Age discrimination at work against health-related professionals in Portugal

Abstract

BACKGROUND:

Age discrimination affects older and younger workers, and prevents equal access to opportunities.

OBJECTIVE:

This study aimed to characterize age discrimination at work in health-related professionals, and to explore its association to demographic variables.

METHODS:

Exploratory cross-sectional, web-based questionnaire survey, including the Workplace Age Discrimination Scale (WADS), performed amongst 369 Portuguese health-related professionals. Participants were classified into two groups: physicians (medical doctors) and non-physicians (all other health-related professions).

RESULTS:

82%of the professionals experienced age discrimination at work, non-physicians being the ones who most often experienced it (WADS 20.1 vs. 17.6). They have been more frequently passed over for a work role, evaluated less favourably and blamed for failures or problems due to their age.

CONCLUSION:

Non-physicians, with less experience in the profession, and with lower quality of life may experience age discrimination more frequently. They need to be closely monitored for discrimination. A key policy priority should be to plan for age diversity teams where older and younger professionals may work together and where older can teach/mentor younger colleagues.

Keywords

Ageism workplace discrimination health-care workers

1 Introduction

Ageism is considered to be the most commonly experienced form of discrimination [1]. Age discrimination can be defined as giving unfavourable treatment or fewer opportunities to an individual due to his or her chronological age (whether old or young) [2 –4], and is one of the most common forms of unfair treatment in the labour market. In a 2017 national survey of American adults over age 45 by AARP (formerly called the American Association of Retired Persons), around 2 out of 3 workers have seen or experienced age discrimination, 55%say discrimination starts in their 50s, making it a widely spread phenomenon [5]. Nonetheless, age discrimination at work has received much less research attention than other forms of discrimination.

Article 26 of the Constitution of the Portuguese Republic guarantees citizens legal protection against any form of discrimination [6]. The Portuguese Labour Code, recently updated in 2018, in its article 24, states that the worker has the right to equal opportunities and treatment regarding access to employment, vocational training and promotion or career conditions, and cannot be privileged, benefited, harmed, deprived of any right or exempt from any duty on grounds of age, among other characteristics such as sex and sexual orientation, marital status, disability, chronic illness, religion, nationality, among others [7]. Any form of discrimination, including age-based discrimination, infringes human rights as described in Article 21 of the Charter of Fundamental Rights of the European Union, which prohibits any kind of discrimination [8].

In an increasingly ageing world, and with changes in retirement rules, workers are expected to reach old age while still in their jobs [9]. There are some stereotypes about older workers, such as the belief that they are less competent, productive, adaptable, unable to learn new solutions, and less healthy than younger ones, thus reducing their hiring and promotion possibilities [9 –11]. However, not only older workers are susceptible to discrimination in the workplace. Younger workers, despite being recognized for their high productivity and low cost, are the most likely to be laid off [3]. To avoid discrimination against older workers, employers prefer to keep older workers in their positions, thus creating reverse ageism against younger workers [3]. This may contribute to a toxic work environment where younger workers are negatively described by their older colleagues and are not allowed to grow or improve in their professions [12]. In different ways, age discrimination is affecting both older and younger workers, preventing equal access to opportunities.

Age discrimination by acting as a social stressor may increase the risk of ill health and has been associated with risk of occurrence of coronary heart disease, stroke, diabetes, chronic lung disease, and depression [13]. Age discrimination is also associated with reduction in both job and life satisfaction [14]. Individuals experience reduced willingness to live, impaired memory and avoidance of preventive health behaviours [15]. Additionally, workers may leave their organizations or retire prematurely [16]. Individuals with negative perceptions about ageing may live 7.5 years less than those with positive perceptions [17]. The number of studies on age discrimination is increasing, as well as the development of instruments that seek to quantify age discrimination at work, even so, most studies used small samples [18].

Previous studies in healthcare have predominantly focused on how older patients are treated and if their treatment is adequate or not, and have shown substantial evidence of the presence of age discrimination in this setting [4, 19]. However, very little research has been done about age discrimination experienced by healthcare professionals at work. Discrimination is a stressor that together with many others commonly faced by healthcare professionals at work (e.g. burnout, fatigue, depression) may increase negative work performances and risk for the patient [20]. It has been suggested that physicians are less discriminated because of age, than nurses, pharmacists, and administrators [21]. Further research is thus needed to measure age discrimination and in the future reduce age stigma and discrimination at work [13].

