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Elder Abuse and Neglect in a Population

Offering Care by a Primary Health Care
Center in Izmir, Turkey
a a
Aygul Kissal PhD & Ayşe Beşer
a
Dokuz Eylül University of Public Health Nursing Department ,
Dokuz Eylül University of Nursing School , Balçova-Inciraltı, Izmir,
Turkey
Published online: 23 Feb 2011.

To cite this article: Aygul Kissal PhD & Ayşe Beşer (2011) Elder Abuse and Neglect in a Population
Offering Care by a Primary Health Care Center in Izmir, Turkey, Social Work in Health Care, 50:2,
158-175

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 Social Work in Health Care, 50:158–175, 2011
Copyright © Taylor & Francis Group, LLC
ISSN: 0098-1389 print/1541-034X online
DOI: 10.1080/00981389.2010.527570

Elder Abuse and Neglect in a Population

Offering Care by a Primary Health Care
Center in Izmir, Turkey

AYGUL KISSAL, PhD and AYŞE BEŞER

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Dokuz Eylül University of Public Health Nursing Department, Dokuz Eylül

University of Nursing School, Balçova-Inciraltı, Izmir, Turkey

The objective of this study is to investigate the prevalence of abuse

and neglect of the elderly aged 65 years and older, living with
their relative in a primary health care center area and affecting
factors. A descriptive study included 331 people aged 65 years.
The most frequent type of abuse was psychological abuse and the
least frequent was sexual abuse. Female gender, low education lev-
els, living with spouses and children, and perception of familial
relationships as average or below average significantly increased
abuse. The nurses providing primary health care should be able
to identify and observe the elderly at risk of abuse and conduct
programs preventing abuse.

KEYWORDS elderly, domestic violence, public health nursing,

Turkey

Violence is an important problem over the world (Krug, Dahlberg, Mercy,

Zwi, & Lozano, 2002). The most frequent type of violence is elder abuse,
which is associated with spouse abuse and familial violence (Artan, 1996;
Walsh et al., 2007; Lowenstein, 2009). In the declaration made by the
World Health Organization (WHO) and the International Network for the
Prevention of Elder Abuse, 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” (Krug et al., 2002; O’Connor, & Rowe, 2005; Neno & Neno, 2005).

Received March 23, 2010; accepted August 12, 2010.

Address correspondence to Aygul Kissal, PhD, Dokuz Eylül University of Nursing School,
Balçova-Inciraltı, Izmir, Turkey. E-mail: aygul.kissal@deu.edu.tr

158
 Elder Abuse and Neglect in Turkey 159

Elder neglect is a failure by a caregiver, family member, staff of social

organizations to satisfy the elder’s daily needs (Keskinoğlu, Giray, Pıçakçıefe,
Bilgiç, & Uçku, 2004; Lecovich, 2005). It is also defined as lack of care or
insufficient care for the elderly with physical weakness, mental disease, or
mental incapacity (Pavlik, Hyman, Festa, & Dyer, 2001).
It has been shown that abuse and neglect may occur in all societies, in
all ethnic and religious groups, and at all economic levels (Krug et al., 2002;
Lecovich, 2005). The studies on the prevalence of elder abuse have revealed
that 2–10% of the elderly suffer from abuse. A study in Australia revealed
physical abuse in 30% of the elderly, psychological abuse in 55%, finan-
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cial abuse in 81%, sexual abuse in 4%, and elder neglect in 25% (Boldy,
Webb, Horner, Davey, & Kingsley, 2002). Comijs, Pot, Smit, Bouter, and
Jonker (1998) from Holland in their study on 1,797 elderly people found
elder abuse in 5.6% of the elderly, physical abuse in 1.2%, financial abuse in
1.4%, and elder neglect in 0.2%. In a study in Korea, the prevalence of elder
abuse was 6.3%, the prevalence of physical abuse was 1.9%, the preva-
lence of financial abuse was 4.1%, the prevalence of psychological abuse
was 4.2%, and the prevalence of elder neglect was 2.4% (Oh, Kim, Martins,
& Kim, 2006). In a systematic review of the general population studies on
the prevalence of elder abuse and neglect, 6% of older people reported
significant abuse in the last month, and 5.6% of couples reported physi-
cal violence in their relationship in the last year. The prevalence of abuse
reported by general population studies showed a great variation (3.2–27.5%),
which was attributed to variation in abuse rates across cultures as well
as the differences in defining and measuring abuse (Cooper, Selwood, &
Livingston, 2008).
Risk factors for elder abuse and neglect can be associated with the older
adults who experience abuse, individuals who are accused of perpetrating
abuse, and environmental conditions.
Risk factors associated with the older adults who experience abuse are
age, gender, emotional status, and financial dependency (Lachs, William,
O’Brien, Hurst, & Horwitz, 1997; Buchwald et al., 2000). Some studies
showed that the people living alone were more frequently exposed to abuse
(Cupitt, 1997), while this was not the case in other studies (Lachs et al.,
1997). Many studies have revealed that the elderly are frequently abused
by their spouses, adult children, and relatives (Boldy, Horner, Crouchley,
Davey, & Boylen, 2005; Oh et al., 2006). Boldy and colleagues (2005)
found that 22% and 21% of the elderly were abused by their daughters
and sons, respectively. Oh et al. (2006) also reported that more than 75–80%
of the elderly were abused by their sons and daughters in law and added
that the married elderly who had low education levels and low financial
status, who were functionally dependent and who lived with their mar-
ried children were more frequently abused. Anme (2004) noted that the
elderly were more frequently abused by their daughters in law and that
 160 A. Kissal and A. Beşer

