Domestic violence against elderly people assisted in primary care

ABSTRACT

This article aims to investigate the prevalence of domestic violence against elderly people in primary care and possible associated factors. A descriptive, cross-sectional study, with 169 individuals aged 60 years and over, of both sexes, enrolled in the Family Health Units (FHU) of the 4.1 micro region of the city of Recife. Elderly people with health impairment that compromised communication and/or cognition were excluded. The data were collected through interviews in the homes or FHU, with socio-demographic issues, self-perceived health and the research instrument to evaluate possible situations of violence, which was developed and validated in Puerto Rico and adopted by the Ministry of Health. There were 133 elderly people with indicative signs of at least one type of violence in their domestic environment, representing a prevalence of 78.7%, with negligence as the most prevalent type (58.5%), followed by psychological (21.5%) and financial (14%). The elderly interviewed who classified their health as regular/poor have this increased risk. The study reinforces the hypothesis of the existence of domestic violence against the elderly. Thus, identifying its prevalence is the first step in addressing this public health problem.

KEYWORDS
Aged; Violence; Primay Health Care

RESUMO

Este artigo objetiva investigar a prevalência de violência doméstica contra idosos assistidos na atenção básica e possíveis fatores associados. Estudo descritivo de corte transversal, com 169 indivíduos de 60 anos ou mais, de ambos os sexos, cadastrados nas Unidades de Saúde da Família (USF) da microrregião 4.1 da cidade do Recife (PE). Idosos com agravo à saúde que comprometesse a comunicação e/ou cognição foram excluídos. Os dados foram coletados por meio de entrevistas nos domicílios ou nas USF, com questões sociodemográficas, saúde autopercebida e instrumento de pesquisa para avaliar possíveis situações de violência, que foi desenvolvido e validado em Porto Rico e adotado pelo Ministério da Saúde. Verificou-se a existência de 133 idosos com sinais indicativos de pelo menos um tipo de violência em seu ambiente doméstico, representando uma prevalência de 78,7%, sendo a negligência o tipo mais prevalente (58,5%), seguida de violência psicológica (21,5%) e financeira (14%). Os idosos entrevistados que classificaram sua saúde como regular/ruim têm esse risco aumentado. O estudo reforça a hipótese da existência de violência doméstica contra os idosos. Assim, identificar a sua prevalência é o primeiro passo para o enfrentamento desse problema de saúde pública.

PALAVRAS-CHAVE
Idoso; Violência; Atenção Primária à Saúde

Introduction

The increase in the elderly population, evident worldwide, is one of the great achievements of the last century^1,2. The number of elderly people increases as a result of the decrease in fertility and mortality and the increase in life expectancy, caused by the improvement of economic and environmental conditions and the evolution of medicine^3-5.

According to the United Nations Organization (UNO), in 2015, there were 901 million elderly people, representing 12% of the general population. The UNO estimates, furthermore, that, by 2050, in all major regions of the world, the number of elderly people will be almost a quarter of its populations, with the exception of Africa⁵.

Following the worldwide trend, in the last censuses carried out, the Brazilian age pyramid has been showing a progressive increase in the proportion of elderly people, according to data from the Brazilian Institute of Geography and Statistics (IBGE). Between 1980 and 2010, the number of elderly people increased from 7,2 million to 20,6 million, ratifying the concreteness of this phenomenon⁶.

The population aging process occurs differently between developed and developing countries. The former ones experience this process associated with improvements in living conditions. In others, such as Brazil, this demographic change is very fast, and social reorganization is not possible to meet the demands of this new age configuration^7-9.

In this context, middle and low income countries, such as Brazil, face the challenge of, even with the relative increase in the inactive population, maintaining economic growth, fiscal sustainability and the appropriate provision of essential services^10,11. This new demographic scenario is quite complex and increasingly requires multidisciplinary studies to better understand it, especially in Brazil, where the effects of aging are even greater due to the speed in which this phenomenon occurs^11,12.

In addition to physiological changes and common pathologies of this age group, the elderly person is also vulnerable to the phenomenon of violence, which can lead to poor quality of life, injuries, morbidity and even death^13,14. Despite the universality of the problem and its historical dimension, in Brazil, society has awakened to the importance of this problem, in anthropological and cultural perspectives, with the raising of awareness of rights^14,15. From the population increase of this age group, society now pays greater attention to its political, socioeconomic and health demands, aiming at the creation of social policies that guarantee the rights of the elderly¹⁶.

