Main findings
From our data it was clear how hard it was for people to work with feelings of loneliness: addressing loneliness involved taking risks and doing things, such as being around others, that did not always feel comfortable. We also found participants reacted differently to their Community Navigator; one person required praise and confidence to progress, while another found working with their Community Navigator created a sense of security and safety to explore their local area. We found people reached different stages in addressing feelings of loneliness, and even where loneliness, depression or anxiety were still present, people had achieved personally significant changes.
We also identified six key factors from the thematic analysis that help explain our narrative findings; factors which could either help or hinder participation and their degree of influence could vary over the course of the programme. Some of the factors relate to the individual participant, such as their desire to connect to others and their level of social confidence, particularly in social situations. Others function predominantly at the interpersonal level, e.g. the participant’s relationship with their Community Navigator, or to structural factors such as the availability of local resources that are both accessible and affordable. To our knowledge, this is the first study that has looked at the way in which individual and contextual factors affect how people with severe depression and/or anxiety participate in a programme aiming to reduce loneliness.
Findings in the context of previous research
Our findings relate to and have implications for four areas of existing research regarding loneliness and wellbeing: asset-based approaches; social identity theory; recovery models; and therapeutic alliance. These are discussed below.
Addressing loneliness is challenging and complex [
21]. Reducing feelings of loneliness was noted by the experts by experience on our working group to require high levels of emotional energy and courage and involved personal costs. The intersection of these efforts with the symptoms of depression and anxiety is a challenge to manage. Our study findings support conclusions from previous research that addressing loneliness may require both practical and psychological changes, such as changes to routine, increasing access to activities, as well as directly focusing on social connections and their appraisal [
24]. Many theories of emotional and social loneliness prioritise the appraisal of relationships [
41] and do not cover a domain that emerged as important in our findings: that of the accessibility of resources locally. The Community Navigator programme is located within Mann et al.’s typology as a “supported socialisation” intervention [
9]. Theoretically, the programme links well to social identity theory [
42] and asset-based approaches [
43] which are key constructs for understanding how and why the Community Navigators approach may achieve benefits for participants. This distinguishes it from programmes underpinned more directly on cognitive or behaviour change models, which are centred on cognitive appraisal, social skills and psycho-education approaches [
44]. Our study suggests that addressing people’s subjective appraisal of their social world may often not be enough to address loneliness: people need information and practical support to access local social resources too. This covers practical issues such as going into open spaces, accessing groups, transport, money and a companion to go out with. We may need to view loneliness within a broader systemic context to move beyond its emotional attributes to also consider wider contextual issues. This supports the value of asset-based approaches in mental health [
45] and resonates with the person-centred approach taken by the Community Navigators, which provided each person with a bespoke package to support their journey to addressing feelings of loneliness. Approaches will also need to consider that progress may not be linear and some barriers, particularly structural issues including poverty, will be hard to address long-term through a programme of individual support.
Identifying people’s interests and what generates ‘meaning’ for an individual was also central. Social identity theory [
44] helps explain how people’s sense of self, self-esteem, belonging and positive social identities are related to positive health outcomes. The Community Navigator strove to enhance and build upon existing identities as well as encourage new meaning through an identity formation process. We noticed that some of the people in the programme had a strong sense of identity such as businessperson, mother, artist. For some participants, depression and anxiety had a ‘stronger’ explanatory impact on how they felt about social relationships than these social identities but there were instances of people re-establishing positive social identities through the support of the Community Navigator. As has been demonstrated for adults with psychological distress [
46], social identity approaches may also hold promise as a way of addressing loneliness among people using secondary mental health services.
‘Recovery’ is often related to five key concepts [
47]: connectedness; hope; identity; meaning in life; and, empowerment. We found the desire to connect with others varied and was a fundamental barrier to reducing loneliness when absent in narratives. People spoke about low confidence in talking to others, poor self-esteem including feeling they did not have much to offer relationships, and poor trust in people. The Community Navigators were tasked with supporting people to develop new social relationships or reconnect with past contacts. If the service user was very reluctant to meet people socially, the focus shifted to using the time to explore opportunities to take up activities and go to different places. These steps are known to stimulate small social interactions otherwise termed ‘weak ties’ within social networks [
48] and can act as bridging social capital [
49]. Where desire to connect with other people was higher, the relationship with the Community Navigator developed more quickly and supported quicker progress thorough the programme to researching opportunities locally and understanding how best to support behaviour change.
