Student Expectations About Mental Health and Aging.

Gerontology & Geriatrics Education

ISSN: 0270-1960 (Print) 1545-3847 (Online) Journal homepage: http://www.tandfonline.com/loi/wgge20

Student Expectations About Mental Health and Aging Michelle Pannor Silver, Natalie Irene Warrick & Alaina Cyr To cite this article: Michelle Pannor Silver, Natalie Irene Warrick & Alaina Cyr (2015): Student Expectations About Mental Health and Aging, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2015.1005288 To link to this article: http://dx.doi.org/10.1080/02701960.2015.1005288

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Date: 05 November 2015, At: 17:28

Gerontology & Geriatrics Education, 00:1–23, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2015.1005288

Student Expectations About Mental Health and Aging MICHELLE PANNOR SILVER Downloaded by [York University Libraries] at 17:28 05 November 2015

Anthropology/Health Studies, University of Toronto Scarborough Campus and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

NATALIE IRENE WARRICK and ALAINA CYR Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada

Drawing from stereotype embodiment theory this study contributes to existing literature by examining whether and how expectations regarding mental health and aging changed for students enrolled in an undergraduate gerontology course at a Canadian research university ( N = 51). At the beginning and end of the course, data from an open-ended word association exercise and the Expectations Regarding Aging (ERA-12) survey was collected and later analyzed. Investigators used content analysis and quantization to examine the word association data and statistical tests to analyze the mental health subscale (ERA-MHS). Findings were integrated and presented in a convergence code matrix. Results show that overall participants had more favorable expectations over time; in particular, ERA-MHS scores indicated less favorable expectations at Time 1 ( M = 48.86) than at Time 2 ( M = 65.36) significant at p < .01, while terms like “successful aging” increased and terms like “depressed” decreased. Findings have implications for geriatric mental health competencies of students in the health professions. KEYWORDS gerontology education, student perspectives, stereotype embodiment theory, health care students, ageism

Address correspondence to Michelle Pannor Silver, Anthropology/Health Studies, University of Toronto Scarborough Campus, 1265 Military Trail, Toronto, Ontario M1C1A4, Canada. E-mail: [email protected] 1

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M. Pannor Silver et al.

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INTRODUCTION Globally, the number of people who are age 60 years and over is expected to more than double by 2050 (Lin, Bryant, & Boldero, 2010), yet societal attitudes toward aging have remained negative (Cuddy, Norton, & Fiske, 2005; Lee, 2009). In particular, misconceptions, negative stereotypes, and biases toward older adults are reportedly prevalent among students in the health sciences (Hayes et al., 2006; Nolan et al., 2008; L. Ross, Duigan, Boyle, & Williams, 2014). The increasing proportion of older adults will translate to increased demand for health services, including specialized mental and behavioral health services (Lun, 2010). To this end, to handle the needs of an aging population, health care professionals must be equipped to provide age-specific and culturally competent geriatric care (Eshbaugh, Gross, & Satrom, 2010; Mackenzie, Gekoski, & Knox, 2006). According to the Substance Abuse and Mental Health Services Administration (SAMHSA; 2007) and Eden, Maslow, Le, and Blazer (2012), even where there is sufficient supply of health professionals, the availability of practitioners who are trained to provide mental and behavioral health services to older adults is insufficient. In Canada alone, approximately 100,000 students are enrolled in health-related university programs (Canadian Institute for Health Information, 2007). As these students become health care professionals, their attitudes and expectations about aging will shape the ways that they interact with aging individuals (Lovell, 2006) and affect the delivery and quality of care they provide to older adults (Ferrario et al., 2007). The World Health Organization defined mental health not only as the absence of psychiatric disease, but as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. (Herrman, Saxena, & Moodie, 2005, p. 2),

a definition that applies to people of all ages. The frequent conflation of mental and cognitive health requires that we differentiate the two although our primary focus in this article is on the mental health dimension of expectations of aging. According to the National Institutes of Health (Hendrie et al., 2006), the definition of cognitive health broadly refers to fluid and crystallized intelligence, general memory, learning and retrieval ability, broad visual and auditory perception, and cognitive processing speed. Mental and cognitive health are multidimensional, likewise they must be viewed with a focus on successful aging instead of normative aging. Consistent with definitions provided by Sarkisian, Hays, Berry, and Mangione (2002), the difference

Student Expectations About Mental Health and Aging

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between the two constructs lies in the fact that studies of cognitive health typically include aspects of cognitive processing and dementia (Hendrie et al., 2006), whereas mental health explores topics such as emotional intelligence, resiliency, mastery and self-efficacy (Baltes & Smith, 2003). Stereotypes about older adults as mentally unwell—specifically that older adults are miserable, bored, lonely, and incompetent—are persistent in Western culture (Abramson & Silverstein, 2004; Bousfield & Hutchinson, 2010). Although it may be true that older adults are at greater risk for depression, social isolation, and suicide (Olson, 2007), these risks may be attributed to common life situations of older adults and not simply a “normal” part of aging (Rothermund & Brandstädter, 2003).

