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. 2024 Mar 1;11(3):e2125. doi: 10.1002/nop2.2125

Increased experiences of loneliness during the COVID‐19 pandemic, emotional distress and changes in perceived physical and mental health: A structural equation model

JoAnn Jabbari 1,2,✉, Stephen Roll 3, Amy McQueen 1, Nancy Ridenour 2
PMCID: PMC10907826  PMID: 38429914

Abstract

Aim

To explore how experiences of increased loneliness during the COVID‐19 pandemic affected emotional distress and changes in perceptions of physical and mental health.

Design

Cross‐sectional study.

Methods

Data from the Socio‐Economic Impacts of Covid‐19 Survey, a national survey administered to 5033 adults in August and September 2020 in the United States, was utilized in this study. Structural equation modelling was used to analyse the associations between increased experiences of loneliness during the pandemic, emotional distress and changes in perceptions of physical and mental health.

Results

Among the 47% of participants who reported increased experiences of loneliness during the pandemic, 31% reported a poorer perceived change in mental health and 12% reported a poorer perceived change in physical health. Increased experiences of loneliness during the pandemic were significantly associated with emotional distress and poorer perceived mental and physical health changes. Emotional distress significantly mediated the effect between increased experiences of loneliness during the pandemic and poorer perceived mental and physical health changes. These findings highlight the importance of producing preventative actions to combat increased loneliness and emotional distress during and after future pandemics in order to improve health perceptions, which can result in negative health outcomes over time.

Keywords: COVID‐19, emotional distress, pandemic loneliness, perceived mental health, perceived physical health

1. INTRODUCTION

Loneliness, or ‘the subjective feeling of being alone (perceived isolation) and the distress that results from discrepancies between ideal and perceived social relationships’ (Perissinotto et al., 2019, p. 658), has become a prevalent social problem with adverse health effects that continue to be discovered. It affects all ages and populations and does not discriminate; anyone can feel lonely at any given time (Cacioppo et al., 2015). Loneliness is experienced worldwide. A recent systematic review and meta‐analysis determined that problematic levels of loneliness were common across 113 countries or territories (Surkalim et al., 2022). Accordingly, the World Health Organization recently declared loneliness a global public health priority (World Health Organization, 2023). Within the United States, a third of adults aged 45 or older reported chronic loneliness before the COVID‐19 pandemic (Wilson & Moulton, 2010). Feelings of loneliness are also common among younger adults. According to results from the 2020 Cigna Loneliness Index survey, also conducted before the COVID‐19 pandemic, 81% of young adults aged 18–22 in the United States reported loneliness (Cigna, 2020).

The presence of loneliness was apparent before the COVID‐19 pandemic and has likely been exacerbated since the onset of the pandemic. COVID‐19 mitigation measures, such as social distancing and lockdowns, disrupted social interactions for many individuals. Decreased social interaction enhanced feelings of loneliness for some during the pandemic. One study relayed that 43% of respondents reported higher levels of loneliness during the pandemic (Killgore et al., 2020). Additional research on COVID‐19 pandemic loneliness showed that up to 70% of respondents reported feeling isolated, left out or lacking companionship some of the time or often in the past week (Groarke et al., 2020). Additionally, intense psychological distress has also been associated with quarantine measures during the COVID‐19 pandemic (Fernández et al., 2020).

2. BACKGROUND

Social interaction is a crucial element for individuals which contributes to the human experience and overall well‐being. Therefore, a lack of fulfilling interactions – resulting in loneliness – can negatively influence individual perspectives and thought processes. These negative outlooks put lonely individuals at greater risk for health conditions. Loneliness has been associated with negative self‐concepts (Goswick & Jones, 1981). Multiple studies have found that individuals who report feelings of loneliness also have worse perceptions of their health (Fisher et al., 2014; Kim, 1999; Özkan Tuncay et al., 2018; Richard et al., 2017; Stickley et al., 2013). Perceptions of health can be influential. Research has shown that self‐rated health measures have proven to be effective predictors of mortality and overall health (Schnittker & Bacak, 2014); therefore, lonely individuals with poor subjective health ratings may be at risk for worse long‐term health outcomes.

