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Original research
Impact of social isolation on mortality and morbidity in 20 high-income, middle-income and low-income countries in five continents
  1. Ryo Naito1,2,
  2. Darryl P Leong1,2,
  3. Shrikant Ishver Bangdiwala1,3,
  4. Martin McKee4,
  5. S V Subramanian5,
  6. Sumathy Rangarajan1,2,
  7. Shofiqul Islam1,2,
  8. Alvaro Avezum6,
  9. Karen E Yeates7,
  10. Scott A Lear8,
  11. Rajeev Gupta9,
  12. Afzalhussein Yusufali10,
  13. Antonio L Dans11,
  14. Andrzej Szuba12,
  15. Khalid F Alhabib13,
  16. Manmeet Kaur14,
  17. Omar Rahman15,
  18. Pamela Seron16,
  19. Rafael Diaz17,
  20. Thandi Puoane18,
  21. Weida Liu19,
  22. Yibing Zhu20,
  23. Yundong Sheng21,
  24. Patricio Lopez-Jaramillo22,
  25. Jephat Chifamba23,
  26. Ismail Rosnah24,
  27. Kubilay Karsidag25,
  28. Roya Kelishadi26,
  29. Annika Rosengren27,
  30. Rasha Khatib28,29,
  31. Leela Itty Amma K R30,31,
  32. Syed Iqbal Azam32,
  33. Koon Teo1,2,
  34. Salim Yusuf1,2
  1. 1Population Health Research Institute, Hamilton, Ontario, Canada
  2. 2Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
  3. 3Department of Health Research Methods, Evidence and Impact, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
  4. 4ECOHOST, LSHTM, London, UK
  5. 5Harvard Center for Population and Development Studies and Department of Society and Human Development, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  6. 6International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
  7. 7Department of Medicine, Queen's University, Kingston, Ontario, Canada
  8. 8Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
  9. 9Eternal Heart Care Centre & Research Institute, Jaipur, India
  10. 10Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, UAE
  11. 11Adult Medicine Research Unit, Philippine General Hospital, Manila, Philippines
  12. 12Department of Angiology, Hypertension and Diabetology, Wroclaw Medical University, Wroclaw, Dolnoslaskie, Poland
  13. 13Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  14. 14School of Public Health, Postgraduate Institute of Medical Education & Research, Chandigarh, India
  15. 15University of Liberal Arts Bangladesh, Dhaka, Dhaka District, Bangladesh
  16. 16Universidad de La Frontera, Temuco, Chile
  17. 17ECLA - Academic Research Organization, Rosario, Argentina
  18. 18School of Public Health, University of Western Cape, Cape Town, Western Cape, South Africa
  19. 19State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Xicheng District, Beijing, China
  20. 20Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, Beijing, China
  21. 21Jiangxinzhou Community Health Service Center, Nanjing, China
  22. 22Masira Research Institute, Universidad de Santander (UDES), Bucaramanga, Colombia
  23. 23Department of Physiology, University of Zimbabwe, College of Health Sciences, Harare, Zimbabwe
  24. 24Community Health Department, Faculty of Medicine, Universiti Kebangsaan Malaysia, Malaysia, Malaysia
  25. 25Division of Endocrinology, Medical Faculty of Istanbul University, Fatih, Turkey
  26. 26Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  27. 27Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, and Region Västra Götaland, Sahlgrenska University Hospital, Goteborg, Sweden
  28. 28Advocate Aurora Research Institute, Downers Grove, Illinois, USA
  29. 29Institute of Community and Public Health, Birzeit University, Birzeit, Palestine
  30. 30Health Action by People, Thiruvananthapuram, Kerala, India
  31. 31Department of Community Medicine, Sree Mookambika Institute of Medical Sciences, Kulasekharam, India
  32. 32Community Health Sciences (CHS) department, The Aga Khan University, Karachi, Pakistan
  1. Correspondence to Salim Yusuf; yusufs{at}mcmaster.ca

Abstract

Objective To examine the association between social isolation and mortality and incident diseases in middle-aged adults in urban and rural communities from high-income, middle-income and low-income countries.

Design Population-based prospective observational study.

Setting Urban and rural communities in 20 high income, middle income and low income.

Participants 119 894 community-dwelling middle-aged adults.

Main outcome measures Associations of social isolation with mortality, cardiovascular death, non-cardiovascular death and incident diseases.

Results Social isolation was more common in middle-income and high-income countries compared with low-income countries, in urban areas than rural areas, in older individuals and among women, those with less education and the unemployed. It was more frequent among smokers and those with a poorer diet. Social isolation was associated with greater risk of mortality (HR of 1.26, 95% CI: 1.17 to 1.36), incident stroke (HR: 1.23, 95% CI: 1.07 to 1.40), cardiovascular disease (HR: 1.15, 95% CI: 1.05 to 1.25) and pneumonia (HR: 1.22, 95% CI: 1.09 to 1.37), but not cancer. The associations between social isolation and mortality were observed in populations in high-income, middle-income and low-income countries (HR (95% CI): 1.69 (1.32 to 2.17), 1.27 (1.15 to 1.40) and 1.47 (1.25 to 1.73), respectively, interaction p=0.02). The HR associated with social isolation was greater in men than women and in younger than older individuals. Mediation analyses for the association between social isolation and mortality showed that unhealthy behaviours and comorbidities may account for about one-fifth of the association.

