There is growing interest in green social prescribing and connecting with nature-based activities to promote social cohesion along with improving levels of health, wealth and well-being. The Outdoor Partnership is a third sector organisation based in North Wales offering nature based social prescribing interventions. Individuals experiencing poor mental health and wellbeing are referred from GPs, community mental health services, and third sector organisations to the ‘Opening the Doors to the Outdoors’ (ODO) programme which is a 12-week outdoor walking and climbing green prescribing intervention. The purpose of the ODO programme is to provide a supportive environment to increase levels of physical activity among participants leading to improvements in overall health and mental wellbeing while promoting socialisation among peers. In this evaluation of a preventative green social prescribing intervention, a mixed method social return on investment (SROI) approach used quantitative and qualitative data from ODO participants. Data collection took place from April 2022–November 2022. Mental wellbeing data was collected at baseline and at 12 weeks using the Short Warwick Edinburgh Mental Wellbeing Scale, a social trust question, an overall health question, and the International Physical Activity Questionnaire- short form. Baseline and follow-up data was available for 52 ODO participants. Results indicate that for every £1 invested in the ODO programme, social values ranging from £4.90 to £5.36 were generated.

The COVID-19 pandemic contributed to longer waiting lists for people seeking to access mental health services. The NHS Five Year Forward View encourages the development of empowerment-based social prescribing interventions to supplement existing mental health programmes. Based in South Wales, EmotionMind Dynamic (EMD) is a lifestyle coaching programme that supports individuals suffering from anxiety or depression. In this evaluation of lifestyle coaching, a mixed-method social return on investment (SROI) methodology was used to value quantitative and qualitative data from face-to-face and online participants. Data collection took place between June 2021 and January 2022. Participants included both self-referred clients and those referred from health services. Mental wellbeing data were collected at baseline and at the end of the programme using the short Warwick–Edinburgh Mental Wellbeing Scale (SWEMWBS) and the General Self-Efficacy Scale (GSES). Baseline and follow-up data were available for 15 face-to-face participants and 17 online clients. Wellbeing valuation quantified and valued outcomes from participants. Results indicated that for every GBP 1 invested, lifestyle coaching generated social values ranging from GBP 4.12–GBP 7.08 for face-to-face clients compared with GBP 2.37–GBP 3.35 for online participants. Overall, lifestyle coaching generated positive social value ratios for both face-to-face and online clients.

Background: A social prescribing (SP) link worker (LW) is responsible for enabling and supporting individuals, by assessing their personal goals and co-producing solutions to make use of appropriate local non-clinical resources or interventions. As an emerging new role, LWs are not regulated by professional bodies associated with SP. Therefore, currently there is no standardised training for LWs who are from varied backgrounds. As such, LWs have varying knowledge about how to deal with individuals with complex needs, which can impact on their decision-making capabilities to seek solutions and navigate complex systems. The purpose of the research was to explore LWs’ level of education, past and current training requirements as well as elicit how much LWs were willing to pay (WTP) to access and undertake training to improve their skill set. Methods: A rigorous mixed method research design was employed which included semi-structured interviews with key stakeholders and quantitative questionnaires including contingent valuation (CV) questions to a population of LWs across Wales from March to June 2020. Qualitative interviews with key stakeholders who commission and deliver social prescribing interventions employing LWs identified perceived link worker qualities and requirements for LW roles. Purposive sampling was used to identify and select individuals that have experience in managing LWs. Due to the COVID-19 pandemic, interviews were carried out exclusively online. LWs self-selected to complete the online questionnaires. Questionnaires gathered data on LW qualifications and demographic information with the CV questions gathering data on the value LW placed on accessing training in SP. Thematic narrative analysis was applied to interpret the data from the semi-structured interviews. Descriptive frequency analysis was conducted on the quantitative data generated from the online questionnaire. Findings: SP coordinators (n = 6) reported that ‘personal skills’ are the most essential skills required by LWs in SP intervention. Training is available for LWs; however, the training undertaken varies depending on the type of intervention delivered, with 70% of LWs previously undertaking training to facilitate their development as an LW. The results from the contingent valuation questionnaire (n = 54) indicated that 100% of the respondents would avail of training. LWs were asked how much they were willing to pay as a single payment for professional training; on average, LWs were WTP GBP 58 from their personal funds to access training and the associated benefits to enhance their skills and knowledge. Interpretation: The semi-structured interviews conducted with the key SP stakeholders yielded rich information and novel insight into LW training. External funding for the salary of the LW is an obstacle for LW development through training. In addition, the questionnaire results regarding stated preference techniques demonstrate that LWs place value on their professional development and would be willing to spend their own money on training to improve their knowledge and skills.

