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Abstract

Loneliness among older adults is a significant public health concern, with evidence highlighting its negative impact on physical and mental health. This study examined healthcare providers’ knowledge, attitudes, and practices (KAP) regarding loneliness among older adults in primary healthcare settings. Sixteen healthcare providers from the Palestinian minority participated in semi-structured, in-depth interviews. Key sub-themes emerged within each KAP domain. In the knowledge domain, most participants demonstrated a basic understanding of loneliness. The attitudes domain highlighted the central role of family in loneliness. In the practice domain, participants described various approaches to addressing loneliness, though efforts were largely individual due to limited resources in primary care clinics. The findings reveal both strengths and gaps, underscoring the need for culturally sensitive, structured interventions, enhanced institutional support, and targeted training to integrate loneliness assessment and management into primary care more effectively.

Keywords

loneliness older adults healthcare providers primary care

What This Paper Adds to Existing Literature

Identifies key gaps in healthcare providers’ understanding and management of loneliness among older adults, particularly within the Palestinian minority population.

Highlights the influence of systemic and cultural factors in shaping healthcare providers’ approaches to loneliness, especially within minority and disadvantaged populations.

Emphasizes the limited focus in previous research on healthcare providers’ roles in detecting and managing loneliness, underscoring the need for further exploration in this area.

Applications to Gerontological Practice, Policy, and/or Research

Calls for targeted training programs to improve healthcare providers’ awareness, knowledge, and skills in recognizing and addressing loneliness in older adults.

Recommends implementing structured screening and intervention protocols in primary healthcare settings to enhance early detection and management of loneliness.

Advocates for policy-level investments to increase resources within primary care institutions, empowering healthcare providers to adopt collaborative and culturally responsive approaches in supporting older adults.

Introduction

Loneliness, as defined by Peplau and Perlman (1982), is a negative and subjective experience arising from a perceived gap between an individual’s existing and desired social relationships. While loneliness affects all age groups, older adults are particularly vulnerable, with prevalence reaching up to 31.6% globally in certain regions, according to a recent meta-analysis (Stegen et al., 2024). Key risk factors for loneliness among older adults include being unmarried or unpartnered, losing a spouse or partner, limited social networks, low social activity, poor self-perceived health, and depression or depressive symptoms, as highlighted in a recent literature review (Dahlberg et al., 2022). These risk factors span demographic, social, health-related, and psychological dimensions, highlighting the complex, and multifaceted nature of loneliness in older adults.

In addition, there is substantial evidence that loneliness among older adults negatively impacts both physical and mental well-being, contributing to conditions such as cardiovascular disease, depression, cognitive decline, and dementia (Dobarrio-Sanz et al., 2021; Gerst-Emerson & Jayawardhana, 2015). Consequently, loneliness among older adults has become a significant public health concern (Gerst-Emerson & Jayawardhana, 2015). The COVID-19 pandemic has further intensified feelings of loneliness and social isolation in this population, and with the global population aging, it is increasingly critical to prioritize these issues within public health strategies (Su et al., 2023).

However, despite the observed correlation between loneliness and increased healthcare provider visits (Gerst-Emerson & Jayawardhana, 2015), most studies in this field primarily focus on the experience of loneliness solely among older adults, often overlooking the critical perspective of healthcare providers. Healthcare providers play a pivotal role in identifying and addressing loneliness, yet the limited research conducted in this area suggests significant challenges in their ability to recognize and address loneliness among older adults. These challenges may stem from time constraints, lack of training, or inadequate resources within the healthcare system (Dobarrio-Sanz et al., 2021; Somes, 2021; Yoshida et al., 2022). Furthermore, this gap in understanding underscores the necessity for more comprehensive investigations to explore the barriers healthcare providers face, examine their knowledge and perceptions regarding loneliness, and develop evidence-based recommendations to enhance their capacity to mitigate loneliness among older adults effectively.

Most studies on loneliness among older adults not only overlook the perspective of healthcare providers but are also predominantly conducted in Europe and the United States, with limited attention given to older individuals in disadvantaged groups and ethnic minority groups (Stegen et al., 2024). One such group that has received insufficient attention is older adults from the Palestinian minority in Israel. The Palestinian minority is the largest ethnic minority in the country, constituting 21.1% of the total population (Central Bureau of Statistics, 2023). While the Palestinian minority is considered a young population, with 40% under the age of 18, the proportion of older adults aged 65 and above has been increasing over the last decade. Currently, 5.3% of the minority population is aged 65 or older, with 36.2% of them aged 75 and above (Myers-JDC-Brookdale Institute, 2023).

