Introduction

Population aging is a worldwide phenomenon and the elderly population is also increasing dramatically in our country (United Nations, World Population Prospects 2017; TUİK, Turkish Statistical Institute 2018a). According to World Health Organization (WHO), the number of adults over 60 in the world was 12% in 2015 and is projected to reach 22% in 2050 (WHO 2015). While Turkey ranked 91st among the eldest countries in 2012, it has moved up to the 66th rank in 2016. The population aged ≥65 years in Turkey has increased by 17% in the last 5 years, and the elderly accounted for 8.3% of the entire population in 2016 (TUİK 2017). The Turkey of 2050 is envisaged as an ‘elderly country’ (TUİK 2018b).

Palmore (1999) defines old age with positive terms such as kindness, wisdom, reliability, prosperity, freedom, political power, eternal youth and happiness, but also with negative terms such as illness, uselessness, homosexuality, diminished mental functions, isolation, poverty and depression (Palmore 1999). The WHO defines ageism as stereotyping and discriminating against people according to their age and approaching and categorizing them with prejudice (WHO 2019). Palmore, on the other hand, defines ageism as a term that includes prejudice, different attitude and actions against people due to their age and expressed with the behavior and attitudes of the people. It states that ageism is the third most common form of discrimination in the world after racism and sexism (Palmore 1999).

Conditions such as illness, disability, dependent living or need for support and decreased contribution in the working population accompany old age. In parallel with aging, the expected cost of aging is one of the most important factors brought to the agendas of countries and international organizations (Lindgren 2016).

Cross-cultural sensitivity is a dynamic concept that is defined as an individual’s ability to develop a positive feeling aimed to encourage an individual to appropriate and effective behavior, and to internalize and appreciate cultural differences. Cross-culturally sensitive individuals understand and appreciate cross-cultural differences and derive positive results from such interaction (Chen 2010).

Respect for the elderly has become a part of Turkish culture with the influence of living with the elderly and the position of the elderly in the family in our culture. However, the changing socio-economic conditions, migration, urbanization and rapidly advancing technology are also causing changes in the Turkish culture (Ozmen 2013).

The attitudes towards the elderly are reported as positive, negative or mixed in studies carried out regarding ageism (Vefikulucay and Terzioglu 2011). And, it becomes important to determine the attitudes and thoughts of the students aimed for the elderly first in order to realize this (Altay and Aydın 2015). It may be told that clinical practices contribute in developing the geriatric nursing skills of students and increase their care and cultural sensitivity towards the elderly (WHO 2011).

Ageism is a global problem (North and Fiske 2012). In this context, evaluation of attitude towards old age in different cultural structures and different ethnicities constitutes social codes. Knowledge these cultural codes in the health services provided to the society helps to find solutions against the attitude of ageism (North and Fiske 2012). It is essential to evaluate the attitudes of the healthcare providers towards the elderly. It is crucial to evaluate the attitudes of young individuals regarding ageism regularly and examine the social and communal characteristics that influence discrimination (such as migration, cultural integration) in order to take early measures against negative ageism. Therefore, conducting a study on young individuals who are university students will ensure that the needs in this field are identified and improved.

Materials and Methods

Study Design

This research was conducted as a relationship seeker to determine the relationship between ageism and cross-cultural sensitivity levels of university students.

Research Centre

Our research was conducted at Ankara Yildirim Beyazit University Health Sciences Faculty.

Particpants

The environment of this research was comprised of 1195 students studying at Ankara Yildirim Beyazit University Health Sciences Faculty Nursing Department, Social Services Department, Physiotherapy and Rehabilitation Department, Nutrition and Dietetics Department and the Geriatric Care Program of Health Services Vocational School of Higher Education, within the boundaries of Ankara province.

The research sample was calculated from the standard deviation value from the ‘Ageism Attitude Scale’ found in the study carried out by Kolcu and Kucuk (2017) (SD = 7.35) and the n = N x σ2 x Z2/ (N-1) x d2 formula that is used under circumstances where the universe is known (Kolcu and Kucuk 2017). The confidence level was accepted as 95% and the deviation as d = 0.60 in the formula (Esin 2014). It was calculated as n = (1195 x (7.35) 2 x (1.9616) 2 / 1194 × 0.62) = 578. The surveys of 76 students were deemed invalid because they had missing responses (Esin 2014). Simple random numbers table was used to select the sample and 502 students from Ankara Yildirim Beyazit University Health Sciences Faculty were included in the study in total, as 226 from the Nursing Department, 38 from the Social Services Department, 114 from the Physiotherapy and Rehabilitation Department, 100 from the Nutrition and Dietetics Department and 23 from the Geriatric Care Program of Health Services Vocational School of Higher Education.

