European Journal of Public Health, Vol. 32, No. 5, 677–683 ß The Author(s) 2022. Published by Oxford University Press on behalf of the European Public Health Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com https://doi.org/10.1093/eurpub/ckac100 Advance Access published on 8 September 2022 ......................................................................................................... Effectiveness of a community intervention to reduce social isolation among older people in low-income neighbourhoods Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 C. Lapena1,2, X. Continente3,4,5, A. Sánchez Mascun ~ ano6, M. Mari dell’Olmo3,4,5, 3,4,5,7 M.J. López 1 Centre d’Atenció Primària Sanllehy, Gerència d’Àmbit d’Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain 2 Unitat de Suport a la Recerca Barcelona Ciutat, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), Barcelona, Spain 3 Evaluation and Intervention Methods Service, Public Health Agency of Barcelona, Barcelona, Spain 4 Spanish Consortium for Research on Epidemiology and Public Health (CIBERESP), Madrid, Spain 5 Sant Pau Institute of Biomedical Research (IIB Sant Pau), Barcelona, Spain 6 Preventive Medicine Department, University Hospital of Bellvitge, Hospitalet de Llobregat, Barcelona, Spain 7 Department of Experimental and Health Sciences at Universitat Pompeu Fabra, Barcelona, Spain Correspondence: Marıa José López, Public Health Agency of Barcelona, Lesseps, 1, 08023 Barcelona, Spain, Tel: þ34 (0) 932027748, Fax: þ34 (0) 932921443, e-mail: mjlopez@aspb.cat Background: Social and demographic trends show a global increase of proportion of older people at risk of social isolation. This study aimed to evaluate the effectiveness of an intervention conducted in low-income neighbourhoods to reduce social isolation and its negative effects on health in older persons. Methods: A quasi-experimental study with a comparison group was performed. The ‘School of Health for Older People’ is a weekly community inter- vention that promotes resources among individuals and communities to enhance their ability to identify problems and activate solutions, encouraging community participation. Data were collected at the beginning and at the end of the intervention. Social support, psychological morbidity and health-related quality of life were measured through questionnaires information on visits to the primary care centre was obtained from the electronic medical records of primary care centres. Multivariate regression models were conducted to assess changes after the intervention. Results: A total of 135 participants were included in the study. The intervention helped to improve participants’ mental health (aPR ¼ 0.46; 95% CI: 0.23–0.90) comparing with the comparison group. Also, the intervention helped to maintain quality of life and social support, which were worsened or maintained respect- ively in the case of comparison group. Conclusions: Our results provide evidence on how a community interven- tion can improve quality of life, mental health and social support in older people. The evidence can help to fill the knowledge gap in this area and might be especially useful for the design of social and public health policies and programmes for older people in disadvantaged neighbourhoods in urban areas. Trial registration: NCT03142048 ......................................................................................................... Introduction persons, home visits and health promotion interventions; these inter- ventions can be provided one-to-one, in group activities or by com- he proportion of elderly people has risen considerably in recent munity engagement.6,14,15,19–21 Tdecades, especially in Europe, which has the oldest population in Most interventions have not been evaluated, and some have only the world.1 In Barcelona, 18.2% of men and 24.7% of women are conducted process evaluation, assessing the number of people 65 years or older, with projections indicating that this number will reached and participants’ satisfaction.22 Other interventions have escalate over time.2,3 been assessed by qualitative methods only, or using weak study Social and demographic trends show a global increase in the propor- designs6,23 to assess their effects. Additionally, there is substantial tion of older people at risk of lack of social relationships.4 Social isolation variability in the measurement tools used and the outcomes represents the objective absence of relationships with other people.5–9 assessed.24 Finally, interventions on social isolation often target spe- Social relationships are not only associated with good mental health, cific population groups: nursing home residents, caregivers, ethnic but their absence is linked to a significant increase in morbidity and minorities, widows and widowers and people with health conditions, mortality8,10,11 because they provide support and moderate the effects such as serious mental health problems, among others.14,16,17,19 of stressors of life in people.10 Moreover, social support increases the Some systematic reviews have been carried out to assess the ef- availability of social resources, self-steem and encourages the adoption fectiveness of interventions in older adults6,19,20 but there is still a of healthy behaviours.10 Because of the high prevalence of social iso- clear lack of conclusive evidence on their impact on social isolation