Analysis of the direct and indirect risk of intrafamily violence against older people

Abstract

Objective

To analyze the direct and indirect risk of intrafamily violence against older people in the city of Manaus (AM), Brazil.

Method

Population-based, quantitative, cross-sectional, descriptive and analytical study, developed in six urban areas of this city from November 2019 to April 2021. The sample consisted of 2.280 older people, using a margin of error of 5% and a Confidence Coefficient of 95%. The Hawlek Sengstock Elder Abuse Screening Test (H-S/EAST), adapted for Brazil, was used.

Results

67.4% were women, mean age 69 years (±6.9), 48.6% were married and 79.9% earned less than 2 minimum wages; 73.6% shared the expenses of the house and 60.9% co-lived with children and grandchildren; it was identified that 99.8% suffered violence (direct and indirect) and 88.8% are constantly at high risk for some type of violence; 44.7% do not have someone to keep them company; 95.3% support someone; 66% feel sad or lonely; 42.6% report excessive use of alcoholic beverages by family members; 45.8% were recently hurt or injured by family members. Women and the oldest were the most violated.

Conclusion

it was evident that the experience of intergenerational co-residence brought to light the reality of intrafamily violence practiced against older people, present in 99.8% of respondents, mainly linked to negligence, omission and financial abuse. Respondents were able to point out problems arising from intra-family relationships, possibly resulting from the absence of a better emotional bond, which puts them in situations of direct and indirect violence.

Keywords
Elderly; Violence; Domestic Violence; Exposure to Violence

Resumo

Objetivo

Analisar o risco direto e indireto da violência intrafamiliar contra a pessoa idosa, na cidade de Manaus, AM, Brasil.

Método

Estudo epidemiológico de base populacional, quantitativo, de natureza transversal, descritivo e analítico, desenvolvido em seis zonas urbanas dessa cidade, no período de novembro de 2019 a abril de 2021. A amostra foi composta por 2.280 pessoas idosas, utilizando-se margem de erro de 5% e Coeficiente de Confiança de 95%. Utilizou-se o Instrumento Hawlek Sengstock Elder Abuse Screening Test (H-S/EAST), adaptado para o Brasil.

Resultados

67,4% eram mulheres, idade média de 69 anos (± 6,9), 48,6% casados e 79,9% ganhavam menos que dois salários mínimos; 73,6% dividiam as despesas da casa e 60,9% corresidiam com filhos e netos; identificou-se que 99,8% sofreram violência (direta e indireta) e 88,8% estão constantemente em elevado risco para algum tipo de violência; 44,7% não têm alguém que lhes faça companhia; 95,3% sustentam alguém; 66% sentem-se tristes ou sós; 42,6% relatam uso excessivo de bebida alcoólica por familiares; 45,8% foram recentemente magoados ou machucados por familiares. As mulheres e os mais longevos foram os mais violentados.

Conclusão

evidenciou-se que a experiência da corresidência intergeracional trouxe à tona a realidade da violência intrafamiliar praticada contra as pessoas idosas, presente em 99,8% dos entrevistados, ligados, principalmente, à negligência, omissão e abuso financeiro. Os entrevistados foram capazes de apontar problemas originados dos relacionamentos intrafamiliares, possivelmente proveniente da ausência de um melhor vínculo afetivo, que os colocam em situação de violência direta e indireta.

Palavras-Chave:
Idoso; Violência; Violência Doméstica; Exposição à Violência

INTRODUCTION

In approximately 26% of Brazilian homes there is at least one older person, many of whom are dependent on care because they have comorbidities, weaknesses in physical, cognitive and emotional/psychological health; most receive some social security benefit, becoming a financial reference in the household where they live¹-³. Given these facts, older Brazilians live at constant risk of suffering violence and abuse at home or outside.

Violence against older people is a universal problem, still little studied because it occurs mainly within the family, imputed by children, spouses or caregivers. Thus, the silence and complicity in the occurrences of violence become a challenge for public and social policies⁴. According to Minayo et al.⁵, although the Brazilian population has acquired health and life improvements, social problems still persist in an important portion of this population that has low income, which makes older people more vulnerable to suffering violence.

