Interventions targeting loneliness and social isolation among the older people: An update systematic review

Experimental Gerontology 102 (2018) 133–144

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Experimental Gerontology journal homepage: www.elsevier.com/locate/expgero

Interventions targeting loneliness and social isolation among the older people: An update systematic review

T

Andrea Posciaa, Jovana Stojanovica, Daniele Ignazio La Miliaa, Mariusz Duplagab, ⁎ Marcin Grysztarb, Umberto Moscatoa, Graziano Onderc, Agnese Collamatia, , Walter Ricciardia,d, Nicola Magnavitaa a

Section of Hygiene, Institute of Public Health, Università Cattolica del Sacro Cuore, Rome, Italy Department of Health Promotion, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland c Institute of Internal Medicine and Geriatrics, Università Cattolica del Sacro Cuore, Rome, Italy d National Institute of Health, Rome, Italy b

A R T I C L E I N F O

A B S T R A C T

Section Editor: Diana Van Heemst

This systematic review aims to summarize and update the current knowledge on the effectiveness of the existing interventions for alleviating loneliness and social isolation among older persons. A search of PubMed, ISI Web of science, SCOPUS, The Cochrane Library, and CINAHL databases was performed. The terminology combined all possible alternatives of the following keywords: social isolation, loneliness, old people, intervention and effectiveness. Eligible studies were published between January 2011 and February 2016 in English or Italian language and regarded the implementation of loneliness/social isolation interventions among the older generations. Outcome measures in terms of the intervention effects needed to be reported. In total, 15 quantitative and five qualitative studies were ultimately included in this review. Eighteen interventions were reported across the quantitative studies. Six out of 11 group interventions (55%), one out of four mixed interventions (25%) and all three individual interventions reported at least one significant finding related to loneliness or social isolation. Our review suggested that new technologies and community engaged arts might be seen as a promising tool for tackling social isolation and loneliness among the older individuals. Future studies need to work on methodological quality and take into consideration the suggestions of the present literature in order to provide firm evidence.

Keywords: Social isolation Loneliness Older persons Update review

1. Introduction The demographic shifting and ageing of the world population are considered a major issue urging for a comprehensive public health action (Poscia et al., 2015). Various strategies have been suggested to tackle the challenges older generations face, and one of the most promising ones is considered to be so called “Healthy Ageing”, namely, the process of developing and maintaining the functional ability that enables well-being in older age (European Commission - DirectorateGeneral for Economic and Financial Affairs, 2014). The ability to maintain relationships is frequently regarded as important to the wellbeing and social relations in general are an essential component of healthy ageing (WHO| World report on ageing and health, 2016). Several studies reported that people with adequate social relationships have a greater likelihood of survival compared to those with poor or insufficient social relationships (Ellwardt et al., 2015; Holt-Lunstad

⁎

et al., 2010; Tabue Teguo et al., 2016). Social isolation and loneliness are distinct but interrelated concepts, that are linked to numerous negative consequences among the older individuals, including health behavioural, psychological and physiological outcomes (Nicholson, 2012). Social isolation is usually characterized as an objective lack of meaningful and sustained communication, while loneliness is more referred to the way people perceive and experience the lack of interaction. Although both are associated with decreases in health status and quality of life, recent literature suggests that the two terms ought to be regarded as distinct characteristics, since they may have independent impacts on health (Dickens et al., 2011). For instance, social isolation is associated with higher mortality in older men and women, but this effect is considered to be independent of the emotional experience of loneliness (Steptoe et al., 2013). When prevalence of loneliness and social isolation among older

Corresponding author at: Section of Hygiene, Institute of Public Health, Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy. E-mail address: [email protected] (A. Collamati).

https://doi.org/10.1016/j.exger.2017.11.017 Received 27 July 2017; Received in revised form 17 October 2017; Accepted 24 November 2017 Available online 02 December 2017 0531-5565/ © 2017 Elsevier Inc. All rights reserved.

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generations is concerned, research reports quite inconsistent figures. It has been suggested that loneliness in older adults is most prevalent in the “oldest old”, referring to individuals aged 80 and over. Seven percent of middle-aged and older adults report feeling intense or persistent loneliness (Skingley, 2013), with a range of 5–16% reported across the literature (Windle et al., 2011). In addition, the review of Dickens et al. (Dickens et al., 2011) reported prevalence figures of social isolation among older people around 7–17%, depending on the definition and outcome measure used. Recently, interventions targeting loneliness and social isolation among older individuals have been extensively studied in the literature. Indeed, several reviews tried to summarize the effects of these interventions, implementing various approaches and incorporating diverse inclusion criteria. Many of them, however, did not include a systematic approach and reached indefinite conclusions, stressing the need for further research (Stojanovic et al., 2017). One of the most recent systematic reviews on this topic evaluated the utility of loneliness interventions among the older generations and covered all primary studies published up to year 2011(Cohen-Mansfield and Perach, 2015). With this premise in mind, our systematic review aims to summarize and update the current knowledge on the effectiveness of the existing interventions for alleviating loneliness and social isolation among older persons.

outcome measures the effects of the intervention for alleviating social isolation or loneliness, using quantitative study designs as well as qualitative analyses examining people's perspectives or experiences. No particular restriction on study design was applied. 2.3. Study selection Our analysis was conducted screening articles titles, abstracts and ultimately analysing full text articles of potentially eligible papers. Two reviewers independently performed these processes and disagreements were resolved through discussion (AP and JS). We hand-searched the reference lists of the retrieved articles to identify additional relevant studies. The systematic review was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supplementary Table 1) (Moher et al., 2009). 2.4. Data extraction Data from the eligible studies were extracted using structured sheets containing information on intervention, type of study, participants' characteristics, follow-up periods, settings, outcomes measured and main findings. The outcomes assessed in the individual papers were classified into four domains. Our particular fields of interest were effect of interventions on dimensions of social health, including data on loneliness and social isolation. Furthermore, secondary outcomes included mental health (depression, mental well-being), physical health and quality of life were assessed, if present. All the results were extracted as between group differences, before-after measurements or measures of effect, along with details regarding statistical significance that were collected through a methodology similar to vote-counting (Hedges and Cooper, 1994). Theoretical basis of the interventions was also a subject of our investigation and we reported whether or not the authors stated that their intervention was based on a theoretical approach (Dickens et al., 2011).