Loneliness is also linked to higher levels of psychological distress (Richard et al., 2017; Stickley et al., 2013). Lonely people often feel unsafe, which activates survival mechanisms that amplify sensitivity to all threats. In turn, loneliness can impact depressed feelings, mood, anxiety, fear and dysphoria (Cacioppo et al., 2006), resulting in emotional distress. Both psychological distress and emotional distress have been defined as, ‘emotional suffering characterized by symptoms of depression (lost interest, sadness, hopelessness) and anxiety (restlessness, feeling tense)’ (Drapeau et al., 2012, p. 105; Seixas et al., 2017). For the purpose of this study, we will utilize the term emotional distress.

Feelings of distress negatively impact perceptions of health (Farmer & Ferraro, 1997). Previous research has shown that emotional distress is a significant mediator between stressors and longitudinal general health (James et al., 2019). Feelings of distress associated with real or perceived lack of social interaction and the effects of prolonged loneliness can be detrimental to the entire individual (Quadt et al., 2020). The emotional state of an individual can produce short‐term physiological reactions to adapt to a situation that can have long‐term detrimental consequences if they are not addressed (DeSteno et al., 2013).

The social distancing efforts intended to mitigate the spread of COVID‐19 increased feelings of loneliness for some. For those who experienced more loneliness during the pandemic, these feelings may have negative consequences for individuals' physical and mental health and health perceptions over time. Feelings of loneliness during the pandemic have been associated with increased depressive symptoms, anxiety, psychological distress and poorer well‐being during the pandemic (Lee et al., 2020; McCallum et al., 2021; Palgi et al., 2020). After only 1 month of social distancing measures, 47.2% of individuals with chronic illnesses reported a decline in physical health and 50.2% reported a decline in mental health (Elran‐Barak & Mozeikov, 2020).

According to Shanahan et al. (2020), ‘pandemics constitute life events associated with uncertainty, ambiguity, and loss of control, each of which is known to trigger stress and emotional distress’ (p. 1). A study conducted by McGinty et al. (2020) reported that 13.6% of respondents reported serious emotional distress during the pandemic compared to 3.4% reporting serious emotional distress before the pandemic. Findings have also determined that emotional distress had significant mediating effects between psychosocial factors and depressive symptoms during the COVID‐19 pandemic (Xin et al., 2020; Yu et al., 2021). To our knowledge, no previous study has examined the potential mediating effect of emotional distress in the relationship between increased feelings of loneliness during the pandemic and perceived changes in health. The mediating role of emotional distress is important as it may explain that loneliness causes a disruption in emotional regulation strategies (Velotti et al., 2020), resulting in coping mechanisms that affect both health behaviours and self‐perceptions related to physical and mental health.

The direct health costs of the pandemic (at least thus far) have been fairly transparent – we have infection, hospitalization and death rates. However, the secondary health effects of the pandemic – on physical health, mental health, loneliness, anxiety and their related consequences (e.g. suicide and associated disorders) – are much less well understood. We explore this issue by focusing on the relationship between a major secondary consequence of the pandemic – loneliness – and its relationship to perceptions of physical and mental health. Using data from a national survey, we explore the impact that increased experiences of loneliness during the COVID‐19 pandemic had on changes in perceived physical and mental health. Using structural equation modelling, we also investigate the role of emotional distress as a mediator between increased experiences of loneliness during the COVID‐19 pandemic and changes in perceived physical and mental health.

This study's exploration of the relationship among loneliness, emotional distress and perceived physical and mental health is grounded in the Cannon–Bard theory of emotion. The Cannon–Bard theory states that the integration of emotional expressiveness is controlled and directed by the thalamus, which initiates the simultaneous arousal of the central and autonomic nervous systems (Roeckelein, 2006, p. 85). The arousal of these systems is enhanced when individuals experience emergency situations which the body views as potentially harmful. The body responds to such events with actions such as increasing the heart rate and respiratory rate to cope with the threat (Roeckelein, 2006).

The COVID‐19 pandemic was an emergent situation and physical threat that had the potential to increase the emotional distress response of many individuals. Additionally, loneliness and isolation experienced during the pandemic may have made individuals particularly vulnerable to heightened negative emotional responses. Per the Cannon–Bard theory, this response may have overstimulated the central and autonomic nervous systems of many individuals. Therefore, involuntary responses by the body to the loneliness and subsequent emotional distress experienced during the COVID‐19 pandemic had the potential to impair health and health perceptions.

