& Geriatric Medicine Intergenerational Programs among Children, Young and Elderly People with Educational Emphasis: An Integrative Review

Programs among Children, Young and Elderly People with Educational Emphasis: An Integrative Review. Abstract Introduction: The social changes affect family relationships and elders’ functions, reflecting on intergenerational relations. Thus, prejudice and negative stereotypes in relation to the age lead to a distorted look of younger generations, impairing the interaction and leading to elders’ exclusion from socializing with other generations. Objective: To discuss the benefits of intergenerational programs between young children and elders, focusing on the educational context. Method: This is an integrative review article, performed in the data- bases Medline, Lilacs, Cinahal and Web of Science. In Virtual Librar-ies/Bibliographic Repositories SciELO and BVS and Capes Portal of Journals using the descriptors: Child; Elderly person; Relationship between generations and Education, and the key words: Intergenerationality, Gerontological Education and Intergenerational Programs and their correspondents in English and Spanish. For the selection of texts, the following inclusion criteria were established: full articles addressing the theme published in Portuguese, English and Spanish, in the period from 2009 to 2018, freely available online. Results: The final sample consisted of seven articles which after data analysis and interpretation, originated the following categories: benefits for generations involved in the program and aging educa tion. Conclusion: The studies are unanimous in stressing the importance of intergenerational relations for strengthening support networks, improving affective exchanges and community integration. Therefore, intergenerationality should be encouraged, since it affects positively both generations and the society as a whole, contributing to a more inclusive society.


Introduction
The end of the 20 th century brought changes in intergenerational relations, especially with the achievement of longevity and permanence of good physical and cognitive conditions of the elderly population for a longer time [1]. These changes result from several factors, such as: increased life expectancy at birth; impact of reduced birth rates; increased life expectancy of the elderly person due to scientific and technological advances and the considerable progress of public health in the course of the last century [2]. This rapid demographic transition imposes challenges unseen by the society, particularly for emerging countries, which did not have time enough for planning and organizing actions in the social sphere and for the demands that have arisen. The ongoing social changes affect family relationships, elders' functions in the household dynamics, that is, intergenerational relationships [3,4]. This longevity has increased the number of generations living in same social and historical time, staying and expanding the generational roles in the family (great-grandparents, grandparents, parents and grandchildren) [1].
In Brazil, historic, cultural and socioeconomic changes resulted in changed contemporary family structure and functioning, culminating in new patterns of intra-family harmony [5]. Some important changes are women's entry into the labor market, moving them from the role of caregiver of the family members; greater number of separations and re-marriages; fewer children; more women heading the family; in addition to the presence of several generations in the family. There is also the emptying of elders' roles in the family, as care, guidance and advices given by them to younger generations have been replaced by services and specialized institutions [6]. The modern western society is segmented into groups selected by the ability of productivity and expectations in relation to generations are different because the chronological age is responsible for determining roles, responsibilities and rights [7], which often results in discrimination, marginalization or exclusion [8].
Currently, being an elderly person means facing various forms of obstacles, because societies still extol news, the youth, the beauty and the innovative, with no space for what is old [9,10]. The term generation is used here in the sociological sense, i.e., as a group of individuals living in certain moment, with similar ages and sharing experiences or with responsibility for it. Two decades ago, national and international agencies pointed to the integration of elders in the society as essential to a healthy aging. The Second World Assembly on Aging highlights, among other issues, the promotion of the concept of "society for all ages", emphasizing the need for elaborating public policies that contemplate the intergenerational solidarity and developing actions that facilitate the interaction between generations with the purpose of inclusion of elders in the community [11].
In Brazil, the National Policy for the Elderly Person -PNI (Law 8.842/94 -Política Nacional do Idoso) and the Byelaw for the Elderly Person (Law 10.741/2003), in line with international guidelines, encourage the promotion of elders' integration to other generations through alternative forms of participation, occupation and conviviality [12,13]. The approximation of different generations can create mutual education, exchange of experiences and emotions, providing mutual learning and enrichment. Intergenerational relations allow elders to contribute to cultural memory, education for the aging, practical knowledge and life lessons. On the other hand, younger people develop in the elderly person greater flexibility in relation to new values, knowledge of present times and behaviors, in addition to having better access to new technologies [14].
The first recorded intergenerational actions date from 1963, in the United States, promoted by the University of Florida, where small children visited an institution that housed elders. In the 90's, there was a diffusion of these actions in Europe and Latin America, starting the so-called Intergenerational Program -IP. Such programs occur through activities, especially cultural and leisure, as a type of non-formal education to bring together generations [15]. In Brazil, in 1992, the Social Service of Commerce (SESC) deployed the intergenerational program entitled "Once Upon a Time... Intergenerational Activities", aiming at encouraging communication between generations through the exchange of experiences among children, adolescents and elders. This IP developed pedagogical and cultural activities in groups, using children's literature as the driving axis of the process of increasing awareness about the problems of old age and aging. This project achieved satisfactory results in relation to synchronism, solidarity and affection between the age segments [16,17].
IPs have different definitions depending on the actions and objectives sought. The International Consortium for Intergenerational Programs defines them as social environments that promote cooperation, exchange of knowledge and experiences between distinct generations, in which young and elderly people build a stage for cultural exchange and mutual care, reaching benefits for individuals and society as a whole [18,19]. IPs want the society to see aging as a gain, not as a problem, since they can mutually benefit the generations involved, representing an opportunity to deconstruct prejudices existing between them. Such programs aim at stimulating the intergenerational dialog through the exchange of experiences between both generations. Studies report that generational practices enable changing the community's point of view in relation to the elderly person, in addition to rescuing the memory of a people through their living heritage, promoting the socialization between generations [16]. Therefore, this article aims to discuss the benefits of intergenerational programs among children, young people and elders focusing on the educational context.

Method
To achieve the aforementioned objective, an integrative literature review on the topic was developed. This type of review consists of a comprehensive methodology, rooted in the Evidence-Based Practice (EBP) and allows analyzing experimental and non-experimental studies, of qualitative or quantitative nature, for an expanded understanding of the studied phenomenon [20]. The process of elaboration of this study occurred in six stages: selection of the review question, sampling of the research, description of the characteristics of the study and its results, analysis of results, interpretation of results and presentation of the review [21].
The study was designed from the following guiding question: How can intergenerational programs among children, young people and elders benefit the generations involved? The search for articles was conducted through surveys in databases: MEDLINE (Medical Literature Analysis and Retrieval System Online), LILACS (Latin American and Caribbean Health Sciences Literature), CINAHL (Cumulative Index to Nursing and Allied Health Literature) and Web of Science. In virtual libraries SciELO (Scientific Electronic Library Online) and VHL (Virtual Health Library) and in Capes Portal of Journals. Data collection took place between October 2017 and February 2018, using Health Sciences Descriptors (DECS), namely: Child; Elderly Person; Relationship between generations and Education and their correspondents in English and Spanish, considering the Boolean term AND. The following keywords were also used: "Intergenerationality", "Gerontological Education" and "Intergenerational Programs" in CAPES Portal of Journals.
The articles were selected according to the following inclusion criteria: fully addressing Intergenerational Programs among chil-dren, young people and elders (with an emphasis on education) as the main subject published in Portuguese, English and Spanish and indexed in these databases, in the period from 2009 to 2018, freely available online. Review articles, manuscripts, editorials, case reports and letters to the editor were excluded. The analysis of the results obtained in the studies oc-curred descriptively, which allowed observing, counting, describ-ing and classifying data, aiming to unify the knowledge about the theme explored in the review [21]. After this step, the interpretation and discussion of the data found generated two categories. The sixth phase of research was characterized by the

