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

Tracy Chippendale; Marie Boltz

doi:10.5014/ajot.2015.014894

Abstract

OBJECTIVE. We investigated the therapeutic benefits (i.e., sense of purpose and meaning in life) of the Living Legends program, which includes life review writing and an intergenerational exchange, compared with life review writing alone, for community-dwelling older adults.

METHOD. This study was a randomized controlled trial with a connected qualitative component. We analyzed quantitative data using independent-samples t tests and written descriptions of program experiences using Collaizi’s qualitative methodology; we then used a triangulation protocol to integrate the qualitative and quantitative data.

RESULTS. For participants in the writing workshop plus intergenerational exchange, sense of purpose and meaning in life increased significantly (p < .0001) compared with those in the writing workshop alone. Qualitative themes revealed additional program benefits.

CONCLUSION. Living Legends enhanced participants’ sense of purpose and meaning in life, a factor known to prevent cognitive loss and disability, compared with life review writing alone.

In the United States and many other countries, the population is aging (Administration on Aging, 2014). The majority of older adults prefer to remain in their own home and age in place rather than move to senior housing or assisted living or moving in with a family member (American Association of Retired Persons, 2011).

Although physical function is important to the ability to age in place, mental health and subjective well-being are also critical to health and wellness for community-dwelling older adults (Lee, 2000; Steptoe, Deaton, & Stone, 2015). Subjective well-being is conceptualized as having three components: evaluative well-being (life satisfaction), hedonic well-being (feelings of happiness and absence of sadness, anger, stress, and pain), and eudemonic well-being (sense of purpose and meaning in life; Steptoe et al., 2015). Depressive symptoms, which reflect poor hedonic well-being, can result in a decline in function, poor rehabilitation outcomes, and an increased risk of institutionalization (Blazer, 2003; Li & Conwell, 2009). Sense of purpose and meaning in life, or eudemonic well-being, also warrants attention because it affects disability status, cognitive function, and mortality among older adults (Boyle, Barnes, Buchman, & Bennett, 2009, Boyle, Buchman, Barnes, & Bennett, 2010; Boyle, Buchman, & Bennett, 2010; Lee, 2000; Steptoe et al., 2015). Therefore, programs that address multiple components of well-being, including depressive symptoms and sense of purpose and meaning in life, are warranted.

Reminiscence and life review have been shown to have a positive effect on the mental health of older adults (Bohlmeijer, Roemer, Cuijpers, & Smit, 2007; Bohlmeijer, Smit, & Cuijpers, 2003). Reminiscence involves recalling specific events from the past and can be done silently or through the spoken word. Life review, which is more formal than reminiscence, involves a systematic review of life events from childhood to the present and includes an integrative component in which people reflect on their lives as a whole (Arean et al., 1993; Haight, Michel, & Hendrix, 1998). Systematic reviews have shown that life review has a larger effect than reminiscence in improving depressive symptoms (Bohlmeijer et al., 2003, 2007). Moreover, life review through writing has been found to be more effective than oral life review (Sherman, 1995).

Health care professionals have used life review through writing as an effective intervention to mitigate depressive symptoms in older adults (Chippendale & Bear-Lehman, 2012). Although life review has been shown to positively affect mood in older adults, additional programs and interventions are called for to address other causes of functional decline and thus promote the health and well-being of community-dwelling older adults. Sense of purpose and meaning in life also influences functional status and has been associated with a reduced risk of Alzheimer’s disease (Boyle, Buchman, Barnes, & Bennett, 2010) and disability (Boyle, Buchman, & Bennett, 2010).

Another way to enhance well-being is to promote an increase in sense of purpose and meaning in life through participation in occupations that provide the opportunity to contribute to family and society, such as volunteering (Chippendale, 2013). Additional benefits of volunteering include increased life satisfaction and improved psychological well-being (Black & Living, 2004). The therapeutic benefits of occupational therapy interventions that incorporate volunteerism in long-term care settings for older adults have been studied (Cipriani, 2007); program examples include making holiday baskets for special needs families (Bower & Greene, 1995) and baking for local children’s hospitals (DePoy, Gallagher, Calhoun, & Archer, 1989). Program benefits for older participants include a more positive attitude toward aging (Bower & Greene, 1995) and higher levels of participation and satisfaction (DePoy et al., 1989).

