Social prescribing for Not in Employment, Education or Training (NEET) young people: A realist evaluation of the C.O.P.E. project in Italy and Portugal

Funding Information: NEET (Not in Employment, Education, or Training) status is associated with psychological distress and suicidality. Social prescribing may offer a policy solution to this. To test this proposition, this study evaluates the mental health outcomes of a social prescribing intervention\u2014C.O.P.E. (Capabilities, Opportunities, Places, and Engagement) project\u2014on young people in a NEET situation in Italy and Portugal. Adopting a realist evaluation approach, this study explores how context and mechanisms interact to generate outcomes. A realist synthesis of NEET interventions and co-production with stakeholders helped to create a programme theory which was tested through a mixed-methods study, combining quantitative cohort data from 416 young people with qualitative interviews with 30 young people, 13 link workers, and 9 team members. The findings indicate significant improvements in mental wellbeing and reductions in psychological distress, particularly among those with clinical mental health issues. Qualitative insights emphasise the importance of trust between link workers and young people, highlighting flexibility, emotional support, and a holistic approach as key factors in fostering engagement. This led to the creation of three programme theories. One of these focuses on young people and is discussed in this article. The study concludes that despite some challenges related to sustainability, training and long-term impact, social prescribing can be an effective tool for supporting youth in a NEET situation, particularly those suffering clinical mental health issues. This paper contributes to the growing evidence supporting social prescribing as an approach to enhance mental health and social inclusion for youth in vulnerable situations.Multifaceted explanations have led to diverse classifications of NEET based on young people specific status. Eurofound (2016), for instance, created seven different groups including re-entrant, short-term unemployed, long-term unemployed, illness/disability, family responsibilities, discouraged and other statuses. Given this diverse classification, a major policy challenge is to design interventions and services capable of engaging all these young people. When young people in a NEET situation are inactive and socially marginalised, they often experience high levels of disengagement from social systems and related services (Bacher et al., 2014). A recent study found that youngsters who remain in the 'NEET trap' are doubly disadvantaged, not only in terms of suffering socioeconomic exclusion but also in missing out on the potential benefits of an early mental health intervention (Maraj et al., 2019). From a policy perspective, support for these young people appear to require a multifaceted approach that starts with recognising their different characteristics and challenges and seeking ad-hoc solutions for each group of young people in a NEET situation.Social prescribing offers a potential practical solution to this as the young person can receive ad-hoc support from a link worker who can connect the young person to a wide range of either services or organisations, primarily delivered by the Voluntary, Community and Social Enterprise (VCSE) sector but sometimes also involving the public and private sectors. If it works well, it focuses on engaging young people to define their needs and aspirations and to build their self-esteem, thus encouraging them to take the first steps towards employment, training, education, socialisation or health and wellbeing (Jarvis and Mitchell, 2024).Although systematic reviews have concluded that the evidence used to assess the effectiveness of social prescribing needs to be more rigorous (e.g. Napierala et al., 2022), growing evidence shows that social prescribing for adults has a beneficial impact, particularly on mental health. Social prescribing literature more specifically focused on children and young people shows that although good quality evidence is currently limited, it has shown improvements in mental wellbeing (Bertotti et al., 2021; Hayes et al., 2023; Rice, 2023). A rapid evidence review (Hayes et al., 2023) noted benefits in personal and mental well-being, including reductions in loneliness, particularly for young people aged 17 and over. However, they cautioned that the evidence base remains limited and called for more robust research with larger, representative samples. The same research also showed that community-based services can be less stigmatising, and act as a buffer whilst waiting to attend more formal mental health support. Finally, policy reports have stressed the potential of social prescribing as an early intervention tool, particularly in reducing barriers to accessing mental health support (Barnardo's, 2023). The only research specifically focussed on social prescribing and young people in a NEET situation draws on the same project (i.e. COPE, see below) that have been used for this article. This is the recent work by Farina et al. (2025) who have explored the role of social prescribing in supporting vulnerable young people in NEET situations through a service ecosystems approach, highlighting the importance of co-creation in interventions targeting this group.Social prescribing differs from other statutory services: (i) it is not predicated on any health or social services' specific agenda; (ii) it offers a flexible number of sessions; (iii) it aims to tackle one's problems by maximising their assets rather than focusing on their needs; (iv) it focuses on listening and empathy which builds trust; and (v) it engages the assets of the third sector which has key capabilities to support specific groups from different cultural, ethnic, and social backgrounds. As social prescribing has been variedly defined (Muhl et al., 2024), it is important to clarify its meaning in this article. We have taken the position that social prescribing includes a referral source which can be a GP, school, employment or other organisations to a link worker (social prescriber) who is responsible for supporting a young person, co-creating and action plan and, when ready, referring the young person onto further mainly non-clinical support activities, typically delivered by the Voluntary, Community and Social Enterprise (VCSE) sector.This paper evaluates the mental health outcomes of one of these pilot social prescribing schemes for young people in a NEET situation in Italy and Portugal. It does so by adopting a realist evaluation approach (Pawson and Tilley, 1997, 2004) which focuses on understanding how interventions work rather than solely focusing on whether health outcomes change. It draws on both quantitative and qualitative data to generate an Intervention Programme Theory which explores how outcomes are generated by the interaction between context and mechanisms. Thus, this article adopts a novel methodological approach to explore a novel social prescribing intervention (C.O.P.E.) focussed on supporting young people in a NEET situation in two countries. The focus on two countries adds an additional novel element to the study as it highlights how the intervention was adapted in two different national contexts. Finally, theories concerning the mechanisms shaping young respondents\u2019 motivations and pathways to well-being will be explored to provide a more conceptual interpretation of findings.C.O.P.E. (Capabilities, Opportunities, Places and Engagement) was an intervention aimed at supporting vulnerable young people (aged 16\u201334) living in Italy and Portugal who are in a NEET situation. Although most literature on NEET individuals examines ages between 15 and 24 (e.g. European Labour Force Survey), there are other countries (e.g. Japan) which consider the age group between 15 and 34 (Bollani, 2020). We decided to extend our research to this wider age group for two reasons: (i) after initial work, we realised that the group between 24 and 34 would benefit even more from COPE, given their more ingrained vulnerability; (ii) We had also experienced initial issues with recruitment so widening the age group would ensure fewer difficulties with meeting our initial target.The intervention uses a social prescribing approach to address young people's social and mental health needs, focusing on their strengths. Through a link worker, who meets with them over flexible sessions, young people receive active listening and support to co-create an Individual Action Plan (IAP) that identifies and guides tailored actions. For link workers to provide the best possible support to young people, a \u2018relational proximity community network\u2019 approach was adopted, which focused on working closely with several organisations, from the public, private and third sectors.The main objectives of C.O.P.E. were as follows: 1) the implementation of an integrated intervention based on an innovative and experimental \u2018relational proximity community network\u2019 approach and social prescribing for the social inclusion of difficult-to-reach young people; and 2) the evaluation of how this intervention may add value and be integrated into the current design of employment centres, youth projects, educational, health and social services for young people in a NEET situation. The intervention aimed to provide a full range of support to 600 young people who have recently been in a NEET situation in Italy and Portugal, including those categorised as disengaged and unavailable.The realist synthesis of reviews was particularly useful in identifying the mechanisms, contextual factors and outcomes of complex interventions aimed at supporting individuals in NEET situations worldwide (Richardson et al., 2020). To ensure quality, we obtained approval from the International Prospective Register for Systematic Reviews - PROSPERO (CRD42022341511) and followed the 19 items from the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) p