The objective of this study was to assess the presence of age discrimination at work in health-related professionals (physicians vs. non-physicians) in Portugal, and to explore the association of age discrimination to demographic variables. Feelings of insecurity and superiority may motivate discrimination against other people. But since it has long been recognised that “doctors are in a unique position of respect and power” [22], as opposed to other health-related professionals, will physicians and non-physicians face similar discrimination?

2 Methods

2.1 Design

A cross-sectional, web-based questionnaire was performed amongst Portuguese health-related professionals, from July to October 2019. This study was conducted in accordance with the ethical standards of the Declaration of Helsinki. Ethical approval for the study was provided by the University of Beira Interior. Informed consent was obtained from all participants. Responses were anonymous. All individuals that self-reported as being a qualified health-related professional (doctor, nurse, pharmacist, physiotherapist, gerontologist, dentist, psychologist, speech therapist, occupational therapist, or other), working in Portugal, during the study period, were eligible to participate in the study after providing informed consent.

Since, to the best of our knowledge, there were no published estimates of the number of health-related professionals working in Portugal, no simple random sample from an existing sampling frame was possible. A multimodal recruitment strategy was used as an alternative. This strategy is effective, time and resource-efficient and enhances the engagement of clinicians [23]. Recruitment methods using social media were previously used successfully in similar online studies and are considered to be highly valuable [24].

In the current study, the recruitment strategy was a mix of: (i) in-person survey invitations delivered during professional meetings, (ii) emails sent to networks of health-related professionals and to the professional network of the study team, (iii) study invitations delivered via social media (Facebook and LinkedIn) amongst relevant professionals and groups, and (iv) snowball method –invited survey responders shared the survey link with other colleagues in their professional networks. Monthly reminders were sent. Participation was voluntary and no reimbursement was offered.

Given the exploratory nature of this study, no formal sample size calculation was performed.

2.2 Instruments

A questionnaire divided into three sections was designed for data collection: (i) demographic and clinical characteristics (sex, age, academic degree, profession, years of experience in the profession, work sector), (ii) 9 questions relating to the Workplace Age Discrimination Scale (WADS) and the scale’s follow-up item “who most often causes the items above that you have experienced?” (10), and (iii) a global quality of life (QoL) question “I am content with the quality of my life right now” [25].

The Workplace Age Discrimination Scale (WADS) was one of the 25 ageism measurement tools identified in a recent literature review published in 2019 [18]. WADS is a 9-item instrument developed by Marchiondo, Gonzales and Ran [10] as a measure of perceived workplace age discrimination, both in its overt and covert forms, against older, middle-aged, and younger workers. The scale contains convergent and discriminant validity, high reliability (Cronbach’s alpha 0.93) [26], and a unidimensional structure across age groups. Researchers can use WADS to identify outcomes of age discrimination and to further compare workers’ discriminatory experiences. Each item of the scale can be responded using a 5-point Likert scale ranging from 1 (never) to 5 (very often) [10]. The answers to the 9-items of the WADS can be used to calculate a summed score, which can vary between 9 and 45, with higher scores representing a worse perception of age discrimination at work.

For the purpose of this study, WADS was translated from English to Portuguese, employing a previously used technique [27]. Permission was requested and granted from the authors of the scale. The English-language items were initially translated by a panel of four general practitioners that were native Portuguese speakers well versed with the English language. Afterwards, the translations were reconciled by the authors after discussion and till a consensus was achieved. The final version was back translated by a native English speaker. It was pilot tested in 10 health-related professionals and no alterations to the questionnaire were needed. In the present study, Cronbach’s alpha (internal consistency) for the total scale was 0.93 –excellent [28].

Global QoL was assessed using the final question found in the FACT-G [25]. Global QoL questions are of great importance since they allow respondents to rate the quality of their lives from their own perspective and based on what is essential to them [29].

2.3 Data analysis

Descriptive and inferential statistics were used to analyze the data from eligible respondents using the IBM SPSS Statistics for Windows, Version 21.0 (IBM Corporation, Armonk, NY). Summary statistics were used to characterize the sample. Participants were classified into two groups: physicians (medical doctors) and non-physicians (all other health-related professions). Comparisons between categorical data were analyzed using the chi-square test. Numerical variables were analyzed using Mann-Whitney U-test or Kruskal-Wallis test when the dependent variable was not normally distributed. Multiple linear regressions were performed for Age Discrimination via ENTER method, the default in SPSS regression where all independent variables are included in the regression equation. For the interpretation of the findings, a significance level of 0.05 was considered.

