The growing problem of social isolation and loneliness

Social isolation and loneliness are widespread among older people and have serious – and too often unrecognized – consequences. They affect 20-30% of older adults [1, 2] and increased among all age groups during the COVID-19 pandemic [3]. Some groups of older people are at particular risk, such as older people with disabilities and mental health conditions, home-based carers, immigrants, and those experiencing life transitions and disruptive life events (such as retirement and bereavement) [2]. The effects of social isolation and loneliness on mortality are comparable to other well-established risk factors such as smoking, obesity, and physical inactivity. They also have a serious impact on physical and mental health and on well-being [2, 4].

Social isolation and loneliness have begun to rise up the public health and wider policy agenda, accompanied by multiple calls for action. The Governments of the United Kingdom and Japan have made ministerial level appointments on loneliness and the United States Surgeon General has identified it as a priority public health issue. A Global Initiative on Loneliness and Connection has been established [5]. The World Health Organization (WHO), the International Telecommunication Union (ITU), the United Nations Department for Economic and Social Affairs (UN DESA), and UN Women have outlined a three-pronged strategy to tackle the challenge [2]. And WHO is exploring other global mechanisms to increase the political attention the issue receives and action to address it.

The growing priority of the issue and the calls for action to tackle it are to be welcomed. But to tackle social isolation and loneliness effectively we need interventions that work. We know from other often closely related fields that not all interventions work, no matter how well-intentioned their developers are or how convinced they are that they are effective. And some actually do harm. So, to avoid wasting scarce resources on interventions that do not work, building a strong evidence architecture should be a top-most priority in this field.

Building the evidence architecture to tackle social isolation and loneliness

To this end, WHO, the Campbell Collaboration, and the Bruyère Institute have released an evidence and gap map on digital interventions for reducing social isolation and loneliness in older adults as part of the UN Decade of Healthy Ageing 2021–2030 (→ access the evidence and gap map). The evidence and gap map is the starting point of a multi-year effort to build the evidence architecture to tackle social isolation and loneliness.

Evidence matters as the “80% rule” states that “80% of social interventions do not work, including many that seem like ‘no brainers’” [6, 7]. In other words, 80% of social interventions are a waste of time and money. This 80% rule comes from findings in education, where 90% of randomized controlled trials (RCTs) – one of the best tools we have to evaluate interventions – have shown weak or no positive effects. It comes from findings in employment and training programmes, where 75% of RCTs trials have shown weak or no positive effects. And it comes from the private sector, where over 80% of 13’000 RCTs conducted by Google and Microsoft reported no significant effects [8, 9].

Research on the effectiveness of psychotherapy – highly relevant to interventions to reduce social isolation and loneliness since many of these involve psychotherapeutic interventions such as cognitive behavioural therapy – has found it may have no effect in some 30–60% of cases [10, 11] and cause harm in 5–10% of cases [11, 12].

Developing a robust evidence architecture – in which evidence and gaps maps play a key role – is the best way to ensure that the best evidence is put to work to reduce social isolation and loneliness.

An evidence architecture aims to institutionalize the use of evidence in policy and practice [6]. It includes both the supply of evidence and – equally, if not more importantly – the stimulation and channelling of demand for evidence. The supply side includes, for instance, primary studies evaluating the effectiveness of interventions; systematic reviews that summarize the findings of multiple primary studies on the effectiveness of interventions; evidence and gap maps; guidelines that steer practitioners and policy makers to interventions that work, and platforms that disseminate the evidence. The demand side includes activities such as use of evidence workshop, evidence needs assessments, and evidence-based budgets that only fund evidence-based interventions [6].

Evidence and gap maps are a foundational component of an evidence architecture. They provide a visual and interactive display of the existing evidence in relation to interventions and outcomes in a particular field and are regularly updated. They serve important purposes. First, they increase the discoverability and use of evidence. Second, they steer implementers away from interventions without evidence and towards those with evidence. Third, they enable the production of higher-level evidence synthesis products such as reviews and guidelines. Fourth, they identify gaps so research can be commissioned in a more coordinated and strategic way [13].

To learn more about evidence and gap maps, watch this video:
 

About this evidence and gap map

Some of the main findings of this evidence and gap map on digital interventions for reducing social isolation and loneliness in older adults are:
 

• Most reviews (72%) are of critically low quality and only 2% are of high quality;
• Some 25% of the reviews were published since the COVID-19 pandemic;
• The evidence is unevenly distributed with most from high-income countries and none from low-income countries;
• The most common interventions identified are digital interventions to enhance social interactions with family and friends and the community via videoconferencing and telephone calls. Digital interventions to enhance social support, particularly socially assistive robots, and virtual pets were also common;
• No study or review included participants from the LGBT community and only one study focused exclusively on people 80 years and older; and
• Very few described how at-risk populations were recruited or conducted any equity analysis to assess differences in effects for populations experiencing inequities [14].