In general, in the current context, violence against the elderly originates from the conflict of interest between the young and old generations. This conflict favors, in most cases, attitudes that demonstrate little value to older people, being placed on the fringes of society because they are considered obsolete¹⁵.

There are, also, morbidities, which lead to decreased functional and cognitive ability, antecedents of relationship of violence, financial dependence and overburden, stress and psychopathological disorder of the caregiver. All of this can lead to violence. Other important factors, in this context, are the problems arising from changes in the contemporary family, such as fewer children, insertion of women in the labor market, divorces, among others^17-20.

Estimating the occurrence of violence against the elderly, as well as its consequences, is difficult, since data sources are scarce and, sometimes, unreliable, and the event is covered by family members and society. In addition, there is a lack of collective awareness of complaints and specialized services for such occurrences²¹.

Given this perspective, this article aims to investigate the prevalence of domestic violence against elderly assisted in primary care and possible associated factors.

Methodology

This is a descriptive cross-sectional study, conducted in the Political-Administrative Region 4, focusing on the microregion (MR) 4.1 in the city of Recife (PE). This area consists of five Family Health Units (FHU). At the time of the investigation, according to information provided by the Units themselves, there were 2,907 elderly enrolled. The sample size was determined from the sample calculation equation for finite population proportion study, which resulted in a total of 169 non-institutionalized elderly people (60 years and over), of both sexes. In this research, the elderly who presented any disease or health problem that compromised communication and/or cognition were excluded.

For the investigation, an interview script was prepared with questions about sociodemographic data and self-perceived health, which was categorized according to the proposed by the project Health, Well-being and Aging (Sabe)²², as: excellent, very good, good, regular and bad.

The instrument used to assess possible situations of violence against the elderly people was developed and validated in Puerto Rico and adopted by the Ministry of Health in the ‘Primary Care Notebooks’²³. This instrument addresses ‘physical’, ‘psychological’, ‘financial and economic abuse’ violence types. Thus, two questions from ‘Primary Care Notebook’ nº 8 were added to investigate ‘sexual violence’, and two more questions to assess ‘negligence’ situation²⁴.

The survey took place between January and May 2016. Data were collected at the homes of the elderly people or at the FHU, according to convenience. All interviews were conducted individually, preserving the participant’s privacy and anonymity.

A databank was built on the Microsoft Excel²⁵ spreadsheet, which was exported to the Statistical Package for Social Sciences (SPSS) software, version 18²⁶, and the databank was validated for further analysis. It is noteworthy that, for the analysis of the social, economic and health profile of the elderly people interviewed, the percentage frequencies were calculated and the frequency distributions of the evaluated factors were constructed. To evaluate the percentages of the levels of the evaluated factors, the Chi-square test was applied for comparison of proportions. It was also performed the description of the types of violence suffered by the evaluated elderly.

It is noteworthy that, for the economic profile, there was a reduction in the sample, as 4 (four) elderly people ignored the answer about their social security situation and 1 (one) elderly did not answer about the income supplement. Although the number of observations is reduced, this does not statistically interfere with the results of the present study.

The contingency table was prepared to evaluate which factors are determinant for the occurrence of violence against the elderly, as well as the Chi-square test for independence. When the Chi-square test assumptions were not met, Fisher’s Exact test was used. All conclusions were based on the significance level of 5%.

The research was approved by the Ethics Committee and Research with Human Beings of the Federal University of Pernambuco (CAAE nº 50970115.8.0000.5208), under opinion nº 1.371.038, in accordance with Resolution nº 466/12 of the Ministry of Health, concerning development of scientific research involving human beings.

Results

Among the 169 elderly participants, 66.3% were female, 66.9% were between 60 and 70 years old, 59.8% declared to be brown-skinned, 56.2% had no partner and 48.2% lived with 1 to 2 people, being the son/daughter, the partner and the grandson/granddaughter the most mentioned. Regarding education, it was observed that complete/incomplete primary was the most prevalent category, with 40.7%. The proportion comparison test was statistically significant in all sociodemographic factors, except for marital status (p-value = 0.106), which indicates that the number of elderly people who have a partner and who do not have a partner is similar.

