ORIGINAL ARTICLE
BEHAVIORAL AND SOCIAL SCIENCES
Prevalence of violence against older adults and associated
factors in Çanakkale, Turkey: A cross-sectional study
Melike Yalçın Gürsoy
1and Fatih Kara
21
School of Health, Public Health
Nursing, Çanakkale Onsekiz Mart
University (COMU), Çanakkale,
Turkey
2
Faculty of Medicine Department
of Internal Medicine Program of
Public Health, Selcuk University,
Konya, Turkey
Correspondence
Dr Melike Yalç
ın Gürsoy, School
of Health, Public Health Nursing,
Çanakkale Onsekiz Mart University
(COMU), Çanakkale, Turkey.
Email: myalcin@comu.edu.tr
Received: 28 March 2019
Revised: 28 October 2019
Accepted: 2 November 2019
Aim: This study was designed to determine the prevalence of domestic violence against older adults and the associated risk factors in Çanakkale, Turkey.
Methods: A cross-sectional, population-based study was carried out, including 1230 indi-viduals aged≥65 years living in the city of Çanakkale, Turkey. The population of the study consisted of 73 367 individuals aged ≥65 years, living in Çanakkale. Sample selection was made with the one-step cluster sampling method. The data were collected by face-to-face interview. The study was approved by the local ethics committee, and written consent was taken from the participants.
Results: Of the participants, 4.1% had experienced physical violence, 2.5% were subjected to sexual abuse, 23.5% had undergone psychological violence and 12.2% had a history of economic violence. The exposure to any of the given violence types was 28.5%. Risk factors related to violence were being married, having children, educated partner, lack of economic independence, poor self-perceived health, administration of medications by others, feeling lonely, dissatisfaction with life, poor perception of family relations and not participating in family decisions.
Conclusions: These results show that violence against older adults is a significant problem in a city in western Turkey. Therefore, an in-depth evaluation of the determined risk factors related to violence and actions for its prevention are warranted. Geriatr Gerontol Int 2020; 20: 66–71.
Keywords: elderly, prevalence, risk factors, violence.
Introduction
Worldwide, populations are rapidly aging.1This increase has ush-ered in many psychological, social and economic problems for older people, which need to be addressed.2One of these problems
is the violence to which older people are subjected regardless of social, economic, ethnic and geographic distinctions.3
Elder abuse is a human rights violation, and thus, is addressed in national and international conventions. A major example is the Toronto Declaration on the Global Prevention of Elder Abuse, dated 17 November 2002. In this declaration, elder abuse is defined 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”.4
Vio-lence can be in the form of physical, psychological/emotional, sex-ual orfinancial maltreatment, as well as neglect or desertion.3
The World Health Organization (WHO) reported that one out of every six older persons has been subjected to one of the afore-mentioned types of violence in community settings during the past year.3 In a meta-analysis by Yon et al., that involved 52 studies
from 28 countries, the rate of older adults who were reportedly exposed to violence was 15.7%, whereas the meta-analysis by Ho et al., which covered 34 studies, found it to be 10.0%.5,6Several
studies carried out in Turkey produced a prevalence rate varying between 13.3% and 68.8%.7–11
Although violence against older adults is seen as a social prob-lem, its identification is challenging. A WHO report, stated that just
4.0% of the total cases of violence were reported.12 The basic
approach in identifying elder abuse is the determination of high-risk factors. A better understanding of high-risk factors might contribute to the development of effective screening methods tofind those who need help, as well as to the formulation of measures and inter-ventions required to address the issue.13Among the factors
associ-ated with violence against older adults are age≥75 years,8,10,14–16
female sex,6,8,11,15,17low education,8,10,15,18,19low income,10,13,15,17 marital status,11 poor physical health,11,15,17 cognitive
impairment,13,20functional dependency,13,19low level of social
sup-port9,21and poor relationships with the family.8,10,13,17
The Turkish population is steadily aging,22 leading to an increased expectation of violence against older adults.3The essen-tial step in preventive public health approach is to understand the magnitude of the condition.5Little is known about the prevalence
of violence against older adults and associated risk factors in Çanakkale. It is believed that the identification of the extent and risk factors of violence against older adults will substantially con-tribute to the planning of efforts in combating this public health hurdle. The purpose of the present study was to identify the fre-quency of violence against older adults and the associated risk fac-tors in the Çanakkale province of Turkey.