Between 2019 and 2021, 30.1% of older Palestinians in Israel experienced significant difficulty with personal care, and 51.9% faced great difficulty performing household activities (Myers-JDC-Brookdale Institute, 2023). Compared to older adults from the general population, Palestinian older adults are at higher risk for chronic diseases, neurological conditions, and poor mental health, partly due to low socioeconomic status and limited awareness of health issues (Abo-Rass et al., 2021; Chernichovsky, Basharat, & Sowers, 2017; Chernichovsky, Bisharat et al., 2017; Dwolatzky et al., 2017). Older adults within the Palestinian minority are experiencing significant social changes, such as a decline in their societal status (Faraj-Falah & Hassoun, 2018), yet they benefit from strong family values and a deep commitment to caregiving within their community (AboJabel & Abo-Rass, 2025).

To our knowledge, only three studies have examined loneliness among Palestinian older adult citizens of Israel. Two studies found that Palestinian older adults reported higher levels of loneliness compared to the general population, while the third study reported the opposite (Khalaila & Vitman-Schorr, 2021; Schorr et al., 2021; Shiovitz-Ezra, 2011). However, these studies were conducted in different contexts—one is outdated, another was conducted during the COVID-19 pandemic, and the third focused solely on attendees of daycare centers, limiting their generalizability. At the same time, research indicates that Palestinian older adults have higher rates of primary care visits (Baron-Epel et al., 2007; Hayek et al., 2020), reflecting the high value placed on healthcare providers within Palestinian society. Primary healthcare providers, particularly family physicians, are regarded as key sources of information and support for both physical and mental health issues (Abo-Rass et al., 2024). Despite this, there is a significant gap in knowledge regarding healthcare providers’ understanding, attitudes, and practices related to loneliness in this population. Exploring their perspectives is crucial for designing effective interventions to address loneliness, as these providers play a pivotal role in implementing tailored strategies and raising awareness among older adults and their caregivers. Their insights are essential to ensuring comprehensive care and support for this vulnerable population.

The Present Study

This study explored family physicians’ and nurses’ knowledge, attitudes, and practices regarding loneliness among older adults in primary healthcare settings. It adopts the Knowledge, Attitudes, and Practices (KAP) framework, originally developed for quantitative surveys to gather information to plan and implement public health programs (Launiala, 2009). In this framework, knowledge refers to objective awareness, attitudes encompass subjective beliefs and perceptions, and practices describe the actual actions in response to a public health issue. However, this study applies a qualitative approach to provide a richer, more nuanced understanding of how primary healthcare providers perceive and address loneliness in their practice.

Methods

Participants

The sample comprised 16 Palestinian family physicians and nurses, citizens of Israel, who work in primary care clinics in Palestinian villages and towns, providing care to older Palestinian adults. Family physicians and nurses were selected as participants because they are typically the first point of contact, health gatekeepers, in the primary healthcare system, and are most likely to engage with a large number of older adults. This was also a part of an international case study project with comparable data collection among family physicians and nurses in Japan (Yoshida et al., 2024). The theoretical saturation principle determined the final sample size (Guest et al., 2006). Table 1 presents the sociodemographic characteristics of the participants. The table shows that 68.75% of the participants were nurses, with half of the sample being female and half being male. The participants’ mean age was 40 years (SD = 9.75, range = 28–58), and their mean work experience was 15.88 years (SD = 9.53, range = 5–32).

Table 1.

Participants’ Sociodemographic Characteristics (N = 16).

Profession: n (%)
Nurse	11 (68.75)
Family physician	5 (31.25)
Gender: n (%)
Female	8 (50%)
Male	8 (50%)
Age: M (SD)	40 (9.75)
Work experience: M (SD)	15.88 (9.53)

Procedure

The Ethics Committee of The Hebrew University approved the research protocol. Approval number: 29032024. The authors posted an advertisement on social media to recruit potential participants, explaining the study’s goals and methods. Several participants expressed interest and referred us to other potential participants they knew, who also willingly agreed to participate through a snowball sampling technique.

