Development, feasibility, and acceptability of a process based intervention to decrease internalized ageism

ABSTRACT

A lifetime of exposure to ageism may be internalized in older adults, and these ageist beliefs that are directed inwards can have severe consequences. However, research on reducing internalized ageism is scarce. To address this, we designed and implemented a six-week online process-based intervention to reduce internalized ageism and to assess its feasibility. The intervention utilized a process-based therapy approach targeting psychological, behavioral, and physiological pathways through which internalized ageism negatively impacts health, as specified by stereotype embodiment theory. Intervention components included education, acceptance and commitment therapy techniques, and attributional retraining. A total of 81 older adult participants participated in the feasibility study. Most participants rated each session and the overall program as very useful after each session (average program usefulness rating of 4.54/5). Participants also attributed a wide range of novel behaviors to this intervention and stated that they felt it changed their perspectives on ageism and/or internalized ageism. Results from this study provide a promising foundation from which to advance research on interventions that address internalized ageism – a problem that has severe consequences on the health and well-being of growing numbers of older adults globally.

KEYWORDS:

• Self-perceptions of aging
• process-based therapy
• acceptance and commitment therapy
• attributional retraining

Introduction

Ageism refers to stereotypes, prejudice, and discrimination toward others or ourselves, based on age (World Health Organization [WHO], 2023). As the number of older adults across the world has increased (United Nations, 2022), so too has the prevalence of negative ageist beliefs (Ng et al., 2015). These ageist beliefs can be found in countries across the globe (Ackerman & Chopik, 2021; Chang et al., 2020), and in individuals of all ages (e.g., Barrett & Cantwell, 2007; Cherry et al., 2016; Lichtenstein et al., 2001; See & Nicoladis, 2010). Beyond the minds of individuals, ageist messaging is woven into the fabric of many cultures. Ageist messaging, beliefs and actions can be found in the workplace (Chang et al., 2020), advertising campaigns and cosmetic industry (Riddler, 2020), social media (Gu & Dupre, 2021), and healthcare (Makris et al., 2015). The pervasiveness of ageism leads to several harmful consequences to the health and well-being of adults and as such, the WHO (2015) highlighted reducing ageism as an important facet of improving general human well-being worldwide.

One of the ways ageism negatively impacts the health and well-being of older adults worldwide is through its internalization (Chang et al., 2020; Levy, 2009). Across a lifetime of exposure to ageist messaging, an individual internalizes these messages, and begins to believe them (Levy, 2009). Once internalized, these ageist sentiments can operate unconsciously, biasing how we see our aging selves. As we age into older adulthood ourselves, these ageist views become directed at not only members of our own age cohort, but ourselves. Indeed, as we age, these stereotypes of older adults become increasingly self-relevant and thus increasingly consequential. The consequences of internalized ageism are multifaceted and harmful. These consequences include but are not limited to, worse quality of life (Top, Eris, & Kabalcioglu, 2012), dissatisfaction in social relationships (Cheng, 2017), and increasing risky behaviors such as drinking and smoking (Villiers-Tuthill, Copley, McGee, & Morgan, 2016), depression (Bai, Lai, & Guo, 2016; Gum & Ayalon, 2018), poor cognitive performance (Levy, Zonderman, Slade, & Ferrucci, 2012), and functional decline (Tovel, Carmel, & Raveis, 2019). Furthermore, internalized ageism was demonstrated to be associated with a 7.5 year reduction in longevity (Levy, Slade, Kunkel, & Kasl, 2002), and this relationship was recently supported by a comprehensive meta-analysis (Westerhof et al., 2023). A related body of work on age-based stereotype threat also suggests that when older adults are confronted by these aging stereotypes, performance on various tasks, and especially cognitive tasks, reliably decreases (Lamont, Swift, & Abrams, 2015; Mayr & Stine-Morrow, 2018). This may be particularly relevant in older adults who have internalized ageist messages, as these stereotypes have become embedded into their belief systems. Thus, internalized ageism has severe negative impacts on the health and well-being of older adults.

Given the severity of the consequences of internalized ageism for older adults, it is necessary to combat internalized ageism. Many educational programs and interventions have proven effective at reducing ageism directed at others (Burnes et al., 2019). However, educational interventions reducing internalized ageism are comparatively scarce, despite the obvious need. Recently, researchers have speculated on what techniques and theoretical foundations might prove useful in designing such an intervention (Steward, 2022). In the current study we outline the program development of our educational program to reduce internalized ageism in older adults, briefly describe the intervention, and present feasibility and acceptability data in a pilot intervention with community-dwelling older adults.

