Introduction
Historically, law, legal rights and people's legal knowledge have received relatively little attention in gerontological literature (Achenbaum Reference Achenbaum1995). However, over the last decade, awareness has been growing of the social relevance that law, legislation and the courts have to the lives of older people (Frolik Reference Frolik2002; Breda and Schoenmaekers Reference Breda and Schoenmaekers2006; Doron Reference Doron2006; McDonald and Taylor, Reference McDonald and Taylor2006; Rothman and Dunlop Reference Rothman and Dunlop2006). This relatively new literature suggests that the law not only plays a passive role, mirroring social values, customs, interests and political power, it also plays an important active role: constructing the meaning of old age, and changing the social reality of older people by providing empowerment and rights.
Until now, no attempt has been made to develop a research tool, which would provide a broad descriptive picture of the actual knowledge (as opposed to perceived knowledge or general awareness) that adults have of the legal rights of older people. This article describes a first attempt to do so, by creating and applying (in Israel) the Facts on Law and Ageing Quiz (FoLAQ). This quiz was developed to provide a short and standardised tool that can be used to assess people's knowledge of older persons' rights in Israel. It is also intended to serve as a research platform for similar studies in other countries worldwide.
Literature review
Knowledge of law and ageing
In recent years, interest in the legal knowledge and perceptions of older people has been growing, as has interest in their actual usage of their legal rights. This scientific interest involves the integration of three different concepts:
1. ‘Knowledge’ – as defined by Meager et al. (Reference Meager, Tyers, Perryman, Rick and Willison2002: 11), in a study on the knowledge of employment rights – requires ‘a theoretical or practical understanding of a subject’. In this sense, ‘knowledge of a legal right or piece of legislation’ implies that the individual could ‘demonstrate some understanding of the detailed provisions of the legislation’. ‘Awareness’ (or ‘general knowledge’) differs from ‘knowledge’, and was not studied in this research. It requires that the individual will only have ‘some idea’ or ‘had heard’ of the legal right. Another important distinction is between ‘perceived knowledge’ (what one subjectively thinks he or she knows), and ‘actual knowledge’ (what one objectively knows in fact). This study is interested in actual knowledge.
2. ‘Legal right’ – while there is a wealth of jurisprudential literature which attempts to define this contested term (Roach Anleu Reference Roach Anleu2000), there are many divisions and classifications in this field, trying to identify different ‘kinds’ of rights and entitlements. For the purposes of this study (and similar studies regarding public knowledge), a broad and inclusive approach was used: legal right is any entitlement, benefit, power or duty that derive from statutory instruments (laws and regulations) or judicial precedents (case law/common law) (McDonald and Taylor Reference McDonald and Taylor2006: 3–4).
3. ‘Older people's rights’; – as described by McDonald and Taylor (Reference McDonald and Taylor2006: 1): ‘there is no single body of law relating specifically to older people’. Thus, in general, there are two different approaches to defining the term ‘older people's rights’. A narrow approach adopts a definition that includes only those specific rights, which relate solely and directly to older persons, due to their old age, as defined by law (e.g. old age pensions). A broader definition, which is known as ‘a multi-dimensional’ approach (Doron Reference Doron2003), includes also legal rights that are directed to the general adult population but in reality (or by nature) are relevant mostly to older persons (e.g. health-care, advance directives or the right to make a will), and legal rights which indirectly affect the rights of older persons (e.g. filial responsibilityand duties or care-givers' benefits). For the purposes of this study, the broader definitional approach was adopted in order to provide a full picture. The broad definitional-approach both to ‘legal rights’ and ‘older people's rights’ also led to the preference for a more relaxed age criterion for the term ‘older people’, that included the ‘young-old’, i.e. those aged 50+(Heckman et al. Reference Heckman, Heckman, Kochman, Sikkema, Suhr and Goodkin2002; Kannus et al. Reference Kannus, Parkkari, Koskinen, Niemi, Palvanen, Järvinen and Vuori1999; and an expanded Neugarten (Reference Neugarten1996) definition of the ‘young-old’, as 55–75), rather than adopting the formal legal definition of old age (67+ years according to Israel's Retirement Age Act 2004).
