1. Introduction

Background

Isolation experienced by older people has been identified as a risk factor in both Australian and international research relating to elder abuse. In the Australian context, the National Elder Abuse Prevalence Study (NEAPS) identified lower levels of social contact with family and friends as a factor associated with a higher likelihood of experiencing elder abuse. Data from the Survey of Older People component of the prevalence study indicate that older people who saw their family and friends infrequently (less than once a week) reported experiencing elder abuse in higher proportions than participants who had regular in-person contact with their family and friends (Qu et al., 2021, p 63). More specifically, the proportion of older participants who reported each form of abuse was higher for those who reported less frequent contact with family and friends compared with those who had more frequent contact.

These findings are consistent with other research identifying isolation as a risk factor for older people experiencing abuse (e.g. Storey, 2020). Research has also shown that social isolation on the part of the victim, and a broad social network on the part of the perpetrator, are associated with lower help-seeking behaviours (Burnes et al., 2019; Vrantsidis et al., 2016). Social isolation was also identified in the NEAPS as being associated with older people reporting they responded to their experience of abuse by avoiding the relevant perpetrator (42%) and a smaller but substantial proportion of older people withdrawing from social contact more generally (13%) (Qu et al., 2021, pp 85-86).

Responses to elder abuse that involve withdrawal from social contact raise concerns about the impact of isolation on the wellbeing of older people. Qualitative data, collected as part of the NEAPS, indicate that where older people responded to their experience of abuse by taking steps to withdraw from their relationship with the perpetrator or from their social interactions more generally, they commonly described this response as ineffective. Withdrawing from the relationship was considered ineffective because such action did not address the issues associated with the abuse, or the abusive behaviour remained unchanged. Attempts to withdraw were also described as ineffective where this led to estrangement from family or friendship groups and/or to social isolation, or where withdrawal of contact was unworkable in practice. Notably, where participants described their withdrawal from their social life as an ineffective response to physical abuse, this was described as exacerbating their isolation. In some instances, withdrawing from social contact also meant that the older person did not receive the care they required (Qu et al., 2021, p 89).

In relation to help-seeking patterns, the experiences of isolated older people reflect a need for improvements in responses to elder abuse. In particular, the reliance on passive avoidant approaches to stop abuse gives rise to concern about the effectiveness and impact of these responses on the wellbeing of older people.

These findings indicate a need for focused research that will support further thinking about the experiences of isolated older people, particularly in the context of the experience of, or risk of, elder abuse. This report will contribute to an exploration of how older people experience social and/or geographical isolation and the supports and services they require.

Research aim and research questions

The aim of this research project was to examine the factors, dynamics and effects of isolation experienced by older people in New South Wales and a consideration of the status of older people's rights in this context. In line with this research aim, the key research questions guiding this project were:

• What are the views of the experiences of isolated older people and what are the effects of isolation on older people, including the effect of isolation on their access to services, their wellbeing and upon the enjoyment of their rights in this context?
• What are service providers' views of the factors giving rise to the isolation experienced by these clients?
• How do service providers currently identify and support access to services by isolated older people?

Methodology

To address the exploratory research aim, the research comprised two elements:

1. A desktop review of relevant Australian and international literature regarding the social and geographical isolation of older people.
2. Semi-structured group interviews and individual interviews with professionals providing services to older people ('service providers') in metropolitan, regional and rural locations throughout New South Wales.

Desktop review

Literature searches were conducted in the Australian Family & Society Abstracts database, as well as in a range of international databases included in the AIFS exclusive Catalogue Plus platform. A range of keywords were searched to capture two key concepts: isolation, and older people. Keywords to capture the concept of isolation included: Isolation or isolated or 'remote location*' or 'remote community*' or 'remote area.*' Keywords searched to capture the concepts of older people included: 'older people' or 'older adults' or 'older persons' or 'old age' or 'seniors' or elderly or 'older adulthood'. Topical terms to narrow down searches were also utilised, which included:

• rights or equity or social justice
• wellbeing or well-being or 'quality of life' and Australia*
• 'systematic review' or 'systematic search' or 'narrative review' or 'scoping review' or 'literature review' or 'review of the literature' or meta-analysis or meta-analyses or 'scoping study' or 'reviews the literature' or 'integrative review' or 'rapid review' and journal article
• dynamics or mechanisms or introduction or overview in title or lived experience*.

As a result of these searches, 191 resources relevant to issues of geographical and/or social isolation were reviewed. A small number of peer-reviewed articles with direct relevance were also included after these searches were completed (e.g. by scanning reference lists of included sources). Our review of the literature was primarily focused on Australian research but also included international literature to provide further context to the Australian evidence.

Semi-structured interviews

The research team applied for ethical clearance for this research from the AIFS Human Research Ethics Committee (HREC), with clearance provided for the project methodology, recruitment materials (including invitations to participate, participant information sheets and consent scripts), interview schedules and ethical protocols. Ethical clearance was received from the AIFS HREC in May 2022.

Professionals providing services to older people were recruited to participate in this study via an invitation to participate in either a group interview or individual interview. This invitation was circulated to service providers by Seniors Rights Service and other key New South Wales based stakeholders. The invitations to participate and project information sheets provided potential participants with detailed information about the research and the contact details for them to express an interest in participating in an interview with the AIFS research team. Prior to participation, participants were informed of the aims of the research, that the research was completely voluntary and could be withdrawn from at any time prior to the de-identification of the interview data.

Informed by the desktop review, semi-structured interview schedules were developed to guide the individual interviews and group interviews. The schedules covered the following areas of enquiry:

• service providers' views on the experiences of isolated older people and the effects of isolation on older people, including the effect of isolation on their access to services, their wellbeing and the enjoyment of their rights in this context
• service providers' views of the factors giving rise to the isolation experienced by these clients
• how service providers currently identify and support access to services for isolated older people.

The interviews with service providers were conducted by telephone or online via the Microsoft Teams platform. Interviews were audio recorded and transcribed. Transcripts were verified by removing all identifying information within 2 weeks of interview completion. Original transcripts were then deleted.

Sample

A total of 20 professional participants took part in either a group or individual interview. Four participants worked in a service that operated across the state covering metropolitan, regional, rural and remote locations. Six participants provided services in a metropolitan location and another 5 worked in a regional area. Two service providers were based rurally, and the location of a further 3 participants was unknown. In relation to the sectors that service providers worked in, 2 participants worked in the public sector, 6 service providers were from the non-government sector and 12 were from the not-for-profit community sector.

Data analysis

Data were analysed using an open-coding method, followed by further selective coding to examine key overlaps and deviations between the identified themes. Core themes most relevant to the research questions were then identified (Charmaz, 2000; Dey, 1999; Janesick, 2000; Punch, 1998; Ryan & Bernard, 2000).

Structure of this report

This report has 3 further sections. The following section provides key insights from the existing literature in relation to the experiences of isolated older people, key factors shaping and giving rise to isolation, the effect that isolation has on older people, and the identification of isolated older people and supporting their access to services. The findings section then presents the key themes identified in the interviews with service providers and is structured according to the research questions. Finally, the summary and conclusion provide a summary of our findings and their implications for practice and future research.

2. Insights from existing research literature

This section provides insights from the review of Australian and international research focusing first on outlining key concepts identified in the literature and commentary regarding the social and geographical isolation of older people. This discussion is followed by an examination of the experiences and effects of isolation on older people, including in relation to the tension between isolation and maintaining independence, the strategies used by older people to address social isolation, the gendered dynamics emerging in this context, and barriers to accessing services and community. The discussion will also consider insight from the literature regarding factors giving rise to social and geographical isolation and in relation to the identification of isolated older people and facilitating their access to support.

Key concepts

Key concepts were identified in the review of Australian and international research literature and commentary and the discussion in this section presents a summary of these concepts, which will be considered in the analysis of the existing research and the findings from the qualitative components of this current research project.

Social isolation

Social isolation is an objective lack of connection and interaction with social networks, which can include family, friends and community (Beridze et al., 2020; Machielse & Duyndam, 2020). Social isolation for older people has been identified as an international public health concern given the established relationship between social isolation and adverse health and wellbeing outcomes for older people (Beridze et al., 2020; Chan et al., 2015; Czaja et al., 2021; Del Pozo Cruz et al., 2021a, 2021b; Freak-Poli et al., 2021; Hajek et al., 2021; Hu et al., 2021; Saito et al., 2021; Santini et al., 2016; Schrempft et al., 2019). Amongst the poor health and wellbeing outcomes associated with social isolation are decreased quality of life (Beridze et al., 2020; Freak-Poli et al., 2021), functional decline (Del Pozo Cruz et al., 2021a, 2021b), decline in cognitive health and function (Shankar et al., 2013), poor mental health (Czaja et al., 2021; Hajek et al., 2021; Santini et al., 2016), poor physical health (Hu et al., 2021), increased risk of mortality (Chan et al., 2015; Machielse & Duyndam, 2020; Saito et al., 2021), low physical activities and problems with maintaining self-care (Schrempft et al., 2019). Social isolation is measured by researchers in different ways; for example, by assessing an individual's connection to their community and social networks. Social isolation can give rise to subjective experiences of loneliness (Beridze et al., 2020; Machielse & Duyndam, 2020).

Geographical isolation

Geographical isolation is marked by logistical and practical barriers to an older person's connection to and active participation in the community. These barriers include:

• socio-economic or financial barriers (Menec et al., 2019; Winterton & Warburton, 2011)
• transportation barriers (Adorno et al., 2018; Lamanna et al., 2020; Levasseur et al., 2020; Pekmezaris et al., 2013)
• technological barriers (Brooke et al., 2022)
• cultural and linguistic barriers (Byrne & Ghaiumy Anaraky, 2022; Holaday et al., 2022)
• cognitive or other impairments as barriers for some older people (Herro et al., 2021).

Geographical isolation is further characterised by logistical and practical barriers, which extend to service design and implementation constraints, affecting older people's access to the 'service infrastructure'. The logistical and practical barriers to this service infrastructure are evident across a broad range of services including:

• legal and dispute resolution services (Community Legal Centres Queensland Inc, 2019; Hunter & De Simone, 2009; Law Council of Australia, 2017)
• health services (Inder et al., 2012; Longman et al., 2013; Parsons et al., 2021; van Spijker et al., 2019; Walsh et al., 2020)
• financial services (West & Ramcharan, 2019)
• social and community services (Commissioner of Senior Victorians [CSV], 2020; Vine et al., 2014).

Loneliness

Feelings of loneliness can be shaped by experiences of social isolation and can be understood by an individual's own view of the quality of and satisfaction with their social connectedness, supports and interactions (Machielse & Duyndam, 2020). Therefore, it is possible for a socially isolated individual to not feel lonely and for a non-socially isolated individual to feel lonely (Beridze et al., 2020; Machielse & Duyndam, 2020).

Social connectedness

Social connectedness is the 'opposite' of loneliness and, like loneliness, has been defined as a subjective experience shaped by an individual's perceived quality of connections with family, friends and community (Morgan et al., 2021).

Ageing 'well'

While what it means to age 'well' can mean different things to different older people, a recent Victorian survey of 4,726 older people and community consultations with 231 older people in the state of Victoria identified 8 key characteristics of ageing well (CSV, 2020). The 8 characteristics of ageing well were underpinned by a desire to maintain independence and autonomy in the ageing process, as well as a need for social and practical supports from family, friends and community. They were as follows (CSV, 2020):

• having a 'positive attitude' about the ageing process and the opportunities it can bring, along with an acceptance that ageing is a challenging process that requires support
• having a purpose in life
• having respect from their communities as valuable contributors to society and living in a community that values and respects older people
• social connectedness (in relation to being socially connected with family, friends and the wider community, including younger people
• having the tools to adapt and thrive through change, periods of transition and within a wider 'changing world'
• safety, in relation to safety at home to enable older people to 'age in place' and in relation to financial security
• having the autonomy to manage physical and mental health
• mobility, specifically personal mobility, as well as having access to suitable transportation.

Ageing in place

Ageing in place refers to older people having options to continue to live at home and be involved in their community as long as possible. Ageing in place does not necessarily refer to remaining in one particular space or home but refers to living autonomously and independently for as long as possible. The ability to age in place is limited by the availability of suitable and affordable housing, as well as well-resourced supports for older people in the home (CSV, 2020). Most survey respondents in a recent Victorian survey of 4,726 older people undertaken by the CSV (2020) valued ageing in place as paramount to ageing well more generally.

Experiences and effects of isolation among older people

The effects of social isolation on the lives of older adults are well-documented in the literature. Older people, themselves, identify it as a key issue, along with strategies they may use to address its impacts, such as making physical excursions into the community to feel more connected. The literature identifies the tension, however, between maintaining independence by being able to undertake household management and self-care and the need for connection with others and support seeking. The literature indicates that gender also plays a role in these experiences, with women more likely to engage in socially connecting activities than men.

Geographical isolation creates a significant barrier to accessing services and may exacerbate the impacts of social isolation by limiting opportunities to connect with others or to access service infrastructure and resources such as transport. Limitations around service delivery, such as access to digital technology and skills or cultural language barriers, may be specific to older people in the community.

Social isolation

Tension between isolation and the maintenance of independence

Older people have reported a problematic tension between social isolation and the desire to maintain independence and autonomy in older age. An Australian qualitative study based on interviews with 29 Australians over the age of 65 suggested that while independence is an ideal that many older people strive to adhere to, there were many negative experiences of independence (Plath, 2008). 'Doing things alone' was considered one of the most important aspects of independence for the majority of participants. Some examples of doing things alone included engaging in everyday activities such as cooking, cleaning, personal care and socialising. Maintaining a sense of 'peace and quiet' and privacy were also important to this conceptualisation of independence. For participants who did not have the physical capacity to do everything in their lives 'alone', still having some things that they could perform themselves was considered important to maintaining overall independence. Some older people reported that the prospect of being 'let down' by other people or feeling like a 'burden' to others presented barriers to asking for help with various activities (Plath, 2008).

