Physical–psychosocial Relationships: Moving towards Healthy Aging

#### **Chapter 4**

## Does Physical Activity Mediate the Effect of Loneliness on Inflammatory and Metabolic Processes?

*Sharon Shiovitz-Ezra, Ohad Parag and Howard Litwin*

#### **Abstract**

The study to be presented in the chapter explores one potential behavioral mechanism by which loneliness affects inflammatory and metabolic processes in old age. Specifically, it addresses whether physical activity mediates the loneliness inflammatory/metabolic dysregulation association. Multivariate linear regressions were applied to data derived from the Health and Retirement Study (HRS). The findings revealed that loneliness was prospectively associated with elevated values of log C-reactive protein (log-CRP) and with amplified levels of Glycated hemoglobin (HbA1c), Cystatin C (CysC), and Body Mass Index (BMI), after controlling for socio-demographics. Second, physical activity mediated the association between loneliness with prospective values of log-CRP and also mediated associations between loneliness and prospective levels of metabolic biomarkers. These findings affirm the contribution (i.e., the mediation), of physical activity to the associations between loneliness and immune and metabolic processes and provide insights concerning the mechanism by which this social—biological connection operates.

**Keywords:** bio-markers, inflammation, metabolic dysregulation, HRS, physical activity, metabolic processes

#### **1. Introduction**

A sense of loneliness is a subjective marker for deficits in one's social relationships conceptualized as the discrepancy between the self-perceived extent of contact and support desired and the actual level of contact and support received [1]. This disparity leads to a cascade of behavioral, neural, hormonal, cellular, and molecular changes in the short-term [2]. In the longer-term, loneliness has been shown to negatively affect health and diminish longevity, especially among older adults [3, 4].

Because of the advancement of the study of the association that exists between loneliness and health in old age, interest has been fostered in better understanding the possible biological basis of this relationship. This is especially the case in industrialized countries where population aging is dramatically increasing and,

correspondingly, the costs of dealing with poor health in old age are escalating [5]. Chronic inflammation is one of the postulated bio-physiological pathways through which loneliness may exacerbate the poor health of many older adults. Findings show, for example, that inflammatory responses that lead to prolonged and systemic immune responses, such as a rise in C-reactive protein (CRP) levels, are correlated with feelings of loneliness [6], while these same inflammatory responses also predict cardiovascular diseases [7] and higher mortality [8].

Another possible explanation for the association between loneliness and health in late life is that metabolic dysregulation serves as a trajectory in which different aspects of social disconnectedness, especially loneliness, are associated with the health condition. Studies underscore that loneliness predicts metabolic dysregulation as indicated by high systolic blood pressure and age-related differences in metabolic functioning [9], on the one hand, and that metabolic processes are linked to one's health state, on the other hand. An example of the latter case is that levels of Glycated hemoglobin (Hba1c), a glucose concentration measure, serve as criteria for diabetes diagnosis [10]. In addition, Body Mass Index (BMI), a measure to assess obesity, as well as Cystatin C, (CysC), a biomarker of kidney function, both prospectively predict cardiovascular events and all-cause mortality among older adults [11, 12]. Recently, loneliness was found to be associated with a change for the worse in several metabolic bio-markers. Specifically, lonely older adults had 39–71% higher odds of developing prospective risk levels in HbA1c, BMI, and metabolic burden [13].

The mechanism through which loneliness is related to inflammatory and metabolic markers, respectively, is yet to be elucidated. Hawkley and Cacioppo [14] outlined several potential mechanisms by which loneliness affects health including compromising health behaviors. They argued that the lonely individual perceives the social world as threatening and that this perspective weakens his or her self-regulation, thus creating patterns of health-compromising behaviors such as physical inactivity, which cause a deterioration of health [14–16]. This hypothesis was supported by Segrin & Passalacqua [17] who found that exercise mediated the association of loneliness with self-rated health. More recently another cross-sectional study carried out in Denmark found that physical inactivity mediated the relationship between loneliness and adverse health condition such as cardiovascular disease [18].

However, to the best of our knowledge, the role of physical activity as a significant agent in the prospective association between loneliness and inflammatory and metabolic biomarkers has not yet been fully tested within the same study. Studies substantiated the relationship between loneliness and engagement in physical activity, with loneliness found to be associated with transitioning from physically active status to sedentary status [19], on one hand. Studies report a positive association between physical activity and improvement in inflammatory and metabolic regulation, as manifested by a more substantial reduction in CRP levels [20] and by higher HbA1c declines [21], on the other hand.

Consequently, the aim of the current inquiry is to address the dynamics of this assumed relationship systematically. Toward this end, we examine whether physical activity mediates the postulated association between loneliness and two key biological processes among older adults, looking specifically at its effect in relation to both inflammation and metabolic deficits. The focus on older adults in the current study is warranted insofar as research has validated that older people face loneliness more frequently [22]. They are also more prone to immune and metabolic defectiveness than are younger adults [23, 24]. Moreover, social-physiological interconnections have *Does Physical Activity Mediate the Effect of Loneliness on Inflammatory and Metabolic Processes? DOI: http://dx.doi.org/10.5772/intechopen.104915*

more prominent effects on older age cohorts [9]. The spotlight on the older age strata is also crucial in that previous studies have revealed that loneliness accelerates physiological aging [16].

#### **2. Materials and methods**

#### **2.1 Data**

The data for the analysis were drawn from the Health and Retirement Study (HRS), a nationally representative, a biennial longitudinal survey sponsored by the National Institute on Aging and the Social Security Administration, and run by the Survey Research Center at the University of Michigan's Institute for Social Research. The HRS gathers a wide range of economic, social, and health data on older adults [25]. The Institutional Review Board of the University of Michigan granted ethical approval [26]. The loneliness data and all of the social-demographic variables for the present inquiry were retrieved from Wave 7 (2006) of the HRS. Information on the frequency of physical activity was taken from Wave 8 (2008). The blood-based inflammatory and metabolic markers, which served as the outcome measures in the current analysis were collected in Wave 9 (2010) of the survey (The HRS collects biomeasures from a portion of the respondents at each Wave, on a rotation basis, and not from the entire sample [27]). The BMI scores, another metabolic outcome, were also taken from the Wave 9 data.

We limited the analytic sample to respondents aged 60 and above who had valid data regarding social-demographic background, loneliness, frequency of physical activity, and at least one inflammatory or metabolic bio-marker from Wave 9. The resultant analytic sample thus numbered some 3,735 respondents. This number varied slightly across the respective multivariate analyses, as has been similarly reported in related studies [28]. Descriptive statistics of the respondents in the current study are reported in **Table 1**.


#### **Table 1.**

*Demographics, loneliness scores, frequency of physical activity, and bio- markers values of the sample.*

#### **2.2 Variables**

#### *2.2.1 Predictor*

Loneliness was evaluated by the abbreviated 3-item form of the R-UCLA Loneliness Scale, a widely used questionnaire that was developed for use in large-scale surveys and was proven to be valid and reliable [29]. Participants were asked on a 3-point scale, ranging from 1 (hardly ever) to 3 (often), how often they felt a sense of (1) being left out, (2) lack of companionship, and (3) isolation. The three items were summed to create a scale score ranging from 3 to 9, with higher scores representing a greater extent of loneliness. As can be seen in **Table 1**, the average loneliness score was M = 4.3, with SE = 0.03.

#### *2.2.2 Outcomes—Bio-measures*

The bio-measures (except for BMI) were produced through the collection of Dried Blood Spot (DBS) samples, a minimally invasive and highly valid method [30]. Inflammatory processes were marked by values of CRP, subsequently log-transformed due to skewed distributions, as has been done previously [31]. Respondents with CRP levels >10 mg/L were excluded from the current CRP analyses because we were interested in low-grade inflammation, also in accordance with Yang et al. [31]. Metabolic processes were represented by levels of –Hba1c, [10] and Cystatin C (CysC, [32]), as well as by BMI (weight/height<sup>2</sup> ) [33].

#### *2.2.3 Mediator*

Respondents were asked about the frequency of moderate physical activity that they carry out in their daily life ("How often do you take part in sports or activities that are moderately energetic such as gardening, cleaning the car, walking at a moderate pace"). Vigorous physical activity ("How often do you take part in sports or activities that are vigorous, such as running or jogging, swimming, cycling, aerobics or gym workout, tennis, or digging with a spade or shove") was also explored for sensitivity analysis. Responses for both types of activities (moderate/vigorous) ranged in the current analysis from 1 ("hardly ever or never") to 5 ("every day").

#### *2.2.4 Covariates*

Variables that have been shown in other analyses to be relevant to the association that exists between social network relationships and levels of inflammatory and metabolic bio-measures among middle-aged and older adults served as covariates in the current inquiry [6, 31, 34]. Specifically, the regressions were adjusted by gender (men, women), age (60–96), ethnic affiliation (White, Black, or Hispanic), marital status (married, not married), the extent of formal education (up to and including a high-school diploma/GED, more than a high-school diploma/GED), employment status (working/not working) and depression (Yes/ No). Covariates were gathered in Wave 7, aside from depression, which was measured at Wave 8, due to low response rate on this question at Wave 7. The reference categories were men, white, not married, up to and including a high-school diploma/GED, currently not working and not depressed.