Methods
This cross-sectional study was carried out in Çanakkale, Turkey. Çanakkale is a city located in northwest Anatolia on the narrowest
shore of the Bosporus. The population studied consisted of 73 367 individuals aged≥65 years, living in all settlements in the province. Sample size calculation was carried out using the follow-ing formula: n = (t× t × P × q) / (d × d) × DEFF (n is sample size, t is Student’s t table value, P is probability of having the condition, q is 1– P, d is margin of error, DEFF is design effect). The design effect, confidence level and margin of error were taken as 2, 95.0% and 0.03, respectively. The expected probability of hav-ing the condition was taken as 13.3% based on the results of the study carried out by Kıssal and Bes¸er.8 We calculated that the
study should reach out to at least 986 people.
The sample selection was based on a single-stage cluster sam-pling, and the block selection was carried out by using probability proportional to size by TurkStat (Turkish Statistical Institute, www.turkstat.gov.tr). The number of addresses in the block was taken as the measure of size. As the≥65 years age average house-hold size was smaller than one for the province, no househouse-hold selection was made. Therefore, 25-unit blocks were created, and the block selection was carried out in a single stage. At the sample selection stage, 116 sets were selected to obtain 2900 households (2900/25 = 116). From the selected households, a total of 1230 people aged≥65 years were successfully interviewed (Fig. 1).
The data of the study were collected with the help of the study authors and interviewers (part-time, salaried university students; n = 8) between March 2017 and July 2017. The interviewers were trained before the data collection; two seminars were carried out with the attendance of all team members. The seminars included content on the study questions, the types of violence against older adults, and the possible clues and signs of violence against older adults. The study was approved by the ethics board of the Faculty of Medicine of Selçuk University in Konya and Çanakkale Gover-nor’s Office for the study (decision dated 28 January 2016 and numbered 3/51). All participants were briefed about the study, and their written consent was obtained.
Within the framework of the clusters determined by TurkStat, households were reached. The study questionnaire was applied to all household members aged≥65 years. If the household had no available respondents, the interviewer passed to the next closest address. All questions in the data collection form were read to the older adults one by one and marked by the researcher. Each ques-tionnaire took approximately 15–20 min to complete.
The data collection tool included questions on sociodemographic characteristics and violence. In determining the exposure of older adults to violence, a checklist covering four sub-dimensions of violence against older adults (physical, sexual, psy-chological and economic), developed by Tanrıverdi and S¸ıpkın, was used.23Any participant who responded positively to one of the subdimensions was categorized as having exposure.
The dependent variables of the study were the presence of physical, psychological, sexual or economic violence. The inde-pendent variables were: age, place of residence, sex, marital status, educational level, partner’s education level, having children, eco-nomic independence, occupational status, perceived income ver-sus expenses, owner of the house, living with who, perceived family relations, participation in family decision, feeling lonely, life satisfaction, self-perceived health, medication use, administration of medications and meet physical needs.
The data obtained were analyzed bySPSSfor Windows version
19 (SPSS, Chicago, IL, USA). Descriptive statistical methods (number, percentage) were used for data evaluation. The χ2-test
was carried out to compare exposure to physical, psychological, sexual, economic or overall violence and risk factors. For multi-variate analysis, the potential risk factors of violence against older
adults identified in univariate analyses were examined using the backward logistic regression analysis. A P-value <0.05 was consid-ered statistically significant.
Results
Data for 1230 participants were analyzed. The mean age of the older adults and their spouses were 70.78 5.66 and 68.78 6.16 years, respectively. Their mean monthly income was TL1843.16 1045.07, and they were living in Çanakkale for 50.30 24.12 years. The other selected individual and family characteristics of the participants are provided in Table 1.
According to the survey, 54.4% of the older adults perceived their health status as“good,” and 73.7% had no disease, whereas 37.9% were hypertensive. Furthermore, 73.8% had at least one medication that they continuously used, 90.7% took their medica-tion regularly and 82.3% kept track of their own medicamedica-tion. In addition, 93.3% were able to meet their physical needs without help.
