Social Work in Health Care

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An exploratory study of factors associated with

social isolation and loneliness in a community
sample

Kimberly M. Cassie , Julie Miller-Cribbs, & Annie Smith

To cite this article: Kimberly M. Cassie , Julie Miller-Cribbs, & Annie Smith (2020): An exploratory
study of factors associated with social isolation and loneliness in a community sample, Social Work
in Health Care, DOI: 10.1080/00981389.2020.1795780

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SOCIAL WORK IN HEALTH CARE
https://doi.org/10.1080/00981389.2020.1795780

An exploratory study of factors associated with social

isolation and loneliness in a community sample
a
Kimberly M. Cassie, PhD , Julie Miller-Cribbs, PhDb, and Annie Smith LMSW,
MPHc
a
Anne & Henry Zarrow School of Social Work, University of Oklahoma, Norman, OK, USA; bOklahoma
Medicaid Endowed Professor in Mental Health, University of Oklahoma, Norman, OK, USA; cSt. John
Health System, Tulsa, OK, USA

ABSTRACT ARTICLE HISTORY

Individuals across a wide variety of demographies find them­ Received 18 November 2019
selves suffering from social isolation or loneliness. Both of these Revised 1 July 2020
conditions have been associated with a variety of negative out­ Accepted 9 July 2020
comes including poor physical, mental and social health. Based KEYWORDS
on data collected from a sample of 420 individuals from Social Isolation; Loneliness;
a community in the South Western US, this research reports Population Health; Mental
on conditions associated with social isolation and loneliness. Health; Wellness
Results of regression analysis indicate sex, stress, loneliness,
community health and social cohesion were statistically signifi­
cantly associated with social isolation. Living alone, depression/
anxiety, stress and social isolation were statistically significantly
associated with loneliness. The implications of these findings for
social work practice and research is discussed.

Introduction/background
Social isolation and loneliness are devasting conditions thought to affect the
health and well-being of individuals across the globe regardless of age, sex, race
or ethnicity (Bailey et al., 2018; Di Julio et al., 2018; Liu et al., 2019). Social
isolation is defined as the absence of meaningful relationships and interactions
with family and friends on a personal level (Leigh-Hunt et al., 2017), while
loneliness is defined as an individual’s disappointment between the quality and
quantity of desired and actual social relationships (Holt-Lunstad et al., 2015).
Social isolation is thought be more objective, while loneliness is subjective. The
two domains are frequently considered together, but not always significantly
associated with one another (Perissinotto & Covinsky, 2014).
Given the extensive negative effects on the physical, mental and social well-
being of individuals, social isolation has been identified as one of the central
“grand challenges” for social work and the discipline has been tasked with
eradicating the condition in the US over the next decade (Uehara et al., 2013).
Beyond social work there is a considerable push to recognize social isolation

CONTACT Kimberly M. Cassie [email protected] University of Oklahoma, Anne & Henry Zarrow School of
Social Work, 4502 E 41st Street, Tulsa, OK 74135
© 2020 Taylor & Francis
2 K. M. CASSIE ET AL.

