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Papi S, Akbari S, Foroughan M, Zanjari N, Moghadasi A M, Zandieh Z. Prevalence of Elder Abuse and its Related Factors among Elderly Referring to Social Security Outpatient Clinic in Yasouj, Iran. Elderly Health Journal 2022; 8 (2) :89-97
URL: http://ehj.ssu.ac.ir/article-1-266-en.html
Prevalence of Elder Abuse and its Related Factors among Elderly Referring to Social Security Outpatient Clinic in Yasouj, Iran
Shahab Papi , Samad Akbari , Mahshid Foroughan , Nasibeh Zanjari , Amir Mohamad Moghadasi , Zhale Zandieh *
Department of Geriatrics, School of Social Welfare, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran , zhzandie@gmail.com
Keywords: Aging, Elder Abuse, Misbehavior, Yasouj
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Prevalence of Elder Abuse and its Related Factors among Elderly Referring to Social Security Outpatient Clinic in Yasouj, Iran
  1. Psychiatry and Behavioral Sciences Research Center, Addiction Institute, Mazandaran University of Medical Sciences, Sari, Iran
  2. Iranian Research Center on Aging, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
  3. Department of Geriatrics, School of Social Welfare, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
  4. Department of Health Education and Promotion, Faculty of Health Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
Article history
Received 20 Jun 2022
Accepted 7 Dec 2022

A B S T R A C T
Introduction: Elder abuse is a major public health concern worldwide. Considering the high prevalence of misbehavior towards the elderly, this study investigated the prevalence of elder abuse and its related factors among the elderly people in Yasouj, Iran in 2021.

Methods: Using a convenience sampling method, this cross-sectional study included 299 older adults aged over 60 years referring to the Social Security Outpatient Clinic in Yasouj. To collect data, we used the Domestic Elder Abuse Questionnaire. To analyze the data, chi-square and multiple logistic regression statistical tests were used.

Results: Of the participants, 55.2 % reported at least one type of misbehavior. While psychological misbehavior had the highest prevalence (41.8 %), rejection had the lowest prevalence (10.7 %). Multiple regression analysis showed that elder abuse was statistically associated with higher educational status (p = 0.002), lower economic status (p = 0.002), and single people reported a higher rate of elder abuse (p = 0.001).
 
Conclusion: According to our results, more than half of the participants reported at least one type of elder abuse, and psychological abuse was the most common type of abuse experienced by the elderly. Since elder abuse can have serious effects on the health and well-being of the elderly, it is critical to identify the related risk factors. Furthermore, it is essential to implement screening programs to increase the awareness of the elderly and caregivers.

Keywords: Aging, Elder Abuse, Misbehavior, Yasouj

Copyright © 2022 Elderly Health Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cite. 

