Concept Clarification and Assessment of Social 

Isolation and Social Support in Older Adults

White Paper

Prepared for: Administration for Community Living 

Office of Performance and Evaluation

Submitted by: Fayrouz Sakr-Ashour 

New Editions Consulting, Inc.

August 19, 2021
i 

Table of Contents

Executive Summary ...................................................................................................... 1

1. Background ............................................................................................................... 3

2. Introduction ............................................................................................................... 5

3. Methodology.............................................................................................................. 7

3.1. Social support ....................................................................................................... 7

3.2. Social isolation...................................................................................................... 7

4. Results ....................................................................................................................... 8

4.1. Concept clarification........................................................................................... 8

4.1.1. Social support................................................................................................. 8

4.1.2. Social isolation.............................................................................................. 13

4.2. Measurement tools ........................................................................................... 17

4.2.1. Social support............................................................................................... 17

4.2.2. Social isolation.............................................................................................. 25

5. Conclusions and future directions ........................................................................ 29

Appendices.................................................................................................................. 37

Appendix a: Definitions of Social Support .................................................................. 37

Appendix b: Definitions of Social Isolation ................................................................. 39
ii

List of Tables

Table 1: Dimensions addressed in the definitions of social support. .............................. 9

Table 2: Dimensions addressed in the definitions of social isolation. ........................... 14

Table 3: A summary of measurement tools for social support. ..................................... 19

Table 4: A summary of measurement tools for social isolation................................... 266
1 

Executive Summary 

The social wellbeing of older adults is essential for their quality of life and guards against important 

physical illnesses. This allows the growing population of older adults to successfully age in their 

communities and curbs healthcare spending resulting from hospitalization and institutionalization. The 

Older Americans Act supports this population through the provision of a wide array of social services 

and programs including home- and community-based services (HCBS). Recent evaluations of these 

programs has highlighted the vulnerability of these groups and the need for better measurement tools 

to assess important social concepts such as social isolation and social support. 

Social isolation and social support are complex concepts that have been linked to the mental and 

physical health of older adults for decades. However, there is no consensus on their definitions or scope, 

which is reflected in the heterogeneity of measurement tools. These disparities have not allowed the 

scientific community to provide evidence-based recommendations and guidance for programs and 

policies that aim at alleviating social isolation and providing social support for older adults. The purpose 

of this review is to summarize the literature in order to clarify the concepts of social support and social 

isolation, review existing measurement tools, and identify tools that have been validated in the older 

adult population.

A literature search was conducted in the academic databases Psychinfo, CINAHL, and Medline. The

terms definition, define, concept, theory, description and meaning were used in the search for 

definitions, and measurement or measure or scale or index or questionnaire or instrument in the search 

for measurement tools. Identifying definitions and measurement tools followed the snowball technique. 

Results emphasized the multidimensionality of these concepts. Dimensions that are important to 

consider when defining the concept of social support include the degree of subjectivity, directionality, 

sources, functions; intentionality and impact, structure, and mechanisms. The existing definitions of 

social isolation also contained a variety of dimensions; structure, degree of subjectivity, quality, 

function, engagement, duration and intentionality, and impact. Many of these dimensions have 

significant implications on the choice of measurement tool to be used.

To summarize measurement tools for social support, they were grouped as either measuring perceived, 

actual social support, or both. While many of the tools included the three common functions; 

instrumental, emotional and informational support, scoring did not necessarily allow the separate 

examination of these functions. Most of the measurement tools referred to informal sources for social 

support. All of the social isolation measurement tools included items that assessed the quantity of the 

individual’s social network, and much fewer tools addressed the quality of the relationships. There were 

items in the social support tools that examined some social isolation dimensions and vice versa, but, 

again, the scoring system did not allow for the separation of these concepts. This would help better 

understand how these two concepts relate to each other in older adults. 

It is clear that no single instrument can capture all of the dimensions included within social support and 

social isolation. However, an understanding of the context and purpose of measurement may help in the

choice of existing tools. What social support and social isolation mean to older adults is of particular 

importance, given the physical and mental limitations they may be facing. Therefore, validation of 

existing tools in this population is necessary. Furthermore, having a strong conceptual basis for the 
2 

future development of tools that can further our understanding of how to best address these growing 

challenges is urgently needed.
3 

1. Background 

The Older Americans Act (OAA), first enacted in 1965, serves to preserve the right for older Americans to 

‘age in place’1

, and to support a dignified aging process and decrease institutionalization (Colello, 2021). 

The legislation provides the 50 states and six territories with grants to deliver a wide array of social 

services and programs for individuals aged 60 years or older. Most of these programs and activities are 

administered by the Administration on Aging (AoA) in the Administration for Community Living (ACL) 

within the Department of Health and Human Services (HHS). This occurs through a nationwide network of 

State Units on Aging, Area Agencies on Aging, in addition to many other aging and social service providers 

in local communities. The OAA programs and services include home- and community-based services 

(HCBS) to support older adults who are at an increased risk of institutionalization. HCBS provides older 

adults with the option of receiving services in their homes. HCBS fall into three categories: 1) in-home 

services (such as personal care, home-delivered meals, and homemaker assistance); 2) community services 

(such as adult day care, congregate meals, and legal and mental services); and 3) other services, which 

include transportation, case management, and other assistance.

Title III C: Nutrition Service Program (NSP), which is part of the HCBS, provides nutrition services for older 

adults, targets those with the greatest need for food assistance; members of racial and ethnic minority 

groups, lower socioeconomic status, rural residents, those with limited English proficiency, and those at 

risk of social isolation and/or institutionalization (Barrett & Schimmel, 2010). The purpose of the NSP is to 

1) decrease hunger and food insecurity; 2) promote socialization; and 3) support the health and wellbeing 

of older adults by providing access to nutrition and other disease prevention and health promotion 

services to prevent or delay the onset of adverse health conditions (Congressional Research Service, 2014). 

The NSP provides meals and a range of nutrition-related services such as nutrition education, screening, 

assessment, and counseling. The meals provided are either congregate meals (CM), which are offered at 

locations such as senior centers, community centers, schools, churches and adult day care centers, or 

home-delivered meals (HDM), which are delivered to homebound older adults (Mabli et al., 2017). 

Meals served in a communal space for CM recipients provide chances for socialization, such as 

interacting with staff and peers during meal times and participating in social activities. Unfortunately, 

older adults on HDM programs may not have these opportunities, and so may potentially be more

socially deprived. It is suggested that the single and brief interaction that HDM participants have with 

the person delivering their meals may be the only direct human interaction an older adult has for the 

entire day (Thomas et al., 2016). This highlights the importance of social contact that an older 

homebound adult has with the person delivering meals in potentially preventing social isolation

(Thomas et al., 2016). 

In 2020, the 116th United States Congress reauthorized the OAA for a five-year period through FY2024, 

renaming the legislation as the Supporting Older Americans Act of 2020. Key amendments to the bill 

emphasize two of the increasing societal challenges that face this vulnerable population: social 

determinants of health (economic and social conditions influencing difference is health status) and 

social isolation and loneliness. Specifically, the Act bolsters efforts to combat social isolation, including 

screening for social isolation as well as education on preventing and responding to negative health 

effects associated with social isolation. Furthermore, it addresses an array of health promotion and 

disease prevention activities, such as self-management of chronic disease and the prevention of falls. 
4 

These activities support the NSP goal of health promotion and disease prevention, and assist older 

adults in living independently in their communities. These efforts can also decrease healthcare 

utilization and costs. 
5 

2. Introduction

Health is defined as “a state of complete physical, mental and social well-being and not merely the 

absence of disease or infirmity” (International Health Conference, 2002). Social well-being is considered 

as important as physical well-being for older adults (Montross et al., 2006). Furthermore, social isolation 

can also pose independent risks for physical and mental health (Cornwell & Waite, 2009). Older adults

place emphasis on their social relationships, identifying them as an important aspect of their aging 

experience (Montross et al., 2006; Teater & Chonody, 2020). In fact, one of the most frequently used 

services that older individuals seek as they age, to assist them in living independently, are social services 

(such as homecare, social activities and personal calls from a network of older adults designed to 

prevent social isolation) (van Bilsen et al., 2008). 

