ORIGINAL PAPER

Graeme Hawthorne

Perceived social isolation in a community sample: its prevalenceand correlates with aspects of peoples lives

Received: 21 February 2007 / Accepted: 10 October 2007 / Published online: 9 November 2007

j Abstract Although there are many studies report-ing perceived social isolation or loneliness and theircorrelates in specific groups, there are few modernprevalence studies. This study reports on the preva-lence of perceived social isolation in an Australiancommunity sample. Randomly sampled Australianadults (n = 3,015) were interviewed using a standardquestionnaire. In addition to perceived social isolationassessed by the Friendship Scale, data were collected onsocio-demographic variables and chronic health con-ditions. The findings suggest that while most partici-pants were socially connected, 9% reported some socialisolation and 7% were isolated or very isolated. Per-ceived social isolation varied by gender and age group,region of birth, relationship, labourforce, and incomestatus. A key finding was that younger adults had higherprobabilities of being classified as being socially iso-lated than did older participants. Depression was verystrongly associated with perceived social isolation.Other health conditions or life experiences associatedwith it were hearing, incontinence and lifetime traumaexposure. The demographic characteristics andchronic health conditions associated with perceivedsocial isolation are structural circumstances of peopleslives. Given there are poor long-term health outcomes,including early death and suicide, there are clear publichealth implications for those trapped by these life cir-cumstances.

j Key words perceived social isolation loneliness social support social isolation prevalence community

Introduction

Although there are many stereotypes of perceivedsocial isolation and loneliness, few recent studies haveexamined its community prevalence. Generally, it hasbeen studied in the young, aged, and those with healthconditions. It is associated with mental and physicalillness [11, 23, 27, 29, 32, 46, 54, 55, 70, 71, 98], spe-cific conditions and behaviours [19, 23, 35, 68, 79],homelessness and ethnicity [27, 68], ageing and ashorter life length [11, 34, 36, 46, 55, 64, 81, 95, 101].

Because mental and physical health conditionsboth predict and are associated with perceived socialisolation, prevalence estimates from non-populationsamples may overstate and distort its correlates.

Based on community sampling, this study ad-dresses Heinrich and Gullones [41] call for a con-temporary prevalence study. It provides prevalenceestimates of perceived social isolation, including itsrelationship with demographic characteristics andhealth conditions.

j Defining perceived social isolation

The link between perceived social isolation and healthcan be explained by psychological theories regardingthe human need for social relationships [14].Attachment theories postulate that childhood experi-ences predispose adult social network behaviours [13,33], that social networks affect responses to stressors[20, 103] and that social support provides a bufferagainst crises [23, 76]. Collectively, these are consis-tent with the existential loneliness hypothesis; i.e. thatpeople need to belong [7, 10, 41, 65]. Because this isan internally regulated need it must reflect the per-spective of the individual [62, 87].

Perceived social isolation is thought to be the ab-sence of this social support (or perceived socialcompetence [4]), where social support is broadly de-fined as living with companionship, social contacts,SP

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G. Hawthorne, PhD (&)Dept. of PsychiatryThe University of MelbourneLevel 1 North, Royal Melbourne HospitalGrattan StreetParkville (VIC) 3050, AustraliaTel.: +61-3/8344-5467Fax: +62-3/9349-2792E-Mail: graemeeh@unimelb.edu.au

Soc Psychiatry Psychiatr Epidemiol (2008) 43:140150 DOI 10.1007/s00127-007-0279-8

participating in a society and feeling a valued andsupported member of a friendship group or com-munity [41, 53, 62, 99]. Perceived social isolationdescribes the subjective feelings of living withoutthese social contacts or supports; it is the self-assessedfeelings of social isolation [56, 73]. It can be con-trasted with objective or actual social isolation, whichdescribes the more objective number of social con-tacts (e.g. the number of people in a persons socialconvoy [38, 53]).

Although the literature has made this distinctionsince Townsend [96] and Weiss [103] who labelledthese emotional and social isolation respectively (alsodescribed as emotional and social loneliness), there isevidence that they share, in Russell et al.s words, asizeable common core of experiences ([84], p. 1,317).Although the UCLA Loneliness Scale, one of the mostpopular scales in this field, measures feelings ofloneliness, when examined against measures of Weisssocial and emotional isolation, it correlated similarlywith both (r = 0.47 and r = 0.44, respectively) [84].Likewise the correlation between the two sub-scales(emotional loneliness and social loneliness) of thede Jong Gierveld Loneliness Scale was r = 0.55 [9].Oshagan and Allen [75] reported that the correlationbetween social isolation and loneliness was r = 0.86and Tomaka et al. [95] reported it was 0.44.

Additionally, some authors have used the termsperceived social isolation and loneliness inter-changeably (e.g. see [57]). Hawkley and Cacioppo[38], however, drew the distinction that loneliness wasthe perceived discrepancy between desired and actualsocial relationshipsa definition which has a longtradition [48, 96, 103]. Thus loneliness may reflectmore immediate feelings (state loneliness) and it hasrecently been described as a temporary phenomenonbrought about by current circumstances (e.g. duringadolescence, difficulties with family relationships)[41, 62, 64, 93]. It is when an individual moves frombeing lonely in this immediate social context sense tosuffering perceived social isolation relatively inde-pendently of the immediate stimulusthe absence ofmeaningful social contact (trait loneliness) or theinability to maintain meaningful social contacts[71]that there may be broader health consequences.Cairns et al. [17], who introduced the term, used it todescribe the self-reported long-term loss of familysupport, care and planning of cancer siblings.

In light of the above, that there is confusion overthe nomenclature is not surprising. Two examplesillustrate this. Although the UCLA Loneliness Scalehas been described as primarily measuring loneliness[83, 85] it has also been reported to measure per-ceived social isolation [1416]. Factor analyses of theUCLA have been reported by Austin [8], Adams et al.[4], Mahon and Yarcheski [61] and Cacioppo et al.[15]. All the items which loaded on Adam et al.sfactor 1 also loaded on Austins factor 1; similarly allof the items that loaded on Austins factor 1 also

loaded on Mahon and Yarcheskis factor 1 and Caci-oppo et al.s factor 1. Yet each research team inter-preted their findings quite differently: Austin labelledhis factor Intimate Others, Adams et al. labelledtheir factor Psychological Loneliness, Mahon andYarcheski labelled their factor Social Network, andCacioppo et al. labelled their factor Isolation. In thesecond example, Holmen et al. [44] used the item Doyou often feel lonely as a measure of social lonelinessand the item Do you experience loneliness toindicate emotional loneliness.

