Study design and participants recruitment
This study used a randomized controlled trial design. We used the primary outcome loneliness to calculate the sample size needed. We adopted the effect size of 0.6 from a similar peer-based trial conducted among socially isolated Hong Kong Chinese older adults to reduce their loneliness [28]. With a power of 0.8 (alpha = 0.05, two-sided), 26 participants for each group and 52 in total were needed to detect such an effect size. G*Power 3.1 was used to calculate the sample size [29]. Taking the potential dropout into consideration, we aimed for 30 participants for each group and 60 in total for the baseline. Intervention group participants received an eight-week peer-based intervention.
Sixty participants were recruited by promoting information about the CCHP in Chinese immigrant communities and independent living and assisted living facilities for Chinese older people in the community. Professional practitioners of the host organization also promoted the program through local Chinese radio programs in Calgary, Canada, word of mouth, and putting program notices in the weekly organization activity newsletters that were printed in free local Chinese newspapers. The recruitment of older participants start from 15 of June 2018. Inclusion criteria for participants were: 1) aged 65 and older, 2) independent in activities of daily living, 3) self-reported as socially isolated or in need of social support, and 4) not clinically diagnosed with a mental disorder or cognitive impairment.
Social workers would screen the eligibility of participants when they signed up. In addition to the above four criteria, those who were evaluated by the social workers as in urgent needs of immediate professional help were excluded from this peer-based intervention and referred to professional help. Such participants may include those who was undergoing life transition or under critical situation such as loss of loved one, mental health challenges, or severe family problem (e.g. abusive relationship), and severe depressive mood.
Sixty-six participants signed up for the program, and six were excluded due to severe needs that required professional support unable to be fulfilled by peer volunteers. After the screening, eligible participants were randomly assigned to either an intervention group (n = 30) or a control group (n = 30). All of the participants were blinded to the group assignment. The name of the participants were put on a participant’s list in sequence once they signed up for the programs. They would be assigned randomly based on the number they were in, for example, participants with an odd number go to control group, and those with an even number go to intervention group. The social workers were assigned to intake the participants with sequence with one participant interval between control and intervention group. However, three participants were considered by the social workers as in urgent need due to being in social isolation were given priority to be assigned into intervention group as special cases due to ethical concerns.
Peer training and intervention implementation
Twenty-four Chinese immigrant volunteers aged 48 to 76 years old were recruited and trained between January and April 2018. All the volunteers received 15 h of training by the fourth author who is a professionally trained Registered Social Worker with over two decades of experience in working with older people and mental health issues. The training contents focused on topics such as basic understanding of mental health, knowledge and skills to offer peer support, how to deal with grief and loss, self-help skills, stress management, goal setting, and how to build healthy relationships. Five classes of core volunteer training were held on 21st of January, 23rd and 30th of April, and 13rd and 20th of August in 2018.
The intervention was from mid July to end of December 2018. In the first week, social workers connected each intervention group participant with two peer supporters. The social workers were not blinded to the group assignment and assigned the trained volunteers to visit participants in the intervention group. Over subsequent weeks, each intervention group participant received two-on-one peer support services through home visits, telephone calls, and activities such as emotional support, referrals, help to establish goals such as self-care and social engagement, problem solving, and mental health and community resources. The reason for a two-on-one match was due to the standard professional practice safety protocol preventing sending only one staff members or volunteer for home visit. Having two peer supporters would also have the benefit of allowing them to be able to pay additional attention to both the individual and living environment in the home visit and subsequent support intervention process. Although the volunteers were unable to provide professional intervention or therapy, they actively listened to and respected the needs of the older participants. During the matching process, there were considerations made regarding the gender, age, language, and education background so that some form of commonalities were linked between the older person and the peer-supporters. Peer supporters also shared personal experiences with participants. Intervention group participants were invited to attend two monthly peer support group meetings organized by a trained staff program coordinator with professional training in social work and a Registered Social Worker, where they met with other participants and peer supporters, intended to help them develop strong, supportive, and sustainable social connections with other older people.
Control group participants only received brief telephone calls from the program coordinator over an eight-week period. The project team believes that these regular calls would just be used for normal social greetings or answering any questions related to program information raised by the call receivers. While a sense of care may be felt by the call receivers, which is common in all forms of social interactions that the call receivers experienced in their routine daily interactions with others, the calls would not explicitly extend any invitation to actions that would trigger further engagement in social participation in programs or social activities. In situation when the participants in the control group were to display emerging health or emotional crisis, the program coordinator would initiate the necessarily crisis intervention over the phone or invite the participant to attend professional support sessions afterward. Under this circumstance, the participant would be excluded from the control group of the study.
Data collection
Baseline and post-tests with control and intervention groups were conducted by social workers via individual interviews took place during home visit to each of the participants in week 1 and 10, respectively. The process of the study design and the procedures is shown in Fig. 1. Ethics approval was granted by the first author’s university. Written consent was obtained from all participants. The control group will be provided the same peer-based intervention after the project was completed and positive outcomes were found.