Social isolation has been linked to depression, stress, anxiety, suicide and worsening quality of life 

among older adults (Monk, 2000; Moreno-Tamayo et al., 2020; Santini et al., 2020). Social isolation has 

also been associated with deteriorating physical capability and malnutrition (Boulos et al., 2017; del 

Pozo Cruz et al., 2021). The deterioration of both physical and mental health can threaten the ability of 

older adults to continue living independently in their communities. Social support can assist older adults 

in adapting to some of the physical and mental decline that occurs in older age (Ellwardt et al., 2013; 

Hays et al., 1997). 

Social support is an important determinant of health status which can attenuate social disparities that 

might impact the health of older adults (Rueda, 2012). A supportive social environment can increase the 

survival of older adults with multimorbidities (Olaya et al., 2017), which represents the majority of NSP 

recipients. Having high levels of social support can help reduce fear of falls in older adults, a major public 

health concern for this population, and significant contributor to healthcare costs (John A. Rizzo et al., 

1998; Quach, 2018; Vo et al., 2020). 

The lack or deficiency of social relationships negatively impacts the use of preventive health services and 

has been associated with increased hospitalization, institutionalization and healthcare cost (Longman et 

al., 2013; Vozikaki et al., 2017). Older adults who cannot maintain independence are a huge cost to the 

healthcare system as a result of health expenditures for hospitalization and/or institutionalization (Office 

of the Actuary, 2016). Evidence suggests that healthcare models that incorporate social support services 

for older adults have shown a decrease in healthcare utilization and costs (Shier et al., 2013; Spiers et al., 

2019). Therefore, attention to social isolation and social support in older adults can lessen the burden on 

health systems. 

The recent lifestyle changes that occurred as a result of the COVID-19 pandemic have impacted social 

relationships and social support as a result of the imposed quarantine, isolation, and social distancing 

(Emerson, 2020; Manca et al., 2020). Older adults were shown to be at an increased risk for severe COVID19 infection, and so the benefit of these lifestyle changes may have outweighed the risk of social isolation 

and loss of social support. Some of the risk of this enforced social isolation was demonstrated through the 

worsening or development of new neuropsychiatric symptoms, and cognitive decline (Noguchi et al., 2021; 

Sepúlveda-Loyola et al., 2020). These findings, when combined with the abovementioned role that social 

connectedness and social support can play in supporting older adults and curbing healthcare costs, 
6

highlight the importance and urgency of the prevention and management of social isolation and the 

provision of social support in this population. 

Despite their importance, planning, design, monitoring and evaluation of effective interventions for social 

isolation and social support may be problematic. This may be the result of the variability in the use of 

terminology referring to these concepts and the measurement tools used for evaluating them, rendering 

comparisons and interpretations challenging (Cohen et al., 2001; Nicholson Jr., 2009). Operationalizing 

some of these concepts in the older adult population can be a further challenge because, for example, 

getting older does not necessarily mean being socially isolated (English & Carstensen, 2014; Szanton et al., 

2016). There is variability in the course that social relationships take as one ages. It is hard to tell to what 

extent loneliness, for example, is reflective of an actual loss of social contact (Cornwell & Waite, 2009). 

People who are socially active and surrounded by an extensive social network may still feel isolated

(Cornwell & Waite, 2009). Older individuals may also be satisfied with a smaller but closer group of people, 

so it seems essential to understand the degree to which older adults’ perceptions reflect actual social 

situations (English & Carstensen, 2014). And therefore, defining and operationalizing these concepts may 

need special consideration for the older adult population. The aim of this study, therefore, is to critically 

appraise the conceptualization and measurement of social isolation and social support in the literature for 

use in programs and interventions targeting older adults. 
7 

3. Methodology

Existing definitions and measurement tools of social support and social isolation were identified through 

a search of academic databases, including Psychinfo, CINAHL, and Medline. Identifying definitions and 

measurement tools followed the snowball technique. Using this technique, all references to definitions 

in the articles found through initial database searches were located. These references were then 

obtained, further references identified from the text, and so on. Although these searches were 

extensive, they cannot be said to be exhaustive. Despite this, the definitions located represent the bulk 

of those that exist and are considered adequate for a critical appraisal of the literature. A statement 

delineating the concepts of social support or social isolation was considered under the following 

circumstances: (a) the author explicitly identifies it as a definition; (b) the author uses it to guide his or 

her discussion of the concept of social support or social isolation. All identified definitions were 

tabulated, and characteristics were grouped according to the dimension that they belong to, to illustrate 

the scope of the concept. For the identification of measurement tools, only studies that discussed the 

development of a measurement tool were retained. Studies that developed measurements to be used 

for special populations (such as pregnant women) were excluded. The different dimensions of the 

measurement tools were determined and tabulated. Initial searches were conducted in October 2020-

January 2021.

3.1. Social support

For the identification of definitions, the term social support was entered into the search of the

databases, which resulted in an unwieldy number of articles. Subsequent searches included terms such 

as definition, define, concept, theory, description and meaning. These searches were more manageable 

and uncovered many, but not all, of the articles used in this study. The inclusion criteria involved books 

and academic journal articles in English published between January 2001 and December 2020. For 

measurement tools, the term social support and measurement or measure or scale or index or 

questionnaire or instrument was entered into the search of these databases. 

An additional category of global/undifferentiated social support was created to denote definitions 

and/or measurements that did not differentiate the function of support or used descriptors that were 

too broad to be grouped under the commonly known functions.

3.2. Social isolation

The terms social isolation and definition, define, concept, theory, description and meaning were used as 

the search terms for the databases. Books and academic journal articles were included if they were 

published in English, between January 2007 and December 2020. Research on social isolation is less 

abundant than that on social support, and so we used a seminal concept analysis article (Nicholson Jr., 

2009), which reviewed literature between 1983 and 2007. The terms social isolation and measurement 

or measure or scale or index or questionnaire or instrument was used to search for measurement tools 

of social isolation. 
8 

4. Results 

4.1. Concept clarification

4.1.1. Social support

Different dimensions are subsumed within the umbrella of social support, however, no single definition 

grasps the complexity of the phenomenon (Turner & Brown, 2010). A number of dimensions are 

considered when defining the concept of social support, which include degree of subjectivity 

(actual/available or perceived); directionality (received or provided); sources (e.g. formal or informal); 

function (e.g. emotional, informational and tangible); intentionality and impact (positive or negative); 

structure (e.g. number and frequency of social ties); and mechanisms (main or buffering effect). It is 

important to note that the process of social support does not occur in a vacuum, but within a social 

ecology and is shaped by the social context (e.g. stressors and available social roles), characteristics of 

the provider and the recipient (e.g. social skills, personality and distress) (Vaux, 1990a). A summary of 

the dimensions included in the various definitions (Appendix a) is provided in Table 1. 
9 

Table 1: Dimensions addressed in the definitions of social support.

