Structural Health System Differences and Loneliness in Older Adults: A Cross-Cluster Analysis

Abstract Loneliness and social isolation are major public health challenges among older adults in Europe, affecting 10-30% of this population. They are linked to adverse health outcomes, greater healthcare use, and higher system costs. The COVID-19 pandemic further exacerbated these issues. Contributing factors include chronic illness, limited care access, and sociodemographic disparities. However, the role of healthcare system and socioeconomic differences across countries remains underexplored. Using data from SHARE Wave 9 COVID-19 Survey 2 (N = 18,703) across 10 European countries, we grouped nations into three healthcare system clusters based on socioeconomic and health indicators: Cluster 1 (Belgium, France, Luxembourg, Netherlands, Denmark, Finland), Cluster 2 (Latvia, Lithuania), and Cluster 3 (Estonia, Poland). Loneliness differences were assessed using the Kruskal-Wallis test, and mediation/moderation models examined associations with chronic disease, home care, age, and gender. Loneliness levels varied significantly across clusters (χ²(2)=310.44, p < 0.001), with Cluster 2 showing the highest mean rank and Cluster 1 the lowest. Chronic disease predicted loneliness, with home care mediating the effect. Gender moderated the relationship (stronger among women), as did age in Clusters 1 and 2. Cluster 2, with fewer resources and a younger aging population, showed the strongest chronic illness-loneliness link. Loneliness in older Europeans varies by healthcare system cluster. The chronic disease-loneliness connection is shaped by home care access, age, and gender. Targeted, integrated interventions-such as social prescribing and collaboration between health and social services-are especially needed in under-resourced countries. These findings underscore the urgency for equitable, cluster-specific strategies to combat loneliness in Europe's aging populations. Key messages • This study explores how social support and technology use influence loneliness among individuals aged 50+ across three European country clusters, grouped by healthcare system type. • Social support and technology use play crucial roles in alleviating loneliness among older adults in Europe, with notable differences by healthcare system cluster, gender, and age.