Results
The search performed in the databases and virtual libraries initially returned 293 articles: 24 in MEDLINE via PubMed, 1 in SciElo, 17 in LILACS, 10 in CINAHL, 8 in the Web of Science, 111 in VHL and 122 in the Capes Portal, in the search by subject, with 47 containing the keyword Intergenerational Programs; 36 Gerontological Education; and 39 Intergenerationality. After reading the abstracts, the full texts and exclusion duplicates, seven articles were selected as the final sample for this study. Figure 1 shows the flowchart describing the steps performed for obtaining the selected articles.
Among the selected articles, two are Brazilian, two Americans, one Israeli, one Japanese and one Colombian. Of them, two were in Portuguese, one in Spanish and four in English. With respect to the research site, they were more frequently performed in the school environment (4), followed by long-term institutions (3) ( Table 1 and 2).
The research participants were children aged from four years up to high school students and elders, with a predominance of activities involving 5 year-old children. In most studies (5), elders assumed roles of mentors with the possibility of guiding children and adolescents, sharing knowledge and discussing intergenerational content, coordinating and scheduling activities, allowing the transmission of cultural traditions and the interaction between different generations. In one study, children, mediated by a facilitator, assumed roles of teachers in computer and internet activities. In another, high school students and elders from a long-term institution exchanged letters; both groups participated equally regarding the performance in the activities.
As for the modalities of activities developed in the intergenerational programs, there were: assistance to teachers in the classroom with literacy support, support to mathematics, sciences, computer classes, oral narration, practices of reading and writing, dialogs, manual work, cooperative games and traditional games, puppet theater, dance (dance music), theater plays and dramatizations. After carefully reading the selected articles and based on the pertinent literature, the publications were classified, resulting in two categories, namely: 1) Benefits for the generations involved in the program, subdivided into four subcategories (Changes in attitudes; Empowerment; Co-education and Emotional bond) and 2) Aging education. Next, these data are discussed.

Benefits of the generations involved in the program
The articles analyzed reported that children had many improvements upon the intergenerational programs, such as: greater interest and frequency in reading, improved behavior in the classroom, better school performance and greater concern with others [23]. In addition, they improved their communication processes demonstrating greater proximity, time and fluency in conversations, in addition to enlarging the panorama of knowledge in an experimental environment that allowed perceiving elders' abilities. In this context, the objective of intergenerational programs is to create a learning environment that contributes to strengthening the cognitive process and the emergence of new personal relationships [28].
Children and adolescents reported that the coexistence with the elderly people assured them learning opportunities through dialogic activities, allowing learning, with elderly people's life histories, a little more about the time of their youth, social and personal aspects, thus promoting cultural retrieval, besides being more open to conversations, to respecting elders and learning more about different subjects [27]. These results corroborate those found in another study, which showed improvements in children in language development, self-confidence, in addition to changing their image of elderly people and understanding their limitations [29].
A survey carried out to assess the prevalence and perceptions of the impact of IP at schools concluded that these programs promote a series of advantages for children and young people as a change in the social representation about elders and age, attitudes, improved self-confidence and self-efficacy, in addition to behavioral changes both in school as in family relationships [30]. The articles analyzed also showed benefits for elders, such as the possibility of their recognition of values and ability to transmit them to younger generations. In addition to recognizing they can also learn from the experiences and knowledge of children and adolescents [27].
There were also reports of improved self-esteem, greater willingness to perform daily tasks as well as alternative activities and the possibility of learning new ways to play a game previously known by them [24]. Elders were also willing to release the young people still living inside of them, which could be recorded in the speech: "When I get close to them, I feel happy and satisfied, it fulfills me!" [27]. The articles show that the sense of self-efficacy, that is, a person's self-perception of ability to complete a specific task or solve a problem, is fed by the intergenerational activity [24,[26][27][28][29][30]. The elders gradually undo their fears to begin a relationship with younger people due to the continued strengthening, motivation and support from colleagues, and the memories of what was worked in the training process, giving rise to forces to create, adapt stories, remember and transmit, playfully and with a simple language, their life experiences.
These spaces allow them to feel productive and positioned in a participatory manner in cases in which they act as active agents, managers and proponents of structuring of workshops and in their development, leaving aside the sedentary life style with personal gains for their physical and mental health [28]. The disruption of social  isolation and loneliness, often associated with aging, is achieved through these intergenerational projects, improving the sense of belonging and usefulness to society by reducing the distance between young and elderly people and promoting the rescue of a feeling of appreciation [26].
A program of intergenerational reminiscence in which children and elders interacted through storytelling and use of some objects by the elders to help them recall their memories resulted in improved emotional loneliness, quality of life with more positive attitudes in relation to the future and an immersive and enjoyable experience for the elders [22]. In Baltimore (USA), in a program called Experience Corps, elders benefited with reduced difficulty of locomotion and improved the doing of daily activities, with reduced fragility, number of falls, loss of memory and increased social interaction. The program could serve as a model of social approach to health promotion with meaningful and productive roles for elders [23].
The exchange of letters between high school students (first to third grades) and elderly people from a Long-Term Institution (LTI) in São Paulo showed, two months after the beginning of the intergenerational intervention, an improvement in depressive symptoms of some elderly patients previously diagnosed with this pathology, as well as a decrease in the score of the Geriatric Depression Scale used [27]. A study conducted in Tokyo argues that the participation in intergenerational exchanges with children has positive effect on strengthening the Sense Of Coherence (SOC) of elderly people, which can prevent depression [31].
The results of elders' participation in programs of illustrated book reading indicate that intergenerational exchanges with children has positive effect on strengthening the Sense Of Coherence (SOC) of elderly people, which can prevent depression, in addition to strengthening the maintenance of physical functioning, intellectual activity and intergenerational relations [25]. Some frequent psychosocial risk factors in the life of the elderly population, such as the loss of their main support networks and the free expression of feelings and emotions, are minimized with the effective execution of a support network. The gains reflect not only on the prevention of cognitive deterioration, but also on the promotion of new knowledge and learning [28].

