Pone 0239560
Pone 0239560
Pone 0239560
RESEARCH ARTICLE
* smeyer@who.int
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a1111111111 Abstract
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a1111111111 The majority of the existing evidence-base on violence against women focuses on women
of reproductive age (15–49), and globally there is sparse evidence concerning patterns of
and types of violence against women aged 50 and older. Improved understanding of differ-
ing patterns and dynamics of violence older women experienced is needed to ensure appro-
OPEN ACCESS priate policy or programmatic responses. To address these gaps in the evidence, we
Citation: Meyer SR, Lasater ME, Garcı́a-Moreno C conducted a systematic review of qualitative literature on violence against older women,
(2020) Violence against older women: A including any form of violence against women, rather than adopting a specific theoretical
systematic review of qualitative literature. PLoS framework on what types of violence or perpetrators should be included from the outset, and
ONE 15(9): e0239560. https://doi.org/10.1371/
journal.pone.0239560
focusing specifically on qualitative studies, to explore the nature and dynamics of violence
against older women from the perspective of women. Following pre-planned searches of 11
Editor: Stefano Federici, Università degli Studi di
Perugia, ITALY
electronic databases, two authors screened all identified titles, abstracts and relevant full
texts for inclusion in the review. We extracted data from 52 manuscripts identified for inclu-
Received: April 12, 2020
sion, and conducted quality assessment and thematic synthesis from the key findings of the
Accepted: September 8, 2020 included studies. Results indicated that the vast majority of included studies were conducted
Published: September 24, 2020 in high-income contexts, and did not contain adequate information on study setting and con-
Peer Review History: PLOS recognizes the text. Thematic synthesis identified several central themes, including the intersection
benefits of transparency in the peer review between ageing and perceptions of, experiences of and response to violence; the centrality
process; therefore, we enable the publication of of social and gender norms in shaping older women’s experiences of violence; the cumula-
all of the content of peer review and author
responses alongside final, published articles. The
tive physical and mental health impact of exposure to lifelong violence, and that specific bar-
editorial history of this article is available here: riers exist for older women accessing community supports and health services to address
https://doi.org/10.1371/journal.pone.0239560 violence victimization. Our findings indicated that violence against older women is prevalent
Copyright: © 2020 Meyer et al. This is an open and has significant impacts on physical and mental well-being of older women. Implications
access article distributed under the terms of the for policy and programmatic response, as well as future research directions, are highlighted.
Creative Commons Attribution License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the original
author and source are credited.
Health Organization Joint Programme on outcomes, abortion (often in unsafe conditions), HIV and sexually transmitted infections,
Strengthening Methodologies and Measurement depression, alcohol-use disorders and other mental health problems [1–5]. The 2030 Sustain-
and building national capacities for Violence
able Development Goals [SDGs] include as one of their targets (5.2) under Goal 5 on gender
against Women data. The funders had no role in
study design, data collection and analysis, decision equality, the elimination of all forms of violence against women and girls. Indicator 5.2.1, mea-
to publish, or preparation of the manuscript. suring intimate partner violence [IPV]: Proportion of ever-partnered women and girls aged 15
years and older subjected to physical, sexual or psychological violence by a current or former
Competing interests: The authors have declared
that no competing interests exist. intimate partner in the previous 12 months, is proposed to track the measurement of progress
in achieving this goal. The indicator does not include an upper age limit, and data on older
women (aged 50 and above), including but not limited to intimate partner violence, are needed
to support national and global monitoring of violence against women of all ages, including for
monitoring of the SDGs.
The majority of existing violence against women surveys and data have focused on women
of reproductive age (15–49), as they suffer the brunt of intimate partner violence and non-
partner sexual violence [6]. A growing number of surveys are now including women older
than 49 years, however globally there is sparse evidence concerning patterns of and types of
violence against women aged 50 and older, and limited understanding of barriers to reporting
and help-seeking amongst older women who are subjected to violence [7]. Compared to
women of reproductive age, women aged 50 and above may experience different relationship
dynamics which influence forms of abuse [8, 9], and some evidence indicates that older
women experience different types of violence, for example, psychological violence and verbal
abuse, compared to younger women’s experiences of physical and sexual violence [10]. For
older women, recent exposure to violence may be interlinked with violence victimization at
different stages of the life-course [11, 12]. Dynamics of ageing may shape experiences of vio-
lence, for example, provision of care to a dependent partner may influence decisions to dis-
close or report abuse [10]. They are also more likely to experience violence from other family
members, including children, and from carers. Currently, the evidence-base of qualitative and
quantitative data concerning violence against older women is limited, and a better understand-
ing of these differing patterns and dynamics is needed to ensure appropriate policy or pro-
grammatic responses to violence against older women and service development and provision
for older women affected by violence [10, 11]. To address these gaps in the evidence, we con-
ducted a systematic review of qualitative literature on violence against older women.
expanding and clarifying types of violence, perpetrators, linkages to particular risk factors, and
physical, mental and social impacts of violence against older women.
In the present review, we aimed to build on previous systematic reviews and strengthen the
evidence-base by i) including studies and evidence focused specifically on women; ii) includ-
ing any form of violence against women, rather than adopting a specific theoretical framework
on what types of violence or perpetrators should be included from the outset; iii) focusing on
women aged 50 and above (as many surveys often specifically focus on women of reproductive
age, which is considered to be up to 49 years of age); and iv) focusing specifically on qualitative
studies, to explore the nature and dynamics of violence against older women from the perspec-
tive of women. We aimed to identify, evaluate and synthesize qualitative studies from all coun-
tries, exploring violence against women aged 50 and above, identifying types and patterns of
violence, perpetrators of violence, and impacts of violence on various outcomes for older
women, including physical and mental health and social support, and women’s responses to
experiences of violence. We include the following forms of violence: elder abuse, family vio-
lence and intimate partner violence. Elder abuse is defined as “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” [24]. Intimate partner violence is defined as
“behaviour by an intimate partner or ex-partner that causes physical, sexual or psychological
harm, including physical aggression, sexual coercion, psychological abuse and controlling
behaviours” [25]. Family violence is often used interchangeable with intimate partner violence,
however, also encompasses abuse and violence perpetrated by other family members, for
example, adult children or in-laws. While there is no universal agreed-upon definition of older
women, for the purposes of this review, we define older women as women aged 50 and above,
while recognizing that aging and age are social phenomenon, and definitions vary across orga-
nizations, cultures and communities. The protocol was pre-registered with PROSPERO, Regis-
tration Number: CRD42019119467, https://www.crd.york.ac.uk/prospero/display_record.
php?ID=CRD42019119467 (see also [26]).
