Ⅰ. Introduction
According to MacManus (2018), ageism may become the most detrimental social problem in the twenty-first century, possibly even rivaling racism. The authors highlight survey results indicating that approximately two-thirds of Americans think that older adults do not understand young people and over 80 percent of Americans do not think young people understand older adults. One point where misunderstandings and differences occur is in the political world. Older adults are more likely to be involved in the political world. In contrast, registration and voting rates are lower among younger generations. Involvement in the political world has been found to increase the most in young adults with increased exposure to information and life experiences. Intergenerational (IG) contact, defined as nonfamilial interactions between different generations allowing for shared experiences, knowledge, and skills that are mutually beneficial, is essential in bridging the generational gap (Hanks & Ponzetti, 2004). According to O’Dare, Timon, and Conlon (2019), benefits of IG friendships include information exchange, technology use, and the sharing of life experiences affecting ways of thinking, being, and living.
Ageism, defined as prejudice or discrimination due to age has a negative effect on both young people and older adults (Nelson, 2005). Donizzetti (2019) found detrimental effects on occupational performance and increases their susceptibility for clinical depression, decreased self-efficacy, and reduced cardiovascular and immune function. According to the World Health Organization (n.d.), older adults with negative attitudes towards young people may live 7.5 years less than those with positive attitudes. According to Larkin, Sadler, and Mahler (2005), young people are often characterized by older adults as disrespectful, avoidant of responsibility, and prone to taking unnecessary risks. In recent years, a new concept of “emerging adulthood” has been used to describe individuals aged 18 to 25 who gradually assume adult roles and attempt to consolidate their identities (Trzesniewski & Donnellan, 2014). This trend is different from how older generations transitioned into adulthood and has created a cultural shift that creates a disconnect between generations and may be a source of ageist beliefs. The concept of emerging adulthood has elicited different opinions from members of society, particularly from older adults. A study investigating emerging adulthood sampled 641 individuals, aged 18 to 87, and found that respondents held more positive feelings toward older adults than emerging adults and adolescents (Trzesniewski & Donnellan, 2014). Data showed that emerging adults were viewed as immoral, narcissistic, overconfident, self-centered, less hardworking, and lazier in comparison to older generations. Not only does this negative perception affect young people individually, but it affects the entire young birth cohort, regardless of individual characteristics. Due to the collective categorization of younger generations, there is rising concern about not growing out of this “emerging adulthood” phase. This is important because the cohort stereotypes will persist regardless of societal experiences, which warrants the need for interventions to reduce these discriminatory beliefs toward young people (Trzesniewski & Donnellan, 2014). Ageism is “one of the most institutionalized forms of prejudice” in today's society (Nelson, 2005). The societal norms in America tells aging adults that they are useless, unwanted, and an economic burden. Young people are told that getting old is bad, with over $114 billion spent in 2015 to hide the physical signs of aging (Seegert, 2016). Interventions that counteract these stereotypes are needed in the American society now more than ever.
Segregation by age is a frequent and increasingly observed trend among activity participation in the U.S. (Kingson, Cornman, & Leavitt, 1996; Larkin et al., 2005). There is a sharp divide between generations, referencing the Silent Generation (aged 73 to 90), Baby Boomers (aged 54 to 72), Generation X (aged 38 to 53), Millennials (aged 22 to 37), and Generation Z (aged 6 to 21) (Bialik & Fry, 2019). This divisions can be due, in part, to the advancement of technology, increased educational attainment, geographical separation, differences in life experiences due to societal demands, and different marriage or familial norms.
Programs that facilitate IG contact are becoming more abundant and strive to bridge the generational gap by creating positive and benevolent relationships. IG activities to increase nonfamilial shared experiences and are dated back to the 1960’s (Hanks & Ponzetti, 2004). The programs were initially developed in the United States and have spread globally since then. Common participants in these programs have included older adults from assisted living facilities, community wellness programs, and nursing homes, and young people from preschools, day-care centers, and elementary schools, all the way to universities.
An estimated combined total of 2.5 million children and adolescents participate in an IG program each year (Raposa et al., 2019). However, limited research has examined the impact that IG programs have on decreasing ageism toward young people (Abrams & Houston, 2006; Garstka, Schmitt, Branscombe, & Hummert, 2004; Hagestad & Uhlenberg, 2005; Snape & Redman, 2003).
