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THIS PAPER IS IN THE FOLLOWING E-COLLECTION/THEME ISSUE:

Formative Evaluation of Digital Health Interventions (1801) Behavior Change
(600) Web-based and Mobile Health Interventions (2577) e-Mental Health and
Cyberpsychology (1170) Use and User Demographics of mHealth (286) Loneliness and
Social Isolation (69) Occupational Health and Ergonomics/Prevention at the
Workplace (189)

Published on 6.11.2023 in Vol 7 (2023)

Preprints (earlier versions) of this paper are available at
https://preprints.jmir.org/preprint/48864, first published May 09, 2023.


DIGITALLY ENABLED PEER SUPPORT INTERVENTION TO ADDRESS LONELINESS AND MENTAL
HEALTH: PROSPECTIVE COHORT ANALYSIS


DIGITALLY ENABLED PEER SUPPORT INTERVENTION TO ADDRESS LONELINESS AND MENTAL
HEALTH: PROSPECTIVE COHORT ANALYSIS

Authors of this article:

Dena M Bravata 1, 2 ;   Joseph Kim 2, 3 ;   Daniel W Russell 2, 3 ;   Ron
Goldman 2, 4 ;   Elizabeth Pace 5
Article Authors Cited by Tweetations (2) Metrics
 * Abstract
 * Introduction
 * Methods
 * Results
 * Discussion
 * References
 * Abbreviations
 * Copyright

ORIGINAL PAPER



 * Dena M Bravata1,2, MD, MS ; 
 * Joseph Kim2,3, PhD ; 
 * Daniel W Russell2,3, PhD ; 
 * Ron Goldman2,4, BBA ; 
 * Elizabeth Pace5, MSM, RN 

1Center for Primary Care and Outcomes Research, Stanford University, San
Francisco, CA, United States

2Wisdo Health, Inc, New York, NY, United States

3Department of Human Development & Family Studies, Iowa State University, Ames,
IA, United States

4Department of Technology Management and Innovation, Tandon School of
Engineering, New York University, New York City, NY, United States

5Peer Assistance Services, Inc, Denver, CO, United States


CORRESPONDING AUTHOR:

Joseph Kim, PhD



Department of Human Development & Family Studies

Iowa State University

86 Lebaron Hall

Ames, IA, 50011

United States

Phone: 1 515 294 6316

Email: jkim7@iastate.edu



ABSTRACT

Background: Social isolation and loneliness affect 61% of US adults and are
associated with significant increases in excessive mental and physical morbidity
and mortality. Annual health care spending is US $1643 higher for socially
isolated individuals than for those not socially isolated.


Objective: We prospectively evaluated the effects of participation with a
digitally enabled peer support intervention on loneliness, depression, anxiety,
and health-related quality of life among adults with loneliness.


Methods: Adults aged 18 years and older living in Colorado were recruited to
participate in a peer support program via social media campaigns. The
intervention included peer support, group coaching, the ability to become a peer
helper, and referral to other behavioral health resources. Participants were
asked to complete surveys at baseline, 30, 60, and 90 days, which included
questions from the validated University of California, Los Angeles Loneliness
Scale, Patient Health Questionnaire 2-Item Scale, General Anxiety Disorder
7-Item Scale, and a 2-item measure assessing unhealthy days due to physical
condition and mental condition. A growth curve modeling procedure using
multilevel regression analyses was conducted to test for linear changes in the
outcome variables from baseline to the end of the intervention.


Results: In total, 815 ethnically and socially diverse participants completed
registration (mean age 38, SD 12.7; range 18-70 years; female: n=310, 38%;
White: n=438, 53.7%; Hispanic: n=133, 16.3%; Black: n=51, 6.3%; n=263, 56.1% had
a high social vulnerability score). Participants most commonly joined the
following peer communities: loneliness (n=220, 27%), building self-esteem
(n=187, 23%), coping with depression (n=179, 22%), and anxiety (n=114, 14%).
Program engagement was high, with 90% (n=733) engaged with the platform at 60
days and 86% (n=701) at 90 days. There was a statistically (P<.001 for all
outcomes) and clinically significant improvement in all clinical outcomes of
interest: a 14.6% (mean 6.47) decrease in loneliness at 90 days; a 50.1% (mean
1.89) decline in depression symptoms at 90 days; a 29% (mean 1.42) reduction in
anxiety symptoms at 90 days; and a 13% (mean 21.35) improvement in
health-related quality of life at 90 days. Based on changes in health-related
quality of life, we estimated a reduction in annual medical costs of US $615 per
participant. The program was successful in referring participants to behavioral
health educational resources, with 27% (n=217) of participants accessing a
resource about how to best support those experiencing psychological distress and
15% (n=45) of women accessing a program about the risks of excessive alcohol
use.


Conclusions: Our results suggest that a digitally enabled peer support program
can be effective in addressing loneliness, depression, anxiety, and
health-related quality of life among a diverse population of adults with
loneliness. Moreover, it holds promise as a tool for identifying and referring
members to relevant behavioral health resources.


JMIR Form Res 2023;7:e48864

doi:10.2196/48864




KEYWORDS

peer-support (4); social isolation (55); loneliness (65); companionship
(3); depression (868); anxiety (565); quality of life (284); occupational health
(53) 


WE RECOMMEND

 1. Web-Based Presence for Social Connectedness in Long-Term Care: Protocol for
    a Qualitative Multimethods Study
    Anna Garnett et al., JMIR Res Protoc, 2023
 2. The Impact of a Digital Intervention (Happify) on Loneliness During
    COVID-19: Qualitative Focus Group
    Eliane M Boucher et al., JMIR Mental Health, 2021
 3. Improving Mild to Moderate Depression With an App-Based Self-Guided
    Intervention: Protocol for a Randomized Controlled Trial
    Ina Beintner et al., JMIR Res Protoc, 2023
 4. Engagement, Satisfaction, and Mental Health Outcomes Across Different
    Residential Subgroup Users of a Digital Mental Health Relational Agent:
    Exploratory Single-Arm Study
    Valerie L Forman-Hoffman et al., JMIR Formative Research, 2023
 5. e–Mental Health Program to Prevent Psychological Distress Among
    French-Speaking International Students in a Linguistic-Cultural Minority
    Context (Ottawa, Alberta, and Quebec): Protocol for the Implementation and
    Evaluation of Psy-Web
    Idrissa Beogo et al., JMIR Res Protoc, 2023

