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Ann Geriatr Med Res > Volume 26(3); 2022 > Article
Maryam, Masoomeh, Masomeh, Nahid, and Monir: Broken Toughness: Iranian Older Adults’ Perceptions of Abuse

Abstract

Background

Older people abuse includes intentional or unintentional conduct or omission of a specific behavior by a trusted person that causes injury or distress to older people. This study described older peoples’ perceptions of abuse in Iranian society.

Methods

This qualitative study applied a conventional content analysis method to understand the perceptions of abuse among older Iranian people. Twenty older residents were selected by purposeful sampling. Data were collected through in-depth, semi-structured, and face-to-face interviews. The six-step Graneheim and Lundman content analysis method guided data analysis. MAXQDA software version 10 was used to manage the data.

Results

The data analysis led to the identification of three main themes: broken toughness, hidden abuse, and exploitation. The first theme had two sub-themes: domination and disturbed peace and tranquility.

Conclusion

Abuse resulted from a combination of causes and factors. Abuse was hidden in many cases and was not limited to physical abuse. The other examples of abuse included disrespect, deprivation of authority, disturbed tranquility, and financial exploitation of older adults.

INTRODUCTION

One of the most obvious demographic changes in the 21st century is the aging of the population, which affects all countries worldwide, including Iran.1) People live longer due to improvements in living conditions, increase in life expectancy, and advances in medicine.2) Old age in high-income countries is 65 years of age, while in low-income countries, people ≥60 years are considered older adults.3) In Iran, the retirement age is 60 years, which marks the beginning of old age.4) An aging population is defined as an increase in the ratio of older people compared to other age groups5); if this ratio is ≥7%, the population is considered old.6) Accordingly, Iran became an old population in 2006, with more than 7.2% of the population ≥60 years of age.7)
The increase in the older adult population, followed by an increase in chronic diseases, often increases the dependence and disability of older people in society. These factors, along with risk factors such as cognitive disorders, poor health, functional disorders, and dependence on caregivers, make older adults vulnerable to abuse.8) Moreover, increasing numbers of older adults in families may negatively affect the physical and mental condition of family members, which may lead to economic pressure, emotional stress, irresponsibility, fatigue, and social isolation, which, in turn, may lead to antisocial behavior, violence, and abuse. Abuse of older adults is a type of domestic violence, which is considered a major health problem in today's society.9)
Abuse of older adults includes intentional or unintentional conduct or omission of a specific behavior by a trusted person that causes injury or distress to older adults. This behavior may be repeated only once or several times and may occur as physical, psychological, sexual, and financial abuse or neglect.10) With the increasing population of older adults in Iran, special social conditions such as urbanization, modernization, changes in traditional values, conflict between the value system of the current and old generations, and readiness to accept responsibility for the care of older adults have caused families to fail to fulfill their roles and responsibilities towards their older members, ultimately exposing older adults to abuse and its consequences.11)
Statistics show that 3.2% to 27.5% of older adults have experienced abuse.12) A systematic review reported the prevalence rates of abuse in different countries, from 2.6% in the United States to 4% in Canada, 18.4% in Israel, and 29.3% in Spain.13) While accurate statistics on the prevalence of abuse in Iran are lacking, Heravi-Karimooi et al.11) reported that 1.6%–19.3% of Iranian older people in Tehran had experienced various forms of abuse.
How older adults react to abuse varies between individuals and is influenced by a variety of factors, including the physical/mental abilities and dependency of these older adults, as well as cultural factors and the perception of older adults about abuse.14) In one study, about half of the older adults exposed to abuse described it as a family conflict and denied any ill-treatment; moreover, some older adults believed that others had the right to treat them in that way.15) Some victims stated that they only sought help when the abuse was so severe that it was no longer tolerable or when they were confident that resources were available to help them. Several older adults also ignored abuse for various reasons, including shame and embarrassment, dependence on family members, and fear of rejection or revenge.16-18)
A review of the literature shows that, considering the culture of Asian countries and the level of available social support for older adults, there is a lack of knowledge concerning the perceptions of abuse among older adults. These perceptions may change under the influence of the sociocultural and family context of a society.19) Since there is no published data in Iran regarding older adults’ perception of abuse, this study was conducted to understand and describe this topic.