2. Materials and methods 2.1. Search strategy We performed a systematic search of PubMed, ISI Web of science, SCOPUS, The Cochrane Library, and CINAHL databases in order to identify potentially eligible papers not included in previously published review of Cohen-Mansfield et al. (Cohen-Mansfield and Perach, 2015). Two investigators were independently involved in this process (AP and JS). Our search terminology derived from the scoping review of Prohealth 65+ Project (“65 + PRO-HEALTH - Home page,”, n.d.) and it included a broad initial search for health promotion, prevention, and related interventions addressed to the older population (Duplaga et al., 2016). The search was designed according to the PICO model, incorporating both classical health promotion definition and types of intervention specified by McKenzie et al. (McKenzie et al., 2013). The example of PubMed search terminology is outlined below: (“social isolation” OR solitude OR aloneness OR loneliness OR “emotional isolation”) AND (older OR elder* OR senior* OR geriatric OR aged OR ageing OR ageing OR “Old age” OR “Old people“) AND (“social participation” OR “social support” OR “social involvement” OR promotion OR program OR programme OR plan OR intervention OR “Health promotion” OR prevention OR Campaign* OR “Health programme” OR “Health program” OR “Health prevention” OR “Social care” OR “Social intervention” OR Screening OR “Health education” OR “Health literacy” OR “Health communication” OR “Health advocacy” OR “Community advocacy” OR “Social campaign” OR “Social campaigns” OR “Health coaching” OR “Environmental change strategies” OR “Healthy environment” OR “Community mobilization” OR “Behavior modification” OR Screening OR “Primary prevention” OR “Health screening” OR “Support groups” OR “Social network” OR “Social gathering” OR “Health changes” OR “Legislation” OR “Regulation”) AND (Effectiveness OR Efficacy OR Efficiency OR Impact OR Evidence OR Outcomes).

2.5. Study evaluation The Effective Public Health Practice Project (EPHPP) tool (Moher et al., 2009) was used for evaluation of included quantitative studies, due to its suitability with various study designs. This tool compromises of 6 evaluation parts (selection bias, study design, confounders, blinding, data collection method, and withdrawals and dropouts) that can influence the formation of the final - overall rate (ie, strong, moderate, or weak). Qualitative study designs were evaluated using the set of criteria proposed by Salmon et al. (theoretical framework, value of study, data collection, participant description, data analysis, data interpretations) (Salmon, 2013). 3. Results 3.1. Study selection At the beginning, 1815 potential articles were identified and 429 duplicate papers were excluded. 1386 articles were title screened and 441 abstracts were assessed afterwards. According to the inclusion criteria outlined in the Materials and methods section, 15 quantitative and 5 qualitative studies were ultimately included in the qualitative synthesis (Fig. 1).

2.2. Inclusion criteria

3.2. Findings from the quantitative research

We included all English or Italian language studies that regarded implementation of loneliness/social isolation interventions, published between January 2011 and February 2016. Studies were deemed eligible if they were explicitly targeted at the population older than 65 or those papers specifically targeting the older persons (i.e. explicated in their title or in the aim of their abstract). Research needed to report as

3.2.1. Study characteristics Out of 15 studies providing outcome measures (Alaviani et al., 2015; Bartlett et al., 2013; Bøen et al., 2012; Davidson et al., 2014; Gaggioli et al., 2014; Hind et al., 2014; Honigh, 2013; Jones et al., 134

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A. Poscia et al. Fig. 1. Flowchart.

Records identified through database searching (n = 1815)

Duplicates removed (n = 429)

Records screened (n = 1386)

Abstracts assessed for eligibility (n = 441)

Full-text articles assessed for eligibility (n = 105)

Records excluded as not related to the topic (n = 945)

Abstracts excluded (n = 336)

Articles excluded: - not satisfying eligibility criteria - already covered in previous reviews

(n = 85)

Studies included in qualitative synthesis (n = 20)

Quantitative research (n =15)

Qualitative research (n =5)

interventions included older generations and the gender distribution shows that women represented a majority of subjects. In regard to interventions themselves, eleven were delivered within a group format, three were individual interventions and four used mixed approach. Moreover, types of intervention showed great variety. Seven studies (Alaviani et al., 2015; Bartlett et al., 2013; Bøen et al., 2012; Honigh, 2013; Low et al., 2015; Nicholson and Shellman, 2013; Saito et al., 2012) reported use of social support interventions, usually discussion, counselling, therapy or education, and the majority was delivered inside complex interventions. On the other hand, social activities, in form of social programmes, were offered in two studies (Bartlett et al., 2013; Gaggioli et al., 2014), while physical activity interventions were offered in three studies (Bartlett et al., 2013; Bøen et al., 2012; Mulry and Piersol, 2014), either as fitness programme or as recreational activity within a complex intervention. Four studies (Hind et al., 2014; Jones et al., 2015; Robinson et al., 2013; Van Der Heide et al., 2012) included use of technologies, such as companion robot, telephone befriending intervention, internet use and Care TV intervention. Singing sessions

2015; Low et al., 2015; Mulry and Piersol, 2014; Nicholson and Shellman, 2013; Perkins, 2012; Robinson et al., 2013; Saito et al., 2012; Van Der Heide et al., 2012), four were RCT and six had a pre-post study design. Other included study designs involved pilot trials and quasiexperimental studies. Main study characteristics are reported in the Table 1. The majority of studies included community dwelling older adults (82%), while only three were based in home care centres. As far as geographical area of interventions is concerned, great part of studies was Europe based (5), followed by Australia (4), America (3) and Asia (2). One study did not report the data on setting. The follow-up periods varied greatly across the studies, with minimum values of three weeks and maximum of two years. Table 1 reports characteristics of participants as well. The discrepancy between the number of interventions (18) and the number of included studies (15) is due to the fact that Barlett et al. (Bartlett et al., 2013) reported three different demonstration pilot projects in their study and to the fact that Jones et al. (Jones et al., 2015) focused on two different delivery modes of the same intervention (one-to-one and small group). As noted, all the 135

136

Participants drawn from the Norwegian Population Register

A group of community dwelling older adults.

