In PEGASIS

An ancient Indian parable tells of six blind men who are asked to describe an elephant. Each man is touching a different part of the elephant and each claims that an elephant is only that piece that he can feel and describe. The men are intransigent in their beliefs about the elephant, until the king tells them that each of them is correctly describing a piece of the elephant, but that it is much bigger, and has all of the characteristics that each is describing. Thus, by working together and sharing their knowledge, they are able to describe the beast known as an elephant. At the same time, they learn that they are blind, and that there are different ways of seeing and knowing the same thing.

While social isolation may be the elephant, PEGASIS—the Pan-Edmonton Group Addressing Social Isolation of Seniors—is just one of the group of blind men trying to describe the beast and figure out what to do with it. In fact, it is like we are one of a thousand blind people in the middle of a zoo, all trying to describe what we are “seeing”, and to determine what we are going to do with these bizarre and diverse creatures. Some of us have figured out that our elephant—social isolation—is growing, but we have not yet found a way to incorporate everyone’s description of the elephant so we can work together on solving the problem.

Intuitively, the solution to seniors’ social isolation is to facilitate social connectedness and belonging. That doesn’t seem so difficult until we start looking at the factors related to the human experience of feeling connected, valued and belonging. The issue becomes infinitely more complex when we try to factor in differences between isolation and loneliness, choice and circumstance, and the challenges of individual versus collective resources and decision-making.

Defining loneliness and social isolation

The terms loneliness and social isolation are often used interchangeably, but researchers conceptualize loneliness and social isolation as different concepts.[1-4]

Loneliness is the feeling of being without the type of relationships one desires.[1] It describes a shortfall between a person’s actual and desired quality and quantity of social engagements. Loneliness is measured using questions that seek the person’s feelings about the quality of their relationships and social activities.[4]

Social isolation is conceptualized as an external, objective measurement of an individual’s social networks and social interactions [5]. Researchers typically measure the size of the person’s social networks and the number of interactions they might have with others in their social network.[4]

One person may have few social contacts and not feel lonely, while another who has many contacts and a busy social life may be lonely.[1, 6] Therefore, the definition that the Pan-Edmonton Group is using for social isolation comes from a 2006 report by Janice Keefe that includes both objective measurement of social networks (quantity) and the person’s subjective perceptions of loneliness (quality):

Social isolation is a low quantity and quality of contact with others. Social isolation involves a situation of few social contacts, few social roles, and the absence of mutually-rewarding relationships[7].

Why should we be concerned about social isolation and loneliness?

Social isolation and loneliness increase costs to the health system. People who are lonely and/or socially isolated experience significantly higher rates of chronic disease, greater impairments, lower general wellbeing, more depression and higher rates of premature mortality than those who are socially connected.

Social isolation and loneliness reduce quality of life/life satisfaction. Seniors consistently rank relationships with family and friends second only to health as the most important factor in their lives. [8]

When seniors are lonely and disengaged from their families, friends and communities, society doesn’t fully benefit from their contributions. Older adults contribute a lot to society. They pay for services and supports, pay taxes, volunteer, give generously to charities, look after grandchildren, and provide care for spouses and family members and many others in their communities. [9]

Effective interventions

Interventions and activities aimed at reducing social isolation and loneliness are widely advocated as a solution to this growing problem. However, there is very little published evidence demonstrating the benefits of interventions. [10-14] Several reviews have found a few interventions that demonstrate reductions of social isolation and loneliness, but the quality of evidence was generally weak.[13, 14] Flawed intervention and research designs in the past have precluded proper evaluation of efficacy.[11, 14, 16]

What are the characteristics of effective interventions? The factors include:

  1. Projects adapted to local contexts. A good understanding of the target group’s need for acceptance and social support is necessary to design effective interventions. [7, 14] A community development approach that took advantage of local strengths was more successful than those not designed to adapt to the community contexts.[10, 14]
  2. Planning approaches that involved older people in design and implementation of the intervention were more effective than those designed exclusively by professionals.[13, 14] Inclusion of seniors in program design tended to preserve and enhance their autonomy and control. Older adults found interventions designed by others were patronizing.[13]
  3. Interventions focusing on older adults’ productive engagement and participation were more effective that those using passive approaches.[11, 17, 18] Doing things increases the older adult’s social contacts significantly more than watching or listening.
  4. Isolated older adults need to be invited and encouraged to become engaged. Just because the seniors centers or programs are there does not mean that socially isolated older adults will attend those programs.[13, 14]

Individuals and groups participating in the National Roundtable on Reducing Seniors’ Social Isolation[19] lauded the value of the World Health Organization’s “age-friendly communities” initiative currently in place in Edmonton. This model addresses eight key domains of community living that enable seniors with varying needs and capacities to live in security, good health, and to participate fully in society. These domains include transportation, housing, social participation, respect and social inclusion, civic participation and employment, communication and information, community support and health services, and outdoor spaces and buildings. They recommend development in the following areas[7, 11,13, 19]

  • Supporting transportation initiatives;
  • Increasing affordable and suitable housing and care options to meet the varied needs of older adults;
  • Increasing community awareness of services for seniors;
  • Increasing the service delivery capacity of small community agencies;
  • Supporting the development of outreach programs for seniors;
  • Supporting informal caregivers;
  • Reducing fear, stigma or ageist attitudes that prevent seniors from accessing community services/programs or being socially active in their community;
  • Building a sense of community to encourage interactions and connections among neighbours and the larger community;
  • Developing collaborative approaches.

