Social isolation and loneliness are often used to refer to the same concept, however, in public health research, some important differences exist. Social isolation is more of an objective measure based on the size of one’s social network and the frequency of social interactions. On the other hand, loneliness refers to the subjective discrepancy between one’s desired level of social connection and actual social connection. Dr. Mehrete Girmay joins the Public Health Insight Podcast to discuss the impact of social isolation on population health and their association with premature mortality and chronic diseases.
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Social isolation and loneliness are often used to refer to the same concept, however, in public health research, some important differences exist. Social isolation is more of an objective measure based on the size of one’s social network and the frequency of social interactions. On the other hand, loneliness refers to the subjective discrepancy between one’s desired level of social connection and actual social connection. Dr. Mehrete Girmay joins the Public Health Insight Podcast to discuss the impact of social isolation on population health and their association with premature mortality and chronic diseases.
Follow us on Instagram, Twitter, LinkedIn, and Facebook. We would love it if you shared your thoughts with us through direct message on your social media platform of choice or by emailing us at ThePublicHealthInsight@gmail.com
Icon made by Freepik from www.flaticon.com
[00:00:00] Sully: Public health as a population-based field of science focused on preventing disease and promoting health every week, we will be engaging in interactive discussions and analyses of the latest public health issues affecting you and your communities all around the world. This is the Public Health Insight podcast.
[00:00:24] Gordon: My name is Gordon, and I'm here with Ben, Leshawn, Linda, Sully, Wil, and the special guests will be introduced later.
[00:00:33] Ben: Before we move on, is important to note that the views expressed in this podcast are our own and do not represent any of the organizations we work for or affiliated with.
[00:00:41] Gordon: The outbreak of COVID-19 will have a long-term and profound impact on our physical health and mental wellbeing in a variety of ways.
[00:00:49] Commentary published by Bay Wu in the Global Health Research and Policy Journal titled "Social Isolation and Loneliness Among Older Adults in the Context of [00:01:00] COVID-19: a Global Challenge" outlined some of the negative outcomes associated with social isolation and loneliness, as well as some potential strategies that can be implemented to address these issues.
[00:01:14] In this episode we'll be exploring the broader issue of social isolation and loneliness as a determinant of health and to potential public health interventions to address an emerging crisis that has been dubbed the loneliness epidemic by Dr. Vivec Marty, the formal, the former surgeon general for the United States to discuss this important public health issue.
[00:01:37] We've invited a special guest. She's a public health analyst in the office of health equity at the Health Resources and Services Administration under the US Department of Health and Human Services. She holds both a doctorate in public health education and master of public health from Southern Illinois University [00:02:00] at Carbondale, and a bachelor's degree in sociology from the University of North Carolina at Chapel Hill. She completed her postdoctoral studies and received certification in global health through Harvard University, and is also trained in unconscious bias. Her major research interests include social determinants of health, global health inequalities and disparities, health literacy, tobacco cessation, women's health, immigrant health and social justice issues related to race, ethnicity, nationality, and education. Her research highlights, optimal health outcomes for marginalized populations remain primary public health concerns. Please welcome Dr. Mehrete Girmay..
[00:02:47] Dr. Mehrete Gimray : Good afternoon, everyone.
[00:02:48] Gordon: Good afternoon. One thing I'm curious about is Training unconscious bias. Can you tell us a little bit more about?
[00:02:55] Dr. Mehrete Gimray : Yeah, absolutely. I've always been interested in the topic and of course [00:03:00] throughout public health education has been exposed to what unconscious bias actually means and how it can be reflected in the work that we do.
[00:03:08] It wasn't until I began my research on international graduate students from my dissertation that I realized the impact of unconscious bias and again, how it can inform and impact our work. And so I just thought about, what can I do to further my education and training so that it can inform and steer my research efforts as well.
[00:03:29] So I just pursued an extra sort of certification around unconscious bias.
