The Gerontologist

cite as: Gerontologist, 2019, Vol. 59, No. 2, e98–e108

doi:10.1093/geront/gnx020
Advance Access publication May 16, 2017

Literature Review

Ageism in Health Care:A Systematic Review of Operational

Definitions and Inductive Conceptualizations

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José Manuel Sousa São José, PhD,1,* Carla Alexandra Filipe Amado, PhD,2
Stefania Ilinca, PhD,3 Sandra Catherine Buttigieg, PhD,4 and Annika Taghizadeh Larsson, PhD5
Faculty of Economics, University of Algarve and CIEO, Faro, Portugal. 2Faculty of Economics, University of Algarve and
1

CEFAGE-UALG, Faro, Portugal. 3European Centre for Social Welfare Policy and Research, Vienna, Austria. 4Department of
Health Services Management, University of Malta, Msida. 5Department of Social and Welfare Studies, Linköping University,
Norrköping, Sweden.

*Address correspondence to: José Manuel Sousa São José, PhD, Faculty of Economics, University of Algarve and CIEO, Campus de Gambelas,
8005-139 Faro, Portugal. E-mail: jsjose@ualg.pt

Received: October 11, 2016; Editorial Decision Date: February 16, 2017

Decision Editor: Rachel Pruchno, PhD

Abstract
Purpose: International and national bodies have identified tackling ageism in health care as an urgent goal. However, health
professionals, researchers, and policy makers recognize that it is not easy to identity and fight ageism in practice, as the iden-
tification of multiple manifestations of ageism is dependent on the way it is defined and operationalized. This article reports
on a systematic review of the operational definitions and inductive conceptualizations of ageism in the context of health care.
Design and Methods: We reviewed scientific articles published from January 1995 to June 2015 and indexed in the elec-
tronic databases Web of Science, PubMed, and Cochrane. Electronic searches were complemented with visual scanning of
reference lists and hand searching of leading journals in the field of ageing and social gerontology.
Results: The review reveals that the predominant forms of operationalization and inductive conceptualization of ageism in
the context of health care have neglected some components of ageism, namely the self-directed and implicit components.
Furthermore, the instruments used to measure ageism in health care have as targets older people in general, not older
patients in particular.
Implications: The results have important implications for the advancement of research on this topic, as well as for the
development of interventions to fight ageism in practice. There is a need to take into account underexplored forms of
operationalization and inductive conceptualizations of ageism, such as self-directed ageism and implicit ageism. In addition,
ageism in health care should be measured by using context-specific instruments.
Keywords: Ageism, Health care, Systematic review

Almost 50 years ago, Robert Butler (1969, p. 243) coined the Hoffman, 1986) in the fields of psychology (Gatz & Pearson,
concept of ageism, having then offered the following definition 1988), psychiatry (Ray, Raciti, & Ford, 1985), rehabilitation
of it: “prejudice by one age group towards other age groups.” (Benedict & Ganikos, 1981), and dentistry (Gilbert, 1989), to
His work signaled increased societal and research interest in name just a few. Currently abundant evidence of ageism in the
the phenomenon of ageism and strategies to combat it. Initial health care domain, as well as in other domains, has accumu-
studies on ageism in health care revealed ageist attitudes and lated (Levy, 2016). A report by the Economist Intelligence Unit
practices of professionals (Greene, Adelman, Charon, & on health care strategies for an ageing society, published in

© The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. e98
For permissions, please e-mail: journals.permissions@oup.com.
The Gerontologist, 2019, Vol. 59, No. 2 e99

2009, underlined that there is strong evidence of widespread on the definition and operationalization of ageism, which
ageism in medical treatment around the world (Economist results from the negligence with respect to its conceptual
Intelligence Unit, 2009). This evidence had been previously aspects (Iversen, Larsen, & Solem, 2009).
confirmed by other reports at national level, such as in the This article intends to provide a systematic review of
United States (Alliance for Aging Research, 2003) and the operational definitions and inductive conceptualizations
United Kingdom (Roberts, Robinson, & Seymor, 2002). of ageism, which have been used/produced by empirical
Ageism in health care can be found in social interactions, research on ageism in health care. By operational defini-
in organizational cultures, and in health policies. In each tions, we mean the specific way in which a construct is meas-
of these levels of reality, it can assume multiple manifesta- ured in quantitative studies, referring to the dimensions/
tions. For example, at the microlevel of reality, ageism may components and respective indicators which are defined
be conveyed by conscious or unconscious behaviors and before data collection (from the construct to data collec-
attitudes of health care professionals, patients, and their tion). In turn, by inductive conceptualizations, we mean the

