Title: How living in rural areas contributes to feelings of loneliness in diverse rural communities, and the role communities play in addressing social inequality
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Aims and Objectives: The Welsh Government (2018) report that 54% of people have experienced feelings of loneliness. This is exacerbated in rural areas where individuals at risk of loneliness are disproportionately affected by limited transportation, outmigration, and closure of local amenities, leaving individuals isolated and without support (Hart, 2016; National Assembly for Wales (NAW), 2017). The negative association between social isolation, loneliness and health and wellbeing outcomes are increasingly recognised in older populations (Holt-Lunstad et al., 2015); however, the rural older population is becoming increasingly diverse (Manthrope et al., 2012) and less is understood about potential inequalities that pertain to loneliness in rural areas of Wales, and which may be exacerbating equality, diversity and challenges of inclusion. For example, rural communities may include agricultural families who have lived in the area over generations of time. Ageing in place is a known predictor to protect against the effects of loneliness (DeKoning, Stathi, & Richards, 2017) with established residents being more likely to have wider connections and networks in the local community. However, the outmigration of family and youth to seek employment opportunities in urban centres is increasingly leaving those who are ageing in place with weaker social networks and support. In addition, agricultural living is a recognised risk factor of loneliness through the nature of its isolation and antisocial working patterns (Public Health Wales & Mental Health Foundation, 2019). However, rural and coastal locations also attract the in-migration of urban residents from England and Wales at the point of retirement seeking a quieter pace of life, or the rural idyll. With less established community ties, individuals experiencing bereavement or ill health before the opportunity has arisen to fully integrate into their communities can result in increased risk of loneliness and social exclusion. Similarly, whilst still a minority, individuals from BAME communities are increasingly represented in rural areas having moved due to employment (often in the health and social care sector) and are therefore aging in place, or having moved as a retirement choice in later life (Manthrope et al., 2012). However, BAME communities are often geographically dispersed across rural regions and as such their specific cultural or social needs may be dissipated or overlooked in the critical mass of the wider population leaving them at increased risk of loneliness. This provides just one example of the potentially hidden communities at risk of rural isolation and highlights how the needs of these diverse communities, in terms of language choice, social and cultural preferences are likely to differ. A review by Courtin & Knapp in 2015 exploring the health consequences of isolation and loneliness for older adults identified a lack of research exploring the effects for ‘other’ at-risk groups, not widely represented in the wider literature. However, researching specific interventions to determine which intervention type is likely to be most effective has been challenged by Age UK (2015) who following a review of interventions to address perceived isolation and loneliness concluded that there was lack of robust and reliable research to demonstrate the effectiveness of any specific intervention type over another. Instead, they commended community approaches that adapted to the needs of the community and became ‘structural enablers’. These structural enablers focused more on the mechanisms that could support the community to maximise volunteering, community assets and resources. Compassionate communities, where citizens support frail or older members of the community to be actively involved in their community to combat loneliness have been promoted in rural Shropshire and North Powys; however, there is recognition that the model depends upon the available time and capacities of volunteers which varies from community to community (Cronin, 2015).There is therefore a need to understand who is at risk of loneliness in rural Wales, and how their needs to address loneliness might differ so that community initiatives can be supported to develop their approaches in an inclusive and sustainable manner. The overarching aim of this programme of PhD research would be to understand how rural communities can be supported to develop effective initiatives designed to tackle loneliness in a manner that is inclusive and considerate of the diverse nature of the rural populations in Wales. To achieve this aim, the programme will comprise four research studies designed to address the following research questions: 1. Who are the key rural populations known to be at risk of loneliness in Wales? With specific consideration of diverse rural populations and regions (e.g., country, coastal, and agricultural communities, Black and ethnic minorities etc. 2. How do rural residents experience loneliness, and what are their needs in terms of community support? With specific consideration of identified populations from question 1. 3. How do existing examples of community and social enterprise initiatives contribute to overcoming rural loneliness? a. To what extent are these successful, sustainable and addressing the needs of the diverse rural population? 