Maintaining Social Connections in the Setting of COVID-19 Social Distancing: A Call to Action

The COVID-19 pandemic is the biggest public health crisis the United States has faced in generations. The devastating direct medical consequences of COVID-19 have been accompanied by far-reaching economic and social consequences, including increased risk of social isolation and loneliness.

Social isolation is conceptualized as the objective lack of social contact with others,¹ such as the absence of a live-in partner or limited contact with others. Loneliness is conceptualized as a subjective experience and refers to the perception of social isolation or the feeling of being lonely.¹ Even when people are not socially isolated, they might feel lonely if their contact with others does not provide enough of a sense of social support and connection. Both social isolation and loneliness are associated with an increased risk of morbidity and mortality,^1,2 and thus it is no surprise that even before the COVID-19 crisis, Vivek Murthy, the former US surgeon general, referred to loneliness as a national epidemic.³

THE IMPACT OF COVID-19

Shelter-in-place orders have encouraged people to remain in their homes except for essential activities. Although staying inside is absolutely crucial to flattening the curve of the pandemic, it is important to recognize that these socially restrictive guidelines heighten the risk of experiencing or exacerbating social isolation and loneliness. Therefore, it is important to emphasize strategies to bolster social support and connectedness despite physical-distancing measures. We offer suggestions for providers, health systems, and public health officials considering how to respond to social isolation and loneliness in the setting of COVID-19 social distancing.

Assessing in Health Care Settings

Several National Academies reports have emphasized assessment of social isolation or loneliness in clinical settings and documentation in electronic health records, and have identified tools for clinicians to assess these concepts.^1,4 Although in-person primary care visits have decreased to observe social-distancing guidelines, health systems have rapidly transitioned these visits to telehealth, which still allows providers the opportunity for assessment. For providers that have not assessed social isolation or loneliness with their patients before, the near universal experience of shelter-in-place orders and physical-distancing measures may serve as an opportunity to bring up these topics. Assessment by other public health professionals and essential service workers coordinating and providing care to patients should be considered as well.

Providing Targeted Resources

Maintaining social contact can improve overall mental health, enhance feelings of social connectedness, and decrease loneliness.⁵ Providers can encourage social contact via appropriately distanced in-person visits, telephone calls, video calls, and e-mail. Additionally, many organizations in the public, private, and philanthropic sectors have developed interventions to specifically help promote social connections and reduce loneliness via telephone calls, Web sites, or mobile phone applications. These existing tools can be used to maintain social connections as a way to adapt to restrictions on in-person gatherings.

Even with the availability of resources, many people may still experience the sequelae of social isolation and loneliness, which include depression and anxiety.¹ Health care providers should explain that although it can be normal to experience transient feelings of stress and anxiety, it is important to share these feelings with trusted social network connections and health care professionals. Providers should also emphasize having a plan in place for how to access help and resources if stress or mental health symptoms become unmanageable (see the box on p. 1368), including knowing the criteria for deciding whether to go to clinics in person for care and treatment.

BOX 1— Examples of Mental Health Support Lines.

• National Suicide Prevention Lifeline: This national network of local crisis centers provides emotional support to people in emotional distress or crisis. Telephone: 1-800-273-8255; Web site: https://suicidepreventionlifeline.org.

• Friendship Line: This service, run by the Institute on Aging, serves as both a crisis intervention hotline and a warmline for nonemergency emotional support calls for adults 60 years and older. Telephone: 1-800-971-0016; Web site: https://www.ioaging.org/services/all-inclusive-health-care/friendship-line.

• National Alliance on Mental Illness Helpline: This hotline provides resources and support to people living with mental health conditions as well as their family and caregivers. Telephone: 1-800-950-NAMI (6264); Web site: nami.org/help.

Considerations for Vulnerable Populations

Nouri et al.⁶ recently emphasized that many vulnerable populations experience limited digital literacy, including those with lower socioeconomic status and limited health literacy. Additionally, people unable to access or use the Internet and smartphones will have fewer opportunities to access certain social resources. These concerns are particularly relevant to older adults living in nursing homes and assisted-living facilities. Experiencing either limited digital literacy or lack of digital access, in combination with visitor restrictions during the pandemic, can increase the risk of social isolation and loneliness. Although there is no easy fix for this issue, the health care system should seek solutions to reach patients with limited digital literacy and access. For example, a recent Veteran Affairs’ pilot study provided patients with iPads as a way to facilitate telehealth.⁷ This type of solution has the potential to allow providers to assess social isolation and loneliness in at-risk patients while simultaneously providing them access to other electronic resources and support.

The social consequences of COVID-19 are occurring in parallel with devastating economic consequences. Because social isolation and loneliness are associated with social risk factors such as food insecurity, providers and other public health professionals should consider assessing for other social risk factors among patients identified as being isolated or lonely, and should also consider assessing for social isolation and loneliness among patients with other identified social risk factors.

Partnering Beyond the Health Care System

Public health tools have the potential to reach people who have no connection to health systems. One such tool is outreach campaigns promoting contacting people unable to use the Internet or making telehealth visits through nonelectronic methods such as telephones and physically distanced checks. Other potential practices could involve partnering with programs in other sectors that are active during social distancing. For example, meal delivery services and postal services have been used to help address social isolation and loneliness in certain countries. Other approaches might involve working with community-based organizations already working with socially isolated and lonely populations, building on the infrastructures already in place.

FUTURE DIRECTIONS

Social isolation and loneliness have never been more relevant to health and well-being. Now is the time for clinicians, health systems leaders, and public health officials to acknowledge the importance of these problems and to integrate patient assessment and assistance with other care activities. A National Academies of Sciences, Engineering, and Medicine report specifically highlights the role that public health can play in this work, including reframing interventions using a public health framework that address primary, secondary, and tertiary prevention.¹ However, there still remain significant research gaps in the implementation and effectiveness of programs addressing social isolation and loneliness, leaving the following research directions to explore:

• Identification of successful practices to incorporate social isolation and loneliness assessments into clinical and public health practices, including strategies for vulnerable populations and populations with limited digital literacy;

• Determination of which clinical and public health interventions are most effective and for which populations¹; and

• Development of evidence-based best practices to prevent and address social isolation, loneliness, and their sequelae by connecting at-risk populations with community-based resources.¹

CONCLUSIONS

The COVID-19 pandemic is an unprecedented public health crisis, with substantial health, social, and economic implications. As we face changes to social routines as a country, it is important to remember that “social distancing” should refer to physical distancing and isolation, but not social isolation. The health benefits of social support were clear before COVID-19. But now, more than ever, is a time to finally implement and develop best practices that encourage patients to stay socially connected, promoting health and wellness during this difficult time and informing practices for the future after physical-distancing measures are lifted.