Introduction
Globally, adults over 65 represent 9% of the population, equivalent to 703 million individuals, and this population is inordinately burdened by loneliness.1–3 COVID-19 stay-at-home measures increased the number of lonely older adults to 43.1%.3 Loneliness affects day-to-day quality of life, correlating with increased depression, anxiety, suicide, obesity, cognitive decline, heart disease, stroke, and death.4–6 Further, a meta-analysis showed that mortality rates increased by 26% to 32% in those who reported feeling lonely, socially isolated, or were living alone, which is comparable to risk factors for conditions such as obesity and substance abuse.6 Increasing socialization is commonly believed to lessen loneliness, and social phone programs may be one way to accomplish this.
The experience of community-dwelling older adults socially distancing during the COVID-19 pandemic in Saskatchewan, Canada, was examined by our research team, and we found increased feelings of anxiety, low mood, and loneliness.7 Older adults were forced to be more antisocial and missed prosocial activities, such as volunteering or community involvement.7 Further, as COVID-19 continued, older adults became less concerned about their physical safety and more concerned about meeting their social and emotional needs.8 The lack of prosocial behavior in older adults negatively influenced their quality of life, physical health, and mental health.4,5,9
Many individuals have used technology, such as Zoom or FaceTime, to cope during the COVID-19 pandemic. However, older adults are often uncomfortable using this technology or they are unable to access it10; therefore, the use of phone calls for social connection has become increasingly important. Our research group conducted a study that paired health care students with older adults for social phone visits. Although the study focused on student learning, participants expressed how the older adults enjoyed the phone visits.11 These findings highlighted the need to further examine the impact of social phone programs on older adults.
A preliminary search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, JBI Evidence Synthesis, Campbell Systematic Reviews, and Epistemonikos was conducted and no current or in-progress systematic reviews were found on the use of social phone programs with older adults.
Through a search of the literature, community organizations, and mental health programming, several outreach programs that use social phone programs were discovered. A few examples include the Canadian Red Cross Friendly Calls Program, CHATS, and Phone Pals.12–14 Each of these programs provides a phone service for older adults; however, their websites do not include any research data, and the duration and frequency of the social phone calls vary by organization.
A search of the literature identified several quantitative and qualitative studies that found social phone programs could effectively decrease loneliness and improve health. For instance, in a mixed methods study, participants showed a non-significant decrease in loneliness and a statistically significant health improvement.15 Studies were found that examined the use of social phone programs during the COVID-19 pandemic, and new research continues to be published.11,15–18
The proposed mixed methods systematic review will synthesize existing academic and gray literature. Given the limited research on this topic, both qualitative and quantitative studies will be included, providing a more complete picture of the effectiveness and experience of social phone programs.19 The synthesis will examine the impact of social phone programs on loneliness and/or mood in community-dwelling older adults, and will identify gaps in the existing literature. Findings will be compiled into various knowledge translation products for academics, community organizations, and older adults. Community organizations will be provided with a summary of the findings and recommendations for existing programs. This information will allow community organizations to implement changes to better meet the needs of older adults.
The objective of this systematic review is to examine both the effectiveness and experience of social phone programs on loneliness and/or mood in community-dwelling older adults.
Review questions
- What is the effectiveness of social phone programs on loneliness and/or mood in community-dwelling older adults?
- What is the experience of social phone programs on loneliness and/or mood in community-dwelling older adults?
Inclusion criteria
Participants
This review will consider studies that include older adults (60Â years or older, in line with the United Nations definition of older adults).20 Studies that include a variety of ages will be used if the information on older adults can be extracted separately. If the mean or median age is over 60, the data will be used in its entirety. The older adults must be community-dwelling; living in free-standing homes, apartments, or senior living complexes; and may or may not be receiving support, such as meals, housekeeping, or home care. Older adults may have comorbidities; however, studies will be excluded if they examine one type of chronic illness (eg, people with prostate cancer) and management or adaptation to the chronic illness. Studies that focus on individuals living in supportive care environments, such as care homes that provide 24-hour care, will be excluded.
