Old age is one of the most vital periods of human life [1]. According to the most recent World Health Organization (WHO) report, the number of people over 60 is expected to double by 2050, requiring fundamental social changes [2]. In Iran, the Population and Housing Census report in 2015 estimated the number of people over 60 as 7,414,091, forming 9.3% of the overall population [3].

The consequences of an increasing number of elderly people in the family include negative effects on their physical and mental status, economic pressures, mental disorders and emotional tensions, lack of responsibility and tolerance, and individual fatigue and social isolation of family members, and these consequences can be followed by the emergence of anti-social behaviors and increasing violence [4]. Under such circumstances, families are often not prepared to take care of the elderly, and in combination with other social factors such as urbanization, modernity, changing traditional values, and the contrast between the value systems of the new and old generations, families sometimes do not play their proper role for the elderly, who may be exposed to domestic elder abuse [5]. A common definition of elder abuse approved by WHO and the International Network for the Prevention of Elder Abuse is as follows: “Elder abuse is a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.” [6,7].

The WHO reported that in 2017, around 1 out of 6 old people experienced some form of abuse [8], and the results of a meta-analysis in 2017 indicated that in the last year, 15.7% of people aged 60 years and over underwent some form of abuse [9].

Abuse often occurs in family settings, such as at home [10,11], and the first perpetrators of elder abuse are the family members of elderly individuals [10]. Elder abuse is a multidimensional problem [11]; some explanations have stressed the victim’s features and/or those of the abusers, while others have emphasized living conditions or family status [12]. Most studies have reported that women, physical disability and functional impairment, dependence on others, poor physical and/or mental health, low income or poverty, and lack of social support were major risk factors associated with elder abuse [6,10,12-14].

Abuse exerts negative effects on mental and physical capacity, social status, and structures [15], and is associated with negative outcomes, including mental distress, morbidity, and death [16]. Furthermore, this issue is very costly in terms of the possibility of transfer to a nursing home and hospitalization [7].

Gender is an important factor in aging, and women are better represented than men in higher age groups. This issue was vividly illustrated by the 2016 Iran-wide census, in which more than 50% of the elderly were women [3]. Furthermore, the high prevalence of age-related diseases in older women [17], and the failure to identify many cases of abuse, especially in women, make abuse a serious threat and harm to the elderly; thus, identifying the prevalence of elder abuse and the factors associated with its occurrence could be a major step in determining how to prevent abuse and in facilitating protection of the elderly. For these reasons, the present study aimed to present up-to-date data on the abuse of elderly women and related factors in Tehran, Iran.

This was a cross-sectional, descriptive-analytical study conducted in the urban area of Tehran, the capital of Iran, among elderly women who were covered by health centers associated with Shahid Beheshti University of Medical Science, which is one of the biggest universities of Iran. Its health centers include many areas in Tehran, with a population of about 4,122,406, of whom 278,721 are old women. The aging population in these areas is increasing rapidly, which has drawn increasing attention to the problems faced by this age group.

Table 1 presents the study subjects’ general characteristics, divided into their demographic and general characteristics and their family characteristics. This table also presents the number and percentage of participants who experienced abuse stratified according to the variables studied. The mean age of the study subjects was 67.63±6.62 years, and the age group of 60-62 years made up the largest proportion (27.3%). More than half of the elderly (53.5%) were literate, 161 (61.9%) were married, and 177 (68.1%) suffered from a chronic disease; other data are shown in Table 1.

In Table 2, the mean total score for elder abuse and the mean scores of the 8 subscales are given. The mean score of abuse among the study subjects was 19.29±19.03, and more than 90% of the subjects (n=235) had experienced at least 1 type of abuse. Authority deprivation (68.5%) and psychological abuse (63.5%) were the most common types of abuse, and rejection (11.2%) was the least common type.

The ordinal logistic regression analysis indicated that the likelihood of experiencing more severe abuse in illiterate elderly women was almost 1.20 times greater than in literate women, and in the elderly with a household size ≥2, the odds of abuse were 1.48 times higher than in the elderly with a smaller household. Moreover, the odds of experiencing more severe abuse in the elderly with an income lower than 8 million rials were 1.11 times higher than in the elderly with an income above 15 million rials. Furthermore, the odds of experiencing more severe abuse in those older than 72 years were 2.07 times greater than those of the elderly who were 60-62 years of age. However, only age showed a significant association with abuse (p=0.04). The variables of employment status, insurance status, dependence on supporting organizations, smoking, hookah use, and drug use were removed from the ordinal logistic analysis due to the small number of samples at some levels. The results of the univariate and multivariate ordinal logistic regression analysis are shown in Table 3.

The objective of the present study was to evaluate the status of abuse and some of its associated factors among elderly women living in Tehran. The mean total abuse score was 19.29±19.03, and 90.4% of respondents reported having experienced some form of abuse, of which authority deprivation (68.5%) and psychological abuse (63.5%) were the most common forms and rejection (11.2%) was the least common. These results are consistent with those of some previous studies, but very different from those of others.

