Introduction

Abuse of older persons (AO) is a public health burden as regards the consequences of AO on health (Lachs et al. 1998; Acierno et al. 2010; McGarry et al. 2011). Multinational comparable data on the prevalence rate of AO are scarce (Lachs and Pillemer 2004; Mitka 2011; Penhale and Kingston 1995; Podnieks et al. 2010). Conceptual (e.g. definition of AO) and methodological differences (e.g. assessment) limit the extent to which comparisons can be made between studies (Dyer et al. 2000; Acierno et al. 2010; Cooper et al. 2006, 2008; Krienert et al. 2009). Changes in population structure indicate a potential for an upward trend in prevalence of AO because of the ageing population.

Several studies suggested prevalence rates of AO. In the USA, in 1988, a study on a random sample of 2,020 people aged 65+ in Boston was conducted assessing physical, and verbal AO, and neglect (Pillemer and Finkelhor 1988). This study determined a prevalence rate of 32 %. The evidence was gathered and synthesized by a systematic review in 2008 suggesting prevalence rates of AO between 3.2 and 27.5 % (Cooper et al. 2008). Since this systematic review, in the last 5 years, six national prevalence studies of elder abuse have been conducted investigating national samples from the USA (Acierno et al. 2010; Laumann et al. 2008), Israel (Lowenstein et al. 2009), UK (Biggs et al. 2009), Spain and Ireland (Naughton et al. 2012). These studies suggested national prevalence rates of AO. A study from the USA (Laumann et al. 2008) of people aged 57–85 years (n = 3,005), reported past 12 months prevalence rate for verbal abuse (9.0 %), physical abuse (0.2 %) and financial abuse (3.5 %) (Acierno et al. 2010). Another study from the USA, (n = 5,777, 60+) (Acierno et al. 2010), suggested past 12 months prevalence rates for emotional AO (4.6 %), physical AO (1.6 %), sexual abuse (0.6 %), financial AO (5.2 %) and for neglect (5.1 %). A national prevalence survey of AO against persons aged 65+ (n = 1,045) in Israel (Lowenstein et al. 2009) suggests prevalence rates among the Jewish population of Israel (n = 948) (1.6 % for physical/sexual AO, 14.5 % for verbal AO, 6.4 % for financial abuse and 26 % to neglect). A survey of AO towards persons aged 66 years+ (n = 2,106) in the UK reported past 12 months prevalence rates of AO between 0.2 and 1.1 % (psychological 0.4 %, physical 0.4 %, sexual 0.2 %, financial 0.7 %, neglect 1.1 %) comparable to the prevalence estimates from Spain (psychological 0.3 %, physical 0.2 %, sexual 0.1 %, financial 0.2 %, neglect 0.3 %) (Marmolejo 2008) and Ireland (psychological 1.2 %, physical 0.5 %, sexual 0.02 %, financial 1.3 %, neglect 0.3 %) (Naughton et al. 2012).

A major problem for comparing prevalence rates between studies is the definition of AO (Dong et al. 2010; Podnieks 2006; Acierno et al. 2010). Furthermore, it might be that not the full range of types of AO is assessed and/or an instrument with limited validity and reliability is used (Acierno et al. 2010; Fulmer 2003). To build an existing research and address the limitations of national samples, we designed a study on AO in seven cities from seven countries in Europe based on a joint definition based on the Revised Conflict Tactics Scales. We assess four domains (domain 1: age, gender, migration history; domain 2: education, occupational attainment; domain 3: marital status, living situation; domain 4: housing tenure, financial strain). We aimed to examine past 12 months prevalence rates of psychological, physical, sexual, financial AO and neglect of individuals in seven cities in Europe, and to assess the association between correlated factors and types of AO. We hypothesized that country was independently associated with AO.

Methods

Study design and setting

The ABUEL study (abuse of the elderly in Europe) is a cross-sectional community study of individuals aged 60–84 years of the general population in seven cities in Europe (Germany, Greece, Italy, Lithuania, Portugal, Spain and Sweden). The methods, sampling strategy and response rates have been described elsewhere (Lindert et al. 2011). We used random sampling methods based on municipal registries (Stuttgart, Germany; Ancona, Italy; Kaunas, Lithuania, Stockholm, Sweden; Porto, Portugal; Granada; Spain) or on the random route method (Athens, Greece).