4. How can communities be supported to develop inclusive initiatives to overcome loneliness in their diverse populations? Design and method: The programme of research will be structured around four research studies which cumulatively provide an evidence base for the support needs of rural communities to enable them to effectively address loneliness with better consideration of the diversity and needs of the broad, and potentially hidden, members of the rural population. Study 1 will involve a systematic review of the academic literature supported by an initial scoping exercise amongst key social care and stakeholder organisations such as Rural Health and Care Wales, AgeUK, and County Council services to consider what is already known about the diversity of rural populations in Wales, their risk of loneliness, and where there may be hidden need currently under-represented in the academic literature and/or policy. Study 2 will involve a series of semi-structured interviews (approximately 20) with individuals who have self-identified, or who have been identified via gatekeeper organisations as experiencing loneliness, but with particular consideration of the diversity of groups identified in study 1. This study will explore in detail, the factors perceived to have contributed to loneliness, how loneliness is experienced and how individuals perceive the role of, and the opportunity for the community to offer support. Particular consideration will be given to how inclusive current initiatives are perceived to be, to what extent these meet their needs and what initiatives would be considered appealing. Study 3 will seek to utilise a case study approach by considering approximately 6 existing community and social enterprise initiatives contributing to addressing loneliness in rural communities. Initiatives will be identified through the activities such as the scoping in stage 1, engagement with relevant organisations such as, Rural Health and Care Wales, Community County Councils, and third sector organisations, word of mouth from individuals involved in study 2 and public outreach. For each initiative, focus groups and semi-structured interviews will be conducted with stakeholders including the community organisers, beneficiaries and any associated community social care organisations to provide a comprehensive understanding of the role initiatives play in tackling rural loneliness. This study will consider the drivers for community initiatives, how scope, aims and approach are agreed, challenges experienced, and benefits gained from the perspectives of the individual beneficiaries, community organisers and wider community organisations. Study 4 will seek to consolidate the findings from studies 1-3 and will engage stakeholders to co-create policy recommendations to support rural communities to develop initiatives to address social isolation with specific consideration of the inclusion and diversity of the rural population. The study will engage relevant social care organisations, community groups, and end users in a workshop where research findings will be disseminated and activities designed to co-create a set of recommendations and considerations to better support rural community initiatives. • Planning and use of resources: Given the rural nature of the PhD a key cost resource will include travel and subsistence contributions. This will support the ability of the candidate to travel to different rural communities across Wales in order to fully represent the diverse communities of rural and coastal towns and with the ability to visit remote locations, without easy transport infrastructure, hence requiring over night stays and subsistence support. A total of £3600 is requested for travel and subsistence. To support travel in studies 2 and 3 as well as conference attendance, £2500 is requested (6250 miles @£0.40pm by car, but with scope for use of public transport where appropriate). Subsistence of £1100 is requested to support overnight accommodation and subsistence. Conference fees (£600) are sought for two National conferences. It is anticipated that presentation of study 2 and 3 findings will be of academic interest in conference such as the British Psychological Society Conference (BPS), BPS division of health psychology conferences and conferences with a rural focus such as the Annual conference of the Highlands an Islands ‘rethinking remote’ and Rural Health and Care Wales’ annual rural health and social care conference. This will ensure a platform for the student to establish an academic reputation and network whilst disseminating the findings of the research to relevant social care audiences. £900 is sought to support refreshments during individual interviews and focus groups as well as supporting study 4’s workshop and final public engagement dissemination event. The predominant method of data collection will be the recording of qualitative interviews and focus groups. As such, the purchase of a Dictaphone is requested at £80 to facilitate this. • Method of analysis: The research will employ in-depth qualitative analysis throughout the programme of research. It is anticipated that the systematic literature review of study 1 will predominantly result in qualitative research studies, and as such frameworks for the qualitative synthesis of academic literature, such as Thomas and Harden (2008) will be utilised as a framework to guide the meta-synthesis and interpretation of the literature based review. The