Content

Though research on interventions addressing internalized ageism is scarce, theoretical foundations to build such interventions exist. Process-based therapy (PBT) is a meta-model of intervention design that suggests targeting core mediating variables based on testable theories to achieve desired change. In other words, it is the “contextually specific use of evidence-based processes linked to evidence-based procedures to help solve the problems … of particular people” (Hofmann & Hayes, 2019, p. 38). PBT accomplishes this by focusing on six core processes of psychological change: cognition, emotion, attention, self, motivation, and behavior (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022). Targeting these six processes of change promotes psychological flexibility (i.e., an individual’s ability to be cognitively and emotionally open, to be aware of the internal and external aspects of the present moment, and to be more engaged in living a values-focused life; Falletta-Cowden, Smith, Hayes, Georgescu, & Kolahdouzan, 2022). Psychological flexibility was the construct most responsible for change in a review of therapeutic outcome literature, and has successfully been targeted through interventions proven effective with older adults (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022). Employing a PBT approach could help to reduce internalized ageism, understand the mechanisms behind this reduction, and tailor the intervention to particular populations of individuals with internalized ageism. Though the six processes of PBT and psychological flexibility are an effective way of conceptualizing and guiding intervention targets, they are not specific to internalized ageism.

Stereotype embodiment theory (SET; Levy, 2009) offers further guidance on potential targets within a PBT framework that may specifically act on internalized ageism. SET posits that once ageism is internalized, it negatively affects health outcomes of individuals through psychological, behavioral, and physiological pathways. Steward (2022) speculated that targeting mechanisms along these pathways may reduce the negative consequences of internalized ageism. Based on his review of the extant literature, he suggests targeting self-efficacy, perceived control, and purpose in life along the psychological pathway; physical activity along the behavioral pathway; and biomarkers of stress along the physiological pathway.

Perceived control is a salient target to consider when designing an intervention to reduce internalized ageism (Steward, 2022). Perceived control can be bifurcated into primary and secondary control (Rothbaum, Weisz, & Snyder, 1982). Primary control, the sense of control you have when your behaviors produce the intended outcome in the external world (Haynes, Heckhausen, Chipperfield, Perry, & Newall, 2009), is a prudent target in an intervention attempting to reduce the impact of internalized ageism due to a multitude of factors. First, perceived control mediates the psychological pathway through which internalized ageism negatively impacts health (Levy, Slade, Kunkel, & Kasl, 2002). Second, it is an effective mechanism of change that acts on the PBT processes of emotion and cognition (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022). Third, it reduces the internalization of help-seeking stigma in older adults and may thus reduce the internalization of ageism (Murphy, Mackenzie, Dryden, & Hamm, 2024). Fourth, brief interventions targeting perceived control in older adults may increase physical activity (Sarkisian, Prohaska, Davis, & Weiner, 2007), another potential mechanism in decreasing internalized ageism (Steward, 2022). Secondary control, on the other hand, is an adaptive psychological state of control that can exist when goals cannot be achieved because direct influence is not possible, and an individual adjusts some aspect of themselves and accepts their circumstances (Chipperfield et al., 2012). Secondary control is also important to consider and is thought to be increasingly important in later life (Heckhausen & Schulz, 1995). Indeed, secondary control predicts many positive health outcomes in older adults (Chipperfield et al., 2012).

Mindfulness is another important construct to target. As mentioned above, Steward (2022) suggests utilizing stress-management techniques to target biomarkers of stress along the physiological pathway of SET. Targeting mindfulness is one such way to achieve this, addressing the attentional process of PBT. Furthermore, researchers speculate that older adults’ emotion regulation strategies may align with interventions that focus on mindfulness (Geiger et al., 2016) as older adults report higher levels of mindfulness than younger adults (Hohaus & Spark, 2013; Mackenzie, Karaoylas, & Starzyk, 2018). An approach that focuses on mindfulness in older adults is in line with the capitalization model of intervention (Geiger et al., 2016), which suggests focusing on strengths (e.g., mindfulness) and is preferable to focusing on weaknesses (Cheavens, Strunk, Lazarus, & Goldstein, 2012; Wingate, van Orden, Joiner, Williams, & Rudd, 2005). Adding further support for its utility, mindfulness was the second most frequent mechanism of change in a review of therapeutic outcome research (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022).

Several evidence-based interventions exist that act on the evidence-based targets suggested by PBT (Hofmann & Hayes, 2019) and SET (Levy, 2009). Attributional retraining (AR), a brief intervention designed to promote adaptive behavior by targeting cognitions, motivation, and primary control (Haynes, Perry, Stupnisky, & Daniels, 2009), has been successfully employed with samples of older adults and may thus be a valuable tool in an intervention to decrease internalized ageism (e.g., poor strategy; Parker et al., 2022; Sarkisian, Prohaska, Davis, & Weiner, 2007). Third-wave cognitive behavioral therapies, such as acceptance and commitment therapy (ACT), address secondary control, mindfulness, and psychological flexibility, and have been speculated by researchers to reduce internalized ageism (Lester & Murrell, 2021). ACT attempts to increase psychological flexibility through six distinct strategies (Hayes, Strosahl, & Wilson, 2011). ACT promotes acceptance (i.e., willingness to contact negative or unwanted experiences), defusion (i.e., separating oneself from one’s thoughts), perspective taking (i.e., keeping perspective of oneself within one’s experiences), mindfulness (i.e., being in touch with and aware of one’s experiences), values (i.e., awareness of what is of value, purpose, or meaning in one’s life), and committed action (i.e., behaving in values-consistent ways in one’s life). In doing so, ACT targets the six processes of PBT and the psychological flexibility; (1) defusion acts on cognition, (2) acceptance acts on emotion, (3) mindfulness acts on attention, (4) perspective taking acts on self, (5) values act on motivation, and (6) committed action acts on behavior (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022). Finally, several educational interventions have been successfully employed to reduce ageism directed toward others (Burnes et al., 2019), and are thus likely a viable tool to employ when targeting internalized ageism.

In summary, though many interventions have been successful in reducing ageism (Burnes et al., 2019), much prior research in this area has lacked a coherent theoretical foundation, has not explicitly explored underlying mechanisms of change, and there has been little work done to specifically reduce internalized ageism. However, drawing on empirical research and theoretical frameworks to target mechanisms along pathways put forth by SET and the processes of PBT, many tools such as AR and ACT may be employed within an education-based PBT intervention to reduce internalized ageism.

Objectives

In the current study we evaluated the feasibility and acceptability of the Reimagine Aging program, a six-week process-based intervention aimed at decreasing internalized ageism in a sample of community dwelling older adults. We had three main objectives in this feasibility study; to determine whether participants: (1) found the program useful; (2) were engaged with the program; and (3) felt the program resulted in a change of their views on ageism and internalized ageism, and change in their behaviors.

Design and methods

Participants

We recruited participants by e-mail from a pool of 207 individuals who registered for the six-session Reimaging Aging program being offered by the Centre on Aging at the University of Manitoba. Participants were able to partake in the program through computer, smart device, or landline telephone. They were explicitly told that participating in the research component of the study was optional, and that the program remained available to them regardless of research participation. They received no compensation for participating in the program generally or the research component. Furthermore, given logistical constraints of this initial feasibility and acceptability trial, the authors had only two weeks prior to program launch to gather consent and preliminary information from participants to partake in the research, which limited research participation. To be eligible for inclusion in the research component of this study, consenting participants had to be 55+ years of age and fluent in spoken and conversational English (N = 81).

Design

This research received ethics approval from the University of Manitoba Research Ethics Board (REB1; protocol number: HE2022–0384). Participants completed an online battery of confidential questionnaires including sociodemographic information, questions pertaining to behavior change, and measures of internalized ageism, perceived control, psychological flexibility, and mindfulness at baseline (i.e., prior to the intervention starting), immediately following the intervention, and again at a two-month follow up. Participants could also complete anonymous feedback surveys after each of the six sessions. They were sent e-mails linking to an online survey hosted on Survey Monkey. In the current study, we included sociodemographic data and questions pertaining to behavior change from these confidential surveys, and data from the anonymous feedback surveys following each session. For results of statistical change data using psychometrically validated measures of internalized ageism, perceived control, psychological flexibility, and mindfulness, see Murphy, Mackenzie, Porter, & Chipperfield, in press.

Intervention

Educational environment

The Reimagine Aging intervention included six weekly sessions. Each individual session was approximately 90-minutes long, and consisted of video lectures, small group discussions, in-session individual activities, assigned between-session activities, and bonus activities. All sessions were conducted live over Zoom and participants were able to join by computer, smart device, or telephone. Although we did not track how participants joined, few if any participants in the research study used the telephone option. Activities and video lectures were prerecorded in a studio and streamed live to intervention participants. Participants chose whether to receive handouts of all slides and activities as physical copies by mail, or electronically via e-mail. Discussion portions of each intervention session took place in Zoom break-out rooms of four to six participants, and lasted 15 minutes. The first author was the primary facilitator of all sessions.

Activities, learning goals, and objectives

Several older adult community organizations and an academic advisory board advised on the development of the interventions and provided feedback on whether the program would be well received by the older adults they serve. This advisement consisted of several meetings where program concepts, logistics (e.g., in-person versus virtual, number of sessions, length of sessions) and program materials were discussed and agreed upon. The following sections outline the three key components of the intervention (i.e., AR, ACT, and education) and each session. For a detailed description of each of the six sessions, and the activities included within and between each of the sessions, see supplementary materials.

AR

AR targeted participants’ perceived control and aimed to reduce the attribution of negative outcomes to being “too old” using a 15-minute prerecorded video. This video was adapted from an AR video designed to increase adaptive thinking surrounding physical activities in older adults (see Parker et al., 2022). Briefly, the video discussed the importance of attributing outcomes to something controllable (vs. uncontrollable). Attributing outcomes to “old age” was used as an example of uncontrollable attributions (i.e., something to avoid). Special consideration was also given to (1) identifying what is and what is not in your control and (2) adjusting expectations based on circumstance. Example behaviors used to explain concepts included physical activity and utilizing technology. Afterward, participants discussed the video and reflected on how this might be applied to their own lives as a means of consolidation. AR targeted the cognitive, emotional, and motivational processes of PBT.

ACT

The intervention included techniques from all six components of the psychological flexibility model of ACT (i.e., defusion, perspective taking, acceptance, mindfulness, awareness of values, and committed action; e.g., Hayes, 2019). These techniques targeted participants’ psychological flexibility with respect to the construct of internalized ageism. Participants learned to separate themselves from their thoughts, take on new perspectives on aging, accept their internal experiences as they are, be present with their experiences, identify their values, and create plans to commit to actions in line with their identified values. ACT targeted all six processes of PBT (i.e., cognitive, emotional, self, attentional, motivational, and behavioral processes)

Education

Education played a central role in the intervention, with participants educated about ageism, internalized ageism, the negative consequences of ageism, and positive views of aging. Regarding ageism, participants were provided education on what instances of ageism look like, as well as the potential consequences. They were also provided education that countered ageist myths. For instance, findings from empirical research demonstrating that various aspects of life improve with age were presented. The same educational approach was then applied to the concept of internalized ageism, in that participants were taught what internalized ageism is, and what its consequences are. They also received instruction on how to combat its influence throughout the program. Furthermore, across the six sessions, psychoeducation was employed to teach the various techniques and skills taught through the AR and ACT intervention tools described above. Education was used to encouraged participants to reframe how they view aging and to facilitate participants creating their own personal definitions of what it means to age successfully. To conclude the program, we provided education on achieving behavioral change (e.g., habit formation) to consolidate the lessons taught throughout the program. Education targeted both cognitive and self-processes of PBT.

Measures

Program usefulness

Participants responded to “How useful was this session for you?” after each session and ““How useful was the program for you?” after the final session, on a scale from 1 (Not Very Useful) to 5 (Very Useful) within the anonymous surveys. The average of all participants’ scores indicated perceived usefulness for each individual session and for the complete program.

Program engagement

Participant response rates to the question “How useful was this session to you?” were used as a proxy for continued engagement throughout the program. Participants also responded to the questions “Did you complete the between-session activities we assigned after each session?” and “Did you complete any of the bonus activities after each session?” as 1 (yes) or 2 (no) within the anonymous surveys to measure engagement with program materials.

Participant change

Participants responded to the question “Has the program as a whole changed any of your thoughts/reflections related to ageism (i.e., negative stereotypes and beliefs about older adults) or internalized ageism (i.e., taking on negative stereotypes and beliefs of older adults and directing them at yourself or other older adults)” within the anonymous survey following the final session. This item measured whether participants felt that the program had shifted their views on ageism and/or internalized ageism. We chose this item to evaluate whether the participants’ attitudes changed from a phenomenological perspective. Note that additional research on this program demonstrated that participants experienced large reductions on psychometrically validated measures of internalized ageism (Murphy, Mackenzie, Porter, & Chipperfield, in press). Participants were also asked “As a result of this program, have you engaged in any new behaviors/actions or tried new things?” If yes, they were asked to share examples.

Evaluation and assessment

A total of 81 individuals consented to participate in the research. The average age of participants was 70.6 (SD = 6.4 years), ranging from 58 to 85. See Table 1 for sociodemographic data from participants who provided baseline data and did not withdraw (N = 75).

Table 1. Sample Sociodemographic Characteristics.

Characteristic		n	%
Gender
	Male	6	8.0
	Female	69	92.0
Education
	High school or equivalent	7	9.3
	College diploma, or trade certificate/diploma	13	17.3
	Bachelor’s degree	30	40.0
	Graduate degree	25	33.3
Race/ethnicity
	White	62	82.7
	Indigenous	3	4.0
	Filipino	3	4.0
	Latin American	3	4.0
	Chinese	1	1.3
	South Asian	2	2.7
	Black	1	1.3
Marital status
	Married or Common Law	36	48.0
	Separated or Divorced	19	25.3
	Widowed	13	17.3
	Single (Never Married/Common Law)	7	9.3
Household income
	$0–$50,000	15	20.0
	$50,000–$100,000	45	60.0
	$100,000+	15	20.0
Occupation status
	Full-time employed	4	5.3
	Part-time employed	9	12.0
	Volunteer	2	2.7
	Retired	60	80.0

Note. N = 75. Participants’ mean age was 70.6 years, SD = 6.4 years.

To evaluate how useful participants found the program (objective one), we analyzed usefulness ratings for the individual sessions and the program as a whole. Both the usefulness of each session and the usefulness of the entire program were rated overwhelmingly positively (the average values were 4 out of 5 or above). See Table 2 for the average rating, and the distribution of ratings for each session individually and the whole program.

Table 2. Session and Intervention Usefulness Ratings.

	Session Number (N)
	One (78)	Two (80)	Three (75)	Four (75)	Five (77)	Six (76)	Program (79)
Rating	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
5	34 (43.6)	41 (51.3)	35 (46.7)	39 (52.0)	46 (59.7)	50 (65.8)	52 (65.8)
4	22 (28.2)	22 (27.5)	25 (33.3)	24 (32.0)	22 (28.6)	20 (26.3)	20 (25.3)
3	16 (20.5)	13 (16.3)	11 (14.7)	8 (10.7)	7 (9.1)	6 (7.9)	5 (6.3)
2	4 (5.1)	4 (5.0)	4 (5.3)	3 (4.0)	2 (2.6)	0 (0.0)	2 (2.5)
1	2 (2.6)	0 (0.0)	0 (0.0)	1 (1.3)	0 (0.0)	0 (0.0)	0 (0.0)
Average	4.05	4.25	4.21	4.29	4.45	4.58	4.54

Note. 5 = “Very Useful” and 1 = “Not Useful.” Average = the average of ratings for the respective session. Program = Responses regarding the entire program.

To determine the level of program engagement (objective two), we evaluated survey response rates as a proxy for attendance and we measured activity completion rates. Feasibility data supported that the program engagement remained high throughout the program. Across the six sessions, the average response rate to the session-by-session feedback survey was 94.9%, and ranged between 92.6% and 98.8%, which suggests that at least 92% of research participants attended each session. Note that many more participants took part in the program, but they did not consent to have any details, such as attendance, shared. Furthermore, only three participants (3.7%) who consented to take part in the study dropped out because of other commitments, timing constraints, and lack of interest. In terms of engagement with the between-session activities, 80.8% of respondents indicated that they completed the assigned between session activities, and 79.5% indicated that they completed the bonus activities.

To probe participants perceptions of whether the program led to changes in their attitudes and behaviors (objective three), we evaluated data on perceived changes in views toward ageism/internalized ageism, and perceived changes in behaviors. Participants perceived themselves as changed by the program; most (88.7%) indicated that their views on ageism and/or internalized ageism had shifted. Furthermore, 60 (80.0%) of the 75 respondents indicated that they had engaged in new behaviors/actions or tried new things as a result of the intervention. Of the 71 respondents at the two-month follow up, 60 (84.5%) indicated that they had engaged in new behaviors/actions or tried new things. We analyzed qualitative responses and organized them into categories using basic summative content analysis (Hsieh & Shannon, 2005). See Table 3 for a list of categories, descriptions, and example quotes. See Table 4 for the frequency count of each respective category. We note that participant responses were allowed to be placed in multiple categories when relevant (e.g., when participants listed several behavior changes). Thus, a single participant response could appear across several categories. The behavior changes reported by participants were rich and spanned multiple categories of functioning. The most commonly reported category of change in behavior was incorporating the intervention activities and tools (i.e., mindfulness, cognitive defusion, acceptance, values-based living, perspective taking, behavior formation techniques, and AR mindset-shifts) into their everyday life. This supports the acceptability and feasibility of the current intervention. Other novel behaviors fell into categories of physical engagement (e.g., increasing or engaging in new physical activity or health dietary changes), cognitive engagement (e.g., engaging in learning or new cognitive activities), and social engagement (e.g., joining new committees and clubs, purposefully meeting new people, spending more intentional time with loved ones, trying stand-up comedy for the first time). Other categories of behavior change included self-care, volunteering, and travel.

Table 3. Codebook of the new behaviors attributed to the intervention by participants.

Category	Example Quote
Program Activities and Tools (e.g., mindfulness)	“I’ve been meditating daily, separating, accepting, putting them on leaves on a stream… All daily. This has been life changing for me.”
Physical Activity	“I’ve finally gone back to the [exercise gym]. Thoroughly enjoying it – aerobics classes, zumba, yoga, weights, etc.”
Learning/Cognitive Activities	“[I] applied to a master’s program at the university.”
Trying New Things	“As part of Winnipeg Comedy Festival, I’m getting ready to do my first open mic comedy event today and I couldn’t be more excited. I used to think I was too old to do that.”
Increased Family Time	“I’ve started… making sure I talk to my children every day.”
Ageism Awareness	“I catch myself more often when my own internalized ageism beliefs and attitudes are making me feel less adequate, or when the reflex response is to put myself down when I forget something or see my wrinkled face in the mirror each morning. I am more often able to see past my internalized negative biases and treat myself and others more kindly.”
Meeting New People	“I’ve just returned [from] a 1.5 week vacation I went on by myself after the program ended. I booked it three weeks into the program. I met so many people!”
Volunteering	“I’ve been using a Ukrainian/English translator on my phone to help volunteer to speak with Ukrainian newcomers to Winnipeg. I got over my shyness of not speaking Ukrainian. It’s been wonderful and I’ve made several meaningful connections”
Spending Time with Friends	“I have made a concerted effort to meet with friends and family members on outings.”
Miscellaneous Self-Care	”[I] joined a Fibromyalgia support group”
Writing	“I’ve started writing an autobiography”
Ageism Activism	“I am also more aware of internalized ageism and able to catch myself especially around negative body image; it’s still a struggle, but awareness is the first step and I now have that … I take ageism more seriously; seeing it in the same category as racism and sexism makes me more ready to push back against it.”
Artistic and Musical Activity	“Started playing guitar again”
Travel	“I went on a vacation by myself for the first time, something I always wanted to do but was too nervous.”
Dietary Changes	“I took a cooking class and have actually started to cook again versus buying prepared food. I have already had 2 appointments with a dietician with the goal of eating food to support aging well.”
Completing Tasks	“I finished painting my ceilings and walls! I thought I’d never do it again and I paced myself to adjust. So, I finished it which was incredible.”
Seeking Mental Health Services	“I have started seeing a mental health therapist to help me get through the challenges and struggles of caregiving.”
Organizing Affairs	“Getting affairs in order to prepare for retirement by contacting relevant parties.”
Relating to Others Differently	“More tolerance to younger people’s ignorance [and] a positive view of myself and other older adults”
Business	“I’ve started a floral business”
Improving Sleep Habits	“Working on better sleep, actually trying to go to bed earlier so I can get 7–8 hrs of sleep.”
Increased Work	”‘I’ve been happily picking more shifts at my job and actually enjoying it.”