The second and third authors contacted participants via email to schedule interviews. All interviews were conducted in Arabic by the second and third authors, both of whom have extensive experience in qualitative interviewing. The interviews were conducted via Zoom, lasted approximately 30 min each, and were recorded and subsequently transcribed. To ensure confidentiality, all identifying information was removed from the transcripts. Before conducting the interviews, participants received an additional explanation about the study and signed an informed consent form.

Interview Guide

The interview guide began with general questions such as, “Can you tell me about yourself?” and “What do you know about loneliness?” These initial questions were designed to establish rapport with participants and gather baseline information about their personal perspectives. The guide used the KAP Framework to explore knowledge, Attitudes, and practices about loneliness among older adults. Specific questions included, “How do you identify loneliness among older adult patients?” “How do you respond when you identify loneliness in one of older adult patients?” and “What are your views on the support Arab older receive from health institutions?” Additionally, the interview included a very brief sociodemographic questionnaire to collect essential participant information.

Data Analysis

Interviews were analyzed thematically following Braun et al. (2014), using a directed qualitative content analysis guided by the KAP Framework and conducted with ATLAS.ti version 9. In the first stage, the first three authors independently analyzed 18.75% of the interviews through a deductive coding process, categorizing data under the pre-established domains of knowledge, attitudes, and practice. Within each category, an inductive approach was applied to identify emerging themes. Discrepancies in coding were resolved through discussion, leading to developing a structured codebook with themes and subthemes. In the second stage, the first two authors assessed intercoder reliability by independently coding three interviews using the finalized codebook, achieving a 92% agreement rate (Bernard, 2011; O’Connor & Joffe, 2020). The primary researcher then coded the remaining interviews. Finally, illustrative quotes were selected to support the analysis (Miles et al., 2013).

Results

Results are organized using the Knowledge, Attitudes, and Practices framework. Each domain is presented with its respective subthemes, providing a structured analysis of the findings. Table 2 summarizes the subthemes identified in the study.

Table 2.

The Study’s Main Themes and Sub-Themes.

Theme	Sub-themes
Theme 1: Knowledge	1.1 Understanding of loneliness: Its risk factors and consequences
Theme 1: Knowledge	1.2 Identification of loneliness
Theme 2: Attitudes	2.1 Family as a double-edged factor
	2.2 Increasing loneliness among Palestinian older adults
	2.3 Sociocultural influences on loneliness
Theme 3: Practice	3.1 Approaches to addressing loneliness
Theme 3: Practice	3.2 Practical challenges and individual efforts

Theme 1: Knowledge

Understanding of Loneliness: Its Risk Factors and Consequences

Most participants demonstrate a foundational understanding of loneliness, reflected in their ability to identify its risk factors and consequences. They recognize that loneliness among older adults is influenced by various factors, including living alone, the loss of a spouse, and declining physical health, particularly when it limits mobility. However, all of them reported that the most prominent risk factor is the lack of family support, which was unanimously identified as a major contributor to loneliness.

Their health condition, along with the treatments and medications they take, can contribute to their loneliness. Additionally, as they age and feel that no one is around them—that their children and family are not by their side or offering support—it can deeply affect them, making loneliness even more difficult to bear. I believe these are the key factors influencing their well-being. An elderly person who is retired, without a caregiver or friends, may experience even greater isolation, especially as many of their peers have passed away or become distant, leading to fewer social connections (Participant 3, Nurse).

The participants’ comprehension of loneliness extends to its consequences, as they consistently describe its psychological and physical repercussions. The most prominently reported consequence is depression, which participants identify as a direct emotional response to feelings of loneliness. Additionally, they highlight other manifestations, including persistent low moods and physical illnesses, which they perceive as both a cause and an effect of loneliness.

Loneliness has a significant impact on the psychological state, making them feel sad, isolated, and depressed (Participant 8, Physician).

Loneliness, of course, affects many aspects, including behavior and health. As I mentioned, when a person is alone, they become afraid of sleeping, feel unwell, and suffer from various illnesses. Additionally, elderly individuals often struggle to move and go out to socialize. They spend most of their time at home and need assistance with household tasks, which further contributes to their loneliness (Participant 15, Physician).

