Rural Social Isolation, with Carrie Henning-Smith

Organizations and resources mentioned in this episode:

• University of Minnesota Rural Health Research Center
• Social Relationships and Mortality Risk: A Meta-analytic Review, PLoS Medicine, 7(7), e1000316, 2010
• Addressing Rural Social Isolation as a Health and Mortality Risk Factor, University of Minnesota Rural Health Research Center research project and related publications
• Rural Health Models and Innovations: Geezers, Gulpers, and Gardeners, Rural Health Information Hub
• Center for Community-Engaged Learning, University of Minnesota
• Minnesota LSTA (Library Services and Technology Act) Five-Year Plan: 2023-2027, State Library Services, Minnesota Department of Education

Transcript

Andrew Nelson: Welcome to Exploring Rural Health, a podcast from the Rural Health Information Hub. My name is Andrew Nelson. In this podcast, we'll be talking with a variety of experts about providing rural healthcare, problems they've encountered, and ways in which those problems can be solved. This is an episode about social isolation.

Today I'm talking to Dr. Carrie Henning-Smith. She's the Deputy Director of the University of Minnesota's Rural Health Research Center. Thank you for joining us today, Carrie.

Carrie Henning-Smith: It's my pleasure. I'm really glad to be here for this conversation.

Andrew Nelson: Absolutely. First of all, can you tell us what social isolation is?

Carrie Henning-Smith: Okay. This is a really important place to start. Social isolation is an objective lack of people or social contact, social relationships in your life. There are other ways that we measure social well-being, though. They include loneliness, which is a subjective measure of whether or not someone's social needs are being met. So people, everyone has a different level of social need that they have for themselves, and people know for themselves whether or not they feel like that's being met. And then it's also important to understand who someone lives with, if someone's living alone or not. These are all distinct from each other, but interrelated, and really important to look at.

Andrew Nelson: How have you seen that social isolation can adversely affect different people's health or safety?

Carrie Henning-Smith: Social isolation is so intricately tied with other health outcomes. I really think of social well-being as a health outcome in and of itself, but above and beyond that, being socially isolated or lonely, especially for a prolonged period of time, are associated with a really wide range of negative health outcomes. These include poorer immune system functioning, cognitive decline, heart disease, and mortality. There was a study that came out several years ago now, but it's been very widely cited, from researchers at Brigham Young University, showing that prolonged loneliness is associated with the same health risks as smoking 15 cigarettes a day. Also, associated with the same risk as being obese. And we have put a lot of attention in public health on those health risk factors. I think we've put less attention on social well-being.

Andrew Nelson: Have you seen that there are differences as to how and how much people experience social isolation across the rural-urban continuum?

Carrie Henning-Smith: Yeah, I have. We, in our work at the University of Minnesota Rural Health Research Center, have investigated this question and found some differences, and other researchers have also found differences in social well-being across the rural-urban continuum. What I can say about all of that combined is that the results are pretty mixed. We have a complex story. Pretty consistently, research shows that rural residents have greater social cohesion. So, this sense of community and connectedness with your neighbors, with your larger community. And we found in our own research and other research has borne this out, that rural residents have larger social networks. They have bigger families, but also more friends, more people in their lives. Despite that, in a study that we published a few years ago, we found that older adults in rural communities reported bigger social networks, but they also reported that they were more lonely, which to me, tells me a couple of things. It points at the importance of looking at multiple measures of social well-being; just one measure alone won't tell us the whole story. And it points to a disconnect. People might have a large social network, might feel connected to their community, but there might still be barriers to their social well-being altogether.

Andrew Nelson: Does that mean that in many cases somebody in a rural area that has a large social network while still experiencing social isolation, because while they know a lot of people, or they have a lot of friends, they're just not regularly interacting with them?

Carrie Henning-Smith: Yes, that's exactly right. And we have some theories about why that might be based on qualitative research that we've done, that look at specific barriers to social interaction and social activity for rural residents. So having people in your life is really important, but it's not the whole answer. You still need something to help you actually meaningfully connect with those people.

Andrew Nelson: Sure. You were speaking just now about groups of older people. What differences in incidence of social isolation have you seen between different demographics, whether men or women or younger people or older people, and what did you find were the causes of those differences?

Carrie Henning-Smith: Yeah, this is such an important question. I'm really glad you're asking it. I want to start by saying that loneliness and social isolation are really common. Most people will experience one or both of those at some point in their life. I think that's important to say. Just to normalize it. There's a lot of stigma around saying that you're lonely or feeling isolated. And so just saying that, just normalizing it and saying that most people will experience this at some point, if they're not currently experiencing it, that is important. Despite that, from the research that we've done and research that lots of other folks have done, I can say that there are different risks for different pockets of the population. And I spoke just a minute ago about older adults. Older adults face unique risks of social isolation and loneliness just because of the many life transitions that happen at that period in life — perhaps retirement, perhaps losing a partner or spouse or friends, children moving away, perhaps change in health and functional status.

