"Connect Local": protocol for the evaluation of a codesigned whole of community approach to promote social connection in older adults.

Background: There is wide acknowledgement in the literature that social connection is protective against loneliness and depression. More robust research, however, is needed to evaluate interventions that promote social connection. This protocol paper outlines the evaluation of a community-wide social connection program, Connect Local, in metropolitan Melbourne, Australia to support people 65 years and older to increase access to local community services/activities; and to ascertain impact on social connection, loneliness, depressive symptoms, physical and mental wellbeing, and use of health services. Methods: A Type 1 Hybrid design, including program effectiveness, cost-effectiveness, and implementation evaluation of the Connect Local program, will be undertaken. Eighty-eight participants aged ≥65 years with one or more chronic health condition, who are also either experiencing or at risk of loneliness, social isolation and depressive symptoms will be invited to participate in the evaluation. Outcomes, measured at baseline, 3, 6 and 12 months, include loneliness, social isolation, depressive symptoms, social anxiety, goal attainment, wellbeing, quality of life and health care utilisation. A gender and age matched comparator group of 88 individuals will be recruited from outside the intervention local government area. Impact of the intervention on community service providers in the target region will be evaluated using mixed methods, where triangulation will be used to combine the qualitative and quantitative data using a deductive-simultaneous design. Changes in wellbeing and quality of life of community volunteers will also be measured. All groups will be interviewed to ascertain their experience and perceptions of the program. The economic evaluation will use a Social Return on Investment (SROI) approach, to include outcomes at the individual, community, and system levels. Implementation outcomes will consider Reach, Adoption, Feasibility, Acceptability, Appropriateness, Fidelity, and Sustainability of the intervention. Discussion: This study will provide a better understanding of the impacts of a community-wide social connection approach in older adults, the community and broader system. Clinical trial registration: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=385192; Identifier ACTRN12623000968673.

Addressing loneliness and social isolation in 52 countries: a scoping review of National policies.

BACKGROUND: Even prior to the advent of the COVID-19 pandemic, there was ample evidence that loneliness and social isolation negatively impacted physical and mental health, employability, and are a financial burden on the state. In response, there has been significant policy-level attention on tackling loneliness. The objective of this scoping review was to conduct a loneliness policy landscape analysis across 52 countries of the UN European country groups. Our policy analysis sought to highlight commonalities and differences between the different national approaches to manage loneliness, with the goal to provide actionable recommendations for the consideration of policymakers wishing to develop, expand or review existing loneliness policies. METHODS: We searched governmental websites using the Google search engine for publicly available documents related to loneliness and social isolation. Seventy-eight documents were identified in total, from which 23 documents were retained. Exclusion of documents was based on predetermined criteria. A structured content analysis approach was used to capture key information from the policy documents. Contextual data were captured in a configuration matrix to highlight common and unique themes. RESULTS: We could show that most policies describe loneliness as a phenomenon that was addressed to varying degrees in different domains such as social, health, geographical, economic and political. Limited evidence was found regarding funding for suggested interventions. We synthesised actionable recommendations for the consideration of policy makers focusing on the use of language, prioritisation of interventions, revisiting previous campaigns, sharing best practice across borders, setting out a vision, evaluating interventions, and the need for the rapid and sustainable scalability of interventions. CONCLUSIONS: Our study provides the first overview of the national loneliness policy landscape, highlighting the increasing prioritisation of loneliness and social isolation as a major public health and societal issue. Our findings suggest that policymakers can sustain this momentum and strengthen their strategies by incorporating rigorous, evidence-based intervention evaluations and fostering international collaborations for knowledge sharing. We believe that policymakers can more effectively address loneliness by directing funds to develop and implement interventions that impact the individual, the community and society.

The Influence of Social Dynamics on Biological Aging and the Health of Historically Marginalized Populations: A Biopsychosocial Model for Health Disparities.