and loneliness as an epidemic that should be named as a public health priority

(Holt-Lunstad et al., 2017; Leigh-Hunt et al., 2017)
In early 2019, a nonprofit hospital in the South Western US engaged in
a community health needs assessment in collaboration with the health depart­
ment and research faculty from a local university. The purpose of the assess­
ment was to comply with 2010 Patient Protection and Affordable Care Act
regulations and to identify health needs in the service area. Results informed
the development of this study. The purpose of this research is to more closely
examine the factors associated with social isolation and loneliness.
More than 8 million adults aged 50 and older in the US are thought to suffer
from social isolation (AARP, 2019), while more than a third of individuals (or
more than 42 million individuals) aged 45 and older are thought to be lonely
(Wilson & Moulton, 2010). However, recent research suggests loneliness and
social isolation are conditions that affect individuals regardless of age or health
status. In an international survey of adults aged 18 and over, just under
a quarter of individuals in the US and UK reported experiencing loneliness or
social isolation compared to only 9% of adults in Japan (Di Julio et al., 2018).
These differences might be attributable to the more collective nature of Asian
cultures compared to the more individualistic nature of cultures in the US and
the UK. While much research to date has focused on social isolation among
older adults, data from this study suggest adults under the age of 50 experience
social isolation and loneliness at slightly higher rates than those age 50 and over.
Based on current US census projections, this suggests over 72 million
Americans may suffer from the ill effects of social isolation or loneliness.
Social isolation and loneliness have been found to negatively affect a variety
of physical health, mental health and social outcomes. Most notably, the effect
of these conditions has been likened to the harmful of effects of obesity or
smoking the equivalent of 15 cigarettes a day (J. Holt-Lunstad et al., 2010).
Research has clearly demonstrated a link between social isolation and lone­
liness with increased mortality and morbidity (Cacioppo & Cacioppo, 2014).
Premature death is a particular problem among those younger than 65 experi­
encing social isolation that are socially isolated (Holt-Lunstad et al., 2015).
Further evidence of the detrimental effects of social isolation and loneliness
have been observed in a number of other physical health domains. According
to one survey, 55% of those reporting social isolation indicated it negatively
affected their general health (Di Julio et al., 2018). Poorer executive function­
ing (Cacioppo & Cacioppo, 2014), increased susceptibility to infectious dis­
eases (Pressman et al., 2005), increased pain (Karayannis et al., 2019),
increased sleep disturbances (Cacioppo & Cacioppo, 2014) and higher rates
of chronic health conditions, such as coronary artery disease, muscular dys­
trophy, acute respiratory failure, renal failure, dementia and cancer (Bailey
et al., 2018; Eakin et al., 2017; Lindsay et al., 2019; Penninkilampi et al., 2018;
 SOCIAL WORK IN HEALTH CARE 3

Valtorta et al., 2016; Van Deudekom et al., 2018) have also been linked to
social isolation and loneliness.
Over half of lonely and socially isolated individuals said the conditions
negatively affected their mental health (Di Julio et al., 2018). More specifically,
social isolation has been linked to increased rates of depression, anxiety and
stress (Campagne, 2019; Liu et al., 2019; Teo et al., 2013). Almost a third of
those that are socially isolated or lonely had considered harming themselves due
to the lack of social connectedness and 15% had considered performing
a violent act (Di Julio et al., 2018). Those experiencing social isolation or
loneliness often engage in poor coping mechanisms to contend with the nega­
tive effects of the conditions. Forty-three percent report overeating, 34% smoke
cigarettes or use tobacco and 21% turn to alcohol or drugs (Di Julio et al., 2018).
In terms of social outcomes, people reporting loneliness or social isolation
were also more likely to express dissatisfaction with life in regard to finances,
employment, housing and family compared to those not reporting loneliness or
social isolation (Di Julio et al., 2018). Almost half of those experiencing social
disconnectedness reported that loneliness or social isolation negatively affected
their personal relationships. A third said social isolation and loneliness affected
their ability to perform their job responsibilities (Di Julio et al., 2018).
Recognizing the dearth of information regarding social isolation and loneliness,
we made it a priority to intentionally examine these conditions in our community.
This research examines both individual and community level factors associated
with social isolation and loneliness. Findings from this research should fill the gaps
in our understanding of these phenomenon and inform social work practice on
factors important to the recognition and treatment of these conditions.

Methodology
Sample

Data for this research were drawn from a convenience sample of individuals
(N = 420) recruited through social media. The availability of the survey and
invitations to participate were announced through Facebook, the Nextdoor
app, and an e-mail campaign targeting low-income households in the service
area. The service area consisted of four counties in a midwestern state. The
online survey took respondents 20–30 minutes to complete. Respondents were
given an opportunity to win one of four 100 USD gift cards at the end of the
survey as a participation incentive.
4 K. M. CASSIE ET AL.

Measures

Social isolation
Social Isolation was measured with the Patient-Reported Outcomes Information
System (PROMIS) Short Form v2.0 – Social Isolation 4a. The instrument
contains four items asking respondents to rate the frequency in which they
feel “ . . . avoided, excluded, detached, disconnected from, or unknown by,
others . . . ” (PROMIS – Social Isolation, 2015, pg. 1). Raw scores were converted
into standardized T-scores based on scoring guidelines. Prior research has
established the instrument as a valid and reliable measure of social isolation
among the English speaking population in the US (Carlozzi et al., 2019; Hahn
et al., 2014).

