Perceived Frequency and Importance of Elder Abuse Risk Factors in Arabic-Speaking Immigrant Communities ()
1. Introduction
Worldwide, the percentage of older persons (i.e. 60+ years of age) is on the rise, and the risk of elder abuse is increasing. In their meta-analysis, Ho and colleagues [1] reported a 10% to 34% prevalence rate of elder abuse. In Canada, it is estimated that 4% - 10% of all older adults experience some form of abuse [2] [3] [4]. However, these may be underestimates and not reflect the reality because elder abuse is often unreported. For example, the World Health Organization (WHO) suggests that only about one in every 24 cases of elder abuse is reported to authorities [5]. Underreporting is often caused by fear of retributions from carers, embarrassment, fear of consequences for the abuser, and lack of or unfamiliarity with support services [6] [7] [8] [9]. Underreporting is more prominent among immigrant older adults because of migration-related factors, including language barriers, social isolation, difficulties in transportation, and unfamiliarity with the (new) country’s cultural, social, political, and legal systems [10] [11] [12].
The WHO [5] defines elder abuse as “a single or repeated act, or lack of appropriate actions occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person.” Elder abuse is associated with negative short- and long-term health outcomes and premature mortality [13] [14] [15]. The high prevalence of elder abuse and its negative impact on health and well-being demand the development of interventions to address it. This need is heightened in diverse immigrant communities.
This paper focuses on the key factors for elder abuse in the Arabic-speaking immigrant communities in Canada. The percentage of Arabic-speaking immigrants in Canada has increased by 29.9% since the 2011 census [16]. While a few studies have explored elder abuse in immigrant communities in Canada [10] [11] [17], there is no research on risk factors for elder abuse in the Arabic-speaking communities. A comprehensive understanding of the risk factors is crucial for designing interventions [18] to prevent or reduce elder abuse. Designing interventions requires identifying influential factors—circumstances, events, conditions, or capabilities—that contribute to the risk [19] of elder abuse that are amenable to change. Involvement of Arabic-speaking older adults in identifying risk factors is a critical initial step in the development of interventions that respond to their needs and experiences.
2. Study Objectives
This study focused on identifying factors that Arabic-speaking older immigrants residing in Toronto, Ontario, perceived as influential in increasing the risk of elder abuse. The first phase of the integrated strategy for the cultural adaptation of interventions [20] was implemented. It involved a comprehensive review of risk factors for elder abuse, and a quantitative study. The specific objectives of the study were: 1) to determine the risk factors perceived by Arabic-speaking older immigrants as frequent and important in contributing to elder abuse, and 2) to examine gender-based differences in their perceptions.
3. Review of Risk Factors for Elder Abuse
We conducted a search and review of the literature to identify risk factors for elder abuse in the postmigration context in Canada. Articles written in English and published between 2010 and 2021 were searched using health (e.g. AGELINE, MEDLINE) and psychosocial (e.g. PsychINFO, Sociological Abstracts) databases. Articles were included in the review if they reported on the results of quantitative, qualitative, or mixed-method studies that investigated risk factors for elder abuse in older immigrants. In total, 17 articles were selected, and their findings were synthesized to identify elder abuse risk factors.
Thirteen risk factors were identified as contributing to elder abuse in the postmigration context. (Re)settlement creates a range of challenges in older immigrants’ lives, which increase their physical, emotional, and financial dependence on others (primarily, children) which in turn, heightens their vulnerability to abuse.
