The effects of the coronavirus disease 2019 (COVID-19) pandemic upon human health, economic activity and social engagement have been swift and far reaching. Emerging evidence shows that the pandemic has had dramatic mental health impacts, bringing about increased anxiety and greater social isolation due to the physical distancing policies introduced to control the disease. In this context, it is possible to more deeply appreciate the health consequences of loneliness and social isolation, which researchers have argued are enduring experiences for many people and under-recognised contributors to public health. In this paper, we examine the social and psychological consequences of the COVID-19 pandemic, with a focus on what this has revealed about the need to better understand and respond to social isolation and loneliness as public health priorities.
Social isolation and loneliness are understood to be distinct conditions, yet each has been found to predict premature mortality, depression, cardiovascular disease and cognitive decline. Estimates of the prevalence and distribution of social isolation and loneliness vary, possibly ranging from one-in-six to one-in-four people, and the lack of knowledge about the extent of these conditions indicates the need for population monitoring using standardised methods and validated measures.
Reviews of the evidence relating to social isolation and loneliness interventions have found that befriending schemes, individual and group therapies, various shared activity programs, social prescription by healthcare providers, and diverse strategies using information and communication technologies have been tried. There remains uncertainty about what is effective for different population groups, particularly for prevention and for addressing the more complex condition of loneliness. In Australia, a national coalition – Ending Loneliness Together – has been established to bring together researchers and service providers to facilitate evidence gathering and the mobilisation of knowledge into practice. Research–practice partnerships and cross-disciplinary collaborations of this sort are essential for overcoming the public health problems of loneliness and social isolation that have pre-existed and will endure beyond the COVID-19 pandemic.
The speed and scale of the impacts wrought by the spread of the COVID-19 virus are beyond the lived experience of most Australians, and it will likely be some years before we adequately understand and account for these impacts. The dramatic rise in infections recorded in March 2020, followed by a growing tally of deaths, presented individuals with the enormous challenge of rapidly making sense of the reality and severity of this threat. The introduction of mandatory physical distancing requirements, which were escalated and widened on a weekly basis, entailed personal adjustments and losses in many areas of life, and exposed greater numbers of people to social isolation and loneliness.
While the locus of action in the national response to the COVID-19 pandemic has been upon monitoring and controlling the spread of the disease, it has been notable that the mental health impacts of the pandemic have featured prominently in public discussion.1,2 Evidence of the social and psychological effects generated by the pandemic has come from multiple sources. Frontline providers of telephone help services, including Lifeline and Beyond Blue, have reported dramatic increases in calls from people experiencing anxiety and loneliness.3,4 The Australian Bureau of Statistics’ national Household impacts of COVID-19 survey of 1000 adults found that 28% of women and 16% of men reported feeling lonely as result of the pandemic, and that this was the most common personal stressor identified.5 A survey of 1000 young people (aged 13–17 years) conducted by UNICEF Australia found that almost half of respondents said COVID-19 had negatively affected their levels of stress and anxiety (47%), and almost one-quarter (24%) felt isolated and did not know where to turn for support.6 These observations are consistent with findings from studies in numerous countries during past disease outbreaks (e.g. SARS, Ebola, H1N1 influenza), which have found that a sense of isolation arising from loss of usual routine and contact with others is commonly reported, along with elevated levels of stress, fear, low mood, irritability, frustration and boredom.7,8
It is clear that the physical distancing regulations instituted to control COVID-19 have had significant psychosocial consequences for young people and adults. This experience is a salutary reminder of the vital contribution that social connection makes to health and wellbeing. Researchers who have been investigating social isolation (an absence of social connections) and loneliness (subjective dissatisfaction with relationships) have been arguing for some years that these are under-recognised determinants of health status.9 Although there are different dimensions to these psychosocial conditions, each has been found to predict premature mortality, depression, cardiovascular disease and cognitive decline, and to be associated with higher engagement in unhealthy behaviours (e.g. smoking and physical inactivity).10,11 A meta-analysis of the contribution of social isolation, living alone, and loneliness to earlier mortality found that these led to an elevated risk of 26–32%, which is of a similar magnitude to that of established risk factors, such as obesity and substance abuse.12
It may be that the widespread exposure of Australians to social isolation during the COVID-19 lockdown will create greater awareness and concern about those in the population who experience both social isolation and loneliness on an ongoing basis. Loneliness was already a growing concern in a pre-COVID-19 world. In 2018, the Australian loneliness report, an online survey of 1678 Australians aged 18–89 years, found that one-in-four people reported problematic levels of loneliness (using a psychometric loneliness measure).13 The prevalence of social isolation was estimated to be about 16% in an earlier Australian study.14 There have been inconsistent findings relating to the gender and age groups that are most at risk of social isolation and loneliness13,15, which may be due to the different data collection methods that have been used. The adoption of standardised population monitoring to better understand their prevalence, trends, distribution and determinants of social isolation and loneliness would be one sign of greater recognition of the importance of these conditions.