Having the capacity to make one's own decisions was also considered to be central to the concept of independence for older people in this study (Plath, 2008), including the ability to make smaller everyday decisions as well as larger longer-term decisions (e.g. living arrangements). The concept of making one's own decisions was also characterised by the ability to engage in problem solving, and to think through scenarios and weigh up options or having the capacity to prioritise different activities over others. Further to these views, some older people indicated that 'physical and mental capacity' to participate in activities in daily living were important aspects of independence (Plath, 2008).

Notably, having the ability to achieve independent living was considered by some older people to be reliant on access to various resources. For example, having the financial resources to pay for assistance with cleaning or having access to community services were viewed as crucial to the maintenance of independence. Finally, some participants underscored the importance of 'social standing' and 'self-esteem' to facilitating independence in older age. This included having a sense of purpose and maintaining interests and passions, as well as feeling content and having the ability to contribute to society in a meaningful and positive way (Plath, 2008).

At the same time, these participants reported on the flip side of experiences of independence. While seen as an important goal for many older people, 'doing things alone' could also result in experiences of isolation. Doing activities alone and being hesitant to seek support could result in physical pain for some (due to limited physical capacity), and feelings of boredom and loneliness. In relation to making one's own decisions, being required to make decisions unexpectedly or during a period of crisis was considered an isolating and stressful experience for some older people. A more recent qualitative study undertaken in the Netherlands echoed these Australian findings, illustrating that social isolation could be interpreted as 'failure' for some older people and could represent a barrier to seeking assistance (Machielse & Duyndam, 2020).

Limitations in relation to resources and opportunities were also highlighted by some participants as contributing to negative experiences of independence. For example, it might be more challenging for older people caring for a partner or spouse or for those with limited finances to pursue more social activities, despite being motivated to do so (Plath, 2008). Furthermore, some participants expressed difficulties accessing community supports and services designed with older people's needs in mind and/or finding supports tailored to their own needs, and that these difficulties contributed to a feeling of lack of control and autonomy. Moreover, some participants expressed disappointment and frustration around the limited opportunities and roles made available to older people. This meant for some, previous roles they had identified with (such as worker, carer, etc.) were no longer available to them meaning they were no longer valued for these contributions. For some, their lives were now characterised by ageism and poverty, which further isolated and excluded them from the community (Plath, 2008).

Strategies used by older people to address social isolation

A recent qualitative study based on interviews with 25 older, community-dwelling adults in the Netherlands who identified as socially isolated indicated that these participants used a variety of strategies in their everyday lives that had the potential to further isolate them from the community (Machielse & Duyndam, 2020). Major life events such as separation or the loss of a spouse have been documented as triggering social isolation (Machielse & Duyndam, 2020) but daily habits and routines provided participants with a sense of safety, security and control. Some older people described their strategy of intentionally avoiding social interactions within the community due to their understanding that they had little social knowledge or skills to maintain such connections. Others spoke about routines that enabled them to maintain social connections to address their feelings of loneliness. Activities of this nature could include walking through a park in the city to maintain a sense of connection with others (Machielse & Duyndam, 2020). Strikingly, most participants spoke about not feeling the need to change their situation given how challenging it would be for them to shift habits and routines as well as their desire to 'maintain independence'.

Furthermore, in the context of ageist societal attitudes and negative ideas or stigma around being socially isolated, some older people may not identify as being socially isolated, which can make this group particularly challenging to identify for professionals and service providers (Pettigrew et al., 2014).

Gendered dynamics of social isolation

In addressing social isolation for older people, research has underscored the importance of maintaining connections with social networks and immediate family outside of the home, with gendered dynamics being a key element in understanding how older people maintain social connection (Patulny, 2009). Drawing on data from the Australian General Social Survey (2006) and the Australian Time Use Survey (2006), Patulny (2009) reported that retired men spent less time with family and friends outside of the household than men who were not retired. Yet for retired women, the opposite pattern emerged. Findings suggested that men relied more heavily on work-based networks for social contact outside the home and that retirement was a factor that could give rise to social isolation. Therefore, the period around retirement is an important transition point when older people, particularly men, require social support and connection (Patulny, 2009).

A recent Australian study that drew on data collected in Wave 16 (between July 2016 and February 2017) of the Household Income and Labour Dynamics Australia (HILDA) survey data mirrored these findings. Observations included that older men were more likely to report unsupportive relationships and higher levels of community disengagement than older women. Notably, for men, living alone was associated with higher social exclusion (measured by perceived unsupportive relationships). On the other hand, for women, living alone was associated with increased community engagement (Paine et al., 2022).

Geographical isolation

Barriers to accessing services

Existing research in the elder abuse field illustrates that social isolation on the part of the victim, and a broad social network on the part of the perpetrator, are factors associated with lower help-seeking behaviour by older people (Burnes et al., 2019; Qu et al., 2021).

These findings are significant in the context of Australian and international research identifying the barriers to accessing services and supports for geographically isolated older people. They show that barriers relating to a lack of awareness or visibility of available services and a lack of physical access to these services are amplified for older people in rural and remote locations. This lack of physical access to the service infrastructure ranges from legal and dispute resolution services (Community Legal Centres Queensland Inc, 2019; Hunter & De Simone, 2009; Law Council of Australia, 2017) through to health services (Inder et al., 2012; Longman et al., 2013; Parsons et al., 2021; van Spijker et al., 2019; Walsh et al., 2020), financial services (West & Ramcharan, 2019) and social and community services (CSV, 2020; Vine et al., 2014). This lack of access has been identified as affecting an older person's self-efficacy, their physical and mental health and financial wellbeing because they are unable to access legal remedies or to address their health and financial issues or to secure appropriate residential aged care outcomes (Inder et al., 2012; Longman et al., 2013; Parsons et al., 2021; West & Ramcharan, 2019).

Absence of opportunities to connect

Data from the currently available survey component of the Ageing Well study (2020) involving an online survey of Victorian people aged 60 years and over (n = 4,726) illustrated that logistical and practical barriers to social engagement were identified as the highest rated factors reducing the quality of life for older people (CSV, 2020, p 19, Table 2). Just over half of participants in this survey resided in Melbourne; however, there were 18% who resided in rural locations, 15% who resided in regional locations and 10% residing in outer Melbourne. Nearly half of participants nominated the costs and affordability of activities and living expenses (43%) as barriers and more than one-third considered there to be:

• a lack of local opportunities to engage in their community (36%)
• a lack of information on what was available in their community (35%)
• a lack of parking amenities to enable access to facilities in their community (34%) (p 19, Table 2).

This research identified the distances to available services and opportunities to engage in the community as a risk factor, with older people from rural areas describing the impact of limitations in transport options (p 39). Specifically, in relation to access to health services, geographical barriers included the cost of travel and limited availability of transport options in rural locations (p 36). The research describes the need for 'age-friendly local infrastructure, facilities and community transport, particularly in rural areas, to support older people to age in place at home and stay engaged with their community' (p 46).

These findings underscore the need to address logistical and practical factors to support older people to maintain and/or develop their social networks within their local community. This was identified both in high density locations with closer proximity to services and geographically isolated locations (CSV, 2020; Vine et al., 2014), as well as for those in residential aged care (Bernoth et al., 2012; CSV, 2020). Difficulties accessing services and navigating the spatial aspects of community were identified as barriers to older people's ability to connect and feel part of the community, including through intergenerational engagement, which was identified as important (Vine et al., 2014). In this context, access to technology was seen to be a mitigating factor (Berg et al., 2017) but the need for age-friendly technology to support participation was also identified (CSV, 2020; Winterton, 2016).

Factors giving rise to isolation

Social isolation

While there is limited research on service providers' understandings of some of the factors that give rise to social isolation for older people, one Australian study used focus groups with professionals to gain insights on this topic (Ferrara, 2009). For these professionals, significant life events that were considered to invoke isolation included: retirement, relocation, separation, loss of a partner or spouse and changing relationships with adult children (e.g. becoming estranged or cut off from adult children; Ferrara, 2009).

Family conflict and caring responsibilities were also considered to give rise to isolation by participants. For example, an older person could be well-connected with their family, and actively caring for their grandchildren, partner/spouse or their adult children, while being socially isolated and not having access to required supports (Ferrara, 2009).

Furthermore, insecure housing, cost of living pressures and limited income from the Commonwealth aged pension are additional factors that might shape experiences of social isolation in the Australian context (Hillier, 2007), as well as limited access to reliable and accessible transport (Ferrara, 2009; Hillier, 2007). Low self-esteem and lack of confidence were also notable factors (Machielse & Duyndam, 2020), along with disability and illness (Ferrara, 2009).

Geographical isolation

Existing Australian and international literature illustrates a range of factors relevant in the context of geographical isolation. They include:

• the distance between the geographical location of service providers and community infrastructure and activities and the location of older people (CSV, 2020; Parsons et al., 2021; Winterton et al., 2014)
• reduced mobility and 'transportation disadvantage' experienced by older people who have limited access to safe and affordable transport options or to social support to facilitate their travel to access services and participate in the community (Adorno et al., 2018; CSV, 2020; Lamanna et al., 2020; Parsons et al., 2021; ), with both neighbourhood resources and individual resources (including access to a driver's licence) relevant in this context (Levasseur et al., 2020)
• socio-economic disadvantage experienced by older people in relation to knowledge and awareness and ability to navigate services and the financial capacity to use transport and accommodation options to facilitate access to services and supports (CSV, 2020; Inder et al., 2012)
• cultural and linguistic factors that inhibit older people from identifying and accessing services and community activities where they are unable to obtain information about the available services and activities or to access the services and activities in their language, or where they may not be delivered in a culturally appropriate way (CSV, 2020; Holaday et al., 2022; Winterton & Warburton, 2011). (Older people have identified a desire not only to engage with people from their cultural backgrounds but also to engage in cross-cultural opportunities (CSV, 2020).)
• a lack of access to technology-facilitated services and community activities, which compounds the geographical isolation experienced by older people (CSV, 2020; Dong-Kyun, 2017)
• cognitive and other impairments experienced by older people, which are notable factors in the context of geographical isolation (Levasseur et al., 2020).

Identifying isolated older people and enabling access to support

Social isolation

There is limited empirical evidence that sheds light on the strategies used to identify and enable access to support for socially isolated older people. To strengthen this evidence base, researchers have called for the direct involvement of older people in the design and implementation of services and supports to ensure that their requirements are being met (Bartlett et al., 2013; Hughes, 2009). The identification of socially isolated older people can be problematic, given that such individuals are less visible in the community (Pettigrew et al., 2014). However, there is evidence in the Australian context to suggest that health practitioners play a particularly important role in identifying older people in need of support and linking older people into support services (Pettigrew et al., 2014). Research suggests that lack of access to transport is a key barrier to social participation and, therefore, provision of safe, accessible transport must be prioritised to facilitate support for older people (Ferrara, 2009; Hughes, 2009; Kimberley & Simons, 2009). The provision of accessible transport also extends to increasing the capacity of local parking facilities and community transport options for older people (CSV, 2020).

Access to support services need to be provided during the key transpiration periods or 'life changing events' (CSV, 2020) experienced by older people (Ferrara, 2009). These include retirement (with evidence suggesting this is a notable transition period for men (Patulny, 2009)), losing a partner or spouse, and moving (whether this includes 'downsizing' accommodation and continuing to live in the community or transitioning to residential aged care; Ferrara, 2009). Importantly, these supports should be designed to encourage a sense of self-worth and value and to (re)connect older people with past life achievements, employment and other roles (Hillier, 2009).

Of significance in recent research is evidence of the need for older people to have access to the information and resources to assist them in making a transition to living in a residential aged care facility, with research identifying the need for 'better coordination of policies and services to streamline access and delivery' of those services (CSV, 2020, p 6).

Geographical isolation

The review of the existing empirical evidence base identified limited data regarding how service providers identify isolated older people and enable their access to services and supports. Data relating to the identification of isolated older people is evident in the context of the provision of health care services to older people, particularly those with chronic illnesses, including in circumstances where the lack of access to services has exacerbated the older person's health condition (Inder et al., 2012; Longman et al., 2013; Parsons et al., 2021).

The Australian literature identifies improvements in local governance and infrastructure that allow for the building of resources, opportunities and capabilities among service providers to enable better identification of isolated older people in need of support and services (CSV, 2020; Winterton et al., 2014). Similarly, research relating to the provision of services to older people in Scottish rural communities observed that older people are more likely to have complex health needs compared with other age groups which may, in turn, require a broader range of 'primary, community and acute hospital services' (King & Farmer, 2009, p 1). Challenges to this service provision were compounded for older people in rural areas where there were 'diseconomies of scale, travel costs and difficulties in attracting staff' (King et al., 2018).To address the dynamic between disadvantage and isolation, the need to facilitate social networks that operate as buffers, together with integrated approaches and targeted interventions on the part of communities, agencies and governments in the provision of services to older people were identified (King et al., 2018).

Recent research also identified the lessons learned from service provision during the COVID-19 pandemic as relevant to the identification of isolated older people to better enable access to supports and services. This research highlighted the experiences of geographically isolated people, which were exacerbated by the COVID-19 pandemic restrictions but led to service innovations (Sievwright et al., 2021). While virtual platforms were identified as supportive, their limitations were also acknowledged with in-person engagement also required in relevant contexts (Brooke et al., 2022; Holaday et al., 2022).

Summary

Existing literature suggests that isolation, both social and geographical, is a significant feature in the lives of older people. Loneliness, although a distinctly subjective experience, is linked to isolation. The literature indicates that the impact of social and geographical isolation is extensive and negative for the health and wellbeing of individuals, service providers and the broader communities. These findings suggest that a focus on prevention would be beneficial for improving quality of life not only for older people but for those who care for them.

This existing evidence base suggests a consistency of the experience in older people's lives and indicates that policy and practice interventions to address the physical, social and mental health impacts and the underlying factors giving rise to isolation should be a matter of immediate concern. This is particularly so given the increasingly older age profile of the Australian population, with the 65 and over age group expected to more than double from 3.8 million to 8.8 million in the next 25 years (Australian Institute of Health and Welfare [AIHW], 2018).

