Interventions to prevent elder abuse in the community: a mixed-methods systematic review

Intervenções para prevenir o abuso de idosos na comunidade: uma revisão sistemática de métodos mistos

Intervenciones para prevenir el abuso de personas mayores en la comunidad: una revisión sistemática de métodos mixtos

ABSTRACT

Objective:

To identify the interventions proposed in the literature aimed at preventing elder abuse among community-residing elders.

Method:

This was a mixed-methods systematic review that followed the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols checklist. The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews. We included studies published between January 2004 and December 2019 in the databases: LILACS, IBECS, CUMED, CINAHL, MEDLINE and SciELO. The methodological quality of each study included was performed using the Mixed Methods Appraisal Tool.

Results:

Seven studies formed the final sample. Two groups emerged after the analyses: the primary level intervention group, which used health education and coexisting elder abuse groups; and the secondary intervention level, focused mostly on the mental health care of victims of elder abuse.

Conclusion:

There is still a shortage of intervention studies to prevent elder abuse. All the studies selected had a positive outcome, and all interventions can be implemented in nursing care practice.

Elder Abuse; Violence; Geriatric Nursing; Systematic Review

RESUMO

Objetivo:

Identificar na literatura as intervenções propostas para prevenir maus-tratos a idosos residentes na comunidade.

Método:

Revisão sistemática mista conduzida de acordo com a recomendação PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis). O protocolo desta revisão sistemática foi registrado no International Prospective Register of Systematic Reviews. Foram incluídos estudos publicados entre janeiro de 2004 e dezembro de 2019 nas bases de dados: LILACS, IBECS, CUMED, CINAHL, MEDLINE e SciELO. Para avaliar a qualidade metodológica de cada estudo incluído, foi utilizada a Ferramenta para Análise de Métodos Mistos.

Resultados:

Sete estudos formaram a amostra final. Após as análises, emergiram dois grupos, o grupo de intervenção de nível primário, onde foi utilizada educação em saúde e grupos de abuso de idosos coexistentes; e o grupo de intervenção de nível secundário, focado principalmente na atenção à saúde mental dos idosos vítimas de abuso.

Conclusão:

Estudos de intervenção para prevenir o abuso de idosos ainda são escassos. Todos os estudos selecionados tiveram resultado positivo, e todas as intervenções podem ser implementadas na prática assistencial de enfermagem.

Maus-Tratos ao Idoso; Violência; Enfermagem Geriátrica; Revisão Sistemática

RESUMEN

Objetivo:

Identificar las intervenciones propuestas en la literatura dirigidas a prevenir el maltrato a personas mayores residentes en la comunidad.

Método:

Revisión sistemática de métodos mixtos realizada de acuerdo con la recomendación PRISMA (Preferred Reporting Items for Systematic Review and Meta-analysis). El protocolo para esta revisión sistemática se registró en el International Prospective Register of Systematic Reviews. Se incluyeron los estudios publicados entre enero de 2004 y diciembre de 2019 en las bases de datos: LILACS, IBECS, CUMED, CINAHL, MEDLINE y SciELO. Para evaluar la calidad metodológica de cada estudio incluido, se utilizó la Herramienta de Análisis de Métodos Mixtos.

Resultados:

Siete estudios formaron la muestra final. Después del análisis, surgieron dos grupos, el grupo de intervención de nivel primario, donde se utilizó educación para la salud y grupos de abuso de las personas mayores coexistentes; y el grupo de intervención de nivel secundario, enfocado principalmente en la atención de salud mental de personas mayores víctimas de abuso.

Conclusión:

Los estudios de intervención para prevenir el maltrato a las personas mayores aún son escasos. Todos los estudios seleccionados tuvieron resultados positivos y todas las intervenciones se pueden implementar en la práctica del cuidado de enfermería.

Maltrato al Anciano; Violencia; Enfermería Geriátrica; Revisión Sistemática

INTRODUCTION

The World Health Organization (WHO) defines elder abuse as: “actions or omissions committed once or many times that impair the physical and emotional integrity of elder persons and prevent the performance of their social role”¹. The Brazilian Elderly Statute defines elder abuse in a very similar way to the WHO definition, “as any action or omission practiced in a public or private place that causes death, damage or physical or psychological suffering to the elderly”².