lation, together with the evidence of their negative impact on health, and other health-related outcomes. quality of life12,13 and well-being,14–18 they are an important public In Barcelona, the programme ‘Barcelona Health in the health concern.14,15 A range of interventions has been developed to Neighbourhoods’ was launched in 2007 to reduce social inequalities reduce social isolation in older people.6 The scope of these interven- in health and improve the health of the most disadvantaged popu- tions is wide, including the provision of devices, accompanying lations through community health interventions.25 As part of the 678 European Journal of Public Health comprehensive action a weekly community intervention called the 1.5 h, with discussions on health, including biological, psychological ‘School of Health for Older People’ has been implemented in low- and social topics. Attendance was free and sessions were held in income neighbourhoods of Barcelona since 2008.25 This intervention community centres in the selected neighbourhoods. The different aims to reduce social isolation in older people and increase their sessions of the intervention were linked to networking in the neigh- quality of life. bourhood derived from the ongoing community process. Detailed A qualitative evaluation has already been carried out to explore the contents of the intervention are described in the published protocol26 perceptions of those attending the ‘School of Health for Older and in a Supplementary table S1. People’, but no information has been studied regarding health indi- All sessions were designed to encourage interaction among par- cators. Now, the objective of this study was to evaluate the effective- ticipants and to work on personal skills. Most sessions were led by an ness of this intervention, by measuring its impact on self-perceived Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 expert on the topic covered, who worked in the same neighbourhood health, mental health, health-related quality of life (HRQoL), social as the participants (professionals from the health services, social support and primary care use. services, markets or neighbourhood associations). Methods Information sources The main information source was a face-to-face questionnaire, Design designed ad-hoc and composed of items from validated question- Quasi-experimental study, with an intervention group (IG) and a naires.27–31 The same questionnaire was administered before (PRE) comparison group (CG).26 (January 2015) and at the end of the intervention (POST) (June 2015) by the research team and trained personnel from the Setting and subjects Agència de Salut Pública de Barcelona (ASPB). The study population consisted of community-dwelling adults aged 60 years or older living in low-income neighbourhoods in Barcelona Main outcomes (Spain). Two intervention neighbourhoods (Besos and Guineueta) Attendance was registered at each session. At the end participants’ and two comparisons (Trinitat Nova and Raval) were selected on a satisfaction was measured asking them to rate speakers, place/space, convenience basis, ensuring similar socioeconomic characteristics. frequency, schedule, duration and general satisfaction from 0 to 10. Risk of social isolation was not an inclusion criteria. However, people Also participants were asked if they recommend the School of Health considered at risk of solitude by professionals (adults aged 60 years or to a friend. With a yes/no answer. older, living in the four selected neighbourhoods) were tried to be Sociodemographic information was collected in the baseline ques- recruited through professionals of social and health services of primary tionnaire: age, sex, educational level (no education/primary/second- care in the area. Also, people could voluntarily sign up through the ary or university), marital status (married/divorced or separated/ elderly community centres. In both the IG and CG, older people never married/widowed), household type (living alone/with other were informed about the study and once they had expressed their inter- family members/others) and neighbourhood of residence. est in participating, their names and contact telephone numbers were HRQoL was measured through the EuroQoL (EQ-5D-3L) ques- registered. Each participant was contacted and an appointment was tionnaire.27 The five dimensions analyzed were mobility, self-care, arranged in which they were informed about the study. usual activities, pain/discomfort and anxiety/depression, which had The School of Health had not been conducted before in the neigh- three possible answers (no problems, moderate problems and severe bourhoods where the study was performed. All participants from the problems). A final index containing all dimensions was obtained CG were informed that they could participate in a School of Health after assigning a weight to each response and subsequently adjusting it their participation in the study. Meanwhile, all participants could attend according to the reference group. The final index ranged from 0 community activities already established in the neighbourhoods, such as attending civic centres or community dining halls, e.g. although they are (death) to 1 (the best health status). not activities comparable to the evaluated intervention. Mental health was measured through the Goldberg General Health A theoretical sample was recruited with 80 participants