The term perceived social isolation is used in thispaper for three reasons. First, the term itself has beenused since 1979 to describe the subjective feelings ofliving without social connectedness or support [17,38, 57, 67, 70]. Second, loneliness is a widely usedterm, which may describe a normal human experiencewhich may have no particular consequences [103],whereas perceived social isolation is likely to affectfewer people but be across peoples lives [34, 41, 62,64]. Third, recent research shows it is the quality ofrelationships that matters rather than the quantity,suggesting that it is the respondents assessment oftheir relationship with others rather than the numberof social contacts in a persons social network that isimportant [49, 82, 99].

Methods

j Participants

Data were collected from 3,015 participants in the 2004 SouthAustralian Health Omnibus Survey (SAHOS), which is an annualpopulation-based health survey. A full description of the method-ology can be found in Wilson et al. [105]. Australian Bureau ofStatistics (ABS) collectors districts for the 2001 Census were sam-pled based on probability of selection proportional to size (n = 470districts). Within districts, based on every 4th household, 10dwellings were chosen and one person (aged 15+) from eachdwelling interviewed, based on closest last birthday to interviewday.

Of 4,700 selected dwellings 127 were vacant, 405 were non-contactable or inaccessible, in 82 dwellings the respondent did notspeak English, 58 cases were absent during data collection, 62 weretoo ill, and 945 refused. The number of participants was 3,015, awithin scope response of 72% (3,015/(4,700)366)). The SouthAustralian Health Omnibus Advisory Committee independentlyvetted all questions in the survey and gave its ethical approval.Informed consent consistent with the Australian National Healthand Medical Research Council [72] requirements was obtained.

j Materials

Thirteen research groups participated in the SAHOS. This studyreports the Friendship Scale for assessing social isolation, andquestions on demographics and health status.

Demographics

Gender, age, birth country, household size, relationship status,education attainment, workforce participation, location, andhousehold pre-tax income were assessed.

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Due to sparse data (i.e. where the numbers in cells would violatethe assumptions for stable analyses), these demographic variableswere recoded for the initial primary multivariable analyses. Theclassifications used for these analyses were: age (1530/3145/4660/61+ years), birth country (Australia/Other (where other refers tothose borne in the UK/Ireland (367 cases), North-West Europe(125), South-East Europe (72), Asia (102), and Other (76)), edu-cation (primary or high or trade/certificate or diploma or degree),household size (1-person/2+ persons), relationship status (part-nered/not partnered), work (working/not working), living location(metropolitan/rural) and income (AUD$50,000/50,001+).

The Friendship Scale (FS)

This 6-item instrument assesses perceived social isolation [39].Items measure the ease of relating to others, feeling isolated, havingsomeone to share feelings with, finding it easy to get in touch withothers, feeling separate from other people, and being alone andfriendless. The response categories are Almost always/Most of thetime/About half the time/Occasionally/Not at all. The timeframe isthe past 4 weeks. Reliability was Mokken q = 0.81.

Hawthorne [39] recommended that FS scores are categorisedinto 5 levels of perceived social isolation. Those who are very so-cially isolated will obtain scores in the range 011 because they willhave endorsed at least 1 item at level 1 or lower (i.e. have reported anisolating condition most of the time or almost always). Isolatedor low-level social support respondents are those with scores of 1215, which require endorsement of at least two items at or lower thanlevel 2. Some social support refers to the range 1618, because in thisrange at least two items at level 3 or lower must be endorsed. Thesocially connected range is between 19 and 21 because at least oneitem at level 3 or lower must be endorsed. The very socially con-nected will score within the range 2224. This requires endorsementof at least four items at level 4. A person obtaining a score in thisrange cannot have endorsed any item at levels 0 or 1. Because ofsparse data, those classified as being socially isolated or very isolatedwere combined into a single group described as being sociallyisolated for the data analyses presented in Tables 2 and 3.

Regarding interpretation of what the Friendship Scale measures,it is likely that it assesses aspects of both perceived social isolationand loneliness. It has three items covering the feelings of lonelinessand three items probing the importance of actual social contacts. Animportant finding from structural equation (SEM) modelling of the6-items in the Friendship Scale was that although the model wasunidimensional, the items grouped into 2 item sets along the lines ofpositive/negative items [39]. The first set comprised the three itemsfeeling isolated from others/feeling separate from others/feelingalone. The second set was easy to relate to others/someone to sharewith/easy to get in touch with others [39]. These different loadingson the SEM were interpreted as differences in negative/positiveitems because of the unidimensionality of the instrument. Theycould, however, have been interpreted as representing felt loneli-ness (set 1 because all items are about feelings) and perceived socialisolation (set 2 because all 3 items are assessments of contact withothers). There is a parallel here with de Jong Giervelds analysis ofher Loneliness Scale. She reported the same phenomenon and in heroriginal paper reported this as the divide between positive/negativeitems within a unidimensional Rasch model [50], yet later shereinterpreted this to be consistent with Townsends [96, p. 188] andWeiss [103] distinction of social isolation (having few contacts withfamily and community) and loneliness (the unwelcome feeling oflack or loss of companionship) [51].

Health status

General health status was assessed by a standard health-rating item(How would you rate your health? Excellent/good/fair or poor).Due to confounding between this variable and other measures ofhealth (e.g. arthritis) it was not used during analyses of healthconditions.

Arthritis was assessed by Have you ever been told by a doctorthat you have arthritis? Asthma was assessed through Have youever been told by a doctor that you have asthma and Do you stillhave asthma? Both items had to be endorsed for a respondent to beclassified with asthma.

Depression was assessed through the mood module of thePrimary Care Evaluation of Mental Disorders (PRIME-MD) [91,92]. There are 16 items probing DSM-IV depression symptomsexperienced nearly every day during the previous 2 weeks: changein appetite or weight, sleep, and psychomotor activity; decreasedenergy; feelings of worthlessness or guilt; difficulty thinking, con-centrating, or making decisions; recurrent thoughts of death orsuicidal ideation, plans or attempts. Depression classifications aremajor depression (meeting DSM-IV criteria), and other depression(dysthymia, minor depression and partial remission of majordepression).

