Is Elder Abuse and Neglect a Social Phenomenon? Data from the First National Prevalence Survey in...

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Is Elder Abuse and Neglect a SocialPhenomenon? Data from the FirstNational Prevalence Survey in IsraelAriela Lowenstein PhD a , Zvi Eisikovits PhD b , Tova Band-Winterstein PhD c & Guy Enosh PhD da Director, Center for Research and Study of Aging, Faculty ofWelfare and Health Sciences , The University of Haifa , Haifa, Israelb School of Social Work and Director, Center for the Study of Society,Faculty of Welfare and Health Sciences , The University of Haifa ,Haifa, Israelc Departments of Gerontology and Nursing and Research Fellow atthe Center for Research and Study of Aging, Faculty of Welfare andHealth Sciences , The University of Haifa , Haifa, Israeld School of Social Work and Center for the Study of Society, Facultyof Welfare and Health Sciences , The University of Haifa , Haifa,IsraelPublished online: 09 Jul 2009.

To cite this article: Ariela Lowenstein PhD , Zvi Eisikovits PhD , Tova Band-Winterstein PhD &Guy Enosh PhD (2009) Is Elder Abuse and Neglect a Social Phenomenon? Data from the FirstNational Prevalence Survey in Israel, Journal of Elder Abuse & Neglect, 21:3, 253-277, DOI:10.1080/08946560902997629

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Journal of Elder Abuse & Neglect, 21:253–277, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 0894-6566 print/1540-4129 onlineDOI: 10.1080/08946560902997629

WEAN0894-65661540-4129Journal of Elder Abuse & Neglect, Vol. 21, No. 3, May 2009: pp. 1–41Journal of Elder Abuse & Neglect

Is Elder Abuse and Neglect a Social Phenomenon? Data from the First

National Prevalence Survey in Israel

Is Elder Abuse and Neglect a Social Phenomenon?A. Lowenstein et al.

ARIELA LOWENSTEIN, PhDDirector, Center for Research and Study of Aging, Faculty of Welfare

and Health Sciences, The University of Haifa, Haifa, Israel

ZVI EISIKOVITS, PhDSchool of Social Work and Director, Center for the Study of Society, Faculty

of Welfare and Health Sciences, The University of Haifa, Haifa, Israel

TOVA BAND-WINTERSTEIN, PhDDepartments of Gerontology and Nursing and Research Fellow at the Center

for Research and Study of Aging, Faculty of Welfare and Health Sciences, The University of Haifa, Haifa, Israel

GUY ENOSH, PhDSchool of Social Work and Center for the Study of Society, Faculty of Welfare

and Health Sciences, The University of Haifa, Haifa, Israel

This article discusses findings from the First National Survey onElder Abuse and Neglect in Israel, conducted during 2004–2005under the sponsorship of The Association for Planning and Devel-opment of Services for the Aged in Israel (ESHEL) and the NationalInsurance Institute. The goals were to examine the prevalence andseverity of various forms of abuse and neglect from the victims’perspective, to examine correlates and predictors, and to developprofiles of elders at risk. Data were collected through personalinterviews from a national representative sample of communityurban dwellers age 65 and older, using cluster sampling tech-niques and sampling proportionately both Arab and Jewish elders.

This research was supported and funded by ESHEL—The Association for Planning andDevelopment of Services for the Aged in Israel, which also served as an Advisory Committee,and by the National Insurance Institute.

Address correspondence to Ariela Lowenstein, Center for Research and Study of Aging,Faculty of Welfare and Health Sciences, The University of Haifa, Haifa 31905, Israel.E-mail: [email protected]

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254 A. Lowenstein et al.

The sample was composed of 392 males and 650 females, 89%were Jews and 11% were non-Jews. The instrument included socio-demographic data, health and activities of daily living (ADL), ameasure of safety, and a battery to examine seven types of abuse(physical, emotional, verbal, limitation of freedom, financialexploitation, sexual, and neglect). Findings indicate that 18.4% ofthe respondents were exposed to at least one type of abuse duringthe 12 months preceding the interview, the highest form being ver-bal abuse followed by financial exploitation. The rates were quitesimilar between Jews and Arabs. Women were more exposed tophysical violence and Arab women were the most vulnerable.Physical, emotional, verbal, limitation of freedom, and sexualabuse occurred mostly among partners. The rates of physical,sexual, and limitation of freedom abuse, however, were relativelylow. Financial exploitation was mostly inflicted by adult children.Partners as perpetrators had more chronic health problems andphysical and mental disabilities. Children as perpetrators wereunemployed, had various mental health problems, and were sub-stance abusers, often in a process of separation or divorce andtended to live with the victims. Neglect in answering primary needswas found among 20% of the sample, regarding the 3 months pre-ceding the interview. This high rate might be related to elders tend-ing to avoid seeking help or sharing their needs with their families.When victims sought help it was mostly from medical and healthservices. The findings thus corroborate that elder abuse andneglect is a social problem in Israeli society and has to beaddressed in policy discourse and service developments.

KEYWORDS elder abuse, neglect, social problem, Israel, familycontexts

Elder abuse and neglect is gaining increased visibility both internationallyand on specific national scenes. Social and health care professionals arewitnessing increasing attempts to identify this as a social problem and todevelop appropriate societal responses toward both survivors/victims andperpetrators. Underlying this process, there have been several national andcomparative efforts to describe the phenomenon, assess its extent andepidemiology, and provide a data-based picture on the parties involved—both survivors and perpetrators. Such attempts have taken place in NorthAmerica, Canada, and Europe as well as in Asia. National surveys are beingconducted and have been conducted in England, Germany, Spain, Poland,Australia, and Hong Kong. While the data are not uniform, neither in theissues described nor in their quality, there is a broad consensus among

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Is Elder Abuse and Neglect a Social Phenomenon? 255

researchers concerning the need to provide both quantitative and qualita-tive national databases. Such databases can serve for developing policy,practice guidelines, and standards for the various helping professions andmedical practice and legal interventions, which are increasingly evidence-based (Quinn & Heisler, 2002). Despite the potential usefulness of data-bases, until recently, there has been a lack of such a national database inIsrael. Thus, the purpose of the First National Survey on Elder Abuse andNeglect in Israel, carried out during 2003–2004, was to fill that void (Eisiko-vits, Winterstein, & Lowenstein, 2005).