Risk factors for elder abuse in the community can be classified as relating to the following four categories: the elderly, the perpetrator, the relationship and the environment³. Elderly-related factors include cognitive impairment, behavioral problems, psychological problems, dependence, poor physical health or frailty, low income or wealth, past trauma or abuse and ethnicity. Perpetrator-related risk factors include caregiver overload, mental illness, being a victim of domestic violence, and substance abuse. Relationship-related risk factors are family disharmony, and weak family affective bonds. Environmental risk factors are social isolation and a low level of social support^4-5. The relational and environmental factors are the most strongly associated with elder abuse³.

Elder abuse has been associated with a higher risk of premature death, a higher use of health services (especially emergency services and hospital admissions)⁶, a higher use of long-term care facilities, disability, chronic pain, bankruptcy, psychosocial suffering^7-9, and poor physical health¹⁰, and it has thus become a public health problem.

An intervention based on a public health model aimed at preventing elder abuse should operate at the levels of primary, secondary and tertiary interventions: primary interventions target the whole population victim of elder abuse to prevent elder abuse; secondary interventions focus on early identifying and stopping the occurrence of elder abuse; tertiary interventions target elderly people who are victims of abuse and focus on preventing the recurrence of abuse^11-12.

Despite the increased visibility of this subject in recent decades, scientific production remains deficient, particularly with respect to studies on interventions to prevent elder abuse¹¹. In addition to the limited data on prevention-oriented interventions¹³, few interventions are based on scientifically grounded hypotheses and have had their efficacy and effectiveness measured¹⁴. A justification for this scenario can be the few solidified theoretical models that fully explain how these relationships of elder abuse develop, in comparison to studies explaining other forms of violence such as child abuse and violence against women¹⁵.

Despite the availability of quite a few systematic reviews of interventions to prevent elder abuse, there are no mixed-methods systematic reviews on this subject^11,16-19, although a multifactorial and complex subject such as this demands the combined strengths of quantitative and qualitative methods.

Given this scenario, it was necessary to review the scientific literature to answer the following research question: Which strategies are adopted in the interventions to prevent elder abuse in the community?

Accordingly, the aim of this study is to identify the interventions proposed in the literature directed to the prevention of elder abuse in the community.

METHOD

TYPE OF STUDY

This review followed the Preferred Reporting Items for the Systematic Review and Meta-analysis Protocols (PRISMA-P) checklist. The PRISMA-P checklist contains 17 basic items that should be described in a systematic review protocol. The use of a systematic review protocol is important because it ensures rigor and reliability, as it allows for careful and anticipated planning, comparison and replication of the review, and prevents arbitrary and random decision making with respect to inclusion and exclusion criteria²⁰. The protocol of this systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under protocol number CRD42018084565.

This was a mixed-methods systematic review characterized by the synthesis of data or results from studies with different designs, that is, quantitative, qualitative and mixed methods²¹. Because the study question we plan to answer lies within the purview of public health, the mixed-methods systematic review is the most appropriate approach, since public health interventions are complex and cannot be limited to exclusively qualitative or quantitative approaches²².

SELECTION CRITERIA

Criteria for including articles in this review were: full text available in English, Portuguese or Spanish; describing an intervention to prevent or control elder abuse; focused on the community setting; and publication between January 2004 and December 2019. This time period was chosen for this review because 2002 is the year that marks the Second World Assembly on Ageing (WAA) held in Madri, Spain, where world governments gathered to set out the blueprint for an international response to the opportunities and challenges of population ageing in the twenty-first century²³.

The following studies were excluded: observational studies; those that did not define the victims of abuse as being at least 60 years-old; studies of an elder abuse population living in long-term care facilities; medical guides, reviews, comments, technical and scientific reports, ministerial documents, government information, dissertations, theses or monographs; and studies that did not demonstrate ethical conduct.

SEARCH STRATEGY

The secondary databases accessed were Latin American and Caribbean Literature in Health Sciences (LILACS), the Spanish Bibliographical Index of Health Sciences (IBECS), CUMED, the Cumulative Index of Nursing and Allied Health Literature (CINAHL), PubMed and Scientific Electronic Library Online (SciELO). This search phase was performed in December 2019 by two researchers, who worked independently.