in each group Questionnaire (GHQ-12),28,29 which refers to possible problems peo- (IG and CG) (40 people in each neighbourhood), accepting an alpha ple can feel or have in the last 30 days. A final score was calculated risk of 5% and a power of 80% in a unilateral contrast, and assuming a for the 12 items using a binary scoring method for each item, by loss of 10%. Further details are available in the published protocol.26 scoring 0 or 1 depending on the response category. The score ranged Both groups were balanced in terms of the participants’ recruitment site from 0 to 12, with higher scores indicating worse mental health.28 (primary care centres, social services and community centres). The variable was subsequently dichotomized using a cut-off of four The exclusion criteria were: (i) inability to understand or speak points, given that GHQ-12 has lower specificity in the population Spanish or Catalan; (ii) inability to maintain participation for older than 65 years.28,29 Participants scoring four or higher were 6 months and (iii) failure to attend at least 50% of the sessions in more likely to experience mental health problems and were classified the case of participants in the IG. as ‘with psychological distress’. People scoring <4 points were con- sidered as ‘without psychological distress’. Ethical considerations Social support was measured through questions drawn from the Measures of Quality of Life Core Survey of Medical Outcomes Study Participants were informed both verbally and in writing about the (MOS).30 The following two questions were included: ‘How often is aims, methods, procedures and measures of this study. Also about this kind of support available to you? 1) Someone to get together ethical issues, such as confidentiality, their right to ask any questions with for relaxation, and 2) Someone to do things with to help you they might have during the study and to withdraw at any time with- take your mind off things’, with response options of ‘none of the out penalty. All participants signed a written consent form. This time’, ‘a little of the time’, ‘some of the time’ and ‘most/all of the study was approved by the Parc de Salut MAR Clinical Research time’. Social support was also measured through questions drawn Ethics Committee (code n 2015/6500/I). from the National Social Life, Health, and Aging Project (NSHAP) questionnaire31: ‘How often can you/do you feel you can rely on your Description of the intervention friends?’ and ‘How often can you/do you feel that you lack compan- The intervention ‘School of Health for Older People’ was held from ionship?’ with response options of ‘often’, ‘some of the time’ and January to June 2015. It consisted of 22 weekly group sessions of ‘never or hardly ever’. These variables were dichotomized by Effectiveness of a community intervention to reduce social isolation among older people 679 grouping them among those who reported having social support and Table 1 Participants’ demographic characteristics at baseline. School those who reported having it hardly ever or not at all. of Health for Older People, Barcelona 2015 Information was obtained on the number of visits to the primary care centre [general practitioners (GPs) and nurses] for the 6 months IG (N 5 70), CG (N 5 65), Pa n (%) n (%) prior to the intervention and the 6 months after the intervention through the records provided by electronic medical records of pri- Age 0.056 mary care centres. <65 years 9 (12.8) 3 (4.6) 65 to <75 years 31 (44.3) 22 (33.9) Data analysis 75 years 30 (42.9) 40 (61.5) Sex Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 Finally 17 people in the IG (eight from Guineueta and nine from Female 52 (74.3) 56 (86.2) 0.085 Besòs) were excluded from the analyses because they failed to attend Male 18 (25.7) 9 (13.8) the minimum of 50% of the sessions. Causes were death or pro- Educational level No education 35 (50.0) 42 (64.6) 0.164 longed hospital admission, change of address, having to take care Primary 23 (32.9) 19 (29.2) for relatives on the days the intervention was offered and in some, Secondary to university 12 (17.1) 4 (6.2) reason of absence was unknown. In the CG, six people (one person Marital status from Raval and five from Trinitat) were lost to follow-up due to Married 39 (55.7) 24 (36.9) 0.177 telephone registration errors, home relocations or death. These 23 Divorced or separated 2 (2.9) 3 (4.6) people were also excluded of the analysis. We analyzed potential Never married 3 (4.3) 5 (7.7) Widowed 26 (37.1) 33 (50.8) differences in sociodemographic characteristics between excluded Household type and included participants and there were no statistically significant Single 24 (34.3) 31 (47.7) 0.198 differences between them neither in IG nor in CG (Supplementary With family members 45 (64.3) 32 (49.2) table S2). Others 1 (1.4) 2 (3.1) A descriptive analysis of the baseline characteristics of the two IG, intervention group; CG, comparison group. groups was conducted. Percentages (qualitative variables) were com- a: P-values using the chi-square test. pared using the chi-square test and medians (quantitative variables) were compared using the Mann–Whitney U test. Further descriptive analyses were conducted to compare results at baseline (PRE) and at follow-up (POST). Differences between base- (9.4%) (P ¼ 0.023) at baseline. After the intervention, in the CG, the line and 6-month follow-up measurements