3. Findings

This section presents findings drawn from the qualitative data collected in the semi-structured interviews with professionals providing services to older people. The findings provide insight into the range of experiences for isolated older people, including the ways in which geographical isolation can compound experiences of social isolation. Findings in relation to the effects of this isolation on older people and the factors identified as giving rise to isolation are then presented, including in relation to life changes, events and transitions, with the impact of COVID-19 considered in this context. Data relevant to the identification of isolated older people, including risk assessments, and data relevant to facilitating older people and their carers to access support are also discussed in the final part of this section.

Experiences of isolated older people

Data from group interviews and individual interviews with professionals providing services to older people gave insight into the experiences of geographically and socially isolated older people based on their engagement with clients. The issues associated with accessibility to services and supports for clients living in regional, rural and remote locations were evident for these professionals. Consistent with observations made in previous research, the challenges included the impact of the diseconomies of scale in service provision and the resulting limitations in access to advice, services and support:

We [Community Legal Centre], also had a service with [Regional Area] and some of those clients were in country areas where they were very isolated, which meant that that was hard for them to get, you know, advice or support … that was hard because that relied on social workers etcetera going to their homes … There's a lot less services out in the country that's for sure, available to those people … they weren't able to access services because of that geographical isolation. (P04, not-for-profit community sector, metropolitan)

This lack of services in regional and remote locations was identified by a number of participants as a factor increasing the isolation of older people living in these areas (e.g. P06_P1, community sector, regional). One service provider observed how some older people in these circumstances did not identify the lack of availability of services and supports to be an issue and accepted their lack of access to essential services as part and parcel of living in a geographically isolated location:

So, the geographical isolation, they [older people] don't see it as an issue, even though we can't get support, like I had to ring a gentleman in [Regional Town] and [said] 'I can't get you that support out there', and he [client] goes, 'It's all right love. You tried' … So, he couldn't get access to meals … he didn't see it as an issue because he's choosing to live in a remote area. (P01, public sector, rural)

Echoing these experiences, another service provider reflected on the lack of care workers and services available to older people in regional, rural and remote communities, recalling an example of a client who was unable to access a Home Care Package due to his location:

I live in an area where there's plenty of service provision, but the services are not being delivered because of all the issues. We know that there's no care workers or support workers and so you've got people now very vulnerable people who are unable to access these services. I talked with a person the other day, a gentleman who was looking for [a] Home Care Package. He happens to live between, right slap bang in-between [two regional centres] and services won't go either way into where he is. So that's something we keep coming across quite frequently now … older people are being left with nothing, with very little, or they might be able to get limited services and … the providers have not got the support workers to deliver services. (P06_P4, community sector, regional)

The participant continued, explaining that these issues around lack of services in regional, rural and remote communities were not limited to community services but were also present in aged care facilitates, with a number of closures occurring, compounding experiences of isolation for older people:

So, in the last year and a half, there's been a number of closures of very small facilities around New South Wales and I'm sure it's across the whole country and it impacts the regional people more than any others because in a built-up urban area, there's probably another nursing home in the next suburb. In a small town, the next closest bed available could be an hour and a half away … the older person becomes isolated from their families because they own farms or businesses in the small town. So that has been a major impact on isolation for older people just from our observations. (P06_P4, community sector, regional)

Also reflecting on closures of supports and facilities in regional, rural and remote communities, another service provider underscored the lack of transport as being a significant issue alongside facility closures:

The more remote, the worse it is, like the lack of transport, and it seems transport is a big issue with isolation, but it's also those remote facilities where there's a threat of closure … if someone's in a remote community being there their whole life, they got their connections there, then that facility closes. They have to be moved to another facility quite some time away and especially if their spouse or their family doesn't have access to transport … not having access to their community isolates them even more. It is a big thing, I suppose, on their emotional wellbeing. (P06_P6, community sector, regional)

Drawing on an example of an Aboriginal Elder who had already been isolated from family, community and culture, the same participant illustrated how a lack of services could result in further isolation for older people who are in most need of support and connectedness with their family, land, community and culture:

I've come across an Elder who was part of the Stolen Generation and … she was in a small community that was her community where she grew up and where she also then raised a family. Now she had needed to go to care … she spent some time in hospital and the local care facilities wouldn't take her on … the only other option was going 2 and a half hours away from her home and for someone who had already been disconnected from community and family in her early years to do that later on in her later years … is just so distressing. (P06_P6, community sector, regional)

The service provider highlighted that while services and infrastructure were available in some rural and regional towns, they were not accessible to older people with diverse needs; for example, those with limited mobility or financial resources to pay for transportation:

I'm in a regional town … some buildings are not accessible, some [towns] don't have even pathways … I think even transport, when we look at bus services, taxi services, well, are they affordable …? (P06_P6, community sector, regional)

In relation to experiences of social isolation, some service providers described older people who were socially isolated not realising that their isolation was an issue, with their circumstances impacting on their cognition and wellbeing:

People who are socially isolated, they don't realise they're socially isolated. So, they don't see it as an issue. Even though we're seeing that the cognition is going downhill, and the mood is getting worse, they just don't see it as an issue … so people living with dementia who are socially isolated, their caregivers are the ones who do notice it because they're not getting a break. And the break is what was helping them maintain their ability to support the load … so many times I've tried to link people in with going to a social support group just to trying to improve their mood and their outlook on life. They go, 'I'm not interested in it.' (P01, public sector, rural)

This service provider noted that the family of isolated older people were likely to identify and acknowledge the isolation. Older people who appeared to be unconcerned about these circumstances required careful support and encouragement to regain their ability to connect with others in their community. Of further significance were experiences of older people who were caring for a spouse or family member, with some participants highlighting the unique challenges around social isolation faced by carers:

People engaged in care [are] extremely likely to be socially isolated … what we found with all the carers is very often they're caring for a partner who's older themselves. That's a relationship that gives them enormous strength that is enormously valuable for them and there's not much time for anything else, and that's okay … the problem arises when either that relationship doesn't provide that connectedness anymore because of conditions or because of deteriorating circumstances, or when that relationship ends. (P03_P5, community sector, metropolitan, regional and rural)

Some service providers identified a gendered dynamic to the experience of isolation, identifying that women were more likely to engage in social activities and suggesting that men often required further support in this regard. The following service provider described innovative steps to initiate activities considered to be of interest to older men to encourage them to participate in social activities in their community:

I've noticed a lot of groups have more women in them than men. We recognised quite a while ago that on a lot of our social bus trips. The majority of passengers were women and that out of the bus of about 20 odd people we might be lucky to get 1 or 2 men, so we have come up with a new program … called Just for Blokes, and it's the trip for just the men, the destinations they go to are, you know, more male oriented like a motor museum …, those kinds of things, yeah, and we've, we're seeing men that we have never booked, they've never come out with us before, so that tells us that word is travelling … men are much more encouraged to come along because they're just with other men. They share experiences, you know, from their careers or just their life experiences and it's great for their wives. They like to say goodbye to them in the morning and say 'I'll see you this afternoon after you've had a nice day out.' (P02, not-for-profit community sector, metropolitan)

Elaborating on why women might be more inclined to socialise, the participant continued:

I just think they [women] are a bit more proactive and a little bit more aware of the need to have those kinds of friend networks. (P02, not-for-profit community sector, metropolitan)

Another professional who oversaw the delivery of services in the public sector spoke about a different local social support initiative for older men and how it came about:

I was horrified a few years back when I read a report that the rate of suicide amongst older men was the highest of any demographic in our community. So not by number, but by rate. So, men over 85, and it sort of stuck with me … I was also aware like, you know, you look at social support and the current social support opportunities that we have in the community, and very low participation by men. We're talking under 10%. And [it] has been for many, many years with the Commonwealth Home Support Programme, and there's things like the Men's Sheds. They're probably great for people who've hammered and tinkered with tools. But when you think overall, the participation rates [are] that low, that's not good enough as a sector.

And you look at the current … program and people are required to undergo a My Aged Care Assessment, sell their soul ... The marketing's images of frail women, cups of coffee, [playing] bingo … You know [that's] not necessarily that attractive … So, we engaged a group of guys … to guide us in what social support could look like … we've got 14 old guys out today on a gig, and they've done a range of activities that you know, a lot of it's about understanding the mechanics of things and how things work - whether that be, you know, the back of a theatre … or they fix pushbikes or they've done some Bushcare or they've been to the steelworks, like a real range of different things where they get a sort of behind the scenes to and just catch up and then they meet each week in our library to play games as well. (P08, public sector, metropolitan)

Effects of isolation on older people

Interviews with service providers provided insight into the effect of isolation on older people based on their engagement with isolated older clients. Service providers participating in the group and individual interviews identified a range of significant effects on older people arising from their isolated circumstances. The following participant identified both the range and interconnected nature of these effects, which included poor personal or self-care and decreasing mobility among older people not leaving their home. This also included decreased mood and memory from a lack of social interaction, and apathy and reduced engagement in previous areas of interest, together with poor diet potentially arising from both a lack of interest and a lack of access to food and groceries outside the home:

So, what I have seen, people who are socially isolated, they don't eat well. And they may not be well-groomed because what is the point in getting dressed. I can be in my pyjamas all the time. 'I don't have to leave the house', and decreased mobility because they are not using their weight-bearing muscles and bones to walk any distance. Decrease in mood and memory because of not having social interaction that will keep them sparked. Apathy, loss of interest in the usual hobbies and interests. (P01, public sector, rural)

The impact of low self-esteem and confidence was identified as exacerbating the isolation and loneliness experienced by older people in these circumstances, with significant impact on their health and wellbeing, as indicated by the following participant:

They probably wouldn't bother, you know, having a shower every day or, you know, getting dressed in nice fresh, clean clothes every day… people just sort of start to slip away and their self-esteem and their confidence in their ability to put in an effort just exacerbates their loneliness and their isolation, so rather than have to make an effort, they'll just think, 'oh, it's easy to stay at home', you know … 'I don't have to do anything much if I'm just here by myself' … then they just get on this sort of lonely cycle and find it a bit difficult to get out again. Some people, you know, need someone to take their hand and say, 'come on, we're going out, you know, get dressed. Spark up, we'll go out'. Have a really nice time, a conversation, and that's often all it takes, you know, just someone else who cares. (P02, not-for-profit community sector, metropolitan)

This participant identified the circuit breaker, being the encouragement and opportunity to engage, that can move an isolated older person from feeling as though they do not have to undertake everyday activities and help rebuild their self-esteem. Additionally, participating service providers illustrated how experiences of isolation meant that older people were vulnerable to poor health outcomes and abuse due to an absence of trusted professionals and carers monitoring their health and wellbeing:

I think it [isolation] can lead to mental health issues … poor health because [older people are] not, you know, getting their health checks done … they're vulnerable to being taken advantage of by others in the community like neighbours or some people, you know, who identify that they are socially isolated and think they might benefit from that … it leaves them very vulnerable to abuse. (P04, not-for-profit community sector, metropolitan)

The additional barriers for socially isolated people who were also geographically isolated were highlighted by some service providers. For example, the following participant described how a client who had lost a partner who managed the family's meal preparation would be faced not only with the disincentive to prepare a meal when living alone but also be unable to access meal provision services, such as Meals on Wheels, that may be available because of their remote location:

If you've been living with somebody for many, many years and they passed away, it's very difficult to make that adjustment … and if you're eating on your own, we've seen the people tend to not eat a lot or they skip meals or have very, very simple meals, because what's the point in preparing a meal for just myself. (P01, public sector, rural)

Effects of isolation on mental health were also underscored by service providers, with some recalling experiences of frustration for some older people at their circumstances and their inability to take remedial action to address the issues they experienced:

I think [isolation] leads to a lot of depression in our clients … maybe even changes in eating habits, like just getting more health issues. (P03_P2, community sector, metropolitan)

It [isolation] affects the [older person's] mental health and, in some, it impacts their physical health as well, but mental health mainly … sometimes they get very withdrawn and sometimes they get a bit irritated. (P05, non-government sector, metropolitan)

[Client] gets very frustrated and becomes very angry because he doesn't know how to resolve his own problems … on the most recent occasion he's ended up in an institution in [Regional City] because he becomes so escalated because he doesn't know when he's getting his services. The unpredictability of his life escalates his mental health issues … so frustration and anger as well. (P06_P3, community sector, regional)

Factors giving rise to isolation for older people

The discussion in this section illustrates that service providers participating in the interviews were able to pinpoint many of the factors that led to or exacerbated the isolation of older people. COVID-19 impacts created challenges around connecting older people. Other factors identified as catalysts for isolation included significant life events or transitions, such as death of a spouse or family member, a decline in health or having to care for a spouse. Circumstances including older people living away from others in their cultural group or having changes in their family relationships, and experiences of poor mental health (their own or others), substance use or violence were also identified as further compounding experiences of isolation. A lack of service access and access to other infrastructure resources such as transport were factors potentially made more challenging not just by geographical location but by stigma surrounding the loss of independence and loneliness.