The aim of this article is to present data on the prevalence and charac-teristics of elder abuse and neglect in Israel, examine the attributes ofvictims and perpetrators, and look at the contextual variables related toabuse and neglect. Such an undertaking is both illustrative of the emergenceof elder abuse and neglect as a social problem and serves as an instrumentfor achieving visibility in order for the issue to be placed on the forefront ofsocial and political agendas.

In most nations, declines in fertility, improved health, and dramaticincreases in life expectancy have generated growing numbers and propor-tions of older people. Such social change challenges existing prioritiesconcerning the individual, family, and social lives. The aging of the popula-tion is a global phenomenon, even if its pace varies in different countries(Kinsella, 2000). Greater longevity also causes a secondary aging process—an increase in the number of disabled elderly who might need more careand support (World Health Organization/International Network for thePrevention of Elder Abuse [WHO/INPEA], 2002). This adds burdens to fami-lies and welfare states, which are the two major pillars of support in old ageparticularly in the face of constraints in welfare state spending (Daatland, &Lowenstein, 2005; Silverstein, Gans, & Yang, 2006). The transition into acaregiving situation can be highly stressful when the conditions requiringcare are chronic and progressive, as are the majority of later-life illnesses,and are combined with the rapid entry of middle-aged women—the tradi-tional providers of parent care—into the workforce (Aneshensel, Pearlin,Mullan, Zarit, & Whitlatch, 1995). Thus this transition might cause abuseand/or neglect in some families.

The extent to which a problem is defined as a social problem has beenassessed according to six criteria: (a) Humanitarian—does the problemcause suffering to individuals or groups within a society; (b) functional—does the problem threaten the fabric of society; (c) usefulness—does theproblem demand investment from a society; (d) social solidarity—social respon-sibility to the more needy in a society; (e) normative values—social normsregarding behaviors and expectations; and (f) prevalence—do we observe alarge number of individuals who are suffering, threatened, or in need ofspecial investments in services and programs to answer their needs(Schneider, 1985; Spector & Kitsuse, 2000). The question is, then, Is elder

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abuse and neglect a social problem in Israel? In this article, we attempt toanswer this question and show that it is indeed a social problem.

The 2006 census showed the population of Israel to be close to sevenmillion, 80% of whom are Jews and 20% non-Jews (Moslems, Christians,and Druze). The aged (65+) make up about 11% of the population (CentralBureau of Statistics, 2006). Differences exist between the Jewish and non-Jewish aged populations. Within the Jewish sector, the percentage of theaged has almost tripled since the creation of the State of Israel in 1948 andis now close to 12%. Among the non-Jews, however, the elderly make uponly 6.1% of the population because of higher fertility rates which impacton the rate of elders that is thus lower than in the Jewish sector (Brodsky,Shnor, & Be’er, 2006). The aging of Israeli society is related to increased lifeexpectancy, which is currently 78.3 years for men and 82.3 for women, andto the composition and the aging of cohorts from previous immigrationwaves. Close to 17% of the Jewish elderly are disabled in activities of dailyliving (ADL). The percentage is higher among non-Jews, nearing 23%.

To determine if elder abuse and neglect constitute a social phenome-non in the multicultural society of Israel, data were needed to understand ifits prevalence is significant. Such a knowledge base is important becausethe existence of the phenomenon and its visibility are not parallel. Untilrecently only several local studies, mainly incidence studies, within both theJewish (Lowenstein & Doron, 2008; Lowenstein & Ron, 2000a, 2000b;Iecovich, Lankri, & Drori, 2004) and Arab societies (Sharon & Zoabi, 1997)were conducted in Israel. However, the point at which scattered signs beginto represent a pattern of behavior that constitutes abuse is hard to identify,and, consequently, measuring prevalence is a special challenge. Dataobtained by various prevalence or incidence studies vary considerablybecause of the differing methodologies and data sources, and relatively fewnational prevalence or incidence studies exist (Thomas, 2000).

LITERATURE REVIEW

A comparative review of literature concerning previous surveys shows thatwhile elder abuse is widely recognized as a significant social problem inmost Western societies, there are very few systematic surveys based onnationwide representative samples. Initially most surveys, which wereexploratory in nature, suffered from a series of methodological problemsand, therefore, the ability to generalize from these samples was limited(e.g., Block & Sinnott, 1979; Douglas, Hickey, & Noel, 1980; Lau & Kosberg,1979; O’Malley, Segars, Perez, Mitchell, & Knuepfel, 1979).

The second generation of studies from the 1980s, led by the well-knownPillemer and Finkelhor (1988) survey in Boston, were of higher methodologi-cal standards in terms of sample and instruments and set the tone for further

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national studies. Pillemer and Finkelhor found around 3.2% overall abuse andneglect. However, the surveys available show a lack of universally agreed oncriteria as to what kinds of abuse against older persons should be included,even though most include physical, verbal-psychological, economic exploita-tion, and neglect. Pillemer and Finkelhor (1988), for example, did not includeeconomic exploitation in their survey, while Yan and Tang (2001) addedsocial abuse, which had not been previously included. The available surveysfurther suffered from a series of weaknesses, such as unclear and inconsistentdefinitions; inadequate measures without a clear conceptual foundation; lackof population-based data; lack of systematic sampling procedures, whichlimited their representativeness and generalizability (Payne, 2005); and differ-ent methods of data collection, such as the one that was carried out inCanada where data were collected by telephone interviews (Podnieks, 1992).

The variations concerning sampling method, sample size, kinds ofpopulations sampled, and age range limited the ability to develop a cumula-tive knowledge base. Many studies were regional or urban only and did notallow for generalizing on the national level (Comijs, Margriet, Smith, Bouter,& Jonker, 1998; Kurrle, Sadler, Lockwood, & Cameron, 1997). Data collec-tion methods also varied widely and included phone and mail surveys andseldom involved face-to-face interviews. Other studies were based on esti-mates of abuse rates usually reported by professionals, facing the problemof insufficient professional awareness of the problem. Again, such variabilityof data collection methods made comparisons problematic.

