Interventions to reduce social isolation and loneliness among older people

Interventions to reduce social isolation and loneliness among older people: an integrative review

Introduction

Older adults tend to suffer loneliness and social isolation in the later years of life, affecting mental and physical health if unaddressed. A recent review on the impact of loneliness and social isolation on physical and mental health identified various negative consequences such as depression, cardiovascular disease, a decline in the quality of life, decline in cognitive function, and a higher mortality rate (Courtin & Knapp, 2017). Older people identified as chronically lonely are also evidenced to register fewer hours of exercise, possess a greater number of chronic illnesses, rely heavily on tobacco use, have higher depression scores, and require more nursing home stays than others not suffering from loneliness (Malcolm, Frost & Cowie, 2019).

There is still very little knowledge on the mechanics of how loneliness and social isolation affect health. Still, the negative effects on health evidenced are usually associated with the influences these factors have on health behaviors, sleep, and social connectedness (Courtin & Knapp, 2017). The impact of loneliness and social isolation is usually exacerbated in older people due to certain conditions such as declining physical health, residual grief from the death of a spouse or a partner, the higher likelihood of living alone, and a limited number of confiding relationships.

A combination of health factors and other situational factors can lead to loneliness in older adults. This condition instills a perceived lack of companionship and a decline in the quantity or quality of a previously established relationship with a person or a community. Health factors usually associated with causing loneliness in older adults are chronic diseases that impede mental functioning or cause cognitive decline. Such diseases can reduce the individual’s ability to communicate efficiently and may cause lapses in memory, which affect the individual’s ability to recall recent interactions with others (Victor et al., 2020).

Situational factors can include the lack of a confidant, a recent move to a new environment such as a care facility, a recent death of a loved one, and spending extended periods alone and unoccupied (O’Rourke, Collins & Sidani, 2018). Other factors that can reduce loneliness are the size of an individual’s existing social network, the frequency of social contact received, and the quantity of social support received from others.

Statement of the Problem

There are specific population groups whose members are highly prone to suffer from loneliness and social isolation, such as refugees, young care-leavers, and mentally ill people. Older adults are also identified as one of the population groups vulnerable to loneliness, but with a higher possibility of suffering from it due to underlying factors such as losing loved ones, loss of mobility, or loss of income (Age UK Oxfordshire, 2011).

Due to the high risk of this population group, there has been a greater focus on accounting for this group’s members. Developed countries such as the UK maintain accurate statistics of the population of this aging group. In the UK, persons aged 60 and above currently make up approximately 20 percent of the entire population and this value is expected to rise by 4 percent by the year 2030 (Windle, Francis & Coomber, 2011).

In the subsequent 2 decades, the number of the population aged above 80 is expected to triple, and those aged above 90 will double. An examination of the prevalence of loneliness and social isolation among the aged population indicates that between 5 – 16 percent report loneliness, while about 12 percent feel socially isolated (Machielse & Duyndam, 2020).

Loneliness and social isolation are considered issues of public health, and research has highlighted the effect social relationships can have on mortality risk (Key & Culliney, 2018). With the rapidly growing population of the aged all over the world, especially in the US and the UK, the issue of loneliness and social isolation in the elderly is becoming a cause for greater concern, which needs to be addressed speedily for the benefit of the individuals affected and for the society at large. The resultant health issues caused by loneliness and social isolation put more strain on statutory health and social care services. A resolution to this problem will raise the quality of life of the elderly while also reducing the extra pressure put on the limited public health service.

Purpose of the research

The higher risk, the older portion of the population faces suffering loneliness, and social isolation is associated with various underlying factors such as loss of loved ones, restricted movement, and poverty. An examination of the various effects imparted by these conditions, such as depression, high blood pressure, and higher rates of mortality, indicate an occurrence independent of age, gender, race, medication, and pre-existing health conditions (Gouveia, Matos & Schouten, 2016; Sepulveda-Loyola et al., 2020).

In observation of the link between the strength of social relationships and the likelihood of survival, a recent meta-analysis revealed a 50 percent greater chance of survival for individuals with very strong social relations compared to individuals with weaker social relationships. In a representation of this result, if half of the population of a hypothetical group of 100 people dies, there would be ?ve more people alive with stronger social relationships (Bookwala & Gaugler, 2020).

The authors argue that social relationships have a comparable influence on death’s risk just as much as elements such as smoking and alcohol consumption. This influence is stated to be undiminished by the influence of physical activity and obesity. Thus, the status of an individual’s social relationship can dictate the use of health and social care services, as well as the likelihood of early admission into residential or nursing care (Berg-Weger & Morley, 2020).

The benefits to the individuals and society will be realized if the issue of social isolation and loneliness in older adults is addressed and is therefore self-evident. For the individual, the primary benefit which will be obtained is an increase in the quality of life. For society at large, a reduction in the use of health and social care services will save on cost and resources while also increasing the number of potential contributors to the society through volunteer work and caring responsibilities (Jagger et al., 2011).

