Social isolation and loneliness among people living with experience of homelessness: A scoping review

doi:10.21203/rs.3.rs-4618264/v1

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Social isolation and loneliness among people living with experience of homelessness: A scoping review

https://doi.org/10.21203/rs.3.rs-4618264/v1

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Social isolation and loneliness (SIL) are public health challenges that disproportionally affect individuals who experience structural and socio-economic exclusion. The social and health outcomes of SIL for people with experiences of being unhoused have largely remained unexplored. Yet, there is limited synthesis of literature that focused on SIL to appropriately inform policy and facilitate targeted social interventions for people with homelessness experience. The aim of this scoping review is to synthesize evidence on SIL among people with lived experience of homelessness and explore how it negatively impacts their wellbeing.

We carried out a comprehensive literature search from Medline, Embase, Cochrane Library, PsycINFO, CINAHL, Sociological Abstracts, and Web of Science's Social Sciences Citation Index and Science Citation Index for peer-reviewed studies published between 2000 to on January 3rd, 2023. Studies went through title, abstract and full-text screening conducted independently by at least two reviewers. Included studies were then analyzed and synthesized to identify the conceptualizations of SIL, measurement tools and approaches, prevalence characterization, and relationship with social and health outcomes.

The literature search yielded 5,294 papers after removing duplicate records. After screening, we retained 27 qualitative studies, 23 quantitative studies and two mixed method studies. SIL was not the primary objective of most of the included articles. The prevalence of SIL among people with homelessness experience varied from 25–90% across studies. A range of measurement tools were used to measure SIL making it difficult to compare results across studies. Though the studies reported association between SIL, health, wellbeing, and substance, we found substantial gaps in the existing literature. Most of the quantitative studies were cross-sectional, and no study reported on interventions that targeted SIL as a main or secondary outcome.

More studies are needed to better understand SIL among this population and to build evidence for actionable strategies and policies to address its social and health impacts.

Social Isolation and Loneliness

Homelessness

Homeless

Support housing

scoping review

Social isolation and loneliness (SIL) are major social and health issues representing a growing global public health challenge, particularly for socio-economic excluded and underserved population. Social isolation can be defined as a lack of close or meaningful relationships and results from multidimensional experiences associated with exclusion from mainstream society, hopelessness, abandonment, social marginalization, lack of community networks and dissatisfaction with relationships.^1,2 Loneliness is a more personal and subjective multifaceted experience consisting of different types of self-perceived social deficits, including social loneliness, defined as a self-perceived lack of friendships in either quality or quantity and emotional loneliness, experienced as a deficit of intimate attachments such as familial or romantic relationships or feeling alone and isolated.^1–3

SIL has been linked to putting people at increased risk for adverse health outcomes. social distress and premature death. Lack of adequate social support has been reported to increase the odds of premature death by 50%.⁴ Previous studies have also found an association between SIL and increased risk of developing dementia, coronary heart disease and stroke and poorer mental and cognitive health outcomes, consumption of low-quality diet.^5,6 While SIL affects many populations, individuals with experiences of being unhoused are among those with the highest risk of being socially isolated and lonely. First, experiences of homelessness are visible and extreme forms of social exclusion. Unhoused people are more socially disconnected, can feel rejected or abandoned, and may not have appropriate informal (family, relatives, friends) and formal support networks.^7,8 Second, even after being housed, structural form of oppression (i.e., racism) and discrimination associated with previous experience of being unhoused continue to hinder individuals’ lives and can deprive people of meaningful recovery and social integration, connection and relationships.^9–11 People with experiences of being unhoused have self-reported higher odds of poor mental and physical health and loneliness than their housed counterparts.¹² Moreover, people with experiences of being unhoused have lower life expectancy and experience impairments associated with aging earlier than people without experiences of being unhoused.^13–15 These factors make individuals more vulnerable to social and economic abuse, which may affect the ability to build meaningful social connections.

Recent years have seen increased initiatives to address SIL among formerly homeless populations. There is some consensus in social work to consider SIL in needs assessments for social care and health for some specific population groups such as seniors and youth.^16,17 More resources are being allocated to address SIL in supportive housing programs and intervention design.¹⁸ Social prescribing, which involves primary care physicians prescribing social activities to patients as a strategy to strengthen social engagement and lower loneliness, is becoming a growing practice.^19,20 Nonetheless, SIL remains complex to conceptualize, and it has been difficult to measure its prevalence and association with social and health outcomes and other indicators of wellbeing. Without a clear conceptualization and measurement approach, it is uncertain how to design adequate interventions and policies to address SIL.

The aim of this scoping review was to identify, map, and synthesize the findings of qualitative and quantitative studies that measure SIL among people over the age of 18 with lived or living experience of homelessness including those living in supportive or social housing, or staying in emergency or transitional accommodation in order to highlight the gaps in the existing literature and inform the development of future interventions. This scoping review will aim to answer the following questions:

How are SIL conceptualized across studies involving people with experience of homelessness?

What scales and tools are used to measure SIL across these studies?

What is the prevalence of SIL and the relationship between SIL and social and health outcomes in people with experience of homelessness?

