Mixed methods implementation evaluation of community-based intergenerational program to improve the quality of life of the elderly in rural Maharashtra

Abstract

Background

The global rise in aging populations has introduced challenges such as increased social isolation and weakened intergenerational relationships. Intergenerational programs (IGPs) offer some promising strategies to address these issues by encouraging interactions between the older and younger generations by fostering mutual learning, support, and understanding. This study evaluated the feasibility and impact of a community-based intergenerational program in rural Maharashtra, India, with a particular focus on improving the overall well-being of the elderly individuals.

Methodology

A mixed-methods approach was used to evaluate the implementation of community-driven IGP strategies in 18 villages via qualitative methods (in-depth interviews, focus group discussions, force field analysis, spider web analysis, and most significant change stories) and quantitative assessments (quality of Life, generativity, social capital and self-care assessment tools) across 3 years. Stratified random sampling was used to recruit 520 participants across two elderly age groups (60–70 years and > 70 years).

Results

The qualitative data revealed that IGPs improved intergenerational relationships, enhanced communication and appreciation for joint family structures. The key facilitators included community engagement, peer trainers, cultural events, and active involvement from local leaders. Barriers included conflicting agricultural responsibilities, health issues, and limited intergenerational interaction due to mobile use. In the 60–70 years age group, the quality of Life scores was 70.6 at baseline and 68.5 by year 3, the generativity scores was 32.3 at baseline and 28 by year 3, and the social capital scores was 48.3 at baseline to 48.4 by year 3. In the > 70 years age group, the quality of Life score ranged from 66.9 at baseline to 65.4 by year 3, and the generativity scores was 31.8 at baseline and 26.1 at year 3. The social capital score was 45.2 at baseline and 45.5 by year 3. The self-care score was 127 for the 60–70 years age group and 125 for the > 70 years age group at baseline, and 106 for the 60–70 years age group and 103 for the > 70-years age group by year 3. Child-caregiver interactions for the 60 to 70 year-old age group (8.61 at baseline and 9.13 by year 3) and for the > 70-year-old group (9.23 at baseline to 7.74 by year 3).

Conclusion

Community based intergenerational project offer a promising approach to address social isolation and promote well-being in elderly individuals while also enhancing intergenerational connections and community resilience.

Introduction

The world population is undergoing a demographic shift which is characterised by an increase in life expectancy and reduction in fertility rates ultimately resulting in a rapid increase in the number of older adults [1]. Population aging has been referred to as a global phenomenon with substantial implications for social structures, economic systems, and healthcare [2]. Recent advancements in health care and public health have increased life expectancy but they have also increased the challenges of demands on social security systems and put significant strain on intergenerational relationships. Today, the majority of the world’s older population lives in Asia, and this proportion is projected to increase rapidly in the coming years. In some developed countries the older adults constitute a large percentage of the workforce, highlighting the importance of finding ways to integrate them into society [1].

Intergenerational programs (IGPs) are evolving as promising strategies to address these challenges associated with aging. They also cultivate positive outcomes for both older and younger generations [3]. These programs aim to create meaningful interactions between older adults and children or adolescents, promoting mutual learning, support, and understanding [3, 4]. IGPs can take various forms, including playgroups in aged-care facilities, shared-site programs with schools, and community-based initiatives. A key goal of such programs is to combat social isolation and loneliness, which are major concerns for older adults [5].

Research conducted in the developed countries has indicated that intergenerational programs offer benefits to children as well as older adults. These programs enhance social skills, reduce age related biases and improve the overall understanding of aging among children [6, 7]. On the other hand, older adults might have improved mental and physical health, a greater sense of purpose, and increased social engagement. IGPs can foster “grandparent-like” relationships, where older adults can share their wisdom and life experiences with children, contributing to their own sense of generativity and community [5]. Studies have also demonstrated that participation in IGPs was associated with increased sense of meaningfulness and manageability, which in turn can positively impact low mood, boredom and loneliness among elderly participants [8].

In India, the importance of intergenerational solidarity and active ageing has been progressively recognised in national policy. The Government of India’s Atal Vayo Abhyuday Yojana (AVYAY) – a centrally sponsored umbrella scheme for senior citizens explicitly supports programmes to build and strengthen intergenerational relationships between children, youth and older adults, primarily through collaborations with non-governmental organisations, Panchayati Raj institutions and local bodies. For example, the Vriddha Mitra initiative in Maharashtra combines community based elder support with activities that sensitise children and adolescents to issues of ageing and intergenerational harmony, and intergenerational learning centre modesl I nIndia train older adults as volunteer educators for government schoolchildren. Despite such policy and programmatic developments, there remains a dearth of rigorously evaluated, rural, community based intergenerational programmes that explicitly link intergenerational engagement to nurturing care for young children and life skills among adolescents.

