REFLECTION

1

CHAPTER 01

G L O B A L R E P O R T O N

2

GLOBAL REPORT ON AGEISM

G L O B A L R E P O R T O N

Global report on ageism

ISBN 978-92-4-001686-6 (electronic version) ISBN 978-92-4-001687-3 (print version)

© World Health Organization 2021

Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO).

Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”.

Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization (http://www.wipo.int/amc/en/mediation/rules/).

Suggested citation. Global report on ageism. Geneva: World Health Organization; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing.

Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user.

General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommend- ed by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.

Designed by Blossom.it

Front and back cover photography credits: ©Colby Ray/Unsplash ©Mathilda Khoo/Unsplash ©Azrul Shahrani/Unsplash ©Kazi Mizan/Unsplash

CHAPTER 01

CONTENTS

MESSAGE BY THE UNITED NATIONS SECRETARY-GENERAL VII

PREFACE IX

ACKNOWLEDGEMENTS XI

ABBREVIATIONS XIII

EXECUTIVE SUMMARY XV

INTRODUCTION XIX

01. THE NATURE OF AGEISM 1

1.1 Defining ageism 2 1.2 How ageism works and how it arises 8 1.3 Ageism and other "-isms" 9 1.4 Conclusions and future directions 12

02. THE SCALE OF AGEISM AGAINST OLDER PEOPLE 21

2.1 Institutional ageism 22 2.2 Interpersonal ageism 31 2.3 Self-directed ageism 36 2.4 Conclusions and future directions 37

03. THE IMPACT OF AGEISM AGAINST OLDER PEOPLE 47

3.1 The impact of ageism on health 48 3.2 The economic impact of ageism 54 3.3 Conclusions and future directions 56

04. THE DETERMINANTS OF AGEISM AGAINST OLDER PEOPLE 65

4.1 Determinants of interpersonal ageism 67 4.2 Determinants of self-directed ageism 72 4.3 Conclusions and future directions 73

05. THE SCALE, IMPACT AND DETERMINANTS OF AGEISM AGAINST YOUNGER PEOPLE 81

5.1 The scale of ageism against younger people 82 5.2 The impact of ageism against younger people 84 5.3 The determinants of ageism against younger people 86 5.4 Conclusions and future directions 88

V

GLOBAL REPORT ON AGEISMGLOBAL REPORT ON AGEISM

06. STRATEGY 1: POLICY AND LAW 93

6.1 What they are and how they work 94 6.2 How well they work 96 6.3 Examples 97 6.4 Key characteristics and costs 101 6.5 Conclusions and future directions 102

07. STRATEGY 2: EDUCATIONAL INTERVENTIONS 113

7.1 What they are and how they work 114 7.2 How well they work 115 7.3 Examples 116 7.4 Key characteristics and costs 118 7.5 Conclusions and future directions 120

08. STRATEGY 3: INTERGENERATIONAL CONTACT INTERVENTIONS 125

8.1 What they are and how they work 126 8.2 How well they work 127 8.3 Examples 128 8.4 Key characteristics and costs 132 8.5 Conclusions and future directions 134

09. PROMISING STRATEGIES 139

9.1 Campaigns 140 9.2 Potential strategies for mitigating the impact of ageism 145 9.3 Conclusions and future directions 146

10. THE WAY FORWARD 153

10.1 Recommendation 1: invest in evidence-based strategies to prevent and respond to ageism 154 10.2 Recommendation 2: improve data and research to gain a better understanding of ageism and how to reduce it 157 10.3 Recommendation 3: build a movement to change the narrative around age and ageing 159 10.4 Conclusions 161

GLOSSARY 163

INDEX 169

V I

MESSAGE BY THE UNITED NATIONS SECRETARY-GENERAL Ageism is widespread in institutions, laws and policies across the world. It damages individual health and dignity as well as economies and societies writ large. It denies people their human rights and their ability to reach their full potential.

Despite its pervasive nature and harmful impacts, ageism still lacks a solid knowledge base of dedicated research, information, disaggregated data and systematic trends analysis. This new Global report on ageism fills this gap and underscores the need to adopt a forward- thinking, rights-based approach that addresses the underlying societal, legislative and policy structures that support long-standing assumptions about ‘age’ across the life course.

The COVID-19 pandemic has had a devastating impact on older persons. Intergenerational solidarity must be a touchstone in our efforts to recover. Older persons have also made important contributions to the crisis response, as health workers and caregivers. Women, for instance, are over-represented among both older persons and among the paid and unpaid care workers who look after them.

My policy brief on older persons and COVID-19, released in May 2020, highlights the need to recognize the multiple roles that older persons have in society – as caregivers, volunteers and community leaders – and underscores the importance of listening to the voices of people of all ages, valuing their contributions and ensuring their meaningful participation in decision-making.

Addressing ageism is critical for creating a more equal world in which the dignity and rights of every human being are respected and protected. This is at the heart of the 2030 Agenda for Sustainable Development, the world’s agreed blueprint for building a future of peace and prosperity for all on a healthy planet. In that spirit, I commend this report to a wide global audience and look forward to working with all partners to uphold the promise to leave no one behind.

V I I

V I I I

GLOBAL REPORT ON AGEISM

I X

PREFACE COVID-19 has affected people of all ages, in different ways. But beyond the impacts of the virus itself, some of the narratives about different age groups have exposed a deep and older malady: ageism. Older people have been often seen as uniformly frail and vulnerable, while younger people have been portrayed as invincible, or as reckless and irresponsible. Stereotyping (how we think), prejudice (how we feel) and discrimination (how we act) based on age, are not new; COVID-19 has amplified these harmful attitudes.

This global report on ageism could not be timelier. Its main message is that we can and must prevent ageism and that even small shifts in how we think, feel and act towards age and ageing will reap benefits for individuals and societies.

This report shows that ageism is prevalent, ubiquitous and insidious because it goes largely unrecognised and unchallenged. Ageism has serious and far-reaching consequences for people’s health, well-being and human rights and costs society billions of dollars. Among older people, ageism is associated with poorer physical and mental health, increased social isolation and loneliness, greater financial insecurity and decreased quality of life and premature death. Ageism, in younger people has been less well explored in the literature but reported by younger people in a range of areas including employment, health and housing. Across the life course, ageism interacts with ableism, sexism and racism compounding disadvantage.

To achieve the long-lasting, vastly better development prospects that lie at the heart of the Sustainable Development Goals, we must change the narrative around age and ageing. We must raise visibility of and pay closer attention to ageist attitudes and behaviors, adopt strategies to counter them, and create comprehensive policy responses that support every stage of life.

In 2016, the World Health Assembly called on the World Health Organization to lead a global campaign to combat ageism in collaboration with partners. The Global Report on Ageism, developed by WHO in collaboration with the Office of the High Commissioner for Human Rights, the United Nations Department of Economic and Social Affairs and the United Nations Population Fund, informs the campaign by providing the evidence on what works to prevent and respond to ageism.

We all have a role to play in preventing and responding to ageism. The report suggests steps for all stakeholders – including governments, civil society organizations, academic and research institutions and business – to enforce new and existing policies and legislation, provide education and foster intergenerational contact for the benefits of people of all ages.

As countries seek to recover from the pandemic, people of all ages will continue to face different forms of ageism. Younger workers may be even less likely to get jobs. Older workers may become a target for workforce reduction. Triage in health care based solely on age will limit older people’s right to health. We will have to tackle ageism in and after this crisis if we are to secure the health, wellbeing and dignity of people everywhere. As countries

X

GLOBAL REPORT ON AGEISM

build back better from the pandemic and to accelerate progress towards the Sustainable Development Goals, all must adopt measures that combat ageism. Our driving vision is a world for all ages, one in which age-based stereotypes, prejudice and discrimination do not limit our opportunities, health, wellbeing and dignity. We invite you to use the evidence in this report to help this vision become a reality.

Tedros Adhanom Ghebreyesus Liu Zhenmin Director-General World Health Organization

Under-Secretary-General United Nations Department of Economic and Social Affairs

Michelle Bachelet Natalia Kanem United Nations High Commissioner for Human Rights

Executive Director, United Nations Population Fund

X I

The development of this report has been led by an Editorial Committee at the World Health Organization (WHO) comprising Alana Officer, Vânia de la Fuente-Núñez and Christopher Mikton under the overall guidance of Etienne Krug, Director, Social Determinants of Health, and Naoko Yamamoto, Assistant Director-General, Universal Health Coverage/Healthier Populations; and in collaboration with Amal Abou Rafeh, Chief, Programme on Ageing Unit; Rio Hada, Team Leader, Human Rights and Economic and Social Issues Section, in the Office of the United Nations High Commissioner for Human Rights; and Rachel Snow, Chief, Population and Development Branch, United Nations Population Fund. Many other global and regional WHO and United Nations staff provided inputs relevant to their areas of work. Without their dedication, support and expertise this report would not have been possible.

A core group responsible for developing the conceptual framework of ageism that was used in the report included Sophie Amos, Louise Ansari, Liat Ayalon, Jane Barratt, Necodimus Chipfupa, Patricia Conboy, Mary-Kate Costello, Vânia de la Fuente-Núñez, Nathaniel Kendall- Taylor, Angga Martha, Alana Officer, Bhanu Pratap, Jelena Sofranac and Jemma Stovell.

The lead authors on the report were Vânia de la Fuente-Núñez (Chapters 1, 2, 4, 5, 6, 10) and Christopher Mikton (Chapters 2, 3, 5, 7, 8, 9, 10). The report benefited from the rich inputs of many experts and academics. It was also informed by a series of systematic and scoping reviews and qualitative research conducted in collaboration with WHO. The names of the experts and authors are listed under Contributors.

The report also benefited from the efforts of several other people, in particular Miriam Pinchuk, who edited the final text of the report; Blossom for media, graphic design and communication; Judi Curry for proofreading; Christine Boylan for indexing; Sue Hobbs for the design of the figures; and Alexia Sapin and Florence Taylor for their administrative support. Thanks are also due to Alison Brunier, Christopher Black, Sarah Russell, Sari Setiogi and Kazuki Yamada for media and communication.

WHO also wishes to thank the Government of Japan for its generous financial support for the development, translation and publication of this report. The development of the report was also supported through core voluntary contributions to WHO.

CONTRIBUTORS

Authors of background research papers

• A systematic review of existing ageism scales – Liat Ayalon, Pnina Dolberg, Sarmitė Mikulionienė, Jolanta Perek-Białas, Gražina Rapolienė, Justyna Stypinska, Monika Willińska and Vânia de la Fuente-Núñez.

• Ageism, healthy life expectancy and population ageing: how are they related? Alana Officer, Jotheeswaran Amuthavalli Thiyagarajan, Mira Leonie Schneiders, Paul Nash and Vânia de la Fuente-Núñez.

ACKNOWLEDGEMENTSbuild back better from the pandemic and to accelerate progress towards the Sustainable Development Goals, all must adopt measures that combat ageism. Our driving vision is a world for all ages, one in which age-based stereotypes, prejudice and discrimination do not limit our opportunities, health, wellbeing and dignity. We invite you to use the evidence in this report to help this vision become a reality.

Tedros Adhanom Ghebreyesus Liu Zhenmin Director-General World Health Organization

Under-Secretary-General United Nations Department of Economic and Social Affairs

Michelle Bachelet Natalia Kanem United Nations High Commissioner for Human Rights

Executive Director, United Nations Population Fund

X I I

GLOBAL REPORT ON AGEISM

• Campaigning to tackle ageism? Move with the evidence tide – Cassandra Phoenix and Vânia de la Fuente-Núñez.

• Determinants of ageism against older adults: a systematic review – Sibila Marques, João Mariano, Joana Mendonça, Wouter De Tavernier, Moritz Hess, Laura Naegele, Filomena Peixeiro and Daniel Martins.

• Global reach of ageism on older persons’ health: a systematic review – E-Shien Chang, Sneha Kannoth, Samantha Levy, Shi-Yi Wang, John E. Lee and Becca R. Levy.

• Interventions to reduce ageism against older adults: a systematic review and meta- analysis – David Burnes, Christine Sheppard, Charles R. Henderson, Monica Wassel, Richenda Cope, Chantal Barber and Karl Pillemer.

• Scoping review on ageism towards younger populations – Vânia de la Fuente-Núñez, Ella Cohn-Schwartz, Senjooti Roy and Liat Ayalon.

Additional contributors

Rapid reviews and general research support were provided by Gesa Sophia Borgeest on the intersections between ageism and other “-isms”, and by Laura Campo Tena on campaigns to reduce ageism against younger people, COVID-19 and ageism, the impact of ageism on the well-being of older people and strategies to mitigate the impact of ageism. Liat Ayalon, Jane Barratt, Nena Georgantzi, Estelle Huchet and Karl Pillemer drafted Box 2.1 on Ageism and COVID-19. Data analysis on the prevalence of interpersonal ageism against older adults was provided by Jotheeswaran Amuthavalli Thiyagarajan. A review of ageism and statistics was provided by Michael Herrmann. Information and resources on law, policies and related processes were provided by Julia Ferre and Nena Georgantzi. Photos and testimonials were provided by HelpAge International and the United Nations Major Group for Children and Youth, coordinated by Jemma Stovell, and Aashish Khullar and Lucy Fagan, respectively.

Peer reviewers

The peer reviewers for the report were Amal Abou Rafeh, Jotheeswaran Amuthavalli Thiyagarajan, Louise Ansari, Ashton Applewhite, Alanna Armitage, Liat Ayalon, Anshu Banerjee, Jane Barratt, Françoise Bigirimana, David Burnes, George-Konstantinos Charonis, Harsh Chauhan, Silvia Gascon, Vitalija Gaucaite Wittich, Nena Georgantzi, Regina Guthold, Rio Hada, Manfred Huber, Alex Kalache, Nancy Kidula, Marlene Krasovitsky, April Siwon Lee, Becca R. Levy, Ramez Khairi Mahaini, Mary Manandhar, Sibila Marques, Patricia Morsch, Innocent Bright Nuwagira, Hiromasa Okayasu, Martha Pelaez, Silvia Perel Levin, Cassandra Phoenix, Karl Pillemer, Ritu Sadana, Saliyou Sanni, Dorothea Schmidt, Yi Wen Shao, Elisha Sibale, Briget Sleap, Jemma Sovell, Julie Steffler, Yuka Sumi, Tran Bich Thuy, Enrique Vega and Kazuki Yamada.

Conflicts of interest

None of the experts involved in the development of this report declared any conflicts of interest.

X I I I

COVID-19 Novel coronavirus 2019 (also known as SARS-CoV-2)

GRADE Grading of Recommendations Assessment, Development and Evaluation

MIPAA Madrid International Plan of Action on Ageing

PEACE Positive Education about Ageing and Contact Experiences

PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses

STDs Sexually transmitted diseases

UN United Nations

WHO World Health Organization

ABBREVIATIONS

X I V

GLOBAL REPORT ON AGEISM

X V

Age is one of the first things we notice about other people. Ageism arises when age is used to categorize and divide people in ways that lead to harm, disadvantage and injustice and erode solidarity across generations. Ageism takes on different forms across the life course. A teenager might, for instance, be ridiculed for starting a political movement; both older and younger people might be denied a job because of their age; or an older person might be accused of witchcraft and driven out of their home and village.

Ageism damages our health and well-being and is a major barrier to enacting effective policies and taking action on healthy ageing, as recognized by World Health Organization (WHO) Member States in the Global strategy and action plan on ageing and health and through the Decade of Healthy Ageing: 2021–2030. In response, WHO was asked to start, with partners, a global campaign to combat ageism.

The Global report on ageism was developed for the campaign by WHO, Office of the High Commissioner for Human Rights, the United Nations (UN) Department of Economic and Social Affairs and the United Nations Population Fund. It is directed at policy-makers, practitioners, researchers, development agencies and members of the private sector and civil society. This report, after defining the nature of ageism, summarizes the best evidence about the scale, the impacts and the determinants of ageism and the most effective strategies to reduce it. It concludes with three recommendations for action, informed by the evidence, to create a world for all ages.

The nature of ageism

Ageism refers to the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) directed towards people on the basis of their age. It can be institutional, interpersonal or self-directed. Institutional ageism refers to the laws, rules, social norms, policies and practices of institutions that unfairly restrict opportunities and systematically disadvantage individuals because of their age. Interpersonal ageism arises in interactions between two or more individuals, while self-directed ageism occurs when ageism is internalized and turned against oneself.

Ageism starts in childhood and is reinforced over time. From an early age, children pick up cues from those around them about their culture’s stereotypes and prejudices, which are soon internalized. People then use these stereotypes to make inferences and to guide their feelings and behaviour towards people of different ages and towards themselves.

Ageism often intersects and interacts with other forms of stereotypes, prejudice and discrimination, including ableism, sexism and racism. Multiple intersecting forms of bias compound disadvantage and make the effects of ageism on individuals’ health and well-being even worse.

EXECUTIVE SUMMARY

X V I

GLOBAL REPORT ON AGEISM

The scale of ageism

Ageism pervades many institutions and sectors of society, including those providing health and social care, the workplace, the media and the legal system. Health-care rationing on the basis of age is widespread, and older adults tend to be excluded from research and data collection efforts. Older and younger adults are often disadvantaged in the workplace. People get angrier about crimes committed by younger offenders, rather than older, and see these crimes as more serious transgressions. Ageism also shapes how statistics and data, on which policies are based, are collected.

Globally, one in two people are ageist against older people. In Europe, the only region for which we have data, one in three report having been a target of ageism, and younger people report more perceived age discrimination than other age groups.

The impact of ageism

Ageism has serious and far-reaching consequences for people’s health, well-being and human rights. For older people, ageism is associated with a shorter lifespan, poorer physical and mental health, slower recovery from disability and cognitive decline. Ageism reduces older people’s quality of life, increases their social isolation and loneliness (both of which are associated with serious health problems), restricts their ability to express their sexuality and may increase the risk of violence and abuse against older people. Ageism can also reduce younger people’s commitment to the organization they work for.

For individuals, ageism contributes to poverty and financial insecurity in older age, and one recent estimate shows that ageism costs society billions of dollars.

The determinants of ageism

Factors that increase the risk of perpetrating ageism against older people are being younger, male, anxious about death and less educated. Factors that reduce the risk of perpetrating ageism against both younger and older people are having certain personality traits and more intergenerational contact.

Factors that increase the risk of being a target of ageism are being older, being care-dependent, having a lower healthy life expectancy in the country and working in certain professions or occupational sectors, such as high-tech or the hospitality sector. A risk factor for being a target of ageism against younger people is being female.

Three strategies to reduce ageism

Three strategies to reduce ageism have been shown to work: policy and law, educational activities and intergenerational contact interventions.

X V I I

• Strategy 1: Policy and law – Policies and laws can be used to reduce ageism towards any age group. They can include, for example, policies and legislation that address age discrimination and inequality and human rights laws. Strengthening policies and laws against ageism can be achieved by adopting new instruments at the local, national or international level and by modifying existing instruments that permit age discrimination. This strategy requires enforcement mechanisms and monitoring bodies at the national and international levels to ensure effective implementation of the policies and laws addressing discrimination, inequality and human rights.

• Strategy 2: Educational interventions – Educational interventions to reduce ageism should be included across all levels and types of education, from primary school to university, and in formal and non-formal educational contexts. Educational activities help enhance empathy, dispel misconceptions about different age groups and reduce prejudice and discrimination by providing accurate information and counter-stereotypical examples.

• Strategy 3: Intergenerational contact interventions – Investments should also be made in intergenerational contact interventions, which aim to foster interaction between people of different generations. Such contact can reduce intergroup prejudice and stereotypes. Intergenerational contact interventions are among the most effective interventions to reduce ageism against older people, and they also show promise for reducing ageism against younger people.

Three recommendations for action

These recommendations aim to help stakeholders reduce ageism. Implementing them requires political commitment, the engagement of different sectors and actors and context- specific adaptations. When possible, they should be implemented together to maximize their impact on ageism.

• Recommendation 1: Invest in evidence-based strategies to prevent and tackle ageism. Priority should be given to the three strategies supported by the best evidence: enacting policies and laws, and implementing educational and intergenerational contact interventions. To make a difference at the level of populations, these strategies must be scaled up. Where such interventions have not been implemented before, they should be adapted and tested, and then scaled up once they have been shown to work in the new context.

• Recommendation 2: Improve data and research to gain a better understanding of ageism and how to reduce it. Improving our understanding of all aspects of ageism – its scale, impacts and determinants – is a prerequisite for reducing ageism against both younger and older people. Data should be collected across countries, particularly in low- and middle- income countries, using valid and reliable measurement scales of ageism. But the top-most priority should be developing strategies to reduce ageism. The evidence base for the effectiveness of strategies

X V I I I

GLOBAL REPORT ON AGEISM

is developing, but it still falls short of what is needed. Existing strategies should be optimized, their cost and cost–effectiveness estimated and then they should be scaled up. Promising strategies, such as campaigns to reduce ageism, need to be further developed and evaluated.

• Recommendation 3: Build a movement to change the narrative around age and ageing. We all have a role to play in challenging and eliminating ageism. Governments, civil society organizations, UN agencies, development organizations, academic and research institutions, businesses and people of all ages can join the movement to reduce ageism. By coming together as a broad coalition, we can improve collaboration and communication between the different stakeholders engaged in combating ageism.

CONCLUSIONS

It is time to say no to ageism. This Global report on ageism outlines how to combat ageism and, hence, contribute to improving health, increasing opportunities, reducing costs and enabling people to flourish at any age. If governments, UN agencies, development organizations, civil society organizations and academic and research institutions implement strategies that are effective and invest in further research, and if individuals and communities join the movement and challenge every instance of ageism, then together we will create a world for all ages.

X I X

INTRODUCTION Ageing is a natural and lifelong process that, while universal, is not uniform. How we age is shaped by the relationships we have with the social and physical environments we have lived in throughout our lives. How we age also varies according to personal characteristics including the family we were born into, our sex and our ethnicity (1). The longer we live, the more different from each other we become, making diversity a hallmark of older age.

Our age reflects the number of years we have been alive. But what is considered young or old partly depends on context, purpose and culture. At age 18 you may be considered too old to learn to be a competitive gymnast, but too young to run for high political office. Cultures also vary as to what constitutes older age, middle age and youth. A century ago in western Europe and North America, old age started much earlier than it does today.

How we each think, feel and act towards age and ageing – our own and that of others – can either help us thrive or limit the lives we lead and the freedoms we enjoy. When age-based biases permeate our institutions (e.g. legal, health, educational), they can create and perpetuate disparities between groups so that individual-level change alone cannot address ageism, as research on sexism (2) and racism (3) has shown.

Box 0.1 The word ageism

The term ageism was coined in 1969 by Robert Butler, an American gerontologist and the first director of the National Institute on Aging in the United States. While ageism has existed across centuries, countries, contexts and cultures, the concept is relatively new and does not – yet – exist in every language. This can make it challenging to raise awareness about this social phenomenon and to advocate for change. Those languages that lack a specific term for ageism tend to use a proxy, such as Altersdiskriminierung in German, which captures only the dimension of dis- crimination. Other languages that have a specific term, such as Spanish (edadismo or edaismo) and French (âgisme), are only now starting to use it more widely. Iden- tifying a word for ageism in every language would be one way to start generating awareness and change across countries. Although ageism covers any stereotypes, prejudice and discrimination based on age, other terms have also been used to refer to ageism directed against children and youth, including the concepts of adultism (4-6) and childism (7, 8). Ageism will be the only term used in this report to refer to age-based stereotyping, prejudice and discrimination.

Ageism refers to the stereotypes, prejudice and discrimination directed towards others or oneself based on age. Ageism affects people of all ages and will be the only term used in this report to refer to age-based stereotypes, prejudice and discrimination (see Box 0.1).

X X

GLOBAL REPORT ON AGEISM

Why a global report on ageism?

The Global strategy and action plan on ageing and health (2016–2030) (9) and the related World Health Assembly resolution WHA69.3 (10) identified combating ageism as a prerequisite to developing good public policy on healthy ageing and to improving the day-to-day lives of older people. In response, the World Health Organization (WHO) was called on to develop, in cooperation with other partners, a global campaign to combat ageism. While developing the vision and principles of the Global campaign to combat ageism, it became evident that to prevent harm, reduce injustice and foster intergenerational solidarity we need to reduce ageism against people of all ages.

The Decade of Healthy Ageing: 2021–2030, an action plan for the last 10 years of both the Global strategy and action plan on ageing and health and the 2030 Agenda for Sustainable Development, was endorsed in August 2020 by the World Health Assembly and in December 2020 by the United Nations General Assembly (11, 12, 13). Combating ageism – that is, changing how we think, feel and act towards age and ageing, our own and that of others, is one of the four action areas prioritized by the Decade of Healthy Ageing. Combating ageism

Box 0.2 Language

Language conveys meaning and can fuel misconceptions that can lead to ageism. Words such as elderly, old or senior elicit stereotypes of older people as universally frail and dependent, and they are frequently used in a pejorative sense. Similarly, the word juvenile elicits a stereotype of younger people as immature. This report uses neutral language when referring to individuals and groups, including the terms older person, younger person or older people, older populations and younger people.

Ageism is prevalent, deeply ingrained and more socially accepted than other forms of bias. Age-related bias is often seen as humorous or at the least harmless. People fail to see that how age and ageing are framed (e.g. having a senior moment, grey tsunami, the problem of ageing populations, “young people think they know everything”) and the language that is used (see Box 0.2) perpetuate misconceptions and influence the policies we develop and the opportunities we create – or don’t. Ageism, as shown in this report, can change how we view ourselves, can pit one generation against another, can devalue or limit our ability to benefit from what younger and older populations can contribute and can reduce opportunities for health, longevity and well-being while also having far-reaching economic consequences.

To prevent harm, reduce injustice and foster intergenerational solidarity we need to reduce ageism against people of all ages.

X X I

is also integral to achieving progress in the other three actions areas: developing communities in ways that foster the abilities of older people, delivering person-centred integrated care and primary health services that are responsive to the needs of older people and providing older people who need it with access to long-term care.

While ageism has been identified as an important problem, scientific information on ageism is lacking. There is limited agreement on definitions and little internationally comparable information on the scale of the problem and a paucity of evidence on the strategies that work to reduce it.

This report, directed at policy-makers, practitioners, researchers, development agencies, the private sector and civil society, compiles the best evidence on ageism.

Aims

The central themes of this report are the heavy burden that ageism places on individuals and society and the urgent need for action from governments, civil society, the private sector and individuals of all ages.

The goals of the report are to:

• raise awareness about the global nature, scale, impact and determinants of ageism directed against both younger and older people;

• draw attention to the need to prevent ageism, to promote and protect the realization and enjoyment of all human rights for all persons and to present effective intervention strategies;

• call for action across sectors and stakeholders.

The scope of the report supports these goals, and the report is divided into 10 chapters. The first explains what ageism is and how it operates towards both younger and older people. There is much less evidence on ageism against younger people than on ageism against older people, and it is of poorer quality. As a result, the report presents evidence separately about ageism towards

Ageism, as shown in this report, can change how we view ourselves, can pit one generation against another, can devalue or limit our ability to benefit from what younger and older populations can contribute and can reduce opportunities for health, longevity and well-being while also having far-reaching economic consequences.

X X I I

GLOBAL REPORT ON AGEISM

younger and older people. Chapters 2–4 relate only to older people and detail the scale of the problem (Chapter 2), its impact (Chapter 3) and the determinants of ageism (Chapter 4). The fifth chapter compiles all of the evidence about the scale, impact, and determinants of ageism against younger people. The three subsequent chapters (Chapters 6–8) focus on strategies that work to reduce ageism against older and younger people, including policies and laws, and educational and intergenerational activities. Chapter 9 highlights strategies that are promising, but whose effectiveness is not yet proven. Each chapter explains the relevant strategy and how it works; provides an overview of the evidence on effectiveness; identifies the costs and factors that can potentially make the strategy more effective, where such evidence exists; and provides examples. Evidence relevant to younger people is included in boxes.

Because the way that research is conducted is important (see Box 0.3), each chapter has a box evaluating available evidence and suggesting opportunities for future research. Each chapter also offers conclusions and suggestions for future directions, which are drawn together in Chapter 10 to provide broad recommendations for policy and practice.

Box 0.3 How research is conducted on ageism matters

How well we understand ageism depends on how the research on ageism was conducted and how ageism was measured. If our definitions and measures are inaccurate, if the picture that our research produces of its scale and distribution and of the drivers and the impacts of ageism are inaccurate, our efforts to reduce ageism will be less effective. We are more likely to waste time and money. And ageism that could have been averted will persist, with the serious consequences outlined in this report.

The discussion of research in each chapter builds, to an extent, on the previ- ous one. If definitions of ageism (Chapter 1) are not clear, ageism cannot be measured accurately and its scale and distribution (Chapters 2 and 5) cannot be established with confidence. If ageism cannot be measured accurately, it will be more difficult to ascertain the impact of ageism (Chapters 3 and 5). If the determinants of ageism (Chapters 4 and 5) are not identified correctly, strategies to reduce ageism (Chapter 6–9) are unlikely to be effective because the strategies are designed to target these determinants. In addition, without accurate measures of ageism, the effect of the strategies on ageism cannot be evaluated precisely.

X X I I I

Process

The conceptual framework for ageism was developed in collaboration with the core group working on the Global campaign to combat ageism. In alignment with that framework, several steps were taken to compile or collect evidence to inform this report including:

• a review of the global prevalence of ageism towards older people, broadly understood as people aged 50 and older;

• a series of systematic reviews of research about ageism against older people in English, French and Spanish that was carried out by experts that assessed determinants, health impacts, intervention strategies and measurement;

• a scoping review on ageism directed towards younger people, which included evidence on people younger than 50, from peer-reviewed literature in English, Spanish and French;

• targeted searches to identify other forms of published quantitative and qualitative evidence that were conducted in response to gaps identified in the research, including ageism in low- and middle-income countries, ageism towards younger people and the intersections between ageism and other ”-isms”;

• a review of global, national and local campaigns to tackle ageism; and

• personal testimonies from younger and older people.

While there are many perceptions and opinions about the scale, impact and determinants of ageism and the most effective strategies to reduce it, this report has made every effort to base its findings on solid evidence. When deciding on what evidence to report, findings from systematic reviews – which aim to rigorously identify, evaluate and summarize the findings of all relevant individual studies on a topic – have been prioritized over single studies. When no evidence was available, the report points this out and calls for the gap to be filled. Ageism research, like about 90% of the research on psychology and health, is predominantly carried out in high-income countries, which account for some 15% of the global population.

It is anticipated that the policy and practice considerations outlined in this report will be periodically reviewed and revised by the Department of Social Determinants of Health at WHO, in collaboration with partners.

This Global report on ageism charts the steps that are required to combat ageism and, hence, contribute to improving health, increasing opportunities, reducing costs and enabling people to flourish at any age.

X X I V

GLOBAL REPORT ON AGEISM

Moving forward

This Global report on ageism charts the steps that are required to combat ageism and, hence, contribute to improving health, increasing opportunities, reducing costs and enabling people to flourish at any age. The aspiration of those who contributed to this report is that it results in concrete actions that will be taken by all stakeholders, at all levels and across all sectors, and that these actions promote social and economic development, the achievement of human rights across the world and the development of a world for all ages.

X X V

REFERENCES

1. World report on ageing and health. Geneva: World Health Organization; 2015 (https:// apps.who.int/iris/handle/10665/186463, accessed 13 October 2020).

2. Ochoa Garza MK, Feagin JR. Sexism. In: Ritzer G, Rojek C, editors. The Blackwell Encyclopedia of Sociology. Hoboken (NJ): Wiley; 2019.

https://doi.org/10.1002/9781405165518.wbeoss084.pub2. 3. Feagin JR. 2006. Systemic racism: a theory of oppression. New York: Routledge; 2006. 4. Bell J. Understanding adultism: a major obstacle to developing positive youth-adult

relationships. Somerville (MA): YouthBuild USA; 1995 (https://actioncivics.scoe.net/pdf/ Understanding_Adultism.pdf, accessed 12 October 2020).

5. Ceaser D. Unlearning adultism at Green Shoots: a reflexive ethnographic analysis of age inequality within an environmental education programme. Ethnogr Educ. 2014:9;167–81.

6. Kennedy D. The well of being: childhood, subjectivity, and education. New York: SUNY Press; 2012.

7. Pierce CM, Allen GB. Childism. Psychiatr Ann. 1975;5:15-24. https://doi.org/10.3928/0048-5713-19750701-04. 8. Young-Bruehl E. Childism: confronting prejudice against children. New Haven (CT): Yale

University Press; 2012. 9. Global strategy and action plan on ageing and health. Geneva: World Health Organization;

2017 (https://www.who.int/ageing/WHO-GSAP-2017.pdf?ua=1, accessed 27 October 2020).

10. Resolution WHA69.3. The global strategy and action plan on ageing and health 2016–2020: towards a world in which everyone can live a long and healthy life. In: Sixty-ninth World Health Assembly, Geneva, 28 May 2016. Resolutions and decisions, annexes. Geneva: World Health Organization; 2016 (https://apps.who.int/iris/handle/10665/252783, accessed 12 October 2020).

11. WHA73(12). Decade of healthy ageing 2020–2030. In: Seventy-third World Health Assembly, Geneva, 3 August 2020. Agenda item 15.1. Geneva: World Health Organization; 2020 (https://apps.who.int/gb/ebwha/pdf_files/WHA73/A73(12)-en.pdf, accessed 12 October 2020).

12. Resolution A/RES/70/1. Transforming our world: the 2030 Agenda for Sustainable Development. In: Seventieth United Nations General Assembly, 21 October 2015. New York: United Nations; 2015 (https://sustainabledevelopment.un.org/post2015/ transformingourworld, accessed 12 October 2020).

13. Resolution A/75/L.47 United Nations Decade of Healthy Ageing (2021-2030). In: Seventy- fifth United Nations General Assembly, 8 December 2020. New York: United Nations; 2020 (https://undocs.org/en/A/75/L.47, accessed 14 December 2020).

X X V I

GLOBAL REPORT ON AGEISM

F E R N A N D O , 6 4 , P L U R I N A T I O N A L S T A T E O F B O L I V I A

S A U M Y A , 2 4 , I N D I A

X X V I

Discrimination against older people is a serious issue. I was widowed seven months ago and since my wife died, the people, my own family has discriminated against me for being older and widowed. My brothers, my father-in-law no longer l isten to me. They don’t take any notice of what I say and I feel hurt . Some of my children support me, they tel l me to take no notice but it is sad that your own family discriminates against you.

Fernando, 64, The Plurinational State of Bolivia ©Sebastian Ormachea / HelpAge International

Young people based on their age are discriminated and often not included in the decision-making spaces. Their presence and voices are often heard or included just to t ick mark the box of youth inclusion but their recommendations are not included. Young people of age group 18-29 years are either considered perpetrators of violence whom we need to stop or victims who need to be supported but young people are peacebuilders and agents to build positive peace within their communities.

Saumya, 24, India ©Saumya Aggarwal / UN Major Group for Children and Youth

01

CHAPTER 01

1

“ “

“

“

Ageism refers to the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) directed towards others or oneself based on age.

Ageism can manifest at the institutional or the interpersonal level or it can be self-directed.

Ageism can be implicit or explicit depending on our level of awareness of being ageist.

Ageism starts in childhood and is reinforced over time.

Ageism intersects with other “-isms” and can result in compounded disadvantage.

GLOBAL REPORT ON AGEISM

01 1.1 DEFINING AGEISM Age is one of the first characteristics – along with sex and race – that we notice about other people when we interact with them (see Box 1.1) (3). Ageism arises when age is used to categorize and divide people in ways that lead to harm, disadvantage and injustice and erode solidarity across generations.

Ageism takes many forms throughout our lifetime. Imagine being systematically ignored by colleagues and supervisors in the workplace, patronized by your family at home, denied a loan at the bank, insulted or avoided in the street, accused of witchcraft, denied access to your property or land, or not being offered treatment at a clinic, all simply because of your age. These are all examples of how ageism penetrates our lives, from younger age into older age.

Ageism is a multifaceted social phenomenon that the World Health Organization (WHO) defines as the stereotypes, prejudice and discrimination directed towards others or oneself based on age (9). Ageism has several interrelated aspects:

• three dimensions – stereotypes (thoughts), prejudice (feelings) and discrimination (actions or behaviour) (Section 1.1.1);

2

Section 1.1 of this chapter defines ag e ism and i t s th re e ma in dimensions: stereotypes, prejudice and discrimination. A clear and common understanding of ageism is crucial to raise awareness and ensure consistency in research, policy and practice (1-2). The definitions presented here underpin the rest of the report. Section 1.2 describes how ageism works and how it arises. Section 1.3 describes intersections between ageism and other “-isms”, such as sexism and ableism, illustrating their cumulative impacts.

Chapter

CHAPTER 01

Box 1.1

3

Age and stage of life are partly socially determined

Age, although correlated with biological processes, is also socially shaped. Who is considered young or old partly depends on context, purpose and culture (4-6). At age 18 you may be viewed as too old to become a competitive pianist, but too young to coach a professional soccer team. Cultures vary in how they demarcate old age, middle age and youth and in the norms and expectations they have for each of these life stages, which can change over time (7). Environments also shape how we age. Inequalities linked, for instance, to sex, eth- nicity and income determine our access to health care and education across the life course, and they influence how we are at age 50, 60, 70 or 80. A large part of the diversity we see in older age results from the cumulative impact of these health inequities across the life course (8).

• three levels of manifestation – institutional, interpersonal and self- directed (Section 1.1.2);

• two forms of expression – explicit (conscious) and implicit (unconscious) (Section 1.1.3).

1.1.1 Ageism as stereotypes, prejudice and discrimination

The three dimensions of ageism – stereotypes, prejudice and discrimination – each relate to a distinct psychological faculty: thoughts (stereotypes), feelings (prejudices) and actions or behaviours (discrimination).

Stereotypes are cognitive structures that store our beliefs and expectations about the characteristics of members of social groups, and stereotyping is the process of applying stereotypic information (10). Stereotypes guide our social behaviour and often govern what information we seek and remember (11-14).

In ageism, the stereotypes that people hold about age can guide the inferences that they make about other people based on

their age, including their physical and mental capacities, social competencies and political and religious beliefs. These inferences can lead to overgeneralizations that consider every person within a given age group to be the same. For example, a common overgeneralization is that older people are frail, incompetent and friendly (15) or that younger adults are materialistic, lazy and impatient (16).

Age stereotypes can range from positive to negative (17-19), but, being by definition overgeneralizations, both so-called positive and negative stereotypes are inaccurate and potentially harmful. Some age stereotypes cut across regions and cultures (20, 21). For example, older adults tend to be stereotyped as a mixture of warmth (positive) and incompetence (negative) across different countries in Europe, Asia and North and South America, while younger adults are stereotyped as highly competent (positive) but low in warmth (negative) (20, 22-24).

Other age stereotypes tend to differ by contexts and culture (17, 21, 25-28). Table 1.1 provides a catalogue of stereotypes identified in different institutional settings across the world. Which stereotypes

4

GLOBAL REPORT ON AGEISM

Table 1.1. A catalogue of stereotypes identified in different institutional settings and countries

INSTITUTION OR SECTOR STEREOTYPES

YOUNGER PEOPLE ARE… OLDER PEOPLE ARE…

Health and social carea

POSITIVE Healthy Physically active Strong and energetic

Warm Likeable

NEGATIVE Risk-takers Drug-users Stressed and anxious

Rigid Irritable and f rustrating Lonely and isolated Frail and weak Asexual Easily confused Depressed and depressing Needy Disabled

Workb

POSITIVE Energetic Ambitious Tech-savvy Hard-working (middle-aged)

Reliable Committed Experienced Hard-working Socially skilled Good mentors and leaders Able to deal with change

NEGATIVE Narcissistic Disloyal Entitled Lazy Unmotivated Easily distracted

Incompetent and unproductive Unmotivated Resistant to change Harder to train and unable to learn Not flexible Not technologically competent

Mediac

POSITIVE Attractive Healthy Engaged Productive Self-reliant

NEGATIVE Troublesome Violent criminals

Unattractive Unhappy Senile Badly dressed Inactive Dependent Unhealthy Disempowered and poor Vulnerable Diabolical

a For additional information, see references 16 and 33-40. b For additional information, see references 16 and 41-48. c For additional information, see references 32 and 49-51.

5

CHAPTER 01

predominate in a given situation depend largely on the age of the person being ageist (29) and the context, such as the place where the older or younger person is encountered (30, 31). Social and economic changes and shifts in values within a society can lead to stereotypes evolving over time (32).

Prejudice is an emotional reaction or feeling, either positive or negative, that is directed towards a person based on their perceived group membership (1, 52). Prejudice contributes to creating or maintaining hierarchical status relations between groups (53). In the case of ageism, prejudice is directed towards an individual or a group based on perceptions of their age.

Feelings of pity or sympathy are two common forms of prejudice towards older adults (15), and they can generate a desire to exclude oneself from the company of older people (54). In turn, younger people may provoke feelings of fear or aversion, often based on the presumption that they are delinquents or criminals.

Discrimination consists of actions, practices or policies that are applied to people on account of their perceived or real membership in some socially salient group and that impose some form of disadvantage (negative discrimination) or advantage (positive discrimination) on them (55).

In relation to ageism, discrimination relates to behaviours – including actions, practices and policies – that are directed towards people based on their age. Employers who refuse to allow a person to lead a discussion because they consider the person to be too young or who do not allow an employee to attend a training session because they consider the person to be too old to benefit from it are examples of, respectively, negative discrimination towards younger

and older people. Examples of positive actions include offering discounts to younger or older adults who are unlikely to have a regular income.

In short, ageism involves how we think (stereotypes), feel (prejudice) and act (discrimination) in relation to others and ourselves based on age (see Fig. 1.1).

This report focuses on the negative implications of age-based stereotypes, prejudice and discrimination, regardless of whether the specific thoughts, feelings or actions are perceived to be positive or negative.

1.1.2 Institutional, interpersonal and self- directed ageism

Institutional ageism refers to the laws, rules, social norms, policies and practices of institutions that unfairly restrict opportunities and systematically disadvantage individuals on the basis of their age (1, 53, 56). It also refers to the ideologies that institutions foster to justify their ageism.

While institutional ageism can result from conscious and overt efforts made by individuals in an institution (in which case it overlaps with interpersonal ageism), it does not necessarily require the intentional support of the individuals in an institution or any awareness of bias towards younger or older people. Often people fail to recognize the existence of such institutional ageism because the rules, norms and practices of the institution are of long-standing, have become ritualized and are seen as normal. Moreover, institutional ideologies – often tacit – offer justifications for “the way things are done” (1, 53). Thus, while not always intentional, institutional ageism can legitimize the exclusion of people from power and influence, reinforcing an

6

GLOBAL REPORT ON AGEISM

asymmetric power structure that is based on age and age-associated assumptions (57).

Because institutional ageism – like institutional racism or sexism – is not always the result of overt bias on the part of individuals, it often must be inferred from the disparate outcomes occurring between age groups. For instance, in health care, decisions regarding whether or not to withhold life sustaining therapies (e.g. ventilator support, surgery or dialysis) often vary by age contributing to different outcomes for different age groups. These disparate outcomes can then be traced back and attributed, at least in part, to the laws, polices or practices of an institution, which is then considered institutionally ageist.

Thus, a key consideration in institutional ageism is not so much the intention, but the disparate outcomes (55, 57, 58).

Examples of institutional ageism include:

• policies in the health sector that allow care to be rationed by age (59); and

• in the labour sector, discriminatory hiring practices or mandatory retirement ages (42, 43, 60).

Interpersonal ageism refers to ageism occurring during interactions between two or more individuals.

In interpersonal ageism, the perpetrator is distinguished from the target of ageism.

Fig. 1.1. The three dimensions of ageism include stereotypes, prejudice and discrimination. These dimensions may be perceived as positive or negative

7

CHAPTER 01

Fig. 1.2. Interpersonal, institutional and self-directed ageism are intertwined and mutually reinforcing

Examples of interpersonal ageism include:

• disrespecting or patronizing older and younger adults, ignoring their points of view in decision-making or avoiding contact and interactions;

• using an overly accommodating tone and simple vocabulary and sentence structure when interacting with older adults (known as elderspeak). This type of speech, by assuming that older adults are less capable, infantilizes them and increases the likelihood that others will view them as incompetent and incapable, and treat them disrespectfully and impolitely (61, 62);

• insulting older people by saying that they are worthless because of their age, or younger people by saying that they are thoughtless, selfish or criminals because of their age.

Self-directed ageism refers to ageism turned against oneself. People internalize age- based biases from the surrounding culture after being repeatedly exposed to those biases, and they then apply those biases to themselves (63).

Examples of self-directed ageism include:

• people in their twenties who think that they are too young for a job and may be reluctant to apply;

• older individuals who do not believe it is possible to learn new skills later in life and hesitate to enrol at university or take up a new hobby.

The three levels at which ageism manifests itself are intertwined and mutually reinforcing (see Fig. 1.2).

8

GLOBAL REPORT ON AGEISM

Ageist institutional rules, norms and practices, and the ageist ideologies they foster, can shape, and be shaped by, the attitudes of individuals – which underlie interpersonal ageism – who are members of these institutions and wider society.

At the same time, institutional and interpersonal ageism can be internalized and lead to self-directed ageism. And self-directed ageism can result in people conforming to their society’s age stereotypes, which in turn reinforces interpersonal and institutional ageism.

1.1.3 Explicit and implicit ageism

People may not always be aware that they are being ageist. Ageism can be either explicit or implicit, depending on a person’s level of consciousness or awareness of being ageist. In explicit ageism, a person’s ageist thoughts, feelings and actions towards others or themselves are conscious and intentional – that is, within their awareness and control.

In implicit ageism, however, a person’s ageist thoughts, feelings and actions towards others or themselves operate without conscious awareness and are largely unintentional and beyond their control (64). In implicit ageism, individuals do not recognize the thoughts, feelings and actions that are triggered by age stereotypes, and they may rationalize such behaviour by attributing it to other factors.

For example, rather than employers acknowledging that they prefer to hire a younger person, they might invoke an older candidate’s personality or lack of specific training. When a culture’s ageist attitudes are internalized and the ageism within its main institutions has become so routine and normalized that it is no

longer recognized by its members, ageism has become part of the subconscious framework of society, which can be expressed through implicit ageism (65).

1.2 HOW AGEISM WORKS AND HOW IT ARISES

1.2.1 Interactions between stereotypes, prejudice and discrimination

Because our thoughts, feelings and actions influence each other, the relation between stereotypes, prejudice and discrimination is multidirectional (see Fig. 1.3). Stereotypes can influence prejudice and discrimination; discrimination can influence stereotypes and prejudice; and prejudice can influence discrimination and stereotypes. For example, in English, using terms such as elderly to refer to older adults has been shown to evoke negative stereotypes of older people as frail and dependent (stereotypes) (66).

A study found that young adults with negative attitudes towards older adults showed less compassion towards them and wanted to keep their distance from them rather than show them empathy (prejudice) (67). Another study showed that employers who held negative stereotypes about older employees were also more punitive towards them (discrimination) (68).

These relationships between stereotypes, prejudice and discrimination are not automatic. The mere activation of a stereotype does not imply that people will inevitably have negative feelings and act in

9

CHAPTER 01

discriminatory ways (69). These relationships are influenced by contexts, including laws and culture (70).

1.2.2 Ageism starts early in life and is reinforced over time

Ageism starts in early childhood. From the age of 4 years, children become aware of their culture’s age stereotypes through the cues they pick up from people around them (71, 72). They begin to internalize and use these stereotypes to make inferences and to guide their feelings and behaviour towards people of different ages (12, 73). For instance, children in preschool and primary school were shown drawings that depicted a man at four stages of life, and two thirds of the children viewed the oldest man as being ‘‘helpless, incapable of caring for himself, and generally passive’’ (63, 74).

We also draw on our culture’s age stereotypes to perceive and understand ourselves and to guide our behaviour as members of a given age group, which can

result in self-directed ageism at any age. For example, when individuals reach old age, the ageing stereotypes internalized in childhood and then reinforced for decades can become self-stereotypes (63). Indeed, research has shown that older people express attitudes towards their own group that are as negative as those expressed by younger people towards older people (75). For instance, older people in the United States of America were more likely than younger people to oppose federal programmes that benefit them, and their opposition to these programmes was predicted by the stereotypes about ageing that they held (63).

Stereotype-consistent behaviour can also be triggered through what is known as stereotype threat. Stereotype threat arises when people underperform on a task due to worries about confirming a negative stereotype about their group (76, 77). For instance, an older person may do less well on a driving test or cognitive test due to anxiety about confirming stereotypes about older people being bad drivers or mentally slower. Furthermore, by behaving in a stereotype-consistent manner, older adults can help to reinforce prevailing attitudes, which can give rise to further age prejudice and discrimination.

1.3 AGEISM AND OTHER "-ISMS"

Ageism is, to an extent, different from other “-isms”, such as racism or sexism. Whereas other “-isms” involve bias against relatively stable subpopulations that do not vary across the life course, ageism involves bias against a moving target. People belong to different age groups at different points

Fig. 1.3. Stereotypes, prejudice and discrimination interact with and influence each other in multidirectional relationships

1 0

GLOBAL REPORT ON AGEISM

in their lives and, thus, will be more or less likely to perpetrate or be a target of ageism at different times. Another difference between ageism and the other “-isms” is that everyone is susceptible to experiencing it. Ageism also tends to be more accepted and challenged less often than other “-isms” (1, 78), and it has been shown to be more pervasive than sexism and racism across 28 countries in Europe (79).

Ageism can interact with other forms of bias, such as sexism and ableism, and exacerbate disadvantage, which may compound the impact on individuals’ health and well-being (80-82). A growing number of studies have explored the interactions and intersections between different “-isms”. Ageism and ableism and ageism and sexism are two forms of intersection that have been explored in some detail.

1.3.1 Ageism and ableism

Ableism refers to the stereotypes, prejudice and discrimination directed against people with disabilities or those who are perceived to have have a disability. Ageism and ableism are closely intertwined in ways that can often result in mutual reinforcement (4).

For instance, given that stereotypes commonly associated with older people (i.e. they are warm yet incompetent) are the same as those associated with people with disabilities, they may reinforce each other and prevent people from recognizing the diversity seen among older adults with a disability (20). It is also often assumed that disability is the norm in older age (83, 84), which may stem from the fact that most people with disabilities are older (85). Still, this does not mean that most older people live with some form of disability. The discourse around successful ageing, with its emphasis on maintaining able- bodiedness and able mindedness in older age, may have

further reinforced ageism and ableism (86).

In younger people, physical impairment may be particularly undermining, as it challenges people’s expectations regarding active, independent and able-bodied young adults (87). Younger adults with a disability may be treated with disdain or disrespect because they are violating the cultural norm of able-bodiedness, whereas their older counterparts may be treated with support and empathy. For example, a study in the United States found that the link between disability and perceived discrimination is more pronounced among working-age adults relative to persons aged 65 and older (88).