COVID-19 challenges

Many service providers participating in the individual and group interviews described how the COVID-19 pandemic and associated public health measures and restrictions exacerbated the existing challenges of social and geographical isolation for older people. These challenges were often identified as continuing after the lifting of restrictions. Participants recalled that older people often needed encouragement and support to reconnect with services and the community and identified the need for increases in staff resourcing to facilitate the resumption of these connections. The following professional described clients living on regional properties on their own, living without contact with family or community and being impacted in complex ways by the COVID-19 lockdowns:

When we go to see clients more than likely, they [are living on a] regional property on their own or they're living on their own in a channel with very limited contact because their family have moved out of town due to no opportunities for employment. Their living circumstances change, their partner has passed away, so they end up living on their own … and throw COVID on top of that. It's just getting worse … So initially for the 2 years that we were in and out of lockdown, our clients were reluctant to let us into the home because they were wary of getting COVID. So we were offering telephone [ACAT] assessments … and all of the social activities that people had in place through the Commonwealth stopped … since we've opened up, we've noticed an increase in our referral from people who are living alone, wanting to be reconnected with services or reconnected with society … all that socialisation stopped and some of it hasn't restarted because they can't get staffed. So, we've got these older people who are now stuck in their homes, not seeing anybody. (P01, public sector, rural)

This additional resourcing was required to ensure the resumption of access to pre-existing support services and the provision of services for conditions that developed or deteriorated during the COVID-19 pandemic:

I've got one gentleman who's living with dementia, and before COVID he was attending a social support group 6 days a week to support his wife to just manage the care needs … she had tried 2 years to get [husband] into respite … now that we've opened, she's still trying to get him into respite, and now she's trying to get him to permanent care. Then 2 and a half years later, she's still trying. And his social support group didn't restart after COVID [due to] staffing … for my gentleman living with dementia, he didn't realise it. It wasn't bothering him, but his wife was not sleeping … not having a break had a negative impact on her health. (P01, public sector, rural)

The physical and psychological barriers to social engagement were identified by the following service provider, illustrating the challenges not only for older people but also the service providers supporting them in these circumstances:

Unless you know a little bit like the COVID lockdowns and whatnot that we all experienced, you know we were restricted to go out, so … you tend to slip back into that kind of, you know, I'm happy by myself kind of thing, but then you realise you're not really happy so … I think it's a combination of sort of physical and mental attitudes to staying social. (P02, not-for-profit community sector, metropolitan)

The fear that older people and/or their families experienced around the older person contracting COVID-19 was also significant in shaping experiences of isolation, with one participant explaining that although many older people were keen to continue socialising following periods of lockdowns, families sometimes acted as gatekeepers to this engagement:

We also found during COVID that a lot of families were reluctant to have their parents go out … [the older person] probably wanted to go out like just as it was getting out of lockdown, [and] their families would go, 'no, no, I don't want you to go out … it's not safe'. So, they were isolating them even more. So yeah, family members really can impact things. (P03_P2, community sector, metropolitan)

However, participants also described the fear of COVID-19 infection experienced by some older people, which, in turn, exacerbated their isolation:

There is even a fear of COVID … I have spoken to a few people where they were too scared to still go out, even to a basic appointment or whatever, for the fear of COVID. (P06_P6, community sector, regional)

Life changes, events and transitions, including declining physical and/or mental health

Service providers participating in the group and individual interviews described the impact of life events or changes or transitions in life circumstances as contributing to the experience of isolation on the part of older people. Life events were identified as including the departure or death of family (including pets) precipitating, or exacerbating, mental or physical health issues:

Being super aged … all of my friends are dead, I don't know anybody in my community anymore. And I've got no need to leave the home. I'm afraid to leave the home because I'm incontinent or I'm falling. And family moved away during COVID. The death of the significant other. Even death of pets. (P01, public sector, rural)

Indeed, the positive impact that pets can have on improving connectedness for isolated older people has been documented in the literature (Cryer et al., 2021; Ikeuchi et al., 2021), making the loss of a pet a significant transition point. Such events, changes or transitions were linked to a decline in the older person's confidence to engage in life outside the home and to participate in life in the community without the supports and scaffolding previously maintained:

Family moves away … if you have children, you know, [they] have their own lives, they might have their own children. They become involved in their own lives just like the older person did before, and often the families don't have the time to spend with an older person, or they might not even have a good enough relationship with them to want to spend time with them … lack of mobility as well, which is where we [service] come in … people feel a bit nervous about going out as you get older … you can also lose your confidence … you might have had a hip replacement, or you might have any other kind of medical condition that just limits your mobility. Yeah, and I think sometimes you know, people just get used to not going out … they think it's easier. They don't have to make as much of an effort, and I think that can sort of creep into the psyche as well. (P02, not-for-profit community sector, metropolitan)

Mirroring these views, other participants reflected on life transitions, whereby an older person's social networks might have moved or passed away, and where adult children may have started their own families leaving less time to engage with and support the older person, with these life transitions giving rise to experiences of isolation for the older person:

[I can] talk about a lady I spoke to, actually 2 ladies [in] similar situations … older women living alone in the outskirts of [City], [South-Eastern European] women, both of them. And families [are] not nearby. Kids are married and families all over the place [and they] don't get to see their families very often … and needing supports, needing care but the language is a barrier, so they need interpreters … one of the ladies in particular impacted me because she was just in tears talking to me. She was so sad and so lonely … and there are no [South-Eastern European]-specific social supports anywhere near her. (P06_P2, community sector, metropolitan)

As outlined by the participant above, language barriers could compound experiences of isolation if appropriate support services were not available, as was the case in this example. Another service provider reflected on the feelings that could accompany loss of friends, particularly feelings of abandonment and loneliness, and the feeling that there is no longer a place for older people in the community:

Like a lot of our clients, because now in that age group where their friends have already passed on, other friends have gone into aged care and family members have moved on or passed away so there's that feeling of abandonment, but just that loneliness, of not being able to be part of the society like they used to be … that feeling of not having any use. (P05, non-government sector, metropolitan)

Also of importance in understanding the factors that can give rise to isolation for older people was the reluctance of some older people to ask family or friends for support, even if they lived close to the older person. As outlined in the following interview extract, this was often driven by the older person not wanting to burden their family:

Even if the family haven't moved away, which is quite often, they have that the family and the older person will tell us 'Oh my family's far too busy, they've got their own families, they've got a big, busy job. I can't go to them. I can't ask. So, I don't want to trouble them' … and that's a common story that they feel unable to go to the family for support … [they] don't want to be a burden … they'll reach out to our organisation rather than reach out to family. (P06_P4, community sector, regional)

Where an older person is living outside of their cultural community or where they have experienced poor mental health, family separation or complex risk issues including violence and substance misuse, these factors were identified as contributing to an older person's isolation:

I think when there's mental health issues involved, it can isolate people so that if there have been issues in the past with poor mental health and there's been, you know, I guess inappropriate behaviour that's ostracised some of the family then, that can [be] their problem issues with violence. Alcohol abuse can also mean that they're socially isolated. Also I guess when their children have drug and alcohol abuse issues. That can mean that they've … cut contact with the family … and also if they don't marry or have children, don't have those contacts … if English isn't their first language and they don't, they're not sort of part of the community of where they're from, then that can lead to social isolation. (P04, not-for-profit community sector, metropolitan)

Speaking from the perspective of older people who are carers (usually to a partner, spouse or other family member), another participant explained that not having resources such as transport and good health were 'preconditions' to isolation:

The fact that they [carers] don't have enough time to engage with other people and that social connectedness requires [them] to have the resources to socially connect and that's time, that's transport … [their] own physical health. So, these are all preconditions to social isolation. (P03_P5, community sector, metropolitan, regional and rural)

Feelings of fear and stigma around life changes and transitions were also significant for service providers, who spoke about the 'loss of independence' as being challenging and confronting for older people. In other words, there was a wider view that receiving support could result in a complete loss of independence:

The loss of independence, and the loss or health, health is another huge, big thing, like their mobility, which impacts the mental health, so it's like vice versa, and the fear of: What will happen? How? How will it happen? The fear of [the] unknown. (P05, non-government sector, metropolitan)

Some participating service providers suggested that this fear of losing independence drove some older people's decision to avoid engaging in residential aged care services. For example:

I think the main thing is that going in a [aged care] facility is just another way for them [older people] to feel that death is a reality and all of that … they feel that they go to the facility and they're going to go in there and die. (P05, non-government sector, metropolitan)

A broader stigma around life changes and transitions experienced by older people was also described as impacting on experiences of isolation:

Stigma around isolation, especially among older people … this fatalistic approach. So okay, I'm old now. I'm alone and that's how it is. And I'm not gonna change that. (P03_P5, community sector, metropolitan, regional and rural)

However, at the same time, this participant explained that it was not just stigma but a lack of access to various resources, including health and finances, that gave rise to isolation among older people:

But I would really highlight sort of the material resource circumstances first, health, of course, is a resource … and sort of also especially in the caring in the context of informal care, the non-availability of formal care services, the fact that there's no easy way to get respite if you care for a partner in who requires 24-hour supervision. (P03_P5, community sector, metropolitan, regional and rural)

In line with these comments around material resources, as well as deteriorating health, another participant suggested:

Well, transport, not being able to get anywhere without having to plan and a lot of times [older people] use doctor's appointments to get out … and it's an outing for them, I suppose. So, transport. Financial … and health, definitely health. You know, if they're not feeling well, even psychologically … they won't come [to community support groups] and stay home. Another big one is incontinence … bowel issues … mobility is another one. (P03_P2, community sector, metropolitan)

Identification of isolated older people and supporting access to services

Participating service providers working with older people identified that there were screening tools to help identify depression and geographically isolated older people but tools for measuring social isolation varied, and were not a specific focus for many of the participants. These service providers described using more informal methods to screen for social isolation such as drawing on their knowledge of, or connections in, the community or engaging in conversations that could provide a broader picture of the older person's current life circumstances. Supporting older people to access services during COVID-19 restrictions was also identified by participants as challenging, particularly where clients could not use technology for various reasons. Participants also identified broader service delivery challenges including encouraging older clients to take up social supports when the client may not have seen them as being as necessary as more practical services aimed at household management.

Screening tools and assessments

Developing connections in the community was highlighted as an important tool in identifying isolated older people, despite this not being a formal assessment:

There's no screening tools. I think we just ask a lot of questions. So a lot of times we'll hold a meeting and the community … and the community comes to us and basically talks to us about what their needs are and we're able to identify [isolated older people] … I personally hold meetings at the libraries, so I've organised with the [Regional] Shire to have a meeting every month in 4 libraries and then I'll go to [Regional] Council and speak to the library there cause a lot of older people want to come to libraries and they run these really good courses called Tech Savvy and I've been able to get into those groups as well and talk to them about what their experience is regarding aged care. And yeah, it's just advertising with posters and in the local community newspaper. (P06_P3, community sector, regional)

I think we've all got our connections and our local areas that might feedback into us. So ACAT, hospital, social workers in different environments. So, we've built those networks that they're coming to us with that information about someone that's vulnerable and isolated. (P06_P4, community sector, regional)

A participant who works at a community transport service indicated that although there was no particular screening tool applied in their work, there were less formal ways by which they identified whether the older people that they engaged with were experiencing isolation:

Our call centre staff would probably be a little bit more aware of those details. They're engaging in conversation with customers over the phone all the time … people share a lot of information just in conversation over the phone. You know, you'll often find that as soon as you pick up the phone, people are launching into a conversation. And if you're, if you're sort of probing for answers a little bit, you can identify the ones who might have family that's moved away … or they might be living by themselves, so really, we're sort of capturing that opportunity every time we have a phone conversation with any of the customers … there would be particular notes taken and that kind of thing. It's quite a detailed profile on people. (P02, not-for-profit community sector, metropolitan)

Similarly, a service provider from a not-for-profit community organisation that provides the Commonwealth Home Support Programme, social supports, transport and domestic assistance services explained that while they were guided by the wellness and reablement philosophy to assessing the needs of isolated older people, they took a more flexible approach to identification:

We try to follow the wellness and reablement philosophy of the Commonwealth Home Support Programme, which is, you know, allowing [older people] to still have power over what they want to do, but it's not a validated assessment. It's not like the Personal Wellbeing Index. I personally have used the Personal Wellbeing Index and I found that being a bit confronting to some clients … it was very challenging using it because [you need] the skills to ask those questions, but you're not supposed to ask the questions in another way. You're supposed to ask the question as part of the tool and it can bring out quite a very strong response with some clients … another way we do it is through our support plan and just finding out, you know, getting a whole host of a whole picture of the person and who they're connected with … and sometimes we get families who think that their mother or father needs to be more social and connected when really, they don't want to be … they sign up and then they don't attend because they've been told by their daughter or that they need to get out. (P03_P1, community sector, metropolitan)

Another participant from the same service organisation then elaborated on how clients were introduced into the service, indicating that My Aged Care referrals were common and would involve a comprehensive assessment upon referral:

We do a comprehensive assessment to come onto our service. We usually get the referral with My Aged Care … but we also do an assessment. So, we go and visit them face to face or they come here and … we actually do a care plan … which is person-centred and we work out, you know who they interact with in the community, their family support, all that information. And also, we do a social support assessment to see what they want to do that they are unable to do and what the barriers are to that which could be transport could be you know they don't feel comfortable with people … it's been a huge step for them to contact us … it's not easy for people to come into the centre … I guess you identify that maybe they've lost their husband or wife in, you know, recently in the last 2 months and they really have stopped doing anything social. Maybe they relied on their partner to go out. (P03_P2, community sector, metropolitan)

Another service provider explained that given clients had been referred to them from My Aged Care, they had been screened prior, making assessment a less prescriptive process for the service:

We get referrals through other service providers, so they [clients] have had that assessment with them before they come to us … all the clients come through [the] My Aged Care portal … because we get the calls, the referrals through the portal, that assessment has already been done. By the time they come to us, we then, we do our own assessment on them…… our tests take anywhere between half an hour to 40 minutes and depending on how indulgent the client is, sometimes it goes up to an hour.… we ask them about the emergency contact.… then we ask them about their health … we ask them about do you have any friends … how often does your family visit you? Do you have any family? We are asking all these questions … and we make notes on that on our assessment tools and we put the notes in our database … and we try to figure out what their, what are the dynamics of their lifestyle. (P05, non-government sector, metropolitan)

In relation to geographical isolation, one service provider outlined how geographically isolated older people were identified:

We've got a Modified Monash Model scale on My Aged Care. [The scale] consider[s] anybody living in MMM [Modified Monash Model Scale] 6 to be isolated … we see clients in MMM5, which will be considered rural and regional … we cover a huge part of [regional and rural] New South Wales. (P01, public sector, rural)

When asked if this screening tool was useful, the participant responded: 'It's more for My Aged Care for them to see where we're seeing people.' In recalling the types of supports available for older people in their area, the participant continued:

What's available? Because as I said, each town has a different availability and they've got daycare centres where they [older people] can go and do activities. The centre-based respite where they go to a centre, go and have trips, have meals … if somebody has said to me, I wanted to make a change, we can try and put them on a restorative program to help them re-engage with the community. (P01, public sector, rural)

Service providers also outlined the screening tools employed to assess social connectedness and symptoms of depression and anxiety:

I wouldn't say we do [have a social isolation screening tool] but we do a geriatric depression screen … and we ask a question about how socially connected you are to the community and what activities do you like to engage in, and if the client indicates that their activities are more solo activities, they prefer to do it at home, we would then indicate that they are socially isolated on our assessment tool. (P01, public sector, rural)

In considering what would be useful to have in a screening tool, the participant proposed that it would need to be an objective test that could be applied by all service providers:

I suppose it would have to be an objective screening tool where we could ask objective questions for a client and after saying their level of social isolation … not subjective, because that's where we go into trouble because we all have different ways of explaining things. (P01, public sector, rural)

The interview data provided insight into the structured risk assessment employed in the Aged Care Assessment Team (ACAT) assessment process. It captured familial circumstances, engagement in social activities and connections in the community, an assessment of the older person's health care and social needs, including an assessment of the older person's psychological wellbeing pursuant to the geriatric depression scale and an assessment of the social and environmental supports currently in place, as outlined in the following example:

I would introduce myself and explain my role and then ask the client their understanding of why I was there. Once we got all the legal paperwork out of the way I would explain the assessment process to them and how long it's going to take of their time and their rights to stop at any stage. Then I would be asking questions about who's who in your family, who's important to you, who do you speak to and who is in contact with you?

