Social Prescribing and Long-Term Conditions in Viet Nam: Where Could Community-Connected Care Add Value?

Social Prescribing and Long-Term Conditions in Viet Nam: Where Could Community-Connected Care Add Value?

Category: Viet Nam Context

Living with a long-term health condition rarely happens only in a clinic. A person with diabetes may see a healthcare professional several times a year, but food choices, physical activity, medication routines, finances and family support shape what happens on all the other days. Someone recovering from stroke may receive appropriate medical treatment but still struggle with mobility, confidence, social participation or finding suitable activities close to home. An older person living with several conditions may understand what clinicians have recommended yet find it difficult to move between services, travel to appointments or manage everyday life without support.

This is where social prescribing and community-connected care may have something to add. Their role is not to replace medical treatment, rehabilitation or professional care. It is to recognize that successful long-term condition management is influenced by what happens between healthcare encounters, in homes, families and communities, and to help people connect with appropriate non-clinical resources when those resources could address needs that healthcare alone cannot.

For Viet Nam, this distinction is particularly important. Noncommunicable diseases account for around 80% of deaths, while the country is expanding the management of hypertension and diabetes closer to where people live. In September 2026, WHO reported that a large-scale Ministry of Health initiative was screening around 10 million people for hypertension and diabetes each year and had brought more than 2 million people into treatment. Strengthening accessible, high-quality clinical care at community level is essential. The question for social prescribing is different: what additional support may help people live with and manage their conditions once appropriate clinical care is in place?

Long-term conditions involve more than disease control

The term long-term conditions is useful because it focuses on the experience of living with health problems that require ongoing management. It overlaps substantially with chronic noncommunicable diseases, but the practical idea is broader. People may be living with cardiovascular disease, diabetes, chronic respiratory disease, cancer, neurological or musculoskeletal conditions, mental health problems, or several conditions at the same time.

Clinical management remains central. Blood pressure needs appropriate assessment and treatment. Diabetes requires evidence-based monitoring and management. Cancer, chronic respiratory disease and cardiovascular disease require condition-specific professional care. Rehabilitation is necessary when rehabilitation is clinically indicated. Community activity cannot substitute for these responsibilities.

But disease control is only one part of living well with a long-term condition. People may also need help becoming more physically active, rebuilding confidence after illness, reducing unwanted social isolation, finding peer support, accessing practical or financial assistance, participating in meaningful activities, navigating services or supporting a family caregiver. These issues can influence whether an otherwise sound clinical plan is realistic in everyday life.

Social prescribing becomes relevant not because these needs are less important than medical needs, but because they often require a different kind of response.

What does the evidence actually tell us?

The evidence is encouraging in some areas, but it does not justify a broad claim that social prescribing improves long-term conditions in general.

A 2025 scoping review focused specifically on adults living with long-term conditions and included 37 sources of evidence covering 65 different conditions. Diabetes was the most frequently represented condition. Most referrals originated in primary care, and people were commonly connected with exercise, information and advice, mental health support, social and leisure activities, and condition-specific support. But the geographical concentration of the evidence was striking: 31 of the 37 sources came from England, with most of the remainder from Ireland or elsewhere in the UK and only one from the United States. The review identified no study from a non-Western setting.

Effectiveness evidence has also remained uncertain. A 2024 systematic review and meta-analysis included 12 randomized or quasi-randomized studies involving 3,566 adults with long-term conditions. Some condition-specific interventions showed improvements, including quality of life in cancer studies and diabetes-specific psychological outcomes, and there was some evidence relating to physical activity. However, the interventions were heterogeneous, nine of the 12 studies were judged to have a high risk of bias, general psychological well-being did not show significant improvement, and the authors concluded that the overall quality of evidence remained poor.

A newer Bayesian re-analysis, published on 28 September 2026, adds an important but more nuanced implementation insight. It included 10 reports from nine randomized trials involving 4,840 participants. The authors found a modest positive signal for achieving trial-defined physical-activity targets, with an odds ratio of 1.31. They also reported that higher participation was associated with greater benefit. However, eight of the nine trials evaluated exercise-oriented interventions, only one evaluated a link-worker model, the pooled binary physical-activity estimate came from two compatible trials, and adherence comparisons were based on post-randomization data and therefore should not be interpreted as causal effects. The useful lesson is not that referral automatically produces benefit, but that what happens after referral, whether people can actually engage with appropriate support, matters greatly.

This distinction is highly relevant for Viet Nam. The responsible message is not “social prescribing works for chronic disease.” It is that some people living with long-term conditions have social, practical and behavioral needs that community-connected care may help address, while the appropriate model, implementation process and outcomes still need to be tested in the Vietnamese context.

