Only the Lonely: a randomized controlled trial of a volunteer visiting programme for older people experiencing loneliness

Abstract

Loneliness is a significant problem among older people living in Ireland. The negative effects of loneliness on physical and emotional health are well documented in the literature. This study was established in the context of a dearth of effective interventions to alleviate loneliness. A peer visiting intervention for community dwelling older adults experiencing loneliness was designed and subjected to the rigor of a Randomized Controlled Trial. It consisted of ten home visits to the intervention participants from
a volunteer, themselves an older person. The volunteer built up a rapport with
the participant and encouraged them to identify a social connection they wished to establish. Several participants made new social connections outside their home while most continued to receive visits from their volunteer following the end of the study period.
The main study finding was very positive. The primary outcome, loneliness, decreased in the intervention group at one month and three month follow up. Potential benefits for the volunteers were also identified, in particular a decrease
in loneliness. Both participants and volunteers reported that they enjoyed the intervention.
The intervention is low cost and could be incorporated into existing support services or non-government organizations caring for community dwelling older adults. It is a potentially scalable model to deal with the major societal challenge of loneliness.

Full text

Only the Lonely:
a randomized controlled trial of a volunteer visiting
programme for older people experiencing loneliness

1
Only the Lonely:
a randomized controlled trial of a volunteer visiting
programme for older people experiencing loneliness
Research Team
Prof. Brian Lawlor (Principal Investigator)
Dr. Jeannette Golden (Co- Principal Investigator)
Dr. Gillian Paul (Project Manager)
Prof. Cathal Walsh (collaborator and statistical advice)
Associate Prof. Ronan Conroy (collaborator and statistical analysis)
Ms. Emma Holfeld (Research Assistant)
Ms. Maureen Tobin (Research Assistant)

Section
2
At a Window
Carl Sandburg, 1878 - 1967
Give me hunger,
O you gods that sit and give
The world its orders...
Give me your shabbiest,
weariest hunger!
But leave me a little love,
A voice to speak to me in the day end,
A hand to touch me in the dark room
Breaking the long loneliness.
In the dusk of day-shapes
Blurring the sunset,
One little wandering, western star
Thrust out from the changing shores
of shadow.
Let me go to the window,
Watch there the day-shapes of dusk
And wait and know the coming
Of a little love.

3
As recent research has found, the majority of
Irish older people are very happy. However for
some loneliness is a big problem. Loneliness
happens when there is a mismatch between
a person’s actual and desired quality (and
quantity) of social contacts. We know that
it is not necessarily the quantity of contacts
but the quality that makes the difference - a
single strong bond may be more important
than several weak social relationships.
While loneliness is something that can occur
at any stage in life, the number of people
available for social contact can reduce in
later life for a variety of reasons. The loss
of a life partner or close friend can be a
cause of great loneliness and can result
in a person feeling unable or unwilling to
try to socialise alone. Family members or
younger neighbours may have moved away
or emigrated leaving older people with fewer
people to call on when they need help or
simply to talk to when feeling lonely. Ill health
can affect people in many ways, maybe
causing them to lose condence in their
ability to go out on their own or resulting in
them being conned to the house if there is
nobody nearby to help them get out.
Although they are the minority, we need
to be aware that there are lonely people
all over Ireland wishing they could reach
out to others or have someone drop
in unexpectedly for a chat. This report
identies one successful intervention for
tackling loneliness. It offered benets for
the participants and for the volunteers who
gave their time to help other people.
As Chair of Age Friendly Ireland I would
encourage all of the many agencies,
statutory and non-statutory alike, who are
actively supporting the roll out of the Age
Friendly Cities & Counties Programme
across the country to consider this research.
The successful intervention provides one
low cost, practical way of dealing with the
problem and is an intervention that could be
readily adopted by a range of community
groups and other organisations that operate
across the country.
FOREWORD

4
The research team would like to thank all
the people who contributed to the study.
We would particularly like to thank all the
participants and volunteers, without whom
the research would not have been possible.
We very much appreciate the time and
commitment they devoted to the study.
We would also like to acknowledge the
contribution of the many individuals
working in the community setting who
assisted us in the recruitment and
organization of the study.
Finally we would like to thank the
Ageing Well Network and the Atlantic
Philanthropies for funding the study. In
particular thanks are due to Ms. Anne
Connolly and Ms. Sylvia McCarthy from
the Ageing Well Network for their support
throughout the study period.
ACKNOWLEDGEMENTS

5
Loneliness is a signicant problem among
older people living in Ireland. The negative
effects of loneliness on physical and
emotional health are well documented in the
literature. This study was established in the
context of a dearth of effective interventions
to alleviate loneliness. A peer visiting
intervention for community dwelling older
adults experiencing loneliness was designed
and subjected to the rigor of a Randomized
Controlled Trial. It consisted of ten home
visits to the intervention participants from
a volunteer, themselves an older person.
The volunteer built up a rapport with
the participant and encouraged them to
identify a social connection they wished to
establish. Several participants made new
social connections outside their home
while most continued to receive visits from
their volunteer following the end of the
study period.
The main study nding was very positive.
The primary outcome, loneliness,
decreased in the intervention group at
one month and three month follow up.
Potential benets for the volunteers were
also identied, in particular a decrease
in loneliness. Both participants and
volunteers reported that they enjoyed
the intervention.
The intervention is low cost and could be
incorporated into existing support services
or non-government organizations caring
for community dwelling older adults. It is a
potentially scalable model to deal with the
major societal challenge of loneliness.
EXECUTIVE SUMMARY

