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PLOS ONE

RESEARCH ARTICLE

Violence against older women: A systematic


review of qualitative literature
Sarah R. Meyer ID1*, Molly E. Lasater2, Claudia Garcı́a-Moreno1
1 Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva,
Switzerland, 2 Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore,
Maryland, United States of America

* smeyer@who.int
a1111111111
a1111111111
a1111111111 Abstract
a1111111111
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.

Data Availability Statement: All relevant data are


within the manuscript and its Supporting Introduction
Information files. Violence against women is a major public health problem, a gender inequality issue and a
Funding: This study is funded by the Department human rights violation. There are significant serious and long-lasting impacts of violence on
for International Development, UNWomen-World women’s physical and mental health, including injuries, unintended pregnancy, adverse birth

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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.

Current frameworks on violence against women and existing evidence


Gaps in research and evidence stem in part from conflicting theoretical approaches, definitions
and conceptual frameworks concerning violence against older women. The dominant theoret-
ical frameworks are the older adult mistreatment framework and older adult protection frame-
work [7, 13, 14]. The older adult mistreatment framework conceptualizes violence against
older women as a form of elder abuse, focusing on age as the primary factor influencing vul-
nerability to exposure to violence. The older adult protection framework specifically under-
stands violence within the context of care-giving and institutional arrangements, where older
adults’ often be gender neutral, and the adult protection framework can result in a framing of
older adults as inherently impaired and vulnerable. In addition, the IPV framework primarily
understands vulnerability to violence in terms of gender inequality and partnership dynamics,
which may neglect analysis of how ageing and partner violence intersect. These differing
frameworks inform multiple aspects of research, including study design, data collection and
analysis, and reporting, resulting in fragmented data and evidence. For example, some
research utilizing the older adult mistreatment framework lacks a focus on the gendered
dimensions of violence [14, 15], and other studies have solely focused on women in

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PLOS ONE Violence against older women: a systematic review of qualitative literature

institutional settings, neglecting measurement of violence perpetrated by intimate partners


and other family members [13].
Existing syntheses of evidence on violence against older women often reflect these differing
conceptual frameworks. Employing an older adult mistreatment framework, a systematic
review of quantitative studies of elder abuse (against men and women aged 60+) found that
the global prevalence of elder abuse in community settings is 15.7% in the past year, with psy-
chological abuse and financial abuse as the most prevalent forms of abuse reported [16]. This
review reported prevalence by type of violence, but did not report on perpetrators. Analysis of
studies conducted in institutional settings found women, aged 60 and above, to be significantly
more vulnerable to abuse, with psychological abuse as the most prevalent form of violence, fol-
lowed by physical violence, neglect, financial and sexual abuse [17]; this analysis included data
reporting staff-to-resident abuse. Analysis of quantitative data of women aged 60 and above in
the systematic review of quantitative studies of elder abuse found a global prevalence of elder
abuse against women of 14.1% in the past year, with psychological abuse reported as the most
prevalent form of violence, followed by neglect [16]. The focus of this review was prevalence of
different sub-types of violence, and type of perpetrator was not considered. Another systematic
review of quantitative data on interpersonal violence (physical and/or sexual violence) against
older women (aged 65 and above) in community dwellings primarily employed an IPV frame-
work, finding prevalence of reported interpersonal violence ranged from 6 to 59% over a life-
time, from 6 to 18% since turning 50, and 0.8 to 11% in the past year, however, results
indicated that definitions of violence vary widely and affect prevalence estimates [18]. Synthe-
ses of quantitative literature have identified prevalent forms of violence against older women,
highlighting limitations in the evidence-base due to variations in definitions and methodology,
and a primary emphasis on populations in high-income, Western countries. These reviews
have captured a wide range of types of violence, however, have not considered type of perpe-
trators or patterns of co-occurring types of violence.
Alongside these systematic reviews of quantitative data, some reviews have included quali-
tative and mixed methods studies. An empirical review of IPV in later life examined 27 quanti-
tative, 22 qualitative and 7 mixed-methods studies, finding that forms of IPV amongst older
women in later life shifted from a higher prevalence of physical and sexual abuse during repro-
ductive years, to a higher prevalence of forms of psychological abuse [19]. A review of qualita-
tive research on IPV amongst older women identified a number of relevant themes, including
patterns of abuse that were continuous and consistent with previous experiences of abuse in
families of origin and previous relationships [20]. A systematic review and meta-synthesis of
qualitative studies of IPV and older women focused on how previous exposure to IPV influ-
enced health-seeking behaviours, specifically mental health care [21]. An empirical review of
quantitative and qualitative studies of sexual violence against older people identified wide-
spread variation in prevalence rates across studies, and a range of perpetrators, primarily inti-
mate partners or adult children [22]. A recent narrative review of quantitative, qualitative and
mixed methods studies of IPV against women aged 45 and above concluded that women’s
“age and life transitions mean that they may experience abuse differently to younger women.
They also face unique barriers to accessing help, such as disability and dependence on their
partners” [23].
However, amongst these existing systematic reviews of qualitative literature, none have
focused specifically on older women, while also being inclusive of any form of violence. In
order to improve understanding of violence against older women, it is important to explore
patterns, dynamics and experiences through examination of the qualitative literature. Qualita-
tive data on violence against older women complements quantitative evidence not only by
offering insight into lived experiences of older women subjected to violence, but also by

