Despite the absence of a widely accepted definition, social prescribing (SP) generally refers to the enablement of health care professionals to refer a patient or client to a social prescriber (eg, link worker, community connector, community navigator, health coach, health trainer, and so on). The social prescriber is responsible for the co-design of interventions to improve the individual’s health and well-being [1]. Once seldom acknowledged, or at best, paid “lip service,” social and behavioral determinants of health are now becoming increasingly more recognized as centrally critical to the provision of effective person-centered intervention in clinical practice and disease management [2]. Accordingly, a spate of SP-based interventions have been reported in recent times, including those from the United Kingdom and Americas [3], Scandinavia [4], and Australia [5,6]. Despite a paucity of definitive evidence regarding SP, benefits cited include improvements in health behaviors, mental health, and reductions in the use of tertiary care facilities for lifestyle diseases [1,7-10].

Obesity, one of the more prominent contemporary lifestyle-related diseases, has reached pandemic proportions globally and shows no signs of abating [11,12]. Consistent with global trends, the prevalence of obesity in Australia has increased in the past few decades, with 63.4% of adults and 27.6% of children with overweight and obesity in 2014-2015 [13]. If left unchecked, adult obesity and rates of severe obesity in Australia are predicted to reach 35% and 13%, respectively, by 2025 [14]. A further complication is that people living in geographically remote parts of Australia have a disproportionately higher prevalence of obesity. For instance, adults from regional (1.53 times higher) and rural areas (1.32 times higher) were more likely to have obesity than their counterparts from major city or urban areas [15]. Obesity also disproportionately affects low socioeconomic communities with a greater disease burden [16]. Tasmania, as a regional state with low socioeconomic status, has some of the highest rates of adult and childhood obesity and requires urgent intervention.

The rampant global prevalence of obesity is also an indication that the prevailing, disease-oriented biomedical approach to health service delivery is inadequate/ineffective at arresting the spread and mitigating the damaging consequences of the condition [17]. There is an urgent need to shift the focus from reactive disease-based treatments to incorporate some consideration of how individuals and communities are influenced by a growing global, regional, and local interdependence and an increasingly complex array of interlinking factors. Accordingly, more proactive, upstream, preventive efforts, and action to improve health and reduce obesogenic factors are required to arrest the increasing prevalence of obesity [18]. In essence, this requires a paradigm shift from the traditional “biomedical approach of care,” wherein the cause of illness is primarily thought to reside in the body, to a “biopsychosocial model,” which provides a basis for understanding the broader determinants of disease to arrive at treatment and service response plans [19].

Recent evidence from whole-of-community approaches anchored in systems science principles holds some promise in denting the harmful impact of obesity [20-22]. Dynamic systems theory posits that biological, social, and contextual factors interact in dynamic ways to influence health and participation across the lifespan [18]. Bronfenbrenner person-centered ecological framework allows the varied interactive interpersonal dynamics that influence development (and therefore health and obesity) to be examined [23]. At the center of the system, the individual brings their own unique characteristics, such as their age, genetics, life experiences, temperament, and coping strategies, and other familial, social, economic, and political layers of influence that sit around them [23]. Fundamentally, effective whole-of-system approaches are not limited by predefined agendas; instead, they are reliant on localized community input for context-specific, holistic, preventive work that acknowledges the synergistic interaction of a myriad of biological, social, economic, and environmental factors [24]. This approach has a commonality with effective SP interventions [25]. Following this logic, a community-driven SP approach could be just as effective in obesity prevention as any other initiative anchored in systems thinking. Herein, we discuss an SP protocol aimed at obesity prevention in Circular Head, a local government area (LGA) in Northwest (NW) Tasmania.

It is imperative that SP models undergo rigorous evaluation using systems science approaches and mixed methods research to ensure understanding of what worked, why it worked, and in what contexts. A multimethod approach to triangulate insights from quantitative and qualitative research that enables the assessment of impact on individuals, community groups, and the health care system will be implemented within the initial 3-year pilot phase of the project. For instance, a range of health and well-being and health care usage outcomes will be measured (Figure 5) to evaluate the efficacy of the SP program. Evaluation will include a review of implementation efforts, project impacts, plans for sustainability, and feedback from participants, educators, administrators, and stakeholders.

Given traditional evaluation tools are often ill-suited for co-design work in community settings, we intend to use a ripple effects mapping approach, a participatory technique to engage stakeholders in visually mapping project efforts and results to collect impact data [44]. Specifically, focus group techniques to work with participants to process and reflect on their lived experiences and collectively and visually map project efforts and results. We envisage that the use of mapping will trigger verbal responses, increase the frequency and depth of responses, and aid participants in recalling, organizing, and reflecting on experiences. It is intended that a series of modified nominal group technique (mNGT) consensus method group processes will be executed annually to evaluate progress. The core steps (silent generation, round robin, clarification, and voting [ranking and rating]) [45] of the mNGT approach will facilitate collaborative decision-making and, importantly, enhance equitable participation of stakeholders. Where possible, the progress of key components will also be compared against the 5 pillars (a common agenda, shared measurement systems, mutually reinforcing activities, continuous communication, and backbone support organizations) of the “collective impact” framework [46].