Loneliness
Loneliness was measured with the 3-item Loneliness Scale (Hughes et al.,
2004). The scale asks participants the frequency with which they experience
behaviors associated with loneliness. Higher scores indicate greater levels of
loneliness. Previous research has found the instrument to be reliable with good
internal consistency when compared to the use of the 20 item UCLA
Loneliness Scale (Hughes et al., 2004).

Depression and anxiety

Anxiety and depression were measured using the Patient Health
Questionnaire-4 (PHQ-4), a brief 4-item screening instrument commonly
used in health care settings. Scores range from 0–12 with higher scores
indicating greater levels of depression and anxiety. Psychometric testing has
revealed the PHQ-4 to be a valid and reliable instrument for measuring
depression and anxiety among similar samples (Mills et al., 2015).

Stress
The Stress Overload Scale Short Form is a valid and reliable 10-item instru­
ment used to measure two domains of stress: personal vulnerability (PV) and
event load (EL, Amirkhan, 2018). PV refers to innate characteristics of stress
such as an individual’s feelings of powerlessness or inadequacy in dealing with
stressful events (Amirkhan, 2012). EL refers to external demands perceived by
an individual, such as feeling rushed to complete tasks or overwhelmed by
one’s responsibilities (Amirkhan, 2012). Scores were calculated for each
domain and individuals were coded as being at high risk the specified domain
or low risk based on scoring guidelines (Amirkhan, 2018).
 SOCIAL WORK IN HEALTH CARE 5

Health
To rate personal health, respondents were asked, “Would you say that in
general your health is: excellent, very good, good, fair or poor?” Higher scores
indicated a poorer self-evaluation of one’s health.

Self care
Respondents were asked, “Generally speaking, how often do you make time to
relax or engage in self-care activities (such as participating in activities you
enjoy or engaging in stress reducing activities other than TV)?” Responses
were then coded into a binary variable with those participating with self-care
regularly or always coded as 1 and other responses coded as 0.

Community health
Respondents were asked to rate the health of their community based on a five-
point scale. Responses were recoded into a dichotomous variable with those
rating the health of their community as excellent, very good or good as a 1, and
those rating the health of their community as fair or poor as 0.

Neighborhood safety
Participants were asked three questions to assess the extent to which they
perceived their neighborhood to be safe for walking, violence and crime that
were previously used in research and found to be reliable by Tamayo et al.
(2016). Possible responses were agreement, disagreement or a neutral option.
Positive responses were coded as 1, negative statements as −1 and neutral
statements as 0. Responses were summed. Possible scores ranging from −3 to
+3 with higher scores indicating greater neighborhood safety.

Social cohesion
Social cohesion and trust were measured with five questions as discussed by
Sampson et al. (1997). Statements assessed participant perceptions regarding
the degree to which their neighborhood is close knit, their neighbors are
trustworthy and the extent to which neighbors share similar valued. Possible
responses were agreement, disagreement or a neutral option. Positive
responses were coded as 1, negative statements as −1 and neutral statements
as 0. Responses were summed. Possible scores ranging from −5 to +5 with
higher scores indicating greater levels of social cohesion.

Demographics
Three demographic characteristics were considered: sex, race/ethnicity and
age. Respondents were asked to indicate the sex assigned to them at birth.
To measure race/ethnicity respondents were asked, “Are you Hispanic,
Latino/a/ex or Spanish origin?” Additionally, respondents were asked,
“Which one or more of the following would you say is your race?”
6 K. M. CASSIE ET AL.

Options included white, black or African Americans, American Indian or

Alaskan Native, Asian, Native Hawaiian or Pacific Islander or Other.
Individuals indicating their race was solely white were coded as 1 and
others that responded to the question were coded as 0. Finally, respondents
were asked to provide their age in years. Employment and hours worked
were assessed by asking respondents, “Are you currently employed?” Those
who were employed were then asked, “In a typical week, considering all
sources of employment, how many hours a week do you work?” Since
individuals with a more active work life are less likely to feel lonely or
isolated, those working on average 30 hours or more each week were coded
1, while those working less than 30 hours a week and those who were
unemployed coded as 0. To determine if respondent lived alone, they were
asked, “How many individuals live in your household?” Those living alone
were coded as 1 while those living with others were coded as 0.