Methods
Search strategy
In this systematic review, we searched 11 electronic databases–PubMed, PsycINFO, Embase,
CINAHL, PILOTS, ERIC, Social Work Abstracts, International Bibliography of the Social Sci-
ences, Social Services Abstracts, ProQuest Criminal Justice and Dissertations & Theses Global,
from 1990. We conducted searches that combined the following domains as part of the
research question: 1) age (50 and above); AND 2) women; AND 3) violence; AND 4) qualita-
tive methodology. For each of these domains, we identified the relevant keywords and search
terms, which varied by database; the search strategy was appropriately modified for each data-
base, including syntax and specific terms, topics and/ or headings. The search strategy for
PubMed is included in S1 File. Searches were conducted in April 2018 and updated in July
2019. We did not limit the search by year of publication or language.
We also hand searched reference lists of relevant existing systematic reviews, which we
identified both through background research and through the formal database searches, and
reviewed relevant references (44 identified). We consulted with 49 experts on violence against
older women or older adults, including researchers, practitioners and policy makers, from all
regions globally. All experts were contacted and followed-up with a minimum of 2 contacts. 26
experts responded with 424 articles, 64 of which were duplicates. We reviewed the full text of
43 articles and ultimately included 2 in the full review. Grey literature was not systematically
searched; grey literature submitted by experts was initially considered for inclusion, however,
conducting comparable data extraction and quality assessment for grey literature alongside the
peer-reviewed literature was not possible.
We identified 18 non-English language articles for full-text review. For 17 of these articles,
we identified a native speaker external reviewer who was provided with inclusion and exclu-
sion criteria and consulted with authors regarding final inclusion (4 Portuguese, 7 Spanish, 1
Hebrew, 1 Dutch, 1 German, 1 Danish, 2 French). One non-English article (in Farsi) was not
reviewed as the research team could not engage a Farsi speaker to review the article. The exter-
nal reviewers consulted with SRM to decide on inclusion of full texts, and conducted data
extraction and quality assessment on 3 articles identified for inclusion (2 Spanish, 1 Portu-
guese) [27–29].
Quality assessment
All included studies were assessed for quality using an adapted version of the Critical Appraisal
Skills Programme [CASP] scale. The adapted scale included the following questions [30]:
1. Was there a clear statement of the aims of the research?
2. Is a qualitative methodology appropriate?
3. Are the setting(s) and context described adequately?
Fig 1. Identification of included studies. From: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items
for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(6): e1000097. doi:10.1371/journal.pmed1000097. For more
information, visit www.prisma-statement.org.
https://doi.org/10.1371/journal.pone.0239560.g001
4. Was the research design appropriate to address the aims of the research?
5. Is the sampling strategy described, and is this appropriate?
6. Is the data collection strategy described and justified?
7. Is the data analysis described, and is this appropriate?
8. Are the claims made/findings supported by sufficient evidence?
9. Is there evidence of reflexivity?
Synthesis
An Excel spreadsheet to compile all relevant findings and quotations from the studies for the-
matic analysis was developed. Two of the authors (SRM and MEL) coded the main findings
extracted from each study. We used line-by-line coding on a sub-set of articles, developing a
set of over-arching themes and sub-themes for a draft codebook. The coding proceeded as an
iterative process, with the two authors each separately coding the main findings using the draft
codebook, discussing coding results, and refining the codebook based on overlap and redun-
dancies identified. After all data were coded, we tallied all occurrences of each code and further
explored areas of overlap and merged sub-themes with low numbers of codes, finalizing the
broad themes and focused sub-themes. For non-English articles included, the external
reviewer translated primary quotations into English and thematic analysis on these articles
was conducted alongside the English language articles.
Reporting
The synthesis and all aspects of the systematic review process are reported following the
21-item checklist provided in the Enhancing Transparency in Reporting the Synthesis of Qual-
itative Research statement [31] and the PRISMA checklist [S2 and S3 Files].
Results
Studies identified and characteristics
Our searches of 11 databases yielded 9318 articles, with an additional 468 articles identified
through cross- referencing and expert recommendation. After removing duplicates, 7834 arti-
cles remained. We identified 417 articles that were potentially eligible and included in full text
screening. Two of these articles had not yet been published. Additionally, 1 Farsi language
study was unable to be translated and assessed against the selection criteria. Fifty-two articles
met criteria for inclusion in this systematic review (Fig 1). The 52 included articles represent
data from 31 studies.
Quality assessment
Application of the adapted version of CASP scale yielded variable results across the 52 articles
assessed [see Table 2]. Ratings of research methodology, statement of research aims and selec-
tion of appropriate research design were overall high. The majority (46 articles) [29, 32–76]
Table 1. (Continued)
First author Publication Study Research question(s) Sample (number, age Data collection method and Type(s) of violence and
year location– range) analysis method perpetrator(s)
country
(region)
Band- 2015 Israel What is the lived experience of 31 Face-to-face in-depth interviews; IPV–physical, sexual,
Winterstein (EURO) elderly women with lifelong phenomenological analysis emotional, economic
IPV? Age range: 60–84 Male partner
Band- 2015 Israel What are the subjective 11 dyads (parent and Face-to-face in-depth interviews; Family violence/ elder
Winterstein (EURO) experiences of family members child); Age range of thematic analysis–identifying the abuse–physical violence,
involved in violent, abusive, and parents: 65–90 basic components of the verbal aggression,
neglecting relationships? experience and placing them into financial exploitation,
units of meaning according to the and forms of neglect.
What is an abusive relationship? study aim, coding and Child
What does it mean to suffer? conceptualizing into unique
What are the perceptions of theoretical categories, and
those who are being abused? organizing main themes and
What are the elements that describing the reciprocal relations
make life in abuse possible? between them
How do actors involved in the
drama of abuse give coherence
of their life?
Band- 2019 Israel To differentiate between the 16; Age range: 63–84 In-depth, semi-structured face-to- IPV–physical, sexual,
Winterstein (EURO) lived experience of two groups face phenomenological interviews; verbal
of women caregiving for a Interpretive phenomenological Male partner
partner with dementia; One analysis (IPA)
group was coping with lifelong
IPV and dementia-related
violence (Group 1); the other
group was coping with
dementia-related violence only
(Group 2).
Barbosa 2015 Brazil To understand the impact of 17; Age range: 18–68 Face-to-face in-depth interviews; IPV–sexual, physical
(AMRO) sexual violence suffered by structured narration analysis
women with mental disorders
based on self-reports of these
experiences.
Bhatia 2019 India To unearth the causes of partner 38; Age range: 50 and Face-to-face in-depth interviews IPV and family
(SEARO) violence in later life, to above (4) and focus group discussions violence–physical,
understand the patterns of (2); Analysis methods not emotional, financial
partner violence in later life and described Husband, male partner,
to understand psychological and other relatives
social consequences faced by
women undergoing partner
violence in later life.