Instruments used to assess the epidemiology of elder abuse were based onstudies of intimate violence surveys. Violence was measured by the adaptedversions of the Conflict Tactics Scales (CTS2) (Straus, Hamby, Boney-McCoy, &Sugarman, 1996 while neglect was measured by the Older Americans Resourcesand Services (OARS [tool for neglect]), based on ADL standard measurements(Ogg & Bennett, 1992; Pillemer & Finkelhor, 1988; Podnieks, 1992). For eco-nomic exploitation and emotional abuse, specific items were devised in eachsurvey around similar content areas. Most surveys assessed the emotional andphysical state of the victims using measures based on the Diagnostic and Statis-tical Manual of Mental Disorders (DSM) or the Hamilton Rating Scale forDepression and assessed anxiety. In the estimate-based studies, specific report-ing forms were devised that included source, signs of identification, types ofabuse, perpetrator attributes, victim characteristics, and contextual variables andcauses leading to abuse (National Center on Elder Abuse, 1998).

From this brief review, it becomes obvious that there are both conceptualand methodological problems hindering the development of a comprehensivecomparative picture and the presentation of cumulative databases on elderabuse and neglect from a cross-national perspective. The lack of agreementconcerning the definition of elder abuse further exacerbates these difficulties.

Ambiguity and disagreements prevail, particularly in light of the factthat neither researchers nor various disciplinary groups (i.e., social workers,

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doctors, lawyers, gerontologists, nurses) were able to agree on a consensualdefinition and there was no attempt to integrate elder abuse with domesticviolence and economic white-collar crime despite a wide overlap betweenthese phenomena (Payne, 2005). The scope of elder abuse varies bothlocally and cross-culturally as a function of whether a restrictive or a broaddefinition is used and varies from prevalence rates of 3% to studies showingprevalence rates of 6%, with the exception of the study in Hong Kong,which points to 21.4%. In Australia prevalence was estimated at 6% (Kurrle,2004). However, more than one in five respondents indicated that the trueprevalence rate might be 15% or more. In a very recent United Kingdom(UK) national prevalence study, the rates were from 2.4% when only familymembers and care workers as perpetrators were identified; it increased to4% when neighbors and friends were included (O’Keeffe et al., 2007).

Thus, to date it is clear that this domain is extremely complex, containing abroad and diverse set of characteristics and relations occurring within the con-text of familial and trust relationships. It is clear from this review that difficultiesstill exist in constructing a unifying research framework in which to study elderabuse because of a lack of comparison groups, a lack of representative nationalsurveys, and difficulties in measurement (Kosberg, Lowenstein, Garcia, & Biggs,2004; Lachs & Pillemer, 1995; Pillemer & Finkelhor, 1988; Whittaker, 1996).

THE ISRAELI NATIONAL PREVALENCE STUDY

The specific goals of The First National Survey on Elder Abuse and Neglectin Israel were fivefold: (a) to learn the scope of the phenomenon of elderabuse and neglect and its various forms; (b) to attempt to understand thenature of this social issue from the viewpoints of the victims and perpetra-tors; (c) to study the factors leading to abuse and neglect; (d) to developprofiles of elders and family members who are at risk of abuse and neglectand describe the attributes of the perpetrators; and (e) to develop policyrecommendations for intervention and treatment models. Policy should bebased on translating research findings into service development and inter-ventions—evidence-based practice.

The Israeli epidemiological survey attempts to deal with at least someof the methodological shortcomings of other databases. The survey wasconducted among a national representative sample of the urban commu-nity-dwelling elders in Israel and examines all categories of abuse andneglect. For the purpose of this article, elder abuse is defined broadly asdestructive and offensive behavior inflicted on an elder person within thecontext of a trusting relationship. This behavior occurs consistently and withsuch severity and frequency that it produces physical and psychologicalpain, social or financial harm, and unnecessary suffering, loss, or violationof human rights and induces harm to the elder person’s quality of life

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(Hudson, 1989). The broad definition was consciously used for this surveygiven the social-action orientation of the researchers. We believed that atthe time the study was initiated, there was an urgent need to place elderabuse on the social agenda. Thus, a more inclusive definition leads toincreased social and political attention to elder abuse at the expense of per-haps stretching the boundaries of abusive behaviors toward this population.Yet we stayed well within the boundaries of accepted definitions in similarstudies done elsewhere. When operationalized, the definitions were similarto those of the U.S. National Center on Elder Abuse (1998). Defining neglectseems more problematic in light of the distinction between intended andunintended neglect and the controversy as to how neglect should be mea-sured (Comijs et al., 1998; National Center on Elder Abuse, 1998; Podnieks,1992). We identify neglect in our survey as intended when we can identifypurposeful refusal or failure to fulfill and answer an elder’s basic needs inorder to punish or harm him or her (e.g., unclean living conditions, riskylife circumstances, failing to provide basic physical and mental health ser-vices). When these actions occur with no intent, the neglect is defined asunintended (Brandle & Horan, 2002).

METHODS

Sample and Data Collection

The survey used complex sampling techniques based on the data from TheCentral Bureau of Statistics (Central Bureau of Statistics, 1995). First, randomurban statistical areas were selected and in each area a stratified sample wasdrawn based on gender, proportional to the size of the elders in the area.The addresses of the older person’s households were obtained from thelocal municipalities in the designated areas. The refusal rate was close to25%. A total of 1,045 elders (392 males and 653 females) completed usablequestionnaires, constituting a good representation of the elder population inIsrael, including different subgroups by age, gender, education, income,family status, and ethnicity (elders living in sheltered housing, old age andnursing homes, and assisted living facilities were excluded as well as elderssuffering from severe cognitive decline).

Table 1 presents data on the sociodemographic profile of the sample.Half of the elders were between the ages of 70 and 79 (48.6%), 20% werebetween age 80 and 89, and 2.4% were age 90 older. Women made upabout 62% of the sample. Eighty-nine percent were Jewish and 11% werenon-Jews. A little more than half of the elders were married (51.1%) and48.9% were widowed, divorced, or single. At the time of the study 32.8% ofthe participants were living alone and 50% were living with another person.About 19.7% had no formal education, 34.4% had completed primaryschool, 36.9% had completed high school, and 18.9% had higher education.

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About 70% had a low to very low income—about 2,000 Israeli shekels permonth.