This map shows that evidence in this area is fast accumulating. 97 systematic reviews and 103 primary studies are included in this map of digital interventions. Some 80% of the primary studies are randomized controlled trials, the gold standard in evaluation studies (though the quality of the individual randomized controlled trials was not evaluated). Another 100 reviews and 450 primary studies are included in a forthcoming map of in-person interventions across all age groups.

Evidence and gap maps are the starting point for building an evidence architecture. They identify and map what evidence there is. They do not summarize the findings into an overall assessment of what works, nor do they make recommendations about which interventions should be implemented. Those are the jobs of other components of the evidence architecture – of systematic reviews, reviews of reviews, and guidelines – components on which we are currently working.

This evidence and gap map will soon be followed by another on in-person interventions to reduce social isolation and loneliness across all age groups. We have also started work on guidelines. These will be based on multiple systematic reviews and reviews of reviews, which will tell us what works and what does not, and will make recommendations about which interventions to implement. And we plan to create an evidence platform to distil this evidence in a form optimally useful to policy- and decision-makers. These are all important steps in building the strong evidence architecture needed to ensure the best evidence is put to work to make older people less lonely and isolated.

References
 

1. Surkalim, D. L., Luo, M., Eres, R., Gebel, K., van Buskirk, J., Bauman, A., & Ding, D. (2022, February 9). The prevalence of loneliness across 113 countries: systematic review and meta-analysis. bmj, 376, e067068. https://doi.org/10.1136/bmj-2021-067068
2. World Health Organization. (2021). Social isolation and loneliness among older people: advocacy brief.
3. Ernst, M., Niederer, D., Werner, A. M., Czaja, S. J., Mikton, C., Ong, A. D., Rosen, T., Brähler, E., & Beutel, M. E. (2022). Loneliness before and during the COVID-19 pandemic: A systematic review with meta-analysis. American Psychologist.  https://doi.org/10.1037/amp0001005
4. National Academies of Sciences, E., & Medicine. (2020). Social isolation and loneliness in older adults: Opportunities for the health care system. National Academies Press.
5. Global Initiative on Loneliness and Connection. Retrieved 23 November 2022 from https://www.gilc.global/
6. White, H. (2019). The twenty-first century experimenting society: the four waves of the evidence revolution. Palgrave Communications, 5(1), 1-7. https://doi.org/10.1057/s41599-019-0253-6
7. White, H., & Gough, D. (2020). Using evidence in social policy: from NICE to What Works. In Using Evidence to End Homelessness (pp. 181-195). Policy Press.
8. Baron, J. (2018). How to solve U.S. social problems when most rigorous program evaluations find disappointing effects. Retrieved 23 November 2022 from https://www.straighttalkonevidence.org/2018/03/21/how-to-solve-u-s-social-problems-when-most-rigorous-program-evaluations-find-disappointing-effects-part-one-in-a-series/
9. Pfeffer, J., & Sutton, R. I. (2006). Hard facts, dangerous half-truths, and total nonsense: Profiting from evidence-based management. Harvard Business Press.
10. Hengartner, M. P. (2018). Raising awareness for the replication crisis in clinical psychology by focusing on inconsistencies in psychotherapy research: How much can we rely on published findings from efficacy trials? Frontiers in Psychology, 9, 256. https://doi.org/10.3389/fpsyg.2018.00256
11. Lambert, M. J. (2011). What have we learned about treatment failure in empirically supported treatments? Some suggestions for practice. Cognitive and Behavioral Practice, 18(3), 413-420. https://psycnet.apa.org/doi/10.1016/j.cbpra.2011.02.002
12. Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2(1), 53-70. https://doi.org/10.1111/j.1745-6916.2007.00029.x
13. Saran, A., & White, H. (2018). Evidence and gap maps: a comparison of different approaches. Campbell Systematic Reviews, 14(1), 1-38. https://doi.org/10.4073/cmdp.2018.2
14. Welch, V. A., Ghogomu, E., Barbeau, V., Dowling, S., Doyle, R., Beveridge, E., Boulton, E., Desai, P., Huang, J., Elmestekawy, N., Hussain, T., Wadhwani, A., Boutin, S., Haitas, N., Kneale, D., Salzwedel, D. M., Simard, R., Hebert, P., Mikton, C. (2022, October 29). Digital interventions to reduce social isolation and loneliness in older adults: An evidence and gap map. SocArXiv. https://doi.org/10.1002/cl2.1260