Buchbinder 2003 Israel Describe and analyze the 20; Age range: 60–80 Face-to-face in-depth interviews; IPV–physical,
(EURO) experiences and perceptions of content analysis in psychological, and
older battered women in coping phenomenological method sexual
with and surviving the violence. Male partner
Chane 2015 Ethiopia What is the lived experience of 15 (9 women); Age Face-to-face in-depth interviews; Family violence/ elder
(AFRO) abused elders and how can we range: 64–93 interpretative phenomenological abuse–financial,
increase understanding of elder analysis informed by hermeneutic physical, psychological
abuse? phenomenology Family members,
community members
Chane 2015 Ethiopia What are the types and nature 15 total, 9 women; 64– Face-to-face in-depth interviews; Family violence/ elder
(AFRO) of abuse and neglect from the 85 coding following interpretative abuse–financial,
perspective of elders in Ethiopia phenomenological analysis physical, psychological
who experienced abuse in approach Family members,
noninstitutional settings? community members
(Continued )
Table 1. (Continued)
First author Publication Study Research question(s) Sample (number, age Data collection method and Type(s) of violence and
year location– range) analysis method perpetrator(s)
country
(region)
Cheung 2015 Hong Kong How does IPV victimization 2; 63 and 69 Not described; not described IPV–Verbal, physical,
(WPRO) manifest itself among older controlling behaviours,
women? financial, emotional
Male partners
Cronin 2013 USA How do women make meaning 15; Age range: 60–89 Face-to-face in-depth interviews; IPV–Physical
(AMRO) with their experiences with narrative life history approach to controlling behaviours,
domestic violence; The focus of coding verbal, emotional,
this study is women’s lives after financial control
violence, and the ways in which Male partners
they have coped with the
challenges of living and aging.
de Menezes 2013 Brazil To analyze the aggressive 4 couples–each pair Semi-structured interviews; IPV and family
(AMRO) behavior in the relationship aggressor and caregiver; thematic content analysis violence–physical,
between elderly with symptoms Age range of caregivers: threats, psychological
of dementia and their family 68–77 Elderly receiving care
caregivers.
Eisikovits 2015 Israel What are the ways in which 17; Age range: 60–84 Semi-structured in-depth IPV–physical,
(EURO) young and old battered women interviews; content analysis psychological
perceive, understand and Male partners, husbands
experience suffering from
violence, how do they build
these experiences into the
central theme of their life and
how do they reconstruct them
in a manner that makes their
lives livable?
Fakari 2013 Iran Describe daily life experience 13; mean age 62 Face-to-face in-depth interviews; IPV and elder abuse–
(EMRO) (of violence against older “holistic methods of analysis” physical and
women) just in the same way psychological, financial
they occurred in reality. exploitation
Not stated
Grunfeld 1996 Canada How does violence impact the 4; Age range: 63–73 Face-to-face open-ended in-depth IPV and family
(AMRO) lives of elderly women? interviews; thematic analysis violence–physical,
emotional, financial,
controlling behaviours
Husbands, children and
grandchildren
Guruge 2010 Canada What are older immigrant 43; Age range: 48–85 In-depth interviews and focus IPV and family
(AMRO) women’s experiences and group discussions violence–emotional,
responses to abuse and neglect? physical, sexual,
financial abuse, neglect,
controlling behaviours
Husbands, children,
children-in-law
Hightower 2006 Canada What is the experience of 64; Age range: 50–87 Interviews and group sessions; not IPV and family
(AMRO) violence and abuse of women described violence–financial,
aged 50 and older? sexual, physical,
emotional/
psychological,
controlling behaviours
Male partners and other
family members
(Continued )
Table 1. (Continued)
First author Publication Study Research question(s) Sample (number, age Data collection method and Type(s) of violence and
year location– range) analysis method perpetrator(s)
country
(region)
Lazenbatt 2013 UK (EURO) How do older women with an 18; Age range: 53–72 Face-to-face semi-structured in- IPV–physical,
abusive partner for more than depth interviews; thematic psychological,
30 years cope with domestic analysis controlling behaviours
violence and how does it affect Male partner
their wellbeing?
Lazenbatt 2014 UK (EURO) How ‘older women’ cope with 18; Age range: 53–72 Face-to-face in-depth interviews; IPV–physical,
domestic violence and how it thematic framework analysis psychological/
affects their wellbeing, using a based on ‘salutogenesis’ emotional abuse, sexual
theoretical framework of theoretical dimensions were used abuse, financial
‘salutogenesis’ to consider to explore their ‘wellbeing and exploitation
coping resources used in coping’ Male partner
lifelong abuse
Lichtenstein 2009 United To identify barriers to reporting 15; Age range: 50–84 Focus group discussions (2); IPV–physical, verbal
States domestic violence to law constant comparison method Husband
(AMRO) enforcement among older
African American women in the
rural south. How does age,
ethnicity, and gender intersect
with rurality and systems such
as old boys’ networks in
creating barriers to reporting
domestic violence to law
enforcement?
Lowenstein 1999 Israel To describe possible reasons for 12 couples, of which 9 of Face-to-face in-depth interviews; IPV–physical,
(EURO) the phenomenon of elder the women were victims coding–not described further controlling/
spousal abuse in second of spousal abuse; 60+ psychological
marriages, and to identify Partners
possible risk factors for abuse
based on reports by remarried
elderly who were victims of
spousal abuse
McGarry 2010 United What are women’s experiences 16; Age range: 59–84 Face-to-face in-depth interviews; IPV–physical,
Kingdom of domestic abuse and what is iterative approach and informed emotional, sexual, Male
(EURO) its effect on their health and by the analytic hierarchy model partner
lives?
McGarry 2014 United What are the service responses 3; Age range: 60–65 Semi-structured phone interviews; Elder abuse, family
Kingdom to abuse among older people Analytic Hierarchy Mode and violence and IPV
(EURO) across a range of sectors? What constant comparative method Any
are the perspectives of older
people either as survivors of
abuse or as older people with an
interest in service development?
Montminy 2005 Canada How is psychological violence 15; Age range: 60–81 Face-to-face in-depth interviews; IPV–psychological
(AMRO) against older women manifest content analysis Male partner
experienced in the marital
context?
