Fakoya et al.

BMC Public Health (2020) 20:129

https://doi.org/10.1186/s12889-020-8251-6

RESEARCH ARTICLE Open Access

Loneliness and social isolation interventions

for older adults: a scoping review of
reviews
Olujoke A. Fakoya* , Noleen K. McCorry and Michael Donnelly

Abstract
Background: Loneliness and social isolation are growing public health concerns in our ageing society. Whilst these
experiences occur across the life span, 50% of individuals aged over 60 are at risk of social isolation and one-third
will experience some degree of loneliness later in life. The aim of this scoping review was to describe the range of
interventions to reduce loneliness and social isolation among older adults that have been evaluated; in terms of
intervention conceptualisation, categorisation, and components.
Methods: Three electronic databases (CINAHL, Embase and Medline) were systematically searched for relevant
published reviews of interventions for loneliness and social isolation. Inclusion criteria were: review of any type,
published in English, a target population of older people and reported data on the categorisation of loneliness
and/or social isolation interventions. Data extracted included: categories of interventions and the reasoning
underpinning this categorisation. The methodology framework proposed by Arskey and O’Malley and further
developed by Levac, et al. was used to guide the scoping review process.
Results: A total of 33 reviews met the inclusion criteria, evaluating a range of interventions targeted at older
people residing in the community or institutionalised settings. Authors of reviews included in this paper often used
the same terms to categorise different intervention components and many did not provide a clear definition of
these terms. There were inconsistent meanings attributed to intervention characteristics. Overall, interventions were
commonly categorised on the basis of: 1) group or one-to-one delivery mode, 2) the goal of the intervention, and
3) the intervention type. Several authors replicated the categorisation system used in previous reviews.
Conclusion: Many interventions have been developed to combat loneliness and social isolation among older
people. The individuality of the experience of loneliness and isolation may cause difficulty in the delivery of
standardised interventions. There is no one-size-fits-all approach to addressing loneliness or social isolation, and
hence the need to tailor interventions to suit the needs of individuals, specific groups or the degree of loneliness
experienced. Therefore, future research should be aimed at discerning what intervention works for whom, in what
particular context and how.
Keywords: Loneliness, Lonely - Social isolation - socially isolated - older adults, Aged - ageing population - scoping,
Scoping review

* Correspondence: [email protected]
Centre of Excellence for Public Health, Centre for Public Health, Queen’s
University, Belfast, Northern Ireland

© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Fakoya et al. BMC Public Health (2020) 20:129 Page 2 of 14

Background Given the increasing burden of loneliness and its im-

Loneliness and social isolation are international public pact on health and wellbeing, it is not surprising that
health concerns that particularly affect the ageing society there has been a growing academic literature, public and
globally [1]. Loneliness and social isolation are distinct policy interest worldwide in loneliness and social isola-
but interrelated concepts. According to Valtorta and tion. For example, the Campaign to End Loneliness
Hanratty [2], one of the most widely used definitions of began in 2010 in the United Kingdom (UK) and aimed
loneliness constitutes of social and emotional loneliness: to create connections among older age people [8]. In
loneliness is a subjective negative feeling associated with Denmark, a campaign titled ‘Danmark spiser sammen’
a perceived lack of a wider social network (social loneli- which when translated in English means ‘Denmark eats
ness) or absence of a specific desired companion (emo- together’ was established in 2015 as a popular movement
tional loneliness). There is much less consensus about against loneliness [15]. The Australian Coalition to End
the definition of social isolation however authors have Loneliness (ACEL), inspired by the Campaign to End
approached it as a multidimensional concept, defining Loneliness in the UK, was developed in Australia in
social isolation as the objective lack or paucity of social 2016 and aimed to use evidence-based interventions and
contacts and interactions with family members, friends advocacy to increase awareness of, and address, loneli-
or the wider community [2]. ness and physical social isolation [16]. ACEL did not
Loneliness and social isolation are risk factors for all- clarify what was meant by the term ‘physical social isola-
cause morbidity and mortality with outcomes compar- tion’ and this further highlights the varied terminology
able to other risk factors such as smoking, lack of exer- used regarding loneliness and social isolation. There are
cise, obesity and high blood pressure [3–5]. In addition, also growing campaigns in the Netherlands and New
loneliness has been associated with decreased resistance Zealand to tackle loneliness [1]. ALONE, a national or-
to infection, cognitive decline and mental health condi- ganisation in Ireland that offers support to older people,
tions such as depression and dementia [3]. Whilst every launched a Christmas campaign in 2018 called ‘Have a
individual will experience loneliness at some point in Laugh for Loneliness’ which encouraged families, friends
their lives to a certain degree [6], research has and communities to get together during the winter in
highlighted that older people are particularly vulnerable order to combat loneliness in their communities [17].
to experiencing loneliness and social isolation [7, 8]. Ap- Several reports about the range and types of loneliness
proximately 50% of individuals aged over 60 are at risk interventions have been published globally. Within the
of social isolation and one-third will experience some United Kingdom, these have included reports by organi-
degree of loneliness later in life [3]. Although loneliness sations such as Age UK [18] and the Institute of Public
and social isolation have been associated with a reduc- Health in Ireland [19]; guidelines by the National Insti-
tion in health status and therefore a decreased quality of tute for Clinical Excellence [20]; reviews by the Social
life, findings suggest that both concepts may have inde- Care Institute for Excellence [7, 21], and material col-
pendent impacts on health and therefore should be lated by the Campaign to End Loneliness [1]. The Can-
regarded as individual characteristics [9]. However, there adian Counselling and Psychotherapy Association
is also an overlap in the factors which contribute to (CCPA) have published guidelines for addressing loneli-
loneliness and social isolation and sometimes authors ness [22]. Similarly, in the United States of America
use the terms interchangeably [10, 11]. (USA), organisations such as Humana [23], have pub-
Risk factors for loneliness and social isolation lished reports and a toolkit to overcome loneliness and
among older people include: family dispersal, de- social isolation, and the National Institute on Aging (Na-
creased mobility and income, loss of loved ones, and tional Institutes of Health) [24] have published reports
poor health. It is thought that societal change includ- on improving the development of interventions to re-
ing reduced inter-generational living, greater geo- duce loneliness and social isolation.
graphical mobility and less cohesive communities The report published by Age UK [25] specifically
have also contributed to higher levels of loneliness in highlighted the gap between evidence of what consti-
the older population [7, 12]. Due to advancements in tutes an effective ‘loneliness intervention’ in the aca-
public health and medical technologies, in addition to demic literature and the practice of those delivering
improved sanitation, the average life expectancy of interventions. Nevertheless, service providers are experi-
the population aged 60 years or over has increased encing increasing demand to provide initiatives to tackle
globally, resulting in a projected 56% growth in this loneliness, even in the absence of empirical evidence to
population from 901 million to 1.4 billion by 2030 fully support their innovations.
[13]. Healthy life expectancy however still lags behind, There are several published systematic reviews of lone-
and the increasing prevalence of loneliness contrib- liness and/or social isolation interventions, e.g. Cattan
utes to this state of affairs [14]. and White [26], Cattan, et al. [10] and Dickens, et al. [9].
Fakoya et al. BMC Public Health (2020) 20:129 Page 3 of 14

