Gerontology & Geriatrics Education

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wgge20

Attitudes toward aging of health professions

students: Implications for geriatrics education

Dylan J. Jester , Kathryn Hyer , Anna Wenders & Ross Andel

To cite this article: Dylan J. Jester , Kathryn Hyer , Anna Wenders & Ross Andel (2020): Attitudes
toward aging of health professions students: Implications for geriatrics education, Gerontology &
Geriatrics Education, DOI: 10.1080/02701960.2020.1835657

To link to this article: https://doi.org/10.1080/02701960.2020.1835657

View supplementary material

Published online: 28 Oct 2020.

Submit your article to this journal

Article views: 33

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=wgge20
GERONTOLOGY & GERIATRICS EDUCATION
https://doi.org/10.1080/02701960.2020.1835657

Attitudes toward aging of health professions students:

Implications for geriatrics education
a a
Dylan J. Jester , Kathryn Hyer , Anna Wendersa,b, and Ross Andel a,c

a
School of Aging Studies, University of South Florida, Tampa, Florida, USA; bMorsani College of Medicine,
University of South Florida, Tampa, Florida, USA; cDepartment of Neurology, Memory Clinic, 2nd Faculty of
Medicine, Charles University and Motol University Hospital, Prague, Czech Republic

ABSTRACT KEYWORDS
We compared attitudes toward aging of students from several health Ageism; attitudes about
professions (N = 1,156: 286 medical, 275 pharmacy, 213 undergraduate older patients; student
nursing, 160 graduate nursing, 139 Internal Medicine residents, 49 attitudes; geriatrics
physical therapy, and 34 physician assistant), and assessed the con­ workforce enhancement
program
struct validity of the Image of Aging Scale. Physical therapy and
graduate nursing students reported more positive attitudes toward
aging in comparison to all other health professions (all p <.001).
Differences in attitudes were not strongly affected by demographic
variables, clinical exposure, desire to pursue primary care, or interest in
providing care to older adults. The Image of Aging Scale yielded good
internal reliability and adequate construct validity for health profes­
sions students. Health professions students’ attitudes toward aging
largely reflect the students’ professional training, rather than student
characteristics or career goals. The Image of Aging Scale is a robust
measure of attitudes toward aging in health professions students and
in older adults.

Introduction
Improving attitudes toward aging has become a central goal of many geriatrics educational
interventions (Samra, Griffiths, Cox, Conroy, & Knight, 2013). Attitudes toward aging affect
the quality of healthcare given to older patients through overtreatment (e.g., pursuing
curative treatments near the end-of-life) or undertreatment (e.g., not providing adequate
pain relief) (Ouchida & Lachs, 2015). Additionally, more positive attitudes toward aging
will influence students’ willingness to consider geriatrics as a career path (Fitzgerald, Wray,
Halter, Williams, & Supiano, 2003; Hughes et al., 2008). Given the national geriatrics
workforce shortage, a focus on improving student attitudes toward aging may be one way
to increase the number of providers who care for older adults.
Interventions seeking to improve attitudes have relied on simulation experiences
(Varkey, Chutka, & Lesnick, 2006), geriatrics clinical skills training (Goeldlin et al., 2014),
and empathy development through interaction, intergenerational programs, or training
modules (Abeyaratne, Bell, Dean, White, & Maher-Sturgess, 2020; Chippendale & Boltz,
2015; Gonzales, Morrow-Howell, & Gilbert, 2010; Riess, Kelley, Bailey, Dunn, & Phillips,
2012). In a meta-analysis of 63 studies (Burnes et al., 2019), ageism-reducing interventions

CONTACT Dylan J. Jester djjester@usf.edu School of Aging Studies, University of South Florida, Tampa, FL 33612
Supplemental data for this article can be accessed on the publisher’s website.
© 2020 Taylor & Francis Group, LLC
2 D. J. JESTER ET AL.

were found to significantly improve attitudes toward older adults, knowledge of aging, and
comfort with older adults.
Reviews of health professions students’ attitudes toward aging reveal that physicians,
medical students, and nursing students are most often recruited for geriatrics training
programs despite the important role of other professions such as physical therapy, phar­
macy, or physician assistant students (Liu, While, Norman, & Ye, 2012; Samra et al., 2013).
Overall, student nurse attitudes toward aging appear to be more positive than medical
students (Liu et al., 2012). Analyses of physical therapy (Blackwood, Sweet, & Martin, 2014;
Hobbs, Dean, Higgs, & Adamson, 2006) and pharmacy students (Adkins, Mayhew, Gavaza,
& Rahman, 2012; Gavaza, Smith, & Adkins, 2012) suggest relatively positive attitudes
toward aging, though an absence of a commonly-used comparison group (e.g., medical
students) reduces the interpretability of the results. Moreover, student attitudes are gen­
erally not affected by student demographics (Adkins et al., 2012; Hughes et al., 2008),
though this has yet to be shown in all student health professions groups and deserves greater
investigation.
Assessing the student attitudes of multiple health professions may help training pro­
grams (i.e., Geriatrics Workforce Enhancement Programs (Health Resources and Services
Administration, 2018) [GWEPs]) by identifying professions that may require additional
empathy development during geriatrics educational interventions. Given the potential
impact of ageism on healthcare outcomes for older adults (Ouchida & Lachs, 2015),
a better understanding of the biases held by multiple professions of healthcare providers
is crucial.
One measure to assess attitudes toward aging is the Levy, Kasl, and Gill (2004) Image of
Aging Scale. This 18-item measure assesses older adults’ self-reported positive and negative
attitudes toward aging. Given its ease of administration, others (Chippendale, 2015;
Chippendale & Boltz, 2015; Jester, Hyer, Guerra, Robinson, & Andel, 2019; Lytle & Levy,
2019; Thompson & Weaver, 2016) have used the Image of Aging Scale with various health
professions students to assess students’ attitudes toward aging.
Based on previous research, we build on current knowledge regarding the geriatrics
education literature in four ways: 1) We report differences in student attitudes by health
profession. Hypothesis 1: Given literature suggesting that nursing students (Liu et al., 2012),
pharmacy students (Adkins et al., 2012; Gavaza et al., 2012), and physical therapy students
(Blackwood et al., 2014; Hobbs et al., 2006) generally have positive attitudes toward aging
and older adults, we hypothesized that graduate nursing, undergraduate nursing, physical
therapy students, and pharmacy students will have more positive attitudes toward older
adults than physician-centered professions (i.e., medical students, Internal Medicine resi­
dents, and physician assistant students). 2) We examine differences in attitudes by profes­
sion after controlling for relevant demographic, clinical exposure, and career aspiration
variables. Hypothesis 2: Given the previously observed findings that demographics matter
little when measuring attitudes toward aging in student populations (Adkins et al., 2012;
Hughes et al., 2008), we hypothesized that differences in attitudes toward aging across
professions will be unaffected after controlling for covariates. 3) We provide an initial
assessment of construct validity of the Image of Aging Scale in students from various health
professions. Hypothesis 3: The Image of Aging Scale would have good psychometric
properties as determined by the adequacy of the construct validity and internal reliability. 4)
We report differences in attitudes toward aging by academic semester. Hypothesis 4: Given
 GERONTOLOGY & GERIATRICS EDUCATION 3