Diabetes was assessed by Have you ever been told by a doctorthat you have diabetes?

Hearing status was assessed by asking Do you usually havedifficulty hearing what people say to you in a quiet room? Theresponse categories were If they speak loudly to you/If they speaknormally to you/If they whisper to you/None of the above.Endorsement of any of the first three responses indicated hearingdifficulties.

Urinary incontinence was assessed with the 4-level Inconti-nence Severity Index (ISI) [88, 89] and faecal incontinence with theWexner Continence Grading Scale [52]. Due to sparse data, acomposite score was constructed. Cases with no symptoms on ei-ther measure were classified as having no incontinence, somesymptoms on either or both as mild incontinence, and severesymptoms on either or both as severe incontinence.

Obesity was represented by the Body Mass Index (BMI) com-puted from height and weight. To obtain a measure of obesity, BMIwas dichotomized at the standard classification for obesity: those

Results

j Participants

Females comprised 50.9% of participants, and themean age was 45.3 years (SD = 18.7 years). Forcountry of birth, 74.4% were Australian-born, 12.2%UK/Ireland-born, 4.2% North Europe-born, 3.4%Asia-born, 2.4% South Europe-born and 2.5% bornelsewhere. For relationship status, 61.9% were part-nered, 24.1% had never married, 8.5% were separatedor divorced, and 5.6% were widowed. Primary schooleducation only was reported by 18.4%, 32.5% hadcompleted high school, 12.6% held a trade qualifica-tion, 22.6% a certificate or diploma and 13.9% auniversity degree. Full time employment was reportedby 38.8%, part-time employment by 16.9%, unem-ployment by 2.1%, home duties by 11.0%, retired by18.7%, 9.5% were studying and for 3.1% occupationwas unknown.

The distribution of FS scores is given in Fig. 1,which shows the proportions classified as very so-cially connected, socially connected, with some so-cial isolation, socially isolated and very sociallyisolated.

Table 1 shows social isolation prevalence by agegroup and gender. As shown in the table, there weresystematic differences across the lifespan. The agegroup with the highest proportion of those classifiedas being socially isolated (i.e. being isolated or veryisolated) was those aged 1530 years. The age groupwith the lowest proportion of those classified as beingisolated or very isolated was those aged 60+ years.For males the highest proportion classified as beingisolated or very isolated was those aged 3145 years(9.3%), and the lowest proportion those aged60+ years (4.8%). For females the highest proportionclassified as being isolated or very isolated was thoseaged 1530 years (13.5%), and the lowest proportionthose aged 60+ years (4.8%).

To explore the findings in relation to the youngestadults (those aged 1530 years) and older adults(aged 60+ years) two sub analyses were undertaken.

Given the literature suggests that for youngeradults, partnering is a key indicator of perceived so-cial isolation, the youngest adult cohort (aged 1530 years) was examined from this perspective. Therewas no significant age effect within the cohort; so agewas not included in the final analysis. Examination byrelationship status, gender and health status showedthat when compared with those who were living witha partner, those who were single were almost 6 timesmore likely to be isolated/very isolated (OR: 5.76,95%CI: 2.3314.24) and those who were separated,divorced or widowed were 20 times more likely to beisolated/very isolated (OR: 20.68, 95%CI: 4.9586.33).Females were more likely to be socially isolated whencompared with males (OR: 2.03; 95%CI: 1.193.47),and those in poor health were also more likely to besocially isolated when compared with those in excel-lent health (OR: 9.65, 95%CI: 4.6919.86).

For older adults the literature suggests an age effectwith the very old suffering social isolation [82]. So theanalysis of those aged over 60 years was undertakenfrom this perspective. The age groups were 6170, 7180 and 81 years. No significant differences were foundby age group or gender (v2age group = 3.44, df = 4,P = 0.49, and v2gender = 2.57, df = 2, P = 0.28).Importantly, there was no significant difference bythese age groups by health status (v2 = 13.55, df = 8,P = 0.10) suggesting that the respondent sample ofolder adults was a healthy sample. Consequently ageand gender were not included in the following analysis.When the cohort of older adults was examined, therewas an effect by relationship status showing that thosewho were not partnered (widowed, separated or di-vorced) were more likely to be socially isolated whencompared with the partnered (married or in a de factorelationship) (OR: 2.83, 95%CI: 1.365.88), and that

0-5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 240

100

200

300

400

500

600

700

800

N. C

ases

SociallyIsolated

5%

SomeIsolation

9%

SociallyConnected

25%

VeryConnected

59%

Veryisolated

2%

Fig. 1 Distribution and interpretation of FS scores

Table 1 Prevalence of perceived social isolation by gender and age group

Gender Age group Total N Socially isolateda

Someisolation (%)

Isolated/veryisolated (%)

Male 1530 393 13.7 6.43145 421 10.9 9.34660 355 7.0 6.560+ 311 6.4 4.8

Female 1530 377 9.8 13.53145 404 6.2 4.74660 371 7.8 6.260+ 382 9.2 4.7

All 1530 770 11.8 9.93145 826 8.6 7.04660 726 7.4 6.360+ 693 7.9 4.8

Notes: a See Fig. 1 for details of data distribution and classificationStatistics: Male: v2 = 21.45, df = 6, P < 0.01; Female: v2 = 35.89, df = 6,P < 0.01; All: v2 = 28.43, df = 6, P < 0.01

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those who were single (never married) were also morelikely to be socially isolated (OR: 4.99, 95%CI: 1.1022.71).

Table 2 reports socio-demographic and Table 3chronic health conditions associations after recodingas described in the methods section. Each table pre-sents the results of a single multivariate logisticregression model.

