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Eurohealth Observer 3

PREVENTING SOCIAL AND AMONG OLDER PEOPLE

By: Joanna Marczak, Raphael Wittenberg, Lorraine Frisina Doetter, Georgia Casanova, Stella Golinowska, Montserrat Guillen and Heinz Rothgang

Summary: Social isolation and loneliness among older people are

Funding acknowledgement: linked to lower quality of life, cognitive function, wellbeing and The work reported in this article formed part of the CEQUA Project, independence, and contribute to increased use of health and social which has received financial support from the European Union under care services. As populations age, implementing policies to identify, grant agreement No VS/2015/0276. Responsibility for this article rests prevent and reduce social isolation and loneliness has therefore solely with the authors. emerged as a major concern for health and social care policy makers. Across Europe, action is being taken to address social isolation and

Joanna Marczak is Research loneliness. While the evidence on the effectiveness of measures is Officer and Raphael Wittenberg is Deputy director and Associate variable, examples show that much can be done to promote social Professorial Research Fellow, Care Policy and Evaluation Centre, integration and improve the quality of life of older people. London School of Economics and Political Science, UK; Lorraine Frisina Doetter is Senior Research Keywords: Older People, Social Isolation, Loneliness, Social Care Prevention Fellow and Heinz Rothgang is Director, Department of Health, Long Term Care and Pension Policy, Research Center on Inequality Introduction The significant negative physical and and Social Policy, University of mental health consequences of social Bremen and both are Project Social isolation and loneliness can occur isolation and loneliness contribute to Directors, Collaborative Research at almost any age, but while they are an Center 1342, University of Bremen, increased use of health and social care emergent problem among younger people, Germany; Georgia Casanova* is services and bring substantial costs for Researcher, Centre for Socio- they still predominantly affect individuals health systems. Implementing policy Economic Research on , at older ages. It has been estimated, for Italian National Institute of Health actions to identify, prevent and reduce example, that almost half of individuals and Science on Ageing (INRCA- social isolation and loneliness has IRCCS), Italy; Stella Golinowska aged over 60 are at risk of experiencing therefore emerged as a major concern is Professor, Centre for Social social isolation, while one-third will for health and social care policymakers, and Economic Research, Poland; experience some degree of loneliness. 1 Montserrat Guillen is Director, in particular as populations age. Action Social isolation and loneliness among older Riskcenter, Research Group on is being taken across Europe to address Risk in Insurance and Finance, people have been linked to lower quality social isolation and loneliness. While the University of Barcelona, Spain. of life, cognitive impairment, reduced Email: [email protected] evidence on the effectiveness of measures well-being and loss of independence. is variable, examples show that much can Longitudinal evidence has shown that Raphael Wittenberg and be done to promote social integration and Joanna Marczak contributed the oldest old who experience cumulative improve companionship and emotional equally to this report. exposure to social isolation and loneliness support to older people. In this article we are at greatest risk of experiencing synthesise findings from a rapid literature negative consequences for physical health * This study has been partially review to assess the effectiveness of some and well-being. 2 supported by Ricerca Corrente funding of these interventions. from the Italian Ministry of Health to IRCCS INRCA.

