Manan Ahuja, MD1, Kaitlin Lewis, MD1, Sawayra Owais, MSc2, Jordana Compagnone, MD3, Laura Fallico, MD1, Francine Fishbein, MD4, Isabella Stefanova, MD1, Kai Man Xu, MD5, Shannon Gui, MD6, Tricia Woo, MD1, Sharon Marr, MD6, Justin Lee, MD1
1Department of Medicine, McMaster University, Hamilton, ON;
2MD/PhD Program, McMaster University, Hamilton, ON;
3Department of Medicine, Dalhousie University, Halifax, NS;
4Department of Medicine, University of British Columbia, Vancouver, BC;
5Department of Family Medicine, Queen’s University, Kingston, ON;
6Department of Medicine, University of Toronto, Toronto, ONDOI: https://doi.org/10.5770/cgj.29.857
ABSTRACT
Social isolation and loneliness are associated with many adverse health outcomes. The COVID-19 pandemic increased its prevalence and disproportionately affected older adults. Since telephone befriending was a potentially feasible and safe intervention during the pandemic, the McMaster Phone-a-Friend Program (PFP) was developed using this strategy to try to reduce social isolation and loneliness among older adults. Thus, this study aimed to evaluate the effectiveness and long-term feasibility of PFP. Community-dwelling older adults in Ontario, Canada were matched to trained university student volunteers, who provided social engagement and pandemic-related education through weekly telephone calls. Two main referral sources were used: 1) older adults identified by their primary care provider as at risk for social isolation; and 2) older adults referred for multi-modal frailty rehabilitation, where telephone befriending was a desired component intervention. Older adults completing ≥4 calls were contacted to participate in a telephone survey to provide program feedback. Of the 220 active participants in August 2021, 60 participated in our survey. At the time of survey completion, the mean number of calls completed was 8.3. The mean age of participants was 75.6 years and 71.7% (n=43) identified as female. Furthermore, 58.3% (n=35) of the participants agreed or strongly agreed that they felt less lonely after participating in the program and 68.3% (n=41) stated they would participate in the program after the pandemic resolves. The intergenerational PFP telephone befriending program is a safe and effective method of reducing or possibly preventing social isolation and loneliness among at-risk community-dwelling older adults.
Key words: older adults, loneliness, social isolation, COVID-19
Social isolation and loneliness have been described as the new geriatric giants.(1,2) Not only is social isolation associated with increased rate of mood disorders,(3,4,5) but also with poor cardiovascular health, cognitive impairment, falls,(6) and death.(5) Amongst community-dwelling older adults, the prevalence of social isolation and loneliness is estimated to range from 6–43% and 10–50% respectively.(2)
Older adults are vulnerable to social isolation and its adverse effects if they live alone, and face challenges related to multiple comorbidities, lower socioeconomic status, or reduced access to health care.(7) Physical distancing restrictions during the COVID-19 pandemic led to increased social isolation,(8) and the disproportionately higher proportion of COVID-19 cases among older adults likely resulted in individuals staying at home out of fear, regardless of current public health recommendations.(9)
Examples of social isolation interventions utilized by older adults included social support, physical activity, and technological interventions (e.g., robot companions).(10,11) While these interventions have been shown to be effective at reducing social isolation, they may not be cost-effective, scalable, or accessible for all older adults. Telephone befriending is an intervention of particular interest due to its feasibility, safety, and accessibility.(12) Studies have shown it can decrease loneliness and increased community engagement,(13) but they have largely been short-term without any feedback from participants regarding its efficacy.
In this study, we sought to evaluate the effectiveness of an intergenerational telephone befriending program developed and implemented by health-care students to provide outreach to older adults in Ontario, Canada. Known as the Mac Phone-a-Friend Program (PFP), the program was developed to provide social comfort and companionship via telephone to older adults in the community to prevent and reduce social isolation and loneliness. To our knowledge, few studies have examined sustainability of telephone-based befriending programs.