Theoretical Framework Expectations about aging can also influence the health behaviours of older adults. Motivation for enhancing our understanding of student perceptions regarding aging draws from theoretical work on ageism (Palmore, 2001) and stereotype embodiment theory that states that attitudes and expectations may shape how stereotypes are manifest (Levy, 2009). Stereotype embodiment occurs when cultural stereotypes become reified, altering the health and functioning of older adults (Levy, 2009). Age stereotypes exert their influence through three different pathways: psychological, behavioral, and physiological. The psychological pathway highlights the importance of older people’s own expectations, in that expectations may shape their health behaviors (Levy & Leifheit-Limson, 2009; Sarkisian et al., 2002). The behavioral pathway relates to healthy practices, because negative stereotypes often presume that preventative health practices are futile because health problems are an inevitable result of aging (Levy & Myers, 2004). The physiological pathway involves the autonomic nervous system and the physiological impact of subliminal exposure to positive or negative stereotypes. Age stereotypes thus become expectations that develop into self-fulfilling prophecies (Levy & Leifheit-Limson, 2009).

LITERATURE REVIEW Coursework in gerontology provides an opportunity to improve students’ understanding of the normative changes of aging and the implications those changes have on individuals and society (Lin et al., 2010), but conflicting evidence exists as to whether and how a gerontology course may affect student attitudes and expectations (Aud, Bostick, Marek, & McDaniel, 2006; Cottle & Glover, 2007; Ferrario et al., 2007). Validated surveys such as the Expectations Regarding Aging (ERA; Sarkisian et al., 2002) or Facts on Aging Quiz (FAQ; Palmore, 1977, 1998) have been used in previous research


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to assess expectations, knowledge, and misconceptions about aging (i.e., Bardach, Gayer, Clinkinbeard, Zanjani, & Watkins, 2010; Joshi, Malhotra, Lim, Ostbye, & Wong, 2010; O’Hanlon, Camp, & Osofsky, 2006; Roters, Logan, Meisner, & Baker, 2010; Stubblefield & Knapp, 2000). In purely quantitative studies that have used the aforementioned surveys to evaluate the effects of a gerontology course on student expectations, students’ knowledge and attitude scores toward older adults had improved in some (Bardach et al., 2010; Cottle & Glover, 2007; Runkawatt, Gustafsson, & Engström, 2013), whereas other research found no change in student attitudes (Snyder, 2006; Stuart-Hamilton & Mahoney, 2003). The challenge posed by using only quantitative approaches is that they do not necessarily offer any explanation as to why this divergence may occur (Creswell & Clark, 2011). Likewise, researchers using qualitative approaches found that when the gerontology course included elements of narrative review about older persons there were net positive effects on students’ knowledge, skills, attitudes, and personal development (Villar, Fabà, & Celdrán, 2013). Changes in nursing students’ knowledge and attitudes of older adults following a gerontology course have been explored by Aud et al. (2006) and Lee (2009) through the use of methods which combined the FAQ survey (Palmore, 1977, 1998) and Kogan Scales (Kogan, 1961) along with open-ended comments and subjective writings. The use of these three measures supported Lee (2009) and Aud et al. (2006) in capturing attitudes and beliefs thought to be important to the social construction of aging but do not adequately address students’ future expectations of aging giving rise to our selection of the ERA-12 (Sarkisian et al., 2002) for this particular study. Although their findings suggest that students’ scores on the quantitative measures remained negative indicating that attitudes toward aging did not change following the course, some students did report more positive feelings toward older adults in open-ended comments and subjective reports collected on course evaluations. Consequently, divergence between attitude scores and open-ended comments within the same study suggest that underlying beliefs toward older adults and expectations are complex, necessitating an approach that used a validated survey instrument and a means of allowing participants to use their own words to best illuminate these complexities. Although some studies to date have considered students’ expectations and attitudes as they relate to older adults in general (Krout & McKernan, 2007), to the physical aspect of aging (Henderson, Xiao, Siegloff, Kelton, & Paterson, 2008; Lee, 2009) and to cognitive changes (Chippendale, 2013), less attention has been paid to the mental health aspects of aging. The aim of this study was to examine whether participating in a gerontology course embedded in a health studies program at a large research university changed students’ expectations regarding aging and mental health using a research design that included an open-ended question and a survey questionnaire. In this study we put forward three research questions: (1) What words do


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students associate with aging and mental health, and how do these change over time? (2) How do student expectations regarding aging and mental health change after participating in a gerontological health studies course, as measured by a validated survey? and (3) In what ways does the collection of an open-ended question and a survey questionnaire contribute to a deeper understanding of the malleability of student expectations of mental health and aging?

