Social Representations of Violence among Brazilian Older People with Functional Dependence

Abstract

Elder abuse is a multifactorial public health issue deeply affected by silence and discrimination. This paper aims to analyze the social representations of violence among older people with functional dependence based on the theory of social representations. A qualitative exploratory–descriptive study was conducted with a sample of 21 older people enrolled in a home-based program in Vitória da Conquista, Bahia, Brazil. A sociodemographic survey and an interview script were used for data collection. The data were analyzed using the content analysis technique and QSR NVivo^® software. Concerning the social representations of violence, older people’s narratives revealed a broad perception of the phenomenon through the following categories: multivariate phenomenon, ageism, neglect, and denial. The identification of the subtle forms of violence against older people and the exploration of this issue from the perspective of these vulnerable people can contribute to the production of new knowledge and the creation of mechanisms by which to raise awareness of and prevent this issue, as well as to break the silence surrounding it through reporting.

1. Introduction

Elder abuse is a multifactorial public health issue with consequences in several contexts, leading to higher mortality rates, health care utilization (hospitalization, emergency services, and mental health services), and various forms of physical and psychological symptoms [1]. Although it is an old phenomenon, cases of violence against older people gained visibility after 1975 when British journals published articles about granny-battering [2,3].

Around one in six people aged 60 and older experienced some form of abuse in community settings during the past year. The WHO defines elder abuse as any single or repeated act, or the 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].

These forms of maltreatment, abuse, or violence are classified based on their nature as follows: (i) physical, which is the intentional use of physical force to cause pain, injury, physical coercion, or domination; (ii) emotional or psychological, which is characterized by verbal or non-verbal aggressions that cause distress, mental pain, or fear in the older person; (iii) financial, which corresponds to the illegal or improper use of an older person’s financial resources, belongings, or property; (iv) sexual, which refers to a non-consensual sexual contact, act, or game of any kind with the older person; and (v) neglect, which is the failure or refusal to provide necessary care to the older person and may represent a conscious or intentional act of infliction of physical or emotional suffering [5].

In Brazil, although the cases of violence against older people are increasing, the available data are not an accurate representation of reality because many events are not reported or even acknowledged as an episode of violence [6,7], especially within the family environment.

Although robust international studies on the prevalence of violence against older people in family settings are scarce, these events affect around 141 million people worldwide, making it a neglected global public health priority, especially when compared to other types of violence [8].

The vulnerability of older people is mainly caused by their functional dependence, that is, the need for assistance with everyday tasks such as hygiene and eating [9]. Moreover, Brazilian families often set up a new family dynamic to meet older people’s care needs, creating a new family nucleus in which children move into the home of their parents or parents move into the home of their children and start living with their daughters-in-law, sons-in-law, and grandchildren. However, this alternative is also a risk factor for violence as it can lead to intergenerational conflicts [6,9,10].

As for the risk factors for violence against older people, studies have focused mainly on the victims’ characteristics rather than on the aggressors’ characteristics, such as caregiver burden, mental health, and substance abuse, which can be determining factors for violence. Moreover, most studies on risk factors for violence against older people have used a cross-sectional design, hindering the ability to determine the causal relationship between risk factors for vulnerability and violence against older people [11].

Thus, given the social nature of this multigenerational phenomenon, the theory of social representations (TSR) was used to explore the issue from a broad and multidisciplinary perspective [12]. Several studies on violence have used the TSR to subjectively discuss this phenomenon and explore its complexity [13,14,15,16].

The TSR constitutes a form of practical socially constructed knowledge to give meaning to the reality of everyday life. It is a particular form of acquiring knowledge and communicating acquired knowledge, ordering it based on the perceptions that produce the world [12].

All social representations have a purpose: to make familiar something unfamiliar [12]. They enable communication by providing the members of a community with a code by which to identify and classify the several aspects of their individual and social context [17].

Social representations conceptualize the nature of the stimuli we receive and give them meaning [18]. The social aspect refers to the individuals who construct meanings, which, in turn, are developed through social interaction. Thus, in the essence of this theory, individuals appropriate themselves of reality and interiorize the social concept [12,19]. Therefore, the social representation of violence evoked by individuals emerges from the interaction between individual and collective perceptions. In understanding this theory, it is essential to highlight that its role is related to the development of behaviors and attitudes and that individuals assign meanings to their reality and, consequently, build the social representations of a given object through social interaction [12].

For this reason, this study aims to explore the social representations of violence among older people with functional dependence.

