Expressions of ageism during the pandemic as perceived by older persons

Expressões de idadismo durante a pandemia segundo a percepção de pessoas idosas

Ana Luiza Blanco ana.bllanco@gmail.com

Universidade Estadual de Campinas, Brazil

Samila Sathler Tavares Batistoni

Universidade de São Paulo, Brazil

Daniella Pires Nunes

Universidade Estadual de Campinas, Brazil

The pandemic caused by the novel coronavirus (COVID-19) represents one of the greatest humanitarian crises of the last 100 years, with more than 135 million cases worldwide and unprecedented impacts on public, economic, political, and social health.1 Global evidence pointed out that all individuals were susceptible to the disease; however, the older population has a higher mortality rate when compared to the younger population.2

Age is the variable most associated with the likelihood of death due to COVID-19, and mortality rates in older persons due to the disease have grown exponentially in all countries during this period.2 Parallel to this scenario, it is noted that the pandemic has not only had an impact on the mortality of older persons around the world, but has also exposed stereotypes, prejudices, and discrimination against this population, reinforcing institutionalized ageism, devaluation, stigma, and isolation that already existed before this scenario.3,4,5,6

Ageism is a social phenomenon defined by Robert Butler as any prejudicial attitude related to ageing, prejudice against older persons and discriminatory policies and practices based on age.7

The literature points to several concepts of ageism, and the World Health Organization (WHO) proposed the most comprehensive definition.6,7,8,9,10,11 It conceptualizes ageism as the set of stereotypes, prejudice, and discrimination directed at a person based on age. It can be manifested in an institutional environment, interpersonally, or be self-directed. Ageism also has two forms of expression: implicit or explicit, depending on the individual’s level of awareness of the prejudice.6

Stereotypes are cognitive representations that include beliefs about the physical and mental status, and social skills of a given social group. Most often, stereotypes lead to generalizations that consider people within a certain age group as equal.6,8

In turn, prejudice is an emotional reaction or feeling towards a person considering their age, comprising an affective dimension. Finally, discrimination consists of a behavioral component and involves actions, practices, or policies that are applied to people based on their age.6,8

Due to the implicit nature of ageism, discrimination can be understood in two ways:

1. 1. Objective discrimination, ie, when the individual experiences a discriminatory action; and
2. 2. Perceived discrimination, when an individual experiences discrimination and is aware that they are being discriminated against.9

Studies indicate that perceived discrimination is one of the most reliable sources for assessing ageism, and it is essential to ask the discriminated individual about their lived experiences to obtain a complete picture of perceived age discrimination.9

Perceived discrimination has negative impacts on an individual’s well-being. Perceptions of discrimination have been linked to heightened physiological and psychological stress responses. As a chronic stressor, perceived discrimination can increase over time and eventually affect one’s physical and mental health. Frequent exposure to perceived age discrimination can lead to social withdrawal, reduced cultural engagement, and resistance to making appointments with health personnel.9

The scenario of ageism became even more critical with the COVID-19 pandemic, due to the widespread discourses that disregarded the contributions of older persons to society, strengthening the homogeneous view of them as vulnerable, a negative stereotype of age widely incorporated and disseminated.12

Public and media discourses during the pandemic initially suggested that only older persons would be at risk of being infected with the virus. This framing of vulnerability influenced the perceived risk for COVID-19, which in turn affected health behaviors and the spread of the virus. The vulnerability narrative misrepresented age as a risk indicator, when in fact other factors were more important, such as the severity of preexisting comorbidities.5,13

When analyzing Twitter posts during the pandemic, one study found that 1 in 10 tweets implied that the lives of older people are less valuable, minimizing the pandemic as affecting older people.13 Other scholars pointed out that high mortality rates in this group were “normal,” while the deaths of younger individuals were more unfair.5

According to the literature the most frequent manifestations of ageism during the pandemic included undocumented deaths of older persons, such as the failure of public authorities to report mortality figures of older persons; ageist public discourses, leading to the misrepresentation of COVID-19 as an “old people’s problem;” stricter restrictions on older persons, which exacerbated isolation; devaluation of older persons through social media; and ageism in the decision-making algorithm for the allocation of a scarce number of resources.13,14,15,16

As a crisis can also be seen as an opportunity for change, studies that explore ageism and the perception that older persons had of this phenomenon during the pandemic have the potential to clarify whether older persons are treated less favorably due to their age and generate discussions to improve health care for this population.17

Considering those factors, it can be stated that the pandemic has reinforced the existing long-term institutionalized ageism in society and has affected the well-being of older persons, making it necessary to further study the topic and to conduct specific interventions to support this population during the pandemic, ensuring social support and protection for older persons.

Therefore, the aim of this study was to describe expressions of ageism perceived by older persons during the COVID-19 pandemic.