Measures
Primary outcomes
Loneliness was measured using the De Jong Loneliness Scale-6, which has been translated into Chinese and validated among Hong Kong Chinese older adults with satisfactory reliability and validity [30]. The first three questions measure emotional loneliness (e.g. ‘I experience a general sense of emptiness’). Answers ‘yes’ or ‘more or less’ were coded as 1 and ‘no’ was recoded as 0. The other three questions measure social loneliness (e.g. ‘There are plenty of people I can rely on when I have problems’). Answers ‘more or less’ or ‘no’ were recoded to 1, and ‘yes’ was recoded as 0. Overall scores range from 0 to 6, with 0 indicating no loneliness and a higher score indicating more severe loneliness [30].
Social support was measured using the Lubben Social Network scale (LSNS) [31], a 10-item scale that has been translated into Chinese and validated among Hong Kong Chinese older adults. The scale measures family networks (3 items), friend networks (3 items), and interdependent relationship (4 items). Higher overall scores indicate higher levels of social support. Barriers to social participation was measured using the Keele Assessment of Participation [32], which was translated and back-translated for this study. This 15-item scale measures an individual’s restrictions to participation in activities such as daily living, work, and social activities, and includes four screening questions (‘If yes, proceed to the next question’). Answers include ‘all the time’, ‘most of the time’, ‘some of the time’, ‘a little of the time’, and ‘none of the time’. The first two were recoded as 0, and the other three recoded as 1. Overall scores range from 0 to 11, with 0 indicating no restriction in social participation. The scale demonstrated an acceptable level of internal consistency within this sample with the Cronbach’s alpha being 0.64 and 0.65 for the baseline and post-intervention evaluation, respectively.
Secondary outcomes
Life satisfaction was measured by a single question (‘In general, how satisfied are you with your life?’), with answers ranging from 1 = very unsatisfied to 4 = very satisfied. The score was further recoded into two categories: unsatisfied (answering ‘very unsatisfied’ and ‘unsatisfied’) and satisfied (answering ‘satisfied’ and ‘very satisfied’). Happiness was also measured by a single-item question (‘In general, how happy do you feel?’), from 0 = very unhappy to 10 = very happy. We chose the two single-item measurements because these two single-item questions have been widely used in research with Chinese older adults [33, 34]. Moreover, simple structured assessment tools were needed due to the characteristics of the older participants who may unable to endure prolong interviews and complicated interview protocols.
Depression was measured using the General Depression Scale (GDS-4), which has been translated in Chinese and validated among Hong Kong Chinese older adults [35, 36]. It includes four questions (e.g. ‘Are you basically satisfied with your life?’, ‘Do you feel that your life is empty?’), with participants answering yes = 1 or no = 0. Answers to positive items were recoded, with overall scores ranging from 0 to 4 and higher overall scores indicating more severe depressive symptoms. A cut-off point of 2 was adopted, as suggested by Cheng and Chan [36]. Overall scores of 0 and 1 were coded as ‘no depressive symptom’ and scores of 2 and greater were coded as ‘depressive’. Anxiety was measured using the Chinese version of the Geriatric Anxiety Inventory – Short Form (GAI-SF) [37, 38]. It includes five statements (e.g. ‘I worry a lot of the time’), with participants answering yes = 1 or no = 0. Overall scores range from 0 to 5, with higher scores indicating greater anxiety.
Resilience was measured using the two-item Connor-Davidson Resilience Scale (CD-RISC 2) [39], which includes two statements measuring whether an individual is ‘able to adapt to change’ and ‘tends to bounce back after illness or hardship’. The Chinese version has been validated [40]. Answers range from 0 = not true at all to 4 = true nearly all the time. Overall scores range from 0 to 8, with higher scores indicating greater resilience. Purpose in life was measured using the seven-item subscale of Ryff’s Psychological Well-being Scale (e.g. ‘I tend to focus on the present, because the future nearly always brings me problems’;) [41]. A Chinese version has been translated [42]. Answers range from 1 = completely disagree to 6 = completely agree. Answers to negative items were recoded. Higher overall scores indicate a higher level of purpose in life.
Statistical analysis
The intent-to-treat (ITT) approach was adopted for all data analyses. Independent samples t-tests (or Mann Whitney’s test for non-normal distributed continuous variables) were used to test baseline differences between intervention and control groups. Skewness and Kurtosis normality test was conducted. Chi-square tests were conducted for categorical variables, and Fisher’s exact test were conducted if the size of any category was small (< 5) [43]. Analysis of variance was used to evaluate continuous outcomes, with time being the within-group factor and control/intervention as the between-groups measure. Factorial logistic regressions were conducted for depression and life satisfaction, which are dummy variables. Conclusion about the effectiveness of the intervention were based on the time by group interaction coefficients of the models.
Paired samples t-tests (or Wilcoxon signed rank test for non-normal distributed continuous variables) were conducted to compare pre- and post- scores for all outcome variables for the intervention and control groups respectively. The magnitude of changes between the intervention and control groups was compared via independent samples t-test (or Mann Whitney’s test for non-normal distributed continuous variables). Cohen’s d was calculated for the between-group differences variables that showed a significant change. A two-tail p-value < 0.05 was set as the significant confidence level. All analyses were performed using Stata 15.0 (StataCorp).