People with disabilities are also treated as if they are either significantly older or younger than people of the same age without disability. Often they are viewed either as an older person in a stereotypical state of decline or as a child with limited competence and autonomy (89). At the same time, there is evidence that programmes, expenditures, and goals for people with disabilities differ substantially across age groups in ways that suggest ageism (90). For example, in the United States, government expenditures per recipient are substantially higher for younger individuals with disabilities, and care options rejected by younger people with disabilities (e.g. institutional care) are often considered acceptable for older adults (90). In Sweden, disability policies have been found to serve children and young adults better than older persons with disabilities (91). This is particularly problematic if we consider that older people are disproportionately represented in disability populations (85).

1.3.2 Ageism and sexism

Research on the combined impact of sexism and ageism in older age has concluded that older women – relative to older and younger

1 1

CHAPTER 01

men and younger women – bear the brunt of multiple forms of discrimination.

The term “gendered ageism” has been coined to cover the intersection of age and gender, and it refers to differences in ageism faced by women compared with men (92, 93). Women are often in a situation of double jeopardy in which patriarchal norms and a preoccupation with youth result in a faster deterioration of older women’s status compared with that of men (94). This double jeopardy also explains why the physical appearance of older women is judged differently than that of older men (95-99). Men with grey hair and wrinkles are seen as distinguished, wise and experienced, whereas grey hair and wrinkles are considered to make women look unattractive in many cultures. Women also face greater pressure than men to hide signs of ageing through the use of hair dye and anti-ageing products (100-102), and they are targeted by an ever-growing anti-ageing beauty industry (103).

Two other ways in which the intersection between ageism and sexism manifest are through accusations of witchcraft and discrimination directed against older widows. In parts of sub-Saharan Africa, accusations of witchcraft are widespread, with older women being persecuted and accused of causing ill luck, disease or death (104). In many parts of the world, older widows are socially ostracized or discriminated against. For instance, they are denied the right to inherit the property they shared with their husbands (105, 106) (see Section 2.2 of Chapter 2).

The interaction between ageism and sexism can manifest in many different institutions. For example, in health care, disparities have been documented in terms of older women’s access to preventive care and treatment. Multiple studies conducted in the United States have reported that older men

generally receive more thorough medical examinations, more follow-up and more evidence-based medical care than women do, and men are also more likely to receive preventive care (107-110).

In employment, the disadvantages of being too young or too old impact women more than men. This suggests that in these age ranges, being a woman intensifies age prejudice (60, 101), which not only has an effect on a woman’s career but also on her ability to access a pension in older age (92). Compared with older men, older women typically have had fewer years in the workforce, have earned less and are less likely to have pensions or substantial retirement savings.

1.3.3 Other “-isms”

Although research has mainly focused on the intersections of ageism with ableism and sexism, there may be as many intersections as there are forms of stereotypes, prejudice and discrimination, including with racism, classism, heterosexism, homophobia and transphobia.

An important intersection that has not been sufficiently explored is that between ageism and racism, but this field of research is growing. For example, in Canada there is evidence that stigma acts as a barrier to black female youth accessing mental health services and support (111). In the United States minority women were more likely to report unfair treatment based on age than other respondents, including white men (112).

Another intersection that is being increasingly explored is that of ageism and heterosexism and sexuality (113-115). A growing body of cross-cultural research recognizes the importance of examining how age, gender and sexuality work together and with other forms of exclusion, including those based

1 2

GLOBAL REPORT ON AGEISM

on ethnicity and class, to form a range of inequalities (or opportunities) for people as they age. Qualitative studies revealed that older lesbians report frequent experiences of homophobia, heterosexism and ageism in the health care system and elsewhere (116), and that older black gay men and lesbian women feel alienated from the black community, deliberately conceal their sexual identity and orientation, and feel isolated (117). These findings suggest that how these identities are managed may have an impact on an individual’s adjustment to the ageing process.

Despite these advances in research, further research is needed to explore the intersections between ageism and these other “-isms” and the multiple and compounding forms of discrimination that they elicit.

1.4 CONCLUSIONs AND FUTURE DIRECTIONS

This chapter described what ageism is and how it works. It provides the conceptual basis for the rest of the report. Ageism refers to the stereotypes (how we think), prejudice (how we feel) and discrimination (how we act) directed towards people based on their age. It manifests itself at three levels – institutional, interpersonal and self-directed – and can be either explicit or

implicit. Age-based stereotypes, prejudice and discrimination interact and mutually reinforce each other. Ageism tends to start early in life and be reinforced over time through interactions between individuals and their social environments. Ageism can also interact and intersect with other “-isms”, such as sexism, ableism and racism, thus exacerbating disadvantage.

The definition of ageism proposed in this report is the result of a decades-long process of refinement, and it enjoys considerable consensus among ageism researchers.

Future priorities for understanding the nature of ageism should include:

• promoting the use of the definition proposed in this report to enable cross-cultural comparisons of research and practice;

• improving our understanding of the way in which different languages and cultures refer to ageism to improve translatability;

• increasing awareness among all key stakeholders of what ageism is, particularly in low- and middle- income countries, to foster a shared understanding of the issue and stimulate action;

• conducting further research on the ways in which ageism intersects with other “-isms”, which will have important implications for the actions taken to tackle ageism and other forms of stereotypes, prejudice and discrimination.

Ageism can also interact and intersect with other “-isms”, such as sexism, ableism and racism, thus exacerbating disadvantage.

1 3

CHAPTER 01

REFERENCES

1. Iversen TN, Larsen L, Solem PE.A conceptual analysis of Ageism. Nord Psychol. 2009;61(3):4–22. https://doi.org/10.1027/1901-2276.61.3.4.

2. Ceaser D. Unlearning adultism at Green Shoots: a reflexive ethnographic analysis of age inequality within an environmental education programme. Ethnogr Educ. 2013;9(2):167–81. https://doi.org/10.1080/17457823.2013.841083.

3. North MS, Fiske ST. An inconvenienced youth? Ageism and its potential intergenerational roots. Psychol Bull. 2012;138(5):982–97. https://doi.org/10.1037/a0027843.

4. Overall C. Old age and ageism, impairment and ableism: exploring the conceptual and material connections. NWSA J. 2006;18(1):126–37.

https://doi.org/10.1353/nwsa.2006.0016. 5. Togunu-Bickersteth F. Perception of old age among Yoruba aged. J Comp Fam Stud.

1988;19(1):113–22. https://doi.org/10.3138/jcfs.19.1.113. 6. Togonu-Bickersteth F. Chronological definitions and expectations of old age among

young adults in Nigeria. J Aging Stud. 1987;1(2):113–24. https://doi.org/10.1016/0890-4065(87)90002-8. 7. Troyansky DG. Aging in world history. London: Routledge; 2015. 8. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/handle/10665/186463, accessed 28 September 2020). 9. Officer A, de la Fuente-Núñez V. A Global campaign to combat ageism. Bull World Health

Organ. 2018;96(4):295–6. https://doi.org/10.2471/BLT.17.202424. 10. Kite ME, Whitley BJ, editors. Psychology of prejudice and discrimination. New York:

Routledge; 2016. 11. Fiske ST. Stereotyping, prejudice, and discrimination. In: Gilbert DT, Fiske ST, Lindzey

G, editors. The handbook of social psychology, fourth edition. New York: McGraw-Hill; 1998:357–411.

12. Krings F, Sczesny S, Kluge A. Stereotypical inferences as mediators of age discrimina- tion: the role of competence and warmth. Br J Manag. 2011;22(2):187–201. https://doi. org/10.1111/j.1467-8551.2010.00721.x.

13. Wheeler SC, Petty RE. The effects of stereotype activation on behavior: a review of possible mechanisms. Psychol Bull. 2001;127(6):797–826.

https://doi.org/10.1037/0033-2909.127.6.797. 14. Amodio DM, Devine PG. Stereotyping and evaluation in implicit race bias: evidence

for independent constructs and unique effects on behavior. J Personal Soc Psychol. 2006;91(4):652–61. https://doi.org/10.1037/0022-3514.91.4.652.

15. Cuddy AJ, Fiske ST. Doddering but dear: process, content, and function in stereotyping of older persons. In: Nelson TD, editor. Ageism: stereotyping and prejudice against older persons. Cambridge (MA): MIT Press; 2002:3–26.

16. Duffy B, Shrimpton H, Clemence M. Millennial: myths and realities. Paris: IPSOS Mori; 2016 (https://www.ipsos.com/sites/default/files/2017-07/ipsos-mori-thinks-millennial-myths-and-re- alities.pdf, accessed 13 October 2020).

17. Hummert ML, Garstka TA, Shaner JL, Strahm S. Stereotypes of the elderly held by young, middle-aged, and elderly adults. J Gerontol. 1994;49(5):P240–9.

https://doi.org/10.1093/geronj/49.5.p240. 18. Doddery but dear? Examining age-related stereotypes. London: Centre for Ageing

Better; 2020 (https://www.ageing-better.org.uk/sites/default/files/2020-03/Doddery- but-dear.pdf, accessed 13 October 2020).

1 4

GLOBAL REPORT ON AGEISM

19. Musaiger AO, D’Souza R, Al-Roomi K. Perception of aging and ageism among women in Qatar. J Women Aging. 2013;25(3):273–80. https://doi.org/10.1080/08952841.2013.791602.

20. Cuddy AJC, Norton MI, Fiske ST. This old stereotype: the pervasiveness and persistence of the elderly stereotype. J Soc Issues. 2005;61(2):267–85.

https://doi.org/10.1111/j.1540-4560.2005.00405.x. 21. Lockenhoff CE, De Fruyt F, Terracciano A, McCrae RR, De Bolle M, Costa PT Jr., et al.

Perceptions of aging 26 cultures and their culture-level associates. Psychol Aging. 2009;24(4):941–54. https://doi.org/10.1037/a0016901.

22. Fiske ST, Cuddy AJC, Glick P, Xu J. A model of (often mixed) stereotype content: compe- tence and warmth respectively follow from perceived status and competition. J Personal Soc Psychol. 2002;82(6):878-902. https://doi.org/10.1037//0022-3514.82.6.878.

23. Cuddy AJ, Fiske ST, Kwan VS, Glick P, Demoulin S, Leyens JP, et al. Stereotype content model across cultures: towards universal similarities and some differences. Br J Soc Psychol. 2009;48(Pt 1):1-33. https://doi.org/10.1348/014466608X314935.

24. de Paula Couto MCP, Koller SH. Warmth and competence: stereotypes of the elderly among young adults and older persons in Brazil. Int Perspect Psychol. 2012;1(1):52–62.

https://doi.org/10.1037/a0027118. 25. Bergman YS, Bodner E, Cohen-Fridel S. Cross-cultural ageism: ageism and attitudes toward

aging among Jews and Arabs in Israel. Int Psychogeriatr. 2013;25(1):6–15. https://doi.org/10.1017/S1041610212001548. 26. North MS, Fiske ST. Modern attitudes toward older adults in the aging world: a cross-cultural

meta-analysis. Psychol Bull. 2015;141(5):993–1021. https://doi.org/10.1037/a0039469. 27. Lagace M, Charmarkeh H, Grandena F. Cultural perceptions of aging: the perspective of

Somali Canadians in Ottawa. J Cross Cult Gerontol. 2012;27(4):409–24. https://doi.org/10.1007/s10823-012-9180-3. 28. Intrieri RC, Kurth ML. Racial differences in attitudes toward aging, aging knowledge, and

contact. Educ Gerontol. 2018;44(1):40–53. https://doi.org/10.1080/03601277.2017.1388962. 29. Hummert ML, Shaner JL, Garstka TA, Henry C. Communication with older adults – the

influence of age stereotypes, context, and communicator age. Hum Commun Res. 1998;25(1):124–51. https://doi.org/10.1111/j.1468-2958.1998.tb00439.x.

30. Kornadt AE, Rothermund K. Contexts of aging: assessing evaluative age stereotypes in differ- ent life domains. J Gerontol B Psychol Sci Soc Sci. 2011;66(5):547-56.

https://doi.org/10.1093/geronb/gbr036. 31. Levy BR, Leifheit-Limson E. The stereotype-matching effect: greater influence on functioning

when age stereotypes correspond to outcomes. Psychol Aging. 2009;24(1):230–3 https://doi.org/10.1037/a0014563. 32. Fayehun O, Adebayo K, Gbadamosi O. The media, informal learning and ageism in Ibadan,

Nigeria. Niger J Sociol Anthropol. 2014;12(1):13449. https://doi.org/10.36108/njsa/4102/12(0190). 33. Higashi RT, Tillack AA, Steinman M, Harper M, Johnston CB. Elder care as “frustrating” and

“boring”: understanding the persistence of negative attitudes toward older patients among physicians-in-training. J Aging Stud. 2012;26(4):476–83.

https://doi.org/10.1016/j.jaging.2012.06.007. 34. Greene MG, Adelman R, Charon R, Hoffman S. Ageism in the medical encounter: an explor-

atory study of the doctor–elderly patient relationship. Lang Commun. 1986;6(1-2):113–24. https://doi.org/10.1016/0271-5309(86)90010-8.

35. Michielutte R, Diseker RA. Health care providers’ perceptions of the elderly and level of interest in geriatrics as a specialty. Gerontol Geriatr Educ. 1984;5(2):65–85.

https://doi.org/10.1300/j021v05n02_08.

1 5

CHAPTER 01

36. Reyes-Ortiz CA. Physicians must confront ageism. Acad Med. 1997;72(10):831. https://doi.org/10.1097/00001888-199710000-00001. 37. Gomez-Moreno C, Verduzco-Aguirre H, Contreras-Garduno S, Perez-de-Acha A, Alcalde-

Castro J, Chavarri-Guerra Y, et al. Perceptions of aging and ageism among Mexican physicians-in-training. Clin Transl Oncol. 2019;21(12):1730–5.

https://doi.org/10.1007/s12094-019-02107-w. 38. Marquet M, Missotten P, Schroyen S, Nindaba D, Adam S. Ageism in Belgium and Burundi: a

comparative analysis. Clin Interv Aging. 2016;11:1129-39. https://doi.org/10.2147/CIA.S105298. 39. Ozdemir O, Bilgili N. Attitudes of Turkish nursing students related to ageism. J Nurs Res.

2016;24(3):211–6. https://doi.org/10.1097/jnr.0000000000000131. 40. Rush KL, Hickey S, Epp S, Janke R. Nurses’ attitudes towards older people care: an inte-

grative review. J Clin Nurs. 2017;26(23-24):4105–16. https://doi.org/10.1111/jocn.13939. 41. Smeaton D, Parry J. Becoming an age-friendly employer: evidence report. London: Centre for

Ageing Better; 2018 (https://www.ageing-better.org.uk/sites/default/files/2018-09/ Being-age-friendly-employer-evidence-report.pdf, accessed 13 October 2020).

42. Bal AC, Reiss AE, Rudolph CW, Baltes BB. Examining positive and negative perceptions of older workers: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2011;66(6):687-8. https://doi.org/10.1093/geronb/gbr056.

43. Harris K, Krygsman S, Waschenko J, Laliberte Rudman D. Ageism and the older worker: a scoping review. Gerontologist. 2018;58(2):e1–14. https://doi.org/10.1093/geront/gnw194.

44. Posthuma RA, Campion MA. Age stereotypes in the workplace: common stereotypes, moderators, and future research directions. J Manag. 2009;35(1):158–88.

https://doi.org/10.1177/0149206308318617. 45. Kluge A, Krings F. Attitudes toward older workers and human resource practices. Swiss J

Psychol. 2008;67(1):61–4. https://doi.org/10.1024/1421-0185.67.1.61. 46. Twenge JM. Generation me – revised and updated: why today’s young Americans are

more confident, assertive, entitled – and more miserable than ever before. New York: Simon and Schuster; 2014.

47. Finkelstein LM, Ryan KM, King EB. What do the young (old) people think of me? Content and accuracy of age-based metastereotypes. Eur J Work Organ Psychol. 2013;22(6):633– 57. https://doi.org/10.1080/1359432x.2012.673279.

48. Gibson KJ, Zerbe WJ, Franken RE. The influence of rater and ratee age on judgments of work-related attributes. J Psychol. 1993;127(3):271–80.

https://doi.org/10.1080/00223980.1993.9915561. 49. Makita M, Mas-Bleda A, Stuart E, Thelwall M. Ageing, old age and older adults: a social

media analysis of dominant topics and discourses. Ageing Soc. 2019:1–26. https://doi.org/10.1017/S0144686X19001016. 50. Loos E, Ivan L. Visual ageism in the media. In: Ayalon L, Tesch-Römer C, editors.

Contemporary perspectives on ageism. Cham: Springer; 2018:163–76 (https://link.springer.com/chapter/10.1007/978-3-319-73820-8_11, accessed 13 October 2020).

51. Griffin C. Representations of the young. In: Roche J, Tucker S, Flynn R, Thomson R, editors. Youth in society: contemporary theory, policy and practice. London: Sage; 2004:10–8.

52. Stangor C, Jhangiani R, Tarry H. Principles of social psychology, first international edition. Vancouver (Canada): BC Campus Open Education 2017 (https://opentextbc.ca/socialpsychology/, accessed 13 October 2020).

53. Dovidio JF, Hewstone M, Glick P, Esses VM. Prejudice, stereotyping and discrimination: theoret- ical and empirical overview. In: Dovidio JF, Hewstone M, Glick P, Esses VM, editors. The Sage handbook of prejudice, stereotyping and discrimination. Thousand Oaks (CA): Sage; 2010:3–28.

1 6

GLOBAL REPORT ON AGEISM

54. Posthuma RA, Wagstaff MF, Campion MA. Age stereotypes and workplace age discrimi- nation: a framework for future research. In: Hedge JW, Borman WC, editors. The Oxford handbook of work and aging. Oxford: Oxford University Press; 2012:298–312.

55. Altman A. Discrimination. In: Zalta EN, editor. Stanford encylopedia of philosophy [website]. Stanford (CA): Center for the Study of Language and Information, Stanford University; 2020 (https://plato.stanford.edu/entries/discrimination/, accessed 20 September 2020).

56. Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ. Institutional ageism in global health policy. BMJ. 2016;354:i4514. https://doi.org/10.1136/bmj.i4514.

57. Heikkinen S, Krekula C. Ålderism—ett fruktbart begrepp [Ageism—a useful concept]? Sociol forsk. 2008:45:18–34 (in Swedish) (https://sociologiskforskning.se/sf/article/view/19233, accessed 13 October 2020).

58. Berard TJ. The neglected social psychology of institutional racism. Sociology Compass. 2008;2(2):734–64. https://doi.org/10.1111/j.1751-9020.2007.00089.x.

59. Ben-Harush A, Shiovitz-Ezra S, Doron I, Alon S, Leibovitz A, Golander H, et al. Ageism among physicians, nurses, and social workers: findings from a qualitative study. Eur J Ageing. 2017;14(1):39–48. https://doi.org/10.1007/s10433-016-0389-9.

60. Duncan C, Loretto W. Never the right age? Gender and age-based discrimination in employment. Gend Work Organ. 2004;11(1):95–115. https://doi.org/10.1111/j.1468-0432.2004.00222.x.

61. Williams KN, Herman R, Gajewski B, Wilson K. Elderspeak communication: impact on demen- tia care. Am J Alzheimers Dis Other Dement. 2009;24(1):11–20.

https://doi.org/10.1177/1533317508318472. 62. Balsis S, Carpenter BD. Evaluations of elderspeak in a caregiving context. Clin Gerontol.

2006;29(1):79–96. https://doi.org/10.1300/J018v29n01_07. 63. Levy BR. Mind matters: cognitive and physical effects of aging self-stereotypes. J Gerontol B

Psychol Sci Soc Sci. 2003;58(4):P203–11. https://doi.org/10.1093/geronb/58.4.p203. 64. Levy BR, Banaji MR. Implicit ageism. In: Nelson TD, editor. Ageism: stereotyping and prejudice

against older persons. Cambridge (MA): MIT Press; 2004:49–75. 65. Levy BR. Eradication of ageism requires addressing the enemy within. Gerontologist.

2001;41(5):578–9. https://doi.org/10.1093/geront/41.5.578. 66. Finding the frame: an empirical approach to reframing aging and ageism. Washington (DC):

Frameworks Institute; 2017 (https://www.frameworksinstitute.org/publication/find- ing-the-frame-an-empirical-approach-to-reframing-aging-and-ageism/, accessed 13 October 2020).

67. Bergman YS, Bodner E. Ageist attitudes block young adults’ ability for compassion toward incapacitated older adults. Int Psychogeriatr. 2015;27(9):1541–50.

https://doi.org/10.1017/S1041610215000198. 68. Rupp DE, Vodanovich SJ, Crede M. Age bias in the workplace: the impact of ageism and

causal attributions. J Appl Soc Psychol. 2006;36(6):1337–64. https://doi.org/10.1111/j.0021-9029.2006.00062.x. 69. Voss P, Bodner E, Rothermund K. Ageism: the relationship between age stereotypes

and age discrimination. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:11–31 (https://link.springer.com/ chapter/10.1007/978-3-319-73820-8_2, accessed 13 October 2020).

70. Dovidio JF, Brigham JC, Johnson BT, Gaertner SL. Stereotyping, prejudice, and discrimination: another look. In: Macrae CN, Stangor C, Hewstone M, editors. Stereotypes and stereotyping. New York: Guilford; 1996:276–322.

1 7

CHAPTER 01

71. Seefeldt C. Children’s attitudes toward the elderly: a cross-cultural comparison. Int J Aging Hum Dev. 1984;19(4):319–28. https://doi.org/10.2190/DFTB-2HCV-AHJW-6LFJ.

72. Montepare JM, Zebrowitz LA. A social-developmental view of ageism. In: Nelson TD, editor. Ageism: stereotyping and prejudice against older persons. Cambridge (MA): MIT Press; 2002:77–125.

73. Cuddy AJ, Fiske ST, Glick P. The BIAS map: behaviors from intergroup affect and stereotypes. J Personal Soc Psychol. 2007;92(4):631–48. https://doi.org/10.1037/0022-3514.92.4.631.

74. Seefeldt C, Jantz RK, Galper A, Serock K. Using pictures to explore children’s attitudes toward the elderly. Gerontologist. 1977;17(6):506–12.

https://doi.org/10.1093/geront/17.6.506. 75. Nosek BA, Banaji MR, Greenwald AG. Harvesting implicit group attitudes and beliefs from a

demonstration web site. Group Dyn. 2002;6(1):101–15. https://doi.org/10.1037//1089-2699.6.1.101. 76. Lamont RA, Swift HJ, Abrams D. A review and meta-analysis of age-based stereotype threat:

negative stereotypes, not facts, do the damage. Psychol Aging. 2015;30(1):180–93. https://doi.org/10.1037/a0038586. 77. Steele CM. Whistling Vivalidi: and other how stereotypes affect us and what we can do.

New York: W.W Norton; 2010. 78. Palmore E. Ageism comes of age. J Gerontol B Psychol Sci Soc Sci. 2015;70(6):873–5. https://doi.org/10.1093/geronb/gbv079. 79. Ayalon L. Perceived age, gender, and racial/ethnic discrimination in Europe: results from the

European Social Survey. Educ Gerontol. 2014;40(7):499–517 https://doi.org/10.1080/03601277.2013.845490.

80. Gayman MD, Barragan J. Multiple perceived reasons for major discrimination and depression. Soc Mental Health. 2013;3(3):203–20. https://doi.org/10.1177/2156869313496438.

81. Grollman EA. Multiple forms of perceived discrimination and health among adolescents and young adults. J Health Soc Behav. 2012;53(2):199–214. https://doi.org/10.1177/0022146512444289.

82. Grollman EA. Multiple disadvantaged statuses and health: the role of multiple forms of discrimination. J Health Soc Behav. 2014;55(1):3–19.

https://doi.org/10.1177/0022146514521215. 83. Kelley-Moore JA, Schumacher JG, Kahana E, Kahana B. When do older adults become “dis-

abled”? Social and health antecedents of perceived disability in a panel study of the oldest old. J Health Soc Behav. 2006;47(2):126–41.

https://doi.org/10.1177/002214650604700203. 84. Taylor P, Morin R, Parker K, Cohn D, Wang W. Growing old in America: expectations vs.

reality. Washington (DC): Pew Research Center; 2009 (https://www.pewresearch.org/ wp-content/uploads/sites/3/2010/10/Getting-Old-in-America.pdf, accessed 13 October 2020).

85. World report on disability 2011. Geneva: World Health Organization, World Bank; 2011 (https://apps.who.int/iris/handle/10665/44575, accessed 13 October 2020).

86. Gibbons HM. Compulsory youthfulness: intersections of ableism and ageism in “successful aging” discourses. Rev. Disabil Stud. 2016;12:1–19 (http://hdl.handle.net/10125/58668, accessed 13 October 2020).

87. McPherson BD. Sociocultural perspectives on aging and physical activity. J Aging Phys Act. 1994;2(4):329–53. https://doi.org/10.1123/japa.2.4.329.

88. Namkung EH, Carr D. Perceived interpersonal and institutional discrimination among persons with disability in the U.S.: do patterns differ by age? Soc Sci Med. 2019;239:112521.

1 8

GLOBAL REPORT ON AGEISM

https://doi.org/10.1016/j.socscimed.2019.112521. 89. Paterson K, Hughes B. Disability studies and phenomenology: the carnal politics of everyday

life. Disabil Soc. 1999;14(5):597–610. https://doi.org/10.1080/09687599925966. 90. Kane RL, Priester R, Neumann D. Does disparity in the way disabled older adults are treated

imply ageism? Gerontologist. 2007;47(3):271–9. https://doi.org/10.1093/geront/47.3.271. 91. Jönson H, Larsson AT. The exclusion of older people in disability activism and policies – a case

of inadvertent ageism? J Aging Stud. 2009;23(1):69–77. https://doi.org/10.1016/j.jaging.2007.09.001. 92. Jyrkinen M. Women managers, careers and gendered ageism. Scand J Manag. 2014;30(2):175–

85. https://doi.org/10.1016/j.scaman.2013.07.002. 93. Krekula C, Nikander P, Wilińska M. Multiple marginalizations based on age:

gendered ageism and beyond. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:33–50 (https://link.springer.com/ chapter/10.1007/978-3-319-73820-8_3, accessed 13 October 2020).

94. Barrett AE, Naiman-Sessions M. ‘It’s our turn to play’: performance of girlhood as a collective response to gendered ageism. Ageing Soc. 2016;36(4):764–84.

https://doi.org/10.1017/S0144686x15000021. 95. Deuisch FM, Zalenski CM, Clark ME. Is there a double standard of aging? J Appl Soc Psychol.

1986;16(9):771–85. https://doi.org/10.1111/j.1559-1816.1986.tb01167.x. 96. Sontag S. The double standard of aging. In: Pearsall M, editor. The other within us: feminist

explorations of women and aging. New York: Routledge; 1997:19–24. 97. Musaiger AO, D’Souza R. Role of age and gender in the perception of aging: a communi-

ty-based survey in Kuwait. Arch Gerontol Geriatr. 2009;48(1):50–7. https://doi.org/10.1016/j.archger.2007.10.002. 98. Lincoln AE, Allen MP. Double jeopardy in Hollywood: age and gender in the careers of film

actors, 1926–1999. Sociol Forum. 2004;19(4):611–31. https://doi.org/10.1007/s11206-004-0698-1. 99. Cruikshank M. Learning to be old: gender, culture, and aging, third edition. Lanham (MD):

Rowman & Littlefield; 2013. 100.Dingman S, Otte MEM, Foster C. Cosmetic surgery: feminist perspectives. Women Ther.

2012;35(3-4):181–92. https://doi.org/10.1080/02703149.2012.684536. 101. Jyrkinen M, Mckie L. Gender, age and ageism: experiences of women managers in Finland and

Scotland. Work Employ Soc. 2012;26(1):61–77. https://doi.org/10.1177/0950017011426313. 102. Clarke LH, Griffin M. Visible and invisible ageing: beauty work as a response to ageism. Ageing

Soc. 2008;28(5):653–74. https://doi.org/10.1017/S0144686x07007003. 103. Calasanti T. Bodacious berry, potency wood and the aging monster: gender and age relations

in anti-aging ads. Soc Forces. 2007;86(1):335–55. https://doi.org/10.1353/sof.2007.0091. 104.Eboiyehi FA. Convicted without evidence: elderly women and witchcraft accusations in

contemporary Nigeria. J Int Women’s Stud. 2017;18(4):247–65 (https://vc.bridgew.edu/cgi/ viewcontent.cgi?article=1976&context=jiws, accessed 13 October 2020).

105.Eboiyehi FA, Akinyemi AI. We are strangers in our homes: older widows and property inher- itance among the Esan of South-South Nigeria. Int J Ageing Dev Ctries. 2016;1(2):90–112 (https://www.inia.org.mt/wp-content/uploads/2017/01/1.2-4-Nigeria-90-to-112-Final.pdf, accessed 13 October 2020).

106.Kimani EN, Maina LW. Older women’s rights to property and inheritance in Kenya: culture, policy, and disenfranchisement. J Ethn Cult Divers Soc Work. 2010;19(4):256–71.

https://doi.org/10.1080/15313204.2010.523647.

1 9

CHAPTER 01

107. Gochfeld M. Sex–gender research sensitivity and healthcare disparities. J Womens Health (Larchmt). 2010;19(2):189–94. https://doi.org/10.1089/jwh.2009.1632.

108.Cameron KA, Song J, Manheim LM, Dunlop DD. Gender disparities in health and healthcare use among older adults. J Womens Health (Larchmt). 2010;19(9):1643–50.

https://doi.org/10.1089/jwh.2009.1701. 109. Travis CB, Howerton DM, Szymanski DM. Risk, uncertainty, and gender stereotypes in health-

care decisions. Women Ther. 2012;35(3-4):207–20. https://doi.org/10.1080/02703149.2012.684589. 110. Chrisler JC, Barney A, Palatino B. Ageism can be hazardous to women’s health: ageism, sexism,

and stereotypes of older women in the healthcare system. J Soc Issues. 2016;72(1):86–104. https://doi.org/10.1111/josi.12157.

111. Taylor D, Richards D. Triple jeopardy: complexities of racism, sexism, and ageism on the expe- riences of mental health stigma among young Canadian Black women of Caribbean descent. Front Sociol. 2019;4:43. https://doi.org/10.3389/fsoc.2019.00043.

112. Collins TA, Dumas TL, Moyer LP. Intersecting disadvantages: race, gender, and age discrimi- nation among attorneys*. Soc Sci Q. 2017;98(5):1642–58. https://doi.org/10.1111/ssqu.12376.

113. Barrett C, Hinchliff S. Addressing the sexual rights of older people: theory, policy and practice. London: Routledge; 2017.

114. King A, Almack K, Jones RL, editors. Intersections of ageing, gender and sexualities: multidisciplinary international perspectives. Bristol: Policy Press; 2019 (https://open- researchlibrary.org/viewer/14844558-066b-417b-b1ba-3c700424b02e/1, accessed 13 October 2020).

115. Harding R, Peel E, editors. Ageing and sexualities. London: Taylor & Francis; 2016. 116. Averett P, Yoon I, Jenkins CL. Older lesbian experiences of homophobia and ageism. J

Soc Serv Res. 2013;39(1):3–15. https://doi.org/10.1080/01488376.2012.727671. 117. Woody I. Aging out: a qualitative exploration of ageism and heterosexism among

aging African American lesbians and gay men. J Homosex. 2014;61(1):145–65. https://doi.org/10.1080/00918369.2013.835603.

2 0

GLOBAL REPORT ON AGEISM

VERA , 82 , K YRGY ZSTAN

2 1

CHAPTER 01

C H A P T E R 0 2

There are cases in the hospitals when we have to wait in long queues to see a doctor and when we are seen, some doctors don’t bother to lis ten to ever y thing we have to say, let alone examine us properly. When we start telling the doctors what our health problems are, they of ten say that these problems are due to our age and that they are natural changes . I feel ver y unwanted and helpless but there are no places to go and complain about this . Even if we did complain, I doubt they would listen to us .

Vera, 82 , Kyrgyzstan ©Malik Alymkulov/ HelpAge International

02

2 1

“

“

2 2

GLOBAL REPORT ON AGEISM

2.1 Institutional ageism Institutional ageism can manifest itself across different institutions, such as those providing health and social care, and in the workplace, the media and the legal system.

2.1.1 Ageism in health and social care

Health care rationing by age is widespread. A systematic review in 2020 showed that in 85% (127) of 149 studies, age determined who received certain medical procedures or treatments (1). One study of five medical centres in the United States examined how age affected the decisions of medical staff to withhold life- sustaining therapies in 9000 patients who had illnesses with high mortality rates. Medical staff were more likely to withhold ventilator support, surgery and dialysis as the patient’s age increased. For ventilator support, the rate of decisions to withhold therapy increased 15% with each decade of age; for surgery, the increase per decade was 19%; and for dialysis, it was 12% (2).

Older adults tend to be excluded from health research even though they account for a

Ageism against older people is widespread across institutions, including those providing health and social care, and in workplaces, the media and others.

Ageism is pervasive across populations:

• 1 in 2 people worldwide are ageist;

• in Europe, 1 in 3 older people report having been a target of ageism.

Ageism is more prevalent in low- and middle- income countries.

GLOBAL REPORT ON AGEISM

02 Chapter

2 2

This chapter presents evidence on the scale of institutional ageism, interpersonal ageism and self-directed ageism. Section 2.1 describes the reach of institutional ageism by examining how it manifests itself in a variety of institutions. Section 2.2 surveys the evidence on the prevalence of interpersonal ageism around the world. Section 2.3 presents an overview of what little is known about the magnitude of self- directed ageism. Having an accurate understanding of the scale of ageism against older people is a critical first step for efforts to reduce it.

2 3

CHAPTER 02

disproportionate share of the total burden of disease and the use of prescription medicines and therapies. A systematic review found evidence of ageism in all 49 studies that investigated the link between age and exclusion from different types of health research (1). These studies showed that older persons were systematically excluded from clinical trials in cardiology, internal medicine, nephrology, neurology, preventive medicine, psychiatry, rheumatology, oncology and urology, even though many of the conditions under study are more prevalent in older age.

Thus, the patients enrolled in many clinical trials are not representative of the actual distribution of patients in the general population, and the findings of such research – on the safety and efficacy of treatments – may not apply to older populations (1). Research into Parkinson’s disease, which mainly affects older populations, clearly highlights this exclusion. A systematic analysis of 206 research studies recruiting patients with Parkinson’s disease found that almost 50% of them excluded patients who were older than 79.3 years (3).

The extent to which health and social care workers hold ageist attitudes towards patients, while perceived to be high, is uncertain (4, 5). A review of 12 literature reviews of ageism among health-care workers (e.g. nurses, health-care providers in general, medical and nursing students) concluded that the evidence is contradictory and inconclusive, and that many of the studies were of poor quality.

This review highlights the urgent need for high-quality studies on ageism among health and social care workers, given that ageism is linked to reduced health care access (5). A 2017 review of nurses’ attitudes towards the care of older people concluded that there was a paucity of

research on the topic and that the limited evidence indicated that nurses’ attitudes are complex and contradictory (6).

Several studies also show that mental health professionals are not adequately trained to work with older patients, lack the clinical skills needed to diagnose and work with older patients who have mental health problems, hold negative attitudes towards this population and are less willing to work with them (7).

Although the demand for social care, including long-term care, has risen and is expected to rise further in response to population ageing (8), research on the manifestations of ageism in social care, including long-term care, is limited, particularly in lower-resource settings (4). Nonetheless, the few studies that exist report clear manifestations of ageism in long-term care. For example, a study in Canada found that most older residents in long-term care institutions perceived communication with caregivers as ageist. Caregivers used controlling language and infantile and patronizing patterns of communication (9). In long-term care institutions in Israel, ageism was evident through the lack of accurate medical diagnoses, the objectification of older residents, the routine neglect of their needs and attempts to save money at their expense (10).

In Australia, several inquiries and reviews revealed the presence of ageism in the long-term care sector, for instance, in the types of services available to older people, the language used when interacting with older people and in assumptions about older people’s preferences and capabilities. In response, the Australian Human Rights Commission made a submission to the Royal Commission into Aged Care Quality and Safety that included a series of

2 4

GLOBAL REPORT ON AGEISM

recommendations about how to address ageism in long-term care by adopting a human rights perspective (11).

Age bias may affect the type of information that health-care workers seek during their interactions with patients. For example, a study found that psychiatrists in the United Kingdom take a sexual history much more frequently from middle-aged men than from older men (12), which could have

implications for the early detection and treatment of sexually transmitted diseases (STDs) or other conditions (see Chapter 3, Section 3.1).

A further example of the insidious presence of ageism in health and social care has been evidenced during the novel coronavirus 2019 (COVID-19) pandemic that has affected societies and economies to their core (see Box 2.1).

Box 2.1 Ageism and COVID-19

WHO declared the outbreak of novel coronavirus disease 2019 (COVID-19) a pandemic on 11 March 2020 (13). Global evidence has shown that older people face a significantly higher case-fatality rate from this disease than people in younger age groups (14, 15). The case-fatality rate is also increased in those with underlying conditions that affect the immune, cardiovascular and respiratory systems, and these conditions are common in older age (16, 17). In many countries, evidence shows that more than 40% of deaths related to COVID-19 have been linked to long- term care facilities, with figures being as high as 80% in these facilities in some high-income countries (14).

This pandemic has not only taken a devastating toll on the lives of many older people around the world but also has exposed ageist stereotypes, prejudice and discrimination against older adults. There have been reports of discriminatory practices in access to health services and other critical resources in several countries, especially among older people living in long-term care facilities (18, 19). For example, in some contexts scarce resources, such as ventilators or access to intensive care units, have been allocated according only to chronological age (20). This can be considered unethical and ageist in the context of this pandemic, given that chronological age is only moderately correlated with biological age or short- term prognosis, and that older people have been most affected in terms of severe outcomes in this pandemic (21, 22).

Chronological age has also been used to determine physical isolation measures in different countries. For example, in the United Kingdom, adults aged 70 and older were initially instructed to self-isolate for 4 months (23); in Bosnia and Herzegovina, older adults were not allowed to leave their homes for several weeks during the outbreak (24); and in Colombia (25) and Serbia (26), lockdown measures targeted only older adults. Strategies for lifting lockdown measures in many countries also made distinctions by chronological age. For example, in several cities in the United Arab Emirates, people older than 60 years were not allowed to enter shopping malls or restaurants once they reopened following the period of population confinement

2 5

CHAPTER 02

(27). Similarly, in the Philippines, people older than 60 years were not allowed to take Metro Manila’s four railway systems once these resumed operations with the lifting of community confinement (28).

Using chronological age as the sole criterion for physical isolation measures and for extending periods of confinement is discriminatory because it fails to account for the very diverse capacities and needs of older populations. Such measures can increase the risks of social isolation and loneliness, limit older people’s ability to engage in self-care behaviours and challenge the ability of health and social care systems to respond to older peoples’ pre-existing medical and social needs, which can ultimately have a detrimental impact on older people’s health and well-being (29-31). The physical isolation of older people from their traditional social network (i.e. family, friends, care professionals) in the midst of the pandemic has also put them at greater risk for discrimination and abuse, be it in long-term care settings or at home (32-34). In addition, portraying the disease as an “older person’s illness”, by requiring only older adults to physically isolate or recommending that younger people stay home to protect their grandparents, may discourage younger people and others from following public health guidelines (35).

Ageism has also manifested in news and media coverage of the pandemic, with older adults being generally portrayed as a homogeneous, vulnerable group that is substantially different from other age groups (36). Portraying older adults as frail, vulnerable and in need of protection ignores the great diversity that is evidenced in older age. Such messaging can also have serious impacts on the health and well- being of older adults. Although it is necessary to identify and inform the populations who are most at risk, the ageist narrative around younger and older people runs the risk of pitting generations against each other, as illustrated by the rapid spread of the hashtag “boomer remover” in reference to the virus severely affecting older adults. In fact, nearly a quarter of all Twitter communication concerning older adults and COVID-19 has been classified as ageist (37). A comparable study based on the Chinese Weibo platform (which is similar to Twitter) found that the most popular themes related to COVID-19 and older persons concerned their contributions to society, but the themes of vulnerability and the need to protect older adults were also present (38). In Spain, an analysis of 501 headlines across two national newspapers found that 358 of these (71%) portrayed older people in a negative way (39).

The mathematical models of COVID-19 that have been used to guide the response to the pandemic have also often failed to consider populations in long-term care, an omission which is a form of ageism in statistics and data, given that the risk of spread of COVID-19 is higher in these facilities than in the general population (40).

The COVID-19 pandemic has not only exposed ageism in different settings but it has also presented the opportunity for many positive initiatives, reflective of solidarity and cohesion. For example, online information has been specifically developed for older adults (41), campaigns about older people’s mental health have been conducted (42), and digital technologies and support for their use have

2 6

GLOBAL REPORT ON AGEISM

also been developed to help older people communicate during confinement (43). Older persons have also taken part in many solidarity initiatives by responding to helplines, remotely helping children with their homework and by returning to work, in the case of retired front-line health-care workers.

The content of this box is based on a rapid review of the literature conducted in May 2020 and repeated in August 2020 using the search terms “ageism”’ and “COVID-19” or “corona” in Google Scholar. The initial review was supplemented by a search using the functions “cited by” and “related to” in Google Scholar to identify additional articles once a relevant article was found. More specific search terms were also used to identify any missing articles, including “media”, “policy”, “lockdown”, “triage”, “long-term care”, “nursing homes”, “residential care” and “COVID-19” or “corona”. The same search strategy was used in Google search. As this was not a systematic review of the evidence, it is possible that relevant literature was missed, including that on other possible manifestations of ageism against younger or older people.

2.1.2 Ageism in the workplace

Several reviews have demonstrated that ageism in the workplace occurs throughout the work cycle: during recruitment, once someone is employed and during dismissal or retirement processes (1, 44-47). Ageism in the workplace can limit older people’s income, as explained in Chapter 3.

For example, a systematic review of 60 studies found that employers were less likely to hire older applicants than younger applicants; that once employed, older workers had less access to training; and that those who faced ageism in the workplace were more likely to retire early (1).

A meta-analysis, which quantitatively summarized the effect of ageism on older workers in the workplace, found that the process of hiring older workers, their career advancement, performance appraisals and evaluations of interpersonal skills were all affected by ageism (44). The specific examples provided below illustrate the manifestations of ageism occurring during different phases of the work cycle.

Across a range of sectors (e.g. hospitality, sales, accountancy), younger workers are more likely to be interviewed and hired relative to both middle-aged and older adults (48). For example, in Spain, when employers were presented with the curriculum vitae of an older and a younger candidate who had equivalent characteristics, younger candidates were favoured over middle- aged candidates across six occupations (49). In this research, candidates aged 28 years had a call-back rate for an interview that was 77% above that of the 38-year-old candidates. The disadvantage experienced by older applicants may increase with jobs that require specialized training or in workplaces affected by technological change (50, 51). These research findings are echoed in a 2015 survey of public perception that found more than half of Europeans believed that age was a disadvantage for job applicants who were 55 years and older, but only 16% believed it was a disadvantage for jobseekers younger than 30 years (52).

Ageism, for those in employment, affects access to training opportunities, with older workers being most affected. A study in

2 7

CHAPTER 02

Switzerland found that 53% of employees of all ages believed older workers are harder to train, and 52% believed older workers are less interested in challenging jobs (53). The Survey of Health, Ageing and Retirement in Europe found that nearly half of all employed people older than 50 in Greece, Hungary, Poland and Spain reported not having had training opportunities (54).

Ageism may also contribute to older workers retiring prematurely. In an experimental study involving older white-collar workers in Belgium, those presented with negative information about older workers’ abilities were then more likely to express intentions to retire early than those presented with positive information (55).

2.1.3 Ageism and the media

Ageism is widespread in the media (56-59). Representations on television and social media and in print are crucial because they influence our everyday perceptions and interactions, including how we relate to older people, and they shape how we each see ourselves growing old (58).

A review of 25 empirical studies, conducted from 1982 to 2020, that analysed the visual representations of older people in print and television advertisements and programmes in Europe and North America found that until the 1990s, older adults were underrepresented and portrayed negatively. In the 1990s, although older adults continued to be underrepresented, there was a shift from negative stereotypes of older adults as unattractive, unhappy, unhealthy, lonely and dependent to a new stereotype of older adults as active, enjoying life and maintaining a healthy lifestyle (58). Implicit in this shift to a portrayal of positive ageing may lurk a more subtle form of ageism: that good health in later life is the choice and responsibility of

the individual and that inequalities in access to resources have little influence (58).

Two studies illustrate the underrepresentation of older people in the media. The first found that only 1.5% of characters on television in the United States were older people, and most of them had minor roles and were often portrayed for comic effect, drawing on stereotypes of physical, cognitive and sexual ineffectiveness (60). The second, an analysis of prime time television series in Germany, found that only 8.5% of main characters were older adults (61).

Ageism in social media is receiving increased research attention. A study focusing on the representation of ageing and older people on Twitter based on 1200 tweets found that the language used in tweets often reinforces negative stereotypes of older adults as a disempowered, vulnerable and homogeneous group, and ageing as something to be resisted, slowed or disguised (62). Another study of 354 tweets found that 12% (43) contained ageist language (63). An analysis of 84 Facebook groups that focused on older individuals found that ageism was rife within the groups. An analysis of the descriptions that introduced the groups showed that all but one focused on negative age stereotypes: 74% (62/84) excoriated older individuals, 27% (23/84) infantilized them and 37% (31/84) advocated banning them from public activities, such as shopping (64).

Media portrayals of older people vary around the world. A review of 25 studies from a range of countries across the WHO Regions of the Americas, Europe, South-East Asia and Western Pacific, which examined how older people are portrayed in the mass media, found important differences between these societies, as well as among Asian countries (57). For example, in the print media in China, Hong Kong Special

2 8

GLOBAL REPORT ON AGEISM

Administrative Region, vulnerability was a dominant theme (65), while in the Chinese mass media, filial respect for older people was prominent (66, 67). A comparison of how older people were portrayed in prime time television advertisements in the Republic of Korea and the United States found that older people were more likely to play major roles and be positively portrayed in the Republic of Korea (68).

In Japan, an analysis of some 3000 television advertisements broadcast on the five major commercial television stations found that older people were portrayed in more favourable ways, appeared more often and in more important roles in 2007 than in 1997. Still, older people continued to be underrepresented (69). A study in which Nigerian students were asked to describe how older people were represented in Nigerian films showed that they believed older people were portrayed as “wicked”, “weak”, “poor” and “diabolical” (70).

Ageism and sexism interact in the media. An analysis of 2000 Hollywood films found that women are given less dialogue the older they get: 38% of dialogue was spoken by women aged 22–31 years and 20% by those aged 42–65 years. In contrast, male actors get more lines as they age, up until age 65. At the age of 65, they begin to be viewed as old. At that point, men speak just 5% of the dialogue and women speak 3% (71). The fact that women are far less likely to be represented in media than men are has been reported from around the world (61, 68, 72, 73).

2.1.4 Ageism and the legal system

Ageism against older people in the legal system has been studied with regard to the use of arbitrary age limits in legislation, and in court proceedings and their outcomes.

Examples of arbitrary limits include legislation that specifies upper age limits for organ transplantation regardless of the intrinsic capacity of the patient (74), and legislation that mandates retirement from work based solely on chronological age (75, 76).

Studies of court proceedings and their outcomes have also identified the presence of ageism. A study conducted in Israel asked older women about their legal experience during divorce proceedings in later life. These women reported that they experienced ageism in the way that lawyers and judges treated them (77). Another study in Israel, which examined the knowledge and attitudes of lawyers toward ageing and older persons, found that lawyers expressed low levels of knowledge about ageing, but had mostly neutral and non-ageist attitudes towards their older clients (78).

Another study disentangled the effects of age and sex on witness credibility (79). Some 1300 undergraduate students read a case summary and witness statement in which the sex and age (49, 69, 79 or 89 years) of the witness were varied. The study found that older witnesses were not perceived to be less credible than younger witnesses, and the study also found that older men, but not older women, were regarded as more credible than middle- aged witnesses.

2.1.5 Other institutional settings

Ageism manifests across a range of other institutions and sectors, including housing, technology, finance, responses to emergencies and in the way statistics and data are collected and compiled, all of which have received less attention in research.

2 9

CHAPTER 02

Housing

In housing, age-based discrimination can occur during the screening of potential tenants, in the terms and conditions that apply to tenants and in the way people are required to leave (80). For instance, in Japan a study revealed that discrimination against older tenants was associated with several factors including fear that older tenants would get into disputes with other tenants; worries about negligence and safety problems, such as fires; and concerns that older tenants would stay a long time, making it difficult to raise their rent (81). Ageism can also manifest itself in the lack of accessibility, safety and quality in housing for older people (82).

Technology

While technology holds promise to improve the lives of older people, a digital divide has opened up between older and younger people that is partly due to ageism (83-85). For example, older adults who internalize the stereotype that older people cannot master technology may not even try to adopt new technologies (85). Ageist stereotypes may also explain why older adults are seldom included in focus groups assessing the design of new digital technologies (84).

Financial institutions

Many credit and loan schemes, particularly in low- and middle-income countries, have been found to discriminate against older people, often making it impossible for them to join. Women are particularly disadvantaged – a further example of how ageism and sexism interact – as they often have no independent income, no control over fixed assets such as land that could act as collateral and limited exposure to business or the formal employment sector (86, 87).

Financial institutions in high-income countries acknowledge that ageism is widespread (88, 89). Yet studies on ageism in the financial services are exceedingly rare. A report by the United Kingdom’s Financial Conduct Authority stated that older people are likely to find themselves victims of age discrimination in financial services because age – but not gender or race – can be used as a risk factor in pricing financial products, and financial institutions can refuse to provide products to certain age groups. For instance, because insurance risks are not distributed uniformly across age bands, upper age limits are set for most new travel insurance policies, and mortgages and private health insurance premiums are higher for older people (90, 91).

Natural disasters and conflict-related emergencies

The neglect of older people during natural disasters and conflict-related emergencies has become more visible in recent years (92-97). Older people make up a large and increasing number of those affected by emergencies (92), including natural disasters and conflicts. For example, Fig. 2.1 illustrates the disproportionate impact natural disasters can have on older people (93). Older people are also neglected in funding allocated for humanitarian responses. A 2016 report examined humanitarian funding delivered through the UN consolidated appeals process, using it as a proxy indicator for the degree to which the specific needs of older people are reflected in humanitarian programming (94). It found that of the 16 221 projects implemented between 2010 and 2014, only 6% (1009) included one or more activities that either targeted older people or that included older people alongside other vulnerable groups. Only 51% (513) of these projects were funded.

3 0

GLOBAL REPORT ON AGEISM

Fig. 2.1. Comparison of populations affected by and fatalities during natural disasters in Nepal and the Philippines, by age

Source: reproduced with permission from the International Federation of Red Cross and Red Crescent Societies (93).

Statistics and data

Ageism also manifests itself in the way statistics and data are collected and compiled. Examples include data simply not being collected about older people or when such data are collected, they are not disaggregated. For instance, many public health data sets focus on women aged 15-49 years or lump all data into a single age group of >60 years or >65 years, thus hiding the vast diversity among older people.

