Research in Gerontological Nursing

Empirical Research 

Internet Programming to Reduce Loneliness and Social Isolation in Aging

Lindsay B. Mullins, PhD, FNP-BC; Lisa Skemp, PhD, RN, FGSA, FAAN; David Reed, PhD; Myra Emerson, MA, JD

Abstract

Loneliness and social isolation in older adults carry mortality risks similar to cigarette smoking. The study aim was to use a Culturally Informed Healthy Aging (CIHA) assessment process in Housing and Urban Development (HUD) communities of older adults (N = 262). Through the CIHA assessment process, older adults identified pertinent health problems and the study team developed a health intervention, an Internet Information Station (IIS). The IIS pilot study included computer lesson participation (n = 261), written feedback (n = 42), and the revised University of California, Los Angeles (R-UCLA) Loneliness Scale (n = 11). Increased confidence with technology and connectedness were reported, and a significant difference in “There is no one I can turn to” was observed (IIS compared to non-IIS). The IIS remains an active site for interaction 1-year post intervention. These pilot results supplement the research on older adult engagement in problem identification, intervention design, and outcomes measurement.

Target:

Older adults living in HUD communities.

Intervention Description:

Through CIHA assessment, health problems were identified, and the IIS was developed and implemented.

Mechanisms of Action:

Lessons were developed (e.g., computer basics, connecting with technology, open forum) and evaluated. Pre and post lesson, the R-UCLA Loneliness Scale measured social isolation and loneliness.

Outcomes:

Older adults were engaged in problem identification, program development, and implementation. Feelings of connectedness improved; however, program evaluation with the R-UCLA scale was difficult to obtain.

[Research in Gerontological Nursing, 13(5), 233–242.]

Abstract

Loneliness and social isolation in older adults carry mortality risks similar to cigarette smoking. The study aim was to use a Culturally Informed Healthy Aging (CIHA) assessment process in Housing and Urban Development (HUD) communities of older adults (N = 262). Through the CIHA assessment process, older adults identified pertinent health problems and the study team developed a health intervention, an Internet Information Station (IIS). The IIS pilot study included computer lesson participation (n = 261), written feedback (n = 42), and the revised University of California, Los Angeles (R-UCLA) Loneliness Scale (n = 11). Increased confidence with technology and connectedness were reported, and a significant difference in “There is no one I can turn to” was observed (IIS compared to non-IIS). The IIS remains an active site for interaction 1-year post intervention. These pilot results supplement the research on older adult engagement in problem identification, intervention design, and outcomes measurement.

Target:

Older adults living in HUD communities.

Intervention Description:

Through CIHA assessment, health problems were identified, and the IIS was developed and implemented.

Mechanisms of Action:

Lessons were developed (e.g., computer basics, connecting with technology, open forum) and evaluated. Pre and post lesson, the R-UCLA Loneliness Scale measured social isolation and loneliness.

Outcomes:

Older adults were engaged in problem identification, program development, and implementation. Feelings of connectedness improved; however, program evaluation with the R-UCLA scale was difficult to obtain.

[Research in Gerontological Nursing, 13(5), 233–242.]

Loneliness among older adults is a growing public health concern with a mortality risk that is similar to cigarette smoking (Gerst-Emerson & Jayawardhana, 2015). Loneliness is associated with social isolation and can be expected to increase as the population ages with concomitant losses of mobility, increases in health problems, changes in economic status, and the loss of partners and friends due to death and relocation (Czaja et al., 2018). These losses impede the maintenance or acquisition of desired relationships, also resulting in a higher incidence of loneliness. Technology and the internet have been used to address isolation and help older adults remain socially engaged (Cresci & Jarosz, 2010). The purpose of the current study was to evaluate the effectiveness of a community-engaged Internet Information Station (IIS) program to address social isolation and loneliness in a senior living community.

Social Isolation and Loneliness

Social isolation is the lack of social contacts (Beller & Wagner, 2018). When a person lives alone, the risk of social isolation is increased. As people grow older, the likelihood of experiencing age-related losses increases, and the losses are acute and widespread. These losses include role changes associated with retirement and decreases in the number of people one interacts with. Because these losses are an inevitable consequence of aging, the human need to connect to others becomes even more necessary for social support. Social support, however, becomes more difficult to obtain because of the decreasing number of peers and required social engagements (Administration on Aging, 2016).