Volunteerism can also take place through intergenerational programs, defined as programs that engage different generations, such as a younger and an older generation, in mutually beneficial planned activities (Ayala, Hewson, Bray, Jones, & Hartley, 2007). Intergenerational programs can include activities to facilitate exchange between the generations, including English as a second language tutoring (Yuen, Huang, Burik, & Smith, 2008), recreational activities (Underwood & Dorfman, 2006), reminiscence (Chonody & Wang, 2013; Chung, 2009; Underwood & Dorfman, 2006), and life review (Zucchero, 2010). Therapeutic benefits of volunteer programs that incorporate an intergenerational exchange include enhanced well-being (Yuen et al., 2008), increased intergenerational understanding (Underwood & Dorfman, 2006; Zucchero, 2010), appreciation of the opportunity to share stories (Chonody & Wang, 2013), opportunity to serve as a role model and mentor and form mutual relationships (Zucchero, 2010), and decreased depressive symptoms (Chung, 2009).

Intergenerational programs incorporating volunteerism have focused primarily on older adults with dementia (Chung, 2009) or those residing in long-term care settings (Underwood & Dorfman, 2006; Yuen et al., 2008) rather than community-dwelling well elders. For programs incorporating the therapeutic benefits of sharing life experiences, the focus has been on reminiscence rather than life review (Chonody & Wang, 2013; Chung, 2009; Underwood & Dorfman, 2006), which is the less effective of the two approaches (Bohlmeijer et al., 2003, 2007). In a program that included life review and engaged students with community-dwelling well elders, older adults did not have the opportunity to generate their own written work (Zucchero, 2010), but writing about life experiences, as opposed to describing them orally, can offer enhanced benefits (Pennebaker, Kiecolt-Glaser, & Glaser, 1988; Petrie, Fontanilla, Thomas, Booth, & Pennebaker, 2004). Moreover, quantitative evidence in the form of a randomized controlled trial (RCT) can provide strong evidence for the benefits of community-based programs and therefore justify their costs.

Given that both life review through writing and intergenerational programs offer therapeutic benefits for older adults, combining the two interventions may multiply their benefits. In addition to addressing depressive symptoms through life review, the combined approach can target sense of purpose and meaning in life, a factor known to mitigate functional decline. This combined approach is consistent with Erikson’s (1950) Theory of Psychosocial Development, in which the last two stages of human development include mentoring the next generation and reflecting back on one’s life as a whole.

This article describes an evaluation of the Living Legends program, an intervention incorporating the opportunity for community-dwelling well elders to systematically review their lives in a writing workshop and then share their knowledge and experiences with the next generation during an intergenerational exchange with health science students. We sought to fill knowledge gaps by investigating the enhanced therapeutic benefits of life review writing plus intergenerational exchange through quantitative and qualitative measures and a strong research design. We hypothesized that older adults who participated in Living Legends would have an enhanced sense of purpose and meaning in life compared with older adults who participated in life review writing alone. We elicited the qualitative experiences of participants to gather a more complete picture of the therapeutic benefits of the program (O’Cathain, Murphy, & Nicholl, 2010).

Method

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:

What are your reactions to the reading?
Are there aspects of the story you would like clarified?
Is there any background information you would like explained?
Can you identify with the story in any way?
Share your related experiences.

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

Cognitive Screening.

All participants scored >2 on the Mini-Cog as a condition of inclusion. Compared with the Mini-Mental Status Examination (MMSE; Folstein, Folstein, & McHugh, 1975) and the Cognitive Abilities Screening Instrument (Teng et al., 1994), the Mini-Cog had the highest sensitivity (99%) and correctly classified the greatest percentage of participants (96%; Borson et al., 2000). Borson et al. (2000) determined that unlike the MMSE, the diagnostic value of the Mini-Cog was not influenced by education or language.

Sense of Purpose and Meaning in Life.

The Presence subscale of the Meaning in Life Questionnaire (MLQ–Presence; Steger, 2010) was used to assess the extent to which participants felt a sense of purpose and meaning in life. The tool has demonstrated good internal consistency, and convergent validity was established using correlations with similar constructs including life satisfaction, positive emotions, intrinsic religiosity, extroversion, and agreeableness (Steger, Frazier, Oishi, & Kaler, 2006). Negative correlations were found between MLQ–Presence and depression, negative emotions, and neuroticism; correlations with other meaning measures ranged from .58 to .74; and 1-mo test–retest reliability coefficients were .70 (Steger et al., 2006). Although initially validated among college students, the tool has since been validated with adults with mental illness and with adults and older adults who were caregivers (Chan, 2014; Schulenberg, Strack, & Buchanan, 2011).

MLQ–Presence includes five statements pertaining to sense of purpose and meaning in life. Responses are recorded using a 7-point Likert scale ranging from absolutely untrue to absolutely true. Scores range from 5 to 35, with a higher score indicating greater sense of purpose and meaning in life.

Demographics and Baseline Measures.

The baseline questionnaire, designed by the principal investigator, was used to ascertain demographic information including age, gender, ethnicity, education level, self-rated health, and assistance needed with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Participants were asked about their highest level of education and their ethnicity through open-ended questions; we categorized this information to provide descriptive data for the sample (see Table 1). Self-rated health was measured by asking participants to rate their overall health in the past 4 wk on a Likert scale ranging from very poor to excellent; responses were converted into numerical values from 0 (very poor) to 5 (excellent). To ascertain functional status, participants were asked about the ADLs and IADLs for which they required assistance from another person. The ADL question addressed bathing, dressing, and brushing teeth and hair; the IADL question addressed meal preparation, shopping, community mobility, money management, medication management, and housekeeping. The number of ADLs (0–4) and IADLs (0–6) requiring assistance were recorded.

Table 1.

Participant Characteristics (N = 39)

	M (SD) or n (%)
Variable	Control Group (n = 16)	Treatment Group (n = 23)	t or χ²	p
Age, yr	75.81 (10.86)	77.85 (8.55)	−0.65	.52
Gender			0.47	.49
Male	1 (6.3)	3 (13.0)
Female	15 (93.8)	20 (87.0)
Ethnicity			3.27	.20
White	8 (50.0)	15 (65.2)
African-American	6 (37.5)	8 (34.8)
Middle Eastern	2 (12.5)	0 (0)
Education			1.82	.77
Some high school	0 (0)	1(4.3)
High school graduate	2 (12.5)	4(17.4)
Some college	2 (12.5)	5(21.7)
College graduate	5 (31.3)	5(21.7)
Graduate studies	7 (43.8)	8(34.8)
Self-rated health (0–5)	3.50 (1.16)	3.17(1.07)	0.91	.37
ADLs requiring assistance	0.13 (0.50)	0.09(0.28)	2.84	.24
IADLs requiring assistance	1.19 (1.47)	1.09(1.16)	3.78	.44
Different leisure interests	5.13 (1.50)	5.22(1.38)	−0.20	.84
Leisure activities/mo	85.13 (26.84)	81.83 (32.63)	0.33	.74
Life review writing workshop sessions attended	5.88 (1.8)	6.83(1.34)	8.0	.24
GDS pretest score	4.94 (3.99)	5.30(5.15)	−0.24	.81
MLQ–Presence pretest score	22.44 (4.40)	24.52(6.81)	−1.16	.29

Note. ADLs = activities of daily living; GDS = Geriatric Depression Scale, 30-question version; IADLs = instrumental activities of daily living; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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Table 1.

Participant Characteristics (N = 39)

	M (SD) or n (%)
Variable	Control Group (n = 16)	Treatment Group (n = 23)	t or χ²	p
Age, yr	75.81 (10.86)	77.85 (8.55)	−0.65	.52
Gender			0.47	.49
Male	1 (6.3)	3 (13.0)
Female	15 (93.8)	20 (87.0)
Ethnicity			3.27	.20
White	8 (50.0)	15 (65.2)
African-American	6 (37.5)	8 (34.8)
Middle Eastern	2 (12.5)	0 (0)
Education			1.82	.77
Some high school	0 (0)	1(4.3)
High school graduate	2 (12.5)	4(17.4)
Some college	2 (12.5)	5(21.7)
College graduate	5 (31.3)	5(21.7)
Graduate studies	7 (43.8)	8(34.8)
Self-rated health (0–5)	3.50 (1.16)	3.17(1.07)	0.91	.37
ADLs requiring assistance	0.13 (0.50)	0.09(0.28)	2.84	.24
IADLs requiring assistance	1.19 (1.47)	1.09(1.16)	3.78	.44
Different leisure interests	5.13 (1.50)	5.22(1.38)	−0.20	.84
Leisure activities/mo	85.13 (26.84)	81.83 (32.63)	0.33	.74
Life review writing workshop sessions attended	5.88 (1.8)	6.83(1.34)	8.0	.24
GDS pretest score	4.94 (3.99)	5.30(5.15)	−0.24	.81
MLQ–Presence pretest score	22.44 (4.40)	24.52(6.81)	−1.16	.29

Note. ADLs = activities of daily living; GDS = Geriatric Depression Scale, 30-question version; IADLs = instrumental activities of daily living; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

We included measures of depressive symptoms and level of participation in leisure activities as possible confounders. We measured depressive symptoms using the Geriatric Depression Scale, 30-item version (GDS; Lelito, Palumbo, & Hanley, 2001) and level of participation in leisure activities by asking participants to list the types and frequency of leisure activity participation using self-recall; frequency of participation was recorded as total number of leisure activities per month.

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).

Results

Approximately one-third of the older adults who were approached agreed to participate. Reasons given for nonparticipation included lack of interest or inability to commit to the program and study. All participants had a negative screen for probable dementia. The initial sample size was 47 across the four sites. However, 6 participants dropped out of the study before the second writing workshop session for personal reasons (e.g., an ill spouse), because of time constraints, or because they had previously conducted a life review. Twenty-three participants were randomized to the writing workshop plus intergenerational program (treatment group), and 18 were randomized to the writing workshop alone (control group). The final sample consisted of 23 in the treatment group and 16 in the control group because 2 control participants were lost to follow-up (see Figure 1).

Figure 1.

Participant enrollment and attrition.

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Analyses using χ² tests of independence and independent-samples t tests were used to detect any significant differences between the 8 participants who dropped out and the 39 who remained in the study. No significant differences were found in age, ethnicity, education, self-rated health, number of ADLs or IADLs requiring assistance, number of leisure interests, level of leisure participation, GDS score, or MLQ–Presence score. However, there was a significant difference for gender, χ² = 3.89, p = .05; a disproportionate number of participants who dropped out of the study were male. Demographic and other baseline data for the total sample are presented in Table 1.

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).

Table 2.

Change in MLQ–Presence Scores, by Group (N = 39)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	23.25 (6.36)	22.52 (6.91)	0.33	37	.74
Posttest 2	19.75 (6.50)	23.87 (6.30)	−1.98	37	.06
Change in score	−3.50(3.65)	1.04 (2.62)	−4.53	37	.00

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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Table 2.

Change in MLQ–Presence Scores, by Group (N = 39)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	23.25 (6.36)	22.52 (6.91)	0.33	37	.74
Posttest 2	19.75 (6.50)	23.87 (6.30)	−1.98	37	.06
Change in score	−3.50(3.65)	1.04 (2.62)	−4.53	37	.00

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

Table 3.

Change in MLQ–Presence Scores for Participants With Scores <25, by Group (n = 19)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	18.13 (4.52)	17.27 (6.47)	0.32	17	.75
Posttest 2	14.63 (4.98)	20.09 (7.20)	−1.84	17	.08
Change in score	−3.50(4.31)	2.18 (3.22)	−3.30	17	.004

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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Table 3.

Change in MLQ–Presence Scores for Participants With Scores <25, by Group (n = 19)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	18.13 (4.52)	17.27 (6.47)	0.32	17	.75
Posttest 2	14.63 (4.98)	20.09 (7.20)	−1.84	17	.08
Change in score	−3.50(4.31)	2.18 (3.22)	−3.30	17	.004

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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,

It touched me when [name omitted] read his piece and mentioned he could not relate to my story of a close friendship. What was especially moving was that it inspired him to examine his own life and to realize that his mother was actually a close friend.

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.”

Discussion

In this RCT, we examined the effects of the occupation-based Living Legends program on sense of purpose and meaning in life among community-dwelling older adults. The results revealed a statistically significant increase in sense of purpose and meaning in life for the treatment group but not for the control group. The program was particularly beneficial for participants who had low initial scores for sense of purpose and meaning in life; the difference between subgroups may reflect a ceiling effect for participants whose initial MLQ–Presence scores were high.

Although life review through writing has been shown to have therapeutic benefits for older adults, including a decrease in depressive symptoms (Chippendale & Bear-Lehman, 2012; Mastel-Smith, McFarlane, Sierpina, Malecha, & Haile, 2007), the addition of an intergenerational program in which life stories and experiences can be shared with the next generation of health professionals offers enhanced therapeutic benefits for older adults, namely an increase in sense of purpose and meaning in life. Given that Living Legends targets sense of purpose and meaning in life, a risk factor for disability and cognitive loss and therefore for institutionalization (Boyle et al., 2009; Boyle, Buchman, Barnes, & Bennett, 2010; Boyle, Buchman, & Bennett, 2010), participation in the program may help older adults remain at home longer. The results also suggest that Erikson’s (1950) life stage of generativity versus stagnation may persist beyond middle age into older adulthood; participants in the intergenerational program, whose mean age was 78 yr, described their interest in and enthusiasm for interacting and sharing their knowledge with the younger generation.

Qualitative data in the form of written feedback on program experiences were convergent with and complementary to quantitative findings. The qualitative themes illuminated the quantitative findings and provided additional support for the therapeutic benefits of the program, which included cognitive stimulation, social support, positive views of youth, and the opportunity to inspire the next generation. Participants noted that the program provided opportunities to share their life adventures, create legacies, and inspire students (the next generation) to examine their own lives, shedding light on the quantitative findings regarding enhanced sense of purpose and meaning in life. For example, the program provides opportunities for participants to take on the role of educator or role model.

The qualitative findings are consistent with previous studies of intergenerational programs that incorporated volunteerism (Underwood & Dorfman, 2006; Zucchero, 2010). Zucchero (2010) found that community-dwelling older adults who engaged with students in a program that incorporated life review experienced positive emotions and perceived themselves as serving as a role model. Underwood and Dorfman (2006) studied an intergenerational program that incorporated reminiscence rather than life review and included older adults residing in long-term care. Consistent with our findings, they found that the older adults enjoyed sharing their life experiences and had changed perceptions of young adults after participating in the program.

