Outreaching to find and engage older people “no-one knows”: a necessary element of work to address social isolation and loneliness

Abstract

Purpose

The purpose of this paper is to share a model of skilled outreach working to find and engage the hidden group of socially isolated and lonely older people who are reluctant or unable to access community activities, formal services or support. The model can inform the practice of community development, housing or other workers concerned with initiating behaviour change among older people to increase their social connectedness.

Design/methodology/approach

This practice-focused paper presents a description of key elements of the Ageing Better in Camden (ABC) outreach approach along with a snapshot of operational data and examples from interviews/case studies to indicate impact of the work.

Findings

ABC’s Outreach Team engaged with individuals facing significant barriers to social connection including physical and mental health problems, living alone, bereavement and caring responsibilities. A high proportion of Team engagements were with men (41%) who are typically hard to engage. In total, 23% of people who the Team met took some “Action” towards social connection. Qualitative examples indicated that encounters with the Team could be uplifting and act as a “nudge” towards “Action”. This paper discusses the need to strengthen evidence of the impact of the approach and challenges of doing so.

Originality/value

There are few descriptions in practice or research literature of outreach work with older people and the elements which make it effective. This paper addresses this gap.

Citation

MacIntyre, H., Collins, A. and Stapleton, J. (2023), "Outreaching to find and engage older people “no-one knows”: a necessary element of work to address social isolation and loneliness", Working with Older People, Vol. 27 No. 3, pp. 237-246. https://doi.org/10.1108/WWOP-07-2022-0031

Introduction

In this article, we describe an outreach approach which was a key strand of Ageing Better in Camden (ABC), a programme aiming to tackle social isolation and loneliness (SIAL) among older residents. This outreach approach was developed to find and engage with the group of socially isolated or lonely older people who may be reluctant to access formal services or other support and manage their lives without it. As such, they are hidden from view: the older people “no-one knows”.

The challenges of reaching the older people no-one knows

The problem of SIAL among older people is well-documented (Age UK, 2018; Aiden, 2016). Both are predictive of physical and mental health problems; older people are more likely to experience several risk factors associated with SIAL such as retirement and bereavement; and because of the ageing population in the UK, it is a growing problem with two million older people expected to be lonely by 2023 if the problem is not addressed (Age UK, 2018).

However, for the people no-one knows, this issue can only be addressed if efforts are made to find and engage with them. This is a potentially challenging task. With reference to accessing health and social care services in the USA, Florio and Raschko (1998) highlight the substantial number of older individuals living in the community who may be at risk because they are not motivated or able to seek support they need. Reasons may be complex and include depression, early-stage dementia, suspicion of services and fear of losing independence. Individuals may also lack support networks of friends and family who might encourage them to seek help or make referrals on their behalf. Such factors are also likely to hinder the engagement of many older people with local groups and activities designed to address SIAL. A UK study, which examined methods of identifying lonely older people so that they can be encouraged to access relevant support (Goodman et al., 2015), discusses the stigma around loneliness which might make them reluctant to do so.

Yet “gatekeeping” or “wayfinding” services (Windle et al., 2011) designed to support individuals to overcome barriers to social connection often rely on referrals from existing services or from friends and family and so are unlikely to be reaching the people no-one knows. This applies to Social Prescribing or Community Navigator services (e.g. see Ageing Better 2019, 2022), which are becoming part of mainstream provision in the UK (Office for Health Improvement and Disparities, 2021).

Outreach as a method of finding and engaging with the older people no-one knows

High-quality community outreach work, used to find the older people no-one knows but, crucially, also to engage those who are reluctant to take up offers of help, offers a solution to this problem by encouraging individuals to make their first steps towards better social connection. In setting out a general method of outreach, Andersson (2013) states that the purpose of outreach is “creating the pre-requisites for a process of social change” (p. 177) in particular by establishing a “linkage” between the hard to reach individual and “change agents” (p. 176) who can provide ongoing support to make changes in areas identified as problematic by the individual during interaction with the outreach worker. He refers to the skill, knowledge and commitment required of outreach workers for these efforts to be effective: knowledge of relevant local places where workers can bring about encounters; knowledge of local support on offer and networks which facilitate the process of linking an individual to relevant change agents; and the use of empathic social skills necessary to initiate and maintain communication, build relationships and motivate an individual to embark on change.

