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Mechanisms through which befriending services may impact the health of older adults: A dyadic qualitative investigation

Mechanisms through which befriending services may impact the health of older adults: A dyadic... Befriending services are often delivered to older adults with a view to improving social connectedness, but they may also lead to improved health. The objective of the current study was to explore potential mechanisms through which befriending services might impact the health of older adults. Data were collected from 13 befriendee-befriender dyads (n = 26), using a constructivist grounded theory and dyadic analytic approach. Potential mechanisms were described, using a realist evaluative framework of mechanistic processes in a complex intervention context. Five mechanisms of action triggered by the intervention were identified: supporting health behaviours; providing emotional support; improving mood; getting cognitive stimulation and novelty; and providing opportunities for socialising. We identified five potential mechanisms through which befriending services might impact health for older people. Our results suggest potential mechanisms through which befriending might positively impact the health of older people, and which should be evaluated empirically in future research. Keywords healthy ageing, intervention, loneliness, social support, subjective wellbeing, volunteering Introduction National College of Ireland, Ireland Befriending interventions provide supportive Maynooth University, Ireland Trinity College Dublin, Ireland relationships on a voluntary basis via regular University of Newcastle, UK visits or phone calls, most typically to those Queen’s University Belfast, UK experiencing social isolation and loneliness ALONE, Ireland (Dean and Goodlad, 1998; Gardiner et al., Corresponding author: 2018; Siette et al., 2017). Little evidence exists Joanna McHugh Power, Department of Psychology, that befriending interventions actually alleviate Maynooth University, Room 3.08, John Hume Building, loneliness (Beckers et al., 2022; Cattan et al., Maynooth, Co. Kildare, Ireland. 2005; Krohne et al., 2022). In the context of Email: Joanna.McHughPower@mu.ie 2 Journal of Health Psychology 00(0) such lack of evidence, Age UK have expressed pathways to improved health (e.g. quitting concerns about the application of befriending smoking, getting exercise). interventions to the problem of loneliness As such there is limited but growing evi- (Jopling, 2015). dence that befriending is good for health includ- However, befriending interventions might ing mental health. We may further clarify how yield benefits other than reducing loneliness. A befriending interventions might impact mental group-based, long-running Finnish interven- and physical health by considering mechanisms tion, Circle of Friends, has demonstrated posi- of action, which is a priority for such complex tive effects on cognitive function (Pitkala et al., interventions as befriending (Fakoya et al., 2011), psychological wellbeing (Routasalo 2021) (Bonell et al., 2022; Moore et al., 2014). et al., 2009), mortality, subjective health and Inspection of such mechanisms is typically a healthcare utilisation (Pitkala et al., 2009). A task left relatively neglected by qualitative structured peer-to-peer support program, mean- researchers exploring befriending and its impact while, failed to demonstrate any effect on phys- (Balaam, 2015; Fakoya et al., 2021), and such ical health (Schwei et al., 2021), although neglect has been cited as the root cause of a methodological limitations may have occluded broader lack of understanding of how befriend- the detection of an effect. Similar issues with ing impacts older adults (Gardiner and Barnes, methodological quality or design have been 2016). Qualitative approaches are capable of highlighted elsewhere in the befriending litera- yielding critical insights into potential mecha- ture (Siette, et al., 2017). With respect to mental nisms underlying complex interventions, by health, befriending interventions yield a thera- allowing direct engagement with intervention peutic effect on depressive symptoms and emo- recipients (Bonell et al., 2022). In other words, tional distress (Mead et al., 2010) (but see qualitative research goes beyond asking ‘what criticisms of Mead’s conclusions; El-Baalbaki works’ to asking ‘how it works’ (Godfrey, et al., 2010), psychiatric symptoms (Sikira 2015). Intervention mechanisms can be defined et al., 2021), and can enhance emotional well- as ‘new human responses, actions, and interac- being (Moss et al., 2021) tions triggered by the provision of new eco- There is a rationale for expecting a positive nomic, informational or other resources’ effect of befriending on health, defined as ‘a (Bonell et al., 2022: 2). Per Bonell’s descrip- state of complete physical, mental, and social tion, mechanisms are not directly observable wellbeing, and not merely the absence of dis- but affect some outcome (in our case, the out- ease or infirmity’ (World Health Organization, come of interest is improved health). 1995). Elective relationships have a positive Previous research has explored the mecha- impact on health, and it could therefore be nisms through which befriending might impact expected that these benefits might also be seen loneliness and mental health. Two studies have in the context of befriending relationships looked at potential mechanisms through which (Berkman et al., 2000; Golden et al., 2009). befriending impacts loneliness and social isola- Berkman’s causal cascade model, while more tion (Fakoya et al., 2021; Krohne et al., 2023). broadly about the impact of social contexts on Another qualitative study explored potential health, may also offer a theoretical framework mechanisms through which befriending services through which to understand the various ways might improve wellbeing at end of life, and in which social connection (potentially encom- demonstrated that befrienders might impact passing that offered by befrienders) could wellbeing by providing meaningful interactions, impact health in later life (Berkman et al., a sense of connectedness, supporting family 2000). For instance, in Berkman’s model, one members, and cognitive engagement (Gardiner could draw a pathway from informational social and Barnes, 2016). However, empirical evi- support (which could theoretically be delivered dence for such mechanisms in the link between in a befriending context) to health behavioural befriending interventions and health is lacking. Hannigan et al. 3 As such, the aim of the current study was to such as later-life re-partnered couples (Koren, build a theory of the mechanisms through which 2016). befriending might impact health, by interview- Dyadic analysis, meanwhile, is the analysis ing the older person users and the voluntary of data from interviews with any dyad or pair of providers (‘befrienders’) of a befriending ser- interest, and is compatible with other traditions vice. While previous studies of befriending of qualitative analysis, including grounded the- have similarly interviewed both members of the ory analysis. Dyadic analysis can create a befriending ‘dyad’ (Bantry-White et al., 2018), deeper understanding of a relationship since it the older person user and the befriender, they permits triangulation by comparing the per- have not explicitly compared dyadic input spectives of both members of a dyad on the (Breheny et al., 2020). Comparing the views of relationship (Eisikovits and Koren, 2010). befrienders and the older persons who use the According to Eisikovits and Koren (2010), indi- service is likely to provide a more comprehen- vidual interview data are desirable to supple- sive understanding of how befriending may ment dyadic joint interviews, since participants impact the health of older users. may feel constrained by the presence of the We used the 32-item COREQ checklist and other dyad member if only dyadic interviews the American Psychological Association jour- are conducted. The dyadic approach is suitable nal article reporting standards for qualitative in research concerning couples or pairs, such research (‘JARS-qual’) to structure our report- as the relationship between the befriender and ing (Levitt et al., 2018; Tong et al., 2007). the older person who is using the service (here- after referred to as the older person). As such, since we wanted to explore a topic which con- Theoretical framework and cerned an existing dyad, dyadic analysis is study design appropriate. The study was conducted as the qualitative arm in a parallel convergent mixed-methods study Context, recruitment and (citation masked for review). A constructivist sample grounded theory framework was used (Charmaz, 2006) coupled with principles from In Ireland, befriending services are provided by dyadic analysis (Eisikovits and Koren, 2010). a range of voluntary and non-governmental Grounded theory is a methodology which uses a organisations, and have been networked by highly systematic inductive approach to build- ALONE under the Community Impact Network ing a theory which is ‘grounded’ in data (Glaser (https://alone.ie/community-impact-network/). and Strauss, 2009); constructivist grounded ALONE is a nongovernmental organisation theory, meanwhile, is more relativist than tradi- dedicated to supporting the lives of vulnerable tional grounded theory, emphasising the active older adults. Their befriending service involves role of the participant in constructing their own non-structured, weekly visits from trained reality and encouraging the integration of matched volunteers to the homes of older peo- reflexive and contextual information in the ple. Befrienders are matched for age, gender development of a grounded theory (Charmaz, and location to older persons, and older persons 2006). Constructivist grounded theory is par- and befrienders can request a rematch if they ticularly suitable when trying to understand the feel there is little rapport. Beyond providing mechanisms of action in interventions related to training to volunteers, which encourages health (Hunter et al., 2016; Yu and Liu, 2010). weekly visits of 1 hour duration, there is no sur- Grounded theory with dyadic analysis has pre- veillance of the types of engagement or number viously been used to effect with populations of interactions (see Burke, 2015). 