What is the value of social connection guidelines?

Background

The rise in loneliness and social isolation across societies is increasingly recognized as a significant public health and social issue (OSG, 2023a) – particularly in the wake of the COVID-19 pandemic, which called attention to the crisis (Ernst et al., 2022; Pai & Vella, 2021; Smith & Lim, 2020; Killgore et al., 2020; Novak et al., 2020). Research has highlighted that loneliness and social isolation pose substantial health risks comparable to well-established risk factors such as smoking and exceeding that of others like obesity, sedentary living, high blood pressure, and poor nutrition (Wang et al., 2023). The pervasive and accelerating trend of social disconnection (Cox, 2021; Buecker et al., 2021), expedited by the advent of new technologies (such as television, social media, and possibly artificial intelligence; Twenge, 2013; Twenge et al, 2019; SGO, 2023b), intensifies the need for urgent intervention on social health (Trad et al., 2020).

In response, public health guidelines for social connection have been proposed as a potentially important tool for catalyzing social and cultural change and promoting individual and community health (Card, 2023; Holt-Lunstad, 2023; Aschaiek, 2022). Such guidelines build on existing national interventions, such as the creation of ministerial positions focused on loneliness and the development of national strategies to address loneliness (Pimlott, 2018). On one hand, such guidelines could raise the status of social health as a public health priority. On the other hand, guidelines might also be met with criticism concerning their practicality, intrusiveness, applicability, and the potential risk of creating stigma around social behavior (Barco-Leme et al., 2021; Siedler et al., 2021; Slater & Mudryj, 2018; Andresen, 2007).

Purpose

The purpose of this evidence brief is to (1) examine the rationale for public health guidelines for social connection, (2) scope out the potential benefits and harms of public health guidelines, and (3) explore the potential content of public health guidelines for social connection.

In meeting these aims, we recognize that guidelines are a very basic public health measure (Zuber et al., 2023; Scott et al., 1994) and that addressing the epidemic of loneliness and social isolation likely requires considerably greater investments to identify the multi-faceted, multi-component solutions (Harvey & Kitson, 2015; WHO, 2023a, 2023b). We also emphasize that public health guidelines are primarily a prevention tool, and that their utility in treating people who are lonely and isolated is likely limited (Cattan et al., 2005; Masi et al., 2013; Holt-Lunstad, 2023). Finally, we acknowledge from the outset that equity is a top public health priority and that any guidelines developed by public health bodies must attend to the needs of diverse communities (Solar & Irwin, 2005).

Evidence from Existing Studies

Rationale for Public Health Guidelines for Social Connection

Social disconnection, lack of social support, loneliness, and social isolation have a wide-variety of negative effects at both the personal and social level. In this section, we briefly explore the health and social effects of social disconnection and rely on these as a fundamental rationale for public health guidelines designed to prevent loneliness and social isolation.

Health Effects of Social Disconnection. Numerous studies corroborate the deleterious health effects of loneliness and social isolation (Wang et al., 2023).Research in recent years has conclusively demonstrated the paramount importance of social connections to overall health, shedding light on the substantial and multifaceted ways that loneliness and social isolation can impact wellbeing (Holt-Lunstad, 2022; Holt-Lunstad et al., 2017). Some experts even argue that social connection is the most significant modifiable factor for depression (Wickramaratne et al., 2022; Choi et al., 2020). Furthermore, the health impact of chronic social isolation is comparable to smoking 15 cigarettes a day, a striking figure that underscores the severity of loneliness as a public health concern (Holt-Lunstad, 2010). The effects of loneliness and social isolation can infiltrate various aspects of health, from mental to physical. They contribute to increased rates of cardiovascular disease, cognitive decline, and, notably, depression (Wang et al., 2023). They can heighten stress, negatively affecting immune system functioning and accelerating biological aging (Brown et al., 2018; Pourriyahi et al., 2021). Moreover, the health effects of loneliness and social isolation are more severe than many other recognized risk factors. For instance, studies have shown that chronic loneliness can be worse for one's health than living with air pollution or adhering to an unhealthy diet (Pantell et al., 2013). It is also more damaging than sedentary living, a lifestyle lacking the recommended levels of physical activity, and obesity (Wang et al., 2023), both of which have received much more public health attention. This compelling body of evidence underscores just how critical social connection is to our health. As such, prioritizing social health in public policies and interventions is not just desirable; it is a vital necessity (Holt-Lunstad, 2022; Holt-Lunstad et al., 2017). It highlights the urgency for more comprehensive understanding, awareness, and strategies to address loneliness and social isolation as significant public health issues.