semi-structured interviews of study 2 and the interviews and focus groups from study 3, will be transcribed verbatim, and analysed utilising thematic analysis following the descriptive frameworks of Braun & Clarke (2006) to identify the underlying conceptual themes associated with the individual experience of loneliness, perceptions of social initiatives and inclusion (study 2) and the factors influencing the design, implementation, effectiveness, inclusivity and sustainability of community initiatives (study 3). Study 4 will seek to consolidate and synthesise the findings from studies 1-3 to work with stakeholders to co-create policy recommendations to support rural communities to develop initiatives to address loneliness but with better consideration of the inclusion and diversity of the rural population. The study will engage relevant social care organisations, community groups, and end users in a workshop where synthesised research findings will be disseminated and activities designed to co-create a set of recommendations and considerations to better support rural community initiatives. • Expected outputs and outcomes: The primary outcome of the PhD will be the doctoral thesis; however the programme of research is anticipated to generate a number of additional impactful outputs. 1) A systemic review paper synthesising the literature regarding the rural populations at risk of loneliness and highlighting potentially hidden populations amongst the wider rural demographic. 2) An academic paper outlining the individual experiences of loneliness from the perspective of a diverse rural population. 3) A research report for Rural Health and Care Wales outlining the needs of different rural populations across Wales and highlighting key community initiatives with respect to successes, challenges and sustainability. 4) A policy document outlining recommendations for social organisations to support rural communities to develop initiatives to tackle rural loneliness with consideration of wider social inequality and social diversity. • Dissemination and impact: In additional to the outputs listed above, the PhD will result in at least 2 academic conference presentations, in conferences such as the British Psychological Society’s Annual Conference, and Rural Health and Care Wales’ Annual conference. Public engagement talks to disseminate findings to an academic and general public audience will also be generated culminating in a dissemination event showcasing the research findings to the local general public and organisations. Close partnership working with Rural Health and Care Wales and developing the programme of research around their wider strategic workplan will ensure direct relevance to policy and pathways to impact. Rural Health and Care Wales’s Management bring together three health boards spanning a large rural area across Mid Wales (Betsi Cadwaladr UHB, Hywel Dda UHB, Powys THB) and Welsh Ambulance Service Trust, in addition to the local Authorities of Ceredigion, Gwynedd and Powys with additional representation from Community Hospitals and people/patient representatives from Ceredigion, Gwynedd and Powys. Working in alignment with their strategic aims therefore offers a direct route to impact through the organisations and groups representing the health and social care of vast areas of rural Mid Wales.

Lay abstract: The aim of this PhD research is to understand how rural communities can be supported to develop effective initiatives to tackle loneliness in a manner that is inclusive and considerate of the diverse nature of rural communities in Wales. To achieve this aim, the programme will comprise four research studies designed to address the following questions: 1. Who are the rural adult populations known to be at risk of loneliness in Wales? with consideration of diverse rural populations and regions (e.g., country, coastal, agricultural communities, Black and Ethnic Minorities etc)? 2. How do adult rural residents experience loneliness, and what are their needs in terms of community support? With specific consideration of identified populations from question 1. 3. How do existing examples of community initiatives contribute to overcoming rural loneliness? a. To what extent are these successful, sustainable and addressing the needs of the diverse rural population? 4. How can communities be supported to develop inclusive initiatives to overcome loneliness in their diverse populations? Utilising a combination of a desk-based literature review and individual semi-structured interviews with rural adults experiencing loneliness the research will add to academic literature and build on the body of evidence that will provide a greater understanding of inequalities that pertain to loneliness in rural Wales. Case study research focused on existing community initiatives will provide improved understanding of whether and how community initiatives are contributing to addressing loneliness with consideration of inclusivity relevant to their community diversity. This will enable the identification of models of best practice in community support that can be practically implemented or facilitated in rural areas to address issues of loneliness and will provide the opportunity to recognise where existing community support may be experiencing challenges in reaching hidden need with the aim of developing support mechanisms to improve social inclusion.

Research activity codes: 2.4 SURVEILLANCE AND DISTRIBUTION;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE