
==== Front
J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-255
10.4103/jehp.jehp_630_23
Original Article
Using the ecological approach to explain risk factors of elder abuse in Iran (A qualitative study)
Andani Maryam Rahmati
Zamani Fereshteh
Rahimi Majid
Mansourian Marjan 1
Mostafavi Firoozeh
Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
1 Department of Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
Address for correspondence: Prof. Firoozeh Mostafavi, Department of Health Education and Promotion, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran. E-mail: mostafavi@hlth.mui.ac.ir
2024
29 7 2024
13 25509 5 2023
06 8 2023
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

World Health Organization suggests that different societies should investigate the causes of abuse in their culture.

AIMS:

This study was conducted to investigate the risk factors of elder abuse in Iran using an ecological approach.

MATERIALS AND METHODS:

This is a qualitative study, and the participants were older adults and caregivers. The data were collected using 66 interviews. Analysis of data was simultaneously performed with data collection, using MAXQDA 10, and results were reported based on Elo’s recommendation.

RESULTS:

Five main categories of data analysis were obtained based on Bronfenbrenner’s model: exo-system: conflict of care with caregivers’ jobs, meso-system: failure to meet expectations of support systems, macro-system: social culture, socioeconomic structure, status of enactment, and implementation of legal and financial laws.

CONCLUSIONS:

This study showed risk factors of elder abuse in the sociocultural context of Iran, and its results can be used for health promotion interventions.

Bronfenbrenner's model
elder abuse
health promotion interventions
qualitative study
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pmcIntroduction

Elder abuse (EA) is a major public health problem.[12] Globally, the population of older adults (OA) in Iran will double from 2015 to 2050, and it is expected that in 2050, 30% of the total population will be OA.[134] Due to this trend and the limited resources available to meet the needs of OA, a large population is at risk of EA.[5] According to studies, EA is not a one-dimensional problem, and multiple factors at different levels contribute to its increased risk. For this reason, researchers suggested that an ecological framework can help to understand abuse and the implementation of community-based interventions.[678]

One of the ecological frameworks that is used to study multifactorial issues is the Bronfenbrenner model (BM), which is a useful conceptual framework for studying EA because it helps to understand related risk factors and how they interact by considering relevant systems.[8910]

BM is an ecological model in which individuals are described based on their multiple surrounding environments.[7] According to this model, systems are microsystem (caregiver and OA relationship), meso-system (relationship between OA, family, and principle setting), exo-system (the environments outside the OA in which other family members participate), and macro-system (ideological values and norms in a certain culture).[81112] Such a model can be used in qualitative studies of directed content analysis[13] to extract risk factors related to EA and classify them at different levels of society.

According to the above explanations, despite the importance of EA, sociocultural risk factors have been less investigated,[14] and in Iran, despite conducting review studies on the prevalence of EA or factors related to it in groups such as elderly women,[1516171819] no study was found on the risk factors of EA at different ecological levels. This qualitative study was conducted with an ecological approach to achieve a deeper understanding of EA risk factors at the exo-, meso-, and macro-system levels.

Materials and Methods

Study design and setting

This qualitative study was conducted using directed content analysis.

Study participants and sampling

The participants of the study included the OA, their official and institutional caregivers, employees of the Ministry of Health (MoH), welfare organization, the Ministry of Justice, and the Forensic Medicine Organization [Tables 1 and 2].

Table 1 Classification of study participants

Category	Participant	Number	Explanation	
1	Care recipient (CR)	39	Care recipient (key informant)	
2	Non-official caregivers (NOC)	8	Family member	
3	Institutional caregivers (IC)	6	Nursing home caregivers	
4	Other participants (OP)	13	Head of a welfare organization, Ministry of Health, Ministry of Justice, The Forensic Medicine Organization	

Table 2 Characteristics of CR

Demographic characteristics	n (39)	
Age	
   60–70 years	29	
   71–80 years	7	
   Over 80 years	3	
Gender	
   Men	10	
   Women	29	
Level of education	
   Under high school diploma	31	
   High school diploma and upper	8	
Marital status	
   Single, widow/widower, divorced	22	
   Married	17	
Housing	
   Living in the nursing home	8	
   Living with family	31	

A purposeful sampling method was employed to determine the research population[20] with the maximum variation. In different regions, the interviewer met informants in their homes (community dwellers), nursing homes, daycare homes, workplaces, and healthcare centers.

Data collection tool and technique

Data were obtained from unstructured open interviews. Only four of the 66 interviews were conducted over the phone. The interviews were recorded for all participants except for five individuals who were unwilling to have their interviews recorded. All interviews were transcribed verbatim and then typed. A total of 66 interviews were conducted and lasted for 20 minutes to an hour. Data collection continued until its saturation point, and MAXQDA10 software was used for analysis.

