Multicultural voices: Attitudes of older adults in the United States about elder mistreatment

Abstract

Despite international growth in policies to increase the identification and response to elder abuse and neglect, there remain considerable barriers to treating the problem. Some of these barriers may be attributed to how older adults from different racial/ethnic backgrounds define, experience, and seek to remedy elder mistreatment. Using focus group discussions based on case vignettes, this paper examines how older adults from different racial and ethnic backgrounds in the United States perceive elder mistreatment. Five focus groups were conducted with African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino Whites and African American caregivers for older adults. While similar definitions and meanings of elder abuse were expressed across the different racial/ethnic groups, Latino participants introduced additional themes of machismo, respect, love, and early intervention to stop abuse, suggesting that perceptions/beliefs about elder mistreatment are determined by culture and degree of acculturation in addition to race/ethnicity. Most differences in attitudes occurred within groups, demonstrating that perceptions vary by individual as well as by culture. In identifying scenarios that constitute elder mistreatment, some participants felt that certain cases of abuse are actually the persistence of intimate partner violence into old age. Participants also indicated that victims may prefer to tolerate mistreatment in exchange for other perceived benefits (e.g., companionship, security); and out of fear that they could be placed in an institution if mistreatment is reported. Findings suggest the need for person–centred intervention and prevention models that integrate the cultural background, care needs, and individual preferences of older adults.

Introduction

For over three decades, research on elder mistreatment (EM) has sought to better understand its multiple facets, the magnitude of the problem, and the associated risks and causes (Comijs et al. 1999; Fulmer et al. 2005; Pillemer and Finkelhor 1988; National Research Council [NRC] 2003; Tatara 1999). Because EM is increasingly viewed as both a social and legal issue, remedies often require partnerships among social service agencies, health care, and the justice system (Connolly 2010; Quinn and Heisler 2004). In the United States, individual states, rather than the Federal government, developed their own definitions and approaches, many emphasising mandatory reporting laws to identify and promote investigation of EM. Although these efforts have increased recognition and concern for EM, one area missing from the discussion is the voices of older adults themselves, including the perspectives of minority elders. Therefore, the study reported in this paper sought to examine how older adults from different ethnic and cultural backgrounds define EM, the contextual factors they identify as the cause of EM, and their attitudes about reporting abuse.

Definitions of elder abuse and neglect vary widely, hindering efforts by researchers, policy makers, and practitioners to describe the extent of the problem and mount a coordinated response. The World Health Organisation adopted the definition of the United Kingdom’s Action on Elder Abuse (1995) that classifies elder maltreatment as, “a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person (WHO 2008),” but has argued that future definitions “require a cultural context” (WHO/INPEA 2002: 9). Similarly, in the United States, an expert panel convened by the National Research Council (Bonnie and Wallace 2003) defined elder abuse as, “intentional actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder,” and neglect as, “failure by a caregiver to satisfy an elder’s basic needs or to protect the elder from harm (pg. 1).” These definitions offer a starting point for researchers to explore the issue, but may not align with the perspectives of older adults themselves, particularly racial/ethnic minorities who may approach EM from unique socio-cultural orientations.

International literature on how older adults from diverse societies view EM reveals a more nuanced perspective. Synthesising definitions cross-nationally, the WHO and the International Network for the Prevention of Elder Abuse (INPEA) report that older adults perceive EM as any violation of human, legal, and medical rights; any deprivation of choices, decisions, status, finances, and respect; and any form of neglect, including social exclusion, isolation, and abandonment (WHO/INPEA 2002). Therefore, policymakers and practitioners looking to serve vulnerable populations may need to adopt a more inclusive framework that recognises diverse and subtle forms of mistreatment.

Another limitation of current EM definitions is that they insufficiently account for the contextual and interpersonal perception of abuse. What is considered abuse by one individual may not reach the standard of abuse for another (Comjis et al. 1999; Fulmer et al. 2005). For example, Matsuda (2007) found that abusive caretaking behaviours directed at dependent elders with dementia were judged as less abusive than the same behaviours directed at dependent elders without dementia. In a survey by Childs, Hayslip, Radika and Reinberg (2000), respondents judged abusive behaviours perpetrated by a middle-aged person toward an elder as more abusive, severe, and reportable than the same behaviours perpetrated by an older adult. Furthermore, middle-aged respondents were more likely than young-adult respondents to label psychological maltreatment as abuse, indicating that the age of the perceiver and the age of the abuser influence how EM is defined. In a study by Selwood, Cooper and Livingston (2007), family caregivers were significantly more likely than paid caregivers to believe that it is neglectful to permit a cognitively impaired older adult not to bathe if s/he refuses. In contrast, Ayalon (2011) found that home-care professionals were more likely to identify behaviours as neglect compared to family caregivers. Thus, beliefs about what actions constitute EM vary based on the characteristics of the individual perceiving the behaviours and the context of those behaviours.

In addition to individual perceptions, it is also important to recognise the socio-cultural context in which beliefs and attitudes about EM develop. In the United States, early research found that African Americans were more likely than Caucasians, Puerto Rican Americans and Japanese Americans to identify financial exploitation as a form of EM (Anetzberger, Korbin and Tomita 1996). Moon and Williams (1993) found that Korean Americans were significantly less likely to identify various scenarios as abuse compared to Caucasians and African Americans; and African Americans were the racial/ethnic group most likely to utilise formal help-seeking options to resolve abuse (e.g., police, 911, lawyers), and the least likely group to turn to family members and other relatives for assistance. Other research found that African Americans and Caucasians shared similar views about the causes of elder abuse, which significantly differed from the views of Korean Americans who were more tolerant of EM overall (Moon and Benton 2000). These findings suggest that language and degree of assimilation with American culture may be a stronger driver of EM beliefs than race or ethnicity alone (Moon 2000). In contrast to the cross-cultural variation in EM perspectives reported by earlier studies, a focus group study conducted in 2005 found a high level of consistency in EM definitions across African American, Caucasian, and Mexican American elders (Mouton et al. 2005). This could signify that recent advocacy efforts and education about EM in the United States have produced greater congruence in beliefs among older adults from different racial/ethnic backgrounds.