Nahmiash 2004 Canada What is the interacting 16 participants (14 Face-to-face in-depth interviews; Elder abuse–sexual,
(AMRO) relationship between the victims, 2 abusers); 12 of content analysis physical
environmental context of care the 14 victims were Care-givers and/ or
giving and abuse and neglect of female; Age range: 61– partners
older adults. 78
(Continued )
Table 1. (Continued)
First author Publication Study Research question(s) Sample (number, age Data collection method and Type(s) of violence and
year location– range) analysis method perpetrator(s)
country
(region)
Pillemer 2011 USA What are the major forms of 53 units in 3 facilities, Identified all resident-to-resident Elder abuse
(AMRO) resident to resident aggression 122 events identified; no aggression events in several Other residents or
that occur in nursing homes? age range specified nursing homes over 2 week period nursing homes
through resident interview,
certified nursing assistant
interview, and interviewer
observation; sorted events into
categories
Ramsey- 2003 USA What are the patterns of elder 130 cases (consultation Review of consultation files from IPV and elder abuse–
Klawsnik (AMRO) sexual abuse, both marital and files); not specified Protective Services Program of the sexual
incestuous? What are the abuse Massachusetts Executive Office of Partner, caregiver,
dynamics, problems Elder Affairs; analysis method not family members
confronting victims, and described beyond “qualitatively
perpetrator characteristics? analysed”
Richards 2013 Uganda How women’s and men’s Total 31; 16 women. Face-to-face in-depth interviews IPV–physical, sexual
(AFRO) gendered experiences from Age range: 60 and over and FGDs; framework approach and psychological
childhood to old age have to coding Male partners
shaped their vulnerability in
relation to HIV both in terms of
their individual risk of HIV and
their access to and experiences
of HIV services
Roberto 2013 USA What are the issues facing rural 10; Age range: 54–70 Face-to-face in-depth interviews; IPV–emotional, physical
(AMRO) older women who wish to lead not described and sexual
safe and violence-free lives and Male partners
to identify the com-munity
support needed to help them
successfully rebuild their lives.
Roberto 2018 USA How women experienced IPV 10; Age range: 54–70 Face-to-face in-depth interviews; IPV–Emotional,
(AMRO) over the course of their lives and open coding and focused coding physical, financial
in different contexts; what exploitation
resources were helpful when Male partners
older women exited abusive
partnerships
Ron 1999 Israel What are the main factors, 12 couples, of which 9 of Face-to-face in-depth interviews; IPV–verbal, emotional,
(EURO) particularly social factors such the women were victims coding–not described further physical, financial
as the need for intimacy and of spousal abuse; 60+ exploitation, caregiver
sexuality, which cause tension neglect
among elderly remarried Partner
couples and lead to abuse by the
spouses?
Rosen 2019 United To analyze legal records to 87 cases; Age range: 60– Analyzed narratives from police IPV and family
States describe in detail acute 95 reports of acute physical elder violence–physical
(AMRO) precipitants of physical elder abuse; cross-case analysis of Child, spouse/
abuse. narratives in police reports to companion, grand child
identify codes, coded narratives
Ruelas- 2014 Mexico To analyze health care providers 6 older women; Age Semi-structured interviews; Elder abuse–neglect,
Gonzalez (AMRO) and older patients’ perceptions range: 65–87 analysis using grounded theory psychological violence,
about elder abuse by health approach, content analysis. discrimination
personnel of public health Health care
services. professionals and
caregivers
(Continued )
Table 1. (Continued)
First author Publication Study Research question(s) Sample (number, age Data collection method and Type(s) of violence and
year location– range) analysis method perpetrator(s)
country
(region)
Schaffer 2008 Australia What are the needs of older and 90; Age range: 50–78 Phone-in–asked women to call in IPV–type(s) not
(WPRO) isolated women who live with and tell their stories to a nation- specified
domestic violence? wide call in service; some Male partner
“personal” and “group”
interviews; analysis method not
described
Sawin 2011 USA What are the experiences of 11; Age range: 51–84 Face-to-face in-depth interviews; IPV–financial control,
(AMRO) older women diagnosed with coding following hermeneutic psychological control
breast cancer while phenomenological strategy of Male partner
experiencing intimate partner inquiry
abuse?
Smith 2015 USA How older women/mothers 15; Age Range: 62 and Face-to-face in-depth interviews; Family violence–
(AMRO) understand and respond to their older coding (type not specified) disrespect, physical and
adult children who are abusive psychological
and/or “difficult”; How older Adult child
low-income women make sense
of their adult children’s
problems.
Souto 2015 Brazil What are older Brazilian 11; Age range: 66–85 Face-to-face in-depth interviews; Family violence and
(AMRO) women’s experiences of Schutz’s motivation theory used as IPV–psychological
psychological domestic framework for thematic coding violence, including
violence? How do older verbal abuse, financial
Brazilian women experience abuse, neglect
their daily life when they are Male partner, family
victims of psychological members
domestic violence? How do
older Brazilian women respond
to psychological domestic
violence? What are older
Brazilian women’s needs,
expectations, and aims in
dealing with the psychological
domestic violence in their lives?
Souto 2019 Canada How is IPV experienced by 10; Age range: 60–81 Face-to-face in-depth interviews; IPV–physical, sexual,
(AMRO) Portuguese-speaking older Schutz’s motivation theory used as emotional, economic
immigrant women? How is framework for thematic coding abuse, controlling
women’s daily life related to behaviours
IPV? How does this group Male partner
respond to IPV situations?
What are these women’s needs,
expectations, and aims in
dealing with IPV?
Spencer 2019 Canada How family carers of persons 10; Age range: 23–83, Participants kept weekly diary of IPV and family
(AMRO) with cognitive impairment median age 64 (only interactions with person for who violence–physical,
respond to fear, intimidation, results attributed to they provided care, and follow-up verbal, emotional
and violence, over time and women aged 50 and interview following completion of Husband with dementia
across different settings above included in diary; narrative analysis (7); mother (3)
review analysis)
(Continued )
Table 1. (Continued)
First author Publication Study Research question(s) Sample (number, age Data collection method and Type(s) of violence and
year location– range) analysis method perpetrator(s)
country
(region)
Teaster 2006 USA What is the trajectory of, and 10: Age range: 50–69 Face-to-face in-depth interviews; IPV–controlling
(AMRO) community responses to, open coding and then applied behaviours, physical,
violence in late life? Aim is to coding scheme developed verbal, emotional
further understanding of IPV in Male partners
rural communities by
examining responses to violence
from the perspective of aging
women, as well as those entities
intervening in their cases (e.g.,
APS caseworkers, women’s
shelters, law enforcement).
Tetterton 2011 USA What are effective interventions 1; Age range: 63–65 Face-to-face in-depth interviews; IPV and family
(AMRO) for women above the age of 60 generated case studies from data violence–physical,
who have experienced IPV? and used phenomenological emotional
What are the experiences of approach to conduct thematic Male partner and adult
older women who experienced analysis son
IPV?
