Elder Abuse Prevention in Brazil, Norway and Slovakia: a Narrative Review

Elder abuse is globally recognised as a human right and public health problem affecting the quality of life and wellbeing of people being exposed, but it also affects the society in terms of economic costs of the consequences of abuse. Elder abuse is expected to increase as the world's population is getting older.

Krug et al. (2002) described violence as an umbrella term, and many terms are used to describe the phenomenon of negative actions that may occur between people in close relations: violence, abuse, mistreatment, maltreatment and neglect. In this article, ‘abuse’ will mainly be used, but also ‘violence’. The WHO (2022) defines elder abuse as a single or repeated act, or a lack of appropriate action, occurring within any relationship where trust is expected, which causes harm or distress to an older person aged 65+. Abuse constitutes a violation of human rights, and it includes physical, sexual, psychological, and emotional abuse; financial and material abuse; abandonment; neglect and actions causing a serious loss of dignity and respect (Hall et al. 2016; Silva et al. 2018). Elder abuse can take place in institutions (often nursing homes) and within family settings (older adults who depend on other people to perform complex and basic activities are those most exposed to situations of abuse) or having a more structural ground taking place in the way society treats or lacks to treat the elderly population (Atkinson et al. 2023; Máriássyová & Ujházyová, 2021). Although the issue of elder abuse is commonly viewed as a problematic dyadic relationship between victim and perpetrator, Jackson & Hafemeister (2016) and De Liema et al. (2018) described the issue at the first as a monolithic phenomenon (dyadic relationship problems) and later as a multidimensional phenomenon that requires a multidisciplinary approach from various fields, including public health policies, psychology, social work, medicine, justice, criminology, sociology and gerontology.

In older adults, the decline in functional capacity, the impact of polypharmacy, cognitive deficits and age-related physiological changes can lead to impaired mobility and the worsening of clinical disorders. These health challenges, added to the context of abuse, can lead to reduced quality of life and increased risk of institutionalisation, hospitalisation and mortality (Klinedinst et al. 2022; Zilbershlag et al. 2023). Additionally, older adults may experience social isolation due to declining physical and mental health, sensory impairment, a lack of supportive relationships and immigration status, among other factors (Gallo et al. 2022). Changes that come with age may often increase vulnerability. The causes of elder abuse vary, with research highlighting age discrimination, mental and physical health problems in close relationships or as a result of the societal structure, and family and carer problems (Shepherd & Brochu, 2021; Wei & Balser, 2022). Elder abuse in close relationship spheres can occur as a result of family disputes or caregiving stress related to responsibilities in taking care of older family members. Abuse of older family members may also occur due to financial burdens, a lack of support and emotional stress. However, elder abuse in close relationship is added to the structural dimension of violence that in this research can be exemplified by a lack of educational programmes, slow implementation, inadequate revision of laws and regulations, and poorly developed support and resources which contribute to weaken the prevention chain (Atkinson & Robertson, 2023).

This study is based on new prevention strategies aiming at the prevention of stages of a disease and operating at the levels of primordial, primary, secondary, tertiary and quaternary prevention strategies within multidisciplinary collaboration from individual level, through community practice to national policy (Kisling & Das, 2023; Martins et al. 2018). Primordial prevention focuses on social and environmental conditions to reduce risk factors for the whole population. Laws and national policies often promote these measures. This prevention strategy is relevant to avoid elder abuse with the good national policies and laws with focus on social conditions like socioeconomic system within social welfare. Primary prevention targets the whole population to educate them and prevent exposure to risk factors; secondary prevention focuses on the early identification of actual elder abuse and stopping the occurrence; and tertiary prevention targets the treatment of elder abuse victims and focuses on preventing the recurrence of abuse and mitigation of this type of actions (Sousa et al. 2021; Day et al. 2017). According to Martins et al. (2018), quaternary prevention primarily concerns the risk of exposure to overtreatment or overdiagnosis. However, it is also important to protect individuals from unnecessary medical interventions. Regarding elder abuse, it is important to consider whether this preventive strategy will have an impact on the older adults over time and how they may react. The topic of quaternary prevention is currently being debated in the medical field, and it has not yet been fully integrated into medical practice.

In this study, an older adult is defined as someone aged 65 or over, and the focus is on describing common elder abuse prevention measures in three selected countries.

Comparing vastly different countries might seem to have difficulty in identifying the fine-grain differences which are more apparent when studying similar countries, whereas comparing similar countries may miss the bigger picture of transnational differences. The researchers selected three different countries to maximise diversity along the dimension in question. Brazil represents a developing country with a rapidly ageing population and unique challenges in elder care, highlighting strategies in resource-constrained settings. Norway exemplifies a Scandinavian model with a robust welfare system, offering insights into elder abuse prevention in a context of social equality and extensive public services. Slovakia offers a perspective from a post-socialist European country, shedding light on the evolution of elder abuse prevention amid transitioning policy frameworks. The latest statistical overview of elder abuse in each of the three countries is presented. In order to investigate elder abuse prevention, the researchers from Norway created a network of researchers from the three following countries to participate in this study.

