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Missing Voices: Views of Older Persons on Elder Abuse

This publication, jointly produced by the World Health Organization (WHO) and the International Network for the Prevention of Elder Abuse (INPEA) in 2002, summarizes the findings of a study that was the first step in instituting an international global strategy on elder abuse. What I found particularly striking about the publication, which focuses on abuse in developing countries, is its relevance for developed countries. It addresses such seldom talked-about issues as the roles of gender, poverty, and social exclusion. It is available on-line at http://www.who.int/ageing/projects/elder_abuse/missing_voices/en/index.html

If tackling elder abuse in our own countries isn’t challenging enough, the prospect of addressing it globally is staggering. By 2025, the global population of people over the age of 60 is expected to reach 1.2 billion. One million people turn 60 every month and 80 % of these are in the developing world.

Missing Voices draws from focus groups of elder and primary health care workers in five developing countries: Argentina, Brazil, India, Kenya, and Lebanon; and three developed ones: Austria, Canada, and Sweden. In developing countries, the term primary health care workers typically refers to non-physicians, ranging from medical assistants and nurse practitioners to village “mobilizers,” volunteers, or aides who combine modern health science and technology with traditional healing to address basic health issues like family planning, pre and post natal care, nutrition, and disease prevention. Most are women who are chosen by their communities. The study’s goal was to identify key themes, perceptions, beliefs, and attitudes about abuse held by elders and primary health care workers in developing and developed countries. Eight groups of eight to ten people were held in each country.

Several common themes emerged. In sharp contrast to the “mainstream” literature on elder abuse, which has focused on characteristics of perpetrators and victims, interpersonal dynamics, substance abuse, mental illness, and cognitive disabilities, and interpersonal conflicts, the groups addressed abuse as a larger societal concern. Prominent themes include gender, socio-economic status, social exclusion, poverty, traditional cultural roles, and human rights. There was a prevailing view that women, particularly the poor, childless, and widowed, are the most affected.

Changing social roles were seen as being responsible. In the past, women remained at home and were the primary caregivers for children, dependent older adults, and households. As more women worldwide enter the job market, it has reduced the availability of family caregiving, resulting in emotional and physical neglect, verbal abuse and physical abuse.

Lack of sufficient income after retirement was also seen as a primary cause. Worldwide, only 30% of elders are covered by pension schemes. Lack of legal protections with respect to inheritance laws further affect many elders. For example, a respondent in Lebanon, where religious courts are responsible for dividing inheritances among beneficiaries, described a case in which the court deprived an elder of his inheritance on the basis that he was mentally incompetent. The situation is worse for women. In many African countries, for example, widows’ property is passed on to their elder sons or back to their husbands’ families. In other traditional societies, older widows are subject to abandonment and “property grabbing.”

Elders’ lack of access to health care and social services was another common theme. Decreasing rates of communicable diseases in the developing world over the last few decades has led to increased prevalence of long-term, disabling diseases and a heightened need for long term care. Lack of public funding for basic services places pressure on families and leads to financial pressure, stress, and burden. The poorest members of society are the worst off, and many older adults (especially older women), fall into this category.

Health care professionals were perceived as part of the problem by focus group members, who described health care workers as being inadequately trained to understand ageing and the problems of older people, or not having enough time to listen. Focus groups participants in Kenya claimed that hospitals were rife with corruption and conflict of interest,

Many, however, viewed health care professionals as victims too, citing poor working conditions and low pay as contributing to abuse. Nurses at one hospital confessed that they “do not look kindly upon older patients who have trouble settling their bills” because they realize that their working conditions will only improve with larger revenues from patients. Others affirmed a link between the treatment of health care workers and patients. Many felt that there was prejudice against geriatrics as a field and that people who worked with elders were viewed as being less qualified by professionals and administrators. This is reflected in low salaries in this specialty.
Specific forms of abuse that were described include:

• Abandoning older family members in health care facilities such as hospitals. Participants from Kenya citing abandonment as most significant issue in elder abuse. Health workers estimated that between 15 to 30% of older patients end up abandoned in the hospitals, which is directly related to the fact that the elder or their families have to pay directly for health care services.
• Placement into long-term care is considered by many to be abusive. It is regarded as a last response for the very poorest people with no family to care for them.
• Disrespect of elders emerged as being among the most painful forms.
• Conflict between daughters-in-law and mothers-in-laws were mentioned by respondents in India, Lebanon, and Austria. These conflicts were almost universally mentioned by female participants from Lebanon. In India, a law that is intended to protect daughters-in-law from dowry-related abuse by in-laws requires police to make arrests based on daughters-in-law word alone. Focus group participants reported that some daughters-in-law have used the law as a form of elder abuse, by making false police reports.
• Economic crises. As a result of economic downturns in Argentina and Brazil, for example, adult children are moving back into their parents’ homes, sometimes forcing them to move out.
• In Sub Saharan African countries, including Mozambique, acts of violence against elders often stem from accusations of witchcraft connected with unexplained events.
• “Mourning rites of passage” for widows in most of Africa and South Asia can include cruel practices, sexual violence, forced marriages and evacuation from their homes.

The study further points out cultural and religious values and traditions that mitigate abuse and neglect. In particular, religion was cited as an important protective factor. Strong religious injunctions to respect and care for older adults, particularly one’s parents, were described. In some countries, religious institutions care for destitute elders. Focus group members in Kenya pointed out that traditional healers, who are typically elders, are key to religious practice and play an important role in society by providing an alternative to the health care system, which is underfunded, inaccessible to the poor, and often seen as corrupt.

Focus group participants suggested ways to stop elder abuse and neglect. Recommendations included raising awareness, encouraging positive contact between generations, empowering elders to advocate on the own behalf, and providing recreational facilities and opportunities to combat isolation, Solutions to “structural problems” include strong protective laws and improved health care.

Based on their findings, WHO/INPEA developed recommendations for the global strategy, which include the development of a screening and assessment tool for use in primary health care settings, an educational package on elder abuse for primary health care professionals and the development of a research methodology ‘kit’ to study elder abuse.