The use of the dependency ratio (the number of older people [aged > 60 or > 65]/ the number of working-age adults [aged 15–64]) is another instance of ageism as, in effect, it assumes that all older people are dependent. Many older people continue to contribute to the economy. Older adults

offer in-kind or financial support to their children or grandchildren. They volunteer. Many – especially those in countries with no or limited retirement benefits – continue to work in formal or informal employment as long as they can (98). The dependency ratio fails to reflect this.

A third example often pointed to is the indicator of premature mortality, defined as the percentage of 30-year-old people who will die before their 70th birthday from a range of diseases, including cardiovascular disease, cancer, diabetes or chronic respiratory disease. This indicator is used by WHO and included in the Sustainable Development Goals and has been interpreted as “a strong signal in favour of discriminating against older people in the allocation of health resources and the collection of data” (99).

Education

Education is a key institution in which ageism is only starting to receive attention. In the United States, for instance, in 2014, nearly 300 000 adults aged 55 years or older were enrolled in higher education, and 21.5% of the population aged 70 years or older was enrolled in some form of lifelong learning or adult education (100).

Ageism in higher education in the United States takes different forms, facilitated by the historically age-segregated structure of higher education. It can manifest itself in attitudes directed against older people on the part of staff and students and as negative attitudes on the part of older people themselves about returning to their studies. Ageist structural barriers, such as a lack of funding and support services (e.g. to help with technology), also often stand in the way of older people studying (101). Very little evidence on ageism in education is available from the rest of the world.

3 1

CHAPTER 02

Box 2.2

2.2 Interpersonal ageism This section provides an overview of the prevalence of interpersonal ageism, focusing both on the prevalence of ageist attitudes across countries and cultures, and reported experiences of ageism.

2.2.1 Holding ageist attitudes

An estimate of the prevalence of interpersonal ageism based on a survey of more than 83 000 people from 57 countries covering all six WHO Regions of the world, conducted between 2010 and 2014, showed that at least one in every two people held moderately or

highly ageist attitudes (i.e. stereotypes and prejudice) (102).

This study also classified countries as low, moderate, or high in ageist attitudes and found that 34 of the 57 countries were classified as moderate or high (see Fig. 2.2). The highest prevalence of ageism was in low-income and lower-middle-income countries (e.g. India, Nigeria, and Yemen): 39% of survey participants from low-income and lower-middle-income countries were high in ageist attitudes. This is concerning, given that about half (48.3%) of the world’s population lives in low-income and lower- middle-income countries: 9.3% in low-income countries and 39% in lower-middle-income countries (103).

Lower prevalence rates were found in higher-income countries (e.g. Australia,

The quality of the scales used to measure ageism

A systematic review of the scales used to measure ageism directed against older people was carried out to evaluate their reliability and validity (i.e. their quality) (106). It identified 11 different scales used to measure ageism, but only the Expectations Regarding Aging scale met the three minimum standards for reliability and validity. This scale assesses only the stereotype dimension of ageism, both towards other people and towards oneself. Thus, it does not evaluate the other two dimensions of ageism: prejudice and discrimination. No scale had high cross-cultural validity, a serious limitation for conducting any cross-national or cross-cultural studies. The review also found that of the many different measures of implicit ageism, none had been assessed in the minimum of three studies needed to be included in the review. To our knowledge, even less is known about the quality of scales used to measure ageism as it affects other age groups or to measure institutional ageism.

An unavoidable conclusion of the review is that existing estimates of the prevalence of ageism, given they were carried out using instruments often lacking reliability and validity, may not be accurate. There is urgent need to develop and validate a scale that can accurately measure the true magnitude and distribution of all the different dimensions of ageism (106). Given the fundamental importance of having a reliable and valid measure of ageism, WHO and its collaborators are developing such a scale as a matter of priority.

3 2

GLOBAL REPORT ON AGEISM

Japan and Poland): 69% of participants from high-income countries were low in ageist attitudes compared with 18% from low- income and lower-middle-income countries.

Regarding distribution across sociodemographic characteristics, analyses of these data showed that the prevalence of highly ageist attitudes was slightly higher among younger people and males, and it was markedly higher among people who had less education (102). Importantly, this study used a more comprehensive measure of ageism than many previous studies (see Box 2.2). The WHO African and South-East Asia Regions were the two regions where the largest proportion of the population held moderately or highly ageist attitudes (85.2% and 86.4%, respectively), whereas the Western Pacific Region had the lowest proportion of the population – 36.6% –holding moderately or highly ageist attitudes (see Fig. 2.3). A further analysis of the data showed that there were no marked differences in ageist attitudes between men and women in any WHO region (102).

Ageism across countries and cultures

Variations in the rates of ageism across countries and cultures and the factors that may account for these variations are just beginning to be explored. The analysis from WHO presented above, based on data from 57 countries, clearly showed that rates of ageism vary across the world, with low- and lower-middle-income countries having the highest rates.

A 2015 review of 37 papers explored the issue of cross-cultural variation in ageism in greater depth (104). The starting point was the prevailing belief that cultures in the WHO South-East Asia and Western Pacific Regions (e.g. China, India, Japan, Philippines and Viet Nam) hold older adults in higher esteem than in anglophone cultures (i.e.

Australia, Canada, New Zealand, United Kingdom and the United States) and cultures in the WHO European Region (e.g. Austria, Denmark, Greece and Sweden) owing to the stronger collectivist traditions of filial piety.

The analysis found evidence for the opposite pattern: anglophone cultures and those in the WHO European region appear to hold older adults in higher esteem than cultures in the WHO South-East Asia and Western Pacific Regions do. On closer inspection, however, the picture is more complex.

For instance, the review found that people in China, Japan and the Republic of Korea exhibited the greatest negativity towards older people within the WHO South-East Asia and Western Pacific Regions. Non- anglophone Europeans had the greatest negativity towards older people compared with North American and other anglophone countries. Additionally, people in two countries (France and Switzerland) had more negative perceptions of older people than people in the WHO South-East Asia and Western Pacific Regions. This analysis also found that negative views of older people appear to be driven by recent, rapid demographic changes in population ageing (see Chapter 5).

These and other findings highlight the inadequacy of using broad, geographical generalizations to understand contemporary attitudes towards older adults (104, 105).

A 2019 review of attitudes towards ageing and older people in Arab cultures identified seven empirical studies (107). The review paints an inconclusive and heterogeneous picture and calls for more and better research. Some of the studies pointed to more positive perceptions of ageing in Arab cultures than in the other countries studied

3 3

CHAPTER 02

Fig. 2.2. Map of countries showing countries classified as low, moderate or high in ageist attitudes

Fig. 2.3. Prevalence of population holding moderarately or highly ageist attitudes by WHO region, from a further analysis of data in reference 102

Note: The percentages apply only to the pooled data of the countries included in the analysis for each region (e.g. the 12 countries in the WHO Eastern Mediterranean Region).

3 4

GLOBAL REPORT ON AGEISM

(e.g. France, the Netherlands), such as more tolerance of older people, a stronger perception of older people as contributing to society and a greater sense of filial piety. But in other studies, sometimes conducted within the same country, a more negative view prevailed. The inconclusive findings may be related to differences among the respondents in terms of gender, age, urban or rural residence and education level. The authors speculate that the differences may also partly be due to the pressure of social norms that prescribe reverence for older people. This may lead respondents to feel reluctant to express negative views about individual older people, but freer to be critical of older people in general.

Ageism across time

Age stereotypes related to older adults may have become more negative over time, as suggested by limited evidence from the English-speaking world (108, 109). However, global data on historical trends in prevalence are lacking. A study based on an analysis of the 400 million word Corpus of Historical American English (1810–2009) found that age stereotypes have become more negative – in a linear way – during the past 200 years and that age stereotypes switched from being positive to negative around 1880. Two main factors were associated with this switch: the medicalization of ageing and the proportion of the population older than 65 years (108).

Another study, using Google Books’ Ngram Viewer search engine, which charts word frequencies in more than 5 million fiction and non-fiction books published between 1800 and 2000, found that from the early 1900s there was a shift from more positive to fewer positive terms about older adults, which may reflect a change in attitudes towards them (109). The analyses also

revealed that young and old women have been underrepresented in literature for the past 200 years, with the greatest difference appearing in 1900 when the term “old man” occurred more than three times more often than did “old woman”.

2.2.2 Experiences and perceptions of interpersonal ageism

Knowing the proportion of people who hold ageist attitudes is important; however, these figures are incomplete and are likely to be underestimations. Data on attitudes are likely to be underestimations, given people’s tendency to provide socially acceptable responses instead of choosing responses that reflect their true attitudes and behaviours (110). In addition to data on attitudes, information on the number of people who report experiencing ageism is essential; however, cross-national data on age-based discrimination derive predominantly from European countries and focus only on perceived age discrimination.

Across 28 countries in Europe, more than one in three people aged 65 years or older reported being a target of ageism (i.e. insulted, abused or denied services because of their age). The only age group to report higher rates of ageism were those aged 15–24 years (see Chapter 5).

Older people, along with all other age groups, also reported experiencing more discrimination based on age than discrimination based on sex, race or ethnic background (see Fig. 2.4) (111). More recent comparable data are available about the proportion of people who perceive that discrimination against people aged 55 or older is very or fairly widespread in the European Union. Findings vary from a high of two out of three people in Bulgaria (63.1%) to a low of one out of four people in Denmark (23.6%) (see Fig. 2.5) (112).

3 5

CHAPTER 02

Fig. 2.4. Percentage of people responding to the European Social Survey who reported experiencing unfair treatment because of their age, sex or race or ethnic background, by age group, 2008–2009 (includes only individuals who did not rate their experience as 0 on a scale that ranged from 0, indicating they had never experienced unfair treatment, to 4, indicating it was experienced very often)

Source: reproduced with permission from Abrams et al. (111).

Fig. 2.5. Comparison of perceptions of discrimination against people aged ≥ 55 years in 25 European Union countries

Source: reproduced with permission from Rychtaříková (112).

3 6

GLOBAL REPORT ON AGEISM

Although comparable cross-national data from other parts of the world about experiences and perceptions of ageism are lacking, some country-specific studies are available. For instance, in a nationally representative sample of people aged 50 years and older in Brazil, 16.8% of the population surveyed reported feeling that they had been the victim of some type of discrimination during the past year. This proportion was higher among urban dwellers than rural dwellers, most likely to occur in health care settings, and least likely to occur at work (113).

Discrimination against widows – of which there are some 250 million in the world – and accusations of witchcraft, both of which often target older women, are examples of how ageism interacts with sexism and puts older women in a situation of double jeopardy (114-116). Although quantitative data about the exact scale of discrimination against widows and accusations of witchcraft are scarce, these phenomena are widely reported to occur, particularly, but not exclusively, in sub-Saharan Africa (115, 117, 118). The forms of injustice that widows are subjected to – based on the intersection of their status as a widow, their gender, and often their age – are manifold, with some being widespread and others more culturally specific.

One example is the theft of widows’ property and the denial of their inheritance, which is reported to occur in sub-Saharan Africa, South America, South Asia and

the Middle East (118). Another example includes traditional widowhood customs, such as the social ostracism of widows, bans on remarriage and so-called cleansing rituals. These so-called cleansing rituals, which occur in parts of sub-Saharan Africa, sometimes require the widow to have sexual intercourse with a brother-in-law or another man to remove evil spirits (115, 118).

Accusations of witchcraft, most of which are directed at older women, are reported to occur frequently in countries in sub- Saharan Africa. Such accusations may result in the older woman being ostracized and neglected, driven out and banished from her community, or burned, stoned, chained up and, in some instances, killed (115, 118). In the United Republic of Tanzania, for instance, some 2500 older women were reportedly killed between 2004 and 2009 after being accused of witchcraft (119). In Burkina Faso, hundreds of older women accused of witchcraft (and called les mangeuses d’âmes, or soul eaters) have been either killed or banished (120). In northern Ghana, more than 1000 older women who were alleged to be witches have been driven out of their homes and are living in makeshift camps (121).

2.3 Self-directed ageism

Self-directed ageism can have a serious impact on people’s health, as shown in Chapter 3. But cross-national population- based studies of the prevalence of self- directed ageism are rare. In Panama, a study found that almost half (46.3%) of respondents aged 18–65 years recalled having engaged in self-directed ageism at least once, usually in response to a personal physical deficit (122).

Discrimination against widows and accusations of witchcraft are examples of how ageism interacts with sexism and puts older women in a situation of double jeopardy.

3 7

CHAPTER 02

Several studies have explored self- perceptions of ageing (i.e. people’s perceptions of themselves as they age), sometimes viewed as a proxy for self- directed ageism. For instance, studies have explored the distribution of self- perceptions of ageing according to different sociodemographic characteristics, including gender, race, ethnicity and education. A study in Germany found that positive self- perceptions of ageing increase in midlife but then decrease in later life (123). Findings about the relation between gender and self-perception have been inconsistent (124-126). People with higher incomes and education appear to have more positive self-perceptions of ageing than people with lower incomes and education (123, 127).

2.4 Conclusions and future directions

Ageism against older people is pervasive globally. It manifests itself in all key institutions in society. For example, in health and social care, where health care is sometimes rationed based on age; in the workplace during recruitment, employment and processes of retirement and dismissal; and in the media, where older people are often underrepresented.

Globally, at least one in two people hold ageist attitudes towards older adults. Across the countries in the European Social Survey, one in three older people has experienced ageism. Thus, ageism affects billions of people globally – and its spread may be increasing. Ageism constitutes both a serious and widespread human rights problem and a far-reaching public health problem, as both this chapter and Chapter 3, which discusses the impact of ageism, demonstrate.

Future priorities for understanding the scale of the problem should include:

• monitoring and tracking ageism in a range of key institutions, particularly among health and social care workers, in the housing sector, in the legal system and during emergencies, as well as in low- and middle-income countries more generally;

• using the instruments being developed to measure all of the different types and dimensions of ageism (see Box 2.2);

• conducting population-based surveys of ageism using these newly developed instruments to better estimate the global prevalence and distribution of, and trends in, ageism, including self-directed ageism;

• conducting studies on the intersection between ageism and other “isms”, including on situations of discrimination against widows and accusations of witchcraft.

Ageism affects billions of people globally and constitutes both a serious and widespread human rights problem and a far- reaching public health problem.

3 8

GLOBAL REPORT ON AGEISM

REFERENCES

1. Chang ES, Kannoth S, Levy S, Wang SY, Lee JE, Levy BR. Global reach of ageism on older persons’ health: a systematic review. PLOS ONE. 2020;15(1):e0220857.

https://doi.org/10.1371/journal.pone.0220857. 2. Hamel MB, Teno JM, Goldman L, Lynn J, Davis RB, Galanos AN, et al. Patient age and

decisions to withhold life-sustaining treatments from seriously ill, hospitalized adults. Ann Intern Med. 1999;130(2):116–25. https://doi.org/10.7326/0003-4819-130-2-199901190-00005.

3. Fitzsimmons PR, Blayney S, Mina-Corkill S, Scott GO. Older participants are frequently excluded from Parkinson’s disease research. Parkinsonism Relat Disord. 2012;18(5):585–9. https://doi.org/10.1016/j.parkreldis.2012.03.003.

4. de São José JMS, Amado CAF. On studying ageism in long-term care: a systematic review of the literature. Int Psychogeriatr. 2017;29(3):373–87.

https://doi.org/10.1017/S1041610216001915. 5. Wilson DM, Nam MA, Murphy J, Victorino JP, Gondim EC, Low G. A critical review of

published research literature reviews on nursing and healthcare ageism. J Clin Nurs. 2017;26(23-24):3881–92. https://doi.org/10.1111/jocn.13803.

6. Rush KL, Hickey S, Epp S, Janke R. Nurses’ attitudes towards older people care: an integrative review. J Clin Nurs. 2017;26(23-24):4105–16. https://doi.org/10.1111/jocn.13939.

7. Bodner E, Palgi Y, Wyman MF. Ageism in mental health assessment and treatment of older adults. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:241–62 (https://link.springer.com/chapter/10.1007/978-3-319-73820-8_15, accessed 15 October 2020).

8. Spasova S, Baeten R, Coster S, Ghailani D, Peña-Casas R, Vanhercke B. Challenges in long term care in Europe: a study of national policies 2018. Brussels: European Commission; 2018 (https://ec.europa.eu/social/main. jsp?catId=738&langId=en&pubId=8128&furtherPubs=yes, accessed 15 October 2020).

9. Lagacé M, Tanguay A, Lavallée M-L, Laplante J, Robichaud S. The silent impact of ageist communication in long term care facilities: elders’ perspectives on quality of life and coping strategies. J Aging Stud. 2012;26(3):335–42. https://doi.org/10.1016/j.jaging.2012.03.002.

10. Band-Winterstein T. Health care provision for older persons: the interplay between ageism and elder neglect. J Appl Gerontol. 2015;34(3):Np113–27.

https://doi.org/10.1177/0733464812475308. 11. A human rights perspective on aged care: submission to the Royal Commission into Aged

Care Quality and Safety. Sydney: Australian Human Rights Commission; 2019 (https://agedcare.royalcommission.gov.au/system/files/2020-06/AWF.500.00267.0002.

pdf, accessed 15 October 2020). 12. Bouman WP, Arcelus J. Are psychiatrists guilty of “ageism” when it comes to taking a sexual

history? Int J Geriatr Psychiatry. 2001;16(1):27–31. https://doi.org/10.1002/1099-1166(200101)16:1<27::Aid-gps267>3.0.Co;2-s. 13. WHO Director-General’s opening remarks at the media briefing on COVID-19 – 11 March

2020. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/director-general/speeches/detail/who-director-general-s- opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020).

14. COVID-19 data: effects of COVID-19 across the life course. In: World Health Organization, Maternal, Newborn, Child and Adolescent Health and Ageing data portal [website]. Geneva:

3 9

CHAPTER 02

World Health Organization; 2020 (https://www.who.int/data/maternal-newborn-child- adolescent-ageing/covid-19-data, accessed 16 June 16 2020).

15. Weekly epidemiological update – 3 November 2020. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/weekly-epidemiological-update---3- november-2020, accessed 4 November 2020).

16. Zheng Z, Peng F, Xu B, Zhao J, Liu H, Peng J, et al. Risk factors of critical & mortal COVID-19 cases: a systematic literature review and meta-analysis. J Infect. 2020;81:e16–25.

https://doi.org/10.1016/j.jinf.2020.04.021. 17. Sanyaolu A, Okorie C, Marinkovic A, Patidar R, Younis K, Desai P, et al. Comorbidity and its

impact on patients with COVID-19. SN Compr Clin Med. 2020;2:1069–76. https://doi.org/10.1007/s42399-020-00363-4. 18. Suarez-Gonzalez A, Matías-Guiu JA, Comas-Herrera A. Impact and mortality of the first

wave of COVID-19 on people living with dementia in Spain. In: International Long-Term Care Policy Network [website]. London: London School of Economics and Political Science; 2020 (https://ltccovid.org/wp-content/uploads/2020/08/Impact-of-COVID-19-on-people- living-with-dementia-in-Spain-10-August.pdf, accessed 13 October 2020).

19. Lessons to be drawn from the ravages of the COVID-19 pandemic in long-term care facilities. In: Council of Europe [website]. Strasbourg: Council of Europe, Commissioner for Human Rights; 2020 (https://www.coe.int/en/web/commissioner/news-2020/-/asset_publisher/ Arb4fRK3o8Cf/content/lessons-to-be-drawn-from-the-ravages-of-the-covid-19- pandemic-in-long-term-care-facilities?inheritRedirect=false, accessed 14 October 2020).

20. Joebges S, Biller-Andorno N. Ethics guidelines on COVID-19 triage – an emerging international consensus. Crit Care Med. 2020;24:201. https://doi.org/10.1186/s13054-020-02927-1.

21. Sprung CL, Danis M, Iapichino G, Artigas A, Kesecioglu J, Moreno R, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med. 2013;39:1916–24. https://doi.org/10.1007/s00134-013-3033-6.

22. Ethics and COVID-19: resource allocation and priority-setting. Geneva: World Health Organization; 2020 (WHO-RFH-20.2; https://www.who.int/ethics/publications/ethics- and-covid-19-resource-allocation-and-priority-setting/en/, accessed 13 October 2020).

23. Paton C. Coronavirus UK: elderly to be isolated for four months as part of COVID-19 plans. In: The National [website]. Abu Dhabi; The National; 2020 (https://www.thenationalnews. com/world/europe/coronavirus-uk-elderly-to-be-isolated-for-four-months-as-part-of- covid-19-plans-1.992514, accessed 13 October 2020).

24. Cerimovic E, Wurth M, Brown B. Bosnia and Herzegovina’s coronavirus curbs on children and older people are ill-conceived. In: Balkan Insight [website]. Sarajevo: Balkan Investigative Reporting Network; 2020 (https://balkaninsight.com/2020/04/02/bosnia-and- herzegovinas-coronavirus-curbs-on-children-and-older-people-are-ill-conceived/, accessed 13 October 2020).

25. So L, Tanfani J, Cocks T, Kelly T. Coronavirus spreads fear, isolation, death to elderly worldwide. In: Reuters, Healthcare and Pharma [website]. London: Thomson Reuters; 2020 (https://www. reuters.com/article/us-health-coronavirus-elderly-insight/coronavirus-spreads-fear- isolation-death-to-elderly-worldwide-idUSKBN2172N8, accessed 13 October 2020).

26. Vasovic A. Serbia imposes night curfew, orders elderly indoors. In: Reuters, Transportation [website]. London: Thomson Reuters; 2020 (https://www.reuters.com/article/ us-health-coronavirus-serbia/serbia-imposes-night-curfew-orders-elderly-indoors- idUSKBN2143XR, accessed 13 October 2020).

4 0

GLOBAL REPORT ON AGEISM

27. Jackson J. UN chief: discrimination of older people during pandemic must stop. In: Sierra Leone Times [website]. Sydney: Sierra Leone Times; 2020 (https://www.sierraleonetimes. com/news/264911308/un-chief-discrimination-of-older-people-during-pandemic-must- stop, accessed 13 October 2020).

28. Subingsubing K. LRT, MRT ban for elderly, moms-to-be under GCQ. In: Philippine Daily Inquirer [website]. Manila: Inquirer.net; 2020 (https://newsinfo.inquirer.net/1271069/lrt- mrt-ban-for-elderly-moms-to-be-under-gcq, accessed 13 October 2020).

29. Pfefferbaum B, North CS. Mental health and the COVID-19 pandemic. New Engl J Med. 2020;383:510–12. https://doi.org/10.1056/NEJMp2008017.

30. Steinman MA, Perry L, Perissinotto CM. Meeting the care needs of older adults isolated at home during the COVID-19 pandemic. JAMA Intern Med. 2020;180:819–20.

https://doi.org/10.1001/jamainternmed.2020.1661. 31. Tyrrell CJ, Williams KN. The paradox of social distancing: implications for older adults in the

context of COVID-19. Psychol Trauma. 2020;12:S214. https://doi.org/10.1037/tra0000845. 32. Gardner W, States D, Bagley N. The coronavirus and the risks to the elderly in long-term

care. J Aging Soc Policy. 2020;32:310–5.https://doi.org/10.1080/08959420.2020.1750543. 33. Bradbury‐Jones C, Isham L. The pandemic paradox: the consequences of COVID-19 on

domestic violence. J Clin Nurs. 2020;29:2047–9. https://doi.org/10.1111/jocn.15296. 34. Makaroun LK, Bachrach RL, Rosland A-M. Elder abuse in the time of COVID-19–increased

risks for older adults and their caregivers. Am J Geriatr Psychiatry. 2020;28:876–80. https://doi.org/10.1016/j.jagp.2020.05.017. 35. Fraser S, Lagacé M, Bongué B, Ndeye N, Guyot J, Bechard L, et al. Ageism and COVID-19:

what does our society’s response say about us?, Age Ageing. 2020;49:692–5. https://doi.org/10.1093/ageing/afaa097. 36. Le Couteur DG, Anderson RM, Newman AB. COVID-19 through the lens of gerontology. J

Gerontol A. 2020;75:e119–20. https://doi.org/10.1093/gerona/glaa077. 37. Jimenez-Sotomayor MR, Gomez-Moreno C, Soto-Perez-de-Celis E. Coronavirus, ageism,

and Twitter: an evaluation of tweets about older adults and COVID-19. J Am Geriatr Soc. 2020;68:1661–5. https://doi.org/10.1111/jgs.16508.

38. Xi W, Xu W, Ayalon L, Zhang X. A thematic analysis of Weibo topics (Chinese Twitter hashtag) regarding older adults during the COVID-19 outbreak. J GerontolB Psychol Sci Soc Sci. 2020;2020;gbaa148. https://doi.org/10.1093/geronb/gbaa148.

39. Bravo-Segal S, Villar F. La representación de los mayores en los medios durante la pandemia COVID-19: ¿hacia un refuerzo del edadismo? [Older people representation on the media during COVID-19 pandemic: a reinforcement of ageism?] Rev Esp Geriatr Gerontol. 2020;55:266–71. https://doi.org/10.1016/j.regg.2020.06.002.

40. Pillemer K, Subramanian L, Hupert N. The importance of long-term care populations in models of COVID-19. JAMA. 2020;324:25–6. https://doi.org/10.1001/jama.2020.9540.

41. Kraków dla seniora [Kraków for a senior]. Krakow: Krakow City Hall; 2020 (https://dlaseniora.krakow.pl/, accessed 15 October 2020). 42. Vlaamse Ouderenraad. Kopzorgen verdienen zorg [Campaign for the psychological well-

being of older people]. Brussels: Vlaamse Ouderenraad; 2020 (https://kopzorgen.be/, accessed 28 October 2020). 43. Getting started KIT. In: Age Action Ireland [website]. Dublin: Age Action Ireland; 2020 (https://www.ageaction.ie/how-we-can-help/getting-started-kit, accessed 15 October 2020).

4 1

CHAPTER 02

44. Bal AC, Reiss AE, Rudolph CW, Baltes BB. Examining positive and negative perceptions of older workers: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2011;66(6):687–98. https://doi.org/10.1093/geronb/gbr056.

45. Harris K, Krygsman S, Waschenko J, Laliberte Rudman D. Ageism and the older worker: a scoping review. Gerontologist. 2018;58(2):e1–14. https://doi.org/10.1093/geront/gnw194.

46. Posthuma RA, Campion MA. Age stereotypes in the workplace: common stereotypes, moderators, and future research directions. J Manag. 2009;35(1):158–88.

https://doi.org/10.1177/0149206308318617. 47. Truxillo DM, Finkelstein LM, Pytlovany AC, Jenkins JS. Age discrimination at work: a review of

the research and recommendations for the future. In: Colella A, King E, editors. The Oxford handbook of workplace discrimination. New York: Oxford University Press; 2018:129–42.

https://doi.org/10.1093/oxfordhb/9780199363643.013.10. 48. de la Fuente-Núñez V, Schwartz E, Roy S, Ayalon L. A scoping review on ageism against

younger populations. Unpublished. 49. Albert R, Escot L, Fernandez-Cornejo JA. A field experiment to study sex and age

discrimination in the Madrid labour market. Int J Hum Resour Manag. 2011;22(2):351–75. https://doi.org/10.1080/09585192.2011.540160. 50. Daniel K, Heywood JS. The determinants of hiring older workers: UK evidence. Labour Econ.

2007;14(1):35–51. https://doi.org/10.1016/j.labeco.2005.05.009. 51. Malul M. Older workers’ employment in dynamic technology changes. J Behav Exp Econ.

2009;38(5):809–13. https://doi.org/10.1016/j.socec.2009.05.005. 52. European Union Directorate General for Communication. Special Eurobarometer 437: discrimination in the EU in 2015 [online database]. Brussels: European Commission; 2015 (https://data.europa.eu/euodp/en/data/dataset/S2077_83_4_437_ENG, accessed 15

October 2020). 53. Kluge A, Krings F. Attitudes toward older workers and human resource practices. Swiss J

Psychol. 2008;67(1):61–4. https://doi.org/10.1024/1421-0185.67.1.61. 54. Abuladze L, Perek-Białas J. Measures of ageism in the labour market in international social

studies. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:461–91 (https://link.springer.com/chapter/10.1007/978-3-319-73820-8_28, accessed 15 October 2020).

55. Gaillard M, Desmette D. (In)validating stereotypes about older workers influences their intentions to retire early and to learn and develop. Basic Appl Soc Psychol. 2010;32(1):86–98 https://doi.org/10.1080/01973530903435763.

56. Appel M, Weber S. Do mass mediated stereotypes harm members of negatively stereotyped groups? A meta-analytical review on media-generated stereotype threat and stereotype lift. Commun Res. 2017; 2017. https://doi.org/10.1177/009365021771554.

57. Bai X. Images of ageing in society: a literature review. J Popul Ageing. 2014;7(3):231–53. https://doi.org/10.1007/s12062-014-9103-x.

58. Loos E, Ivan L. Visual ageism in the media. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:163–76

(https://link.springer.com/chapter/10.1007/978-3-319-73820-8_11, accessed 15 October 2020). 59. Ylänne V. Representations of ageing in the media. In: Twigg J, Martin W, editors. Routledge

Handbook of Cultural Gerontology. Routledge: London, UK; 2015. p. 369-75. 60. Zebrowitz LA, Montepare JM. “Too young, too old”: stigmatizing adolescents and elders. In:

Heatherton TF, Kleck RE, Hebl MR, Hull JG, editors. The social psychology of stigma. New York: Guilford Press; 2000:334–73.

4 2

GLOBAL REPORT ON AGEISM

61. Kessler EM, Rakoczy K, Staudinger UM. The portrayal of older people in prime time television series: the match with gerontological evidence. Ageing Soc. 2004;24(4):531–52.

https://doi.org/10.1017/S0144686x04002338. 62. Makita M, Mas-Bleda A, Stuart E, Thelwall M. Ageing, old age and older adults: a social

media analysis of dominant topics and discourses. Ageing Soc. 2019:2019:1–26. https://doi.org/10.1017/S0144686X19001016. 63. Gendron TL, Welleford EA, Inker J, White JT. The language of ageism: why we need to use

words carefully. Gerontologist. 2016;56(6):997–1006. https://doi.org/10.1093/geront/gnv066. 64. Levy BR, Chung PH, Bedford T, Navrazhina K. Facebook as a site for negative age

stereotypes. Gerontologist. 2014;54(2):172–6. https://doi.org/10.1093/geront/gns194. 65. Gibb H, Holroyd E. Images of old age in the Hong Kong print media. Ageing Soc.

1996;16(2):151–75 https://doi.org/10.1017/S0144686x00003275. 66. Cheng H, Schweitzer JC. Cultural values reflected in Chinese and US television commercials.

J Advert Res. 1996;36(3):27–44. 67. Lin CA. Cultural values reflected in Chinese and American television advertising. J Advert.

2001;30(4):83–94. https://doi.org/10.1080/00913367.2001.10673653. 68. Lee O, Kim BC, Han S. The portrayal of older people in television advertisements: a cross

cultural content analysis of the United States and South Korea. Int J Aging Hum Dev. 2006;63(4):279–97 https://doi.org/10.2190/ELLG-JELY-UCCY-4L8M.

69. Prieler M, Kohlbacher F, Hagiwara S, Arima A. The representation of older people in television advertisements and social change: the case of Japan. Ageing Soc. 2015;35(4):865–87. https://doi.org/10.1017/S0144686X1400004X.

70. Fayehun O, Adebayo K, Gbadamosi O. The media, informal learning and ageism in Ibadan, Nigeria. Niger J Sociol Anthropol. 2005;12(7):134-4.

71. Anderson H, Daniels M. Film dialogue from 2,000 screenplays, broken down by gender and age. In: The Pudding [website]. New York: The Pudding (https://pudding.cool/2017/03/film- dialogue/index.html, accessed 15 October 2020).

72. Vasil L, Wass H. Portrayal of the elderly in the media – a literature-review and implications for educational gerontologists. Educ Gerontol. 1993;19(1):71–85. https://doi.org/10.1080/0360127930190107.

73. Harwood J, Roy A. Social identity theory and mass communication research. In: Harwood J, Giles H, editors. Intergroup communication: multiple perspectives. Bern: Peter Lang; 2005:189–211.

74. Katvan E, Doron I, Ashkenazi T, Boas H, Carmiel-Haggai M, Elhalel MD, et al. Age limitation for organ transplantation: the Israeli example. Age Ageing. 2017;46(1):8–10.

https://doi.org/10.1093/ageing/afw162. 75. Doron I, Georgantzi N. Introduction: between law, ageing and ageism. In: Doron I, Georgantzi

N, editors. Ageing, ageism and the law: European perspectives on the rights of older persons. Cheltenham (England): Edward Elgar Publishing; 2018:1–13.

76. Doron I, Numhauser-Henning A, Spanier B, Georgantzi N, Mantavani E. Ageism and anti- ageism in the legal system: a review of key themes. In: Ayalon L, Tesch-Römer, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:303–20

(https://doi.org/10.1007/978-3-319-73820-8_19, accessed 15 October 2020). 77. Ohayon-Glicksman H. Grey divorce: the divorce experience of older women under Israeli

family law. Haifa: University of Haifa; 2018.

4 3

CHAPTER 02

78. Ontzik-Heilburn I, Or-Chen K. [Approach to elderly clients among lawyers in Israel: attitude towards the elderly and knowledge concerning the elderly among lawyers]. Gerontol Geriatr. 2014;41(3):31–49 (in Hebrew).

79. Mueller-Johnson K, Toglia MP, Sweeney CD, Ceci SJ. The perceived credibility of older adults as witnesses and its relation to ageism. Behav Sci Law. 2007;25(3):355–75.

https://doi.org/10.1002/bsl.765. 80. Spencer C. Ageism and the law: emerging concepts and practices in housing and health.

Toronto, ON: Law Commission of Ontario; 2009 (https://www.lco-cdo.org/wp-content/ uploads/2014/01/older-adults-commissioned-paper-spencer.pdf, accessed 15 October 2020).

81. Nakagawa M. Why is there discrimination against the elderly? Experimental and empirical analyses for the rental housing market in Japan. Osaka: The Institute of Social and Economic Research, Osaka University; 2003 (Discussion paper No. 578; https://www.iser.osaka u.ac. jp/library/dp/2003/DP0578.pdf, accessed 15 October 2020.

82. Home and dry: the need for decent homes in later life. London: Centre for Ageing Better; 2020 (https://www.ageing-better.org.uk/sites/default/files/2020-03/Home-and-dry-report.

pdf, accessed 15 October 2020). 83. Cutler SJ. Ageism and technology. Generations. 2005;29(3):67–72. 84. Mannheim I, Schwartz E, Xi W, Buttigieg SC, McDonnell-Naughton M, Wouters EJM, et al.

Inclusion of older adults in the research and design of digital technology. Int J Environ Res Public Health. 2019;16(19):3718. https://doi.org/10.3390/ijerph16193718.

85. McDonough C. The effect of ageism on the digital divide among older adults. J Gerontol Geriatr Med. 2016;2:1–7. https://doi.org/10.24966/GGM-8662/100008.

86. Randel J, German T, Ewing D, editors. The ageing and developoment report: poverty, independence and the world’s older people. London: Routledge; 1999.

87. Ageing in the twenty-first century: a celebration and a challenge. New York/London: United Nations Population Fund, HelpAge International; 2012 (https://www.unfpa.org/ publications/ageing-twenty-first-century, accessed 15 October 2020).

88. Migliaccio JN. The ageism within and how to counter it. J Financ Serv Prof. 2019;73(2):26–31. 89. Timmermann S. How do we (and our clients) feel about getting older? It’s time to reframe

aging. J Financ Serv Prof. 2017;71(5):36–39. 90. McLoughlin V, Stern S.Ageing population and financial services. London: Finacial Conduct

Authority; 2017 (Occasional paper 31; https://www.fca.org.uk/publication/occasional- papers/occasional-paper-31.pdf, accessed 15 October 2020).

91. Hejny H. Age discrimination in financial services: the United Kingdom case. E-Journal Int Comp Labour Stud. 2016;5(3):1–21. http://arro.anglia.ac.uk/id/eprint/701118.

92. Duault LA, Brown L, Fried L. The elderly: an invisible population in humanitarian aid. Lancet Public Health. 2018;3(1):e14. https://doi.org/10.1016/S2468-2667(17)30232-3.

93. Leave no one behind: developing climate-smart/disaster risk management laws that protect people in vulnerable situations for a comprehensive implementation of the UN Agenda 2030. Geneva: International Federation of Red Cross and Red Crescent Societies; 2020

(https://media.ifrc.org/ifrc/what-we-do/disaster-law/leave-no-one-behind/, accessed 4 March 2020).

94. Shami H, Skinner M.End the neglect: a study of humanitarian financing for older people. London: HelpAge International; 2016 (https://www.helpage.org/silo/files/end-the-neglect-a study-of-humanitarian-financing-for-older-people.pdf, accessed 15 October 2020).

95. Karunakara U, Stevenson F. Ending neglect of older people in the response to humanitarian emergencies. PLOS Med. 2012;9(12):e1001357.

https://doi.org/10.1371/journal.pmed.1001357.

4 4

GLOBAL REPORT ON AGEISM

96. Older persons in emergencies: an active ageing perspective. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43909, accessed 15 October 2020).

97. Older people in emergencies: considerations for action and policy development. Geneva: World Health Organization; 2008 (https://apps.who.int/iris/handle/10665/43817, accessed 15 October 2020).

98. Measure what you treasure: ageism in statistics. New York: United Nations Population Fund; 2020. 99. Lloyd-Sherlock PG, Ebrahim S, McKee M, Prince MJ. Institutional ageism in global health

policy. BMJ. 2016;354:i4514. https://doi.org/10.1136/bmj.i4514. 100.Whitbourne SK, Montepare JM. What’s holding us back? Ageism in higher education. In:

Nelson T, editor. Ageism: stereotyping and prejudice against older persons Cambridge (MA): MIT Press; 2017:263–90.

101. DiSilvestro FR. Continuing higher education and older adults: a growing challenge and golden opportunity. New Dir Adult Contin Educ. 2013;140:79-87.

https://doi.org/10.1002/ace.20076. 102. Officer A, Thiyagarajan JA, Schneiders ML, Nash P, de la Fuente-Núñez V. Ageism, healthy

life expectancy and population ageing: how are they related? Int J Environ Res Public Health. 2020;17(9):3159. https://doi.org/10.3390/ijerph17093159.

103. Classifying countries by income. In: The World Band [website]. Washington (DC): World Bank; 2019 (https://datatopics.worldbank.org/world-development-indicators/stories/the- classification-of-countries-by-income.html, accessed 21 January 2020).

104. North MS, Fiske ST. Modern attitudes toward older adults in the aging world: a cross-cultural meta-analysis. Psychol Bull. 2015;141(5):993–1021. https://doi.org/10.1037/a0039469.

105. Lockenhoff CE, De Fruyt F, Terracciano A, McCrae RR, De Bolle M, Costa PT Jr., et al. Perceptions of aging across 26 cultures and their culture-level associates. Psychol Aging. 2009;24(4):941–54. https://doi.org/10.1037/a0016901.

106. Ayalon L, Dolberg P, Mikulioniene S, Perek-Bialas J, Rapoliene G, Stypinska J, et al. A systematic review of existing ageism scales. Ageing Res Rev. 2019;54:100919.

https://doi.org/10.1016/j.arr.2019.100919. 107. Ibrahim CN, Bayen UJ. Attitudes toward aging and older adults in Arab culture: a literature

review. Z Gerontol Geriatr. 2019;52:180–7. https://doi.org/10.1007/s00391-019-01554-y. 108. Ng R, Allore HG, Trentalange M, Monin JK, Levy BR. Increasing negativity of age

stereotypes across 200 years: evidence from a database of 400 million words. PLOS ONE. 2015;10(2):e0117086. https://doi.org/10.1371/journal.pone.0117086.

109. Mason SE, Kuntz CV, McGill CM. Oldsters and Ngrams: age stereotypes across time. Psychol Rep. 2015;116(1):324–9. https://doi.org/10.2466/17.10.PR0.116k17w6.

110. Fisher RJ. Social desirability bias and the validity of indirect questioning. J Consum Res. 1993;20(2):303–15 https://doi.org/10.1086/209351.

111. Abrams D, Russell PS, Vauclair CM, Swift H. Ageism in Europe: findings from the European Social Survey. London: Age UK; 2011 (https://www.ageuk.org.uk/Documents/EN-GB/ For-professionals/ageism_across_europe_report_interactive.pdf?dtrk=true, accessed 15 October 2020).

112. Rychtaříková J. Perception of population ageing and age discrimination across EU countries. Popul Econ. 2019;3:1. https://doi.org/10.3897/popecon.3.e49760.

113. de Souza Braga L, Caiaffa WT, Ceolin APR, De Andrade FB, Lima-Costa MF. Perceived discrimination among older adults living in urban and rural areas in Brazil: a national study (ELSI-Brazil). BMC Geriatr. 2019;19(1):67. https://doi.org/10.1186/s12877-019-1076-4.

114. Chilimampunga C, Thindwa G. The extent and nature of witchcraft-based violence against children, women and the elderly in Malawi. Lilongwe: Royal Norwegian Embassy; 2012

4 5

CHAPTER 02

(http://www.whrin.org/wp-content/uploads/2014/06/Witchcraft-report-ASH.pdf, accessed 15 October 2020).

115. Ude PU, Njoku OC. Widowhood practices and impacts on women in sub-Saharan Africa: an empowerment perspective. Int Soc Work. 2017;60(6):1512–22.

https://doi.org/10.1177/0020872817695384. 116. Empowering widows: an overview of policies and programmes in India, Nepal and Sri

Lanka. New York: UN Women; 2014 (https://asiapacific.unwomen.org/en/digital-library/ publications/2015/09/empowering-widows#view, accessed 15 October 2020).

117. Eboiyehi FA. Convicted without evidence: elderly women and witchcraft accusations in contemporary Nigeria. J Int Women’s Stud. 2017;18(4):247–65.

https://vc.bridgew.edu/jiws/vol18/iss4/18/. 118. Harma RF. World widows report: a critical issue for the Sustainable Development Goals.

London: The Loomba Foundation; 2016 (https://www.theloombafoundation.org/sites/ default/files/2019-06/WWR.pdf, accessed 15 October 2020).

119. Sleap B. Violence against older women: tackling witchcraft accusations in Tanzania. In HelpAge International [website]. London: HelpAge International; 2011

(https://www.helpage.org/search/?keywords=tackling+witchcraft+accusations+in+ Tanzania, accessed 15 October 2020). 120. Discrimination against older women in Burkina Faso. London: Help Age International 2010

(https://tbinternet.ohchr.org/Treaties/CEDAW/Shared%20Documents/BFA/INT_ CEDAW_NGO_BFA_47_8112_E.pdf, accessed 15 October 2020).

121. Igwe L. Fighting witchcraft accusations in Africa. In: James Randi Educational Foundation (blog). Fort Lauderdale (FL): James Randi Educational Foundation; 2011 (http://archive.randi. org/site/index.php/swift-blog/1500-fighting-witchcraft-accusations-in-africa.html, accessed 15 October 2020).

122. Campos ID, Stripling AM, Heesacker M. “Estoy viejo”[I’m old]: internalized ageism as self referential, negative, ageist speech in the Republic of Panama. J Cross Cult Gerontol. 2012;27(4):373–90. https://doi.org/10.1007/s10823-012-9181-2.

123. Wurm S, Wolff JK, Schuz B. Primary care supply moderates the impact of diseases on self perceptions of aging. Psychol Aging. 2014;29(2):351–8. https://doi.org/10.1037/a0036248.

124. Kim ES, Moored KD, Giasson HL, Smith J. Satisfaction with aging and use of preventive health services. Prev Med. 2014;69:176–80. https://doi.org/10.1016/j.ypmed.2014.09.008.

125. Kleinspehn-Ammerlahn A, Kotter-Grühn D, Smith J. Self-perceptions of aging: do subjective age and satisfaction with aging change during old age? J Gerontol B Psychol Sci Soc Sci. 2008;63(6):P377–85. https://doi.org/10.1093/geronb/63.6.p377.

126. Sun JK, Kim ES, Smith J. Positive self-perceptions of aging and lower rate of overnight hospitalization in the US population over age 50. Psychosom Med. 2017;79(1):81–90.

https://doi.org/10.1097/PSY.0000000000000364. 127. Kwak M, Ingersoll-Dayton B, Burgard S. Receipt of care and depressive symptoms in

later life: the importance of self-perceptions of aging. J Gerontol B Psychol Sci Soc Sci. 2014;69(2):325–35. https://doi.org/10.1093/geronb/gbt128.

4 6

GLOBAL REPORT ON AGEISM

G E R T R U D E , 6 0 , KENYA

4 7

CHAPTER 01

4 7

C H A P T E R 0 3

Teaching is in my blood. It is no surprise I felt devastated when the Government told me at the age of 50 that I must stop working. They told me I was old and that I should allow young people to do the teaching. I felt bitter and angr y.

Gertrude, 60, Kenya ©Benj Binks / HelpAge International

03

“ “

4 8

GLOBAL REPORT ON AGEISM

3.1 The impact of ageism on health

Ageism has a serious impact on all aspects of health, which is defined by WHO as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (1) (see Fig. 3.1). Ageism thus constitutes an important, and hitherto neglected, social determinant of health. Its impact on health is on par with, if not greater than, that of racism, a form of prejudice and discrimination whose health consequences have been widely studied (2).

A global systematic review on the impacts of ageism on health commissioned for this report, which included 422 studies from 45 countries, found that in 405 (96%) studies, ageism was associated with worse outcomes in all of the health domains examined (2) (see Box 3.1). The association between ageism and health outcomes was strongest for self-directed ageism. The effects of ageism on health are seen in all parts of the world, have increased over time, and are most likely to impact disadvantaged groups. Furthermore, older people with lower levels of education are more likely to experience the health consequences of ageism. The review found there were health impacts from ageism in all 45 countries and across all areas (2). However, of

Ageism shortens lives; leads to poorer physical health and worse health behaviours; impedes recovery from disability; results in poorer mental health; exacerbates social isolation and loneliness; and reduces quality of life.

Ageism takes a heavy economic toll on individuals and society, contributing to financial insecurity and poverty and costing society billions of dollars.

GLOBAL REPORT ON AGEISM

03 Chapter

4 8

This chapter details the serious impacts of ageism against older people (see Fig.3.1). Section 3.1 describes the dramatic impact ageism has on health (including on well-being), leading, for instance, to preventable death and serious physical and mental health problems. Section 3.2 explores the heavy economic toll ageism takes on older people and on national economies. Overall, the impact of ageism is so serious and its costs appear to be so high that an intervention with only a modest effect has the potential to improve lives substantially and cut the economic costs of ageism significantly.

4 9

CHAPTER 03

the 422 studies included, 78.2% were conducted in North America or Europe, and only 1 study was conducted in Africa.

Consistent with other recent studies (3-5), many of the health consequences of ageism found in the systematic review appear to be increasing. This may be associated with financial downturns, as research has shown that economic crises lead to increases in prejudice and discrimination (2, 6, 7). Although the overall evidence of ageism among health-care workers is inconclusive, as shown in Chapter 2, it is possible that it may be increasing, perhaps because of the growing time pressure health workers are under (2).

3.1.1 The impact of ageism on physical health

Ageism is associated with earlier death (2). This finding was consistent across 10 studies that examined this ultimate end point in Australia, China, Germany and the United States (9-17). In China, researchers

found that older persons prone to self- directed ageism had an almost 20% higher likelihood of dying over the six-year study period than those with more positive self- perceptions (17).

Ageism is linked to poorer physical health, and it impedes recovery from disability. A total of 50 (96%) of the 52 studies that investigated the impact of ageism on physical illness found a link (2). Physical illness was measured by functional impairment, the presence of chronic conditions and the number of acute medical events and hospitalizations. For instance, in a study in Connecticut, United States, older persons who held positive age stereotypes were 44% more likely to fully recover from severe disability than those with negative age stereotypes (18).

Ageism increases risky health behaviours. In all 13 studies of this topic (2), people who had experienced ageism were more likely to adopt risky health behaviours, such as eating an unhealthy diet, not taking their medication as prescribed,

Fig. 3.1. The impacts of ageism on older people

5 0

GLOBAL REPORT ON AGEISM

drinking excessively or smoking, or some combination of these. A study of older people in Ireland that examined the relation between self-directed ageism and cigarette and alcohol use, showed that greater awareness of, and stronger emotional reactions to, ageing increased the likelihood of smoking (19).

Ageism contributes to poor sexual and reproductive health and is associated with an increase in rates of Sexually transmitted diseases (STDs). Epidemiological research from around the world indicates that rates of STDs are increasing in older people, and ageism may have a part to play in this (20-22).

Older people may be at greater risk of STDs due at the lack of information and campaigns targeted at them. Older people are also less likely to seek diagnosis and treatment because there is limited information about STDs, a lack of sexual health services for older people and a fear of encountering ageist attitudes towards their sexuality (21).

The exclusion of older people from surveillance data and research studies on STDs may also have contributed to the increase in STDs in this population by reducing awareness of the risk of STDs among older people (21, 22).

Box 3.1 Opportunities for research on the impact of ageism against older people

The systematic review commissioned for this report on the impact of ageism against older people marks a major step forward in improving the quality of research in this area (2). It was conducted according to the Preferred Reporting Items for Sys- tematic Reviews and Meta-Analyses (PRISMA) guidelines (8), based on a search of 14 electronic databases, included only studies that used appropriate designs and carefully assessed the quality of the studies. In addition, the review performed sen- sitivity – sometimes called “what if” – analyses and showed that the findings would have been the same if all of the studies had been of higher quality or included more participants.

This review was unable to estimate the strength of the association between ageism and its effects. To do this, studies would need to use more standardized and comparable definitions and measures of these effects. Estimating the strength of associations between ageism and its impacts, and more clearly demonstrating that ageism is indeed the cause of these impacts, rather than simply being associated with them, are areas where future studies and reviews should focus. The former would provide information on the relative importance of the different impacts of ageism, whereas the latter would increase our confidence that the relations between ageism and its putative effects are real. Future studies might also try to estimate the population attributable fraction for ageism at the level of countries, regions and the world. The population attributable fraction is the proportional reduction in population disease or mortality that would occur if exposure to a risk factor – ageism in this case – was reduced. For instance, it would allow us to say that if ageism was reduced by X%, longevity would be increased by Y%.

5 1

CHAPTER 03

For example, in China, 15.8% of all STD cases in men and 9.8% of all STD cases in women occurred in those aged 50 years and older, and people aged 65 years and older accounted for some 10% of newly reported cases in 2016 (23, 24).

In Botswana, the country with the second highest HIV prevalence in the world, rates of HIV prevalence in older men have increased from 17.2% in 2004 to 27.8% in 2013 and in older women from 16.3% in 2004 to 21.9% in 2013 (20).

Both interpersonal and institutional ageism can contribute to inappropriate medication use, including inappropriate prescribing, polypharmacy and medication nonadherence, all of which can have serious consequences.