Section
6

7
INTRODUCTION 9
1. STUDY 1: RANDOMIZED CONTROLLED TRIAL 13
1.1. Methods 13
1.2. Results 20
2. STUDY 2: DESCRIPTIVE STUDY OF THE VOLUNTEERS 27
2.1. Methods 27
2.2. Results 29
3. STUDY 3: QUALITATIVE STUDY OF PARTICIPANTS 31
3.1. Methods 31
3.2. Results 32
4. STUDY 4: QUALITATIVE STUDY OF VOLUNTEERS 39
4.1. Methods 39
4.2. Results 39
5. DISCUSSION 53
6. REFERENCES 56
7. APPENDIX 1 58
CONTENTS

Section
8
“where there is an unpleasant or
inadmissible lack of (quality of)
certain relationships...the number of
existing relationships is smaller than
is considered desirable”

9
Social isolation and loneliness are common
in older people and negatively impact on
their day-to-day lives. Social isolation is an
objective measure of lack of relationships
with other people, whereas loneliness
refers to the subjective and negative
appraisal of the quality of these supports
and relationships and has been dened as:
‘.... a situation experienced by the
individual as one where there is an
unpleasant or inadmissible lack of (quality
of ) certain relationships. This includes
situations, in which the number of existing
relationships is smaller than is considered
desirable or admissible, as well as
situations where the intimacy one wishes
for has not been realized.’
(De Jong Gierveld, 1987; 120)
Loneliness can be classied into two
types: social or emotional. (Weiss, 1973)
Social loneliness occurs due to a lack of
social connection or integration. Emotional
loneliness refers to a lack or loss of an
attachment gure such as an intimate
partner (O’Luanaigh and Lawlor 2008).
Although social isolation and loneliness
may coexist in individuals they are not
necessarily connected (De Jong Gierveld et
al 2006). For instance an individual may be
lonely and not socially isolated, or socially
isolated and not lonely.
Several studies have documented the
extent of loneliness among community
dwelling older people in Ireland. Golden
et al (2009) reported a prevalence of
INTRODUCTION
Introduction

10
Introduction
loneliness of 35% among 1299 people
over the age of 65 years living in their own
homes in Dublin. In a national telephone
survey of 683 people over the age of 65
years Drennan et al (2008) identied low
levels of social and family loneliness but
relatively high levels of romantic loneliness.
It is well documented that loneliness and
social isolation are detrimental to the
health of older people and are associated
with depression (Cacioppo et al 2006),
hypertension (Hawkley et al 2006) disturbed
sleep (Cacioppo et al 2002) and excess
mortality (Holwerda et al 2012, and Shiovitz-
Ezra et al 2010). In previous work conducted
in Ireland both loneliness and isolation were
independently associated with depression,
with loneliness having a relatively greater
impact and both together accounting for 70%
of the prevalence of depression in the sample.
(Golden et al 2009) Furthermore, engagement
with the community and friends, rather than
family, appears to be more important in terms
of quality of life and mood.
Two systematic reviews of interventions
targeting loneliness and social isolation in
“The value of the peer relationship has
previously been evaluated in a broad
variety of health issues”

11
Introduction
older people support the implementation
educational and social group activities.
(Cattan et al 2005 and Dickens et al 2011)
Befriending and home visiting schemes
have yet to be proven to be effective. (Cattan
et al 2005) In particular interventions to
reduce loneliness in older people based on
a home visits from a peer require rigorous
evaluation. In an intervention to reduce
loneliness the peer relationship could
facilitate the sharing of common interests,
backgrounds and may foster reciprocity
within the dyad. (Cattan et al 2003)
Peer support in the context of healthcare
has been dened as the provision of
support to a selected individual from a
person with similar characteristics and
life experiences. (Dennis 2003) The value
of the peer relationship has previously
been evaluated in a broad variety of
health issues such as diabetes (Smith et
al 2011), post natal depression (Dennis
et al 2009), and teenage sex education
(Stephenson et al 2004). There have been
varying results from such peer support
interventions. Peer support is often
provided on a voluntary basis. (Smith et
al 2011) There are documented positive
effects of volunteering (Barrett et al 2011)
and so potentially both the recipient and the
provider may benet from participating in
an intervention of voluntary peer support.
The study presented below was established
in the context of a lack of evidence
surrounding home visiting schemes for
older people experiencing loneliness
in which the visitors are peers of the
participants. The study was set in both
urban and rural areas of three counties in
the east of the Republic of Ireland.
It aimed to test the effectiveness of a brief
peer visiting programme for community
dwelling older adults who are lonely, and
to explore the participants and volunteers’
experience of the programme. To achieve
this overarching aim the following
individual studies were conducted by the
research team:
1. A Randomized Controlled Trial (RCT) of a
volunteer intervention for older people who
experience loneliness
2. A descriptive study of the effect of
participating in the study on volunteers
3. A qualitative study of the experience of the
participants during the study
4. A qualitative study of the experience of
the volunteers during the study
The methods and main results of the four
studies are presented separately below.
This is followed by a general discussion of
the results Ethical approval for the studies
was provided by the joint Adelaide, Meath
incorporating the National Children’s
Hospital (AMNCH) and St James’s Hospital
Ethics Committee.

Section
12

13
Study 1
This RCT aimed to implement a brief
peer visiting programme for community
dwelling older adults who experience
loneliness and to test the effectiveness of
the programme.
1.1. Methods
Recruitment of participants
One hundred people participated in the
study. The inclusion criteria for participation
were as follows:
• Be aged over 60 years
• Be community dwelling
• Have no signicant memory problems
• To score 3 or more on the De Jong
Gierveld Loneliness Scale OR answer ‘Yes’
to the question Item 5 on the CESD scale
‘Would you say that much of the time
during the past week you felt lonely?’
• Agree to have a volunteer visiting them
in their own home if allocated to the
intervention group
1. RANDOMIZED
CONTROLLED
TRIAL (RCT)

14
Study 1
Potential participants were identied by
people working with older people in the
community including general practitioners,
public health nurses, parish staff, day
centre staff, home helps and members of
local active retirement groups. Individuals
identied were asked if they were
interested in participating in the study and
if so information was sent to them. This
was followed up by a phone call from a
member of the research team.
If the individual was in agreement they
were visited by a researcher who explained
the study in more detail. On expressing a
desire to participate they gave informed
consent and were screened for loneliness.
If they scored 3 or more on the De Jong
Gierveld Loneliness Scale or answered
‘Yes’ to Item 5 on the CESD scale ‘Would
you say that much of the time during
the past week you felt lonely?’ they were
deemed to be experiencing loneliness and
were eligible for inclusion in the study.
Sample size and
randomization
The sample size calculation estimated
that 50 participants were required for each
group. Block randomization was conducted
and a computer generated random
sequence list was used to randomly
allocate participants. Group allocation
was concealed from both participants and
the researchers until after baseline data
collection was conducted.

