The number of individuals 65 and older in the United States has increased steadily and comprised 15% of the population in 2014, and is projected to increase to 21% by 2030 (Colby & Ortman, 2015). The proportion of older adults in Korea is projected to increase rapidly from 13.2% in 2016 to 24.3% by 2030, whereas that of adolescents ages 9 to 24 is expected to decrease from 18.7% in 2016 to 13.7% by 2030 (Korean Statistical Information Service, 2014). In addition, structural changes, such as a growing trend toward nuclear families and a complex information technology infrastructure, reduce opportunities for intergenerational communication that enables youth to positively perceive older adults (Choi & Lee, 2014; Kersten, 2002; Kim, 2002). If negative perceptions of older adults among other generations arise, older adults may experience psychological maladjustment due to loss of self-esteem and emotional problems (e.g., alienation, loneliness) (Choi & Lee, 2014). For adolescents, negative interactions with others, society, and the school environment may cause conflict leading to depression, anxiety, withdrawal, anger, smoking, drinking, truancy, running away from home, and school violence (Kim, 2008; Schleider & Weisz, 2016). These changes have given rise to a generational gap between older adults and adolescents. Therefore, affirmative interactions between older adults and adolescents may be helpful to overcome the generational gap and find the meanings and values of life.
Therefore, the purposes of the current study were to (a) develop an intergenerational program based on symbolic interactionism for nursing home residents and adolescents; and (b) examine its effects on ego integrity, positive emotion, and facility adaptation in nursing home residents, as well as ego identity, positive emotion and school adaptation in adolescents, and adolescents' perception of older adults.
A pretest–posttest control group non-synchronized design was used to examine the effects of the intergenerational program. To prevent contamination of the experiment, the control group was examined first and the experimental group was examined second.
Participants were residents from three nursing homes and adolescents from three general high schools. Inclusion criteria for nursing home residents were having a score ≥20 on the Korean version of the Mini-Mental State Examination (MMSE-K; Kwon & Park, 1989), a score <22 on the Geriatric Depression Scale (Kee & Lee, 1996), and no diagnosis of dementia. Nursing home residents were excluded if they had an acute illness, such as influenza. In Korean nursing homes, most residents are diagnosed with stroke or dementia, and approximately 20% have MMSE-K scores ≥24 (Kim, 2016).
Sample size was calculated as needing a total of 120 participants (60 older adults and 60 adolescents), using G*Power version 3.1.2, with a significance level of 0.05, power of 0.80, and effect size of 0.65 according to a previous study (Kim, 2010). In consideration of the attrition rate, 132 participants (66 older adults and 66 adolescents) were recruited. Participants were randomly assigned to experimental and control groups.
The 6-week intergenerational program was developed based on the ADDIE model (Morrison, 2010), comprising five stages: analysis, design, development, implementation, and evaluation.
Analysis. Through the literature review, relevant program contents, related theories, and measurement methods were identified. Using the research information service, science and technology information integration service, Ministry of Health and Welfare, and the National Health Insurance Corporation, with a combination of search terms (i.e., “elderly,” “elderly care facility,” “nursing home,” “program,” and “intergeneration”), 24 articles and three research reports were selected. Most intergenerational programs included art and music therapies for children and older adults. Only one study examined adolescents and older adults, and investigated adolescents' perceptions of older adults without a control group. PubMed, PsycINFO, Trip, and the Cochrane Library were also searched using the terms “intergenerational,” “program,” “elderly,” and “elders,” and 35 articles were selected. The foreign research focused on the effects of a single program (e.g., life review). The younger generation most matched with older adults was university students. Theoretical frameworks included interaction or communication theories.
Through focus group interviews with three nursing home administrators, three practitioners, three residents, and three high school students who had volunteer experience in nursing homes, potential difficulties in applying the intergenerational program and useful program contents were identified. In addition, the current authors visited two nursing homes, investigated the current status of various programs for residents, and identified the environmental obstacles that might arise in the application process of the intergenerational program.
