Notes
Article history
The research reported here is the product of an PHR Evidence Synthesis Centre, contracted to provide rapid evidence syntheses on issues of relevance to the health service, and to inform future PHR calls for new research around identified gaps in evidence. Other reviews by the Evidence Synthesis Centres are also available in the PHR journal.
The research reported in this issue of the journal was funded by the PHR programme as project number 16/08/44. The contractual start date was in October 2017. The final report began editorial review in August 2019 and was accepted for publication in October 2019. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The PHR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.
Declared competing interests of authors
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© Queen’s Printer and Controller of HMSO 2020. This work was produced by Salway et al. under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
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Chapter 1 Introduction
Background
Social isolation and loneliness are widely recognised as major public health problems, affecting large numbers of people across the lifespan, particularly older people. 1 Social isolation has been defined as a lack of interactions and relationships with other people, ‘a deprivation of social connectedness’. 1 Loneliness has been conceptualised and defined in a variety of ways,2,3 but it is generally recognised as a complex and unpleasant emotional state related to, but distinct from, social isolation. Several, although not all, conceptualisations of loneliness explicitly identify both ‘social integration’ and ‘intimacy’ as the dimensions of loneliness. 4
Loneliness is clearly, in and of itself, a dimension of ill-being. In addition, the health risks of loneliness and social isolation are increasingly highlighted. 5 Both have been found to be associated with a range of physical and mental health problems. 6–12 A predominance of cross-sectional studies has precluded examination of the direction of causality, although bidirectionality seems likely. Research from 2011 suggests that loneliness and social isolation may each have independent impacts on health through their effects on health behaviours. 13 Social isolation may also affect health through biological processes. 13 Both loneliness and social isolation have also been found to be adversely associated with aspects of functional status in older adults, particularly among more disadvantaged individuals. 14 A 2010 meta-analysis across all ages estimated an average 50% increased likelihood of survival for people with stronger social relationships. 15
Although much of the available research focuses on older people, social isolation and loneliness have also been found to be associated with poor mental health and health-damaging behaviours at younger ages, with pregnant and postpartum women and adolescents receiving particular attention to date. 16,17
Determinants of social isolation and loneliness operate at micro, meso and macro levels, including individual, family, community, neighbourhood and wider society. 18 Interventional activity with the potential to affect social isolation and loneliness (whether positively or negatively) is, therefore, diverse. To date, however, most interventional research has tended to adopt a fairly narrow, individualised approach. There is a need to better understand the wider determinants of social isolation and loneliness, and to understand how initiatives interact with elements and processes within wider socioecological systems.
The health and well-being of migrants and people from ethnic minority backgrounds is a growing policy concern in many parts of the world, and these groups may face particular risks of social isolation and loneliness. Although the collective terms ‘migrant’ and ‘ethnic minority’ (or ‘minority ethnic’) conceal significant heterogeneity, evidence suggests important patterning of social isolation and loneliness by migration status and ethnicity. Our own work using qualitative and quantitative UK data confirmed important ethnic differences in patterns of social networks and interactions, with black African women emerging as a group with low levels of social connection and support. 19 Very high rates of loneliness have been found in ethnic minority elders, particularly those with family origins in China, Africa, the Caribbean, Pakistan and Bangladesh. 20 Social isolation may be higher among minority ethnic children than among majority ethnic children,18 with very high levels among new migrants, asylum seekers and refugees. 21,22 Perinatal depression is high among some UK migrant and ethnic minority women, and is associated with isolation and poor support. 23 Similar findings are reported elsewhere. 17,24,25
These high risks among some migrant and ethnic minority groups relate, in part, to the concentration of risk factors that affect socioeconomically disadvantaged sections of society more generally (e.g. poverty, poor housing, unemployment). 26–28 In addition, however, exclusionary processes and structures linked to migrant/ethnic minority identities present additional risks. Cumulative exposure to racial discrimination, including microinsults and fear of attack, can increase social isolation and mental ill health. 29 Wider societal discourses and negative media portrayal can undermine a sense of belonging and self-worth. For newly arrived individuals, limited language skills, uncertain legal status, lack of familiarity with organisational processes and few local co-ethnic ties can hamper the development of supportive social networks. 22 Furthermore, broader policy relating to housing and resettlement, immigration and entitlement to public services and welfare will often differentially affect social relationships by ethnicity. Migrant and ethnic minority people also tend to have less access to interventions aimed at tackling social isolation and loneliness. Practitioners may erroneously assume that ‘they look after themselves’,30 while questions about the importance of promoting co-ethnic versus interethnic social ties for health promotion remain. 31
In sum, social isolation and loneliness are complex and widespread problems, with migrant and ethnic minority people facing some particular risks. Identifying effective and feasible interventional strategies to reduce unwanted social isolation and loneliness among ethnically diverse and migrant populations should therefore be a priority for local and national public health decision-makers.
Identifying effective and feasible interventional strategies to reduce unwanted social isolation and loneliness among ethnically diverse and migrant populations is, therefore, an urgent need.
Rationale
A series of earlier reviews have usefully categorised some of the interventional approaches and confirmed that some interventions are effective at reducing social isolation and/or loneliness, particularly group-based and shared interest-focused activities for older people. 2,32–38 The current project aimed to extend this earlier work in three important ways.
First, we focused on population groups that have, to date, received very little attention. To our knowledge, just one prior small-scale review has focused on the needs and experiences of migrant and/or ethnic minority people. 39
Second, we aimed to include a wide range of interventional activity. Earlier reviews have often taken a narrow, individually-focused approach and looked exclusively at interventions specifically designed to address loneliness and/or social isolation. Policy and practice reports from 2015 highlight the need to consider the impacts of policy and initiatives in a wider range of sectors. 18,31
Third, we adopted a ‘systems theory-driven’ approach. Prior work has focused predominantly on answering simple effectiveness questions. Although important, this approach pays little attention to the complex, dynamic and multifaceted nature of the problem and its potential solutions. We adopted a systems approach, grounded in realist ontology, with the aim of generating a more thorough understanding of how and why interventional activity plays out in particular ways in particular contexts, as well as identifying missed opportunities to protect against, and alleviate, isolation and loneliness.
Research objectives
The overall aim of the project was to synthesise the available evidence and produce new insights relating to the range of interventions that have attempted to address unwanted social isolation and loneliness among people identifying as migrant and/or ethnic minority, plus the logic, functioning and effects of such interventions. The primary purpose was to inform future action aiming to reduce social isolation and/or loneliness among ethnically diverse populations.
We conceptualised unwanted social isolation and loneliness as emergent properties of a system, in which processes operating at individual, family, community and population level are intimately connected. 40–42 Our primary effort was directed towards examining interventions and initiatives that were intended, or had the potential, to reduce social isolation and/or loneliness. We also aimed to uncover broader features of socioecological systems that interplay with, and affect, these outcomes. We aimed to improve understanding of what happens when interventions are introduced into particular settings by looking for evidence on the system processes that ensue, particularly those that amplify or dampen intended causal pathways.
Outline of the report
Chapter 2 sets out our research questions and describes our methodological approach and the methods employed. In Chapter 3, we describe the findings from the preliminary review of theory, understandings and measurement of social isolation and loneliness. We describe how these were used to shape the scope of the project and to develop a model of the proximate determinants of loneliness among our population groups of focus. Chapter 4 presents an overview of the varied initiatives that were identified from the published and grey literature and develops a typology of interventions. In Chapter 5, we describe the three most common intervention types in more detail, via the development of programme theory and logic models, as well as identifying the common, and distinct, causal chains that are posited within other intervention types. Chapter 6 synthesises the empirical data from the evaluative intervention studies to assess what is known about how interventions operate in practice, and their effects and outcomes. In Chapter 7, we draw on insights from across the data sources to consider how interventions interplay with wider system factors. We examine the evidence on system processes shaping the risk of social isolation and loneliness for our groups of interest, and how such processes affect implementation and reach. In Chapter 8, we juxtapose current UK interventional activity with what is known about the causes of isolation and loneliness, to identify areas of alignment and opportunities for action. We consider the system conditions that might support or hamper more successful and sustained action. We suggest what a more holistic system approach to ‘loneliness-proofing’ among ethnically diverse populations might look like. Finally, in Chapter 9, we identify the limitations of our research approach and the available evidence base. We suggest implications for practice and identify recommendations for future research.
Chapter 2 Methods
Introduction
Our aim was to combine an effectiveness review with a theory-informed review methodology,43 informed by ‘systems-thinking’. 44 Theory-informed reviews seek to go beyond the bounded remit of systematic reviews of effects, extending the enquiry from ‘what works’ to ‘what happens’. 43,45 We combined traditional desk-based methods with participatory consultation panel (CP) input. The review protocol is registered on PROSPERO (an international prospective register of systematic reviews) as CRD42017077378. 46 The methods are presented here as sequential. However, identification, analysis and synthesis occurred iteratively and in parallel.
Review questions
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What types of interventional approaches to addressing social isolation and/or loneliness among migrant and/or ethnic minority people have been developed and evaluated?
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How effective are such interventions at reducing social isolation and/or loneliness when compared with usual or no intervention?
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What health outcomes have been examined in relation to these interventions?
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What negative effects have resulted from such interventions?
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Do effects (positive and negative) of interventions vary for different people (e.g. by gender, age, income)?
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What ‘programme theory’ and assumed underlying mechanisms inform interventions?
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What system factors increase or decrease social isolation and loneliness among migrant and/or ethnic minority people?
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What happens when similar interventions are introduced into different contexts? What processes (both anticipated and unanticipated) ensue and how do these reflect the interplay of local and wider system elements?
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What system conditions support or hamper successful and sustained implementation?
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To what extent do current interventional approaches address the known determinants of social isolation and/or loneliness among migrant and/or ethnic minority people? Where are the gaps?
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What are the costs associated with such interventions?
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What implications are there for roll-out at scale in the UK?
Rationale for review methodology
In adopting a ‘systems theory-informed’ approach, we acknowledge that real-world problems, such as social isolation and loneliness, are complex and multifaceted. 47 Interventions aimed at addressing such problems are complex, and their effects are determined by multiple, interacting factors. 44 Linear approaches to causation, as captured in simple effectiveness questions, are ineffectual in surfacing an understanding of how interventions interact with, shape and are shaped by their contexts. Such interactions include positive or negative feedback loops and may result in planned, unanticipated and unintended consequences. Understanding such complex situations requires the disentangling of interventions, actors, mechanisms of change, outcomes and contexts, characterised by a systems approach, grounded in realist ontology. The project sought to generate a nuanced understanding of how and why interventional activity plays out in particular ways in particular contexts, as well as identify missed opportunities to protect against, and alleviate, isolation and loneliness. Table 1 shows how the review methodology addresses the review questions.
Methodology | Typology development | Theory-based review | Effectiveness review | Synthesis of costs | CPs | International or UK focus |
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1. Types of interventional approach | ||||||
Described | ✓ | ✓ | ✓ | International | ||
Evaluated | ✓ | |||||
2. Effectiveness of interventions | ✓ | International | ||||
3. Health and well-being outcomes of interventions | ✓ | International | ||||
4. Negative effects resulting from interventions | ✓ | ✓ | ✓ | International | ||
5. Differential effects of interventions (e.g. by gender, age, income) | ✓ | ✓ | ✓ | International | ||
6. ‘Programme theory’ and underlying mechanisms | ✓ | ✓ | International | |||
7. System factors | ✓ | ✓ | UK | |||
8. Differential effects of contexts | ✓ | ✓ | ✓ | UK | ||
9. System conditions affecting implementation | ✓ | ✓ | UK | |||
10. How interventional approaches address determinants | ✓ | ✓ | UK | |||
11. Costs associated with interventions | ✓ | International | ||||
12. Implications for roll-out at scale in the UK | ✓ | ✓ | ✓ | UK |
Literature search methods
Figure 1 shows the various searching approaches employed (numbered 1–7) and how each contributed to the suite of synthesis products.
Initial database searches (approach 1)
Initial searches of electronic databases sought studies in which the target population was identified as either (1) migrant and/or ethnic minority people (however defined and labelled by authors), or (2) a client group, population or neighbourhood diverse in terms of ethnicity/migrant status, and for which the study included a focus on the outcomes of interest. Early searches confirmed the importance of widening core terms/labels (social isolation, isolation, loneliness) to include (sense of) belonging, social connectedness, social networks, social ties and social relationships. It also revealed a need to consider studies that included outcomes that are a potential part of a causal pathway to social isolation and loneliness. A comprehensive list of search terms was developed iteratively from exploratory searches, medical subject heading (MeSH) terms and harvesting keywords from relevant reviews. As anticipated, indexing of social isolation and loneliness outcomes was variable, requiring identification of appropriate free-text terms. Searches of three key electronic databases (MEDLINE, Applied Social Sciences Index and Abstracts, and Social Science Citation Index via Web of Science) were undertaken in October 2017, using free-text and MeSH terms (see Appendix 1 for examples). No date restrictions were applied. A UK filter was initially tried, but this was not successful across the databases; therefore, we opted to retrieve international literature.
Review of prior reviews (approach 2)
We conducted a review of reviews to engage with the wider literature (theoretical and empirical) around social isolation and loneliness (i.e. not specific to migrant/ethnic minority people). All types of review, including evidence from UK and international studies, were included, not just those that were intervention related. We adopted a two-stage approach, with an initial batch of reviews being read and extracted in detail using a Microsoft Excel® (Microsoft Corporation, Redmond, WA, USA) template, and subsequent reviews being screened more quickly so that only material that added to the emerging theoretical picture was extracted. All of the prior reviews were examined carefully for identification of relevant intervention-/initiative-related studies. The review of reviews surfaced definitions and theories around loneliness, social isolation and related concepts. It also identified prior intervention typologies, informing our own thinking on the utility of categorisations, which was explored with the Project Advisory Group (PAG). Identification of intervention terms/labels revealed that some were too generic to be usefully employed in further searches, for example ‘support group’. We therefore decided, with agreement from the PAG, to focus on terms implicitly about isolation or loneliness, for example ‘friendship group’. Further reviews of potential relevance were identified during screening and extraction for the other review components, and via ongoing literature alerts, revealing this as a very active area of research. These were examined to (1) ensure that no relevant empirical intervention studies were overlooked and (2) identify useful theory to inform the review approach.
Additional search techniques (approaches 3, 4, 5 and 6)
We undertook targeted electronic database searches in October 2018 (approach 3) using a list of interventional approaches compiled through the aforementioned stages of searching and sifting, and suggestions from the PAG and CPs (e.g. befriending/companionship, cognitive–behavioural therapy/counselling, friendship groups, neighbourhood cohesion, shared spaces/housing design), and a list of loneliness measurement scale terms.
Complementary searches were conducted by forward and backward citation-searching (approach 4) using Publish or Perish information management systems (Publish or Perish Inc., Houston, TX, USA) and the reference lists of included intervention studies. Typically, most included studies cited between eight and 20 papers, although older or influential studies cited considerably more than this. The yield from citation-searching compares favourably with screening from electronic subject searches, and search methods using forward and backward citation-tracking are particularly valuable in finding documents to develop and test provisional theories. 48
Members of the PAG also made recommendations (approach 5), particularly in terms of theoretical material and prior reviews. Throughout the project period, journal alerts (approach 6) were used to capture newly published material up to the end of August 2019.
Grey literature identification (approach 7)
Grey literature was included to identify UK-based interventions/initiatives of relevance. We identified grey literature by Google searches (Google Inc., Mountain View, CA, USA) using key terms (both generic and intervention-specific, as harvested from earlier searches); searching websites of relevant policy, practice, research and advocacy organisations and contacting their research and evaluation departments by e-mail; contacting subject experts and using subject-relevant e-mail distribution groups; and searching OpenGrey. Grey literature searching was completed in July 2018.
The search for empirical literature was recorded for audit trail purposes. The search process was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. 49
Selection of included studies
For the database searches, results were downloaded to EndNote version 9 [Clarivate Analytics (formerly Thomson Reuters), Philadelphia, PA, USA] and then exported to EPPI-Reviewer version 4 (Evidence for Policy and Practice Information and Co-ordinating Centre, University of London, London, UK), where screening, data extraction and appraisal took place. Initial screening for relevance of the title and abstract was undertaken by one reviewer, with any uncertain items referred to a second reviewer. A second round of single-reviewer full-text screening for inclusion/exclusion was undertaken by four team members applying a piloted, refined and finalised checklist. Ten per cent of papers were double-screened to ensure consistent application. Uncertainties were resolved by discussion. The team maintained a detailed audit of the process of screening and selection.
Initial inclusion criteria for empirical papers were twofold: (1) the population of interest should be either (a) migrant and/or ethnic minority people (however defined and labelled by authors) or (b) a multiethnic client group, population or neighbourhood, of which at least 10% identify as migrant and/or ethnic minority; and (2) the study should include empirical data relating to social connectedness, social support, belonging, isolation, and/or loneliness. Full-text screening of the potential intervention/initiative papers resulted in three categories of papers:
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intervention-evaluative (qualitative and/or quantitative evaluation)
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intervention-descriptive (e.g. intervention development; no process or outcome evaluation)
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non-intervention empirical (qualitative and/or quantitative data presented on patterns or determinants, but no relevant intervention or initiative described).
Some additional inclusion criteria were applied to generate suitable subsets of the papers for each of our syntheses, as described in the chapters that follow.
In addition, the screening approach flagged a large number of ‘theory’ papers that did not present any relevant empirical material, but were retained because of their potential to make a useful conceptual contribution, as shown in Chapters 3 and 4.
For the grey literature searches, results were copied and pasted into Excel, where they were screened. The same inclusion criteria were applied, although only intervention papers were retained. Many documents referred to multiple interventions or initiatives. Initiatives identified in the grey literature were allocated to two categories: (1) detailed, reasonable-quality evaluative report of the initiative and (2) description only or limited evaluative document. Very few were allocated to the first category; those in the first category were incorporated into the EPPI-Reviewer database of published literature for subsequent extraction. The remainder were retained in Excel and a short extraction template was used to summarise the information available.
Data extraction
We developed and tested an extraction template before finalising it and preparing it in EPPI-Reviewer. Extractions for the theory-driven review were initially undertaken by one reviewer, and validated via a process of iterative team discussions and revisiting of papers. Templates used both structured and interpretive coding. We extracted both verbatim and precis text. Visual representations were extracted or generated by reviewers to demonstrate programme theory and wider system elements. Diagrams were uploaded to the EPPI-Reviewer database (see example in Appendix 2). Papers that included quantitative outcome measures were flagged in EPPI-Reviewer. Quantitative effectiveness information was double-extracted from these studies using a Microsoft Excel template, compared and agreed; data-checking was undertaken by a third reviewer for consensus. Table 2 presents the extraction criteria.
Criteria extracted for effectiveness review | Information extracted for the theory-driven systems review |
---|---|
|
|
Quality assessment
For the theory-informed review, papers were not excluded on the basis of quality; instead, their contributions were moderated on the basis of three criteria:
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relevance – articulated in terms of potential contribution to analysis and/or synthesis
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rigour – whether or not the method used to generate data is credible and trustworthy
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richness – the extent to which a quantitative or qualitative study contributed to an understanding of the phenomena of interest or to the mechanisms by which an intervention achieves its effect.
For the effectiveness review, we applied the Cochrane Risk of Bias assessment tool to all randomised controlled trials (RCTs); for non-randomised studies, we described the overall study design.
Quantitative synthesis
Intervention/initiative papers suitable for quantitative data extraction were flagged if they reported outcome measures relating to loneliness, unwanted social isolation, sense of belonging, and/or perceived social support (see Chapter 3 for justification). Many of these papers employed scales that incorporate multiple diverse dimensions of social connectivity and well-being. At this stage, the team explored the feasibility and potential utility of network meta-analysis, by grouping papers by (1) population/setting (2) outcome measure and (3) form of intervention. This exploration revealed that, notwithstanding some coherence in terms of theory, outcomes and interventional approach, significant methodological and reporting limitations existed across many of the papers. With agreement from the PAG, we subsequently opted for a narrative synthesis based around hypotheses (see Chapter 6).
Theory development
The process of developing programme theories and visual depictions drew on four complementary sources of insight, which were combined in an iterative fashion:
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grand and mid-range theories, described in Chapter 3
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insights from CP workshops
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advice from the PAG
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empirical papers describing and evaluating interventions.
The team created ‘preliminary groupings’, representing a mixture of population groups and settings, with individual members of the team analysing groups of related papers; the preliminary groupings were older migrant and ethnic minority people, international students, ethnic minority students, technologies and parents/pregnant women. This was a pragmatic step intended to make the initial stages of theory development easier by providing each team member with a set of reasonably coherent papers.
To complement formal data extraction of empirical papers, we undertook an initial round of data synthesis that employed structured templates in Microsoft Word (Microsoft Corporation, Redmond, WA, USA), in which we characterised the inputs, functions, strategies and causal chains between these elements and proximate determinants and relevant outcomes (using colour-coding to distinguish hypothesised or demonstrated relationships). Throughout the review, theories were sought, developed and/or refined to explain how a programme (or programme component) achieves its outcomes. The team further sought to identify, at a general level, the inter-relationship of contexts, mechanisms and outcomes. Theories used were developed and/or refined from the data, and/or were the product of refinement of existing substantive theory.
Consultation panels
The project was intended to be participatory, with members of the public and community-based workers contributing importantly to the theory-driven elements of the review. We convened groups, which we named ‘consultation panels’. This term acknowledged the probable extent of participation that could be achieved within the constraints of the project design and commissioning process. 50 Ethics approval for the CPs was granted by the University of Sheffield’s School of Health and Related Research (ScHARR) Research Ethics Committee (reference number 016132).
Recruitment and participants
Consultation panel participation was based on interest in the topic, an ability to relate the topic to real-world experiences and a capacity to consider the influence of broader social processes. It was not a requirement that participants were lonely or isolated. The purpose of the CPs was not to elicit revealing or distressing personal stories, but to offer insight into processes through which loneliness and social isolation arise and can be addressed. We decided to convene three CPs based around broad age/life-stage groups: young adults/students, working-age people and older people. Potential participants were identified in partnership with community-based organisations and existing black and minority ethnic (BME) and migration-oriented networks. After interested respondents had been approached and given an opportunity to reflect, researchers contacted them by telephone to discuss the project in more detail. Members were selected to ensure broad representation across social characteristics (e.g. gender, ethnicity), as well as their active contribution. We recruited between six and 11 individuals to each CP (two in Sheffield and one in Leicester). Overall, 34 participants contributed. Two interested participants, from a minority group that was under-represented in the CP workshops, were included in one-to-one telephone and face-to-face discussions as they were unable to attend the workshops. Participants were members of the public and people working in community-based roles with good knowledge of local communities. All participants self-identified as a migrant and/or having an ethnic minority identity. The groups included recent arrivals and more established migrants, as well as UK-born individuals. One panel included people who had been forced to migrate. Individuals who did not speak English fluently were not excluded. One participant was provided an interpreter to assist during workshops. Our approach to the CPs did not make any prior assumptions about differences in experiences between migrant and UK-born ethnic minority people. Exercises encouraged participants to examine the commonalities and divergences within and between groups of people ascribed particular ethnic and migration labels.
The management and ethos of the consultation panels
Workshops were held in local venues familiar to many of the participants. Timings were arranged in consultation with members.
The approach was based on participatory principles set out by INVOLVE. 51 Our approach was informed by Group Model Building methods,52 which emphasise the importance of adopting an iterative process of dialogue, building, testing and improvement, and the need to attend carefully to group dynamics. Early ground rules were collaboratively developed during introductory sessions to ensure that everyone had the opportunity to create an enabling ethos. Important principles suggested by CP members were respectful dialogue, listening carefully and making sure that information shared among the group was not divulged beyond the group.
Participants were offered £50 shopping vouchers to recognise their contributions to the half-day workshops. All travel expenses and any care costs were paid.
Structure and content of consultation panel sessions
One introductory session and two half-day workshops were organised for each group. A final co-creation session with CP members from all the three groups was convened to generate visual outputs.
Meeting 1: introductory session (April–June 2018)
Three 90-minute ‘meet-and-greet’ sessions allowed people to get to know one another and provided a gentle introduction to the topic and the role of CP members. Simple engagement exercises were used to encourage mixing and open discussion. An interactive exercise uncovered participants’ understandings of ‘loneliness’ and ‘social connectedness’. These sessions were relaxed and helpful in terms of generating a positive working atmosphere and allowing participants to begin to explore complex and, sometimes emotive, issues. The exercise products were used as a springboard to discussion in workshop 1.
Consultation panel workshop 1 (June–July 2018)
Three CP workshops, involving 27 participants (see Appendix 3), took place; each lasted 4 hours. Structured exercises were employed to elicit (1) open-ended exploration of experiences of, causes of and solutions to isolation and loneliness, and (2) reflection on early findings of the effectiveness review, including early representations of intervention logic models/programme theory. The workshops elicited additional ideas about intervention components and functioning, and context, as well as system elements that affect isolation/loneliness. Audio-recording, detailed note-taking and visual diagramming captured contributions. Appendix 5 includes illustrative examples of workshop materials.
Consultation panel workshop 2 (March–April 2019)
Twenty-one people participated in the second round of CP workshops, seven of whom were new recruits (see Appendix 4). Attrition was most evident among the student group and the older persons group; attrition among students was explained by students completing their course. Attrition among the older persons group may have been linked to a break in continuity among the research team. Each workshop lasted 4 hours. Discussions were audio-recorded and detailed notes were taken; visual diagramming was also employed. The aim of this phase was to interrogate and ‘sense-check’ representations of system elements, connections and interdependencies. Panels drew on real-world experiences to confirm or refute draft system models, and particularly focused on processes that could amplify or dampen the intended mechanisms of interventions/initiatives. Discussions sought to identify some overlooked elements and additional relationships and extended knowledge on how system components interact to generate intended and unintended outcomes. Appendix 5 includes illustrative examples of workshop materials.
Visual output co-creation session (August 2019)
A final 3-hour session drew on the expertise of a visual scribe. Panel members from across the three groups co-created of a series of visual outputs that represented some of the individual, family, community and wider system factors that can generate social isolation and loneliness among ethnic minority and migrant people. This was achieved through participatory exercises. Panel members generated a series of visualised personas that communicated the complex of factors that can inform loneliness and social isolation. See Appendix 6 for examples.
Consultation panel contribution
Consultation panel workshops contributed importantly to the review in the following ways:
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critique and expansion of the concepts of social isolation and loneliness, based on lived experience
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generation of theory, through panel member narratives, on how social isolation and loneliness operate across different levels of the system
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shaping the inclusion and typing of interventions and initiatives
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identification of upstream, mid-range and individual factors that can influence the effectiveness of interventions
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commentary on, and refinement of, draft models of proximate and distal causes of social isolation and loneliness
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identification of why interventions/initiatives are more or less accessible, and work more or less well, for different people
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identification of some gaps and uncertainties in the team’s analysis that warranted follow-up, with such insights informing follow-on database searches.
At each stage, our analysis drew across the insights from the three CPs to highlight elements of the constructed theory that were: supported, refuted, or refined/extended by CP testimony, as well as new system characteristics not previously identified.
Adaptations to the review process
As the review progressed, we opted to focus attention on three common interventional approaches (see Chapters 4–6). This was both pragmatic and offered analytical purchase, because other interventions were commonly characterised by sub-elements of these three common types. We focused review efforts, including CP discussion, on these three types, while remaining open to identifying further interventions that did not conform to this typology.
Final participatory workshop
In July 2019, a final participatory workshop was held involving a small number of CP members, together with practitioners from local authorities and third-sector organisations. Participants were invited to participate as ‘teams’ representing particular cities or other local authority areas. Around 50 participants attended, and six local areas were represented. We shared emerging findings and sought feedback on draft intervention logic models and a broader system diagram. Local teams were invited to map local action against the system model, with the aim of revealing examples of promising practice, missed opportunities for action, conflicting action (or policy) that undermines social connectedness and/or efforts to tackle isolation and loneliness, and potential for modification or disinvestment. Workshop discussions were captured in real time by a visual scribe; detailed notes were also taken. Insights from the workshop were subsequently integrated with the other data sources.
Chapter 3 Identifying the theoretical scope of the project
Introduction
The first stage of the project involved developing a conceptualisation of loneliness that was appropriate to our population groups of interest, as well as an overarching theory of the proximate determinants of loneliness that could guide our subsequent interrogation of the evidence relating to interventional approaches. We undertook an iterative process of exploring and synthesising conceptualisations and approaches to identifying or measuring relevant concepts, drawing on four complementary sources:
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prior evidence syntheses focused on loneliness and related concepts (n = 79)
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CP discussions
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theory extracted from the first batch of 49 identified intervention studies
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additional theoretical material suggested by the above three sources.
Loneliness and social isolation
Concepts and definitions
Loneliness can be considered a ‘chaotic concept’; variously defined and measured, debated and contested. From a public health perspective, loneliness is seen as a problem because it has been associated with a range of negative physical and mental health outcomes. Growing concerns about levels of loneliness, particularly among the elderly, might also be a seen as a moral panic, as politicians, civil society and the media invoke images of the breakdown of the social fabric of families and communities.
It is now commonly accepted that social isolation and loneliness are not the same; the former relates to the objective state in which an individual has little contact with family members, friends or neighbours,53 and the latter relates to a subjective assessment that one’s social relationships are inadequate. This distinction is useful because it draws our attention to the quality of social relationships and interactions, and suggests that a person who, at face value, is not isolated from other people can, nevertheless, be lonely. At the same time, the distinction also suggests that people who have little social contact may not necessarily feel lonely. Although true, research does suggest a strong correlation between the number and intensity of social ties and the risk of loneliness. 54 Individuals who live solitary lives without feeling alone seem to be the exception. Understanding loneliness as resulting from the interplay of a deficit in social connection and an individual’s cognitive assessment of the adequacy of relationships seems likely to be more fruitful. 55
It has been suggested that loneliness can arise because an individual perceives any or all of the quantity, quality or modality of their relationships to be lacking. 56 There is also the issue of which relationships, when perceived to be lacking, can generate loneliness. Some authors have drawn a distinction between ‘intimate’ and ‘social’ loneliness; the former relates to perceived inadequacy in close, affirmative, confiding ties (typically family members and close friends), whereas the latter relates to a perceived lack of relationships that provide camaraderie. Questions are raised about whether different types of relationships are functionally distinct and necessary for emotional well-being, providing an individual with different forms of social sustenance, or whether they are, instead, interchangeable. Common definitions and measures of loneliness frequently merge both intimate and social dimensions, such as Rook’s:4
[A]n enduring condition of emotional distress that arises when a person feels estranged from, misunderstood or rejected by others and/or lacks appropriate social partners for desired activities, particularly activities that provide a sense of social integration and opportunities for emotional intimacy.
Rook4
Although Rook’s4 definition suggests an ‘enduring’ condition, the need to recognise variation in the temporal and spatial characteristics of loneliness has also been noted. Loneliness may be a temporary state, often linked to life stages or transitions or a change in circumstances, or it may be long lasting. Loneliness may also be situationally specific, experienced only in a particular sphere or space of life, such as the home, the workplace or at school. The intensity of loneliness also varies. For some, it is an extreme state of emotional distress, whereas for others it is less intense. 56 These elements of chronicity versus transience, generalised versus situation specific, and variations in intensity can co-occur in any combination. Some measures of loneliness use scales that could, in theory, enable assessment of the degree of intensity of loneliness, although this approach has been rare to date. Longitudinal data on the fleeting versus enduring nature of loneliness are also rare. Some research focuses on experiences of loneliness in particular settings, often framed in terms of ‘sense of belonging’, a concept that has particular resonance for our population groups of interest, as discussed more in Sense of belonging and racism. To date, there is little evidence of the implications of these different forms of loneliness for physical and mental health across the lifespan.
Closely related concepts
Our review of prior evidence syntheses highlighted the very limited attention to migrant and ethnic minority people in research on loneliness, and raised queries as to whether or not existing theoretical frameworks were adequately specified with respect to the experiences of these groups. In addition, our first round of CP workshops, and preliminary extraction from the first batch of 49 intervention studies, suggested the importance of drawing on a wider range of theory and concepts. As shown in Box 1, CP members associated diverse inter-related ideas and terms with the notion of ‘loneliness’.
No emotional support.
Lack of social support.
No one to turn to.
No one to talk to.
Nobody to confide in.
No friends or family.
Feeling like you have no one.
Lack of in-depth relationships.
Barriers to connecting with my family.
Unable to trust people.
Fear and experience of negative social interactions
No one likes me living here.
I don’t feel safe.
Exclusion.
Being reminded I do not belong here.
Fear of being rejected.
Racism.
Social pressures of friendship groups.
Workplace exclusions and hostility.
Family expectations; family judgemental.
Not being understood even though speaking in English.
Feeling like I do not belong
‘Fish out of water’.
Being trapped when I can go to better places like home.
Feeling I don’t belong.
Not understanding cultural references.
Cut off; torn.
Bilqul alag thalag (completely separated).
Akelaa (alone, apart).
Tanhaa (solitude).
Not engaged.
Not feeling part of . . .
Not being able to connect.
Authenticity; not being able to be myself
Feeling misunderstood.
Feeling like you have no one to be yourself around.
Nobody to share my interests and activities.
Lost.
Hiding/hidden; invisible.
No internal security.
Hard to admit that I am alone, that I am struggling here.
Needing someone with same ethnic identity.
Nobody to speak my language with.
Nobody to discuss racism, colonialism.
Loss of social role; unable to contribute
Feeling like you can’t contribute anything useful.
Homesickness.
Away from extended family networks.
Boredom.
Unmet expectations.
Disappointment with social interactions.
Not feeling valued by others
Being undervalued.
Even your peers do not value you.
Unwanted.
Feeling of dread.
Feeling forgotten.
Feeling unimportant.
Put on one side.
Nobody cares about me.
Sadness; depression.
We therefore identified related bodies of work concerned with social relationships, which have tended to develop in parallel to those focused on isolation and loneliness, that could usefully inform the project, including social support, social networks and social integration, and sense of belonging. Table 3 illustrates the significant overlaps between these concepts by presenting some of the common measurement tools that have been used to capture these constructs. Then we discuss these commonalities, as well as some of the distinctions that provide potentially useful theoretical additions for the current project.