Research in the United Kingdom and other European nations has more recently explored cross-cultural perspectives on elder abuse, including the perspectives of racial/ethnic minorities. In a racially/ethnically diverse community sample of middle- and older-aged adults in the UK, 74 per cent of respondents identified “lack of respect” as a form of EM and more respondents mentioned psychological abuse (72 per cent) than physical abuse (41 per cent). Very few participants spontaneously identified sexual abuse or neglect (5 per cent and 10 per cent, respectively), and no White Europeans or South Asians mentioned sexual abuse as a type of EM (Bowes, Avan and Macintosh 2008). In 2006, the Cross-Cultural Definitions of Family Violence and Abuse survey was administered in several European countries. Findings reveal similarities across nations in the forms of abuse/neglect that were recognised by older respondents. Psychological neglect and abandonment were the most frequent examples of abuse provided by German citizens (König and Leembruggen-Kallberg 2006); psychological and physical neglect were two of the most commonly cited abuse–types given by Greek citizens (Daskalopoulos, Kakouros and Stathopoulou, 2006); and English respondents (residing in the UK) generally provided examples of EM that were acts of omission, such as neglect, rather than commission (e.g., hitting, yelling; Daskalopoulos et al. 2006). These cross-national findings in the identification of elder neglect suggest that caring for older relatives may be a shared cultural expectation in Europe, and that disregarding caretaking obligations is a serious form of EM.

As developed nations continue to grow in racial and ethnic diversity, it is important to revisit early research questions about how community and family culture shape perceptions of EM (Anetzberger, Korbin and Tomita 1996; Benton 1999; Moon and Williams 1993 Tatara, 1999). Failure to update the evidence on how elders currently define mistreatment in domestic settings may result in inaccurate identification of abuse and its risk factors, leading to ineffective remedies that are unsuited to the needs and preferences of victims (Mouton et al. 2005; Manthorpe and Bowes 2010, Rittman, Kuzmeskys and Flum 1999). Moreover, studies showing different perceptions of what constitutes abuse among Caucasians, African Americans, and Korean-Americans (Benton 1999; Moon and Williams 1993) have suggested that culturally appropriate strategies help to identify, prevent, and address EM in minority populations.

The purpose of the present study was to explore perceptions of EM held by older adults from different racial and ethnic groups in Los Angeles, California, one of the most culturally diverse cities in the world. Five focus groups were conducted with African American, Latino, and non-Latino White older adults, as well as with African American caregivers of older adults. Because previous research suggests that cultural differences in EM definitions may be driven by the degree of acculturation with Western culture (Moon 2000), we decided to conduct separate sessions with two groups of Latino elders—one English-speaking, and one monolingual Spanish-speaking. Furthermore, research has found that acts believed by those in a caregiving role to promote the older adult’s health, such as coercing him or her to take prescribed medications, are not necessarily viewed as abuse (Matsuda 2007; Moon and Benton 2000). Therefore, this study included one focus group comprised of informal (family) caregivers for dependent elders to determine whether caregivers have unique perspectives on EM compared to older adults. The caregivers in this study were all African American. Specific research questions included:

1. What specific contexts and circumstances do older African American, Latino, and non-Latino Whites define as EM, and how do their perceptions compare to those of African American caregivers of older adults?

2. Are there racial/ethnic/cultural variations in how EM is perceived and beliefs for how it should be addressed?

3. What cultural or contextual factors influence EM reporting and what are the perceived barriers to reporting?

The overall aim of this study was to inform the development of contextual and culturally based interventions and policy responses to EM that are more responsive to the beliefs of older adults and family caregivers.

Methods

A qualitative study was conducted using focus groups with African American, Latino, and non-Latino White older adults, as well as African American caregivers of older adults. This study was reviewed and approved by the University of Southern California (USC) Institutional Review Board.

Recruitment

Participants were recruited through local agencies in Los Angeles serving older adults, including senior centres and caregiver support groups. Research flyers were tailored to each recruiting organisation by adding their agency’s logo. Staff from participating organisations posted and distributed flyers to their clients. Older adults interested in registering for the focus group sessions were requested to contact the research staff by phone. To maintain anonymity, participants were asked to register using their initials only. Recruitment criteria included being 65 years or older and a member of the specific group of interest (caregiver vs. ethnic/racial minority older adult): (1) English-speaking Latino, (2) Spanish-speaking Latino, (3) African American, (4) non-Latino White, and (5) caregiver for an older adult. These particular groups were selected because they represent the diverse racial and ethnic composition of Los Angeles. In an effort to increase the diversity and range of perspectives on EM, focus groups included both males and females.

Protocol

Building on previous work on elder abuse and race/ethnicity (Benton 1999; Moon and Williams 1993), an open-ended focus group protocol was developed by an advisory panel of experts in elder abuse, cultural diversity and qualitative research. Questions for discussion by focus groups were presented using various case scenarios depicting relationship conflict and potential opportunities for abuse. The following is an example of a case scenario:

“John and Mary have been together since they were in their early 20’s. They are now in their late 60’s. Throughout their relationship, they sometimes argue, yell, and scream at each other. They call each other names and insult each other.”