2. Materials and Methods

2.1. Study Design

This qualitative exploratory–descriptive study is based on the TSR [12]. It is part of the project “Qualificação dos cuidadores e aspectos relacionados à qualidade de vida dos idosos dependentes na atenção primária e terciária: proposição, implementação e avaliação de protocol” (Caregivers’ training and aspects related to the quality of life of dependent older people in primary and tertiary care: proposition, implementation, and evaluation of a protocol) developed at the Universidade Estadual do Sudoeste da Bahia, Brazil.

2.2. Sample and Data Collection Procedure

A total of 21 older people registered at the Municipal Home-Based Care Program for Older People with Disabilities (Programa de Atendimento Municipal Domiciliar ao Idoso com Limitação, PAMDIL) in Vitória da Conquista, Bahia, Brazil, participated in this study.

Vitória da Conquista, where PAMDIL is implemented, is the third-largest city in the state of Bahia, with around 306,866 inhabitants. Of these, 3048 are adults over the age of 60, which corresponds to the WHO’s [20] definition of older people in developing countries such as Brazil. It corresponds to the health hub of the southwestern region, serving 72 municipalities in the state of Bahia and northern Minas Gerais [21]. PAMDIL is a home-based care program for people with a disabling condition that limits their ability to visit a health care unit. The program includes home visits every two weeks by a team of two doctors and two nursing technicians.

As for the sampling procedure, the initial step was to identify the older population registered in PAMDIL from a database with 781 addresses. Then, considering that the program was inactive for three years, the researchers identified 251 addresses of older people from four Basic Health Units served by the program and made 176 home visits.

After this initial process, 101 households remained because 52 addresses were excluded because the older people refused to participate or did not live in the identified address and another 23 addresses because the older person had died. After applying the inclusion and exclusion criteria, 21 older persons, that is, over the age of 60, were selected to participate in this study. This procedure is illustrated in Figure 1.

As previously mentioned, the PAMDIL program was inactive for some time, leading to a significant reduction in the number of home visits because many addresses initially registered in the program were outdated. In addition, some of the health units in which the program was implemented were not part of the sample because they were located in a dangerous region of Brazil that could compromise the researcher’s safety.

The inclusion criteria were: (i) having preserved cognition as assessed by the Mini-Mental State Examination [22,23] (MMSE), (ii) having any degree of functional dependence as assessed by the Barthel scales [24,25] and the Lawton–Brody Instrumental Activities of Daily Living Scale [26,27], and (iii) living with relatives. The exclusion criteria were: (i) living alone, (ii) being functionally independent, and (iii) having any cognitive impairment.

The data collection instruments were a sociodemographic survey and a semi-structured interview script with guiding questions on the topic such as “How would you define violence?”, “How would you define abuse?”, and “Has anyone in your family ever treated you violently?”.

2.3. Data Analysis

Bardin’s [28] content analysis technique was used together with the QSR NVivo^® software (QSR International, Burlington, MA, USA). Content analysis enables the inference of knowledge about the conditions of the production and reception of messages. The information contained in the messages is explored through systematic procedures that reveal the meaning behind the analyzed words [28].

This type of analysis is divided into three phases: (i) pre-analysis, (ii) exploration of the material and treatment of the results, and (iii) inference and interpretation. In the pre-analysis, the material is organized through text skimming, which leads to the formulation of the objectives and hypotheses that substantiate the interpretation. The second phase consists of the exploration of the material through the coding of the recording units. Finally, the last phase consists of data treatment based on the categorization and regrouping of common characteristics [28].

QSR NVivo^® software organizes and structures data and has been used in various areas of knowledge. By categorizing the narratives, the software allows identification of the trends that structure the descriptive information in the text and developing nodes, subnodes, word clouds, and cluster diagrams.

A word cloud is used to help visualize the categories and analyze the content by highlighting the most frequently mentioned words, culminating in their graphic representation. On the other hand, the cluster diagram resulting from the cluster analysis allows visualization of interrelated semantic groups, clustering the words/values/attributes that share similarity [29].

2.4. Ethical Issues

This study followed Resolution No. 466/12 of the National Health Council. It was submitted to and approved by the Research Ethics Committee of the Universidade Estadual do Sudoeste da Bahia (Opinion no. 1.875.418). Participants signed an informed consent form that described the purpose of the study, its objectives and risks, and the possibility to withdraw from the study at any time without prejudice.

3. Results

Table 1. Sociodemographic characterization of dependent older adults. Vitória da Conquista/BA, 2018.