The significant socio-demographic predictors ofsocial isolation were being an immigrant (OR: 2.35),single (OR: 2.52), not working (OR: 3.23), and livingin a household with an annual income AUD$50,000; these

Table 3 Common health conditions, life exposures and perceived social isolation

Predictors Level Model A Model B

Reference group Comparatora b OR 95%CIs b OR 95%CIs

Arthritis No Yes )0.31 0.73 0.401.36 )0.11 0.97 0.961.57Asthma No Yes )0.33 0.72 0.431.19 )0.22 0.80 0.511.25Depression No symptom Other 2.03 7.62 4.9411.75

Major 3.06 21.42 14.4731.72Diabetes No Yes 0.18 1.20 0.662.17 0.40 1.49 0.842.54Hearing Normal Impaired 0.48 1.62 1.112.35 0.72 2.06 1.472.87Incontinenceb None/mild Severe 1.13 3.09 1.765.42 1.54 4.65 2.887.52Obesity Normal weight range Obese 0.04 1.04 0.691.58 0.14 1.15 0.791.66Trauma exposurec 2 Exposures 3+ Exposures 0.33 1.39 0.922.10 0.88 2.43 1.713.45Vision Normal/mild impairment Severe impairment 0.18 1.20 0.602.40 0.47 1.61 0.872.98

Model statistics: Logistic regression. Hosmer & Lemeshow v2, Model A: v2 = 3.66, df = 8, P = 0.89, Model B: v2 = 6.36, df = 8, P = 0.61Note: Age included in both analyses, but not showna Regarding the analysis numbers: Arthritis = 287; Asthma = 394; Depression other = 253; Depression major = 241; Diabetes: 229; Hearing impairment = 692;Incontinence = 157; Obese = 532; Trauma 3+ exposures = 411; Vision = 161b Describes both urinary and faecal incontinencec Lifetime trauma exposure

Table 2 Socio-demographic predictors of perceived social isolation

Predictor Level b OR 95%CIs

Reference group Comparatora

Gender Male Female )0.22 0.80 0.591.08Birth region Australia Other 0.85 2.35 1.633.40Age 1530 3145 0.33 1.40 0.892.19

4660 0.06 1.06 0.661.7061+ )1.09 0.34 0.200.57

Relationship status Partnered Not partnered 0.92 2.52 1.663.82Education attainment Primary/high/trade Certificate/degree )0.03 0.97 0.701.35Labourforce status Working Not working 1.17 3.23 2.284.59Household size 2+ Persons 1-Person 0.29 1.34 0.852.12Area of residence Metropolitan Rural 0.19 1.20 0.871.66Household income >$50,000 pa $50,000 pa 0.37 1.44 1.032.02

Model statistics: Hosmer & Lemeshow v2 = 3.38, df = 8, P = 0.91a Regarding the analysis numbers: Female = 1,535 cases; Other = 365; 3145 years = 825; 4660 years = 726; 61+ years = 693; Not partnered = 1,150; Cer-tificate/degree = 1,100; Not working = 1,336; 1-person household (i.e. living alone) = 441; Rural = 902; Income $50,000 pa = 1,447

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were therefore collapsed into a single group (the ref-erence group). Income groups significantly differentto this reference group were those with incomes

data collection procedures, sampling strategies orthey may reflect real differences in populations. Forexample, Routasalo et al. [82] used a single leadingquestion to probe loneliness (Do you suffer fromloneliness?), whereas in this study a scale with fullyknown psychometric properties was used. For a dis-cussion of single item versus scales assessing loneli-ness the reader is referred to Victor et al. [100]. Thestudy findings may reflect the study sampling strat-egy, which excluded the seriously ill, those in sup-ported accommodation, hostels, hospitals andnursing homes. These people may be socially isolatedgiven that Hawthorne [39] reported that for thoseliving in a nursing home the mean FS score was 12.22.These exclusions may imply that weaker and morevulnerable older adults are not represented in thefindings; an observation which would be consistentwith Ellaway et al.s [30] finding among thoseattending GPs. Participants were older adults suffi-ciently healthy to be living in the community. Readersshould, however, keep in mind that in Australia over90% of older adults live in their own homes in thecommunity [2]. Lauder et al. [59] in a communitystudy reported that the lonely people were those whomissed having a good friend, the company of otherswho could be trusted and having peoplearoundconditions that are likely to apply to thosewith poor health who are in institutional care, but notnecessarily to healthy older adults living in the com-munity.

These conditions may also apply to younger adultswho are single, separated or divorced. The separateanalysis of the youngest adults (those aged 1530 years) showed all too clearly the importance of anintimate relationship and the effect of relationshipbreakdown. The findings suggest that there are sig-nificant gender issues here that were not apparent forthe older age groups. These findings are consistentwith the literature cited throughout this paper thatloneliness primarily reflects a lack of intimacy with asignificant other or others, or a lack of connection to asocial network.

Another possible explanation is that there are fewpopulation-based studies of social isolation: moststudies have been in defined populations, such as olderadults, twins or adolescents [25, 27, 34, 68, 77, 94]. Theimplication is that cross-age group comparisons arerarely made and that the assumption that social iso-lation is an inevitable part of healthy aging needs to bere-examined. The findings are also consistent withresearch showing that mental health (other than cog-nitive impairment, such as dementia) does not dete-riorate over the lifespan [1, 6, 22, 40, 42, 47, 80, 97],perhaps due to a decrease in negative affect and thatageing involves socio-emotional selectivity, leading toincreased importance of the quality of social rela-tionships rather than the number [18, 21, 81].

That those born in South Europe were more likelyto report perceived social isolation when compared

with the Australian-born was surprising since theseimmigrants arrived in Australia an average of44 years (SD = 7 years) previously. It is consistentwith previous research showing higher levels ofdepression and anxiety among immigrants fromSouth Europe [66]. Those born in Asia, who were alsomore likely to be classified as being isolated whencompared with the Australian-born, had arrived morerecentlyon average 13 years (SD = 11 years) pre-viously. That there was no significant difference inperceived social isolation, when compared with theAustralian-born, for those from the UK/Ireland orNorth Europe may suggest that language, race andculture differences remain lifelong social barriers.

The associations between relationship status, livingalone, income and perceived social isolation wereconsistent with the literature, suggesting that thoseliving alone (97% of whom had never married or wereseparated or divorced) were more likely to be sociallyisolated [11, 59, 64, 77, 81, 93]. Since there is a trendtowards people living alone [3] there are potentiallong term public health implications given livingalone is associated with depression, suicide, suicidalideation and earlier death [55, 63]. Those who wereliving alone were twice as likely to have majordepression when compared with those living withothers (OR: 2.25; 95%CI: 1.623.11). Sub-groupanalyses between gender, restricted income, livingalone, and perceived social isolation showed a com-plex pattern suggesting females aged 1559 yearsliving under these circumstances were 4 times morelikely to be socially isolated when compared witholder females living under similar circumstances, afinding consistent with Wang et al. [101]. Thatworkforce participation was negatively associatedwith perceived social isolation was consistent withresearch on the benefit of work on well-being [59,102].