*Does Physical Activity Mediate the Effect of Loneliness on Inflammatory and Metabolic Processes? DOI: http://dx.doi.org/10.5772/intechopen.104915*

#### **2.3 Data analysis**

Multiple multivariate linear procedures were employed. The main effect of loneliness on the four bio-markers was analyzed separately for each of the biomarkers: log CRP, Hba1c, BMI, and CysC, after adjusting for the sundry controls (gender, age, ethnic pertaining, education, marital status, employment status, and depression status). The Ns for the respective analyses were: log-CRP (n = 3127), Hba1c (n = 3402), BMI (n = 3538), CysC (n = 3362). The STATA software program 15.0 was used in this stage of the study.

In the second phase of the analysis, physical activity was added to the regressions as a mediator. However, this potential mediation effect was explored only when the main effect of loneliness was significant in phase 1. The second phase was carried out using the PROCESS macro in the SPSS statistical program. The SPSS analytic software was preferred here because it computes the direct and indirect effects in multiple mediator models, by calculating the product of coefficients [35]. Finally, the significance of the mediation was tested by means of bootstrapping, a nonparametric technique that does not require a-priori assumptions about the data distribution [36]. This method empirically estimates the sampling distribution by repeatedly resampling the data. When the confidence interval of 95 percent, which is based upon 1000 bootstrap samples, excludes zero, the mediation effect is significant [37].

#### **3. Results**

#### **3.1 Phase 1: main effects**

The Prediction model results showed that being lonely at Wave 7 was associated with having higher log-CRP levels (β = 0.06, p < 0.01), higher Hba1c levels (β = 0.05, p < 0.01), higher BMI scores (β = 0.06, p < 0.01) and higher CysC values (β = 0.05, p < 0.01) at Wave 9, after adjusting for gender, age, ethnic pertaining, education, marital status, employment status and depression status.

#### **3.2 Phase 2: mediation effect**

The Prediction models in **Figures 1–4**, depict the associations of loneliness with prospective levels of log-CRP, Hba1c, BMI, and CysC with physical activity as a potential mediator. We elaborate here on the association between loneliness with prospective levels of log-CRP (**Figure 1**) since all other associations present a similar pattern of results. As demonstrated in **Figure 1**, higher levels of loneliness were significantly associated with increased prospective values of log-CRP (path c). However, the beta coefficient for the effect of loneliness on the frequency of physical activity (path a) and the beta coefficient for the effect of frequency of physical activity on levels of log-CRP (path b), were both significant. Also, the direct effect of loneliness in the presence of the mediator (path c') was weaker than the total effect of loneliness (path c). This highlights a feasible indirect effect of loneliness through the frequency of physical activity [38]. In other words, greater loneliness decreased the frequency of subsequent physical exercise (β = −0.14) and this reduction in physical activity elevated the prospective levels of log-CRP (β = −0.11). When the mediator was used, the direct effect between loneliness and Log-CRP levels was still significant but weaker, which suggests partial mediation.

**Figure 1.**

*The mediation effect of physical activity upon the association of loneliness with prospective log-CRP levels. Adjusted by all variables in the Prediction model. Based upon 1000 bootstrap samples.*

**Figure 2.**

*The mediation effect of physical activity upon the association of loneliness with prospective Hba1c levels. Adjusted by all variables in the Prediction model. Based upon 1000 bootstrap samples.*

#### **Figure 3.**

*The mediation effect of physical activity upon the association of loneliness with prospective BMI levels. Adjusted by all variables in the prediction model. Based upon 1000 bootstrap samples.*

To test whether the mediation effect was significant we applied a bootstrap method. As may be seen in **Figure 1**, the association between loneliness with prospective levels of log-CRP was partially mediated because path c' was still significant. The confidence interval of 95 percent, which was based upon 1000 bootstrap samples, was between 0.01 and 0.02, thus indicating mediation [37]. As already mentioned,

*Does Physical Activity Mediate the Effect of Loneliness on Inflammatory and Metabolic Processes? DOI: http://dx.doi.org/10.5772/intechopen.104915*

**Figure 4.**

*The mediation effect of physical activity upon the association of loneliness with prospective CysC levels. Adjusted by all variables in the prediction model. Based upon 1000 bootstrap samples.*

similar results emerged in all the other relevant associations that were found to be significant in the first phase (i.e, between loneliness and the prospective concentrations of metabolic biomarkers (**Figures 2–4**).

Dividing the (standardized) indirect effect by the (standardized) total effect [39] showed that the indirect path of physical activity accounted for 25 percent of the association of loneliness with prospective values of log-CRP, 14 percent of the association with Hba1c, 32 percent of the association with BMI, and 36 percent of the association with CysC (not shown in the Figures). Sensitivity analysis of engagement in more vigorous physical activity showed very similar results (not shown).

#### **4. Discussion**

This study examined whether physical activity mediates the effect of loneliness on inflammatory and metabolic processes among older Americans. We found, in the first phase of the study, that loneliness was, indeed, associated with increased levels of inflammation, measured 4 years later, as reflected by heightened values of (log) CRP [6]. Similarly, loneliness was associated with subsequent low metabolic regulation, also measured 4 years later, as manifested by elevated concentrations in all three of the metabolic measures that were examined: BMI, Hba1c, and CysC. These measures encompass several different aspects of metabolic processes, such as glucose concentration, kidney function, and CVD profiling, thus emphasizing the effect of loneliness on metabolic process as a whole [10, 33].

As noted, the primary focus of the current study was to consider whether physical activity mediates the loneliness—biomarker associations that emerged in the initial phase of the analysis. The findings show that the association of loneliness with the inflammatory marker log-CRP was partially mediated by the physical activity indirect pathway, which accounted for a quarter of the total effect. In addition, all of the significant associations between loneliness and prospective metabolic bio-markers were either partially or entirely mediated by physical activity. Of particular note is that this indirect effect was not at all minor, as it accounted for a substantial portion of the associations between loneliness and prospective BMI and CysC levels, with about a third of these associations being attributed to it. To the best of our knowledge, these findings are the first to affirm the contribution (i.e., the mediation), of physical activity to the

associations between loneliness and immune and metabolic processes and to provide insights concerning the mechanism by which this social—biological connection operates.

The results of this study have important implications insofar as they suggest the deleterious effects of loneliness upon inflammatory and metabolic processes in later life, which have been reported in prior studies [6, 7, 9], can be mediated by physical activity. Our analyses showed that this might indeed occur due to engagement in any level of physical activity, whether moderate or vigorous. This implies that even moderate physical activity serves as a mechanism by which loneliness affects health in old age.

One potential limitation should be taken into account when interpreting the results of our analysis. We do not control whether the loneliness scores that were taken as the baseline indicator in the current analysis (Wave 7 of the HRS) represent transient or chronic loneliness. These two types of loneliness are conceptually different. Whereas transient loneliness may motivate individuals to reconnect with other individuals, loneliness that is accrued over time increases withdrawal [15]. This is a minor shortcoming; however, insofar as most older people have stable loneliness ratings over time [40].

In conclusion, this study identifies an important psycho-physiological mechanism that may be present among older adults. It documents that physical activity mediates the effect of loneliness on inflammatory and metabolic processes in a representative national sample of older Americans. Reduced engagement in physical activities in later life explains to some degree the deleterious health effects of loneliness.

#### **Acknowledgements**

The HRS (Health and Retirement Study) is sponsored by the National Institute on Aging (grant number NIA U01AG009740) and is conducted by the University of Michigan.

#### **Author details**

Sharon Shiovitz-Ezra1 \*, Ohad Parag2 and Howard Litwin2

1 Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of Jerusalem, Jerusalem, Israel

2 Israel Gerontological Data Center (IGDC), The Hebrew University of Jerusalem, Jerusalem, Israel

\*Address all correspondence to: sharon.shiovitz@mail.huji.ac.il

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Does Physical Activity Mediate the Effect of Loneliness on Inflammatory and Metabolic Processes? DOI: http://dx.doi.org/10.5772/intechopen.104915*

#### **References**

[1] Peplau LA, Perlman D. Perspectives on loneliness. In: Peplau LA, Perlman D, editors. Loneliness: A Sourcebook of Current Theory, Research and Therapy. New York: Wiley; 1982. pp. 1-8

[2] Cacioppo JT, Cacioppo S. Loneliness in the modern age: An evolutionary theory of loneliness (ETL). Advances in Experimental Social Psychology. 2018;**58**:127-197

[3] Jessen MAB, Pallesen AVJ, Kriegbaum M, Kristiansen M. The association between loneliness and health–a survey-based study among middle-aged and older adults in Denmark. Aging & Mental Health. 2017;**22**(10): 1338-1343

[4] Luo Y, Hawkley LC, Waite LJ, Cacioppo JT. Loneliness, health, and mortality in old age: A national longitudinal study. Social Science & Medicine. 2012;**74**(6):907-914

[5] Cacioppo JT, Cacioppo S. Social relationships and health: The toxic effects of perceived social isolation. Social and Personality Psychology Compass. 2014;**8**(2):58-72

[6] Steptoe A, Owen N, Kunz-Ebrecht SR, Brydon L. Loneliness and neuroendocrine, cardiovascular, and inflammatory stress responses in middle-aged men and women. Psychoneuroendocrinology. 2004;**29**(5):593-611

[7] Honda H, Qureshi AR, Heimbürger O, Barany P, Wang K, Pecoits-Filho R, et al. Serum albumin, C-reactive protein, interleukin 6, and fetuin a as predictors of malnutrition, cardiovascular disease, and mortality in patients with ESRD. American Journal of Kidney Diseases. 2006;**47**(1):139-148