With advanced age, older immigrants may experience impairment in physical and/or cognitive functioning, thus require assistance in performing daily activities, from their family members who also have to fulfill other responsibilities. The increased burden may lead to frustration, conflict, and abuse [21] [22] [23]. Gender is another risk factor—older women are more likely to be abused than older men [24] because of sexist and patriarchal practices, and gender role expectations. Sponsorship status and length of time in Canada affect older immigrants’ vulnerability to abuse. Canadian immigration policies make newcomer older adults dependent on their sponsors (i.e. their children) for 20 years [25]. Thus, newcomer older adults do not qualify for Old Age Security. They also find it challenging to secure employment in Canada because of structural barriers [21] [23] such as discrimination in the workplace. Older immigrants who do not speak English may not be able to gain employment [26] [27] [28]. Lack of income [29] [30] [31] and resulting financial dependence on their children [21] [23] [32] put older immigrants at risk for abuse. Also challenges in conversing with others outside the home, result in social isolation, which in turn, increases their emotional dependence on their family. Limited functioning and English proficiency can also contribute to physical dependence on others to engage in daily activities such as shopping, and transportation to access health services and social events [26] [27] [28] [32]. Cultural values and financial challenges [29] [33] may result in older immigrants co-residing with children and grandchildren, which can create conflict among different generations, leading to abuse. Belonging to racialized, cultural, or ethnic groups increases older immigrants’ risk for social isolation and structural abuse [34].
None of the above-noted studies included Arabic-speaking older immigrant women and men—a gap we address.
4. Study Methods
4.1. Design
The study represented the quantitative component of a mixed-method project to identify risk factors for elder abuse in the Arabic-speaking immigrant community in Toronto, Ontario. The project’s protocol has been published (see [20]). Only the methods pertaining to the quantitative data collection and analysis are described here.
4.2. Ethical Considerations
The project protocol was approved by the Research Ethics Board at Ryerson university (REB # 2017-084). Eligible participants were invited to attend a group session. Before the session started, two bilingual research assistants (RAs) reviewed the study’s aims and activities, reiterated the voluntary nature of participation, clarified the benefits and risks to, and rights of participants, and addressed any questions that potential participants had before obtaining their written or oral consent based on their preference.
4.3. Setting and Population
Close to 500,000 Arabic-speaking immigrants live in Canada, more than half of whom reside in the Greater Toronto Area (GTA), located in the Southwest region of Ontario, Canada [8]. Arabic-speaking immigrants come to Canada from a range of countries including: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Quatar, Saudi Arabia, Sudan, Syria, Tunisia, United Arab Emirates, and Yemen. While there is diversity among immigrants from these countries, they also share similar cultural, gender, and family values and beliefs [35], as well as political challenges that shape their approaches to family relations.
This study focused on Arabic-speaking immigrants in the GTA.
4.4. Sample
Participants were selected if they: 1) were 60 years of age or older; 2) were living in the GTA at the time of data collection; 3) had been in Canada for less than 20 years; 4) self-identified as Arabic-speaking; and 5) had personal experience of elder abuse or knew others in their community who had experienced it.
Participants were recruited using three strategies. Flyers (in Arabic) were posted in various community settings (e.g. food stores, religious or community centers) frequented by Arabic-speaking immigrants. Staff at partnering community agencies announced the study at community events. Participants were also asked to share information about the study within their social networks.
Purposive sampling was used to recruit a comparable number of participants in terms of age (“young-old,” “middle-old,” and “old-old”), length of stay in Canada (<5, 6 - 10, 11 - 20 years), gender, and sponsorship status (self-sponsored; sponsored by spouse or children; other, e.g. refugee). Eight focus groups were held with older immigrants (four with older women and four with older men) across the GTA. Each group consisted of six to eight participants, as recommended by previous research, to generate meaningful discussions [36] [37] [38]. In total, 55 Arabic-speaking older immigrants participated: 24 women and 31 men. The total sample size was considered appropriate to describe older immigrants’ perceptions of risk factors, and to detect moderate-to-large gender differences in perceptions [39].
4.5. Variables and Measures
Participants completed two questionnaires. The first entailed a sociodemographic profile. Standard questions, developed by Statistics Canada, were used to obtain information about participants’ age, gender, marital status, number of children, level of education, proficiency in English, language spoken at home, citizenship status, length of time in Canada, and country of origin.
The second questionnaire assessed participants’ perceptions of the 13 elder abuse risk factors identified from the literature review, providing support for its content validity. The questionnaire presented a clear label of each factor, followed by a short description in simple lay terms of the factor’s association with elder abuse. The questionnaires were translated into Arabic by bilingual RAs, following the procedure Sidani and colleagues [40] described. Bilingual staff at partnering community agencies that provide health and social services to Arabic-speaking individuals reviewed the translated version of the questionnaires for accuracy and appropriateness of wording.