[00:03:35] Gordon: That's why we brought you on for your expertise on the topic of social isolation and loneliness. So as is customary on our podcasts, we start by defining the issues we're going to be discussing, which are social isolation and loneliness.
[00:03:49] And I want to get your take on, how these terms are used interchangeably a lot in public discourse and the literature, but how are they similar and how are they different?
[00:03:58] Dr. Mehrete Gimray : Simply social [00:04:00] isolation is the lack of social connections. It's an objective measure of the number of contacts that people have and it's typically categorized by whether an individual belongs to a social network. Loneliness, however, is a subjective feeling and it's about the gap between a person's desired level of social contact and then their actual level of social contact. Essentially the feeling of being alone, regardless of the amount of social context, it can refer to the perception that one's intimate and social needs are not being met. It's centered, essentially around the perceived quality of the person's relationships. There are some stark differences and like you mentioned, oftentimes we use the terms interchangeably and to a certain extent that's okay. It's acceptable, but there are some differences, right?
[00:04:47] Social isolation can lead to loneliness and some people at others can feel lonely without being socially isolated and it's important to note that, people can be isolated, like physically alone, actually alone [00:05:00] and not feel lonely. So it really just differs from person to person and so we have to treat it that way as well.
[00:05:05] Gordon: And I've seen a lot of examples actually, where people who are partners or have a lifelong partnership living in the same house. I've seen cases where, some of those in those sample populations experience, higher rates of loneliness than people that are living alone.
[00:05:21] So it goes to the point that you're mentioning that it's not, as you talked about loneliness being more subjective and then social isolation being a more objective measure of the, the quality and the numeracy of those you don't social contacts. We can see that it's not simply being with someone it's just, it's how meaningful that connection is to you in the present, right?
[00:05:44] Dr. Mehrete Gimray : Absolutely. That's essentially what we're trying to capture is that it's not about the quantity. It's the quality, it's the the fact of having people in place, a camaraderie that's built, and sustained and it's meaningful so that you can count on them, [00:06:00] not only during the bad times, but the good times.
[00:06:02] And so it's, yeah, that's it, that's the key with social isolation and loneliness. We try to address it oftentimes with, just saying increase the quantity of your social network, but it's not that it's the quality of it. Is it meaningful? Yeah.
[00:06:17] Wil: Yes, it's a, more of the specifics of social isolation and as you said, it is more of an objective measurement of the number of individuals that you have in your social network. But I'm just curious, like a number that's you typically use as like a cutoff and anything that, oh, maybe over that or under, that would be considered the individual being considered socially isolated or not isolated, or does this kind of differ from person to person or contexts?
[00:06:46] Dr. Mehrete Gimray : Yeah, that's a good question. And so there, there's not much research that at least that I've seen, that would lend itself to I guess practitioners being able to say, if you have this number of friends or social connections, then you won't be [00:07:00] considered socially isolated. Yeah, because I think again, just like you mentioned, it is, you take this on a case by case basis and some people are just fine with having, two quality friends or family members loved ones who're there during moments where they're suffering in silence or where they just need extra support.
[00:07:17] But then there's others that require, more of a social network and a larger social network- and so I think it just depends on the person. So that's why sometimes it's very difficult to just use the umbrella term of, okay, you're socially isolated if you only have one friend or two friends, two friends for some people that's just enough. Yeah. It's just enough.
[00:07:37] Gordon: So you can be socially isolated, but not lonely, but not lonely.
[00:07:41] Dr. Mehrete Gimray : Absolutely. Yeah. Yeah.
[00:07:42] Linda: I think the jumps or dives into, I guess the different types of loneliness, because Mehrete, like you were saying, someone could have a few close contacts and that's enough for them, but someone who has that is still feeling lonely. There's research showing that there are different types of loneliness, and so things like [00:08:00] intimate loneliness or relational or collective. So maybe for someone intimate loneliness or having intimate partner is not enough, they need that more collective sense of giving me an idea as well.