The PICo strategy²⁴ was used to define the research question and was structured as follows: Population of interest - Elder people living in the community; Intervention - Intervention aimed at prevention/control of violence; Context - Preventing abuse of elders living in the community. Item C of the PICo strategy was not used, since this study was not restricted to clinical trials with a group comparison. Thus, we considered the context (Co) of the study. Based on each item of the PICo strategy, both Descriptors in Health Sciences (DeCS) and keywords were found, enabling us to compose the search strategy. Once chosen, the descriptors and keywords were then combined by using the Boolean operators OR and AND for application in the databases, as shown in Chart 1.

Chart 1
Search strategies used in databases.

Database Online Library	Search strategies
LILACS, IBECS and CUMED (via Virtual Library of Health - VHL)	(Idoso OR "Pessoa Idosa" OR "Pessoa De Idade" OR "População Idosa" OR "Terceira Idade") AND ("Educação em Saúde" OR "Ensaio Clínico" OR "Estudo de Intervenção" OR Intervenção OR Educação OR "Intervenção Educativa") AND ("Maus-tratos ao Idoso" OR Violência OR "Violência Doméstica" OR "Violência na Família" OR "Violência Sexual" OR "Abuso Físico" OR Estupro OR Abuso OR Maus-tratos). Filters: language (English, Portuguese and Spanish); publication year (2004 to 2019) and type of document (article).
PubMed	(Aged OR Elderly OR "Older People" OR "Ageing People" OR Ageing OR "Older Adults" OR Age) AND ("Health Education" OR "Clinical Trial" OR "Intervention Studies" OR Interventions) AND ("Sexual Violence" OR "Domestic Violence" OR "Aged Abuse" OR "Elder Neglect" OR "Elder Abuse" OR "Violence" OR " Family Violence" OR "Physical Abuse" OR Rape OR Mistreatment OR "Elderly Victimization" OR "Crime Prevention" OR "Elder Mistreatment" OR "Financial Violence"). Filters: language (English, Portuguese and Spanish); year of publication (2004 to 2019) and type of document (article).
SciELO (via scielo.br)	(Aged OR Elderly OR "Older People" OR "Ageing People" OR Ageing OR "Older Adults" OR Age) AND ("Health Education" OR "Clinical Trial" OR "Intervention Studies" OR Interventions) AND ("Sexual Violence" OR "Domestic Violence" OR "Aged Abuse" OR "Elder Neglect" OR "Elder Abuse" OR "Violence" OR " Family Violence" OR "Physical Abuse" OR Rape OR Mistreatment OR "Elderly Victimization" OR "Crime Prevention" OR "Elder Mistreatment" OR "Financial Violence"). Filters: language (English, Portuguese and Spanish); year of publication (2004 to 2019) and type of document (article).
CINAHL (via Ebsco Host)	(Aged OR Elderly OR "Older People" OR "Ageing People" OR Ageing OR "Older Adults" OR Age) AND ("Health Education" OR "Clinical Trial" OR "Intervention Studies" OR Interventions) AND ("Sexual Violence" OR "Domestic Violence" OR "Aged Abuse" OR "Elder Neglect" OR "Elder Abuse" OR "Violence" OR " Family Violence" OR "Physical Abuse" OR Rape OR Mistreatment OR "Elderly Victimization" OR "Crime Prevention" OR "Elder Mistreatment" OR "Financial Violence" ). Filters: language (English, Portuguese and Spanish); year of publication (2004 to 2019) and type of document (article).

The literature search results were added and managed using a free reference management software (Mendeley-Desktop version 1.17.7; London-England). The use of this type of tool reduces the likelihood of errors in the cataloging of studies found.

The selection of studies was performed independently by two researchers. This selection was performed in three steps: (1) an initial screening that involved reading only the title, (2) a second screening that involved reading the abstract, and (3) a third screening that involved reading the full text. Disagreements were resolved by a third researcher.

DATA ANALYSIS AND TREATMENT

This review used a convergent synthesis approach to analyze the mixed-method studies found, specifically the parallel-results convergent synthesis design that consists of independent syntheses of qualitative and quantitative evidence and an interpretation of the results in the discussion²⁵. Our study quality analysis was performed using the Mixed Methods Appraisal Tool (MMAT), which is a checklist developed to provide a quality assessment tool for quantitative, qualitative and mixed-method studies included in mixed-methods systematic reviews²¹. The MMAT criteria were developed based on an analysis of the quality assessment items of the reviewed studies of 17 mixed-methods systematic reviews in the health field. The MMAT is focused on the public health context, particularly for issues related to complex interventions, and therefore, its use in the context of elder abuse is appropriate²⁶.