Nursing students are 1st, 2nd, 3rd and 4th grade students and attend clinical practice with the elderly every year. Nursing 4th grade students take 2 credit geriatrics course. Nutrition and dietetic department includes 1st and 2nd grade students. They don’t have curriculum about the elderly. It is incidental for them to come across with the elderly during clinical practice. Physical therapy and rehabilitation department includes 1st and 2nd grade students. Geriatrics course is available in 3rd grade. As of 2nd grade, they attend to clinical practice and encounter the elderly. Social services department includes 1st and 2nd grade students. They don’t have curriculum about the elderly. It is incidental for them to come across with the elderly during clinical practice. Elderly care department students include 1st and 2nd grade students. Elderly care students take geriatrics course as of 1st grade and they attend to clinical practice.

Research Inclusion Criteria

Students enrolled as university students at the aforementioned University and the related departments, were 18 years’ old and above and accepted to participate in the research on volunteerism basis were included in the research.

After obtaining the ethics board permit and institution permits, the course teacher of the department where the survey will be applied was briefed first and an appointment was set. The program was planned considering the exam periods. The informed consent form was distributed to the students prior to the course, on the previously determined day and time; the data were collected with the survey form that was handed out after they were briefed by the researcher. The questions of the volunteers regarding the study were responded by the researchers. An average time of 20 min was given to collect the data.

Data Collection

Socio-demographic and Elderly Aimed Attitude Data Form, Positive and Negative Ageism Scale, Cross-Cultural Sensitivity Scale that were prepared as a result of literature reviews were used to collect the data.

Socio-Demographic and Elderly Aimed Attitude Data Form

The socio-demographic and elderly aimed attitude data form was prepared as a result of literature reviews (Karadag et al. 2012; Koc et al. 2013, 2018; Shiovitz-Ezra et al. 2016), it is comprised of 19 questions consisting of age, sex, family type, educational status, perceived income status, place lived at the longest, status of living with an elderly individual in the family, status of having received a training on elderliness prior to undergraduate-associate education, whether a training on geriatric care is necessary or not, experience with elderly people, finding oneself adequate to provide care to geriatric patients, presence of a geriatric care certificate, desire to work with geriatric patients or in geriatrics clinic following undergraduate-associate graduation, having visited a nursing home previously, the age as of which the elderliness period starts, where they want their parents to spend their lives when they get old, experiencing problems in providing care to elderly individuals, frequency of communication with elderly people and the reason for desiring to work with the elderly.

Positive and Negative Ageism Scale (PNAS)

The scale validity and reliability were tested by Yurttas and Sarikoca (2018). This scale is a measuring tool that was developed to measure the attitudes of university students regarding ageism and consists of two sub-dimensions (Yurttas and Sarikoca 2018).

One of these sub-dimensions is ‘Positive Ageism Sub-dimension’; it consists of 13 items (1, 2, 7, 9, 10, 12, 13, 14, 17, 18, 20, 21, and 23) and measures the positively discriminating attitudes of university students aimed for the elderly. The highest score that can be obtained from this sub-dimension is 65 and the lowest possible score is 13. A high score obtained indicates that the level of positive attitude aimed for the elderly is high.

The other sub-dimension – ‘Negative Ageism Sub-dimension’ consists of 10 items (3, 4, 5, 6, 8, 11, 15, 16, 19, and 22) and is inversely scored since it contains negative expressions against the elderly. A high score obtained by inverse scoring indicates that the level of negative attitude aimed for the elderly is low. The highest score that can be obtained from this sub-dimension is 50 and the lowest possible score is 10. The ‘Negative Ageism Sub-dimension’ measures the negatively discriminating attitudes of university students towards the elderly (Yurttas and Sarikoca 2018). The general Cronbach Alfa for the scale is 0.801. In our study, Cronbach Alfa is 0.775.

Cross-Cultural Sensitivity Scale

The scale that was developed by Chen and Starosta (2000) is comprised of 24 questions. A likert scale of 5 as ‘5= Absolutely agree’, ‘4= Agree, ‘3= Indecisive, ‘2= Disagree, ‘1= Absolutely disagree’ was used for the responses corresponding to the expressions of the participants (Chen and Starosta 2000).

The scale has 5 sub-dimensions.

  1. 1-

    ‘Participation in Cross-cultural Interaction’ is related with the feelings of participants about participating in cross-cultural interaction. It is comprised of 7 questions as items 1, 11, 13, 21, 22, 23, 24.

  2. 2-

    ‘Respecting Cultural Differences’ addresses the tendencies or bearing capacities of the participants regarding different cultures and ideas. It consists of 6 questions, as items 2, 7, 8, 16, 18, 20.

