Understanding and Responding to the Health Effects of Loneliness and Social Isolation in Ontario Home Care Community-Dwelling Older Adults

Abstract

Social isolation and loneliness are distinct concepts that are often treated as interchangeable in the literature. Both have been linked to various health behaviours and outcomes that may increase the risk of mortality, especially in older adults. However, contradictory results are often reported with some studies finding no mediation from health behaviours in the connection between loneliness and health outcomes or mortality. Similarly, the associations reported between loneliness and mortality are not always statistically significant. Within the aging population, home care recipients can be exceptionally vulnerable to loneliness-related outcomes because of their complex health needs and social changes (e.g., widowhood) that may put them at a higher risk of isolation. Social prescribing involves the implementation of social resources and programs to address biomedical concerns by connecting traditional clinical practices with community support services and activities. This upstream approach has been popularized to address and prevent loneliness, particularly after public health isolation measures implemented in COVID-19. However, the evidence base related to social prescribing, loneliness, social isolation, and health outcomes is limited. This dissertation involves a scoping review regarding social prescribing in community based older adults; development of a standardized index of social isolation; secondary analysis of the associations of loneliness and isolation with health behaviours and health outcomes; and description of a community engagement effort to codevelop targeting strategies and map resources that could be used to respond to loneliness and social isolation in one region of southern Ontario. The latter project exemplifies efforts by one region to identify and respond to loneliness and social isolation with available community resources. However, evaluation of the effectiveness of those services is not in scope for this dissertation. Study 1 is a scoping review that investigates the use of social interventions to address loneliness and social isolation in community-dwelling older adults. It provides an overview of existing literature to examine the types of resources implemented in social prescribing, as well as how social isolation and loneliness were measured in each study. The review demonstrates an array of resources that were used to target social isolation and loneliness, with the majority of successful programs including a socialization aspect; however, results were unclear due to inconsistent terminology and measurement tools. This suggests the interest in prescribing social interventions is not matched by consistent empirical evidence in support of its implementation. To establish best practices in this area, terminology and measures need to be standardized for loneliness, social isolation, and for specific types of social prescribing interventions. Study 2 involves the creation and validation of an Index of Social Isolation (ISI) based on data from the interRAI Home Care assessment. Candidate indicators were identified based on the literature. The ISI is intended to serve as an objective measure of isolation, whereas loneliness is considered to be a subjective experience in response, at least in part, to objective isolation. Four variants were created and tested, with the final ISI consisting of a count of six items. This index can be used as a continuous measure, but the analyses also identified meaningful cut-points based on the association with loneliness. Finally, the ISI was examined longitudinally to demonstrate sensitivity to contextual variables and external events. This new measure has strong potential for use within future interRAI data studies and for routine clinical practice in home and community care. Study 3 is a two-part examination of the associations of loneliness and social isolation with health behaviours and health outcomes. First, a cross-sectional analysis was done to examine health behaviours among socially isolated and lonely community-dwelling older adults receiving home care services. These may represent mediating variables linking social isolation to health outcomes. The three health behaviours considered (smoking, inadequate nutrition, medication non-adherence) reflect different mechanisms through which loneliness and isolation may be related to health. This is followed by a longitudinal analysis of the onset of new health outcomes using transitions in three different indicators of health: self-rated health, pain scores, and self-reported mood disturbance. The findings provide further insights regarding the effects of social isolation and loneliness on health, including health effects that differ between social isolation and loneliness. Study 4 is a retrospective cross-sectional needs assessment of community-dwelling older adults receiving home care services in the Huron-Perth region of Ontario, Canada. As part of a collaboration with local community partners, we compared the health needs of older adults in Huron-Perth to those in the rest of Ontario in order to identify opportunities to mobilize social resources in the community. Huron-Perth is overall a healthier region than the rest of Ontario; but important variations are evident within subregions. Loneliness and social isolation were of particular interest due to high prevalences in Huron-Perth. Study 5 provides a resource inventory of all social resources that could be used to target social isolation and loneliness in community-dwelling older adults residing in Huron-Perth, Ontario. Our findings supplemented the needs assessment done in Study 4 by summarizing and understanding the capacity of each nonmedical community service in the Huron-Perth region. Further analysis examined how the resources correspond to those found to be effective in reducing social isolation and loneliness in older adults in the literature in Study 1. The five studies captured in this dissertation provide a comprehensive examination of the complex relationships between loneliness, social isolation, health behaviour, and health outcomes in community-dwelling older adults. The included studies provide a strong foundation for future interRAI research on social isolation and loneliness while simultaneously providing key insights for the development and integration of social isolation and loneliness identification and targeting mechanisms. In conclusion, this dissertation strengthens knowledge on the identification and measurement of social isolation while providing important insights into the relationships of social isolation, loneliness, health behaviours, and health outcomes, as well as how to best implement nonmedical resources to intervene.