Regarding chronic health conditions and perceivedsocial isolation, the findings showed a monotonicallyincreasing likelihood of isolation for each additionalchronic health condition. This finding is very similarto that of Havens et al. [37], although their study wasin an older population. The magnitude of the in-creases in the odds ratios by the number of healthconditions suggests that ill health has a crucial rela-tionship with perceived social isolation. That majordepression is overwhelming in its association withperceived social isolation (OR: 23.29) is consistentwith the literature suggesting a complex net of causalfactors involving both [5, 16, 24, 27]. Table 3 showsdepression was a confounder for both hearing andtrauma exposure. Hearing loss has been shown inother literature to be associated with both depressionand social isolation [69]. Equally, depression is a well-known consequence of trauma exposure [12, 74]. Theassociation between incontinence and social isolationhas also been previously reported [26, 60], although itwas surprising that incontinence was a stronger

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predictor than several other common health condi-tions: perhaps this reflects the embarrassment asso-ciated with it.

Regarding the other chronic measures (arthritis,asthma, diabetes, obesity and vision impairmentexamined in Table 3), there is less certainty. Tomakaet al. [95], in a study of the elderly, reported no sig-nificant association between asthma or diabetes andsocial isolation, which is consistent with this study.However, they did report an association betweenarthritis and social isolation, whereas in this studythere was no significant association. It is possible thisdiscrepancy reflects the two study populations. Forvision impairment, on the univariate analysis therewas an association (OR: 1.95), which was not con-firmed on the multivariate analysis. This finding issimilar to that of Savikko et al. [90], raising the pos-sibility that sensory loss has a similar effect on socialisolation but that hearing loss is more important be-cause it is more common.

Although perceived social isolation may be atemporary effect of circumstances, this studys sta-tistical models suggest otherwise. The demographiccharacteristics and chronic health conditions associ-ated with it are not temporary: they are structuralcircumstances with which people live over time. Theimplication is that perceived social isolation as mea-sured by the FS may be an enduring feature of peo-ples lives [59]. As shown by the reviewed literatureregarding long term health outcomes for the sociallyisolated, there are public health implications for thosetrapped by these life circumstances. These may rangefrom poorer health status over the lifetime, lifelonghigher consumption of both community supports andhealth services, to worse health outcomes fromtreatments for chronic conditions. These implica-tions, however, are subject to further research into therelationship between the increasing number ofyounger people choosing living alone [3] and theirhealth.

The findings are subject to the cross-sectional re-search design, which limits causal relationships. Whe-ther the associations reported in this study betweenvarious health conditions and social isolation arecausative is thus unknown: there is evidence fromlongitudinal studies that causation could be reciprocal[16]. There is also some evidence that childhood socialisolation may be associated with known biologicalmarkers of adult chronic health conditions [19]. Thiscaveat is subject itself to logical criteria suggestingplausible causal relationships. For example, the asso-ciation between incontinence and social isolation. It isreasonable to argue the incontinence would havecaused the social isolation, rather than the other wayround. In contrast, the relationship between depressionand social isolation is problematic given that there isevidence causation operates both ways [5, 16, 78].

The findings will understate social isolation prev-alence since the study method excluded the seriously

ill, those in supported accommodation, hostels, hos-pitals and nursing homes. These people may be so-cially isolated given that Hawthorne [39] reportedthey obtained particularly low scores on the FS (seeabove). Finally, many of the conditions reported inthis study were assessed by a single item or werescales, which for reasons of sparse data were dichot-omized. It is possible this has obscured complexrelationships.

Conclusion

Although there are many papers reporting perceivedsocial isolation and its correlates, there are fewmodern prevalence studies. This study reports theprevalence of perceived social isolation in an Aus-tralian population sample.

The findings suggest that 16% reported some socialisolation (including being isolated and very isolated)and 7% were either isolated or very isolated. Therewere different patterns of social isolation by genderand age group. The key socio-demographic correlateswere birthplace, relationship, labourforce and incomestatus. A key finding was younger adults had higherprobabilities of being socially isolated than did olderadults.

When perceived social isolation was examined byvarious chronic health conditions the data showeddepression was strongly associated with it. Indeeddepression may have been a consequence of otherlong-term health conditions, such as trauma expo-sure. Severe incontinence was also associated withperceived social isolation. The findings have publichealth implications and indicate the need for furtherresearch.

j Acknowledgements Large complex studies are carried out byteams of researchers, and this study is no exception. I would par-ticularly like to thank the Ms Elayne Crnkovic and Ms NatalieScarlet from the Community Care Branch, Australian Common-wealth Department of Health and Ageing; Ms Kerry Markoulli,Director, Special Needs Strategies Section, Australian Common-wealth Department of Health and Ageing; A/Professor Anne Taylorfrom the Population Research & Outcome Studies Unit, Depart-ment of Health, South Australia; and Ms Jan Sansoni from theAustralian Health Outcomes Collaboration, Centre for HealthServices Development, University of Wollongong. The SouthAustralian Health Omnibus Survey is a user-pays health survey,and I would to thank those collaborators who gave permission fortheir data to be used, in particular Professor Robert Goldney fromthe Department of Psychiatry at Adelaide University; Mr WillHallahan, Executive Officer, Western Palliative Care Service, theQueen Elizabeth Hospital; Dr Roger Hunt, Director Western Pal-liative Care Service, the Queen Elizabeth Hospital; Ms Gillian Leachfrom Arthritis South Australia; Professor Alastair MacLennan fromthe Department of Obstetrics and Gynaecology, Womens andChildrens Hospital Adelaide; Dr Monika Nitschke from the Envi-ronmental Health Service, Department of Health South Australia;Dr Richard Osborne from the Centre for Rheumatic Disease at TheUniversity of Melbourne; Dr Pat Phillips from the Endocrine andDiabetes Service, West Adelaide Health Service; Professor RichardRuffin from the Department of Medicine at the Queen Elizabeth

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Hospital and North West Adelaide Health Service; Dr Gary Starrfrom Health Promotion SA, Department of Health, South Australia;Ms Laura Fisher from Ramsay Health Care (The Adelaide Clinic);Ms Rosemary Warmington, Chief Executive Officer, the CarersAssociation South Australia; and Ms Carmel Williams from theIntegration Team Health Promotion Branch Department of HealthSouth Australia. There are no competing interests for the author.This study was funded by a grant from the Community CareBranch, Australian Commonwealth Department of Health andAgeing.

