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Linda Fried - Loneliness social infrastructure IPH.1218

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Linda Fried - Loneliness social infrastructure IPH.1218

  1. 1. 1 Designing a New Social Infrastructure for the 21st Century: Designing Out Loneliness Linda P. Fried, M.D., M.P.H. Dean and DeLamar Professor Mailman School of Public Health Columbia University
  2. 2. 2 SmokingprevalenceinNYC 8% 10% 12% 14% 16% 18% 20% 22% 21.6% Monitor adult smoking prevalence Monitor youth smoking 18% 15% 19.2% Raise taxes on tobacco (City & State) Protect people from tobacco smoke 18.4% 18.9% 11% Warn about the dangers of smoking 17.5% • 300,000 fewer smokers • 100,000 fewer smoking-related deaths in future years 16.9% 8.5% Prevalence of Smoking in New York City 1993 - 2007
  3. 3. 3 A COMBINATION OF POPULATION-BASED/PUBLIC HEALTH AND CLINICAL RESPONSES ESSENTIAL TO DECREASING SMOKING
  4. 4. 4 Time to elevate social connection and designing out loneliness into a public health agenda • Efforts to alter the signal (eg, loneliness) without altering the actual behavior (eg, social connection) likely to be ineffective Holt-Lunstadt 2015
  5. 5. 5 WE NEED EACH OTHER
  6. 6. 6 PREVENTION VIA “STRUCTURAL ENABLERS”: PUBLIC HEALTH ANALYSES AND SOLUTIONS
  7. 7. 7 3 types of loneliness 1. Intimate, emotional loneliness: significant others 2. Social, relational loneliness: quality friendships or family connections 3. Public or collective loneliness: meaningful connection to a person’s valued social identities or “active network of group or social entity beyond the level of individuals, in collective space”. Weak ties, low-cost social support; social capital. Consequence: promotion of social identification and cooperation in adverse conditions; people more likely to act for common good. • Best negative predictor of collective loneliness: number of voluntary groups to which an individual belonged. Source: Cacioppo, Cacioppo, Boomsma 2014
  8. 8. 8 Consequences of social isolation and loneliness • For the individual: Social connections alleviate stress of life circumstances (Jacoby SF, 2017) • For society: − Loss of assets of older population − Low collective efficacy: implications − Higher health needs, utilization (outpatient, ER) and costs − Suicide rates Source: Gerst-Emerson and Jayawardhanaa 2015; Cheng et al;Taube E 2014;
  9. 9. 9 We are all in this together: Loneliness is contagious • Number of days an individual was lonely each week was found to influence the levels of loneliness of friends, neighbors and spouses. • An individual’s loneliness can contribute to the loneliness of others • Social norms and constructs are needed to counter contagion Source: Cacioppo, Fowler, Christakis 1009
  10. 10. 10 The contexts of social connection of the 20th century: not sufficient to 21st C needs; not designed to optimize longer lives • Community infrastructure not sufficient − Weakened public goods: libraries, community centers, anachronistic senior centers − Rural areas: transport for connection often inadequate − Internet-based connection – increasing tribalism and dominance of messaging based on anger and disaffection − For many older adults: roles diminished; housing isolates • Networks of family and friends − Dispersed for jobs − Loss to mortality, divorce, family restructuring, retirement − Young people at risk; existential crisis • Civic organizations and religious community connection for meaning and purpose − Loss of connection to purpose leads to loss of collective efficacy
  11. 11. 11 Need new 21st C infrastructure of connection and cohesion • Social connections fostered in clinical care context = remediation • Social connections made one-at-a-time can succumb to norms • Prevention: Making social connections the easy option, normative, because designed into society in 21st C context facilitates person-to-person solutions • Potential: older adults bring unprecedented assets which society needs; building connection to strengthen via making older people part of society, would design out loneliness
  12. 12. 12 2 of 3 types of loneliness potentially responsive to social infrastructure, connection 1. Intimate, emotional loneliness: significant others 2. Social, relational loneliness: quality friendships or family connections 3. Public or collective loneliness: meaningful connection to a person’s valued social identities or “active network of group or social entity beyond the level of individuals, in collective space”. Weak ties, low-cost social support; social capital. Consequence: promotion of social identification and cooperation in adverse conditions; people more likely to act for common good. • Best negative predictor of collective loneliness: number of voluntary groups to which an individual belonged. Source: Cacioppo, Cacioppo, Boomsma 2014