When reviewing existing literature in this field, one finds a wide array of anecdotal research. This literature involves a mix of studies on awareness, knowledge and usage of legal rights that can be divided into two general types. The first examines the awareness and knowledge of either the general adult population or, more specifically, of the older population, with regard to specific legal fields. In the United States, for example, the American Association of Retired Persons (AARP) has been very actively conducting these kinds of broad surveys, in order to study people's knowledge about, and perceptions and usage of, legal rights regarding old age and specific fields of law such as advance directives (Silberman Reference Silberman2004); pension plan fees (Turner and Korezyk Reference Turner and Korezyk2004); assisted living (Cicero and Bridges Reference Cicero and Bridges2003), and wills, durable power of attorney and living trusts (American Association of Retired Persons 2000).
In most cases, these surveys reveal that people do not know enough about older people's rights. In 2006, for example, AARP surveyed public perceptions of the costs of long-term care in order to compare them with the reality of such costs (AARP 2006). The findings revealed that Americans do not have sufficient knowledge of their legal rights with regard to long-term care: 59 per cent mistakenly thought that Medicare would pay for an extended nursing home stay, and 52 per cent believed that Medicare covered assisted living costs. These surveys usually also reveal correlations between socio-demographic factors and knowledge of legal rights: men knew more than women about legal rights for example (Turner and Korezyk Reference Turner and Korezyk2004), and more educated and wealthy people knew more about their legal rights than less well educated and poorer people (AARP 2000).
Attempts to examine people's knowledge of older people's rights are not unique to the US. In Israel, for example, an attempt has been made to build on the American experience by conducting similar surveys of older Israelis. Using an American survey as a basis (AARP 2000), Doron and Gal (Reference Doron and Gal2006) studied what older persons thought they knew (i.e. their perceived as opposed to their actual knowledge) about three specific preventive legal tools for old age: (1) living wills, (2) wills, and (3) trust accounts. The study showed that, while the majority of the participants were aware that they had the legal right to write a will, only a minority was aware of their right to have a living will or to use a trust account. Furthermore, from a comparative perspective, it was found that Israelis' knowledge of living wills and trust accounts was much lower than that of those surveyed in the US.
The second class of research into people's knowledge of rights in old age focuses on the knowledge of professionals concerning the legal rights of their older clients with regard to their particular field of expertise. Jackson and Warner (Reference Jackson and Warner2002), for example, studied the knowledge possessed by physicians (geriatricians, general practitioners, psychiatrists, and last-year medical students) in the UK concerning the legal issues of consent and capacity in medical settings. This UK study found that physicians had knowledge of capacity issues that is far from adequate. Their knowledge regarding testamentary capacity was poor, for example, and correct answers were given by only nine of the 79 physicians who participated. Similarly, Wilson, Setterlund and Tilse (Reference Wilson, Setterlund and Tilse2003) found that social workers in Australia lack knowledge of the legal aspects of older people's entry into care facilities for old people. These social workers reported that ‘they knew least about aged care agreements and that they were also more likely to consider this knowledge as “not relevant to my work”’ (p. 161).
A review of these studies of people's knowledge of the legal rights of the older generation reveal that, while interest and the amount of work being undertaken is growing, no attempt had previously been made to develop a standardised research tool capable of being used to assess, study and describe people's knowledge of the legal rights of older persons as a whole. As a result, thus far, no study has attempted to paint a broad picture of the knowledge that older people have with regard to their legal rights.
The importance and relevance of developing the Facts of Law and Ageing Quiz
It is important to develop a knowledge quiz for assessing people's knowledge of the legal rights of older persons for several reasons. The first is that knowledge quizzes can be used to measure and compare the level of information that different groups have and to identify the most frequent misconceptions. Knowledge quizzes also stimulate discussion, because most people are amazed at the amount of legal rights that they are either unaware of or have misconceptions about. This is important because participants can be given immediate feedback on their misconceptions, which can be corrected by presenting and discussing the facts with them. Knowledge quizzes can also easily and efficiently be used to examine the effects of lectures, courses, or other training experiences and educational interventions, by comparing scores before and after the training that has been provided.