2.1 Search methods

The scoping review protocol followed the methodology outlined by Arksey and O’Malley, Levac et al.¹⁸ and is guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses extention for Scoping Reviews (PRISMA ScR)²¹. Comprehensive literature searches were carried out by an information specialist (CZ) in Medline (Ovid platform), Embase (Ovid), Cochrane Central Register of Controlled Trials & Cochrane Database of Systematic Reviews (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Sociological Abstracts (ProQuest), and Web of Science's Social Sciences Citation Index and Science Citation Index. The search strategies had a broad range of subject headings and keywords, adapted for each database, for the two core concepts of SIL and homelessness or social housing, combined with the Boolean operator AND. The searches were limited to articles in English, French, and Spanish published between 2000 to October 27, 2021, followed by a search update on January 3rd, 2023. Comments, editorials, and letters were excluded from the search. There were a total 8,398 results from these two rounds of searches prior to de-duplication (7356 at search one and 1042 at search two) and the records were compiled in EndNote. The complete search strategies as run are included in the supplementary material.

2.2 Screening process

We established the following inclusion criteria for the scoping review: peer-reviewed qualitative and quantitative original research papers published in English, French, or Spanish between 2000-and January 3, 2023 that targeted homeless or formerly homeless adult populations or marginally/vulnerably housed populations (people living in supportive housing, shelter services); examined or included in the analyses: loneliness, social isolation, social disconnection, solitude, loneliness, social withdrawal, abandonment, lack of contact, social exclusion or rejection.

We excluded papers that were systematic or scoping reviews, papers where the studied populations did not include adults or youths; where the field activities and data were collected from caregivers or other workers, and not formerly homeless/roofless or marginally housed and vulnerably housed; that only focused on social exclusion, networking or community integration and did not refer to loneliness or social isolation; and those published before 2000 or in a language other than English, French or Spanish.

The results from all searches were imported to Covidence systematic review software, where duplicates were removed. The searches yielded 5,294 papers for screening after the deletion of duplicates. Four researchers (AY, EG, FM, and MP) screened the article titles and abstracts independently and in duplicate in Covidence using the predetermined inclusion and exclusion criteria. The full-text of the articles that met our eligibility criteria were then assessed by two independent reviewers. At both stages, differences in voting were discussed and resolved as a group, including the Principal Investigator (JL). In total, 52 articles met the criteria for data extraction and analyses. The PRISMA diagram in Fig. 1 shows the flow of information through the different stages of the review.

The main characteristics and findings of the selected studies were extracted in an Excel database file by the four researchers (AY, EG, FM, and MP) and reviewed by the Principal Investigator (JL). A summary of the extracted data can be found in Table 1 and Table 2.

3.1 Overview of included studies

The main characteristics of the 52 articles included in this review are outlined in Table 1 and Table 2 below. Most articles (n = 42) were published from 2010 and later and were conducted in the US (n = 16) and Canada (n = 16). Study methodology was almost evenly split into quantitative (n = 23) and qualitative (n = 27), and a very small number (n = 2) used a mixed methods approach. Among quantitative studies, 18 had a cross-sectional or one-point-in-time design, and five used a longitudinal design. Most of the qualitative studies (15) used a thematic analysis approach.

Table 1: Quantitative Studies Summary

Table 2: Qualitative and Mixed Method Studies Summary

3.2 Characteristics of the populations covered in included studies

Among the included articles, four focused on women^22–25 and older women²⁶; five studies examined a solely male populations^27–30 or older men.³¹ In total, 10 articles focused on older adults, which was usually included early aging starting from 50 years ³²or 55 years ³³ of age and above for populations with experience of homelessness. We found no studies that focused on non-binary groups, though gender-diverse self-identified individuals were included in six of the studies.Moreover, there were a small number of studies (n = 6) focused on youth. Three of these were quantitative studies^34–36 that compared homeless youth and young adults to youth in the general population. The other three were qualitative studies^37–39; two described how youth experience loneliness^38,39; one study identified strategies for dealing with feelings of loneliness among homeless adolescents.³⁷ Three studies^40–42 focused on a population of veterans who were currently experiencing homelessness or were formerly homeless and living in either subsidized or supportive housing. Participants’ ethnicity was reported in most of the studies (n = 32).

3.3 Social isolation and loneliness as the primary objective

Only 18 of the 52 studies focused on SIL as their primary objective or included SIL in the main research questions. Of these 18 studies, 13 were quantitative and five were qualitative (See Table 1 and Table 2. In the remaining 34 articles, SIL neither was the main objective nor clearly stated in the objectives or research questions. In those studies, SIL was usually considered as one of the potential explicative or control factors^43–45, and eventually emerged or were co-created from the participants’ narratives.

3.4 Conceptualization of social isolation and loneliness

Different theoretical frameworks were used to contextualize SIL in relation to unhoused or homelessness experiences. For some studies, SIL was embedded in the homelessness experience, since homelessness is in itself a form of social exclusion, which limits people’s participation in society.^28,46 Lafuente et al.²⁸ explained the experience of unhoused men through the lens of social disaffiliation theory. They explained that situational changes (i.e., loss of employment) or intrinsic factors (voluntary withdrawal) caused participants to become socially disaffiliated. Narratives on isolation from this study revealed feelings of alienation, powerlessness, self-rejection, depression, loneliness and unworthiness. Similarly, the study by Burns et al.³¹ explained how the transient nature of being unhoused creates interrelated dimensions of social exclusion, generating a sense of invisibility, identity exclusion (i.e., racism), exclusion of social ties and meaningful interactions with the community, thus leading to social isolation.

