The Social Prescription: Dispensing Wellness Beyond the Medication

Abstract

In the realm of healthcare, the significance of social connections cannot be overstated. Beyond the traditional focus on pharmacological interventions and medical procedures, recognizing and nurturing positive social relationships has emerged as a fundamental aspect of lifestyle medicine. This article delves into the multifaceted nature of social connections and their profound impact on health outcomes, particularly in the context of chronic diseases like hypertension, mental health disorders, heart disease, and dementia. Moreover, it explores strategies for healthcare practitioners, with a special emphasis on pharmacists, to foster positive connections with patients, thereby enhancing shared decision-making, self-management, and overall well-being.

“Positive social connections is an important pillar within the lifestyle style medicines pillars.”

Introduction

It is well known across scientific disciplines that humans are a social species and social connections are critical for reproduction, development, and survival. ¹ Social connections are more than just having family and friends to provide support, but it is a complex system with various factors, including the presence and interactions of diverse social connections and roles such as marital status, social integration, and social isolation. It’s crucial to assess both the functionality and quality of these social ties, accounting for disparities between received and perceived support, feelings of loneliness, as well as any strains in relationships or experiences of social isolation or exclusion. Taking a multidimensional approach to social connections can enhance the efficiency of public health initiatives. Concentrating solely on one aspect may leave gaps in addressing social deficits and overlooked opportunities for health promotion and prevention. Studies indicate that social connections impact our mental, physical, and behavioral well-being, contributing to longer lifespans, improved health outcomes, and enhanced overall wellness. ²

Evidence of Positive Connections and Health Outcomes

Chronic diseases pose significant health challenges, with the number of affected individuals steadily rising. Among the most prevalent chronic illnesses including hypertension, effective management is crucial. ³ Management of these disease states entails various components such as medication adherence, physical activity, and lifestyle modifications. This article will summarize some of the evidence that shows the relationship between positive connections and selected medical conditions.

Hypertension

Medication nonadherence significantly contributes to poorly controlled hypertension. Various factors such as poverty, limited education, unemployment, and insufficient social support contribute to nonadherence. Among these factors, inadequate social support remains an undervalued and understudied source of nonadherence. A systematic review conducted by Shahin et al. evaluated fourteen articles to assess the influence of patient social support on medication adherence among individuals with hypertension. Of these articles, nine revealed statistically significant correlations between medication adherence and social support (P < .05).

Certain indications propose that successful communication between healthcare providers and patients significantly impacts medication adherence, yet this achievement may not always be feasible for the typical patient due to associated costs. Social support is multifaceted, and receiving quality support from family and friends can assist patients in maintaining active care despite physical, social, and economic challenges. Among support sources, family members were perceived as the most accessible and effective in fostering medication adherence. Although healthcare support was referenced in two of the fourteen studies, only one demonstrated a weak correlation between pharmacist support and medication adherence. This study demonstrated that self-efficacy and social support increased over the duration of patient participation in the clinical trials, meanwhile medication adherence improved over time regardless of whether patients were enrolled in the control or intervention group. ⁴ While healthcare support may not yield the same effectiveness as support from family and friends, it remains essential for healthcare providers to ensure patients receive necessary support. ³ Providers should educate patients on the significance of acquiring adequate support to enhance overall health and treatment adherence. Additionally, for patients lacking familial or social networks, healthcare professionals can guide them towards supportive resources and connect them with social workers.

Dementia

Poor social literacy can serve as a warning sign of cognitive impairment. ⁵ One of the initial manifestations of dementia is the withdrawal from social interactions, linked to a decline in the perception and comprehension of social cues and situations. A recent randomized controlled trial involving 250 elderly adults, participating in one-hour group discussions three times a week resulted in a statistically significant increase in brain volume observed through magnetic resonance imaging (MRI), along with improved performance in neuropsychological testing when compared to peers who did not engage in scheduled interactions. A systematic review and meta-analysis conducted by Evans et al., ⁶ examined the relationship between social isolation and cognitive function during later life. The study showed that social indicators demonstrated the strongest correlation with global cognitive measures and elements of social isolation are notably linked to diminished cognitive function in older age. Effect sizes suggest that maintaining a broad social network and participating in social activities contribute modestly yet significantly to averting cognitive decline in later life.

Mental Health

The necessity of social distancing during the COVID-19 pandemic highlighted adverse effects on mental health, leading to the hypothesis that social connections are vital for fostering positive mental health outcomes. Morina et al ⁷ conducted a meta-analysis examining longitudinal studies to explore the relationship between physical and mental health and social connections through variables such as social isolation, living alone, and loneliness. Their results suggest that insufficient social connections are linked to conditions including depression, social anxiety, psychosis, and suicidality. This study also found negative health outcomes towards other disease states including frailty, coronary heart disease, stroke, early mortality, malnutrition, hospital readmission in patients with heart failure, and vaccine uptake.