15
Study 1
Data collection
Data were collected from participants in
their homes at baseline and at one and
three months post intervention using a
researcher-administered questionnaire.
Intervention group
The intervention contained four
elements: the recruitment, training and
retention of volunteers and home visits
to the intervention participants from the
volunteers. Each intervention participant
was matched with a volunteer. Volunteers
visited them for an hour once a week
for ten weeks over approximately a
three month period. Initially the aim of
these visits was to develop a rapport
with the participant. The volunteer then
encouraged the participant to identify a
social connection they would like to make
and that would be sustainable beyond the
timeframe of the study. If a participant
had difculty identifying a connection the
volunteer helped the participant in the
process as they had knowledge of local
services and social activities. Potential
barriers were identied and feasible ways
to overcome the barriers were discussed
with the participant.
The elements of the intervention are
detailed in Figure 2.1.

16
Study 1
Figure 1.1. Details of the intervention
The intervention consisted of the
following four components:
1. Recruitment of volunteers
Local volunteer services and active
retirement groups were asked to identify
individuals they deemed suitable for the
role of volunteer. The inclusion criteria
for volunteers was as follows:
Aged over 55 years•
Cognitively intact/ no signicant •
memory problems
Had the capacity and commitment to •
undergo the training required
Had a full understanding of •
condentiality
Agreed to undertake to liaise with the •
research team if problems arose during
the course of their visits to participants
Agree to the Garda (Police) clearance •
process prior to taking up the role
of volunteer
A member of the research team met
potential volunteers to discuss the study
in more detail. Individuals interested
in becoming a volunteer were asked
to provide names of two referees who
were then contacted by a member of the
research team.
2. Volunteer training
All the volunteers attended 2 training
sessions, which were conducted by the
research team. The content of these
sessions was as follows:
Introduction to the project•
Role of the volunteer (including •
boundaries of their role)
Background to loneliness and •
social isolation
Local services for older people•
Trouble shooting•
Communication skills •
Role play•
Condentiality •
3. Retention and support
of volunteers
Retention of volunteers was crucial
to the intervention. Volunteers were
supported in their role though the
following structures:
Contact details and explicit support •
from the research team
Feasible time commitment to •
the project
Outline of responsibilities/ •
volunteer policy
Adequate training (outlined above)•
Course handbook and information •
booklet on services and activities for
older people in their locality
Telephone call from a member of the •
research team following each visit
A referral system was established so •
if a volunteer encountered a problem
in the course of their visits they will

17
Study 1
referred the problem to a member of
the research team.
Problems referred were discussed by •
the team and a decision was made as
to how best to proceed with the referral.
Social event for all volunteers at the •
end of the study
4. Home visits
Each intervention participant was
matched with a volunteer. Volunteers
visited them for an hour once a week for
ten weeks over approx. a three month
period. Initially the aim of these visits was
to develop a rapport with the participant.
The volunteer then encouraged the
participant to identify a social connection
they would like to make and that would
be sustainable beyond the timeframe of
the study. If a participant had difculty
identifying a connection the volunteer
helped the participant in the process as
they had knowledge of local services and
social activities. Potential barriers were
identied and feasible ways to overcome
the barriers discussed with the participant.
All intervention participants were invited to
a social event at the end of the study.

18
Study 1
Control group
Participants in the control group received
their usual individualized care from
community services. In addition, they
received a home visit from a member of the
research team to conduct data collection
at the three data collection time points
outlined below. At the nal data collection
time point, 3 months, each control
participant was offered an information
booklet on services and activities for older
people in their locality and a discussion
with the member of the research team
regarding what activity might suit them. All
control participants were invited to a social
event following the completion of the study.
Main outcomes
The primary outcome was loneliness
as measured by the De Jong Gierveld
Loneliness Scale (11 item). The secondary
outcomes included a range of psychosocial
nd biophysical outcomes as listed below:
Psychosocial outcomes
The Center for Epidemiologic Studies •
Depression (CESD) Scale
The Lubben Social Network Scale•
The Montreal Cognitive Assessment •
Scale (MOCA)
Hospital Anxiety and Depression •
Scale (HADS)
CASP 19 (Control, Autonomy, Self-•
Realisation and Pleasure scale )
The Pittsburgh Sleep Quality Index (Item 6)•
OSLO social support scale •
Biophysical outcomes
Body Mass Index•
Grip strength•
Timed up and go •
Data management and analysis
Each participant was allocated a unique
identication number. The anonymous data
were entered into Excel and then transferred
into STATA for statistical analysis.
“The volunteer then encouraged
the participant to identify a social
connection they would like to make
and that would be sustainable beyond
the timeframe of the study.”