Variables	N	%
Age range
60–79 years	10	47.62%
80 years or over	11	52.38%
Mean age 7,923,809,524
Std. Dev. 2,828,427,125
Gender
Female	17	80.95%
Male	4	19.05%
Marital status
Widowed	10	47.62%
Married	7	33.33%
Single	4	19.05%
Education level
Literate	16	76.19%
Did not attend school/illiterate	5	23.81%
Income
1 to 2 minimum wages	18	85.71%
More than 3 minimum wages	3	14.29%

Source: Study data.

shows that the majority of older people in the sample were women (80.95%), aged 80 years or above (52.38%), widowed (47.62%), literate (76.19%), and had a family income of one to two minimum wages (85.71%).

Concerning the social representations of violence, older people’s narratives revealed a broad perception of the phenomenon, indicating an understanding of physical, psychological, and financial violence, neglect, and ageism. They also revealed a trend toward the most veiled themes: denial and lack of knowledge.

The word cloud in Figure 2 shows the most frequently mentioned words and expresses the several meanings that violence against older people can assume. Some of the most evoked words were no, to do, beat, take care, lack, mistreat, leave, nobody, harm, mistreat, and old.

Four categories emerged from the analysis: multivariate phenomenon, ageism, neglect, and denial.

The analytical categories are presented below.

3.1. Multivariate Phenomenon

In the multivariate phenomenon category, the analyzed information showed that the participants’ perception of violence against older people is not restricted to an isolated act but rather integrates a range of actions from physical violence to psychological violence (through insults) and even financial violence, as can be observed in the following statements:

Abuse is mistreating, beating, not treating well. To be left adrift.

BR_ID_1

To shout, “Disgusting old man, disgusting old woman”. That’s abuse.

BR_ID_2

It’s a rude person without education, who doesn’t know how to treat older people, isn’t it? Because you must know how to care, right? Some people don’t even know how to treat their mother. They treat their mother like they treat anyone else, don’t they? And they don’t respect their mother. I think it’s wrong. It’s a mistake. Because an older person has to be treated with care, with attention, right? But I don’t know... I don’t understand. But it’s the lack of respect, of consideration, because there’s no respect for the mother.

BR_ID_16

My son withdraws cash, okay? Sometimes he does the shopping, sometimes I do the shopping. I like to buy my own things because he doesn’t buy everything, then I take it up with him, right? But then he keeps the card for himself. We want to buy the things we like, don’t we? Sometimes he complains “you’re spending too much” and I say “I spend my money to buy the things I like”. I don’t like everything…. I like the best things.

BR_ID_8

This last excerpt from one of the participants reveals both the several acts that may constitute violence and a problem that acts both as a predictive factor for abuse and a type of symbolic violence.

3.2. Ageism

The participants mentioned ageism very frequently, so it became an analytical category.

The ageism category reveals older people’s recognition of a phenomenon that, despite occurring frequently, is not always easy to identify because of its veiled nature. Older people recognize violence based on the prejudice against this age group and express their indignation, noting that everyone will age. The social representations that characterize this premise are observed in the following excerpts:

I think that mistreating another person like this, I think that if the person is nervous (...) I think that’s it. But thank God I can’t even say because nobody does that to me. Now I think that... people often don’t like old people because they’re old, they’re old... I have seen many people saying, “because so-and-so is old”, you will never get old, will you? When I see a person saying this… I see the old ladies there... I say, “So you will never get old, will you?”

BR_ID_7

Ah, I don’t know... Some people mistreat, we see them mistreating on TV. It’s very ugly, it’s very cruel to be mistreated... We were once young, and those mistreating are young and will get old... God willing, they will get old, won’t they? Because nobody knows what life will be like for those who mistreat older people, the sick, or the children, when they get old... nobody knows...

BR_ID_6

3.3. Neglect

The participants also recognized that, in association with the problem of ageism, violence against older people often assumes a pattern of a lack of care.

The neglect category includes the social representations unveiled by many older people compared to the other categories. Of the 21 participants, at least eight evoked this type of violence, identifying it through the lack of or poor-quality care. Older people characterize this representation based on the lack of basic care, such as not being given any food or water, as shown in some of the following excerpts:

Ah, there are many, many types. Not listening to the older person is a type of abuse. Not caring, not being careful to avoid a fall, not feeding, isn’t it? It’s a lack of culture, lack of education, and lack of love. Mainly lack of love.

BR_ID_19

Oh, my dear, it’s not a good thing. I think abuse is being bad to the older person. Doing bad things to them, not taking care of them properly, not giving them their medicine on time, not helping them in any way. To me, this is abuse, and a lot of it.

BR_ID_13

Abuse is leaving them there... forgetting about them... not giving them a bath...not...not giving them food, not doing anything is abuse.

BR_ID_21

3.4. Denial

The last analytical category, denial, makes us reflect on how complexities still permeate the theme of violence. Given that it is still surrounded by stigma and conventions, there is a trend towards silence, especially in home settings.