Losses impede the maintenance or acquisition of desired relationships, also resulting in a higher incidence of loneliness. Loneliness is a subjective feeling that occurs when a person's social needs do not correspond, in quantity or quality, to their social relationships (Beller & Wagner, 2018; Fisher & Philips, 1982). Risk factors for loneliness are: (a) poor self-assessed health; (b) depression; (c) functional dependence; (d) low self-efficacy; (e) reduced social network size and interactions; and (f) recent bereavement (Prieto-Flores et al., 2010). These risk factors are exacerbated by living alone, lack of close family ties, reduced connections with culture of origin, and an inability to actively participate in local community activities (Singh & Misra, 2009).

Correlations between social isolation and loneliness have been shown to be small (Coyle & Dugan, 2012). For example, even socially connected individuals can feel lonely, just as socially isolated individuals can be satisfied with their social relationships. This disparity suggests that although social isolation and loneliness are related, the concepts remain mostly independent of each other (Beller & Wagner, 2018). Although independent, Beller and Wagner (2018) found that loneliness and social isolation have a synergistic effect on mortality—the greater the social isolation, the greater the effect of loneliness on mortality. Irrespective of demographic characteristics and health problems, social isolation and loneliness are associated with impaired cognitive functioning and poorer mental and physical health, as well as increased mortality (Cacioppo & Cacioppo, 2014).

There are three widely reported tools to measure loneliness in older adults. The De Jong Gierveld Loneliness Scale (De Jong Gierveld, 1987), a single-item question “Are you lonely?” (Campaign to End Loneliness, 2018), and the University of California, Los Angeles (UCLA) Loneliness Scale (Russell et al., 1978). The single-item direct question about loneliness was initially developed for researchers and health care providers (Campaign to End Loneliness, 2018). Although easy to administer, the wording is negative and approaches loneliness as a one-dimensional concept. The UCLA Loneliness Scale was first published in 1978 and has been revised (R-UCLA) in wording and in number of items over a period of approximately 20 years (Russell et al., 1980; Russell et al., 1978; Russell, 1996). Version 3, the most recent, is a 20-item measure that assesses how often a person feels disconnected from others (Russell, 1996). For more than 3 decades, the UCLA Scale, followed by the R-UCLA Scale, has been considered the most psychometrically sound measure of loneliness available and has been used in an estimated 80% of empirical studies on loneliness (Allen & Oshagan, 1995; Nicolaisen & Thorsen, 2014; Teppers et al., 2013). Penning et al. (2014) examined the measurement and invariance properties of the R-UCLA and De Jong Gierveld Loneliness Scale for research involving middle-aged and older adults. Although the De Jong scale was shown to have relative utility with older adults, there was a need for attention to the item wording and lack of measurement invariance, confirming that the R-UCLA was the sounder measure of loneliness within the older adult population (Penning et al., 2014).

Internet Interventions to Address Loneliness in Older Adults

Older adult internet users have been shown to have increased communication with those in their social networks; to maintain geographically dispersed connections; to benefit from more convenient searches; to learn more from health-related information; to have increased ability to research non-health-related information; to read more news/magazines/books; to engage in more continuing education activities; to have more awareness of, and connection to, interest/support/hobby groups, events, and resources in their immediate and global communities; to appreciate the convenience of online shopping, banking, travel arrangements, and related information; and to have increased use of computer- and internet-based entertainment (AARP, 2009). Of these internet uses, Culley et al. (2013) found that older adults used the internet on the phone or computer for the following: 44% to search for information, 43% to keep in touch with family, and 35% to search for health information. van Boekel et al. (2017) identified subgroups of older adult internet users ranging from practical users, who used it for practical and financial purposes, to social users, who used it mostly for social and leisure activities. Of the eight evidence-based sources reviewed, all had one common conclusion: affordable technology education, whether individually or in a group, minimizes aspects of social isolation (van Boekel et al., 2017).

Over the past 2 decades, internet technology has increased access to health-related and non-health-related information and has facilitated communication and social connections transcending geographic distances at relatively low cost (Choi & Dinitto, 2013). Older adults who have health problems, feel lonely, and are socially isolated are especially likely to benefit from using internet technology because it allows them to perform an increasingly diverse array of tasks. This ability is especially important when considering that they may lack family, friends, and health and social service providers who can help with these tasks (Xie, 2007, 2011). When designing internet work spaces and courses for older adults, three key factors are important: (a) providing internet access in a central, inviting location; (b) including hands-on practice with adult learners; and (c) engaging multiple generations in courses to support intergenerational learning (BH Tech Group, 2019; Jones et al., 2015; National Council on Aging, 2014; Power et al., 2007).

