Introduction
Research priorities
Conclusion
References

 

 

 

 

 

Introduction

In this article, we describe a novel approach in older persons’ housing, a recently established cohousing development, ‘New Ground’ in London, UK. Cohousing is a form of grouped housing designed and managed by those who reside within it. Further characteristics include resident selection, organisational shared values, a focus on social interaction and mutual support, and a mixture of private and shared spaces and facilities.1 We consider whether this approach may have beneficial effects in alleviating or protecting from loneliness in older people.

Social isolation and loneliness have detrimental effects on health and quality of life and are increasingly being recognised as a public health concern. Loneliness and social isolation increase the risk of anxiety, depression, suicide, sleep problems and cardiovascular disease.25 The risk of Alzheimer’s disease is more than double in lonely compared with non-lonely people, and loneliness is associated with more rapid cognitive decline.6 These results were sustained when researchers controlled for social isolation.

Loneliness is a subjective negative experience, the discrepancy between the level of social connectedness a person desires and what they perceive they have.7 Social isolation is an objective paucity of contacts and interactions between a person and a social network.7 The increased likelihood of seven-year mortality is 26% for loneliness, 29% for social isolation and 32% for living alone, in studies adjusting for age, sex and health conditions.8

Mechanisms behind adverse health effects include changes in health behaviour such as diet, alcohol and smoking, stress, likelihood of seeking emotional support, immune and cardiovascular system changes and worsened sleep along with consequent metabolic, hormonal and neurological changes.9,10

 

Cohousing, loneliness and social isolation

Fromm surveyed 71 respondents from three US cohousing communities.1 Respondents’ weekly conversations with neighbours improved from two
to 8–11 hours per week in the cohousing compared with previous residences; increases of 370–400%. 100% of residents felt able to ask neighbours for help with tasks when unwell, compared with 40% in previous residences.1

Residents in two urban mixed-age cohousing developments in California spend 62% of their time outside the community, 32% in private space, and 6% in communal or semi-private spaces, and spend 4% engaged in social interaction with others in the community (17-26 hours per month).11 In a Swedish cohousing study the preferred shared activities were daily meals followed by coffee meetings.12

However, increasing social interaction may not be sufficient to prevent loneliness. Loneliness is only weakly correlated with social isolation.13

‘New Ground’ is the only established cohousing development for older people in the UK, completed in November 2016. It was developed by the Older Women’s Cohousing (OWCH) group. Beyond promoting social interaction, life in ‘New Ground’ has other features that may reduce loneliness. Managing their community facilitates recognition of each other’s values, shared purpose and improved self-esteem. Autonomy may moderate the effects of social isolation on loneliness.14 A sense of ownership of a person’s environment contributes to a sense of social belonging.1517 Knight et al randomised care home residents to groups that either have collective input versus no control into the design of their communal living space.18 The former group had increased social identification, psychological comfort, quality of life and physical well-being, interacted more and used communal spaces more frequently.

The quality of relationships, group cohesion and social support will depend on the nature of OWCH group dynamics and leadership. Effective teams have a clear goal, results-driven structure, competent members, unified commitment, a collaborative climate, standards of excellence, external support and recognition, and principled leadership.19

Shared-decision making and property management can be arduous and time-consuming. OWCH’s busiest members sometimes attend several meetings a day. In Fromm’s study, 90% are members of at least one working group, 50% more than one and 20% three or more, and whole communities meet at least monthly.1

At one-year, OWCH is in the ‘autonomy’ phase according to Shaffer & Anundsen’s model of community development; during which residents experience conflict, instability and changing social relationships.20

Well-being is more strongly associated with negative than positive social experiences.7 Depending on how social support is delivered and received, it may be perceived as either ‘supportive’ or ‘smothering’ and either acknowledged or not appreciated.21 Problems may arise if support is not of the correct type; is more or less than required; it generates a deceptive false sense of self-efficacy; or if the provider is not able to emotionally or physically cope with its provision.23,25

 

Table 1. Quotes from ‘New Ground’ residents21,22

“What are we learning? We have not before had to test boundaries between private and communal space, personal and group expectations, different habits and ways of living.”

“Actually, to begin with I thought, “oh hell, it’s boarding school,” because of having to adjust to all these different personalities”

                      

Post-retirement migration

The process of developing ‘New Ground’ from inception to moving took 18 years. Delays during completion were challenging for residents. For one, the stress triggered a 5-day acute and transient memory loss (in response, others provided support using a rota system).21

Many residents moved from other counties or London boroughs, leading to potential loss of social contacts. Post-retirement migration in the UK is common and can be prompted by relationship changes, retirement, or ill health.6,26,27 There are spikes at 60–65, when movers are attempting to improve their lifestyle and environment, and after age 75, when movers are ‘coerced’ by the need for formal or informal care. The earlier ‘lifestyle’ movers tend to be comparatively economically well-off.26,28 Elders are less likely to have friends or relatives able to help them move.29 Delays in moving can worsen health outcomes.29,30 Hence, a third category, ‘planners’, in the middle age range move in anticipation of ill health before being forced to and while they have the energy.29 Drivers behind migration include the location’s appeal such as sense of community and cultural activities, moving closer to support networks, or housing availability.26,29,31 This potentially frees up larger homes for families and reduces pressure on social services.29,31

Whilst post-retirement migration may be associated with loneliness,32 confounding factors contribute such as health or relationship changes that triggered the move. Usually, older migrants have fewer opportunities such as work to help integrate into new environments.33 The community at OWCH might mitigate this.