Social Effects of Social Disconnection. Additionally, Loneliness and social isolation, while profoundly impacting individual wellbeing, also ripple outward, contributing to a multitude of social problems, including criminal behavior, anti-government beliefs, selfishness, anti-social behaviour, and radicalism (Doosje et al., 2016; Cacioppo et al., 2017; Heu et al., 2018; Jozan, 2020; Wood, 2020; Becker et al., 2021; Card et al., 2022). For example, loneliness and social isolation are associated with an increase susceptibility to extreme ideologies and even violence (Martens & Palermo, 2005; Wood, 2020; Hug, 2013). Indeed, individuals feeling unseen, unheard, and unvalued may find the acceptance and purpose they crave in fringe groups that exploit these feelings of disconnection (Pfundmair et al., 2022). Similarly, loneliness can lead to isolation and withdrawal – reducing social cohesion and connection (Cacioppo & Cacioppo, 2014). There are also economic considerations, with studies showing that loneliness is a significant economic burden, diverting funding from other community resources and assets (Mihalopoulos et al., 2019). Thus, addressing loneliness and social isolation extends beyond improving individual health; it is integral to the health and cohesion of communities and societies. Increasing social connection could foster more harmonious neighborhood relations, enhance social capital and mobility, and counteract the appeal of extremist ideologies, ultimately contributing to more inclusive, resilient, and harmonious societies.

The Potential Benefits and Risks of Public Health Guidelines

Based on other public health guidelines, the existing evidence suggests that social connection guidelines could act as a useful health promotion tool: fostering research, guiding intervention development, provoking policy changes, and giving prominence to social connection in public health discourse (Kumar et al., 2012); as well as these guidelines might be limited in their potential impact due to inherent challenges associated with the construction of guidelines critiques (Guggleberger, 2018). This section reviews these potential benefits and harms, relying on evidence from existing national guidelines related to alcohol use, nutrition, physical activity, and other health related behaviours.

Potential Benefits. While evaluations of existing guidelines are generally limited (Bacon, 2020; Pereira et al., 2022; Cassetti et al., 2022), the available literature highlights their potential utility in promoting health, guiding interventions, fostering greater investments into social health research, and influencing policies focused on generating social health.

First, public health guidelines play a foundational role in health promotion by offering evidence-based recommendations designed to enhance population health, turning complex scientific data into understandable, practical advice (Bull et al., 2020; Moore et al., 2017; LaRocca et al., 2012). As such, they increase access to information, thereby improving health literacy, which has the potential to improve behaviour (Sorensen, 2012; Greyson & Johnson, 2015; Coughlin et al., 2020). Generally speaking, behaviour change interventions – including mass media and health promotion campaigns – have the potential to achieve their desired effect (Jepson et al., 2010), particularly when such interventions are person-centered and respectful of individual autonomy (Samdal et al., 2017). More specifically, research on other public health guidelines suggest that most people are aware of them and a considerable proportion of individuals strive to adhere to these guidelines in order to achieve the desired health aims (Jackson et al., 2023; Corkum et al., 2022; Mbogori, 2021; Slater & Mudryj, 2018). The widespread adoption of guidelines highlights another potential benefit: establishing strong social norms that invite prosocial behavior and encourage social interaction. Indeed, social norms are recognized as relatively consistent predictors of behavior (Ball et al., 2010; Van Den Broucke, 2014)

Second, public health guidelines provide the blueprint for health interventions and clinical services. They lay out clear, measurable targets that can guide interventions and clinical practice (Dempsey et al., 2020; Dubasi et al., 2019), as well as help individuals set personal goals for themselves (Yngve & Tseng, 2010; Shilts, 2004).

Third, guidelines also foster research by identifying clear areas of focus in public health. By highlighting areas of importance and providing measurable benchmarks, they encourage researchers to explore these topics further, fostering a better understanding and leading to more effective interventions over time. For example, alcohol guidelines have been noted for their role in motivating alcohol research (Mukamal & Ding, 2016).