A decrease in sense of purpose and meaning in life scores for the control group may indicate a negative reaction to their group assignment. However, participants were notified well in advance about study procedures and their assigned group. Moreover, reactions to group assignment would more likely have been reflected in the first posttest because control group participants learned at that point that they had not been randomly selected to participate in the intergenerational program.

Stressors and sense of control in older adults’ most highly valued life roles, such as caregiver, spouse, or grandparent, can negatively affect sense of purpose and meaning in life (Krause, 2004; Krause & Shaw, 2003). The decrease in sense of purpose and meaning in life among control participants over time may have been attributable to life stressors commonly associated with aging and older adulthood. The effect of socioeconomic status on the prevalence and intensity of life stressors is well documented (Cohen, Doyle, & Baum, 2006), and two of the research sites provide services to low-income seniors and two serve the needs of moderate- and low-income older adults. Results suggest that participation in volunteer or mentorship programs such as Living Legends may offer a protective effect with regard to the negative effects of role-related and economic stress.

Space to run the program was provided by the community organizations. Therefore, the only cost was the salary for an occupational therapist to coordinate and run the 1.5 hr/wk program for 12 wk and to provide weekly phone calls and email reminders for participants and students to promote regular attendance. In future studies, investigation of a dose effect and cost–benefit analysis are warranted.

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.

Implications for Occupational Therapy Practice

The results of this study have the following implications for occupational therapy practice:

The Living Legends program promotes participation in meaningful occupations and life roles, a fundamental component of occupational therapy practice.
The program can be implemented by occupational therapists in community-based sites to enhance sense of purpose and meaning in life in older adults and thus promote healthy aging.

Conclusion

The Living Legends program, which includes a life review writing workshop followed by an intergenerational exchange with health science students, resulted in a statistically significant increase in sense of purpose and meaning in life for the treatment group participants compared with the control group participants, who participated in the life review writing workshop alone. Given that sense of purpose and meaning in life is an important factor in preventing cognitive decline, disability, and mortality (Boyle et al., 2009; Boyle, Buchman, Barnes, & Bennett, 2010; Boyle, Buchman, & Bennett, 2010), the Living Legends program appears to be an effective health promotion and prevention intervention for community-dwelling older adults.

Acknowledgments

This research was supported by a grant from the Fan Fox and Leslie R. Samuels Foundation. The authors acknowledge the support and collaboration of the staff at Central Harlem Senior Center, Penn South Program for Seniors (and its sponsor Penn South Social Services, Inc., and program services partner Jewish Association Serving the Aging), Stanley M. Isaacs Neighborhood Center, and Educational Alliance NORC programs. A special thanks goes to all the participants and to Tal Arnon and Bindu Rai for their assistance with and commitment to the project.

References

Administration on Aging. (2014). Aging statistics. Retrieved from http://www.aoa.gov/Aging_Statistics/

American Association of Retired Persons. (2011). Aging in place: A state survey of livability policies and practices. Retrieved from http://assets.aarp.org/rgcenter/ppi/liv-com/aging-in-place-2011-full.pdf

Arean, P. A., Perri, M. G., Nezu, A. M., Schein, R. L., Christopher, F., & Joseph, T. X. (1993). Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults. Journal of Consulting and Clinical Psychology, 61, 1003–1010. http://dx.doi.org/10.1037/0022-006X.61.6.1003 [Article] [PubMed]

Ayala, J. S., Hewson, J. A., Bray, D., Jones, G., & Hartley, D. (2007). Intergenerational programs: Perspectives of service providers in one Canadian city. Journal of Intergenerational Relationships, 5, 45–60. http://dx.doi.org/10.1300/J194v05n02_04 [Article]

Black, W., & Living, R. (2004). Volunteerism as an occupation and its relationship to health and wellbeing. British Journal of Occupational Therapy, 67, 526–532. [Article]

Blazer, D. G. (2003). Depression in late life: Review and commentary. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 58, 249–265. http://dx.doi.org/10.1093/gerona/58.3.M249 [Article]

Bohlmeijer, E., Roemer, M., Cuijpers, P., & Smit, F. (2007). The effects of reminiscence on psychological well-being in older adults: A meta-analysis. Aging and Mental Health, 11, 291–300. http://dx.doi.org/10.1080/13607860600963547 [Article] [PubMed]

Bohlmeijer, E., Smit, F., & Cuijpers, P. (2003). Effects of reminiscence and life review on late-life depression: A meta-analysis. International Journal of Geriatric Psychiatry, 18, 1088–1094. http://dx.doi.org/10.1002/gps.1018 [Article] [PubMed]

Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multi-lingual elderly. International Journal of Geriatric Psychiatry, 15, 1021–1027. http://dx.doi.org/10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6 [Article] [PubMed]

Bower, M. D., & Greene, D. (1995). Altruistic activity and older adults in long term care facilities. Physical and Occupational Therapy in Geriatrics, 13, 47–61. http://dx.doi.org/10.1080/J148v13n03_04 [Article]

Boyle, P. A., Barnes, L. L., Buchman, A. S., & Bennett, D. A. (2009). Purpose in life is associated with mortality among community-dwelling older persons. Psychosomatic Medicine, 71, 574–579. http://dx.doi.org/10.1097/PSY.0b013e3181a5a7c0 [Article] [PubMed]

Boyle, P. A., Buchman, A. S., Barnes, L. L., & Bennett, D. A. (2010). Effect of a purpose in life on risk of incident Alzheimer disease and mild cognitive impairment in community-dwelling older persons. Archives of General Psychiatry, 67, 304–310. http://dx.doi.org/10.1001/archgenpsychiatry.2009.208 [Article] [PubMed]

Boyle, P. A., Buchman, A. S., & Bennett, D. A. (2010). Purpose in life is associated with a reduced risk of incident disability among community-dwelling older persons. American Journal of Geriatric Psychiatry, 18, 1093–1102. http://dx.doi.org/10.1097/JGP.0b013e3181d6c259 [Article] [PubMed]

Chan, W. C. H. (2014). Factor structure of the Chinese version of the Meaning in Life Questionnaire among Hong Kong Chinese caregivers. Health and Social Work, 39, 135–143. http://dx.doi.org/10.1093/hsw/hlu025 [Article] [PubMed]

Chippendale, T. (2013). Elders’ life stories: Impact on the next generation of health professionals. Current Gerontology and Geriatrics Research, 2013, 493728. http://dx.doi.org/10.1155/2013/493728

Chippendale, T., & Bear-Lehman, J. (2012). Effect of life review writing on depressive symptoms in older adults: A randomized controlled trial. American Journal of Occupational Therapy, 66, 438–446. http://dx.doi.org/10.5014/ajot.2012.004291 [Article] [PubMed]

Chonody, J., & Wang, D. (2013). Connecting older adults to the community through multimedia: An intergenerational reminiscence program. Activities, Adaptation and Aging, 37, 79–93. http://dx.doi.org/10.1080/01924788.2012.760140 [Article]

Chung, J. C. C. (2009). An intergenerational reminiscence programme for older adults with early dementia and youth volunteers: Values and challenges. Scandinavian Journal of Caring Sciences, 23, 259–264. http://dx.doi.org/10.1111/j.1471-6712.2008.00615.x [Article] [PubMed]

Cipriani, J. (2007). Altruistic activities of older adults living in long term care facilities: A literature review. Physical and Occupational Therapy in Geriatrics, 26, 19–28. http://dx.doi.org/10.1080/J148v26n01_02 [Article]

Cohen, S., Doyle, W. J., & Baum, A. (2006). Socioeconomic status is associated with stress hormones. Psychosomatic Medicine, 68, 414–420. http://dx.doi.org/10.1097/01.psy.0000221236.37158.b9 [Article] [PubMed]

Colaizzi, P. F. (1978). Psychological research as the phenomenologist views it. In R. S. Valle & M. King (Eds.), Existential phenomenological alternatives for psychology(pp. 48–71). New York: Oxford University Press.

DePoy, E., Gallagher, C., Calhoun, L., & Archer, L. (1989). Altruistic activity versus self-focused activity: A pilot study. Topics in Geriatric Rehabilitation, 4, 23–30. http://dx.doi.org/10.1097/00013614-198907000-00005 [Article]

Erikson, E. H. (1950). Eight stages of man. In Childhood and society (pp. 219–243). New York: Norton.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-Mental State”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. http://dx.doi.org/10.1016/0022-3956(75)90026-6 [Article] [PubMed]

Haight, B. K., Michel, Y., & Hendrix, S. (1998). Life review: Preventing despair in newly relocated nursing home residents short- and long-term effects. International Journal of Aging and Human Development, 47, 119–142. http://dx.doi.org/10.2190/A011-BRXD-HAFV-5NJ6 [Article] [PubMed]

Krause, N. (2004). Stressors arising in highly valued roles, meaning in life, and the physical health status of older adults. Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 59, 287–297. http://dx.doi.org/10.1093/geronb/59.5.S287 [Article]

Krause, N., & Shaw, B. A. (2003). Role-specific control, personal meaning, and health in late life. Research on Aging, 25, 559–586. http://dx.doi.org/10.1177/0164027503256695 [Article]

Lee, Y. (2000). The predictive value of self assessed general, physical, and mental health on functional decline and mortality in older adults. Journal of Epidemiology and Community Health, 54, 123–129. http://dx.doi.org/10.1136/jech.54.2.123 [Article] [PubMed]

Lelito, R. H., Palumbo, L. O., & Hanley, M. (2001). Psychometric evaluation of a brief geriatric depression screen. Aging and Mental Health, 5, 387–393. http://dx.doi.org/10.1080/13607860120080350 [Article] [PubMed]

Li, L. W., & Conwell, Y. (2009). Effects of changes in depressive symptoms and cognitive functioning on physical disability in home care elders. Journal of Gerontology, 64, 230–236.

