Introduction:
This website is an overview of the findings of the Honors Thesis completed by Claire Pishko and Haley Harelson, students from Arizona State University’s Barrett, the Honors College. After the onset of the COVID-19 pandemic, life for many individuals changed drastically. As quarantine and shelter-at-home orders were implemented to prevent the spread of the COVID-19 virus, individuals found themselves adapting to new, unprecedented ways of living. Many were isolated from the majority of the world for extended periods of time. This change was felt by everyone, but uniquely by individuals at the highest risk for transmission of the COVID-19.
To better understand the health implications of social isolation and the resulting feelings of loneliness, Claire and Haley joined the social isolation research project under Dr. Bradley Doebbeling. This project focused on social isolation and loneliness in older adults, who were profoundly impacted by the COVID-19 pandemic. They were hopeful to uncover successful strategies and provide resources for individuals to combat feelings of social isolation and loneliness.
The goal of this thesis was to further understand how the COVID-19 pandemic has impacted loneliness in older adults, age 50+. Older adults are also more vulnerable to social isolation and loneliness as they are very dependent on family members or support through community services3. The study examined ways older adults maintained social connectedness and overcame loneliness during and after the COVID-19 pandemic. The results from this project were analyzed in order to uncover strategies to successfully overcome feelings of social isolation and loneliness.
Claire joined the project aiming to better understand the effects of social isolation and loneliness on health outcomes. This project has allowed her to explore some of the numerous elements that contribute to an individual's health. Claire will graduate from ASU's Barrett, the Honors College in May of 2022 with a B.S. in Biochemistry with a minor in Mathematics.
Haley joined the project with the goal of learning data analysis techniques. This project has allowed her to analyze qualitative and quantitative data sets and perform complex data visualizations. She will graduate from ASU's Barrett, the Honors College in May of 2022 with a B.S. in Data Science on the Computer Science track.
This Honors Thesis was completed in conjunction with faculty members from ASU’s College of Health Solutions, ASU's Edson College of Nursing, and ASU's Herberger Institute for Design and the Arts. The thesis committee consisted of Dr. Bradley Doebbeling from ASU's College of Health Solutions and Dr. Maurico Meja from ASU's Herberger Institute for Design and the Arts.
Background:
What is social isolation? Social isolation is “a state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a minimal number of social contacts, and are deficient in fulfilling and quality relationships”6. Unfortunately, social isolation is very prevalent within older adults, with around 24% of community-dwelling adults age 65 and older experiencing social isolation11. Social isolation has numerous adverse effects and can occur independently or in tangent with loneliness.
What is loneliness? Loneliness is “the perception of social isolation or the subjective feeling of being lonely5. Before the onset of the COVID-19 pandemic, 43% of adults age 60 and older reported feelings of loneliness8. In a 2012 study by Perrissinotto et al., loneliness was a predictor of functional decline and death in older adults over the age of 60. For example, participants categorized as "lonely" had a 24.8% decline in activities of daily living versus a 12.5% decline in "not lonely" participants8.
Prior to the onset of the COVID-19 pandemic, social isolation and loneliness were well-defined and were generally understood to have adverse effects on generalized health13. However, the implementation of strict stay at home orders after the onset of the COVID-19 pandemic made it abundantly clear that health organizations need to better understand and respond to social isolation and loneliness as public health priorities10. Pre-COVID-19 pandemic studies' estimates of social isolation and loneliness vary on a case to case basis. The data is somewhat inconsistent, showing a range of one-in-six individuals feeling lonely to one-in-four people feeling lonely. The lack of knowledge about the extent of these conditions indicates the need for further, more extensive, research on the topic.
The COVID-19 pandemic has drawn attention to social isolation and loneliness for all ages, particularly older adults. Older adults have been identified as the most vulnerable, at-risk segment of the population for social isolation and loneliness, which was further exacerbated at the start of the COVID-19 pandemic. Elderly people do not only belong to the SARS-CoV-2 risk group, but also to those who suffer increased morbidity and mortality as a result of the withdrawal of social interaction and mental stimulation9.
Starting in late February and early March of 2020, quarantine strategies were imposed to prevent the spread of the COVID-19 infection. Some of these quarantine strategies included state-wide lock downs, mandated curfews, restrictions on group gatherings, cancellation of planned social and public events, closure of mass transit systems, as well as others. These restrictions created a massive disruption to individuals, families, communities, and the whole world. COVID-19 restrictions affected nearly all of the world’s population, and reality as we knew it was altered. For many, daily life changed dramatically. The "normal” ways of life were suspended until the resolution of the COVID-19 pandemic. While almost all groups of people were affected by the restrictions imposed as a result of the COVID-19 pandemic, some were more at risk to experience feelings of isolation and loneliness.