Eurohealth — Vol.25 | No.4 | 2019 4 Eurohealth Observer

and their intended outcomes. 3 They singing group initiative in the United were: social facilitation interventions, Kingdom was found to reduce Box 1: Definitions psychological therapies, health and social and and increase mental care provision, animal interventions, health related quality of life, with the Social isolation relates to lack of befriending interventions, and leisure/skill intervention marginally more cost- contact with family, friends or other development. effective than usual activities. 7 A study of people. The extent of social isolation a Friendship Enrichment Programme in can therefore be assessed from data the Netherlands, which involved 12 weekly about the frequency and duration of Evidence on effectiveness of group lessons in self-esteem, relational such contacts. interventions to reduce social isolation and loneliness competence, phases in friendship Loneliness is an emotional formation and social skills, also resulted feeling, which may or may not be One-to-one interventions in a significant reduction in loneliness accompanied by social isolation within a year after the programme, There is some evidence that one-to-one and can only be assessed by asking with a combination of developing new interventions can improve psychological people whether they feel lonely. friendships and improving existing and physical well-being. For example, a friendships reducing loneliness. 8 study on home visiting in a retirement home in the USA over a two-month period illustrated an increase in social activity, The number of older people has been amount of time spent in active pursuits rising and will continue to rise across and number of activities planned among Social Europe. This is due partly to the baby participants. 4 A study among older people boom cohorts reaching old age but also to in Ireland who received a volunteer visit isolation and increased life expectancy. It is important for 10 weeks compared to usual treatment for the quality of life of older people and demonstrated a decrease in loneliness. 5 loneliness their families that the period in which they Another example, from Canada, involving experience social isolation, loneliness and volunteer visitor programmes in the contribute to disability reduces rather than rises as life community showed increased social expectancy increases. integration at six weeks, but no effect on increased use of perceptions of intimacy, nurturance and It is important recognise that while guidance. 4 However, another Canadian health and social measures to reduce social isolation study involving volunteer weekly home and loneliness are often implemented visits showed no effect on social and care services together, these concepts are not the same leisure activities, or satisfaction with ‘‘ (see Box 1). Nevertheless, other interventions were less social relationships at either three or six successful in reducing social isolation and months. 4 In the Netherlands, computer loneliness. For instance, a hen-keeping Types of interventions to prevent and and training sessions delivered by project in England where volunteers were reduce social isolation and loneliness an instructor over a two week period to trained to establish hen-houses and support community dwelling older people with no Interventions aiming to reduce social other older people to maintain them, previous internet experience and computer isolation can be broadly classified did not result in any long-term change use over a 12-month period reported no into one-to-one interventions; group in reported loneliness, depression and effect on loneliness or size interventions; neighbourhood and anxiety, although it did overall increase at either 4 or 12 months compared with a community interventions; and technology quality of life of participants. 9 Similarly, control group. 4 focused interventions. More specifically, a psychological group rehabilitation in they may include at the individual level Finland, where facilitated groups met Group based interventions ‘befriending’ and at the collective, group once a week for three months with the level a range of services from lunch clubs Evidence has also shown that group-based aim to empower participants and promote to schemes that help people widen their interventions to prevent social isolation friendships did not improve loneliness or social circles or promote health and well- and loneliness are often effective. For social networks between groups, although being. Wider community programmes example, in Finland delivery of socially a significantly larger proportion of group promote participation in various activities stimulating group activities including ‘art participants found new friends during the (e.g. sport facilities, libraries) as well as and inspiring activities’, ‘group exercise follow-up year. 10 joining and using outreach and volunteer and discussion’ and ‘therapeutic writing programmes. and group therapy’ reduced isolation Technology focused interventions and loneliness in older people, improved Emerging evidence also shows that A thematic analysis identified that well-being and cognitive function and also technology-focused interventions can these types of interventions could be lowered health care costs of participants. 6 successfully contribute to reducing social classified into six categories based on In another example, a 14-week community isolation and loneliness in older people. their purpose, their mechanisms of action

