Introduction

Loneliness and social isolation among older adults are recognized as significant public health concerns, with both mental and physical well-being at risk [1,2]. Loneliness correlates with a range of adverse health outcomes, including increased risk of cardiovascular disease, depression, cognitive decline, and mortality [3,4]. As populations across the world, the challenges posed by loneliness among the older adult population are becoming more widespread, particularly in societies where traditional family structures are evolving. Urbanization and modern work demands may leave older adults without adequate social connections, which is increasingly seen in both Western and non-Western societies [5,6]. These global patterns are especially apparent in Iran, where shifts in population age, urban movement, and family dynamics have contributed to a larger older adult population at increased risk of social isolation [7,8]. Loneliness and social isolation in older adults not only increase vulnerability to depression and chronic disease but also place a substantial burden on healthcare systems through higher rates of hospitalization [9,10]. Addressing these issues is essential both for individual well-being and the sustainability of health services.

The role of social connectivity in promoting psychological well-being and cognitive health has become a focal point in geriatric and gerontological research. Engaging in social and community activities can be a protective factor for older adults from cognitive decline, supports independent living, and lowers institutionalization risks [11,12]. Through engagement in activities such as art, music, and technology, older adults can engage in communication with others, build skills, and help one another, especially with digital skills. Group discussions and support groups offer emotional support, while health and wellness activities provide practical guidance on managing health. These peer-based interactions enhance knowledge, social bonds, and cognitive well-being. These findings emphasize the need for older adults to alleviate loneliness and also to foster regular social interaction in environments where older adults can thrive. Studies have shown that older adults actively involved in community programs and engaged in meaningful activities contribute significantly to community cohesion and personal fulfillment; including volunteering, mentoring, or participating in social clubs [13,14]. Hands-on environmental efforts, such as planting along creek banks, protecting local habitats, planting trees, and gathering environmental data, were aimed at creating a better world for future generations, enhanced the wellbeing of older adults [14].

In Iran, like in other countries facing rapid demographic shifts, supporting the growing population of older adults has become a priority. Changes in family dynamics and increased urbanization have disrupted traditional support systems, leading to higher levels of isolation and loneliness among older Iranians [15–17]. Around the world, various interventions, including social facilitation interventions, psychological therapies, befriending interventions and leisure/skill development, have shown positive impacts in reducing loneliness and improving quality of life for older populations [18–20]. However, to be effective, it is important that community-based interventions be culturally adapted to meet the specific needs and context of Iranian older adults.

Challenges encountered by older adults, such as maintaining social engagement and managing health concerns over time, suggest a need for ongoing support and structured activities to sustain the intervention’s benefits [5,19]. Furthermore, the program’s success such as group-based exercises and internet-based interventions [21], illustrates the importance of accessible community spaces in fostering a sense of belonging and meaningful engagement among older adults [9,22,23]. For interventions to have sustained impact, they need iterative review, opportunity for adaptation and ongoing awareness and engagement reinforcement to meet the changing needs of older adults. In an enhanced fitness program, periodic updates like new exercises and intensity adjustments kept participants engaged and improved their physical health over time [24]. Similarly, a senior connections project showed that updating social activities to reflect participants’ interests and cultures sustained connections and reduced loneliness among older adults [25,26]. These examples underscore the importance of flexibility and ongoing program development to ensure that interventions remain relevant and beneficial in the long term.

The present study examined the long-term effects the “Design, Implementation, and Evaluation of an Informal Home Care Support Intervention Program (HoSIP) for Lonely Older Adults in the Community”, which was originally conducted from 2020 to 2022 [27]. The original study included three phases including a cross-sectional study which assessed the factors influencing subjective loneliness and quality of life among lonely older adults living in the community [28]. Following this, the insights gained from the initial study guided the design of HoSIP, implemented over a period of 12 weeks. The findings from this intervention were previously published [29]. This study aims evaluating the sustainability and long-term outcomes of the Home Care Support Intervention Program (HoSIP) to Reduce Loneliness among Community-dwelling Older Adults: A two-year follow-up study. Existing intervention studies targeting older adult populations typically concentrate their evaluation efforts on immediate post-intervention outcomes, failing to conduct longitudinal assessments of participants’ subsequent experiences. Additionally, comprehensive evaluation of intervention effectiveness on target variables is rarely conducted during brief assessment windows (e.g., three months) or extended follow-up periods spanning 6–12 months. Consequently, implementing systematic evaluation of both sustainability and long-term intervention effects would serve a dual purpose: determining program durability while simultaneously measuring comprehensive intervention impact across all study variables. Notably, the present intervention employs a participant-directed management approach, wherein older adults assume primary responsibility for program implementation without researcher interference, constituting a distinctive methodological innovation.