4 Journal of Health Psychology 00(0) Through COVID-19, befrienders we spoke total, 15 dyads had their details passed to the to in this study continued their relationships research team—all 15 contacted by the staff with their matched older person via the phone member at ALONE consented to having their or visits outdoors. As part of a broader evalua- details passed on. Due to non-response, inter- tion of the impact of the ALONE befriending views were ultimately conducted with 13 dyads. service on new older person users, we also recruited existing older persons using the Data collection and setting ALONE befriending service, using a critical case sampling design, which is highly purpo- Two interview guides, one for the older persons sive and thus high in rigour. User-befriender and one for the befrienders, were developed dyads were the unit of recruitment. Estimating according to constructivist grounded theory sample size in a grounded theory context is guidelines (Charmaz, 2006). That is, we began always challenging (Charmaz, 2006). We with sensitising concepts from our literature employed the informational power approach to review as tools for encouraging our participants sample size estimation (Malterud et al., 2016), to reflect on a purposively narrow question: which requires consideration of: specificity of how befriending might impact health. We study aim (here: specific); sample specificity designed the schedule to elicit an in- (here: very specific, since critical case sampling depth reflection using open-ended and non- was used); use of theory (here: no); dialogue judgemental questions. Whether interview quality (here: expected to be moderate due to schedules in constructivist grounded theory are lack of prior relationship with interviewers); highly structured or more loose depends on the and analytic strategy (here: cross-case). skill level of the researcher; we kept ours mod- Judgements made using this framework yielded erately structured but flexible depending on low to moderate sample size requirements, tak- incoming data. Following Charmaz’ recom- ing into account the research team’s prior expe- mendations (2006), we used an initial list of riences in conducting research with similar open-ended, contextualising questions, fol- populations of older adults, so a sample of 10– lowed by intermediate questions which probed 15 dyads was agreed. Inclusion criteria for the specific question of how befriending might recruitment were that dyads had to be in exist- impact health, followed by some wrap-up ques- ence for at least 1 year as a pair; living within tions eliciting any other feedback the partici- the greater Dublin area (this was later relaxed); pant may have which was not covered by the and capable of providing informed consent to preceding schedule. The intermediate questions participate in the research. Initially, all inter- were based on sensitising concepts including: views were planned in person, but with the first impressions of the older person; changes in advent of COVID-19, interviews following the older person’s physical and mental health; Dyad 3 were all done by phone, meaning that changes to the befriending relationship and vis- participants were then recruited from all over its; perspectives on the impact of befriending on Ireland (since the geographical inclusion crite- health; changes desired to the service; lessons rion was a practical one, designed to limit the learned from being a befriender. The interview amount of travel necessary by the interviewer). guide for older persons focused on the follow- Ultimately, interviews were completed with 13 ing areas: life before service uptake; their dyads. A staff member in ALONE recruited all experience of loneliness; managing wellbeing; participants and, with consent, passed their how they started to get the service; expectations details to the research team, who then under- of the service; impact of the befriender on went the process of informed consent with all them and their lives. Prior to the interview each participants. The study was approved by the participant was sent an information sheet local Research Ethics Committee at the Faculty and consent form which they returned if inter- of Health Sciences, Trinity College Dublin. In ested in engaging in the study. The first dyad Hannigan et al. 5 Table 1. Sample characteristics of n = 12 dyads. Dyad number Role Age Gender Date of Duration of interview Duration of befriending interview (minutes) relationship 2 Older person 82 Female 23/5/19 19 2 years 2 Befriender 43 Female 11/6/19 32 2 years 3 Older person 69 Female 22/1/20 53 3 years 3 Befriender 36 Female 29/1/20 36 3 years 4 Older person 74 Female 18/4/20 45 15 months 4 Befriender 58 Female 16/4/20 40 15 months 5 Older person 86 Female 05/06/20 39 2 years 5 Befriender 47 Female 05/06/20 25 2 years 6 Older person 86 Male 22/06/20 61 18 months 6 Befriender 35 Male 12/06/20 48 18 months 7 Older person 81 Female 07/07/20 46 2 years 7 Befriender 24 Female 21/07/20 18 2 years 8 Older person 76 Male 13/10/20 39 1 year 8 Befriender 59 Male 4/09/20 44 1 year 9 Older person 78 Male 03/11/20 74 2 years 9 Befriender 42 Male 02/11/20 25 2 years 10 Older person 71 Female 25/01/21 41 3 years 10 Befriender 37 Female 17/11/20 32 3 years 11 Older person 69 Female 19/01/21 37 1 year 11 Befriender 24 Female 26/11/20 20 1 year 12 Older person 79 Female 17/12/20 59 2 years 12 Befriender 39 Female 27/11/20 24 2 years 13 Older person 96 Female 15/12/20 20 1 year 13 Befriender 45 Female 01/12/20 26 1 year interviewed yielded very short interviews (4 phone-based interviews for each dyad member and 11 minutes respectively) which was subse- (from dyad 4 onwards), as most older partici- quently judged to be an issue in researcher pants were unable to engage in online inter- training, so the data from these interviews was views and conference calls would yield poor not retained for analyses. Aside from the first data in this context. Although we conducted two included dyads, each interview was con- dyadic interviews with dyads 2 and 3, only their ducted on the phone and lasted between 18 and individual interview data were pooled for anal- 59 minutes (see Table 1). ysis (to ensure consistency with the remaining For the first three dyads, individual inter- dyads). The dyadic analysis of individual inter- views and a joint interview (i.e. with both mem- views is in fact exactly what was advocated by bers of the dyad present in a single interview) the original authors of the approach (Eisikovits were conducted, all in person. However, the and Koren, 2010) on the grounds that they ena- arrival of the COVID-19 pandemic and associ- ble each participant to tell their own story, and ated public health guidelines implemented in that supplementing such individual interviews Ireland in March 2020 meant that face-to-face with a joint interview might negatively ‘affect interviews were no longer possible. The deci- the benefits of both the separate and the joint sion was made to limit the data collection interviews’ by changing the audience (Eisikovits for the remaining ten dyads to separate and Koren, 2010: 1643). 6 Journal of Health Psychology 00(0) procedure were reported to allow readers to Rigour and reflexivity gauge transferability and dependability of We undertook strategies to ensure rigorous, results; and the reflexive practices of the reflexive research was conducted. We devel- research team (discussion, memos) worked to oped a rigorous conceptual framework in which promote the confirmability of the study results. to position the research aim. Data collection While member checks were not employed was undertaken by multiple individuals and in this study, due mostly to the difficulties of transcripts were analysed by multiple individuals phone-based data collection during COVID- —two for each transcript—(authors JMcHP, 19, we presented the study results to a group of CH, EH)), to ensure triangulation and to enable befriending service users at the end of the the calculation and resolution of inter-rater study in a half-day workshop, and discussed agreement. In keeping with the principles of the results with them. The aim of this work- constructivist grounded theory, we analysed the shop was to sense-check study results, clarify transcripts from each dyad immediately after potential misunderstandings, and discuss data collection and prior to collecting data from potential applications of the findings. The the next dyad, so inter-rater agreement was cal- workshop was recorded using field notes taken culated at each interim point, and was never by a research assistant, and the research team below 80%. When differences were found in then reviewed their interpretation of the study the analyses conducted by the two raters of each results, the final version of which are pre- transcript, the results were discussed until a sented below. resolution was reached. Triangulation was fur- Data availability statement: we did not seek ther permitted through the dyadic analytic tech- consent from participants to archive their data, nique, which allowed the research team to so regrettably there is no way to share the data compare and contrast findings across members from this study. We wrote the ethics application of a dyad. for this study in 2018 and since have always Authors JMcHP and CH (both academic sought to archive data. psychologists) were trained to doctoral level and had substantial prior experience of research Analysis interviews, while author EH (a research assis- We used a constructivist grounded theory ana- tant) was trained to Masters level and had lytic method (Charmaz, 2006) informed by received training to conduct the interviews. principles of dyadic analysis (Eisikovits and Interviewers did not interact with the dyads Koren, 2010). While interviews were conducted prior to the interviews other than to arrange the separately, analysis was conducted dyadically. interview by phone. All three interviewers were As per grounded theory principles, the first step psychologists working in the field of geronto- of line-by-line initial coding was completed logical research and academic psychology, and with each interview transcript, followed by a all were involved in an evaluation of the process of focused coding, with a final step of befriending service (led by author JMcHP as theoretical coding. Initial codes were retained Principal Investigator, and CH as co-investiga- until they were no longer useful in relation to tor). Continued discussion making use of the emerging theory. Codes were retained only memos between the primary researchers if they arose from multiple dyads. Then, com- (JMcHP, CH, EH) facilitated development of parisons between members of each dyad were the themes. made and overlaps and contrasts noted. To Trustworthiness of the study findings was of ensure the analysis was trustworthy, audio- concern throughout the study (Lincoln, 2005). recorded interviews were first transcribed Transcripts were typed verbatim from audio verbatim, analysed by two researchers indepen- recordings of all interviews, thus improving the dently, and a process of peer debriefing was study credibility; sample characteristics and Hannigan et al. 7 Figure 1. A grounded theory of five potential mechanisms through which befriending may impact the health of older adults, with respect to contextual factors identified in the study. used with the co-authors of this manuscript and isolation, leading to referrals, OP10: ‘I was with a Patient and Public Involvement (PPI) actually in hospital . . . they told me they were committee established at the beginning of the putting me in contact with ALONE’. study. As per guidelines (Koren, 2016), data Older persons also mentioned their pre- were presented per theme with quotations from intervention mobility issues (OP2, 3, 5, 9, 10), each partner of a dyad, further enhancing study chronic health issues (OP4), and mental health rigour. issues (OP10, OP15). Dissonance within the dyad was clear for some, for example, Dyad 4, where OP4 mentioned that ‘my health is not so Results bad . . . I’d say I’m healthier than maybe a lot The two samples were described in Table 1. of people my age’ while BF4 commented ‘She’s Five intervention mechanisms were identified: not in the best of health . . . I don’t exactly supporting health behaviours (exercise, nutri- know what her health problems are’. However tion, access to healthcare); providing emotional this dissonance may be due to broader negative support; improving mood; getting cognitive perceptions of ageing and its impact on health, stimulation and novelty; providing opportuni- as described among befrienders previously ties for socialising (see Figure 1). Participants (Breheny et al., 2020). discussed how these mechanisms operated in Another critical contextual factor was the the context of pre-intervention health and pre-intervention loneliness experienced most loneliness. older