Social and Mental Health Factors Involved in the Severity of Loneliness in Older Individuals in a Spanish Rural Area

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript reports findings from a cross-sectional analysis of the predictors of loneliness in a representative sample of older adults in a Spanish rural area. These predictors included demographics, insomnia, depression, activities of daily living (ADL) and instrumental activities of daily living (IADL). The authors reported the relevance of loneliness in this sample and identified putative predictors of emotional and social loneliness. The study benefits from a representative sample of older people, and using validated assessments/ measures of these predictors. The authors report some interesting results, which may shed light on the understanding of correlates of loneliness in older adults (which has been an interest of research for the past two decades). I have some comments for the authors’ consideration, as follows:

Overall:

-          The authors highlighted ‘unwanted’ loneliness throughout the manuscript. However, this descriptor of ‘unwanted’ may not be necessary as loneliness, as it is defined as an aversive experience (also ref lines 42- 44, p. 1) and it is always undesired. I suggest deleting this descriptor of loneliness throughout the manuscript.

Title:

-          As the predictors include health-related variables such as depression, ADL and IDAL, which are beyond ‘social factors’, the title should also mention ‘health factors’ for a more accurate account of the entire study

Introduction:

-          The introduction did not adequately argue for a need or research gap to examine loneliness among older adults living in rural areas (vs urban settings). Also, the authors need to make a case as to why it is theoretically or empirically important to explore loneliness in the setting of a rural area in Spain (i.e. Ademuz) for a better understanding for international readers.

Methods:

-          It is mentioned that the sample was ‘selected representatively from the population of interest’ (lines 114- 115, p. 3). Please give details on the sampling strategies applied to achieve representativeness in this sample.

-          For the use of the Goldberg Anxiety and Depression Scale, it is not clear if the anxiety or depression subscales, or both as a total score were used in the analysis. In the later sections, only ‘depression’/ ‘depressive symptoms’ was mentioned, so I guess only the depression subscale was reported and analyzed. If this is not the case, please revise the wording and clarify it in the Methods.

-          I would suggest deleting the word ‘changes in’ in line 209 (p.5), as this study did not have a longitudinal component to examine the changes in variables.

-          In the analyses, the authors treated loneliness as both continuous (section 3.2, where correlation and t-test were applied) and categorical with the established cutoff (section 3.3, where logistic regression was applied), which is a bit confusing. Instead of considering loneliness as both continuous and categorical, the authors may take a stance to select only one approach and follow it throughout the entire manuscript for consistency and coherence. In case the authors prefer keeping both, some justifications should be made.

Results:

-          Please be consistent with the number of decimal places of p-values- 3 decimal places should be reported.

-          In Figures 2 and 3, it is confusing to see the asterisk for statistical significance placed right above one of the bars, but not in-between them- as the asterisks indicate the significance of the comparisons of mean levels between the two categories. Please revise the figures for better clarity.

-          The meaning of the phrase ‘most significant associations were observed for emotional loneliness’ (line 307, p.8) is not clear. Please elaborate and revise to align with the statistical findings.

Discussion:

Given that social loneliness (but not emotional loneliness) was associated with age, the authors suggested that ‘This study found that a moderate degree of loneliness is related to aging and suggested that although it can appear at any stage of life, it is more common at advanced ages’ (line 348 – 350, p. 9). This statement needs further unpacking and elaboration to echo the findings. The authors may further speculate the reason why age was associated with social loneliness, but not emotional loneliness.

Author Response

-The manuscript reports findings from a cross-sectional analysis of the predictors of loneliness in a representative sample of older adults in a Spanish rural area. These predictors included demographics, insomnia, depression, activities of daily living (ADL) and instrumental activities of daily living (IADL). The authors reported the relevance of loneliness in this sample and identified putative predictors of emotional and social loneliness. The study benefits from a representative sample of older people, and using validated assessments/ measures of these predictors.

Answer:  Many thanks for these positive comments.