19
Study 1
290 individuals referred
174 not
interested
1 RIP prior to
baseline data
collection
100 screened
positive and
included in
the study
15 screened
negative
3 lost to follow
up at one
month
48 followed up
at one month
9 lost to follow
up at one
month
40 followed up
at one month
51 Control 49 Intervention
4 lost to follow
up three
months
47 followed
up at three
months
10 lost to
followed up at
three months
39 followed
up at three
months
Figure 1.2. Flow chart of participants

20
Study 1
1.2. Results
Participants
Of the 100 originally-randomized
participants, there were 88 participants
(40 in the intervention group and 48 in the
control group) available for follow-up at one
month. Three controls had dropped out, and
of the 9 intervention participants who had
been lost to the study, four had dropped out,
a further four had become too physically
unwell to participate (three of whom were
admitted to hospital) and one had died.
Between one- and three-month follow-ups
a further three participants were lost from
the intervention group: in the case of two of
these, the volunteer stopped visiting as the
person was either in bed or not at home on
several occasions on which visits had been
arranged. The third simply withdrew from
the study. One further participant from the
control group withdrew from the study
between one and three months.
Demographics
The intervention and control groups were
similar in age, sex, marital status and
education. Three quarters of participants
in both groups were female. The mean age
was similar in both groups (81.5 years in
the control group and 80 in the intervention
group). The majority of participants were
widowed. Forty seven percent of participants
in the control group had less than 16 years
education compared to 61% in the intervention
group, though this difference was not shown
to be statistically signicant. (Table 5.1)

21
Study 1
Table 1.1 Characteristics of the 88 participants followed to
one month
Control Intervention Sig
Number 48 40
Sex
Women 37 (77%) 30 (75%) 0.819*
Men 11 (23%) 10 (25%)
Age (median, IQR) 81.5 (13.5) 80 (9) 0.906**
Marital status
Single 21% 18% 0.611*
Married/cohabits 13% 8%
Separated/Divorced 4% 3%
Widowed 63% 73%
Education level
Less than 16 years 47% 61% 0.155*
16 year or more 53% 39%
*Chi-squared and **Mann-Whitney Wilcoxon tests

22
Study 1
Outcomes at one month
follow-up
Total scores on the primary outcome
measure, the De Jong Gierveld scale, were
signicantly lower in the intervention group
(p=0.027, adjusted for baseline values).
While there was no difference between the
groups on the social loneliness subscale,
the scores on the emotional loneliness
subscale were signicantly lower in the
intervention group (p=0.016). Although the
Lubben social network scale scores also
differed between the groups with higher
scores in the intervention group, this fell
short of statistical signicance when
adjusted for baseline scores (p=0.055).
While there was no signicant difference
between the groups on the total CESD
scale score, those in the intervention group
had signicantly lower scores on the scale
depression item (item 7).
They also had lower scores on the
loneliness item (item 5) but this fell short of
statistical signicance when adjusted for
baseline scores. (Table 5.2)

23
Study 1
Table 1.2 Primary and secondary outcomes in the trial groups at
one month
Mean scores
Control
N=48
Intervention
N=40
Difference (95%
CI)¶ Sig*
De Jong Gierveld scale
Total score 6.7 5.3 1·1 (0·10 to 2·1) 0.027
Social loneliness 2.4 1.8 0·4 (–0·1 to 1·0) 0.113
Emotional loneliness 4.4 3.6 0·8 (0.2 to 1.4) 0.016
Lubben Total score 21.5 23.3 2.2 (–0.05 to 4.5) 0.055
CESD Total score 3.6 2.8 0.51 (–0.45 to
1.47) 0.314†
CESD 5 - Felt Lonely 66.7% 42.5% OR: 0.44 (0.17 to
1.1) 0.085‡
CESD 7 - Felt sad 60.4% 25.0% OR: 0.22 (0.08 to
0.61) 0.004‡
* All comparisons are adjusted for baseline scores on the appropriate measure. Signicance levels
based on regression (†Poisson regression or ‡logistic regression) with robust standard errors.
¶ Differences adjusted for baseline levels, differences in proportions expressed as adjusted
odds ratios.
Outcomes at three month
follow-up
At three months, there were 47 control and
39 intervention participants. Total scores
on the primary outcome measure, the De
Jong Gierveld scale, were signicantly
lower in the intervention group (p=0.003,
adjusted for baseline values). This reflected
differences between the groups on both the
social loneliness subscale (p=0.022) and the
emotional loneliness subscale (p=0.015).
Once again, the Lubben social network scale
scores did not differ signicantly between
the groups (p=0.065) with higher scores in
the intervention group.
While there was no signicant difference
between the groups on the total CESD
scale score at three months, those in the
intervention group had signicantly lower
scores on the scale depression item (item
7) and scores that fell short of statistical
signicance on the loneliness item (item 5).
(Table 5.3)

24
Study 1
Of the intervention participants that were
followed up at three months 30 had
sustained a new social connection since
the commencement of the study. Twenty
ve of the participants continued to receive
visits from a volunteer, mostly the original
volunteer they were allocated to at the
beginning of the study. Seven participants
were referred to a local befriending
organisation in some cases were allocated
another visitor. Two participants joined
their local active retirement club, two joined
their local group for older people and one
joined a gardening club.
This descriptive study aimed to describe
the volunteers as a group and explore
the potential impact of their role as a
volunteer on their wellbeing. A number of
measures including loneliness, depression,
anxiety, social network and cognition were
assessed using standardized self-reported
ratings before and after the study period to
determine whether there were any changes
in these measures over the course of the
study period.
Table 1.3 Primary and secondary outcomes in the trial groups at
three months
Mean scores
Control
N=47
Intervention
N=39
Difference (95%
CI)¶ Sig*
De Jong Gierveld scale
Total score 7.0 5.3 1·4 (0.5 to 2.3) 0.003
Social loneliness 2.7 1.8 0·6 (0.1 to 1.2) 0.022
Emotional loneliness 4.3 3.4 0·8 (0.2 to 1.4) 0.015
Lubben Total score 22.2 23.8 2.1 (–0.1 to 4.2) 0.065
CESD Total score 3.8 2.7 0.6 (–0.2 to 1.4) 0.229†
CESD 5 - Felt Lonely 61.7% 33.3% OR 0.39(0.14 to
1.06) 0.066‡
CESD 7 - Felt sad 57.4% 28.2% OR 0.30(0.11 to
0.80) 0.016‡
* All comparisons are adjusted for baseline scores on the appropriate measure. Signicance levels
based on regression (†Poisson regression or ‡logistic regression) with robust standard errors.
¶ Differences adjusted for baseline levels, differences in proportions expressed as adjusted
odds ratios.