people interviewed, likely exacerbated by the COVID-19 pandemic and associated social distancing measures in place in Ireland during Contextual factors 2020 and 2021, for example, OP13: ‘I was Some older persons had sought or been referred lonely, yeah. Well, living on your own is very to the befriending service, for reasons of loneli- lonely’. BF13 also felt that OP13 was very ness (OP2, 3, 4, 9) depression (OP15), and lonely because of the lack of visitors during the physical illness (OP5, 6, 10, 11). Physical ill- pandemic: ‘She is very lonely even now, well, ness was, for some, causing or at risk of causing currently with the way the situation is, very 8 Journal of Health Psychology 00(0) lonely, very, very lonely. ‘Cos there’s not as that OP7 became more comfortable with her many people calling down’. Almost all partici- over time, and more able to ask for favours like pants reported feeling lonely, and one befriender lifts to hospital appointments: ‘She would have claimed that the intervention service would kind of come out of her shell a little bit more relieve such loneliness: for example, BF8: and as we got to know each other . . . she’d be ‘Sometimes older people settle into their loneli- a lot more open . . . to ask maybe if she needed ness but we’re probably taking them out of it a to go to the hospital or an appointment . . . I little bit more’. have no problem taking her’. In such contexts, then, five mechanisms Sometimes healthcare access involved visit- were identified as being triggered by the ing the chemist particularly during the COVID- befriending intervention and likely to yield pos- 19 pandemic, for example, OP10: ‘BF10, as I itive impacts on health. said, was a little angel. So, she went to the chemist for me when I needed and things like Mechanism 1: Supporting health behaviours. that. But I hated asking her to do anything for Based on our data, we posit that befriending me’/BF10: ‘I mean she knows I’m right down services may improve health through the mech- the road from her and I’m always saying please anism of support from befrienders in relation to let us know if you need anything’. the older person’s engagement in health behav- iours, such as exercise engagement and healthy Mechanism 2: Providing emotional support . Based nutrition. Some befrienders had a clear active on our data, we suggest that befriending ser- role in supporting the older person’s health, vices may play a role in supporting health sometimes by informational support and through the mechanism of emotional support encouragement. For some of the older persons, provided by befrienders for the older persons. the befriending visit was an opportunity to take Many dyads stated that befrienders became exercise safely, since many had issues with sta- confidantes for their partners, providing emo- bility and mobility, for example, BF13 described tional support for them, particularly in the con- some exercises she did with OP13: ‘I was show- text of family difficulties. Dyads differed in the ing her a few exercises in the chairs, they were extent to which they shared personal informa- chair exercises, and she said but I’d need you tion with each other. For some, the chat was here all the time; I couldn’t do them on my kept light, for example, OP7: ‘we just sit and own’. chat and we watch “Say Yes to the Dress” and Befrienders also had a role to play in nutri- criticise everybody’/BF7: ‘you’d visit and tional support. Two befrienders described help- you’d have a cup of tea, and then after a while it ing their partners to get groceries: OP15: ‘she got to where we knew which biscuits each other brings me this time more food, you know? She liked and we’d have brought them’. In one say what you want ‘cos I will bring, sometimes dyad, the befriender would typically confide in I say nothing, but sometimes she buys more!’/ the older person, rather than the other way BF15: ‘I think I helped her out buying the stuff, around: OP5: ‘I wouldn’t be talking very much I think she found all that really good as well . . . about personal things’/BF5: ‘We would chat what I’ve done really is brought her to the about different things to do with my personal supermarket or brought her to the shops if she life and it’s, not that it’s a bit of therapy but it is needed something’. at the same time you know? . . . she has no Befrienders also facilitated access to health- problem giving you that little bit of advice’. care. BF7 made herself available to bring OP7 Many dyads reported confiding in each other to the hospital for appointments: ‘I suppose she about family issues, such as OP12: ‘BF12 is a may, like if she couldn’t get a lift up to the hos- very good listener and she tells me, you know, pital she may not have gone to the hospital for she put a different slant on things I mightn’t that visit if you get what I mean’. BF7 noted think about, you know? Especially as things Hannigan et al. 9 are, she knows family trouble here now . . . befriending services may improve health of she’s like a counsellor! . . . She’s gone through older persons, specifically their cognitive the tears and everything with me’/BF12: ‘I health, by providing cognitive stimulation. think at times it’s like she has a safe space or Many dyads described the ways in which the she’s able to tell me even that she’s going to befriending partnership introduced stimulation counselling, whereas some of her family may and novelty to the lives of the older person. OP3 not know things are happening . . . I suppose for instance referred frequently to the amount she didn’t feel like she even had a space to just that she learned from her befriending partner: talk about what was happening for her . . . she ‘BF3 has educated me in a way . . . I think if really was very isolated in that regard’. BF12 she were an older person, we’d just be talking later added that she was grateful that OP12 had about our kids and grandkids’. Some dyads sought counselling; ‘I think it was really impor- highlighted the content of their conversations, tant that she got her separate counselling as well which often concerned shared interests or cur- because I’m conscious of my role in it too . . . rent affairs. For OP4, the befriending visits you don’t want to disempower somebody’. were mostly about chatting, whereas BF4 described these chats as being educational: ‘I Mechanism 3: Improving mood. Based on our like just having someone to talk to every week data, we propose that befriending services may and someone to invite into my home’/BF4: improve health partly by improving the mood ‘we’ve great chats, she’s very well read, very of older persons. Central to many interviews highly educated, so there’s nothing we don’t was the fun involved in the befriending visits, discuss’. BF8 referred, in response to a question and some older people felt that this improved about whether his relationship impacted OP8’s their health, for example, OP8: ‘BF8 being jolly health, by referring to cognitive stimulation: ‘I and happy is, and having a joke is a good thing think I can keep him engaged’. too. You know, they say laughs are the best Similarly, for some pairs, the opportunity of medicine’; OP8: ‘we do play cards, we have a an intergenerational exchange provided its own very competitive game . . . we’d have a good novelty to older persons. For instance, OP3: ‘I laugh anyway’. think what amazes me she’s so young. And I’m OP7 felt that befriending improved her 69 nearly. To me that, to have that friendship mood, rather than her physical wellbeing: ‘I with someone that age, it’s fantastic’/BF3: ‘It’s mean it hasn’t taken the rheumatoid away or a real enhancement because I think that we all anything like that but it does mentally, mentally, tend to fall into step with the people we’re in I mean if I`m having a bad day and I know that college with, the people we work with -our own BF7 is coming, for example she’s coming this demographic’. Both OP3 and BF3 reported that evening and I look forward to her coming, she’s they had a true friend in each other, meaning a very positive thing in my life’. BF7 also that the befriending service had yielded a true described that she felt able to improve the mood friendship. Similarly, OP12 was very interested of OP7 up if needed: ‘she might be a bit down in hearing about her partner’s life: OP12: ‘I and you can sense that she might be down when look forward to the visit now. It’s the younger you go in on a Tuesday evening or whatever but person’s view’. you kind of know how to work it . . . if she’s in bad form you kind of know how to perk her up Mechanism 5: Opportunities for further socializ- a wee bit’. OP3 described the impact that her ing. Based on our data, we propose that the befriender had by saying ‘When BF3 came she befriending service itself may improve health brought me out of myself’. through offering further opportunities for social engagement. Interestingly, the organisa- Mechanism 4: Providing cognitive stimulation and tion itself may have also provided some social novelty. Based on our data, we propose that context. One service the participants spoke 10 Journal of Health Psychology 00(0) highly about was the ‘check-in’ phone call say she seems worse overall than when I met some of them had received, OP3: ‘there’s her so I can’t say I’d see any negative changes another girl from the office rings you every but I do know there are phases, if you will’. now and then, to ask you are you happy with Similarly, BF3 felt that she had not caused any your relationship with your companion that substantial changes in her partner: ‘I wouldn’t comes. So at any time you can change your think she’s changed a huge amount, no. I know companion, you know, if you don’t see eye to that she enjoys my visits and I know she looks eye with someone’. Her befriender had an forward to them so whether it perks her up on additional insight into the value of the service the day, yeah maybe, but I don’t think that’s a for OP3, BF3: ‘She likes the fact that there’s change’. now somebody else in her life, and when I say However, among our sample, many of whom somebody else, I mean another organisation, had poor health, it is possible that a lack of another institution, another thing to identify decline reflects the best possible outcome, if the with and ally herself to. There’s another ele- befriending intervention served to offset an ment of connectedness’. Participants spoke existing decline in health. frequently about the events organised by ALONE as being highlights, for example, Discussion BF15: ‘the events were something I know I would have enjoyed pre-COVID, so I think We used a constructivist grounded theory things like that people really like and appreci- approach to understanding how participants ate and get a lot out of so I think they’ve been understand the ways in which befriending might brilliant at doing that stuff as well before impact health, and built a grounded (in the data) COVID, but I think eventually they’ll be able theoretical description of how this might occur. to go back to doing those things’; OP4: ‘I go The current study found evidence for five and I meet the ALONE people, I go and have potential mechanisms through which befriend- lunch, an ALONE lunch, once a month in a ing may impact health, and which may contrib- hotel, it’s meant to be really part of the cinema ute to our underdeveloped theoretical club outing, but I don’t go to the cinema I just understanding (Lester et al., 2012). Furthermore, go to lunch and a few other people do the same while prior research has focused on the impact thing. And it’s a social occasion and it’s lovely. of befriending on mental health (Fakoya et al., It’s very nice, yeah’. BF9 