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relatives, such as ordering fewer diagnostic tests for older constructs which emerge from an inductive analysis (from
patients when compared to young patients, and assuming data collection to the construct), which is normally con-
that communicating with older patients is very frustrating. ducted in qualitative studies. It is important to underline
Ageist behaviors and attitudes in the context of health that we are interested in the way ageism, as a concept, has
care are far from innocuous, given that the amount and been operationalized and inductively conceptualized rather
quality of care requested, delivered, and received is affected than in the evidence of the phenomenon of ageism. Hence,
by the existence of ageism (Ouchida & Lachs, 2015). this systematic review aims to answer the following review
A recent study conducted in the United States found that questions: How has ageism in health care been operational-
“one in 17 [adults over the age of 50 years] experience fre- ized in quantitative studies? How has ageism in health care
quent health care discrimination, and this is associated with been inductively conceptualized in qualitative studies? To
new or worsened disability by 4 years” (Rogers, Thrasher, the best of our knowledge, no published review with simi-
Miao, Boscardin, & Smith, 2015, p. 1413). In the worst lar objectives exists.
scenarios, ageism in health care may imply a higher prob- It is our conviction that answers to the aforementioned
ability of death for older patients than for younger patients questions will raise awareness of the need to take into
(Grant, Henry, & McNaughton, 2000; Peake, Thompson, account underexplored forms of operationalization and
Lowe, & Pearson, 2003). inductive conceptualizations of ageism. This will enable us
Because of its potential harmful effects, the issue of to capture the full picture of this phenomenon. In addi-
ageism has gained increasing importance on the political tion to contributing to the advancement of research, a more
agendas of international and national bodies. In 2010, comprehensive operationalization and inductive conceptu-
the General Assembly of the United Nations called upon alization of ageism in health care would put us in a better
Member States “to eliminate and address discrimination position to identify and fight it in practice.
on the basis of age and gender” (United Nations, 2010, There is an expectation that research on ageism, includ-
p. 3). In 2012, the European Network of Equality Bodies ing ageism in health care, will increase significantly in the
(Equinet) elected tackling ageism as an essential condition coming years due, in part, to the rapid population ageing
to promote active ageing (Equinet, 2011). In the United (Levy & Macdonald, 2016) and the implementation of a
Kingdom, the Equality Act 2010 made age discrimination European Concerted Research Action on ageism (http://
illegal, meaning that the National Health Service cannot notoageism.com/). Considering this expectation, in our
provide services on the basis of the patients’ age, unless view, this review is not only necessary but also timely.
there are justified reasons.
However, eradicating ageism from health care is not an
easy task. Ageist health policies and regulations can be iden- Conceptual Framework
tified easily and be abolished in a relatively short period of There are two central concepts in this review that we need
time. The same cannot be said in relation to more indirect to clarify: ageism and health care. Regarding ageism, we
and subtle forms of ageism, such as unconscious age-based adopt the extended definition proposed by São José and
rationing in clinical decisions. These covert forms of ageism Amado (2017) that builds on the work of Iversen and col-
are not only difficult to identify but also difficult to change leagues (2009):
(Dey & Fraser, 2000; Roberts et al., 2002).
Therefore, identifying the multiple manifestations of Ageism is defined as negative or positive stereotypes,
ageism, including those more surreptitious or invisible, is prejudice and/or discrimination against (or to the advan-
a fundamental prerequisite to developing interventions and tage of) us on the basis of our chronological age or on
policies to eradicate ageism in health care. Nevertheless, the basis of a perception of us as being “old,” “too old,”
in order to identify the full spectrum of ageism manifesta- “young” or “too young.” Ageism can be self-directed or
tions in health care, one first needs to know how to define other-directed, implicit or explicit and can be expressed
and operationalize it. To date, there is no broad consensus on a micro, meso or macro-level.
e100 The Gerontologist, 2019, Vol. 59, No. 2

This definition includes four dimensions, each one with and discrimination in favor of someone on the basis of
its respective components: the dimension of the three clas- age (e.g., giving priority to older patients when prescrib-
sic components (cognitive-stereotypes, affective-prejudice, ing treatments), while the negative component consists of
behavioral-discrimination); the self-directed/other-directed stereotypes, prejudices, and discrimination in disfavor of
dimension (self-directed ageism, other-directed ageism); the someone on the basis of age (all the other examples offered
conscious/unconscious dimension (explicit ageism, implicit previously). More illustrations of the different components
ageism); and the positive/negative dimension (positive age- of ageism can be found in the Supplementary Appendices
ism, negative ageism). From our viewpoint, the micro-, meso- 2–4, Section A.
and macro-levels are not dimensions of the phenomenon but With respect to the concept of health care, we adopt
rather the levels of reality in which the phenomenon mani- the following general definition by the World Health
fests. Combining the four dimensions and respective compo- Organization (2004, p. 28): “Services provided to indi-
nents of ageism, we obtain a conceptual framework with 24 viduals or communities by health service providers for the