Historically marginalized populations are susceptible to social isolation resulting from their unique social dynamics; thus, they incur a higher risk of developing chronic diseases across the course of life. Research has suggested that the cumulative effect of aging trajectories per se, across the lifespan, determines later-in-life disease risks. Emerging evidence has shown the biopsychosocial effects of social stress and social support on one's wellbeing in terms of inflammation. Built upon previous multidisciplinary findings, here, we provide an overarching model that explains how the social dynamics of marginalized populations shape their rate of biological aging through the inflammatory process. Under the framework of social stress and social support theories, this model aims to facilitate our understanding of the biopsychosocial impacts of social dynamics on the wellbeing of historically marginalized individuals, with a special emphasis on biological aging. We leverage this model to advance our mechanistic understanding of the health disparity observed in historically marginalized populations and inform future remediation strategies.

Association Between Objective Social Isolation and Unmet Medical Needs: A Nationwide Cross-sectional Study in Korea.

OBJECTIVES: The aim of this study was to analyze the relationship between objective social isolation (SI) and unmet medical needs (UMN) in adults aged 19 and older. METHODS: A cross-sectional analysis was conducted of 208 619 adults aged 19 and older, excluding missing data, using the 2019 Korea Community Health Survey. To analyze the association between objective SI and UMN, the chi-square test and logistic regression analysis were performed. RESULTS: The prevalence of UMN was 1.14 times higher (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.06 to 1.23) among those with SI than among those without SI, and the OR for groups with 5 SI types was 2.77 (95% CI, 1.86 to 4.12) compared to those with no SI types. In addition, a stratified analysis by age group showed that the association between SI and UMN existed even in groups under 64 years old. However, among those aged 65 and older, SI was associated with an OR of 1.53 (95% CI, 1.37 to 1.71) for UMN compared to non-SI. As the number of SI types increased, the prevalence of UMN also increased, indicating a strong association between SI and UMN in older adults. CONCLUSIONS: This study found that individuals with SI experienced UMN due to fear and anxiety about interpersonal relationships. Therefore, based on the results of this cross-sectional study, it is necessary to investigate the causal relationship between SI and UMN through future longitudinal data.

1 plus 1 is more than 2: mental health problems, financial difficulties, and social exclusion in a cross-sectional study of 28,047 general-population adults.

BACKGROUND: Mental health problems and financial difficulties each increase the risk of social exclusion. However, few large studies representing a broad age range have investigated the combined social effect of having both difficulties. The purpose of this cross-sectional study was to examine associations of mental health problems, financial difficulties, and the combination of both with social exclusion. METHODS: This analysis was based on responses from 28,047 adults (age > 18 years) from the general population participating in The Norwegian Counties Public Health Survey 2019. Respondents answered questions about their financial situation, mental health problems, and social exclusion. Social exclusion was measured as a lack of social support, low participation in organized social activities, low participation in other activities, missing someone to be with, feeling excluded, and feeling isolated. Adjustments for sex and age were made in multivariable logistic regression analyses. RESULTS: Having mental health problems or financial difficulties was associated with various measures of social exclusion (odds ratios [ORs] with 95% confidence intervals [CIs]: 1.33 [1.23-1.43] to 12.63 [10.90-14.64]). However, the odds of social exclusion strongly increased for respondents who reported a combination of mental health problems and financial difficulties compared with those who did not report either (ORs [CIs]: 2.08 [1.90-2.27] to 29.46 [25.32-34.27]). CONCLUSIONS: Having the combination of mental health problems and financial difficulties is strongly associated with increased risk for social exclusion, far beyond the effect of either factor alone.

[Social Determinants of Mental Health among Refugees in Germany - The Influence of Postmigratory Social Isolation and Resources on Psychopathology and Utilization Behavior]. / Soziale Determinanten für die psychische Gesundheit von Geflüchteten in Deutschland ­ Der Einfluss postmigratorischer sozialer Isolation und Ressourcen auf Psychopathologie und Inanspruchnahmeverhalten.

