Designing a new social infrastructure for the 21st century: Designing out Loneliness

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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

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Monitor youth
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Raise taxes on tobacco
(City & State)
Protect people from
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Warn about the
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• 100,000 fewer smoking-related deaths in
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Prevalence of Smoking in New York City
1993 - 2007

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A COMBINATION OF
POPULATION-BASED/PUBLIC
HEALTH AND CLINICAL
RESPONSES ESSENTIAL TO
DECREASING SMOKING

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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

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WE NEED EACH OTHER

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PREVENTION VIA “STRUCTURAL
ENABLERS”: PUBLIC HEALTH
ANALYSES AND SOLUTIONS

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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

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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;

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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

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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

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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

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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

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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

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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)

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Social infrastructure:
1. Physical conditions that bring us together

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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

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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

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Use existing organizations for social
interactions within and across generations
• Schools
• Churches
• Business
• Retail shops
• Parks
• Community hubs

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Intergenerational Transfers are the
Fabric of a Resilient Society

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The issue: high and rising rates of
loneliness
A multigeneration issue:
• For older adults
• For middle age adults
• For young adults
• For adolescents

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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

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OLDER ADULTS OUR ONLY
INCREASING NATURAL
RESOURCE: WITH LARGE,
UNTAPPED ASSETS
– THAT WE NEED
So
)

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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

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NEED BOTH SOLUTIONS FOR “DEFICITS”
OF AGING
AND “ASSET” MODELS THAT INTEGRATE
OLDER PEOPLE IN SOCIETY AND BENEFIT
FROM ASSETSNo assets

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The Societal Issues
• Aging population worldwide
• What people DO during this 1/3 of their lives
matters:
– For their own well-being
– For society

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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

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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

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Social Infrastructure
2.The social organization that enables social capital to
develop and makes it normative

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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?”

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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

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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

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Rx?

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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

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Baltimore Sun, 06/11/06 by Joe Polazzolo – Sun Reporter

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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

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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…

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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

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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.

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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

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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

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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

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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

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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)

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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

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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

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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

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Baltimore Sun, 06/11/06 by Joe Polazzolo – Sun Reporter

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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

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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

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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

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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

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Volunteers from the Baltimore
Experience Corps Program

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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

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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

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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

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Implications

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New generative roles with meaning,
purpose and impact: Experience Corps

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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

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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

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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?

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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

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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

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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

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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

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Next Generation of Age-Friendly Cities
and Communities
• Design out loneliness through social infrastructure