1. Literature Review on the Impact of Ageism on Young People and Older Adults
Bratt, Abrams, Swift, Vauclair, and Marques (2017) investigated the levels of perceived ageism through data retrieved in the European Social Survey in a population of early to late adulthood (15 to 105 years old, Mean age = 47.54). Twenty-nine countries were included with 56,272 participants. Bratt et al. found that individuals aged 15-49 experienced the highest levels of ageism compared with all other age groups. The high level of perceived ageism among young people warrants the need to investigate the effects of ageism on this population in more depth. Current research focuses on the effects of ageism solely towards older adults. Given that ageism leads to many negative outcomes for individuals across the lifespan, IG interventions should target the reduction of ageism reciprocally.
A systematic review conducted by Ronzi, Orton, Pope, Valtorta, and Bruce (2018) included 27,354 participants and evaluated the impact that IG interventions have on the health and wellbeing in community-dwelling older adults. The interventions that yielded an overall positive impact on health outcomes included music and singing, art and culture, and multi-activity interventions and resulted in positive outcomes among older adults through the formation of relationships with young people. This systematic review examines the effectiveness of IG interventions by addressing the question, “In a population of older adults, are IG programs effective in reducing ageism toward young people?” In this review, young people are defined as youth and adolescents between the ages of 10 and 24 (World Health Organization, 2018).
Ⅱ. Methods
After identifying a focused question, members of the research team searched the following electronic databases to select articles; PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google Scholar, Scopus, and Cochrane Database of Systematic Reviews. Additional studies were identified by hand-searching the reference lists of relevant review articles.
The initial search process yielded 4,661 potential articles. EndNote: Clarivate Analytics was used to facilitate the screening process with the removal of duplicates and review of subsequent studies. The search strategy combined key terms listed in figure I, published within the past 30 years, in the English language, and found in peer-reviewed journals. Exclusion criteria consist of studies with samples that are too inclusive to generalize to the rest of the population, involving political relationships and adults with chronic diseases. To be considered for final inclusion, studies met the following criteria: (1) implementation of an IG program and (2) specifically have a quantitative or qualitative outcome measure assessing ageism toward young people. No RCTs were found during the comprehensive review of published and gray literature. Table 1 outlines the screening process adopted by the AOTA (2017) systematic review guidelines. Risk of bias was evaluated for each article to identify any underlying factors that could affect the cumulative evidence (Table 3) (Viswanathan et al., 2012).
1. Search Terms
Terms listed in Table 2 were included in the search process. Variations of the search terms were used to describe relevant populations and interventions to widen the scope of available resources. The following are Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines provided by the AOTA (2017) were used to determine the level of evidence for each article: a level I study includes systematic reviews, meta-analyses, and randomized controlled trials, a level II study includes two groups and nonrandomized studies, a level III study includes one group nonrandomized participants, a level IV study includes descriptive studies, and a level V includes case reports or expert opinions. This systematic review examined three level II studies, four level III studies, one level IV study, and four qualitative studies.
Ⅲ. Results
Of the 4,661 articles retrieved, 12 studies met the inclusion criteria focusing on IG programs that incorporate reciprocal ageism outcome measures.
Among the studies, three were level II, four were level III, one was level IV, and four were qualitative studies. To quantitatively assess ageism, two studies used the Anxiety About Aging Scale (Lasher & Faulkender, 1993), two studies used the Aged Group Evaluation and Description Inventory (Knox, Gekoski, & Kelly, 1995), one study used the Fraboni Scale of Ageism (Fraboni, Saltstone, & Hughes, 1990), one study used the Aging Semantic Differential Scale (Polizzi, 2003), one study used the Loyola Generativity Scale (McAdams & de St. Aubin, 1992), one study used the Life Satisfaction Scale (Neugarten, Havinghurst, & Tobin, 1961), one study used SF-36 (Contopoulos-Ioannidis, Kouri, Karvouni, & Ioannidis, 2009), one study used the Geriatric Depression Scale (Sheikh & Yesavage, 1986), one study used Kogan’s Attitude Toward Older People (Kogan, 1961), one study used Belgrave’s Behavioral Observation tool (Newman, Morris, & Streetman, 1999), and one study used Lubben Social Network Scale (Lubben et al., 2006). To qualitatively assess decreased ageism, semi-structured interviews were administered, followed by a detailed coding process for eight articles.