For example, Cattan and White [26] critically reviewed grouped or categorised loneliness and social isolation
the evidence of effectiveness of health promotion inter- interventions?
ventions targeting social isolation and loneliness among How have review authors defined the terms used to
older people. It was reported that an effective interven- categorise interventions?
tion to combat social isolation and loneliness among How have review authors described their reasoning for
older people tended to be long-term group activity categorising interventions in the format used?
aimed at a specific target group, with an element of par- Are there any similarities or differences in the terms
ticipant control using a multi-faceted approach [26]. used to categorise interventions across the reviews?
Cattan, et al. [10] conducted a systematic review to de-
termine the effectiveness of health promotion interven- Methods
tions that targeted social isolation and loneliness among The conduct of this scoping review was based on the
older people, and found educational and social activity framework and principles reported by Arksey and
interventions that target specific groups can alleviate so- O’Malley [28] and further recommendations provided by
cial isolation and loneliness among older people. How- Levac, et al. [29]. Additional guidance on reporting by
ever, the effectiveness of home visiting and befriending Peters, et al. [27] was also used. As the primary interest
schemes remains unclear [10]. Similarly, a systematic re- was in capturing how loneliness and social isolation in-
view conducted by Dickens, et al. [9] aimed to assess the terventions are categorised and described in the litera-
effectiveness of interventions designed to alleviate social ture, an efficient way of doing this was to focus on
isolation and loneliness in older people. It was reported review papers (of any type) rather than primary litera-
that common characteristics of effective interventions ture. Appropriate adjustments were made to reflect the
were those developed within the context of a theoretical nature of the evidence (i.e. only secondary evidence) be-
basis, and those offering social activity and/or support ing reviewed. The review included the following 5 key
within a group format. Interventions where older people phases [28]:
were active participants also appeared more likely to be
effective [9]. Stage 1: Identifying the research question
Within this diverse literature, there are a range of Stage 2: Identifying relevant studies
frameworks used to categorise loneliness/social isolation Stage 3: Study selection
interventions, often without clear definitions or ration- Stage 4: Charting the data
ale. Hence, there is a need to: map, organise and synthe- Stage 5: Collating, summarising and reporting the
sise the large and diverse body of literature in this area; results
describe the range of intervention types; and to synthe-
sise their content and characteristics. The optional ‘consultation exercise’ recommended by
Scoping reviews are useful for synthesising research Arskey and O’Malley [28] was not conducted.
evidence and are often used to categorise existing litera-
ture in a field. They can be used to map literature in Information sources and search strategy
terms of nature, features and volume; to clarify defini- Following several preliminary scoping searches which
tions and conceptual boundaries; and to identify re- were intended to gain familiarity with the literature and
search gaps and recommendations. They are particularly aid with the identification of key words, three health
useful when a body of literature exhibits a large, com- bibliographic databases (Medline, EMBASE and Cumu-
plex or heterogeneous nature [27]. lative Index to Nursing and Allied Health Literature
(CINAHL)) were searched for relevant literature from
their inception until the date that the search was con-
Scoping review objectives
ducted (15th June 2018). Searches were devised in col-
The objective of this scoping review is to map the large
laboration with an information specialist librarian and
body of literature and to describe the range of interven-
the research team. The search strategy was developed to
tions to reduce loneliness and social isolation among
identify reviews of loneliness/social isolation interven-
older adults. By focusing on existing reviews of loneli-
tions for older people, but the strategy was tailored to
ness/social isolation interventions, it aims to synthesise
the specific requirements of each database as seen in
the ways in which interventions have been conceptua-
Additional file 1: Table S1. Grey literature was searched
lised and their components described.
using Google (including Google Scholar) and the first 30
links (sorted by relevance) were compared against the
Scoping review questions inclusion criteria. Backward citation chaining was also
How have authors of the reviews that were included in undertaken which involved hand-searching the reference
this paper (hereafter referred to as ‘review authors’) lists of the reviews identified to find other relevant
Fakoya et al. BMC Public Health (2020) 20:129 Page 4 of 14

