| BackgroundThe world's population is now ageing at an unprecedented rate generated by decliningfertility and improved health and associated longevity. In China, the percentage of thepopulation aged60years and over increased from10.5%in2000to14.0%in2009, and it isexpected to increase to17.17%(10.5%) by the year2020.The ageing population is one of the most challenging problems of contemporarysocieties which has a direct effect upon public health and social care systems with a higherincidence of chronic diseases with advancing age contributing to increased levels of disability,diminished quality of life and increased need for health care from a workforce who valuethem and are committed to work with them. However, healthcare professionals are reported tohave persistently negative attitudes towards older people regardless of specialties. Thispotentially adversely affects the quality of care provided, particularly in terms of staffbehaviour, interactions, available treatments and healthcare services. Nurses are the largestoccupational group of health professionals and thus they may be able to effect significantchanges in the health of others. Due to changing population demographics, it is essential tounderstand nurses' attitudes towards older people and the variables relating to positive ornegative attitudes if high quality care is to be assured.Objectives1．To understand and compare attitudes towards older people and the level of the variablessuch as the knowledge about older people in Chinese and British nurses2．To understand and compare the correlation between attitudes and its potential relatingfactors in Chinese and British nurses3．To explore the predictors for the attitudes in Chinese and British nurses4．To examine the psychometric indicators of the scales or scores used in this study andfurther to develop Chinese version of these scales after cultural adjustment. MethodsBased on the Theory of Reasoned Action, KAP, and the systematic literature review, across-sectional survey was undertaken in two samples of645qualified nurses working atthree large hospitals in Shanghai, and750qualified nurses enrolled on continuing professionaleducation courses within a large university in London, UK. A total of465Chinese nurses and552British nurses completed questionnaires with a response rate of72.1%and79.3%,respectively. Data analysis were based on valid questionnaires from465Chinese nurses and552British nurses. Additionally, one group of nurses (n=47) from China were recruited toassess test-retest reliability over a two-week period.All analyses were performed using Statistical Package for Social Sciences (SPSS)software, version13.0for windows.A self-administered questionnaire was completed by participants. The questionnairecomprised: Kogan's Attitudes towards Old People scale (KOP), Facts on Aging Quiz (FAQ),The Aging Anxiety Scale (AAS), Professional Commitment Scale (PC), Healthcare resourcesallocation scale (HCRA), Demographic and professional data including age, gender, ethnicity,whether living with an older person, place of work, educational level, clinical specialty, jobtitle and response to the statement 'I like working with older patients' using a four pointLikert type scale from strong agree to strongly disagree.Categorical variables were presented as frequencies and percentages and compared usingNor-parameter test. Continuous and ordinal variables were presented as median and means±standard and compared using T-test or Nor-parameter test. Spearman analysis was used toexplore the correlation between attitudes and the ordinal variables. FANOVA was used toestablish a model of attitudes towards older people in Chinese nurses and British nurses,respectively.All scales were evaluated by critical ration (CR) for items analysis, content validity ration(CVR) for content validity, factor analysis for construct validity, Cronbach alpha for internalconsistency reliability and intra-class correlation coefficient (ICC) for test-retest reliability.Results1. Psychometric properties of the scalesExcept for several items, the items of Chinese or English version employed in the currentstudy had significant CR values (P<0.01)(1) Chinese version1) Means of CVR were higher than0.95. 2) All scales with cumulative contribution rate of variance greater than50%wereconfirmed, except for KAOP.3) Of all scales and its construct factors, alpha coefficients were ranged from0.586to0.882;33.3%with the value higher than0.80.4) Of all scales, ICCs for test-retest reliability (across two weeks) were ranged from0.898to0.982.(2) English version1) All scales with cumulative contribution rate of variance greater than50%wereconfirmed, except for KAOP.2) Of all scales and its construct factors, alpha coefficients were ranged from0.551to0.881;40%with the value higher than0.80.2. Attitudes towards older people and the level of the variables in Chinese andBritish nursesThe Chinese nurses and British nurses both had positive attitudes towards older peoplewith median of113and133, respectively. Regarding the knowledge of older people, Chinesenurses had low level than British nurses (p<0.001). Chinese nurses had neutral attitude towardself-aging with a median of32, however, British nurses had positive attitudes towardsself-aging with a median of38. Both of the two samples had high level of professionalcommitment with a median of39and46, respectively, and positive attitudes towardshealthcare resources allocation among older people with a median of21and20, respectively,however, British nurses had higher professional commitment and more positive attitudes(p<0.001). Further, British nurses had higher preference to work with older patients comparedwith Chinese nurses (p<0.001).3．