The specific interventions in the reviewed studies differed between programs, but commonalities included extended contact, community-centered activities, and the presence of mentorship roles. Eleven of the twelve articles yielded statistically significant effects in the reduction of ageism toward young people.
For comprehensive program comparison, four recurrent themes were identified throughout the 12 studies. The studies with similar results were then compared to assess IG program effectiveness and outcomes related to the reduction of ageism. The four themes are: (1) the formation of reciprocal relationships, (2) the challenging of older adult misconceptions toward young people, (3) positive effects on older adults’ attitudes toward young people, and (4) older adults renewed hope in societal successors.
1. Formation of Reciprocal Relationships
A common outcome of IG programs was the formation of reciprocal relationships. This can be broadly defined as participants from both age groups reporting the formation of meaningful relationships with each other supported by significant quantitative measures or qualitative measures. The outcomes of six studies addressed this theme with of 454 participants.
Bertram et al. (2018) conducted a level II study in which eight older adults (aged 74-90), 34 college students, and 21 children (aged four to five) participated in self-selected activities with the objective of assessing perceptual change between the generations. The results showed that in recent years they enjoyed the children because of their energy and expressed the need to care for and teach them in order to benefit the future. The young children found the older adults to be fun and good playmates. The results of the study showed significant gains in positive attitudes and judgements reciprocally. The young children found the older adults to be fun and good playmates. The results of the study showed significant gains in positive attitudes and judgements reciprocally.
Leedahl et al. (2019) conducted a level III study in which the Engaging Generations Program implemented a reverse mentoring program with 87 older adults (Mean age = 72.96) and 28 younger adult mentors (Mean age = 21.82) using three models of intervention. The objective was to use technology as a means of bringing generations together. Students’ attitudes toward aging, comfort working with older adults, and confidence in teaching older adults improved following the program. Older adults’ enjoyment from working with technological devices showed significant improvements with a medium effect size. The program helped participants feel comfortable and confident using technology, which allowed a new world to open up and ultimately led to decreased levels of isolation and depression.
Skropeta, Colvin, and Sladen (2014) conducted a level III study in which an IG playgroup program (IPP) provided a leisure lifestyle program offered in an aged care facility for 48 older residents (Mean age = 85), 41 child caregivers, and 50 children, aged 0-4 years old. A mixed methods study was conducted with the objective of providing a comprehensive analysis of IG playgroups. Older adults viewed this program as a “rewarding experience being in the company with young children.” As an IG intervention, the IPP allowed for connections between the three age groups, new perspectives for the children as well as the older adults. This program promoted awareness and understanding between the generations and led to a reduction of ageism.
Breck, Dennis, and Leedahl (2018) conducted a qualitative study in which the Engaging Generations Cyber-Seniors implemented a reverse mentoring program with 87 older adults OAs (Mean age = 73.45) and 28 young adults (Mean age = 21.81). The younger adults provided technology support and knowledge to the older adults with the objective to improve social connection by increasing digital competence of older adults. Three themes emerged from qualitative synthesis: (1) increased sense of self-efficacy among older adults, (2) the breaking down of age-related stereotypes, and (3) IG connection. The reverse mentoring intervention yielded a strong impact on creating the IG connections, acknowledged by all participants.
Larkin et al. (2005) conducted a qualitative study in which the Big Brother Big Sister program (BBBS) assessed the benefits of volunteering in a mentorship program for older adults volunteers (Mean age = 55-66). The volunteers and mentees participated in individualized activities including building puzzles, watching TV, playing card games, and eating meals together. The strong relationships grew to resemble familial ties over time. The program allowed for close relationships with younger people who needed the care and ultimately yielded reciprocal benefits.
Zucchero (2010) conducted a qualitative analysis in which the Co-Mentoring Project (CMP) implemented an IG service-learning project with 14 older adults (Mean age = 76.17). The objective for this project was to explore the experiences of active older adults who participate in IG programs with college students. Eighty-six percent of participants described the formation of a reciprocal relationship through completion of the CMP. The majority of participants stated the relationship formed with their student was the most important benefit of the program.