Community senior citizens moving into city A within two years prior to the intervention (excluding residential facilities)

Older people receiving homecare from Proteion Thuis (a Dutch home care organization).

Community dwelling seniors particularly socially isolated mature-aged graziers.

Community dwelling seniors particularly clients from existing services

Community dwelling seniors (older people at risk of social isolation, within different social settings) particularly clients from existing services Older adults from social senior centres that are affiliated with the ANCESCAO organization; Student participants from primary schools located in the same area Non-institutionalized older people, specifically groups at high risk of loneliness

Bøen et al., 2012

Perkins, 2012

Saito et al., 2012

Van Der Heide et al., 2012

Bartlett et al., 2013 1

Bartlett et al., 2013 2

Bartlett et al., 2013 3

Honigh, 2013

Gaggioli et al., 2014

Participants

Author, year

Pre-post study

Quasi-experimental pre-test post-test intervention study

parallel-group RCT

G

G

M

Pre-post study

Pre-post study

G

G

Pre-post study

I

Pre-post study

RCT

G

M

Pilot trial

RCT

Type of study

G

G

Int typea

Table 1 Main characteristics of the interventions reported within studies with quantitative designs.

6 weeks

2 years (2008–2010)

Three weeks

12 months (2005/ 2007)

Six months, (2005/ 2006)

Six months, (2005/ 2006)

12 months

6 months

6 weeks

12 months

Follow-up

The intervention consisted of: 1. A mass media campaign; 2. Information meetings (Tips on healthy ageing); 3. Psychosocial group courses focusing on the development of coping and communication skills; 4. Social activation by the community-based Neighbours Connected intervention; 5. Training of intermediaries Telephone befriending intervention

The CareTV duplex video/voice network. CareTV has following applications: (1) Alarm Service (2) Care Service (3) Good morning/good evening service (4) Welfare and housing and (5) Family Contact. Seniors Connecting: A regular fitness programme and an arts programme, with a focus on building individual/ community capacity by providing transport and training Connecting Points– Connecting People: Community forums, better integration of services for older people including establishing a shop front contact point, development of an action plan and resource kit, and the implementation of a ‘buddy system’ Culturally Appropriate Volunteer Services (CAVS): social/leisure activities and library services for older migrants through two ethnic community organizations Intergenerational reminiscence program led by a psychologist. Sharing of personal memories with the younger participants.

An educational, cognitive, and social support program focused on improving community knowledge and networking with other participants.

A structured horticultural therapy (HT) program consisting of: 1) Herb of the Day, 2) Learning a Planting Technique, 3) Main Activity, and 4) Cooking a Snack

A preventive senior centre programme, addressing psychosocial problems. Discussion groups and physical training were included.

Intervention

Hervey Bay, Australia (Regional setting)

Brisbane, Australia (Urban/metropolitan setting)

/

/

De Jong Gierveld Loneliness Scale; Adaptation of The Duke Social Support Index (DSSI)

De Jong Gierveld Loneliness Scale; Adaptation of The Duke Social Support Index (DSSI)

De Jong Gierveld Loneliness Scale; Adaptation of The Duke Social Support Index (DSSI)

UK (continued on next page)

Loneliness Literacy Scale, developed within the framework of Healthy Ageing; Social Support ListInteractions (SSL12-I); De Jong Gierveld loneliness scale

Greenvale, Australia: (Remote/rural setting)

/

Province of Gelderland, Netherlands.

Not specified

/

The usual municipal health and welfare services and social activities.

Tokyo, Japan

No intervention

Italian versions of Loneliness Scale (ILS); Italian version of WHO Quality of Life Scale; Rosenberg's Self Esteem Scale; Flow State Scale

Carol Stream, Illinois Wake Forest, North Carolina.

No intervention

Oslo-3 Social support scale (OSS-3); Beck Depression Inventory (BDI); Life satisfaction-scores on a question about quality of life; Self-reported health-scores on a question of health. Well-being (WHO-5 Well-Being Index); Self-esteem (Rosenberg SelfEsteem Scale); Self efficacy (Garden Experience Measure); Social connectedness/isolation (The Friendship Scale). Japanese version of LSI-A; Japanese version Geriatric Depression Scale GDS scale; Ando-Osada-Kodama AOK loneliness scale; Indicators of social support, network and activity De Jong Gierveld Loneliness Scale; Feelings of safety- questionary developed in cooperation with experts of the homecare organization.

Castanese, Italy

Oslo, Norway

Usual daily activities

Outcome measure

/

Setting

Control

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Independently living older people registered with general practices.

Community-dwelling older adults, users of the CARELINK program

Older adults from Selwyn Heights retirement home (hospital and rest home areas)

Older community-dwelling people: Home care clients of Silver Chain (health and aged care service provider) and the readership of a local community newspaper Urban community older adults who self-identified as having difficulty with community mobility

City-dwelling old women who referred to the centre with a moderate loneliness level

Participants recruited through existing contacts with older people through UK's largest charity for older people—tenants of Plymouth Community Homes Participants recruited through existing contacts with older people through UK's largest charity for older people—tenants of Plymouth Community Homes Older adults from five aged home care providers, including 2 specializing in care for ethnic minorities

Hind et al., 2014

Nicholson and Shellman, 2013

Robinson et al., 2013

Davidson et al., 2014

Alaviani et al., 2015

Jones et al., 2015 1

137

Low et al., 2015

Jones et al., 2015 2

Mulry and Piersol, 2014

Participants

Author, year

Table 1 (continued)

Pre-post study

G

Quasi-experimental study

Pre-post study

I

M

Quasi-experimental

G

mixed method design

G

One group pre–post-test design

RCT

G

M

Posttest-only design

Type of study

I

Int typea

12 months

1st follow-up/up to 42 weeks 2nd follow-up/up to 44 weeks

1st follow-up/up to 42 weeks 2nd follow-up/up to 44 weeks

Jan–Nov 2013

4 weeks

8 weeks

12 weeks

Sept 2004–Jan 2005

Follow-up

The Lifestyle Engagement Activity Program (LEAP)- a training and practice change program for home care case managers and care workers to incorporate social support and recreational activities as part of home care.