Conclusion Social isolation is associated with increased risk of mortality in countries at different economic levels. The increasing share of older people in populations in many countries argues for targeted strategies to mitigate its adverse effects.

  • public health
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2020-004124

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    Footnotes

    • Handling editor Sanni Yaya

    • Twitter @DarrylLeong, @rajeevgg

    • Contributors RN, DL and SY contributed to the study concept and design. SIB, SI and SR were responsible for the acquisition of data. RN, DL, MMK and SY drafted the manuscript. SVS, AJA, KEY, SAL, RG, AY, ALD, AS, KFA, MK, OR, PS, RD, TP, WL, YZ, YS, PL-J, JC, IR, KK, RK, AR, RK, LIAKR, SI and KT contributed to the critical revision of the manuscript. SY is guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

    • Funding SY is supported by the Marion W Burke endowed chair of the Heart and Stroke Foundation of Ontario.The PURE study is an investigator-initiated study that is funded by the Population Health Research Institute, Hamilton Health Sciences Research Institute (HHSRI), the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, Support from Canadian Institutes of Health Research’s Strategy for Patient Oriented Research, through the Ontario SPOR Support Unit, as well as the Ontario Ministry of Health and Long-Term Care and through unrestricted grants from several pharmaceutical companies [with major contributions from AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, and GlaxoSmithKline], and additional contributions from Novartis and King Pharma and from various national or local organisations in participating countries. These include: Argentina: Fundacion ECLA (Estudios Clínicos Latino America) ; Bangladesh: Independent University, Bangladesh and Mitra and Associates; Brazil: Unilever Health Institute, Brazil; Canada: This study was supported by an unrestricted grant from Dairy Farmers of Canada and the National Dairy Council (U.S.), Public Health Agency of Canada and Champlain Cardiovascular Disease Prevention Network; Chile: Universidad de La Frontera [DI13-PE11]; China: National Center for Cardiovascular Diseases and ThinkTank Research Center for Health Development; Colombia: Colciencias (grant 6566-04-18062 and grant 6517-777-58228); India: Indian Council of Medical Research; Malaysia: Ministry of Science, Technology and Innovation of Malaysia (grant number: 100-IRDC/BIOTEK 16/6/21 [13/2007], and 07-05-IFN-BPH 010), Ministry of Higher Education of Malaysia (grant number: 600-RMI/LRGS/5/3 [2/2011]), Universiti Teknologi MARA, Universiti Kebangsaan Malaysia (UKM-Hejim-Komuniti-15-2010); occupied Palestinian territory: the United Nations Relief and Works Agency for Palestine Refugees in the Near East, occupied Palestinian territory; International Development Research Centre, Canada; Philippines: Philippine Council for Health Research and Development; Poland: Polish Ministry of Science and Higher Education (grant number: 290/W-PURE/2008/0), Wroclaw Medical University; Saudi Arabia: Saudi Heart Association, Dr.Mohammad Alfagih Hospital, The Deanship of Scientific Research at King Saud University (Research group number: RG -1436-013), Riyadh; Saleh Hamza Serafi Chair for Research of Coronary Heart Disease, Umm AlQura University, Makkah, Saudi Arabia; South Africa: The North-West University, SA and Netherlands Programme for Alternative Development, National Research Foundation, Medical Research Council of South Africa, The South Africa Sugar Association, Faculty of Community and Health Sciences; Sweden: Grants from the Swedish state under the Agreement concerning research and education of doctors; the Swedish Heart and Lung Foundation; the Swedish Research Council; the Swedish Council for Health, Working Life and Welfare, King Gustaf V:s and Queen Victoria Freemason’s Foundation, AFA Insurance; Turkey: Metabolic Syndrome Society, AstraZeneca, Sanofi Aventis; United Arab Emirates: Sheikh Hamdan Bin Rashid Al Maktoum Award For Medical Sciences and Dubai Health Authority, Dubai.

    • Disclaimer The external funders and sponsors had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; in the preparation, review, or approval of the manuscript; or in the decision to submit the manuscript for publication.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval The PURE protocol was approved by the ethics committees in the participating centres. All participants provided written informed consent.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data are available upon request. An exclusive licence: The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, a worldwide licence to the Publishers and its licensees in perpetuity, in all forms, formats and media (whether known now or created in the future), to (i) publish, reproduce, distribute, display and store the Contribution, (ii) translate the Contribution into other languages, create adaptations, reprints, include within collections and create summaries, extracts and/or, abstracts of the Contribution and convert or allow conversion into any format including without limitation audio, (iii) create any other derivative work(s) based in whole or part on the on the Contribution, (iv) to exploit all subsidiary rights to exploit all subsidiary rights that currently exist or as may exist in the future in the Contribution, (v) the inclusion of electronic links from the Contribution to third party material where-ever it may be located and (vi) licence any third party to do any or all of the above. All research articles will be made available on an open access basis.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.