Information is sometimes lacking about the efficacy and safety profiles of medications for older people because the necessary age-specific clinical trials have not been conducted: this is a form of institutional ageism that can result in inappropriate prescribing and polypharmacy (25-27). Poor coordination of care for older people, ineffective communication and inadequate education of older adults about medication are forms of institutional and interpersonal ageism that can lead to medication nonadherence (28-30).

Largely due to inappropriate prescribing, some 25% of patients aged 70–79 years suffer from adverse drug events compared with about 4% among those aged 20–29 years (25, 31, 32).

Polypharmacy, which is widespread among older people, results in a host of negative consequences: increased health care costs, adverse medication reactions, reduced intrinsic capacity and higher occurrence of geriatric syndromes, such as falls (28, 33).

More than 10% of older adults’ admissions to acute care may be caused by nonadherence to medication regimens (34), and a quarter of admissions of older adults to nursing homes may be due to older people’s inability to self-administer medication (35).

3.1.2 The impact of ageism on mental health

Ageism is also associated with poorer mental health. Some 96% (42/44) of the studies (2) that examined the relationship between ageism and mental health found evidence that ageism influenced psychiatric conditions. In 16 studies, ageism was associated with the onset of depression, increases in depressive symptoms over time and lifetime depression. When older American veterans resisted negative age stereotypes, they were found to be less likely to experience suicidal ideation, anxiety and post-traumatic stress disorder (36).

Based on figures for 2015, globally, about 6.33 million cases of depression are estimated to be attributable to ageism, with 831 041 cases occurring in more developed countries and 5.6 million cases in less developed countries (2).

Ageism accelerates cognitive impairment. Four of the five studies (80%) in the review that investigated a possible link between ageism and cognitive impairment found a relationship (2). One of the studies, in Germany, followed up 8000 people over several years and revealed that negative self-perceptions of ageing accelerated cognitive decline as measured by cognitive processing speed, whereas positive self- perceptions slowed it down (37).

These findings complement the large body of experimental studies on this topic summarized in several meta-analyses (38-40). These have shown that when

5 2

GLOBAL REPORT ON AGEISM

older people are exposed to negative stereotypes – regardless of whether they are conscious of it – their cognitive ability and memory decrease, a phenomenon known as stereotype threat (see Chapter 1, Section 1.2). An implication of these findings is that poorer results in clinical or workplace assessments of cognitive functioning in older adults may be partly due to exposure to negative stereotypes (39).

Ageism in the media negatively impacts health and cognitive performance. Ageist stereotypes in the media can have a negative impact on older people’s self-esteem, health status, physical well-being and cognitive performance (12, 41, 42). Underrepresenting or misrepresenting older people in the media is not harmless, and Chapter 2 showed that it is widespread. A meta-analysis found that no more than brief exposure to stereotypes in the media had small, harmful effects on older people’s performance on memory tasks (43).

Ageism in the workplace is associated with health problems. Workplace ageism predicted worse health in most of the 27 studies that evaluated its health impacts (2). For instance, a study of more than 6 000 employees in Finland revealed that perceived age discrimination at work led to subsequent long-term sick leave (44). This is probably due to a chain reaction in which work stress first increases the risk of health symptoms, which later increases long-term sickness absence (44).

3.1.3 The impact of ageism on social well-being

Ageism can have a far-reaching impact on older people’s general quality of life and can also affect specific aspects of their social well-being. For instance, ageism can lead to social isolation and loneliness and restrict older people’s sexuality. Ageism may also

be associated among older people with greater fear of crime and an increased risk of experiencing violence and abuse.

General quality of life

All 29 studies included in the 2020 systematic review that looked at ageism and quality of life found that ageism had a negative impact on quality of life (2). For instance, a study that evaluated the impact of attitudes towards ageing and quality of life among older people in 20 countries – including two middle-income countries, Brazil and Turkey – produced consistent findings across all of the countries: quality-of-life judgements made by people aged between 60 and 100 years were the product of older men’s and women’s perceptions of health-related circumstances and attitudes towards the physical and psychosocial aspects of the ageing self (45).

Social isolation and loneliness

Ageism contributes to social isolation and loneliness, which are widespread among older people. And social isolation and ageism have serious impacts on health and longevity.

Ageism increases social isolation and loneliness in three main ways. First, ageism can result in feelings of being undesired, unwanted, betrayed and socially rejected, which can lead to social withdrawal. Second, as in a self-fulfilling prophecy, older people can internalize ageist stereotypes – for instance, that old age is a time of social isolation and low social participation – and then act accordingly, by withdrawing from society. Third, ageist society-wide laws, norms and practices, such as mandatory retirement or design features of the living environment (e.g. inaccessible transport, cracked or uneven sidewalks), can act as barriers to older adults’ participation in social activities, leading to social isolation and loneliness (46).

5 3

CHAPTER 03

In a 2020 review, ageism was found to be a risk factor for poor social relationships in all 13 studies that examined this association (2). For instance, the negative self-perceptions of ageing held by older Chinese people were associated with their dissatisfaction in the social support provided by their children (47).

Rates of loneliness and social isolation are high among older people. In Finland and the United Kingdom, 40% of older adults living in the community reported experiencing some degree of loneliness (48, 49). In China, 24.8% of older adults living in the community reported that they sometimes felt lonely, and 8.3%, often or always felt lonely (50).

Multiple studies and reviews have shown that social isolation and loneliness have serious impacts on the mortality of older people, on their physical health and functioning (e.g. heart disease, diabetes, mobility, activities of daily living) and on their mental health (e.g. depression, anxiety and cognitive decline) (51-55).

Sexuality

Sexuality is another important aspect of older people’s relationships that ageism can impact. Despite a recognition that sexuality is important to older people, ageist portrayals of sexuality in later life in the media, attitudes of health care and long-term care providers and of older people themselves often impede the free and full expression of older people’s sexuality (56). Older people have a right to sexual health, defined by WHO as a state of physical, mental and social well- being in the sphere of sexuality (57).

Studies in multiple countries – including Alger ia, Egypt, Indonesia, Mexico, Morocco, Nigeria and the Philippines – have consistently found that older people continue to engage in sexual activities

and view sexuality as a major component of their quality of life and well-being (54, 56, 58-61). Yet the topic of older people’s sexuality often remains taboo. When it is addressed, it is often from a biomedical perspective that portrays older people as asexual and assumes decline in sexual function in later life. This assumption appears to be the result of too narrow a definition of sexual function (e.g. excluding solo, non-penetrative and same-sex sexual activity) and too great a focus on biological determinants of sexual function (e.g. declining levels of testosterone) to the exclusion of psychological and social determinants (e.g. depression, presence or absence of partners and characteristics of the relationship with a partner) (62).

Research shows that older people often internalize ageist stereotypes and myths regarding sexuality in later life. They are reluctant to express their sexuality and are often hesitant to discuss sexual issues with their doctors for fear of being met with disapproval. Older women have been found to internalize ageist cultural norms of beauty and to view themselves as unattractive (63, 64).

In many parts of the world, older women’s sexuality may be exposed to the double jeopardy of ageism and sexism. A study in sub-Saharan Africa showed that myths, prejudices and misconceptions, rooted in religious and traditional customs and beliefs, often cause older women who show an interest in sex to be judged as behaving inappropriately and disrespectfully: a double standard that does not apply to men (65).

Health-care providers’ education and training often does not prepare them to adequately address sexual health in older people, and many consider the topic

5 4

GLOBAL REPORT ON AGEISM

to be outside their scope of practice (66-68). In long-term care facilities, staff knowledge about sexuality among older people is often limited, and they are uncomfortable discussing sexuality with older people. The privacy required for sexual expression is rarely provided; clear policies regarding sexuality are often lacking; and prospective residents are seldom given information about how their sexual and intimacy needs will be respected (56, 68-70).

At the same time, the promotion of active and successful ageing may sometimes create unrealistic expectations concerning sexuality that may be at odds with the reality of some older people, a more subtle form of ageism that contributes to shame and loss of self-esteem (62, 71).

Fear of crime

Ageism may have a role in how police and policy-makers treat older people as being particularly vulnerable to crime, in sensationalistic media portrayals of – generally rare – attacks on older people and in depictions of them as prisoners of fear who are terrified to leave their homes. Such representations of older people may become internalized, lead to older people overestimating their vulnerability and fuel their fear of crime, resulting in the paradox of older people having a high fear of crime, but a low risk of victimization (72).

Violence and abuse

Ageism may increase the risk of violence being perpetrated against older people. According to a recent global review of the prevalence of violence against older people, some 15.7% of older people – or almost 1 in 6 – are victims of abuse. Some 11.6% of older people are victims of psychological abuse, 6.8% of financial abuse, 4.2% of neglect, 2.6% of physical abuse, and 0.9% of older people are victims of sexual abuse (73).

Although it is possible that ageism increases the risk of violence against older people, empirical evidence for the link between the two remains limited (74, 75). Negative stereotypes of older people (e.g. as dependent and burdensome), prejudices and discrimination dehumanize them and could contribute to making violence against older people more permissible (75-77).

Ageism may act as a risk factor for the financial abuse of older people by financial service institutions, defined as direct or indirect practices of these institutions that target or threaten the financial well-being of older people. An example might be selling inappropriate financial products to older people or pressuring them to invest their assets against their will (78).

3.2 The economic impact of ageism

Evidence of the economic impact of ageism is extremely limited, both for individuals and whole societies. What evidence exists, however, suggests that the economic costs of ageism may be high.

In many parts of the world, older women’s sexuality may be exposed to the double jeopardy of ageism and sexism.

5 5

CHAPTER 03

Estimates of the economic costs of health and social problems are important. They define the burden of the problem for society in financial terms. They can be used to justify intervention programmes and are required for assessing programmes’ cost– effectiveness. Estimates can be used to help set policy and planning priorities and guide the allocation of research funds (79-81). They are also critical for understanding how health and social problems slow social and economic development. Finally, estimates of economic costs raise the visibility and, thus, the political and funding priorities of health and social problems.

Given the growth in the population of older people globally, but particularly in low- and middle-income countries, ending poverty in all its forms everywhere, as called for by the 2030 Agenda for Sustainable Development (82), depends on ending poverty among older people. And ending poverty among older people depends, at least partly, on tackling ageism.

3.2.1 Ageism, poverty and financial insecurity among older people

Ageism may increase the risk of poverty and financial insecurity in older age. The previous chapter of this report, on the scale of ageism, showed that ageism occurs throughout the employment cycle, from hiring and recruitment through to training, advancement opportunities and retention, and all the way to retirement. Although the cumulative financial impact of ageism over an employee’s lifetime has not been estimated, there is no doubt that ageism leaves people less well off than they would have been otherwise.

There is some evidence from Australia that ageist discrimination in the labour market is associated with the unemployment

or underemployment of older people and dependency on social security, thus contributing to poverty among older adults (83).

Laws that mandate retirement age have sometimes been interpreted as being a form of institutional ageism that contributes to older people’s financial insecurity. However, their impact on older people’s financial status is not straightforward and continues to be a matter of debate, depending on, among other factors, the level of provision of state pensions in a country (84, 85).

The loss of financial secur ity and subsequent fall into poverty can have devastating impacts on an older person. They can result in a rapid decline in health, earlier mortality and dependency on state welfare systems, where such systems exist (86, 87). Yet studies looking at how ageism contributes to poverty remain rare. More research in this area should be carried out as a matter of priority in high-, middle- and low-income countries.

3.2.2 The economic burden of ageism on society

Ageism costs society billions of dollars, but, to date, few estimates of the economic costs of ageism to the wider society and economy, particularly at the level of countries, have been carried out. A study on ageism in the workplace found that in a company of 10 000 persons in the United States, disengagement

Although the cumulative financial impact of ageism over an employee’s lifetime has not been estimated, there is no doubt that ageism leaves people less well off than they would have been otherwise.

5 6

GLOBAL REPORT ON AGEISM

of workers due to age discrimination led to some 5000 unexcused days of absence and about US$ 600 000 in lost salary payments per year (88). Estimates in Australia suggest that if 5% more people aged 55 or older were employed, there would be a positive impact of 48 billion Australian dollar on the national economy annually (89).

The first study of the economic burden of the health consequences of ageism on a national economy, conducted in the United States, was published in 2020 (90). The study calculated the costs of ageism to the United States over 1 year in relation to the eight most expensive health conditions for all persons aged 60 years or older. The eight health conditions were: cardiovascular disease, chronic respiratory disease, musculoskeletal disorders, injuries, diabetes mellitus, smoking-related diseases, mental disorders and noncommunicable diseases. Overall, the study found that in the United States, annually one in every seven dollars – or US$ 63 billion in total – spent on health care for the eight most-expensive conditions was due to ageism. Negative self- perceptions of ageing cost US$ 33.7 billion; negative age stereotypes, US$ 28.5 billion; and age discrimination, US$ 11.1 billion. These findings make a strong case for implementing interventions to reduce ageism (90). Even if an intervention only has a modest impact by, for example, reducing the number of cases of these serious health conditions by 5%, in the United States this would amount to a savings of US$ 3.15 billion or 852 000 million fewer cases of these eight health conditions.

3.3 Conclusions and future directions

As a public health problem, ageism is an important social determinant of health that has too long been neglected. But ageism is also a development and human rights issue with serious consequences.

Drawing on some 500 studies from more than 50 countries, this chapter has shown that the stereotypes, prejudice and discrimination associated with ageism take a heavy toll on the health and well-being of older people, that ageism costs countries billions of dollars a year and that it may be contributing to poverty among older people. These findings suggest that it is ageism – and not older people – that places a heavy burden on society.

Ageism increases risky health behaviours, negatively affects physical and mental health, accelerates cognitive decline, slows recovery from disability and reduces longevity. The impacts of ageism extend beyond the body, undermining social relationships and contributing to older people being socially isolated and lonely, and it may increase their fear of crime and risk of being a target of violence and abuse. Even if interventions to reduce ageism were to have only small effects, they could lead to big improvements in older people’s lives and large savings for countries.

Future priorities to improve understanding and to direct actions on the impact of ageism as well as strengthen the case for combating it should include:

• raising public awareness of the far-reaching detrimental effects of ageism;

A study found that in the United States, annually one in every seven dollars spent on health care for the eight most- expensive conditions was due to ageism.

5 7

CHAPTER 03

• filling the research gaps, including:

(i) demonstrating that the relationships between ageism and the impacts identified in this chapter are indeed causal and not simply associations (see Box 3.1);

(ii) generating more research on the impacts of ageism in low- and middle-income countries; and

(iii) understanding if and how the impacts of ageism vary across individual characteristics (e.g.

age, gender, race, disability, sexual identity), contexts and countries;

• producing estimates of the economic impacts of ageism and determining how ageism contributes to poverty among older people, its wider costs to national economies, and how ageism contributes to slowing social and economic development, particularly in low- and middle- income countries.

5 8

GLOBAL REPORT ON AGEISM

REFERENCES

1. What is the WHO definition of health? In: World Health Organization [website]. Geneva: World Health Organization; 2020

(https://www.who.int/about/who-we-are/frequently-asked-questions, accessed 29 August 2020).

2. Chang ES, Kannoth S, Levy S, Wang SY, Lee JE, Levy BR. Global reach of ageism on older persons’ health: a systematic review. PLOS ONE. 2020;15(1):e0220857.

https://doi.org/10.1371/journal.pone.0220857. 3. Mason SE, Kuntz CV, McGill CM. Oldsters and Ngrams: age stereotypes across time.

Psychol Rep. 2015;116(1):324–9. https://doi.org/10.2466/17.10.PR0.116k17w6. 4. Ng R, Allore HG, Trentalange M, Monin JK, Levy BR. Increasing negativity of age

stereotypes across 200 years: evidence from a database of 400 million words. PLOS ONE. 2015;10(2):e0117086. https://doi.org/10.1371/journal.pone.0117086.

5. Spangenberg L, Zenger M, Glaesmer H, Brahler E, Strauss B. Assessing age stereotypes in the German population in 1996 and 2011: socio-demographic correlates and shift over time. Eur J Ageing. 2018;15(1):47–56. https://doi.org/10.1007/s10433-017-0432-5.

6. Krosch AR, Amodio DM. Economic scarcity alters the perception of race. Proc Natl Acad Sci U S A. 2014;111(25):9079–84. https://doi.org/10.1073/pnas.1404448111.

7. Johnston DW, Lordan G. Racial prejudice and labour market penalties during economic downturns. Eur Econ Rev. 2016;84:57–75. https://doi.org/10.1016/j.euroecorev.2015.07.011.

8. Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097.

9. Gu DA, Dupre ME, Qiu L. Self-perception of uselessness and mortality among older adults in China. Arch Gerontol Geriatr. 2017;68:186–94. https://doi.org/10.1016/j.archger.2016.10.015.

10. Kotter-Gruhn D, Kleinspehn-Ammerlahn A, Gerstorf D, Smith J. Self-perceptions of aging predict mortality and change with approaching death: 16-year longitudinal results from the Berlin Aging Study. Psychol Aging. 2009;24(3):654–67. https://doi.org/10.1037/a0016510.

11. Levy BR, Bavishi A. Survival advantage mechanism: inflammation as a mediator of positive self-perceptions of aging on longevity. J Gerontol B Psychol Sci Soc Sci. 2018;73(3):409–12. https://doi.org/10.1093/geronb/gbw035.

12. Levy BR, Slade MD, Kunkel SR, Kasl SV. Longevity increased by positive self-perceptions of aging. J Personal Soc Psychol. 2002;83(2):261–70.

https://doi.org/10.1037//0022-3514.83.2.261. 13. Maier H, Smith J. Psychological predictors of mortality in old age. J Gerontol B Psychol Sci

Soc Sci. 1999;54(1):P44–54. https://doi.org/10.1093/geronb/54b.1.p44. 14. Rakowski W, Hickey T. Mortality and the attribution of health problems to aging among

older adults. Am J Public Health. 1992;82(8):1139–41. https://doi.org/10.2105/Ajph.82.8.1139. 15. Sargent-Cox KA, Anstey KJ, Luszcz MA. Longitudinal change of self-perceptions of aging

and mortality. J Gerontol B Psychol Sci Soc Sci. 2014;69(2):168–73. https://doi.org/10.1093/geronb/gbt005.

5 9

CHAPTER 03

16. Stewart TL, Chipperfield JG, Perry RP, Weiner B. Attributing illness to ‘old age’: consequences of a self-directed stereotype for health and mortality. Psychol Health. 2012;27(8):881–97. https://doi.org/10.1080/08870446.2011.630735.

17. Zhao Y, Dupre ME, Qiu L, Gu D. Changes in perceived uselessness and risks for mortality: evidence from a national sample of older adults in China. BMC Public Health. 2017;17(1):561. https://doi.org/10.1186/s12889-017-4479-1.

18. Levy BR, Slade MD, Murphy TE, Gill TM. Association between positive age stereotypes and recovery from disability in older persons. JAMA. 2012;308(19):1972–3.

https://doi.org/10.1001/jama.2012.14541. 19. Villiers-Tuthill A, Copley A, McGee H, Morgan K. The relationship of tobacco and

alcohol use with ageing self-perceptions in older people in Ireland. BMC Public Health. 2016;16(1):627. https://doi.org/10.1186/s12889-016-3158-y.

20. Matlho K, Randell M, Lebelonyane R, Kefas J, Driscoll T, Negin J. HIV prevalence and related behaviours of older people in Botswana – secondary analysis of the Botswana AIDS Impact Survey (BAIS) IV. Afr J AIDS Res. 2019;18(1):18–26.

https://doi.org/10.2989/16085906.2018.1552162. 21. Minichiello V, Rahman S, Hawkes G, Pitts M. STI epidemiology in the global older

population: emerging challenges. Perspect Public Health. 2012;132(4):178–81. https://doi.org/10.1177/1757913912445688. 22. Tavoschi L, Dias JG, Pharris A, Schmid D, Sasse A, Van Beckhoven D, et al. New HIV

diagnoses among adults aged 50 years or older in 31 European countries, 2004–15: an analysis of surveillance data. Lancet HIV. 2017;4(11):e514–21.

https://doi.org/10.1016/S2352-3018(17)30155-8. 23. NCSTD/CCDC. 2008 national report of epidemiological data on STDs from sentinel sites in

China. Bull STI Prev Control. 2009:1-8. 24. Cui Y, Shi CX, Wu Z. Epidemiology of HIV/AIDS in China: recent trends. Global Health J.

2017;1(1):26–32. https://doi.org/10.1016/S2414-6447(19)30057-0. 25. Fialova D, Onder G. Medication errors in elderly people: contributing factors and future

perspectives. Br J Clin Pharmacol. 2009;67(6):641–5. https://doi.org/10.1111/j.1365-2125.2009.03419.x. 26. Fialova D, Topinkova E, Gambassi G, Finne-Soveri H, Jonsson PV, Carpenter I, et al.

Potentially inappropriate medication use among elderly home care patients in Europe. JAMA. 2005;293(11):1348–58. https://doi.org/10.1001/jama.293.11.1348.

27. Petrovic M, Somers A, Onder G. Optimization of geriatric pharmacotherapy: role of multifaceted cooperation in the hospital setting. Drugs Aging. 2016;33(3):179–88.

https://doi.org/10.1007/s40266-016-0352-7. 28. Fialova D, Kummer I, Drzaic M, Leppee M. Ageism in medication use in older patients. In:

Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:241–62 (https://link.springer.com/chapter/10.1007/978-3-319-73820-8_14, accessed 15 March 2020).

29. Sabaté E, editor. Adherence to long-term therapies: evidence for action. Geneva: World Health Organization; 2003 (https://apps.who.int/iris/handle/10665/42682, accessed 18 March 2020).

30. Scheen AJ, Giet D. [Non compliance to medical therapy; causes, consequences, solutions]. Rev Med Liege. 2010;65(5-6):239–45 (in French). PMID: 20684400.

31. Beard K. Adverse reactions as a cause of hospital admission in the aged. Drugs Aging. 1992;2(4):356–67. https://doi.org/10.2165/00002512-199202040-00008.

6 0

GLOBAL REPORT ON AGEISM

32. Spinewine A, Fialova D, Byrne S. The role of the pharmacist in optimizing pharmacotherapy in older people. Drugs Aging. 2012;29(6):495–510. https://doi.org/10.2165/11631720-000000000-00000.

33. Qato DM, Wilder J, Schumm LP, Gillet V, Alexander GC. Changes in prescription and over- the counter medication and dietary supplement use among older adults in the United States, 2005 vs 2011. JAMA Intern Med. 2016;176(4):473–82. https://doi.org/10.1001/ jamainternmed.2015.8581.

34. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther. 2001;26(5):331–42. https://doi.org/10.1046/j.1365-2710.2001.00363.x.

35. Strandberg LR. Drugs as a reason for nursing home admissions. J Am Health Care Assoc. 1984;10(4):20-3. PMID: 10267407.

36. Levy BR, Pilver CE, Pietrzak RH. Lower prevalence of psychiatric conditions when negative age stereotypes are resisted. Soc Sci Med. 2014;119:170–4. https://doi.org/10.1016/j.socscimed.2014.06.046.

37. Seidler AL, Wolff JK. Bidirectional associations between self-perceptions of aging and processing speed across 3 years. GeroPsych. 2017;30(2):49–59.

https://doi.org/10.1024/1662-9647/a000165. 38. Horton S, Baker J, Pearce GW, Deakin JM. On the malleability of performance –

implications for seniors. J Appl Gerontol. 2008;27(4):446–65. https://doi.org/10.1177/0733464808315291.

39. Lamont RA, Swift HJ, Abrams D. A review and meta-analysis of age-based stereotype threat: negative stereotypes, not facts, do the damage. Psychol Aging. 2015;30(1):180–93. https://doi.org/10.1037/a0038586.

40. Meisner BA. A meta-analysis of positive and negative age stereotype priming effects on behavior among older adults. J Gerontol B Psychol Sci Soc Sci. 2012;67(1):13–7. https://doi.org/10.1093/geronb/gbr062.

41. Levy BR, Slade MD, Kasl SV. Longitudinal benefit of positive self-perceptions of aging on functional health. J Gerontol B Psychol Sci Soc Sci. 2002;57(5):P409–17. https://doi.org/10.1093/geronb/57.5.P409.

42. Loos E, Ivan L. Visual ageism in the media. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:241–62 (https://link. springer.com/chapter/10.1007/978-3-319-73820-8_11, accessed 27 February 2020).

43. Appel M, Weber S. Do mass mediated stereotypes harm members of negatively stereotyped groups? A meta-analytical review on media-generated stereotype threat and stereotype lift. Commun Res. 20172017. https://doi.org/10.1177/0093650217715543.

44. Viitasalo N, Natti J. Perceived age discrimination at work and subsequent long-term sickness absence among Finnish employees. J Occup Environ Med. 2015;57(7):801–5. https://doi.org/10.1097/Jom.0000000000000468.

45. Low G, Molzahn AE, Schopflocher D. Attitudes to aging mediate the relationship between older peoples’ subjective health and quality of life in 20 countries. Health Qual Life Outcomes. 2013;11(1):146. https://doi.org/10.1186/1477-7525-11-146.

46. Shiovitz-Ezra S, Shemesh J, McDonnell-Naughton M. Pathways from ageism to loneliness. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018:131–48 (https://link.springer.com/chapter/10.1007/978-3-319-73820-8_9, accessed 2 March 2020).

47. Cheng ST. Self-perception of aging and satisfaction with children’s support. J Gerontol B Psychol Sci Soc Sci. 2017;72(5):782–91. https://doi.org/10.1093/geronb/gbv113.

6 1

CHAPTER 03

48. Savikko N, Routasalo P, Tilvis RS, Strandberg TE, Pitkala KH. Predictors and subjective causes of loneliness in an aged population. Arch Gerontol Geriatr. 2005;41(3):223–33. https://doi.org/10.1016/j.archger.2005.03.002.

49. Victor CR, Scambler S, Bowling A, Bond J. The prevalence of, and risk factors for, loneliness in later life: a survey of older people in Great Britain. Ageing Soc. 2005;25(6):357–75. https://doi.org/10.1017/S0144686x04003332.

50. Zhong BL, Chen SL, Tu X, Conwell Y. Loneliness and cognitive function in older adults: findings from the Chinese Longitudinal Healthy Longevity Survey. J Gerontol B Psychol Sci Soc Sci. 2017;72(1):120–8. https://doi.org/10.1093/geronb/gbw037.

51. Ayalon L, Shiovitz-Ezra S. The relationship between loneliness and passive death wishes in the second half of life. Int Psychogeriatr. 2011;23(10):1677–85. https://doi.org/10.1017/S1041610211001384.

52. Barg FK, Huss-Ashmore R, Wittink MN, Murray GF, Bogner HR, Gallo JJ. A mixed-methods approach to understanding loneliness and depression in older adults. J Gerontol B Psychol Sci Soc Sci. 2006;61(6):S329–39. https://doi.org/10.1093/geronb/61.6.s329.

53. Cacioppo JT, Hughes ME, Waite LJ, Hawkley LC, Thisted RA. Loneliness as a specific risk factor for depressive symptoms: cross-sectional and longitudinal analyses. Psychol Aging. 2006;21(1):140–51. https://doi.org/10.1037/0882-7974.21.1.140.

54. Courtin E, Knapp M. Social isolation, loneliness and health in old age: a scoping review. Health Soc Care Community. 2017;25(3):799–812. https://doi.org/10.1111/hsc.12311.

55. Social isolation and loneliness in older adults: opportunities for the health care system. Washington (DC): National Academies Press; 2020.

56. Gewirtz-Meydan A, Hafford-Letchfield T, Benyamini Y, Phelan A, Jackson J, Alayon L. Ageism and sexuality. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism. Cham: Springer; 2018. p. 149-62 (https://link.springer.com/ chapter/10.1007/978-3-319-73820-810, accessed 16 March 2020).

57. Lusti-Narasimhan M, Beard JR. Sexual health in older women. Bull World Health Organ. 2013;91(9):707–9. https://doi.org/10.2471/BLT.13.119230.

58. Agunbiade OM, Ayotunde T. Ageing, sexuality and enhancement among Yoruba people in south western Nigeria. Cult Health Sex. 2012;14(6):705–17. https://doi.org/10.1080/13691058.2012.677861.

59. Kontula O, Haavio-Mannila E. The impact of aging on human sexual activity and sexual desire. J Sex Res. 2009;46(1):46–56. https://doi.org/10.1080/00224490802624414.

60. Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. New Engl J Med. 2007;357(8):762–74. https://doi.org/10.1056/NEJMoa067423.

61. Nicolosi A, Laumann EO, Glasser DB, Moreira ED Jr., Paik A, Gingell C, et al. Sexual behavior and sexual dysfunctions after age 40: the global study of sexual attitudes and behaviors. Urology. 2004;64(5):991–7. https://doi.org/10.1016/j.urology.2004.06.055.

62. DeLamater J, Koepsel E. Relationships and sexual expression in later life: a biopsychosocial perspective. Sex Relatsh Ther. 2015;30(1):37–59.

https://doi.org/10.1080/14681994.2014.939506. 63. Gott M, Hinchliff S. Barriers to seeking treatment for sexual problems in primary care: a

qualitative study with older people. Fam Pract. 2003;20(6):690–5. https://doi.org/10.1093/fampra/cmg612. 64. Vares T. Reading the ‘sexy oldie’: gender, age(ing) and embodiment. Sexualities.

2009;12(4):503–24. https://doi.org/10.1177/1363460709105716.

6 2

GLOBAL REPORT ON AGEISM

65. Chepngeno-Langat G, Hosegood V. Older people and sexuality: double jeopardy of ageism and sexism in youth-dominated societies. Agenda. 2012;26(4):93–9.

https://doi.org/10.1080/10130950.2012.757864. 66. Dogan S, Demir B, Eker E, Karim S. Knowledge and attitudes of doctors toward the

sexuality of older people in Turkey. Int Psychogeriatr. 2008;20(5):1019–27. https://doi.org/10.1017/S1041610208007229. 67. Haesler E, Bauer M, Fetherstonhaugh D. Sexuality, sexual health and older people: a

systematic review of research on the knowledge and attitudes of health professionals. Nurse Educ Today. 2016;40:57–71. https://doi.org/10.1016/j.nedt.2016.02.012.

68. Mahieu L, Van Elssen K, Gastmans C. Nurses’ perceptions of sexuality in institutionalized elderly: a literature review. Int J Nurs Stud. 2011;48(9):1140–54.

https://doi.org/10.1016/j.ijnurstu.2011.05.013. 69. Gilmer MJ, Meyer A, Davidson J, Koziol-McLain J. Staff beliefs about sexuality in aged

residential care. Nurs Prax N Z. 2010;26(3):17–24. PMID: 21188913. 70. Mahieu L, de Casterle BD, Acke J, Vandermarliere H, Van Elssen K, Fieuws S, et al. Nurses’

knowledge and attitudes toward aged sexuality in Flemish nursing homes. Nurs Ethics. 2016;23(6):605–23. https://doi.org/10.1177/0969733015580813.

71. Woloski-Wruble AC, Oliel Y, Leefsma M, Hochner-Celnikier D. Sexual activities, sexual and life satisfaction, and successful aging in women. J Sex Med. 2010;7(7):2401–10.

https://doi.org/10.1111/j.1743-6109.2010.01747.x. 72. Pain RH. ‘Old age’ and ageism in urban research: the case of fear of crime. Int J Urban Reg

Res. 1997;21(1):117–128. https://doi.org/10.1111/1468-2427.00061. 73. Yon YJ, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community

settings: a systematic review and meta-analysis. Lancet Glob Health. 2017;5(2):E147– 56. https://doi.org/10.1016/S2214-109X(17)30006-2.

74. de Lima MP, Vergueiro ME, Gonzalez A-J, Martins P, Oliveira JG. Relations between elder abuse, ageism and perceptions of age. Int J Humanit Soc Sci Educ. 2019;5(6):91–102. https://doi.org/10.20431/2349-0381.0506012.

75. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: global situation, risk factors, and prevention strategies. Gerontologist. 2016;56(Suppl. 2):S194–205.

https://doi.org/10.1093/geront/gnw004. 76. Nelson TD. Ageism: prejudice against our feared future self. J Soc Issues. 2005;61(2):207–

21. https://doi.org/10.1111/j.1540-4560.2005.00402.x. 77. European report on preventing elder maltreatment. Copenhagen: World Health

Organization, Regional Office for Europe; 2011 (https://apps.who.int/iris/ handle/10665/107293, accessed 24 March 2020).

78. Naughton C, Drennan J. Exploring the boundaries between interpersonal and financial institution mistreatment of older people through a social ecology framework. Ageing Soc. 2016;36(4):694–715. https://doi.org/10.1017/S0144686x14001433.

79. Byford S, Torgerson DJ, Raftery J. Cost of illness studies. BMJ. 2000;320(7245):1335. https://doi.org/10.1136/bmj.320.7245.1335.

80. Larg A, Moss JR. Cost-of-illness studies: a guide to critical evaluation. Pharmacoeconomics. 2011;29(8):653–71. https://doi.org/10.2165/11588380-000000000-00000.

81. Rice DP. Cost of illness studies: what is good about them? Inj Prev. 2000;6(3):177–9. https://doi.org/10.1136/ip.6.3.177.

82. Resolution A/RES/70/1. Transforming our world: the 2030 Agenda for Sustainable Development. In: Seventieth United Nations General Assembly, 21 October 2015.

6 3

CHAPTER 03

New York: United Nations; 2015 (https://sustainabledevelopment.un.org/post2015/ transformingourworld, accessed 12 October 2020).

83. Age discrimination – exposing the hidden barrier for mature age workers. Sydney: Australian Human Rights Commission; 2010 (https://humanrights.gov.au/our-work/age- discrimination/publications/age-discrimination-exposing-hidden-barrier-mature-age, accessed 25 March 2020).

84. Lain D. Helping the poorest help themselves? Encouraging employment past 65 in England and the USA. J Soc Policy. 2011;40(3):493–512.

https://doi.org/10.1017/S0047279410000942. 85. McDonald L. The evolution of retirement as systematic ageism. In: Bronwell P, Kelly JJ,

editors. Ageism and mistreatment of older workers: current reality, future solutions. New York: Springer; 2013:69–90.

86. Davies M, Gilhooly M, Harries P, Gilhooly K. Financial elder abuse: a review of the literature. London: Brunel University, Brunel Institute for Ageing Studies; 2011.

87. Kwan C, Walsh CA. Old age poverty: a scoping review of the literature. Cogent Soc Sci. 2018;4(1):1478479. https://doi.org/10.1080/23311886.2018.1478479.

88. Wilson DC. The price of age discrimination: when older workers face discrimination, everybody loses. In: Gallup Business Journal [website]. London: Gallup; 2006 (https://news. gallup.com/businessjournal/23164/price-age-discrimination.aspx, accessed 25 March 2020).

89. National prevalence survey of age discrimination in the workplace: report 2015. Sydney: Australian Human Rights Commission; 2015 (https://humanrights.gov.au/sites/default/ files/document/publication/AgePrevalenceReport2015.pdf, accessed 25 March 2020).

90. Levy BR, Slade MD, Chang ES, Kannoth S, Wang SY. Ageism amplifies cost and prevalence of health conditions. Gerontologist. 2020;60(1):174–81. https://doi.org/10.1093/geront/gny131.

6 4

GLOBAL REPORT ON AGEISM

ISABEL , 80, THE PLURINATIONAL STATE OF BOLIVIA

6 5

CHAPTER 01

6 5

C H A P T E R 0 4

Older people are discriminated against at home because the family don’t understand them. The children, the daughter-in-law, the neighbours don’t understand and this is how the discrimination and abuse begins . However public institutions are the worst perpetrators of age discrimination.

Isabel , 80, The Plurinational State of Bolivia ©Sebastian Ormachea / HelpAge International

04

“

“

6 6

GLOBAL REPORT ON AGEISM

Findings in this chapter are primarily based on a comprehensive systematic review of the determinants of ageism against older adults (1). Only those determinants for which a clear association was found between a risk or protective factor and ageism are reported.

Dozens of other possible determinants – such as race and ethnicity, working or caring for older people, socioeconomic status, employment status, being part of a collectivist or traditional culture – were examined in the review, and either no association with ageism was found or the results were mixed. Several of these possible determinants, as well as others not examined – such as the presence of a social welfare system and universal health coverage – require further investigation. Furthermore, few of the studies included in the systematic review were conducted in low- and middle-income countries (1).

This chapter supplements the overview of the main determinants of ageism identified to date with a brief survey of three of the main theories of ageism for which there is considerable empirical support. Theories of ageism are explanations that specify the underlying causal mechanisms that produce ageism.

Individual characteristics associated with perpetrating interpersonal ageism against older people are age, sex, education, anxiety about or fear of death, certain personality traits, contact with older people and knowledge about ageing.

Individual characteristics associated with being a target of interpersonal ageism are older age, poorer health status and care dependence.

The main contextual determinants of interpersonal ageism are the healthy life expectancy of the country and working in certain professions and occupational sectors.

Individual characteristics associated with self- directed ageism are having poorer mental and physical health and lacking positive contact with grandchildren.

GLOBAL REPORT ON AGEISM

04 Chapter

6 6

Identifying the determinants of ageism – both the risk and protective factors – is a prerequisite for developing effective strategies to reduce ageism. Risk factors are characteristics that increase the likelihood of ageism. Protective factors are characteristics that decrease the likelihood of ageism or provide a buffer against risk. To work, strategies to reduce ageism must target the determinants that cause ageism.

Section 4.1 of this chapter focuses on the determinants of interpersonal ageism. It examines individual characteristics associated with being a perpetrator and a target of interpersonal ageism and the contextual-level determinants of interpersonal ageism. Section 4.2 addresses the determinants of self- directed ageism. No evidence was found about the determinants of institutional ageism, a notable gap.

6 7

CHAPTER 04

For strategies to reduce ageism to be effective, the causal mechanisms that are modifiable must be targeted (2-4). The specific programme theories or theories of change that underlie the development of effective strategies to reduce ageism draw on such broader, empirically supported theories of ageism (5-7).

4.1 Determinants of interpersonal ageism

This section provides an overview of the main determinants of interpersonal ageism, including individual characteristics associated with being a perpetrator or target of ageism and contextual determinants of interpersonal ageism (see Table 4.1).

4.1.1 Individual characteristics associated with being a perpetrator of ageism

Age, sex or gender, and education

A recent study in 57 countries found that being younger, male and having a lower level of education increase the likelihood of a person being highly ageist. The effect of education was more marked than those of being younger or male, which increase the risk of ageism against older people only slightly (8). Having a lower level of education also increases the probability of an individual being moderately ageist (8). Previous smaller studies have shown similar results regarding sex or gender (9-13), age (14-16) and education (17, 18). However, these findings have not always been consistent (1).

Among health and social care professionals, however, age and sex/gender have not always been found to be determinants of ageism. A 2013 systematic review that included 25 studies found that age and gender were not consistent predictors of nurses’ attitudes towards older patients (19). But among nursing students and registered nurses in Greece and Sweden, young age (< 25) and being male were found to be important risk factors for ageism towards older patients (20,21).

Physicians with more years of education were less likely to be ageist towards older patients (22). Being exposed to content about ageing in gerontological courses was also found to improve perceptions about and attitudes towards older adults in social care (23). This holds promise for future educational activities for health-care professionals that aim to increase knowledge about ageing and older age.

Anxiety about ageing and fear of death

Individuals with a higher level of anxiety about ageing or a fear of death display increased ageist attitudes (1). Although these findings come from a limited number of studies, they support the well-established theory of ageism known as terror management theory (see Box 4.1), which posits that older adults present an existential threat to younger people and generate death anxiety because they serve as a constant reminder of one’s mortality and vulnerability (24).

Personality traits

A few studies have also found that individuals with the personality traits of agreeableness, extroversion, conscientiousness and personal collectivism are less likely to be ageist – that is, these characteristics act as protective factors against ageism (1).

6 8

GLOBAL REPORT ON AGEISM

TYPE OF DETERMINANT TYPE OF ASSOCIATION

IN T

E R

P E

R S

O N

A L

A G

E IS

M

IN D

IV ID

U A

L- LE

V E

L D

E TE

R M

IN A

N TS

P E

R P

E TR

A TO

R

Age Younger More ageism (risk factor)

Sex/gender Male More ageism (risk factor)

Education Lower level More ageism (risk factor)

Anxiety about or fear of death Higher More ageism (risk factor)

Personality traits Agreeableness, extroversion, conscientiousness and a collectivistic orientation

Less ageism (protective factor)

Contact with older age groups, particularly the quality of the contact, including grandparent– grandchild contact and intergenerational f riendships

Higher quality contact Less ageism (protective factor)

Knowledge about ageing Greater knowledge about ageing Less ageism (protective factor)

TA R

G E

T Age Older More ageism (risk factor)

Health status and care dependence

Poorer health status and greater care dependence

More ageism (risk factor)

C O

N TE

X TU

A L-

LE V

E L

D E

TE R

M IN

A N

TS

Proportion of older adults in country Unclear

Healthy life expectancy of country Lower More ageism (risk factor)

Profession and occupational sector

Some professions and occupational sectors (e.g. high technology)

More ageism (risk factor)

Presentation of older people in experimental studies that simulate real-life settings

Positive presentation with more information

Less ageism (protective factor)

Comparison with younger people More ageism (risk factor)

S E

LF -D

IR E

C T

E D

A

G E

IS M

IN D

IV ID

U A

L- LE

V E

L D

E TE

R M

IN A

N T S

Mental and physical health Poorer More ageism (risk factor)

Contact with grandchildren More contact Less ageism (protective factor)

Table 4.1. Determinants of ageism against older people

6 9

CHAPTER 04

Box 4.1 Three theories of ageism that have empirical support

Theories of ageism point to the underlying causal mechanisms that produce ageism. Specific programme theories or theories of change that underlie the development of effective strategies to reduce ageism draw on these broader, empirically supported theories of ageism.

Terror management theory: Terror management theory suggests that ageism results from our fear of death. It holds that humans’ ubiquitous needs for meaning and self-esteem arise, in part, as efforts to secure ourselves psychologically from the awareness of mortality. Older individuals present an existential threat to younger people because they remind them that death is inescapable. Our fears of death, physical decay and loss of dignity and self-worth generate negative reactions towards, and a desire to distance ourselves from, older people, which manifest as stereotypes, prejudice and discrimination against older people. It is proposed that by learning to acknowledge and cope more directly with fears associated with our physical and mortal natures, we can counter these fears and reduce ageism (24, 32, 33).

Intergroup threat theory and intergroup contact theory: Intergroup threat theory holds that individuals react in hostile ways towards out-groups, particularly when out- groups are perceived as potentially harmful, posing either real or symbolic threats. Real threats refer to threats to a group’s power, resources and welfare, whereas symbolic threats are threats to a group’s world view, belief system and values (34). This theory can help explain why younger adults, who represent direct competition to middle-aged adults, may experience ageism in society. Even in cases in which individuals do not identify a specific threat from an out-group, they may choose to demonstrate biases that can help create a positive distinction between their group (in-group) and other groups (out-groups) (35).

Intergroup contact theory can be viewed as the flip side of intergroup threat theory. Intergroup contact theory holds that contact between groups under optimal conditions reduces intergroup threat and its concomitant stereotypes, prejudice and discrimination. The causal mechanisms through which it does this involve reducing anxiety about intergroup contact and increasing perspective-taking and empathy. Enhanced knowledge about the out-group also plays a role, albeit less strong. Optimal conditions are hypothesized to be having the groups share equal status and common goals; fostering situations that encourage intergroup cooperation; and having the support of authorities, law or custom (25, 36-38). The theory of intergroup contact has been extensively tested with different racial and ethnic groups, people with physical disabilities and mental health conditions, as well as with people of different age groups (37, 38). Intergenerational contact strategies are largely based on intergroup contact theory.

7 0

GLOBAL REPORT ON AGEISM

Stereotype embodiment theory: This theory proposes that members of stigmatized groups tend to assimilate stereotypes about themselves from society, leading to negative self-perceptions than can influence their health (39). Stereotype embodiment theory has four main components. First, it helps explain the process by which people internalize, from an early age, the age stereotypes that are salient in their culture. Second, it holds that stereotypes can operate unconsciously. Third, stereotypes gain salience as people reach certain milestones associated with a particular age, such as retirement. Fourth, stereotypes are embodied through three main pathways: physiological, behavioural and psychological. The physiological pathway is related to the physiological stress caused by considering that the negative perceptions of ageing are applicable to oneself. For instance, older individuals subliminally exposed to negative age stereotypes demonstrated a heightened cardiovascular response to stress (40). The behavioural pathway acts through changes in behaviours, such as people who view growing old negatively not attending medical examinations because they consider illness to be normal in older age. The psychological pathway involves the generation of expectations that act as self-fulfilling prophecies(39, 41). Each of these pathways offers potential targets for interventions. For instance, the psychological and behavioural pathways could be changed by educational interventions that alter what is considered normal in older age. Although this theory has been mainly used to explain self-directed ageism in older age, it is likely that the same mechanism operates in self-directed ageism at other ages since people are exposed to stereotypes about different age groups from childhood onwards.

Contact with older age groups

There is considerable evidence that having contact with people in older age groups, particularly higher quality contact, reduces the likelihood of ageism – that is, better quality contact acts as a protective factor against ageism.

A systematic review has shown that better quality contact, both with older people in general and with grandparents and other relatives in particular, reduced ageism (1). This confirms findings from previous reviews (25, 26). Studies examining the link between intergenerational friendships and ageism are rare (27). A study in 25 European Union countries found that those who reported cross-age friendships tended to be less ageist and that this applied to both younger

and older people (28). The rarity of such intergenerational friendships may partly explain the widespread ageism documented in Chapter 2 (28, 29). For instance, in 25 European Union countries some 18% of young people aged 18–30 years reported having friends who were aged 70 years or older. In this study, younger women were less likely than younger men to have cross- age friendships (28).

This is pertinent when considering possible interventions to reduce ageism because activities can be organized to bring different generations together. The influence of this risk factor on ageism can be explained through intergroup contact theory (see Box 4.1), which posits that greater exposure to older or younger people can help decrease prejudice towards them (30, 31).

7 1

CHAPTER 04

Knowledge about ageing

Evidence suggests that having knowledge about ageing protects against ageism. In other words, the greater a person’s knowledge about ageing, the less ageist they tend to be.

Of the studies included in a review conducted for this report that examined the relationship between knowledge about ageing and ageism, 18 found that having knowledge about ageing was associated with less ageism (42-59), and five studies found that there was either no association between the two or that it was mixed or inconsistent (60-64).

All but one of these studies used the same measure of knowledge of ageing, the Facts on Ageing Quiz, whose validity as a measure of knowledge of ageing has been questioned (65). Another limitation is that these studies do not generally specify which dimension or dimensions of ageism (i.e. stereotypes, prejudice or discrimination) this knowledge protects against.

4.1.2 Individual characteristics associated with being a target of ageism

Age

As people age their likelihood of being a target of ageism increases: the older the person, the more likely they will be a target of ageism (1).

Health status and care dependence

Being in poor health or care dependent has been found in one study to be a risk factor for negative perceptions of older people (66). Another study found a possible bias against older adults who are ill or more care dependent (67). This suggests that how

older adults are perceived might depend on the health status associated with their age rather than on age itself (67).

4.1.3 Contextual determinants of interpersonal ageism

Proportion of older people in a country

A recent rigorous study conducted in 57 countries that had a sample of more than 80 000 participants found that the higher the proportion of older people in a country, the less ageism there was in the country – that is, having a high proportion of older people acts as a protective factor against ageism (8).

Previous studies had come to the opposite conclusion: that the higher the proportion of older people in a country, the greater the ageism against them (12, 68). A possible explanation for these inconsistent findings is that it may be the rate of change in the proportion of older people that matters and not the proportion itself. Countries whose population age structures are changing faster might be more prone to ageism (69).

Healthy life expectancy

The lower the healthy life expectancy in a country – that is, the average number of years that a newborn can expect to live in full health – the higher the likelihood of individuals holding highly or moderately ageist attitudes (8).

Countries with a lower expectancy for healthy life are more likely to have older adults in poor health, and increasing people’s exposure to those who have poor health in older age is likely to reinforce negative attitudes towards getting older. In turn, ageist attitudes are likely to be internalized as one grows older, and are likely to be

7 2

GLOBAL REPORT ON AGEISM

applied to oneself in the form of self- directed ageism, which can decrease health and functioning, as explained in Chapter 3. This highlights the need to invest in policies that promote healthy ageing practices and allow individuals to live longer and healthier lives (70).

While having a lower proportion of older people in a country may be a risk factor for interpersonal ageism, and a lower expectancy for healthy life is likewise a risk factor for interpersonal ageism, a recent study in 57 countries found that in the aggregate these two risk factors also increase the likelihood of a country being highly or moderately ageist (8).

Profession and occupational sector

Ageism is reported to be widespread in certain types of professions and occupational sectors, such as computer programming, online marketing and hospitality, and in sectors such as new technologies and start-ups (71), with the term “Silicon Valley ageism” being used to describe this phenomenon (72).

Presentation of older people in experimental studies

In experimental studies that simulate real- life contexts (e.g. through the use of videos, vignettes, evaluation of curriculum vitae), how people are presented (i.e. whether negatively or generically described as an older person or whether they are described with more positive, detailed and specific information) influences their likelihood of being the target of ageist attitudes.

A positive presentation decreases ageism, and a negative presentation increases it (1). In studies that simulate employment contexts, whether individuals are compared with a younger or an older person can also

be a risk factor. Several studies found that older workers are given more negative evaluations when the same evaluator is also rating younger workers (73-75).

This direct comparison might influence ratings of the targets of ageism by creating a situation in which age becomes especially salient, even when all other characteristics are equal. This determinant has potential implications for strategies aiming to reduce ageism, in particular for educational interventions and campaigns.

Using an optimal presentation – e.g. positive and with enough individuating information, and avoiding comparison with younger people – when presenting an older person could potentially help reduce ageism.

4.2 Determinants of self-directed ageism

This section provides an overview of the main determinants of self-directed ageism, including mental and physical health, contact with grandchildren and knowledge about ageing (see Table 4.1).

4.2.1 Mental and physical health

The few studies that have explored the factors that influence self-directed ageism in older people have found that individuals with poor mental and physical health are more likely to exhibit ageism towards themselves (1). This highlights again the need to invest in ageing-related policies and interventions that allow individuals to live both longer and healthier lives.

7 3

CHAPTER 04

7 3

4.2.2 Contact with grandchildren

Older people who have positive contact with their grandchildren are less likely to be negatively affected by stereotype threat, a form of self-directed ageism (76). Stereotype threat refers to an older person’s fear that they might confirm negative stereotypes about older people and, thus, perform more poorly on a task related to the stereotype, such as a test of mathematical or other cognitive ability.

4.2.3 Knowledge about ageing

One study in Australia and the United Kingdom that examined self-directed ageism seemed to indicate that participants who have greater knowledge about ageing may feel more positively about their own ageing, but the results were not conclusive (50).

Given that self-directed ageism appears to be widespread and has profound effects on health and well-being (see Chapter 3), it will be important to extend our knowledge of other determinants of self-directed ageism beyond the two identified so far.