the substantial changes to geriatrics curricula across several colleges via the GWEP
(Appendix S1), we hypothesized that attitudes would improve over each semester.

Methods
Data & procedure
Data were collected in health professions students’ classes either in-person or over the
Internet using Qualtrics from Spring 2017 through Spring 2019. Faculty in the Colleges of
Medicine (including medicine, physician assistant, and physical therapy), Pharmacy, and
Nursing asked students to complete the survey after consenting. Internal Medicine residents
completed forms during geriatrics clinical rotations. The study was approved by the
University of South Florida’s Institutional Review Board. In total, 1,156 students and
residents completed the Image of Aging Scale and provided information about their
profession. Additionally, a subset of the original 1,156 students (47%, n = 541) reported
detailed demographic information. These 541 students were used to ascertain whether the
inclusion of demographic covariates would explain differences in attitudes toward aging by
profession.

Demographic measures
Respondents self-reported age group, sex, race, ethnicity, veteran status, whether they had
a rural upbringing, number of years of education in their field, number of years of clinical
experience in their field, their profession of study, and answered yes/no to questions about
their intent to pursue a career in primary care (“Do you intend/plan/would like to pursue
a career in primary care? e.g., family, internal medicine, adult/gero, general pediatrics, ob/
gyn, etc.”) and a career providing care to older adults (“Do you intend/plan/would like to
pursue a career in providing care to older adults? e.g., geriatrician, adult/gero, NP, etc.”).

Image of aging scale

We assessed attitudes toward aging using the 18-item Image of Aging Scale (Levy et al.,
2004). The two 9-item subscales that comprise this scale assess positive or negative
attributes of older adults. Following Levy et al. (2004), our directions read, “After each
word or phrase, please tell me the number from 0 to 6 that best shows how well the word
matches your image or picture of old people in general, with 0 being furthest from what you
think and 6 being closest to what you think.” Adjectives were as follows: Activity (Active,
Walks Slowly), Appearance (Well-Groomed, Wrinkled), Cognition (Wise, Senile), Death
(Full-of-Life, Dying), Dependence (Capable, Helpless), Personality (Positive Outlook,
Grumpy), Physical Health (Healthy, Sick), Relationships (Family-Oriented, Lonely), and
Will-to-Live (Will-to-Live, Given Up) (Levy et al., 2004). We primarily chose the Image of
Aging Scale for its brevity and appropriateness for measuring positive and negative attitudes
toward aging. Given that the scale is much shorter than other stereotype-based measures
that index attitudes toward aging (e.g., 34-item Kogan Attitudes Toward Old People Scale
or 32-item Aging Semantic Differential; Kogan, 1961; Rosencranz & McNevin, 1969), it was
a preferable choice to reduce the amount of time required to complete the survey. In an
4 D. J. JESTER ET AL.

increasingly digital world, shorter surveys that maintain good construct validity may be
useful to maintain high response rates in overwhelmed student populations. That said,
a variety of scales exist (Ayalon et al., 2019) and future work should examine their
comparative effectiveness specifically in student populations, preferably with a large,
diverse, sample of health professions students.

Statistical analyses
Means, standard deviations, and corresponding p-values from analysis of variance
(ANOVA) and pairwise t-tests with Bonferroni correction were calculated for the Image
of Aging Scale by profession. Linear regressions before (crude) and after covariate adjust­
ment (adjusted) were used to estimate differences in attitudes toward aging by profession
after controlling for potentially influential demographics. Multicollinearity was assessed
with variance inflation factors (VIF), with a score of 10 or greater signifying issues with
multicollinearity. R Statistical Software v.3.6.1 was used.
Because the Image of Aging Scale was originally developed to assess older participants’
age-related stereotypes (Levy et al., 2004), we calculated Cronbach’s alphas to determine the
internal reliability of the Image of Aging Scale with student responses. We also conducted
a confirmatory factor analysis (CFA) to test if the items loaded on the two prespecified
positive/negative constructs. In order to assess the fit of the CFA, several statistics were
used, including: root mean square error of approximation (RMSEA; < 0.08 suggests
adequate fit), comparative fit index (CFI; > 0.95 suggests adequate fit), and standardized
root mean square residuals (SRMR; < 0.08 suggests adequate fit) (Schreiber, Nora, Stage,
Barlow, & King, 2006). The latent variable variances (positive and negative) were fixed at
one, allowing all paths and the latent covariance to vary. CFA analyses were carried out
using the “sem” package in R.