Participants were asked whether this behaviour constitutes abuse. After the first scenario was presented and discussed, modifications were made to the basic structure of the vignette to determine if it changed how participants viewed the behaviours. Adjustments consisted of altering the age or gender of the victim/perpetrator, their relationship (spouse versus parent-child), the degree of impairment/dependency of the victim, the frequency and duration of the behaviour (e.g., occurring recently versus having occurred throughout the past 40 years) and the type of mistreatment (verbal, physical, sexual, and financial). Scenarios either depicted both characters engaging in the behaviour (bidirectional), or one perpetrator and one victim. Hypothetical examples, accounts of past abuse involving friends or acquaintances and other topics introduced by focus group participants were welcomed for discussion to obtain additional perspectives on EM. Before each session, participants were advised both verbally and in a written consent form provided that they were not expected to, nor should they, describe their personal experiences with abuse because study personnel would be required to report these incidents to Adult Protective Services in compliance with mandatory reporting laws in California. Adult Protective Services are the state agencies responsible for responding to non-institutional reports of EM in the United States.

Focus groups were conducted on-site at the participating organisations in private rooms and lasted approximately 90 minutes. All focus groups were audio recorded and co-facilitated by a male and female trained moderator. Because the first group was asked to provide feedback on the research protocol, those participants received a cash payment of 20 USD; participants in subsequent groups each received a 10 USD cash payment. All participants received lunch.

Demographic Measures

At the beginning of each session, participants were asked to complete a demographic handout containing questions about their gender, age group (10-year intervals), race, marital status, education level, employment, living arrangement, income, and whether they had provided care for an older adult in the last five years. Forms were reviewed for completion by the facilitators and a Spanish-speaking co-facilitator provided assistance in completing the form as needed.

Analysis

Recordings were transcribed verbatim to maintain the richness and integrity of the dialogue, and then were reviewed by the focus group moderators to ensure accuracy and address ambiguities. The Spanish language group recording was transcribed in Spanish and then translated into English by two bilingual members of the research team, who used the original recording to confirm that idiomatic expressions were accurately translated. All transcriptions were loaded into a spreadsheet program for coding and thematic analysis (Stockdale 2002). Two investigators separately coded the transcripts, developed new codes by employing an iterative process of systematic review and continuous comparison of higher-order thematic categories, and revised coding patterns accordingly. Two investigators reconciled coding differences by discussing the context and meaning behind ambiguous statements. Initial themes arising from the focus group protocol—age, gender, duration of abuse, reciprocity, and impairment/dependency—were augmented with additional themes and subthemes using a grounded theory approach (Strauss 1987). Grounded theory is an inductive analysis method that allows concepts to emerge from the data (Glaser and Strauss 1967). Resulting themes and subthemes were reviewed for face validity by two of the investigators upon final review of the transcripts.

Results

Sample description

Table 1 presents the demographic characteristics of the sample. A total of five ethnically homogenous focus groups were conducted, one each with African Americans (n=11), English-speaking Latinos (n=6), Spanish-speaking Latinos (n=12), non-Latino Whites (n=9), and family caregivers who were all African American (n=5). The age limit for participating was lowered from 65 to 55 because some participants brought younger companions to the focus groups and asked that they be included.

Table 1.

Sample characteristics

	Frequency (Percent)
	All participants (n=43)	African American group (n=11)	English-speaking Latino group (n=6)	Spanish-speaking Latino Group (n=12)	Non-Latino White Group (n=9)	Caregiver Group (n=5)
Gender
Female	30 (70)	10 (91)	3 (50)	7 (58)	5 (56)	5 (100)
Age group
Under 65 years	7 (16)	1 (9)	2 (33)	1 (8)	2 (22)	0 (20)
65-74 years	20 (47)	7 (63)	0 (0)	8 (67)	2 (22)	3 (60)
75-84 years	11 (26)	2 (18)	2 (33)	3 (25)	3 (33)	1 (20)
85+ years	5 (12)	1 (9)	2 (33)	0 (0)	2 (22)	0 (0)
Primary spoken language
English	32 (74)	11 (100)	4 (67)	3 (25)	9 (100)	5 (100)
Spanish	11 (26)	0 (0)	2 (33)	9 (75)	0 (0)	0 (0)
Race/Ethnicity
Black	15 (35)	11 (100)	0 (0)	0 (0)	0 (0)	4 (80)
Caucasian	9 (21)	0 (0)	1 (17)	0 (0)	8 (89)	0 (0)
Latino	13 (30)	0 (0)	4 (67)	7 (58)	1 (11)	1 (20)
Refused/Missing	6 (14)	0 (0)	1 (17)	5 (42)	0 (0)	0 (0)
Marital status
Divorced	6 (14)	1 (9)	3 (50)	0 (0)	1 (11)	1 (20)
Married	13 (30)	5 (46)	1 (17)	3 (25)	3 (33)	1 (20)
Single	8 (19)	1 (9)	0 (0)	5 (42)	1 (11)	1 (20)
Widowed	16 (37)	4 (36)	2 (33)	4 (33)	4 (44)	2 (40)
*Reside with
Alone	21 (49)	5 (46)	0 (0)	9 (75)	5 (56)	2 (40)
Child/Grandchild	4 (9)	1 (9)	0 (0)	1 (8)	1 (11)	1 (20)
Spouse	11 (26)	5 (46)	0 (0)	2 (17)	3 (33)	1 (20)
Refused/Missing	7 (16)	0 (0)	6 (100)	0 (0)	0 (0)	1 (20)
Education level
Less than high school	9 (21)	1 (9.1)	1 (17)	7 (58)	0 (0)	0 (0)
High school grad/GED	14 (33)	4 (36)	3 (50)	3 (25)	4 (44)	0 (0)
Some college	8 (19)	2 (18)	1 (17)	1 (8)	3 (33)	1 (20)
College grad	5 (12)	2 (18)	1 (17)	1 (8)	0 (0)	1 (20)
Postgraduate	7 (16)	2 (18)	0 (0)	0 (0)	2 (22)	3 (60)
Currently a caregiver
Yes	21 (49)	6 (55)	2 (33)	3 (25)	5 (56)	5 (100)
Current work status
Retired	37 (86)	11 (100)	5 (83)	9 (75)	8 (89)	4 (80)
Paid employee	3 (7)	0 (0)	1 (17)	1 (8)	0 (0)	1 (20)
Homemaker	1 (2)	0 (0)	0 (0)	1 (8)	0 (0)	0 (0)
Volunteer	1 (2)	0 (0)	0 (0)	0 (0)	1 (11)	0 (0)
Refused/Missing	1 (2)	0 (0)	0 (0)	1 (8)	0 (0)	0 (0)
Low-income / Less than 10,000 USD per year	17 (40)	2 (18)	2 (33)	10 (83)	3 (33)	0 (0.0)

^*Note: The English-Speaking Latino focus group was not asked to specify the people whom they reside with.