4.3 Conclusions and future directions

Considerable evidence is available about the determinants of interpersonal ageism, both for those who perpetrate ageism (i.e. age, sex, level of education, anxiety about or fear of death, personality, past contact with older people) and for those who are targets of it (i.e. age, health status and dependence on others for care). Some evidence is available about the contextual

determinants of ageism (i.e. the proportion of older adults in a country, the expectancy for healthy life in a country and being in certain professions and occupational sectors).

Limited evidence is available about the determinants of self-directed ageism (i.e. mental and physical health and contact with grandchildren). Strategies to reduce ageism are unlikely to work unless they target those determinants that (i) have been shown to be the main causes of ageism and (ii) are modifiable (see Box 4.2).

Future priorities for understanding the determinants of ageism are outlined below.

• Current research gaps in relation to those determinants of interpersonal ageism, for which evidence is currently lacking or inconclusive, should be addressed. These include socioeconomic status and the presence of a social welfare system. The determinants of self-directed and institutional ageism, for which little evidence is available, should also be investigated. It is essential that studies on the determinants of all forms of ageism are conducted across countries, including low- and middle-income countries, to assess whether they vary across cultures and contexts. It is equally important that studies are conducted to assess the relative importance and causal status of different determinants of ageism (see Box 4.2).

• Our improved understanding of the determinants of ageism should be used to inform the theories of change and programme theories that underpin the development of strategies to reduce ageism.

7 4

GLOBAL REPORT ON AGEISM

Box 4.2 Opportunities for research on the determinants of ageism against older people

The systematic review on the determinants of ageism towards older people (1), on which much of this chapter is based, represents a significant step forward in research efforts seeking to identify the determinants of ageism. This review, which followed the PRISMA guidelines (77), was based on searches in 14 databases; included some 200 papers in English, French, and Spanish that identified 14 determinants of ageism categorized according to a multilevel framework; and carefully assessed the quality of the studies included.

However, this systematic review revealed several limitations in the underlying studies. Half of the studies were assessed as being of medium quality. Another limitation was that due to the heterogeneity of risk factors evaluated in the studies, it was not possible to use meta-analytic techniques that would have provided information about the strength of the association between each risk factor and ageism and, thus, an idea of their relative importance.

Future research should consider using more standardized definitions and measures of risk factors to increase comparability and allow findings to be subject to meta- analysis (1). A further limitation, which future studies should address, was that most studies were correlational in nature, and so the causal status of the determinants could not be assessed. Designing interventions to target risk factors that are not causally related to ageism increases the likelihood that the interventions will not work (78, 79).

7 5

CHAPTER 04

REFERENCES

1. Marques S, Mariano J, Mendonca J, De Tavernier W, Hess M, Naegele L, et al. Determinants of ageism against older adults: a systematic review. Int J Environ Res Public Health. 2020;17(7):2560. https://doi.org/10.3390/ijerph17072560.

2. Krieger N, Zierler S. What explains the public’s health? A call for epidemiologic theory. Epidemiology. 1996:7(1):107–9. https://doi.org/10.1097/00001648-199601000-00020.

3. Pearce N, Vandenbroucke JP. Educational note: types of causes. Int J Epidemiol. 2020;49(2):676–85. https://doi.org/10.1093/ije/dyz229.

4. Weed DL. Theory and practice in epidemiology. Ann N Y Acad Sci. 2001;954(1):52–62. https://doi.org/10.1111/j.1749-6632.2001.tb02746.x.

5. Breuer E, Lee L, De Silva M, Lund C. Using theory of change to design and evaluate public health interventions: a systematic review. Implement Sci. 2015;11(1):63.

https://doi.org/10.1186/s13012-016-0422-6. 6. De Silva MJ, Breuer E, Lee L, Asher L, Chowdhary N, Lund C, et al. Theory of change: a

theory driven approach to enhance the Medical Research Council’s framework for complex interventions. Trials. 2014;15(1):267. https://doi.org/10.1186/1745-6215-15-267.

7. Donaldson SI. Mediator and moderator analysis in program development. In: Sussman S, editor. Handbook of program development for health behavior research and practice. Thousand Oaks (CA); Sage 2001:470–96.

8. Officer A, Thiyagarajan JA, Schneiders ML, Nash P, de la Fuente-Núñez V. Ageism, healthy life expectancy and population ageing: how are they related? Int J Environ Res Public Health. 2020;17(9):3159. https://doi.org/10.3390/ijerph17093159.

9. Fraboni M, Saltstone R, Hughes S. The Fraboni Scale of Ageism (FSA): an attempt at a more precise measure of ageism. Can J Aging. 1990;9(1):56–66.

https://doi.org/10.1017/S0714980800016093. 10. North MS, Fiske ST. A prescriptive intergenerational-tension ageism scale: succession, iden-

tity, and consumption (SIC). Psychol Assess. 2013;25(3):706–13. https://doi.org/10.1037/a0032367. 11. Rupp DE, Vodanovich SJ, Crede M. Age bias in the workplace: the impact of ageism and

causal attributions. J Appl Soc Psychol. 2006;36(6):1337–64. https://doi.org/10.1111/j.0021-9029.2006.00062.x. 12. Lockenhoff CE, De Fruyt F, Terracciano A, McCrae RR, De Bolle M, Costa PT Jr., et al.

Perceptions of aging across 26 cultures and their culture-level associates. Psychol Aging. 2009;24(4):941–54. https://doi.org/10.1037/a0016901.

13. Bodner E, Bergman YS, Cohen-Fridel S. Different dimensions of ageist attitudes among men and women: a multigenerational perspective. Int Psychogeriatr. 2012;24(6):895–901.

https://doi.org/10.1017/S1041610211002936. 14. Kite ME, Stockdale GD, Whitley BE, Johnson BT. Attitudes toward younger and older adults:

an updated meta-analytic review. J Soc Issues. 2005;61(2):241–66. https://doi.org/10.1111/j.1540-4560.2005.00404.x. 15. Chopik WJ, Giasson HL. Age differences in explicit and implicit age attitudes across the life

span. Gerontologist. 2017;57(Suppl. 2):S169–77. https://doi.org/10.1093/geront/gnx058. 16. Kite ME, Wagner LS. Attitudes toward older adults. In: Nelson TD, editor. Ageism:

stereotyping and prejudice against older persons. Cambridge (MA): MIT Press; 2002:129–61. 17. Thorson JA, Whatley L, Hancock K. Attitudes toward the aged as a function of age and

education. Gerontologist. 1974;14(4):316–8. https://doi.org/10.1093/geront/14.4.316.

7 6

GLOBAL REPORT ON AGEISM

18. Abrams D, Russell PS, Vauclair CM, Swift H. Ageism in Europe: findings from the European Social Survey. London: Age UK; 2011.

19. Liu YE, Norman IJ, While AE. Nurses’ attitudes towards older people: a systematic review. Int J Nurs Stud. 2013;50(9):1271–82. https://doi.org/10.1016/j.ijnurstu.2012.11.021.

20. Söderhamn O, Lindencrona C, Gustavsson SM. Attitudes toward older people among nursing students and registered nurses in Sweden. Nurse Educ Today. 2001;21(3):225–9.

https://doi.org/10.1054/nedt.2000.0546. 21. Lambrinou E, Sourtzi P, Kalokerinou A, Lemonidou C. Attitudes and knowledge of the Greek

nursing students towards older people. Nurse Educ Today. 2009;29(6):617–22. https://doi.org/10.1016/j.nedt.2009.01.011. 22. Leung S, Logiudice D, Schwarz J, Brand C. Hospital doctors’ attitudes towards older people.

Intern Med J. 2011;41(4):308–14. https://doi.org/10.1111/j.1445-5994.2009.02140.x. 23. Kane MN. Social work students’ perceptions about incompetence in elders. J Gerontol Soc

Work. 2006;47(3–4):153–71. https://doi.org/10.1300/J083v47n03_10. 24. Martens A, Goldenberg JL, Greenberg J. A terror management perspective on ageism. J Soc

Issues. 2005;61(2):223–39. https://doi.org/10.1111/j.1540-4560.2005.00403.x. 25. Drury L, Abrams D, Swift HJ. Making intergenerational connections – an evidence review.

London: Age UK; 2017 (https://www.ageuk.org.uk/Documents/EN-GB/For professionals/ Research/Making_Intergenerational_Connections Evidence_Review(2017).pdf?dtrk=true, accessed 13 October 2020).

26. Christian J, Turner R, Holt N, Larkin M, Cotler JH. Does intergenerational contact reduce ageism: when and how contact interventions actually work? J Arts Humanit. 2014;3(1):1–15.

27. Van Dussen DJ, Weaver RR. Undergraduate students’ perceptions and behaviors related to the aged and to aging processes. Educ Gerontol. 2009;35(4):342–57.

https://doi.org/10.1080/03601270802612255. 28. Dykstra PA, Fleischmann M. Are societies with a high value on the Active Ageing Index more

age integrated? In: Zaidi A, Harper S, Howse K, Lamura G, Perek-Bialas J, editors. Building evidence for active ageing policies. Singapore: Springer; 2018:19–37.

29. Abrams D, Vauclair CM, Swift H. Predictors of attitudes to age across Europe. London: Department of Work and Pensions; 2011 (Research Report No 735; https://assets.publish- ing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/214509/ rrep735.pdf, accessed 13 October 2020).

30. Allport GW. The nature of prejudice. Oxford: Addison-Wesley; 1954. 31. Dovidio JF, Gaertner SL. Reducing prejudice: combating intergroup biases. Curr Dir Psychol

Sci. 1999;8(4):101–5. https://doi.org/10.1111/1467-8721.00024. 32. Bergman YS, Bodner E. Ageist attitudes block young adults’ ability for compassion toward

incapacitated older adults. Int Psychogeriatr. 2015;27(9):1541–50. https://doi.org/10.1017/S1041610215000198. 33. Burke BL, Martens A, Faucher EH. Two decades of terror management theory: a meta-

analysis of mortality salience research. Pers Soc Psychol Rev. 2010;14(2):155–95. https://doi.org/10.1177/1088868309352321. 34 Stephan WG, Stephan CW. Intergroup threat theory. In: Kim Y, editor. The international

encyclopedia of intercultural communication, Vol. 3. Hoboken (NJ): Wiley; 2017:1–12. 35. Tajfel H, Turner J. An integrative theory of intergroup conflict. In: Hogg MA, Abrams D,

editors. Intergroup relations: essential readings. Philadelphia (PA): Psychology Press; 2001:94–109.

7 7

CHAPTER 04

36. Paluck EL, Green DP. Prejudice reduction: What works? A review and assessment of research and practice. Annu Rev Psychol. 2009;60:339–67. https://doi.org/10.1146/annurev.psych.60.110707.163607.

37. Pettigrew TF, Tropp LR. A meta-analytic test of intergroup contact theory. J Pers Soc Psychol. 2006;90(5):751–83. https://doi.org/10.1037/0022-3514.90.5.751.

38. Pettigrew TF, Tropp LR. How does intergroup contact reduce prejudice? Meta‐analytic tests of three mediators. Eur J Soc Psychol. 2008;38(6):922–34.

https://doi.org/10.1002/ejsp.504. 39. Levy B. Stereotype embodiment: a psychosocial approach to aging. Curr Dir Psychol Sci.

2009;18(6):332–6. https://doi.org/10.1111/j.1467-8721.2009.01662.x. 40. Levy BR, Hausdorff JM, Hencke R, Wei JY. Reducing cardiovascular stress with positive self-

stereotypes of aging. J Gerontol B Psychol Sci Soc Sci. 2000;55(4):P205–13. https://doi.org/10.1093/geronb/55.4.p205. 41. Fawsitt F, Setti A. Extending the stereotype embodiment model: a targeted review. Transl

Issues Psychol Sci. 2017;3(4):357. 42. Allan LJ, Johnson JA. Undergraduate attitudes toward the elderly: the role of knowledge,

contact and aging anxiety. Educ Gerontol. 2008;35(1):1–14. https://doi.org/10.1080/03601270802299780. 43. Barnett MD, Adams CM. Ageism and aging anxiety among young adults: relationships with

contact, knowledge, fear of death, and optimism. Educ Gerontol. 2018;44(11):693–700. https://doi.org/10.1080/03601277.2018.1537163.

44. Boswell SS. Predicting trainee ageism using knowledge, anxiety, compassion, and contact with older adults. Educ Gerontol. 2012;38(11):733–41. https://doi.org/10.1080/03601277.2012.695997.

45. Cherry KE, Brigman S, Lyon BA, Blanchard B, Walker EJ, Smitherman EA. Self-reported ageism across the lifespan: role of aging knowledge. Int J Aging Hum Dev. 2016;83(4):366– 80. https://doi.org/10.1177/0091415016657562.

46. Chung S, Park H. How young and older people differ in discriminatory behaviour towards older people? An explanation of the knowledge–attitude–behaviour continuum model. Ageing Soc. 2019;39(9):1996–2017. https://doi.org/10.1017/S0144686X18000405.

47. Cooney C, Minahan J, Siedlecki KL. Do feelings and knowledge about aging predict ageism? J Appl Gerontol. 2020:0733464819897526. https://doi.org/10.1177/0733464819897526.

48. Donizzetti AR. Ageism in an aging society: the role of knowledge, anxiety about aging, and stereotypes in young people and adults. Int J Environ Res Public Health. 2019;16(8):1329. https://doi.org/10.3390/ijerph16081329.

49. Even-Zohar A, Werner S. The effect of educational interventions on willingness to work with older adults: a comparison of students of social work and health professions. J Gerontol Soc Work. 2020;63(1–2):114–32. https://doi.org/10.1080/01634372.2020.1712511.

50. Getting L, Fethney J, McKee K, Churchward M, Goff M, Matthews S. Knowledge, stereotyping and attitudes towards self ageing. Australas J Ageing. 2002;21(2):74–9.

https://doi.org/10.1111/j.1741-6612.2002.tb00421.x. 51. Gewirtz-Meydan A, Even-Zohar A, Werner S. Examining the attitudes and knowledge of

social work and nursing students on later-life sexuality. Can J Aging. 2018;37(4):377–89. https://doi.org/10.1017/S0714980818000260.

52. Goriup J, Lahe D. The role of education and knowledge about aging in creating young people’s attitudes to the elderly. Acta Educ Gen. 2018;8(1):63–75.

https://doi.org/10.2478/atd-2018-0004.

7 8

GLOBAL REPORT ON AGEISM

53. Kurth ML, Intrieri RC. Attitudes, perceptions, and aging knowledge of future law enforcement and recreation majors. Educ Gerontol. 2017;43(6):313–26. https://doi.org/10.1080/03601277 .2017.1296297.

54. Lahe D, Goriup J. The role of knowledge about aging in creating young people’s attitudes to the elderly. Solsko Polje. 2017;28(1/2):115–130.

55. Milutinovic D, Simin D, Kacavendic J, Turkulov V. Knowledge and attitudes of health care science students toward older people. Med Pregl. 2015;68:382-6.

doi/10.2298/MPNS1512382M. 56. Rababa M, Hammouri AM, Hweidi IM, Ellis JL. Association of nurses’ level of knowledge

and attitudes to ageism toward older adults: cross-sectional study. Nurs Health Sci. 2020;22(3):593–601. https://doi.org/10.1111/nhs.12701.

57. Shiovitz-Ezra S, Ayalon L, Brodsky J, Doron I. Measuring ageism based on knowledge, attitudes and behavior: findings from an Israeli pilot study. Ageing Int. 2016;41(3):298–310. https://doi.org/10.1007/s12126-016-9251-9.

58. Stahl ST, Metzger A. College students’ ageist behavior: the role of aging knowledge and perceived vulnerability to disease. Gerontol Geriatr Educ. 2013;34(2):197–211.

https://doi.org/10.1080/02701960.2012.718009. 59. Wisdom NM, Connor DR, Hogan LR, Callahan JL. The relationship of anxiety and beliefs

toward aging in ageism. J Sci Psychol. 2014:10–21. 60. Cottle NR, Glover RJ. Combating ageism: change in student knowledge and attitudes regard-

ing aging. Educ Gerontol. 2007;33(6):501–12. https://doi.org/10.1080/03601270701328318. 61. Boswell SS. “Old people are cranky”: helping professional trainees’ knowledge, attitudes,

aging anxiety, and interest in working with older adults. Educ Gerontol. 2012;38(7):465–72. https://doi.org/10.1080/03601277.2011.559864.

62. Intrieri RC, Kurth ML. Racial differences in attitudes toward aging, aging knowledge, and contact. Educ Gerontol. 2018;44(1):40–53. https://doi.org/10.1080/03601277.2017.1388962.

63. Narayan C. Is there a double standard of aging? Older men and women and ageism. Educ Gerontol. 2008;34(9):782–7. https://doi.org/10.1080/03601270802042123.

64. Stuart-Hamilton I, Mahoney B. The effect of aging awareness training on knowledge of, and attitudes towards, older adults. Educ Gerontol. 2003;29(3):251–60.

https://doi.org/10.1080/713844305. 65. Cowan DT, Fitzpatrick JM, Roberts JD, While AE. Measuring the knowledge and attitudes

of health care staff toward older people: sensitivity of measurement instruments. Educ Gerontol. 2004;30(3):237–54. https://doi.org/10.1080/03601270490273169.

66. Gekoski WL, Knox VJ. Ageism or healthism? Perceptions based on age and health status. J Aging Health. 1990;2(1):15–27. https://doi.org/10.1177%2F089826439000200102.

67. James JW, Haley WE. Age and health bias in practicing clinical psychologists. Psychol Aging. 1995;10(4):610–6. https://doi.org/10.1037//0882-7974.10.4.610.

https://doi.org/10.1037/0882-7974.10.4.610. 68. Ng R, Allore HG, Trentalange M, Monin JK, Levy BR. Increasing negativity of age

stereotypes across 200 years: evidence from a database of 400 million words. PLOS ONE. 2015;10(2):e0117086. https://doi.org/10.1371/journal.pone.0117086.

69. North MS, Fiske ST. Modern attitudes toward older adults in the aging world: a cross-cultural meta-analysis. Psychol Bull. 2015;141(5):993–1021. https://doi.org/10.1037/a0039469.

70. World report on ageing and health. Geneva: World Health Organization; 2015 (https://apps. who.int/iris/handle/10665/186463, accessed 13 October 2020).

7 9

CHAPTER 04

71. Gaster L. Past it at 40? A grassroots view of ageism and discrimination in employment. Bristol (England): Policy Press; 2002.

72. Kuchler H. Silicon Valley ageism: ‘They were, like, wow, you use Twitter?’. Financial Times.30 July 2017 (https://www.ft.com/content/d54b6fb4-624c-11e7-91a7-502f7ee26895, accessed 13 October 2020).

73. Finkelstein LM, Burke MJ, Raju NS. Age-discrimination in simulated employment contexts – an integrative analysis. J Appl Psychol. 1995;80(6):652–63.

https://doi.org/10.1037/0021-9010.80.6.652. 74. Gordon RA, Arvey RD. Age bias in laboratory and field settings: a meta-analytic investiga-

tion. J Appl Soc Psychol. 2004;34(3):468–92. https://doi.org/10.1111/j.1559-1816.2004.tb02557.x.

75. Bal AC, Reiss AE, Rudolph CW, Baltes BB. Examining positive and negative perceptions of older workers: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2011;66(6):687–98.

https://doi.org/10.1093/geronb/gbr056. 76. Abrams D, Crisp RJ, Marques S, Fagg E, Bedford L, Provias D. Threat inoculation: experienced

and imagined intergenerational contact prevents stereotype threat effects on older people’s math performance. Psychol Aging. 2008;23(4):934–9. https://doi.org/10.1037/a0014293.

77. Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097.

78. Case S, Haines K. Risky business? The risk in risk factor research. Crim Justice Matters. 2010;80(1):20–2. https://doi.org/10.1080/09627251.2010.482234.

79. Kraemer HC, Kazdin AE, Offord DR, Kessler RC, Jensen PS, Kupfer DJ. Coming to terms with the terms of risk. Arch Gen Psychiatry. 1997;54(4):337–43. https://doi.org/10.1001/ archpsyc.1997.01830160065009.

8 0

GLOBAL REPORT ON AGEISM

MRIDUL , 29, INDIA

8 1

CHAPTER 01

8 1

C H A P T E R 0 5

A s a youth, I just become another number of the ‘demographic dividend’ or an issue to be resolved, completely disregarding my political and social engagement . A s a youth, if I want to do something for society, ‘ volunteering and learning’ is suggested by people already earning ver y well , even if I have been doing that for more than a decade. With each dollar given to me, extra standards of accountability and transparency are also conveyed formally/ informally as if being young means incompetent , careless and/or corrupt .

Mridul , 29, India ©Mridul Upadhyay / UN Major Group for Children and Youth

05

“

“

8 2

GLOBAL REPORT ON AGEISM

5.1 The scale of ageism against younger people

Ageism against younger populations manifests across a range of institutions including the workplace, the legal system and politics. There is also growing evidence of interpersonal ageism directed against younger adults from population-based studies, which suggest that in Europe it may be more prevalent than interpersonal ageism against older people. No evidence is available on the magnitude of self-directed ageism in younger populations.

5.1.1 Institutional ageism

Ageism in the workplace

Although no reviews have systematically assessed how ageism affects younger populations in the workplace, a recent scoping review found increasing evidence that ageism towards this group manifests itself most markedly once they are employed, especially in terms of pay and benefits (1). This applies more to younger women than younger men, a case of ageism

Little is known about ageism against younger people (those aged < 50 years), with most of the evidence focusing on its prevalence and manifestations.

Ageism against younger populations occurs in institutions such as the workplace and the legal and political systems, and in Europe it appears to be more prevalent than ageism against older people.

The impact of ageism against younger people is still poorly understood.

The main determinants of ageism against younger populations include certain personality traits, whether there is contact with other age groups, health status and care dependence, and working in certain professions or sectors.

GLOBAL REPORT ON AGEISM

05 Chapter

8 2

This chapter surveys what is known about ageism against younger people, that is, those aged < 50 years. Section 5.1 covers evidence on the scale of ageism against younger people; Section 5.2, its impact; and Section 5.3, the determinants of ageism against younger people.

8 3

CHAPTER 05

intersecting with sexism. Younger workers also report not feeling valued, being subject to negative age stereotypes and belittling comments and being generally perceived as incompetent because they look young (1). Data from the European Working Conditions Survey 2015, which included nearly 44 000 workers in 35 countries, found that among those employed, age discrimination peaked at the ages of 20 years and again at 59 years (see Fig. 5.1) (2).

Ageism may also force younger workers out of employment. A study conducted in Australia between 2002 and 2005 that looked at the circumstances leading to the dismissal of 1259 employees aged 15 to 24 years, reported that about 8% of cases were due to age-based discrimination (3).

More research is needed to examine ageism against younger people occurring during hiring to determine if it is due to the age of the candidate or other factors, such as qualifications and work experience, fit between the position and the applicant, job level or workplace context (e.g. dynamic versus stable) (1).

Fig. 5.1. Percentage of employees experiencing age discrimination during the past 12 months by age, Europe, 2015

Source: reproduced with permission from Mullan et al. (2).

Ageism in the legal system

A scoping review of ageism directed towards younger populations found that crimes committed by younger offenders elicited greater anger, were perceived to be more serious transgressions and considered to deserve more severe punishment than those committed by older offenders. Findings are mixed when the age of the victim of crime is considered, with some studies showing that transgressions were evaluated more seriously and received recommendations for more severe punishment when the victim was an older adult and others showing no effect of age (1). A study in the United States found that employers were most likely to win a court case when the employee was younger rather than older (4).

Ageism and politics

An increasing number of studies have also explored how ageism manifests itself in politics, finding that there is a tendency to doubt, deny or dismiss the voices of youth and children; regulate their identities; and generally limit their efforts in political and advocacy movements (1), for example, by dismissing their input in political discussions or raising questions about the authenticity of youth organizers’ perspectives.

Ageism towards younger people in politics interacts with sexism and racism. One study looked at the experiences of young women labour activists participating in youth programmes and found that the age of the women intersected with their gender and racial identity to create systemic disadvantage and unfavourable experiences (5).

Another study found that young women activists in Egypt often faced limitations due to their age and gender in filling political roles or engaging with formal institutions (6).

8 4

GLOBAL REPORT ON AGEISM

Studies simulating mayoral elections found that the age of the political candidate had more influence on voting behaviour than sex or gender or race, with middle-aged candidates preferred over younger candidates (7, 8).

Middle-aged adults, especially men, have the greatest status, wealth and power, according to studies that examined the level of status and power accorded to people based on their age. Younger adults were perceived to have the lowest status, wealth and power (1).

Other institutions

Little research has investigated if and how ageism against younger people manifests in other institutions, such as health care, the media and financial institutions. Regarding housing discrimination, a 2002 report in Canada found that younger applicants were sometimes rejected by landlords for being too young to live alone (9).

5.1.2 Interpersonal ageism

Ageist attitudes towards younger adults

While no comparable, global cross-national data are available about ageist attitudes towards younger adults, there appears to be a general tendency to report less positive feelings towards younger rather than older adults (10, 11).

In an analysis based on the fourth wave of the European Social Survey (2008–2009), which included a representative sample of some 55 000 participants aged 15 years or older in 28 European countries, younger adults received lower ratings than older adults across a range of positive stereotypes (10). As illustrated in Fig. 5.2, people in their twenties received lower ratings across the four characteristics examined in the survey, which included

being seen as friendly, competent and viewed with respect, and having high moral standards.

Reported experiences of interpersonal ageism

In the European Social Survey (2008–2009), those aged 15–24 years reported experiencing the most unfair treatment because of their age: 55% of them thought that someone had shown them a lack of respect or treated them badly (see Fig. 5.3). Also, like every other age group, those aged 15–24 years reported experiencing more discrimination based on age than discrimination based on gender, race or ethnic background (see Fig. 2.4) (10).

Thus, the evidence of institutional and interpersonal ageism directed against younger people is limited to the WHO European Region. Evidence on the scale of self-directed ageism against younger people is lacking.

5.2 The impact of ageism against younger people

Evidence for the impact of ageism on younger people is extremely limited – only 10 studies were identified – and has produced inconsistent findings (1).

Ageism may affect health when it intersects with other “-isms”. One study in Brazil, which investigated the impact of different forms of discrimination on mental disorders, showed that ageism on its own was not associated with mental disorders, but it was associated when it co-occurred with racism or classism, or both (12).

8 5

CHAPTER 05

Fig. 5.2. Likelihood that most people view those aged 20–29 and those older than 70 years as possessing certain characteristics (mean scores across European Social Survey countries, 2008–2009; scale ranged from 0, indicating not at all likely, to 4, indicating very likely)

Source: reproduced with permission from Abrams et al. (10).

Fig. 5.3. Percentage of people in countries in the European Social Survey (2008–2009) who thought someone showed a lack of respect or treated them badly because of their age, by age group (includes only individuals who did not rate their experience 0 on a scale that ranged from 0, indicating they had never experienced this treatment, to 4, indicating they had experienced it very often)

Source: reproduced with permission from Abrams et al. (10).

Evidence suggests that ageism has a limited impact on younger people’s well-being and self-esteem. A study that included a large sample of Europeans revealed that perceived

age discrimination had the biggest impact on people’s happiness and life satisfaction between the ages of 40 and 70 years and the smallest impact on those aged between

8 6

GLOBAL REPORT ON AGEISM

20 and 30 years and 70 years and older (13). In support of these findings, another study found that age discrimination had no impact on younger adults’ well-being (14).

Two other studies showed that ageism had a limited impact on younger people. The first reported that the more self- conscious younger workers were about being stereotyped, the worse their mood and the less satisfied they were with older co-workers (15). The second concluded that age-biased communication behaviours had only a slightly negative impact on younger adults’ self-esteem or life satisfaction relative to older adults. However, when older adults were perceived as adjusting their speech style to younger people, younger people’s sense of collective self-esteem was enhanced (16).

Findings about the impact of ageism on cognitive performance are inconsistent. Two studies examined the impact of younger people’s exposure to negative age stereotypes on their cognitive performance. One found that it had a negative impact (17), the other that it had a positive impact, but only when younger people saw themselves as under the control of powerful people; otherwise, it had no effect (18).

In the workplace, studies show that perceived age discrimination reduces both younger and older people’s commitment to the organization (19, 20). A qualitative study also revealed that ageism affected the work identities of younger female workers and led them to consciously portray themselves as older and less feminine through their dress, speech and behaviour (21).

While this limited body of evidence has identified some negative effects of ageism against younger people, the findings are weak and inconsistent. Furthermore, important effects of ageism identified

among older people – such as serious health and economic effects – remain largely unexplored among younger people.

5.3 The determinants of ageism against younger people

Different individual characteristics associated with being a perpetrator of ageism or being a target of ageism have been identified in the literature, as have a series of contextual determinants of ageism directed towards younger populations (1).

5.3.1 Individual characteristics associated with being a perpetrator of interpersonal ageism

Several individual characteristics may be associated with becoming a perpetrator of ageism against younger people, including sex or gender, age, a lack of cross-generational friendships and certain personality traits (see Table 5.1).

The findings regarding sex or gender as a determinant for perpetrating ageism against younger people are inconsistent. Some studies suggest that women might be less ageist against younger people than men, while others found there was no difference (11, 22-24).

The overall picture is unclear about whether older or younger age is a risk factor for perpetrating ageism against younger people (1). For instance, in a study on the visual inspection of faces, older people spent more time examining the faces

8 7

CHAPTER 05

TYPE OF DETERMINANT TYPE OF ASSOCIATION

IN T

E R

P E

R S

O N

A L

A G

E IS

M

IN D

IV ID

U A

L- LE

V E

L D

E TE

R M

IN A

N TS

P E

R P

E TR

A TO

R

Sex Unclear

Age Unclear

Personality traits Agreeableness Conscientiousness

Less ageism (protective factor) More ageism in workplace (risk factor)

Contact with other age groups, including grandparent–grand- child contact and intergenera- tional f riendships

More intergenerational f riend- ships

Less ageism (protective factor)

TA R

G E

T

Sex Female More ageism (in some profes- sional contexts) (risk factor)

Health status and care dependence Poorer health More ageism (risk factor)

C O

N TE

X TU

A L-

LE V

E L

D

E TE

R M

IN A

N TS

Profession and occupational sector

Some professions and occupa- tional sectors (e.g. teaching) More ageism (risk factor)

Presentation of younger people in experimental studies that simulate real-life settings

More detailed information about the younger person

Less ageism (protective factor)

of people their own age than the faces of people of other ages, as did younger people (25). Other studies indicate that younger people may sometimes display more ageist attitudes towards people their own age rather than other age groups (26, 27).

The personality trait of agreeableness is associated with having less ageist attitudes towards younger people (26). Conscientiousness, however, appears

to predict more ageism towards the performance of younger workers (28).

A study in 25 European Union countries found that older people who reported having cross-age friendships tended to be less ageist against younger people than those who did not report such friendships. However, older people were still more ageist against younger people than younger people who reported having cross-age friendships were against older people (29).

Table 5.1. Determinants of ageism against younger people

8 8

GLOBAL REPORT ON AGEISM

8 8

GLOBAL REPORT ON AGEISM

5.3.2 Individual characteristics associated with being a target of interpersonal ageism

There is limited evidence about the individual characteristics that may be associated with becoming a target of ageism.

There is some evidence that being female may, in certain professional occupations, increase the likelihood of being a target of ageism directed against younger people. For instance, one study showed that students had lower expectations about the performance of young, unattractive female teachers than of young, unattractive male teachers or teachers of other ages (30).

Being in poor health or care dependent has also been found in one study to be a risk factor for negative perceptions of younger people (31)

5.3.3 Contextual determinants of interpersonal ageism

Profession and occupational sector has been identified as a possible contextual determinant of interpersonal ageism. In some professions, there is limited evidence of ageism against younger people. For instance, in an experimental study, preference was shown by participants for hiring a middle-aged applicant over a young applicant for a job as a tour guide, despite the candidates having the same qualifications (32). Another study suggests that younger teachers are held to higher standards of professional competence than older teachers (30).

The amount of information provided about a younger person has also been described as a possible contextual determinant of ageism. In experimental studies that

simulate real-life contexts, the more information that is presented about a younger person, the less likely it is that they will be subject to ageism (30, 33-35).

5.3.4 Institutional and self- directed ageism

There is no evidence about determinants of institutional ageism against younger people, nor is there any evidence about determinants of self-directed ageism among younger people.

5.4 Conclusions and future directions

Too little is known about the scale, impact and determinants of ageism against younger people. However, there is some evidence that it occurs in the workplace and in legal and political systems. In Europe, the only region for which data are available, attitudes towards younger people are often more negative than they are towards older people; and younger people report experiencing more aged-based discrimination than any other age group.

The impact of ageism against younger people, par ticularly the cumulative impact over the life course, is not well understood. The main determinants of ageism against younger people include the personality traits of agreeableness (protective factor) and conscientiousness (risk factor), having contact with other age groups (protective factor), being care dependent or in poor health (risk factors) and working in certain professions or sectors (risk factors). Future priorities for increasing our understanding of ageism

8 9

CHAPTER 05

8 9

Box 5.1 Opportunities for research on ageism against younger people

The findings about ageism directed against younger populations are mainly based on a scoping review commissioned for this report (1). This review used a comprehensive search strategy that included 13 different databases and three different languages (English, French and Spanish). It included 263 quantitative and qualitative studies and provided the first systematic effort to assemble evidence about ageism towards younger people, defined as those younger than 50 years. The scoping review was supplemented by an appraisal of the quality of the evidence on the impact and determinants of ageism against younger people.

One limitation of the studies identified was that many were cross-sectional in nature. This makes it difficult to establish whether the associations found – between ageism and impacts, on the one hand, and determinants and ageism, on the other – are, in fact, causal. Another limitation relates to the inconsistent terminology used to refer to ageism against younger people (e.g. adultism, kiddism), which makes comparability across studies complicated.

Future research should explore the determinants and prevalence of ageism against younger people across high-, middle- and low-income countries, including institutional, interpersonal and self-directed ageism. It is most important to investigate the impact of ageism on younger populations, including its health and economic impacts, both in the shorter term and cumulatively over the life course. If ageism against younger people turns out to be widespread but to have a limited impact, then perhaps addressing it should be less of a priority than reducing ageism against older people. It is possible, however, that cumulatively over the life course ageism against younger people takes a serious toll. We also encourage researchers to conduct more studies on ageism as it affects children, given that this is an area that is relatively underexplored.

directed against younger people should include:

• monitoring ageism in a range of institutional settings, including the workplace and legal and political institutions;

• improving our understanding of all aspects of the problem – its scale, impact and determinants – especially in low- and middle- income countries, where there is currently almost no research and

younger people often make up the bulk of the population (see Box 5.1);

• ensuring that our improved understanding of the scale, impact and determinants of ageism against younger people informs the strategies that are adopted to address ageism against younger people.

9 0

GLOBAL REPORT ON AGEISM

REFERENCES

1. de la Fuente-Núñez V, Schwartz E, Roy S, Ayalon L. A scoping review on ageism against younger populations. Unpublished.

2. Mullan J, Llave OV, Wilkens M. Working conditions of workers of different ages: European Working Conditions Survey 2015. Luxembourg; Publications Office of the European Union: 2017 (https://www.eurofound.europa.eu/sites/default/files/ef_publication/field_ef_ document/ef1747en.pdf, accessed 2 April 2020).

3. Kellner A, McDonald P, Waterhouse J. Sacked! An investigation of young workers’ dismissal. J Manag Organ. 2011;17:226–44. https://doi.org/10.5172/jmo.2011.17.2.226.

4. Miller CS, Kaspin JA, Schuster MH. The impact of performance appraisal methods on age discrimination in employment act cases. Pers Psychol. 1990;43:555–78.

https://doi.org/10.1111/j.1744-6570.1990.tb02396.x. 5. Kainer J. Intersectionality at work: young women organizers’ participation in labour youth

programs in Canada. Resour Fem Res. 2016;34:102-32. (https://jps.library.utoronto.ca/ index.php/rfr-drf/article/view/27574, accessed 22 October 2020).

6. Salem R, Ibrahim B, Brady M. Negotiating leadership roles: young women’s experience in rural Egypt. Women’s Stud Q. 2003;31:174–91 (https://www.jstor.org/stable/40003326, accessed 16 April 2020).

7. Piliavin JA. Age, race, and sex similarity to candidates and voting preference. J Appl Soc Psychol. 1987;17:351–68. https://doi.org/10.1111/j.1559-1816.1987.tb00318.x.

8. Sigelman L, Sigelman CK. Sexism, racism, and ageism in voting behavior: an experimental analysis. Soc Psychol Q. 1982;45:263–9. https://doi.org/10.2307/3033922.

9. Novac S, Darden J, Hulchanski D, Seguin A-M. Housing discrimination in Canada: the state of knowledge. Ottawa: Canada Mortgage and Housing Corporation; 2002 (http://www. hnc.utoronto.ca/pdfs/home/Novac_Discrimination-Lit-Re.pdf, accessed 16 July 2020).

10. Abrams D, Russell PS, Vauclair CM, Swift H. Ageism in Europe: findings from the European Social Survey. London: Age UK; 2011 (https://www.ageuk.org.uk/Documents/EN-GB/ For-professionals/ageism_across_europe_report_interactive.pdf?dtrk=true, accessed 12 May 2020).

11. Ayalon L. Feelings towards older vs. younger adults: results from the European Social Survey. Educ Gerontol. 2013;39:888–901. https://doi.org/10.1080/03601277.2013.767620.

12. Bastos JL, Barros AJD, Celeste RK, Paradies Y, Faerstein E. Age, class and race discrimination: their interactions and associations with mental health among Brazilian university students. Cad Saude Publica. 2014;30:175–86.

https://doi.org/10.1590/0102-311X00163812. 13. Hnilica K. Discrimination and subjective well-being: protective influences of membership in

a discriminated category. Cent Eur J Public Health. 2011;19:3–6. https://doi.org/10.21101/cejph.a3608. 14. Garstka TA, Schmitt MT, Branscombe NR, Hummert ML. How young and older adults

differ in their responses to perceived age discrimination. Psychol Aging. 2004;19:326–35. https://doi.org/10.1037/0882-7974.19.2.326.

15. Ryan KM, King EB, Finkelstein LM. Younger workers’ metastereotypes, workplace mood, attitudes, and behaviors. J Manag Psychol. 2015;30:54–70.

https://doi.org/10.1108/JMP-07-2014-0215. 16. Noels KA, Giles H, Cai D, Turay L. Perceptions of inter-and intra-generational

communication in the United States of America and the People’s Republic of China: implications for self-esteem and life satisfaction. S Pac J Psychol. 1999;10:120–35.

https://doi.org/10.1017/S0257543400001085.

9 1

CHAPTER 05

17. Andreoletti C, Lachman ME. Susceptibility and resilience to memory aging stereotypes: education matters more than age. Exp Aging Res. 2004;30:129–48.

https://doi.org/10.1080/03610730490274167. 18. Hehman JA, Bugental DB. “Life stage-specific” variations in performance in response to

age stereotypes. Dev Psychol. 2013;49:1396–406. https://doi.org/10.1037/a0029559. 19. Snape E, Redman T. Too old or too young? The impact of perceived age discrimination.

Hum Resour Manag J. 2003;13:78–89. https://doi.org/10.1111/j.1748-8583.2003. tb00085.x.

20. Rabl T, Triana M-C. How German employees of different ages conserve resources: perceived age discrimination and affective organizational commitment. Int J Hum Resour. 2013;24:3599–612. https://doi.org/10.1080/09585192.2013.777936.

21. Worth N. Who we are at work: millennial women, everyday inequalities and insecure work. Gend Place Cult. 2016;23:1302–14. https://doi.org/10.1080/0966369X.2016.1160037.

22. Diekman AB, Hirnisey L. The effect of context on the silver ceiling: a role congruity perspective on prejudiced responses. Personal Soc Psychol Bull. 2007;33:1353–66.

https://doi.org/10.1177/0146167207303019. 23. Erber JT, Szuchman LT, Prager IG. Ain’t misbehavin’: the effects of age and intentionality on

judgments about misconduct. Psychol Aging. 2001;16:85–95. https://doi.org/10.1037/0882-7974.16.1.85. 24. Kogan N. A study of age categorization. J Gerontol. 1979;34:358–67. https://doi.org/10.1093/geronj/34.3.358. 25. He Y, Ebner NC, Johnson MK. What predicts the own-age bias in face recognition

memory? Soc Cogn. 2011;29:97-109. https://doi.org/10.1521/soco.2011.29.1.97. 26. Gluth S, Ebner NC, Schmiedek F. Attitudes toward younger and older adults: the German

aging semantic differential. Int J Behav Dev. 2010;34:147–58. https://doi.org/10.1177/0165025409350947. 27. Gross EF, Hardin CD. Implicit and explicit stereotyping of adolescents. Soc Justice Res.

2007;20:140–60. https://doi.org/10.1007/s11211-007-0037-9. 28. Kmicinska M, Zaniboni S, Truxillo DM, Fraccaroli F, Wang M. Effects of rater

conscientiousness on evaluations of task and contextual performance of older and younger co-workers. Eur J Work Organ Psychol. 2016;25:707–21.

https://doi.org/10.1080/1359432X.2016.1147428. 29. Dykstra PA, Fleischmann M. Are societies with a high value on the Active Ageing Index

more age integrated? In: Zaidi A, Harper S, Howse K, Lamura G, Perek-Bialas J, editors. Building evidence for active ageing policies. Singapore: Springer; 2018:19–37.

30. Goebel BL, Cashen VM. Age stereotype bias in student ratings of teachers: teacher, age, sex, and attractiveness as modifiers. College Student Journal. 1985;19:404–10.

(https://psycnet.apa.org/record/1987-23500-001, accessed 21 October 2020). 31. Gekoski WL, Knox VJ. Ageism or healthism? Perceptions based on age and health status. J

Aging Health. 1990;2(1):15–27. https://doi.org/10.1177%2F089826439000200102. 32. Luoh H-F, Tsaur S-H. Customers’ perceptions of service quality: do servers’ age stereotypes

matter? Int J Hosp Manag. 2011;30:283–9. https://doi.org/10.1016/j.ijhm.2010.09.002. 33. Kite ME, Johnson BT. Attitudes toward older and younger adults: a meta-analysis. Psychol

Aging. 1988;3:233–44. https://doi.org/10.1037/0882-7974.3.3.233. 34. Kite ME, Stockdale GD, Whitley BE Jr, Johnson BT. Attitudes toward younger and older

adults: an updated meta‐analytic review. J Soc Issues. 2005;61:241–66. https://doi.org/10.1111/j.1540-4560.2005.00404.x. 35. Kite ME, Wagner LS. Attitudes toward older adults. In: Nelson TD, editor. Ageism:

stereotyping and prejudice against older persons. Cambridge (MA): MIT Press; 2002:129–61.

9 2

GLOBAL REPORT ON AGEISM

KHALED, 26 , EGYPT

CHAPTER 01

C H A P T E R 0 6

A s a young man interested in working in human rights , I s tarted working in this f ield early by engaging in various activities and from then I faced a lot of discrimination due to my young age.

Khaled, 26 , Egypt ©Khaled Emam / UN Major Group for Children and Youth

06

9 3

“ “

9 4

GLOBAL REPORT ON AGEISM

Policies and laws can be used to reduce or eliminate ageism against any age group.

Policies and laws to reduce or eliminate ageism include, for instance, legislation addressing age discrimination and inequality, policies to ensure respect for the dignity of all persons regardless of age and human rights laws.

Some direct evidence shows that polices and laws reduce ageism, and there is indirect evidence that policies and laws reduce other “-isms” (e.g. racism, sexism) and could, therefore, also work to reduce ageism.

GLOBAL REPORT ON AGEISM

06 Chapter

9 4

6.1 What they are and how they work

The enactment of policies and laws constitutes an important strategy that can be used to reduce or eliminate ageism, especially discrimination on the grounds of age (1). Policies are plans, commitments or courses of action that are undertaken to affect a given issue within a society. Policies generally provide a framework against which proposals or activities can be tested or measured. Examples of policies include complaints mechanisms and plans for action in employment and health institutions that seek to eliminate age-based discrimination and to empower people to claim their rights to equal access and participation. Laws correspond to the system of rules that a particular country or community recognizes as regulating the actions of its members and that it may enforce by imposing penalties. Laws also help guarantee the protection of all human rights and enable individuals to hold their governments to account. A distinction can be made between international and national law. International law defines the legal responsibilities and obligations of signatory states in their conduct with each other and in their treatment of individuals within state boundaries. International conventions or treaties

This chapter provides information about the first strategy that can be used to eliminate or reduce ageism: policy and law. Section 6.1 describes this strategy and how it works in reducing ageism. Section 6.2 presents evidence on its effectiveness whilst Section 6.3 provides examples of this type of intervention from different countries and regions. Section 6.4 outlines the cost of this type of intervention and characteristics that can improve its effectiveness.

9 5

CHAPTER 06

and international custom are two important sources of international law. National law, which is often referred to as domestic law, refers to those laws that exist within a particular country. Although distinct, policies and laws are intimately linked; for example, policy can be translated into legislation, and legislation can include an obligation to formulate new policy.

The way in which policies and laws can reduce ageism is fourfold. First, according to deterrence theory, outlawing a given behaviour or practice can reduce that behaviour to the extent that sanctions are consistently imposed (2, 3). For example, employers are less likely to discriminate when anti-discrimination laws are in place, given that these create an expected cost of a magnitude that equals the cost of the violation if caught (e.g. attorney’s fees, fines) times the probability of being caught (4).

Second, policies and laws can help reduce ageism by creating a clear social norm that ageism is socially unacceptable (2, 5-7). Being aware of the stance of one’s community has been shown to impact the extent of prejudice one expresses, even when attitudes are stated privately and there is no possibility of criticism (7-12).

Third, according to the theory of cognitive dissonance (13), government-level policies and laws, by forcing people to change their behaviour, can eventually change most people’s underlying attitudes too, as they will need to reconcile the dissonance between their attitudes and their behaviour. Fourth, laws and policies can increase diversity in the surrounding population (e.g. in the workplace) and shape the physical and sensory surroundings, which can, in turn, affect the degree of implicit bias that individuals exhibit (14, 15). For example, laws regulating discrimination in the workplace can increase the presence of representatives

of the protected groups, as well as prohibit the use of demeaning visual depictions of a particular group, which can lower implicit bias against members of that group (14).

The legal treatment of ageism, and age discrimination specifically, entails certain difficulties. There may be a range of circumstances in which age is considered a rational and legitimate reason for distinguishing between different groups of persons (16). For example, the use of an age-based distinction to determine who is entitled to pension benefits has been presented in the past as a rational reason for distinguishing between different age groups based on the argument that no other practical or fair way exists to decide who should qualify (17). Encouraging equal respect for the dignity of people of different ages may also, on occasion, require treating age groups differently (18). This means that not all forms of differential treatment on the basis of age may qualify as wrongful discrimination. The key question is whether differential treatment on the grounds of age undermines the human rights principles of dignity, autonomy and participation and whether the justification tests used to assess its legitimacy are contaminated by ageist stereotypes, assumptions and prejudice.

Policies and laws aimed at tackling ageism are quite varied and include anti-age discrimination and equality legislation and policies that define actions to ensure adequate respect for the dignity and equality of status of all persons irrespective of their age; policies that aim to change perceptions of older or younger people; and human rights law, which provides a system that codifies the human rights of older and younger persons and makes those rights enforceable. Different mechanisms are used to implement and monitor policies and laws, including human rights agencies, courts, ombudspersons and bodies working to uphold treaties and to ensure equality.

9 6

GLOBAL REPORT ON AGEISM

6.2 How well they work

Evaluating the effect of national laws and policies is a long-standing challenge, in part due to the difficulty of attributing observed changes to the implementation of laws or policies, especially when randomized controlled trials are not possible, affordable, ethical or feasible (19-22). Does the policy or law in question actually produce the effects observed, or are these effects caused by some other, confounding factor? (19, 20). The studies that do exist generally focus on the impact and effect of the use of the law, the measures put in place to enforce the law and their effectiveness, the contribution of the measures to the achievement of overall social policy goals, and the effect on the socioeconomic position of certain groups (23).

In the field of ageism, the few studies that have been carried out have focused on anti-discrimination laws in the field of employment in Australia, Canada, Europe and the United States. These studies have generally found positive effects of these laws (24-29). For example, the introduction of the Age Discrimination in Employment Act in the United States in 1967, which recognizes only bias against older workers, caused a small positive and significant effect on overall employment for older workers (24). It has prohibited employers from adopting and enforcing mandatory retirement policies on the basis of an employee’s chronological age (with limited exceptions for employees in certain executive positions, as well as firefighters and law enforcement officers) (28, 29). Still, some studies have shown that when not adequately drafted and enforced, anti- age discrimination laws can have unintended consequences, such as when companies hire

fewer older workers as a means to avoid exposure to possible litigation (26).

The effect of national anti-discrimination legislation has been further studied in other areas (e.g. race, sex or gender and sexual orientation) in a range of high-income countries, and it has largely been found that it helps to reduce discrimination (7, 23, 30- 32). The most systematic effort to assess the effects of national anti-discrimination laws looked at impact assessments of these laws, which addressed various grounds (e.g. age, sex or gender, and disability) in 12 different countries, including several in Europe as well as other high-income countries such as Australia, Canada and the United States (23).

Benefits resulting from the adoption of anti-discrimination laws were highlighted in all of the analysed studies and included higher participation of all individuals in society, including in employment and education. Additionally, the adoption of effective anti-discrimination laws helped narrow the pay gap between protected groups and the general population and increase educational attainment in these groups (23). The enforcement of anti- discrimination legislation can also reduce the acceptability of discrimination in the broader community and the extent of interpersonal discrimination (7).

Measuring the direct or indirect effects of international law is equally challenging, as it is often difficult to establish a conclusive causal link between a treaty system and legislative or policy reforms on the domestic level (33). Still, mounting evidence supports the assumption that the process of formulating and ratifying an international treaty and advocacy and monitoring of state performance can contribute to changes in law, policy and practice at the national level. This is illustrated in several case studies and in official UN reports and reviews

9 7

CHAPTER 06

that assessed changes at the national level following countries’ ratification of the Convention on the Rights of Persons with Disabilities (34, 35), the Convention on the Elimination of All Forms of Discrimination against Women (36, 37) and the International Convention on the Elimination of All Forms of Racial Discrimination (38). Another study that looked at the changes resulting from the ratification of six UN human rights treaties in 20 countries found that individual countries took tangible steps to incorporate treaty norms into their domestic legal structures and cultures (39). Importantly, a couple of studies have even reported that at least the Convention on the Elimination of All Forms of Discrimination Against Women had a small but statistically significant and positive effect on women’s rights, even when other key factors were controlled for (40, 41).

At the regional level, there is evidence that the enforcement of the European Convention on Human Rights by the European Court of Human Rights has not only resulted in individual plaintiffs being awarded damages but also in European governments revising legislation on such matters as gay rights and age discrimination (33).

Other examples of human rights courts include the Inter-American Court of Human Rights, which rules under the American Convention on Human Rights, and the African Court on Human and People’s Rights, which rules under the African Charter on Human and People’s Rights and whose output is growing (33).