Basic computer use, how to get online and search the Internet, online shopping, email, Skype or Face Time, and online news and entertainment.

Multi-strategy program based on constructs of Pender's Health Promotion model (Perceived benefits, barriers, self- efficacy, interpersonal influences, behaviours) Basic computer use, how to get online and search the Internet, online shopping, email, Skype or Face Time, and online news and entertainment.

Let's Go, a community mobility program - didactic presentations, peer exchange, direct experience, personal reflection, exploration of alternative transportation options and experiential learning.

University student model of care intervention. Variety of techniques (reminiscence, exercise-talk discussions, goal-oriented, social engagement-directed discussions, coaching, modelling). Interaction with an advanced companion robot Paro that responds to contact and other stimuli in its environment by moving or imitating the noises of a baby harp seal. Discussion groups were held during sessions Weekly singing sessions led by an experienced musician.

Intervention

Plymouth, UK.

/

New South Wales, Australia

Plymouth, UK.

/

/

Gonabad, Iran

New Jersey, USA

No intervention

/

Perth, Western Australia

Hillsborough, Auckland, New Zealand

Bus trips; alternative activity - crafts, movies, or bingo; Interaction with the resident dog

/

Mid-sized urban community in the northeastern United States

Setting

No intervention

Usual health and social care provision.

Control

The Homecare Measure of Engagement Staff report HoME-S; Client-Family interview HoME-CF; Cohen-Mansfield Agitation Inventory; Agitation, Dysphoria, Apathy subscale of The Neuropsychiatric Inventory -Clinician Rating Scale; Geriatric (continued on next page)

Lubben Social Network Scale; De Jong Gierveld loneliness scale; Tennant's Short Warwick-Edinburgh Mental Well-Being Scale

Lubben Social Network Scale; De Jong Gierveld loneliness scale; Tennant's Short Warwick-Edinburgh Mental Well-Being Scale

The Impact on Autonomy and Participation Questionnaire (IPAQ); The Modified Falls Efficacy Scale (MFES); The Let's Go Participant Survey; Semi-structured interviews evaluating perspectives and reactions to the program UCLA loneliness scale; Questionnaires based on Pender's Health Promotion Model about loneliness

UCLA Loneliness Scale (UCLA); Geriatric Depression Scale (GDS); Medical Outcomes Study Short-Form (SF-36) Health Survey

UCLA Loneliness scale; Geriatric Depression Scale (GDS); Quality of Life for Alzheimer's Disease (QoLAD); Observations of residents' social behaviours when the robot/resident dog was present/absent

Short Form questionnaire-36 items (SF-36); Patient Health Questionnaire (PHQ-9); European Quality of Life-5 Dimensions (EQ-5D) score; General Perceived Self-Efficacy Scale (GSE); de Jong Gierveld Loneliness Scale score; Office for National Statistics (ONS) well-being measure Lubben Social Network Scale-LSNS

Outcome measure

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Depression Scale; Revised UCLA Loneliness Scale;

a G-group; I-individual; M-mixed. Higher number of interventions (17) with respect to the number of included studies (15) is due to the fact that the three different demonstration pilot projects in the study of Barlett et al. were reported separately.

Author, year

Table 1 (continued)

Participants

Int typea

Type of study

Follow-up

Intervention

Control

Setting

Outcome measure

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were performed in the study of Davidson et al. (Davidson et al., 2014), while use of horticultural therapy was proposed by Perkins et al. (Perkins, 2012). 3.2.2. Study findings As far as effectiveness of the interventions is concerned, six out of 11 group interventions (55%), one out of four mixed interventions (25%) and all three individual interventions reported at least one significant finding on social health outcomes of loneliness and social isolation. The data are presented in the tables 2 and 3. Interventions implemented within complex programs, incorporating various approaches seemed to provide most success. The study of Saito et al. (Saito et al., 2012) included Japanese older participants experiencing recent residential relocation. Educational, cognitive, social support programme focused on improving community knowledge and networking with other participants and various community “gatekeepers”. The role of “gatekeepers” was to facilitate connections between the study participants and community services. This group-based program showed significant changes in loneliness levels and informal social support, in comparison with the control group. Two quasi-experimental studies investigated multi-strategy interventions, one was based on Pender's Health Promotion model (Alaviani et al., 2015) and the other incorporated social support and recreational activities within The Lifestyle Engagement Activity Program (Low et al., 2015). Alaviani et al. (Alaviani et al., 2015) reported significantly lower scores of loneliness among the city-dwelling older individuals, while Low et al. (Low et al., 2015) did not confirm this association in the mixed initiative reported, although functional social support increased significantly among the home care clients. Moreover, one university student model of care intervention (Nicholson and Shellman, 2013) was explored in a sample of community-dwelling older adults. Variety techniques used in this one-to-one intervention (reminiscence, exercise-talk discussions, social engagement-directed discussions, coaching, etc.) showed significant improvements in social health outcomes. Indeed, the participants of the comparison group were nearly 12 times more likely to be socially isolated. However, the authors stressed that the generalizability of the findings is rather low and that future implications are warranted only after conducting a randomized controlled trial with a larger and more diverse sample. Furthermore, the potential of intergenerational reminiscence therapy in reducing loneliness has been confirmed in the feasibility study of Gaggioli et al. (Gaggioli et al., 2014). The intervention included groups of seniors and children, guided by a psychologist that encouraged older participants to share their memories and promote interaction. Out of four studies reporting interventions using technologies, three showed significant improvements in at least one of the outcomes in the social health domain. Jones et al. (Jones et al., 2015) explored the effects of the internet use on older peoples' contacts with others, loneliness, and mental health. The intervention included both individual and small group sessions that covered basic computer use, how to get online and search the Internet, online shopping, email, Skype or FaceTime, and online news and entertainment. Volunteer help to go online delivered in small group format significantly increased social contacts and reduced loneliness among the older persons. Since animal therapy showed some success in the past, research has turned to creating companion robots that have the potential to offer similar benefits. Psychosocial effects of advanced companion robot Paro were shown to decrease loneliness in older people from one retirement home. The comparison to the control group attending normal activities indicated that a companion robot has an affect comparable to a live animal and might address some of the unmet needs of older people (Robinson et al., 2013). A study published in 2012 (Van Der Heide et al., 2012) examined whether Care TV, which has various applications including alarm 138