were assessed for both percentage of participants with psychological distress doubled at the the IG and CG and were compared with the McNemar test, sign-test follow-up (from 9.4% to 21.9%; P ¼ 0.021) (table 2). or Wilcoxon test, as appropriate. The percentage difference or scor- Regarding self-perceived health, the percentages were similar in ing difference between baseline and 6-month follow-up were calcu- the two groups and did not differ significantly after the intervention lated and were compared between the IG and the CG using the two- (table 2). sample McNemar test or Mann–Whitney U test. Regarding social support (table 3), questions extracted from the MOS To assess the effectiveness of the intervention, multivariate questionnaire showed no differences between the IG and the CG at Poisson regression models with robust variance were built for quali- baseline. Comparison between baseline and follow-up showed an in- tative variables and a multivariate Box–Cox regression model was crease in social support in the IG in terms of having someone to get built for the quantitative variable (EuroQol utilities). Models con- together with for relaxation (from 34.8% to 59.4%) and having someone tained as independent variables the group to which participants to do things with to help them take their mind off things (from 40% to belonged (IG or CG) and the measurement taken at baseline. 61.4%). There were no significant changes in social support in the CG. All analyses were conducted using SPSS v25 and Stata v13. There were differences between groups in well-being through interaction with others at baseline. In the CG, 23.8% of the partic- ipants thought they could rely on friends often, while this percentage Results was 44.3% in IG. The percentage of participants who expressed a lack Participants’ demographic characteristics are summarized in table 1. of companionship often or some of the time was higher in the CG A total of 135 participants were included in the study: 70 were than in the IG. After 6 months, no pre–post differences were recruited in the IG and 65 in the CG. About 90% were older than obtained in either group (table 3). 64 years and 80% were women. Most of them had no education After adjusting for the baseline measurement, the decrease in the (57.0%), were married or widowed (90.4%) and 57.0% were living HRQoL utilities was lower in the IG than in the CG (b ¼ 0.090; with other family members. There were no differences between the P ¼ 0.001) (table 4). IG and CG. The percentage of participants suffering psychological distress on Attendance rates were 85.7% in the Besòs neighbourhood and the BHQ-12 decreased by 10.1% after the intervention in the IG, but 76.5% in Guineueta. As for overall satisfaction, 98.6% of the partic- increased by 12.5% in the CG. After adjustment by measurements ipants would recommend the activity to a friend. Satisfaction with taken at baseline, participants in the IG were more likely to have different items received scores of around nine: speakers (8.74), place improved their mental health [adjusted prevalence ratio (aPR)¼0.46; (9.20), frequency (9.09), schedule (9.06), duration (9.28) and overall 95% confidence interval (95% CI): 0.23–0.90]. score (9.01) (data not shown in tables). Results of the intervention on social support indicators are shown The five dimensions of the HRQoL showed no differences between in table 4. In questions drawn from the MOS questionnaire there was the IG and CG at baseline. When comparing PRE and POST meas- an improvement in the IG. However, there were no significant differ- urements, there were no differences in the IG, while the CG showed ences between the two groups. Regarding MOS, the percentage of an increase in the prevalence of problems in all dimensions except participants without someone to get together with for relaxation for self-care. The median scores of the EuroQoL utilities index were decreased by 24.6% after the intervention in the IG, but increased 0.799 in the IG and 0.790 in CG at baseline. After the intervention, by 14.1% in the CG. In contrast, when asked whether they felt they utilities scores did not significantly change in the IG and worsened in could not rely on friends, the percentage in the CG increased by 4.8% the CG to 0.739 (P < 0.001) (table 2). while that in the IG increased by 1.4%. For lack of companionship, Regarding mental health, the prevalence of people experiencing the CG improved by 3%, and the IG decreased by 2.9%. After adjust- psychological distress was higher in the IG (24.6%) than in the CG ing for the measurement at baseline, the difference in the percentage 680 European Journal of Public Health Table 2 Health-related quality of life (HRQoL), mental health (GHQ-12) and perceived health among participants at baseline and after the intervention. School of Health for Older People, Barcelona 2015 Characteristics IG (n 5 70) CG (n 5 65) Pa n (%) n (%) n (%) n (%) Baseline Follow-up Pb Baseline Follow-up Pb QUALITY OF LIFE (EQ-5D questionnaire) Mobility No problems 56 (81.2) 49 (71.0) 0.189 51 (78.5) 40 (61.5) 0.013 0.697 Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 Some problems/confined to bed 13 (18.8) 20 (29.0) 14 (21.5) 25 (38.5) Self-care No problems 66 (95.7) 65 (94.2) 1 59 (90.8) 57 (87.7) 0.727 0.315 Some problems/unable to wash or dress myself 3 (4.3) 4 (5.8) 6 (9.2) 8 (12.3) Usual activities No problems 60 (87.0) 59 (85.5) 1 58 (89.2) 50 (76.9) 0.039 0.685 Some problems/unable to perform my usual 9 (13.0) 10 (14.5) 7 (10.8) 15 (23.1) activities Pain/discomfort No pain 38 (55.1) 40 (58.0) 0.815 34 (52.3) 21 (32.3) 0.007 0.784 Moderate/extreme pain or discomfort 31 (44.9) 29 (42.0) 31 (47.7) 44 (67.7) Anxiety/depression Not anxious or depressed 53 (76.8) 49 (71.0) 0.481 51 (78.5) 36 (55.4) 0.001 0.819 Moderately/extremely anxious or depressed 16 (23.2) 20 (29.0) 14 (21.5) 29 (44.6) EuroQoL utilities (0–1), median (IQR) 0.799 (0.705–1.000) 0.790 (0.705–1.000) 0.372 0.790 (0.701–1.000) 0.739 (0.493–0.793) 0.000c 0.382d c MENTAL HEALTH (GOLDBERG GHQ-12 questionnaire)e With psychological distress 17 (24.6) 10 (14.5) 0.052 6 (9.4) 14 (21.9) 0.021 0.023 Without psychological distress 52 (75.4) 59 (85.5) 58 (90.6) 50 (78.1) PERCEIVED HEALTH Good/very good 38 (54.3) 40 (57.1) 0.754 31 (47.7) 28 (43.1) 0.629 0.444 Fair/bad/very bad 32 (45.7) 30 (42.9) 34 (52.3) 37 (56.9) IG, intervention group; CG, comparison group. a: P-values at baseline using the chi-square test or Fisher test to assess differences between the IG and CG. b: P-values based on McNemar test to assess differences between baseline and follow-up in the same group. c: P-values based on the Wilcoxon sign test to assess differences between baseline and follow-up in the same group. d: P-values at baseline based on the Mann–Whitney U test to assess differences between the IG and CG. e: Score on the GHQ-12 using binary scoring method (0–0–1–1) ranges from 0 to 12, the caseness threshold is 4. of those who could not rely on friends decreased significantly in the study concerns the organizational aspects present in our interven- IG compared with the CG (aPR ¼ 0.77; 95% CI: 0.61–0.96). tion, such as the quantity and type of going-out activities offered, the Finally, no significant changes were observed in the number of leadership of the group coordinators and the encouragement of con- health visits to primary care centres, either to GPs or nurses (data nections. In this intervention, most of the sessions were conducted by not shown in tables). leaders and stakeholders in their own neighbourhoods, allowing par- ticipants to get in touch with each other and learn of new resources. Discussion Social isolation is also associated with depressive symptoms. Mental health improved after the intervention in the IG, but signifi- Results show that the intervention helped to maintain or improve cantly worsened in the CG. A systematic review19 that assessed 36 participants’ health in terms of quality of life, mental health and studies focussed on the health impact of social capital interventions social support. In contrast, there was no change in participants’ in older people, and found that they were ineffective in changing self-perceived health and primary care use. mood. As occurred in quality of life, the way connections were A loss of capabilities and quality of life is common with advancing fostered in the School of Health by maintaining the shared interests age.32 This intervention succeeded in maintaining levels of HRQoL of the group, promoting reciprocity and allowing exchange of expe- and in improving mental health, while those of participants in the riences could have played a key role. CG declined, as expected at this age. Another aspect to consider is that this intervention was carried out Another intervention implemented by primary care professionals in most deprived neighbourhoods. Social determinants affect peo- and conducted in Spain also aimed to alleviate loneliness among ple’s health by worsening the health of those living in the most under older people at risk.33 The intervention consisted of alternate visits privileged neighbourhoods.2 Community interventions want to com- to community places and sessions to discuss the visits. However, that bat social inequalities, as a priority people with worse health would intervention produced no improvement either in the mental or the be more likely to improve it. In that way, evidence suggests that physical components of HRQoL. These differences with our study combining different recruitment methods could be the most effective might be due to the use of a different instrument to assess quality of way to reach the target population.36 Recruitment through health life (EuroQol vs. SF-12). EuroQoL was chosen because it is the most and social services in this study allowed participants to derive greater commonly used tool to calculate utilities for cost-effectiveness anal- benefit from the intervention. This was also confirmed by partici- yses,34 which is foreseen in the near future. Moreover, EuroQol has pants’ satisfaction and high adherence, in contrast with other inter- shown superior performance to that of the SF-12 and is considered ventions that reported low attendance rates.24 These data, obtained one of the best indicators to estimate HRQoL.35 Another reason why in the process evaluation, also help to explain the good results in these results may differ from those obtained by the prior Spanish mental health and quality of life. Participants probably did not miss Effectiveness of a community intervention to reduce social isolation among older people 681 Table 3 Social support (MOS and NSHAP questionnaires) among participants at baseline and after the intervention. School of Health for Older People, Barcelona 2015 IG (n 5 70) CG (n 5 65) Pa Social support