Research shows that the prevalence of domestic violence against older people is higher than in other contexts, related, in most cases, to dependence on family care, low social conditions and time spent at home after retirement⁶-⁸. Poltronieri et al.⁹ state that violence against older people leads to increased morbidity and mortality and institutionalization, in addition to prolonged hospitalization; they generate serious consequences in terms of mental health and family and social relationships.

The World Report on Violence Prevention points out that Brazil is not among the countries that investigate violence against older people, showing that strategies to combat violence are created without the problem having been studied and that there is a gap in statistics on violence, observed through underestimated data⁷. Therefore, it is clear that Brazil lacks a public agenda that presents several modalities and possibilities of protection services, so that longevity does not seem to be a burden but a bonus that the older person wants to experience¹⁰.

There are few population-based studies that directly investigate older people themselves, whether or not they were victims of violence. When they exist, the prevalence rates of these studies differ greatly and their scarcity prevents a more accurate view of the magnitude and characterization of violence against older people.

In order to learn more about the risk of violence against older people in the city of Manaus, Amazonas, Brazil, and the need for a protective service, this study sought to analyze the direct and indirect risk of intrafamily violence against older people in the city. It is believed that the systematic identification of older people in situations of violence or in life contexts that promote a greater risk to suffer is the first step to visualize the phenomenon and seek to develop intersectoral actions that respond with effective solutions to this problem.

METHOD

This is a population-based, quantitative, cross-sectional, descriptive and analytical study.

In 2018, the urban area of the city of Manaus, AM, Brazil, had a population of 2,145,444 with a projection of 108,081 older people, distributed in the six administrative zones of the city¹. Based on the universe of this older population, a sample size calculation was performed, reaching 380 individuals per zone, making a total of 2,280 older people who corresponded to the final study sample, with an estimated prevalence of 50%¹¹, 5% margin of error and 95% Confidence Coefficient.

The convenience sample was initially obtained by inviting older people to participate in the research in community centers, churches, associations and other senior care services in the neighborhoods of the respective zones. Due to the pandemic, some senior care services were paralyzed and the research continued with an approach to older people who sought health services in the districts of the city’s administrative areas. Data collection took place from November 2019 to April 2021.

For data collection, the Hawlek Sengstock Elder Abuse Screening Test (H-S/EAST), adapted for Brazil, was used. It is an instrument aimed at identifying signs of presence (direct) and suspicion (indirect) of violence/abuse in older people. Most of the items that make up the instrument not only focus on specific symptoms of violence, but also identify conditions related to events associated with abuse that may precede the violence itself and, thus, be preventable¹². The instrument was replicated on the Survey Monkey Platform, accessed from tablets for interviews and data production.

The variables investigated in the H-S/EAST identify the risk of physical and psychological abuse, violation of personal rights, isolation and financial abuse by third parties. One point was assigned for each affirmative answer, with the exception of items, in which the point was given for the negative answer. A “no” answer to items 1, 6, 12 and 14; an “other person” answer to item 4; and a “yes” answer to everyone else was scored in the “abused” direction. In the clinical context, a score of three or more indicates an increased risk of some type of violence¹².

Eligibility criteria were: older people aged 60 years or more, living in the urban area of the city of Manaus (AM), and able to respond coherently to the instrument’s questions. As an exclusion criterion, all those who showed some manifestation of suffering during the application of the instrument (such as crying or others), who declared themselves indigenous and who showed difficulty in understanding the questions inherent in the form were considered. The study was submitted to the Research Ethics Committee of the State University of Amazonas, as recommended in the ethical precepts of Resolution 466/2012 of the National Health Council (CNS) and approved under Opinion: 3,173,698. All signed the Informed Consent Form (TCLE).

Data were presented through tables, where the simple absolute and relative frequencies for categorical data were calculated. In the analysis of quantitative data, when the hypothesis of normality was accepted using the Shapiro-Wilk test, the Mean and the Standard Deviation (SD) were calculated, however, when the hypothesis of normality was rejected, the Median and the Quartiles Q₁ (25%) and Q₃ (75%).