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Table 2 Results of 18 interventions (social health outcomes). Author, Year

Number of participants

Age range Mean age (SD)

Gender

Intervention effect

Bøen et al., 2012

I = 37 C = 55 I = 27 C=7

> 65 years

I = 59.5% female C = 54.7% female 30 female

A non-significant increase in social support in both groups appeared, but was greatest in the intervention group. Results indicate no significant differences in pre- and post-test scores between the two groups for well-being, garden experience and social connectedness. A significant difference between the groups for selfesteem and garden knowledge was found. The intervention program was effective for improving subjective wellbeing, informal social support, and familiarity with services in the community and for reducing loneliness among older people who experienced a recent residential relocation. At a group level, feelings of loneliness significantly decreased, as well as emotional loneliness and social loneliness scores. Individually, total loneliness decreased between start and end of the study in 54 out of the 85 clients (63%). No significant differences in loneliness and social support from the start to the end of programme. No significant differences in loneliness and social support from the start to the end of programme. Greater loneliness reported at programme start, than in the end (results were significant). Social support at the end of the program was significantly higher. The older people reported a decrease in feelings of loneliness after the intervention (emotional loneliness decreased significantly, but social loneliness did not). No significant changes in social support and loneliness could be observed over time in either the intervention or the control group.

Perkins, 2012

Age range 57–87 Mean age 72 (9.26)

Saito et al., 2012

I = 20 C = 40

Age range 66–84 I 72.6 (4.4) C 72.8 (4.8)

I = 60% female C = 30% female

Van Der Heide et al., 2012

N = 85

Mean age 73.1 (11.2)

60% female

Bartlett et al., 2013 -1 Bartlett et al., 2013 -2 Bartlett et al., 2013 -3

N = 31

Age range 55–80 Mean 65 (1.2) Age range 57–81 Mean 69 (2.2) Age range 63–86 Mean 78 (1.7)

57% female

Gaggioli et al., 2014

Older people = 32 Students = 114

No data

Honigh, 2013

I = 440 C = 418

Hind et al., 2014

I = 30 C = 26

Nicholson, 2012

I = 28 C = 28

Robinson et al., 2013

I = 17 C = 17

Older people 67.53 (6.04) Students 10.99 (1.47) > 65 years I 73.6 (5.9) C 73.8 (6.4) Aged > 74 years I 83.2 (6) C 80.2 (3.8) > 65 years I 82.9 (9.7) C 82.3 (7.9 Age range 55–100 years

Davidson et al., 2014

Silver Chain group = 13 Community group = 16 N=7

Mulry and Piersol, 2014

N = 15 N = 13

Silver Chain 79 (4.2) Community 76 (5.2)

73% female 54% female

I = 56% female C = 53% female I = 69% female C = 53% female I = 71.4% female C = 75% female 40 residents (13 men) were present at the beginning

at least 62

Silver Chain group = 94% female Community group = 58% female 57% female

Alaviani et al., 2015

I = 75 C = 75

Age range 60–74

100% female

Jones et al., 2015 1

One-on-one group = 58

Female 71.5% of total

Jones et al., 2015 2

Small group = 86

Age range 75–84 One-on-one group 79.0 (7.5) Age range 75–84 Small group 74.3 (8.2)

Low et al., 2015

N = 189

Age range 52.8–113.6 Mean 82.6 (8.1)

Female 71.5% of total

73.5% female

The pilot study met its recruitment targets but an insufficient number of volunteers was recruited to deliver the service. The trial closed early. The participants of the comparison group were nearly 12 times more likely to be socially isolated (results were statistically significant). A significant decrease in loneliness was observed among the intervention group, when comparing to the controls. The impact of the resident dog and social robot on the social environment was noticed. Residents talked to and touched the robot significantly more than the resident dog. There are no measureable benefits of the intervention. Study-specific measures indicated that many participants had positive gains.

Majority of participants maintained or improved on the social life and participation subscale at the program's conclusion and follow-up reporting social life and relationships were fair or better. The average score of loneliness in the intervention group was significantly lower after the study. Barriers to stop loneliness, perceived social self-efficacy and interpersonal influences increased. One-on-one intervention affected significantly social networks of the participants. Small group intervention significantly increased social contacts, reduced loneliness, and improved mental well-being of the older people. Clients reported a significant increase in self- or family-reported client engagement and a significant decrease in apathy, dysphoria, and agitation. There were no significant differences in clients' measures of loneliness.

I-intervention group C-control group.

support intervention of Saito et al. (Saito et al., 2012) improved mental well-being and the authors suggested that effective programs should utilize existing community resources and should take into account specific needs of the individuals.

service, family contact and care service, has the potential to engage the older people in meaningful social contacts by a video connection to avoid loneliness. After 12 months of follow up, feelings of loneliness significantly decreased among those who received homecare services. Only few interventions reported outcomes on mental and physical health, showing rather limited effectiveness (Table 3). Surprisingly, interventions incorporating physical activity did not reach firm conclusions or did not measure physical health outcomes. Besides improving social health, the guided computer use reported in the study of Jones et al. (Jones et al., 2015) showed positive effects on mental wellbeing and quality of life of the older individuals. Furthermore, social

3.2.3. Quality assessment of quantitative primary research Quality assessment of the quantitative research designs is presented in the Supplementary Table 2 and it revealed that majority of included studies had weak ratings (n = 13, 87%). The remaining two were qualified as moderate (13%). The section that refers to the blinding was of particular concern. This part addresses attempts to blind the 139

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Table 3 Outcomes of the interventions within quantitative studies by significance. Author, year

Theory baseda

Delivery modeb

Social health Loneliness

Bøen et al., 2012 Perkins, 2012 Saito et al., 2012 Van Der Heide et al., 2012 Bartlett et al., 2013 - 1 Bartlett et al., 2013 - 2 Bartlett et al., 2013 - 3 Gaggioli et al., 2014 Honigh, 2013 Hind et al., 2014 Nicholson and Shellman, 2013 Robinson et al., 2013 Davidson et al., 2014 Mulry and Piersol, 2014 Alaviani et al., 2015 Jones et al., 2015 Jones et al., 2015 Low et al., 2015 (76)

