Preventing Loneliness

5/28/2018 Preventing Loneliness

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By Karen Windle, Jennifer Francis and Caroline Coomber

Key messages Older people are particularly vulnerable to

social isolation or loneliness owing to lossof friends and family, mobility or income.

Social isolation and loneliness impact uponindividuals quality of life and wellbeing,

adversely affecting health and increasingtheir use of health and social care services.

The interventions to tackle social isolationor loneliness include: befriending,mentoring, Community Navigators, socialgroup schemes.

People who use befriending or CommunityNavigator services reported that they wereless lonely and socially isolated following theintervention.

The outcomes from mentoring services areless clear; one study reported improvementsin mental and physical health, another thatno difference was found.

Where longitudinal studies recordedsurvival rates, older people who were partof a social group intervention had a greaterchance of survival than those who had notreceived such a service.

Users report high satisfaction with services,benefiting from such interventions byincreasing their social interaction and

community involvement, taking up or goingback to hobbies and participating in widercommunity activities.

Users argued for flexibility and adaptationof services. One-to-one services could be

more flexible, while enjoyment of groupactivities would be greater if these couldbe tailored to users preferences.

When planning services to reduce socialisolation or loneliness, strong partnershiparrangements need to be in place betweenorganisations to ensure developed servicescan be sustained.

We need to invest in proven projects.Community Navigator interventions

have been shown to be effective inidentifying those individuals who aresocially isolated. Befriending services canbe effective in reducing depression andcost-effective.

Research needs to be carried out oninterventions that include differentgenders, populations and localities.

There is an urgent need for morelongitudinal, randomised controlledtrials that incorporate standardisedquality-of-life and cost measures.

October 2011 Review date: October 2014

39RESEARCH BRIEFING

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IntroductionThis is one in a series of research briefings aboutpreventive care and support for adults.

Prevention is broadly defined to include a widerange of services that:

promote independence

prevent or delay the deterioration of wellbeingresulting from ageing, illness or disability

delay the need for more costly and intensiveservices.

Preventive services represent a continuum of

support ranging from the most intensive, tertiaryservices such as intermediate care orreablement, down to secondary or earlyintervention, and finally, primary preventionaimed at promoting wellbeing. Primaryprevention is generally designed for people withfew social care needs or symptoms of illness. Thefocus therefore is on maintaining independenceand good health and promoting wellbeing.1 Therange of these wellbeing interventions includesactivities to reduce social isolation, practical helpwith tasks like shopping or gardening, universalhealthy living advice, intergenerational activitiesand transport, and other ways of helping peopleget out and about.

Just as the range of wellbeing services isextensive, so too is the available literatureexamining how well they work. For this researchbriefing, the focus has been narrowed to theeffectiveness and cost-effectiveness of services

aimed at preventing social isolation andloneliness. Our review question was: To whatextent does investment in services that preventsocial isolation improve peoples wellbeing andreduce the need for ongoing care and support?

While social isolation and loneliness are oftenused interchangeably, one paper2 examined thedistinct meanings that people attach to eachconcept. Loneliness was reported as being asubjective, negative feeling associated with loss(e.g. loss of a partner or children relocating),while social isolation was described as imposedisolation from normal social networks caused byloss of mobility or deteriorating health. This

briefing focuses on services aimed at reducing theeffects of both loneliness and social isolation.Although the terms might have slightly differentmeanings, the experience of both is generally

negative and the resulting impacts areundesirable at the individual, community andsocietal levels.

What is the issue?There are a number of population groupsvulnerable to social isolation and loneliness,(e.g. young care-leavers, refugees and those withmental health problems). Nevertheless, olderpeople (as individuals as well as carers) havespecific vulnerabilities owing to loss of friendsand family, loss of mobility or loss of income.3

In consequence, there has been a policyconcentration on this group.47 The statistics onpopulation ageing in the UK (and in manydeveloped countries) are well known. Thoseaged 60 and above currently account forapproximately 20 per cent of the population andthis proportion is expected to rise to 24 per cent

by 2030.8

In the next 20 years, the population ofthose aged over 80 will treble and those over 90will double.9 In exploring prevalence, it isestimated that across the present populationaged 65 and over, between 5 and 16 per centreport loneliness,10 while 12 per cent feel sociallyisolated.9 In looking at the experiences of anationally representative sample, Victor et al11

found that 2 per cent of individuals reported thatthey were always lonely, 5 per cent that theywere often lonely and 31 per cent rated

themselves as sometimes lonely. Such figuresare likely to expand with increasing familydispersal and growing numbers of older peopleand the older-old those aged 80 and over.12

Why is it important?Perhaps not surprisingly, social isolation andloneliness impact on quality of life andwellbeing,1315 with demonstrable negativehealth effects.12 Being lonely has a significantand lasting effect on blood pressure, with lonelyindividuals having higher blood pressure thantheir less lonely peers. Such an effect has been