Positive Connections and Health Care Practitioners

Positive connections can be developed between health care practitioners—particularly pharmacists—and patients. Developing trust within our relationships is a key method for sustaining relationships, including those we have with the patients we treat. ⁸ This trust can be developed by encouraging our patients to practice self-efficacy through shared decision-making, supportive self-management, cultural competence, and personalized care. Increasing patient knowledge, skills, and confidence they have in disease management health education to include lifestyle modifications, nutrition, exercise, and stress management techniques.

While we are able to create these social connections with our patients, the data shows that this connection provides a weak influence on health outcomes and the true benefit comes from the connections and support of family and friends. As healthcare providers, we have the ability to encourage our patients to create and sustain these positive social connections outside of our offices and in social situations, even if it might seem daunting to our patients.

One of the most utilized methods of promoting patients to have behavior change including creating positive social connections is through motivational interviewing. ⁹ This method is a patient-centered approach that facilitates a process of self-discovery, prompting patients to delve into and develop their own motivations for change. It is important to highlight that motivational interviewing is particularly beneficial for patients who currently lack motivation to change. Motivational interviewing empowers patients to initiate changes aimed at fostering positive social connections through a joint effort between healthcare providers and patients, fostering self-exploration and decision-making. This approach aims to evoke intrinsic motivations for seeking positive social connections, developing confidence in their capacity to establish these connections, and employing empowering language while respecting the patient’s autonomy and contributions.

As time progresses beyond the initial intervention, the effectiveness of motivational interviewing diminishes, suggesting that transitioning to goal setting with patients could be advantageous for sustaining behavior changes and further enhancing positive social connections. ⁹ Patients should be directed towards formulating goals that aim to achieve their desired outcomes rather than eliminating undesired ones as this facilitates a more tangible assessment of success. Additionally, goals should strike a balance between being aspirational and realistically attainable to foster positive expectations and confidence in one’s ability to succeed. These goals should emphasize the gradual mastery of the process of forming new positive social connections, rather than adopting an all-or-nothing approach focused solely on immediate, ultimate outcomes. If patients are having trouble exploring goals of their own, some examples to explore include initiating conversations with at least one new person each week in a social setting, commit to attending one social gathering or event each month, dedicating time to volunteer for a cause or organization that is meaningful to you, join a group or a club related to a hobby or interest, make an effort to stay in touch with existing friends by scheduling regular catch-ups or phone calls, engage in acts of kindness to others, and focus on actively listening to others during conversations by asking open-ended questions and showing genuine interest in their perspectives. After patients have established goals to develop their connections, it is critical to support successful pursuit by guiding them to specify actionable steps and timelines for goal achievement, as well as preemptively addressing potential obstacles and devising strategies to mitigate their impact. Integral aspects of facilitating goal attainment include fostering automatic habits through consistent engagement in desired behaviors and encouraging patients to maintain focus on their overarching goal rather than fixating on individual obstacles.

Self-Monitoring

As a provider, it is impossible to constantly supervise and monitor every aspect of their journey towards achieving their goals. Therefore self-monitoring emerges as a potent method to motivate patients by taking an active role in fostering positive social connections offering them awareness, accountability, and motivation followed by the ability to adjust their behaviors based on feedback. ¹⁰ Patients are prompted to pay attention to their social interactions and the quality of their relationships. By tracking their social behaviors, they become more aware of their social habits and patterns and have the ability to recognize opportunities for improvement. This also holds patients accountable for their efforts to make and sustain positive connections. When patients monitor their progress towards social goals, they take ownership of their actions and a sense of responsibility and commitment to making meaningful connections is created. This also can serve to be a motivating tool as self-monitoring provides patients with tangible evidence that allows them to visualize their efforts and their progress. This evidence reinforces their motivation to continue making positive connections. While patients might feel inclined to withhold unhealthy behaviors or embellish healthy ones, providers should promote complete honesty to maximize the usefulness of their records. The last piece of self-monitoring comes from feedback; by reviewing their records, patients can identify patterns, trends, and areas of strength or weakness in their social interactions. This feedback enables patients to make informed decisions about the effectiveness of their strategies, thus enhancing their ability to make and maintain positive social connections.

Conclusion

Positive social connections is an important pillar within the lifestyle style medicines pillars. While there is some evidence published that shows the impact on a patient’s health and quality of life, gaps and opportunity for research regarding the role social connections have on medication adherence and overall outcomes with disease management remain. ³ Health care practitioners can find ways to help patients emphasize this aspect in their life by having conversations about what social connections are currently present and what possible options there can be for someone who does not have them. Tailoring recommendations to patients individually will be important as well considering positive social connections may look different to each person. Engaging in these conversations may open new ways to promote health and wellness in our patients.