  3. 3-

    ‘Self-confidence in Cross-cultural Interaction’ questions how self-confident the participants are in the cross-cultural environment. It consists of 5 questions, as items 3, 4, 5, 6, 10.

  4. 4-

    ‘Enjoying Cross-cultural Interaction’ is related with reacting positively or negatively to communicating with people from different cultures. It is comprised of 3 questions, as items 9, 12, 15.

  5. 5-

    ‘Being Attentive to Cross-cultural Interaction’ is aimed to examine the efforts of the participants to understand what happens in cross-cultural interaction. It is comprised of 3 questions, as items 14, 17, 19.

Items 2, 4, 7, 9, 12, 15, 18, 20 and 22 of the scare are scored inversely. The Cronbach Alpha coefficients calculated in two different applications, carried out within the scope of the reliability study of the original scale, are 0.86 and 0.88. Cronbach Alfa is 0.728 in our study.

Ethics

Permissions were obtained from the authors for the Positive and Negative Ageism Scale (PNAS), Cross-cultural Sensitivity Scale that were used in the research. Ethics board approval was obtained from Yildirim Beyazit University Ethics Board, by protocol Number: 19.04.2019–23, prior to starting the research. Written permission was obtained from the volunteer university students that participated in the research, with the informed consent form.

This research can solely be generalized to the studied sample.

Data Analysis

Statistical Package for the Social Sciences (SPSD) for Windows 15.0 statistics package program was used to evaluate the obtained data. Descriptive statistics, Student t-test, One-Way ANOVA, Kruskal Wallis, correlation analysis test statistical analysis methods were used in evaluation.

The dummy variables, coded below, were produced for analysis:

Findings

The mean age of the participants was 20.36 ± 1.85 years and 432 (86.1%) participants were female. From the students that were included in the research, 45% were Nursing, 22.7% were Physiotherapy and Rehabilitation, 19.9% were Nutrition and Dietetics, 7.6% were Social Services and 4.8% were associate geriatric care students. 93% (467) of the students study in a department at the undergraduate level. Generally, majority of the students (86,5% (434)) did not study regarding old age before undergraduate/graduate level. Only 3,2% (16) has elderly care certificate.

The distribution of demographic characteristics presented in Table 1.

Table 1 Distribution of students by demographic characteristics
Full size table

Among the groups, there is a significant difference in terms of the total average scores of positive ageism for the desire to receive training about elderly care (p = 0.000), having an experience with an elderly individual (p = 0.000), the desire to work with geriatric patients after graduation (p = 0.001) and the idea of where the parents should live when they are older (p = 0.000).

There is a significant difference in terms of the total average scores of negative ageism for the desire to work with geriatric patients after graduation (p = 0.003), the age at which the old age period begin (p = 0.000), the idea of where the parents should live when they are older (p = 0.035) and experiencing problems while giving care to the elderly individual (p = 0.000).

Among the groups, there is a significant difference in terms of the total average scores of positive ageism for the desire to receive training about elderly care (p = 0.001), having an experience with elderly individual (p = 0.009), the desire to work with geriatric patients after graduation (p = 0.000), the desire to work with geriatric patients after graduation (p = 0,000), the age at which the old age period does not begin (p = 0.001), experiencing problems while giving care to the elderly individual (p = 0.000), and where the parents should live when they get older (p = 0.000) (Table 2).

Table 2 Distribution of PNAS scores as based on the socio-demographic and elderly oriented characteristics of students
Full size table

A statistically significant difference was found when the mean score of self-confidence in cross-cultural interaction, which is a sub-dimension of the cross-cultural sensitivity scale, was compared with feeling oneself adequate in providing care to a geriatric patient (p < 0.05). A statistically significant difference was found in the cross-cultural sensitivity mean scores between departments (p = 0.020). The cross-cultural sensitivity scores of students studying in the geriatric care department were found to be less than those studying in the other healthcare fields.

While there is a weak level advanced significant relationship between positive ageism variable and negative ageism variable (r = 0.308, p < 0.001), there is a positive high level advance significant relationship with the Positive and Negative Ageism Total (r = 0.821, p < 0.001) variable. There is a positive weak level advance significant relationship with Cross-cultural Sensitivity Scale Total variable. Table 3 shows Correlations of PNAS and Cross-cultural Sensitivity Scale Scores.