Elder abuse is a multifaceted issue that has implications for individuals and societies worldwide, and the strategies for prevention vary depending on the context. This study outlines the common preventive measures adopted in three different countries. In order to comprehend and elucidate the phenomenon of abuse, as well as its connection to the various dimensions of elder abuse and prevention, the ecological framework, specifically the multisystemic Bronfenbrenner's ecological framework (1979) along with Krug et al. (2002), is employed. This framework offers a perspective encompassing four interconnected levels, which evolve over time in what is known as the chronosystem. It highlights the intricate factors associated with elder abuse: (1) The micro-level pertains to individuals' relationship with themselves and their immediate environment, considering demographic factors like education, income or age within smaller social circles like family and friends. This includes experiences of abuse during childhood and the physical and mental health of individuals. (2) The meso-level describes the closer relationships between individuals and their immediate environment, particularly within the family context. For example, it examines the dependence between older adults and their caregivers who are often relatives and the living conditions in which they coexist. (3) The exosystem-level refers to the broader social milieu that indirectly affects the individual, encompassing social networks, community-based activities, and community or local social and healthcare providers. Here, the quality and availability of evidence-based knowledge among healthcare providers can have an impact on elder abuse. (4) Macrosystems are shaped by the societal norms, traditional cultural values, criminal justice policies and social welfare systems of a country. Inadequate legislation or socioeconomic changes within the social welfare system can have adverse consequences for elder abuse. All these levels are complementary and interconnected, and the individual's circumstances within these processes must be considered over time, as denoted by the chronosystem level (Bronfenbrenner, 1979). Furthermore, the ‘World report on violence and health’ (WHO, 2002) outlines levels of abuse prevention and public health intervention that closely align with the levels of Bronfenbrenner's ecological framework and continue to hold relevance to this day.

Results revealed that research in this area has utilised a diverse range of methodological approaches to investigate elder abuse prevention within the three selected countries. Three main categories for the implementation of public health policies in Brazil, Norway and Slovakia for the prevention of elder abuse were identified. These categories are as follows: (1) proactive approach within primordial and primary prevention, (2) interdisciplinary collaboration within primary and secondary prevention, and (3) education for healthcare professionals within all forms of prevention.

The prevalence of elder abuse is becoming an increasingly urgent public health issue (Sousa et al. 2021; Botngård et al. 2020; Paiva & Tavares, 2015; Blay et al. 2017; Galisova & Flimelova, 2014). To effectively address this problem, governments and organisations have implemented various measures to prevent violence and protect older adults.

In Brazil, elder abuse is a growing concern. In response, the Brazilian government has implemented various laws, policies and prevention measures including public campaigns aimed at raising awareness and reducing stigma, as well as support hotlines and social services for victims. Non-governmental organisations also play a crucial role in the prevention of elder abuse in Brazil, providing legal and psychological support to victims. Despite these efforts, much work remains to be done to improve the effectiveness of prevention measures and reduce the rates of elder abuse in Brazil (Sousa et al. 2021; Rodrigues et al. 2017; Blay et al. 2017).

In Norway, the prevention of elder abuse is still developing. The public health system includes mandatory protection of citizens from abuse in the context of providing care for patients and the recipients of social services according to the Norwegian Act on General Health Services §3-3a and the Act on Specialised Health Services §2-1f (Ministry of Health and Care Services, 2023). Some Norwegian municipalities have adopted a model called SafeEst – TryggEst in Norwegian – which aims to create an interdisciplinary action between the police and social care organisations and to help prevent, uncover and deal with cases of abuse against vulnerable adults (Ministry of Health and Care Services, 2023; Elvegård et al. 2020). In addition, Norwegian Centre for Violence and Traumatic Stress Studies (2022) described that the government has implemented a national programme of violence prevention, including training programmes for healthcare providers and a focus on inter-organisational cooperation. This public webpage provides an overview of support and protection services, including information on a violence and abuse hotline, local crisis shelters, centres for victims of assault, protective services for older adults, a national contact line, anger management services and family counselling services. There are contact services for both victims of domestic violence and people who are vulnerable or suspected of being at risk. Botngård et al. (2020) pointed out that explicit laws against child maltreatment, intimate partner violence and sexual violence all exist in Norway, but there is no specific law concerning elder abuse. The preventive home visits (PHV) which are already provided are well-organised forms of care that map individual needs and support coping strategies for older adults. It is a targeted proactive approach with a preventive effect aimed at ensuring well-being (Cronfalk et al. 2017). Through visits, interdisciplinary cooperation for health care in the community is facilitated and the feeling of safety is increased, and at the same time, information about possible help for abuse is disseminated individually.