Mastel-Smith, B. A., McFarlane, J., Sierpina, M., Malecha, A., & Haile, B. (2007). Improving depressive symptoms in community-dwelling older adults: A psychosocial intervention using life review and writing. Journal of Gerontological Nursing, 33, 13–19. [PubMed]

O’Cathain, A., Murphy, E., & Nicholl, J. (2010). Three techniques for integrating data in mixed methods studies. British Medical Journal, 341, c4587. http://dx.doi.org/10.1136/bmj.c4587 [Article] [PubMed]

Pennebaker, J. W., Kiecolt-Glaser, J. K., & Glaser, R. (1988). Disclosure of traumas and immune function: Health implications for psychotherapy. Journal of Consulting and Clinical Psychology, 56, 239–245. http://dx.doi.org/10.1037/0022-006X.56.2.239 [Article] [PubMed]

Petrie, K. J., Fontanilla, I., Thomas, M. G., Booth, R. J., & Pennebaker, J. W. (2004). Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: A randomized trial. Psychosomatic Medicine, 66, 272–275. http://dx.doi.org/10.1097/01.psy.0000116782.49850.d3 [Article] [PubMed]

Schulenberg, S. E., Strack, K. M., & Buchanan, E. M. (2011). The Meaning in Life Questionnaire: Psychometric properties with individuals with serious mental illness in an inpatient setting. Journal of Clinical Psychology, 67, 1210–1219. http://dx.doi.org/10.1002/jclp.20841 [Article] [PubMed]

Sherman, E. (1995). Differential effects of oral and written reminiscence in the elderly. In B. H. Haight & J. D. Webster (Eds.), The art and science of reminiscing (pp. 255–264). Washington, DC: Taylor & Francis.

Sierpina, M. (2002). Share your life story workshops. Galveston: University of Texas Medical Branch.

Steger, M. F. (2010). The Meaning in Life Questionnaire. Retrieved from http://www.michaelfsteger.com/wp-content/uploads/2013/12/MLQ-description-scoring-and-feedback-packet.pdf

Steger, M. F., Frazier, P., Oishi, S., & Kaler, M. (2006). The Meaning in Life Questionnaire: Assessing the presence of and search for meaning in life. Journal of Counseling Psychology, 53, 80–93. http://dx.doi.org/10.1037/0022-0167.53.1.80 [Article]

Steptoe, A., Deaton, A., & Stone, A. A. (2015). Subjective wellbeing, health, and ageing. Lancet, 385, 640–648. http://dx.doi.org/10.1016/S0140-6736(13)61489-0 [Article] [PubMed]

Teng, E. L., Hasegawa, K., Homma, A., Imai, Y., Larson, E., Graves, A., . . . White, L. R. (1994). The Cognitive Abilities Screening Instrument (CASI): A practical test for cross-cultural epidemiological studies of dementia. International Psychogeriatrics, 6, 45–58. [Article] [PubMed]

Underwood, H. L., & Dorfman, L. T. (2006). A view from the other side: Elders’ reactions to intergenerational service-learning. Journal of Intergenerational Relationships, 4, 43–60. http://dx.doi.org/10.1300/J194v04n02_04 [Article]

Yuen, H. K., Huang, P., Burik, J. K., & Smith, T. G. (2008). Impact of participating in volunteer activities for residents living in long-term-care facilities. American Journal of Occupational Therapy, 62, 71–76. http://dx.doi.org/10.5014/ajot.62.1.71 [Article] [PubMed]

Zucchero, R. A. (2010). Share your experience and I’ll lend you my ear: Older adult outcomes of an intergenerational service-learning experience. Gerontology and Geriatrics Education, 31, 383–402. http://dx.doi.org/10.1080/02701960.2010.528275 [Article] [PubMed]

Table 1.