This is a cross-sectional, exploratory, and descriptive study that used data from a convenience sample of aged people in different regions of Brazil.

For the study design, all the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement were considered.

Snowball Sampling Method was the sampling technique used. To calculate the sample size, the G^*Power 3.1.9.2 software was used, and a significance level of 5%, test power of 80%, and effect size of 0.15 were assumed. Considering a rate of 15% for possible losses, the minimum sample size was 125 participants.

The study eligibility criteria included people aged 60 years or older who used digital devices (smartphones, tablets, computers) and had access to the Internet to answer the form. Illiterate people and individuals residing in long-term care institutions were excluded.

For the elaboration of the study protocol and data collection, an electronic form was created containing the assessment tools of the research variables on the REDCap platform, designed for the elaboration of online surveys and databases. The form was disseminated on social networks (Instagram, Facebook, WhatsApp) and in universities, Open Universities for Older People and academic leagues, from January to June 2022, when the epidemiological control of the pandemic had been established.

Stereotypes were investigated using the free word association technique. This technique consists of leading individuals to express their thoughts, feelings, and memories spontaneously about a given context, thus facilitating an uncensored understanding of the real meaning that something has for the individual.18

The technique works through inductive stimuli, ie, the individual needs to indicate as quickly as possible the first words that come to mind.18 In this study, participants were presented with the following stimulus: “What does it mean to be an aged person to you? Define it in up to five words.” Participants described the words that came to mind from the inductive term “aged person,” as adopted in a previous study on age prejudice.19

Prejudice was assessed using the Anxiety about Aging scale, proposed by Lasher and Faulkender,20 translated and adapted by Vieira21 in Brazil. The scale has four categories:

1. 1. Fear of older persons,
2. 2. Psychological concerns,
3. 3. Physical appearance, and
4. 4. Fear of social loss and autonomy.20,21

Each category contains 5 Likert-type questions, whose answers range from “strongly agree” to “strongly disagree.”

The score ranges from 0 to 60 points and the calculation of the results involves summing the scores of single items to obtain a total score that reflects the level of anxiety about ageing. There is no cut-off score to interpret the scale, only the parameter that higher total scores may indicate higher levels of anxiety about ageing, while lower scores may indicate lower levels of anxiety.20

This instrument was used as a measure for assessing prejudice, as it expresses the feelings people have towards their ageing process. As prejudice involves the emotional realm, that is, the positive or negative feelings directed at a person based on age, the scale manages to capture the emotions and feelings perceived by the participants in relation to age. According to Vieira and Lima,19 the same criterion was used to measure this dimension, showing that individuals who have greater anxiety about aging also express more ageist attitudes and prejudice.21

The Ageism Survey developed by Palmore,22 a widely used instrument in studies exploring the prevalence and impact of ageism, was used to assess discrimination experienced by older persons. In Brazil, the instrument was linguistically adapted by Couto et al.23

The Ageism Survey contains 20 items whose answers are measured on a Likert-type scale: (0) the episode “never occurred,” (1) “occurred once” and (2) “occurred more than once.”19 The total score of the scale ranges from 0 to 40 points, and higher scores indicate more discrimination. For this study, if older persons experienced at least one instance of discriminatory acts, it was considered as yes.22

To assess perceived discrimination during the pandemic, the researchers developed a questionnaire composed of questions with dichotomous answers (yes × no), which included questions related to the following contexts: “Did you feel discriminated against:”

1. 1. When you sought medical or health care;
2. 2. When you had to (go out shopping, go to the pharmacy, etc.);
3. 3. When reading news, videos, and texts on the Internet;
4. 4. By policies, practices, or norms related to the pandemic;
5. 5. By your family, friends, or anyone close.

The Research Ethics Committee approved the study, opinion No. 5.132.862, and all participants completed the Informed Consent Form to participate in the study.

Data analysis was performed using the Stata program, version 17.0. The results were presented as percentages, means, standard deviation, and medians. Data related to stereotypes were organized and categorized using Atlas.Ti. After transcribing the descriptors, a content analysis was conducted, comprising three stages: pre-analysis, material exploration, and inference and interpretation.

The study sample consisted of 134 aged people living in different regions from Brazil. In this population, 84.33% were female, 67.91% were aged between 60 and 69 years old, 52.99% were married, 76.10% had more than 12 years of schooling, 50.39% reported an income less than or equal to 4 minimum wages, 81.82% self-declared as white, and 76.12% lived in Southeastern Brazil.

As for the stereotypes, based on the descriptors the participants provided, a word cloud was generated with the terms found (Figure 1). Subsequently, each word was analyzed and grouped into four main categories of definition of older persons, as follows:

FIGURE 1
Word cloud on the perceptions of aged people about old age (n = 134).