Intervention
The quantitative and qualitative components of the review will consider studies that examine social phone programs for older adults. The programs must be for socialization purposes, with a focus on social visiting and building friendly relationships. Phone programs for wellness checks, psychological purposes, pharmacological purposes, health follow-ups, or any physical health promotion will be excluded. Social phone programs include one-on-one, voice-only calls through any medium, such as phone or computer, for any frequency, duration, length of time, or number of phone calls. Any programs that use group calls or other forms of communication, such as video calls, texting, messaging, robot calls, or emailing, will be excluded. Social phone programs may be conducted by trained or untrained peers, volunteers, students, employees, or health care professionals.
Comparator
Studies with a usual care group as a comparator will be included as well as studies with no comparator, such as a cross-sectional design or pre- and post-design.
Outcomes
The quantitative component will consider studies that include loneliness, and/or any measure of mood (depression, low mood, etc.) as outcomes. Outcomes can be measured using any method, including observation, validated scales, self-report, or health system data.
Phenomenon of interest
The qualitative component of this systematic review will include any studies that examined the broad experience of participating in a social phone program. Experience includes any emotional or social impacts and discussions of participants’ enjoyment or concerns about their experience of the intervention.
Context
The qualitative component will consider studies that investigate older adults who are community-dwelling and participated in a social phone program. The adults may be living with others, including their spouse, friends, or family members. Adults receiving full-time formal or informal care will be excluded. Studies from all geographic and cultural contexts will be included.
Types of studies
This review will consider quantitative, qualitative, and mixed methods studies. Quantitative studies will include any type of original, peer-reviewed quantitative research (eg, randomized controlled trials, pre- and post-test designs, prospective studies, retrospective studies, cross-sectional studies, case study designs). Qualitative studies will include any type of original, peer-reviewed qualitative research (eg, grounded theory, exploratory, phenomenology, narrative inquiry). Mixed methods studies will only be considered if data from the quantitative or qualitative components can be extracted independently.
Methods
The review will be conducted in accordance with the JBI methodology for mixed methods systematic reviews.19,21,22 The protocol has been registered with PROSPERO (CRD42022335119).
Search strategy
An initial limited search of MEDLINE was undertaken to identify published and unpublished articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles, were used by a health sciences librarian to develop a full search strategy for MEDLINE (Ovid; see Appendix I), which was then peer-reviewed by a second health sciences librarian. The search strategy, including all identified keywords and index terms, will be adapted for each included database and/or information source. The reference list of all selected articles will be screened for additional studies relevant to the search.
Studies published in any language will be included and translated, where possible, using Google Translate, team members’ language skills, or a professional translator. There will be no date limitations.
The databases to be searched are MEDLINE (Ovid), CINAHL Plus with Full Text (EBSCO), PsycINFO (Ovid), and Embase. In addition, the following sources will be searched for research protocols, theses, and dissertations: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and ProQuest Dissertations and Theses. Conference proceedings will be used to identify potentially relevant studies and authors will be contacted for preprint articles.
Study selection
Following the search, all identified citations will be collated and uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia) and duplicates removed. All records will then be imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).23 Following a pilot test, titles and abstracts will be screened by 2 or more independent reviewers for assessment against the inclusion criteria. Potentially relevant studies will be retrieved for full-text screening. The full text of selected citations will be assessed in detail against the inclusion criteria by 2 or more independent reviewers. Reasons for exclusion of papers at full text that do not meet the inclusion criteria will be recorded and reported in the review. Any disagreements that arise between the reviewers at each stage of the study selection process will be resolved through discussion or with another reviewer. The results of the search and the study inclusion process will be reported in full in the final review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.24
Assessment of methodological quality
Quantitative papers (and the quantitative component of mixed methods papers) will be assessed by 2 independent reviewers at the study level for methodological validity prior to inclusion in the review using standardized critical appraisal instrument from JBI SUMARI.22 Qualitative papers (and the qualitative component of mixed methods papers) will be assessed by 2 independent reviewers for methodological validity prior to inclusion using the standardized critical appraisal instrument from JBI SUMARI.22 The critical appraisal checklist for qualitative research is a 10-question checklist that examines congruity between methodology and methods, researcher positionality, participant voices, ethical approval, and appropriate conclusions.22 The results of critical appraisal will be reported in narrative and tabular format. All studies, regardless of the results of their methodological quality, will undergo data extraction and synthesis (where possible). Critical appraisal results will be reported and will also be included in the analysis of the findings.