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possibilities of operationalizing ageism (see Table 1). These purpose of promoting, maintaining, monitoring or restor-
multiple forms of operationalization also serve to classify the ing health.” Considering the purpose of this review, we
inductive conceptualizations of ageism. exclude long-term care from this definition, although in
Following Abrams, Swift, Lamont, and Drury (2015) and some countries, long-term care is an integral part of the
Iversen and colleagues (2009), it is important to clarify that health care system. We based this decision on the findings
the cognitive component refers to “what we think about,” of a European research project, designated by “Interlinks,”
accounting for stereotypes (e.g., holding the assumption that there is a functional differentiation (in terms of ser-
that older patients are problematic), while the affective vices provided, providers, methods, legal frameworks, and
component refers to “what we feel about,” accounting policies) between health care, social care, and long-term
for prejudice (e.g., to dislike having conversations with care for older people (Billings, Leichsenring, & Wagner,
older patients). Finally, the behavioral component refers 2013). Therefore, long-term care responses, such as nursing
to “how we behave towards,” accounting for discrimina- homes, day care centers, “meals on wheels,” and other ser-
tion (e.g., asking fewer questions to older patients than to vices intended to support activities of daily living (bathing,
younger patients when making a diagnosis). In turn, the dressing, toileting, etc.), are excluded from the definition of
self-directed component refers to ageism directed towards health care adopted in this review.
people of one’s own age or towards oneself (e.g., assuming
that I am too old to receive certain treatments), whereas the Methods
other-directed component refers to ageism directed from a
This systematic review followed the guidance for under-
person (or persons) towards a person (or persons) of other
taking reviews in health care provided by the Center for
age groups (e.g., believing that older patients are always
Reviews and Dissemination (CRD) at the University of
complaining about their health). Looking now at the rows,
York (CRD, 2009) and the Preferred Reporting Items for
the explicit component corresponds to conscious ageism
Systematic Reviews and Meta-Analyses (PRISMA) (Moher,
(ageist beliefs, feelings, and behaviors, which are con-
Liberati, Tetzlaff, & Altman, 2009).
sciously enacted) and the implicit component corresponds
to unconscious ageism (ageist beliefs, feelings, and behav-
iors, which are automatically enacted without conscious Inclusion and Exclusion Criteria
awareness). Consciously believing that older patients are We established the inclusion/exclusion criteria in relation to
always complaining about their health can be an exam- timespan, language, study focus, study type, and publication
ple of explicit ageism, while not asking for information type. We searched for studies published from January 1, 1995
about sexual life to older patients can be an example of to June 30, 2015. Our searches date back to 1995, as research
implicit ageism (a health professional may not be aware of on ageism in health care barely existed before this date.
this behavior, based on the assumption, also unconscious, We included studies exclusively reported in English,
that older people do not have active sexual lives). Finally, which is the common language of communication among
the positive component consists of stereotypes, prejudices, the authors of this paper.

Table 1. Multiple Possibilities of Operationalizing Ageism

Cognitive Affective Behavioral

Self-directed Other-directed Self-directed Other-directed Self-directed Other-directed

Explicit Positive 1 2 3 4 5 6
Negative 7 8 9 10 11 12
Implicit Positive 13 14 15 16 17 18
Negative 19 20 21 22 23 24
The Gerontologist, 2019, Vol. 59, No. 2 e101

Regarding the study focus, we only included studies Selection of the Publications
which meet, cumulatively, the following criteria: to address The identified publications were selected according to the
ageism in health care (studies not focused on ageism, and PRISMA flow diagram (Moher et al., 2009). All the stages
studies focused on ageism, but in long-term care and social of the selection process were carried out in parallel by two
care, were excluded); to make an explicit reference to the authors of this article, working independently, and any dis-
terms “ageism” or “ageist” (studies making reference only agreements were resolved by consensus.
to “age discrimination” and related terms were excluded,
as this review intends to systematize the way the specific
concept of ageism has been worked in empirical research); Data Extraction
and to provide an operational definition of ageism or an
All relevant data contained in the reviewed articles were
inductive conceptualization of ageism (studies offering
extracted to a data extraction form. We pilot-tested a pre-
solely conceptual definitions of ageism, i.e., definitions of
liminary version of this form in five randomly selected