METHOD Downloaded by [York University Libraries] at 17:28 05 November 2015

Participants Undergraduate students at a large research university in Ontario, Canada who were enrolled in a one-semester course in gerontology during the winter term of the 2014 school year were invited to participate in this research study (N = 51). Participation in the study did not affect student grades. Of the 53 eligible students who provided written consent to participate in this study, one did not finish the course and another student provided incomplete information on the questionnaire. Participant demographics were relatively homogenous. More than one half (51%) of participants listed health and mental health studies as their major program of study. The average age was 21 years (range 19–25), and 47% were in their third year of study. Most participants were female (90%). The proportion of Canadian-born participants in the study (55%) was similar to the proportion for the City of Toronto (47.8% Canadian-born citizens) (Statistics Canada, 2012). Among students who immigrated to Canada, the average time living in Canada was 12.98 years (SD = 4.9). Descriptive statistics from these variables are presented in Table 1.

Measures WORD ASSOCIATION EXERCISE A word association exercise was used to elicit responses that reflect underlying associations and relationships between concepts to explore the personal unconscious (Spiteri, 2005). Word association protocols are widely used within psychological and linguistic disciplines as a measure of a participant’s growing lexicon (Strauss, Sherman, & Spreen, 2006). According to Fitzpatrick, Playfoot, Wray, and Wright (2013), use of a principled method for collecting, scoring (categorizing), and analyzing word association responses—as in the case of the protocols used in this research—aid in evaluating reliability and validity in behavioral responses over time. To ensure replicability of our protocols, strategies aimed at increasing rigor were embedded within

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TABLE 1 Characteristics of Participant Sample Participant Responses (N = 51) Variable


Sex Male Female Age Country of origina Canada Born abroad Years in Canadab 4 – 13 14 – 23 Year of education 2 3 4 5 and more Majora Humanities Health & mental health studies Math & science a b

n

%

5 46 51

9.8 90.2 100

28 22

55 43

13 11

54 46

M = 12.98 SD = 4.9

11 24 13 2

21.6 47.1 25.5 5.9

M = 3.18 SD = .89

17 26 6

33 51 12

M = 21 SD = 1.5

Cases missing data. Only students born abroad reported.

the research design; this included an audit trail that was used to record completed tasks and track key decisions made with regard to the categorization of the word association data. These precautions improved the transparency, credibility, and dependability of our analysis of the word association data, but do not improve test–retest reliability, as would be expected, owing to sensitivity of responses to learned material and passage of time (T. P. Ross et al., 2007). It has been used in recent scholarly work to gain a richer understanding of visceral feelings on a range of contemporary topics (i.e., Harvey, Coifman, Ross, Kleinert, & Giardina, 2014; Yarkoni, 2010). Participants were given one minute to respond to the following: In the space below, please write down the first words that come to your mind when you think of the words: aging, elderly, older adult, or senior. Remember that you are invited to be open and honest in your response and that there are not any right answers.

After the time was up, participants were instructed to move on to the ERA12 survey.


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EXPECTATIONS REGARDING AGING (ERA-12) SURVEY The ERA-12 is a shortened version of the 38-item survey that measures expectations regarding aging in older adults (Joshi et al., 2010; Sarkisian, Steers, Hays, & Mangione, 2005) validated in a number of studies (i.e., Sarkisian, Shunkwiler, Aguilar, & Moore, 2006; Sarkisian et al., 2005). It includes three four-item scales that address expectations about physical health (Questions 1–4), mental health (Questions 5–8), and cognitive function (Questions 9–12), as well as an overall expectations regarding aging scale when combining all 12 items. Higher scores on the ERA-12 are associated with expectations of achievement and maintenance of high physical, mental and cognitive functioning for self and others while aging, whereas lower scores are indicative of expected declines. The observed interitem reliability for the overall score and mental health portions in this sample is as follows: Cronbach’s alpha was α = –0.60 for Time 1 mental health and exceeded α = .33 for the Time 2 mental heath portion of the scale, and, for the overall ERA-12 itself, α = .351 and α = .521. As demonstrated by Sarkisian et al. (2005) acceptable levels of reliability and construct validity for the ERA-12 scales were established in two different samples of community-dwelling older adults (n = 429 and n = 643) with Cronbach’s alpha, α = .75 for the mental health subscale and α = .88 overall. Within this study, construct validity for the ERA-38 was established based upon correlations with other validated measures of self-reported health (i.e., Geriatric Depression Scale by Hoyl et al., 1999) and indicators of successful aging (Mental Component Survey–12; Ware, Kosinski, & Keller, 1995). The shortened ERA-12 (Sarkisian et al., 2005) has also been shown to capture 88% of the variation in the ERA-38 overall score (Sarkisian et al., 2002). Although initially intended for older adults, the ERA-12 has been validated in three other samples of similar size in younger adults (i.e, Davis, Bond, Howard, & Sarkisian, 2011; Galambos & Curl, 2013; Roters et al., 2010). The Cronbach’s alpha reported by these studies ranged from 0.75 to 0.82, indicating that for larger samples it is generally a strong and reliable measure with good internal validity.