Evidence for the above points is provided by other types of knowledge quizzes developed for use in the field of ageing, (although these were not developed specifically to address the issue of ageing and the law). Such tools include the Palmore Facts of Ageing Quiz (Palmore Reference Palmore1977; Palmore Reference Palmore1980; Palmore Reference Palmore1981); the Facts on Osteoporosis Quiz (Ailinger, Lasus, and Braun Reference Ailinger, Lasus and Braun2003); the Marriage Quiz (Larson Reference Larson1988); the Alzheimer's Disease Knowledge Test (Dieckmann et al. Reference Dieckmann, Zarit, Zarit and Gatz1988) and the Knowledge of Memory Aging Questionnaire (Cherry et al. Reference Cherry, West, Reese and Yassuda2000).
There are also specific legal justifications for the development of the FoLAQ. The FoLAQ tool is important because people's knowledge of law can be used to assess the success or failure of legislative reforms. One way to assess the success of new legislation is to study how aware the target population is of its content and the rights it grants. One way to assess the success or failure of the Americans with Disabilities Act, for example, would be to study the knowledge of the law displayed by personnel/human-resource managers (Fusiller and Williams Reference Fusilier and Williams1996).
Legal knowledge assessment is especially important because knowledge of the law is a prerequisite for social change (Roach Anleu Reference Roach Anleu2000). Entrenched attitudes, values and practices do not change simply because legal reform has been undertaken. In actuality, much work is needed in the fields of public and professional awareness, education, advocacy and empowerment to bring about these changes. One of the most important first steps in this long journey of ‘translating’ the law into social reality is to increase people's knowledge of their rights under the law, as knowledge of the law is essential if laws are to be implemented, and assimilated and observed by society. As argued by Felstiner, Abel and Sarat (Reference Felstiner, Abel and Sarat1980), the ability to ‘name’ an infringement of rights relies on legal knowledge and awareness. Without being able to ‘name’, one cannot move on to ‘blame’ or ‘claim’, i.e. to actively seek for relevant advocacy and advice in order to restore or protect one's rights.
Finally, knowledge of the law is (or should be) considered an important part of the gerontological ‘tool-box’. There is a growing awareness in recent years of the need to improve legal literacy within the gerontological discipline. As stated by Doron and Hoffman (Reference Doron and Hoffman2005: 629):
[T]he time is ripe for gerontological education to recognize the importance of exposing students of gerontology in academic frameworks to study of the law, and to acknowledge that the field of law and ageing – or ‘jurisprudential gerontology’ (as in ‘sociological gerontology’ or ‘environmental gerontology’) – should become an integral part of the interdisciplinary knowledge which every gerontologist should be exposed to during the education experience.
In light of the above literature review, it seems that there is a need to design a tool able to ascertain older people's actual knowledge of their legal rights. The goal of this research, therefore, was to develop and validate the ‘Facts of Law and Ageing Quiz’. The following research questions were examined: (1) what is the level of general knowledge displayed by persons aged 50 and over with regard to their legal rights in old age, and (2) what are the socio-demographic correlates of this knowledge?
Methods
Method and sample
A telephone survey was conducted towards the end of 2005 in Israel. The research population consisted of adult Jewish, Hebrew-speaking people, aged 50 or more years, living in the community in Israel. Using a random digit dialling, computer-assisted telephone interview (CATI), from a national database of household telephone numbers across Israel, a randomly-chosen sample of 227 persons aged 50 and over, was asked 33 closed questions. The response rate was 78 per cent, (56 persons refused to be interviewed and nine persons stopped the interview without finishing it), which is a good response rate for this kind of study (Marin Vanoss and Perez-Stable Reference Marin, Vanoss and Perez-Stable1990; Triplett and Abi-Habib Reference Triplett and Abi-Habib2003).
The sample consisted of 47.6 per cent men and 52.4 per cent women, very similar to the general Jewish population in the same age group (47.7% and 52.3% respectively; CBS 2007), and they ranged from 50 to 86 years-of-age (mean 63.48; SD 9.5). Most had lived in Israel for most of their adult lives (mean number of years in Israel 49.25; SD 12.87); the majority were married (69.5%, compared to 67.8% in the general Jewish population in the same age group; CBS, 2007) and secular (52.9%, compared to 48% in the general adult Jewish population), and levels of education differed (21.6% had not been to high school; 28.6% had had a high school education; 18.1% had had post-high school education; and 32% held a bachelor's degree and higher). It should be recognised that because the research was telephone administered, the sample was biased toward the more independent, healthy and wealthy older population.