research [30]. Electronic search results were exported in the review (where appropriate), number of interven-
into an Excel spreadsheet and duplicates deleted. Add- tions reviewed (where appropriate), categories used by
itional file 1: Table S1 details the search terms and the review authors, and any explanation given by the au-
strategy. thors in regards to the categorisation of interventions. It
should be noted that the following parameters were not
Eligibility criteria applicable to non-systematic type reviews such as basic
Whilst loneliness and social isolation are distinct con- literature reviews and some evidence reviews: inclusion
cepts (as defined previously), we have included both out- criteria; number of primary studies; and number of in-
comes as a focus of the review but have taken care to terventions reviewed.
document the review findings in relation to these con-
cepts. Hence, papers were included if they satisfied all of Results
the following eligibility criteria: Literature search
Electronic searches identified 529 citations, resulting in
1) A review of any type; 485 unique citations to be screened for inclusion follow-
2) Available in English language; ing removal of duplicates (see Fig. 1). The titles and ab-
3) Focus of the review on loneliness and/or social stracts were assessed for their relevance to the review
isolation interventions for older adults/elderly based on the inclusion criteria (Stage 1 screening),
individuals; resulting in 46 citations being retained. The full texts of
4) Reported a categorisation of loneliness and/or social all these citations were obtained and after applying the
isolation interventions or grouped interventions. inclusion criteria (Stage 2 selection), 30 citations were
excluded; 12 did not provide data relevant to categorisa-
Reviews of interventions in any setting or context, in- tion of loneliness and/or social isolation intervention(s),
cluding older populations with existing physical or men- 15 were not reviews and three did not have a primary or
tal health problems were of interest. Since there are secondary objective of reducing loneliness and/or social
various definitions of the age range of ‘older’ popula- isolation. An additional 17 citations were identified
tions, a lower age limit was not specified as an inclusion through backward citation chaining and these citations
criteria. Rather, reviews were included which identified were also included. As such, 33 citations were included
themselves as focusing on older people. There were no in the scoping review (see Fig. 1). Characteristics of the
limiters applied in relation to date or subject, but the included reviews are shown as a structured table and as
search was limited to reviews published in English be- a narrative summary in Additional file 2: Table S2.
cause of limited resources for translation.
Characteristics of reviews
Selection of reviews There is increasing interest and research in the area of
The selection of relevant reviews was undertaken in loneliness and social isolation among the older popula-
three stages: 1) Initial screening of the title and abstract tion. The first review appeared in 1984 and following
which was conducted by the first author (OAF), 2) re- that, there were three more reviews up until the year
trieval and screening of the full text which was com- 2003. Subsequently, there were more frequent publica-
pleted independently by the first and second authors tions of literature on loneliness and/or social isolation
(OAF and NMC), with discrepancies resolved through and at least one review was published consecutively
discussion with all three authors, and 3) data extraction every year from 2010 onwards. This information is rep-
and collation. The agreement coefficient was 97%. Pa- resented in a diagrammatic form in Fig. 2.
pers that did not meet the criteria were excluded, with
the reason(s) for exclusion recorded. The Preferred Type of reviews
Reporting Items for Systematic Reviews and Meta- Review papers were published between 1984 and 2017
Analysis (PRISMA) chart (Fig. 1) reports the phases of and of these, systematic reviews were the most common
paper identification and selection. type of reviews obtained [9, 10, 26, 31–41], followed by lit-
erature reviews [6, 42–47], evidence reviews [18, 48–50],
Data extraction and charting narrative reviews [25, 51, 52], and other types of review in-
Eligible papers were independently reviewed by OAF cluding critical [53], empirical [54], rapid [55] and integra-
and NMC and the following data were extracted: author tive review [11]. This information is represented in a
information (title, author and year of publication), aims diagrammatic form in Fig. 3.
and objectives of the review, type of review (e.g. system- Of those reviews which employed a systematic means
atic, literature etc.), inclusion criteria used in the review of selecting eligible primary research (n = 14), ten papers
(where appropriate), number of primary studies included included only studies published in English, two review
Fakoya et al. BMC Public Health (2020) 20:129 Page 5 of 14