the elderly at advanced ages and with incontinence were more frequently
abused.
Risk factors associated with individuals who are accused of perpetrat-
ing abuse are physical and functional limitations, insufficient knowledge
and skills, alcohol addiction, substance abuse, and financial dependency of
the people responsible for elderly people (Goodrich, 1997; Levine, 2003;
O’Connor & Rowe, 2005). As a matter of fact, the transition into a caregiv-
ing situation can be highly stressful when the conditions requiring care are
chronic and progressive as in the majority of later-life illnesses. An increasing
stress on family members caring for older adults may result in rising levels
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of abuse and neglect (Lowenstein, 2009).

Risk factors associated with environmental conditions such as the place
and use of the home and unhealthy conditions (heat, water, pest infestation,
ramps, etc.) are reported to play in elder abuse and neglect (Goodrich,
1997).
At present it is acknowledged globally that elder abuse exists and
has taken priority over many other research topics (Erlingsson, 2007).
Throughout the world, while there have been studies on the prevalence
of elder abuse, few studies have concentrated on key conceptual issues
for policy, practice, and the understanding of different forms of abuse and
neglect. Insufficient theoretical development hinders obtaining systematic
cumulative knowledge, based on universally agreed and standardized tools,
and decreases the ability to find out common themes and their relation-
ship to local idiosyncrasies present in the field. In addition, no attempt
has been made to develop theoretical knowledge grounded in data from
the studies on elder abuse itself (Lowenstein, 2009). Research on elder
abuse is characterized with lack of diversity, slow increase of qualitative
research, limited involvement of older persons and family members as par-
ticipants, and minimal contributions from developing countries (Erlingsson,
2007).
Every country has laws to protect elders from abuse, neglect, and
exploitation and social workers, physicians, nurses, and police officers are
mandated in protection laws to report elder abuse and neglect (Bergeron,
2006). However, many of them do not report their suspicions of elder abuse
for several reasons. First, they may not be aware that they have to do it or
they may be worried about losing client/patient rapport if they are known to
file the report. Second, they may not be able to screen for abuse or recognize
abuse. Third, they may perceive elder abuse as a usual outcome of ageism
and tolerate it. Last, they may believe that the elder has the right to live
however he or she chooses irrespective of the severity of abuse (Bergeron,
2006).
There is not a standard procedure to follow for notifications of elder
abuse in the health care system of Turkey. Therefore, some cases of elder
abuse are missed. There have been few studies on a detailed picture of elder
 Elder Abuse and Neglect in Turkey 161