Results
A total of 1,156 students and residents from seven health professions groups provided their
attitudes toward aging. Our results report difference in attitudes by profession and semester.

Attitudes toward aging by profession (Hypothesis 1)

Figure 1 displays the total score, positive score, and negative score of the Image of Aging
Scale by seven health professions groups. Attitudes toward aging varied by profession
(F = 18.80, p < .001). Both physical therapy and graduate nursing students had more
positive views of aging than pharmacy students, undergraduate nursing students, and
physician-centered professions (e.g., medical students, residents, and physician assistants)
(all p < .001). Medical residents, pharmacy, physician assistant, and medical students did
not differ among each other in their views toward aging. However, medical residents viewed
older adults more negatively than undergraduate nursing students (p = .03). See Table 1 for
descriptive statistics and p-values for these comparisons, and Supplemental Table S1 for
attitudes by student year/standing or concentration within each profession.
 GERONTOLOGY & GERIATRICS EDUCATION 5

Figure 1. Image of Aging Scale scores by profession.

Note. N = 1,156. Total Image of Aging Score is the Positive Subscale minus the Negative Subscale. See
Table 1 for statistically significant differences. Analyses included 286 medical students, 275 pharmacy
students, 213 undergraduate nursing students, 160 graduate nursing students, 139 Internal Medicine
residents, 49 physical therapy students, and 34 physician assistant students.

Attitudes toward aging, profession, & demographics (Hypothesis 2)

Using the full sample and not controlling for covariates (n = 1,156), physical therapy
students (β: 1.24, p < .001), graduate nursing students (β: 0.93, p < .001), and undergraduate
nursing students (β: 0.29, p = .008) reported more positive attitudes toward aging in
comparison to medical students.
Additional demographic variables were obtained from a subset of the total sample
(n = 541) (Supplemental Table S2). Before covariate adjustment, physical therapy students
(β: 1.17, p < .001), graduate nursing students (β: 1.41, p < .001), and undergraduate nursing
students (β: 0.47, p = .06) were statistically different (or trending) in comparison to medical
students (Table 2). After controlling for age, sex, race, ethnicity, veteran status, rural
upbringing, education, clinical exposure, desire to pursue primary care, and desire to
provide care to older adults, physical therapy (β: 0.95, p < .001) and graduate nursing (β:
1.03, p < .001) students viewed older adults more positively than medical students, though
the differences were modestly smaller. Undergraduate nursing students’ attitudes toward
aging were not statistically different from medical students after covariate adjustment. All
covariates only explained an additional 2% of the variance in the Image of Aging Scale total
score. Desire to pursue a career in geriatrics was associated with more positive attitudes
toward aging (β: 0.38, p = .005).

Reliability & psychometric properties (Hypothesis 3)

Cronbach’s alphas indicated good internal reliability for both positive (.84) and negative
(.85) subscales of the Image of Aging Scale with health professions students. Supplemental
Figure S1 shows the full CFA model, including the covariance between the positive and
negative latent constructs, the path values for each item of the subscales, and the error
variance estimates for each item of the subscales. Fit for this model was adequate (RMSEA:
0.07, SRMR: 0.06, CFI: 0.89), despite the test statistic suggesting otherwise (χ2: 903.83, df:
134, p < .001). See Appendix S2 for information on the strongest and weakest factors for
both positive and negative subscales.
 6
D. J. JESTER ET AL.

Table 1. Difference in Image of Aging Scale total score by profession.

Physical Therapy Graduate Nursing Undergraduate Nursing Pharmacy Medical Student Physician Assistant Medical Resident
(n = 49) (n = 160) (n = 213) (n = 275) (n = 286) (n = 34) (n = 139)
Student Health Profession M (SD) M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
Total 1.73 (1.31) 1.42 (1.45) 0.78 (1.31) 0.56 (1.28) 0.50 (1.11) 0.42 (0.84) 0.36 (1.02)
(Positive – Negative)
Positive Subscale 3.92 (0.67) 3.94 (0.79) 3.53 (0.75) 3.48 (0.77) 3.37 (0.65) 3.37 (0.64) 3.44 (0.71)
Negative Subscale 2.19 (0.92) 2.52 (0.99) 2.75 (0.91) 2.92 (0.96) 2.86 (0.76) 2.94 (0.64) 3.08 (0.72)
Significant differences using pairwise t-tests for total score on the Image of Aging Scale
Physical Therapy Graduate Nursing Undergraduate Nursing Pharmacy Medical Student Physician Assistant Medical Resident
Physical Therapy -
Graduate Nursing p = 1.00 -
Undergraduate Nursing p <.001 p <.001 -
Pharmacy p <.001 p <.001 p =.95 -
Medical Student p <.001 p <.001 p =.24 p = 1.00 -
Physician Assistant p <.001 p <.001 p = 1.00 p = 1.00 p = 1.00 -
Medical Resident p <.001 p <.001 p =.03 p = 1.00 p = 1.00 p = 1.00 -
Note. N = 1156. Bonferroni-corrected pairwise t-tests with pooled standard deviations were used.
 GERONTOLOGY & GERIATRICS EDUCATION 7