Dimensions Evaluation Directionality Source Function Additional 

dimensions

Other 

constructs Author, year Actual Perceived Adequacy Quality Received Provided Formal Informal Instrumental Emotional Informational Global

Caplan, 1974  X X X  X X  X X X 

Mechanism 

of action X

Cobb, 1976 X  X X  X X  X X  X X X

Kahn, 1979  X X X   X X   X X X X

Schaefer et 

al., 1981 X   X     X X X X X X

Pilisuk, 1982  X X X  X X    X X X X

Procidano & 

Heller, 1983 X  X   X X X X X   X X

Leavy, 1983  X  X  X X  X X X  X X

Berkman, 

1983  X X X  X X     X X X

Barrera & 

Ainlay, 1983  X X X   X     X X

Intimate and 

positive 

social 

interaction

Shumaker & 

Brownell, 

1984 X X X X   X X X X X X

Intent of 

benefit X

Thoits, 1986  X X X X X X  X X X X

Mechanism 

of action

Coping, 

active 

participation
10

Heller et al., 

1986

X



XX



XX



XXXXXX

Lin, 1986

X



XX



XX



XXXX

Vaux, 1988

X



XX



X



XXXXXX

Hupcey, 1998



XXX



X



XXX



Intent of 

benefit

X

Cohen et al., 

2000



XX



X



XXX



XX

Cohen, 2004



XXX



XXX



XX

Intent of 

benefit

X

Finfgeld-

Connett, 

2005



XXX



XX



XXXX

Turner & 

Brown, 2010



XX



XXXXXX



Structural 

support

X

 
11

Dimensions 

a. Degree of subjectivity

A critical dimension in defining social support is to clarify the degree of subjectivity of the construct. 

Enacted or experienced social support refers to the actual support available, a more observable, 

objective indicator (Cohen, Underwood, et al., 2000; Lin, 1986). Perceived support, on the other hand, is 

a reflection of the recipient’s understanding and evaluation of the support assumed to be available, 

including adequacy and quality of that support (I. G. Sarason & Sarason, 1985). Both enacted and 

perceived social support have shown independent pathways and relationships with health (O’Conor et 

al., 2019; Stephens et al., 2011; Yan, 2020). More controversy lies in the relationship between received 

social support and health (Uchino, 2009). Some argue that the positive correlation is context specific, 

depending on factors such as the need for social support, and the form of support received. The degree 

of correlation between the two types of support has not been consistent in the literature, which may be 

partially the result of a poor understanding of the exact mechanisms by which each exert their impact 

on health and well-being (Uchino, 2009). Another possibility may be the lack of consistency in definition 

and/or validity of the tools used in the populations being measured.

b. Mechanism(s)

Social support is hypothesized to exert its effect directly; commonly referred to as main or direct effect, 

and/or through altering the response to stress; the buffering or moderator effect. The main-effect 

model proposes that social support acts directly to benefit the individual’s daily living by fulfilling his/her 

basic social needs (Thoits, 1986), or through emotionally induced effects on immune system functioning 

(Pilisuk, 1982). While the buffering effect of social support is assumed to be related to a stressful 

situation, and acts by facilitating coping and adaptation (Cassel, 1976). Numerous biopsychosocial 

mechanisms have been proposed to explain the positive impact of social support on resilience to stress 

but the exact mechanisms remain largely unknown (Ozbay et al., 2007).

The two mechanisms proposed above are not mutually exclusive, however, some authors choose to 

support one mechanism over the other in their definitions of social support, which may have 

repercussions on the operationalization of these definitions. Structural and objective aspects of social 

support have been proposed to exert main effects, while perceived social support is suggested to 

operate through a stress buffering mechanism (Berkman and Glass 2000). The difference between 

definitions that adopt a buffering-effect model and those that subscribe to the main-effect model also 

lies in the timing of support, where main-effects elude to a more continuous role for social support and 

buffering effects highlight the role of social support in times of stress (Cohen & Wills, 1985).

c. Directionality

Few authors include terminology that recognizes the bidirectionality of social support (Cohen, 2004; 

Turner & Brown, 2010), as most only refer to the receipt of social support. Equal exchange is believed to 

be optimal for supportive functions that are exchanged through social relationships (Homans, 1961). 

Furthermore, there is evidence to support the positive role that social support can have on the provider 

and not just the receiver (Antonucci & Jackson, 1990). Older adults who provide social support have a 

decreased likelihood of depressive symptoms and greater life satisfaction (Reed, 2005). Many of the 

supportive functions depend on having the ability and resources to meet the needs of another person, 

which are likely to decrease with age (Antonucci & Jackson, 1990). Therefore, older adults are more 
12

prone to mental disorders and decreased quality of life. Furthermore, the inability to reciprocate may be 

a barrier to asking for help from natural support systems such as family, friends and/or neighbors 

(Antonucci & Jackson, 1990). In such situations, older adults may have an increased need for formal 

supportive functions, such as those provided by healthcare providers, local and national organizations. 

d. Source

Most of the literature discussing support is focused on natural support systems, or informal sources of 

support that may be available to an individual by way of his/her social network. Yet, other formal 

supportive services provided may be available to provide assistance for vulnerable populations or 

subgroups. For example, Cohen and colleagues (Cohen, Underwood, et al., 2000) identify ‘formal 

support groups’ as one of the societal resources for support provisions in their definition. However, the 

majority of reviewed definitions do not reference the range of potential sources for social support. 

Informal support is often considered as the unpaid provision of assistance that is commonly provided by 

family members, close friends, and neighbors, while formal support is care that is provided by 

professionals who are paid for their service (Gaugler & Kane, 2001; Williams & Dilworth-Anderson, 

2002). And so, social relationships constitute a viable source for social support, however many 

definitions suggest that it is the sole source within which social support is exchanged (Kahn, 1979). In 

making that assumption, definitions may imply that support is synonymous with the function of one’s 

social relationships, losing any unique utility (K. Rook, 1983). These issues makes it increasingly 

challenging to operationally distinguish between these two concepts. And so, while social network 

analysis can certainly provide information on the structure of the informal social support available, 

however the notion that all networks are supportive and/or that these networks are the single source 

for support is often misleading (Schaefer et al., 1981). 

e. Function

The function of social support is one of the most commonly mentioned dimensions in defining the 

concept. The three most common functions are emotional (demonstrations of love, care, sympathy, 

empathy, etc.), instrumental (provision of goods and/or services), and informational (provision of 

guidance, feedback, resources for medical assistance, etc.) social support. Each of these may have a 

different relationship with health, however the literature examining these constructs separately in older 

adults is scarce. There is still a great deal to learn about the various functions of support and how they 

work to lower or raise levels of distress and to facilitate or impair physical health. By specifying the 

functions of support in future research, we may be able to advance our understanding of the role of 

social relationships in health and disease. 

The utility of social support as a stress buffer is contingent upon the match between the social support 

function provided and the coping requirement posed by the stressor (Cohen & McKay, 1984). 

Uncontrollable events such as harms or losses may entail social support functions that foster emotioncentered coping while controllable events such as threats or challenges may need a more problemcentered coping strategy (Cutrona & Russell, 1990). While there may be a marked need for one support 

function over the other, depending on the stressful event, all of the functions of support are thought to 

play a role in the general well-being (Cutrona & Russell, 1990). 
13

f. Intentionality and impact

The conversation on social support often has the underlying assumption of benefit, and the intentional

efforts to help someone but only a few definitions actually reference this postulation (Vaux, 1990b). 

Support that is not sought is often negatively perceived. It may, therefore, be beneficial to differentiate 

between the help that the recipient seeks out and help that is passively received (Barrera, 1986; Cutrona 

& Russell, 1990). Furthermore, the type of social support provided needs to match the need to be 

beneficial. For example, emotional support is critical in medical illness, but in cases of some illnesses 

involving physical limitations, instrumental support may also be necessary to compensate for the 

physical abilities lost and/or the financial strains that resulted from that illness. This highlights that, 

sometimes, a single stressful event may require multiple types of support to address the deficit created 

as a result of this stressor (Cutrona & Russell, 1990).

4.1.2. Social isolation

The theoretical concept of social support can be considered more mature than that of social isolation. 

The conception of social isolation is multidisciplinary, which may have contributed to the lack of 

consensus to date on its definition, scope and measurement (Courtin & Knapp, 2017). A variety of 

dimensions are reflected in the definitions of social isolation, which include structure (e.g. number and 

frequency of social ties), degree of subjectivity (isolation/loneliness), quality, function (e.g. social 

support and social control), engagement, duration and intentionality, and impact. A summary of the 

dimensions addressed in the different definitions (Appendix b) is provided in Table 2.
14

Table 2: Dimensions addressed in the definitions of social isolation.