-The authors report some interesting results, which may shed light on the understanding of correlates of loneliness in older adults (which has been an interest of research for the past two decades).

Answer:  Many thanks for these positive comments.

-I have some comments for the authors’ consideration, as follows:

Overall:

The authors highlighted ‘unwanted’ loneliness throughout the manuscript. However, this descriptor of ‘unwanted’ may not be necessary as loneliness, as it is defined as an aversive experience (also ref lines 42- 44, p. 1) and it is always undesired. I suggest deleting this descriptor of loneliness throughout the manuscript.

Answer: According to Reviewer’s suggestion we have deleted “unwanted”.

-Title:

As the predictors include health-related variables such as depression, ADL and IDAL, which are beyond ‘social factors’, the title should also mention ‘health factors’ for a more accurate account of the entire study

Answer: Done as suggested we have added “mental health factors”.

-Introduction:

The introduction did not adequately argue for a need or research gap to examine loneliness among older adults living in rural areas (vs urban settings).

Answer: According to the Reviewer’s suggestion, we have commented on the rotational to investigate loneliness in rural areas as follows:

“To date, there is a paucity of studies that have explored the potential impact of geographic factors on individuals’ loneliness (Abshire et al., 2022; Burnette el al., 2021). One gap identified related to this aspect is whether there are differences between living in rural and urban areas in loneliness (Menec et al., 2019). On one side, it could be considered that rural areas might be associated with greater loneliness due to the long distances, lack of infrastructure and transportation and sparsely population regions (Abshire et al., 2022; Thapa et al., 2018). On the other hand, usually, there are stronger community connections in rural areas which could be advantageous in reducing social isolation and loneliness (Hussain et al., 2023; Menec et al. 2015). Indeed, research findings regarding urban and rural differences in social isolation and loneliness have been inconsistent (Hussain et al., 2023; Menec et al., 2019) suggesting the need for further research on these possible differences. In Spain, as in other places, the dynamics of social networks of older adults in rural communities and its relationship with loneliness has not been studied.”

Abshire DA, Graves JM, Amiri S, Williams-Gilbert W. Differences in Loneliness Across the Rural-Urban Continuum Among Adults Living in Washington State. J Rural Health. 2022 Jan;38(1):187-193. doi: 10.1111/jrh.12535. Epub 2020 Nov 12. PMID: 33180354; PMCID: PMC8674765

Burnette D, Ye X, Cheng Z, Ruan H. Living alone, social cohesion, and quality of life among older adults in rural and urban China: a conditional process analysis. International Psychogeriatrics. 2021;33(5):469-479. doi:10.1017/S1041610220001210

Hussain B, Mirza M, Baines R, Burns L, Stevens S, Asthana S, Chatterjee A. Loneliness and social networks of older adults in rural communities: a narrative synthesis systematic review. Front Public Health. 2023 May 15;11:1113864. doi: 10.3389/fpubh.2023.1113864. PMID: 37255758; PMCID: PMC10225733.

Menec V, Bell S, Novek S, Minnigaleeva G, Morales E, Ouma T et al. Making rural and remote communities more age-friendly: Experts’ perspectives of issues, challenges, and priorities. J Aging Soc Policy. 2015;27: 173–191. pmid:25647697

Thapa D, Visentin D, Kornhaber R, Cleary M. Migration of adult children and mental health of older parents ‘left behind’: An integrative review. PLOS ONE. 2018;13(10): e0205665. pmid:30346972

Also, the authors need to make a case as to why it is theoretically or empirically important to explore loneliness in the setting of a rural area in Spain (i.e. Ademuz) for a better understanding for international readers.