Analysis plan

Data were analyzed using SPSS, version 24. Descriptive statistics were con­
sidered. T-tests were conducted to compare social isolation and categorical
variables. The basic assumptions regarding regression analysis were met.
Given the satisfaction of these assumptions, a three-level linear regression
model was used to examine the relationship between social isolation, lone­
liness and independent variables. At the first level social isolation and lone­
liness were considered as dependent variables with demographic
characteristics of the sample. At the second level, health and mental health
factors were added to the model. At the third level, perceived neighborhood
characteristics were added.

Results
Descriptive statistics
A total of 420 individuals provided complete information for the survey
online. Participant ages ranged from 18 to 90 with a mean of 51.77
(SD = 14.86), suggesting most participants were between the ages of 36 and
67. As noted in Table 1, the majority of the sample was female (75%), while the
remainder was male (25%). Most participants resided with others (83%), while
the remainder lived alone (17%). White respondents made up the greatest
number of participants (80%) with a minority (20%) representing more than
one race or another race/ethnicity. Individuals earning less than 39,999 USD
annually represented 22% of the sample while those earning between 40,000
USD and 79,999 USD represented a third of the sample. Those earning 80,000
 SOCIAL WORK IN HEALTH CARE 7

Table 1. Descriptive statistics, categorical variables,

N = 420.
Variable N %
Sex
Male 103 25
Female 317 75
Race
Not White 83 20
White 337 80
Annual Income
< $19,999 20 5
$20,000 – $39,999 72 17
$40,000 – $59,999 72 17
$60,000 – $79,999 69 16
$80,000 – $99,999 52 12
$100,000 – $119,999 49 12
$120,000 – $149,999 31 8
> $150,000 55 13
Works 30 or More Hours/Week
No 158 38
Yes 262 62
Lives Alone
No 349 83
Yes 71 17
Personal Health
Excellent 46 11
Very Good 168 40
Good 132 31
Fair 58 14
Poor 16 4
Regularly Engages in Self Care Activities
No 306 73
Yes 114 27
Community Health 1 1
Excellent 8 2
Very Good 76 18
Good 160 38
Fair 140 33
Poor 36 9

USD and 119,999 USD represented 24% of the sample and those earning more
than 120,000 USD represented 21% of the sample.
Social isolation t-scores for participants ranged from 35 to 74 with a mean
of 48.31 (SD = 8.87). Loneliness scores ranged from 3–9 with a mean of 4.55
(SD = 1.87). PHQ-4 scores ranged from 0–12, but tended to be low with
a mean of 2.54 (SD = 2.73). Stress scores for personal vulnerability and event
load ranged from 1–5. The mean PV was 1.67 (SD = 0.87). The mean EL was
2.38 (SD = 1.14). Neighborhood safety scores ranged from −3 to +3 with
a mean of −0.01 (SD = 0.99). Social cohesion scores ranged from −5 to +5 with
a mean of 2.25 (SD = 2.35).
Descriptive statistics of categorical variables are outlined in Table 1. Over
half of participants rated their health as excellent/very good, almost a third as
good and 18% rated their health as fair or poor. Almost three-quarters did not
engage in self-care activities regularly. Sixty-two percent of participants
8 K. M. CASSIE ET AL.

reported working 30 or more hours each week. Just over a quarter of the
sample rated their community health as excellent, very good or good while less
than three quarters rated their community health as fair or poor.

Characteristics associated with social isolation

Table 2 indicates the findings at each step of the regression. Each of the models
is a predictor of social isolation, accounting for 8% to 68% of the variance in
social isolation. When demographic factors alone were considered in model 1,
statistically significant relationships were noted with greater social isolation
observed among younger adults, those with lower incomes, those not working
30 hours or more each week and those living alone. When health and mental
health characteristics were added in model 2, statistically significant relation­
ships were observed with greater social isolation observed among females,
those experiencing PV stress and those experiencing loneliness. The addition
of perceived community characteristics is shown in model 3. Relationships
observed in model 2 remained and statistically significant relationships
between social isolation and community health and social cohesion emerged
in the final model. More specifically, greater social isolation was noted among
participants rating their community health more positively and those in areas
with lower levels of perceived social cohesion.