Loneliness and related concepts | ‘Loneliness’ (UCLA scale57) | ‘Sense of belonging’ (Pak’s58 measure) | ‘Social support’ (Social Provisions Scale59) | ‘Social integration’ (Hausmann’s measure)60 |
---|---|---|---|---|
Emotional loneliness (lack of intimacy; lack of emotional support) |
|
|
|
|
Social loneliness (lack of fit; lack of companionship; lack of social validation) |
|
|
|
|
Social isolation (lack of connectedness and social interactions) |
|
|
|
More generally, drawing on the sociology of emotions, we looked for complementary understandings of ‘feeling lonely’ that went beyond the individual, to consider social, cultural and power-related dimensions. Burkitt61 argues that all emotions are relational, stating that ‘how we come to see and feel about ourselves is inseparable from how we imagine that others see and feel about us’. 61 It is perhaps surprising that work on loneliness to date appears to pay rather scant attention to these interactive and relational dimensions.
Social support
The distinction between the quality and the quantity of social relationships found in theories of loneliness and social isolation is mirrored in the literature concerned with the conceptualisation and measurement of ‘social support’. For instance, Gottleib and Bergen62 note the importance of distinguishing between the structure of a person’s social network on the one hand, and the resources that arise from such social ties on the other, eschewing the suggestion that ‘people’s social ties are unconditionally supportive’. 62 Theoretical work in this field has highlighted the importance of examining both sources of support and the types of support that are available and/or provided.
Gottleib and Bergen62 define social support as ‘social resources acquired from non-professionals in the context of both formal support groups and informal helping relationships’, whereas others also regard professionals as potential sources of support. 63
Work in the 1980s sought to identify types of social support. Barrera64 identified five types of social support: emotional, instrumental, companionship, informational and esteem support; House and Kabarl65 opted for four types of social support: emotional, tangible, informational and appraisal. Barrera64 also argued that a distinction should be drawn between perceived support and that which is actually mobilised and received, and empirical research62 has tended to show that it is people’s sense of support that provides a buffering effect in stressful or challenging situations. Clearly, the concept of perceiving a lack of available social relationships that can provide emotional and affirmational support and companionship is akin to the definitions of loneliness commonly employed.
In addition, social support literature draws attention to the qualitative adequacy of the support offered, that is the manner and associated meaning that is conveyed through the provision of support. An offer or provision of social resources that is made in an unsuitable way can be unsupportive, or even damaging to the recipient, even if the intention was positive. 62 Spontaneous receipt of social resources from one’s social network may also have a more positive impact than that which has to be requested. 62
These theoretical contributions enhance the loneliness literature by drawing clearer attention to so-called ‘negative social support’, that is interactions and social ties that are experienced as stressful, that are unsupportive and that are detrimental to the individual’s mental well-being. In this literature, ‘negative social support’ has most commonly been identified as emanating from familial relationships, particularly spousal and parent–children ties, that is relationships that are generally expected to provide emotional, affirmational and tangible support. 66
A further emphasis in the social support literature, that is less evident in the work on loneliness, is the reciprocal nature of many supportive social relationships: ‘social support is not a commodity that resides in the provider and passes to the recipient, but . . . is an expression of the mutuality and affection characteristic of the relationship between the parties’. 62 ‘Peer support’ has received particular attention as a route via which effective emotional and information support can be delivered, as it is predicated on the principle of mutuality. 62,67 Non-reciprocal relationships will be perceived as supportive (rather than exploitative or degrading, depending on whether you are the giver or receiver) only if the unidirectional flow meets the expectations of both parties. The expectations people hold about relationships, shaped by individual attributes and collective values, are fundamental to their perceptions of social support. These conceptual contributions reveal the way in which social ties and flows of social resources are mutually constituting. A social relationship (which carries a particular meaning) presents an opportunity for the exchange of resources, the materialised nature and volume of which, in turn, serve to define and give meaning to the relationship. These insights have particular relevance to our focus on ethnic minority and migrant populations. Transition to an unfamiliar social context (whether due to international migration or movement into white-dominated institutions and spaces) can mean both the loss of supportive social ties and exposure to unaccustomed norms of relationship-building. 63,68 Furthermore, formal social support services may be deficient for migrants and minorities owing to a lack of cultural competence. 69
As well as providing useful insights into the meaning and consequences of interpersonal social exchanges, the social support literature usefully draws attention to the potential impact of ‘macrosocial’ variables, such as housing patterns, transport and job conditions, as well as status hierarchies (linked to gender, ethnicity, socioeconomic position), on people’s levels of perceived and actualised social support. 70 Contextual stressors such as poverty and being in an unfamiliar context can mean that social ties become overwhelmed or inadequate, and interactions more negative, creating the need for bolstering of informal support networks. 68
Social networks, social integration and acculturation
As noted above, social support researchers have argued that the structural properties of people’s social ties should be distinguished from their perceived or actual functions. Gottleib and Bergen62 suggest that structural properties of an individual’s social network (number of ties, density and interconnections) are measures of ‘social integration’, that is ‘the extent to which the person is enveloped in the social fabric.’62 Therefore, this notion of social integration is very similar to the concept of ‘social connectedness’ and, in essence, is the opposite of social isolation.
In addition, however, ‘social integration’ has been conceptualised more broadly, and variously, in relation to migrants (and, by extension, ethnic minority individuals). Here the interest has been on migrant social connections across various spheres of life. Ager and Strang’s71 widely cited model identifies 10 inter-related domains of integration and highlights ‘the fundamental role that social connection is seen to have played in driving the process of integration at a local level’. 71 However, although this and other formulations characterise integration as a process involving cognitive and behavioural adaptation on the part of both newcomers and established citizens, a so-called ‘two-way street’, leading to immigrants becoming accepted members of society,72 competing conceptualisations are also highly visible.
Linked to claims of self-segregating minorities who ascribe to values and norms that are incompatible with the host society (portrayed as homogeneous white British), and fears around strong intraethnic ties, ‘integration’ in policy circles has increasingly been understood as a process through which people of migrant and/or ethnic minority identity should adapt to the (imagined) ‘British’ way of life. 73 Such ‘assimilationist’ policy approaches have been critiqued from diverse angles, including their potential to undermine positive social ties within and across ethnic groups. 74
Parallel debates have occurred in relation to the entry of ethnic minority and/or migrant individuals into specific white majority-dominated social spaces and institutions. Some theorists advocate a process of adaptation to the new social way of life, through which newcomers replace their home culture with that of the new social setting. Others critique this approach as ‘cultural suicide’, arguing that successful outcomes require both acquisition of new cultural repertoires alongside the conservation of a sense of self and cultural tradition. 75
Theoretical work around the notion of ‘acculturation’ is also useful here. Berry76 identified the way in which people arriving in a new cultural context are faced with the need to accommodate both their heritage culture and that of the new society (or setting) in which they find themselves. This work drew attention to the varied patterns of association that migrants may establish with both people recognised as members of their ‘in group’ and those who are ‘out group’ members. Empirical work drawing on these ideas has tended to find that newcomers who manage to maintain a positive sense of their own ethnic identity and supportive ties to in-group members, while at the same time also forging positive ties to out-group members, have a lower risk of poor emotional health than those who have ties to either group alone, or no supportive ties at all. 77,78
These contributions are significant for the current project because they highlight the importance of considering the ethnocultural identity of individuals within social relationships and networks, and the implications of such identities for whether or not, and how, relationships meet individual social needs and expectations. Our CP members gave many examples of seeking out, and finding comfort in, relationships with individuals who shared their ethnic (or national) identity; ‘a little safety cocoon with yourself’, as one student CP member called it. At the same time, opportunities to form ties, and to interact informally, across difference were welcomed.
Sense of belonging and racism
Rooted in Durkheim’s79 early work on the social causation of suicide, Spady80,81 developed influential ideas around ‘belonging’, focused on a concern to reduce under-represented group dropout from US higher educational institutions. He identified the risk factors for dropout as ‘a lack of consistent, intimate interactions with others, holding values and orientations that are dissimilar from those of the general social collectivity, and lacking a sense of compatibility with the immediate social system’. 80 A large body of subsequent US work has explored the nature and determinants of ‘sense of belonging’ within predominantly white institutions. Strayhorn82 identified a sense of belonging as rooted in feeling accepted, valued, respected and cared for by peers and the wider institution. Baumeister and Leary83 have argued that the need to belong is a powerful, fundamental and pervasive motivation among human beings, and extends within and beyond particular institutional contexts. Hagerty et al. 84 identify belonging as the experience of personal involvement in a system or environment, together with the experience of being valued, needed and accepted, and ‘fit’ (perceiving that your characteristics articulate with or complement the system or environment).
These insights are particularly relevant to our focus on loneliness among migrant and ethnic minority people, whose sense of ‘mattering’, ‘being valued’ and ‘fitting in’ are frequently undermined. A large body of research is concerned with notions of belonging in a more general sense, to communities and to society at large, and how such belonging is constructed and negotiated by migrants and minorities in the face of exclusionary discourses and processes of ‘othering’. 74,85,86 This work also explores how sense of belonging may interplay with transnationalism. It is important to be alert to the ways in which the maintenance and disruption of transnational social networks may have implications for loneliness among migrants and minorities. Important also is the way in which transnational lives may lead to majority discourse that questions the ‘commitment’ of migrant and minority individuals to belonging where they reside and policies that undermine social connections. 74,87 Older CP members talked vividly about their loss of social connections outside the UK:
Because when we are older we yearn for things we had when we were younger, some of which you will never get back. That can become problematic in the mind . . . Food, connections with individuals who are actually not there anymore. The music, the conversations, the jokes, the understanding of what it is you left back home. Which isn’t there, by the way.
CP older member
The concept of self-worth, although present in the general literature on loneliness,88 is particularly foregrounded in the sense-of-belonging literature, and highly relevant to our focus on migrant and minority groups, whose identities are commonly stigmatised. This suggests the importance of examining the interplay between discrimination, stigma, shame and loneliness. Importantly, racial discrimination can usefully be understood as operating at multiple, interlocking levels. At a structural level, processes of racism are entrenched in laws, policies and practices, and are reproduced in societal institutions and organisations. At a cultural level, the circulation of images, language and symbols in multiple societal arenas – everyday conversation, media, the arts and policy discourse – serves to perpetuate, and normalise, the ideology of inferiority and difference. 89 These insights are important because, in addition to racist interpersonal interactions that might be experienced as outright verbal or physical abuse, or more subtle microaggressions, sense of belonging can be undermined by the material and symbolic properties of ‘white spaces’. 90
Intercultural encounters
A final related body of work seeks to understand patterns of interaction across ethnocultural difference, and how more positive social interactions, and reduced prejudice, can be achieved. Early psychological contributions to this area were framed in terms of ‘contact theory’,91 whereas more recent work has examined the nature of, and opportunities for, ‘meaningful encounters’ that can have a transformatory effect on attitudes and behaviours. 92,93 The importance of bringing this work into view for the present project was supported by our CP members, who underscored the relevance of both positive interethnic ties and negative interactions across ethnic difference, for sense of belonging among migrant and ethnic minority people. For example, a discussion in the working-age Sheffield group centred on increased hostility from neighbours following the Brexit vote, with one member commenting:
When migrant and minority ethnic individuals see the future of this country, they do not see themselves in it.
CP working-age group member
Delineating the scope
The conceptual terrain briefly set out in previous sections was used to inform our subsequent approach to the project in the following ways:
-
identifying the outcomes of interest
-
developing a framework of the proximate determinants of loneliness
-
sensitising to potential interventional strategies (and thereby informing inclusion criteria for interventional studies).
Outcomes of interest
Combining insights from the CP sessions with the theoretical literature, we identified the following types of outcomes, whether assessed quantitatively or described qualitatively, as being dimensions of loneliness, and therefore within remit:
-
emotional loneliness, lack of intimacy
-
social loneliness, (lack of) sense of belonging; feeling isolated
-
feeling unsupported.
A framework of the proximate determinants of loneliness
Our theoretical review confirmed that existing formulations of the underlying causes of, and potential solutions to, ‘loneliness’ are inadequate. In particular, rather than pathologising people’s negative appraisal of existing social relations (employing terms like ‘abnormal’ cognition),2 it is important to acknowledge that individuals are exposed to social ties and interactions that undermine, rather than affirm, and that constrain, rather than facilitate, companionship. Importantly, for migrant and ethnic minority people, these interactions are commonplace, and threats to self-worth are routinely experienced. Furthermore, for many migrants, a loss or weakening of significant social exchanges is a prominent feature of their experience.
An initial scoping extraction of 49 interventions/initiatives involved mapping all of the inputs associated with these initiatives, and identifying the associated strategies (that is the cognitive, behavioural or environmental changes that were intended). We then examined each of these strategies, asking the question ‘how does this strategy have an impact on loneliness experienced at the individual level?’, to identify candidate proximate determinants that aligned with the theory review. We drew up a draft model and discussed it with the CP members. This process resulted in the identification of four proximate determinants, through which, we hypothesised, all initiatives must operate to affect loneliness:
-
increased positive ties and interactions – social relationships and exchanges that are experienced as providing affirmation and authentic companionship (being able to be oneself), often of a reciprocal nature
-
decreased negative ties and interactions – social relationships and exchanges that are experienced as failing to affirm, or as actively undermining, one’s sense of self, and/or failing to provide or actively obstructing valued social activities
-
increased self-worth – perception of being valued by, and valuable to, other people
-
more positive appraisal of existing social ties and interactions – reduced gap between what you want and what you have.
We recognised that these proximate determinants inter-relate with one another, and that there may be two-way causality (or feedback loops) between loneliness and these proximate determinants. For instance, experiencing negative social interactions is likely to undermine one’s self-worth. However, the model suggests that, in theory, interventions must affect loneliness via one, or more, of these determinants. So, for example, it may be possible to reduce loneliness by enhancing self-worth, even if there is no change to the number of positive social ties and interactions that the individual experiences. The model does not distinguish between intimate ties and broader social connections, whether experienced positively or negatively, because we found little indication that such a distinction would be helpful in understanding how interventions function. This decision also reflected a concern that this distinction may be ethnocentric, reflecting Western notions of the nuclear family and primacy of the intimate, heterosexual husband–wife bond. Work by Smart94 alerts us to the ways in which people are active in (re)creating family-type relationships, and that elements of intimacy, support and companionship can be achieved in different ways.
Potential strategies and solutions
Previous review work has categorised interventional strategies into four main types, each of which responds to an identified immediate cause of loneliness. 2 As shown in Table 4, we developed an extended model that enabled us to look for a wider range of potential interventional strategies.
Model | Causal factors | Potential responses |
---|---|---|
Immediate cause | Solutions | |
Masi et al.’s2 | Lack of intimate, supportive social ties | Provide substitute relationships that afford such intimacy and support |
Lack of social connections | Provide opportunities for social connections | |
Lack of skills to build relationships | Equip people with social and communication skills | |
Maladaptive social cognition | Help people to think differently about their social relationships | |
Proximate determinants | Potential strategies | |
Our new model | Lack of positive social ties and interactions |
|
Negative social ties and interactions |
|
|
Low self-worth |
|
|
Negative appraisal of existing ties |
|
Chapter 4 A typology of interventional approaches
Introduction
This chapter addresses the following research question and presents a typology of interventions: what types of interventional approaches to addressing social isolation and/or loneliness among migrant and/or ethnic minority people have been developed and evaluated?
In keeping with our theory-driven methodology, and drawing on the work of Hawe and Shiell,40,41 we adopted an approach to ‘typing’ based on identifying the intended functions that interventions aimed to achieve. We understood a function to be a set of closely related enabling conditions and opportunities for change. The functions that characterise a particular intervention type are, more or less explicitly, underpinned by assumptions about the proximate determinant(s) of loneliness, as well as feasible ways of modifying these determinants, among the intended beneficiaries.
Therefore, although in some cases a particular function dictates some aspects of the form that an intervention takes (i.e. the nature and quantity of resources provided), this is not necessarily the case. Furthermore, distinct intervention types can share some aspects of form. As an example, initiatives that adopt a group-based format appear superficially similar, but can vary importantly in terms of their functions, with some being entirely focused on providing the conditions to equip participants with particular knowledge or skills, whereas others might be characterised by the distinctive function to provide a safe, reciprocal authentic space for group members.
As discussed in Chapter 3, our inclusion criteria encompassed interventions for which the primary goal was not reducing loneliness or social isolation, provided that these interventions had a secondary goal or a (hypothesised) intermediate pathway of increasing social connectedness (increasing positive and/or reducing negative social ties and interactions). For such initiatives, we sought to characterise their functions in terms of how they related to the processes and outcomes of focus in this study.
Having identified diverse intended functions, we sought to create a typology that identified each intervention type by its ‘distinctive’ function. Several types were found to have more than one function, but when this was the case, a function could be identified that was distinctive in the sense that, without this, it would no longer be considered to be this type of intervention. A few functions appeared in more than one intervention type, but our approach meant that they could be considered distinctive in only one type.
Input from the CP workshops was also important to this stage of the project. CP discussions revealed illustrations of how the form of initiatives can be deceptive, and thereby provided support for our focus on articulating functions. Members also helped to refine the way we described functions, for example confirming the inclusion of ‘safe space’ in the description of the distinctive function of shared-identity support groups (see Table 5). They also supported the inclusion of ‘intercultural encounters’ as a type of intervention with potential to affect loneliness, despite these initiatives commonly being framed in terms of social cohesion at a more aggregate level. CP members were unanimous that, although these initiatives were often flawed in practice, in principle they had the potential to affect importantly the proximate determinants and feelings of loneliness, particularly a sense of belonging.
The resultant typology represents generic models of how interventions are intended to function. Its purpose was twofold. First, it provided a structure for mapping the interventional activity that has been subject to documentation and/or evaluation in the published and grey literature. Second, it provided a tool to guide subsequent analyses of how interventions are hypothesised to work and how they play out in the real world.
Overview of the range of interventional approaches
We identified eight types of interventions. Table 5 lists these, along with their distinctive intended functions, and Table 6 shows the distribution of these types by the population subgroups we employed, as found in the published and more detailed grey literature (a total of 170 initiatives). Report Supplementary Material 1 provides brief descriptions of the intervention types found in the rest of the grey literature accessed.
Number | Approach types | Intended distinctive function |
---|---|---|
1 | Befriending | To provide a one-to-one relationship of trust through which an individual with inadequate social connections receives tailored emotional support and companionship |
2 | Shared-identity social support group | To provide a safe, authentic, reciprocal social space where people who recognise some kind of shared identity engage with each other with meaning and enjoyment |
3 | Intercultural encounter | To bring together, in meaningful contact across ethnic/cultural/religious differences, people who do not normally interact |
4 | Psychotherapy | To provide individuals currently living with (or at high risk of) a common mental disorder with structured therapy to help them better understand and adapt their thinking and behaviours (which may contribute to isolation and loneliness) (individual or group therapy) |
5 | Training or equipping focused | To provide individuals with an opportunity to gain new knowledge and/or skills that have relevance to increasing the quantity and/or quality of their social ties and interactions (alone or in a group setting) |
6 | Meaningful activity focused | To provide an opportunity to undertake activity that has meaning for the individual and the potential to enhance self-worth (alone or in a group setting) |
7 | Volunteering | To provide individuals with an opportunity to volunteer that has the potential to enhance self-worth and create new social ties and interactions (alone or in a group setting) |
8 | Light-touch psychological inputs | To expose individuals to brief ‘messaging’ intended to alter perceptions and support more positive appraisal of existing social ties and interactions |
9 | Other (individual focused) | Varied: holistic services (combining several functions flexibly according to need, often including distinctive functions of approaches 1, 2, 5, 6 and 7); social prescribing (connecting people to types 1, 2, 6 and 7 primarily); residential mobility programme (providing opportunity to live in different sociodemographic neighbourhood) |
10 | Other (community, organisation or structural) | Varied: area-level partnership commissioning range of activities (combining several functions aimed at creating opportunities for new social ties and interactions); dedicated campaigning organisations (advocating for service gaps to be filled and system change); holistic co-ordinating agencies (facilitating support by other agencies as well as direct support provision); creation of engaging physical social spaces; community planning exercises |
Beneficiary group of focus | Number of interventions/initiatives identified in published and detailed grey literature | |||||||||
---|---|---|---|---|---|---|---|---|---|---|
Befriending | SSG | Intercultural encounter | Training or equipping | Psychotherapy | Meaningful activity | Volunteering | Light-touch psychological inputs | Other (individual) | Other (structural) | |
People seeking or granted asylum (all ages/life stages) | 5 | 13 | 12 | 5 | 0 | 3 | 1 | 0 | 1 | 3 |
Not people seeking asylum or refugees | ||||||||||
Pregnant women or new mothers | 8 | 3 | 1 | 1 | 7 | 0 | 0 | 0 | 0 | 0 |
Older people | 2 | 4 | 0 | 5 | 0 | 0 | 1 | 0 | 0 | 2 |
University students | 6 | 16 | 4 | 4 | 1 | 0 | 2 | 5 | 0 | 1 |
Children in school setting | 2 | 0 | 2 | 1 | 0 | 0 | 0 | 2 | 0 | 1 |
Children and young people outside educational setting | 0 | 0 | 5 | 0 | 0 | 0 | 0 | 0 | 1 | 0 |
Women in vulnerable or challenging circumstancesa | 3 | 9 | 0 | 0 | 2 | 0 | 0 | 0 | 0 | 0 |
General-population migrants and/or ethnic minorities (no age or stage focus) | 1 | 4 | 1 | 2 | 1 | 2 | 0 | 0 | 3 | 2 |
Majority population alone or multiethnic population including majority | 0 | 0 | 10 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Total | 27 | 49 | 35 | 18 | 11 | 5 | 4 | 7 | 5 | 9 |
In practice, not all of the interventions described in the published and grey literature conform exactly to the intervention types that we developed. In a few cases, interventions combine more than one of the intervention types (and several different functions). These ‘hybrids’ were assigned to the type felt to capture the most prominent distinctive function, with a note being added to describe their syncretic form. We also included two ‘other’ categories to accommodate interventions that did not fit neatly into any of the eight types. These were primarily multifaceted initiatives offering a menu of options to individuals or providing diverse activities and resources at a structural level.
In the next section, we provide a description of each of the identified intervention types, including their distinctive functions, along with an overview of the forms that they took, guided by the Template for Intervention Description and Replication (TIDieR)-Lite framework,95 when appropriate. Chapter 5 further develops the theory of how the common intervention types work and presents pictorial representations (logic models).
Common interventional types
Befriending
The distinctive intended function 1 of interventions included in this type was identified as the creation of a one-to-one relationship of trust through which an individual with inadequate social connections receives tailored emotional support and companionship.
From our published (and more detailed grey) literature search, a total of 27 interventions were categorised into the befriending type, five of which were UK based (papers by McLeish and Redshaw96,97 that examined multiple interventions, some of which focused on our population groups, have been counted as a single intervention, as the analysis was aggregative). Diverse labels were employed to describe the individual acting in a befriending capacity, such as befriender, host, sponsor, tutor, buddy, labour friend, mentor mother and so on. Examples were found for all of our population subgroups except ‘children and young people outside educational settings’.
Appendix 7 sets out all of these interventions, describing the key components, guided by the TIDieR-Lite framework,95 and we summarise these here.
Key components
Recipients (to whom)
These interventions were targeted at individuals identified as having, or being at risk of having, inadequate social connections and/or lacking a sense of belonging in their current social context. None of the studies reported that the initiatives employed formal screening tools to identify eligible recipients, but some involved a process of referral by a professional (e.g. a midwife or a teacher). Five interventions were designed to support individuals seeking, or recently having been granted, asylum. All of these highlighted the challenges faced by individuals finding themselves in unfamiliar and often difficult environments, particularly in relation to establishing social connections. Four interventions targeted the needs of adults with a general focus on settlement and adaptation to the new country, whereas one98 sought to address the needs of schoolchildren of refugee status adapting to their new educational setting. Eight interventions focused on pregnant women and new mothers, and all but one were framed in terms of improving social support as a route to improving birth outcomes. A further initiative provided support to parents, but was not restricted to a narrow age or stage of family-building. 99 Two initiatives were aimed at older people, in both cases focusing on immigrant elders. Six initiatives were aimed at supporting university students to adapt to social and academic life in an unfamiliar learning context (one focused on students of minority ethnicity and five focused on international students). Two initiatives focused on schoolchildren who were identified as being at risk of lacking a sense of belonging in school, and therefore at risk of academic dropout or poor achievement. Finally, three befriender initiatives aimed at supporting women in vulnerable circumstances. Two of these focused on breast cancer survivors and one on newcomers at risk of social isolation and mental ill-health.
Additional functions
In addition to lack of adequate social connections, almost all initiatives also characterised recipients as lacking the necessary information and/or skills to function well in a new and unfamiliar situation. In some cases, the new situation arose because of a physical move to a new country or social context; in others, it represented a life transition or event. As a result, we identified a commonly intended additional function 2: equipping the individual to function well in a new and/or challenging role or context.
In addition, the importance of supporting recipients to connect with other existing support services, as well as to develop their own social connections beyond the befriender, was often emphasised. Therefore, a further commonly intended additional function 3 was linking the individual to wider social support opportunities and services.
Befrienders (by whom)
There was no consistency in terms of labels employed for the ‘befriender’ nor the nature of the role played. Some roles were paid, but the majority were voluntary. Some were played by individuals who had a professional identity that equipped them for the role. However, most involved individuals acting in a lay capacity. In some cases, the individuals playing these roles were labelled as ‘peers’, suggesting a shared identity and/or common experience between the befriendee and the befriender. Other initiatives involved careful matching processes, without suggesting that the two participants were ‘peers’. In most cases, a period of training and induction for befrienders was included.
What
All but one of the initiatives involved face-to-face contact between the befriendee and the befriender, with some also using telephone, e-mail and text messages. Most of the initiatives were described as being flexible, with the content of meetings and activities being tailored to the needs of the befriendee. However, a small number employed standardised materials as resources to be drawn on by befrienders during encounters, such as the Hispanic Labor Friends Initiative. 100
Where
There was variation in terms of where such face-to-face meetings took place. In some cases, these included private homes, whereas in others only public, community venues were used, and in others the contact was still restricted to institutional settings.
Intensity, frequency, duration
There was variation in terms of the frequency of meetings. In most cases, befrienders were expected to provide a minimum amount of contact with the befriendee over a specified period, but with flexibility on the part of the befriendee to seek support as needed. Some schemes were more structured, such as those in school settings. The duration of schemes varied and, although some had flexible endings dictated by the needs of the befriendee, others had fixed durations. As discussed more in Chapter 6, the nature of endings in befriendee–befriender relationships could be problematic.
Grey literature
A large number of UK examples of befriending interventions for migrant and/or ethnic minority people were identified via the grey literature search. Report Supplementary Material 1 (tables 1–8) provides an overview of these initiatives across the different population subgroups. We identified 26 such initiatives, 17 aimed at older people, all of which demonstrated an explicit focus on reducing social isolation and loneliness. An interesting example was Phonelink, providing befriending to older South Asian people in their preferred language by telephone (see Report Supplementary Material 1, #42). Six befriending initiatives were targeted at people seeking asylum or refugees. In several cases, initiatives were linked to broader projects offering social support groups and other activities, as, for example, the African Francophone Woman’s Support project (see Report Supplementary Material 1, #36) and Wai Yin: Kwan Wai Community Café (see Report Supplementary Material 1, #40).
Shared-identity social support groups
The distinctive intended function 1 of interventions included in this type was identified as providing a safe, authentic, reciprocal social space where people who recognise some kind of shared identity engage with each other with meaning and enjoyment.
From our published (and more detailed grey) literature, a total of 49 interventions were categorised into this intervention type, eight of which were UK based (when papers drew on data relating to more than one support group but did not clearly distinguish between them in the findings, they have been counted as just one intervention each). Diverse labels were employed to describe the interventions, including support group, counselling group, self-help group, support network, (multi)cultural centre and others. Appendix 7 sets out the key components of each of these interventions as described in the papers.
Key components
Recipients (to whom)
These interventions were targeted at individuals who were assumed to be at risk of having inadequate social connections and/or lacking a sense of belonging in their current social context, and, in some cases, at risk of conflictual interpersonal relationships. None of the studies reported that the initiatives employed formal screening to identify recipients in terms of isolation or loneliness.
As discussed more in Chapter 6, the ‘shared identity’ of groups was variously understood, with some groups being much more homogeneous than others in terms of ethnic and national identity. Thirteen interventions were designed to support adult individuals seeking, or recently having been granted, asylum. Two of these targeted individuals identifying as a sexual minority. 101,102 Three interventions focused on pregnant women and new mothers. Four initiatives were aimed at older people. In one case, an initiative in Japan appeared to target internal migrants;103 however, we retained this initiative as its logic is very close to those focused on cross-national migrants. Eight initiatives were aimed at supporting international students, and eight involved ethnic minority students. Nine initiatives were intended to support women in vulnerable or challenging circumstances, including those living with illness, those caregiving and victims of domestic abuse. Finally, four initiatives were open to mixed age and life-stage groups.
Additional functions
Several initiatives were framed in terms of providing support to migrant and/or ethnic minority people in the context of stigmatised identities and a hostile wider environment within which the experience of interpersonal, structural and cultural racism is part and parcel of everyday life. As a result, we identified a commonly intended additional function 2: buffering the external hostile context that denigrates minority ethnic/cultural/religious or migrant identity of the group members. A total of 21 interventions included some elements of this function.
In addition, in common with befriending, these initiatives often recognised recipients as lacking the necessary information and/or skills to function well in a new and unfamiliar situation. Therefore, a further commonly intended additional function 3 was identified as equipping the individual to function well in a new and/or challenging role or context; just nine of the reported interventions appeared not to include elements aimed at this function.
Group facilitators (by whom)
Groups were led or facilitated by a variety of people, including those identified as professionals and laypeople, and those in both paid and voluntary roles. In a few cases, groups were bottom-up initiatives, being organised and led by group members themselves. Across a large number of initiatives, the group leadership was designed to support linguistic and cultural appropriateness for group members.
What
A majority of the initiatives involved individuals who considered themselves to be ‘members’ of the group, meeting face to face at a consistent location and time. However, some initiatives were more fluid and flexible, being shared-identity centres or networks offering diverse activities that people could dip in and out of, such as a cultural centre offering card games and chat for Irish men alongside other activities,104 or an African American Student Center that offered a variety of support activities on a flexible attendance basis. 105 Two groups that were based online, one an e-mail distribution list and the other a private web space, both encouraged offline engagement also. 106,107 Groups varied in terms of how open or closed they were to new members. Although the core of all these initiatives was the reciprocal sharing of experiences, insights and information, this happened in a variety of more or less structured ways. A variety of other complementary activities also took place in these group settings, including sharing of food, arts, dancing and music, structured education and skills sessions, outings, role plays and critical debate. Many also incorporated signposting and 14 initiatives included some element of one-to-one support/input to enable individual issues to be addressed.
Intensity, frequency, duration
Groups commonly involved weekly meetings, although some were less frequent. They varied in terms of their duration, with some being completely open-ended, and others having a fixed duration, often guided by a structured programme, such as an extensive 1-year programme for immigrant women in Sweden and the Netherlands,108 and a 10-week course for minority students in the USA. 109
Grey literature
Twenty-five examples of initiatives that could be considered shared-identity social support groups (SSGs) were found in the grey literature (see Report Supplementary Material 1). Examples were found serving different population subgroups, and these initiatives took varied forms. Examples included an initiative for young Muslim women in Birmingham, which aimed to get the women involved in sport and created inclusive physical spaces for people to come together (see Report Supplementary Material 1, #55); a gardening and cooking club for Bengali women in London (see Report Supplementary Material 1, #60); a music-based group for people seeking asylum in Wakefield (see Report Supplementary Material 1, #3); and a cultural kitchen for people seeking asylum in Plymouth (see Report Supplementary Material 1, #14).
Intercultural encounters
The distinctive intended function 1 of interventions included in this type was to bring together, in meaningful contact across ethnic/cultural/religious differences, people who do not normally interact.
From our published (and more detailed grey) literature search, a total of 35 interventions were categorised into this intervention type, 13 of which were UK based.
Key components
Recipients/participants (to whom)
For 12 initiatives, the main targeted beneficiaries were people seeking asylum or refugees;110–121 of these, four focused on children. In one initiative, the participants were pregnant women and parents (predominantly mothers) of small children. 122 Four involved university students,123–126 two involved children in schools127,128 and five involved children and young people outside educational institutions. 129–133 Eleven were open to people of all ages: one involved all ethnic minority people and 10 involved both minority and majority groups. 72,134–141
In terms of the intercultural nature of initiatives, there was great variation in the mix of migration, ethnic and national identities of the participants involved. Furthermore, although some initiatives were carefully orchestrated, and thereby open only to individuals who met particular identity-related inclusion criteria, others were on offer to broader constituencies, such as anyone living in a certain neighbourhood. Examples of orchestrated initiatives included a US scheme whereby people seeking asylum and refugees who shared a national or ethnic identity were brought together with largely white American students,112,113 and an arts-based project in Denmark that engaged a mixed nationality group of asylum-seeking children and involved majority white adult Danes in teaching roles. 120 Initiatives that were more fluid in terms of participants included intercultural football leagues,111,115,142 neighbourhood ‘improvement and integration’ schemes,121,132,137 and designated community leisure and social spaces. 122,139 Although most initiatives involved some form of contact between migrant and/or ethnic minority individuals and the white majority population, three brought together groups that could all be considered minoritised in their current social context. 126,130,141
Two initiatives were established exclusively for women,117,124 whereas the remainder were open to all genders, although some of the sporting initiatives were dominated by men/boys, and the Children’s Centre primarily involved women. 122
Those initiatives that focused on people seeking asylum, refugees, international students and other newly arrived migrants were commonly framed, at least in part, in terms of a high risk of social isolation. However, none of them reported any kind of screening/targeting. The remaining initiatives tended to be framed in terms of increasing social cohesion and positive relations between ethnic groups, sometimes labelled ‘bridge-building’. 133
Additional functions
Although some initiatives simply brought people together, creating a space where meaningful intercultural encounters were expected to develop organically, others included more deliberate activity. We therefore identified intended function 2: ‘myth-busting’ – actively shifting negative beliefs about ‘others’. Sixteen initiatives included some elements that appeared to be aimed at this function.
In addition, some initiatives recognised recipients (usually the migrant/minority participants) as requiring information and/or skills to enable them to function well in cross-cultural encounters, leading to the identification of hypothesised function 3: equipping the individual to function well in cross-cultural encounters. Sixteen of the initiatives appeared to include elements aimed at this function.