The current study is embedded within ‘Sahjeevan’, a community-based intergenerational programme implemented in 18 villages under the Health and Demographic Surveillance System (HDSS) of Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, in rural Maharashtra. The program is academically led by the department of community medicine, MGIMS, in partnership with Adharwad, a local NGO of retired professionals working with older adults, and with active participation from Gram Panchayats and village-level committees. Governance of the Sahjeevan programme operates at multiple levels. At the institutional level, a project steering group within the department of community medicine provides overall technical and operational oversight. At village level, Sahjeevan Samanvay Samitis (intergenerational coordination committees) – comprising elected Panchayat representatives, frontline health and nutrition workers, older adult volunteers, and other local stakeholders plan and monitor activities. Operationally, the programme adopts a cascade implementation model, wherein a small cadre of elderly ‘master trainers’ and peer facilitators are trained on early childhood development, adolescent life skills and elderly self-care and subsequently conduct group sessions and community events that bring together elderly persons, young children, adolescents and caregivers. These activities include oral history sessions, cultural and religious gatherings, intergenerational fairs (‘Sahjeevan Melawas’), and structured games that promote nurturing care, social participation and health ageing.

Despite the growing recognition of the potential benefits of IGPs, there are several gaps in evidence of research studies. A majority of studies have focused on IGPs within residential aged-care facilities and schools, while neglecting community-based settings [9]. Despite the growing interest in intergenerational programs (IGPs), limited evidence exists on their specific potential to foster nurturing care for young children and enhance life skills among adolescents. The intricate dynamics required for effective implementation at both family and community levels remain underexplored. This study addresses these critical gaps by evaluating the feasibility of diverse community-driven strategies that link elderly individuals with younger generations. These strategies aim to enhance and promote the physical and mental well-being of elderly population.

The current IGP research delves into four key objectives: (1) Promoting Nurturing Care: Facilitating meaningful intergenerational interactions that support the developmental needs of young children. (2) Development of Life Skills: Engaging adolescents with older adults to cultivate essential life skills and foster mutual learning. (3) Enhancing Elderly Well-Being: Assessing the impact of intergenerational engagements on the mental health and overall quality of life of seniors. (4) Building Age-Integrated Societies: Exploring pathways for embedding age-inclusivity into family and community structures.

By creating diverse and inclusive environments, IGPs are promising platforms to serve as catalysts for fostering social cohesion and solidarity across generations. Through the lens of healthy aging and holistic development, the study envisions a future where intergenerational connections are the cornerstone of supportive, vibrant, and equitable societies.

This study was done to explore the feasibility of implementing various community-based strategies for linking the elderly with children and adolescents (with a focus on promoting nurturing care for young children and life skills among adolescents) at both the family and community levels to create age-integrated families and societies.

Methodology

Study design, duration and setting

This study employed a mixed-methods implementation research design to evaluate a community-based intergenerational program (IGP) aimed at enhancing the well-being of older adults in rural Maharashtra, Central India. The intervention was implemented over a three-year period (December 2020 to September 2023) across 18 villages under the Health and Demographic Surveillance System (HDSS) of MGIMS, Sevagram. The program lined elderly participants with children and adolescents through structured community-level strategies focusing on early childhood development, adolescent life skills, and elderly self-care. The health and demographic surveillance system (HDSS) platform was established in 2018 and supported by Kasturba Health Society. The HDSS covers approximately a population of 135,649 with 37,132 households and 101 villages of Wardha, a district in Central India. Within this defined geographic area, all households are enumerated and assigned unique identifiers, and trained field workers conduct periodic household visits to update information on births, deaths, pregnancies, migrations and other key demographic events. This continuous surveillance system provides a stable sampling frame and up-to-date population denominators, enabling population-based recruitment of older adults and linkage of survey data with longitudinal demographic information. For the present study, 18 villages were purposively selected from within the HDSS area, and stratified random sampling of individuals aged ≥ 60 years was undertaken from the HDSS database.

Study phases

The program was delivered in three distinct phases: (1) Phase I (Dec 2020–Nov 2021): Formative research and development of training modules, with initial stakeholder engagement and capacity building of frontline health workers (ASHAs and Anganwadi workers) on nurturing care and early childhood development. (2) Phase II (Jan 2022–Jan 2023): Implementation of elderly-focused self-care strategies alongside continued intergenerational activities. A cascade training model was adopted to develop master trainers and village-level peer facilitators. (3) Phase III (Feb 2023–Sep 2023): Community mobilization and program visibility were enhanced through intergenerational fairs (“Sahjeevan Melawas”), competitions, and collaborative activities across generations.

Qualitative methods

Participants and data collection

Qualitative data were collected across all three phases using in-depth interviews (IDIs), focus group discussions (FGDs), participatory tools, and structured observations. Participants included elderly individuals, caregivers, adolescents, frontline workers, local leaders, and members of intergenerational coordination committees.