Yan 2015 Hong Kong What are the factors associated 40 total, 26 women; Age Face-to-face in-depth interviews; IPV and family
(WPRO) with help-seeking behaviors range: 60–81 grounded theory approach to violence–physical,
among mistreated elders in coding psychological, neglect,
Hong Kong? financial exploitation,
sexual
Partner, family
members
Zink 2003 USA What are older women’s 36; Age range: 55–90 Interviews–some face-to-face, IPV–physical,
(AMRO) reasons for remaining in some on telephone; coded using emotional, sexual,
abusive relationships? thematic analysis techniques financial abuse
Male partner
Zink 2004 USA What are the experiences and 38; Age range: 55–90 Interviews–some face-to-face, IPV–physical,
(AMRO) needs of older victims of IPV in some on telephone; coded using emotional, financial,
the health care setting? immersion crystallization sexual
technique Male partner
Zink 2006 USA What are: (a) the types of abuse 38; Age range: 54–90 Interviews–some face-to-face, IPV–physical,
(AMRO) perpetrated by older men some on telephone; coded using emotional, sexual,
against their spouses or dating thematic analysis techniques financial abuse
partners and (b) the victim’s Male partner
interpretation of these
experiences and behaviors?
Zink 2006 USA How older women cope in long- 38; Age range: 55–90 Interviews–some face-to-face, IPV–physical,
(AMRO) term abusive intimate some on telephone; adapted form emotional, verbal
relationships. of grounded theory Husband, boyfriend,
partner
https://doi.org/10.1371/journal.pone.0239560.t001
gave support for research findings with references to primary data (participant quotations,
case study vignettes, case file excerpts). Ten articles [41, 46, 49, 50, 59, 65, 77–80] lacked data
analysis descriptions.
Only 12 articles [29, 35, 38–40, 45, 51, 58, 72–74, 79] reflected on the relationship between
the researchers and the participants (reflexivity). Procedures for ethical research were
described in 36 articles [27, 29, 33–37, 39–41, 45–52, 54, 55, 58, 60, 61, 63, 64, 66–72, 74, 76,
77, 79]. Five articles [43, 44, 56, 73, 75] described obtaining consent, but lacked descriptions of
ethical approval, and 10 articles [32, 38, 42, 53, 57, 59, 62, 65, 78, 80] lacked descriptions of
both ethical approval and obtaining consent. A significant number of articles [32, 34–42,
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
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Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
16 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
17 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
18 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
19 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
20 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
21 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
22 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
23 / 43
Violence against older women: a systematic review of qualitative literature
Table 2. (Continued)
Title/ author Clear Appropriate Description Appropriate Recruitment Data Data analysis Findings Evidence of Ethical issues Total
statement qualitative of setting and research and sampling collection described and supported reflexivity? taken into score
of research methodology? context? design to strategy is strategy appropriate? by sufficient consideration?
aims? address described and described evidence?
PLOS ONE
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Violence against older women: a systematic review of qualitative literature
PLOS ONE Violence against older women: a systematic review of qualitative literature
45–47, 49–51, 53, 54, 56, 57, 59, 61–66, 69, 70, 72–75, 77–79] lacked adequate descriptions of
the study setting and context.
Table 3. (Continued)
Table 3. (Continued)
their children to violence [38, 45, 50, 52, 54, 66, 79]. Several studies linked suffering, regret and
loneliness specifically to psychological violence, which was described as more prominent in
older age, pervasive and damaging to social relationships and self-esteem [51, 56]. The studies
that explored these themes primarily encompassed accounts of violence experienced through-
out intimate relationships–while women were younger and through to older age. These experi-
ences were described and conceptualized by older women as interlinked and continuity of
victimization by intimate partners was emphasized, rather than viewing women’s experiences
of violence in older age as distinct or separate.
Violence, ageing and vulnerabilities. Older women described that ageing diminished
their physical and emotional capabilities to cope with experiences of violence [33, 37, 39, 47].
This sub-theme appeared in 12 manuscripts [33, 37, 39, 40, 43, 47, 48, 53, 55, 59, 62, 76] and
was expressed in relation to various forms of violence–IPV [33, 37, 47], including violence per-
petrated by a spouse due to dementia [40], violence in the context of a new relationship or sec-
ond marriage [48, 53, 55, 59, 62], violence perpetrated by a mentally ill child [39], violence
perpetrated by children-in-law [76], and elder abuse [43]. These studies primarily focused on
current experiences of violence of older women, as changes in physical and emotional capacity
to cope was described in relation to present victimization. As a result of diminishing physical
and cognitive capacities of ageing, old women experienced vulnerabilities and dependency
dynamics–with partners, adult children and caregivers–that exposed them to situations of
abuse [44, 47, 52, 56, 57, 61, 64, 66]. A mother of an adult son with schizophrenia explained,
“When I was younger, I could overcome him faster, save myself, now that I’m old and I have
diabetes, now I have to be faster. . . Now I’m afraid for my life, afraid he will kill me” [39].
Women reported that lack of financial autonomy, often compounded by years of controlling
behaviors perpetrated by a violent spouse, was a central factor in women remaining in abusive
spousal, caregiving and family relationships [44, 47, 52, 56, 64].
Perpetrator-related factors
Some included studies reported on perpetrator-related factors that initiated or exacerbated
forms of violence against older women.
Ageing perpetrators and continuity of abuse. Older women emphasized contexts sur-
rounding IPV in which the perpetrator continues to exercise control, power, and violence,
despite their failing health and old age [41, 47–49, 51, 56, 59, 72, 76, 77]. Women also described
shifting forms of violence, predominantly from physical and/ or sexual to psychological vio-
lence and controlling behaviours [36, 45, 50, 51, 61, 72]. While sometimes the experience of
physical and/ or sexual violence declined, psychological violence persisted and sometimes
escalated [50, 51, 72]. While describing the impacts of continual and intense psychological vio-
lence, one woman said, “he destroys you; you are not even a person anymore” [72]. Control-
ling behaviours were also experienced in the context of cultural norms; for example, in a study
of Sri Lankan immigrant women in Canada, older women described forms of control enacted
by children and children-in-law. One older women reported, “[h]e [the son-in-law] thinks
that I am a widow and why should I have anything on my own name and why can’t I give
everything to them and just be a slave to them” [76].
Perpetrator’s illness as a cause of violence. This sub-theme only emerged in three manu-
scripts [40, 46, 69], however, it is the only instance among the included studies in which older
women described first or new experiences of IPV in older age. Older women who provided
care for spouses with dementia reported aggressive behavior, physical violence, and verbal
abuse [40, 69]. In one study, a woman reported, “I don’t know what’s going on with my hus-
band, he’s never been like that, never hit me before. I’m really worried about him, he’s been
changing so much [. . .] We have been married for 47 years. . .he seems another person [46].”
