It is estimated that in the UK, there are 1.2 million chronically lonely older people, and approximately 500 000 of these individuals do not see or speak to anyone for at least 5 or 6 days a week (Age UK, 2016). The chronic loneliness epidemic is not unique to the UK. It is being increasingly recognised as a growing global public health crisis as the world's population ages and social isolation increases (American Association of Retired Persons, 2010; Vozikaki et al, 2017). The effects of loneliness and social isolation on a person's health and wellbeing are well-documented (Cattan et al, 2005). Loneliness has been found to be a risk factor for cardiovascular disease, stroke, depression and mortality (McDaid et al, 2017). It is commonly cited as being as bad for a person's health as being obese or smoking 15 cigarettes a day (Holt-Lunstad et al, 2010). In addition to the cost to the individual, loneliness has an economic impact on health and social care services. A study by researchers at the London School of Economics calculated the economic cost of ‘an epidemic of loneliness’ to be £6000 per person per year in health and social care (McDaid et al, 2017).
Loneliness is not just a problem found in old age. According to recent reports, younger adults aged between 16 and 34 years reported feeling more lonely than those in older age groups (Mental Health Foundation, 2010; Office for National Statistics (ONS), 2018). Despite this, there is little evidence of the impact of loneliness on young people, or the effects loneliness may have on their health and wellbeing in later life. One study that aimed to examine the profile of loneliness in a prospective, UK-representative cohort of 18-year-olds (n=2232) found that up to a third of participants reported feelings of loneliness ‘some of the time’ (Matthews et al, 2018). Lonelier 18-year-olds were also more likely to describe clinical symptoms of depression and anxiety, have greater alcohol and cannabis dependence and to have attempted suicide. While, in this younger age group, there were no indicators of any impact on physical health, Matthews et al (2018) found that lonelier participants were more likely to be daily smokers and have low levels of physical activity, which could lead to poorer health outcomes in later years.
A recent report produced by NHS Health Scotland (2018) that collated data from a number of Scottish surveys found that a significant minority of people reported feeling disconnected from the community within which they live and having limited neighbourhood support and few contacts whom they could approach at times of personal crisis. Three profiles of people have been identified within the UK population as being at the greatest risk of loneliness (ONS, 2018): young people who rent, who have little trust or sense of belonging in their community; single middle-aged people with long-term health conditions; and widowed older homeowners living alone with long-term health conditions (ONS, 2018). Hence, any appropriate response to the epidemic of loneliness must be inter-generational in nature, as focusing solely on older people would entail ignoring a significant part of the issue.
Thus, an urgent question is emerging over how society addresses the issue of chronic loneliness now and in the future. It has been accepted that health-promotion activities are important to tackling loneliness and social isolation; yet, there is little evidence to identify which interventions are effective in tackling loneliness (Luanaigh and Lawlor, 2008). Allan Kellehear, reporting for Marie Curie, noted that two main challenges are a ‘lack of systematic or comprehensive coverage’ and that responses are ‘led by health services as “services”’ (Kellehear, 2017). Kellehear proposed that solutions to tackle loneliness and social isolation lie within local communities, not health or social care services. This focus on community development to tackle loneliness and social isolation is reflected not only in the strategic plans of other charities (including Macmillan and Age UK), but also in recent strategic policy development of national governments, such as the Scottish and UK Governments, which have both identified the need to tackle social isolation. Whatever the organisation, and whatever age group forms the focus of study, there is a similar narrative: the problems of loneliness and social isolation are increasing, the funding is diminishing and there are multiple small-scale community-based programmes, but there is no underpinning theory or coherent strategy beyond the adoption of a public-health approach to tackle loneliness.
The approach to considering loneliness and social isolation focuses disproportionately on the traditional service response to isolated individuals. A more effective approach to both meet the needs of the community and use resources other than traditional health and social care services would be to develop a theory-based approach based on collective memory. Doing so would aid the development of policy and practice to shift the focus to understanding the work of community actors and how they draw on deeply embedded notions of community and social responsibility. This approach will enhance the practice of community nurses, who face caring for lonely and isolated older people and might offer them a conceptual framework on which to build new ways of working within, and for, their communities.
Compassionate communities
In recent years, there has been an increasing focus on communities taking responsibility for their own health and using a public-health model for this purpose. This approach, known as ‘compassionate communities’, has primarily developed from the concept of ‘compassionate cities’ (Kellehear, 2005). The aim of these social movements has historically centred on facilitating local communities to support people who are dying or nearing the end of life. This is following a growing recognition of the medicalisation and professionalisation of death and dying to the detriment of community involvement and knowledge (Gomes and Higginson, 2006). The model for compassionate communities (Figure 1) has two major components: naturally occurring networks (close connections, including family and friends) and supportive resources (those available within the community in which a person resides). A compassionate community is the combination and activation of both of these elements to enhance the lives of individuals and create benefits to the local community. The focus is working with communities, not for them, and is in contrast to the traditional health and social model of care used within the UK. Different communities will have different needs and, therefore, community projects across the UK are varied.
