Health

That lonely feeling

WHO has recognised loneliness as a public health crisis and is trying to devise a way to measure the condition that affects a quarter of the world population 

 
By Rohini Krishnamurthy
Published: Monday 22 January 2024

Arijeet Mandal’s struggle with loneliness began at the age of 10. He would often wonder why he felt sad when everyone around him was happy. “Back then, I did not know how to describe how I was feeling,” he says. Mandal lost his sibling at age 13 and his mother the following year. “I did not see efforts from my family to process the grief. Three months after my mother’s death, people were too busy trying to get my father remarried. My faith in the institution of family and marriage collapsed,” he says. Though Mandal moved to Kolkata in 2007 and has since become an assistant professor of film studies at the Jadavpur University, he continues to feel lonely. “I am a Dalit man. Most of my friends and colleagues are from upper caste and upper-middle-class. I feel that I am all alone,” he says.

Though seldom talked about in the society, the feeling of loneliness that Mandal has lived with most of his life is experienced by almost a quarter of the world’s population, suggests “The Global State of Social Connections”, the largest worldwide study on loneliness conducted in 2023 by US-based technology firm Meta, and analytics and advisory company Gallup. In India, the study found that as high as 30 per cent of the respondents reported to feeling lonely.

In psychology, loneliness is defined as a subjective feeling of lacking social connections. It is, however, not the same as being alone. “Loneliness is subjective because the experience can vary from one person to another,” says Aparna Shankar, professor of psychology at FLAME University, Pune. This feeling can be triggered by social isolation, which is defined as a lack of social contact. But it can also occur when people are surrounded by friends. For instance, Sheela (name changed) felt the sting of loneliness in her early 20s after she had just moved to Delhi to work at a publishing house. This was in 2013. Hailing from a small town, she describes moving to a big city as a huge cultural shift. “I tried to fit in. I attended parties. But I was feeling empty because there was no emotional connection. In retrospect, it was a very long period of feeling lonely,” she says. Shankar explains that this is because loneliness can occur when one is dissatisfied with the quality of a relationship. Sheela is currently in therapy for depression and anxiety.

The prevalence of loneliness is so high that the World Health Organization (WHO) last November described it as a priority public health problem and announced a new Commission on Social Connection to address it. The commission, comprising 11 psychologists and mental health experts, is tasked with defining a global agenda on social connection, raising awareness and building collaborations for evidence-based solutions.

While a welcome step, experts that Down To Earth (DTE) spoke to warn that the commission will need to address several key knowledge gaps to be able to prescribe effective solutions. For starters, there are inconsistencies in how loneliness is measured. “Given that loneliness is based on a subjective emotional experience, self-reported measures (such as questionnaires) are the most suitable to evaluate it and, given its significance for health, it is pivotal to have validated tools to measure it,” says a July 2021 research paper published in Current Psychology.

DTE analysed two surveys in India—by WHO in 2007-08 and by the Union Ministry of Health and Family Welfare in 2017-18—and found that the participants were asked: “Did you feel lonely for much of the day yesterday?” and “How often did you feel alone in the past week?” Such questions do not help in adequately measuring loneliness. “An individual living in a society that stigmatises loneliness is less likely to be forthcoming,” says Melody Ding, associate professor at the University of Sydney in Australia. But if people are asked if they are happy with their social connections, they are more likely to open up.

Ding also calls for more research to calibrate how loneliness is perceived in different cultures and languages. For example, there is no translation for loneliness in many languages in India, says a 2022 report, “Loneliness in India” by Delhi-based non-profit Ananta Centre, information-focused agency Aspen Digital and Meta. “It could prevent an accurate articulation of the emotion, thus limiting the development of appropriate interventions,” says the report.

Without factoring in language and culture, people might respond differently to the same set of questions. “This is something that still needs a lot of work from the scientific community in terms of the best way of measuring it,” says Ding. In a 2023 paper published in Public Health Research and Practice, Ding and her colleagues urged WHO to develop population-level surveys that use comparable measures of loneliness and social isolation across the globe to understand the prevalence of loneliness.

