Background
In the context of rapid population aging, loneliness has become an important topic in public policy and public health. Compared to younger adults, older adults are at a higher risk of social isolation and participate in fewer social activities, which makes them vulnerable to loneliness with declining physical and cognitive abilities, shifting social roles, and worsening social adaptability [
1‐
3]. This subjective emotional experience arises when older adults feel that the quantity and quality of their social relationships do not actually match their expectations [
4]. Recently, it was reported that 11.9% of older adults worldwide suffer from loneliness [
5]. A study performed by Wei et al. based on data from the 2008/2009 wave from the Chinese Longitudinal Healthy Longevity Survey found that 33.3% of older adults feel lonely [
4]. Loneliness is also strongly associated with negative physical and psychological outcomes in older adults. Previous research has shown that higher levels of loneliness may predict frailty, depression, cognitive decline, an increased risk of cardiovascular disease, suicide, and mortality [
6‐
8]. Therefore, it has become a focal point of mental health issues for older adults on how to alleviate loneliness.
People with social anxiety (SA) often exhibit signs of anxiety, fear, or discomfort in social interactions and even avoid social situations to evade negative comments from others [
9,
10]. The prevalence of SA often decreases with age. Bai et al.‘s assessment of older persons with chronic disease using the Social Avoidance and Distress Scale revealed a lower score compared to a study of a sample of college students [
11]. Nevertheless, the 12-month incidence of diagnosed SA disorders in persons aged 65 and older was reported to be 2.3%, which is the second most frequent anxiety disorder in this age group [
12]. Previous studies have demonstrated a substantial correlation between SA and loneliness in later years. For example, a longitudinal study guided by Lim et al. discovered that SA is only significant predictor of future loneliness, with earlier SA positively predicting future loneliness [
13]. Hoffman et al. [
14] found that older adults with high SA were more likely to experience intimate loneliness (one of the characteristics of loneliness, i.e., lower quantity or quality of intimate companionship) than younger adults. People who feel lonely psychologically actually expect to construct social connections with others [
15]. However, avoidance of social situations and concerns about the threat of social situations may prevent these connections from forming, leading to decreased satisfaction with interpersonal relationships, a lack of intimacy, and increased loneliness in older adults [
14,
16]. Currently, the association between SA and loneliness has been widely studied in children, adolescents, and young adults [
9,
17,
18], while a limited number of studies have been conducted in older adults, most of which use a wide range of ages [
13,
19]. Besides, relevant pathways or internal mechanisms between these variables in older adults have not been completely explored, and further investigation is needed to facilitate prevention and interventions for loneliness in older populations.
The interpersonal model of SA proposes that when social situations may trigger SA, people will adopt self-protective strategies that result in low density and dysfunctional social relationships [
20]. Whether through active, passive, or a combination of both avoidance strategies, individuals tend to have lower expectations of the outcome of their social interactions [
21]. This dysfunctional interpersonal loop has the potential for adverse social effects, such as loneliness [
20]. On this basis, in order to establish a more comprehensive model that enhances the understanding of the relationship between SA and loneliness, the study incorporates two variables (social network and perceived social support (PSS)). Social network concerns the number and frequency of relationships a person establishes and maintains (objective structural aspects of social relationships), consisting of family members, close friends, neighbors, and others individuals in their social circle [
22,
23]. Previous studies have shown that SA is negatively associated with social network, and those with high SA typically have smaller social networks [
24,
25]. The core feature of SA is avoiding social interactions [
16], thus anticipating a reduction in the size and frequency of social network in socially anxious individuals. On the other hand, the idea that positive social network is beneficial to an individual’s physical and mental health is widely supported by theoretical and empirical research [
26‐
28]. Loneliness is significantly impacted by social network, with the latter acting as a negative predictor of loneliness [
28]. In the Amsterdam Longitudinal Study of Aging, Domènech et al. [
29] followed participants over 75 years of age for 11 years and found that decreasing social network size leads to higher levels of loneliness over time. If a person is isolated from family or friends, their perception of quality of life may decline and they are more likely to experience loneliness when functional and emotional needs are not adequately met [
30]. Conversely, positive social contacts and wider networks showed the capacity for social adaptation, generating more social resources and support, allowing older adults to maintain a positive attitude and a sense of belonging [
31]. Collectively, weak social network was likely to be accompanied by SA and loneliness. Thus, based on the interpersonal model of SA and prior evidence, we hypothesized that SA may exacerbate older adults’ dissatisfaction with family and friend network (loneliness) by reducing the size of these ties and the frequency of contact.