  13. 13. 13 Clues for how to design out loneliness: what do older people want? • Connection, within and across generations • Community • Purpose and meaning: contribution to collective good • Generative Impact
  14. 14. 14 Social infrastructure • “The physical conditions that determine whether social capital develops” (Klinenberg E, 2018) • The social organization that enables social capital to develop and makes it normative (Fried)
  15. 15. 15 Social infrastructure: 1. Physical conditions that bring us together
  16. 16. 16 Social infrastructure: design to connect within housing • Design to bring people together • Common spaces for gathering, activities • Lounge areas for conversation • Low traffic streets • Facilitate interactions, activities with meaning and purpose as well as enjoyment between residents, between residents and broader community • Formal and informal physical and social activities, volunteering: within housing and with broader community • Community norms of participation, mutual assistance • Support for vulnerable groups
  17. 17. 17 Designing communities with the physical conditions that determine whether social capital develops • Safety crossing the street • Decrease car speed and frequency • Sidewalks safe and clean • Parks – with bathrooms, parking • Walkability: Design for exercise and walking; destinations nearby • Benches • Lighting • Don’t zone social isolation: locate housing for older adults in areas dense with social activity, near public transport, walking distance access to needed goods and services, libraries, parks • etc
  18. 18. 18 Use existing organizations for social interactions within and across generations • Schools • Churches • Business • Retail shops • Parks • Community hubs
  19. 19. 19 Intergenerational Transfers are the Fabric of a Resilient Society
  20. 20. 20 The issue: high and rising rates of loneliness A multigeneration issue: • For older adults • For middle age adults • For young adults • For adolescents
  21. 21. 21 Building housing that designs in connection, within & across generations • NORCs • Cogenerational housing: for friends, single older adults • For multigenerations • US: senior housing doesn’t permit grandparents raising grandchildren • Communities of nurturance across 3 generations: Generations of Hope Development Corporation • Rentals: Students living in older people’s homes • Nesterly: intergenerational homesharing services • Housing developers creating homes for multiple generations
  22. 22. 22 OLDER ADULTS OUR ONLY INCREASING NATURAL RESOURCE: WITH LARGE, UNTAPPED ASSETS – THAT WE NEED So )
  23. 23. 23 Assets of older adults • Accrued knowledge, expertise, skills • Problem solving abilities, experience handling complex problems • Subjective experience • Integrative social reasoning and judgment of what is important in life • Dominantly optimistic outlook • Generative desire; pay-it-forward stage of life • Critical mass
  24. 24. 24 NEED BOTH SOLUTIONS FOR “DEFICITS” OF AGING AND “ASSET” MODELS THAT INTEGRATE OLDER PEOPLE IN SOCIETY AND BENEFIT FROM ASSETSNo assets
  25. 25. 25 The Societal Issues • Aging population worldwide • What people DO during this 1/3 of their lives matters: – For their own well-being – For society
  26. 26. 26 In the U.S.: a roleless old age • Few meaningful, generative roles • Switch from work roles to retirement can mean: – loss of social connectedness, cognitive stimulation, meaning and purpose; – possibly decreased physical activity; – decreased structured activities
  27. 27. 27 WHAT we DO Matters with aging: Improving Health Outcomes • Physical Activity • Cognitive Activity • Social engagement: – Social networks and support; loneliness – Structured activities – Meaningful, productive roles – Leaving a legacy
  28. 28. 28 Social Infrastructure 2.The social organization that enables social capital to develop and makes it normative
  29. 29. 29 Capabilities of Older Adults are Untapped  Most highly educated older adults in the history of the world  Time, experience, patience, wisdom  Problem solving creativity  Wanting to leave the world a better place: “if not now, when?”