4.6. Data Collection
Participants attended a group session, held at places of convenience to the study participants (e.g. community center). The sessions involved women only, men only, or a mix, based on participants’ comfort and preferences.
During the group session, bilingual RAs explained what participation entailed, clarified any concerns, distributed the questionnaires, and requested participants to complete the questionnaires individually. Participants were instructed to read each risk factor’s description, and to rate: 1) it’s frequency in the Arabic-speaking community, on a five-point response option ranging from never (0) to very frequent (4); and 2) its importance in contributing to elder abuse in the Arabic-speaking community, on a five-point response option ranging from not at all important (0) to extremely important (4).
4.7. Data Analysis
Descriptive statistics were used to analyze the data. This included frequency (and percentage) distribution for categorical variables, and measures of central tendency (mean) and dispersion (standard deviations) for continuous variables. To address objective 1, participants’ ratings of the risk factors’ frequency and importance were analyzed descriptively (i.e. mean and standard deviation). Risk factors with ratings > 2.5 (with a score of 2.0 being the midpoint of the rating scale) were considered to be most frequent and important contributors to elder abuse. To examine gender differences in the risk factors’ ratings (objective 2), we used an independent sample t-test. Cohen’s d was computed to quantify the size of the differences, with values less than 0.35 indicating small, 0.35 to 0.65 moderate, and more than 0.65 as large differences [39].
5. Results
5.1. Participants’ Sociodemographic Profile
Slightly more men (56.4%) than women (43.6%) completed the questionnaires. Their mean age was 68.4 (±7.54; range: 60 - 93). Most participants were married (83.6%) with more than one child (89%). Most (74.5%) had completed high school education; 73% reported adequate English proficiency, and 87% spoke only Arabic at home.
About half (50%) of the participants were permanent residents, 46% were citizens, and 4% were refugees. Most had arrived in Canada in 2010 from different countries: Iraq (n = 31), Syria (n = 17), Palestine (n = 2), Lebanon (n = 1), Jordan (n = 1), Libya (n = 1), Saudi Arabia (n = 1), and Sudan (n = 1).
5.2. Participants’ Perception of Risk Factors
The mean scores for rating of the risk factors’ perceived frequency and importance appear in Table 1. On average, participants rated the following six risk factors as occurring commonly (mean rating ≥ 2.0) in the Arabic-speaking community: English language proficiency, income, emotional dependence, financial dependence, social isolation, and racialized, cultural, or ethnic group status. They perceived seven risk factors as important (mean rating ≥ 2.0): English language proficiency, income, physical dependence, emotional dependence, financial dependence, social isolation, and racialized, cultural, or ethnic group status. Social isolation had the highest mean score (exceeding 2.5), followed by English language proficiency (mean = 2.49) indicating that these are the most frequent and important factors contributing to elder abuse in the Arabic-speaking community. Indeed, social isolation is a consequence of complex intersections of multiple factors, such as language barrier, insecure housing, employment and income, transportation, unfamiliarity with services or lack of linguistically- and culturally-appropriate services, and discriminatory and racist practices within social service [30] [41] [42] [43] [44]. It is inevitable that this risk factor emerges as a significant elder abuse risk factor that concerns many older immigrants.
5.3. Gender Differences in Perception of Risk Factors
As Table 2 shows, gender differences were found in the perceived frequency of two risk factors: advanced age and sponsorship status. These differences were statistically significant (p ≤ 0.05) and of a moderate size (as indicated by the respective Cohen’s d value). Women considered these two factors as commonly occurring in the Arabic-speaking immigrant community. Although not statistically significant, small differences were observed for income, emotional dependence on others, and multigenerational co-residence. On average, the mean ratings scores were higher for women than men.
A statistically significant gender difference was found in the rating of importance for sponsorship status (Table 3). The difference was of a moderate size;
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Table 1. Mean (SD) ratings (range: 0 to 4) of risk factors by participants (n = 55).