Seven participants (out of 43 in total) were under the age of 65, twenty were between 65 and 74, eleven were between 75 and 84 and five were older than 85. All participants in the caregiver group were female, as were all but one of the participants in the African American older adult group. The other three focus groups were comprised of roughly half males and half females. Nearly half of all participants reported living alone, one quarter lived with a spouse, and less than 10 per cent lived with an adult child or grandchild. The English-speaking Latino group participants were not asked about their living arrangement and this information is therefore missing from the demographic summary in Table 1. Thirteen participants were married, sixteen were widowed, eight were single and six divorced. Nearly 80 per cent of all participants reported at least having a high school diploma or General Education Development (GED) degree equivalent. Nearly half the sample attended or graduated from college. The Spanish-speaking Latino group had fewer years of education on average than the English-speaking Latino group—58 per cent did not graduate high school compared to only one participant in the English-speaking Latino group. The vast majority of the sample was retired, including all 11 participants in the African American older adult group. All of the participants in the caregiver focus group and 37 per cent of the participants in the other groups reported providing care for an elder.

Participants in the two Latino groups were asked whether their annual income was greater or less than 10,000 USD, which is close to the 2008 poverty threshold for a single-person household in California. The other three focus groups were simply asked whether they considered themselves “low-income.” Summarising these two income questions into a single variable, approximately 40 per cent of the entire sample identified themselves as “low-income.” Over 80 per cent of the Spanish-speaking Latino group earned less than 10,000 USD/year, compared to 33 per cent of the English-speaking Latinos, 18 per cent of the African Americans, and 33 per cent of the non-Latino Whites. None of the African American caregivers reported having a low-income.

Themes

Transcript analysis revealed ten distinct themes that were common across focus groups, and an additional three themes from the Latino groups (see Table 2). Some themes emerged directly from discussing the case scenarios while others were generated spontaneously. The ten themes are grouped into three broad categories: (1) factors that contribute to EM (risk factors/causes); (2) factors relating to how EM is defined; and (3) factors pertaining to reporting abuse, the consequences of reporting, and prevention strategies or remedies for EM. Themes in the first category (risk factors/causes) include dependency/impairment (financial, physical, and mental) and family. Themes within the second category (definitions/perceptions) include age and gender, bidirectional abuse, and frequency/duration of abuse. Themes in the third category (reporting/preventing/responding to EM) include tacit exchange, concerns about loss of autonomy/nursing facility placement, reporting EM, and knowledge/education. There was a high degree of consistency across focus group discussions, reflecting shared perceptions in EM beliefs among older adults from different racial/ethnic backgrounds, but considerable variation within groups in how individual participants interpreted abuse scenarios. Although there was consistency across groups on core themes, additional variations were offered by the two Latino groups: machismo (expectation of male dominance), respect, love, and early intervention.

Table 2.

Themes and definitions

Thematic Category 1. Factors that contribute to elder abuse (risk factors/causes)
Theme	Definition
Dependency/Impairment Financial Physical Mental	Dependency on one or more support persons due to one or more limitations (financial dependency, physical limitations, cognitive limitations)
Family	Role of family in perpetrating abuse/neglect and influencing reporting behaviour
Thematic Category 2. Factors that influence the definition of elder abuse
Theme	Definition
Age & Gender	Role age and gender play in abuse; Impact of age and gender on definition of abuse
Bidirectional Abuse	Extent to which elder abuse is reciprocal with both partners participating
Frequency/duration	Length and number of times a behaviour has occurred
Thematic Category 3. Factors pertaining to abuse reporting, consequences of reporting, and prevention
Theme	Definition
Tacit Exchange	Knowingly accepting an abusive situation in exchange for a perceived benefit (e.g., companionship, ability to live in community)
Loss of Autonomy/Nursing Home Placement	Fear or threat of losing independence or being placed in nursing facility
Reporting EM	Factors associated with reporting/not reporting abuse
Knowledge/education	Role of knowledge/education in abuse and in prevention of abuse
Latino Specific Themes
Theme	Definition
Machismo	Expectation and influence of male dominance and aggressiveness on abuse
Respect	Issues addressing level of respect within a relationship
Love	Role of love in abusive relationships
Early Intervention	Impact/need for early reporting/therapy, assistance when abuse occurs

Thematic category 1: Risk factors/Causes of EM

Dependency/Impairment

Impairments were viewed as increasing one’s vulnerability to abuse and elicited agreement on definitions of abuse among all ethnic/racial groups. Physical, sexual, and verbal exchanges were all identified as EM if the victim was cognitively or physically impaired or could not provide consent: “…Then I think that would be abuse…because she’s sick and cannot defend herself” (English-speaking Latina). The theme of dependency included issues of financial dependency on the perpetrator as well as issues of dependency due to physical or cognitive impairment. One African American woman stated, “It’s probably [abuse] because of their dependence on a person or maybe the physical, you know, capabilities, you know, maybe put them more at risk.”

Notably, at least one participant in each of the five focus groups remarked that cognitively impaired seniors often display aggressive behaviour as a symptom of their disease. These behaviours were not considered abuse, but if a caregiver were to reciprocate the behaviour, it is abuse. One Latino male commented, “If I have All-Timers [Alzheimer’s] and I’m hitting her, and get upset and keep hitting her, I don’t consider it abuse, it’s a disease. In her half, she’s not aware so she hits me back and then she starts telling me things. That’s abuse.”

