Living Legends: Effectiveness of a Program to Enhance Sense of Purpose and Meaning in Life Among Community-Dwelling Older Adults

Research Design

We used a mixed-methods design, specifically an RCT with a connected qualitative component. We collected and analyzed qualitative data in the form of written responses to questions about the program experience to expand on and illuminate the quantitative findings. We used a triangulation protocol to integrate qualitative and quantitative findings and gain a more complete picture of the benefits of the program. Specifically, we explored whether the quantitative and qualitative findings were convergent, complementary, or contradictory (O’Cathain et al., 2010). The institutional review board at New York University approved the study, and we obtained informed consent from all interested and eligible participants.

Participants

Power analysis using G^*Power (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany) indicated that for a medium effect size, 42 participants were needed. A medium effect size was chosen for the power analysis given that the literature provides no clear data regarding the effect size for intergenerational programs. Although the recruitment goal was 42 participants, we recruited 48 older adults to compensate for possible attrition. We recruited participants from four community-based older adult program sites in New York City. Three sites were naturally occurring retirement community (NORC) programs, and the fourth was a senior center. Each site provides programs and services to help older adults remain at home. All participants were community dwelling, meaning they lived in their own apartment rather than in senior housing or an assisted living facility. Inclusion criteria were age 60 yr or older, ability to speak and write English, and negative screen for probable dementia on the Mini-Cog (Borson, Scanlan, Brush, Vitaliano, & Dokmak, 2000). People with a positive Mini-Cog screen were excluded; participants needed to be able to recall, write, and share their life stories to participate fully in the intervention.

Participants were randomly assigned to the life review writing workshop or writing workshop plus intergenerational exchange program using a table of random numbers generated by Microsoft Excel (Microsoft, Redmond, WA). Six participants were randomized to the intergenerational program at each site to ensure that a minimum number of participants attended each week given the possibility of missed sessions (e.g., because of family commitments or doctor’s appointments). This minimum number of participants was ascertained from the feasibility study.

Intervention

The Living Legends program took place over the course of 1 academic year (Fall 2013 through Spring 2014). Two senior program sites participated in the fall semester and two in the spring semester. All participants took part in the 8-wk “Share Your Life Story” (Sierpina, 2002) life review writing workshop. The workshop includes writing prompts and tips and provides the opportunity to write about life chronologically and receive positive feedback on writing technique from the group leader and other group members. The workshop has an integrative component in which participants write about how their life experiences have shaped who they are. The program met weekly in each of the four community-based program sites and was led by the principal investigator (Tracy Chippendale), an experienced occupational therapist. Nine to 11 participants attended the 8-wk writing workshop at each site.

The intergenerational program, also led by the principal investigator, began 2 wk after the final writing workshop session. The program met once a week for 4 wk and was attended by the participants randomly assigned to the intergenerational program (treatment group) and by health science students. Approximately 6 students and 6 participants attended the intergenerational program at each site. A protocol, previously piloted and modified on the basis of a feasibility study (Chippendale, 2013), was used to guide the intergenerational exchange. Before the start of the first session, the program leader (who was the principal investigator) provided a brief orientation for students that included program expectations and tips for communicating with people who have hearing loss. In the first session of the intergenerational program, all participants introduced themselves to the other program members.

Each session lasted approximately 90 min and included the opportunity for each older adult participant to read one piece of his or her work self-selected from the preceding 8-wk workshop. After each reading, a guided discussion took take place between the older adults and students about the content of the writing. The program leader used verbal prompts such as the following to facilitate the intergenerational exchange:

Before the final week of the intergenerational program, students were asked to write about their experiences in the program, specifically how hearing participants’ life stories had affected them. Students shared their writing orally with the group during the final workshop session.

Measures

Data Collection

We collected data at baseline, after the writing workshop, and at the end of the intergenerational program. The majority of questionnaires and assessments were administered by trained research assistants. However, because of scheduling conflicts, the principal investigator administered some of the pre- and posttests. Research assistants assisted with the distribution and collection of written feedback forms for participants assigned to the intergenerational program. Therefore, for some participants, the research assistants were not blinded to group assignment.

Analysis

Data were analyzed using IBM SPSS Statistics (Version 21; IBM Corporation, Armonk, NY) using a .05 significance level. Descriptive statistics (means, standard deviations, and ranges) were reported to present participant characteristics. χ² tests of independence and independent-samples t tests were used to compare the intervention and control groups at pretest to ensure that no initial differences existed. An independent-samples t test was used to compare the treatment and control groups with regard to change scores on the MLQ–Presence. An intention-to-treat paradigm was used.