25
Study 1

Section
26

27
Study 2
2.1. Methods
Participants
All the volunteers who delivered the
intervention were invited to participate
in this study. In order to be selected as a
volunteer each individual had to meet the
following inclusion criteria:
Be aged over 55 years•
Have no signicant memory problems•
Have capacity and commitment to •
undergo the training required
Have full understanding of condentiality•
Agree to undertake to liaise with the •
research team if problems arose during
the course of their visits to participants
Agree to the Garda (Police) clearance •
process prior to taking up the role
of volunteer
Provide the names of two referees who •
were then contacted by a member of
the research team
2. DESCRIPTIVE
STUDY OF THE
VOLUNTEERS
Study 2

28
Study 2
Data collection
Data were collected from volunteers in their
homes or at a venue of their choice prior
to and following the intervention using a
researcher-administered questionnaire. The
questionnaire included demographic details
and the following psychosocial outcomes:
The De Jong Gierveld Loneliness Scale •
(11 item)
The Center for Epidemiologic Studies •
Depression (CESD) Scale
The Lubben Social Network Scale•
The Montreal Cognitive Assessment •
Scale (MoCA)
Hospital Anxiety and Depression •
Scale (HADS)
CASP 19 (Control, Autonomy, Self-•
Realisation and Pleasure scale)
The Pittsburgh Sleep Quality Index •
(Item 6)
OSLO social support scale•
Data management and analysis
Each volunteer was allocated a unique
identication number. The anonymous data
were entered into Excel and transferred to
STATA for statistical analysis.

29
Study 2
2.2. Results
Forty six volunteers were recruited for the
study. One volunteer was not matched
with a participant due to numbers of
participants randomised to intervention
group, one dropped out of the study and
one was not available for follow up.
Table 3.1 presents the scores of the
volunteers at baseline and follow-up. The
volunteers’ total score on the Dr Jong
Gierveld scale decreased signicantly from
baseline to follow-up (p=0.046, Wilcoxon
matched-pairs signed-ranks test), however,
neither subscale for emotional or social
loneliness showed a statistically signicant
change. There was no signicant change
in the volunteers’ Lubben network score, or
in their scores on the CESD, although the
latter were very low at baseline.
Table 3.1 Mean scores of the volunteers at baseline and follow-up.
Mean scores
Baseline Follow-up Sig*
De Jong Gierveld scale
Total score 2.1 1.6 0.046
Social loneliness 0.6 0.4 0.058
Emotional loneliness 1.7 1.2 0.072
Lubben Total score 33.3 31.8 0.510
CESD Total score 0.9 1.0 0.230
CESD 5 - Felt Lonely 15.2% 7.0% 0.250†
CESD 7 - Felt sad 8.7% 11.6% 1.000†

Section
30

31
Study 3
A qualitative study of participant in the
intervention group was conducted to
explore the participants’ experience of the
intervention. The analysis was conducted
by Ms. Emma Holfeld (2013) for the award
of Masters in Social Science (Social Work),
some of which is presented below.
3.1. Methods
All the intervention participants were invited
to attend a focus group prior to and during
or following the intervention. The topic
guides for the focus groups presented
in Appendix 1 were adhered to as far as
possible. At the end of each focus group the
participants were given a summary of the
conversation that they validated and agreed
was an accurate representation of the
thoughts and views they expressed.
The data from the focus groups were
transcribed verbatim for the purposes of
data analysis. The data were analysed
using framework analysis and the constant
comparison method. The data was examined
in depth for emerging trends. After several
iterations of data analysis the emerging
themes and issues were identied.
3. THE
QUALITATIVE
STUDY OF
PARTICIPANTS
Study 3

32
Study 3
3.2. Results
Thirty three participants attended one or two
of the focus groups. For the purpose of this
report the following themes that emerged
will be discussed: loneliness and barriers
to maintaining social connections and the
participants’ experience of the intervention:
Loneliness and barriers to
maintaining social connections
Participants expressed their thoughts
on loneliness and the barriers they face
in maintaining social connections and
activities as they age.
The most common issue raised was being
no longer physically able to do things
due to deterioration in physical health.
One participant who lives alone and is
wheelchair bound spoke of his sense of
loneliness and increased dependency:
‘When I am in bed this terrible
weakness comes over me, that’s
my heart and I am so weak and
tired and I’m afraid to get out of
bed because my balance has
just gone. If I cried out for help
or a cup of tea or something like
that but I have to do without the
cup of tea as there’s nobody
there’ (Participant 1, Male)
Another participant reported how a lack of
energy affected her ability to engage in
social activities:
‘I haven’t the energy for a lot of things I like
to do’ (Participant 11, Female)
“I haven’t the energy for a lot of
things I like to do”

Section
33

34
Study 3
Lack of transport was an issue raised by
many participants with some reporting
that they had to give up driving due to
deteriorating health:
‘You’re lost without the car’
(Participant 8, Female)
Lack of transport in rural areas was a
particular concern. Where public transport
schemes were in operation participants
complained that of the poor quality of this
service. One participant mentioned difculties
embarking and disembarking the bus and
how drivers can be dismissive of older people:
‘The driver will actually pull
off before you even have your
shopping bag on the bus’
(Participant 10, Female)
Participants highlighted a loss in sense of
community in contemporary society and
reported that neighbours have changed
over time:
‘Society has changed, life is far
more hectic and we are unable
to keep up, there’s a lot of
pressure now’
(Participant 6, Female)
“You don’t t into society as well as you
did when you were young”