Family

There was widespread belief across ethnic groups that victimization by family members, particularly adult children, is a serious problem but that abusers can be anyone known to the victim. According to one Latina, “Brother, sister, grandson, granddaughter, it doesn’t matter, the abuse is still there.” Some participants perceived intergenerational abuse as more severe because of elders’ trust and reliance on family members. A few blamed the increase of EM by younger relatives on changes in generational values. According to one African American woman, “…I would say the young crew, it’s all about the money, what I can get out of it…” Across groups, participants identified adult children as perpetrators of financial abuse, providing numerous examples of seniors who had lost their belongings, changed their wills, or unwittingly transferred property to exploitative children.

Thematic Category 2: Perceptions/Definitions of EM

Age and gender

The age and gender of the characters in the vignettes were altered to determine if these traits influenced perceptions of abuse. Across all racial/ethnic groups, neither age nor gender was viewed as a factor in determining whether an act was abusive. According to one African American participant, “Abuse is abuse…it doesn’t matter who it is or what age or what’s happening.” And a Latino participant stated, “It doesn’t matter, male or female, there is a problem that needs to be issued [addressed].”

Bidirectional abuse

Exchanges between two individuals were not viewed as abuse if the behaviour involved only verbal exchanges. As stated by one participant, “Abuse has to be unequal, and if it is on the same level, how can you complain?” Some participants stated that all aggressive physical acts were abuse, regardless of reciprocity, whereas other participants felt that bidirectional physical exchanges were not abuse. One Latino male commented, “If it’s one to the other one and the other one don’t replies, it’s abuse. But if they both fight each other then…you know…it’s not really abuse…” These disagreements show that some EM perspectives are not explicitly driven by culture or by race, but are based on individual beliefs and experiences.

Frequency/Duration

The vignettes prompted participants to consider the frequency and duration of behaviours as factors influencing the definition of EM. These factors stimulated a wide range of opinions on what constitutes abuse, and were highly dependent on both the type of behaviour and by the individual perceiving the situation, rather than by that person’s ethnic/racial affiliation. All participants stated that unwanted sexual acts were abuse, including those among partners. Additionally, many participants across ethnic/racial groups identified physical mistreatment as abuse regardless of how long or how many times it occurred. According to one African American female, “It doesn’t matter if it’s one or ten times. That particular action is abusive, you know?” However, a few participants attending the Spanish-speaking focus group expressed the view that abuse (whether verbal, physical, or financial) would not be considered abuse if it only occurred once: “Abuse the first time is not abuse,” and, “A couple of times does not make him an abuser. Now if it continues, then it is abuse.”

Aside from physical and sexual abuse, most groups suggested that persistent negative verbal exchanges were considered “normal” to the individuals involved and thus were not EM. According to one man, “I was married for a long time and we fought and went through that, it was just a normal thing,” and another, “So maybe they are hurting each other mentally or emotionally, but they should be used to it by now.” Furthermore, participants in three of the groups—African American caregivers, non-Latino Whites, and English-speaking Latinos—noted that on-going verbal mistreatment might be an established way of communicating between couples in a long relationship. Participants used phrases like, “It’s a way of communicating,” and, “It’s what they thrive on,” to describe the rationale of verbal hostility in long-standing relationships.

Conversely, some participants stated that even infrequent arguing or yelling constitutes abuse: “If I only do it once a week, or once every two weeks, or if I do it a month, it’s abuse” (English-speaking Latina). Another female in the English-speaking Latino group believed that duration defines abuse: “If you let this problem go on for 40 years, then you have a form of abuse.” Again, within-group variability in attitudes about the frequency and duration of mistreatment suggests that EM perceptions originate largely from personal values, beliefs and experiences.

Thematic Category 3: Reporting Abuse, Consequences of Reporting, and Prevention/Interventions for EM

Tacit exchange

Participants discussed the act of tolerating an abusive situation in exchange for support, companionship, and/or remaining in one’s home. In response to a scenario depicting an adult child living off his mother without contributing financially or providing care, an African American caregiver said, “…she is accepting this [financial abuse] as an exchange for the thought that she gets him present.” Responding to a similar scenario, a White male participant stated, “…even though the daughter doesn’t contribute to anything, the mother loves her.” Several participants, particularly in the minority groups, agreed that a financially abusive situation, though not a physically abusive situation, was preferable to living alone if the abuser leaves or is incarcerated. As described by one woman, “And a lot of times they accept certain things because they don’t want to be alone and all.”

Reporting EM

Group differences were found in beliefs about reporting abuse. Participants in the Spanish-speaking group were emphatic about the need to report EM immediately in order to prevent it from escalating, although they did not specify to what agencies or individuals the incident should be reported. Conversely, caregiver group participants noted that there are a lot of grey areas, and one needs to be careful and thorough before reporting abuse: “Someone from the outside can come and evaluate based upon x, y, and z criteria and not really have a true picture of what was going on.”

While the African American and non-Latino White groups expressed firm beliefs in reporting nursing home staff for neglect and physical mistreatment, all groups voiced a reluctance to report family members. As spoken by one Latina, “The love we have for our partner, we don’t report it for fear of sending him to jail,” and, “…this is where it is a disaster because next of kin, the grandmother, the sister, the brother, the father…they’re not going to want to be reported. They don’t.” Fear about losing a spouse or family member to incarceration was expressed pervasively across all groups. One African American participant recounted the experience of friend who was abused: “They, social workers, everybody came and spoke with her, but she told me that she did not want her daughter to go to jail…”

The African American caregiver focus group noted how observations of a potentially abusive interaction differ between those external to the situation (neighbours, Adult Protective Service workers, law enforcement), and the persons involved in the abusive relationship. This group vocalised the contextual nature of mistreatment and believed that caregivers’ perceptions of what constitutes abuse often conflict with professional/legal definitions. According to one woman, “… society doesn’t know what’s going on inside to make an accurate decision. They can only perceive by their standards what they think is goin’ on…and that’s part of the problem here, people getting involved in other people’s lives.”