Previous research has categorised symptoms of COVID-19 / Long COVID into 12 thematic areas including: fever, myalgia, fatigue, impaired cognitive function, and that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life. Our aim was to review the evidence for interventions or best practice to support people with Long COVID, or similar post-viral conditions characterised by fatigue, to return to normal activities. Evidence was included from guidelines, systematic reviews (SR), and primary studies. The primary studies focussed on Long COVID (LC) indicated that there should be a needs-based focus to care for those with LC. Consideration should be given to individuals living with LC in the same way as people with disabilities are accommodated in terms of workplace adjustment. Two SRs indicated that non-pharmaceutical interventions (NPIs) for patients with LC or chronic fatigue syndrome could help improve function for activities of daily life. However, the third, most recent SR, concluded that there is a lack of robust evidence for NPIs. LC fatigue management methods may be beneficial under certain conditions. One SR reported work capability as an outcome however they did not find any studies which evaluated the impact of interventions on return to work/ normal life. One primary study, on individuals with CFS, described a written self-management programme. Following this intervention there was an 18% increase in the number of patients in employment. Policy and practice implications: Long COVID is still being established as a post-viral condition with many symptoms. Patient-centred treatment options such as occupational therapy, self-management therapy and talking therapy may be considered in the same way as for other debilitating conditions. Return-to-work accommodations are needed for all workers unable to return to full-time employment. Due to the nature of the studies included, there was little reported evidence of effectiveness of getting individuals back into their normal activities. Funding statement: The Bangor Institute for Health and Medical Research was funded for this work by the Wales COVID-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government. Rapid Review Details: Review conducted by: Bangor Institute for Health and Medical Research (BIHMR), Bangor University. Review Team: ▪ Dr Llinos Haf Spencer, l.spencer@bangor.ac.uk ▪ Dr Annie Hendry, a.hendry@bangor.ac.uk ▪ Mr Abraham Makanjuola, a.makanjuola@bangor.ac.uk ▪ Ms Bethany Fern Anthony, b.anthony@bangor.ac.uk ▪ Mr Jacob Davies, jacob.davies@bangor.ac.uk ▪ Ms Kalpa Pisavadia, kalpa.pisavadia@bangor.ac.uk ▪ Professor Dyfrig Hughes, d.a.hughes@bangor.ac.uk ▪ Professor Deb Fitzsimmons, d.fitzsimmons@bangor.ac.uk ▪ Professor Clare Wilkinson, c.wilkinson@bangor.ac.uk ▪ Professor Rhiannon Tudor Edwards, r.t.edwards@bangor.ac.uk Review submitted to the WCEC on: 11 January 2023 Stakeholder consultation meeting: 8 ^th November 2022 Rapid Review report issued by the WCEC in: January 2022 WCEC Team: Adrian Edwards, Ruth Lewis, Alison Cooper and Micaela Gal involved in drafting the Topline Summary and editing. This review should be cited as: RR00042_ Wales COVID-19 Evidence Centre Disclaimer: The views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest. TOPLINE SUMMARY: What is a Rapid Review?: Our rapid reviews (RR) use a variation of the systematic review (SR) approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting RR, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1 to 2 months, depending on the breadth and complexity of the research topic/question(s), extent of the evidence base, and type of analysis required for synthesis. Who is this summary for?: Policymakers in Welsh Government to plan and deliver services for individuals with Long COVID as they re-enter training, education, employment, and informal caring responsibilities. Background / Aim of Rapid Review: Previous research has categorised symptoms of COVID-19/Long COVID into 12 thematic areas including: fever, myalgia, fatigue, impaired cognitive function, and that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life (Amdal et al., 2021; de Oliveira Almeida et al., 2022). NICE guidelines highlight the impact of the condition on quality of life and the challenge of determining best practice based on the