Figure 1. Model for compassionate communities
There are several examples of compassionate communities: one project leading the way in Scotland is Compassionate Inverclyde, which aims to promote compassionate citizenship (Compassionate Inverclyde, 2018). It does this through various initiatives that are supported by the local community (including workplaces, schools and individuals) (Box 1). Contributors are not viewed as volunteers, but as local people driven by kindness and friendship.
Box 1.Summary of Compassionate Inverclyde services
- No one dies alone (NODA): aims to support people who have no family or friends available to be with them in the last hours of life in the local hospital. A rota of palliative care companions (specially trained volunteers) ensures there is always someone with the person until they die to ensure that they do not die alone
- Back home boxes: boxes containing various provisions are gifted to anyone being discharged from hospital, regardless of age or need, who lives alone. The boxes include essential items such as tea, milk, bread, a get-well card made by local school children and a blanket knitted by local people and community groups. People, businesses, organisations and groups across Inverclyde donate the provisions. This community act of kindness allows recipients to make a hot drink and light snack for a few days after they are discharged, allowing them to concentrate on getting better without having to worry about shopping.
- The high five wellbeing programme: originally developed for schools, the aim is to help organisations create a culture of kindness, caring and compassion between pupils, colleagues and their wider community. It has been delivered to pupils at schools across Inverclyde, as well as people at the local college, bereavement groups, public groups, youth club and Amazon staff and, more recently, to inmates of the local prison.
- Back home visitors: a visitor scheme that will be based on neighbourliness, whereby a visitor and a young person will visit a socially isolated person, aged over 80 years and who lives alone. The idea developed out of learning from the back home boxes that showed that the majority of these are given to people over 80 years who live alone.
Compassionate Inverclyde has been operational since May 2017. Here are some results up to May 2019:2000 people have received Back home boxes (mainly those aged over 80 years)58 people have benefited from the NODA project20 primary schools and 3 secondary schools have engaged with Compassionate Inverclyde160 local people have been trained to participate in the projects, and 135 are directly involved in the different programmes
The cross–generational initiatives used by Compassionate Inverclyde support the argument that building compassionate and resilient communities that support people nearing the end of life also builds capacity and capability within the community to look after its ageing population, given the growing numbers of the oldest old (Rosenberg et al, 2015). These principles of engaging with local communities to take responsibility for their own health and wellbeing can be used to tackle loneliness and social isolation across generations, benefitting all.
Although there are multiple forms of compassionate communities, one key component is that the models rely on volunteers, or what Compassionate Inverclyde refers to as companions, helpers or visitors, depending on the initiative. These are members of the community who donate their time to engaging with lonely or hard-to-reach individuals. In turn, this action supports the overall aim of the compassionate communities model to reconnect isolated individuals back into a community network.
There is clearly a need for isolated and lonely individuals to be connected with in order to increase wellbeing and decrease public costs, but what is not clear here is why the volunteer is compelled to act and what role the community plays in facilitating and supporting this. One explanation, as presented here, is that community identity, developed through community memory, is a key driver in the volunteer's desire to act. In order to develop this theory, there are two key concepts that need to be explored: community memory and how community influences individual action. This dual focus will enable an analysis of why an individual feels compelled to act and how community identity enables and encourages that action. It is through an understanding of the interaction between community and the individual that we may begin to develop a theoretical understanding of how to tackle loneliness.
Community memory
First discussed by Durkheim in the late 19th and early 20th centuries and then developed further by Maurice Halbwachs, community memory is described by Barbara Misztal ‘as one of the elementary forms of social life’ (2003). In essence, it is a way of describing the development and maintenance of trans-generational community identity. Community memory is a way of describing the development and maintenance of trans-generational community identity. Community memory indicates the ways ‘in which human relationships to the past are actively constructed [in the present]’ (Assman, 2004:26). In other words, community memory is a series of remembrances, and the way in which they are remembered, passed down and re-enacted informs how a community thinks about and describes itself. Although Arnold-de-Simine (2013) noted that ‘collective memory is never simply […] the authentic voice of a group or community’ but rather a ‘socially constructed notion’ (Coser, 1992), there is within this a sense of a workable, continuous line of heritage that informs the present via the past.
Importantly, community memory is different from ‘autobiographical memory’, which can be defined as the ‘memory of events that we have personally experienced in the past’, whereas community, or collective memory, requires ‘the support for a group delimited in space and time’ (Halbwachs, 1992). Moreover, Arnold-de-Simine (2013) suggested that there is no neat separation between what Halbwachs refers to as ‘individual memory’ and ‘collective memory’ and that the two necessarily inform each other:
‘One might say that the individual remembers by placing himself in the perspective of the group, but one may also affirm that the memory of the group realizes and manifests itself in individual memory.’