Fig. 1 PRISMA flow diagram illustrating the search strategy. This flow diagram provides the phases of article identification and selection, which resulted in
the identification of 33 articles that were deemed eligible for inclusion in the review. Prepared in accordance with Tricco AC, et al. PRISMA Extension for
Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018. pp. 467–473. doi: https://doi.org/10.7326/M18-0850

papers included studies published in any language, one on loneliness and other outcomes of interests such as
review included studies published in English and Italian anxiety and depression (n = 3); or other related concepts
[34], and 1 included studies published in English, such as social participation [56], and social connected-
French, Italian and Spanish [41]. ness [35]. While there is a distinction between loneliness
and social isolation, there was not any obvious differ-
Concept of loneliness and social isolation ences in reviews that focused on loneliness or social iso-
In terms of the consideration of the concepts of loneli- lation in terms of the review type, where the research
ness and social isolation, most reviews (28/33) could be was conducted, and how the findings were reported.
assigned to one of three categories: 1) reviews that expli- Loneliness/social isolation was not always reported as
citly focused on interventions to reduce social isolation the primary outcome and was sometimes reported
(n = 4) e.g. Chen and Schulz [37], Findlay [33], Oliver, alongside other health outcomes as seen in three reviews
et al. [47] and Wilson and Cordier [52]; 2) reviews that [36, 38, 40]. A review by Choi, et al. [40] examined the
explicitly focused on interventions to alleviate loneliness effectiveness of computer and internet training on redu-
(n = 11), e.g. McWhirter [6] and Masi, et al. [31] and cing loneliness and depression in older adults. Elias,
Cohen-Mansfield and Perach [53]; and 3) reviews that et al. [38] evaluated the effectiveness of group reminis-
included papers with interventions for both loneliness cence therapy for loneliness, anxiety and depression in
and social isolation (n = 13) e.g. Poscia, et al. [34] and older adults. In a review by Franck, et al. [36], interven-
Cattan, et al. [10]. The remaining five reviews focused tions were reviewed if they addressed social isolation,
Fakoya et al. BMC Public Health (2020) 20:129 Page 6 of 14

Fig. 2 Number of review articles on loneliness and social isolation interventions published from 1984 to 2018. The first review of loneliness and
social isolation interventions appeared in 1984 and following that, there were three more reviews up until the year 2003. There were more
frequent publications of reviews on loneliness and/or social isolation from 2010 onwards

loneliness, or the combination of depression with social Elias, et al. [38] targeted individuals aged ≥60 years.
isolation or loneliness. In a systematic review by Morris, Where age was not specified, review authors used the
et al. [35], the effectiveness of smart technologies was ex- term ‘older people’ or its synonyms, e.g. older adults [40]
amined in improving or maintaining social connectedness. and seniors [39, 56], to describe the target population. It
was stated in two of these reviews that the definition for
Population characteristics the older person was defined by the criteria used in the
The majority of the reviews (n = 24) focused solely on studies included in the review [26, 56].
the older population [9–11, 18, 25, 26, 32–41, 46, 48–51, Some reviews focused on specific subgroups of the
53, 55, 56] but the age range used to define this popula- older population which research has identified to be
tion varied [32, 35–38, 53], or was not specified at all more prone to loneliness and social isolation. For ex-
[9–11, 26, 33, 46, 51, 56]. For example, a systematic re- ample, six reviews focused only on older people residing
view by Morris, et al. [35] targeted older people who live within the community [6, 10, 39, 42, 48, 52], whereas
at home and included participants that were aged ≥45 three focused only on older people living in institutiona-
years, whereas Cohen-Mansfield and Perach [53] and lised settings e.g. care or nursing homes [36, 38, 47].
Chen and Schulz [37] targeted individuals aged ≥55 The majority of reviews (21 in total) included popula-
years; and Chipps, et al. [32], Franck, et al. [36], and tions of both community-dwelling individuals and those

Fig. 3 Type of review articles on loneliness and social isolation interventions published from 1984 to 2018. Systematic reviews were the most
common type of reviews published between 1984 and 2018. Other types of reviews include literature, evidence, narrative, critical, empirical, rapid
and integrative reviews
Fakoya et al. BMC Public Health (2020) 20:129 Page 7 of 14