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found to be independent of age, gender, race,cardiovascular risk factors (including smoking),medications, health conditions and the effectsof depressive symptoms.16 Loneliness is also

associated with depression (either as a causeor a consequence) and higher rates ofmortality.9,15,17,18 A recent meta-analysis foundthat people with stronger social relationships hada 50 per cent increased likelihood of survival thanthose with weaker social relationships. Inunderstanding such a figure, this would meanthat by the time half of a hypothetical sample of100 people had died, there would be five morepeople alive with stronger social relationships.19

As the authors argue, the influence of socialrelationships on the risk of death are comparablewith well-established risk factors for mortalitysuch as smoking and alcohol consumption andexceedthe influence of physical activity andobesity.19 Such negative impact on individualshealth leads to higher health and social careservice use, while lonely and socially isolatedindividuals are more likely to have earlyadmission to residential or nursing care.15,18,20

The benefits to individuals and the widercommunity of reducing loneliness or socialisolation are therefore self-evident. For theindividual, mitigating loneliness will improvequality of life.3,14,15,20 Similarly, such changes mayimpact on subsequent health and social careservice use, limiting dependence on more costlyintensive services and contributing to thehealthy ageing agenda8 by compressingmorbidity.21 Supporting social engagement also

provides benefits to the wider community.Reducing social isolation enables a possibleharnessing of potential contribution to thecommunity through, for examplevolunteering2224 and caring responsibilities.

Given such individual wellbeing, health status,financial and wider community imperatives, therehas been a national and international policyconsensus4,7,27,28 that support must be providedto ameliorate social isolation and to reach thoseliving with or on the brink of loneliness.3 There isless clarity as to the most effective type ofintervention or the sector responsible for delivery(e.g. statutory or third sector). As will be

discussed, the available interventions and theirevidence base have been developingincrementally.

What sorts of interventionsare used in reducing socialisolation or loneliness?We have classified the wide variety ofinterventions to address social isolation orloneliness as one-to-one interventions, groupservices and wider community engagement.3,13,14

One-to-one interventions

These include: befriending,13,14,17,23,24,29

mentoring8,9 and gatekeeping (CommunityNavigator or Wayfinder initiatives).14,29,30

Befriending has been defined as an interventionthat introduces the client to one or moreindividuals, whose main aim is to provide theclient with additional social support through the

development of an affirming, emotion-focusedrelationship over time.17 The process of theintervention differs between individualprogrammes, but usually involves volunteers orpaid workers visiting an individual in their ownhome (or place of care) on a regular, usuallynon-time limited basis. Other models haveevolved to include telephone and groupbefriending.13,14 31 The type of assistance that eachbefriender provides can also differ, but alwaysincludes companionship and may involve provision

of transport and the completion of small errandssuch as picking up medications or shopping.Befrienders work with an extremely wide range ofpopulations: those living with health problems(e.g. individuals with dementia and their carers,those with ongoing mental health problems);those who are going through a transitional lifephase (e.g. young people leaving care); and thosewho want the opportunity to access and enjoysocial activities within the community, but whoneed some support to do so (e.g. those withlearning difficulties, older people with mobilityproblems). Many of the befriending schemes haveemerged from the community level to fill thesocial and emotional gap that may not be met by

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existing statutory health and social serviceprovision31 and are run through community orvoluntary organisations, although funding can beprovided from the statutory sector.

Mentoring concentrates on achieving agreedindividual goals: Mentoring is defined as arelationship between the volunteer and theindividual, based on meeting agreed objectivesset at the outset and where a social relationship,if achieved, is incidental.32 Mentors will workwith the client (often) on a short-term basis, andthus one key goal is to provide clients with thenecessary skills and abilities to ensure that they

are able to continue and sustain any achievedchange following withdrawal of the service.8,9 Aswith befriending schemes, mentors work withinthe umbrella of community or voluntaryorganisations and across populations, includingthe most vulnerable (e.g. young offenders,refugees, victims of domestic violence).

Wayfinders or Community Navigators areusually volunteers who provide hard-to-reachor vulnerable people with emotional, practical

and social support, acting as an interfacebetween the community and public servicesand helping individuals to find appropriateinterventions. The structure and processes ofthis type of service vary across localities andare dependent on population need. Forexample, those Community Navigatorsworking with frail older individuals may carryout a series of home-based face-to-face visitsto discuss concerns and plan, alongside the olderperson, what service or community provisionmay be beneficial. For less frail populations atelephone conversation may be moreappropriate, followed by written informationthat the individual can access and take forwardif they so choose.27,33