Despite relocating issues, Chiodelli found cohousing residents “universally agree that it was well worth the effort”.34 Shin Choi studied 536 participants in 28 senior cohousing communities in Denmark and Sweden; mainly healthy, 70‐year‐olds.35 The majority would strongly recommend their scheme to others to improve quality of life. 242 participants in 12 of 44 (mixed-age and over 40s) cohousing units in Sweden reported a high level of life satisfaction and greater levels of mutual support in cohousing compared with usual communities.12

 

Table 2. Themes that are central to older people’s housing requirements according to the National Housing Federation’s Breaking the Mould project.30

1. Accessibility

2. Space and attractiveness

3. Safety and security

4. Age-friendliness

5. Offer of freedom, choice and flexibility

6. The option to have help at hand

7. Provision of flexible, personalised support

8. The ability for residents to socialise and feel included

 

Architecture and organisational structure

The design of the facilities is vital in promoting social use and engagement. The architect worked with OWCH to consider acoustics and size and flow of spaces. Availability, visibility and accessibility of communal spaces support voluntary and planned interactions while layout of shared walkways, territorial boundaries, density or proximity between units and restrictions on private space can force unplanned or spontaneous interactions.11 ‘New Ground’ is relatively dense—26 units occupy 0.83 acres, which is two thirds green space—which promotes interaction. The development is close to the amenities of the borough’s commercial area and the design aims to reduce barriers to mobility.

Fear of being a victim of crime increases in older age, potentially encouraging older people to withdraw from life.36,37 This may be mitigated by the secure access and support provided by shared living.30

This article focuses on older people, but OWCH accept residents from age 50. Accommodation that segregates retired people can be damaging for integration and social interaction.38 Heterogeneity in residents’ background and demographics creates a diverse skill set for social support. US cohousing residents tend to be diverse in age and household type but not socio-economic class, ethnicity or education, with minority and low-income groups under-represented.39 In two retirement village case studies, tension surfaced between residents with different income, health status and functional ability.40,41 OWCH is striving to improve its diversity.42

It is a challenge for this self-selecting group to attract diverse members and support the most vulnerable, given people from minority groups, refugees and those with mental health problems, sensory deficits and other disabilities are more likely to experience loneliness and suffer more adverse consequences once lonely.43,44

Future issues for the community include new members’ commitment to the organisational values and residents developing ill health or disability such as dementia, affecting their ability to contribute. Their request for dementia psychoeducation may be indicative of (a) individual motivators and fear of dementia, (b) group dynamics and the desire to support each other, and/or (c) a desire to understand the potential implications including care requirements.

 

Research priorities

There is a call for government to provide clear direction for housing strategies and to use preventative social measures that reduce health expenditures.29,31,45,46 Older people currently have limited choice in housing, particularly specialist and for purchase.29 The National Housing Federation argues options must be developed beyond sheltered housing that are attractive to asset-rich over-50s and encourage planned moves ahead of a crisis.30

OWCH believe their life together and mutual support will keep the group happier and healthier for longer. They are contributing towards longitudinal research led by Lancaster University, which will include comparisons of social and healthcare service use and subjective health and well-being measures. Clifton argues that public services tend to deliver care in a transactional approach, with less thought towards relationships.45 However, if people have opportunities to develop mature and strong social ties, they will be able to seek out resources and services themselves.

Future research might study the effects of intergenerational cohousing, given many young people experience loneliness, and of combining affordable housing in communities.

Longitudinal studies will help explain how loneliness changes over time, the biological, psychological and societal mechanisms affecting its progression, and how these factors affect responses to interventions. High-quality studies are needed into interventions. Considering loneliness as an outcome in interventions not directly targeting it will be helpful, such as economic and physical health programmes. Effect sizes to date are modest, demonstrating a need for preventative measures affecting social bonds and motivation to change.32,48 Qualitative studies exploration will be valuable, as will quality health economics work, such as those by McDaid and Knapp.49-50 Services that signpost people over 65 not in paid work to local activities that improve social networks are cost effective, with a conservative estimate of £1.26 return on every £1 spent over five years.51

 

Conclusion

Loneliness and social isolation are common in UK elders and possibly growing. Innovative public health and social care solutions are needed. People moving post-retirement, particularly when by choice, can have beneficial effects towards health and social isolation if the housing and environment are suitable to the person’s needs. Cohousing may have the potential to promote socialisation and neighbourliness and improve factors affecting loneliness such as helping residents feel valued, useful and part of a community. Policymakers should consider the potential health and social benefits of cohousing to support housing strategies.

 

Dr Helen Hopwood, ST4 Psychiatry trainee, Barnet Enfield and Haringey Mental Health Trust

Dr Farhana Mann, Wellcome clinical research training fellow at the Division of Psychiatry, UCL

Conflict of interest: none declared

 

Acknowledgements: The authors thank Dr Melissa Fernandez Arrigoitia, Dr Vivienne Watkin and Dr Robert Tobiansky for their guidance.

 


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