abuse. A study on the elderly living in nursing homes revealed that 25.7%
of the elderly presenting to the nursing homes was exposed to physical
abuse mainly by their daughters-in-law (41.37%) (Artan, 1996). Keskinoğlu
and colleagues (2004) reported that 1.5% and 2.5% of the elderly suffered
from physical abuse and financial abuse respectively. In another study by
Keskinoğlu and colleagues (2007), the prevalence of physical abuse, finan-
cial abuse and neglect was 1.5%, 2.5%, and 27.4%, respectively, in an
area where people with low socioeconomic status lived and 2%, 0.3%,
and 11.2%, respectively, in an area where the people with high socioe-
conomic status lived. Since social security and support systems are not
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sufficient and since extended families are replaced by nuclear families in

developing countries including Turkey, the elderly are deprived of famil-
ial support. In addition, economic conditions get worse and unemployment
rates increase. It is claimed that all aforementioned factors may increase
elder abuse (Keskinoğlu et al., 2004; Tıktık, 2007).
Turkey has the youngest population of Europe. However, with recent
increases in the elder population, problems of the elderly have appeared.
In Turkey, nurses work as primary health caregivers in public health care
centers, which are located nationwide and provide home care visits. They
are in good positions to keep an eye on elder abuse, and as advocates of
the elderly can affect a great deal in detecting and reporting elder abuse,
but we are concerned that the area of elder abuse does not currently form a
mandatory part of the training for nurses. Additionally, this is from the low
level of social awareness in part and from dearth of research in part. There
cannot be found any study on nursing that focuses on the elder abuse and
neglect. Given the scale of the problem, and the fact that care of older people
will increasingly feature in nurses’ work given the aging of the population,
we think that the research on elder abuse is the utmost important task. A
description of this issue will provide guidance for preventive measures to be
taken. Therefore, we aimed to investigate the prevalence of elder abuse and
affecting factors in an elder population living with their families in an area
in İzmir where primary care is provided by a primary health care center.

METHODS
Design
This is a descriptive study.

Setting and Sample

The primary health care center where data were collected provided care for
21,200 people living in four different districts in the city of İzmir. Each district
had different socioeconomic features. The study population included 2,409
 162 A. Kissal and A. Beşer

people aged 65 years and older. A probability sampling method with a con-
fidence interval of 95% and an error margin of 0.05 was used (Sümbüloğlu
& Sümbüloğlu, 1994). As the number of individuals in the universe was
known, sample size was determined as 331 people using the formula [n =
Nt2 pq / d2 (N-1) + t2 pq] (N = 2,409, p = .5, q = 0.5, t = 1.96 (α = 0.05), d =
0.05). Based on the data from household control forms and simple random
sampling, the elderly in the predetermined size were contacted. The people
aged 65 years and older were stratified according to district, gender, and
age. In accordance with the density of each stratum, the number of people
per stratum was determined.
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Procedures
Data were collected at face to face interviews. First, Standardized Mini
Mental State Examination (SMMSE) for educated and uneducated was used
to identify individuals with cognitive disorders and then a semi-structured
questionnaire was used to collect data from the individuals receiving 24 or
over from SMMSE. To increase participation in the study, blood pressures
and blood sugar levels of the elderly were measured before data collection.
Data about elder abuse were collected in a room where the investigator and
the participant were alone.
Individuals with difficulty in speaking and understanding Turkish,
severe visual and hearing losses, dementia and Alzheimer’s disease and
SMMSE scores of lower than 24 were not included in the study. Since the
number of the elderly living alone in the districts was insufficient, those
people were not included in the study. The Katz Index of Independence in
Activities of Daily Living (ADL) was used to determine dependence levels
likely to play a role in elder abuse and neglect.

Dependent and Independent Variables

The dependent variables of the study were listed as follows: Physical abuse,
emotional/psychological abuse, sexual abuse, economic abuse, neglect, and
total abuse. The independent variables used in the study were listed as
follows: Age in years, gender, years of education completed, family income,
people with whom the elderly lived, chronic diseases diagnosed by a doctor,
family relationships, owner of the house/flat, family type, the number of
living children, perceived income, social security, and ADL.

Ethical Approval
Approval was obtained from the ethical committee of Dokuz Eylül University
School of Nursing and the primary health care center. Oral and written
informed consents were obtained from the participants.
 Elder Abuse and Neglect in Turkey 163

Data Collection and Measures

ABUSE EVALUATION FORM

The form was directed toward evaluation of physical, psychological,

sexual, and financial abuse and neglect in the last 6 months. To
test the understandability of the questions, the forms were piloted on
10 elderly people and the questions were found to be understand-
able and acceptable. The form was included the following questions:

1. Do you think that you have ever been neglected by your family
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members, relatives and caregivers)?