In the analysis of categorical data, Pearson’s chi-square test was applied and the Odds Ratio (OR) was calculated in 2x2 tables, and if it was impossible to apply the Pearson test, Fisher’s exact test was applied. In comparing the means, the Analysis of Variance and Tukey’s test were applied to the parametric data. In the analysis of non-parametric data, the Kruska-Wallis test was applied.

RESULTS

Of the 2,280 older people who participated in the survey, 67.4% were female, aged between 60 and 70 years (60%), mean age of 69 years (±6.9), 48.6% were married and 79.9% earned less than two minimum wages, 76.3% reported knowing how to read and write minimally, 73.6% shared household expenses and 60.9% cohabited with children and grandchildren.

Regarding the data obtained through the application of the specific instrument to identify direct and indirect abuse/violence, it is highlighted that only the answers that score for the direction of abused/violent or at risk for violence were presented in the following tables¹².

The main characteristics of the violation of personal rights or direct violence identified in the survey were: is helping to support someone; was forced to do something he didn’t want to; someone have already taken your belongings without your consent; and someone close recently tried to physically or psychologically hurt him (Table 1).

Table 1
Distribution according to data from the H-S/EAST instrument applied to older people in the city of Manaus (AM), Brazil, 2021.

Variables (n = 2280)	fi (%)	95% CI
There is no one to keep you company, take you shopping or to the doctor	1019 (44.7)	42.7 – 46.7
Is helping to support someone	2173 (95.3)	94.4 – 96.1
Often feel sad or lonely	1506 (66.0)	64.1 – 68.0
Someone else makes decisions about your life, such as how you should live or where you should live	380 (16.7)	15.2 – 18.2
Feels uncomfortable with someone in your family	1153 (50.6)	48.5 – 52.6
Not able to take your meds and go places on your own	1803 (80.4)	78.7 – 82.0
Feel that no one wants you around	251 (11.0)	9.8 – 12.4
Someone in your family drinks a lot of alcohol	971 (42.6)	40.6 – 44.6
Someone in the family makes you stay in bed or tells you that you are sick when you know you are not.	138 (6.0)	5.2 – 7.1
Someone has already made you do things you didn't want to do	497 (21.8)	20.2 – 23.5
Someone has taken things that belong to you without consent	728 (31.9)	30.0 – 33.9
Don't trust most of the people in your family	1729 (75.8)	74.0 – 77.6
Someone tells you that you cause a lot of trouble	237 (10.4)	9.2 – 11.7
At home, is (not) free enough to be quiet when you want to	1795 (78.7)	77.0 – 80.4
Someone close recently tried to physically or psychologically hurt you	1045 (45.8)	43.8 – 47.9

• fi = simple absolute frequency; 95%CI = Confidence Interval at the 95% level; Answers that score for the presence/risk of violence: “yes” for items 2, 3, 5, 7, 8, 9, 10, 11, 13, 14 and 15; “no” for items 1, 6, 12 and 14; and “another person” for item 4.

Regarding indirect violence, the following characteristics were identified: there is no one who keeps him company, who takes him shopping or to the doctor; often feel sad or lonely; someone in your family uses alcohol a lot; feel uncomfortable with a family member; not able to take his medicine and go places on his own; does not trust family members; and, at home, he does not have enough freedom to be quiet whenever he wants (Table 1).

The prevalence of violence found in this study, through the H-S/EAST, was 99.8%. It was also identified that 88.8% are at a very high risk of suffering violence of any kind, 32.6% in direct form and 56.2% in indirect form.

In the association of the HS/EAST instrument items with the gender variable, table 2 shows that older women had more occurrence or risk for direct and indirect violence than men, except for items 2, 9 and 13. With regard to men, it is observed that they help more to support other people (item 2). In evaluating this association, eight of the 15 items were significant at the 5% level, most related to older women, showing that gender violence is also present in old age.

Table 2
Distribution according to data from the H-S/EAST instrument in relation to the gender of older people in the city of Manaus (AM), Brazil, 2021.