2. Challenging of the Misconceptions toward Young People
Another common theme is the challenging of the misconceptions toward young people. This category is defined as encouraging open-mindedness and self-reflection of older adults. It also consists of comparing older adults’ beliefs about their younger counterparts prior to and following IG intervention. The desired outcome of this is to challenge older adults to strip their previous beliefs about young people and form new beliefs based on their IG experience. The outcomes of four studies addressed this theme with 263 participants.
As previously mentioned, Bertram et al. (2018) conducted a level II study with outcome measures supporting the significance IG programs have on challenging societal misconceptions. Older adults were impressed by the assistance, dedication, and involvement of the young people. Older adults’ pre- and post-test data showed sustained or increased perceptions of the young people.
Androletti & Howard (2018) conducted a level IV study implementing Working Together: Intergenerational Student Senior Exchange (WISE) program with 21 older adults in an assisted living facility (Mean age = 86.4) and 64 students (Mean age = 21.6) enrolled in an adult development and aging course. The Loyola Generativity Scale (McAdams & de St. Aubin, 1992) and Anxiety about Aging Scale (Lasher & Faulkender, 1993) were used as outcome measures, and the results showed a significant reduction in ageism toward young people. Qualitative data revealed that the majority of older adults reported that the program positively impacted their view of young people. Older adults reported that the program “helped them recognize how intelligent, thoughtful, and polite young adults are today and that “sometimes people say bad things about the youth but that is a misconception”.
Breck et al. (2018) as mentioned above, conducted a qualitative study in which the Engaging Generations Cyber-Seniors implemented a reverse mentoring program. One participant provided insight on how the program helped break down generational stereotypes, stating, “I learned that there are young people working hard to make their lives better with kindness, compassion, and a sense of humor”.
A common qualitative theme from the study by Zucchero (2010) was the transformation of older adult expectations regarding the students. Challenging misconceptions about the young people was noted as an older adult stated, “young people, they aren’t really as bad...I don’t think we hear enough about the really smart kids who are willing to take the time to do things like this”.
3. Older Adults’ Attitudes toward Young People
The third outcome category is defined as targeting the affective domain of older adults and how they feel toward young people. The desired outcome is for these programs to positively influence older adults’ affect toward young people. The outcomes of five studies addressed this theme with 550 participants.
Belgrave (2011) conducted a level II study with 26 older adults OA and 23 elementary-aged children participating in a music-based IG program. Older adults’ attitudes toward the children improved, as well as their views on the younger participants level of goodness, positiveness, and maturity. As the program progressed, observations of older adults’ level of participation, affect, and interaction with young people improved.
Sun, Lou, Dai, To, and Wong (2019) conducted a level II design implementing the Young-Old Link and Growth Program (YOLG) with 150 older adults and 162 adolescents. This study yielded three significant results (1) positive changes in IG attitude, (2) improved sense of comfort interacting with cross-age groups, and (3) positive changes in IG contact. The older adults showed significant changes in visual attention, increase in conversation initiation, and touch. A significant overall effect was observed regarding change in IG attitude for both groups of participants, yielding a large effect size.
In the study previously mentioned by Bertram et al. (2018) the older adults’ attitudes toward college-aged students showed positive sustained attitudes at the program completion. Two themes emerged from the qualitative synthesis: college students are helpful and interesting and there is a need for encouragement and guidance.
Through qualitative synthesis, Leedahl et al. (2019) found that the older adults participants enjoyed interacting with the “young intelligent people”. Those who completed at least three sessions valued this educational approach and increased their attitudes toward the young people.
Jones, Herrick, and York (2014) conducted a qualitative descriptive study with eight lower income adults (Mean age = 71) and five youth (Mean age = 15) who were a part of an emotionally disturbed support group. Results indicate that both of the groups attitudes toward each other changed positively. Seventy-percent of the older adults stated that their attitudes toward the youth and attitudes toward mental illness has positively changed at the conclusion of the program.
4. Hope in Societal Successors
The final outcome category is defined as older adults’ perspectives on the future of society in the hands of younger generations. The desired outcome is for older adults to have a positive and hopeful outlook about young people running society in the future. The outcomes of two studies addressed this theme with 294 participants.