− + + − − − − + + − + − − + + − − +

G G G I G M G G G M I G G M G I G M

Mental health Social isolation

Depression

⁎

⁎

Quality of life

ns

ns

Mental well-being

ns ns

Physical health

ns ns

⁎

⁎ ns ns ⁎

⁎

⁎

⁎

ns

ns /

/

/

/

/

/

⁎ ⁎

⁎

ns

ns

ns

ns

⁎

⁎

ns

⁎

⁎

⁎

ns

⁎

ns

ns ⁎ ns

⁎

⁎

Theory based: + if the authors state some sort of theoretical basis behind the intervention, − there is no mention of any theoretical approach. Delivery mode: G = Group; I = individual; M = mixed. ⁎ Significant positive effect. ns No statistically significant (p ≥ 0.05) outcome. / Trial closed early.

a

b

well-being and successful ageing of the older people. The authors also stressed that health and social care services ought to work more closely in order to reinforce the sustainability and build the evidence of effectiveness and cost-effectiveness of such programmes.

participants and assessor (or caregiver) from the intervention outcomes being examined. The studies prevalently reported limited data or did not report at all the information regarding these issues. The second relevant issue that caught our attention was selection bias section. The majority of the studies used convenience samples leading to populations that were not likely representative of the target population.

3.3.3. Quality assessment of qualitative primary research Criteria proposed by Salmon et al. (Salmon, 2013) were used for assessing the quality of research with descriptive methodologies. Overall, the quality of most studies was rather low, since the authors usually failed to address several key methodological issues (Supplementary Table 3). All five studies accounted for the background literature and four of them added some new findings to the current body of evidence. The studies were quite good in presenting the results, meaning that the authors of only one study reported the data in a superficial manner and the rest of them focused also in interpreting the findings in light of the context and discussing future implications. However, none of the studies discussed the findings based of theories. As far as methodological part of the studies is concerned, majority of the studies did not explain clearly the interviewee recruitment process. Size and the characteristics of the sample were reported, but without any indication whether the number of participants was a result of a theoretical saturation. Furthermore, three studies reported clearly interview protocols and coding procedures and four of them failed to explain how and why a certain setting was chosen.

3.3. Findings from the qualitative research 3.3.1. Study characteristics Five studies (Milligan et al., 2013; Moody and Phinney, 2012; Newall and Menec, 2013; Teater and Baldwin, 2014; Vogelpoel and Jarrold, 2014) with descriptive methodologies and mixed-method approaches were also identified in our search and were ultimately included in our analysis. Three of these were conducted in UK and two in Canada. The majority of participants of the included studies were female, except one study that focused on Men Sheds. Main characteristics and study findings are reported in tables 4 and 5, respectively. Four programmes were conducted in a group format and one represented individual intervention. The one-to-one programme was focusing on support, education and befriending intervention over the telephone. Regarding group interventions, three studies reported Community engaged arts (CEA) programmes, one of which was specifically dedicated to older people with sensory impairments experiencing social isolation. The last one included Men's Sheds where older men had the opportunity to spend time socializing and learning new skills.

4. Discussion 3.3.2. Study findings Social health outcomes, as well as participants' experiences, perspectives and opinions on the intervention itself, were mostly gathered as self-reported end results were collected through semi-structured interviews, focus groups or dynamic observations. Participants generally reported that the interventions had had a positive impact on their social health. For example, community-arts programmes helped participants to expand their community connections, and develop a meaningful role through art, which highlights the fact that CEA can play a distinctive role in supporting social inclusion of community-dwelling seniors. Preventative programmes, operating through charitable and community organizations, have a potential in contributing positively to health,

The purpose of this systematic review was to update the current knowledge on the effectiveness of interventions aimed at alleviating loneliness and social isolation among the older people. Our search yielded 15 quantitative and 5 qualitative studies, which had incorporated various approaches. The results suggested that six out of 11 group interventions (55%), one out of four mixed interventions (25%) and three out of three individual interventions (100%) reported at least one significant finding on social isolation or loneliness. These figures are somewhat diverse to the results of previous reviews published in this field. For example, Cattan et al. (Cattan, 2005) identified group interventions with educational and social activity input to be effective. 140

Experimental Gerontology 102 (2018) 133–144

On the other hand, the review of Cohen-Mansfield compared group and individual interventions, arguing that the group ones were less often evaluated as effective, more often evaluated as potentially effective and less often evaluated as ineffective. There are numerous possible explanations for the variability of intervention effects. For example, group interventions might provide beneficial effects and create a sense of security and belonging, but the true effect of the intervention might be masked by the nature of gathering in a group (Masi et al., 2011). Individual interventions on the other hand, might offer higher quality of created bonds and influence empowerment to engage socially (Nicholson, 2012). Although our results suggest that both group and individual formats might be worthwhile for tackling loneliness and social isolation among the older individuals, it would be presumptions to firmly determine the superiority of one over the other based on the eligible study sample. In addition, if we take into account the methodological quality of the included studies, only two were regarded as moderate quality and all of the others were rated as week. However, it should be taken into account that the section referring to blinding of participants and assessors was one of the critical parts of the assessment scale. The studies reported limited data or did not report at all the information regarding these issues, but we argue that this may be explained by the nature of particular interventions. For instance, if an intervention includes the use of computer technology it is highly unlikely that the caregiver will be blinded to the intervention status. Also, participants included in interventions containing discussion sessions, with an educational input, would probably not be blinded to the research question. If we had not considered the blinding section in the overall scoring, we would have obtained the following results: two studies rated as strong (13%; one group and one individual approach), four studies rated as moderate (27%, out of which three were developed within a group format) and nine weak studies (60%). In reference to the nature of the interventions, our review identified multi strategy programmes, incorporating social support component for instance, as promising tools. Alaviani et al. performed an evaluation of one specific health promotion model (Pender et al., 2006), based on social cognitive theory, and proved it's successfulness in alleviating loneliness, by recognizing behaviours and personal factors with increased efficacy and improving communication and situations (Alaviani et al., 2015). This finding is backed up by one previous review (Dickens et al., 2011), which reported that theory based interventions provided more beneficial effects. Furthermore, interventions that were rated as methodologically strong and showed positive effects were developed within existing services. Such approach was analysed in study of Nicholson and colleagues, where both academic and community resources were used in the intervention that fostered open communication and numerous relationship-building techniques in order to help older adults connect with others (Nicholson and Shellman, 2013). Saito et al. reported an intervention that improved social integration of older individuals experiencing recent relocation in the community by utilizing community volunteering organizations (Saito et al., 2012). Thus, a rational use of existing services might influence the sustainability of interventions and lead to positive outputs, and it would also “resolve” the issue of volunteer participants commonly found across the literature, enabling in that way the intervention to target the intended groups (Pitkala et al., 2009). Three out of four technology interventions reported significant findings and this review supports the use of technology interventions for alleviating loneliness and social isolation, which was consistent with the previous studies (Chen and Schulz, 2016; Choi et al., 2012; CohenMansfield and Perach, 2015). The studies evaluated in our review applied diverse approaches, such as help in computer use, interaction with companion robot and Care TV. A recent meta-analysis (Choi et al., 2012) dealt with computer and Internet training interventions among the older individuals. Five studies were retrieved in the search process, focusing on this specific topic, and overall mean weighted effect size indicated a positive effect of these interventions (Hedges's g

