Intergenerational interaction in health promotion: a qualitative study in Brazil
Integração entre gerações na promoção da saúde: estudo qualitativo no Brasil
Elza Maria de Souza
Divisão de Promoção e Assistência à Saúde da Secretaria de Estado de Saúde do Distrito Federal. Brasília, DF, Brasil
OBJECTIVE: In 1994 a pilot intergenerational project was started in the city of Taguatinga, Brazil, to promote the well-being of both elderly and adolescent populations using reminiscence processes as a means of interaction. The purpose of the study is to evaluate the project from the participants' viewpoint and to improve the contribution of those age groups in building up social capital.
METHODS: From November 1999 to April 2000 a qualitative study using focus groups technique was conducted. Using a discussion guide, 9 groups of students, ranging in age from 13 to 19 years old, and 3 groups of elderly aged 60 years and over were interviewed to collect data regarding their interaction before and after an intergenerational program.
RESULTS: The main findings suggested a change in attitude of young people toward old age and elderly people. Participating elderly people reported improvement in their health status. For both age groups the findings suggested a better understanding between generations.
CONCLUSIONS: It seems that reminiscence intergenerational activity contributes to building up mutual trust and reciprocity. These results seem to indicate this is an alternative for investing in social capital and improving participants' well-being. However, further work is needed to support these findings.
Keywords: Health promotion. Aged. Adolescence. Interpersonal relations. Consumer participation. Aging health, knowledge, attitudes and practice. Focus group. Intergenerational interaction. Reminiscence. Social capital.
OBJETIVO: Em 1994 foi iniciado um projeto de integração entre gerações em Taguatinga, Distrito Federal, com a finalidade de promover o bem estar dos idosos e adolescentes, usando-se o processo de reminiscências como meio de integração. O objetivo do estudo é avaliar o projeto de acordo com a opinião dos participantes e enfatizar a contribuição desses grupos etários na construção de capital social.
MÉTODOS: De novembro de 1999 a abril de 2000 foi conduzida uma pesquisa qualitativa usando-se a técnica dos grupos focais. Seguindo-se um roteiro, nove grupos de estudantes, de 13 a 19 anos de idade, e três grupos de idosos, de 60 anos ou mais foram entrevistados para obtenção de dados relativos às relações intergeracionais, antes e após atividades envolvendo jovens e idosos.
RESULTADOS: Os resultados sugerem mudança de atitude dos jovens em relação aos idosos e à velhice. Os idosos relataram melhora no estado de saúde. Para os dois grupos etários os achados sugerem aprimoramento da convivência entre gerações.
CONCLUSÕES: Os achados parecem indicar que atividades de integração entre gerações usando-se o processo de reminiscências contribuem para fortalecer a confiança mútua e normas de reciprocidade, podendo ser uma alternativa de investimento em capital social e no bem estar dos participantes. No entanto, Estudos adicionais serão necessários para comprovar esses achados.
Descritores: Promoção da saúde. Idoso. Adolescência. Relações interpessoais. Participação comunitária. Saúde do idoso, conhecimentos, atitudes e prática. Grupos de estudo. Integração entre gerações. Reminiscências. Capital social.
As many Latin American countries, Brazil currently is witnessing a rapid ageing of its population while the proportion of young people is still high. The country faces a number of major public health challenges arising from slow social and economic development, extreme socio-economic inequalities and social and demographic changes.3
Elderly people and adolescents in Brazil
Demographic changes in Brazil include rapid population ageing as the country is experiencing the consequences of demographic transition. The rapid increase in the size of the elderly population carries social and economic implications, which require planning and resource allocation.10
Social changes include increased disruption of mechanisms of social integration, increasing socio-economic inequality13 and growing signs of social stress particularly evident in the adolescent population. The conditions of many adolescents are recognized as lacking social cohesion.17 Death rates due to external causes almost doubled among adolescents in the period of 1977 to 1994 and now represent the main cause of death among people five to 39 years old. Rates of violent death are particularly high among 15 to 19 years old.15 In 1998 homicide was the main cause of death in three out of five regions of the country and in twelve states including the capital (Distrito Federal) among people aged 10 to 15 years.20
There are few systematic studies on the elderly population in Brazil, but there are some indications that the well-being of some segments of this population may be jeopardized by social and demographic stresses, lack of understanding and awareness of issues related to ageing and an overall poor social environment.10,19 There is now growing awareness of the link between social environment, aspects of social capital such as trust, norms of reciprocity, citizenship, and civic engagement and health.6,11,14,18,22 The existing data related to elderly and adolescents call for action in order to promote both age groups' health.