References

1. ABS (1997) National Health Survey: SF-36 Population Norms,Australia. Australia Bureau of Statistics, Canberra

2. ABS (1999) Australian Social Trends, 1999. Australian Bureauof Statistics, Canberra

3. ABS (2006) Australian Social Trends, 2005. Australian Bureauof Statistics, Canberra

4. Adams GR, Openshaw DK, Bennion L, Mills T, Noble S (1988)Loneliness in late adolescence: a social skills training study. JAdolesc Res 3:8196

5. Adams KB, Sanders S, Auth EA (2004) Loneliness anddepression in independent living retirement communities:risk and resilience factors. Aging Ment Health 8:475485

6. Alonso J, Angermeyer MC, Bernert S, Bruffaerts R, Brugha TS,Bryson H, Girolamo G, Graaf R, Demyttenaere K, Gasquet I,Haro JM, Katz SJ, Kessler RC, Kovess V, Lepine JP, Ormel J,Polidori G, Russo LJ, Vilagut G, Almansa J, Arbabzadeh-Bouchez S, Autonell J, Bernal M, Buist-Bouwman MA, CodonyM, Domingo-Salvany A, Ferrer M, Joo SS, Martinez-Alonso M,Matschinger H, Mazzi F, Morgan Z, Morosini P, Palacin C,Romera B, Taub N, Vollebergh WA (2004) Prevalence ofmental disorders in Europe: results from the European Studyof the Epidemiology of Mental Disorders (ESEMeD) project.Acta Psychiatr Scand Suppl 109:2127

7. Applebaum F (1978) Loneliness: a taxonomy and psychody-namic view. Clin Soc Work J 6:1320

8. Austin BA (1983) Factorial structure of the UCLA LonelinessScale. Psychol Rep 53:883889

9. van Baarsen B, Snijders TAB, Smit JH, van Duijn MAJ (2001)Lonely but not alone: emotional isolation and social isolationas two distinct dimensions of loneliness in older people. EducPsychol Meas 61:119135

10. Baumeister RF, Leary MR (1995) The need to belong: desirefor interpersonal attachments as a fundamental humanmotivation. Psychol Bull 117:497529

11. Berkman L, Syme L (1979) Social networks, host resistanceand mortality: a nine-year follow-up study of Alameda Countyresidents. Am J Epidemiol 109:186204

12. Blanchard EB, Buckley TC, Hickling EJ, Taylor AE (1998)Posttraumatic stress disorder and comorbid major depres-sion: is the correlation an illusion? J Anxiety Disord 12:2137

13. Bowlby J (1971) Attachment. Pelican, London14. Cacioppo JT, Hawkley LC (2003) Social isolation and health,

with an emphasis on underlying mechanisms. Perspect BiolMed 46:S39S52

15. Cacioppo JT, Hawkley LC, Ernst JM, Burleson MH, BerntsonGG, Nouriani B, Spiegel D (2006a) Loneliness within anomological net: an evolutionary perspective. J Res Pers40:10541085

16. Cacioppo JT, Hughes ME, Waite LJ, Hawkley LC, Thisted RA(2006b) Loneliness as a specific risk factor for depressivesymptoms: cross-sectional and longitudinal analyses. PsycholAging 21:140151

17. Cairns NU, Clark GM, Smith SD, Lansky SB (1979) Adaptationof siblings to childhood malignancy. J Pediatr 95:484487

18. Carstensen LL (1992) Social and emotional patterns inadulthood: support for socioemotional selectivity theory.Psychol Aging 7:331338

19. Caspi A, Harrington H, Moffitt TE, Milne BJ, Poulton R (2006)Socially isolated children 20 years later: risk of cardiovasculardisease. Arch Pediatr Adolesc Med 160:805811

20. Cassel J (1976) The contribution of the social environment tohost resistance: the Fourth Wade Hampton Frost Lecture. AmJ Epidemiol 104:107123

21. Charles ST, Reynolds CA, Gatz M (2001) Age-related differ-ences and change in positive and negative affect over 23 years.J Pers Soc Psychol 80:136151

22. Christensen H, Jorm AF, Mackinnon AJ, Korten AE, JacombPA, Henderson AS, Rodgers B (1999) Age differences indepression and anxiety symptoms: a structural equationmodelling analysis of data from a general population sample.Psychol Med 29:325339

23. Cobb S (1976) Social support as a moderator of life stress.Psychosom Med 317:300314

24. Cohen GD (2000) Loneliness in later life. Am J Geriatr Psy-chiatry 8:273275

25. Coventry WL, Gillespie NA, Heath AC, Martin NG (2004)Perceived social support in a large community sampleageand sex differences. Soc Psychiatry Psychiatr Epidemiol39:625636

26. Criner JA (2001) Urinary incontinence in a vulnerable popu-lation: older women. Semin Perioper Nurs 10:3337

27. DAmore J, Hung O, Chiang W, Goldfrank L (2001) The epi-demiology of the homeless population and its impact on anurban emergency department. Acad Emerg Med 8:10511055

28. Dykstra PA, de Jong Gierveld J (2004) Gender and marital-history differences in emotional and social loneliness amongDutch older adults. Can J Aging 23:141155

29. Elisha D, Castle D, Hocking B (2006) Reducing social isolationin people with mental illness: the role of the psychiatrist.Australas Psychiatry 14:281284

30. Ellaway A, Wood S, MacIntyre S (1999) Someone to talk to?The role of loneliness as a factor in the frequency of GPconsultations. Br J Gen Pract 49:363367

31. Fees BS, Martin P, Poon LW (1999) A model of lonelinessin older adults. J Gerontol Ser B Psychol Sci Soc Sci 54:231239

32. Fratiglioni L, Wang HX, Ericsson K, Maytan M, Winblad B(2000) Influence of social network on occurrence ofdementia: a community-based longitudinal study. Lancet355:13151319

