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ORIGINAL ARTICLE
Year : 2023 | Volume
: 14
| Issue : 1 | Page : 37-41
Loneliness, social support networks, mood, and well-being among the community-dwelling elderly, Mysore
Meghana Narendran1, Renuka Manjunath2, M R Narayana Murthy2
1 Department of Community Medicine, Symbiosis Medical College for Women, Pune, Symbiosis International (Deemed University), Pune, India
2 Department of Community Medicine, JSS Medical College, JSS AHER, Mysore, Karnataka, India
Correspondence Address:
Dr. Meghana Narendran
C-503, Life Montage Society, Opposite Sunny's World, Susgaon, Pune - 411 021, Maharashtra
India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/injms.injms_94_22
Background: Humans are social beings. Older adults more commonly endorse social engagement than physical health when describing successful aging. Deficits in social support have been associated with a wide variety of adverse health outcomes in older age, ranging from physical health to depression and self-harm. In this study, we attempt to identify the relative contributions of subjective social isolation (loneliness) and objective social isolation, measured as support network type, to depression and well-being among the community-dwelling elderly. Therefore, the objective of the study was to estimate the prevalence of loneliness and depression and to know the relationship between social network type, loneliness, and depression among the community-dwelling elderly. Subjects and Methods: A cross-sectional study was done for a period of 6 months. Individuals aged 60 years and above were included and severely ill and bed-ridden patients were excluded from the study. Sampling method used was population proportion to size with sample size of 290. The participants were interviewed using a semistructured questionnaire, where demographic and personal data and social network pattern were collected. Depression was assessed using the Geriatric Depression Scale. Data were analyzed using Statistical Package for the Social Sciences Software, 22.0 version. Descriptive statistics like percentage, mean, and standard deviation were applied. Inferential statistical tests such as the Chi-square test were applied to find out the association and expressed it as statistically significant at a P value < 0.05. Results: Among the study participants, 44.3% were lonely, 19.4% felt hopeless, and only 38% felt satisfaction in life and happiness. "Suggestive Depression" was seen among 48.6% and "Persistent Depressive Mood" was seen in about 20.2% of participants. Loneliness explained the excess risk of depression in the widowed. Similarly, 38.2% had a nonintegrated social network and 32% had integrated social network who also reported being lonely. Conclusion: Loneliness and social networks both independently affect mood and well-being in the elderly, underlying a very significant proportion of depressed mood.
Keywords: Depression, loneliness, mood, social support network, well-being
The elderly population is vast and growing due to the advancement of health-care education. These people face numerous physical, psychological, and social changes that challenge their sense of self and capacity to live happily. Many elderly experience loneliness and depression in their old age, either as a result of living alone or due to a lack of close family ties and reduced connections with their culture of origin, which results in an inability to actively participate in community activities. With advancing age, it is inevitable that people lose connection with their friendship networks and find it more difficult to initiate new friendships and belong to new networks. Social isolation and loneliness have serious consequences for longevity, health, and well-being. In older age, social isolation and loneliness increase the risks of cardiovascular disease, stroke, diabetes, cognitive decline, dementia, depression, anxiety, and suicide. They also shorten lives and reduce the quality of life. Life transitions and disruptive life events (such as retirement; loss of a spouse, partner or friends; migration of children or migration to join children; and disability or loss of mobility), which are more likely to affect older people, put them at particular risk.[1],[2] Social isolation and loneliness are distinct but related concepts. "Loneliness" is the painful subjective feeling – or "social pain" – that results from a discrepancy between desired and actual social connections.[3],[4],[5] "Social isolation" is the objective state of having a small network of kin and nonkin relationships and thus few or infrequent interactions with others. Some studies have found only a weak correlation between social isolation and loneliness.[6],[7],[8] Socially isolated people are not necessarily lonely and vice versa. How lonely a person feels depends partly on their own and their culture's expectations of relationships.[9]
Although there are currently no global estimates of the proportion of older people in the community who are experiencing loneliness and social isolation, estimates for some regions and countries are available. For instance, 20%–34% of older people in 25 European countries[10] and 25%–29% in the USA[11] reported being lonely. A study in 2021 indicated a prevalence of loneliness of 25%–32% in Latin America, 18% in India, but only 3.8% in China.[12] Other estimates of the prevalence of loneliness among older people, however, were 29.6% in China[13] and 44% in India[14] – on a par with or higher than in the rest of the world. Few comparable estimates of the prevalence of social isolation are available. Those available are 24% in the USA,[15] 10%–43% in North America,[16] and 20% in India.[17]
In this study, we attempt to identify the relative contributions of subjective social isolation, i.e., loneliness and objective social isolation, measured in terms of support network type, to depression, well-being, and hopelessness in a representative sample of community-dwellers aged 65 years and over.