Data extraction
For the quantitative component, data will be extracted from quantitative and mixed methods studies by 2 independent reviewers using the standardized JBI data extraction tool in JBI SUMARI.23 The data extracted will include specific details about the participants, study methods, interventions, and outcomes of significance to the review objective. For the qualitative component, data will be extracted from qualitative and mixed methods studies by 2 independent reviewers using the standardized JBI data extraction tool in JBI SUMARI.23 The data extracted will include specific details about the population, context, culture, geographical location, study methods, and the phenomena of interest relevant to the review objective. The findings and their illustrations will be extracted verbatim by 2 reviewers and assigned a level of credibility using the standardized JBI data extraction forms.25
Data synthesis and integration
This review will follow a convergent segregated approach to synthesis and integration according to the JBI methodology for mixed methods systematic reviews using JBI SUMARI.19,21 This will involve separate quantitative and qualitative synthesis, followed by integration of the resultant quantitative and qualitative evidence.
Quantitative studies will, where possible, be pooled using statistical meta-analysis using the MAd package in the R statistical computing environment (R Foundation for Statistical Computing, Vienna, Austria). Effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted (or standardized) final post-intervention mean differences (for continuous data), and their 95% CIs will be calculated for analysis. If possible, effects will be converted to standardized mean differences (Cohen’s d) and then to bias-corrected standardized mean differences (Hedges’ g), using Hedges’ g and its variance for analysis.26 Statistical analyses will be performed using random effects methods.27,28 Subgroup analyses will be conducted where there are sufficient data to investigate loneliness, factors of mood, and/or intervention frequency and duration. Sensitivity analyses will be conducted to test methods by repeating the analysis using the Hunter–Schmidt method using the psychmeta R package. Heterogeneity will be assessed statistically using the standard χ2 and I2 tests, and the prediction interval will be reported. A funnel plot will be generated using the R statistical computing environment to assess publication bias if there are 10 or more studies included in a meta-analysis. Statistical tests for funnel plot asymmetry (Egger test, Begg test, Harbord test) will be performed where appropriate. Cumulative meta-analysis will be attempted, where appropriate, as an additional examination of publication bias.28
Where meta-analysis is not possible, the effects reported in each study will be expressed as bias-corrected standardized mean differences (Hedges’ g), by converting log odds ratios (for binary data) and correlations (for correlational data) to standardized mean difference (Cohen’s d), and from Cohen’s d to Hedges’ g. The findings will be presented in narrative format, including tables and figures, to aid in data presentation.
Qualitative research findings will, where possible, be pooled using JBI SUMARI with the meta-aggregation approach.29 This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings and categorizing these findings based on similarity in meaning. These categories will then be subjected to a synthesis to produce a comprehensive set of synthesized findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible, the findings will be presented in narrative format. Only unequivocal and credible findings will be included in the synthesis.
The findings of each method of synthesis will then be configured. This will involve quantitative evidence and qualitative evidence being juxtaposed together and organized/linked into a line of argument to produce an overall configured analysis. Where configuration is not possible, the findings will be presented in narrative format. Recommendations for practice will be provided to organizations providing social phone programs based on the findings of the review.
Funding
HN received funding for this review from the Social Science and Humanities Research Council, Canada.
Declarations
This review is part of a larger patient-oriented study that includes people with lived experience as team members to ensure that the research is important to the affected population. SP and DN are team members who are older adults who experienced social isolation during the pandemic.
Author contributions
Conceptualization: HN, EL, NHM, BZ, PM, SP, DN, SFL. Original draft preparation: HN, EL. Review and editing: HN, EL, NHM, BZ, SP, DN, SFL. All authors read and agreed to the published version of the manuscript.