3. THE STUDY PURPOSE, HYPOTHESES AND CONCEPTUAL MODEL

Although the association between loneliness and mental and physical health consequences has been well documented, the association among loneliness, emotional distress and health perceptions has not been investigated. More specifically, the mediating role of emotional distress in the relationship between increased loneliness and changes in perceptions of physical/mental health has not been examined. There is also very limited research on these dynamics in the context of the COVID‐19 pandemic, which likely caused the single largest exogenous shift in social behaviours in recent history. It is important to identify whether or not loneliness influences health perceptions during emergency situations and the role that emotional distress has on these relationships in order to plan for preventative actions when future global emergency situations occur. Therefore, the purpose of this study is to detail the relationships between COVID‐19‐related increased experiences of loneliness, perceived physical and mental health and the latent construct of emotional distress. We explore these relationships through a structural equation model, which enables analysis between latent constructs with multiple factor loadings and facilitates testing of mediation effects.

3.1. Hypotheses

Loneliness was negatively associated with perceived changes in physical and mental health during the COVID‐19 pandemic.

Loneliness was positively associated with emotional distress during the COVID‐19 pandemic.

Emotional distress mediated the relationship between loneliness and perceived changes in physical and mental health during the COVID‐19 pandemic.

3.2. Conceptual model

The main concept explored in this study is the relationship between experiences of loneliness during the COVID‐19 pandemic and perceived changes in physical and mental health. The relationship between experiences of loneliness during the COVID‐19 pandemic and perceived changes in physical and mental health was likely affected by emotional distress, therefore it is included in the model as a partial mediator between these constructs as seen in Figure 1.

FIGURE 1.

FIGURE 1

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Conceptual model.

4. METHODS

4.1. Study design

Cross‐sectional study design.

4.2. Data source

Data for this study come from the Socio‐Economic Impacts of COVID‐19 Survey. The survey was administered in August and September 2020 through a large, online survey panel provider in the United States.

4.3. Data collection and recruitment

The sample for this study was constructed using a quota sampling methodology to ensure national representativeness in terms of age, race/ethnicity, gender and income, and data checks reveal that the sample is representative on other key metrics (e.g. state of residence) as well.1 Participants were required to be at least 18 years old and live in the United States. A total of 5033 respondents completed the survey, with a survey response rate of 10.1%.2 Survey questions captured both households' experiences during and – through retrospective questions – prior to COVID‐19, which provided insight related to changes in health‐related perceptions over time. Less than 1% of the sample had missing responses on study variables. These cases were removed through listwise deletion.

4.4. Study variables

4.4.1. Increased experience of loneliness during COVID‐19

Our measure of COVID‐19‐related increased experiences of loneliness comes from a single yes/no question in the survey asking respondents ‘Is your life more lonely because of the COVID‐19 pandemic?’. Participants were coded as experiencing increased loneliness if they responded ‘yes’ to this question and the measure was operationalized as a dichotomous variable (1 = yes; 0 = no). Multiple studies have used single‐item measures of loneliness (Fokkema et al., 2012; Pels & Kleinert, 2016; Shiovitz‐Ezra & Ayalon, 2010). More specifically, similar single‐item measures of loneliness have been used in studies to indicate greater feelings of loneliness since the start of the COVID‐19 pandemic (Lippke et al., 2021; Santini & Koyanagi, 2021; Wickens et al., 2021). Evidence has shown that single‐item loneliness measures have adequate reliability and validity and that various versions of single‐item loneliness measures correlate highly with each other and with scores of multi‐item scales (Mund et al., 2023).

4.4.2. Poorer perceived mental health

We calculated our measure of poorer perceived mental health during the pandemic based on responses to two survey questions. The survey asked respondents ‘In general, how is your mental health currently?’, and ‘How was your mental health before the COVID‐19 pandemic (before March 13, 2020)?’. Responses for each item were given on a 5‐point ordinal scale (1 = excellent, 2 = very good, 3 = good, 4 = fair and 5 = poor). Responses for the current mental health rating were subtracted from the pre‐pandemic mental health rating and then recoded to produce a dichotomous variable to reflect perceived change in mental health (1 = Poorer Mental Health rating; and 0 = Better or Same Mental Health rating).