This kind of work with older people is little mentioned in research reviews on interventions to address SIAL where the main focus is on impacts of different types of groups or activities (e.g. content type, degree of social involvement fostered) that older people might join (Raymond et al., 2013; Poscia et al., 2018). Indeed, Andersson (2013) refers to outreach being used to tackle homelessness, drug abuse, mental disorders, youth problems and street prostitution but not work with older people. Nonetheless, among descriptions of services or projects aimed at tackling SIAL, there are examples of work designed – and so recognising the need – to find lonely older people in the community and signpost them to support. For example, “agent-based referral systems” (Goodman et al., 2015) use a paid worker or volunteer in a locality to identify “excluded or vulnerable people” (Rodden, 2014, p. 3), build relationships with them and link them to suitable services or support. Jopling (2020) provides a case study of “The Great Wirral Door Knock” where volunteers from a range of local organisations called at homes in areas in which there were likely to be large numbers of lonely residents. They engaged older people in conversation about the local area, signposted local services and support and sometimes made onward referrals. However, these descriptions do not substantially address the complexities involved in successful first engagement when individuals may be fearful, sceptical or otherwise reluctant to access support to make social connections from which they may benefit. By contrast, the ABC outreach approach explicitly addressed such ambivalence and so provides an innovative model for initiating change with older people who are socially isolated or lonely.

Ageing Better in Camden outreach approach

Outreach activities

By their very unknown nature, there is no easy way to identify the older people no-one knows so the ABC Outreach Team went out into the community to find them. Detailed descriptions of ABC Outreach activities can be found in referenced practitioner guides and reports. Main activities [1] included:

• Street outreach (Mainey, 2019b) where the Team approached and informally engaged with as many older people as they could in a neighbourhood. They offered an information flyer about current activities and sources of support for older people in Camden. Often, they invited people to a specific informal follow-up Outreach event in a local library or café.

• Doorstep outreach (MacIntyre et al., 2020) where the Team began by going door-to-door to post flyers, then returned to speak to residents in Sheltered and Social Housing blocks to invite them to a pop-up event in the housing block or nearby space.

• Pop-up events (MacIntyre, 2020) were social events in their own right but also information events. At these pop-ups, there would be tea and cake, an opportunity to chat further to the Team and to other local people who came along, and to find out more about local activities and sources of support.

Key features of the outreach approach

Key features of the outreach approach and their functions are listed in Table 1 and described next in more depth. They incorporate the three tasks of outreach set out by Andersson (2013, pp. 175–176): “contact-making” with “hard-to-reach” members of the target group; “initiating social change processes for the target group” by creating a “linkage” to others who can act as “change agents”; and to “establish and maintain social support” necessary for bringing about change.

In terms of “contact-making”, the Outreach Team went to proactively find older people in the community, to where they lived, and to local streets and parks where they would be out and about. Their method of bringing about encounters was crucial. Several days before street or doorstep outreach, they put up flyers or posted them through letterboxes to pre-advertise and give reassurance about who they were, where they would be and what they were doing (MacIntyre et al., 2020). Flyers carefully worded to avoid putting people off. For example, they used the term 60+ rather than “older people”; and invited people to “drop by” and “meet the Age UK Camden Outreach Team” rather than to attend “an event” which might be intimidating. Andersson (2013) discusses the danger of “unmasking” (p. 179) individuals by identifying them as in need through offering help, potentially making them feel stigmatised and alienated. As such, the Team did not focus on the need to identify those who were lonely or isolated as in some approaches (Goodman et al., 2015). They created another reason to initiate interaction (e.g. handing out information sheets or invitations to a pop-up) and were inclusive, talking to everyone rather than prejudging who might be lonely or isolated. They interacted in a warm, informal way using active listening (Colombus, 2021), allowing as much time as needed for a conversation. Any information or suggestions given were person-centred responses to interest or need given in an unpressured way. Both tailoring of support and paying attention to avoidance of stigma have been found to be an effective feature of interventions to tackle social isolation (Victor et al., 2018).