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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,

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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].

Study selection and data extraction


After removing duplicates, study selection proceeded in two stages: in the first stage, two
authors (SRM and MEL) reviewed titles and abstracts of all identified manuscripts. We
included studies that met the following criteria: i) focused on women aged 50 and older, ii)
employed qualitative methodology, and iii) focused on women’s experiences of any type of vio-
lence perpetrated by any type of perpetrator. Studies including men or also including women
aged younger than 50 were included if specific and separate sex and age-specific analyses were
included. We included studies employing any type of qualitative methodology, and mixed
methods studies were included if qualitative data was presented separately. Studies were
excluded if the whole sample was children, adolescents or adults under the age of 50; if the
sample only included men; if the methodology was quantitative, or in the case of mixed meth-
ods studies, if the qualitative results were not separately presented, and if the data only
included the perspectives on violence against women as reported by care providers, health pro-
fessionals, legal professionals and nursing home managers.
After the first stage of title and abstract review, we reviewed the full text of any manuscript
considered relevant by either of the authors. In the second stage, two authors (SRM and MEL)
independently reviewed all articles selected for full text review for eligibility, to reach consen-
sus on inclusion. Any discrepancies were resolved with the input of an external reviewer. Fig 1
indicates the full search and study selection process.
We designed a data extraction Excel spreadsheet specifically for the purposes of the review,
including characteristics of included studies (location of the research, research question),
methodology (conceptual framework or theoretical approach, data collection methods, data
analysis methods, sampling), characteristics of the sample (inclusion and exclusion criteria,
brief description of the sample), types and nature of violence (context of violence, perpetrator
and brief description of impacts of violence). We extracted main findings, participant quota-
tions where possible, and study limitations, if reported. Data extraction was conducted by one
author (MEL), and checked for accuracy by a second author (SRM), with discrepancies
resolved by discussion to reach consensus.

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?

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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?

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PLOS ONE Violence against older women: a systematic review of qualitative literature

10. Does the study demonstrate sensitivity to ethical concerns?


Two authors (SRM, MEL) assessed the quality of the studies, assigning a 1 for each affirma-
tive response and 0 for each negative response, for a final score out of 10. Disagreement was
resolved by discussion between the two authors. Quality assessment was not used to determine
if any studies should be excluded, but rather to assess the strength of each study.

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.

Overview of study characteristics


Study setting (Table 1). Most studies were conducted in high-income countries (HIC),
including the United States of America (n = 16), Israel (n = 12), Canada (n = 7), the United
Kingdom (n = 4), Hong Kong (n = 2), and Australia (n = 1). Six articles were from upper-mid-
dle income countries–Brazil (n = 3), Mexico (n = 2) and Iran (n = 1); and three articles were
from low-income countries–Uganda (n = 1) and Ethiopia (n = 2). One article came from
India, a lower-middle income country.

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]

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PLOS ONE Violence against older women: a systematic review of qualitative literature

Table 1. Characteristics of included studies.