35
Study 3
The neighbours are there
but they are no longer
neighbours anymore’
(Participant 5, Female)
Ultimately some participants felt as older
people they were marginalized by society:
‘You don’t t into society as well
as you did when you were young’
(Participant 7, Male)
More participants living in urban areas than
in rural areas complained of a lack of a
community spirit. Participants from urban
areas had positive views of rural living
compared to living in a town or city:
‘Growing up in the country you
are never short for company, it is
different living in the town. Now
you could be short of company
because everyone is minding
their own business...you could
be passed away for weeks/
months and nobody calls’
(Participant 3, Male)
‘There is still a sense of
neighbourly community in
the country but not in the city.
Loneliness is a factor of the city,
in the city you don’t even say
hello to anyone on the street’
(Participant 9, Male)

36
Study 3
Bereavement was also identied as barrier
to engaging in social activities:
‘My husband and myself used to
go into the pub or hotel together
all the time and now I couldn’t go
on my own’.
(Participant 14, Female)
‘Having a bereavement in your
family, people tend to shun
you and walk in the opposite
direction, they don’t know how
to approach you. You feel like
you’ve done something wrong.’
(Participant 13, Female)
The experience of the intervention
Overall participants had very positive
feedback regarding the intervention. Aspects
that they particularly enjoyed included the
anticipation of the volunteer’s weekly visit
and the companionship of the volunteer:
‘To hear the car stopping
outside and you know it’s for
you. Or somebody saying they
are going to come and you’d be
waiting out in the living room for
them to arrive.’
(Participant 15, Male)
‘It changed my life in every way.
Was something to look forward
to every week which I hadn’t had
before. Another day I’d be sitting in
my own looking at the four walls.
When the volunteer came I’d be
busy, I’d have to get ready for her.’
(Participant 16, Female)
‘If it weren’t for him I wouldn’t
see anyone.’
(Participant 18, Male)
‘We connected from day one, I felt
I had known her a long time and
was really able to open up to her.’
(Participant 21, Female)
Over three quarters of participants reported
that the intervention brought about positive
changes to their lives. In many cases
participants reported to have established a
friendship with their volunteer and planned
to keep in touch following the completion of
the study:
‘We’re friends for life, you
couldn’t get any better than that’
(Participant 3, Male)
‘We can ring each other and go
to one another as we please, if
it weren’t for this project I would
never have known her before.’
(Participant 13, Female)

37
Study 3
Volunteers shared information with
participants regarding social activities in local
community and encouraged them to increase
their level of social activity. Some participants
reported that the volunteer encouraged them
to get out of the house and meet them for a
walk, a cup of tea or lunch:
‘He comes every Wednesday
and we went out for lunch
yesterday. I hadn’t done that in
ten years, I enjoyed it.’
(Participant 18, Male)
Several participants joined a local active
retirement club as a result of motivation
and encouragement from their volunteer
and now attend on a weekly basis. On
participant who joined such a group
expressed how difcult she found
socializing prior to the intervention:
‘I’ve been trying to go to them
[active retirement groups] myself
but I just bottled it every time
I got there, I wouldn’t have the
condence to go in....I watched
them go in and everything. I
found it hard to mingle with new
people you know.’
(Participant 22, Female)

Section
38

39
A qualitative descriptive study of volunteers
was conducted to explore their experience
of the intervention.
4.1. Methods
All the volunteers were invited to attend a
focus group following the intervention. The
topic guides for the focus groups presented
in Appendix 1 were adhered to as far as
possible. At the end of each focus group
the volunteers were given a summary of
the conversation that they validated and
agreed was an accurate representation of
the thoughts and views they expressed.
The data from the focus groups were
transcribed verbatim for the purposes of
data analysis. The data were analysed
using content analysis. After several
iterations of data analysis the emerging
themes and issues were identied.
4.2. Results
Thirty four attended one of four focus
groups. The following themes emerged
from the data: the benets and challenges
of visiting participants; encouraging and
supporting participants to initiate a social
connection; continued visiting; barriers to
developing social connections and support
for volunteers. These are explored in more
detail below.
Study 3
Study 4
4. QUALITATIVE STUDY
OF VOLUNTEERS

40
Qualitative Study of Volunteers
At rst she wouldn’t say much but then
she’d start to tell you little things, only
between herself and myself. It was lovely.
When September came she decided
that she was joining the active
retirement in [local town] so she didn’t
really need me coming down anymore.
One time she mentioned wanting to
join an active retirement group and she
just sat in her car outside and she didn’t
have the courage to go in.
I’m still friends with her now...A truly
lovely person.

41
Qualitative Study of Volunteers
The benets and challenges of
visiting participants
Many of the volunteers expressed how
they benetted from delivering the
intervention. In particular a number
of them expressed a great sense of
enjoyment from visiting their participant.
I enjoyed every minute of it and
I became great friends with her
and the whole family
(Volunteer 24, Female)
We really hit it off from the
beginning. I really enjoyed it.
(Volunteer 18, Female)
I looked forward to the chats
like, because we became such
good friends.
(Volunteer 12, Female)