Measures

Data were collected by face-to-face structured personal interviews at therespondents’ homes after obtaining their agreement and a letter of consent

TABLE 1 Sociodemographic Attributes of the Sample (N = 1,035)

n %

Sex (N = 1,045)Men 392 37.5Women 653 62.5

Country of OriginIsrael 214 20.5South Europe/Canada/South America 110 10.5Asia/North Africa 232 22.1Russia and Eastern (former) USSR countries 411 39.3Others 78 7.5

Religion (N = 1,044)Jewish 928 88.9Muslim 64 6.1Christian 52 5.0

Degree of Religiosity (N = 1,004)Secular 413 39.5Traditional 358 34.3Orthodox 233 22.2

Education (N = 908)Less than 8 years 179 19.78 years 222 24.49–12 years 335 36.9Higher education 172 18.9

Income (Israeli shekel [IS] per month) (N = 1,006)1,000–2,000 303 30.12,001–4,000 428 42.54,001–6,000 163 16.26,001 or more 76 11.1

Family Status (N = 1,045)Married 534 51.7Not married (widowed, divorced, separated) 511 48.3

M SD

Age (N = 1,035) 73.79 7.42Years in Israel (N = 961) 40.51 20.91Years of current marriage (N = 523) 43.79 13.09Number of people in household (N = 975) 2 1.12Health (N = 1,016) 2.5a 1.47

aOn a 0–5-point scale.

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signed by them. The interviews were conducted by graduate students spe-cially trained by the researchers. Each interview lasted between half an hourto an hour.

Socio-demographic data included information about gender, nationality,age, education, income, marital status, and living situation.

Daily functioning (ADL measure) included needs in daily functioning inthree major domains: personal care and hygiene, household activities, andoutdoor mobility and tasks. In addition, we examined needs in handlingfinancial issues.

Health and mental health status data included several questionsregarding general health condition, hospitalization, and medical treatmentsand questions about personal feelings of safety and feelings of loneliness.

Availability of formal and informal social support and utilization ofcommunity resources measured the elder’s relationships with his or her ownfamily members; social and medical services such as nurses, physicians,social workers, private care companies; and other community services.

Types of abuse included physical, verbal-psychological, restriction offreedom, and sexual abuse. They were measured by the CTS2 Scale (Strausset al., 1996) as well as by short situational descriptions and the respondents’reactions to them—the IRTA (intention to react to aggression) scale. Allwere measured in terms of three circles of close relationships: (a) spouse-partner, (b) children and grandchildren, and (c) other family members orcare workers.

Financial exploitation was measured by a series of nine questions andtheir intensity, such as: “you give money to family members on a regularbasis because they pressure you” and “some family member had you sign adocument about financial issues against your will.” This measure was vali-dated in pilot interviews comparing a group of identified victims of financialexploitation and a comparison group that was not exposed to it.

Neglect was measured by five ADL items regarding the discrepancybetween the frequency of situations in which help was needed and not pro-vided in the following domains: personal care, household chores and foodsupply, personal hygiene, help in getting to a doctor, and help in obtainingneeded devices such as eyeglasses. The respondents were asked for the fre-quency of the occurrence of these incidences during the last 3 and 6 monthspreceding the interview. Their answers were recoded first into one dichoto-mous variable measuring general neglect—1 representing all elders whoreported neglect at least once or twice during the last 3 months and 0 repre-senting no occurrence of neglect. We subsequently coded the same eventsalternatively into two dichotomous variables measuring two types ofneglect: neglect in primary needs, which includes neglect in personal care,nutrition, personal hygiene, and getting medical services; and neglect insecondary needs, which includes neglect in household services and fixingpersonal devices. Thus, the various forms of neglect are measured by the

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reported gap between what has been perceived as needed and what hadbeen provided during the 3 months preceding the interview. This calcula-tion was made to consider the time dimension and the gap that existsbetween the needs of the elders and the active action of meeting thoseneeds as defined in other studies in the Netherlands (Comijs et al., 1998)and in Canada (Podnieks, 1992).

Data Analysis

Data were analyzed in three phases. First, descriptive statistics were calcu-lated; then tests of significance, such as chi-square and t-tests, were con-ducted; and finally, multivariate models (logistic regressions) were calculatedto examine the factors affecting the different types of abuse and neglect inorder to estimate the probability of becoming a victim of abuse and neglect.

RESULTS

Descriptive statistics are presented in Tables 2–10. These tables show the prev-alence of the different types of abuse and neglect and the characteristics of fam-ilies who live in these types of situations compared to those who did notexperience it. Predictors of abuse and neglect are then presented, followed bythe characteristics of perpetrators and the patterns of those seeking help.

Data in Table 2 present the prevalence of the different types of abusebased on gender and ethnicity during the last 12 months preceding theinterviews, and of neglect during the last 3 months prior to the interviews.

The data in Table 2 show that, excluding neglect, 18.4% or 191 respon-dents reported that they experienced one of the different types of elderabuse. Relatively high was verbal abuse (14.2%, relating to the last 12months; however, only 4.3% referred to such incidence of abuse during thelast month before the interview), followed by financial exploitation (about6.4%). Physical abuse and sexual abuse were low (about 2%) and 2.7% suf-fered from limitation of freedom, which included, for example, beinglocked at home or being denied telephone use. Neglect in meeting both pri-mary needs (answering needs in basic ADLs), and secondary needs (such ashelp in obtaining new eyeglasses) was the highest (close to 26%), whereasneglect in meeting primary needs only was about 18%.

Marked differences according to gender were found especially withinthe Arab sector—older Arab women were much more exposed to verbalabuse, limitation of freedom, financial exploitation, and neglect. This mightbe related to the more subservient role of the Arab woman within anextended household. Women both in the Jewish and Arab populations weremuch more subjected to physical and sexual violence (χ2 = 5.020, p < 0.05)and especially more so in the Arab population studied.

