Governance pathways for scaling neonatal risk stratification tools in LMIC health systems: a multi-site qualitative study in Kenya.

Social isolation is a major social determinant of health, with a magnitude of risk comparable to that of traditional lifestyle-related factors such as smoking and physical inactivity . A growing body of evidence from cohort studies and meta-analyses has linked social isolation to increased all-cause mortality, cardiovascular disease, and adverse mental health outcomes, highlighting the broad health consequences of diminished social connections . Reflecting this evidence, the World Health Organization has identified social isolation and loneliness as emerging global public health concerns and has called for coordinated actions to strengthen social connections . Despite this recognition, social isolation is a multidimensional construct that has been inconsistently operationalized across studies. It encompasses at least two related but distinct dimensions: subjective loneliness, reflecting perceived deficiencies in social connection, and structural social isolation, which captures objective aspects of social relationships such as social network size, contact frequency, and living arrangements . Measures of structural social isolation vary widely, ranging from validated social network scales, such as the Lubben Social Network Scale (LSNS) and the Berkman-Syme Social Network Index, to single indicators such as living alone, limiting comparability across studies . Moreover, prior research has largely focused on hard outcomes such as mortality and cardiovascular events, whereas associations with symptom burden and the broader prevalence of chronic diseases have received far less empirical attention . An additional concern is that socially isolated individuals may be less likely to engage in healthcare-seeking behaviors, even when experiencing health problems. Previous studies have shown associations between social isolation or loneliness and reduced use of healthcare services, as well as higher levels of unmet healthcare needs . As a result, socially isolated individuals may experience significant symptoms or declines in subjective health while being less likely to receive formal diagnoses of chronic diseases, suggesting that reliance on diagnosis-based outcomes may underestimate their true health burden. However, few studies have simultaneously examined symptom burden, chronic disease prevalence, and healthcare-seeking behaviors within the same population.