Butler's three constructs of ageism in Australasian Journal on Ageing

In much of the Western world, old age is viewed negatively 1, and ageing is regarded as a process of unavoidable and predictable ‘decline and deterioration’ 2. The term ‘ageism’ was initially proposed by Robert Butler, the founding director of the National Institute on Aging in the United States of America (USA) 3. Ageism is typically expressed as discrimination against people on the basis of their age 4 and is manifested through negative stereotypes and perceptions about older adults 5 and, unfortunately, is a fact of life for many older Australians 6. Butler identified three distinct but related aspects of ageism: attitudes and beliefs, behavioural discrimination, and formalised policies and practices 7. In essence, attitudes determine behaviour, which then influence policy development and implementation, which, in turn, influence practice. Studies from gerontology, psychology, communication and sociology have subsequently expanded on Butler's views and have established that ageism is universal 8-10. Ageism is typically exhibited in the language we use to talk to and about older adults, in how they are portrayed in media representations (both online and offline), through employment practices and health-care policies (or the lack thereof), as well as in the attitudes and behaviour of health professionals 8. For this virtual issue, we selected papers published in the Australasian Journal on Ageing (AJA) from 1982 to the present day that illustrate Butler's three constructs of ageism, as highlighted above. In particular, we looked at community and health professionals’ attitudes to ageing, age discrimination and work, as well as ageism and policy. We excluded book reviews, abstracts, most articles describing non-Australian samples and, with two exceptions, editorials. A total of 25 papers were selected for this virtual issue. The numbers of papers illustrating each construct are highlighted in Table 1. Of the seven papers in this theme, three are commentaries or ‘viewpoint’ articles, three are accounts of original research and one provides a brief editorial report of how ageing is regarded in eight different countries. The articles spanned a range of years, with five written in the 1980s, highlighting the emergence of the topic in Australia. In the 1984 editorial 11, eight member nations of the International Federation on Ageing provided brief reports on public attitudes to older people. The growing awareness of structural ageing and the accompanying alarmist rhetoric, the ‘burden’ of care – as fuelled by the Thatcher administration in the UK – saw a shift in public sentiment from positive to negative towards older people across many countries. The three viewpoint articles reflected this negativity 12-14 depicting Australia as a country which hindered ‘successful’ ageing 12 by promulgation of ageist myths and the deleterious labelling of older people as ‘aged’ or ‘frail aged’. In the earliest research article in this sample, Hall et al. 15 looked at the ageist view that posited older people as asexual beings and reported the results of one of the first Australian studies into later life sexuality. In a community sample of 100 senior citizens in Brisbane, the authors reinforced previous research which showed the importance of sexual expression appeared to decline with age. However, as social expectations appeared to limit the number of responses to the sexual questions contained in the survey, the results were difficult to interpret definitively. The authors argued that older people's views of themselves as sexual beings may well have been influenced by the social myth of the asexual older person – a myth which continues today despite considerable research to the contrary 16. The other two research articles were published in the 2000s and reported on (i) an intergenerational pilot program with primary school children using both quantitative and qualitative methods, designed to combat children's negative views and to promote positive views of ageing 17 and (ii) a qualitative interview study which focused on older women's views of ‘successful ageing’; which included a sense of personal agency and being of social value, with an emphasis on quality of life/quality of death 18. Both articles privileged the views of their participants, providing visibility for what was previously termed an ‘invisible’ population 19. Negative perceptions of ageing and older people can detrimentally affect the way health care is delivered. As Karen Hitchcock's critically acclaimed quarterly essay outlined 20, the therapeutic relationship can be compromised by such attitudes, leading to at best, condescending and infantilising attitudes and, at worst, a failure to treat. With one exception, the AJA papers in this section serve to illustrate the nature and scope of ageist beliefs amongst health-care professionals. The eight papers appeared between 1989 and 2016 and variously describe the attitudes and behaviours of nurses, either students or practicing nursing samples across a range of settings (three papers 21-23), gerontology researchers, practitioners and policy makers (one paper 24), social work students (one paper 25), practicing psychologists (one paper 26) and a diverse group of health professionals (health promotion workers, nurses, psychologists, social workers, doctors and physiotherapists (one paper 27)). The final paper in this section, an opinion piece written in 1999 by Gething 28, contains recommendations regarding improving attitudes for nurses working in aged care which are still pertinent today. Two papers focusing on the nursing population 21, 22 used survey measures to assess attitudes to ageing. Of these, one paper used the Reactions to Ageing Questionnaire (RAQ) as well as the Facts about Ageing Quiz and the Aging Semantic Differential to assess the relationship between attitudes to self-ageing and misconceptions/stereotyping about older people 21. These measures were undertaken voluntarily by nurses working predominantly in aged care in both Australia (n = 143) and the UK (n = 213) during in-service training courses or at work. The nurses differed in ages and education (younger and post-high school education in Australia compared to older and predominantly high school educated in UK) although the overall results were very similar. Whilst both samples attributed some positive attributes to older people, the majority of nurses held misconceptions which ‘devalued’ older people and underestimated their abilities. The authors concluded that nurses who had negative expectations about the capabilities of older people were ‘less likely’ to identify issues impacting their well-being. In addition, the 2016 study by Frost et al. 22 cited evidence that negative attitudes to older people increase and intensify during nursing training and become established during clinical placements. However, despite studies that showed improvements could be made by utilising educational strategies which made ageist attitudes and behaviour ‘explicit’, nursing courses remained underdeveloped in this regard. To illustrate, the authors found a high level of ageist attitudes amongst a sample of first year undergraduate nursing students