Loneliness is a common experience, particularly in societies where individualism is more prevalent. Many people have experienced it during lockdown, as we have been confined to our own homes. It is a subjective experience (people can feel lonely even if they have others around them) but it is experienced when there is a difference between perceived and actual social relationships.
When people experience mental health problems they have a tenfold increased likelihood of experiencing loneliness (Meltzer et al. 2013). Loneliness can be caused by the loss of relationships through bereavement, break-ups or moving house, for example. These same life events can lead to depression or other mental health problems. Sometimes people isolate themselves from others when experiencing mental health problems, or are shunned from contact with others due to stigma or discrimination, which can also cause loneliness.
Mental health services do not currently have effective approaches to address loneliness (Mann et al. 2017). If services aim to support people through recovery from mental health problems, it is important to consider their connections with other people. Therefore, Lloyd-Evans et al. (2020) developed the Community Navigator programme to help people increase social contact, and take part in groups and local community activities, with the aim of reducing feelings of loneliness (Lloyd-Evans et al., 2017).
This study used a feasibility randomised controlled trial to test if the Community Navigator programme was feasible and to establish if recruitment, retention and study procedures were robust for a full evaluation using a randomised controlled trial. Qualitative interviews explored the acceptability of the programme with participants, providers and other stakeholders.
The study recruited 40 people with depression or anxiety who were using secondary mental health services in two London NHS mental health trusts. They needed to meet a minimum threshold of loneliness, but few exclusion criteria were applied in order to test the programme with as diverse a group of people as possible. Participants were randomised in a 3:1 ratio to the Community Navigator programme (plus usual care) or care as usual.
Community Navigators met participants individually up to ten times over a six month period, which also included up to three group meetings. The Community Navigators were recruited from local communities on the basis of having excellent local knowledge so that they can connect people to local groups and activities. They worked with each participant to map out places, people and activities who were important to them, using a tool adapted from previous research (Sweet et al., 2018). Community Navigators then worked with participants to create individual ‘Connections Plans’ which identified goals to increase connections with other people, and supported them to put these plans into action. Finally, they initiated group sessions for participants to meet each other and share ideas about local opportunities for social connections.
Outcomes were assessed by researchers six months after baseline, at the end of the programme, though they could not be blinded due to limited resources. They collected data on loneliness, social networks, perceived access to social capital, self-reported activity, depression, anxiety, mental well-being, health-related quality of life and service use.
The experience of the Community Navigator programme was explored in qualitative interviews with a sample of the participants, Community Navigators’ supervisors and participants’ care co-ordinators.
The recruitment target of 40 participants was met after asking 65 people to participate. All met the criteria for loneliness and none withdrew from the study (though one died). Follow-up interviews were conducted with 35 participants (88%) and missing data was very low.
The study was not designed to evaluate the effectiveness of the intervention, but it did find a bigger reduction in loneliness and depression scores among those receiving the Community Navigator programme.
Participants met with Community Navigators an average of seven times and 12 (40%) attended at least one group meeting. 24 of the 30 (80%) participants in the intervention group completed the intervention as per protocol (attending at least three meetings with the Community Navigator). Each participant was provided with a budget of £100 to use to support social activities, but this was used by only nine participants.
Participants reported having a positive experience of the Community Navigator programme. Many reported their relationship with the Community Navigator as being important to them. For example:
“It was wonderful. I really enjoyed the experience, it was amazing. I’d do it again if I could. I’d have another ten sessions and carry on with it.”
– Participant SU14 (Lloyd-Evans et al, 2020, p.11)
However, several participants described making social contacts to be difficult when they felt low or anxious. Some felt that it was not long enough to help them address the longstanding nature of poor mental health and loneliness.
This study found that the Community Navigator programme was feasible and largely positively appraised by participants. It is now ready for evaluation in a full randomised controlled trial. The authors concluded:
“It [this study] suggests that additional support to improve social connections and reduce loneliness would be welcomed by many and meet a gap in current service provision.”
(Lloyd-Evans et al., 2020, p. 16).