Loss of autonomy/Nursing facility placement

Participants expressed persistent concerns around being placed in a nursing facility if it was suspected that they were being abused. Several shared stories of friends who had been placed against their will, generally by family members. Many shared a fear that this could happen to them and a willingness to endure almost any situation that would allow them to remain in their homes (tacit exchange). Nursing facilities as a source of abuse was introduced, particularly within the African American group. According to one participant, “They [nursing facilities] don’t take care of a lot of the elderly because they think you sick and gonna die anyway.” A non-Latino White woman stated, “You wouldn’t even treat your dog the way they’re treatin’ some of the patients.”

Knowledge and education

All groups discussed the need for education about EM. Caregivers advocated for improved public awareness and training on how to properly care for older adults as a mechanism to prevent EM. According to one African American caregiver, “…That’s why they have maternity classes for teenage mothers, because they don’t know how to take care of a baby, and we don’t know how to take care of an elderly.” Notably, caregivers stated that most people who provide care for an older adult would not label themselves a “caregiver”, suggesting that outreach and education efforts need to move beyond professionally identified labels and terminology.

Participants believed that providing accurate information was especially important for those caring for elders with dementia. Some described situations where a spouse with dementia becomes abusive and the partner retaliates not realizing that the behaviour is organically related to the disease. One caregiver said, “… Because they don’t see what they are doing as abuse. It might be pointed out to them that this might not be the best way to resolve a situation.” Participants suggested that rather than reporting these behaviours to Adult Protective Services, these caregivers would benefit from education to better understand the illness and to learn effective methods for addressing problem behaviours.

Latino specific themes

Four themes emerged only from the Latino focus groups: machismo (male expectation of dominance), lack of respect, love between abuser and victim, and the need for early intervention at the first indication of abuse. Most of these ideas were expressed in both the English-speaking and the Spanish-speaking Latino groups, but were emphasised more strongly by the monolingual Spanish-speaking Latinos, who also expressed greater solidarity in their attitudes toward EM.

Machismo

Both Latino focus groups discussed that while gender does not matter in terms of the definition of abuse, in their experience the perpetrator is more likely to be male. According to one older Latina, “…in my opinion, in most marriages, usually it’s the man wants to have that last word, that last say-so, usually…I’m just saying that in my experience, I’ve noticed that more men are more domineering.” This idea was bolstered by a participant discussion of machismo and the submissiveness of women within the Latino culture:

Woman: “… in Latina marriages, it’s always the male. In Latin marriages, the women are more…”

Man: “submissive.”

In the discussion of gender, Latino participants generally referred to male perpetrators as spouses, rather than male children or grandchildren. This suggests that gender constitutes a culturally specific risk factor for abuse among Latinos, such that women from more traditional marriages may be vulnerable to intimate partner violence in old age.

Respect

Lack of respect in a relationship was viewed as a primary contributor to abuse. According to one participant, “Because there wasn’t any mutual respect… the man always wants to be better [than his partner]. Therefore, he is abusing her.” Participants identified some of the scenarios that included negative verbal exchanges as indicating a lack of respect rather than abuse: “For me, it is no more than lack of respect.” One male participant described that if the abuse is one-sided then it should be defined as “abuse”; however, if the abuse is reciprocal, there is no respect between partners in that relationship.

Love

Participants in the Spanish-speaking group expressed an interesting association between love, respect, abuse, and reporting. Some participants indicated that couples or families enduring years of abuse do so because of the love between them, “I say it is a lack of respect towards each other, but because there is love between them, they stayed together.” Others shared that if there is “love” in a relationship than the abuse should not be reported because love is the most important thing. According to one Latina, “If they report it there is no longer love.”

Early intervention

Despite the belief that love is important to consider in determining whether to report abuse, Latino participants paradoxically stated that intervention is needed at the first indication of mistreatment. Participants specified that the timing of reporting is critical in preventing escalation and the development of a long-term pattern of abuse. According to one Spanish-speaking Latino, “You have to stop it cold,” and a Latina stated, “If they had been doing it all their lives one can expect something serious to happen because this is growing and getting worse. Then you can have a bad ending. To prevent this, you have to report it.” Reporting was viewed as a mechanism of prevention rather than punishment. One male participant voiced, “Report it as prevention. For prevention,” and the group agreed. Latino participants did not discuss whether formal or informal interventions were the preferred form of abuse mediation.

Discussion

While prior studies, discussed above, have explored perceptions of elder abuse among different racial and ethnic groups (Antezberger, Korbin and Tomita 1996; Bowes, Avan and Macintosh 2008; Dixon et al. 2009; Moon and Benton 2000; Moon 2000; Mouton et al. 2006), this is the first study to qualitatively compare meanings of abuse specifically among non-Latino Whites, Spanish-speaking and English-speaking Latinos, African Americans, and African American caregivers in the United States. Despite some differences between individuals, findings reveal a startling level of consistency across diverse groups in identifying scenarios that constitute EM or risk for EM. The similarity in attitudes across racial/ethnic groups is comparable to results from other studies in the United States that examined EM perspectives among older adults from different cultural backgrounds (Mouton et al. 2006; Moon and Benton 2000), with the addition of new themes from Latino older adults, particularly those who were monolingual Spanish-speaking. Although there was also consistency in elders’ knowledge about reporting abuse, demonstrating that individuals from different backgrounds are aware of resources for victims, all groups shared concerns about possible negative consequences of reporting.