As for economic characteristics, the group of retired older people (53.9%) and with an income of up to 1 minimum wage (65.5%) was higher. Furthermore, it was found that most do not receive income supplement (56.0%). However, there is also a higher percentage of elderly people who fully contribute to the household’s support (60.9%). The monthly income of the elderly was, on average, R$ 977,20 (nine hundred and seventy-seven reais and twenty cents). Regarding health-related conditions, it was found that 50.9% of the elderly people classify their own health as regular.

Table 1 shows the prevalence of domestic violence against the elderly, which shows that 78.7% of the elderly people said they had suffered some kind of violence, with negligence (58.5%) being the most common type, followed by psychological (21.5%) and financial violence (14%). The proportion comparison test was significant (p-value <0.001), indicating that is significantly higher the number of elderly people who are victims of violence and, especially, negligence.

Table 1
Prevalence and characterization of domestic violence against the elderly enrolled in MR 4.1, Recife (PE), 2016

Assessed factor	n	%	p-valor
Has already suffered violence
Yes	133	78.7	<0.001
No	36	21.3
Type of violence
Negligence	117	58.5	<0.001
Psychological	43	21.5
Financial	28	14.0
Physical	6	3.0
Sexual	6	3.0

• Note: p-value of the Chi-square test for proportion comparison (if p-value was less than 0.05, the percentages of the levels of the assessed factors differ significantly).

A bivariate analysis was performed between domestic violence suffered by the elderly people and independent variables. Regarding the distribution of violence according to the sociodemographic profile of the study participants, there was a higher prevalence of violence among female elderly (83.0%), white (82.5%), aged between 81 and 90 years old (91.7%), without a partner (78.9%), living with 5 or more people (83.3%) and with a level of education up to high school (88.9%).

It is observed that, although a higher prevalence of violence was found in a certain group of elderly people, the independence test was not statistically significant in any of the factors evaluated (all p-values were greater than 0.05). This indicates that the sociodemographic characteristics of the interviewees are not decisive for the increased risk of violence. The test reveals that the event of violence against the elderly people happens identically in all groups of gender, color/race, age, marital status, family composition or level of schooling, without discrimination.

Table 2 deals with the distribution of violence according to the economic profile of interviewees. There was a higher prevalence of domestic violence among elderly pensioners (90.0%), with complementary source of income (100.0%) and who do not contribute to the support of the family (94.4%). Despite the higher occurrence of violence in this group described, the independence test was not statistically significant in any of the factors evaluated (all p-values were greater than 0.05). These results indicate that the financial profile of the elderly is not a determining factor for the occurrence of violence. Thus, it is reaffirmed that the expressive occurrence of violence against the elderly happens without discrimination of the social security situation, income or help to support the house.

Table 2
Distribution of domestic violence against the elderly according to the economic profile of the elderly enrolled in MR 4.1, Recife (PE), 2016

Assessed factor	Suffered violence		p-value
	Yes	No
Social security status
Retired	65(73.0%)	24(27.0%)	0.3312
Pensioner	18(90.0%)	2(10.0%)
Retired and pensioner	4(66.7%)	2(33.3%)
Neither retired nor pensioner	23(82.1%)	5(17.9%)
Benefit	19(86.4%)	3(13.6%)
Revenue complement
Help from family members	53(86.9%)	8(13.1%)	0.2402
Work	9(75.0%)	3(25.0%)
Another source	1(100.0%)	0(0.0%)
Does not have	70(74.5%)	24(25.5%)
Contributes to the livelihood of the house
Yes, totally	79(76.7%)	24(23.3%)	0,2251
Yes, partially	37(77.1%)	11(22.9%)
Does not contribute	17(94.4%)	1(5.6%)

• ¹
  p-value of the Chi-square test for independence (if p-value <0.05, the assessed factor influences the risk for violence against the elderly),
• ²
  p-value of the Fisher's Exact test.

Table 3 shows the distribution of domestic violence against the elderly person according to the self-perceived health condition of the research participants. There is a higher prevalence of violence among the elderly people who considered their health as regular/bad (82.5%). The independence test was statistically significant in the self-perceived health factor (p-value = 0.020), demonstrating that the elderly’s perception of health is a statistically significant factor for the prevalence of the event studied. It was also observed that the elderly people who declared themselves in good health have a 56% increase (PR = 1.56) in the risk of being victims of some kind of violence compared to the elderly people who reported their health as excellent/very good. In part, the group of respondents who rated their health as regular/bad has this risk increased by 65% (PR = 1.65) when compared to the elderly group with excellent/very good self-perceived health.