The mental health of refugees is influenced by a variety of pre-, peri- and postmigratory factors. It remains largely unclear how social determinants influence the utilization of psychiatric-psychotherapeutic treatment. We applied a questionnaire survey to 189 refugees from a clinical sample in a psychiatric hospital and from a control sample, which was not in treatment. The influence of social factors on psychopathology and utilization of care was analyzed by means of a CHAID algorithm. The total sample was highly stressed (54% PTSD and 41.4% depression symptoms). Patients were more severely affected in all psychometric scales as well as in traumatization and they were less able to draw on resources such as a social network or residence permit. The strongest predictor for psychotherapeutic-psychiatric treatment was social isolation in the living environment. For patients, the lack of a work permit was the strongest predictor of depression symptoms. The results point to the importance of postmigratory social determinants for the mental health of refugees. In particular, stable social relationships, together with formal factors such as work permit and residence title, should help to reduce mental distress and the need for psychiatric treatment.

Now or Later? Examining Social and Financial Decision Making in Middle-to-Older Aged Adults.

OBJECTIVES: Contextually driven decision making is multidimensional, as individuals need to contend with prioritizing both competing and complementary demands. However, data is limited as to whether temporal discounting rates vary as a function of framing (gains vs loss) and domain (monetary vs social) in middle-to-older aged adults. It is also unclear whether socioaffective characteristics like social isolation and loneliness are associated with temporal discounting. METHODS: Temporal discounting rates were examined across monetary gain, monetary loss, social gain, and social loss conditions in 140 adults aged 50-90 during the Omicron stage of the pandemic. Self-report measures assessed loneliness and social isolation levels. RESULTS: Results found evidence of steeper temporal discounting rates for gains as compared to losses in both domains. Social outcomes were also more steeply discounted than monetary outcomes, without evidence of an interaction with the framing condition. Socioeconomic and socioaffective factors were unexpectedly not associated with temporal discounting rates. DISCUSSION: Community-dwelling middle-to-older aged adults showed a preference for immediate rewards and devalued social outcomes more than monetary outcomes. These findings have implications for tailoring social and financial incentive programs for middle to later adulthood.

Dynamics of Perceived Social Isolation, Secondary Conditions, and Daily Activity Patterns Among Individuals With Stroke: A Network Analysis of Ecological Momentary Assessment Data.

OBJECTIVE: To assess contemporaneous and temporal dynamics of perceived social isolation (PSI), secondary conditions, and daily activity patterns in individuals post-stroke. DESIGN: Longitudinal observational study using ecological momentary assessment (EMA) as a real-time assessment of an individual's lived experiences. We conducted dynamic network analyses to examine longitudinal associations among EMA variables. SETTINGS: Home and Community. PARTICIPANTS: 202 individuals with mild-to-moderate chronic stroke (median age=60 years; 45% women; 44% black; 90% ischemic stroke; median NIHSS score=2; N=202). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: EMA questions measured PSI, secondary conditions (pain, tiredness, stress, anxiety, worthlessness, difficulty concentrating, and cheerfulness), and daily activity patterns (being at home, being alone, and participating in productive activities). RESULTS: The median EMA response rate was 84%. The contemporaneous model showed that PSI was associated with being home, alone, and all symptoms except pain. The temporal model revealed a pathway indicating that feelings of worthlessness predicted PSI (regression coefficient=0.06, P=.019), followed by stress (regression coefficient=0.06, P=.024), and then by being not at home (regression coefficient=-0.04, P=.013). CONCLUSION: Implementing dynamic network analyses on EMA data can uncover dynamic connections among PSI, secondary conditions, and daily activity patterns after stroke. This study found a significant temporal association between PSI and negative emotions. Feeling isolated was followed by feeling stressed, which was followed by a tendency to be out of home, indicating adaptive behaviors in individuals with stroke. These findings highlight the importance of engaging in out-of-home or outdoor activities to mitigate PSI and negative emotions.

