The data used in this paper is part of a larger study of quality of life among older adults funded by the European Commission, in collaboration with the World Health Organization [10] ; where 23 countries participated, including Norway, 2003-2006. The Norwegian Field Trial study consisted of two cohorts. The largest consisted of a randomly selected stratified sample of older adults from 20 geographically dispersed communities drawn by allocated proportional design by Statistics Norway. Community sizes were up to 5000 inhabitants, 5000 - 20,000 inhabitants, and more than 20,000 inhabitants.

Of the 802 older adults who were sent invitations to participate, 401 consented and were sent questionnaires by mail. Another randomized sample of 89 older adults receiving formalized health care services (home care) was drawn from Statistics Norway to increase participation of frailer older people more likely to have morbidities, primarily with a view to capturing varied levels of quality of life. These frailer older people were also personally interviewed to minimize respondent burden. A total of 282 females and 200 males participated in the study. For the sample participating in the postal survey the response rate was 53%. Unfortunately, no record was kept regarding those participants were asked yet refused to take part by personal interviews. Inclusion criteria were: 60 or more years of age, Norwegian speaking, resident of Norway, no illness likely to cause death within the next six months, and no significant cognitive impairment. Questionnaire packets included study information, informed consent forms, sociodemographic questions, an attitude toward aging scale, and questions assessing quality of life, psychological distress and health. This paper is focused on the attitudes to ageing questionnaire data.

Attitude to Ageing Questionnaire (ATA)

The ATA consists of 24 items comprising a three-facet model based on psychosocial loss, physical change and psychological growth [11] . Psychological loss includes whether older adults equate old age with them being lonely, depressed, feeling currently disengaged from society and excluded from things, and, as they get older, are losing their physical independence, and having difficulty making friends and talking about things. Older adults are also asked about physical changes. Physical changes include feeling old, identity not being defined by age, energy and health at present given their age, physical health problems and not holding them back and exercise regularity and importance. The psychological growth that comes with ageing is about better coping and self-acceptance. Psychological growth includes believing that one’s life has made a difference, seeing age as a privilege and as pleasant, giving and being a good example to others and felt wisdom.Both classical and modern psychometric methods (Structural Equation Modelling and Item Response Theory) were used to establish the reliability and validity of the instrument [10] [11] . All items are based on self-report with ratings ranging from 1 to 5, where 1 reflects strongly disagree or not at all true, and 5 reflects strongly agree or extremely true. Response scales of negative statements are reversed and recoded so that a higher value means more positive attitude (i.e. agreement with a positive statement or disagreement with a negative statement). Time period of assessment is how the older adult feels presently. Internal consistencies with Cronbach’s alpha for subscales of the ATA were: psychosocial loss a = 0.73, physical change a = 0.75 and a = 0.73 for psychological growth.

Total subscale scores were calculated as the sum of item values in the separate domains. Descriptive statistics were used to examine the frequency distributions and means of the variables. To analyze internal consistency of the ATA, Cronbach alpha was applied. A Cronbach alpha coefficient above 0.70 indicates good reliability [12] [13] . The Statistical Package for Social Sciences (SPSS) version 17.0 was used for analysis.

The study was approved by the Norwegian Data Inspectorate and the Regional Ethical Committee. For those participating in the postal survey, informed consent was sent and returned with the battery of instruments sent to the participants. For those participating in the personal interviews, written consent was obtained prior to the interviewing.

The total sample was composed of 58% women and 41% men. Both women and men had a mean age of 76 years. Most adults were married or partnered, 88% women and 87% men. Eleven percent of the women and 13% of the men were non-married, widowed or divorced. Educational status among women showed that 41% had completed primary education, 36% high school, and 23% post-secondary education. Among the men, 28% had completed primary education, 26%, high school, and 55% post-secondary. Both 83% of the women and men appraised themselves to be healthy. In spite of this fact, 28% of both women and men had at least one disease, with 16% of the women and 8% of the men stating they had two diseases. Further, eleven percent of the women and 6% of the men reported three diseases or more.