	Gender (%)
Variables	Female (n=1536)	Male (n=744)	OR	p*
There is no one to keep you company, take you shopping or to the doctor	46.4	41.3	1.23	0.022
Is helping to support someone	93.8	98.4	0.25	<0.001
Often feel sad or lonely	69.7	58.6	1.62	<0.001
Someone else makes decisions about your life, such as how you should live or where you should live	16.9	16.1	0.83	0.632
Feels uncomfortable with someone in your family	54.2	43.0	1.57	<0.001
Not able to take your meds and go places on your own	81.5	78.1	1.23	0.054
Feel that no one wants you around	10.7	11.6	0.92	0.559
Someone in your family drinks a lot of alcohol	44.1	39.4	1.21	0.031
Someone in the family makes you stay in bed or tells you that you are sick when you know you are not.	5.7	6.7	0.84	0.352
Someone has already made you do things you didn't want to do	23.3	18.7	1.32	0.012
Someone has taken things that belong to you without consent	32.4	30.9	1.07	0.469
Don't trust most of the people in your family	75.0	77.6	0.87	0.181
Someone tells you that you cause a lot of trouble	11.5	8.2	1.45	0.017
At home, is (not) free enough to be quiet when you want to	77.7	80.8	0.83	0.096
Someone close recently tried to physically or psychologically hurt you	50.1	37.0	1.71	< 0.001

• OR = Odds Ratio; * Pearson’s chi-square test; p-value in bold italics indicates statistical difference at the 5% level of significance; Answers that score for the presence/risk of violence: “yes” for items 2, 3, 5, 7, 8, 9, 10, 11, 13, 14 and 15; “no” for items 1, 6, 12 and 14; and “another person” for item 4.

When the items of the HS/EAST instrument are associated with the age group of older people, it is observed that the age group equal to or greater than 70 years was the most abused or is at risk of violence, highlighting items 2, 3, 6, 12 and 14, with high percentages. With the exception of item 7, all others were strongly associated (p-value <0.05), showing that the longer they live, the greater the presence of violence or the greater the risk of suffering it (Table 3).

Table 3
Distribution according to data from the H-S/EAST instrument in relation to the age group of older people in the city of Manaus (AM), Brazil, 2021.

	Age group (%)
Variables	≥70 (n=911)	<70 (n=1369)	OR	p*
There is no one to keep you company, take you shopping or to the doctor	58.0	35.9	2.46	<0.001
Is helping to support someone	98.9	92.9	6.87	<0.001
Often feel sad or lonely	73.4	61.1	1.76	<0.001
Someone else makes decisions about your life, such as how you should live or where you should live	24.9	11.2	2.64	<0.001
Feels uncomfortable with someone in your family	55.8	47.1	1.41	<0.001
Not able to take your meds and go places on your own	88.5	68.2	0.28	<0.001
Feel that no one wants you around	13.0	9.7	1.38	0.156
Someone in your family drinks a lot of alcohol	45.8	40.5	1.24	0.012
Someone in the family makes you stay in bed or tells you that you are sick when you know you are not.	10.2	3.3	3.34	< 0.001
Someone has already made you do things you didn't want to do	28.8	17.2	1.94	<0.001
Someone has taken things that belong to you without consent	35.8	29.4	1.34	<0.001
Don't trust most of the people in your family	69.8	79.8	0.58	<0.001
Someone tells you that you cause a lot of trouble	12.1	9.3	1.34	0.032
At home, is (not) free enough to be quiet when you want to	72.4	82.9	0.54	<0.001
Someone close recently tried to physically or psychologically hurt you	50.7	42.6	1.39	< 0.001

• OR = Odds Ratio; *Pearson’s chi-square test; p-value in bold italics indicates statistical difference at the 5% level of significance; Answers that score for the presence/risk of violence: “yes” for items 2, 3, 5, 7, 8, 9, 10, 11, 13, 14 and 15; “no” for items 1, 6, 12 and 14; and “another person” for item 4.

The study sought to identify the level of significance of the variables related to the association of items from the H-S/EAST instrument and family income. Table 4 shows that older people with lower income (<1 minimum wage) are those who suffer most from violence. With the exception of items 4, 6, 7 and 9, all others had a strong association (p-value<0.05). Item 2 shows up with the highest percentage, proving that older people are constantly financially abused, regardless of earnings.

Table 4
Distribution according to data from the H-S/EAST instrument in relation to family income in minimum wages (MW) of older people in the city of Manaus (AM), Brazil, 2021.