also attributed the 2021; Mead, et al., 2010), our current findings change in OP9’s mental state to the organisa- suggest that befriending is likely to yield posi- tion more broadly, ‘OP9 kind of turned his life tive impacts on health defined more broadly. around and you know, maybe ALONE played Previous research focusing on the impact of a part in that too’. befriending on loneliness and social isolation It is worth noting that some participants did had identified four key mechanisms: reciproc- not feel they had made any substantial changes ity, empathy, autonomy and privacy (Fakoya to the lives of their service user by befriending. et al., 2021). The current findings overlap OP10 had not felt any impact of befriending on somewhat: provision of emotional support her mental health: ‘I don’t know whether she’s relies on the empathy of the befriender; but oth- improved my life or not really, it’s still the erwise there is little overlap, suggesting that same. So very hard question to answer, because there are distinct pathways through which I don’t think it has lifted, say my depression, in befriending impacts loneliness and health more any way’. BF10 also felt that OP10 had not broadly. Another descriptive model of befriend- changed because of the service: ‘I think psycho- ing listed some theoretical links between logically and physically I think that you know, befriending and health: attachment, friendship, the physical health issues and anxiety I think do buffering, social networks, social capital build- kind of ebb and flow, so you know, I wouldn’t ing and social inclusion (Balaam, 2015), Hannigan et al. 11 although conceptually these overlap a little It should be clarified that participants them- with our mechanisms. Our results also overlap selves did not often draw the connection somewhat with those of Gardiner on mecha- between the mechanisms they described and a nisms between befriending and wellbeing; positive impact on health. For instance, while meaningful interactions and cognitive stimula- many reported that they provided emotional tion arose as potential mechanisms in their support for each other, there was no description study too (Gardiner and Barnes, 2016). The of the impact such support could yield on mechanism we termed ‘providing emotional health. Such impacts are evident through a syn- support’ also overlaps somewhat with ‘social thesis of the data and prior literature on the support’ as a befriending mechanism impacting topic identifying links between emotional sup- emotional health identified previously (Lester port and health (Reblin and Uchino, 2008). et al., 2012). Findings suggest that there are multiple mech- Results are highly compatible with anisms through which befriending might impact Berkman’s causal cascade model of social health. We used a dyadic approach which extends influences on health (Berkman et al., 2000); beyond existing findings in relation to the mecha- emotional support, supporting health behav- nisms through which befriending impacts the iours, cognitive stimulation, advice and oppor- older person (Krohne et al., 2023). More research tunities for socialising all map on to the is still warranted, however, to confirm the direct psychosocial mechanisms listed in this model. or overall impact of befriending on health. Only improvement of mood does not appear in Currently, mixed findings exist on this impact the causal cascade model, although it could be (Siette et al., 2017), and results have been sty- argued that it is analogous to a sense of wellbe- mied by methodological limitations (Schwei ing (which appears in the model as a pathway, et al., 2021). To attempt to contribute to this situ- influenced by mechanisms). As such, the cur- ation, we conducted a single-case experimental rent findings could be taken as further valida- design evaluation of the ALONE befriending ser- tion of the causal cascade model in the context vice, and demonstrated a therapeutic effect of the of befriending services. It would be of interest service on health-related quality of life of older to evaluate the ‘upstream’ factors listed in the people, alongside evidence that befriending ser- model, and how they influence befriending ser- vices may act by suppressing the negative impact vices in turn. Thus while the identified mecha- of loneliness on health over time. Approaches nisms have some face validity and biological such as this may present interesting avenues for plausibility, because they have to be seen as future research to tackle. operating with complex social systems, other Study conclusions must be tempered with Bradford Hill criteria supportive of a causal reflection on the methodological limitations of warrant would be hard to demonstrate (Holt- the research. We set out to conduct face-to-face Lunstad, 2022). dyadic interviews with the dyads, but were pre- Such system factors include mezzo level fac- vented by the COVID-19 pandemic. While we tors such as the characteristics of social network nonetheless applied a dyadic analysis to separate ties and so it would be of interest to understand interview data, such dyadic data would have how factors such as frequency of face-to-face potentially enriched the current findings. We and organisational contact, reciprocity of ties used constructivist grounded theory to shape the and multiplexity all feed into the identified design and analysis of the study, and interpreted mechanisms in a befriending context. By the results using a realist evaluative definition of same token, we cannot claim that each mecha- mechanism. It is potentially controversial to nism would be triggered in the same way for merge two distinct approaches in this manner, each health outcome nor that their effects are since we did not use realist interviews, but it is equivalent or universal across individuals argued that the realist approach should be flexi- (Rieckmann et al., 2022). ble enough to apply to other methodologies 12 Journal of Health Psychology 00(0) including data collected using a grounded theory pathways are distinguished, we will be in a bet- approach (Kazi and Spurling, 2000). Using the ter position to tailor the interventions to those dyadic approach enabled us to explore disagree- most likely to benefit (Gardner, 2023) or indeed ment between dyad members on their reports. to suggest wider societal action to enhance com- For instance, we found in one theme, supporting munity social capital and social engagement health behaviours, that while befrienders com- (Gregorio, 2022). monly described their efforts to support their In conclusion we report five potential mecha- partner engaging in health behaviours, only some nisms through which befriending services might of the older persons verified these efforts in their impact on the health of its users. We suggest fur- descriptions. It is possible that the befrienders ther quantitative research which measures the were overestimating their role in maintaining the activity of such mechanisms among befriending health of their partners, or alternatively, that the services users to further corroborate whether older participants were unwilling to disclose they demonstrate a mechanistic action in the what may be perceived as dependence on their link between befriending and health. befriending partners (although some did so). Further empirical confirmatory research of the Acknowledgments potential mechanisms identified in this study We wish to thank ALONE, the knowledge user part- would be necessary to understand whether ner organisation, for their role in funding acquisition befrienders truly play a role in supporting health and recruitment, and the participants who gave their behaviours of their partners. time to be part of the research study. Notwithstanding the debate about ex ante Author contributions standards for mechanistic explanation, which we believe our findings meet (Aviles and Reed, CH supervised data collection, helped to design the 2017), further methodological work is required study and analyse the data, and contributed to the to elucidate how a variety of preceding factors writing of the article. MK helped to analyse the data and contributed to the writing of the article. EH was might combine to trigger these putative befriend- involved in data collection, analysing the data, and ing mechanisms’ actions on distal health out- writing the article. BL was involved in formulating comes. However, we cannot claim to have given the research question, designing the study, and writ- a full account of the possible mechanisms at ing the article. FK was involved in formulating the play. For example we already observed that par- research question, designing the study, and writing ticipants seldom drew a connection between the article. SM and AOR were involved in design- mechanisms and health outcomes and by the ing the study, collecting data, and writing the article. same token we are mindful of ongoing work that JMcHP led the study, acquired funding, designed the has advanced a role for unconscious psychologi- study, formulated the research questions, and super- cal processes affecting health behaviours and vised data collection, led data analysis and the writ- outcomes (Hollands et al., 2016). The extent to ing of the article. TS was involved in formulating the research question, designing the study, analysing the which these are important places limits on mech- data, and writing the article. anistic reasoning in realist qualitative inquiry, limits which nevertheless may be loosened and Data sharing statement benefit from emerging work to enhance the syn- ergies between quantitative and qualitative meth- Consent was not given or sought from participants to ods that pursue causal inference (Drury et al., archive their data, so regrettably there is no way to share the data from this study. 2022; Johnson et al., 2019; Proudfoot, 2022). A corollary of such work is that it will facili- Declaration of conflicting interests tate better theorisation and evaluation of befriending services (Bonell et al., 2023). The authors declared no potential conflicts of interest Eventually, when the mediating or moderating with respect to the research, authorship, and/or pub- roles of factors contributing to these mechanistic lication of this article. Hannigan et al. 13 Funding Berkman LF, Glass T, Brissette I, et al. (2000) From social integration to health: Durkheim in the The authors disclosed receipt of the following finan- new millennium. Social Science & Medicine cial support for the research, authorship, and/or pub- 51: 843–857. lication of this article: This research was funded by Bonell C, Ponsford R, Meiksin R, et al. (2023). the Health Research Board Applied Partnership Testing and refining middle-range theory in Award (Grant number APA 2017 004). evaluations of public-health interventions: Evidence from recent systematic reviews and Ethics approval trials. Journal of Epidemiology and Community The study was approved by the Faculty of Health Health 77(3): 147–151. Sciences Research Ethics Committee, Trinity Bonell C, Warren E and Melendez-Torres G (2022) College Dublin (reference: 180501 McHugh Power). Methodological reflections on using qualitative research to explore the causal mechanisms of complex health interventions. Evaluation 28(2): Consent 166–181. Written informed consent was recorded for all Breheny M, Pond R and Lilburn LE (2020) “What participants. am I going to be like when I'm that age?”: How older volunteers anticipate ageing through home Pre-registration visiting. Journal of Aging Studies 53: 100848. Yes: Hannigan, C., Hanly, P., Kee, F., Lawlor, B., Burke L (2015). ALONE Befriending Service Holton, E., Walsh, C., Scharf, T., Coen, R., Leatham, Evaluation Report. Dublin, Ireland: Liz Burke V., Moynihan, S., Lane, K. & McHugh Power, J. Communications. (2020). HALO: Study protocol for a single-case Cattan M, White M, Bond J, et al. 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Mechanisms through which befriending services may impact the health of older adults: A dyadic qualitative investigation