Social Disconnectedness in Individuals with Cardiovascular Disease: Associations with Health Literacy and Treatment Burden.

BACKGROUND: Knowledge is limited on associations between social disconnectedness (i.e. loneliness and social isolation), health literacy and perceived treatment burden in individuals with cardiovascular disease (CVD). However, understanding these associations may be important for clinical practice. METHODS: This study used cross-sectional self-reported data from the 2017 Danish health and morbidity survey entitled 'How are you?', investigating the associations of loneliness and social isolation with low health literacy and high treatment burden in individuals with CVD (n = 2521; mean age = 65.7 years). RESULTS: Logistic regression analysis showed that loneliness and social isolation were associated with low health literacy in terms of difficulties in 'understanding health information' (loneliness: adjusted odds ratio (AOR) = 1.32, 95% confidence intervals (CI) [1.16, 1.50]; social isolation: AOR = 1.47, 95% CI [1.24, 1.73]) and 'engaging with healthcare providers' (loneliness: AOR = 1.53, 95% CI [1.37, 1.70]; social isolation: AOR = 1.21, 95% CI [1.06, 1.40]) and associated with high treatment burden (loneliness: AOR = 1.49, 95% CI [1.35, 1.65]; social isolation: AOR = 1.20, 95% CI [1.06, 1.37]). CONCLUSIONS: Our findings show that loneliness and social isolation coexisted with low health literacy and high treatment burden in individuals with CVD. These findings are critical as socially disconnected individuals experience more health issues. Low health literacy and a high treatment burden may potentially exacerbate these issues.

Informal care and financial stress: Longitudinal evidence from Australia.

The number of people providing informal care has increased considerably in the last years while, at the same time, about one in four Australians have financial stress problems. This study uses rich longitudinal data from the Household, Income and Labour Dynamics in Australia (HILDA) survey to estimate the effect of informal care on financial stress. To establish causality, we exploit a fixed effect-instrumental variable approach to address omitted variable bias and reverse causality problems. Our findings show that informal caregiving increases financial stress between 9.9 and 14.5 percentage points. This finding is robust across a battery of quasi-experimental methods. The effect of informal caregiving on financial stress is more pronounced among males, rural residents and those living in low socioeconomic areas. Our analyses further show that financial fragility and social isolation are important channels through which informal caregiving affects financial stress.

Ongoing Challenges Related to the COVID-19 Pandemic Among People With Brain Injury.

The COVID-19 pandemic exacerbated social isolation among people with traumatic brain injury (TBI). Yet, little is known about how changes in personal factors, environmental factors, or the characteristics of activities affected social participation. We examined experiences with social isolation and barriers to social participation using the person-environment-occupation-performance model as a framework. Twelve adults with TBI participated in a series of three focus groups. Data were analyzed using thematic analysis. We identified two primary themes with sub-themes: (1) social isolation experiences: (1a) emotional impact and (1b) managing personal risk; and (2) greater barriers but a lack of strategies to address them: (2a) access and opportunities and (2b) social and societal factors. New environmental barriers and task demands affected occupational performance, and participants identified few successful strategies to overcome these barriers. Occupational therapy can develop new strategies to re-balance the person-environment fit and enhance social participation.

Ongoing Challenges Related to the COVID-19 Pandemic Among People With Brain InjuryPeople with traumatic brain injury (TBI) have experienced increased social isolation because of the COVID-19 pandemic. There has been limited research to describe how social isolation has been experienced beyond the initial pandemic lockdowns, what limits people from participating in more social activities, and how occupational therapy can help people overcome these new challenges. We interviewed 12 people with TBI to understand their experiences of social isolation using the person­environment­occupation­performance model as a framework. We found that people with TBI have continued to experience worse social isolation, which has affected their emotional well-being. They continue to worry about their risk of exposure and illness. We found that limited opportunities for social activities, inaccessibility of activities, and a lack of social support have contributed to social isolation. Occupational therapy practitioners can help people with TBI develop new strategies to overcome barriers to social participation so they may safely return to important social activities.