- Do you think that they did not provide or delayed care when you
needed it?
- What kinds of needs of yours are not fulfilled or delayed? Could
you please give examples?
2. Have your family members, relatives and caregivers ever used
words or phrases or had behaviors which hurt you?
- Could you give examples for their words and behaviors?
3. Are there any people who have tried to use or seize your
income?
- Are there anyone who tried to take advantage of or size your
property and possessions?
- How do they do it? Could you please give examples?
4. Have your family members, relatives and caregivers ever hurt
your body?
- Could you please give examples for it?
5. Have you ever been exposed to an unacceptable sexual
behavior?
- Could you please give examples?

EVALUATION OF ABUSE AND NEGLECT

The participants who said “yes” to the questions were asked to make
more detailed explanations. In accordance with the responses, the inves-
tigator decided whether abuse and neglect occurred. The total number of
abuses was determined based on the types of abuse experienced by the
elderly. Evaluation of abuse and neglect was only based on comments and
statements made by the elderly.

PHYSICAL ABUSE

Acts like injuring the body of an elder—by throwing an object, kicking,

slapping, pushing, hitting, shaking, and beating—and causing insufficiency
 164 A. Kissal and A. Beşer

and physical hindrances are considered as physical abuse, if they occurred

more than twice a month.

EMOTIONAL/PSYCHOLOGICAL ABUSE

Acts like verbal attacking, disdaining, threatening, humiliating, criticizing

continuously, scaring, nicknaming, and disregarding, which cause stress and
psychological pain to an elder person, are considered as psychological abuse
if they occurred more than twice a month.
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SEXUAL ABUSE

Any sexual relation that occurred without the permission of an elder person,
like rape and stripping, is considered as sexual abuse.

ECONOMIC ABUSE

Legal and illegal use of economic sources of elder people like depriv-
ing of money in spite of his/her need, and taking away and spending
his/her money and jewelry without permission are considered as economic
abuse.

NEGLECT
Neglecting the needs like eating, dressing, heating, and personal hygiene
that cannot be satisfied by elder people themselves, depriving of emotional
and social impulses, leaving alone for a long time, and ignoring the need for
medical treatment, control, and necessary equipment like prosthesis, glasses,
earpiece, and medicine are considered as neglect, if they occurred more than
twice a month.

SOCIODEMOGRAPHIC FEATURES FORM

The form was developed by the investigators in the light of the literature
and was composed of questions about age, gender, marital status, edu-
cation level, and the number of living children, owner of the house/flat,
perceived income, social security, and chronic diseases diagnosed by a
doctor. The elderly were asked whether they had diabetes mellitus, hyper-
tension, heart disease, vascular disease diagnosed by a doctor, and whether
they had other diseases such as cardiac insufficiency, arrhythmias, his-
tory of heart attack, and chronic obstructive lung disease. The elderly
were also asked to provide prescriptions of their treatment and docu-
ments indicating diagnoses of their diseases, which helped to confirm their
diseases.
 Elder Abuse and Neglect in Turkey 165

THE KATZ INDEX OF INDEPENDENCE IN ADL

The scale was developed by Katz et al. in 1963 and composed of six ques-
tions about having a bath, dressing, urine excretion, defecation, mobility,
and nutrition. A score of 3 shows independence in ADL, 2 shows receiv-
ing assistance for ADL, and 1 shows inability to perform ADL. According
to the index, the scores of 0–6 indicate dependence, 7–12 indicate half-
dependence, and 13–18 indicate independence (Rakel, 1995; Shelkey &
Wallace, 1999; Tel & Şahbaz, 2006).
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STANDARDIZED MINI MENTAL STATE EXAMINATION (SMMSE) FOR EDUCATED

The most widely used screening instrument for dementia is Mini Mental
State Examination (MMSE) described by Folstein, Folstein, and McHugh in
1975 and standardized by Molloy, Alemayehu, and Roberts in 1991. It can
be implemented in outpatient clinics and at bed-site by nurses, doctors,
and psychologists given a relevant short training and it takes 10 minutes
to complete the test. The test includes five headings; they are Orientation,
Registration, Attention or Calculation, Recall, and Language and 11 items.
The total score of the test is 30.