Introduction
    Older adults are a vulnerable group in society; they are exposed to various diseases and disabilities and need medical care and social support (1). The probability of elder abuse increases in long-term care. It can lead to an increase in mortality and a decrease in the social and psychological functioning of the elderly, leading to a decrease in their quality of life (2). Elder abuse has a significant relationship with increasing the hospitalization rate, visits to the emergency department, and transfer to nursing homes and care centers (2-4). Therefore, considering the need to maintain health and ensure their comfort and well-being, knowing the prevalence of elder abuse and its risk factors in every society is of particular importance (5).
    According to the definition by the World Health Organization (WHO), elder abuse is doing or not doing a single or consecutive behavior that causes annoyance, distress or harm to the person, causes anxiety or deprives her/his of comfort. It can be done by trusted people such as family and children or other people and occur in the form of physical, psychological, and sexual abuse, financial exploitation, and neglect (6).
    Elder abuse is a common phenomenon in many countries. In a review of 44 studies around the world, the average prevalence of elder abuse was 15.7% (ranging from 3.2% to 27.5%) (7). In another study, the average prevalence of elder abuse in 28 countries was 14.1% in 2017 (8). In an Iranian study, while the highest rate of elder abuse was related to caregiver neglect (38.4%), the lowest rate was related to physical abuse (11.6%) (9). According to a report from the United States Department of Justice, harassment and inappropriate behavior with the elderly is significantly more than the actual amount. Only one out of every 23 cases are reported to the responsible organizations (10). Studies have shown that the highest amount of elder abuse happens by family members and caregivers of the elderly (11). A cross-sectional study conducted in 2013 on 200 elderlies over 65 years of age hospitalized in Meybod Hospital showed a significant relationship between misbehavior and physical and economic dependence of the elderly, especially when the financial burden is on the caregivers. The findings of the study showed that perhaps older women are more economically dependent on their caregivers and are more exposed to abuse (12).
    One study investigated the prevalence of elder abuse in Iran from 2005 to 2015 and reported that the elder abuse rate in Iran was much higher than in other countries. The overall prevalence of elder abuse in Iran in this study was 56.4%. Moreover, emotional abuse (30.7%), psychological abuse (25.4%), neglect (25.1%), financial abuse (19.7%), physical abuse (13.1%), and rejection (11.7%) were the most common types of elder abuse in Iran (13). The results of another Iranian study conducted in Maragheh showed that among the participants, 45.8% reported abuse, including physical abuse (64.9%), psychological abuse (76.3%), neglect (42%), rejection (16.8%), and financial abuse (29.7%). There was a significant association between elder abuse and age. In fact, elder abuse was less common in those aged 60-70 years old (p < 0.001). No significant association was found between elder abuse and body mass index (p = 0.582) and gender (p = 0.258). (14).
    Functional disability and dependence, low income and financial dependence, cognitive and mental disorders, the caregiver's mental health, drug abuse by the caregiver, and dependence on the elderly are among the causes of the elderly misbehavior (15). With the increased age of the elderly, their physical, psychological, and cognitive performance decreases, and these factors may expose them to caregiver abuse (15, 16).
    There are limited studies conducted on elder abuse in Iran with contradictory results. However, no study has evaluated the prevalence and factors affecting elder abuse in Yasouj. Therefore, this study investigated the prevalence of elder abuse and its related factors in Social Security Insurance Clinic in Kohgiluyeh and Boyer Ahmad province.
Methods
Study design
    This cross-sectional study was conducted in 2021 on older adults referred to the outpatient clinic of the social security organization in Yasouj, Kohgiluyeh and Boyer Ahmad province, Iran.
    Yasouj is one of the cities of southwestern Iran and the center of Kohgiluyeh and Boyer Ahmad province. According to the population and housing census of 2010, the population of Yasouj was 108,505 people (50.52% males vs. 49.48% females). Life expectancy in this city was 68.4 years in 1996, and 70.3 years in 2006 (17).
    All older adults aged over 60 years referred to Yasouj Social Security Outpatient Clinic who were capable to communicate and answer the questions verbally were included. Based on a score of 7 or above on the Abbreviated Mental Test, the participants had the appropriate physical and mental ability to give informed consent and they were fully aware of time and place (18).
Participants
    Sampling was done in a convenient method based on the list of patients aged over 60 referred to the Social Security Clinic of Yasouj. Using the available sampling method and based on the prevalence of 56.4% (19), confidence interval of 95%, and the error of 5%, the sample size was calculated as 272 individuals, which increased to 299 after considering 10% attrition rate. The interviews and completing the questionnaires were performed in a safe and private environment. The questionnaire was completed for those who could not read for any reason via interview. Due to the COVID-19 pandemic, the participants filled out the questionnaires according to the related health protocols.
Instruments
    Two questionnaires were used to collect data, including a demographic questionnaire and the Domestic Elder Abuse Questionnaire.
1) Demographic Information Questionnaire: included personal information such as age, marital status, education, place of residence, perceived socioeconomic status, and underlying disease.
2) Domestic Elder Abuse Questionnaire: This questionnaire include 42-items and has eight subscales, including care neglect (11 questions), psychological abuse (8 questions), physical abuse (4 questions), financial abuse (6 questions), deprivation of choice (10 questions), rejection (4 questions), financial neglect (4 questions), and emotional abuse (2 questions). This questionnaire was developed and validated by Heravi et al., (2008) in Iran. The items of the mentioned tool have the options of yes and no. The scores obtained in this questionnaire are in the range of 1-100, and a higher score indicates the presence of more severe symptoms of misbehavior (20).
Data analysis
    The collected data were analyzed in the Statistical Package for the Social Sciences (SPSS V.23) software. Chi-square test was used to check the relationship between each of the variables and types of elder abuse. Multiple logistic regression was used to investigate the statistical relationship between demographic and individual variables.
Ethical considerations
    The study protocol was approved by the Ethics Committee of the University of Rehabilitation Sciences and Social Health, Tehran, Iran (code: IR.USWR.REC.2017.129). The study aims were explained to all participants and they were advised that they could withdraw from the study at any stage. All participants signed a written informed consent.

Results
    Out of 299 participants, 162 (54.2%) were female and 137 (45.8%) were male. While most participants (56.9%) were in the age range of 60-75 years, 18.4% were in the age range of 75-85 years. Most participants (54.8%) were married and 21.7% were illiterate. (Table 1)
    As Table 2 shows, 165 (55.2%) participants stated that they had experienced one type of misbehavior. While the highest prevalence was related to psychological abuse (41.8%), the lowest prevalence was related to rejection (10.7%).
    There was no statistically significant relationship between gender and any type of abuse. However, females experienced more types of misbehavior than males. There was a statistically significant relationship between educational status and psychological abuse and rejection in the elderly. Also, we observed a significant relationship between the place of residence, marital status (except financial negligence), and perceived economic status with misbehavior. As for the perceived economic situation, all types of misbehavior were significantly lower for older adults with better financial situation. There was no significant relationship between such factors as the age groups, number of children, and occupation with any type of misbehavior. Table 3 summarizes the details of the chi-square test.
    Regarding chronic diseases, the highest prevalence of misbehavior was related to patients with cardiovascular disease (59.7%), followed by joint pain (56.1%), gastrointestinal disease (53.2%), blood lipid (51.8%), and diabetes (48.1%). In the elderly with no chronic disease, the misbehavior was 50.7%, 69.2% with people with a chronic disease, and 58.1% with people with two or more chronic diseases. Moreover, there was no significant relationship between the type of chronic diseases and misbehavior.
    As Table 4 shows, the results of multiple regression analysis indicated a statistically significant relationship between educational status and elder abuse (p = 0.002). Moreover, with one grade of increase in the education level, elder abuse increased by 1.2 times in secondary education and two times in diploma education compared to illiterate individuals.
    Elder abuse had a significant relationship with the perceived economic status of the elderly (p = 0.002); in other words, with one unit of increase in the perceived economic status, elder abuse decreased by 0.8. There was a significant relationship between the residence place of the elderly and elder abuse (p = 0.002), so that the prevalence of elder abuse was higher among the elderly living in the city. Moreover, we witnessed a statistically significant relationship between elder abuse and marital status (P = 0.001), so that unmarried individuals were at a higher risk of elder abuse.