Design. Based on the results of the literature review, focus group interviews, and field studies, the objectives, conceptual framework, contents, applicable materials, and measurement variables of the intergenerational program were designed. Program objectives were identified as promoting ego integrity (Erikson & Erikson, 1998), positive emotions (Gross, John, & Richards, 2000), and nursing home adaptation (Jeon, 2014) in older adults. For adolescents, program objectives included improving ego identity (Erikson & Erikson, 1998), positive emotions (Gross et al., 2000), school adaptation (Ukasoanya, 2014), and perception of older adults (Park, 2004). The conceptual framework was derived from symbolic interactionism (Mead, 2015). It was appropriate for adolescents and older adults to interact with each other through language, expressions, and behaviors so that they could understand each other, think positively, and adapt to their environments. Through additional focus group interviews, preferable and applicable contents and the duration of the program were tailored. In addition, complementary activities, such as making picture frames, singing, and painting, were added to promote interactions. The draft version of the intergenerational program was designed and the tools to measure its effects were selected.
Development. To examine the validity of the draft version of the intergenerational program, the expert panel interview was conducted with six experts: one nursing home administrator, one department director from a nursing home, one nursing home manager, one team leader from the Korean youth work agency, one gerontological nursing professor, and one social work professor. The content validity index was measured by the expert group, and contents <0.80 were excluded or revised. Of the program contents, “going for a walk” scored 0.67 and was excluded due to being evaluated as inappropriate because of fall risk. “Adolescents' role play” scored 0.58 and was excluded because it was run by the adolescents group only, reducing opportunities of intergenerational interactions. The length of the program had been planned to be 2 hours per week, but was adjusted to 90 minutes after considering the experts' opinion that it was difficult for nursing home residents to sit for 2 hours. A 6-week intergenerational program was developed including modules with sessions comprising 30 minutes of positive interactions followed by 40 minutes of reminiscence therapy and then 20 minutes of intergenerational interaction reflection.
Implementation and Evaluation. To evaluate the feasibility of the developed program, a pilot study was conducted with five high school students and five nursing home residents. The study process was analyzed, including recruiting and obtaining permission, explaining the program, program preparation, operation progress, termination, and evaluation. The final version of the program was developed after improving the operational and methodological modules by exceeding no more than six students or six older adults per group and by adding the 2-week pre-educational session before meeting the older adults to train the students (Figure A, available in the online version of this article).
The Intergenerational Program Based on Symbolic Interactionism
The final intervention comprised weekly 90-minute sessions over 6 weeks. Each week included three sessions of facilitation, practice, and reflection. Facilitation sessions focused on intimacy; positive emotion; image of older adults, using active dialogue with photographs, journals, and newsletters; making picture frames; painting; and singing. Practice sessions focused on intergenerational communication using phased and in-depth interview with reminiscence therapy to rediscover ego, life values, roles, and contributions. Reflection sessions focused on discussing feelings from the interactions and writing in self-reflection diaries by adolescents.
In addition to demographic data, including gender, age, education, religion, living support, perceived health, grandchildren visiting, meeting with adolescents, number of friends, living parents, type of family (i.e., nuclear or extended), and length of voluntary work, the following information was measured.
Ego integrity was measured using the 31-item ego integrity scale (Kim, 1989). The scale comprises six domains: satisfaction with life, wisdom, attitude toward life, acceptance of death, acceptance of aging, and acceptance of past life. Items are scored on a 5-point Likert scale ranging from 1 = not at all to 5 = strongly agree. Higher scores indicate a higher level of ego integrity. Cronbach's alpha of the instrument at the time of development was 0.93. Cronbach's alpha was 0.92 at baseline in the current study.
The 20-item Korean version of the Positive Affect Negative Affect Schedule (Lee, Kim, & Lee, 2003; Watson, Clark, & Tellegen, 1988) was used to measure positive emotion. This scale comprises 10 adjectives representing positive affect and 10 adjectives representing negative affect. Each item is rated on a 5-point Likert scale ranging from 1 = completely disagree to 5 = strongly agree. The higher the total score after reversing the negative items, the higher the positive emotional level. Cronbach's alpha at the time of translation was 0.84. In the current study, Cronbach's alpha was 0.82 for older adults and 0.86 for adolescents.
Nursing home adaptation was measured by the 23-item nursing home adaptation scale (Lee, 2007). This tool comprises five domains: symptoms related to relocation, friendship, residence acceptance, difficulty in institutional life, and keeping life value. Items are rated on a 5-point Likert scale ranging from 1 = completely disagree to 5 = strongly agree. Higher scores represent higher degrees of adaptation. Cronbach's alpha at the time of development was 0.83, and was 0.73 in the current study.
