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Loneliness is a serious public health issue, and its burden is increasing in many countries. Loneliness affects social, physical, and mental health, and it is associated with multimorbidity and premature mortality. In addition to social interventions, a range of digital technology interventions (DTIs) are being used to tackle loneliness. However, there is limited evidence on the effectiveness of DTIs in reducing loneliness, especially in adults. The effectiveness of DTIs in reducing loneliness needs to be systematically assessed.
The objective of this study is to assess the effectiveness of DTIs in reducing loneliness in older adults.
We conducted electronic searches in PubMed, MEDLINE, CINAHL, Embase, and Web of Science for empirical studies published in English from January 1, 2010, to July 31, 2019. The study selection criteria included interventional studies that used any type of DTIs to reduce loneliness in adults (aged ≥18 years) with a minimum intervention duration of 3 months and follow-up measurements at least 3 months after the intervention. Two researchers independently screened articles and extracted data using the PICO (participant, intervention, comparator, and outcome) framework. The primary outcome measure was loneliness. Loneliness scores in both the intervention and control groups at baseline and at follow-up at 3, 4, 6, and 12 months after the intervention were extracted. Data were analyzed via narrative synthesis and meta-analysis using RevMan (The Cochrane Collaboration) software.
A total of 6 studies were selected from 4939 screened articles. These studies included 1 before and after study and 5 clinical trials (4 randomized clinical trials and 1 quasi-experimental study). All of these studies enrolled a total of 646 participants (men: n=154, 23.8%; women: n=427, 66.1%; no gender information: n=65, 10.1%) with an average age of 73-78 years (SD 6-11). Five clinical trials were included in the meta-analysis, and by using the random effects model, standardized mean differences (SMDs) were calculated for each trial and pooled across studies at the 3-, 4-, and 6-month follow-ups. The overall effect estimates showed no statistically significant difference in the effectiveness of DTIs compared with that of usual care or non-DTIs at follow-up at 3 months (SMD 0.02; 95% CI −0.36 to 0.40;
Our meta-analysis shows no evidence supporting the effectiveness of DTIs in reducing loneliness in older adults. Future research may consider randomized controlled trials with larger sample sizes and longer durations for both the interventions and follow-ups.
RR2-10.1136/bmjopen-2019-032455
Loneliness is a multifaceted public health problem [
Loneliness refers to an individual’s subjective feelings of a perceived discrepancy between actual and desired social relationships [
Loneliness is being addressed through a range of social [
Several published reviews have reported that digital technology interventions (DTIs) are effective in reducing loneliness [
There is limited evidence on the effectiveness of DTIs for loneliness [
The primary objective of this study is to assess the effectiveness of DTIs in reducing loneliness in adults. The secondary objective is to identify DTIs that are used to reduce loneliness in adults.
The main research question was “Are DTIs effective for reducing loneliness in adults?” The secondary question was “What DTIs are used for reducing loneliness in adults?”
The main outcome measure was loneliness. We extracted data on loneliness measured at both the baseline (before the intervention) and follow-ups (at least 3 months after the intervention) for the intervention groups and control groups, if any.
We undertook a systematic review and meta-analysis as suggested in the Cochrane Methods for Systematic Reviews of Interventions [
We registered this systematic review and meta-analysis with the PROSPERO database on June 10, 2019 (registration ID: CRD42019131524) [
A patient and public manager affiliated with our research center reviewed the study protocol and provided suggestions that were incorporated into the protocol. We had no access to any patient diagnosed with loneliness; therefore, we could not include any patients or members of the public in the design and conduct of the study. However, the findings of this study will be disseminated as an open access publication that will be freely available to patients and everyone else globally.
We define the term DTI as an intervention that applies digital technology, that is, the technology, equipment, and apps that process information in the form of numeric codes, usually a binary code [
We selected studies that met our predefined eligibility criteria [
We electronically searched PubMed, MEDLINE, CINAHL, Embase, and Web of Science and covered the publication period from January 1, 2010, to July 31, 2019. We used an a priori list of keywords prepared in our preliminary literature searches [
First, we searched the keywords in the
Literature searches retrieved 4939 articles, of which 965 duplicate articles were removed (
When recommendations differed between reviewers at the title, abstract, and full-text review stages, another reviewer (HCvW) reviewed these articles, and his recommendations to either include or exclude an article were final.
Finally, 92 articles were excluded, and the remaining 6 articles were included in the data extraction (
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) study selection flow diagram.
For data collection, we used an a priori data extraction template (
Characteristics of included studies, participants, sampling methods and sizes, and data collection tools.