Method and materials

Results

Out of the 36 older adults who originally participated in HoSIP, 12 withdrew for personal reasons, and 8 others remained connected only through the WhatsApp group, declining to participate in any in-person sessions, 16 (n = male: 3, and female:13; 44.5%) remained in the follow-up phase and actively engaged with HoSIP, both online and in-person were contacted for this study. The mean age of participants was 73.50 ± 6.58, of whom 81.3% were women. Level of education ranged among participants with 43.8% reporting a secondary or tertiary education (n = 7). Approximately half of participants received an old-age pension (n = 9). Table 1 shows the demographic characteristic of the participants.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Participant demographics (N = 16).

https://doi.org/10.1371/journal.pone.0331987.t001

Table 2 indicates the results of Repeated Measures Analysis of Variance (RMANOVA) at different measurement intervals for six variables of loneliness, general health, and quality of life, self-care ability, perceived social support, and social networks. The results demonstrated statistically significant changes from baseline to two-year follow-up for felling of loneliness, quality of life, perceived social support, social network and self-care ability (p < 0.05). However, there was not a significant difference from baseline and 2 years for general health (p > 0.05). All variables except for general health, had a significant difference over these two years and these changes were in the direction of improvement (Fig 1). The results of post hoc Bonferroni test to investigate the long-term effect of HoSIP illustrated that except for UCALA, all other variables were close to their original state and the changes were not significant.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Repeated measure analysis examining the univariate test at different measurement intervals.

https://doi.org/10.1371/journal.pone.0331987.t002

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. The results of Repeated measure analysis of variance from baseline to Post-Project Assessment (2 years, 2022-2024).

https://doi.org/10.1371/journal.pone.0331987.g001

All participants who remained in the HoSIP after two years agreed to participate in the study (N = 16). The gender distribution among the interviewees was 81% women and 19% men. Overall, 150 initial codes were extracted, which were summarized in 3 main categories and 14 sub-categories. The thematic analysis led to the identification of the long-term effects of HoSIP, as shown in Table 3.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Extracted themes and sub-themes.

https://doi.org/10.1371/journal.pone.0331987.t003

Discussion

The Home care Support Intervention Program (HoSIP) is a peer-to-peer support initiative designed to address loneliness among older adults. To assess the sustainability and long-term effects of this program, an additional follow-up was conducted two years after the intervention period. The findings indicate that HoSIP not only effectively improved the physical and psychosocial health of lonely older adults but also led to enhancements in their social networks and perceived social support.

Making new friends and fostering long-lasting relationship with peers positively influenced the older adults’ lives, providing them meaning, value, and purpose. This aligns with previous research demonstrating that older adults benefit from higher life expectancy, companionship, identity, emotional supports based on functional theory in aging [37], considering digital technology integration as offering older adults’ new meaningful roles while risking exclusion through unequal access, explaining both societal and individual impacts of digital transformation on aging populations [38]. Our finding support this, showing the positive outcomes from interpersonal relationships including receiving energy from each other, learning from friends, establishing relationships with new friends and companions, building trusting with others, enhancing understanding of the needs, feelings and values of others and helping others expanded participants social network and improved their perceived social support. These outcomes expanded participants’ social network and improved their perceived social support, thereby promoting social capital in aging. According to Simons and et al, staying connected through digital media in old age can improve social capital, enhance mental health by reducing depression and loneliness in older adults [39]. This finding aligns with sustained loneliness improvement observed in our two-years follow-up study of HoSIP.

In addition to social benefits, participants experienced improvements in quality of life—particularly in psychosocial aspects such as mood, behaviour, and self-confidence. Since joining the group, some older adults reported greater self-expression and the chance to engage in meaningful volunteer activities, including helping people with disabilities, supporting underprivileged children, learning French, and taking part in cognitive training exercises [40]. These results support finding of a systematic review, in which also noted that improving self-confidence can have a predominant role in the performance of the athletics. Furthermore, participation in HoSIP resulted in participants paying more attention to their bodies, physical functioning, and their feelings, corroborating the ideas of Harleah et al, who suggested that older patients with higher self-care confidence tended to have better overall health and well-being in various aspects of their lives [41]. Post-project, the HAMDAM group members have shown remarkable initiative in organizing a variety of recreational, educational and cognitive activities. They have become more interconnected, more expressive in their community, and more knowledgeable about their rights. These factors have spurred them to independently arrange trips to various cities across Iran and to seek further education on topics relevant to aging and even recreational activities. It is significant that older adults’ involvement in arranging activities could have such a positive impact on their psychological well-being [42]. Based on researcher’s observations some older adults could not adapt to a newly arrived older adults and felt connected to people had been in the group since first years of starting project due to similar living and social circumstances. This experience is in line with Jeroense et al. study, showing some attributes including age, gender, and marital status may influence interpersonal dynamics [43]. Furthermore, the group initially used a daycare center for their activities, contributing to its upkeep through rental payments. However, after a year, the group relocated to a new location. This move resulted in spatial limitations, forcing the cancellation of some classes and most older adults were not able to attend their weekly face-to-face meetings because the new location was not accessible to older adults and required additional travel time, energy, and costs for commuting, reducing some social connection with their peers. Therefore, some older adults transitioned to rely on engagement with the group through the online social network. The limited space of new location led to further barriers for conducting some physical activities including volleyball and football. These barriers could have negative influence on their overall mental health after two years. According to aging in place theory, relocation stress in old age can lead to depression, anger and powerless [43], because older participants had gotten used to that place and changing the place was far painful for them. The new meeting location did not provide older adults a wide space for doing some entertainment activities such as playing volleyball and doing exercise. Prior studies confirmed earlier findings showing that contribution in ongoing physical activities and sports have an important influence on the emotional and physical health of lonely older adults [44].