Characteristics associated with loneliness

Table 3 shows the results at each step of the regression model examining
loneliness. All models were predictors of loneliness, accounting for 11% to

Table 2. Stepwise regression of factors associated with social isolation and demo­
graphic characteristics (Model 1), Mental and physical health conditions (Model 2) and
community characteristics (Model 3).
Variable Model 1 (β) Model 2 (β) Model 3 (β)
Female 1.80 1.29* 1.33*
White 1.38 −0.02 0.11
Age −0.12*** −0.03 −0.03
Income −0.255* 0.10 0.12
Employed 30+ Hours/Week −2.23* −0.53 −0.65
Lives Alone 2.92* 0.06 0.15
Depression/Anxiety 0.24 0.25
Stress, Event Load 0.16 0.21
Stress, Personal Vulnerability 1.33** 1.23*
Loneliness 3.09*** 3.12***
Personal Health 0.35 0.46
Practices Self Care −0.63 −0.61
Community Health 1.14*
Neighborhood Safety 0.35
Social Cohesion −0.25*
Adjusted R2 0.08*** 0.67*** 0.68*
F for Change in R2 6.82*** 126.21*** 3.11*
*p <.05, **p <.01, ***p <.001.
 SOCIAL WORK IN HEALTH CARE 9

Table 3. Stepwise regression of factors associated with loneliness and demographic

characteristics (Model 1), Mental and physical health conditions (Model 2) and com­
munity characteristics (Model 3).
Variable Model 1 (β) Model 2 (β) Model 3 (β)
Female 0.13 −0.13 −0.14
White 0.38 0.14 0.14
Age −0.02*** −0.00 −0.00
Income −0.07*** −0.01 −0.01
Employed 30+ Hours/Week −0.49* −0.15 −0.13
Lives Alone 0.91*** 0.51*** 0.50***
Depression/Anxiety 0.08** 0.07*
Stress, Event Load −0.00 −0.01
Stress, Personal Vulnerability 0.36** 0.26**
Social Isolation 0.13*** 0.13***
Personal Health 0.05 0.03
Practices Self Care −0.14 −0.16
Community Health −0.27*
Neighborhood Safety −0.08
Social Cohesion 0.01
Adjusted R2 0.11*** 0.69*** 0.69*
F for Change in R2 9.15*** 127.59*** 3.07*
*p<.05, **p <.01, ***p <.001.

69% of the variance in loneliness. When demographic factors were considered

in model 1, higher levels of loneliness were observed among younger partici­
pants, those with lower incomes, those not working at least 30 hours a week
and those living alone. In model 2 health and mental health factors were added
to the model. With the exception of living alone, demographic conditions were
not statistically significant in model 2. Statistically significant relationships
between loneliness and PV stress and social isolation were observed with
higher levels of each associated with higher levels of loneliness. The addition
of perceived community characteristics are noted in model 3. Statistically
significant relationships observed in model 2 remained with the emergence
of one additionally statistically significant relationship between loneliness and
community characteristics. More specifically, respondents describing their
community’s health as fair or poor were more likely to experience loneliness.

Discussion
This research offers greater insight into social isolation and loneliness.
Consistent with previous research, when demographic factors alone were
considered in the first regression model greater social isolation and loneliness
was observed among younger adults, those with lower incomes, those not
working 30 hours or more each week and those living alone (Cohen-
Mansdield et al., 2016; Di Julio et al., 2018; Finley & Kobayashi, 2018; Ge
et al., 2017). However, demographics alone explained a very small percentage
of the variance in social isolation and loneliness.
When physical and mental health characteristics were added to the model,
the proportion of variance explained increased and most of the relationships
10 K. M. CASSIE ET AL.

