The Contribution of Neighbourhood Environmental Features to Socio-economic Inequity in Loneliness

Abstract Loneliness is a subjective feeling of unmet desired social relationships and is recognised as a primary determinant of adverse health outcomes and mortality, imposing significant economic burdens on governments worldwide. In Australia alone, the annual healthcare costs attributed to loneliness is estimated at $2.7 billion or approximately $1,565 per person per year. Older adults are particularly vulnerable to loneliness due to the prevalence of life events such as the loss of a partner, friends, or family, along with children relocating during this stage of life. More than 30% reportedly suffering from loneliness worldwide, including in the US, England, Ireland and Australia. older adults often rely on neighbourhood opportunities for social activities, and this becomes more important over time due to declining physical functioning and limited mobility. The importance of neighbourhood features in addressing loneliness in older adults is also evident in initiatives such as ‘Ending loneliness together’ in Australia and global efforts like the ‘Campaign to End Loneliness,’ which advocate for evidence-based interventions at the neighbourhood level that seek to address loneliness and particularly target older adults. Studies have revealed that older adults residing in disadvantaged neighbourhoods, experience higher levels of loneliness and live in areas characterized by inequalities in social determinants of health such as higher walkability, poor quality and quantity of greenspace, and higher crime rates compared to advantaged neighbourhoods. This emphasises the presence of socio-spatial inequality in the distribution of neighbourhood features and neighbourhood socio-economic inequity in loneliness. Inequity represents avoidable and unfair inequality, while inequality explains the unequal or disproportionate distribution of goods, wealth, education, opportunities, rewards, and punishments, which is not necessarily unjust. Few studies have investigated how inequality in modifiable neighbourhood features, such as walkability, quality and quantity of green space, and crime, are associated with inequity in loneliness, especially in the Australian context in middle-aged to older aged adults. This thesis aimed to understand the contribution of socio-spatial inequality in the distribution of modifiable neighbourhood features related to social determinants of health equity (walkability, green space, and crime) to neighbourhood socio-economic inequity in loneliness. Three empirical cross-sectional studies investigated the contribution of socio-spatial inequities in walkability and its components (Chapter 4), greenspace quality and quantity (Chapter 5), and objective and perceived crime (Chapter 6) to neighbourhood socio-economic inequity in loneliness. All three studies utilised 2016 data from HABITAT (How Areas in Brisbane Influence HealTh and AcTivity) dataset, a multilevel longitudinal study of middle-aged adults living in the Brisbane Local Government Area (LGA) in Queensland, Australia, spanning 2007 to 2016. This research identified several key findings that contribute new knowledge to neighbourhood socio-economic inequity in loneliness. Firstly, loneliness was higher in disadvantaged neighbourhoods compared to advantaged neighbourhoods. Socio-spatial inequalities were observed between advantaged and disadvantaged neighbourhoods, with disadvantaged neighbourhoods having higher walkability, street connectivity, land use mix, residential density, poorer quality and quantity of green spaces. and higher objective and perceived crime rates. This research revealed that higher residential density, higher objective and perceived crime contributed to higher levels of loneliness. However, only socio-spatial inequalities in residential density and perceived crime contributed to neighbourhood socio-economic inequity in loneliness. Other neighbourhood features showed no significant contribution in explaining loneliness or inequity in loneliness. Interestingly, while objective crime appeared to explain loneliness, it did not contribute to inequity in loneliness. The results highlight the impact of neighbourhood context as a potential influence on the relationship between inequality in opportunities and health inequities. Findings from this research emphasise the significance of prioritising certain neighbourhood features as interventions aimed at improving specific health outcomes. This includes prioritising factors such as residential density, and objective and perceived crime, over others like walkability or green space, particularly in middle aged and older adults within the specific context of Brisbane, to efficiently combat loneliness. The thesis supported the idea that the mechanisms of neighbourhood effects on health are dynamic and not uniform, necessitating attention and prioritising of certain features based on a specific health outcome, target population, and local context. Findings from the research suggest that loneliness among middle aged and older adults could possibly worsen if inequalities in residential density and perceived crime widen between disadvantaged and advantaged neighbourhoods. This requires a move to more detailed longitudinal investigations to understand if these trends change over time and deepen our understanding of the dynamics involved. Importantly, the evidence produced in this thesis suggests great potential for the application of neighbourhood-level interventions to reduce loneliness among middle-aged to older adults and supporting national and international initiatives aimed at combating loneliness. Policy changes and new evidence-informed initiatives based on these findings could play a crucial role in helping Australia fulfill its commitment to Sustainable Development Goals (SDGs), creating age-friendly neighbourhoods areas promoting healthy aging and improved quality of life for older adults into the future.