Discussion
    The present study investigated the prevalence of elder abuse and its related factors in the elderly referred to the Scial Security Outpatient Clinic in Yasouj. Based on the obtained results, 55.2% of the elderly experienced misbehavior.
    According to official statistics in 2017, the average rate of elder abuse in 28 countries was 14.1% (8). In a meta-analysis study conducted in 2019, the average prevalence of elder abuse in Iran was 48.3% (9). In another Iranian study conducted in Yazd in 2013, it was reported that 79.6% of the elderly had experienced at least one type of elder abuse (21). In 2016, a structured review and meta-analysis study investigated the prevalence of elder abuse in Iran from 2005 to 2015. According to its results, the overall prevalence of elder abuse in Iran was 56.4% (13). In a cross-sectional study, the prevalence of misbehavior towards the elderly in Tehran was generally 87.8% (22). Another study compared the misbehavior among Fars and Turk elderly people in Chaharmahal and Bakhtiari province. The results showed that 17.14% of the participants experienced misbehavior (23). In another study on older women in Sabzevar, 49.39% of the participants reported the experience of misbehavior (24). The findings of Nassiri et al., showed that 63.3% of the study participants experienced at least one type of misbehavior (25). The prevalence of elder abuse was 52.6% in the study conducted by Setodan et al., and the most common type of abuse was emotional neglect by family members (26). Similar to the results of our study, Kisal (27), Amstadter (28), Perez-Carcelles (29), and Oh (30) demonstrated that psychological misbehavior was the most prevalent type of elder abuse.
 
Table 1. The demographic information and underlying variables in the participants
Variable Status Frequency Percentage Elder abuse
Gender Male 137 45.8 89 (53.9)
Female 162 54.2 76 (46.1)
Marital status Unmarried 164 54.8 82 (47.4)
Married 135 45.2 83 (65.9)
Educational level Illiterate 65 21.7 24 (14.5)
Elementary 89 29.8 63 (38.2)
High school 26 8.7 20 (12.1)
Diploma 61 20.4 29 (17.6)
University 58 19.4 29 (17.6)
Age Youngest-old (60-74 years) 170 56.9 93 (56.4)
Middle-old (aged 75-85 years) 55 18.4 33 (20.0)
Oldest-old (Over 85 years) 74 24.7 39 (23.6)
Place of residence Village 146 48.8 94 (57.0)
City 153 51.2 71 (43.0)
Number of children 1 to 3 102 34.1 16 (28.1)
4 to 6 114 48.2 31 (54.3)
More than 6 53 17.7 53 (17.7)
Perceived economic status Good 84 28.1 71 (23.7)
Moderate 118 39.5 120 (40.1)
Weak 97 32.4 108 (36.1)
Occupation status Housewife 69 23.1 43 (26.1)
Disabled 55 18.4 70 (42.4)
Employed 123 41.1 29 (17.6)
Retired 52 17.4 23 (13.9)
Underlying disease No 138 46.2 70 (50.7)
1 disease 13 4.3 9 (69.2)
2 types of disease or more 148 49.5 86 (58.1)
Cardiovascular disease Yes 72 24.1 43 (59.7)
No 227 75.9 122 (53.7)
High blood fat Yes 85 24.4 44 (51.8)
No 214 71.6 121 (56.5)
Diabetes Yes 54 18.1 26 (48.1)
No 245 81.9 139 (56.7)
Digestive disease Yes 47 15.7 25 (53.2)
No 252 84.3 140 (56.6)
Joint pain Yes 47 52.5 88 (56.1)
No 142 47.5 77 (54.2)