Participants and response rate

Overall 4,467 community dwelling individuals aged 60–84 years participated in the ABUEL study. Inclusion criteria were: aged 60–84 years; no dementia or other cognitive impairments; citizens, documented migrants; living in own or rented houses; proficiency of the countries native languages. Mean response rate was 45.2 %.

Independent variables and domains

We assessed four domains of independent factors: domain 1: age, gender and migrant history; domain 2: education and occupational attainment; domain 3: marital status and living situation; domain 4: house tenure, income, employment and financial strain.

Domain 1: age was categorized into years (60–64, 65–69, 70–74, 75–79, and 80–84). Migrant status was assessed by four questions (e.g. “place of birth”, “place of births of parents”, “nationality”, “and language spoken at home”). The interviewees which indicated another place of birth for either themselves or their parents than the country they lived in and another nationality or another language than the natives were categorized as “people with migration history”.

Domain 2: education was grouped into “less than four years”, “four years”, “5–11”, and “other”. Occupation was categorized into six categories: “high white collar”, “low white collar”, “high blue collar”, “low blue collar”, “housewife”, “armed forces”. Domain 3: we assessed marital status (“single”, “married/cohabitant”, “divorced/separated”, “widowed”); and the type of relationship to the person the interviewee was living with.

Domain 4: to assess the financial situation, we assessed ownership of property, type of income, and financial strain. “Ownership” was assessed by asking whether interviewees lived in an own property or in a rented place. Type of income asked for source of income (e.g. “pensions”, “sickness benefits”, “husband’s income”, “financial strain”, “preoccupation with how to make ends meet”) was measured in a ‘‘no/sometimes/often/always’’ format.

Dependent variable: abuse (psychological, physical, sexual, financial) and neglect

We assessed types of AO, and neglect with questions based on the “Revised Conflict Tactics Scale” (CTS-R) which has good psychometric properties as regards internal consistency, construct validity and discriminant validity and has been used in many studies, worldwide (Straus et al. 1996; Cooper et al. 2008). We modified the CTS and measured abuse and neglect using 52 questions with 11 questions on psychological violence, 17 questions on physical AO and physical abuse followed by injuries, eight questions on sexual AO (e.g. physically forced intercourse by the husband, performing sexual acts against the will), nine questions on financial abuse, and 13 questions on neglect. The frequency of AO (“once”, “twice”, “3–5 times”, “6–11 times”, “11–20 times”, and “>20 times”) was collapsed into a dichotomous variable (“never” vs. “ever”). This coding scheme is the same as in other studies using the Revised Conflict Tactics Scales to estimate abuse prevalence.

Assessment procedures

We obtained data between January and July 2009. Written information about local medical and social services for older persons was provided. Follow-up support was offered and provided when needed. Ethics permission was obtained from the national or regional ethics review boards. We did not provide any monetary incentive for participating.

Statistical analysis

We carried out descriptive analyses for all data with weights to correct for the sampling design, using frequency distribution and summary measures. The independent variables consist of four domains. The dependent variable was AO. The associations between the variables were expressed as odds ratios (ORs) with the respective 95 % confidence intervals (CIs). To examine our hypothesis, that country of residence was independently associated with AO, we used multiple logistic regression models calculating adjusted odds ratios (AORs). The significance level was set at P < 0.05. The statistical packages SPSS 15.1 and STATA 11.1 were used.

Results

Characteristics of the study population

We collected data from 4,467 persons. Responses to factors of domain 1 indicated that 57.3 % (2,559) women (Table 1), 5.7 % (256), had a migration history (domain 1). Responses to factors of domain 2 indicated that 14.8 % (661) had an education which was lower than elementary, 39.5 % (1,092) had an elementary education, 39.5 % (1,782) an intermediate and 19.1 % (855) a higher education. Years of education varied between the place of residence of participants. 27.2 % (1,217) had high white collar or low white collar (1,214) occupation. High blue occupation had 15.8 % (570), low blue collar occupation 12.8 % and 14.7 % (656) were housewives. Responses to factors of domain 3 indicated that 6.0 % (270) were single, 65 % (2,903) were married, 7.7 % (343) were divorced or separated, 49.4 % (2,208) lived with a partner, 10.2 % (457) with a partner and with others and 10.2 % (457) with other persons. Responses to domain 4 indicated that 75.9 % (3,392) lived in an own property, and 64.6 % (2,886) were financially strained.