And then we move on to your social activities, how connected you are to your community. And do you need support to connect to your community? … And is a caregiver present. We ask what their support person supports them with and how they are managing and their caregiver role. So, we will do an objective assessment of the caregivers and feelings of being a carer. Then we move on to a general observation of the client … and then we go into a full functional profile of how the client is managing currently. And what supports are in place and where the client has identified the gaps in their support.

And then … personal health and physical health. So, medications, health conditions, oral care, diet … sleep. And then we move into it's like a social profile where we conduct a cognitive assessment and if there is a caregiver there who knows the person well, we'll ask them to do subjective synopsis of where the memory's been going over the past 10 years. Then we'll ask questions about how they are feeling, feelings of loneliness, isolation, depression, anxiety, any changes in their memory, any changes in the mood, any confusion, and then that leaves on to the geriatric depression scale. Then we do an assessment of the home environment to make sure that it's appropriate and meeting the clients' current abilities and needs. We do a personal safety assessment, so making sure the client is not experiencing or at risk of abuse. (P01, public sector, rural)

The comprehensive risk assessment described also captures the extent to which an older person sought a change in circumstances, with strategies identified with the support of the service to facilitate the implementation of a support plan:

We write what they call a support plan. So, we will identify what the client has stated … we will identify the goals they wish to achieve and then we will have agreed strategies to reach those goals and then we write an assessment summary, which is summary of what we have found out at assessment … Then that's sent off to somebody called a delegate who agrees or disagrees with the recommendations that the ACAT assessors put forward. Once all that is finalised, the client receives the copy of everything … also a follow-up phone call after we've completed everything to tell them the outcome of the assessment. (P01, public sector, rural)

This service provider identified how the information from the risk assessment would inform whether an older person was isolated and in need of support, with negative impacts of isolation indicative of the need for support:

Well from [the assessment] questions like who's in contact with you … and then the questions of what do you like to do. And normally some people volunteer 'I like my own company', but if they don't volunteer [that] they like their own company, it's through the assessment … then when we get to the memory and mood, if we're seeing these issues with memory and mood because they're not socially connected … we're kind of seeing a big picture. We just put it all together and go, you're lonely and you're socially isolated. It's impacting on you negatively. (P01, public sector, rural)

Some service providers identified linking to support services that could help address the older person's isolation and ameliorate the consequences arising from their experience of isolation:

We have…a strong connection with some other service providers in this area … There's an organisation called [Shire] Food Services … if they [clients are] not feeling like cooking, they need meals delivered or they just want to pop some other meals into the freezer, [Shire] Food Services is a wonderful organisation who can support them with that and also there's another business called Home Modification Solutions so that they [clients] can tap into that as well and have any, you know, extra rails put into the bathroom or ramp put into the house or any kind of building modifications that would help make their lives easier so that they can be more mobile and safer in their home. We definitely want to try and encourage that. That independence. You know, and when you're feeling independent and healthy and strong, you're much more inclined to be socially connected … we don't physically connect them [to services], we can only tell them about it. But of course, My Aged Care, which is you know, the first port of call, are the ones who can recommend different services to various people once they've had a phone conversation with them, and then often they'll go out to the person's home and just identify other support services that they might require. (P02, not-for-profit community sector, metropolitan)

Supporting older people during COVID-19

Service providers reflected on the challenges that the COVID-19 pandemic presented for isolated older people, particularly for those who did not have access to, or who were not as confident with, utilising online services and supports, such as ordering groceries online. The following service provider explained how a 2-hour shopping service for older people remained an important social outing for older people during COVID-19 lockdowns:

We have a shopping bus that takes people to a local shopping centre where they can, you know, do whatever they need to do in a 2-hour period. Our driver and the transport assistant are there to help people on and off the bus and also assist them with their shopping … they stay there for 2 hours while all the passengers do whatever they want to do… at the end of the 2 hours they all gather back at a table where the driver and assistant have been waiting. And then everyone is supported to get back into the bus with all their shopping and then their shopping is walked to the door for them … that proved to be a very, very crucial service, particularly through lockdown. It was considered an essential service, of course, for people who might not be technically savvy to book groceries and things online. Yeah, so that almost became a bit of a pseudo social bus trip because people needed to connect. (P02, not-for-profit community sector, metropolitan)

The service provider also recalled how volunteer staff at the community transport organisation took on the flexibility of different roles during lockdowns to support older people and reduce potential experiences of loneliness during this period:

We've got a big team of volunteers and we have some paid staff. You know, drivers and transport assistance … and they were visiting people, sort of at a distance in their homes and taking some care packages and things like that when we were sort of in the thick of all the isolation just to let people know that we were thinking about them and that, you know, they could always sing out and call us if they needed anything. (P02, not-for-profit community sector, metropolitan)

Some participants described the challenges associated with moving services online, particularly for older people who may not have had access to or the skills to use technology or had physical challenges such as hearing loss or vision impairment, making an online environment more difficult. For example:

[COVID-19] was hard because we couldn't get into the hospital to assist people, which meant that we had to move to an online service. And I think that made it really hard for older people who often, you know, didn't have access to videos and that sort of thing and phone calls can be tricky … if their hearing's not great the fact that they then weren't coming into the hospital for their normal appointments meant that they weren't accessing services like ours like they normally would. Yeah, so it was, it was tricky and hard for us to do our job because we do rely on face-to-face contact in order to execute documents ... we were able to execute documents online over video, but often, you know, our older clients didn't have access to computers, so we're very reliant on social workers to help with that if they were visiting all the people in the community … I guess because people were stuck at home with their perpetrators … they were more likely to be victims of abuse because of that. (P04, not-for-profit community sector, metropolitan)

Physical disability adds to this as well. You've only gotta lose your sight or your hearing and all this internet is useless … if you've forgotten the small amount of English that you, that you had before, and you've gone back to your original language, which is fairly typical, you know, with dementia, then how do you communicate even with the IT that we've got at the moment. So, there are many issues and that's the way people become disconnected and isolated. (P06_P1, community sector, regional).

On the other hand, some participating service providers described a variety of activities that were available during COVID-19 for those older people who were able to engage online, and how these were directly aimed at alleviating isolation:

During COVID, we did a lot of Zoom groups trivia sessions, and we also did Zumba sessions. We did them via Zoom so that engaged a lot of the clients who were feeling isolated. (P03_P2_ community sector, metropolitan)

The value of this type of contact online or via telephone was apparent to those delivering these services during the isolation largely imposed by COVID-19. One professional whose service provided a social telephone service where daily calls are made to clients at risk of isolation - reported that this service was often the only human contact some clients would have during the COVID-19 lockdowns:

With socially isolated clients, especially over pandemic, over the lockdown periods … that was the time that these calls were really the only calls that they will get … these are the only calls, the human voice that they hear all through the day … So, we were hearing a lot of stories from the clients about how isolated they were. (P05, non-government sector, metropolitan)

Supporting access to services for isolated older people and their carers

Some service providers indicated that isolated older people could experience difficulties accessing the My Aged Care process, which could be confronting for some older people to engage with by themselves. The following participant outlined her role in supporting her clients to become linked in with the My Aged Care system:

We might get someone ring through because they're struggling and they wanna access aged care so they might not even know about My Aged Care … It might be a bit daunting for them to ring themselves, so you're supporting them along the way because My Aged Care is a call centre. Some of the people that work there are absolutely brilliant, and they can get the information. A lot of older people tend to minimise things they're going through, so by having probably a 3-way call with My Aged Care with the older person, myself and My Aged Care, it's actually making sure that they are being heard … So they're getting the right assessment, the right level of assessment. (P06_P6, community sector, regional)

Some service providers suggested that it was challenging to encourage clients to take up social supports, as these kinds of services were not viewed as being as important as more material or practical needs:

Yeah, it's like they'll [clients will] accept personal care but not really social support because they're not seeing it as a high value or high-ticket item ... we're trying to connect people who are having issues with shopping rather than get the shopping delivered. We try and do social support shopping as a recommendation, so at least they're getting out of the house. To go with somebody to do their grocery shopping, to come home. Because if you're getting it delivered to the house, you're not getting out. (P01, public sector, rural)

Therefore, encouraging clients to take up more socially based activities was a strategy used by some service providers, although they acknowledged that some of these social services required the older person to be in good physical health and be located close to where the services are based:

There's a service called Community Transport but you must be able to get in and out of the car or on and off the bus independently. And then you need to be independent for wherever you're going, because you get dropped off. Then there's one company that [provides] activities, social support, individual company activities, that's where somebody will come and pick you up and take you somewhere and be with you … but it's not available in every town. And there's a limit to how far some of the cars will go. So there's a lady who lives in a community called [Town 1], which I think is, I think it's about 50 or 60 plus kilometres away from where I'm based at the moment. And they will drive her around [Town 1] with a social support individual in the car. But if she's coming to [Town 2], she needs to get community transport. She goes, 'I can't manage it. I've got a broken leg.' So getting to her medical appointments is a strain … (P01, public sector, rural)

One legal professional described their surprise at how many of their clients were without trusted people to support them in making decisions and who were vulnerable to abuse:

[I am] surprised by how many of my clients have no one in their lives to be able to point to, to make decisions on their behalf. And it means that they're more at risk of experiencing elder abuse because they don't have someone that they can trust to make their decisions for them if they can't make themselves, yeah. So that can make them really vulnerable. (P04, not-for-profit community sector, metropolitan)

In recognising this vulnerability, the participant elaborated, indicating that the community legal service would connect isolated clients with support services:

[Community legal centre would] hook them up with social services that can assist them to encourage them to think about appointing the New South Wales Trustee and Guardian as their attorney so that if they lose capacity then there's the protection there of the Trustee and Guardian making decisions on their behalf. Yeah, so, and working I guess with the social worker to make sure that they are in touch with services that can assist them … if someone has someone in their life that they can appoint as their attorney, then we try to identify that person. (P04, not-for-profit community sector, metropolitan)

At the same time, this legal service drew parameters around the role they played in supporting older people:

I guess that's not really our role to link them [to support services], so we try to get the social work staff to do that. Because all of our referrals come from, generally, from social work, then we will refer the client back to the social workers to link them up with appropriate services, so we kind of try to restrict our role to being that of a legal advice role. (P04, not-for-profit community sector, metropolitan)

Supporting older people from culturally and linguistically diverse backgrounds was also a priority for many service providers, with the following participant describing the interpreter service, as well as linking older people in with support workers who speak the same language:

A lot of our clients are from culturally and linguistically diverse backgrounds and we use interpreters to be able to communicate with them. Also try to see if we can put them in contact with community workers who speak their language or who work with other members of their community. (P04, not-for-profit 
community sector, metropolitan)

Barriers and enablers experienced by older people to accessing and maintaining engagement with support services

Service providers who participated in the interviews identified diverse barriers to engaging and maintaining engagement with services for isolated older people, including but not limited to physical and mental health, language barriers, financial barriers and practical barriers such as limited access to finances, transportation and/or accessible infrastructure in the community. Key among enablers was the need to maintain community connection and regular community engagement. This engagement was identified as further facilitating access to services and opportunities to inform older people about services available and activities that increased social connection, such as volunteering or digital literacy training.

Barriers

Participants identified barriers to social engagement where older people appeared to be unaware of being, or to not identify as, lonely or isolated, and only signifying that they needed help with specific and more practical services such as day-to-day household management:

The barriers were what I've seen for people to become socially engaged is lack of motivation. Sometimes on their part … or they're just going, 'I just need help with my cleaning.' (P01, public sector, rural)

Stigma around identifying as lonely or aged contributed to lack of engagement with older people not feeling as comfortable to explicitly indicate a need for social contact. Notably, this participant indicated that volunteering provided a more meaningful avenue for older people to engage in social activities.