During such informal encounters, the Outreach Team might discover individuals were lonely or isolated and initiate change by signposting them to social opportunities or support that could help them to live happier lives. This could be preventative in that it could help people to build informal networks that mean they avoid experiencing a crisis situation later where they have no support and no-one to turn to. Others who the Team met might already be in difficult situations which caused or compounded isolation. However, the outreach and pop-ups were not primarily designed to address particular difficulties or needs. They were simply occasions where any older person could make a human connection and feel heard, whether via a brief passing chat or more in-depth interaction. This kind of positive early connection was the foundation for trust and engagement which could encourage older people to make further connections, forming part of the social support necessary for facilitating change (Andersson, 2013).

In addition, at pop-ups, the Team might gently broker connections, introducing people and supporting their conversation. In this way, linkage might be established directly between two or more individuals rather than to a more formal change agent such as a group or activity leader with a remit to support individuals to make new contacts and relationships.

As also noted by Andersson (2013), the Outreach Team recognised that establishing relationships and trust necessary for initiating social change can take time and might occur gradually through meeting an individual on a number of occasions. Therefore, the Team offered their own contact details so that an older person could stay in touch. And, in some cases, they would meet individuals repeatedly during street outreach or at successive pop-up events so that encouragement to initiate social connections could be continued.

Conceptualising impact of the Outreach approach using the “Cycle of Change”

We conceptualised the change “journey” of an older person who encountered the Outreach Team in relation to an adapted version of Prochaska and Velicer’s (1997) “Cycle of Change Model”, a behaviour change model more commonly used in mental health and addiction services. It demonstrates how people make changes, often starting from a place where they do not recognise they have an issue or that aspects of their lives could be improved, and that they could be happier with increased social connection. The model involves movement through five stages: Precontemplation, Contemplation, Determination, Action and Maintenance and Recurrence (see Figure 1). Next, we show how the Outreach Team worked across stages of the Cycle of Change and the impact they could have.

A meeting with the Outreach Service could be the first step for those at the Precontemplation and Contemplation stage. The impact of this contact could be minimal, or it could be very significant. Many of the street outreach interactions were brief, used to promote activities in local community centres or neighbourhood organisations. For some, this may have been the nudge that encouraged them to try a new activity or centre that they did not know existed or had never considered.

Outreach on the street and in sheltered housing was also used to invite people to Team pop-up events in informal “neutral” venues (e.g. a café or library) to create a space for connection for those not wanting to go to community centres or to access other formal activities or support. A pop-up event is a relatively low social ask for people. Often those who say “Yes” to an invitation get cold feet on the day and for isolated people, it may be easier not to go than take the risk of rejection in a social setting. The positive social interaction with the Outreach Team, when they offered a friendly invite, could create a social bridge to attending, increasing the likelihood that a person would come.

An individual can drop into a pop-up, pick up a leaflet and leave quickly. But, once there, they may be guided by skilled staff to stay and chat, possibly considering the idea of making a small change for the first time. These events in neutral venues were particularly successful environments for engaging harder to reach individuals, including men, who are likely to see more formal centres or settings as “not for me” (Mainey, 2019a). For some, these will have acted as “stepping-stone” events which might have given them the confidence to try other activities. Or they could be a space to chat with other local people and possibly form connections with them outside of any activity. Pop-ups and other ongoing contact with the Team could create a “drip, drip” effect with recurring opportunities for people to step into and increase their social connections.

For those already at the Determination stage, committed to change but still unsure what to do, the Outreach Service could trigger positive change by providing activity information or an invitation to a pop-up event. This could encourage a move towards Action where an older person might attend the pop-up or try a new activity or interest. The Team could also help overcome barriers to connection (e.g. mental or physical health problems), e.g. by referring an individual to the Community Connectors service for additional support or by giving advice on transport options.

Once someone had joined an activity or group, they may no longer have needed support. However, the Team could sometimes play a role in Maintenance and Recurrence of social engagement. By continuing to meet or stay in touch with people, they were able to actively encourage and support those who were struggling to sustain new social connections.

Evidencing ABC outreach and its impact

Challenges and methods

Providing evidence of Outreach Team impact posed challenges. The aim of keeping interactions with older people informal and non-intrusive precluded asking them for information about themselves. And many conversations were one-off so that, even if it was appropriate to ask, we could not know, e.g. whether there was any impact on the social connection of those who had taken an activity information leaflet or felt encouraged by an Outreach interaction. However, we have some data indicative of the Team’s effectiveness and present a selection covering the year preceding COVID-19 (April 2021 to March 2022).