Table 1 Characteristics (domain 1: age, gender, migration history; domain 2: education, occupational attainment; domain 3: marital status, living situation; domain 4: ownership, income, financial strain) of older persons living in the communities in seven cities from seven European countries) in 2009 (n = 4,467)
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Prevalence rates of psychological, physical, sexual and financial AO and neglect

Psychological AO varied for men between 9.7 (Spain) and 35.6 % (Sweden), and for women between 6.9 (Italy) and 26.8 % (Germany). Physical AO varied for men between 0.78 (Italy) and 6.0 % (Sweden), and for women between 1.2 (Italy) and 4.6 % (Greece). Physical AO with injuries varied for men between 0.3 (Germany) and 0.9 % (Portugal), and for women between 0.0 (Italy) and 2.0 % (Lithuania). Sexual AO varied for men between 0.0 (Germany) and 0.4 % (Sweden) and for women between 0.2 (Spain) and 1.5 % (Germany). Financial AO varied for men between 2.0 (Sweden) and 9.6 % (Portugal), and for women between 1.7 (Sweden) and 6.6 % (Portugal). Neglect varied for men between 0.0 (Italy) and 1.2 % (Spain), and for women between 1.4 (Spain) and 5.4 % (Portugal) (Table 2).

Table 2 Prevalence of past 12 months AO (psychological, physical, physical with injuries, sexual, financial) and neglect by gender in seven cities from Europe in 2009 (n = 4,467)
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Bivariate analyses of characteristics and types of AO

In bivariate analysis, likelihood of psychological AO was higher for people living in Germany (OR 3.20, 95 % CI 2.38–4.31), Lithuania (OR 2.60, 95 % CI 1.83–3.70), Portugal (OR 1.91, 95 % CI 1.35–2.70) and Sweden (OR 3.70, 95 % CI 2.72–4.89), for the age groups born after 1934. Likelihood of AO was increased for those without house tenure (not owner OR 1.32, 95 % CI 1.07–1.63).

Likelihood of physical AO was higher among persons from Germany (OR 3.39, 95 % CI 1.44–9.96), Greece (OR 3.50, 95 % CI 1.50–8.17), Lithuania (OR 3.91, 95 % CI 1.71–8.94) and Sweden (OR 4.12, 95 % CI 1.80–9.46). Being widowed was related to decreased likelihood of physical AO (OR 0.26, 95 % CI 0.07–0.90).

Likelihood of sexual AO was higher for people, who lived alone (OR 7.52, 95 % CI 1.30–43.56) or were still working (OR 4.71, 95 % CI 1.47–15.06). However, the numbers were small and the 95 % CIs were wide.

Financial AO was increased among people from Portugal (OR 3.05, 95 % CI 1.7–5.27), among older persons (OR 2.26, 95 % CI 1.41–3.61), and among widowed/separated persons (widowed: OR 1.94, 95 % CI 1.37–2.74; separated: OR 2.21, 95 % CI 1.36–1.89). Likelihood of financial AO was lower for women (OR 0.47, 95 % CI 0.31–0.72) and higher for persons with university or similar degree (OR 1.86, 95 % CI 1.06–1.73) (Table 3).

Table 3 Bivariate analyses of characteristics of older persons living in the communities in 7 countries in Europe types of AO in 2009 (n = 4,467)
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Multivariate analyses of characteristics and overall AO and neglect

In multivariate analysis, likelihood of psychological AO was higher for people living in Germany (AOR 3.48, 95 % CI 2.45–4.93), Lithuania (AOR 2.60, 95 % CI 1.83–3.70), Porto, Portugal (AOR 1.91, 95 % CI 1.35–2.70) and Sweden (AOR 3.70, 95 % CI 2.61–5.23), and for the age groups born after 1934. The effect of educational level remained significant in multivariate analysis (primary school AOR 0.77, 95 % CI 0.62–0.97); not owner (AOR 1.29, 95 % CI 1.06–1.58). In multivariate analyses of overall AO, no financial strain was associated with decreased likelihood of overall AO (AOR 0.77, 95 % CI 0.64–0.93) and being from a profession of low blue collar with increased AO (AOR 1.52, 95 % CI 1.10–2.10) (Table 4).