Study, country | Quality of evidencea (reviewers’ assessment) | Research design | Settings | Participants | Main health or medical conditions investigated | Sampling method | Sample size | Participant attrition | Research methods or data collection tools | |||||||||
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Age (years) | Gender | Ethnicity |
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Total | Intervention group | Control group |
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Loneliness scale used | |||||
Tsai et al (2010) [ |
Medium | Quasi-experimental study (NRCTb) | Nursing home | Baseline: experimental group: average age 74.2 (SD 10.18); control group: average age 78.48 (SD 6.75) | Male=24 (experimental group=10; control group=14); female=33 (experimental group=14; control group=19) | Not reported (probably all Taiwanese or Chinese) | Loneliness and depression | Purposive | 57 baseline; 49 end of study | 24 baseline; 21 follow-up | 33 baseline; 28 follow-up | 8 (5 from control group and 3 from experimental group); attrition rate=14% | UCLAc loneliness scale [ |
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van der Heide et al (2012) [ |
Low | Before and after study (with intervention group only, no control group) | Older home care | Baseline: average age 73.2 (SD 11.8), range 32-90; end of study: average age 73.1 (SD 11.2), range 38-90 | Baseline: male=26 (30.2%), female=60 (69.8%), missing values=44; end of study: male=25 (29.4%), female=60 (70.6%), missing values=0 | Not reported | Loneliness and safety issues | Convenience | 130 | 130 | 85=intervention group at the end of study; no control group | 45; attrition rate=34.6% | De Jong-Gierveld loneliness scale (score range: 0-11) [ |
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Larsson et al (2016) [ |
High | Randomized, crossover trial | Living in ordinary housing without any home care services | Range: 61-89, mean 71.2; group 1 (intervention or control group): range 66-89, mean 73.4; group 2 (control or intervention group): range 61-76, mean 69.0 | Male=6; female=24, (3 males and 12 females each in group 1 [intervention or control group] and group 2 [control or intervention group]) | Not reported (probably all Swedes) | Loneliness | Randomized (after recruitment) | 30 | 15 baseline, 14 follow-up | 15 baseline, 14 follow-up | 2 (1 participant each from intervention and control groups); attrition rate=6.7% | UCLA loneliness scale [ |
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Czaja et al (2018) [ |
High | Multisite randomized controlled trial | Living in independent housing in the community | Baseline: total sample mean 76.15 (SD 7.4), range: 65-98; intervention (PRISMd System) group: mean 76.9 (SD 7.3); control (Bindere) group: mean 75.3 (SD 7.4) | Baseline: female=78% (number not reported), male=22% (number not reported); PRISM or intervention group: female 79.3% (n=119); Binder (control) group: female 76.7% (n=115) | Baseline: White=54% and non-White=46%; PRISM or intervention group: non-White or Hispanic=8% (n=12); Binder group: non-White or Hispanic=10% (n=15) | Social isolation, social support, loneliness, and well-being | Randomized | 300 (150 in each intervention [PRISM] group and control [Binder] group) | 150 baseline; 134 follow-up | 150 baseline; 118 follow-up | 56 (45 at 6 months and 11 at 12-month follow-up); attrition rate=18.7% | UCLA loneliness scale (score range 20-80) [ |
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Morton et al (2018) [ |
High | 2 (condition: training, control)×2 (population: domiciliary, residential)×2 (time: baseline, follow-up) design | Receiving care in own home or supported housing in the community ( |
Female: mean 80.71 (SD 8.77); male: data not reported | Follow-up: total=76; female=50, male=26 | Not reported | Well-being and social support | Randomized | 97 baseline; 76 follow-up | 53 baseline; 44 follow-up | 44 baseline; 32 follow-up | 21 (9 experimental group; 12 control group); attrition rate=21.6% | UCLA loneliness scale (score range 20-80) [ |
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Jarvis et al (2019) [ |
High | Randomized control study | Inner-city residential; NGOf care facilities for resource-restricted older people (aged ≥60 years) | Mean 74.93 (SD 6.41); range 61-87 | Baseline: male=6 (18.8%), female=26 (81.2%) | Mostly Asian (of Indian origin), numbers not reported | Maladaptive cognitions and loneliness | Randomized | Baseline=32 (intervention group=15, control group=17), final=29 (intervention group=13, control group=16) | 15 baseline; 13 follow-up | 17 baseline; 16 follow-up | 3 (2 intervention group, 1 control group); attrition rate=15.6% | De Jong-Gierveld loneliness scale (score range 0-11) [ |
aQuality of evidence grades: high (we are very confident that the true effect lies close to that of the estimate of the effect), moderate (we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different), low (our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect), and very low (we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect).
bNRCT: nonrandomized clinical trial.
cUCLA: University of California, Los Angeles.
dPRISM: Personal Reminder Information and Social Management.
eBinder refers to a group of participants who received a notebook with printed content similar to the Personal Reminder Information and Social Management System.
fNGO: nongovernmental organization.