Subjects and MethodsA community-based cross-sectional study was conducted in a declared slum area, Medar's block, Mysuru city, Karnataka. The study included individuals who are 60 years of age and above residing in the study area. Persons with stroke with aphasia, loss of hearing, and those who are affected with loss of memory were excluded from the study. In a total population of 12,240 in the urban field practice area, the prevalence of depression in Urban India was taken as 21.9%.[18] Therefore, the sample size was calculated to be 290. The field practice area was divided into six sectors, and according to probability proportion to size the elderly in each sector was calculated to be A-104, B-73, C-38, D-29, E-29, and F-17, respectively. After obtaining informed consent from the study participants, sociodemographic information was obtained using a semistructured questionnaire (age, gender, education, income, marital status, type of family, standard of living index and social network pattern, and history of existing medical illness). Loneliness and well-being were assessed using geriatric mental state (GMS-AGECAT) items. Loneliness was based on three GMS items. The first item asks "Do you feel lonely?" This item will be referred to as "simple loneliness." The second rate is whether the participant "cannot turn away from their loneliness. It will be referred to as "intrusive loneliness". The third is the rate of being "bothered or distressed by current loneliness". We will refer to this property as "painful loneliness". Social networks were assessed using the Practitioner Assessment of Network Type schedule developed by Wenger and Tucker.[19] The schedule classifies social networks into one of five types. In this analysis, we will contrast those with a locally integrated social network, identified by Wenger[19] as optimal in older age, with those having any other sort of network. Persistent depressed mood present in the month before the interview was assessed using GMS symptom rating. The presence of hopelessness and suicidal feelings was assessed using GMS ratings on five symptoms: whether life was seen as not worth living, seeing the future as bleak, having a general feeling of hopelessness or despair, wishing to die in the month before the interview, and death wishes expressed as either suicidal plans or acts or wishing to be dead but rejecting suicide. Well-being was assessed using two GMS items, life satisfaction, and happiness. Geriatric Depression Scale was used to estimate the prevalence of depression. Cognitive impairment was assessed using Mini-Cog. Activities of Daily Living(ADL) was assessed using Barthel Index.
ResultsThe study was conducted among 290 participants, among which 69.3% were between the age group of 60 and 69 years and 58.4% were female. About 93% were widows and 41.5% stayed with siblings and 34% remained alone at home [Table 1]. About 24% were in a joint family and 32.5% were in nuclear family. In the study, it was observed that 80.7% had diabetes, 44.1% hypertension, 24.8% had combined hypertension and diabetes, and 11% of the participants had more than three comorbid conditions. Loneliness was felt in about 26.5% of individuals, wherein 13.1% felt intrusive loneliness (being bothered and distressed by current situation) and 7.9% had painful loneliness (those who cannot turn away from loneliness). The feeling of well-being was assessed based on "life satisfaction" and "happiness" items from GMS-AGECAT tool, where only 68% individuals had a good feeling of well-being. It was interestingly noted that about 35.9% of individuals had a private restricted network who did not want to get indulged in any social gatherings and had never got themselves involved in any social activities in their community whereas, about 56% were self-contained, and neither were dependent on their siblings nor children for their livelihood. About 37.9% were local family dependent, 45.2% were locally integrated, and 47.9% had a wider community focused social network. A significant association was seen between poor social support network system and loneliness among those elderly who were locally integrated, locally self-contained, wider community focused and those with privately restricted networks, with P value <0.001, 0.001, 0.002 and 0.003, respectively [Table 2]. Depression was assessed based on Geriatric Depression Scale, wherein about 48.6% were suggestive of depression and 20.3% had persistent depression. In depression and social support network, depression was widely associated with poor social support network, which was found to be statistically significant (P < 0.001) [Table 3]. Loneliness and depression were going hand in hand and was seen more in those who had simple, intrusive, and painful loneliness, which was statistically significant (P < 0.001) [Table 4]. Poor well-being was significantly associated with feeling of loneliness with a P < 0.001 [Table 5]. In the study, only 1.5% had mild disability and their activity of daily living was disturbed due to their disability and only 9.7% had cognitive impairment.