Social support is categorized into received social support and PSS [
32]. PSS is broadly defined as individuals’ perceptions of the availability of social support in their networks, emphasizing the subjective emotional experience and satisfaction of an individual when they feel respected, supported and understood in society (functional aspects of social relationships) [
23,
32]. Compared to received social support, PSS has a stronger relationship with a person’s mental health [
33]. According to Hobfoll’s conservation of resources theory, people are susceptible to resource loss when faced with stressful circumstances, yet protecting and maintaining resources can mitigate the potential negative consequences of stress [
34]. Therefore, PSS may act as an adjustable resource to alleviate stress and promote individual mental health. Ren et al. discovered that PSS had a negative association with SA and moderated the link between physical activity and SA in left-behind children [
35]. Among older adults, PSS was a protective factor against loneliness, and the predictive effect of chronic diseases on loneliness was more significant with low levels of PSS [
36]. However, to our knowledge, no thorough investigation has been made into the mechanisms of the moderating role of PSS in the triadic interaction between SA, social network, and loneliness in older persons. A high level of PSS can make older persons feel valued and motivated to socially interact, expanding their social networks when they suffer anxiety due to socially uncertain situations and negative evaluations. Thus, based on the conservation of resources theory and existing research evidence, we hypothesized that PSS moderates the mediating effect of the social network on the association between SA and loneliness.
One of the most well-liked psychosocial models currently explores how social network and social support buffer the effects of life events or changes on health [
22]. Social network highlights the quantity of social relationships, whereas social support emphasizes the function of social relationships. They explain different aspects of interpersonal relationships. By incorporating both social network and PSS into the model, this study aims to provide a more comprehensive understanding of the effects of social relationships on SA and loneliness in older adults, enrich research on loneliness in older adults, and provide a new empirical basis for reducing loneliness in older adults. The research hypothesis are as follows:
Discussion
This study employed social network as the mediating variable and PSS as the moderating variable to construct a moderated mediation model. In addition to elucidating the processes by which SA affects loneliness in older adults, this novel evidence provided important responses to the conditions under which SA affects loneliness, and contributed to the development of effective targeted interventions. Specifically, SA had an impact on older adults’ loneliness through social network. Additionally, PSS moderated the relationship between SA and social network as well as the relationship between social network and loneliness.
In this study, SA had a significant positive predictive effect on loneliness, in line with findings from several studies [
14,
19]. The outcome highlights SA is a risk factor of becoming lonely, and that assessing and intervening in SA in older adults can help identify and reduce loneliness. Furthermore, social network was further found to play a mediating role between SA and loneliness, confirming the validity of hypothesis 2. SA not only affected feelings of loneliness directly, but also exerted an indirect effect on loneliness through social network. Several reasons contribute to this phenomenon: first, over time, older adults may experience negative events, such as age-related physical limitation, retirement or widowhood, which lead to negative self-perceptions and feelings of disconnection from an increasingly fast-paced and rapidly evolving society [
51,
52]. Experience SA, especially if fearful of social situations and negative evaluations, can lead to small network and infrequent social interaction, making it more difficult to build and sustain intimate social ties [
24,
25]. Consequently, they are more susceptible to social isolation. Second, studies have consistently shown a strongly negative relationship between social network and loneliness [
15,
28,
53]. Social network can serve as a protective factor against loneliness when they satisfy older adults’ demands for a sense of belonging and desired social relationships [
53]. Due to the influence of the traditional culture of filial piety in China [
4], most elderly have deep-rooted family values and expect close, interdependent family relationships. However, as children move out and the proportion of empty nesters gradually increases, the size and density of older adults’ family network may gradually decrease [
27]. The social network will be single and fixed. Many senior citizens choose to migrate to their adult children’s hometowns, accompanied by language and cultural barriers, may contribute to a decline in existing network, making it challenging to make new friends [
51,
54]. All these problems can lead to social isolation and loneliness.
Altogether, the study of the mediating role of social network has enriched the understanding of the inter mechanisms underlying the relationship between SA and loneliness, highlighted the exploration of the antecedents of social network, and validated the interpersonal model of SA. Future practice should pay attention to developing effective strategies that not only address the issue of SA among older people, but also strive to strengthen social network in order to reduce the occurrence of loneliness.