Procedures INTERVENTION: GERONTOLOGY COURSE Between data collection time points, students participated in a gerontological health studies course. The course focused on presenting students with a substantial range of disciplinary perspectives on the phenomena of aging including anthropology, sociology, psychology, and economics. The objectives of participating in the course were to critically examine research on health and aging in Canada, contrast successful aging and age-related


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decline, reflect on worldwide demographic trends in aging and public policies related to health and aging, and produce a research paper relevant to health and aging. Theoretical frameworks were introduced to students in a manner that was integrated into substantive topics. For example, in a module about financial well-being, work, and retirement basic principles from microeconomic theory were introduced as well as discussions about the life course perspective (i.e., Elder & Rockwell, 1979) and the resource perspective (Wang, Henkens, & van Solinge, 2011). In addition to this, students were asked to consider the continued relevance of role theory, continuity theory, and activity theory (i.e., Alley, Putney, Rice, & Bengtson, 2010; Bengtson, Rice, & Johnson, 1999) and to question the implications of theoretical frameworks on their own understanding of different facets of mental health and aging (Clarke, Marshall, House, & Lantz, 2011). Topics covered during the course included a module on health care, aging, and social structures in Canada as they compare to other comparably developed countries; cognitive function and decline; financial well-being, work, and retirement; physical mobility and adapted environments; family and social support; and a module on death, dying, and longevity. The readings assigned for the course were designed to help students contextualize and question different understandings of mental health at later points in the life course. For example, some readings featured ethnographic accounts while others relied predominantly on quantitative methodology to assess mental health through psychometric scales. Guest speakers from the Ministry of Health and Long-Term Care provided students with examples of the implications of mental health issues among older adults on the health care system and discussed specific policies that aim to address mental health needs for older adults. An independent research assistant with no association to the gerontology course presented students with written and oral information about the study, administered written consent forms prior to participation, and assigned a unique ID number to each student participant. After providing written consent, participants completed a questionnaire package during the second week (Time 1) and again during the 12th week (Time 2) of a 13-week course. At Time 1, the questionnaire package contained three parts: a demographic survey, a word association exercise, and the ERA -12item survey. At Time 2, the questionnaire contained identical versions of the word association exercise and the ERA-12. The demographic survey collected basic demographic information on each participant including age, sex, year of study, major, country of birth, and number of years living in Canada. The course instructor, also the study’s principle investigator, did not participate in data collection and did not access any collected data until all student grades had been submitted at the end of the course. Ethical approval for the study was obtained from the lead author’s Office of Research Ethics.


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Design & Analysis A pre–post study design was used to examine changes in students’ expectations of aging and mental health over time as illustrated in Figure 1. Researchers used content analysis to interpret the word association data (Mayring, 2004) with the aim of uncovering meaning in context, interpreting the terms from a realist perspective and interpreting the data (Vaismoradi, Turunen, & Bondas, 2013). Members of the research team each conducted an independent review of word association data sets to identify terms related to mental health guided by the categories identified by Sarkisian et al. (2002): life satisfaction, loneliness, happiness, depression, anxiety, emotional wellbeing, and grief. This was followed by two authors (AC & NW) extracting data independently via content analysis coding of the word association data, which allowed for cross-referenced coding and discussion of judgment-based decisions. The principal investigator (MS) was consulted during the analysis to ensure that interpretations were consistent in the context of the subject matter. All mental health terms identified in the word association data set were assigned a negative, neutral, or positive valence. Examples of positive terms included enjoy life, relaxed, fun, fulfillment, and helpful. Examples of negative terms included dependence, lonely, and sad. The only term attributed a neutral valence was mental health. The identified mental health terms were quantized by assigning a negative, neutral, or positive valence (Sandelowski, Voils, & Knafl, 2009) and given a score of –1, 0, or +1, respectively, labeled words as positive (indicated an affirmative or encouraging adjective/adverb/ noun), neutral (held no judgment value for adjective/ adverb/noun), or negative (indicated a declining or deleterious adjective/ Data Collection

Analysis

Time 1

Time 2

Word Association Task

Word Association Task

Integration

Content Analysis

Gerontology Course (13 weeks) Descriptive Statistics & t test

ERA-12 Survey

Quantization and content analysis of words for convergence or divergence with ERA-MHS

ERA-12 Survey

FIGURE 1 The pre–post study design. ERA-12 = expectations regarding aging survey (12-item); ERA-MHS = expectations regarding aging survey-mental health subscale.