Another study found that women who had experienced lifelong IPV understood dementia-
related violence as a continuation of aggression, dominance and abuse, whereas women who
had only been exposed to dementia-related violence took solace in a diagnosis, felt grief over
the loss of their spouse as he used to be, and tried to maintain intimacy and affection in a previ-
ously caring and loving relationship [40].
control, enabling abusers to take advantage of older women’s age, frailty, and illness, for exam-
ple, appropriating part or all of the victims’ property [43, 44, 57].
Lifelong IPV
Many older women described experiences of IPV throughout their life-course. Several sub-
themes were identified related to lifelong patterns of violence, cumulative consequences of
IPV, and linkages of violence in older age to earlier experiences of violence.
Continuation of patterns of IPV in old age. Older women described experiences of IPV
in older age as a continuation of the patterns of violence experienced throughout the relation-
ship [33, 40, 49, 59, 70–72, 77]. Several articles described years to decades long relationships
characterized by IPV [40, 70, 71, 77]. For example, older women living in rural Kentucky, USA
explained that the longer they were in the relationship with their abuser, the more the violence
became more normalized and accepted [70].
Earlier experiences of violence. Associations between older women’s earlier experiences
with violence, including witnessing of violence as a child, and current experiences of IPV,
were discussed in several articles [48, 49, 61, 70, 71, 80]. For example, in a study by Roberto
and colleagues, many women who had experienced physical abuse as a child or young woman
interpreted controlling behaviors as love, and did not recognize emotional abuse later in life
until the abuse became physical or affected their health [61]. Linkages were also uncovered
between experiences of abuse as a child or young woman with current abuse by their adult
children [57, 71].
Cumulative impacts of violence. Older women described several consequences of experi-
ences of lifelong IPV. In one study, older women related the impacts of lifelong violence to
that of a chronic illness, which alters or limits one’s quality of life [47]. Older women fre-
quently linked experiences of violence with physical health consequences, including bodily
pain, reduced mobility, and hearing problems, [37, 47, 54, 67], as well as mental health and
emotional impacts, including depression [41, 50, 51, 54, 67], anxiety [54, 67], panic attacks
[54], suicidal ideation [41], loneliness [34, 51], and loss of self-esteem [34, 50, 51, 54].
explained, "And when you go to the doctor. . .they run down the list. . .and then it’s always,
you know, “Well, is it abuse?” “Well, yes emotional.” “Well, what kind of emotional?” “Verbal.”
“Oh, OK.” And they mark it, and that’s it” [74].
Coping mechanisms
Older women reported various approaches to coping with the experience and impacts of dif-
ferent forms of violence, often employing several different coping mechanisms such as leaving
relationship with an abuser and emotion-based coping strategies such as alcohol or drug
usage, in order to navigate difficult decisions, maintain their health and well-being, and protect
other family members in the context of exposure to violence.
Leaving a relationship. In 11 of the included manuscripts older women described
remaining in an abusive relationship, family context or caregiver relationship, as a form of
coping [33, 34, 38, 42, 45, 46, 48, 57, 65, 70, 73], and in six manuscripts, leaving a relationship
was employed as a coping mechanism [42, 45, 61, 69, 76, 77]. In one study, older women
explained that they had previously not been able to leave a relationship with an intimate part-
ner for the sake of their children, whereas once their children had left the house, they felt freer
to reject violent behavior [42]. Older women’s own health problems were described as a trigger
for choosing to leave an abusive relationship [61].
Isolation, substance use and emotion-based coping strategies. Older women
described isolating themselves from family, friends and social support, using alcohol or
drugs to cope with experiences of violence, and reframing experiences of violence, often
through minimizing experiences [33, 34, 37–39, 47, 50, 51, 61, 68, 69, 73, 79]. Older women
explained that if they were to seek support, family or friends would blame them for their
experiences of violence, leading women to choose social isolation as a coping strategy [50,
69]. Older women also described using drugs and alcohol as a means to numb themselves to
their daily experiences of violence [50]. One woman explained, “He (my husband) got his
medical partner to prescribe Valium for me in the 1970’s and I am still taking it, especially
when I feel hopeless and in despair. I know that I am addicted to it and worry that at 68
years I will never be able to survive without them.” [50]. Older women also reported employ-
ing forgiveness of violent and controlling intimate partners as a coping mechanism [34, 38].
Older women who remained in a relationship with their abuser often described employing
emotional detachment as another coping strategy [33, 37, 47, 69]. Lastly, older women
described how they reframed their experiences of abuse, by excusing abusive spouses for
their actions or employing strategies to deliberately diminish the severity of abuse, such as
forgetting experiences of abuse [34, 38, 61, 68, 73]. While emotional detachment was
described as causing isolation and loneliness, older women also perceived it as a form of
“inner resistance” [37], a vital means of opposing intimacy and connection with an abusive
partner, and as particularly vital in the case of IPV, where the safety of a woman’s home is
threatened by violence [47].
Behaviors to enhance safety. Older women described taking actions in order to enhance
their own safety in the face of violence [36, 67, 69, 70, 75]. In some instances, older women
first called police or applied for formal legal support, such as a protection order, in the face of
violence. In one study, a woman explained, “I called the police because he [my partner] pushed
me down on the countertop and poured a cup of tea over me. It was as though he wanted to
strangle me. They took him into custody for 24 hours” [36]. In several instances, legal authori-
ties, including police, provided limited support, leaving women unable to find long-term solu-
tions to the violence they experienced [70].
Discussion
This systematic review was motivated by a need to improve understanding of similarities and
differences in dynamics, patterns and experiences of violence against older women, in a con-
text whereby the vast majority of research, evidence, policy and service provision is targeted
towards women of reproductive age. We reviewed available qualitative studies on violence
against older women in order to address existing gaps in evidence and data. We also sought to
provide insight into the lived experiences of older women experiencing violence, and an
understanding of the types and patterns of violence, perpetrators of violence, and health
impacts of violence among older women. The included studies primarily address IPV, with
fewer emerging from the older adult mistreatment framework. Most research examined spe-
cific types of violence in isolation, for example, IPV or abuse from an adult child, and there
were no examples of studies that included polyvictimization or experiences of any type of vio-
lence against older women. The strong emphasis on older women’s experiences of IPV gives
voice to the experiences of older women subjected to violence and shows how it can persist
over time; however, some sites, perpetrators and types of violence against older women may be
excluded from view, including that of violence enacted by other family members and non-fam-
ily caregivers and of women living in institutional care.
