Joyful Singing, Healthy Living

Adults age sixty-five and above are currently the fastest-growing segment of the US population. In 2016, there were 47.8 million individuals age sixty-five and over in the United States (US Census Bureau 2017), and this number is expected to more than double by 2060. By 2040, nearly half of older adults are expected to come from diverse racial/ethnic and socioeconomic backgrounds (Vincent and Velkoff 2010; Johnson, Rodriquez-Salazar, et al. 2018). San Francisco’s population of older adults is higher than the national norm. “Our current health and social systems are not prepared to help support our rapidly increasing population of older adults,” said Julene Johnson, associate dean for research and professor at the University of California, San Francisco School of Nursing. “For instance, there’s a high percentage who experience loneliness and social isolation, and depression also is relatively high. There’s a need to develop novel approaches to help older adults stay engaged in the community and also stay connected” (CMC press release 2018).

In this article we describe the Community of Voices program, a cross-sector approach to a high-quality, culturally responsive, older-adult choir program designed to help reduce loneliness and increase interest in life for older adults. We also share resources for those interested in learning more about developing community choirs.

The Need for Innovative Programs for Older Adults

Older adults are at heightened risk for isolation. A combination of factors lead to this risk, including living on a fixed income, experiencing mobility impairment, and losing social contacts as peers pass away or suffer declining health (Steptoe et al. 2013).

Isolation can lead to a variety of negative outcomes. Social isolation and loneliness are associated with higher rates of mortality, likely due in part to lack of a support network to encourage medical attention when acute symptoms develop (Steptoe et al. 2013). Research also suggests that isolation can lead to greater use of certain components of the health care system, including emergency room visits and admission to nursing homes (British Columbia Ministry of Health 2004). Feelings of loneliness are linked to poorer cognitive function and faster cognitive decline (Cacioppo and Hawkley 2009). The National Council on Aging (2016) reports that isolated seniors are at heightened risk for abuse by others. Social isolation is also linked to poor health (Seeman et al. 2001) and has been found to be comparable to obesity, sedentary life styles, and possibly even smoking in its impact on health (Cacioppo et al. 2002).

Choirs: A Great Fit for Older Adults

To address the problem of isolation, the City of San Francisco is increasing its funding of preventive and wellness-based programs to help older adults remain active, independent, and involved in community. These programs are more cost-effective than interventions further downstream, and early indications show that these programs can help older adults thrive in their communities longer, putting off the need for more intensive and expensive services. Creative aging programs are poised to help reframe aging and provide older adults with meaningful opportunities for engagement in their communities (Johnson, Rodriquez-Salazar, et al. 2018).

Singing is a popular cultural activity that can require little to no previous training to participate and involves the entire body in breathing, physical movement, and brain activity. Choirs bring people together and can be customized to reflect and respond to diverse cultural communities. The Community of Voices (COV) research study examined whether singing in a community choir is a cost-effective way to promote health and well-being among culturally diverse older adults. It involved a partnership between the University of California, San Francisco (UCSF), the San Francisco Department of Aging and Adult Services (DAAS), and the San Francisco Community Music Center (CMC). The study was funded by a five-year grant to UCSF from the National Institute of Aging, a division of the National Institutes of Health.

The COV study (Johnson, Stewart, et al. 2018) found that singing in a choir reduced loneliness and increased an interest in life. UCSF researchers found that older adults who sang in a choir for six months experienced significant improvements in loneliness and interest in life. As one participant said,

When I began singing in the choir I was very depressed. I didn’t even want to get up and dressed in the morning. I had only been in the country (from Mexico) for two years and did not have many connections here. After joining the choir I started to come back to life. I loved singing with the choir, made several friends, and even started dancing again. I helped to organize a folk dance to perform with the choir. It has been a wonderful experience for me. (translated from Spanish)

Cross-Sector Collaboration Anchors Success

CMC’s Older Adult Choir program expanded through its participation in the COV research study. Twelve older adult choirs were formed during the course of the study, and every choir unanimously voiced intense interest in continuing after the study ended. Many singers expressed that the choir had changed their lives and that they wanted (and needed) to keep singing.

As choirs have cycled out of the study, they have been sustained by CMC in collaboration with DAAS and senior center partners. Singers and senior center partners engaged in the process of establishing choirs as an ongoing program integral to each senior center site. Members acted as advocates for the program and helped to identify resources and opportunities for the choirs. DAAS senior center partners and DAAS have also invested in the program, looking to the choirs as community connectors, promoting engagement and combating isolation, and helping to create an age-friendly city.