Participant Characteristics (N = 39)

	M (SD) or n (%)
Variable	Control Group (n = 16)	Treatment Group (n = 23)	t or χ²	p
Age, yr	75.81 (10.86)	77.85 (8.55)	−0.65	.52
Gender			0.47	.49
Male	1 (6.3)	3 (13.0)
Female	15 (93.8)	20 (87.0)
Ethnicity			3.27	.20
White	8 (50.0)	15 (65.2)
African-American	6 (37.5)	8 (34.8)
Middle Eastern	2 (12.5)	0 (0)
Education			1.82	.77
Some high school	0 (0)	1(4.3)
High school graduate	2 (12.5)	4(17.4)
Some college	2 (12.5)	5(21.7)
College graduate	5 (31.3)	5(21.7)
Graduate studies	7 (43.8)	8(34.8)
Self-rated health (0–5)	3.50 (1.16)	3.17(1.07)	0.91	.37
ADLs requiring assistance	0.13 (0.50)	0.09(0.28)	2.84	.24
IADLs requiring assistance	1.19 (1.47)	1.09(1.16)	3.78	.44
Different leisure interests	5.13 (1.50)	5.22(1.38)	−0.20	.84
Leisure activities/mo	85.13 (26.84)	81.83 (32.63)	0.33	.74
Life review writing workshop sessions attended	5.88 (1.8)	6.83(1.34)	8.0	.24
GDS pretest score	4.94 (3.99)	5.30(5.15)	−0.24	.81
MLQ–Presence pretest score	22.44 (4.40)	24.52(6.81)	−1.16	.29

Note. ADLs = activities of daily living; GDS = Geriatric Depression Scale, 30-question version; IADLs = instrumental activities of daily living; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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Table 1.

Participant Characteristics (N = 39)

	M (SD) or n (%)
Variable	Control Group (n = 16)	Treatment Group (n = 23)	t or χ²	p
Age, yr	75.81 (10.86)	77.85 (8.55)	−0.65	.52
Gender			0.47	.49
Male	1 (6.3)	3 (13.0)
Female	15 (93.8)	20 (87.0)
Ethnicity			3.27	.20
White	8 (50.0)	15 (65.2)
African-American	6 (37.5)	8 (34.8)
Middle Eastern	2 (12.5)	0 (0)
Education			1.82	.77
Some high school	0 (0)	1(4.3)
High school graduate	2 (12.5)	4(17.4)
Some college	2 (12.5)	5(21.7)
College graduate	5 (31.3)	5(21.7)
Graduate studies	7 (43.8)	8(34.8)
Self-rated health (0–5)	3.50 (1.16)	3.17(1.07)	0.91	.37
ADLs requiring assistance	0.13 (0.50)	0.09(0.28)	2.84	.24
IADLs requiring assistance	1.19 (1.47)	1.09(1.16)	3.78	.44
Different leisure interests	5.13 (1.50)	5.22(1.38)	−0.20	.84
Leisure activities/mo	85.13 (26.84)	81.83 (32.63)	0.33	.74
Life review writing workshop sessions attended	5.88 (1.8)	6.83(1.34)	8.0	.24
GDS pretest score	4.94 (3.99)	5.30(5.15)	−0.24	.81
MLQ–Presence pretest score	22.44 (4.40)	24.52(6.81)	−1.16	.29

Note. ADLs = activities of daily living; GDS = Geriatric Depression Scale, 30-question version; IADLs = instrumental activities of daily living; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

Table 2.

Change in MLQ–Presence Scores, by Group (N = 39)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	23.25 (6.36)	22.52 (6.91)	0.33	37	.74
Posttest 2	19.75 (6.50)	23.87 (6.30)	−1.98	37	.06
Change in score	−3.50(3.65)	1.04 (2.62)	−4.53	37	.00

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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Table 2.

Change in MLQ–Presence Scores, by Group (N = 39)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	23.25 (6.36)	22.52 (6.91)	0.33	37	.74
Posttest 2	19.75 (6.50)	23.87 (6.30)	−1.98	37	.06
Change in score	−3.50(3.65)	1.04 (2.62)	−4.53	37	.00

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

Table 3.

Change in MLQ–Presence Scores for Participants With Scores <25, by Group (n = 19)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	18.13 (4.52)	17.27 (6.47)	0.32	17	.75
Posttest 2	14.63 (4.98)	20.09 (7.20)	−1.84	17	.08
Change in score	−3.50(4.31)	2.18 (3.22)	−3.30	17	.004

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.

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Table 3.

Change in MLQ–Presence Scores for Participants With Scores <25, by Group (n = 19)

MLQ–Presence Score	Control Group M (SD)	Treatment Group M (SD)	t	df	p
Posttest 1	18.13 (4.52)	17.27 (6.47)	0.32	17	.75
Posttest 2	14.63 (4.98)	20.09 (7.20)	−1.84	17	.08
Change in score	−3.50(4.31)	2.18 (3.22)	−3.30	17	.004

Note. df = degrees of freedom; M = mean; MLQ–Presence = Meaning in Life Questionnaire, Presence subscale; SD = standard deviation.