[00:08:12] Dr. Mehrete Gimray : Yeah, it's interesting to really dive in. That was just a very good point. When I looked at the international graduate students for my research, there was two types of loneliness that particularly stood out, which was personal loneliness, simply it just occurred, when you have a loss of contact with family and friends, and then there are other types of loneliness for them was social loneliness, just simply due to the loss of social networks.
[00:08:31] So like you said, there's just so many different types of loneliness that can manifest. So that was a good point.
[00:08:36] Ben: So my question was what in your research, did you find any nuances or risk factors for individuals who are different on the spectrum between introverted or extroverted?
[00:08:47] So for example, the research says, introverted people are more likely to value smaller social circles that have more meaningful connections to them versus extroverted. Would which focus on the quantity? So I was [00:09:00] wondering if your research had any take on that?
[00:09:02] Dr. Mehrete Gimray : Yeah. So my research in particular, I just went into, to be honest, to explore the experiences of cultural experiences of international graduate students, to the US to the, to the host university, to their respective academic programs.
[00:09:16] And then what came from that, from that research was the participants all has been sharing that they had experienced some form of social isolation and like you said, it is dependent. A lot of it was I found differences between the male participants and the female participants. Some of the males were okay not talking to their family that lives abroad, where the female participants they've valued just a bit more that, that connection and talking to their parents every day and their siblings every day. So I did find some there and then, but all of them, like I mentioned, all of the partitions explain that, especially during their period of initial arrival, they experienced these pronounced feelings around social isolation and loneliness. So within my research, to answer your question, I, for me, what I [00:10:00] experienced and learned through their experiences was that of course, different types of loneliness can manifest- like we talked about. It did differ just according to personality, like you mentioned, but also like I said, the male participants and female participants, there were some differences there as well.
[00:10:15] Gordon: Yeah. That's very interesting because in public health, you study health outcomes and stuff at the population level, but it doesn't mean then when you identify something like loneliness, it doesn't mean that.
[00:10:28] The solution will be a blanket solution has to be tailored to the individuals experiencing loneliness. Thanks for sharing that this is a great discussion. But I wanted to bring us to loneliness as a social determinant of health. So I just wanted to do a bit of a a thought experiment.
[00:10:44] So we know that resilience and social supports are important for health and wellbeing overall and we know that many different populations, including seniors- and I want to highlight seniors, especially since many of them [00:11:00] have died alone in hospitals or even long-term care homes or assisted living facilities.
[00:11:06] So with all this information that we have about social connectedness being a protective determinant of health, do you think that the mortality rate that we're seeing, for seniors living in this COVID-19 pandemic was at all influenced by the prevalence of loneliness that existed before the pandemic philosophical?
[00:11:25] Dr. Mehrete Gimray : Yeah, but this it's a very good question. Yeah, I think the senior population, they face just in general, greater risks, of living alone and chronic. So it's not shocking that their rates have been what they've been, and unfortunately, with the crisis that we're dealing with, and family members being unable to be with their loved ones at times, it just adds to that feeling of loneliness and social isolation.
[00:11:49] Older adults already have, typically smaller social networks and are prone to loneliness, and it, even if they're home it can affect their physical health, in other ways, too, with the [00:12:00] elderly feeling less motivated sometimes and especially relative to, eating healthy and working out.
[00:12:05] And for some, even with medication management and control, so I think it's just important that we, first of all, it's good that we're highlighting this to public health issue. But I hope that people, when they're hearing about physically distancing, when you have a loved one that may be a senior or adult population, it's important that we, yes, physically distanced to help mitigate transmission, but that we are socially distancing, that we, yeah, because we know that there's a strong link and connection to mental health outcomes. Again, it's not surprising that it's affecting the senior population the way that it is, but there's certainly things that we can do to help with that.
[00:12:41] Leshawn: I think with your question Gordon, it brings to mind for me, It's like thinking about what's been going on lately with COVID-19.