Changes in Attitudes
Negative stereotypes can affect young people's impression regarding the intellectual competence of elderly volunteers and the desire to interact with them may influence the ability to ask their help. Therefore, the more positive the child's attitude with respect to the elderly person's ability to help in the classroom and in the motivation that leads to participate in the program, the greater the probability to ask their help [25]. For young people, the intergenerational exchange allowed, in addition to the deconstruction of prejudice in relation to age, changing the way they conceive it and meeting a new friend to share the difficulties and experiences of their generation and receive advices and guidances [26]. Regarding the change in attitudes, children and adolescents reported, in the articles, that their stigmatized perception on elders changed positively after the intergenerational meetings, especially regarding the reduction of prejudice [27].
The activities mediated by dialogical practices demonstrated the ability to bring together generations through coexistence and that this can be facilitated if mutual care is a priority, as well as respect and appreciation of elders, recognizing them as mediators of knowledge. The reports show that young people began to have more respect, patience and care with elders [27]. Attitudes changed in both age segments among the participants of the Israeli Multigenerational Connection Program (MCP) once, before the program, they were reluctant to meet and coexist with elders. It allowed reducing stereotypes in relation to age, the perception of values such as tolerance, respect and understanding as well as the cultural retrieval of the world knowledge of the elderly person. On the other hand, elders improved their perception on the contribution of knowledge and teaching skills of children, characterizing them as experienced teachers [32].
Most elders report positive changes regarding the way of seeing children and adolescents and, relating with them as well as an awakening of feelings of respect for younger people, with the desire to become more accessible with the understanding that they also have knowledge and experience able to assist them. They also reported that listening to young people's stories and conflicts fulfilled them with a sense of accomplishment once it allowed rescuing memories often forgotten [27].

Empowerment
The intergenerational activities promoted the empowerment of their participants. The proximity between generations promotes self-confidence and elders feel empowered when receiving roles of mentors that provide the opportunity to guide children, sharing knowledge, teaching rules of games, transmitting cultural traditions and being able to contribute to the society [24]. As interactions occur, elders improve the proposed action plan and assume their roles of dancers, actors, tutors, apprentices, etc., because their self-esteem and self-belief are recovered through the other's recognition and appreciation strengthened by social interaction [28].
The children improved their pedagogical performance, adjusting to elders' time and needs, but attributed their empowerment to themselves, i.e., their teaching skills and contribution to knowledge. On the other hand, when acquiring technological knowledge through by using the computer and internet, elders improved their self-confidence, expansion and enrichment of social networks, cultivating feelings of appreciation, acceptance and respect, overcoming the fear and self-prejudice [32].

