Almost a year into the COVID-19 pandemic, the U.S. faces another health crisis – one of loneliness. Between lockdowns, social distancing, and the fear that contact with others could make us sick, many people are living in isolation.

But there are ways to cope.

On the latest episode of The Dose podcast, Matthew Pantell and Laura Shields-Zeeman, researchers at the University of California, San Francisco, talk about how innovative programs from around the world could help mitigate the effects of isolation.

To learn more about innovative programs that are trying to address loneliness and social isolation, read this To the Point post.

Transcript

SHANOOR SEERVAI: Hi, everyone. Welcome to The Dose. We’ve been talking about COVID-19 for almost a year, but we haven’t paid nearly enough attention to another pandemic that people are living through; a pandemic of loneliness, lockdowns, social distancing, and this constant fear that other humans, even the people we love, could make us sick has meant that many of us are living in isolation. So on today’s show, we’re talking about what happens to our health when we are deprived of human contact. My guests are Matt Pantell, a pediatrician and assistant professor at the University of California, San Francisco, and Laura Shields, a researcher at UCSF. Now, Laura is working remotely from her home country, the Netherlands, where she heads the Department of Mental Health at the Dutch Institute for Mental Health and Addiction.

Matt, Laura, welcome to the show.

MATT PANTELL: Thank you.

LAURA SHIELDS: Thanks so much.

SHANOOR SEERVAI: So I think everyone who’s listening is familiar with what it’s like to feel lonely, but to get us on the same page, could you start by explaining what we’re talking about when we say social isolation and loneliness?

MATT PANTELL: Absolutely. Yeah. While the concepts are sometimes used interchangeably, what we usually refer to for social isolation is more of an objective term; so the objective lack of social contact with others or limited contact. So if you aren’t in a partnered relationship, if you don’t speak with friends, if you don’t participate in group activities — the lack of those things objectively is what we call social isolation. Whereas loneliness is more of a subjective feeling. It’s the perception of social isolation or the subjective feeling of being lonely. So you could be actually very socially connected. You could live in a partner relationship and live with someone and participate in groups and talk with friends frequently, but you might still feel lonely. So they’re two related, but distinct concepts.

SHANOOR SEERVAI: Mm-hmm. I guess when we think about the pandemic, everybody, to a certain extent, is now being subjected to this objective social isolation. Whereas whether or not somebody experiences loneliness may or may not be the case.

MATT PANTELL: Exactly. Exactly. So now, people who may have seen others in person before, and that is now cut off because of the pandemic, even though they are now technically more isolated, they might not feel more lonely if they are still keeping up with friends via phone or other communications. So that’s exactly right.

SHANOOR SEERVAI: Okay. That’s really helpful. So thinking about that time before the pandemic, which is hard to imagine, but anyway, obviously social isolation and loneliness were bad for people’s health at that time, even before they were socially distancing. Can you talk a little bit about why.

LAURA SHIELDS: So I think we’ve seen through quite a substantial body of evidence that weaker social relationships do have a variety, or result in a variety of poor health outcomes, and that goes also for an increased risk of almost all causes of mortality. We know that also it puts us at risk for symptoms of depression, for instance, which can then have also further effects on our physical health afterwards. It’s also been associated with cognitive decline and an increased risk of dementia, as well as with stroke and with heart disease. So we know that there’s both a lot of associations with social isolation and loneliness or feelings of loneliness with our physical and our mental health.

MATT PANTELL: Studies have shown that that risk is sort of comparable to traditional clinical risk factors in medicine like obesity and high cholesterol and high blood pressure. In fact, it’s a similar association with mortality as smoking about 15 cigarettes per day.

SHANOOR SEERVAI: Wow. If we think about the way that as a society, we treat, for example, the ill effects of obesity or the ill effects of smoking, do we have similar approaches to treating isolation and loneliness?

MATT PANTELL: I think in the United States right now, we’re not treating it like those other risk factors we identify. We’re not treating it consistently like that. Although, there is a growing enthusiasm to address social isolation and loneliness in the context of health settings because they are such strong predictors of mortality and other health outcomes.

SHANOOR SEERVAI: Mm-hmm. So that’s what both of you do research about, right? Programs, both in the U.S. and across the world, that have had some success at addressing isolation and loneliness. Could we talk about some of those programs and your work?

MATT PANTELL: Sure. Yeah. So we have been working with a group called UCSF’s SIREN, which stands for Social Interventions Research and Evaluation Network. Laura and I are both researchers in that group. Over the last year, what we’ve been doing is looking at different programs, both in the United States, but also internationally, programs that are designed to address social isolation, loneliness, or both.

LAURA SHIELDS: So we did a big review of all sorts of interventions and programs around the world and we developed a set of criteria on how to arrive at a set of five key programs or interventions that we thought would be promising, especially for the U.S. context to delve into further. Those are a combination of group-based interventions that really focus on eliciting positive group dynamics to share experiences of loneliness or social isolation and come up with therapeutic sometimes but also group-based storytelling techniques to really arrive at individual strategies to be taken away from these group settings to reduce feelings of loneliness or strategies to reduce social isolation.