Author, year Presence/Quantity Structure

Function(s)

Quality Perceived 

(Loneliness) Social 

support Other

Weiss, 1974  X X Social engagement X X

Delisle, 1988  X X X  X

Institute of Medicine (US) 

Division of Health 

Promotion and Disease 

Prevention, 1992

 X X X X X

Lien-Gieschen, 1993  X  X X X

Wenger et al., 1996  X X X X X

Lubben & Gironda, 1996  X  X X 

Schwarzer et al., 2004   X X X 

Machielse, 2006  X X X  X

Hawthorne, 2006  X  Companionship X 

Gierveld et al., 2006  X X X  X

Nicholson Jr., 2009  X X X  

Cornwell & Waite, 2009    Companionship X X

Biordi & Nicholson, 2013  X X X X 

Steptoe et al., 2013  X X X X X

Dury, 2014  X X Social engagement, 

belonging

 X

Zavaleta et al., 2014  X X X  X

Holt-Lunstad et al., 2015  X  X  X

Alpert, 2017  X X X X X

Wang et al., 2017    X  

Weldrick & Grenier, 2018  X X Social engagement, 

belonging

 X
15

Dimensions

a. Structure

The quantitative component refers to the structural features of the individual’s social network such as 

the number of contacts, frequency of contact, density, and diversity. The most widely used measure of 

network structure is network size (Brissette et al., 2000). Many definitions have confined social isolation 

to a loss/absence/decrease of social contact or ties. This approach is problematic given what we know 

about social relationships in older adults and how they may be satisfied with a smaller social circle 

(Bruine de Bruin et al., 2020). While an emphasis on quantity at some level is fundamental because the 

complete absence of social contacts necessitates social isolation, the opposite is not always true. In 

addition, terms that lack specificity such as ‘minimal contact’ may be difficult to operationalize and 

hence, not reflect an accurate picture of the older adult’s social relationships. Finally, an individual’s 

social ties can exist at different social spheres; at the household level (e.g. relationship with spouse), 

neighborhood, and/or larger community. Few definitions make a reference to the possible sources of 

social contact and even fewer definitions acknowledge the larger society as a potential source of more 

peripheral, yet relevant social ties (Granovetter, 1973).

b. Degree of subjectivity

Loneliness refers to the perception of social isolation; an inadequacy of social relationships, and is 

probably the one concept most invoked when social isolation is considered (Lubben & Gironda, 1996; 

Machielse, 2006; Schwarzer et al., 2004). It is considered as the subjective (psychologic) emotional state 

of the individual. Loneliness is not a necessary condition for social isolation, as both conditions can exist 

apart from each other (Biordi & Nicholson, 2013). Individuals may have numerous social ties and still 

feel lonely. Conversely, an individual may have little contact with others but not experience loneliness

(Chappell & Badger, 1989). Actual and perceived social isolation are related, but not identical, both 

having different relationships with physical and mental health in older adults. Some definitions describe 

social isolation to encompass loneliness (Lubben & Gironda, 1996; Machielse, 2006; Schwarzer et al., 

2004), whereas others have confined their definition to the objective state of social isolation (Alpert, 

2017; Gierveld et al., 2006; Holt-Lunstad et al., 2015; Steptoe et al., 2013). Many definitions did not 

clearly specify this dimension (Delisle, 1988; Hawthorne, 2006; Institute of Medicine (US) Division of 

Health Promotion and Disease Prevention, 1992; Lien-Gieschen, 1993; Lubben & Gironda, 1996; 

Nicholson Jr., 2009; Weiss, 1974). Many definitions use the degree of subjectivity to differentiate 

between social isolation as an objective construct and loneliness as a subjective construct. However, 

social isolation can develop subjectively, for example, as a result of the diminished quality of social 

relationships.

c. Quality 

Quality refers to the perceived value of someone’s social relationships and has been suggested to 

include the quality of certain key relationships (e.g., partner), and qualitative information on all of 

someone’s individual social contacts (e.g., rating how many of a person’s contacts are friends) (Wang et 

al., 2017). The quality of social relationships may have more of an impact on social isolation and health 

than the number of ties (Pinquart & Sorensen, 2001), suggesting that a few solid relationships may be 

more beneficial than multiple ties of poor quality (Biordi & Nicholson, 2013). However, peripheral, less 

intimate ties can play a significant role in the quality of life of older adults by enhancing the benefits of 
16

more central and stronger social ties, protecting against social isolation and loneliness (Berkman et al., 

2000; Cloutier-Fisher et al., 2011; Fingerman et al., 2004). Therefore, definitions that make no reference 

to quality may not be operationalized into measures that capture the significance of social relationships. 

Finally, the quality of social relationships should be distinguished from the overall appraisal of the 

perceived adequacy of social relationships. The latter is not directly related to the quality of specific 

individual relationships (Wang et al., 2017).

d. Function

An individual’s social relationships may impact his/her health and well-being in a variety of ways. Having 

multiple social roles may promote a sense of predictability and control over one’s life (Thoits, 1983), 

which is suggested to positively impact self-care (Cohen, 1988). These social relationships provide 

further social control, which can affect the individual’s health by; 1) direct influence of the person’s 

health practices, or 2) indirectly through the regulating responsibilities that are correlated with social 

roles (K. S. Rook et al., 1990). Having multiple social roles can also promote positive self-esteem and selfworth, which, in turn, enhance one’s ability to cope with stressful life situations and prevents depression 

(Cohen, 1988; Thoits, 1983). Social relationships offer meaning and purpose to one’s life, which 

positively impacts the individual’s psychological health (Thoits, 1983). Furthermore, having a diverse 

self-concept, which is a reflection of the individual’s multiple social position within their network, has 

been proposed to influence how one perceives and reacts to negative life events(Cohen, Benjamin, et 

al., 2000). Additionally, one’s social network can provide social support; psychological or material 

resources, that are ‘intended to benefit an individual’s ability to cope with stress (Cohen, 2004). 

e. Engagement

Terms such as ‘human interaction’, ‘participation in social activities’ and ‘engagement’ social 

connectedness relay that contact per se may not be sufficient to for an individual to not be socially 

isolated. Older adults can have many social contacts, but not engage with them. For example, they may 

have several friends, but they are not called or visited. Situations imposed on older adults, such as 

physical illness/limitations, may further disconnect them from meaningful discourse with people 

important to them (Merchant et al., 2020).

f. Impact

Social relationships are encouraged due to the aforementioned positive functions that they can play in a 

person’s physical and mental health. However, social relationships can also have negative consequences 

on health (Cohen et al., 2001; Nicholson Jr., 2009). An increase in social contact of isolated older adults 

may not always be health protective (Cohen et al., 2001). For example, social ties may encourage 

socially deviating or unhealthy behavior, present a source of conflictual interactions and stress for the 

individual, negatively impact a person’s self-identity and respect if one is not feeling appreciated, and/or 

provide mismatched or unhelpful social support (Umberson et al., 2010). These negative consequences 

do not take away from the importance of social relationships, and underscore the potential 

consequences of using definitions that presume benefit of social relationships.

g. Duration and intentionality

Social isolation may be situational, resulting from recent stressful life events or circumstances (e.g. 

recent loss, moving to a new community) or structural aspects that have likely persisted for many years 
17

(e.g. personality type or mental health) (Machielse, 2006). For example, some older adults may show a 

life-long pattern of having a small group of friends and less interest in replacing lost social ties. They may 

prefer solitary activities such as reading books and gardening (Cloutier-Fisher et al., 2011). Therefore, it 

is important to consider the dimension of intentionality when defining the concept of social isolation, 

and to distinguish social isolation from the positive state of aloneness or solitude. In solitude, an 

individual distances themselves from their social network, indicating that it is considered more of a 

voluntary initiative instigated by the individual, and is more often accompanied by positive feelings 

(Biordi & Nicholson, 2013). 