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adverb/noun) (Sandelowski, 1993). Valence scores were calculated for each category at Time 1 and Time 2 by adding up the scores of corresponding terms. Using a repeated-measures cross-sectional design (Campbell & Stanley, 1966) data collected from the ERA-12 survey was analyzed by assessing responses for each item on a 4-point Likert-type scale ranging from 1 (definitely true) to 4 (definitely false). The summative overall score for the ERA-12 ranged from 12 to 48 (with each domain ranging from 4 – 16). Overall ERA-12 scores and mental health subscale (ERA-MHS) scores were calculated from participant responses and were transformed to scores ranging from 0 to 100, as per the algorithm provided by Sarkisian et al. (2005). Responses to the ERA-MHS were recoded into dichotomous responses of “true” or “false” by collapsing “definitely” and “somewhat” true and false into their respective categories; frequencies of true and false responses were tallied for each question at both time points. Paired samples t tests were used to determine if there were statistically significant differences between participants’ overall ERA-12 and ERA-MHS scores at Time 1 and Time 2. SPSS v21 software was used to conduct statistical analyses on these scores (IBM Corp, 2012). The results of these inferential tests are reported, as are effect sizes (Cohen’s d) and confidence intervals. A reliability analysis was conducted to validate the Cronbach’s alpha (measure of internal consistency reliability) obtained from these data and validate these results against Sarkisian et al. (2005). The significance level used for all tests is p = .05. Subsequent to separate analyses, data from the open-ended word exercise and the survey questionnaire were analyzed with the intent of observing whether there was any mutual illumination of findings (Woolley, 2009). Results from the survey questionnaire at Time 1 and Time 2 are presented in Table 4. Open-ended word exercise data are presented in Table 4. Changes in the frequency and valence of terms related to mental health on the word association and frequency of true and false responses on questions from the ERA-MHS were used to determine points of concordance or disagreement and overall change from Time 1 to Time 2.

RESULTS Nine categories related to mental health were present in the content analyses of the word association exercise. The categories dependence on others, relaxation, social involvement, loneliness, sadness, mental health, social inclusion, and overall well-being appeared in Time 1 and Time 2 data sets, whereas life enjoyment appeared only at Time 2. Most categories identified matched those mentioned by Sarkisian et al. (2002) with the addition of dependence on others, mental health, and social inclusion. These categories were added to ensure that we were exhaustive in our coding and inclusive


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TABLE 2 Themes Identified From Word Association Exercise and Corresponding Examples With Valence Assignment Themes

Examples of Words (valence)

Dependence on others Relaxation Social involvement Loneliness Sadness/happiness


Mental health Social inclusion Life enjoyment Overall well-being

Dependent/dependence (–), need help (–), reliance (–), independence (+) Relaxed (+), free from stress (+), not stressed out (+) Active (+), helpful (+), sharing (+), generous (+) Lonely (–), alone (–), less social (–), isolated (–) Sad (–), unhappy (–), depressed (–), happy (+), happy after retirement (+) Mental health (N), emotional (–), mental health problem (–) Kind (+), compassionate (+), social (+), friends, good company, friendly (+) Enjoy life (+), finding pleasure in hobbies (+), fun (+), Fulfillment (+), Increased quality of life (+), Successful aging (+), Regretful (–), Bored (–)

of all mental health words generated by students. Examples of terms within each category are provided in Table 2. There was a marked increase in the occurrence of mental health terms from Time 1 to Time 2. A notable increase in the frequency of positively valenced terms was observed when comparing the frequencies and valence of terms from Time 1 to Time 2 (Figure 2). The most striking change occurred within the category relaxation. Other categories that increased were life

Word Frequency

Time 1 Time 2

Positive

Negative

FIGURE 2 Word frequency at Time 1 and Time 2.