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the meaning of ageism adopted before data collection, were
articles and the form was subsequently refined. The final
excluded). These criteria are justified by the aim and ques-
version of the data extraction form includes the follow-
tions of this review, as well as the concept of health care
ing items: author and date, aims of the study, theoretical
adopted in this review.
underpinnings, conceptual definition of ageism, opera-
We also only included studies based on empirical
tional definition of ageism, inductive conceptualization of
research, excluding theoretical studies, opinion articles,
ageism and research design and methods of data collection.
policy documents, and literature reviews. However, we vis-
The process of data extraction was executed in parallel by
ually scanned the reference lists of literature reviews with
two authors of this article, working independently, and any
the aim to identify relevant studies.
disagreements were resolved by consensus.
Finally, in order to ensure quality in the reviewed
Systematic reviews which look at the available empiri-
publications, we only included articles published in peer-
cal evidence normally conduct a quality appraisal of the
reviewed journals.
reviewed studies, which is focused on the quality of the
results/findings. Considering that, on one hand, our sys-
Search Strategy tematic review does not look at findings/results but rather
at operational definitions and inductive conceptualiza-
The electronic databases Web of Science, PubMed, tions and that, on the other hand, there is no established
and Cochrane were searched in order to find relevant methodology for quality appraisal in conceptual or con-
studies. In the Web of Science database, we searched struct reviews, we decided not to undertake a quality
in “all databases,” selecting the option “basic search” appraisal of the reviewed studies. This decision was also
and using the following fields and keywords/specifi- taken in other reviews of operational definitions (e.g.,
cations: TOPIC: (“ageism” or “ageist”) AND TOPIC: Cosco, Prina, Perales, Stephan, & Brayne, 2013; Ozawa
(“healthcare” or “health care”); Timespan: 1995–2015. & Sripad, 2013).
Subsequently, this search was refined by: DOCUMENT
TYPES: (ARTICLE OR REVIEW) AND LANGUAGES:
(ENGLISH). Data Synthesis
In the PubMed database, we selected the option “advan­ The data that were needed to answer the review ques-
ced” and used the following fields and keywords/specifications: tions were synthesized by using two approaches: narra-
“ageism”[Title/Abstract] OR “ageist”[Title/Abstract] AND tive synthesis (Popay et al., 2006) and thematic synthesis
“healthcare”[Title/Abstract] OR “health care”[Title/Abstract] (Thomas & Harden, 2008). Narrative synthesis “(…)
AND “1995/01/01”[Date-Publication]:”2015/06/30”[Date- refers to an approach to the systematic review and syn-
Publication] AND “english”[Language] AND “journal thesis of findings from multiple studies that relies pri-
article”[Publication Type]. marily on the use of words and text to summarize and
Finally, in Cochrane database, we also selected the explain the findings of the synthesis. While narrative syn-
option “advanced search” and used the keywords “ageism” thesis can involve the manipulation of statistical data, the
OR “ageist” in the fields “Title, Abstract, and Keywords.” defining characteristic is that it adopts a textual approach
We limited the search by “Publication Year from 1995 to to the process of synthesis to ‘tell the story’ of the find-
2015.” ings from the included studies.” (Popay et al., 2006, p. 5).
Searches in these electronic databases were comple- Normally, a narrative synthesis is supported by “tabula-
mented with visual scanning of reference lists from litera- tion,” which consists in organizing and presenting data in
ture reviews and articles which met the inclusion criteria. tabular form. In turn, thematic synthesis consists, basi-
We also conducted a hand search of the following jour- cally, in reducing the extracted data by a process of trans-
nals on the field of ageing and social gerontology: The forming “free codes” in “descriptive themes” and these
Gerontologist, Journal of Aging Studies, and European themes in more abstract ones, the “analytical themes”
Journal of Ageing. (Thomas & Harden, 2008).
e102 The Gerontologist, 2019, Vol. 59, No. 2

We started by collecting all the indicators of ageism,

No. of studies

Note: The numbers between square brackets correspond to the identification numbers of the reviewed studies, which are described in Supplementary Appendix 1. The total number of indicators in the other-directed component
both quantitative and qualitative, explicitly reported in
the reviewed studies. By indicators of ageism, we mean a

Table 2. Number of Indicators and Studies in Each Component and Operationalization of Ageism (Quantitative Studies Which Did Not Administered Scales of Ageism)
cognition, feeling, or behavior chosen to measure or cap-

16

20

1
1
ture ageism. Then, these indicators were submitted to four
operations. First, they were categorized in facets of ageism,

No. of indicators
following the basic procedures of thematic synthesis. The
facets were categorized by stereotypes, prejudice, and dis-
crimination and by the specific themes found within each
of these three components (see Supplementary Appendices

38

47

2
2
2–4, Section A). Second, all the indicators were classified in
terms of the components of ageism described in the con-

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43 [1; 2; 3; 4; 5; 6; 7; 9; 13; 14; 18; 20;
ceptual framework section (see Supplementary Appendices

37 [1; 2; 3; 4; 5; 7; 13; 14; 18; 20; 23;

2–4, Section A). Third, we counted the indicators included
in each facet and in each component (see Supplementary
Appendices 2–4, Section B). Finally, on the basis of the last
count, we counted the indicators and the studies included

27; 29; 31; 33; 34; 37]

in each of the 24 forms of operationalization/induc-
tive conceptualization of ageism, as described in Table 1

29; 31; 33; 34]

Other-directed
(see Tables 2–4).