Answer: Thank you, according to, we have added this information in the last part of the Introduction:

“Spain is currently one of the European countries that suffers most from depopulation of rural areas, with 52% of the population living in cities of more than 50,000 inhabitants, while only 3.2% live in municipalities with less than 1000 inhabitants, a phenomenon currently called “Emptied Spain” (Mileto et al., 2021). Among the depopulated rural areas, the Rincón de Ademuz is the least populated region of Valencia (located 2 hours North-West driving from Valencia), with a population density of 6 inhabitants per square kilometre, which places it among the most unpopulated areas in Spain. In addition, in recent decades it has experienced a significant demographic recession, which has stabilised in recent years. Among its characteristics, it could be highlighted that it has an aging population, with low density, high dispersion and negative growth. These areas have experienced some of the greatest demographic decline in the Valencian region, in the context of a marked socioeconomic crisis linked to their rural and peripheral situations (Calvo-Palomares et al., 2023). Therefore, we hypothesized that the population could perceive social isolation and loneliness and we considered imperative to explore this issue and associated social and mental health factors.”

Mileto C, Vegas F, Llatas C, Soust-Verdaguer B. A Sustainable Approach for the Refurbishment Process of Vernacular Heritage: The Sesga House Case Study (Valencia, Spain). Sustainability. 2021; 13(17):9800.

Calvo-Palomares R, Aguado-Hernández JA, Sigalat-Signes E, Roig-Merino B. Evaluation of Territorial Capacity for Development: Population and Employment. Land. 2023; 12(9):1773.

-Methods:

It is mentioned that the sample was ‘selected representatively from the population of interest’ (lines 114- 115, p. 3). Please give details on the sampling strategies applied to achieve representativeness in this sample.

Answer:  According to Reviewer’s suggestion we have specified sampling as follows:

“The sample was selected first by contacting the mayors' offices of the 7 municipalities o and the health center of the region El Rincón de Ademuz. These entities distributed information brochures about the study to the older individuals who met the inclusion requirements (being 65 years of age or older and not suffering from cognitive impairment). The interested persons left their telephone numbers to be first contacted by phone, and if they agree, the psychologist went to their homes to present the study, sign the informed consent form and conduct the interview. Based on estimation of municipalities’ data, in these municipalities of the Rincón de Ademuz, 652 people over 65 years of age were counted, but those living permanently (year-round) in the region numbered about 280 people (the rest usually live most of the year in different cities close to their children).  Of these, those living in the community and not suffering from cognitive impairment were estimated 156. Accepting an alpha risk of 0.95 for a precision of +/- 0.05 units in a two-sided test for an estimated proportion of 35% of loneliness, 108 subjects (out 156) were considered sufficient for the representation of the target population. However, the sampling procedure was based on convenience and participants’ availability and it was not randomized.

The estimation of loneliness a priori (35%) was based on a pilot study and more specifically, in published data in Spain reporting a prevalence around 30-40% % in rural areas in Spain (Hernández-López et al., 2024). Considering the final results of our study, we observed a prevalence of 30.6 % of loneliness in the study sample leading to a sample size of 106 participants, which fits with the a priori estimation based on literature.”

Hernández-López MJ, Hernández-Méndez S, Leal-Costa C, Ramos-Morcillo AJ, Díaz-García I, López-Pérez MV, García-González J, Ruzafa-Martínez M. Prevalence of Unwanted Loneliness and Associated Factors in People over 65 Years of Age in a Health Area of the Region of Murcia, Spain: HELPeN Project. J Clin Med. 2024 Sep 21;13(18):5604.

-For the use of the Goldberg Anxiety and Depression Scale, it is not clear if the anxiety or depression subscales, or both as a total score were used in the analysis.

Answer: we have specified that we used the score of each subscale in order to evaluate separately depression and anxiety symptoms.

-In the later sections, only ‘depression’/ ‘depressive symptoms’ was mentioned, so I guess only the depression subscale was reported and analyzed. If this is not the case, please revise the wording and clarify it in the Methods.

Answer: We have better specified we have analysed both anxiety symptoms score and depressive symptoms score.

-I would suggest deleting the word ‘changes in’ in line 209 (p.5), as this study did not have a longitudinal component to examine the changes in variables.

Answer: Done as suggested.