STANDARDIZED MINI MENTAL STATE EXAMINATION (SMMSE)

FOR UNEDUCATED

Ganguli et al. adapted the test for Indians with low education levels. Ertan
et al. from Turkey, using the latter version, formed Standardized Mini Mental
Test in 1999 for the uneducated SMMSE. The criteria developed by Molly
et al. for the administration of the test in 1997 were translated into Turkish,
modified, and incorporated into the test (Ertan et al., 1999).
A score of 0–9 shows severe cognitive disorder, 10–19 shows mod-
erate cognitive disorder, 20–23 shows mild cognitive disorder, and 24–30
shows normal cognition (Rakel, 1995; Molloy & Standish, 1997; Maral et al.,
2001).
The investigators observed how SMMSE for educated and uneducated
was used in practice and received training for the administration of the test.

Data Analysis
Chi-square test was used to analyze data about personal and familial
variables and logistic regression analyses to determine the coefficient for
the factors that affect elder abuse (p < .05 was considered significant).
SPSS (SPSS, Version 11.0 for Windows 2000) was used for data entry and
analysis.
 166 A. Kissal and A. Beşer

RESULTS

The mean age of individuals included in the study was 72.5 ± 5.60 years.
Out of 331 old individuals, 56.8% were female and 43.2% were male. Table 1
shows demographic features of the participants.

TABLE 1 Demographic Features of the Participants

Features n %

Gender
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Female 188 56.8

Male 143 43.2
Age (Years)
65–69 119 36.0
70–74 94 28.4
75 and over 118 35.6
Education Level
Not literate 43 13.0
Literate 42 12.6
Primary school 121 36.6
Secondary school 43 13.0
High school and higher 82 24.8
People With Whom the Participants Lived
Spouse 157 47.4
Spouse and children 71 21.5
Children (son and/or daughter) 61 18.4
Other (siblings, niece/nephews, grandchildren) 42 12.7
Family Type
Nuclear 309 93.4
Extended 22 6.6
Chronic Diseases
Yes 260 78.5
No 71 21.5
Activities in Daily Life (ADL)
Independent 326 98.5
Dependent 5 1.5
Family Relationships
Excellent 123 37.2
Satisfactory 161 48.6
Average and below average 47 14.2
Family Income
Income higher than expenditures 11 3.3
Income equal to expenditures 162 48.9
Income lower than expenditures 158 47.8
Owner of the House/Flat
The elderly and/or their spouses 283 85.5
Children 27 8.2
Other (rented, relatives) 21 6.3
Social Security
Yes 329 99.4
No 2 0.6
Total 331 100.0
 Elder Abuse and Neglect in Turkey 167

TABLE 2 Prevalence of Types of Abuse

Abuse

Yes No

Types of abuse n % n %

Physical abuse 14 4.2 317 95.8

Psychological abuse 31 9.4 300 90.6
Financial abuse 7 2.1 324 97.9
Sexual abuse 3 0.9 328 99.1
Neglect 27 8.2 304 91.8
Total 44 13.3∗ 287 86.7
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∗
The individual who suffered from one or more types of abuse.

Prevalence of Elder Abuse and Neglect

Of the elders, 9.4% suffered from psychological abuse, 8.2% neglect, 4.2%
physical abuse, 2.1% financial abuse, and 0.9% sexual abuse (Table 2).

Risk Factors of Elder Abuse and Neglect

A higher rate of the old women experienced abuse than the old men
(p < .05). There was no significant difference in the rates of abuse between
age groups (p > .05). However, a lower rate of the individuals aged 65–69
years suffered from abuse (12.6%). The old people with lower education lev-
els more frequently experienced abuse (p < .05) There was no significant
difference in the rates of abuse in terms of family income (p > .05). The
participants living with their spouses and children more frequently expe-
rienced abuse (p < .05). However, no significant difference in abuse was
found in terms of chronic diseases and the owner of the house/flat (p >
.05). The participants who found their family relationships average/below
average more frequently experienced abuse (p < .05) (Table 3).
As shown in Table 4, the female elderly 3.36 times more frequently
experienced abuse than the male elderly (p < .05). The elderly graduating
from primary school and those with lower education 2.43 times more fre-
quently suffered from abuse than those graduating from secondary school
and having higher education levels (p > .05). The old people living with
their spouses and children 3.94 times more frequently experienced abuse
(p < .05). The old people with average and below average family rela-
tionships 8.72 times more frequently suffered from abuse than those with
satisfactory family relationships (p < .05).