	Family income (%)
Variables	<1 MW (n=1.087)	≥1 MW (n=119)3)	OR	p*
There is no one to keep you company, take you shopping or to the doctor	47.5	42.2	1.24	0.011
Is helping to support someone	90.8	99.4	0.06	<0.001
Often feel sad or lonely	72.3	60.4	1.72	<0.001
Someone else makes decisions about your life, such as how you should live or where you should live	16.0	17.3	0.91	0.420
Feels uncomfortable with someone in your family	55.0	46.5	1.41	<0.001
Not able to take your meds and go places on your own	81.4	79.3	0.88	0.209
Feel that no one wants you around	12.1	10.1	1.22	0.129
Someone in your family drinks a lot of alcohol	46.4	39.1	1.34	<0.001
Someone in the family makes you stay in bed or tells you that you are sick when you know you are not.	5.3	6.7	0.78	0.171
Someone has already made you do things you didn't want to do	24.1	19.7	1.29	0.011
Someone has taken things that belong to you without consent	35.2	28.9	1.33	<0.001
Don't trust most of the people in your family	71.1	80.1	0.61	<0.001
Someone tells you that you cause a lot of trouble	11.9	9.1	1.35	0.028
At home, is (not) free enough to be quiet when you want to	75.3	81.8	0.68	<0.001
Someone close recently tried to physically or psychologically hurt you	51.1	41.1	1.50	< 0.001

• OR = Odds Ratio; * Pearson’s chi-square test; p-value in bold italics indicates statistical difference at the 5% level of significance; Answers that score for the presence/risk of violence: “yes” for items 2, 3, 5, 7, 8, 9, 10, 11, 13, 14 and 15; “no” for items 1, 6, 12 and 14; and “another person” for item 4.

Table 4 also shows that, although the older person is one of the main maintainers of the house, they do not have enough freedom within the home environment and a significant percentage do not trust their family members.

DISCUSSION

Intra-family violence is largely committed by children, grandchildren, great-grandchildren or the older person’s partner; it involves affective bonds and daily coexistence. It is usually violence suffered in silence. In general, any intentional physical, moral, psychological and/or social harm, resulting from acts (or omissions) of the family or guardian(s), that violate the standards of respect and dignity of the older person¹³,¹⁴.

With regard to direct violence, it involves at least two participants: the issuer and the victim of violence. The issuer performs a certain action that falls on the victim, the object of violence. The harm resulting from direct violence can be of a physical or psychological nature, such as bodily injury or fear and insecurity. Indirect violence are structural or cultural threats of violence, that is, it is everything that prevents the reduction of the distance between the real and the potential, reducing the victim’s capacity to supply their basic human needs, putting them at risk¹⁵.

The results of the study showed that, even in the absence of disease and need for care, 99.8% of the older people in the survey have recently suffered violence directly or indirectly, and 88.8% are at increasing risk, with a score of three or more according to the HS/EAST instrument, to suffer some type of violence. Using the same assessment instrument, a study carried out in the North¹⁶ and another in the Southeast¹⁷ of Brazil, found a prevalence of violence of 52% and 56%, respectively. In a study with a cohort of 3,159 Chinese older people, a prevalence of 15.8% was found¹⁸.

Therefore, it is observed that the prevalence rates found in the study in question are much higher than the others. It is likely that the private environment during the interview favored the participants’ freedom of speech, ensuring confidentiality and security, which would not happen if the interview took place in the home environment and in the presence of an abusive family member. This requires greater attention to the population studied and greater investments in public policies aimed at protecting older people and preventing violence.

Violence against older people manifests itself in different ways, reflected in social inequalities arising from poverty, misery and discrimination; in everyday communication and interaction; institutionally, in the absence of management in the execution of social policies and by institutions that provide care services to older people. This is a problem of multiple causes with devastating consequences, as it entails low quality of life and lack of security, which further favors the continuous aggressions to the physical, mental and spiritual health of older people¹⁹-²¹.

According to the data presented in table 1, in the family context, violence was mainly caused by the lack of family care and attention, negligence, financial abuse and indirect abandonment (present, even in the coexistence of other family members).