Group services

Supportive interventions that fall within groupservices include day centre-type services (such aslunch clubs), and social group schemes which aimto help people widen their social circles.3 Thenumber and extent of services is thus broad.Those interventions within social group schemesincorporate self-help and self-support

groups13,14,30 that cover a number of areas (e.g.bereavement, friendship, creative and socialactivities, health promotion). Their structure andway of working depend on the needs of the

population to whom the intervention isaddressed. For example, a group focused onsocial activities can be open to all14 whileanother wishing to build self-efficacy andindependence for older socially isolated womenwould be restricted to the original groupmembers to ensure an appropriate sense ofsharing and safety.3436 Such groups can be highlystructured to achieve specific aims30 or moreorganic, developing activities dependent on the

interests of the group members.33

Facilitation ofgroups can be peer-led or carried out by specialiststaff within health and social care.18,30 Socialgroup schemes also include those focused onrehabilitation and health promotion. Forexample, one programme, Lifestyle Matters,involved individuals aged 60 and over living inthe community and attending an eight-monthcourse (two hours per week) at which theyexplored a number of healthy living areasincluding health and ageing, health through

physical and mental activity and endings andnew beginnings.30

Wider community engagement

Wider community engagement includesprogrammes that support individuals to increasetheir participation in existing activities (e.g. sport,use of libraries and museums)3 as well as to useand join outreach programmes37 and volunteerschemes.2224,28 One example of an outreach

programme is the professionally conducted choirrun by the Levine School of Music in Washington,DC.37 Older people (mean age 79) were recruitedto the choir and attended weekly singingrehearsals for 30 weeks as well as putting onpublic performances of their work.

Volunteer schemes are extremely broad,involving the structured engagement ofbefriending or mentoring or, for example,community organised Time Banks that usehours of time rather than currency and where thetype of support volunteers undertake depends ontheir own skills as well as the needs of the widercommunity.29



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What does the research show?The outcomes of interventions toprevent social isolation

The wide variety of interventions and theirdifferent outcome measures make it difficult tobe certain what works for whom. The only clearfinding is that there is, as yet, no conclusiveempirical evidence that computer and/orinternet usage impacts on loneliness, physicalor psychological outcomes.14,30,38 Someevaluations, either singly reported orincorporated within systematic reviews, haveargued that such interventions are effective in

reducing loneliness.30,39 However, small samplesand inadequate matching of comparison orcontrol groups have led to unreliable outcomes.For example, in one study that providedcomputer and follow-up internet training to12 older people the authors stated: We cannotconclude that the reduction in lonelinessobserved among the participants could beattributed to the intervention.39

In contrast, there is some evidence that groupinterventions (e.g. closed self-help groups) aremore effective than one-to-one support (e.g.telephone support services).13,14 Nevertheless,when individual studies are explored, there aredifferential outcomes: some group activities haveno impact while there are specific one-to-oneinterventions that are seemingly effective. Inbringing together the available evidence for thissection of the briefing, 12 papers are included thatused validated outcome measures and assessed

the effectiveness of seven interventions, whilefour papers brought together findings withinsystematic reviews. The final paper29 carried outdecision modelling to assess cost-effectiveness.

In exploring the impact of interventions (orintervention types), changes across threeoutcomes are reported: loneliness, health andwellbeing (including mental health), and healthservice use.

Reduction in loneliness

Achieving a reduction in individual loneliness wasreported across very different types of

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intervention. For one-to-one interventions,evidence was available that people who usedWayfinder or Community Navigator servicesbecame less lonely and socially isolated following

such contact.14,30 Similarly, an evaluation of a USpaid befriending intervention reported thatappropriate companionship had been provided,mitigating loneliness.23

Somewhat less definitive findings were seenwithin evaluations of group services orinterventions. Two systematic reviews identifiedclosed self-help or support groups as effective inreducing loneliness and social isolation.13,14 The

single studies provided helpful wider descriptionsof the structures and processes of such groups,although differential outcomes were reported. A12-week closed group that aimed to developself-efficacy in terms of social integration, andfocused each week on different topics relating tofriendship, found no change in loneliness. Thoseindividuals who used the intervention wereseemingly still as lonely after the course as theywere before.34,35 Nevertheless, a further closedmodel that included social group activities (art

and inspiring activities, group exercise anddiscussion and therapeutic writing and grouptherapy) reported that 95 per cent of theparticipants (mean age 80) felt that their feelingsof loneliness had been alleviated during theintervention.20 Within the Washington choir (agroup activity focused toward wider communityengagement), it was found that although therewas a slight decrease in loneliness at follow-up,this was not statistically significant and there waslittle difference between the intervention andcomparison groups.37

Health and wellbeing

Within this area, changes in a number ofoutcomes were explored: depressive symptoms,physical health, health-related quality of life andmortality. Those one-to-one interventionsreporting a reduction in depressivesymptomology included a paid befriendinginitiative based in the US.34 A systematic reviewon the effectiveness of befriending alsosupported such outcomes, finding thatbefriending had a modest but significant effecton depressive symptoms in the short and long