Identification of Loneliness

All participants, without exception, reported recognizing loneliness in older adults primarily when the individuals explicitly expressed it. Direct reports from older adults were perceived as the most straightforward and unambiguous way to identify loneliness, serving as the clearest signal for healthcare providers.

In general, an elderly person will say directly that they are lonely. When we talk to them, they speak a lot, and through this, you realize that they want someone to talk to, to express their negative feelings, and that they are experiencing loneliness (Participant 2, Nurse).

However, while participants demonstrated a relatively strong understanding of loneliness in terms of its risk factors and consequences, their ability to recognize loneliness in practice appeared less definitive. A notable level of confusion emerged among participants, with nearly half conflating the symptoms of depression with the signs of loneliness. Symptoms such as unkempt appearance, low mood, and verbal expressions about a willingness to die were often cited as indicators of loneliness.

I understand that an elderly person tends to feel lonely when they are feeling down or not dressed appropriately for the weather. Their facial expressions often appear sad, and sometimes they cry (Participant 6, Physician).

Lonely older adults say: ‘Oh God, take me and give me peace.’ They wish for death, saying, ‘Don’t let me be a burden on anyone (Participant 7, Nurse).

Interestingly, participants highlighted an additional, more indirect method of identifying loneliness: frequent clinic visits. Many observed that when older adult individuals begin visiting the clinic repeatedly, often without a clear medical need, and frequently inquire about medications, these behaviors are interpreted as subtle expressions of loneliness. This behavioral pattern served as a red flag for the participants, prompting further inquiry into the patient’s underlying social and emotional state.

I see that many elderly people experiencing loneliness frequently visit the clinic, not for physical illnesses but for other reasons. The first sign that an elderly person may have a problem is their repeated visits. They come regularly and keep asking questions. For example, they take one medication each day instead of all at once, which signals their loneliness (Participant 4, Nurse).

Theme 2: Attitudes

Family as a Double-Edged Factor

All participants, both physicians and nurses, emphasized the central role of the family in the context of loneliness among Palestinian older adult people. They consistently highlighted that the family’s involvement, or lack thereof, is a key determinant in whether loneliness is prevented or exacerbated. On one hand, the care and attention provided by family members, particularly children, are seen as the most significant protective factors against loneliness. On the other hand, the absence of family support or neglect by family members is perceived as one of the primary causes of loneliness among older adults.

If an elderly person has only one or two children who are busy and inattentive, with no grandchildren or family support, they will inevitably experience loneliness. Regardless of their circumstances, as long as they are surrounded by a supportive family that fills their life with care and companionship, even in times of hardship or illness, loneliness becomes unlikely (Participant 10, Nurse).

Participants perceive that it is the responsibility of families to care for their older adults, even suggesting that families are the ultimate solution to the problem of loneliness. They strongly believe that it is the family’s role to maintain older adults’ well-being and protect them from experiencing loneliness.

The family should be the first to understand and support the elderly, which requires effort and dedication. However, it is the children’s responsibility to care for their parents. A brief five-minute visit is not enough; someone must be present, attentive to their well-being, and considerate of their emotional needs. Caring for elderly parents should be a shared responsibility among all children and family members (Participant 9, Physician).

Increasing Loneliness Among Palestinian Older Adults

All participants believed that Palestinian older adults are now experiencing and reporting higher levels of loneliness compared to the past. They attributed this trend to significant societal changes that have weakened traditional social connections. Key factors include children living farther away from their older adult parents, longer working hours that limit family interactions, and the reduced availability of daughters and daughters-in-law—who traditionally played a central caregiving role—to visit and care for their older adult parents.

From what I observe as a doctor, complaints of loneliness among the elderly have been increasing in our Palestinian society in recent years (Participant 1, Nurse).

In recent years, many things have changed—the structure and nature of the family have shifted. Families are smaller, and both men and women now work. In the past, the daughter-in-law would stay home to care for her elderly in-laws and young children. Today, with both men and women working at least eight hours a day, it has become difficult for them to care for their families. This creates a gap, leaving the elderly feeling alone (Participant 13, Nurse).