Parkinson and Turner (2019) conducted a level III review implementing the DOROT summer internship program with 140 older adults OAs and 140 teenage volunteers. The program engaged teens and older adults in positive experiences to alleviate social barriers. As a result of participating in DOROT, a majority of older adults had renewed hope about the future, with one participant stating, “I feel so good about the kids I meet...It makes me feel so good about the future”.
A study conducted by Zucchero (2010), suggested that a common qualitative theme was the transformation of expectations about the students in the program. One participant in the CMP had extensive experience with college-aged persons and after the program stated, “what I came out of this is that we probably will leave the world, in many ways, to a wonderful new generation...renewed hope for those coming along”.
5. No Significance
Chien and Tann (2017) conducted a level III Multigenerational Learning Program (MLP) with 196 older adults (Mean age = 65.77), ten college students (Mean age = 20.4), and 163 children (Mean age = 9.28). The MLP participants included middle and older aged adults, college students, and children with activities consisting of music, arts, crafts, reading, and games. The objective of the study was to improve IG understanding and attitudes reciprocally, while simultaneously challenging negative stereotypes and misconceptions toward the aging population. Pre- and post-test questionnaires were administered to gauge attitudes, and the results indicated that there was no significant difference on all measures. There was an observed increase in attitudes, but the high pre-test means made it difficult for any drastic change in attitudes to occur over the course of the program.
6. Risk of Bias
Of the twelve articles, the eight studies utilizing quantitative outcome measures were evaluated for risk of bias. The risk of bias table was generated based on AOTA (2017) systematic review guidelines (Table 3). These guidelines provided a resource to evaluate the study design and analyze outcomes. Moderate risk of bias in random sequence generation and allocation concealment are present in the studies evaluated. The high risk of bias within selection bias is to be expected from evaluation of current literature (Ronzi et al., 2018). IG programs are suggested to yield more positive results and retain participants when paired based on common interests or gender.
7. Rigor in Qualitative and Mixed Method Studies
Rigor was assessed in the included qualitative studies, as well as in the qualitative components of the mixed method studies. One study, conducted by Zucchero (2010), used moderately-structured focus groups to gather qualitative data on participants. An open coding method was utilized to analyze data from focus group transcripts, and each member of the research team contributed, indicating there was triangulation. An audit trail was well maintained throughout the data collection and analysis processes to ensure rigor. However, using focus groups as a means of data collection could have compromised participants’ privacy or confidentiality, which potentially produced bias. Other studies used various types of qualitative methodology, but the utilization of means, such as triangulation and audit trail remained consistent.
Ⅳ. Discussion
This is the first systematic review to synthesize the evidence on the effectiveness of IG programs in reducing ageism toward young people. Previous reviews have supported the significance of such programs in reducing ageism toward older adults, but this review supports the reciprocal impact. This review addresses the pressing problematic issue of ageism by providing new and meaningful findings about the effectiveness of IG programs. After identifying 12 studies that solely assess the perceptions of older adults, it became evident that IG programs can be effective in reducing ageist beliefs reciprocally. By data analysis of quantitative and qualitative programs, it expands the impact that IG programs can have on both age groups.
Overall, moderate evidence supports the effectiveness of IG programs on reducing ageism toward young people. Moderate evidence is defined by the AOTA Systematic Review Guidelines (2017) as having multiple moderate-quality studies with sufficient evidence to support outcomes, however confidence is constrained by the size or quality of studies. Eleven of the 12 studies included in the review yielded statistically significant results in a reduction of ageism. The study by Chien and Tann (2017) aimed at improving attitudes of older participants toward younger participants and vice versa. While attitudinal improvements were achieved through the Multigenerational Learning Program, the pre-test means were already so high, so the results were negligible due to a possible ceiling effect.
A survey with 56,272 respondents conducted by Bratt et al. (2017) found that participants aged 15-49 reported higher levels of age discrimination toward themselves than older adults did. This is important because as a whole, emerging adults are viewed negatively and seen as narcissistic, overconfident, less hardworking, and lazier in comparison to older adults, which ultimately impacts how they are treated by society as they assume mature societal roles. This is problematic because these ageist beliefs toward young people may be perpetual and impose long-term negative effects on this aging cohort. Due to the scarcity of research showing the negative effects of ageism toward young people and effective interventions to reduce the associated impacts, this review explores these areas.