What this suggests, in terms of community-based approaches to the alleviation of loneliness, is that individual and community identity are interlinked and informed via collective memory. The social practising of collective memory consists of the continual reinforcing of community and individual identity through the use of cultural memory. Thus, communities maintain their social identity, their trans-generational permanence, via frequent formal and informal reference to a collective memory. Social isolation, one of the key drivers in loneliness, has the effect of depriving an individual of their connection to a wider social identity by limiting the frequency of social remembrance. The significance of this, as Arnold-de-Simine (2013) suggested, is that ‘memory is not just an instrument to stake out collective identities but is always played out in the dynamics between individual and social frameworks’. It is these dynamics that are lost through loneliness and re-established by community-based interventions.
Community memory and community identity
As community memory is passed down from generation to generation, it helps to define the relationship between the community and individuals within that community. Indeed, Arnold-de-Simine (2013) suggested that the link between the community and the individual cannot be changed, as an individual's memory can only be developed within a social context. This is supported by Misztal (2003), who described the interface between community, identity and remembering; and identifying collective memory as a key element in the development of individual and social identity. The main notion here is the inter-generational passing down of memory in order to inform contemporary community and individual identity and the idea that the identity of a contemporary social group is fundamentally informed by continuity with the past. Halbwachs (1992) stated that, remembering, and so the affirmation of identity, occurs through engagement with others who have shared memories. Applied to the tackling of social isolation, this would suggest that what community volunteers should do to address loneliness is establish a context in which common remembrances can be shared.
Hence, although the theoretical link between community memory and individual identity is well established, what is less clear is what motivates the volunteer to act. To address this, we need to draw on Bourdieu's (1984) theory of habitus, which helps to explain the effect of the community on the individual's actions.
Community and habitus
Habitus concerns the idea of individual motivation within the context of the community. Bourdieu (1984) questioned how an individual's agency can be ‘regulated without being the product of obedience to rules’. In other words, if the individual is not acting in response to rules (nobody orders community volunteers to engage with lonely individuals), then what does motivate them?
Bourdieu (1984) described habitus as ‘[s]ystems of durable, transposable dispositions, [that] function as structuring structures’. These dispositions are the individual's everyday, mundane practices that are developed over time and in reference to the ‘structuring structures’ of the community. That is, living within a community and understanding the various elements of history that define that community influences the way an individual responds to or acts in any given circumstance. Here, the volunteer's knowledge of the community leads to the development of dispositions that enable community-specific responses. Hence, community memory equips the volunteer with the appropriate community knowledge and strategies for engagement that enable them in the first instance to make contact with the isolated individual and then, over time, to successfully negotiate numerous modalities that effectively enable them to act as a bridge between the isolated individual and the wider community. In the context of tackling loneliness, Bourdieu's (1984) theory allows for an understanding that volunteers simultaneously recognise community as a collection of individuals, groups and institutions that exist at a certain moment (and so one that is subject to significant change over time) and as a site with deep roots. This duality enables volunteers to act with shared, perhaps unarticulated, community values while also providing practical knowledge of the networks and services available to isolated individuals.
Conclusion
Perhaps the significance of considering the work done by community-based volunteers in tackling loneliness through the use of collective memory is that it reinvigorates community networks and re-establishes the individual within a community-based nexus. Halbwachs (1992) suggested that ‘[t]he reality is that we are never alone […] because we always bring with us and always bear in us a lot of people’. In turn, this suggests that individuals working within a community employ the culture of that community to re-establish culture-affirming networks via community memory. Consequently, it is the act of the volunteer in using their local knowledge, community-based networks and free time that can be seen as belonging to an established theoretical framework. This helps describe why community-focused solutions to tackling loneliness are effective and should be used instead of service-based solutions. This explicit focus on the community positions community nurses at the centre of developing strategies for local interventions based on the particular need of the community that they are caring for. While it is difficult to give examples that will resonate with individual communities, community nurses could undertake a local community asset assessment to develop a better understanding of what is available already within their local community. This should include trans-generational activities to connect people, irrespective of age. This approach ensures that strategies for connecting isolated individuals are community-specific and use community knowledge and community memory as a mechanism for addressing this increasing societal issue.
KEY POINTS
- Tackling social isolation and loneliness is an area of growing concern in societies worldwide
- To date, there has been no theoretical model on which communities can build to tackle social isolation and loneliness
- The use of collective memory could be an underpinning theory that draws conceptual links between compassionate communities and the role they can play in tackling social isolation and loneliness
- Community nurses can draw on the theory of collective memory to develop new community-based services to tackle social isolation and loneliness within their practice areas
CPD REFLECTIVE QUESTIONS
- How many patients on your caseload have you identified as being socially isolated or lonely?
- Reflect on the social connections and community links of patients you have identified or feel are at risk of loneliness.
- Discuss with colleagues what community services already exist within your area to link to those you have identified as socially isolated or lonely.
- How can you draw on the underpinning theory of collective memory to reach those who are lonely and housebound?