DISCUSSION

The results of this study show the prevalence rate of elder abuse in a
Turk population group at 0.9–9.4% in various types of abuse. This level
 168 A. Kissal and A. Beşer

TABLE 3 The Distribution of the Rates of Abuse by SocioDemographic Features

Presence Absence of
of abuse abuse Total

n % n % n % χ2 p

Gender
Female 32 17.0 156 83.0 188 100 4.53∗ 0.03
Male 12 8.4 131 91.6 143 100
Age (Years)
65–69 15 12.6 104 87.4 119 100 0.08 0.96
70–74 13 13.8 81 86.2 94 100
75 and over 16 13.6 102 86.4 118 100
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Education Level
Primary school and lower 34 16.5 172 83.5 206 100 4.17∗ 0.04
Secondary school and higher 10 8.0 115 92.0 125 100
Family Income
Income equal to or higher than 19 11.0 154 89.0 173 100 1.29∗ 0.26
expenditures
Income lower than 25 15.8 133 84.2 158 100
expenditures
People With Whom the Elderly
Lived
Spouse 15 9.6 142 90.4 157 100 17.55 0.01
Spouse and children 20 28.2 51 71.8 71 100
Children (son and/or daughter) 6 9.8 55 90.2 61 100
Other (siblings, niece/nephew, 3 7.1 39 92.9 42 100
grandchildren)
Chronic Disease
Yes 37 14.2 223 85.8 260 100 0.58∗ 0.44
No 7 9.9 64 90.1 71 100
Family Relationships
Satisfactory 24 8.5 260 91.5 284 100 37.78∗ 0.00
Average/below average 20 42.6 27 57.4 47 100
Owner of the House/Flat
The elderly themselves and/or 40 14.1 243 85.9 283 100 1.24 0.53
their spouses
Children 2 7.4 25 92.6 27 100
Other (rented, relatives) 2 9.5 19 90.5 21 100
Total 44 13.3 287 86.7 331 100
∗
Yates’ correction was made.

of elder abuse is in Turkey similar to those found in Western societies.

In the present study, the prevalence of physical abuse was 4.2%. Several
studies have revealed that the prevalence of physical abuse ranged from
0.43% to 5.4% (Anme, 2004; Lecovich, 2005; Oh et al., 2006; Moon, Lawson,
Carpiac, & Spaziano, 2006). Two population based studies from Turkey
revealed a lower prevalence of physical abuse (Keskinoğlu et al., 2004,
2007). Keskinoğlu and colleagues (2004) found a lower prevalence of phys-
ical abuse and attributed it migration to the region and traditional features
of the society. The higher prevalence of physical abuse in this study can be
ascribed with elderly dependence on other people due to their low income
and with poor family relationships.
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TABLE 4 Odds Ratios of Risk Indicators for Elderly Total Abuse in Logistic Regression Analyses (N = 331)

95% OR confidence
Variables Predictors interval (Cl) β S.E Wald p

Total abuse Gender Female 3.36 (1.342–8.411) 1.212 .468 6.698 0.010
Male 1.00∗
Education level Primary school and lower 2.43 (0.935–6.319) .888 .487 3.321 0.068
Secondary school and higher 1.00∗
The people with Spouse and children 3.94 (1.692–9.175) 1.371 .431 10.104 0.001
whom the
participants

169
lived
Children (son and/or daughter) 0.45 (0.147–1.407) −.786 .575 1.868 0.172
Other (siblings, niece/nephew, 0.40 (0.099–1.646) −.905 .716 1.597 0.206
grandchildren)
Spouse 1.00∗
Family Average and below average 8.72 (3.951–19.252) 2.166 .404 28.741 0.000
relationships
Satisfactory 1.00∗
∗
Reference category.
 170 A. Kissal and A. Beşer