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References (61)

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SAGE
Copyright
© The Author(s) 2024
ISSN
1359-1053
eISSN
1461-7277
DOI
10.1177/13591053241235846
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Abstract

Befriending services are often delivered to older adults with a view to improving social connectedness, but they may also lead to improved health. The objective of the current study was to explore potential mechanisms through which befriending services might impact the health of older adults. Data were collected from 13 befriendee-befriender dyads (n = 26), using a constructivist grounded theory and dyadic analytic approach. Potential mechanisms were described, using a realist evaluative framework of mechanistic processes in a complex intervention context. Five mechanisms of action triggered by the intervention were identified: supporting health behaviours; providing emotional support; improving mood; getting cognitive stimulation and novelty; and providing opportunities for socialising. We identified five potential mechanisms through which befriending services might impact health for older people. Our results suggest potential mechanisms through which befriending might positively impact the health of older people, and which should be evaluated empirically in future research. Keywords healthy ageing, intervention, loneliness, social support, subjective wellbeing, volunteering Introduction National College of Ireland, Ireland Befriending interventions provide supportive Maynooth University, Ireland Trinity College Dublin, Ireland relationships on a voluntary basis via regular University of Newcastle, UK visits or phone calls, most typically to those Queen’s University Belfast, UK experiencing social isolation and loneliness ALONE, Ireland (Dean and Goodlad, 1998; Gardiner et al., Corresponding author: 2018; Siette et al., 2017). Little evidence exists Joanna McHugh Power, Department of Psychology, that befriending interventions actually alleviate Maynooth University, Room 3.08, John Hume Building, loneliness (Beckers et al., 2022; Cattan et al., Maynooth, Co. Kildare, Ireland. 2005; Krohne et al., 2022). In the context of Email: Joanna.McHughPower@mu.ie 2 Journal of Health Psychology 00(0) such lack of evidence, Age UK have expressed pathways to improved health (e.g. quitting concerns about the application of befriending smoking, getting exercise). interventions to the problem of loneliness As such there is limited but growing evi- (Jopling, 2015). dence that befriending is good for health includ- However, befriending interventions might ing mental health. We may further clarify how yield benefits other than reducing loneliness. A befriending interventions might impact mental group-based, long-running Finnish interven- and physical health by considering mechanisms tion, Circle of Friends, has demonstrated posi- of action, which is a priority for such complex tive effects on cognitive function (Pitkala et al., interventions as befriending (Fakoya et al., 2011), psychological wellbeing (Routasalo 2021) (Bonell et al., 2022; Moore et al., 2014). et al., 2009), mortality, subjective health and Inspection of such mechanisms is typically a healthcare utilisation (Pitkala et al., 2009). A task left relatively neglected by qualitative structured peer-to-peer support program, mean- researchers exploring befriending and its impact while, failed to demonstrate any effect on phys- (Balaam, 2015; Fakoya et al., 2021), and such ical health (Schwei et al., 2021), although neglect has been cited as the root cause of a methodological limitations may have occluded broader lack of understanding of how befriend- the detection of an effect. Similar issues with ing impacts older adults (Gardiner and Barnes, methodological quality or design have been 2016). Qualitative approaches are capable of highlighted elsewhere in the befriending litera- yielding critical insights into potential mecha- ture (Siette, et al., 2017). With respect to mental nisms underlying complex interventions, by health, befriending interventions yield a thera- allowing direct engagement with intervention peutic effect on depressive symptoms and emo- recipients (Bonell et al., 2022). In other words, tional distress (Mead et al., 2010) (but see qualitative research goes beyond asking ‘what criticisms of Mead’s conclusions; El-Baalbaki works’ to asking ‘how it works’ (Godfrey, et al., 2010), psychiatric symptoms (Sikira 2015). Intervention mechanisms can be defined et al., 2021), and can enhance emotional well- as ‘new human responses, actions, and interac- being (Moss et al., 2021) tions triggered by the provision of new eco- There is a rationale for expecting a positive nomic, informational or other resources’ effect of befriending on health, defined as ‘a (Bonell et al., 2022: 2). Per Bonell’s descrip- state of complete physical, mental, and social tion, mechanisms are not directly observable wellbeing, and not merely the absence of dis- but affect some outcome (in our case, the out- ease or infirmity’ (World Health Organization, come of interest is improved health). 1995). Elective relationships have a positive Previous research has explored the mecha- impact on health, and it could therefore be nisms through which befriending might impact expected that these benefits might also be seen loneliness and mental health. Two studies have in the context of befriending relationships looked at potential mechanisms through which (Berkman et al., 2000; Golden et al., 2009). befriending impacts loneliness and social isola- Berkman’s causal cascade model, while more tion (Fakoya et al., 2021; Krohne et al., 2023). broadly about the impact of social contexts on Another qualitative study explored potential health, may also offer a theoretical framework mechanisms through which befriending services through which to understand the various ways might improve wellbeing at end of life, and in which social connection (potentially encom- demonstrated that befrienders might impact passing that offered by befrienders) could wellbeing by providing meaningful interactions, impact health in later life (Berkman et al., a sense of connectedness, supporting family 2000). For instance, in Berkman’s model, one members, and cognitive engagement (Gardiner could draw a pathway from informational social and Barnes, 2016). However, empirical evi- support (which could theoretically be delivered dence for such mechanisms in the link between in a befriending context) to health behavioural befriending interventions and health is lacking. Hannigan et al. 3 As such, the aim of the current study was to such as later-life re-partnered couples (Koren, build a theory of the mechanisms through which 2016). befriending might impact health, by interview- Dyadic analysis, meanwhile, is the analysis ing the older person users and the voluntary of data from interviews with any dyad or pair of providers (‘befrienders’) of a befriending ser- interest, and is compatible with other traditions vice. While previous studies of befriending of qualitative analysis, including grounded the- have similarly interviewed both members of the ory analysis. Dyadic analysis can create a befriending ‘dyad’ (Bantry-White et al., 2018), deeper understanding of a relationship since it the older person user and the befriender, they permits triangulation by comparing the per- have not explicitly compared dyadic input spectives of both members of a dyad on the (Breheny et al., 2020). Comparing the views of relationship (Eisikovits and Koren, 2010). befrienders and the older persons who use the According to Eisikovits and Koren (2010), indi- service is likely to provide a more comprehen- vidual interview data are desirable to supple- sive understanding of how befriending may ment dyadic joint interviews, since participants impact the health of older users. may feel constrained by the presence of the We used the 32-item COREQ checklist and other dyad member if only dyadic interviews the American Psychological Association jour- are conducted. The dyadic approach is suitable nal article reporting standards for qualitative in research concerning couples or pairs, such research (‘JARS-qual’) to structure our report- as the relationship between the befriender and ing (Levitt et al., 2018; Tong et al., 2007). the older person who is using the service (here- after referred to as the older person). As such, since we wanted to explore a topic which con- Theoretical framework and cerned an existing dyad, dyadic analysis is study design appropriate. The study was conducted as the qualitative arm in a parallel convergent mixed-methods study Context, recruitment and (citation masked for review). A constructivist sample grounded theory framework was used (Charmaz, 2006) coupled with principles from In Ireland, befriending services are provided by dyadic analysis (Eisikovits and Koren, 2010). a range of voluntary and non-governmental Grounded theory is a methodology which uses a organisations, and have been networked by highly systematic inductive approach to build- ALONE under the Community Impact Network ing a theory which is ‘grounded’ in data (Glaser (https://alone.ie/community-impact-network/). and Strauss, 2009); constructivist grounded ALONE is a nongovernmental organisation theory, meanwhile, is more relativist than tradi- dedicated to supporting the lives of vulnerable tional grounded theory, emphasising the active older adults. Their befriending service involves role of the participant in constructing their own non-structured, weekly visits from trained reality and encouraging the integration of matched volunteers to the homes of older peo- reflexive and contextual information in the ple. Befrienders are matched for age, gender development of a grounded theory (Charmaz, and location to older persons, and older persons 2006). Constructivist grounded theory is par- and befrienders can request a rematch if they ticularly suitable when trying to understand the feel there is little rapport. Beyond providing mechanisms of action in interventions related to training to volunteers, which encourages health (Hunter et al., 2016; Yu and Liu, 2010). weekly visits of 1 hour duration, there is no sur- Grounded theory with dyadic analysis has pre- veillance of the types of engagement or number viously been used to effect with populations of interactions (see Burke, 2015). 