Table 2. Hierarchical linear regression determining Image of Aging Scale total score (n = 541).
Step 1 (Crude Model) Step 2 (Covariate-Adjusted Model)
Variables β (SE) p Variables β (SE) p
Profession of Study Profession of Study
Medical Student (Ref) - - Medical Student (Ref) - -
Physical Therapy 1.17 (0.25) <.001 Physical Therapy 0.95 (0.28) <.001
Pharmacy 0.14 (0.14) .32 Pharmacy −0.01 (0.17) .94
Medical Resident −0.05 (0.14) .72 Medical Resident 0.01 (0.23) .97
Graduate Nursing 1.41 (0.20) <.001 Graduate Nursing 1.03 (0.31) <.001
Undergraduate Nursing 0.47 (0.25) .06 Undergraduate Nursing 0.09 (0.34) .79
Covariates
Age
< 30 years (Ref) - -
≥ 30 years 0.35 (0.18) .05
Male Sex −0.23 (0.12) .06
Nonwhite Race −0.06 (0.13) .63
Hispanic Ethnicity −0.05 (0.17) .76
Veteran History (Yes) 0.33 (0.31) .30
Grew up in a Rural Area (Yes) −0.03 (0.15) .87
Education in Field
< 1 year 0.09 (0.18) .63
1 year −0.10 (0.21) .63
2–3 years 0.32 (0.18) .08
4–6 years (Ref) - -
≥ 7 years −0.02 (0.21) .91
Clinical Years of Exposure
0 years (Ref) - -
1 year −0.08 (0.15) .59
2–3 years −0.10 (0.18) .57
4–6 years −0.17 (0.25) .51
≥ 7 years −0.08 (0.32) .80
Desire to Pursue a Career in Primary Care −0.16 (0.12) .19
Desire to Provide Care to Older Adults 0.38 (0.13) .005
Note. N = 541. Adjusted R2Crude =.12. Adjusted R2Adjusted =.14. All variance inflation factor values were less than four,
suggesting no issues of multicollinearity among the covariates. See Supplemental Table S2 for the distributions of the
covariates.

Attitudes toward aging by semester (Hypothesis 4)

The number of students assessed by semester were: Spring 2017: 176, Fall 2017: 480, Spring
2018: 79, Summer 2018: 229, Fall 2018: 162, Spring 2019: 30. Attitudes toward aging were
statistically different by semester (F = 2.36, p = .04). However, no semester differences were
found after controlling for multiple comparisons with a Bonferroni correction for increased
risk of Type I error (all p > .05). See Supplemental Figure S2 for a graphical representation.

Discussion
Data from 1,156 students from seven health professions groups over six academic semesters
were collected to assess attitudes toward aging by profession, the appropriateness of the
Image of Aging Scale, and semester change in attitudes. Student and resident attitudes
toward aging vary by profession, with physical therapy and graduate nursing students
viewing aging most positively. These results expand prior work on attitudes toward aging
by allowing for the comparison of multiple professions, where most studies were limited to
assessing one profession without a comparison group (Liu et al., 2012; Samra et al., 2013).
Differences in attitudes were robust to a host of student demographic, clinical exposure, and
8 D. J. JESTER ET AL.

career aspiration variables. Consistent with prior literature on the effect of demographics on
attitudes toward aging (Adkins et al., 2012; Hughes et al., 2008), we found that covariates
only explained an additional 2% of the variance in the attitude total score. For GWEPs or
other geriatrics training interventions, these findings are encouraging because unmodifiable
personal characteristics such as age, sex, race and ethnicity, veteran status, or rural upbring­
ing play little if any role in attitudes; attitudes toward aging appear to be amenable to
change.

Nursing
The relatively positive attitudes in graduate nursing students compared to medical students
may be due to the area of specialization for the Master of Science in Nursing and Doctor of
Nursing Practice programs, as most chose Adult/Gerontology Acute Care or Family
Practice (Supplemental Table S1). Additionally, the graduate nursing program at the
University of South Florida experienced an enrichment of geriatrics curricula and training
from the GWEP grant, which may have also influenced attitudes (Michael et al., 2019).
These differences in concentration and curricula exposure may also explain why under­
graduate nursing students reported more negative attitudes toward aging than their grad­
uate nursing counterparts.

Physical therapy
Regarding physical therapy, Blackwood and Sweet (2017) suggest that interactions with
older adults may be highly valued by first-year physical therapy students and that these
interactions – whether personal or professional – inform their future attitudes and
beliefs by removing ageist stereotypes. Prior work suggests that both nursing and
physical therapy students have a strong interest to work with older adults, that these
students are highly confident in their decision, and that a combination of attitudes,
interaction frequency, and quality of interactions may contribute to greater interest in
working with older patients (Jackson et al., 2017). Although we were unable to accurately
measure interaction quality or quantity among graduate nursing and physical therapy
students, our models did suggest more positive attitudes even after controlling for
potentially relevant variables such as interest in geriatrics, interest in primary care,
clinical years of exposure, and years of training. We speculate that the context in
which graduate nursing and physical therapy students interact with older patients
(e.g., primary care settings where meaningful interactions beyond the medicalization
of the older patient may take place, rehabilitative settings where physical functioning
may be improving) may enhance attitudes, though future work is needed to test this
notion directly. Little is known on how attitudes toward aging change as physical therapy
students progress through their training. Although our findings suggest slight decreases
with increased training, students in Year 1 and Year 2 are almost equivalent and
attitudes of students in Year 3 may be affected by individual preferences given the
small sample size. Future work should examine if these findings hold with larger samples
of physical therapy students.
 GERONTOLOGY & GERIATRICS EDUCATION 9