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term when compared with usual care or notreatment.17 Individuals involved in befriendinginterventions reported that they felt lessdepressed following the intervention. The finding

of a 0.27 standardised mean difference (95 percent CI, 0.48 to 0.06) did not meet theNational Institute for Health and ClinicalExcellence (NICE) depression guidelines. It isnecessary to demonstrate a standardised meandifference of 0.5 or above if the technology is tobe adopted. Nevertheless, as the authors argue,these effect sizes of befriending in the short andlonger term are not substantively different tothose associated with conventional treatments in

primary care such as collaborative care andcounselling.17

Two mentoring initiatives found divergentoutcomes. A non-randomised observationalstudy reported that improvements in individualdepressive symptomology were maintainedat 12 months follow-up.9 Nevertheless, a secondstudy (a case controlled trial) that exploredthe same community mentoring intervention working with socially isolated people for up

to 12 weeks to restore older peoplesself-confidence, self-esteem and social identity found there were no robust improvements indepressive symptoms, physical health, socialactivities, social support or morbidity.8 This sametrial reported that the intervention groupdemonstratedpooreroutcomes, reportingsignificantly less improvement in health status(as measured through the EQ-5D) than thecontrol group.

A number of group initiatives improved healthand wellbeing. Members of the Washington choirreported improved physical health and areduction in falls in contrast to the comparisongroup.37 A significant improvement in subjectivehealth was also reported by those older peopletaking part in the social group activities art andinspiring activities, group exercise anddiscussion and therapeutic writing and grouptherapy.15 This latter study also exploreddifferences in survival (or mortality). At twoyears, survival was 97 per cent in the interventiongroup and 90 per cent in the control group astatistically significant between-groupdifference.15

Health service use

Of the papers selected for inclusion in this review,only two group-based interventions explored

before and after service use.15,37

Cohen et al37

reported that while self-reported visits to theprimary care practitioner (GP) rose in bothintervention and comparison groups, those in theintervention group reported fewer visits (meanof 6.73 per person compared with 10.84). Pitkalaet al15 measured hospital bed days, physician visitsand outpatient appointments. Across all services,the intervention group had significantly less usage.

Peoples views on the interventions

The concentration on quantitative outcomemeasures meant that there was necessarilylimited reporting on users experiences. Thoseinterventions that included appropriatequalitative methods (interviews, diaries orobservation) and analyses were a group activitymodel,15,20 a mentoring outreach programme,9 abefriending initiative23 and a closed groupeducative programme.3436

In general, it would seem that users reportedhigh satisfaction with the services. They felt theyhad benefited from such interventions and(perhaps more importantly) recognised that theyhad changed specific areas of their lifestyle.36

For example, users of the short-term mentoringoutreach service reported that they hadincreased their social interaction and communityinvolvement, taking up or going back to hobbiesor wider community activities. They also said thattheir self-esteem had improved and that they felt

physically and mentally better. They hadincreased their physical activity, were sleepingbetter and had reduced their medication.9 Forthose physically frail or housebound users,one-to-one befriending or mentoringinterventions able to visit on a regular basis wereparticularly welcome: It has meant everything tome. It has helped me so much. With my mind, Imean, its taken so much loneliness away andworrying.23 Peer support and cohesion (where

discussed) were central to a positive experienceof the interventions.15,20,3436

Few users gave constructive criticism as to theirexperience of the intervention. Such silence is



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documents, longer-term funding,33 absent orminimal criminal record checks3).

Nevertheless, commentators cited a number of

components central to ensuring the effectivenessof any intervention. In exploring the planningstage of any service, there was a need to beaware of and use existing community resourcesand to build community capacity.14 Older peopleshould be involved in any planning as well asimplementation and evaluation,13,14 and beenabled to choose and (re)structure the contentof any ongoing programme.9,20 There was a needfor high-quality selection, training and ongoing

support of facilitators, coordinators andvolunteers.1315,30 There were some indications inthe literature that volunteers belonging to thesame generation, sharing common culture andbackground, were likely to be more effective inbuilding relationships with a service recipient.13

However, in a further study, volunteers being ofthe same age was not seen as a centralrequirement.24 There was some support forstrong external management or facilitation ofany group intervention. Older people should be

allowed to self-select to groups, and there is aclear need for facilitators to assess individualsappropriately and thus place them with othershaving similar interests.15,18,20

Implementing effective interventions

Perhaps the first task is to identify thosepopulations within localities that are at risk of, orsuffer from, social isolation or loneliness. Newprocedures through the joint strategic needs

assessment and health and wellbeing boards42could respond by allowing such identification,supported by appropriate and rigorousconsultation and involvement of older people: Ifschemes to target loneliness in older people are tobe effective, they must involve older people atevery stage, including planning, development,delivery and assessment. Often the vital step ofasking what people want is missed out whendesigning services.3 Prior to designing anyprogramme, there also needs to be a clearunderstanding across organisations and individualsabout what is beingprevented whether thoseinterventions being considered are to amelioratesocial isolation or mitigate loneliness.11

not necessarily surprising: few older people feelable to risk negative comment when they arereliant on any service. Nevertheless, some spokeabout the rigidity of their intervention, arguing

for more flexible provision. For example, withinthe befriending programme, one user suggestedthat it would be more helpful if the befriendercould sometimes change their usual visitingtime and day.23 Adaptation was similarlyimportant to users within the short-termmentoring intervention, with their enjoyment ofactivities mediated by the extent to which thementors could tailor these to the userspreference, abilities and level of confidence.

