This article draws on investigations by its authors, and from American and Italian interventions to provide recommendations for decreasing social isolation in older adults for policy makers, researchers, and other professionals committed to supporting the improved social integration of older adults. The article argues that to mitigate social isolation it is critical to foster a sense of belonging (personal involvement in a system or environment so people feel they are an integral part of that system or environment). Suggestions are provided on how to leverage systematic interventions to foster isolated older adults’ sense of belonging to their communities.
social isolation, older adults, United States, Italy, social integration, sense of belonging
Social isolation is usually defined as an objective deficit in meaningful social contact, measured in terms of network size and community involvement (Victor et al., 2000). Older adults are especially prone to experiencing social isolation. Their social ties may be reduced due to retirement, death, or institutionalization of friends and relatives, increased likelihood of living alone, and changing geographical and physical mobility of their social network (Cacioppo and Hawkley, 2003). Isolated older adults are at high risk for poor health outcomes (Steptoe et al., 2013).
Social isolation is likely to increase risk for depression (Santini et al., 2020), cancer (Sumis et al., 2016), cognitive impairment (Poey, Burr, and Roberts, 2017), and diabetes (Nonogaki, Nozue, and Oka, 2007). All of this has, unfortunately, become much worse during the COVID-19 pandemic (Gupta, Tang, and Higgs, 2020), as well as other public health crises (Ozaki et al., 2017).
In this article we draw on our prior investigations (Portacolone et al., 2019; Portacolone et al., 2018), as well as from interventions in the United States (Johnson et al., 2020) and Italy (Portacolone et al., 2015), to provide recommendations for decreasing social isolation in older adults. These recommendations are intended for policy makers, researchers, and other professionals committed to supporting the improved social integration of older adults. The recent effort by the National Academy of Sciences (2020) to identify opportunities at the systems level for decreasing social isolation inspired these recommendations.
To mitigate social isolation it is critical to foster a sense of belonging, defined as “the experience of personal involvement in a system or environment so that persons feel themselves to be an integral part of that system or environment” (Hagerty, et al., 1992). Participating in meaningful activities, such as attending a soccer game, taking part in community groups, going to church, walking in a local park, and chatting with storekeepers or neighbors can foster a sense of belonging. A sense of belonging is critically important to overall psychological well-being, given long-standing evidence that it can reduce depression and the risk of suicide (Wastler et al., 2020).
The Importance of Belonging
The salience of belonging emerged in our interactions with socially isolated older adults in studies focusing on older adults living alone, with and without cognitive impairment (Portacolone, 2011; Portacolone et al., 2019), as well as socially isolated older residents of high-crime neighborhoods (Portacolone et al., 2018). Personal preferences characterized a yearning to belong to one’s community, which manifested as a desire to participate in a multitude of activities, including fishing, swimming, attending sporting events and concerts, dating, dancing, playing chess, practicing Qi Gong, going to church, meeting friends at coffee shops or fast-food establishments, “partaking” in dinners with friends, or “going out.” These experiences were important sources of positive feelings, meaning, and fulfillment.
Singing in a choir is “…the only place and time where I enjoy myself,” said one study participant.
The importance of belonging manifested in a recent intervention to promote singing in a diverse sample of older adults (Johnson et al., 2020). Older adults with no or limited experience in choral singing were invited to join a new choir in their neighborhood. The intervention involved 390 older adults, the majority of them from racial or ethnic minorities. The goal of the intervention was to assess the effects of choir singing on participants’ physical, cognitive, and psychosocial health. The sense of belonging that this intervention fostered among choir participants emerged in their narratives (Allison et al., 2020).
Some participants explained that regularly singing in the choir took them out of their “confinement,” or isolation. “It's the only place and time where I enjoy myself,” explained one older woman who lived alone. A sense of belonging stemmed from the commitment to attend scheduled choir sessions in the community, finding new friendships or building on existing relationships with individuals in one’s own neighborhood, learning songs from different cultures, being together as a group, and singing in the community, as when choirs sang in the streets during festivals. A participant said, “When we would go perform, that’s when you feel like you’re interesting, important to your own life and to others.” Performing in public places fostered a sense of belonging, thus decreasing social isolation and strengthening ties with the community.
Another salient example of an intervention to foster a sense of belonging comes from Italy. Although it applies to persons with mental disorders, its lessons are applicable to aging. This intervention began in the late 1970s, in Trieste, a coastal town between Venice and Slovenia, and was conducted by Franco Basaglia, a psychiatrist inspired by the French philosopher Michael Foucault (Burns, 2019). Basaglia referred to social integration as diritto di cittadinanza, i.e., the right to be a citizen, which echoes the sense of feeling “at home in the world” (Sacks, 1999).
With the support of political authorities, a team of psychiatrists and healthcare workers helped Basaglia to relocate many people with mental disorders from a large local asylum back into the community. Working with politicians was critical to ensure that these foundational changes remained in place long-term. The capstone of Basaglia’s work was a law forbidding the institutionalization of persons with mental disorders, a law that remains active now despite his premature death.
After their relocation to the community, Basaglia developed a system to foster social integration (for details see Portacolone et al., 2015) in multiple domains. Initiatives included support finding housing and managing the household, training to acquire skills to enter the workforce, and subsidies to local firms to hire people with mental disorders. The people were invited to join soccer teams, literary circles, and theater troupes directed by well-known directors. They began working in hotels, restaurants, and radio stations. Famous jazz artists and writers performed at events organized by many individuals in this community initiative. A common thread of these activities was an intention to integrate people with mental disorders into the social fabric of the community.