33. Fromm-Reichmann F (1959) Loneliness. Psychiatry 22:11534. Giles LC, Glonek GF, Luszcz MA, Andrews GR (2005) Effect of

social networks on 10 year survival in very old Australians: theAustralian longitudinal study of aging. J Epidemiol CommunityHealth 59:574579

35. Hanson BS (1994) Social network, social support and heavydrinking in elderly mena population study of men born in1914, Malmo, Sweden. Addiction 89:725732

36. Hanson BS, Isacsson SO, Janzon L, Lindell SE (1989) Socialnetwork and social support influence mortality in elderly men.The prospective population study of Men born in 1914,Malmo, Sweden. Am J Epidemiol 130:100111

37. Havens B, Hall M, Sylvestre G, Jivan T (2004) Social isolationand loneliness: differences between older rural and urbanManitobans. Can J Aging 23:129140

38. Hawkley LC, Cacioppo JT (2003) Loneliness and pathways todisease. Brain Behav Immun 17(Suppl 1):S98S105

39. Hawthorne G (2006) Measuring social isolation in olderadults: development and initial validation of the FriendshipScale. Soc Indic Res 77:521548

40. Hawthorne G, Osborne R, Sansoni J, Taylor A (2007) The SF36Version 2: critical analysis of population weights, scoringalgorithms and population norms. Qual Life Res 16:661673

41. Heinrich LM, Gullone E (2006) The clinical significance ofloneliness: a literature review. Clin Psychol Rev 26:695718

42. Henderson AS, Jorm AF, Korten AE, Jacomb P, Christensen H,Rodgers B (1998) Symptoms of depression and anxiety duringadult life: evidence for a decline in prevalence with age. Psy-chol Med 28:13211328

148

43. Henderson AS, Scott R, Kay DW (1986) The elderly who livealone: their mental health and social relationships. Aust N Z JPsychiatry 20:202209

44. Holmen K, Ericsson K, Winblad B (2000) Social and emotionalloneliness among non-demented and demented elderly peo-ple. Arch Gerontol Geriatr 31:177192

45. Holmen K., Furukawa H (2002) Loneliness, health and socialnetwork among elderly peoplea follow-up study. ArchGerontol Geriatr 35:261274

46. House J, Robbins C, Metzner H (1982) The association ofsocial relationships and activities with mortality: prospectiveevidence from the Tecumseh Community Health Study. Am JEpidemiol 116:123140

47. Hybels CF, Blazer DG (2003) Epidemiology of late-life mentaldisorders. Clin Geriatr Med 19:663696, v

48. de Jong Gierveld J (1978) The construct of loneliness: com-ponents and measurement. Essence 2:221237

49. de Jong Gierveld J (1987) Developing and testing a model ofloneliness. J Pers Soc Psychol 53:119128

50. de Jong Gierveld J, Kamphuis F (1985) The development of aRasch-type loneliness scale. Appl Psychol Meas 9:289299

51. de Jong Gierveld J, Tilburg TV (2006) A 6-item scale foroverall, emotional and social loneliness: confirmatory tests onsurvey data. Res Aging 28:582598

52. Jorge JM, Wexner SD (1993) Etiology and management offecal incontinence. Dis Colon Rectum 36:7797

53. Kahn RL (1979) Aging and social support. In: Riley WM (ed)Aging from birth to death: interdisciplinary perspectives.Westview Press, Boulder, pp 7791

54. Kaplan GA, Roberts RE, Camacho TC, Coyne JC (1987) Psy-chosocial predictors of depression. Prospective evidence fromthe human population laboratory studies. Am J Epidemiol125:206220

55. Kawachi I, Colditz G, Ascherio A, Rimm E, Giovannucci E,Stampfer M, Willett W (1996) A prospective study of socialnetworks in relation to total mortality and cardiovasculardisease in men in the USA. J Epidemiol Community Health50:245251

56. Lau AS, Litrownik AJ, Newton RR, Landsverk J (2003) Goinghome: the complex effects of reunification on internalizingproblems among children in foster care. J Abnorm ChildPsychol 31:345358

57. Lauder W, Mummery K, Jones M, Caperchione C (2006a) Acomparison of health behaviours in lonely and non-lonelypopulations. Psychol Health Med 11:233245

58. Lauder W, Mummery K, Sharkey S (2006b) Social capital, ageand religiosity in people who are lonely. J Clin Nurs 15:334340

59. Lauder W, Sharkey S, Mummery K (2004) A communitysurvey of loneliness. J Adv Nurs 46:8894

60. Lukaz K (1995) Urinary incontinence: suffering in isolation.Can Nurse 91:2326

61. Mahon NE, Yarcheski A (1990) The dimensionality of theUCLA Loneliness Scale in early adolescents. Res Nurs Health13:4552

62. Marangoni C, Ickes W (1989) Loneliness: a theoretical reviewwith implications for measurement. J Soc Pers Relat 6:93128

63. Marquet RL, Bartelds AI, Kerkhof AJ, Schellevis FG, van derZee J (2005) The epidemiology of suicide and attempted sui-cide in Dutch General Practice 19832003. BMC Fam Pract6:45

64. Maxwell G, Coebergh B (1986) Patterns of loneliness in a NewZealand population. Community Ment Health N Z 2:4861

65. Mayers AM, Svartberg M (2001) Existential loneliness: a re-view of the concept, its psychosocial precipitants and psy-chotherapeutic implications for HIV-infected women. Br JMed Psychol 74:539553

66. Minas H, Klimidis S, Stuart GW (1995) Mental health of men ofnon-English speaking background. In: Jorm A (ed) Men andmental health. National Health and Medical Research Council,Commonwealth of Australia, Canberra, pp 129138

67. Miner MH, Munns R (2005) Isolation and normlessness:attitudinal comparisons of adolescent sex offenders, juvenileoffenders, and nondelinquents. Int J Offender Ther CompCriminol 49:491504

68. Mullins L, Elston C, Gutkowski S (1996) Social determinantsof loneliness among older Americans. Genet Soc Gen PsycholMonogr 122:453473

69. Mulrow CD, Tuley MR, Aguilar C (1992) Sustained benefits ofhearing aids. J Speech Hear Res 35:14021405

70. Murberg TA (2004) Long-term effect of social relationships onmortality in patients with congestive heart failure. Int J Psy-chiatry Med 34:207217