In Slovakia, elder abuse prevention measures include training programmes for healthcare providers, crisis centres for victims and public awareness campaigns targeting both older adults and their families (Čereyová, 2020). A national action plan is in place to combat violence against older adults (Máriássyová & Ujházyová, 2021). However, implementation of these measures remains a challenge due to limited funding and resources, and there is a need for continued evaluation and improvement of the effectiveness of these measures. Cintulova and Kafkova (2021) stressed that the intervention centres, in close cooperation with the police and other institutions, generally provide victims of domestic violence with comprehensive counselling services consisting of legal, socio-legal and psychological assistance to older adults threatened by domestic violence. The centres are legally obliged to aid the older person seeking assistance within 48 hours of receiving a copy of the police record. The services they provide consist of social therapy activities, assistance in exercising rights and legitimate interest, and in the making of personal arrangements; the services are provided as outpatient, field and residential services. Intervention centres can also be contacted in an informal way by older adults or someone in their vicinity such as neighbours, acquaintances or friends who notice potential signs of threats against a vulnerable older person; valuable advice and information is then offered to ensure effective assistance. The intervention centres assess the family situation to see if this is indeed a case of domestic violence and provide an overview of legal services and other options available to the older adult; they also coordinate information between institutions within the framework of interdisciplinary cooperation and educate the relevant professions, including the police force, social workers, carers, etc. Intervention centres either operate in the towns and cities or operate as a home-visit service (Cintulova & Kafkova, 2021).

The public health policies implemented to prevent elder abuse align with the multisystemic Bronfenbrenner's ecological model considering various factors influencing elder abuse. The Bronfenbrenner model emphasises personal characteristics, proximal processes, context and time in understanding phenomena. Our analysis of the ecological framework highlights the importance of interventions at different ecological system levels. For instance, ageism interventions often focus on societal macrosystem approaches, but there is a need for more active-oriented interventions at personal and relational levels (Gendron et al., 2022; Cintulova & Kafkova, 2020; Blay et al., 2017; Suoto et al., 2015). Additionally, studies emphasise the significance of understanding intergenerational trauma within an ecological framework to develop effective treatment plans (Phelan, & O'Donnell, 2020; Galisova & Flimelova, 2014). When addressing elder abuse, according to Vincenti & Chapman (2019), factors like personal characteristics, proximal processes, context and time play crucial roles in identifying and preventing financial exploitation. By incorporating ecological perspectives, interventions can be more comprehensive and impactful in safeguarding older individuals. Similarly, the elder abuse prevention framework categorises prevention efforts into primordial, primary, secondary, tertiary and quaternary levels, addressing factors like ageism, education, intervention, screening tools, professional responses and policy impacts (Kisling & Das, 2023; Martins et al. 2018). By integrating these frameworks, a comprehensive approach can be developed to identify, prevent and intervene in cases of elder abuse, considering individual, familial, societal and systemic factors.

According to Pillemer et al. (2016), preventive measures that are considered the most promising include the following: interventions by carers with a focus on relieving the burden of family caregiving; increasing financial literacy through target education courses or follow-up programmes for vulnerable older adults; establishing emergency telephone helplines for persons who have experienced abuse; and multi-disciplinary teams and collaborations between professionals from various helping professions and other stakeholders. Gutterman (2023) describes several possibilities to improve the implementation of prevention: recognising elder abuse (physical, sexual, psychological, financial and neglect) and encouraging the prosecution of offenders; training law enforcement officers, health and social service providers, spiritual leaders, advocacy organisations and groups of older people to recognise and deal with elder abuse; increasing awareness of the injustice of elder abuse through public information and awareness campaigns; and involving the media in these efforts.

Elder abuse prevention in all three countries could be improved by the following: i)

Raising public awareness: Campaigns with a focus on ageism prevention, advocacy programmes and educational programmes for older adults and their families can raise awareness of the importance of ageing in place, care options and the different forms of abuse and risk factors. Information about the local support services and legal procedures relevant to elder abuse should be made easily accessible and freely available to the public.

Older adults can become victims of abuse due to their advanced age, poor health and greater dependence. Elder abuse has profound negative socioeconomic impacts on older adults as well as their immediate families, which can have significant social, psychological and health implications. The prevention of elder abuse requires a solution involving community leaders, healthcare providers, and government and non-governmental organisations. By striving to eliminate this epidemic with comprehensive education, protection and support, we can ensure that older adults live their latter days in dignity and without fear of violence. Their protection is in the hands of society and the responsibility of the state through its public health policy and preventive programmes, alongside the increased awareness of the lay population and experts through education. Our findings bring a greater understanding of elder abuse prevention in place for protecting the elderly in Brazil, Norway and Slovakia and bring possibilities for critical discussions, bench learning and addressing the complexities of elder abuse on academic level and also on international level. While each country has its own strengths and weaknesses, there is still room for improvement and for collaboration between the countries. More effective prevention measure and lower rates of elder abuse worldwide could be achieved through increased knowledge sharing and international cooperation.

While there are limitations associated with presenting a review of such a diverse group of studies, this paper presents a valuable synthesis of the empirically derived prevention and allows the reader to obtain a comprehensive overview of the quality of research in this area. Finally, several applied implications and research directions are highlighted, which may contribute to the development of further study and ultimately to improvements in prevention on the public health level and a reduction in future instances of abuse and neglect.