Prevalence, pattern and predictors of elder abuse in rural communities of Edo State, Nigeria

TL;DR

This study found that elder abuse is common in rural Edo State, Nigeria, with neglect being the most frequent type and children often being the abusers.

Contribution

The study provides new insights into the prevalence and patterns of elder abuse in rural Nigerian communities.

Findings

The prevalence of elder abuse was 79.3%, with neglect being the most common form.

Children of the victims were identified as the main perpetrators of abuse.

Factors like gender, marital status, and financial status were significant predictors of abuse.

Abstract

This study aimed to investigate the prevalence, pattern, and predictors of elder abuse in two rural communities in Edo State, Nigeria.

A cross-sectional study.

Individuals residing in rural communities in Edo state were studied.

Two hundred and thirty-two participants aged ≥ 60 years.

The prevalence and pattern of elder abuse, and predictors of abuse.

The mean age of participants was 73.2±9.1 years, and the prevalence of elder abuse was 79.3%. The pattern of abuse observed was neglect (73.4%), financial abuse (64.1%) and emotional abuse (53.8%), with many of the perpetrators being children of the victims. Risk factors associated with abuse in this study included sex (p = 0.009), marital status (p = 0.028), employment status (p = 0.002), educational qualification (p = 0.001), living arrangement (p = 0.001), financial status (p = 0.017), and dependency level (p = 0.015). The top barriers to help-seeking by the elderly were stigmatisation (24.4%), fear of retaliatory assault (19.3%) and abandonment (19.4%) respectively.

Elder abuse is prevalent in the study area, with neglect being the most typical form of abuse and children of the victims are the major perpetrators. Consequently, concerted efforts to respect and care for the elderly should be directed by all stakeholders at the International, Federal, State, and Local Levels (including the community and family).

None declared

Tables

Table 2. Prevalence and pattern of elder abuse among the respondents

Variables	Frequency, n (%)
Have you ever been abused?
Yes	184 (79.3)
No	48 (20.7)
Type of abuse received
Physical abuse	72 (39.1)
Emotional abused	99 (53.8)
Neglect	135 (73.4)
Financial abuse	118 (64.1)
Sexual Abuse	1 (0.5)
Knowledge of any abused person around you?
Yes	171 (73.7)
No	61 (26.3)

Table 3. Perpetrators of elder abuse among the abused elderly

Perpetrators	Freq. n(%)
Spouse	9 (4.9)
Children(Married/unmarried)	81 (44.0)
Grandchildren	15 (8.2)
Neighbour	28 (15.2)
Relatives	21 (11.4)
Others (e.g. househelps, caregivers)	30 (16.3)

Full text

Introduction

Elder abuse is rapidly becoming a social and public health problem globally.1,2 Elder abuse is 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.3

There is a rise in the ageing population, and the number of older persons is increasing due to global improvements in healthcare and increasing life expectancy. With this, there is also a rise in elder abuse. In the coming decades, there will be a dramatic increase in the population of the elderly and, invariably, the number of those at risk of abuse. It is estimated that by 2025, one million people will reach the age of 60 every month.

By 2050, the global population of those aged 60 years and above is expected to more than double, from 900 million in 2015 to approximately 2 billion, with 80% of these individuals projected to be from the developing world.4 However, the current situation and future outlook suggest that the quest for better life and greener pastures will continue to result in mass rural-urban migration of many young adults, leaving older parents in the rural areas.5

Elder abuse is a global health problem with varying prevalence. However, in many countries, awareness about its existence is just developing as it is a concealed problem, hidden from public view and cloaked under the shroud of family secrecy.6

Generally, five types of elder abuse have been identified, and these include 1) physical abuse i.e. such physical assaults, physical restraints and force feeding, 2) emotional/psychological abuse i.e. verbal harassment or humiliation and other behaviours that cause mental anguish, pain or distress on an elderly person, 3) Financial/material abuse or exploitation, 4) sexual abuse i.e. rape and coerced nudity, and any sexual assault, 5) abandonment, neglect or failure to provide adequate care.7-10

This study assessed the prevalence, pattern and predictors of elder abuse in rural communities of Edo State, Nigeria. Findings from this study will fill the existing gap in the literature on elder abuse in Nigeria, as well as provide information to all relevant stakeholders on the burden of the problem and the need for improved social security for the elderly.