In-depth interviews were conducted across three phases: Phase I (n = 17) with community leaders and frontline health workers (Sarpanch, Panchayat Samiti members, ASHAs, ANMs) to explore intergenerational interaction strategies and community engagement; Phase II (n ≈ 15) with ASHAs, Anganwadi workers, caregivers, and master facilitators to understand implementation challenges; and Phase III (n = 16) with diverse stakeholders to evaluate project aspects. Focus group discussions (FGDs) were also conducted in three phases: Phase I to explore community needs and project willingness; Phase II (n = 15) with elderly groups and the Sahjeevan Coordination Committee; and Phase III (n = 12) with adolescents (n = 4), elderly groups (n = 4), and the Sahjeevan-Samnvay Samiti (n = 4). The overarching objectives of IDIs and FGDs were to explore the evolution of the elderly’s social standing and identify facilitating and hindering factors.

Given the complexity of implementing a multi-component intergenerational programme across diverse rural communities, and the likelihood of emergent, context-specific outcomes, a combination of conventional qualitative techniques and participatory evaluation tools was employed. Additional qualitative techniques included Spider Web and Most Significant Change technique to systematically appraise perceived changes and to surface rich, narrative accounts of impact that may not be capture by structured questionnaires.

Spider Web method is a participatory visual tool in which participants collectively score their perceptions of performance or change across multiple domains on a radial diagram. For this study, eight domains of intergenerational engagement were pre-defined in consultation with community stakeholders [10]. This method was selected because it allowed stakeholders to jointly reflect on and quantify their perceptions of change across multiple dimensions, facilitated comparison between stakeholder groups, and provided a semi-quantitative complement to the narrative insights obtained from FGDs and IDIs. Most significant change technique is a participatory story based monitoring and evaluation approach widely used in complex social and community development programmes. 10 Most Significant Change (MSC) stories were collected across five sectors (two per sector) to capture transformative experiences. MSC stories were independently scored by a panel of evaluators, and the two highest-scoring stories were selected as the most impactful. All interviews and FGDs were audio-recorded, transcribed verbatim, and analysed using thematic analysis to identify recurring patterns and insights. MSC technique was chosen because it is particularly suited to complex, participatory interventions that may generate multi-dimensional outcomes. This technique complemented IDIs and FGDs by providing in-depth, participant-driven account of change, highlighting mechanisms through which the intergenerational programme influenced family relations, caregiving practices and community engagement. Collectively, the combination of IDIs, FGDs, Spider Web and MSC stories enabled a comprehensive understanding of both implementation processes (facilitator and barriers) and perceived outcomes, and allowed triangulation between narrative, participatory and semi-quantitative perspectives.

Quantitative methods

Participants and sampling

A stratified random sampling method was used to select participants aged ≥ 60 years from the HDSS database. The population was stratified into two age groups (60–70 years and > 70 years). Of the 4,415 eligible elderly individuals (2,612 aged 60–70 years; 1,803 aged > 70 years), 520 participants were enrolled annually in Years 2 and 3, and 460 in baseline and Year 1.

Assessment tools

To assess multiple dimensions of elderly well-being and intergenerational engagement, four structured instruments were administered to all participating older adults: (a) WHO Quality of Life – BREF WHOQOL-BREF [11]. Overall quality of life was measured using the WHOQOL-BREF, a 26-item instrument developed by WHO to provide a cross culturally comparable assessment of subjective quality of life across four domains: physical, psychological, social and environmental well-being. Each item is rated on a 5-point Likert scale, with higher scores indicating better perceived quality of life. Domain scores were calculated and transformed to a 0-100 scale as per WHO guidelines. The WHOQOL-BREF has been previously translated, culturally adapted and psychometrically evaluated in multiple Indian settings, including studies among community-dwelling older adults [11–13]. (b) Social Capital Scale [14]: Perceived social capital was assessed using a structured social capital scale capturing 6 domains (group and network, trust and solidarity, collective action and co-operation, information and communication, social cohesion and inclusion, empowerment and political action). The tool has been adapted and validated in rural India with internal consistency of 0.80 [15, 16]. (c) Loyola Generativity Scale [17]: Assessed the participants’ sense of purpose and contributions to future generations on a 20-item instrument rated on a 4-point Likert scale from “strongly disagree” to “strongly agree”, originally developed by McAdams and de St Aubin. The LGS has demonstrated good psychometric properties in diverse adult and older-adult populations [18, 19]. (d) Self-Care Assessment Tool: Examined daily living skills and autonomy among elderly individuals. The tool was prepared by an expert team in the department of community medicine and comprised items across domains including nutrition, sleep, physical activity, health responsibility, interpersonal, spiritual and stress. The tool was pilot tested in the same population.

Sample size calculation

Based on a prior unpublished study, the expected improvement in WHOQOL-BREF scores was from 52.5 (SD = 22.5) to 58.5 (SD = 24.0). With a 95% confidence level and 80% power, the estimated minimum sample size was 260 per stratum, accounting for a 10% non-response rate. In practice, 460 participants were enrolled in the baseline and year 1, and 520 in years 2 and 3, enhancing statistical power.

