REVISION PROTOCOL

Ageism against elderly people in health services: scoping review protocol

Pricila Oliveira de Araújo1, Evanilda de Souza Santana Carvalho1

1State University of Feira de Santana, Feira de Santana, BA, Brazil

ABSTRACT

Objectives: To map and characterize scientific productions on ageism against elderly people in health services; to identify expressions of ageism; and to describe measures to prevent and combat ageism against elderly people in health services. Methods: Publications in English, Spanish and Portuguese will be included, without temporal restriction, including primary studies, theses, and dissertations in order to retrieve the largest number of publications. The search strategy will be applied in PUBMED, SCIELO, LILACS, CINAHL, PsycINFO, Ageline, Embase, Scopus, Web of Science Core Collection, Capes Theses, Cybertesis, DART-E, RCAAP, and B-ON. The selection of titles, abstracts, and full texts will be performed by two reviewers, independently and blinded. The reference list of articles retrieved in full format will be screened for inclusion. Two reviewers will extract data and present them in figures, graphs, and narrative summaries. Differences will be resolved by consensus or participation of a third reviewer.

Descriptors: Ageism; Aged; Health Services.

INTRODUCTION

The term ageism was used for the first time by the gerontologist and psychiatrist Butler(1) to refer to the restlessness, repulsion, and aversion on the part of young and middle-aged people towards aging, illness, disability, impotence, "uselessness" and death, which are usually linked to people with advanced age. Currently, it is recognized that ageism can be directed at any age group; however, until now, prejudice against the elderly has received more attention since, in western contexts, they are commonly represented as fragile, weak, dependent, non-productive, and whose health problems are naturalized and understood as a normal part of aging(2).

The literature treats ageism as a multifaceted concept that involves three distinct dimensions: cognitive (stereotypes), affective (prejudice), and behavioral (discrimination). The cognitive dimension encompasses negative aging stereotypes, acquired very early and tend to act as self-fulfilling prophecies in old age(3). Stereotypes are activated when the specificities of the elderly are disregarded and can generate labels that mean separating people into different categories and activating beliefs that depreciate the subjects and cause negative consequences in different areas of life(4). The affective dimension (prejudices) creates distinctions within groups or outside them, while the behavioral comprises the discrimination that occurs when using exclusionary practices toward others, placing them in disadvantageous social positions because of their age(1).

Regarding the origin, ageism can occur from three levels: the microstructural, which emerges from the subject himself and his thoughts, emotions, and actions (self-directed ageism); the mesostructural, which arises from groups, organizations, and other social entities; and the macrostructural, which can be developed from cultural or social values ​​as a whole. Regardless of origin, ageism can be subtle and hardly noticed, or explicit and well known. It shapes the elderly people's perception of their abilities and needs, as well as the vision of the people around them(2).

Ageism in health services is expressed through biased attitudes and practices related to age; it is present at the cultural and institutional levels and has an important impact on the healthcare provided to the elderly, in addition to enhancing inequalities in health systems and services(5).

Stereotypes, prejudices, and discrimination that operate in the context of these services are significantly associated with worse health conditions, as they also generate denied access to health care, diagnoses, and treatments, indicate reduced longevity, low quality of life and well-being, health-risk behaviors, poor social relationships, physical illness, mental illness, and cognitive impairment(4). That said, it is necessary to know the coping measures implemented in health services to combat ageism against the elderly since there are no clear guidelines on reducing negative views of old age through targeted interventions(6).

With the COVID-19 pandemic, this old phenomenon gained visibility in Brazil and the world through the hashtag #BoomerRemover, a pejorative concept highlighting prejudiced and discriminatory attitudes towards age(7). When the number of cases of this infection started to increase in the world, elderly people were portrayed as a risk group, vulnerable, and who should be willing to risk their lives to save the youngest and help society in general. The above perceptions rekindled prejudiced views about aging, and chronological age became the only criterion for adopting restrictive measures to combat the coronavirus and determine access to healthcare resources. People over 60 are automatically considered vulnerable, dependent, and as having a limited social contribution(8). This generalization tends to disregard social inequalities and precarious living conditions that significantly influence the vulnerabilities to which this population is exposed(9).

Given the above and considering the new elements that the pandemic can add to the study and deepening of ageism in health services, a preliminary search was carried out, with the descriptors "ageism" and "health", conducted in February 2021 at PROSPERO, PubMed, OSF, JBI Evidence Synthesis, and Cochrane Database of Systematic Reviews, and no scoping review mapping the characteristics, expressions, and coping strategies of ageism against older people in health services was found.