42

43
Qualitative Study of Volunteers
At rst she wouldn’t say much
but then she’d start to tell you
little things, only between herself
and myself. It was lovely.
(Volunteer 14, Female)
I did [enjoy the visits], yes, I did.
It was quite, he was good to
listen to and so well read and
so well-travelled. Far above my
head intellectually.
(Volunteer 3, Female)
Others reported some challenges with the
visits including communications difculties:
He is very conservative about
certain things...... I found all
along I had to be on my guard
a lot as to what I said to him...
He’s the type of man that isn’t
too familiar with meeting people
and he has this barrier, he’ll only
go so far with you but no further.
(Volunteer 19, Male)
Encouraging and supporting
participants to initiate a
social connection
The focus of the intervention was to
encourage and support participants to
initiate a new social connection or re kindle
a previous connection. This was achieved
in some cases:
I got within him altogether
because he was very outgoing
and he joined the leisure centre,
or not the leisure centre, he
played bingo and cards and
things....he joined a group.
(Volunteer 5, Male)
When September came she
decided that she was joining
the active retirement in [local
town] so she didn’t really need
me coming down anymore.
(Volunteer 21, Female)

44
Qualitative Study of Volunteers
In one case the volunteer helped her
participant to overcome a particular fear of
joining an active retirement:
One time she mentioned
wanting to join an active
retirement group and she just
sat in her car outside and she
didn’t have the courage to go
in. But since our visits I’ve got
her involved in the [local active
retirement group] and she did
come a number of times.... So it
wasn’t all negative she did join
and she felt really good about it.
(Volunteer 26, Female)
Some of the volunteers encouraged
their participant to re kindle an old social
connection and facilitated a meeting
between two old friends:
It involved meeting a neighbour.
The neighbour ended up being
an old friend of my participant
so I re-introduced them to one
another and ended up ferrying
them across to see one another.
They are still in touch now.
(Volunteer 16, Female)
Although some participants did make
a new social connection they were not
always sustained:
He’s the type of man in my
opinion that no one will ever be
able to change. I did get him out
to active retirement for 3 weeks
which was a big step. He came
to play whist with the ladies. The
reports from the ladies were he
didn’t speak, he just stuck to his
cards and that was that. Very
much a loner of an individual.
He stopped after three weeks.
(Volunteer 19, Male)
She was already at the door
waiting for me with the hair
done etc. and I introduced her to
everybody in the hall and it was a
great enjoyable day but nothing
came of it. I had thought if she
met the gang from the [active
retirement] that she may join
eventually and it would be a great
outlet for her but nothing came
of it. She wasn’t ready to take on
something on a weekly basis.
(Volunteer 18, Female)

45
Qualitative Study of Volunteers
Continued visiting
Although some participants did not
initiate a social connection outside of their
home many remained in contact with
their volunteer, which in itself could be
considered a new social connection:
She enjoyed the visits and I
really enjoyed going to her too
you know. So much so that
I continue now through [the
local volunteer visiting scheme]
(Volunteer 2, Female)
I’m still friends with her now...A
truly lovely person.
(Volunteer 24, Female)
Once we got the rst day out of
it we just gelled and got on great
and we still keep in touch. But a
very nice person I found it all a
great experience. I really learned
something from him.
(Volunteer 10, Male)
But my participant was a very
quiet person, very much into
herself. As time went on we
actually became good friends.
She’s away now at the moment
but we always keep in contact
by phone. I really enjoyed it.
(Volunteer 13, Female)

46
Qualitative Study of Volunteers
Barriers to developing
social connections
The volunteers spoke of the barriers to
developing social connections. Some
volunteers felt that their participants were
resistant to change and that this negatively
impacted on making new connections:
I tried to get her involved in
things like going back to the
library to do the knitting circle
and other things that she used
to do, but she said no I have
had all that, done all that. So
basically I couldn’t get her back
to anything.
(Volunteer 4, Female)
One volunteer reported how his
participant was restricted socially due to
his responsibilities of caring for his wife:
Well because of his wife being
sick, he couldn’t actually leave
the house. He was essentially
tied to the ground. My visits
were something that he would
look forward to. He lives on a
farm so sometimes he gets out
to do a bit of farm work with his
son, milking cows etc. I plan to
keep in touch with him.
(Volunteer 22, Male)

47
Qualitative Study of Volunteers
She’s a person that used to really enjoy
going out dancing etc. but due to a
stroke everything stopped, she lost
all her condence and stopped going
to anything.
They have a huge big at screen
television and their radio but they are
lonely. They don’t have people coming
to visit them, it’s not that they don’t
want visitors but they live in a rural
area, and you know the way society
has gotten now, people don’t call in for
visits anymore.

48
Qualitative Study of Volunteers
Other issues identied as barriers to social
engagement included lack of transport,
declining physical health and bereavement:
The difculty with my lady
was that she doesn’t drive and
lives in the middle of nowhere.
She was always depending on
neighbours for lifts into town.
(Volunteer 15, Female)
She’s a person that used to
really enjoy going out dancing
etc. but due to a stroke
everything stopped, she lost
all her condence and stopped
going to anything.
(Volunteer 25, Female)

49
Qualitative Study of Volunteers
He was lonely too however, he
misses his wife terribly who died
a few years ago. He told me that
that’s the one thing he misses
in life. There’s some things you
just can’t replace for people no
matter how hard you try. The
way he was talking you could
see he missed his wife. I’d say
they were a very happy couple.
(Volunteer 10, Male)
Two volunteers raised the issue of
societal changes and how they impacted
on the social lives of their participants:
They have a huge big flat screen
television and their radio but
they are lonely. They don’t have
people coming to visit them, it’s
not that they don’t want visitors
but they live in a rural area, and
you know the way society has
gotten now, people don’t call in
for visits anymore. They looked
forward to my visits though.
(Volunteer 17, Male)
And it didn’t dawn on me for
a while but what they [family
members] do is come in, potter
about, put the dinner in the oven,
do their little bits and bobs but
nobody actually sits down to talk
to them and to listen to them.
(Volunteer 16, Female)
Training and support
for volunteers
The volunteers were asked about their
experience of their training. They were
very positive about it and no suggestions
regarding changing the content were raised.
I enjoyed the training and the
support from [the researcher]. I
found it excellent.
(Volunteer 15, Female)
Two volunteers felt the role was intuitive
and one felt that he did not require training:
We didn’t really need any
training, it came naturally.
(Volunteer 22, Male)

50
Qualitative Study of Volunteers
I enjoyed the training and the
support from [the researcher]. I found
it excellent.
You never felt you were on your own,
there was always back up support
there if you needed it.
I found [the researcher] very supportive,
from going with me in the beginning
and then especially as things evolved
for me she was very supportive.