Built on current best practices and relied upon as a guide for the current research project, the BH Tech Group (2019) developed individual and group lessons to share information technology concepts as well as to guide older adults and classmates on their connected devices. The purpose of this research was to describe program development and implementation and evaluation of the community-engaged, culturally informed IIS program to address social isolation and loneliness in senior living community members.

Method

The university and U.S. Housing and Urban Development (HUD) affiliated health care system reviewed the proposal and exempt Institutional Review Board status was received. An inductive community-engaged research partnership design was used. This design uses a culturally informed community health assessment (CIHA) process to develop and maintain the partnership at all stages of the research process. This process included a description of the cultural context of the community or communities, identification of health issues (isolation and loneliness), and development and implementation of a culturally informed internet health intervention to increase social support and decrease isolation and loneliness in four HUD senior living communities.

The culturally informed community health research and practice model (Figure 1) begins with an assessment process that uses ethnographic inductive exploratory interviews, participant observation, photographs, surveys, and mapping, as well as review of documents and epidemiological data to describe the cultural and health context of the HUD community. Early in this community assessment process, key formal and informal community leaders were identified and partnerships formed. Working with key leaders, a Community Advisory Board (CAB) was formalized to inform the assessment of the community context and help researchers better understand community strengths and needs. Assessment strategies used over a 1-year period included formal and informal interviews with older adult residents and HUD site managers, focus groups, participant observations captured in field notes and photographs, home visits, a resident health survey, and review of documents (i.e., Administrator-On-Call Reports, Health Service Visit Log, quarterly CAB meetings, the National Health & Aging Trends Study (NHATS) about technology use, and review of community artifacts) (Table 1). Participants provided initial and ongoing consent during data collection. Consistent with principles of the culturally informed research process, participants were involved in all stages of the research to include validation of the results.

Culturally informed community health research and practice model.Note. C/PH = Community/Public Health; CAB = Community Advisory Board; EBP = evidence-based practice; ER = emergency room.

Figure 1.

Culturally informed community health research and practice model.

Note. C/PH = Community/Public Health; CAB = Community Advisory Board; EBP = evidence-based practice; ER = emergency room.

Assessment Strategies to Determine Community Needs

Table 1:

Assessment Strategies to Determine Community Needs

Inductive content analysis was used to analyze the field notes, interviews, and focus group data. t tests and chi-square tests were used to test for change over time in continuous and nominal quantitative measures, respectively. Researchers returned to key participants for review of the preliminary results with data collection and analysis continuing until there was a descriptive understanding of the community context and experience with the IIS.

Setting

The HUD community was selected because the university had an affiliation with the larger health care system who requested the establishment of a HUD–School of Nursing partnership in the care of older adults. This request was made because these older adults are under-served in the areas of health promotion and primary and secondary prevention, thereby necessitating unwarranted and expensive acute care and exacerbations of chronic care conditions. In addition, residents may not have primary health care providers, or they may not access their providers in a timely manner resulting in a frequent use of costly ambulance services and emergency department care.

Cultural Context

The HUD community is a federally funded community of five buildings in an urban, high-crime, low-income area of the Deep South that houses low-income, ethnically diverse older adults age 62 and older. The five HUD buildings are located in a 29,000 square-yard area in a gated community. One of the five buildings in the center provides offices for administrators and has a large activity center. The other four apartment buildings form the perimeter around the activity center.

Over the course of the year, there were an average of 262 independent living residents, with an average male age of 73.75 years and average female age of 75.25 years. Eleven residents were older than 90, with the oldest being 101. All but one of the apartments housed individuals, with one apartment occupied by a couple. The average monthly income was $1,004 and average annual out-of-pocket medical expense was $1,758. Residents had lived in the community for an average of 7 years, and the most common reasons for vacating were nursing home placement (n = 12) and death (n = 12). Ninety-five percent of residents were from the local urban area, and 5% had been relocated after a major natural disaster. Residents were African American (61.4%), Caucasian (36.6%), Asian (1.2%), and Hispanic (0.8%).