We conducted a mixed methods prospective study of older adults (aged ≥65 years) referred to the PFP by health-care providers or community organizations within southern regions of Ontario, Canada. The PFP was modelled after a similar program developed by University of Toronto medical students.(14) Older adults were matched to trained student volunteers who called their older adult partner once weekly to provide social support. The length of each call was determined by the participant and their volunteer. The intervention did not have a predetermined end date and continued indefinitely unless otherwise agreed upon by the older adult and volunteer.
Our study had two distinct referral sources. Group 1 participants were referred by their primary care providers as being at risk for social isolation based on their clinical judgement. Group 2 participants were referred by a multi-modal community frailty rehabilitation program, where telephone befriending was one of the desired component interventions. Differences between these groups in terms of baseline characteristics and survey results were compared using the two-sided t-test and chi-squared test. Participants who completed fewer than four calls were not surveyed and were therefore excluded from outcome analyses. Missing or unreported data were not imputed.
Research volunteers (not involved in making social calls) contacted participants to obtain their consent to acquire survey feedback about their experience in the program. Their participation did not affect their intervention enrolment. After a minimum of four weeks of program participation, a 27-question survey was administrated that identified participants’ sociodemographic and elicited their perceived satisfaction and experience with the program. This survey was pilot tested with a small number of participants. Inductive analysis was conducted to identify themes within the qualitative analysis following the recommendations of Thorne.(15) Descriptive statistics were used to summarize the demographic, program, and survey data. We report the survey results in accordance with the CROSS reporting guidelines for survey studies.(16)
This project was approved by the Hamilton Integrated Research Ethics Board as a quality assurance study.
The McMaster Phone-a-Friend Program had 220 active older adult participants between May 2020 and August 2021 connected to over 160 student volunteers. Of the 220 participants, 60 completed the survey (27.3% response rate). At the time of survey completion, the mean number of calls completed was 8.3. Table 1 shows participants’ baseline characteristics. Participants had a mean age of 75.6 years and 71.7% (n=43) identified as female. The majority were single (65.0%, n=39), and lived alone (63.3%, n=38). Thirty per cent (n=18) of the participants joined because they were isolated during the pandemic.
TABLE 1 Baseline characteristics of total participants and based on Groups 1a and 2b
As shown in Figure 1, 58.3% (n=35) of the participants felt less lonely after program participation and 54.9% (n=33) stated the program improved their quality of life. Furthermore, 68.3% (n=41) indicated that they would continue to participate outside the context of a pandemic. A common theme was that participants enjoyed the routine companionship from student volunteers. Themes for improvement and reasons why participants may have left included: wanting to try different mediums of communication (e.g., videoconferencing) and adequate social support outside of the program.
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FIGURE 1 Survey results from all participants (A) and comparing participants (B) in Group 1 (community referrals from primary care providers for older adults at risk for social isolation) vs. Group 2 (referrals from multi-modal community frailty rehabilitation program) | ||
Referral source analyses showed that there were 36 participants in Group 1 and 24 participants in Group 2. Group 1 participants were more likely to be living alone (p<.001), were single (p<.001), reported subjective financial constraints (p<.05), and were less likely to help other family members/friends with daily tasks (p<.05). They were also more likely to want to participate in the program even outside the context of a pandemic (p<.05) and more likely to feel that their loneliness was reduced during program participation in comparison to Group 2 (p<.001). All study results are demonstrated in Figure 1.
The complete participant survey is provided in Appendix A, with quotations from open-ended responses included in Appendix B.