One thing I've found, I did a project with the local council here. It was called the Loneliness Project. And there was a whole heap of local providers who were on that project, and we tried to reach out to people who are lonely and hook them up with volunteers to form a relationship and going out. After the end of that project, it wasn't that successful. And we tried to figure out why that wasn't successful and one of them was that a lot of people didn't like to identify themselves as lonely, and some of them even wanted to be a volunteer. (P03_P2, community sector, metropolitan)

Within this context around the stigma of ageing, the My Aged Care online portal was described as a barrier by some service providers, with clients being required to register to access services and, in doing so, confirming they are older even if they do not identify as such:

We've lost clients who won't attend [service] because they, as you know, part of our funding, they [are] required to register with My Aged Care … and people said, look, I don't feel like I'm ready for that yet. (P03_P2, community sector, metropolitan)

Also referring to the impact of stigma and ageism in preventing some older people from accessing supports and services, another service provider explained:

The other thing is, of course stigma around accessing and services and support and stigma around the actual condition of loneliness … ageism is another thing. (P03_P5, community sector, metropolitan, regional and rural)

Not identifying as a carer was also described as a barrier to accessing support for older people:

So, a big barrier to carers accessing support is realising that they are a carer, that what they're doing is kind of above and beyond normal family responsibility and that they might need some help. And that is really the biggest barrier we face with service access for carer supports. (P03_P3, community sector, metropolitan, regional and rural)

The complexities around service navigation, which was intertwined with digital access and literacy, were also raised by service providers, who suggested that more concrete support was required in this area:

My Aged Care was a good idea but it still really is very cumbersome process for the elderly … I don't know advocacy people that would help you, you know, go through the process of all these services that are available … an intermediary of sorts, between My Aged Care and the client themselves … the clients find it very daunting. 'I need help. But I go to My Aged Care … I'm put on hold if I call on the phone. If I'm supposed to go to the website, I'm not very internet literate, because I'm 80 years old.' (P09, community sector metropolitan)

The complexities between services and where to go, what you can access, how you access that … limited support around service navigation [is] available and kind of other there are services kind of filling those gaps, but not really being paid or funded to do that. (P03_P4, community sector, metropolitan, regional and rural)

The other barrier, too, might be something very practical, like being able to use the telephone and navigate the system to get on to actually talk to someone. And of course language barriers … maybe there's some kind of cognitive deficit or visual, you know, auditory, deficit, whatever it may be, a combination of those things. (P06_P4, community sector, metropolitan)

Declining physical and mental health issues, which could often lead to lack of self-confidence, were also identified as preventing full engagement in services for some older people:

We find that some clients have a lot of mental health issues that prevent them from engaging fully with our services … they'll come to the groups but only on the periphery. They won't engage … there was one lady. She used to be quite social too. Then she had quite a few health issues. So then she stopped coming up to our centre and she just lost her confidence … I think dementia is also a big factor for us. We only mainly see people with early onset but it can be a big barrier to people accessing our service. (P03_P2, community sector, metropolitan)

A number of participating service providers identified that physical or language barriers reduced clients' ability to seek social support. For example:

Some of them just can't speak English at all, some of the people they just don't have even that level of English, and especially at that age, you revert back to your own language. (P05, non-government sector, metropolitan)

I guess if they're not inpatients of the hospital, if they're not engaged with the hospital … they won't come in contact with us and they, because they are socially isolated, they may not seek medical attention when they need it. Also, there's language barriers. Physical mobility, which might mean that they're, you know, not able to get to their normal appointments and that would mean they may not be put in contact with us when they are put in to contact with us. We might not be able to assist them if there's no one that they can appoint into [an attorney role]. You know those important. Fear, so there might be victims of abuse, and that might prevent them from accessing our service … the perpetrators of abuse, like the children, might … prevent them from contacting us. (P04, not-for-profit community sector, metropolitan)

Indeed, the ability to build long-term trust and connection in culturally and linguistically diverse and Aboriginal and Torres Strait Islander communities with short-term funding for service providers was also raised as a key barrier to access for these older people:

Especially with CALD and with Aboriginal communities, we have a problem that we can't reach Aboriginal communities because they want long-term, they need long-term trust. So and you can't build long-term trust in a 3-year project that after 3 years goes to different provider, it gets completely changed or has budget interruption and then gets rebuilt. (P03_P5, community sector, metropolitan, regional and rural)

Various barriers around linking older people to services were identified with core factors being funding and staffing levels, or the limitations of geographical distance:

A lack of capacity for the service provider to do the service. It could be funding; it could be staffing. Could be geographical location of the client. That could be just that little bit too far out of where they do the service. (P01, public sector, rural)

So we see that people that have financial hardship may not have a vehicle, may not be able to go to a social outings with friends and family, which can cause them social isolation … we see the, you know, the reality [of] remoteness element in particular where there's transport issues or large distances to travel in order to participate in social activities, we see accessibility issues. (P03_P3, community sector, metropolitan, regional and rural)

There were also barriers in the sense that some providers would not operate in geographic locations that were deemed to be unprofitable as described by one service provider:

Aged care providers in home care now, when before they would actually intake that person or onboard them … I [now have] to identify whether that was going to be profitable to the company or not. And if it wasn't, it was out, completely out. So, they've got more isolation. (P06_P4, community sector, regional)

Enablers

Maintaining connections and engaging regularly with the community was identified as crucial for some service providers in raising awareness among older people about services they are eligible to access. For example, the following participant described various discussions she had with older people who may be eligible to access the community transport service:

I ask people, who knows about [Community Transport Service], and even the other day out of a room of 100 people, I would say maybe 20 put up their hand to say they know of [Community Transport Service] but from that group there would have been 6 who use us, so that's quite a low proportion, and I think the trouble is that a lot of older people simply are not aware of the services that they're entitled. And that's something else I like to reiterate, I say, you know, we've all paid taxes for years and years and years. These services are for you to use when you want them and need them so it just seems to be a lack of education so you know there could be much more high-profile marketing advertisements and that kind of thing on TV. The government really needs to tap into that opportunity. (P02, not-for-profit community sector, metropolitan)

In reflecting on the importance of this strategy to facilitate older people's access to services, the participant continued, drawing attention to the importance of challenging negative ideas around being older:

I think there needs to be much more on the ground education … to just let people know about those services and I guess to encourage the ones who are less inclined, I think. I think what I've noticed is that a lot of people sort of nod and go, oh yes, that's nice. That's nice for other older people, but I'm not old yet … and it's not until you explain how beneficial using these services would be for them that the penny starts to drop, and they think oh okay, well I don't have to be old and decrepit to use these services … then once they start using the services, that's when they just really embrace the opportunity. (P02, not-for-profit community sector, metropolitan)

Providing older people with flexible and meaningful options for engagement with services was also raised as a key enabler by service providers participating in the interviews, with the following participant recalling the experience of some clients:

We started our exercise program and, in that program, we got a lot of lonely people … our team leaders [are] really engaged with the participants, developed a relationship and that made them come back and word of mouth. We got their friends, everybody. They felt safe … a lot of people don't like commitment, you know? And so, they know they can come and go. They've got a base of people. They can form some friendships but they don't have to rely on those. (P03_P2, community sector, metropolitan)

Facilitating meaningful engagement for older people was raised by most participants as being one of the most important enablers, with meaningful engagement looking different for different older people. An example of this enabler was the provision of volunteering opportunities:

So we got lots of volunteers, but I think they were volunteers and, also, the target people. So a lot of people want to have a meaningful engagement … they don't wanna say that they're lonely because maybe they're concerned that people would then try to fix that for them … maybe they only wanna be, you know, social to a certain extent. (P03_P2, community sector, metropolitan)

Older volunteers were described as skilled professionals whose contribution was important and valued:

We can get people come into our centre who, you know, early 70s and they've retired. And they go, oh, you know, 'I thought I wanted to retire, but now that I've retired, I'm just feeling it really lost, you know, is there any volunteering opportunities?' And we do use volunteers ... ex-teachers, you know, teaching English to our new arrivals … so yeah, they're an unknown, recognised source, the volunteers. (P03_P2, community sector, metropolitan)

In the following example, another participant recalled the experience of an older person who was meaningfully engaged in a computer literacy course that not only provided her with tangible skills but with social connection:

[A client] used to come here weekly to the centre and then, during COVID, she obviously, well, she used to come up for computer lessons … she ended up coming for about 6 months. She'd just come every weekend to the computer lessons because that was her way of, yeah, socialising here. And she loved to interact with our computer tutor. (P03_P1, community sector, metropolitan)

Strikingly, this was a similar experience for older carers who took social connection away from digital literacy courses:

The way to engage people often is indirectly … We have this great project … that actually was a project to improve digital literacy and what came out in the evaluation is that a lot of people so, basically, and that all the people they get on iPad, they get taught how to use the iPad in order to be able to participate in the community, in order to sort of engage with services as well, because they're all online and through the pandemic, this was very important and what we found is that actually a lot of participants there enjoyed and really took the social connection from these courses, precisely because they were about something else. (P03_P5, community sector, metropolitan, regional and rural)

Finally, a 'personal touch' and service continuity were considered important enablers to facilitating older people's engagement with services:

I think the personal touch is a really big enabler and unfortunately, again, just it's very hard to justify a personal touch in 'funder land' basically. And I think what we see and from our evaluation results and what we hear from carers, particularly older carers, is I just wanna be able to talk to someone that can guide me in the right direction because there's so much available. But it's hard to know where to get it. (P03_P3, community sector, metropolitan, regional and rural)

Personal continuity in the actual support worker, so that [clients] don't have to explain themselves over and over again to a new person. And I mean, worst case, if they have in-home services, having a different stranger coming every week to do sort of. Formal services are a type of relationship that can break social isolation but only if there is actually a continuing personal level to that service relationship. (P03_P5, community sector, metropolitan, regional and rural)

Additional or improved services and supports required to address the needs of isolated older people

Interview participants identified a need to reframe the negativity around the ageing process to combat isolation and highlighted the positive impacts of social connection as important for improving service provision to older people. Adapting the My Aged Care portal to make navigation simpler and to include social connection supports as an option were also highlighted as opportunities. Participants viewed primary health care providers such as general practitioners as important avenues for older people seeking services and suggested that increased funding support for general practitioners to work with older people would be beneficial. The data also show that community opportunities for local government and local businesses to improve networks, activities and services around social isolation for older people in their community were also viewed as important.

Broader government policy strategies

Reframing what ageing means and what it can look like was raised as an important strategy to incorporate in government messaging and services by some participants, with one service provider suggesting the need to highlight the positive impacts that social connection as people age can have:

But also to highlight [to] older people that being socially active and engaged is a positive part of their journey. You're getting them to see it that you know, it's not just cooking and cleaning, you know, getting out of that is really important. Being connected is really important. (P01, public sector, rural)

The need to change the language around the ageing process was identified as being important to reframe some of the negative connotations of ageing. By framing ageing more positively, rather than emphasising a person's needs or lack of ability, barriers to reaching out or feeling like a burden could be reduced, as suggested one service provider:

I think they need to change some of the terminology like, you know, it's not just about being frail and aged and not being able to do your vacuuming. (P03_P2, community sector, metropolitan)

Additionally, participants suggested improving positive engagement with people as they age could go some way to reframing messages around getting support. Promoting a service as supporting the maintenance of independence or using targeted government communication could engage people early and reduce the stigma for individuals:

I think also a reframing of the purpose of aged care services and a real workaround. It's not because you can't do it, it's not disabling you. It's actually there to support you to be independent. It's there to help you. It's there to help you stay at home for longer and reframing kind of, you know, you want to get back to doing all the things you like. Well, here's some reablement type activities you can get involved in … if we look at some of the health promotion activities, you turn 50, you get a bowel cancer kit for example. What are the initiatives around, you know you turn 65. Okay, here's a conversation starter about aged care. Yes, you might not need it right now, but here's all these different things that you might want to think about and have a look at and we'll link you or someone to have a chat about what ageing might look like … it's less confrontational. It's less kind of formal. It's not, you know, I can't cope at home. And I'm scared they're gonna put me in a nursing home. It's actually about that supportive approach. (P03_P4, community sector, metropolitan, regional and rural)

I don't know … making a positive thing out of the negative thing, encouraging them [older people] all to grow old well. (P01, public sector, rural)

The way that the My Aged Care portal framed the importance of social support and connection was also lacking, as suggested by a participant who explained that opportunities to intervene early were lost:

If someone accesses My Aged Care online, there's, you know, they can go through the menu. They can tick it. Yes, they need domestic assistance. Yes, they need social support shopping. But there's nothing in there to say that, you know, what I do need is some social connections. You know that's the only thing they want … people have been turned away because they don't fit the criteria, they've been told through My Aged Care that basically they're too well to be having those problems. So, you know, there's lost opportunity for someone to join, to be connected up with their community. (P03_P2, community sector, metropolitan)

Of further importance was that navigating the My Aged Care website was described as challenging for clients, particularly where there may be lower rates of technology literacy or technology access amongst older people:

I think with the government, the government level, one thing that they can do is make accessing these services easier for the client. At the moment, just accessing these services is an absolute nightmare. Just navigating through My Aged Care, it's just a nightmare … How many older people do go on websites? … How many people have access to the computers? How many people are okay to go on website and navigate, and it's not an easy website either … [the services are] not accessible to the people who need them the most. (P05, non-government sector, metropolitan)

I don't know about you but My Aged Care is a very challenging system to navigate. (P01, public sector, rural)

To help to address some of these issues, one service provider suggested that expanding access to information sessions on My Aged Care, and sessions about how to navigate aged care services more broadly, would be invaluable for older people:

I think those kinds of information sessions on a regular basis that are organised by My Aged Care or any of the other government aged care departments should be put on fairly regularly because we've, I think, there's just before I came, they had done several, but certainly the one that I attended. You know, there were more than 150 people there and they're hungry for information and I just think that it needs to be regularly on the calendar of, you know, clubs and shopping centres and government advertising and that kind of thing. But people need to understand that first step. They need to understand the process. To register with My Aged Care, some people find that a little bit daunting and they don't want to admit that they're getting older. You know, they sometimes even think that … people are going to come into their house and steal things and, you know, invade their privacy. We need to explain to them that that's not the case, that it's simply a support mechanism and that, you know, it's available for them. (P02, not-for-profit community sector, metropolitan)

The participant above suggested that part of this education around accessing aged care services could not be divorced from discussions around the challenges older people face when becoming older and encountering negative stereotypes around the ageing process, which can exacerbate fear of accessing services. On a broader government scale, primary health care providers such as general practitioners were also highlighted as playing a key role in not only identifying isolated older people but in supporting them to access required services. Therefore, one service provider called for greater and more consistent funding for general practitioners (GPs) to facilitate this work:

I think GPs have an important role to play. Because most people have a GP … there could be some training for GPs for them to be able to identify older people who don't have any, you know, who are isolated and for them to be able to be a referral source … I think that's really important for GPs also to be adequately funded to be able to do the job they need to do so that also older people are able to access GPs and be able to be bulk billed … for aged care facilities to be educated in protecting, you know, older people. Setting up relationships between, you know, schools or other volunteers to come, yeah, create those relationships. (P04, not-for-profit community sector, metropolitan)

Local government and organisational strategies

Participants referred to some opportunities for local governments or councils to become involved in addressing the needs of isolated older people, with one service provider highlighting the need to build social connections at the local level:

Because [the] aged care sector itself is so stretched and so understaffed and overworked … [local] councils should come on board with more … I know they do have groups and all, but there are lots of people who can't go to these groups. Their mobility is less, they can't go [due to] health reasons … I think visiting the [older people] who want a visit … maybe engaging neighbours. (P05, non-government sector, metropolitan)

One service provider called for a more holistic, cooperative approach that involved governments, councils and local businesses in facilitating support for isolated older people:

Shopping centres and places like that … that benefit financially from the community visiting them could be more proactive with transferring that information … I have a very good relationship with the local council here and I know a lot of the staff there and they've been really, really proactive in organising different groups and things like that and the first one they did when I started with [Community Transport Service] was in a shopping centre and they just had a gathering of people they put on a morning tea … and Council was talking to them about the things that they're doing, and then they just invited me to stand up, sort of fairly impromptu, and talk about [Community Transport Service] … So, I think, I think it's a whole community approach to this. It's the government approach. It's a corporation approach … the more we talk, the more we alert people to what's available to them, the less likely this loneliness and isolation is likely to take hold. (P02, not-for-profit community sector, metropolitan)

At the organisational level, some service providers described their intention to coordinate their work with other services:

We're looking at and trying to find better ways of working with other organisations as well … and we're doing a little bit of work with the department … because the Royal Commission also identified that the department, our funders, need to be more present and more aware. And so, they're working with us as a bit of a pilot program as to how the department and our service can work together better so that, you know, we can provide the services that are needed. (P06_P1, community sector, regional)

Summary

The findings presented in this section indicate a range of experiences for isolated older people, with the data indicating that older people in regional, rural and remote areas are more likely to face additional factors that could lead to or exacerbate social isolation. These additional factors exacerbating social isolation include service issues such as transport, labour and infrastructure challenges. In this way, geographical isolation is identified as having the potential to compound social isolation.