The 60-item adolescent ego identity scale (Park, 2003) was used to measure adolescents' ego identity. The scale comprises six domains: subjectivity, self-acceptance, future conviction, goal orientation, initiative, and intimacy. Items are rated on a 5-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree. Higher scores indicate higher ego identity. Cronbach's alpha at the time of development was 0.95. In the current study, Cronbach's alpha was 0.74.
The 32-item school life adaptation scale (Yoo, 1994) was used to measure school adaptation. This scale comprises four domains: adaptation to relationship with teachers, adaptation to friendship, adaptation to school courses, and adaptation to school rules. Items are rated on a 5-point Likert scale ranging from 1 = completely disagree to 5 = strongly agree. Higher scores indicate greater adaptation to school life. Cronbach's alpha at the time of development was 0.79. In the current study, Cronbach's alpha was 0.87.
The 28-item image scale for the elderly (Park, 2004) measured the positive perception of older adults. The scale has three dimensions: physical image, psychological image, and social image. It uses semantic differential scaling of 1 point for very much (negative), 2 points for slightly (negative), 3 points for intermediate, 4 points for slightly (positive), and 5 points for very much (positive). Higher scores indicate more positive perceptions of older adults. Cronbach's alpha at the time of development was 0.69. In the current study, Cronbach's alpha was 0.87.
Ethical Consideration and Study Procedures
Ethical approval of the current study was obtained from the university institutional review board. Consultations with teachers in charge of each school were conducted with eligible adolescents, during which they considered the burden of participation on adolescents' studies; adolescents were then recommended for recruitment. Adolescents were informed of the study via school bulletin boards. Individuals who agreed to participate were recruited and the purpose and method of the study were explained to them and their guardians, and then consent was obtained from both. For older adults, three nursing homes were randomly partnered with three high schools. After explaining the study to department directors and receiving permission, detailed explanations of the study were given to older adults who met inclusion criteria, and then their consent was obtained if they wanted to participate. All participants were assured of their confidentiality, and it was clarified that they could stop participating in the study at any time.
To control for bias, the current authors differentiated between the researcher running the program (J.L.) and the researcher collecting data (J.K.). The experimental group participated in the intergenerational program and the control group participated in the daily programs provided by the facilities. Adolescents in the control group provided indirect support during the daily programs, such as transferring equipment. In the experimental group, the intergenerational program was conducted for 6 weeks with one 90-minute session per week at three nursing homes. The program operator was a qualified gerontological nursing specialist with a certification in psychotherapy with experience in conducting various programs in nursing homes. The program was conducted with five or six residents and five or six adolescents, with one program assistant (nursing PhD candidate). One practitioner (social worker) from each nursing home also assisted the program. During the program, the program assistant and nursing home practitioner observed participants and gave breaks to those who were tired or uninterested. Pre-tests and posttests were conducted at intervals of 8 weeks.
Data were analyzed using SPSS version 20.0. Participant characteristics and research variables were analyzed using descriptive statistics. The homogeneity of the experimental and control groups for the general characteristics and study variables were analyzed using chi-square test, Fisher's exact test, and t test. The changes in scores of study variables from pretest to posttest were analyzed using t test between groups.
The participant selection process is shown in the Figure. Among 132 participants, three adolescents in the experimental group dropped out due to absence from the program for more than 2 weeks, and three adolescents in the control group dropped out due to their parents' worry about their studies. Therefore, data were excluded for three residents matched with three adolescents from the experimental group, and three residents from the control group. The situation was explained to the older adults so that they would not feel any inconvenience, and facility staff members were matched with them and they finished the program together. The final sample included a total of 120 participants (30 residents and 30 adolescents in the experimental group, and 30 residents and 30 adolescents in the control group). Homogeneity of the general characteristics between groups was verified (Table 1).
Flow diagram of participant selection process.
Homogeneity Test Between Groups (N = 120)
Baseline Differences Between Groups
Among nursing home residents, there were no significant differences in ego integrity (t = 1.65, p = 0.104), positive emotion (t = 1.12, p = 0.265), or facility adaptation (t = 0.49, p = 0.625), indicating that the two groups were homogeneous (Table 1). The experimental and control groups of adolescents were homogeneous, with no significant differences in ego identity (t = 0.46, p = 0.645), positive emotion (t = −1.07, p = 0.289), school adaptation (t = 0.72, p = 0.478), or positive perception of older adults (t = 0.73, p = 0.468).
Effects of the Intervention: Between-Group Differences
Effects of the intergenerational program are described in Table 2. The older adult experimental group had higher increases in levels of ego integrity (t = 4.81, p < 0.001), positive emotion (t = 3.67, p = 0.001), and nursing home adaptation (t = 4.98, p < 0.001) compared to the control group.