4.4.3. Poorer perceived physical health

We calculated our measure of poorer perceived physical health during the pandemic based on responses to two survey questions. The survey asked respondents ‘In general, how is your physical health currently?’, and ‘How was your physical health before the COVID‐19 pandemic (before March 13, 2020)?’. Responses for each item were given on a 5‐point ordinal scale (1 = excellent, 2 = very good, 3 = good, 4 = fair, and 5 = poor). Responses for the current physical health rating were subtracted from the pre‐pandemic physical health rating and then recoded to produce a dichotomous variable to reflect perceived change in physical health (1 = Poorer Physical Health rating; and 0 = Better or Same Physical Health rating).

4.4.4. Emotional distress

The latent construct for emotional distress was derived from the 4‐item Patient Health Questionnaire (PHQ‐4). The PHQ‐4 is a validated measure that consists of the PHQ‐2 and the 2‐item Generalized Anxiety Disorder scale (GAD‐2) and is used as an ultra‐brief screener for depression and anxiety, respectively, as well as general psychological (emotional) distress (Kroenke et al., 2009). Four indicator variables were used to produce the latent construct for emotional distress. The four questions from the PHQ‐4 captured how often in the prior 7 days participants (1) felt anxious, (2) felt worried and (3) found little pleasure in doing things (‘weary’) and felt down or hopeless (‘hopeless’) during the COVID‐19 pandemic. Response options included 1 = not at all, 2 = several days, 3 = more than half the days and 4 = nearly every day.

4.5. Data analysis

All analyses were conducted using Mplus Version 8.4. First, a confirmatory factor analysis was performed to test the factorial validity of the latent construct for emotional distress. Post hoc model modifications such as adding correlated error terms suggested by modification indices were considered for inclusion in the model if theoretically justified and necessary to improve model fit. Such correlations identify significant associations between measures that are not captured by their shared association explained by the latent construct. The fit of our first confirmatory factor analysis model (X 2 = 731.889; p < 0.001; root mean square error of approximation [RMSEA] = 0.270 (90% confidence interval = 0.253–0.286); comparative fit index [CFI] = 0.954) was improved after correlating the error terms between the two anxiety‐related variables (i.e. ‘anxious’ and ‘worried’) from the latent construct, as suggested by modification indices. All factor loadings were significant (p < 0.001). The R‐squared value was greater than 0.4 for each indicator, and the model produced acceptable fit indices for the RMSEA and CFI confirming an acceptable model (X 2 = 18.737; p < 0.001; RMSEA = 0.059 (90% confidence interval = 0.038–0.084); and CFI = 0.999).

Specifically, model fit was evaluated using the comparative fit index (CFI) and root mean square of approximation (RMSEA) with 90% confidence interval. RMSEA values <0.05 with an upper bound 90% confidence interval <0.08 indicate very good model fit. RMSEA values from 0.05–0.08 with an upper bound 90% confidence interval <0.1 indicate reasonable fit. CFI values >0.95 indicate good model fit (Bowen & Guo, 2011). A non‐significant chi‐square value is also an indicator of good model fit; however, large sample sizes (N ≥ 400) typically result in significant chi‐square values, reducing the reliability of this measure (Bowen & Guo, 2011). Due to the large sample size used in this study, chi‐square was not used as a measure to assess model fit.

Following the confirmatory factor analysis, we used a structural equation model to test the partial mediation model. Specifically, a structural equation model tests all model paths simultaneously to estimate the associations among all model variables. Our hypothesized model specified direct paths from loneliness (predictor) to perceived physical and mental health (correlated outcomes) and an indirect path through emotional distress (mediator). Mplus provides standardized and unstandardized path estimates. As recommended, the mean and variance‐adjusted weighted least squares estimation method was used because the model included categorical variables (Bowen & Guo, 2011). The Model Indirect command in Mplus, which is used to produce indirect and total effects and their standard errors, was used to provide statistical tests of mediation in the output (Muthén & Muthén, 1998‐2017). The standardized option for the output command was also used to obtain standardized direct and indirect effects and their standard errors (Muthén & Muthén, 1998‐2017).