The findings in our review confirm results from prior reviews, systematic and otherwise, of
similar bodies of literature. For example, Pathak et al.’s review of IPV against older women
noted a decline in physical violence against older women, whereas other forms of violence
remained stable or increased, a finding that was reflected in our data [23]. Some of the studies
included in the present review also confirm partners’ retirement and children leaving home as
precipitating factors for increase of IPV against older women, indicating points for potential
intervention and support for older women. In a review of qualitative literature on IPV against
older women, Finfgeld-Connett noted that older women actively choose coping strategies that
enable them to “make the best of their situations” [20], a conclusion that is also supported by
some of the results of our review. In other cases, staying in a relationship with an abuser
appears to be driven by gender norms and feelings of duty towards a partner. In addition [34,
38], coping strategies such as use of alcohol and other harmful substances appeared to result in
poor health and lack of well-being [34, 37–39, 47, 50, 51, 61, 68, 69, 73, 79]. Recurring themes
emphasizing the pervasive impact of violence against older women on physical and mental
health, relationships, social networks, hope and sense of well-being, in our systematic review
and other previous reviews, indicate the importance of taking violence against older women,
in all its manifestations, seriously as a public health and human rights issue. As was identified
in previous reviews, there is relatively little evidence concerning the emergence of violence in
later life, particularly in the case of IPV. In the case of the majority of studies included in our
review, older women described shifting but continuous patterns of violence throughout the
life-course, although a small sample of studies identified new relationships and dementia of an
intimate partner as factors precipitating the violence [40, 46, 48, 53, 55, 59, 62, 69].
Comparing the IPV-specific evidence generated in this review to the existing evidence-base
on IPV against women of reproductive age, some notable continuities and differences are evi-
dent. Firstly, our findings confirm the extensive impact of IPV exposure on physical and men-
tal health, which has been widely researched amongst women of reproductive age [2, 82–85].
However, our data indicate that IPV amongst older women is commonly experienced in the
context of exposure to lifelong IPV, and that the physical and mental health impacts are cumu-
lative, compounded by ageing processes, and often exacerbated by changes in social situation
also triggered by ageing. Ability to employ physical or cognitive coping mechanisms that had
been effective earlier in life may diminish for older women [33, 37, 39, 47]. In addition,
alongside depression, anxiety and post-traumatic stress disorder, which are the most com-
monly measured and reported mental health impacts of IPV amongst women of reproductive
age [86–88], older women discussed hopelessness and regret as pervasive and important psy-
chosocial impacts of IPV in older age. There may be some similarities between younger wom-
en’s experiences of shame and stigma [89–93] and older women’s feelings of regret, however,
regret and hopelessness may be specifically central to older women’s experiences of violence,
particularly IPV. Secondly, our results confirm that exposure to IPV is often linked to experi-
ences of violence in childhood; older women in studies included in this review indicated that
growing up in families where violence was commonly witnessed and experienced was inter-
linked with exposure to IPV in adulthood and through to older age, a finding that is evident in
data on women of reproductive-age [94–96]. Thirdly, there appear to be common challenges
for women of reproductive age and older women in leaving an abusive relationship, including
perceptions of the importance of remaining in a relationship for the sake of children, indicat-
ing the commonality of the importance of social and gender norms in driving decision-making
[97–101]. Implications garnered from research with women of reproductive age experiencing
IPV are relevant here; similarly, it should not be assumed that older women want to or can
leave an abusive situation, and services provided should recognize and be sensitive to this.
Finally, our findings highlight specific issues for consideration in the case of violence against
older women, including changes in type and prevalence of controlling behaviours [36, 45, 50,
51, 61, 72, 77] and forms of financial control that occur alongside IPV [43, 53, 62, 64, 78].
These behaviours have the potential to significantly restrict options and limit ability for older
women experiencing violence, even more than in younger women. Currently however, these
may be under-recognized as specific risk factors for older women.
Global research on violence against women has increasingly explored the significant influ-
ence of social and gender norms on prevalence of and risk factors for violence against women
of reproductive age [102–105]. Our findings indicate that social and gender norms also con-
tinue to strong influence older women’s responses to and experiences of violence. Older
women described social and gender norms as shaping their decisions to stay in relationships,
to provide care for an abusive spouse, and often as reinforcing shame and social isolation.
There is substantial overlap between norms identified in this review with the existing evi-
dence-base on social and gender norms on women of reproductive age, for example, the norm
of keeping violence victimization private and overall injunctions concerning silence surround-
ing IPV. Some evidence indicates positive impacts of violence prevention interventions
focused on changing social and gender norms [106]. However, these programs have not been
specifically tested for feasibility and acceptability with older adults, and careful consideration
of how and if addressing social and gender norms amongst older adults could result in reduced
violence perpetration is needed.
Our review identified significant gaps in the evidence-base concerning older women’s expe-
riences of violence in low and middle-income countries (42 articles in HIC vs. 10 articles
LMIC). Within studies conducted in high-income countries, with a few exceptions [52, 61, 70,
76, 80], the focus of the included studies was on older women from Western cultural back-
grounds. The sparse coverage of several regions globally, and low and middle-income popula-
tions overall, indicates that our findings cannot be generalized to older women globally, and
that there are likely important influences on and impacts of violence against older women that
are currently missing from view. While we can assume that older women in low and middle-
income contexts also experience violence, the existing evidence base, for both qualitative and
quantitative data, fails to adequately shed light on patterns and prevalence [16, 17]. In addition,
as found in our quality assessment, included articles contained very little detail on the contexts
in which the research was conducted [32, 34–42, 45–47, 49–51, 53, 54, 56, 57, 59, 61–66, 69, 70,
72–75, 77–79], which makes it difficult to link the evidence from this review to specific contex-
tual factors. Further exploration of context-specific issues such as living conditions and associ-
ated norms, for example, norms governing that older widows live with children and children’s
families is needed. In addition, exploration of perceptions of capabilities and appropriate social
roles for older women in different socio-cultural contexts is warranted. Perceptions and expe-
riences of ageing processes, and specific issues such as widowhood, differ significantly in dif-
ferent cultural contexts, and existing qualitative and quantitative data do not include these
diverse factors or account for their relationship with violence against older women.
Our findings indicate that older women affected by violence need social and community
support to help them cope and address the anxiety and stress associated with threats to their
safety. Older women affected by violence may be particularly isolated, with social isolation
concomitant with ageing compounded by social isolation due to violence victimization. Some
of the studies indicated that older women do not understand or define their experiences as
abuse or violence, but do seek support regardless. As such, there may be potential for services
and interventions designed to address social isolation and targeted for all older women to
address violence against older women. Various interventions that have been found to be effec-
tive in reducing social isolation and improving social outcomes for older persons, such as
group support through discussion groups, individual support through home visiting, and psy-
chosocial education programs, could be effective in improving social support for older women
affected by violence [107]. Currently, services for older persons are overall extremely limited
in low and middle-income contexts, and dynamics of social and community support for older
persons vary considerably in non-Western cultural contexts. The current qualitative evidence-
base does not indicate if older women affected by violence in low and middle-income contexts
would benefit from similar interventions or if integrating response to and support for violence
against older women into aged-care services are a feasible way to reach older women affected
by violence.