2 [32]
2 [32]
Results

(behavioral) is 45, because 39 indicators (37 explicit and two implicit) have the potential to measure both positive and negative ageism.
45
20
The searches in electronic databases yielded a total of 311
publications. After removing 100 duplicates and adding 15

Self-directed
more articles from searching reference lists, we obtained Behavioral
a total of 226 publications to screen. After applying the
inclusion/exclusion criteria to titles and abstracts, 181
0

0
0

0
0
publications were excluded. The majority of the screened
Other-directed

publications were excluded because they are not based

on empirical research. Upon screening the full text publi-
cations, eight publications were excluded, chiefly because
1 [23]

they do not offer an operational definition of ageism. This

0

0
0

1
1
means that 37 articles were included in this review (see
Figure 1).
Self-directed

Almost all reviewed articles were published after 2000

Affective

and most of them after 2010. Due to the inclusion criteria,

1 [23]

all of the reviewed studies provide an operational or induc-

0

0
0

1
1

tive conceptualization of ageism. In addition, most of them

also provide a conceptual definition of ageism, although
Other-directed

some only implicitly, and about a quarter do not offer any

2 [15; 23]

conceptual definition. It is also worth mentioning that only

1 [15]

a minority of the studies make an explicit reference to their

theoretical underpinnings (see Supplementary Appendix 1).
0
0

3
2

We created three groups of studies in order to organize

Self-directed

the presentation of the results: quantitative studies which

Cognitive

did not administer validated scales of ageism (21 studies),

quantitative studies which administered validated scales
0

0
0

0
0

of ageism (8 studies), and qualitative studies (8 studies).

There are two mixed methods studies, which were incor-
Negative

Negative
Positive

Positive

porated in the group of quantitative studies, given that

No. of indicators

data analysis followed a clear quantitative logic. From

No. of studies

this point onwards, the reviewed studies are referenced by

their identification numbers, as described in Supplementary
Explicit

Implicit

Appendix 1. The full references of the reviewed studies are

also found in Supplementary Appendix 1.
The Gerontologist, 2019, Vol. 59, No. 2 e103

Quantitative Studies Which Administered

Validated Scales of Ageism
Eight studies administered validated scales of ageism.
Most of these studies adopted only one scale, whereas one
study adopted two scales and another one three scales. The
scales of ageism which were administered were the follow-
ing: Attitudes Towards Older People Scale (Kogan, 1961),
Aging Semantic Differential Scale (Rosencranz & McNevin,
1969), Facts on Aging Quiz (Palmore, 1998), Fraboni Scale
of Ageism (Fraboni, Saltstone, & Hughes, 1990), Reactions
on Aging Questionnaire (Gething, 1994). All the scales are
composed of several statements (with the exception of the

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Aging Semantic Differential Scale) and use a Likert scale
format. It is important to clarify that these scales were not
designed to measure ageism towards older persons in the
Figure 1. Process of the selection of publications. context of health care, but rather towards older persons in
general (a more detailed characterization of theses scales
Quantitative Studies Which Did Not Administered can be found in Supplementary Appendix 3, Section C).
Validated Scales of Ageism We considered each statement of the scales as one indi-
The 50 indicators of ageism, which were used by quantitative cator of ageism, with the exception of the Aging Semantic
studies that did not administered validated scales of ageism, Differential Scale, in which each pair of adjectives was con-
are distributed between 22 facets of ageism. Almost all of sidered to have two indicators. The 173 indicators used by
these facets account for discrimination (19 out of 22), with the quantitative studies that administered validated scales
only 1 accounting for stereotypes and beliefs and 2 account- of ageism are distributed between 34 facets of ageism.
ing for prejudice. Among the discrimination facets, those Almost all indicators relate to the facets that account for
which refer to discrimination in treatment and management stereotypes and beliefs (28 out of 34). There are four facets
(13 out of 19) stand out, with discrimination in prescribing accounting for prejudice and two accounting for discrimi-
treatments and access to care services/facilities, being the 2 nation. The great majority of the facets which account for
facets covered by the largest number of indicators and stud- stereotypes and beliefs has older people as targets (24 out
ies. Four facets of discrimination refer to diagnosis, with the of 28), with the exception of four facets which are directed
facet accounting for discrimination in ordering/performing to ageing, old age, and the priority given by medical prac-
diagnostic tests/examinations being the one which includes titioners to older persons. Among the facets accounting for
more indicators and studies. Only one facet of discrimina- stereotypes and beliefs about older people, the one focused
tion accounts for clinical trials and another one for survival on interaction style and mood stands out, as it is covered
rates (see Supplementary Appendix 2, Section B). by a significant number of indicators and by all studies (see
If we look now at the number of indicators and studies Supplementary Appendix 3, Section B).
by components of ageism, we verify that there are major We also found significant imbalances in the distribution
imbalances between the attention that each component of the indicators by components of ageism (see Table 3).
receives in the literature (see Table 2). Among the classic The cognitive and affective components are covered by
components (cognitive, affective, behavioral), the behav- the same number of studies but the cognitive component
ioral component is clearly predominant. Strong contrasts includes much more indicators than the affective compo-
are also found with respect to the self-directed or other- nent. The behavioral component is covered only by five
directed components, as well as explicit and implicit com- indicators and one study. In turn, the other-directed com-
ponents, heavily favoring the other-directed and explicit ponent is clearly predominant when compared to the self-
ones. Regarding the last two components (positive and directed component. The explicit component is covered by
negative), we find a significant balance, although with a all the indicators and by all the studies, contrasting clearly
slight predominance of the negative component. with the implicit component, which was not covered at
Table 2 also shows the number of indicators and stud- all. The absence of indicators and studies in the implicit
ies which are inserted in each of the 24 possible forms of component is not surprising, as all of the aforementioned
operationalizing ageism. Two main forms of operational- scales were developed to measure explicit forms of ageism.
izing ageism emerge as the most predominant, namely Finally, we find a slight predominance of the negative com-
“behavioral, other-directed, explicit, negative” and “behav- ponent when compared with the positive component, as it
ioral, other-directed, explicit, positive.” The majority of the is covered by more indicators and studies.
other possible forms of operationalization are not covered The studies which administered scales of ageism have
at all, whereas the remaining ones have between one and employed three major forms of operationalization, namely
two indicators and one and two studies. “cognitive, other-directed, explicit, negative,” “affective,
e104 The Gerontologist, 2019, Vol. 59, No. 2