The moderating role of PSS
According to hypothesis 3, the results demonstrated that PSS moderated the mediation role of social network. In the pathway of “SA → social network”, social network was higher in the high PSS state at both low and high SA, suggesting a protective effect of PSS on social network reduction due to SA. However, this protective effect rapidly diminished with higher SA, indicating that PSS is a stress-vulnerability factor in pathway 1. Although there was no support for stress-buffering in the result, there was also an indication of the protective effect of PSS. Rueger et al.’s study on the association between PSS and depression conceptualized protective factors’ buffering effect in two different ways: stress-buffering (effects of social support are enhanced) and reverse stress-buffering (effects of social support are dampened) [
55]. The finding of this study was consistent with reverse stress-buffering model, where the protective effect of PSS is limited. High level of PSS arose from interpersonal relationships, which, to some extent, created part of the social network for older adults. It can boost confidence in older adults and keep them emotionally upbeat to cope with stressful threats in social settings, therefore becoming useful in preventing the reduction of social network in older adults suffering from SA [
3,
56]. The cognitive-behavioral model of SA [
57], however, posits that individuals with SA will be preoccupied with self-representations that they regard as faulty or related to not meeting social expectations or norms. When seeking PSS, older adults may focus on diminished physical functioning, compare themselves to those believed to be highly capable, and acquire low self-esteem [
58,
59]. On the other hand, when older adults suffer from high level SA, they may be more sensitive to any perceived differences in social relationships and adopt negative and avoiding attitudes, thereby denying appropriately received social support and resulting in a lack of PSS. Low self-esteem and hypersensitivity to social situations weakened the protective role of PSS in the process of SA-induced social network narrowing. It might also be understood that once stress reaches a certain level, PSS may lose its ability to offset SA. In the case of low PSS, older adults’ social networks may have been restricted. Therefore, their social networks changed less regardless of high or low SA.
Regarding the pathway of “social network → loneliness”, the study also found that loneliness decreased significantly with the increase of social network in the case of high PSS, suggesting that PSS plays a facilitating role in the process of social network affecting loneliness, consistent with the conservation of resources theory [
34]. When older adults feel high PSS, they gain more value-affirming, self-worth and life satisfaction [
3,
30]. They exhibit more positivity and optimism when interacting with others and are able to perceive the benefits of objective social networks, which, in turn considerably improve social networks, such as network size [
2,
29], and reduce loneliness. In addition, the connection between older adults and those in their social networks who provide support not only promotes the development of intimate relationships, but also increases the likelihood of exposure to health information, further boosting mental health [
60]. Conversely, the study discovered that in the event of reported poor PSS, the decrease in loneliness did not change significantly with increasing social network, indicating that the elderly could not effectively access the positive effect of social network when lacking social support. Therefore, they were unable to successfully reduce loneliness through expanding their social network. Accordingly, building a strong social support network is an important way for older adults to maintain a good psychological state since it may help social network strengthen and mitigate loneliness. Nevertheless, given the relatively limited protective effect of PSS, just trying to increase their level of PSS may not be appropriate for lonely older adults experiencing SA. How to reduce SA in older adults may be the focus of interventions.
Limitations
The current research still has some limitations. First, as the study was designed as a cross-sectional survey, making causal inferences was not possible. However, the moderated mediation model was based on a theoretical foundation and supported by previous empirical studies, so the cross-sectional survey can still provide valuable information about the relationships between variables. More longitudinal studies are needed in the future to improve the representativeness of the moderated mediation model. Second, the LSNS- 6 scale was used to measure social network in the study, which includes relatively objective items characterizing the structure of social relationships (i.e. size of active network, size of intimate network and frequency of contact). But the size of social network and the frequency of contact among different older adults might affect the availability and effectiveness of resources as well as the study results. It is recommended that the role of these variables be further explored to suggest more detailed interventions. Third, although the questionnaire used in this study has been validated in previous studies with satisfactory reliability and validity, all variables were based on older adults’ self-report, introducing the possibility of self-report bias. Finally, due to the dialect problem, only non-random sampling, rather than random sampling, could be used in the study, which affected the representativeness of the study sample to some extent.
Relevance to clinical practice
This study provides new perspectives for nursing home or community managers to lessen loneliness in older adults. First, prompt screening and treatment for SA can be an effective measure to identify and reduce loneliness in older adults. The degeneration of psychological and physical functions brought about by aging makes the elderly less adaptable to social and more fearful of negative evaluation, so they tend to avoid social situations. It is necessary to provide cognitive behavioral training to this population to reduce SA. Second, older people with SA may not initiate social interactions. Social assistance and inviting them to participate in community building or in the daily management of the nursing home contribute to the expansion of social network. Third, the assessment and intervention of PSS also deserve attention. Measures to increase the perceived support of older adults, especially emotional support from family and friends, should be taken along with improving social network to enhance their use of PSS and reduce loneliness. For example, nursing home or community managers can work with family and friends to establish small social support groups, organizing regular speech contests, group interaction activities, and changing the location of the event from time to time to help participants with SA adjust to different social situations. However, it’s crucial not to overstate the role of protective resources such as PSS.
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