living in long-term care [9, 11, 18, 25, 31–35, 37, 40, 41, New Zealand (n = 2), South Africa (n = 1), Austria
44–46, 49–51, 53, 55, 56]. Residential status was not re- (n = 1), Slovenia (n = 1) and Iran (n = 1).
ported in three reviews [26, 43, 54]. This population
characteristic is represented diagrammatically in Fig. 4. Categorisation of interventions
Only two of the 33 reviews [41, 52] included gender as There was a broad range of terms that review authors
an inclusion criteria, and these two papers focused spe- used to describe the characteristics of interventions,
cifically on interventions targeted at the male population such as: format [31], delivery mode [9, 31, 34], goal [42,
only, including Men’s Sheds [52] and gendered interven- 44, 46], type [9, 31, 34, 53], focus [53], and nature [46],
tions for older men [41]. Men’s Sheds are community- and often the same terms had different meanings. Some
based organisations that provide a space for older men authors used two or more categorisation systems as seen
to participate in craftwork and engage in social inter- in the reviews by Dickens, et al. [9] and Poscia, et al.
action [52]. Review authors often reported that the gen- [34], where interventions were categorised by both their
der distribution of participants in primary research ‘delivery mode’ and ‘type’. Alternatively Grenade and
involving loneliness/social isolation was heavily skewed Boldy [46] categorised interventions by their ‘nature’ and
towards the female population [31, 33, 34, 37, 39]. The ‘goal’, and Cohen-Mansfield and Perach [53] categorised
subsets of the female population reported in the reviews interventions based on their ‘focus’ and ‘type’. Masi,
includes: isolated older women, women at risk of suicide, et al. [31] categorised interventions based on their ‘type,
senior women on the housing waiting list [33]; format and mode’. It was common (n = 20) for review
community-living, chronically ill women [31]; women authors to categorise interventions on the basis of
with primary breast cancer, community-dwelling, single whether they were delivered via a ‘group’ or ‘one-to-one’
women [34]; and community-dwelling low-income [9, 10, 18, 26, 31, 33, 34, 36, 38, 39, 42, 44–46, 49–51,
women with low perceived social support [39]. 53, 55, 56]. In a review by Raymond, et al. [56], social
participation interventions were delivered in an individ-
Countries in which interventions were delivered ual or group context. Elias, et al. [38] explored the ef-
The countries in which interventions were delivered was fectiveness of group reminiscence therapy in alleviating
not reported in some of the review papers (n = 16). Of loneliness whereas the Medical Advisory Secretariat [39]
the papers that did report this (n = 17), USA was the evaluated in-person group-based interventions in allevi-
most reported (n = 14), followed by Netherlands (n = 13), ating loneliness and social isolation among community-
Canada (n = 10), UK (n = 9), Australia (n = 8), Sweden dwelling care seniors. The term ‘mode’ was used fre-
(n = 8), Finland (n = 5), Taiwan (n = 5), Israel (n = 4), quently within review papers but often with inconsistent
Norway (n = 4), Germany (n = 4), Japan (n = 3), China meanings. By way of illustration, Poscia, et al. [34] and
(n = 2), Hong Kong (n-2), Denmark (n = 2), Italy (n = 2), Dickens, et al. [9] referred to the categorisation of

Fig. 4 Pie-chart of residential status of populations included in eligible reviews identified. The majority of reviews (n = 21) included populations of
both community-dwelling individuals and those living in long-term care. Six reviews focused solely on older people residing within the
community and three focused solely on older people living in institutionalised settings such as care or nursing homes. Three reviews did not
report the residential status of the target population
Fakoya et al. BMC Public Health (2020) 20:129 Page 8 of 14

interventions via group or one-to-one delivery as ‘mode’, and included interventions aimed to: 1) provide social
and classified interventions as individual, group or mixed support, 2) increase opportunities for social interaction
(both individual and group). In contrast, delivery ‘mode’ in and 3) teach lonely people to master social skills.
Masi, et al.’s [31] review referred to ‘technology’ or ‘non- A total of six reviews focused on technology-based in-
technology’ based interventions, and ‘format’ was used to terventions to improve communication and social con-
describe whether the intervention was implemented on a nection among older people [32, 35, 37, 40, 47, 48]. An
one-to-one basis or as a group (if more than one person evidence review by Age UK [48] reviewed the use of
participated in the intervention at the same time or if the modern (e.g. internet) and assistive technology (e.g. tele-
intervention involved asynchronous interactions such as care or telehealth) in maintaining and establishing social
internet-based chat room exchanges). contact. Chen and Schulz [37] reviewed the effects of
Some review authors categorised interventions by their communication programs such as telephone befriending,
type (n = 4) [9, 31, 34, 53], and the descriptions for this computer and internet, and high-technology apps such
category also varied. In a review by Dickens, et al. [9], in- as virtual pet companions in reducing loneliness and so-
terventions categorised by their ‘type’ were described as: cial isolation in the elderly. The effectiveness of e-
‘offering activities’ (e.g. social or physical programmes), interventions which can be described as online activities
‘support’ (discussion, counselling, therapy or education), e.g. computer or internet training and usage; interper-
‘internet training’, ‘home visiting’ or ‘service provision’. sonal communication e.g. Skype; and internet-operated
In another review, intervention type was described as: 1) therapeutic software e.g. Nintendo Wii entertainment
social skills training if it focused on improving partici- system and videogames, were synthesised and assessed
pants’ interpersonal communication skills, 2) enhancing for decreasing social isolation and loneliness among
social support if the intervention offered regular con- older people living in community/residential care [32].
tacts, care or companionship, 3) social access if the One systematic review evaluated the effectiveness of
intervention increased opportunities for participants to smart technologies [35], which can be described as
engage in social interaction (e.g. online chat room or so- internet-based support groups and computer use and
cial activities), and 4) social cognitive training if the training, whereas the potential of videophone technology
intervention focused on changing participants’ social in improving communication between residents and
cognition [31]. family members was reviewed by Oliver, et al. [47]. In
Similar to the categories used in the review by Masi, another review, computer and internet training among
et al. [31], Poscia, et al. [34] categorised interventions by lonely and depressed older adults were examined [40].
their type, further describing the category as offering: [1] The rationale for the categorisation of interventions
social support (e.g. discussion, counselling, therapy or was reported in the majority of reviews (n = 21). It was
education), 2) social activities, in form of social pro- stated in an integrative review by Gardiner, et al. [11]
grammes, 3) Physical activity (fitness programme or rec- that interventions were categorised based on their pur-
reational activity), 4) technology (e.g. companion robot, pose, intended outcomes and mechanisms by which they
telephone befriending or internet use), 5) singing ses- targeted loneliness and social isolation. Gardiner, et al.
sions, and 6) horticultural therapy. By contrast, when [11] highlighted the importance of this categorisation
Cohen-Mansfield and Perach [53] categorised interven- given the growing diversity in intervention types, and
tions by their ‘type’ this referred to whether interven- considered rigorous and transparent categorisation to be
tions were delivered in a ‘group’ or ‘one-to-one’. a necessary pre-requisite for identifying which elements
Three reviews categorised interventions by their ‘goal’ of interventions influence their effectiveness. Their the-
[42, 44, 46]. In two of these reviews [42, 44] the same matic synthesis identified six categories which included:
constructs were used to define goals and these were: 1) social facilitation interventions, psychological therapies,
to facilitate social bonding e.g. via cognitive behaviour health and social care provision, animal interventions,
therapy or social skills training, 2) to enhance coping befriending interventions, and leisure/skills development.
with loneliness e.g. through support groups, and 3) to In a narrative synthesis by Jopling [25], interventions
prevent loneliness from occurring e.g. through commu- were grouped in accordance to addressing three key
nity awareness and educational programs. In the third challenges: 1) reaching lonely individuals, 2) understand-
review [46], the authors implicitly addressed these three ing the nature of an individual’s loneliness and develop-
constructs but used different terminology, i.e. to enhance ing a personalised response, and 3) supporting lonely
people’s social networks, and promote personal efficacy individuals to access appropriate services.
and behaviour modification, and/or skills development. Other reviews [36–41, 47–51, 55] did not report a ra-
A similar categorisation system was used by Cacioppo, tionale for the categorisation of interventions (as seen in
et al. [45], but these review authors labelled this category Additional file 2: Table S2). Some review authors justi-
as ‘models of loneliness interventions’ rather than ‘goal’, fied their categories on the basis that they had been used
Fakoya et al. BMC Public Health (2020) 20:129 Page 9 of 14