  30. 30. 30 Parallel issues in an aging society • Profound societal unmet needs • Aging viewed in terms of needs/deficits, without benefits; – Rolelessness of aging • Can we address both simultaneously? – develop new, meaningful, roles and responsibilities for older adults in an aging society? – design for health promotion? – Promote a win-win: for society, for older adults
  31. 31. 31 WHAT IF WE COULD CREATE NEW, MEANINGFUL, GENERATIVE WAYS FOR PEOPLE TO STAY ENGAGED AFTER RETIREMENT - AND DESIGN THEM TO INCREASE PHYSICAL, COGNITIVE AND SOCIAL CONNECTION AND ACTIVITY? A WIN-WIN: TARGET ROLES TO SOCIETAL UNMET NEEDS
  32. 32. 32 Rx?
  33. 33. 33 One Model for such a Win-Win: Experience Corps • High intensity volunteering for older adults • High impact roles in public elementary schools improving outcomes for children • Critical mass of older adults: – Shift outcomes for schools – Force for social benefit – Social networks and friendships • Health promotion program embedded • Fried 2004 • Fried et al, 2004
  34. 34. 34 Baltimore Sun, 06/11/06 by Joe Polazzolo – Sun Reporter
  35. 35. 35 The Experience Corps: Evidence-Based Model  Who: Volunteers 60 and older  Where: Serve in public elementary schools: K-3  How: Meaningful roles; important unmet needs  High intensity: 15 hours per week  Sustained dose: full school year  Critical mass, teams in each school  Reimbursement: Monthly stipend to reimburse for expenses  Health behaviors: physical, social and cognitive activity  Diversity: older adults of varied backgrounds, skills Freedman and Fried; Experience Corps monograph, 1997 Fried LP et al 2004, J Urb Health
  36. 36. 36 New, High Impact Roles for Older Volunteers: Evidence-based Experience Corps  Academic support:  Literacy support  Opening/maintaining school libraries  Math support  Computer support  Behavioral support:  Conflict resolution, positive attention  School attendance  Parental outreach  Public Health: Asthma club  More roles to come…
  37. 37. 37
  38. 38. 38 Experience Corps Participation- Generative Role Performance Intervention Primary Pathways Mechanisms Primary Outcomes Improved teacher retention Improved aggregate academic performance Improved school climate Child building pathway (direct impact on children K-3 from face-to-face interaction) Social capital pathway (indirect impact on the school) School Parameters: Community resources Parent participation Collective efficacy Teacher parameters: Teacher efficacy Teacher morale Time on task Child Parameters: Literacy Skills Readiness to learn Behavioral disruptions Cost Benefits: Children School Experience Corps’ Societal Causal Pathway: School Outcomes
  39. 39. 39
  40. 40. 40 Early Results: Impact of Experience Corps on K-3rd Graders, Baltimore  Behavioral issues: ↓ Office referrals ↓ Suspensions  Standardized tests: ↑ Vocabulary, reading and math scores improved significantly in K, 1st and 2nd graders with Experience Corps (v. control schools).  3rd graders: ↑8.2% scoring proficient /advanced in reading, v. ↓5%, in comparison schools.