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For instance, use of a video network in outcomes and the difficulty of obtaining 6 Pitkala KH, Routasalo P, Kautiainen H, Savikko N, the Netherlands which allowed users to data to assess what would have happened Tilvis R. Effects of psychosocial group rehabilitation contact a nurse 24/7 and to interact with in the absence of the preventative on health, use of health care services, and mortality of older persons suffering from loneliness: a carers, friends and family contributed to a interventions. randomised, controlled trial. Journal of Gerontolgy: significant reduction in loneliness in older Medical Sciences 2009;64A(7):792 – 800. users. 11 Similarly, a decrease in loneliness Further research is needed to enhance our 7 Coulton S, Clift S, Skingley A, Rodriguez J. was reported by users who participated understanding of how interventions can Effectiveness and cost-effectiveness of community in a national pilot study in the United mediate social isolation and loneliness singing on mental health-related quality of life Kingdom of telephone befriending support and to provide more robust evidence on of older people: randomised controlled trial. projects, where volunteers provided effectiveness. There is also a need to Br J Psychiatry 2015;207(3):250 – 5. 12 emotional support for older people. investigate which groups of older people 8 Stevens NL, Martina CM, Westerhof GJ. Meeting In Finland and Slovenia, provision of are most prone to suffer from social the need to belong: predicting effects of a friendship computer sessions teaching basic isolation and loneliness and would benefit enrichment program for older women. Gerontologist information technology (IT) skills and most from interventions. Future studies 2006;46(4):495 – 502. training on Skype and internet use also need to address some of the challenges 9 Cook G, Cook M, Thynne E, Chandler C. led to a significant reduction in loneliness involved in evaluating preventative An evaluation of ‘HENPOWER:’ Improving Wellbeing overall especially for those using email, interventions to ensure that they are & in Care Settings. Northumbria University, 2013. although there was no reported change in sufficiently robust to inform policy and loneliness among those using Skype. 13 practice reliably. 10 Routasalo PE, Tilvis RS, Kautiainen H, Pitkala KH. Effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, Governments should consider including Policy implications / implications older people: randomized controlled trial. Journal of for the future in their strategies for preventing disability Advanced Nursing 2009; 65(2):297–305. and promoting health and wellbeing policy 11 Loek AH, Willems CG, Spreeuwenberg MD, Research indicates that loneliness and initiatives to reduce social isolation and Rietman J. Implementation of CareTV in care for social isolation increase the likelihood loneliness in old age. Agencies responsible the elderly: the effects on feelings of loneliness of people experiencing adverse health for commissioning services for older and safety and future challenges. Technology & outcomes and are linked to various people should consider supporting a Disability 2012;24(4):283 – 291. conditions such as high , range of measures to prevent or reduce 12 Cattan M, Kime N, Bagnall AM. The use of heart disease, obesity, depression, social isolation and loneliness. Further telephone befriending in low level support for socially cognitive decline, Alzheimer’s disease, studies should be undertaken to improve isolated older people – an evaluation. Health & Social sensory and mobility impairments. A wide the evidence on effective ways to combat Care in the Community 2011;19(2):198 – 206. range of interventions has been developed social isolation and loneliness. Policy 13 Blazun H, Saranto K, Rissanen S. Impact of to tackle social isolation and loneliness strategies and priorities for commissioning computer training courses on reduction of loneliness amongst older people. Although numerous preventative measures should take account of older people in Finland and Slovenia. Computers in Human Behavior 2012;28(4):1202 –12. interventions reviewed here reported of the developing evidence. some success in reducing social isolation and loneliness, there was a significant References heterogeneity between interventions. For example, evidence indicates that 1 Landeiro F, Barrows P, Musson EN, Gray AM, group level interventions may be more Leal J. Reducing social isolation and loneliness in older people: a systematic review protocol. beneficial than one-to-one interventions, BMJ Open 2018:7(5). and interventions that include social 2 activity and support were more likely to Malcom M, Frost H, Cowie J. Loneliness and social isolation causal association with health-related be effective. It should be noted however lifestyle risk in older adults: a systematic review that the effectiveness of interventions and meta-analysis protocol. Systematic Reviews may depend on their specific content, the 2019;8(48). specific groups of older people to whom 3 Gardiner C, Geldenhuys G, Gott M. Interventions they are offered and the specific context to reduce social isolation and loneliness among older in which they are offered. people: an integrative review. Health & social care in the community 2018;26(2):147 – 57.

The methodological quality of evaluations 4 Dickens AP, Richards SH, Greaves CJ, may also be contributing to the variability Campbell JL. Interventions targeting social isolation of their findings. Assessing effectiveness in older people: a systematic review. BMC Public and cost-effectiveness of preventative Health 2011;11(647):1 – 22. interventions can be challenging for 5 Lawlor B, Golden J, Paul G, et al. Only the Lonely: several reasons. These include the use a randomized controlled trial of a volunteer visiting of various interventions simultaneously, programme for older people experiencing loneliness. Dublin: Age Friendly Ireland, 2014. the long time periods required to assess

Eurohealth — Vol.25 | No.4 | 2019