Ethical consideration

The individuals’ consent for interviews was obtained, as well as a statement of the confidentiality of the information and interviews.

Data analysis

Data analysis was conducted based on the suggested steps of Elo simultaneously with data collection, and the results were categorized based on the levels of the BM.[21] The texts were read several times, and then open codes were given to them; similar codes were classified, and the main categories were made.

Rigor

The criteria of Guba and Lincoln were used to enhance the scientific stability and validity of the data.[20] Various methods, such as long-term engagement (data were collected over 20 months) trust building, and member checks, were used to increase the data credibility. Also, interviews were taken at different times, and places, and with different participants. Confirmability was performed via member checking by participants and peer checking by authors, and then the findings were revised based on their comments. To enhance the verification and data dependency, external checks (the text of the interviews was given separately to two faculty members who were not part of the research team, and the things that were pointed out were applied in the analysis) were used. Participants were precisely described to ensure transferability. Profiles and original data were retained for subsequent evaluation. Moreover, the processes of data collection and analysis were explained step by step to provide the opportunity to repeat the study for others.

Results

The qualitative analysis generated five main categories that describe the risk factors for EA based on the participants’ subjective opinions [Table 3].

Table 3 Risk factors of EA based on Bronfenbrenner’s model

System based on Bronfenbrenner’s model	Main category	Generic category	
Exo-system	Conflict of care with caregivers’ jobs	Lack of law for supporting the employed caregivers	
Lack of support in the workplace for caregivers	
Meso-system	Failure to meet expectations of support systems	Failure to fulfill older adults care in the health system	
Defects in the implementation of older adult’s care program in the health system	
Failure to fulfill the expectations in older adults’ welfare support	
Macro-system	Social culture	Intergenerational differences	
Changing the lifestyle	
Misunderstanding of the aging phenomenon	
Gender differences	
Age discrimination	
Weak social power of the elderly	
Cultural barriers to report of abuse	
Socioeconomic structure of society	Lack of social infrastructure for supporting older adults	
Lack of part-time care centers for older adults	
Lack of financial support for older adults	
Status of enactment and implementation of legal and financial laws	Lack of legal or criminal laws for older adults	
Lack of ongoing financial laws for older adults	

Exo-system

Conflict of care with the caregiver’s job

Working caregivers face difficulties in providing full care for their elderly parents.

When the hourly leave of working caregivers is not agreed upon, they not be with the care recipient on time. One working caregiver said, “Sometimes my old mother isn’t feeling well and I ask for hourly leave; those in charge will not agree, so the mother stays alone.” (NOC)

Caregivers may be under financial pressure due to non-payment of their care allowance. One caregiver said, “I pay for my mother’s nurse, but I don’t receive the allowance; this puts financial pressure on me, and sometimes I don’t hire a nurse and the mother is left alone.” (NOC)

Refusal to transfer the caregiver to a location closer to the care recipient’s residence may result in a deficiency in care. One caregiver explained, “I requested to move my workplace to a location closer to my home to be by my mother’s side more quickly, but those in charge accepted five years later.” (NOC)

Meso-system

Failure to meet expectations of support systems

Owing to the health system’s nature and mission, it is expected that all conditions about the promotion of OA’s health will be met.

An employee of the Ministry of Health (MoH) said about the inadequate facilities for OA’s care in health centers:

“Certain health care facilities have stairs leading to the upper floors but no elevator. As a result, the OA are never eligible for the service, which is abuse.” (O)

The lack of appropriate educational programs for OA and their families in the field of EA is one of the shortcomings of the health system. An employee of the MoH said, “The health system doesn’t provide adequate education for families and OA to help prevent EA.” (O)

An employee of the MoH said about the lack of a prevention program for EA in the health system:

“EA isn’t part of the health system’s programs, and our support services are inadequate.” (O)

Another organization that supports OA is the welfare organization.

Nursing homes may have deficiencies in providing care for the OA. An employee of the welfare organization said, “According to Maslow’s hierarchy of needs, nursing homes meet the most basic needs; however, the remainder of the needs remain unmet.” (IC)

Another employee stated, “As an elderly expert, I am dissatisfied with nursing homes because we frequently have non-standard facilities for OA care.” (O)

Macro-system

Social culture

Some cultural characteristics of society may increase the risk of EA.

