Experiences of Everyday Ageism and the Health of Older US Adults

This cross-sectional study investigates the prevalence of everyday ageism and its association with mental and physical health among adults ages 50 to 80 years.


Introduction
Ageism is a common, socially condoned type of discrimination in the US. [1][2][3] Ageism refers to stereotypes, prejudice, and discrimination related to old age, aging processes, and older adults.
Major life events rooted in age-based discrimination have been associated with poor health outcomes. [4][5][6] Less is known about routine ageism and whether it may also be associated with poorer health. Routine ageism affects more people and occurs more frequently, such as in comments about a "senior moment" or the barrage of antiaging commercials. These are examples of everyday ageism, defined as "brief verbal, nonverbal, and environmental indignities that convey hostility, a lack of value, or narrow stereotypes of older adults." 7 Everyday ageism is often subtle and may or may not be intentionally discriminatory. Nonetheless, these microaggressions may communicate that older adults are not fully accepted and respected, appreciated for their individuality, or deserving of the rights and privileges afforded other members of society.
Ageism and its associations with health are relatively understudied compared with other types of discrimination. 1 A 2021 systematic review 8 reported consistent evidence suggesting an association between ageism and adverse health outcomes. A noted limitation was that the examined studies lacked comprehensive ageism measures, instead assessing 1 or 2 types of intrapersonal ageism (eg, internalized beliefs and stereotypes). Experimental studies [9][10][11][12] have found associations between examples of everyday ageism (eg, priming participants with negative, ageist stereotypes and ageist discrimination) and a variety of adverse health outcomes. Population-level survey research may augment this work by investigating the magnitude and generalizability of ageism as a potential health risk. Scales are needed that capture the multiple manifestations and mechanisms of ageism identified in the literature (eg, Iverson et al, 13 Levy, 14 and Swift et al 15 ), including everyday ageism.
Multidimensional scales are particularly important to evaluate the collective and potentially synergistic associations of ageism with health and to identify particularly harmful forms. This study had 3 objectives: to examine the prevalence of everyday ageism among US adults ages 50 to 80 years using the newly developed, multidimensional Everyday Ageism Scale; explore disparities in everyday ageism; and investigate associations between everyday ageism and health. It builds on a brief report of preliminary findings 16 by incorporating the Everyday Ageism Scale, which has subsequently been developed and documented as psychometrically sound, 7 and comprehensively reporting study methods and findings. Everyday ageism was anticipated to be reported by an overwhelming majority of older US adults, consistent with previous ageism estimates from convenience samples of older adults 17 ; more common among socially and economically disadvantaged groups; and associated with poor physical and mental health outcomes.

Methods
This cross-sectional study was conducted in partnership with the University of Michigan National Poll on Healthy Aging (NPHA). The NPHA was deemed exempt from review and the requirement for informed consent waived by the University of Michigan Institution Review Board because data were deidentified. This study was also exempt and informed consent waived because studies of deidentified data are not classified as regulated human participant research under the Common Rule.
Poststratification weights reflect US Census population characteristics and differential participation rates; they factor in sex, age, race and ethnicity, language, education, income, home ownership, geographic variables, and nonresponse. Participants complete self-administered surveys online, with Ipsos providing web-enabled devices and free internet as needed.
This study is based on wave 6 of the NPHA, which was completed by 2048 older US adults in December 2019 and included questions on everyday ageism. 16 The survey response rate was 2048 of 2664 individuals (76.9%). The analytic sample included 2035 participants and did not differ demographically from 13 excluded individuals missing data on their experiences with everyday ageism.

Measures Everyday Ageism
The Everyday Ageism Scale was used to assess the amount of routine ageism participants reported experiencing in their daily lives. 7 The scale captures a phenomenon similar to everyday discrimination 20 but emphasizes age-specific discrimination. Items ask about easily identifiable    participants completing at least 9 of 10 items. Higher scale scores indicated more everyday ageism, with a potential range of 0 to 30. Cronbach α was 0.761.