Of the participants, 28.5% were exposed to at least one type of violence, 4.1% experienced physical violence, 2.5% had under-gone sexual violence, 23.5% received psychological violence and 12.2% had economic violence. In addition, it was found that
Figure 1 Participantflow chart. Considering the non-responses and unavailability, the total number of households sampled were calculated as 2900. From the selected
households, older people who failed to comprehend the questionnaire questions or had difficulties in speaking or understanding Turkish (n = 5), and older people who refused to participate in the study (n = 8) were not included in the study. Finally, the survey was carried out with 1230 older adults.
43.3% of those who applied physical violence during the past year were their spouses. Furthermore, 34.2% of the older adults were subjected to violence once a year. In case of exposure to violence, 10.3% of the victims reported to the emergency healthcare ser-vices, 5.4% received support from an institution and 7.7% were issued reports certifying their health status.
Some variables affecting the prevalence of violence against older adults are presented in Table 2. For multivariate analysis, the potential risk factors identified in previous analyses (P < 0.05) were examined by using the backward logistic regression analysis. Based on the logistic regression analysis, those who had children (odds ratio [OR] 2.01) and felt lonely (OR 1.34) were more likely to experience any types of violence, and those who had economic independence (OR 0.50), were satisfied with life (OR 0.68), who had a perception of family relationships being medium/good (OR 0.47) and participating in family decisions (OR 0.72) were less likely to experience violence. Those who had medications admin-istered by others (OR 3.35) and felt lonely (OR 1.86) were more likely to experience physical violence, and those who were satisfied with life (OR 0.37) and has a medium/good perception of family relationships (OR 0.28) were less likely to experience violence. Those with an educated partner (OR 2.33) were more likely to experience sexual violence, and those with a perception of medium/good family relationships (OR 0.27) were less likely to experience violence. Those who felt lonely (OR 2.06) were more likely to experience psychological violence, and those who were single (OR 0.34), had economic independence (OR 0.52), were satisfied with life (OR 0.64) and had medium/good perception of family relationships (OR 0.39) were less likely to experience violence.
Discussion
The present study showed that 28.5% of older adults were exposed to at least one type of violence recently. The prevalence of violence against older adults was reported to be 9.9% in Korea,174.5% in Malaysia,215.7% in Brazil,1610.0% in India18
and 40.1% in Poland.24In various studies carried out in Turkey,
the rate of exposure to any type of violence ranged between 13.3% and 70.9%.7–11,15The rate of exposure to any type of vio-lence found in the present study was consistent with the studies mentioned above, but it was higher compared with the studies from other countries. This difference might be the result of the different measurement tools used, or the way violence is perceived and expressed differently in diverse cultures.
In the present study, 4.1% of the participants were exposed to physical violence. Globally, the lowest prevalence rate of physical violence against older adults was reported in Canada (0.5%) and the USA (1.4%), followed by Europe (1.67%).14As to studies
car-ried out in Turkey, the prevalence of physical violence vacar-ried between 1.5% and 10.2%.7–11Also, we observed that older people Table 1 Selected individual and family characteristics of older
adults Variables n % Place of residence Urban 756 61.4 Rural 474 38.6 Sex Female 650 52.8 Male 580 47.2 Marital status Married 840 68.3 Single/divorced/widow 390 31.7 Educational level (n = 1215) Uneducated 381 31.3 Primary school 540 44.4 Secondary and higher 294 24.3 Partner’s education level (n = 971)
Uneducated 227 23.4 Primary school 495 51.0 Secondary and higher 249 25.6 Having children Yes 1139 92.6 No 91 7.4 Economic independence Yes 1086 88.3 No 144 11.7 Occupational status Working 84 6.8 Not working 1146 93.2 Perceived income vs expenses (n = 1166)
Balanced 825 70.8
Negative 192 16.5
Positive 149 12.7
Owner of the house
Self 684 55.6 Children 95 7.7 Spouse 266 21.6 Rental 160 13.0 Other 25 2.1 Living with
Spouse and/or children 946 76.9
Caregiver 17 1.4 Alone 229 18.6 Other 38 3.1 Self-perceived health (n = 1225) Poor 100 8.2 Medium 412 33.6 Good 713 58.2 Administration of medications (n = 960) Self 791 82.3 Spouse/children/caregiver 169 17.7 Feel lonely (n = 1224) Never 559 45.7 Occasionally 450 36.8 Frequently 215 17.5 Life satisfaction (n = 1227) Highly satisfied/satisfied 1068 87.0 Unsatisfied/highly unsatisfied 159 13.0 Perceived family relations (n = 1209)
Poor 38 3.1 Medium 259 21.4 (Continues) Table 1 Continued Variables n % Good 912 75.5
Participation in family decisions (n = 1218)
Yes 954 78.3
Partially 232 19.1
No 32 2.6
were exposed to physical violence by their spouses. There are sim-ilar reports that the perpetrators of abuse are mostly family mem-bers and relatives.10,15,16,25A possible reason behind this might be that care is generally provided by one of the family members, who could be distressed due to the burden of care.