According to the Ottawa Charter, health promotion has been defined as the process of enabling people to increase control over and improve their health25 .Therefore, health promotion has become an important and vital force in the new public health movement in which health is conceived also as a social phenomenon, which requires intersectoral interaction, interdisciplinary alliances and community participation.
While the discussion concerning elderly is mainly focused on the public health impact on ageing population, adolescence has been associated mainly with violence, early pregnancy, HIV infection and drug abuse. Although important, this one-sided discussion can perpetuate the idea that adolescents and elderly are only consumers of care. However, on the other side, there is the important role of these age groups of contributing to improve social cohesion through intergenerational interaction activities that still needs to be further explored.
Intergenerational interaction programs have become popular in many developed countries based on the assumption that some activities are valuable in a wide range of settings where elderly and young people voice their opinions.8 Such activities have become a means of addressing social problems and promoting their well-being. However, these beliefs have been disseminated mainly based on the enthusiastic perceptions of programmers. Very few experiences have been evaluated using sound methodologies that can show their effectiveness.23
Intergenerational health promotion program in Taguatinga, Distrito Federal
In 1994 the "Secretaria de Estado da Saúde" (State Department of Health) in partnership with the "Secretaria de Estado da Educação" (State Department of Education) started in Taguatinga, one of Brasília's peripheral cities, a pilot project for intergenerational interaction. The elderly registered in a health center (Health Center 1) nearby a high school (Taguatinga's School Complex 4) were encouraged to share their life experiences with students in the classrooms. Approximately 200 seventh and eighth grade students participated, with an average of 25 elders of both sexes attending about ten sessions a year. Each session comprised of five groups with 40 students and 5 elders each. Sessions of approximately one hour were held in the classrooms fortnightly. Different kinds of stimuli were used to trigger the participants' recollections, such as interviews, old objects or photos and other. The accounts were recorded and illustrated by the students for presentations open to the community. Details related to the development of activities have been published elsewhere.21 Reminiscence, the process of recollecting past experiences, was chosen as a means of interaction given the value of this practice for elderly people and its significance as a cultural resource for the community.5 The project was aimed to improve social cohesion, self-perception of elderly health status, reduce stereotypes and prejudice between generations, enhance components of social capital such as trust and reciprocity10,18 and provide a source of social and emotional support for the participants. The purpose of the present study is to evaluate from the participants' viewpoint whether the overall aim of the project has been achieved, as well as to provide some insight regarding the role young and elderly people can play in their community.
From November 1999 to April 2000 a qualitative study was undertaken using focus group techniques and the participation of seventh and eighth grade students of Taguatinga's secondary school, Brazil, and elders of the neighboring community. This was the school where the intergenerational interaction project described above was initiated. Unlike other cities, Taguatinga has a much diversified population as for educational attainment, socio-economic status and occupation.
For the study, 84 randomly selected students from different social backgrounds, ranging from 13 to 19 years old, stratified by age and sex, were divided into 9 groups. The wide range of ages in these groups is due to educational ability. Twenty-six elderly people of both sexes aged 60 years and over were divided into 3 groups separated by sex as shown in Figure. For being included in the study, participants were required to have been participating in the project for at least a year. The focus groups sessions took place at the school and followed a discussion guide of semi-structured questions that are shown in Box. Group discussions were facilitated and tape-recorded by two undergraduate female university students trained in the research technique by a research coordinator. The tapes were transcribed verbatim for analysis by the interviewers and the research coordinator. The collected data was analyzed by theme.
These were the predominating opinions among the groups.
Young people's opinions
As to the main lessons learned and satisfaction with their participation in the project, all students interviewed reported the importance of getting to know more about the past. The majority also reported learning how to value elderly people, and not to discriminate them. For example, they quoted:
'The project is not only useful to inform us about the past but to promote mutual learning and understanding'.
All female groups reported improvement in their communication with elderly people while three out of five male student groups mentioned that they learned how to share experiences. Two groups observed that there was less violence in the past.