Methods

This was a community-based cross-sectional study carried out among the elderly (male and female of 60 years and above) between May 2019 and May 2020 at two rural towns: Eror, in Esan Northeast LGA, with an estimated population of 8,837,11 and Ogba, on the outskirts of Oredo LGA, with an estimated population of 12,506.12. These towns were selected using a multistage sampling technique. Firstly, two of the three senatorial districts that make up Edo state were selected using simple random sampling by ballot. Edo South and Edo Central were selected, which comprised seven (7) and five (5) Local Government Areas (LGAs) respectively. One LGA was further selected from each senatorial district. Thus, Oredo LGA was selected from Edo South and Esan Northeast LGA from Edo Central. A rural community was therefore chosen randomly from each Local Government Area (LGA) by ballot.

The sample size consisted of 232 respondents, calculated using the Cochran formula.13 The inclusion criteria were any consenting elderly person (male and female) in the selected study areas. Elderly persons with cognitive impairment, those with communication difficulties (e.g., those with speech defects, deafness, and blindness), and those who were physically too ill to participate were excluded from the study.

A multistage sampling technique was used to select respondents for the study. Data was collected using pretested, interviewer - administered semi-structured questionnaire adapted from a standardised questionnaire on elder abuse and neglect developed by the World Health Organization (WHO, 2008); and a mini mental state examination (MMSE) guide adapted from the mini mental state examination by the London Alzheimer society to assess the cognitive ability of the respondents by testing their orientation to time, place, immediate recall, object identification and simple calculation ability.

The questionnaire obtained information on basic Sociodemographic characteristics of respondents, Awareness, knowledge and perception of elder abuse, Prevalence and pattern of elder abuse and Factors associated with abuse. Nigerian Pidgin, a common means of communication, was used to interpret the questionnaire for most respondents; however, in some cases, the local language was used when necessary. Respondents' ages were determined by asking them about their ages or by estimation (if unknown to them) from historical events like the 1947 eclipse of the sun, Nigeria's independence (1960) or the civil war (1967-1970). Due to the sensitivity of the topic and the confidentiality required, help for interpretation by community members was not sought. Thus, any person with communication difficulties was excluded from the survey.

Positive answers to assess the various types of abuse attracted a mark each, while a negative answer scored zero. A score of one or more in any category of the pattern of abuse was taken as a positive experience for that type of abuse. Thereafter, frequencies and percentages were derived for the various patterns of abuse. Prevalence was calculated as the number of individuals who had experienced any abuse in the past year before the study, divided by the total number of respondents interviewed, and expressed as a percentage (x100). Awareness of elder abuse was assessed with a “Yes” and “No” response to a question asked (Have you ever heard the term elder abuse?), and the proportion of respondents with a positive answer was estimated. A level of awareness greater than 50% was regarded as a good level for that community. The ability to give an example in each pattern of abuse was used to assess knowledge. An accurate answer to each pattern of abuse was scored 1. Thus, the overall score was five. A score of 3 and above was assigned to indicate good knowledge, and a score of less than 3 was adjudged to indicate poor knowledge; thereafter, the proportion of respondents with good knowledge was estimated.

Data analysis was conducted using IBM SPSS (International Business Machines Statistical Package for the Social Sciences) Version 23, through which spreadsheets, frequency tables, and cross-tabulations were generated. Inferential statistics were used to test for association between variables using the chi-square test. Predictors of elder abuse were determined using logistic regression analysis. Statistical significance was set at p<0.05.

Ethical approval for the study was obtained from the Ethical Committee of the Irrua Specialist Teaching Hospital, Irrua, Edo State, with reference number ISTH/HREC/20171023/33. Permission was also obtained from the Chairmen of the selected local government areas and community leaders of the selected communities. Participation was entirely voluntary, and confidentiality and anonymity were assured. Verbal as well as written informed consent was obtained from the participants, and they were also informed of their right to decline or withdraw from the study at any time without consequence.