Interventions, outcomes, measurements, results, and conclusions of included studies.
Study | Interventions | Comparators | Intervention duration | Follow-up duration | Outcomes: loneliness scores by measurement stages, mean (SD) | Results or findings | Conclusion by the authors of the study | ||||||
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Baseline | 3 months | 4 months | 6 months | 12 months |
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Tsai et al (2010) [ |
Videoconferencing (using either MSNa messenger or Skype) | Regular care | 3 months | 3 months | Intervention group=50.58 (SD 11.16); control group=46.55 (SD 9.07) | Intervention group=47.33 (SD 13.50); control group=46.68 (SD 9.08) | Not measured | Not measured | Not measured | Loneliness: intervention group mean: baseline 50.58 (SD 11.16), 1 week 49.75 (SD 11.79), and 3 months 47.33 (SD 13.50); control group mean: baseline 46.55 (SD 9.07), 1 week 47.06 (SD 8.75), and 3 months 46.68 (SD 9.08); differences between groups were compared at 3 points (baseline, 1 week, and 3 months) using multiple linear regression of the generalized estimating equations. Unadjusted or fixed effect size of effectiveness of videoconferencing intervention (videoconference vs control): at 1 week was β=−1.21, SE 0.50, |
Videoconferencing alleviates depressive symptoms and loneliness in older residents in nursing homes | ||
van der Heide et al (2012) [ |
CareTV including Caret duplex video or voice network | No control group and no comparator | 12 months | 12 months | Intervention group=5.97 (SD 2.77); no control group | Not measured | Not measured | Not measured | Intervention group=4.02 (SD 3.91); no control group | Group-level total loneliness: inclusion stage: mean 5.97 (SD 2.77), end of study: mean 4.02 (SD 3.91), |
CareTV intervention decreased the feeling of loneliness in the participants; however, participants were feeling moderate loneliness at the end of the study | ||
Larsson et al (2016) [ |
SIBAsb, that is, social activities via social websites | No comparator intervention reported | 3 months | 34 weeks (exposure for 3 months to each group) | Group 1 (I/Cc group)=45.53 (SD 7.41); group 2 (C/Id group)=43.93 (SD 8.61) | Group 1 (I/C group)=42.43 (SD 7.44); group 2 (C/I group)=41.93 (SD 8.82) | Not measured | 3 months after cross over: group 1 (I/C group, no intervention)=42.0 (SD 7.34); group 2 (C/I group, intervention introduced)=39.50 (SD 10.42) | Not measured | Percentage change between time 2 and time 1: group 1: mean score 0.07% (SD 0.07), |
SIBA interventions have the potential to reduce experiences of loneliness in socially vulnerable older adults. | ||
Czaja et al (2018) [ |
PRISMe system | A notebook with printed content similar to that within the PRISM (intervention) group: included a Lenovo |
12 months | 12 months | Intervention (PRISM) group=39.8 (SD 9.7); control (Binderg) group=40.2 (SD 10.3) | Not measured | Not measured | Intervention (PRISM) group=37.8 (SD 9.54); control (Binder) group=40 (SD 10.62) | Intervention (PRISM) group=36.9 (SD 9.16); control (Binder) group=38.43 (SD 9.37) | Baseline: loneliness PRISM group: mean score 39.8 (SD 9.7); Binder group: mean score 40.2 (SD 10.3), follow-up at 6 months: PRISM group 37.8, Binder group 39.6; follow-up at 12 months: PRISM group 36.9, Binder group 38.3 | Technology-based apps such as the PRISM system may enhance social connectivity and reduce loneliness among older adults. | ||
Morton et al (2018) [ |
EasyPC—a customized computer platform with a simplified touch-screen interface | Care as usual plus regular carer visits | 3 months | 4 months | Intervention (training) group (total of residential and domiciliary groups)=1.92 (SE 0.10, SD 0.73); control group (total of residential and domiciliary groups)=2.08 (SE 0.12, SD 0.80) | Not measured | Intervention (training) group (total of residential and domiciliary groups)=1.86 (SE 0.10, SD 0.66); control group (total of residential and domiciliary groups)=2.12 (SE 0.11, SD 0.62) | Not measured | Not measured | Loneliness scores mean: intervention (training) group: residential group: time 1=1.95 (SE 0.16), time 2=1.92 (SE 0.16), domiciliary group: time 1=1.89 (SE 0.13), time 2=1.79 (SE 0.13), total time 1=1.92 (SE 0.10), time 2=1.86 (SE 0.10); control group: residential group: time 1=2.13 (SE 0.18), time 2=2.20 (SE 0.17), domiciliary group: time 1=2.02 (SE 0.16), time 2=2.05 (SE 0.15), total time 1=2.08 (SE 0.12) and time 2=2.12 (SE 0.11) | Internet access and training can support the self and social connectedness of vulnerable older adults and contribute positively to well-being. | ||
Jarvis et al (2019) [ |