Given such individual and societal consequences, a national and international policy consensus has been reached to support those living in social isolation and ‘to reach those living with or on the brink of loneliness’ (Windle et al., 2011). Some of the problems stunting the implementation of efforts to achieve this purpose are the lack of clarity on the best way to achieve this and identifying the sector responsible for such matters (e.g., statutory or third sector). As will be highlighted in this paper, the available implementation efforts and the corresponding evidence base have been growing incrementally.

Research questions

The integrative review’s purpose is to identify the types of intervention which will be most applicable in addressing the issue of loneliness and social isolation in older adults. To achieve this, the research will answer the following questions:

· What are the required components, the necessary activities, the mode of delivery, and the frequency of delivery of the intervention type to address loneliness and social isolation in older adults?

· What will be the intervention type’s effectiveness if the hypothesized mechanisms of the effect of that intervention type are mapped to factors that may influence social connectedness?

Methodology

A qualitative research method will be applied for this research work for the flexible approach the method offers to the collection and analysis of data. The data collection for this research will be extracted from previous research, and the analysis will also be drawn from previous research works. Through this, new knowledge and understanding will be revealed.

The research design will be a systematic review. The review will be performed in compliance with the reporting guidelines and criteria checklist established in the Preferred Reporting Items for Systematic Review (PRISMA) (Moher et al., 2015) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidance for systematic review reporting.

This study is an integrative literature review on interventions that address social isolation and loneliness in older adults. The integrative review design allows for the consideration of various methodologies and is applicable for informing evidence-based practice using different primary research methods (Gardiner, Geldenhuys & Gott, 2018). This method was selected for this function, as multiple methods will be employed in generating new insights.

The quantitative research method will be used to analyze the effectiveness of any intervention type used. The quantitative method will be applied to provide an insight into the impact of an intervention type and the mechanism of action of that intervention type. Through this, the factors which influence the success of an intervention type can be isolated and observed.

This will help modify intervention types to create adapted contextual ones, which will still record success and effectiveness in different local settings. This will narrow the gap amid the national scope of the intervention effort, which may be funded by national organizations, and the local settings in which the application will occur. This adaptability will be highly required in maintaining success in the highly diversified population demographics internationally (Gardiner et al., 2018).

Interventions for social isolation and loneliness specifically tailored to address a certain demographic of the population have recorded success in the past. Using a community development approach, these interventions were designed and implemented with input from the service users (Gardiner et al., 2018). As a result of this success, service user and public and patient involvement have gained rising relevance in recent times, most notably in health service development and research design.

Recent findings suggest that the community development approach will help develop interventions that will be most suited for addressing the needs of a particular group of people. An additional benefit this approach might grant is the productive engagement of the targeted people in the intervention process, yielding a better outcome than a passive interaction. A similar argument to this finding is made in the review by Dickens et al. (2011), which reported a greater likelihood of success in participatory interventions. This finding might function to the greatest effect in the designing of non-group or solitary interventions.

Data collection process

Three electronic health bibliographic databases, Medline, EMBASE and Cumulative Index to Nursing and Allied Health Literature (CINAHL), will be searched for the relevant literature. The search will be performed using keywords identified from several preliminary scoping searches which will also function to provide familiarity with the literature to be used. The range of the search will extend from the date each of the databases was created, to the date the search is conducted (March 2021).

To conduct the search, keywords and database-specific subject headings will be used to identify literature which discuss the relevant topics. The literature on social connectedness will be searched for by using terms identified in collaboration with a health sciences librarian, terms such as ‘social connectedness’, ‘connectedness’, ‘lonely’ and ‘loneliness’.

For literature on intervention and strategy, the terms which will be used are identified from a previous systematic review (Leeman, et al., 2015), this includes terms such as ‘therapy’, ‘treatment’, ‘strategy’ and ‘intervention studies’. The searches will be conducted in collaboration with an information specialist librarian and a research team. The search strategy will be separately adapted to suit the requirements of each database but will perform the same function of identifying reviews which discuss loneliness/social isolation interventions for older adults.

The search engine Google (including Google Scholar) will be used to generate grey literature and the first 30 links generated (sorted by relevance) will be checked for relevance against the inclusion criteria. Backward citation chaining will also be employed to increase the volume of reviews available by searching the reference lists of selected reviews (Boland, Cherry & Dickson, 2017). The results generated from the electronic search on each database and the search engine used will be inputted into a Microsoft Excel spreadsheet, and any duplicate identified will be deleted.

Inclusion/exclusion criteria

The criteria used for this search will be broad in interpretation for the search to be comprehensive. Inclusion of article will occur if the article: (1) describes an intervention evaluated using any qualitative, quantitative, or mixed-methods design, or examines the strategies older adults or caregivers use to promote social connectedness in a qualitative study; (2) identifies the primary goal of an intervention as one or more of the indicators of social connectedness (i.e., feelings of belonging or feelings of caring about others); (3) targets adults 55 years and above; and (4) is available in full text in either English or French language.