Research tool
One of the most challenging parts of this research was designing the research tool. The questionnaire consisted of two parts. The first part was relatively simple, and contained 12 closed, socio-economic questions, which were designed to provide basic background data on the participant. The background information covered by these questions included data on gender, age, income, marital status; level of education; number of children, type of occupation, place of birth and religiosity.
The second part of the research tool was the knowledge questionnaire. Since no such tool for this specific area has been developed in the past, an attempt was made to learn about the methodological issue involved by considering a similar and well-known tool – the Palmore Facts on Ageing Quiz (PFoAQ). Although not used in the legal sphere, the PFoAQ was designed to serve a very similar purpose, in that it was meant to assess knowledge of facts on ageing in general. From the extensive literature available regarding the PFoAQ, three key issues were identified: (1) the questionnaire should be short, simple, and easy to understand, and should cover the central key factual fields of ageing; (2) the tool should require the respondent to give answers to multiple-choice questions, to avoid them giving yes/no answers; and (3) the statistical analysis should take into account any ‘I don't know’ answers.
In order to cover all the key issues in the field of law and ageing, basic elder-law textbooks were analysed (Dayton Gallanis and Wood Reference Dayton, Gallanis and Wood2003; Frolik and Barnes Reference Frolik and Barnes2003; Frolik and Kaplan Reference Frolik and Kaplan2006; Soden Reference Soden2005). Based on these criteria, a draft questionnaire was drawn up containing 20 multiple-choice legal questions. The questionnaire had questions on the following legal fields: (1) social security old-age pension rights (hereinafter ‘social pension’), including supplementary income support; (2) occupational pension rights, including labour rights and retirement age; (3) long-term care (both community-based and institution-based); (4) national health-care insurance and patients' rights vis-à-vis Health Maintenance Organisations (the Israeli equivalent to Medicare and Medicaid programmes in the USA); (5) local/municipal rights, e.g. local property tax; (6) informal-care/filial responsibility rights; (7) elder abuse and neglect, legal protection and guardianship; and (8) legal planning (both financial and health-care aspects).
Procedure
The draft questionnaire was sent for validation to 10 experts in the field of law and ageing in Israel: lawyers, legal scholars, and academics in the field of gerontology and social work. Various comments were received, concerning both the content and the wording of the choice answers. Corrections and revisions to the research tool were made accordingly and ultimately all external experts agreed on the questions and answers provided. A pilot study was then conducted on 25 adults over the age of 50, in order to verify that the questionnaire was clear and could be easily understood. Once again small adjustments were made accordingly. Finally, the random survey was conducted as described above.
It should be noted that, from the perspective of reliability, the usual tests (such as item-to-total correlation and item discriminatory power) are inappropriate for such a quiz. Inter-item correlations are low, because the items represent many different dimensions of knowledge about law (pensions, health, financial tools, social security, and more). As in other knowledge-testing tools, apparently, what most people know about one area of elder law has little correlation with what they know about other dimensions (Palmore Reference Palmore1981).
Results
General knowledge
First, general knowledge was examined. Each participant received five points for each correct answer, allowing a maximum ‘knowledge score’ of 100 if all answers were correct. After all the participants' questionnaires had been graded, the average score of all participants was 43.08 (SD=16.54; Mdn=45; Min=0; Max=80).
Specific knowledge
The next step involved examining specific knowledge, in other words looking into the specific questions and answers, and also taking into account the ‘I don't know’ answers (i.e. perceived knowledge) (see Table 1). This comparison showed that there were two questions to which the majority of the participants felt they simply did not know the answer: question 1 – which was concerned with the value of the basic social old-age pension and to which 58 per cent of participants answered ‘don't know’; and question 3 – which was concerned with the value of the supplementary income support.
Table 1. Summary of all replies to the Facts on Law and Ageing Quiz
Notes: ADL: Activity of daily living. HMO: Health Maintenance Organisation. LTC: Long-term care.
Three questions were identified as those that the most participants felt they knew the answer to (i.e. these questions had the least number of ‘I don't know’ answers). These three questions dealt with three different fields of law, and were not related to social security or health-care insurance. Specifically, they were question 11 – which was concerned with the right to a discount for local property tax payments (only 15 per cent replied ‘don't know’); and questions 17 and 19 – which were concerned with artificially prolonging the life of an older person against their wishes (18 per cent answered ‘don't know’) and the mandatory reporting of elder abuse (18 per cent answered ‘don't know’).