Table 2. Frequency distribution of types of misbehavior in the participants
Types of misbehavior Number (percentage)
Psychological 125 (41.8)
Physical 38 (12.7)
Financial 35 (11.7)
Rejection 32 (10.7)
Neglect of care 76 (25.4)
Emotional neglect 57 (19.1)
Financial neglect 43 (14.4)
Deprivation of authority 83 (27.8)
Total 165 (55.2)
Table 3. The status of types of misbehavior based on demographic variables
Care neglect Psychological Physical Financial Deprivation of choice Rejection Financial neglect Emotional neglect Types of misbehavior
Gender Female 42 (55.3) 7 (53.6) 24 (63.2) 22 (62.9) 50 (60.2) 21 (65.6) 28 (65.1) 29 (50.9) 89 (53.9)
Male 34 (44.7) 58 (46.4) 14 (36.8) 13 (37.1) 33 (39.8) 11 (34.4) 15 (34.9) 28 (49.1) 76 (46.1)
Educational level Illiterate 11 (14.5) 20 (46.4) 6 (15.8) 7 (20.0) 10 (12.0) 7 (21.9) 6 (14.0) 10 (17.5) 24 (14.5)
Elementary 22 (28.9) 47 (37.6) 8 (21.1) 13 (37.1) 29 (34.9) 3 (9.4) 8 (18.6) 23 (40.4) 63 (38.2)
High school 9 (11.8) 14 (11.2) 6 (15.8) 2 (5.7) 9 (10.8) 2 (6.3) 5 (11.6) 4 (7.0) 20 (12.1)
Diploma 16 (21.1) 23 (18.4) 6 (15.8) 6 (17.1) 15 (18.1) 10 (31.3) 12 (27.9) 12 (21.1) 29 (17.6)
University 18 (23.7) 21 (16.8) 12 (31.6) 7 (20.0) 20 (24.1) 10 (31.3) 12 (27.9) 8 (14.0) 29 (17.6)
Age groups 60-74 years 39 (51.3) 75 (60.0) 16 (42.1) 18 (51.4) 45 (54.2) 17 (53.1) 23 (53.5) 36 (63.2) 93 (56.4)
75-85 years 16 (21.1) 24 (19.2) 11 (28.9) 9 (25.7) 16 (19.3) 7 (21.9) 7 (16.3) 12 (21.1) 33 (20.0)
Above 85 years 21 (27.6) 26 (20.8) 11 (28.9) 8 (22.9) 22 (26.5) 8 (25.0) 13 (30.2) 9 (15.8) 39 (23.6)
Place of residence City 41 (53.9) 68 (54.4) 23 (60.5) 18 (51.4) 48 (57.8) 15 (46.9) 25 (58.1) 25 (43.9) 94 (57.0)
Village 35 (46.1) 57 (45.6) 15 (39.5) 17 (48.6) 35 (42.2) 17 (53.1) 18 (41.9) 32 (56.1) 71 (43.0)
Marital status Married 34 (19.7) 63 (36.4) 16 (9.2) 106 (40.2) 39 (22.5) 12 (6.9) 18 (10.4) 28 (16.2) 82 (47.4)
Unmarried 42 (33.3) 62 (49.2) 22 (17.5) 20 (57.1) 44 (34.9) 20 (15.9) 25 (19.8) 29 (23.0) 83 (65.9)
Economic status Good 15 (19.7) 20 (16.0) 8 (21.1) 4 (11.4) 14 (16.9) 4 (12.5) 9 (20.9) 9 (15.8) 71 (23.7)
Moderate  37 (48.7) 57 (45.6) 19 (50.0) 21 (60.0) 35 (42.2) 12 (37.5) 18 (41.9) 24 (42.1) 120 (40.1)
Weak 24 (31.6) 48 (38.4) 11 (28.9) 10 (28.6) 34 (41.0) 16 (50.0) 16 (37.2) 24 (42.1) 108 (36.1)
Number of children 1 to 3 22 (28.9) 39 (31.2) 17 (44.7) 8 (22.9) 24 (28.9) 24 (28.9) 11 (34.4) 17 (39.5) 16 (28.1)
4 to 6 38 (50.0) 64 (51.2) 13 (34.2) 20 (57.1) 43 (51.8) 43 (51.8) 13 (40.6) 16 (37.2) 31 (54.3)
More than 6 16 (21.1) 22 (17.6) 8 (21.1) 7 (20.0) 16 (19.3) 16 (19.3) 8 (25.0) 10 (23.3) 53 (17.7)
Occupation status Housewife 16 (21.1) 32 (25.6) 10 (26.3) 8 (22.9) 25 (30.1) 12 (37.5) 14 (32.6) 13 (22.8) 43 (26.1)
Employed 33 (43.4) 52 (41.6) 12 (31.6) 10 (28.6) 31 (37.3) 10 (31.3) 14 (32.6) 23 (40.4) 70 (42.4)
Disabled 15 (19.7) 24 (19.2) 9 (23.7) 12 (34.3) 15 (18.1) 6 (18.8) 9 (20.9) 14 (24.6) 29 (17.6)
Retired 12 (15.8) 17 (13.6) 7 (18.4) 5 (14.3) 12 (14.5) 4 (12.5) 6 (14.0) 7 (12.3) 23 (13.9)