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Table 3 presents findings on the prevalence of the different types ofabuse according to gender and relationships to the perpetrators. The data inTable 3 consistently show that most perpetrators of physical, sexual, andlimitation of freedom abuse were spouses-partners, whereas in the area of

TABLE 2 Frequency of Types of Abuse and Neglect, by Gender and Nationality, During the12 Months Preceding the Interview (N = 1,045)

Jewish population (n = 948) Non-Jewish population (n = 97)

Men (n = 355)

Women (n = 593) Total

Men (n = 37)

Women (n = 60) Total

Physical and sexual abuse

3 12 15 – 6 60.8% 2.1% 1.6% 10.0% 6.2%

Verbal abuse 55 79 134 2 9 1115.8% 13.7% 14.5% 5.4% 15.3% 11.5%

Limitation of freedom 9 15 24 – 4 42.6% 2.6% 2.6% 6.7% 4.1%

Financial exploitation 18 42 60 2 7 95.1% 7.2% 6.4% 5.4% 11.7% 9.3%

Total abuse (not neglect)

67 105 172 4 15 1918.9% 17.9% 18.3% 10.8% 25.0% 21.3%

Neglect 76 147 233 6 14 2024.6% 26.8% 26.0% 17.1% 23.7% 19.6%

Total abuse and/or neglect

120 213 333 9 24 3333.9% 35.9% 35.2% 27.3% 40.0% 34.0%

Note: Percentages were calculated according to the total number of respondents within a specific group(e.g., out of 355 Jewish males).

TABLE 3 Frequency of Types of Abuse for the Previous 12 Months and ofNeglect for the Previous 3 Months, by Gender and Familial Closeness (N = 1,045)

Men Women Total

n % n % n %

Physical and Sexual AbuseSpouse 2 0.7 9 2.8 11 1.8Family member 1 0.3 6 0.9 7 0.7Other caregiver – – 1 0.2 1 0.1

Verbal AbuseSpouse 48 16.7 56 17.6 104 17.1Family member 10 2.7 31 5.0 41 4.1Other caregiver 2 0.6 14 2.5 16 1.8

Freedom LimitationSpouse 8 2.8 12 3.8 20 3.3Family member 1 0.3 4 1.0 7 0.7Other caregiver – – 1 0.2 1 0.1

Financial ExploitationSpouse 2 0.2 3 0.3 5 0.5Family member 23 2.2 18 1.7 41 3.9

Neglect 82 23.8 122 26.5 243 25.6

Note: Percentages are based on the number of respondents who answered each question.

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financial exploitation most perpetrators were adult children. Only a verysmall percentage of perpetrators were care workers.

It is quite obvious that such behaviors have harmful impacts on thevictims. For example, about 10% of those suffering from physical and sexualabuse needed medical treatment and about 5% were referred to an emer-gency room. The impact of financial exploitation on the victims was mostlyemotional damage (30% of those exposed to it) and, of course, economicdeficits (reported by close to 19% of those exposed to it) as well as socialisolation (reported by 17%).

Data in Table 4 present the prevalence of different categories of neglectaccording to gender during the last 3 months preceding the interviewamong those who reported that their needs were not answered.

The data in Table 4 indicate that a large gap exists among those whoneeded medical treatment and did not receive it—about half of thosereporting neglect; also about half of those needing help with services athome did not receive them. A relatively high percentage of women (about32%, compared to only 19% among men) did not receive proper nutritioneither because they were too disabled to buy food or could not prepare itby themselves. Overall, women reported more neglect in receiving appro-priate medical care and assistance with personal hygiene and nutritionwhile men reported more neglect in household chores. This might berelated to a gender-based division of labor.

Data in Table 5 show the frequency of neglect in answering primary aswell as secondary needs. The data indicate the following among thoseneglected by not having their caregivers respond to their primary needs:nutrition, about 8% were neglected during the past 3 months, 1.5% duringthe past month, and about 2% during the past week; personal hygiene,

TABLE 4 Frequency of Neglect During the Last 3 Months Preceding the Interview, byGender

Total neglecta (N = 243)Occurred at least once or twice

in the last 3 monthsb

Needing Total Neglected

Men (n = 82)

Women (n = 161)

Service typeb n %a n %a n %a

Medical services 124 51.0 42 55.3 82 54.7Nutrition 57 23.5 13 18.8 44 31.7Needing devices (hearing, eyeglasses),

house repairs100 41.2 42 57.5 58 42.0

Personal hygiene 62 25.5 22 34.9 40 34.2Home care services 123 50.6 34 49.3 89 59.7

Note: Frequency of neglect is defined as the gap between needs and answers to meet those needs.aBased on all reported neglect. bReports of neglect may appear in multiple categories.

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about 3% during the last 3 months or past week and 1.5% during the lastmonth; receiving medical help, about 8% did not receive such needed careat least once or twice during the past 3 months, 4% during the past month,and 2% during the past week. As far as secondary needs are concerned:about 8% did not receive needed services at home, such as fixing brokendevices, during the past 3 months and 6.3% did not get eyeglasses, hearingaids, and so on, taken care of during the past 3 months. In many cases ofneglect, the elders also suffered from another type of abuse, such as verbalabuse or financial exploitation.

For each type of abuse and for neglect, descriptive statistics of familialand sociodemographic attributes were calculated, comparing those sufferingfrom abuse and/or neglect to those elders who did not report it. Tables 6–8present examples of verbal abuse, financial exploitation, and neglect.

Data in Table 6 relate to verbal abuse. No differences on all attributeswere found among men suffering from it compared to the nonsufferers.However, differences were found among women—those suffering from ver-bal abuse were younger (t = 2.348; p < 0.05) with a lower level of education(t = 2.415; p < 0.01) and they tended to live more with others or in multi-generational households (t = -2.776; p < 0.05).

Data in Table 7 relate to financial exploitation. No significant statistical dif-ferences were found, according to gender, when comparing the two groups.Data in Table 8 present findings on neglect. As far as men are concerned, thosesuffering from neglect had lower income as per the comparison group (t =3.109; p < 0.001), and their health situation was more problematic (t = 5.554; p< 0.001). Women who suffered from neglect also had lower income (t = 3.081;p < 0.01), a lower educational level (t = 5.810; p < 0.001), and their health situa-tion was also more problematic (t = 5.543; p < 0.01).

Data in Table 9 present the findings from the logistic regression show-ing the significant predictors of the different abuse types and neglect.