[00:12:49] Let's just say since, at least in north America, since maybe early or late January, March till now, how many months has it been? Five, six months maybe.[00:13:00] I'm curious and the literature talks a lot. Yeah. Chronic loneliness. So what exactly would that period entail? Would six months be at the point where you would see kind of these differences in kind of mortality rates that could be attributed to loneliness and going back to that, the difference between chronic loneliness and just loneliness as just the biological kind of drive, it should be.
[00:13:24] Loneliness has had a purpose in terms of our biology. And I think it's embedded into us as well for certain beneficial aspects. Yeah.
[00:13:31] Gordon: So like loneliness in the acute sense motivates you to seek out social connections to quell that loneliness because we're in state instinctively, we're not wired to be alone.
[00:13:42] We value the company of other people. Absolutely. Yeah. And to that point, it's also important as a point of caution that when we talk about loneliness, like for example, there was a meta analysis published where people who self reported experiencing loneliness were I think [00:14:00] 26% more likely to die from all causes.
[00:14:02] The important thing here, when we talk about, studies in public health is that it's an association that is not necessarily an independent variable. And what I mean by that is loneliness might be also associated with risk factors that increase premature mortality and the research has muddy on how much of a role loneliness in of itself plays in exacerbating these negative outcomes.
[00:14:25] Dr. Mehrete Gimray : Yeah, absolutely. We think of loneliness and isolation, both of those- we think about the mental health implications, and it's linked, but we don't think about the physical and again, it wasn't until I performed my own research that I realized just how what types of effects it can have physically.
[00:14:43] Yeah I'm excited that there's research that's coming out. It's unfortunate that this is the case, but it's good that it's being magnified in such a bright light.
[00:14:52] Gordon: And that that's a perfect segue into what I was going to say next, because some of those, the mental health side of it, you talk about even things [00:15:00] like risk of suicide, but then you can also talk about the direct physiological responses that involve the stress response and inflammatory response, right?
[00:15:10] Dr. Mehrete Gimray : Yeah.
[00:15:10] Gordon: And we know when the body's experiencing chronic stress, it affects things like sleep quality. It affects, your blood pressure and your risk of cardiovascular diseases. The research does show though even despite the caution, I just made that loneliness is associated with a variety of physical health outcomes.
[00:15:30] Dr. Mehrete Gimray : Absolutely. There's research, that's shown that social isolation and loneliness, are linked to higher risks for a variety of physical and mental conditions. It includes high blood pressure, heart disease a weakened immune system obesity, anxiety, depression, alzheimer's disease cognitive decline, and even death.
[00:15:51] So it's important that we look at it, you know how it can manifest itself, both physically and mentally, and, research shows that isolated individuals who [00:16:00] report, frequent these frequent feelings of loneliness, they suffer higher rates of morbidity and mortality, depression, infection and, like I mentioned, cognitive decline and simply, a reduction in lifespan. So it's yeah. So it's important again, that we're just there, we're paying attention to how it's, how the potential of its impact.
[00:16:18] Gordon: Yeah, and one thing, for me, that's an, you would know more because this is your area of expertise in research.
[00:16:24] It's hard to tease out, even things, like obesity, is it that social connections make it more likely for you to engage in, physical activity and then hence reduces your risk of obesity? Or is it work in a more direct mechanism where you're, it changes your physiology in a way that predisposes you to be obese or have things like other chronic conditions like heart disease?
[00:16:47] I think just for me doing the research, I find it frustrating that you end up with more questions than answers.
[00:16:53] Dr. Mehrete Gimray : Yeah. Yeah. That's a good point. I think so, talking and diving a little deeper into the obesity I, I [00:17:00] think why social connection is so important in that capacity is because similar to what we were mentioning about the elderly population, if you have someone that sort of motivates you, to work out and to be more physically.
[00:17:11] Yeah, and to eat well and to take your medication, if that's the case, then you have a greater chance of obviously being healthy. But without that devoid of that, you run the risk of facing these health challenges. And for someone that relies on their social network, maybe they walk together or they ran together daily.