MATERIALS AND METHODS

This study was conducted in 2017 and employed a descriptive qualitative design and applied a content analysis method.

Study Participants

Twenty older people residing in Rasht Province were selected through purposeful sampling. The inclusion criteria were age ≥60 years, ability to speak, Abbreviated Mental Test (AMT) score >7, and experience of abuse. To achieve maximum variation, this study included both women and men with different educational backgrounds. The participants were recruited from families, retirees, municipal health centers, public parks, religious associations, mosques, clinics, and workplaces.

Data Collection

Data were collected using in-depth, semi-structured, face-to-face interviews for 10 months between October 2016 and August 2017. The time and place of the interviews were chosen in agreement with the participants. The interviews lasted 30–60 minutes depending on the participants’ circumstances. Participant recruitment continued until the data were saturated and no new data were obtained. Before the interview, the study aim and the participants’ rights were explained to the participants and informed consent was obtained.
The interviews began with general questions about personal characteristics. The participants were then asked to share their experiences of abuse. They were also asked about their perceptions of abuse. During the interview, follow-up questions were posed to clarify ambiguities; for instance, “Can you give an example in this regard” or “Can you explain more about this?” The interviews ended with open-ended questions such as “Is there anything else you would like to add?”

Ethical Considerations

This study was approved by the Ethics Committee of the Research Council of Tehran University of Medical Sciences (Code No. IR.TUMS.FNM.REC.1396.4459). Written or oral informed consent was obtained from all participants. The participants received information about the study aim, their rights as participants, and how the research data were used and stored. They were informed that their study participation was voluntary and that they could withdraw from the study at any time without any consequences. The participants permitted the researchers to record the interviews after being reassured about the confidentiality of the data.
This study complied the ethical guidelines for authorship and publishing in the Annals of Geriatric Medicine and Research.20)

Data Analysis

A conventional content analysis method was used to analyze the data. The interviews were recorded and then transcribed using the Microsoft Word software at the first opportunity after the interviews. The transcribed text was read several times to obtain a general understanding. Then, the semantic units were identified according to the study objectives. Finally, initial codes were prepared. The codes were categorized in terms of similarities and differences, forming classes and subclasses. This process was continued until the main themes were extracted. MAXQDA-10 software (VERBI GmbH, Berlin, Germany) was used to manage the large volume of data.

Trustworthiness

This study used various methods to increase the rigor of the results. The extracted codes were reviewed by the research team such that the data were independently coded and classified by the researchers. The extracted themes were then compared to each other. In cases of disagreement over the themes, the researchers met and discussed them until an agreement was reached. Member checks were also conducted by sharing the extracted codes with some participants and asking them to confirm the extracted codes or note their opinions about possible inconsistencies. A peer-review method was also performed. Several interviews were randomly selected and given to researchers familiar with the qualitative method and who were not part of the project. Attempts were made to recruit participants with maximum variation to ensure the broader transferability of the results.

RESULTS

The findings of this study were the result of interviews conducted with 18 older adults (14 women and 6 men), ranging in age from 61 to 92 years. The other demographic characteristics of the participants are presented in Table 1. Analysis of the data resulted in three themes: broken toughness, hidden abuse, and exploitation. The first theme had two sub-themes: domination and disturbed peace and tranquility.

Broken Toughness

Broken toughness was described as unacceptable and inappropriate behaviors that emotionally harmed older people and damaged their identity, self-esteem, and self-worth. These behaviors include dominating older people and disturbing their peace and tranquility.

Under Domination

Older adults considered the dominating behaviors by those around them to be a form of abuse. They believed that these behaviors would limit their authority and deprive them of a peaceful life. Depriving older people of the right to choose and imposing other family members’ opinions and decision-making on them deprives older adults of their authority.
Older adults were dissatisfied and annoyed with others making decisions. The participants did not feel weak or incapacitated to the extent that others viewed them as old or disabled. An older woman who was forced by her son to leave her free life in a villa and live in an apartment despite her wishes complained that she had no choice but to choose her place of residence. “Life in a cage,” she said. (About her place …)
  • “I did not want to live in an apartment. I felt imprisoned and caged when my son sold my villa and forced me to live in an apartment.” (P9)