Bell and Walsh²⁹ conceptualized SIL among individuals experiencing homelessness as being driven by mainstream normative conceptions of homelessness and the stigma of homelessness. The authors suggest that conceptions of homelessness conflate between notions of “rooflessness” and “rootlessness” which “denotes the absence of support and inclusion in one’s community driving experiences of isolation and loneliness.”²⁹

In the study by Baker et al.,⁴⁶ SIL is discussed as part of a new landscape of a network society and digital exclusion. The rapid development of information and communication technologies (ICT) has drastically changed human communication and interactions leaving many behind and out of the communication flows. The authors explained that aging combined with many social disadvantages like histories of homelessness, multiple complex needs, rural areas of residence, and economically restricted mobility can contribute to creating or keeping affected older adults disconnected and socially isolated.

Meaning and experiences of social exclusion and, in particular, SIL were further voiced through semi-structured qualitative interviews or focus groups in different studies included in this review. Often, participants reflected on how broader structural stigmatization and alienation associated with housing insecurity contributed to their perceived SIL. Jurewicz et al.⁴⁷ highlighted how systemic policies and practices affecting individuals experiencing homelessness who used substances, generate and contribute to the ongoing experiences of housing precarity, loneliness and isolation. Participants further discussed the social challenges and complex interrelationship between substance use and homelessness such as the strain in social relationships as a result of substance use.⁴⁷ Similarly, Martínez et al.,⁴⁸ described how experiences of loneliness are driven by a lack of meaningful relationships, conflicts with families, a lack of social inclusion, and marginalization faced by individuals residing in a residential center in Gipuzkoa, Spain. In the study by Johnstone et al.,⁴⁹ social isolation was defined as being related to not having perceived opportunities to develop multiple group memberships.

Experiences and conceptualizations of loneliness were not strictly dependent upon one’s lack of access to housing. Two studies discussed how the transition into housing, whether supportive or transitional, further exacerbated experiences of loneliness and isolation.^40,50 Polvere, Macnaughton and Piat⁵⁰ and Winer et al.⁴⁰ highlighted that the transition to living within congregate-supported settings or independent apartments can be linked to experiences of SIL even when people are offered social engagement activities. Some participants reported feeling voluntarily isolated as they did not want to engage with others and some participants anticipated social isolation due to transitioning into a new environment.

3.5 Measurement tools to assess social isolation and loneliness

There were multiple approaches to measuring SIL across the studies, including widely used and validated multi-item scales and single-item measures. There were three main scales that were developed, tested or used to measure SIL: the Rokach Loneliness Questionnaires, the UCLA Loneliness Scale and its revised versions, and the De Jong Gierveld Loneliness Scale.

The Rokach Loneliness Questionnaire

Five studies used the Rokach Loneliness Questionnaire.^{34–36,51,52} The Rokach Loneliness Questionnaire^34,35 measures causes of loneliness and coping strategies and has been used in studies with young people aged 15–30 in Toronto, Canada. The questionnaire measures the experience of loneliness across five factors, with yes/no items on five subscales: emotional distress such as pain or feelings of hopelessness; social inadequacy and alienation including a sense of detachment; growth and discovery such as feelings of inner strength and self-reliance; interpersonal isolation including alienation or rejection; and self-alienation such as feelings of numbness or denial. The items on the interpersonal isolation subscale relate to an overall lack of close or romantic relationships.

The UCLA Loneliness Scale

Six of the studies in this review used the UCLA Loneliness Scale or a revised version. Novacek et al.⁴¹ assessed subjective feelings of SIL among Black and White identifying veterans with psychosis and recent homelessness compared with a control group at the onset of the COVID-19 pandemic. The 20-item scale was used to measure subjective feelings of SIL over the past month. Participants rated their experience ranging from “never” to “often,” with higher scores indicating higher subjective feelings of loneliness. Lehmann et al.³⁰ used a revised version of the UCLA Loneliness Scale to examine individual factors including loneliness that are relevant in people experiencing homelessness to report their victimization to police. The researcher recruited 60 self-identified adult males ages 19 to 67 currently experiencing homelessness in Germany and used a revised and shorter German UCLA Loneliness Scale developed by Bilsky and Hosser,⁵³ to measure loneliness. The scale is composed of 12 items with a 5-point Likert scale ranging from 0 (“not at all”) to 5 (“very much”) and positively formulated items were recorded to reflect a higher level of loneliness. The load factors for the scale are experiences of general loneliness, emotional loneliness, and inner distance. Drum and Medvene⁵⁴ used the UCLA-R Loneliness Scale, which has been adapted for an older adult population to measure loneliness among older adults living in affordable seniors housing in Wichita, Kansas. This version is composed of 23 items, with a four-point Likert scale-type of response options. Participants’ total score ranged from 20 to 80, with a higher score representing greater loneliness.

Tsai et al.⁵⁵, Dost et al.⁵⁶ and Ferrari et al.⁵⁷ used a shortened revised version of this scale, the UCLA Loneliness Scale Version 3, which consists of three items: “how often they feel they lack companionship, how often they feel left out, and how often they feel isolated from others.” Participants self-reported their responses using a 3-point Likert scale (“hardly ever,” “some of the time,” and “often”) to answer questions. A summed score of 3 to 5 is defined as not lonely and a summed score of 6 or more is defined as lonely. The 3-item scale is used widely in research and clinical settings as a short assessment of loneliness.