One of the reasons for the lack of attention to OA’s care is that families prioritize children over parents. One OA said this:

“Our children are concerned about their children, so they’re uninterested in taking care of us.” (CR)

The older generation is more patient in caring for parents than the younger generation; one OA said, “We care for our old parents because we are the senior generation, but the younger generation lacks the patience to care for old parents.” (CR)

Lifestyle changes may contribute to poor care for OA. Migration of children abroad to study causes the OA to remain alone. A participant said, “Families have sent their children abroad to study, leaving their parents alone.” (O)

The lifestyle change has caused children to be heavily involved in work and spend less time caring for their parents. A participant said, “Ancient culture is fading. The way of life has shifted, and busy children aren’t able to take enough care of their parents.” (O)

Rather than accepting the old age period, the OA endures it and waits for death. One institutional caregiver said this: “The OA isn’t accepting old age as a period of life; they tolerate it, and this results in disease and disability, which leads to EA.” (IC)

The culture of the target community differentiates between the remarriage of old men and women. An employee of the welfare organization said this:

“Remarriage isn’t customary for older women. When women don’t remarry, they become lonely and vulnerable to EA.” (O)

The belief that the OA will die soon and that the cost of services should be borne by younger generations makes society pay less for their care. An employee of the MoH said, “Some believe that because the OA has reached the end of their lives, there is no reason to spend money on care. This makes OA vulnerable to EA.” (O)

The OA’s lack of ability to defend their rights may make them vulnerable to EA. An employee of the MoH said this:

“OA has a weak voice, are oppressed, frugal, accept difficulty, are satisfied with their circumstances, and defend their rights infrequently, which makes them ignored and defenseless against EA.” (O)

OA who are victims of EA does not report it for various reasons. A participant stated one of the reasons:

“They believe reporting the abuse is embarrassing and thus tolerate it” (O).

One of the officials of the MoH said, “Because the majority of OA are religious, they believe that breaking my heart would result in a curse on my child, and thus they ignore and conceal their feelings.” (O)

Another participant expressed another reason for not reporting EA:

“They believe they’re a burden, and they frequently don’t report their abuse.” (O)

Socioeconomic structure of society

Inappropriate social infrastructure causes problems for OA. One caregiver said, “The condition of the street isn’t good; the wheelchair gets stuck and can fall, so I don’t take my mother out of the house, and she gets annoyed.” (NOC)

Due to the lack of part-time care centers for OA, working caregivers face problems providing care. One caregiver explained, “There is no part-time care for OA that I can put my mother in when I am at work so that she isn’t left alone at home.” (NOC)

Paying an insufficient pension to the retired OA creates financial problems for them. One old lady said, “We pay the living expenses with the pension for ten days, and we don’t know how to spend the rest of the month.” (CR)

The lack of insurance support for rehabilitation services makes OA unable to receive full care. One caregiver said, “OA rehabilitation services aren’t covered by insurance. Individuals can’t afford the costs and don’t get enough care.” (IC)

The lack of social support for disabled OA increases the pressure on their caregivers and causes care deficiencies. One participant explained, “Social support for OA isn’t appropriate. In-home long-term care services do not exist for them, which increases the pressure on families.”(O)

Status of enactment and implementation of legal and financial laws

The absence of some preventive laws causes caregivers to commit financial abuse of OA. A judge said, “Although the decisions of a person suffering from dementia aren’t recognized in jurisprudence, the civil law recognizes these decisions, and this causes them to be financially abused.” (O)

There is no special law to protect victims of EA, a lawyer said in this regard:

“If an OA reports abuse, the general rules apply, as there is no specific law prohibiting EA.” (O)

Discussion

This study aimed to investigate the risk factors of EA with an ecological approach and was unique in that it paid attention to the sociocultural background of the target community.

Exo-system

Conflict of care with the caregiver’s job

Non-payment of care allowances to caregivers, employment of caregivers far from the residence of OA, and the employer’s lack of cooperation in granting hourly leave are factors that cause caregivers to be unable to provide complete care for OA. Other studies have suggested that a lack of legal and financial support and poor working conditions for caregivers may increase the risk of EA.[82223] Exo-systemic risk factors may be a source of stress for caregivers, and studies have stated caregiver stress is a risk factor for EA.[142425]

Meso-system

Failure to meet expectations of support systems

The MoH and the welfare organization in Iran have programs aimed at improving the health of OA, but they may have shortcomings. Some health centers do not have suitable conditions for the presence of OA, and it may cause defects in their care. The health system does not have a program to prevent EA and OA, and family members’ educational needs are not met in this system. Other studies have cited a lack of awareness among health service providers, a lack of healthcare standards, and policy based on the perspective of authorities rather than audiences as factors influencing EA in care systems.[1314] However, Rajanala et al. discussed the conflicts of caregivers with health systems in their study and stated that these conflicts, the most common of which were related to communication and access to healthcare providers, cause stress and burden for caregivers, which have been raised as risk factors for EA.[2627]

Another organization related to the OA in Iran is the welfare organization, which supervises nursing homes. Poor service quality, a focus on physical needs, and neglect of emotional needs may increase the likelihood of EA.

Although previous articles reported low knowledge of official caregivers and a lack of standard screening tools as risk factors for EA in meso-systems,[823] the findings of this study are unique to the target community.