For any of the above-mentioned definitions to be able to guide measurement, there needs to be a clear 

understanding of the scope of the concept being measured, and the dimensions encompassed within 

that concept. However, the intent of this discussion is not to suggest that there should be one “right” 

definition for social support or social isolation. The variety of dimensions used in defining the concepts 

of social support and social isolation is an acknowledgement of the complex nature and may suggest 

that the definition(s) of choice may depend on the context. And so, from a programmatic perspective, it 

is critical to consider the objective(s) and population of interest when choosing a definition to match the 

purpose of the measurement. 

4.2. Measurement tools

4.2.1. Social support

Analysis of most of the existing measurement tools provide additional information on how social 

support and social isolation are assessed. While no single instrument needs to capture all of the 

dimensions of the concepts of social support or social isolation, the dimensions measured should be 

complete and relevant to the purpose of measurement. It is clear that the variations in the 

conceptualization of social support and social isolation are reflected in the operationalization of the 

constructs. Most of the reviewed measurement tools did not mention the definition that was used for 

social support or social isolation to guide their instrument development. The following section provides 

a broad overview of the full set of social support measurement tools that were reviewed, highlighting 

major findings. Table 3 provides a more detailed summary of each measure.

Actual support

The Social Support-Resources, Social Support List-Interactions (SSL-I) (including the shorter version, 

(SSL12-I), Close Persons Questionnaire (CPQ), Social Support Network Inventory (SSNI), and the Social 

Support Measure measured actual social support. All of these tools measured the receipt of social 

support, however the Social Support Resources, SSNI and Social Support Measurements also had items 

that addressed social support provision and reciprocity. The SSL12-I used a general term, ‘people’, to 

refer to the resources for social support, which would not be helpful in differentiating between formal 

and informal resources for support. In addition, the SSNI was the only measure that included some 

formal sources of support that the respondent can specify. The remaining tools only made reference to 

informal sources of support. 

All of the instruments measured the three most common functions of social support, emotional, 

instrumental and informational social support, except for CPQ and SSNI, which did not examine 
18

informational social support. SSL12-I, CPQ and the Social Support Measure were, however, the only 

tools that provided information on the internal consistency of the subscales measuring these different 

functions. It should also be noted that some of the measurements included assessments of other 

constructs such as social network composition and structure, and social integration. 

Perceived support

The majority of the reviewed measurement tools examined perceived social support. Similar to the tools 

measuring actual social support, most of the perceived social support tools examined received social 

support. The Social Networks and Support Measurement Tool, Older Adult ́s Perceived Social Support 

Scale, Perceived Social Support (PSS), Social Provisions Scale (SPS), and Index of Social Support (ISS) also 

included items that examined reciprocity. However, items did not necessarily specify the function of the 

reciprocated social support. 

The Social Support-Appraisal measurement tool and the Multidimensional Social Support Questionnaire 

(MSSQ) examined a single function of social support; appraisal and instrumental support, respectively. 

The majority of the multidimensional measurement tools reported the internal consistency of the 

subscales for the different functions. Social Support Questionnaire (SSQ), Multidimensional Scale of 

Perceived Social Support (MSPSS), Social Networks and Support Measurement Tool, and Perceived 

Social Support (PSS) included items that did not specify any function(s) of social support (global 

support), and used general terms such as ‘help’ in some of their items while the Older Americans 

Resources and Services (OARS) Social Support Scale, Social Support Index, 11-item Duke Social Support 

Index (DSSI), and the Index of Social Support restricted their items to global support.

Actual and perceived support

The Arizona Social Support Interview Schedule, Inventory of Socially Supportive Behaviors (ISSB), DukeUNC Functional Social Support Questionnaire (FSSQ), and the abbreviated 23-item Duke Social Support 

Index (DSSI) measured both actual and perceived social support. All of these mixed tools measured only 

received social support. The FSSQ and DSSI measured actual instrumental social support and perceived 

global social support. Excluding the ISSB, which did not specify the resource for social support, all of 

these measurements specified informal sources of social support, but did not differentiate between the 

different subgroups within the informal group, as neighbors, friends and/or family. 
19

Table 3: A summary of measurement tools for social support.

measurement tool Author, 

year

Number of

questions Direction Evaluation Function Source(s) Other 

constructs

Validation in 

older adults

I. Actual support

Social Support ListInteractions (SSL-I)Van 

Sonderen 

1991/1993

34 Received Actual Emotional support 

(everyday and in 

problem situations)

Instrumental

Informational

Esteem support

Unspecified ("people") X X

Social Support List-12 

Interactions (SSL12-I)

Ormel et al., 

1992

12 Received Actual Emotional support 

(everyday and in 

problem situations)

Instrumental

Informational

Esteem support

Unspecified ("people") X 

Close Persons Questionnaire 

(CPQ) 

Stansfeld & 

Marmot 

1992

10 Received Actual Emotional

Instrumental

Negative aspects of 

support

Informal- specified

Kin/Non-kin/close 

persons* *specified by 

respondent

Social 

networks, 

social support 

adequacy

X

Social Support Network 

Inventory (SSNI)

Flaherty et. 

al, 1983

11 Received 

+ 

Reciprocity

Actual Emotional

Instrumental

Event-related

Formal and informalrespondent can specify 

"friends, family, 

coworkers, clergy, 

doctors, groups, etc., 

who are an important 

part of [his/her] life at this 

time"'

X Developed in a 

sample that 

included older 

adults

Social Support-Resources Vaux, 1982 8 Received

Perceived Actual

Emotional

Instrumental 

Informational

Informal*-specified

Family

Friends

*specified by respondent

Network 

structure, 

composition

X

The Social Support Measure Krause & 

Markides, 

1990

41 Received

Provided 

Actual Emotional

Instrumental

Informational

Informal (natural support 

systems; "people")

Integration 

(assessed 

provision of 

Developed in a 

sample of older 

adults
20

the 3 

contents)

II. Perceived support

Social Support Questionnaire Schaefer et 

al., 1981

64 

(Emotional)

9 (Tangible)

16 

(Informational

)

Received Perceived Emotional

Instrumental

Informational

Specified by respondent 

(for informational and 

emotional)

X X

Social Support Index (SSI) Wilcox, 1981 18 Received Perceived Emotional

Instrumental

Informational

Unspecified X X

Norbeck Social Support 

Questionnaire

Norbeck et 

al., 1981

9 Received Perceived Affect

Affirmation

Instrumental

Specified by respondent Duration & 

frequency of 

contact

Validated in a 

sample that 

included older 

adults

Older Americans Resources 

and Services (OARS) Social 

Support Scale

Blazer et al., 

1982

10 Received Perceived Global

Unspecified

(someone)

Roles and 

attachment, 

social 

interaction



Social Support Index Bell et al., 

1982

8 Received Perceived Global Informal-differentiated

Friends

Relatives

Significant other

X Developed in a 

sample that 

included older 

adults

Social Support Questionnaire 

(SSQ) 

Sarason et 

al., 1983

27 Received Perceived Global

Emotional

Appraisal

Informational

Specified by respondent X X

Interpersonal Support 

Evaluation List (ISEL)

Cohen & 

Hoberman, 

1983

40 Received Perceived Instrumental

Appraisal

Self-esteem

Unspecified Belonging X
21

Socially Supportive Behaviors 

(SSB)

Vaux et al, 

1987

45 Received Perceived Emotional 

Instrumental

Informational

Informal-differentiated

Family

Friends

Socializing X

8 item Duke-UNC Functional 

Social Support Questionnaire

Broadhead 

et al., 1988

8 Received Perceived Confidant

Emotional

Unspecified X Developed in a 

sample that 

included older 

adults

Multidimensional Scale of 

Perceived Social Support 

(MSPSS)

Zimet, 1988 12 Received Perceived Emotional

Global

Informal- differentiated

Family

Friends

Significant other

X X

Mannheim Interview on 

Social Support (MISS)

Veiel, 1990 12 Received Perceived Psychological 

Everyday Support

Instrumental 

Everyday Support

Psychological Crisis 

Support

Instrumental Crisis 

Support

Specified by respondent X X

(Medical Outcomes Study) 