TABLE 5 Frequency of Different Types of Neglect

Neglect type (N = 168, 16.1%)

Neglect frequency

NeverOnce or twice in 3 months

Once or twice a month

Once or twice a week

Nutrition 752 25 12 2093.0% 3.1% 1.5% 1.9%

Personal hygiene 673 23 14 2591.6% 3.1% 1.9% 3.4%

Medical services 781 71 36 1786.3% 7.8% 4.0% 1.9%

Home services 712 64 35 2485.3% 7.7% 4.2% 2.9%

Aids 715 51 31 1887.7% 6.3% 3.8% 2.2%

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TABLE 6 Demographic and Familial Attributes of Victims of Verbal Abuse, by Gender

Men Women

AbuseWithout abuse Abuse

Without abuse

M SD M SD M SD M SD

Age 74.75 5.99 75.76 7.15 70.91 7.37 72.93 7.45Years in Israel 41.31 19.47 39.69 21.95 47.05 13.18 40.10 21.35Income 2.57 0.99 2.30 1.01 2.03 0.83 1.96 1.03Number of years married 44.91 9.25 45.62 12.69 45.30 9.86 42.21 14.21Number of persons living at home 2.17 0.82 2.15 1.10 2.20 0.92 1.89 1.19Degree of religiosity 1.70 0.66 1.77 0.82 2.01 0.74 1.86 0.82Education 2.67 1.12 2.79 1.13 2.11 0.93 2.51 1.09Health status 2.44 1.14 2.67 1.46 2.2 1.53 2.47 1.45

N % N % N % N %

Living arrangementShared 50 18.5 220 81.5 58 22.5 200 77.5Without spouse 7 6.0 109 94.0 30 7.9 349 92.1

NationalityJewish 55 15.8 294 84.2 79 13.7 499 86.3Other 2 5.4 35 94.6 9 15.3 50 84.7

TABLE 7 Demographic and Familial Attributes of Victims of Financial Exploitation, byGender

Men Women


Without abuse

M SD M SD M SD M SD

Age 76.60 6.54 75.54 7.03 70.87 6.79 72.77 7.43Years in Israel 47 15.59 39.79 21.70 45.27 18.25 40.73 20.73Income 2.26 1.19 2.34 1.00 1.94 0.94 1.98 1.01Number of years married 42.71 14.35 45.54 12.12 39.19 14.58 43.03 13.45Number of persons living at home 2.00 1.26 2.15 1.05 1.80 1.14 1.93 1.16Degree of religiosity 1.90 0.72 1.74 0.80 1.98 0.70 1.87 0.82Education 3.00 1.37 2.76 1.1 2.22 0.99 2.49 1.08Health status 2.11 1.49 2.67 1.45 2.23 1.39 2.45 1.46

N % N % N % N %



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As the data indicate, for physical and sexual abuse, two factorspredicted 33% of the variance, namely familial situation and level of educa-tion. A married elder is more prone to this type of abuse as well as an olderperson with a lower level of education. For verbal abuse, the followingwere significant predictors and predicted 18% of the variance: ethnicity(Jewish elders had more probability of suffering from it) and married elderswith a lower educational level but with a higher income level. Additionally,those feeling neglected and more lonely who had more contacts with medi-cal services (probably due to ill health) have higher chances of sufferingfrom verbal abuse. Limitation of freedom was predicted by three variables,which explain 21% of the variance: familial status (married more thanunmarried); those feeling higher degrees of loneliness; and those employingcare workers (apparently being more frail). Regarding financial exploitation,only one variable, the subjective feeling of being neglected, was significantand predicted 14% of the variance. The more one feels neglected, thehigher the chances that he or she will be exposed to financial exploitation.As for neglect, four variables predicted 25% of the variance. Namely, Jewishelders more than non-Jewish, the more ADL needs the higher the probabil-ity of being neglected, and the more the older person needs economicassistance, the more he or she might suffer from neglect. In other words,elders who exhibited higher degrees of frailty and had limited financialresources were more susceptible to neglect. This also was reflected in them

TABLE 8 Demographic and Familial Attributes of Victims of Neglect, by Gender

Men Women


Without abuse

M SD M SD M SD M SD

Age 74.81 6.76 73.13 7.14 72.87 7.74 72.91 7.46Years in Israel 40.12 21.91 40.04 21.38 40.90 20.67 40.06 20.94Income 1.99 0.83 2.37 1.00 1.68 0.68 2.04 1.03Number of years married 44.14 12.05 45.87 12.53 42.39 13.32 42.71 13.72Number of persons at home 2.04 0.83 2.22 1.13 1.87 0.98 1.96 1.23Degree of religiosity 1.85 0.73 1.76 0.82 1.99 0.80 1.87 0.81Education 2.79 1.12 2.72 1.12 2.25 1.03 2.56 1.09Health status 1.78 1.31 2.74 1.43 1.81 1.39 2.56 1.43

N % N % N % N %



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268

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being in closer contact with medical services because of their health needs.Feelings of loneliness were approaching significance.

To sum up, apparently personal and familial resources were related tomost abuse types, except for financial exploitation, and to neglect. Marriedelders with ill health, thus having more ADL needs that prompted them toseek medical assistance, with a lower educational level and needingeconomic support were more prone to being abused or neglected.

At this point, we will sum up the main characteristics of the perpetrators.For physical and sexual abuse, if it occurred between spouses/partners, therate of aggressive men was high and most of them lived together with thevictims. The perpetrators suffered from physical and mental health prob-lems and some from of dementia. Regarding this type of abuse by adultchildren, they mostly suffered from either alcohol or drug addictions, livedwith the victims, were unemployed, and had marital problems—were eitherdivorced or separated. Verbal abuse among spouses/partners occurred byboth men and women who were living together and, again, had physicaland mental health problems with some suffering from dementia. Amongadult child perpetrators there was a higher rate of daughters, many ofwhom were unemployed with marital problems and some suffered frommental problems and addictions. Regarding limitation of freedom, similarattributes were found both among spouses/partners and adult children asperpetrators. As for financial exploitation, most perpetrators were adult chil-dren, again with marital problems, mostly unemployed, and with mentalproblems and addictions. Regarding neglect, among spouses it was mostlymen who neglected their wives/partners but were themselves sufferingfrom the above attributes. There were no specific attributes that we can pin-point regarding adult children who neglected their older parents.

Data in Table 10 present findings on the rate and frequency of applyingto or using different community services. The data indicate that most contact,of at least once a month, was with medical services, mostly with the familyphysician (about two-thirds of respondents who were abused) and with thenurses at the health clinics (about 40%), followed by home care workers(22%) and use of pensioners clubs (21%). Additionally, 18% were in contactwith nursing companies (which provide home care services under Israel’sLong Term Care Insurance Law of 1988) and 16.5% approached social work-ers at the local welfare offices in the different municipalities. However, a rela-tively large percentage of abused or neglected elders did not approach or useany of the available community services.