The correlations between attitudes and its potential factors in Chinese andBritish nurses(1) The relationship between attitude and demographic data1) Chinese nurses: Nursing years was negatively correlated with attitudes(r=-0.095,p<0.05. However, all other demographic data had no association with attitudes.2) Bristish nurses: More positive attitudes were among nurses in any White group, didnot live with older people, working in community or specialized department, with a degree ofpostgraduate, and being a clinical specialist (p<0.05or p<0.001).(2) The relationship between attitude and other variables1) Chinese nurses: Attitudes was significantly associated with knowledge of older people (r=0.226), anxiety about self-aging (r=-0.231), professional commitment (r=0.244), attitudestowards healthcare resources allocation among older people (r=-0.246), however, workpreference with older people had no effect on attitudes towards older people.2) British nurses: Similarly, British nurses' attitudes was significantly associated withknowledge of older people (r=0.202), anxiety about self-aging (r=-0.237), professionalcommitment (r=0.128), attitudes towards healthcare resources allocation among older people(r=-0.447), and work preference with older people had effect on attitudes towards olderpeople.4．The predicting model for the attitudes in Chinese and British nurses1) Chinese nurses: The variables included in the final attitudinal model showed that morepositive attitudes were significantly associated with less anxiety regarding self-aging, higherprofessional commitment, more positive attitudes towards healthcare resource allocationamong older people. Although education level and specialty had no significant effect, therewas evidence of an interaction between them.2) British nurses: More positive attitudes were significantly associated with moreknowledge of older people, less anxiety regarding self-aging, more positive attitudes towardshealthcare resource allocation among older people, being white and being clinical nursespecialist, and working in specialized department.Conclusion1. Psychometric properties of the scalesAll scale, either Chinese versions or English versions, had good reliability and validconstructs, which could be explained clearly. The Chinese versions also had good stability.The psychometric properties of Chinese version were similar to the English version althoughthe Chinese short scales such as PC or HCRA were better than the English version.2. Attitudes towards older people and the level of the variables in Chinese andBritish nursesThe Chinese nurses and British nurses both had positive attitudes towards older people,but reported low level of knowledge. Chinese nurses had neutral attitude toward self-aging,however, British nurses had positive attitudes towards self-aging. Both of the two samples hadhigh level of professional commitment and positive attitudes towards healthcare resourcesallocation among older people, with British nurses had higher professional commitment andmore positive attitudes. Further, British nurses had higher preference to work with older patients.3．The correlations between attitudes and its potential factors in Chinese andBritish nursesFor Chinese nurses, nursing years was negatively correlated with their attitudes, whilefor British nurses, more positive attitudes were in any White group, those who did not livewith older people, working in community or specialized department, with a degree ofpostgraduate, and being a clinical specialist.Both the Chinese nurses and the British nurses' attitudes were associated with knowledgeof older people, anxiety about self-aging, professional commitment and attitudes towardshealthcare resources allocation among older people. Besides, the preference to work witholder people had effect on attitudes toward older people in British nurses.4．The predicting model for the attitudes in Chinese and British nursesAccording to the ANOVA analysis, Demographic was excluded from the Chinese nurses'model except the interaction between education level and specialty, furthermore, less anxietyregarding self-aging, more positive attitudes towards healthcare resource allocation amongolder people, and higher professional commitment were associated with more positiveattitudes. Similarly, Variables including anxiety regarding self-aging, attitudes towardshealthcare resource allocation among older people was included in the British nurses' model,besides, nurses with higher knowledge, being white, being clinical nurse specialist andworking in specialized department had main effect on British nurses' attitudes.
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