4 Journal of Health Psychology 00(0) Through COVID-19, befrienders we spoke total, 15 dyads had their details passed to the to in this study continued their relationships research team—all 15 contacted by the staff with their matched older person via the phone member at ALONE consented to having their or visits outdoors. As part of a broader evalua- details passed on. Due to non-response, inter- tion of the impact of the ALONE befriending views were ultimately conducted with 13 dyads. service on new older person users, we also recruited existing older persons using the Data collection and setting ALONE befriending service, using a critical case sampling design, which is highly purpo- Two interview guides, one for the older persons sive and thus high in rigour. User-befriender and one for the befrienders, were developed dyads were the unit of recruitment. Estimating according to constructivist grounded theory sample size in a grounded theory context is guidelines (Charmaz, 2006). That is, we began always challenging (Charmaz, 2006). We with sensitising concepts from our literature employed the informational power approach to review as tools for encouraging our participants sample size estimation (Malterud et al., 2016), to reflect on a purposively narrow question: which requires consideration of: specificity of how befriending might impact health. We study aim (here: specific); sample specificity designed the schedule to elicit an in- (here: very specific, since critical case sampling depth reflection using open-ended and non- was used); use of theory (here: no); dialogue judgemental questions. Whether interview quality (here: expected to be moderate due to schedules in constructivist grounded theory are lack of prior relationship with interviewers); highly structured or more loose depends on the and analytic strategy (here: cross-case). skill level of the researcher; we kept ours mod- Judgements made using this framework yielded erately structured but flexible depending on low to moderate sample size requirements, tak- incoming data. Following Charmaz’ recom- ing into account the research team’s prior expe- mendations (2006), we used an initial list of riences in conducting research with similar open-ended, contextualising questions, fol- populations of older adults, so a sample of 10– lowed by intermediate questions which probed 15 dyads was agreed. Inclusion criteria for the specific question of how befriending might recruitment were that dyads had to be in exist- impact health, followed by some wrap-up ques- ence for at least 1 year as a pair; living within tions eliciting any other feedback the partici- the greater Dublin area (this was later relaxed); pant may have which was not covered by the and capable of providing informed consent to preceding schedule. The intermediate questions participate in the research. Initially, all inter- were based on sensitising concepts including: views were planned in person, but with the first impressions of the older person; changes in advent of COVID-19, interviews following the older person’s physical and mental health; Dyad 3 were all done by phone, meaning that changes to the befriending relationship and vis- participants were then recruited from all over its; perspectives on the impact of befriending on Ireland (since the geographical inclusion crite- health; changes desired to the service; lessons rion was a practical one, designed to limit the learned from being a befriender. The interview amount of travel necessary by the interviewer). guide for older persons focused on the follow- Ultimately, interviews were completed with 13 ing areas: life before service uptake; their dyads. A staff member in ALONE recruited all experience of loneliness; managing wellbeing; participants and, with consent, passed their how they started to get the service; expectations details to the research team, who then under- of the service; impact of the befriender on went the process of informed consent with all them and their lives. Prior to the interview each participants. The study was approved by the participant was sent an information sheet local Research Ethics Committee at the Faculty and consent form which they returned if inter- of Health Sciences, Trinity College Dublin. In ested in engaging in the study. The first dyad Hannigan et al. 5 Table 1. Sample characteristics of n = 12 dyads. Dyad number Role Age Gender Date of Duration of interview Duration of befriending interview (minutes) relationship 2 Older person 82 Female 23/5/19 19 2 years 2 Befriender 43 Female 11/6/19 32 2 years 3 Older person 69 Female 22/1/20 53 3 years 3 Befriender 36 Female 29/1/20 36 3 years 4 Older person 74 Female 18/4/20 45 15 months 4 Befriender 58 Female 16/4/20 40 15 months 5 Older person 86 Female 05/06/20 39 2 years 5 Befriender 47 Female 05/06/20 25 2 years 6 Older person 86 Male 22/06/20 61 18 months 6 Befriender 35 Male 12/06/20 48 18 months 7 Older person 81 Female 07/07/20 46 2 years 7 Befriender 24 Female 21/07/20 18 2 years 8 Older person 76 Male 13/10/20 39 1 year 8 Befriender 59 Male 4/09/20 44 1 year 9 Older person 78 Male 03/11/20 74 2 years 9 Befriender 42 Male 02/11/20 25 2 years 10 Older person 71 Female 25/01/21 41 3 years 10 Befriender 37 Female 17/11/20 32 3 years 11 Older person 69 Female 19/01/21 37 1 year 11 Befriender 24 Female 26/11/20 20 1 year 12 Older person 79 Female 17/12/20 59 2 years 12 Befriender 39 Female 27/11/20 24 2 years 13 Older person 96 Female 15/12/20 20 1 year 13 Befriender 45 Female 01/12/20 26 1 year interviewed yielded very short interviews (4 phone-based interviews for each dyad member and 11 minutes respectively) which was subse- (from dyad 4 onwards), as most older partici- quently judged to be an issue in researcher pants were unable to engage in online inter- training, so the data from these interviews was views and conference calls would yield poor not retained for analyses. Aside from the first data in this context. Although we conducted two included dyads, each interview was con- dyadic interviews with dyads 2 and 3, only their ducted on the phone and lasted between 18 and individual interview data were pooled for anal- 59 minutes (see Table 1). ysis (to ensure consistency with the remaining For the first three dyads, individual inter- dyads). The dyadic analysis of individual inter- views and a joint interview (i.e. with both mem- views is in fact exactly what was advocated by bers of the dyad present in a single interview) the original authors of the approach (Eisikovits were conducted, all in person. However, the and Koren, 2010) on the grounds that they ena- arrival of the COVID-19 pandemic and associ- ble each participant to tell their own story, and ated public health guidelines implemented in that supplementing such individual interviews Ireland in March 2020 meant that face-to-face with a joint interview might negatively ‘affect interviews were no longer possible. The deci- the benefits of both the separate and the joint sion was made to limit the data collection interviews’ by changing the audience (Eisikovits for the remaining ten dyads to separate and Koren, 2010: 1643). 6 Journal of Health Psychology 00(0) procedure were reported to allow readers to Rigour and reflexivity gauge transferability and dependability of We undertook strategies to ensure rigorous, results; and the reflexive practices of the reflexive research was conducted. We devel- research team (discussion, memos) worked to oped a rigorous conceptual framework in which promote the confirmability of the study results. to position the research aim. Data collection While member checks were not employed was undertaken by multiple individuals and in this study, due mostly to the difficulties of transcripts were analysed by multiple individuals phone-based data collection during COVID- —two for each transcript—(authors JMcHP, 19, we presented the study results to a group of CH, EH)), to ensure triangulation and to enable befriending service users at the end of the the calculation and resolution of inter-rater study in a half-day workshop, and discussed agreement. In keeping with the principles of the results with them. The aim of this work- constructivist grounded theory, we analysed the shop was to sense-check study results, clarify transcripts from each dyad immediately after potential misunderstandings, and discuss data collection and prior to collecting data from potential applications of the findings. The the next dyad, so inter-rater agreement was cal- workshop was recorded using field notes taken culated at each interim point, and was never by a research assistant, and the research team below 80%. When differences were found in then reviewed their interpretation of the study the analyses conducted by the two raters of each results, the final version of which are pre- transcript, the results were discussed until a sented below. resolution was reached. Triangulation was fur- Data availability statement: we did not seek ther permitted through the dyadic analytic tech- consent from participants to archive their data, nique, which allowed the research team to so regrettably there is no way to share the data compare and contrast findings across members from this study. We wrote the ethics application of a dyad. for this study in 2018 and since have always Authors JMcHP and CH (both academic sought to archive data. psychologists) were trained to doctoral level and had substantial prior experience of research Analysis interviews, while author EH (a research assis- We used a constructivist grounded theory ana- tant) was trained to Masters level and had lytic method (Charmaz, 2006) informed by received training to conduct the interviews. principles of dyadic analysis (Eisikovits and Interviewers did not interact with the dyads Koren, 2010). While interviews were conducted prior to the interviews other than to arrange the separately, analysis was conducted dyadically. interview by phone. All three interviewers were As per grounded theory principles, the first step psychologists working in the field of geronto- of line-by-line initial coding was completed logical research and academic psychology, and with each interview transcript, followed by a all were involved in an evaluation of the process of focused coding, with a final step of befriending service (led by author JMcHP as theoretical coding. Initial codes were retained Principal Investigator, and CH as co-investiga- until they were no longer useful in relation to tor). Continued discussion making use of the emerging theory. Codes were retained only memos between the primary researchers if they arose from multiple dyads. Then, com- (JMcHP, CH, EH) facilitated development of parisons between members of each dyad were the themes. made and overlaps and contrasts noted. To Trustworthiness of the study findings was of ensure the analysis was trustworthy, audio- concern throughout the study (Lincoln, 2005). recorded interviews were first transcribed Transcripts were typed verbatim from audio verbatim, analysed by two researchers indepen- recordings of all interviews, thus improving the dently, and a process of peer debriefing was study credibility; sample characteristics and Hannigan et al. 7 Figure 1. A grounded theory of five potential mechanisms through which befriending may impact the health of older adults, with respect to contextual factors identified in the study. used with the co-authors of this manuscript and isolation, leading to referrals, OP10: ‘I was with a Patient and Public Involvement (PPI) actually in hospital . . . they told me they were committee established at the beginning of the putting me in contact with ALONE’. study. As per guidelines (Koren, 2016), data Older persons also mentioned their pre- were presented per theme with quotations from intervention mobility issues (OP2, 3, 5, 9, 10), each partner of a dyad, further enhancing study chronic health issues (OP4), and mental health rigour. issues (OP10, OP15). Dissonance within the dyad was clear for some, for example, Dyad 4, where OP4 mentioned that ‘my health is not so Results bad . . . I’d say I’m healthier than maybe a lot The two samples were described in Table 1. of people my age’ while BF4 commented ‘She’s Five intervention mechanisms were identified: not in the best of health . . . I don’t exactly supporting health behaviours (exercise, nutri- know what her health problems are’. However tion, access to healthcare); providing emotional this dissonance may be due to broader negative support; improving mood; getting cognitive