The fifth meeting under the theme of ‘Talking about the Human Rights of Older Persons’ took place online on September 15, 2021, with Dr Christopher Mikton. Dr Mikton is a Technical Officer of Demographic Change and Healthy Ageing at the Department of Social Determinants of Health, Division of Healthier Populations, World Health Organization (WHO). He has been working for the WHO in the area of Healthy Ageing for two years. Before that he worked in WHO’s Prevention of Violence Unit for almost nine years. Most recently, he was involved as a co-lead researcher of WHO Global Report on Ageism published in March 2011 and the lead-researcher of Advocacy Brief: Social Isolation and Loneliness among Older People published in 2021.
During the meeting, he introduced the rationale behind the development of Advocacy Brief: Social Isolation and Loneliness among Older People. He also addressed its key messages and policy implications, and WHO’s future research direction in the area of healthy ageing.
1. The Background of the Advocacy Brief
The interest in social isolation and loneliness across all age groups has grown and has become a policy priority area in quite a few countries for the last five to ten years, most prominently in Japan, the UK, Holland and Germany. While a general interest in and concern with social isolation and loneliness have moved up in the policy agenda, there has been a relative lack of research on and interest in social isolation and loneliness among older persons. The WHO had also recognized the health implications of loneliness for older persons for some years, but had not conducted serious research on this. Acknowledging this, the WHO has decided to utilize its Decade of Healthy Ageing that it embarked on in 2020 as an opportunity to start addressing some of issues that had been neglected in relation to social isolation and loneliness among older people. This is also supported by a whole body of research that was published in the last decade or so, which showed that social isolation and loneliness have serious impacts on people’s health in general, beyond the particular case of older people. The impact of social isolation and loneliness can be accumulative and manifests itself more intensively in older age. It is shown that social isolation and loneliness can increase the mortality rate and the risks of physical and mental health problems including dementia, anxiety and depression. In short, behind this research, there was the realization that social isolation and loneliness are important risk factors for physical and mental health, and for mortality. The causal links between social isolation and loneliness and health risks have been increasingly recognized.
2. Relations between Social Isolation and Loneliness
There are many challenges in measuring the degree of loneliness. Living alone is often seen as a factor that increases social isolation and loneliness. However, the correlation between living alone, social isolation and loneliness is not straightforward. For instance, Scandinavian countries tend to have the highest level of single-occupant households in the world but people in these societies do not necessarily suffer from a higher level of social isolation and loneliness. As far as the WHO’s research is concerned, it is not clear yet whether or not social isolation and loneliness have increased globally: some studies show that the level of social isolation and loneliness has increased in China in recent years while it has stayed the same or decreased in Europe. There is no data yet pointing unequivocally into one direction.
It is important to distinguish the concepts of social isolation and loneliness. Social isolation refers to the objective and quantitative social conditions/interactions in which people are isolated from each other. Loneliness refers to individuals’ subjective feelings arising from the discrepancies between the social relations people want/expect and the social relations that they actually have. Loneliness therefore in part depends on individual and cultural expectations concerning social contact. For instance, one recent study shows that people in Scandinavian countries suffer less from loneliness than those in southern European countries even if they are socially more isolated. In other words, people in more individualistic northern Europe appear to have lower expectations about the number of social connections they should have while people in more collectivist/communalist societies have higher expectations for social connection and tend to feel more lonely even if they are less socially isolated compared to their northern European counterparts.
3. Policy Implications
To the extent that cultural factors play a role in determining loneliness as experienced across different societies, it is quite difficult to draw out a set of policies that can be applicable universally. One of the policy considerations should be that one has to demonstrate empirically whether or not loneliness is increasing. Many perceptions and assumptions are in circulation but it is important to establish an evidence-based clear understanding of the status of loneliness. It is also important to distinguish living alone, social isolation and loneliness. While these might be closely related, they not always are: each of these is independently associated with an increase in the risks of mortality. Even if many different evaluations have been conducted, existing evidence is low in quality and not strong enough to recommend any particular courses of action. A big challenge in this field therefore is to establish and develop an evidence-based understanding of the current situation and identifying what works and what does not.
All kinds of different possible interventions have been tried to assess and intervene in social isolation and loneliness, from social skills training and cognitive behavioral therapy to psychotherapeutic mental health support. Various efforts include befriending services where volunteers call over and visit older persons on a regular basis, social prescribing where the health sector sends people to the social sector to alleviate loneliness, improving transportation to help older persons’ mobility and designing houses in a way to have common areas where people can meet and interact. Despite all these attempts, it is not yet conclusive what works best. Given the current status of evidence, policy recommendations are difficult to make, and further research is needed.
4. WHO’s Plans
The Advocacy Brief is just a start for addressing this area and the WHO is planning to address social isolation and loneliness in a more sustained way within the UN Decade of Healthy Ageing 2021 -2030. WHO is currently creating two Evidence Gap Maps. The aim of the first is to map out all evidence and digital interventions available in relation to social isolation and loneliness among older persons. About 200 studies have been identified: this identification is about what researches have been carried out, where they have been conducted and what quality they are. After this, a further Evidence Gap Map will be conducted on non-digital, face-to-face interventions. Upon completion of the Evidence Gap Map on digital and non-digital interventions, the WHO will move on to developing a set of guidelines for national governments. The guidelines will be developed on the basis of evidence and propose a set of policy recommendations that the national ministries of health or health agencies should adopt. This project is starting next year and is expected to take several years. These will be “living” guidelines: to the extent that this issue is fast moving, they will be updated regularly online. Additionally, linking these two, there will be an Evidence Portal where all evidence is synthesized. This will be mainly aimed at policy and decision makers.
In parallel to this, although the role of the WHO is not clear yet, it is anticipated that a network of program developers and evaluators should be developed in an effort to accelerate global interventions in social isolation and loneliness. In this respect, the Policy Brief is a very first small step towards this grand ambition as part of the Decade of Healthy Ageing. This series of project plans on social isolation and loneliness will be carried out in the next five to ten years and will be one of the priorities within the WHO.
The WHO is also planning to build a network of a small group of member states that are particularly interested in these issues, prompting them to fund pilot projects to spearhead other countries’ future efforts. It is currently having initial-stage conversations with some countries. It is interested in having a conversation with Korea. Given the high level of suicide among older persons in Korea, the Korean government might be interested in joining the WHO’s initiative.
5. Future & Key Messages
While a clear correlation between living alone and loneliness is yet to be established in scholarly research, the fact that the UK and Japanese governments appointed ‘loneliness ministers’ suggests that loneliness is increasing across many parts of the world. The issue of loneliness will be one of the key policy considerations in the years ahead. However, it is important to be careful not to be nostalgic about the past. Modern societies also offer new ways of human connections and any conclusion should be based on robust research. It is also important to remind ourselves that the key is not so much about human connections as such but the quality of human connections, how much one feels comfortable, accepted and involved. WHO is interested in working closely with AGAC to cooperate to deepen our understanding of social isolation and loneliness.
Hae-Yung Song (manji74@asemgac.org)