Thus, this review is justified by the possibility of providing implications for future studies, contributing as a guide for the formulation of policies and strategies to reduce ageism in health services, as well as helping in the training of health workers.

The general objective of this review is to compare the scientific productions on ageism against elderly people in health services.

The secondary objectives are: to characterize studies on ageism against elderly people in health services, to identify expressions of ageism against elderly people in health services, and describe measures to prevent and combat ageism against elderly people in health services.

General review question

How does the scientific literature approach ageism against elderly people in health services?

Sub-questions:

What are the characteristics of studies on ageism against elderly people in health services (methods, participants, types of health services researched, and instruments for measuring the phenomenon)?

How is ageism against older people expressed in health services?

Which measures exist to prevent and combat ageism against elderly people in health services?

Keywords

Elderly, old age, aging, old, older people, older adults, senior, aged, geriatric, older adulthood, prejudice, ageism, discrimination, stereotypes, health services.

Inclusion criteria

Participants

Participants will be health professionals working in health services and old people who use health services.

Concept

Studies that address the expressions of ageism and respective synonyms will be included in this review, which are stereotypes, prejudices, and age discrimination, suffered by the elderly, revealed from any concerns, repulsion, aversion, and exclusion due to aging and old age. Ageism can be expressed in three dimensions: cognitive, which involves stereotypes, images, and beliefs and is related to what people think about aging and the elderly; affective, which includes age prejudice; and behavioral, which involves discrimination, exclusion, and marginalization of the elderly(1,2).

Context

The review will consider studies carried out in health services, which involve all components of the health system provided in primary, secondary, and tertiary care. Health services are establishments intended to promote people's health, protect them from diseases and injuries, prevent and limit the damage caused to them and rehabilitate them when their physical, psychological, or social capacity is affected(10).

Sources of evidence

This proposed scoping review will consider, as sources of evidence, full texts of primary studies, theses, and dissertations, available in the main health, psychology, and gerontology databases, published in Portuguese, English, and Spanish, and without time restriction, with the justification of retrieving as many publications as possible.

The review will consider, as sources of evidence, quantitative studies, whether clinical and interventional, observational, case studies, ecological studies and time series, qualitative studies of any nature that use primary data, and studies with secondary data. Review studies, opinion articles, theoretical essays, commentaries, books, and book chapters will not be included.

METHODS

The scoping review will be conducted according to the JBI methodology for scoping reviews(11) and is registered in the Open Science Framework (OSF) registration platform (https://osf.io/pv2by).

Search strategies

The search strategy will aim to find primary studies, theses, and dissertations in various databases and will be organized into four phases:

Phase 1: initial search on PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) via Business Source Complete (EBSCO), performed to identify articles on the subject and keywords found in titles, abstracts, and MeSH descriptors to compose the search strategy (Figure 1), which will be applied and adapted to all the databases that will be part of this research.

Source: Prepared by the authors, 2021.

Figure 1 - Research strategy. Feira de Santana, Bahia, Brazil, 2021

Phase 2: the search strategy will be applied to PubMed Portal (NLM/NCBI), Scientific Electronic Library Online (SCIELO), Latin American and Caribbean Health Sciences Literature (LILACS), CINAHL (EBSCO), PsycINFO, Angeline, Embase, Scopus, and Web of Science Core Collection. The portals and databases above were chosen because they constitute large collections of publications in the areas of the intended study. The elaboration of search keys and the collection of articles in the different databases will be developed with the support of a librarian specialized in reviews.

Phase 3: screening reference lists of articles retrieved in the full-text search and included in the final selection for inclusion in the study. In case of unavailability of access to full texts in the databases, the authors of the scientific productions may be contacted.

Phase 4: search for gray literature through the Capes Theses portal, Cybertesis Thesis Digitalis Repository, DART-Europe E-theses Portal, Open Access Scientific Repositories of Portugal (RCAAP), and Online-b-on (Online Knowledge Library). The authors of the selected documents may be contacted if there is any doubt about reading the study or lack of information.

Selection of studies

After the search, the identified studies will be grouped and sent to the EndNote tool (Clarivate Analytics, USA) to remove duplicate studies. Then, two reviewers will perform the reading and selection of titles and abstracts independently and blinded, using the Rayyan Intelligent Systematic Review tool, according to the inclusion criteria of this study. They may include or exclude scientific productions. Subsequently, after resolving possible differences between the reviewers in the selection of titles and abstracts, the full texts will be read by two reviewers, independently and blinded, and the reasons for excluding the productions will be quantified and justified. Differences may be resolved through consensus between the two reviewers or through the decision of a third reviewer. The findings of this review will be reported using the PRISMA flow diagram for new systematic reviews, which include searches of databases, registers, and other sources(12), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) checklist will be used as a guide for preparing the final report(13).

