In Bosnia and Herzegovina, social prescribing researchers form new connections

After a stroke, Mrs. B of the United Kingdom suffered impaired speech and physical abilities that led her to withdraw from her typical social circle, eventually just staying home. This isolation took a toll on her well-being until she was referred to a staff member at the Kent County Council, who encouraged her to become involved in community groups. Gradually, social participation boosted Mrs. B’s confidence and outlook until she was able to travel by rail to visit family and friends. She now leads workshops for other stroke survivors and collaborated with University of Kent researchers studying stroke recovery.  

The story of Mrs. B and others like her serve as case studies in a report on the Connected Communities project, a four-year study at Kent County Council and other sites in the United Kingdom and France that evaluated a 12-week social prescribing program for participants 64 and older. Social prescribing is a model of care in which a “link worker” or other entity with relationships to local community groups helps a person in need find activities aligned with their interests and goals.  

Proponents of social prescribing favor a holistic approach to care in which a person’s social needs are addressed as well as their medical needs. “Mental, physical and social health are all linked,” said University of Essex researcher Dragana Vidović, who was involved in the Connected Communities project. She and her colleagues found that over the 12-week period, social prescribing significantly reduced self-reported loneliness at three of the four research sites. 

The National Health Service has embraced social prescribing to reduce the negative societal and public health effects of loneliness. As part of their 2019 Long Term Plan, the agency committed to funding social prescribing so that every primary care system in the United Kingdom would have access to a link worker by 2024. Smaller social prescribing programs have been introduced in at least sixteen other countries, mostly in western Europe, east Asia and North America, including the United States. Now, Vidović believes the model could work in a very different context: her home country of Bosnia and Herzegovina. 

Vidović was raised outside of the city of Banja Luka in what is now the Republic of Srpska, the majority-Serb administrative entity within Bosnia and Herzegovina. The Republic of Srpska and the state’s largely Croat-Bosniak entity, the Federation of Bosnia and Herzegovina, were established at the end of the Bosnian War in 1995. 

Bosnia and Herzegovina remains disconnected from the international public health community 30 years after the war, says Vidović. “It’s taken a while to rebuild these links to the outside world.”

In years past, Vidović says, language barriers were a larger obstacle, but now organizational obstacles are the biggest hurdle. For example, the country is not a part of the European Union, so it is excluded from collaborative efforts among researchers in member states, such as the European Social Survey.  

To address this information gap, she and her collaborators at the University of Banja Luka published their own survey of loneliness in the Republic of Srpska last fall in the European Journal of Public Health. Over 10 percent of the 1231 survey participants reported sometimes or always feeling lonely. While this is lower than the 18 percent of respondents who said they never felt lonely, the researchers concluded that loneliness levels in the Republic of Srpska are about the same as in the United Kingdom, which has social prescribing initiatives in place.  

The authors also found that across all age groups, people who reported more loneliness were more likely to visit a general practitioner, and reasoned that social prescribing efforts could thus alleviate strain on the nation’s care system. In a recent survey of citizens in six Balkan nations including Bosnia and Herzegovina, over half of respondents expressed distrust in either the private or public sector of their country’s health system. Bosnian participants were the most likely to report a negative experience with a health care provider in the past year. 

Vidović and her colleagues cite the Banja Luka With a Human Face initiative as a potential model for social prescribing measures in Bosnia and Herzegovina. This program organizes free group activities for children and adolescents, people with disabilities and elderly people. While its focus is social participation rather than loneliness, the program coordinated efforts between community organizations, governmental departments, and the health and social service sectors. Vidović says this level of mobilization is needed for a social prescribing program to work. 

Evidence from the United Kingdom highlights difficulties in implementing social prescribing programs. A small 2024 study of link workers, beneficiaries, NHS employees and other stakeholders identified challenges such as information technology integration, awareness of social prescribing among patients and general practitioners, adequate pay and training for link workers, and the need for sectors to communicate without compromising patient privacy. 

Such an organized effort could be a challenge in Bosnia and Herzegovina, which Vidović notes has an “expansive” bureaucracy across the country’s two administrative entities, as well as throughout other levels of government. However, she anticipates that the greatest challenge in implementing a social prescribing program in the country will not be coordinating between the two entities but bridging what she sees as a stark urban-rural divide in resources and capacity. 

Furthermore, critics argue the theoretical benefits of social prescribing are not yet supported by sufficient real-world data. A 2017 review of social prescribing research characterized existing studies as containing serious design flaws that compromise their value, such as not following up with participants over a long enough period and failing to compare results to a control group that did not receive the social prescribing intervention.  

Social psychiatry professor Rob Poole of Bangor University in Wales says adoption of the model has outpaced the evidence because social prescribing offers policymakers a feel-good fix that elides more stubborn inequalities, which he argues are at the root of poor health outcomes. Social prescribing is “an appealing idea to many people because it also allows politicians to address the social determinants of health without making any structural changes to society,” he says. 

Poole notes that the kinds of recreational activities promoted through the model are harder to access for people from poor or otherwise disadvantaged backgrounds. For instance, a patient advised to increase outdoor physical activity must find time and a safe environment to experience these benefits. In the 2024 survey of social prescribing stakeholders in the United Kingdom, one participant described frustration with the cost of transportation to the program’s services, especially as they struggled with the cost of living overall. 

Poole believes patients can benefit from social activity, but that more effective change would come from a fundamental transformation of a state’s economic and health care systems. Still, loneliness is a mounting public health concern worldwide that demands action even in the face of structural inequalities.  

One longitudinal study of older adults in the United States found that higher levels of loneliness were associated with a shorter total life expectancy by more than three years. Isolation may also be driving doctor visits beyond a person’s underlying health needs. Another United States study found that loneliness in older adults predicted greater use of physician services, but not necessarily greater hospitalizations. 

Along with their research, Vidović’s coauthor Strahinja Dimitrijević of the University of Banja Luka established a new course on loneliness at his institution, which Vidović says is the only curriculum of its kind in the region. 

Mental health is “really not taken seriously” in Banja Luka, says an undergraduate student in Dimitrijević’s course, who wished to remain anonymous as she spoke about her struggles with mental illness. An aspiring psychology researcher, her interest in the field is informed by her personal background, which includes a history of suicide attempts and panic attacks. In her experience, while private clinics are often too expensive for the average worker, local public mental health services are overbooked. She describes a “national mental health crisis” during the COVID-19 pandemic as appointments were even harder to come by, a challenge she says persists to this day. 

A successful social prescribing program could reduce pressure on this system while reinvigorating community organizations. In another case study from the Connected Communities project, another participant from Kent reignited his love of photography and videography through his contact with Screen South, a local digital media organization. He in turn created promotional materials for local social group Men’s Shed, driving growth in membership. In the Republic of Srpska, such an effect could further the goals of the Banja Luka with a Human Face program, increasing civic engagement. Given the challenges in developing a social prescribing program, this day is likely still far away.