perceptions of ageing and its impact on health, stimulation and novelty; providing opportuni- as described among befrienders previously ties for socialising (see Figure 1). Participants (Breheny et al., 2020). discussed how these mechanisms operated in Another critical contextual factor was the the context of pre-intervention health and pre-intervention loneliness experienced most loneliness. older people interviewed, likely exacerbated by the COVID-19 pandemic and associated social distancing measures in place in Ireland during Contextual factors 2020 and 2021, for example, OP13: ‘I was Some older persons had sought or been referred lonely, yeah. Well, living on your own is very to the befriending service, for reasons of loneli- lonely’. BF13 also felt that OP13 was very ness (OP2, 3, 4, 9) depression (OP15), and lonely because of the lack of visitors during the physical illness (OP5, 6, 10, 11). Physical ill- pandemic: ‘She is very lonely even now, well, ness was, for some, causing or at risk of causing currently with the way the situation is, very 8 Journal of Health Psychology 00(0) lonely, very, very lonely. ‘Cos there’s not as that OP7 became more comfortable with her many people calling down’. Almost all partici- over time, and more able to ask for favours like pants reported feeling lonely, and one befriender lifts to hospital appointments: ‘She would have claimed that the intervention service would kind of come out of her shell a little bit more relieve such loneliness: for example, BF8: and as we got to know each other . . . she’d be ‘Sometimes older people settle into their loneli- a lot more open . . . to ask maybe if she needed ness but we’re probably taking them out of it a to go to the hospital or an appointment . . . I little bit more’. have no problem taking her’. In such contexts, then, five mechanisms Sometimes healthcare access involved visit- were identified as being triggered by the ing the chemist particularly during the COVID- befriending intervention and likely to yield pos- 19 pandemic, for example, OP10: ‘BF10, as I itive impacts on health. said, was a little angel. So, she went to the chemist for me when I needed and things like Mechanism 1: Supporting health behaviours. that. But I hated asking her to do anything for Based on our data, we posit that befriending me’/BF10: ‘I mean she knows I’m right down services may improve health through the mech- the road from her and I’m always saying please anism of support from befrienders in relation to let us know if you need anything’. the older person’s engagement in health behav- iours, such as exercise engagement and healthy Mechanism 2: Providing emotional support . Based nutrition. Some befrienders had a clear active on our data, we suggest that befriending ser- role in supporting the older person’s health, vices may play a role in supporting health sometimes by informational support and through the mechanism of emotional support encouragement. For some of the older persons, provided by befrienders for the older persons. the befriending visit was an opportunity to take Many dyads stated that befrienders became exercise safely, since many had issues with sta- confidantes for their partners, providing emo- bility and mobility, for example, BF13 described tional support for them, particularly in the con- some exercises she did with OP13: ‘I was show- text of family difficulties. Dyads differed in the ing her a few exercises in the chairs, they were extent to which they shared personal informa- chair exercises, and she said but I’d need you tion with each other. For some, the chat was here all the time; I couldn’t do them on my kept light, for example, OP7: ‘we just sit and own’. chat and we watch “Say Yes to the Dress” and Befrienders also had a role to play in nutri- criticise everybody’/BF7: ‘you’d visit and tional support. Two befrienders described help- you’d have a cup of tea, and then after a while it ing their partners to get groceries: OP15: ‘she got to where we knew which biscuits each other brings me this time more food, you know? She liked and we’d have brought them’. In one say what you want ‘cos I will bring, sometimes dyad, the befriender would typically confide in I say nothing, but sometimes she buys more!’/ the older person, rather than the other way BF15: ‘I think I helped her out buying the stuff, around: OP5: ‘I wouldn’t be talking very much I think she found all that really good as well . . . about personal things’/BF5: ‘We would chat what I’ve done really is brought her to the about different things to do with my personal supermarket or brought her to the shops if she life and it’s, not that it’s a bit of therapy but it is needed something’. at the same time you know? . . . she has no Befrienders also facilitated access to health- problem giving you that little bit of advice’. care. BF7 made herself available to bring OP7 Many dyads reported confiding in each other to the hospital for appointments: ‘I suppose she about family issues, such as OP12: ‘BF12 is a may, like if she couldn’t get a lift up to the hos- very good listener and she tells me, you know, pital she may not have gone to the hospital for she put a different slant on things I mightn’t that visit if you get what I mean’. BF7 noted think about, you know? Especially as things Hannigan et al. 9 are, she knows family trouble here now . . . befriending services may improve health of she’s like a counsellor! . . . She’s gone through older persons, specifically their cognitive the tears and everything with me’/BF12: ‘I health, by providing cognitive stimulation. think at times it’s like she has a safe space or Many dyads described the ways in which the she’s able to tell me even that she’s going to befriending partnership introduced stimulation counselling, whereas some of her family may and novelty to the lives of the older person. OP3 not know things are happening . . . I suppose for instance referred frequently to the amount she didn’t feel like she even had a space to just that she learned from her befriending partner: talk about what was happening for her . . . she ‘BF3 has educated me in a way . . . I think if really was very isolated in that regard’. BF12 she were an older person, we’d just be talking later added that she was grateful that OP12 had about our kids and grandkids’. Some dyads sought counselling; ‘I think it was really impor- highlighted the content of their conversations, tant that she got her separate counselling as well which often concerned shared interests or cur- because I’m conscious of my role in it too . . . rent affairs. For OP4, the befriending visits you don’t want to disempower somebody’. were mostly about chatting, whereas BF4 described these chats as being educational: ‘I Mechanism 3: Improving mood. Based on our like just having someone to talk to every week data, we propose that befriending services may and someone to invite into my home’/BF4: improve health partly by improving the mood ‘we’ve great chats, she’s very well read, very of older persons. Central to many interviews highly educated, so there’s nothing we don’t was the fun involved in the befriending visits, discuss’. BF8 referred, in response to a question and some older people felt that this improved about whether his relationship impacted OP8’s their health, for example, OP8: ‘BF8 being jolly health, by referring to cognitive stimulation: ‘I and happy is, and having a joke is a good thing think I can keep him engaged’. too. You know, they say laughs are the best Similarly, for some pairs, the opportunity of medicine’; OP8: ‘we do play cards, we have a an intergenerational exchange provided its own very competitive game . . . we’d have a good novelty to older persons. For instance, OP3: ‘I laugh anyway’. think what amazes me she’s so young. And I’m OP7 felt that befriending improved her 69 nearly. To me that, to have that friendship mood, rather than her physical wellbeing: ‘I with someone that age, it’s fantastic’/BF3: ‘It’s mean it hasn’t taken the rheumatoid away or a real enhancement because I think that we all anything like that but it does mentally, mentally, tend to fall into step with the people we’re in I mean if I`m having a bad day and I know that college with, the people we work with -our own BF7 is coming, for example she’s coming this demographic’. Both OP3 and BF3 reported that evening and I look forward to her coming, she’s they had a true friend in each other, meaning a very positive thing in my life’. BF7 also that the befriending service had yielded a true described that she felt able to improve the mood friendship. Similarly, OP12 was very interested of OP7 up if needed: ‘she might be a bit down in hearing about her partner’s life: OP12: ‘I and you can sense that she might be down when look forward to the visit now. It’s the younger you go in on a Tuesday evening or whatever but person’s view’. you kind of know how to work it . . . if she’s in bad form you kind of know how to perk her up Mechanism 5: Opportunities for further socializ- a wee bit’. OP3 described the impact that her ing. Based on our data, we propose that the befriender had by saying ‘When BF3 came she befriending service itself may improve health brought me out of myself’. through offering further opportunities for social engagement. Interestingly, the organisa- Mechanism 4: Providing cognitive stimulation and tion itself may have also provided some social novelty. Based on our data, we propose that context. One service the participants spoke 10 Journal of Health Psychology 00(0) highly about was the ‘check-in’ phone call say she seems worse overall than when I met some of them had received, OP3: ‘there’s her so I can’t say I’d see any negative changes another girl from the office rings you every but I do know there are phases, if you will’. now and then, to ask you are you happy with Similarly, BF3 felt that she had not caused any your relationship with your companion that substantial changes in her partner: ‘I wouldn’t comes. So at any time you can change your think she’s changed a huge amount, no. I know companion, you know, if you don’t see eye to that she enjoys my visits and I know she looks eye with someone’. Her befriender had an forward to them so whether it perks her up on additional insight into the value of the service the day, yeah maybe, but I don’t think that’s a for OP3, BF3: ‘She likes the fact that there’s change’. now somebody else in her life, and when I say However, among our sample, many of whom somebody else, I mean another organisation, had poor health, it is possible that a lack of another institution, another thing to identify decline reflects the best possible outcome, if the with and ally herself to. There’s another ele- befriending intervention served to offset an ment of connectedness’. Participants spoke existing decline in health. frequently about the events organised by ALONE as being highlights, for example, Discussion BF15: ‘the events were something I know I would have enjoyed pre-COVID, so I think We used a constructivist grounded theory things like that people really like and appreci- approach to understanding how participants ate and get a lot out of so I think they’ve been understand the ways in which befriending might brilliant at doing that stuff as well before impact health, and built a grounded (in the data) COVID, but I think eventually they’ll be able theoretical description of how this might occur. to go back to doing those things’; OP4: ‘I go The current study found evidence for five and I meet the ALONE people, I go and have potential mechanisms through which befriend- lunch, an ALONE lunch, once a month in a ing may impact health, and which may