The MMAT is comprised of four sections, one for each study design: qualitative studies, randomized controlled trials, nonrandomized studies, and mixed methods. Each section has a different number of items that can be answered with either yes, no or I can’t tell; the authors can give a score to each answer in order to have a final score of all studies assessed. In this review, the MMAT was used to analyze the methodological quality of the selected studies, but no score was attributed to the studies, and neither was MMAT an exclusion criterion for this review²¹.

Data were extracted to preserve the context of the findings, as described in a study that addressed techniques to extract findings in mixed-method synthesis studies²⁷. This data extraction process was performed using two instruments developed by the researcher. The first instrument contained metadata of the study: journal of publication, authors, institution of the main author, year of publication and country of study. The second instrument was the type of study, purpose of the study, number of participants, location, type of violence, intervention, level of prevention targeted by the study, evaluation of results, and limitations of the study.

ETHICAL ASPECTS

Because of the nature of this study, approval from a Research Ethics Committee was unnecessary.

RESULTS

Based on the search strategy and the inclusion and exclusion criteria presented in the methodology, seven studies constituted the final sample^28-34. Figure 1 presents the selection process for these manuscripts.

Figure 1
PRISMA flowchart of the selection process of studies according to PRISMA.

The earliest study selected for this review²⁸ was published in 2007, and the most recent in 2018³⁴. The year with the highest number of publications was 2011, with two selected studies^30-31. There was a predominance of studies from countries in the North^28-30 and Central America^31-33, with only Iran³⁴⁾ providing a study from outside these areas.

Four of the institutions of origin of the main author were universities^28,31,33-34, two were health services agencies^29,32 and one was a domestic violence victim service agency³⁰. Two studies were of mixed-methods^32-33, two were qualitative^28,30 and three were quantitative^29,31,34. The number of participants in each intervention ranged from two³⁰ to 69²⁹ victims of elder abuse, but this information is absent in one of the studies³².

In two of the selected studies, the target population of the intervention were both the elder abuse victims and their relatives^28,33, while another study was focused only on elder abuse female victims of violence³⁰. The most often addressed type of elder abuse among the selected studies was a broad, unspecified form of violence^28-29,32-34.

Chart 2 details the interventions described in each study. Only two levels of prevention targeted in these interventions emerged in the articles: primary and secondary prevention. Interventions focused on the elder abuse who had not yet been identified as victims of violence^31-34, and on the elder abuse who were already victims of violence^28-30.

Chart 2
Aims, interventions and outcomes of selected articles.