The sampling frame was derived from a comprehensive Health and Demographic Surveillance system (HDSS) database of MGIMS, Sevagram. A stratified simple random sampling design was employed, with strata defined by age groups ( 60–70 years and above 70 years) to ensure representative participant selection. From the 18 villages selected, 4,415 participants were identified, with 2,612 in the 60–70 age group and 1,803 above 70 years.

Data analysis

Data analysis was conducted separately for the qualitative and quantitative components and later integrated during interpretation to enable a comprehensive understanding of the program’s implementation and impact. Quantitative outcomes are presented descriptively due to the implementation evaluation design and participants were not consistent across all years hence inferential testing was not performed.

Results

Qualitative findings

During the implementation of the project, a range of qualitative methods were employed for both midline and endline evaluations. The endline findings from all phase I, II and, III are presented in the sections below:

A. Spider web method

The Spider Web method (Fig. 1) was utilized to assess the perceived changes before and after the implementation of the Sahajeevan program across eight distinct domains of intergenerational programs. Across all four stakeholder groups—Sahajeevan Samanvay Samiti, caregivers, adolescents, and elderly—there was a consistent outward shift in the red lines (representing “after Sahajeevan”), indicating improvement in most domains. Each stakeholder group showed improvements, though the nature and intensity varied. The greatest improvements were seen in interaction (Domain 2), participation (Domains 1 and 6), and mutual respect and knowledge sharing (Domains 3 and 8). These findings confirm that a structured, community-based intergenerational program can reshape perceptions, increase elderly engagement, and enhance relationships across generations in rural settings.

Fig. 1.

Radar chart depicting stakeholder perceptions of change across intergenerational engagement domains

In total, 18 Spider Webs were collected, representing the maximum clusters within the project area. This method engaged four distinct participant groups: (1) Sahjeevan Samanvay Samiti (Intergeneration coordination committee). (2) Caregivers. (3) Adolescents. (4) Elderly.

No.	Domain
1	Participation of the elderly in ECD/ Adolescents well-being activities at the family and community levels.
2	Improved in the interaction between two generations
3	Respect for elderly and their opinions in the family
4	Self-confidence of master trainers in the village
5	Master trainers were able to reach elderlies in the village
6	Increased participation of elderly in village work
7	Bonding and interaction of elderly with peer group
8	Transfer of skills or knowledge from elderly to younger generation

B. Most Significant Change (MSC) stories

As part of the endline evaluation, a total of 10 Most Significant Change (MSC) stories were collected. The Intergenerational Project, which spans 18 villages across five sectors, provided two MSC stories from each sector.

A facilitator read all ten stories aloud to the evaluation team. Following this, a discussion was held where the evaluators reflected on each story. After the discussions, each evaluator assigned a score to the stories individually. The median scores were then calculated, and the two stories with the highest median scores were selected as the Most Significant Change stories.

No.	Selected Changes	Median Score
1. 2.	Mandwa Sahjeevan Coordination Samiti has worked on this project not as a project but as a campaign. And they always tried to give it a different direction. Therefore, the work of the committee continues even today. At present the meeting of the committee is held on a regular basis at a fixed time. In each meeting, what kind of work was done in the previous month is discussed and the work of the upcoming month is also planned after taking opinion of all the members. There is a continuous effort to improve the quality of work of committee. They are trying to spread the concept of Sahajeevan and its importance from house to house through school and college students. For this, the committee started doing awareness through rally with school students. And guidance is being given on how important elderly and children are to each other’s development. Efforts are being made to increase their participation by holding various competitions and encouraging them with prizes to convince them of the importance of Sahajeevan. 58-year-old Hemraj Shelke from Ganeshpur village has been suffering from diabetes for about 10 years. Before the Sahajeevan project came, he had to take care of himself. He also did not know how to take care of diabetes. The other members of the household were not interacting with him, even not asking about his health condition either. The household members were limited only to giving him daily meals. And there was no communication or inquiry from the family members regarding his health. After attending the training of Sahjeevan, Mr. Hemraj Shelke gained good knowledge of Diabetes and started taking a good care of his chronic illness. A real difference began to be seen in their lives. Later son, daughter-in-law, grandson also participated in the training. As a result of this everyone in the house started taking care of Hemraj Shelke. The family began to communicate with each other. Even the son now takes them to Kiran Clinic and brings medicines for him. Daughter in law also helps Mr. Hemraj by preparing breakfast and gives him reminder regarding medicines on time. This has made the atmosphere in the house lively.	9 8

C. Qualitative findings from FGDs/IDIs and observation

Qualitative insights were drawn from Focus Group Discussions (FGDs), In-Depth Interviews (IDIs), and observations conducted over three years. These insights were grouped into four thematic areas: (1) Facilitating factors for implementation, (2) Barriers for implementation, (3) Impact of the project and (4) Suggestions for future programs and activities. These four thematic domains capture the core insights derived from the comprehensive qualitative engagements conducted through IDIs, FGDs, and detailed observations over the three-year duration of the intergenerational project.