-In the analyses, the authors treated loneliness as both continuous (section 3.2, where correlation and t-test were applied) and categorical with the established cutoff (section 3.3, where logistic regression was applied), which is a bit confusing. Instead of considering loneliness as both continuous and categorical, the authors may take a stance to select only one approach and follow it throughout the entire manuscript for consistency and coherence. In case the authors prefer keeping both, some justifications should be made.

Answer:  The main outcome of the study, loneliness, was treated loneliness as both continuous (section 3.2, where correlation and t-test were applied) and categorical with the established cutoff (section 3.3, where logistic regression was applied). We used the categorical variable of loneliness in the multivariate analysis because most of the study assessing prevalence used cut-off score to assess the presence or not of loneliness thus this allows comparisons among different studies and different instruments. We in fact performed also a linear regression analysis in order to explore the relationship between the presence of loneliness as a continuous variable and various predictor variables.

-Results:

Please be consistent with the number of decimal places of p-values- 3 decimal places should be reported.

Answer: We put 3 decimals in each p value.

-In Figures 2 and 3, it is confusing to see the asterisk for statistical significance placed right above one of the bars, but not in-between them- as the asterisks indicate the significance of the comparisons of mean levels between the two categories. Please revise the figures for better clarity.

Answer: We have moved the location of the asterisks according to Reviewer’s suggestion.

-The meaning of the phrase ‘most significant associations were observed for emotional loneliness’ (line 307, p.8) is not clear. Please elaborate and revise to align with the statistical findings.

Answer: We have re-elaborate the sentence as follows: “Gender and depressive symptoms were significantly associated with emotional loneliness (Table 3).”

-Discussion:

Given that social loneliness (but not emotional loneliness) was associated with age, the authors suggested that ‘This study found that a moderate degree of loneliness is related to aging and suggested that although it can appear at any stage of life, it is more common at advanced ages’ (line 348 – 350, p. 9). This statement needs further unpacking and elaboration to echo the findings. The authors may further speculate the reason why age was associated with social loneliness, but not emotional loneliness.

Answer: According to Reviewer’s suggestion we have further speculated about age and loneliness relationship as follows:

“One possibility the perception of self-isolation can vary with age, thus influencing in turn, the perception of loneliness.  A study performed in older individuals in Malaysia report-ed that 49.8% of older people are at risk of social isolation (Ibrahim et al. 2013). Although an association between age and social isolation has been demonstrated, the perception of loneliness decreases with age, and that would justify the results of our study and others (Beutel et al., 2017). A meta-analysis study conducted in older adults identified a U-shaped association between loneliness and age (Piquart et et al., 2001).”

Ibrahim R, Abolfathi Momtaz Y, Hamid TA. Social isolation in older Malaysians: prevalence and risk factors. Psychogeriatrics 2013;13:71–9

Beutel, M.E.; Klein, E.M.; Brähler, E.; Reiner, I.; Jünger, C.; Michal, M.; Wiltink, J.; Wild, P.S.; Münzel, T.; Lackner, K.J.; et al. Loneliness in the general population: Prevalence, determinants and relations to mental health. BMC Psychiatry 2017, 17, 97

Pinquart, M.; Sorensen, S. Influences on Loneliness in Older Adults: A Meta-Analysis. Basic Appl. Soc. Psychol. 2001, 23, 245–266.

Reviewer 2 Report

Comments and Suggestions for Authors

Very interesting and well written article. It would be interesting to tease out more information about the differences between having children and living with children. 

Author Response

-Very interesting and well written article. It would be interesting to tease out more information about the differences between having children and living with children. 

Answer:  Many thanks for these positive comments. We have specified as follows:

“The results of the multivariate analyses demonstrated significant associations between loneliness and the presence of offspring, but not with living with them or the presence of grandchildren (p>0.05). The relationship between having offspring and experiencing loneliness in older people is a complex topic that has been the subject of research in various studies. Some studies suggest that the presence of offspring may act as a protective factor against loneliness in old age, while others have found contradictory results. Some studies have suggested that older people with offspring reported less loneliness, particularly in the emotional realm, while no differences were observed for social loneliness. Having children could, therefore, act as a protective factor against emotional loneliness, but it does not seem to influence individuals’ social life or network of relationships [44].”