Similarly, for those individuals with more severehealth problems or disabilities there was arequest for greater mentor support a needfor the mentor to be available longer than the12-week limit or to visit more often within theexisting timeframe. Users also reported theimportance of a skilled mentor. If mentors wereunable to encourage users in the right way,users felt disempowered and less confident,feeling blamed for their lack of progress.9 A finalbarrier to full use of interventions was that of

transport. Users reported that lack of availabletransport limited those activities that could beattended or any meetings with each otheroutside the intervention.9 To overcome thesedifficulties, some pilot programmes providedtransport to the venue by minibus.15,20

Unfortunately, it is likely that cost wouldprohibit such arrangements if an interventionwas rolled out across a wider locality.

Organisational implicationsEffective interventions (e.g. befriending,17,23,24

Wayfinders,14,29 and creative group sessions9,15,20)can and do work in day-to-day services. Perhapsthe most important factor and one rarelydiscussed in the empirical papers is the need forhealth and social care statutory services tosuccessfully work alongside the voluntarysector.7, 22,40,41 Volunteers (supported through avoluntary agency) delivered five (of the seven)interventions. Yet there was no discussion as tothe need for appropriate partnershiparrangements or those effective structures orprocesses that could ensure available servicesand volunteers (e.g. appropriate tender


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Certain projects need to be funded andimplemented. Wayfinder or CommunityNavigator interventions have been effective inidentifying those individuals who are truly

socially isolated or lonely14,29 and in ensuringsignposting to appropriate services. Similarly,there is good evidence that befriendingservices are effective in reducing depression andcost-effective when compared with usualcare.17,23,24,29 Creative groups tailored for differinginterests and needs lead to reductions inloneliness and re-engagement with the widercommunity,13,14,20 and demonstrate that thedeteriorating health effects of loneliness may be

reversed by an intervention which sociallyactivates lonely, elderly individuals.15

Nevertheless, as discussed above, good practiceneeds to be embedded within such programmesin relation to:

the selection and training of volunteers

consistency and rigour in assessment processes(including the incorporation of levels ofloneliness in any medical assessment10)

ongoing support and encouragement forparticipants to continue attendance

programme flexibility allowing the targetingand tailoring of interventions.

Cost and cost-effectiveness

No evaluation or research study included ananalysis of cost-effectiveness: Research intocost-effectiveness is especially sparse, withlittle economic research even into

programmes with evidence of effectiveness.30Nevertheless, limited cost data were providedin two papers.

Decision-modelling was used by Knapp et al29

to demonstrate the economic impact ofbefriending interventions and CommunityNavigators, compared with what might havehappened in the absence of any such service.The likely care pathways of individuals weremodelled and the costs and outcomes at eachstage estimated. Along with the costs of formalservice provision, those unpaid resources andopportunity costs provided by family and/orinformal carers were included.

It was estimated that for befriending schemes, atypical service would cost around 80 per olderperson within the first year and the reduced needfor treatment and support would provide about

35 in savings. The authors also argued thatsuch savings would be likely to continue in futureyears. When factoring in the quality of lifeimprovements as a result of the reduction indepression17,33 it was argued that the monetaryvalue would be around 300 per person per year,well exceeding the costs of the intervention. Theeconomic benefits from Community Navigatorswould seem to be greater.29 Knapp et alestimated that the cost per person would be a

little under 300. To this they added the costs ofa visit to a Citizens Advice Bureau or Job CentrePlus, bringing the total cost to 480 per personper year. Nevertheless, they estimated that theeconomic benefits (e.g. move into employment,fewer services used) would amount toapproximately 900 in the first year.

Costs were also provided by Pitkala et al15 intheir follow-up study of those individualsinvolved in the closed activity groups.20 The

total cost of health service use (hospital beddays, physician visits and outpatientappointments) was 1,522 per person per year inthe intervention group, compared with 2,465in the control group. This statistically significantdifference between the groups of 943 wasgreater by 62 than the costs of the intervention 881 per person.