Not specified UK

UK

G

Mixed-method approach Qualitative study A social prescribing service-arts workshop programme for older adults with sensory impairments experiencing social isolation. Sheds provide a space for older men to meet, socialise, teach and learn new skills and participate in ‘DIY’ or similar activities with other older men. All three Sheds aimed to target lone-dwelling, lonely and socially isolated older men from deprived areas. Vogelpoel and Jarrold, 2014 Milligan et al., 2013

G

UK Mixed method approach G

Canada Process evaluation I

12 weeks

Participant observation, interviews, document analyses allowed reaching the final conclusions Health and limitations; Loneliness; Social isolation and meaningful social contact; Program feedback Self-reported social relationships and social connections; The questionnaire consisted of (i) Index of Arts as Self-Health Enhancers; (ii) Index of Arts as Self-Developing Activities; and (iii) Index of Arts as Community Builders. Interviews and dynamic observation; Outcomes included self-confidence, social isolation, establishment of new friendships and mental well-being. Self-report and perceived health and well-being gathered through semistructured interviews and focus groups 6-week period in the spring 2008 May–Sept 2011 Oct–Dec 2011 Started in Jan 2008 Canada Qualitative study

A Community-Engaged Arts (CEA) program for older community-dwelling adults participating in the Arts, Health and Seniors Program Community-engaged social program - Senior Centre Without Walls offering social and educational opportunities over telephone The Golden Oldies - a CEA program that provides an environment and resources for older adults to get together and sing songs for 1 h a week. Moody and Phinney, 2012 Newall and Menec, 2013 Teater and Baldwin, 2014

G

Intervention Author, year

Table 4 Main characteristics of the studies with qualitative designs.

Type

Type of study

Setting

Follow-up

Outcome measure

A. Poscia et al.

141

142

CEA-Community engaged arts programme.

Men Sheds

Milligan et al., 2013

a

Arts workshop programme

Vogelpoel and Jarrold, 2014 N = 62 100% male

N = 12 75% female

N = 120 82.5% female

N = 26 92% females

Senior Centre Without Walls – telephone intervention

Newall and Menec, 2013

The Golden Oldies- CEA singing sessions

N = 20 95% female

CEAa program

Moody and Phinney, 2012

Teater and Baldwin, 2014

Participants (N, Gender)

Intervention

Author, year

Table 5 Summary of key finding from the qualitative studies assessed (N = 5).

Median: Shed 1:73.8 Shed 2: 68 Shed 3: 69.5

Range: 61–95 Mean: > 80

Mean: 74

Range: 57–85

Range: 65–90

Age

- were very satisfied with the program - reported that SCWOW had several positive effects (e.g., connecting to the larger community, affecting mental well-being) - - did not report barriers to participation were identified. Between 73.1 and 98% of participants agreed or strongly agreed that the programme contributed to their selfdevelopment, health and sense of community as well as revealing a statistically significant increase in self-reported health prior to participation in the programme to the time of the study. Qualitative analysis (n = 5) revealed three themes—the Golden Oldies as: (i) a reduction in social isolation and increase in social contact; (ii) a therapeutic source; and (iii) a new lease for life. The development of supportive relationships between participants was identified where skills, practical advice and mutual support were shared. Increased self-confidence, new friendships, increased mental wellbeing and reduced social isolation was noted. Sheds appeared to: provide a supportive environment, influencing positively men's wellbeing; to alleviate isolation through important connections developed between older men; to provide mental stimulation. Shed activity were seen to stimulate greater levels of physical activity and they sought to encourage greater health awareness among older men, through both formal (organized visits by professionals working in health promotion) and informal (Sheds may provide a particular space in which older men feel at ease discussing health and health seeking behaviours) mechanisms.

- expanding community connections - developing a meaningful role through art - - working together within a group towards shared goals The participants: - reported having no difficulty using the telephone system

Supporting social inclusion of community-dwelling seniors can be achieved through three distinctive roles of CEA:

Study findings

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Ignazio La Milia, Agnese Collamati. Analysis and interpretation of data: Stojanovic Jovana, Andrea Poscia, Nicola Magnavita, Umberto Moscato, Onder Graziano, Agnese Collamati, Walter Ricciardi. Drafting of manuscript: Stojanovic Jovana, Andrea Poscia, Agnese Collamati, Daniele Ignazio La Milia, Nicola Magnavita. Critical revision: Mariusz Duplaga, Marcin Grysztar, Umberto Moscato, Onder Graziano, Walter Ricciardi.