Social barriers leading to isolation were often linked to a reluctance to seek help for a variety of complex reasons or circumstances where older people did not identify as isolated. The effects of isolation on older people were widely reported by service providers. These impacts included reduced overall wellbeing, including in relation to mental and physical health that could further impact motivation to maintain self-care. Participants also reported clients having lower self-esteem and confidence and decreased mood and memory function, further reducing the likelihood of them engaging socially and potentially exacerbating existing issues of mobility and social connection. Apathy and reduced engagement in previous areas of interest together with poor diet potentially arising from both a lack of interest and lack of access to food and groceries outside the home were other identified issues.

Factors giving rise to isolation for older people included significant life events or transitions, such as death of a spouse or family member, a decline in health or having to care for a spouse. This experience could be compounded for older people living away from others in their cultural group or having changes in their family relationships. The impacts of COVID-19 restriction were identified as creating challenges, and experiences of poor mental health (their own or others), were identified as further contributing to isolation. A lack of service access (including culturally appropriate services) and other infrastructure resources such as transport were also identified as limiting the ability to take action to combat social isolation. Geographical location and stigma associated with the loss of independence from ageing and the surrounding loneliness or feeling like a burden were also factors identified as making engagement with others more challenging.

In relation to the identification of isolated older people and supporting their access to services, screening tools for measuring social isolation varied. Informal methods to screen for social isolation included service providers drawing on their knowledge of, or connections in, the community or engaging in conversations that could provide a broader picture of the older person's current life circumstances. The data also show that the My Aged Care initial assessment meant that some service providers felt a less prescriptive approach could be taken subsequent to this formal assessment. The nature of questioning used in some assessment tools specifically targeted at identifying social isolation were described as potentially confronting for older people, particularly where service staff lacked the skills or training to use them. Service providers also noted that some people were comfortable with their level of social interaction despite appearances or assessments that could identify them as isolated.

Providing support to older people during COVID-19 restrictions was identified by participating service providers as challenging, particularly where clients could not use technology for various reasons. During that time, service staff took on a wider range of roles in an effort to maintain contact and connection for older people. Participants also identified broader service delivery challenges including encouraging older clients to take up social supports when the client may not have seen them as being as necessary as more practical services aimed at household management. Strategies to increase social interaction by service providers included opportunities to provide social interaction and an outing from the home. Service providers identified that some of these attempts at more socially based activities could require participants to be more physically healthy. The needs of older people from culturally diverse backgrounds were also identified.

More generally, a diverse range of barriers to engaging and maintaining engagement with services for isolated older people were highlighted, including physical and mental health, language barriers, financial barriers and practical barriers such as limited access to finances, transportation and/or accessible infrastructure in the community. Key among the enablers identified was the need to maintain community connection and regular community engagement, which, in turn, facilitated access to services' activities that increased social connection.

Additional and improved services and supports to address the needs of isolated older people were also identified including the need to reframe negative perceptions of ageing, with participants highlighting the positive impacts of social connection as important for improving service provision to older people. Specific improvements suggested by participants included adapting the My Aged Care portal to make navigation simpler and the inclusion of social connection supports as an option. Primary health care providers were described as an important avenue for older people seeking services and suggestions to increase support for general practitioners to work with older people were made by participating service providers. Community opportunities for local government and local businesses to improve networks, activities and services around social isolation for older people in their community were also viewed as important.

4. Summary and conclusion

Summary

This report sets out the findings of the Factors, Dynamics and Effects of Isolation for Older People: An Exploratory Study. This qualitative research was commissioned by Seniors Rights Service with the aim to investigate and understand the experiences and needs of isolated older people in New South Wales. The following research questions were explored:

• What are the views of the experiences of isolated older people (from the perspective of service providers) and what are the effects of isolation on older people, including the effect of isolation on their access to services, their wellbeing and upon the enjoyment of their rights in this context?
• What are service providers' views of the factors giving rise to the isolation experienced by these clients?

How do service providers currently identify and support access to services by isolated older people? Insights from existing literature

The review of existing literature suggests that isolation, both social and geographical, is a significant feature in the lives of older people and that loneliness, although a distinctly subjective experience, is linked to this isolation of older people. The literature indicates that the impacts of social and geographical isolation are extensive and negative for the health and wellbeing of individuals, service providers and the broader communities, suggesting that a focus on prevention would be beneficial for improving quality of life not only for older people but for those who care for them. This existing evidence base suggests a consistency of the experience in older people's lives and indicates that policy and practice interventions to address the physical, social and mental health impacts and the underlying factors giving rise to isolation should be a matter of immediate concern. This is particularly given the increasingly older age profile of the Australian population, with the 65+ age group expected to more than double from 3.8 million to 8.8 million in the next 25 years (AIHW, 2018).

Findings based on the interviews with service providers

Experiences of isolated older people

The findings in this exploratory study illustrated how experiences of isolation were occurring in a broader social context characterised by ageism and social stigma around the ageing process, and how these dynamics were experienced by older people in their everyday lives. Service providers who participated in the interviews reflected on their clients' experiences of both social and geographical isolation, with geographical isolation identified as exacerbating the existence and experience of social isolation. Limited service capacity and accessibility to services and infrastructure in regional, rural and remote communities was identified as not only limiting access to advice, services and supports but also compounding the social isolation experienced by older people. The lack of 'profitability' associated with supporting older clients in regional or remote areas for some private companies was also raised as a concern by some service providers.

Effects of isolation on older people

A range of significant effects on older people were identified as arising from experiences of isolation. These effects were often interconnected and included poor personal or self-care and decreasing mobility among older people not leaving their home; decreased mood and memory from a lack of social interaction; apathy and reduced engagement in previous areas of interest; often together with poor diet potentially arising from both a lack of interest and lack of access to food and groceries outside the home.

Factors giving rise to isolation for older people

Factors giving rise to isolation for older people were identified as including experiences of significant life events or transitions, such as the death of a spouse or family member, a decline in their own health or having to take on a caring role for a partner or spouse. These significant events or transitions may be compounded for older people living away from family or others in their cultural group. Changes in familial relationships including distance from adult children and other family members were also identified. The impact of COVID-19 restrictions was identified as creating challenges, and experiences of poor mental health for themselves or others, substance abuse issues or violence were also identified as further contributing to isolation. A lack of access to services, including culturally appropriate services, and other infrastructure resources, such as transport, were highlighted as limiting the ability to take action to combat social isolation. As noted, geographical location and stigma associated with the loss of independence from ageing and surrounding loneliness or feeling like a burden were also factors identified as making engagement with others more challenging.

Identification of isolated older people and supporting access to services

Tools for identifying socially isolated individuals were diverse, with some service providers explaining that various informal approaches to identification were preferred. Semi-structured conversations with older clients about their lives and their needs, as well as engaging with, and being visible in, the community, holding events and information sessions with other service providers and/or older people were nominated as effective means of identifying isolated older people.

There were some participants who referred to more formal assessment tools and others described the application of the My Aged Care assessments as informing their risk assessment practices. However, the nature of questioning used in some assessment tools specifically targeted at identifying social isolation were described by some participants as potentially confronting for older people. An added challenge when identifying isolated older people for service providers was that some older people did not identify as isolated or indicated that they were content with their level of social connectedness.

Service providers recalled taking on a more flexible approach to their services during COVID-19 lockdowns, noting that many older people felt further isolation during this period due to limited access to technology or limited computer literacy. Some service providers also indicated that they were able to support older people to maintain social connection during lockdowns and restrictions by continuing to participate in more practical supports, such as assisted shopping trips or in cases where they had digital literacy.

A range of barriers and enablers to engaging and maintaining engagement with services and supports were reported to be experienced by isolated older people, with key barriers being related to physical and mental health, language barriers, financial barriers and practical barriers such as limited access to finances, transportation and/or accessible infrastructure in the community. Key enablers included services being visible and engaged in the community as well as services challenging negative societal ideas and discourses around the ageing process. Other service providers drew attention to the importance of not just facilitating engagement but facilitating meaningful engagement, which provided older people with the opportunity to draw on their skills and passions and to have flexibility in the activities they chose to participate in.

Additional or improved services and supports to address the needs of isolated older people

Opportunities to improve service provision for isolated older people in New South Wales were identified in the interviews, with some participants calling for government to play an instrumental role in reframing the negativity around the ageing process and highlighting the positive impacts of social connection. Adapting the My Aged Care portal to make navigation simpler and to include social connection supports were also highlighted as opportunities. Some participants also called for increased support for primary health care providers such as general practitioners to identify and support older people by linking them in with support services. Additionally, service providers identified opportunities for local councils and organisations to work cooperatively to address service gaps to provide a sense of community and inclusion for older people.

Conclusion

This exploratory study provided empirical data on the experiences of isolated older Australians living in New South Wales and the effects of social and geographical isolation on these older people. It also provided empirical data on how service providers across New South Wales identify isolated older people and facilitate their access to supports and services.

This research illustrated the profound effects of isolation on the wellbeing of older people, with a range of factors underpinning the social and geographical isolation experienced by older people. In addition to significant life events and transitions, and to health and logistical factors, the stigma associated with ageing and loneliness were also identified as key factors giving rise to isolation. The data provide insight into the physical and mental health, language barriers, financial barriers, and the logistical, technological and other practical barriers to the identification and provision of services to isolated older people.

More specifically, service delivery during the COVID-19 pandemic highlighted both the need to and the challenges associated with identifying isolated people and the inequities in the accessibility of services and social connectivity. Awareness-raising activities that reframe the need for social connection as a positive aspect of the ageing process and offering clear options to seek social engagement supports, including on the My Aged Care portal, were identified as potential improvements in the resources for older people at risk of or experiencing isolation.

The comments of some participants suggest consideration should be given to a review of the accessibility of the My Aged Care portal for older people and their carers. Activities at the local community level were also considered to have the potential to improve services and supports to address the needs of isolated older people, including local government and local business engagement to improve networks, activities and services around social isolation for older people in their community. Accessibility to general practitioners was identified as an important avenue for support for older people seeking services, with participants nominating the benefits associated with increased funding to enable these practitioners to work with older people to facilitate their access to services. More generally, reframing perceptions of ageing was also raised as an important strategy in the messaging undertaken by service providers and governments, as a means of highlighting the positive effects of social connectedness as people age.

As an exploratory study, this research has highlighted the need for data from older people themselves, including from older Aboriginal and Torres Strait Islander peoples, culturally and linguistically diverse people and older men, to inform measures to address the needs of socially and geographically isolated older people. Particular focus should be given to research regarding the experiences and needs of older carers whose caring responsibilities compound their experience of isolation, and on the experiences and needs of older people in regional and remote areas where geographical isolation also exacerbates their experience of social isolation.

5. References

Australian Institute of Health and Welfare (AIHW). (2018). Older Australian at a glance. Canberra: AIHW.

Adorno, G., Fields, N., Cronley, C., Parekh, R., & Magruder, K. (2018). Ageing in a low-density urban city: Transportation mobility as a social equity issue. Ageing & Society, 38(2), 296-320. doi:10.1017/S0144686X16000994

Bartlett, H., Warburton, J., Lui, C.-W., Peach, L., & Carroll, M. (2013). Preventing social isolation in later life: findings and insights from a pilot Queensland intervention study. Ageing and Society, 33(7), 1167. doi:10.1017/S0144686X12000463

Berg, T., Winterton, R., Petersen, M., & Warburton, J. (2017). 'Although we're isolated, we're not really isolated': The value of information and communication technology for older people in rural Australia. Australasian Journal on Ageing, 36(4), 313-317. doi:10.1111/ajag.12449.

Beridze, G., Ayala, A., Ribeiro, O., Fernández-Mayoralas, G., Rodríguez-Blázquez, C., Rodríguez-Rodríguez, V. et al. (2020). Are loneliness and social isolation associated with quality of life in older adults? Insights from Northern and Southern Europe. International Journal of Environmental Research and Public Health, 17(8637), 8637-8637. doi:10.3390/ijerph17228637.

Bernoth, M. A., Dietsch, E., & Davies, C. (2012). Forced into exile: The traumatising impact of rural aged care service inaccessibility. Rural and Remote Health, 12, 1924.