Gaps in the research evidenceHow the research evidence could beimproved

The research evidence on loneliness and socialisolation has developed incrementally over thelast two decades, beginning to build an evidencebase of what works for whom. Although it couldbe argued that there is no longer the dearth ofevidence found in earlier systematic reviews,13,14

evaluations within this area are stillcompromised by weak methodologies.30 Aswith much research in statutory social care andthird-sector provision, future evaluation needsto concentrate on appropriately measuring



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appropriate measure of quality of life andcollected data from the same individuals beforethe intervention and one year later. The resultswere positive with statistically significant

improvements in mental health and health utilityscores. Such continuing outcomes could indicateto commissioners that such an intervention isworth investment. However, in the secondevaluation,8 a prospective controlled trial wascarried out. Two groups were recruited, onereceiving the intervention and one usual care,with data collected from each group. Nosignificant between-group differences werefound. That is, the group receiving the

intervention demonstrated no better physical ormental health outcomes than if they had notbeen offered the service. As the authorscomment, the between-group trial data did notreflect improvements in mental health status andin depressive symptoms that were reported in theearlier observational study. These very differentfindings when a comparative group is includedperhaps emphasise the necessity of carrying outcontrolled and preferably randomised trials thatincorporate multiple methods, rather than simply

qualitative and observational research.

Measurement of cost-effectiveness is complexand, as has been discussed, is rarely a core partof any evaluation of preventative services. Ifcost-effectiveness is to be measuredappropriately, key tools need to be included tocollect data on:

individual service use before and after theintervention

organisational set-up and implementationcosts44

the level and extent of informal carersupport45

the use of wellbeing measures (e.g. ASCOT,GHQ-12 or EQ-5D) to derive the social care orhealth-related quality adjusted life year(QALY) gained by the project or intervention.

Such best practice in evaluations wouldenable a robust and rigorous assessment ofwhether the piloted or planned implementationis cost-effective as compared to usual care.Nevertheless, it is also recognised that available

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(rather than merely assessing) quality-of-lifeoutcomes and cost-effectiveness.

To ensure that changes in quality of life can be

robustly measured, there first needs to berecognition that cross-sectional research(although often providing good snapshots) willnot necessarily allow attribution of effect. If weare to know whether specific programmes are ableto change individuals quality of life, or impact ontheir care pathway, those referred to any initiativeneed to be asked their views before the start of theintervention as well as following such contact.Qualitative semi-structured or in-depth interviews

are invaluable in being able to tease out views andsupport theoretical and thus policy developmentwithin specific practice areas. Nevertheless, suchresearch does not necessarily allow for assessmentof the impact of the intervention. A wider use ofstandardised quality of life measures needs to beembedded within any evaluative practice. This willallow for measurement of change, as well assupporting comparisons across other programmesor interventions that may similarly have used suchmeasurement tools. The measurement tools of

EQ-5D (a health-related quality of life tool) andASCOT (a social care related quality of life tool)have been identified and nationally adoptedwithin the outcomes frameworks as tools tomeasure quality in health and social care, and infuture will allow for a broader comparison acrossdelivery models.43

However, although comparing outcomes fromdifferent interventions provides insight aboutthe level and extent of effect, it is now becoming

essential to include a comparison or controlgroup (preferably with randomisation) withinany rigorous evaluation. We need to be able toseparate out what would have happened tothe individual if they had not received theservice the counter-factual argument. Withoutcontrol or comparison groups, there can beover-interpretation of the data: single-grouppre-post and non-randomised comparisonstudies yield larger mean effect sizes relative to

randomised comparison studies.12

For example, two papers included within thisreview explored the outcomes of an outreachmentoring service.8,9 The first9 used an


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funding and indeed the expertise of theevaluators may not allow such an approach.

Knapp et al29 used a decision-modelling

approach to show the economic impact ofdifferent initiatives to support communitycapacity-building. Such an approach permits costcalculation without the necessity of more costlyand lengthy primary research, and provides abaseline for commissioners and policy-makersfrom which to make decisions. However, theemphasis in this paper is (not surprisingly) ondocumenting the outcomes. This leads to minimaldescription of the raw data underlying the

modelling, or the level of sensitivity analysisundertaken. To allow appropriate assessment ofwhether the recommended outcomes are robust,greater detail needs to be provided.

What the evidence does not tell us

When measuring the impact of projects onspecific outcomes (reduction in loneliness,improvements in health and wellbeing andchanges in health service use), one of the

remaining questions is whether these can beimplemented in the English social and health caresystem. In short, are these projects transferable?Those Wayfinder initiatives that successfullyreduced loneliness were UK-based,14 while incontrast evidence on reduction of loneliness bybefriender interventions was drawn from theUS.23,24 The latter provided direct payments tobefrienders, a structure unlikely to be replicatedin England. Nevertheless, the process itself theprovision of companionship and small errands to

vulnerable individuals is already in place in theUK31,32 and providing positive outcomes.17,31