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The study is based on the assumption that ‘unwanted loneliness in older people, especially those living in rural areas, is a phenomenon that has received little attention in research and can have detrimental effects on physical and emotional well-being.’ This is a relevant topic in the field of knowledge, duly aligned with the scope of the journal.

In comparison with other published material, including the article from the International Journal of Environmental Research and Public Health (2022) by three of the four researchers on the topic in Valencia (Spain), the authors themselves state that ‘very few studies have addressed the problem of unwanted loneliness among older people residing in rural áreas.’ This fact indicates some traits of originality and may fill some specific gaps in the field, adding some points to the subject area compared with other published material. At first, the manuscript is of interest to the scientific community and the journal's readers.

Not clearly specified in the abstract, the manuscript objective is ‘to investigate the prevalence and factors associated with unwanted loneliness in older people residing in the rural área’ of Rincón de Ademuz (Valencia, Spain). This goal would be better understood with the clear specification of a main question (and/or hypothesis) addressed by the research.

Section 1 (Introduction) contextualizes the theme for the Spanish situation and generalizes loneliness into three types (social, emotional, and existential), complementing with its risks and consequences for health and other fields. It also clarifies that its assessment in the article is ‘associated with demographic, social, and health characteristics, as well as the influence of the presence of family members, depressive symptoms, sleep quality, and basic and instrumental activities of daily living, affect the experience of unwanted loneliness in this specific context.’

However, a large part of these introductory arguments are based on old references, with about 73% being over 10 years old, and only slightly more than 15% being from the last quinquennium. These conditions reduce the contemporaneity of the state of the art on the theme

Section 2 (Materials and Methods) clarifies the cross-sectional and observational design of the study, carried out in a sample of older people living in the study área, which comprises 108 participants (aged between 65 and 91 years) selected representatively from the population of interest, based on pre-established criteria.

Next, the information collection procedures are presented, both for the use of the instrument composed of the De Jong-Gierveld Loneliness Scale 2010, specifically designed to measure both emotional and social loneliness, and for its association with the application of a questionnaire by a trained psychologist. It is important to highlight the authors' compliance with ethical research prerequisites.

The assessment of emotional and social loneliness is based on the scale of that model, dated 1987, may exclude some up-to-date aspects. The three response options (no, more or less, and yes) and the three established categories (no loneliness, moderate loneliness, and severe loneliness) may lead to results centered on the average, which could be highlighted by the authors as a certain limitation of the study. Additionally, the exposition of the psychogeriatric assessment could be illustrated in synthetic tables for ease of understanding the adopted attributes.

The statistical analysis is explained succinctly but sufficiently clearly. In general terms, the materials and methods section allows for the reproducibility of the work.

Even so, it is worth noting that over 63% and 27% of the methodological references are over two and one decade old, respectively, and none are within the last five years. Again, there may be lapses related to the procedural contemporaneity of the article.

Section 3 (Results) begins with the sample characteristics of the study population, but for those unfamiliar with the Spanish reality, there is insufficient information about the location of the study area, including illustrations like maps, as well as relevant regional and/or national general data to understand the overall context of the study. Thus, the assessment of loneliness and its association with sociodemographic variables, as well as the multivariate analyses, assume excessively statistical characteristics.

Part of this problem is resolved in Section 4 (Discussion), in which the scientific debate is based on more current references, with a little over 61% corresponding to the last decade, of which about 62% are from the last five years

Although relatively consistent, Section 5 (Conclusions) is very succinct and could detail the limitations of the work further. It could also elaborate more on its contributions (and answers to the possible investigative question and/or hypothesis) across various aspects

As previously stated, one of the main points of improvement for the article is the updating of references, which, although appropriate, correspond to almost 62% being over a decade old and only about 22% pertaining to the last five years. Another suggested improvement concerns the inclusion of some of the figures and tables mentioned above.