6.3 Examples Six examples illustrate different types of policies and laws from different parts of the world that aim to tackle ageism against

older people. The first four examples relate to international and regional instruments, whereas the last two relate to national instruments. Examples on the use of policy and law to tackle ageism against younger populations are shown in Box 6.1.

6.3.1 Political Declaration and Madrid International Plan of Action on Ageing

In 2002, the UN General Assembly endorsed the Political Declaration and Madrid International Plan of Action on Ageing (MIPAA) (42).

In Article 5, the declaration makes a commitment to eliminating all forms of discrimination, including age discrimination. Endorsed by 159 governments, MIPAA is not legally binding, and its implementation is voluntary.

Every five years, countries analyse the state of implementation of MIPAA and the actions required to make progress. The process involves a participatory element to engage civil society and older persons, and it is designed to assist countries in receiving feedback on the policies and programmes that they have implemented. Following review and appraisal at the national level, UN Regional Commissions consolidate the information. Reviews and appraisal processes culminate with a global review by the UN Commission for Social Development.

The progress made in developing policies to eliminate age discrimination at the country level following the adoption of this political declaration is reported through its monitoring processes as well as through dedicated studies that generally have found that governments have gradually developed and implemented legal and policy measures to prevent age discrimination (43-46).

9 8

GLOBAL REPORT ON AGEISM

Box 6.1 Policy and law to reduce or eliminate ageism against younger people

As illustrated in the examples in this box, policies and laws have also been used as strategies to eliminate or prevent ageism against younger people, although there is limited research about their effectiveness. For example, the World Programme of Action for Youth to the Year 2000 and Beyond, adopted by the UN General Assembly in 1996, provides a policy framework and practical guidelines for national action and international support to improve the situation of young people around the world (59). It is intended to support the full enjoyment of all human rights and fundamental freedoms by young people, encourage governments to take action against violations of these rights and freedoms, and promote non-discrimination and tolerance, equality of opportunity, solidarity, security and the participation in society of all young women and men. Every 2 years, the UN General Assembly and the Commission for Social Development receive a report from the Secretary- General and adopt a resolution on policies and programmes involving youth.

The Iberoamerican region has also been a pioneer in promoting and protecting the rights of younger people through the Iberoamerican Convention on Rights of Youth, which entered into force in 2008. This Convention lays out specific rights for people aged between 15 and 24 years and recognizes them as strategic actors in development (60). It also has an additional protocol, adopted in 2016, which clarifies and strengthens some of the Convention’s articles. For example, it allows for an extension of the upper age limit considered in the Convention, with a view to adapting the definition of youth to the legal and demographic realities of each country (61). The Convention does not have a monitoring system similar to international treaty monitoring bodies, but it has established a tracking system through which state parties are required to submit a report every two years to the Secretary-General of the Iberoamerican Youth Organization (62). A total of seven countries have ratified this treaty: The Plurinational State of Bolivia, Costa Rica, Dominican Republic, Ecuador, Honduras, Spain and Uruguay.

Another example is the African Youth Charter, which entered into force in August 2009 and underscores the rights, duties and freedoms of youths aged 15 to 35 years. It also paves the way for the development of national programmes and strategic plans for the empowerment of young people. It aims to ensure that youth are protected against all forms of discrimination and involved in decision-making in the region, including in the development agendas of African countries. It does not provide for a specific follow-up and monitoring mechanism, but Article 28 sets out the responsibilities of the African Union Commission to ensure that state parties respect their commitments and fulfil the duties outlined in the Charter (62, 63). A total of 39 countries in Africa have ratified the charter and, therefore, are bound by its provisions (64).

9 9

CHAPTER 06

6.3.2 The employment equality framework directive of the European Union

A milestone in protection from age discrimination in the European Union was Council Directive 2000/78/EC of 27 November 2000 establishing a general framework for equal treatment in employment and occupation, which implemented a structure for ensuring equality for individuals in employment and their occupation regardless of their age, among other protected characteristics (47). The Directive limits the circumstances under which national law in European Union Member States may permit employers to subject employees to different treatment on the grounds of age, thus establishing minimum requirements for protection against discrimination. Member States must ensure there are judicial or administrative procedures for those who believe they have been discriminated against and must provide guidance on sanctions, which may include compensation (27). The Directive also requires Member States to promote social dialogue with the aim of fostering equal treatment through “the monitoring of workplace practices, collective agreements, codes of conduct and through research” (47, 48).

The European Commission is responsible for assessing the national legislation of Member States to see if it correctly reflects the requirements of the Directive. If it does not, the Commission can launch infringement procedures against the Member State concerned. In turn, the Court of Justice of the European Union helps advance interpretation of the Directive in cases of uncertainty or lack of clarity in specific clauses (49).

All countries of the European Union have introduced this legislation, and it has achieved a number of important outcomes. It placed age alongside other grounds in the European

Union’s anti-discrimination and equality agendas, was responsible for introducing anti-age discrimination laws in many Member States for the first time, increased the scope of protection in those few States that already had some legislation in place (27, 48) and set minimum standards throughout the European Union. It also helped to challenge structural inequalities in the labour market, such as the use of upper age limits in job advertisements (50).

Despite the advances achieved through this Directive, there are still areas for improvement. For example, the broad discretion afforded to national jurisdictions to set aside equal treatment has led to diverging national practices and levels of protection against age discrimination across the European Union (51). Also, the framework focuses only on employment and does not cover other important areas in which age discrimination might occur, such as education, housing and social protection (see Chapter 2).

In 2008, the European Commission proposed a new draft Directive to protect everyone living in the European Union against discrimination beyond the workplace (e.g. in access to goods and services) that is based on age, disability, sexual orientation and religion or belief. If adopted, this law would complete the European Union framework by affording age a similar level of protection as currently exists for race and gender under law (52).

6.3.3 The African Union Protocol on the rights of older persons

The African Union Protocol to the African Charter on Human and People’s Rights on the Rights of Older Persons in Africa is another major development. Adopted in January 2016, this protocol is the product of many years of consultations, and it reinforces the commitments made in the 2002 African

1 0 0

GLOBAL REPORT ON AGEISM

Union Policy Framework and Plan of Action on Ageing (53). The Protocol prohibits all forms of discrimination against older persons (Article 3), and it covers a range of rights including access to health services, and the rights to employment, social protection and education, thus providing a framework for governments to protect those rights. Still, the Protocol does not explicitly prohibit discrimination on the basis of age, which may limit its interpretation at the national level.

The Protocol, if ratified and implemented, has the potential to improve older Africans’ enjoyment of their rights. This Protocol has been ratified by two countries, Benin and Lesotho. Twelve additional countries have signed the Protocol, which indicates their willingness to ratify it (54).

6.3.4 The Inter-American Convention on Protecting the Human Rights of Older Persons

The Inter-American Convention on Protecting the Human Rights of Older Persons is the first regional treaty that fully safeguards older people’s human rights. It explicitly prohibits discrimination on the grounds of age (Article 5); encourages positive attitudes towards and dignified, respectful and considerate treatment of older persons; and promotes the recognition of older people’s experience, wisdom, productivity and contributions to the development of society (55).

Countries ratifying the Convention must adopt measures to prevent, sanction and eradicate violations of the rights of older persons. They must also adopt and implement affirmative measures to carry out the rights set forth in the Convention, including policies, plans and legislation. It is also the duty of states to establish and promote public institutions that specialize in protecting

and promoting the rights of older persons. As for the protected rights, the Convention establishes the rights to equality and non- discrimination on the grounds of age, to life and dignity, to independence and autonomy, to work and education, to physical and mental health and to give free and informed consent in the realm of health care, among others.

By adopting this Convention, countries across the region show their commitment to addressing ageism and the denial of human rights in older age, and they have recognized that explicit, legally binding human rights standards, and the accountability mechanisms that accompany them, are necessary to do this. The Convention entered into force in 2017, and seven countries have ratified the treaty: Argentina, the Plurinational State of Bolivia, Chile, Costa Rica, Ecuador, El Salvador and Uruguay. It is too soon to evaluate its effectiveness, but it is expected that its ratification will help establish minimum regional standards for protecting the rights of older persons and it will have strong potential to encourage countries to adopt new public policies and legislative frameworks (56).

6.3.5 Uruguay’s legal and policy frameworks

The national legal and policy frameworks of Uruguay prohibit any discrimination on the basis of age and guarantee older and younger persons equal and effective legal protection against discrimination. The Constitution establishes that everyone is equal before the law (Article 8), and the country has taken a number of measures to counter age-based discrimination in specific sectors, including employment, by means of affirmative action policies and a specific ban on discriminating against any worker on the grounds of age.

The Institución Nacional de Derechos Humanos (National Institution of Human Rights) and the Oficina del Defensor del

1 0 1

CHAPTER 06

Pueblo (Ombudsperson’s Office) was formally established in 2012 to promote and protect human rights, as defined by Uruguayan law. Other mechanisms have also been established in the country to promote and protect human rights including the Defensor del Vecino de Montevideo (Office of the Public Defender of Montevideo), which promotes and defends the rights of all inhabitants of Montevideo, and the Secretaría de Derechos Humanos (Human Rights Secretariat), which is in charge of monitoring and evaluating the human rights situation. Also, Uruguay was the first state to deposit the instrument of ratification of the Inter-American Convention on Protecting the Human Rights of Older Persons, on 18 November 2016.

These existing legal and policy instruments could be further strengthened by providing adequate human, technical and financial resources (57) and ensuring greater coordination between the National Institution of Human Rights and the Ombudsperson’s Office. There is also a need for studies to further evaluate the impact of these legal and policy frameworks in Uruguay.

6.3.6 Equal Opportunities Act of Mauritius

While the Constitution of Mauritius does not explicitly refer to discrimination based on age, specific enactments, such as the Equal Opportunities Act of 2012, do explicitly prohibit such discrimination in various spheres of activity, namely employment; education; the provision of goods, services or facilities; accommodation; access to premises and sports; and societies, registered associations and clubs. The Equal Opportunities Act established the Equal Opportunities Commission and the Equal Opportunities Tribunal, which consider complaints about the infringement of rights protected under the Act. The Equal Opportunities Commission is an independent

and autonomous institution that attempts to bring about conciliation between parties in a dispute. Cases in which conciliation cannot be reached may be referred to the Equal Opportunities Tribunal. In 2014, the Commission referred two cases related to age-based discrimination to the Tribunal (58). No comprehensive assessment of the Equal Opportunities Act has been conducted.

6.4 Key characteristics and costs

Few methodologically rigorous studies have sought to assess the factors that contribute to the effectiveness of laws and policies in tackling ageism. A few studies do, however, offer some indication about the potentially important characteristics of laws and policies that can increase their effectiveness, including one that comprehensively examined the factors contributing to the acceptance and effectiveness of national anti-discrimination laws in 12 countries that focus on grounds such as age and disability (23). Still, several studies included in this analysis had flawed designs or provided limited methodological information, which limits the conclusions that can be derived (23). Some of these potentially important characteristics are outlined below.

• Strong monitoring and enforcement mechanisms: several studies identified weak enforcement mechanisms as one important factor limiting the success of anti- discrimination laws (23, 27, 32, 65). Monitoring and enforcement mechanisms can take multiple forms, including the establishment of national councils or commissions, equality bodies or ombudspersons.

1 0 2

GLOBAL REPORT ON AGEISM

1 0 2

GLOBAL REPORT ON AGEISM

• Public awareness about the law or policy and clarity on its provisions: anti-discrimination legislation appears to be most effective if accompanied by awareness raising and dissemination of information about the policy or law at various levels (7, 23, 27, 48, 65, 66). For legislation and policy to have effects in a given community, at least some members of the public need to be aware of its existence. This is necessary to ensure that legislation has an instrumental effect on a given individual such that the individual aims to avoid the specific penalties in the law and also for individuals to be aware that they can file complaints if they experience violations of the law, in this case, age discrimination. It is equally important for the provisions of the law or policy to be clear and include information about who can file a case and under what conditions, and what the burden of proof is.

• Strong civil society activism: domestic nongovernmental organizations can play an important role in the process of reform and can help enhance the impact of reporting about violations of laws or progress made in implementing treaties, conventions or policies (36, 40, 67).

• Resource availability: a lack of resources, including funding for enforcement and monitoring bodies, can negatively affect the implementation of policies and laws (23, 40, 67-69).

• Democracies: Evidence suggests that international laws may be most effective in stable or consolidating democracies (69, 70) because these may be more likely to adhere to treaty obligations, due to the presence of

internal monitors that make it more difficult to conceal a dissonance between expressed and actual behaviours.

• Existing social norms: the implementation and effectiveness of an anti-discrimination law are enhanced when the law builds on and formalizes a norm within the society that was already widely observed (23).

• Public consultation: the meaningful engagement of the people whom the law or policy is likely to affect is essential to ensure that their needs and concerns are met (68, 71).

The estimated costs of policies and laws vary widely and depend on factors such as the geographical coverage (e.g. international, regional or national), the provisions of the policy or legislation, the need for training to support implementation and the monitoring and enforcement mechanisms required (23). One study estimated the cost of the law- making component of a new public health law, and found that in high-income countries, such as New Zealand and the United States, the average cost of new public health legislation ranges between US$ 382 000 and US$ 980 000 (72). Still, these estimates did not factor in the costs of implementing the provisions of the law or those associated with monitoring and enforcement.

6.5 Conclusions and future directions

Evidence shows that enacting policies and laws can be an important strategy to reduce or eliminate ageism, and it appears

1 0 3

CHAPTER 06

1 0 3

Box 6.2The UN Open-Ended Working Group on Ageing and the possibility of a new UN convention on the rights of older persons

The UN General Assembly established the Open-Ended Working Group on Ageing in 2010 (78). Its purpose is to strengthen the protection of older people’s rights by reviewing how existing instruments address these rights, identifying gaps in protection and exploring the feasibility of developing new instruments and measures. It is the first intergovernmental body outside of the UN Human Rights Council that annually brings together national human rights institutions (79) with UN Member States, nongovernmental organizations and UN agencies. Since its establishment, the Working Group has held discussions about key areas of older people’s lives, including discrimination, health and long-term care, autonomy and independence, social exclusion, social security, violence and abuse, and end-of-life and palliative care. Since 2019, Member States have been able to present recommendations negotiated in Working Group sessions for consideration by the UN General Assembly (80). Based on the proposals made to improve the promotion of older people’s rights, in 2014 the Human Rights Council appointed for the first time an Independent Expert on the Enjoyment of All Human Rights by Older Persons (81).

The Working Group is the primary forum for debate on the development of an international human rights treaty or convention regarding the rights of older persons. Indeed, in 2012, the UN General Assembly requested that the Working Group consider proposals for an international legal instrument to promote and protect the rights and dignity of older persons and present, at the earliest possible date, a proposal containing, the main elements that should be included in such an instrument that are not addressed sufficiently by existing mechanisms (82). The UN Secretary-General has further highlighted the need to build stronger legal frameworks to protect the human rights of older persons, including by accelerating the efforts of the Working Group to develop proposals for an international legal instrument (83).

A UN convention is a legally binding document, which is enforceable by law, that outlines the rights of a specific group (e.g. women) or addresses a specific issue (e.g. torture). Any UN Member State can ratify a UN convention, thereby agreeing to abide by its rules. Once a country ratifies a convention, it must either adapt its national laws and policies or adopt new legislation to put into effect the rights included in that treaty. Thus, a convention can provide a framework based on rights, equity and social justice to guide policy responses to demographic ageing. It can encourage a paradigm shift from one in which older people are considered as passive recipients of welfare to one in which older people are seen as active rights holders.

UN Member States have expressed a variety of views on how to best promote and protect the human rights of older persons, including through enhancing the use of existing legal instruments or drafting a dedicated instrument. The Working Group continues to focus on more in-depth and open, substantive discussions to fully understand the issues, identifies elements that require further elaboration and considers appropriate solutions.

1 0 4

GLOBAL REPORT ON AGEISM

to be affordable. Policies and laws aimed at tackling ageism are quite varied and can include legislation addressing age discrimination and inequality, policies to ensure respect for the dignity of all persons regardless of age, and human rights laws. Along with educational interventions and intergenerational contact activities, policies and laws are among the most important strategies to include in any effort to combat ageism.

Future priorities in relation to policy and legislation interventions are detailed below.

• International policy and legislative guarantees against age discrimination should be increased. In international law, there is no specific legal instrument to dispel prejudice and discrimination against older people, and most international human rights instruments do not explicitly list age as a prohibited ground of discrimination. An international convention could turn aspirations into binding obligations and result in national legislation and policy, as has happened with other conventions such as the Convention on the Rights of Persons with Disabilities (34, 35), the International Convention on the Elimination of All Forms of Racial Discrimination (38) and the Convention on the Elimination of all Forms of Discrimination Against Women (36, 37). Support for the development of a new UN treaty on the human rights of older persons has increased recently, especially since the establishment of the UN Open-Ended Working Group on Ageing (see Box 6.2).

• It is critical to develop and enforce national anti-discrimination laws and policies, modify or repeal existing laws

and policies that may be ageist and improve access to justice for those making complaints on the grounds of age discrimination or ageism more broadly. Although there has been steady progress in the adoption of national legal and policy provisions prohibiting discrimination on the basis of age (17), their scope and coverage are uneven compared with guarantees against discrimination on other grounds. Many inconsistencies and gaps also exist in terms of specificity, alignment with international law, legal and material scope, protection from both direct and indirect discrimination, differential treatment and exceptions, as well as in terms of monitoring and access to remedies (51). There is also a need to develop protections from intersectional and cumulative discrimination through policies and laws (e.g. discrimination based on both age and disability) (73-76).

• Public awareness about anti- discrimination and human rights laws and policies should be increased.

• It is important to conduct research to improve understanding of the effectiveness of existing and new anti- discrimination legislation and policies at the national and international levels (see Box 6.3).

• Estimates of the costs of policy and legislation interventions should be improved. Without accurate and comparable estimates of cost, the cost–effectiveness of interventions can neither be estimated nor compared. WHO’s cost–effectiveness and strategic planning model (known as WHO-CHOICE) can be used for costing the implementation of new laws and policies (77).

1 0 5

CHAPTER 06

Box 6.3 Opportunities for research on policy and law

Although no systematic reviews are available about the effects of policies and laws on addressing ageism, evidence on the effectiveness of laws in tackling ageism and other “-isms” supports the use of this strategy to reduce or eliminate it. It will be important for future research to focus on conducting rigorous impact assessments of existing and new anti-discrimination laws and on policies aiming to eliminate ageism, as well as to assess the contributing factors to effectiveness (23). It is key that studies are conducted in low- and middle-income countries and that they also investigate the impact of these interventions on tackling ageism beyond the employment sector, given that most of the evidence has focused on employment- related outcomes in only a limited range of countries.

Given that randomized controlled trials are not always a possible or ethical design when evaluating policies and laws, future studies could use a range of techniques to address the challenges of attributing observed changes to the implementation of a given law or policy, for example, by using a statistical technique known as differences in differences, which aims to isolate the effect of a law on specific outcomes. Using this type of analysis, studies have compared, for example, the outcomes of older workers before and after a change in discrimination law (e.g. the introduction of the Age Discrimination in Employment Act in 1967 in the United States or changes in state laws) with those of an unaffected control group, such as younger workers or older workers in countries without legal changes, or both (24).

Additional methods have also been proposed to overcome other challenges encountered in evaluating laws and policies using observational designs, for example, by using regression discontinuity designs, instrumental variables or near– far matching approaches to address the issue of unobserved confounders (19). Or propensity score matching (i.e. a statistical matching technique that attempts to estimate the effect of a policy by accounting for the covariates that predict exposure to the policy) can be used to address the issue of constructing a comparison population when a well-matched comparator is not immediately available (19).

Qualitative comparative analysis is another method that has been increasingly used (84). This is a mixed quantitative and qualitative technique that is based on multiple case studies and that aims to determine which logical conclusions multiple case studies support and which can help explain why change happens in some cases but not others (85).

1 0 6

GLOBAL REPORT ON AGEISM

REFERENCES

1. Fredman S. The age of equality. In: Fredman S, Spencer S, editors. Age as an equality issue: legal and policy perspectives. Oxford: Hart; 2003:21–70.

2. Grasmick HG, Green DE. Legal punishment, social disapproval and internalization as inhibitors of illegal behavior. J Crim Law Criminol. 1980;71:325–35.

https://doi.org/10.2307/1142704. 3. Nagin DS. Deterrence in the twenty-first century. Crime Justice. 2013;42:199–263.

https://doi.org/10.1086/670398. 4. Landes WM. The economics of fair employment laws. J Political Econ. 1968;76:507–52.

https://doi.org/10.1086/259426. 5. Tapp JL, Kohlberg L. Developing senses of law and legal justice. J Soc Issues. 1971;27:65–

91. https://doi.org/10.1111/j.1540-4560.1971.tb00654.x. 6. Zimring F, Hawkins G. The legal threat as an instrument of social change. J Soc Issues.

1971;27:33–48. https://doi.org/10.1111/j.1540-4560.1983.tb00180.x. 7. Barron LG, Hebl M. The force of law: the effects of sexual orientation antidiscrimination

legislation on interpersonal discrimination in employment. Psychol Public Policy Law. 2013;19:191–205. https://doi.org/10.1037/a0028350.

8. Stangor C, Sechrist GB, Jost JT. Changing racial beliefs by providing consensus information. Personal Soc Psychol Bull. 2001;27:486–96.

https://doi.org/10.1177/0146167201274009. 9. Blanchard FA, Crandall CS, Brigham JC, Vaughn LA. Condemning and condoning racism: a

social context approach to interracial settings. J Appl Psychol. 1994;79:993–7. https://doi.org/10.1037/0021-9010.79.6.993. 10. Blanchard FA, Lilly T, Vaughn LA. Reducing the expression of racial prejudice. Psychol Sci.

1991;2:101–5. https://doi.org/10.1111/j.1467-9280.1991.tb00108.x. 11. Monteith MJ, Deneen NE, Tooman GD. The effect of social norm activation on

the expression of opinions concerning gay men and blacks. Basic Appl Soc Psych. 1996;18:267–88. https://doi.org/10.1207/s15324834basp1803_2.

12. Zitek EM, Hebl MR. The role of social norm clarity in the influenced expression of prejudice over time. J Exp Soc Psychol. 2007;43:867–76.

https://doi.org/10.1016/j.jesp.2006.10.010. 13. Festinger L. A theory of cognitive dissonance. Stanford: Stanford University Press; 1957. 14. Jolls C. Antidiscrimination law’s effects on implicit bias. New Haven (CT): Yale Law

School; 2005 (Yale Law and Economics Research Paper No. 343; https://ssrn.com/abstract=959228, accessed 20 September 2020). 15. Dasgupta N, Asgari S. Seeing is believing: exposure to counterstereotypic women

leaders and its effect on the malleability of automatic gender stereotyping. J Exp Soc Psychol. 2004;40:642–58. https://doi.org/10.1016/j.jesp.2004.02.003.

16. O’Cinneide C. Age discrimination and European law. Luxembourg: European Commission; 2005 (https://www.equalitylaw.eu/component/edocman/age-discrimination-and- european-law-en/Download?Itemid=, accessed 20 September 2020).

17. O’Cinneide C. The growing importance of age equality. Equal Rights Rev. 2013;11:99–110 (https://www.equalrightstrust.org/ertdocumentbank/Colm%20O’Cinneide%20ERR11. pdf, accessed 20 September 2020).

18. Duncan C. The dangers and limitations of equality agendas as means for tackling old-age prejudice. Ageing Soc. 2008;28:1133–58. https://doi.org/10.1017/S0144686X08007496.

1 0 7

CHAPTER 06

19. Basu S, Meghani A, Siddiqi A. Evaluating the health impact of large-scale public policy changes: classical and novel approaches. Annu Rev Public Health. 2017;38:351–70. https://doi.org/10.1146/annurev-publhealth-031816-044208.

20. Wing C, Simon K, Bello-Gomez RA. Designing difference in difference studies: best practices for public health policy research. Annu Rev Public Health. 2018;39:453–69.

https://doi.org/10.1146/annurev-publhealth-040617-013507. 21. Duncan C, Loretto W. Never the right age? Gender and age-based discrimination in

employment. Gend Work Organ. 2004;11:95–115. https://doi.org/10.1111/j.1468-0432.2004.00222.x. 22. Neumark D. The Age Discrimination in Employment Act and the challenge of population

aging. Res Aging. 2009;31:41–68. https://doi.org/10.3386/w14317. 23. Niessen J, Masselot A, Larizza M, Landman T, Wallace C. Comparative analysis of

existing impact assessments of anti-discrimination legislation: mapping study on existing national legislative measures – and their impact in – tackling discrimination outside the field of employment and occupation on the grounds of sex, religion or belief, disability, age and sexual orientation. Brussels: European Commission; 2006

(http://hdl.handle.net/20.500.12389/19830, accessed 20 June 2020). 24. Adams SJ. Age discrimination legislation and the employment of older workers. Labour

Econ. 2004;11:219–41. https://doi.org/10.1016/j.labeco.2003.06.001. 25. Neumark D, Song J. Do stronger age discrimination laws make social security reforms

more effective? J Public Econ. 2013;108:1–16. https://doi.org/10.3386/w17467. 26. Lahey J. State age protection laws and the Age Discrimination in Employment Act. J Law

Econ. 2008;51:433–60. https://doi.org/10.3386/w12048. 27. Lahey JN. International comparison of age discrimination laws. Res Aging. 2010;32:679–

97. https://doi.org/10.1177/0164027510379348. 28. Kapp M. Looking at age discrimination laws through a global lens. Generations.

2013;37:70–5 (https://ssrn.com/abstract=2243721, accessed 20 September 2020). 29. Ashenfelter O, Card D. Did the elimination of mandatory retirement affect faculty

retirement? Am Econ Rev. 2002;92:957–80. https://doi.org/10.1257/00028280260344542.

30. Burstein P. Discrimination, jobs, and politics: the struggle for equal employment opportunity in the United States since the New Deal. Chicago: University of Chicago Press; 1998.

31. Donohue JJ, Heckman J. Continuous versus episodic change: the impact of civil rights policy on the economic status of Blacks. Cambridge (MA): National Bureau of Economic Research; 1991 (NBER Working Paper No. 3894; https://www.nber.org/papers/w3894. pdf, accessed 20 September 2020).

32. Gunderson M. Male–female wage differentials and policy responses. J Econ Lit. 1989;27:46–72 (http://www.jstor.org/stable/2726941, accessed 20 September 2020).

33. Cassel D. Does international human rights law make a difference. Chic J Int Law. 2001;2:8 (https://chicagounbound.uchicago.edu/cjil/vol2/iss1/8/, accessed 20 September 2020).

34. Petersen CJ. The Convention on the Rights of Persons with Disabilities: using international law to promote social and economic development in the Asia Pacific. Univ Hawaii Law Rev. 2013;35:821 (https://heinonline.org/HOL/LandingPage?handle=hein.journals/ uhawlr35&div=33&id=&page=, accessed 20 September 2020).

1 0 8

GLOBAL REPORT ON AGEISM

35. Harpur P, Bales R. The positive impact of the Convention on the Rights of Persons with Disabilities: a case study on the South Pacific and lessons from the US experience. North Ky Law Rev. 2010;37:363–88 (https://ssrn.com/abstract=2000174, accessed 15 June 2020).

36. Byrnes AC, Freeman M. The impact of the CEDAW convention: paths to equality. Sydney: University of New South Wales Law; 2012 (UNSW Law Research Paper No. 2012-7) https://doi.org/10.2139/ssrn.2011655.

37. Byrnes AC. The Convention on the Elimination of all Forms of Discrimination Against Women and the Committee on the Elimination of Discrimination Against Women: reflections on their role in the development of international human rights law and as a catalyst for national legislative and policy reform. Sydney: University of New South Wales Law; 2010 (UNSW Law Research Paper No. 2010-17; https://ssrn.com/ abstract=1595490, accessed 20 September 2020).

38. Tang K-I. Combating racial discrimination: the effectiveness of an international legal regime. Br J Soc Work. 2003;33:17–29. https://doi.org/10.1093/bjsw/33.1.17.

39. Heyns C, Viljoen F. The impact of the United Nations human rights treaties on the domestic level. Hum Rights Q. 2001;23:483–535.

https://doi.org/10.1353/hrq.2001.0036. 40. Hill DW. Estimating the effects of human rights treaties on state behavior. J Politics.

2010;72:1161–74. https://doi.org/10.1017/s0022381610000599. 41. Englehart NA, Miller MK. The CEDAW effect: international law’s impact on women’s

rights. J Hum Rights. 2014;13:22–47. https://doi.org/10.1080/14754835.2013.824274. 42. Political declaration and Madrid International Plan of Action On Ageing. In: Report of the

Second World Assembly on Ageing: Madrid, 8–12 April 2002. New York: United Nations; 2002 (https://undocs.org/A/CONF.197/9, accessed 7 September 2020).

43. Sidorenko AV, Mikhailova ON. Implementation of the Madrid International Plan of Action on Ageing in the CIS countries: the first 10 years. Adv Gerontol. 2014;4:155–62.

https://doi.org/10.1134/S2079057014030060. 44. Third review and appraisal of the Madrid International Plan of Action on Ageing, 2002:

preliminary assessment. Report of the Secretary-General. New York: Economic and Social Council of the United Nations; 2016 (https://www.un.org/ga/search/view_doc. asp?symbol=E/CN.5/2017/6, accessed 14 June 2020).

45. Second review and appraisal of the Madrid International Plan of Action on Ageing, 2002: report of the Secretary-General. New York: Economic and Social Council of the United Nations; 2012 (https://undocs.org/E/CN.5/2013/6, accessed 14 June 2020).

46. First review and appraisal of the Madrid International Plan of Action on Ageing: preliminary assessment. Report of the Secretary-General. New York: Economic and Social Council of the United Nations; 2007 (https://undocs.org/E/CN.5/2008/7, accessed 14 June 2020).

47. Council Directive 2000/78/EC of 27 November 2000 establishing a general framework for equal treatment in employment and occupation. Luxembourg: Publications Office of the European Union; 2000 (https://eur-lex.europa.eu/legal-content/EN/ TXT/?uri=celex%3A32000L0078, accessed 10 October 2020).

48. Meenan H. Age discrimination in Europe: late bloomer or wall-flower. Nord Tidsskr Menneskerettigheter. 2007;25:97–118.

49. Davies G. Activism relocated: the self-restraint of the European Court of Justice in its national context. J Eur Public Policy. 2012;19:76–91. https://doi.org/10.1080/13501763.2012.632146.

1 0 9

CHAPTER 06

50. Annexes to the Joint Report on the application of the Racial Equality Directive (2000/43/ EC) and the Employment Equality Directive (2000/78/EC). Brussels: European Commission; 2014 (Commission staff working document; http://eur-lex.europa.eu/legal-content/EN/ TXT/PDF/?uri=CELEX:52014SC0005&from=en, accessed 29 June 2020).

51. Georgantzi N. The European Union’s approach towards ageism. In: Ayalon L, Tesch-Römer C, editors. Contemporary perspectives on ageism.Cham: Springer; 2018:341–68

https://link.springer.com/chapter/10.1007/978-3-319-73820-8_21, accessed 20 September 2020).

52. Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions – non- discrimination and equal opportunities: a renewed commitment {SEC(2008) 2172}. Brussels: European Commission; 2008 (https://eur-lex.europa.eu/legal-content/EN/TXT/ PDF/?uri=CELEX:52008DC0420&from=en, accessed 14 June 2020).

53. Protocol to the African Charter on Human and People’s Rights on the Rights of Older Persons. Addis Ababa: African Commission on Human and People’s Rights; 2016 (https:// au.int/sites/default/files/treaties/36438-treaty-0051_-_protocol_on_the_rights_of_ older_persons_e.pdf, accessed 26 June 2020).

54. Protocol to the African Charter on Human and People’s Rights on the Rights of Older Persons; status list. Addis Ababa: African Union; 2020 (https://au.int/en/treaties/protocol- african-charter-human-and-peoples-rights-rights-older-persons, accessed 26 June 2020).

55. Inter-American Convention on Protecting the Human Rights of Older Persons. Washington (DC): Organization of American States; 2015 (http://www.oas.org/en/sla/dil/docs/inter_ american_treaties_A-70_human_rights_older_persons.pdf, accessed 28 June 2020).

56. Mikołajczyk B. International law and ageism. Pol Yearb Int Law. 2015;XXXV:83–108. https://doi.org/10.7420/pyil2015c.

57. Visit to Uruguay – report of the Independent Expert on the Enjoyment of All Human Rights by Older Persons. Geneva: United Nations, Office of the High Commissioner for Human Rights; 2019 (https://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/42/43/ Add.1, accessed 25 June 2020).

58. Report of the Independent Expert on the Enjoyment of All Human Rights by Older Persons, Rosa Kornfeld-Matte: addendum – mission to Mauritius. Geneva: United Nations, Office of the High Commissioner for Human Rights; 2015 (https://ap.ohchr.org/ documents/dpage_e.aspx?si=A/HRC/30/43/Add.3, accessed 23 June 2020).

59. World Programme of Action for Youth to the Year 2000 and Beyond. New York: United Nations; 1996 (Resolution A/RES/50/81; https://undocs.org/A/RES/50/81, accessed 20 September 2020).

60. Iberoamerican Convention on Rights of Youth (https://www.refworld.org/ docid/4b28eefe2.html, accessed 20 September 2020).

61. Convención Iberoamericana de Derechos de los Jóvenes y Protocolo Adicional: Tratado Internacional de Derechos de la Juventud (https://oij.org/wp-content/ uploads/2017/01/Convenci%C3%B3n.pdf, accessed 20 September 2020).

62. Youth and human rights: report of the United Nations High Commissioner for Human Rights. New York: United Nations; 2018 (https://undocs.org/pdf?symbol=en/A/ HRC/39/33, accessed 20 September 2020).

63. African Youth Charter. Addis Ababa: African Union Commission; 2006 (https://au.int/ en/treaties/african-youth-charter, accessed 20 June 2020).

1 1 0

GLOBAL REPORT ON AGEISM

64. List of countries which have signed, ratified/acceded to the African Youth Charter. Addis Ababa: African Union; 2019 https://au.int/sites/default/files/treaties/7789-sl- AFRICAN%20YOUTH%20CHARTER.pdf, accessed 24 June 2020).

65. Havinga T. The effects and limits of anti-discrimination law in the Netherlands. Int J Sociol Law. 2002;30:75–90. https://doi.org/10.1016/S0194-6595(02)00022-9.

66. Hepple B, Coussey M, Choudhury T. Equality: a new framework. Report of the Independent Review of the Enforcement of UK Anti-Discrimination Legislation.Oxford: Hart; 2000.

67. Zwingel S. How do international women’s rights norms become effective in domestic contexts: an analysis of the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) [dissertation]. Nuremberg: Ruhr-Universität Bochum; 2005 (https://d-nb.info/97814287X/34, accessed 25 September 2020).

68. Fisher RJ. Social desirability bias and the validity of indirect questioning. J Consum Res. 1993;20:303–15. https://doi.org/10.1086/209351.

69. Neumayer E. Do international human rights treaties improve respect for human rights? J Conflict Resolut. 2005;49:925–53. https://doi.org/10.1177/0022002705281667.

70. Hafner-Burton EM, Tsutsui K. Justice lost! The failure of international human rights law to matter where needed most. J Peace Res. 2007;44:407–25.

https://doi.org/10.1177/0022343307078942. 71. Report of the Independent Expert on the Enjoyment of All Human Rights by Older

Persons, Rosa Kornfeld-Matte. Geneva: United Nations, Office of the High Commissioner for Human Rights; 2015 (https://www.undocs.org/A/HRC/30/43, accessed 20 September 2020).

72. Wilson N, Nghiem N, Foster R, Cobiac L, Blakely T. Estimating the cost of new public health legislation. Bull World Health Organ. 2012;90:532–9.

https://doi.org/10.2471/BLT.11.097584. 73. Tackling multiple discrimination: practices, policies, and laws. Luxembourg: Office for

Official Publications of the European Communities; 2007 (http://ec.europa.eu/social/ BlobServlet?docId=776&langId=en, accessed 20 September 2020).

74. Frierson JG. Sex plus age discrimination: double jeopardy for older female employees. J Individ Employ Rights. 1997;6:155–166. https://doi.org/10.2190/T09J-DL85-0P1A-CA9R.

75. McLaughlin JS. Falling between the cracks: discrimination laws and older women. Labour. 2020;34:215–38. https://doi.org/10.1111/labr.12175.

76. Lynch KJ. Sex-plus-age discrimination: state law saves the day for older women. ABA J Labor Employ Law. 2015;31:149–70 (https://www.jstor.org/stable/26410785?seq=1, accessed 20 September 2020).

77. Cost effectiveness and strategic planning (WHO-CHOICE): tables of costs and prices used in WHO-CHOICE analysis. In: World Health Organization [website]. Geneva: World Health Organization; 2020 (http://www.who.int/choice/costs/en, accessed 29 June 2020).

78. Follow-up to the Second World Assembly on Ageing. New York: United Nations; 2011 (Resolution A/RES/65/182; https://undocs.org/A/RES/65/182, accessed 20 September 2020).

79. National institutions for the promotion and protection of human rights. New York: United Nations; 2016 (Resolution A/RES/70/163; https://undocs.org/en/A/RES/70/163, accessed 20 September 2020).

80. Follow-up to the Second World Assembly on Ageing. New York: United Nations; 2020 (Resolution A/RES/74/125; https://undocs.org/en/A/RES/74/125, accessed 25 September 2020).

1 1 1

CHAPTER 06

81. Historical background of the establishment of the mandate. In: Office of the High Commissioner for Human Rights [website]. Geneva: United Nations, Office of the High Commissioner for Human Rights; 2020 (https://www.ohchr.org/EN/Issues/ OlderPersons/IE/Pages/Background.aspx, accessed 24 September 2020).

82. Towards a comprehensive and integral international legal instrument to promote and protect the rights and dignity of older persons. New York: United Nations; 2013 (Resolution A/RES/67/139; https://undocs.org/A/RES/67/139, accessed 20 September 2020).

83. The impact of COVID-19 on older persons. New York: United Nations; 2020 (https://www.un.org/development/desa/ageing/wp-content/uploads/

sites/24/2020/05/COVID-Older-persons.pdf, accessed 29 September 2020). 84. Rihoux B, Rezsöhazy I, Bol D. Qualitative comparative analysis (QCA) in public policy

analysis: an extensive review. Ger Policy Stud. 2011;7:9–82 (https://spaef.org/ article/1317/Qualitative-Comparative-Analysis-QCA-in-Public-Policy-Analysis-an- Extensive-Review, accessed 29 September 2020).

85. Berg-Schlosser D, De Meur G, Rihoux B, Ragin CC. Qualitative comparative analysis (QCA) as an approach. In: Rihoux B, Ragin CC, editors. Configurational comparative methods: qualitative comparative analysis (QCA) and related techniques. Thousand Oaks (CA): Sage; 2009:18– 45.

1 1 2

GLOBAL REPORT ON AGEISM

CELIN, 61 , HAITI

CHAPTER 01

C H A P T E R 0 7

I am not ashamed to be an old person; it is a stage in life which is inevitable. I think we need to teach people that stigmatizing people because of their age is wrong.

CELIN, 61 , HAITI ©Joseph Jn-Florley / HelpAge International

07

“ “

1 1 3

1 1 4

GLOBAL REPORT ON AGEISM

Educational interventions include instruction that transmits information, knowledge and skills, as well as activities to enhance empathy through role-playing, simulation and virtual reality.

Research shows that educational interventions are among the most effective strategies for reducing ageism against older people. Nothing is known about their effectiveness for reducing ageism against younger people.

These interventions are feasible and affordable.

Educational interventions have a central role to play in any effort to reduce ageism.

GLOBAL REPORT ON AGEISM

07 Chapter

1 1 4

7.1 What they are and how they work

Educational interventions to reduce ageism refer to diverse activities, which are often combined. These include instruction that transmits information, knowledge, skills and competencies aimed at reducing ageist stereotypes, prejudice and discrimination. Educational interventions also include activities intended to enhance empathy through perspective- taking, using, for instance, role-playing, simulation and virtual reality. Many educational interventions also either include an element of intergenerational contact or are combined with fully fledged intergenerational contact interventions (see Section 7.2) (1, 2).

Educational interventions can be delivered either face- to-face or online. Face-to-face and online instruction may include lectures or modules on ageism that are integrated into specific courses (e.g. on geriatrics, gerontology or ageing and health) or whole courses addressing ageism that are integrated into curricula (e.g. in medical, nursing and social work schools). Face- to-face educational interventions can also take place during service learning (i.e. learning combined with community service to provide pragmatic instruction

Section 7.1 of this chapter describes educational interventions – the second strategy to address ageism. Section 7.2 reviews available evidence on their effectiveness, and Section 7.3 provides examples of this type of intervention from various countries. This chapter also presents, in Section 7.4, those characteristics that can make this intervention more effective, as well as its costs.

1 1 5

CHAPTER 07

and reflection while simultaneously meeting community needs), clinical rotations or attachments (e.g. students shadowing physicians) and mentoring (i.e. during which a more experienced or knowledgeable person helps to guide a less experienced person). Most interventions have taken place in formal educational settings (i.e. schools, colleges, universities), and only a few have taken place in non-formal learning settings (e.g. a workplace or community centre) (3, 4).

Educational interventions that seek primarily to transmit information and knowledge operate on the assumption that stereotypes, prejudices and discrimination are the result of ignorance, mistaken information, misconceptions and simplistic thinking. Providing accurate information and counter-stereotypic examples, dispelling misconceptions about a particular age group and teaching more complex thinking skills allow people to consciously reconsider and update their beliefs, feelings and behaviours and lead to a decrease in ageism (1, 5-9).

Empathy-enhancing activities are a type of educational intervention that is increasingly used to address ageism. Empathy refers to the ability to sense other people’s emotions and to imagine what someone else might be thinking or feeling (10). Empathy-enhancing activities aim to generate identification with, and awareness of, another person’s or group’s suffering, generally through perspective-taking exercises used to counter stereotypes, prejudice and discrimination.

Such exercises seek to increase emotional engagement, compassion and the desire to help. Such interventions use, for example, role-play activities, simulation games and immersive virtual reality to allow participants to imagine or experience the world from a different perspective, thus challenging stereotypes and prejudices (11-13).

Most educational interventions – both those that seek primarily to transmit knowledge and those that aim to enhance empathy – have targeted interpersonal ageism, rather than self-directed or institutional ageism, and most of the interventions that have been evaluated were implemented in high- income countries.

7.2 How well they work

A 2019 systematic review of 23 educational interventions aimed at reducing ageism reached encouraging conclusions (1). It found that educational interventions had a small to medium effect on attitudes towards ageing and older people (a standardized mean difference of 0.34), including on stereotypes and prejudice. It also found a small to medium effect on knowledge of ageing (a standardized mean difference of 0.41), including effects on information and misconceptions about the ageing process (1, 14, 15).

Twenty-one of the 23 educational interventions included in the review were from the United States, 1 was from Australia and 1 from Taiwan, China, all of which are high-income countries (1).

Educational interventions to reduce ageism refer to diverse activities, which are often combined. These include instruction that transmits information, knowledge, skills and competencies aimed at reducing ageist stereotypes, prejudice and discrimination.

1 1 6

GLOBAL REPORT ON AGEISM

It is likely that educational interventions will also work to reduce ageism in low- and middle-income countries, but they need to be tested there. This systematic review confirms the findings of a previous review of educational interventions for addressing ageism among students, which suggested that educational interventions change both attitudes and knowledge related to ageism (2). The review also dispels the inconclusive findings of two older and less rigorous reviews of educational interventions, one of which assessed impacts on medical students and doctors (16) and the other on health- care providers (17).

7.3 Examples Four examples illustrate different types of educational interventions from various parts of the world. The first, from Iran, is an educational intervention that includes an intergenerational element. The second and third, from the United States and Australia, concern interventions aimed at, respectively, high-school students and university students. All three primarily rely on classroom-based instruction. The last is an empathy-enhancing activity that used virtual reality to counter ageism among university students in the United Kingdom.

7.3.1 Workshops and conversations in Iran

In the Mazandaran Province in Iran, an educat iona l inte r vent ion with an

intergenerational element was conducted among elementary, middle, high-school and university students.

The intervention consisted of 10 workshops about human development across the life course, and it included lectures, discussions, movies and pamphlets, all focusing on issues important to ageing. The intervention also included conversations with older adults.

Before the intervention, the elementary, middle and high-school students were found to be more ageist than their university counterparts. The intervention led to lower scores on the Fraboni Scale of Ageism, indicating less ageism, for all groups of students, with the largest decrease on the affective dimension of the scale. The study also found that ageism was more prominent among nursing and medical students than other types of university students (18).

7.3.2 Life-story documentaries in the United States

In a face-to-face educational intervention in the United States, students watched and then discussed life-story documentaries. For instance, one told the story of Sam Ballard and his four marriages; it included his reflections on finding love, losing love, and the meaning of love and relationships over his life.

Another told the story of Mary Starke Harper, an African American woman from Alabama, who became a psychologist, social scientist and a nurse; was awarded an honorary law degree; and advised six presidents on policy and research into mental health and ageing.

The intervention was found to strengthen students’ sense of kinship and belonging with older people, their engagement with and interest in older people, and how enthusiastic they felt about and how

It is likely that educational interventions will work to reduce ageism in low- and middle- income countries, but they need to be tested there.

1 1 7

CHAPTER 07

impressed they were with older adults. It also led to decreases in antagonism and antipathy towards older people and avoidance of older people. However, it did not lead to more positive feelings towards older people (e.g. “I like older people” or “I feel positively towards older people”), a greater sense of comfort with older people or to less discriminatory attitudes towards older people (19).

7.3.3 Curriculum-based intervention in Australia

A face-to-face educational intervention for high-school students in Australia consisted of four interactive weekly sessions, involving group discussions, games, role-plays and case studies. It was integrated into a health and society curriculum. The high-school students were also given homework during which they had to practice the new skills they had learned with older people in their lives. Almost all of the students were in contact with older people, such as grandparents, other relatives or family friends (20).

Session 1 encouraged students to discuss what it means to be an older person in today’s society to help them consider older people’s perspectives. The main question for this session was, “What might older individuals expect of me?”

Session 2 aimed to raise self-awareness of ageist attitudes and stereotypes. The main question for this session was, “What have older individuals done for or contributed to society?” Its goal was to challenge students’ perceptions of older people and broaden their understanding of older people’s lives to help students move beyond hasty judgements about whether older people deserve respect.

Session 3 promoted mutual respect through asking adolescents to reflect on what they

would like older people to understand about them. The main question for this session was, “What would I like back from older people (for a mutually respectful interaction)?”

Session 4 aimed to foster positive and respectful interactions between adolescents and older individuals by teaching interpersonal skills. The main question for this session was, “What can I do (i.e. how can I behave) to increase mutually respectful interactions?” This session was designed to overcome adolescents’ tendency to avoid initiating interactions with older individuals for fear of negative reactions and uncertainty about how to cope.

This intervention led to greater knowledge and fewer misconceptions about older people, less negative bias, more positive attitudes (including stereotypes) and improved social skills related to older people.

7.3.4 Virtual reality in the United Kingdom

A research team in the United Kingdom used three virtual reality activities to foster empathy for older people among university students (11). In the first activity, students used an app to create a visual image of themselves as an older person. In the second, aimed to simulate the experience of social exclusion and isolation that many older adults experience, students wore a virtual reality headset that gave them the experience of taking part in a dinner during which they were not included in interactions. In the third activity, students were guided through an immersive experience of completing several everyday tasks in the home of an older person with moderate frailty (e.g. making a hot drink, answering the door). Through virtual reality, the speed of their movements and reactions was slowed, their hearing was dulled and their vision blurred. The students reported

1 1 8

GLOBAL REPORT ON AGEISM

1 1 8

GLOBAL REPORT ON AGEISM

becoming more aware of older adults’ experiences and having increased empathy and respect for older people.

7.4 Key characteristics and costs

It is not known which subtype of educational intervention is more effective: instruction- based or empathy-enhancing. Nor is it known which characteristic of each subtype (e.g. online or classroom-based instruction; role-playing, simulation or virtual reality) is associated with greater effectiveness (see Box 7.1).

A chal lenge to ident i f y ing which characteristics are associated with effectiveness is the heterogeneity of educational interventions. For example, while most of the studies in the systematic review relied primarily on courses and lectures to transmit information and knowledge, some also included an element of intergenerational contact, role-playing or simulation. Nevertheless, several studies provide some pointers to potentially important characteristics of educational interventions, and these are outlined below.

• Small doses over time may be better than a dedicated course. One study compared modes of instructional delivery and found that both receiving information in

the form of a dedicated course over one semester and infusing the same information over the whole of the curriculum led to improvements in attitudes towards older people, but infusion over time worked marginally better than a dedicated course (21).

• Presenting information in a positive light can help counteract pre- existing stereotypes and prejudices about older age. A challenge in educational interventions is striking the right balance between, on the one hand, being honest and comprehensive about ageing and, on the other, not painting too negative a picture that ends up being counterproductive (22, 23). The risk is that when efforts are made to present both the positive and negative facets of ageing, participants may focus on and remember the experiences and information that reinforce their pre- existing negative stereotypes and prejudices. It is probably advisable to err on the side of positivity when developing educational interventions, as research on the presentation of older people in experimental studies suggests (reviewed in Chapter 4). The effects of interventions to reduce stereotypes and prejudice also tend to dissipate quickly when pre- existing stereotypes and prejudices are rekindled by the surrounding culture (6).

• Group discussions or skills training is required to reinforce education. Changes in attitudes towards older people brought about by information alone tend to fade quickly unless they are reinforced by subsequent activities, such as group

Presenting information in a positive light can help counteract pre-existing stereotypes and prejudices about older age.

1 1 9

CHAPTER 07

discussions or social skills training (9, 24, 25).

• The effects of role-playing can be enhanced by debriefing and by having students play the part of the older person. A systematic review of interventions that sought to enhance empathy in student health

professionals through role-play activities made two suggestions. First, it is important for students to play not only the role of the health professional but also that of the older patient. Second, a debriefing session should be included to allow students to translate the experience of role- playing into empathic behaviours (26).

Box 7.1

1 1 9

Opportunities for research on educational, intergenerational, and combined educational and intergenerational interventions

The findings on educational interventions, intergenerational contact interventions and combined educational and intergenerational contact interventions are based on a high-quality systematic review and meta-analysis commissioned for this report: the first such meta-analysis in the field (1). This review included 63 studies and was conducted in accordance with the PRISMA guidelines (29). A total of 14 electronic databases were searched, and the quality of individual studies was carefully appraised as well as the body of evidence across studies for each outcome.

However, the quality of the underlying studies was not high. Only six of the 63 studies were randomized controlled trials. More than half of the studies were rated as being at high risk of bias on four or more of the six dimensions assessed using the Cochrane Risk of Bias tool. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to assess the quality of the body of evidence across studies for each of the ageism outcomes: the overall quality was rated as moderate for three of the outcomes and low and very low for the remaining two (30). In future, researchers should strive to conduct studies of higher quality with less risk of bias.