Table 4. Predictors of misbehavior based on multiple logistic regression model
Covariates Level Coefficient p-value
Age - -0.018 0.25
Gender Male - -
Female -0.250 0.32
Place of residence Village - -
City 0.595 0.015
Educational level Illiterate - -
Elementary -0.43 0.31
High school 1.23 0.002
Diploma 2.06 0.002
University 0.334 0.41
Perceived economic status Weak - -
Moderate 0.115 0.68
Good -.819 0.01
Occupation status Employed - -
Housewife 0.65 0.15
Retired 0.27 0.59
Disabled 0.39 0.44
Marital status Unmarried - -
Married -1.53 0.001
Having a chronic disease 1 disease - -
No -0.347 0.65
2 types of disease or more -0.284 0.69
Cardiovascular diseases No - -
Yes -0.33 -0.24
High blood fat No - -
Yes 0.079 0.77
Diabetes No - -
Yes 0.366 0.26
Digestive disease No - -
Yes 0.084 0.8
Joint pain No - -
Yes 0.09 0.71
    According to the disengagement theory, the elderly people are almost socially isolated and receive less attention. Their needs are sometimes neglected, while they still can play a role (31). One of the main reasons for the high prevalence of elder abuse in Iran is the passive and indifferent view towards the elderly, which has removed them from the natural cycle of social activities.
As stated, the percentage of elder abuse in Yasouj was about three times the world average and even more than the national average. This can be due to differences in lifestyle, age, gender, marital status, children's financial status, society's general culture, and society's view of the elderly. There was no significant relationship between gender and any type of misbehavior. However, females experienced more types of misbehavior compared to males. The results of this study regarding the absence of a significant difference between the two genders were consistent with the studies carried out by Morowati et al., in Yazd (21) and Manoochehri et al., in Tehran (22). This may be due to cultural issues. A housewife with no source of income expects someone (father, husband, family members) to take care of her and is financially dependent on them; so, she is more vulnerable to misbehavior.
    Based on the findings of our study, there was a significant relationship between educational status and the prevalence of misbehavior among the elderly. This is in line with the studies conducted by Haghighatian et al., (32), Karimi et al., (34), Achappa et al., (19), and Heravi-Karimooi et al., (33, 35). This indicates a meaningful relationship between education and misbehavior. However, the studies by Morowati et al., (21), Gil et al., (36), Manoochehri et al., (22), Saatlou et al., (37), Heravi Karimooi et al., (38), and Keyqobadi et al., (24), did not observe any significant relationship between misbehavior and education level.
    In the present study, apart from emotional neglect, we witnessed a significant relationship between marital status and misbehavior and its types in the elderly. This result is consistent with the studies conducted by Karimi et al., (34), and Papi et al., (16), on older adults; the participants in the mentioned studies mentioned that their spouses had died and they experienced elder abuse more than other older adults. While there was no significant difference between single and married people in terms of harassment in the study by Saatlou et al., (38), the average harassment rate in single older adults was higher than that of married ones. In the study by Manoochehri et al., (22), there was no significant relationship between marital status and the prevalence of misbehavior. This could be due to the difference in the cultural origins and social structure of the participants.
    Based on the findings of the present study, there was a significant relationship between the residence place and misbehavior, so that the prevalence of misbehavior in the elderly living in the city was higher than that in the elderly living in the village. In the studies by Cadmus et al., (39) and Nassiri et al., (25), the elderly living in the city suffered more from the risk of abuse than the elderly living in the village, which is consistent with the results of our study. This may be due to family workload, psychological pressures, and problems of urban life. Life in cities flows faster than in villages. An older adult with a low speed of moving and adapting and communicating skills experiences a higher rate of misbehavior in cities. In the study by Borji et al., although the overall prevalence of misbehavior was higher in the elderly living in rural areas, there was no significant difference in this regard (40).
    Our results showed a significant relationship between misbehavior and the perceived economic status of the elderly. According to the current economic conditions in Iran, many people do not have enough income for their living expenses; this issue has created problems and tension in people's relationships. Meanwhile, it has caused misbehavior towards the elderly with a weaker economic status. This issue is consistent with the exchange theory because some people may expect financial support from the elderly. In contrast, the elderly who are financially weak do not have such ability and are exposed to more misbehavior.
    Hosseini et al., (23) showed that neglect, rejection of the elderly, and financial misconduct had a significant relationship with income. The study by Haghighatian et al., also showed a significant relationship between the socioeconomic status of the family and the abuse rate of the elderly (32). The results of these studies are inconsistent with those reported by Belvis et al., and Lopes et al. (41, 42).
    The results of several studies indicated a significant relationship between age and all cases of elder abuse (22, 40, 43). In some studies, a higher age was associated with a higher rate of elder abuse (12, 35, 37). But in another study, it was stated that suffering from a chronic disease can aggravate elder abuse; so, there was a significant relationship between the disease and elder abuse (44).
    The awareness among the European elderly about regarding the examples of elder abuse and the existence of legal protections in this regard has caused them to be less exposed to misbehavior (45). In Iran, despite the religious beliefs, values​, and culture of honoring the elderly, the life form and modernity have influenced the relationships between family members, and the care of the elderly has received less attention in the last few decades. The lack of accurate statistics and the lack of expression of many cases of elder abuse by the elderly can be another reason for the difference between the results of some studies and the present study.

Conclusion
    The present study showed that more than half of the elderly were subjected to elder abuse. The most common type of misbehavior experienced by the elderly was psychological abuse. Likewise, perceived economic status, place of residence, marital status, and education level were among the factors affecting elder abuse. Such findings highlight the need for continuous and principled treatment of this social and health problem. Clarifying this phenomenon from its various aspects should be one of the primary priorities in this regard. This is possible only by adopting a comprehensive approach and requires the participation and cooperation of all organizations involved in social and health affairs, experts and specialists in social welfare, doctors, nurses, social workers, psychologists, and social members. Accordingly, it seems essential to pay special attention to preventing elder abuse among vulnerable older adults with cognitive problems and those reliant on others, living in homes and care centers. This physical and mental health problems of older adults make them more vulnerable.
    This study was conducted in an urban area. So, it is not possible to generalize the results to other areas of the country. Disseminating information about the awareness of various social programs that target the elderly is necessary to reduce abusive behaviors. Further studies with more diverse and larger sample sizes are required to identify the factors affecting elder abuse.

Study limitations
The present study was conducted only in one of the urban areas of the country, and it is not possible to generalize the results of this study to other areas of the country, both deprived and privileged.

Conflict of interests
    The authors declared no conflict of interest.

Acknowledgments
    We acknowledge the support of the Technology Deputy of the University of Social Welfare and Rehabilitation Sciences, the personnel of Yasouj Clinics, and the enthusiastic participation and cooperation of the elderly.

Authors’ contributions
Zhale Zandieh, Shahab Papi;conceived of the presented idea.
Methodology: Nasibeh Zanjari;
Investigation, Writing – original draft, and Writing – review & editing: All authors;
Data collection, Samad Akbari, Amir Mohamad Moghadasi
Data analysis: Mahshid Foroughan
Funding acquisition and Resources: Zhale Zandieh
All authors have an equal share in this study, have read the manuscript, approved the final version and agreed to be accountable for all aspects of the work.