Authors (year)	Aims	Interventions	Outcomes
Holkup et al. (2007)(28)	Describes an elderly, family-centered and community-based intervention: Family Care Conference (FCC).	The FCC has six steps: referral, screening, family involvement, logistical preparation, family reunion and follow-up.	During the follow-up phase, family meetings are held to evaluate the results achieved by the family, in order to identify any necessary changes to the plan and provide positive encouragement. The number of meetings will depend on how difficult the family found it to implement the proposed plan; of the 10 families that participated in the project, five managed to solve their problems in only one meeting, four had two family meetings, and one had three family meetings.
Sirey et al. (2015)(29)	Examine the feasibility of implementing routine screening for depression and anxiety in a system of elder abuse services; test the acceptability of a mental health intervention called Providing Options to Elderly Clients Together (PROTECT) to improve depression and the outcomes of elder abuse cases; identify the most acceptable format for providing mental health services in the practice of elder abuse.	The PROTECT intervention combines problem-solving psychotherapy with anxiety management techniques. The PROTECT resolution therapy is applied in eight sessions, with (at least) the first session held in person. Each subsequent session is conducted using either face-to-face meeting or face-to-face problem-solving worksheets.	The degree of completion of activities, client satisfaction, response to elder abuse interventions and perceived improvement are documented in session progress notes by the PROTECT therapist. The article did not contain any results on the effectiveness of the intervention strategy used.
Tetterton, Farnsworth (2011)(30)	Increase the understanding of professionals about Interpersonal Violence (IPV) in elder abuse women; discuss barriers faced by this population; describe interventions used when dealing with IPV cases in elder abuse women.	The authors conducted two case studies with elder abuse female victims of IPV and identified three essential positions that should be adopted by professionals when performing any intervention with elder abuse female victims of IPV. These positions were: user embracement and captivation of clients; encouraging and supporting the narration of their stories; and offering assistance in the process of empowerment.	The case study and the research notes provided data that supported the conceptualization of effective interventions for elder abuse women who had experienced IPV. Both women began to regain control by identifying and resolving vulnerabilities that others had used against them for decades. The researchers identified this as "empowerment from within" to recognize the long and hard work that older women themselves must carry out to deal with IPV.
Vinent et al. (2011)(31)	To carry out an educational intervention to modify knowledge on elder abuse.	The program of activities was carried out in eight work sessions with themes related to different types of violence and their manifestations, causes and consequences. Two-hour sessions were held twice a week. At the end of each session, there were reflections on what had been covered.	After the educational intervention, the questionnaire was again evaluated with the same initial characteristics, and the knowledge modifications that occurred before and after the intervention were evaluated. At the end of the intervention, all the elder abuse people with inadequate knowledge showed a 100% increase in knowledge levels, with a significance level of p <0.05.
Fernández et al. (2012)(32)	Apply an educational intervention program that promotes assertive behavior in the elder abuse.	The study used an Educational Intervention Program prepared by the group of authors and advisors of this research and validated by expert criteria through the methodology of preference, with a total of 10 experts and a 10% rate of error.	The following methods were used at the beginning and end of the program for diagnosis and evaluation: observation, experience, focus group, interview, and triangulation of techniques (interview and focus group) to obtain the results. Five themes were addressed before and after the intervention: attitude toward old age, daily activities, respect for the elderly, attitude to sexuality in the elderly, and assertive attitude in the elderly. All these aspects changed positively after the intervention, but only the assertive attitude component of the elder abuse resulted in a statistically significant change, p <0.05.
Hernández et al. (2014)(33)	Describe an educational intervention to prevent and control elder abuse; characterize the victims of violence according to sociodemographic and sociocultural variables; determine the frequency of elder abuse.	An educational intervention was conceived based on specific teachings intended for the family and the elder abuse victim to prevent elder abuse, based on instructions for healthy lifestyles that promote appropriate interpersonal exchanges between different generations. Manifestations that can be identified as abuse were also discussed.	How the results were evaluated and whether there were positive results as an outcome of the intervention were not described.
Etbsari et al., (2018)(34)	Design and implement an empowering educational intervention to prevent elder abuse.	The content of the educational interventions was based on the dimensions of health promoting behavior and included physical activity, recreation and entertainment, sleep, nutrition, interpersonal relations and social support, responsibility for health, mental health, and older adult stress management. Educational technology methods, such as lectures, questions and answers, and problem-solving were used. The intervention was carried out in twenty 45- to 60-minute training sessions over 6 months.	Knowledge of elder abuse, high self-efficacy, high social support and high health promoting lifestyle was significantly greater in the intervention group; the frequency of elder abuse risk was also significantly lower in the intervention group after the intervention. The intervention had the highest impact on increasing social support and promoting healthy behaviors.

Three out of the four interventions that focused on primary prevention were of Cuban origin and used educational approaches aimed at modifying the concepts about what was or was not considered elder abuse³¹, teaching assertive behavior to the elder person³², and promoting adequate communication practices between the elder person and the family³³ in order to strengthen family relations and prevent conflicts.

The other intervention was conducted in Iran, based on primary prevention and aimed to design and implement an elder abuse empowerment program for elder people who visited health centers in Tehran. The intervention content was similar to those developed in Cuba, although with a better methodological approach since it was a clinical trial³⁴.

The studies of American origin that focused on secondary prevention were more heterogeneous regarding the type of intervention used. One such study, whose population were elderly women victims of interpersonal violence, described the most effective approaches used by the researchers when working with these victims in a counseling service³⁰.

The selected study that focused on secondary prevention was published in 2015 and reported an intervention used with elder people who sought care at a referral service for elder abuse in New York²⁹. This intervention was offered to victims with positive screening for depressive symptoms and anxiety. The intervention was based on the problem-solving theory and directly and indirectly influenced the outcome of violence cases because it taught problem-solving skills related to the violence that had occurred and addressed problems that both influenced the occurrence of violence and were the result of violence, such as depression and anxiety.