De Jong Gierveld Loneliness Scale

Valerio-Urena, Herrara-Murillo and Rodriguez-Martinez⁵⁸ examined the association between perceived loneliness and internet use among 129 currently homeless single adults aged 35–60 staying in a public shelter in Monterrey, Mexico.. The authors used questions from the De Jong Gierveld Loneliness Scale, which has 11 items with three alternatives (1 = no, 2 = more or less, 3 = yes) and asks about having friends or people to talk with or contact, feeling empty or missing other people’s company, and having people or friends you can trust. The subscales measure emotional loneliness (due to the lack of a close relationship) and social loneliness (due to the lack of a general social network), scores range between 0 (no solitude) and 11 (extreme solitude).

3.5.1 Other social isolation and loneliness scales

Some of the quantitative studies used subscales or single questions from measurement tools that were not primarily designed to measure SIL. For example, Cruwys et al.⁵⁹ used the short form of the Young Schema Questionnaire, which included 75 items with five items assessing each of the 15 schemas. This study focused on the social isolation schema, which was described as “the feeling that one is isolated from the rest of the world, different from others, and or/ not part of a group.” The social isolation schema was measured using questions such as “I don’t fit in; I don’t belong; I’m a loner; I feel outside the groups.” Respondents answered with a 6-point scale from 1 if “completely untrue to me” to 6 if “describes me perfectly.” In this study, participants who responded with 5 or 6 (“Mostly true of me” or “describes me perfectly”) on the scale were assigned 1 point, otherwise they were assigned 0 points.

Wrucke et al.⁶⁰ investigated factors associated with cigarette use among people with experiences of homelessness. Social isolation was one of the variables hypothesized to be associated with smoking among this population. The authors used the short form of social isolation questionnaire developed using the Patient-Reported Outcomes Measurement Information System (PROMIS). PROMIS defines social isolation as the “perceptions of being avoided, excluded, detached, and disconnected from, or unknown by others.” It uses a 4-item social isolation questionnaire to capture each of these dimensions, for which the options of responses range from never to always.

In their study, Drum and Medvene⁵⁴ used the Lubben Social Network Scale (LSNS) to measure social isolation in addition to the UCLA-R Loneliness Scale mentioned above. LSNS was used as a measure of risk of isolation and included 10 items; three (3) items referred to family networks, three items (3) to friend networks and four items (4) to confident relationships. Each of the items had a five-point Likert scale-type response option, with the total adding up to a score between 0 and 50. A higher score on the LSNS meant greater risk of social isolation. Participants were categorized based on their LSNS score as low risk (0–20), moderate risk (21–25), high risk (26–30), or isolated (31–50).

Ferreiro et al.⁶¹ used one question from the 22-item Camberwell Assessment of Need (CAN) to measure loneliness among Housing First program participants in Spain. The onne item asks, “Does the person need help with social contact?” and the answer was classified as a serious problem if a respondent answered, “Frequently feels lonely and isolated.” Rodriguez-Moreno²³ used the General Health Questionnaire (GHQ-28) which includes a subscale of somatic symptoms, anxiety and insomnia, social dysfunction and depression to study the mental health risk of women with homelessness experience. The GHQ has one question related to “feeling lonely or abandoned.” Similarly, Vazquez et al.⁴³ reported one question on the extent participants feel lonely or abandoned using a 4-point Likert scale ranging from “not at all” to “a lot.” Pedersen, Gronbaek and Curtis,⁶² Bige et al.⁴⁴ and Muir et al.⁴⁵ also measured loneliness using a one question item. Another study by Rivera-Rivera et al.⁴² examined factors associated with readmission to a housing program for veterans using a number of tools and administrative data to create a profile of participants. In their study, social isolation was measured using the relationships section of the significant psychosocial problem areas of the Social Work Behavioral Health Psychosocial Assessment Tool where isolation/withdrawal can be listed with yes or no options.⁴²

3.6 Prevalence and scores of social isolation and loneliness: Quantitative evidence

The prevalence of SIL varied from 25% to more than 90% across studies included in this review. Based on LSNS risk categorizations, Drum and Medvene⁵⁴ found over one-quarter (25.8%) of participants were categorized as being socially isolated and nearly one in five (19.4%) as being at high risk for social isolation. Cruwys et al.⁵⁹, using the Young Schema Questionnaire-2 found more than one-quarter (28%) of participants reported elevated social isolation at time T1 (day 1) of the study, with no change in social isolation reported at time T2 (2 weeks after leaving temporary accommodations). An examination by Rivera et al. ⁴² of 620 patient records of veterans who requested services at the Homeless Program of the VA Caribbean Healthcare System from 2005 to 2014 found that over one-third (34.7%) reported experiencing social isolation. In a study with 1,306 socially marginalized people recruited at shelters and drop-in centres in Denmark, more than one-quarter (28.4%) reported often unwillingly being alone.⁶² Bige et al.⁴⁴ found that more than 90% out of 421 people experiencing homelessness were socially isolated.

Using the De Jong Gierveld Loneliness Scale, Herrara-Murillo and Rodriguez-Martinez ⁵⁸ estimated an average score of 7.12 for loneliness among surveyed participants, which is between moderate and severe loneliness (score = 8.0). Ferrari et al.⁵⁷ also found a high mean score among homeless adults (score = 6) at the baseline of the study, based on the revised 3-item UCLA scale. Rokach⁵² reported homeless adults had significantly higher mean subscale scores than non-homeless adults on four of five subscales measuring loneliness: interpersonal isolation (3.44 vs 2.82), self-alienation (1.92 vs 1.27), emotional distress (2.97 vs 2.73), and social inadequacy and alienation (2.92 vs 2.70).