Evidence from the Western Pacific reinforces that caution. A 2026 regional scoping review included 42 peer-reviewed studies and 13 grey-literature sources. Models varied substantially in structure, funding, target populations and implementation, and only one of the peer-reviewed studies came from Viet Nam. Direct Vietnamese evidence therefore remains extremely limited.

A broader global scoping review published in July 2026 reached a similar conclusion about the maturity of the evidence. Among 115 peer-reviewed empirical studies from 16 countries, around 64% came from the United Kingdom. Psychosocial outcomes such as well-being, loneliness, confidence and social connectedness were reported more consistently, while clinical and health-system outcomes were more variable. That is another reason to avoid judging early social-prescribing initiatives only by downstream measures such as hospital utilization.

Where could community-connected care add value?

One potential area is supporting everyday self-management. Clinical advice may include increasing physical activity, improving diet, stopping smoking or participating in rehabilitation, but advice and implementation are not the same thing. A person may need an appropriate local activity, peer support, practical education or help overcoming barriers before a recommendation becomes realistic in everyday life.

Exercise was the most commonly reported category of community activity in the 2025 long-term conditions review. That does not mean everyone with a long-term condition should simply be referred to an exercise group. An activity needs to be appropriate for the person's condition, functional capacity, preferences and any clinical restrictions. Someone with unstable disease, new symptoms or significant functional impairment may need clinical assessment or rehabilitation rather than a general community activity. Springer Link

A second area is social connection and meaningful participation. Long-term illness can gradually narrow a person's world. Disability, fatigue, retirement, reduced mobility or repeated illness may reduce participation in work, family or community life and disrupt relationships and routines that previously gave the day structure and meaning.

Social prescribing may help when unwanted isolation or loss of meaningful participation is part of the problem, but it should not assume that everyone living alone is lonely or that joining a group automatically improves well-being. The starting point should be the person's priorities. For one person, a walking group may be meaningful. For another, it may be volunteering, learning, cultural or faith-based activity, peer support or reconnecting with a community they already value.

A third area is practical and social barriers to managing health. The long-term conditions review identified pathways connecting people with financial, housing, employment, personal-care and other forms of practical support alongside health and social activities. These issues matter because a technically correct treatment plan may still be difficult to follow when someone is worried about income, transportation, caregiving or basic living needs.

Social prescribing cannot resolve structural poverty or replace formal social-protection systems. It can, however, help make practical and social needs visible and support people in reaching appropriate existing services that they might otherwise struggle to find or navigate.

Navigation may matter as much as the community activity

For some people with long-term conditions, the challenge is not simply whether a useful service exists. It is navigating between multiple services.

A person with multimorbidity may be seeing several specialists, taking multiple medications, attending different facilities and receiving advice from different teams. Another person may need rehabilitation, follow-up healthcare and practical assistance after hospital discharge. Family members may already be coordinating much of this informally.

In these situations, care navigation and social prescribing can overlap. The useful intervention may be less about “prescribing an activity” and more about helping the person understand what support exists, which service fits their needs, how to reach it and what to do when the first connection does not work.

The 2025 review found that while most pathways originated in primary care, referrals also came from secondary care, community services and other settings. This suggests that people with complex long-term conditions may need routes to support that extend beyond a single point of care.

This has particular relevance in Viet Nam. Community-connected care should not become another isolated referral system. Its potential value lies in helping bridge gaps between clinical services, social support and community resources when those gaps are genuinely affecting people's ability to manage their health and daily lives.

Older people, multimorbidity and family caregiving

This issue will become increasingly important as Viet Nam ages. The 2024 Mid-Term Population and Housing Census reported 14.2 million people aged 60 or older, 2.8 million more than in 2019, and projected that the number could approach 18 million by 2030. Pasted markdown

Ageing does not automatically mean illness, disability or dependency, and social prescribing should never be offered simply because someone is older. But the likelihood of living with multiple long-term conditions, functional limitations and more complex care needs increases with age. The emerging challenge is therefore not only disease-specific management but also how health, social and community support can work together over time.

Viet Nam already has community assets relevant to this discussion. Intergenerational Self-Help Clubs are one example. In August 2025, the Prime Minister issued Decision No. 1648/QĐ-TTg, approving expansion of the model through 2035. The Decision aims to establish at least 12,000 new clubs by 2035 while maintaining the quality of existing clubs.

These clubs are not social prescribing services, and they should not be relabeled as such. They illustrate a more useful principle: community-connected care in Viet Nam does not have to begin by inventing entirely new organizations. A future pathway could identify, understand and, where appropriate, connect people with existing community assets that genuinely match their needs.

The same principle applies to local associations, exercise groups, rehabilitation resources, social-work services, peer-support activities and other community initiatives. The key question is not whether a resource can be placed in a directory. It is whether it is suitable, accessible, safe, currently available and capable of supporting the person being connected to it.