The oldest study selected that also addressed secondary prevention and was published in 2007 described a project called the Family Care Conference (FCC), which was developed on a tribal reservation, based on the elder person, the family and the community and promoted family reunions for families that were reported, referred by another service, or sought the project because they were facing difficulty with an elder family member²⁸. This project was inspired by another project developed in New Zealand among the Maori ethnic group, and its principles involve restorative justice rather than the punitive justice prevalent in Western cultures.

DISCUSSION

During the analysis of the selected studies, two groups emerged: studies focused on primary prevention and studies focused on secondary prevention. This finding corroborates those reported in another study that investigated interventions against violence directed at elder people living in the community³⁵. The primary prevention group was homogeneous: all four studies^31-34 used educational strategies and developed their interventions in groups of elder people, two developed their interventions in existing groups of elder people, and the third and fourth developed their interventions in a group of elder people specifically created for the development of the intervention.

The organization of cohabitation groups for elder people is therapeutic in its own right, since social isolation is a risk factor³⁶ that influences depression³⁷. Greater social participation helps to form protective support networks, which can improve the symptomatology of depression. In addition to generating a sense of control and power in decision making, these support networks can help people cope with stressors, thus promoting supportive and caring relationships³⁸.

Although three studies^31,33-34 carried out educational interventions that clarified what is considered violence to elder people and their families, modified and elucidated concepts and typologies, and two of them^31,34 showed results with statistical significance, with all participants in the intervention modifying the concepts concerning the understanding of violence, there is still no evidence that a better awareness of the concept of abuse has an effect on experiences of violence.

Although no studies have demonstrated the relationship between the level of knowledge of violence and the probability of victimization, interventions such as those reported in these two selected studies are important because they improve elder people’s knowledge of the subject and may influence the search for help in a situation of violence³⁹.

A 2013 study investigated the elderly’s understanding of violence and noted that psychological and physical violence were more easily perceived by the elder person than neglect and financial violence³⁸.

One³⁰ of the three studies in the secondary intervention group was based on two case studies of elder victims of intimate violence who sought counseling. It described the essential approaches in the care of these elder women, as well as approaches that should be essential in professional assistance to victims. The identified conduct was embracement and captivation of the client by encouraging and supporting the sharing of their stories and assisting in the empowerment process.

Empowerment can be defined as a significant change in experiences of power lived by individuals in their interactions in society. It is constructed through an interactive process in which individuals devoid of power establish a significant goal for themselves, aimed at increasing their power, and act and work toward achieving their goal through their internal and external resources, observing and reflecting on the impact of their actions⁴⁰.

Regardless of its nature, violence is marked by the inability of the victims to prevent or stop abuse despite their efforts, generating a sense of powerlessness because the situation is not under their control⁴¹. Several studies report a relationship between the feeling of impotence and depression and depressive symptoms^3,8,36,40.

Depression is an indicator of one’s mental health state and can be characterized as either a risk factor or a consequence of elder abuse, therefore, it is key in the prevention and intervention actions against this violence⁸. In the context of domestic violence, empowerment is seen as one of the main targets to be achieved⁴². An increase in the sense of empowerment of victims of domestic violence is related to decreased depressive symptoms, decreased post-traumatic stress, greater chances of reporting new cases of abuse, and better long-term results in general^40-42.

The interventions proposed in the above mentioned study³⁰ occurred in the context of counseling elder female victims of intimate violence, using support and encouragement to narrate their stories along with the empowerment process as tools that can be used by any professional when providing care to elder victims of violence.

The second study³¹ in the secondary interventions group was focused on mental health as a risk factor and consisted of applying an educational intervention program that promoted assertive behavior in the elder person. Assertiveness can be defined as interpersonal behavior in which individual boundaries are established, and needs are expressed clearly and directly⁴³. An assertive person demonstrates the ability to defend his or her own or another’s rights in a calm and positive way without alienating the rights and feelings of others⁴⁴. A similar approach was found in the clinical trial carried out in Tehran, which also focused on the elder people’s assertiveness, but had a broader aim and also focused on promoting a healthy lifestyle, self-knowledge, and social support³⁴.

Lack of assertiveness can manifest itself in two diametrically opposed ways: excessive kindness, that is, submission; or excessive hostility, that is, aggressiveness. This lack of assertiveness has been associated with several clinical problems, including anxiety, depression, severe mental illness, low self-esteem, and relationship satisfaction⁴⁵. As previously shown, depression and the mental health status of the elder person are both the cause and the consequence of the violence suffered by the elder person⁸, therefore, interventions that target improvement of the mental wellbeing of the elder person qualify as both primary and secondary prevention of elder abuse.