3.7 Social isolation and loneliness evidence in qualitative studies

Twenty-nine studies reported qualitative evidence with the majority (n = 15) using thematic analysis to convey experiences of SIL among participants with histories of being unhoused or housing precarity. In most qualitative studies, participants referred to lack of social connectedness, weak relationships with community members, family, or friends, feelings of abandonment, or a desire to withdraw. In a study by Bower, Conroy and Perz⁸, researchers explored experiences of social connectedness, isolation and loneliness among 16 homeless or previously homeless adults aged 22–70 in Sydney, Australia. Participants described feelings of rejection through marginalization and stigma, rejection from family, lack of companionship, and shallow and precarious relationships with others, which made them feel alone.⁸

Similarly Burns et al.,³¹ reported social isolation among older adults with histories of chronic homelessness living at a single-site permanent supportive housing program in Montreal, Canada. Participants revealed that they were socially excluded based on their ethnicity and sexual orientation, which made them feel isolated. Participants in the study by Lafuente²⁸ attributed their feelings of isolation to experiences of being unhoused and narratives from 10 male-identifying participants centered on discussions of isolation, including feelings of alienation, depression, loneliness, resignation, unworthiness and withdrawal. Participants shared their feelings of being “frightened, sad, lonely, and frustrated” and wanting to “withdraw from society”.²⁸ Kaplan et al.⁶³ and Grenier et al.³³ also reported concerns of social isolation due to lack of strong familial ties among participants in their study, which impacted engagement with services and contributed to feeling isolated and ostracized.

In a study of 46 adults using shelters and drop-in centres in Denmark, participants reported challenges with develop lasting and meaningful social relationships with others.⁶⁴ With data from the 30 participants included in the analysis, the authors categorized SIL into 5 groups: socially related and content (n = 9) characterized by satisfying relations with social and professional groups; satisfied loners (n = 5) centered on social isolation bringing rewards of peace and quiet; socially related but lonely (n = 4) focused on superficial social relations; socially isolated (n = 9) comprised of sporadic social connections; and in-between (n = 3) characterized by broad networks, however feeling unsatisfied with social networks.⁶⁴

Other studies focused on experiences of SIL in relation to the negative consequences of being unhoused and associated stigma. Bell et al.²⁴ revealed participants’ feelings of worthlessness as a result of the social stigma of being unhoused. Participants described homelessness as: “walking around with a big sign on your head that says, “I’m worthless” … the way you are looked on by society, like you feel like an alien…you always have to leave because you’re not welcome, you’re not welcome, you’re not welcome anywhere. In a town of a million people you are made to feel like you’re by yourself and you’re alone because there is nowhere to go.” Another study aimed to understand the experiences of SIL among 11 adults aged 22–60 (5 self-identified females; 6 self-identified males) staying in residential centers in Spain.⁴⁸ Participants reported loneliness as a chronic and persistent experience. One participant described it as follows: “I’ve always felt lonely, everywhere I’ve been, even having people around me…It’s not about being physically alone…it’s a loneliness inside.”⁴⁸

Nonetheless, transitioning from homelessness to housing does not imply a reduction of SIL, at least in the short term. Several qualitative studies^{65,66, 40, 67, 50} were conducted with participants of the At Home / Chez Soi study, a pragmatic randomized controlled trial in Canada that used a Housing First approach to provide housing and supports to individuals experiencing homelessness and with mental illness health. ⁹ Some participants who received housing experienced loneliness⁶⁷ whereas others expressed concerns about not being able to cope with social isolation following a transition to independent housing.⁵⁰ Moving into housing can contribute to SIL with a shift from being surrounded by people in a shelter or in jail, to living alone.^{65, 25} One participant said: “It’s [the transition] hard because I’m used to having people around me all the time.” ⁵⁰ In a study by Winer et al.⁴⁰, some participants who received housing chose not to socialize or build relationships: “But I don’t socialize here at all. I didn’t think, I didn’t realize that I would be so isolated. You know, I could go knocking on doors and try to be friends with people. But I just don’t bother to do that. I’m not interested in reaching out.”

Other studies that examined individuals accessing transitional accommodation reported that participants’ positive comments illustrated connections with peers and program staff and these connections resulted in them no longer feeling lonely or isolated.⁴⁹ Over one-third (34%) of participants reported positive experiences with respect to their accommodations, interactions with caseworkers and with their peers/other residents, which made them not feel lonely or isolated. Another study⁶⁸ found access to supportive housing was also associated with reduction in drug use; while some participants were spending time alone, they did not report feeling lonely. Some reported having pets and others did volunteer work to help them overcome feelings of social isolation.

Other studies reported SIL among young populations with homelessness experience. A study by Rew ³⁷ conducted interviews and focus groups with 32 homeless youth ages 16–23 participating in a community outreach project in central Texas and found reasons for loneliness included personal loss, traveling and being away from family and friends, and at certain times, for example at night, during winter, or specific occasions such as holidays and birthdays: “I just get lonely at night…more at night.”³⁷ Another study by Johari et al³⁹ conducted interviews and focus groups with 13 individuals ages 18–29 in Iran about their experiences of homelessness. Participants described feeling lonely, harassed and abandoned by society. Themes that emerged from the interviews included “avoidance of/ by society, comprehensive harassment, and lack of comprehensive support”.³⁹ Participants reported feeling isolated due to a loss of self-confidence and social trust. One participant shared, “I have nothing to do with anyone, and I am alone.”