MOS- Social Support Survey

Sherbourne 

& Stewart, 

1991

19 Provided Perceived Emotional

Instrumental

Informational

Affection

Unspecified 

('someone')

Positive 

interaction

Developed in a 

sample that 

included older 

adults

11-item Duke Social Support 

Index (DSSI)

Koenig et 

al., 1993

11 Received

Perceived

Global Informal -undifferentiated

(Friends and family)

Social 

interactions 

(actual)



Social Support-Appraisal Vaux, 1996 23 Received Perceived Appraisal Informal-differentiated

Family

Friends

X X

Multidimensional Social 

Support Questionnaire 

(MSSQ)

Gangemi, 

2010

34 Received Perceived Instrumental Informal-differentiated

Significant others

Non-significant others

X X
22

The 10-item Social Provisions 

Scale (SPS-10)

Caron, 2013 10 Received Perceived Emotional

Informational

Appraisal

Informal-undifferentiated 

("friends, family 

members, coworkers, 

community members and 

so on")

X X

5-item Social Provisions 

Scale (SPS-5)

Orpana et. 

al, 2019

5 Received Perceived Emotional 

Appraisal

Informal-Undifferentiated 

("friends, family 

members, coworkers, 

community members and 

so on")

X Developed in a 

sample that 

included older 

adults

Social Networks and Support 

Measurement Tool

Ahmed et 

al., 2018

28 Received

Provided

Perceived Global

Emotional

Informal-differentiated

Partner

Family

Neighbors

Friends

X Developed in a 

sample of older 

adults

Older Adult ́s Perceived 

Social Support Scale

Nazari et al. 

2020

34 Received

(+1 item on 

provided 

practical 

support)

Perceived Emotional

Instrumental

Spiritual

Informal- undifferentiated

("close people")

Negative 

interactions

Developed in a 

sample of older 

adults

Perceived Social Support 

(PSS)

Procidano & 

Heller, 1983

20 (Friends)

20 (Family)

Received

Provided

Perceived Global

Emotional

Informational

Informal-differentiated

Friends

Family

X X

The Social Provisions Scale 

(SPS)

Cutrona & 

Russell, 

1984

24 Received 

Provided 

(opportunity 

for 

nurturance)

Perceived Emotional

Instrumental

Informational

Appraisal

Informal- undifferentiated 

("friends, family 

members, coworkers, 

community members and 

so on")

Social 

integration



Index of Social Support (ISS) James & 

Davies, 

1987

9 Received

+ 

Reciprocity 

items 

(unspecifie

d support)

Perceived Global Informal- undifferentiated 

("Family, neighbors, 

friends, acquaintance")

X X

III. Mixed
23

Arizona Social Support 

Interview Schedule

Barrera 

1980

6 Received Actual

Perceived

Instrumental

Informational

Appraisal

Informal-undifferentiated Intimate 

interaction, 

social 

participation

X

Inventory of Socially 

Supportive Behaviors (ISSB)

Barrera et al. 

1981

40 Received Actual

Perceived

Instrumental

Informational

Esteem

Unspecified 

(people)

X X

Duke-UNC Functional Social 

Support Questionnaire 

(FSSQ) 

George et al. 

1988

35 Received Actual 

(Instrumental)

Perceived 

(Global)

Global

Instrumental

Informal-undifferentiated

(Family/friends)

Size of 

network, 

frequency of 

interaction

Developed in a 

sample that 

included older 

adults

23-item Duke Social Support 

Index (DSSI)

Koenig et 

al., 1993

23 Received Actual 

(Instrumental)

Perceived 

(Global)

Global

Instrumental

Informal-undifferentiated

(Family/friends)

Social 

interactions

Developed in a 

sample of older 

adults

Positive and Negative Social 

Exchanges (PANSE)

Newsom, 

2005

24 Received Actual

Perceived

Emotional

Instrumental

Informational

Informal-undifferentiated

("people you know")

Companionsh

ip

Developed in a 

sample of older 

adults
24

Issues to consider in the choice of measurement tool

1. Actual or perceived?

Evaluating the objective existence of social support or the individual’s assumption that it is or can be 

available if needed depends on the question being posed and the hypothesized mechanism of action. Most 

of the reviewed tools measure perceived social support, which is easier to measure, with ample evidence of 

its positive association with physical and mental health (Wilcox & Vernberg, 1983). It is important to note 

that global appraisal of perceived social support does not vary markedly over time, while measures of 

actual supportive function(s) can reflect the impact of an intervention. However, there is merit in including 

both enacted and perceived social support, given the lack of consensus on how they relate to one another, 

and/or if they have an independent relationship with health. 

2. Received or provided?

The ability to reciprocate may be compromised by illness, and limitations imposed by homebound status. 

This may suggest that social support from informal social sources might not be sought by sicker, 

homebound older adults (Antonucci & Jackson, 1990). It is possible that older adults who are not able to 

reciprocate social support prefer to use formal support services and/or have an increasing need for them. 

3. Composite or separate score?

While the majority of the reviewed tools measured two or more functions of social support, studies have 

combined them into a single score and did not test psychometric properties of the subscales. This limits the 

ability to identify unique effects of particular function(s).

4. Which supportive function(s)?

Certain content may be relevant for particular types of contexts, for example evidence shows that 

instrumental support may buffer financial stressors but not interpersonal stressors (Peirce et al., 1996). For 

some illnesses, physical limitation may require instrumental social support to replace or compensate for 

the loss of physical ability (Cutrona & Russell, 1990). Measurements tools that do not specify the content(s) 

of social support may not provide the information necessary for evaluating the support-enhancing 

functions provided by interventions and programs. For example, the NSP provides meals, nutrition 

counseling and education, as well as information on additional resources that could be of assistance to 

older adults. It is, therefore, important to measure both instrumental and informational support. However, 

measuring other functions of social support may improve the understanding of additional support needs of 

this population, and/or uncover important relationships between the different functions (Cutrona & 

Russell, 1990). 

5. What is the source of social support?

According to the provider, social support can be divided into formal and informal social support. Formal social 

support is that obtained from outside the person’s social network, by individuals and/or organizations in 

accordance with appropriate policies and regulations and tends to have the characteristics of regularity and 

stability. Informal social support is provided by the person’ social network of family, friends and neighbors. 

There is a certain degree of complementarity between formal and informal social support, however, some 

functions, such as emotional support from family, cannot be replaced (Lu et al., 2020). Support from family 

and friends may be more valued, but they may be less knowledgeable in providing informational support on 
25

relevant and useful aid than other resources (B. Sarason et al., 1990). Additionally, formal social support 

becomes increasingly important for older adults as they become increasingly dependent and/or outlive 

individuals in their social circle(s). For example, formal social support positively contributes to mental health 

especially in the absence of informal support, in those with limited and/or declining physical and cognitive 

functions (Muramatsu et al., 2010; Williams & Dilworth-Anderson, 2002). The content, quality and satisfaction 

with support can vary according to the source of support, which can influence the impact of support, and/or 

when the person seeks it (Antonucci, 1983). Therefore, depending on the purpose of measuring social 

support, inquiring about the source of support may be necessary. 

4.2.2. Social isolation

There is a growing literature on the role of social relationships in the health and wellbeing of older adults. 

Researchers developed conceptual and methodological tools to better understand the nature of social 

isolation. Below is a summary of the tools identified and reviewed (Table 4).

Actual (objective) 

The majority of the reviewed measurement tools are designed to measure objective social isolation. The 

most common structural aspects of the individual’s social relationships that are measured are the presence 

and/or size of the person’s network. However, Berkman-Syme Social Network Index (SNI) is the only 

measurement tool that solely considers the individual’s network structure dimension of objective social 

isolation. The Interview Schedule for Social Interaction (ISSI), Lubben Social Network Scale (LSNS), the 

Mobility in Aging Study Social Networks and Social Support, and the Social Isolation Scale (SIS) measure the 

quality and the social support function of social relationships in addition to the structural dimension. 