The participants believed that, at this age, despite some physical problems, they had many experiences that made them independent of others who tried to make decisions about their lives. The findings of this study demonstrated that older people with higher levels of education suffered more from deprivation of their independence by their children and others.
One of the most distressing problems mentioned by the older adults in this study was the restriction imposed on them to communicate with other family members or social communication, which could lead to feelings of loneliness and cause psychological problems, including despair, depression, boredom, feelings of helplessness, and anxiety. One of the participants (P2) stated the following:
  • “I do not have independence in my house. One day my brother called and wanted to come over to see me. My son yelled and shouted why my brother should come now. He said go and make an excuse to prevent hip from coming over; why is my brother trying to come without notice? I had to get permission from him to see my brother, and that made me very angry.” (P2)

Human beings are born with the need for communication and intimacy. Satisfying this need requires positive communication and interaction with others, especially with family members. Thus, by limiting communication, older adults experience deprivation, which can lead to feelings of loneliness. Attempts to eliminate this sense of loneliness in older adults can reduce the risk of complications such as depression.

Disturbed Peace and Tranquility

Older adults referred to the loss of peace and tranquility due to the negligence of family members as a form of abuse. These findings indicated that older adults showed depressive behaviors. They talked about the behaviors and actions that deprived them of a peaceful life. Harassment through noise, clutter, and indiscipline in tidying the house and bringing home strangers disturbed older people and stressed them mentally. Thus, after going through the ups and downs of life, older adults increasingly require mental and physical peace to be able to spend this stage of life with a sense of satisfaction.
In this study, noise was perceived as a serious threat to the peace and tranquility of older people. Noise can have an indirect impact on older people in the form of irritation, physical and mental fatigue, sleep disturbances, increased heart rate, and high blood pressure. An older woman who was suffering from the noise made by her young grandchildren said:
  • “The young people in this generation sleep until noon and stay awake until midnight. My grandchildren’s room is next to mine. All nights, I hear the sound of laughter or talking over the phone to friend or listening to music. Sometimes in the middle of the night, he began eating while the sound of dishes and utensils is coming from the kitchen.”

Hidden Abuse

The older adults in this study were exposed to hidden abuse, including psychological harassment. Behaviors such as neglect, constant blame, intimidation, disrespect, and disregard were some of the hidden abuses experienced by the study participants. These behaviors, while not having visible physical effects, were highly annoying and distressing to the participants. From the point of view of the older adults, these behaviors were a type of abuse.
One of the hidden abuses was blame, including reminders of shortcomings in a two-way relationship and behaviors with the intention of humiliating and exercising power over older adults. Blame distorts another person’s personality and creates a feeling of worthlessness for older adults, leading to a loss of dignity and self-confidence. Blaming in front of others and the constant criticism of older adults by their children were perceived as tormenting. The older adults used the phrase “getting injured” to express the depth of their psychological distress:
  • “I always find myself exposed to his reproach and horrible criticism, which bothers me a lot and takes away my confidence. He blames me for everything I do. I feel I have been injured. Like a dagger that breaks everything to pieces, I am injured and broken into pieces by his constant rebukes.” (P7)

Older adults have emotional, livelihood, security, and recreational needs and like to participate in social activities. Thus, family members and the community should be aware of these needs and strive to provide them. As people age, their emotional needs may increase. From the point of view of older adults, making them wait is emotional abuse. No matter how good the financial situation of the older adult, they still emotionally need others and society. The older adults stated that they expected love and affection, meeting loved ones, and quicker responses from their family members and community.
The older adults in the present study experienced negligence from their family members in meeting their health needs. Unkindness, lack of empathy and sympathy, not visiting, not answering their questions and lack of attention deprived the older people of their emotional needs, to the degree that they felt "abandoned". The older adults stated that their children did not visit them often because of work-life difficulties.
Lack of support by family members in matters such as cleaning, shopping, cooking, and financial and banking affairs were other experiences of abuse.
  • “With this disease, I have to do everything on my own. I am on dialysis three times a week. None of my children would take me to the clinic. I go there alone. My wife died two years ago, this house needs cleaning, and no one does the cooking. The hospital staff, who know that I live alone, sometimes feel sorry for me and adjust my dialysis time close to lunch time, so that I can have a Hot Bite." (P19)

Ignoring their attachments was another psychological abuse experienced by older adults in this study. Belonging means loving something. Belonging is a psychological property. Older adults are particularly sensitive to their belongings, as they have sentimental value. Older adults should be allowed to maintain their belongings and their sense of ownership and belonging should be respected.