The elderly included in this study most frequently experienced psycho-

logical abuse (9.4%). The prevalence of psychological abuse ranges from
3.2–14.8% in the studies reported from other countries (Comijs et al., 1998;
Pavlik et al., 2001; National Center on Elder Abuse [NCEA], 2006; Oh et al.,
2006). It has been claimed that relationships between the elderly and their
caregivers and insufficient social support of the caregivers may increase psy-
chological abuse (Yan & Tang, 2004; Wang, 2006). As a matter of fact, elder
citizens are respected in Turkish culture. However, the family structure and
cultural values seem to have been increasingly disrupted. This might explain
the high prevalence of psychological abuse in this study. In addition, older
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adults can be blamed for the behaviors of the abusing perpetrators. In fact,
perceptions of the elderly people might have caused a higher prevalence
of psychological abuse. However, the results of this descriptive study are
evaluated by the researcher according to the responses of elder individu-
als. Thus, the methodological restraints of the study have to be taken into
consideration.
Consistent with the literature, we found a higher rate of financial abuse
in the elderly people with low socioeconomic status. The prevalence of
financial abuse has been reported to range between 1.4–17% (Lachs et al.,
1997; Comijs et al., 1998; Anme, 2004; Oh et al., 2006; Keskinoğlu et al.,
2007). The elderly exposed to financial abuse are usually unmarried or wid-
owed, have relatively poor health, and are socially isolated, and the elderly
exposed to neglect tend to be very old and have cognitive and physical
impairment (Dyer, Pavlik, Murphy, & Hyman, 2000).
The least frequent type of abuse in the present study was sexual abuse
(0.9%). However, higher rates of sexual abuse have been reported in the
literature (Boldy et al., 2002; Anme, 2004). Pavlik, Hyman, Festa, and Dyer
(2001) found lower rates of sexual abuse among the elderly (0.2%). No
sexual abuse was found in Moon and colleagues’ study in 2006.
In the present study, data about types of abuse were collected in a
separate room without other members of the families. However, even their
presence at home might have prevented the participants from talking freely.
In addition, sexuality might have been considered as a private thing and the
participants might have found it unacceptable to talk about it. There have
not been any studies on sexual abuse among elder Turkish people. This
may also show that sexuality is considered as a taboo subject in the Turkish
population.
Neglect was the second most frequent condition in this study. In the
study by Keskinoğlu and colleagues in 2004, the prevalence of confirmed
neglect was 3.5% and the prevalence of possible neglect was 29%. In another
study by Keskinoğlu and colleagues (2007), the prevalence of neglect was
27.4% in a population with low socioeconomic status and 11.2% in a pop-
ulation with high socioeconomic status. Oh and colleagues (2006) noted
the prevalence of elder neglect was low in Korea (2.4%) and this low rate
 Elder Abuse and Neglect in Turkey 171

of elder neglect can be explained by the belief that actions harmful to the
elderly are a taboo in Korean culture. Moon and colleagues in 2006 reported
that there were seven cases of neglect, representing 17% of the total inci-
dents affecting 23% of the victims. Many studies have revealed higher rates
of neglect than that found in the present study (Lachs et al., 1997; Pavlik
et al., 2001; NCEA, 2006). For low-income older adults with health and men-
tal health problems, lack of adequate public social service and health care
programs, including provision of necessary medications and medical sup-
plies and medication managements, are also likely to be serious risk factors
for self neglect/neglect (Choi, Kim, & Asseff, 2009). It may be that most of
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the elderly people in this study were functionally independent.