Sociodemographic Characteristics
Sociodemographic characteristics included age in years, age group (50-64 or 65-80 years), sex (man or woman), self-identified race and ethnicity (categories were Hispanic, non-Hispanic Black, non-Hispanic White, and other racial categories), married or living with a partner (yes or no); education (Յhigh school diploma, some college, or Նbachelor's degree), annual household income (21 income ranges), employed (yes or no), metropolitan area (yes or no), region (Midwest, Northeast, South, or West), and media use indicating mean hours spent viewing television, the internet, or magazines daily (>4, 2-4, or <2). For race, participants were asked to select all that applied: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, or a different race; options for ethnicity were Hispanic or Non-Hispanic. Race and ethnicity were asked in separate questions. These were recoded to reflect the largest racial and ethnic categories used in health disparities research in the US: all those identifying as Hispanic (any race); non-Hispanic Black, non-Hispanic White, and all other racial categories, including those identifying with more than 1 racial group. There were no missing sociodemographic data, with the exception of media use (6 individuals were omitted from regression analyses).

Health Outcomes
We examined 2 general indicators of physical health and 2 of mental health. Fair or poor physical health indicated responses of fair or poor to a single item: "In general, how would you rate your physical health?" (reference group: good or better). Chronic health conditions reflected the raw number of diagnosed chronic health conditions among 9 conditions: hypertension, high cholesterol, heart disease or attack, stroke, diabetes or prediabetes, cancer, chronic lower respiratory disease, osteoarthritis or joint problem, and chronic pain. Fair or poor mental health indicated responses of fair or poor to a single item: "In general, how would you rate your mental health?" (reference group: good or better). Depressive symptoms signified report of some depressive symptoms at least several days during the prior 2 weeks (reference group: no symptoms). We used the 2-item Patient Health Questionnaire 21 (PHQ-2), which asked participants if they were bothered by little interest or pleasure in doing things or by feeling down, depressed, or hopeless.

Statistical Analysis
Analyses were completed with Stata statistical software version 17.0 (StataCorp), poststratification weights, and 2-tailed significance tests with P < .05. Prevalence of everyday ageism was examined in 2 ways. First, any experiences with everyday ageism was assessed. This was indicated by often or sometimes or strongly agree or agree responses to any items in the full Everyday Ageism Scale. Any experiences were also determined for each of the 3 scale categories (ie, subscale dimensions) and specific forms of everyday ageism (ie, individual scale items). Second, aggregate scale scores were used to assess the amount of everyday ageism overall (full scale), by category, and by specific form. categories and forms were associated with the greatest difference in identified outcomes. This entailed replicating the models while first replacing the full scale with 3 category scale scores and next replacing it with 10 individual items.

Differences and Disparities in Everyday Ageism
Adults ages 65 to 80 years reported a larger mean amount of everyday ageism than those ages 50 to

Everyday Ageism and Health
Everyday ageism was associated with poor physical and mental health across all 4 outcomes examined ( Table 2 and  Figure 3C). Probabilities of depressive symptoms were higher and increased 65.4% to 90.3% with each SD (Table 2 and Figure 3D).
Post hoc analyses were used to investigate everyday ageism categories and forms associated with the greatest increases in risk of poor health outcomes (eTables 1 and 2 in the Supplement).
Internalized ageism was associated with the greatest increases in risk for all 4    Outcomes are adjusted for age, sex, race and ethnicity, married or living with partner status, education level, household income level, employment status, metro area, region, and daily media use.