current evidence (National Institute for Health and Care Excellence et al., 2022). Treatments for other post-viral syndromes may also apply to people living with Long COVID (Wong and Weitzer, 2021). Our aim was to review the evidence for interventions or best practice to support people with Long COVID, or similar post-viral conditions characterised by fatigue, to return to normal activities (including return to the workforce, education, childcare, or housework). Key Findings: Evidence was included from guidelines (n=3), systematic reviews (SRs) (n=3), and primary studies (n=4). Extent of the evidence base: ▪ Two SRs included non-pharmacological interventions for Long COVID or post-viral syndromes, including Long COVID (Chandan et al., 2022; Fowler-Davis et al., 2021). The remaining SR focused on interventions for Chronic Fatigue Syndrome (CFS). ▪ The four primary studies were conducted in the UK, USA, Norway, and Turkey. The SRs included studies from across Europe, Asia, Africa, and Australasia. ▪ Included SRs and primary studies evaluated non-pharmaceutical interventions, including fatigue management, exercise therapy, Cognitive Behavioural Therapy (CBT), workplace support, self-management, sleep therapy, music therapy, and counselling. ▪ Two relevant guidelines were identified for Long COVID and one for ME/CFS. The Long COVID guideline was aimed at employers, and the ME/CFS guideline was aimed at service providers and users. Recency of the evidence base: ▪ Included papers were from 2014 to 2022. Evidence of effectiveness: ▪ The primary studies focussed on Long COVID indicated that there should be a needs-based focus to care for those with Long COVID (Lunt et al., 2022; Skilbeck, 2022; Wong et al., 2022). Consideration should be given to individuals living with Long COVID in the same way as people with disabilities are accommodated in terms of workplace adjustment (e.g. part-time hours, working from home, or hybrid working). ▪ Two SRs indicated that non-pharmaceutical interventions for patients with Long COVID or CFS could help improve function for activities of daily life (Fowler-Davis et al., 2021; Larun et al., 2019). However, the third and most recent SR concluded that there is a lack of robust evidence for non-pharmaceutical interventions (Chandan et al., 2022). ▪ Long COVID fatigue management by exercise therapy, electrical nerve stimulation, sleep and touch therapy, and behavioural self-management may be beneficial when: physical and psychological support is delivered in groups, people can plan their functional response to fatigue, strengthening rather than endurance is used to prevent deconditioning, fatigue is regarded in the context of an individual’s lifestyle and home-based activities are used (Fowler-Davis et al 2021). ▪ One SR (Chandan et al 2022) reported work capability as an outcome however they did not find any studies which evaluated the impact of interventions on return to work/ normal life. ▪ One primary study concentrated on individuals with CFS (Nyland et al., 2014). Nyland et al. (2014) described a written self-management programme featuring active coping (with CFS) strategies for daily life. Following this intervention, there was an 18% increase in the number of patients in employment (from baseline to follow-up) (Nyland et al., 2014). Best quality evidence: ▪ The three SRs (Chandan et al., 2022; Fowler-Davis et al., 2021; Larun et al., 2019) were of high quality, as was one of the cohort studies (Lunt et al., 2022). Policy Implications: ▪ Long COVID is still being established as a post-viral condition with many symptoms. The Welsh Government may seek to consider patient-centred treatment options such as occupational therapy, self-management therapy and talking therapy (such as Cognitive Behavioural Therapy) in the same way as for other debilitating conditions including ME/CFS. ▪ Return-to-work accommodations are needed for all workers unable to return to full-time employment. ▪ Due to the nature of the studies included, there was little reported evidence of effectiveness of getting individuals back into their normal activities. Strength of Evidence: Confidence in the findings is low. Only four primary studies reported outcomes relating to work capacity and return to normal activities such as childcare and housework.