Studies will not be excluded, centered on the year of publication or the publication status. Two independent reviewers will apply the inclusion/exclusion criteria in selecting the literature, which will be used from a random selection of full-text articles that will indicate the inter-rater agreement. Any discrepancy between the reviewers on a selected or discarded article will be discussed until a consensus is reached.

Extraction of Data

To objectively analyze the data, the study will first clarify how the data is to be extracted. Secondly, the study aims to locate the exact positions in the articles where the data has been extracted and how it will be documented. Additionally, the study will provide illustrative examples to demonstrate the relevance of the data in the study. If a single study has multiple reports, the study will group them in the data extraction tables to appear as one for analysis.

The format of documenting the articles employed in the study will include the author’s name, the year published, and an indication of whether it is a peer-reviewed article, book, or dissertation. Additional information, including the study design, contextual details (i.e., target population, country and cultural background of participant and setting), and information about the sample (i.e., age, gender, marital status, etc.), will be provided if the study uses quantitative and qualitative studies.

For articles describing or evaluating interventions, the study will provide the theoretical framework employed by the authors on the intervention, such as theories or the author’s rationale for integrating discussion on the intervention, and show its relevance to the subject of study- social loneliness. The key issues the study will focus on regarding the intervention discussed will be the goal of the intervention, components and activities, how it was administered, and the quantity of dosage.

The goal is what the intervention was designed to achieve, while the activities refer to the actions undertaken while the intervention was being administered. The delivery mode is the means through which the intervention was administered, and the dosage is the measure of exposure. The study will seek supporting shreds of evidence on the strategies explored and identified as possible interventions of promoting social connectedness among older adults from qualitative studies that have explored the subject of aging and loneliness.

Analysis of Content

Content analysis is a research methodology used in the analysis of written, verbal or visual communication messages. It is a flexible research method that considers the meaning and the context within which the material was written. The objective of content analysis in research is to provide a framework within which knowledge about the subject of study can be extracted and understood.

A qualitative content analysis follows three-step approaches: conventional, directive, and summative (Assarroudi et al., 2018). The subject will determine the choice of qualitative content analysis approach under study and the theoretical framework that the researcher chooses.

In this study, manifest content analysis was found to be appropriate to be used in describing the phenomenon under study. Data analysis will first begin with a review of the literature to provide more background information on the study subject. A word-for-word read will be employed to capture key terms in the form of codes in the literature materials to achieve this. Subsequently, a summary of the thoughts and analysis from the literature review will follow. In summarizing, the codes will be sorted into categories based on relevance and relation to each other. The categories will be vital in forming meaningful themes.

Analysis Procedure

Frequencies calculated will be used in describing the context parameters such as the target populations. The strategies from qualitative studies will be analyzed in three ways. First, an initial list consisting of two indicators of social connectedness/loneliness (including caring for and about others and feelings of belongings) and nine possibly modifiable influencing elements (i.e., social support, social network, self-reported health, technology use, formal group membership, mental and emotional well-being, community-based social participations, religious affiliation, as well as, use of services like homecare) identified from previous reviews (O’Rourke et al., 2018) will be used for the initial coding. Secondly, the findings of those studies will be coded and sorted; those that are related will be put together and new codes created if need be. Lastly, the frequency of indicators and factors addressed across the examined studies will be evaluated (Sandelowski & Barroso, 2006).

Using manifest content analysis, the interventions will be analyzed by similar grouping interventions and identifying their components. The first author will complete the analysis, and the last one will review the findings. The first and the second authors will then assess the extent to which the studies have hypothesized the mechanisms of effect mapped to the indicators and the list of factors influencing social connectedness independently. The independence of reviewers is aimed at ensuring that the findings of this study are reliable. A discussion and review of coded data will be employed in articulating any discrepancies until a consensus is arrived at on the list of factors targeted by each intervention.

Validity and Reliability

In research, validity signifies the degree to which the research method had measured the study’s objective as set out before the study began (Kumar, 2018). The objective of this study is to describe loneliness among the elderly and its associated interventions. A review of literature implies that the data obtained for the study is from reliable published scientific articles. The articles used in the study have to demonstrate clear relevance to the topic under study and hence will be validating the study.

For a research tool to be considered reliable, it has to be consistent, predictable, stable, and accurate. The degree of stability and consistency of the tool is directly correlated to its reliability. A scale or a test is reliable if measurements arrived at repeatedly yielding the same results under constant conditions (Kumar, 2018).

All coders will have to be trained and have codebooks before the process of analysis. The training will ensure that all coders share a mental model of the skill, construct, and the phenomenon they will be coding. Lack of stability during the coding can result in coders arriving at different judgments, affecting the study’s reliability and validity. To reduce this risk, recoding can be done at a later date.

Reproducibility is not a typical goal for qualitative research (Assarroudi et al., 2018), but for proposal content analysis, codes defined before and during the analysis will retain their meanings. The coders will embrace the reproducibility of their codebook to maintain a detailed audit trail, including descriptions of the methods used in creating and defining the codes and measures taken to ensure inter-rater reliability.