[8] Yeun JY, Levine RA, Mantadilok V, Kaysen GA. C-reactive protein predicts all-cause and cardiovascular mortality in hemodialysis patients. American Journal of Kidney Diseases. 2000;**35**(3):469-476

[9] Hawkley LC, Masi CM, Berry JD, Cacioppo JT. Loneliness is a unique predictor of age-related differences in systolic blood pressure. Psychology and Aging. 2006;**21**(1):152-164

[10] American Diabetes Association. Standards of medical care in diabetes–2010. Diabetes Care. 2010;**33**(Suppl. 1):S11-S61

[11] Asia Pacific Cohort Studies Collaboration. Body mass index and cardiovascular disease in the Asia-Pacific Region: An overview of 33 cohorts involving 310 000 participants. International Journal of Epidemiology. 2004;**33**(41):751-758

[12] Shlipak MG, Sarnak MJ, Katz R, Fried LF, Seliger SL, Newman AB, et al. Cystatin C and the risk of death and cardiovascular events among elderly persons. New England Journal of Medicine. 2005;**352**(20):2049-2060

[13] Shiovitz-Ezra S, Parag O. Does loneliness 'get under the skin'? Associations of loneliness with subsequent change in inflammatory and metabolic markers. Aging & Mental Health. 2018;**2018**:1-9

[14] Hawkley LC, Cacioppo JT. Loneliness matters: A theoretical and empirical review of consequences and mechanisms. Annals of Behavioral Medicine. 2010;**40**(2):218-227

[15] Cacioppo JT, Hawkley LC. Perceived social isolation and cognition. Trends in Cognitive Sciences. 2009;**13**(10):447-454

[16] Hawkley LC, Cacioppo JT. Aging and loneliness: Downhill quickly? Current Directions in Psychological Science. 2007;**16**(4):187-191

[17] Segrin C, Passalacqua SA. Functions of loneliness, social support, health behaviors, and stress in association with poor health. Health Communication. 2010;**25**(4):312-322

[18] Christiansen J, Larsen FB, Lasgaard M. Do stress, health behavior, and sleep mediate the association between loneliness and adverse health conditions among older people? Social Science & Medicine. 2016;**152**:80-86

[19] Hawkley LC, Thisted RA, Cacioppo JT. Loneliness predicts reduced physical activity: Cross sectional & longitudinal analyses. Health Psychology. 2009;**28**(3):354-363

[20] Albert MA, Glynn RJ, Ridker PM. Effect of physical activity on serum C-reactive protein. The American Journal of Cardiology. 2004;**93**(2):221-225

[21] Umpierre D, Ribeiro PA, Kramer CK, Leitão CB, Zucatti AT, Azevedo MJ, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: A systematic review and metaanalysis. JAMA. 2011;**305**(17):1790-1799

[22] Tijhuis MA, De Jong-Gierveld J, Feskens EJ, Kromhout D. Changes in and factors related to loneliness in older men. The Zutphen Elderly Study. Age and Ageing. 1999;**28**(5):491-495

[23] Ershler WB, Keller ET. Age-associated increased interleukin-6 gene expression, late-life diseases, and frailty. Annual Review of Medicine. 2000;**51**(1):245-270

[24] Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: Findings from the third National Health and Nutrition Examination Survey. JAMA. 2002;**287**(3): 356-359

[25] Heisler M, Cole I, Weir D, Kerr EA, Hayward RA. Does physician communication influence older patients' diabetes self-management and glycemic control? Results from the Health and Retirement Study (HRS). The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2007;**62**(12):1435-1442

[26] World Medical Association. Ethical principles for medical research involving human subjects. Bulletin of the World Health Organization. 2001;**79**(4):37

[27] Mitchell UA, Ailshire JA, & Crimmins EM. Change in cardiometabolic risk among blacks, whites, and hispanics: Findings from the Health and Retirement Study. The Journals of Gerontology: Series A. 2018;**74**(2):240-246

[28] Assari S. Association between obesity and depression among American Blacks: Role of ethnicity and gender. Journal of Racial and Ethnic Health Disparities. 2014;**1**(1):36-44

[29] Hughes ME, Waite LJ, Hawkley LC, Cacioppo JT. short scale for measuring loneliness in large surveys: Results from two population-based studies. Research on Aging. 2004;**26**(6):655-672

[30] McDade TW, Williams S, Snodgrass JJ. What a drop can do: Dried blood spots as a minimally invasive method for integrating biomarkers into population-based research. Demography. 2007;**44**(4):899-925

[31] Yang YC, Boen C, Gerken K, Li T, Schorpp K, Harris KM. Social relationships and physiological

*Does Physical Activity Mediate the Effect of Loneliness on Inflammatory and Metabolic Processes? DOI: http://dx.doi.org/10.5772/intechopen.104915*

determinants of longevity across the human life span. Proceedings of the National Academy of Sciences. 2016;**113**(3):578-583

[32] Laterza OF, Price CP, Scott MG. Cystatin C: An improved estimator of glomerular filtration rate? Clinical Chemistry. 2002;**48**(5):699-707

[33] Katzmarzyk PT, Srinivasan SR, Chen W, Malina RM, Bouchard C, Berenson GS. Body mass index, waist circumference, and clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents. Pediatrics. 2004;**114**(2):e198-e205

[34] Hawkley LC, Hughes ME, Waite LJ, Masi CM, Thisted RA, Cacioppo JT. From social structural factors to perceptions of relationship quality and loneliness: The Chicago health, aging, and social relations study. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences. 2008;**63**(6):S375-S384

[35] Hayes AF. Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach. New York, NY: Guilford Press; 2013

[36] Preacher KJ, Hayes AF. Asymptotic and resampling strategies for assessing and comparing indirect effects in multiple mediator models. Behavior Research Methods. 2008;**40**(3):879-891

[37] Preacher KJ, Hayes AF. SPSS and SAS procedures for estimating indirect effects in simple mediation models. Behavior Research Methods. 2004;**36**(4):717-731

[38] Baron RM, Kenny DA. The moderator–mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology. 1986;**51**(6):1173

[39] Preacher KJ, Kelley K. Effect size measures for mediation models: Quantitative strategies for communicating indirect effects. Psychological Methods. 2011;**16**(2):93

[40] Victor CR, Bowling A. A longitudinal analysis of loneliness among older people in Great Britain. The Journal of psychology. 2012;**146**(3):313-331

#### **Chapter 5**

## Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns, and Antidotes for Older Adults

*Amy Joy Lanou, Jeff Jones, Louise Noble, Thomas Smythe, Lauren Alexa Gambrill, Emma Olson and Tasha Woodall*

#### **Abstract**

Social isolation and loneliness are critical social drivers of health and need to be recognized as such. Safety efforts due to the COVID-19 pandemic have increased social isolation, highlighted the digital divide for older adults and rural communities, and have exacerbated related health concerns especially among older adults. Opportunities for increasing social connectedness of older adults and others who are isolated must be prioritized to decrease the impact of social isolation and loneliness on mental and physical health. Recommendations for policies, programs, and other actions addressing social isolation as a determinant of healthy aging by supporting community and individual social connectedness are highlighted using case examples from the western region of North Carolina. The purpose of this chapter is to urge policy makers and health professionals to prioritize policies, programs, and support for social connectedness as an antidote to turn the tide on the widespread impact of social isolation on the health of older adults.

**Keywords:** social isolation, loneliness, social distancing, social connection, older adults

#### **1. Introduction**

Although definitions vary, loneliness is most often described as a subjective term referring to the discrepancy between the quantity and quality of relationships that one has and what they desire. Social isolation, a more objective measure, has been alternatively defined as the "state of having few social relationships or infrequent social contact with others" or the "pervasive lack of social contact or communication, participation in social activities or having a confidant" among others [1, 2].

A growing body of evidence indicates that social isolation and loneliness are impacting health and health outcomes around the world. Two international literature reviews recently completed in the United Kingdom and in Finland included findings from studies in 23 countries across five continents. The Centre of Excellence for Public Health at Queen's University in Northern Ireland reviewed social isolation interventions in 33 studies conducted in 21 countries, and concluded that tailored approaches are needed to address loneliness and social isolation [3]. Tampere University in Finland reviewed 23 studies conducted in 13 countries and found that technological approaches are useful for assessing loneliness and social isolation among older adults and for alleviating loneliness safely without risk of infection transmission due to in person contact [4]. Both reviews found that the amount of research from the international scientific community on this topic has increased significantly during the past decade [3, 4].

Social isolation prevalence varies worldwide, but reports indicate rates as high as a third of older adults aged 65+ in some countries. Rates in European countries range from 19.6–34% and in Latin America from 25.3% to 32.4% [5]. A National Academy of Medicine (NAM) Consensus Study (2020) reported a 24% rate of social isolation in the U.S., while prevalence rates in Australia and India were lower at 19% and 18.3%, respectively [6]. The association between social isolation and loneliness is complex. Rates of loneliness are lower than rates of social isolation in some countries but exceed them in others. The NAM study ("Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System") reported that 43% of adults aged 60+ in the U.S. report feeling lonely, while rates in Europe are much lower and range from 3–10% [7, 8].