Baseline Follow-up Pb Baseline Follow-up Pb Questions extracted from the MOS questionnaire n (%) n (%) n (%) n (%) How often is this kind of support available to you? Someone to get together with for relaxation Never/a little/some of the time 45 (65.2) 28 (40.6) 0.001 36 (56.3) 27 (42.2) 0.108 0.290 Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 Most/all of the time 24 (34.8) 41 (59.4) 28 (43.8) 37 (57.8) Someone to do things with you to help you take your mind off things Never/a little/some of the time 42 (60.0) 27 (38.6) 0.012 35 (54.7) 27 (42.2) 0.170 0.534 Most/all of the time 28 (40.0) 43 (61.4) 29 (45.3) 37 (57.8) Questions extracted from the NSHAP questionnaire How often do you feel you can rely on your friends? Often 31 (44.3) 30 (42.9) 1.000 15 (23.8) 12 (19.0) 0.684 0.013 Some of the time/never or hardly ever 39 (55.7) 40 (57.1) 48 (76.2) 51 (81.0) How often do you feel that you lack companionship? Often/some of the time 28 (40.0) 30 (42.9) 0.815 38 (58.4) 36 (55.4) 0.832 0.032 Never or hardly ever 42 (60.0) 40 (57.1) 27 (41.6) 29 (44.6) IG: intervention group; CG: comparison group. a: P-values at baseline using the chi-square test or Fisher test to assess differences between intervention and comparison groups. b: P-values based on the McNemar test to assess differences between baseline and follow-up in the same group. Table 4 Health-related quality of life (HRQoL), psychological distress (mental health GHQ-12 questionnaire), perceived health and social support (MOS and NSHAP questionnaires). Differences between participants at baseline and after the intervention. School of Health for Older People, Barcelona 2015 Unadjusted differences in median Pa b (P-value)b score between baseline and follow-up HRQoL (Euroquol utilities) IG 0.009 0.006 0.090 (0.001) CG 0.051 Ref Unadjusted differences Pa aPRc (95% CI) between PRE–POST in % Psychological distress (Goldberg questionnaire)d IG 10.1% 0.003 0.46 (0.23–0.90) CG 12.5% Ref Poor Perceived health IG 2.8% 0.345 0.81 (0.62–1.08) CG 4.6% Ref Social support (MOS questionnaire) How often is this kind of support available to you? I don’t have anyone to get together with for relaxation IG 24.6% 0.185 0.90 (0.61–1.33) CG 14.1% Ref I don’t have anyone to do things with to help me get my mind off things IG 21.4% 0.469 0.89 (0.59–1.34) CG 12.5% Ref Social support (NSHAP questionnaire) How often can you/do you feel. . . . . .Cannot rely on your friends IG 1.4% 0.726 0.77 (0.61–0.96) CG 4.8% Ref . . .that you lack companionship IG 2.9% 0.525 0.90 (0.65–1.25) CG 3% Ref IG, intervention group; CG, comparison group; aPR, adjusted prevalence ratio; 95% CI, 95% confidence interval; Ref, reference category. a: P-values based on the Mann–Whitney U test or the two-sample McNemar test to assess differences in the changes between IG and CG after the intervention. b: Multivariate Box–Cox regression model adjusted for the baseline measurement. c: Multivariate Poisson regression models with robust variance adjusted by the measurement taken at baseline. d: Psychological distress was defined as scoring four or more points on the GHQ-12. 682 European Journal of Public Health sessions because activities allowed them to discover resources and Interventions like ‘The School of Health for the older people’ are opportunities in their neighbourhood, and moreover they felt ses- not only effective, but are also low cost compared with other kind of sions were an opportunity to enjoy the company of peers. This is interventions or medical technologies. Community interventions consistent with findings observed in a qualitative evaluation carried may play a key role in improving the quality of life, mental health out in these participants through focus groups. The participants and social support of populations at high risk of vulnerability, such reported that during the rest of the week, they looked forward to as older people and those living in deprived neighbourhoods. attending the School of Health. In addition, according to this quali- tative evaluation, they specially appreciated peer relationships, the Supplementary data new links with people in their communities and being heard.37 This could also contribute to social support that was also increased in Supplementary data are available at EURPUB online. Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 terms of having someone to get together with for relaxation and someone to do things with to help them take their mind off things. Acknowledgements Given that lower social relationships increase morbidity and reduce life expectancy,1,10 the results of this evaluation reinforce the idea To the Evaluation Group of the ‘Schools of Health for Older that our intervention could be a protective health factor. People’(Alba Sánchez, Anna Fernández, Anna Pérez, Camila Some authors have demonstrated that social isolation impair well- Astorga, Carme Cortina, Carolina Lapena, Cristina Rey, Elia Diez, being, increasing the use of health services.15,22 No changes were Enriqueta Pujol, Ferran Daban, Gemma Castillo, Iolanda Robles, observed in the number of health visits after this intervention, con- Lucıa Artazcoz, Marıa José López, Mariona Pons, Marc Marı- sistent with the findings of a similar previous study.33 An explan- Dell’Olmo, Montse Petit, Natalia Sagarra, Nuria Calzada, Olga ation is that most appointments in older people are pre-arranged and Juárez, Xavier Bartoll and Xavier