Some qualitative studies reported on SIL among people with experiences of homelessness in the context of COVID-19.^{38,69,70, 66} These studies explained how social distancing and other public health restrictions disrupted social relationships with housing staff, other residents, family members and communities and reduced access to services. Participants discussed how an increased fear and a lack of social networks exacerbated feelings of social isolation during lockdown periods: “Aside from not being allowed to go out the f… door aye. I’m not allowed out. Everybody else can go for a walk, I am imprisoned in the square.”⁷⁰ Another study by Noble et al. ³⁸ analyzed the impact of COVID-19 on 45 youth ages 16–24 living in emergency shelters in Toronto, Canada. Youth stressed that the pandemic and associated public health restrictions (closed common spaces, canceled in-person activities, social distancing and single-occupancy sleeping arrangements) led to reduced access to important social networks, and an associated increase in feelings of SIL: “Like, right now, because of everyone’s at home, because of the lockdown and you can’t really like meet people […] it’s a very challenging moment, it’s testing me, another limit of me”.³⁸

3.8 Intersectionality in homelessness, social isolation and loneliness

Studies found that identities played a critical role in shaping SIL experiences among people with homelessness experience. People reported different SIL experiences and faced different related-SIL forms of challenges based on their gender⁵⁷, ethnicity and sexual orientation,³¹ and age.³⁵ For example, Ferrari et al.⁵⁷, using the revised 3-item UCLA scale, found women had statistically significant and higher mean loneliness scores (6.29) compared with men (5.57). Using the same scale, Dost et al.⁵⁶ reported an average loneliness score of 5.2 (SD = 1.9); among self-identified men it was 5.1 (SD = 1.9) and among self-identified women, it was 5.4 (SD = 2.0) (n = 265 reported frequency of loneliness). Using the De Jong Gierveld Loneliness Scale, Herrara-Murillo and Rodriguez-Martinez⁵⁸ found young participants (˂35 years of age) reported slightly higher levels of loneliness (mean score = 7.88) compared with older adult participants (between 35–60) (mean score = 7.4). Rokach^34,35 found homeless youth, compared to young adults, had higher mean subscale scores on interpersonal isolation (3.43 vs. 2.84) and self-alienation (1.91 vs. 1.48).

Other studies among younger populations also described how young people with experience of being unhoused and coping with SIL are significantly different than their housed counterparts and older adults. Histories of addiction, rejection, trauma, and violence were intertwined with loneliness for young people with experience of homelessness.^35,37–39 A study by Rokach³⁵ focusing on the experiences of loneliness among homeless youth in Canada found that causes of loneliness included feeling of personal inadequacy, developmental deficits, unfulfilling intimate relationships, relocation, and social marginality, which are unique to these groups of individuals when compared with older adults.

Toolis et al.²⁵ examined how multi-faceted forms of structural inequities faced by self-identified women experiencing homelessness (i.e., stigmatization, violence, and child apprehension) drive social exclusion experiences from services, peers, and broader society. This study illustrated how organizational settings with a culture of acceptance, support and mutuality can help women develop positive affirming relationships with one another that can alleviate social isolation. In thisanalysis, participants highlighted how their transgender identity contributed to experiences of isolation and loneliness and how their experiences were driven by forms of oppression prevalent across social service spaces such as co-ed shelters.²⁵

3.9 Association between SIL and social distress

SIL are strong determinants of social wellbeing and recovery pathways for people with homelessness experience and this was highlighted in multiple studies. Cruwys et al.⁵⁹ found that the social isolation schema predicted lower social identification with homelessness services. Individuals with negative social experiences with homelessness services were less likely to become socially engaged with new groups, and this relationship remained over time. SIL was also associated with poor or restless sleeping patterns, particularly women with restless sleep compared with men as reported by Davis et al.²⁴ Moreover, Tsai et al.⁵⁵ found that measures of loneliness (percentage relative importance = 17.12) as measured by the shortened revised version 3 of the UCLA Loneliness Scale and severity of substance use (percentage relative importance = 16.93) were the most important variables associated with any lifetime eviction and lifetime homelessness. Participants also depicted signs of social distress due to SIL, including the fear of dying alone. Studies by Bazari et al.⁷¹ and Finlay, Gaugler and Kane⁷² highlighted the unique challenges of older adults with homelessness experience, including concerns of dying alone. Van Dongen et al.⁷³ examined medical and nursing records from 61 adults receiving end-of-life care in shelter-based nursing care settings in the Netherlands and found that one quarter (n = 15) of patients died alone.

3.10 Association between SIL and health

SIL was significantly associated with physical and mental health outcomes for people with experiences of homelessness. Drum and Medvene54 found a negative correlation between subjective health and SIL (r = − .39, p > 0.03). SIL was associated with higher odds of reporting poor health and mental health among both self-identified men and women (p = 0.069) as reported by Pedersen, Gronbaek and Curtis.62 This relationship was also confirmed by a study by Valerio-Urena, Herrara-Murillo and Rodriguez-Martinez58 where participants who reported being ill had a higher level of SIL than those who reported being healthy.