Participants also emphasized that these changes extend beyond the immediate family to the broader social fabric. They noted a marked decline in the frequency and spontaneity of visits between extended family members and among older adults themselves. Unlike in the past, when such interactions were more natural and required little coordination, current social visits often involve significant planning, making them less frequent and less integral to daily life. This shift has further contributed to the loneliness feelings of older Palestinian adults.

Back in the day, I remember when we were at home, my uncle or cousin would suddenly visit, and my parents would enjoy sitting, talking, and drinking coffee. In the evenings, neighbors would often drop by unannounced. Today, this has changed—such spontaneous visits have nearly disappeared. People visit far less, and now everything requires appointments and planning. Things have become much more difficult for the elderly, as they no longer have the same opportunities to meet and enjoy time together as they once did (Participant 13, Nurse).

Sociocultural Influences on Loneliness

Although all participants reported that older adults experience more loneliness today than in the past, most believe that Palestinian older adults experience less loneliness compared to their counterparts in Western cultures. They attribute this difference to Arab cultural and religious norms, which emphasize respect for older adults and intergenerational care. In contrast, participants observed that Western cultures do not ascribe a special status to older adults or place similar values on caring for them. These Arab norms are seen as creating a supportive environment that helps protect Arab older adults from loneliness.

I believe that loneliness among the elderly in our society exists, but it is much less prevalent compared to other societies. Families here provide strong support for their elderly members. From my experience working in another place considered Western, I have observed that loneliness is less common among us because children uphold values and standards that emphasize respect for their elderly parents. They do not allow themselves to abandon them, unlike in some other societies. Our religion emphasizes caring for the elderly and being dutiful to them. I can say the elderly in our society are highly respected (Participant 11, Nurse).

However, not all participants shared this perspective. Some of them argue that Western societies may experience less loneliness among older adults because they provide more comprehensive social and community frameworks. These frameworks include organized activities, hobby groups, and access to community centers specifically tailored for older adults. Such opportunities, they claimed, offer Western older adult populations a wider range of social engagement options beyond familial relationships, enabling them to stay active and connected within their communities, which can mitigate loneliness more effectively.

The issue of loneliness among elderly Arabs is often hidden. It exists—perhaps even more than in other societies—but remains unspoken. Unlike in Jewish Israeli society, where there are sheltered homes, day centers, and vibrant internal communities filled with activities, we lack such frameworks. There isn’t a single sheltered home for our elderly, and while some day centers exist, they neither focus on enrichment nor foster a true sense of community. There are no dedicated spaces for the elderly—no cafés, accessible public streets, or parks—all of which further deepen and reinforce their loneliness (Participant 16, Nurse).

Theme 3: Practice

Approaches to Addressing Loneliness

Participants described a variety of approaches they use to address loneliness among older adults, demonstrating a strong commitment to both understanding the issue and providing support. Their strategies were varied and multi-faceted. Many participants explained that when they notice signs of loneliness, their first step is to engage in meaningful conversations with older adult individuals. They emphasized the importance of showing genuine interest and asking thoughtful questions to understand better the context and underlying factors contributing to the person’s feelings of loneliness. Some participants noted that they take action by reaching out to healthcare providers, such as social workers, as part of their response.

First of all, an elderly person experiencing loneliness receives a lot of attention from me. I might visit them at home, talk to them, ask about their condition and emotions, and try to understand what can help them. I also look for people close to them and attempt to connect with them. They have many needs, and I must follow up with them personally—they are not just an ordinary patient (Participant 5, Physician).

Honestly, I work with social workers because it is essential not to handle this issue alone. Doctors, nurses, and social workers must work together. When there is a need to involve someone, I reach out because I cannot solve the problem on my own. In our clinic, at least from my personal experience, whenever I have a patient who I feel needs to see a psychologist or physiotherapist, I make sure to refer them (Participant 2, Nurse).

Additionally, many participants highlighted the importance of encouraging older individuals to participate in social activities, particularly by helping them integrate into day centers.

In Palestinian society, there is a misconception about social activities for the elderly and day centers. There is a lack of awareness about the psychological well-being of the elderly. Many believe that day centers are only for those who are frail or dependent, and that going to one is shameful. I work to correct this perception, explaining that day centers are not just for those who are disabled but also to prevent loneliness. Elderly individuals can go there to play chess, eat healthy meals, take sewing courses, and engage in enjoyable activities. I often encourage them to participate in these activities, meet people, and visit the day centers to stay socially connected (Participant 7, Nurse).