contrib- hotel, it’s meant to be really part of the cinema ute to our underdeveloped theoretical club outing, but I don’t go to the cinema I just understanding (Lester et al., 2012). Furthermore, go to lunch and a few other people do the same while prior research has focused on the impact thing. And it’s a social occasion and it’s lovely. of befriending on mental health (Fakoya et al., It’s very nice, yeah’. BF9 also attributed the 2021; Mead, et al., 2010), our current findings change in OP9’s mental state to the organisa- suggest that befriending is likely to yield posi- tion more broadly, ‘OP9 kind of turned his life tive impacts on health defined more broadly. around and you know, maybe ALONE played Previous research focusing on the impact of a part in that too’. befriending on loneliness and social isolation It is worth noting that some participants did had identified four key mechanisms: reciproc- not feel they had made any substantial changes ity, empathy, autonomy and privacy (Fakoya to the lives of their service user by befriending. et al., 2021). The current findings overlap OP10 had not felt any impact of befriending on somewhat: provision of emotional support her mental health: ‘I don’t know whether she’s relies on the empathy of the befriender; but oth- improved my life or not really, it’s still the erwise there is little overlap, suggesting that same. So very hard question to answer, because there are distinct pathways through which I don’t think it has lifted, say my depression, in befriending impacts loneliness and health more any way’. BF10 also felt that OP10 had not broadly. Another descriptive model of befriend- changed because of the service: ‘I think psycho- ing listed some theoretical links between logically and physically I think that you know, befriending and health: attachment, friendship, the physical health issues and anxiety I think do buffering, social networks, social capital build- kind of ebb and flow, so you know, I wouldn’t ing and social inclusion (Balaam, 2015), Hannigan et al. 11 although conceptually these overlap a little It should be clarified that participants them- with our mechanisms. Our results also overlap selves did not often draw the connection somewhat with those of Gardiner on mecha- between the mechanisms they described and a nisms between befriending and wellbeing; positive impact on health. For instance, while meaningful interactions and cognitive stimula- many reported that they provided emotional tion arose as potential mechanisms in their support for each other, there was no description study too (Gardiner and Barnes, 2016). The of the impact such support could yield on mechanism we termed ‘providing emotional health. Such impacts are evident through a syn- support’ also overlaps somewhat with ‘social thesis of the data and prior literature on the support’ as a befriending mechanism impacting topic identifying links between emotional sup- emotional health identified previously (Lester port and health (Reblin and Uchino, 2008). et al., 2012). Findings suggest that there are multiple mech- Results are highly compatible with anisms through which befriending might impact Berkman’s causal cascade model of social health. We used a dyadic approach which extends influences on health (Berkman et al., 2000); beyond existing findings in relation to the mecha- emotional support, supporting health behav- nisms through which befriending impacts the iours, cognitive stimulation, advice and oppor- older person (Krohne et al., 2023). More research tunities for socialising all map on to the is still warranted, however, to confirm the direct psychosocial mechanisms listed in this model. or overall impact of befriending on health. Only improvement of mood does not appear in Currently, mixed findings exist on this impact the causal cascade model, although it could be (Siette et al., 2017), and results have been sty- argued that it is analogous to a sense of wellbe- mied by methodological limitations (Schwei ing (which appears in the model as a pathway, et al., 2021). To attempt to contribute to this situ- influenced by mechanisms). As such, the cur- ation, we conducted a single-case experimental rent findings could be taken as further valida- design evaluation of the ALONE befriending ser- tion of the causal cascade model in the context vice, and demonstrated a therapeutic effect of the of befriending services. It would be of interest service on health-related quality of life of older to evaluate the ‘upstream’ factors listed in the people, alongside evidence that befriending ser- model, and how they influence befriending ser- vices may act by suppressing the negative impact vices in turn. Thus while the identified mecha- of loneliness on health over time. Approaches nisms have some face validity and biological such as this may present interesting avenues for plausibility, because they have to be seen as future research to tackle. operating with complex social systems, other Study conclusions must be tempered with Bradford Hill criteria supportive of a causal reflection on the methodological limitations of warrant would be hard to demonstrate (Holt- the research. We set out to conduct face-to-face Lunstad, 2022). dyadic interviews with the dyads, but were pre- Such system factors include mezzo level fac- vented by the COVID-19 pandemic. While we tors such as the characteristics of social network nonetheless applied a dyadic analysis to separate ties and so it would be of interest to understand interview data, such dyadic data would have how factors such as frequency of face-to-face potentially enriched the current findings. We and organisational contact, reciprocity of ties used constructivist grounded theory to shape the and multiplexity all feed into the identified design and analysis of the study, and interpreted mechanisms in a befriending context. By the results using a realist evaluative definition of same token, we cannot claim that each mecha- mechanism. It is potentially controversial to nism would be triggered in the same way for merge two distinct approaches in this manner, each health outcome nor that their effects are since we did not use realist interviews, but it is equivalent or universal across individuals argued that the realist approach should be flexi- (Rieckmann et al., 2022). ble enough to apply to other methodologies 12 Journal of Health Psychology 00(0) including data collected using a grounded theory pathways are distinguished, we will be in a bet- approach (Kazi and Spurling, 2000). Using the ter position to tailor the interventions to those dyadic approach enabled us to explore disagree- most likely to benefit (Gardner, 2023) or indeed ment between dyad members on their reports. to suggest wider societal action to enhance com- For instance, we found in one theme, supporting munity social capital and social engagement health behaviours, that while befrienders com- (Gregorio, 2022). monly described their efforts to support their In conclusion we report five potential mecha- partner engaging in health behaviours, only some nisms through which befriending services might of the older persons verified these efforts in their impact on the health of its users. We suggest fur- descriptions. It is possible that the befrienders ther quantitative research which measures the were overestimating their role in maintaining the activity of such mechanisms among befriending health of their partners, or alternatively, that the services users to further corroborate whether older participants were unwilling to disclose they demonstrate a mechanistic action in the what may be perceived as dependence on their link between befriending and health. befriending partners (although some did so). Further empirical confirmatory research of the Acknowledgments potential mechanisms identified in this study We wish to thank ALONE, the knowledge user part- would be necessary to understand whether ner organisation, for their role in funding acquisition befrienders truly play a role in supporting health and recruitment, and the participants who gave their behaviours of their partners. time to be part of the research study. Notwithstanding the debate about ex ante Author contributions standards for mechanistic explanation, which we believe our findings meet (Aviles and Reed, CH supervised data collection, helped to design the 2017), further methodological work is required study and analyse the data, and contributed to the to elucidate how a variety of preceding factors writing of the article. MK helped to analyse the data and contributed to the writing of the article. EH was might combine to trigger these putative befriend- involved in data collection, analysing the data, and ing mechanisms’ actions on distal health out- writing the article. BL was involved in formulating comes. However, we cannot claim to have given the research question, designing the study, and writ- a full account of the possible mechanisms at ing the article. FK was involved in formulating the play. For example we already observed that par- research question, designing the study, and writing ticipants seldom drew a connection between the article. SM and AOR were involved in design- mechanisms and health outcomes and by the ing the study, collecting data, and writing the article. same token we are mindful of ongoing work that JMcHP led the study, acquired funding, designed the has advanced a role for unconscious psychologi- study, formulated the research questions, and super- cal processes affecting health behaviours and vised data collection, led data analysis and the writ- outcomes (Hollands et al., 2016). The extent to ing of the article. TS was involved in formulating the research question, designing the study, analysing the which these are important places limits on mech- data, and writing the article. anistic reasoning in realist qualitative inquiry, limits which nevertheless may be loosened and Data sharing statement benefit from emerging work to enhance the syn- ergies between quantitative and qualitative meth- Consent was not given or sought from participants to ods that pursue causal inference (Drury et al., archive their data, so regrettably there is no way to share the data from this study. 2022; Johnson et al., 2019; Proudfoot, 2022). A corollary of such work is that it will facili- Declaration of conflicting interests tate better theorisation and evaluation of befriending services (Bonell et al., 2023). The authors declared no potential conflicts of interest Eventually, when the mediating or moderating with respect to the research, authorship, and/or pub- roles of factors contributing to these mechanistic lication of this article. Hannigan et al. 13 Funding Berkman LF, Glass T, Brissette I, et al. (2000) From social integration to health: Durkheim in the The authors disclosed receipt of the following finan- new millennium. Social Science & Medicine cial support for the research, authorship, and/or pub- 51: 843–857. lication of this article: This research was funded by Bonell C, Ponsford R, Meiksin R, et al. (2023). the Health Research Board Applied Partnership Testing and refining middle-range theory in Award (Grant number APA 2017 004). evaluations of public-health interventions: Evidence from recent systematic reviews and Ethics approval trials. Journal of Epidemiology and Community The study was approved by the Faculty of Health Health 77(3): 147–151. 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Journal

Journal of Health Psychology – SAGE

Published: Jan 1, 2025

Keywords: healthy ageing; intervention; loneliness; social support; subjective wellbeing; volunteering

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