Comments on the Quality of English Language

The manuscript needs small spelling and grammatical adjustments, as well as minor typing corrections. It is suggested to reduce excessively long paragraphs that make the text difficult to interpret.

Author Response

-The study is based on the assumption that ‘unwanted loneliness in older people, especially those living in rural areas, is a phenomenon that has received little attention in research and can have detrimental effects on physical and emotional well-being.’ This is a relevant topic in the field of knowledge, duly aligned with the scope of the journal.

Answer:  Many thanks for these positive comments.

-In comparison with other published material, including the article from the International Journal of Environmental Research and Public Health (2022) by three of the four researchers on the topic in Valencia (Spain), the authors themselves state that ‘very few studies have addressed the problem of unwanted loneliness among older people residing in rural áreas.’ This fact indicates some traits of originality and may fill some specific gaps in the field, adding some points to the subject area compared with other published material. At first, the manuscript is of interest to the scientific community and the journal's readers.

Answer:  Many thanks for these positive comments. We have better specified this aspect in the Introduction section as follows:

““To date, there is a paucity of studies that have explored the potential impact of geographic factors on individuals’ loneliness (Abshire et al., 2022; Burnette el al., 2021). One gap identified related to this aspect is whether there are differences between living in rural and urban areas in loneliness (Menec et al., 2019). On one side, it could be considered that rural areas might be associated with greater loneliness due to the long distances, lack of infrastructure and transportation and sparsely population regions (Abshire et al., 2022; Thapa et al., 2018). On the other hand, usually, there are stronger community connections in rural areas which could be advantageous in reducing social isolation and loneliness (Hussain et al., 2023; Menec et al. 2015). Indeed, research findings regarding urban and rural differences in social isolation and loneliness have been inconsistent (Hussain et al., 2023; Menec et al., 2015) suggesting the need for further research on these possible differences. In Spain, as in other places, the dynamics of social networks of older adults in rural communities and its relationship with loneliness has not been studied.”

New references:

Abshire DA, Graves JM, Amiri S, Williams-Gilbert W. Differences in Loneliness Across the Rural-Urban Continuum Among Adults Living in Washington State. J Rural Health. 2022 Jan;38(1):187-193. doi: 10.1111/jrh.12535. Epub 2020 Nov 12. PMID: 33180354; PMCID: PMC8674765

Burnette D, Ye X, Cheng Z, Ruan H. Living alone, social cohesion, and quality of life among older adults in rural and urban China: a conditional process analysis. International Psychogeriatrics. 2021;33(5):469-479. doi:10.1017/S1041610220001210

Hussain B, Mirza M, Baines R, Burns L, Stevens S, Asthana S, Chatterjee A. Loneliness and social networks of older adults in rural communities: a narrative synthesis systematic review. Front Public Health. 2023 May 15;11:1113864. doi: 10.3389/fpubh.2023.1113864. PMID: 37255758; PMCID: PMC10225733.

Menec V, Bell S, Novek S, Minnigaleeva G, Morales E, Ouma T et al. Making rural and remote communities more age-friendly: Experts’ perspectives of issues, challenges, and priorities. J Aging Soc Policy. 2015;27: 173–191. pmid:25647697

Thapa D, Visentin D, Kornhaber R, Cleary M. Migration of adult children and mental health of older parents ‘left behind’: An integrative review. PLOS ONE. 2018;13(10): e0205665. pmid:30346972

-Not clearly specified in the abstract, the manuscript objective is ‘to investigate the prevalence and factors associated with unwanted loneliness in older people residing in the rural área’ of Rincón de Ademuz (Valencia, Spain). This goal would be better understood with the clear specification of a main question (and/or hypothesis) addressed by the research.

Answer: According to Reviewer’s suggestion we have added: “We hypothesize there are specific social and mental health factors that associate with loneliness as they have not been studied in this setting. “

-Section 1 (Introduction) ….