Acknowledgments
Amanda Ross-White, for her mentorship and for peer-reviewing the search strategy; Reid MacDonald, for assistance with preparing the statistical analysis.
Appendix I: Search strategy
MEDLINE(R) (Ovid)Â <1946 to June 29, 2022>
Date searched: June 29, 2022
| # |
Search |
Results retrieved |
| 1 |
exp aged/ |
3,408,895 |
| 2 |
exp geriatrics/ |
31,185 |
| 3 |
exp geriatric nursing/ |
13,808 |
| 4 |
(centarian* or centenarian* or elder* or eldest or frail* or geriatri* or nonagenarian* or octagenarian* or octogenarian* or old age* or older adult* or older age* or older female* or older male* or older man or older men or older patient* or older people or older person* or older population or older subject* or older woman or older women or oldest old* or senior* or senium or septuagenarian* or supercentenarian* or very old*).ti,ab,kf. [line 1-4 - OVID expert searches https://tools.ovid.com/ovidtools/expertsearches.html] |
642,089 |
| 5 |
exp Frail Elderly/ |
14,069 |
| 6 |
exp "Aged, 80 and over"/ |
1,007,923 |
| 7 |
or/1-6 |
3,648,291 |
| 8 |
exp Independent Living/ |
10,020 |
| 9 |
exp Community Integration/ |
428 |
| 10 |
exp Community Health Services/ |
325,496 |
| 11 |
exp Housing for the Elderly/ |
1652 |
| 12 |
exp Deinstitutionalization/ |
3301 |
| 13 |
exp Homebound Persons/ |
707 |
| 14 |
((communit* or home or independent*) adj3 (living or dwelling)).ti,ab,kf. |
47,466 |
| 15 |
("in home" or "at home" or "own home" or "own homes" or home-based or homebased or homebound or community or "in place" or deinstitutionaliz*).ti,ab,kf. |
699,070 |
| 16 |
or/8-15 |
954,184 |
| 17 |
exp Telephone/ |
33,648 |
| 18 |
exp Cell Phone/ |
20,681 |
| 19 |
exp "Cell Phone Use"/ |
350 |
| 20 |
(phone or telephone or VoIP or "mobile phone" or tele-visit* or tele-chat* or tele-conf* or telechat* or teleconf* or televisit*).ti,ab,kf. |
95,177 |
| 21 |
or/17-20 |
112,238 |
| 22 |
exp Social Isolation/ |
21,403 |
| 23 |
exp Loneliness/ |
5541 |
| 24 |
exp Emotions/ |
386,368 |
| 25 |
exp Adaptation, Psychological/ |
136,922 |
| 26 |
Dependency, Psychological/ |
2465 |
| 27 |
Codependency, Psychological/ |
283 |
| 28 |
exp Social Support/ |
78,032 |
| 29 |
exp Friends/ |
6382 |
| 30 |
exp "Quality of Life"/ |
246,648 |
| 31 |
exp Empowerment/ |
688 |
| 32 |
Social Deprivation/ |
52 |
| 33 |
Mental Health/ |
54,504 |
| 34 |
exp Depression/ |
142,606 |
| 35 |
Social Support/ |
77,127 |
| 36 |
("mental health" or isolat* or lonel* or asocial or "social exclusion" or "social deprivation" or disconnect* or disengange*).ti,ab,kf. |
1,675,737 |
| 37 |
(connect or connection or connections or connected or relationship* or social or friend* or wellbeing or well-being or "well being").ti,ab,kf. |
2,473,431 |
| 38 |
or/22-37 |
4,473,898 |
| 39 |
exp Health Services for the Aged/ |
18,149 |
| 40 |
exp Program Evaluation/ |
82,297 |
| 41 |
exp Program Development/ |
30,225 |
| 42 |
exp Preventive Health Services/ |
655,252 |
| 43 |
(program* or initiative* or strateg* or project* or model* or support* or activit* or service* or intervention* or volunteer* or participa*).ti,ab,kw. |
10,826,208 |
| 44 |
or/39-43 |
11,197,920 |
| 45 |
7 and 16 and 21 and 38 and 44 |
2473 |
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