 1. THE COMBINED EFFECTS OF SOCIAL ISOLATION AND LONELINESS ON PSYCHOLOGICAL
    WELL-BEING DURING THE COVID-19 PANDEMIC
    Ke Li et al., Innov Aging, 2022
 2. HARNESSING THE POWER OF NETWORKS TO ADDRESS SOCIAL ISOLATION, LONELINESS,
    DEPRESSION, AND ELDER ABUSE
    Tobi A Abramson et al., Innov Aging, 2019
 3. Longitudinal Associations Between Loneliness and Cognitive Ability in the
    Lothian Birth Cohort 1936
    Judith A Okely et al., The Journals of Gerontology: Series B, 2018
 4. The Impact of Sheltering in Place During the COVID-19 Pandemic on Older
    Adults’ Social and Mental Well-Being
    Anne C Krendl et al., The Journals of Gerontology: Series B, 2020
 5. The impact of the COVID-19 pandemic on the wellbeing of Irish Men’s Shed
    members
    Aisling McGrath et al., Health Promotion International, 2020

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INTRODUCTION

In the landmark 2023 Advisory on loneliness, isolation, and social connection,
the US Surgeon General warned about the public health crisis that loneliness,
isolation, and disconnection pose to the American public [Our epidemic of
loneliness and isolation. The U.S. Surgeon General's Advisory on the health
effects of social connection and community. Office of the Surgeon General. 2023.
URL:
https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf
[accessed 2023-05-03] 1]. Prior to the COVID-19 pandemic, 61% of all US adults
reported feeling lonely [Buecker S, Mund M, Chwastek S, Sostmann M, Luhmann M.
Is loneliness in emerging adults increasing over time? A preregistered
cross-temporal meta-analysis and systematic review. Psychol Bull 2021
Aug;147(8):787-805 [CrossRef] [Medline]2,Bowers A, Wu J, Lustig S, Nemecek D.
Loneliness influences avoidable absenteeism and turnover intention reported by
adult workers in the United States. J Organ Eff 2022;9(2):312-335
[https://www.emerald.com/insight/content/doi/10.1108/JOEPP-03-2021-0076/full/html]
[CrossRef]3] and nearly 72% of Medicaid beneficiaries reported being lonely
[Demarinis S. Loneliness at epidemic levels in America. Explore (NY)
2020;16(5):278-279 [https://europepmc.org/abstract/MED/32674944] [CrossRef]
[Medline]4]. From the years 1976 to 2019, the rate of loneliness has increased
yearly [Our epidemic of loneliness and isolation. The U.S. Surgeon General's
Advisory on the health effects of social connection and community. Office of the
Surgeon General. 2023. URL:
https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf
[accessed 2023-05-03] 1,Loneliness and the workplace: 2020 U.S. report. The
Cigna Group. 2020. URL: https:/ /www. cigna.com/ static/ www-cigna-com/ docs/
about-us/ newsroom/ studies-and-reports/ combatting-loneliness/
cigna-2020-loneliness-report. pdf [accessed 2023-01-15] 5]. During the pandemic,
people of all ages, in all countries, experienced unprecedented social isolation
[Martínez-Garcia M, Sansano-Sansano E, Castillo-Hornero A, Femenia R, Roomp K,
Oliver N. Social isolation during the COVID-19 pandemic in Spain: a population
study. Sci Rep 2022;12(1):12543 [https://doi.org/10.1038/s41598-022-16628-y]
[CrossRef] [Medline]6-Banerjee D, Rai M. Social isolation in Covid-19: the
impact of loneliness. Int J Soc Psychiatry 2020;66(6):525-527
[https://journals.sagepub.com/doi/abs/10.1177/0020764020922269?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub
0pubmed] [CrossRef] [Medline]8]. Social isolation is the objective lack of
interaction with others (as happens when people live alone) [Ong AD, Uchino BN,
Wethington E. Loneliness and health in older adults: a mini-review and
synthesis. Gerontology 2016;62(4):443-449 [https://doi.org/10.1159/000441651]
[CrossRef] [Medline]9]. Loneliness is a similar yet distinct concept, referring
to the subjective, unwelcome feeling of being alone or the gap between one’s
expectations of the quantity and quality of social relationships and what is
actually experienced [Perlman D, Peplau LA. Toward a social psychology of
loneliness. In: Duak S, Gilmour R, editors. Personal Relationships: Personal
Relationships in Disorder. London: Academic Press; 1981:31-5610]. Loneliness and
social isolation are associated with significantly decreased capacity for
self-care [Kasikci E, Dayapoglu N. Examination of the level of disability,
loneliness and self care ability of patients with multiple sclerosis. Int J
Caring Sci 2020;13(3):1668-1677
[http://internationaljournalofcaringsciences.org/docs/16_dayapoglu_original_13_3_2.pdf]11,Tomstad
S, Dale B, Sundsli K, Saevareid HI, Söderhamn U. Who often feels lonely? A
cross-sectional study about loneliness and its related factors among older
home-dwelling people. Int J Older People Nurs 2017;12(4):e12162 [CrossRef]
[Medline]12]; lower quality of life [Barnes TL, MacLeod S, Tkatch R, Ahuja M,
Albright L, Schaeffer JA, et al. Cumulative effect of loneliness and social
isolation on health outcomes among older adults. Aging Ment Health
2022;26(7):1327-1334
[https://www.tandfonline.com/doi/full/10.1080/13607863.2021.1940096] [CrossRef]
[Medline]13,Anderson OG, Thayer CE. Loneliness and social connections: a
national survey of adults 45 and older. AARP Research. 2018. URL:
https://www.aarp.org/research/topics/life/info-2018/loneliness-social-connections.html
[accessed 2023-10-03] 14]; and increases in physical and mental health morbidity
and mortality including depression, anxiety, cognitive impairment, coronary
heart disease, and stroke [Christiansen J, Qualter P, Friis K, Pedersen SS, Lund
R, Andersen CM, et al. Associations of loneliness and social isolation with
physical and mental health among adolescents and young adults. Perspect Public
Health 2021;141(4):226-236 [CrossRef] [Medline]15-Smith BJ, Lim MH. How the
COVID-19 pandemic is focusing attention on loneliness and social isolation.
Public Health Res Pract 2020;30(2):3022008
[https://doi.org/10.17061/phrp3022008] [CrossRef] [Medline]27]. Moreover,
loneliness is associated with increased health care use including a 15% increase
in outpatient physician and emergency room visits and a 36% increase in
inpatient admissions compared to nonlonely populations [Barnes TL, MacLeod S,
Tkatch R, Ahuja M, Albright L, Schaeffer JA, et al. Cumulative effect of
loneliness and social isolation on health outcomes among older adults. Aging
Ment Health 2022;26(7):1327-1334
[https://www.tandfonline.com/doi/full/10.1080/13607863.2021.1940096] [CrossRef]
[Medline]13,Gerst-Emerson K, Jayawardhana J. Loneliness as a public health
issue: the impact of loneliness on health care utilization among older adults.
Am J Public Health 2015;105(5):1013-1019 [CrossRef] [Medline]28].