other-directed, explicit, negative,” and “cognitive, other-

No. of studies
directed, explicit, positive” (see Table 3). However, the
first operationalization is covered by more than half of all
indicators and was used by all studies, while the second

0
0
7
8
operationalization includes the same number of studies but
with much fewer indicators. The third operationalization
Table 3. Number of Indicators and Studies in Each Component and Operationalization of Ageism (Quantitative Studies Which Administered Scales of Ageism)

No. of indicators was adopted by seven studies, although it has more indica-
tors than the second operationalization. Among the other
possible forms of operationalization, most of them are not
covered by any indicator and study, two have a relatively
0
0
40
133

significant number of indicators but only one study, one has

only one indicator and five studies, and the remaining ones
Other-directed

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have five or fewer indicators and only one study.
5 [24]

Qualitative Studies
5
1
0
0
0

Note: The numbers between square brackets correspond to the identification numbers of the reviewed studies, which are described in Supplementary Appendix 1.
The 18 indicators of ageism which were used by the qualita-
Self-directed

tive studies are distributed between two major facets of age-

Behavioral

ism, the facets accounting for stereotypes and beliefs about

older patients (seven out of 14) and the facets accounting
0
0
0
0
0
0

for discrimination in treatment and management (six out

of 14). There is one facet accounting for discrimination in
18 [10; 11; 12; 21; 24; 25;
1 [10; 11; 21; 25; 26; 36]

diagnosis and another one accounting for discrimination

in social interactions in the context of health care settings.
There is no facet accounting for prejudice. The facets cov-
Other-directed

ered by the largest number of indicators and studies are

the ones accounting for “stereotypes and beliefs about the
older patients: symptoms” and “discrimination in treat-
26; 36]

ment and management: disempowering older patients,”

19
8
0
0

although closely followed by the others (see Supplementary

Appendix 4, Section B).
Self-directed

In line with the previous two groups of studies, the qual-

Affective

12 [12]

itative studies also exhibit some imbalances with respect

to the distribution of the indicators and studies by compo-
0

12
1
0
0

nents of ageism (see Table 4). The cognitive and behavio-

ral components are covered by nearly the same number of
37 [10; 11; 12; 21; 25; 26; 36]

indicators and studies, given that five indicators are dupli-

90 [10; 11; 12; 21; 24; 25;

cated in the cognitive component (one indicator measures

both self-directed and other-directed ageism, while four
indicators measure both explicit and implicit ageism). The
Other-directed

affective component is not covered at all. In turn, the other-

directed component includes more indicators and stud-
26; 36]

ies than the self-directed component. With respect to the

127
8
0
0

explicit and implicit components, the first one is covered by

all the indicators and all the studies (in Table 4 it appears
19 indicators, as 1 indicator is duplicated), whereas the sec-
Self-directed
Cognitive

ond one has much less indicators and fewer studies. The
2 [12]
8 [12]

positive component is not covered at all, contrasting clearly

10
1
0
0

with the negative component, which includes all the indica-

tors and all the studies.
Negative
Negative

Looking now at the inductive conceptualizations of

Positive
Positive

No. of indicators

ageism, we find three major conceptualizations: “cogni-

No. of studies

tive, other-directed, explicit, negative,” “behavioral, other-

directed, explicit, negative,” and “cognitive, other-directed,
Explicit

Implicit

implicit, negative” (see Table 4). We verify that the first

two conceptualizations are covered by the same number
The Gerontologist, 2019, Vol. 59, No. 2 e105

of indicators but the first one includes one more study. The

No. of studies
vast majority of the other possible conceptualizations are
not covered by any studies and three conceptualizations
have up to two indicators and two studies.