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)
Agoff 2006 Mexico To identify personal, cultural, 26; Age range: 26–72 Open-ended face-to-face IPV–any type
(AMRO) and institutional factors that interview; analysis guided by Male partner
hinder resolution of domestic grounded theory, focusing on two
violence, to identify factors that aspects: subjective perceptions of
facilitate the violence. violence and barriers to
overcoming violence
Ayres 2001 United How do you define the concept 11 Transcripts of first session of a Elder abuse–Verbal,
States of abuse within the context of community-based intervention; physical, emotional
(AMRO) ageing women who are at risk concept analysis abuse
for or experiencing physical or 50 and older for Elderly family member
emotional injury inflicted by caregiver; 55 and older receiving care (spouses
elderly family members for for elderly family or parents)
whom they provide care? member
Band- 2009 Israel How is intimate violence shaped 40 couples; Age range: Face-to-face in-depth interviews; IPV–Physical,
Winterstein (EURO) and how does it change 60–84 content analysis emotional, economic,
throughout the lives of older psychological
battered women? How is Male partner
continuous IPV experienced in
old age and how age and
violence interact and change
throughout the life span
Band- 2010 Israel What are the unique 25; Age range: 60–84 Face-to-face in-depth interviews; IPV–physical, emotional
Winterstein (EURO) experiences of old battered content analysis Male partners
women from the dimensions of
intentionality of the body in
time and space?
Band- 2010 Israel What are various perceptions of 21; Age range: 60–80 Face-to-face semi-structured in- IPV–physical, emotional
Winterstein (EURO) the attempts to forgive others depth interviews; content analysis Male partners
and the self throughout this
lifelong process, as described by
older women who have lived
with intimate partner violence?
What are the lived experiences
of forgiveness of older abused
women throughout a life of
IPV?
Band- 2012 Israel Explore the constructions of N = 30 (15 couples, Face-to-face in-depth interviews; IPV–physical, sexual
Winterstein (EURO) aging in intimate partner n = 15 women) dyadic analysis approach focused
violence as narratives of Male partner on identifying overlap and Age range: 62–84
couplehood or narratives of old contrast in the couple data;
age; explore how couples, who analyzed transcripts as whole life
are living in lifelong IPV, story, then performed separate
constructed aging in IPV. categorical-content analysis
consistent with the narrative
approach.
Band- 2014 Israel How do parents experience 16 parents (11 mothers); Face-to-face in-depth interviews; Family violence—
Winterstein (EURO) their aging process in the Age range: 58–94 content analysis in physical, emotional
context of being abused by their phenomenological method abuse, financial, neglect
adult children with mental Adult children with
disorder? How do they describe mental disorders
the influence of the aging
process on the relationship
dynamics? How does living in
such shared reality impacts their
aging needs?
(Continued )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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 )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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 )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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 )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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 )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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 )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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,

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Table 2.

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

research aims? appropriate? and


justified?
Agoff, C., Rajsbaum, A., yes yes yes yes yes yes yes yes yes yes 10
& Herrera, C. (2006).
Perspectivas de las
mujeres maltratadas sobre
la violencia de pareja en
México. Salud pública de
México, 48(S2), 307–314.
Ayres, M. M., & Woodtli, yes yes no no no no yes yes no no 4
A. (2001). Concept
analysis: abuse of ageing
caregivers by elderly care
recipients. Journal of
Advanced Nursing, 35(3),
326–334.
Band-Winterstein, T., & yes yes no yes yes yes yes yes yes yes 9
Avieli, H. (2019). Women
Coping With a Partner’s
Dementia-Related
Violence: A Qualitative
Study. Journal of nursing
scholarship.

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Band-Winterstein, T., & yes yes no yes yes yes yes yes no yes 8
Eisikovits, Z. (2009).
“Aging out” of violence:
The multiple faces of
intimate violence over the
life span. Qualitative
Health Research, 19(2),
164–180.
Band-Winterstein, T., & yes yes no yes no yes yes yes no yes 7
Eisikovits, Z. (2010).
Towards
phenomenological
theorizing about old
women abuse. Ageing
International, 35(3), 202–
214.
Band-Winterstein, T., yes yes no yes no yes yes yes yes no 7
Eisikovits, Z., & Koren, C.
(2011). Between
remembering and
forgetting: The experience
of forgiveness among
older abused women.
Qualitative Social Work,
10(4), 451–466.
(Continued )

15 / 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

research aims? appropriate? and


justified?
Band-Winterstein, T. yes yes no yes yes yes yes yes no yes 8
(2012). Narratives of
aging in intimate partner
violence: The double lens
of violence and old age.
Journal of Aging studies,
26(4), 504–514.
Band-Winterstein, T., yes yes no yes yes yes yes yes yes yes 9
Smeloy, Y., & Avieli, H.
(2014). Shared reality of
the abusive and the
vulnerable: The
experience of aging for
parents living with
abusive adult children
coping with mental
disorder. International
Psychogeriatrics, 26(11),
1917–1927.
Band-Winterstein, T. yes yes no yes yes yes yes yes no yes 8
(2015). Aging in the