1. 1. Experienced and wise (wisdom, experience, experienced, knowledge, and capable);
2. 2. Dependent, with limitations and frail (limitation, slow, incapable, dependent, debilitated, weak, and frail);
3. 3. Person presenting biopsychosocial changes (wrinkles, abandonment, forgetfulness, dementia, changes in appearance, flaccidity, low immunity, memory, loneliness, retired);
4. 4. Quiet, with free time to enjoy life (free time, tranquility, and rest).

In relation to prejudice, the mean score of the participants on the Aging Anxiety scale was 35.0 points (SD = 5.30; median = 35.5; minimum = 22; maximum = 60). As for discrimination, participants had a mean score of 7.0 points (SD = 6.8; median = 5; minimum = 0; maximum = 40).

Most participants (93.50%) reported having experienced some type of discrimination, according to the Ageism Survey items. The most prevalent discriminatory acts were “telling jokes about older persons” (72.39%), in addition to experiencing discrimination in care settings by health personnel, such as “associating pain with age” (50.00%), “being treated patronizingly” (49.25%), “assuming deafness” (24.63%), and “assuming inability to understand due to age” (23.88%), as shown in Table 1.

TABLE 1
Distribution (%) of aged people according to type of discrimination (n = 134).

The type of discrimination most experienced during the context of the COVID-19 pandemic showed a higher frequency of institutional discrimination, such as policies, practices, or norms related to the pandemic (38.06%), and when reading and watching the news in newspapers, the Internet, and television (35.07%), as shown in Table 2.

TABLE 2
Characterization of participants by type of discrimination experienced during the pandemic (n = 134).

The data revealed expressions of ageism among older persons. The stereotypes that older persons themselves report are still permeated by ambivalence, with a greater tendency to report negative characteristics – dependence, physical fragility, cognitive losses, loneliness, sadness, depression, illness, and changes in physical appearance. Positive characteristics also represented views traditionally related to wisdom and experience, maturity, and free time to enjoy life.

These findings are similar to those found in other studies.24,25 Aging stereotypes can be perceived from three representations, namely: biological (evidenced by physical changes, illness, and disability), psychological (experience, resilience, and tranquility) and social (abandonment, isolation, loss of social roles, and use of free time).22 However, even stereotypes with positive content can be sources of what has been termed in the gerontological literature as “benevolent ageism.”26

The stereotype content model proposes that stereotypes have two main dimensions: warmth and competence. Older persons are often stereotyped in a patronizing way, being perceived as loving but lacking in physical and cognitive competence. This suggests an ambivalent dynamic that can lead to feelings of pity, rejection, and compassion. In this sense, benevolent ageism can result in both patronizing help and social exclusion.26

Stereotypes are often formed and reinforced through social messages, media depictions, and cultural norms.11 These stereotypes can perpetuate negative attitudes and discriminatory behaviors towards older persons. This is because communication plays a role in the construction of meanings, and the media participate in the formation of subjectivities by expressing a set of values, knowledge, and social practices that shape social identity.27,28

Accordingly, during the pandemic, the meaning attributed to older persons was that of “debilitated people and risk group,” a phrase uttered in announcements of the president in force during the pandemic. These pronouncements reinforced the symbolic ideal that an aged person is a fragile being in physical and mental decline, devoid of socio-political purposes, and unworthy of assistance during a global crisis.28,29

A number of studies show that maintaining more negative age stereotypes leads to a reduction in well-being, cognitive performance, physical functioning, health, and longevity.30,31 Nevertheless, the WHO warns about the importance of addressing ageism as one of the pillars for the decade of healthy ageing, aiming to deconstruct generalized and stereotyped views of old age through educational actions, policies, and programs aimed at the entire population.32

As to prejudice, participants were found to have lower levels of anxiety about aging. Other studies have shown that young people tend to have higher levels of prejudice and anxiety about aging than older people, endorsing feelings of rejection and repulsion towards old age.33,34 Thus, it is believed that this lower anxiety comes from experiencing different losses in old age, which generate greater resilience to deal with adversity.33

As for discrimination, the results of the Ageism Survey revealed that the most prevalent experiences of discrimination episodes among participants were related to the context of interpersonal relationships and with health personnel.

A study assessed the prevalence of discrimination in Brazilian aged people and identified that the most experienced discriminations among participants in healthcare contexts were associated with age, pain, deafness, and inability to understand.23

The pervasiveness of ageism among health personnel can result in practices that put older persons at risk. One study found that generalized negative attitudes towards aged people among doctors, medical students and nurses, for example, led to refusal of certain treatments or failure to identify problems early.35

A study conducted with mental health personnel showed that most respondents inferred the normality of depressive symptoms in aged, which in turn also restricts access to treatment and results in unresolved care.34 The author establishes that this view stems from a lack of training in geriatrics and gerontology, and warns of the importance of gerontological education as an intervention for future research.