In a meta-analysis of 50 studies from throughout the world, the overall prevalence of abuse of elderly women was estimated to be 14.1%, and estimates were obtained for the prevalence of psychological abuse (11.8%), neglect (4.1%), financial abuse (3.8%), sexual abuse (2.2%), and physical abuse (1.9%) [21]. In a study in the city of Pune, India, abuse was reported among 47.0% of elderly women [22]. In the Prevalence Study of Abuse and Violence against Older Women (AVOW) study, 28.1% of old women underwent abuse; as such, those results are dramatically different from those of the present study. In the AVOW study, psychological abuse and physical violence were the most and least common forms of abuse, respectively [17].

Turning to studies conducted in Iran, in the study by Khalili et al. [23], similar to the present study, many elderly women (80.0%) stated that they had experienced abuse, but unlike the current study, financial abuse was the most common type of abuse. In studies conducted by Alizadeh-Khoei et al. [24], and Hosseini et al. [25], abuse was only reported among 14.7 and 17.4% of the elderly, and physical abuse was the most common type in both studies.

One of the reasons for the differences in the reported prevalence is that there is no obvious and unique definition of elder abuse, meaning that the definition and estimation of elder abuse vary across environments and studies. Other reasons include the lack of unique standards and tools, variation in data collection methods, and the existence of various values and norms in different societies with resulting differences in definitions and perceptions of acceptable behavior. Nonetheless, some likely reasons for the high prevalence of elder abuse in Iranian families include rapid changes in family values and structures, which have caused the elderly, who always strive to preserve their beliefs, traditions, and values, to experience conflict with the existing circumstances and their families, resulting in conflicts among Iranian elderly and their families. Furthermore, elderly Iranian women by tradition occasionally undertake the responsibility of caring for their children and grandchildren against their will, and this phenomenon causes conflicts and opposition in Iranian families; in addition, restrictions on working outdoors may result in the elderly becoming economically dependent on their family members, which is a common background for abuse and financial neglect.

In the present research, only old age was identified as a significant risk factor for elder abuse. Most studies, such as those conducted in the US [26,27], Malaysia [28], Europe (the AVOW study) [29], and a study by Ghodoosi et al. [4], in contrast with the present research, reported that the elderly in younger age groups were exposed to more abuse. In contrast, some other studies in Mexico [30], Portugal [31], and Iran [32] reported findings similar to those of this study, with a higher prevalence of abuse among the elderly in older age groups. More widespread abuse among older people can be explained through the possibility that diseases related to age and the vulnerability of old individuals provide the circumstances for elder abuse. As a consequence, older women are exposed to a greater risk of abuse and its outcomes; this is compounded by the fact that relatively light forms of physical abuse, such as pushing, can lead to serious injuries in the elderly [9].

In the present study, the results also indicated that elderly women with a lower income were more frequently exposed to abuse than those with a higher income. These findings are consistent with studies conducted in Mexico, Ireland, India, and the US [33]. In a study by Nori et al. [34], a statistically significant difference in elder abuse was found between those with a monthly income lower than 0.5 million rials and those with a monthly income over 5 million rials.

In a study by Skirbekk & James [35], it was found that only having few or no years of formal education was associated with abuse. Although the current study found that illiterate participants were exposed to higher odds of abuse, that relationship was not significant. Other studies [32,36,37], congruent with the current study, did not show a significant relationship between higher abuse and lower education. In contrast, the study by Alizadeh-Khoei et al. [24] suggested lower odds of abuse and neglect in the elderly with primary or higher education compared to their illiterate counterparts. The views of elderly women, including an emphasis on their traditional gender role and valuing the domestic role, cause them to be less inclined to pursue education and employment; this makes them more dependent on their family and relatives, and increases their likelihood of experiencing abuse [38].

In this study, similar to the AVOW study, the odds of abuse were higher among the elderly with a larger household size [17]. In contrast, in the study by Skirbekk & James [35], the likelihood of abuse in larger households was lower.

The results of this study and many other studies indicate that elderly women are exposed to many types of abuse. This is a very important health and social issue that requires attention and action, such as proper contextualization of healthy aging; informing the community and families about the physical, mental, emotional, and other needs of the elderly; and efforts by the government to provide support for the elderly to be more independent and better-educated as a way to promote their health. Furthermore, old age is an important risk factor for domestic elder abuse in women, and this is an important issue that needs to be addressed.

Since the elderly women in this study were only drawn from 3 urban districts of Tehran, including the north, east, and Shemiranat districts, and were also covered by health centers, it is possible that the characteristics of these participants differ from those of elderly women living in other districts of Tehran and those not covered by the health centers. Accordingly, the present study may not represent all dwellers of Tehran or all Iranian elderly people.

Furthermore, characteristics of the abusers and certain other important factors that could potentially influence elder abuse, such as socioeconomic status and other social factors, were not investigated in the present study.