The essential characteristics of interventions should also be identified with greater rigour. This will (i) allow interventions to be optimized, (ii) help identify which characteristics contribute to effectiveness when two or more interventions are combined, and (iii) provide some guidance on the characteristics of a strategy that are key to its effectiveness, especially in a new context in which interventions cannot be retested. The Template for Intervention Description and Replication checklist and guide (31) was developed by an international team of experts to promote full and accurate descriptions of interventions. We encourage researchers to use this checklist and guide when they plan and report on evaluations of interventions to reduce ageism.

1 2 0

GLOBAL REPORT ON AGEISM

• The key characteristics of effective virtual reality interventions include ensuring that participants are fully immersed in a scene and experience what it is like to be in an older person’s body. The more effectively virtual reality simulates being in the world of the other person and the greater the feeling one is really in that world (i.e. the greater the sense of immersion), the more empathy seems to be generated. And the more an individual has the impression of experiencing the world through another’s body (i.e. the greater the sense of embodiment), the greater the empathy generated (12).

• A review of virtual reality-based simulations used to train health professionals about mental illness found that such interventions seem to have a larger impact on the empathy of those with a health- care background compared to those without (27). This review also highlights the lack of consensus on the optimal content of such interventions and on the protocols for their delivery, points that also are relevant to virtual reality interventions used to reduce ageism.

The Aging Game is one of the few educational interventions shown to be effective and whose cost has been estimated (23, 28). In the Aging Game, medical students experience simulated physical, sensory and cognitive deficits,

which tend to increase with age. The intervention takes half a day and involves some 30 students at a time. It is estimated to cost about US$ 33 per workshop per student, which is relatively affordable. Knowing the cost of effective interventions is important. Without accurate and comparable estimates of cost, the cost– effectiveness of interventions cannot be estimated. Further accurate estimates of educational interventions are required.

7.5 Conclusions and future directions Evidence shows that educational interventions are effective in reducing ageism and appear to be affordable. Such interventions are, however, quite heterogeneous. They encompass disparate types of interventions, such as those that seek to transmit information and knowledge in a classroom setting or online and empathy- enhancing activities that include role-play, simulation games and immersive virtual reality. Educational interventions and intergenerational contact activities are among the most effective interventions for reducing ageism, and the two work well when combined (see Chapter 8).

Future priorities for educational interventions should include:

• developing, testing and scaling up educational interventions in all countries to reduce ageism against older people, but particularly in low- and middle-income countries where they are rare, across formal (e.g. school, colleges, universities) and non-formal (e.g. workplaces) educational settings;

Evidence shows that educational interventions are effective in reducing ageism and appear to be affordable.

1 2 1

CHAPTER 07

• developing, testing and scaling up educational interventions that reduce self-directed and institutional ageism, few of which are available;

• describing the characteristics of the interventions in a standardized way, so the interventions can be

replicated more easily and their essential characteristics be better identified (see Box 7.1);

• estimating the cost and cost– effectiveness of educational interventions where such estimates are lacking.

1 2 2

GLOBAL REPORT ON AGEISM

REFERENCES

1. Burnes D, Sheppard C, Henderson CR Jr., Wassel M, Cope R, Barber C, et al. Interventions to reduce ageism against older adults: a systematic review and meta-analysis. Am J Public Health. 2019;109:e1-9. https://doi.org/10.2105/AJPH.2019.305123.

2. Chonody JM. Addressing ageism in students: a systematic review of the pedagogical inter- vention literature. Educ Gerontol. 2015;41:859–87.

https://doi.org/10.1080/03601277.2015.1059139. 3. Formal, non-formal and informal learning. In: Council of Europe, Linguistic Integration of Adult

Migrants [website]. Strasbourg: Council of Europe; 2020 (https://www.coe.int/en/web/ lang-migrants/formal-non-formal-and-informal-learning, accessed 24 September 2020).

4. Recognition of non-formal and informal learning. In: Organisation for Economic Co-operation and Development [website]. Paris: Organisation for Economic Co-operation and Development; 2020 (http://www.oecd.org/education/skills-beyond-school/recognitionofnon-formaland- informallearning-home.htm, accessed 24 September 2020).

5. Dasgupta N. Mechanisms underlying the malleability of implicit prejudice and stereotypes. In: Nelson TD, editor. Handbook of prejudice, stereotyping, and discrimination. New York: Psychology Press; 2009:267–84.

6. FitzGerald C, Martin A, Berner D, Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol. 2019;7:29. https://doi.org/10.1186/s40359-019-0299-7.

7. Lai CK, Marini M, Lehr SA, Cerruti C, Shin JE, Joy-Gaba JA, et al. Reducing implicit racial preferences: I. A comparative investigation of 17 interventions. J Exp Psychol Gen. 2014;143:1765–85. https://doi.org/10.1037/a0036260.

8. Paluck EL, Green DP. Prejudice reduction: what works? A review and assessment of research and practice. Annu Rev Psychol. 2009;60:339–67.

doi10.1146/annurev.psych.60.110707.163607. 9. Ragan AM, Bowen AM. Improving attitudes regarding the elderly population: the effects of

information and reinforcement for change. Gerontologist. 2001;41:511–5. https://doi.org/10.1093/geront/41.4.511. 10. What is empathy? In: Greater Good Magazine [website]. Berkeley (CA): University of California

at Berkeley, Greater Good Science Center; 2020 (https://greatergood.berkeley.edu/topic/ empathy/definition, accessed 2 August 2020).

11. Hudson J, Waters T, Holmes M, Agris S, Seymour D, Thomas L, et al. Using virtual experiences of older age: exploring pedagogical and psychological experiences of students. In Hudson J, Kerton R, editors. Proceedings of the Virtual and Augmented Reality to Enhance Learning and Teaching in Higher Education Conference 2018. Chichester (UK): IM Publications Open; 2019:61–72. https://doi.org/10.1255/vrar2018.ch7.

12. Louie AK, Coverdale JH, Balon R, Beresin EV, Brenner AM, Guerrero APS, et al. Enhancing empathy: a role for virtual reality? Acad Psychiatry. 2018;42:747–52.

https://doi.org/10.1007/s40596-018-0995-2. 13. Oh SY, Bailenson J, Weisz E, Zaki J. Virtually old: embodied perspective taking and the reduc-

tion of ageism under threat. Comput Hum Behav. 2016;60:398–410. https://doi.org/10.1016/j.chb.2016.02.007. 14. Lipsey MW, Wilson DB. Practical meta-analysis. Thousand Oaks (CA): Sage; 2001. 15. Rosenthal JA. Qualitative descriptors of strength of association and effect size. J Soc Serv

Res. 1996;21:37–59. https://doi.org/10.1300/J079v21n04_02.

1 2 3

CHAPTER 07

16. Samra R, Griffiths A, Cox T, Conroy S, Knight A. Changes in medical student and doctor attitudes toward older adults after an intervention: a systematic review. J Am Geriatr Soc. 2013;61:1188–96. https://doi.org/10.1111/jgs.12312.

17. Brown CA, Kother DJ, Wielandt TM. A critical review of interventions addressing ageist attitudes in healthcare professional education. Can J Occup Ther. 2011;78:282-93.

https://doi.org/10.2182/cjot.2011.78.5.3. 18. Sum S, Emamian S, Sefidchian A. Aging educational program to reduce ageism:

intergenerational approach. Elder Health J. 2016;2:33–8. 19. Yamashita T, Hahn SJ, Kinney JM, Poon LW. Impact of life stories on college students’

positive and negative attitudes toward older adults. Gerontol Geriatr Educ. 2018;39:326– 40. https://doi.org/10.1080/02701960.2017.1311884.

20. Mellor D, McCabe M, Rizzuto L, Gruner A. Respecting our elders: evaluation of an edu- cational program for adolescent students to promote respect toward older adults. Am J Orthopsychiatry. 2015;85:181–90. https://doi.org/10.1037/ort0000041.

21. Jansen DA, Morse WA. Positively influencing student nurse attitudes toward caring for elders: results of a curriculum assessment study. Gerontol Geriatr Educ. 2004;25:1–14. https://doi.org/10.1300/J021v25n02_01.

22. Merz CC, Stark SL, Morrow-Howell NL, Carpenter BD. When I’m 64: effects of an interdisciplinary gerontology course on first-year undergraduates’ perceptions of aging. Gerontol Geriatr Educ. 2018;39:35–45. https://doi.org/10.1080/02701960.2016.1144600.

23. Pacala JT, Boult C, Hepburn K. Ten years’ experience conducting the Aging Game work- shop: was it worth it? J Am Geriatr Soc. 2006;54:144–9.

https://doi.org/10.1111/j.1532-5415.2005.00531.x. 24. Intrieri RC, Kelly JA, Brown MM, Castilla C. Improving medical students’ attitudes toward

and skills with the elderly. Gerontologist. 1993;33:373–8. https://doi.org/10.1093/geront/33.3.373. 25. Yu CY, Chen KM. Experiencing simulated aging improves knowledge of and attitudes

toward aging. J Am Geriatr Soc. 2012;60:957–61. https://doi.org/10.1111/j.1532-5415.2012.03950.x. 26. Bearman M, Palermo C, Allen LM, Williams B. Learning empathy through simulation: a

systematic literature review. Simul Health Care. 2015;10:308–19. https://doi.org/10.1097/SIH.0000000000000113. 27. Wan WH, Lam AHY. The effectiveness of virtual reality–based simulation in health pro-

fessions education relating to mental illness: a literature review. Health. 2019;11:646–60. https://doi.org/10.4236/health.2019.116054.

28. Pacala JT, Boult C, Bland C, O’Brien J. Aging Game improves medical students’ attitudes toward caring for elders. Gerontol Geriatr Educ. 1995;15:45–57.

https://doi.org/10.1300/J021v15n04_05. 29. Moher D, Liberati A, Tetzlaff J, Altman DG, the PRISMA Group. Preferred reporting

items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med. 2009;6(7):e1000097. https://doi.org/10.1371/journal.pmed.1000097.

30. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336:924-6. https://doi.org/10.1136/bmj.39489.470347.AD.

31. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687. https://doi.org/10.1136/bmj.g1687.

GLOBAL REPORT ON AGEISM

OLIPCIA , 74 , HAITIOLIPCIA , 74 ,

HAITI

CHAPTER 01

C H A P T E R 0 8

I think that it is important [that] the whole society and the government in particular focus on creating a mutual understanding between younger and older people.

Olipcia, 74 , Haiti ©Joseph Jn-Florley / HelpAge International

08

1 2 5

“ “

1 2 6

GLOBAL REPORT ON AGEISM

Intergenerational contact interventions aim to foster interaction between different generations.

Research shows that intergenerational contact and educational interventions are among the most effective interventions for reducing ageism against older people, and they are promising for reducing ageism against younger people.

Interventions that combine education and intergenerational contact also work to reduce ageism against older people and they have a slightly larger effect on attitudes than intergenerational contact interventions used alone, but they have little effect on knowledge about ageing.

Intergenerational contact interventions should be included in any comprehensive effort to reduce ageism, along with relevant policies, laws and educational interventions.

GLOBAL REPORT ON AGEISM

08 Chapter

1 2 6

8.1 What they are and how they work

Intergenerational contact interventions aim to foster interaction between people of different generations, and they are an important strategy to tackle ageism. They typically involve bringing together older and younger people to work cooperatively on tasks to encourage cross-generational bonding and understanding (1).

Intergenerational contact activities are often divided into those that involve direct contact and those that involve indirect contact. Direct contact involves face- to-face interaction, which can occur in various contexts, such as older and younger people playing games, gardening, making art or engaging in music therapy together or teaching each other; younger people visiting nursing homes or doing service learning with older people; older people conducting extended interviews or holding discussions with younger people or vice versa; or older and younger people living together, sometimes

This chapter discusses another effective strategy to eliminate ageism: intergenerational contact interventions.

Section 8.1 describes this intervention and how it works in addressing ageism. Section 8.2 reviews the evidence on its effectiveness and Section 8.3 provides real-world examples of this type of intervention. Section 8.4 summarizes the evidence on the factors that can make this intervention more effective and its costs.

1 2 7

CHAPTER 08

referred to as home-sharing. School-based programmes are among the most common direct intergenerational contact activities. These might involve older people meeting with students once a week for an hour or two, for instance, to share stories, paint together or share recipes and cook together.

Intergenerational friendships and contact between grandparents and grandchildren are also forms of direct intergenerational contact that can potentially reduce ageism (2). Thanks to increased longevity, more young people have living grandparents than ever before in history. Relationships with grandparents also provide many younger people with their first and most frequent contact with older adults (1). Skipped-generation households, in which grandchildren live with their grandparents, are common in some parts of the world (e.g. Africa, eastern Europe, Latin America and the Caribbean), either due to children being orphaned by parents who had AIDS or because their parents migrated for work (3).

While intergenerational friendships and contact between grandparents and grandchildren do not, strictly speaking, constitute interventions, and no study to date has examined the effect of grandchild– grandparent contact or intergenerational friendship on ageism as its main purpose, they are addressed in this section due to their importance.

Indirect intergenerational contact interventions entail participants being exposed to another age group without a direct or face-to-face encounter. Extended and imagined indirect contact are sometimes distinguished. Extended indirect contact occurs when, for instance, a friend of a similar age is known to have friends in another age group. It is based on the idea that a friend of yours is a friend of mine. Imagined indirect contact works by asking people to imagine having

a positive encounter with a person from another age group (2).

Intergroup contact theory explains how intergenerational contact interventions work in reducing ageism. Facilitating contact between groups under optimal conditions reduces intergroup prejudice and stereotypes, to a lesser extent, by reducing anxiety about intergroup contact and increasing perspective-taking and empathy (4, 5).

Optimal conditions occur when both groups have equal status and common goals, and when there is intergroup cooperation and the support of authorities, law or custom (2, 4-6) (see Box 4.1 in Chapter 4). Evaluations of interventions based on this theory, which have included interventions to reduce ageism, demonstrate that the effects of intergroup contact can generalize beyond the immediate participants in the intervention to the entire out-group (4, 5).

8.2 How well they work Intergenerational contact strategies are among the most effective interventions for reducing ageism against older people, along with educational interventions.

Evidence is increasing that interventions based on intergenerational contact work to reduce ageism against older people. A systematic review that included evaluations of 21 different intergenerational contact interventions aimed at reducing ageism against older people found that they had a small effect on attitudes (a standardized mean difference of 0.18), including on stereotypes and prejudice (7). It also showed that these interventions had a moderate effect on knowledge (a standardized mean

1 2 8

GLOBAL REPORT ON AGEISM

difference of 0.53), including on information and misconceptions about the ageing process (see Chapter 7, Box 7.1).

All of the studies in the review were from high-income countries, except for one from China, an upper-middle-income country (7). So although there are some grounds to assume that such interventions will also work in low- or middle-income countries, this is not certain (8-11). The systematic review also evaluated the effects of interventions that combined educational and intergenerational contact activities (see Box 8.1).

In the review, only two of the 40 intergenerational contact and combined intergenerational contact and educational interventions targeted anxiety about participants’ own ageing, which is related to self-directed ageism. And none addressed institutional ageism (7).

The results of this systematic review confirm the findings of previous reviews. For instance, a systematic review of interventions testing intergroup contact theory that included 54 studies looking at prejudice against older people found that the interventions were effective (5), as did another review of intergenerational contact programmes (2).

While only limited evidence is available about the effectiveness of such interventions to reduce ageism against younger people, it is nevertheless promising (Box 8.2).

It is impor tant to emphasize that intergenerational contact has other benefits in addition to reducing ageism. For older people, it can, for example, lead to improved health and psychosocial well-being, and increased self-esteem, and it can reduce distress, decrease loneliness, lead to a greater sense of social connectedness and strengthen intergenerational solidarity (2, 20, 21).

8.3 Examples The first of the four examples of intergenerational contact interventions presented in this section involves older and younger people playing video games together in Singapore. The second example, from China, Hong Kong Special Administrative Region, describes a form of service learning for nursing and medical students. The third example discusses an intervention in Portugal in which students engaged in sustained intergenerational contact by sharing older people’s homes. The last example involves only brief, imagined intergenerational contact among students in the United Kingdom.

8.3.1 Video games in Singapore

This intergenerational intervention in Singapore involved direct contact between older and younger people who paired up to play video games six times over two months. The older participants were recruited from activity centres in the local community and had a mean age of 76 years; the younger participants were recruited from local schools and had a mean age of 17 years.

Both younger and older participants who played video games together reported more positive changes in intergroup anxiety (e.g. they felt less awkward and self-conscious, and more confident when interacting with members of the other group) and attitudes (e.g. as measured along the dimensions of foolish–wise, boring–interesting and inactive–active) than participants in the control group, who did not play video games together. The results showed that enjoyment of the game had an important role in reducing intergenerational anxiety and improving attitudes among older people but not among the younger participants (16).

1 2 9

CHAPTER 08

Box 8.1 Combined educational and intergenerational contact interventions Educational and intergenerational contact interventions are frequently implemented together. A total of 19 of the 63 studies included in a systematic review commissioned for this report consisted of such combined interventions (7).

Interventions that combined education and intergenerational contact had a slightly larger effect on attitudes towards older adults (a standardized mean difference of 0.43), including on both stereotypes and prejudice, than those that involved only intergenerational contact (a standardized mean difference of 0.18). But there was no difference in effects on attitudes between interventions that combined education and intergenerational contact and those that used only education. Nor were there any differences in effects on attitudes between education-only and intergenerational contact-only interventions. Also, combined interventions had no significant effect on knowledge, but education-only and intergenerational contact–only interventions had, respectively, small and moderate effects on knowledge (7, 12, 13).

Further analyses combined results from education-only, intergenerational contact– only, and combined education and intergenerational contact interventions and produced several noteworthy findings (7). The analyses found that although these interventions had a small effect on attitudes and knowledge in high-school and university-level age groups, they were not effective in improving attitudes in pre- primary and primary school–aged children. No studies examined their effect on knowledge in pre-primary and primary school students. The analyses also revealed that the dose of the intervention was not related to improvements in attitudes or knowledge. Finally, interventions also appeared to increase younger participants’ level of comfort when interacting with adults, but seemed to have no effect on their prejudicial attitudes towards their own ageing (a proxy for self-directed ageism).

Eighteen of the 19 combined interventions included in the review were implemented in the United States and one was in Canada (7). So we cannot be completely sure whether these findings about combined interventions apply to low- or middle-income countries.

Example: Positive Education about Ageing and Contact Experiences from the United States

The Positive Education about Ageing and Contact Experiences (PEACE) programme is an example of a combined education and intergenerational contact intervention to reduce ageism that was aimed at younger people and delivered online (14). The intervention consisted of presenting a series of true/false statements about ageing and older people. For instance, participants had to decide whether the statement “depression is more frequent among older adults than among younger people” was true or false. For the educational component, the correct responses and accompanying explanations were provided after the participant had answered the questions.

1 3 0

GLOBAL REPORT ON AGEISM

The contact component was a form of indirect, extended contact and consisted of an additional response to the question about depression that described an intergenerational relationship in a positive way: “Max (aged 22 years) … admires Charles’ positive take on life and hopes to be more like him. …”

When tested, this simple, easy to implement and presumably inexpensive online intervention improved attitudes towards older people and knowledge about ageing. Potentially, it could be developed into a more in-depth intervention and delivered widely online to reduce ageism. An evaluation of the PEACE programme found that the combined intervention was generally not any more effective at reducing ageism outcomes than either the educational or the intergenerational contact components alone (14).

8.3.2 Service learning in China, Hong Kong Special Administrative Region

This intervention for nursing and medical students in China, Hong Kong Special Administrative Region, consisted of three components: a half-day introductory workshop, a 10-week interaction period and a half-day intergenerational sharing session. During the interaction period, older adults and students were paired, and they identified mutual learning objectives (e.g. about age- related changes, the challenge of chronic illness in old age, or a healthy lifestyle in later life). Then the pairs met from one to two hours per week. They discussed topics such as age-related changes, the challenge of chronic illness in old age and having a healthy lifestyle in later life. The goal was for younger students to learn about the reality of ageing and how their older partners coped.

The intervention increased medical and nursing students’ overall knowledge of ageing and their understanding of mental health needs in old age and reduced their negative attitudes toward older adults (22).

8.3.3 Home-sharing in Portugal

The Aconchego programme, which started in Portugal in 2004, encourages sustained,

direct intergenerational contact. In this programme, older people provide housing to university students and, in exchange, students help alleviate older people’s loneliness and isolation.

This programme carefully matches older people who live on their own with students who need accommodation, paying close attention to mutual expectations, interests and personal histories. At first, demand for the programme came mainly from students looking for accommodation, but in time, as older people became more familiar with the programme and trusted it more, demand from older people increased. The programme started in Porto, a city with large populations of students and older people; it was then replicated in Lisbon and in Coimbra, two other cities with many students. Although the Aconchego programme has been carefully monitored, its impact on ageism has not been evaluated (23, 24).

This model has spread to some 16 countries, including Australia, Belgium, Canada and the Republic of Korea; sometimes it is known as home-sharing (25). While some qualitative evaluations of home-sharing programmes have been carried out in relation to outcomes other than ageism (26), no rigorous evaluation assessing their impact on ageism has been conducted.

1 3 1

CHAPTER 08

Box 8.2 Intergenerational contact interventions to reduce ageism against younger people

The evidence is promising for the effectiveness of using intergenerational contact strategies to reduce ageism against younger people. A rapid review conducted for this report identified five studies evaluating the effectiveness of these strategies that used a design with a comparison group (either randomized or not randomized) (15-19). All of these studies examined ageism against both younger and older people. Four of the studies found that such interventions work to reduce ageist attitudes towards younger people (15-17, 19), while one found they made no difference (18).

Example: The Young–Old Link and Growth Intergenerational Programme in China, Hong Kong Special Administrative Region

An example of one of these interventions is The Young–Old Link and Growth Intergenerational Programme in China, Hong Kong Special Administrative Region.

This programme aimed to combat age-related stereotypes and facilitate positive interactions between younger and older adults in China, Hong Kong Special Administrative Region (19). It comprised six sessions that brought together 167 older people from community social services and 179 younger people from secondary schools. The programme was run by social workers who specialized in working with younger and older people.

The first stage – the foundation stage – consisted of two rounds of training of the social workers selected to deliver the intervention. The second stage – known as the stimulation stage – provided information to the participants to help them get to know one another. This stage consisted of two 2-hour sessions, one for older people and one for younger people. Older people watched a video on youth development to better understand the needs of contemporary youth, and younger people engaged in exercises that simulated the impairments that older people may have (e.g. blurred vision). The third stage – known as the consolidation stage – consisted of two day-long sessions attended by both groups together. The first involved setting collective goals (i.e. identifying sightseeing locations suitable for both generations), and the second, achieving the goals (i.e. visiting the sites together). This was followed by two additional 2-hour sessions, in which older and younger people participated together, focused on preparing, rehearsing and delivering group presentations about the sites visited.

An evaluation found positive changes in intergenerational attitudes, an increased sense of comfort with participants of a different generation, and increased interactions on the parts of both the younger and older participants. However, the changes were generally larger for the younger participants than for the older participants (19).

1 3 2

GLOBAL REPORT ON AGEISM

1 3 2

GLOBAL REPORT ON AGEISM

8.3.4 Imagined contact in the United Kingdom

A brief intervention based on a form of indirect and imagined intergenerational contact was used with the aim of reducing both explicit and implicit negative attitudes towards older people among undergraduate students in the United Kingdom.

The students were instructed to spend two minutes imagining themselves meeting an older stranger for the first time. They were also asked to imagine that they found out some interesting and unexpected things about the person.

This simple and inexpensive intervention led to reductions both in explicit negative attitudes towards older people (e.g. the students felt less cold, less suspicious, less hostile) and in implicit bias in favour of young people over older people. The authors note, however, that imagined contact likely has less powerful and long-lasting effects than direct, face-to-face intergenerational contact (27).

8.4 Key characteristics and costs

Several studies provide some indication about which factors contribute to the effectiveness of intergenerational contact, including between grandparents and grandchildren and between friends of different generations.

• According to intergroup contact theory, one of the optimal conditions for intergenerational contact activities is to ensure that the groups are of equal status. A common feature of unsuccessful programmes to reduce ageism among younger people

against older people appears to be the unequal status between the younger and older participants. Unequal status can arise when tasks favour the skills of one group over the other, or there are unequal numbers in the different age groups or differing levels of familiarity with the environment. For instance, an intervention taking place in a school, which might be unfamiliar to older people, and that includes many younger people and only a few older people is likely to create unequal status. Having lower status in a contact situation may exacerbate pre-existing anxieties about participating in activities. If the status between groups is markedly unequal, intergenerational activities may actually increase prejudice (2, 4).

• The quality of the contact between groups in intergenerational activities (e.g. how well older and younger people get on or how emotionally close they feel) is another key factor that may be more important than the frequency of contact in reducing stereotypes and prejudice against older people (1). Better quality contact can be fostered by organizing tasks that build confidence, avoiding situations in which either party patronizes the other and encouraging self- disclosure during which participants share personal information with one another. However, encouraging self-disclosure requires careful design: research suggests that older adults telling stories about the past increases the closeness of contact, but if older adults divulge too much personal information, it can lead to poor communication and negative outcomes (2, 28, 29). Thus,

1 3 3

CHAPTER 08

1 3 3

it is important to include balanced amounts of self-disclosure from both parties and for the stories of the past not to be too personal (2).

• Activities that increase cooperation through goal sharing and that reduce competition between age groups appear to be important, in keeping with the idea of optimal conditions in intergroup contact theory. Activities than foster cooperation include taking part in, for instance, arts and crafts projects, intergenerational choirs and orchestras and cooking. It is equally important to ensure that activities or tasks that confirm negative stereotypes about either group are avoided, as well as the presence of onlookers who are not participating in the programme and situations in which individuals can sidestep contact altogether (2).

• A review found that the more well structured and carefully designed the interventions were, the more effective they were (e.g. ensuring that instructors are well trained, clear instructions are given to participants, and intervention protocols are used) (20).

• One study points to the potential importance of how participants are grouped, whether in pairs or larger groups of mixed ages. It suggests that activities performed in child– older adult dyads (e.g. structured conversations and moving to music) had a more positive effect on stimulating interaction than activities occurring in a larger group (e.g. singing or playing an instrument) (15)

Several factors, which could potentially be manipulated in an intervention, appear

to enhance the positive impact on ageism that contact between grandparents and grandchildren and between friends of different generations can have. These factors partly overlap with the characteristics of the successful intergenerational contact interventions discussed above.

• A systematic review found that both the quality and frequency of contact with grandparents have robust and independent ageism- reducing effects (30). However, some research suggests that for good- quality contact to positively affect attitudes towards grandparents, it also needs to be relatively frequent (2, 31). High-quality contact seems to be characterized by increased self-disclosure and perspective- taking by both parties; younger people treating grandparents as individuals; younger people avoiding using overly accommodating speech, sometimes referred to as elderspeak (e.g. not using baby talk with older adults); and younger people having little anxiety about interacting with grandparents (2, 31). Although little research has examined the characteristics of intergenerational friendship that lead to a reduction in ageism, it appears that self- disclosure, perspective-taking and empathy by both parties play key roles (2).

• Parental encouragement and shared family identity also play roles in the impact that contact between grandchildren and grandparents has on ageism. Generally, grandchildren who identify more strongly with their family and whose parents encourage relationships with their grandparents have more favourable perceptions of older adults (29).

1 3 4

GLOBAL REPORT ON AGEISM

• Findings about the effect on ageism of living or having lived with an older person are inconclusive (32-35). More research is required to clarify the roles of factors such as the state of health of the older person, the type of relationship (e.g. grandparent, other relative, non-relative), the quality of the relationship and the cultural norms governing intergenerational living (29, 36, 37).

Little information is available about the costs of intergenerational contact interventions. However, several reviews emphasize that the costs of such interventions are likely to be low (particularly those based on imagined and extended indirect contact in which older people are not required to participate) and such interventions are easy to implement (1, 2, 7). For instance, the intervention in Singapore in which older and younger people played video games together is presumably affordable and straightforward to implement (16). Still, exact estimates of the costs of these interventions are needed.

8.5 Conclusions and future directions

Evidence shows that interventions that foster intergenerational contact are among the most effective interventions for reducing ageism against older people. They also appear to be affordable and relatively easy to implement.

While interventions that combined education and intergenerational contact had a slightly larger effect on attitudes, including on prejudice and stereotypes, than those that involved intergenerational contact alone, they did not have a larger effect than

education-only interventions, and they had no effect on knowledge. Education- only and intergenerational education-only interventions had, respectively, small and moderate effects on knowledge.

Future priorities in relation to intergenerational contact interventions should include the following:

• It is essential to develop, test and scale up intergenerational contact- only and combined educational- and intergenerational-contact interventions to reduce ageism against both older and younger people in all countries, but especially in low- and middle-income countries.

• There is a need to identify the essential characteristics of intergenerational contact interventions and the right mix of intergenerational and educational- components in combined interventions (see Box 8.2).

• Interventions that aim to reduce self-directed and institutional ageism should be developed.

• It is important to estimate the costs of intergenerational contact- only and combined educational- and intergenerational-contact interventions.

• Equally important is the need for further research to determine the optimal conditions under which contact between grandparents and grandchildren and intergenerational friendships lead to reductions in ageism. This should be followed by the development and testing of interventions to foster these relationships and reduce ageism.

1 3 5

CHAPTER 08

REFERENCES

1. Christian J, Turner R, Holt N, Larkin M, Cotler JH. Does intergenerational contact reduce ageism: when and how contact interventions actually work? J Arts Humanit. 2014;3:1–15 (https://www.theartsjournal.org/index.php/site/article/view/278/214, accessed 10 April 2020).

2. Drury L, Abrams D, Swift HJ. Making intergenerational connections – an evidence review. London: Age UK; 2017 (https://www.ageuk.org.uk/Documents/EN-GB/ For-professionals/Research/Making_Intergenerational_Connections-Evidence_ Review(2017).pdf?dtrk=true, accessed 14 May 2020).

3. Living arrangements of older persons around the world. New York: United Nations Department of Economic and Social Affairs, Population Division; 2019 (No. 2019/2; https://www.un.org/en/development/desa/population/publications/pdf/popfacts/ PopFacts_2019-2.pdf, accessed 16 May 2020).

4. Pettigrew TF, Tropp LR. A meta-analytic test of intergroup contact theory. J Personal Soc Psychol. 2006;90:751–83. https://doi.org/10.1037/0022-3514.90.5.751.

5. Pettigrew TF, Tropp LR. How does intergroup contact reduce prejudice? Meta‐analytic tests of three mediators. Eur J Soc Psychol. 2008;38:922–34. https://doi.org/10.1002/ejsp.504.

6. Paluck EL, Green DP. Prejudice reduction: what works? A review and assessment of research and practice. Annu Rev Psychol. 2009;60:339–67. https://doi.org/10.1146/ annurev.psych.60.110707.163607.

7. Burnes D, Sheppard C, Henderson CR Jr., Wassel M, Cope R, Barber C, et al. Interventions to reduce ageism against older adults: a systematic review and meta-analysis. Am J Public Health. 2019;109:e1–9. https://doi.org/10.2105/AJPH.2019.305123.

8. Chu J, Leino A. Advancement in the maturing science of cultural adaptations of evidence- based interventions. J Consult Clin Psychol. 2017;85:45–57. https://doi.org/10.1037/ccp0000145.

9. Gardner F. Parenting interventions: how well do they transport from one country to another? Florence (Italy): UNICEF; 2017 (Innocenti Research Brief 2017-10; https://www. unicef-irc.org/publications/pdf/IRB_2017_10.pdf, accessed 24 April 2020).

10. Gardner F, Montgomery P, Knerr W. Transporting evidence-based parenting programs for child problem behavior (age 3–10) between countries: systematic review and meta- analysis. J Clin Child Adolesc Psychol. 2016;45:749–62. https://doi.org/10.1080/15374416. 2015.1015134.

11. Leijten P, Melendez-Torres GJ, Knerr W, Gardner F. Transported versus homegrown parenting interventions for reducing disruptive child behavior: a multilevel meta-regression study. J Am Acad Child Adolesc Psychiatry. 2016;55:610–7. https://doi.org/10.1016/j. jaac.2016.05.003.

12. Lipsey MW, Wilson DB. Practical meta-analysis. Thousand Oaks (CA): Sage; 2001. 13. Rosenthal JA. Qualitative descriptors of strength of association and effect size. J Soc Serv

Res. 1996;21:37–59. https://doi.org/10.1300/J079v21n04_02. 14. Lytle A, Levy SR. Reducing ageism: education about aging and extended contact with older

adults. Gerontologist. 2019;59:580–8. https://doi.org/10.1093/geront/gnx177. 15. Belgrave M. The effect of a music therapy intergenerational program on children and older

adults’ intergenerational interactions, cross-age attitudes, and older adults’ psychosocial well-being. J Music Ther. 2011;48:486–508. https://doi.org/10.1093/jmt/48.4.486.

1 3 6

GLOBAL REPORT ON AGEISM

16. Chua P-H, Jung Y, Lwin MO, Theng Y-L. Let’s play together: effects of video-game play on intergenerational perceptions among youth and elderly participants. Comput Hum Behav. 2013;29:2303–11. https://doi.org/10.1016/j.chb.2013.04.037.

17. Meshel DS, MCGlynn RP. Intergenerational contact, attitudes, and stereotypes of adolescents and older people. Educ Gerontol. 2004;30:457–79. https://doi.org/10.1080/03601270490445078.

18. Pinquart M, Wenzel S, Sö Rensen S. Changes in attitudes among children and elderly adults in intergenerational group work. Educ Gerontol. 2000;26:523–40.

https://doi.org/10.1080/03601270050133883. 19. Sun Q, Lou VW, Dai A, To C, Wong SY. The effectiveness of the Young–Old Link and

Growth Intergenerational Program in reducing age stereotypes. Res Soc Work Pract. 2019;29:519–28.

https://doi.org/10.1177/1049731518767319. 20. Canedo-Garcia A, Garcia-Sanchez JN, Pacheco-Sanz DI. A systematic review of the

effectiveness of intergenerational programs. Front Psychol. 2017;8:1882. https://doi.org/10.3389/fpsyg.2017.01882.

21. Maley M, Yau H, Wassel M, Eckenrode J, Pillemer K. Intergenerational programs: evidence and outcomes. Ithaca (NY): Cornell University, Bonfenbrenner Center for Translational Research; 2017 (https://www.bctr.cornell.edu/wp-content/uploads/2017/06/Systemic- Translational-Review-intergenerational-programs.pdf, accessed 16 May 2020).

22. Leung AY, Chan SS, Kwan CW, Cheung MK, Leung SS, Fong DY. Service learning in medical and nursing training: a randomized controlled trial. Adv Health Sci Educ. 2012;17:529–45.

https://doi.org/10.1007/s10459-011-9329-9. 23. Jarrett D. Aconchego program. In: Social Innovation Exchange [website]. London: Social

Innovation Exchange; 2010 (https://socialinnovationexchange.org/insights/aconchego- program, accessed

15 February 2020). 24. Programa Aconchego. In: Porto [website]. Porto (Portugal): Câmara Municipal do Porto;

2020 (http://www.cm-porto.pt/bonjoia-projetos/populacao-senior-programa-aconchego,

accessed 19 February 2020) (in Portuguese). 25. 2019 Congress – Brussels, Belgium: Sixth World Homeshare Congress. In: Homeshare

International [website]. Oxford: Homeshare International; 2020 (https://homeshare.org/ world-homeshare-congresses/2019-congress-brussels-belgium/, accessed 19 February 2020).

26. Quinio V, Burgess G. Is co-living a housing solution for vulnerable older people? Cambridge: University of Cambridge, Cambridge Centre for Housing & Planning Research; 2018 (http://www.nationwidefoundation.org.uk/wp-content/uploads/2019/02/ Literature-Review-_web-version-300119.pdf, accessed 20 May 2020).

27. Turner RN, Crisp RJ. Imagining intergroup contact reduces implicit prejudice. Br J Soc Psychol. 2010;49:129–42. https://doi.org/10.1348/014466609X419901.

28. Harwood J, Soliz J, Lin MC. Communication accommodation theory: an intergroup approach to family relationships. In: Braithwaite DO, Baxter L, editors. Engaging theories in interpersonal communication: multiple perspectives. Thousand Oaks (CA): Sage; 2006.

29. Soliz J, Harwood J. Shared family identity, age salience, and intergroup contact: investigation of the grandparent–grandchild relationship. Commun Monogr. 2006;73:108–32.

https://doi.org/10.1080/03637750500534388.

1 3 7

CHAPTER 08

30. Marques S, Mariano J, Mendonca J, De Tavernier W, Hess M, Naegele L, et al. Determinants of ageism against older adults: a systematic review. Int J Environ Res Public Health. 2020;17:2560.

https://doi.org/10.3390/ijerph17072560. 31. Harwood J, Roy A. Social identity theory and mass communication research. In: Harwood J, Giles H,

editors. Intergroup communication: multiple perspectives. Bern: Peter Lang; 2005:189–211. 32. Allan LJ, Johnson JA. Undergraduate attitudes toward the elderly: the role of knowledge, contact

and aging anxiety. Educ Gerontol. 2008;35:1–14. https://doi.org/10.1080/03601270802299780. 33. Drake JT. Some factors influencing students’ attitudes toward older people. Soc Forces. 1957:266–

71. https://doi.org/10.2307/2573511. 34. Hweidi IM, Al-Obeisat SM. Jordanian nursing students’ attitudes toward the elderly. Nurse Educ

Today. 2006;26:23–30. https://doi.org/10.1016/j.nedt.2005.06.003. 35. Yılmaz F, Çolak MY. The effects of intergenerational relations and ageing anxiety on attitudes

toward ageism. Acad Res Int. 2017;8:45–54. 36. Celdrán M, Villar F, Triadó C. Thinking about my grandparent: how dementia influences adolescent

grandchildren’s perceptions of their grandparents. J Aging Stud. 2014;29:1–8. https://doi.org/10.1016/j.jaging.2013.12.004. 37. Flamion A, Missotten P, Marquet M, Adam S. Impact of contact with grandparents on children’s and

adolescents’ views on the elderly. Child Dev. 2019;90:1155–69. https://doi.org/10.1111/cdev.12992.

1 3 8

GLOBAL REPORT ON AGEISM

B U A K H I A W , 8 4 , THAIL AND

CHAPTER 01

C H A P T E R 0 9

We don’t have control over other people’s thoughts . What we can do is to control and shape our own thoughts and behaviour.

Buakhiaw, 84 , Thailand ©Paiboon Yeelar / FOPDEV / HelpAge International

09

1 3 9

“ “

1 4 0

GLOBAL REPORT ON AGEISM

Based on some evidence for their effectiveness in other areas, campaigns may be a promising strategy to reduce ageism.

Research on strategies to mitigate the impact of ageism after it has occurred is still at an early stage. Nonetheless, some approaches may hold some promise for lessening the impact of negative stereotypes.

Both campaigns and strategies to mitigate the impact of ageism should be further developed and tested as rigorously as possible before they are scaled up.

Other strategies to mitigate the impacts of all dimensions of ageism – stereotypes, prejudice and discrimination – should be developed and tested.

GLOBAL REPORT ON AGEISM

09 Chapter

1 4 0

This chapter discusses two strategies to address ageism that are supported by limited evidence, but which hold promise. Section 9.1 surveys the evidence for campaigns to reduce ageism, a strategy often used, but for which there is no direct evidence of effectiveness. That there is some evidence for the effectiveness of campaigns in other areas provides grounds to think they might also work to reduce ageism. Section 9.2 summarizes the evidence for strategies to mitigate the impact of ageism against older people after it has occurred; however, some of these are only potential strategies.

9.1 Campaigns

9.1.1 What they are and how they work

Campaigns are purposive attempts to inform or influence behaviours in large audiences within a specified period by using an organized set of communication activities and featuring an array of mediated messages delivered through multiple channels to produce non-commercial benefits to individuals and society (1, 2).

Campaigns use either traditional media (e.g. television/ cinema advertising, radio, billboards, the press, signs in buses, taxis, etc.) or new media (e.g. social media, targeted landing pages, pay-per-click advertising, digital banners and signage, Facebook, Twitter, YouTube advertisements, etc.) (3).

Campaigns generally seek to reduce ageism either directly, by changing individual behaviour, or indirectly, by changing laws and policies and shifting social norms. Often, they do both. When they operate indirectly, campaigns seek to influence policy-makers, civil

1 4 1

CHAPTER 09

society, political and opinion leaders, the media and the general public to increase the visibility of an issue, alter perceptions of who is responsible for causing the issue and mobilize constituencies, all to create an environment conducive to changes in individual behaviour (1, 4, 5). In recent years, campaigns have increasingly been used to address ageism, as the examples in Section 9.1.3 illustrate.

9.1.2 How well they work

No high-quality studies demonstrate the effectiveness of campaigns to reduce ageism (6). Testing the effectiveness of campaigns is inherently challenging, which may explain why so few ageism campaigns have been evaluated (see Box 9.1) (7-9). Still, some evidence exists from campaigns addressing other health issues and other forms of stereotypes, prejudice and discrimination.

One of the most comprehensive reviews of the literature on the effectiveness of health campaigns includes a systematic review

of 36 other systematic reviews, as well as three new systematic reviews of primary studies (3). It summarized the evidence for mass media campaigns targeting six risk factors for noncommunicable diseases: alcohol use, diet, illicit drug use, physical activity level, sexual and reproductive health, and tobacco use (3).

The review found moderate evidence that mass media campaigns can reduce sedentary behaviour and influence sexual health-related behaviours and treatment- seeking behaviours (e.g. through the use of helplines to quit smoking and sexual health services). The evidence for an impact on tobacco use and level of physical activity was mixed. The evidence for an impact on alcohol use was limited, and there was no impact on illicit drug use. Campaigns appear to have less of an impact on behaviour change than on knowledge and awareness.

Overall the evidence suggests that health campaigns have a small beneficial effect, even if the findings are somewhat mixed (3, 10, 11).

Box 9.1

Opportunities for research on campaigns to reduce ageism

Campaigns are more difficult to evaluate using rigorous designs than many other types of interventions (7-9). It is difficult to use randomized controlled trials to evaluate most campaigns (9). Cluster–randomized trials are rigorous designs that are occasionally used instead, but they are also challenging (9, 12, 13).

In most cases, campaigns are evaluated using weaker designs that produce findings in which we have less confidence (7-9, 13). Indeed, when a weaker design is used to evaluate a campaign, the campaign often – misleadingly – appears to work twice as well as when the same campaign is evaluated using a more rigorous design (14).

The priority is to conduct the most rigorous evaluations possible of campaigns aiming to reduce ageism, and guidance is available (7, 9, 15, 16); once their effec- tiveness is demonstrated, the next step is to identify their essential characteristics.

1 4 2

GLOBAL REPORT ON AGEISM

A review of systematic reviews evaluating mass media campaigns for reducing prejudice and discrimination against people with mental health conditions found that campaigns had small to moderate positive impacts on stigma-related knowledge, attitudes and intended behaviour (i.e. desire for contact with people with a mental health condition) (17).

An earlier review found that mass media interventions had a small to moderate effect on reducing negative attitudes towards people with mental health conditions, but they had mixed effects on discrimination (18).

High-quality evidence is sparse about campaigns that work to reduce stereotypes, prejudice and discrimination based on race and ethnicity, and it shows a mixed picture (19-21).

Thus, campaigns may offer a promising strategy to tackle ageism. Even if campaigns have only a small effect, with sufficient reach and penetration at the population level they could nevertheless bring about significant change (18).

9.1.3 Examples

This section highlights a few international and local campaigns, including one run by a coalition of groups and another by a global network. The first example describes a worldwide campaign taking place in several low- and middle-income countries.

The second example is an ongoing, research-based, national campaign in Australia, while the third concerns an innovative city-based campaign in Canada. While the previous examples focus on campaigns to reduce ageism against older people, Box 9.2 provides an example of a campaign to reduce ageism against younger people.

Take a Stand Against Ageism: an international campaign

Take a Stand Against Ageism is an ongoing campaign taking place in different regions of the world, and it is led by HelpAge International, a global network of organizations working with and for older people. The campaign takes its name from the theme for the 2016 International Day of Older Persons (6).

The aims of the campaign are to increase the awareness of ageism among HelpAge network members, campaigners and supporters and to increase the visibility of older people’s lived experiences of ageism to ensure that older people are no longer denied their rights simply because of their age.

Campaign resources are available from HelpAge International and include guides to conducting consciousness-raising workshops and ageism role-plays (22).

This campaign comprises many ongoing campaigns, and the activities vary across countries. For instance, in Bangladesh more than 2000 older and younger people, development workers, students and journalists formed a human chain to demand government action to support a UN Convention on the rights of older people. Activities organized in Mozambique included a march in Maputo, two radio debates with representatives from the government and older people’s associations, and a health fair.

The EveryAGE Counts campaign in Australia

EveryAGE Counts is an ongoing advocacy campaign in Australia that was launched in 2018 and is run by a coalition of organizations aimed at tackling ageism against older Australians. Its vision is “a society where every person is valued, connected and

1 4 3

CHAPTER 09

Box 9.2

respected regardless of age and functional health” (23).

The overall goal is to build strong, new foundations to enable current and future generations to age well. The campaign seeks to shift entrenched negative social norms about ageing and older people and to reframe older age as a valid, positive and meaningful part of life.

EveryAGE Counts seeks to bring about social change by engaging in advocacy, political engagement and public campaigning for policy change; addressing specific structural

barriers to participation for older people (e.g. in the workplace and health care); and increasing the diversity and accuracy of representations of older people in the media, arts and public discussions.

Campaign activities have included pledge- signing events at Parliament House during which participants acknowledge that they “stand for a world without ageism” (23); hosting or participating in community-based events to build awareness of the campaign and increase membership; and developing and disseminating materials such as a quiz (Am I ageist?) and a magazine (The real old),

Not Too Young to Run: a campaign to reduce ageism against younger people in politics

In November 2016, the global campaign Not Too Young to Run was launched by a partnership including the UN and several other international and nongovernmental organizations (25). It aims to address ageism against younger people in the political process by promoting their right to run for public office. In a fast-changing world where more than 50% of the population is younger than 30 years-old, but less than 2% of elected legislators are, the campaign highlights the fact that the active participation of young people in electoral politics is essential to ensure thriving and representative democracies worldwide (26).

The campaign seeks to (i) raise awareness of the lack of young people in public office by collating global statistics by country concerning youth and politics and also identifying barriers to participation; (ii) advocate for the rights of young people to run for public office and leadership positions, and for increased participation of young people in politics and government; government; and (iii) gather input and ideas from young people around the world with regards to their participation in political decision-making processes through an online public consultation. The campaign also highlights young leaders already in elected positions and tries to inspire young people to run for office.

The campaign scales up the movement of the same name that was started by civil society groups in Nigeria in May 2016. This movement contributed to the Nigerian Government enacting legislation in 2018 that reduced the age limit for state legislators and those in the federal House of Representatives from 30 years to 25 years; for senators and governors, from 35 to 30 years; and for the president from 40 to 35 years (25, 26).

1 4 4

GLOBAL REPORT ON AGEISM

which encourages people to think about ageism and to speak out against it (23).

Research has played an important part in the development of the campaign. For instance, a research project looking at the drivers of ageism provided the foundational evidence that informed the campaign’s strategy (23).

The Best Before Date campaign in Canada

The Best Before Date campaign in Peterborough, Canada, was a city-wide marketing campaign aiming to tackle ageism, that took place in 2013-2014. Launched as part of Seniors’ Month, it sardonically showed people of all ages with a fake “best before” date tattooed on their forehead to highlight the stigma related to ageing.

The campaign included television spots, YouTube videos, print and radio ads, and an interactive website where users could take a quiz to find out their own best before date and upload a picture of themselves to have the date “tattooed” on their forehead. The campaign aimed to reduce ageism by changing perceptions in Peterborough that older adults are a drain on resources and a nuisance, old-fashioned and out of touch with new ways and technology and an impediment to people’s busy everyday lives. It also aimed to emphasize the valuable knowledge and experience older people can offer the community. However, no findings about the impact of this campaign are available (6, 24).

9.1.4 Key characteristics

Based on research that evaluated campaigns addressing other areas and the limited evidence about anti-ageism campaigns (6), the following characteristics of campaigns against ageism may be associated with effectiveness.

• Dose: Generally, the longer the duration of and the greater the intensity or exposure to the campaign, the more effective it will be. However, consensus is lacking about the exact dose necessary for a successful campaign (3). The US Centers for Disease Control and Prevention has suggested that advertisements for tobacco prevention campaigns should be aired for at least six months to affect awareness, 12–18 months to establish the campaign’s themes and have an impact on attitudes and 18–24 months to have an impact on behaviour (27).

• Framing: Framing can influence our perceptions, attitudes, actions and how ageing and other issues are perceived and responded to (28-30). Framing refers to how an issue is communicated, where the communication starts, what is emphasized, how it is explained and what is left unsaid.

• Types of messaging and denormalizing behaviour: In anti- ageism campaigns, it is preferable to present simple messages about achievable actions and images that avoid reinforcing the two extremes of ageing – the heroes of ageing and bodily decline (6). In general, campaign messages that denormalize a behaviour (i.e. increase its social unacceptability, thus reinforcing the perception that it is neither mainstream nor a normal activity in society) may be more effective than other types of messages (3).

• Interactive and social media channels: Health campaigns, particularly sexual health campaigns,

1 4 5

CHAPTER 09

that have interactive components (e.g. personalized emails) and use social media appear to be more effective than those using static components (e.g. having someone watch an online video) (3, 31, 32).

• Community engagement: Engaging community representatives – including older and younger people – when developing campaigns is likely to be important. One way this can be done is by having community representatives help design the campaign and by using participatory action research. Community representatives can contribute by identifying experiences of ageism and helping to design communication tools (6).

• Funding and partnerships: Ensuring there is sustainable, long-term and flexible funding is likely to benefit campaigns. This often requires obtaining money from several sources (e.g. government departments, grant funding agencies). It also appears helpful to be associated with a larger programme (e.g. WHO’s Age-Friendly Cities and Communities Programme) and to work in partnership (e.g. with health-care providers or media studios) (6).

• Combining campaigns: Effects may be enhanced when campaigns against ageism are combined with other strategies. There is some limited evidence that when mass media campaigns are used as awareness tools, compliance with laws and regulations may be increased (e.g. using seat belts, alcohol regulations) (11, 33). However, although combining strategies into multicomponent and multilevel

interventions may sometimes result in enhanced effects (e.g. smoking cessation), this is not always the case (e.g. for campaigns to increase physical activity, reduce childhood obesity and the risks of cancer) (34-37).

• The role of culture: Cultural appropriateness contributes to the effectiveness of health campaigns, particularly international campaigns and campaigns in multicultural societies. Guidance for ensuring cultural appropriateness is available (29, 38-41). Culture can also be an entry point for engaging in focused collective dialogue about ageism with local communities, opinion leaders, faith-based leaders, traditional elders and other agents of change. Such dialogues can become the starting point for culturally informed campaigns that are designed with local representatives and other communication activities (e.g. using digital media, video and storytelling) (42).