Exploitation

Exploitation of older adults was perceived by the participants as another form of abuse, which took advantage of older adults throughout their lives. The older adults in the present study were only physically and financially exploited. They did not refer to other forms of exploitation such as sexual exploitation. Most of the older adults who were exploited were women or older adults who were physically or financially dependent.
Exploitation was also experienced as a threat, fear, and violence. An older woman who was severely abused by her husband said:
  • “I went to bed a little early last night, I was not feeling well, but he called me seven times. At night, he woke me up for whatever he wanted, and I had to provide him. One time he wanted water, another time he wanted tea, or fruit or medication. I had to serve him like a servant. I am no longer comfortable with him.” (P10)

Deception involves breaking interpersonal covenants. The participants talked about lying, cheating in marriage, cheating in business, and fraud. They stated that some market sellers took advantage of their age and sold goods at higher prices.
Fraud against older adults was another example of the exploitation of older adults by their children. Forcing older people to share their capital, misuse of their properties and assets for personal gain, and claiming inheritance were examples of financial exploitation mentioned by the participants.
  • “My problem is my children. They expect financial help from me. I’m retired and do not have that much money. My salary provides for me and my wife, but they expect me to sell the house I live in and meet their financial needs. But I cannot do that now at this age.” (P14)

DISCUSSION

The results of this study illustrated older adults’ perception of abuse in Iran. The participants referred to abuse as a factor that disrupted their strength and tranquility in old age. They also referred to hidden abuse and exploitation of older adults.
According to the participants, psychological and verbal abuse were frustrating. The participants discussed psychological harassment, pain, and discomfort, which were no less than physical harassment. Physical abuse is not the only type of abuse that results in injury, as it includes a broader range such as threats, psychological and emotional violence, humiliation, ridicule, and obscenity. The impact of such behaviors is greater than that of physical abuse.21) In another study, psychological abuse was the most common abuse mentioned by older adults. Approximately 68.8% of the study participants had experienced psychological abuse, 37% had experienced neglect, 6.3% had experienced financial abuse, and 3.8% had experienced physical abuse. None of the participants had been sexually abused. Another study in Iran demonstrated that psychological and financial abuses were the most prevalent abuse among older adults.22) The reported rates of psychological abuse were 20.7% in Spain, 29.7% in Sweden, 27.1% in Germany, and 21.9% in Portugal.23) Another study showed that the highest prevalence of abuse in the United States and the United Kingdom were physical and verbal violence, respectively.9) Many studies have confirmed that psychological abuse is one of the most important types of domestic abuse among older people. For example, Filipska et al.,24) Pi et al.,10) Heravi-Karimooi et al.,11) and Koosheshi and Valadvand25) reported the importance of psychological abuse. The similarities and differences in the types of abuse in Western, Eastern, and American societies can be attributed to cultural differences. Psychological abuse is more prevalent in Eastern societies, including Iran. This can perhaps be attributed to the strong emotional bonds and attachments, especially emotional attachments between parents and children. This type of relationship leads to widespread interactions and, sometimes, excessive expectations of parents and children from each other such that some behaviors are considered abusive from their point of view. However, economic problems and rising inflation in recent years have deprived children of financial support, which, in the presence of severe economic pressures on children, may lead to the financial abuse of their parents.8)
In the study of Heravi-Karimooi et al.,11) the nature of abuse included “highly disturbing emotional behavior” and “disrespect.” The participants stated that the abuse of older people was a distressing emotional behavior and an unpleasant, torturous, difficult, and painful inner experience. In the present study, almost all participants identified disrespect as a form of abuse. Disrespect is a form of psychological abuse among older adults.23) Disrespect includes behaviors and attitudes that violate cultural norms. In many Asian cultures, disrespect may be considered the most important form of abuse.26) The older adults in the present study considered any behaviors that made them feel humiliated and ignored, especially in the public, to be disrespectful. A