As a basic foundation for success, each partner must see the positive impact of the program on its own goals, making it a mutually beneficial collaboration. DAAS played a critical initial role in identifying strong senior center partners for the choirs. DAAS has also played a role in sustaining the choirs, providing funding, and identifying sites where it sees the potential for a choir to address a community issue. DAAS is focused on supporting cost-effective interventions that provide engagement opportunities, mitigate the effects of isolation, and lead to improved health outcomes. Executive Director Shireen McSpadden said, “There are studies that show that isolation has negative effects on people, particularly on older adults. [The choirs are] one way people can forget about that for a while. They can come together; they have something to look forward to. It’s amazing, the transformative power [of coming together through music].”

Senior center partners see the choirs as an attractive program that brings new older adults into their centers to sing but then also to learn of other activities and services. Senior center partners identify what music will be most relevant for their community, which guides the selection of an appropriate professional choir director. The center also supports recruitment and provides the location for choir rehearsals and performances.

The CMC provides professional music instructors, who select and arrange music, tailoring the curriculum to reflect the cultural traditions and interests of choir members. Professional choir directors with accompanists conduct the choir sessions. CMC also supports recruitment, organizes performances, and spearheads ongoing data collection and evaluation processes. For CMC, partnering with senior centers offers the opportunity to extend its mission to provide accessible music education in an effective way by providing choirs where older adults gather, removing transportation barriers.

Choir Program Design: A Culturally Responsive Approach

The San Francisco cross-sector model of culturally responsive older adult choir programs can be a model for other cities and regions, showing how partnerships can act as a cornerstone of a successful older adult choir program, drawing on the strengths of each of the collaborators.

The older adult choir model today relies on four basic components, which grew out of the design of CMC choirs launched in 2011 and was further developed through the COV study to develop a more intentional approach toward maximizing physical, cognitive, and psychosocial benefits:

1. Mutually beneficial, collaborative relationships with senior center partners;
2. A culturally responsive and neighborhood-based approach, with repertoire, teachers, language, and other cultural elements tailored to each site;
3. Weekly rehearsals led by music professionals, who provide physical, social, creative, and cognitive benefits, including physical warm-ups, vocal technique, and socializing adapted for older adults; and
4. Performances in the community, which serve to affirm cultural identity, allow choirs to share their accomplishments, and act as community ambassadors; performances also act as outreach activities for the choirs and senior center partners.

Activities, approach, language, and repertoire are tailored to meet participant interests, to be appropriate for older adults with various singing abilities, and to be challenging enough to facilitate growth and mastery over time. New choir directors are given training in best practices for working with older adults and the principles of the program, including opportunities to observe a veteran choir director run a choir session. Participant input is strongly encouraged and shapes many aspects of program delivery, increasing a sense of cultural affirmation and commitment.

Key to the success of a choir is hiring professional choir directors and accompanists who are deeply rooted in the communities where they teach, and musically fluent in their primary cultural traditions, which can vary significantly from community to community. For example, in San Francisco, a Mexican choir director conducts Mission District Latino choirs that sing music from Mexico and Latin America. African American older adults from the Western Addition and Bayview Hunters Point participate in choirs with directors who are from these communities and teach gospel and jazz music. In South of Market, a Filipino choir director teaches songs in Tagalog at the Bayanihan Equity Center. This attention to local needs is facilitated by close partnerships with the staff at each senior center, who directly observe benefits to those they serve, including reduced isolation, increased socialization, and an enhanced sense of well-being.

Rehearsal routines, including physical and vocal warm-ups, breathing, and vocal technique, are tailored for older adults. Integrating physical activity throughout the session, for instance, by standing to sing some songs and sitting for other activities, engages choir members in increased physical movement. Memorizing some songs and learning songs in new languages offer opportunities for cognitive engagement (Johnson, Rodriquez-Salazar, et al. 2018). Providing a snack or water break in the middle of the session provides an intentional time for socializing and community building.

Performance is a core component, allowing singers to demonstrate their skills and provide inspiration to their communities by modeling healthy aging. In San Francisco, choirs perform at their host sites and at a wide range of community events (e.g., other senior centers, libraries, street festivals) in prominent civic locations. In San Francisco, older adult choirs have performed at prestigious festivals, including the Mission District Cinco de Mayo Festival, the Día de los Muertos Festival at Davies Symphony Hall, the Yerba Buena Gardens Festival, and the Black Cuisine Festival in the Bayview neighborhood.