In the limited number of included studies that addressed older women’s experiences with
and expectations of health-care providers, concerns were raised including lack of confidential-
ity and health care providers not taking women’s abuse seriously [74]. Health care providers
are in a unique position to provide support and response for women who have been affected
by violence. The World Health Organization’s Clinical and Policy Guidelines and Clinical
handbook provide guidance for health care providers in providing woman-centred care, com-
passionate first-line psychosocial support, and linkages to multi-sectoral services [108]. In the
case of older women, women may come in contact with primary, secondary or tertiary health
care services for reasons related to chronic disease and ageing-related injuries, for example, or
as care-givers for spouses or children. There is a need to explore how and where violence pre-
vention and response for older women in the health system could be feasible and acceptable.
For example, gerontologists and other specialists providing elder-care specific services could
be provided tools and skills to identify and support women who may be subjected to violence.
In addition, as identified in this and other reviews of violence against older women, there are
factors that may act as precipitating factors for increase or initiation of violence, including
changes in caregiving dynamics or retirement of a spouse, and these could be points of poten-
tial intervention and additional support for older women, especially if there is a history of past
violence.
evidence concerning violence against older women, regardless of type of violence and perpe-
trator, allowing insights into the overall focus of the evidence-base, which revealed limited
engagement with elder abuse against women and family violence perpetrated by non-partners,
for example, children. Additionally, we followed a rigorous protocol, adhering to a preregistra-
tion protocol in line with ENTREQ guidelines [31]. We carried out an extensive systematic
review across 11 databases, supplemented by hand searched references lists and article recom-
mendations from 49 experts on violence against women or older adults, and therefore it is
unlikely that published articles would have been overlooked in this review. We reviewed all
articles in any language, apart from Farsi.
In order to minimize selection bias or for relevant articles to be missed, two authors
screened all titles and abstracts and all articles at the full text review stage. At the data extrac-
tion phase, only MEL extracted relevant data, introducing the possibility of transcription
errors. Despite this limitation, all extracted data was double checked by SRM to minimize
potential of missing descriptive data, and both completed independent quality appraisals to
minimize potential for biased assessments. Additionally, during the analysis phase, both
authors coded article main findings and key quotes, and developed descriptive and analytical
themes to strengthen the interpretation and synthesis of findings.
Another limitation of the findings of this review is the concentration of studies in higher-
income contexts, which greatly limits the transferability of findings to low- and middle-income
populations. In addition, the small number of studies conducted in low and middle-income
countries entailed that comparison of patterns between high-income and low and middle-
income contexts was not possible. This review was also limited by the quality of included arti-
cles. Many articles did not clearly report on study setting and context, sampling procedures,
data analysis, reflexivity, and research ethics. Moreover, many articles included samples of
older women across wide age ranges (e.g. 65–85 years old). The available evidence does not
disaggregate findings to enable understanding of whether or how women in different age
groups experience violence differently, despite significant variation in living conditions,
employment and health status of women aged 50–64 vs. 65 and up, for example. This lack of
specificity limited our ability to understand the differential causes, experiences and impacts of
violence among specific age groups of older women.
Our findings indicate that for older women who had experienced violence throughout the
life-course, aspects of ageing, such as frailty, injuries, chronic disease, and cognitive decline,
make coping with different forms of violence more difficult than earlier in life. Qualitative and
quantitative research does not currently shed light on associations between types of violence,
chronicity of violence, and physical and mental health outcomes for older women, and addi-
tional research in this area is warranted. Other themes that emerged in our review call for fur-
ther research. Regret and hopelessness were commonly described as significant issues for older
women; these factors appear to significantly influence well-being, psychosocial health and
physical and mental health. However, these outcomes are rarely measured, and these may fur-
ther impact other specific mental health and psychosocial issues for older women subjected to
violence. Further research could explore if and how regret and hopelessness amongst older
women differs from shame and stigma as currently measured and reported amongst women of
reproductive age, and further elucidate its impacts on psychosocial well-being. In addition,
economic and financial abuse appeared to be correlated and interlinked with older women’s
experiences of violence, and barriers to leaving abusive relationships; terminology and defini-
tions of these forms of abuse are varied and often unclear, and measures often cover several
constructs [109]. While there is some growing consistency in how economic and financial
aspects of abuse are conceptualized and measured, there is more work needed on how to assess
economic or financial abuse, and understand its linkages with physical and mental health
outcomes.
Conclusion
The current qualitative data available on violence against older women has important limita-
tions, including that it is predominantly derived from high-income countries, often does not
address context, is focused on IPV to the exclusion of other types of violence and perpetrators,
and does not disaggregate by age group. However, our findings highlight some important
issues. IPV persists into older age, and shares characteristics and impacts as in younger age
groups. In some cases, there may be factors, such as a partner’s retirement or illness such as
dementia, which can precipitate or increase violence. As shown in quantitative reviews, physi-
cal violence tends to decrease with age while psychological abuse and controlling behaviours
increase, and financial and economic abuse are important elements of older women’s experi-
ences of violence and control. Older women described being strongly influenced by social
norms that dictate a sense of duty to stay in a relationship with an abusive partner, a desire to
protect children, and shame and silence surrounding experiences of violence. More research is
needed, particularly from LMICs to fill in the many gaps in the evidence-base. However, it is
clear that action to support older women in abusive relationships is needed. Services for older
people need to be aware of the prevalence and forms of violence against older women and
know when to identify and respond in a sensitive and non-judgmental way, to improve pre-
vention of and response to violence against older women.
Supporting information
S1 File. PubMed search strategy.
(DOCX)
S2 File. ENTREQ checklist.
(DOCX)
S3 File. PRISMA checklist.
(DOC)
Author Contributions
Conceptualization: Sarah R. Meyer, Claudia Garcı́a-Moreno.
Data curation: Sarah R. Meyer, Molly E. Lasater.
Formal analysis: Sarah R. Meyer, Molly E. Lasater, Claudia Garcı́a-Moreno.
Funding acquisition: Claudia Garcı́a-Moreno.
Investigation: Sarah R. Meyer, Molly E. Lasater.
Methodology: Sarah R. Meyer, Claudia Garcı́a-Moreno.
Resources: Claudia Garcı́a-Moreno.
Supervision: Claudia Garcı́a-Moreno.
Writing – original draft: Sarah R. Meyer.
Writing – review & editing: Molly E. Lasater, Claudia Garcı́a-Moreno.
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