Table 4. Frequency counts of categories of new behaviors identified by participants in open-ended responses.

	Time 1	Time 2
New Behavior	n	n
Intervention Activities and Tools	28	27
Physical Activity	24	24
Learning/Cognitive Activities	8	13
Trying New Things	8	12
Increased Family Time	9	9
Meeting New People	6	11
Ageism Awareness	5	9
Volunteering	7	7
Spending Time with Friends	5	9
Miscellaneous Self-Care	5	6
Seeking Mental Health Services	5	6
Ageism Activism	4	4
Artistic and Musical Activity	3	5
Travel	2	6
Dietary Changes	2	3
Completing Tasks	2	2
Seeking Mental Health Treatment	1	3
Organizing Affairs	2	1
Relating to Others Differently	2	1
Business	1	1
Improving Sleep Habits	1	1
Increased Work	1	1

Note. N = 60 for each time point, representing only the participants who indicated they engaged in novel behaviors. Participant responses were allowed to be placed into multiple categories when relevant. Time 1 = Responses from post intervention survey. Time 2 = Responses from two-month follow up survey.

Discussion & conclusions

Initial data supports the feasibility and acceptability of this six-week online educational intervention designed to reduce internalized ageism and its negative consequences for community-dwelling older adults. Response rates to weekly anonymous feedback surveys suggested that close to 90% of research participants consistently attended the program throughout, and only three individuals dropped out. Beyond attendance, engagement with program material was high as indicated by responses to both the assigned and bonus between session activities. Even two months later, many participants indicated that they continued to employ the intervention activities in their daily lives. The sessions were also rated as very useful. Furthermore, over four-fifths of participants reported that the program accomplished its goal in shifting their views of ageism and internalized ageism. Finally, in the eyes of the participants, the intervention led to several tangible behavior changes. Overall, the program seems to be engaging, perceived as useful, and feasibly effective in changing the attitudes and behaviors of participants.

Participants attributed changes in behaviors to the intervention that reflected altered views of aging suggestive of reductions in internalized ageism. Participants wrote that the intervention led to an increased awareness of internalized ageism, with one participant highlighting the importance of awareness in fighting internalized ageism. Other participants highlighted that they were more often able to catch themselves when internalized ageist beliefs were negatively impacting them. Further still, some reported engaging in behaviors they previously thought they were too old to do (e.g., physical activity, travel, comedy, graduate school, etc.). From a phenomenological perspective, the intervention was successful in reducing internalized ageism for most participants. These findings are congruent with a recent randomized controlled study that found an educational intervention was efficacious in reducing negative aging stereotypes in older adults (Doncel-García et al., 2022).

Most participants indicated that they completed the intervention activities in between sessions. This high level of compliance with between session activities is comparable to the best of what might be expected in related interventions, where homework compliance is often challenging (Tang & Kreindler, 2017). Beyond this reported engagement with the intervention activities between sessions, incorporating the tools that were provided within the intervention into their daily lives was the most common category of behavior change reported. This was true immediately following the intervention and at a two-month follow-up. This is especially promising, since these techniques work together to target psychological flexibility, which is the most common construct that mediates positive outcomes in psychological intervention literature (Hayes, Ciarrochi, Hofmann, Chin, & Sahdra, 2022). That these tools were so commonly incorporated into the participants’ lives also supports the feasibility and acceptability of the ACT and AR based techniques we employed within this educational intervention.

Steward (2022) highlights change in physical activity as an important behavioral lever to pull along the behavioral pathway posited by SET to protect against the negative health outcomes of internalized ageism. Increases in physical activity were the second most reported change in behavior and included activities such as increased walking, joining fitness classes, and hiring personal trainers. This finding is in line with randomized controlled trials that found targeting attitudes toward older adults (Wolff, Warner, Ziegelmann, & Wurm, 2014) and self-perceptions of aging (Beyer, Wolff, Freiberger, & Wurm, 2019) were efficacious in bolstering the positive outcomes associated with interventions targeting physical activity levels in later life. Although the AR portion of the intervention employed examples such as adjusting exercise goals and avoiding attributing a lack of exercise to “old age,” participants were never directly instructed to increase levels of physical activity. Still, AR has been demonstrated to reliably increase physical activity in older adults, and thus may be in part responsible for this increase in physical activity (Sarkisian, Prohaska, Davis, & Weiner, 2007). ACT techniques may also have contributed to this change in behavior. It is possible that when participants were instructed to identify behaviors that aligned with their personal values, they chose behaviors that increase physical activity.