Table 3 Correlations of PNAS and Cross-cultural Sensitivity Scale Scores
Full size table

Discussion

We evaluated the attitudes of the students towards the elderly using PNAS in this study conducted with students studying in different fields of healthcare. We determined a positive ageism in the students in general. In the studies that are carried out regarding ageism, there are a number of studies demonstrating that the attitudes towards the elderly are positive (Yilmaz et al. 2017; Koc et al. 2013; Uysal et al. 2020; Shiovitz-Ezra et al. 2016; Baser and Cingil 2018, 2019) as well as studies demonstrating that they are negative (Rathnayake et al. 2016; Alkaya and Okuyan 2017; Koc et al. 2018). Our findings in this research are similar to the studies reporting positive attitudes towards the elderly. Our study shows that students hold negative ageism as well as positive ageism. In parallel with our findings, there are studies reporting positive or negative ageism or a mixture of both (Vefikulucay and Terzioglu 2011).

Students having experience with the elderly affects ageism. In the study of Karadag et al. (2012), they concluded that as the students share different settings, time and experiences with the elderly, their status of satisfaction increased and they are pleased with this (Karadag et al. 2012). This is a pleasing result. We believe that having experience influenced the result positively since the students had close relationships with the elderly and their biases were reduced.

We found a statistically significant difference when we examined the desire to work with geriatric patients following graduation. The positive ageism mean scores of those who wanted to work with geriatric patients following graduation were higher than those who did not want to work with geriatric patients, and the ratio of students who wanted to work with geriatric patients following graduation was determined as 46.8%. In a study conducted with nursing students, Yilmaz demonstrated that the students did not feel ready or did not want to work with the elderly after they graduated and did not have adequate knowledge about the elderly people (Bahadir-Yilmaz 2018). Another study reported that students wanted to work with elderly individuals (Yilmaz and Ozkan 2010). We believe that the desire of the students to work with the elderly following graduation improved the positive attitude in our study.

We observed that 53.8% of the students lived with an elderly in the family, when we examined the analysis of the results aimed for the elderly. We did not find a statistically significant difference when we compared living with an elderly individual with the positive and negative ageism mean scores. However, we observed that the negative ageism scores of those who lived with an elderly were higher. In different studies conducted with university students, the positive discrimination score for the elderly of those who lived with an elderly person in the family at any time of their lives was significantly higher than those who did not (Dincer et al. 2016). The fact that they want to live with their parents after starting a family also positively affects elderly discrimination (Baser and Cingil 2019). This result may be explained as the students forming the study group were affected by the elderly they lived with, and their negative attitudes towards the elderly and the elderliness process increased.

We observed that the Self-confidence in Cross-cultural Interaction mean score of students studying at the health sciences faculty was 15.69 ± 1.54 in our study. Similar with our study, the Self-confidence in Cross-cultural Interaction mean score was found as 17.59 ± 3.39 in a study that Bulduk et al. conducted in the vocational higher school of healthcare services (Bulduk et al. 2017).

We observed that the level of finding oneself adequate to provide care to a geriatric patient was higher in students with high self-confidence in cross-cultural interaction. An individual from a different culture may experience fear, have communication problems while providing care to the patient and experience problems due to factors such as not knowing how to remove cultural barriers (Pandey et al. 2014). A study reported that the ratio of nurses who were not trained in cross-cultural nursing were high and the participants were willing to participate in a training program in order to be able to understand the culture of the community they lived better (Yilmaz et al. 2017). It is believed that expanding cross-cultural education in the health sciences faculty will increase self-confidence along with knowledge and this will positively influence communication with patients and the quality of care.

The study was conducted only in one university and one society. This research can solely be generalized to the studied sample. The result of the studies are self-reported; there was not any observation in the current study. According to the results of the study, we recommend that the curricula of Medical and high school students should be revised and enable all students to provide care for the elderly in their clinical practice.

Conclusion

In conclusion, it was found that ageism is affected by the desire to receive training about elderly care, having an experience with elderly individual, the desire to work with geriatric patients after graduation, the age at which the old age period begins, where the parents should live when they get older, experiencing problems while giving care to the elderly individual. It was determined that students studying in the nursing, physical therapy and rehabilitation, elderly care departments of the Faculty of Health Sciences have a curriculum related to the elderly during their education period and they have experience with the elderly individual in the internship. It was observed that the nutrition and dietetics department and the social service department did not take a course related to old age and their encounters in internships were incidental. For this reason, the courses towards the elderly are recommended in the first year of the education of all Faculty of Health students, and it is recommended that all students experience and work with the elderly during the education in order to further reduce the ageism.

Our study presents important findings in terms of determining the attitudes of Eastern and Western societies towards ageism. There are multiple factors in ageism regarding positive and negative attitudes. The health care service that is differentiated from cultural traditions may not be sufficient. Accordingly, data on old age and ageism should be integrated in the delivery of modern health care services. Such activities involving the elderly individuals and making trips to the nursing home in the city where the university is located can be recommended.