When asked about violence against older people, some participants instinctively reacted by denying its occurrence in their reality so as to protect their family nucleus. It is important for older people to state that they have never been a victim of violence in their homes, as can be seen in the following excerpts:

I’m not mistreated, I never was. Abuse is not treating someone well.

BR_ID_5

It’s really bad... it’s bad to talk about it. I don’t even know what to say because I don’t know what it is. I don’t feel it (...) beating older people, beating the women, beating the men. It must be because they don’t obey them. It must be because when they say something, they respond with anger. I don’t know. I’ve never seen it. And I don’t even know if it happened to anyone I know.

BR_ID_10

I don’t know. Oh, my dear, I don’t know. It never happened to me like this. Here everyone likes me, thank God.

BR_ID_14

Figure 3 shows a cluster diagram allowing the visualization of patterns and connections based on the similarities shared by the words in the analyzed narratives.

The image analysis (it is important to consider the location, color, and size of the nodes, which indicate the proximity or remoteness of the elements) confirms the main categories in this study, considering the arrangement of the words in older people’s narratives.

There is a proximity of the purple elements, which mainly characterize the neglect category, and the green nodes represent the denial category. The ageism category is represented by the brown nodes in the lower-left corner.

4. Discussion

According to the paradigm advocated by the theory of social representations [12], the individual is not a passive subject, a mere recipient of information from the surrounding environment; this individual is an active participant because he/she constructs their social reality and is constructed in it [12].

Therefore, knowing and exploring the social representations of the phenomenon of violence against older people helps us understand and identify possible solutions to this problem. Social representations provide a code that allows one to define and categorize various aspects of the analyzed context, and, consequently, to design interventions to tackle this phenomenon [19].

In line with the results found in this study, violence against older people assumes different characteristics. It is an object of multidisciplinary scope that involves historical, social, cultural, moral, health, and legal issues.

The social representations evoked in the multivariate phenomenon category convey this premise and emphasize the seriousness of the problem because the participants mentioned the different manifestations that violence against older people can assume. In addition to physical violence, this study also found other forms of violence against older people, such as psychological abuse, financial abuse, and neglect.

Violence against older people can have severe physical and mental, financial, and social consequences, including, for example, physical injury, premature mortality, depression, cognitive decline, financial devastation, and institutionalization in nursing homes. The consequences of abuse can be especially severe for older people due to the natural aging process, which can lead to functional dependence/disability, poor physical health, cognitive impairment, poor mental health, and low economic capacity [30]. Moreover, the multiple risk factors (e.g., functional dependence, disability, cognitive and physical impairment, drug use, multigenerational households, and income) make it an even more difficult challenge to address [31,32,33].

Concerning the multifactorial nature of the phenomenon, both in the process of causality and characterization, there is a major difficulty in using a single concept, and the use of the terms maltreatment, abuse, and violence often generates discussion in the literature [34,35]. In this study, they are treated as synonyms.

The results found in studies in this field demonstrate the condition of chronicity of violence, which is in line with the social representations evoked by older people in this category [8,36]. These results demonstrate the occurrence of repeat violence or polyvictimization, that is, the co-occurrence of two or more types of violence over a one-year period, with these events being perpetrated by family members, friends, neighbors, or even formal caregivers [7,9,37].

Based on the interviews, this study found that older people are more susceptible to violence because they require more physical care or have a higher degree of dependence. Thus, functional vulnerability can negatively influence family relationships and lead to family burnout due to unprepared caregivers.

For this reason, it is essential to unveil the meanings and representations of violence since a reduction of the phenomenon may result in a limited understanding of a multicausal, subjective process and trigger different emotions and feelings in the victim [38].

A subjective dimension with a strong influence on the occurrence of violence is revealed by the ageism category.

Ageism refers to the prejudices and stereotypes to which older people are exposed on the basis of their age [39]. This multifaceted process includes three dimensions: (i) the cognitive, involving the stereotypes; (ii) the affective, involving prejudice; and (iii) the behavioral, involving discrimination [40].

Studies have shown that ageism has a negative impact on older people’s health, well-being, and quality of life and that the adoption of negative attitudes toward aging increases the risk of mortality, functional decline, and cognitive decline [30,41].

This premise is in line with our study in that the participants evoked ageism as a form of violence, a veiled process, also as a result of the cultural factors influencing it and the symbolic way in which it presents itself.

Violence is usually considered only in its physical manifestation, making subtle events almost invisible. Domination and exploitation in the exercise of symbolic power are instituted on the relational bases of subjugation and affective and trust relationships that promote this domination over a group of marginalized people [42,43].