'Now we have learned how to respect them, we are able to understand and accept the way they are and they understand us. This is really a way to share experiences'.
When questioned about the activities they shared with the elderly, four out of five male and one out of four female groups reported feeling at ease talking to them. Some examples of students' opinions:
'We are afraid of discussing some subjects even with our parents but we feel free to do so with the elders. Anything we asked was welcomed'.
'The elders calm us down, they are patient with us'.
Most of male and female groups recommended the project to all young people, while two female groups stressed its importance to street children and two groups recommended it to adolescents in custody as well.
'In the project we keep ourselves busy, so we don't get involved either with drugs or guns'.
Regarding their previous views of old age, four out of five of male and two out of four female groups admitted being prejudiced, as they stated:
'We were very prejudiced, we did not like to get along with elders, but during this time with them we changed. The project changed our way of thinking'.
All female groups stated that before taking part in the project they thought that elderly people were very boring.
In a small proportion, two out of five male groups had a negative image of old age. They used to associate it with dependency, illness, loneliness, and boredom as well as being critical. Three out of five of male groups and one out of four of female groups said they had the impression that elders were old fashioned.
'Until now, we thought that getting old meant being boring, nitpicking and disapproving. Nobody would love us. In the project, we realized that if we reach old age like them we will be able to be loved'.
Finally they were asked if the project had influenced their relationship with their family. The results were surprisingly positive. They reported a substantial improvement in their relationship not only with their grandparents but also with their parents. They began to understanding and respecting their point of views:
'Now we understand that what they tell us is true. Before we thought it was only lies so as to make us behave. We learned how to trust other people and how to value our grandparents'.
The young people however pointed out several negative aspects of the project they would like to see improved. All male groups and three out of four female groups complained about the bad manners of a few colleagues that disturbed the reminiscence sessions. Most of the groups also stated that the length of the sessions was too short and the intervals between sessions were too long. They would have liked to meet every week. Three out of five males and one out of four female groups complained about the small number of elderly people. Two out of five male groups stated that there are still many prejudiced colleagues in the group.
Elderly people's opinions
All groups agreed that the project was important to promote mutual learning, understanding and respect, as stated by their comments:
'The integration is something fantastic. We learn with them, they learn with us. They became more and more affectionate and friendly with older people. It is happiness'.
Two female groups stated they also learned how to interact with adolescents and how powerful the project was in changing their views on young people and vice-versa. They quoted:
'We realized that not all young people are troublesome and they realized that not all older people are boring or quarrelsome'.
'Before they did not care about us. They used to ignore us because, you know, older people are worthless. For this reason we also used to ignore them but now they have learned how to respect us and we have learned how to respect them as well'.
All groups stated the activities' benefits of strengthening sympathies and developing empathy. The women pointed out that the project gave them the opportunity to reduce isolation and share their emotions.
'The project strengthened the bond not only with young people but also with others.We made new friends'.
'When the year was over we missed them because we learnt to love them. They captivated us by treating us the way they did. They hug us kindly'.
The male group stated the importance of the project as a way of helping the country to keep young people away from drugs.
'The reminiscence project can help the government and the country in promoting children's education and preventing drug abuse'.
When asked about their satisfaction with the project, all groups mentioned how enjoyable they found friendship with the adolescents, their recognition and appraisal.
'The project is not good only to integrate generations but also to situate the elderly people in society'.
The male group mentioned the satisfaction with being admired by young people, the opportunity of meeting other people and taking part in other activities as well as a feeling of freedom.
'There is a feeling of freedom, we can understand each other. We meet the students and they hug us. They are getting along with us and we are getting along with them. They become increasingly friendlier with elderly people'.
The women stated enjoying the outings and partying together, as can be evidenced by some statements:
'At the beginnin'g they felt ashamed to be seen with us, but now they do enjoy it'.
Like the students, the elderly people also reported some negative aspects. All the groups emphasized the low attendance of elderly. Men mentioned the need to increase the number of monitors. They complained about the little support provided by the school's headmaster and the lack of transportation for participants. They also suggested the project could advance on a quicker pace. Women complained about the length of sessions that was too short, and that the intervals between sessions were too long. One group complained about the bad manners of a few students.
The female groups have been recommending the project to their acquaintances while the male groups think it should take place in every school.