The impact of social isolation and loneliness on health care spending is
enormous, with Medicare spending US $6.7 billion annually due to social
isolation [Anderson OG, Thayer CE. Loneliness and social connections: a national
survey of adults 45 and older. AARP Research. 2018. URL:
https://www.aarp.org/research/topics/life/info-2018/loneliness-social-connections.html
[accessed 2023-10-03] 14]. On average, health care spending is US $1643 higher
annually for socially isolated individuals compared to those who are not
socially isolated [Shaw JG, Farid M, Noel-Miller C, Joseph N, Houser A, Asch SM,
et al. Social isolation and medicare spending: among older adults, objective
social isolation increases expenditures while loneliness does not. J Aging
Health 2017;29(7):1119-1143 [https://europepmc.org/abstract/MED/29545676]
[CrossRef] [Medline]29]. Employers bear a significant burden of excessive costs
associated with social isolation and loneliness, given that loneliness typically
increases in midlife and affects working adults [Pinquart M, Sorensen S.
Influences on loneliness in older adults: a meta-analysis. Basic Appl Soc Psych
2010;23(4):245-266 [CrossRef]30-Victor CR, Yang K. The prevalence of loneliness
among adults: a case study of the United Kingdom. J Psychol 2012;146(1-2):85-104
[CrossRef] [Medline]32]. Employees who report feelings of loneliness are twice
as likely to miss work due to illness, be less productive, and quit their jobs
as those who are not lonely [Barnes TL, MacLeod S, Tkatch R, Ahuja M, Albright
L, Schaeffer JA, et al. Cumulative effect of loneliness and social isolation on
health outcomes among older adults. Aging Ment Health 2022;26(7):1327-1334
[https://www.tandfonline.com/doi/full/10.1080/13607863.2021.1940096] [CrossRef]
[Medline]13]. Lonely workers report, on average, 5.7 more days of absenteeism
per year compared to nonlonely employees [Bowers A, Wu J, Lustig S, Nemecek D.
Loneliness influences avoidable absenteeism and turnover intention reported by
adult workers in the United States. J Organ Eff 2022;9(2):312-335
[https://www.emerald.com/insight/content/doi/10.1108/JOEPP-03-2021-0076/full/html]
[CrossRef]3]. The total annual costs of avoidable absenteeism have been
calculated as US $154 billion, with an average annual cost per lonely employee
of US $1590 [Bowers A, Wu J, Lustig S, Nemecek D. Loneliness influences
avoidable absenteeism and turnover intention reported by adult workers in the
United States. J Organ Eff 2022;9(2):312-335
[https://www.emerald.com/insight/content/doi/10.1108/JOEPP-03-2021-0076/full/html]
[CrossRef]3].

Several interventions have been evaluated for their effectiveness in reducing
loneliness and its associated psychological distress [Losada-Baltar A,
Martínez-Huertas JÁ, Jiménez-Gonzalo L, Del Sequeros Pedroso-Chaparro M,
Gallego-Alberto L, Fernandes-Pires J, et al. Longitudinal correlates of
loneliness and psychological distress during the lockdown situation due to
COVID-19. Effects of age and self-perceptions of aging. J Gerontol B Psychol Sci
Soc Sci 2022;77(4):652-660 [https://europepmc.org/abstract/MED/33438002]
[CrossRef] [Medline]33]. Effective strategies typically include 4 features such
as providing emotional support (resulting in the feeling “I am seen and heard”),
supporting a sense of worth (resulting in the feeling “I am valued”), supporting
a sense of belonging (resulting in the feeling “I belong”), and developing
reliable alliance (resulting in the feeling “I can rely on others and that
others can rely on me”) [Cutrona CE, Russell DW. The provisions of social
relationships and adaptation to stress. Adv Pers Relationships 1987;1(1):37-67
[https://www.researchgate.net/profile/Daniel-Russell-3/publication/271507385_The_Provisions_of_Social_Relationships_and_Adaptation_to_Stress/links/54c960b40cf2807dcc265ce2/The-Provisions-of-Social-Relationships-and-Adaptation-to-Stress.pdf]34].
A recent meta-analysis found that a reminiscence intervention was effective;
however, there was only 1 study supporting this finding [Hickin N, Käll A,
Shafran R, Sutcliffe S, Manzotti G, Langan D. The effectiveness of psychological
interventions for loneliness: a systematic review and meta-analysis. Clin
Psychol Rev 2021;88:102066 [CrossRef] [Medline]35]. Disappointingly, cognitive
behavioral therapies, which are available to many commercially insured and other
covered populations, were found to have the smallest effect size in alleviating
loneliness [Hickin N, Käll A, Shafran R, Sutcliffe S, Manzotti G, Langan D. The
effectiveness of psychological interventions for loneliness: a systematic review
and meta-analysis. Clin Psychol Rev 2021;88:102066 [CrossRef] [Medline]35]. Some
evidence points to peer support as an effective, scalable, and economical
solution for addressing various mental health issues but it has not been widely
studied for loneliness [Gillard S. Peer support in mental health services: where
is the research taking us, and do we want to go there? J Ment Health
2019;28(4):341-344
[https://www.tandfonline.com/doi/full/10.1080/09638237.2019.1608935] [CrossRef]
[Medline]36-Repper J, Carter T. A review of the literature on peer support in
mental health services. J Ment Health 2011;20(4):392-411 [CrossRef]
[Medline]39].

Peer support is defined as the interpersonal connection based on shared life
experiences characterized by empathy and validation [Gillard S. Peer support in
mental health services: where is the research taking us, and do we want to go
there? J Ment Health 2019;28(4):341-344
[https://www.tandfonline.com/doi/full/10.1080/09638237.2019.1608935] [CrossRef]
[Medline]36]. Peer support has been associated with increased engagement in
self-care; improved quality of life; and reduced substance use, depression
symptoms, and hospital admission rates for some mental health disorders
[Davidson L, Bellamy C, Guy K, Miller R. Peer support among persons with severe
mental illnesses: a review of evidence and experience. World Psychiatry
2012;11(2):123-128 [https://europepmc.org/abstract/MED/22654945] [CrossRef]
[Medline]40,Bologna MJ, Pulice RT. Evaluation of a peer-run hospital diversion
program: a descriptive study. Am J Psychiatr Rehabil 2011;14(4):272-286
[CrossRef]41]. In addition, a meta-analysis examining the effectiveness of
digital peer support found that the use of technology to facilitate the delivery
of peer support is feasible and effective [Naslund JA, Aschbrenner KA, Marsch
LA, Bartels SJ. The future of mental health care: peer-to-peer support and
social media. Epidemiol Psychiatr Sci 2016;25(2):113-122
[https://europepmc.org/abstract/MED/26744309] [CrossRef] [Medline]38,Fortuna KL,
Naslund JA, LaCroix JM, Bianco CL, Brooks JM, Zisman-Ilani Y, et al. Digital
peer support mental health interventions for people with a lived experience of a
serious mental illness: systematic review. JMIR Ment Health 2020;7(4):e16460
[https://mental.jmir.org/2020/4/e16460/] [CrossRef] [Medline]42]. Thus, the
objective of this study was to evaluate the effects of participation using a
digital peer support intervention on loneliness, depression, anxiety, and
quality of life among adults who are lonely.