Interventions to Reduce Loneliness in Community-Living Older Adults: a Systematic Review and Meta-analysis.

BACKGROUND: The problem of loneliness has garnered increased attention from policymakers, payors, and providers due to higher rates during the pandemic, particularly among seniors. Prior systematic reviews have in general not been able to reach conclusions about effectiveness of interventions. METHODS: Computerized databases were searched using broad terms such as "loneliness" or "lonely" or "social isolation" or "social support" from Jan 1, 2011 to June 23, 2021. We reference mined existing systematic reviews for additional and older studies. The Social Interventions Research & Evaluation Network database and Google were searched for gray literature on Feb 4, 2022. Eligible studies were RCTs and observational studies of interventions to reduce loneliness in community-living adults that used a validated loneliness scale; studies from low- or middle-income countries were excluded, and studies were excluded if restricted to populations where all persons had the same disease (such as loneliness in persons with dementia). RESULTS: A total of 5971 titles were reviewed and 60 studies were included in the analysis, 36 RCTs and 24 observational studies. Eleven RCTs and 5 observational studies provided moderate certainty evidence that group-based treatment was associated with reduced loneliness (standardized mean difference for RCTs = - 0.27, 95% CI - 0.48, - 0.08). Five RCTs and 5 observational studies provided moderate certainty evidence that internet training was associated with reduced loneliness (standardized mean difference for RCTs = - 0.22, 95% CI - 0.30, - 0.14). Low certainty evidence suggested that group exercises may be associated with very small reductions in loneliness. Evidence was insufficient to reach conclusions about group-based activities, individual in-person interactions, internet-delivered interventions, and telephone-delivered interventions. DISCUSSION: Low-to-moderate certainty evidence exists that group-based treatments, internet training, and possibly group exercises are associated with modest reductions in loneliness in community-living older adults. These findings can inform the design of supplemental benefits and the implementation of evidence-based interventions to address loneliness. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO ( CRD42021272305 ).

Difference-Making Pathways to Frailty Through Social Factors: A Configurational Analysis.

BACKGROUND AND OBJECTIVES: Social disconnection is highly prevalent in older adults and is associated with frailty. It is unclear which aspects of social disconnection are most associated with frailty, which ones are difference-making, and which combination of social factors are directly linked to frailty. RESEARCH DESIGN AND METHODS: We conducted a secondary coincidence analysis (CNA) of 1,071 older adults from the Rush Memory and Aging Project (mean age 79.3 ± 7.1; 75.8% female) to identify combinations of social factors that are difference-making for frailty. We included 7 demographic (e.g., age, sex, socioeconomic status) and structural (e.g., social network), functional (e.g., social support, social activity), and quality (e.g., loneliness) aspects of social connection. An established cut score of 0.2 on a frailty index was used to define frailty as the outcome. RESULTS: CNA produced 46 solution models for the presence of frailty in the data set. The top-scoring model was underfit, leaving a final complex solution path for frailty with the highest fit-robustness score that met the fit parameter cutoffs. We found that the combination of loneliness, low social activity, and older age was present 82% of the time when frailty was present. DISCUSSION AND IMPLICATIONS: The combination of loneliness, social activity, and old age is difference-making for frailty, and supports the inclusion of social factors in frailty prevention and intervention. Further research is needed in diverse data sets to better understand the interrelationships between the 3 aspects of social connection and frailty.

Tellegacy: An Intergenerational Wellness and Health Promotion Project to Reduce Social Isolation and Loneliness in Older Adults: A Feasibility Study.