The results in Table 1 show the overall mean score for the three ATA subscales and the mean values for each item on the scale. Among males and females, attitudes to ageing were found to be quite similar between the genders, although, a few statistical differences were found. Total subscale mean scores on psychosocial loss, physical change and psychosocial growth showed no significant differences between men and women.

Although aging occurs at varying rates, women have been found to find ageing more negative than men [14] . Sontag (1972) described this negativism as the “double paradox of ageing” which portrays women entering old age at a younger point than for men. She contended that getting older is less profoundly wounding for a man, as men are allowed to age without penalty, in several ways women are not. Results of our study showed that both men and women felt that old age represented a time of loss, however, women were more negative than men. Why women had greater negative attitudes towards ageing may have several explanations. One reason could be that older women suffer more from multiple and long-term illnesses and disabilities and may be institutionalized and require help from others for longer periods of time. In contrast, men are more likely to have a spouse available to act as a primary caregiver in times of need. Although, the majority of both men and women in our sample appraised themselves as being healthy, more women suffered from two or more chronic conditions. Such illnesses, in turn, may have a deleterious effect on women’s lives and social support networks.

Women’s feeling of loss may be related to appraising more issues as important to their quality of life. This may also be connected to the fact that they have more multiple past-present identities than men. In an earlier study with the same Norwegian sample, comparison across genders revealed that a fourth of the items on a quality of life scale were more important to women [15] . Various psychological issues were important for women such as feeling hopeful, personal beliefs, and positive attitudes towards death and dying. Also, mental activities such as remembering important information, being able to think through everyday activities and making decisions were valued together with the importance of social relationships. Regarding the importance of information, Benjamini, Leventhal, & Leventhal [16] found that women applied a greater number of sources of information when making self-assessed judgments. Perhaps being more attentive to contextual surroundings makes women more conscious of their loss of important sources.

Women have a different relationship to their bodies than men which may have impacted their attitudes. Body image and appearance have been found to be more important to older women than men [17] . According to standards of ageing, men have been described as ageing gracefully, gaining in status and becoming more dignified with age, whereas, women are described as becoming unattractive and of less value. As such, age-related changes in body image and attitudes toward body ageing may represent greater threats to self-identity for women and contribute to higher levels of anxiety among older women, especially changes in their faces. Similarly, Clarke and Griffin [18] argued that women’s ageing appearances were pivotal to their experiences of ageism where they engaged in beauty work such as dying their hair and cosmetic surgery to fight against social invisibility. However, Leichty and Yarnal [19] found among women (60 - 69 years), that they gave less priority to their appearance in favour of health and internal characteristics. In another study exploring body image and self- esteem in adulthood (65 - 85 years), Baker and Gringart [20] found body-image concerns differed between men and women. Whilst women appeared to develop various strategies to counter the effects of ageing, men seemed to be more negatively affected, in particular, to body functioning. Similar findings also show that men are more negatively stereotyped than women [21] . In another study (22 - 62 years) men were found to conceptualize their bodies as a holistic entity where women had compartmentalized conceptualizations. Here again, men focused on functionality, whereas women tended to focus on display [22] . As such, women may experience a greater sense of loss in connection with their ageing bodies.

Feeling of loss among older women could also be due to the fact that they compare themselves to younger and middle aged women. Since the Second World War, women’s increased educational opportunities, widening occupational and public roles, greater capacity for self?realization and their increased capacity to control their fertility are opportunities few older women have experienced. Older women were largely engaged in childcare and domestic support for their husbands. Feeling of loss in women may therefore reflect a culmination of lifetime experiences within social structures influenced by gender disparity.