The results of the study showed that older people are continually subjected to situations of direct or indirect violence by family members. The data show that, even living with other family members, they feel alone, complain about the lack of company, report feeling uncomfortable and distrustful with people in their own family, in addition to not feeling freedom in their own home. This characterizes important risks, since the family plays a fundamental role in the aging process and, even in the absence of dependence, the presence of close family members should provide security and biopsychosocial well-being to the older person¹³.

Considering the results of the study, it is observed that many family arrangements formed in intergenerational co-residence are maintained from the perspective of costs and benefits, where the older person participates in general expenses, directly supports some people, however, even being the owner and maintainer of the house, they do not participate in decisions, do not have the desired freedom and are often financially exploited.

The presence of financial violence was visible as one of the most frequent forms of abuse against older people. Barros et al.²² state that the financial profile of the older person is not a determining factor for the occurrence of violence, highlighting that violence occurs between those who contribute (90%) and those who do not contribute (94%) to the family’s support. The expressive occurrence of violence against older people happens without discrimination of the social security situation, income or help to support the home.

The data point to relationships marked by conflicts and feelings of hurt, rejection and abandonment. Studies show that the success of intrafamily relationships is not a one-off achievement, on the contrary, it is built by individual and collective experiences throughout life, by sharing, by effective communication and by bonds of affection and intergenerational respect¹³,¹⁹,²⁰. Data on intrafamily violence against older people in national and international studies confirm the results of this study²¹-²⁶.

It is known that family relationships have undergone many changes over time, however, despite the demographic, economic and sociocultural changes that most families go through, no institution can replace the role that the family plays in the life of the older person²⁷-²⁹.

Another important data identified in the study was the occurrence of violence against older women. Although women play the role of caregivers even in old age and live longer than men, they weaken more, needing attention and care, generating demands on the family²⁹,³⁰. The constant exposure of older women to situations of direct and indirect violence produces a sickening context of life, reducing their years of life³⁰.

The issue of violence against women from a young age may be one of the reasons why older women appear at greater risk of suffering violence and of maintaining this dynamic throughout the aging process²⁴,³¹. In Brazil, violence against women is a serious social phenomenon that needs structural confrontation and the involvement of the entire society. Studies show that older women aged between 60-69 years, widows, white race/color and with a low level of education make up the highest percentage of cases of violence against older people⁸,²²,³², corroborating the results of this research.

The results of this study also revealed that the longer the person is long-lived and dependent, the greater the risk of violence, and the worse the economic condition, the greater the financial abuse. For Oliveira et al, advanced age, added to socioeconomic and health conditions that cause dependence, reduce the individual’s ability to maintain their autonomy, independence and quality of life, favoring greater vulnerability to violence³³.

In this study, gender, age and family income were the factors most associated with direct and indirect violence and the increased risk of suffering from them. These factors only differ from other studies in relation to the prevalence rate, keeping the same variables²¹-²⁶.

It is inferred that Brazil has advanced legislation to guarantee the rights of those over 60, including the fight against violence. Such laws, linked to public policies, need to be directed towards care for healthy aging, integrated and intersectoral actions to promote health and comprehensive care for older people.

As limitations of the study, the following are pointed out: the use of self-reported data by older people with the possibility of memory bias; the nature of the data extracted from a convenience sample, which included a smaller number of dependent older people, limiting the generalizability of the results; the ethno-cultural factor, which led to the exclusion of self-declared indigenous participants; and social distancing, as a result of the COVID-19 pandemic that limited data collection spaces.

CONCLUSION

The experience of intergenerational co-existence experienced by many families brings to light the reality of intra-family violence practiced against older people, with a prevalence of 99.8% in this research, mainly linked to negligence, omission and financial abuse, which puts at risk the lives of many of them. It was found that older men and women were able to point out problems arising from intrafamily relationships, possibly arising from the lack of a better emotional bond, which put them at risk for violence. The individuals interviewed were mainly exposed to negligence, which generates direct and indirect violence, explaining the omission of those responsible for their protection: the family, society and the State.

• No funding was received in relation to the present study.

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Edited by

Edited by: Tamires Carneiro de Oliveira Mendes

Publication Dates

• Publication in this collection
  01 Sept 2021
• Date of issue
  2021

History

• Received
  17 May 2021
• Accepted
  19 July 2021