Fourth and finally, public health guidelines wield significant influence on policy (Raphael & Bryant, 2006). They serve as a robust, evidence-based platform for advocating health-supportive policies and have been instrumental in driving legislation, ranging from restrictions on alcohol sales to mandates for physical education in schools.

In sum, public health guidelines support individuals, healthcare providers, researchers, and policy makers to prioritize key health issues. The creation of public health guidelines for social connection might therefore advance the social health of individuals and communities.

Potential Risks. Public health guidelines, while beneficial, are not without potential drawbacks. Indeed, guidelines can be oversimplified, lack evidentiary support, be poorly received by the public, and create stigma (Lagerlof et al., 2021). Below we discuss these issues:

First, public health guidelines inevitably grapple with the delicate task of simplifying complex health issues into accessible, digestible advice for the public (Green, 2015). As such, the guidelines can be overly complex. For example, exercise guidelines using terms such as “sedentary” and “vigorous” can make it difficult for individuals to understand what is being asked of them (Nobles et al., 2020). Conversely, guidelines can also be over-simplified. For example, some have criticized dietary guidelines and their focus on macro-nutrients as contributing to higher rates of obesity and overconsumption (Woolf & Nestle, 2008; Marantz et al., 2008). Similarly, researchers have noted that there is remains considerable knowledge gaps with respect to nutrition – pointing to complex issues such as variations in the bioavailability of nutrients (Laville et al., 2017). Social connection is likewise complex and context-dependent meaning that any guidelines on social connection will likely be, at least to some extent, over-simplifications.

Second, established guidelines are also challenged by the diversity within the target populations they serve to help. For example, people have noted that exercise guidelines are not universal, but must be adapted to different age groups (McLaughlin et al., 2010). Similarly, individual contexts vary considerably and individual choice in behavior is constrained by these contextual factors (Lindsay, 2010; Nakkeeran et al., 2021; Newson et al., 2013). These realities underscore the very real challenges in developing guidelines that focus on the right aspects of social well-being and are also universally applicable. Individual differences in needs make this especially challenging. For example, men and women differ in their patterns and responses to alcohol consumption – highlighting challenges in providing public health guidelines that are appropriate to those with diverse needs (Greaves et al., 2022). Similar challenges can be foreseen when considering social connection guidelines and the likely high levels of variation in individual’s social needs and circumstances.

Third, criticism arises from a lack of sufficiently high quality causal evidence to support specific recommendations (Chiolero et al., 2020). Such charges have been levied at nearly all public health guidelines (Teicholz et al., 2015; Holmes et al., 2018; Suitor et al., 2007).

Fourth, the perception of public health guidelines as overly prescriptive or unrealistic (Anderson & Wallace, 1988; Shaw, 2016) For example, Hollman et al. (2022) notes that guidelines related to children’s screen time are perceived as unachievable and warns that unaligned public perceptions can reduce the effectiveness and adoption of public health guidelines.

Fifth, concerns have been raised that public health guidelines and health promotion campaigns can inadvertently (or overtly) contribute to stigma. Indeed, public health guidelines imply that individuals have control over their behaviours. They can also be seen to define some behaviours as healthy and others as unhealthy, which can contribute to the moralization of specific patterns of behavior (Turan et al. 2019; Brown, 2018; Roberts & Weks, 2018). For example, stigmatizing health promotion techniques have been widely used to discourage substance use – resulting in substantial harm for individuals who use drugs(Williamson et al., 2014). Such stigma often has a counterproductive effect. For example, rather than promoting healthy living, weight-related stigma has been linked to worse health outcomes for overweight individuals (Pearl et al., 2021; Vartanian & Porter, 2016). Similar challenges are likely to emerge with the creation of social health guidelines, particularly given pre-existing stigma attached to loneliness (Barreto et al., 2022; Kerr & Stanley, 2021; Lau & Gruen, 1992).

In sum, public health guidelines for social connection may be challenged by their oversimplification of complex matters, over-generalization to universal populations, a lack of sufficiently high-quality supporting evidence, poor public reception for unrealistic or overly prescriptive guidelines, and the risk that they may reinforce stigma and moralize social behavior.