Although reporting of domestic violence is considered as a crucial step in combating physical violence, just 5.4% of the older adult victims received support from an institution. A WHO report from 2016 showed that just 4% of the violence cases were reported.20In the traditional family structure of Turkey, the family
is held in high esteem, and the dominating understanding is that anything that happens within the family should remain in the fam-ily. Therefore, it might be difficult for older adults to disclose abuse. Older adults who file official complaints with judicial authorities are usually sent to nursing homes. Therefore, older adults who want to stay in their own homes might opt for con-cealing violence.
The type of violence to which older people were least exposed during the past year was sexual violence (2.5%). However, in the present study, the frequency of sexual violence was considered still
high, but the fact that it was lowest among other types of abuse is consistent with some studies in the literature.5,7–10,15,21,24,26In the studies carried out in Turkey, the prevalence of sexual violence ranged between 0.4% and 3.2%.7–9However, we believe that the low prevalence of sexual violence might be due to the cultural teaching that private life should not be shared with strangers.
A substantial proportion of the present participants were sub-jected to psychological violence (23.5%). It was identified as the most frequent type of violence based on the results of the studies in the literature.5,7–11,15,17,20,21In the studies carried out in Tur-key, psychological violence had a prevalence ranging between 8.1% and 66.1%.7–11The results of the present study show simi-larity with domestic and international literature. Psychological vio-lence includes some negative behaviors targeting older people. Accordingly, it can be expected to have a higher prevalence than other types of violence.
Regarding the prevalence, psychological violence was followed by economic violence (12.2%). This type of violence was reported as 11.9% in Macedonia15and 36.5% in Poland.24In the studies
carried out in Turkey, the prevalence of economic violence varied Table 2 Logistic regression analysis related to the risk factors for violence against older adults
Variables† Any type of violence (n = 1194) Physical violence (n = 877) Sexual violence (n = 956) Psychological violence (n = 1202) Economic violence (n = 1191) OR P OR P OR P OR P OR P Marital status Married‡ Single/divorced/widow 0.34 <0.001 0.40 <0.001 Having children No‡ Yes 2.01 0.021 2.93 0.049
Partner’s education level Uneducated‡ Educated 2.33 0.017 Economic independency No‡ Yes 0.50 0.001 0.52 0.003 0.41 <0.001 Self-perceived health Poor‡ Medium/good 0.70 0.021 Administration of medications Self‡ Spouse/children/caregiver 3.35 0.002 Feel lonely Never‡ Occasionally/frequently 1.34 0.004 1.86 0.052 2.06 <0.001 1.43 0.026 Life satisfaction Not satisfied‡ Satisfied/highly satisfied 0.68 0.024 0.37 0.019 0.64 <0.001 Perceived family relations
Poor‡
Medium/good 0.47 <0.001 0.28 <0.001 0.27 <0.001 0.39 <0.001 0.67 0.037 Participation in family decisions
No‡
Yes/partially 0.72 0.023 0.45 <0.001
Constant −1.637 0.037 −7.701 <0.001 −8.854 <0.001 2.720 <0.001 2.214 0.025 Hosmer–Lemeshow Test 0.093 0.383 0.570 0.529 0.186
Nagelkerke R-squared 0.163 0.321 0.096 0.217 0.168
†All variables significant in the univariate analyses for each dependent variable were included in the model using the backward conditional method. ‡Reference category. OR, odds ratio. Note: p-value <0.05 was considered statistically significant.
between 2.1% and 21.5%.7–11The results of the present study are consistent with other studies carried out in Turkey, but the preva-lence of economic viopreva-lence was higher than reported by studies carried out in other countries. A possible reason for this might be that in the traditional family structure in Turkey, older people continue to share the same house with family members, and, therefore, arefinancially dependent on them.
