Association Between Loneliness and Patient Experience in a Primary Health Care Setting

Abstract

Loneliness is increasingly recognized as a public health concern with implications for health care experiences. This cross-sectional study surveyed 2,673 adult patients from a primary care practice in Ontario, Canada. Using the University of California-Los Angeles 3-item Loneliness Scale and 6 patient experience indicators, we examined associations between loneliness and patient experience via a Bayesian multivariate cumulative logit model. Lonely patients had significantly lower odds of reporting positive experiences across multiple domains. Findings suggest that loneliness may negatively influence how patients perceive care. Primary care clinicians are well positioned to identify loneliness and implement interventions that promote connection and improve patient experience.

INTRODUCTION

Loneliness is a significant public health concern, associated with increased risk of mortality and morbidity.¹ According to the Centers for Disease Control and Prevention, loneliness increases the risk of premature death by 26%, which is comparable to smoking 15 cigarettes a day.²

Emerging evidence suggests that loneliness may influence a patients’ experience in health care settings. A lack of meaningful communication with clinicians can intensify feelings of disconnection.³ While US research has linked loneliness to reduced satisfaction within Medicare services,⁴ our study contributes by focusing on aspects of care that are important to patients in a person-centered approach.⁵ This study examines the relationship between loneliness and experience within an integrated care model in Ontario, Canada.

METHODS

Study Design and Setting

We conducted a cross-sectional survey of adult patients constituting the majority of the population from a primary care practice of an Ontario Health Team. Surveys were distributed via e-mail and postal mail from December 2023 through March 2024. Among the 35,350 individuals invited to participate 2,993 responded (8.4%). We excluded patients aged under 18 years and those who completed less than 10% of the survey, resulting in 2,673 survey responses.

Exposure

Loneliness was measured using the University of California-Los Angeles (UCLA) 3-item loneliness scale.⁶ Respondents rated how often they felt isolated, left out, or lacking companionship with response options of always, sometimes, rarely, or never. Response scores were summed; scores of 6 to 9 were categorized as lonely, and 3 to 5 as not lonely.⁷

Outcomes

Patient experience was assessed across 4 domains using 6 outcome indicators, each measured on a Likert scale. The domains (outcome indicators) were: (1) accessing care (timeliness, care coordination); (2) having someone to count on (clinician checks if care was received); (3) being heard (clinicians understand needs; clinicians listen carefully); and (4) self-management (confidence in knowing how to manage your health).

Covariates

Analyses adjusted for sex, race, depressive symptoms (Patient Health Questionnaire-2 [PHQ-2]), health status (EuroQol 5-Dimension [EQ-5D] scale), and indicators of socioeconomic status (ie, financial hardship, food and housing insecurity).

Analyses

We described patient characteristics by loneliness status. We applied a Bayesian multivariate cumulative logit model within a flexible seemingly unrelated regression (SUR) framework to examine the association between loneliness and 6 outcome indicators of patient experience. As these outcomes potentially reflect overlapping constructs, a SUR framework allowed us to jointly model all 6 ordinal outcomes while accounting for shared variance across equations. For each outcome, we applied weakly informative priors consistent with best practices in Bayesian regression.^8,9 For regression coefficients we specified normal distribution (0, 2.5) priors, and for intercepts (cut points) we specified t test (3, 0, 10) priors. We used complete-case analysis; of the 2,673 respondents 2,236 (84%) had complete data across all model variables and were included in regression analyses. Missingness was minimal across most outcome variables (less than 5%), except for 1 outcome variable with 7.7% missing data. The primary exposure (ie, loneliness) also had low missingness (3.1%). For each outcome, we presented model results as adjusted odds ratios with corresponding 95% credible intervals (CrIs). Analyses were conducted using R version 4.4.2 (R Foundation for Statistical Computing).

RESULTS

Baseline Characteristics

In our final sample, 2,138 patients (83%) were categorized as not lonely, and 453 (18%) were categorized as lonely (Table 1). Compared with those who were not lonely, those who were lonely had a higher proportion of women (67.1% vs 59.1%) and younger individuals, aged 18-44 years (17.7% vs 9.3%). Lonely patients had significantly higher depressive symptoms (mean PHQ-2 scores 1.18 vs 0.62) and lower health-related quality of life (EQ-5D score 0.45 vs 0.71).

Table 1.