Medicine & Pharmacy

Kishimoto, Nagoshi, Williams, Masaki, and Blanchette (2005) found that attitudes toward
aging were significantly more positive for first-year medical students in comparison to
more advanced students and residents, suggesting a decline with greater training. We
provide preliminary analyses by year of training in Supplemental Table S1 for each
profession. Overall, we find that first-year medical students and first-year pharmacy
students have the poorest attitudes toward aging in the beginning and ending of their
training, following a U-shaped curve. Our findings may reflect competing effects of
greater clinical exposure and the burden of managing clinically complex patients on
attitudes toward aging. While greater exposure to older patients may improve attitudes
initially, the clinical complexity of the average older adult is a major barrier to students’
interest in pursuing geriatrics (Meiboom, de Vries, Hertogh, & Scheele, 2015).
Alternatively, the results may be affected by the small sample sizes in each year and
should be examined further.
Internal Medicine residents reported poorer attitudes toward aging as training increased,
specifically in Post Graduate Year 3 (PGY-3). Prior work suggests that geriatrics rotations
during residency are more related to positive attitudes toward aging than geriatrics curri­
cula during medical school (Tufan et al., 2015). While a geriatrics rotation is necessary for
graduation from our Internal Medicine residency, very few graduates assume primary care
positions (i.e., 15% in 2015, 7% 2016, 9% 2017, 9% 2018, 3% 2019). Our residents’ disinterest
in primary care may explain why attitudes toward aging are generally low. The larger
difference in attitudes for PGY-3 may reflect specialization (i.e., our PGY-3 residents have
more elective rotations) whereas PGY-1 and PGY-2 residents may be undecided on their
future specialty. Future studies should employ a mixed methodology to better understand
the etiology of attitude changes.

Effect of covariates
Our study and other literature suggests that more positive attitudes toward aging are
associated with an interest in geriatrics (Fitzgerald et al., 2003; Hughes et al., 2008). This
is contrary to Burnes' et al. (2019) meta-analysis that ageism interventions did not increase
the willingness to work with older adults. These contradictory findings may be due to
Burnes' et al. (2019) focus on interventions, while our study was observational.
Alternatively, it may be that a desire to care for older adults is unique from the attitudes
one holds (Burbank, Burkholder, & Dugas, 2018). This is certainly conceptualized in prior
literature that suggests that a variety of factors impact the decision to care for older adults,
such as the financial prospects and the “status” of geriatric medicine as a specialty in the
physician community, clinical complexity of the patient, and lack of exposure to older
adults (Meiboom et al., 2015). No other covariates had much of an effect on the attitudes
toward aging, including the effect of clinical exposure (Table 2). However, differences in
attitudes toward aging may be affected by the year of training within the program rather
than the years of clinical exposure.
10 D. J. JESTER ET AL.

Improving attitudes toward aging

The federal government has led substantial efforts to stimulate the interdisciplinary training
of geriatrics professionals (i.e., GWEP, Administration for Community Living caregiver
training, Centers for Disease Control and Prevention Healthy Brain Initiative, Centers for
Medicare and Medicaid Services Caregiver Workgroup, Veteran Affairs Geriatrics
Research, Education, and Clinical Centers) (Weiss, 2019). In our study, graduate student
nurses had among the most positive attitudes toward aging. This supports Flaherty and
Bartels' (2019) proposal that geriatrics interprofessional teams led by nurse practitioners are
one potential solution to the geriatrics workforce shortage. We speculate that one bypro­
ductof increasing interdisciplinary geriatrics care with nurse practitioners and physical
therapists may be improved team attitudes toward older patients.
Health professions faculty must consider their role in improving geriatrics education and
interprofessional team skills. One salient goal should be the reduction of ageism and
negative attitudes toward aging held by health professions students. For universities and
medical centers to tackle ageism in health professions students, faculty intervention may be
needed. Prior work has suggested that medical faculty carry specific beliefs when teaching
geriatrics primary care content. That is, faculty prioritize general primary care skill acquisi­
tion that may fit any patient population (e.g., describing medications, performing a physical
assessment) over more sensitive topics such as age-related urinary or sexual health (Hyer
et al., 2019). Furthermore, these attitudes and belief systems may impact the beliefs and self-
rated knowledge of medical student and resident trainees (Jester et al., 2019).

Health effects of attitudes

Beyond providers, patient attitudes toward aging have powerful health effects as well. Prior
literature has suggested that positive subjective aging and attitudes toward aging are related
to improved survival (Sargent-Cox, Anstey, & Luszcz, 2014), functional health (Sargent-
Cox, Anstey, & Luszcz, 2012), cognition (Stephan, Caudroit, Jaconelli, & Terracciano,
2014), and even biomarkers of Alzheimer’s disease (Levy et al., 2016). Indeed,
a systematic review of 422 articles found that 96% show adverse health outcomes related
to ageism in 11 health domains (e.g., denied access to healthcare resources, employment,
mental health, physical health) across 45 countries (Chang et al., 2020). Ageism-related
adverse health outcomes also have enormous economic costs, estimated at 63 USD billion
over one year (Levy, Slade, Chang, Kannoth, & Wang, 2020). Given the numerous adverse
effects on older adults’ health and the attributed negative economic impact, improving
attitudes toward aging through intervention must be considered a worthwhile priority. For
example, Levy, Pilver, Chung, and Slade (2014) have shown the beneficial effects of stereo­
type interventions on physical functioning in older adults. Clearly, multiple opportunities
exist to reduce ageism, whether at the student, provider, or patient-level.

Effect of GWEP
Our study period from Spring 2017 to Spring 2019 spanned the GWEP intervention at the
University of South Florida. Unfortunately, no strong semester effects were found. This was
surprising given the large amount of geriatrics curricula development, access to
 GERONTOLOGY & GERIATRICS EDUCATION 11

interprofessional educational experiences, installation of distinguished lectures in geriatrics,

and increased access to geriatrics clinical exposures as a result of the GWEP (See Appendix
S1 for more information about our GWEP’s involvement). We speculate that these null
results may reflect methodological limitations such as a lack of longitudinal data at the
student level (intraindividual change) or the profession makeup of each semester’s sampled
cohort. Alternatively, it may be that first-year or second-year students were oversampled
and less exposed to geriatrics curricula that would be integrated later in their training
(Supplemental Table S1).