value = 0.546, 95% CI [0.033–1.059]). Furthermore, one study identified eight different technologies with potential beneficial effects, including general ICT, video games, robotics, personal reminder information and social management system (Khosravi et al., 2016). Moreover, the review of Cohen-Mansfield supported the use of technology interventions for tackling loneliness, in both one-to-one and group formats (Cohen-Mansfield and Perach, 2015). The variety of these interventions offers enormous potential, by offering different possibilities and ways of engagement. However, tailoring them to match the specific needs of the seniors and providing sufficient training is crucial in order to provide better performance (Stojanovic et al., 2017). Five studies, with qualitative methodologies, were identified through our search, and their inclusion in the criteria of this review was related to the fact that these methodologies may provide valuable insights, not only related to the effectiveness of the interventions, but also related to factors that may influence their implementation (Jackson and Waters, 2005; Rychetnik et al., 2002). Community engaged arts, for instance, have helped the older generations to expand their community connections and establish supportive relationships with other participants (Moody and Phinney, 2012). But they also enabled themto get in touch with their own creativity and develop meaningful roles through art. One study reported beneficial effects of participatory arts programmes for older people with sensory impairments (Vogelpoel and Jarrold, 2006). This would be of particular importance not only because the evidence on the interventions targeting sensory impaired individuals is missing, but also because these groups more often state lower estimates of self-reported health and engage in fewer social interactions (Capella-McDonnall, 2005; Crews and Campbell, 2004; Schneider et al., 2011). Despite the current research activities in this field, numerous issues arose when evaluating the interventions to reduce loneliness and social isolation among the older people. One of those is related to the lack of consensus on the definitions of these two terms (Dickens et al., 2011), and the struggle related to the measurements of these outcomes (Skingley, 2013). Furthermore, the nature of the interventions varied greatly and made the direct comparison very difficult. Additionally, a bias might have been introduced since our review included only publications on English or Italian language. Considering the strengths of our review, we aimed at finding every possible study on this matter and we adopted a broad search terminology, using various databases with minimal restrictions in the search process. Moreover, we included all studies providing outcome measures, regardless of the study design.

Funding “This publication arises from the project Pro-Health 65 + which has received funding from the European Union (2013 12 10 Pro Health 65+), in the framework of the Health Programme (2008–2013). The content of this publication represents the views of the author and it is his sole responsibility; it can in no way be taken to reflect the views of the European Commission and/or the Executive Agency for Health and Consumers or any other body of the European Union. The European Commission and/or the Executive Agency do(es) not accept responsibility for any use that may be made of the information it contains. Publication financed from funds for science in the years 2015–2017 allocated for implementation of an international co-financed project”. Preliminary results from this work have been presented as pitch presentation at the 9th European Public Health Conference “All for Health, Health for All” at the ACV - Austria Center Vienna, Vienna, 9–12 November 2016. Conflicts of interest None declared. Appendix A. Supplementary data Supplementary data to this article can be found online at https:// doi.org/10.1016/j.exger.2017.11.017. References 65 + PRO-HEALTH - Home page [www document], n.d. http://www.pro-health65plus. eu/ (accessed 10.13.17). Alaviani, M., Khosravan, S., Alami, A., Moshki, M., 2015. The Effect of a Multi-strategy Program on Developing Social Behaviors Based on Pender's Health Promotion Model to Prevent Loneliness of Old Women Referred to Gonabad. 3. pp. 132–140. Bartlett, H., Warburton, J., Lui, C.-W., Peach, L., Carroll, M., 2013. Preventing social isolation in later life: findings and insights from a pilot Queensland intervention study. Ageing Soc. 1–23. http://dx.doi.org/10.1017/S0144686X12000463. Bøen, H., Dalgard, O.S., Johansen, R., Nord, E., 2012. A randomized controlled trial of a senior centre group programme for increasing social support and preventing depression in elderly people living at home in Norway. BMC Geriatr. 12, 20. http://dx. doi.org/10.1186/1471-2318-12-20. Capella-McDonnall, M.E., 2005. The effects of single and dual sensory loss on symptoms of depression in the elderly. Int. J. Geriatr. Psychiatry 20, 855–861. http://dx.doi. org/10.1002/gps.1368. Cattan, M., 2005. Preventing social isolation and loneliness among older people: a systematic review of health promotion interventions. Ageing Soc. 25, 41–67. http://dx. doi.org/10.1017/S0144686X04002594. Chen, Y.-R.R., Schulz, P.J., 2016. The effect of information communication technology interventions on reducing social isolation in the elderly: a systematic review. J. Med. Internet Res. 18, e18. http://dx.doi.org/10.2196/jmir.4596. Choi, M., Kong, S., Jung, D., 2012. Computer and internet interventions for loneliness and depression in older adults: a meta-analysis. Healthc. Inform. Res. 18, 191–198. http://dx.doi.org/10.4258/hir.2012.18.3.191. Cohen-Mansfield, J., Perach, R., 2015. Interventions for alleviating loneliness among older persons: a critical review. Am. J. Health Promot. 29, e109–e125. http://dx.doi. org/10.4278/ajhp.130418-LIT-182. Crews, J.E., Campbell, V.A., 2004. Vision impairment and hearing loss among community-dwelling older Americans: implications for health and functioning. Am. J. Public Health 94, 823–829. Davidson, J.W., McNamara, B., Rosenwax, L., Lange, A., Jenkins, S., Lewin, G., 2014. Evaluating the potential of group singing to enhance the well-being of older people. Australas. J. Ageing 33, 99–104. http://dx.doi.org/10.1111/j.1741-6612.2012. 00645.x. Dickens, A., Richards, S., Greaves, C., Campbell, J., 2011. Interventions targeting social

5. Conclusion Although the number of studies on interventions targeting loneliness and social isolation among the older people is constantly increasing, our review did not reach solid conclusions. Some interventions have brought promising results, even though their generalizability is questionable. This review identified new technologies as a promising tool for tackling social isolation and loneliness among the older individuals along with community engaged arts, which brought positive results especially among sensory impaired populations. Having in mind that included studies did not contain all beneficial traits of successful interventions highlighted in previous reviews, our final remark relates to this fact and suggests that future research in this field should embrace recommendations of the present literature in order to provide firm evidence. Authors contributions Study conception and design: Andrea Poscia, Nicola Magnavita, Mariusz Duplaga. Acquisition of data: Stojanovic Jovana, Andrea Poscia, Daniele 143

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