The success of the intergenerational project was driven by several enabling factors. Accessible and well-equipped venues ensured smooth implementation. Financial support from Gram Panchayats played a critical role by providing necessary resources like lighting, furniture, and logistical aid. Leveraging community festivals such as Ganpati, Durga Devi, and Datta Jayanti created opportunities for engagement and enhanced participation.

Facilitating Factors	Description
Availability of Adequate Facilities	Provision of suitable venues and financial support from Gram Panchayats facilitated smooth execution of activities.
Utilization of Festival Gatherings	Leveraging cultural festivals (e.g., Ganpati, Durga Devi, Datta Jayanti) to engage communities and increase participation.
Elderly Group Formation and Community Involvement	Establishing dedicated elderly groups and integrating them with existing community groups, such as Bhajan groups and Self-Help groups, to extend outreach.
Organizing Competitions and Cultural Events	Conducting events like painting competitions, rangoli contests, and mother-in-law-daughter-in-law fairs to stimulate interest across age groups.
Support and Encouragement from Gram Panchayats	Active involvement of local governance bodies, including village leaders, provided critical resources and encouraged participation.

The establishment of elderly groups and their integration with existing community organizations, including Bhajan groups, Hari Path groups, and Self-Help groups, significantly amplified outreach. Elderly health camps served as an additional strategy to boost involvement. Events like painting competitions, rangoli contests, and fairs aimed at mother-in-law and daughter-in-law relationships further piqued interest across diverse age groups. Notably, the active involvement of village leaders and Gram Panchayat members strengthened community engagement.

Elderly participants and Adharwad members emphasized the pivotal role of dedicated peer trainers in fostering local participation and education. Sahajeevan Melawa (community fairs) emerged as a highly effective platform, where elderly-led stalls sparked enthusiasm among children. Oral history sessions bridged generational gaps, altering adolescents’ perceptions of the elderly and fostering mutual learning. The establishment and reinforcement of Sahajeevan Samiti (Intergenerational Coordination Committees) were deemed vital for sustaining project activities. Participants appreciated interactive training approaches, including actionable songs and activity-based games, which significantly enhanced engagement. Trainings were well-received, with the Rope game for early childhood development, musical chairs for physical activity, and card games for nutrition and dementia receiving positive feedback.

“Teaching through games and entertainment is good”- an elderly male from Dhamangaon.

Barriers to implementation

Despite its achievements, the project faced several challenges that hindered smooth execution. A key limitation was the conflict between elderly participants’ agricultural responsibilities and project schedules, resulting in reduced availability. Health issues, including illnesses and decreased physical fitness, further restricted participation. Forgetfulness about training schedules and session content created additional inconsistencies.

Barrier	Description
Loss of Daily Wages and Farm Work	Loss of daily wages and farm work during the day limited elderly participation in the project.
Elderly Illness and Forgetfulness	Health issues and forgetfulness hindered active involvement, affecting attendance and retention of training content.
Financial Difficulties for Program Resources	Difficulty securing financial resources disrupted the execution of program activities.
Limited Inter-generational Interaction	High use of TV and mobile devices by children reduced intergenerational interactions, affecting project goals.
Lack of Parental Receptiveness	Frustrations arose as parents did not value or engage with the knowledge shared by elderly participants post-training.
Seasonal Challenges and Duration of Training	Rainy season logistics and prolonged sessions caused discomfort and focus issues for elderly participants.
Difficulty in Comprehending Training	Some elderly participants struggled to understand the content, limiting their engagement in project activities.
Impact of Illness	Illness among the elderly was a recurring barrier, affecting overall participation in project activities.

Financial constraints were another obstacle, making it difficult to maintain program continuity. High levels of TV and mobile usage among younger participants limited intergenerational interactions. Some elderly individuals expressed frustration over parents undervaluing the insights they shared during training sessions. Seasonal challenges, particularly during the rainy season, disrupted project activities. Prolonged training sessions caused physical discomfort for some elderly participants, while others faced difficulties comprehending the training material. Recurring illnesses among the elderly further affected their ability to fully engage with the program.

“Elderly tell parents of 0-to-3 years children regarding development. If they didn’t listen due to different priorities in their life, elderly feel sad. Still, we make our effort. We also took programs for adolescents in Buddha Vihara, in schools” – a female peer trainer from Mahakal.

Impact of the project

The project generated significant and positive impacts. Respondents reported an increased awareness of the importance of intergenerational relationships, with positive changes in elderly participants’ mindsets fostering improved communication and closer family ties. Elderly individuals actively shared traditional skills, such as crafting and playing musical instruments, with younger generations. They also assumed greater responsibility for children’s nutritional needs, reflecting enhanced sense of responsibility and involvement.