Effectiveness of the Image of Aging Scale

We report good internal reliability and for the first time, adequate construct validity of the
Image of Aging Scale in health professions students and residents. This is a significant
contribution to the literature, given that Levy et al. (2004) originally developed the scale for
older participants. According to the CFA (Supplemental Figure S1), some adjectives better
indexed positive (e.g., using Full of Life vs. Wise) and negative attitudes (e.g., using Sick vs.
Wrinkled) toward aging. These results should be considered in the future development of
scales that utilize adjectives rather than scales that use full statements. One example is the
Geriatrics Attitudes Scale (Reuben et al., 1998), where students agree or disagree with
statements (e.g., “Most old people are pleasant to be with.”) or scenarios (e.g., “The federal
government should reallocate money from Medicare to research on AIDS or pediatric
diseases.”).

Implications
The Image of Aging Scale addresses nine age-related stereotypes: Activity (Active, Walks
Slowly), Appearance (Well-Groomed, Wrinkled), Cognition (Wise, Senile), Death (Full-of-
Life, Dying), Dependence (Capable, Helpless), Personality (Positive Outlook, Grumpy),
Physical Health (Healthy, Sick), Relationships (Family-Oriented, Lonely), and Will-to-Live
(Will-to-Live, Given Up). According to the CFA, this scale measures positive and negative
attitudes toward aging via stereotypes quite well in student populations. While we present
statistical differences among professions, it has yet to be seen whether these differences manifest
into disparities in care, such as providers perpetrating ageism. Pedagogical and clinical training
systems must recognize and attempt to improve student attitudes toward aging, as any level of
ageism in student populations should be considered problematic. Harmonization of geriatrics
curricula across several colleges is no doubt an undertaking, but it may become more feasible as
advances in curricula mapping and gap analysis disseminate (Michael et al., 2019). Recognizing
that health professions students may be particularly prone to negative attitudes toward aging
near the end of their program (see Supplemental Table S1) may help when modifying or
integrating geriatrics curricula for advanced students. Because stereotypes may lead to prejudice
and discrimination, it is imperative that negative age-related stereotypes are addressed early-on
and that geriatrics curricula and experiential learning are provided throughout the training
program.
12 D. J. JESTER ET AL.

Limitations
Our study has limitations. First, assessing attitudes longitudinally at the student-level
(intraindividual) was not achievable due to the limited reporting of unique student identi­
fication numbers. It is also conceivable that some students were ultimately measured more
than once. In sensitivity analyses, we estimated the means and standard deviations of those
with unique student identification numbers (i.e., excluding those who did not report an
identification number, or identification numbers that appeared to be duplicated due to repeat
assessments). In this sample of 1,014 students (88% of the full sample), findings stayed
consistent. Second, changes to the survey methodology from Spring 2017 to Spring 2019
affected the collection of demographic information. The Image of Aging Scale was given in
several different formats over the two years (e.g., paired with other surveys, assessed alone,
electronic assessment versus paper assessment), thus harmonization of the datasets ultimately
created missing values for demographics data. Third, numbers of students from each
profession were drastically different and may impact the statistical power and generalizability.
This is primarily because health professions have smaller or larger cohort sizes (e.g., physical
therapy cohorts are considerably smaller than medical student cohorts). Fourth, acquiescent
responding bias may have played a role in the students’ responses to the Image of Aging
Scale. Given that students received an informed consent document prior to completing the
survey, they were aware that the survey was intended to examine their attitudes toward aging.
Additionally, the students were asked by faculty associated with the GWEP to participate.
While acquiescent responding bias may have skewed results toward positive responses (as
seen by the relative homogeneity of the positive scale means between professions in Figure 1),
we still found substantial variability between groups. Finally, all students came from one
academic institution. While our sample size was substantial and our sampling diverse among
different colleges, students at one institution may behave or think more similarly than
students from other institutions due to faculty culture and state demographic effects.

Conclusion
We found that physical therapy and graduate nursing students reported more positive
attitudes toward aging in comparison to medical students and residents, pharmacy students,
undergraduate nursing students, and physician assistant students. Health professions stu­
dents’ attitudes toward aging largely reflect the professions in which the students receive
training, rather than student characteristics or career goals. It is possible that didactic
approaches that take into account preexisting attitudes toward aging can more effectively
foster and promote interest in geriatrics among students in health professions. Finally, our
results support the use of the Image of Aging Scale in student and resident populations with
good construct validity and internal reliability, despite its original development for older
adults.

Acknowledgments
We would like to acknowledge Adrian N. S. Badana, Ph.D., M.P.H., Lucy Guerra, M.D., M.P.H.,
Melanie Michael, D.N.P., M.S., Dawn Schocken, M.P.H., Amy Schwartz, Pharm.D., Todd Wills, M.
 GERONTOLOGY & GERIATRICS EDUCATION 13

D., and Cheryl Wilson, D.N.P. for their early contribution to this project and the Geriatrics
Workforce Enhancement Program at the University of South Florida.

Funding
This work was supported in part by funds from the U.S. Department of Health and Human Services
(HHS), Bureau of Health Professions (BHPr), Health Resources and Services Administration
(HRSA): 6U1QHP28739-01-01.

ORCID
Dylan J. Jester http://orcid.org/0000-0001-9878-9633
Kathryn Hyer http://orcid.org/0000-0002-6445-3602
Ross Andel http://orcid.org/0000-0003-4083-4790

Conflicts of Interest
All authors report no known conflicts of interest.