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TABLE 3 Comparison of Mean ERA-12 and ERA-MHS Scores From Time 1 to Time 2 Time 1 (N = 51) Domain Aging (overall) Mental Health

Time 2 (N = 51)

M

SD

CI

45.86

9.05

42.5, 51.46

M

SD

CI

Mean Difference [95% CI]

53.49 10.47 48.22, 57.82 −7.63 [–10.89, –4.36]

Test Statistic, p Value t(50) = –4.68, p < .01

48.86 12.02 41.02, 52.46 65.36 16.19 57.72, 72.72 −16.50 [–22.16, –10.85] t(50) = –5.86, p < .01


ERA-12 = expectations regarding aging survey (12-item); ERA-MHS = expectations regarding aging survey-mental health subscale; CI = confidence interval.

enjoyment, social involvement, and overall well-being. Similarly, the occurrence of negatively valenced categories decreased, particularly the categories dependence on others and sadness. The mean of the overall ERA-12 scores was smaller at Time 1, indicating more negative expectations (M = 45.86) than at Time 2 (M = 53.48); this result was statistically significant at p < .001 (Table 3). Similarly, the mean of the ERA-MHS scores showed a statistically significant (p < .001) increase in favorable expectations of aging and mental health from Time 1 (M = 48.86) to Time 2 (M = 65.36). The effect size for the overall ERA-12 scores (Cohen’s d = –.779) indicates a large effect and the ERA-MHS scores (Cohen’s d = –1.16) a very large effect between Time 1 and Time 2. The 95% confidence interval for the mean difference in overall ERA-12 scores was –10.89 to –4.36 and for the ERA-MHS score was –22.16 to –10.85 (Table 3).

Integrated Results Table 4 illustrates the total count of themes that emerged from the word association exercise at Time 1 and Time 2. The collection of open-ended word associations and ERA scores with a specific focus on mental health (Table 5) provided greater clarity about the malleability of expectations of aging by uncovering areas of divergence and convergence. We discovered that findings converged in three and diverged on one of these constructs. CONVERGENCE BETWEEN CATEGORIES SOCIAL INVOLVEMENT DEPENDENCE ON OTHERS AND ERA-12 QUESTION “I EXPECT THAT GET OLDER I WILL SPEND LESS TIME WITH FAMILY AND FRIENDS.”

AND AS I

At Time 1, the categories social involvement and dependence on others had valences of +1 and –11, respectively (Table 4), whereas 61% of participants indicated true on Question 5 of the ERA-12 (Table 5). At Time 2, these expectations were virtually reversed. The categories social involvement had a valence of +7 and dependence on others had a valence of –4, whereas only 24% of participants indicated Question 5 of the ERA-12 was true. These findings suggest that at by the end of the course participants came to better understand how older adults contribute to society.

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TABLE 4 Total Count of Themes Appearing in Word Association Data at Time 1 and Time 2 Occurrences


Theme (Valence)

Time 1

Time 2

11 1 1 4 4 1 0 6 6 1 1 0 0 0 1

6 2 7 2 7 8 4 2 5 0 2 2 1 2 1

13 1 23 37

38 0 13 51

Dependent/need help (–) Independence (+) Active/social involvement (+) Lonely/alone/less social (–) Social inclusion (+) Relaxed/free from stress (+) Life enjoyment (+) Sadness/depressed (–) Happiness (+) Mental health (N) Emotional/mental health problem (–) Fulfillment (+) Increased quality of life (+) Successful aging (+) Regretful/bored (–) Total Positive Neutral Negative Number of terms used

TABLE 5 Dichotomized Results From the ERA-12 Mental Health Subscale Questions at Time 1 and Time 2 Time 1 (N = 51) ERA-12 Questions 5. Spending less time with friends and family as one ages. 6. Being lonely is just something that happens when people get old. 7. As people get older they worry more. 8. It’s normal to be depressed when you are old Overall ERA-MHS scores

Time 2 (N = 51)

True n ( %)

False n (%)

True n (%)

False n (%)

31 (60.8)

20 (39.2)

12 (23.5)

39 (76.5)

20 (39.2)

31 (60.8)

10 (19.6)

41 (80.4)

13 (25.5)

38 (74.5)

21 (41.2)

30 (58.8)

38 (74.5)

13 (25.5)

12 (23.5)

39 (76.5)

M = 48. 85 SD = 12.02

M = 65.36 SD = 16.19

ERA-MHS = expectations regarding aging survey-mental health subscale.

CONVERGENCE BETWEEN CATEGORIES LONELINESS AND SOCIAL INCLUSION AND ERA-12 Q UESTION “B EING L ONELY I S J UST S OMETHING T HAT H APPENS WHEN PEOPLE GET OLD” At Time 1, the categories loneliness and social inclusion had valences of –4 and + 4, respectively, whereas 39% of participants indicated Question

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6 of the ERA-12 was true. At Time 2, these expectations were slightly more positive. These findings suggest that exposure to concepts such as the nature of the family in late life may have given students greater perspective on the social aspects that contribute to mental health.