Table 3
Distribution of domestic violence against the elderly according to the self-perceived health condition of the elderly enrolled in MR 4.1, Recife (PE), 2016

Assessed factor	Suffered violence		p-value
	Yes	No
Self-perceived health
Excellent/very good	7(50.0%)	7(50.0%)	0.0201
Good	32(78.0%)	9(22.0%)
Regular/bad	94(82.5%)	20(17.5%)

• ¹
  p-value of the Chi-square for independence (if p-value <0.05, the assessed factor influences the risk for violence against the elderly).

Discussion

The subject of aging has never been so prominent in a developing country, as is the case of Brazil, due to the undeniable increase in longevity, associated with the improvement of quality of life. There are many challenges for health professionals and society in face of this new reality, which has brought to light the discussion about the performance of different social actors in different contexts. In addition, this scenario requires the development of new policies that encourage prevention and comprehensive health care for the elderly person²⁷.

Various factors may intervene in the health of the elderly. Among them, is violence, a theme that has been growing in scientific productions. However, the targeting of the elderly group is more recent, which leads to a lack of information²⁸. The complexity of the theme may contribute to this reality, as it makes its recognition and management difficult¹⁸.

In the present study, it was observed that the analysis of the sociodemographic profile of the population is similar in many aspects to other studies conducted with the elderly^18,29,30. Female predominance, brown-skinned color, age between 60 and 70 years old, absence of partner, living accompanied, retired, with low education and 4.9 years of schooling, on average, configure the profile found in the sample of this research.

The highest prevalence of older people of female gender is observed in the vast majority of studies on aging, in the most diverse contexts addressed^30-32. To this fact the specialized literature has attributed the denomination of feminization of old age, which is characterized by the greater number of elderly women compared to the number of men in this age group.

Factors contributing to this difference can be listed, such as gender inequality in life expectancy, biological factors, difference in exposure to mortality and occupational risk factors, and alcohol and tobacco use. Added to this is a difference in behavior regarding the relationship with health and illness, as women tend to spend more time and attention to self-care, seeking more health services^33-35. Following the world trend, the results of the last demographic census conducted in Brazil, in 2010, demonstrate this feminization of old age. According to the IBGE, females represent 55.5% of the elderly population⁶.

Regarding economic characteristics, the findings are similar to other studies in the area. It is observed, in these studies, a majority of retired elderly people and who need to fully contribute, sometimes, to the support of their homes^30,36.

With regard to self-perceived health, just over half of the elderly people interviewed considered their health as regular. Lima-Costa³⁷ state that self-assessment of health expresses the integrated perception of the individual, considering the biological, psychosocial and social dimensions, which gives, therefore, reliability and validity equivalent to other more complex measures of health condition.

In this research, the majority of the elderly people attributed unsatisfactory values to their own health, a finding similar to that of Sabe Project, which showed a percentage of 53.8% in this same aspect²². Belém et al.³⁸ analyzed the self-assessment of health of the elderly people enrolled in the Family Health Strategy of Campina Grande, Paraíba. In this context, more than half of the participants considered their health as regular (51.4%) and poor (15%). Divergent results, however, were found in the household inquiry conducted in the city of Guarapuava, Paraná, where 54.8% of the elderly rated their own health as good and 31.7% as poor³⁹.

Self-perceived health assessments are no longer considered impressions related to actual health conditions. Recent researches have shown that individuals who refer to their own health condition as scarce or poor have substantially higher mortality risks than those who report more positive perceptions of health²².

The results presented here differ from the social tendency that the elderly person is a decadent and incapable being. Fortunately, this perspective on aging has been deconstructed. This is due to the increase in life expectancy and, consequently, the growing interest and investments in studies related to the subject of aging⁸.

Regarding the prevalence of violence against the elderly people, it is important to point out that the comparison of the results exposed in this research with previous studies should be carefully made. This is due to the fact that the theme in question involves different concepts and different methodologies, especially regarding the type of study and the instrument used to evaluate the event of violence. That said, this discussion is extremely complex^40,41.

