SI/L have reached epidemic proportions in the U.S. (12). Although SI/L represent distinct concepts, they are often used interchangeably in the literature (1). While social isolation refers to an objective state of having few social relationships or infrequent social contact with others, loneliness reflects the individual’s subjective dissatisfaction with the frequency and closeness of relationships despite the actual interactions with others (3).

SI/L are associated with some similar and distinct negative health outcomes. These include heart disease, depression, anxiety, suicidality, dementia, frailty, nursing home admission, and premature disability and death (3, 13, 14). Studies estimate that SI/L are associated with a 26–29% increased risk of all-cause mortality (1). Recent research indicates that social isolation is a stronger predictor of all-cause mortality, while loneliness is more strongly associated with poor psychological well-being (2). Annually, social isolation results in $6.7 billion in additional Medicare spending (15).

Roughly 25% of older adults (ages 65 years and older) in the United States are socially isolated and 43% of adults ages 60 years and older feel lonely (3). Older adults are at increased risk of SI/L due to predisposing factors such as advanced age, lower educational attainment, living alone, chronic conditions, functional and cognitive impairment, smaller social networks, loss of family or friends, and retirement, among others (3). Some rural older adults have an even higher risk because they are more likely to live alone than their urban counterparts (16) and may not see or even communicate with another person for days at a time. Older adults in rural Appalachia may have greater susceptibility to the adverse health and psychological outcomes associated with SI/L due to underlying poor health status (7, 17) and limited access to behavioral and mental health services (4). Thus, it is important to take these factors into consideration when addressing SI/L in rural Appalachia (18).

Tennessee is home to more than 1.6 million residents over age 60 (19). Based on reports from America’s Health Rankings, Tennessee consistently falls in the bottom quartile of states for health outcomes among older adults over age 65 (20). Notable challenges include disease burden, limited access to clinical care and supportive social services, and risk of social isolation (20). In Tennessee, 52 out of 95 counties are in Central Appalachia. This region of Appalachia is predominately non-Hispanic White (21) and has experienced the largest growth in the older adult population in the region (22).

The Appalachian region is disproportionately burdened with poor social, economic, and health-related outcomes (22). Among 41 health indicators, the Appalachian region lags behind the U.S. on 33 of them, including seven of the 10 leading causes of death (7). Rural parts of the region have even greater risk for premature disability and mortality than urban areas (7). In this article, “rural” is defined as sparsely populated areas lying outside of urban centers (23) as defined by the United States Department of Agriculture Rural–Urban Commuting Area Codes (24). Many of the rural communities lack the infrastructure and resources to support healthy longevity (5, 7, 22). Consequently, rural older adults living in Appalachia often experience unique challenges to aging-in-place, which refers to having the ability to live safely and independently in one’s own home and community for as long as one chooses to do so (25). Rural older adults in these communities face a number of obstacles to social interactions, such as geographic isolation, environments that are not always walkable or socially conducive, a lack of economic resources, and restricted access to cellular and broadband Internet. Rural older adults are also more vulnerable to health problems because they are typically less mobile than their younger counterparts and more dependent on resources specific to their local community, creating difficulty in accessing mental health services among other medical services (26–28).

We conducted a needs assessment survey of older adults using purposive sampling in three affordable housing apartment complexes in a county within Northeast Tennessee between February and March 2023. This project was reviewed by the Institutional Review Board (IRB) at East Tennessee State University and deemed non-human subjects research because it was a needs assessment conducted for multi-stakeholder planning purposes to inform age-friendly initiatives. Participants were recruited via flyers distributed to residents of the apartments either in person or via mail. Residents were eligible to complete the survey if they were ages 62 years and older and spoke English. On the scheduled dates, two needs assessment team members returned to the apartments. While the university IRB deemed this needs assessment as non-human subjects research, our team took extra precautions to ensure respect and ethical considerations were addressed. During the resident engagement process, team members described the purpose of the needs assessment and received verbal consent from individuals prior to distributing the self-administered surveys. Only those who agreed to participate were given surveys to complete. Twelve individuals declined to participate in the needs assessment, and one individual did not meet the eligibility criteria. A total of 82 older adults completed the survey which took approximately 30 minutes to complete. Participants received $50 upon completion of the survey.

The 67-item survey was organized into the following seven thematic sections: general daily life; health status; socialization/recreation; relationships with others; neighborhood characteristics; programs and services for older adults; and sociodemographic characteristics.

We conducted bivariate analysis to identify potential risk factors associated with SI/L. Variables with a p-value of ≤0.20 (51) in the simple logistic regression models were included in multiple logistic models using stepwise-backward selection procedures. Through this process, variables were systematically eliminated based on their p-values until those remaining in the model had a significance level of 10% (52, 53). Variance inflation factors (VIF) were computed for each multiple logistic regression model to assess multicollinearity, and no evidence of multicollinearity between risk factors was found (all VIFs <1.20). The analysis used SAS (SAS 9.4, SAS Institute, Inc., Cary, NC).