Moreover, the study by Patanwala et al.32 showed that participants in the moderate-high physical symptom burden category had a significantly higher SIL score than participants in the minimal-low physical symptom burden category (p˂0.001). In addition, homeless veteran participants who reported SIL were 1.36 (95% CI: 1.04–1.78) more likely to report readmission to the Homeless Program of the VA Caribbean Healthcare System when compared with those who did not report social isolation.42

Furthermore, people with severe mental health problems are generally at higher risk of being socially isolated or feeling alone. For example, Rodriguez-Moreno23 compared homeless adult women at high risk of mental-ill health (HW-MI) and homeless women not at high risk of mental-ill health (HW-NMI) and found that HW-MI participants reported feeling significantly lonelier than homeless women without this risk (d = .56).

3.11 Association between SIL and substance use

Other studies reported interrelationship between SIL and substance use among people with experience of homelessness. Lafuente28 reported participants relapsed to alcohol and other risk behavior and conditions due to SIL: “I've started drinking and at this particular time. They offered to put me back into treatment and at this time I was not homeless…and I refuse it…the alcohol has really taken over me". Another study discussed how substance use contributed to SIL for participants who identified as male.47 The participants explained that use of substances affected their social relationships in different ways including adding strain in relationships, limiting availability of resources from social relationships, and the interplay between substance use and feelings of social isolation at earlier and later stages in life.47

In this scoping review, we summarized findings from studies that measured SIL among people with histories of homelessness and housing precarity. A total of 52 studies published between 2000 and 2023 met the eligibility criteria and were included in this review. We reported how the authors of these studies conceptualized SIL and what scales and tools they used to measure SIL. We also presented the prevalence of SIL and findings on the association between SIL and wellbeing, health and social outcomes, and substance use for people with experience of homelessness.

Most studies included in this review were published in 2010 and later, which shows a growing interest in this area. However, studies that have a specific focus on SIL and associated health and social outcomes are scarce. Only one-third of the studies included in this review identify SIL as their primary goal or one of their main research questions. Most of the quantitative studies used a cross-sectional methodology, and we did not find any intervention studies that addressed SIL among people with histories of homelessness as the primary or secondary outcome. Despite these limitations, the included studies summarized in this review provide an important overview of SIL among people with histories of homelessness.

Three main theoretical corpuses were used to conceptualize SIL in the context of housing and homelessness experience across the studies: theory of social exclusion28,31,46, theory of social disaffiliation28, and theory of digital exclusion (also called digital divide).74 Some studies mentioned structural stigma and alienation to explain systematic biases, policies and practices resulting in reinforcing SIL among people with histories of homelessness, particularly among people who use alcohol and other substances.29 This suggests that SIL is a complex issue, embedded in a larger societal problem of socio-economic exclusion, which makes people who are marginalized by structural systems feel invisible, powerless and detached from society. Moreover, the shift to a more digital world, which requires some digital literacy and access to ICT, may lead to increased SIL and barriers to services for people with homelessness experience.

Our review outlines the various measurement tools that have been developed, adapted, or used to measure SIL, including the Rokach Loneliness Questionnaire,34,35 the UCLA Loneliness Scale41 and different revised versions,53,55–57 and the De Jong Gierveld Loneliness Scale.58 While Ferreiro et al.61, Rodriguez-Moreno23 and and Muir et al.45 used either a subscale or a single-item question from measurement tools that were not specifically designed to measure SIL. We found that the proportion of studied populations who reported SIL varies largely, from 25–90% across studies. However, the range of measurement scales used to measure SIL across studies limits consistency and comparability between studies; therefore, these results should be interpreted with caution.

Studies included in this review also showed how personal identities play a role in how an individual may perceive their experiences of SIL and how it affects them as they navigate health, social and housing services. In one study,25 a participant described how they were rejected from a shelter agency because they are transgender. Other studies also showed relationships between SIL and age, self-identifying as a woman and these findings are in line with what has been reported in studies carried out in the general population.75,76

Findings from studies included in this review showed a relationship between SIL, health and social distress among people with homelessness experience. SIL was associated with poor sleeping patterns,24 and with lower social identification with homelessness services,59 with any lifetime eviction and lifetime homelessness.55 Related to health, SIL is negatively associated with subjective health,54, self-reported illness,58, health and mental health among both men and women,62 severe mental health problems,23 and substance use.47 These findings are in line with what has been reported in studies carried out in other population groups, where an association has been found between SIL and health behavior and physical heath77–79 including risk of heart disease, stroke, hospitalization and death and mental health.1,80,81

There are several potential reasons for the relationship between SIL and negative health 4desire of affected people to participate in social and physical activities79,82 or use healthcare services, thereby increasing the likelihood of developing or exacerbating mental and physical health problems.83,84 Additionally, individuals with SIL issues combined with homelessness experience may lose their self-esteem, perceived worthiness, and self-confidence.28,39This situation can be worsened if individuals perceived that their SIL is related to ageism, their racial or ethnic background or discrimination based on gender identify or sexual orientation.31 As an adaptive behavior, individuals may withdraw themselves, become physically less active and participative, and less prone to accessing healthcare and other basic services, which increases the risks for both physical85 and mental health problems 47,81including obesity and associated health issues, depression, food and sleeping issues, suicidal ideation and premature deaths.86–88