Each of the four apartment buildings functioned as a unique community, and residents organized themselves informally first by building, then by floor, then by ethnic group, and lastly by family group, if it existed. Approximately 75% of residents did not leave the property for anything other than a health care appointment once every 2 to 3 months. Twenty-five percent of residents left to pick up personal items such as groceries, clothing, and medications. Residents rarely reported leaving for social reasons, including family gatherings.

CAB representatives from each building explained that loneliness and isolation were primary concerns. One resident, Mr. B., explained, “They [residents] are bored as hell with nothing to do.” And Ms. L. described how “If we aren't out there [outside buildings] talking, we sit with four walls. I get tired of looking at four walls.” With the typical humid subtropical climate, excessive heat and humidity led to minimal public activity among residents. Outside each building, three to five residents would gather on two benches, one on either side of the front door, most commonly after lunch and before dinner. Residents explained that they watched the activity in the parking lot, which consisted mostly of medical vans picking up and dropping off residents. As one resident explained, “I like to sit outside if I get tired of being in my apartment, I can sit out here and visit.”

To address social isolation and loneliness, residents recommended that a community-centered IIS be set up in each of the four buildings. One explained, “We don't go to those other buildings” because “we all do things different.” For example, one building is smoke-free and another building has a resident who is “in charge” and will put together potlucks but “other buildings are not invited.” Residents explained that “computers are expensive but keep the mind going.” They believed computers would help get them out of their apartments, meet others, and, more specifically, “research things and go on Facebook®, play games, read news.” To learn how to do this, they recommended a computer class. One resident had just joined a day program and they had a computer class; she wanted to know how they “could get it there and HUD couldn't.”

The Intervention

In partnership with the CAB and ongoing resident input, the priority identified was to develop an internet program to address social isolation and loneliness. The needs of the residents varied from low-skill level (e.g., how to turn a computer on) to higher-skill level (e.g., posting pictures on social media). An internet search of evidence-based technology curricula was conducted. The Council on Aging and the BH Tech Group curricula were two of the most cited programs that were built to serve older adults. Using their examples, a series of lessons were created with community residents and the CAB (Table 2). These lessons were on different topics regarding computers and technology, rather than one lesson only. The IIS program included the culturally informed curriculum and environmental modifications to meet the needs of older adults.

Computer Classes Offered and Description of Course Content

Table 2:

Computer Classes Offered and Description of Course Content

Information Station Development and Implementation

Wi-Fi was not initially installed in the common areas, and gaining internet access to the provided computers was impossible because of the cinder block walls. Installation of wireless internet in the common areas of each of the four buildings led to residents visiting the common areas more frequently and allowed residents to use their existing Wi-Fi devices if they had them. Wi-Fi access also encouraged residents who did not have internet in their apartments to come out into the common area.

Working with members of the CAB and other residents, two computers with enlarged screens and accompanying Americans with Disabilities Act (ADA)–approved desk and chairs were purchased for each apartment building (eight computers and desks altogether). Each IIS was set up in a manner the residents found desirable. For example, lamps were included for reading, desks were wheelchair accessible, and a book was created that provided easily labeled internet links of the most common things residents reported were needed (e.g., fresh fruit and vegetables, social entertainment, transportation) and what was locally available.

Once the stations were set up, the research team worked with its university service-learning program. Students were recruited to offer technology classes as their service-learning project for the semester. To prep students, a member of the research team met with each student and reviewed communication skills and an overview of the program. Students were then provided a template for each of the three lessons: (a) computer basics on the parts of a computer, how to turn on a computer, and the different programs on a computer; (b) internet basics to include internet safety, creating an email account, surfing the web, and online shopping; and (c) social media that includes establishing a Facebook account and finding friends through social media. Students were encouraged to adapt the lesson's template to fit their comfort level. For example, they could demonstrate on a PC or Apple® device.

In concert with the CAB, culturally appropriate flyers were created and placed under the doors of each apartment and posted in the building common areas. Participants were incentivized to attend lessons by receiving a free mouse pad and light refreshments. Each lesson was offered in each building two different times during the day for a semester, and anyone could attend. For example, if a resident attended the lesson in Building 1 but wanted to hear it again, they could travel to Building 2 or attend on another day. Participation was encouraged, and all residents were welcome to attend all lessons offered.