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shadow of violence: A
phenomenological
conceptual framework for
understanding elderly
women who experienced
lifelong IPV. Journal of
Elder Abuse & Neglect, 27
(4–5), 303–327.
Band-Winterstein, T. yes yes yes yes yes yes yes yes yes yes 10
(2015). Whose suffering is
this? Narratives of adult
children and parents in
long-term abusive
relationships. Journal of
Family Violence, 30(2),
123–133.
Barbosa, J. A. G., Souza, yes yes yes yes no yes yes no no yes 7
M. C. M. R. D., & Freitas,
M. I. D. F. (2015).
Violência sexual:
narrativas de mulheres
com transtornos mentais
no Brasil. Revista
Panamericana de Salud
Pública, 37, 273–278.
(Continued )

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

research aims? appropriate? and


justified?
Bhatia, P., & Soletti, A. B. yes yes no yes no yes no yes no yes 6
(2019). Hushed Voices:
Views and Experiences of
Older Women on Partner
Abuse in Later Life.
Ageing International, 44
(1), 41–56.
Buchbinder, E., & yes yes no yes no yes yes yes no no 6
Winterstein, T. (2003).
“Like a wounded bird”:
Older battered women’s
life experiences with
intimate violence. Journal
of Elder Abuse & Neglect,
15(2), 23–44.
Chane, S., & Adamek, M. yes yes yes yes yes yes yes yes no no 8
E. (2015). Factors
contributing to elder
abuse in Ethiopia. The
Journal of Adult
Protection, 17(2), 99–110.

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Chane, S., & Adamek, M. yes yes yes yes yes yes yes yes no no 8
E. (2015). “Death Is Better
Than Misery” Elders’
Accounts of Abuse and
Neglect in Ethiopia. The
International Journal of
Aging and Human
Development, 82(1), 54–
78.
Cheung, D. S. T., Tiwari, yes yes no no no no no no no yes 3
A., & Wang, A. X. M.
(2015). Intimate partner
violence in late life: a case
study of older Chinese
women. Journal of Elder
Abuse & Neglect, 27(4–5),
428–437.
Cronin, V. L. (2013). yes yes no yes yes yes yes yes yes yes 9
Silence Is Golden: Older
Women’s Voices and The
Analysis of Meaning
Among Survivor’s of
Domestic Violence.
Syracuse University,
Dissertation.
(Continued )

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

research aims? appropriate? and


justified?
do Rosário de Menezes, yes yes no yes yes yes no yes no yes 7
M., Bastos Alves, M., dos
Santos Souza, A., Almeida
da Silva, V., Nunes da
Silva, E., & Souza
Oliveira, C. M. (2013).
Aggressive Behavior in
the relationship between
old and the family
caregiver in dementias.
Ciencia, Cuidado e Saude,
12(4).
Eisikovits, Z., & Band- yes yes no yes yes yes yes yes no yes 8
Winterstein, T. (2015).
Dimensions of suffering
among old and young
battered women. Journal
of Family Violence, 30(1),
49–62.
Fakari, F. R., Hashemi, M. yes yes no no no no no no no no 2
A., & Fakari, F. R. (2013).

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A Qualitative research:
Postmenopausal women’s
experiences of abuse.
Procedia-Social and
Behavioral Sciences, 82,
57–60. R: 1050
Grunfeld, A. F., Larsson, yes yes yes yes yes yes yes yes no yes 9
D. M., MacKay, K., &
Hotch, D. (1996).
Domestic violence against
elderly women. Canadian
Family Physician, 42,
1485.
Guruge, S., Kanthasamy, yes yes yes yes no yes yes yes no yes 8
P., Kokarasa, J., Wan, T.
Y.W., Chinichian, M.
Shirpak, K. R. (2010).
Older women speak about
abuse & neglect in the
post-migration context.
Women’s Health and
Urban Life, 9(2), 15–41.
(Continued )

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

research aims? appropriate? and


justified?
Hightower, J., Smith, M. no yes no no yes no no yes no yes 4
J., & Hightower, H. C.
(2006). Hearing the voices
of abused older women.
Journal of Gerontological
Social Work, 46(3–4),
205–227.
Lazenbatt, A., & Devaney, yes yes no yes yes yes no yes no yes 7
J. (2014). Older women
living with domestic
violence: coping resources
and mental health and
wellbeing. Current
nursing journal, 1(1), 10–
22.
Lazenbatt, A., Devaney, J., yes yes no yes yes yes yes yes yes yes 9
& Gildea, A. (2013). Older
women living and coping
with domestic violence.
Community practitioner,
86(2), 28–33.