Continente) and all the participants related to chronic diseases, which need regular medical follow-up. in the study. Therefore, these appointments are generated by health professionals and are a characteristic of the local health system, which is a country- Funding specific. Moreover, perceived health did not vary in this study, con- sistent with the fact that ‘health’ is often understood as referring only This work was supported by the 8th Institute for the Investigation in to physical health, and that chronic diseases would not vary by par- Primary Healthcare (IDIAP) Jordi Gol Grant Concession ticipation in the School of Health. ‘Convocatòria d’una estada a una Unitat de Recerca de l’IMIM o l’ASPB o l’IDIBAPS [grant number 2013/01], funded by the Catalan Health Institute. Limitations and strengths This study has some limitations. First, the use of questionnaires can Conflicts of interest: None declared. lead to information bias. However, the same questionnaire was used before and after the intervention, and therefore a systematic infor- mation bias would not affect the change observed. Furthermore, the number of visits to primary care centres (GPs and nurses) was dir- Key points ectly obtained from the objective records provided by these centres. Second, the items to determine social isolation were not previously • There is a lack of evidence on the effectiveness of community validated. However, there is a wide variability in the scales used to interventions to reduce social isolation in older people. assess this term in previous studies.20,23 In this study, indirect items • The intervention evaluated in this study improved quality of related to social support have been used, which have been found well life, mental health and social support in older people. correlated with social isolation.9,14,15,20 • Community interventions may play a key role in improving Third, the sample size was small, which could limit its power to the health of populations at high risk of vulnerability, such as find significant changes in some items or the opportunity to stratify older people and people living in deprived neighbourhoods. by different types of population. However, the sample size was suf- ficiently large to assess differences between paired-samples for the main variables of the study and is in line with the sample sizes used in similar evaluation studies.19,20 Finally, this is a pre–post study with a 6-month follow-up. References Therefore, only short-term effects of the intervention were explored. 1 Luo Y, Hawkley LC, Waite LJ, et al. Loneliness, health, and mortality in old age: a Future evaluations should be conducted to determine whether the national longitudinal study. Soc Sci Med 2012;74:907–14. effects of the intervention persist over time. Moreover, they should be designed in order to analyze also the influence of the community 2 Enquesta de salut de Barcelona. Agència de Salut Pública de Barcelona. Available at: https://www.aspb.cat/wp-content/uploads/2018/07/Enquesta-salut-Barcelona-2016- factors in the intervention. 17.pdf (July 2020, date last accessed). This study has also important strengths. First, the effectiveness of an intervention like this is not usually evaluated. Second, the health 3 Idescat. Projeccions de poblacions. 2014. Available at: http://www.idescat.cat/cat/ outcomes were evaluated using validated questionnaires, which idescat/publicacions/cataleg/pdfdocs/pp2013-2051pr.pdf (July 2020, date last ensured the validity of the results and their comparability with those accessed). of other studies. Third, a quasi-experimental study including a CG 4 Goll JC, Charlesworth G, Scior K, et al. Barriers to social participation among lonely allowed to disregard the attribution of the effects to factors other older adults: the influence of social fears and identity. PLoS One 2015;10:e0116664. than the intervention, increasing the internal validity of the study. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4338142/. 5 Weiss RS. Loneliness: The Experience of Emotional and Social Isolation, Vol. XXII. Cambridge, MA, USA: The MIT Press, 1973: 236. Conclusions and implications for practice 6 Gardiner C, Geldenhuys G, Gott M. Interventions to reduce social isolation and This work provides a novel contribution to the literature and evi- loneliness among older people: an integrative review. Health Soc Care Community dence on how a 6-month community intervention can improve qual- 2018;26:147–57. ity of life, mental health and social support in older people living in 7 Cacioppo JT, Cacioppo S. Social relationships and health: the toxic effects of per- low-income neighbourhoods. ceived social isolation. Soc Personal Psychol Compass 2014;8:58–72. Effectiveness of a community intervention to reduce social isolation among older people 683 8 Steptoe A, Shankar A, Demakakos P, et al. Social isolation, loneliness, and all-cause 24 OHTAC Public Engagement Subcommittee. Public Engagement for Health mortality in older men and women. Proc Natl Acad Sci USA 2013;110:5797–801. Technology Assessment at Health Quality Ontario—Final Report from the Ontario 9 Gierveld J, Tilburg T, Dykstra P. New ways of theorizing and conducting research in Health Technology Advisory Committee Public Engagement Subcommittee. Toronto: the field of loneliness and social isolation. In: Vangelisti A, Perlman D, editors. The Queen’s Printer for Ontario, 2015: 57. Available at: http://www.hqontario.ca/evi Cambridge Handbook of Personal Relationships (Cambridge Handbooks in dence/publications-and-ohtac-recommendations/other-reports/specialreports. Psychology). Cambridge: Cambridge University Press, 2018: 391–404. doi:10.1017/ 25 Colell E, Sánchez-Ledesma E, Novoa AM, et al. Community health assessment of the 9781316417867.031 programme "Barcelona Health in the Neighbourhoods". Methodology for a par- 10 Holt-Lunstad J, Smith TB, Layton JB. Social relationships and mortality risk: a meta- ticipatory process. Gac Sanit 2018;32:396–9. analytic review. PLoS Med 2010;7:e1000316. 