The lessons were most often in a presenter format followed by small group discussion and practice either on the IIS computers or residents' devices. Each time a lesson was taught, it was evaluated on organization, course materials, participation, and open-ended qualitative feedback. Using input from the evaluations, the course was modified to include more time spent in small groups to practice on devices and answer questions about the devices the residents already owned.

The R-UCLA Loneliness Scale was used to assess loneliness, and use of technology was measured with the 12 items from the NHATS that measured technological environment. These were administered during the community assessment before any health program interventions took place and between 6 and 8 weeks after the technology courses were completed.

Ongoing ethnographic interviews and observations provided information on resident uptake of the intervention. To determine how often residents were coming out of their apartments, observations of common areas were collected. Logs were kept at the front desks for residents to sign-in when they used the information stations, and computer histories were collected once per week for 2 months.

Results

Participants and Participation

Participation in the technology lessons was higher than participation observed during the baseline assessment of community events. The community assessment showed that, according to the community newspaper calendar, approximately four events usually occur on the property each week. Participation in these events was approximately 5% to 7% (13 to 18 community members) per event. During the technology lessons, two of the four buildings consistently had higher participation by approximately 50%. For example, for the highest attended lesson, Building A had 13 participants, Building B had 11, Building C had seven, and Building D had five participants. Of the 24 lessons offered (each lesson was offered eight times, four times on one day in each building and four times another day), participation increased to 10% to 12% of residents (average 26 to 30 participants) per event.

The average participant was African American, a woman, and 69 to 78 years old. Participants most often had their own device ranging from a flip phone, tablet, smart device, or laptop. Three different participants brought devices they had never used because they did not know how. Mr. L. wanted to learn how to use his tablet that was given as a gift from his grandchildren. He wanted to listen to music. Mrs. H. had an old flip phone that was given to her when her daughter got a new smartphone. Mrs. L. had a smart-phone that she said was “smarter than me.” She wanted to use it to read the newspaper.

Course Evaluations

Course evaluations were designed to assess the helpfulness and delivery of each lesson. There were three statements, and residents were asked to rate each one on a scale from strongly disagree to strongly agree. The statements were: (1) The course was well organized; (2) the course materials (such as handouts) increased my knowledge of the course content; and (3) the presentation helped me learn about computers. At the end, there was an area for additional comments. All participants completed the evaluation and reported that they had increased confidence in their technology skills, improved connectedness to others when learning how to use email and social media, and more readiness to schedule health care appointments online. Participants believed the presentation was helpful (100%) and organized (98%).

Loneliness and Isolation

Most importantly, the current study aimed to determine the impact of the IIS on loneliness and isolation. Loneliness was assessed using the R-UCLA Loneliness Scale at two different intervals: the first was during the community assessment and before any health program interventions took place, and the second occurred after the technology course, between 4 and 6 weeks after the courses were complete.

R-UCLA Loneliness Scale Results. Comparing the items on the R-UCLA Loneliness Scale, there was a significant difference (p = 0.023) on one item, “There is no one I can turn to,” with the technology class group scoring significantly lower (less lonely) than the baseline (community assessment period) group. The difference between groups on the total score for the scale was not statistically significant (p = 0.13), but the mean total score after the technology classes was lower than the mean at baseline, with a standardized effect size of 0.48, which is close to a medium effect size in Cohen's widely used classification. The written course evaluation comments and participation results add further light to this finding with residents reporting increased confidence in technology skills, improved connectedness, and more ability to schedule things (e.g., physician's appointments).

Social Isolation and Information Station Observations. After the Wi-Fi was installed in the buildings, the IISs were set up, and the computer lessons were delivered, activity increased in the common areas in each building. According to the building managers, coffee groups and general visiting in the common areas had twice as many participants compared to before the IISs. For example, in Building D, which had the fewest attendees at the technology lessons, the common area went from being predominately empty throughout the day to having between two and eight residents at any given time.

The NHATS tool was used as a follow up and showed that there were statistically significant increases in residents reporting access to a computer (from 40% to 65%; p = 0.013) and reporting access to more than one computer (from 0% to 19%; p = 0.003). Furthermore, computer history logs were collected from the computers at the information stations to determine what the residents used the computer to access. Most site visits were informational (55%), social (18%), medical health (9%), shopping (7%), and miscellaneous (11%).