Interestingly, several participants described taking an extra step by contacting a family member of the older individual. They viewed this as a way to share observations about the person’s loneliness and to encourage the family to become more involved in addressing the issue.

The first thing I do when I see an elderly patient who clearly feels lonely is to talk to their family and children. I try to explain what their loved one is experiencing and feeling, as they may not realize that their family member is struggling with loneliness. I observe whether they take responsibility, engage, and take steps to address the situation. If, after some time, I see that they are not involved or showing interest, I turn to the social worker for support (Participant 14, Physician).

Practical Challenges and Individual Efforts

All participants unanimously reported significant challenges stemming from a lack of resources within health insurance organizations (HBO) and health institutions to address loneliness among older adults. These challenges include a shortage of social workers and psychologists, as well as an absence of programs and activities specifically designed for older adults. Participants emphasized that these gaps hinder their ability to address the issue of loneliness within their professional capacity comprehensively.

The medical and nursing staff are aware of loneliness among the elderly, but there are not enough resources to properly address this issue. For example, a social worker is not available in our clinic, or in other clinics, appointments take months. A social worker, who plays a crucial role in supporting these patients, is often missing, and physiotherapists are also unavailable. In the Arab community, there is a lack of specialized professionals and services, both inside and outside clinics. There are no adequate facilities or institutions to accommodate the needs of older adults (Participant 5, Physician).

Furthermore, participants emphasized that loneliness among older adults does not receive adequate attention within the broader health and welfare policy framework. This neglect is particularly evident in the shortage of day centers for older adults, especially within the Palestinian minority. This lack of prioritization extends to HBO, further deepening resource shortages and restricting systemic support for effectively addressing loneliness.

From my experience, health policies do not prioritize the issue of loneliness. Their focus is on physical health problems, with no attention given to the psychological well-being of the elderly. As nurses, there is not much we can do in primary care beyond referring them to a social worker. However, in my experience, social workers often lack the tools to effectively address the issue and mainly inform the elderly about their rights, without offering real solutions. In reality, there are very few rights for the elderly, and those that exist are difficult to access in our minority (Participant 16, Nurse).

However, participants also identified significant challenges to their individual efforts. One of the most frequently mentioned obstacles was the lack of time, which was driven by high workloads and understaffing at HBO. The shortage of personnel not only increases their responsibilities but also reduces the time they can dedicate to each older individual. This tension between their desire to help and their practical constraints was described as a source of frustration and concern.

The conditions in which we, the medical staff, work in the primary care clinics are challenging—there are no sufficient resources, and there are not enough doctors and nurses. We have a small staff handling a large number of patients, leading to constant pressure and a lack of time. This makes it difficult to deeply address the issue of loneliness. For example, I might be with a patient when I am suddenly called for another, leaving no time to properly engage in conversations or provide the necessary support (Participant 12, Nurse).

Discussion

This qualitative study, based on the KAP framework, explored healthcare providers’ knowledge, attitudes, and practices regarding loneliness among older adults in primary care settings serving the Palestinian minority in Israel, and the discussion examines the findings in each of these domains in order.

Regarding the knowledge domain, we found that healthcare providers demonstrated a high overall level of knowledge about loneliness among older adults, particularly in relation to its risk factors and consequences. Participants identified several key contributors to loneliness, including widowhood, limited social networks, and declining physical health, which aligns with previous studies that highlight these as primary determinants of loneliness in older populations (Dahlberg et al., 2022; Gerst-Emerson & Jayawardhana, 2015). However, despite their overall knowledge, we identified that healthcare providers primarily attribute symptoms of depression—such as social withdrawal, low mood, and self-neglect—to loneliness when assessing older adults. This challenge likely stems from the strong relationship between loneliness and depression, as they share overlapping emotional and behavioral manifestations, a phenomenon well-documented in the literature (Cacioppo et al., 2010; Powell et al., 2021; Singh & Misra, 2009). While loneliness is a subjective social experience, depression is a clinically diagnosable condition with biological and psychological foundations that often require medical intervention (Mann et al., 2022; Singh & Misra, 2009). Misidentifying loneliness as depression—or vice versa—can lead to inappropriate treatment approaches (Fakoya et al., 2020), such as prescribing antidepressants instead of implementing social interventions. This underscores the need for training programs that equip healthcare providers with the skills to assess loneliness as a distinct issue and ensure that interventions are properly tailored. In any case, this result reinforces the need for a clearer and more structured definition of loneliness, distinguishing it from overlapping constructs, to improve health outcomes in older adults (Barnes et al., 2022).