Steward (2022) also suggested physical, social, and cognitive engagement as strategies to increase self-efficacy and reduce internalized ageism. In addition to the physical engagement strategies just discussed, participants provided several examples of social and cognitive engagement as new behaviors they attributed to the intervention. Once again, this speaks to the utility of the program given that physical, cognitive, and social engagement are suggested ways to increase self-efficacy (Steward, 2022). Self-efficacy has been shown to mediate the connection between life-style factors and internalized ageism (Steward & Hasche, 2022), and the relationship between internalized ageism and multiple health outcomes along the psychological pathway of SET (e.g., Tovel, Carmel, & Raveis, 2019; Yeom, 2014). It may be that, prior to the intervention, participants may have been avoiding physical, social, and cognitive tasks that they valued due to internalized ageism.

The findings may have wide-ranging implications across the field of educational gerontology. Gerontologists in higher education may integrate the content and activities of the intervention into various curricula and share with students to raise awareness about internalized ageism. Those engaged in community work may partner with local community organizations serving older adults to offer aspects of the intervention’s content or activities to address internalized ageism, or utilize the findings to advocate for policies and programs that combat ageism and internalized ageism to promote the well-being of older adults. Those focused on intergenerational educational efforts may wish to offer similar interventions to older adults as well as younger adults, to combat internalized ageism and ageism directed toward others.

Limitations and future directions

This initial feasibility data is extremely promising; however, it should be interpreted in lieu of its limitations. While participant ages varied, the sample was predominantly female, White, and highly educated. Though the proportion of White participants (83%) was lower than that of the older adult population in Manitoba, Canada where this study took place (i.e., 87%; Government of Manitoba, 2023), and Canada as a whole (i.e., 85%; Statistics Canada, 2022), ageism may intersect with other forms of discrimination that are not highly represented in the current sample. As a result of the relatively homogenous sample, generalizability is limited, particularly since few men were engaged with the program. Still, ageism is an experience nearly every older adult will face, and the program was designed to have each participant adapt it to their own lives and experience. Theoretically, the program’s feasibility should generalize across groups of people. Second, this intervention was hosted on Zoom, and despite an option to join by landline, this likely limited the research sample to those who used smart devices and computers. Thus, results may not generalize to older adults without access to internet, or without familiarity with online technology. Additionally, this data is only suggestive of the intervention feasibility. The self-report nature of our data is a limitation, particularly as internalized ageism was not measured directly. However, additional research conducted on this intervention has demonstrated large reductions in psychometrically sound measures of internalized ageism that were maintained at two-month follow up (Murphy, Mackenzie, Porter, & Chipperfield, in press). Future research, however, should incorporate a control group to establish causality and to consider expectancy effects. Furthermore, future research will evaluate the implementation of this program on an online learning platform that hosts educational courses and can reach large numbers of older adults in a resource efficient manner.

Conclusion

To conclude, this educational intervention, to our knowledge, represents the first substantive intervention that takes place over an extended period and is based in established theory to target internalized ageism among older adults. Rooted in SET and based on suggestions by Steward (2022), we employed a PBT approach to target internalized ageism through various mediating mechanisms. This intervention was well received by participants; it was overwhelmingly rated as very useful, they maintained high levels of engagement throughout, and they reported improvements in perceptions of ageism and internalized ageism. Furthermore, and perhaps most importantly, participants attributed several tangible behavior changes to the intervention – changes that may have a protective impact against the negative consequences of internalized ageism now and into the future. Thus, the findings from this study suggest that this educational intervention is both feasible and acceptable as a theory-based method of reducing internalized ageism and improving the lives of individuals as they age.

Acknowledgements

This program was developed by the study authors with the input of Dr. Tara Stewart, Dr. Stephanie Chesser, the Manitoba Association of Senior Communities (Connie Newman), A & O: Support Services for Older Adults (Amanda Macrae and Stacey Miller), and Men’s Shed (Doug Mackenzie).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/02701960.2024.2360395

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.