References
Abeyaratne, C., Bell, J. S., Dean, L., White, P., & Maher-Sturgess, S. (2020). Engaging older people as
university-based instructors: A model to improve the empathy and attitudes of pharmacists in
training. Currents in Pharmacy Teaching and Learning, 12(1), 58–64. doi:10.1016/j.
cptl.2019.10.011
Adkins, D. M., Mayhew, S. L., Gavaza, P., & Rahman, S. (2012). Pharmacy students’ attitudes toward
geriatric nursing home patients. American Journal of Pharmaceutical Education, 76(5), 81.
doi:10.5688/ajpe76581
Ayalon, L., Dolberg, P., Mikulionienė, S., Perek-Białas, J., Rapolienė, G., Stypinska, J., . . . de la Fuente-
núñez, V. (2019). A systematic review of existing ageism scales. Ageing Research Reviews, 54,
100919. doi:10.1016/j.arr.2019.100919
Blackwood, J., & Sweet, C. (2017). The influence of ageism, experience, and relationships with older
adults on physical therapy students’ perception of geriatrics. Gerontology & Geriatrics Education,
38(2), 219–231. doi:10.1080/02701960.2015.1079709
Blackwood, J., Sweet, C., & Martin, A. (2014). Attitudes toward aging of physical therapists and
student physical therapists. Physical & Occupational Therapy in Geriatrics, 32(4), 281–293.
doi:10.3109/02703181.2014.934943
Burbank, P. M., Burkholder, G. J., & Dugas, J. (2018). Development of the perspectives on caring for
older patients scale: Psychometric analyses. Applied Nursing Research, 43, 98–104. doi:10.1016/j.
apnr.2018.07.002
Burnes, D., Sheppard, C., Henderson, C. R., Jr, Wassel, M., Cope, R., Barber, C., & Pillemer, K. (2019).
Interventions to reduce ageism against older adults: A systematic review and meta-analysis.
American Journal of Public Health, 109(8), e1–e9. doi:10.2105/AJPH.2019.305123
Chang, E.-S., Kannoth, S., Levy, S., Wang, S.-Y., Lee, J. E., & Levy, B. R. (2020). Global reach of ageism
on older persons’ health: A systematic review. PloS One, 15(1), 1–24. doi:10.1371/journal.
pone.0220857
Chippendale, T. (2015). Factors associated with interest in working with older adults: Implications for
educational practices. Journal of Nursing Education, 54(9), S89–S93. doi:10.3928/01484834-
20150814-16
14 D. J. JESTER ET AL.

Chippendale, T., & Boltz, M. (2015). Living legends: Students’ responses to an intergenerational life
review writing program. Journal of the American Geriatrics Society, 63(4), 782–788. doi:10.1111/
jgs.13236
Fitzgerald, J. T., Wray, L. A., Halter, J. B., Williams, B. C., & Supiano, M. A. (2003). Relating medical
students’ knowledge, attitudes, and experience to an interest in geriatric medicine. The
Gerontologist, 43(6), 849–855. doi:10.1093/geront/43.6.849
Flaherty, E., & Bartels, S. J. (2019). Addressing the community-based geriatric healthcare workforce
shortage by leveraging the potential of interprofessional teams. Journal of the American Geriatrics
Society, 67(S2), S400–S408. doi:10.1111/jgs.15924
Gavaza, P., Smith, B., & Adkins, D. (2012). Effect of an introductory pharmacy practice experience
geriatric rotation on pharmacy students’ learning outcomes: A qualitative study. The Consultant
Pharmacist®, 27(12), 849–856. doi:10.4140/TCP.n.2012.849
Goeldlin, A. O., Siegenthaler, A., Moser, A., Stoeckli, Y. D., Stuck, A. E., & Schoenenberger, A. W.
(2014). Effects of geriatric clinical skills training on the attitudes of medical students. BMC Medical
Education, 14(1), 233. doi:10.1186/1472-6920-14-233
Gonzales, E., Morrow-Howell, N., & Gilbert, P. (2010). Changing medical students’ attitudes toward
older adults. Gerontology & Geriatrics Education, 31(3), 220–234. doi:10.1080/
02701960.2010.503128
Health Resources and Services Administration. (2018). Geriatrics workforce enhancement program
(GWEP). Retrieved from https://bhw.hrsa.gov/grants/geriatrics
Hobbs, C., Dean, C. M., Higgs, J., & Adamson, B. (2006). Physiotherapy students’ attitudes towards
and knowledge of older people. Australian Journal of Physiotherapy, 52(2), 115–119. doi:10.1016/
S0004-9514(06)70046-0
Hughes, N. J., Soiza, R. L., Chua, M., Hoyle, G. E., MacDonald, A., Primrose, W. R., & Gwyn
Seymour, D. (2008). Medical student attitudes toward older people and willingness to consider
a career in geriatric medicine. Journal of the American Geriatrics Society, 56(2), 334–338.
doi:10.1111/j.1532-5415.2007.01552.x
Hyer, K., Jester, D. J., Badana, A. N. S., D’Aoust, R., Robinson, B. E., Guerra, L., . . . Andel, R. (2019).
Medical faculty beliefs: Self-rated importance and confidence in teaching geriatrics primary care.
Journal of the American Geriatrics Society, 67(3), 576–580. doi:10.1111/jgs.15759
Jackson, J., Clark, A., Pearse, L., Miller, E. A., Stanfield, H., & Cunningham, C. J. (2017). Explaining
student interest and confidence in providing care for older adults: The role of demographics and
life experiences. Journal of Gerontological Nursing, 43(3), 13–18. doi:10.3928/00989134-20160901-
04
Jester, D. J., Hyer, K., Guerra, L., Robinson, B. E., & Andel, R. (2019). Beliefs regarding geriatrics
primary care topics among medical students and internal medicine residents. Gerontology &
Geriatrics Education, 1–13. doi:10.1080/02701960.2019.1661841
Kishimoto, M., Nagoshi, M., Williams, S., Masaki, K. H., & Blanchette, P. L. (2005). Knowledge and
attitudes about geriatrics of medical students, internal medicine residents, and geriatric medicine
fellows. Journal of the American Geriatrics Society, 53(1), 99–102. doi:10.1111/j.1532-
5415.2005.53018.x
Kogan, N. (1961). Attitudes toward old people: The development of a scale and an examination of
correlates. The Journal of Abnormal and Social Psychology, 62(1), 44. doi:10.1037/h0048053
Levy, B. R., Ferrucci, L., Zonderman, A. B., Slade, M. D., Troncoso, J., & Resnick, S. M. (2016).
A culture–brain link: Negative age stereotypes predict Alzheimer’s disease biomarkers. Psychology
and Aging, 31(1), 82–88. doi:10.1037/pag0000062
Levy, B. R., Kasl, S. V., & Gill, T. M. (2004). Image of Aging Scale. Perceptual and Motor Skills, 99(1),
208–210. doi:10.2466/pms.99.1.208-210
Levy, B. R., Pilver, C., Chung, P. H., & Slade, M. D. (2014). Subliminal strengthening: Improving older
individuals’ physical function over time with an implicit-age-stereotype intervention. Psychological
Science, 25(12), 2127–2135. doi:10.1177/0956797614551970
Levy, B. R., Slade, M. D., Chang, E. S., Kannoth, S., & Wang, S. Y. (2020). Ageism amplifies cost and
prevalence of health conditions. The Gerontologist, 60(1), 174–181. doi:10.1093/geront/gny131
 GERONTOLOGY & GERIATRICS EDUCATION 15