between demographic characteristics and social isolation and loneliness dis­

appeared. While the same demographic factors were noted to be significant in
explaining both social isolation and loneliness in model 1, the same could not
be said for physical and mental health characteristics. When considering social
isolation in model 2, statistically significant relationships between women,
those with higher PV stress and those with greater levels of loneliness emerged.
When considering loneliness in model 2, statistically significant relationships
between living alone remained and new relationships emerged. More specifi­
cally, those with greater levels of depression/anxiety, PV stress and social
isolation were more likely to experience higher levels of loneliness.
While social isolation and loneliness are not always interrelated
(Perissinotto & Covinsky, 2014), it is interesting to note the relationship
between the two concepts in these findings. Some have argued that social
isolation may be a desired state based on introverted personalities (Svoboda,
2007), however the relationship between the two may suggest that social
isolation and loneliness are not desired traits. If social isolation were the
desired state of social connectedness for individuals, they would not also
experience loneliness since it only exists when there is a discrepancy between
the desired and real social connectedness.
Also consistent with previous research, this study found significant associa­
tions between social isolation, depression, anxiety, and stress (Campagne,
2019; Di Julio et al., 2018; Liu et al., 2019; Teo et al., 2013). Further research
should explore the relationship between depression, anxiety, stress and social
connectedness, as causality has not adequately been determined. Does social
isolation result in mental health or is the reverse true? What about the possible
mediating role of depression? Could it be that depression is preventing
individuals from engaging in self-care activities which in turn increases one’s
depression, feelings of powerlessness and ultimately social isolation?
Answering these questions would be of great help in the quest to understand
and intervene to reduce social isolation.
The addition of perceived community characteristics in model 3 adds
understanding of social connectedness. The inverse relationship between
community health and social isolation and loneliness bears further considera­
tion. Respondents that felt more positively about their community’s health
were more likely to demonstrate higher levels of social isolation. Interestingly,
respondents viewing their community’s health more negatively were more
likely to report higher levels of loneliness. These findings are unexpected and
cannot be examined more closely with this data. Future research may want to
consider a more in-depth examination of such findings. Increased social
isolation was also noted in communities perceived as less socially cohesive.
However, very little research has examined the relationship between commu­
nity characteristics and social connectedness. Further research is needed
before conclusive generalizations can be drawn.
 SOCIAL WORK IN HEALTH CARE 11

The lack of a statistically significant relationship between age and social

isolation and loneliness is especially noteworthy. In the first model, age
emerged as a statistically significant factor associated with social connected­
ness. Two things are remarkable about this. First, the relationship between age
and social connectedness was negative suggesting that younger individuals
experience greater social isolation and loneliness than older individuals.
Second, the relationship between age and social connectedness was not present
with the addition of other individual and community level factors in subse­
quent models. This suggests that while much research to date has limited the
examination of social connectedness to adolescents, older adults or special
populations, such as those living with chronic disease or family caregivers,
social isolation and loneliness appear to be conditions affecting individuals
across the lifespan and not an age specific or disease specific occurrence. More
research is needed to examine how social connectedness changes and influ­
ences individual outcomes across the lifespan.
A significant limitation of this study is generalizability. Sample recruitment
for this study was heavily reliant on a convenience sample of social media
users. Future research drawn from a more representative sample based on sex,
race/ethnicity, age and socioeconomic status is needed. Despite these limita­
tions, this research is a good starting point to better understanding social
isolation in a typical South Western community.
For social workers this research highlights the importance of including thor­
ough assessments of social networks with clients of all ages. Treatment plans
should incorporate client education regarding the relationship between social
isolation and desired outcomes. Strategies should be developed to keep clients
connected in a meaningful way to relationships that are important to them.
Further from a macro perspective culture change initiatives are needed to
strengthen community relations and help individuals connect with others in our
technologically driven society. Social enterprise has been effective at reducing
social isolation and loneliness in Scotland and may have some transferability to the
US (Kelly et al., 2019). However, the greater culture and context of communities
must be considered to fully understand these phenomena before interventions will
likely be effective. For example, the Amish community, where the sense of
community and collective goodwill is paramount, are likely to view social isolation
and loneliness very differently than individuals in Silicon Valley, California that
are more technologically driven in both their businesses and social lives. Bearing
community context in mind, collaboration between social work practitioners and
researchers is needed to develop and test practices with the potential to enhance
social networks and relationships among the most vulnerable in our society.

ORCID
Kimberly M. Cassie, PhD http://orcid.org/0000-0003-2379-9743
12 K. M. CASSIE ET AL.

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