Brooke, J., Dunford, S., & Clark, M. (2022). Older adult's longitudinal experiences of household isolation and social distancing during the COVID-19 pandemic. International Journal of Older People Nursing, e12459. doi:10.1111/opn.12459

Burnes, D., Acierno, R., & Hernandez-Tajada, M. (2019). Help-seeking among victims of elder abuse: Findings from the National Elder Mistreatment Study. Journals of Gerontology: Social Sciences, 5(74), 891-896.

Byrne, K. A., & Ghaiumy Anaraky, R. (2022). Identifying racial and rural disparities of cognitive functioning among older adults: The role of social isolation and social technology use. The Journals of Gerontology. Series B, Psychological Sciences and Social Sciences. doi:10.1093/geronb/gbac055

Chan, A., Raman, P., Ma, S., & Malhotra, R. (2015). Loneliness and all-cause mortality in community-dwelling elderly Singaporeans. Demographic Research, 32, 1361-1382.

Charmaz, K. (2000). Grounded theory objectivist and constructivist methods. In N. Denzin, & Y. Lincoln (Eds.). The handbook of qualitative research, 2nd edition. New York: Sage Publications.

Commissioner for Senior Victorians (CSV). (2020). Ageing well in a changing world. Melbourne: Commissioner for Senior Victorians. Retrieved from Ageing well in a changing world (seniorsonline.vic.gov.au)

Community Legal Centres Queensland Inc. (2019). Evidence & analysis of legal need. Brisbane, Qld: Community Legal Centres Queensland Inc. Retrieved from apo.org.au/node/253551https://communitylegalqld.org.au
/sites/default/files/downloads/pages/evidence_and_analysis_of_legal_need_final.pdf

Cryer, S., Henderson-Wilson, C., & Lawson, J. (2021). Pawsitive connections: The role of Pet Support Programs and pets on the elderly. Complementary Therapies in Clinical Practice, 42, 101298. doi.org/10.1016/j.ctcp.2020.101298

Czaja, S., Moxley, J. H., & Rogers, W. A. (2021). Social support, isolation, loneliness, and health among older adults in the PRISM randomized controlled trial. Frontiers in Psychology, 12. doi:10.3389/fpsyg.2021.728658

Del Pozo Cruz, B., Perales, F., Alfonso-Rosa, R. M., & Del Pozo-Cruz, J. (2021a). Bidirectional and dynamic relationships between social isolation and physical functioning among older adults: A cross-lagged panel model of US National Survey data. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 76(11), 1977-1980. doi:10.1093/gerona/glab110

Del Pozo Cruz, B., Perales, F., Alfonso-Rosa, R. M., & Del Pozo-Cruz, J. (2021b). Impact of social isolation on physical functioning among older adults: A 9-year longitudinal study of a U.S.-representative sample. American Journal of Preventive Medicine, 61(2), 158-164. doi:10.1016/j.amepre.2021.02.003

Dey, I. (1999). Grounding grounded theory. Cambridge, MA: Academic Press.

Dong-Kyun, P. (2017). Technologies to reach older persons with health-care services. Asia-Pacific Population Journal, 32(1), 75-103.

Ferrara, H. (2009). Seniors' social isolation: A scoping study. Retrieved from Perth, WA: Centre for Social and Community Research, Murdoch University.

Freak-Poli, R., Ryan, J., Tran, T., Owen, A., McHugh Power, J., Berk, M. et al. (2021). Social isolation, social support and loneliness as independent concepts, and their relationship with health-related quality of life among older women. Aging & Mental Health, 1-10. doi:10.1080/13607863.2021.1940097

Hajek, A., Brettschneider, C., Mallon, T., Kaduszkiewicz, H., Oey, A., Wiese, B. et al. (2021). Social support and health-related quality of life among the oldest old: Longitudinal evidence from the multicenter prospective AgeCoDe-AgeQualiDe study. Quality of Life Research: An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation.

Herro, A., Lee, K. Y., Withall, A., Peisah, C., Chappell, L., & Sinclair, C. (2021). Elder mediation services among diverse older adult communities in Australia: Practitioner perspectives on accessibility. Gerontologist, 61(7), 1141-1152. doi:10.1093/geront/gnaa146

Hillier, M. (2007). Rebuilding connections: Creating opportunities for socially isolated older Australians: Evaluation of the Brotherhood of St Laurence Community Care Socialisation Program. Fitzroy, Vic: Brotherhood of St Laurence.

Holaday, L. W., Oladele, C. R., Miller, S. M., Dueñas, M. I., Roy, B., & Ross, J. S. (2022). Loneliness, sadness, and feelings of social disconnection in older adults during the COVID-19 pandemic. Journal of the American Geriatrics Society, 70(2), 329-340. doi:10.1111/jgs.17599

Hu, J., Fitzgerald, S. M., Owen, A. J., Ryan, J., Joyce, J., Chowdhury, E. et al. (2021). Social isolation, social support, loneliness and cardiovascular disease risk factors: A cross-sectional study among older adults. International Journal of Geriatric Psychiatry, 36(11), 1795-1809. doi:10.1002/gps.5601

Hughes, A. (2009). Keeping connected in the community: a report for Anglicare Australia. Reid, ACT. Retrieved from library.bsl.org.au/jspui/bitstream/1/2043/1/KeepingConnectedintheCommunity.pdf

Hunter, R., & De Simone, T. (2009). Women, legal aid and social inclusion. Australian Journal of Social Issues, 44(4), 379-398.

Ikeuchi, T., Taniguchi, Y., Abe, T., Seino, S., Shimada, C., Kitamura, A. et al. (2021). Association between experience of pet ownership and psychological health among socially isolated and non-isolated older adults. Animals, 11(3), 595.

Inder, K. J., Lewin, T. J., & Kelly, B. J. (2012). Factors impacting on the well-being of older residents in rural communities. Perspectives in Public Health, 132(4), 182-191.

Janesick, V. (2000). The choreography of qualitative research design: Minuets, improvisation and crystallization. In N. Denzin & Y. Lincoln (Eds.), The handbook of qualitative research, 2nd edition. New York: Sage Publications.

Kimberley, H., & Simons, B. (2009). The Brotherhood's social barometer : living the second fifty years (9781921623035) Fitzroy, Vic. Retrieved from library.bsl.org.au/bsljspui/bitstream/1/6040/1/KimberleySimon_Social_Barometer_living_the_second_fifty_years_2009.pdf

King, G., & Farmer, J. (2009). 'What older people want: evidence from a study of remote Scottish communities.' Rural and Remote Health, 9(2), 1166.

King, S., Yan, L., Paleologos, Z., Dunne, R., Bellamy, J., & Bijen, G. (2018). Going it alone: A study of lone person households, social isolation and disadvantage in Sydney. Sydney: Anglicare. Retrieved from www.anglicare.org.au/media/3948/anglicaresydney_going_it_alone_2018.pdf

Lamanna, M., Klinger, C. A., Liu, A., & Mirza, R. M. (2020). The association between public transportation and social isolation in older adults: A scoping review of the literature. Canadian Journal on Aging / La Revue Canadienne du Iieillissement, 39(3), 393-405. doi:10.1017/S0714980819000345

Law Council of Australia. (2017). The Justice Project: Older persons. Consultation paper. Braddon, ACT: Law Council of Australia.

Levasseur, M., Routhier, S., Clapperton, I., Doré, C., & Gallagher, F. (2020). Social participation needs of older adults living in a rural regional county municipality: Toward reducing situations of isolation and vulnerability. BMC Geriatrics, 20(1), 1-12. doi:10.1186/s12877-020-01849-5

Longman, J., Passey, M., Singer, J., & Morgan, G. (2013). The role of social isolation in frequent and/or avoidable hospitalisation: rural community-based service providers' perspectives. Australian Health Review: A publication of the Australian Hospital Association, 37(2), 223-231. doi:10.1071/AH12152

Machielse, A., & Duyndam, J. (2020). Strategies of socially isolated older adults: Mechanisms of emergence and persistence. Journal of Aging Studies, 53, 100852. doi:10.1016/j.jaging.2020.100852

Menec, V. H., Newall, N. E., Mackenzie, C. S., Shooshtari, S., & Nowicki, S. (2019). Examining individual and geographic factors associated with social isolation and loneliness using Canadian Longitudinal Study on Aging (CLSA) data. PLoS ONE, 14(2), e0211143-e0211143. doi:10.1371/journal.pone.0211143

Morgan, T., Wiles, J., Park, H.-J., Moeke-Maxwell, T., Dewes, O., Black, S. et al. (2021). Social connectedness: What matters to older people? Ageing & Society, 41(5), 1126-1144.

Paine, N., Rachele, J. N., & Turrell, G. (2022). Sociodemographic characteristics and social exclusion among the oldest old. Australasian Journal on Ageing.

Parsons, K., Gaudine, A., & Swab, M. (2021). Experiences of older adults accessing specialized health care services in rural and remote areas: a qualitative systematic review. JBI Evidence Synthesis, 19(6), 1328-1343. doi:10.11124/JBIES-20-00048

Patulny, R. (2009). The golden years? Social isolation among retired men and women in Australia. Family Matters, 83, 39-47.

Pekmezaris, R., Kozikowski, A., Moise, G., Clement, P., Hirsch, J., Kraut, J. et al. (2013). Aging in suburbia: An assessment of senior needs. Educational Gerontology, 39(5), 355-365. doi:10.1080/03601277.2012.700849

Pettigrew, S., Donovan, R., Boldy, D., & Newton, R. (2014). Older people's perceived causes of and strategies for dealing with social isolation. Aging & Mental Health, 18(7), 914-920. doi:10.1080/13607863.2014.899970

Plath, D. (2008). Independence in old age: The route to social exclusion? British Journal of Social Work, 38(7), 1353-1369.

Punch, K. (1998). Introduction to social research quantitative and qualitative approaches. Sage Publications.

Qu, L., Kaspiew, R., Carson, R., Roopani, D., De Maio, J., Harvey, J. et al. (2021). National Elder Abuse Prevalence Study: Final report. Melbourne: Australian Institute of Family Studies.

Ryan, G. W. & Bernard, R. (2000). Data management and analysis methods. In N. Denzin & Y. Lincoln (Eds.). (2000). The handbook of qualitative research, 2nd edition. Sage Publications.

Saito, M., Aida, J., Cable, N., Zaninotto, P., Ikeda, T., Tsuji, T. et al. (2021). Cross-national comparison of social isolation and mortality among older adults: A 10-year follow-up study in Japan and England. Geriatrics & Gerontology International, 21(2), 209-214. doi:10.1111/ggi.14118

Santini, Z., Fiori, K. L., Tyrovolas, S., Haro, J. M., Feeney, J., & Koyanagi, A. (2016). Structure and function of social networks, loneliness, and their association with mental disorders among older men and women in Ireland: A prospective community-based study. European Psychiatry, 33(Supplement), S178-S179. doi:10.1016/j.eurpsy.2016.01.381

Schrempft, S., Jackowska, M., Hamer, M., & Steptoe, A. (2019). Associations between social isolation, loneliness, and objective physical activity in older men and women. BMC Public Health, 19(1), 1-10. doi:10.1186/s12889-019-6424-y

Shankar, A., Hamer, M., McMunn, A., & Steptoe, A. (2013). Social isolation and loneliness: Relationships with cognitive function during 4 years of follow-up in the English Longitudinal Study of Ageing. Psychosomatic Medicine, 75(2), 161-170. doi:10.1097/PSY.0b013e31827f09cd

Sievwright, A., Meltzer, A., Varadharajan, M., Campbell, P., Atkins, M., Kaleveld, L. et al. (2021). Service innovation deep dive: Capturing and leveraging learnings from service innovation during COVID-19: National report. Centre for Social Impact, The University of Western Australia, Swinburne University of Technology and University of New South Wales. Retrieved from www.csi.edu.au/media/uploads/sidd_national_report_centre_for_social_impact.pdf

Storey, J. E. (2020). Risk factors for elder abuse and neglect: A review of the literature. Aggression & Violent Behavior, 50, 101-339.

van Spijker, B. A., Salinas-Perez, J. A., Mendoza, J., Bell, T., Bagheri, N., Furst, M. A. et al. (2019). Service availability and capacity in rural mental health in Australia: Analysing gaps using an Integrated Mental Health Atlas. The Australian and New Zealand Journal of Psychiatry, 53(10), 1000-1012. doi:10.1177/0004867419857809

Vine, D., Buys, L., & Aird, R. (2014). Conceptions of 'community' among older adults living in high-density urban areas: An Australian case study. Australasian Journal on Ageing, 33(2), 1-6.

Vrantsidis, F., Dow, B. Joosten, M., Walmsley, M., & Blakey, J. (2016). The older person's experience: outcomes of interventions into elder abuse. Melbourne: National Ageing Research Institute and Senior's Rights Victoria. Retrieved from seniorsrights.org.au/wp-content/uploads/2016/06/SRV-NARI-Outcomes-Report-2016-FINAL-Web-6-June-2016.pdf

Walsh, K., O'Shea, E., & Scharf, T. (2020). Rural old-age social exclusion: A conceptual framework on mediators of exclusion across the lifecourse. Ageing & Society, 40(11), 2311-2337. doi:10.1017/S0144686X19000606

West, R., & Ramcharan, P. (2019). The emerging role of financial counsellors in supporting older persons in financial hardship and with management of consumer-directed care packages within Australia. Australian Journal of Social Issues, 54(1), 32-51. doi:10.1002/ajs4.55

Winterton, R. (2016). Organizational responsibility for age-friendly social participation: Views of Australian rural community stakeholders. Journal of Aging & Social Policy, 28(4), 261-276. doi:10.1080/08959420.2016.1145504

Winterton, R., Clune, S., Warburton, J., & Martin, J. (2014). Local governance responses to social inclusion for older rural Victorians: building resources, opportunities and capabilities. Australasian Journal on Ageing, 33(3), E8-E12.

Winterton, R., & Warburton, J. (2011). Models of care for socially isolated older rural carers: Barriers and implications. Rural and Remote Health, 11(3), Article 1678.

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