Baseline Demographic Characteristics by Loneliness Status

Characteristic	All respondents	Not lonely	Lonely	P value
Group size, No. (%)	2,591 (100.0)	2,138 (82.5)	453 (17.5)	…
Sex, No. (%)
Female	1,568 (60.5)	1,264 (59.1)	304 (67.1)	<.001
Male	979 (37.8)	846 (39.6)	133 (29.4)
Missing data	44 (1.7)	28 (1.3)	16 (3.5)
Age, No. (%), y
18-44	279 (10.8)	199 (9.3)	80 (17.7)	<.001
45-64	688 (26.6)	549 (25.7)	139 (30.7)
≥65	1,619 (62.5)	1,387 (64.9)	232 (51.2)
Missing data	5 (0.2)	3 (0.1)	2 (0.4)
Race, No. (%)
Multi-race	106 (4.1)	83 (3.9)	23 (5.1)	.114
Non-White	44 (1.7)	37 (1.7)	7 (1.5)
White	2,400 (92.6)	1,990 (93.1)	410 (90.5)
Prefer not to answer	34 (1.3)	23 (1.1)	11 (2.4)
Missing data	7 (0.3)	5 (0.2)	2 (0.4)
Having difficulty paying bills at the end of month, No. (%)
Never	1,610 (62.1)	1,430 (66.9)	180 (39.7)	<.001
Rarely	386 (14.9)	312 (14.6)	74 (16.3)
Sometimes	394 (15.2)	264 (12.3)	130 (28.7)
Always	114 (4.4)	62 (2.9)	52 (11.5)
Prefer not to answer	76 (2.9)	62 (2.9)	14 (3.1)
Missing data	11 (0.4)	8 (0.4)	3 (0.7)
Having money left for food after paying bills, No. (%)
Never	23 (0.9)	14 (0.7)	9 (2.0)	<.001
Rarely	47 (1.8)	24 (1.1)	23 (5.1)
Sometimes	238 (9.2)	138 (6.5)	100 (22.1)
Always	2,204 (85.1)	1,902 (89.0)	302 (66.7)
Prefer not to answer	68 (2.6)	50 (2.3)	18 (4.0)
Missing data	11 (0.4)	10 (0.5)	1 (0.2)
Worried about losing their place to live, No. (%)
Never	1,795 (69.3)	1,609 (75.3)	186 (41.1)	<.001
Rarely	274 (10.6)	228 (10.7)	46 (10.2)
Sometimes	369 (14.2)	220 (10.3)	149 (32.9)
Always	107 (4.1)	47 (2.2)	60 (13.2)
Prefer not to answer	43 (1.7)	32 (1.5)	11 (2.4)
Missing data	3 (0.1)	2 (0.1)	1 (0.2)
PHQ-2 score, mean (SD)	0.72 (1.40)	0.62 (1.11)	1.18 (1.79)	<.001
EQ-5D score, mean (SD)	0.66 (0.38)	0.71 (0.34)	0.45 (0.45)	<.001

EQ-5D = EuroQuol 5 dimension measure of health status; PHQ-2 = patient health questionnaire 2-item scale.

Indicators of socioeconomic status revealed greater financial insecurity among lonely patients. Only 40% of lonely patients reported never having difficulty paying bills (compared with 67% of non-lonely patients) and fewer reported always having money left for food (67% lonely vs 89% not lonely). Only 41% of lonely patients said they never worried about losing housing (vs 75% not lonely).

Associations

After adjusting for covariates, loneliness was associated with significantly lower odds of positive experiences across 5 of 6 outcome indicators: care coordination, having someone to count on, clinician understanding, clinician listening, self-management. There was no significant association between loneliness and timeliness of access to their clinician (Table 2).

Table 2.