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Table 2. Comparison of women’s and men’s mean (SD) ratings (range: 0 to 4) of the risk factors frequency of occurrence.
women perceived this risk factor as more important in contributing to abuse than men did. Moderate, yet statistically non-significant differences were observed for the importance of English language proficiency and income; women’s
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Table 3. Comparison of women’s and men’s mean (SD) ratings (range: 0 to 4) of the risk factors importance.
mean scores were higher than men’s mean scores. Small differences were noted for emotional dependence on others and racialized, cultural, or ethnic group status: women reported higher importance for emotional dependence whereas men reported higher importance for racialized, cultural, or ethnic groups.
6. Discussion
Using a community-based collaborative approach, this study engaged Arabic-speaking older immigrants in identifying factors that most increase their vulnerability to abuse. The identified risk factors would inform the selection of evidence-based interventions or the development of new interventions to prevent or reduce elder abuse, and mitigate its impact on health and well-being in the Arabic-speaking immigrant community. This approach to designing interventions can enhance the acceptability and uptake of, and satisfaction with the interventions [45].
The study sample consisted of 55 Arabic-speaking older immigrants. While it is a small sample, it represents the sociodemographic characteristics of Arabic-speaking older immigrants [16], and was adequate to detect moderate-sized differences [40] in the reporting based on gender.
Overall, the mean ratings of the risk factors hovered around the midpoint of the rating scale. There was concordance in the ratings of the risk factors’ frequency and importance—factors perceived as most frequent were also considered important in increasing vulnerability to elder abuse. This convergence in ratings provides strong evidence in the identification of the most influential risk factors in the Arabic-speaking immigrant community: social isolation and lack of English language proficiency.
A wide range of interventions have been proposed to address social isolation, including strategies to engage older adults in physical, social, recreational and/or leisure activities; support groups; intergenerational programs; animal, occupational, or psychosocial therapy; as well as education and skills development [46] [47] [48]. Of these, physical activity, social activity, support groups, and animal therapy were effective in reducing social isolation in the general older adult population. Their acceptability to Arabic-speaking older immigrants may be examined in future studies.
English-as-a-second language classes are available (for free) to older immigrants in Canada. Participants explained that language classes in formal environments require daily attendance and also limit students’ interactions, but some kept going to these classes to help overcome their isolation. They prefer informal settings that combine activities with language learning. However, these programs do not qualify for free transportation services or subsidies, making it difficult for older immigrants to learn English, which in turn, increase their social isolation and their dependence on others.
Women rated sponsorship status as a risk factor. A plausible explanation of this gendered difference is that, at the family level, older women are often sponsored to help their children with grandchild care as well as cooking, cleaning, and other household work. Their sponsorship status creates situations of debt and gratitude that often oblige women (more than men) to be in situations of unpaid and labour-intensive work at home.
Gender differences were also observed in the rating of the importance of English language proficiency and income. Women perceived these factors as more important than men did, perhaps because women may not have received higher education (along with that English language training) in their home country, and hence may not have had a source of income due to patriarchal practices. These additional vulnerabilities must be taken into account when designing interventions.
7. Limitations
Despite extensive recruitment, only 55 older immigrants participated in the study. As noted earlier, the sample is representative of the demographic characteristics of Arabic-speaking older immigrants, but may not reflect the variability in the experience of risk factors of elder abuse. The participants were primarily recruited via word-of-mouth or flyers; therefore, older adults who are really isolated and as such more vulnerable to elder abuse may not have participated in the study. Additional research is needed to explore the risk factors experienced by frail older adults who are also more vulnerable to elder abuse as well as individuals living in suburban and rural areas.
8. Conclusion
Older Arabic-speaking women and men perceived social isolation and English language proficiency as most influential in increasing their vulnerability to abuse. These two risk factors also intersect with systemic barriers, such as racist and ageist workplace practices that prevent older immigrants from obtaining employment and income opportunities. Policy and practice changes are needed to fully address these risk factors on older immigrants. Evidence-based interventions are available to address these risk factors, but their acceptability within the Arabic-speaking immigrant communities should be examined in future research.
Acknowledgements
This project was funded by the Ministry of Senior Affairs in Ontario, Canada.