Actual and perceived (loneliness)

Two of the reviewed measurement tools combined items that assess the objective and perceived 

(loneliness) aspect of social isolation; the Canadian Longitudinal Study on Aging Social Isolation Index (CLSASII) and the 10-item Social Isolation Scale.
26

Table 4: A summary of measurement tools for social isolation.

Measurement tool Author, 

year

Number 

of 

question

s

Structure Functions Other 

dimension

s 

Quality Loneliness Validation in 

Presence/ older adults

Quantity 

Other structural 

dimensions

Social 

support

Other 

functions

Berkman-Syme 

Social Network Index 

(SNI) 

Berkman 

& Syme, 

1979

6  Sources of social 

contact Χ X X X X

Developed in 

a sample that 

included older 

adults

Interview Schedule 

for Social Interaction 

(ISSI) 

Henderso

n 1981 52  X

Received 

emotional 

support

X

Perceived 

adequacy, 

acquaintanc

eship, 

friendship

 X

Developed in 

a sample that 

included older 

adults

The Lubben Social 

Network Scale-18

Lubben & 

Geronda, 

2004

18 

Frequency of 

contact, sources 

(family, 

neighbors & 

friends)

Received 

global & 

emotional 

support

X X X X X

Lubben Social 

Network Scale 

(LSNS) 

Lubben, 

1988 10 

Sources of 

contact (family & 

friends)

Instrumental 

& emotional 

support 

(provision & 

receipt)

X X X X 

Lubben Social 

Network Scale-6 

(LSNS-6)

Lubben & 

Geronda, 

2003

6 

Frequency of 

contact, sources 

(family & friends)

Global 

support X X X X 

The Social 

Disconnectedness 

Scale 

Cornwell 

& Waite, 

2009

8 

Frequency of 

contact, sources 

(family, 

neighbors & 

friends)

Global 

support X Social 

participation X X 

National Health and 

Aging Trends Studysocial isolation 

measure

Pohl et al., 

2017 5 

Sources of 

contact (partner, 

family & friends), 

quantity

X X Social 

participation X X 
27

International Mobility 

in Aging Study-Social 

Networks and Social 

Support Scale 

(IMIAS-SNSS)

Ahmed et 

al., 2018 28 

Sources of 

contact (partner, 

family, friends & 

friends), quantity

Includes 

received 

emotional 

support 

(actual & 

perceived) & 

provided 

global support 

(actual & 

perceived)

Meaning and 

purpose, 

positive selfesteem and 

self-worth

X  X 

Social Isolation Scale 

(SIS)

Nicolson 

et al., 

2020

6 

Sources (family, 

neighbors & 

friends), quantity

X X

Intimacy, 

perceived 

adequacy

 X 

Canadian 

Longitudinal Study on 

Aging Social Isolation 

Index (CLSA-SII)

Wister et 

al. 2019 24 

Frequency of 

contact, sources 

(children, 

siblings, other 

relatives, 

neighbors & 

friends)

Emotional/inf

ormational 

support, 

affectionate 

support, 

tangible 

support

X

Community 

participation

, perceived 

adequacy

Positive 

social 

interactions



Developed in 

a sample of 

older adults

10-item Social 

Isolation Scale 

Ranjan & 

Yadav, 

2019

10  X X X Intimacy X  X
28

Issues to consider in the choice of measurement tool

1. Should objective social isolation or loneliness be measured?

Examining both loneliness and social isolation can aid in the understanding of the older adult’s social situation 

and provide new directions for effective intervention programs targeting this population. As mentioned, these 

two concepts are not identical, and therefore it is important that measurement tools that combine the 

evaluation of social isolation and loneliness have a scoring system that allows the differentiation between 

four groups; socially isolated and lonely, socially isolated but not lonely, lonely but not socially isolated, 

neither lonely nor socially isolated (Newall & Menec, 2019). 

2. Should the measure evaluate availability or other structural features of social 

isolation? 

Tools that only measure the availability and/or quantity of social relationships may not be able to 

accurately identify socially isolated older adults. Programs assessing social isolation in older adults would 

benefit from identifying the source of these social relationships, whether they are with family, friends, or a 

more formal environment such as that of congregate meal settings in the Nutrition Service Program.
29

5. Conclusions and Future Directions

There is ample evidence demonstrating the importance of social factors for the physical and mental health of 

older adults. However, lack of clarity and consensus on the conceptual definition(s) and scope of social 

support and social isolation, and consequently, the operationalization of these definitions may have 

contributed to the staggering progress made in understanding the nature of these concepts in this vulnerable 

population. Additionally, understanding the interplay between social support and social isolation in older 

adults can provide insights into the design of interventions that address either of these concepts, and can 

point toward relevant outcomes for measuring the effectiveness of these programs.

The nature of social support and social isolation depends on the context in which they are being measured, 

including the characteristics of the population of interest. This context goes beyond individual level factors, to 

include, for example, neighborhood and community level factors (e.g. transportation facilities and safety). 

Understanding the meaning of social support and social isolation for older adults can help refine how they are 

defined in the literature, and consequently, how they are measured. This is particularly important for high risk 

groups, such as older adults with multiple chronic diseases and/or those who are homebound, who may have 

a different view of social support and/or social isolation. A client-based approach such as that offered through 

community-based participatory research may also provide better direction of ways to deliver interventions.

Furthermore, exploration of the risk factors and mechanisms through which social support and social isolation 

can influence health outcomes in older adults, whether and how gender, cultural and/or socioeconomic 

differences are at play, can offer guidance into the design of effective and better targeted interventions. It 

may be that effective support and social connectedness follow a dose-response relationship with health and 

are dependent on a certain ‘degree’ of deficiency. It is unlikely that a ‘one size fits all’ approach to 

interventions addressing social support and social isolation is effective. Additionally, programs aiming at 

providing social support and alleviating/preventing social isolation in older adults can benefit from the 

characterization of the relationship between the different dimensions of support (e.g. perceived and enacted 

support, formal and informal), and that between actual and perceived social isolation. These findings can help 

prioritize interventions and provide further guidance into the most cost-effective use of resources. However, 

many of issues have not been adequately explored in the literature, and the lack of reliable and valid 

measurement tools in older adults may have impeded such progress.

There is consensus that both social support and social isolation are not unitary concepts. However, most of 

the existing measurement tools for the two concepts attempt to combine dimensions of each concept. 

Furthermore, some measurement tools do not make a clear distinction between social support and social 

isolation. Consequently, such measurements may offer little conceptual meaning and practical application. A 

solid theoretical foundation is necessary for the design of the measurement tools for these two concepts. 

Conceptual clarification followed by construct validation are needed for each concept. Empirical construct 

validation through, for example, the multi-trait multi-method matrix would be helpful, given the multiplicity 

of existing measurement tools. In summary, more fine-grained questions need to be addressed and further 

development of measurement tools is necessary for programs and policies to effectively address the growing 

epidemic of social isolation and social support needs of the expanding and vulnerable older adult population.
30

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Appendices

Appendix a: Definitions of Social Support

(Author, year) Definition(s)

(Caplan, 1974) “Set of relationships with one or more significant others or groups that help the individual deal with the 

general issues of life or that provide special assistance”; 

“Both enduring and short term support are likely to consist of 3 elements: the significant others help the 

individual mobilize the psychological resources and master his emotional burdens; they share his tasks; and 

they provide him with extra supplies of money, materials, tools, skills and cognitive guidance to improve his 

handling of his situation”;

“It is not an all-inclusive analysis of the meaning and significance of social ties and groupings”

(Cobb, 1976) “Information leading the subject to believe that he is cared for and loved, esteemed and valued, and that he 

belongs to a network of communication and mutual obligation” 