METHODS

RECRUITMENT

Adult participants aged 18 years and older living in Colorado were recruited via
social media campaigns on Facebook and TikTok between January and April 2022 to
participate in a peer support program developed by Wisdo Health. The ads
included text, images, and videos describing the Wisdo peer support app
[AI-driven peer support community. Wisdo Health. URL:
https://www.wisdo.com/index.html [accessed 2023-01-15] 43] as a safe digital
community where participants who feel alone can connect with others going
through similar life experiences. Participants were offered 1 year of free
access to the digital peer support platform but were not otherwise compensated
for their participation.

MEASURES

OVERVIEW

Participants were asked to complete 4 surveys such as when joining the program
(baseline) and then after 30, 60, and 90 days of peer support. All surveys were
administered within the app. Each survey was available for participants to
complete during a 10-day window. We collected demographics at baseline and used
the member’s zip codes to calculate their social vulnerability index according
to the Centers for Disease Control and Prevention [CDC/ATSDR social
vulnerability index. Agency for Toxic Substances and Disease Registry. URL:
https://www.atsdr.cdc.gov/placeandhealth/svi/index.html [accessed 2023-02-28]
44], which accounts for 16 social factors including poverty, lack of vehicle
access, and crowded housing. The following measures were included in the
surveys.

UNIVERSITY OF CALIFORNIA, LOS ANGELES (UCLA-3) LONELINESS SCALE

This validated measure of loneliness [Hughes ME, Waite LJ, Hawkley LC, Cacioppo
JT. A short scale for measuring loneliness in large surveys: results from two
population-based studies. Res Aging 2004;26(6):655-672
[https://europepmc.org/abstract/MED/18504506] [CrossRef] [Medline]45] includes
the following questions: How often do you feel that you lack companionship? How
often do you feel left out? How often do you feel isolated from others? For each
question, participants were asked to choose among 1=hardly ever, 2=some of the
time, and 3=often. A total score of 4 or greater is considered positive for
loneliness, and a score of 7 to 9 is considered severely lonely.

PATIENT HEALTH QUESTIONNAIRE 2-ITEM SCALE

The Patient Health Questionnaire 2-Item Scale (PHQ-2) is a validated measure
[Kroenke K, Spitzer RL, Williams JBW. The Patient Health Questionnaire-2:
validity of a two-item depression screener. Med Care 2003;41(11):1284-1292
[CrossRef] [Medline]46] that asks about the frequency of depressed mood and
anhedonia over the past 2 weeks. Items are scored from 0 (not at all) to 3
(nearly every day). A total score of 3 or greater indicates that a major
depressive disorder is likely.

GENERAL ANXIETY DISORDER 7-ITEM SCALE

A single item from the validated General Anxiety Disorder 7-Item Scale (GAD-7)
[Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing
generalized anxiety disorder: the GAD-7. Arch Intern Med 2006;166(10):1092-1097
[https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/410326]
[CrossRef] [Medline]47] was used: “Over the past 2 weeks, how often have you
been bothered with feeling nervous, anxious, or on edge?” This item was scored
from 0 (not at all) to 3 (nearly every day).

UNHEALTHY DAYS

This validated measure captures information on the physical and mental health
status of individuals and on the impact of health status on quality of life
[Kaplan RM, Hays RD. Health-related quality of life measurement in public
health. Annu Rev Public Health 2022;43:355-373
[https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-052120-012811?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub
0pubmed] [CrossRef] [Medline]48]. It includes 2 questions: “Thinking about your
physical health, which includes physical illness and injury, for how many days
during the past 30 days was your physical health not good?” and “Thinking about
your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not
good?” The 2-item measure assessing physically and mentally unhealthy days is
highly correlated with traditional measures of health, including morbidity,
mortality, and health care costs. Each additional unhealthy day is associated
with an incremental cost increase of US $15.64 per member per month [Cordier T,
Slabaugh SL, Havens E, Pena J, Haugh G, Gopal V, et al. A health plan's
investigation of Healthy Days and chronic conditions. Am J Manag Care
2017;23(10):e323-e330 [https://www.ajmc.com/pubMed.php?pii=87312] [Medline]49].

PROGRAM SATISFACTION

Participants were asked whether they would recommend the program to others,
whether they believe that the program should be made available to everyone in
Colorado, and to provide subjective comments.

INTERVENTION

OVERVIEW

The Wisdo intervention is a peer support and social health platform designed to
enable the 4 pillars of social health such as emotional support, reassurance of
worth, a sense of belonging, and reliable alliance (Figure 1) [Cutrona CE,
Russell DW. The provisions of social relationships and adaptation to stress. Adv
Pers Relationships 1987;1(1):37-67
[https://www.researchgate.net/profile/Daniel-Russell-3/publication/271507385_The_Provisions_of_Social_Relationships_and_Adaptation_to_Stress/links/54c960b40cf2807dcc265ce2/The-Provisions-of-Social-Relationships-and-Adaptation-to-Stress.pdf]34,Kemperman
A, van den Berg P, Weijs-Perrée M, Uijtdewillegen K. Loneliness of older adults:
social network and the living environment. Int J Environ Res Public Health
2019;16(3):406 [https://www.mdpi.com/resolver?pii=ijerph16030406] [CrossRef]
[Medline]50-Cutrona CE, Russell DW. Social provisions scale. J Abnorm Psychol
1987;1:37-67 [CrossRef]53]. The platform is available as a native app on iOS and
Android devices and as a web app on personal computers and is HIPAA (Health
Insurance Portability and Accountability Act) and System and Organization
Controls (SOC) 2 + HITRUST (Health Information Trust) compliant. Members can be
anonymous on the platform as they are not asked to use their real names. Since
its launch in 2018, over 500,000 adults aged 17 to 80 years have participated in
the platform’s peer support communities. There are 5 key aspects to the peer
support intervention such as self-mapping, connecting with peers, group
coaching, referrals to other behavioral health resources, and the ability to
become a peer helper.

‎Figure 1. The 4 pillars of social health: The 4 pillars of social health are
derived from the Social Provisions Scale [Cutrona CE, Russell DW. Social
provisions scale. J Abnorm Psychol 1987;1:37-67 [CrossRef]53].