Leaders/facilitators (by whom)
Most initiatives involved one or more individuals playing a facilitating or supporting role; in the majority of cases, these individuals were trained in their role. Facilitators could be professionals or laypeople, paid or unpaid, and several initiatives combined these characteristics in their facilitating ‘teams’. Several of the initiatives provided opportunities for beneficiaries/participants to contribute actively to the endeavour, particularly those that were neighbourhood based and of longer duration.
What
The nature of activities was varied, but four broad types of encounter were more common: arts based,110,114,120,127,132,143 music based,126,128,136 sports based,111,115,130,142 sharing conversation (more or less structured)72,112,113,116–118,122,124,125,133,134,138,140,144 and neighbourhood improvement projects. 121,141 Other formats included an online collaborative game,129 diverse team-based activities over a 4-week programme,131 poster and social media campaigns,118,145 community gardens139 and other community spaces. 137 Several initiatives combined multiple activities, such as neighbourhood improvement with sports or arts activities.
Intensity, frequency, duration
These initiatives varied greatly in terms of their intensity and duration, as well as in terms of how prescriptive or flexible they were in relation to individual exposure/participation.
Grey literature
A total of 33 examples of initiatives that could be considered intercultural encounters were found in the grey literature (see Report Supplementary Material 1). Examples involved diverse population groups and varied activities, such as a theatre-based project involving young people and recently arrived migrants in Coventry (see Report Supplementary Material 1, #1), a music concert linking older people of Bangladeshi and white British ethnic identity in London (see Report Supplementary Material 1, #31), and a schools-based anti-racism and welcome campaign in Scotland (see Report Supplementary Material 1, #52).
Other intervention types
Appendix 8 describes all of the other included interventions, guided by the TiDieR-Lite framework. 95 A brief description of each type is given in the following sections.
Training or equipping focused
Although other interventions, notably SSGs and befriending, could include an element of training or equipping, these interventions were distinctive in their focus on this function: to provide individuals with an opportunity to gain new knowledge and/or skills that have relevance to increasing the quantity and/or quality of their social ties and interactions. Eighteen interventions were identified as being of this type.
Recipients/participants (to whom)
The recipients of these interventions were people seeking asylum and/or refugees (n = 5), pregnant or postpartum women (n = 1), older people (n = 5), university students (n = 4) (three of which focused on international students), children in school (n = 1) and mixed age/life-stages (n = 2).
Leaders/facilitators (by whom)
Diverse facilitators/trainers were involved, professionals and laypeople, paid and unpaid, and, in some cases, employing co-facilitation models.
What
Several initiatives focused on equipping migrant or ethnic minority individuals with the sociocultural skills, as well as contextual information and navigational skills, perceived to be necessary to function well in a new/challenging role or social setting. 146,147 However, others focused on equipping recipients with a narrower set of skills, such as learning to drive148 or improving balance,149 or took an approach focused on health and well-being. 150–152 Some of these initiatives shared some similarities with SSGs in that they adopted an approach of bringing together people who had similar experiences or ethnocultural background, such as a project convening ‘Senior Meetings’ in Sweden. 153 However, these initiatives foregrounded the training element rather than the creation of a shared, reciprocal space. The majority involved face-to-face training in a group setting, but a few used remote, digital media. 146,151,154
Intensity, frequency, duration
Most of these interventions involved a fixed number of sessions and duration because they followed some kind of predetermined curriculum. However, the durations varied considerably.
Psychotherapy
Eleven psychotherapy interventions were identified. The distinctive function of these initiatives in relation to our focus of interest was identified as follows: to provide individuals currently living with (or at high risk of) a common mental disorder with structured therapy to help them better understand and adapt their thinking and behaviours (which may contribute to isolation and loneliness). Eight out of 11 interventions were framed in terms of treating or preventing depression, whereas three had a broader focus on well-being in the context of challenging situations. 155–157
Recipients (to whom)
Seven of these interventions were targeted at pregnant or postpartum women: six in the USA158–163 and one in the UK. 164 One was provided to international students,155 one to African American women aged 30–60 years,165 one to carers of people living with Alzheimer’s disease (who were mainly, although not exclusively, women)156 and one to African American men. 157
Three were delivered in a group setting only,155,164,165 four were delivered via individual one-to-one sessions only,158,160,162,163 and four included both group and individual components156,157,159,161 (although, in the case of Eisdorfer et al. ,156 this meant an individual or family group session with the therapist).
By whom
In all but one case,164 the intervention was delivered by a health-care or social care professional or someone with training in psychotherapy or counselling.
What
All interventions involved face-to-face contact with a therapist, and some also included telephone contact. All followed a structured programme; some were manualised. Three interventions employed a form of interpersonal psychotherapy. 158,160,162 Four described some kind of ‘cognitive–behavioural’ intervention. 155,159,161,164,165 One programme163 incorporated both interpersonal psychotherapy and cognitive–behavioural therapy methods. Elligan157 described an African-centred and spiritually centred psychotherapy focused around racism and the impact of oppression of black men’s lives. Eisdorfer et al. 156 examined an intervention that employed structural ecosystem therapy alongside the provision of technology (a computer–telephone integrated system) that was intended to support communication both with the therapist and with family and friends. 156 Eight of the interventions included explicit design elements aimed at achieving cultural relevance to recipients. Two were explicit in addressing racism as central to the lived experience of recipients. 157,161
Where
Interventions were delivered in diverse settings, but were primarily community based, including recipients’ homes. There was often an emphasis on avoiding stigma, and maximising the comfort and convenience to participants.
Intensity, frequency, duration
These interventions tended to be time-bound, typically involving weekly interactions and lasting up to around 4 months, although some were longer in duration. 156,158
In addition to the 11 psychological therapy interventions, several SSG interventions were described as employing some elements of ‘psychotherapy’, ‘psychoeducation’ or ‘counselling’ as inputs to their training/equipping function. 166–168
Meaningful activity focused
Although meaningful activity was a characteristic of other intervention types, notably SSGs, these interventions were distinctive in their focus on this function alone: to provide an opportunity to undertake activity that has meaning for the individual and the potential to enhance self-worth. Just five initiatives were identified as being of this type, although some of those typed as equipping or training could also be considered meaningful activity, such as tai chi classes. 152
Recipients/participants (to whom)
Recipients were people seeking asylum or refugees (n = 3), and people at any age or life stage group (n = 2).
Leaders/facilitators (by whom)
These activities tended to be loosely structured and user led. The arts-based initiative did involve an artist supporting the participants. 169
Intensity, frequency, duration
The gardening projects tended to be open-ended and of the frequency and intensity determined by the users themselves. The arts-based project was a 20-week initiative.
Volunteering
One volunteering-based intervention was identified for older people, Experience Corps; this is a well-established initiative in the USA that involves placing older people in primary schools to support young children, and attracts a high proportion of African American participants. 174,175 Vickers176 reported on volunteering initiatives for people seeking asylum and refugees in UK. Two initiatives involved opportunities for minority students in the USA to engage in volunteering that showcased their language and culture. 58,177
Volunteering was also an element in some of the SSGs, and the intercultural encounters, particularly those reported in the grey literature.
Light-touch psychological inputs
Interventions of this type expose individuals to brief ‘messaging’ that is intended to alter perceptions and support more positive appraisal of existing social ties and interactions. Five initiatives of this type involved university students60,178–181 and two involved school children. 182,183 All were US based, and a majority of these involved the same group of researchers. In all cases, the focus was on increasing students’ sense of belonging – fitting in and being valued – in their educational institution, with the longer-term goal of supporting retention and academic achievement.
An example is an initiative that involved a 1-hour laboratory-based exercise intended to convey the message that social adversity in school is short-lived, and not attributable to fixed qualities of self or one’s ethnic group. Students were given the results of an ostensible survey of senior students about their experiences of college. They were then asked to write an essay and prepare to deliver a speech to new students that echoed the findings of the survey. The intention was that students would internalise the message and not experience subsequent ‘ambiguous’ social interactions as social setbacks or indicators of their lack of fit. 179
Other (individual)
We also identified a further five initiatives delivered at the individual level that did not fit easily within the eight types already mentioned. One of these was a social prescribing initiative involving referral to varied local programmes or activities and support from a volunteer tailored to individual needs. 184 Another was a US programme in which people living in deprived neighbourhoods were entered into a lottery that, for some, gave them the chance to move to a better-off area, with the potential for opportunities for better housing, education and employment, but uncertain impacts on social connections. 185,186 Strang187 evaluated the Holistic Integration Service for refugees in Scotland, which included a large number of different components, including some directly relevant to social connectedness. Franz188 described an outreach social work initiative that involved engaging first- and second-generation migrant youth in Austria in music and creative activities, with the potential to positively affect social connections and self-worth, and Kipling189 examined the role of citizenship ceremonies on integration and belonging.
Other (community, organisation or structural)
A further nine initiatives were identified that were judged to have relevance to social connectedness, particularly bridging ties and sense of belonging, for migrant and/or ethnic minority groups, but that operated at organisational and partnership levels, seeking to create an enabling environment, or to support delivery by other agencies. Papers that described these initiatives did not include exploration of individual-level processes or outcomes. These papers examined UK Children’s Fund strategies aimed at supporting social network-building among refugee and asylum-seeking children;190 refugee support organisations in Austria;191 a multicomponent organisation in Peterborough, UK, involving both direct service provision to refugees and a base for other community projects;192 a US action research initiative involving older people in shaping physical and social environments;193,194 an approach to social capital development among a US Latino community;195 an active learning pedagogical change initiative in a US university;196 a school-wide model that aimed to enhance prosocial behaviour;197 French local authority policies relating to accommodation of Roma migrants (villages d’insertion);198 and community-based organisations providing settlement services in South Australia. 199
Chapter 5 Intervention logics
Introduction
In this chapter we address the research question: what ‘programme theory’ and assumed underlying mechanisms inform interventions?
The process of developing these programme theories and visual depictions drew on four complementary sources of insight, combined in an iterative fashion:
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grand and mid-range theories, described in Chapter 3
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empirical published papers describing interventions
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insights from CP workshops
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grey literature describing interventions.
Having completed data extraction using EPPI-Reviewer for the first batch of empirical papers, we undertook an initial round of data synthesis, which employed structured templates in Microsoft Word in which we characterised the inputs, functions, strategies and causal chains between these elements and the four proximate determinants and the outcomes of interest (using colour-coding to distinguish hypothesised or demonstrated relationships). Draft generic logic models were developed for the three most common interventional forms that we identified in Chapter 4. These models were discussed and refined during two rounds of CP workshops, as well as via cross-reference to descriptions in the grey literature. They are therefore informed by 170 interventions/initiatives reported in 203 published papers, plus 84 grey literature intervention descriptions.
The resultant models are ‘ideal type’ depictions of the interventional approach that aim to capture the main elements of the intervention and their inter-relationships. Not all examples of each intervention type involved all elements in the models, and the models omit some elements that were present in some interventions. The aim of these models was to provide hypotheses regarding the functioning of interventions that could direct the subsequent analyses, that is to identify potential pathways between functions, strategies and outcomes.
The generic logic models are presented in terms of four main components: (1) the distinctive and additional functions of the intervention (the enabling conditions and opportunities for change that are intended to result from deliberate inputs – highlighted dark purple in Figures 2–4); (2) the intermediate strategies (the cognitive, behavioural and/or environmental changes that are anticipated to happen as a result of achieving the functions – highlighted blue in Figures 2–4); (3) the four proximate determinants by which any impact on loneliness must be achieved (highlighted orange in Figures 2–4); and (4) loneliness (the final outcome of interest, defined broadly as discussed in Chapter 4) (highlighted light purple in Figures 2–4).
As our focus was on typing interventions according to their function, and subsequently articulating the assumed operational processes of the interventions, the logic models do not specify precise inputs (the form of the intervention) that are necessary to achieve the functions. The question of which inputs have been found to be necessary to successfully achieve which functions is examined in Chapter 6 via the empirical data.
A further noteworthy point is that, at the levels of functions and strategies, the models include some ‘clusters’ of elements. The use of these clusters is both pragmatic, enabling a reduction in the number of separate elements depicted in the models, and theoretical, because these elements are presumed to inter-relate very closely so that there may be little analytical purchase in trying to delineate the precise relationships among them. That said, when evidence allows, some attempt to refine these relationships is made in Chapter 6.
To simplify the depiction, unless otherwise indicated, all the arrows in the logic diagrams (see Figures 2–4) represent positive relationships; an increase in the preceding (left-hand) element is hypothesised to lead to an increase in the succeeding element. Therefore, some elements are identified in the negative, for example ‘reduced internalised stigma’.
Befriending
Figure 2 depicts the generic logic model/programme theory for befriending interventions. The distinctive function of this type of intervention was identified as being the provision of a one-to-one relationship of trust that provides tailored emotional support and companionship. This distinctive function is further described in terms of providing an opportunity for the befriendee to engage flexibly according to his/her own needs and preferences; express feelings and share experiences; receive affirmation and encouragement; demonstrate one’s competence and value; and engage in enjoyable, authentic social activities. This function is given the shorthand label ‘one-to-one tailored support’.
Aspects of this distinctive function were suggested by interventions in both the published and grey literature. For instance, Ardal et al. 200 described an initiative for migrant mothers with babies being cared for in an intensive care unit whereby parent buddies were trained in empathic listening skills and were intended to make themselves available for ‘open-ended conversations that flowed from the mother’s needs’. The Tower Hamlets Friends and Neighbours (see Report Supplementary Material 1, #43) scheme for older people was depicted as providing opportunities for befriendees to express feelings and share experiences, and receive affirmation and encouragement, via the co-creation of life-story profiles using reminiscence exercises.
The model shows this distinctive function acting to increase positive social bonds (proximate determinant 1) for the befriendee both directly, through the creation of the befriender–befriendee relationship, and indirectly, via increased trust/sense of security, which, in turn, leads to improved interactions with existing social ties and also new social bonds and interactions. Improvements in interactions with existing ties also results in reduced negative social bonds (proximate determinant 2).
The distinctive function is also shown operating via the normalisation of social challenges and reduced internalised stigma, plus increased self-confidence/empowerment/mastery, both of which, in turn, act to increase self-worth (proximate determinant 3). The potential for normalisation, or social validation, to be a pathway in befriending interventions was suggested by theory relating to peer support as well as empirical papers in which there was deliberate matching of befrienders and befriendees on a particular experiential attribute, as in the case mentioned earlier in which the buddies were women who had themselves gone through the experience of having a baby in intensive care. 200
Additional function 2 for this type of intervention was identified as equipping the befriendee to function well in a new or challenging role or context (often linked to change or transition) (shorthand: ‘equipping for context’). This additional function is further described as providing the opportunity for increased knowledge of relevant systems, norms and processes; development of sociocultural and communication skills; and development of practical, problem-solving and/or coping skills for the current context.
As an example, Darwin et al. 201 described a doula intervention aimed at supporting pregnant women living with human immunodeficiency virus (HIV). Doulas were intended to provide women with information about pregnancy in the context of living with HIV and to help them to prepare for their birth. Similarly, befrienders in the scheme for refugees described by Askins202 were expected to provide befriendees with information and advice about their new home and support English language skills development via informal conversational practice. CP workshop discussions also emphasised the importance of knowledge and skills, particularly related to unfamiliar sociocultural norms, for new migrants as well as for UK-born ethnic minority individuals entering unfamiliar, white-dominated social contexts.
The ‘equipping for context’ function is shown as operating via increased self-confidence/empowerment/mastery, which, in turn, acts to increase self-worth (proximate determinant 3). This additional function is also shown to improve interactions with existing ties, which, in turn, links to both positive social bonds (proximate determinant 1) and reduced negative social bonds/interactions (proximate determinant 2).
In addition, ‘equipping for context’ is shown as acting to increase positive appraisal of existing social bonds/interactions (proximate determinant 4). This causal pathway is suggested by interventions that aimed to equip befriendees with knowledge of relevant norms and cultural meanings, such as Blair’s203 description of community ambassadors who sought to mediate between the expectations regarding family relationships held by elderly South Asian newcomers and their established adult children in the USA, and Weekes et al. ’s98 description of adult tutors providing cultural context and meaning of homework tasks and teacher requests as part of their ‘scaffolding’ support to refugee children.
Finally, additional function 3 for this intervention type was identified as follows: linking the befriendee to other social support opportunities and services (shorthand ‘linking to support’). This additional function is further described as providing the opportunity to receive tangible and practical support, navigation, advocacy and social introductions.
The Canadian host programme204 illustrates this intended function well with its explicit focus on addressing newcomers’ lack of community, professional and social links. Hosts are expected to introduce their clients to people in their social and professional networks and to connect them to other relevant social networking opportunities. Similarly, an intervention involved senior student mentors linking international students to societies, social networks and opportunities for part-time employment. 205
This ‘linking to support’ function is shown as operating via the creation of new social bonds and interactions for the befriendee with both formal and informal sources of support, which, in turn, creates positive social bonds (proximate determinant 1). In addition, this function is shown as increasing trust/sense of security (as it demonstrates the befriender’s responsiveness to the befriendee’s needs), which, in turn, improves interactions with existing ties.
Four potential positive feedback loops are also illustrated in the befriending logic model. First, reversing the notion of a ‘reinforcing loneliness loop’,206 the logic model suggests that, as befriendees increase in confidence and acquire mastery over their new context, they experience improved interactions with existing ties (e.g. international students communicating more easily with host students or faculty members), which, in turn, serves to further increase confidence/self-efficacy/mastery. Similarly, increasing levels of trust and sense of security are shown to lead to improved interactions with existing ties (e.g. women communicating more effectively with health-care professionals caring for them or their baby), which, in turn, supports trust and sense of security. Third, increasing levels of trust and sense of security (which is likely to coincide with decreased stress/worry) is shown to lead to befriendees accessing wider opportunities for social interaction and support, which can in turn act to reinforce feelings of trust and security. Finally, increased confidence/empowerment/mastery is also shown in a potential positive feedback loop with access to new social bonds and interactions, suggesting that a positive reinforcing spiral may ensue as befriendees engage in greater social contact both within and beyond the opportunities introduced via the befriending intervention itself.
Shared-identity social support groups
Figure 3 depicts the generic logic model/programme theory for SSG interventions. The distinctive function of this type of intervention was identified as follows: providing a safe, authentic, reciprocal social space where people who recognise some kind of shared identity engage with each other with meaning and enjoyment (shorthand ‘safe, reciprocal space’). This distinctive function is further described in terms of providing an opportunity for group members to make new friendships; share feelings and experiences (listen and be heard); give and receive affirmation and encouragement; give and receive information and advice; demonstrate one’s competence and value; engage in enjoyable, authentic social activity; and engage in activity that has meaning or purpose to them. Some aspects of this function overlap with those of befriending, but it is the creation of a group setting in which reciprocal exchange of emotional and informational support can occur that is distinctive.
Aspects of this distinctive function were suggested by interventions in the published and grey literature, as well as in theoretical literature on social support and group work. For instance, a group established to support black American students in predominantly white universities drew on Yalom’s207 key characteristics of effective support groups, including cohesion (bonds of caring and connectedness), catharsis (emotional release) and interpersonal learning (members learning from each other in the social microcosm of the group). 208–210 In a contrasting example, a professional- and peer-led group for older people in the USA clearly aimed at generating this kind of reciprocal and affirming space by focusing on peer interaction and enhancing a ‘sense of mastery’ among participants. 211
It has been suggested that group-based interventions may be superior to one-to-one input for individuals lacking social support across diverse contexts. For instance, Dipeolu et al. ,167 discussing international students, stated that:
. . . group support offers advantages over individual counseling because groups can instil hope, modify feelings of being alone, impart information, assist students to feel needed and useful, help them to develop socializing techniques, promote interpersonal learning, and provide a sense of community and group cohesion.
Dipeolu et al. 167
The model shows this ‘safe reciprocal space’ function acting to increase positive social bonds (proximate determinant 1) for group members both directly, through the creation of new friendships in the group (1a), and indirectly, via increased trust/sense of security (1b), which, in turn, leads to improved interactions with existing social ties and also access to new social bonds and interactions. Improvements in interactions with existing ties also results in reduced negative social ties and interactions (proximate determinant 2). A further causal chain is shown operating via normalisation/reduced internalised stigma/positive ethnocultural identity (1c). This hypothesised relationship was articulated well by a staff member involved in developing a group for people seeking asylum having run one-to-one counselling for some time:
So, we knew at that point that there was a need for people to meet together and learn more about their community, to share common experiences. Because they tend to feel alone; that they are experiencing what they are experiencing on their own, not realising that other people in their very immediate environment are going through very similar issues. So this project was born out of that.
Active Communities programme, People’s Health Trust. 212
The ‘safe, reciprocal space’ function is also hypothesised to increase self-confidence/mastery/coping behaviours (1d), particularly as a result of the reciprocal exchange of information and advice, and to directly affect the positive appraisal of existing ties (proximate determinant 4) (1e), as a result of the reciprocal exchange and reflection on social relationship experiences within the group.
Additional function 2 for this type of intervention was identified as buffering the external hostile context that denigrates minority ethnic/cultural/religious or migrant identity of the group members (shorthand: ‘buffering hostility’). This additional function is further described as providing the opportunity to understand racism and the impact that it has, receive validation, develop navigation and resiliency skills, and encounter positive co-ethnic role models. The inclusion of this function is particularly informed by the empirical literature on under-represented students’ experiences in predominantly white institutions in the USA, as well as the literature on structural and cultural racism. 213 The logic model depicts this function as acting via both normalisation/reduced internalised stigma/positive ethnocultural identity (3a) and increased sense of trust/reduced stress (3b), to subsequently affect proximate determinants 1, 2 and 3.
Finally, additional function 3 for this intervention type was identified as equipping the group members to function well in a new or challenging role or context (often linked to change or transition) (shorthand: ‘equipping for context’). This additional function mirrors function 2 of the befriending type, and is further described as providing the opportunity for increased knowledge of relevant systems, norms and processes; development of sociocultural and communication skills; development of practical, problem-solving and/or coping skills for the current context; and knowledge of local context and resources. ‘Equipping for context’ is shown as operating via increased self-confidence/empowerment/mastery, which, in turn, acts to increase self-worth (proximate determinant 3). This function is also shown to improve interactions with existing ties, which, in turn, links to both positive social ties (proximate determinant 1) and reduced negative social ties/interactions (proximate determinant 2). In addition, function 3 (‘equipping for context’) is hypothesised as acting to increase positive appraisal of existing social ties/interactions (proximate determinant 4). This causal pathway is informed by acculturation theory76 and suggested by interventions that aimed to equip group members with knowledge of relevant norms and cultural meanings, such as groups established for African refugees in Canada that included sessions designed to improve understanding and adjustment to familial roles and relationships in the new cultural context. 63,214–216 Finally, ‘equipping for context’ may increase access to wider existing opportunities for social interaction and support via the provision of relevant information.
The same four potential feedback loops represented in the befriending model were also identified in the SSG model.
Intercultural encounters
Figure 4 depicts the generic logic model/programme theory for intercultural encounters. This model is more tentative than for the previous two intervention types, reflecting the fact that fewer initiatives were directly concerned with the review outcomes of interest, and that related theory has not tended to include a focus on individual-level loneliness. The interventional logic is also complicated by the fact that, although our primary interest is in the proximate determinants and outcomes for migrant/minority individuals, the changes that interventions aim to achieve relate to the cognition and behaviours of ‘out-group’ (particularly majority ethnicity) members also. For simplicity, the model does not distinguish participant identities, but rather presents all changes as potentially occurring to all participants. We note below where some pathways are more relevant to migrant/minority participants.
The distinctive function of this type of intervention was identified as being to bring together, in meaningful contact across ethnic/cultural/religious differences, people who do not normally interact (shorthand: ‘meaningful interethnic contact’). This distinctive function is further described in terms of providing an opportunity to share stories and experiences (listen and be heard), demonstrate competence and value, engage in purposeful activity and engage in enjoyable social activity. The articulation of this function is informed by contact theory91 and more recent empirical literature on meaningful encounters. 93,130 The importance of creating encounters to which individuals that are routinely reminded of their deficit status can contribute, and in which their cultural heritage and knowledge is valued, was emphasised in the logic of several initiatives. 112,113,117 The need for encounters to be ‘meaningful’, rather than fleeting and insignificant, to achieve interpersonal connection, as well as destabilise dominant, negative narratives about the ‘other’, was also a common theme. 137,142
Additional function 2: ‘myth-busting’ – actively shifting negative beliefs about ‘others’ (shorthand: ‘myth-busting’); this was identified as providing the opportunity to gain knowledge of other cultures and religions, to appreciate other people’s circumstances and to understand racism and its impacts. For example, a UK project for women117 was described as teaching British women about migrant women’s lives, their cultures, religions and migration experiences, and promoting understanding and empathy.
Additional function 3 was identified as follows: equipping individuals to function well in cross-cultural encounters (shorthand: ‘equipping for contact’), via providing the opportunity to increase knowledge of systems, norms, and processes; develop social and communication skills; and gain knowledge of the local context.
The logic model shows distinctive function 1, ‘meaningful interethnic contact’, acting to increase ‘other-group orientation’/recognition of commonalities/respect and acceptance of difference (1a). These changes are hypothesised to occur in all participants of the intercultural encounter, not just those of migrant or ethnic minority identity (indeed, it may be changes to majority participants that have the biggest potential to affect positively social interactions within and beyond the group). Further pathways of effect are illustrated via increased sense of security/trust and/or reduced stress and worry (again, relevant to all participants) (1b), more positive ethnocultural identity/normalisation/reduced stigma (relevant to minoritised participants) (1c) and increased self-confidence/mastery/coping (relevant to all, but particularly minoritised, participants) (1d). Finally, ‘meaningful interethnic contact’ is shown as leading to changes in proximate determinant 4 (1e), as intercultural exposure may potentially lead directly to individuals adjusting their interpretation of social interactions with ‘others’ without the volume or objective nature of such interactions being affected. As an example, CP members talked about having to adjust to the British habit of asking ‘how are you?’ without really wanting to hear the honest answer, which they had initially found to be very rude and upsetting.
Function 2, ‘myth-busting’, is shown as affecting ‘other-group orientation’ (2a) and sense of security/trust (2b), whereas function 3, ‘equipping for contact’, is shown to affect self-confidence/mastery (3a) and sense of security/trust (3b).
The logic model depicts the intermediate changes, which are affected by one or more of the intervention functions, as affecting collectively in a positive way encounters within the initiative, interactions with existing ties beyond the initiative (e.g. family members, colleagues or neighbours) and also access to new, wider opportunities for social interaction beyond the initiative.
These three sets of changes in social interactions are then shown as affecting proximate determinants 1 and 2 (pathways 6 and 7).
Pathways 4 and 5 in the model also indicate that improvements in positive ethnocultural identity and/or in self-confidence/mastery can have an impact on self-worth (proximate determinant 3), independent of any changes in patterns of social interaction.
Importantly, the model also represents ‘spillover effects’ via pathway 8. Intercultural encounter interventions are hypothesised to have positive effects on the attitudes and behaviours of non-participants in the local area or organisation in which the initiative is operating, or in the wider social networks of participants. Effects may occur because the initiative itself is visible to others, and thereby demonstrates positive intercultural encounters, and/or via the role modelling or direct advocacy of participants beyond the initiative. The model shows increased ‘neighbourliness’/’connectedness’ resulting from this spillover. In turn, this is shown to reduce negative social ties and interactions and to increase positive ties and interactions for minoritised individuals.
Other interventions: hypothesised causal chains
The logic embedded in some of the other interventional types identified in Chapter 4 included both some of the same hypothesised causal chains in the three generic models presented above and some additional potential causal chains that warrant consideration.
Training or equipping focused
As noted in Chapter 4, several of these initiatives focused on equipping migrant or ethnic minority individuals with the sociocultural skills, as well as contextual information and navigational skills, perceived to be necessary to function well in a new/challenging role or social setting. 146,147 As a result, the logic of these initiatives mirrors the ‘equipping for context’ function found in befriending (function 2) and in SSGs (function 3). In a few cases, these interventions focused on equipping recipients with a narrower set of skills, such as learning to drive148 or improving balance,217 or took an approach focused more on health and well-being. 150,151 Nevertheless, in relation to our focus of interest, the logic of these initiatives can be depicted using the same causal chains. Those interventions that utilised a group-based format, either alone or in combination with individual elements, could also be represented as directly creating the opportunity for recipients to form new social ties with other group members (although this was not the primary function and was not always made explicit).
Psychotherapy
Interpersonal psychotherapy158,160,162 was described as aiming to improve an individual’s ability to cope with, adapt to and improve his/her social environment. This type of therapy has a problem-solving focus and addresses the ways in which individuals communicate their attachment needs to others, thereby aiming to facilitate the development of more supportive relationships. 160 ‘Cognitive–behavioural’ interventions155,159,161,164,165 similarly aim to enhance recipients’ awareness of social interactions, and improve social and communication skills. Jesse et al. 159 noted that:
[W]hile a CBI [cognitive–behavioural intervention] cannot compensate for lack of partner or other support in women’s lives, the women can use skill-building activities to help build a healthier support network, to communicate better with existing support persons, and to learn to ask for what they need/want.
Jesse et al. 159
An African-centred and spiritually centred psychotherapy group for black men similarly focused on understanding and improving social relationships within and beyond the family. 157 In an intervention for carers of people living with Alzheimer’s disease,156 structural ecosystem therapy was described as building up family relationships and assets, and restructuring specific interactions within the family, and between the family and other systems, that may contribute to caregiver burden.
The key causal chains hypothesised for most of these interventions operated via ‘improved interactions with existing ties’ to affect proximate determinant 2, that is to reduce negative ties and interactions. These initiatives were also expected to increase access to new social ties, and thereby operate on loneliness via proximate determinant 1. Intermediate changes that were hypothesised included reduced stress/increased trust and increased self-confidence/mastery.
Those interventions that utilised a group-based format, either alone155,164,165 or in combination with individual elements,156,157,159,161 could also be depicted as intending to directly create the opportunity for recipients to form supportive social ties with other group members (i.e. pathway 1a on the befriending and SSG models).
Meaningful activity-focused
In common with intervention types mentioned above, meaningful activity initiatives that were communal in nature (e.g. community gardens170) could be hypothesised as acting partly via the creation of positive social ties and interactions. However, this type of initiative was distinctive in that its core focus was on the individual engaging in an activity, through choice, that provides a sense of purpose and fulfilment, and often an opportunity to develop mastery and self-confidence. In addition, such activities may result in reduced rumination. These activities are hypothesised as acting on loneliness primarily via increased self-worth and via more positive appraisal of existing social ties and interactions.
Although not represented in our published papers, acts of religious observance, such as prayer, meditation and fasting, were identified by CP members as a further type of meaningful activity that can be supported by interventions, or indeed undermined, and are hypothesised as affecting loneliness via self-worth and an experienced positive connection to God.
Volunteering
The main hypothesised causal chains associated with volunteering relate to the provision of an opportunity for the individual to ‘give back’ and, in so doing, to demonstrate both competence and value, and to gain self-confidence. Increased self-worth is anticipated to result from this. Because volunteering will also often involve direct social interactions, as in the case of older people working in teams to support young school children,174 there is also the potential for a direct increase in positive social ties.
Light-touch psychological inputs
Interventions of this type are unusual in that they include no inputs that are intended to alter the number or quality of a recipient’s social ties and interactions (at least not in the short term). Instead, they are intended to operate via adjustment of the recipient’s cognition so that they develop a more positive appraisal of existing social ties and interactions (proximate determinant 4), and greater self-worth (proximate determinant 3), which then results in an increased sense of belonging. The primary assumed causal chain is via the normalisation of social challenges and/or reduction in internalised stigma.
Chapter 6 Intervention effects and outcomes
Introduction
This chapter addresses the following research questions:
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How effective are interventions at reducing social isolation and/or loneliness when compared with a usual or no intervention?
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Do effects of interventions vary for different people (e.g. by gender, age, income)?
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What negative effects have resulted from interventions?
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What health outcomes have been examined in relation to these interventions?
Rather than focusing solely on the outcome measures of interest, we also examined the evidence available in support, or refutation, of the various causal pathways postulated in the logic models presented in Chapter 5. The aim was to increase understanding, not simply of whether or not interventions are effective, but the routes by which they achieve their outcomes. Notwithstanding the complex, and multidirectional, causal chains that are likely to operate in practice, the logic models essentially depict four generic causal relationships that were used to guide the synthesis of available evidence (see Figures 2–4):
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A: inputs (nature and quantity of resources provided) → B: functions.
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B: functions (enabling conditions and opportunities for change) → C: strategies.
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C: strategies (resultant shifts in cognition, behaviours and/or environmental conditions) → D: proximate determinants.
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D: proximate determinants → E: outcomes.
In addition, in both the befriending and SSG logic models, the distinctive function 1 is depicted as leading directly to increased positive social ties and interactions, as they directly create new social relationships (B→D).
For this stage of the analysis, we included the subgroup of 124 intervention papers that were identified as ‘evaluative’ and that provided qualitative or quantitative evidence relating to the processes and outcomes as experienced by the recipients of, or participants in, the initiatives. When information about an intervention’s causal processes and outcomes was available solely through the eyes of those delivering it, we excluded these papers from the analysis presented in this chapter (although relevant information from these papers contributed to the analyses presented in Chapters 4, 5, 7 and 8).
We drew on the structured templates already described in Chapter 5, focusing here on the extracted evidence relating to the processes that actually ensued in practice (rather than all those that might have been intended). For each intervention type, we considered the evidence in support of each of the casual chains (referring to the labels on the diagrams to indicate the part of the model being examined). We also looked for evidence of feedback loops. We then synthesised the evidence relating to effects on each of the proximate determinants, and the final outcomes of interest.
Next we considered the evidence available in relation to the inputs required to achieve the identified functions. The level of detail provided on interventional content and causal pathways was very varied across the papers, making it difficult to characterise inputs and processes in several cases.
In the following sections, we provide a synthesis of the main findings with selective supporting material, first for befriending, then for SSGs and finally for intercultural encounters. We then incorporate qualitative evidence from the broader set of interventions relating to common causal pathways, as well as some additional pathways that are not represented in the three common initiatives, but that warrant consideration.
We then develop generic hypotheses relating to the effectiveness of initiatives in relation to final outcomes, and use these to examine the complete set of quantitative evaluations that were available.