Similarly, the finding that closed social groupsdiminish feelings of loneliness is not necessarilynegated simply because the research took placein Finland.15,20 These activities are replicable andit is argued that those projects that produce themost effective outcomes are designed by, ortailored to the needs of, the older peoplethemselves and the locality. The greateststrength of successful upstream or lower-levelprovision is that the interventions do notdemonstrate (or demand) complicatedstructures or processes. By far the majority areprovided by volunteers and delivered through

voluntary organisations working alongsidethe community.33

Nevertheless, there is little robust outcome data

on those interventions that have included BMEcommunities,46 rural populations3 or the mostfrail and excluded those in care homes, refugeesetc. From reviewing the primary research,there are some concerns about whether thosesocially isolated or lonely individuals are beingappropriately reached by some of theinterventions. For example, those receiving abefriending initiative were found to score well onsocial integration and wellbeing when comparedwith normative scores for elders in the US.23 Forthe group choir initiative, the comparison groupreported a higher level of loneliness than theintervention group.37 Similarly, for other groupinterventions, success was dependent on groupmembers being well motivated and wanting tomake substantial life changes, with high dropoutrates where perhaps motivation was absent.3436

Windle et al30 noted that a disappointing featureof the papers included within their systematic

review was the disproportionate numberfocusing on relatively healthy older people in thecommunity, predominately women. With fewexceptions we know little about older people inlong-term care facilities, notably those who arefrail or over 80. Few interventions were targetedat alleviating poverty and none at older peoplefrom ethnic or sexual minorities. Within thisreview, although there are papers that includethe most frail and lonely,9,18 there are few thatincorporate all populations the majority of

individuals being white and female thus limitinghow far successful outcomes can beextrapolated.18, 24,3436,38

Implications fromthe researchThere is good evidence that one-to-oneinterventions such as befriending andCommunity Navigators reduce lonelinessand improve health and wellbeing.14,17,20,23,24

Users report high satisfaction with the servicesand there are some indications that involvingusers in the planning, implementation and



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evaluation of the programmes improvesoutcomes. Nevertheless, interventions also needto permit flexibility of delivery and necessaryadaptation to the needs of the population.

Where we have the evidence, both types ofintervention appear to be cost-effective whencompared with usual care.29 For social groupinterventions15,20 and wider communityinitiatives37 there is similarly good evidencethat appropriately facilitated cultural andhealth-related interventions reverse thedeteriorating effects of social isolation andloneliness.15

Some interventions may well be promotingand delivering promising practice despite thefact that there is little robust evidence of theireffectiveness although changes in outcomesmay well be happening. For example, thementoring intervention that supported andempowered older people8,9 reported that wheredifferences were found between the interventionand control groups, the intervention group hadpoorer outcomes. In part, such a lack of evidenceis due to the insufficient size of the groups, the

methods selected (purely qualitative, rather thanstandardised measures, cross-sectional ratherthan longitudinal approaches) and a lack ofrandomisation to enable an understanding ofthe impact of the service. Similarly, there have

been few studies of population sub-groupsthat might enable us to understand forwhom such interventions may be mostappropriate.

It is possible that this review understates thebenefits that can be derived from small servicesproviding emotional support to those who aresocially isolated or lonely. The necessity for suchpreventative projects is supported by thecoalition government: When people developcare and support needs, our first priority shouldbe to restore the individuals independence andautonomy. With the solid basis provided in the

Spending Review for social care, there is noreason for councils to restrict support to thosewith the most intensive needs. This not onlyserves local people poorly, it is a falseeconomy.42 Nevertheless, as the extent anddepth of the real reduction in social care spendbegins to bite, it may be very easy for councils torefocus their provision away from such servicesto concentrate on secondary and tertiaryprevention strategies in order to avoid moreimmediate admissions and readmissions. While

our findings are mixed, they also demonstratethat the contribution of wellbeing services tohealth improvement is worthy of attention byboth social care and health resourcecommissioners.

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Useful linksThe Campaign to End LonelinessA campaign which draws on research and

inspiration from across the UK to offer ideasto both individuals and those working witholder people.www.campaigntoendloneliness.org.uk/

AgeUK, Social Inclusion and Lonelinessresearch hubProvides links to academic research units,charities, and funders which focus on socialinclusion and loneliness topics in ageing.www.ageuk.org.uk/professional-resources-

home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/

Department of Health, National Evaluationof Partnerships for Older People Projects(POPP)The final evaluation of the POPP programme,which was funded by the Department of Healthto develop services aimed at promoting olderpeoples health, wellbeing and independence.

www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111240

Support LineOffers confidential support including forpeople who feel socially isolated.www.supportline.org.uk/

Do-itFor information relating to volunteering.www.do-it.org.uk/

Related SCIE publicationsSocial Care TV: Prevention: promoting wellbeingwww.scie.org.uk/socialcaretv/