SELF-MAPPING

New members are onboarded to the platform with a self-mapping exercise that is
critical for assigning the participant to a curated social support community
comprised of helpful peers with shared lived experiences. The self-mapping
element includes 4 steps (Figures 2A-2E). First, members select the community
they want to join based on a topic they are concerned about and that makes them
feel most lonely. Members choose from over 50 communities covering areas such as
behavioral health (eg, anxiety, depression, loneliness, and alcohol use),
physical health (eg, diabetes, heart failure, and cancer), family (eg, caregiver
and parenthood), workplace (eg, burnout, stress, and working remotely), and
self-growth (eg, positive thinking and starting to exercise; Figure 2A). On
average, members join 6 communities during their first year on Wisdo.

‎Figure 2. Program application: new members are on-boarded to the platform with
a self-mapping exercise, which includes 4 steps. The first step (A) is to select
the first community they want to join based on a topic they are concerned about
and that makes them feel most lonely. In the second step (B), members are asked
to identify as either “been there” or “there now” on a series of 25 to 35 key
challenges, obstacles to health, gaps in care, and milestones that are
frequently experienced by individuals in their selected community. In the third
step (C), members choose up to 3 personal goals from a list of 10. In the fourth
step, members answer brief, validated measures (D). The members are connected to
specific peers based on shared lived experience and how helpful those peers have
been to similar members (E).

Second, members are asked to identify as either “been there” or “there now” on a
series of 25 to 35 key challenges, obstacles to health, gaps in care, and
milestones that are frequently experienced by individuals in their selected
community (Figure 2B). On average, members click on 20 such milestones per
community they join, providing in-depth insights into their experiences to date.
As members click through each step, they can see how many people on the platform
have clicked the same step, further promoting 2 important pillars of social
health such as a sense of belonging and emotional support.

Third, members choose up to 3 personal goals from a list of 10 (eg, making new
friends, better managing stressful events, and improving sleep) relevant to
their community (Figure 2C). As members click on a goal, they can see how many
other members on the platform have already accomplished it. Members can track
their progress toward achieving each goal.

Finally, members answer brief validated measures (Figure 2D). These responses
establish a baseline for members’ social and mental health and enable them to
track changes over time.

As members continue to join additional communities, establish goals, and answer
follow-up surveys, the self-mapping information shared by members during
onboarding is used by the platform’s artificial intelligence engine to create
curated connections with helpful peers, identify members to join group coaching
sessions to develop social health skills, and connect members with covered
clinical programs and services to support social barriers to care.

CONNECTING WITH PEERS

The peer support platform continuously suggests connections with helpful peers
based on the number of shared steps (ie, “been there” and “there now”) and how
helpful these peers have been to similar participants. Once connected,
participants can chat on the app one-on-one and in group settings and receive
emotional, nonjudgmental support and encouragement (Figure 2E). They can also
share “empathy-charged” reactions to posts by other members that build up
emotional support and a sense of worth, such as “Helpful,” “Love,” and “Been
There.” The community is moderated by trained staff augmented by its artificial
intelligence engine, which monitors over 600 keywords and phrases that could
indicate a potential risk. Members who fail to follow the program’s code of
conduct are warned and may be banned from the platform.

GROUP COACHING

Members can join weekly group video coaching sessions conducted by certified
life coaches via video. For anonymity, participants can choose not to turn on
their video cameras. Each group coaching topic allows members to connect around
a shared goal and skill (eg, building emotional resilience, developing a sense
of purpose, and developing a sense of self-worth) or interest (eg, travel,
books, and exercise). Together, this support from peers and groups provides the
key elements of a loneliness intervention, namely emotional support, reassurance
of worth, a sense of belonging, and reliable alliance.

REFERRAL TO OTHER BEHAVIORAL HEALTH AND SOCIAL DETERMINANTS OF HEALTH BENEFITS
PROGRAMS

The program matches participants to covered benefits and community services
offered by their employer, health plan, government agencies, or local
nonprofits. Once a participant is flagged as a candidate for a covered benefit,
the program deploys a combination of several tactics, including in-app messages,
push notifications, and an invitation to relevant coaching sessions to inform
and motivate the member to engage with the relevant covered benefit.

ABILITY TO BECOME A PEER HELPER

Highly rated members who are frequently considered helpful by other community
members are invited to enroll in a web-based training program to earn a Helper
badge. The program includes 5 modules covering topics such as providing
emotional support, motivational interviewing skills, and caring for oneself.
Each module is followed by a quiz. Users who successfully complete the training
are awarded the Helper badge and provided with an explanation of how their
performance will be continuously monitored and assessed to ensure safety and
quality on the platform. On average, 10%-20% of members joining the peer support
platform successfully complete the training and earn the Helper badge. This
format promotes 2 important pillars of social health such as reliable alliance
and reassurance of worth.

STATISTICAL ANALYSIS

We computed means at baseline for each of the outcomes of interest. Since not
all participants completed follow-up surveys at each of the measurement periods,
we compared the baseline scores on the outcome measures for individuals who did
and did not complete the subsequent surveys. The results indicated that none of
the differences in the outcome measures from the baseline survey differed
significantly between individuals who did or did not complete the subsequent
surveys.

To conduct the analyses of change and include all cases in the analyses, we
tested for change over time on the outcome variables using a growth curve
modeling procedure via multilevel regression analyses. We tested for linear
changes in the outcome variables and included a predictor variable that
reflected whether the individual had complete data over time across the 3
surveys. The inclusion of this last predictor variable allowed us to test
whether the pattern of change on the outcome variable varied for participants
with complete data across the 3 surveys versus participants with only partial
data.

ETHICAL CONSIDERATIONS

Given that all data used in this analysis were routinely collected as part of
standard program participation and were deidentified, this protocol was
considered exempt from human subjects’ consent (WCG IRB protocol Wisdo.001;
January 26, 2023).



RESULTS

PARTICIPANT CHARACTERISTICS

Overall, 4500 people clicked on a recruitment ad, 1141 installed the app on
their smartphones, and 815 completed the registration process and joined the
study. The average age of participants was 38 (SD 12.7; range: 18-70) years, 310
(38%) identified as female, 438 (53.7%) identified as White, 133 (16.3%) as
identified Hispanic, 51 (6.3%) as identified Black, and 263 (56.1%) were
categorized as having a high social vulnerability score (Table 1).