The Content of Potential Public Health Guidelines for Social Connection

To date, no countries have adopted public health guidelines for social connection. However, guidelines are currently under consideration for development by several organizations, including the United States Surgeon General’s Office and the World Health Organization. Despite the lack of available guidelines, Holt-Lunstad (2023) argues that national social connection guidelines could focus on the size of social networks, frequency of social interactions, sources of social connection, context or mode of interaction, and the quality of social relationships. As such, guidelines will need to discuss the importance of social connection to health and wellbeing; assess the key features, mediators, and moderators of social health; consider variations in individual social needs; explore what levels, types, and frequencies of social interaction are determinant of health outcomes; identify context-specific barriers and facilitators to social connection; and assess the specific needs of key communities.

In crafting guidelines for these and other domains, it is important to consider the benefits and risks associated with the creation of public health guidelines for social connection. In particular, guidelines should be accessible, acceptable, and appropriately tailored. As well, given that the existing evidence related to social health is of relatively low quality compared to the bodies of work supporting other public health guidelines, initial guidelines must be developed with care through broad consultations. It is also important to regularly re-assess the evidence related to the guidelines in order to update them as needed.

Analyses from External Consultations with Social Health Experts

Seeking to inform the development of public health guidelines for social connection, we conducted a Delphi study with international experts in public health and social psychology (n = 95). To begin this process, we began with a series of brainstorming activities in order to inform the guideline development process. These brainstorming activities focused on outlining key issues in the guideline development process, identifying potential guidelines for social connection, and listing key contextual factors. A thematic analysis of participants open-text responses was undertaken resulting in four broad themes related to (1) key principles related to the development of social connection guidelines, (2) potential guidelines for individuals, (3) potential guidelines for organizations and communities, and (4) important contextual factors for addressing and preventing loneliness and social isolation.

Principles for Developing Social Connection Guidelines

Experts identified a number of important principles that they felt were important for the guideline development process. These principles focused on what the guidelines should include and how they should be developed and presented to the public. In doing so, experts highlighted the necessity of an inclusive and consultative process in the development of these guidelines. This would involve the engagement of a diverse set of stakeholders, including individuals with lived experience, experts in the field, and community leaders. Such inclusivity is vital for the guidelines to be universally applicable yet adaptable to specific cultural contexts and target populations. Moreover, they stressed the importance of transparency in the guidelines and that the recommendation should be backed by a clear evidentiary basis, with regular updates to keep up with evolving research. Along these lines, the experts also emphasized that it was important for guidelines to be accessible and disseminated effectively across diverse demographic groups, facilitated by an implementation plan and evaluation metrics.

In terms of the content of guidelines, experts suggest that the guideline development process should be careful to not be overly prescriptive, while also being simple and achievable. It was suggested that individuals might benefit most from advice that would help them set personal goals rather than receiving specific numeric targets. Additionally, the experts advocated for careful framing that acknowledges the complexities of social connection (e.g., different dimensions of social needs) and avoids stigmatization. Finally, it was commonly noted that the guidelines should address both individual-level and collective responses to prevent loneliness. The sections below outline the individual-level and collective guideline’s proposed.

Social Health Guidelines for Individuals

Experts provided diverse recommendations for potential guidelines. Among these, experts underscored the critical role of educating the public on the importance of prioritizing social health and helping individuals undertake a self-assessment to set tangible social connection goals, including quantifiable goals for regular social interactions, emphasizing the importance of regular and frequent social engagement with individuals from diverse sources (e.g., coworkers, neighbours, family, friends, and even strangers). They noted that such goals would help individuals balance their needs for solitude and social interaction. In line with this, experts recommended a diversified approach to social connections, advising individuals to build a resilient network consisting of a close circle of trusted individuals and a broader array of relationships. The experts also underscored that addressing social health would need to help individuals develop a positive mindset and healthy social cognition. As part of this, they recommended that individuals should be encouraged to actively seek social engagement, manage social anxiety through incremental exposure, and avoiding negative assumptions about others' perceptions. They also emphasized the importance of utilizing digital technologies judiciously to foster genuine connections while cautioning against passive consumption. Taking things deeper, they also discussed relationship building processes – beginning with strategies for meeting new people and following through with strategies for deepening relationships. To help individuals meet new people, experts encouraged frequenting places that allow for repeated interactions and using non-verbal cues to signal openness to new connections. They suggested that relationships could be deepened through regular contact, the creation of shared experiences, and through emotional generosity. They also provided advice for relationship challenges, highlighting the importance of open communication, learning from past experiences, and seeking professional help when navigating complex emotional landscapes. More generally, they also emphasized that individuals should be encouraged to take on leadership roles – initiating social interactions and advocating for policies that promote social wellbeing.