Befriending
The analysis in this section is based on 19 separate interventions, reported in 24 papers. Table 7 presents a summary of the evidence for the various relationships hypothesised in the befriending logic model, and Appendix 9 provides more detail for each intervention.
Initial causal pathways | Qualitative studies (n) | Quantitative studies (n) | ||
---|---|---|---|---|
Supporting | Refuting | Supporting | Refuting | |
Function 1: one-to-one tailored support | ||||
(1a) Function 1 → positive social tie | 10 | 0 | 0 | 0 |
(1b) Function 1 → increased security/trust/reduced worry | 10 | 0 | 0 | 0 |
(1c) Function 1 → normalisation of challenges/reduced internalised stigma | 3 | 0 | 0 | 0 |
(1d) Function 1 → self-confidence/mastery/coping behaviours | 2 | 0 | 0 | 0 |
Function 2: equipping for context | ||||
(2a) Function 2 → self-confidence/mastery/coping behaviours | 9 | 0 | 1 | 0 |
(2b) Function 2 → increased security/trust/reduced worry | 7 | 0 | 1 | 0 |
(2c) Function 2 → positive appraisal of existing ties | 0 | 0 | 0 | 0 |
Function 3: linking to support | ||||
(3a) Function 3 → access to wider opportunities for social support and interaction | 8 | 0 | 0 | 0 |
Proximate determinants | ||||
Increased positive social ties and interactions | 11 | 0 | 1 | 0 |
Increased positive social ties and interactions, aside from the befriender | 4 | 4 | 0 | 3 |
Decreased negative ties and interactions | 8 | 0 | 0 | 0 |
Increased self-worth | 10 | 0 | 1 | 1 |
Increased positive appraisal of existing ties and interactions | 0 | 0 | 0 | 0 |
Outcomes: improvements in loneliness, isolation, belonging and/or feeling supported | 9 | 0 | 3 | 4 |
Distinctive function 1: one-to-one tailored support
Our generic logic model identifies the distinctive function of befriending interventions as ‘provision of a one-to-one relationship of trust that provides tailored emotional support and companionship to the befriendee’. The assumption is that, if such a relationship is established, there is a direct improvement in the befriendee’s level of positive social ties and interactions (proximate determinant 1) via pathway 1a.
Pathway 1a: what evidence is there that befriender interventions directly result in recognition of the befriendee–befriender relationship as a positive social tie on the part of the befriendee?
Qualitative evidence documented that 10 of the interventions96,97,99,100,200–202,204,205,218–220 achieved a positive social tie between the befriender and befriendee for a majority of recipients, and a further two studies221,222 provided some evidence for this effect for some recipients. For the remaining interventions, no data were presented in the studies to demonstrate whether or not this social tie was achieved. When achieved, the positive social tie was commonly described by recipients in terms of ‘friendship’ or ‘family’.
The generic logic model further described function 1 in terms of providing the opportunity to engage flexibly according to the befriendee’s own needs and preferences, express feelings and share experiences, receive affirmation and encouragement, demonstrate competence/value and engage in enjoyable social activities. Several of the qualitative papers provided evidence in support of some of these elements as contributing to the achievement of pathway 1a. No papers included any quantitative analysis of the relationships between these elements and the nature of the social tie established.
‘Being heard’, namely having a befriender who listens actively and creates a non-judgemental space in which the befriendee feels able to express their emotions openly, was demonstrated via qualitative data as an important element that results in a positive social tie in nine interventions,96,99,200–202,204,205,218,219 as was the importance of a personalised, responsive, reliable and flexible offer of support. Providing affirmation and encouragement was a further dimension of befriender interventions that was consistently identified as important to the building of a relationship experienced as positive and supportive. 96,99,200–202,204,205,218,219 Two evaluations202,218 identified the way in which giving practical support and help to deal with day-to-day issues and material hardship (e.g. second-hand baby clothes; shopping and cooking) could also be interpreted by beneficiaries as affirmative and encouraging. Having the opportunity to demonstrate competence and/or value was not explicitly evidenced in any of the 19 interventions as instrumental to achieving a close social tie between befriender and befriendee, although no contrary evidence was reported either. Engaging in social activities with the befriender was mentioned as an element of several interventions, but only explicitly implicated in pathway 1a in two studies. 205,219 This finding may reflect the fact that those papers providing more detailed evidence were often focused on people in particularly challenging circumstances (e.g. women caring for preterm babies) for whom socialising (and social belonging) was likely to be a lower priority need at the time than intimacy and emotional support. It was also difficult to disentangle paired activity with the befriender from activities aimed at linking the befriendee to other networks of social support and services (function 3).
Pathway 1b: what evidence is there that achievement of one-to-one tailored support leads to an increased sense of security/trust and/or reduced stress or worry?
There was consistent qualitative evidence (from 10 studies) that the achievement of function 1 leads to an increased sense of security/trust and reduced stress or worry among befriendees. 96,99,100,200–202,204,205,218,219 There was no quantitative exploration of these relationships (see below for information on depression/anxiety outcomes). As with pathway 1a, the key elements of function 1 that were demonstrated as contributing to an increased sense of security/trust and reduced worry were ‘being heard’, being able to engage flexibly according to one’s own needs and receiving affirmation and encouragement.
Pathway 1c: what evidence is there that achievement of one-to-one tailored support leads to normalisation of social challenges and reduced internalised stigma?
Three studies explicitly identified this pathway. 96,200,218 All of these interventions involved befriender–befriendee pairs that were matched on shared experiential identity. Again, the elements that were found to be important were ‘being heard’, being able to engage flexibly according to one’s own needs and receiving affirmation and encouragement.
Pathway 1d: what evidence is there that achievement of one-to-one tailored support leads to increased self-confidence/mastery/coping behaviours?
There was some evidence in two papers200,201 that achievement of function 1 could, in itself, lead to increased confidence and self-efficacy. However, because all the initiatives that demonstrated such one-to-one tailored support also involved some elements of function 2 (‘equipping for context’) (which were clearly important in increasing self-confidence/mastery; see below), it was difficult to disentangle the effects of these two elements.
Additional function 2: equipping for context
Our generic logic model identifies ‘equipping the befriendee to function well in a new or challenging role or context (often linked to change or transition)’ as additional function 2 of befriending initiatives. This function was further described as providing the opportunity for beneficiaries to increase knowledge of relevant systems, norms, and processes; develop social and communication skills; and also develop practical, problem-solving and coping skills. All of the evaluative studies included here described befriender interventions that included some element of this function.
Pathway 2a: what evidence is there that achievement of equipping for context leads to increased self-confidence, and/or mastery and coping behaviours?
Eight studies96,98,99,200–202,204,205,218,219 provided qualitative evidence that the provision of opportunities to develop knowledge and skills relevant to their new role or environment, such as caring for a new child or negotiating college life, led to increased self-confidence, feelings of empowerment, mastery and/or coping skills. One study provided some quantitative data in support of this pathway. 219
Pathway 2b: what evidence is there that achievement of equipping for context leads to an increased sense of security/trust and/or reduced stress or worry?
The provision of contextually relevant information, particularly the interpretation of unfamiliar norms and practices, was identified as important in building trust and reducing fear and stress in seven qualitative evaluations. 99,100,200,201,204,205,218,219 One study provided some quantitative data in support of this pathway. 219
Pathway 2c: what evidence is there that achievement of equipping for context leads to more positive appraisal of existing ties?
No evidence in support, or refutation, of this causal pathway was found in the set of included studies.
Additional function 3: linking to support
Our generic logic model identifies an additional function 3 of befriender interventions as ‘linking the befriendee to other social support opportunities and services’. This function was further described as potentially providing the opportunity for beneficiaries to receive tangible support (e.g. transport), advocacy, navigation and direct social introductions. Ten of the evaluative studies included here described befriender interventions that included some element of this function.
Pathway 3a: what evidence is there that achievement of linking to support leads to access to wider opportunities for social support and interactions?
Eight studies96,99,100,202,204,205,218,219 provided qualitative evidence in support of this pathway. Importantly, the relevance of linking befriendees to both informal and formal sources of support was indicated across several of these studies. Three studies96,99,218 also demonstrated the advocacy and linking role that befrienders can play in supporting people to access other services.
Feedback loops
The logic model identifies four potential positive feedback loops (see Figure 2). Although none of the studies reviewed focused on these relationships in any detail, some evidence in support of some loops was found. For example, McLeish and Redshaw’s96 findings described the way in which some peer supporters introduced groups of mothers to each other and suggested that this could contribute to a virtuous circle of increasing confidence and social connectedness (feedback loops 1 and 4). Similarly, Askins202 described how, over time, some befriendees became more confident and able to engage in new connections, which, in turn, led to greater confidence and firmer relationships, so that they became ‘progressively more involved.’ 202
Second-order causal links and proximate determinants
The logic model suggests that, as self-confidence/empowerment/mastery increases, this should lead to befriendees accessing wider opportunities for social support and interaction (pathway 4), as well as improved interactions with existing ties (pathway 5). Similarly, the logic model suggests that increased trust and reduced worry/stress should also lead to befriendees accessing wider opportunities for social support and interaction (pathway 6), as well as improved interactions with existing ties (pathway 7). We found some qualitative evidence in support of these pathways, but it was often difficult to disentangle pathways, as increased confidence/mastery was often presented as interplaying with increased trust and reduced worry in these qualitative studies. For instance, McLeish and Reshaw96 concluded that befriending schemes often had ‘substantial and interlocking positive impacts on emotional wellbeing’. 96 Improved interactions with family ties was identified as an important intermediate effect of several initiatives:99,200,201,218
By talking things over with my family support worker it has been a lot of help to us all. Before, he was beating me and my kids had physical abuse . . . But the worker talked to him . . . and he thinks it has helped. He used to call her his sister.
Gray99
Evidence from Askins202 suggests that, for some individuals who are seeking asylum, developing trust is a long-term process and persistent mistrust can impede the development of new social ties. These findings suggest that equipping such newcomers with the knowledge and skills to operate in their new home is not sufficient to lead to the development of new close social ties, nor necessarily improved interactions with existing ties, thereby demonstrating that these pathways are distinct.
Increased positive social ties
All 19 befriending interventions included in this stage of the analysis clearly intended to increase the positive social ties and interactions experienced by the beneficiaries. Eleven studies96,98–100,200–202,204,205,218,219 provided qualitative data that suggested that the interventions were successful in achieving this goal. One study204 also provided quantitative follow-up survey data that indicated that the scheme was successful in this way for a large proportion of beneficiaries.
An important consideration is whether or not the initiatives were able to achieve an increase in positive social ties and interactions aside from the immediate befriender–befriendee relationship. As noted above, function 3, ‘linking to support’, was clearly intended in a large number of the initiatives, but it is important to remember that the creation of additional ties and interactions will not necessarily be perceived as positive by the beneficiary; it is the quality of such ties and interactions that is crucial. For example, in a study223 focused on the Lifestyle Engagement Activity Program (LEAP) for older people in the USA, there was evidence of increased social participation, but it was unclear whether or not this constituted positive social interactions, as perceived by the beneficiaries. Four studies202,204,205,219 provided qualitative data that suggested that the interventions were indeed generally successful in this regard. The picture appeared to be more variable in the group of papers relating to interventions for pregnant women and new mothers and families, with such broader ties being achieved by some, but not all, beneficiaries. 96,99,201,218 Two studies221,224 reported quantitative data that suggested that the initiative had no effect on this proximate determinant, and one study225 reported a negative effect, which was difficult to interpret. The remaining papers presented no relevant data, despite this being an apparent objective.
Fewer negative ties and interactions
Nine initiatives66,99,100,200,201,204,205,219,222 had the objective of reducing the number of negative ties and interactions experienced by beneficiaries; for all except one66 of these, there was some evidence of success in this regard. These negative ties and interactions could relate to family and friends (e.g. three studies99,100,201 reported that befrienders worked to support women to improve their relationships with their partners). The negative experiences could also relate to ties and interactions with professionals in positions of power, such as health-care professionals100 or teachers. 99,222 Only one study99 included some suggestion of befrienders supporting clients to deal with more overt interpersonal racism and discrimination. Action aimed at changing such negative interactions was beyond the scope of most befriending interventions.
Increased self-worth
Fourteen of the 19 initiatives identified improving self-worth as an objective. Ten of these demonstrated success in achieving increased self-worth via qualitative data, and one226 demonstrated an increase quantitatively (although for boys only). Among the qualitative studies there was consistent evidence that befriendees experienced the schemes as a positive boost to their feelings of being valued, via pathways 8, 9 and 10, as indicated on the logic model and illustrated in the data presented in Distinctive function 1: one-to-one tailored support. In addition, there was also consistent evidence to suggest that the positive tie and interactions with the befriender in and of themselves were factors in increasing the self-worth of befriendees in many cases. This direct pathway was not included in our generic befriending logic model. In contrast, there was a decrease in self-worth (measured quantitatively by Rosenberg Self-Esteem Scale227) among participants in the New Mothers Network intervention, which involved online mentoring by professional nurses (and did not appear to achieve the distinctive function of befriending in practice). 228
Increased positive appraisal of existing ties and interactions
There was no direct evidence provided by this set of intervention papers to support or refute changes to this proximate determinant.
Outcomes
Nine qualitative evaluations demonstrated reduced feelings of isolation or loneliness, and/or increased feelings of belonging, or of being supported, among a majority of befriendees in receipt of the interventions. However, all involved data collection during, or soon after, the end of the intervention period, so that they provide no evidence relating to longer-term impacts on the review outcomes of interest.
Three quantitative studies reported some kind of positive effect on a relevant outcome. Two evaluations of adult mentor programmes in schools reported an increased sense of belonging to school among children. 222,226 There was an increase in feeling supported among women in receipt of a Promotoras intervention. 229
Four quantitative studies found no effect on review outcomes of interest. Two of these224,228 reported no difference among the recipients in measures of feeling supported. One228 of these also reported no effect on loneliness [using the University of California, Los Angeles (UCLA) Loneliness Scale57]. Low et al. 223 reported no effect on loneliness (using the UCLA Loneliness Scale57) of an intervention among elderly recipients and Quintrell and Westwood221 found no difference in the proportion of international students who described their first year at university as ‘lonely’ between those who had and those who had not been part of a host support programme. Importantly, none of these studies demonstrated pathway 1a, suggesting that they failed to achieve the distinctive function of befriending, namely one-to-one tailored support. We return to these quantitative studies later when we consider some generic hypotheses about likely effectiveness.
Differential processes and outcomes
Few of the studies reported on differential outcomes or considered intersectionality. There was evidence of a gender difference in the intervention’s impact on self-worth in one of the school-based initiatives, with only boys benefiting. 226 However, a majority of the befriender initiatives reviewed were targeted at women only.
Achieving functions: what inputs are important?
Identity of befriender
Our logic model did not include any specific requirement in relation to the identity of the befriender, and evidence from the included studies paints a complex picture.
Findings reported by four studies99,100,200,219 suggested that shared language and ethnic identity between befriender and befriendee were important in the achievement of function 1 (one-to-one tailored support). Five qualitative evaluations96,200,205,218,219 suggested that a sense of shared identity based on having experienced common challenging experiences (e.g. being a mother to a preterm infant, living with HIV, forced migration, being a new university student) can also be important in developing an open and trusting relationship between befriender and befriendee. Shared experiential identity may be a requirement for normalising social challenges faced by the befriendee, and may also be influential in terms of function 2 (equipping for context).
However, although these common identifiers were found to be important in some situations, there was also evidence that all three functions could be achieved across difference, whereby befriender and befriendee do not obviously share ethnic or national identity nor a common challenging experience. 96,202,204 Indeed, befrienders from outside a befriendee’s ethnic or national community could be seen as having more authoritative knowledge, being better connected and being more trustworthy and beyond gossip. 96,97,202
Findings were also inconsistent in relation to a ‘lay’ versus ‘professional’ identity of the befriender. Although befrienders were often highly praised, and compared favourably with professionals, it seems that this relates more to the narrow focus and boundaries of professional roles than to having a professional identity per se.
Almost all the studies evaluated voluntary schemes, and there was little evidence relating to how paid versus voluntary roles influenced the processes or outcomes of the interventions. McLeish and Redshaw218 noted potential pros and cons.
These findings, as a whole, tend to suggest that the attitudes, attributes and behaviours of befrienders are more important than any inherent social identities (while recognising that the importance of enabling befriendees to communicate freely may necessitate matching on a language other than the majority language).
Recruitment, training and support
Appendix 7 briefly describes the processes of recruitment, training and support that were reported in the studies. A majority of studies reported that befrienders went through a process of selection, induction and training, and that befrienders and befriendees were matched on some criteria. However, details were often absent. There were insufficient data to examine relationships between recruitment processes, duration, nature or content of training, patterns of support or matching processes, and the achievement of functions.
Content and boundaries of the interactions
Although the central element of all these initiatives involved one-to-one (usually face-to-face) befriendee-focused conversation, initiatives did vary quite considerably in terms of the nature and content of befriender–befriendee interactions, even in schemes that were ostensibly meeting the needs of similar clients (e.g. those supporting pregnant and postpartum women). So, although some interactions were time-bound and always took place in the same location, others were much more flexible and involved multiple locations, and even outings together. In some cases, the flexibility of interactions appeared to contribute to achieving one-to-one tailored support,96,218 but it was not essential. Interactions that involved trips out and about in the local area also seemed to be useful in increasing befriendee confidence and equipping them with knowledge about local resources and opportunities for subsequent social interactions. 201,202 Only one initiative explicitly identified inputs aimed at addressing material hardship: family support workers in Gray’s99 study supported families to maximise their income and manage their household finances; this input could be considered an aspect of function 2 (equipping for context), and was found to be important in reducing stress and family discord.
Timing, frequency and duration
The importance of having access to a befriender soon after the experience of a challenging transition was highlighted in a few studies. For instance, Menzies et al. 205 reported that provision of a mentor to students within the first month of arrival was important, and, in some cases, women who received their befriender match late in pregnancy did not develop such a close, trusting relationship. 96,97 However, it seems that timing is less crucial for some potential clients, and getting a good match may be more important. 202,204
Befriender schemes varied in terms of the intensity of contact that was expected as a minimum. However, aside from the two mentoring schemes that took place in schools, most adopted a very flexible, client-led approach with befrienders being able to seek contact as and when they needed it, often using telephone, text or e-mail, and this was felt to be instrumental in achieving function 1 (one-to-one tailored support). McLeish and Redshaw96,97 suggested that those schemes with stricter rules regarding frequency of contact might not achieve the closeness of relationship as readily as those that are more flexible.
Although befriender programmes varied in terms of whether or not they had a fixed duration, several studies reported the importance of flexible endings. 201,202 In several cases, function 3 (linking to support) was explicitly intended as a way of promoting the transition from one-to-one support to other sustainable connections with groups and activities.
Befriending: negative effects
Two types of potential negative effects were identified by a small number of studies. The first related to the potential for befriendees to become dependent on the befriender, and therefore to be at risk of feelings of loss when the relationship comes to an end. 97,201,224 These studies highlight the need for careful management of emotional relationships, boundaries and expectations, as well as careful consideration of how endings should be orchestrated for particular people in particular circumstances. The second negative effect was reduced self-worth (labelled as ‘self-esteem’) reported in just one study. 228 Previous work has emphasised the importance of selecting and matching befrienders (or mentors) carefully so as to avoid a relationship that undermines, rather than boosts, self-worth. This study involved no such matching and provided online, asynchronous interactions only.
Shared-identity social support groups
This analysis is based on 31 separate interventions, reported in 41 qualitative or quantitative evaluative papers. Table 8 presents a summary of the evidence for the various relationships hypothesised in the SSG logic model; Appendix 10 provides more detail for each intervention.
Initial causal pathways | Qualitative studies (n) | Quantitative studies (n) | ||
---|---|---|---|---|
Supporting | Refuting | Supporting | Refuting | |
Function 1: safe reciprocal space | ||||
(1a) Function 1 → positive social tie | 29 | 0 | 1 | 0 |
(1b) Function 1 → increased security/trust/reduced worry | 20 | 0 | 0 | 0 |
(1c) Function 1 → normalisation of challenges/reduced internalised stigma | 17 | 0 | 0 | 0 |
(1d) Function 1 → self-confidence/mastery/coping behaviours | 14 | 0 | 0 | 0 |
(1e) Function 1 → more positive appraisal of existing ties and interactions | 2 | 0 | 0 | 0 |
Function 2: buffering hostility | ||||
(2a) Function 2 → positive ethnocultural identity/normalisation/reduced internalised stigma | 7 | 0 | 0 | 0 |
(2b) Function 2 → increased security/trust/reduced worry | 6 | 0 | 0 | 0 |
Function 3: equipping for context | ||||
(3a) Function 3 → self-confidence/mastery/coping behaviours | 18 | 0 | 1 | 0 |
(3b) Function 3 → increased security/trust/reduced worry | 10 | 0 | 0 | 0 |
(3c) Function 3 → more positive appraisal of existing ties and interactions | 0 | 0 | 0 | 0 |
(3d) Function 3 → access to wider opportunities for social support and interaction | 8 | 0 | 0 | 0 |
Proximate determinants | ||||
Increased positive social ties and interactions | 29 | 0 | 1 | 0 |
Beyond the group (as well as within) | 16 | 0 | 0 | 0 |
Decreased negative ties and interactions | 7 | 0 | 2 | 0 |
Increased self-worth | 18 | 0 | 1 | 1 |
Increased positive appraisal of existing ties and interactions | 2 | 0 | 0 | 0 |
Outcomes: improvements in loneliness, isolation, belonging and/or feeling supported | 19 | 0 | 6 | 3 |
Distinctive function 1: safe reciprocal space
Our generic logic model identifies the distinctive function of SSG interventions as ‘to provide a safe, authentic, reciprocal social space in which people who recognise some kind of shared identity engage with each other with meaning and enjoyment’ (shorthand: ‘safe reciprocal space’). The assumption is that if such a shared space can be created, there is a direct improvement in the participants’ levels of positive social ties and interactions (proximate determinant 1) via pathway 1a.
Pathway 1a: what evidence is there that shared-identity social support group interventions directly result in recognition of new positive social ties on the part of the group members/participants?
Evaluations of 29 initiatives provided qualitative evidence in support of this pathway, with one paper providing quantitative evidence in support. 248 Two papers103,230 did not report that a majority of group members developed close, positive ties. Group participants typically referred to the group as providing a ‘safe’, ‘easy’, ‘stress-free’ and non-judgemental space, a ‘home from home’ and a place to be oneself, with group members being ‘like family’. In some cases, group members were physically distant from their usual familial or friendship support networks, so that the group provided a more accessible, although complementary, source of companionship and support. In other cases, familial and friendship networks were unable to provide adequate support, or were even a source of negative social interactions and stress, so that the groups provided a substitute [e.g. for some women in vulnerable circumstances and for lesbian, gay, bisexual and transgender (LGBT) individuals].
The generic logic model further described function 1 in terms of providing the opportunity to make new friendships; share feelings and experiences (listen and be heard); give and receive affirmation and encouragement; give and receive information and advice; demonstrate one’s competence and value; engage in enjoyable, authentic social activity; and engage in activity that has meaning or purpose to them.
Several of the qualitative papers provided evidence that these elements contribute to the achievement of pathway 1a. No papers included any quantitative analysis of the relationships between these elements and the nature of the social tie established.
It was not always easy to disentangle the types of reciprocal exchanges that occurred among group members, with emotional, appraisal and informational support often occurring together. The reciprocal sharing of emotional support, both actively listening and being heard, was commonly described in qualitative evaluations as a key element of pathway 1a. 101,102,108,209,215,231–234 For example, participants in the Black Students Network were described as ‘sharing struggles’. 210
The importance of groups providing affirmation was consistently reported across the studies. Such affirmation could come directly from other group members via the sharing of experiences, and also from the facilitator of the group providing encouraging words. In addition, several studies confirmed that affirmation could come from having the opportunity to demonstrate one’s competence or value, either through the provision of advice and information to other group members, or in fewer cases, by the opportunity to utilise one’s skills in a visible way. For example, Means and Pyne177 described how an ethnic minority student was able to use her language skills as part of a US initiative, which ‘showed her how valuable she was in this university-sanctioned space.’177
The importance of the group engaging in activity that had meaning or purpose for the members in order to achieve pathway 1a was suggested by several studies, although this purpose was often also achieved via function 3 (equipping for context). The importance of enjoyable social activity to achieving pathway 1a was less clear, and seemed to vary depending on the needs of the participants. So, although the establishment of a welcoming and comfortable space was essential, the centrality of socialising varied between groups. That said, a majority of studies suggested that the sharing of food and refreshments among group participants was always a positive contributor to group cohesion. Striking the right balance between members experiencing the group as sociable and as purposeful appears to be key.
Pathway 1b: what evidence is there that achievement of a safe, reciprocal space leads to an increased sense of security/trust and/or reduced stress or worry?
Twenty papers included some qualitative evidence in support of this pathway. For example, Pejic235 described women expressing a ‘sense of relief’ at being able to share their experiences.
The availability of emotional support could be important even if it was not drawn on, as noted by Williams et al. :233
Some students however, did not always make use of, or ‘activate,’ potential emotional support, but nevertheless reported feeling as though they benefited from knowing that a community of support was there if it was ever needed.
Williams et al. 233
Pathway 1c: what evidence is there that achievement of a safe, reciprocal space leads to normalisation of social challenges and reduced internalised stigma?
Seventeen qualitative studies included evidence that SSGs achieving function 1 (safe, reciprocal space) result in a process of normalisation or social validation, through which challenges are seen as normal and not a reflection of the individual’s inadequacies:
I think the shared experiences . . . definitely make me feel better. Like, it’s good to know that other people are stressed about the same things that I would stress out about.
Black student, Williams et al. 233
To know I am not the only person experiencing these feelings, different problems but here you find people have the same feelings about life. You feel some encouragement, to know you are not the only one.
Active Communities programme, People’s Health Trust. 212
Pathway 1d: what evidence is there that achievement of a safe, reciprocal space leads to increased self-confidence/mastery/coping behaviours?
Fourteen papers included some qualitative evidence of this pathway being in operation.
For example, Pejic235 reported that coming together and learning from each other provided participants in a Somali parenting group with ‘a newfound confidence and a sense of empowerment.’235 A participant in this study commented:
Before I was shy and I was to myself and I didn’t know how to express myself and my pain.
Pejic235
Additional function 2: buffering hostility
Additional function 2 of social support groups was identified as ‘buffering the external hostile context that denigrates ethnic minority and/or migrant identity’. Fifteen of the evaluative studies63,101,102,104,109,177,208–210,213–216,230,233,236–240 included described support group initiatives that included some element of this function.
Pathway 2a: what evidence is there that achievement of the ‘buffering hostility’ function leads to a more positive ethnocultural identity/normalisation of social challenges and reduced internalised stigma?
There was qualitative evidence relating to seven initiatives, reported in 11 papers,63,104,177,208–210,213,216,233,239,240 that participants gained ethnic/racial identity validation, often through critical discussion of racist processes, as well as the provision of opportunities to demonstrate one’s knowledge and competence, celebrate one’s culture, and to be in close quarters with other, positive, ethnic minority role models. For example, Grier-Reed210 reported that ‘students felt heard, seen, valued, and respected’ and that ‘deficit notions of people of color were dismissed.’210
Pathway 2b: what evidence is there that achievement of ‘buffering hostility’ function leads to increased sense of security/trust and/or reduced stress or worry?
There was some qualitative evidence in support of this pathway relating to six initiatives, reported in 10 papers. 63,104,177,208–210,213,216,233,240 For example, Stewart et al. 63 found that some participants reported isolation linked to discrimination, and that sharing experiences of racism and discrimination with their peers in the support group helped to reduce worry.
Additional function 3: equipping for context
Additional function 3 of support group interventions was as follows: equipping group members to function well in a new or challenging role or context (often linked to change or transition). All but three of the evaluative studies included here described support groups that included some element of this function.
Pathway 3a: what evidence is there that achievement of ‘equipping for context’ leads to increased self-confidence and/or mastery and coping behaviours?
There was some qualitative evidence in support of this pathway relating to eighteen initiatives. 66,101,108,109,177,212,214–216,231–236,238,239,241–247 One paper provided some quantitative data in support. 248 A quotation from a participant at a community day centre for asylum seekers in Canada illustrates this causal chain:
There are trainings that take place that allow an asylum seeker to be truly active, to understand. [. . .] when you understand the system, it enables you to do something, to open yourself up, and to flourish.
Chase and Rousseau236
Pathway 3b: what evidence is there that achievement of ‘equipping for context’ leads to an increased sense of security/trust and/or reduced stress or worry?
There was qualitative evidence relating to 10 initiatives in support of this pathway. 66,101,214–216,231,232,234,236,238,239,241,243,244,246,247 As an example, an intervention in Canada reported that new skills and understanding for parenting in the Canadian context resulted in reduced stress and worry linked to childrearing among newcomer parents. 63
Pathway 3c: what evidence is there that achievement of ‘equipping for context’ leads to more positive appraisal of existing ties?
There were no papers that provided data in support of this pathway.
Pathway 3d: what evidence is there that achievement of ‘equipping for context’ leads to access to wider opportunities for social support and interaction?
Qualitative evidence relating to eight initiatives107,177,214,215,236,239,242,244,249 suggested that the achievement of function 3 (equipping for context) directly enabled participants to take up new opportunities to access social support and social interactions. For example, direct provision of information about leisure and social activities via the online NewBridger system107 led to greater participation in community life and access to services and formal sources of support. Saito et al. 103 reported quantitative data showing increased familiarity with services.
Feedback loops
Few studies explicitly explored potential feedback loops, but some evidence was available indirectly via participant stories. Some examples are given here.
Feedback loop 4 (see Figure 3): refugee women exposed to a peer support group plus mobile phone initiative were reported as becoming ‘more confident about travelling to places outside their home or community, which led to feelings of empowerment and self-capability among the women’. 234
Some papers also suggested positive feedback loops between the sharing of knowledge and advice within the group, growing confidence, and the experience of positive social ties. That is, the more group members share, the more they grow in confidence and the more they feel connected. 210,235 This concurs with the theory presented in Chapter 3 that the performance of social interactions/exchanges and the meaning of relationships are co-constituting.
Second-order causal pathways and proximate determinants
Increased positive social ties and interactions
All 31 initiatives of this type clearly intended to increase the positive social ties and interactions experienced by the beneficiaries, 29 provided qualitative evidence of success in this regard and one provided descriptive quantitative data. 238
As with befriending, an important consideration is whether or not the initiatives were able to achieve an increase in positive social ties and interactions beyond the group. There was some qualitative evidence from 16 initiatives63,101,102,108,204,208–210,215,216,231,232,235,236,239,240,242,245,249–251 of increased positive social ties and interactions for beneficiaries beyond the group itself. This could involve group members interacting with one another outside the group’s parameters and/or group members taking up other opportunities to access social support and positive interaction:
Now she comes to my house with her husband, and we go to hers. All because of the telephone.
Afghan group member, Walker et al. 241
Other papers did not make it explicit whether or not new ties and interactions extended beyond the group.
It is also of interest to know whether or not SSGs can enhance members’ interethnic social ties and interactions, particularly with the more privileged white majority. Although this was not reported systematically, there was evidence from several studies that SSGs can provide a foundation from which migrant and/or ethnic minority people can gain the confidence, knowledge, skills and networks to connect across ethnic difference:
. . . when I used to see new people, I wouldn’t initiate conversation. But now, when I see people, I feel that I can speak up. . . . by participating in this program, it is a subtle change, a change to a more open mind.
Phinney et al. 249
Fewer negative ties and interactions
Seven evaluations included some qualitative evidence in support of SSGs resulting in fewer negative ties and interactions, and two237,238 provided some quantitative evidence.
In eight cases, the improvements involved familial relationships, and in two cases improvements in co-ethnic interactions outside the family were mentioned.
Studies tended to suggest that acquisition of communication skills, and reduced stress and increased sense of security, were instrumental in improving interactions with existing ties (pathways 5 and 7).
Increased self-worth
A total of 25 initiatives aimed to increase participant self-worth (in some cases labelled ‘self-esteem’). Feeling as if one did not ‘matter’ and was invisible was identified as an important issue for many beneficiaries:
Every mother in the program wanted to be seen as someone who was important and visible to others.
Pejic235
Qualitative evidence relating to 18 initiatives63,101,102,108,177,208–210,213–216,232–236,239–244,246,247,249,250 and quantitative evidence relating to one237 suggested achievement of this proximate determinant. One paper230 aimed to increase self-worth but reported no such effect.
In many of the papers, there was evidence to suggest that the sharing of advice and information among group members was particularly important in increasing self-worth, that is the feeling of being valued by others. 215,232,235,236,250 In most cases, this was explicitly linked via increased self-confidence and empowerment (pathway 8). In other papers, the data appeared to suggest a direct pathway from function 1 (safe, reciprocal space) to self-worth. For instance, Lin107 reported that NewBridger members are aware and proud that their network is a mutual help group:
We help each other at NewBridger. Helping (other) people gives me satisfaction. (There is a) sense of achievement. . . . I like to share what I know with other people. I really enjoy it.
Lin107
The acquisition of tangible skills, such as improved host language skills, was also an important route to enhanced self-worth, via confidence and improved coping behaviours. 215 Other papers illustrated the pathway between positive ethnocultural identity and reduced internalised stigma and self-worth (pathway 9). 215,232,242,250
Outcomes
Evaluations of 19 interventions provided qualitative evidence that members had reduced feelings of social isolation or loneliness or developed a sense of belonging as a result of participating in the group:
What I gained was, you know, the sense of belonging.
Pejic235
Notwithstanding poor study designs, six studies103,214,230,237,238,248 included some quantitative evidence in support of an effect on relevant outcomes, whereas three63,101,109 provided quantitative evidence of no such effect.
As with the befriending initiatives, no studies involved long periods of follow-up, so none was able to offer evidence on whether or not positive outcomes were sustained.
Differential processes and outcomes
Most studies did not report on differential outcomes between subgroups nor engage in any analysis of intersectional processes. In two studies, focused on newly arrived refugees, authors found that the development of social networks by participants was dependent on pre-existing networks and assets, with some groups starting from a much lower level and developing more slowly. 214,215,243
Canuso68 reported that the group format did not work for two participants who had significant additional difficulties.