There's a lot that happens in someone's life in the older ages that might impact social well-being. And older adults actually do not face the highest risks of loneliness in social isolation. The most recent research, including data that's been collected during the COVID-19 pandemic, shows that the highest risk for social isolation and loneliness is among younger adults. And this brings me a lot of concern, knowing the long-term health impacts of being socially isolated and lonely. I'm really worried about what this means for the future for all of those younger adults. I'm worried about what it means for the ways that we're involving and connecting with them. There are also differences by gender, but those tend to be somewhat mixed. A lot of research shows they have relatively similar rates of loneliness and social isolation, but their risk factors are very different.

Historically, men were more likely to base their social networks around work, and women were more likely to have diversified social networks. But women are also more likely to outlive their partners, which places them at unique risk later in life. And then I also want to call out that there are higher rates and higher risk of social isolation and loneliness among many black, indigenous and people of color [BIPOC], and also among members of the LGBTQ+ population. We've found that in our work, so it bears out in rural populations, and I've seen that in other research that people have done nationally, not looking specifically at rural residents. And I think the cause there, I think what might be going on, is that it's indicative of it being isolating to be in the minority in your community or feel like others don't see or understand your lived experience.

So, we just talked about some of the demographic differences and demographic risk factors, but there are other things that contribute to social isolation and loneliness. Research, including the work that we've done consistently shows that being low-income puts you at higher risk, as does being in poor health or having a disability. And I think there are specific reasons for those. If you are low or lower income, you may need to focus your time and attention on putting food on your table and making the rent payment. And that might not leave a lot of time for developing, nurturing, fostering social relationships or finding opportunities for social activity. And being in poorer health or having a disability sometimes means that you are spending time attending to your health appropriately. And it might also indicate that there are not accessible or available social activities for you, that it's harder to find places that are accommodating and accessible and available to you.

There are other risk factors that are associated with all of these — not having access to transportation, not having access to digital connectivity, not having places to gather in your community that feel safe and welcoming. And all of those are distinctly challenging in rural communities. But I do also want to mention that rural communities have many assets, and I think this is part of why we see strong social cohesion in rural communities. People tend to know one another. People are slightly less likely to move. Migration is lower in rural communities, and altogether you have a strong sense of community as a result.

Andrew Nelson: You mentioned social media just now, and we often hear about how social media can have kind of a mixed impact on people's well-being. Could you talk about some of the factors in rural communities, like social media or other things, that can either contribute to or help protect people from social isolation?

Carrie Henning-Smith: Yeah. Social media is such a mixed bag, and it's so complex, but we can't ignore the reality of it. It plays a major role in life today. Whether you engage with it personally or not, it's still a reality of our society and life. And so a few things I want to say about social media. The research really is very mixed on the impacts on social well-being of using social media. But what we know is that if you are passively using social media, just sort of scrolling through and seeing these glamorous lives that everyone else is living, seeing everyone else looking happy and making the perfect food or on vacation or whatever it is, that is detrimental for mental health and social well-being, you end up comparing yourselves to others. And no one comes out on top in that equation. But for people who use social media to connect with one another — to form relationships, and then ideally move from that digital space to an a in-person interaction, actually meeting and getting to know one another — that's been shown to have very positive benefits on social well-being and mental health.

And so I want to recognize that in rural communities, there are unique challenges and opportunities here. The obvious challenge is that rural communities still face inequities related to broadband internet access and being able to afford it, even if it is available in your community. I know there's been a lot of investment recently in broadband expansion, which is wonderful, but that's just a first step we know to go further to make sure that people can afford the broadband and make sure that people have a device with which to use and access it, and that they know how to use that device in a way that feels comfortable and that lets them have these meaningful interactions. But also in rural communities, back to the idea of being lonely in your community, perhaps you don't feel like anyone else in your small town knows your lived experience or understands what you're going through. Social media can provide a real opportunity for people to make connections with others around the country and around the world who might understand what it's like to have a particular health condition, or to be LGBTQ+ or to be BIPOC, or whatever that condition is or that situation is, that might feel isolating in some communities. Social media can really provide opportunities to make those connections that can be very meaningful.

And again, rural communities have so many things going for them, so many assets, really building on the fact that there is strong social capital that people tend to know one another. That's such a strength and such a wonderful place to build on. And then there are organizations, entities in rural communities that can really play a major role here. Faith-based communities are one of them. And we know that participation in faith-based communities is higher in rural communities than in urban. And so that presents a real opportunity and a real strength for rural to connect people with one another. But there's also a role for schools and libraries and healthcare and all of these other social institutions that we have to connect people with one another and give meaningful opportunities for gathering. But despite those strengths and those assets, there are of course challenges.

And these challenges I don't think will be a surprise to anyone listening. They're the same challenges that emerge when we talk about just about any rural health issue. Transportation is a huge one to have meaningful social interaction. You can do that over the computer or the phone. But you also need to be able to see people in person. And if transportation is a barrier, if you don't have access to transportation, that can really make it challenging. And transportation is just this perennial complex issue in rural communities. On top of transportation, some rural communities have fewer gathering places, or they may have gathering places, but the hours are limited. The accessibility of those places may be limited for people who need a physically accessible environment. So just having enough available, accessible, and welcoming social infrastructure is a real challenge in rural communities.