Table 1: Distribution of study participants based on socio demographic characteristics (n=290)
Table 2: The association between social support network and loneliness among the elderly (n=290)
Table 3: The association between social support network and depression among the elderly (n=290)
Table 4: The association between loneliness and depression among the elderly (n=290)
Table 5: The association between well-being and loneliness among the elderly (n=290) Discussion The prevalence of the aging population is increasing not only in developed countries but also in developing countries like India. A demographic transition has been accompanied by changes in society and the economy. The well-being of older persons has been mandated in the Article 41 of the Constitution of India, which directs that the State shall within the limits of its economic capacity and development make effective provision for securing the right to public assistance in case of old age.[20]
Loneliness is common in the elderly. In our study, 27% of the elderly experienced loneliness. Studies of the elderly in "Western-type" cultures have generally reported prevalences of loneliness of between 25% and 45%.[21],[22],[23] In the present study, about 7.9% prevalence of painful loneliness and 13%of intrusive loneliness was seen similar to Victor's[24] finding of a 7% prevalence of "severe loneliness" in a large UK sample and Hawthorn's[25] 7% prevalence of significant perceived social isolation in an Australian community sample respectively. Widowhood was the single most important predictor of loneliness, in common with other studies.[26] We found an increase in loneliness with age and greater levels in women. However, risk factors such as physical disability and widowhood become more common with age, and when we adjusted for these, the effects of both age and sex on prevalence became nonsignificant. This suggests that the rising prevalence of loneliness in older age is associated with a rising prevalence of the risk factors for loneliness, rather than an intrinsic aging effect, and that older women have no greater intrinsic vulnerability to loneliness than men but encounter the risk factors more often.
The prevalence of integrated social network type is higher than that reported from other European studies.[27] Similarly, the present study did not find a gender difference in the prevalence. Though there was a significant overlap between loneliness and social isolation in our sample, about 45% of participants with an integrated social network reported being lonely. Nonintegrated social network had similar risk factors to loneliness, with two exceptions-first, those who lived alone were less likely to be socially isolated, but were more likely to be lonely. Second, widowhood was a risk factor for loneliness, but not for nonintegrated social network, highlighting the distinction between objective and subjective social isolation. Social networks have a powerful effect on mental health. In this study, subjective appraisal of social support mediated some of the relationship between social network and depression. In this study, both loneliness and nonintegrated and integrated social networks were associated with depression and well-being. Almost two-thirds of the population had the prevalence of depressed mood in our study which was associated with loneliness, and among those who were lonely, over 80% of the risk of Depressed mood was attributed to their loneliness. The corresponding figures for nonintegrated social network are more modest, although clearly important. Roughly more than 60% of the prevalence of depressed mood in the population was associated with nonintegrated social network, and, in those with such a network, more than 30% of their risk of depression was attributable to their social network. Taken together, these findings underline the importance of the social context of psychological well-being. Social isolation, whether subjective (loneliness) or objective (nonintegrated social network), accounted for more than 60% of the prevalence of depressed mood in our elderly participants.
Widowhood was the most important predictor of loneliness, and the higher prevalence of loneliness in widowhood accounted for the higher prevalence of depression in this group, suggesting that assessing loneliness is important in the bereaved elderly. While the major determinant of hopelessness was depressed mood, it is notable that even in nondepressed participants loneliness and social isolation were independently associated with well-being. The highest prevalence of hopelessness was in those who were depressed, lonely, and socially isolated, but it is notable that the prevalence of hopelessness in nondepressed participants who were lonely and isolated was almost identical to that of depressed participants who were neither lonely nor socially isolated. Loneliness and social isolation combined with depression was associated with a very high prevalence of hopelessness. The clinical importance of this constellation of loneliness, social isolation, and hopelessness is underlined by a study which reported that depressed elderly patients who self-harm were more hopeless, lonelier, and were more likely to have a nonintegrated social network.[28],[29] The current study adds to the small number of community level studies showing the association of loneliness with prevalence of depression independently of social network type. In the current study, it was found that there was a significant association between the risk of depression which was increasing with the severity of loneliness, and the highest risk was among those having painful and intrusive loneliness.
The absence of supportive relationships and difficult or unfulfilling relationships can increase loneliness. Life transitions and disruptive life events such as retirement and bereavement can increase the risks of both social isolation and loneliness among older people.[2],[3],[30]
ConclusionMost of the elderly people were found to be average in the dimension of sociability and preferred remaining engaged in social interactions. The elderly with a locally integrated and self-contained social network were found to have intrusive loneliness and those with wider community and private network had painful loneliness. The feeling of well-being was dependent on the three factors namely depression, social support network and loneliness. Therefore, loneliness and social support networks both independently affect mood and well-being among the elderly, underlying a very significant proportion of depressed mood.
We recommend robust screening for mental health problems regularly in clinics for elderly population, so that a larger hidden part of iceberg can be explored, and efficient geriatric health-care services are provided.
Acknowledgment
We would like to acknowledge our medicosocial workers for their help in smooth data collection.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
References
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