Table 1. Demographic characteristics of sample participants.a

CharacteristicsValuesAge (years) (N=815), n (%)
18-25122 (15)
26-34212 (26)
35-44236 (29)
45-54139 (17)
55-6482 (10.1)
65 and older24 (2.9)Gender (N=815), n (%)
Female310 (38)
Male473 (58)
Nonbinary16 (2)
Other16 (2)Race (N=815), n (%)
Asian19 (2.3)
American Indian21 (2.6)
Black51 (6.3)
Hispanic133 (16.3)
White438 (53.7)
Other153 (18.8)Social Vulnerability Index (N=469), n (%)
High263 (56.1)
Medium2 (0.4)
Medium-low41 (8.7)
Low163 (34.9)

aThe table displays the demographic characteristics of the sample participants.
The participants represent diverse groups with the majority having a high score
on the social vulnerability index.

ENGAGEMENT WITH PEER SUPPORT

On average, participants joined 6 communities during the pilot period. The most
commonly selected communities were loneliness (n=220, 27%), building self-esteem
(n=187, 23%), coping with depression (n=179, 22%), anxiety (n=114, 14%),
exercising regularly (n=65, 8%), and coping with alcohol addiction (n=49, 6%;
Table 2).

When joining a community, on average, participants picked 16.3 (SD 4.3) “there
now” indications and 12.0 (SD 3.8) “been there” during their self-mapping
process. Overall, 71% (n=579) of participants reported “there now” steps
associated with behavioral health challenges, 32% (n=261) with sleep problems,
and 13% (n=106) with nutrition challenges. On average, members chose 2.3 (SD
0.46) goals (the maximum allowed was 3). The most common goals were making new
friends (n=228, 28%), improving my relationships with those around me (n=147,
18%), and avoiding negativity (n=130, 16%; Table 3).

On average, participants visited the platform 3 times a month, sent 40 messages,
and established 10 new meaningful connections, defined as connections where both
users interacted in a back-and-forth conversation on the platform. Throughout
the study, engagement in the platform remained high, with 90% (n=733) engaged
with the platform after 60 days and 86% (n=701) engaged with the platform after
90 days. Many members viewed messages from peers (n=701, 86%) and groups (n=652,
80%). Members were also active in sending private or group messages (n=399,
49%). Overall, 68% (n=554) of registered users engaged in conversations with a
peer within their first month on the platform, 43.9% (n=358) during their second
month, and 32% (n=261) during their third month. Members who received the Helper
badge reported a high percentage of engagement in conversation, with 50% (n=61)
of them engaged in conversation during their third month.

Table 2. Commonly selected communities (N=815).a

Community nameParticipants, n (%)Loneliness220 (27)Building self-esteem187
(23)Coping with depression179 (22)Anxiety114 (14)Exercising regularly65
(8)Coping with alcohol addiction49 (6)Coping with substance use24 (3)LGBTQIAb24
(3)Coping with loss16 (2)Coping with drug addiction8 (1)

aThe most commonly selected communities were loneliness and building
self-esteem.

bLGBTQIA: lesbian, gay, bisexual, transgender, queer, intersex, and asexual.

Table 3. Commonly reported goals of participants (N=815).a

GoalParticipants, n (%)Making new friends228 (28)Improve my relationships with
those around me147 (18)Avoiding negativity130 (16)Being more accepting98
(12)Improving my sleep82 (10)Being able to better manage stressful events73
(9)Avoiding comparisons with others65 (8)Have a positive impact on the world65
(8)Learning mindfulness65 (8)Start to exercise and stick with it65 (8)Improve my
diet65 (8)Finding like-minded support49 (6)Reduce alcohol or other drug
consumption49 (6)Helping others41 (5)Practicing forgiveness41 (5)

aThe most commonly cited goals for peer support were making new friends and
improving relations with others.

REFERRALS TO BEHAVIORAL HEALTH RESOURCES

In total, 27% (n=217) percent of participants clicked the link to access an
educational module about how to support peers experiencing alcohol misuse or
psychological distress. Additionally, 15% (n=45) of all female members clicked
the link to access an educational module on the risks of excessive alcohol
consumption for women.

CLINICAL OUTCOMES

OVERVIEW

Of the 815 participants, 595 completed the baseline survey, and 130 completed
one or more of the subsequent surveys.

LONELINESS

The average loneliness score at baseline was 7.41 (SD 1.65), with 98% (n=583)
screening positive for loneliness (UCLA-3 Loneliness Scale score of 4-9) and
68.7% (n=409) screening as severely lonely (UCLA-3 Loneliness Scale score of
7-9). After 90 days, 41.5% (n=54) of individuals who screened as severely lonely
(UCLA-3 Loneliness Scale score of 7-9) when joining the study had lower
loneliness scores and 4.6% (n=6) scored as no longer lonely (UCLA-3 Loneliness
Scale score of 3). Overall, 10.4% (n=13) individuals who screened as lonely when
joining the study (UCLA-3 Loneliness Scale score of 4-9) scored as not lonely
after 90 days (UCLA-3 Loneliness Scale score of 3) and 31.5% (n=41) reported no
change in their loneliness level.

There was a statistically significant decrease over time in levels of loneliness
(b=–0.01; t197=–5.65; P<.001; Figure 3). Overall, loneliness decreased 11.6%
(mean 6.46) within the first 30 days and 14.6% (mean 6.47) between the baseline
and 90-day assessments. The participants who only reported loneliness at
baseline and at 30 days had the greatest improvement in loneliness. The change
over time in loneliness did not differ significantly between participants with
complete data versus individuals with only partial survey data (t196=0.62).

‎Figure 3. Change in Loneliness: UCLA Loneliness scores between 3 and 4 indicate
nonlonely participants. Scores between 4 and 7 indicate lonely individuals.
Scores between 7 and 9 indicate severely lonely individuals. The average score
for participants with complete data (gray line) and incomplete data (orange and
blue lines) indicates that the groups were all severely lonely. The participants
who only reported loneliness at baseline and at 30 days had the greatest
improvement in loneliness (blue line). The change in loneliness over time did
not differ for participants with complete data (gray line) versus incomplete
data (orange and blue lines). UCLA-3: University of California, Los Angeles.

DEPRESSION

The average depression score at baseline was 3.49 (SD 1.91). In total, 61%
(n=363) of participants joined the study with a score of 3 or higher (ie,
screened at risk for depression); of these, 65% (n=236) reported below-risk
levels of depression (<3 on PHQ-2) within 30 to 90 days. Overall, there was a
33.1% (mean 2.12) decline in depression symptoms by 30 days and a 50.1% (mean
1.89) decline in depression symptoms between baseline and day 90 (Figure 4;
b=–0.02; t197=–6.48; P<.001). This decline did not vary as a function of whether
the participant completed all 4 surveys (t196=–0.40).

‎Figure 4. Change in depression: PHQ-2 scores between 0 and 3 indicate a major
depressive disorder is unlikely and PHQ-2 scores between 3 and 6 indicate a
major depressive disorder is likely. The average scores at baseline for
participants with complete data (gray line) and incomplete data (orange and blue
lines) indicate that all groups were likely to have a major depressive disorder.
Upon completion of 1 assessment after 30 days, all groups observed a decline in
PHQ-2 scores and were unlikely to have depression. PHQ-2: Patient Health
Questionnaire 2-Item Scale.