3
0
8
0
Discussion
No. of indicators
This systematic review aims to answer two review ques-
tions: How has ageism in health care been operationalized
in quantitative studies? How has ageism in health care been

5
0
19
0

inductively conceptualized in qualitative studies?

We found two main forms of operationalizing ageism

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in the quantitative studies that did not administer scales
8 [8; 17; 19; 22; 35]

of ageism and three main forms of operationalizing age-

Other-directed

ism in the quantitative studies that administered scales of

Table 4. Number of Indicators and Studies in Each Component and Inductive Conceptualization of Ageism (Qualitative Studies)

Note: The numbers between square brackets correspond to the identification numbers of the reviewed studies, which are described in Supplementary Appendix 1. ageism. If we look at the two groups of quantitative studies
as a whole, we can verify that the components of ageism
which are completely absent in these five forms of opera-
5
8
0
0
0

tionalization are the self-directed and the implicit compo-

nents. This has clear implications for the study of ageism
Self-directed

in the context of health care, as well as for developing

Behavioral

interventions to tackle ageism in practice. With respect to

1 [8]

the self-directed ageism in relation to older patients, this

1
1
0
0
0

component of ageism can assume several manifestations,

such as refusing certain diagnostic procedures/tests and
Other-directed

certain treatments because of the perception of being “too

old,” and believing that certain symptoms have to do with
“normal ageing” (articles 19 and 28). If we do not pay
due attention to these practices, attitudes, and beliefs, we
0
0
0
0
0
0

run the risk of not capturing the full picture of ageism in

health care, underestimating its prevalence and perpetuat-
Self-directed

ing situations with potential severe consequences for older

Affective

patients. Furthermore, self-directed ageism tends to be

implicit (unconscious), which makes it particularly insidi-
0
0
0
0
0
0

ous and harmful (Levy & Banaji, 2002). This justifies the
importance of identifying the possible manifestations of
8 [8; 16; 17; 19; 30; 35]

self-ageism in the context of health care, so that appropri-

ate interventions can be developed to fight them.
Regarding implicit ageism, it is important to underline
Other-directed

4 [19; 30; 35]

that it is insidious (Levy & Banaji, 2002) and can assume

different manifestations in health care, such as believing
that older people do not fit in the hospital environment
6
12
0
0

(article 30) and believing that older patients cannot tolerate

the same treatment administered to younger patients (arti-
cle 35). Many ageist practices are rooted in implicit nega-
Self-directed

2 [19; 28]

tive stereotypes about older people and old age (Nelson,

Cognitive

2002) and this is also found in the care contexts (Clarke,

1 [19]

Bennett, & Korotchenko, 2014). A review of the literature

2
3
0
0

on ageism and age discrimination in primary and com-

munity health care in the United Kingdom concluded that
Negative
Negative
Positive
Positive

“Age barriers are often implicit rather than explicit so that

No. of indicators

simply removing age criteria from clinical protocols and

No. of studies

guidelines will not necessarily eliminate ageist practices”

(Clark, Hayes, Jones, & Lievesley, 2009). This urges us
Implicit
Explicit

to take into account the implicit component of ageism in

future operationalization and inductive conceptualization
e106 The Gerontologist, 2019, Vol. 59, No. 2

of this concept, as we can only effectively tackle ageism The inductive conceptualizations of ageism offered
in health care if we are able to identify and measure their by qualitative studies include facets of ageism account-
implicit manifestations. ing for discrimination but almost exclusively in treatment
We also verified that the quantitative studies which did and management. As we had the opportunity to note, this
not administer scales of ageism neglected the facets of dis- also happens with respect to the dominant forms of opera-
crimination in diagnosis and clinical trials. Ageism in diag- tionalizing ageism found in the quantitative studies that
nosis is no less important than ageism in treatment and did not administer scales of ageism. The implications are
management, and for this reason the existing negligence of discussed above.
the first facet should be overcome. Concerning clinical tri-
als, international regulatory agencies recommend avoiding
arbitrary upper age limits, as the exclusion of older persons Recommendations for Future Research
from clinical trials implies that health professionals have Based on the discussion of the results, priority recommen-