  41. 41. 41 Experience Corps in Schools leads to • Potential for Improved teacher retention (NRTA) • Improved perceptions of the contributions of older people - by principals and teachers • Anecdotally: improved understanding by children of positive life courses; children have an advocate
  42. 42. 42 Experience Corps: Potential Model of the Win-Wins of an Aging Society  Societal benefits of an aging population: High impact roles for older adults to improve academic success of children in public elementary schools  Societal approach to addressing needs of older adults:  Roles that meet generative desires  Compression of morbidity: frailty, disability, falls, memory  Health disparities
  43. 43. 43 Cortical plasticity; Memory Executive function Experience Corps Participation - Generative Role Performance Intervention Primary Pathways Mechanisms Intermediate Mechanisms Outcomes: Preserve Strength, balance Social Integration & Support Generativity Physical Activity Cognitive Activity Social Activity, Engmnt. Psycho-Social Well-being Complex task performance Frailty Mobility Function Falls Experience Corps Activities are Designed to Prevent Frailty and Benefit the Health of Older Adult Volunteers
  44. 44. 44 Experience Corps Randomized Controlled Trial, Baltimore • N=702 • Age: 60-89; mean age: 67 • Women: 85% • Race: Black, 92%; white: 5% • Education: <high school: 44%; >some college: 56% • Income: <$15,000: 30%; $15-35,000: 36%; >$35,000: 34% • Major morbidities: 2 • Fried LP 2013; GruenewaldTL et al 2016
  45. 45. 45 Baltimore Experience Corps Trial Intervention Outcomes Experience Corps • Intensive training • Meaningful roles • Role flexibility • Significant dose • Critical mass/team service • Infrastructure support • Expense reimbursement PHYSICAL (gait speed, strength, balance, mobility disability, activities of daily living engagement/ability) COGNITIVE (sped of processing, memory, executive functioning) PSYCHOSOCIAL (social: social integration, social support, social activity; psychological: generativity/perceived social usefulness, purpose in life, personal growth, self-efficacy, depression)
  46. 46. 46 Evidence of Intermediate Effects: Experience Corps vs. Controls  Behavioral Risk Factors:  Physical activity  Cognitive activity  Social supports  Intermediate effects:  Strength, performance, energy, falls  Depressive symptoms  Cognition (executive); brain activation
  47. 47. 47 Volunteering improves social supports and networks • Meet new people, make friends • Develop a sense of community • Reduction in depression; improved positive affect, life satisfaction • Feeling need and appreciated amplifies relationship between volunteering and psychosocial wellbeing • EC: Significant increase in number of people can turn to for help Anderson ND 2014; Fried LP 2004
  48. 48. 48 Experience Corps RCT: Positive expectations of aging affect social connection in program • EC participants with more positive expectations of aging at baseline – and at least average perceived support availability: – At 12 months: had greater overall perceived support availability – At 24 months later: had made more new friends – Over 24 months: For women: higher engagement in moderate- to-high-intensity physical activity • Menkin JA et al, 2017;Andrews RM 2017
  49. 49. 49 Baltimore Sun, 06/11/06 by Joe Polazzolo – Sun Reporter
  50. 50. 50 Experience Corps participants: focus groups • Rewards and positive experiences of EC participation: – Enjoyment 100% – Bonding/making social connections: 100% – Satisfaction with structural elements of the volunteer experience: 88% – Developing a special relationship with a child: 88% – Feeling a sense of reciprocity with others: 38% – Feeling valued as a volunteer: 38% – Sharing one’s life story/wisdom: 25% • VarmaVR et al 2015
  51. 51. 51 To give is to receive . . . “It feels good to be accepted, that you have worth, value, and wisdom.That you're dependable, that you made a difference in the lives of others.” ~Experience Corps volunteer
  52. 52. 52 Experience Corps: Measure of generativity • Generative desire – I want to make a difference in the lives of others – I want to give back to my community – I want to create new things or ways of doing things – I want to share my experiences with other people – I want to mentor people younger than me – I want to do something that will be valuable to others for a long time – I want to show people younger than me how to do things • Generative achievement – I feel like I made a difference in my community – I feel like I will do things that will last for a long time – I feel like I will be remembered for a long time – I feel like I am doing things that will leave a legacy – I feel like I am giving back – I feel like I am making a difference in the lives of others GruenewaldT et al 2016