In addition, most providers relied on explicit self-reports from patients to identify loneliness among older adults, suggesting that loneliness was primarily addressed only when patients verbalized their feelings. This is concerning, as research indicates that individuals from collectivist cultures, in contrast to those from individualist cultures, tend to suppress emotions (Huwaë & Schaafsma, 2018), a pattern also observed among older adults from the Palestinian minority, who were found to underreport negative emotions and personal experiences (AboJabel et al., 2015). At the same time, some participants reported identifying loneliness through frequent, medically unnecessary clinic visits, recognizing it as a potential indicator of loneliness. This aligns with prior research showing that lonely older adults tend to seek healthcare services at higher rates (Gerst-Emerson & Jayawardhana, 2015). However, the reliance on both direct self-reports and indirect behavioral cues suggests a lack of systematic approaches for identifying loneliness. This highlights the need to develop a structured, culturally adapted protocol for detecting loneliness among older adults from this minority group, as well as other minorities with similar characteristics.

The second theme explored was healthcare providers’ attitudes, where we found that participants perceived the family’s role in loneliness as crucial, highlighting both its protective and risk-enhancing aspects. This finding is not surprising and aligns with the prevailing perception within the Palestinian minority that family bears the primary responsibility for caring for older adults (AboJabel & Abo-Rass, 2025). The literature supports this view, showing that in other collectivist and traditional societies, families are also perceived as the primary source of emotional and physical support for older adults (Ng & Indran, 2021). However, a key concern emerging from these findings is that both the community and healthcare providers tend to limit the responsibility for loneliness solely to families. This narrow perspective may hinder a more comprehensive approach to addressing loneliness and prevent the development of broader institutional solutions. Instead of placing the entire burden on families, a more integrated approach that includes institutional and community-based interventions is needed to ensure a shared responsibility in supporting older adults and mitigating loneliness.

However, participants also noted that family disengagement in older adult care within Palestinian society is becoming increasingly common due to economic pressures, urban migration, and evolving gender roles. As younger generations relocate for education and employment, and as more women participate in the workforce, the traditional caregiving model is shifting, reducing the availability of family-based support (AboJabel et al., 2024). For participants, this family disengagement, along with broader sociocultural changes, has weakened relationships with extended families and the broader community, further increasing loneliness among older adults in the Palestinian minority.

Lastly, our third theme explores healthcare providers’ practices in addressing loneliness among older adults in the Palestinian minority. It is encouraging to find that providers reported a commitment to tackling loneliness, even though their approaches are often informal, unstructured, and based on individual efforts. Their responses reflect an awareness of the issue, an understanding of the importance of social engagement for older adults, and a concern for their mental well-being, as they addressed loneliness by engaging patients in conversation, demonstrating empathy, and encouraging participation in social activities, such as community programs or day centers. However, this observation of informal, unstructured, and personal efforts aligns with findings that highlight the need to incorporate formal, structured assessments of loneliness and prevention programs into routine evaluations of older adults by healthcare providers (Kehrer-Dunlap et al., 2024) and further reinforces our recommendation for establishing a protocol for detecting and addressing loneliness that also includes social factors.

What is less encouraging is that these individual efforts likely emerged due to a lack of institutional support and resources to systematically address loneliness. Participants described a shortage of resources within health insurance funds that could help mitigate loneliness, including a lack of social workers, psychologists, and social programs for older adults. Additionally, they noted a general lack of attention to issues affecting older adults. This is not surprising, as there is indeed a broader lack of Arabic-speaking mental health professionals in health institutes in Israel (Al-Krenawi, 2019; Elroy et al., 2018). The participants’ reports about systemic barriers, such as high workloads and understaffing, that hinder their efforts to address loneliness were also documented in previous studies, where healthcare providers identified similar obstacles limiting their ability to effectively intervene in cases of loneliness (Dobarrio-Sanz et al., 2021). These findings suggest that even when professionals have the willingness, skills, and capacity to identify and address loneliness, they are often unable to do so, not due to their own limitations, but because of structural barriers and resource shortages within healthcare institutions.