A key strength of the present study was the demonstrated sustainability and organic growth of the intervention beyond the formal study period. The older adults remained engaged in the HoSIP and expanded their membership by inviting older adults living with spouses or children to join. As a result, membership increased over the past two years, with new individuals joining the group. At the time of the two-year follow-up, 93 older adults were participating in the online and face-to-face HAMDAM group, of whom 57 had joined during the follow-up period since the program formally ended. Membership continued to rise as participants invited friends and relatives to join. Additionally, seasonal face-to-face talks on topics such as healthy aging, nutrition, and physical activity were introduced during the follow-up period. Every two months, older adults themselves invited experts from various fields to these in-person meetings, leading to empowering, participant-led educational sessions that helped build the older adults’ autonomy.

Several important limitations need to be considered. First, the small sample size was an important limitation of this study. Eight older adults who had been active in the online social network were unable to attend the planned face-to-face group meetings in their homes or communities, which limited our ability to fully assess the HoSIP intervention’s long-term effects on emotional, instrumental, informational, and affiliational support for these individuals. In addition, during the follow-up period, a change in the location of group gatherings—beyond the control and preferences of some older adults—led to further participant withdrawals, reducing the sample size even more. These factors combined to decrease the number of original participants available for recruitment at the two-year follow-up. The final sample size (n = 16) may have reduced the statistical power of our analyses and limited the generalizability of the findings. Despite this limitation, our findings offer valuable insights into the long-term impacts and challenges of sustaining community-based interventions for older adults. Second, the lack of a control group constrains researchers’ capacity to establish causal relationships regarding the intervention’s impact. In the absence of a comparison group that did not undergo the intervention, determining whether documented changes result from the intervention itself or from other variables—including temporal variations in outcomes or external factors—becomes challenging. Third, this study’s qualitative findings did not include any negative themes or critical perspectives. This may be influenced by factors such as social desirability bias, group dynamics, or the voluntary nature of participation, which could have led participants to emphasize positive experiences and downplay or withhold negative feedback. As a result, the findings may not fully capture the range of participant perspectives or potential challenges associated with the long-term effects and sustainability of the HoSIP program.

These findings provide the following insights for future research: 1- In addition to regular face-to-face meetings, older adult should be encouraged where possible to also engage in the group remotely. This will allow for increased access to the program as well as a range of opportunities for further engagement. As technology becomes more integrated into the daily lives of older adults across the world [45], and the use of and familiarity with use of information communication technology such as computers, tablets, and smartphones increased, the numbers of older adults confident and confident to use technology will also increase. Since some participants were assigned responsibility for managing other participants, there were complaints and problems. 2- Any intervention program should provide clear written principles and rules of conduct so that all participants are aware of expectations for the group and can respect the established guidelines. 3- Additional studies using the HoSIP method among various ethnic, cultural, and religious groups would be valuable to give a better understanding of factors influencing loneliness, quality of life, and other related outcomes in these diverse populations. 4- Given that Iran’s Ministry of Health is educating master’s and Ph.D. students in aging studies, there is a need to create employment opportunities for these graduates. To address this, the government should integrate cost-effective community-based programs for older adults into healthcare services. This could involve establishing informal homecare support agencies, allocating funds for their operation, and allowing aging students graduates to supervise these centers. Importantly, the Ministry of Health must implement a registry and safety measures to ensure the well-being of older participants and students in these types of community-based programs.

Conclusion

Initial benefits experienced by participants in the HoSIP program were sustained over time at two-year post-program follow-up. The interventions, co-created with lonely older individuals, positively impacted older adult participants social, emotional, and physical well-being. This project provides valuable insights for future interventions aimed at improving the quality of life for older adults in various care settings. These insights can help reduce the costs associated with hospital readmissions and long-term treatments by implementing simple and cost-effective community-based programs. Governments can benefit from these free and easily accessible resources to implement innovative interventions for community-dwelling older adults. However, it’s crucial for governments to oversee these activities within their communities to ensure safety and legal compliance. This model could serve as a blueprint for aging policies and community health strategies in other middle-income countries.

Acknowledgments

We would like to thank the participants and the authorities of the National Pension Fund (Kaneh Mehr), the daycare authorities in Gorgan City and Aliabad-E Katul County (Kanoon Salmandi Jahandi Degan and Yas), without whose help this work would never have been possible.