Saito et al. 103 reported that a programme for older people was effective on the loneliness outcome (as well as subjective well-being) for those who had at least mild loneliness at the start. In contrast, those who had no loneliness at baseline showed increased familiarity with services but no change in subjective well-being or loneliness. 103 Another programme for older people showed the greatest reduction in loneliness among ethnic minorities. 248
Two studies examined subgroup differences but found no effects, between Hispanic and black students233 and between immigration status groups. 232
Achieving functions: what inputs are important?
In this section we summarise the evidence that was available in relation to how particular inputs (the nature and volume of resources and activities provided) influenced whether or not the groups achieved the intended functions. Chapter 7 presents information on factors that influenced the access and uptake of initiatives.
Shared identity
Although the importance of participants recognising themselves as ‘members’ of the group or centre was illustrated in the majority of papers, the shared identity appealed to in creating such membership was varied.
Several groups were formed around a particular ethnic, linguistic or national identity, and group members identified this as an important aspect of achieving a supportive group environment:101,107,108,164,210,213,215,216,231,232,234,235,237,238,249,250,252
NewBridger is a group of people of same background . . . . if someone throws in a joke, I can truly understand it. I can laugh whole heartedly. . . . I belong here.
Lin107
Two groups were targeted at people who had both an ethnic minority and a sexual minority identity. 101,102
Other groups were more heterogeneous in terms of ethnic or national identity, and instead appealed to shared experiential identity, particularly seeking asylum,212,236,239,242 or being a newly arrived international, or ethnic minority, student at a predominantly white university. 109,177,230,233,244 There was evidence that cohesion could develop as group members recognise shared issues:
When I came here to [the day center], I know so many friends. We make a relationship. If you talk to [other] asylum seekers, it helps. They just tell you, ‘It is OK, it is in God’s hands’. This kind of thing.
Chase and Rousseau236
The importance of creating space and time to develop trust, identify commonalities and promote the essential characteristics of function 1 (a safe reciprocal space) was emphasised in some papers:166,167,212
We have been talking about trust because everyone is from a different country and if we try we can make it friendly . . . so we talk about respecting each other.
Active Communities programme, People’s Health Trust. 212
Looking across the studies, there is some evidence to suggest that the need for homogeneous, ethnic-specific (or national or subnational identity-specific) groups may be greater where other opportunities for authentic social activity are few, where the perceived and actual linguistic and cultural obstacles to interethnic engagement are high and where the perceived or actual stigmatisation of the ethnic identity is high. 108,252
Four initiatives involved organising groups exclusively for people identifying as male,63,101,212,214 whereas 14 provided groups exclusive to women only; the remainder involved a group or groups that were open to all genders. When female-only groups had been formed, these were felt to be essential to creating an acceptable space and one that would be experienced as safe, reciprocal and authentic by members.
Fixed or fluid membership
Initiatives varied in terms of whether group membership was fixed or open to newcomers, and in terms of whether or not there was a clear start and end to the group and whether or not there was any kind of formal screening and admissions process. In some cases, however, these differences related more to the nature of the research design than to the logic of the intervention itself. A variety of pros and cons were identified in relation to closed versus open membership.
A closed group may make the establishment of trust and cohesion among members easier, whereas the addition of new members can provide an opportunity for older persons group members to ‘give back’, via the provision of knowledge and experience; a key process in sustaining group cohesion and a pathway to increased self-worth.
There was insufficient evidence to conclude that one format is always preferable; this is likely to depend on the needs and causes of low support among the group members, particularly the extent to which the sharing of sensitive personal experiences is important. 166
Facilitation and user involvement
Among the evaluative studies, only one250 examined a ‘self-help’ group, with the remainder involving facilitation by someone who was not identified as a group member themselves. Although several initiatives aimed at increasing user involvement in the design, organisation and delivery of group activities over time,210,212,245 having someone in a designated facilitator role appeared to be important to initiating and sustaining the groups. Indeed, it may be important not to expect too much from group participants and to enable users to get involved as much as they feel able,245 rather than risk group participation becoming burdensome.
As with group membership, there was variation across the initiatives in terms of whether or not facilitators were ethnically and/or linguistically matched to group members, as well as whether they were identified as ‘professional’ or ‘peer/lay’. Aside from the obvious need for members to be able to communicate with the facilitator, there was insufficient evidence to draw any conclusions about which model is more successful at achieving the functions. Authors identified pros and cons of facilitators being perceived to be either ethnic/national ‘insiders’ or ‘outsiders’. Some initiatives involved co-facilitation in which the facilitators had contrasting ethnic identities and linguistic competencies, and this seemed to be a successful way of achieving the group functions. 244
As with befriending initiatives, once individuals have decided to try participating in a group, it may be the attributes and behaviours of the facilitators that are most important: warmth and empathy252 and being non-judgemental245 were identified as crucial.
Content
As noted above, there was consistent evidence that effective, and attractive, groups combine both fun and purpose. However, it is clear that the nature of inputs that are perceived as either enjoyable or having purpose/meaning varies depending on participant characteristics and needs. In some cases, participants recognise an urgent need for a particular set of knowledge and skills (e.g. in relation to their new home or new context). In other cases, an effective group may provide the opportunity to pursue more generic meaning, such as through creative or environmental activities. 212,249 Providing opportunities to show competence, for instance via the use of native language, or demonstration of cooking or other skills via voluntary roles linked to the group, were beneficial aspects of some group formats. 242
Several initiatives involved some kind of initial, and/or ongoing, consultation with group members so that the content and format of group meetings and activities was shaped by their needs and preferences. Cultural sensitivity or cultural congruence was also identified as an important consideration in the development and delivery of several initiatives.
Mode: technologies
One initiative was online only,107 whereas two initiatives combined remote with face-to-face interactions. 233,243 In one of these dual mode initiatives, participants reported that the two modes were complementary and enhanced the effectiveness of the initiative. 243,246
Frequency and duration
Groups typically met together on a weekly basis, although, in some cases, interactions were less frequent or ad hoc, depending on members’ motivations to connect. Although a few of the initiatives were open-ended,102,104,107,212,213,236,239 most involved a fixed duration. In common with befriending initiatives, there was evidence that some groups that were time-bound and relatively short in duration were felt to be insufficient to address the needs of participants, whose obstacles to positive social connectedness and well-being were deep-rooted. 164 Nevertheless, these initiatives were successful in achieving their intended functions and having an impact on the proximate determinants, at least in the short term.
In other cases, time-bound groups appeared to be appropriate to the needs of group members, particularly when positive social ties and interactions could be established beyond the group, for instance among student participants who could become connected with other support structures relatively easily.
Shared-identity social support groups: negative effects
Three potentially harmful effects of support group participation were identified in the papers: disclosure of sensitive information by group members within (and possibly beyond) the group; disruption to family relationships; and the potential to inhibit ‘out-group’ interactions, leading to further exclusion from wider society. There was very limited evidence in support of any of these effects; however, most papers did not include any discussion of unanticipated or harmful consequences of the initiatives.
Intercultural encounters
This analysis is based on 22 separate interventions, reported in 26 qualitative or quantitative evaluative papers. Table 9 presents a summary of the evidence for the various relationships hypothesised in the intercultural encounters logic model; Appendix 11 provides more detail for each intervention.
Initial causal pathways | Qualitative studies (n) | Quantitative studies (n) | ||
---|---|---|---|---|
Supporting | Refuting | Supporting | Refuting | |
Function 1: meaningful interethnic contact | ||||
(1a) Function 1 → ‘other-group orientation’ | ||||
Minority participants | 13 | 3 | 2 | 1 |
Majority participants | 11 | 4 | 0 | 0 |
(1b) Function 1 → increased security/trust/reduced worry | ||||
Minority participants | 5 | 2 | 0 | 0 |
Majority participants | 2 | 2 | 0 | 0 |
(1c) Function 1 → positive ethnocultural identity/normalisation/reduced internalised stigma | 3 | 0 | 0 | 0 |
(1d) Function 1 → self-confidence/mastery/coping behaviours | 5 | 1 | 0 | 0 |
(1e) Function 1 → more positive appraisal of existing ties and interactions | 0 | 0 | 0 | 0 |
Function 2: myth-busting | ||||
(2a) Function 2 → ‘other-group orientation’ | ||||
Minority participants | 4 | 0 | 0 | 0 |
Majority participants | 2 | 1 | 0 | 0 |
(2b) Function 2 → increased security/trust/reduced worry | 2 | 0 | 0 | 0 |
Function 3: equipping for contact | ||||
(3a) Function 3 → self-confidence/mastery/coping behaviours | 3 | 0 | 0 | 0 |
(3b) Function 3 → increased security/trust/reduced worry | 0 | 0 | 0 | 0 |
Spillover effects: neighbourliness, connectedness | 2 | 7 | 0 | 0 |
Proximate determinants | ||||
Increased positive social ties and interactions | ||||
Within ‘group’: bonding ties | 12 | 1 | 1 | 0 |
Outside ‘group’: bridging ties (beyond initiative) | 15 (8) | 6 (4) | (2) | (1) |
Decreased negative ties and interactions | 4 | 6 | 0 | 0 |
Increased self-worth | 3 | 0 | 2 | 0 |
Increased positive appraisal of existing ties and interactions | 1 | 0 | 0 | 0 |
Outcomes: improvements in loneliness, isolation, and/or feeling supported | 4 | 2 | 3 | 2 |
Distinctive function 1: meaningful interethnic contact
Our generic logic model identifies the distinctive function of intercultural encounters as being to bring together, in meaningful contact across ethnic/cultural/religious differences, people who do not normally interact. This is further described in terms of providing an opportunity to share stories and experiences (listen and be heard), demonstrate competence and value, engage in purposeful activity and engage in enjoyable social activity.
The level of detail provided in the papers was often limited, and some papers examined multiple different initiatives under the umbrella of a programme, so that it was not possible to examine the elements of function 1 in detail across most papers. Several interventions did include explicit aspects that enabled minority participants to demonstrate competence,110,111,115 and, in some cases, leadership. However, a feeling of unequal value among minority participants was shown to persist in some cases. 112
Pathway 1a: what evidence is there that intercultural encounter interventions achieving meaningful interethnic contact result in increased ‘other-group orientation’ among group members/participants?
There was some qualitative evidence relating to 13 initiatives110–113,115,121,123,126,127,130,131,137,253 and quantitative evidence relating to two initiatives (both involving children)115,128 that ‘other-group’ orientation increased for migrant and/or minority participants. However, for three of these initiatives, qualitative evidence indicated that this shift was not found among all minority participants. 121,127,137 A further quantitative study125 reported no such change. In relation to majority participants, some qualitative data was found in support of this pathway in 11 initiatives. 110,112,113,121,123,126,127,131,137,142,253 Four of these studies also provided refutational evidence (i.e. there were mixed effects across participants). 121,127,137,142 In the case of Matejskova and Leitner’s137 study in Germany, not all of the initiatives under investigation appeared to fully achieve function 1. Data were limited in several of these studies, and no quantitative data were available in relation to majority participants’ ‘other-group’ orientation for any of the initiatives.
Although it was usually not possible to isolate the effects of ‘meaningful contact’ from ‘myth-busting’ (function 2) in those initiatives that included both elements, it is worth noting that several interventions that did not include any deliberate activities aimed at ‘myth-busting’, and adopted instead a more organic approach, nevertheless triggered pathway 1a to some extent.
Pathway 1b: what evidence is there that intercultural encounter interventions achieving meaningful interethnic contact result in an increased sense of security/trust and/or reduced stress and worry among group members/participants?
There was qualitative evidence relating to five interventions112,113,122,131,137 that achieving meaningful interethnic contact resulted in increased trust and/or reduced worry among at least some minority participants. However, the extent of this sense of trust or reduced worry seemed to vary across initiatives. Matejskova and Leitner137 reported a mixed picture, with only some minority participants experiencing increased trust or reduced worry. Parks122 reported increased situation-specific trust for minority female participants who attended a children’s centre open to all. These women reported feeling wary of unknown majority ethnic people beyond the confines of the initiative, perceiving them to be of a different nature to those who participated. In contrast, two studies112,113 did suggest a more generalised reduction in fear and increased sense of security:
This project has made me be open-minded to interact with people, not to fear them just because we don’t speak the same language, just because we don’t look alike. There’s that human aspect to it that despite our differences and culture, our differences in language, our differences in appearance, that we kind of share the same thing.
Hmong participant, Goodkind et al. 112
One qualitative study131 also suggested that this effect occurred for majority participants, whereas the findings reported by Matejskova and Leitner137 again indicated diverse effects, with some, but not all, majority participants experiencing increased trust or reduced worry. Raw127 provided qualitative evidence that suggested that such an effect did not generally result for minority or majority children in a schools-based initiative under evaluation.
Pathway 1c: what evidence is there that intercultural encounter interventions achieving meaningful interethnic contact result in positive ethnocultural identity/reduced internalised stigma?
Three studies112,113,126 provided some qualitative evidence that minority participants gained a more positive sense of ethnocultural identity. Comments from students in a music-based initiative in Israel126 were particularly compelling:
In the beginning I was confused and I felt that my music should be set aside . . . I repressed my music, because I wanted to absorb the Israeli culture as fast as possible . . . today it [my music] has great meaning in my life.
Gilboa et al. 126
Pathway 1d: what evidence is there that intercultural encounter interventions that achieve meaningful interethnic contact result in increased self-confidence/empowerment/mastery among minority participants?
Five studies112,113,121,126,127 provided some qualitative evidence in support of this pathway. For example, Goodkind et al. 113 report on a US initiative bringing students and refugees together that demonstrated ‘increases in participants’ environmental mastery and self-confidence’. 113 However, Raw127 also reported qualitative evidence that suggested that this effect did not result in some schools.
No studies provided any evidence in support or refutation of pathway 1e in the intercultural encounter logic model.
Additional function 2: myth-busting
As noted above, function 2 and function 1 could not easily be disentangled in several of the initiatives, and the causal pathways were not generally clearly articulated in the papers.
Four studies112,113,126,130 provided qualitative data in support of pathway 2a, that ‘myth-busting’ could lead to more positive ‘other-group’ orientation among minority participants, and two studies112,113 provided evidence that ‘myth-busting’ could lead to more positive ‘other-group’ orientation among majority participants, at least in the short term.
One study137 indicated that myth-busting activities were not effective in shifting ‘other-group’ attitudes among majority participants, although these were not delivered in the context of an initiative that had clearly achieved function 1. The studies reported by Goodkind et al. 113 and Goodkind254 that evaluated ‘learning circles’ for students and refugees with two different refugee groups, Hmong and African, also both provided qualitative support for pathway 2b, that myth-busting can lead to increased trust and reduced worry.
Additional function 3: equipping for contact
Just seven interventions included some elements that could be considered to be aimed at function 3, and all of these were focused on people seeking asylum or refugees or other newcomers. In three studies,112,115,122 qualitative evidence was provided to suggest that pathway 3a was achieved, with migrant participants showing increased self-confidence/mastery. Participants in a football-based initiative reported that the leadership training provided had importantly increased their self-confidence:
The most powerful experience I’ve ever had in my life is that leadership program, you know, that changed my life, that changed my thinking . . . you know, make good decisions . . . they give you a good opportunity for you to be a good leader in the community (FS, male).
I: You’re officially coaching . . . how does that feel for you? R: It feels amazing. I look after people, then the people listen to me in the game and stuff (FS, male).
Nathan et al. 115
None of the papers provided convincing evidence for or against the causal chain between ‘equipping for contact’ and increased trust and/or reduced stress or worry, reflecting a lack of exploration of these potential processes.
Proximate determinants
Increased positive ties and interactions
All the initiatives were intended to increase positive ties and interactions for participants. Twelve studies110–113,115,120–122,124,126,131,253 provided qualitative evidence, and one125 provided quantitative support, that initiatives led to increased positive ties and interactions of a ‘bonding’ nature for migrant/minority participants. That is, participants developed ties with people they recognised as being similar to themselves in terms of migrant and/or ethnic status. In one case,124 there was evidence that such ‘bonding’ ties did not develop for some participants and that assumptions about commonalities and ‘safety’, in this case among women who shared international student status, could be too simplistic. Fifteen studies72,110–113,120,121,124,126,127,130,131,142,144,253 provided some qualitative evidence for increased positive ties and interactions across migrant and/or ethnic status, so-called ‘bridging’ ties, in the initiative. However, in four of these studies,121,124,127,142 refutational evidence was also provided, highlighting the contrasting experiences between participants, and two other qualitative studies129,137 also presented evidence that refuted the establishment of positive bridging ties in the initiative.
As with the earlier initiatives, there is particular interest in whether or not participants increased their positive ties and interactions with people beyond the group. Eight qualitative7,72,111,113,121,126,131,253 studies provided some evidence of such a broader impact, although one121 reported that this varied greatly across the three initiatives explored. A further three qualitative studies129,130,241 reported no such increase in positive bridging ties beyond the initiative.
In terms of quantitative studies, two125,128 reported some evidence of increased bridging ties beyond the initaitve. In contrast, one study115 found that, although participants developed close ties within the initiative, which brought migrant children of various national backgrounds together, there was no increase in reported ‘close friends’ within the neighbourhood, suggesting that there had been no impact on bridging ties for participants.
Reduced negative ties and interactions
Eight of the initiatives were intended to reduce negative ties and interactions experienced by participants and, in some cases, among broader groups or communities of which the participants were seen to be representatives. The focus here was on interethnic or interfaith conflict, rather than on negative interactions or lack of support within close interpersonal ties.
No quantitative data were reported that were relevant to this pathway. Four studies110,112,121,127 provided qualitative data that supported a reduction. However, in all four cases these studies also provided refutational evidence, illustrating that these changes occurred only for some participants, or only in some sites of the initiative. Furthermore, Askins and Pain110 also noted that reductions in negative interactions were fragile and not sustained over time and space. Matejskova and Leitner’s137 study, which examined a rather ill-defined set of initiatives in Germany, concluded that there was no consistent evidence of reduced negative interactions. Anderson124 reported that the ‘Women across cultures’ initiative for international students appeared to increase negative interactions for some participants, as it was experienced as an uneasy space.
Increased self-worth
Increasing the self-worth of participants was a clear objective of just four initiatives. In three of these studies,112,113,253 qualitative evidence supported the achievement of shifts in this proximate determinant, with participants expressing feelings of increased dignity and value, whereas in two studies126,128 there was supporting quantitative evidence.
Appraisal of existing social ties and interactions
Just one study (reported in two papers)113,255 provided any evidence in relation to shifts in appraisal of existing ties. Refugee participants originating from African countries showed some decrease in feelings of being discriminated against by white people in a US study.
Pathway 8: evidence for shifts in attitudes and practices among people beyond the initiative
Several of these initiatives had the aspiration to be a catalyst for broader shifts in the attitudes and practices of individuals beyond the immediate initiative, to engender higher levels of ‘neighbourliness’ or ‘connectedness’ among people living, studying or working together. There was, however, very limited evidence in the papers to determine whether or not relevant causal pathways were achieved.
Two papers provided some evidence in support of such a ‘spillover’ effect. 121,144 However, one121 of these highlighted very different processes that unfolded across sites involved in the UK Communities R Us initiative, with evidence of such spillover in just one area, and persistence of poor interethnic community relations in other areas. This report121 highlighted persistent interethnic tensions among younger people, feelings of unease among older people, the need for more sustained work to improve relations, and a lack of obvious leadership going forward.
Six further studies provided qualitative evidence that suggested that such spillover effects were not achieved. 110,127,130,131,137,142 In Matejskova and Leitner’s137 German study, a process of ‘exceptionalisation’ was described, rather than one of generalised, ripple-out effects on attitudes and behaviours:
In the end the positive values gained through an encounter with an immigrant become attached to that individual subject who becomes ‘like us’ whereas the group category remains largely negatively connoted.
Matejskova and Leitner137
In another, involving UK young people, participants talked about the initiative as if it was an ‘unreal’ space, and expressed doubt that their other family members would connect across difference as they had during the programme:
I met people that I would never have met in real life.
Mills and Waite131
Outcomes
Nine studies72,111,113,123–125,127,128,253 provided some data relevant to review outcomes of interest. Four studies72,111,124,253 provided some qualitative evidence, and three113,123,128 provided quantitative evidence, of an increased sense of belonging, feeling supported or reduced feelings of isolation. One of these qualitative studies124 reported mixed findings, with the initiative not being experienced as supportive by all, and two111,253 provided very limited data. One study127 drew on qualitative and descriptive quantitative data and concluded no evidence of improvement in a relevant indicator of belonging. A further study showed no evidence of improvement in a quantitative measure. 125
Differential processes and outcomes
As noted above, several studies noted that interventions did not play out similarly for all participants, or across all sites, but only a few identified systematic differentials between subgroups or contextual characteristics. Borgogni and Digennaro111 noted the low participation of women, and thereby an inability to evaluate the impact on women of an Italian football-based initiative. Mayblin et al. 142 concluded that higher education, and having foreign language skills, were factors that made it easier for some participants to engage in ‘organised encounters’ offered via a Polish football-based initiative. Nathan et al. 115 found that the effects of a football-based initiative for young migrants were similar regardless of how long the young people had been in Australia. Raw’s127 evaluation of a UK school-linking project identified multiple differentials: greater impacts among BME children in terms of other-group orientation and interethnic friendships, particularly BME girls, than white children; strongest effects among year 4 children; and stronger effects among children attending ethnically homogeneous schools than mixed schools. Meanwhile, socioeconomic status and faith versus secular school did not appear to affect outcomes.
Achieving functions: what inputs are important?
As noted above, several papers provided only brief information on the nature of the interventions, so that our ability to isolate key characteristics of inputs that are necessary or sufficient to achieve functions is limited. Nevertheless, the findings that are available tend to support earlier work91 that has characterised the nature of ‘meaningful encounters’.
Participants
The make-up of participants in terms of ethnic and migration status varied considerably across the initiatives. In common with prior work, there was evidence to suggest the importance of bringing members of groups together on an equal-status basis, but challenges to doing so in practice.
When initiatives involved bringing migrant/minority individuals into contact with majority individuals, inequalities in status, and associated narratives of entitlement and legitimacy, were not easily eroded. As Matejskova and Leitner137 state ‘deeply entrenched, uneven power relations are not suspended during face-to-face contact but always saturate it and exceed it.’. 137 Furthermore, in some cases, majority white people simply refused to participate. 121,137
Axes of difference that have important implications for how people perceive each other and develop equal-status relationships may be inadvertently overlooked by those designing intercultural encounter initiatives. For example, in one project there were significant unacknowledged class differentials, as well as faith differences, between the two groups. 130
In one initiative, it was suggested that having an all-female membership was conducive to achieving a more equal, trusting and empathic social space. 117
Of course, when initiatives are aimed at addressing community-level tensions, and the associated social isolation that can result, the potential participants are defined by the neighbourhood. That said, there was some evidence that initiatives that start with small numbers of people, and attract those with more positive out-group orientations, at least in the early stages, may be more successful. 121
Facilitator
Findings, although limited, tended to support prior work in confirming the importance of having someone in a facilitative role, particularly when the individuals coming together represent groups that have a context or history of conflict and mistrust.
Facilitators were found to usefully support the establishment of ground rules; to encourage cross-cultural discussions, reciprocity and celebration of difference; to work through misunderstandings; and to highlight commonalities and diffuse tensions. 110,119,126,127,130 Even when initiatives were intended to be bottom-up, community-improvement endeavours, having someone in a supportive, facilitator role appeared to be important. 121 It was, nevertheless, important that facilitators did not take over, but rather supported participants to engage and take ownership of the activities. 110
There was insufficient evidence to suggest what identity such individuals should have. In some cases, having an ‘outsider’ to the community seemed important,121 in others the lack of community knowledge and ownership among such outsiders was felt to be a disadvantage in supporting the endeavour of integrating the community,110 and ‘insider’ facilitators could, potentially, be role models for positive intercultural encounters (although this was not necessarily unproblematic). 130
Content and format
Although several initiatives involved structured elements aimed at ‘myth-busting’ and enhancing understanding across cultural difference, some evidence suggested that the creation of more informal, multicultural spaces that allow new forms of relationship to emerge at their own pace may be more successful.
Mayblin et al. 130 identified three types of contact in the initiative for young people of Muslim and Jewish identity that she explored: formal interfaith dialogue, shared interest (cricket) and banal sociability. She concluded that it was banal sociability, the hanging-out and chatting about teenage interests, that was the most influential in establishing ‘normal’ relationships between participants. Similarly, Matejskova and Leitner137 noted that projects that engaged immigrants in natural work roles side by side with local Germans were successful in increasing sensibility and empathy among locals, whereas more formal attempts to educate via presentations were not so successful. 137
Several studies suggested that the use of participatory arts approaches could be successful in creating the space for dialogue and/or positive exchanges between people who do not normally interact, to share their feelings and thoughts. 110,120,121,127 Music also seemed to be a successful approach in two studies. 126,128
Engaging in other types of purposeful group activity was also found to be effective in some initiatives, giving participants something to focus on and engage around. Achieving a goal collectively, even if small, could be a boost to positive intergroup connections also. 121,141 It seems probable that offering diverse potential activities, and allowing participants to choose and direct content, is necessary to achieve positive engagement.
Sport was intended as a means to intercultural understanding and connectedness in several initiatives, but there was evidence that meaningful intercultural encounters could be very variable across participants,142 and another indication that individuals, particularly those of majority ethnicity, are not necessarily motivated to put themselves through the ‘effort-intensive nature of encounters across difference’. 137
Duration
Several studies concluded that the intensity and duration of initiatives was inadequate to produce significant and lasting shifts in attitudes and behaviours, or to establish new positive relationships across difference. The need for multiple contacts, ideally across multiple contexts, was suggested by several authors. 130,137 Raw127 found some evidence that those children who had been involved in the school-linking project for longer durations showed greater shifts in attitudes. The initiatives evaluated by Goodkind et al. 112,113 and Hess et al. 255 that showed positive changes for minority and majority participants involved intense interactions over a 6-month period.
Intercultural encounters: negative effects
A few studies suggested that, in some circumstances, intercultural encounters could exacerbate negative attitudes, inequalities in status and racist behaviour. Raw127 found that, in some schools, there was an apparent hardening of negative attitudes towards out-group members, particularly among majority ethnic children. Askins and Pain110 found that when children were involved in a photography project that gave them little active involvement, and instead positioned them as objects, ‘other young people’s comments were predominantly negative, based on (perceptions of) physical difference – the quintessential marker in constructions of difference – leading to arguments or evasion.’110
Goodkind256 found that some Hmong participants did not recognise themselves as imparting knowledge to the white American students they engaged with, instead positioning themselves has having less value (perhaps suggesting that the initiative heightened this negative self-perception, at least for some):
But I don’t think I taught you anything else because I learned more from you, because you know English, and you know how to read and write, and so I think I learned more from you than you learned from me.
Goodkind256
Qualitative evidence relating to causal pathways from other intervention types
Here we briefly review the qualitative evidence from other interventional types relating to key causal pathways already presented, as well some additional pathways that warrant consideration. We also report on some quantitative findings on causal pathways from papers that did not include data on a relevant final outcome (and so are not included in Revisiting the quantitative evaluations).
Pathways to increased positive social ties and interactions
There was some evidence that training/equipping initiatives could increase positive social ties and interactions for participants, either directly if they adopted a strong group-building element (and so, it could be argued, were similar to SSGs),75,257,258 or indirectly if they served to overcome important current obstacles to social interactions. 148 For instance, one paper illustrated that, for older individuals, a training-based intervention designed to reduce the fear of falling significantly reduced reports that a concern about falling had ‘interfered with normal social activities with family, friends, neighbours, or groups’. 217
However, interventions that focused narrowly on equipping participants in some way did not necessarily increase positive social ties. An intervention that aimed at equipping students with intercultural skills reported a small increase in a measure of cross-ethnic social self-efficacy, and an increase in time spent with cross-ethnic friends, but no increase in the number of cross-ethnic friendships. 147 An equipping intervention for older migrants in Sweden, despite aiming to encourage group members to discuss and share experiences, showed no positive impact on positive social ties. 153
Meaningful activities that were communal also showed evidence of increasing positive social ties,170,172,173 as did some volunteering activities. 259
Pathways to reduced negative social ties and interactions
There was evidence from two studies157,164 that interventions that employed psychotherapy could enable participants to develop the skills and confidence to better manage stressful relationships, leading to fewer negative interactions:
Yes, it has. I am managing my family with less stress; I have realized and have gained the knowledge of overcoming my tension when I am dealing with my children and husband. I tell them I can do only so much at a time and they shouldn’t be expecting a lot from me.
Masood et al. 164
Pathways to increased self-worth
There was evidence that meaningful activity initiatives could provide participants with a sense of being competent, of value and of being valued by others. 170,172
Volunteering activities could also increase feelings of self-worth:58,177
I believe it made me feel needed and important. It made me realize that I could use my abilities to help others and made me feel good about myself. The feeling of satisfaction was the most beneficial aspect for me.
Pak58
I feel like this [the SL (service-learning) project] gave Latinos a way to be involved and know that they can actually be a part of something.
Pak58
There was evidence from some interventions that employed psychotherapy that these could lead to enhanced self-worth (labelled as ‘self-esteem’),159,164 and that the active listening and sharing components of these group-based interventions were an important element (in common with befriending and SSG initiatives). 164
There was also evidence that some training/equipping initiatives could enhance self-worth when they successfully equipped participants with the ‘know-how’, confidence and skills that they perceived they needed to operate in an important context. Such initiatives often incorporated a peer-learning approach and involved a normalisation pathway. 75,151,260 Initiatives that failed to equip participants with the know-how and skills they wanted were less successful. 261
Pathways to more positive appraisal of existing ties and interactions
There was evidence from one study that an intervention that employed psychotherapy could enable participants to re-appraise their existing ties in a more positive light. Elligan and Utsey157 reported that participants demonstrated ‘an increased appreciation and love for other African American men’ and greater sense of tolerance for conflict in interpersonal relationships and a renewed interest to maintain intimate/romantic relationships.
Revisiting the quantitative evaluations
Appendix 12 lists the 34 intervention papers included in this analysis, with associated characteristics. Interventions, study designs and outcome measures were too varied to support statistical synthesis. Study quality was also generally moderate to low, with no studies employing RCTs that were assessed as having a low risk of bias. Most studies had short periods of follow-up.
Drawing on the qualitative evidence and theoretical insights, we developed hypotheses regarding probable relationships between interventional characteristics and outcomes that were then used to guide our exploration of the quantitative data.
Hypothesis 1
Loneliness (feeling isolated, feeling unsupported) has a complex aetiology and the underlying causes can vary between individuals. Therefore, interventions that target underlying causes of loneliness are more effective, on average, than those that do not. Three groups of interventions are likely to be effective; these are interventions that:
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focus on a particular group of individuals in a particular setting or circumstance and are designed to address their particular needs
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are flexible enough to enable attention to individual needs
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involve multiple components that link to all, or most, of the proximate determinants.
Befriending initiatives might be considered the most flexible, because they are provided on a one-to-one basis. However, the befriending initiatives examined in the quantitative batch of studies tended not to demonstrate achievement of one-to-one tailored support. Four of these initiatives were unsuccessful. 221,223,224,228 Three papers concluded that the intervention was successful in relation to a relevant outcome: two222,226 focused on schoolchildren, a targeted group that was provided with inputs tailored to a child’s social and academic achievement in school, and the third initiative focused on Spanish-speaking women who were provided a linguistically and culturally tailored input from Promotoras. 229
Four studies examined interventions that provided multiple components aimed at addressing at least three of the proximate determinants. Three of these were reported to be successful. 113,214,230 The fourth63 was not successful in affecting quantitative outcomes, although there was promising qualitative data. The two interventions evaluated by Stewart et al. 63,214 were very similar, suggesting that contextual differences may have moderated the causal processes.
Hypothesis 2
Low self-worth (linked to wider hostile environments) is common among migrant and ethnic minority people. Therefore, interventions that explicitly aim to boost self-worth are more effective, on average, than those that do not. Two groups of interventions are likely to be effective:
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interventions that integrate components that directly enhance self-worth (e.g. opportunities to reciprocate, to demonstrate competence, to build confidence via new skills)
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interventions that enable user involvement and/or ownership.
Overall, the data provide fairly consistent support for this hypothesis. Six studies113,128,214,222,226,237 reported a positive impact on self-worth (quantitatively or qualitatively) and a positive impact on a relevant outcome measure; two further studies182,229 had an explicit intention to affect self-worth (although there were no data presented) and the findings suggested a positive effect on a relevant outcome. In addition, four initiatives did not explicitly mention self-worth, but either supported active user involvement248,262 and/or had a focus on a closely related concept: mastery211,248 or self-efficacy. 103,152
Three interventions had no explicit intention to improve self-worth and did not achieve significant impacts,109,125,146 and one had an intention to improve self-worth but did not appear to include relevant inputs and had no impact on outcomes. 263 A further initiative actually reduced self-worth (despite intentions to boost it) and had no positive effect on feeling supported or on loneliness. 228
In two studies,63,101 there was evidence of increased self-worth, but no associated improvement in outcomes; both focused on people seeking asylum and refugees. In Adam et al. ,101 there was no active involvement of users and there was evidence of unaddressed negative social interactions. In Stewart et al. ,215 there was qualitative evidence to suggest some improvements in perceived isolation and perceived social support.
Two interventions appeared to achieve a positive effect on outcomes despite no explicit attention to increasing self-worth. Both of these focused on international students and employed less rigorous study designs. 144,264
Hypothesis 3
For new migrants, particularly forced migrants, a severe lack of social connections is an important risk factor for loneliness. Interventions that explicitly support the building of a shared-identity social network are more effective than those that do not.
Three studies, focused on migrants, that put an emphasis on building shared identity ties reported an increase in positive social ties and a positive effect on a relevant outcome. 113,214,237
Two befriending interventions did not appear to aim for shared identity ties, and produced no impact on participants’ reports of positive social connections, nor on the final outcome. 221,224 Two initiatives, focused on international student adjustment, included no apparent emphasis on shared identity ties and produced no impact on final outcomes. 125,146
Two studies63,101 did appear to focus on shared identity ties, and did provide qualitative evidence of an increase in positive ties, but reported no impact on loneliness, suggesting that other factors were at play. Notably, in the Adam et al. 101 initiative, the target group was migrant LGBT+ men, and there was some qualitative evidence that experience of negative social interactions was not reduced (see Hypothesis 4).