DIVERGENCE BETWEEN CATEGORIES RELAXATION AND LIFE ENJOYMENT ERA-12 QUESTION “AS PEOPLE GET OLDER THEY WORRY MORE”

AND

At Time 1, the category relaxation had a valence of +1, whereas 26% of participants indicated true to older adults worrying more. At Time 2, there was a substantial positive change in the word association data, but more participants (41%) indicated that they agreed with the statement “As people get older they worry more.” Although these findings seem to diverge, it is possible that, together, they capture how participants’ expectations of aging and mental health became more nuanced. Participants’ may have become more aware of the challenges older adults face (i.e., chronic illness, reduced pensions), while also understanding that enjoying life and being more worried are both representative of aging and mental health.

CONVERGENCE BETWEEN CATEGORIES “SADNESS” AND “MENTAL HEALTH” AND ERA-12 QUESTION “IT’S NORMAL TO BE DEPRESSED WHEN YOU ARE OLD” At Time 1, the categories sadness and mental health had valences of –6 and 0, respectively, whereas 75% of participants indicated “true” on Question 8 of the ERA-12. At Time 2, valences remained fairly consistent, whereas the ERA-12 scores had changed. By the end of the course, participants better understood that depression and sadness are not normal experiences of the aged. Participants’ greater awareness of this fact may better equip them in detecting mental health issues in older adults, leading to more appropriate courses of treatment for patients.

DISCUSSION AND IMPLICATIONS This is the first study we are aware of that used word association with the ERA-12 to investigate whether and how undergraduate students’ expectations regarding aging and mental health changed following exposure to a gerontology course. At the start of the course, participants’ expectations regarding aging and mental health were in line with existing literature on aging stereotypes among young adults (Abramson & Silverstein, 2004; Bousfield & Hutchison, 2010). In reassessing expectations at the end of the course, we discovered that exposure to coursework in gerontology positively influenced participants’ expectations of aging and mental health.



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These expectations were found to be more reflective of the variation in life situations that exists among older adults. Identification of depression and other mental health related symptoms, such as grief, anxiety and emotional well-being are made more difficult by other age-related complicating factors such as cognitive decline common to patients with dementia, the presence of other mental health disorders (i.e., secondary substance abuse), and comorbidity of medical problems limiting physical function (Thorpe, 2009). Providers must be aware of their own perceived bias concerning expectations of aging as well as knowledge of interventions that are age-specific and culturally competent to provide appropriate and effective treatment of mental health disorders (Mackenzie et al., 2006). The existing literature has shown considerable variation when reporting on the impact gerontology courses have on student attitudes (Aud et al., 2006; Bardach et al., 2010; Cottle & Glover, 2007; Ferrario et al., 2007), however variations in study results may be attributed to course differences or reliance on a single method as opposed to an approach that draws from and integrates findings from a survey questionnaire and an open-ended word exercise. Examining the integrated findings from each time point presents two very different ideas about the participants’ expectations regarding aging and mental health. The findings at Time 1 may be an indication of younger people’s expectations of the older adult who is a worry-free dependent that is less fulfilled in their social relationships. The findings at Time 2 paint a portrait of the older adult as an emotionally balanced, active community member who enjoys life despite the challenges they face. We identified that the mental health-related terms used by participants at Time 1 were largely negative, primarily focusing on dependence and sadness, whereas ERA-12 and ERA-MHS scores indicated expected declines with aging. The mental health-related terms used by participants at Time 2 were more positive, with a stronger presence of terms related to social involvement, enjoying life, relaxation, and overall well-being. Additionally, the marked increase in and wider variety of mental health related terms included in the Time 2 word association dataset suggests that participants were more aware of the varying aspects of mental health and aging as the course neared completion. Likewise, overall ERA-12 and ERA-MHS scores increased over time, indicating that expectations of aging improved. Therefore, this study has shown that student expectations of aging and mental health are malleable, and that it is possible to positively influence students’ expectations of aging and mental health through a gerontology course. Researchers have argued that the pervasiveness of ageist attitudes and negative views toward old age have resulted from personal apprehensions and expectations about future selves (Dorfman, Murty, Ingram, Evans, & Power, 2004; Oakes & Sheehan, 2014). Henderson et al.’s (2008) work suggests that quality of life courses improve expectations of aging, where


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biomedical courses may not. McLafferty and Morrison’s (2004) research suggest that coursework in gerontology may “over-rely [on] teaching negative aspects of aging” (p. 446), thus inculcating the next wave of practitioners with skewed expectations of aging for themselves and the persons for whom they provide care. In accordance with stereotype embodiment theory, which suggests that expectations about aging are malleable (Levy, 2009), this study demonstrated that the presentation of the positive aspects as part of the course in gerontology helped to improve students’ expectations of aging and mental health. Our findings offer numerous practical implications for health care educators, researchers and policy makers. Improving care and support to older adults with mental illness requires that specialized educational and training opportunities be made available to meet the increasing demand for mental and behavioral health services (SAMHSA, 2007). Results from this study show that shifting expectations of aging may be achieved by increasing awareness of the practical and emotional intelligence that comes with aging (Cowen, 1985), by emphasizing the problem-solving skills that accumulate over the life span (Baltes & Smith, 2003) and by sharing the commonalities that exist between younger and older adults (Gonzales, Morrow-Howell, & Gilbert, 2010). Educators of health professionals may be especially concerned with core competencies for training in certain areas, particularly in regards to successful models of aging.