The UCLA Loneliness Scale, one of the most widely used tools to measure loneliness in the world, also suffers from many limitations. It cannot, for instance, distinguish between short-term and long-term loneliness. It also does not factor in the cultural realities of the respondents, making it unsuitable for most countries.

Loneliness often pushes people towards several ailments. It increases the risk of cardiovascular diseases by up to 30 per cent and of type-2 diabetes by 98 per cent. A person facing loneliness is also 14 times more likely to be depressed and is highly prone to suicidal thoughts. Loneliness also triggers behavioural changes such as smoking and alcohol abuse.

Shankar says the general perception is that loneliness affects only the old population, but people from all age groups and backgrounds suffer from it. There is also a lot of societal stigma associated with loneliness, and, as a result, people suffering from it often experience extreme shame or fear that they will be further alienated if they talk to others.

Data disparity

A 2022 study published in the British Medical Journal looked at 113 countries or territories and found that most low- and middle-income countries do not report any nationally representative information on loneliness. Most data, the paper finds, are from Europe. “The substantial difference in data coverage between high-income countries (particularly Europe) and low- and middle-income countries raised an important equity issue,” the study highlights.

Low- and middle-income countries like India face different socioeconomic challenges that can trigger loneliness compared to the wealthy world, notes a 2022 paper published in the International Journal of Food and Nutritional Sciences. These include high poverty, income inequality, low education, high dependency ratio, lack of transportation, unplanned urbanisation, rapid industrialisation and a deterioration in social capital.

The paucity of research and data can be seen even in India. The 2022 British Medical Journal paper shows that national prevalence data in the country is only available for older adults, who make up around 10 per cent of the population. There is little information on how widespread it is among adolescents, young and middle-aged adults.

One of the India-specific studies, published in 2020 in Ageing International, shows that nearly 18 per cent of old adults reported feeling lonely. The study by researchers from the International Institute for Population Sciences and Sree Chitra Tirunal Institute for Medical Sciences and Technology interviewed 6,532 adults aged 50 in six states: Assam, Uttar Pradesh, West Bengal, Karnataka, Maharashtra and Rajasthan. The participants were asked if they felt lonely for much of the previous day.

Another study, published in The International Journal of Geriatric Psychiatry in 2021, included a much larger sample size of 72,262 middle-aged and older adults. The paper looked at data from a national community-dwelling survey in India conducted in 2017-18. The participants were asked how often they felt alone in the previous week. Their analysis revealed that the prevalence of moderate loneliness (1-2 days a week) was 20.5 per cent and severe loneliness (3-7 days a week) was 13.3 per cent.

Some studies have examined factors driving loneliness. Shankar and her colleagues assessed the role of work-related factors and food security on older adults’ levels of loneliness by combing the 2017-18 national community-dwelling survey data and filtering out participants below the age of 60 years. She found 31,477 old respondents and of them, 9,309 were employed.

Source: “The prevalence of loneliness across 
13 countries: systematic review and meta-analysis”, published in the British Medical Journal on February 9, 2022

Her theory was that adverse working conditions such as exposure to noxious substances or odours were associated with higher levels of loneliness. A lack of food choice and availability are associated with greater feelings of loneliness among those who work. Her report showed that over 11 per cent of participants reported being lonely most or all of the time and over 20 per cent experienced this feeling some of the time. The study also found that people in unpleasant working conditions had higher odds of loneliness compared to those in jobs requiring more mental effort. Participants facing higher levels of food insecurity had over twofold higher odds of reporting loneliness. The findings were published in a 2023 paper in the Journal of Applied Gerontology.

Research has also pointed to links between a rise in loneliness and urbanisation. “Increased urbanisation means there is more privacy and seclusion. And this has led to many physical and psychological problems,” says Vidya Yadav, assistant professor at Patliputra University, Patna. As a research scholar with the International Institute for Population Sciences in Mumbai in 2016, Yadav had surveyed 450 households in three suburbs of Mumbai: Dadar, Bandra and Chembur, between January and June 2016 and found that around 7 per cent of respondents often felt lonely, and 21 per cent sometimes felt lonely.