A renewed appreciation for joint family structures was observed, accompanied by noticeable improvements in social dynamics and a shift in younger generations’ attitudes toward the elderly. Communication patterns within families improved, with the elderly openly sharing their concerns and emotions, fostering greater understanding. Participants gained a deeper appreciation of the role of touch, play, and nutrition in child development, leading to better intergenerational interactions. Peer support among elderly groups also strengthened, with increased discussions on health and shared concerns creating robust networks of mutual support.

However, the impact was less pronounced in nuclear families, and some community segments exhibited limited progress. Despite these variations, the project’s overall contribution to fostering intergenerational bonds and creating an inclusive community was overwhelmingly positive.

“I eat tobacco but my granddaughter doesn’t like it. She also comes with her grandmother to programs. She started throwing my tobacco outside after attending the programs” – A male elderly from Wabgaon.

“Nuclear family children and adolescents are developing a feeling that if grandparents could live with them, it would be nice” – A peer trainer from Mahakal.

Suggestions for future programs

Participants generated a range of concrete suggestions to sustain and expand the programme. Elderly groups and caregivers requested disease specific awareness activities, particularly on cancer and other non-communicable diseases and emphasized that joint sessions involving adolescent and younger adults could help families recognise early symptoms and support timely care-seeking. Public awareness campaigns, including banners and posters, were recommended to increase visibility. Organizing health camps and conducting de-addiction initiatives were proposed to address pressing community issues.

Relationship-building events, including fairs focused on mother-in-law and daughter-in-law dynamics, were proposed to strengthen family bonds. Orientation sessions for newly married couples were also recommended to promote intergenerational understanding. Introduction of a “Sahjeevan Doot” (Messenger of Sahjeevan) concept was propose in one FGD. Diversified programs targeting cultural and agricultural topics, as well as adolescent-specific needs, were suggested to broaden the scope of the program. Elevating the status of the elderly within the community was another key recommendation. Sahjeevan Samanvay Samiti members proposed establishing Bal Panchayats in each village, where children could take leadership roles in organising intergenerational events, advocating respect for older adults and supporting community health campaigns. Innovative methods, including modern teaching techniques, dedicated leisure spaces, and village fairs, were recommended to further strengthen the elderly’s role within the community.

Such recommendations directly extend the existing intergenerational platform by using child and adolescent participation to address health priorities identified by older adults and their families, rather than introducing disconnected programme components.

“Many People come to Sahajeevan melawa (fair) and the message of our project can reach to larger number of people. Hence, melawa should be taken regularly”- Peer trainer.

“Letter should be spread to all stakeholders a day before meeting. Meeting should be taken at our convenient time when we come back at 1 to 1.30 pm from farms” – Elderly from Wabgaon.

Quantitative findings

Quality of life, generativity, and social capital scores

The mean age of the study participants was 74.56 ± 9.2 years. Among participants aged 60–70 years, WHO Quality of Life (QOL) scores were 70.6 at baseline (2020), remained stable at 70.6 in Year 1, declined to 69.3 in Year 2 and reached 68.5 in Year 3 (Table 1). Loyola Generativity scores decreased from 32.3 at baseline to 28.3 in Year 1, increased to 30.4 in Year 2, and declined again to 28.0 in Year 3. Social Capital scores ranged from 48.3 at baseline to 49.1 in year 2 and 48.4 by year 3.

Table 1.

Combined analysis of WHOQOL, Loyola Generativity and Social Capital scores for age group 60–70 years

	Baseline (2020)	Phase-I	Phase-II	Phase-III
Total QOL	70.6	70.6	69.3	68.5
Total LG score	32.3	28.3	30.4	28
Total Social capital	49.1	48.7	49.1	48.4

Domain scores for WHOQOL were transformed to a 0-100 scale, with higher scores indicating better quality of life. Higher LGS and SC scores indicate higher generativity and higher social capital

WHOQOL World Health Organisation Quality of Life, LGS Loyola Generativity Scale

Among individuals aged > 70 years, QOL scores decline from 66.9 at baseline to 65.4 by Year 3, with intermediate values of 65.4 (year 1) and 65.5 (year 2) (Table 2​). Loyola Generativity scores decreased steadily from 31.8 at baseline to 26.1 by Year 3. Social Capital scores, however, showed a modest and consistent increase from 45.2 at baseline to 45.5 in Year 3.

Table 2.

Combined analysis of WHOQOL, Loyola Generativity and Social Capital scores for age group > 70 years

	Baseline	Phase 1	Phase 2	Phase 3
Total QOL	66.9	65.4	65.5	65.4
Total LG score	31.8	28	28.1	26.1
Total Social capital	45.2	45.3	45.4	45.5

WHOQOL World Health Organisation Quality of Life, LGS Loyola Generativity Score

Self-care scores

Self-care assessments scores which were introduced in year 2 declined across both age groups between Year 2 and Year 3. For participants aged 60–70 years, the mean score dropped from 127 in Year 2 to 106 in Year 3. Similarly, for those aged > 70 years, the score decreased from 125 in Year 2 to 103 in Year 3 (Table 3​).