Understanding the risk factors affecting violence against older adults is crucial to define individuals who are at risk.13No
associa-tion was found between the place of residence, age, sex and expo-sure to any type of violence. There are different discussions about the association between the sex of the victims and exposure to vio-lence. In some studies, it was argued that compared with men, women were exposed to a higher risk of violence due to socioeco-nomic and health-related disadvantages,6,8,11,15,17,18,25 whereas some claimed that the majority of victims comprised men.21These risk factors need to be studied more extensively to clarify disagreements.
In the present study, we observed that single people suffered less psychological and economic violence than married people. In the literature, studies implied less psychological violence against unmarried older people, which is similar to the present find-ings.11,21,26However, we believe that what poses a risk for older adults regarding violence is not their marital status, but their living arrangements. According to the results of the present study, older people who lived with their children were exposed to violence sig-nificantly more than those who did not.
The income level of older adults is considered a major social determinant of violence.13In the present study, older adults who
were financially independent were exposed to less psychological and economic violence. In the same vein, the results of other stud-ies show that lack of economic independence is linked to violence against older adults.15,17,21
WHO, pointed out that poor family relations could be a risk factor for violence against older adults.3In the present study, we found that the older people who described their family relations as “medium/good” were subjected to violence less than those who described them as poor. However, in some studies, thefindings suggested that poor family relations were linked to violence against older adults.8,10,13 Thus, as worsening family relations might pave the way for conflict, increased exposure to violence is expected.
Weak support from family or friends might result in social isolation of older people. We found that older adults who felt alone were subjected to all types of violence, except sexual vio-lence, 1.5–2-fold more compared with those who did not feel lonely. Similarly, Sooryanarayana et al. reported that those who faced the risk of social isolation had twice as much possibility of abuse.21
According to the results of the present study, poor self-perceived health status and the inability to meet one’s own physi-cal needs were associated with violence. In the literature, poor health11,13,15,17and physical inability9,17,19,20 were linked to
vio-lence against older adults, which is consistent with the present findings. These results suggest that poor health and physical inability would make older people more dependent on their care-givers, increasing the risk of exposure to violence.
This is the first community-based study in Çanakkale on violence against older adults. In addition, the large sample size, the inclusion of rural areas and the data collection method used are the strengths of this study. However, there were also some limitations to the study. First, data reporting was based on self-reporting. During the survey application, the older person might have been reluctant to express his/her experiences about
violence due to fear, shame or other reasons. Also, it is not pos-sible to establish causal relationships due to the cross-sectional design of the study. Finally, we adopted the perspective of Dieck in defining violence against older adults.27
However, we did not include neglect as one type of violence.
In Çanakkale province, one out of every four older people was exposed to at least one type of domestic violence during the past year. The most frequent types of violence in decreasing order were psychological, economic, physical and sexual violence. Being mar-ried, educational level of spouses, having children, lack of eco-nomic independence, perceived poor health, failure to keep track of prescriptions, not being content with life, lack of participation in the family’s decisions, perceived family relations and feeling lonely were risk factors for violence.
The present study showed that there was violence against older adults in Çanakkale province, calling for increased precau-tions to protect older adults. In line with the results of the study, we recommend that the economic condition of older adults should be improved to make themfinancially independent, the status of older adults in society should be promoted, social living networks should be developed to ensure that older adults can spend their time actively, support services that would alleviate the burden of caregivers of older adults should be scaled up, fieldwork should be carried out for the protection of older adults in the risk groups from violence, and training should be orga-nized for older adults, their caregivers, healthcare staff and the public.
Disclosure statement
The authors declare no conflict of interest.
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How to cite this article: Gürsoy MY, Kara F. Prevalence of violence against older adults and associated factors in Çanakkale, Turkey: A cross-sectional study. Geriatr. Gerontol. Int. 2020;20:66–71. https://doi.org/10.1111/ggi. 13819