The course evaluation comments added further qualitative detail to residents' feelings toward and behaviors with technology. For example, on one observation, when the residents were working one-on-one or in small groups using their own devices, two older adult women who lived on the same floor of the same building were looking at one another's devices and problem-solving about how to access the newspaper. On another occasion, one resident was observed showing another resident her grandchildren's pictures on Facebook. A final example was the experience of a 92-year-old woman who had moved to the United States from England 15 years ago. She had not seen her sister since her move and was in limited contact with her. In showing her how to look friends up on Facebook, her sister was found, and she was able to look at pictures. She commented, “I never thought I would see her again.”

Lastly, because lessons were conducted at each building, course participation was higher than usual for other existing community events. Holding the events in each building provided an opportunity for neighbors to interact with one another, as one resident said, “on their turf.”

Discussion and Implications

The purpose of the current study was to describe the development of, and evaluate the effectiveness of, a community-engaged, culturally informed IIS program to address social isolation and loneliness in ethnically diverse older adults living in a community of HUD subsidized housing in the Deep South.

Building on Social Capital

For healthy aging of older adults, it is critical to build on existing social capital, such as existing strengths (e.g., friendships, buildings, technology), and to address challenges (e.g., chronic illness, loss and loneliness, geographic location of the property, weather) present in the community. To build on existing social capital, it is important to understand the culture of a group of people. The CIHA community assessment provides systematic strategies to understand how people organize themselves, to recognize patterns of how they function as a community (spending time around the place they live), what they want to do to help strengthen their community (use of computers), and how to best go about it (an information station in each building).

In the current study, residents expressed a desire to have computer classes and computer access that other housing for older adults had, making this program resident-driven. As a result, residents who had access to computers (smart-phones, tablets, etc.) also used the computers in the common areas. Providing internet-connected computers in common areas encouraged residents to leave their apartments. In addition, the computers served as a resource for accessing health information and making appointments. Finally, making the common areas information hubs by adding computers increased interaction among residents. Although other studies have examined the impact of technology on social support and evaluated existing use of technology by older adults, the current study is novel because its core tenets were mobilizing existing cultural capital and using extensive community-driven intervention development.

Evaluation of Community-Level Research

As reported by Mullins et al. (2016), when the community is the unit of measurement, program outcomes are difficult to evaluate and report. Communities are ever-changing, and variables of influence are too numerous to count. As a result, reports of community models of care are scarce in the nursing literature. In the current community-engaged study, use of the R-UCLA Loneliness Scale presented challenges. Although only one item in the pre- and posttest of the scale showed a difference, it is likely that this quantitative measure of a subjective variable was a limitation. Subjective feelings are more challenging to measure as a whole and often take longer periods of time to impact behavior. Four to six weeks was likely too short a period. However, for one item, “There is no one I can turn to,” residents reported feeling less lonely, and this might be explained by the group interaction during the technology lessons. In addition, the difference in total score on the RUCLA Loneliness Scale, although not statistically significant, was in the direction of less loneliness, with a medium effect size that encourages further investigation.

The course evaluation comments added further qualitative detail concerning change in residents' feelings toward and behaviors with technology. Newly learned technological skills that require a level of cognitive and emotional engagement to perform have a higher likelihood of impacting loneliness. In addition, working with community residents and the CAB to translate the technology programs (Council on Aging and BH Tech Group) to be culturally informed likely contributed to the positive responses to the course evaluations, which suggested residents were able to engage with the technology lesson because it was tailored to fit their needs. By conducting each lesson at each building, participants' requests were respected, and the development of local networks was supported, a cultural feature of the community made evident through the community assessment. Holding the events in each building provided an opportunity for neighbors to interact with one another.

Students and Older Adult Interactions

In health professions programs, students interact more commonly with ill older adults in the acute care setting. Through these experiences, students may develop a negative perception of aging and find it a challenge to see older adults as healthy and as valuable, contributing members of society. Integrating students into this program was ideal because the millennial generation is skilled at using technology, and thus it is easy and comfortable for them to teach and discuss it, and it provided a rich environment of intergenerational learning between millennial students and independent-living older adults.