Effects of the Intergenerational Program
The adolescent experimental group had statistically significant higher degrees of ego identity (t = 6.14, p < 0.001), positive emotion (t = 4.01, p < 0.001), school adaptation (t = 3.43, p = 0.001), and positive perception of older adults (t = 5.02, p < 0.001) than the control group.
The intergenerational program pursues mutual understanding and harmonious coexistence of two generations in society, where intergenerational interactions are decreasing. The current study (a) developed the intergenerational program to enable nursing home residents and adolescents to positively perceive themselves and each other based on symbolic interactionism, and (b) examined its effects.
According to symbolic interactionism, there is an intrinsic “me” and a “me” that is seen by others (Mead, 2015). Through the intergenerational program based on symbolic interactionism, nursing home residents and adolescents were able to rediscover their affirmative ego and emotions from positive interactions. With ego identity and positive emotions, they could better adapt to their social environments.
Nursing home residents' ego integrity improved through the intergenerational program. Although no previous studies exist using the intergenerational program with adolescents and older adults in Korea, the current findings were consistent with an experimental study using reminiscence therapy for older adults and a systematic review (Kim, 2010; Lazar, Thompson, & Demiris, 2014). The experimental study (Kim, 2010) used reminiscence therapy with 10 nursing home residents, and participants were able to accept themselves as being worthy through recall activities. In the current study, nursing home residents participating in the intergenerational program could share their experiences and wisdom in depth with the younger generation through phased reminiscence therapy, and had opportunities to positively rediscover their own life values. Because this program included adolescents as matches with older adults (who could have meaningful conversations, unlike existing programs that include preschool children), it could facilitate self-reflection and improve older adults' ego integrity. In addition, older adults' positive emotional levels significantly increased through the intergenerational program. A phenomenological study also found that older adults experienced self-confidence and positive emotions through harmonious relationships between generations (Na, 2011).
The current study's intergenerational program improved older adults' adaptation level. Although nursing home residents report the most difficult time to adapt to facilities is during the first year admitted (Lee, Lee, & Lee, 2009), sustained attention is needed for nursing home adaptation. In nursing home environments, where all schedules of daily life are set, the intergenerational program could provide residents with opportunities to perform valuable roles, as they can share their wisdom with next-generation leaders of the future society.
Similarly, adolescents who participated in the intergenerational program could have the opportunity to engage in deep conversations and interactions with nursing home residents, leading to planning their future lives and gaining wisdom and values of life. Consequently, adolescents' ego identity significantly improved. A previous study of adolescents' volunteer work also found that they experienced an affirmative change in ego identity through playing a social role as a member of society (Park & Kim, 2012). Therefore, it was helpful to include adolescents in the intergenerational program and have them write a self-reflection diary to feel a sense of accomplishment and introspection. Adolescents who participated in the intergenerational program had significantly higher positive emotions than the control group because adolescents in the program could gain a guideline to plan their own lives harmoniously and successfully through the active learning experiences with older adults. Indirect experiences with older adults contributed to having positive emotions and breaking from anxiety about uncertainty (Elezovic, 2005; Schleider & Weisz, 2016).
Adolescents in the intergenerational program experienced better adjustment to school environments than the control group. In a previous study, the more adolescents were satisfied with volunteer activities, the more they became attached to friends and the better they adapted to school life (Cha & Kim, 2015). The maladjustment of adolescents to school life is a serious problem, and the proportion of high school students who left school in 2015 was 1.26%, with school maladjustment being the highest cause at 79.1% (Ministry of Education, 2016), although various programs for adolescents (e.g., art therapies, experiential activities) have since been applied.
The intergenerational program developed in the current study is a new approach in Korea to modeling interactions with older adults by involving adolescents to rediscover life, life values, family, friends, and society through positive interactions. The positive perception of older adults among adolescents in the intergenerational program significantly improved compared to those in the control group. One study also revealed that adolescents' participation in a volunteer program at a senior welfare center improved their positive perception of older adults (Seo, 2013). In a study of the Q methodology for the image of older adults perceived by individuals in their 20s and 30s, the types of perception differed according to individual variations, such as amount of experiences with older adults (Choi & Lee, 2014). This finding suggests that intergenerational programs for nursing home residents could be developed to include various age groups in consideration of the characteristics of each generation.