And then healthcare, I think, plays an important role here, too. Not necessarily as a social convener, although there are rural communities doing innovative things bringing wellness centers or coffee shops or community forums and activities into healthcare facilities. But above and beyond that, healthcare is really important to address the impact of social isolation and loneliness. So, if you live in a rural community where access to healthcare is challenging — perhaps you've lost a clinic or providers or a hospital — getting care that you need in a timely manner to address the impacts of social isolation and loneliness are going to be more challenging. And I think that that's a distinctly rural issue.

Andrew Nelson: So with some of these issues that we've seen are affecting the rural population, what are some things that healthcare providers can do to identify and help to address social isolation in their patients?

Carrie Henning-Smith: This is a great question, and I am hesitant to put the onus on healthcare providers entirely because I know they're already handling so much. They are asked to address such a wide range of social needs and physical and mental health needs in their very short visits that they have with patients. And yet, knowing what we know about the importance of social well-being to, to all other health outcomes, I think it's important for healthcare providers to be aware of this. So as a first step, just understanding why social well-being is so important to health is really important, so educating themselves. But beyond that, there is a lot of work going into developing appropriate screening tools to identify loneliness and social isolation in the clinical setting. And I think that that's a really good first step, but I think it only works if healthcare providers have a way to follow up and refer people if they're found to be socially isolated and lonely.

It's good for healthcare providers to know if someone is feeling that way or if someone doesn't have anyone else in their life that they can turn to. But knowing that is not enough. And so this requires partnerships with other community organizations. It requires, ideally, the involvement of community health workers or community paramedics or a social worker or other people who might have more time to really be with someone to think through possible solutions. And to think with each person who's identified as socially isolated or lonely about what excites them, what social opportunities would they want. There's not a one-size-fits-all fix for this. And so that makes it really hard for providers to address. This is not something where you can simply prescribe a medication or a treatment regimen. What people want for their social lives is going to look different from one person to another. And so this is really about listening to patients and about relationship building.

I love talking about this because I think there are so many creative ideas, and as complex as this problem is, there are just as many innovative solutions out there. I think complex problems offer us opportunities for creative solutions and for addressing a problem from many angles. I just want to put in a plug that I know RHIhub already has lots of great examples throughout the website on ways that rural communities are bringing people together. I'm thinking of one the from rural North Carolina where retired men are coming together for coffee and conversation, which is so simple, but having that deliberate intentional opportunity for people is so meaningful. So that's one of hundreds of examples that I know exist throughout RHIhub, but I want to highlight a couple others that I think are really useful and interesting.

One example is involving the libraries. We recently had a retired woman from northern rural Minnesota go through a community-based training program that we have at the University of Minnesota to address a problem in her community. And the problem she wanted to address was social isolation among older adults. And the solution that she felt held a lot of promise was looking at digital literacy for older adults and digital inclusion for some of the reasons that we've already covered. She was able to work with the Minnesota Library Plan, the Minnesota libraries have a five-year plan, and she was able to work into that five-year plan, additional programming and resources for expanding digital inclusion for older adults in rural libraries, which I think is so exciting. I think libraries offer a lot of opportunity not only for helping people with digital literacy, but also because of the programming that they offer and the ways that they can connect with people.

So that's one example. There are countless examples of intergenerational programming out there. Some of this happens very organically in faith-based communities in particular but there are other organizations that have worked really hard to foster that intergenerational programming, which I think is a real opportunity for rural communities. We know that we are rich with older adults in many rural communities, and I think that we need to see that as an asset. And we need to find ways to give everyone a sense of purpose. Connecting older adults with some of those younger people who might be at higher risk of social isolation is one opportunity here. So connecting for mentorship. One example of this is two-way mentorship, where younger adults are paired with an older adult. They get mentorship and advice on life, but meanwhile they provide the older adults hands-on assistance with using technology and learning how to use a new app or a new device that they might not otherwise have been able to use.

And I think that opportunities like that are really great. Above all, I think what's really important is that we have programs that give people a sense of purpose. That people are not just passive recipients of social contact, but that they feel like they have a voice, that they're seen, that they have purpose. And I think it's important to have some fun with this too. So, it can be a really bleak and hard topic, but I think some of the answers involve ways to bring people together to do what they love or to talk about what they love. That might be food or music or games or being outside. All of those are places where people can connect and gather and form and nurture really meaningful social relationships.

Andrew Nelson: You've been listening to Exploring Rural Health, a podcast from RHIhub. In this episode, we spoke to Dr. Carrie Henning-Smith, Deputy Director of the Rural Health Research Center at the University of Minnesota. Look in our show notes for more information about her work, and visit ruralhealthinfo.org for all things rural health.