Co-education
During the reading of articles, the term Co-education emerged. In this sense, intergenerational activities are perceived as scenarios for mutual exchange of experience and knowledge, enriching children, adolescents and elders once it allows expanding the world vision, promoting dialogs and reflections. The intergenerational activities enrich both generations as they take elders from their built universe by expanding knowledge and add to the young person elders' personal values [23].
A study developed in Australia, in a care institution for elders, the interaction between three generations provided the connection between the participants with exchange of experiences, example of harmonious coexistence with older people, encouraging a greater understanding of the limitations of generations, new bonds of friendship and strengthening the feeling of belonging to the world around them, deepening interpersonal relationships and increasing the capacity of interaction with society and inter-organizational partnerships [33]. A program of computer classes shared among children from the seventh year, and elders from the community enabled the co-education of generations, where children played the role of teachers as digital educators, mediated by a program supervisor. Thus, elders acquired the role of educator transmitting their own knowledge and life experiences according to the theme that emerged while surfing the internet [26].

Emotional Bond
With respect to the emotional bond, elders report it's strengthening through intergenerational activities, once they allowed the effective interaction with children and young people, helping to improve their interpersonal relationships [23]. In the survey conducted in Colombia, children were initially reluctant to relate with other adults outside their family. This feeling is overcome with improved empathy due to the monitoring carried out, firstly, by a team of the school faculty and during the meetings, the cultural and artistic experiences allowed the creation of feelings and expressions of physical affection. The affective exchanges provided by elders and children allowed the closeness and the curiosity to know social aspects between them, which strengthens the relations and bonds in an alternative educational space [28]. According to a study performed with children and elders residing in the same household, the coexistence with children promotes greater emotional support to help in daily activities and constitutes a protective factor for cognitive decline of elders [34].

Aging Education
It is possible to observe the existence of prejudice in relation to the elderly population from parents, relatives and some teachers, who often make negative associations, in which they refer to elders as physically sick and unable to relate to. This image was deconstructed along intergenerational meetings, which allowed caregivers of the child population to re-build, from their own experience, the meaning the term age in relation to the capacity to adapt to changes, the willingness to establish personal relationships, highlighting the creative potential, values and standards under which they work to generate a scenario of growth and development for the children participating in the program and their companions [28].
Exposing gerontological contents addressing the aging process for students is important for the deconstruction of myths and beliefs about the aging process. In addition, students participating in intergenerational activities who experienced positive aspects may positively face the difficulties arising from their own aging process [26]. It is important to mention the role of facilitators or mediators who need to play their roles adequately and conveniently, promoting the process as a commitment, evaluating and directing both participants, ensuring that elders and children are the focus of intergenerational programs [24]. The faculty and parents/guardians often play this role in order to create an empathetic and fruitful relationship to address the social, personal, relational, and academic spheres [28].
A good performance of the interaction between the generations requires emphasizing the importance of presenting the elderly volunteers to children before the beginning of the intergenerational program so that they can know them as people, know a little about their life histories, their former activities and show they are willing to help, as well as understand the motivation to be there, making them more comfortable working together and asking for help [25].
The limitations of the present study refer to the limited number of articles found in the researched literature. This suggests the need for more productions that approach the theme considering the relevance of the discussions about the theme, highlighting the small number of publications at the national level. However, most researches state that the benefits of coexistence between different generations reach children, young people, and elders at the same time, and emphasize the importance of formulating and implementing policies that encourage intergenerational meetings.

Conclusion
The objective of this article was reached because the reading of the publications allowed entering the thematic of these programs, in addition to identifying and discussing the contents that emerged, mainly the benefits reached for children, young people and elders, from the intergenerational interaction focusing on the educational context. Understanding the dynamics of the intergenerational programs proposed and published in the literature is extremely pertinent, since it led to an approximation of the theoretical framework and some effective actions in this context.
The schools and LTI where IPs were developed contemplated the participants of the activities, regardless of family ties, besides providing a scenario for exchanging knowledge and discussing subjects related to aging with deconstruction of prejudices between the different generations and the formation of new concepts about old age and the aging process. The selected articles highlighted themes such as benefits for children, young people and elders, and others, which contemplated the attitudes involved in intergenerational activities such as changing stereotypes and attitudes, narrowing the emotional bond, empowerment, co-education and aging education.
In general, they present reflections and practices related to the intergenerational programs that allowed obtaining a panorama of the current publications in this theme, among the adopted inclusive criteria, in several countries and realities. The studies are unanimous in highlighting the importance of intergenerational relations for strengthening support networks, improving affective exchanges and community integration. Therefore, intergenerationality should be encouraged, since it has positive effects on both generations, and on society as a whole contributing to make it more inclusive.