ANXIETY

The average anxiety score at baseline was 1.86 (SD 1.00), with 87.9% (n=523) of
participants reporting feeling nervous, anxious, or on the edge for at least
several days over the past 2 weeks and 30% (n=179) saying they experience these
feelings nearly every day. Participants had a 20.1% (mean 1.35) reduction in
anxiety symptoms by day 30 and a 29% (mean 1.42) reduction in anxiety from the
baseline to day 90 (Figure 5). There was a statistically significant decline in
levels of anxiety over time (b=–0.16; t197=–3.42; P<.001). This pattern of
results did not appear to vary for participants who provided complete data
versus individuals who did not complete all the surveys (t196=–0.18).

‎Figure 5. Change in anxiety: the average GAD-7 single-item score is displayed
on the y-axis and the assessment of anxiety at 30-day intervals is on the
x-axis. The average anxiety score declined over time for individuals with
complete data (gray line) and incomplete data (orange and blue lines); however,
they did not differ significantly. GAD-7: General Anxiety Disorder 7-Item Scale.

HEALTH-RELATED QUALITY OF LIFE

The average number of unhealthy mental health days at baseline was 20.1 (SD 9.9)
days, and the average number of unhealthy physical health days at baseline was
15.9 (SD 11.4) days. At baseline, 88.9% (n=529) reported having 6 or more
mentally unhealthy days in the prior month and 52.9% (n=315) reported having 6
or more physically unhealthy days during the same period. There was a
statistically significant (13%) improvement in health-related quality of life
from the baseline survey (mean 24.63, SD 10.34) to the 90-day survey (mean
21.35, SD 9.13; t39=2.02; P=.05). On average, participants reported 3.28 less
monthly unhealthy days after 90 days on the platform. This indicates the
potential of the platform to drive an annual reduction of medical costs equaling
US $615 per participant (3.28 days×US $15.64 estimated cost reduction per
unhealthy day×12 months).

PROGRAM SATISFACTION

Overall, 88% (n=91) reported that they would recommend the peer support platform
to others, and 98% (n=102) of participants said that they believed that the
program should be made available to everyone in Colorado. In subjective
comments, participants frequently wrote that being able to connect and talk with
others who have shared lived experiences in a safe, judgment-free, and
supportive environment was the most valuable part of their experience. No
participants wrote a negative comment.



DISCUSSION

This study of the use of a novel peer-support platform by a demographically
diverse population demonstrated 5 key findings. First, adults of a wide range of
ages, genders, and social vulnerability seek and remain engaged with digitally
enabled peer support for loneliness. Throughout the study, engagement in the
platform remained high, with 86% (n=701) engaged in the platform after 90 days.
This is significantly higher compared to digital community–driven applications,
which on average have a 19% retention rate after 90 days, and mental health apps
which, on average, have a 3% retention rate after 30 days [Community benchmark
report 2023. Threado. URL: https://www.threado.com/community-benchmark-report
[accessed 2023-01-15] 54,Baumel A, Muench F, Edan S, Kane JM. Objective user
engagement with mental health apps: systematic search and panel-based usage
analysis. J Med Internet Res 2019 Sep 25;21(9):e14567
[https://www.jmir.org/2019/9/e14567/] [CrossRef] [Medline]55]. Relatedly,
participants seemed highly satisfied with the digital peer support program, with
88% (n=91) of participants recommending that it be made available to others. Men
have been observed to be less likely to seek support for mental health compared
to women [Kwon M, Lawn S, Kaine C. Understanding men's engagement and
disengagement when seeking support for mental health. Am J Mens Health
2023;17(2):15579883231157971
[https://journals.sagepub.com/doi/abs/10.1177/15579883231157971?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub
0pubmed] [CrossRef] [Medline]56]. The high rate of participation (n=473, 58%)
and engagement in males point to the effectiveness of the program in drawing men
seeking peer support. With minorities and underrepresented populations reporting
higher than average rates of loneliness, the results of this study also suggest
that the platform can increase the outcomes of diversity equity and inclusion
initiatives implemented by government agencies and employers [Bowers A, Wu J,
Lustig S, Nemecek D. Loneliness influences avoidable absenteeism and turnover
intention reported by adult workers in the United States. J Organ Eff
2022;9(2):312-335
[https://www.emerald.com/insight/content/doi/10.1108/JOEPP-03-2021-0076/full/html]
[CrossRef]3,AI-driven peer support community. Wisdo Health. URL:
https://www.wisdo.com/index.html [accessed 2023-01-15] 43].

Second, participation in peer support was associated with a significant
reduction in loneliness with an 11.6% (mean 6.46) improvement within the first
30 days, increasing to 14.6% (mean 6.47) by day 90. Loneliness occurs at all
stages of the life span with young adults reporting the highest mean levels of
loneliness and older adults also reporting high levels of loneliness [Bruce LD,
Wu JS, Lustig SL, Russell DW, Nemecek DA. Loneliness in the United States: a
2018 National Panel survey of demographic, structural, cognitive, and behavioral
characteristics. Am J Health Promot 2019 Nov;33(8):1123-1133
[https://journals.sagepub.com/doi/abs/10.1177/0890117119856551?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub
0pubmed] [CrossRef] [Medline]57,Margrett JA, Daugherty K, Martin P, MacDonald M,
Davey A, Woodard JL, et al. Affect and loneliness among centenarians and the
oldest old: the role of individual and social resources. Aging Ment Health 2011
Apr;15(3):385-396 [https://europepmc.org/abstract/MED/21491224] [CrossRef]
[Medline]58]. Interventions to address loneliness and social isolation have
historically been observed to reduce loneliness within a short time period,
however, with a small effect size [Hoang P, King JA, Moore S, Moore K, Reich K,
Sidhu H, et al. Interventions associated with reduced loneliness and social
isolation in older adults: a systematic review and meta-analysis. JAMA Netw Open
2022 Oct 03;5(10):e2236676 [https://europepmc.org/abstract/MED/36251294]
[CrossRef] [Medline]59]. The results of this study suggest that a digitally
enabled peer support platform can be an effective approach to mitigating
loneliness, which has become a prominent issue due to its high prevalence in the
United States [Bowers A, Wu J, Lustig S, Nemecek D. Loneliness influences
avoidable absenteeism and turnover intention reported by adult workers in the
United States. J Organ Eff 2022;9(2):312-335
[https://www.emerald.com/insight/content/doi/10.1108/JOEPP-03-2021-0076/full/html]
[CrossRef]3,Demarinis S. Loneliness at epidemic levels in America. Explore (NY)
2020;16(5):278-279 [https://europepmc.org/abstract/MED/32674944] [CrossRef]
[Medline]4,Anderson OG, Thayer CE. Loneliness and social connections: a national
survey of adults 45 and older. AARP Research. 2018. URL:
https://www.aarp.org/research/topics/life/info-2018/loneliness-social-connections.html
[accessed 2023-10-03] 14].