A variety of intervention styles were used in the studies, but the strong majority of interventions incorporated IG contact and led to the reduction of negative impacts of ageism toward young people. Regardless of the interventions and programs implemented, standardized outcome measures yielded statistically significant evidence in the reduction of ageism through IG programs.
Evaluation of the outcomes of participation produced the following themes explaining the impact of IG interventions: (1) they support the formation of a reciprocal relationship, (2) they challenge the misconceptions held by older adults toward young people, (3) they positively change older adults’ attitudes toward young people, and (4) they renew the hope of older adults about the future of society successors.
Six studies found outcomes to support of the formation of reciprocal relationships through IG programs. Of the six studies, one was a level II, two were level III, and three were qualitative studies. This indicates moderate evidence that IG interventions result in reciprocal relationships and ultimately reduce ageism toward young people. Four studies supported challenging age-based misconceptions toward young people as an outcome. Of the four studies, one was level II, one was level IV, and two were qualitative studies. This indicates moderate evidence suggesting that IG interventions can challenge, and possibly reverse misconceptions held by older adults toward young people. Five studies supported the outcome of positive changes in older adults’ attitudes toward young people and found moderate evidence. Of the five studies, three were level II, one was level III, and one was a qualitative study. Two studies support the impact IG programs have on positively changing older adults’ futuristic views of society and found a low level of evidence. Of the two studies, one was a level III and one was a qualitative study. The included studies provide support for the reduction of ageist beliefs toward young people. The evidence highlights the need for further execution of reciprocal outcome measures in pre-existing mentorship programs.
1. Strengths and Limitations
Through review of the risk of bias for the quantitative studies, a low risk of allocation, performance, and reporting bias were found in the majority of the articles. Additionally, the qualitative studies were assessed, and the use of triangulation and audit trails in the data collection and analysis processes contributed to the high level of rigor.
Overall, these studies consisted of large sample sizes. Arguably, the most important strength of this review was the examination of current literature through compiling and analyzing studies which explored the effectiveness of IG programs on reducing ageism toward young people. Much of the current literature is focused on how older adults are impacted by ageism, though many young people perceive they are most affected (Bratt et al., 2017). This review specifically explores the effectiveness of IG interventions to reduce ageism toward young people and paves the way for future research to continue to be conducted in this area.
Limitations are as follows. Over half of the studies had a high risk of selection bias, which includes random sequence generation and allocation concealment. Due to scarcity of relevant evidence, there were no level I studies included. It is recommended that researchers conduct randomized controlled trials, examine the literature of non-English language, and conduct IG programs addressing the reciprocal reduction of ageism. IG programs will provide a way to improve current ageist beliefs in today’s society.
2. Implications for Occupational Therapy Education, Research and Practice
Occupational therapy practice has the potential to play an integral and unique role in future programs targeting the reduction of ageism across the lifespan. Aforementioned, ageism toward older adults has been shown to negatively impact their occupational performance, overall well-being, and quality of life (Belgrave, 2011). Inversely, research shows older adults hold ageist beliefs against young people, of whom this review is centralized. Occupational therapy works with individuals of all ages, inherently views individuals in a holistic manner, and strives to improve individuals’ quality of life. Many of the IG interventions are community-based and occupational therapy provides services to individuals, groups, and populations (AOTA, 2014). Occupational therapists could develop and oversee the implementation of evidence-based IG interventions to combat ageism toward both age groups.
AOTA (2016) outlines the area of productive aging as part of the discipline’s scope of practice. This area accommodates the aging population by (1) promoting health and quality of life and (2) facilitating participation in meaningful occupations. IG experiences can address this emerging initiative.
With the high prevalence of age-based segregation, a major cultural shift, and rise in the aging population, IG programs are highly warranted. These programs increase IG interdependence and bridge the age-related gap in society creating positive and benevolent relationships. Ultimately, IG programs supports productive aging and positively impacts the psychosocial and physical wellbeing of individuals across the lifespan.