A study performed in a context of a Family Health Strategy in Primary Health Care points out some challenges for the creation of an anti-ageing health system, including training of health personnel in different care settings, organization of coordinated interprofessional care, providing incentives for care centered on older persons, promotion of digital inclusion, approach to psychosocial aspects, and the engagement of aged people, their families, caregivers, and health personnel in the overall process of care.36

As a result, ageism among health personnel can affect the quality of care provided and, in turn, increase negative risks for the overall health of older persons, especially mental health, such as depression, low self-esteem, anxiety, and loneliness.34,35 Therefore, interventions aimed at health personnel should be a priority to minimize ageism towards older persons.

Thus, ageism should be tackled in different ways, through educational actions in gerontology, policy formulation addressing age inequalities, and implementation of intergenerational interventions for mutual collaboration between generations.36

In the context of the pandemic, news and discourses in newspapers, as well as age-related practices or policies, have stereotyped aged people as a vulnerable group.29 As observed in other studies, the most reported type of ageism among participants in this study was institutional ageism.4,16

Social media has played an important role in spreading ageism during the COVID-19 pandemic, influencing people’s attitudes and perceptions. Studies suggest that social media users tend to prefer information that confirms generalized beliefs and polarizing content.26 This relationship between social media use and polarization within certain groups may explain the opposing and contradictory views on ageing, which intensify age stereotypes.26

According to a recent study conducted by Araujo et al.,37 which analyzed newspaper reports in Brazil during the pandemic, the presence of ageist speeches from different public figures was extremely present in Brazil. Transcripts of the president’s speeches, which minimized the risks of the disease, attributing consequences and mortality only to aged people, as well as deputies who promoted speeches that made the death of this population expected.

The COVID-19 pandemic has therefore made the stigmatization of older persons more evident. These results show how much these discourses and narratives resonated with older persons population, resulting in exclusion and a greater sense of perceived discrimination at institutional level.

The study by Araujo et al.37 also points out that the narratives found in the newspapers placed older persons as “the other in the pandemic,” and this narrative was often reproduced by older persons themselves at the micro-level, by family members, managers and politicians, social and health institutions at the meso-level, and by the State at the macro-level. The implementation of institutional policy to raise awareness of ageism, such as awareness campaigns and health education programs, is still incipient, especially in Brazil.37

Certainly, this study presents some limitations that could be addressed in future studies. Firstly, as a cross-sectional study, it is not possible to assess and compare the prevalence of ageism over time. It would be interesting to conduct longitudinal studies to track changes in attitudes and perceptions towards ageism over time.

Second, the use of an online form and snowball sampling may have led to excessive homogeneity in the sample, which limits the population’s representativeness. We would recommend expanding the sample and applying different recruitment methods to include people from different geographical areas in Brazil, with different educational backgrounds and social status.

Third, the exclusion of the institutionalized aged limited the understanding of ageism experienced among this group, which was particularly affected during the COVID-19 pandemic. It would be relevant to include this population in future studies to obtain a more comprehensive view of ageism.

Finally, it is important to mention that this study did not include people who had no access to the Internet, which makes it difficult to include groups with lower schooling and higher vulnerability to discrimination due to no access to the Internet.

In spite of these limitations, the study addressed the three dimensions of ageism (stereotypes, prejudice, and discrimination) during the COVID-19 pandemic. The results provided insights into the negative stereotypes older persons attributed to themselves, the prevalence of discrimination, and the contexts in which they felt most discriminated against.

These results can contribute to broaden the discussion on this issue among health personnel, health managers, and policy makers so as to develop actions that take into account the importance of combating ageism, to improve the care directed to older persons and their quality of life, especially in healthcare settings.

Further studies are suggested to explore ageism in different sociodemographic and health scenarios, in addition to proposing interventions aimed at gerontology education and evaluating the impact of these actions on reducing ageism. Addressing ageism requires joint efforts from all social and political levels, aiming to convey positive messages associated with ageing and to create an atmosphere of respect, empathy, and solidarity for aged people, especially during the COVID-19 pandemic.

The results of this study highlight the perception of ageism among older persons during the pandemic. Most participants reported negative stereotypes associated with ageing, such as dependence and frailty. In addition, they faced discrimination both at interpersonal and institutional levels, especially in healthcare settings.

These findings emphasize the need for initiatives to raise awareness among the population about the ageing process, fighting against myths, stereotypes, and negative representations about old age and ageing. It is equally important to invest in professional training in gerontology so as to better understand the needs and challenges aged people face in different areas.

In addition, the findings highlight the importance of conducting further studies to deepen our understanding of this phenomenon and to develop effective interventions to reduce discrimination against aged people. We suggest including gerontology education throughout the entire training process of individuals, to create a society that respects and values all ages, recognizing ageing as a natural process common to everybody.