Table 3.

Self-Care Total score (Mean(SD))

Age Group (60- 70yrs)		Age Group (> 70yrs)
Phase-II	Phase-III	Phase-II	Phase-III
127(24)	106(20.3)	125(23.9)	103(20.3)

Higher self -care scores indicate good self-care practices

Child-Caregiver Interaction (CCI) scores

Child-caregiver interactions scores among elderly participants showed variability across the study period. For individuals aged 60–70 years, the mean scores were 8.61 at baseline, declined to 8.2 in Year 1, increased to 9.91 in Year 2 and decreased to 9.13 in Year 3. In the > 70 years group, baseline scores were 9.23, declined to 6.o in year 1, increased to 8.31 in year 2 and decreased to 7.74 in year 3. (Table 4​).

Table 4.

Child-Caregiver interaction (CCI) scores

Age Group (60-70yrs)					Age Group (> 70yrs)
Mean (SD)	Baseline (2020)	Phase-I	Phase-II	Phase-III	Baseline (2020)	Phase-I	Phase-II	Phase-III
	8.61(3.51)	8.2(3.94)	9.91(4.22)	9.13(4.47)	9.23(3.05)	6(4.30)	8.31(4.89)	7.74(5.25)

CCI scores were calculate from the 13 questions related to interactive activities between caregiver and child

Adolescent-elderly interactions

Self-reported interactions between adolescents and elderly participants showed mixed trends. Discussion and storytelling activities increased in both age groups, rising from 8.8% to 9.5% for 60–70 years and from 7.5% to 8.1% for > 70 years between Years 2 and 3. However, the proportion of adolescents assisting the elderly in overcoming difficulties decreased across both groups, from 7.1% to 6.3% in 60–70 years and from 6.4% to 6.1% in > 70 years. The percentage of adolescents showing respect for elderly individuals declined slightly, from 22.9% to 21.9% in 60–70 years and from 26.6% to 26.3% in > 70 years (Table 5).

Table 5.

Adolescent – elderly interaction

	Age Group (60-70yrs)		Age Group (> 70yrs)
	Year2(2022)	Year3(2023)	Year2(2022)	Year3 (2023)
Adolescent Elderly Discussion and Storytelling	92(8.8%)	99(9.5%)	78(7.5%)	84(8.1%)
Adolescents helping Elderly overcome difficulty	74(7.1%)	66(6.3%)	67(6.4%)	63(6.1%)
Adolescent give love and respect to elderly	68(22.9%)	65(21.9%)	79(26.6%)	78(26.3%)

Mixed-methods integration

Taken together, the quantitative and qualitative findings provide a nuanced picture of the programme’s impact. Quantitative scores for quality of life, generativity and social capital remained constant across the three-year period in both the age groups. In contrast, qualitative findings from FGDs, IDIs, Spider Web exercises and MSC stories consistently indicated perceived improvements in intergenerational interaction, respect for older adults and social participation of the elderly. Participants described greater involvement of older adults in childcare and adolescent guidance, stronger peer networks and increased recognition of older adults’ roles within families and community. The discrepancy between limited change in quantitative scores and rich narratives of social and relational change suggests that the programme may have helped modestly improve psychosocial well-being in a context of complex societal structure health challenges. This might have also generated specific relational benefits that are not fully captured by generic quality of life scores.

Discussion

The mixed methods implementation evaluation of community-based intergenerational programme in rural Maharashtra found that, over three years, quality of life, generativity and social scores among older adults remained broadly stable, with only modest changes in mean values, while qualitative data indicated marked perceived improvements in intergenerational interaction, respect for older adults, and social participation. Stakeholders described greater involvement of older adults in nurturing young children and mentoring adolescent, strengthened peer networks, and enhanced recognition of older adults’ roles in families and communities. Together, these findings indicate that a structured, community-based intergenerational programme is feasible and acceptable in a low-resourced rural setting, and can generate important social and relational benefits for older adults even when changes in standardised scale scores are modest.

Most empirical work on intergenerational programmes has been conducted in high income countries and more frequently in institutional settings such as residential old age homes and day care centres. These studies generally report improvements in social engagement, sense of purpose, attitudes towards ageing and in some cases, mood and loneliness among older adults participating in structured intergenerational activities [20, 21]. The present study extends this literature by demonstrating the feasibility of implementing a multi-component, community-driven intergenerational programme in a rural Indian context, using existing village-level committees, frontline health workers and elderly peer facilitators rather than stand-alone institutional sites. This aligns with recent calls to move beyond site-based programmes towards intentional and scalable intergenerational strategies that are integrated into community systems and age-friendly planning [9, 22, 23].