In the next stage the participants' responses were again analysed, but the ‘I don't know’ answer was ignored. Instead, the analysis considered only those respondents who thought they knew the correct answer and chose an option. Once again, the lowest knowledge scores related to question 1 (only 10 per cent knew the correct answer) and question 3 (only 8% knew the correct answer), both of which were concerned with issues of basic social security, old age pensions and supplementary income in old age.
The next two lowest-scored questions (questions 10 and 12) touched upon specific financial rights in relation to national health-insurance coverage in Israel. Question 10, which was concerned with co-payments by older persons to professional physicians (i.e. not their family doctor), and only 16 per cent of participants were able to answer correctly (24.5% if the ‘I don't know’ group was excluded). Question 12 was concerned with the discounts available to older people when purchasing medications, which are included in the basic health-care services basket. Only 16 per cent knew the correct answer (28% of the ‘I don't know’ group was ignored). An interesting finding in this context was the fact that question 17 (which concerned the right of an older person not to have their life artificially prolonged if they were suffering an incurable disease) had one of the lowest ‘I don't know’ rates of reply. Although this made it one of the questions with the highest ‘perceived knowledge’ rates, it was also one of the questions for which the fewest correct answers were given (only 19% answered correctly).
The questions with the highest scores for correct answers also related to the national health-care insurance, but did not touch upon financial rights; instead they covered more general principles and issues of freedom of choice. The most correctly answered questions were question 9, concerning the fact that old-age long-term care is not covered under Israel's national health-care insurance act (67% knew the correct answer), and question 15, concerning older patients' right to replace their family physician like any other patient (67% knew the right answer).
Fields of knowledge
As described in the methodology section, the 20 questions in the questionnaire assessed knowledge in eight different fields of the law. Table 2 shows the ranking of knowledge by the score in the different fields of the law. As can be seen, the fields in which there was least knowledge of the law were old age pensions (social security), and the fields concerning informal care-givers' rights and legal planning. The fields in which there was relatively greater knowledge were municipal rights, legal protection and long-term care.
Table 2. Knowledge of specific fields of law
Notes: † out of 100; * calculation includes ‘I don't know’ answers; ** calculation excludes ‘I don't know’ answers.
Correlations between socio-demographics and knowledge of rights
Finally, relationships between the socio-demographic background of the participants and the different scores regarding their knowledge of the law, as described above, were examined using Pearson correlations. In general, there was no statistically significant correlation between the level of knowledge of the legal rights of older people and the number of children, level of religiosity, type of occupation (self-employed or hired worker), or the fact that the person was born Israeli or had immigrated to Israel.
Statistically significant correlations were found between the level of knowledge and the following factors: economic situation – the better off the person was financially, the more knowledge he or she had (r=0.22, p<0.01); age – the older the person was, the less he or she knew about legal rights (r=−0.22, p<0.01); gender – men (M=46.20) knew more about their rights than women (M=40.25) (Z=2.52; p<0.05 by Wilcoxon text,); and education – the higher the level of education, the better knowledge the person had (χ2=25.4, p<0.0001 by Kruskal-Wallis Test). A significant association was also found for the respondents' country of origin – people who were born in Israel knew their rights better than those who originally were born in Asia/Africa (χ2=8.4, p<0.05 by Kruskal-Wallis test).
Discussion
Knowledge of the law
The most important finding of this study, which is supported by previous, more specific surveys, is that there is a general need to improve the knowledge of older persons in relation to their legal rights in old age (Doron and Gal Reference Doron and Gal2006). More specifically, the findings of this study support those of other studies, in that among older people, the less-educated, poor, older-old, and women, are more vulnerable (because they know less about their rights) and are less able to exercise citizenship in their later years (Turner and Korezyk Reference Turner and Korezyk2004). Hence, this study supports not only existing calls actively to provide and improve public education, advocacy and training with regard to legal rights in old age, but also calls for special attention and focus on specific older population groups.
