Highlights
The HEAL-HOA randomized clinical trial (RCT) provides robust evidence for the long-term efficacy of brief, telephone-delivered psychological interventions in mitigating late-life loneliness. The following highlights summarize the core findings:
- Lay counselor-delivered interventions using Behavioral Activation (BA) and Mindfulness (MF) significantly reduced loneliness at 12 months compared to a befriending control group.
- The effects were sustainable, with improvements extending to secondary outcomes such as sleep quality, life satisfaction, and psychological well-being.
- Social isolation was identified as a key mediator, accounting for 13.5% to 18.0% of the total treatment effect on loneliness.
- The telephone-based delivery model effectively bypassed the digital divide, reaching low-income, digitally excluded older adults who are often neglected by modern digital health initiatives.
The Growing Crisis of Late-Life Loneliness
Loneliness in older adults is not merely a subjective feeling of distress; it is a significant public health determinant associated with a 26% increase in all-cause mortality. The clinical consequences of chronic loneliness are comparable to those of smoking or obesity, contributing to accelerated cognitive decline, cardiovascular disease, and depression. Despite its clinical importance, interventions targeting loneliness often suffer from limited scalability or fail to reach the most vulnerable populations—specifically those living in financial hardship and those who are digitally excluded.
The Helping Alleviate Loneliness in Hong Kong Older Adults (HEAL-HOA) trial addressed a critical unmet need by testing low-intensity, scalable interventions delivered via traditional telephony. This approach is particularly relevant for older adults who may lack the technological literacy or hardware required for internet-based interventions, ensuring that the most isolated individuals are not left behind by the digital transformation of healthcare.
Trial Methodology: Reaching the Digitally Excluded
The HEAL-HOA trial was a 3-arm, assessor-blinded randomized clinical trial conducted between April 2021 and April 2024. The study recruited 1,151 participants aged 65 or older who met specific criteria for vulnerability: living alone, experiencing financial hardship, being digitally excluded (no smartphone or internet use), and reporting significant loneliness. The mean age was 76.6 years, and over 80% of the cohort suffered from at least one chronic illness.
Intervention Arms
Participants were randomized into three groups, each receiving eight 30-minute sessions over four weeks, delivered by trained lay counselors via telephone:
- Telephone-Delivered Behavioral Activation (Tele-BA): This intervention focused on the link between activity and mood. Participants were encouraged to identify and schedule rewarding activities, thereby increasing positive reinforcement from their environment and reducing social withdrawal.
- Telephone-Delivered Mindfulness (Tele-MF): This arm utilized mindfulness-based techniques to help participants cultivate present-moment awareness and non-judgmental acceptance of their thoughts and feelings, specifically targeting the cognitive-affective aspects of loneliness.
- Telephone-Delivered Befriending (Tele-BF): Serving as an active attention control, this group received regular social contact and conversation from lay counselors without specific therapeutic components.
Primary and Secondary Clinical Outcomes
The primary outcomes were measured using the UCLA Loneliness Scale (UCLA-LS) and the De Jong Gierveld Loneliness Scale (DJGL). Assessments occurred at baseline and at 1, 3, 6, and 12 months. The results indicated a clear superiority of the active interventions over the control group.
Long-Term Loneliness Reduction
At the 12-month follow-up, both Tele-BA and Tele-MF demonstrated statistically significant reductions in loneliness compared to Tele-BF. For the Tele-BA group, the mean difference (MD) on the UCLA-LS was -0.73 (95% CI, -1.29 to -0.16; P = .01). For the Tele-MF group, the MD was -0.72 (95% CI, -1.24 to -0.20; P = .003). Similar trends were observed using the DJGL scale, confirming the robustness of the findings across different measurement tools.
Improvements in Holistic Well-Being
Secondary outcomes revealed that the benefits of BA and MF extended beyond social connection. Participants in the active intervention arms reported significant improvements in sleep quality, life satisfaction, and overall psychological well-being. Notably, these interventions also appeared to mitigate perceived stress and depressive symptoms more effectively than befriending alone. The persistence of these effects at one year suggests that the skills learned during the brief 4-week intervention period (e.g., activity scheduling or mindfulness practice) were integrated into the participants’ daily lives.
Mechanistic Insights: The Role of Social Isolation
A sophisticated component of the HEAL-HOA trial was the exploration of mediation pathways. The researchers hypothesized that while loneliness is a subjective experience, it is often driven by the objective state of social isolation. The mediation analysis confirmed that a reduction in social isolation at the 6-month mark partially mediated the reduction in loneliness at 12 months. Specifically, social isolation accounted for 13.5% of the effect in the Tele-BA group and 18.0% in the Tele-MF group.
This suggests that Tele-BA works by prompting individuals to re-engage with their social environment (reducing objective isolation), while Tele-MF may help individuals better manage the distress associated with being alone while also potentially making them more open to social interactions. These findings provide a biological and behavioral plausibility for why these brief interventions yield long-term results.
Clinical and Public Health Implications
From a health policy perspective, the HEAL-HOA trial offers a blueprint for addressing the loneliness epidemic in aging societies. The use of lay counselors—individuals without formal clinical degrees but trained in specific protocols—is a critical example of ‘task-shifting.’ This approach allows for the delivery of mental health support at a fraction of the cost of professional therapy, making it feasible for large-scale implementation within community centers or public housing systems.
Furthermore, the reliance on telephone delivery addresses the equity gap in healthcare. As many health systems move toward mobile apps and telehealth platforms, older adults with low digital literacy are increasingly marginalized. This study proves that ‘low-tech’ solutions can be highly effective, provided they are grounded in evidence-based psychological principles.
Study Limitations
While the results are compelling, some limitations warrant caution. The study was conducted within the specific socio-cultural context of Hong Kong, which has high population density and unique social structures. The participants were predominantly female (73.2%), and while this reflects the demographic reality of older adults living alone, it may limit generalizability to men. Additionally, while the interventions were effective, the effect sizes were modest, suggesting that for some individuals, more intensive or multifaceted support may be required.
Conclusion
The HEAL-HOA trial demonstrates that brief, telephone-based behavioral activation and mindfulness interventions delivered by lay counselors are effective, sustainable, and scalable solutions for reducing loneliness in at-risk older adults. By targeting both the behavioral patterns and the cognitive appraisals associated with loneliness, these interventions provide a dual-pathway approach to improving late-life well-being. For clinicians and policymakers, these findings highlight the importance of maintaining non-digital avenues for mental health support and the potential of task-shifting to meet the growing psychological needs of an aging population.
Funding and Trial Registration
This study was supported by various health and social welfare funds in Hong Kong. Trial Registration: ChiCTR2300072909.
References
Tang VFY, Jiang D, Kwok JYY, Yeung DY, Choi NG, Warner LM, Ho RTH, Chou KL. Behavioral Activation and Mindfulness Interventions in Reducing Loneliness and Improving Well-Being in Older Adults: The HEAL-HOA Randomized Clinical Trial. JAMA Netw Open. 2026 Feb 2;9(2):e2557170. doi: 10.1001/jamanetworkopen.2025.57170. PMID: 41637070.