Significance:
Loneliness is a subjective perception of lack of meaningful relationships and social isolation is a lack of social engagement and social contacts. During the COVID-19 pandemic, social engagements and contacts ceased, leaving individuals void of meaningful relationships. To avoid these feelings, individuals had to implement novel strategies to improve their social connectedness. Improving social connections requires addressing both social isolation and loneliness5.
Social isolation and loneliness are two discrete yet interconnected factors that contribute to an individuals' general health, happiness, and wellbeing. Social isolation and loneliness are associated with a 29% and 26% increased risk of mortality, respectively2.
The risk of social isolation on mortality is comparable to smoking 15 cigarettes a day and exceeds the risks of obesity. Furthermore, social isolation increases the risk for cardiovascular disease, serious illness, functional decline and disability, malnutrition, depression and anxiety, dementia, and many more.
Feelings of loneliness increase an individuals' likelihood to experience stress disorders, irritability, insomnia, emotional distress, mood disorders, including depressive symptoms, fear and panic, and anxiety12. Additionally, chronic loneliness often decreases participation in physical activity, leading to increased risk of frailty and fractures1.
In general, feeling connected to others is a fundamental human need that is imperative to well-being and survival. A lack of social connections create adverse health effects that increase ER Utilization, healthcare provider visits, hospital admissions, and admission to long term care facilities.
In 2015, the Grand Challenges for Social Work identified social isolation and loneliness as one of the top three priorities for social work4. As individuals have become far less connected than in previous generations, social isolation and loneliness has been a public health concern and priority for some time; however, the start of the COVID-19 pandemic brought to light the importance of social connectedness.
The physical distancing guidelines implemented to prevent the spread of COVID-19 increased feelings of social isolation and loneliness in older adults. Physical distancing further heightened risk of social isolation and loneliness10. Social distancing was enacted to limit disease transmission including shelter-in-place orders, stay-at-home-orders, physical distancing, as well as others.
During the pandemic, social isolation decreased risk of COVID-19 infection, but significantly impacted individuals' subjective feelings of social isolation and loneliness. These guidelines created a social connectivity paradox10 where older adults had to avoid the people, places, and services they rely upon for companionship, support and resources.
In 2015, the Grand Challenges for Social Work identified social isolation and loneliness as a top three priority for social work. As individuals have become far less connected than previously, social isolation and loneliness has been addressed prior to the COVID-19 pandemic. However, the start of the COVID-19 pandemic brought a significant amount of attention to the issue.
Methods:
This study utilized two primary data sets. For simplicity and clarity, we will refer to these data as data set one and data set two. Data set one included participants from the on-going longitudinal study, “Aging In the Time of COVID-19” (Guest et al., ongoing) from the Center for Innovation in Healthy and Resilient Aging at Arizona State University. This study researched how COVID-19 and the resulting physical/social distancing impacted aging individuals' health, wellbeing, and quality-of-life. The study involved a brief 15-25-minute online survey regarding participants’ social connections, health, and experiences during COVID-19. This study gathered information about participants’ comorbid conditions, age, sex, location, etc. The UCLA Loneliness Scale and the PROMIS Social Isolation Score were used as standard measurements of social isolation and loneliness. These scales are defined below:
UCLA Loneliness Scale: A 20-item scale designed to measure one’s subjective feelings of loneliness as well as feelings of social isolation. Participants rate each item as either O (“I often feel this way”), S (“I sometimes feel this way”), R (“I rarely feel this way”), N (“I never feel this way”).
For more information on the UCLA Loneliness Scale click here
PROMIS Social Isolation Score: The PROMIS Social Isolation item bank assesses perceptions of being avoided, excluded, detached, disconnected from, or unknown by, others. The item bank does not use a time frame (e.g. over the past seven days) when assessing social isolation.
For more information on the PROMIS Social Isolation Score click here
Data set two consisted of qualitative data from interviews with older adults (n = 22), aged 50 and older. Participants from the original, longitudinal study, Aging In the Time of COVID-19, who did not report loneliness were sent an email inviting their participation in an interview.
This study asked participants to describe successful strategies older adults used to remain socially engaged during COVID-19. Participants were challenged to identify meaningful activities in which older adults engaged during the COVID-19 pandemic.
Agreeable participants were provided informed consent and were scheduled for a semi-structured interview. A standard moderators guide was approved by the IRB at ASU and was used as a reference by the trained interviewers. Interviews occurred via Zoom or over the phone depending on participants’ preference. The interviews were audio-recorded and transcribed verbatim. Thematic analyses were performed on the interview transcripts by two independent reviewers. Disagreements were resolved by discussion between these two reviewers. This analysis was facilitated by Atlas TI software.