First, operational data was used to collect information on numbers and gender of individuals who met the Outreach Team and who attended pop-up events. There was also evidence that some individuals who chose to share their details later accessed community activities. We used this to provide a snapshot of outreach activity and impact in terms of conversion rates from those engaged during street/doorstep outreach to those who responded with “Action”. And through longer conversations with approximately one in 10 of the people they met, the Team were able to identify some types of difficulties faced by those they met which were likely to compound SIAL, adding to understanding of the circumstances of the people the Team engaged.

Second, we collected evidence of impact via brief, light-touch interviews with 37 individuals during six pop-ups in Sheltered Housing (asking them about why they came, how well the event was organised and whether they got anything out of it – see MacIntyre, 2020). Interviewees gave consent to use this data in reports or articles about the service.

Third, we obtained consent for use of some case studies of individuals who the Team met repeatedly and so were informative about outcomes of earlier encounters.

Data

From April 2021 to March 2022, the Outreach Team had 2,738 street or doorstep conversations. In total, 41% were with older men compared with a third who took part in Ageing Better activities overall (Campbell-Jack et al., 2021). Barriers to social connection faced by these individuals included mental and physical health and mobility problems; living alone with no friends or family nearby and being reluctant to engage with others; bereavement; and caring responsibilities.

Operational data showed that, overall, at least 23% of people the Team engaged moved to some “Action” following an encounter with the Outreach Team, either by attending a pop-up or joining a community activity. As an example, Table 2 provides more detailed data for one pop-up event at Kentish Town library where the Team had invited people to drop in for tea/coffee and a chat. The conversion rate from street outreach to attendance at the event was 28%.

Interviews provided some examples of immediate impact of engagement with the Outreach Team. For example, sheltered housing residents talked about the effect of first meeting the Team on their doorsteps. One said:

It’s very uplifting to have three visitors when you don’t even know what a visitor is any more […] I’m not forgotten, not old and forgotten.

Another mentioned the visit had acted as the “slight nudge” for him to attend the pop-up event in his housing scheme. After attending pop-ups in their housing schemes, examples of comments were:

I feel better, more like a human. You feel like you're in a little box on your own: I hate it. When I moved here, I thought I would mix with people but you don't.

I know they [other residents] exist but usually we just wave. But today we're here in the same place.

The following case study provides an example of the Outreach Team supporting a move from “Determination” to “Action”.

Tom is in his mid-70s and lives alone. The local gym where he exercised closed down. Without internet or a mobile phone and living on a state pension, he was finding it difficult to find a new affordable, local gym. Without exercise, he began to have pains in his legs and back. On his way home from shopping, Tom saw a poster for an Outreach Team outdoor pop-up offering local “What’s on” information and advice about how to safely exercise using gym equipment in the park. Tom came along, had a one-to-one session with the exercise instructor and the Team also arranged to send him information about free and low-cost options to exercise locally. When the Team re-met him a few months later he thanked them: he had found an affordable gym and already attended it 17 times. He also took outreach information from this meeting to pass on to the Tenants and Residents Association where he lived.

Discussion

The ABC Outreach approach offers a carefully considered method for proactively finding and engaging the older people “no-one knows”: a hidden group who are socially isolated or lonely but not engaged with formal activities or services. Person-centred, non-stigmatising elements of engagement used by the Outreach Team have been identified as effective elements of other interventions to tackle SIAL among older people (Victor et al., 2018). And the approach includes outreach practices more commonly used to tackle homelessness or youth problems including “contact-making” in the community away from formal settings and interacting in an empathic way to build trust and relationships which underpin the older person’s engagement with outreach workers and with their linking to support needed to achieve change (Andersson, 2013).

Indeed, operational data showed that ABC Outreach enabled contact-making with a large number of older people. A potential criticism is that this is inefficient because many of the older people encountered will not be lonely or isolated. And because the Team deliberately avoided asking for personal information, we cannot know the number. However, even for the non-lonely, signposting tailored social opportunities and support can have the effect of preventing future SIAL and associated distressing and costly problems. And there can be a ripple effect when individuals like Tom pass outreach information on to other local older people contributing to general community cohesion.