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  12. Ghodoosi A, Fallah Yakhdani E, Abedi HA. Studying the instances of elder abuse and their relationship with age and sex in the hospitalized elderly. Iranian Journal of Forensic Medicine. 2014; 20(4): 367-76.
  13. Molaei M, Etemad K, Taheri Tanjani P. Prevalence of elder abuse in Iran: A systematic review and meta-analysis. Salmand: Iranian Journal of Ageing. 2017; 12(2): 242-53. [Persian]
  14. Alaviani M, Kolbadinezhad N, Khodayari MT, Rahimi R, Jafari S. Prevalence of elder abuse in Maragheh, Iran 2017. Journal of Mazandaran University of Medical Sciences. 2019; 29(176): 105-15. [Persian]
  15. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: global situation, risk factors, and prevention strategies. The Gerontologist. 2016; 56(Suppl 2): 194-205.
  16. Papi S, Karimi Z, Saadat Talab F, Hosseini F, Afrouzeh H, Yousefi M, Norouzi S. Relationship between health literacy and multi-infections based on gender differences in the elderly. Health Education and Health Promotion. 2021; 9(2): 105-10.
  17. Jalil S. Natural and human geographical study of Yasuj city. Kharazmi University. 2020; 31: 41-59. [Persian]
  18. Bakhtiyari F, Foroughan M, Fakhrzadeh H, Nazari N, Najafi B, Alizadeh M, et al. Validation of the Persian version of abbreviated mental test (AMT) in elderly residents of Kahrizak charity foundation. Iranian Jjournal of Diabetes and Metabolism. 2014; 13(6): 487-94.
  19. Achappa S, Rao B, Holyachi S. Bringing elder abuse out of the shadows: A study from the old age homes of Davangere district, Karnataka, India. International Journal of Community Medicine and Public Health. 2016; 3(6): 1617-22.
  20. Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi MT, Hajizadeh E. Designing and determining psychometric properties of the domestic elder abuse questionnaire. Salmand: Iranian Journal of Ageing. 2010; 5(1): 7-21. [Persian]
  21. Morowatisharifabad MA, Rezaeipandari H, Dehghani A, Zeinali A. Domestic elder abuse in Yazd, Iran: a cross-sectional study. Health Promotion Perspectives. 2016; 6(2): 104-10.
  22. Manouchehri H, Ghorbi B, Hosseini M, Oskuyee NN, Karbakhsh M. Degree and types of domestic abuse in the elderly referring to. Advances in Nursing and Midwifery. 2008; 18(63): 39-45.
  23. Hosseini RS, Salehabadi R, Javanbakhtian R, Alijanpour Aghamaleki M, Borhani nejad VR, Pakpour V. A comparison on elderly abuse in Persian and Turkish race in Chaharmahal Bakhtiari province. Journal of Sabzevar University of Medical Sciences. 2016; 23(1): 75-83. [Persian]
  24. Keyghobadi F, Moghaddam Hosseini V, Keyghobadi F, Rakhshani MH. Prevalence of elder abuse against women and associated factors. Journal of Mazandaran University of Medical Sciences. 2014; 24(117): 125-32. [Persian]
  25. Heravi Karimooi M, Nassiri H, Jouybari L, Sanago A, Chehrehgosha M. The prevalence of elder abuse in Gorgan and Aq-Qala cities, Iran in 2013. Salmand: Iranian Journal of Ageing. 2016; 10(4): 162-73. [Persian]
  26. Seutodan Hagh H, Rezaeipandari H, Mousavi S, Allahverdipour H. Frequency and gender pattern of elder abuse among community dwelling older adults in the urban area of Tabriz, Iran. Salmand: Iranian Journal of Ageing. 2021; 15(4): 458-71. [Persian]
  27. Kissal A, Beşer A. Elder abuse and neglect in a population offering care by a primary health care center in Izmir, Turkey. Social Work in Health Care. 2011; 50(2):158-75.
  28. Amstadter AB, Zajac K, Strachan M, Hernandez MA, Kilpatrick DG, Acierno R. Prevalence and correlates of elder mistreatment in South Carolina: the South Carolina elder mistreatment study. Journal of Interpersonal Violence. 2011; 26(15): 2947-72.
  29. Pérez-Cárceles MD, Rubio L, Pereniguez JE, Pérez-Flores D, Osuna E, Luna A. Suspicion of elder abuse in South Eastern Spain: the extent and risk factors. Archives of Gerontology and Geriatrics. 2009; 49(1): 132-7.
  30. Oh J, Kim HS, Martins D, Kim H. A study of elder abuse in Korea. International Journal of Nursing Studies. 2006; 43(2): 203-14.
  31. Cumming E, Dean LR, Newell DS, McCaffrey I. Disengagement: a tentative theory of aging. Sociometry. 1960; 23(1): 23-35.
  32. Haghighatian M, Fotouhi M. Sociocultural factors affecting elderly abuse. Health System Research Study. 2012; 8(7 supplement): 1117-26.
  33. Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi M, Hajizadeh E, Seyed-Bagher-Maddah M, et al. Elder abuse from the perspectives of elderly people. Advances in Nursing & Midwifery. 2008; 17(61): 26-38. [Persian]
  34. Karimi M, Elahi N. Elderly abuse in Ahwaz city and its relationship with individual and social characteristics. Salmand: Iranian Journal of Ageing. 2008; 3(1): 42-7. [Persian]