Living In Network-Connected Communities WhatsApp group for low-intensity cognitive behavioral therapy | Usual care, a separate WhatsApp group (Living In Network-Connected Communities 2) | 3 months | 4 months | Not measured | Intervention group=2.31 (SD 1.49); control group=2.47 (SD 2.1) | Intervention group=1.38 (SD 1.33); control group=4.0 (SD 1.32) | Not measured | Not measured | Loneliness levels: total=baseline−intervention on time 1−intervention on time 2.; |
Low-intensity cognitive behavioral therapy mobile health supported by the social networking platform of WhatsApp (Living In Network-Connected Communities) showed significant improvements in loneliness and maladaptive cognitions. |
aMSN: Microsoft Network.
bSIBA: social internet-based activity.
cI/C: intervention/control.
dC/I: control/intervention.
ePRISM: Personal Reminder Information and Social Management.
fLCD: liquid-crystal display.
gBinder refers to a group of participants who received a notebook with printed content similar to the Personal Reminder Information and Social Management System.
SGSS and DN independently extracted data from all included studies (n=6) using the data extraction template (
We report both a narrative synthesis (narrative summary) and a statistical (quantitative) synthesis (meta-analysis) of our review, as suggested for reporting of a systematic review on effectiveness [
In the meta-analysis, we have included 5 studies and pooled extracted data on loneliness measured by continuous loneliness scales, that is, the University of California, Los Angeles (UCLA) loneliness scale [
In meta-analysis, the standardized mean difference (SMD) as a summary statistic for reporting continuous data has been suggested for studies that assess the same outcome but use different scales to measure the outcome [
In our review, the main outcome, that is, loneliness, was measured using different loneliness scales, which included the UCLA loneliness scale (score range 20-80) [
The Cochrane guidelines for systematic reviews and meta-analysis [
We extracted data from 6 studies, which included 5 clinical trials [
We calculated the SMDs from the extracted data, that is, loneliness mean scores with SD and sample sizes in the intervention and control groups at follow-up measurements at 3 months and beyond. For conducting meta-analysis, we used the Cochrane Review Manager (RevMan) software, version 5.3.5 [
We assessed the quality of research by applying the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach [
We assessed the risk of bias by focusing on 5 domains: the evaluation of sequence generation, allocation concealment, blinding (outcome assessors), incomplete data, selective outcome reporting, and assessing other biases using the Cochrane guidelines [
We checked heterogeneity, that is, variation in study outcomes or intervention effect sizes between studies, by the Cochran Q test with a significance level of
We report the findings of meta-analyses using SMDs with 95% CIs as a statistical summary, with the forest plots [
Findings about the characteristics of the studies, including the study designs, settings, participants, interventions, comparators, sample sizes, participant attrition, and data collection methods or tools used, are presented in
Searches of PubMed, MEDLINE, CINAHL, Embase, and Web of Science generated a total of 4939 articles (
The total number of participants enrolled in all 6 included studies was 646 (mean 108, SD 102; median 77, IQR 32-130). Studies varied in total sample sizes (mean 108, SD 102; range 30-300), and the sample sizes of the intervention and control groups also varied at both the baseline and follow-up measurements across the studies (
Participants’ average age was between 73 and 78 years (SD 6-11). Total enrolled participants included 66.1% (427/646) women and 23.8% (154/646) men, whereas for 10.1% (65/646) of participants, no information about their gender was available. Studies varied in the proportion of male and female participants (female: mean 66%, SD 16%; range 46%-81%; male: mean 25%, SD 9%; range 19%-42%). Only 2 studies reported on participants’ ethnicity—White (54%) and non-Whites (46%) in the US study [
A total of 4 studies were RCTs [
A total of 4 studies were conducted in developed countries, namely, the Netherlands [
The settings included living in independent housing in the community [
Participants were selected by random sampling in 66.7% (4/6) of studies [
DTIs included social internet-based activities, that is, social activities via social websites [
The duration of the intervention was 3 months in 4 studies [
The loneliness measurement tools used were the UCLA loneliness scale [
Narrative synthesis showed that there was a reduction in loneliness in the intervention groups at the follow-ups compared with baseline (
We conducted 3 meta-analyses, 1 each for follow-up measurements at 3, 4, and 6 months, involving 3, 2, and 2 studies, respectively.