The NAM report also noted that social isolation is associated with a 50% increased risk of dementia, 29% increased risk of heart disease and 32% increased risk of stroke, and others have found that social isolation presents a substantial risk for increased morbidity, premature mortality and dysregulation of health biomarkers (blood pressure, C-reactive protein and cortisol levels) comparable to the risk associated with obesity, hypertension or daily tobacco use and is also associated with mental health morbidities such as depression, anxiety and dementia [9–11]. Loneliness is "characterized by impairments in attention, cognition, affect, and behavior that take a toll on morbidity and mortality through their impact on genetic, neural and hormonal mechanisms" [10]. It is associated with higher rates of depression, anxiety and suicide and, among heart failure patients, is associated with a nearly 4-fold increased risk of death, 68% increased risk of hospitalization, and 57% increased risk of emergency department visits [6].

The digital divide may further compound the risk of social isolation for older adults. Although technology use in this population increased 55% from 2000 to 2016, one third of older adults report never using the internet, and rates of smartphone ownership in adults aged 65+ remain 42% lower than that of adults aged 18 to 64. This same study found especially low rates of access and use among adults aged 80+. Adults aged 65 to 69 are about twice as likely to say they ever go online (82% vs. 44%) or have broadband at home (66% vs. 28%) and roughly four times as likely to say they own smartphones (59% vs. 17%) as their counterparts aged 80+ [12]. In addition to access and technology usage issues, hearing loss and impaired vision, common in the older adult population, can further complicate digital service accessibility [13]. Shteinlukht found that 60% of older adult respondents reported challenges utilizing digital platforms for virtual appointments [14].

This excess burden of vulnerability and disparate use of technology is further compounded by challenges unique to rural areas. The Western North Carolina (WNC) region has a 44% higher proportion of persons age 65+ than North Carolina as a whole and, of the 23 counties in the region, 83% [15] are classified as rural [16, 17]. Henning-Smith found that "older adults in rural areas were more than 10 percentage points more likely to report feeling left out often or at least some of the time,"

#### *Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

and 5% of them reported having no friends at all [18]. Another Henning-Smith study (2020) found that, "although older adults in rural areas report having larger social networks than their urban area counterparts, they also report higher levels of loneliness, indicating structural barriers to connecting" [19]. The disproportionate impact of the digital divide on older adults in rural areas has also been well documented. A Pew Research Center report demonstrated consistently lower rates of smartphone, computer and tablet ownership and lower rates of access to broadband internet at home in rural adults vs. urban adults (two-thirds vs. three-quarters) [15]. Rural adults who do have internet access are often unable to participate in synchronous activities such as video-conferencing for telehealth or social calls due to slower speeds and poor, unstable connectivity caused by low bandwidth [20]. Even those who have internet access and use it for social contact may not fully benefit, as several studies have demonstrated that indirect modes of contact such as Facebook and other internet-based platforms may not influence health in the same way or to the same degree as direct, in-person contact [21]. "As a result, older adults in rural areas are among the most likely to be left out of any creative, technologically-based adaptations to meet social and other needs during this crisis" [22].

Social isolation and loneliness impact health at the individual level and, arguably, also at the social or "conditions" level. The World Health Organization (WHO) defines social determinants of health as "the non-medical factors that influence health outcomes" or "the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life." While some lists of social determinants of health include social isolation or connectedness, as in WHO's list with "social inclusion and non-discrimination," often the factors shaping this condition of daily life are left out of efforts to address social determinants of health [23]. Place is an important factor that shapes conditions of daily life [23]. For example, living in a rural, mountainous, or otherwise remote region makes social connection, broadband access, and health care utilization more difficult. Other forces and systems at play include social norms and social policies such as those implemented to curb the spread of COVID-19 infection which concomitantly increased social isolation across the globe.

In this chapter, the unintended consequences of measures to reduce COVID-19 morbidity and mortality on social isolation are outlined, followed by a discussion of the importance of supporting and re-engaging social connectedness to combat social isolation, and recommendations to policy makers, communities and health professionals on how to effectively respond to these concerns are discussed. Considering social isolation as a social determinant of health and taking action to increase social connectedness among is important to reduce chronic disease, and improve physical and mental well-being for older adults.

#### **2. Impact of pandemic mitigation on older adults in the United States**

On March 13, 2020, as a result of the COVID-19 pandemic, the President of the United States declared a national emergency [24]. At the same time, the majority of US states issued stay-at-home orders in response to the pandemic [25]. By April of 2020, the White House Coronavirus Taskforce and the Centers for Disease Control (CDC) were recommending that individuals wear face coverings to slow the spread of SARS-CoV-2 [26]. In many US states, face coverings were eventually mandated in public areas, and various social distancing policies persisted well into the pandemic [27]. These measures ultimately mitigated viral transmission and concomitant harms in the US [28, 29]. Nevertheless, many unmistakable harms are inherent to pandemic mitigation efforts as well [2, 30]. The potential for harm is especially concerning for the older adult population. In an attempt to shield vulnerable populations from severe illness and death, policymakers and health officials also risked raising their susceptibility to the deleterious physiological, psychological, and emotional effects of social isolation.

In comparison with 18–29-year-old individuals, 67–74-year-olds are five times more likely to be hospitalized for COVID-19 and 65 times more likely to die from the disease. For those 75–84 years old, hospitalization is 8 times more likely, while death is 150 times more likely than for young adults. For people who have reached 85+ years of age, hospitalizations are 10 times more likely, and they are 370 times more likely to die of COVID-19 [31]. In March 2020, older adults also reported that they perceived their risk of death to be higher than that of younger adults or children [32]. Taken together, older adults are right to feel heightened concern about the potential consequences of contracting SARS-CoV-2. And now, even in light of the availability and utilization of effective vaccinations, heightened fear of contracting the virus lingers among some older adults [33].

The authors have heard stories from community members indicating they were fearful of and avoiding seeking medical care, shopping for essential items, visiting friends and loved ones, receiving gifts, coming in close contact with neighbors, and other activities. At a mass vaccination site in Western North Carolina during the first weeks of vaccine availability, several older adults shared that they had literally not left their homes in a year. Evidence is emerging that this problem is not unique to this region: older adults throughout the US have experienced similar difficulties and were leaving their homes less often [34, 35]. Many put off routine medical care or discontinued health-supporting behaviors such as daily visits to a facility for safe exercise or were no longer able to congregate for shared meals at senior centers, churches or other community gathering sites. An 88-year-old community member visited the Silver Sneakers program at a nearby YMCA 5 to 6 days a week before the "lockdown" and counted on these daily visits for maintaining strength, balance, life outlook and mental acuity. A year and a half into the pandemic he fell at home, broke his hip, and spent 6 weeks hospitalized and in rehabilitation. Six months later, his struggle to regain this strength and baseline level of independence continues. This person's story provides a clear example of how these trends are a cause for concern, not only for ethical reasons but also with respect to health promotion, chronic disease management, and prevention.

While the implementation of shelter-in-place orders, the closing of public spaces, and a decrease in a variety of available services were necessary precautions to slow the spread of the virus, they created a harmful impact on mental health. These policies, in conjunction with advice from the CDC that older adults practice especially rigorous social distancing, have had a large negative impact on the mental health of those 65 and older [36]. While there is reason to believe social isolation in older adults has needed attention for some time, with studies from as early as 2012 estimating that up to 40% of older adults may suffer from social isolation at some point the effects of COVID-19 on day-to-day life brought the impact of social isolation into clearer focus [37]. One older adult explained their experience with isolation, "I don't have very many friends here. I only have a few, and they prefer to send texts. I have no family, and my neighbors aren't very friendly, so I basically have no one to talk to." Data from a 2021 National Health and Aging Trends Study suggests a decrease in weekly

*Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

in-person contact from 61–39% for at-home individuals and a drop from 56–22% for those in residential care [38].

Even people living in shared housing facilities, retirement homes, long-term care facilities, nursing homes and other congregate sites were subjected to restrictions aimed at reducing exposure. Many were required to stay in their rooms or quarters for months at a time. Some older adults reported reductions in the services offered within their community living facility. Maintenance workers were no longer allowed to enter resident apartments for work orders, laundry and cleaning services were reduced, and tenants' overall support and supervision decreased. One person shared with the authors that these conditions had a significant impact on their mental and emotional wellbeing.

The pandemic necessitated a divergence from in-person communal gatherings, such as worship services, congregate meals, special interest group gatherings, graduations, and other events. Instead, some organizations arranged for individuals to "drive-in" or "drive-up" for special events or transitioned to video conference worship, funerals, graduations or even weddings. Others, like senior centers serving a daily meal, increased their capacity to distribute hot meals to older adults at home by rapidly expanding their food delivery services or partnering with organizations such as Meals on Wheels. Meanwhile, access to gatherings vanished for those who do not own transportation or have digital access, are physically unable to drive or use a device, or are fearful of arranging transportation.

The way people shop for groceries, acquire medications from pharmacies and visit their care providers also underwent dramatic changes during the pandemic. Many younger and more affluent individuals have the option to acquire essential supplies via online shopping and/or the use of delivery applications. While home delivery of hot meals, groceries, and other goods has been important for survival, it also comes at a cost. No-contact delivery options, created for safety reasons, have taken even momentary contact with others out of the equation. For example, a hot meal dropped off without contact is far different than sitting around a table to share a meal with others for feelings of connection.