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Lichtenstein, B., & yes yes yes yes yes yes yes yes no yes 9
Johnson, I. M. (2009).
Older African American
women and barriers to
reporting domestic
violence to law
enforcement in the rural
deep south. Women &
Criminal Justice, 19(4),
286–305.
Lowenstein, A., & Ron, P. yes yes no yes no yes yes yes no no 6
(1999). Tension and
conflict factors in second
marriages as causes of
abuse between elderly
spouses. Journal of Elder
Abuse & Neglect, 11(1),
23–45.
McGarry, J., Simpson, C. yes yes no yes yes no yes yes no yes 7
(2010). How domestic
abuse affects the
wellbeing of older
women. Nursing Older
People, 22(5), 33–38.
(Continued )

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

research aims? appropriate? and


justified?
McGarry, J., Simpson, C., yes yes yes yes yes yes yes yes no yes 9
& Hinsliff-Smith, K.
(2014). An exploration of
service responses to
domestic abuse among
older people: findings
from one region of the
UK. The Journal of Adult
Protection, 16(4), 202–
212.
Montminy, L. (2005). yes yes no yes yes yes yes yes no no 7
Older women’s
experiences of
psychological violence in
their marital
relationships. Journal of
Gerontological Social
Work, 46(2), 3–22.
Nahmiash, D. (2004) yes yes no yes yes no yes yes no no 6
Powerlessness and Abuse
and Neglect of Older

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Adults, Journal of Elder
Abuse and Neglect, 14:1,
21–47.
Pillemer, K., Chen, E. K., yes yes yes yes yes yes yes yes yes yes 10
Van Haitsma, K. S.,
Teresi, J., Ramirez, M.,
Silver, S., . . . & Lachs, M.
S. (2011). Resident-to-
resident aggression in
nursing homes: Results
from a qualitative event
reconstruction study. The
Gerontologist, 52(1), 24–
33.
Ramsey-Klawsnik, H. no yes no no no no no yes no no 2
(2004). Elder sexual abuse
within the family. Journal
of Elder Abuse & Neglect,
15(1), 43–58.
(Continued )

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

research aims? appropriate? and


justified?
Richards, E., Zalwango, yes yes yes yes yes yes yes yes no yes 9
F., Seeley, J., Scholten, F.,
& Theobald, S. (2013).
Neglected older women
and men: Exploring age
and gender as structural
drivers of HIV among
people aged over 60 in
Uganda. African journal
of AIDS research, 12(2),
71–78.
Roberto, K. A., Brossoie, yes yes yes yes yes yes no no no no 6
N., McPherson, M. C.,
Pulsifer, M. B., & Brown,
P. N. (2013). Violence
against rural older
women: Promoting
community awareness
and action. Australasian
journal on ageing, 32(1),
2–7.

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Roberto, K. A., & yes yes no yes yes yes yes yes no yes 8
McCann, B. R. (2018).
Violence and abuse in
rural older women’s lives:
a life course perspective.
Journal of interpersonal
violence.
Ron, P., & Lowenstein, A. yes yes no yes no yes yes yes no no 6
(1999). Loneliness and
Unmet Needs of Intimacy
and Sexuality—Their
Effect on the
Phenomenon of Spousal
Abuse in Second
Marriages of the
Widowed Elderly. Journal
of Divorce & Remarriage,
31(3–4), 69–89.
(Continued )

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

research aims? appropriate? and


justified?
Rosen, T., Bloemen, E. yes yes no yes no yes yes yes no yes 7
M., LoFaso, V. M., Clark,
S., Flomenbaum, N. E.,
Breckman, R., . . .
Pillemer, K. (2019). Acute
precipitants of physical
elder abuse: qualitative
analysis of legal records
from highly adjudicated
cases. Journal of
Interpersonal Violence,
34(12), 2599–2623.
Ruelas-González, M. G., yes yes yes yes yes yes yes no no no 7
Pelcastre-Villafuerte, B.
E., & Reyes-Morales, H.
(2014). Maltrato
institucional hacia el
adulto mayor:
percepciones del
prestador de servicios de
salud y de los ancianos.