  35. Heravi-Karimooi M, Rejeh N, Montazeri A. Health-related quality of life among abused and non-abused elderly people: a comparative study. Payesh. 2013; 12(5): 479-88. [Persian]
  36. Gil APM, Kislaya I, Santos AJ, Nunes B, Nicolau R, Fernandes AA. Elder abuse in Portugal: findings from the first national prevalence study. Journal of Elder Abuse & Neglect. 2015; 27(3): 174-95.
  37. Saatlou E, Hossaini F, Sakeni Z. Assessment of elder abuse in adult day care centers. Journal of Geriatric Nursing. 2018; 2(1): 91-103. [Persian]
  38. Heravi Karimoei M, Rejeh N, Foroughan M, Montazeri A. Elderly abuse rates within family among members of senior social clubs in Tehran. Salmand: Iranian Journal of Ageing. 2012; 6(4): 37-50. [Persian]
  39. Cadmus E, Owoaje E, Akinyemi O, Nwachukwu C. P2-377 A rural-urban comparison of the prevalence and patterns of elder abuse in Oyo State, South Western Nigeria. Journal of Epidemiology & Community Health. 2011; 65: 327.
  40. Borji M, Asadollahi K. Comparison between perceived misbehavior by urban and rural elderlies. Iranian Journal of Psychiatric Nursing. 2016; 4(3): 41-50. [Persian]
  41. De Belvis AG, Avolio M, Spagnolo A, Damiani G, Sicuro L, Cicchetti A, et al. Factors associated with health-related quality of life: the role of social relationships among the elderly in an Italian region. Public Health. 2008; 122(8): 784-93.
  42. Lopes A. Welfare arrangements, safety nets, and familial support for the elderly in Portugal [PhD thesis]. London School of Economics and Political Science; 2006.
  43. Nori A, Rajabi A, Esmailzadeh F. Prevalence of elder misbehavior in northern Iran (2012). Journal of Gorgan University of Medical Sciences. 2015; 16(4): 93-8. [Persian].
  44. Akbari A, Assar S, Hosseini F. Relationship between elder abuse, life satisfaction and individual and social variables among elderly referred to health centers in Rafsanjan. Journal of Military Caring Sciences. 2020; 7(2): 159-67. [Persian]
  45. Biggs S, Manthorpe J, Tinker A, Doyle M, Erens B. Mistreatment of older people in the United Kingdom: findings from the first national prevalence study. Journal of Elder Abuse & Neglect. 2009; 21(1): 1-14. [Persian]
Type of Study: Research | Subject: General
Received: 2022/06/20 | Accepted: 2022/12/7 | Published: 2022/12/29
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10. National Institute on Aging. Elder abuse [Internet]. 2016 [cited 2022 Jan 12]; Available from: https://www.nia.nih.gov/health/elder-abuse
11. Storey JE. Risk factors for elder abuse and neglect: a review of the literature. Aggression and Violent Behavior. 2020; 50: 101339.
12. Ghodoosi A, Fallah Yakhdani E, Abedi HA. Studying the instances of elder abuse and their relationship with age and sex in the hospitalized elderly. Iranian Journal of Forensic Medicine. 2014; 20(4): 367-76.
13. Molaei M, Etemad K, Taheri Tanjani P. Prevalence of elder abuse in Iran: A systematic review and meta-analysis. Salmand: Iranian Journal of Ageing. 2017; 12(2): 242-53. [Persian]
14. Alaviani M, Kolbadinezhad N, Khodayari MT, Rahimi R, Jafari S. Prevalence of elder abuse in Maragheh, Iran 2017. Journal of Mazandaran University of Medical Sciences. 2019; 29(176): 105-15. [Persian]
15. Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: global situation, risk factors, and prevention strategies. The Gerontologist. 2016; 56(Suppl 2): 194-205.
16. Papi S, Karimi Z, Saadat Talab F, Hosseini F, Afrouzeh H, Yousefi M, Norouzi S. Relationship between health literacy and multi-infections based on gender differences in the elderly. Health Education and Health Promotion. 2021; 9(2): 105-10.
17. Jalil S. Natural and human geographical study of Yasuj city. Kharazmi University. 2020; 31: 41-59. [Persian]
18. Bakhtiyari F, Foroughan M, Fakhrzadeh H, Nazari N, Najafi B, Alizadeh M, et al. Validation of the Persian version of abbreviated mental test (AMT) in elderly residents of Kahrizak charity foundation. Iranian Jjournal of Diabetes and Metabolism. 2014; 13(6): 487-94.
19. Achappa S, Rao B, Holyachi S. Bringing elder abuse out of the shadows: A study from the old age homes of Davangere district, Karnataka, India. International Journal of Community Medicine and Public Health. 2016; 3(6): 1617-22.
20. Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi MT, Hajizadeh E. Designing and determining psychometric properties of the domestic elder abuse questionnaire. Salmand: Iranian Journal of Ageing. 2010; 5(1): 7-21. [Persian]
21. Morowatisharifabad MA, Rezaeipandari H, Dehghani A, Zeinali A. Domestic elder abuse in Yazd, Iran: a cross-sectional study. Health Promotion Perspectives. 2016; 6(2): 104-10.