Social Care TV: Prevention: Reablementwww.scie.org.uk/socialcaretv/

Social Care TV: The mental health wellbeing ofelders in black and minority ethnic communitiesvideos www.scie.org.uk/socialcaretv/

SCIE Research briefing 22: Obstacles to usingand providing rural social care

www.scie.org.uk/publications/briefings/briefing22/index.asp

SCIE Research briefing 35: Black and minorityethnic people with dementia and their access tosupport and serviceswww.scie.org.uk/publications/briefings/briefing35/

SCIE Research briefing 36: Reablement:a cost-effective route to better outcomes

www.scie.org.uk/publications/briefings/briefing36/

SCIE Report 38: Supporting black and minorityethnic older people's mental wellbeing: accountsof social care practicewww.scie.org.uk/publications/reports/report38.asp

SCIE Report 41: Prevention in adult safeguardingwww.scie.org.uk/publications/reports/report41/index.asp
http://www.ageuk.org.uk/professional-resources-home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/http://www.ageuk.org.uk/professional-resources-home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/http://www.ageuk.org.uk/professional-resources-home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/http://www.ageuk.org.uk/professional-resources-home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/http://www.ageuk.org.uk/professional-resources-home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111240http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111240http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111240http://www.scie.org.uk/publications/briefings/briefing22/index.asphttp://www.scie.org.uk/publications/briefings/briefing22/index.asphttp://www.scie.org.uk/publications/briefings/briefing35/http://www.scie.org.uk/publications/briefings/briefing35/http://www.scie.org.uk/publications/briefings/briefing36/http://www.scie.org.uk/publications/briefings/briefing36/http://www.scie.org.uk/publications/reports/report38.asphttp://www.scie.org.uk/publications/reports/report38.asphttp://www.scie.org.uk/publications/reports/report41/index.asphttp://www.scie.org.uk/publications/reports/report41/index.asphttp://www.scie.org.uk/publications/reports/report41/index.asphttp://www.scie.org.uk/publications/reports/report38.asphttp://www.scie.org.uk/publications/briefings/briefing36/http://www.scie.org.uk/publications/briefings/briefing35/http://www.scie.org.uk/publications/briefings/briefing22/index.asphttp://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_111240http://www.ageuk.org.uk/professional-resources-home/knowledge-hub-evidence-statistics/research-community/social-inclusion-and-loneliness-research/


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30. Windle, G. et al. (2008) Public healthinterventions to promote mental well-beingin people aged 65 and over: systematic reviewof effectiveness and cost-effectiveness,

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professionally conducted cultural programson the physical health, mental health, andsocial functioning of older adults', TheGerontologist, vol 46, no 6, pp 726734.

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Dutch experiment in using ECT to overcomeloneliness among older adults',Aging andMental Health, vol 11, no 5, pp 496504.

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46. Manthorpe, J., et al. (2009) '"We are notblaming anyone, but if we don't know aboutamenities, we cannot seek them out": blackand minority older people's views on the

quality of local health and personal socialservices in England,Ageing & Society, vol 29,2009, pp 93113.

About the development of this productScoping and searchingFocused searching began in November 2010 and was completed in January 2011. The scope

included peer reviewed papers reporting evaluations of interventions aimed at reducing socialisolation and loneliness. Priority was placed on systematic reviews and controlled effectivenessstudies. Poor quality studies with no discernible methodology, no outcome measures and nocontrol were excluded from synthesis. Papers published before 2000 were excluded.

Peer review and testingThe authors have research and topic expertise. The briefing was peer reviewed internallyand externally.

About SCIE research briefingsSCIE research briefings provide a concise summary of recent research into a particular topic andsignpost routes to further information. They are designed to provide research evidence in anaccessible format to a varied audience, including health and social care practitioners, students,managers and policy-makers. They have been undertaken using methodology developed by SCIE.The information on which the briefings are based is drawn from relevant electronic databases,journals and texts, and where appropriate, from alternative sources, such as inspection reportsand annual reviews as identified by the authors. The briefings do not provide a definitivestatement of all evidence on a particular issue. SCIE research briefing methodology wasfollowed throughout (inclusion criteria; material not comprehensively quality assured; evidencesynthesised and key messages formulated by author): for full details, seewww.scie.org.uk/publications/briefings/methodology.asp

SCIE research briefings are designed to be used online, with links to documents and otherorganisations websites. To access this research briefing in full, and to find other publications, visitwww.scie.org.uk/publications/briefings/


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The implementation of individual budgetschemes in adult social care

Identification of deafblind dual sensoryimpairment in older people

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Stress and resilience factors in parentswith mental health problems and

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Experiences of children and young peoplecaring for a parent with a mental healthproblem

Childrens and young peoples experiencesof domestic violence involving adults in aparenting role

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Factors that assist early identificationof children in need in integrated orinter-agency settings

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The contribution of social work and social

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Reablement: a cost-effective route to

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Preventing Loneliness