Two studies144,264 provided contradictory evidence, in that the interventions did not appear to aim to increase shared identity ties but, nevertheless, reported improvements in relevant outcome measures for international students. It is worth noting that, in the Brunsting et al. 264 intervention, the participants were 86% Chinese students, and so may have developed shared identity ties even though this was not an explicit aim. This initiative was intended to operate via a shift in international students’ appraisal of the adequacy of their social ties, although no data relating to this causal pathway were provided.
Hypothesis 4
Having social ties and interactions that are experienced negatively is common among migrant and ethnic minority people. These can be (1) stressful intimate ties (due to living in conditions of material deprivation etc.) and/or (2) exposure to hostility and microaggressions in varied social settings, including with service providers and ‘agents of the state’. These negative social interactions can undermine the effect of positive social ties, and create loneliness. Interventions that fail to address persistent negative social ties and interactions are less successful than those that do address them.
Few of the quantitative studies explicitly engaged with these causal processes.
Two initiatives, focused on people seeking asylum and refugees, included an explicit focus on reducing negative interactions and provided some evidence of success in this regard, as well as reporting a positive effect on outcomes. 214,237 A further initiative, focused on schoolchildren, also provided some evidence of a reduction in negative interactions and reported a positive outcome effect. 222 Four further initiatives had an explicit aim to reduce negative ties and interactions, and reported a positive impact on outcomes, although no data were provided on this proximate determinant. 113,155,158,160 One initiative aimed to affect this determinant, but appeared not to be successful and also reported no impact on the loneliness outcome. 101 One study failed to affect the outcome despite some evidence of positive ties within the group; qualitative data suggested that this was because negative intrafamilial ties had not been addressed for many of the women. 165
One initiative recognised the importance of addressing negative ties, but provided no data on this determinant (and did not appear to provide credible inputs to address it), and reported no effect on the outcome. 228 A further initiative, for international students, recognised these factors and reported no effect on a relevant measure, but did report an impact on the outcome. 264 An initiative for refugees reported some qualitative data of impact on negative ties, but no effect on final outcome. 63
Twenty-two initiatives provided no information to suggest that they recognised or targeted negative ties and interactions. Ten of these reported no impact on final outcomes. 60,109,125,146,159,221,223,224,263,265 Twelve initiatives reported a positive impact on a relevant outcome,103,128,144,150,152,179,182,226,229,230,248,262 although, as already noted, study quality was often poor.
Hypothesis 5
For individuals who have multiple, interlocking risk factors, addressing loneliness will take time, and short-term improvements may not be sustained. Interventions that are longer term, or that include effective transition arrangements to connect individuals with secure follow-on sources of support, are more likely to be effective than those that are of a fixed, shorter duration.
Quantitative studies did not include sufficiently long durations of follow-up to test this hypothesis.
Health outcomes
Seven quantitative evaluations included measures of mental ill-health (depression and/or anxiety): five reported positive effects113,158,160,165,229 and two reported no effect. 223,224 Six initiatives, all focused on older people, included measures of physical health and well-being. 103,150,152,248,263,265 Two reported a positive impact on a subjective quality-of-life/well-being measure. 103,248 Three reported a positive impact on a physical activity-related measure. 150,152,265 One reported no significant effect on either activities of daily living or self-rated health. 263
Chapter 7 Understanding the wider ‘system’: risks for loneliness and factors influencing intended solutions
Introduction
This chapter is concerned with factors in the wider socioecological system, in terms of both how they influence people’s risk of feeling lonely and their interplay with initiatives that aim to protect against, or reduce, social isolation and loneliness. The chapter addresses the following research questions:
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What are the causes of social isolation and loneliness among migrant and/or ethnic minority people?
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What happens when similar interventions are introduced into different contexts? What processes ensue? (Moderating factors).
The chapter presents a UK picture, integrating information extracted from the UK published and detailed grey literature, alongside insights from the CP workshops. We draw here on the available evidence on causes of loneliness, and intervention or initiative implementation processes, extracted from 41 UK intervention studies, as well as 65 UK papers that were identified as ‘non-intervention empirical’ during our screening process. Empirical papers were those that presented qualitative or quantitative data on levels and patterns of social isolation, social support and/or loneliness among our population groups of interest. Identifying important relationships in a complex system is challenging, so too is identifying the appropriate boundaries to adopt for the system under study. The analysis presented in this chapter is descriptive, and does not seek to quantify the strength of relationships between factors in the system. The elements and processes identified are based on a narrative synthesis of recurring themes across our complementary data sources.
Figure 5 presents a generic model, illustrating the various points at which wider system factors can impinge on interventional activity. However, our CP workshops, and our review of published literature, revealed that many of the key factors that undermine or support the implementation and operation of deliberate initiatives are relevant across multiple causal chains in the model. Furthermore, these processes are also implicated in the creation of, or protection against, risk for social isolation and loneliness more generally. We therefore adopt a thematic approach to this chapter, dealing with sets of processes operating at individual, family, organisation, neighbourhood and wider societal levels in turn (while recognising the inter-relationships between these levels). In each section, we present evidence relating to causes of social isolation and loneliness, as well as highlighting how these factors interplay with initiatives (including their relevance for particular interventional forms, when apparent) and approaches to intervention more broadly.
Individual-level factors
Self-confidence; self-worth
A theme of low self-confidence undermining people’s ability to form and maintain social connections was common across all CP groups. CP members across all groups also identified important feedback loops. Supportive relationships serve to enhance self-worth, which, in turn, encourages more interaction and the chance to develop new relationships:
Boosting the confidence is the key, it also gives them a feeling of sense of worth – they are not useless, they are not old . . .
CP older persons group
Being confident in your heritage and can go out in the world and say that ‘this is me, my heritage’ and you can go and show this.
CP student group
The student CP members felt that self-worth was a ‘defining thing’, and noted that a lack of self-confidence could prevent people from taking up the opportunities around them to engage socially. They also noted how contextually sensitive self-confidence and self-worth could be, and how the lack of supportive people around a person could quickly undermine these feelings.
Low levels of confidence could prevent people from taking up available offers of support. A CP member shared a story of a young male asylum seeker who was fearful of attending a youth group and needed the safety of one-to-one supportive chats over a period of time before being confident, and trusting, enough to engage with the group. Askins202 found that some people seeking asylum were not even confident enough for a one-to-one befriending service.
Several closely related factors were identified, via the CPs and published literature, that feed into low confidence and undermine self-worth.
Fear
Fear of unfamiliar, and changing, places was noted as an important factor in CP discussions, and was thought to be closely linked to loneliness. Fear of being rejected and judged was identified as encouraging students of the same nationality to stick together. Fear was also felt to be prominent among older people:
I run a group with about 30 older African Caribbean women. They are at risk of becoming socially isolated as they are fearful to get out of home after six [o’clock] because they don’t have any transport to get to places. They are fearful of being attacked, fearful of going out after dark, and even when it’s not dark, and actually at quite a risk of social isolation.
CP older persons group
There was evidence that initiatives involving accompanied outings and navigational support can be helpful in reducing fear and increasing confidence:108,202
Sometimes isolation keeps you within the home and you feel grounded in one place, but then if you have the courage to go out and do some courses, that helps.
CP working-age group
English-language skills
Limited ability to communicate in English was linked to restricted social engagement in published literature and the CP discussions, particularly for new migrants122 and some older people.
Consultation panel members felt that the significance of not having English-language skills could become more acute with ageing, as people lose spouses and children who previously provided support and companionship, and a link to the English-speaking world. Opportunities to develop English-language skills are valued by new migrants, although CP members felt that some offers were overly formal and focused on targets that are not relevant to participants who want to acquire functional English and confidence to interact verbally in everyday spaces.
Change, transitions and loss of social role
A further theme that was commonly described as undermining self-confidence, and having an effect on people’s ability to make positive social connections, related to change and transitions that lead to a loss of social roles, and a ‘loss of self’. This was reported in both CP workshops and the published literature. International student CP members described the move to university as ‘very destabilising’, in this regard:
. . . not only have you left your home, but you have also left where your place was. If you were involved in anything, you have left that. You’re coming to this place where you don’t know where to fit into the structure. ‘Cause other people already have their structures already. It takes time to find where you fit in.
CP student group
This was also a particular theme in relation to the experience of forced migrants, for whom the ‘loss of self’ can be particularly acute, with family ties, employment and other aspects of identity being abruptly lost:187,239
The major problem that I faced here was the loss of my identity and the stigma of being different. I don’t think people understand how traumatic and stressful it is unless they have personally gone through it. . . .
Christodoulou. 239
Initiatives that helped people to orient themselves and ask questions in a non-judgemental atmosphere were identified by CP members as helpful, such as orientation week activities for international students and a drop-in ‘tea and biscuits’ session for people seeking asylum at which people were encouraged to speak in English and received help with navigating systems. The former was identified as useful in terms of conveying some culturally specific communication tips, and providing accompanied trips about the city. Family members could also help older people adjust to changes in their social context:
My son says [name of place] has become so lively now. I was missing the [Punjabi] community before, but I have started to see things differently now. Since my son made this comment about how lovely it was, now, I take my friends, go and enjoy.
CP older persons group
Ill-health and disability
The relatively high levels of chronic ill-health and disability among ethnic minority groups, particularly older people, was identified as an important factor that both contributes to isolation and loneliness and undermines people’s ability to take up interventions. Again, this theme appeared in both published studies and CP discussions.
The negative spiral of depression, leading to social isolation, leading to more chronic depression was highlighted in CP workshops. CP members described how people can ‘become stuck’, and breaking out of depression, isolation and low self-worth can be very difficult.
Physical ill-health among older people was felt to be a particular issue, and the importance of outreach services was highlighted. The Irish centre evaluated by Cant and Taket104 catered to people who felt particularly isolated and unable to visit the project because of health problems by providing a culturally sensitive telephone befriending service.
Material resources
The impact of limited material resources on people’s ability to engage in social activities, both informal and of a more structured provision, was mentioned across all CP groups. Students talked about being invited to go to the pub, but not having the money to do so. Other CP members talked about people seeking asylum not being able to participate in activities that were intended to connect them to others, such as free swimming sessions when not having the money to buy swimming trunks. Lack of money was a particularly prominent theme for forced migrants, in both the CPs and the published literature, with some not even being able to accept an offer of going for a cup of coffee with a friendly neighbour. Furthermore, the expectation of having to pay can deter people from venturing into community centres and other spaces,69 and having to ask for favours (e.g. eating with friends when awaiting benefits) can put a strain on social relationships. 187 There were numerous examples of how interventions can fail to adequately consider the resource constraints that people face. 131,202 In Askin’s202 study, befrienders had to work around the lack of resources experienced by asylum-seeking individuals by meeting in befriendees’ houses, as this involved no direct cost such as bus fares or buying drinks.
Awareness and familiarity
Consultation panel members noted that older people and newer migrants may have limited awareness of opportunities for social connection and support, and may be reluctant to venture too far afield. There was a feeling that many people rely on friends and family for information and recommendations about places to go and things to do. Places can feel unfamiliar and threatening both to new arrivals and to established residents as their character changes over time.
Low uptake of interventions was reported by CP members and in published papers. Word of mouth, and working through people and organisations already known to intended beneficiaries, can be helpful in increasing participation over time, and breaking down mistrust and/or scepticism. 110,266 Respectful partnering with local community organisations to reach ethnic minority people had been successful in some locations. 267 In the case of some initiatives, there may also be a need to explain unfamiliar content to prospective participants. For example, Pakistani women with depression who were invited to join a psychotherapy-based support group described their initial apprehension about the nature of the groups and the degree of disclosure that would be expected. 268
Individual needs and preferences for social relationships and contact
Consultation panel workshop discussions often focused on the ways in which particular interventional forms would not be suitable for everyone, highlighting the range of individual attributes and circumstances that shape needs and preferences for social contact and relationships.
Age and life-stage
Consultation panel members felt that the need for social contact varies across the life course in terms of both type and quantity. Several members suggested that the need for friends and sociable activity declines as one ages, being more important in young adulthood, with middle-aged and older people being more attracted to engage collectively with people in something that is meaningful and productive. At the same time, retirement was identified as an important transition, and one that is more difficult for some than others:
Going back to the question of what are the things in our life that prepare us against loneliness, if you were in a people-oriented job, you get a chance to refine your people skills, but there are a few jobs where you don’t get the chance to refine those skills. So, if sociability is a skill, we need to be able to practise it.
CP older persons group
Gendered preferences and expectations
Consultation panel members and published papers identified diverse ways that gendered norms and identities shaped preferences. Men were often identified as being less likely to want to join groups and engage in activities that required ‘opening up’, suggesting the need for loosely structured, informal activities to better attract men. 144,212
Within-ethnic group and across-group preferences
Discussions in CP workshops generally conveyed the message that migrants and people from ethnic minority backgrounds want to have a mix of social ties and are keen to engage across ethnic difference. The potential for people to connect and find commonality around various aspects of identity or experience was also emphasised (echoing the findings on SSGs reported in Chapter 6), so that ethnic identity need not necessarily be the salient feature in encounters. It was also clear that some new migrants, particularly international students, could be disappointed by a lack of hoped-for close relationships with local people:187,269
Here the culture and the people are different. I was excited when I first arrived in the UK but soon I realised how difficult everything was . . .
Refugee, Strang et al. 187
However, CP members also identified that individuals vary in terms of how motivated they are to interact with different types of people and to try out new things. Although some CP members identified an attitude characterised as ‘I don’t know, and I don’t want to know’, others felt that apparent reluctance to engage across difference is more likely to be rooted in fear and low confidence, as well as poor language skills, as noted in English-language skills. Supporting evidence was provided in published papers:122,187
Yes, I feel myself different from other people, I’m sure they feel me different from them . . . I wish to feel myself as part of the community, but it is difficult . . . It’s not people’s problem, it’s my problem because I have to talk in English very well to mix with them, so they can understand me, they can feel if I am good or not good, they can then judge me and decide if they want to talk with me or not . . .
Children’s centre migrant mother, Parks. 122
At the same time, however, CP members identified the need for opportunities to socialise in ethnically homogeneous groups at times:270
Not saying we want separate lives, but at certain points, it is important community is central and these community provisions need to be with people that share similar backgrounds.
CP older persons group
While, in part, reflecting a desire for cultural commonality and shared authentic expression, this need was also linked to the obstacles people experienced to ‘being themselves’ in predominantly ‘white spaces’. For instance, CP members talked about experiencing people objecting to them speaking their mother tongue and attracting unwelcome attention when wearing traditional clothing or hairstyles. Moreover, as discussed further below, for some, the need for intraethnic social ties clearly relates to a need to feel safe, to escape hostility experienced elsewhere and to enable mutual support in the face of racism:
My enduring friendships are, I think inevitably, two South Asians friends of mine. All three are British South Asians . . . So it’s the sharing of that shared hardship that helps us endure and then the shared stories of being racially abused . . . that brings us together.
CP student group
In one of the projects I was involved with, it involved quite a diverse community. We found some failure because people hesitated to mix with people from other backgrounds – particularly people with very strong religious beliefs. Language was also a main thing, we were complained about why we were using a particular language.
CP older persons group
There may also be more practical aspects of intervention organisation, venues and timings for instance, that play out differently for people from different ethnic or religious groups because of the way they fit, or clash, with other aspects of day-to-day living:
There was also another thing about the hidden individual and considerations of family convenience of when they could attend, which was different between different ethnic groups. And we have really diverse communities.
CP older persons group
Both CP discussions and published papers also raised the importance of being aware of potential factions within ethnic or national communities. Cant and Taket104 highlighted the deliberately non-sectarian approach of the Irish centre, which made that project accessible to older Irish people from a variety of backgrounds. CP members recalled instances when project deliverers overlooked important internal divisions and historical animosity between groups of people who were assumed to be ‘from the same group’.
It is important to also note that, in relation to intercultural encounter initiatives, a particular challenge is involving majority white British people. There is often poor interest and these initiatives are often felt to fail in reaching those sections of society whose attitudes and behaviours are prejudicial. 121,142
Individual preferences
Consultation panel members reported that some people do not like to join groups, and argued that there is a need for flexible activities for which there is a ‘low threshold’ for entry and people can do as much or as little as they choose. Centres that offer spaces and activities in which people participate side by side, rather than having to engage in conversation such as film clubs,104 gardening or artwork, can be attractive for some, and may enable transition into more engaged activity over time (or provide sufficient input to protect against loneliness for some).
More generally, CP members noted the importance of having varied activities on offer to people because people find meaning and enjoyment in a variety of ways. Engaging local people in shaping the offer of activities was identified as important and demonstrated in several grey literature intervention examples. It was also suggested that projects and activities that may not be explicitly focused on social isolation and loneliness can, nevertheless, play an important role if appropriately designed. A member of the older-age CP group talked about a project she was involved with – Play Dominoes, Talk Prostate:
So what I’m doing is mixing the positive connector of playing dominoes, which is an African Caribbean cultural thing, with the negative connector of talking prostate, and that has resulted in as many as 25 men coming in every week to play dominoes and talk about prostate cancer, going for the checks.
CP older persons group
Individual needs
Consultation panel discussions also drew attention to the varied underlying factors that can lead to feelings of loneliness among particular people (e.g. loss of intimate relationships following bereavement vs. a sense of being an undervalued outsider among highly skilled new migrants). CP members felt that the published evaluations of interventions often did not offer a sufficiently nuanced discussion of how interventions might play out for different people.
Some published papers also highlighted variation in individual need. For instance, a group-based psychotherapy intervention for South Asian women was highly appreciated, but some participants wanted one-to-one support in addition, to allow more sensitive issues to be discussed. 164
In addition, as discussed in Chapter 6, interventions that fail to address significant unmet relationship expectations for participants will probably not be effective at protecting against or reducing loneliness.
In collective initiatives and interventions, there is a need to recognise that the motivations for participating may well vary across participants, and this may have implications for dynamics. Parks122 noted this for white British women and new migrant mothers who frequented Children’s Centres. While the former tended to seek friendly social contact for them and their young children, the latter were often more focused on acquiring language skills.
Furthermore, both CP discussions and published papers questioned the adequacy of short-term, fixed-duration initiatives to address the needs of many individuals, whose isolation and loneliness, and, in some cases, associated mental ill-health, were rooted in complex social and economic circumstances. 164
These insights into individual variation in need highlight the importance of targeting, tailoring (or flexibility) and signposting, as discussed in Chapter 8.
Faith and spirituality
Faith (as opposed to religious identity) as a resource that can protect against loneliness was identified by members in two of the CPs. There were no UK intervention papers that explicitly paid attention to this aspect, although some US-based initiatives did. We are aware of initiatives beyond the scope of this project that have been developed in the UK to allow the integration of people’s faith (and personal religious resources) into recovery from depression (although these are not directly concerned with loneliness). 271
Family-level factors
Loss of family ties and support
All of the CPs talked about family ties as being foundational to a person’s sense of being supported and belonging. Student CP members talked about the difficulties they faced being a long way from family members who were an important source of emotional and affirmational support. Efforts were made to keep in touch through social media, but time differences and virtual contact did not feel the same as face-to-face interactions for some. These CP members also felt that some relationships were lost, or weakened, irreparably with the passage of time. Loss of family was also a salient theme in the published studies relating to forced migrants:
No, I do not think that here is like Albania, because there are so many things . . . . I miss family.
I never lived alone, I am coming from a family where I have five sisters and I always surrounded people, and I was scared of living alone.
Refugees, Strang et al. 187
Older CP members also talked vividly about the permanent loss that results from being a long-term migrant. This sense of loss related not simply to loss of social relationships, but to a loss of place:
It’s not there anymore – it has changed, no longer the close family. Once the parents have gone, you go back to visit and they’re not there. House has gone, and no one to share and no memories are left.
CP older persons group
Despite loss of family ties, there was also evidence of active agency on the part of forced migrants. Clayton272 looked at young ethnic minority people in Leicester and found that they were active in maintaining both local and transnational ties that were important in their sense of belonging; multifaceted identities were not necessarily in conflict, and their religious identities were important. 272
Recognition of the importance of maintaining transnational ties, and support to do so, appeared to be limited in UK interventions. A pilot initiative in Sheffield identified by a CP member sought to equip older Chinese people to use smartphones and WeChat (Tencent Holdings Ltd, Shenzhen, China) so that they could connect with relatives in and outside the UK.
Families as sources of stress; negative social support
Both CP discussions and published literature highlighted the importance of recognising that family relationships were not necessarily supportive for migrant and ethnic minority people. Furthermore, given expectations of close family ties and reciprocal obligations, poor family relationships could often be felt very acutely:
But, there is an expectation of having to please your parents. There can be a feeling that you are not pleasing your parents and not living up to their expectations. This can undermine sense of support. In this situation, individuals may be going out and about and connecting with others, but they may still feel isolation and loneliness if parents don’t give support to them.
CP working-age group, talking about South Asian women experiencing divorce
In the papers describing psychotherapy and group-based support for women, negative support from spouses, conflict with children and unfulfilled expectations of support were common themes contributing to feelings of isolation and loneliness. 201,218,250,252
Consultation panel members who were migrants, both students and those who were working, talked about the way that interactions with family members and close friends ‘back home’ were not necessarily supportive:
If my mum says to me when I’m feeling frustrated and sad ‘Come back to [name of country]’, it is very different to her saying ‘Oh don’t worry, you’ve just had a bad day, why not go out for a walk?’.
CP working-age group member
People could be judgemental, have high expectations and make assumptions about the migrant ‘having an amazing time’. This could make migrant individuals less inclined to keep in contact with their relatives and encourage them to conceal their need for support. CP members noted that such expectations can make people feel that they are not achieving, undermine self-worth and increase feelings of isolation:
You are torn between the two. . . . I put it as a negative sort of connection. If you feel that connection is there, you feel you have got that responsibility and the perception is you’re scared, you aren’t there – land of opportunity, but you are torn – you long for it, you want to hear your mother’s voice, but you try, you know, you are torn.
CP student member
There were also disappointments at not being able to share new experiences with close friends:
My girlfriend back in Mexico – I didn’t feel lonely by this time – but I was sharing all my new experiences here and for her it was not that exciting because she was in the same routine. I felt lonely because she wasn’t sharing with me, this feeling or this emotion.
CP student member
Family members were also found to restrict access to interventions in some cases. Masood et al. 164 reported mixed support for South Asian women to attend a group-based initiative, and Gater et al. 268 identified resistance from family members, particularly husbands, as a ‘major hindrance’. 268 Gater et al. 268 noted that family members ‘did not recognise depression as meriting outside help and lacked faith in the appropriateness of the intervention’, indicating the importance of gaining trust and providing culturally sensitive care.
Family members could also discourage positive cognitive and behavioural shifts among people who were participating in projects aimed at creating positive connections. The Respect and Understanding – Building Inclusive Communities (RUBIC) project116 was described as a multilayered model that tackled attitudes in students’ homes, as well as involving students in leadership activities, as this was anticipated to have ‘a much deeper impact’ than working with young people alone.
Failure to address sources of negative social support may mean that interventions are not successful, as the provision of positive ties may be insufficient to counteract negative ones if they are significant relationships about which the individual holds particular hopes and expectations. However, relatively few of the UK initiatives appeared to actively engage with these issues.
Competing demands and responsibilities
Competing responsibilities and demands were identified as undermining people’s abilities to invest in their social relationships, as well as their access to and engagement with interventions.
Housework and child-care responsibilities were highlighted for women. For instance, ‘homework’ expectations of a group-based psychotherapy initiative were difficult for South Asian women with child-care responsibilities to complete. 164 Similarly, refugee women with children found it difficult to combine child-care responsibilities with the timing of English classes. 187
Consultation panel members suggested that men from migrant communities were also at risk of being socially isolated owing to their felt duty to earn for their families. For instance, many male members of the Chinese community were identified as working long unsociable hours in the restaurant trade, leading to being isolated not only from family, but from the wider community.
Interventional approaches could increase participation by providing child care, and convenient scheduling. In addition, both CP members and published evidence suggested that the content of initiatives is important, in that people may feel able to prioritise, and justify to other family members, activities that provide clear practical skills and knowledge that have value beyond the individual.
Stigma
Felt and enacted stigma relating to feelings of social isolation and loneliness were highlighted in all CP workshops. As noted above, migrant individuals could feel reluctant to admit to family members ‘back home’ that they needed support, when they were perceived to be the lucky ones.
Consultation panel members felt that men felt particular stigma to admitting feeling unsupported or lacking in social connections, with gendered expectations forcing them to ‘man up’ and ‘suffer in silence’.
At a family level, there can be resistance to individuals, particularly older people, accepting support or engaging in initiatives, because it reflects badly on other family members who have a perceived obligation to meet those needs themselves.
Consultation panel members suggested that initiatives that enable participants to involve their wider family members from time to time, for instance a gardening project, may be more acceptable and also provide a way for the individual to demonstrate competence and to strengthen important family ties.
Interventions that adopted neutral labels, for example ‘Thursday night chat’, or that were framed in terms of aspects of development could be less stigmatising. As an example, international students may feel embarrassed and illegitimate in devoting time to a support group that takes time away from their studies, but may feel able to join a group that is focused on adapting to life in a new academic environment (which at the same time provides emotional support and companionship).
Neighbourhood and community-level factors
Feeling unwelcome; interpersonal racial harassment
There was a strong and consistent theme of feeling unwelcome:
I feel lonely everywhere, not just in London. People don’t like migrants, especially if you have the face of an Arab or a Muslim . . .
I felt remarkably unwelcome in the UK. There was a distinct feeling that you, as a ‘foreigner’ were not welcome . . .
Refugee participants, Christodoulou. 239
More seriously, direct experience, and fear, of racial abuse as something that limits people’s social interactions and contributes to feelings of isolation and lack of belonging among both migrants and ethnic minority people was a consistent theme across all CPs and the published literature. In a vivid example, a member of our older people’s CP described how someone spat in her face in a local area as she was dressed in her traditional clothes. In another, they described newly arrived migrants in one area of the city running to the bus stop as quickly as possible to evade the torrent of verbal abuse from neighbours. In Gray’s99 study, the young and the elderly in the Bangladeshi community were found to feel especially vulnerable, with respondents citing multiple incidents of theft and bullying:
I had a mugger who took my money. [. . .] The mugger hit me as well, so I reported it to the police like my family support worker told me to. [. . .] Now I’m afraid to go outside myself and I’m afraid for my son to go outside alone.
Gray99
The risk of abuse was exacerbated by poverty. For instance, children attending school in old clothes became a target owing to their ‘visible poverty and cultural differences’. 99
A CP member recounted experiences of neighbour abuse:
I know that when we moved into a bigger house in [name of place] in the centre, our neighbours weren’t happy from next door, that a Pakistani family has moved in; ‘Our house prices will go down’. They did everything possible to offend us, sort of thing.
CP working-age group
Experiences of racial abuse and harassment were identified as a particular problem for those seeking asylum and refugees. In part, this was identified as being related to having no control over their housing and being housed in areas where other residents hold racist attitudes. In addition, however, the overwhelmingly negative portrayal in the media and politics was felt to be a significant contributing force.
Furthermore, although CP members recognised that skin colour, religious dress and other aspects of appearance can make some migrant and ethnic minority people particularly visible, fear of racism was common among white European migrants also:
I know of someone from Polish origins who told her children not to speak in Polish outside because then they will become easily identifiable.
CP working-age group member
Consultation panel members felt that the prevailing negative racial climate limited people’s knowledge, and uptake, of opportunities to engage in activities and programmes aimed at tackling isolation and loneliness. They also expressed concerns that progress towards building self-confidence and a sense of belonging that might be achieved in group-based activities, and other initiatives, can be undermined by negative experiences out and about – themes that resonate with the published evidence on intercultural encounters that are reported in Chapter 6.
Although some UK initiatives that were reviewed explicitly engaged with racism, recognising this as part and parcel of migrant and minority experiences, this was uncommon aside from those labelled as intercultural encounters. Notably, recognition of the need to address racism was more prominent in SSGs in the USA than in those in the UK.
Neighbourliness
Importantly, as well as revealing a negative focus on racism, CP members and the published literature also highlighted the positive potential of ‘neighbourliness’ or ‘conviviality’, that is the positive, relatively fleeting, encounters between people in public spaces that could contribute to a feeling of being ‘at home’:190
Strangers sometimes can be positive social connectives. I can walk down the street and I can talk for England and I would just meet someone and speak to them as though I’ve known them for years, and just listening to other people and people having a different outlook in life, that can be a positive thing that can uplift you, so it’s a positive connective.
CP older persons group
Some interventions appeared to have successfully drawn on this reservoir of goodwill and desire to connect. For example, Refuweegee118 has managed to mobilise very large numbers of people in Glasgow to be part of a welcome initiative for newly arrived refugees.
Confidence in encountering such neighbourliness could, however, be very context specific. Unfamiliar places can make people wary, and undermine the potential for conviviality, as can rapid changes in the make-up of an area:
The university is a safe zone. If I’m within the structure of the university, I can go anywhere. When I’m in the wider city, I don’t really fit in. Going for a national insurance number, the vibe was ‘what is going on?’. There should be a way to facilitate this with the job centre as a student. Nobody is facilitating you.
CP student group
There are big issues with neighbours. It’s changing. People move on. Someone has come next door to me, with a different language. A large influx of Nigerian, Polish, Latvian and other, makes me feel less belonging.
CP older people
Community assets and geographies; natural spaces of encounter and connection
The presence, or absence, of spaces and places for social encounters and connections was highlighted as important.
There were concerns about restricted opportunities for everyday interactions in some localities, such as residential buildings not being conducive to sustained and repeated exposure to neighbours, and missed opportunities during new planning projects to create associational spaces that are open to everyone. Although the notion of self-segregating communities has been challenged, some studies did note the limited opportunities in some parts of the country, particularly for children, to interact routinely across ethnic and religious difference. 110,127,130,131
Consultation panel members talked about libraries as important spaces where ‘all sorts of people’ can come together.
Churches and other places of worship were also felt to be important for both established ethnic minority groups and new arrivals as places to feel safe and to connect around a shared religious identity, and, in some cases, a shared ethnic (or national) identity too:
How I met my Jamaicans here in Sheffield is that one Jamaican led to another who led me to another . . . this helped me because she led me to a church and I meet a lot of Jamaicans; the Windrush generation and all that.
CP student group
Sports clubs were also identified as having the potential to bring people together and facilitate new social ties, in some cases across ethnic difference, and in others within self-identifying ethnic or national groups:
I work for [name of place] ethnic minority sports club and we have got 100 women playing sports every week. We’ve got lots of women coming every Saturday from the Tamil community and playing netball. So that kind of sports element brings them together, groups of women.
CP working-age group
However, as noted in Chapter 6, the published evidence on sports activities as sites of positive encounter is mixed, and suggests the importance of facilitation.
Some ethnic communities were identified as lacking permanent community spaces which they could occupy and make their own. For instance, use of a general community venue by Lychee Red, a support group for Chinese older people in Leeds, was felt to be inadequate by members. 267
As well as physical meeting places, some CP members identified virtual communities and networks that could provide an important social support and companionship:
It’s both. So it’s professional in that, so being a woman and being black, in a professional role you’re not just a minority, you’re a super-minority. . . . [this contact makes] you see yourself or your potential self and it’s really inspiring. Other professional elements would be, like, workplace conflicts; I’ve had this myself, where people say things that are, like, really racist or really sexist and you don’t necessarily have the tools to [address this] . . . people know where you’re coming from. On a personal level, it’s just a nice community for discussion and debate.
CP student group; talking about an online network
Importantly, however, these ‘bottom-up’ places of naturalistic encounter could exclude, as well as include, people. An example was given of a local authority that had intervened to ensure that a local market remained a welcoming space for everyone following the development of interethnic group tensions and fear among some people around accessing this facility. Some CP student members shared their experiences of not quite fitting into any of the on-campus ‘community assets’ that were available:
You have that situation where you feel like you don’t fit in anywhere.
I think it works both ways . . . In groups, talk can be ‘British’ in one group and ‘Nigerian’ in another. May exclude. Too British to be Nigerian and too Nigerian to be British: I don’t belong anywhere!
CP student group
Transport
Consultation panel members noted that public transport can be unreliable, and unwelcoming, making people less inclined to venture out of their home. Getting about can be made harder for those who have poor English-language skills, and those who do not drive or have no access to a car. Similar evidence came from some of the published papers:
You find people who don’t welcome you and they are really racist and, you know, they abuse you on the bus and, you know, say words. I been, it happens to me, and one time I was really, really upset and I was crying when I went home.
Female participant, Strang et al. 187
Inadequate transport options also hampered people’s ability to participate in some initiatives,164 whereas other initiatives included special provision to facilitate access. For instance, a group-based psychotherapy intervention for Pakistani women provided taxis with a female companion. 268 More generally, intervention papers talked about using accessible venues, although this could relate to the identity and familiarity of venues as well as their physical location.
Organisational-level factors
Alienating systems and processes
All CPs identified ways in which official systems and processes frequently act to ‘other’ and undermine a sense of belonging among migrants and ethnic minority people. A student CP member described experiences of having to deal with visa arrangements, ‘reminding me that I am different, not a member of society, do not belong here.’ Another CP member described the insensitive processes of the welfare benefit office:
On Fridays, they get Muslim men to come and sign when it is Friday prayer times, exactly, spot-on, that time of the day. These kinds of things, they do get to people.
CP working-age group
And another CP member described poor experiences in a care home:
It’s lack of cultural awareness [affecting my wife’s end-of-life care]. Different religions . . . [My wife] was at the care home, every day they would send an Anglican priest. She’s a Hindu. After a couple of weeks, I said ‘you are out of order, my wife’s a Hindu, you sending a Christian’. After that they identified a Hindu priest . . . They are not sensitive to the cultural needs of different people. It’s a ‘one size fits all’ so you provide one service to the majority community and the rest have to fall in line. Social services have this problem.
CP older persons group
The negative impact of systems and processes on the self-worth and social connectedness was most significant among those seeking asylum and refugees. The system created demands on their time and sapped energy for building social relationships and engaging in relevant activities. 21,187,239 In addition, unstable housing undermined people’s ability and motivation to establish social connections; adding to feelings of uncertainty and insecurity:
And my first experience at Heathrow when I ran and I went to the immigration office and I said ‘I’m in trouble, I’m seeking protection’. It started from there, the way you are treated is like you are a criminal. You lose total control and you are less human, you are an underclass. And the housing is the same, it compounds, so it’s not just having no choice. You get housed in areas where the housing stock is really cheap, poor housing, no aspiration, and you are stuck – no opportunities as well.