Energized by their experience singing together, members take on active roles, helping to choose repertoire, assisting with concert production, arranging para-transit, designing and creating choir stoles, recruiting new members, and engaging in public advocacy. One singer said, “Choir has given me so much energy and enthusiasm because it makes me happy to sing for others and to see them become happy hearing us sing.”

Community Building: Cultural Affirmation, Trust, Service, and Empowerment

Over the past eight years since CMC started its older adult choir program, community ties between older adult choirs and their host communities as well as the broader community have become evident. Through weekly rehearsals in which choir members meet in a culturally responsive learning environment and develop ongoing friendships with other choir members, their choir directors, and accompanists, a tremendous synergy develops that leads to a cycle of empowerment.

Because of these trusting relationships, the choir can become a place for singers to seek solutions to pressing issues. For example, one senior center director shared with CMC that they were grateful that two choir members, one who was facing homelessness and the other food insecurity, were able to learn of programs that could help them. Although they were coming to the senior center, they did not approach staff about their problems until they were connected by a CMC choir director.

Choir members become support systems for each other, reaching out when a fellow member is sick, providing support and connections for people facing dire circumstances, such as eviction, organizing transportation to events for fellow choir members, and so on. The choirs also become a place for self-expression and creativity; several participants wrote songs for their choirs to sing.

The choirs are able to support other important community needs through performance. For instance, one choir sang to support a local campaign to provide free public transportation for older adults and people with disabilities. Another choir sang to support the Dignity Fund, a proposition approved by voters in 2017 that allocates city general funds for older adult services. Multiple choirs have sung at an array of healthy aging events hosted by participating senior centers and other community partners.

The singers’ empowerment is synergistic in several ways. The choir as a vital cultural community provides personal and social benefits. By helping others, participants gain a larger sense of purpose and meaning in their lives. Performing expands the senior center outreach in the most effective and authentic way possible, through the voices of those involved. Senior centers report that the choirs play an important role in bringing new members into their sphere to access their services, such as lunch programs and health and technology services. Ultimately, older adults become organized as they participate in choirs and can serve as powerful ambassadors and advocates for issues of concern to their community.

Through DAAS, San Francisco has joined the World Health Organization’s Global Network for Age-Friendly Cities and Communities and has been engaged in a planning process to ensure that San Francisco is an age- and disability-friendly city. One attribute of an age-friendly city is that it provides opportunities for older adults to experience engagement and inclusion. The choirs truly provide a community-based and culturally relevant way for older adults to engage with their communities, make lasting friendships, practice memorization and breathing, and have fun.

Conclusion

Older adult choirs offer an innovative approach to meeting the needs of older adults. Cross-sector collaboration creates an important foundation for this creative aging initiative that helps reduce isolation and increase interest in life among older adults. In San Francisco, we have seen how developing a high-quality culturally responsive program, directed by choir professionals, can yield meaningful results. Choir members develop support networks and can become more involved in their community.

Undoubtedly continued research is needed to reveal more about benefits of community choirs for older adults. What is clear, however, is their strong potential as part of a strategy to create age-friendly cities. Choirs can be part of intergenerational work and can be organized not only in senior and neighborhood centers but also at senior residences and other creative venues where people gather. The strong experience of the CMC-led choirs in San Francisco, the partnership with DAAS and senior center sites, and the COV Manual are important resources for replication of this model.

Sylvia Sherman is the program director of Community Music Center.

Shireen McSpadden is executive director of the San Francisco Department of Aging and Adult Services.

Julene K. Johnson, PhD, is a professor at the UCSF’s Institute for Health & Aging and the UCSF’s Center for Aging in Diverse Communities. She was the principal investigator of Community of Voices research study.

NOTES

1. Translation from original quote, provided in Spanish: “It elevates my mood and, through music I am connected to my culture.”

Resources for Older Adult Choirs

Community of Voices Study Choir Program Manual (https://cov.ucsf.edu/program-manual). This manual is a resource for those interested in research and best practices for developing older adult choirs. It provides an overview of the Community of Voices research study and choir program and includes information about criteria for selecting choir directors and accompanists, developing repertoire, running a choir rehearsal, vocal and physical warm-ups, performances, vocal considerations for older adults, and developing financial resources for older adult choirs.