We identified several gaps in the studies included in this review. First, SIL was not the primary objective of the majority of the included studies. Thus, there was limited interest to provide a clear definition of SIL or a detailed description of its measurement. Second, the quantitative studies used different measurement tools, with some of them not primarily conceived to measure SIL, thus making comparisons across studies difficult. Additionally, many of these studies used a one-time point survey and covered very small and not generally representative samples. Thus, the estimation of the prevalence of SIL among people with homelessness experience and living in supportive or social housing remained exploratory, and the studies cannot establish causality between SIL and physical or mental health conditions or with social wellbeing. Studies that are mainly focused on SIL, and more longitudinal and targeted interventions are required to better understand the potential links between SIL and these outcomes, and to include more specific and objective health outcomes like depression or anxiety disorder, drug and alcohol disorder, use of services, suicidal ideation and attempts or premature aging. Third, the existing literature is very limited in analyzing how SIL impacts some populations differently, in particular women89,90 and non-binary or gender-diverse groups.91,92 Mayock and Bretherton93 discussed how gender shapes the trajectories of women experiencing homelessness. Research has demonstrated that women are often affected by and respond to homelessness in different ways than males, and thus have different experiences of homelessness.89 Self-identified queer people/people who are sexually diverse and/or trans- and gender-diverse and are experiencing homelessness similarly have a distinct experience.91 Hail-Jares et al.92 discussed how queer youth experience higher homelessness rates and greater housing instability compared to their cisgender and heterosexual counterparts. Gender diverse youth who must choose between staying in the family home, maintaining their LGBTQ2S identity, and continuing to be physically and mentally safe, often may consider homelessness as the perceived safer option.94 In addition, future homelessness-related studies examining SIL should also seek to make methodological distinctions that reflect differences based on gender identity and not consider queer/gender-diverse people as a homogenous group.

Finally, we found no studies that particularly explored SIL among people with homelessness experience from a particular ethnicity. Given the significant impact of ethnicity on experiences of homelessness, it is likely that ethnicity plays an important role or has a multiplier effect in the way SIL is experienced. 95,96 Further research that include diverse population would help in informing policy change and programming.

In conclusion, the findings of this scoping review show a high prevalence of SIL among people with homelessness experience or living in supportive housing, and how it may differently affect some groups of this population, such as youth, women, and gender-diverse individuals. These studies also show the potential association between SIL and social, mental, and physical outcomes. More studies are needed to better understand SIL among different populations and to assess the relationship between SIL and health and social outcomes. Testing and validating SIL measurement tools would help to improve the quality of evidence. Additional research in diverse populations and countries is highly needed. As implications for public policies, these studies highlight that SIL is a prevalent and significant issue in the lives of people with homelessness experience. However, longitudinal and interventional studies are needed to build evidence to inform actionable strategies to address SIL among people with homelessness experience.

Ethics approval and consent to participate: Not applicable

Consent for publication: Not applicable

Availability of data and materials: All data generated or analysed during this study are included in supplementary information files.

Competing interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding: This research was undertaken, in part, thanks to funding from the Canada Research Chairs Program (Stephen Wesley Hwang). This research was also supported the Canadian Institutes of Health Research (CIHR) Foundation Grant (FDN-167263) awarded to Stephen Wesley Hwang, and Canadian Institutes of Health Research (CIHR) Fellowship Award (RAT-171348) in partnership with Canada Mortgage and Housing Corporation awarded to James Lachaud. The funding institutions had no role in the collection, analysis, and interpretation of the data, nor in the preparation, revision, or approval of the present manuscript. The views expressed in this publication are solely those of the authors.

Author Contributions

JL had full access to all of the data and takes responsibility for the integrity of the data and the accuracy of the results. JL, AY, and SH conceptualized and designed the review. JL, AY, MF, MP, EG, CZ, CM, and SW performed data acquisition, analysis, or interpretation. JL, AY, MF, MP, and EG drafted the manuscript. JL, AY, MF, MP, EG, CZ, CM, and SW performed critical revision of the manuscript for important intellectual content. JL, AY, EG, and SH were responsible for administrative, technical, or material support. JL and SH obtained funding.

Acknowledgements

The authors thank the members of MAP Centre for Urban Health Solutions Community Expert Group for participating in reviewing the scoping review protocol and manuscript. We also thank Parvin Merchant the Director of Support Services Department at Houselink and Mainstay Community Housing for her input and support of this project. Lastly, we are grateful for the review by Jesse I.R. Jenkinson at MAP Centre for Urban Health Solutions.

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Tables 1-2 are available in the Supplementary Files section.

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Social isolation and loneliness among people living with experience of homelessness: A scoping review

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Version 1

Abstract

Figures

1. Introduction

2. Methods

2.1 Search methods

2.2 Screening process

3. Results

3.1 Overview of included studies

3.2 Characteristics of the populations covered in included studies

3.3 Social isolation and loneliness as the primary objective

3.4 Conceptualization of social isolation and loneliness

3.5 Measurement tools to assess social isolation and loneliness

3.5.1 Other social isolation and loneliness scales

3.6 Prevalence and scores of social isolation and loneliness: Quantitative evidence

3.7 Social isolation and loneliness evidence in qualitative studies

3.8 Intersectionality in homelessness, social isolation and loneliness

3.9 Association between SIL and social distress

3.10 Association between SIL and health

3.11 Association between SIL and substance use

4. Discussion

5. Gaps in the existing literature and recommendations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1