Training that promotes assertiveness has been used successfully in a variety of contexts involving abuse; with students in the context of bullying^43,46-48, with nurses in the context of conflicts between health professionals^44,49, and in the context of domestic violence^33,50.

The last study²⁹ on the secondary interventions group was also focused on the mental health status of the elder person. This was a randomized controlled pilot study that provided an adapted version of problem-solving therapy associated with anxiety control techniques for elder victims of violence who sought help in a community-based treatment. Problem-solving theory is an intervention developed within cognitive-behavioral therapy. It is aimed at teaching individuals a set of cognitive and behavioral skills (tools) to improve their ability to cope more effectively with a variety of stressors that potentially lead to negative physical health and mental health outcomes⁵¹.

Problem-solving therapy is effective in reducing depressive symptoms and controlling anxiety, and quite effective in addressing frequent problems of old age related to disability, decreased mobility, activities of daily living, and social functioning³.

The three main factors addressed in the interventions described above were impotence, assertiveness, and (indirectly) problem-solving skills, which are individual traits rooted in cultural and social factors⁴⁹. Society often infantilizes elder people⁵² and associates old age with disability and illness⁵³, making elder people question themselves and their value, as well as their ability to find a place in society³⁷.

The study²⁸ describing the implementation of an intervention to manage cases of violence or risk of violence in an American Indian reservation based on a model used by Maori natives in New Zealand with principles of restorative justice was the most discordant article among the seven selected. This study markedly differs from the others because it adopted a community approach. Despite its focus on the elder person, the difficulty of this intervention involved the particularity of the scenario. Some of the challenges were the different conceptualizations of what consists elder abuse for the indigenous culture and the secular culture³⁹, along with the social role of the elder person in the indigenous culture that influenced the success of this intervention.

All studies in this systematic review had positive outcomes and could be implemented in nursing practice, particularly those of the primary intervention group, which were based on deconstructing false beliefs about what ageing means, and building assertiveness and empowerment, which are all already attempted by nurses, especially those working in public health services. The nursing professional is in a privileged position to prevent elder abuse, because they work with elder people and the whole population at the primary intervention level and across all levels of nursing care.

According to the quality assessment performed in the study using the MMAT, the seven selected studies did not describe the study design in detail, used small sample sizes, did not provide enough information to understand the randomization of participants and the blindness of the study, and did not favor the replication of studies in other contexts. This finding corroborates that reported by other authors^36,54 and represents the current scenario of the literature on interventions aimed at preventing elder abuse. This lack of methodological rigor of studies in this area directly affects managers who need scientific-based evidence for the development of public policies and decisions concerning this population¹¹.

The main limitations identified in the selected studies were the small sample sizes, and the greatest sample size was of 69 participants²⁹. Another one was the absence of a detailed description of the intervention applied, such as the time of each meeting and the technologies used, both of which are details that allow the replication of the intervention. Another limitation was the lack of an evaluation of results after the application of the intervention, through which would be possible to measure its effectiveness. The context of some interventions also appeared as a limitation, since it presented particularities and characteristics that influenced the positive response, and would be modified in cases of elder abuse victims of violence in different circumstances. All studies selected for the review had their full text available through the university database system, but only a small number of them were free for the whole community.

A limitation of this systematic review was the selection only of studies targeting the elder person. This restricted the findings and consequently, the applicability to the different components of elder abuse: relationship, perpetrator and environment; and the definition of elder people as individuals of 60 years of age or more, which excluded studies from countries with different definitions; and the language limitation.

CONCLUSION

The interventions to prevent elder abuse that target the elder person can be divided into two groups: primary level interventions, and secondary level interventions. Health education through elder people coexistence groups and mental health care were the prevalent approach to elder abuse prevention in the primary and secondary intervention group, respectively. All interventions had positives outcomes and could be implemented within the nursing care practice. There is still a shortage of studies on abuse prevention in the field.

REFERENCES

• ¹
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Publication Dates

• Publication in this collection
  16 Apr 2021
• Date of issue
  2021

History

• Received
  23 Oct 2019
• Accepted
  03 Aug 2020