in previous reviews, e.g. two reviews [10, 33] replicated construct [68]. While there were fewer reviews identified
the categorisation used in a previous study by Cattan that specifically focused on social isolation (n = 4) com-
and White where intervention studies were divided into pared to loneliness (n = 11), there were no differences in
four categories based on the programme or method type, terms of the countries where the research was conducted,
i.e. group activity; one-to-one intervention; service deliv- the review type, or how the findings were reported. Distin-
ery; and whole community approach [26]. Likewise, guishing between the concepts of loneliness and social iso-
McWhirter [6] used similar categories as Rook and Peplau lation is important when describing the goals of
[57], such as cognitive-behavioural therapy, social skills interventions and hence for specifying intervention char-
training, and the development of social support networks; acteristics that are relevant and effective in addressing
Andersson [42] categorised interventions based on the each of these problems [4]. This clarity is necessary if ser-
typology of social network interventions by Biegel, et al. vice providers are to use the accumulated evidence to
[58] (either clinical treatment, family caretaker enhance- choose interventions which are appropriate and effective
ment, case management, neighbourhood helping, volun- relative to their service context and goals, for matching in-
teering linking, mutual aid/self-help, and community dividuals to appropriate interventions, and for choosing
empowerment); and Masi, et al. [31] categorised the inter- appropriate outcome measures for evaluation. Rook [44]
vention type (i.e. providing social access, social cognitive made reference to the causes of loneliness and often
training, social skills training or social support) based on linked these with the ‘goal’ of the interventions. Social in-
similar constructs used in the reviews by Rook [44], hibition or deficient social skills were linked to loneliness
McWhirter [6], Cattan and White [26], Findlay [33], for some people and hence it was suggested that helping
Cattan, et al. [10] and Perese and Wolf [43]. lonely individuals establish interpersonal ties might im-
prove how they relate to others or provide new opportun-
Discussion ities for them to have social contact. Alternatively, in
The objective of this scoping review was to map the circumstances where an individual was geographically iso-
large body of literature and describe the range of inter- lated, an intervention which improves the social network
ventions aimed at reducing loneliness and/or social iso- may be more appropriate.
lation among older adults. By focusing on existing Review authors have used a range of terms to categor-
reviews of loneliness/social isolation interventions, it ise the characteristics of interventions, such as mode of
aimed to synthesise the ways in which interventions have delivery, focus, nature, format, type and goal, but often
been conceptualised and their components described. with different meanings. Interventions were commonly
There are various interpretations of loneliness and so- categorised only by whether they were delivered to a
cial isolation in the literature. Social isolation can be de- group or to an individual. This is an important charac-
fined as ‘a state in which an individual lacks a sense of teristic because group interventions are likely to be more
belonging socially, lacks engagement with others, and appropriate for addressing social loneliness among indi-
has a minimal number of social contacts which are defi- viduals with insufficient social links [69] than one-to-
cient in fulfilling quality relationships’ [59–62]. On the one interventions. However, it is only one of many inter-
other hand, loneliness can be defined as a ‘subjective vention characteristics which may be directly, or via
state based on a person’s emotional perception of the interaction with other characteristics, associated with
number and/or quality of social connections needed in intervention effectiveness.
comparison to what is being experienced at the time’ Terms and terminology are important when undertak-
[63, 64]. There is evidence to suggest that both concepts ing research in the field of loneliness [70]. Consistency
are distinct [9, 65–67] as an individual can have a large in the definition of the terms and terminology increases
number of social connections and still experience the accuracy, improves reporting, and aids in the replication
subjective feeling of loneliness, or alternatively be object- of interventions across contexts [71].
ively isolated but not experience loneliness [68]. For In some reviews, the underlying theoretical basis or ra-
some individuals, social isolation is a risk factor for lone- tionale for the categorisation of interventions was not
liness [18], and hence interventions designed to target provided. Lack of theoretical underpinnings or explana-
social isolation may also alleviate loneliness. For other tions as to why interventions were categorised in a cer-
individuals, where the pathway to loneliness is not as a tain manner could lead to difficulty when attempting to
result of social isolation, such interventions are likely to distinguish in what context a particular category of
have limited impact. intervention is most appropriate or effective. This re-
Although it is generally understood that loneliness and duces the value of the accumulated evidence base, since
social isolation are distinct concepts, some review au- we are less able to identify candidate characteristics that
thors have stated that the terms are often used inter- may contribute to the effectiveness of interventions.
changeably [10, 11, 46] or are conflated into a single Hence, there is a need for the development of a
Fakoya et al. BMC Public Health (2020) 20:129 Page 10 of 14