Women’s feeling of loss may also be related to a sense of diminished sense of control over their lives. Importantly, a sense of control has been shown to be an important resource for avoiding loneliness in later life among Norwegians, especially for people with impairment [23] . In our study, men had more positive attitudes to their physical functioning as compared to women, and felt that physical problems did not hold them back from doing what they wanted to do. Consequently, they may have stronger beliefs regarding their physical stamina needed to control important outcomes in their lives. Men have also been described as retaining power within the caring relationship, whether or not they are carer, or the cared for, with maintaining a sense of control and previous routine over finances and major decisions [24] . Interestingly, Slagsvold and Sørensen [25] found among Norwegians (40 - 79 years), that women felt less personal control than men. In this study, traditional sex roles and limited opportunities prevented women from occupying positions in society that encouraged the development of a sense of control. Women’s poorer physical health and lower education were also related to their lower sense of control. In our sample, women were less educated than men; consequently, level of education may have impacted gender attitudes.

Both men and women experienced difficulty in talking about feelings. This finding has also been reported by a large Norwegian survey (2012) showing that 12% of those 67 years or older have little contact with friends, 9% are without a close friend and 9% have little contact with good friends by phone, email, internet, etc. [26] . The finding is noteworthy considering the majority of adults in our study were married and both genders were lonely. Interpersonal communication is a critical tool for life adjustment at any age. Communication serves as an important role in maintaining affiliation with others. With aging, communication skills may decrease due to physiological changes in hearing, voice and speech processes, and changes in physical health, depression and cognitive decline. These issues may have attributed to difficulties in discussing feelings and making friends. Lack of sharing possibilities may also be influenced by the fact that family responsibility norms are described as being weaker in Norway as compared to countries further south and east of Europe [27] . On the other hand, data from national surveys show that expectations towards grandparent’s role are comparatively high in Norway, with 60% of grandparents report taking care of grandchildren at least monthly [28] .

From a life developmental perspective, the concept of “life review” has been described as being related to developmental task of later age [29] . Much research has shown that reviewing back has contributed significantly to resolution of past conflicts and injustices and to reconciliation and serenity [30] [31] . Thus, reminiscing and written review could enhance talking about difficult feelings. According to Erikson [9] . Successful resolution of development rests in forming a sense of trust and care for the next generation. In this stage, older people seek ways to give their talents to the next generation, moving beyond self-concerns of identity. Since women felt they had gained wisdom from aging and meant their lives had made a difference, in reviewing back, such positive attitudes could be also be explored also in relation to why they felt unsuccessful in passing on their experiences to others. For older men, who felt strongly that they did pass on such experiences, reviewing could be beneficial not only to themselves but also to identifying ways to strengthen intergenerational connections. This is specifically important because the behavior and life course experiences of older adults’ children have been found to be related to their own attitudes to ageing [32] . Life review has also been shown to help create positive attitudes towards ageing, resolve conflicts and generate new perspectives [33] [34] .

Both men and women felt excluded from activities due to their age. In another study, which applied the Attitudes to Ageing Questionnaire among older adults, feeling excluded from activities was also a major finding [35] . Older people who are not satisfied with life or who experience poor health may become more easily excluded [36] . Feelings of exclusion, should be considered in light of other negative attitudes such as lack of friends, talking about feelings and feeling lonely.Such attitudes may result in older adults’ feeling less valued, dispensable and as useless members of society [37] . Consequently, encouraging social participation and fostering meaningful relationship is especially important for older adults and could enhance opportunities for new friendships, provide opportunities to share feelings, and help reduce loneliness. Research has suggested that active participation in society by club attendance, volunteering, visiting senior centers, group activities, taking new classes and physical activity contribute to a more positive attitude towards ageing [38] . For older adults who master modern technology, computer and communication technologies have been shown to improve quality of life among older people and provide a valuable means for mental stimulation and social interaction [39] .