While the views of African American and non-Latino White participants often aligned, a key variation in the current study was the unique EM perspective offered by Latino participants. Interestingly, these differences included additional viewpoints, rather than disparate beliefs about EM, and include machismo, respect, love, and a need for early intervention at the first sign of abusive behaviour. This difference between the Latinos, particularly the Spanish-speaking group, and other groups is similar to Moon and Benton’s (2000) finding that Korean Americans differed from African American and Caucasian older adults in their views, perhaps due to a closer connection to their native Korean culture. According to ecological theories of human development (Bronfenbrenner, 1979), belief-systems are embedded within socio-cultural and geopolitical contexts that shape the norms, traditions, and interpersonal relationships between people in a group. Thus, personal views about how elders should be treated and how responsibilities should be allocated among family members are influenced early in life by an individual’s socio-cultural context. Using language as a proxy for acculturation, the African American and non-Latino White participants, as well as English-speaking Latinos to some extent, are presumably immersed in American culture and therefore share more similar beliefs and values about EM. Alternatively, Spanish-speaking Latinos may maintain cultural identities closer to their native countries, which provide them with different perspectives on EM. Moon (2000) suggests that studying degree of acculturation may be more appropriate than race or ethnicity alone when exploring differences in EM perspectives among varying cultures.

Lack of respect was seen as a factor contributing to abuse as well as a form of abuse among Latinos. Vasquez and Rosa (1999) identified respect as an important cultural value that guides interpersonal relationships and connotes recognition of status. Latinos considered a violation of respect a serious moral trespass, especially when directed at older adults who traditionally have higher status. The connection between lack of respect and EM has appeared in other international studies on elders’ definitions of EM (WHO 2002; Bowes, Avan and Macintosh 2008), indicating that researchers, policymakers, and service providers need to classify EM more broadly as infringement on an elder’s personal dignity and human rights.

There was universal agreement among all focus groups that gender and age were not factors to consider in defining EM, although Latino participants were quick to point out that males were significantly more likely to perpetrate abuse against females, particularly male spouses. They identified the cultural influence of machismo (e.g., male dominance in society) as the driving source of this gender imbalance. Some researchers have proposed that a culture of negative machismo may contribute to abuse against older women (Vazquez and Rosa 1999; Cardona et al. 2007), yet studies of domestic violence have not found this to be the case (Jasinski 1998; Perilla 2000; Perilla, Bakeman and Norris 1994).

Being 65 or older was not perceived as an inherent vulnerability. However, all focus groups agreed that abusing individuals with physical and/or cognitive dependencies constituted “worse” abuse, clearly distinguishing between independent, intact older adults, and those who are too impaired to recognise or stop mistreatment. In identifying physical or cognitive vulnerability as a key component of EM, focus group participants aligned with the NRC Panel report (Bonnie and Wallace 2003), as well as other qualitative research on how older adults classify vulnerability (Dixon et al. 2010).

There was some disagreement about the meaning of frequency and duration of harmful behaviours as determinants of abuse, particularly for psychological and physical mistreatment. Most of this discordance was found within groups, rather than across racial/ethnic groups, suggesting that individual differences in perception about EM duration and frequency may supersede cultural differences. Some participants expressed the view that negative physical and verbal exchanges were abusive regardless of the frequency or duration. Others indicated that these actions were not abuse if both parties understood them to be “normative” in the relationship, or if they happened only once.

The finding that some older adults do not consider long-standing abuse between aged spouses/partners as EM highlights the idea that some elder abuse is actually intimate partner violence (spousal abuse) that happens to persist into old age (Penhale 2003). In a qualitative study by Walsh and colleagues (2007), many participants, particularly women, witnessed or experienced spousal violence beginning from marriage and lasting through old age. Participants stated that victims begin to accept the abuse after repeated exposure, and that cultural understandings of the role and status of married women influence whether the violence is tolerated. It is important to note that participants’ perspectives in the current study were not framed within the context of gender. Participants often referred to scenarios where the female partner was responsible for committing on-going abuse, including verbal threats or showing disrespect toward her spouse. Because many studies have found that spouses/partners are the primary offenders of elder abuse (Acierno et al. 2010; Pillemer and Finkelhor 1988), future research exploring the connections between intimate partner violence and elder abuse will help identify how mistreatment changes as partners become more vulnerable with age.

The notion that older adults would choose to live in an abusive situation rather than live alone or in an institution is particularly important. Participants described, and seemed to support, situations where elders prefer to endure abuse or neglect in exchange for a perceived improvement in quality of life (e.g., companionship, security, avoiding placement). Social exchange theory posits that individuals seek to maximise rewards and minimise losses or punishments in a relationship (Dowd, 1975). Some EM scholars point to social-exchange theory to explain why overburdened caregivers abuse or exploit dependent elders (see Wilber and McNeily 2001 for review), but the theory is seldom applied to the other side of the dyad—dependent elders—who may tolerate abuse or exploitation (a loss/punishment) for receipt of care or shelter (a perceived benefit/gain). By emphasising the idea of “tacit exchange,” focus group members implied that victims may believe that they have more power and control in an acknowledged abusive relationship than in a “protective setting,” such as a nursing facility.

The fear of nursing home placement was particularly strong among the African Americans, who spontaneously identified nursing facilities as a source of EM. These participants endorsed a preference to undergo abuse by a family member over placement in a potentially more abusive facility. Fear of institutionalisation as a consequence of reporting abuse may in fact be warranted. A study by Lachs and colleagues (2002) found that elder mistreatment referrals to Adult Protective Services were a significant predictor of nursing home placement.