Because numerous undergraduate college age students do not regularly interact with older adults, being comfortable with the content was important to set a positive atmosphere for the sessions. As a result, residents learned how to use technology from experts, and students were able to learn about the individual older adults in seeing their families on social media and helping craft emails to loved ones. Other skills were important as well, specifically computer basics, internet safety, and accessing reliable health information sources, and practicing these skills provided a platform for connection between the generations.

Sustainability

The computers and computer stations remain in the HUD Property Information Station areas. To sustain the internet program, the research team partnered with the University Service-Learning director to incorporate the IIS intervention. Teaching technology sessions at the HUD property is now one of the service-learning offerings for students. Students collaborate with the HUD service coordinator and schedule times to hold the sessions. Based on feedback from HUD residents, the content of the sessions changes as the residents master skills and then request programs to learn new skills. For example, sessions were offered on tracing genealogy based on the desire of older adults attending the sessions.

Limitations

Alternative explanations of the results could be offered. For example, it is possible that the act of intervening itself, apart from the content of the intervention, could have produced at least some of the results found (Hawthorne effect). It is also possible that internet use might have increased simply due to trends in society in general. Use of a comparison group with an appropriate sham intervention would have permitted assessing these and other alternative explanations. This study, however, was a pilot study with the intent of testing methods for using the CIHA model to develop a culturally relevant health intervention and then assess its impact on a community. Subsequent research building on the current study could include the use of a comparison group. It must be recognized though, that a comparison group would have its limitations. Because of the complexity and uniqueness of individual communities, any two communities selected to be either an intervention or comparison group would differ in some significant respects, and the conclusion that the intervention itself was responsible for the outcomes found in the intervention group would still depend to some extent on qualitative judgment.

Conclusion

Independent-living older adults experience social isolation and loneliness at an alarming rate, which is of consequence to their cognitive functioning, mental and physical health, as well as life expectancy. As such, employing community-level programming that is wanted and desired and is possible for communities remains challenging but critical. Findings suggest desirable utility of the Culturally Informed Community Health Research and Practice Model, particularly the use and enhancement of existing resources to develop and implement an intervention. The study also adds to the limited research on low-income, ethnically diverse older adults in government-subsidized housing.

The community-engaged CIHA model assessment; the CAB development and process; and the health program intervention development, implementation, and evaluation were described. These activities resulted in the culturally informed IIS that provided access to a number of technology-related features and influenced outcomes related to social isolation, loneliness, and general socialization among a community of ethnically diverse older adults living in subsidized housing. These results may begin to address some of the challenges Mullins et al. (2016) identified when evaluating community models of care and community-level programming.

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Assessment Strategies to Determine Community Needs

SourceData Collected
Fieldwork225 hours with corresponding field notes for inductive content analysis
Interviews63 informal interviews; 28 formal interviews; two focus groups
Researcher nurse practitioner home visits10 resident apartments
Administrator-On-Call Reports336 incidents from October 2014 to September 2015
Resident Health Survey81 returned
Health Service Visits1,016 health service visitors per month
Community artifactsCommunity flyer, internet search, windshield survey, walking survey
Community Advisory Board (CAB) meetingsFour CAB meetings, ongoing

Computer Classes Offered and Description of Course Content

ClassDescriptionCourse Content
1Computer 101• Basic skills on how to operate a computer
2Connecting with Technology

Introduction to the internet, internet safety, news and shopping on the internet, and social media and establishing an email account

Social media introduction that includes establishing a Facebook® account and finding friends through social media

3Computer Q & A• Open forum for residents to ask about previous information or work one-on-one with their existing devices
Authors

Dr. Mullins is Sister Agnes Marie Fitzsimons Endowed Chair of Gerontology, Franciscan Missionaries of Our Lady University, Baton Rouge, Louisiana; Dr. Skemp is Professor and Chair, Health Systems, Leadership, and Policy, Marcella Niehoff School of Nursing, Loyola University, Chicago, Illinois; David Reed is Independent Researcher, and Myra Emerson is Independent Researcher, Chapel Hill, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Lindsay B. Mullins, PhD, FNP-BC, Sister Agnes Marie Fitzsimons Endowed Chair of Gerontology, Franciscan Missionaries of Our Lady University, 5414 Brittany Drive, Baton Rouge, LA 70808; email: lindsay.mullins@franu.edu.

Received: September 03, 2019
Accepted: November 05, 2019
Posted Online: April 14, 2020

10.3928/19404921-20200320-01

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