The benefits and challenges of collaborative approaches

Given the complexity and scope of social isolation, collaborative approaches that bring together key players, cluster programs and offer a multi-disciplinary approach are more likely to have an impact than individual projects operating in isolation from one another. Organizations that typically have not joined forces before are now drawing together to work closely on solutions and PEGASIS is setting up the conditions for these, and other, organizations to collaborate.

Tasked with finding new and collaborative ways to create a sustainable impact, how do community partners define and tackle their challenges? How can new interventions be developed and implemented while also retaining all that is going well with existing programs? Can partners agree on exactly what changes need to be made, by whom and when? How do they sort out differences of perspective and priority while staying focused on collective solutions? How will they measure successes? How will they decide to switch gears if something doesn’t seem to be working?

Time is a vital ingredient in this messy, questioning, exploratory approach to tackling social problems. Time for thinking––both critically and creatively; time to question assumptions; time for visioning and for flexible plan making, for deep collaborative engagement with people who bring richly different perspectives, and for pushing through potentially difficult decision making. In complex interventions, the time committed to thoughtful, reflective learning processes can pay off by identifying problems early, highlighting priorities for action, shifting resources to where they’re most needed, and building sustainable teamwork.

These are the challenges of the PEGASIS backbone project, to bring the many stakeholders together to collaboratively describe our elephant, find ways of sharing our knowledge, and work together.

References

1. De Jong Gierveld, J., N. Keating, and J.E. Fast, Determinants of loneliness among older adults in Canada. Canadian Journal on Aging, 2015. 34(2): p. 125-136.

2. Ong, A.D., B.N. Uchino, and E. Wethington, Loneliness and Health in Older Adults: A Mini-Review and Synthesis. Gerontology, 2016. 62(4): p. 443-449.

3. Petersen, J., et al., Longitudinal Relationship Between Loneliness and Social Isolation in Older Adults. Journal of Aging & Health, 2016. 28(5): p. 775-795.

4. Valtorta, N.K., Kanaan, M., Gilbody, S. & Hanratty, B., Loneliness, social isolation and social relationships: what are we measuring? A novel framework for classifying and comparing tools BMJ Open 2016;6:4(4): p. e010799

5. Blozik, E., et al., Social network assessment in community-dwelling older persons: Results from a study of three European populations. Aging Clinical and Experimental Research, 2009. 21(2): p. 150-157.

6. Keating, N. and T. Scharf, Revisiting social exclusion of older adults. From Exclusion to Inclusion in Old Age: A Global Challenge, 2012: p. 163-170.

7. Keefe, J.A., M., Fancey, P., & Hall, M., A profile of social isolation in Canada. 2006, Nova Scotia Centre on Aging and Mount Saint Vincent University Halifax, Nova Scotia.

8. Victor, C.R. and M.P. Sullivan, Loneliness and isolation, in Routledge Handbook of Cultural Gerontology. 2015. p. 252-260.

9. Mei, Z., et al., Gifts of a Lifetime: The contributions of older Canadians Final report. 2013, Seniors Association of Greater Edmonton (SAGE): Edmonton

10. Cattan, M., N. Kime, and A.M. Bagnall, The use of telephone befriending in low level support for socially isolated older people – an evaluation. Health and Social Care in the Community, 2011. 19(2): p. 198-206.

11. Cohen-Mansfield, J. and R. Perach, Interventions for alleviating loneliness among older persons: A critical review. American Journal of Health Promotion, 2015. 29(3): p. e109-e125.

12. Franck, L., N. Molyneux, and L. Parkinson, Systematic review of interventions addressing social isolation and depression in aged care clients. Quality of Life Research, 2016. 25(6): p. 1395-1407.

13. Miller, A., et al., Social inclusion of vulnerable seniors: A review of the literature on best and promising practices in working with seniors. 2015, Constellation Consulting Group.: Calgary, AB. p. 187.

14. Gardiner, C., G. Geldenhuys, and M. Gott, Interventions to reduce social isolation and loneliness among older people: an integrative review. Health & Social Care in the Community, 2016: p. n/a-n/a.

15. Courtin, E. and M. Knapp, Social isolation, loneliness and health in old age: a scoping review. Health & Social Care in the Community, 2015: p. n/a-n/a.

16. Bartlett, H., et al., Preventing social isolation in later life: Findings and insights from a pilot Queensland intervention study. Ageing and Society, 2013. 33(7): p. 1167-1189.

17. Wilson, D.M., et al., Upstream thinking and health promotion planning for older adults at risk of social isolation. International Journal of Older People Nursing, 2011. 6(4): p. 282-288.

18. Pettigrew, S., et al., Older people’s perceived causes of and strategies for dealing with social isolation. Aging & Mental Health, 2014. 18(7): p. 914-920.

19. Wister, A. and N.S. Council, Report on the social isolation of seniors. 2014, National Seniors Council: Ottawa