Can an ecological-transactional systems model in occupational therapy contribute to a social prescribing programme?


Purpose
The spread and level of loneliness is today considered a public health issue. Attempts to promote or reduce the level of loneliness have been made, one of which is social prescribing (SP), developed and extensively used. Complex interventions such as SP are advised to be connected to theory.


Design/methodology/approach
For this purpose, the Person-Environment-Occupation-Participation model (PEOP) will be reviewed and used as an example, both as a way of organize occupational knowledge and as a model for practice.


Findings
Occupational therapy underpinned by transactional system theory such as the PEOP model seems to give comprehensive and relevant support in the SP process. Particularly, this model can guide practitioners through crucial phases when assessing needs, matching interests and goals with relevant occupations, as well as understanding of important components embedded in the program.


Originality/value
This opinion piece offers insights in why and how specific components connected to SP needs to be understood by theory and applied by personnel to facilitate a meaningful and sustainable occupational performance for the individuals.



Introduction
SP is a treatment model aiming at reducing loneliness by facilitating individuals to engage in social occupations. Enabling social participation is among other occupational related participatory initiatives, the core of our occupational therapy profession. As such, in this opinion piece we argue that occupational therapists guided by theory should be the obvious team player to frame SP initiatives into a more person-centred pathway to facilitate a more sustainable occupational engagement and participation.
Social participation is considered to be a vital part of daily life for all people, especially among older adults, and is related to aspects of health and well-being (Levasseur et al., 2015). Research indicates that some groups of older adults report a high level of loneliness (Nyqvist et al., 2017;Dahlberg et al., 2015) and loneliness are closely connected to social engagement (McHugh Power et al., 2019;Zhang et al., 2018). The spread and level of loneliness is today considered a public health issue.
SP programs are described to be a non-medical referral when health professionals link patients to support in the community to counteract complex social problems, i.e. loneliness and improve health and well-being (Bertotti et al., 2018). The referral mechanisms and service offered through the programs vary across settings, target groups and time (Chatterjee, 2017). Nevertheless, the process usually involves screening for nonmedical needs and referrals to social activities offered by community-based organizations and supported by a coordinator (Bickerdike et al., 2017;Kimberlee, 2013). The coordinator has the challenging task of understanding the needs of the client, and from that, acting as a bridge between primary care professionals and the panoply of social opportunities. Although, SP programs are using occupations to support health and well-being, occupational therapists have not actively engaged in this initiative to diminish a major societal and occupational problem (Thew et al., 2017) despite their unique competence as agents for change . As such, we challenge the effect of "one size fits all" programs of SP, but instead more accurately person-centred programs tailored to individuals in need should be promoted. This justifies why occupational therapists and occupational therapy theory could enrich SP programs.
We in-line with others (Fixsen et al., 2020;Savage et al., 2020) argues that a theoretical foundation is requested in SP programmes. As a first step, theorization could offer insights in how to organise knowledge and facilitate a meaningful and sustainable occupational performance during the process of SP. Thus, as suggested (Ikigugu et al., 2019) a theoretical conceptual practice model that can guide reasoning and inform therapeutic decisions seems to be needed. Secondly, this kind of model can support and explain the intended outcome of the program as well as be used as a tool for guiding clinicians. Thirdly, underpinning a clinical program with a theoretical conceptual practice model also has a potential for guiding future studies.
Particular phases in the SP process have been described as crucial for success, i.e. facilitation of sustainability in occupational engagement and participation: the occupations prescribed match the patients' needs and expectations; occupations prescribed are accessible for the person; and participation is initially supported in an adequate way (Husk et al., 2019).
These phases seem to be a fundamental area of expertise for occupational therapists, but how can they be fully understood and informed by theory?

Application of theory
For this purpose, the PEOP model  will be reviewed and used as an example to outline how to organize knowledge relevant to the occupational performance needs of humans, as well as inform how the knowledge can be used to facilitate a sustainable engagement in meaningful social activities. The PEOP model is designed to support occupational therapists in collaboration and work with their clients in addressing occupational performance issues . Our attempt in this manuscript to underpin SP in Sweden (SPiS) with theory would be in line with the Salford SP Hub¨s emphasis on the need for updating theoretical underpinnings of SP practice (http://hub.salford.ac.uk/ssph/).
The PEOP model should be considered as an ecologicaltransactional system model (Baum et al., 2015) emphasizes a client-centred approach and recognise the importance of collaboration with the client that includes significant others just like the SP process indicates. The client-centred approach is significant to match the individual with relevant and valued occupation of their own choice in the prescribing process, accordingly we can use the PEOP model as a guide. The PEOP model would suggest us to collect and analyse the client's capabilities within identified important dimensions of the person ,e.g. intrinsic. By analysing the personal dimensions (psychological, physiological, cognitive) we can truly understand the individual's capabilities, his or her strengths and limitations in performance of occupations. The assessment of a person's needs and capacity is crucial in the SP process (Wildman et al., 2019;Husk et al., 2019;Heijnders and Meijs, 2018) and the PEOP model as a theoretical conceptual model support with comprehensive guiding. Through this analysis the first phase of the matching procedure is grounded in an occupational-based framework.
Furthermore, to fully understand a client's prerequisite for the occupational performance and participation, information about extrinsic or environmental factors and also the demands of specific tasks need to be collected. These factors incorporate aspects e.g. your culture, values but also the welfare system and social support around you. The PEOP model emphasizes environment resources in terms of whether they enable or act as a barrier to performance (Christansen et al., 2015). This might include e.g. living in urban or rural settings, being able to cover costs for activities, having access to culturally relevant activities, access to support through social network. Through a structured analysis of barriers and enablers guided by the PEOP model, regarding the personal capabilities, values, interests and the environments demand, informed practitioners can be guided in how to introduce and support the individual's participation in the prescribed occupation. This last step is crucial for practitioners to fully understand the complex comprehensive picture of the individual's ability to engage in desired occupations. We argue that it¨s this step in SP, the matching, which is the core in our profession. Guided by PEOP, our occupational lens combined with our theoretical transactional view of how occupational engagement affect health and wellbeing within the individual in their environment, we can facilitate a sustainable engagement emerging from the individuals own choice of meaningful purposeful valued occupations. In addition, tailoring of the support for occupational engagement as outlined in the PEOP should be supported by the analysis of the fit between the patient's interests and goals, unique intrinsic factors, and contextual extrinsic factors. Thus, we can conclude that facilitated by the PEOP model, a successful matching and tailored support can be achieved by emphasizing the interaction between the person, the environment and the structure of the task. Unless an indepth initial assessment, matching and tailoring of relevant support for occupational engagement is carried out in a structured way guided by PEOP, the core idea of SP might fail.

Conclusion
The PEOP as an ecological-transactional system model can emphasize guidance towards behavioural change through the use of client-centred and occupation-based strategies that engage individuals in valued occupations. Therefore, as SP relies on engagement in occupation as intervention and with behavioural change as the outcome, we argue that occupational therapy is significant and should be actively involved to inform the work with SP. The project SPiS is developing its structure inspired by the PEOP model (see Figure 1) and will continue to study the effectiveness of such an initiative (Johansson et al., 2021), an initiative where occupational therapists have an active role in the prescription process and play an important part of the primary health-care team.
To conclude, we argue for the urgent need of theoretical underpinning to account for how complex interventions such as SP works, for whom and why, to guide further implementation (Tierney et al., 2020) and to facilitate a sustainable, meaningful and client-centred occupational performance for the individuals in need.