Strengths and limitations
This study fulfilled its aims. It established the feasibility of the evaluation of the Community Navigators programme and of the programme itself. It has thereby taken a step towards filling in a gap in the evidence base about interventions for people with mental health problems, which address loneliness.
The researchers noted several limitations. They observed that the study was conducted in London so the operation of the programme in towns or rural areas across the UK has not been established. They also noted that blinding of the researchers was not possible, though this could be built into a full trial.
Several participants noted that they found the contact with the Community Navigators the most beneficial aspect of the intervention, with some wanting it to go on for longer. There was a tension between developing a relationship with the Community Navigator (which was important for the success of the programme) and with supporting participants to make contact with other people in their local community. Some found the latter much more challenging than the former, suggesting that a social support intervention may be required for some, whereas a community-based activity intervention would be more relevant for others. It is possible that some people may benefit more from a befriending intervention than community navigation, though this will require further exploration.
The provision of a Community Navigator programme may allow community mental health teams to absolve themselves of some responsibility for making connections with the communities they serve. The Community Mental Health Framework for Adults and Older Adults (National Collaborating Centre for Mental Health, 2019) highlights the importance of teams being embedded within their local communities, forging strong connections with the voluntary and community sectors. The Community Navigator programme will need to support teams to achieve this, rather than individualising the ‘problem’ of loneliness too much. If this became the responsibility of all practitioners, it is possible that the new Framework could be more effectively implemented.
The Community Navigator programme is described by the authors as a low-cost intervention. However, with the prospect of a global recession around the corner, it may be challenging for NHS mental health trusts to find funding for this. Although high quality evidence may help convince cash-strapped commissioners, the more the programme can become embedded within community mental health teams, the more likely it is to be funded.
Implications for practice
This study offers preliminary evidence of the feasibility of the Community Navigators programme in helping to alleviate depression and loneliness. More research is required before it can be recommended for use in routine care.
Statement of interests
Martin Webber has conducted similar research in this field. He has developed and evaluated Connecting People, a social intervention for people with mental health problems to enhance their connections with others. Further information and references to relevant papers can be found at: https://connectingpeople.net/.
Martin Webber is a co-applicant with Bryn Lloyd-Evans and other collaborators on a proposal to evaluate Community Navigators in a full randomised controlled trial.
Lloyd-Evans, B., Frerichs, J., Stefanidou, T., Bone, J., Pinfold, V., Lewis, G., et al. (2020). The Community Navigator Study: Results from a feasibility randomised controlled trial of a programme to reduce loneliness for people with complex anxiety or depression. PLoS ONE, 15, e0233535. https://doi.org/10.1371/journal.pone.0233535
Lloyd-Evans, B., Bone, J.K., Pinfold, V., Lewis, G., Billings, J., Frerichs, J., et al. (2017). The Community Navigator Study: a feasibility randomised controlled trial of an intervention to increase community connections and reduce loneliness for people with complex anxiety or depression. Trials, 18, 493. https://doi.org/10.1186/s13063-017-2226-7
Mann, F., Bone, J.K., Lloyd-Evans, B., Frerichs, J., Pinfold, V., Ma, R., et al. (2017). A life less lonely: the state of the art in interventions to reduce loneliness in people with mental health problems. Social Psychiatry & Psychiatric Epidemiology, 52, 627-638. https://doi.org/10.1007/s00127-017-1392-y
Meltzer, H., Bebbington, P., Dennis, M.S., Jenkins, R., McManus, S., & Brugha, T.S. (2013). Feelings of loneliness among adults with mental disorder. Social Psychiatry and Psychiatric Epidemiology, 48, 5-13. https://doi.org/10.1007/s00127-012-0515-8
National Collaborating Centre for Mental Health (2019). The Community Mental Health Framework for Adults and Older Adults. London: NHS England.
Sweet, D., Byng, R., Webber, M., Enki, D.G., Porter, I., Larsen, J., et al. (2018) Personal wellbeing networks, social capital and severe mental illness; exploratory study. British Journal of Psychiatry, 212(5), 308–17. https://doi.org/10.1192/bjp.bp.117.203950