Emerging research demonstrates that social isolation and loneliness are linked to significant physical and mental health conditions. To address these concerns, the Tellegacy program was developed as an intergenerational health-promoting intervention to ameliorate older adult social isolation and loneliness in an effort to increase wellness. The purpose of this study was to reflect on testing of the Tellegacy program as a behavioral intervention. University students trained in goal setting, mindfulness, and listening strategies were paired with 11 older adults in the northern Midwest area via weekly in-person and phone conversations. Oral reminiscence therapies were used and books containing their stories were given to the older adults after participation. Older adults were surveyed using the University of California Los Angeles Loneliness Scale, Satisfaction of Life Scale, and patient health questionnaire-9 (PHQ-9) scale to elucidate the effectiveness of the intervention. Improved scores in loneliness, satisfaction of life, and PHQ-9 demonstrated favorable improvements in older adults. Additional benefits for the student Legacy Builder were revealed from self-reported changes. This suggests the potential benefits of structured encounters between trained students and isolated or lonely older adults. The Tellegacy intergenerational feasibility program warrants further studies to fully demonstrate its impact on health outcomes.

Sandwich-Gen on young people and their mental health issues: how to connect financial responsibility and avoid loneliness.

The sandwich generation in youth and their mental health issues sometimes go unnoticed. Financial responsibilities that cause social isolation increase the potential to feel lonely. On the other hand, knowledge regarding final responsibility is also needed by young people. Responding to these two things, it is necessary to design policies that are relevant to the need for mental health services for the younger generation as a sandwich generation.

Social isolation and subsequent health and well-being in older adults: A longitudinal outcome-wide analysis.

BACKGROUND: Social isolation has become a serious public health issue. However, most previous studies examine the relationship between social isolation and a single outcome. We aimed to conduct holistic assessments to understand the multidimensional impacts of social isolation on health and well-being. METHODS: We used the three-wave data (2013, 2016, and 2019) obtained from the Japan Gerontological Evaluation Study. Our exposure, obtained from the 2016 survey, was the Social Isolation Index (SII) comprising five components: no partner, poor interaction with children, poor interaction with relatives, poor interaction with friends, and no social participation). We assessed 36 health and well-being outcomes across six dimensions obtained from the 2019 survey: physical/cognitive health, health behaviours, mental health, subjective well-being, social isolation, and cognitive social capital. Pre-exposure characteristics and prior outcome levels in 2013 were adjusted. We included 47,318 respondents for 4 outcomes (death, dementia, and functional disability) and 34,187 respondents for 32 other outcomes. The Bonferroni correction was used to correct for multiple tests. RESULTS: The total SII scores were associated with a wide range of health and well-being outcomes across the six dimensions. Specifically, we found a robust association between an SII score of four or greater with mortality (Odds ratio: 1.89; 95% CI: 1.46-2.43). Among the five components of the SII, poor interaction with friends and no social participation showed robust associations with a wide range of health and well-being. We also found some robust evidence regarding effect modification by gender and age in the associations between the components of the SII and health and well-being. CONCLUSIONS: Social isolation, specifically social interaction with friends and social participation, may affect a wide range of health and well-being among older adults.

Social isolation, loneliness, and their correlates in older Japanese adults.

BACKGROUND: Loneliness and social isolation are elevated in older adults and associated with a range of detrimental outcomes. Despite this, there has been little research on these phenomena or on similarities and differences in their occurrence or combination in older Japanese adults. The current study aims to (i) determine what factors are associated with social isolation and loneliness among older adults in Japan; and (ii) describe the characteristics of individuals who are socially isolated but not lonely, as well as those who feel lonely but are not socially isolated. METHODS: Data were analysed from 13 766 adults aged ≥65 years who participated in the 2019 wave of the Japan Gerontological Evaluation Study. Poisson regression analysis was used to examine associations. RESULTS: Among older Japanese adults, the attributes of higher age, male gender, lower socioeconomic status, being a welfare recipient, and having depressive symptoms were associated with social isolation, while lower socioeconomic status, unemployment, welfare receipt, and poor physical and mental health were associated with loneliness. In addition, better educated, and mentally and physically healthy people were less likely to feel lonely even when socially isolated, while people who were not working and who had mental or physical health problems were more likely to feel lonely even if they were not socially isolated. DISCUSSION: Our results indicate that in order to reduce unwanted social isolation and loneliness among older Japanese adults, in the first instance the focus should be on those individuals who are socioeconomically disadvantaged and unhealthy.