CP working-age group
Strang et al. 187 found that access to English-language classes (that could support the social connectedness of asylum seekers and refugees) was impeded by the need to attend appointments, particularly immediately after being granted status.
Consultation panel members also noted a reluctance to complain about organisational practices among migrant and ethnic minority people, for fear of repercussions:
It’s hard to complain when you’re older. If you feel unhappy about the service – feel unable to challenge poor care.
CP older persons group
Staffing: skills, identities and behaviours
Although overt racist discrimination was less commonly identified within organisational settings than out and about at community level, evidence across our sources indicates that the experience of microaggressions is commonplace.
Examples were given of individuals in authority or service-providing positions, through their comments and behaviours, undermining the self-worth of migrant and ethnic minority individuals and contribute to a sense of not mattering, not belonging and not fitting in:106,273,274
You know like they’ve got to eat restaurant-style and we have to eat with our right hand because the prophet – peace be upon him – ate with his right hand, and that’s how we eat. But the schools are telling the kids that they can’t do that, and that’s confusing for the kids.
CP working-age group
My mum was in a home and you notice others who don’t have family or carers. And some carers are not carers, if you know what I mean. Some dread the carer, they want someone who speaks their language and has respect. Some are crying out for help because of loneliness. For the aged, hygiene and incontinency are the big things – they all contribute to loneliness.
CP older persons group
Wilkins and Lall275 found that ethnic minority student teachers experienced stereotypical attitudes among their white peers and that, as teachers, their contribution was often narrowly constructed in terms of their ethnic identity, leaving them feeling isolated and marginalised. Garner et al. 274 found that poor communication between health-care professionals and West African mothers led to difficulties in understanding needs, and an increased sense of isolation among the women.
In one case, past experiences at a local Children’s Centre had been so negative that a support group project had moved to another more neutral venue to encourage attendance and create a positive atmosphere. 245
Again, there was consistent evidence to suggest that people seeking asylum and refugees are perceived particularly negatively, and frequently experience microaggressions:
When they assume I’m an international student, here just to study, the reaction, the conversation that you have is totally different. People accept you, you are international, they respect you. Many times . . . I have said I’m still a refugee, it’s totally different – the reaction. The judgement comes in, you – you are less important, you are not capable. That’s the perception.
CP working-age group
Furthermore, because these individuals typically have few family or friends in the country, insensitive treatment by professionals was felt to be particularly detrimental:
If they do not get the appropriate support from services or even people, it actually knocks their confidence back and then obviously they are not able to actually connect.
CP working-age group
In relation to interventions aimed at tackling isolation and loneliness among migrant and ethnic minority people, as mentioned in Chapter 6, some aimed to adopt explicitly culturally competent models.
A further relevant dimension was the creation of volunteering opportunities in initiatives for current or former recipients. This approach could be helpful in diverse ways, providing a wider range of visible ethnic diversity and language skills among providers, as well as opportunities for volunteers to develop skills and self-confidence. Volunteering provided a much-needed opportunity to demonstrate value and reciprocate, key factors in boosting self-worth:176
Opportunities to help others makes you feel better.
CP older persons group
I feel so empowered to see how far I’ve come. Not just to be now a service user, it was a little bit of, like, upgrade in life, I felt like.
Black African mentor mother, McLeish and Redshaw218
Having volunteers who share the ethnic or migrant identity of potential beneficiaries can also help to develop trust and increase access. McLeish and Redshaw96 noted the challenges to building trust among pregnant women, with asylum-seeking women being fearful and suspicious. In that study,96 volunteer peer supporters reported that they find it easier to be open with other ‘asylum people’ and that being non-judgemental helped in forming a close connection.
However, Vickers176 suggests the need to think carefully about who gets to volunteer when working with refugee (and migrant) groups, as the need for confidence, education and language skills means that opportunities go to people from relatively privileged backgrounds, with the potential to create divisions between these people and refugees who arrive with less human and social capital.
Consultation panel members also raised the issue of negative experiences in workplaces that can undermine self-worth and create a sense of not belonging. In some cases, these experiences were felt to ‘spill over’, generating more chronic loneliness for some people, particularly those for whom their career is an important part of self-identity. The review of published literature did not identify any initiatives based in workplaces, suggesting an important evidence gap:
In the office that I manage, people ask me for the manager, ‘where is the manager?’ and that keeps happening. It’s like ‘how can this African guy be the manager or the in-charge?!’.
CP working-age group
Wider society; structural and cultural racism
Dominant UK policy and media narratives
A strong message from CP members was that the wider hostile environment towards migrants (and, by extension, ethnic minority people) seriously undermines people’s sense of belonging, and can mean that people do not take up the services and support that are on offer.
Connections to professional staff who might provide support and reduce isolation are compromised because migrants are fearful and find it hard to trust professionals.
Encounters at community level are also undermined. For instance, young Muslims in one study133 reported that, despite their efforts in social action, charity-giving and interfaith involvement, they remain victims of negative media stories. This study also illustrated the way in which ‘bridge-building’ projects, aiming to create positive ties between people of different faiths and ethnicities, are susceptible to being incorporated into popular and dominant narratives around terrorism and security. 133
Ripple effects of ‘remote’ events
This societal backdrop also means that remote events are felt close to home, and directly affect migrant and ethnic minority people’s sense of security and belonging. 127,130
Raw127 examined a school-linking project around the time of the 2005 terrorist attacks and found that primary school children were directly affected. Muslim children reported feeling scared (‘I don’t know if they might be angry with us’), and white British children expressed mistrust (‘suspicious of brown people now’). 127
Intersecting risks
The sections above include some examples of intersectionality identified by CP members. The interplay of ageism and racism is highlighted for older people, while sexism and racism were simultaneously experienced by female CP student members who referred to being a ‘a super-minority’.
In addition, CP group discussions and published evidence suggest that there are some subgroups of individuals who had particular sets of attributes and circumstances that suggested very high levels of risk for isolation and loneliness: those not granted asylum; unaccompanied minors; older asylum seekers; LGBT+ asylum seekers; asylum seekers with mental ill-health, HIV or other stigmatised conditions; undocumented migrants; ethnic minority people who experienced intimate partner violence or had extensive caring responsibilities; and members of small, low-skilled, dispersed communities.
In the above cases, individuals were often detached from, and faced obstacles to forming, connections both with people they recognised as sharing their ethnic identity and across ethnic difference.
A vivid example was provided by Selman et al. ,276 who described the experiences of Somali parents of children with autism who faced stigma and isolation. These people found themselves with an absence of supportive family ties, obstacles to co-ethnic ties (stigma, lack of understanding, fear of ‘gossip’, lack of trust), rejection by white/majority society and dependence on inadequate services and professionals.
Chapter 8 Current UK approaches and potential new directions
Introduction
This chapter addresses the following research questions:
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To what extent do current interventional approaches address the known determinants of social isolation and/or loneliness among migrant and/or ethnic minority people? Where are the gaps?
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What system conditions support or hamper successful and sustained implementation?
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What are the costs associated with such interventions?
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What implications are there for roll-out at scale in the UK?
We take a UK-focused approach in this chapter, drawing on the published and grey literature relating to the UK, as well as insights from the CP workshops, and the final practitioner workshop.
Provision versus need
Table 10 provides a preliminary assessment of the nature of deliberate intervention in the UK, in comparison to the identified risk factors for isolation and loneliness. It is not possible to comment on the adequacy of the volume of provision with the data we had to hand. Rather, the aim is to flag up any causes or interventional strategies that might, so far, be overlooked.
Underlying causes | Promising [and possible] interventional strategies | UK activity volume (initial assessment from published and grey literature) |
---|---|---|
Few positive social ties and interactions | ||
Lack of bonding ties, opportunities for authentic social activity |
|
Some |
Unfulfilled desires to build interethnic ties |
|
Some |
Separation from family members |
|
Few |
Lack of resources, competing demands, inadequate transport to take up opportunities |
|
Few |
Fear, low confidence, lack of mobility, poor health |
|
Some (mainly for women, older people, asylum seekers or refugees) |
Negative ties and interactions | ||
Stressful family relationships |
|
Few (for women) |
Overt racism in day-to-day interactions |
|
Few |
|
Some (uncertain impact) | |
Microaggressions, particularly from significant others, for example peers, teachers, service providers, bus drivers |
|
Few |
Low or precarious self-worth | ||
Lack of familiarity with context |
|
Few (mainly for asylum seekers/refugees, pregnant women) |
Change/transition: social roles and confidence undermined |
|
Some |
Experience of negative ties and interactions |
|
As above |
Negative appraisal of existing ties and relationships | ||
Lack of familiarity with sociocultural context; misinterpretation of cues and exchanges |
|
Few |
‘Stereotype threat’ – expectation of negative interactions |
|
None |
Loss of significant relationships |
|
Some |
Several approaches seem to be adopted relatively rarely in relation to our population groups of interest: direct transfer of resources to support social participation; provision of safe spaces to discuss and develop coping strategies for racism; provision of information, skills and navigational support for new contexts; and equipping people with social and communication skills (e.g. via psychoeducation approaches). Providing training in (and access to) digital technologies was also rarely reported in the published and grey literature that we accessed. However, our approach may have overlooked relevant initiatives of this type if they were badged in terms of ‘digital literacy’ rather than in terms of enhancing social connectedness. Furthermore, CP discussions suggested that this type of initiative may be on the rise, and newer initiatives may not yet be documented in a way that would have been picked up by our searches.
In addition, our search strategies found no evidence of any initiatives in the UK that employ light-touch psychological interventions to support positive thinking about social interactions; this is a strategy that appears to have shown some success in relation to increasing sense of belonging among minority students in educational institutions in the USA.
We found no evidence in our data of strategies that are effective in tackling overt racism, or increasing the cultural competence of organisations, with knock-on positive implications for our proximate determinants or outcomes. And, although we identified a large and varied set of ‘intercultural encounter’ initiatives in the UK, none provided strong evidence of impact.
Towards a systems approach
Consultation panel discussions and the practitioner workshop highlighted the disjuncture between the published literature, which tended to focus narrowly on individual initiatives, and the reality of a complex system in which individuals may encounter diverse provision, as well as other resources and processes, that support or hamper their social connectedness. The need to identify whether or not and how interventions, wider services and community assets work together to protect against, and reduce, loneliness, among migrants and ethnic minority people was emphasised. We developed a visual representation of a potential systems approach to ‘loneliness-proofing’ that was shared and refined during the practitioner workshop (Figure 6). Several broad considerations were highlighted, as briefly discussed in the following sections.
Targeting and tailoring
Recognising the multifaceted nature of loneliness and its underlying causes, the importance of targeting and tailoring initiatives was highlighted. Enabling people to identify their own needs and select from a menu of support options was suggested. Recognising that people may have multiple needs was also identified as important by CP members and practitioner workshop participants. Published research provided supporting evidence. For instance, Strang et al. 187 noted that refugees report high levels of social connections with friends and family, and yet still express a strong sense of homesickness and loss at being apart from close family members, suggesting that certain needs were unmet. In Chapter 6, we presented evidence that tended to support the contention that interventions that target underlying causes of loneliness are more effective, on average, than those that do not, whether these be carefully tailored approaches or approaches that are multifaceted, allowing a range of potential underlying causes to be addressed.
A further important dimension was the importance of working with, rather than against, people’s existing social ties and connections. The importance of recognising the ways in which interventions can inadvertently undermine existing ties was noted, as well as the need to support people to protect, rekindle and strengthen ties when they can. This was a theme found across our consultation work and the published literature, although many intervention designs were not explicit in terms of these considerations.
Signposting and referring
Linked to targeting and tailoring is the importance of signposting people to appropriate provision.
Concerns were expressed in published literature and CP discussions that, although initiatives may be beneficial to those who are involved in them, those most in need of support often remain unreached (see Chapter 7). In addition, there was evidence that fixed-term interventions can be problematic if they do not include effective ways of linking beneficiaries to more sustainable social networks and sources of support. 96,164,218
There were some examples in the published literature of good partnership-working that supported the identification and signposting of migrant and/or ethnic minority individuals in need of support. 104,190,192
However, a common theme at our practitioner workshop was that professionals, as well as community members, had inadequate knowledge of available resources and services in their local area that could meet the needs of migrant and ethnic minority people. There was a need for better communication across organisations. Furthermore, some people felt that signposting and partnership-working had deteriorated in recent years as funding had been cut and third-sector organisations increasingly felt that they were in competition with each other. White British practitioners, who were in the majority at our workshop despite its focus, also felt ill-informed about community assets that could be relevant to minority individuals, further underscoring the importance of improved links to community-based organisations that serve these populations.
Embedding and diversifying
A further theme was the importance of recognising that people have very varied preferences, and that there is therefore a need for varied provision. CP members told us that not everyone will want to join a ‘group’ and ‘not everyone wants to do gardening!’. It was also pointed out that lots of existing activities and community assets are already protecting against loneliness, such as churches and other places of worship, but that these are not necessarily well supported financially or recognised for their contribution.
Furthermore, a wider range of activities that could have the potential to make an impact are currently overlooked when the issue of loneliness is under consideration. CP members and workshop participants felt that there was work to be done to ensure that public spaces and generic activities (e.g. leisure spaces, libraries) were more conscious of promoting positive social connectedness in general, and more inclusive and welcoming to migrants and ethnic minority people in particular. Positive examples were given as possible role models.
Engaging local people
As noted in Chapter 7, ‘neighbourliness’ appears to play an important role in boosting people’s sense of belonging. CP members, and some published papers, provided examples of how local people had been effectively engaged in initiatives aimed at welcoming newcomers,118,253 as well as some intercultural encounters involving diverse, established communities. School and university students have also been engaged in some relevant projects, although we found no evaluations in the UK literature. These examples raise the possibility of untapped potential for addressing loneliness among our population groups of interest.
Challenging aversion to ethnic-specific provision
A further theme that arose across the data sources was the aversion in current UK policy at both local and national levels to investing in initiatives that are seen as serving only one particular community. There is an important tension between the demonstrated need for opportunities to build and celebrate intraethnic ‘bonding’ ties, and policy orientations that consider such ties to be threatening, and seek instead to prioritise bridging ties across difference. 190
Most participants in our practitioner workshop felt that they were currently expected to design initiatives that are ‘for everyone’. This policy stance did, however, appear to vary somewhat across localities. For instance, the evaluation by Wigfield and Alden267 suggested that, in Leeds, several ethnic-specific initiatives had been supported, and well received, in recent years as part of the Time to Shine programme.
Costs, resources and funding regimes
Very little information was presented on costs of interventions in the published UK evaluations, and there were no assessments of cost-effectiveness.
A large number of the reported initiatives involved volunteers in their provision, suggesting that such initiatives may represent good value for money. On the other hand, in a few cases, authors reported that initiatives were relatively expensive compared with provision for other groups because of the need for ‘culturally sensitive’ additions. 268
Consultation panel members and participants in the practitioner workshop bemoaned the commonly short-term funding regimes that were currently in place, making it difficult to sustain provision, and the small amounts of money that were devoted to tackling complex individual and neighbourhood issues:
In the 80s, there were about 20 luncheon clubs. We are not holding luncheon clubs anymore. It’s cut, cut, cut. The elderly will end up in hospital then, costing more money . . .
CP older persons group
There was evidence in the grey literature too that initiatives commonly involved small investments and were not sustained. 245 For instance, in the intercultural pilots evaluated by Wilson and Zipfel,121 areas were provided with just £7000 to cover project management and £3000 for actual activities in the neighbourhood. Practitioner workshop participants reported that levels of investment in community-level activities were low, and expectations of rapid improvements unrealistic.
Chapter 9 Limitations, implications and conclusions
In drawing out implications and conclusions from the present project, several limitations should be acknowledged both in terms of the research design and execution, and in relation to the evidence base currently available for synthesis.
Limitations of the research
Searching and literature retrieved
We adopted a broad and inclusive approach to searching and screening relevant literature. Nevertheless, there was a need for a manageable approach. We opted to restrict our searching to a smaller number of electronic databases than originally planned in the protocol, as the initial yield from three databases was high. In keeping with the theory-informed approach, we decided that an iterative approach using citation follow-up and targeted searches was a more appropriate use of available resources. It is, of course, possible that this design decision resulted in some relevant evidence being overlooked.
In addition, we opted not to include search terms related to religion or religious identity, but, instead, to focus on those related to ethnicity, race and migration. This may have resulted in some relevant material not being captured. CP discussions highlighted the importance of faith to many ethnic minority people.
Furthermore, there may be material residing in other literatures (e.g. relating to health promotion, how to tackle racism, build social capital and community assets, and enhance cultural competence of organisations) that is not explicitly linked through to our proximate determinants or outcomes, and so was not picked up through our searches.
Our assessment of gaps in current UK provision is likely to be compromised by under-reporting of activity in grey and published literature. This may be a particular problem for short-term initiatives targeted at our population groups of interest. We suspect many missed opportunities to document initiatives and to learn about intervention processes and outcomes.
Consultation panels
We believe that the CPs were successful; feedback from participants was overwhelmingly positive. CP involvement importantly shaped the research findings. Nevertheless, we acknowledge that earlier engagement, and a greater depth of participation, would probably have been even more valuable. For instance, earlier engagement might have led us to include religious search terms in our database searches. Employing Cook et al. ’s50 framework, we achieved variable levels of participation across the project life cycle, including ‘compliance’, ‘consultation’ and ‘co-operation’. Importantly, however, we also noted the emergence of significant new understanding (characteristic of Cook et al. ’s50 ‘co-learning’ participation level), although this was not within a framework of action-planning in the current project. Failure to establish a London CP, as originally intended, was also a limitation, as this might have offered complementary insights to those from the panels convened in Leicester and Sheffield.
Limitations of the evidence base
Overall, the number of UK papers was small and the quality inadequate. None of the quantitative outcome papers were UK based. Although the use of CP workshops and our synthesis of UK grey literature provided useful complementary evidence, generalisations of findings to the UK context are inevitably cautious.
Testing the causal chains in the logic models was not always possible, as the level of detail provided on interventional content and causal pathways was very varied across the papers, making it difficult to characterise inputs and processes in several cases. There were few quantitative data available on causal chains and moderating factors.
Assessment of the effectiveness of interventions was compromised by study quality. Quantitative papers were generally assessed as being of moderate to low quality, with no studies employing RCTs that had a low risk of bias. Most studies had short periods of follow-up, a serious shortcoming also identified in a 2018 general review of loneliness interventions. 56
A further limitation across both UK and non-UK literatures was the lack of attention to differential access to, and experiences and outcomes of, interventions between population subgroups. Linked to this, very few papers examined intersectionality; that is, the way in which multiple dimensions of individual identity and social location may interplay to create particular disadvantage and risk. 277 Chapter 7 identified some population subgroups that have such ‘intersecting risks’, but the volume of literature was low. Attention to migration histories and sociocultural contexts was also absent in much of the intervention literature, and there were few studies that demonstrated meaningful involvement of affected populations in the design of the initiatives being evaluated.
Implications for practice
Several implications for UK practice emerge from the knowledge generated through this study. These include opportunities to think differently about the nature of loneliness and its potential solutions, as well as promising avenues to improve existing interventional approaches and develop innovative ways of addressing loneliness among migrant and ethnic minority people.
Conceptualising loneliness
Study findings support the complex nature of loneliness and the importance of recognising its multiple dimensions: emotional loneliness (lack of intimacy); social loneliness, (lack of) sense of belonging, feeling isolated; and feeling unsupported.
Study findings demonstrate the utility of the four proximate determinants model to thinking about the routes to reducing or protecting against loneliness: increase positive social ties and interactions, reduce negative social ties and interactions, increase self-worth, and enhance positive appraisal of existing social ties and interactions:
-
Those designing or commissioning loneliness strategies and interventions for local populations may find the model useful in understanding the aetiology of loneliness and potential avenues for action.
-
Practitioners seeking to prevent or reduce risk of loneliness among individuals could use the model in identifying underlying causes/risks and tailoring solutions.
Understanding interventions
Study findings demonstrate the value of identifying the functions of interventions, and their intended pathways of effect, rather than focusing narrowly on the superficial form that they take.
Logic models developed for befriending and SSG interventions were well supported by the evidence. Several of the causal chains identified were also demonstrated in other intervention types:
-
Those designing or commissioning interventions may find these models helpful in assessing the probable success of proposed or existing initiatives by determining whether or not functions and causal pathways are achieved.
Study findings suggest that interventions that target the proximate determinants of loneliness are more effective than those that do not:
-
Those designing or commissioning interventions may find it useful to assess whether or not interventions are likely to be successful in targeting the proximate determinants via tailoring to the particular identified risk factors of a group of beneficiaries; being flexible enough to enable attention to individual risk factors; or involving multiple components that link to all, or most, of the proximate determinants.
Study findings support the assertion that interventions that explicitly aim to boost self-worth are more effective than those that do not:
-
Those designing or commissioning interventions may find it useful to assess whether or not interventions integrate components that directly enhance self-worth (e.g. opportunities to reciprocate, to demonstrate competence, to build confidence via new skills) and/or enable user involvement and a sense of ownership, while avoiding overburdening users.
Findings demonstrate that experiencing negative social ties and interactions is common among migrant and ethnic minority people. There was also some evidence that interventions that fail to address this proximate determinant are ineffective at reducing loneliness:
-
Those designing or commissioning interventions can assess whether or not interventions are adequately combating negative social ties and interactions when they contribute to loneliness among recipients.
Enhancing existing approaches
Shared-identity social support groups
Findings demonstrate that SSGs can be effective across diverse contexts and participants, and identify characteristics of successful initiatives:
-
To enhance success, those designing, commissioning and delivering SSGs can consider ways to ensure that members feel safe and can ‘be themselves’; to cultivate shared identity and reciprocity among members; to provide non-judgemental facilitation and ethos; to enable activity that is regarded by group members as both enjoyable and purposeful; to provide opportunities for members to demonstrate their competence and value; to allow members to shape content and format; to support (rather than undermine) pre-existing social ties, particularly family relationships; and to include activity to buffer the wider hostile context.
Findings suggest that migrant and ethnic minority people value social connections both within and across the ethnic group that they identify with. Findings also highlight the importance of building co-ethnic bonding ties and engaging in authentic social activity, and suggest limited support to do so in the UK context:
-
Those designing, commissioning and delivering initiatives to combat loneliness may find it helpful to consider whether or not available SSGs (e.g. groups, centres, programmes) provide adequate spaces and opportunities for minority ethnocultural celebration and validation.
Befriending
Findings suggest that some befriending initiatives are successful, but that others fail to achieve the distinctive function of ‘one-to-one tailored support’, and also that there are some potential downsides. However, such one-to-one support may be essential for people in highly vulnerable circumstances. Characteristics of more successful initiatives were highlighted:
-
To enhance success, those designing, commissioning and delivering befriending initiatives can consider ways to ensure that befriendees feel heard, affirmed and encouraged; to allow responsiveness to individual needs and preferences; to provide opportunities to demonstrate value and competence; to equip befriendees with skills and resources to build wider social ties; and to address negative (or unfulfilled) social ties.
-
To avoid negative effects, those designing, commissioning and delivering befriending initiatives can consider ways to carefully match befrienders and befriendees; to ensure shared understanding of the nature of the relationship; to attend to and reduce power asymmetry; to focus on building befriendee self-worth; and to allow flexible endings and/or create links to onward sustainable sources of support.
Intercultural encounters
There is some evidence to suggest that intercultural encounter initiatives may have the potential to positively affect dimensions of loneliness, but that they are currently not optimised in terms of these outcomes. Findings suggest that intercultural encounter initiatives are often too short term and limited in scope to achieve their goals:
-
Those designing, commissioning and delivering intercultural encounter initiatives could usefully consider (1) how they could more effectively incorporate functions from SSGs shown to address the proximate determinants of loneliness among migrant and ethnic minority people, (2) how to maximise learning from practice regarding ways to positively shift attitudes and behaviours towards ‘other groups’ and (3) longer-term investments with careful monitoring of a wider range of individual and collective impacts.
Other interventional approaches
Study findings indicate that interventions that are narrowly focused on equipping participants with skills or knowledge intended to support social connectedness are unlikely to be successful for most people at risk of loneliness:
-
Those designing, commissioning and delivering interventions aimed at equipping/training can usefully consider ways to ensure that the skills and information are those that participants themselves identify as needed, to provide opportunities for positive social connections, to incorporate elements that can boost self-worth (opportunities to show competence and value and build self-confidence), and to recognise and counter negative interactions as part of the migrant/minority experience.
Wider system factors and opportunities for action
The study co-produced with practitioners and CP members a ‘loneliness-proofing’ diagram (see Figure 6) that highlights meso- and macro-level processes that influence the risk of loneliness:
-
Those designing or commissioning loneliness strategies and interventions for local populations may find the diagram useful for mapping current activity, identifying gaps and highlighting opportunities for more impactful action.
Findings suggested a number of areas in which current UK activity appears to be low:
-
Those designing or commissioning loneliness strategies and interventions for local populations may consider whether or not action is needed to reduce exposure to negative social interactions (e.g. provision of safe spaces); create associational spaces where people can mingle free of charge; engender neighbourliness among multiethnic communities; address the lack of material resources and poor access to transport that can undermine social connections for some; equip people with skills to improve social relationships; provide training in, and access to, digital technologies to connect across distance; eliminate microaggressions from significant others (e.g. teachers, bus drivers and service providers); provide information, skills and navigational support for people new to their social context; and improve collaboration, signposting and referral between services and resources.
-
Local policy-makers may also find it helpful to consider whether or not broader policy-framing and culture creates (or undermines) an enabling environment in which to tackle loneliness among migrant and ethnic minority groups, and whether or not the contributions of core services and anchor institutions are clear.
Implications for research
Focusing on the UK evidence base relating to migrant and ethnic minority populations, there is a need for research to:
-
co-produce interventional approaches with migrant and ethnic minority people that address the underlying nature and causes of loneliness among these populations (while allowing for heterogeneity and intersectionality)
-
evaluate existing interventions that are being delivered, particularly SSGs, intercultural encounters and multicomponent programmes, by combining careful articulation of intervention logic with rigorous outcome measurement over longer periods of follow-up
-
explore the feasibility, acceptability and impact of interventions currently rare in the UK, including digital technologies, social and communication skills, direct provision of material resources, and light-touch psychological interventions (in institutional settings)
-
synthesise evidence on approaches to tackling racism at interpersonal, structural and cultural levels and their impact on loneliness and other health outcomes
-
examine social connectedness and loneliness as outcomes in evaluations of a wider range of activity, including workplace well-being programmes, transport, housing, sport and physical activity, family support and parenting programmes and psychotherapy, that have the potential to have a positive or negative impact on loneliness
-
examine the role of faith-based organisations, and the role of faith and spirituality, in protecting against loneliness
-
understand more about the role of individual ‘appraisal of existing relationships’ in the production of loneliness and viable strategies for affecting this proximate determinant
-
examine workplaces of various types as a social sphere in which the risk of loneliness may be exacerbated (or indeed mitigated) for migrant and ethnic minority people.
The present study has demonstrated the value of combining a review of published research with active involvement of members of the public; we suggest that future evidence syntheses can learn from the approaches developed here. We also suggest that the logic models developed for common interventional approaches can be used to guide future research.
Conclusions
Common conceptualisations of ‘loneliness’ can be usefully extended to recognise four proximate determinants when focusing on migrant and ethnic minority populations: (1) positive social ties and interactions, (2) negative social ties and interactions, (3) self-worth and (4) appraisal of existing ties.
A wide variety of interventions have been introduced that have the potential to affect loneliness among these groups, the majority operating via proximate determinants 1–3. Befriending, SSGs and intercultural encounters were the most common types. It was possible to develop credible programme theory for the first two of these types, but logic was more tentative for the third.
Evaluation of intervention processes and outcomes was limited by study content and quality. Evidence of positive outcomes was strongest for SSGs. Evidence indicated that some befriending initiatives were successful, but others failed to achieve important elements of the model. Few intercultural encounter studies reported relevant outcomes, although some did provide some evidence of improvement in relevant outcome measures. There was very little evidence relating to long-term impacts for any of the initiatives.
An interlocking set of factors operating at individual, family, community, organisational and wider societal levels produce risk of loneliness, and undermine access to, and impact of, interventions. Interpersonal, structural and cultural racism operate in various ways throughout the system to produce the risk of loneliness.
Overall, the UK evidence base is limited and of inadequate quality. Although a large number of UK initiatives are evident in the grey literature, many appear to be short-lived and remain unevaluated. Activity also often appears to be unco-ordinated. Some interventional strategies that have shown promise elsewhere appear to be rarely adopted in the UK.
A more holistic, systems approach to ‘loneliness-proofing’ for these groups is suggested. This would involve: targeting and tailoring interventions to individual needs, provision of a varied range of formal and informal opportunities for social connection both within and across ethnic groups, effective signposting and referral between agencies, engagement of the general public to increase neighbourliness, and concerted efforts to tackle racism and improve cultural competence in organisations.
Acknowledgements
University of Sheffield
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Emma Everson Hock: risk-of-bias assessment of quantitative papers.
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Edanur Yazici: grey literature extraction and CP workshop facilitation.
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Sarah Baz: grey literature extraction and CP workshop facilitation.
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Natalie Bennett: CP workshop facilitation.
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Jean Hamilton: statistical advice.
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Katie Powell: protocol development.
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Sarah Crede: CP workshop note-taking.
Advisory group members
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Soo Downe, University of Central Lancashire.
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James Nazroo, University of Manchester.
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Jabeer Butt, Race Equality Foundation.
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Ghazala Mir, University of Leeds.
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Annmarie Connolly, Public Health England.
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Isabella Goldie, Mental Health Foundation.
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Janet L Harris, University of Sheffield.
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Karen Barker, Red Cross.
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Mark Petticrew, London School of Hygiene and Tropical Medicine.
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Olivia field, Red Cross.
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Samir Jeraj, Race Equality Foundation.
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Andrea Wigfield, University of Sheffield.
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Susan Cooke, Red Cross.
Consultation panel members and organisers
Shahid Ali, Zanib Rasool, Edyta Bancer, Ursula Myrie, Yvonne Witter, Bereket Loul, Karen Tsui, Nighat Khan, Rodrigo Edema, Pauline Yau, Jean-Marie Minani, Alan Lo, Nupur Chowdhury, Prithvi Venkateswaran, Arturo Serratos De Vecchi, Hareen De Silva, Christy Braham, Pamela Campbell-Morris and Rohini Corfield.
We acknowledge the contribution of all the CP members who did not wish to have their names included in this report, but who contributed to the research. We would also like thank Vinod Kotecha and Anil Gohil, Confederation of Indian Organisations in Leicester, The Race Equality Centre in Leicester and Yvonne Witter and colleagues of Darnall Well Being, Sheffield, for their valuable assistance in the organisation of the panel workshops.
Others
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Laura Evans, Nifty Fox Creative: creation of visual outputs for dissemination and consultation events, and running the final consultation workshop.
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Jo Reynolds, Sheffield Hallam University: grey literature identification and extraction.
Contributions of authors
Professor Sarah Salway (https://orcid.org/0000-0002-7688-5496) (Professor of Public Health): study conceptualisation, data generation, analysis, interpretation and report-writing.
Dr Elizabeth Such (https://orcid.org/0000-0003-2242-3357) (Research Fellow): study conceptualisation, data generation, analysis, interpretation and report-writing.
Dr Louise Preston (https://orcid.org/0000-0001-7477-4517) (Senior Research Fellow): study conceptualisation, data generation, analysis and report-writing.
Dr Andrew Booth (https://orcid.org/0000-0003-4808-3880) (Reader in Evidence Based Information Practice and Director of Information, ScHARR): study conceptualisation, interpretation and report-writing.
Dr Maria Zubair (https://orcid.org/0000-0001-9199-6576) (Research Associate): data generation and analysis; review of final report.
Professor Christina Victor (https://orcid.org/0000-0002-4213-3974) (Professor of Gerontology and Public Health): study conceptualisation, interpretation, review of final report.
Professor Raghu Raghavan (https://orcid.org/0000-0002-3346-0877) (Professor of Mental Health): study conceptualisation, data generation, review of final report.
Data-sharing statement
This is an evidence synthesis study focusing primarily on qualitative evidence; therefore, the data generated are not suitable for sharing beyond those contained in the report. Further information can be obtained from the corresponding author.
Disclaimers
This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the PHR programme or the Department of Health and Social Care. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the PHR programme or the Department of Health and Social Care.
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- Goodkind JR. Effectiveness of a community-based advocacy and learning program for hmong refugees. Am J Community Psychol 2005;36:387-408. https://doi.org/10.1007/s10464-005-8633-z.
- Hess JM, Isakson B, Githinji A, Roche N, Vadnais K, Parker DP, et al. Reducing mental health disparities through transformative learning: a social change model with refugees and students. Psychol Serv 2014;11:347-56. https://doi.org/10.1037/a0035334.
- Goodkind JR. Promoting Hmong refugees’ well-being through mutual learning: valuing knowledge, culture, and experience. Am J Community Psychol 2006;37:77-93. https://doi.org/10.1007/s10464-005-9003-6.
- Mitschke DB, Aguirre RTP, Sharma B. Common threads: improving the mental health of Bhutanese refugee women through shared learning. Soc Work Ment Health 2013;11:249-66. https://doi.org/10.1080/15332985.2013.769926.
- Sporting Equals, Age UK . Fit As a Fiddle: Final Evaluation Report – January 2012. Sporting Equals – Older People Faith and Community Strand n.d. www.ageuk.org.uk/Documents/EN-GB/ID201168_fit_As_A_fiddle_Evaluation_Report_fiNAL130313_fiNAL.pdf?dtrk=true (accessed 18 May 2020).
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- Praetorius RT, Mitschke DB, Avila CD, Kelly DR, Henderson J. Cultural integration through shared learning among resettled Bhutanese women. J Hum Behav Soc Environ 2016;26:549-60. https://doi.org/10.1080/10911359.2016.1172997.
- Rania N, Migliorini L, Sclavo E, Cardinali P, Lotti A. Unaccompanied migrant adolescents in the Italian context: tailored educational interventions and acculturation stress. Child Youth Serv 2014;35:292-315.
- Michael YL, Farquhar SA, Wiggins N, Green MK. Findings from a community-based participatory prevention research intervention designed to increase social capital in Latino and African American communities. J Immigr Minor Health 2008;10:281-9. https://doi.org/10.1007/s10903-007-9078-2.