However, a large part of these introductory arguments are based on old references, with about 73% being over 10 years old, and only slightly more than 15% being from the last quinquennium. These conditions reduce the contemporaneity of the state of the art on the theme

Answer: According to Reviewer’s suggestion we have added more recent references:

Freedman A, Nicolle J. Social isolation and loneliness: the new geriatric giants: Approach for primary care. Can Fam Physician. 2020 Mar;66(3):176-182.

Carrasco PM, Crespo DP, García AIR, Ibáñez ML, Rubio BM, Montenegro-Peña M. Predictive factors and risk and protection groups for loneliness in older adults: a population-based study. BMC Psychol. 2024 Apr 26;12(1):238. doi: 10.1186/s40359-024-01708-7.

Lennartsson C, Rehnberg J, Dahlberg L. The association between loneliness, social isolation and all-cause mortality in a nationally representative sample of older women and men. Aging Ment Health. 2022 Sep;26(9):1821-1828.

Holt-Lunstad J, Smith TB, Baker M, Harris T, Stephenson D. Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspect Psychol Sci. 2015 Mar;10(2):227-37.

Zhang X, Dong S. The relationships between social support and loneliness: A meta-analysis and review. Acta Psychol (Amst). 2022 Jul;227:103616.

Paquet C, Whitehead J, Shah R, Adams AM, Dooley D, Spreng RN, Aunio AL, Dubé L. Social Prescription Interventions Addressing Social Isolation and Loneliness in Older Adults: Meta-Review Integrating On-the-Ground Resources. J Med Internet Res. 2023 May 17;25:e40213.

Abshire DA, Graves JM, Amiri S, Williams-Gilbert W. Differences in Loneliness Across the Rural-Urban Continuum Among Adults Living in Washington State. J Rural Health. 2022 Jan;38(1):187-193. doi: 10.1111/jrh.12535. Epub 2020 Nov 12. PMID: 33180354; PMCID: PMC8674765

Burnette D, Ye X, Cheng Z, Ruan H. Living alone, social cohesion, and quality of life among older adults in rural and urban China: a conditional process analysis. International Psychogeriatrics. 2021;33(5):469-479. doi:10.1017/S1041610220001210

Hussain B, Mirza M, Baines R, Burns L, Stevens S, Asthana S, Chatterjee A. Loneliness and social networks of older adults in rural communities: a narrative synthesis systematic review. Front Public Health. 2023 May 15;11:1113864. doi: 10.3389/fpubh.2023.1113864. PMID: 37255758; PMCID: PMC10225733.

-Section 2 (Materials and Methods) clarifies the cross-sectional and observational design of the study, carried out in a sample of older people living in the study área, which comprises 108 participants (aged between 65 and 91 years) selected representatively from the population of interest, based on pre-established criteria.

-Answer: thank you, it is as you understood.

-Next, the information collection procedures are presented, both for the use of the instrument composed of the De Jong-Gierveld Loneliness Scale 2010, specifically designed to measure both emotional and social loneliness, and for its association with the application of a questionnaire by a trained psychologist. It is important to highlight the authors' compliance with ethical research prerequisites.

Answer: According to Reviewer’s suggestion we have added in the Methods section the following:

“The study will be conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and the Belmont Report. All participants will sign a consent form whereby they will be informed of the terms of their participation and the study research goals. Data collected will be anonymized, and only the research team will have access to them. Confidentiality of the participants’ personal data will be guaranteed throughout the whole of the research process. Participants will also be informed that they can discontinue their participation at any time without further consequences.”

-The assessment of emotional and social loneliness is based on the scale of that model, dated 1987, may exclude some up-to-date aspects. The three response options (no, more or less, and yes) and the three established categories (no loneliness, moderate loneliness, and severe loneliness) may lead to results centered on the average, which could be highlighted by the authors as a certain limitation of the study.

Answer: According to Reviewer’s suggestion we have added the following limitation of the study in the Discussion section:

“This study presents some limitations. For instance, participants were selected

by convenience sampling which could limit the representatives of the results.