22. Manouchehri H, Ghorbi B, Hosseini M, Oskuyee NN, Karbakhsh M. Degree and types of domestic abuse in the elderly referring to. Advances in Nursing and Midwifery. 2008; 18(63): 39-45.
23. Hosseini RS, Salehabadi R, Javanbakhtian R, Alijanpour Aghamaleki M, Borhani nejad VR, Pakpour V. A comparison on elderly abuse in Persian and Turkish race in Chaharmahal Bakhtiari province. Journal of Sabzevar University of Medical Sciences. 2016; 23(1): 75-83. [Persian]
24. Keyghobadi F, Moghaddam Hosseini V, Keyghobadi F, Rakhshani MH. Prevalence of elder abuse against women and associated factors. Journal of Mazandaran University of Medical Sciences. 2014; 24(117): 125-32. [Persian]
25. Heravi Karimooi M, Nassiri H, Jouybari L, Sanago A, Chehrehgosha M. The prevalence of elder abuse in Gorgan and Aq-Qala cities, Iran in 2013. Salmand: Iranian Journal of Ageing. 2016; 10(4): 162-73. [Persian]
26. Seutodan Hagh H, Rezaeipandari H, Mousavi S, Allahverdipour H. Frequency and gender pattern of elder abuse among community dwelling older adults in the urban area of Tabriz, Iran. Salmand: Iranian Journal of Ageing. 2021; 15(4): 458-71. [Persian]
27. Kissal A, Beşer A. Elder abuse and neglect in a population offering care by a primary health care center in Izmir, Turkey. Social Work in Health Care. 2011; 50(2):158-75.
28. Amstadter AB, Zajac K, Strachan M, Hernandez MA, Kilpatrick DG, Acierno R. Prevalence and correlates of elder mistreatment in South Carolina: the South Carolina elder mistreatment study. Journal of Interpersonal Violence. 2011; 26(15): 2947-72.
29. Pérez-Cárceles MD, Rubio L, Pereniguez JE, Pérez-Flores D, Osuna E, Luna A. Suspicion of elder abuse in South Eastern Spain: the extent and risk factors. Archives of Gerontology and Geriatrics. 2009; 49(1): 132-7.
30. Oh J, Kim HS, Martins D, Kim H. A study of elder abuse in Korea. International Journal of Nursing Studies. 2006; 43(2): 203-14.
31. Cumming E, Dean LR, Newell DS, McCaffrey I. Disengagement: a tentative theory of aging. Sociometry. 1960; 23(1): 23-35.
32. Haghighatian M, Fotouhi M. Sociocultural factors affecting elderly abuse. Health System Research Study. 2012; 8(7 supplement): 1117-26.
33. Heravi-Karimooi M, Anoosheh M, Foroughan M, Sheykhi M, Hajizadeh E, Seyed-Bagher-Maddah M, et al. Elder abuse from the perspectives of elderly people. Advances in Nursing & Midwifery. 2008; 17(61): 26-38. [Persian]
34. Karimi M, Elahi N. Elderly abuse in Ahwaz city and its relationship with individual and social characteristics. Salmand: Iranian Journal of Ageing. 2008; 3(1): 42-7. [Persian]
35. Heravi-Karimooi M, Rejeh N, Montazeri A. Health-related quality of life among abused and non-abused elderly people: a comparative study. Payesh. 2013; 12(5): 479-88. [Persian]
36. Gil APM, Kislaya I, Santos AJ, Nunes B, Nicolau R, Fernandes AA. Elder abuse in Portugal: findings from the first national prevalence study. Journal of Elder Abuse & Neglect. 2015; 27(3): 174-95.
37. Saatlou E, Hossaini F, Sakeni Z. Assessment of elder abuse in adult day care centers. Journal of Geriatric Nursing. 2018; 2(1): 91-103. [Persian]
38. Heravi Karimoei M, Rejeh N, Foroughan M, Montazeri A. Elderly abuse rates within family among members of senior social clubs in Tehran. Salmand: Iranian Journal of Ageing. 2012; 6(4): 37-50. [Persian]
39. Cadmus E, Owoaje E, Akinyemi O, Nwachukwu C. P2-377 A rural-urban comparison of the prevalence and patterns of elder abuse in Oyo State, South Western Nigeria. Journal of Epidemiology & Community Health. 2011; 65: 327.
40. Borji M, Asadollahi K. Comparison between perceived misbehavior by urban and rural elderlies. Iranian Journal of Psychiatric Nursing. 2016; 4(3): 41-50. [Persian]
41. De Belvis AG, Avolio M, Spagnolo A, Damiani G, Sicuro L, Cicchetti A, et al. Factors associated with health-related quality of life: the role of social relationships among the elderly in an Italian region. Public Health. 2008; 122(8): 784-93.
42. Lopes A. Welfare arrangements, safety nets, and familial support for the elderly in Portugal [PhD thesis]. London School of Economics and Political Science; 2006.
43. Nori A, Rajabi A, Esmailzadeh F. Prevalence of elder misbehavior in northern Iran (2012). Journal of Gorgan University of Medical Sciences. 2015; 16(4): 93-8. [Persian].
44. Akbari A, Assar S, Hosseini F. Relationship between elder abuse, life satisfaction and individual and social variables among elderly referred to health centers in Rafsanjan. Journal of Military Caring Sciences. 2020; 7(2): 159-67. [Persian]
45. Biggs S, Manthorpe J, Tinker A, Doyle M, Erens B. Mistreatment of older people in the United Kingdom: findings from the first national prevalence study. Journal of Elder Abuse & Neglect. 2009; 21(1): 1-14. [Persian]
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