In relation to their health status, all groups related relief of their pain and aches. The male group quoted:
'We learn many things for our own benefits from our colleagues because one needs to learn how to defend himself against illnesses'.
For women the project helped them to alleviate their depressive moods and gave them a feeling of more energy at the same time it helped them to improve their overall well-being, humor, and memory:
'We all got better. This is a therapy for us. It is keeping us out of bed'.
Concerning their views of old age, the female group seemed preoccupied with their negative image.
'The project helps raising awareness among people to make them appreciate more the elderly. Because we are older it does not mean we are dead. Did you know that?'
The male group realized that old age is not an illness:
'Old age is not an illness. We will die of old age but with health'.
When asked about the impact of the project on their relationship with their family, the women admitted they are receiving more attention and encouragement from their children, while men acknowledged having found their own importance in the family when participating in an outside activity.
'The old people bounded at home doing nothing become unbearable. We feel thrown away'.
'I feel fulfilled and useful and I feel I am contributing to better days for the humankind. It is wonderful'.
The findings suggest an overall improvement in the intergenerational understanding, improvement in elderly' health status and young people's attitude toward old age. Through a positive contact they not only enjoyed the interaction but also changed their view of each other. It corroborates the findings of a literature review carried out by Chellan (1981).4 The author stated that the idea of cross-generational perceptions of each other depends on the quality of intergenerational relations.
An important finding was the perceptions some groups of students had that they feel free to talk to elders and the contact with elders made them more peaceful. It led them to believe that this kind of activity can prevent violent behavior and drug abuse among young people. The elder male group also reached the same conclusion. It seems that this engagement with elders could provide affection ties that encourage trust, reciprocity, and autonomy and become a protective factor for those resilient children from disrupted families. This assumption requires further investigation. The capacity of resilient children to find a stable relationship with an adult outside their home was described earlier and cited by Wadsworth (1999).24
In the study sample it was strongly suggested there are prejudice and stereotypes among participants of all ages and young people had negative attitudes toward elders and old age. The studies related to attitudes toward ageing have shown controversial findings, varying from negative, positive and indifferent attitudes.2,9,16 The controversy in findings is probably related to the diversity of methodologies used to date.
Although the general opinion was predominantly positive, participants pointed out some negative aspects that deserve more attention for improving the activities. It is necessary to work with those students who still have negative attitudes toward elderly people and those who disturb the sessions. This is probably because teachers are still working with big groups due to the small number of facilitators involved. The literature recommends reminiscence groups of ten individuals.21
In general, the adolescents meet the elderly every fifteen or twenty days for 50-minute sessions. Participants suggested it should be on a weekly basis as intended at the beginning of the project. They also suggested sessions should last more than an hour in order to discuss subjects more in depth. Another suggestion of both age groups was to increase the number of elderly people participating in the sessions.
The overall impression of participants seems to indicate a change in attitude of young and elderly people. This finding corroborates other intergenerational interaction programs.7,12 It appears that intergenerational interaction using reminiscence processes increase trust, reciprocity and respect among participants. Given that those aspects are components of social capital,11,18 it is therefore possible to suppose that this activity should be an alternative for community empowerment and social cohesion improvement, which is the aim of the health promotion movement stated in the Ottawa Charter.25
Previous studies have shown strong evidence that social cohesion has a positive effect on health11,22 and that increasing the level of participation reduces social exclusion and improves quality of community life.1 It seems that the present study replicates those findings. It also seems to suggest that intergenerational activity based on reminiscence is a source of emotional support that contributes to the improvement of social interaction and consequently to the individual and the community's well-being. However, there is a need of further investigation to confirm these findings. A larger project with a combination of quantitative and qualitative methods is in progress as part of a PhD program in health promotion.
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Elza Maria de Souza
SQN 115 Bloco "G" Ap 208
CEP: 70772-070 Brasília, DF, Brasil
E-mail: email@example.com or firstname.lastname@example.org
Research project funded by British Embassy in Brazil, Pan-American Health Organisation, Regional Office for Brazil in Brasília, DF and Fundação de Apoio ao Desenvolvimento Científico e Tecnológico na Área da Saúde (FUNSAUDE - Processo n. 001/99)
Received on 15/7/2002
Approved on 28/4/2003