We also looked at several programs which focus on using technological interventions or use of technology. One, including a robot that’s actually a seal, which is designed to engage with the user in an interactive way and mimic interactions that you would have socially with other people. We also focused on a few cases that looked at using simple designed, user-centric designed technology tablet, a tablet-type device to really connect older people much more easily to their family members and friends without having to worry so much about the logistical constraints often encountered with use of technology.

SHANOOR SEERVAI: Mm-hmm. So let’s get into each of these because they’re all interesting and different in their own way. Group-based interventions, I imagine that the pandemic has made it particularly difficult to implement these in a way of actually being able to get a group of people physically together. So how did some of these interventions work before the pandemic and how have they adapted?

LAURA SHIELDS: One of the programs that we interviewed extensively was called Circle of Friends that comes out of Finland. It’s been running for quite a few years now, all over Finland and it’s modeled, before the pandemic, was based on having a group of older people who identify as lonely come together in a social space. So, for instance, a community center or a restaurant or a public space that they agree upon and have a group facilitator kind of encourage group dynamics to do a shared activity together and just encourage positive social engagement. And after time, the group facilitator leaves the group and the idea is that the group will continue to meet on their own without the facilitator being there.

During the pandemic, there were, of course, lockdown measures in Finland as well to curb the number of cases of COVID-19. They were exploring, at the time of the interviews, possibilities to move some of these group sessions to online using laptops or smartphones. In some cases, they were also exploring in regions that had identified safe ways to meet in person, for instance, doing a socially distance walk in a park. They were also exploring ways to do that.

SHANOOR SEERVAI: That’s really interesting. Let’s talk more about socially distanced interactions later, but what are ways in which to make tech more user-friendly for older people?

MATT PANTELL: One of the cases that we studied really illustrates this and that was called Comp. Comp is essentially, a user-center designed tablet, as Laura described it. It’s basically the size of a . . . it’s the size I’d say of a laptop screen and it stands alone and it just has one dial on it that sort of kind of like a radio dial. So you turn it on and then if it keeps turning, sort of the volume goes up. It was developed by a company called No Isolation. It was developed with older people in mind that weren’t as tech savvy or used to using digital products as much as maybe some younger people.

The idea behind it is once you have it installed in someone’s home who can then turn it on and off as they please, although many people just keep it on, then other users of the program that are more tech savvy and own iPads and own iPhones, typically, the model that they talk about is if there’s a grandparent who isn’t tech savvy, then the grandparents’ grandchildren and children can use their iPhones to call into the Comp with FaceTime or some face-to-face mechanism and then they will appear on that screen without the primary user having to do anything.

LAURA SHIELDS: There are a number of platforms. In other countries in New Zealand, you have senior nets, I believe. In the Netherlands, you have similar types of programs that offer training to seniors in different formats to bridge that sort of digital divide with using different platforms and different devices and that’s been ramped up during the pandemic to really help move that ahead. You get a phone call on your landline, for instance, which is the case for many seniors, and then you just walk through how to use the device. I’ve also heard of people sending manuals by mail with pictures on step-by-step instructions on how to use a particular platform. There’s also, at least here in the Netherlands, a very active encouragement publicly to help your neighbors out and help people just around the corner on your streets, of course, with a safe distance of a one and a half meters and with a mask on, but to also support with helping your neighbors get set up with, for instance, a laptop over the fence or standing at the door. That’s also been shown a lot in our media here.

SHANOOR SEERVAI: That sounds really helpful. Then the third thing you mentioned was a robot seal. Can you talk about how this is helping people deal with social isolation?

MATT PANTELL: It’s a robot seal that essentially can be trained sort of by interactions to perform, if you will, for the user, actions that it finds sort of more helpful or pleasing. So, for example, it is used a lot in people who are experiencing cognitive decline and dementia. So, for example, if it does something like makes a sound or it makes a motion and it’s sort of hit, it will not do that again. If it makes a sound or emotion and it’s pet, it’ll do that again. It sort of takes that feedback. During the pandemic, we’ve spoke with someone who uses it in her daily practice with people who are living in nursing homes and she talked about how without being able to have visitors come in, she was seeing actually a lot more symptoms of loneliness and of having mental health issues and higher levels of depression and anxiety. She anecdotally said that she thought it was actually more helpful during the pandemic and people were more interested in using it because they were just, in her eyes, experiencing so much of the sequelae of the social isolation and loneliness.

SHANOOR SEERVAI: I can imagine. A lot of the things you’ve been talking about are programs and interventions for older adults, but I feel like people of all ages have been experiencing increased loneliness right now. Is that the case?