26 López MJ, Lapena C, Sánchez A, et al.; Evaluation Group of the “Schools of Health for older people”. Community intervention to reduce social isolation in older adults Downloaded from https://academic.oup.com/eurpub/article/32/5/677/6694067 by Fundacio Biblioteca Josep Laporte user on 09 October 2023 11 Cohen-Mansfield J, Hazan H, Lerman Y, et al. Correlates and predictors of loneli- in disadvantaged urban areas: study protocol for a mixed methods multi-approach ness in older-adults: a review of quantitative results informed by qualitative insights. evaluation. BMC Geriatr 2019;19:44. Int Psychogeriatr 2016;28:557–76. 27 Herdman M, Badia X, Berra S. El EuroQol-5D: una alternativa sencilla para la 12 Hawton A, Green C, Dickens AP, et al. The impact of social isolation on the health medición de la calidad de vida relacionada con la salud en atención primaria. Aten status and health-related quality of life of older people. Qual Life Res 2011;20:57–67. Primaria 2001;28:425–30. 13 Rico-Uribe LA, Caballero FF, Olaya B, et al. Loneliness, social networks, and health: 28 Goldberg DP, Oldehinkel T, Ormel J. Why GHQ threshold varies from one place to a cross-sectional study in three countries. PLoS One 2016;11:e0145264. another. Psychol Med 1998;28:915–21. 14 Dickens AP, Richards SH, Greaves CJ, et al. Interventions targeting social isolation 29 Rocha KB, Pérez K, Rodrıguez-Sanz M, et al. Propiedades psicométricas y valores in older people: a systematic review. BMC Public Health 2011;11:647. normativos del General Health Questionnaire (GHQ-12) en población general 15 Windle. SCIE Research Briefing 39: Preventing Loneliness and Social Isolation: espa~ nola. Int J Clin Health Psychol 2011;11:125–39. Interventions and Outcomes. 2011. Available at: http://www.scie.org.uk/publica 30 Revilla Ahumada L, Luna del Castillo J, Bailón Mu~ noz E, et al. Validación del tions/briefings/briefing39/ (July 2020, date last accessed). cuestionario MOS de apoyo social en Atención Primaria. Medicina de Familia (And) 16 Cattan M, White M, Bond J, et al. Preventing social isolation and loneliness among 2005;1:10–8. older people: a systematic review of health promotion interventions. Ageing Soc 31 Cornwell EY, Waite LJ. Measuring social isolation among older adults using mul- 2005;25:41–67. tiple indicators from the NSHAP study. J Gerontol B Psychol Sci Soc Sci 2009;64B: 17 Findlay. Interventions to Reduce Social Isolation Amongst Older People: Where Is i38–46. The Evidence? 2003. Available at: http://www.iscet.pt/sites/default/files/obsolidao/ 32 Liu N, Zeng L, Li Z, et al. Health-related quality of life and long-term care needs interventions_reduce_social_isolation_among_older_people_evidence.pdf (May among elderly individuals living alone: a cross-sectional study in rural areas of 2016, date last accessed). Shaanxi Province, China. BMC Public Health 2013;13:313. 18 Gandy R, Bell A, McClelland B, Roe B. Evaluating the delivery, impact, costs and 33 Coll-Planas L, Del Valle Gómez G, Bonilla P, et al. Promoting social capital to benefits of an active lives programme for older people living in the community. Prim alleviate loneliness and improve health among older people in Spain. Health Soc Health Care Res Dev 2017;18:122–34. Care Community 2017;25:145–57. 19 Coll-Planas L, Nyqvist F, Puig T, et al. Social capital interventions targeting older 34 De Smedt D, Clays E, Annemans L, De Bacquer D. EQ-5D versus SF-12 in coronary people and their impact on health: a systematic review. J Epidemiol Community patients: are they interchangeable? Value Health 2014;17:84–9. Health 2017;71:663–72. 35 Ye Z, Sun L, Wang Q. A head-to-head comparison of EQ-5D-5 L and SF-6D 20 Chatterjee HJ, Camic PM, Lockyer B, Thomson LJM. Non-clinical community in Chinese patients with low back pain. Health Qual Life Outcomes interventions: a systematised review of social prescribing schemes. Arts Health 2018; 2019;17:57. 10:97–123. 36 Ige J, Gibbons L, Bray I, Gray S. Methods of identifying and recruiting older people 21 Masi CM, Chen H-Y, Hawkley LC, Cacioppo JT. A meta-analysis of interventions to at risk of social isolation and loneliness: a mixed methods review. BMC Med Res reduce loneliness. Pers Soc Psychol Rev 2011;15:219–66. Methodol 2019;19:181. 22 Valtorta N, Hanratty B. Loneliness, isolation and the health of older adults: do we 37 Lapena C, Continente X, Sánchez Mascu~ nano A, et al. Qualitative evaluation of a need a new research agenda? J R Soc Med 2012;105:518–22. community-based intervention to reduce social isolation among older people in 23 Landeiro F, Barrows P, Nuttall Musson E, et al. Reducing social isolation and disadvantaged urban areas of Barcelona. Health Soc Care Community 2020;28: loneliness in older people: a systematic review protocol. BMJ Open 2017;7:e013778. 1488–503.