Data also shows that the Team were successful in engaging with people facing a range of significant barriers to social connection such as physical and mental health problems. And there were signs that ABC Outreach was having an impact in terms of encouraging movement towards the “Action” stage of the “Cycle of Change” (Prochaska and Velicer, 1997). Conversion rates showed that about a quarter of those who the Team met during street or doorstep outreach were engaged enough to take “Action” (Prochaska and Velicer, 1997) to attend a subsequent pop-up in a communal area in sheltered or social housing, or in an informal community space such as a café, library or park. Interviews with sheltered housing residents illustrated how the non-stigmatising, unrushed, empathic, person-centred meeting on a doorstep could be “uplifting” and could encourage attendance at a pop-up event. As such the Team could be said to be initiating important first steps to change for those who faced barriers to connection. Attending a pop-up may or may not lead to further action but for some, like Tom, person-centred signposting can make a rapid, important difference in overcoming barriers to isolation.

The ABC programme, including its Outreach service, has come to an end. Yet the ABC Outreach approach has heightened relevance as we seek to overcome the social disconnection brought about by the COVID-19 pandemic. It will be of value to those aiming to engage with older people and to signpost them to social opportunities in this context. For example, housing managers could draw on these methods to support their residents; and at the time of writing the approach is attracting interest from community development workers and organisations with a remit to promote physical activity for older people and who have found the engagement process difficult. This difficulty is not surprising given the complex reasons (Florio and Raschko, 1998) including stigma around loneliness (Goodman et al., 2015) meaning that the people “no-one knows” will often be unable or unwilling to seek help which can improve their social connections and quality of life.

Providing evidence of the impact of this outreach has been challenging and further non-intrusive data collection by those adopting the approach could strengthen understanding of its effectiveness. This could include the kind of conversion, case study and light touch interview data presented here with efforts made to explore the perceptions of those who did not accept outreach invitations or information as well as those who did. Another possibility is to calculate the costs of outreach in relation to counterfactual situations where there is no outreach engagement with an unknown lonely or isolated individual and no change is made to their lives. However, Andersson (2013) points out that this kind of evaluation will include the impact of a whole system of support of which outreach is a part, rather than of the specific effectiveness of outreach work.

Regardless of who carries out this kind of skilled work or of the approach taken to evidencing it, we argue that work to address SIAL will not be complete without efforts made to find and engage the older people no-one knows and to address the risks that they face.

Figures

Figure 1

The cycle of change model adapted to show impact of the ABC outreach approach

Table 1

Key features of the ABC Outreach approach

Features of ABC Outreach	Function
• Proactively going to find people 60+ in the community, face-to-face and by putting up flyers carefully worded to reassure/avoid alienation	Enables contact-making
• Creating initial and repeat encounters which were non-stigmatising, unrushed, empathic and person-centred	Provides positive social experience to encourage • Development of trust/relationships, creating openness to help • Feelings of safety and social confidence which support subsequent social interactions
• Providing information about local social opportunities and support	• Builds individual knowledge of local social opportunities and support, matched to interests and needs • Combines with positive social experience/developing confidence to increase likelihood of taking up opportunities
• Organising informal “low social risk” pop-up events in the community (e.g. at cafes, libraries and parks) which were inclusive, unpressured and socially supportive	Offers alternative social opportunities which • Can bypass individual reluctance to attend more formal activities and locations (e.g. at community centres) or those which are perceived as “cliquey” • Provide opportunities to socialise and connect with other local older people
• Supporting individuals to attend a pop-up, e.g. if they had mobility problems or lacked confidence to attend	Overcomes additional barriers to engagement
• Using light touch “stepping-stone” approach to signposting social opportunities/support or to fostering interactions between individuals	Provides the possibilities for the individual to make social connections without becoming dependent on Outreach workers

Table 2

Example of conversion from street outreach to “Action” by attending a pop-up social event at Kentish Town Library

Street outreach engagements	103
Men	41 (39%)
Women	62 (61%)
Information given/taken including library pop-up event info, information & advice service postcard, local groups and activities listing	94 (91%)
Expressions of intent to attend	42 (41%)
Older people attending library pop-up	29 28% conversion from outreach engagement
Men	12 (41%)
Women	17 (59%)
Approximate percentage of people attending alone (if known)	80%

Note

1. During periods of COVID-19 restriction, the Outreach Team adapted their practice with regulations and with COVID safety in mind. Detailed descriptions of these COVID-context activities can be found at www.ageingbetterincamden.org.uk/outreach