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Social Determinants of Health
December 29, 2020

Social Isolation and Loneliness: Imperatives for Health Care in a Post-COVID World

Author Affiliations
  • 1Social Work and Community Health, Rush University Medical Center, Chicago, Illinois
  • 2Center for Health Policy and Media Engagement, George Washington University School of Nursing, Washington, DC
JAMA Health Forum. 2020;1(12):e201597. doi:10.1001/jamahealthforum.2020.1597

The importance of social determinants of health has been gaining traction in the health care sector during the last decade. Social determinants of health have been found to be responsible for 80% to 90% of health outcomes, and an abundance of research has demonstrated that no matter the advancements in medicine and health care, the health of the individuals and communities will not improve if these root-cause social factors are not addressed. The coronavirus disease 2019 (COVID-19) pandemic is highlighting one of these factors: social isolation.

Social isolation, defined as an “objective deficit in the number of relationships with and frequency of contact with family, friends, and the community,” is associated with increased rates of loneliness and suicide, hypertension, and other physical health effects that may be mediated by neurohormonal-immunological pathways. Demonstrated to be as dangerous to health as smoking 15 cigarettes per day, social isolation has been identified as worthy of being a public health priority.

In 2017, the AARP reported that only 14% of older adults in the US were socially isolated, but accounted for $6.7 billion in additional Medicare spending. In a national survey in August 2020, 61% of those aged 50 years or older reported experiencing social isolation since the pandemic began. The isolation is compounded for those living in rural areas. Nonetheless, the US health care system seldom screens for or discusses social isolation with patients.

A 2019 National Academies of Science, Engineering, and Medicine report, “Integrating Social Care Into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health,” noted that being able to screen for patients’ social needs requires valid and reliable tools and the systems for routinizing their use. In addition to social isolation, screening tools should also include a focus on loneliness, which is different from social isolation. Loneliness arises from a discrepancy between desired and actual level of social connection, and is itself associated with detrimental health effects.

The UK has begun to include social isolation in its policies and approaches. In 2018, then Prime Minister Theresa May included social isolation and loneliness as strategic priorities, appointing a Minister of Loneliness, dedicating funds to address the issue, and joining with tech companies to innovate creative solutions. This national focus has led to significant innovations, such as the city of Leeds equipping frontline city workers with an app that allows them, when they are out in the community, to document possible signs of isolation at an address (such as closed curtains or piles of mail); the app then creates heat maps that inform the city’s community outreach in a more efficient way. In 2020, current Minister of Loneliness, Baroness Barran, announced the awarding of £5 million (about $6.7 million US dollars) to nonprofit organizations for initiatives to reach out to the growing numbers of people who are at risk for loneliness.

If the COVID-19 pandemic has taught the health care community and others anything, it is that there is a capacity to adapt and change course. Rush University Medical Center in Chicago (where 2 of the authors work) has added a social connection question in its standard social determinants of health screening tool (“In a typical week, how many times do you talk with family, friends, or neighbors?”) and have referral pathways to interventions such as a friendly caller initiative in which volunteer community members, Rush employees, students, and AmeriCorps members make weekly socialization calls to older adults who request them. To date, more than 600 friendly calls have been completed. To improve upon the approach, a co-design process is underway, engaging individuals who have reported isolation or loneliness.

Consumer groups looking at the effects of loneliness and isolation on those in long-term care facilities during the pandemic have recommended ways to expand socialization and visitation policies, while continuing to uphold infection control strategies. For instance, peer mentoring programs between residents help to maintain social connections and have demonstrated additional benefits for the resident who volunteers as a mentor. An increasing number of states are providing guidance for long-term care facilities to allow flexibilities for “essential caregivers” to visit residents in an effort to minimize the unintended consequences of isolation on resident health and well-being.

Moving forward, there must be continued acknowledgement of the inherent connection between social isolation and the other social determinants of health, as well as leveraging of relationship-based care and community-level supports to address social needs. Public Health Solutions, a public health nonprofit organization that focuses on improving the health and well-being of vulnerable families and communities in New York City, determined that older adults living in public housing were experiencing heightened social isolation during COVID-19, in part because they were unable to access and use the internet to connect for medications, health visits, access to food, and social support. This organization is working with the New York City Housing Authority to bring the internet to older adults in one public housing building in East Harlem, provide the hardware and software to connect virtually, and the necessary instruction on its use. If successful, it will be expanded to other senior housing complexes. Initiatives of this nature will inform discussions of treating access to broadband and the internet as public utilities.

Similar innovations are happening elsewhere, but not yet at a large enough scale. Although structural changes in society can provide upstream approaches to preventing social isolation, there are 2 significant barriers for health care systems: the lack of time available as a part of routine care to screen for and discuss isolation and loneliness during visits, and the lack of direct reimbursement for such discussions under fee-for-service payment systems. Although capitated payment does create an incentive to invest in preventive care, most health systems and payers have a plethora of population health and quality improvement initiatives underway. This makes it difficult to pinpoint the return on investment of initiatives focused specifically on loneliness and isolation and thus to secure ongoing resources.

Connection to others is a fundamental piece of what it means to be human. It provides meaning and purpose in life and creates safety nets of supports that individuals turn to during adversity. Yet, to the detriment of the most vulnerable fellow humans, society has consistently prioritized values like self-reliance and independence over connection and interdependence. The pandemic is highlighting that this must change now and continue during the postpandemic era.

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Article Information

Correction: This article was corrected on January 5, 2021, to add the middle initial and fix the incorrect academic degree and license for the second author in the byline.

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Diana J. Mason, PhD, RN, Center for Health Policy and Media Engagement, George Washington University School of Nursing, 1919 Pennsylvania Ave NW, Ste 500, Washington, DC 20006 (djmasonrn@gmail.com).

Conflict of Interest Disclosures: Dr Mason reported serving on the board of directors for Public Health Solutions and chairing the National Advisory Board for the Center for Health and Social Care Integration based at Rush University System for Health. No other disclosures were reported.

Additional Contributions: We acknowledge Bonnie Ewald, MA (Center for Health and Social Care Integration at Rush University System for Health), for her thoughtful review and editing of the manuscript.

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    1 Comment for this article
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    Social Isolation and Loneliness - Adolescents and Young Adults
    Richard Ricciardi, PhD | George Washington University
    Thank you your article stressing the importance of determinants of health, and isolation and loneliness, and their significant impact on health outcomes and importantly mental health outcomes and suicide. My clinical practice is focused on adolescents and young adults (AYA), who do much of their socializing over social networking and digital screens and not in person - and there is evidence that the AYA population, along with the elderly population that you mention, is experiencing severe loneliness and isolation. The loneliness in the AYA population has many causes, along with how they spend their leisure time – looking at digital screens all alone, leading to increasing feelings of isolation and loneliness. Despite generational differences, all humans have a unifying and essential biological and psychological feature – human face to face relationships and human physical touch.
    CONFLICT OF INTEREST: None Reported
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