using the Relating to Older People Evaluation (ROPE). They argued that the use of the ROPE should also be extended to clinical settings in addition with, what they termed, ‘structured reflection’ to combat ageism amongst nurses. The third paper conducted a cross-cultural review of the literature from 2004 to 2012 23. It found 648 articles describing emergency department (ED) nurses’ awareness and understanding of ageing as well as attitudes towards older people in their care. Once exclusions were applied, the review looked at 16 articles and concluded that despite emergency department nurses’ extensive expertise, they lacked the ‘knowledge and skills’ necessary for gerontological nursing. The authors argued that given structural ageing and the anticipated increased number of older people accessing health-care services, such a role could no longer be seen as the ‘sole domain of specialist geriatric nurses’. Further, without appropriate education, ageist attitudes could continue to affect emergency department nurses’ care of older people. The earliest paper in this section was from 1989 24. In it, Russell argued that gerontology as a whole saw ‘sickness, frailty and dependence’ as problems associated only with older people, and ageing generally, which needed to be ‘managed’ – mainly because of the prevailing ageist view that older people were incapable of managing themselves. She used the results of a content search of Australian women's magazines to illustrate ageist attitudes and how these attitudes could (negatively) influence professional practice. In the workplace, discrimination translates into barriers that prevent older people from gaining access to work, using particular skills or accessing promotion or equal pay. A group of six papers from AJA highlighted that age discrimination in the workplace has been alive and well in Australia despite age discrimination laws being in place since 2004 29. A paper from 1996 30 found that amongst executives of 104 companies and a random sample of 525 employees, older employees were seen to have some positive qualities, such as loyalty. However, ‘older’ workers – classified as anyone over 45 years – were deemed less interesting for recruiters. Another study 31 found evidence of age discrimination in a Western Australian sample of accounting assistant employers, with older women the most subject to discrimination. Further, Bennington and Weir 32 analysed how resumes could disadvantage older workers and, subsequently, encourage discrimination. In 2000, Cully et al. 33 reviewed the evidence about barriers to older people participating in training for work in Australia. They concluded that the Australian government could do more to facilitate older workers’ access to training opportunities. This conclusion was reinforced by Encel and Studencki 34, who indicated that apart from age, lack of specialised skills mitigated against older workers successfully acquiring jobs. Finally, another study illustrated that there were age-insensitive attitudes to people with low computer skills and recommended that managers be more sensitive to strategies to assist older workers acquire new skills 35. In 2012, the Australian Human Rights Commission (AHRC) 29 highlighted the steps Australia has been undertaking to facilitate older workers taking their place in the workforce. Consequently, the participation rate amongst older workers has been increasing steadily over the last twenty years amongst 55–64 year olds and people over 65 36. However, despite these laws as well as shifting the pension age to allow people to work longer and other welcome government initiatives, it is clear that age discrimination in the workforce continues. For instance, the AHRC's more recent report found that 27% of workers over the age of 50 had experienced workplace discrimination, most notably when applying for a new job 37. Ageist attitudes can have significant damaging repercussions, as it means that older adult needs and priorities are often omitted from vital national health, research and policy agendas 38. A surprisingly small number of papers published in AJA examined policy issues and ageism in Australia. A 2005 paper 39 discussed generational justice in aged care policy in Australia and the United Kingdom and considered the impact of policies about residential aged care on intra- and intergenerational justice. The issue of intergenerational responsibilities – whether younger generations would be willing or expected to look after older generations and vice versa – is a topical issue, with house ownership declining amongst younger generations and housing assets of older generations continuing to be protected when considering some government entitlements. Howe and Healy 39 made the point that generational equity had only recently come to the ageing policy agenda. They predicted that policies of continuing intragenerational transfers of paying for aged care would continue into the future. Biggs et al. 40 analysed migration policies and the impact they might have on discrimination against older people. They concluded that creating barriers to older migration could perpetuate age discrimination. However, they also pointed to some positive changes in public perception of the roles older people play. A related theme was noted in a 2008 paper 41, which speculated that ‘cultural racism’ might be responsible for the trend that led to the ethnic aged being underserved by local health-care and social care services. A 2013 paper 42 considered Australian policy on human rights in an international context. It noted that Australian laws on age discrimination and government reports on the economic potential of older people and positive ageing, as well as Australia's role in the age-friendly cities movement, were all broad initiatives aimed at reducing ageism. Despite the many research initiatives designed to highlight and address ageist practices, coupled with the ongoing advocacy of organisations such as COTA and AAG, it is clear that some ageist attitudes are still prevalent in Australia, as they are in the rest of the world. Scanning the AJA publications for papers related to ageism, we noted that Seneca's two thousand -year-old view that old age is a disease (‘Senectus morbidus est’) has continued to the present day, with the emphasis on health and ageing research in the journal and far less space devoted to other perspectives of ageism. Few legal or policy analyses of Australia's responses to an ageing population were found in the journal whilst social analyses were well represented. Nevertheless, in the 35-year time span covered here (1982–2016), there have been some positive changes, as reflected in the papers summarised. Future ageism research is merited in Australia, by conducting policy analysis to determine whether community attitudes and changes in training for health professionals are being mirrored in policy change. In addition, alternative perspectives such as media analysis, historical perspectives or the role of the arts in mitigating ageism are areas that warrant further research. Butler's 47-year-old concept of ageism continues to be useful in raising awareness of society's response to our ageing population. The authors have no conflicts of interest to declare.