previous study reported that older Koreans considered their grandchildren’s ignorance of them to be disrespectful. From their perspective, not speaking the mother tongue in conversation with parents, direct opposition to older people, or lack of attention and value of older people when entering the home were considered disrespectful behaviors.27) Older Chinese adults also reported disrespect as the most serious form of abuse. In one study, Chinese seniors noted sharing responsibility among family members as a form of disrespect for them. They believed that, in this case, they would be exchanged like a ball among family members, which they perceived to be a kind of disrespect.28,29) In Japanese culture, parental blame by children is a form of disrespect for parents and older adults.30) Heravi-Karimooi et al.11) reported that the participants stated that they needed respect more than water and food, and that disrespect was worse for them than thirst and hunger. Older people’s description of disrespect in that study included rejection, neglect, lack of a dignified life, and violation of their rights. Another psychological abuse reported by older adults in the present study was a lack of communication with older adults. A study of Chinese and Korean older adults reported that failure to communicate with older adults was also considered a form of psychological humiliation and punishment.31-33)
Financial expectations and pressure on older adults to sell their property and assets against their will, expropriation, fraud in transactions, and the prevention of older adults from making decisions regarding their own property and assets, use of older people’s pensions, and unauthorized transfers of property were among the financial abuses experienced by older adults in the present study. A previous study reported that older adults spent their financial resources on educating their children and sacrificing their personal needs in favor of their children.34) The older adults in our study experienced financial abuse such as pressure from family members to acquire land, property, and capital; in contrast, a study in Africa reported theft as the most common financial abuse. The unauthorized acquisition of property and assets belonging to older adults was also reported.35)
The present study had several limitations, including the age of the participants and their fatigue during the interview, which might have affected their responses. Therefore, the researchers adjusted the interview times according to the participants’ physical and mental conditions. The abuse of older adults is a hidden problem among many families and is a social taboo according to the prevailing culture in Iranian communities; hence, many abused older adults were not willing to be interviewed. Therefore, participant recruitment in this study was difficult and long. The process of dealing with abuse and its consequences is part of the education of medical students, as well as part of continuing educational programs for healthcare professionals. The results of the present study may help health workers to provide essential social, economic, welfare, and health support to older adults and their families. Health care providers can also benefit from employing specialized expert teams to design and implement support programs. Empowering older adults and their families plays an important role in preventing abuse. As the abuse of older adults is multidimensional and context-based, similar studies should be conducted in other contexts with diverse cultures and religions to gain a better understanding of the phenomenon.
In conclusion, the results of this study revealed that abuse may be hidden in many cases and was not limited to physical abuse. Other examples of abuse include disrespect, deprivation of authority, disturbed peace and tranquility, and financial exploitation of older adults. The results of this study can help increase knowledge in the field of abuse of older adults.

ACKNOWLEDGMENTS

CONFLICT OF INTEREST

The researchers claim no conflicts of interest.

FUNDING

This study was part of a PhD dissertation by the first author, who was financially supported by Tehran University of Medical Sciences.

AUTHOR CONTRIBUTIONS

Study concept and design, ME, MA; Acquisition of subjects and/or data, ME, MA, MZ; Analysis and interpretation of the data, ME, MA, MZ, NN; Preparation of the manuscript, ME, MA, MZ, NN.

Table 1.
Participants’ characteristics
Characteristic n (%)
Mean age (y) 68.9
 60–75 18 (90)
 76–90 1 (5)
 >90 1 (5)
Sex
 Male 6 (30)
 Female 14 (70)
Education
 Illiterate 2 (10)
 Primary and junior high school 6 (30)
 High school 2 (10)
 University 5 (25)
Marital status
 Married 9 (45)
 Widowed 7 (35)
 Divorced 3 (15)
 Single 1 (5)
Living arrangements
 Alone 5 (25)
 With spouse 7 (35)
 With children 6 (30)
 With relatives 2 (10)
Place of residence
 Rural areas 7 (35)
 Urban areas 13 (65)
Abuser
 Children 11 (55)
 Spouse 5 (25)
 Relatives 4 (20)

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