Data extraction

Data will be extracted from the analysis corpus by two reviewers, using a data extraction instrument developed by the JBI(11), adapted by the reviewers to meet the research objectives (Figure 2), and which deals with study identification (authorship, title, year of publication, journal, volume, and number), main objective, research question, inclusion criteria, methodology (type of study, participants, context, and instruments to measure the phenomenon) and results (expressions of ageism and prevention and coping measures). This information may be modified by the reviewers throughout the data extraction process to meet the study objectives better. Changes that may be made to the instrument will be reported in the final text of the scoping review. Possible discrepancies regarding the data extracted by the reviewers will be resolved through discussion and consensus or by data extraction made by a third reviewer. In three studies, pilot testing of the instrument will be carried out by the reviewers to familiarize themselves with data extraction. In case of doubt in the extraction of data or missing information in the article, the studies' authors may be contacted.

Source: Adapted from the JBI Manual for Evidence Synthesis, 2020.

Figure 2 - Data extraction tool. Feira de Santana, BA, Brazil, 2021

Data analysis and presentation

The results of this scoping review will be presented as a narrative summary and through figures, graphs, and/or tables that will be constructed to portray the findings and meet the review's objectives. For a better presentation of the data, a table will be prepared that will contain the authors, titles, objectives, methods (study design and information about the mnemonic population and context of each selected article), and expressions of ageism in health services. The temporal evolution of the publications will be presented in the form of a line graph, and the other information in simple statistics and narrative summaries.

*Paper extracted from the doctoral thesis “Ageism against elderly people in health services: analysis of the concept and forms of expression of this phenomenon in the COVID-19 pandemic”, presented to the State University of Feira de Santana, Feira de Santana, Bahia, Brazil.

CONFLICT OF INTERESTS

The authors have declared that there is no conflict of interests.

REFERENCES

1. Butler RN. Age-ism: Another form of bigotry. The Gerontologist. 1969;9(4):243–246. https://doi.org/10.1093/geront/9.4_part_1.243

2. Ayalon L, Tesch-Romer C. Introduction to the section: Ageism, Concept and Origins. In: Ayalon L, Tesch-Romer C, editors. Contemporary Perspectives on Ageism [Internet]. Cham (CH): Springer International Publishing AG; 2018 [cited 2022 mar 17]. p. 1-9. Available from: https://link.springer.com/content/pdf/10.1007/978-3-319-73820-8.pdf

3. Marques S, Mariano J, Mendonça 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 apr 8;17(7):2560. https://doi.org/10.3390/ijerph17072560

4. 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 jan 15;15(1):e0220857. https://doi.org/10.1371/journal.pone.0220857

5. Wyman MF, Shiovitz-Ezra S, Bengel J. Ageism in the Health Care System: Providers, Patients, and Systems. In: Ayalon L, Tesch-Romer C, editors. Contemporary Perspectives on Ageism [Internet]. Cham (CH): Springer International Publishing AG; 2018 [cited 2022 mar 17] p. 193-212. Available from: https://link.springer.com/content/pdf/10.1007/978-3-319-73820-8.pdf

6. 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(8):e1-e9. https://doi.org/10.2105/AJPH.2019.305123

7. 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 Aug;49(5):692-695. https://doi.org/10.1093/ageing/afaa097

8 Ayalon L. There is nothing new under the sun: ageism and intergenerational tension in the age of the COVID-19 outbreak. Int Psychogeriatr. 2020 Oct;32(10):1221-1224.  https://doi.org/10.1017/S1041610220000575

9. Osorio-Parraguez P, Jorquera P, Tessini MA. Vejez y vida cotidiana en tiempos de pandemia: estrategias, decisiones y câmbios. Horiz. Antropol. 2021 jan/abr;(59):227-243. https://doi.org/10.1590/S0104-71832021000100012

10. Agência Nacional de Vigilância Sanitária (BR). Tecnologia da Organização dos Serviços de Saúde [Internet]. Brasília (DF): Anvisa; 2003c [cited 2022 mar 17]. Available from:  https://www.anvisa.gov.br/servicosaude/organiza/index.htm

11. Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil, H. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z, editors. JBI Manual for Evidence Synthesis [Internet]. Adelaide: JBI; 2020. Available from: https://synthesismanual.jbi.global/. https://doi.org/10.46658/JBIMES-20-12

12. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. J Clin Epidemiol. 2021;(134):103-112. https://doi.org/10.1016/j.jclinepi.2021.02.003

13. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467-473. https://doi.org/10.7326/M18-0850.

Submission: 03/12/2022

Approved: 06/21/2022