Specific ‘holes’ in the knowledge of the law
Beyond the broad conclusion stated above, this study with its unique design revealed that, at least in Israel, there are certain areas of legal rights in which older persons have significantly less knowledge. These areas mostly pertain to the national legal schemes of social security in old age, and the rights of older persons within the national health-insurance scheme. It can be hypothesised that, since these rights are granted ‘automatically’ under Israel's social security system, the general notion is that there is no need for people to know their legal rights, since ‘the State will take care of it’. This may explain why in other areas of the law, such as occupational pensions, local taxation or informal care, the level of knowledge was higher, because in these fields the rights are not automatically granted: they fall under the personal responsibility of the older person. This hypothesis needs further research.
Culture and law
Any study regarding knowledge of the law should bear in mind the fact that it is situated within a legal-cultural context. Comparative jurisprudential literature emphasises the fact that different legal systems reflect different legal cultures. A well-known (and disputed) example is the cultural gap between the highly individualistic and litigious American legal system and the highly communal and non-litigious Japanese legal system (Dean Reference Dean1997; Wollschlager Reference Wollschlager and Baum1997). Another example is the conceptual division between common-law legal systems, which are case-law based, and continental-law legal systems, which are statute-based (De Cruz Reference De Cruz1999). There is little doubt that these cultural differences directly influence studies that attempt to assess public knowledge in the field of legal rights.
From this perspective, Israel provides a good case study for studying knowledge of the law in a multi-cultural society. Its legal system is a mix of both common-law and European continental-law traditions; and its society is composed of a significant body of immigrants from all over the globe (Shachar Reference Shachar, Shapira and DeWitt-Arar1995). Moreover, some findings may be explained through the cultural lens. The finding that younger people hold better knowledge of their rights may be seen as a reflection of a cultural change in Israeli society, which has been transforming into a more ‘legalistic’ and litigious society. Furthermore, the finding that the Israeli-born had better knowledge on their legal rights than those who were born in Africa/Asia, may also represent the more ‘western’-oriented culture of Israeli-born people.
Limitations
Despite the attempts made to design the research tool as well as possible, several limitations should be acknowledged. First, due to financial constraints, the final sample was smaller than planned. Secondly, as with any telephone-based research, low-income families and other people without telephones were not included. Thirdly, it is very difficult to make broad and accurate generalisations about ‘legal knowledge,’ especially in a knowledge field so wide as in the case of older people's rights, based on a 20 questions quiz. This is true of any kind of short quiz, and one has to keep in mind that the picture provided by such a tool is partial. Finally, important minority groups (new immigrants and older people living in institutional settings, as well as the non-Jewish Arab minority) were not all included in the sample. Despite these limitations, the findings of this study provide a first-of-its-kind picture of the knowledge of the legal rights that Israel's older people have and offer a basis for the development of research and practice in the field.
Future research developments
One of the specific challenges in constructing the FoLAQ is the fact that, unlike the Palmore FoAQ for example, every country (and in many cases, even every state or province) has a different legal system and a different set of rights for older persons. As discussed above, the difference across nations is not only in their laws but also in their legal culture. This raises the question as to what extent the tool presented here could be used in other countries. The answer is that the research tool is effective across different legal systems, since the major legal fields of knowledge are the same in different countries. For example, the question regarding the existence of the legal right to community-based long-term care is relevant everywhere. However, the questionnaire will have to be adapted to suit specific legal systems, by changing the content of the multiple-choice answers. This adaptation will allow, for the first time in this area, researchers from different countries and cultures to compare the level of knowledge of elderly persons regarding the law in their societies. These comparative findings would always need to take into account the legal-cultural differences among societies.
Future practice developments
Looking into future usages of the FoLAQ knowledge-testing tool and its further development, two issues should be addressed. First, our findings show that there is a need to differentiate between general and specific knowledge of law. For example, it is important to have knowledge about people's legal right to receive an old age pension from social security schemes at a certain age. However, there is also a need to know the exact amount of money one is entitled to receive. In other words, one of the issues that needs to be addressed in the future development of the FoLAQ is the need to include, within a specific field of law, questions that will touch both on knowledge about the existence of a legal right as well as on knowledge about the actual substance of that right. Moreover, the development of a standardised instrument such as the FoLAQ might allow us to assess systematically the effectiveness of educational and/or intervention campaigns aimed at increasing elderly persons' knowledge about their rights. Finally, in the future, an electronic version of the quiz can be established on websites to enable self-testing of legal knowledge.