APPENDIX A All survey questions
APPENDIX B Open-ended survey questions and quotations (sample responses)
This study demonstrates that the intergenerational PFP telephone befriending program was a safe, feasible, and effective program to reduce social isolation and loneliness among community-dwelling older adults during the COVID-19 pandemic. Our findings are consistent with a recent randomized controlled trial that demonstrated improvement in loneliness in older adults after receiving regular phone calls for four weeks compared to the control group.(17) While studies on telephone befriending are limited, a number of other community engagement interventions have been employed to target social isolation among community-dwelling older adults. The various methodologies and evaluation measures used make it difficult to form comparisons.(18) However, many of these programs have shown similar benefits as PFP in different populations around the world.(18,19,20,21)
A key facet of PFP is connecting younger adults with older adults. This may have contributed to the positive outcomes, as previous intergenerational programs have shown improvement in physical and mental health.(22,23) The University of Michigan National Poll on Healthy Aging found increased feelings of lack of companionship, isolation from others, and more infrequent social contact during the pandemic compared to pre-pandemic results, highlighting a growing need for an effective intervention.(24) Our results demonstrate that telephone befriending initiatives may be one potential solution to worsening mental health for older adults.
Intervention effectiveness may be dependent on risk levels for social isolation. Due to two different referral mechanisms, our program consisted of two groups of older adults with different baseline sociodemographics. Participants referred as “at risk” by their primary care providers (Group 1) were more likely to live alone, be single, experience more financial constraints, and be less likely to help others with daily tasks. These are all risk factors for social isolation,(7,25) and it is possible that those at higher risk may derive greater benefit from program participation. Group 1 participants were more likely to have felt less lonely and more willing to participate in the program after pandemic resolution. This suggests that it is important to identify the most vulnerable older adults, as they can benefit from targeted intervention.
Identified areas for improvement included improved targeting of older adults and option for alternate means of communication apart from telephone calls. Since PFP is a student-run program, it relied on primary care providers to refer those they deemed at risk of social isolation; the program did not internally screen older adults for loneliness or social isolation prior to enrolment. Implementation of a screening tool (e.g., Three-Item Loneliness scale) could provide a quick and reliable means of identifying at-risk older adults over the telephone so as to provide a more targeted intervention.(26) Furthermore, as the digital literacy of older adults continues to improve over time, participation does not need to be limited to telephone calls.(27) Offering alternate methods of communication may help enhance program reach and effectiveness, but this needs further exploration. Studies suggest that instant communication using mobile applications can also reduce loneliness in older adults.(28) However, video chatting, which was also brought as a potential alternate method of communication, has an uncertain level of evidence in reducing loneliness among older adults.(29)
This study has several limitations. First, its generalizability is restricted by the small sample size, the single geographic setting in Ontario, and the lack of ethnic diversity (as all 60 participants were Caucasian). Second, the absence of a control group limits our ability to account for potential confounders influencing participants’ responses. Third, the study was conducted across multiple waves of the COVID-19 pandemic, during which public health restrictions varied; these fluctuations may have amplified or diminished the program’s impact on social isolation. Fourth, we did not objectively measure social isolation and loneliness. The available measures relied on subjective self-report or clinician impression, which reflected either the presence or perceived risk of social isolation or loneliness. Finally, response bias cannot be excluded, as individuals who were more satisfied with the program may have been more likely to complete the survey. Future research should incorporate larger and more diverse samples, include control groups, and employ validated objective measures to enhance the robustness and generalizability of findings.
The intergenerational PFP telephone befriending program is a safe and effective way to reduce or help prevent social isolation and loneliness in at-risk older adults, with potential benefits extending beyond the COVID-19 pandemic to other situations that contribute to isolation in this population.
We would like to thank the University of Toronto Student-Senior Isolation Prevention Partnership for their assistance in helping establish Mac PFP, and specifically their executives including: Monisha Persaud, Geoffrey Sem, Victoria O’Driscoll, and Sumana Naidu.
We have read and understood the Canadian Geriatrics Journal’s policy on conflicts of interest disclosure and declare we have none.
This research did not receive external funding.
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Correspondence to: Justin Lee, MD, GERAS Centre for Aging Research, 88 Maplewood Avenue, Rm. 160, Hamilton, ON Canada L8M 1W9, E-mail: lee343@mcmaster.ca
COPYRIGHT
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No-Derivative license (https://creativecommons.org/licenses/by-nc-nd/4.0/), which permits unrestricted non-commercial use and distribution, provided the original work is properly cited.
Canadian Geriatrics Journal, Vol. 29, No. 1, MARCH 2026