Exact details of the outcome measures will be decided in consultation with the community, as their suitability will be based on nature of referrals, prescribed activities, participant needs, and resourcing. Nevertheless, in line with the popular approaches in contemporary SP initiatives, it is envisaged that a mix of subjective well-being, quality of life, behavior change, physiological changes, frequency of health service access, medication usage, and development of social networks will be measured either quantitatively or qualitatively [43,47]. In addition, where practicable, the social return on investment will also be measured using contextually appropriate inputs [48,49].

This proposal describes a diverse approach for primary prevention of obesity-related lifestyle diseases and strategy for improvement of future health and well-being in a remote and socioeconomically disadvantaged population. The SP approach anchored in systems thinking described above could be an effective means of moderating prevalence and consequences of obesity at a community level. Key focal points of this intervention include peer education, health screening, service accessibility, workforce connectivity, food literacy, better nutrition, physical literacy, habitual PA, mental health, social isolation, and community connectedness. The Circular Head Health and Well-being Coalition will be established to address health and well-being inequities affecting people in the region. This collective will be responsible for providing direction for the implementation of the whole-of-community Circular Head Health and Well-being Strategy, broadly based on principles of SP.

As per the global accord in contemporary times, Australia also has a health care system that has a treatment-oriented and reactive bias. For instance, the extant 31 Primary Health Networks of Australia that prioritize mental health, First Nation people’s health, population health, health workforce, digital health, aged care, and alcohol/drugs are fundamentally designed for “commissioning of health services” for consumers with diagnosed conditions. Further, Australia is one of the lowest spenders on preventive health (~2 billion per annum; ~1.5% of the total health budget; ~US $89 per person every year) among the Organisation for Economic Co-operation and Development nations such as Canada, the United States, and New Zealand. This is despite public health research consistently indicating that most preventive health interventions are cost-effective (mainly through cost reductions in treating complex conditions), improve quality of life and longevity, and minimize the burden on the health care system as a whole [50]. Therefore, considering the urgency of obesity prevention and health intervention in Circular Head, the SP approach we describe is both timely and necessary.

The effectiveness of an SP initiative may also rely on the collective buy-in from the wider stakeholder group, including, most importantly, the community members. As such, consistent and frequent education regarding the nature and benefits of the program from inception to conclusion will be vital. Further, expansive networking and development of governance structures that entail strong leadership from all stakeholder groups is also of utmost importance. The whole-of-systems approach proposed in this research with SP as the central tenet is expected to address all of the above and improve community cohesion, social engagement, reciprocity in peer support, and community confidence in accessing pertinent resources for improving health and well-being outcomes. Community ownership of public health initiatives has shown significant promise in other settings [51-54], with a satisfactory compromise between community lived experience and contemporary scientific evidence being the key driver of success.

Translation of lifestyle disease–related research findings into sustainable practice is a public health priority. However, existing research indicates that this transition is largely ineffective due to limitations such as insufficient scaling-up for systemwide integration and lack of emphasis on the nonlinear and complex overlapping of various (development, implementation, sustainment, etc) program stages [55-57]. Much of the existing evidence base being underpinned by linear models of cause and effect is also exacerbating this issue. The whole-of-systems approach of the CAPITOL Project, along with 3 years of preliminary work [58-60] and early and frequent engagement of stakeholders in all aspects of project planning, is expected to elicit maximal translatory potential of the current SP initiative. Further, community-wide, representative consultation and equity in decision-making and agenda setting is also considered best practice in this line of intervention [53].

This proposed SP approach can have several limitations. Despite the potential benefits, a robust and generalizable protocol for satisfactory data collection and evaluation of any SP protocol will be challenging. For instance, given the inherent heterogeneity of designs in SP initiatives [61], it is not feasible to gain a wider consensus on the most appropriate outcome measures [62]. Further, nonlinearity of SP initiatives and the inevitability of multiple, fleeting, and intersecting components can also exacerbate this complexity [63]. Consequently, we posit that a realist approach, which acknowledges a set of context-specific outcomes (both biomedical and social determinants) of importance, will yield the most effective SP system in any given setting. As the outcomes will be reliant on local contextual factors, the generalizability of the findings will also be limited and might not be particularly applicable outside of the area under study. Further, any number of commonly reported practical challenges to generating evidence around SP, such as forging collaborative relationships while maintaining researcher independence, lack of a control group for outcome comparison, accuracy of health and social care service usage data, sustained resourcing, and consent and privacy matters, can also be relevant in this instance [64].

The need for complex processes and outcomes that drive change within a whole system and the necessity of doing away with linear approaches to mitigating complex public health issues has been echoed consistently in recent times [65]. Nevertheless, the practicalities of real-life implementation of whole-of systems approaches are ill-defined. This proposal describes a practicable set of approaches for stakeholder engagement and community participation in uplifting health and well-being standards in a locality with poor socioeconomic and health outcomes.

The Tasmanian Charter of Health Rights and Responsibilities states the following:

The proposed SP initiative will provide a viable opportunity to the residents in Circular Head to have a real-life, at scale attempt to co-design a sustainable solution to their health and well-being challenges while inculcating democratic partnerships between all project members as collaborators through every stage of the project. Further, the proposed program will help to increase access to peer and other support workers able to assist community members to navigate the system and receive adequate, timely, and situational support—a need frequently highlighted in the region [66].