71. Murberg TA, Bru E (2001) Social relationships and mortalityin patients with congestive heart failure. J Psychosom Res51:521527

72. NHMRC (1999) National Statement on Ethical conduct inResearch Involving Humans. Commonwealth of Australia,Canberra, 80 pp

73. Nielsen Forman D, Videbech P, Hedegaard M, Dalby Salvig J,Secher NJ (2000) Postpartum depression: identification ofwomen at risk. Br J Obstet Gynaecol 107:12101217

74. ODonnell M, Creamer M, Pattison P (2004) Posttraumaticstress disorder and depression following trauma: under-standing comorbidity. Am J Psychiatry 161:13901396

75. Oshagan H, Allen RL (1992) Three loneliness scales: anassessment of their measurement properties. J Pers Assess59:380409

76. Peplau LA, Perlman D (eds) (1982) Loneliness: a sourcebookof current theory, research and therapy. Wiley, New York

77. Peters A, Liefbroer AC (1997) Beyond marital status: partnerhistory and well-being in old age. J Marriage Fam 59:687699

78. Phifer JF, Murrell SA (1986) Etiologic factors in the onset ofdepressive symptoms in older adults. J Abnorm Psychol95:282291

79. Plouffe L, Jomphe Hill A (1996) Distressed and lonely: healthand social determinants among residents in seniors housing.J Clin Geropsychol 2:5160

80. Regier DA, Boyd JH, Burke JD Jr, Rae DS, Myers JK, KramerM, Robins LN, George LK, Karno M, Locke BZ (1988) One-month prevalence of mental disorders in the United States.Based on five epidemiologic catchment area sites. Arch GenPsychiatry 45:977986

81. Revenson TA, Johnson JL (1984) Social and demographic corre-lates of loneliness in late life. Am J Community Psychol 12:7185

82. Routasalo PE, Savikko N, Tilvis RS, Strandberg TE, Pitkala KH(2006) Social contacts and their relationship to lonelinessamong aged peoplea population-based study. Gerontology52:181187

83. Russell DW (1996) UCLA Loneliness Scale (Version 3): reli-ability, validity, and factor structure. J Pers Assess 66:2040

84. Russell D, Cutrona C, Rose J, Yurko K (1984) Social andemotional loneliness: an examination of Weisss typology ofloneliness. J Pers Soc Psychol 46:13131321

85. Russell D, Peplau L, Cutrona C (1980) The revised UCLALoneliness Scale: concurrent and discriminant validity evi-dence. J Pers Soc Psychol 39:472480

86. SPSS (2006) SPSS for Windows, Version 14.0.2. SPSS Inc.,Chicago

87. Sand L, Strang P (2006) Existential loneliness in a palliativehome care setting. J Palliat Med 9:13761387

88. Sandvik H, Hunskaar S, Seim A, Hermstad R, Vanvik A, BrattH (1993) Validation of a severity index in female urinaryincontinence and its implementation in an epidemiologicalsurvey. J Epidemiol Community Health 47:497499

89. Sandvik H, Seim A, Vanvik A, Hunskaar S (2000) A severityindex for epidemiological surveys of female urinary inconti-nence: comparison with 48-hour pad-weighing tests. Neuro-urol Urodyn 19:137145

90. Savikko N, Routasalo P, Tilvis RS, Strandberg TE, Pitkala KH(2005) Predictors and subjective causes of loneliness in anaged population. Arch Gerontol Geriatr 41:223233

149

91. Spitzer RL, Kroenke K, Williams JB (1999) Validation andutility of a self-report version of PRIME-MD: the PHQ pri-mary care study. Primary care evaluation of mental disorders.Patient Health Questionnaire. JAMA 282:17371744

92. Spitzer RL, Williams JB, Kroenke K, Linzer M, deGruy FV 3rd,Hahn SR, Brody D, Johnson JG (1994) Utility of a new pro-cedure for diagnosing mental disorders in primary care. ThePRIME-MD 1000 study. JAMA 272:17491756

93. Steptoe A, Owen N, Kunz-Ebrecht SR, Brydon L (2004)Loneliness and neuroendocrine, cardiovascular, and inflam-matory stress responses in middle-aged men and women.Psychoneuroendocrinology 29:593611

94. Tijhuis MA, De Jong-Gierveld J, Feskens EJ, Kromhout D(1999) Changes in and factors related to loneliness in oldermen. The Zutphen Elderly Study. Age Ageing 28:491495

95. Tomaka J, Thompson S, Palacios R (2006) The relation ofsocial isolation, loneliness, and social support to diseaseoutcomes among the elderly. J Aging Health 18:359384

96. Townsend P (1963) The family life of old people. PenguinBooks, London

97. Trollor JN, Anderson TM, Sachdev PS, Brodaty H, Andrews G(2007) Prevalence of mental disorders in the elderly: theAustralian National Mental Health and Well-Being Survey.Am J Geriatr Psychiatry 15:455466

98. Turner RJ (1981) Social support as a contingency in psycho-logical wellbeing. J Health Soc Behav 22:357367

99. Victor C, Scambler S, Bond J, Bowling A (2000) Being alone inlater life: loneliness, social isolation and living alone. Rev ClinGerontol 10:407417

100. Victor CR, Scambler SJ, Bowling A, Bond J (2005) Theprevalence of, and risk factors for, loneliness in later life: asurvey of older people in Great Britain. Ageing Soc 25:357375

101. Wang N, Iwasaki M, Otani T, Hayashi R, Miyazaki H, Xiao L,Sasazawa Y, Suzuki S, Koyama H, Sakamaki T (2005) Per-ceived health as related to income, socio-economic status,lifestyle, and social support factors in a middle-aged Japanese.J Epidemiol 15:155162

102. Warr P (1999) Well-being and the workplace. In: KahnemanD, Diener E, Schwartz N (eds) Well-being: the foundations ofhedonic psychology. Russell Sage Foundation, New York, pp392412

103. Weiss RS (1973) Loneliness: the experience of emotional andsocial isolation. MIT Press, Cambridge

104. WHO (1997) Composite international diagnostic interview.World Health Organization, Geneva

105. Wilson D, Wakefield M, Taylor A (1992) The South AustralianHealth Omnibus Survey. Health Promot J Austr 2:4749

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