Similarly, the rate of telemedicine usage increased drastically in April of 2020 and remained a critical part of care delivery well into the pandemic. Yet telemedicine was accessed less often by older adults [39, 40]. Older adults are less likely to access the internet, as underscored by the fact that more than half of adults 80+ years of age were not accessing the internet in the years before the pandemic [41]. Further, individuals with medical conditions and those who live in rural areas also access the internet less frequently than healthy individuals living in non-rural areas [42]. As a result, it is likely that medically complex older adults, especially those who live in a rural area, experienced a higher burden than that of their counterparts. Clinicians' abilities to perform remote monitoring that would typically guide clinical decisionmaking was also limited since, for example, Medicare Part B coverage for blood pressure monitoring devices is inconsistent and difficult to access [43]. Finally, cognitive, and sensory impairments, more prevalent among older people, pose a barrier to providing effective care via video or telephone visit, even among those who are able to access the proper technology to make these visits feasible.

Wearing a facial covering when in public is arguably one of the simplest and least infringing pandemic mitigation tools on offer. For many people, wearing a facial covering creates negligible restrictions on liberty and does not constitute a legitimate risk to their health or wellbeing. For some older adults however, facial coverings present significant challenges, especially for those experiencing decreased hearing ability. Before the beginning of the pandemic, people with decreased hearing ability were facing difficulties communicating in noisy healthcare settings, which can lead to negative clinical outcomes [44]. Facial coverings can reduce the volume and clarity of verbal communications while also obscuring mouth movements and facial expressions, which many people who have difficulty hearing rely upon to compensate [45]. This loss of sensory input can make communication in both clinical and non-clinical environments more difficult and may lead to lower levels of care efficacy and satisfaction while also causing increased feelings of marginalization, higher levels of confusion, and lower overall levels of connectedness. In addition, face coverings present other challenges. They make it more difficult to recognize others and more difficult to read facial expressions. A shared smile or look of concern can make a difference in how a person feels and responds to others. People with asthma, or other respiratory problems sometimes find wearing a mask especially challenging. Finally, those who wear glasses, have a challenge seeing when they fog up due to mask wearing, which can increase risk of falls, reduce driving safety among other concerns.

The elevated health risks that COVID-19 poses for older adults are a significant burden that weighs heavily on a vulnerable population, creating inequities. Importantly, the most underserved and vulnerable older adults stand to suffer the most. In the context of the current pandemic, social distancing guidelines have created nascent barriers to multiple dimensions of wellbeing in older adults. Therefore, the need to address the negative effects of pandemic mitigation policies on this population is a pressing issue of social justice.

#### **3. Social connectedness as an antidote**

Social connectedness or connection to others is a factor in maintaining both physical and emotional wellbeing throughout life. Social connection is the experience of feeling close and connected to others, including feeling valued, cared for, and loved. Dr. Brené Brown, a Research Professor of Social Work at the University of Houston, describes it this way: "Connection is the energy that exists between people when they feel seen, heard and valued; when they can give and receive without judgment; and when they derive sustenance and strength from the relationship" [46]. Described as a core human need and fundamental drive, social connection is an important antidote to social isolation [47].

#### **3.1 Relationships**

Feeling socially connected is linked to both the quality and quantity of meaningful relationships with others. The first line of social support often comes in the form of either family or peers in a shared dwelling. Whether living with a spouse or other family member or being part of a living community, physical proximity to other adults often provides some level of social connectedness. For many, human touch is an important expression of connection, and simple acts of touch such as hugs or touching a hand or shoulder provide reassurance, warmth, and are expressions of care [48]. Evidence shows that a healthy level of social support improves the chances of maintaining or initiating healthy behaviors and that increased proximity to other adults results in more social support [49].

*Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

#### **3.2 Connection to community**

Connectedness is important beyond the individual level. Social connectedness at the community level can also confer important benefits for individual health and society at large. Community gathering places play a significant role in promoting social connection within our society, especially for older adults [50]. Churches, senior centers, affinity groups, and other social hubs all provide a space for individuals to seek out community and social interaction. The use of gyms, YMCAs, malls, and parks for exercise not only improves physical health through movement, but also supports brain health and social connection [49, 51]. Opportunities to engage in learning or share expertise, such as that available at the Osher Lifelong Learning Institutes or institutions of higher education, also provide social connection for engaged members. Regular formal or informal gatherings of friends reduce stress and contribute to social connectedness, such as Moas in the Okinawan tradition "to complain, have fun, lend support," or family, such as intergenerational weekend meals [52].

#### **3.3 Aging in place**

Social connectedness is recognized as an important factor in building and maintaining age-friendly communities. Age-friendly communities are those that offer community and individual support for aging in place, defined as the ability to continue to live in the environment of one's choice, often at home or in another familiar place. Using a World Cafe forum, researchers sought to understand social connectedness from those approaching retirement and to learn about factors that would keep aging adults in their respective communities as they age. One of the key themes that emerged was "social reciprocity [defined as] giving and receiving to/from one's community," was perceived to be important in promoting social connectedness. Participants also shared the need for both formal and informal avenues for volunteering in their community as a means of feeling socially engaged [53].

Supports for aging in place in the face of physical limitations which also support social connection include home medical care, meal delivery services, home health aides who support activities of daily living, home safety assessments for falls risk, community health worker supports, and home-based primary care, among other in-home services. In addition to home healthcare agencies, geriatric care managers, senior relocation specialists, senior concierge services, and a vast array of technology services represent some of the emerging industries created to support the transition from a paradigm that has long favored institutionalization for older adults whose needs cannot be met at home, toward one promoting aging in place. Supporting older clients' wishes to sustain their level of social connectedness within their home community may enable those accessing these services to stand a greater chance of aging in place successfully.

#### **3.4 Connecting across the miles**

Telephones are a tried-and-true method for connecting people who cannot visit as often as they would like to connect. In recent years, technology has vastly changed the ability of individuals to connect with each other across distances great and small. Through instant messaging and phone calling, social connection is available with the press of a button, and with video chatting faces and body language are visible as well. While this has helped with social interaction for a large number of people, evidence shows there is a disparity for those 65+ in ability to access and use newer technology, especially those that rely on stable internet access [12]. Projects that increase the availability of smartphones and related technologies and support the use of these devices and services with older adults help to address this digital divide [54]. When devices and broadband are readily available, digital communication can be used to mitigate the negative effects of social isolation and loneliness. Increasing evidence demonstrates online presence and communication is linked to lower depression rates and less reported loneliness in older adults [55]. The ability to connect with family members, friends, or specific community forums such as Alzheimer's Association increases one's connectedness even when performed digitally [56].

#### **4. Effective response is needed: recommendations and case examples**

Clear, effective responses are needed to address and mitigate the increases in social isolation among older adults that have been exacerbated by pandemic mitigation strategies [22, 57]. This section outlines five key recommendations and examples of policies and projects poised to make or already making a difference in North Carolina that may be used as models or jumping-off points for other creative efforts to address social isolation, increase social connectedness and promote the health of older adults and their ability to safely continue aging in place.

#### **4.1 Recommendation 1: social isolation and its antidote, social connectedness, should be recognized as a social determinant of health and should be a consideration in health policy decisions**

Research has shown that social connectedness is a key social determinant of health (SDOH) that applies to individuals across age, ability, access, and area of service. In fact, the "[f]ormer US Surgeon General Vivek Murthy, MD, MBA, describes loneliness as being similar to thirst. It's the body's way of telling a person that it needs something. We need each other…" [22]. Recognizing the importance of social connection at the individual and community levels affords policymakers an opportunity to improve the health of older adults through such actions as including social connection on lists of agency priorities for addressing social determinants of health. These actions stand to bring this concern, of particular importance for older adults and others disproportionately impacted by COVID mitigation policies, to the forefront.

A case in point is the North Carolina Department of Aging and Adult Services, which has partnered with two university-based teams to bring attention to the need for understanding of social isolation, loneliness, and related health risks including depression and suicide among the 16 Area Agencies on Aging in NC. They have partnered with the NC Center for Health and Wellness and a team of researchers in Georgia to develop and provide resources to partners in the aging network in NC through www.healthyagingNC.com.

Healthy Aging NC is a statewide resource center for evidence-based health programs. The site links a network of program providers to participants seeking classes and support for chronic disease self-management including diabetes, arthritis, and heart disease, falls prevention, chronic pain self-management, improving balance, among others. Many of the providers of evidence-based programs nationwide have traditionally relied on in-person delivery of these programs. The Healthy Aging NC

*Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

team has provided support and training for partners to rapidly move these programs to remote or hybrid formats, recognizing that losing access to the programs not only reduces opportunities for addressing these chronic conditions and challenges, but also increases social isolation [57].

The reach of these programs marketed and supported through Healthy Aging NC has remained strong during the COVID-19 pandemic with 56 falls prevention workshops offered in 2020 (758 enrolled participants and 289 completers), and with 78 workshops offered in 2021 (677 enrolled participants and 450 completers). In remotely-offered Walk with Ease programs for arthritis and joint pain management, the number of participants enrolled increased dramatically from 20 to 29 in 2018– 2019 to 680 in 2020 and 149 in 2021 (personal communication). In addition, as part of this effort to increase connectedness, a new section on social engagement programs, a tool for self-assessment of social isolation, and health coaching opportunities which provide support for changing a behavior have been added to the website to increase referrals to these and other programs.