The present study found an occurrence of violence against the elderly of 78.7%. Mascarenhas et al.⁴², in a study conducted in 524 Brazilian municipalities, found that 67.7% of the elderly were victims of physical violence and 29.1% of psychological violence. Although with the reservations mentioned above, it can be said that this prevalence was the closest to the results presented in this research, which were a little beyond what most studies analyzed has shown. A household inquiry conducted by Paiva⁴³ in Uberaba, Minas Gerais, showed that 20.9% of the elderly participants were victims of violence. Bolsoni et al.⁴⁴, in a population-based study in Florianópolis, Santa Catarina, reached a 13% prevalence of the event in question.

By bringing the discussion closer to the context of this study regarding the population and type of violence assessed, Apratto Junior²⁹ stratified different forms of domestic violence, in a study conducted in Niterói, Rio de Janeiro. This study showed that 43.2% of the elderly participants reported at least one episode of psychological violence and 10% of physical violence.

These disparities can be explained by the existence of a great diversity of methodological designs, as well as the various ways of assessing violence against the elderly people. This way, although these methodologies show important data, it is not possible to standardize the data found. Consequently, the comparison of results between studies on violence against the elderly becomes difficult, requiring, therefore, caution.

Duque et al.¹⁸ conducted a research similar to this study when determining the occurrence and factors associated with domestic violence against the elderly people in a particular microregion of Recife, Pernambuco, in the context of primary care. Despite the similarity in the methodological procedure, in the studied population and the instrument used to assess violence, there were only 20.8% of elderly people in a possible situation of violence.

Negligence was the most prevalent type of violence here, representing 58.5% of cases, followed by psychological and financial type, corresponding to 21.5% and 14.0% of cases evaluated, respectively. Excluding negligence from the comparative study may explain why such similar studies present such divergent results.

In the analyzed literature, no studies with similar results regarding negligence-type violence were found. However, Paraíba e Silva⁴⁵ outlined the profile of violence against the elderly people in Recife, Pernambuco, and observed that negligence was the second most prevalent type (29.64%), only behind physical violence.

National and international investigations find the most diverse prevalence of violence against the elderly person. Yan, Chan and Tiwari⁴⁶ carried out a systematic review of the prevalence rates of elder abuse and found that violence is prevalent worldwide. According to the authors, prospective studies suggest that older people who are abused and neglected are at higher risk of mortality. In the United States, 5% to 10% of people age 65 and older have been abused by someone they depend on for care or protection. Data from Canada show prevalence rates of 7% for emotional violence and 1% for financial as well as physical or sexual violence. In the United Kingdom, they are 5.4% for emotional or verbal violence, 1.5% for physical and 1.5% for financial⁴⁶.

Although there is a diversity of methodological designs and with regard to the typology used in the classification of violence, from the studies presented here, it is possible to see the relevance of the issue in question at national and international levels.

Finally, the bivariate analysis between violence against the elderly and the other variables showed statistical significance only with the self-perceived health variable. Therefore, researches involving self-perceived health of the elderly and domestic violence have not been found in the consulted literature. However, it is plausible to point out that a situation of violence can interfere with the elderly’s response when asked about their health perception.

The methodology used here does not allow to determine the cause and effect relationship, only exposing factor and effect at the same time. Even so, the results indicate gaps to be explored in the study of domestic violence against the elderly, with greater rigor in the definition of the method and refinement in the statistical analysis, by enabling, thus, more security in designing strategies to prevent this type of violence.

Final considerations

The findings exposed in this study, although they do not guarantee the real magnitude of the event, reiterate the relevance of the theme of violence against the elderly. Nevertheless, estimating the prevalence of abuses and possible associated factors is the initial step for their management and prevention.

Even though it was conducted in only one microregion of a municipality, this study contributes to the visualization of the problem, justifying its relevance. It is also worth mentioning the importance of the context of primary care in the study of the problem of violence against the elderly, considering the proximity with the user provided by this level of care.

However, it is important to emphasize that there is still much to be studied about the problem of violence against the elderly people, which makes the expansion of scientific production on the subject in question essential.

• Financial support: non-existent

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Publication Dates

• Publication in this collection
  25 Nov 2019
• Date of issue
  Jul-Sep 2019

History

• Received
  16 Oct 2018
• Accepted
  24 June 2019