Third, given that loneliness is often comorbid with depression and anxiety, a
key finding of this study was that participants reported significant
improvements in depression and anxiety symptoms (50.1%, mean 1.89 and 29%, mean
1.42, respectively, at 90 days). This promising finding suggests that as
employers and health plans seek interventions to increase access to behavioral
health services for their populations, peer support should be considered among
the solution set. Moreover, these findings should be evaluated in future studies
with full Patient Health Questionnaire-9 and GAD-7 instruments.

Fourth, participants reported a 13% (mean 21.35, SD 9.13) reduction in the
number of monthly mentally and physically unhealthy days after 90 days on the
platform when compared to baseline. The results of the platform point to the
importance of peer support in improving clinical outcomes and improving the
quality of life of participants. The magnitude of this improvement may have
partially been a result of the use of the 2-item measure assessing physically
and mentally unhealthy days compared to the original, long form of the
health-related quality of life. Due to the large number of questions already
included in the participant survey, the short 2-item form was used in this
study. A future study will include the original health-related quality of life
instrument or similar instruments (eg, EQ-5D or the 36-Item Short Form Survey
[SF-36]).

At US $15.64 per unhealthy day, one could estimate that participation in peer
support was associated with a US $615 reduction in annual medical costs. This
finding warrants further exploration with a detailed economic analysis of
participation with digitally enabled peer support for lonely populations.

Finally, the platform was successful in referring participants to mental health
education resources, with 27% (n=217) of participants accessing a resource about
how to best support those experiencing psychological distress and 15% (n=45) of
women accessing a program about the risks of excessive alcohol use. This finding
suggests that a peer support platform can be applied to effectively identify,
motivate, and connect appropriate users with community services, clinical
programs, and health literacy resources. Given the challenges of engaging
members with valuable employer- and health plan–sponsored programs for which
they are eligible, the role of a digitally enabled peer-support platform as a
benefit navigation and engagement tool warrants future study.

The implication of this study is that a digitally enabled peer support platform
is a resource for addressing the epidemic of loneliness, depression, and
anxiety. A significant consideration for clinicians is systematic screening to
identify adults who are lonely and to refer them for enrollment in the platform.
Health insurance providers could consider covering fees associated with
participation in the platform for patients who screen positive for loneliness
using validated instruments. The costs associated with loneliness are
significant. Thus, providing access to a scalable digitally enabled peer support
platform could be a cost-effective or perhaps even cost-saving intervention.

This study had 3 key limitations. First, all participants were adults from
Colorado. While there is no reason to suspect that clinical characteristics of
adults with loneliness in Colorado vary significantly from those elsewhere in
the United States, future studies should evaluate geographically diverse
populations. Second, this study did not have a control group, and our
statistical power was limited by the number of participants who completed the
surveys at all time points. A randomized controlled trial that compares peer
support to other interventions available to similar populations (such as
cognitive behavioral therapy) would be a valuable contribution to the
literature. Finally, we did not separately evaluate each of the pillars of the
intervention: “emotional support, reassurance of worth, a sense of belonging,
and reliable alliance.” Each of these pillars is a component of the Social
Provisions Scale [Cutrona CE, Russell DW. Social provisions scale. J Abnorm
Psychol 1987;1:37-67 [CrossRef]53], and future studies analyzing the factors of
social provisions will be an important area to examine.

The Surgeon General recently wrote [Our epidemic of loneliness and isolation.
The U.S. Surgeon General's Advisory on the health effects of social connection
and community. Office of the Surgeon General. 2023. URL:
https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf
[accessed 2023-05-03] 1]:

> Loneliness and isolation represent profound threats to our health and
> well-being. But we have the power to respond. By taking small steps every day
> to strengthen our relationships, and by supporting community efforts to
> rebuild social connection, we can rise to meet this moment together.

We believe that digitally enabled peer support represents a valuable
evidence-based tool for creating meaningful social connections for a wide range
of at-risk populations.



ACKNOWLEDGMENTS



The study was funded and conducted in collaboration with Peer Assistance
Services, a Colorado nonprofit dedicated to the prevention and intervention of
substance use and mental health concerns. They had no role in the development or
approval of this manuscript. DR was supported by ongoing grants (2019-R2-CX-0013
and 2017-SI-AX-004) from the US Department of Justice.

DATA AVAILABILITY

Data used in this analysis will be made available upon reasonable request to the
corresponding author.

CONFLICTS OF INTEREST



DMB, JK, RG, and DWR were employees of, consultants to, or board members of
Wisdo. EP was an employee of Peer Assistance Services.



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--------------------------------------------------------------------------------

‎

ABBREVIATIONS

GAD-7: General Anxiety Disorder 7-Item ScaleHIPAA: Health Insurance Portability
and Accountability ActHITRUST: Health Information TrustPHQ-2: Patient Health
Questionnaire 2-Item ScaleSF-36: 36-Item Short Form SurveyUCLA-3: University of
California, Los Angeles Loneliness Scale


--------------------------------------------------------------------------------

Edited by A Mavragani; submitted 09.05.23; peer-reviewed by I Pyykko, T Badger;
comments to author 21.08.23; revised version received 08.09.23; accepted
29.09.23; published 06.11.23

Copyright

©Dena M Bravata, Joseph Kim, Daniel W Russell, Ron Goldman, Elizabeth Pace.
Originally published in JMIR Formative Research (https://formative.jmir.org),
06.11.2023.

This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/),
which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work, first published in JMIR Formative Research, is
properly cited. The complete bibliographic information, a link to the original
publication on https://formative.jmir.org, as well as this copyright and license
information must be included.



CITATION

Please cite as:

Bravata DM, Kim J, Russell DW, Goldman R, Pace E
Digitally Enabled Peer Support Intervention to Address Loneliness and Mental
Health: Prospective Cohort Analysis
JMIR Form Res 2023;7:e48864
doi: 10.2196/48864 PMID: 37930770

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THIS PAPER IS IN THE FOLLOWING E-COLLECTION/THEME ISSUE:

Formative Evaluation of Digital Health Interventions (1801) Behavior Change
(600) Web-based and Mobile Health Interventions (2577) e-Mental Health and
Cyberpsychology (1170) Use and User Demographics of mHealth (286) Loneliness and
Social Isolation (69) Occupational Health and Ergonomics/Prevention at the
Workplace (189)


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