#### **4.2 Recommendation 2: human service organizations, policymakers, governmental and private foundation funders should prioritize programmatic opportunities to increase social connection for older adults**

The onset and continuation of the COVID-19 pandemic has provided opportunities for a wide range of public health, health promotion and human services providers to get creative with reaching socially-isolated adults with readily available technologies. A case example of a program that was rapidly developed to respond to increased social isolation among older adults in WNC is the Social Bridging Project (SBP).

The SBP was implemented as a response to concerns about the potential impact of social isolation on older adults as a result of the pandemic. It was formed as a partnership between the Mountain Area Health Education Center's Center for Health Aging and the NC Center for Health and Wellness at University of North Carolina Asheville with COVID-response funding from the NC Policy Collaboratory. The project's aim is to provide older adults who were isolated or lonely with a source of social connection, technology support and referrals to needed resources. SBP engaged university students as wellness callers to contact older adults in western NC whose lives were impacted by the stay-at-home measures.

During an evaluation of SBP in 2021, several participants remarked upon the impact and consequences of social isolation, including feelings of loneliness, a lack of connectedness or belonging and feelings of 'invisibility' or that their lives did not matter. One participant related, "I don't talk about my feelings very much, even with my children, because I don't want to worry them." Another shared, "ihere's a lot of older people where the children are in other states or other countries, and they're just not available and we forget that we need to be a community. Now that I've lost my vision and can't be on Facebook, I can't stay in touch with my family anymore." Another said, "it's hard when you feel like nobody cares" [58].

The Social Bridging Project team has been making wellness check-in calls to older adults to provide regular social support to isolated older adults in order to mitigate the onset of social isolation and loneliness and to help bridge the gap that exists between older adults and technology use. Not only do these calls provide social stimulation, but wellness callers are also able to connect participants to a variety of community resources. SBP has helped connect individuals to COVID-19 related information, food assistance, transportation, and provided various forms of technological support.

Between March 2020 and February 2022, the team has made 1304 wellness checkin calls. Of those calls, 658 led to what were considered productive conversations, and 78 percent of these left participants reporting that they felt 'significantly better' due to receiving the call. Some interactions led to outcomes that greatly affected the lives of our participants. One participant who was houseless was assisted in developing a social media platform for their business. Another participant took advantage of SBP assistance to shift their therapy practice to telehealth, allowing them to continue working through the pandemic. These are just two examples of positive outcomes stemming from SBP support.

In the summer of 2021, a survey was conducted in order to gather data from SBP participants about their experience in the program [58]. Participants were offered the chance to provide feedback and reflect with the survey provider. A number of quotes are listed below highlighting the significant impact the Social Bridging Project had on some of its participants.

"The other day I was having a really, *really* bad day. I've got psychiatric issues. It was one of those days where my mental health providers were not giving me what I needed. I really needed someone to talk to help me get grounded. I didn't tell [caller] I was having a crisis because I knew he would tell me to call my therapist, but he helped me a lot."

"It made me feel like [loneliness] was a recognized problem. It wasn't just my problem. Back in my grandmother's time she had family around her, and it was a community where she could walk from one family to the next."

"It made me feel like I could have a part of the future; that she and also the program thought that geriatric people were important enough to have this program."

"The non-threatening way to get my tech questions answered. And it's very expensive to hire somebody to help with tech. Without your program I never would have made it this far…. Your program is worth its weight in gold. It has been invaluable in getting me to think outside the box."

These quotes illustrate the ways in which the Social Bridging Project participants were being affected by the program. Not only were practical solutions found for the needs of the participants, but positive emotional outcomes and feelings of social support were also experienced. One participant even notes the improved outlook they had on society as an older adult after feeling included by SBP.

#### **4.3 Recommendation 3: medical providers and health teams should build on efforts to reach people in their homes or communities with whole person medical and health care**

In-home medical care is infamous for being difficult to access due to issues with availability or cost. Policies aimed at bolstering payments for in-home and community-based caregiving, such as that proposed as part of President Biden's "Build Back Better" infrastructure bill, would provide a much-needed pathway to improving older Americans' access to these services that are often essential to aging in place. Infusing more dollars into programs that support the direct care workforce for older adults living at home is also likely to improve the quality and availability of care provided.

Furthermore, efforts should be made to improve the financial feasibility of programs shown to benefit multiple dimensions of older adult wellbeing, such as home-based primary care, through advocacy for value-based payment models or risk-sharing arrangements. As it currently stands, Medicare's standard fee-for-service structure has not adopted value-based reimbursement principles, and this has a

*Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

significant impact on the ability of medical practices to offer this impactful service in a way that is financially sustainable.

Finally, enhanced reimbursement for telemedicine visits, particularly phone visits, would allow clinicians to continue providing medical care, behavioral health support, medication management, etc. for older adults with barriers to either inoffice visits (e.g., due to transportation difficulties) or video telehealth visits (e.g., due to broadband or technology access) while maintaining clinical solvency. In their chapter on telemedicine and telehealth, Chiang, and co-authors state "Advances in telecommunication technologies have introduced many ways to bridge geographic distance and time, in order to connect clinicians, patients and families and facilitate the remote delivery of health care services and education" [59]. This is important to ensure that socially isolated older patients, already at increased risk of adverse health events by virtue of their isolation, do not also suffer substantial gaps in medical care for their chronic health conditions that would further exacerbate their risk.

#### **4.4 Recommendation 4: broad public (community and governmental) support for infrastructure and technology access and education projects is needed**

Large, publicly funded infrastructure projects are needed to expand broadband access in rural areas. Technology and education projects will help to bridge the digital divide and bring medical and social support to people in rural areas and to those unable to leave their homes safely or easily. Policies and projects that bridge the digital divide especially for rural places and older adults or others socially isolated in their living situations are important. While interventions to increase digital access may not satisfactorily replace in-person interaction, they can help to supplement communication during times when face-to-face connection with other individuals is not possible.

Emergency policies put in place during the early months of the pandemic increased the ability of health care providers to deliver and bill for a wide variety of virtual visits (telehealth) including medical, psychiatric, specialist, dental, orthopedic, pharmacy and other services [60, 61]. While there are some disadvantages to the more widespread use of telemedicine that was brought on by the pandemic, many believe the benefits outweigh the drawbacks [62]. Key advantages of telemedicine include its cost effectiveness, the extension of access to specialty services, and the possibility of reducing the impact of a looming shortage of doctors especially in rural settings. In order to realize the promise of telemedicine and be prepared for future public health emergencies, policy makers need to expand technological resources into rural places, and health care providers need "to fully immerse telemedicine services into the healthcare landscape" [62].

For people who have not grown up with computers, smartphones, and other handheld digital technologies, increasing access to telecommunication capabilities needs to be paired with opportunities to learn how to use these technologies. A case example of a technology education and support program from western NC is the App State Cyber-Seniors program. In collaboration with the international Cyber-Seniors© organization, the program pairs Appalachian State University students with local older adults to teach digital and technology literacy skills such as the use of devices or video conference platforms, and to find resources for online education and local, remotely delivered resources and support. The program is designed to support social reciprocity (between students and elders) and to close the digital divide while reducing social isolation and loneliness among adults living in a mountainous rural region of the state [63].

#### **4.5 Recommendation 5: public health efforts should center place and use a place-based approach to addressing social isolation and other health and social determinants of health concerns**

Although social isolation and its health impacts are global phenomena, and some strategies such as provision of technology infrastructure and support for policies that prioritize social connectedness will have broad applicability, the efforts to address social connectedness as a social determinant of health should be specific to place. A place-based approach means taking the context of place, community and people's experience including history, culture, norms, and stories into account as policies, programs, and actions are planned. According to a WNC-located Master of Public Health Program in Asheville, "[p]lace-based public health centers people and their communities as the catalyst for transforming systems to promote wellbeing for all. Local residents, not institutions, hold the history, knowledge, and ways of interacting with place. As such, a place's inhabitants and institutions work in relationship, using interdisciplinary and participatory processes, to create and lead efforts to sustainably improve the social drivers of health and ultimately actualize health equity."

By utilizing a place-based approach, public health teams are more likely to address community and public health in ways that enact health equity in systems, organizations, and communities.

An excellent example of how centering place in public health efforts can be seen in community health worker (CHW) networks. Community health workers (CHWs) are increasingly important players in supporting the health of people where they live, worship, work, eat and play. CHWs are trained lay persons who generally come from and reside in the community where they work, who provide culturally relevant health information, help people access the resources and care they need, provide informal guidance, and advocate for community health needs among other activities [64]. CHWs often connect with people in their homes or in community settings, adding to social connection while supporting access to health care or social determinant of health needs, and this approach could be a valuable way to support older adults experiencing loneliness, social isolation and many other mental, physical, or technological needs.

In 2021, the NC Center for Health and Wellness in partnership with Mountain Area Health Education Center and community-based organizations conducted a mixed methods evaluation of the "Community Health Workers as Culturally-Responsive COVID Support in WNC Communities" initiative to explore the impact and quality of CHW services across 17 counties over the yearlong period. Across the methods used, the research team saw significant impacts of the community health workers, particularly in rural communities and among "hidden" or "abandoned" and hard-to-serve groups. While the research did not focus on older adults, several of the findings related to the CHW's impacts on health and social determinants highlight the importance of a place-based approach and could be particularly important among isolated older adults.