DISCUSSION

The national epidemiological study is the first of its kind in Israel. The find-ings provide estimates for the extent of abuse and neglect among older

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people living in their homes in the community. The data were collected andanalyzed with policy and service implications in mind. The strength of thestudy lies in its examination of a representative sample of 1,045 older peo-ple in Israel, which was rigorously selected. Face-to-face interviews werecarried out in the respondents’ homes, and the sample was not an identifiedsample, as in many previous studies. The response rate was quite high—about 75% agreed to be interviewed. In addition, the study differentiatedand compared the attributes of abused and neglected elders to those inter-viewed who were not subjected to abuse and/or neglect. Also, rigorousmethods of measurement were employed, using a relatively large battery ofquestionnaires and addressing three areas: abuse and/or neglect amongspouses, abuse and/or neglect among elder parents and their adult childrenand other family members, and abuse and/or neglect relating to relation-ships with care workers. This was done to address some of the difficultiesinherent in previous studies, as outlined in the literature review.

The major stakeholders—such as representatives from the Ministries ofWelfare and Health through their participation in ESHEL (The Associationfor Planning and Development of Services for the Aged in Israel), whichfunded the study, and the National Insurance Institute—were involved inconsultation about study design, serving as a steering advisory committee.

The findings point toward much higher estimates of elder abuse thanprevious studies, including the recent UK prevalence study (O’Keeffe et al.,2007), that usually range from 4 to 6%. The UK study, however, indicatesthat “there are good reasons for thinking that our estimate is conservativeand that some mistreated people, including some of those who are mostvulnerable, will not have been included in our survey” (National Center onElder Abuse, 1998, p. 4). Also, most studies, including the UK study, relate

TABLE 10 Frequency of Approaching or Using Different Community Services

Frequency of Approaching Existing Services

At least once a month

At least once a year

Did not approach

N % N % N %

Social worker (welfare department) 171 16.5 174 16.8 692 66.7Social worker (in other services) 30 2.9 62 6.0 936 91.1Nurse at health clinics 395 38.4 209 20.3 425 41.3Family doctor 699 67.4 216 20.8 122 11.8Volunteer 32 3.2 7 0.7 973 96.1Day center workers 55 5.4 4 0.4 962 94.2Seniors club workers 214 21 15 1.5 791 77.5Nursing company 182 17.9 41 4.0 791 78.0Home care worker 226 22.1 7 0.7 788 77.2Supportive neighborhood 27 2.8 27 2.8 927 94.5

Note: Percentages are based on the number of respondents for each item.

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to events of abuse and neglect occurring within the last 12 months preced-ing the interview, whereas our measures, especially those of neglect, relateto the last 3 months preceding the interview.

The overall estimate of being subjected to at least one type of abuseand to neglect in primary needs was about 18%. These findings correspondto the data from Hong Kong that found a prevalence of 21.4%, but lookedonly at physical, verbal, and social abuse (Yan & Tang, 2001). Relativelyhigh in our study was financial exploitation (about 6%) and neglect. Inmany instances these two types occurred jointly. In the recent UK study,neglect was also the predominant form of mistreatment, even though therates are low (1.1%). The prevalence of neglect and financial exploitationstand out against the perceptions in the literature of abuse as physical vio-lence. Verbal abuse in our study was close to 6% during the last 3 monthsprior to the interview, similar to the Finnish study (Kivela, Kongas-Saviaro,Kesti, Pahkala, & Ijas, 1992). In the Dutch study it was 3.2% (Comijs et al.,1998), but in Hong Kong they found almost 21% of this type of abuse. Thelatter study, however, was conducted on an unrepresentative sample ofelders in sheltered housing and community centers.

The data show that the risk factors for abuse and neglect were similarto those presented in the literature, that is, living arrangements and familyrelations, lack of personal resources such as income and education, as wellas health and ADL problems and subjective perceptions of loneliness andfeelings of being neglected. Regarding living arrangements, one has to bearin mind, however, that almost all those married lived together and the rateof multigenerational households in Israel is relatively high (about 24%) ascompared to other countries (Brodsky et al., 2006).

Women were more likely than men to experience certain forms ofelder abuse, such as physical and sexual abuse and financial exploitationand neglect. For physical and sexual abuse, as well as for verbal abuse andlimitation of freedom, a higher percentage of the perpetrators werespouses/partners and the rate was higher among Arab women. The status ofolder Arab women is still much lower than within the Jewish sector. Wifeabuse in general was found to be higher in the Arab community than in theJewish sector (Haj-Yahia, 1996; Sharon & Zoabi, 1997). Given the patriar-chal structure of the family in the Arab culture, women are less visible andfewer can be encountered in the various social systems that deal with eld-erly in general and elder abuse in particular. Thus the social problem ofelder abuse among women may be significantly higher but undetected.

The higher rates we found are evidence that, indeed, elder abuse andneglect is a significant social phenomenon in Israel and should beaddressed as such in the public and political discourses, as well as by thescientific community, justice system, and clinical community. It should benoted that although general awareness of elder abuse began to surface inIsrael only in the late 1980s, the country’s welfare authorities and legal

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establishment long before have had to deal with cases of abuse andviolence directed at older people. Thus, throughout the years Israel hasenacted various laws to cope with such abuse (a detailed description of thevarious laws relating to abuse can be found in Lowenstein & Doron, 2008).Also, a mandatory reporting law exists—Amendment 26 to the Penal Code,1989.

It was interesting to note that physical abuse usually occurred jointlywith other types of abuse, which might imply the so-called aging out of thistype of violence with the parallel tendency to turn to inflict other types ofmistreatment. Also, verbal abuse, financial exploitation, and neglecthappened together many times. This might be congruent with the literatureon violence among partners that shows verbal abuse as a first step in theprocess of mistreatment. It should be said that such transformation of phys-ical abuse to other more psychologistic forms lowers its visibility but not itspotentially harmful effects, therefore requiring special attention in under-standing the mechanisms of such transformation. The relatively higher ratesof verbal abuse might in a way correspond to data from the cross-nationalOASIS study, in which Israel was a partner, and where higher levels of bothfamily solidarity and family conflict were found (OASIS – Old Age andAutonomy: The Role of Service Systems and Intergenerational FamilySolidarity – was funded under the 5th framework program of the EuropeanUnion, Contract No. QLK6-TC1999-12182). These results might stem frommore open lines of communication in families and the willingness toexpress both positive and negative emotions (Katz & Lowenstein, 2003;Lowenstein, 2007).