51
Qualitative Study of Volunteers
I found [the researcher] very
supportive, from going with
me in the beginning and then
especially as things evolved for
me she was very supportive.
(Volunteer 11, Female)
Participants in one focus group discussed
the benet of the support phone call from
a member of the research team after
each visit:
That fact that [the researcher]
called you after each visit was
very good....I needed that....
and she called really that day
so it [the visit] was fresh in your
mind. (Volunteer 32, Female )
I think it was a lot of common
sense...to listen to the person
and to be a good listener.
(Volunteer, Male 34)
The volunteers were very positive about
the support they received from the
research team during the intervention:
You never felt you were on your
own, there was always back up
support there if you needed it.
(Volunteer 20, Male)
You knew there was somebody
there who would take it on board
for you if you had a problem.
(Volunteer 18, Female)

Section
52

53
5. DISCUSSION
For community dwelling older people a
brief intervention of home visiting from a
peer was shown to be a feasible method
of reducing loneliness. To our knowledge
this is the rst time that the benet of
such an intervention has been reported in
a randomized controlled trial. Both total
loneliness and emotional loneliness mean
scores were lower in the intervention group
at one month and three months. The mean
score for social loneliness was lower in the
intervention group at three months.
Emotional loneliness has been found to
be difcult to alleviate so this nding is
a very important addition to the existing
literature. There was no change in the
remaining study outcomes.
It was apparent from the qualitative
studies that both the participants and
volunteers very much enjoyed the visits
and benetted from the interaction.
Similar results are presented by Butler
(2006) in a mixed methods descriptive
study of the Senior Companion Program.
The study identied benets for both
volunteers and participants, all of whom
were over 60 years of age. The ndings
of both studies are supported by Cattan
et al’s (2005) argument that older people
emphasize the need for reciprocity in
social support and this may be more likely
to occur in in a peer relationship where
people are from the same generation.
Study 3
Discussion

54
Discussion
A focus of the volunteer visits was to
encourage the participant to make a new
social connection. The ndings from the
qualitative study of the volunteers revealed
that this aspect of the intervention was
challenging. Several participants joined
a local club however the most common
social connection established was the
friendship with their volunteer.
Forty two per cent of older people in
Ireland engage in voluntary work: 15 %
once a week, 11% once a month and
16% at least once a year. (Barrett 2011)
The benets of volunteering are well
documented in the literature. Barrett et
al (2011) in The Irish Longitudinal Study
of Ageing (TILDA) reported that quality
of life people in over the age of 50 years
improved with frequency of engagement
in voluntary work. Potential benets of
engaging in volunteering were apparent
in our study of the volunteers. The
mean score for loneliness lower among
volunteers following the intervention.
Although this result is interesting, it is
important to note that the mean score for
loneliness in this group was already low
at baseline and so the reduction may not
be clinically signicant. Also the study
was observational in design and it is not
possible to ascertain if the reduction in
loneliness was as a result of volunteering
in the study.
There are some limitations to the study,
for example due to the nature of the
intervention it was not possible to blind
the participants from their allocation.
However the results are promising
and present a feasible and acceptable
intervention for reducing loneliness
in older people. It engages volunteers
as a valuable natural resource of the
community and is delivered by the
community for the community. The
intervention is low cost and so could be
easily adopted in current economically
challenging times by existing
support services or non-government
organizations caring for community
dwelling older adults.

55
Discussion

56
References
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58
Appendix

59
Appendix
1. Topic guide for focus
groups with participants in the
intervention group prior to or
during the intervention
Introductory questions
Often our social lives change as we go •
through life and in our old age. Do you
agree with this?
Why do you think so? •
Transition questions
Is there much going on for older people •
in you locality?
What social activities do you know of? •
Key questions
Would you like to get out and about more?•
What kind of social activities would •
appeal to you?
What stops you from getting involved •
in social activities?
What activities do you engage in at •
home/ how do you manage your time?
Final question
• Would anyone like to add to what has
been said?
2. Topic guide for focus
groups with participants in the
intervention group following
the intervention
FOCUS GROUP 2
Introductory questions
Have you enjoyed being a part of •
the project?
Can you identify what you enjoyed •
most about the taking part?
Key questions
How did the volunteer help you think •
about social connections?
What did you nd particularly useful?•
Did you make any changes as a result •
of being involved in the project?
Please explain more about •
these changes.
What could we do to improve the •
project if we were to continue it on?
Final question
• Would anyone like to add to what has
been said?
7. APPENDIX 1 - TOPIC GUIDES FOR
FOCUS GROUPS

60
3. Topic guide for focus groups
with volunteers
Introductory questions
Did you enjoy being a volunteer?•
What did you enjoy most about being •
a volunteer?
What did you nd difcult about being •
a volunteer?
Training and support
Did you feel adequately trained and •
supported for your role as a volunteer?
Can you explain what was •
particularly useful?
Can you identify anything that should •
be added to the volunteer training and
support structure?
Social connections
Did you nd it difcult to encourage •
the person you visited to make a new
social connection?
If yes, can you explain the difculties •
you encountered?
Do you have any ideas as to how these •
difculties could be overcome?
Did the person you visited make a new •
social connection during the time you
were visiting them?
If yes, what connection did they make?•
If they did not make a new social •
connection can you identify reasons why?
Ending
Would anyone like to add to what has •
been said?
Appendix