Each group agreed that there is reluctance to report abuse by family members. These beliefs mirror findings from a study of older Mexican immigrants (Sanchez 1999), where most respondents stated that they would discuss the situation with family members rather than report abuse to authorities. The desire to protect abusive family members suggests a strong tendency for underreporting among older victims (Bonnie and Wallace 2003) and helps to explain the reluctance of older adults to confirm incidents reported by others. Some participants stated that elders do not report victimization to authorities because they do not want the abuser sent to jail. Despite this belief among older adults, it is rare that the criminal justice system in the United States effectively prosecutes and incarcerates abusers (Connolly 2010; Payne, Berg and Toussaint 2001). Therefore, the fear of incarceration may reflect a more general mistrust of law enforcement, particularly among minority populations who have experienced a history of negative interactions with state authorities (Hagan, Shedd and Payne 2005; Lurigio, Greenleaf and Flexon 2009).

Paradoxically, the Spanish-speaking Latino group advocated early intervention at the first sign of abuse, perhaps to restore family harmony and respect. These groups did not specify which agencies or individuals would be sought for assistance. Given the tendency of Latinos to rely on kin networks to resolve family conflicts (Montoya 1997; Sanchez 1999), and low levels of reporting among Latino immigrants (DeLiema et al. 2012), informal support by family members may be favoured over involvement by law enforcement or Adult Protective Services, the state agencies that respond to cases of elder abuse reported in the community. To increase formal abuse reporting, Montoya (1997) and Cardona and colleagues (2007) recommend a non-punitive empowerment approach that directly involves the family in generating and implementing solutions to help Latino victims of EM.

Participants in this study were very familiar with EM, and every group shared stories of abuse experienced by friends and relatives, particularly stories of financial exploitation. Additionally, they were well aware that Adult Protective Services is the agency to call to report elder abuse in community settings. This knowledge differed from a study of women’s perspectives on abuse, where participants were familiar with EM but not with Adult Protective Services (Dakin and Pearlmutter 2009). This disparity may be related to geographic variation (Ohio state compared with California state), differences in participation in community services, and differences in elder abuse awareness and education campaigns by location.

Caregivers in the present study were more cautious in their definition of abuse, contending that abuse could not be judged without having a full understanding of the situation and history of the relationship. Caregivers were also the strongest advocates for education and training for the public, specifically for families caring for older adults with cognitive disorders. This perhaps arises from personal experiences and challenges they have encountered in caring for their family members. There was a general consensus that more information about and support for family caregivers would reduce abuse and neglect.

Limitations

This was an exploratory qualitative study conducted within a large metropolitan area in the United States. Knowledge and beliefs about EM may differ by region. Additionally, our study included only one homogenous group of African American caregivers, and a relatively small sample of individuals from other ethnic/racial groups. Further studies should determine the perspectives of caregivers from other cultural backgrounds, and conduct multiple focus groups to determine whether these results emerge in other group discussions. Focus groups included both males and females, except for the all female caregiver group. Gender pressures may have influenced group dynamics or driven some of the discussion of EM, but generally there were no significant differences in EM beliefs expressed between males and females. A central aim of this study was to explore the meaning of age, gender, frequency/duration, and family relationships as they pertain to EM. These characteristics were integrated directly into the case scenarios and thus it is unknown whether these themes would have been spontaneously discussed without the vignette prompts. Finally, participants were recruited through community agencies for older adults, and therefore may be more educated than other older adults about EM policies and Adult Protective Services through their connection with social service professionals.

Future directions for elder abuse intervention

Findings from this study suggest that older adult perspectives on EM vary by individual and do not necessarily reflect current EM policies or practices in the United States or internationally. For example, participants did not support age alone as a risk factor for EM, although they did identify mental and physical disabilities as risk factors associated with increased vulnerability. In California, as in many other states, both older adults and younger adults with disabilities are protected under EM legislation.

Second, participants identified many scenarios in which elder abuse is actually the persistence of intimate partner violence into old age as opposed to a distinct form of violence exclusive to vulnerable elders. And finally, many participants did not support using the criminal justice system to resolve cases of EM involving family members, even though this approach has achieved growing momentum and support among policymakers (Connolly 2010). Participants suggested preventative approaches (training/awareness campaigns) and non-punitive intervention methods (respect for the victim’s autonomy and care preferences) as a way to minimise or resolve EM.

The factors that focus group participants discussed as influencing abuse reporting offer important insights to guide policy and intervention efforts. Concerns that older adults under-report EM (NRC 2003) were supported in this study, specifically in terms of reluctance to report family members and acceptance of abuse to avoid nursing facilities (tacit exchange). Participants across all racial/ethnic groups expressed a hesitancy to call social services when abuse is suspected. Rather than reporting EM immediately, they suggested a need to understand how victims view their situation and how they wish to improve their care in a way that ensures personal safety but does not leave family relationships in turmoil. This approach supports interventions that are empathetic and person-centred as the next step in tackling elder abuse. Interventions that acknowledge the culture, safety needs, and individual care preferences of victims may reduce misconceptions about the consequences of reporting abuse, leading to improved adherence to interventions and better case outcomes. These “person-centred” approaches are primarily used in health and long-term care settings. They embrace collaboration between patients and care providers and emphasise care decisions/interventions that promote the patient’s dignity (Vladeck and Westphal 2012). Person-centred methodologies offer the means to explore a shift in the delivery of adult protection services toward greater victim empowerment.

Although not the specific aim of this study, seniors and caregivers provided several suggestions for preventing and reducing the incidence of EM. These include improved outreach and education, particularly among family members who may be caring for older adults with disabilities, early intervention to prevent escalation, and an understanding of what cultural variations contribute to EM. New perspectives on EM were offered by the Latino participants, many of who were immigrants to the United States. In any country, older-aged immigrants represent a group that may be particularly vulnerable to EM because of their reliance on family members for care, lower average income, and greater isolation from social service agencies (Montoya 1997; Kim et al. 2011). EM professionals should be attentive to the unique cultural beliefs of immigrants and accommodate their individual needs into protection and treatment strategies. Based on the EM perspectives that emerged from this study and the growing diversity of elders worldwide, it is increasingly vital to consider the multicultural and individual perspectives of older adults to guide EM prevention and intervention efforts.