MATT PANTELL: Yeah. You bring up a very good point because before the pandemic, a lot of the focus of research and of . . . a lot of the focus of research and campaigns about social isolation and loneliness and how harmful they could be were aimed at, I’d say, adult and even older populations in the United States. I’ve seen much more anecdotally, much more interest in talking about this among all populations since the pandemic, which I attribute to an increased awareness of loneliness after experiencing all of this social isolation. But, for example, there are studies that have shown that younger adults are actually experiencing increases in loneliness during the pandemic, especially during the first few months after the pandemic started in the United States.

SHANOOR SEERVAI: Right. What about kids who are used to going to school and spending the whole day with their friends? Now, they’re just stuck at home with maybe a laptop or a tablet, or maybe not even.

MATT PANTELL: Right. Right. Even one of the people that we were interviewing for our project said that even though the program about what she was talking was focused on adults, she had noticed during the pandemic so many more teenagers and kids experiencing the effects of social isolation and loneliness. So I do think that it is bringing more awareness to the effects that social isolation have on populations of all ages.

SHANOOR SEERVAI: So we’ve talked about individual programs, but if we try to zoom out as a whole and think about a health system that was really trying to combat loneliness at a nationwide level, but before the pandemic hit, are there any countries that stand out to you?

LAURA SHIELDS: I would say first and foremost is the U.K. It’s been widely, well, in the media, and reported that there was, in 2018 as a result of the Jo Cox Commission report on loneliness, the government decided to take its first steps in addressing loneliness and appointed, I believe, the world’s first minister to lead work nationally on tackling loneliness, which they subsequently, had a large fund launched in partnership with a number of national foundations. They started to review the evidence base on loneliness and they, I think importantly, published a strategy for loneliness. Since then, I understand that they’ve been reviewing about 60 commitments nationally on ways in which they tackle loneliness, and that’s ranged from training frontline workers in the public sector on how to identify loneliness and take action on it. That includes job center; so employment center, staff members.

They’ve expanded substantially their social prescribing strategy, which is essentially, thinking about primary care professionals that would instead of prescribe a medication or a treatment, to actually prescribe a referral to a community group activity like Men’s Sheds or a community exercise class instead of a treatment or medication, and following up on that and training different types of primary care staff to work on social prescribing. They’ve also done a national campaign on loneliness, which really brought together a number of businesses and organizations to get involved. Importantly, I think they’ve also made funding available not only to collect data at the municipality level and loneliness to be able to understand how trends change over time, but they’ve also made funding available for research. As Matt just spoke about, one of the areas that we don’t know as much about in terms of interventions and strategies for loneliness and social isolation is for young people. The funds available in the U.K. have started to explore possibilities to do projects and intervention development in that.

SHANOOR SEERVAI: I wonder if, from everything, all the programs that you’re looking at, are there lessons for the U.S. from other countries that could help us as we return to normal, emerge from the pandemic of loneliness?

MATT PANTELL: I guess some lessons we can learn are that one, we can incorporate programs or essentially, practices that do facilitate social connection, even in a socially distanced way. So I’ll say, for example, we looked at a lot of programs and we looked at whether they changed their programs during the pandemic to accommodate social distancing. A lot of them did. Whether that was implementing guidelines, such that instead of groups meeting inside, they met outside with masks, socially distanced. Exercise classes were converted to online classes. There was lots of innovation that occurred to accommodate social distancing. So I think one thing we can learn from programs abroad and in the United States is that there are ways to set up safe practices to promote social connection, even in the face of social distancing. We saw that innovation come rapidly.

LAURA SHIELDS: Just to add to what Matt just said is that I think with a lot of the programs that we spoke to and looked into, a key component across them was creating a supportive environment where people felt comfortable and psychologically safe to share their experiences of loneliness and also, other factors that might’ve influenced that trajectory over time. I think the pandemic has only amplified the need to find alternative ways online, for instance, to create that safe space, to create that supportive environment where we can share what we’re going through on a daily basis, what we are struggling with at different phases of the pandemic, how our experiences are changing. So I think that having that supportive environment and finding ways to create it as our daily lives change is something that we can keep going from the programs we spoke to.

The second is that feelings of anxiety or depression or stress are pretty normal reactions to an unprecedented situation like this. I think that we don’t fully know what the scale of the adverse mental health impacts of the pandemic are going to be yet, but I do see one relevant thing to do is that during the pandemic, a lot of mental health services, help lines, digital interventions got a boost and were much more low threshold for people to access in times of need. I would really encourage those, that easy access to such services to continue even after the pandemic has subsided, in order to make sure that it can address the needs that might emerge or be staggered over time according to what’s needed in the population.

SHANOOR SEERVAI: The Dose is hosted by me, Shanoor Seervai. I produce this show along with Joshua Tallman for the Commonwealth Fund. Special thanks to Barry Scholl for editorial support, Jen Wilson and Rose Wong for our art and design, and Paul Frame for web support. Our theme music is, “Arizona Moon,” by Blue Dot Sessions, with additional music from Podington Bear. Our website is thedose.show. There you’ll find show notes and other resources. That’s it for The Dose. Thanks for listening.

Show Notes

Bios: Matt Pantell and Laura Shields-Zeeman