9.2 Potential strategies for mitigating the impact of ageism

Very few studies have evaluated strategies – or potential strategies – for mitigating the impact of ageism after it has occurred.

A study using data from a national survey in Japan found that being subject to perceived

1 4 6

GLOBAL REPORT ON AGEISM

1 4 6

GLOBAL REPORT ON AGEISM

age discrimination negatively affected job satisfaction in older men. However, elevated levels of social support from managers and co-workers decreased the impact of the perceived discrimination (43).

An intervention in the United States with older participants of Chinese background protected them against the effects of stereotype threat. The intervention reminded participants of their Confucian values. It consisted of participants reading a script that, first, stated they should be proud of their ancient traditions that honour the role of older adults and, second, reassured them that these values had been successfully transmitted to the younger generation. The stereotype threat consisted of being told that they would be taking a memory test to see how ageing affects memory, and the results would be compared with those of younger people. The intervention did not, strictly speaking, mitigate the effects of ageism (i.e. the stereotype threat) after it occurred, but rather inoculated participants against the effects of ageism before it occurred. Nonetheless, one can hypothesize that it might also work to mitigate the effects of ageism after it has occurred (44).

Several other studies have shown in laboratory experiments that exposing participants to implicit, positive age stereotyping improved physical function (45, 46), memory performance (47, 48) and cardiovascular measurements (49).

The use of implicit or subliminal stereotypes refers to being exposed in a way that allows for perception but without full conscious awareness – for instance, through words being flashed on a screen at high speed.

It is possible that such exposure to implicit, positive age stereotypes may not only have the beneficial effects noted above but also may mitigate the effects of exposure to

negative ageist stereotypes and perhaps other forms of ageism, although this has not yet been demonstrated. If this were shown to be the case, such laboratory experiments might have the potential to be turned into interventions to mitigate the effects of ageism after it has occurred.

9.3 Conclusions and future directions

Campaigns to reduce ageism and strategies for mitigating its impact are potentially important strategies to address ageism, but research on them is limited. Developing them further and generating more evidence of their effectiveness should be priorities.

9.3.1 Campaigns

No campaigns to reduce ageism have been evaluated for effectiveness. But based on evidence about the effectiveness of campaigns in other areas of health – such as sexual health – and in reducing stereotypes, prejudice and discrimination related to mental health conditions, campaigns represent a promising strategy to combat ageism.

Future priorities in relation to campaigns to reduce ageism are described below.

• There is a need to develop and test campaigns that address different forms of ageism (i.e. institutional, interpersonal and self-directed ageism) using the most rigorous designs possible (see Box 9.1).

• It is critical to develop, implement and evaluate campaigns in low- and middle-income countries. Only one

1 4 7

CHAPTER 09

1 4 7

of the campaigns included in a recent review of anti-ageism campaigns – the global campaign organized by HelpAge International (6) (see Section 9.3.1) – took place in low- and middle-income countries.

• The cost and cost–effectiveness of anti-ageism campaigns should be estimated. Campaigns can be expensive. Hence, it is critical to ensure that they are cost-effective. Evidence for the cost–effectiveness of campaigns in all areas of health is extremely limited, other than for smoking, for which there is moderate evidence of cost–effectiveness (3).

9.3.2 Strategies for mitigating the impact of ageism

Research on strategies to mitigate the impact of ageism is still at an early stage. Only a handful of studies are available.

Some are laboratory experiments rather than fully developed interventions. Nonetheless, these strategies may hold some promise for lessening the impact of negative stereotypes.

Given the pervasiveness of ageism and its serious and far-reaching impacts – described in Chapters 2 and 3, respectively – future priorities in relation to mitigating the impact of ageism should include:

• investigating whether exposure to implicit positive stereotypes might help mitigate the effects of negative stereotypes and other forms of ageism and, if so, how this could be turned from laboratory findings into scalable interventions;

• developing, testing and scaling up strategies to mitigate the impact of all dimensions of ageism – that is, stereotypes, prejudice and discrimination.

1 4 8

GLOBAL REPORT ON AGEISM

REFERENCES

1. Rice RE, Atkin CK. Theory and principles of public communication campaigns. In: Public communication campaigns. Thousand Oaks (CA): Sage; 2012:3–19.

2. Rogers EM, Storey JD. Communication campaigns. In: Berger C, Chaffee S, editors. Handbook of communication science. Thousand Oaks (CA): Sage; 1987:817–46.

3. Stead M, Angus K, Langley T, Katikireddi SV, Hinds K, Hilton S, et al. Mass media to communicate public health messages in six health topic areas: a systematic review and other reviews of the evidence. Public Health Res. 2019;7(8):1–205.

https://doi.org/10.3310/phr07080. 4. Cislaghi B, Heise L. Theory and practice of social norms interventions: eight common

pitfalls. Global Health. 2018;14:83. https://doi.org/10.1186/s12992-018-0398-x. 5. Coffman J. Public communication campaign evaluation: an environmental scan of

challenges, criticisms, practice, and opportunities. Washington (DC): Communications Consortium Media Center; 2002 (https://citeseerx.ist.psu.edu/viewdoc/ download?doi=10.1.1.575.7053&rep=rep1&type=pdf, accessed 22 March 2020).

6. Campaigning to tackle ageism: current practices and suggestions for moving forward. Geneva: World Health Organization; 2020 (https://www.who.int/publications/m/item/ campaigning-to-tackle-ageism, accessed 25 September 2020).

7. Noar SM. Challenges in evaluating health communication campaigns: defining the issues. Commun Methods Meas. 2009;3:1–11. https://doi.org/10.1080/19312450902809367.

8. Noar SM, Palmgreen P, Zimmerman RS. Reflections on evaluating health communication campaigns. Commun Methods Meas. 2009;3:105–14.

https://doi.org/10.1080/19312450902809730. 9. Sixsmith J, Fox K, Doyle P, Barry MM. A literature review on health communication

campaign evaluation with regard to the prevention and control of communicable diseases in Europe. Stockholm: European Centre for Disease Prevention and Control; 2014

(https://op.europa.eu/s/ompT, accessed 24 March 2020). 10. Anker AE, Feeley TH, McCracken B, Lagoe CA. Measuring the effectiveness of mass-

mediated health campaigns through meta-analysis. J Health Commun. 2016;21:439–56. https://doi.org/10.1080/10810730.2015.1095820.

11. Snyder LB, Hamilton MA, Mitchell EW, Kiwanuka-Tondo J, Fleming-Milici F, Proctor D. A meta-analysis of the effect of mediated health communication campaigns on behavior change in the United States. J Health Commun. 2004;9(Suppl. 1):71–96.

https://doi.org/10.1080/10810730490271548. 12. Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. Population-based prevention

of child maltreatment: the U.S. Triple P System Population Trial. Prev Sci. 2009;10:1–12. https://doi.org/10.1007/s11121-009-0123-3.

13. Ryan R, Hill S, Broclain D, Horey D, Oliver S, Prictor M. Supplementary guidance for authors undertaking reviews with the Cochrane Consumers and Communication Review Group. In: Cochrane Collaboration; 2013 (https://cccrg.cochrane.org/sites/cccrg.cochrane.org/ files/public/uploads/Study_design_guide2013.pdf, accessed 15 March 2020).

14. Snyder LB, Hamilton MA, Huedo-Medina T. Does evaluation design impact communication campaign effect size? A meta-analysis. Commun Methods Meas. 2009;3:84–104.

https://doi.org/10.1080/19312450902809722. 15. Bauman A. Precepts and principles of mass media campaign evaluation in Australia.

Health Promot J Aust. 2000;10:89–92.

1 4 9

CHAPTER 09

16. O’Kane N, Gough A, Hunter R, McKinley M. Social media and public health mass communication interventions: a systematic review of evaluation methods. York: National Institute for Health Research; 2016 (https://www.crd.york.ac.uk/prospero/display_ record.php?RecordID=49280, accessed 10 June 2020).

17. Gronholm PC, Henderson C, Deb T, Thornicroft G. Interventions to reduce discrimination and stigma: the state of the art. Soc Psychiatry Psychiatr Epidemiol. 2017;52:249–58. https://doi.org/10.1007/s00127-017-1341-9.

18. Clement S, Lassman F, Barley E, Evans-Lacko S, Williams P, Yamaguchi S, et al. Mass media interventions for reducing mental health-related stigma. Cochrane Database Syst Rev. 2013;(7):CD009453. https://doi.org/10.1002/14651858.CD009453.pub2.

19. McBride M. What works to reduce prejudice and discrimination? A review of the evidence. Edinburgh: Scottish Government; 2015 (https://www.gov.scot/publications/ works-reduce-prejudice-discrimination-review-evidence/, accessed 24 March 2020).

20. Paluck EL, Green DP. Prejudice reduction: what works? A review and assessment of research and practice. Annu Rev Psychol. 2009;60:339–67.

https://doi.org/10.1146/annurev.psych.60.110707.163607. 21. Sutton M, Perry B, Parke J, John-Baptiste C. Getting the message across: using

media to reduce racial prejudice and discrimination. London: Crown Copyright, Department of Communities and Local Government; 2007 (https://tandis.odihr.pl/ bitstream/20.500.12389/20228/1/04628.pdf, accessed 29 March 2020).

22. Age Demands Action Global 2016 toolkit. London: HelpAge International; 2016 (http://www.helpage.org/download/57becbe416492/, accessed 2 July 2020). 23. EveryAGE Counts. In: EveryAGE Counts [website]. Sydney: EveryAGE Counts; 2020

(https://www.everyagecounts.org.au/, accessed 24 September 2020). 24. BrandHealth wins big at Clio Awards with ‘Best Before Date’ campaign. In: MyKawartha.

com [website]. Peterborough (Ontario); Kawartha Media Group; 2014 (https://www. mykawartha.com/news-story/4877390-brandhealth-wins-big-at-clio-awards-with- best-before-date-campaign/, accessed 20 March 2020).

25. Not Too Young to Run: promoting the rights of young people running for public office and leadership positions. Geneva: Human Rights Council; 2016 (https://www.ohchr. org/Documents/Issues/Democracy/Forum2016/OSGEY_IPU_UNDP_SideEvent.pdf, accessed 16 September 2020).

26. Launching global campaign promoting right of young people to run for public office: Not Too Young to Run. In: Office of the Secretary-General’s Envoy on Youth [website]. New York: United Nations Office of the Secretary General’s Envoy on Youth; 2020 (https:// www.un.org/youthenvoy/2016/11/launching-global-campaign-promoting-rights- young-people-run-public-office/, accessed 16 September 2020).

27. Schar E, Gutierrez K, Murphy-Hoefer R, Nelson DE. Tobacco use prevention media campaigns: lessons learned from youth in nine countries. Atlanta (GA): US Department of Health and Human Services, Centers for Disease Control and Prevention; 2006 (https:// stacks.cdc.gov/view/cdc/11400, accessed 24 March 2020).

28. Busso DS, Volmert A, Kendall-Taylor N. Reframing aging: effect of a short-term framing intervention on implicit measures of age bias. J Gerontol B Psychol Sci Soc Sci. 2019;74:559–64. https://doi.org/10.1093/geronb/gby080.

29. Cho H, Boster FJ. Effects of gain versus loss frame antidrug ads on adolescents. J Commun. 2008;58:428–46. https://doi.org/10.1111/j.1460-2466.2008.00393.x.

1 5 0

GLOBAL REPORT ON AGEISM

30. Dardis FE, Baumgartner FR, Boydstun AE, De Boef S, Shen FY. Media framing of capital punishment and its impact on individuals’ cognitive responses. Mass Commun Soc. 2008;11:115–40. https://doi.org/10.1080/15205430701580524.

31. Maher CA, Lewis LK, Ferrar K, Marshall S, De Bourdeaudhuij I, Vandelanotte C. Are health behavior change interventions that use online social networks effective? A systematic review. J Med Internet Res. 2014;16:e40. https://doi.org/10.2196/jmir.2952.

32. Naslund JA, Kim SJ, Aschbrenner KA, McCulloch LJ, Brunette MF, Dallery J, et al. Systematic review of social media interventions for smoking cessation. Addict Behav. 2017;73:81–93. https://doi.org/10.1016/j.addbeh.2017.05.002.

33. Bou-Karroum L, El-Jardali F, Hemadi N, Faraj Y, Ojha U, Shahrour M, et al. Using media to impact health policy-making: an integrative systematic review. Implement Sci. 2017;12:52. https://doi.org/10.1186/s13012-017-0581-0.

34. Cantera CM, Puigdomenech E, Ballve JL, Arias OL, Clemente L, Casas R, et al. Effectiveness of multicomponent interventions in primary healthcare settings to promote continuous smoking cessation in adults: a systematic review. BMJ Open. 2015;5:e008807.

https://doi.org/10.1136/bmjopen-2015-008807. 35. Gittelsohn J, Novotny R, Trude ACB, Butel J, Mikkelsen BE. Challenges and lessons

learned from multi-level multi-component interventions to prevent and reduce childhood obesity. Int J Environ Res Public Health. 2019;16:30.

https://doi.org/10.3390/ijerph16010030. 36. Russ LB, Webster CA, Beets MW, Phillips DS. Systematic review and meta-analysis of

multi-component interventions through schools to increase physical activity. J Phys Act Health. 2015;12:1436–46. https://doi.org/10.1123/jpah.2014-0244.

37. Weiner BJ, Lewis MA, Clauser SB, Stitzenberg KB. In search of synergy: strategies for combining interventions at multiple levels. J National Cancer Inst Monogr. 2012;2012:34– 41. https://doi.org/10.1093/jncimonographs/lgs001.

38. Cooke-Jackson A. Multicultural campaigns. In: Thompson TL, editor. Encyclopedia of health communication. Thousand Oaks (CA): Sage; 2014:898–900.

39. Kreuter MW, McClure SM. The role of culture in health communication. Annu Rev Public Health. 2004;25:439–55. https://doi.org/10.1146/annurev. publhealth.25.101802.123000.

40. Kreuter MW, Lukwago SN, Bucholtz RD, Clark EM, Sanders-Thompson V. Achieving cultural appropriateness in health promotion programs: targeted and tailored approaches. Health Educ Behav. 2003;30:133–46. https://doi.org/10.1177/1090198102251021.

41. Tan NQP, Cho H. Cultural appropriateness in health communication: a review and a revised framework. J Health Commun. 2019;24:492–502.

https://doi.org/10.1080/10810730.2019.1620382. 42. Bossio D, Exon J, Schleser M, McCosker A, Davis H. The OPERA Project: community

co-design of digital interventions for primary prevention of ageism and elder abuse. Melbourne (Australia): Swinburne University of Technology; 2019 (https://apo.org.au/ sites/default/files/resource-files/2019-12/apo-nid270896.pdf, accessed 24 September 2020).

43. Harada K, Sugisawa H, Sugihara Y, Yanagisawa S, Shimmei M. Perceived age discrimination and job satisfaction among older employed men in japan. Int J Aging Hum Dev. 2019;89:294–310. https://doi.org/10.1177/0091415018811100.

1 5 1

CHAPTER 09

44. Tan SC, Barber SJ. Confucian values as a buffer against age-based stereotype threat for Chinese older adults. J Gerontol B Psychol Sci Soc Sci. 2020;75:504–12.

https://doi.org/10.1093/geronb/gby049. 45. Hausdorff JM, Levy BR, Wei JY. The power of ageism on physical function of older

persons: reversibility of age-related gait changes. J Am Geriatr Soc. 1999;47:1346–9. https://doi.org/10.1111/j.1532-5415.1999.tb07437.x.

46. Levy BR, Pilver C, Chung PH, Slade MD. Subliminal strengthening: improving older individuals’ physical function over time with an implicit-age-stereotype intervention. Psychol Sci. 2014;25:2127–35. https://doi.org/10.1177/0956797614551970.

47. Hess TM, Hinson JT, Statham JA. Explicit and implicit stereotype activation effects on memory: do age and awareness moderate the impact of priming? Psychol Aging. 2004;19:495–505. https://doi.org/10.1037/0882-7974.19.3.495.

48. Levy B. Improving memory in old age through implicit self-stereotyping. J Personal Soc Psychol. 1996;71:1092–107. https://doi.org/10.1037/0022-3514.71.6.1092.

49. Levy BR, Hausdorff JM, Hencke R, Wei JY. Reducing cardiovascular stress with positive self-stereotypes of aging. J Gerontol B Psychol Sci Soc Sci. 2000;55:P205–13.

https://doi.org/10.1093/geronb/55.4.p205.

1 5 2

GLOBAL REPORT ON AGEISM

SISAY, 65 , ETHIOPIA

BERKEHAN, 21 , TURKEY

CHAPTER 01

C H A P T E R 1 0

We need to act now as youth and call the world to action for the future we are dreaming of, and capable of creating.

Berkehan, 21 , Turkey ©Berkehan Erkılıç / UN Major Group for Children and Youth

The world should prohibit and discard all negative stereotypes and end the discrimination of older people. Once this is done, the world would be surprised of the things older men and women can contribute. A world without ageism would make ever y generation […] positive in their outlook on life.

Sisay, 65 , Ethiopia ©Erna Mentesnot Hintz / HelpAge International

10

1 5 3

“ “

“ “

1 5 4

GLOBAL REPORT ON AGEISM

To prevent and respond to ageism, priority should be given to the three strategies supported by the best evidence: policy and law, educational interventions and intergenerational contact interventions (Recommendation 1).

It is equally important for countries to improve data and research to gain a better understanding of ageism and how to reduce it (Recommendation 2).

Every stakeholder has a role to play in addressing ageism and should be part of the movement to change the narrative around age and ageing (Recommendation 3).

These recommendations should be implemented together where possible to maximize their impact.

GLOBAL REPORT ON AGEISM

10 Chapter

1 5 4

The Global report on ageism has assembled the best scientific information about ageism to understand and help improve the lives of people of all ages. Building on the evidence in the preceding chapters, this chapter presents three recommendations to assist stakeholders in taking action to prevent and eliminate ageism across the world. These recommendations fall under the umbrella of the Global campaign to combat ageism that the United Nations is championing as part of the Decade of Healthy Ageing: 2021-2030.

Implementing these recommendations requires strong commitment and the involvement of different sectors (e.g. health and social care, education, work and employment, legal and media) and actors (e.g. governments, civil society organizations, UN agencies, development organizations, academic and research institutions, businesses and people of all ages). Each recommendation identifies key actions for these different stakeholder groups.

It is essential that countries tailor these recommendations to their specific contexts. Where possible, a multipronged approach that includes all key recommendations should be favoured, as it is through concerted and comprehensive action that transformative change is most likely to occur.

10.1 Recommendation 1: invest in evidence-based strategies to prevent and respond to ageism

Governments, civil society organizations, UN agencies, development organizations and other stakeholders

1 5 5

CHAPTER 10

should draw upon the evidence-based solutions presented in this report to effectively tackle ageism.

First, countries should implement policies and laws with adequate legal and material scope to prohibit age discrimination and to foster the equal rights of all persons regardless of their age. It is equally important that countries modify or repeal existing laws or policies that permit age discrimination and that they put in place enforcement mechanisms and monitoring bodies to ensure effective implementation.

International policy and legislative guarantees against age discrimination could also be increased. In international law, there is currently no specific legal instrument to protect the human rights of adults and to dispel prejudice and discrimination against people on the basis of their age, and most international human rights instruments do not explicitly list age as a prohibited ground of discrimination.

Second, national governments and other actors should design and deliver formal and non-formal educational activities because these are among the most effective strategies to tackle ageism and are also likely to be affordable. Educational activities can help to dispel misconceptions about different age groups and reduce prejudice and discrimination by transmitting information or enhancing empathy towards people of other ages through perspective-taking, for instance, by using role-playing, simulation and virtual reality to reduce ageism. These types of interventions can be implemented across all levels of education, from kindergarten to university and life-long learning platforms.

Third, investments should be made in intergenerational contact interventions, which aim to foster interaction and contact between people of different generations.

Under optimal conditions, contact between different age groups can reduce intergroup prejudice and stereotypes, and the effects may generalize beyond the immediate participants in the intervention to the entire out-group. Intergenerational contact interventions are among the most effective interventions to reduce ageism against older people, and they show promise for reducing ageism against younger people. In addition, they appear to be affordable and relatively easy to implement.

10.1.1 Specific actions by stakeholder group

Below is an overview of the specific actions that can be taken by different groups of stakeholders to implement evidence-based strategies to reduce or prevent ageism.

Governments can:

• build human and institutional capacities to develop and implement evidence-based strategies to tackle ageism;

• draft and implement laws and policies that prohibit discrimination on the grounds of age, and modify or repeal any existing laws or policies that directly or indirectly discriminate against people on the basis of their age; these actions should be taken in consultation with older and younger people;

• put in place enforcement mechanisms and monitoring bodies to enable the effective implementation of laws and policies addressing discrimination, human rights and inequality;

• ratify existing regional treaties that protect the rights of older or younger adults;

1 5 6

GLOBAL REPORT ON AGEISM

• support the development of further protections through international law and ratify any new instruments that may be developed;

• implement educational activities across formal and non-formal education sectors to tackle ageism aimed at different age groups;

• provide resources for the implementation of intergenerational contact interventions.

United Nations agencies and development organizations can:

• support countries in their implementation of evidence-based strategies to tackle ageism;

• contribute to the development of the Global campaign to combat ageism;

• build understanding within the UN system of ageism and the capacity to identify and address it using evidence-based strategies;

• identify and revise existing ageist policies and practices;

• fund civil society organizations working to address ageism in low- and middle-income countries.

Civil society organizations can:

• advocate for the development of laws addressing discrimination and inequality and their enforcement, and also help monitor the application of these laws;

• build the capacity of older and younger adults to advocate for and monitor the implementation

of laws addressing discrimination and inequality, and strengthen their participation in these activities;

• design and deliver evidence-based educational programmes and intergenerational activities to tackle ageism against different age groups and incorporate these activities into existing programmes, if possible;

• seek and establish collaboration between older people’s organizations and youth organizations to encourage intergenerational activities and collaborations.

Academic and research institutions can:

• design and deliver evidence- based educational programmes and intergenerational activities to tackle ageism against different age groups;

• work with governments and civil society to identify the essential characteristics of the three evidence- based interventions that work to tackle ageism – making changes in policies and law and intervening through educational activities and intergenerational contact.

The private sector can:

• develop and implement policies and interventions in businesses to prevent and respond to instances of ageism (e.g. by developing intergenerational mentorship programmes);

• build the capacity of employees and employers to detect and respond to ageism;

1 5 7

CHAPTER 10

• monitor the production of movies, television series, advertisements, magazine and newspaper articles, books and other forms of media to ensure that they are not ageist.

10.2 Recommendation 2: improve data and research to gain a better understanding of ageism and how to reduce it Successfully addressing ageism will require improving our understanding of all aspects of it and how to reduce it. More and better quantitative and qualitative data should be collected, particularly in low- and middle-income countries, about the prevalence and distribution of all forms of ageism against older and younger people – that is, institutional, interpersonal and self-directed. It is equally important to obtain better estimates of the prevalence of ageism in specific institutions, such as health and long-term care, the workplace, the media and legal systems. These data should be collected using measurement scales for ageism that are reliable, valid, cross-culturally valid and comparable. WHO is initiating, in collaboration with other partners, the development of such a scale to measure ageism.

Measures, methodologies and data tools that are being used for policy and programme development and evaluation need to be

revised to reflect the latest scientific evidence in order to identify outdated concepts and biased approaches (e.g. the use of the dependency ratio).

A better understanding of the impacts of ageism against older and younger people and the costs of ageism – for individuals across their life course and for the wider society – is critical to persuade policy- makers and the public of the far-reaching impacts of ageism and to mobilize them to tackle it. Our lack of understanding of the impact of ageism against younger people is a gap that must be addressed. It is only by gaining a better understanding of the impacts of ageism against younger people across their life course that we will be able to establish how serious a problem it is and what priority it deserves.

Successfully addressing ageism will also require gaining a better understanding of the determinants of ageism against older and younger people, both risk and protective factors, their relative importance, their causal status and whether determinants are the same across countries and cultures.

Most importantly, successfully addressing ageism will require undertaking sustained and coordinated research efforts to refine existing effective strategies, including policy and law, educational and intergenerational contact interventions. It will also require further research into promising strategies (e.g. campaigns), improved estimates of the cost–effectiveness of each possible strategy and then the scale up of those strategies that have been shown to be both effective and cost-effective.

Implementation research will also be required to help identify the essential components of effective strategies; develop and test new strategies in multicentre and multi-country trials; adapt existing

1 5 8

GLOBAL REPORT ON AGEISM

strategies to new contexts; and explore the barriers to and facilitators of sustained, large-scale implementation of strategies to reduce ageism.

To help with these tasks, it will also be important for countries to carry out readiness and capacity assessments to pinpoint those areas that need to be strengthened to be able to successfully scale up strategies to reduce ageism; assessments will be needed of, for instance, human and institutional resources, funding, political will and support and coordination and governance.

Low- and middle-income countries must be a top-most priority across all areas of data collection and research, since the majority of data and research on all aspects of ageism comes from high-income countries where a minority of the world’s population lives. These countries are also a priority because the highest prevalence of ageism, at least against older people, was seen in low- and lower-middle- income countries.

10.2.1 Specific actions by stakeholder group

Below is an overview of some of the specific actions that can be taken by different groups of stakeholders to improve the data and research about ageism.

Governments can:

• allocate resources to those aspects of ageism-related research judged to be a priority in the country and channel those resources through relevant national science-funding bodies and foundations;

• modify any national or local data collection approaches that may be age-biased;

• support testing of the measurement scale for ageism that WHO is developing with other partners;

• include modules on ageism against younger and older people in national social surveys and in national data collection exercises addressing ageing and health and other relevant topics, drawing on a validated scale for ageism, such as the one that is being developed by WHO and other collaborators.

United Nations agencies and development organizations can:

• include modules about ageism against younger and older people in international surveys that they help conduct, such as the Demographic and Health Survey;

• increase capacities for research and data collection, and fund researchers working on ageism, particularly in low- and middle- income countries;

• review statistical concepts, data collection instruments and methodological approaches used in policy development and assessment in order to identify and revise any that may be age-biased;

• support the collection and dissemination of age-disaggregated information about older and younger people;

• develop with WHO a valid measurement scale for ageism and encourage governments and research institutions to use it in stand-alone studies or ensure it is integrated into other data collection efforts.

1 5 9

CHAPTER 10

Civil society organizations can:

• contribute to the evaluation and monitoring of strategies to reduce ageism and collaborate with researchers to support applied research on ageism;

• advocate for governments to revise age-biased data collection instruments and methodological approaches, to continue to build a strong evidence base about ageism and to use validated scales for ageism, such as the one that is being developed by WHO and collaborators;

• produce evidence, in collaboration with research institutions, of the lived experience of ageism from the perspectives of older and younger people and of the impact it has on their lives.

Academic and research institutions can:

• conduct high-quality research to address the gaps in data and research identified in this report and to develop and scale up effective and cost - effective strategies to reduce ageism, in consultation with people in the relevant age groups;

• support testing of the measurement scale for ageism that WHO is developing with other collaborators and encourage its uptake across research activities on ageism.

The private sector can:

• conduct comprehensive and rigorous evaluations of ageism in the workplace;

• financially support research on ageism through relevant national science-funding bodies and foundations.

10.3 Recommendation 3: build a movement to change the narrative around age and ageing

Ageism is endemic and will continue to spread unless appropriate action is taken, both to prevent ageism and to respond to it. We all have a role to play. Countries (at all levels and across all institutions), international organizations (including UN agencies, nongovernmental organizations, multinational corporations), national organizations, communities and individuals can all join the movement to change the narrative around age and ageing.

A number of international agencies, regional institutions and UN bodies are either already working to address ageism or have mandates or activities highly relevant to reducing ageism, including those dealing with human rights, international law, economic matters and sustainable development. International nongovernmental organizations and the private sector can help raise awareness locally and globally as anti-ageist citizens, employers and corporate entities and act to reduce ageism within their own structures. Although there have been joint efforts, coordination across all these agencies and stakeholder groups is still insufficient. This should be remedied to avoid unnecessary duplication and to

1 6 0

GLOBAL REPORT ON AGEISM

benefit from the economies of pooling expertise, networks, funding and in-country resources and to take collective action to reduce ageism within these institutions.

Developing a global coalition to drive this movement and help change the narrative around age and ageing should be explored to improve cooperation and communication between different stakeholder groups working in this area. A coalition could achieve better sharing of knowledge, agreement on goals to prevent and respond to ageism, and coordination of action. For example, a network of researchers and practitioners could greatly enhance the world’s knowledge base as well as help refine the intervention strategies, discuss methodologies and critically examine research results.

A broader exchange of information and ideas is crucial to future progress, alongside the work of government authorities, service providers and advocacy groups. Advocacy groups working on changing the narrative around age and ageing as well as those working on sexism, racism and ableism are important partners in combating ageism because they can mobilize resources, gather and convey information about important problems and mount campaigns that can impact decision-makers.

Therefore, much could be gained by developing a coalition that can facilitate the implementation of evidence-based strategies, the exchange of information, the development of joint research and advocacy work.

10.3.1 Specific actions by stakeholder group

Below is an overview of some of the specific actions that can be taken by different groups of stakeholders to build a movement to change the narrative around age and ageism.

Governments can:

• convene and coordinate national and local multisectoral and multi- stakeholder coalitions to prevent and respond to ageism;

• contribute to the global coalition aiming to change the narrative around age and ageing, including by sharing knowledge and experience.

United Nations agencies and development organizations can:

• develop and contribute to the global coalition aiming to combat ageism, particularly by bringing the organization’s expertise to the coalition (e.g. the International Labour Organization could support policies and legislation in the workplace);

• support governments and civil society organizations seeking to build capacity to implement evidence-based strategies;

• develop technical guidance to help different stakeholders change the narrative around age and ageing;

• take steps to end ageism within the UN and within developmental organizations, including by reviewing existing policies and practices and developing new norms and standards as required.

Civil society organizations can:

• advocate to encourage governments to combat ageism, and also develop national coalitions to support advocacy efforts;

1 6 1

CHAPTER 10

• identify systematic ageism and report it to the relevant authorities (e.g. equality bodies, ombudsperson, national human rights institutions);

• join and contribute to the global coalition and support the implementation of actions recommended by the coalition;

• raise awareness of and build understanding in communities about what ageism is and why we should all work to challenge it.

Academic and research institutions can:

• contribute knowledge and information to the global coalition;

• help monitor and evaluate programmes and activities aimed at tackling ageism.

The private sector can:

• contribute to the global coalition by implementing evidence-based interventions in businesses and sharing information about best practices.

10.4 Conclusions

It has taken more than 50 years since the word ageism was coined to build an evidence base that will allow transformative change in how we all think, feel and act towards age and ageing.

Today we can act. This report has identified three key strategies to tackle ageism across the world: making changes in policies and laws and intervening through educational activities and intergenerational contact. It has further outlined areas for research that should be pursued to advance our understanding of this phenomenon and how best to tackle it.

Everybody can and must do something to put an end to ageism. If governments, UN agencies, development organizations, civil society organizations and academic and research institutions implement those strategies that have been found to be effective, if they invest in further research and if individuals and communities challenge every instance of ageism that they encounter, we will together create a world for all ages.

1 6 2

GLOBAL REPORT ON AGEISM

1 6 3

Ableism refers to the stereotypes, prejudice and discrimination directed towards individuals with disabilities or those who are perceived to have a disability. Ableism assumes that people with a disability are defined by their disabilities and are inferior to individuals who do not have a disability.

Age is the time lived since birth. Although correlated with biological processes, age is also socially and culturally shaped.

Ageing is the process of becoming older and represents the accumulation of changes over time, encompassing physical, psychological and social changes. The changes that constitute and influence ageing are complex. At a biological level, ageing is associated with the gradual accumulation of a wide variety of molecular and cellular damage. Over time, this damage leads to a gradual decrease in physiological reserves, an increased risk of many diseases and a general decline in the capacity of the individual. Ultimately, it will result in death.

Ageism refers to the stereotypes, prejudice and discrimination directed towards others or oneself based on age.

Attitudes include both stereotypes and prejudice.

Campaign refers to purposive attempts to inform or influence behaviours in large audiences within a specified period by using an organized set of communication activities and featuring an array of mediated messages delivered through multiple channels to produce non-commercial benefits to individuals and society.

Care dependence arises when an individual’s functional ability has fallen to a point where they are no longer able to undertake the basic tasks that are necessary for daily life without the assistance of others.

Denormalization refers to increasing the social unacceptability of a behaviour by reinforcing the perception that it is neither a mainstream nor a normal activity in the society in question.

Determinants refer to both risk and protective factors. Risk factors are characteristics that increase the likelihood of a particular outcome, ageism in the case of this report. Protective factors are characteristics that decrease the likelihood of an outcome or provide a buffer against risk. To be effective, interventions must target causal determinants that change the outcome – that is, reduce ageism – and not just determinants that are associated – perhaps spuriously – with the outcome.

Discrimination consists of any actions, practices, laws or policies that are applied to people based on their perceived or real membership in a socially salient group and that impose some form of direct or indirect disadvantage (negative discrimination) or advantage (positive discrimination) on them. In the case of age-based discrimination, these actions, practices and policies are directed at people perceived to belong to a specific age group.

GLOSSARY

1 6 4

GLOBAL REPORT ON AGEISM

Educational activities or programmes refer to any activities that provide instruction with the intention of improving knowledge, skills and competencies. Formal education refers to education or learning that takes place in a formal institution of learning, such as a school or university; follows a syllabus; has clear learning objectives; and is officially accredited. Non-formal education or learning is usually intentional and takes place in an institution such as a workplace or community centre. However, it does not necessarily follow a syllabus, nor is it necessarily accredited.

Effect size is a quantitative measure of the strength of a relationship between two variables that uses a standard metric. It is particularly useful for quantifying how effective one intervention is in relation to another.

Elder abuse is a single or repeated act or a lack of appropriate action occurring within any relationship in which there is an expectation of trust, that causes harm or distress to an older person. Elder abuse can take various forms, such as financial, physical, psychological and sexual. It can also be the result of neglect.

Elderspeak refers to the adjustments to speech patterns that are sometimes made by younger people when communicating with older adults, such as speaking more slowly or more loudly, shortening sentences or using limited or less complex vocabulary. These simplified speech patterns are implicitly based on the assumption that older adults are cognitively impaired or incapable of understanding normal speech.

Empathy refers to the ability to sense other people’s emotions, coupled with the ability to imagine what someone else might be thinking or feeling.

Explicit ageism refers to ageism that is consciously and intentionally engaged in by a person. It is often contrasted with implicit ageism, which operates largely outside of conscious awareness.

Framing refers to how information on a given issue is packaged and presented. Through framing, issues can be highlighted and placed within a particular context to encourage or discourage certain interpretations. Framing thus exercises a selective influence over how people view reality.

Gendered ageism refers to the intersection between ageism and gender bias and may account for differences in the ageism faced by women and men.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Human rights are the rights people are entitled to simply because they are human beings, irrespective of their age, citizenship, nationality, race, ethnicity, language, gender, sexuality or abilities. When these inherent rights are respected, people are able to live with dignity and equality, free from discrimination. The concept of human rights has its origins in a wide range of philosophical, moral, religious and political traditions, and it has evolved over time.

1 6 5

Impact refers to the consequence, effect or influence of one thing on another.

Implicit ageism is ageism that is engaged in by a person without conscious awareness and intention.

Institutional ageism refers to the laws, rules, norms, policies and practices of institutions – and the ideologies that are fostered to justify them – that unfairly restrict opportunities and systematically disadvantage individuals based on their age.

Intergenerational contact activities and interventions aim to foster interaction and contact between people of different generations or age groups, often to reduce ageism. They can either involve direct contact through face-to-face interactions or indirect contact through, for instance, virtual conversations or imagined contact.

Interpersonal ageism refers to ageism occurring during interactions between two or more individuals. In interpersonal ageism, the perpetrator is distinguished from the target of ageism.

Intersectionality is a theoretical framework for understanding how different aspects of a person’s social and political identities combine (e.g. gender, sex, race, class, sexuality, religion, disability, physical appearance) and may potentiate each other to shape an individual’s or group’s experience and create unique modes of discrimination and privilege.

Law is the system of rules that a particular country or community recognizes as regulating the actions of its members and that may be enforced by imposing penalties. It includes international law and national law. International law defines the legal responsibilities of states in their conduct with each other and their treatment of individuals within state boundaries. National law or domestic law refers to those laws that exist within a particular country.

Older person is a person whose age has passed the median life expectancy at birth. In this report, persons above the age of 50 are considered older persons.

Policies refer to decisions, plans and actions that are undertaken to achieve specific goals within a society.

Prejudice is an affective reaction or feeling that is directed towards an individual who belongs to a specific social group. In the case of ageism, prejudice is directed towards individuals perceived to belong to a specific age group, regardless of whether they actually belong to that group.

Protective factors are characteristics that decrease the likelihood of an outcome (ageism in this report) or provide a buffer against risk.

Racism refers to the stereotypes, prejudice or discrimination directed against people based on their race, and it usually involves the belief that one’s own race is superior to other races. There is now wide agreement that the concept of race is primarily a social construct without biological meaning, and it is only a very weak proxy for human genetic diversity.

1 6 6

GLOBAL REPORT ON AGEISM

Ratification defines the international act whereby a state indicates its consent to be bound to a treaty or convention.

Risk factors are characteristics that increase the likelihood of an outcome (ageism in this report).

Self-directed ageism refers to ageism turned against oneself. People internalize biases based on age from the surrounding culture after being repeatedly exposed to them, and they then apply the biases to themselves.

Sexism is prejudice, stereotyping or discrimination, typically against women and girls, on the basis of sex or gender.

Sexuality is a central aspect of being human, which encompasses sex, gender identities and roles, sexual orientation, eroticism, sexual pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.

Social care refers to assistance with the activities of daily living, such as personal care or maintaining a home.

Social norms are rules or expectations of behaviour that apply within a specific social or cultural group. Often unspoken, these norms offer social standards of appropriate and inappropriate behaviour, governing what is (and is not) acceptable and coordinating our interactions with others. A variety of external and internal pressures are thought to maintain cultural and social norms. Thus, individuals are discouraged from violating norms by the threat of social disapproval or punishment and the feelings of guilt and shame that result from the internalization of norms.

Standardized mean difference is used as a summary statistic in meta-analyses when the studies all assess the same outcome but measure it in different ways (e.g. if all of the studies measure depression, but they use different scales to measure it). In such a case, it is necessary to standardize the results of the studies to a uniform scale before they can be combined. The standardized mean difference expresses the size of the intervention effect in each study relative to the variability observed in that study.

Stereotype threat arises when people underperform on a task due to concerns about confirming a negative stereotype about their group. For instance, an older person may do less well on a driving test or cognitive test due to anxiety about confirming stereotypes about older people being bad drivers or mentally less capable.

Stereotypes are cognitive structures that store our thoughts, beliefs and expectations about the characteristics of members of social groups. In the case of ageism, age stereotypes are used to make inferences about, and guide behaviour towards, people of a given age group.

1 6 7

Stereotyping is the process of applying stereotypes, which can lead to overgeneralizations that consider every person within a given social group to be the same.

Younger person is a person who is younger than the median life expectancy at birth. In this report, people younger than the age of 50 are considered to be younger people.

Youth is a period of transition from childhood to adulthood. For statistical purposes, youth is often considered to encompass people between the ages of 15 and 24, although there is little consensus on the exact age range.

Well-being refers to the total universe of human life domains, including the physical, mental and social aspects, that make up what can be called a “good life”. It includes domains such as happiness, satisfaction and fulfilment.

1 6 8

GLOBAL REPORT ON AGEISM

1 6 9

INDEX A Ableism 10 Abuse 54 Academic institutions, actions 156, 159, 161 Aconchego programme 132 Adult education 30 Adultism xix Adverse drug events 51 Advertisements 27, 28 African Court on Human and People’s Rights 97 African Union Protocol 99–100 African Youth Charter 98 Age, determinant of ageism 67, 71, 86–87 Ageism definition 2–8 measurement scales 31 other “-isms” and 9–12 terminology xix theories 69–70 Aging Game 120 Anti-ageing industry 11 Anti-discrimination laws 96, 99 Anxiety about ageing 67 Attitudes 31–34, 84 Australia campaigns 142–144 educational intervention 117 long-term care 23–24 poverty 55 workplace ageism 56, 83

B Beauty industry 11 Belgium, workplace ageism 27 Best Before Date campaign 144 Botswana, HIV 51 Brazil impact of ageism 84 perception of ageism 36 Build a movement to reduce ageism xviii, 159–161 Burkina Faso, witchcraft 36 Butler, Robert xix

C Campaigns 140–145, 146–147 Canada campaigns 144 housing 84 long-term care 23 racism and ageism 11 Care dependence 71, 88 Childism xix Children, development of ageism 9 China loneliness 53 media portrayal of older people 28 mortality 49 sexually transmitted diseases 51 China, Hong Kong Special Administrative Region intergenerational contact intervention 130, 131 media portrayal of older people 27–28 Civil society organizations 102, 156, 159, 160–161 Cleansing rituals 36 Clinical trials 23, 51 Cognitive dissonance 95 Cognitive function 51–52, 86 Community engagement 145 Conflict-related emergencies 29 Contact with older people see Intergenerational contact interventions Context, interpersonal ageism 71–72, 88 Convention on the Elimination of All Forms of Discrimination Against Women 97 Convention on the Rights of Persons with Disabilities 97 Costs see Economic costs Country-related variations in ageism 32–34, 71–72 Court proceedings 28 COVID-19 pandemic 24–26 Credit schemes 29 Crime fear of 54

1 7 0

GLOBAL REPORT ON AGEISM

victims of 83 Cross-cultural differences 32–34 Culturally appropriate campaigns 145

D Data collection xvii–xviii, 30, 157–159 Decade of Healthy Ageing: 2021–2030 xx Definition of ageism 2–8 Democracies 102 Denormalizing behaviour 144 Dependency ratio 30 Depression 51 Determinants of ageism xvi, 65–79, 86–88 Deterrence theory 95 Development organizations, actions 156, 158, 160 Direct intergenerational contact 126–127 Disability 10, 49 Discrimination 3, 5, 8–9 Domestic law 95

E Economic costs ageism against older people 54–56 campaigns 145, 147 educational interventions 120 intergenerational contact interventions 134 laws and policies 102, 104 Education as a determinant of ageism 67 institutional ageism against older people 30 interventions to reduce ageism xvii, 113–123, 128, 129–130, 155 Egypt, ageism in politics 83 Elderspeak 7 Empathy-enhancement 115 Employment see Workplace Enforcement of laws and policies 101 European Convention on Human Rights 97 European Union, employment equality framework directive 99 EveryAGE Counts 142–144 Evidence-based strategy implementation xvii, 154–157 Experience of ageism 34–36, 84 Expectations Regarding Aging scale 31 Experimental studies, presentation of older

people 72 Explicit ageism 8 Extended indirect contact 127

F Facebook 27 Facts on Ageing Quiz 71 Family identity 134 Fear of death 67, 69 Film dialogue 28 Financial abuse 54 Financial insecurity 55 Financial institutions 29 Finland loneliness 53 workplace ageism 52 Framing 144 Friendships 70, 87, 127, 133–134

G Gender, determinant of ageism 67, 86 Gendered ageism 11, 28, 29, 36, 53, 88 Germany cognitive decline 51 self-perception of ageing 37 television characters 27 Ghana, witchcraft 36 Government actions 155–156, 158, 160 Grading of Recommendations Assessment, Development, and Evaluation (GRADE) 119 Grandchildren and grandparents 70, 73, 127, 133–134 Group discussion 118–119

H Health care 4, 11, 22–26, 56 Health-care workers 22, 23, 24, 49, 67, 130 Health impact of ageism 48–54, 56 Health status 71, 72, 88 Healthy life expectancy 71–72 HelpAge International 142 Heterosexism 11–12 Higher education 30 HIV 51 Hollywood films 28 Home-sharing 132 Homophobia 12

1 7 1

Housing ageism in 29, 84 home-sharing 132 Human rights legislation 97 Humanitarian programmes 29

I Iberoamerican Convention on Rights of Youth 98 Imagined indirect contact 127, 132 Impact of ageism xvi, 47–63, 84–86 Implicit ageism 8 Implicit bias 95 Implicit stereotypes 146 Indirect intergenerational contact 127 Individual characteristics perpetrators of ageism 67–71, 86–87 targets of ageism 71, 88 Information provision 88, 115, 118 Institutional ageism 5–6, 8, 22–30, 82–84, 88 Insurance premiums 29 Interactive campaigns 144–145 Inter-American Convention on Protecting the Human Rights of Older Persons 100 Inter-American Court of Human Rights 97 Intergenerational contact interventions xvii, 70, 125–137, 155 Intergroup contact theory 69, 127 Intergroup threat theory 69 International Convention on the Elimination of All Forms of Racial Discrimination 97 International law 94–95 Interpersonal ageism 6–7, 8, 31–36, 67–72, 84, 86–88 Iran, educational intervention 116 Israel legal system 28 long-term care 23

J Japan housing 29 mitigating the impact of ageism 145–146 television advertisements 28

K Knowledge about ageing 71, 73, 128

Korea, media portrayal of older people 28

L Language xix, xx Laws xvii, 93–111, 155 Legal system, ageism in 28, 83 Life-story documentaries 116–117 Lifelong learning 30 Literature 34 Loan schemes 29 Loneliness 52–53, 128 Long-term care 23–24, 54

M Mauritius, Equal Opportunities Act (2012) 101 Measures of ageism 31 Media 4, 25, 27–28, 52 Medication use 51 Mental health 23, 51–52, 53, 72, 84 Mitigating impact of ageism 145–146, 147 Monitoring of laws and policies 101 Mortality 49, 53

N Narrative change 159–161 National law 95 Natural disasters 29 Nature of ageism xv, 1–19 Neglect 54 Nigeria films 28 politics 143 Not Too Young to Run campaign 143

O Occupational sectors 72, 88 Older people, ageism against conflict-related emergencies 29 in data collection 30 determinants xvi, 65–79 economic impact 54–56 education 30 financial institutions 29 health and social care 11, 22–26, 56 health impact 48–54 housing 29 impact of xvi, 47–63

1 7 2

GLOBAL REPORT ON AGEISM

institutional ageism 22–30 interpersonal ageism 31–36, 67–72 legal system 28 media 25, 27–28, 52 natural disasters 29 scale of xvi, 21–45 self-directed ageism 36–37, 72–73 in statistics 30 technology 29 workplace 11, 26–27 Open-Ended Working Group on Ageing (UN) 103 Organ transplantation 28 Overgeneralizations 3

P Panama, self-directed ageism 36 Parental role 134 Parkinson’s disease 23 Partnership working 145 Pension provision 55, 95 Perception of ageism 34–36 Personality traits 67, 87 Physical abuse 54 Physical appearance 11 Physical health 49–51, 53, 72 Policies xvii, 93–111, 155 Political Declaration and Madrid International Plan of Action on Ageing (MIPAA) 97 Politics 83–84, 143 Polypharmacy 51 Population attributable fraction 50 Portugal, intergenerational contact intervention 132 Positive Education about Ageing and Contact Experiences (PEACE) programme 129–130 Poverty 55 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 50, 74, 119 Prejudice 3, 5, 8–9 Premature mortality 30 Prescribing practice 51 Print media 27–28 Private sector actions 156–157, 159, 161 Professional sectors 72, 88

Psychological abuse 54 Public awareness 102 Public consultation 102 Public health data 30

Q Quality of life 52

R Racism 11, 83 Recommendations for action xvii–xviii, 154–161 Reduction of ageism build a movement xviii, 159–161 campaigns 140–145, 146–147 educational interventions xvii, 113–123, 128, 129–130, 155 intergenerational contact interventions xvii, 70, 125–137, 155 policy and law xvii, 93–111, 155 Research institutions, actions 156, 159, 161 Research opportunities xvii–xviii, xxii, 50, 74, 89, 105, 119, 141, 157–159 Resource availability 102 Retirement 27, 28, 55 Risky health behaviours 49–50 Role-playing 119

S Scale of ageism xvi, 21–45, 82–84 School curriculum-based intervention 117 Self-directed ageism 7, 8, 36–37, 72–73 Self-esteem 85–86, 128 Self-perceptions 37 Self-stereotypes 9 Service learning 130 Sex, determinant of ageism 67, 86 Sexism 10–11, 28, 29, 36, 53 Sexuality 11–12, 53–54 Sexually transmitted diseases 24, 50–51 “Silicon Valley ageism” 72 Singapore, intergenerational contact interventions 128, 130 Skipped-generation households 127 Smoking 50 Social care 4, 22–26 Social isolation 52–53, 128

1 7 3

Social media 25, 27, 144–145 Social norms 95, 102 Social skills training 118–119 Social well-being 52–54, 85–86, 128 Socially-determined age 3 Spain, workplace ageism 26 Stakeholder actions 155–157, 158–159, 160–161 Statistics, ageism in 30 Stereotype embodiment theory 70 Stereotype threat 9, 52, 73 Stereotypes 3–5, 8–9, 146 Subliminal stereotypes 146 Sub-Saharan Africa, widows and witchcraft 11, 36 Sweden, disability policies 10 Switzerland, workplace ageism 27

T Take a Stand Against Ageism 142 Teaching profession 88 Technology 29 Television 27, 28 Terror management theory 67, 69 Theories of ageism 69–70 Time-based variation in ageism 34 Tobacco prevention campaigns 144 Travel insurance 29 Twitter 25, 27

U UN Open-Ended Working Group on Ageing 103 United Kingdom educational intervention 117–118 financial institutions 29 intergenerational contact intervention 132 loneliness 53 United Nations agencies, actions 156, 158, 160 United Republic of Tanzania, witchcraft 36 United States ableism 10 anti-discrimination laws 96 combined educational and intergenerational contact intervention 129–130 educational intervention 116–117

health care costs of ageism 56 health care rationing 22 higher education 30 mitigating impact of ageism 146 racism and ageism 11 television characters 27 workplace ageism 55–56 Uruguay, policy and laws 100–101

V Video games 128, 130 Violence, risk to older people 54 Virtual reality intervention 117–118, 120

W Weibo 25 Well-being 52–54, 85–86, 128 WHO-CHOICE 104 Widows 11, 36 Witchcraft 11, 36 Withholding therapy 22 Witness credibility 28 Women, ageism against 11, 28, 29, 36, 53, 88 Workplace 4, 11, 26–27, 52, 55–56, 82–83, 86, 99 Workshops 116 World Programme of Action for Youth to the Year 2000 and Beyond 98

Y Young–Old Link and Growth Intergenerational Programme 131 Younger people, ageism against 81–91 determinants xvi, 86–88 housing 84 impact of xvi, 84–86 institutional ageism 82–84, 88 intergenerational contact interventions 128, 131 interpersonal ageism 84, 86–88 legal system 83 policy/law-led reduction strategies 98 politics 83–84, 143 scale of xvi, 82–84 workplace 82–83, 86

1 7 5

CHAPTER 01

1 7 6

GLOBAL REPORT ON AGEISM