A further distinctive feature of this intervention is its explicit linkage of intergenerational engagement with the three interconnected domains which is nurturing care for young children, life-skills development among adolescents and self-care and psychosocial well-being among older adults. While previous studies have shown that intergenerational contact can improve childrens’ attitudes ageing and reduce ageism. A few studies embedded early childhood development and adolescent life-skills objectives within an intergenerational framework in low and middle income countries [22]. By positioning older adults as mentors and knowledge holders for younger generations, “Sahjeevan” operationalised the concept of generativity in day to day family and community practices rather than just treating older adults as beneficiaries.

The apparent discrepancy in quantitative scores and rich qualitative narratives is noteworthy and has been noted in other complex community interventions [3, 21]. Several explanations are possible. First, the older adults were ageing over the period of three years and experiencing more time with chronic conditions which would tend to worsen quality of life and self-care scores over time. Maintaining relatively stable scores may itself represent a positive outcome. Second, generic instruments such as the WHOQOL-BREF, social capital and standard generativity scales may not reflect the dimensions which emerged from the qualitative data and participatory Spider Web and Most Significant Change stories [22].

Strengths and limitations

The study has several limitations that should be considered when interpreting the findings. First, the evaluation did not include a control group limiting causal inference opening the possibility that some observed changes reflect secular trends, ageing trajectories, or contextual shocks rather than programme effects. Second, participant engagement in programme activities and follow-up assessments may have been influenced by self-selection (e.g. more motivated, healthier or socially connected older adults) which may bias estimates of acceptability and perceived benefits.

Third, key outcomes relied largely on self-reported instruments, which are vulnerable to recall bias and social desirability bias. Moreover, some measures used in this study (particularly the self-care tool developed and piloted locally) may have limited psychometric validation for rural Indian geriatric populations potentially reducing sensitivity to change in community level interventions.

Fourth, the study was conducted in a single HDSS in rural Maharashtra, which may limit generalisability to urban settings which has different sociocultural and health-system characteristics. Finally the complex multi-component nature of the intervention and variability in exposure across villages and individuals may have diluted detectable quantitative effects, even when the qualitative accounts indicated meaningful relational social change.

Despite these limitations, the study has several strengths. It used population based sampling frame within an established HDSS. The three year implementation period and mixed methods design supported triangulation and provided a detailed understanding of the implementation processes and stakeholder perceived impacts that are not fully captured by standardised scales.

Implications for practice and policy

At the policy level, the National Program for Health Care of the Elderly (NPHCE) and the Ayushman Arogya Mandir – Health and Wellness Centre initiative recognise the role of ASHAs and other frontline health workers in promoting healthy ageing and dedicated training materials on elderly care have been developed recently. But these modules focus majorly on chronic disease management and health promotion but do not provide structured guidance on facilitating intergenerational activities. The “Sahjeevan” programme demonstrated how such intergenerational content can be integrated into existing ASHA and community-level platforms providing an opportunity for future revision of frontline worker training modules.

Conclusion

Over the past three years, the formative findings highlighted that many older adults experienced isolation, social detachment, purposelessness and a strong need for self care. This mixed methods implementation evaluation indicates that a community based intergenerational program embedded within rural governance structures in Maharashtra is feasible and acceptable. While quantitative scores showed modest changes over time, qualitative and participatory findings suggest improvements in intergenerational interaction, respect for older adults and elderly participation in family and community life. The implementation was facilitated by community engagement, elderly peer trainers, Gram panchayat and local leader involvement and the strategic use of cultural events. Barriers included competing livelihood and agricultural demands, health constraints and reduced intergenerational time linked to mobile/television usage among younger family members. The programme experience and locally co-developed materials provide practical lessons for adapting and integrating structured intergenerational components into routine community and primary care platforms, with future evaluations needed to assess effects on standardised health and quality of life outcomes more robustly.

Authors’ contributions

SG, RM and RK: Conception of idea , proof reading, AJ, SG, AM, AR, CM, PB, AD and Manashri Bhuyar: Proposal writing, final report writing and manuscript layout, AJ, Manashri Bhuyar: collection and organisation of data. AJ, SG, RM, RK and Manashri Bhuyar XD: manuscript review. AJ, Manashri Bhuyar, RK, RS, BB and MB : Data analysis, discussion and writing of the manuscript. AJ, Manashri Bhuyar and MB: wrote the main manuscript. All authors contributed to the proof reading of the article and approved the submitted version.

Funding

This work was supported by the WHO SEARO [APW PO No – 202800501] for development of the implementation package.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was reviewed and approved by the institutional ethics committee, MGIMS, Sevagram (approval number: MGIMS/IEC/COMMED/04/2021). All procedures involving human participants were conducted in accordance with the Declaration of Helsinki (2013 revision). Informed written consent was obtained from all participants prior to participation.

Consent for publication

Not applicable.

Competing interests

Author Rajesh Khanna is an employee of WHO-SEARO. This affiliation is disclosed as a potential competing interest. However the funder had no role in data collection, analysis, interpretation, manuscript drafting, or the decision to submit”.