comprehensive framework that encompasses, defines, loneliness/social isolation interventions which rely on
and elucidates all the key constructs identified in this more than one mechanism, therefore making it unclear
scoping review. Without this framework, research to which particular aspect of the intervention contributed
identify the effective mechanisms of loneliness interven- most to its success or failure.
tions will be undermined by lack of clarity around inter- The heterogeneous nature of the interventions aimed
vention characteristics. at alleviating loneliness and/or social isolation among
Interventions to reduce loneliness and/or social isola- the older population; the settings where they are deliv-
tion are complex as they have several interacting compo- ered e.g. care home or community; the group or one-to-
nents (e.g. goals, personnel, activities, resources and one intervention delivery mode; and the population
delivery mode), which may interact with features of the characteristics described in this scoping review, present
local context in which they are applied (e.g. age profile a challenge for policy recommendations. The individual-
of participants, health status, environment such as hous- ity of the experience of loneliness is also an important
ing, and cultural characteristics) [72]. These characteris- issue which has also been highlighted in the literature, as
tics need to be sufficiently described in order to allow this may cause difficulty in the delivery of standardised
use of the body of evidence to identify which character- interventions [3]. There is no one-size-fits-all approach
istics (or combination of characteristics) are effective in to loneliness interventions [25, 70], and it is recom-
a particular context and for which specific population. mended that the assessment of individual needs should
The Template for Intervention Description and Repli- be conducted during the early phases of intervention,
cation (TIDieR) checklist and guide, published by Hoff- with subsequent tailoring of programmes to meet the
mann, et al. [73] was developed as an extension of the needs of individuals [77], specific groups or the degree
Consolidated Standards of Reporting Trials (CONSORT) and determinants of the individual’s loneliness. This in-
2010 statement [74] and the Standard Protocol Items: cludes sociodemographic factors i.e. age, poverty, being
Recommendations for Interventional Trials (SPIRIT) a carer; the social environment i.e. access to transport,
2013 statement [75]. The TIDieR checklist provides a driving status and place or resident; and physical or
standardised template for authors to describe key mental health [2]. It is also essential to consider the
elements for reporting of non-pharmacological interven- needs of less well-researched groups such as individuals
tions. The development of the checklist is associated with physical disabilities, or ethnic minority groups,
with a wider movement towards standardising caregivers, recent immigrants, individuals with hearing
research reporting, demonstrated by the growing and visual impairments, those who have been isolated
EQUATOR (Enhancing the QUAlity and Transpar- for a long time, and older men [78]. Several review au-
ency Of health Research) network [73]. The overarch- thors have reported that the uptake of participants in
ing purpose of the TIDieR checklist is to prompt the primary studies was heavily skewed towards the fe-
authors to describe interventions sufficiently in order male population. This may be due to the reluctance of
to allow their replication [73]. older men to engage with services and activities com-
The benefits of using the TIDieR framework is that it pared to women [41]. Moreover, women also have a lon-
can be used for better description and reporting of inter- ger life expectancy across nations than men, and are
ventions. This may lead to a more standardised report- more likely to participate in research studies [37].
ing of intervention characteristics particularly in the Systematic reviews are most appropriate for synthesis-
primary literature, and therefore make synthesis of the ing the findings of research that evaluates clinical treat-
literature more consistent. Additionally, it allows for ments (simple interventions) [79] and consequently base
comparison of key characteristics of interventions and their estimates of effectiveness on one (or more) of the
for synthesis of interventions that share similar charac- intervention characteristics, e.g. group or individual de-
teristics. The checklist makes it easier for authors to livery settings. Complex interventions have several inter-
structure the accounts of their interventions/services; for connecting parts and it is recognised that the evaluation
editors to assess these descriptions; and for readers to of this type of interventions should go beyond the ques-
use the information [73]. However, although the TIDieR tion of effectiveness to identify ‘mechanisms’ of action
checklist may go some way towards assisting with the which can be described as the resources offered through
reporting of complex interventions, it might not be able an intervention and the way that people respond to
to capture the full complexity of these interventions [73] those resources (for example, how do resources intersect
such as the interaction between different intervention with participant’s beliefs, reasoning, attitude, ideas and
components or their combined effect, the difficulty or opportunities?) [80, 81]. Hence, a realist review may be a
complexity of behaviours/skills required either by those more suitable approach to research synthesis when
delivering or receiving the intervention; and also vari- attempting to understand the mechanisms by which
ability of outcomes [76]. This is particularly relevant to complex social interventions work (or not) in particular
Fakoya et al. BMC Public Health (2020) 20:129 Page 11 of 14