According to Beauvoir [44], society views old age as a condition and an unpleasant social category commonly associated with illness, impotence, and physical decline. This population is reserved a place of marginality because their end is death, which is also in line with the participants’ reports.

The subtle prejudice and stigmatization from, for example, the overvaluation of youth, mainly through the media and the beauty industry, feed into these stereotypes because they devalue the characteristics of an aging skin or body, imposing once again a negative sense of aging and the naturalization of this prejudice and symbolic violence [43,45].

Although there is a growing movement of research and exploration of this topic and greater awareness and understanding of elder abuse, symbolic violence often tends to go unnoticed when older people are infantilized or lose their autonomy [46], which aligns with the participants’ reports.

Society perpetrating symbolic violence against older people through stereotyping and ageism makes us reflect on the influence of this mindset on the care process and how neglect can be a consequence of this type of prejudice.

The neglect category evoked by most participants reveals how the lack of care is a relevant form of violence.

Neglect includes the multiple forms of disregard or abandonment of older people, such refusing or omitting essential and necessary care [38].

A review of studies on Brazilian older people published between 2013 and 2017 showed that older women are the main victims of violence in home settings and that family neglect is a highly recurrent type of violence [10]. A study on 169 older people registered in five Family Health Units revealed that 78.7% of the participants had already suffered some type of violence, especially neglect, which accounted for 58.5% [47]. International studies have also found similar results [1,48,49].

However, the available results regarding this type of violence may not be sufficiently reliable, considering the underreporting and non-recognition of neglect as a type of violence, especially in the home environment [9,10].

In this category, the social representations identified in older people’s reports show that discussions and programs to raise awareness and prevent violence against older people are important tools to address this issue. However, despite the progress already achieved, intense work needs to be developed in this area because the subjective issues around this topic are still taboo for society, as can be seen in the social representations of the denial category.

By denying the occurrence of violence and due to a lack of knowledge regarding this, the older people in this study confirm how complex and sensitive this theme has become.

Considering that the main aggressors were revealed to be the older people’s children in several studies [7,50], there seems to be an even greater trend toward silence because it is someone and a problem within the family.

The findings in this category are in line with those of other studies. Reports of refusal and answers such as “I don’t know” are increasingly frequent in the literature and reflect the cultural and moral influence that one should not complain about the family [6,9].

Thus, the participants recognize that violence is a multicausal phenomenon that can occur in different ways, and most of them mention that neglect is the most common type of violence. They believe that violence and maltreatment occur due to their age, which is a characteristic of the ageism and symbolic violence to which they are commonly exposed, despite not being always identified as such.

The relevance and the need to explore this theme are highlighted when the participants evoke social representations of denial and the lack of knowledge about the topic. Thus, it can be concluded that the multiple circumstances and causes of violence against older people in the family environment remain surrounded by complexity and silence.

One of the limitations was the sample size. Future studies should also include the training of health and social workers in issues related to violence against older people, such as the creation and development of accessible support systems that raise awareness of and help prevent this issue while responding to older people’s complex needs. Moreover, this issue should be explored from older people’s perspectives to overcome the moral and cultural limitations of this social and public health problem.

5. Conclusions

The results of this study confirm the importance of researching and exploring this topic. Several studies have been conducted on the lived experience of violence against older people and help-seeking behaviors in recent years. However, more research is needed to gain a more comprehensive understanding of how older people manage their experiences of abuse.

This knowledge is essential to improve the social responses to older people experiencing abuse. For example, there is still little information on what facilitates the disclosure of violence against older people, with much of the research coming from the perspective of professionals rather than older people themselves. Moreover, it is common to use victim services to recruit participants. Therefore, the perspective of older people who have never sought help may be ignored.

The voices of the victims and vulnerable people themselves need to be heard to improve the social response. Studies need to be conducted with samples from different contexts to better understand how older people perceive and manage experiences of violence.

Furthermore, we can analyze the results, namely, those concerning the category of denial, and reflect on new research strategies/methods that may reveal social representations of violence. Researchers require an attitude that encourages approaching the relevant groups to problematize these topics and to raise awareness among the community while deconstructing some paradigms of “doing” science.

Therefore, the involvement of citizens (e.g., older people) in the research process may help researchers find solutions that can help to raise awareness among the elderly population who are victims of this phenomenon.

The involvement of older people in the research process makes science more citizen-oriented and can occur in all or some of the stages of the research cycle: establishing the objectives, study design, data collection, and even data analysis. In addition to adding value to the research, this can increase the adherence and receptivity of the older people subjected to violence, which is still a subject surrounded by silence.