Family caregivers also need to remain visible. Long-term condition management in Viet Nam often involves relatives arranging transportation, organizing medication, attending appointments, helping with daily activities and coordinating care across services. UNFPA reported in February 2026 that 99% of older people depend on family care and women shoulder 72% of care responsibilities, illustrating both the importance of family support and the limitations of relying on it too heavily.

Community-connected care should therefore consider caregivers as part of a person's real-world context while respecting the individual's preferences, autonomy and privacy. Sometimes useful support may also be directed toward the caregiver, through information, navigation, peer support, skills development or other appropriate resources. But social prescribing should not become a mechanism for shifting responsibilities that properly belong to healthcare, social care or other professional services onto families or community volunteers.

What should remain firmly within clinical and professional care?

This boundary needs to be explicit. Social prescribing should not be used to manage uncontrolled hypertension, adjust medication, assess new chest pain, treat severe depression, manage acute deterioration, replace rehabilitation when rehabilitation is clinically indicated, or delay necessary specialist care.

A community exercise activity is not physiotherapy. Peer support is not psychotherapy. A general nutrition activity does not replace individualized clinical nutrition care when that is required. A navigator should not become an informal clinician simply because they work closely with people who have complex conditions.

Community-connected care is strongest when everyone understands what it is not expected to do.

The same discipline is needed when evaluating outcomes. If a pilot connects people with physical activity, social participation, peer support or practical assistance, the first question should not automatically be whether hospital admissions fell. More immediate questions may be whether the person reached the resource, whether it matched their needs, whether participation was sustained, whether barriers were reduced, and whether well-being, confidence, social connection or self-management changed.

Recent randomized evidence reinforces this implementation point, but it should be interpreted carefully. The September 2026 Bayesian analysis suggests that engagement after referral may be important, while referral counts alone tell us very little about whether someone actually received and used the intended support. Because its adherence comparisons were observational after randomization, however, they should be treated as suggestive rather than proof that participation itself caused the better outcomes.

Clinical outcomes such as blood pressure or HbA1c may be relevant in carefully designed condition-specific interventions when there is a plausible pathway by which the intervention could influence them. But those measures should not be used to imply that social prescribing itself is a clinical treatment.

Why the timing matters for Viet Nam

Viet Nam is already strengthening the management of noncommunicable diseases closer to people's homes. WHO reported in September 2026 that the hypertension and diabetes management model had expanded to around 5,000 commune- and ward-level health stations across 52 of the former 63 provinces and centrally governed cities, and that approximately 420,000 patients were being managed at grassroots level each month. The model uses standardized treatment approaches, two-way referral, professional training and online reporting to strengthen continuity of care.

The legal context has also changed. Law No. 114/2025/QH15 on Disease Prevention, effective from 1 July 2026, expressly covers prevention and control of noncommunicable diseases. Articles 28–30 include prevention of risk factors, early detection and prevention, and management of noncommunicable diseases in the community. The law provides for counseling, monitoring and management of people with noncommunicable diseases and for control of risk factors that can worsen disease or contribute to dangerous complications. It does not, however, create a legal category or national program called social prescribing.

That distinction matters. Clinical NCD infrastructure should remain focused on its healthcare functions. But it may provide a logical setting in which selected non-clinical needs affecting long-term condition management can also be recognized.

One person receiving hypertension care may also be struggling with physical inactivity and unwanted isolation. Another may find regular attendance difficult because of transportation or caregiving responsibilities. A third may need professional social work rather than community activity. A fourth may need nothing beyond high-quality clinical care.

A responsible pathway needs to distinguish among them.

This is why automatically screening everyone with a long-term condition and issuing a “social prescription” would be a poor interpretation of the concept. A more appropriate starting point is what matters to the person, whether an important non-clinical need exists, whether an appropriate community resource could realistically help, and whether the person wants that connection.

A reasonable early approach would start small and learn

Direct Vietnamese evidence on social prescribing remains very limited. That argues for careful implementation and evaluation rather than premature scale-up.

An early pilot could focus on a clearly defined population — for example, adults living with hypertension or diabetes in a commune or ward health setting, or older people living with multiple long-term conditions. It could identify a manageable set of non-clinical needs, map real community resources, establish an appropriate navigation function and define clear boundaries among clinical care, professional social work and community support.

The pathway could then examine whether connections actually happen. Useful measures might include needs identified, referral appropriateness, connection attempts, completed connections, reasons for failed connections, participation, patient-reported well-being, confidence in self-management, social connection, physical activity where relevant, equity of access and the experiences of healthcare and community partners.