[00:17:30] Because we've had these mandates. Again, to help with the mitigation of the transmission, help mitigate transmission it's it can be very be certainly challenging for them to continue on their workout plan, let's say, or their their diet, whatever it may be, so it can impact them in that way and then in turn, subsequently, their weight increases which puts them at risk for other health, health issues.
[00:17:52] Gordon: People like you out there trying to deepen the scientific community's understanding of these issues, because for one thing [00:18:00] that you mentioned earlier in the discussion, even the problem of loneliness and social isolation, maybe historically being used interchangeably, it makes it hard to track these indicators over time.
[00:18:12] If there was a different definition being in the nineties and early two thousands. And it's hard to say while loneliness has increased by 10% in the last 20 years, because you're not using the same measurements. So I think is important, from what you're saying too, to have these things, while in a colloquial kind of discussion, you might use these terms interchangeably, it's important that people also even understand the differences between the two. The end result is often quite related.
[00:18:40] Dr. Mehrete Gimray : Yeah, absolutely. It can help, the distinction is important, especially in regards to research efforts and focus and how it can perhaps subsequently inform policy changes even, and how practitioners may seek to address these issues.
[00:18:53] Since, we know that addressing social isolation and loneliness, can't only involve, like we mentioned earlier, simply promotingan [00:19:00] increase in an individual's like social circle, to help combat feelings of loneliness or isolation, but we should instead at least that's what research is showing, focused efforts on individuals establishing and maintaining those meaningful relationships that we talked about earlier.
[00:19:14] Linda: Yeah. Cause normally you hear things like loneliness and it's just passed off as it's subjective. It's not as impactful as the way you eat for example. But actually it has very significant physical impacts and to me it was surprising because we've come so far in medicine, there's a medication for almost everything, but at the same time, it's still an important factor that we often miss is how meaningful are your social interactions?
[00:19:39] Gordon: Yeah. Yeah. And that's a good point to learn that because I was even reading to that being socially isolated and lonely. If you experienced those things, it doesn't mean that your clinically experiencing anxiety or depression. So it's a separate thing, right? So it's like you couldn't use a medication to treat depression in order to treat loneliness [00:20:00] in a sense.
[00:20:00] Dr. Mehrete Gimray : And there's really also not an agreed upon point. We, were acute emotions of loneliness transitioning to a chronic. Issue, producing long-term consequences. So yeah, I it's still very, it's a challenging issues to define and classify.
[00:20:14] Leshawn: Yeah and I think that's a great point because we're talking about research, we're talking about subjectivity when it comes to loneliness specifically there have been scales developed to maybe standardize that effort to measure as loneliness.
[00:20:27] So for example, There is something called the three scale loneliness scale developed by the UCLA, and I'll just list off a couple of the questions. There's three of them. So the first question asks, how often do you feel that you lack companionship and then the options are hardly ever some of the time or often?
[00:20:46] The second question is how often do you feel left out? Hardly ever, some of the time, or often. And the last question. How often do you feel isolated from others? Is it hardly ever some of the time or often? [00:21:00] So when you, for example, use one of these scales, there are often some limitations that come along with it, right?
[00:21:06] If you're doing this assessment, for example, at a physician's office or for a research study, your first limitation would be that's a snapshot of your perceived level of. At that particular time of the day you're taking the test. And then we know that loneliness can change over time. So when you have these measures for research study, how do you, how can you compare people that score a certain number on that scale?
[00:21:29] Like a four on the scale versus an eight on the scale? It doesn't necessarily mean you're double as lonely as. Another person, right? Yeah.
[00:21:36] Linda: I agree. I agree with that. Yeah. There's so many things that we have to consider. You're absolutely right. Because, it's like a snapshot in time- like at that moment, I, one of us can be feeling lonely, but you can ask the same question a day later, two days later, and we're not feeling lonely, we're not feeling isolated. We do feel a part of a social circle and we feel connected. And yeah, it's really hard to capture and say, this person is feeling or is, and [00:22:00] classifying them as socially isolated or lonely.
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