence”
Alleviating symptoms of mental health conditions including depression and anxiety:
22% were “somewhat confident” and 56% “very confident”. Compared to 13% “somewhat lacking in confidence” and 9% “not sure”
Reducing symptoms and severity of stress:
26% were “somewhat confident” and 56% were “very confident”. Compared to 17% “somewhat lacking in confidence”
Reducing risk and complications of diabetes:
17% were “somewhat confident” and 17% “very confident”. Compared to 22% “not confident and 9% “somewhat lacking in confidence”. Overall, 35% were “not sure”
Reducing risk and complications of cardiovascular problems:
26% were either “somewhat confident” and 30% “very confident”. Compared to 17% “not confident” or 9% “somewhat lacking in confidence”. Overall, 17% were not sure
Who can most benefit?
‘Everyone’, ‘all those interested’ and ‘anyone’ was mentioned most frequently and qualified by one respondent: ‘Everyone – but practitioners formally trained in motivational interviewing techniques and screening for readiness for change will only make it reality’.
Other comments reflected a wide range of opinions:
- ‘Anyone motivated enough to want to improve their health and wellbeing through self-care’
- ‘Many people willing to commit to learning how to help themselves to improved health and well-being within their daily lives’
- ‘Anyone at risk of ill health or poor wellbeing’
- ‘People in need of better body awareness and control’
- ‘Many of the patients who repeatedly report to their GP who actually need some gentle exercise and or mental health support’
- ‘Client with mental health involvement such as stress, anxiety, depression plus those with complex health conditions’
- ‘Unemployed, older people, those with medical conditions including mental health’
- ‘Older people (to reduce falls), everyone (mental health, LTCs) General public, people with mental ill health, people with long term conditions, single parents’
- ‘Hopefully those that do not have the financial ability to go to yoga classes and need to look after their physical and mental well-being’
- Both practitioners (being able to share the yoga) and patients of all ages and with many different ailments – it would be a holistic treatment for improving quality of life in the majority of cases
Evaluating social prescribing
The top five ways in which currently social prescribing schemes are evaluated are:
- Measurement of mental health & wellbeing (including quality of life, confidence & self-esteem and wellbeing scales): 87%
- Measurement of engagement with social prescribing scheme (attendance and drop-out rates etc): 73%
- Measurement of impact on demand (level of medication prescribing, demand for GP services, referral to secondary care, A & E visits, emergency hospital admissions etc): 47%
- Measurement of physiological and physical parameters (eg HbA1c, blood pressure, weight, levels of physical activity etc): 33%
- Measurement of economic impact (social return on investment (SROI), cost per QALY, impact on housing, employment and welfare status): 33%
Other measures cited were:
- Impact on community engagement
- Pre/post assessment with individual often looking at wemwbs
- As per original randomised control trial (outcome measures) plus Feedback and Friends and Family Test
- Variations across each social prescribing initiative
- Not enough R&D resource to do it properly or with CMFs across initiatives to compare and contrast them properly
Challenges when evaluating social prescribing schemes
The main challenges associated with evaluating social prescribing schemes broadly fall into the following categories:
- Access to NHS data
- Difficulty in collecting follow up data on vulnerable clients
- Capturing data on those who choose not to engage with the service
- Evaluation needs to cover referral processes applicable to all forms of social prescriptions
Quality of evidence
- Clients writing down something in a feedback form which contradicts what is being said within a session
- Evaluating aspects that are difficult to measure. E.g. Happiness and the ability to manage life changes
- Social prescribing should only be used to refer patients to appropriate activities/ interventions which have a proven evidence base and are delivered by professional/trained service providers
- Tendency for doctors to adopt ‘gold standard’ techniques derived from drug research paradigm which are wholly inappropriate for subjective and social interventions
- Too much emphasis on quantitative data
- Outcomes may not be realised for a long term
- Consistency in capturing and/or surveying participants
Training & education
- Rating schemes can be challenging as not all raters have training in using the rating tools
- GP knowledge and implication – Patient awareness and motivation to engage
- Awareness amongst GPs and general public
- How to educate the link worker / health champions about which yoga programmes are appropriate
- Finance to pay for unbiased independent evaluation
- We need to stop seeing individual activities as the solution but a combination of factors. Gardening provides similar evidence to dance, which provides similar evidence to knit and knatters etc.’
- Funding / subsidies
- Funding for high quality but pragmatic evaluations, professionalisation of being an Evaluator (ie. embedding requirement of education/training/experience of research methods into commissioners’/SPs’ expectations.)’
Key success criteria
The three most important critical success factors for an effective social prescribing initiative were selected as follows:
- Healthcare professional buy-in
- Funding for third sector providers
- Patient centred, user empowerment, co design of service with users
Funding from primary care and link workers with the right skills and training were also considered important.
The top three factors that need to be addressed in order to implement a social prescribing scheme offering yoga were:
- The availability of quality yoga provision in the area and its accessibility to the community
- Being convinced of yoga’s impact on health and wellbeing, based on the evidence
- Being able to communicate what yoga is and how people would benefit in terms relevant to them
‘Understanding/profiling who would most benefit’ and ‘being convinced of the cost effectiveness of yoga’ were also important.
The role of yoga is evolving as a useful tool for the holistic healing of both body and mind in order to alleviate some of the ills of modern society. These include inactivity (‘sitting disease’), information overload, disconnection and alienation, insomnia, stress and anxiety.
While this data set was relatively small and reflected the views of yoga ‘enthusiasts’, it did point to specific needs in the following areas to help secure yoga’s rightful place in social prescribing:
- Social prescribers familiar with yoga, and even those generally confident over its health benefits would benefit from further education on yoga’s role, especially in diabetes and cardiovascular problems
- Social prescribers familiar with yoga believe a wide range of people could potentially benefit. This indicates the importance of getting other social prescribers to ‘try it out’ while also understanding its full potential
- Further research and clarity is needed on the best ways in which to evaluate social prescribing and on what measures (qualitative, quantitative, individual vs community, biological, economic, social etc), and how this relates to yoga. Challenges with evaluation relate to access, quality of evidence, training and funding
- The following are key to implementing a social prescribing scheme offering yoga:
1) Availability of quality yoga provision in the local community
2) Education for social prescribers on yoga’s impact on health and wellbeing, based on the evidence
3) Education for social prescribers to effectively communicate what yoga is and how people would benefit in terms relevant to them
Overall, the feedback received from this survey yielded important insights to inform two of the four key priorities that the Social Prescribing Network has identified to focus on in 2018:
- Link worker development and training
- Understanding the outputs and outcomes of social prescribing