contexts [62]. The realist review is a model of research discerning what interventions work for specific subsets
synthesis that is designed to work with complex inter- of this population; the contexts where these interven-
ventions or programmes and provides an explanatory tions work; and the mechanisms by which they operate
analysis aimed at discerning what works, for whom, in in that given context. This information will be highly
what circumstances, in what respects and how [82]. This valuable in the planning and implementation of pro-
approach is more likely to result in findings that will grammes to reduce loneliness and social isolation, and
help to identify and tailor interventions to fit the profile improving the wellbeing of older people.
of the individual and their pathway to loneliness.
Supplementary information
Strengths and limitations Supplementary information accompanies this paper at https://doi.org/10.
1186/s12889-020-8251-6.
A strength of this scoping review is that it is the first re-
view of its type to examine the range of loneliness inter- Additional file 1: Table S1. Scoping review search strategies.
ventions for the older population and to describe how Additional file 2: Table S2. Characteristics of reviews included in the
these interventions have been reported and categorised. scoping review.
It has highlighted the need for an appropriate framework
to specify and describe the nature of loneliness and so- Abbreviations
cial isolation interventions, ideally a framework which ACEL: Australian Coalition to End Loneliness; CCPA: Canadian Counselling
and Psychotherapy Association; CINAHL: Cumulative Index to nursing and
defines interventions based on their mechanisms of ac- allied health literature; CONSORT: Consolidated standards of reporting trials;
tion, and as a result helps to tailor or choose interven- EQUATOR: Enhancing the QUAlity and Transparency Of health Research;
tions which are matched to the individual’s needs and ICT: Information communication technology; PRISMA: Preferred reporting
items for systematic reviews and meta-analysis; RCT: Randomised controlled
pathway to loneliness. Although this review utilised mul- trial; SPIRIT: Standard protocol items: recommendations for interventional
tiple databases and grey literature, searching other data- trials; TIDieR: Template for intervention description and replication;
bases such as Cochrane Library and PsychInfo may have UK: United Kingdom; USA: United States of America; VC: Videoconferencing
yielded other relevant published papers relevant to the
Acknowledgements
aims of this scoping review. In addition, because the re- This review is part of a PhD project of the first author, OAF, supervised by
view was limited to papers published in the English lan- NMC and MD.
guage, it is possible that other potentially relevant
Authors’ contributions
reviews were omitted. A quality assessment of the re- OAF, NMC and MD conceptualised the review. OAF took the lead in writing
views included was not undertaken, although this is not the review however NMC was also heavily involved in the production of the
always necessary for scoping reviews (Arksey and O’Mal- review. OAF and NMC designed the systematic search strategies. OAF
conducted the searches which was overseen by NMC and MD. OAF, NMC
ley, 2006). and MD assessed citations for inclusion. OAF carried out the data extraction
and analysed the data. OAF drafted the initial manuscript. OAF, NMC and
Conclusion MD contributed to writing the manuscript. All authors read and approved
the final manuscript.
A broad range of interventions have been developed in
an attempt to combat loneliness and social isolation Funding
among older people. Interventions were often cate- Not applicable.
gorised solely on the basis of whether they were Ethics approval and consent to participate
delivered to a group or an individual. Moreover, the As the scoping review methodology was aimed at synthesising information
underlying theoretical basis or rationale for the categor- from available publications, ethical approval was not required.
isation was not provided in a third of reviews. Lack of Consent for publication
theoretical reasoning could lead to difficulty when Not applicable.
attempting to distinguish in what context a particular
category of intervention is most appropriate or effective, Competing interests
The authors declare that they have no competing interests.
and also by which mechanisms these interventions work
to reduce loneliness and social isolation. Comprehensive Received: 30 January 2019 Accepted: 21 January 2020
description of these interventions, using appropriate and
consistent terminology should be encouraged as this will References
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