Social Health Guidelines for Organizations and Communities

In addition to these individual-level guidelines outlined above, experts also discussed guidelines that could be targeted to the organizational or community level. Indeed, the need for multi-faceted guidelines at the organizational and community levels to foster social health was repeatedly underscored by experts who felt that individual-level guidelines were likely insufficient for promoting social health. First, the experts argued that public awareness campaigns and educational initiatives would be needed. They recommended that such campaigns adopt a multi-generational approach that educates both parents and children through age-appropriate curricula. They also suggested that employers, landlords, and community leaders were crucial stakeholders who would also need to be informed on how to support individuals and their social health in different contexts. In describing the social and community-level interactions, experts also emphasized the need to collaborate with marginalized and special-needs communities to break down barriers to social connection and to promote inclusion within the broader community. They noted that this would extend not only to the social environment, but also through improving accessibility through the design of public spaces (e.g., traffic-free gathering spaces, social and cooperative housing), the provision of public transportation and universal internet access, and efforts to reduce stigma for key populations. The experts also strongly endorsed policy-level interventions, such as shorter workweeks and paid time off, to create time and space for social connections. The integration of social considerations into various policy domains, including housing and public safety, was repeatedly noted. Furthermore, they noted the need for funding that would support organizations to adopting these prosocial policies and practices. Finally, they also noted that research would be needed for the ongoing assessment of social health and argued for more robust surveillance systems, including clinical screenings for loneliness and social isolation. In discussing the needs for these systems, they specifically spoke to the importance of increasing scientific rigor and ensuring that appropriate investments in research among key populations were made.

Important Contextual Factors for Social Health

Finally, the experts identified a wide variety of social-ecological factors that were important to social health and would need to be considered throughout the guideline development and implementation process. At the individual-level they discussed cognitive biases, self-esteem, social anxiety, health challenges, and attachment barriers as key challenges. At the interpersonal-level they noted the importance of family and relationship dynamics. They also noted context-specific issues, such as work-related stressors, neighborhood safety, and other environmental determinants (including those related to the built environment, community programming, and transportation). Some barriers that were population-specific were also discussed, including language barriers, stigma and discrimination, and cultural issues related to individualism and collectivism. There was also discussion from several experts about the effective (and ineffective) use of digital technologies, including social media. In summary, the experts discussed a wide variety of specific barriers and facilitators that might play a role in shaping adherence to public health guidelines or the utility of such guidelines for different individuals and groups.

In summary, the experts consulted in our study recognized the potential value of social connection guidelines, at both the individual and community/organizational level – but also emphasized that social connection guidelines had a limited role and would therefore need to be incorporated into a larger social health strategy to promote and facilitate healthy social behavior at the individual and population level.

Discussion

The evidence suggests that evidence-based public health guidelines for social connection have the potential to enhance individual well-being by promoting awareness and education about social health needs and advancing social health research, practice, and policy. However, challenges exist, such as gaps in scientific evidence, issues with generalizability, and the balance between individual-specific and broadly applicable recommendations. Additional concerns include the risk of unintentionally stigmatizing loneliness through the guidelines. Despite these hurdles, consultation with experts, ongoing refinement, and strategic implementation could mitigate these challenges – just as is done for other public health guidelines which face these same challenges.

Conclusion

Based on the evidence summarized above, we conclude that there is potential utility in developing and implementing public health guidelines for social connection, provided they are evidence-based and thoughtfully executed. Efforts should be undertaken to explore expert and community support guidelines and evaluate the quality of evidence relevant to potential guidelines. To be effective, these guidelines should promote equity, focus on both individual-level and social conditions, be sensitive to diverse social health needs, and be carefully implemented to ensure strong public and professional confidence.