Results

A total of 230 elderly persons were interviewed, with close to half (46.1%) between 60 and 69 years old, and a mean age of 73.2±9.1 years. There were more females, 135 (58.2%), while most of the respondents, 180 (77.6%), were retired. Approximately two-thirds, 141 (60.8%), were married. A little over a quarter of the respondents, 63 (27.2%), had primary education, a third, 77 (33.2%), had secondary education, while 68 (29.3%) had no formal education. More than two-fifths, 104 (44.8%), were living with their children or grandchildren, while the same number also reported being financially dependent on others.

The result displayed in Table 2 indicates that the majority of the respondents, 184 (79.3%), reported having been abused before, with neglect 135 (73.4%), financial abuse 118 (64.1%) and emotional abuse (53.8%) being the commonly experienced forms of abuse.

Table 3 shows that more than two-fifths, 81 (44.3%) perpetrators of abuse were the children of the victims, followed by house-helps/caregivers, 30 (16.3%), neighbours, 28 (15.2%) and relatives, 21 (11.4%).

There is a statistically significant association between elder abuse and sex (p = 0.009), marital status (p = 0.028), employment status (p = 0.002), educational qualification (p = 0.001), living arrangement (p = 0.001), financial status (p = 0.017), and dependency level (p = 0.015). Being a female, divorced/cohabiting, unemployed, having no formal education, living with children, being dependent in activities of daily living, and partially self-sufficient financially were associated with elder abuse.

Age, sex, marital status, employment status, and educational status were the sociodemographic predictors of abuse in rural areas. Other predictors were living arrangement, financial situation, level of dependency (ADL), and having assistance at home, which were all associated with elder abuse in the rural communities (p<0.05). The odds ratio of abuse for the females (OR =2.06; CI =1.141 -4.672) shows that females are twice as likely to be abused as their male counterparts in rural communities. Divorced elderly (OR =3.435; CI =1.694 -7.789) and the widowed (OR =5.135; CI =1.093 -9.042) were about three and five times more likely to suffer from abuse than elders that are single respectively; the unemployed (OR =4.816; CI =1.134 -7.270), had a higher likelihood of approximately five times more chances of suffering an abuse than the employed; elders with no formal education were approximately three time more likely to be abused than elders with tertiary educational status (OR =2.995; CI =1.013 -4.118); living with married children (OR =2.683; CI =1.243 -5.045) and family members (OR = 3.736; CI =1.624 - 6.275) increases the chances of being abused by approximately three and four times more than those living alone respectively; being abused was about 3 times higher for the financially dependent elders than the economically independent. The chances of being abused among the dependent were approximately 3 times higher than the independent, while having assistance at home made elders in the rural communities eight times more exposed to abuse.

A majority, 142 (77.2%), of the abused victims had ever reported being abused to other people, with 94 (66.2%) of them seeking help from family members. In most cases (62.7%), no action was taken against the perpetrator. Significant barriers to help-seeking behaviour were stigmatisation 33, 24.4%), fear that reporting will worsen the abuse or the caregiver may leave (26, 19.3%).

Discussion

This study evaluated the prevalence, pattern, and predictors of elder abuse, as well as barriers to help-seeking behaviour in two rural communities of Edo State, Nigeria. The prevalence of elder abuse found in this study was 73.4%. This implies that over two-thirds of elderly persons in the communities had been abused.

The result of this study is consistent with the findings from a study done in Imo state, which revealed that the majority (78.8%) of the elders have been abused,14 and in contrast to that of Okojie,15 who reported a prevalence of 14.7%. However, the findings are lower than what was reported from some studies in Northern Nigeria, where the burden of elder abuse was as high as 93.7% in Nasarawa state,16 and 100% in Kano state.17

The patterns of abuse in this study show that neglect is the most predominant form of abuse, followed by financial abuse and emotional abuse, with sexual abuse being the least. This finding is in tandem with studies done by Akpan in Akwa-Ibom,18 as well as studies in India, the USA and the UK, which portrayed neglect as the most typical type of elder abuse.19-21 However, it negates the findings from some other studies that have reported psychological/emotional abuse as the primary form of abuse.14-17 Another study reported mixed findings of neglect among elderly women and psychological abuse among men.17 Generally, the possible reasons for the high prevalence of elder abuse may include: breakdown of the extended family system, near collapse of our social support system and the quest for better life and greener pastures, which has led to mass rural-urban migration of many young adults.4 The high pattern of elder abuse due to neglect and financial issues is more worrisome and hazardous for elders in developing countries like Nigeria, where the standard of living is very low and in which the social welfare support system is absent for the elderly.