The descriptive statistics are presented in Table 1. The needs assessment included 82 participants. Roughly 18% of the participants were ages 80 years and older. The majority were non-Hispanic white (95.1%), and nearly three-fourths (70.7%) were female. A little more than two-thirds (69.5%) reported incomes of $24,000 or less or had less than a high school degree or graduated from high school. Most participants lived in the county for 5 years or longer (75.6%), were unmarried (e.g., single, widowed, divorced) (92.6%), and lived alone (91.5%). One-in-three (37.8%) were frail.

As for neighborhood conditions, most participants rated the community livability as high (81.7%); whereas one-quarter reported resource-related barriers to aging-in-place (28.0%) and over half reported low levels of knowledge about community services (54.9%). Regarding interpersonal relationships and activities, almost half reported boredom (46.3%) and four-in-ten wanted to participate in more activities (40.2%). Although more than half of participants wanted more friends (56.1%), only one-quarter of participants were interested in opportunities for intergenerational engagement (28.0%).

Four-in-ten participants were socially isolated (41.5%) and over one-third of participants were lonely (36.6%).

Table 2 presents a summary of the outcomes from both simple and multiple logistic regression analyses conducted to identify predictors of social isolation and loneliness.

The approach merits several strengths in the rural context. First, the community needs assessment builds on existing efforts in the community to address the unmet needs of rural older adults. By proactively engaging local community leaders, many of whom are 65 years or older, in the process, our approach champions grassroots engagement and ownership of the initiative (10). Second, our approach leverages local capacity, resources, and readiness for change. Rural nonprofits often face financial, geographic, and staffing challenges that limit their reach and impact on rural older adults (10, 32). A network approach mobilizes multi-sectoral stakeholders and creates the necessary infrastructure to implement change initiatives to address the health and social needs of rural older adults (10). Last, our approach provides community leaders with access to local data to drive policies and the development of initiatives to better support rural older adults (10, 11). In national and statewide assessments, data on rural populations are often suppressed due to low response rates and small sample sizes. Grassroots initiatives have the advantage of having access to hard-to-reach populations, such as rural older adults, to aid networks and coalitions in making informed decisions for their communities.

A multifaceted approach is needed to address SI/L in this rural community (3). Findings from the needs assessment underscore the importance of addressing the built environment features to enhance access to healthcare services, transportation, broadband, information, and social engagement and volunteer opportunities (3, 56). Additionally, volunteer-led and home-based initiatives that enhance social contact via non-digital means are promising, low-cost approaches that this community can employ to reduce SI/L among rural older adults who have mobility issues, limited income, or lack access to transportation (57, 58).

The findings also highlight the significance of considering the length of residence in this community as a critical factor in understanding social isolation among older adults. Specifically, it reveals that newcomers to the area (i.e., those who have lived in the community for less than 5 years) are at a higher risk of experiencing social isolation. Similar findings have been reported elsewhere (59). This finding underscores the need for the development and implementation of initiatives, such as orientation programs aimed at healthcare staff and community organizations to facilitate a deeper understanding of “what matters” to older adults across various domains, including social, psychosocial, and spiritual determinants of their health and well-being. Orientation programs (60) can equip individuals with the necessary knowledge and tools to engage with older adults in a holistic manner, considering their individual preferences, values, and priorities. Such programs can also assist older adults with navigating the available resources and services in the community. Identifying community engagement opportunities and connecting older adults with those resources can help create a supportive environment that promotes social interactions, community engagement, emotional well-being, and a sense of purpose (3, 31). By incorporating the principles of such person-centered care, these programs may have potential to help professionals develop a comprehensive understanding of each older adult’s unique social support system and psychosocial needs (31).

By investing to build an ecosystem of support, rural communities can address the evolving health and social needs of older residents (60). The American Association of Retired Persons (AARP) Network of Age-Friendly Communities can guide local efforts. The age-friendly community movement builds on the World Health Organization’s eight domains of livability framework which was developed to guide communities in becoming more age-friendly, livable, and connected (61, 62). Despite having a growing proportion of older adults in Central Appalachia (22), age-friendly initiatives have been slow to emerge in the region (63).

Since implementing the needs assessment described in this article, efforts are now underway to work with the AARP State Office to obtain the designation as an Age-Friendly county. Network members will build upon the findings from the needs assessment and conduct listening sessions with the community. The goal is to explore key issues on a deeper level, assess community readiness for change, and identify leverage points and opportunities for improvement. By using a data-driven approach and guidance from evidence-based strategies, network members can tailor efforts to the needs of their community members. Other rural communities can learn practical lessons from this needs assessment to expand local efforts to promote healthy aging.