However, this was a descriptive study with the principal aim of determining the

prevalence of loneliness in this population and this was achieved. On the other

hand, it was conducted in a concrete rural area. It would be interesting to reply it in other rural regions as well as to conduct comparative  studies in contexts with different geographic characteristics, such as rural and  urban settings. In addition to this, it could be interesting to conduct mixed-methods studies, combining quantitative with qualitative data, to be able to  explain further some of the results.”

-Additionally, the exposition of the psychogeriatric assessment could be illustrated in synthetic tables for ease of understanding the adopted attributes.

Answer: We have included data on psychogeriatric assessments in table 1 “Table 1. Sociodemographic characteristics and psychogeriatric assessments.”

-The statistical analysis is explained succinctly but sufficiently clearly. In general terms, the materials and methods section allows for the reproducibility of the work.

Answer:  Many thanks for these positive comments.

-Section 3 (Results) begins with the sample characteristics of the study population, but for those unfamiliar with the Spanish reality, there is insufficient information about the location of the study area, including illustrations like maps, as well as relevant regional and/or national general data to understand the overall context of the study.

Answer: According we gave more information about the location of the study area at the end of the Introduction section:

“Spain is currently one of the European countries that suffers most from depopulation of rural areas, with 52% of the population living in cities of more than 50,000 inhabitants, while only 3.2% live in municipalities with less than 1000 inhabitants, a phenomenon currently called “Emptied Spain” (Mileto et al., 2021). Among the depopulated rural areas, the Rincón de Ademuz is the least populated region of Valencia (located 2 hours North-West driving from Valencia), with a population density of 6 inhabitants per square kilometre, which places it among the most unpopulated areas in Spain.”

-Part of this problem is resolved in Section 4 (Discussion), in which the scientific debate is based on more current references, with a little over 61% corresponding to the last decade, of which about 62% are from the last five years.

Answer: Thank you

-Although relatively consistent, Section 5 (Conclusions) is very succinct and could detail the limitations of the work further. It could also elaborate more on its contributions (and answers to the possible investigative question and/or hypothesis) across various aspects

-Answer: According to Reviewer’s suggestion we have added in this section the following paragraph:

“The principal contribution of this study has been to explore the prevalence of  loneliness and associated factors in older adults living in rural areas, an issue that has been  understudied so far. Moreover, this research has allowed to identify some of the factors  that are related to the loneliness perception. This knowledge will contribute to the design of tailored and individualized interventions for this population.”

-As previously stated, one of the main points of improvement for the article is the updating of references, which, although appropriate, correspond to almost 62% being over a decade old and only about 22% pertaining to the last five years. Another suggested improvement concerns the inclusion of some of the figures and tables mentioned above.

-Answer: we thank the Reviewer for his/her insightful suggestions aimed to improved the quality of the manuscript.

-The manuscript needs small spelling and grammatical adjustments, as well as minor typing corrections. It is suggested to reduce excessively long paragraphs that make the text difficult to interpret.

Answer: Done as suggested

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

As noted in my initial review, the manuscript reports findings from a cross-sectional analysis of the predictors of loneliness in a sample of older adults in a Spanish rural area. The authors are commended for providing a thorough response to my suggestions and a clear summary of the revisions. The Introduction is more informative and consistent to read, and the Methods and Results are clearer to readers now. One final comment is: there are occasions the authors claimed the sample to be ‘representative’ (e.g. line 140, p. 3; line 385, p.10), but in line 547, p. 13, the authors suggested that ‘participants were selected by convenience sampling which could limit the representatives of the results’. Please resolve this inconsistency here.

Author Response

One final comment is: there are occasions the authors claimed the sample to be ‘representative’ (e.g. line 140, p. 3; line 385, p.10), but in line 547, p. 13, the authors suggested that ‘participants were selected by convenience sampling which could limit the representatives of the results’. Please resolve this inconsistency here. Answer: We thank the Reviewer for his/her suggetsions, we have eliminated in all part of the manuscript the reference to "represnetative" which is not .

Author Response File: Author Response.pdf