Several studies have reported sexual abuse as the least common type of abuse,21,22 and this was corroborated by our finding of only one case of sexual abuse in an elderly female, in the rural community who had not only been abused sexually by the strangers, but had resorted to transactional sex as a means of livelihood due to neglect by her family members.

According to the findings of this study, the majority of the perpetrators of abuse were children of the victims and family members. Adult children are the most likely to extort pensions, steal property, blackmail, neglect, and physically, psychologically, and sexually abuse their elders.6,23 Other studies of elder mistreatment also indicate that family members are the most frequent perpetrators of elder abuse,19 with the perpetrators usually adult children, grandchildren, and other relatives; professional caregivers; and close friends or others in a position of trust.24-26

This study's findings show that being a female, divorced, unemployed, having no formal education, living with married children, being dependent at activities of daily living and partially self-sufficient financially were significant predictors of elder abuse. This finding is similar to those of a study conducted by Ibrahim in Awe, Nasarawa State, and Ekot in Akwa Ibom State, Nigeria.16,26 Contrary to reports by other studies that elder abuse is not gender specific, with no association between gender and elder abuse, as both genders are equally susceptible,20,27 this study found that being female was significantly associated with elder abuse, which is similar to reports from some previous studies.16,22 Plausible explanations are increased vulnerability and inability to defend oneself, increased financial dependency emanating from the inferior status accrued to the girl child by the society, as well as losing the right to inheritance and lower opportunities to education and wealth creation in a male-dominated environment.

This study identified that living with married children and other family members is a risk factor for abuse, with a three- and four-time risk, respectively, than those living alone. This is similar to findings from studies in Bangladesh, Israel and New York, which reported that living with married children and other family members was significantly associated with abuse.28-30 It is however in contrast with studies done in Oyo and Akwa Ibom state, which reported that living alone is a risk factor for abuse21,31 as well as in comparison to a study by Perez et al which found no relationship, nevertheless, they attributed abuse to possible dysfunctional relationship existing between the victim and the perpetrator.32

Regarding help-seeking behaviour, this study found that the elderly exhibit good help-seeking behaviour, with help primarily sought from family members and community leaders, rather than formal support services, which were used by only a few.

This is in tandem with a study in the USA,33 that reported that help-seeking through reporting to police or other authorities was low among elderly abused victims, and mainly occurred among victims of physical abuse and poly-victimisation.

Regarding barriers to non-reporting, no respondent in the rural area claimed ignorance of who or where to seek help in the event of abuse, which may imply that rural dwellers have good neighbourliness and community support. However, this study reported that the significant barriers to help-seeking were fear of stigmatisation, scandalisation of offsprings (as perpetrators of abuse mainly were the victims' children and other family members), fear that the abuse may worsen, fear of a strained relationship with the caregiver and that the perpetrator to who they are dependent upon for care may leave.34,35

The estimated prevalence from this study may be underreported because most elderly persons are reluctant to fully disclose relevant information on issues of abuse due to various factors. However, this was addressed by conducting private and confidential interviews with the elderly. Also, this study was conducted among the cognitively intact elderly, as well as those with no communication difficulties. Thus, abuse among the cognitively impaired and severely ill elderly, who are mostly thought to be the group at most significant risk of abuse, was not assessed.

Conclusion

In conclusion, elder abuse is highly prevalent in this study, with neglect as the most typical form of abuse, and children of the victims are the major perpetrators. The significant risk factors for elder abuse in this study are; being a female, divorced/cohabiting, unemployed, having no formal education, living with married children, being dependent at activities of daily living and partially self-sufficient financially.

Against this background, the following recommendations are made: The United Nations and other relevant organisations should intensify efforts on the promotion of World Elder Abuse Awareness Day (June 15 of every year), while the government at all levels (Federal, State and Local) should implement sustainable policies and interventions including enlightenment and education, provision of social safety nets and healthcare services. The importance of relevant interventions at the community and family level, especially concerning respect and care for the elderly, cannot be overemphasised.