4.6. Ethical considerations

The survey was approved by the university's institutional review board (Washington University in St. Louis, IRB ID #202004100). All participants in the study provided informed consent before study participation. The data obtained from the surveys were kept confidential and used only for academic research purposes.

5. RESULTS

5.1. Descriptive results

A total of 5033 respondents completed the survey. The age of participants ranged from 18 to 89 years (median age = 47, SD = 17.1); 48% of the sample were men. Of the participants, 60% were White, 13% were Black, 6% were Asian and 18% were Hispanic. Table 1 displays the demographic characteristics of the survey participants.

TABLE 1.

Demographic characteristics of participants.

Variable M ± SD or %
Age (years) 46.7±17.1
Gender
Male 48%
Female 51%
Race/Ethnicity
White 60%
Black 13%
Asian 6%
Hispanic 18%
Other 3%
Income 78,509 ± 69,560 a
Marital status
Single, never married 35%
Married 51%
Separated 1%
Divorced 10%
Widowed 3%
Highest education level
Less than high school degree 2%
High school degree or equivalent 14%
Some colleges, no degree 17%
Certificate or technical degree 4%
Associates degree 10%
Bachelor's degree 28%
Some graduate or professional school 4%
Graduate or professional degree 21%
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Abbreviations: M, mean; SD, standard deviation.

a

Income has been winsorized at the upper 99th percentile to account for extreme values.

Nearly half (47%) of the survey respondents reported that their life was lonelier due to the pandemic, while 21% of respondents reported worse mental health during the pandemic (compared to pre‐pandemic mental health) and 9% rated their physical health as worse during the pandemic (compared to pre‐pandemic physical health). Regarding participants who reported greater loneliness during the COVID‐19 pandemic, 31% reported a poorer perceived change in mental health and 12% reported a poorer perceived change in physical health.

Almost half of respondents reported some feelings of emotional distress (reporting experiencing an indicator of emotional distress in the previous 7 days between ‘several days’ and ‘nearly every day’). About half (51%) of respondents reported some anxiety, 45% reported some worry, 44% reported some weariness and 43% reported some hopelessness. The mean values for each of these indicators were between 1.7 and 1.8, indicating that the average respondent reported that they felt each indicator of emotional distress in the previous 7 days between ‘not at all’ and ‘several days’. Table 2 presents the Spearman correlations for the observed variables utilized for analysis.

TABLE 2.

Spearman correlations (N = 5010).

Observed variable Poorer perceived physical health Poorer perceived mental health Anxious Worried Weary Hopeless Increased experience of loneliness during COVID‐19
Poorer perceived physical health 1.000
Poorer perceived mental health 0.263 1.000
Anxious 0.204 0.318 1.000
Worried 0.201 0.284 0.815 1.000
Weary 0.198 0.282 0.683 0.689 1.000
Hopeless 0.212 0.310 0.746 0.763 0.779 1.000
Increased experience of loneliness during COVID‐19 0.092

0.243

0.280

0.258

0.275

0.300

1.000
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5.2. Structural equation modelling

The structural equation model shown in Figure 2 confirmed our hypothesized mediation model and fit the data well, X 2 = 49.099 p < 0.001; CFI = 0.992; and RMSEA = 0.028 (90% confidence interval = 0.02–0.036). Table 3 reports the standardized and unstandardized coefficients of all direct and indirect effects in our model and shows that all structural path coefficients between the model variables were statistically significant. Although the size of the associations was similar between emotional distress and poorer perceived changes in mental and physical health, the residual direct effect of loneliness was greater on perceptions of worsened mental health compared with physical health. As expected, perceptions of poorer mental health and physical health were moderately positively correlated. Increased loneliness during the pandemic was associated with poorer perceived physical health (β = 0.065, p = 0.01) and poorer perceived mental health (β = 0.234, p < 0.001). Increased loneliness during the pandemic was also directly associated with increased emotional distress (β = 0.294, p < 0.001).

FIGURE 2.

FIGURE 2

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Graphic presentation of the mediation model with standardized coefficients. **p = 0.01, ***p < 0.001.

TABLE 3.

Direct and indirect effects in structural equation model.

Effect Standardized path coefficients Unstandardized path coefficients Standard error p
Direct
Increased experiences of loneliness during COVID‐19➔ Emotional distress 0.294*** 0.484 0.013 <0.001
Increased experiences of loneliness during COVID‐19➔ Poorer perceived physical health 0.065** 0.131 0.025 0.01
Increased experiences of loneliness during COVID‐19➔ Poorer perceived mental health 0.234*** 0.498 0.019 <0.001
Emotional distress➔ Poorer perceived mental health 0.34*** 0.439 0.018 <0.001
Emotional distress ➔ Poorer perceived physical health 0.337*** 0.415 0.022 <0.001
Indirect
Increased experiences of loneliness during COVID‐19➔ Emotional distress➔ Poorer perceived mental health 0.1*** 0.212 0.007 <0.001
Increased experiences of loneliness during COVID‐19➔ Emotional distress➔ Poorer perceived physical health 0.1*** 0.201 0.008 <0.001
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**

p = 0.01.

***

p < 0.001.

The strength of the relationship between the variables is further explained by assessing the squared multiple correlations of the constructs which were all statistically significant (p < 0.001). The squared multiple correlations revealed that increased experiences of loneliness during the COVID‐19 pandemic and emotional distress explained 22% of the variance of poorer perceived changes in mental health and 13% of the variance of poorer perceived changes in physical health.

6. DISCUSSION

Loneliness was identified as a growing public health issue before the pandemic and has been deemed an epidemic of its own (Murthy, 2017). While many were enduring feelings of loneliness before the pandemic, some studies have shown that these feelings increased due to the social distancing and mitigation efforts related to COVID‐19. The aim of this study was to investigate the impact that increased experiences of loneliness during the COVID‐19 pandemic had on changes in perceptions of physical and mental health. Additionally, the mediating role of emotional distress between increased experiences of loneliness during COVID‐19 and perceived changes in physical and mental health was investigated. The results revealed that increased experiences of loneliness during the pandemic had a significant direct and indirect impact on poorer perceived physical and mental health. The results also showed that emotional distress had a significant mediating role between increased feelings of loneliness and poorer perceived physical and mental health.

We used structural equation modelling to determine the impact of increased experiences of loneliness during COVID‐19 on changes in health perceptions and to determine the mediating role of emotional distress between these relationships. The results confirmed findings from previous studies that loneliness has a negative impact on perceptions of health (Fisher et al., 2014; Richard et al., 2017; Stickley et al., 2013). Research has shown that self‐rated health measures have proven to be effective predictors of mortality and overall health (Schnittker & Bacak, 2014), which further emphasizes the importance of our results.

All of the hypotheses tested by the study were supported by the structural equation model and exhibited the negative impact that increased loneliness during the COVID‐19 pandemic had on changes in perceptions of physical and mental health. The first hypothesis was verified by the model, as shown by the significant relationship between increased experiences of loneliness during COVID‐19 and poorer perceived changes in physical and mental health. Increased experiences of loneliness were associated with both poorer physical health perceptions (β = 0.065, p = 0.01) and poorer mental health perceptions (β = 0.234, p < 0.001). These findings support evidence from a study conducted by Bierman et al. (2021), which determined that greater loneliness experienced during the COVID‐19 pandemic was associated with declines in self‐rated health. Although both findings in our study were significant, increased experiences of loneliness had a greater negative impact on changes in the perceptions of mental health than physical health.

It is important to note that mental health and emotional distress are related but distinct concepts (Payton, 2009). Our findings are in line with previous research that found moderate correlations between feelings of distress and mental health (Payton, 2009). The correlations between poorer perceived changes in mental health and all of the individual indicator variables for emotional distress were below 0.32, exhibiting weak‐to‐moderate correlation. Mental health is more than just the absence of negative symptoms, such as emotional distress. According to the World Health Organization (2018), mental health is ‘a state of balance, both within and with the environment. Physical, psychological, social, cultural, spiritual and other interrelated factors participate in producing this balance (para. 1)’. Therefore, the emotional experiences of distress (such as anxiety, worry, hopelessness and discontent) are some of many factors that can contribute to mental health.