- Gustafsson S, Berglund H, Faronbi J, Barenfeld E, Ottenvall Hammar I. Minor positive effects of health-promoting senior meetings for older community-dwelling persons on loneliness, social network, and social support. Clin Interv Aging 2017;12:1867-77. https://doi.org/10.2147/CIA.S143994.
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- Fried LP, Carlson MC, Freedman M, Frick KD, Glass TA, Hill J, et al. A social model for health promotion for an aging population: initial evidence on the Experience Corps model. J Urban Health 2004;81:64-78. https://doi.org/10.1093/jurban/jth094.
- Ismail L, Mackenzie J. Convening and facilitating support groups for South Asian family carers of people with dementia: experiences and challenges. Dementia 2003;2:433-8. https://doi.org/10.1177/14713012030023012.
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- Bell J. Migrants: keeping a foot in both worlds or losing the ground beneath them? Transnationalism and integration as experienced in the everyday lives of Polish migrants in Belfast, Northern Ireland. Soc Identities 2016;22:80-94. https://doi.org/10.1080/13504630.2015.1110359.
- Doku F, Meekums B. Emotional connectedness to home for Ghanaian students in the UK. Br J Guid Counc 2014;42:383-402. https://doi.org/10.1080/03069885.2014.916396.
- Mir G, Ghani R, Meer S, Hussain G. Delivering a culturally adapted therapy for Muslim clients with depression. Cog Behav Ther 2019;12. https://doi.org/10.1017/S1754470X19000059.
- Clayton J. Living the multicultural city: acceptance, belonging and young identities in the city of Leicester, England. Ethn Racial Stud 2012;35:1673-93. https://doi.org/10.1080/01419870.2011.605457.
- Vitale A, Ryde J. exploring risk factors affecting the mental health of refugee women living with HIV. Int J Environ Res Public Health 2018;15. https://doi.org/10.3390/ijerph15102326.
- Gardner PL, Bunton P, Edge D, Wittkowski A. The experience of postnatal depression in West African mothers living in the United Kingdom: a qualitative study. Midwifery 2014;30:756-63. https://doi.org/10.1016/j.midw.2013.08.001.
- Wilkins C, Lall R. ‘You’ve got to be tough and I’m trying’: black and minority ethnic student teachers’ experiences of initial teacher education. Race Ethn Educ 2011;14:365-86. https://doi.org/10.1080/13613324.2010.543390.
- Selman LE, Fox F, Aabe N, Turner K, Rai D, Redwood S. ‘You are labelled by your children’s disability’ – a community-based, participatory study of stigma among Somali parents of children with autism living in the United Kingdom. Ethn Health 2018;23:781-96. https://doi.org/10.1080/13557858.2017.1294663.
- Hancock A-M. Intersectionality: An Intellectual History. Oxford: Oxford University Press; 2016.
- Shaw SA. Bridge Builders: A qualitative study exploring the experiences of former refugees working as caseworkers in the United States. J Soc Serv Res 2014;40:284-96. https://doi.org/10.1080/01488376.2014.901276.
- Hudson DB, Campbell-Grossman C, Keating-Lefler R, Cline P. New Mothers Network: the development of an Internet-based social support intervention for African American mothers. Issues Compr Pediatr Nurs 2008;31:23-35. https://doi.org/10.1080/01460860701877183.
- Brage Hudson D, Campbell-Grossman C, Brown S, Hanna KM, Ramamurthy B, Gorthi B, et al. Enhanced New Mothers Network cell phone application intervention: interdisciplinary team development and lessons learned. Compr Child Adolesc Nurs 2017;40:126-35. https://doi.org/10.1080/24694193.2016.1273979.
- De Joseph JF, Norbeck JS, Smith RT, Miller S. The development of a social support intervention among African American women. Qual Health Res 1996;6:283-97. https://doi.org/10.1177/104973239600600208.
- Linley JL. Racism here, racism there, racism everywhere: the racial realities of minoritized peer socialization agents at a historically white institution. J Coll Stud Dev 2018;59:21-36. https://doi.org/10.1353/csd.2018.0002.
- Westwood MJ, Barker M. Academic achievement and social adaptation among international students: a comparison groups study of the peer-pairing program. Int J Intercult Relat 1990;14:251-63. https://doi.org/10.1016/0147-1767(90)90008-K.
- Haynes-Maslow L, Allicock M, Johnson L-S. Peer support preferences among African-American breast cancer survivors and caregivers. Support Care Cancer 2017;25:1511-17. https://doi.org/10.1007/s00520-016-3550-2.
- Nápoles-Springer AM, Ortíz C, O’Brien H, Díaz-Méndez M. Developing a culturally competent peer support intervention for Spanish-speaking Latinas with breast cancer. J Immigr Minor Health 2009;11:268-80. https://doi.org/10.1007/s10903-008-9128-4.
- Cochrane E, Gulec N, Hershkowitz D, Ledoux M, Lee D, Mertaban M, et al. Evaluating Services for Bhutanese Elders at the Champlain Senior Center 2015. https://scholarworks.uvm.edu/cgi/viewcontent.cgi?article=1209%26context=comphp_gallery (accessed 18 May 2020).
- Kieffer EC, Caldwell CH, Welmerink DB, Welch KB, Sinco BR, Guzmán JR. Effect of the healthy MOMs lifestyle intervention on reducing depressive symptoms among pregnant Latinas. Am J Community Psychol 2013;51:76-89. https://doi.org/10.1007/s10464-012-9523-9.
- Carr JL, Koyama M, Thiagarajan M. A women’s support group for Asian international students. J Am Coll Health 2003;52:131-4. https://doi.org/10.1080/07448480309595735.
- Delgado-Romero Edward A, Wu Y-C. Asian international students in counseling programs: a group intervention to promote social justice. J Specialists Group Work 2010;35:290-8. https://doi.org/10.1080/01933922.2010.492896.
- Johnson DR. Examining sense of belonging and campus racial diversity experiences among women of color in STEM living-learning programs. J Women Minor Sci Eng 2011;17:209-23. https://doi.org/10.1615/JWomenMinorScienEng.2011002843.
- Lin YY. Understanding the benefits of an Asian music therapy student peer group. Aust J Music Ther 2014;25:28-44.
- Smith TB, Chin L-C, Inman AG, Findling JH. An outreach support group for international students. J Coll Couns 1999;2:188-90. https://doi.org/10.1002/j.2161-1882.1999.tb00156.x.
- Ashing-Giwa K, Tapp C, Rosales M, McDowell K, Martin V, Santifer RH, et al. Peer-based models of supportive care: the impact of peer support groups in African American breast cancer survivors. Oncol Nurs Forum 2012;39:585-91. https://doi.org/10.1188/12.ONF.585-591.
- Tam C, Poon V. Developing a support group for families with children with disabilities in a Canadian Chinese church community. J Pastoral Care Counsel 2008;62:343-51. https://doi.org/10.1177/154230500806200404.
- Williams E, Barton P. Successful support groups for African American caregivers. Generations 2003;27:81-3.
- Goodkind J, LaNoue M, Lee C, Freeland L, Freund R. Feasibility, acceptability, and initial findings from a community-based cultural mental health intervention for American Indian youth and their families. J Community Psychol 2012;40:381-405. https://doi.org/10.1002/jcop.20517.
- Lood Q, Gustafsson S, Dahlin Ivanoff S. Bridging barriers to health promotion: a feasibility pilot study of the ‘Promoting Aging Migrants’ Capabilities study’. J Eval Clin Pract 2015;21:604-13. https://doi.org/10.1111/jep.12345.
- Im H, Rosenberg R. Building social capital through a peer-led community health workshop: a pilot with the Bhutanese refugee community. J Community Health 2016;41:509-17. https://doi.org/10.1007/s10900-015-0124-z.
- Naidoo L. Developing social inclusion through after school homework tutoring: a study of African refugee students in Greater Western Sydney. Br J Sociol Educ 2009;30:261-73. https://doi.org/10.1080/01425690902812547.
- Frick KD, Carlson MC, Glass TA, McGill S, Rebok GW, Simpson C, et al. Modeled cost-effectiveness of the Experience Corps Baltimore based on a pilot randomized trial. J Urban Health 2004;81:106-17. https://doi.org/10.1093/jurban/jth097.
- Frick KD, McGill S, Tan EJ, Rebok GW, Carson MC, Tanner EK, et al. The costs of Experience Corps (R) in public schools. Educ Gerontol 2012;38:552-62. https://doi.org/10.1080/03601277.2011.595311.
- Fried LP, Carlson MC, McGill S, Seeman T, Xue Q-L, Frick K, et al. Experience Corps: A dual trial to promote the health of older adults and children’s academic success. Contemp Clin Trials 2013;36:1-13. https://doi.org/10.1016/j.cct.2013.05.003.
- Morrow-Howell N, Hong S-L, McCrary S, Blinne W. Changes in activity among older volunteers. Res Aging 2012;34:174-96. https://doi.org/10.1177/0164027511419371.
- Hausmann LRM, Ye F, Schofield JW, Woods RL. Sense of belonging and persistence in white and African American first-year students. Res High Educ 2009;50:649-69. https://doi.org/10.1007/s11162-009-9137-8.
- Ong ASJ, Ward C. The construction and validation of a social support measure for sojourners: the Index of Sojourner Social Support (ISSS) scale. J Cross Cult Psychol 2005;36:639-61. https://doi.org/10.1177/0022022105280508.
- Revenson T, Schiaffino K. Development of a Contextual Social Support Measure for Use with Arthritis Populations. Proceedings of the Arthritis Health Professionals Association: Seattle, WA; 1990.
- Walton GM, Cohen GL. A question of belonging: race, social fit, and achievement. J Pers Soc Psychol 2007;92:82-96. https://doi.org/10.1037/0022-3514.92.1.82.
- Cohen S, Hoberman HM. Positive events and social supports as buffers of life change stress. J Appl Soc Psychol 1983;13:99-121. https://doi.org/10.1111/j.1559-1816.1983.tb02325.x.
- Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Pers Assess 1988;52:30-41. https://doi.org/10.1207/s15327752jpa5201_2.
- Goodenow C. The psychological sense of school membership among adolescents: Scale development and educational correlates. Psychol Schs 1993;30:79-90. https://doi.org/10.1002/1520-6807(199301)30:1<79::AID-PITS2310300113>3.0.CO;2-X.
- Weinert C. Evaluation of the Personal Resource Questionnaire: a social support measure. Birth Defects Orig Artic Ser 1984;20:59-97.
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- Cohen GL, Garcia J, Purdie-Vaughns V, Apfel N, Brzustoski P. Recursive processes in self-affirmation: intervening to close the minority achievement gap. Science 2009;324:400-3. https://doi.org/10.1126/science.1170769.
Appendix 1 Search strategy examples
MEDLINE: initial search (October 2017)
-
refugee*.ti,ab.
-
asylum seeker*.ti,ab.
-
(migrant* or immigrant* or emigrant*).ti,ab.
-
Refugees/
-
“Emigrants and Immigrants”/
-
“transients and migrants”/
-
1 or 2 or 3 or 4 or 5 or 6
-
((Human or child or people or person) adj traffick*).ti,ab.
-
(“first generation” or “second generation” or “third generation”).ti,ab.
-
(“new arrival*” or settler* or newcomer*).ti,ab.
-
((Multi or trans or cross) adj cultural*).ti,ab.
-
(Multi adj (ethnic or racial or lingual)).ti,ab.
-
diaspora.ti,ab.
-
ethnic groups/
-
9 or 10 or 11 or 12 or 13 or 14
-
(traveller* or Gypsies or Gypsy or Gipsy or Gipsies or Romany or Romanies or Romani or Romanis or Rromani or Rromanis or Roma).ti,ab.
-
(black or blacks or “Black African*” or “Black British” or “British African” or “Afrocaribbean*” or BME or BAME or afro-caribbean* or african-caribbean* or caribbean or african*).ti,ab.
-
((European* or arab* or somali* or algeri* or yemini* or Syria* or vietnamese or chinese or caribbean* or Pakistani* or Bangladeshi* or Punjabi* or Somali* or Gujarati* or Japanese or Asian* or Irish or Indian* or Bengali* or Afghanistani* or Turkish or Kurdish or Yemeni* or Albanian* or Polish or Poland or poles or German* or African* or American* or Jamaican* or Nigerian* or Kenyan* or Zimbabwean* or Philippin* or filipino* or “Sri Lankan*” or French or Italian or Chinese or Cantonese or Australia* or Somalia* or Portugues* or Canadian* or Ghanaian* or Lithuanian* or “Hong Kong” or Spanish or Iranian* or “New Zealand” or Kiwi* or Romania* or Iraqi* or Turkish or Cypriot* or Malaysian* or Dutch or Ugandan* or Bulgarian* or Afghan* or Brazilian* or Slovak* or Mauritan* or Singapore* or Nepales* or Hungarian* or Latvian* or Russian* or Tanzanian* or Thai* or Swedish or Greek or Zambia* or Czech or Egyptia* or Trinidad* or Tobago* or Maltese or Austrian* or Belgian* or Libyan* or Korean* or Danish or Swiss) adj (culture* or men or women or male* or female* or people or population* or communit* or neighbourhood* or neighborhood* or group* or area* or demograph* or minorities or minority or ethnic*)).ti,ab.
-
16 or 17 or 18
-
7 or 8 or 15 or 19
-
(loneliness or lonely or alone*).ti,ab.
-
(isolation or isolated).ti,ab.
-
(alienation or alienated).ti,ab.
-
(social adj (inclusion or included or exclusion or excluded or detach* or integrat* or participat* or engage* or interact* or support* or connect* or relations* or coherence or network or assimilat* or acculturat* or accept* or settl*)).ti,ab.
-
((social or bonding or bridging) adj capital).ti,ab.
-
21 or 22 or 23 or 24 or 25
-
20 and 26
-
exp Great Britain/
-
(national health service* or nhs*).ti,ab,in.
-
(english not ((published or publication* or translat* or written or language* or speak* or literature or citation*) adj5 english)).ti,ab.
-
(gb or “g.b.” or britain* or (british* not “british columbia”) or uk or “u.k.” or united kingdom* or (england* not “new england”) or northern ireland* or northern irish* or scotland* or scottish* or ((wales or “south wales”) not “new south wales”) or welsh*).ti,ab,jw,in.
-
(bath or “bath’s” or ((birmingham not alabama*) or (“birmingham’s” not alabama*) or bradford or “bradford’s” or brighton or “brighton’s” or bristol or “bristol’s” or carlisle* or “carlisle’s” or (cambridge not (massachusetts* or boston* or harvard*)) or (“cambridge’s” not (massachusetts* or boston* or harvard*)) or (canterbury not zealand*) or (“canterbury’s” not zealand*) or chelmsford or “chelmsford’s” or chester or “chester’s” or chichester or “chichester’s” or coventry or “coventry’s” or derby or “derby’s” or (durham not (carolina* or nc)) or (“durham’s” not (carolina* or nc)) or ely or “ely’s” or exeter or “exeter’s” or gloucester or “gloucester’s” or hereford or “hereford’s” or hull or “hull’s” or lancaster or “lancaster’s” or leeds* or leicester or “leicester’s” or (lincoln not nebraska*) or (“lincoln’s” not nebraska*) or (liverpool not (new south wales* or nsw)) or (“liverpool’s” not (new south wales* or nsw)) or ((london not (ontario* or ont or toronto*)) or (“london’s” not (ontario* or ont or toronto*)) or manchester or “manchester’s” or (newcastle not (new south wales* or nsw)) or (“newcastle’s” not (new south wales* or nsw)) or norwich or “norwich’s” or nottingham or “nottingham’s” or oxford or “oxford’s” or peterborough or “peterborough’s” or plymouth or “plymouth’s” or portsmouth or “portsmouth’s” or preston or “preston’s” or ripon or “ripon’s” or salford or “salford’s” or salisbury or “salisbury’s” or sheffield or “sheffield’s” or southampton or “southampton’s” or st albans or stoke or “stoke’s” or sunderland or “sunderland’s” or truro or “truro’s” or wakefield or “wakefield’s” or wells or westminster or “westminster’s” or winchester or “winchester’s” or wolverhampton or “wolverhampton’s” or (worcester not (massachusetts* or boston* or harvard*)) or (“worcester’s” not (massachusetts* or boston* or harvard*)) or (york not (“new york*” or ny or ontario* or ont or toronto*)) or (“york’s” not (“new york*” or ny or ontario* or ont or toronto*))))).ti,ab,in.
-
(bangor or “bangor’s” or cardiff or “cardiff’s” or newport or “newport’s” or st asaph or “st asaph’s” or st davids or swansea or “swansea’s”).ti,ab,in.
-
(aberdeen or “aberdeen’s” or dundee or “dundee’s” or edinburgh or “edinburgh’s” or glasgow or “glasgow’s” or inverness or (perth not australia*) or (“perth’s” not australia*) or stirling or “stirling’s”).ti,ab,in.
-
(armagh or “armagh’s” or belfast or “belfast’s” or lisburn or “lisburn’s” or londonderry or “londonderry’s” or derry or “derry’s” or newry or “newry’s”).ti,ab,in.
-
28 or 29 or 30 or 31 or 32 or 33 or 34 or 35
-
(exp africa/or exp americas/or exp antarctic regions/or exp arctic regions/or exp asia/or exp oceania/) not (exp great britain/or europe/)
-
36 not 37
-
27 and 3
MEDLINE: additional search (October 2018)
-
refugee*.ti.
-
asylum seeker*.ti.
-
(migrant* or immigrant* or emigrant*).ti.
-
(“first generation” or “second generation” or “third generation”).ti.
-
(“new arrival*” or settler* or newcomer*).ti.
-
((Human or child or people or person) adj traffick*).ti.
-
((Multi or trans or cross) adj cultural*).ti.
-
(Multi adj (ethnic or racial or lingual)).ti.
-
diaspora.ti.
-
1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9
-
“Emigrants and Immigrants”/
-
ethnic groups/
-
Refugees/
-
gypsies/
-
“transients and migrants”/
-
11 or 12 or 13 or 14 or 15
-
(traveller* or Gypsies or Gypsy or Gipsy or Gipsies or Romany or Romanies or Romani or Romanis or Rromani or Rromanis or Roma).ti.
-
(black or blacks or “Black African*” or “Black British” or “British African” or “Afrocaribbean*” or BME or BAME or afro-caribbean* or african-caribbean* or caribbean or african*).ti.
-
((European* or arab* or somali* or algeri* or yemini* or Syria* or vietnamese or chinese or caribbean* or Pakistani* or Bangladeshi* or Punjabi* or Somali* or Gujarati* or Japanese or Asian* or Irish or Indian* or Bengali* or Afghanistani* or Turkish or Kurdish or Yemeni* or Albanian* or Polish or Poland or poles or German* or African* or American* or Jamaican* or Nigerian* or Kenyan* or Zimbabwean* or Philippin* or filipino* or “Sri Lankan*” or French or Italian or Chinese or Cantonese or Australia* or Somalia* or Portugues* or Canadian* or Ghanaian* or Lithuanian* or “Hong Kong” or Spanish or Iranian* or “New Zealand” or Kiwi* or Romania* or Iraqi* or Turkish or Cypriot* or Malaysian* or Dutch or Ugandan* or Bulgarian* or Afghan* or Brazilian* or Slovak* or Mauritan* or Singapore* or Nepales* or Hungarian* or Latvian* or Russian* or Tanzanian* or Thai* or Swedish or Greek or Zambia* or Czech or Egyptia* or Trinidad* or Tobago* or Maltese or Austrian* or Belgian* or Libyan* or Korean* or Danish or Swiss) adj (culture* or men or women or male* or female* or people or population* or communit* or neighbourhood* or neighborhood* or group* or area* or demograph* or minorities or minority or ethnic*)).ti.
-
17 or 18 or 19
-
(“berkman-syme” or “de jong giervald” or “duke adj2 item” or “duke UNC” or ENRICHD or gijon or litwin or lubben or “medical outcomes study” or “multidimensional scale of perceived social suppor” or MSPSS or “negative affect scale”).ti,ab.
-
(“nottingham health profile social isolation” or “older american* research and service center” or “oslo adj 3” or “personal resource questionnaire” or “UCLA loneliness” or “wenger support network” or “campaign to end loneliness” or selsa).ti,ab.
-
(“social and emotional loneliness scale” or “social disconnectedness scale” or “social adjustment scale” or “health education impact questionnaire” or “scale of perceived social support” or ISEL or “interpersonal support evaluation list” or SPS).ti,ab.
-
21 or 22 or 23
-
20 and 24
-
(((((((project* or intervention* or program* or programme* or case) adj study) or case) adj studies) or policy or policies or initiative* or audit or evaluation or evaluative or research or comparison* or comparator* or study) adj design) or data).ti.
-
20 and 26
-
((Lunch or conversation or social or conversation or support or activity or discussion or liaison) adj (club or class or group)).ti.
-
(Companion* or befriend or doula or mentor* or home visit* or navigator* or mediator* or navigation* or mediation* or neighbour* or neighbor* or volunteer* or peer support*).ti.
-
(((((((contact zone or organised encounter* or integrative moment* or associational space* or inter) adj faith) or inter) adj cultural) or inter) adj ethnic) or cultural event* or faith tour or walking tour or heritage project).ti,ab.
-
28 or 29 or 30
-
20 and 31
-
25 or 27 or 32
-
limit 33 to (english language and humans and yr = “2000 -Current”)
Appendix 2 Early logic models
Appendix 3 Consultation panel details: workshop 1
Characteristic | Sheffield, June 2018 | Leicester, July 2018 | Sheffield, July 2018 |
---|---|---|---|
Life stage | Family-building/working age | Older people | Younger people/university students |
Participants (n) | 10 (including two one-to-one discussions) | 11 | 6 |
Age range (years) | 25–54 | 45,a ≥ 50 | ≤ 34 |
Gender | 3 male; 7 female | 5 male; 6 female | 3 male; 3 female |
Migration status and ethnicity | Mix of people with British BME background, both born in the UK and born overseas; migrants from the EU; people with a refugee background | Mix of people with British BME background, born overseas and born in the UK; British black Caribbean; British black African; British Pakistani; British Indian; British Chinese |
|
Exercise 2 focus | Four interventions discussed: | Four interventions discussed:
|
Four interventions discussed:
|
Appendix 4 Consultation panel details: workshop 2
Characteristic | Sheffield, March 2019 | Leicester, April 2019 | Sheffield, March 2019 |
---|---|---|---|
Life stage | Family-building/working age | Older people | Younger people/university students |
Participants (n) | 8 | 6 | 7 |
Participants (n) in both CP1 and CP2 | 8 | 3 | 3 |
Age range (years) | 25–54 | 45,a ≥ 50 | ≤ 34 |
Gender | 3 male; 5 female | 2 male; 4 female | 3 male; 4 female |
Migration status and ethnicity | Mix of people with British BME background, both born in the UK and born overseas; migrants from the EU; people with a refugee background | Mix of people with British BME background born overseas and born in the UK; British black Caribbean; British black African; British Pakistani; British Indian |
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Exercise focus |
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Appendix 5 Examples of consultation panel workshop exercises
Appendix 6 Examples of visual outputs co-created with consultation panels
Logos reproduced with permission from Nifty Fox Creative and The University of Sheffield.
Appendix 7 Overview of interventions/initiatives in the three common types
Number | Study and location | Study design; sample size; main outcome/focus | Recipients | Befriender identity | Organisational set-up and support | Format of interactions; degree of structure, frequency and duration | Inputs provided aimed at additional functions 2 and 3 |
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1 | Askins 2014;202 UK (Newcastle upon Tyne, north-east England) |
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2 | Government of Canada 2010;204 Canada |
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3 | Renner 2012;224 Austria |
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4 | Shaw 2014;278 USA |
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No information |
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5 | Weekes 2011;98 Australia |
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Support system for tutors in schools |
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✓ Function 2: English language informal practice; practise classroom skills; help with homework, providing cultural context and meaning to tasks |
6 | Ardal 2011;200 Canada |
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Social worker on the service acted as consultant during the relationship |
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✓ Function 2: information provided; support to parenting/being a mother in NICU context |
7 | Campbell-Grossman 2009,66 Hudson 2008279 and Hudson 2012;228 USA |
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Two research nurses supported by research team |
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8 | Brage Hudson 2017;280 USA |
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Research nurses supported by research team |
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9 | Darwin 2017;201 UK, five sites |
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10 | DeJoseph 1996;281 USA |
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Intervention implemented in research context only |
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11 | Hazard 2009;100 USA |
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Pregnant women seen in the health centre assigned a ‘labor friend’ by 32 weeks’ gestation |
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12 | McLeish 2016;218 UK |
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Programme run by ‘Positively UK’ voluntary organisation |
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✓ Function 2: information to reinforce medical advice; practical strategies and problem-solving |
13 |
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14 | Blair 2012;203 USA |
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Delivered by seven community organisations |
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15 | Low 2015;223 Australia |
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✓ Function 3: supporting access to other services and social connections |
16 | LaRosa 2017;219 USA |
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‘Peer coach’, volunteer | Anchored in the wider programme of education |
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17 | Linley 2018;282 USA |
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Descriptive study focused on PSA experiences | Descriptive study focused on PSA experiences | Descriptive study focused on PSA experiences |
18 | Menzies 2015;205 Australia |
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19 | Quintrell 1994;221 Australia |
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20 | Tolman 2017;225 USA |
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No further description of institutional support |
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Nothing explicitly mentioned |
21 | Westwood 1990;283 Canada and Australia |
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No further description of institutional support |
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22 | Holt 2008;222 USA |
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Co-ordinators met with each mentor individually or in a small group of 2–4 mentors once a week to discuss tasks and any challenges |
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✓ Function 2: provision of information, study skills practice and support to sociocultural skills |
23 | Portwood 2005;226 USA |
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A district co-ordinator administers and implements the programme at district level, including co-ordination with volunteers, teachers and administrators |
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No information provided |
24 | Haynes-Maslow 2017;284 USA |
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‘Peer supporter’ | No information provided | No information provided | No information provided |
25 | Nápoles-Springer 2008;285 USA |
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‘Community advocates’ | No information provided | No information provided |
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26 | Tran 2014;229 USA |
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Monthly support meetings with the facilitator for four to nine booster sessions, to completion of monthly activity log and discuss experience |
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27 | Gray 2002;99 UK |
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Regular supervision and debriefing sessions by managers |
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Number | Study and location | Study design, sample size; main outcome/focus | Recipients | Group identity/label; facilitation; user involvement | Location, venues; organisational set-up and support | Format and content of group interactions; intensity, frequency and duration; degree of flexibility; any one-to-one inputs? | Inputs provided aimed at additional functions 2 and 3 |
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1 | Adam 2011;101 Canada |
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2 | Chase 2018;236 Canada |
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3 | Christodoulou;239 UK |
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4 | Cochrane 2015;286 USA |
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Details unclear | In Champlain Senior Center providing services and a community space |
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5 | Frost 2016;231 USA |
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Refugee resettlement agency premises – classroom |
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6 | Koh Lee 2018,243 Liamputtong 2016,234 Walker 2015,241 Wollersheim 2013247 and Wollersheim 2017;246 Australia |
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7 | Logie 2016;102 Canada |
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African Caribbean community and AIDS service |
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8 | Msengi 2015;242 USA |
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Project directors advertise programme and guide activities for participants |
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9 | Pejic 2016;235 USA |
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10 | People’s Health Trust 2018;212 UK |
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11 | Stewart 2011214 and Stewart 2012;215 Canada |
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12 | Stewart 201563 and Stewart 2018;216 Canada |
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13 | Weine 2003;237 USA |
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Weekly supervision of facilitators |
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14 | Canuso 2003;68 USA |
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Pregnancy Care Campaign – group event as central organising feature |
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15 | Kieffer 2013;287 USA |
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Community venue at community organisations, and private homes |
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16 | Rooney 2014;238 Australia |
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Location unclear |
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17 | Cant 2005;104 UK |
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18 | Collins 2006211 and Collins 2006;248 USA |
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19 | Phinney 2014;249 USA |
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20 | Saito 2012;103 Japan |
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21 | Carr 2003;288 USA |
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22 | Chalungsooth 2009;168 USA |
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The group convened at the university’s coffee house, a location that was easily accessible and familiar to most students |
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23 | Clauss-Ehlers 2007;230 USA |
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University premises |
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24 | Cunningham 2015;213 USA |
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University premises; ‘Institutionally Designated Safe Space’ |
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25 | Delgado-Romero 2010;289 USA |
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Campus location |
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26 | Dipeolu 2007;167 USA |
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27 | Grier-Reed 2008,240 2010,209 2013,210 2016;208 USA |
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28 | Johnson 2011;290 USA |
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Varied |
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29 | Jones 2012;105 USA |
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University premises, and outings elsewhere |
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30 | Lin 2014291 USA |
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Homes of group members |
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31 | Liptow 2016;109 USA |
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32 | Means 2017;177 USA |
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33 | Page 2015;244 USA |
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Four groups met in a room in the counselling centre and three groups met in locations outside the counselling centre |
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34 | Smith 1999;292 USA |
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Non-stigmatising venues, for example cultural centres, English as a second language departments |
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35 | Williams 2017;233 USA |
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Venue unclear, Chicago, IL |
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36 | Yakunina 2010;166 USA |
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International students |
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Non-stigmatising venues; welcoming atmosphere |
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37 | Ashing-Giwa 2012;293 USA |
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Varied, community-based health centres, cancer centres and churches |
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Insufficient detail – varied groups |
38 | Chaudhry 2009252 and Gater 2010;268 UK |
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39 | Hatzidimitriadou 2009;69 UK |
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Community-based venues |
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40 | Ismail 2003;266 UK |
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Venue chosen by participants – generic day-care centre known and respected; informal setting; not labelled as dementia related |
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41 | Morales-Campos 2009;232 USA |
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Community-based organisation |
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42 | Nieuwboer 2016;108 Sweden and the Netherlands |
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43 | Siller 2017;250 Austria |
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Location unclear |
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44 | Tam 2008;294 Canada |
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Self-help type group | Chinese immigrant church |
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45 | Williams 2003;295 USA |
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46 | Local Government Association;106 UK |
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47 | People’s Health Trust 2017;245 UK |
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48 | Lin 2009;107 Canada |
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Online, and various venues |
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49 | Goodkind 2012;296 USA |
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Various locations; multicomponent initiative |
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Number | Study and location | Study design; sample size; main outcome/focus | Recipients | Initiative label/identity; facilitation; user involvement | Organisational set-up and support; location, venues | Format and content of interactions; intensity, frequency and duration; degree of flexibility/tailoring | Inputs provided aimed at additional functions 2 and 3 |
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1 | Askins 2011;110 UK |
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2 | Borgogni 2015;111 Italy |
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Complex, multilevel intervention targeting local districts with high levels of migrant settlement; close partnership with existing stakeholders and organisations |
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3 | Goodkind 2014113 and Hess 2014;255 USA |
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Refugee–student pairs fixed over time; fostering comfort and trust |
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4 | Goodkind 2004,112 2005254 and 2006;256 USA |
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5 | Naidoo 2011;114 USA |
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6 | Nathan, 2013;115 Australia |
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7 | British Academy, 2017;116 UK |
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8 | British Academy, 2017;117 UK |
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9 | British Academy, 2017;118 UK |
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10 | Phillimore 2017;253 UK |
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11 | Whyte 2017;120 Denmark |
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12 | Wilson 2008;121 UK |
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Part of a larger Refugee Housing Integration Programme. Small-scale community-based projects, funded under larger scheme |
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13 | Parks 2015;122 UK |
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14 | Abe 1998144 and Geelhoed 2003;123 USA |
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15 | Anderson 2008;124 New Zealand |
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Women Across Cultures | Fortnightly low-key meetings and activities as well as occasional larger events that were also open to family and friends |
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16 | Gilboa 2009;126 Israel |
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17 | Sakurai 2010;125 Australia |
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Supervisor (academic), a few senior international students |
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18 | Frankenberg 2016;128 Germany |
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19 | Raw;127 UK |
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20 | Franz 2015;129 Austria |
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21 | Mayblin 2016;130 UK |
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22 | Mills 2017;131 UK |
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23 | British Academy 2017;132 UK |
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24 | Slatcher 2017133 UK |
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25 | Berryhill 2006;141 USA |
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26 | Mayblin 2016;142 Poland |
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A grass-roots project | Commitment to antiracism, antisexism and antihomophobia | City-wide football league; teams must include players from at least three different nationalities |
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27 | Caponio 2017;135 Italy |
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28 | de Quadros 2017;136 Sweden |
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29 | Philipp 2015;143 UK |
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30 | DCLG;145 UK |
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Area-wide initiative involving various local partner organisations, led by Local Strategic Partnership |
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31 | Matejskova 2011;137 Germany |
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Community venues |
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32 | Shinew 2004;139 USA |
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Gateway Greening | Various neighbourhood gardening plots |
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33 | Thomas 2016;72 USA |
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34 | Riis 2017;138 Denmark |
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35 | Wilson 2013;140 UK |
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International not-for-profit network |
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Appendix 8 Overview of other interventions/initiatives
Study and location | Study design, sample size; main outcome/focus | To whom | By whom | What | Where; intensity, frequency, duration | Proximate determinants targeted (explicitly or implicitly); main broad strategies intended |
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Beeber 2013;162 USA |
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Health-care professional – nurse |
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Eisdorfer 2003;156 USA |
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Health-care professional – therapist |
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Elligan, 1999;157 USA |
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Health-care professional – clinical psychologist, African American male |
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Gray, 2104;163 USA |
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Social worker, with enhanced role |
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Grote 2009;158 USA |
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Health-care professional |
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Jesse 2016;159 USA |
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Health-care professional plus ‘Resource Mom’ support staff |
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Masood 2015;164 UK |
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Muñoz 2007;161 USA |
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Facilitators with training in clinical psychology and supervised by licensed clinical psychologist |
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Mynatt 2008;165 USA |
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Church counsellor |
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Smith 2014;155 Australia |
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Psychology-trained facilitators; local and international students (role models) |
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Toth 2013;160 USA |
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Trained therapists, experienced, weekly supervision |
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Study and location | Study design, sample size; main outcome/focus | To whom | By whom; user involvement? | What | Where; intensity, frequency, duration; personalisation? | Proximate determinants targeted (explicitly or implicitly); main broad strategies intended |
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Arola 2019,153 Barenfeld, 2015, Gustafsson 2017263 and Lood 2015;297 Sweden |
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