Regarding physical changes, positive attitudes toward activity and exercising played an important role for both genders. Activity limitation is one of the most frequent geriatric clinical syndromes with both individual and societal effects. Importantly, the concept of activity is central to the International Classification of Functioning, Disability and Health (ICF) and is considered vital to successful ageing [40] . Research has shown that age?related changes in physical functioning pose the greatest threat to how people see themselves ageing physically. Activities of daily living, mobility and energy were found to be most important to both women and men’s quality of life from 22 centers worldwide [41] . Also, findings from a Norwegian national survey among those 60 years of age and older, found that 13% reported decreases in physical activity [42] . Environmental conditions have also been shown to impact physical activity among Norwegian older adults. Halvorsrud and colleagues found that maintaining physical functioning depended on the accessibility of indoor and outdoor environments in order to perform physical activities among older Norwegian adults [43] [44] . Performing day to day activities is vital in order to enhance energy maintenance and exercise capacity. Consequently, interventions which help adults maintain physically active lifestyles, in spite of reduced energy, are important in contributing to positive ageing attitudes. Women, in particular, may need extra support in finding physical activities they can master as they experienced to a greater degree more physical problems holding them back from activities. A Norwegian study by Bergland et al. [45] found that walking was one of the best forms of physical activity for older Norwegian adults.

Both genders had positive attitudes toward feeling their identity was not defined by age. Queniart and Charpentier [46] . examined views of three generations of older women and found they refused to define themselves as “ older” or “elderly women” largely due to the persistent stereotypes liking old age to dependency, social isolation and fragility. Importantly, in this study, representations of ageing expressed positive values of autonomy, independence, consistency and integrity, maintenance of physical and intellectual health and being socially active. Also, Westerhof and Barrett [47] found in two large surveys, focused on middle age development, that feeling younger than one’ actual age was related to higher levels of satisfaction and positive effect and to lower levels of negative effect, even when controlling for sociodemographic variables. Similarly, what age people feel,has been found to be a more sensitive indicator, than chronological age, to many indicators of health, psychological and social characteristics [48] . In a Norwegian study exploring the predictors of subjective age (40 - 79 years), chronological age, good physical health, good mental health, a high level of personal mastery and having lower education significantly was found to predict a youthful subjective age perception [23] . Importantly, feeling younger than one’s age has been shown buffering effects on health. For example, Rippon & Steptoe [49] found lower mortality among people who felt three years or younger their actual age. These authors suggested that greater resilience, sense of empowerment and will to live, as well as specific behaviors such as adhering to medical advice might explain the lower mortality rates.

Notably, both genders felt there were many positive things about growing in spite of the fact they acknowledged existing losses and physical changes. Positive attitudes to ageing have been found in other national and international research, but unfortunately, become less visible against existing negative stereotypes of ageing. For example, Bryant et al. [50] found among older people 60 and over, that positive attitudes were associated with higher levels of satisfaction, better self-report physical and mental health and lower levels of anxiety and depression, after controlling for confounding variables. Further, better financial status and being employed were also associated with more positive attitudes toward ageing. Previous Norwegian cross-sectional data shows positive attitudes with life satisfaction increases from ages 40 to 80 [51] . These trends can also be corroborated by findings from large Western surveys showing stable or increasing life satisfaction from middle age up until at least age 70 [52] . In another Norwegian study of adults receiving nursing care services, many were found to be very resourceful in spite of the fact they had need for home health services [53] . Such positive attitudes of older Norwegians may be reflective of culture and environmental factors connected to the social welfare system. Health care is publicly available and almost free of charge [54] . However, another interpretation could be that older adults have lower expectations and / or aspirations. Older adults are part of a generation influenced by wars, poverty, food rationing, hard physical work and limited resources. Consequently, they represent a generation who are used to having little and could be presently satisfied with what they have. However, positive emotions could also be related to age-related decline in the processing of negative emotional information, which in turn, may contribute to the reported decline in emotional problems in older people [55] . On the other hand, positive attitudes may reflect older adults’ a shift or change in their internal standards, values and conceptualizations of self, representing a way to accommodate psychosocial losses and physical changes and enhance psychosocial well-being [56] .