We analyzed participants’ written descriptions of the intergenerational exchange program experience using Colaizzi’s (1978) phenomenological analysis method. Two coders (Boltz and Chippendale) were used to increase the reliability of the analysis. Each coder read through all the transcripts and extracted significant statements (i.e., statements that pertained to the participant’s program experiences). Meaning was assigned to each significant statement. The two coders discussed statements identified as significant and their assigned meanings until consensus occurred. Coders individually grouped formulated meanings into corresponding themes and then discussed their decisions jointly until they achieved consensus. A triangulation protocol was used to integrate the qualitative and quantitative findings (O’Cathain et al., 2010).

Workshop Attendance

Participants attended a mean of 6 sessions (range = 1–8) of the 8-wk life review writing workshop; no significant difference was found between groups with regard to writing workshop attendance. Participants assigned to the treatment group attended a mean of 3 sessions (range = 1–4) of the 4-wk intergenerational program.

Increase in Sense of Purpose and Meaning in Life

Initial analysis using χ² tests of independence and independent-samples t tests revealed no significant differences between the treatment and control groups with regard to age, gender, ethnicity, education, number of leisure interests, level of leisure activity participation, GDS scores, or MLQ–Presence scores (see Table 1). A change score was used to measure the difference in MLQ–Presence scores from Posttest 1 (after the writing workshop) to Posttest 2 (after the intergenerational program). Treatment and control group scores on this measure differed significantly (see Table 2). Moreover, the effect size (Cohen’s d) was 1.24, which is considered very large. Levene’s test for equality of variances was not significant, and although group size was unequal, skewness ratios were <2, indicating that the underlying assumptions of this test were met. When we conducted a subgroup analysis to include only participants with low MLQ–Presence scores (i.e., ≤24; Steger, 2010), the independent-samples t test revealed that the difference between groups was also significant (see Table 3).

Qualitative Findings

Qualitative analysis of older adult participants’ written responses describing their experiences in the program revealed six themes: (1) positive experience; (2) promotion of well-being; (3) positive views of students; (4) value of a supportive program environment; (5) sharing and cultivating; and (6) shared experiences, interests, and emotions. Responses indicating that participation in the program was a positive experience described the program as “fascinating,” “healing,” “exciting,” and “an adventure.” Promotion of well-being was reflected in comments describing the program as providing cognitive stimulation, having a positive effect on mood, and being helpful in organizing one’s thoughts. Comments also indicated that participants found the physical act of writing to stimulate fine motor skills; one wrote, “I have learned that writing and sharing these memories keeps your brain busy, your fingers nimble, and your heart rejoicing.”

Participation also resulted in positive views of students. Participants perceived the students to be active listeners, respectful, open and curious, and interested in the past, and participants felt that the students were inspired by listening to their life stories. One participant wrote, “I saw and heard (regardless of age) respect, interest, readiness to take in what others had to contribute.” Another participant reported, “The students were able to relate these experiences to their personal life, which were very similar to ours. It was indicated that they were inspired and learned a lot from us.” The theme value of a supportive program environment was reflected in comments about being accepted, having a facilitator who listened, and experiencing a safe and comfortable social environment. One participant wrote, “I felt it was a special safe place for me to come. Everybody was very supportive.” Some participants expressed a desire for more sessions.

The theme of sharing and cultivating was revealed through codes that included sharing life adventures, creating legacies, and inspiring students to examine their own lives. As described by one participant,

A subtheme in the theme of sharing and cultivating was that the program was a learning opportunity. Participants described how the experience not only caused them to reflect on their own lives but resulted in an appreciation for the lives of others. A diversity of experiences was noted. Older adults reported mutual learning both by themselves and by students. Another subtheme, new views and modified perceptions, also emerged; participants described changed perceptions of themselves, of youth, and of growing older. One participant stated, “The other reason I loved this experience was the fact that getting old is not that bad. It showed me how vibrant you can be even into your 90s.” Another remarked, “The fact that the students are joining the healing/helping professions increases my optimism, my faith in young healers developing a much needed more respectful, supportive attitude towards senior patients.”

Finally, participants reported experiencing shared experiences, interests, and emotions with their peers as well as with students. One wrote, “It was interesting sharing the diversity of experiences and seeing how much we are alike as well as unique.” Another participant wrote, “The young lady that sat next to me and I bonded from our first meeting. We both loved animals and talked about her present dogs and the one I had but had to leave behind.” Another stated, “I observed that although there is a difference in ages, we still share some of the same concerns and interests.”

Limitations

Although the results provide support for the benefits of the intervention, the posttests were completed within a few weeks of program completion; therefore, the long-term effects are unknown. Sense of purpose and meaning in life increased significantly for the treatment group, but the clinical significance of a 1.04- or 2.18-point increase in MLQ–Presence scores is not clear. Therefore, the health and functional implications of specific levels of sense of purpose and meaning in life require further study. The sample comprised predominantly women, which may affect the generalizability of findings. Those who dropped out of the study and those who remained differed significantly with respect to gender; in the future, it would be beneficial to investigate further the attrition rate among male participants. Finally, for some participants, the research assistants were aware of group assignment, which could have introduced bias. However, use of a standardized measure lessened the risk of bias.