(Kahn, 1979) “Interpersonal transactions that include one or more of the following: the expression of positive affect of one 

person towards another; the affirmation or endorsement of another person's behaviors, perceptions, or 

expressed views; the giving of symbolic or material aid to another. The key elements in supportive 

transactions are thus affect, affirmation and aid”

(Schaefer et al., 

1981)

“An evaluation or appraisal of whether and to what extent an interaction, pattern of interactions, or 

relationship is helpful” 

(Pilisuk, 1982) “Social support refers to those relationships among people that provide not only material help and emotional 

assurance, but also the sense that one is a continuing object of concern on the part of other people” 

(Procidano & 

Heller, 1983)

[Perceived] “the extent to which an individual believes that his/her needs for support, information, and 

feedback are fulfilled” 

(Leavy, 1983) “The availability of helping relationships and the quality of those relationships”

(Berkman, 

1983)

“The emotional, instrumental, or financial aid that is obtained from the social network” 
38

(Barrera & 

Ainlay, 1983)

“Behavioral transactions provided by natural social support systems' can be classified into six categories; “1) 

Material aid: providing tangible materials in the form of money and other physical objects; 2) Behavioral 

assistance: sharing of tasks through physical labor; 3) Intimate interaction: traditional nondirective counseling 

behaviors such as listening, expressing esteem, caring and understanding; 4) Guidance: offering advice, 

information or instruction; 5) Feedback: providing individuals with feedback about their behavior, thoughts or 

feelings; 6) Positive social interaction: engaging in social interactions for fun and relaxation”

(Shumaker & 

Brownell, 1984)

“An exchange of resources between 2 individual's perceived by the provider or recipient to be intended to 

enhance the wellbeing of the recipient”

(Thoits, 1986) “Coping assistance, or the active participation of significant others in an individual's stress-management 

efforts” 

(Heller et al., 

1986)

[A social activity that] “is perceived by the recipients of that activity as esteem enhancing or if it involves the 

provision of stress-related interpersonal aid (emotional support, cognitive restructuring or instrumental aid)”

(Lin, 1986) “The perceived or actual instrumental and/or expressive provisions supplied by the community, social 

networks, and confiding partners” 

(Vaux, 1988) “A metaconstruct of three distinct conceptual components: support network resources, supportive behavior 

and subjective appraisals of support”; “A complex transactional process involving an active interplay between 

a focal person and his or her support network”

(Hupcey, 1998) “A well-intentioned action that is given willingly to a person with whom there is a personal relationship and 

that produced an immediate or delayed positive response in the recipient”

(Cohen et al., 

2000)

“The social resources that persons perceive to be available or that are actually provided to them by 

nonprofessionals in the context of both formal support groups and informal helping relationships” 

 (Cohen, 2004) “Refers to a social network’s provision of psychological and material resources intended to benefit an 

individual’s ability to cope with stress”

(FinfgeldConnett, 2005)“Is an advocative interpersonal process that is centered on the reciprocal exchange of information and is 

context specific', identifying 2 types of support; emotional and instrumental”

(Turner & 

Brown, 2010)

“A multidimensional concept involving perceived, structural, and received support”
39

Appendix b: Definitions of Social Isolation

(Author, year) Definition(s)

(Weiss, 1974) “The absence of an engaging social network”

(Delisle, 1988) “Denotes a lack of quantity and quality of social contacts”

(Institute of 

Medicine, 1992)

“Defined structurally as the absence of social interactions, contacts, and relationships with family and friends, 

with neighbors on an individual level, and with “society at large” on a broader level” 

(Lien-Gieschen, 

1993)

[Within the elderly population] “occurs as a process in which individuals lose their sense of personal integrity or 

connection with resources within the society”

(Wenger et al., 

1996)

“Objective state of having minimal contact with other people”

(Lubben & 

Gironda, 1996)

“Social networks, social support and loneliness”

(Schwarzer et al., 

2004)

“Refers to the structure and quantity of social relationships, such as the size and density of networks and the 

frequency of interaction, but also sometimes to the subjective perception of embeddedness”

(Machielse, 2006) “Lack of meaningful relations”;

“Adequate definition of social isolation in which not only the objective aspects but also the quality and 

assessment of social relationships of an individual is weighed out”

(Hawthorne, 2006) “Defined as living without companionship, having low levels of social contact, little social support, feeling 

separate from others, being an outsider, isolated and suffering loneliness” 

(Gierveld et al., 

2006)

“Concerns the objective characteristics of a situation and refers to the absence of relationships with other 

people”; 

“People with a very small number of meaningful ties”

(Nicholson Jr., 

2009)

“A state in which the individual lacks a sense of belonging socially, lacks engagement with others, has a 

minimal number of social contacts and they are deficient in fulfilling and quality relationships” 
40

(Cornwell & Waite, 

2009)

[Two distinct aspects]: “Social disconnectedness; characterized by a lack of contact with others and indicated 

by situational factors, such as a small social network, infrequent interaction, and a lack of participation in social 

activities and groups, and perceived isolation; characterized by the subjective experience of a shortfall in one’s 

social resources such as companionship and support; 1) Lack of social network robustness and a lack of 

participation in social activities, 2) One’s perception of the supportiveness, closeness, adequacy, and 

companionship” 

(Coyle & Dugan, 

2012)

“Social isolation is the objective lack of relationships and social interaction”

(Biordi & 

Nicholson, 2013)

“Is the distancing of an individual, psychologically or physically, or both, from his or her network of desired or 

needed relationships with other persons"- vs. belonging or connectedness”;

“A loss of place within one's group(s)” 

(Steptoe et al., 

2013)

“An objective and quantifiable reflection of reduced social network size and paucity of social contact”

(Dury, 2014) “An individual lacking a sense of belonging, social engagement and quality relationships with others”

(Zavaleta et al., 

2014)

“The inadequate quality and quantity of social relations with other people at the different levels where human 

interaction takes place (individual, group, community and the larger social environment)”

(Holt-Lunstad et 

al., 2015)

“Objective social isolation; 'Pervasive lack of social contact or communication, participation in social activities, 

or having a confidant” 

(Alpert, 2017) “An objective state of having minimal social contact with others”;

“Occurs in situations when an individual has a paucity of social contacts with family, friends, and/or the wider 

community”

(Wang et al., 

2017)

Authors “developed a model with five domains incorporating all the concepts relevant to social isolation: 1) 

Social network—quantity (refers to quantity of social contact; e.g., the number of people in someone’s social 

network, number or frequency of someone’s social contacts over a period of time); 2) Social network—

structure (refers to characteristics of social contacts, not involving any appraisal of the quality of the 

relationship: e.g., network density (how many of the people in someone’s social network also know each 

other), and the characteristics of someone’s social contacts (e.g., how many are kin, colleagues, mental health 

staff, or mental health service users); 3) Social network—quality (refers to the perceived quality of 

relationships. This domain includes measures of the quality of specific important relationships (e.g., partner 
41

and parents). It also includes measures of qualitative information about all someone’s individual social 

contacts (e.g., rating how many of someone’s social contacts are friends, how many could be confided in, and 

how many would be missed); 4) Appraisal of relationships—emotional ((Emotional) refers to overall appraisal 

of the perceived adequacy or impact of relationships: e.g., loneliness or emotional social support. This domain 

does not directly relate to, and is not measured by, the number of or quality of specific individual relationships); 

and 5) Appraisal of relationships—resources (refers to perceived overall access to resources from someone’s 

social relationships: e.g., tangible social support)”

(Weldrick & 

Grenier, 2018)

Builds on Nicholson, 2009: “(1) number of contacts; (2) belonging; (3) inadequate relationships (non-fulfilling); 

(4) engagement; (5) quality of network members.” But adds: [A macro perspective]; “experience of social 

isolation as a social and cultural phenomenon' and not only as an individualized objective phenomenon”;

“To include social and structural dimensions' which include: ‘1) duration and time, 2) place and space 

(community vs. institutional settings, age-friendly cities movement, rural vs. urban); 3) considerations of 

inequality and exclusion (Minority ethnic and language groups, LGBTQ groups”