The second hypothesis was also confirmed by the model. There was a significant relationship between increased loneliness during the COVID‐19 pandemic and emotional distress (β = 0.294, p < 0.001). According to the model, greater loneliness increased feelings of emotional distress during the COVID‐19 pandemic. Recent research has also determined that feelings of pandemic loneliness are positively associated with stress, anxiety, worry about the virus and finances and fear of infections (Horesh et al., 2020). Navigating the pandemic's personal, social and economic consequences has been challenging for many. Our findings suggest that increased loneliness during the pandemic enhanced negative internal emotions and may have reduced effective emotional regulation.

Finally, regarding the third hypothesis, emotional distress did partially mediate the relationship between increased experiences of loneliness and poorer perceived physical and mental health. Emotional distress was a significant mediator between increased loneliness during the pandemic and had both direct and indirect effects on poorer perceived physical and mental health. Emotional distress can impact attitude changes, cognition, decision making and health behaviours that result in poorer perceptions of health (DeSteno et al., 2013). The significant mediating effects of emotional distress between loneliness during COVID‐19 and poorer perceived mental health support evidence that emotional distress was a significant mediator between psychosocial factors and depressive symptoms during the pandemic (Xin et al., 2020; Yu et al., 2021).

The indirect effect of increased experiences of loneliness during the COVID‐19 pandemic on changes in physical health perceptions through emotional distress was greater than the direct effect of greater loneliness on changes in physical health perceptions. It is possible that the coping mechanisms during COVID‐19 used to adapt to emotional distress resulted in negative health behaviours, such as a poor diet (Salazar‐Fernández et al., 2021) or decreased motivation to exercise, which influenced poorer health perceptions. Additionally, these results reinforce that people judge their health status based on their experiences and that emotional symptoms also affect perceptions of physical health. The negative changes in perceptions of health also occurred fairly quickly during the pandemic in our national sample, indicating that increased loneliness and emotional distress can rapidly impact health perceptions.

The descriptive statistics from the study reveal that the pandemic has greatly increased feelings of loneliness, with 47% of respondents stating that they experienced more loneliness during the pandemic. These findings are in line with recent research during the COVID‐19 pandemic that also confirmed higher levels of loneliness (Groarke et al., 2020; Lee et al., 2020; Lewis, 2020). Additionally, the amount of variance of poorer perceived mental and physical health explained by increased loneliness and emotional distress in the model was an unexpected finding. Increased experiences of loneliness and emotional distress accounted for 22% of the total effects on poorer perceived mental health and 13% of the total effects on poorer perceived physical health.

6.1. Study strengths and limitations

The data used for this study are cross‐sectional, which may impact the reliability of the results as respondents were asked to relay feelings about the past during the present. In addition, mediation was tested using cross‐sectional observational data, and therefore causal interpretations cannot be applied to these results. Also, it is possible that physical and mental health perceptions may impact each other. While we have correlated these variables, the link may be directional. As exploring directionality between perceived changes in physical and mental health goes beyond the scope of our study, future studies should consider this relationship more closely. Another limitation of the study is that similar to other surveys conducted during the pandemic, we drew our study sample from an online panel of respondents. While this sample is similar to the U.S. population on a wide variety of metrics, including age, gender, race/ethnicity, income and geography, it also has higher educational attainment than the U.S. population and may differ on other observed and unobserved characteristics. While this should not affect the internal validity of our estimates, it may affect the generalizability of our analysis.

The strengths of the study include the addition of emotional distress as a way to better understand the mechanisms by which increased experiences of loneliness during the COVID‐19 pandemic are related to poorer perceptions of health. An additional strength is our ability to understand both mental and physical health perceptions in relation to increased loneliness during COVID‐19, as much of the research on COVID‐19 and loneliness tends to focus on mental health alone. Another strength is that a large sample constructed to be nationally representative across key socio‐demographic indicators was used in the study. Most importantly, the study provides relevant findings that fill the gap on the effects of increased experiences of loneliness on perceived physical and mental health changes during the COVID‐19 pandemic.

6.2. Recommendations for further research

Future research should focus on longitudinal data and the effects of pandemic loneliness and health perceptions at different points in time during and after the COVID‐19 pandemic. Our analysis focused on the test of a conceptual model. Future studies could build on this model with the addition of covariates such as the use of online technology during COVID‐19, age, gender, race and socioeconomic status.