The present study showed that the elderly women experienced abuse
3.36 times more than the elderly men, consistent with the results of studies
from Turkey (Keskinoğlu et al., 2007) and other countries (Pavlik et al., 2001;
NCEA, 2006). However, in one study by Oh and colleagues (2006) the males
were found to experience abuse more than the females. The high rate of
abuse among the females can be explained by the fact that the women could
share their problems more easily, were more submissive, had low education
levels and were financially dependent. In Turkey, inequality between men
and women persists. In fact, traditionally men are given priority in most
parts of the country. In addition to this unfair treatment, women may also
be exposed to violence. Unfortunately, elderly women are also affected by
the inequality between the genders and violence.
Although some studies showed a higher rate of abuse among the elderly
with low education levels (Oh et al., 2006; Keskinoğlu et al., 2007), other
studies revealed no effect of education on elder abuse (Shugarman, Fries,
Wolf, & Morris, 2003). This may be because education plays an impor-
tant role in health promotion behaviors, exercising rights and expressing
opinions.
The elderly living with their spouses and children suffered from abuse
3.94 times more than those spouses in this study. The studies from devel-
oped countries indicated that living with family members was the leading
risk factor in elder abuse (Artan, 1996; Lachs et al., 1997; Krug et al., 2002;
Yan & Tang, 2004; Boldy et al., 2005; Keskinoğlu et al., 2007). Moon and
colleagues (2006) indicated that the victim’s wife was a perpetrator in at
least half of the eight cases involving multiple types of abuse and also in
four of the five physical abuse cases. They also noted that except for one
case, family members, specifically spouse, son, and daughter, were identi-
fied as perpetrators in all cases of neglect. The reason why the elderly living
with spouses were more frequently exposed to abuse can be disrupted fam-
ily relationships and insufficient communication and problem-solving skills.
However, a thorough evaluation of relationships between family members
and the elderly could not be made. In this study, the participants noting that
their relationship with their family members were average or below average
 172 A. Kissal and A. Beşer

experienced abuse 8.72 times more than the participants noting that they
had a satisfactory relationship. Likewise, Oh and colleagues (2006) reported
a direct relationship between elder abuse and average and below average
familial relationships. The findings regarding the family characteristics in
this study provide an important insight into the relationships between family
dynamics and elder abuse. In a positive atmosphere, family members share
their problems, support, love, and show respect for each other. However,
absence of a positive environment may affect family members. In this study,
disrupted relationships between family members might have increased elder
abuse.
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This study showed several factors that may have an impact on abuse
and neglect. The female gender, low education levels, living with spouses
and children, and perception of familial relationships as average and below
average were found to increase abuse. The number of elder abuse and
neglect victims can be higher to the extent that health professionals (nurses,
social workers, gerontologists, doctors, etc.) are able to detect possible
signs of abuse or neglect and that patients disclose potentially abusive or
neglectful situations to the health professionals. Because the phenomenon
of elder abuse and neglect is so complex and multi-dimensional, it has to be
addressed by multi-professional and inter-disciplinary approaches. In fact,
social laws require that social workers, nurses, physicians, and police offi-
cers should report elder abuse and neglect. Research shows that nurses,
social worker, and health care professionals are increasingly aware of the
need to understand and respond to the abuse of older people.
The results of this study are of great importance to nurses and social
workers. They have close contact with the society and know the dynam-
ics of the society very well. Therefore, they can play an active role in
detecting and monitoring elder abuse and taking appropriate precautions.
They should plan support programs for the elderly experiencing abuse and
their families. Nurses and social workers should take account of all types of
abuse while evaluating the elderly. Since elderly people are more frequently
exposed to abuse, nurses, social workers and other health professionals
should participate in programs aiming at increasing awareness of gender
equality, plan programs to improve education and financial status of women
and cooperate with other health professionals when needed. They should
provide guidance for elderly people in seeking help in cases of neglect
and abuse and coordination between institutions that play a role in solving
the cases. Since assessment of abuse is not a standard procedure, public
health nurses, social workers, and other health professionals can create a
system for recording and following cases of abuse in primary health care
centers. They should contribute to searching causes and results and preven-
tion of neglect and abuse of the elderly. They should keep in mind that
poor familial relationships, low education levels, and elderly staying with
their spouse and children can be a risk factor for neglect and abuse of the
 Elder Abuse and Neglect in Turkey 173

elderly so that cases of abuse can be detected earlier and so that appropri-
ate interventions can be started. In addition, they should focus on education
of both the elderly and other age groups to increase their awareness in
elder abuse.
Data were obtained at face to face interviews with the elderly; how-
ever, presence of other family members at home might have prevented the
participants from commenting about abuse. The results of this descriptive
study are only based on the elderly’s comments. Also, the study was only
restricted with the elderly living with their families. In addition, characteris-
tics of individuals who are accused of perpetrating abuse or stress created
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by this condition, shown to be the factors playing the most important role in
elder abuse and neglect, were not considered in this study. Further prospec-
tive and qualitative studies using focus group interviews should concentrate
on these issues.

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