Table 4 the communities in seven cities in seven countries in Europe in 2009 (n = 4,467)
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Discussion

In Europe, we identified psychological AO as the most prevalent type of AO in our study of older individuals in seven countries in Europe. Our prevalence estimates of psychological AO were high, compared to other studies which report much lower prevalence estimates, e.g. the recent study from Ireland (2.2 %) (Naughton et al. 2012) and from the UK (Biggs et al. 2009). However, almost the same prevalence rate of 27.5 % for abuse of women was found in a recent study for Sweden (Zinzow et al. 2009).

Domains (except country of residence) and AO

Factors of domain 1 (age, gender, migration history) were associated with types of AO. Interviewees aged 60–64, 65–69 and 70–79 years reported higher psychological AO. The youngest (aged 60–64) and the oldest (aged 80–84 years) reported more physical AO than those in the other age groups. Women in all age countries reported more sexual abuse and more neglect than men, which is in line with available studies on sexual AO (Cooper et al. 2008). Factors of domain 2 (education, occupational attainment) were positively associated with increased psychological AO. Factors of domain 3 (marital status, living situation) were negatively associated with psychological abuse, divorced/separated and being widow/er reported was positively associated with financial AO. Finally, interviewees who reported financial strain reported more AO than counterparts. The strongest association was found between country of residence and AO.

Country of residence and AO

AO was associated with being from Germany, Lithuania, and Sweden. There might be three explanations: the first explanation is related to possible differences in awareness between cultures. It is likely that differences between cities/countries partly reflect differences between cultures in threshold for awareness of AO. A second explanation might be that AO is distinct in each country because of collective life events, such as exposure to harsh parenting in childhood (Samelius et al. 2010; Zink et al. 2006; McHugh and Frieze 2006; Anderson 2005). These findings are on line with the studies from the USA suggesting major life events as major factors for experiencing AO (Acierno et al. 2010). Studies suggest that exposure to violence in childhood is associated with revictimization and exposure or perpetration of violence in adult life (Korbin et al. 1995; Schwartz et al. 2006; Straus and Savage 2005). The relationship of childhood family violence with psychosocial problems of children (Samelius et al. 2010), dating partners (Zink et al. 2006) and intimate female to male partner violence (McHugh and Frieze 2006) has been suggested by many studies. Recent studies suggest that intimate-partner violence might increase during and after exposure to collective violence especially among men (Anderson 2005; Friedman et al. 2011; Vissing et al. 1991). This might be an explanation for the high rates in Germany and Lithuania. A third explanation might be that we predominantly found psychological AO in our sample and the associated domains are mainly associated with psychological violence and less with other types of AO. A fourth explanation might be that the associations depend on methodological reasons, e.g. in the instrument used which might be very sensitive in psychological AO.

Strengths and limitations

The study has several strengths. First, the large sample was recruited in seven cities from seven countries in Europe. Second, we used an internationally validated inventory. In addition, we provided interviewer training, and emphasis on ethical and safety considerations. Some limitations are important to consider. First, the cross-sectional design limits our ability to establish temporality of AO and domains. Second, we cannot identify real rates of victimization in our study. Third, the response rate varied. This could introduce measurement bias in the study; low response rates might lead to an underestimation of AO. Fourth, the interviewees were recruited from regional samples and may not be representative for the respective countries. Fifth, like in any other study based on self-reporting, there might be recall bias. Sixth, we excluded people with disabilities and those living in care institutions. In addition, the number of cases was very low for some types of AO which makes analyses difficult.

Conclusion

In spite of potential limitations, we can report for the first time ever comparable data on AO in seven countries of Europe. Our findings suggest that prevalence rates of AO differ between countries. Herewith, our hypothesis that city of residence of the older individual is independently of the four domains assessed in this study associated with AO was confirmed. Preventing the prevalence of AO might depend on very early interventions to prevent revictimization.