An encouraging phenomenon to emerge from the collective experience of home isolation during the COVID-19 pandemic has been the diverse and creative ways that families, neighbours and communities have sought to maintain social connection. Many in Australia will have received a #viralkindness leaflet in their letterbox, likely dropped there by a neighbour, with an offer to buy groceries, collect essential medicines, or just call for a friendly chat.16 Other examples of outreach and connection have been impromptu musical performances in public spaces for local residents, use of apps such as WhatsApp and Nextdoor for network building and support, and a great many affirming acts of generosity shown to strangers (from food drops to paying forward toilet rolls).17 This mobilisation of grassroots action has revealed a reservoir of energy and community capacity that might be drawn upon to tackle the enduring loneliness and social isolation experienced by many.
Although the spontaneous acts of kindness catalysed by the COVID-19 lockdown may have been beneficial for community morale, the actual impacts these have upon loneliness will likely never be known. In fact, researchers in the field of loneliness and social isolation have highlighted that there remain significant gaps in knowledge about what works to address these issues.18,19 The types of interventions that have been reported in the literature include befriending schemes (often delivered by volunteers), one-to-one and group therapies to address relationship difficulties, shared activity programs (e.g. exercise, adult learning etc.) to foster social connection, social prescription by healthcare providers, and various uses of information and communication technology (e.g. social media, videoconferencing, internet training).20,21 Of these, it appears that the only strategies that have demonstrated effectiveness are those that facilitate engagement in meaningful, satisfying group activities, and psychological interventions to address the maladaptive cognitions associated with loneliness.22
It is clear that, despite the public health significance of loneliness and social isolation, there is surprisingly little evidence to guide strategies to prevent or mitigate these conditions. A consequence of this is that many of the myriad programs that are being offered to improve social connectedness and wellbeing, though well-intentioned, are of uncertain benefit. Greater investment in program evaluation is therefore critical. Furthermore, although loneliness and social isolation are related, they are distinct conditions and a solution to reduce social isolation may not lead to lower incidence of loneliness.18 Addressing loneliness is more complex and nuanced than simply increasing social connection. Hence it is crucial that comprehensive solutions are developed that are appropriate to the nature and determinants of each of these conditions.
Ending Loneliness Together (also known as the Australian Coalition to End Loneliness) is a national initiative established in 2017 to coordinate evidence-based action to tackle loneliness in Australia.23 This not-for-profit organisation was formed to bring government and nongovernment service providers together with scientists from a range of disciplines to build the knowledge base and advocate for effective approaches to ending loneliness among people living in Australia. The network has identified a broad lack of evidence in the Australian context, including prevalence rates, predictors, consequences and maintenance factors associated with loneliness. This is especially so in regard to the diverse factors across multiple domains – social, psychological, economic, community, health, and service utilisation – that may be impacted by and/or contribute to loneliness. Ending Loneliness Together will also inform more comprehensive evaluation (including impact assessment) of strategies to reduce loneliness among different population groups, and provide a vehicle for disseminating this evidence to frontline service providers.
The population-wide restrictions on normal social interactions in work, leisure, education and community contexts that have been instituted during the COVID-19 public health crisis have forced us to pay attention to the way we interact and live with others. We must recognise the reality of loneliness and social isolation as enduring experiences beyond this health crisis. The inadequate attention that has been given to these issues is reflected in insufficient investment in monitoring, investigation of causes and maintenance factors, and evaluation of strategies to reduce the prevalence and impact, and this must be redressed. The long-term public health impacts of social isolation and loneliness can be turned around by the collaborative efforts of practitioners and researchers from multiple disciplines to generate evidence-based policy and programs.
Externally peer reviewed, invited. BS is a Board Member and Associate Editor with Public Health Research & Practice. He had no part in the peer review process for this paper.
© 2020 Smith and Lim. This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International Licence, which allows others to redistribute, adapt and share this work non-commercially provided they attribute the work and any adapted version of it is distributed under the same Creative Commons licence terms.