CHWs participated in a focus group and responded to a survey to share the services they provided and their perceptions of their impact. One CHW described the incredible range of services she provided (30 in total), which were for both health issues and social determinants and meeting urgent needs. One CHW shared that she felt the social connections she made were particularly important: "It is a pleasure to be able to help these people and to see the smiles on their faces and to see what they achieve…you have a connection with these people that you see every day" (2021 CHW Focus Group). Another said making connections in the community and building trust was incredibly important: "they open their door, and they open their lives to us" (2021 CHW Focus Group).

#### *Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

Community-based researchers also interviewed community members who had received CHW services, and the list of services and resources they reported receiving from CHWs was extensive. Services included COVID-related resources such as educational information, personal protective equipment (PPE), hand sanitizer, cleaning supplies, and vaccine information. While many community members found these resources and supplies important, most also received non COVID-related help, which they really valued. These resources included connection to housing, transportation, connection with Pisgah Legal for health insurance assistance, referrals to financial programs, connection with food stamps, food boxes, rental assistance, medication assistance, and help paying bills. Housing and transportation were resources that were most mentioned by community members, with housing lifted up as being a resource that there just is not enough of in Western North Carolina. An additional resource that many community members reported receiving was emotional support. This emotional support felt especially important to many, as they may or may not have had others in their lives to provide this: "it's good to have somebody, especially if you don't have nobody to come around" (September 2021 Interview). CHWs were often described as becoming members of the family. These connections were valuable to community members because they generally made them feel better and sometimes helped them to feel less isolated and alone.

Continued and expanded investment in Community Health Workers as vital members of the healthcare workforce could help meet community members' health, emotional and social needs.

#### **5. Conclusions**

Social isolation is an important concern among older adults and is associated with poor health outcomes. Older adults have been disproportionately impacted by increases in social isolation exacerbated by COVID-19 pandemic mitigation policies and efforts. For these reasons three broad-based recommendations should be employed at the at the county, state, and country levels. Social isolation and its antidote, social connectedness, should be recognized as a social determinant of health. Governments at all levels should legislate and support for broad band access and technology infrastructure. And, public health efforts should center place and use a place-based approach to addressing social isolation, healthy equity, and other health and social determinants of health concerns. In addition, more localized support is necessary to turn the tide on the widespread impact of social isolation on the health of older adults. State, county, and local policy makers, human service organizations, and funders must prioritize programmatic opportunities to increase social connection for older adults. These efforts will need to include education and ongoing support for the use of digital technologies. Finally, medical providers and health teams should build on efforts to reach people in their homes or communities with whole person medical and health care. Projects and practices in western NC may serve as a model for implementation of these recommendations in other places.

#### **Acknowledgements**

This work was supported by a grant from the Dogwood Health Trust. The authors wish to acknowledge the following individuals for their contributions, Ellen Bailey, Nadia Mazza, Jill Juris Naar, and Katie Cox.

### **Conflict of interest**

The authors declare no conflicts of interest.

### **Author details**

Amy Joy Lanou1 \*, Jeff Jones2 , Louise Noble2 , Thomas Smythe2 , Lauren Alexa Gambrill3 , Emma Olson2 and Tasha Woodall4,5

1 NC Center for Health and Wellness and UNC Asheville – UNC Gillings Master of Public Health Program, University of North Carolina Asheville, Asheville, North Carolina, USA

2 NC Center for Health and Wellness, University of North Carolina Asheville, Asheville, North Carolina, USA

3 University of Washington, Seattle, Washington, USA

4 Mountain Area Health Education Center, Asheville, North Carolina, USA

5 UNC Eshelman School of Pharmacy, UNC School of Medicine, Chapel Hill, NC, USA

\*Address all correspondence to: alanou@unca.edu

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

#### **References**

[1] Medicine NA of S Engineering, and, Education D of B and SS and, Division H and M, Sciences B on B Cognitive, and Sensory, Policy B on HS, Adults C on the H and MD of SI and L in O. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: National Academies Press; 2020

[2] Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: A Meta-analytic review. PLoS Medicine. 2010;**7**(7):e1000316. DOI: 10.1371/ journal.pmed.1000316

[3] Fakoya OA, McCorry NK, Donnelly M. Loneliness and social isolation interventions for older adults: A scoping review of reviews. BMC Public Health. 2020;**20**:1. DOI: 10.1186/ s12889-020-8251-6

[4] Latikka R, Rubio-Hernández R, Lohan ES, Rantala J, Fernández FN, Laitinen A, et al. Older adults' loneliness, social isolation, and physical information and communication technology in the era of ambient assisted living: A systematic literature review. Journal of Medical Internet Research. 2021;**23**(12):e28022. DOI: 10.2196/28022

[5] Gao Q, Prina AM, Prince M, Acosta D, Sosa AL, Guerra M, et al. Loneliness among older adults in latin america, China, and India: Prevalence, correlates and association with mortality. International Journal of Public Health. 2021;**66**:604449. DOI: 10.3389/ijph.2021.604449

[6] National Academies of Sciences, Engineering, and Medicine. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press; 2020. DOI: 10.17226/25663

[7] Australian Government. Australian Institute of Health and Welfare. Ageing and Aged Care [Internet]. 2017. Available from: https://www.aihw.gov. au/getmedia/d18a1d2b-692c-42bf-81e2- 47cd54c51e8d/aihw-australias-welfare-2017-chapter5-1.pdf.aspx#:~:text=It%20 is%20estimated%20that%20around,2016

[8] EU Science Hub. How Lonely Are Europeans? The European Commission's Science and Knowledge Service [Internet]. 2019, June. Available from: https://ec.europa.eu/jrc/en/news/ how-lonely-are-europeans

[9] Stickley A, Koyanagi A. Physical multimorbidity and loneliness: A population-based study. PLoS One. 2018;**13**(1):e0191651-e0191651. DOI: 10.1371/journal.pone.0191651

[10] Hawkley LC, Cacioppo JT. Loneliness matters: A theoretical and empirical review of consequences and mechanisms. Annals of Behavioral Medicine. 2010;**40**(2):218-227. DOI: 10.1007/ s12160-010-9210-8

[11] Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspectives on Psychological Science. 2015;**10**(2):227-237. DOI: 10.1177/1745691614568352

[12] Anderson M, Perrin, A. Tech adoption climbs among older adults [Internet]. 2017. Pew Research Center. Available from: https://www. pewresearch.org/internet/wp-content/ uploads/sites/9/2017/05/PI\_2017.05.17\_ Older-Americans-Tech\_FINAL.pdf

[13] Graham J. Technology Divide Between Senior "Haves" and

"Have-Nots" Roils Pandemic Response [Internet]. 2020. KHN. Available from: https://khn.org/news/technology-dividebetween-senior-haves-and-have-notsroils-pandemic-response/

[14] Shteinlukht T. COVID-19 Pandemia impact on mental health of older adults and possible treatment options. The American Journal of Geriatric Psychiatry. 2021;**29**(4):S102-S103

[15] Perrin A. Digital gap between rural and nonrural America persists [Internet]. 2019. Pew Research Center. Available from: https://www. pewresearch.org/fact-tank/2019/05/31/ digital-gap-between-rural-andnonruralamerica-persists/

[16] US Census Bureau. Data census [Internet]. 2021

[17] North Carolina Office of State Budget and Management. The Urban and Rural Faces of North Carolina [Internet]. 2021, July. North Carolina Government. Available from: https://files.nc.gov/ ncosbm/documents/files/2018ACSNC.pdf

[18] Henning-Smith C, Moscovice I, Kozhimannil K. Differences in social isolation and its relationship to health by rurality. The Journal of Rural Health. 2019;**35**(4):540-549. DOI: 10.1111/jrh.12344

[19] Henning-Smith C. Meeting the social needs of older adults in rural areas. JAMA Health Forum. 2020;**1**(11):e201411. DOI: 10.1001/jamahealthforum.2020.1411

[20] Kaur H . Why rural Americans are having a hard time working from home [Internet]. 2020, April 29. CNN. Available from: https://www.cnn. com/2020/04/29/us/rural-broadbandaccesscoronavirus-trnd/index.html

[21] Hamilton J. Maybe isolation, not loneliness, shortens life. Shots: Health news from NPR [Internet]. Available from: http://www.npr.org/sections/ health-shots/2013/03/26/175283008/ maybe-isolation-not-loneliness-shortenslife [Accessed July 22, 2015]

[22] Henning-Smith C. The unique impact of COVID-19 on older adults in rural areas. Journal of Aging & Social Policy. 2020;**32**(4-5):396-402

[23] World Health Organization. Social determinants of health. Available from: https://www.who. int/westernpacific/health-topics/ social-determinants-of-health

[24] Santoli JM. Effects of the COVID-19 pandemic on routine Pediatric vaccine ordering and administration — United States. MMWR. Morbidity and Mortality Weekly Report. 2020;**69**:591-593. DOI: 10.15585/mmwr.mm6919e2

[25] Moreland A. Timing of state and territorial COVID-19 stay-at-home orders and changes in population movement — United States. MMWR. Morbidity and Mortality Weekly Report. 2020;**69**:1198- 1203. DOI: 10.15585/mmwr.mm6935a2

[26] Fisher KA. Factors associated with cloth face covering use among adults during the COVID-19 pandemic — United States. MMWR. Morbidity and Mortality Weekly Report. 2020;**69**:933- 937. DOI: 10.15585/mmwr.mm6928e3

[27] Wright AL, Chawla G, Chen L, Farmer A. Tracking mask mandates during the Covid-19 pandemic. Social Science Research Network. 2020:1-14. DOI: 10.2139/ssrn.3667149