Liu, Y. E., While, A. E., Norman, I. J., & Ye, W. (2012). Health professionals’ attitudes toward older
people and older patients: A systematic review. Journal of Interprofessional Care, 26(5), 397–409.
doi:10.3109/13561820.2012.702146
Lytle, A., & Levy, S. R. (2019). Reducing ageism: Education about aging and extended contact with
older adults. The Gerontologist, 59(3), 580–588. doi:10.1093/geront/gnx177
Meiboom, A. A., de Vries, H., Hertogh, C. M., & Scheele, F. (2015). Why medical students do not
choose a career in geriatrics: A systematic review. BMC Medical Education, 15(1), 101. doi:10.1186/
s12909-015-0384-4
Michael, M., Wilson, C., Jester, D. J., Andel, R., D’Aoust, R., Badana, A. N., & Hyer, K. (2019).
Application of curriculum mapping concepts to integrate multidisciplinary competencies in the
care of older adults in graduate nurse practitioner curricula. Journal of Professional Nursing, 35(3),
228–239. doi:10.1016/j.profnurs.2019.01.007
Ouchida, K. M., & Lachs, M. S. (2015). Not for doctors only: Ageism in healthcare. Generations, 39(3),
46–57.
Reuben, D. B., Lee, M., Davis, J. J., Eslami, W., Osterweil, M. S., Melchiore, D. G., & Weintraub, N. T.
(1998). Development and validation of a geriatrics attitudes scale for primary care residents.
Journal of the American Geriatrics Society, 46(11), 1425–1430. doi:10.1111/j.1532-5415.1998.
tb06012.x
Riess, H., Kelley, J. M., Bailey, R. W., Dunn, E. J., & Phillips, M. (2012). Empathy training for resident
physicians: A randomized controlled trial of a neuroscience-informed curriculum. Journal of
General Internal Medicine, 27(10), 1280–1286. doi:10.1007/s11606-012-2063-z
Rosencranz, H. A., & McNevin, T. E. (1969). A factor analysis of attitudes toward the aged. The
Gerontologist, 9(1), 55–59. doi:10.1093/geront/9.1.55
Samra, R., Griffiths, A., Cox, T., Conroy, S., & Knight, A. (2013). Changes in medical student and
doctor attitudes toward older adults after an intervention: A systematic review. Journal of the
American Geriatrics Society, 61(7), 1188–1196. doi:10.1111/jgs.12312
Sargent-Cox, K. A., Anstey, K. J., & Luszcz, M. A. (2012). The relationship between change in
self-perceptions of aging and physical functioning in older adults. Psychology and Aging, 27(3),
750. doi:10.1037/a0027578
Sargent-Cox, K. A., Anstey, K. J., & Luszcz, M. A. (2014). Longitudinal change of self-perceptions of
aging and mortality. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 69
(2), 168–173. doi:10.1093/geronb/gbt005
Schreiber, J. B., Nora, A., Stage, F. K., Barlow, E. A., & King, J. (2006). Reporting structural equation
modeling and confirmatory factor analysis results: A review. The Journal of Educational Research,
99(6), 323–338. doi:10.3200/JOER.99.6.323-338
Stephan, Y., Caudroit, J., Jaconelli, A., & Terracciano, A. (2014). Subjective age and cognitive
functioning: A 10-year prospective study. The American Journal of Geriatric Psychiatry, 22(11),
1180–1187. doi:10.1016/j.jagp.2013.03.007
Thompson, E. H., Jr, & Weaver, A. J. (2016). Making connections: The legacy of an intergenerational
program. The Gerontologist, 56(5), 909–918. doi:10.1093/geront/gnv064
Tufan, F., Yuruyen, M., Kizilarslanoglu, M. C., Akpinar, T., Emiksiye, S., Yesil, Y., . . . Yavuzer, H.
(2015). Geriatrics education is associated with positive attitudes toward older people in internal
medicine residents: A multicenter study. Archives of Gerontology and Geriatrics, 60(2), 307–310.
doi:10.1016/j.archger.2014.12.004
Varkey, P., Chutka, D. S., & Lesnick, T. G. (2006). The aging game: Improving medical students’
attitudes toward caring for the elderly. Journal of the American Medical Directors Association, 7(4),
224–229. doi:10.1016/j.jamda.2005.07.009
Weiss, J. (2019). Commentary on the geriatric healthcare workforce: Leveraging the potential of
interprofessional teams. Journal of the American Geriatrics Society, 67(S2), S409–S411.
doi:10.1111/jgs.15847