Three studies [
Forest plot of standardized mean differences for loneliness at the 3-month follow-up (digital technology intervention vs control).
Two studies [
Forest plots of standardized mean differences for loneliness at the 4-month follow-up (digital technology intervention vs control).
A meta-analysis involving 2 studies [
Forest plots of standardized mean differences for loneliness at the 6-month follow-up (digital technology intervention vs control).
The risk of bias assessment, that is, the risk of bias graph and risk of bias summary are presented in
Risk of bias summary. Review authors’ judgments about risk of bias in included studies: Czaja et al, 2017 [
Risk of bias graph. Review authors’ judgments about each risk of bias item are presented as percentages across all included studies.
The quality of evidence was moderate, very low, and moderate in meta-analyses involving 3 [
GRADE (Grading of Recommendations Assessment, Development and Evaluation) quality of evidence summary. DTI: digital technology intervention; RCT: randomized controlled trial; SMD: standardized mean difference.
To determine whether DTIs are effective in reducing loneliness in adults, we appraised peer-reviewed empirical research involving the application of DTIs in adults with loneliness. Our systematic review provides a narrative summary (qualitative synthesis) as well as a meta-analysis (statistical synthesis) of the findings. The narrative summary of 6 studies included in our review showed a reduction in loneliness in the intervention groups at follow-up compared with baseline (
Our meta-analysis also revealed that CIs of the summary effects of 2 studies, that is, the studies by Larsson et al [
Overall, the findings of our meta-analysis showed no evidence supporting the effectiveness of DTIs in reducing loneliness in older adults.
The quality of evidence of the included studies was very low to moderate (
Loneliness is influenced by culture [
There are limited published meta-analyses on technological interventions for tackling loneliness, and a few existing studies have covered literature published up to 2009 [
A meta-analysis by Masi et al [
Interestingly, our findings provide new insights about DTIs and loneliness. Our meta-analysis showed no statistically significant reduction in loneliness in the intervention groups compared with the control groups at the 3 -, 4-, and 6-month follow-ups. Thus, our findings show no evidence supporting the effectiveness of DTIs in reducing loneliness in older adults, which goes beyond the findings of a recent Cochrane review that reported no evidence of video calls being effective in reducing loneliness in older adults [
In addition, our findings refute and contradict a commonly held view that digital technology can solve the problem of loneliness, especially in older people. Nonetheless, digital technologies provide tools and means that facilitate social connection [
Nonetheless, a review has reported that some nontechnological interventions are effective in reducing loneliness in older people [
Our study had some limitations: the inclusion of only 6 studies with heterogeneous sets of results and the minimum intervention duration of 3 months, which could have resulted in the inclusion of a small number of studies and possible exclusion of potential studies that would have provided useful evidence.
In addition, we could not conduct subgroup and meta-regression analyses due to the very limited number of studies (n=5) in the meta-analysis and lack of data on loneliness by participants’ demographic characteristics. In addition, our study might be narrow because we excluded some studies [
Moreover, another limitation of our review could be the use of a meta-analysis based only on follow-up data. For example, a study by Tsai et al [
As recommendations for future research, we suggest that researchers involved in trials agree on a common measure of loneliness and consider reporting of results in a standardized way, which will allow pooling of baseline-adjusted estimates of the treatment effect rather than differences in follow-up means.
Our meta-analysis showed no evidence supporting the effectiveness of DTIs in reducing loneliness in older adults. Therefore, there is a need for further research involving RCTs [
Literature searches.
digital technology intervention
Grading of Recommendations Assessment, Development and Evaluation
participant, intervention, comparator, and outcome
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
randomized controlled trial
standardized mean difference
University of California, Los Angeles
The authors acknowledge support from Liz Callow of Bodleian Health Care Libraries, University of Oxford, for running literature searches. The authors are grateful to Dr Alexandra Farrow (Brunel University London) for checking the first version of the manuscript. This research was funded by the National Institute for Health Research Oxford Biomedical Research Centre (Research Grant IS-BRC-1215-20008). The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health.
None declared.