[28] Chu DK, Akl EA, Duda S, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: A systematic review and meta-analysis. *Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

Lancet. 2020;**395**(10242):1973-1987. DOI: 10.1016/S0140-6736(20)31142-9

[29] Badr HS, Du H, Marshall M, Dong E, Squire MM, Gardner LM. Association between mobility patterns and COVID-19 transmission in the USA: A mathematical modelling study. The Lancet Infectious Diseases. 2020;**20**(11):1247-1254. DOI: 10.1016/ S1473-3099(20)30553-

[30] Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: The need for prevention and early intervention. JAMA Internal Medicine. 2020;**180**(6):817-818. DOI: 10.1001/jamainternmed.2020.1562

[31] CDC. Cases, Data, and Surveillance. Centers for Disease Control and Prevention [Internet]. February 11, 2020. Available from: https://www.cdc. gov/coronavirus/2019-ncov/covid-data/ investigations-discovery/hospitalizationdeath-by-age.html

[32] Bruine de Bruin W. Age differences in COVID-19 Risk perceptions and mental health: Evidence from a National U.S. survey conducted in March 2020. The Journals of Gerontology: Series B. Feb 2021;**76**(2):e24-e29. DOI: 10.1093/ geronb/gbaa074

[33] Hadjistavropoulos T, Asmundson GJG. COVID stress in older adults: Considerations during the omicron wave and beyond. Journal of Anxiety Disorders. 2022;**86**:102535. DOI: 10.1016/j.janxdis.2022.102535

[34] Santini ZI, Jose PE, York Cornwell E, et al. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): A longitudinal mediation analysis. The Lancet Public Health. 2020;**5**(1):e62-e70. DOI: 10.1016/ S2468-2667(19)30230-0

[35] Roe CM, Rosnick CB, Colletta A, Babulal GM. Reaction to a pandemic: Social distancing and driving among older adults during COVID-19. Journal of Applied Gerontology. 2021;**40**(3):263- 267. DOI: 10.1177/0733464820966516

[36] Flint AJ, Bingham KS, Iaboni A. Effect of COVID-19 on the mental health care of older people in Canada. International Psychogeriatrics. 2020;**32**(10):1113-1116. DOI: 10.1017/ S1041610220000708

[37] Nicholson NR. A review of social isolation: An important but underassessed condition in older adults. The Journal of Primary Prevention. 2012;**33**(2-3):137-152 Available from: https://link.springer.com/content/ pdf/10.1007/s10935-012-0271-2.pdf

[38] Freedman VA, Hu M, Kasper JD. Changes in older adults' social contact during the COVID-19 pandemic. Journals of Gerontology - Series B Psychological Sciences and Social Sciences. 2021 Sep 16:gbab166. DOI: 10.1093/geronb/ gbab166. Epub ahead of print

[39] Cortez C, Mansour O, Qato DM, Stafford RS, Alexander GC. Changes in short-term, long-term, and preventive care delivery in US Office-based and telemedicine visits during the COVID-19 pandemic. JAMA Health Forum. 2021;**2**(7):e211529. DOI: 10.1001/ jamahealthforum.2021.1529

[40] Eberly LA, Kallan MJ, Julien HM, et al. Patient characteristics associated with telemedicine access for primary and specialty ambulatory care during the COVID-19 pandemic. JAMA Network Open. 2020;**3**(12):e2031640. DOI: 10.1001/ jamanetworkopen.2020.31640

[41] Hunsaker A, Hargittai E. A review of internet use among older adults. New Media & Society. 2018;**20**(10):3937-3954. DOI: 10.1177/1461444818787348

[42] Wang JY, Bennett K, Probst J. Subdividing the digital divide: Differences in internet access and use among rural residents with medical limitations. Journal of Medical Internet Research. 2011;**13**(1):e1534. DOI: 10.2196/jmir.1534

[43] Woodall T, Ramage M, LaBruyere JT, McLean W, Tak CR. Telemedicine services during COVID-19: Considerations for medically underserved populations. The Journal of Rural Health. 2021;**37**(1):231-234

[44] Chodosh J, Weinstein BE, Blustein J. Face masks can be devastating for people with hearing loss. BMJ. 2020;**370**:m2683. DOI: 10.1136/bmj.m2683

[45] Nguyen DD, McCabe P, Thomas D, et al. Acoustic voice characteristics with and without wearing a facemask. Scientific Reports. 2021;**11**(1):5651. DOI: 10.1038/s41598-021-85130-8

[46] Brown B. The Gifts of Imperfection: Let Go of Who you Think you're Supposed to be and Embrace Who you Are. Center City, Minnesota: Hazeldon; 2010

[47] Baumeister RF, Leary MR. The need to belong: Desire for interpersonal attachments as a fundamental human motivation. Psychological Bulletin. 1995;**117**(3):497-529. DOI: 10.1037/0033-2909.117.3.497

[48] Burleson MH, Roberts NA, Munson AA, Duncan CJ, Randall AK, Ha T, et al. Feeling the absence of touch: Distancing, distress, regulation, and relationships in the context of COVID-19. Journal of Social and Personal Relationships. 2022;**39**(1):56-79. DOI: 10.1177/02654075211052696

[49] Lindsay Smith G, Banting L, Eime R, O'Sullivan G, van Uffelen JGZ. The

association between social support and physical activity in older adults: A systematic review. International Journal of Behavioral Nutrition and Physical Activity. 2017;**14**:56. DOI: 10.1186/ s12966-017-0509-8

[50] Berkman LF, Kawachi I, Glymour MM. Social capital, social cohesion, and health. In: Social Epidemiology. Oxford, England: Oxford University Press; 2014

[51] Cotman CW, Berchtold NC, Christie LA. Exercise builds brain health: Key roles of growth factor cascades and inflammation. Trends in Neurosciences. 2007;**30**(9):464-472. DOI: 10.1016/j. tins.2007.06.011. Epub 2007 Aug 31. Erratum in: Trends Neurosci. 2007 Oct;30(10):489. PMID: 17765329

[52] De Felicis J. 13 Unusual Ways to Shed Stress (Lessons from the World's Blue Zones) - Blue Zones [Internet]. 2022. Available from: https://www.bluezones. com/2022/02/13-unusual-ways-to-shedstress-lessons-from-the-worlds-bluezones/

[53] Emlet CA, Moceri JT. The importance of social connectedness in building agefriendly communities. Journal of Aging Research. 2012;**2012**:173247. DOI: 10.1155/2012/173247

[54] Lee NT. Public Policy Can Improve Older Adults' Access to Technology. Washington, DC: The Brookings Institution; 2017. Available from: https://www.brookings.edu/blog/ techtank/2017/06/05/public-policycan-improve-older-adults-access-totechnology/

[55] Fang Y, Chau AKC, Wong A, Fung HH, Woo J. Information and communicative technology use enhances psychological wellbeing of older adults: The roles

*Perspective Chapter: Social Distancing and Isolation – Unintended Consequences, Concerns... DOI: http://dx.doi.org/10.5772/intechopen.104997*

of age, social connectedness, and frailty status. Aging & Mental Health. 2018;**22**(11):1516-1524. DOI: 10.1080/13607863.2017.1358354

[56] Cotten SR. Examining the roles of Technology in Aging and Quality of life. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences. 2017;**72**(5):823-826. DOI: 10.1093/geronb/gbx109

[57] Suragarn U, Hain D, Pfaff G. Approaches to enhance social connection in older adults: An integrative review of literature. Aging and Health Research. 2021;**1**(3):100029. DOI: 10.1016/j. ahr.2021.100029

[58] Noble LW, Olson E, Woodall T, Jones J, Smythe T, Whitlock C, et al. The social bridging project: Intergenerational phone-based connections with older adults during the COVID-19 pandemic. Gerontology and Geriatric Medicine. 2022 Apr 4;**8**:23337214221083473. 1-10. DOI: 10.1177/23337214221083473

[59] Chiang MF, Starren JB, Demiris G. In: Shortliffe EH, Cimino JJ, editors. Telemedicine and Telehealth. Cham: Biomedical Informatics. Springer; 2021. DOI: 10.1007/978-3-030-58721-5\_20

[60] Public Health Institute Center for Connected Health Policy. State Telehealth Laws & Reimbursement Policies [Internet]. 2020. Available from: https:// www.cchpca.org/sites/default/files/2020- 05/CCHP\_%2050\_STATE\_REPORT\_ SPRING\_2020\_FINAL.pdf

[61] Turner Lee N, Karsten J, Roberts J. Removing regulatory barriers to telehealth before and after COVID-19 [Internet]. 2020. Brookings Institution. Available from: https://www.brookings. edu/research/removing-regulatorybarriers-to-telehealth-before-and-aftercovid-19

[62] Kichloo A, Albosta M, Dettloff K, et al. Telemedicine, the current COVID-19 pandemic and the future: A narrative review and perspectives moving forward in the USA. Family Medicine and Community Health. 2020;**8**:e000530. DOI: 10.1136/ fmch-2020-000530

[63] Appalachian State AppState Cyber-Seniors [Internet]. 2021. Available from: https://ihhs.appstate.edu/outreach/ appstate-cyber-seniors

[64] U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions. (2007). Community Health Worker National Workforce Study. Washington, DC: US Department of Health and Human Services; 2007

## Section 3