  53. 53. 53 Experience Corps RCT: Generative desire and achievement • Those 60+ randomized to EC (compared to controls): – Baseline: Comparable levels of generative desire and achievement – Follow-up: • Had significantly higher levels of generative desire and perceptions of generative achievement at 4, 12 & 24 mos. • Dose response effect: greater magnitude of intervention effect with greater exposure to EC program First large-scale, experimental demonstration that participation in an intergenerational civic engagement program can positively alter self-perceptions of generativity in older adulthood. Gruenewald TL, et al, 2016
  54. 54. 54 Volunteers from the Baltimore Experience Corps Program
  55. 55. 55 EC goals • Attract older adults to service through opportunity to fulfill desires for generative engagement, and thereby enhance generative achievement • By intentional design, transform human capital of older adults into critical mass of social capital
  56. 56. 56 Model of Social Capital Activation Transform Human to Social Capital Social norms/Trust  Impact Investment to Support Civic Society Collective Action and Impact Stock of Human Capital Opportunities to Take Collective Action
  57. 57. 57 Experience Corps/AARP in US Designed 1990-1995 First Demo: 1996  Freedman and Fried, 1997  Fried et al 2004 Philadelphia Minneapolis, MN Portland, OR Port Arthur, TX South Bronx, NYC Baltimore City Beaumont, TX Cleveland Grand Rapids, MI New York City San Francisco Tempe, AZ Baltimore County Boston Evansville, IN Marin, CA New Haven, CT Oakland, CA Revere, MA St. Paul, MN Tuscon, AZ Operating Today in 20 U.S. Cities
  58. 58. 58 Implications
  59. 59. 59 New generative roles with meaning, purpose and impact: Experience Corps
  60. 60. 60 Our only increasing natural resource is potential social capital of older adults Experience Corps: first intentional experiment to create social capital of an aging society on a large scale Hypothesis: Roles to support children’s school success could attract and activate social capital Build Social Capital • Design, invest in and build the new social institutions and roles, and new communities, that include older people in society, and enable benefitting from their assets – Roles with meaning, purpose and impact – Responsibility for the future and agency to help get there • Design for critical mass, social cohesion and collective efficacy • The older generation can enable the success of the younger through new kinds of social organization • Design out loneliness
  61. 61. 61 Incorporating the social capital of older adults into roles and responsibilities for the 21st C • Social capital can be built or strengthened • Design in meaning and impact • Design out loneliness • Build collective efficacy • Roles for older adults – for all backgrounds – Eg: Experience Corps • Societal roles include, not exclude, older adults – Eg,Americorps, Peace Corps – Eg, Communities that Care Model to prevent youth delinquency and violence
  62. 62. 62 Future Potential: Senior Volunteering that Enhances Health and Activates the Benefits of an Aging Society • Experience Corps • Volunteers in Medicine • Public Health roles? • Emergency Preparedness roles? • Environmental roles • Other?
  63. 63. 63 Challenging issues of our present and future that the assets of older adults could help solve • Wasting second demographic dividend • Young adults disaffected, • Diseases of despair; opioid epidemic • Environmental despoliation, climate change
  64. 64. 64 Models for social infrastructure • Global studies on import of generative roles • Recognition that older people are needed • Meaningful roles for longer lives • Paid work • Volunteerism for social impact
  65. 65. 65 What will work for whom • Develop methods for mapping community assets and needs • Aggregate best practices locally and globally • Recognize that loneliness is a complex system problem: no one solution sufficient
  66. 66. 66 Social engagement as the basis for building successfully aging communities • Building a new life stage: the range of roles for older adults • New model for public health at community level • Role creation unlocks the opportunities of longer lives • Roles at scale enables assets of older age to improve communities • Potential to: – resolve health disparities – strengthen intergenerational cohesion – Decrease loneliness and isolation at all ages
  67. 67. 67 Next Generation of Age-Friendly Cities and Communities • Design out loneliness through social infrastructure

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