3 Results

Table 1 shows the demographic characteristics of the 369 Portuguese health-related professionals in the study sample (202 physicians and 167 non-physicians). The major differences between the subgroups of physicians and non-physicians were that non-physicians were mostly female (p = 0.006), of younger age (p = 0.006), had higher academic degrees (p = 0.026) and were largely private sector employees (p < 0.001). Both physicians and non-physicians had similar years of professional experience (p = 0.635).

Table 1
Characteristics of the 369 Portuguese health-related professionals

Total (N = 369) Health-related professionals

Physician (N = 202) Non-physician (N = 167) p-value^*

Sex, Women, %(n)^a 75.9 (280) 70.3 (142) 82.6 (138) 0.006

Age, years

Mean^b(SD; min–max) 37.9 (11.7; 21–70) 39.6 (12.7; 25–70) 35.8 (9.9; 21–62) 0.006

Young workers 18–29 years, %(n)^a 27.9 (103) 23.3 (47) 33.5 (56) 0.022

Middle aged workers 30–49 years, %(n) 53.9 (199) 54.5 (110) 53.3 (89)

Older workers 50 + years, %(n) 18.2 (67) 22.3 (45) 13.3 (22)

Academic degree, %(n)^a 0.026

Bachelor or licentiate 60.7 (224) 65.8 (133) 54.5 (91)

Higher degrees (Postgraduate/Master/PhD) 39.3 (145) 34.2 (69) 45.5 (76)

Experience in the profession, years

Mean^b (SD; min–max) 13.1 (11.7; 0–46) 14.0 (13.0; 1–46) 12.1 (9.8; 0–41) 0.635

< 15 years, %(n)^a 69.4 (256) 71.3 (144) 67.1 (112) 0.381

≥15 years, %(n) 30.6 (113) 28.7 (58) 32.9 (55)

Work sector, %(n)^a < 0.001

Public 53.4 (197) 66.8 (135) 37.1 (62)

Private 23.8 (88) 5.0 (10) 46.7 (78)

Both 22.8 (84) 28.2 (57) 16.2 (27)

Quality of life

Mean^b (SD; min-max) 3.6 (1.1; 1–5) 3.7 (1.0; 1–5) 3.4 (1.1; 1–5) 0.014

	Total (N = 369)	Health-related professionals
Sex, Women, %(n)^a	75.9 (280)	70.3 (142)	82.6 (138)	0.006
Age, years
Mean^b(SD; min–max)	37.9 (11.7; 21–70)	39.6 (12.7; 25–70)	35.8 (9.9; 21–62)	0.006
Young workers 18–29 years, %(n)^a	27.9 (103)	23.3 (47)	33.5 (56)	0.022
Middle aged workers 30–49 years, %(n)	53.9 (199)	54.5 (110)	53.3 (89)
Older workers 50 + years, %(n)	18.2 (67)	22.3 (45)	13.3 (22)
Academic degree, %(n)^a				0.026
Bachelor or licentiate	60.7 (224)	65.8 (133)	54.5 (91)
Higher degrees (Postgraduate/Master/PhD)	39.3 (145)	34.2 (69)	45.5 (76)
Experience in the profession, years
Mean^b (SD; min–max)	13.1 (11.7; 0–46)	14.0 (13.0; 1–46)	12.1 (9.8; 0–41)	0.635
< 15 years, %(n)^a	69.4 (256)	71.3 (144)	67.1 (112)	0.381
≥15 years, %(n)	30.6 (113)	28.7 (58)	32.9 (55)
Work sector, %(n)^a				< 0.001
Public	53.4 (197)	66.8 (135)	37.1 (62)
Private	23.8 (88)	5.0 (10)	46.7 (78)
Both	22.8 (84)	28.2 (57)	16.2 (27)
Quality of life
Mean^b (SD; min-max)	3.6 (1.1; 1–5)	3.7 (1.0; 1–5)	3.4 (1.1; 1–5)	0.014

Notes: ^a χ²-test. ^bMann–Whitney U-test. ^*p-value of comparison variabilities between physician vs. non-physician sample groups. SD =Standard deviation.

In the study sample, 18 out of 100 health-related professionals stated to have never experienced age discrimination at work in the past year. The rest had experienced it from as rarely to very often.

Table 2 shows that for each of the 9 items of the WADS, on average, health-related professionals rarely experienced age discrimination in the workplace, in the last year. Nonetheless, non-physicians reported having experienced age discrimination more often than physicians (WADS total score of 20.1 vs. 17.6; p = 0.039).