6.3. Implications for practice and policy

The findings of this study provide direction for clinical practice and policy. The results can be used to inform upstream approaches to mitigate loneliness, a national public health concern. Social determinants of health account for 80%–90% of modifiable contributors to health outcomes (Magnan, 2017). The National Academies of Sciences, Engineering, and Medicine (2019) recommends five categories as a framework for strengthening social care integration into the delivery of healthcare: awareness, adjustment, assistance, alignment and advocacy. As a result of this study, the five categories can be utilized as a template to improve future responses to increased feelings of loneliness during global emergencies. Additionally, loneliness may impact emotional distress and/or perceptions of health for healthcare workers themselves. Sheikhbardsiri et al. (2021) determined that single nurses had more anxiety and depression when compared to married nurses during the COVID‐19 pandemic, further indicating a need for ongoing efforts to increase psychological and social support for patients and clinicians.

Additionally, policies are not in place that support loneliness screening and treatment by nurses and clinicians. It is important for public health nurses to understand the impact of loneliness on health. Social determinants of health, such as loneliness, need to be integrated into assessments and care planning in order to improve patient outcomes. Furthermore, the predominant model of healthcare provider payment, fee‐for‐service, does not provide incentives for the prioritization of social care (National Academies of Sciences, Engineering, and Medicine, 2019). Addressing psychosocial needs does not currently equate to adequate reimbursement for clinicians. Therefore, policy reform efforts should focus on allowing clinicians to receive funding and reimbursement to assess and treat social needs. There are many challenges related to implementing a healthcare delivery framework related to social care, such as loneliness. However, the results of this study indicate that preventative actions taken to address loneliness may reduce costly physical and mental health outcomes in the future.

7. CONCLUSION

The results of this study provide evidence for the impact that increased experiences of loneliness during the COVID‐19 pandemic had on changes in perceived health. The complexity of the body's response to increased experiences of loneliness is further explained by the mediating effects of emotional distress on poorer perceived changes in physical and mental health. During the aftermath of the emergency status of the global pandemic, it is essential for there to be increased awareness about the continued risks of experiencing increased feelings of loneliness. The repercussions of the global health crisis may result in additional poor health outcomes for a variety of reasons. The results of this study bring to light a concerning issue related to the COVID‐19 crisis: increased experiences of loneliness during COVID‐19 were associated with poorer perceived physical and mental health. Additionally, emotional distress significantly mediated the relationship between increased experiences of loneliness during the pandemic and poorer perceived mental and physical health.

AUTHOR CONTRIBUTIONS

Conceptualization: J.J. and N.R.; Methodology: J.J. and A.M.; Software: J.J.; Validation: J.J. and A.M.; Formal analysis: J.J.; Data curation: S.R.; Writing–original draft preparation: J.J.; Writing–review and editing: S.R., A.M. and N.R.; and Visualization: J.J. All authors have read and agreed to the published version of the manuscript.

FUNDING INFORMATION

This work was supported by the Annie E. Casey Foundation, JP Morgan Chase Foundation and Mastercard Center for Inclusive Growth. The content is solely the responsibility of the authors and does not necessarily represent the official views of the study's funders.

CONFLICT OF INTEREST STATEMENT

The authors declare that there is no conflict of interest.

ACKNOWLEDGEMENTS

JoAnn Jabbari is a 2021–2023 Jonas Scholar.

Jabbari, J. , Roll, S. , McQueen, A. , & Ridenour, N. (2024). Increased experiences of loneliness during the COVID‐19 pandemic, emotional distress and changes in perceived physical and mental health: A structural equation model. Nursing Open, 11, e2125. 10.1002/nop2.2125

Footnotes

1

Research has demonstrated that online, non‐probability samples using Qualtrics panels, the online panel used in this study, generate samples that closely approximate those of the General Social Survey, which is considered the gold standard in survey administration (Zack et al., 2019). One caveat is that our sample is more educated than the general population (53% of our sample holds bachelor's degrees, as compared to roughly 37% in the U.S. population, per Census Bureau estimates), which may limit the external validity (although not the internal validity) of our estimates.

2

Survey response rates were calculated using the American Association for Public Opinion Research's RR2 measure, which includes respondents who took part in the survey but were later excluded due to quota requirements (The American Association for Public Opinion Research, 2016). The response rate of 10.1% compares favourably to other national surveys administered during the pandemic, such as the Census Household Pulse Survey (Census Bureau, 2021).

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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