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Review question/objective What is the effectiveness of educational interventions designed to improve health care student behaviors and/or attitudes toward older people? Background According to population projections, one quarter of all people living in the developed world will be 65 years or over within the next few decades. Currently in the UK, 17% of the population is over 65, with this set to rise to 25% by 2051.1 In the year 2000, 12.9%, or one in every eight Americans, were in this age group.2 Forecasts indicate this will increase to 19% by 2030.2 Likewise, in Canada, the 65 and older age group is set to increase from 13.2% in 2005 to 24.5% by 2036.3 In Australia, this age group is set to nearly double, from 13% in 2007 to 24% by 2056.4 A number of factors have been attributed to these changes. Some of these include: medical advances, increased fertility rates, better health care and education, and the coming of age of “baby boomers”.5,6 The aging population poses a number of challenges for the provision of high quality and targeted services to older people. Declining health, functioning and independence is a natural consequence of aging. As people age they are more likely to suffer from chronic diseases which affect their daily living, such as heart disease, arthritis, diabetes and dementia.6,7 Additional non-physical challenges such as social isolation, financial constraints, transportation issues, lack of education and access to health care services are also at play.8,9,10 Each of the aforementioned issues affecting older people do not occur in isolation but are inter-related. Loss of social networks and support, and significant life events, such as the death of a spouse or close friends, for example, adversely affect mortality and morbidity.11 The complexity of these intertwined biopsychosocial issues amongst older adults impacts on the demand for health and social services. The increasing demand on health and social services by this demographic is well documented across all disciplines. In nursing, global nursing shortages are attributed to multiple factors of which an aging population tops the list.12 The demand for hospital bed days is projected to almost double over the next 45 years, requiring additional doctors, nurses and specialist medical staff.13 The requirements for post discharge and community health and social services care are also rising as hospital bed shortages necessitate shorter stays.14 As the demand for services to treat older patients increases so does the necessity for trained health care professionals who are equipped to meet their complex, multidimensional needs. Undergraduate health care students begin their studies with preconceived ideas about older adults.15 They are not learnt intentionally but based on past experiences with their own grandparents, extended families and friends, employment experiences and/or media portrayal of the elderly.16,17 Undergraduate education based on a biomedical model can also indirectly increase negative beliefs and attitudes towards these patients with students viewing them in terms of their aliments rather than holistically.18 It is also evident that regular contact and interaction with older adults is diminishing due to changing societal pressures and family dynamics.19 Increasing numbers of health care students are therefore entering professions with little or no experience with older people who will become their most frequent patients. As these beliefs and attitudes can positively or adversely affect patient care,20 it is imperative that specialist education and experience with older adults be integrated into undergraduate health care courses. An initial review of the literature found primary studies involving a range of educational interventions across a variety of health care disciplines. Interventions included placements within geriatric or community facilities, traditional didactic teaching approaches, workshops, simulation and gamification, or combinations of these. For example, one study involving first year psychology students used “The Game of Late Life”, which was designed to allow students to image themselves as older adults as they move through various stages of life and encounter events along the way.21 Statistically significant improvements in attitudes were seen following the intervention.21 Several studies explored the use of “The Aging Game”, a simulation game that allows students to experience sensory deficits and functional dependency.22 All studies reported varying degrees of success in improving medical, nursing and allied health student attitudes towards older adults.23,24,25 This review therefore aims to evaluate the effectiveness of educational interventions designed to improve health care student behaviors and/or attitudes toward older people. Inclusion criteria Types of participants This review will consider studies that include undergraduate health care students from disciplines including: medicine, nursing, psychiatry, social work, paramedicine, speech therapy, physiotherapy, occupational therapy and dietetics. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the outcomes of educational interventions which are designed to improve health care student behaviors and/or attitudes toward older people (≥ 65 years). The intervention may include any educational activity that aims to improve participant attitudes or behavior. These may include but will not be limited to interventions that incorporate traditional didactic methods, simulation, clinical placements, case studies, service learning, workshops and gamification. The interventions may be a “once-off” or over multiple sessions. Types of outcomes This review will consider studies that measure health care student behaviors and/or attitudes toward older people following an educational intervention. Studies that use validated measures of attitudes towards older people, such as Aging Semantic Differential26 and Kogan's Old People Scale27 will be considered, in addition to studies that describe behavioral or attitudinal change through any observer- or self-report or survey or questionnaire. Types of studies The quantitative component of the review will consider both observational and experimental study designs for inclusion. These will include randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies, cross sectional studies, case series and case reports. Search strategy The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for studies not identified through the database searches. Only studies available in English and published from 1995 to the current date will be considered for inclusion in this review. This date range is most relevant for studies relating to the education of health care professionals and the care of aging populations. The databases to be searched include: Ovid MEDLINE, CINAHL, PsycINFO, ERIC and Scopus The search for unpublished studies will include: ProQuest Dissertation and Theses, Google Scholar, Web of science core collection, Mednar Initial keywords to be used will be: student, undergraduate, health occupations, healthcare, health care, paramedic, medic, nurse, psychiatrist, psychologist, social worker, speech therapist, physiotherapist, occupational therapist, dietician education, teaching, instruction, pedagogy, method, approach, intervention, technique, strategy, innovation, program, design behavior, attitude aged, aging, elderly, old, older, greater than or equal to 65, Synonyms, truncations and MeSH terms associated with the above key words will be combined using Boolean operations such as ‘OR’ and “AND” for the search. Assessment of methodological quality Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Data extraction Quantitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Results from quantitative papers will, where possible, be pooled using JBI- MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different quantitative study designs included in this review. Subgroups will include undergraduate discipline, year level and age. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate. Conflicts of interest There are no conflicts of interest.
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