Limitations and Suggestions for Future Research Although this study uniquely examines student expectations about aging and mental health by integrating findings from an open-ended word exercise and a validated survey questionnaire, there were some limitations. Participant responses may have changed over time due to factors other than the course (i.e., not enough time between ERA-12 measurements, practicing, fatigue, natural development). The timing and presentation of course material may have shaped the frequency of terms appearing in the Time 2 word association data, possibly due to a recency effect, where material learned more recently is better recalled than older material (Neath & Knoedler, 1994). Researchers attributed a positive, neutral or negative valence to words based on single word responses from word association data. Given that this may have introduced some minor interpretive latitude on behalf of the researchers, it is important to consider what effect this process may have had on our results. Fortunately, though some terms included in the word association data sets could be interpreted as ambiguous (e.g., slow could be interpreted as cognitive or physical slowing), we did not find any ambiguous terms relating to mental health. The factor loadings in the principal components analysis (PCA) for the expectations regarding aging survey-mental



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health subscale (ERA-MHS) at Time 1 did not align as theoretically conceptualized by Sarkisian et al. (2005). As a general rule of thumb a bare minimum of 10 observations per variable are necessary to avoid computational difficulties and produce stable estimates with the PCA (Tabachnick & Fidell, 2007). Our relatively small sample size may have contributed to the lower than expected Cronbach’s alpha for the Time 1 and Time 2 measures on the ERA-MHS subscale and as a consequence the α = .70 reliability standard for group comparisons as put forth by Nunnally and Bernstein (1994) was likely not met. The low Cronbach’s alpha could indicate that some items did not correlate positively with one another. What is interesting is that the Cronbach’s alpha improved significantly from the Time 1 mental health to the Time 2 mental health subscale. At Time 1, it was assumed that there was no prior exposure to coursework in mental health and aging.What this suggests is that the ERA-12 may not perform as predicted by Sarkisian et al. (2002) with respect to small samples of young adults without prior exposure to concepts and principles of mental health and aging. Because the original ERA-12 was intended to capture older adults’ expectations of their own experiences with aging they could rely upon personal experience whereas a young adult without such insight may not know enough about the experience of mental health in old age to make informed opinions to respond to the true/false categories in a manner consistent with theory. Consequently, their report on a relatively small number of items for the mental health subscale did not conform to the predicted manner at Time 1. This study further motivates the need for future studies, which investigate the validity of ERA-12 in samples of younger adults. Notably, Roters et al. (2010) maintained internal validity (i.e., Cronbach alpha greater than 0.8) of the ERA-12 among a demographically similar sample (upper-year undergraduate students at a large, Canadian metropolitan university with an average age of 21.5); however this was with a much larger sample size (N = 145), which may explain the inconsistency of our results. In future studies, researchers may also choose to perform member checking with participants to clarify any instances of ambiguity in the word association task. Use of other methods such as individual interviews and focus groups, in conjunction with validated survey instruments, may also provide a more in depth explanation of expectations about aging among this population. To further advance knowledge in this area, further research is required to examine how changed expectations of aging and mental health impacts delivery of care to older adults.

CONCLUSIONS The purpose of this study was to explore how students’ expectations of mental health and aging changed after participating in a gerontology health

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studies course. In this study, the case was made for ongoing usage of multiple methods strategies for investigating future research on mental health in aging by demonstrating how integrated findings contribute to a deeper understanding of the malleability of student expectations of mental health and aging. Ultimately, our research suggests that providing better quality of care for the growing population of older adults will require students of health and aging to have more positive, albeit realistic perspectives about aging and mental health issues.


ACKNOWLEDGMENTS The authors would like to thank the 51 undergraduate students who participated in this study as well as Sasithra Kanageswaran and Connie Phung for their work as research assistants on this project. The authors would also like to acknowledge the support of Dr. Katie Dainty, Dr. Robin Hayeems, and all of the graduate students who participated in the Health Services Research course.

FUNDING Natalie Warrick, MSc, PhD Student, would like to gratefully acknowledge the funding support provided by the Ontario Graduate Scholarship, the Toronto Rehab Kirshenblatt Memorial Scholarship and the Saint Elizabeth Healthcare Michael Decter Health Leadership and Policy Studies Scholarship.

ORCID Michelle Pannor Silver

http://orcid.org/0000-0003-3870-7434

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