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limited clinical evidence when treating older patients, with dations for future research on ageism in health care can be
obvious risks for the later. formulated. First, considering that any operational defini-
There is one more aspect related to the quantitative tion and inductive conceptualization is influenced, at least
studies which used scales of ageism that is important to partially, by the conceptual definition of the phenomenon
mention. The indicators (statements) of these scales do not under study, we recommend that future studies adopt a
measure ageism directed towards older patients but rather comprehensive conceptual definition of ageism, like the one
towards older people in general. There are even some state- provided in this article. As argued by Iversen and colleagues
ments which are irrelevant to health care, such as the fol- (2009, p. 5), “A clear definition may thus be the starting
lowing one included in the Attitudes Towards Older People point on the way to achieving a higher degree of reliability
Scale: Most old people would prefer to quit work as soon and validity in future studies of ageism.”
as pensions or their children can support them (for other Second, we recommend that future research make efforts
examples, please refer to Supplementary Appendix 3, to measure and assess stereotypes and prejudices specifi-
Section A). In this respect, it is important to recognize that cally directed towards older patients. If we think of scales
the condition of being an older patient is different from or similar instruments, this could be achieved by selecting
the condition of being an older person, and this leads us older patients as the targets of statements containing ste-
to believe that there are stereotypes, prejudices, and dis- reotypes and prejudices.
criminatory practices specifically related to the condition Third, it would be important that future studies devote
of being an older patient. Furthermore, considering that special attention to measuring and assessing self-stereotyp-
there is evidence that some health professionals have posi- ing, self-prejudice, and self-discrimination. This could be
tive attitudes towards older people, but exhibit negative done through different research methods and approaches,
attitudes towards older patients (Penner Ludenia, & Mead, such as scales and other self-reporting techniques, experi-
1984), probably the prevalence of ageism would not be the mental designs (similar to those adopted by articles 1 and
same if we administered a scale of ageism in which the tar- 2), interviews, and diaries. In addition to the manifestations
gets were older patients instead of older persons. In our and prevalence of self-directed ageism, it would also be
viewpoint, measuring/capturing ageism directed specifically important to explore its etiology and consequences.
towards older patients in the context of health care has Fourth, implicit ageism also deserves more attention
two chief advantages. First, it enhances our understand- in future research. However, measuring and assessing this
ing of the phenomenon of ageism in the particular setting component of ageism is a particularly difficult task, as
of health care. Second, this understanding is essential to recognized by Abrams and colleagues (2015) and by the
develop interventions to tackle ageism specifically tailored authors of one of the reviewed studies (article 32). One of
to the reality of health care, and these tailored interventions the instruments that are commonly used to measure implicit
are more likely be more effective. For example, we are con- ageism is the Implicit Association Test (IAT). However, this
vinced that interventions to fight ageism in the daily prac- instrument has some limitations, as it is unable, for exam-
tices of health care professionals would be more effective ple, to capture how implicit ageism is produced and repro-
if focused on negative stereotypes and prejudices towards duced through language in daily life (Gendron, Welleford,
older patients rather than towards older people in general. Inker, & White, 2016). In this respect, it is important to
With regard to qualitative studies, we found that the underline that we still know little about how implicit biases
self-directed, affective and positive components are absent are manifest in naturally occurring social interactions
in the inductive conceptualizations produced. The implica- (Stivers & Majid, 2007). Therefore, one of the main chal-
tions of the inattention devoted to the self-directed compo- lenges regarding the study of implicit ageism in the context
nent were already addressed. In turn, ignoring aspects of of health care, as in other contexts, is to develop research
affective and positive ageism also contributes to a partial approaches able to capture it in naturally occurring inter-
exploration of ageism in health care, mainly with respect to actions. Videotaping the care encounters is an interesting
its manifestations and prevalence. research approach to achieve this (see Stivers & Majid,
The Gerontologist, 2019, Vol. 59, No. 2 e107

2007), but participant observation could also be a valid Supplementary Material

approach, given that it is very powerful in grabbing the
Supplementary data are available at The Gerontologist
finer and the taken for granted aspects of daily practices.
online.
Still in relation to implicit ageism, it would also be impor-
tant to explore in more depth not only its manifestations
and prevalence, but also its etiology and consequences. Funding
There are other recommendations that should not be
This paper is funded by FCT-Foundation for Science and Technology
dismissed by future studies, such as discrimination in diag-
and FEDER/COMPETE (Project UID/SOC/04020/2013; POCI-01-
nosis, discrimination in clinical trials, and positive ageism. 0145-FEDER-007659; Grant UID/ECO/04007/2013). This pub-
lication is also supported by COST (the acronym for European
Cooperation in Science and Technology) IS1402 on ageism.
Strengths and Limitations

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The inclusion of quantitative and qualitative studies adds
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