Table 2

Characterization of the 9 items of the Workplace Age Discrimination Scale (WADS)

Items	min-max	Total (N = 369) mean (SD)	Physician (N = 202) mean (SD)	Non-physician (N = 167) mean (SD)	p-value^*
I have been passed over for a work role/task due to my age	1–5	2.0 (1.2)	1.8 (1.1)	2.3 (1.4)	< 0.001
My contributions are not valued as much due to my age	1–5	2.1 (1.2)	2.0 (1.1)	2.2 (1.3)	0.276
I have been given fewer opportunities to express my ideas due to my age	1–5	2.3 (1.3)	2.2 (1.2)	2.5 (1.4)	0.064
I have unfairly been evaluated less favourably due to my age	1–5	2.0 (1.1)	1.9 (1.0)	2.2 (1.2)	0.007
I receive less social support due to my age	1–5	1.7 (1.1)	1.5 (1.0)	1.9 (1.2)	0.002
I have been treated as though I am less capable due to my age	1–5	2.6 (1.3)	2.5 (1.3)	2.6 (1.4)	0.328
I have been treated with less respect due to my age	1–5	2.2 (1.3)	2.2 (1.2)	2.3 (1.3)	0.699
Someone has delayed or ignored my requests due to my age	1–5	2.0 (1.2)	1.9 (1.2)	2.0 (1.2)	0.707
Someone has blamed me for failures or problems due to my age	1–5	1.9 (1.2)	1.7 (1.0)	2.1 (1.3)	0.003
WADS overall “age discrimination”	9–45	18.7 (8.8)	17.6 (7.8)	20.1 (9.6)	0.039

Notes: ^*p-value of comparison of discrimination between physician vs. non-physician sample groups (Mann–Whitney U-test); SD = Standard deviation.

When non-physicians are compared with physicians, they stated that due to their age, they have been more frequently: i) passed over for a work role/task (p < 0.001); ii) evaluated less favourably (p = 0.007); iii) received less social support (p = 0.002); and iii) blamed for failures or problems (p = 0.003).

Age discrimination at work originated mostly from patients (43,6%), co-workers with the same profession of the participant (35.8%), patients’ families (32.8%), supervisors (27.6%), and co-workers with a different profession than that of the participant (23.3%).

Table 3 shows that from univariate analysis, higher perception of age discrimination at work was statistically related with the age group and the professional experience for both physicians and non-physicians; and related with the work sector for physicians only. Pairwise comparisons revealed no statistically differences between (a) middle aged versus young physicians (p = 0.098); (b) older versus young/middle aged non-physicians (p > 0.05); (c) public sector working physicians versus physicians that worked in both sectors (p = 0.333).

Table 3

Association between WADS overall “age discrimination” and sample’s characteristics

	Health-related professionals
	Physician (N = 202) mean (SD)	p-value	Non-physician (N = 167) mean (SD)	p-value
Sex^a		0.115		0.161
Women	18.0 (7.0)		20.0 (9.0)
Men	17.0 (9.0)		19.0 (11.0
Age group^b		< 0.001		0.009
Young workers 18–29 years	21.0 (7.0)		23.0 (9.0)
Middle aged workers 30–49 years	18.0 (8.0)		19.0 (9.0)
Older workers 50+ years	14.0 (8.0)		19.0 (11.0)
Academic degree^a		0.679		0.883
Bachelor or licentiate	17.0 (8.0)		20.0 (9.0)
Higher degrees (Postgraduate/Master/PhD)	18.0 (8.0)		20.0 (10.0)
Experience in the profession, years^a		< 0.001		< 0.001
< 15 years	19.0 (8.0)		22.0 (9.0)
≥15 years	13.0 (6.0)		17.0 (10.0)
Work sector^b		0.002		0.414
Public	17.0 (8.0)		21.0 (10.0)
Private	11.0 (3.0)		20.0 (9.0)
Both	19.0 (8.0)		19.0 (8.0)

Notes: ^aMann–Whitney U-test. ^bKruskal–Wallis test. SD = Standard deviation.

Table 4 shows that having less experience in the profession, being a non-physician and having a lower quality of life were associated with statistically significant WADS total score increments, i.e. with experiencing age discrimination at work more frequently.

Table 4

Multiple linear regression for WADS overall “age discrimination”

Variable	B	SE _B	β
Intercept	32.96	2.62	–
Age group	–	–	–
Experience in the profession, years	–4.29	1.24	–0.23^*
Sector	–	–	–
Health-related professionals	1.79	0.88	0.10^*
Quality of life	–2.18	0.40	–0.26^*

Notes: B = unstandardized regression coefficient; SE_B = standard error of the coefficient; β= standardized coefficient ^*p < 0.05.