The September 2026 Bayesian review illustrates why this distinction matters. Eight of its nine randomized trials were exercise-oriented and only one evaluated a link-worker model. Its findings are therefore more useful as evidence that implementation and engagement matter than as evidence for one universal form of social prescribing.

Implementation also requires appropriate governance. Decree No. 110/2024/ND-CP, effective from 15 October 2024, provides Viet Nam's general regulatory framework for social work. Circular No. 51/2024/TT-BYT, effective from 1 March 2025, regulates social-work services and processes specifically in medical examination and treatment establishments licensed to operate as hospitals. Circular No. 29/2026/TT-BYT, effective from 25 August 2026, regulates social-work practice and continuing social-work knowledge. These instruments are relevant where professional social work is involved, but they do not establish social prescribing, and social work should not be treated as synonymous with social prescribing.

Information governance also needs to be designed from the beginning. Viet Nam's Law No. 91/2025/QH15 on Personal Data Protection and Decree No. 356/2025/ND-CP have both been in force since 1 January 2026. Article 26 of the Law specifically addresses health information and generally requires the data subject's consent during its collection and processing, subject to statutory exceptions. A social-prescribing or navigation pathway that collects, processes or shares personal or health information therefore needs to comply with the applicable data-protection requirements.

From managing disease to supporting life with disease

Social prescribing is sometimes discussed as if healthcare simply needs to refer more people into the community. For long-term conditions, that misses the deeper opportunity.

The real question is what makes it difficult for someone to live with and manage a condition over months and years. Sometimes the answer is clinical and belongs firmly within healthcare. Sometimes it is rehabilitation or professional social work. Sometimes it is financial pressure, isolation, loss of confidence, difficulty navigating services or lack of meaningful activity. Often several factors coexist.

Community-connected care can add value when it responds to those needs without pretending to replace clinical treatment.

For Viet Nam, the strongest case for exploring social prescribing in long-term conditions is therefore not that it offers another treatment for diabetes, hypertension or other chronic diseases. It is that good long-term condition care extends beyond disease control, and some of the factors that shape people's ability to live well cannot be addressed by healthcare alone.

The next step should not be to prescribe more community activities. It should be to learn which people need an additional connection, what kind of support they need, which community resources can genuinely help, whether the connection actually happens, and how that support can complement, rather than compete with, high-quality clinical care.

References

1. Wilson A, Noble H, Galway K, Doherty J. Social prescribing for people living with long-term health conditions: a scoping review. Systematic Reviews. 2025;14:114. doi:10.1186/s13643-025-02848-6.

2. O'Sullivan DJ, Bearne LM, Harrington JM, et al. The effectiveness of social prescribing in the management of long-term conditions in community-based adults: a systematic review and meta-analysis. Clinical Rehabilitation. 2024;38(10):1306–1320. doi:10.1177/02692155241258903.

3. Huang M, Fu G, Du Z. Bayesian re-analysis suggests participation rather than referral underlies the benefits of social prescribing for chronic diseases. Frontiers in Public Health. 2026;14:1951236. doi:10.3389/fpubh.2026.1951236.

4. Lwin KS, Wong MSJ, Tan MH, et al. Organization and implementation of social prescribing in the Western Pacific Region: a scoping review. The Lancet Regional Health – Western Pacific. 2026;67:101714. doi:10.1016/j.lanwpc.2025.101714.

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6. World Health Organization Viet Nam. Strengthened grassroots health care brings NCD services to 10 million in Viet Nam. 8 September 2026.

7. General Statistics Office of Viet Nam. Results of the 2024 Mid-Term Population and Housing Census. 2025.

8. UNFPA Viet Nam. Population Ageing in Viet Nam: From Demographic Transition to Development Opportunity. 10 February 2026.

9. Prime Minister of Viet Nam. Decision No. 1648/QD-TTg approving the project to expand Intergenerational Self-Help Clubs through 2035. 1 August 2025.

10. National Assembly of Viet Nam. Law No. 114/2025/QH15 on Disease Prevention. Issued 10 December 2025; effective 1 July 2026.

11. Government of Viet Nam. Decree No. 110/2024/ND-CP on Social Work. Effective 15 October 2024.

12. Ministry of Health of Viet Nam. Circular No. 51/2024/TT-BYT on the implementation of social work in medical examination and treatment establishments. Effective 1 March 2025.

13. Ministry of Health of Viet Nam. Circular No. 29/2026/TT-BYT on social-work practice and updating social-work knowledge. Effective 25 August 2026.

14. National Assembly of Viet Nam. Law No. 91/2025/QH15 on Personal Data Protection. Effective 1 January 2026.

15. Government of Viet Nam. Decree No. 356/2025/ND-CP detailing certain articles and measures for implementation of the Law on Personal Data Protection. Effective 1 January 2026.