Six key themes were identified as positive deviance approaches. These were communication facilitation, activities, community engagement, acts of service, mindfulness and reflection, and making new connections.
The target audience for the findings of this study are older adults, aged 50+, who are experiencing feelings of social isolation and/or loneliness. We have created a visual essay including the findings of our two study methods. Using the information from data set one and data set two, we have gathered resources that can aid in overcoming feelings of loneliness and isolation.
Discussion:
By mid-April of 2020, more than ninety percent of the world’s population was under some form of lock down due to the COVID-19 pandemic. Government imposed lockdowns were implemented to protect citizens and vulnerable groups from contracting the virus. Older adults are the segment of the population most vulnerable in this pandemic, in part due to their weaker immune systems and increased likelihood of having a chronic condition such as heart disease, diabetes, lung disease and cancer. The outbreak of COVID-19 had a profound impact on older adults’ health and well-being. One of the most affected health outcomes is social isolation and loneliness. By and large, the world demonstrated extreme unpreparedness for the COVID-19 pandemic.
Initially, a literature search was performed to understand the effects of social isolations and subjective feelings of loneliness. Once the implications were understood, the project explored the strategies used by older adults who overcame social isolation and loneliness during and after the COVID-19 pandemic. This study identified six positive deviance approaches to avoid these feelings. These six approaches included activities, communication facilitation, community engagement, acts of service, mindfulness and reflection, and making new connections.
Activities were the most common way that individuals avoided social isolation and loneliness, and was mentioned n = 310 times in the participant interviews. As in person activities had ceased, individuals were challenged to take up new activities and find new hobbies. Some examples of activities that individuals participated in included podcasts, walking, reading, hiking, gardening, writing, and many others.
Older adults were challenged to adapt to new forms of communication during the COVID-19 pandemic in order to remain connected to their friends and family. Communication facilitation was mentioned n = 274 times in the participant interviews as a positive deviance strategy. Some examples of successful communication facilitation include email, phone calls, social networks (Facebook, Instagram, etc.), instant messaging, Zoom, and others. Communication facilitation also allowed older adults to make new connections, one of the six identified positive deviance strategies.
Many older adults practiced mindfulness and reflection as a coping strategy to deal with the changes brought on by the COVID-19 pandemic and was mentioned n = 155 times. Mindfulness and reflection was defined as a participant reflecting or providing insight into their given situation, how they processed said situation, or discussing opportunities to have this reflection. Mindfulness and reflection typically included participants noting their behavior, practices, or strategies to maintain well-being. Examples include having something new on your calendar everyday, reflecting on how one’s past experiences have prepared them well for current circumstances, keeping busy and maintaining control, planning activities for trips or getting away to reflect.
Community engagement (n = 105) and acts of service (n = 54) were two positive deviance approaches that individuals used to tackle feelings of social isolation and loneliness. Community engagement was defined as activities organized by the community or within the community that people are participating in. Examples of community engagement include neighborhood bands, outdoor art exhibits, outdoor murals, online events, and others. Acts of service were identified as activities where individuals supported others or engaged in community service of some sort. Some examples include patient advocacy, help with groceries or errands, getting vaccine appointments, as well as others.
While this study did undercover some key insights to social isolation, loneliness, and strategies to prevent these conditions, there were several limitations that make the findings difficult to generalize. To start, about 87% of the respondents were female while only about 13% were male. Furthermore, a vast majority of the respondents identified as white (about 96%), while less than 1% of respondents identified as any other race. Roughly 2% identified as "other", meaning they did not feel that the other options accurately identified their race. In order for this study to be more generalizable, a sample would need to be more representative of the actual population. In future studies, outreach tactics would need to reach a wider audience in order to capture more diverse and inclusive data.
Conclusion:
The purpose of this Honors Thesis was to understand the effects of social isolation and loneliness on an individuals' well-being and to understand successful strategies used in avoiding social isolation and feelings of loneliness in older adults (50+) during the pandemic.
Social isolation and loneliness are serious yet underappreciated public health risks that affect a significant portion of the older adult population. Additionally, a significant proportion of adults in the United States report feeling lonely. After the start of the COVID-19 pandemic, a third of the global population have experienced lockdowns due to the outbreak. The COVID-19 pandemic increased the number of older adults who were socially isolated after many countries have issued stay-at-home orders.
Through the analysis of two different data sets, we concluded six positive deviant approaches to overcoming isolation and loneliness including taking up new activities, adapting to new forms of communication, making new connections, practicing mindfulness and reflection, engaging in the community, and participating in acts of service. This project demonstrated the importance of social connections and communication, particularly in the aging population.