The importance of ‘therapeutic relationships’ [
50] guided the recruitment of people into Community Navigator roles. Priorities within recruitment included collaboration, empathy and respect in provider-client relationships as well as qualities found in peer support workers such as building trust [
51] and appropriate use of personal disclosure [
52]. The relationship with the Community Navigator emerged as a central influence on participation in the programme, with the personal qualities of the Community Navigator valued and acknowledged as well as the quality of relationship. We found that key Community Navigator characteristics valued by service users in the programme were flexibility of approach, authenticity in the relationship, sharing personal views and information, and using an encouraging, solution-focused approach. The approach was not judgements over ‘success’ and ‘failure’ but the role of Community Navigators was to support context specific progression. Progress included opening the door and conversing with the Community Navigator as well as for others more visible progress such as joining a new activity group.
Community Navigators acknowledged how hard it was in the context of health problems including mental health and sleep issues, as well as pervasive life difficulties such as relationship breakdown, financial concerns, immigration and housing insecurity to work with feelings of loneliness. The dedicated support could not always overcome other deeply embedded problems that some of those we worked with experienced. Although everyone interviewed signed up to take part in a social programme to address loneliness, not everyone was able to fully participate with their Community Navigator.
Strengths and limitations
The co-produced approach to the design, delivery, analysis and write-up of this study was one of its strengths allowing expertise from experiential, clinical and academic experience to shape the study and its findings. The analysis process was rigorous, involving multiple readings of transcripts and time for discussion of codes and themes to come to a shared agreement about meaning. We have endeavoured to be transparent in the methods underpinning our analysis and in the evidence illustrating our results, to increase the credibility and trustworthiness of our findings [
53]. The novel two-stage analysis approach was chosen to both keep a focus on the whole person and their individual story, consistent with the programme’s person-centred approach, whilst also searching for common themes across the data set.
Although we spoke to many of the people who took part in the feasibility study, our findings did not include those who we could not contact or did not consent to an interview. These individuals may have faced other challenges to participating in the programme. We also only worked in two NHS Trusts in inner and outer-London metropolitan environments, so would need further research to explore loneliness programmes in rural settings, where the range of options for social engagement may be more limited and transport is more of a challenge. This paper explores the views of programme participants: we acknowledge that other stakeholders, including the Community navigators, and involved family and mental health staff, might also have useful perspectives on factors influencing participation in the programme. A summary of stakeholders’ views on the acceptability of the programme has been reported elsewhere [
28].
Implications for research
While more research is still needed to fully understand the experience and drivers of loneliness for people with mental health problems, it is also a priority to develop and test of interventions which can alleviate loneliness, informed by current evidence, theory and first-hand knowledge.
This study has underlined the importance of researchers considering not only whether an intervention is effective, but also understanding what may affect the achievement of successful outcomes, especially in an area such as loneliness where human factors may affect intervention delivery in unanticipated ways. Future evaluations should include process evaluation components and areas that are rural or more asset poor, to investigate how such a programme would work where social resources are less widely or immediately available. Our study indicates several potential moderators and mechanisms of the effect of the Community Navigator programme, which we recommend could usefully be measured in a future trial to understand how the intervention may be reducing loneliness and improving health outcomes: these include: the therapeutic alliance, perceived self-efficacy; extent of positive social identities, and perceived neighbourhood social capital.
The many positive appraisals of the Community Navigator programme suggest a socially focused, asset-based approach to reducing loneliness may be suitable for people with severe anxiety or depression using secondary mental health services. We do not yet have definitive evidence regarding its effectiveness for reducing loneliness and improving health outcomes however: a larger research trial is recommended involving multiple sites. This could also allow for exploration of intervention effectiveness in different population sub-groups, and different geographical settings.
Implications for practice
Addressing loneliness is both difficult and essential for wellbeing: people who are lonely tend to be more critical of others and themselves, be more self-conscious in social situations, and enter relationships with greater mistrust. However, our study shows that, despite internal and external barriers, people with severe depression and anxiety want help and can take steps to address loneliness. Some people will need more extensive work to address their own internal challenges to getting involved. Consideration should thus be given to who is offered a programme to address loneliness, to check they have sufficient desire to develop social connections at that point in time. Individuals may have other goals, such as gaining a new qualification, where other forms of support could better assist. Reviewing the six factors influencing participation may be one way to explore suitability for the programme; we urge flexibility in doing so, using the factors as a guide not a checklist.
It is also important to consider how people can be prepared to make the most of a time-limited loneliness intervention, for instance through conversations to identify interests and goals prior to taking part or supporting people to become more used to leaving their homes. Another element of timing is being able to take a pause in the programme when fluctuating mental health or other life factors make engagement difficult. There was limited opportunity for this within the constraints of a short-term research trial, but where possible, this should be considered for loneliness programmes offered as part of an ongoing clinical service.