Loneliness and objective social isolation are differentially associated with anomalous perceptions in community-dwelling older adults.

INTRODUCTION: Anomalous perceptions are characterised by the subjective experience of a range of distorted and/or hallucinatory percepts. Whilst considerable attention has been paid to the neurocognitive processes contributing to anomalous perceptions amongst older adults, less is known about the social factors (e.g. social isolation, loneliness). Furthermore, it is unknown whether loneliness and social isolation are associated with different types of anomalous perceptions, including anomalous body-centred self-experiences and anomalous external experiences. METHODS: This study examined the cross-sectional relationships between loneliness, objective social isolation, and anomalous perceptions in a sample of community-dwelling older adults (N = 242, Mage = 71.87 ± 7.73, range = 52-91, 67.8% female) using structural equation modelling. RESULTS: Higher levels of loneliness were associated with more anomalous body-centred self-experiences and anomalous external experiences. Those reporting more loneliness also reported higher levels of anxiety and depression; however, the relationship between loneliness and anomalous perceptions was not mediated by these factors. Social disconnection from a religious group was associated with more anomalous external experiences and being married/living with a partner was associated with more anomalous body-centred self-experiences. CONCLUSIONS: These findings suggest that loneliness and social isolation have differential associations with anomalous perceptions in older adults and provide additional evidence that attending to loneliness in older adults is important.

Our Souls Look Back and Wonder: Reflections on Belonging and Being Invisible in Medicine.

Addressing the unequal impact of health disparities on historically marginalized communities is a top public health priority. Diversifying the work force has been lauded as key to addressing this challenge. Contributing to diversity in the workforce is the recruitment and retention of health professionals previously excluded and underrepresented in medicine. A major obstacle to retention, however, is the unequal way in which health professionals experience the learning environment. Through this perspective of 4 generations of physicians and medical students, the authors seek to highlight the similarities that have persisted over 40 years in the experiences of being underrepresented in medicine. Through a series of conversations and reflective writing, the authors reveal themes that spanned generations. Two common themes among the authors are the feeling of not belonging and feeling invisible. This is experienced in various aspects of medical education and academic careers. The lack of representation, unequal expectations, and over taxation contributes to the feeling of not belonging, leading to emotional, physical, and academic fatigue. Feeling invisible, yet paradoxically being hyper-visible, is also common. Despite the challenges, the authors conclude with a sense of hope for the future, if not for them, for the generations to come.

The intersection of race and financial strain: The pain of social disconnection among women in the United States.

Objectives: Considerable attention has been directed at increased social isolation and loneliness during the COVID-19 pandemic and their impact on later-life psychological well-being. There is a dearth of research on the effect of financial strain and associated psychosocial mechanisms on loneliness among women across racial groups. It is unclear how racial status and financial strain intersect to impact later-life loneliness amid immense uncertainty, social isolation, and anxiety induced by the pandemic.Methods: Based on our nationwide Web-based survey (n = 1,301), we used ordinary least square regression to examine the effects of financial strain on loneliness among Black and White women and assessed the role of emotional support in contributing to such effects.Results: We found that Black women face significantly more financial strain than White women but also receive more emotional support and experience less loneliness. Findings show that women experiencing financial strain report increased loneliness, but the negative effects of financial strain are significantly greater for Black women than for White women. Our mediation analysis revealed that emotional support made a significant contribution to the effects of financial strain on loneliness in White women but not in Black women.Discussion: Despite shared vulnerability and social isolation across the general population, our findings suggest that negative effects of financial strain on loneliness among women continue to differ across race, even amid the pandemic. Our findings demonstrate how emotional support explains the relationship between financial strain and later-life loneliness in a racially distinct manner.