4 Discussion

A key strength of the research lies within the fact that the present study is the first evaluation of age discrimination at work perceived by health-related professionals in Portugal. Overall, most of the health-related professionals experienced some form of age discrimination in the workplace in the past year. Non-physicians were more likely to have experienced age discrimination compared to physicians, in line with previous studies [21]. The unique characteristics of the doctor-patient relationship may protect physicians from age discrimination. Non-physicians also perceived lower quality of life than physicians (p = 0.014), supporting the assumption that the perception of being discriminated based on one’s age is associated with reduced life satisfaction [14].

As expected from the available literature [10], co-workers and supervisors were considered to be perpetrators of age discriminatory behaviour. Also, mistreatment by patients and their families was mentioned, this came as no surprise since the present study assessed the perceptions of health-related professionals. An implication of this is the possibility that health-related professionals may benefit from learning effective response strategies to empower their responses when facing patients [30].

Similar to studies with workers in general [3], in the current study perpetrators may consider younger health-related professionals as inexperienced, and older health-related professionals as being out of date with most recent research, which may explain the present results where higher perception of age discrimination at work was statistically related with the age group and the professional experience for both physicians and non-physicians. Therefore, additional learning opportunities to all health-related professionals and mentorships between younger and older health-related professionals may be needed to fight age discrimination practices, as previously stated [31].

In the present study, having less experience in the profession was associated with experiencing age discrimination at work more frequently. These results agree well with a 2019 study that assessed 1000 workers over the age of 40 and that found that one in three people who have experienced age discrimination in the workplace experienced it for the first time early in their career (i.e. before the age of 45) [31]. In another recent study, 40%of young workers (25–34 years old) stated to have experienced age discrimination at work [21].

In spite of existing in Portugal non-discriminatory legal principles applicable to both private and public employees [32], the current study showed that physicians working for the public sector experienced more discrimination compared to private practice physicians (p = 0.002). Laws alone may not be enough to prevent age discrimination towards physicians. This is an important issue for future research.

In the current study, men and women experienced age discrimination at similar rates, matching the results of previous research [31].

This study suffers from several limitations –notably related to selection bias, since non-physicians were mostly female, of younger age, had higher academic degrees and were largely private sector employees, when compared to the group of physicians. Current results, therefore, need to be interpreted with caution. An issue that was not addressed in this study was the analysis of causal relationships between experiences of age discrimination against health-related professionals and the outcomes of patients’ health. This would be a fruitful area for further longitudinal research.

5 Conclusions

The results of the present study have significant implications for the understanding of age discrimination against health-related professionals in the workplace –individuals having less experience in the profession, being a non-physician and having a lower quality of life may experience age discrimination more frequently. These are the health-related professionals that will need to be closely monitored for discrimination. A key policy priority should, therefore, be to plan for age diversity teams where older and younger health-related professionals may work together and where older health-related professionals can teach and mentor younger colleagues [31].

Conflict of interest

None to report.

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	Total (N = 369)	Health-related professionals
		Physician (N = 202)	Non-physician (N = 167)	p-value^*
Sex, Women, %(n)^a	75.9 (280)	70.3 (142)	82.6 (138)	0.006
Age, years
Mean^b(SD; min–max)	37.9 (11.7; 21–70)	39.6 (12.7; 25–70)	35.8 (9.9; 21–62)	0.006
Young workers 18–29 years, %(n)^a	27.9 (103)	23.3 (47)	33.5 (56)	0.022
Middle aged workers 30–49 years, %(n)	53.9 (199)	54.5 (110)	53.3 (89)
Older workers 50 + years, %(n)	18.2 (67)	22.3 (45)	13.3 (22)
Academic degree, %(n)^a				0.026
Bachelor or licentiate	60.7 (224)	65.8 (133)	54.5 (91)
Higher degrees (Postgraduate/Master/PhD)	39.3 (145)	34.2 (69)	45.5 (76)
Experience in the profession, years
Mean^b (SD; min–max)	13.1 (11.7; 0–46)	14.0 (13.0; 1–46)	12.1 (9.8; 0–41)	0.635
< 15 years, %(n)^a	69.4 (256)	71.3 (144)	67.1 (112)	0.381
≥15 years, %(n)	30.6 (113)	28.7 (58)	32.9 (55)
Work sector, %(n)^a				< 0.001
Public	53.4 (197)	66.8 (135)	37.1 (62)
Private	23.8 (88)	5.0 (10)	46.7 (78)
Both	22.8 (84)	28.2 (57)	16.2 (27)
Quality of life
Mean^b (SD; min-max)	3.6 (1.1; 1–5)	3.7 (1.0; 1–5)	3.4 (1.1; 1–5)	0.014