Discussion
This cross-sectional study documented the pervasiveness of everyday ageism and its associations with poor health among older US adults using the newly developed, multidimensional Everyday Ageism Scale. 7 More than 9 of 10 adults ages 50 to 80 years in the nationally representative NPHA sample reported experiencing 1 or more forms of everyday ageism regularly. This was generally consistent with previous ageism prevalence rates (77%-91%) derived from other ageism measures and convenience samples of older North American adults. 17 Previous findings on ageism differences and disparities have been inconsistent. 22 This study identified disparities in everyday ageism by age and socioeconomic status. The patterning was consistent with social stratification in the US in which populations are multiply marginalized at intersections of their identities (eg, being an older adult and low income). 23 Documented differences by race and ethnicity were opposite the typical patterning of social disadvantages, although not without precedent in ageism research. 24 Identified differences likely reflected racial and ethnic variations in perceptions of everyday ageism rather than exposure. 25 Ageism may be the first major type of discrimination some White adults experience, which may increase their awareness compared with other racial and ethnic groups more habituated to discrimination. Given the centrality of race and ethnicity in the lives of members of racial and ethnic minority groups, they may attribute discrimination to their race or ethnicity rather than their age. Research on more objective examples of ageism (eg, employment discrimination) supports the premise that older adults who are members of racial and ethnic minorities experience more ageism. 25,26 More research is needed to investigate how everyday ageism may be associated with health disparities within the older adult population and whether social identities moderate associations between everyday ageism and health.
Everyday ageism was associated with all 4 health outcomes examined, including 2 indicators each for physical and mental health. Odds of negative health outcomes increased 59.0% to 110.5% with 1 SD increase in everyday ageism. The associated number of chronic health conditions also increased, albeit less markedly. Although this study could not determine whether experiences with everyday ageism preceded the development of poor health or vice versa, empirical research suggests that ageism is associated with greater changes in health than the converse. 27,28 Everyday ageism may affect health outcomes via multiple pathways. Ageism may hamper quality of older adults' interactions with health care clinicians. Ageist cues, beliefs, and interpersonal interactions may serve as stereotype threats, primes for stereotype embodiment, and models of normative expectations for older adults, all of which have been associated with poor health with poor health may experience more ageist messages and discrimination (and discrimination based on health and disability) and personally relevant evidence supporting negative beliefs associating age with health.
Internalized ageism was the category most commonly endorsed in our study (81.2% of participants) and associated with the largest increases in risk for all health outcomes. This provides further evidence suggesting the importance of this dimension of ageism, which has been most frequently investigated in relation to health. 8,12,14 The item stating that "having health problems is part of getting older" is worthy of comment given its high endorsement rate and questions about whether the item captured ageism or immutable outcomes of chronological aging. Associating poor health with old age may be the most deeply rooted aging stereotype, despite evidence to the contrary (for example, 82.3% of participants in the current study rated their physical health as good or better). Several issues may contribute to the potency of this stereotype. Physiological and cognitive changes accompanying old age are often characterized negatively as "problems" or "deterioration," rather than viewed neutrally as part of human development. 33 A growing body of research implicates ageism in poor health outcomes. 1,8,9,14 Disentangling health outcomes attributable to chronological aging from preventable health outcomes attributable to the social construct of ageism is a challenge for future research. Altering societal attitudes associating poor health and aging may prove even more difficult.
Frequent ageism in interpersonal interactions was less commonly reported (44.9%) but also associated with all negative health outcomes. Exposure to ageist messages, while common (65.2%), was the only category exhibiting mixed associations with the health outcomes. Because ageist messages may shape individual and societal beliefs about aging and older adults, 14,34 it is plausible that ageist messages may be associated with health indirectly. Collectively, our findings suggest that all 3 categories of everyday ageism should be considered potentially associated with detrimental health outcomes.
Study results may inform intervention efforts to reduce potential health harms associated with ageism. Frequent exposure to commonplace ageist messages, interactions, and beliefs often perceived as trivial may be more harmful than is generally recognized. Internal and external sources of ageism may have ramifications for health. Taken together, our findings suggest that multilevel and multisector interventions may be most effective at reducing age-based discrimination and promoting more positive, nuanced views of aging.