Limitations, Implications, and Conclusions

One limitation of this study is that, as a qualitative study, the findings are based on a relatively small and convenience sample of healthcare providers, with a relatively young mean age, further constraining generalizability. While we achieved diversity in participants’ characteristics in terms of gender and work locations, two-thirds of the sample consisted of nurses, potentially limiting the perspectives of physicians and other professionals. Additionally, since some participants were referred by others, there is a possibility of selection bias, as those with similar views or experiences may have been more likely to participate. Although such recruitment is common in qualitative research, future studies should ensure more independent and systematic recruitment strategies to enhance the sample’s representativeness. Future research also requires larger samples with a more balanced representation of physicians and other types of healthcare workers (including social workers) to provide a more comprehensive understanding of how healthcare providers perceive and address loneliness among older adults. Employing a mixed-methods approach could help quantify and advance the generalizability of the findings on healthcare providers’ knowledge, attitudes, and practices regarding loneliness.

Despite its limitations, this exploratory study has important implications. Theoretically, it is the first to examine Palestinian healthcare providers’ perspectives on loneliness among older adults. This study contributes to the general knowledge in this field, as limited studies focus on healthcare providers addressing loneliness. Additionally, it provides a unique contribution by highlighting the experiences of minority and disadvantaged groups, where systemic and cultural factors may shape loneliness differently. Currently, an international comparative case study is underway to discuss commonalities and differences in approaches needed to address loneliness across different cultures and socioeconomic and political environments (Yoshida et al., 2024).

Practically, the findings emphasize the need for training programs for healthcare providers to raise awareness and enhance their knowledge regarding loneliness, equipping them with the necessary skills to diagnose and address it effectively. Additionally, the study highlights the importance of structured screening and addressing protocols in primary healthcare settings to facilitate the early detection of loneliness. Furthermore, the findings underscore the need for policy-level investments to increase resources within healthcare institutions, enabling healthcare providers to support better older adults experiencing loneliness and integrate effective interventions into their practice.

In conclusion, this study offers important insights into how healthcare providers understand and address loneliness among older adults in the Palestinian minority. The findings highlight strengths and gaps in their approaches, emphasizing the need for structured interventions, greater institutional support, and targeted training to better incorporate loneliness assessment and management into primary care. By addressing these challenges through a collaborative and culturally responsive approach, healthcare systems can play a crucial role in improving older adults’ well-being and social connectedness.

Footnotes

Acknowledgements

We thank the Takemi Program in International Health at the Harvard T.H. Chan School of Public Health for supporting this research project.

ORCID iD

Fareeda Abo-Rass

Ethical Considerations

The Ethics Committee of The Hebrew University approved the research protocol. Approval number: 29032024.

Author Contributions

F.A-R: Conceptualization, project administration, data analysis, manuscript writing—original draft preparation. H.A. and M.H.: Data collection, data analysis, manuscript review and editing. K.Y. and A.G.: Conceptualization, manuscript review and editing. A.G.: Supervision.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Exploring Healthcare Providers’ Knowledge,Attitudes,and Practice of Loneliness Among Older Adults: A Qualitative Study

Abstract

Keywords

What This Paper Adds to Existing Literature

Applications to Gerontological Practice, Policy, and/or Research

Introduction

The Present Study

Methods

Participants

Procedure

Interview Guide

Data Analysis

Results

Theme 1: Knowledge

Understanding of Loneliness: Its Risk Factors and Consequences

Identification of Loneliness

Theme 2: Attitudes

Family as a Double-Edged Factor

Increasing Loneliness Among Palestinian Older Adults

Sociocultural Influences on Loneliness

Theme 3: Practice

Approaches to Addressing Loneliness

Practical Challenges and Individual Efforts

Discussion

Limitations, Implications, and Conclusions

Footnotes

Acknowledgements

ORCID iD

Ethical Considerations

Author Contributions

Funding

Declaration of Conflicting Interests

References