The high rates of neglect were somewhat surprising because in boththe Jewish and Muslim religions respect for elders and “honor thy father andthy mother” are imbedded within the religion and cultural traditions. Onepossible explanation is related to the unwillingness of older parents whovalue their autonomy to burden their children and become dependent onthem even though their physical situation might deteriorate and their needfor help increase. This is congruent with data from the qualitative IsraeliOASIS study (Katz & Lowenstein, 2003) and the recent qualitative study ofelder abuse (Winterstein, Eisikovits, & Lowenstein, 2007).

Despite the deleterious effects of abuse and neglect, the reactions ofthe victims were moderate, especially regarding financial exploitation. Prob-ably those elders dependent on others experienced lower self-esteem, asfound also by Talbott (1990) in his study of older mothers. However, theeffects of abuse and neglect on the quality of life of the elders are quite dev-astating and should be taken into account when developing policies andservices. When elders turned to community services for help, it was mostlyaround health and ADL problems, which are apparent in increasing old agein general. The abused elders suffer from “double exclusion,” both as eldersand as abused older persons. However, the high rate of turning to health

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and medical services points to the importance of activating the healthsystem to identify, refer, and treat cases of abuse and neglect.

The attributes of the perpetrators are similar to those found in previousstudies. Physical and sexual abuse and limitation of freedom mostlyoccurred among spouses and were inflicted more by men who had physi-cal, functional, and mental health problems. Adult children perpetratorsmostly lived with the victims; suffered from emotional and mental prob-lems, addictions, and marital problems; and in many instances were unem-ployed. In many cases interdependency between victims and perpetratorsexisted. However, contrary to expectations, relationships with home careworkers did not lead to abuse and/or neglect and in many cases, home careworkers were sources of support to the older respondents.

To sum up, the data point to relatively high prevalence rates of certaintypes of abuse and neglect where in many instances there was a combinationof being exposed to more than one type of abuse. We have to bear in mindthat there are some subgroups that are more at risk of suffering from abuseand neglect, such as older women and, especially, older Arab women; thosewith low socioeconomic status; and those who are socially isolated or whoreported feelings of neglect, loneliness, or not feeling safe in their homes.Data clearly show that social support and especially family support act as abuffer against stress situations in general and impacts the quality of life ofelders (Antonucci & Akiyama, 1991; Lowenstein, 2007; Silverstein & Bengtson,1994). Thus, many of those older persons who were exposed to abuse and/orneglect were at a point of accumulation of disadvantage (Pillemer, 2007).

Before turning to some policy recommendations, a word of caution aboutthe limitations of the study. First, the data relate only to the urban older popula-tion in Israel. In addition, we did not interview demented elders or those suffer-ing from mental problems. Elders in old age and nursing homes also wereexcluded. These subgroups seem to be at risk and should be further researched.It was believed at the onset of this study that there are a set of differential inter-vening variables in institutional abuse that are related to the institutional contextand deserve separate attention and investigation. Also, the study is cross-sectional and reflects a picture at one time point, and thus longitudinal orprospective studies are needed. Furthermore, the data were collected based onthe subjective experiences of the respondents, without checking against moreobjective screening data as in cases of identified abuse and neglect.

Based on the findings presented here, we present the following mainrecommendations. First, there is a need to bring to public awareness thescope and epidemiology of the phenomenon in order to overcome preva-lent myths about the inexistence or low rate of abuse and/or neglect amongIsraeli elders. Because there is a relatively high degree of religiosity in thesociety, faith leaders should become aware and be educated and involvedin helping to identify elder abuse as well as collaborate in planning preven-tion and intervention strategies. Older people should be aware of the role

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that faith leaders can play and that they can approach them for counseling.Second, it is essential to try to identify elders at risk through universal healthservices that are nonstigmatic but still capable of handling or referring theclients in need of help. Third, given that most abuse in the communityoccurs within the family and by family members, such as spouses and adultchildren (depending on the kind of abuse), it is imperative to focus onfamily centered treatment models for abusers while simultaneously workingwith as many family members as possible within a family system, focusingon strategies of conflict resolution. Fourth, there is an urgent need todevelop solutions for adult children who live with abused elders and areknown to suffer from mental illness and various forms of addictions. Muchof the abuse was caused by dependency of elders on these children anddependence of these children on their older parents. Creating boundariesand distance between such children and their parents may have a significantpreventive effect. On the other hand, as older persons are reluctant to com-plain of financial exploitation, for instance, particularly when the perpetra-tors are their adult children, which is often the case, special programs toidentify this type of abuse should be developed.

It appears that elder neglect is emerging as a major social problem inIsrael and that it crosses gender boundaries. Special attention should bepaid to identify neglect both among the general population and amongvictims of abuse. More resources should be invested in developing specialservices for the Arab elders, and especially older women. Finally, contraryto expectations, care workers seldom abused the elders in their care andwere one of the major sources of support to the abused older persons. Thismay be explained by the fact that an array of private and nonprofit organi-zations were established to screen and supervise these workers. Also, manyof the abused elders were still in relatively good physical condition andwere thus less dependent. This might explain the lower rate of abuse bycare workers when compared to other studies. In addition, the web offamily relations that exists in the Israeli culture serves as an additionalmechanism of social control. Given the importance of this human resource,these care workers should be trained and provided with skills to identifyabuse and collaborate with professionals on preventing and treating abuse.

REFERENCES

Aneshensel, C. S., Pearlin, L. I., Mullan, J. T., Zarit, S. H., & Whitlatch, C. J. (1995).Profiles in caregiving: The unexpected career. San Diego, CA: Academic Press.

Antonucci, T. C., & Akiyama, H. (1991). Social relationships and well being. Generations,15, 39–44.

Block, M., & Sinnott, J. (Eds.). (1979). The battered elder syndrome: An exploratorystudy. Unpublished manuscript, University of Maryland.

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Is Elder Abuse and Neglect a Social Phenomenon? Data from the First National Prevalence Survey in...

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