Yadav’s paper also found some issues with a government housing scheme. In 1995, the Maharashtra government launched a rehabilitation scheme to provide free housing for slum dwellers. “I found high levels of loneliness among those residing in slum rehabilitation buildings. They have shifted from that horizontal slum area to the vertical apartments. This shift may have affected sensory connectedness and the traditional flows as the buildings and the flats were allocated randomly to the households, which may have hampered their collective identity and their social support network,” she says.

Evidence is also emerging that the current cost-of-living pressure is likely to exacerbate loneliness, suggests a policy paper, “Tackling Loneliness”, published in March 2023 by the UK government.

The COVID-19 pandemic has worsened the problem because it has altered the typical patterns of social connection for many people, says “The Global State of Social Connections” report.

This is consistent with several studies that have shown social distancing and lockdowns during the pandemic have led to increased rates of loneliness.

Countries with a plan 

The fallout of the world’s limited understanding about loneliness is that there are limited policy mechanisms or long-term interventions to fight loneliness, says Debanjan Banerjee, consultant neuropsychiatrist at Apollo Multispecialty Hospitals, Kolkata. Identifying lasting interventions for loneliness is one of the intended outcomes of the WHO commission. Ding’s 2023 research paper notes that there has been an uptick in intervention studies addressing loneliness in the last five years. “We now need an overall synthesis of the findings from intervention studies to be undertaken with an implementation lens to derive clear recommendations of which interventions work, for whom, and pin what contexts,” states the paper.

Currently, only two countries—the UK and Japan—have a dedicated ministry to fight loneliness. The UK in 2018 became the first country to set up a Union Ministry of Loneliness. In 2021, after the pandemic, Japan followed suit.

The UK ministry has three guiding objectives: reduce stigma around loneliness, introduce initiatives that bring about a lasting change and improve the evidence base on loneliness.

The country, in the past five years, has innovated several schemes such as conducting loneliness training for receptionists at government hospitals to identify and interact with patients who are lonely to running a “Happy Cab” service in Leeds county. The Happy Cab offers a door-to-door service to get people where they need to go and have a conversation on the way. All drivers have received happiness training to help them create a positive and welcoming environment. Journey-sharing is encouraged, so that passengers can meet new people from their area and socialise. According to the Royal College of General Practitioners, “Three out of four general physicians (in the UK) say they see between 1 and 5 people a day who have come in mainly because they are lonely.”

Japan, in May 2023, enacted a legislation to arrest loneliness among its people. A 2022 study published in Psychiatry Research suggests that 41.1 per cent of Japanese are lonely. The legislation calls for the creation of a Headquarters for Promotion of Measures for Loneliness and Isolation to formulate a priority policy that will serve as guidelines for measures to curb loneliness. The country has also mandated local governments to set up councils made up of groups that offer help to people suffering from social isolation.

The governments of Denmark and the US have also established national programmes of work to address loneliness, social isolation and social connection. A May 2023 report released by the US government says that even before the pandemic, about half of the country’s adults were experiencing measurable levels of loneliness.

In India, like in most countries across the world, there are no policies targeting loneliness. The issue does not find mention in the “National Mental Health Survey of India, 2015-16” released by the Union Ministry of Health and Family Welfare. The country has two existing national policies dealing with older adults. The National Policy on Older Persons, 1999, talks about loneliness once in the entire policy document. But that is in context of volunteers being encouraged to assist older adults who are confined to their homes, explains Shankar in her 2023 paper. Similarly, the National Policy for Senior Citizens, 2011, mentions loneliness just once, noting that it is higher among older women than men.

The 2022 International Journal of Food and Nutritional Sciences paper notes that India needs to conduct longitudinal studies, where participants are tracked for risk factors or health outcomes over time, which can also last decades. Such research can then be used to develop or implement effective interventions.

It remains to be seen if WHO’s Commission on Social Connection, which is expected to release its first report by mid-2025, will highlight these issues. “The report will form a common reference guide for every stakeholder, including physicians, organisations, social workers and policymakers,” says Banerjee.

This was first published in the January 16-31, 2024 print edition of Down To Earth

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