Considering the pervasive social isolation of older adults in the United States, fostering a sense of belonging is the key to addressing social isolation. A sense of belonging should be mutual among older and younger generations. On the one hand, the older adult would feel involved and integrated into the social fabric. On the other, younger generations would understand the richness of living in a society where people of different ages feel truly integrated.
Challenges Unique to the United States
To foster this sense of belonging, cultural humility and empathic curiosity are essential. Instead of imposing solutions, it is critical to seek to learn about the personal world of each isolated older adult. Specifically, it is important to spend the time to understand what matters to them, what they are missing, and what fulfills them. All the while, it is critical to ensure cultural sensitivity and respect. Resources should be allocated to ensure that older adults’ perspective is elicited by professionals or researchers from the same race or ethnicity, cultural background, and language preference (Portacolone et al., Under Review). Older adults often suggest strategies to foster social integration, such as eating dim sum in a neighborhood cafe, joining or watching Tai Chi classes, people watching, or group discussions of the arts (Machielse and Duyndamm, 2020).
Interventions must be long-term and affordable.
Once activities that foster a sense of belonging in one’s community are identified, the next step is to develop mechanisms that will allow for sustained and consistent enjoyment of these activities. These mechanisms should be long-term and affordable. Programs that rely upon temporary funding or volunteers can be less effective, or even alienate older adults when they are suddenly discontinued. Below are two examples from the authors’ research that highlight the importance of prioritizing interventions that are long-term and affordable.
One author identified an activity, swimming, which would foster a sense of belonging for an isolated and blind older resident of a high-crime neighborhood. The study participant longed to swim in a nearby swimming pool he used to frequent in his youth. The author and the study participant went together to the pool, and the older adult subsequently enjoyed being in the water and hearing the chatter, despite not swimming. Afterward, he explained how much he enjoyed the activity and asked the researcher to take him again.
However, continuing these individual visits would have been unsustainable. To make this a viable intervention that was long-term and affordable, potential strategies might include: a shuttle service for the older man and other neighbors interested in going to the swimming pool, affordable rates to use the pool, and available personnel at the swimming pool who could assist him and others in using the services.
More than a decade ago, the executive director of a Program for the Inclusive Care for the Elderly (PACE), told the first author about a case of an isolated man in the program who lost his will to live. Alarmed by his decline, the PACE interdisciplinary care team consulted on strategies. After a home care aide learned that the patient was passionate about music, he was invited to be a DJ in the adult day center, which improved his sense of belonging and his mood. In this case, this creative solution was sustainable due to a stable care team setting that was affordable. Taken together, these examples underscore the importance of first identifying what matters to the isolated older adult and then developing a structure to facilitate long-term access to specific meaningful activities that foster social integration, which is a recommendation of the recent report from the National Academies of Science to reduce elders’ isolation in the United States (2020).
This article’s emphasis on a sense of belonging to reduce social isolation builds on prior conceptual frameworks in three ways. First, it broadens the definition of social isolation to include a paucity of meaningful ties with one’s community. The traditional definition of social isolation focuses on the number and frequency of contacts with human beings or community activities.
Second, it emphasizes fostering a sense of belonging and meaningful activities, based on long-standing interests. This is a significant move beyond a common solution such as of giving elders robot pets to decrease their isolation (Moyle et al., 2017), which is an initiative that raises several ethical issues as discussed elsewhere (see Portacolone et al., 2020).
Developing a sense of belonging is also a significant move beyond the often-offered “friendly companion” model (Marmor, 2003), which relies upon volunteers visiting isolated older adults at home. While this model is valuable, it only partially fosters a sense of belonging. First, the older adults may enjoy other activities than the friendly visitor can accommodate (i.e., swimming, eating out). Second, the power balance is skewed as the older adult is usually a passive recipient of the goodwill of the assigned volunteer. Volunteers visiting the older adults out of their goodwill can stop the visits at any time if other competing obligations arise. Basaglia’s model is useful to encourage strategies for connecting the isolated older adult to existing organizations and groups within his or her community, rather than focusing on home activities. Third, this article recommends better characterizing the notion of a sense of belonging in older adults, a concept that has not been explored in depth in aging studies.
‘If, as a society, we truly care about isolated older adults, we need to supply the societal funding for these activities.’
If, as a society, we truly care about isolated older adults, we need to supply the societal funding for these activities. Given the highly competitive claims on healthcare spending, it is notable that some countries prioritize the social needs of isolated persons above aspects of healthcare considered of critical importance in the United States. In the Netherlands, in their report “Choices in Healthcare,” the Dunning Commission prioritized providing socially inclusive, meaningful activities for older adults with dementia over building hospitals near highways to save more lives from car accidents (Holland, 1992).
Having identified their highest ethical priority as social solidarity, they argued that to lose one’s life is terrible, but to be alive and excluded is even worse. While it is doubtful that a libertarian country like the United States would make that decision, it serves as a remarkable message about why it is critical to provide funding to better include older adults in society.
Social isolation is a pervasive issue among older adults worldwide, which can be addressed once it is properly and consistently targeted by national programs. Rather than traditional strategies that focus solely on isolated older adults’ personal sphere, strategies to address social isolation may be more successful when prioritize long-term and affordable solutions aimed at cultivating an overall sense of belonging to our social fabric.
Elena Portacolone, MPH, MBA, PhD, is an associate professor at the Institute for Health & Aging at the University of California San Francisco (UCSF). Julene K. Johnson, PhD, is a professor at the Institute for Health & Aging, Center for Aging in Diverse Communities, UCSF. Jodi Halpern, MD, PhD, is the Chancellor’s Chair, professor of Bioethics and Medical Humanities in the University of California at Berkeley-UCSF Joint Medical Program, in Berkeley, California. Ashwin Kotwal, MD, is an assistant professor of Medicine, Division of Geriatric Medicine, at UCSF.
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