Community of Voices Research

(https://cov.ucsf.edu/publications):

Johnson, Julene K., Anna M. Nápoles, Anita L. Stewart, Wendy B. Max, Jasmine Santoyo-Olsson, Rachel Freyre, Theresa A. Allison, and Steven E. Gregorich. 2015. “Study Protocol for a Cluster Randomized Trial of the Community of Voices Choir Intervention to Promote the Health and Well-Being of Diverse Older Adults.” BMC Public Health 15, no. 1049 (October). PMCID: PMC4603966.

Johnson, Julene K., Steven E. Gregorich, Michael Acree, Anna M. Nápoles, Jason D. Flatt, Dana Pounds, Alexandria Pabst, and Anita L. Stewart. 2017. “Recruitment and Baseline Characteristics of the Community of Voices Choir Study to Promote the Health and Well-Being of Diverse Older Adults.” Contemporary Clinical Trials Communications 8 (December): 106–13. PMCID: PMC5791898.

Johnson, Julene K., Anita L. Stewart, Michael Acree, Anna M. Nápoles, Jason D. Flatt, Wendy B. Max, and Steven E. Gregorich. 2018. “A Community Choir Intervention to Promote Well-Being among Diverse Older Adults: Results from the Community of Voices Trial.” Journals of Gerontology: Series B, November. https://doi.org/10.1093/geronb/gby132. https://www.ncbi.nlm.nih.gov/pubmed/30412233.

Documentary on CMC Older Adult Choir Program: This documentary includes an overview of the program with participant interviews and performance footage: https://sfcmc.org/adults/older-adult-choir-program/.

References

British Columbia Ministry of Health. 2004. “Social Isolation among Seniors: An Emerging Issue.” An investigation by the Children’s, Women’s and Seniors Health Branch, British Columbia Ministry of Health.

Cacioppo, John T., James H. Fowler, and Nicholas A. Christakis. 2009. “Alone in the Crowd: The Structure and Spread of Loneliness in a Large Social Network.” Journal of Personal Social Psychology 97, no. 6 (December): 977–91.

Cacioppo, John T., and Louise C. Hawkley. 2009. “Perceived Social Isolation and Cognition. Trends in Cognitive Sciences 13, no. 10 (October): 447–54.

Community Music Center (CMC). 2018. “Groundbreaking UCSF Study Finds Community Choirs Reduce Loneliness and Increase Interest in Life for Older Adults.” Press release. https://sfcmc.org/about/press-room/groundbreaking-ucsf-study-finds-community-choirs-reduce-loneliness-increase-interest-life-older-adults/.

Johnson, Julene K., Martha Rodriquez-Salazar, Sylvia Sherman, Jennifer Peringer, Anna M. Nápoles, Shireen McSpadden, and Anita L. Stewart. 2018. Community of Voices Study Choir Program Manual. https://cov.ucsf.edu/program-manual.

Johnson, Julene K., Anita L. Stewart, Michael Acree, Anna M. Nápoles, Jason D. Flatt, Wendy B. Max, and Steven E. Gregorich. 2018. “A Community Choir Intervention to Promote Well-Being among Diverse Older Adults: Results from the Community of Voices Trial.” Journals of Gerontology: Series B, November. https://doi.org/10.1093/geronb/gby132.

National Council on Aging. 2016. “Elder Abuse Facts.” Accessed January 6, 2016. https://www.ncoa.org/public-policy-action/elder-justice/elder-abuse-facts/.

Seeman, Teresa E., Tina M. Lusignolo, Marilyn Albert, and Lisa Berkman. 2001. “Social Relationships, Social Support, and Patterns of Cognitive Aging in Healthy, High-Functioning Older Adults: MacArthur Studies of Successful Aging.” Health Psychology 20, no. 4 (July): 243–55.

Steptoe, Andrew, Aparna Shankar, Panayotes Demakokos, and Jane Wardle. 2013. “Social Isolation, Loneliness, and All-Cause Mortality in Older Men and Women.” Proceedings of the National Academy of Sciences 110, no. 15 (April 9): 5797–5801.

US Census Bureau. 2017. “The Nation’s Older Population Is Still Growing, Census Bureau Reports.” News release, June 22. https://www.census.gov/newsroom/press-releases/2017/cb17-100.html.

Vincent, Grayson K., and Victoria A. Velkoff. 2010. The Next Four Decades: The Older Population in the United States: 2010 to 2050. Washington, D.C.: US Department of Commerce, Economics, and Statistics Administration, US Census Bureau.