Macro-system

Social culture

In this study, sociocultural risk factors, based on BM, were classified at the macro-system level.[8] The younger generations prioritize their own children’s needs over their parents and may neglect them, whereas previous generations valued parents above all else. Younger generations lack the patience necessary to manage caregiving, most likely due to a lack of experience coping with adversity. These factors cause EA, which is consistent with other studies showing that respectful relationships between parents and children are deteriorating and that young people increasingly abuse OA.[127]

An Iranian family welcomes OA and takes care of them but cannot fulfill their obligations due to social conditions.[28] Emigration of children and children’s busy schedules are lifestyle changes that lead to neglecting the care of OA and EA. Child migration and OA loneliness as cultural factors contributing to abuse in societies were children traditionally care for OA.[1] Some studies considered converting a traditional family to an industrial one and changes in living conditions as cultural factors contributing to EA.[827]

When the OA reach this stage of life, frequently unprepared to deal with this phenomenon, they accept aging and believe they must wait for death, resulting in their dependence on caregivers and EA. Although studies show OA dependency on caregivers as a risk factor for EA,[2930] the finding of our study about the cultural factor creating dependency in OA is unique.

Women are not permitted to remarry for cultural reasons, and this isolation causes them to become dependent on caregivers, making them vulnerable to EA. This is consistent with studies that identified gender differences as a risk factor for EA in older women.[823]

Age discrimination against OA is one of the most prevalent forms of discrimination in contemporary societies,[31] and EA is one of the negative consequences of ageism.[32] Given the OA’s increased likelihood of dying, some elderly related expenses may be avoided, which causes EA. This is consistent with other studies showing that the belief in the OA’s worthlessness is weak and dependent on cultural factors contributing to EA.[1814]

OA are typically appreciative of their circumstances, and due to their society’s dominant culture, which encourages OA to accept their current conditions, they cannot realize their social rights. Hence, society provides less social support and creates an environment conducive to EA. Although this is a unique finding in our study, other studies suggest that the lack of social support is a risk factor for EA.[14]

OA may refuse to report EA due to sociocultural and religious constraints. They are ashamed of the EA report. Also, OA feels that when they are being abused by their children, God will be angry with them; therefore, they do not want their children to be damned and consequently keep negative feelings to themselves and forgive their children. Believing that they are a burden on caregivers makes OA feel entitled to abuse, and as a result, abuse goes unreported. Non-reporting of EA is a cultural risk factor, and based on some studies, it was not reported to preserve family cohesion.[2327] The victims’ unwillingness to seek help has been a serious impediment to effective prevention efforts.[3132] Some reasons for not reporting EA are unique to the target community.

Socioeconomic structure of society

While caregivers may be accused of disregarding the OA’s desires, such as having fun outside the home, they prefer to keep the OA at home due to conditions in society, such as difficulty with wheelchairs in public places.

The lack of part-time care centers has caused problems for working caregivers; they are forced to leave the OA alone, which results in EA. OA requiring rehabilitation services do not receive subsidies for their long-term care, which entails high financial costs. Although the financial problems of OA and caregivers have been raised in studies as a risk factor for EA[2529] our findings in terms of addressing the background factors of EA are unique.

Status of enactment and implementation of legal and financial laws

Protection for OA frequently exists in the form of general rules and regulations shared with other victims. Moreover, lawyers and judges conduct reviews of EA cases per applicable laws.[33] Although there are cases in jurisprudence to prevent abuse of the property of OA with Alzheimer’s disease, civil law has allowed some perpetrators to seize the property of OA without their consent, which leads to an increase in the amount of financial abuse. Wang categorized the non-implementation of the EA reporting law as a macro-system level risk factor.[27] The study of legal laws related to EA is unique in this study.

Conclusions

This study identified risk factors for EA at various levels based on the sociocultural context of the target population. Some factors were contextualized within the Iranian sociocultural context; this may not be the case in other communities. Considering the results of the study, it is suggested that planning for long-term culture-building should be based on the rich cultural heritage of Islamic and Iranian culture. It is advised that more studies be designed to investigate elements of Islamic Iranian culture that prevent EA. Finally, health policymakers are advised to design and implement EA health promotion interventions at the national level with an ecological approach.

Financial support and sponsorship

This study was funded by Vice-Chancellery for Research and Technology, Isfahan University of Medical Sciences, project number 396617.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The researchers are grateful to everyone who cooperated in the study, especially Doctor David Burnes, whose constructive comments and suggestions helped to improve the quality of the manuscript.

The present study was based on a PhD thesis in the field of health education and promotion with a code of ethics (IR.MUI.REC.1396.3.617) approved by Research Ethics Committee, Vice-Chancellery for Research and Technology, Isfahan University of Medical Sciences, Isfahan, Iran.
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