Associations Between Loneliness and Health Care Experiences

Domain	Outcome indicators	Response options	No. (%)a	aOR (95% CrI)
Accessing care	In the last 12 months, how would you describe the length of time it took to access your regular health care clinician?	About right	1,582 (70.8)	1.23 (0.94-1.58)
		Somewhat too long	163 (7.3)
		Much too long	491 (22.0)
	When you consider how you and all your health care clinicians help you take care of your health, how coordinated would you say your overall health care is?	Very coordinated	203 (9.1)	0.69 (0.54-0.89)b
		Somewhat coordinated	785 (35.1)
		Not coordinated	1,248 (55.8)
Having someone to count on	In general, how confident are you that your regular health care clinician or other health care professional checks to make sure you receive the health care you need?	Very confident	1,082 (48.4)	0.75 (0.59-0.95)b
		Somewhat confident	827 (37.0)
		Not very confident	226 (10.1)
		Not at all confident	101 (4.5)
Being heard	In general, how well do you feel your health care clinicians understand your health care needs?	Very well	1,417 (63.4)	0.71 (0.55-0.91)b
		Somewhat well	680 (30.4)
		Not very well	109 (4.9)
		Not at all well	30 (1.3)
	In general, would you say your regular health care clinician or other health care professionals listen carefully to you?	Always	1,380 (61.7)	0.75 (0.58-0.97)b
		Often	603 (27.0)
		Sometimes	202 (9.0)
		Rarely	45 (2.0)
		Never	6 (0.3)
Self-management	In general, how confident are you that you know the things that you need to do to take care of and manage your health?	Very confident	1,403 (62.7)	0.66 (0.50-0.86)b
		Somewhat confident	734 (32.8)
		Not very confident	82 (3.7)
		Not at all confident	17 (0.8)

aOR = adjusted odds ratio; CrI = credible interval.

^aPercentage represents the distribution percentage of analyzed responses with missing data excluded.

^bThese values are significant. Regression models were adjusted for sex, race, depressive symptoms, health status, income, food, and housing status.

DISCUSSION

Patients experiencing loneliness were significantly less likely to report positive health care experiences. They were less likely than non-lonely individuals to report feeling that they were listened to and understood, that their clinician had checked whether they received needed care, that their care was coordinated, and that they had confidence in managing their health. Loneliness may shape how patients perceive interpersonal aspects of care. It is interesting to note that loneliness was not associated with perceived timeliness of access to care. This may reflect that timely access, while important, is shaped more by systemic or logistic factors (eg, appointment availability, clinic scheduling) than by social or emotional factors such as loneliness. It is possible that loneliness more strongly influences relational aspects of care (eg, feeling heard or understood) than structural dimensions.

The relationship between loneliness and patient-reported experiences may be bidirectional: individuals who feel lonely may perceive health care encounters as less supportive, which could deepen their sense of isolation. This is particularly concerning in primary care, where strong therapeutic relationships are foundational.

Primary care offers a key opportunity for loneliness identification and intervention. Brief validated tools such as the 3-item UCLA Loneliness Scale⁶ can support targeted screening. When implemented thoughtfully, social risk screening can support personalized care planning. However, screening must be sensitive to workflow demands and patient willingness to engage.¹⁰

Promising interventions include social prescribing, in which clinicians refer patients to non-clinical supports such as peer groups, recreational programs, and volunteer activities to promote social connection.¹¹ Evidence also supports structured interventions such as social skills training and group cognitive-behavioral therapy, which have been shown to reduce loneliness, particularly for high-risk individuals.¹²

Limitations

This study reflects the experiences of one Ontario Health Team and may not be generalizable. The low response rate (8.4%) may introduce nonresponse bias, as could the high proportion of women and older respondents. While this is a limitation, our response rate is consistent with international practice-based surveys that do not offer participant incentives. For example, the Organization for Economic Co-Operation and Development’s Patient-Reported Indicator Surveys report patient response rates ranging from 6% to 47%, with similar concerns around representativeness noted across countries.¹³ Patients experiencing heightened loneliness or different care experiences may have been less likely to respond, potentially underestimating the association. The sample also lacked racial diversity (ie, 92% of participants identified as White), which may limit the applicability of findings to more diverse populations. Although we adjusted for depressive symptoms, other unmeasured mental health factors may confound results. We adapted the UCLA 3-item scale¹⁴ with different reponse options from the original⁶: (1) never or rarely instead of hardly ever; (2) sometimes instead of some of the time; and (3) always instead of often. These changes may limit comparability to other 3-item results. Finally, causal relationships cannot be inferred from this cross-sectional study.

CONCLUSION

These findings highlight the potential role of loneliness in shaping how patients perceive their health care experiences. Given the association, addressing loneliness in the clinical setting may improve patient experience and quality of care, and reduce health disparities linked to social isolation. Ensuring that clinics have appropriate behavioral health supports and resources may also contribute to addressing these issues.