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salud pública de méxico,
56(6), 631–637.
Sawin, E. M., & Parker, B. yes yes no yes yes yes yes yes no yes 8
(2011). “If looks would
kill then I would be dead”:
intimate partner abuse
and breast cancer in older
women. Journal of
Gerontological Nursing,
37(7), 26–35.
Schaffer, J. (1999). Older yes yes no no yes yes no yes no no 5
and isolated women and
domestic violence project.
Journal of Elder Abuse &
Neglect, 11(1), 59–77.
Smith, J.R. (2015) yes yes no yes yes yes yes yes no yes 8
Expanding Constructions
of Elder Abuse and
Neglect: Older Mothers’
Subjective Experiences,
Journal of Elder Abuse &
Neglect, 27:4–5, 328–355.
(Continued )

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

research aims? appropriate? and


justified?
Souto, R. Q., Merighi, M. yes yes yes yes yes yes yes yes no yes 9
A. B., Guruge, S., & de
Jesus, M. C. P. (2015).
Older Brazilian women’s
experience of
psychological domestic
violence: a social
phenomenological study.
International Journal for
Equity in Health, 14(1),
44.
Souto, R. Q., Guruge, S., yes yes yes yes yes yes yes yes no yes 9
Merighi, M. A. B., & de
Jesus, M. C. P. (2016).
Intimate partner violence
among older Portuguese
immigrant women in
Canada. Journal of
Interpersonal Violence,
34(5), 961–979
Spencer, D., Funk, L. M., yes yes no yes yes yes yes yes no yes 8

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Herron, R. V., Gerbrandt,
E., & Dansereau, L.
(2019). Fear, defensive
strategies and caring for
cognitively impaired
family members. Journal
of gerontological social
work, 62(1), 67–85.
Teaster, P. B., Roberto, K. yes yes no yes yes yes yes yes no yes 8
A., & Dugar, T. A. (2006).
Intimate partner violence
of rural aging women.
Family Relations, 55(5),
636–648.
Tetterton, S., & yes yes no yes no no no no yes yes 5
Farnsworth, E. (2011).
Older women and
intimate partner violence:
Effective interventions.
Journal of Interpersonal
Violence, 26(14), 2929–
2942.
(Continued )

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

research aims? appropriate? and


justified?
Yan, E. (2015). Elder yes yes yes yes yes yes yes yes no yes 9
abuse and help-seeking
behavior in elderly
Chinese. Journal of
Interpersonal violence, 30
(15), 2683–2708.
Zink, T., Regan, S., yes yes no yes yes yes yes yes no no 7
Jacobson Jr, C. J., & Pabst,
S. (2003). Cohort, period,
and aging effects: A
qualitative study of older
women’s reasons for
remaining in abusive
relationships. Violence
Against Women, 9(12),
1429–1441. R: 347
Zink, T., Jacobson, C. J., yes yes no yes yes yes yes yes yes yes 9
Regan, S., Fisher, B., &
Pabst, S. (2006). Older
women’s descriptions and
understandings of their

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abusers. Violence Against
Women, 12(9), 851–865.
Zink, T., Jeffrey Jacobson yes yes no yes yes yes yes yes yes yes 9
Jr, C., Regan, S., & Pabst,
S. (2004). Hidden victims:
The healthcare needs and
experiences of older
women in abusive
relationships. Journal of
Women’s Health, 13(8),
898–908.
Zink, T., Jacobson Jr, C. yes yes no yes yes yes yes yes yes no 8
J., Pabst, S., Regan, S., &
Fisher, B. S. (2006). A
lifetime of intimate
partner violence: Coping
strategies of older women.
Journal of Interpersonal
Violence, 21(5), 634–651.
https://doi.org/10.1371/journal.pone.0239560.t002

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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.

Descriptions and patterns of types of violence


Older women described IPV, family violence and elder abuse of various types, perpetrated by a
range of perpetrators [Table 1]. Among the specific types of violence reported in the articles in
this review, across IPV, elder abuse and family violence, physical violence was most frequently
reported [27, 32–54, 57, 60–63, 66, 69–80], followed by emotional/ psychological [28, 32, 36–
39, 41–51, 53, 54, 56, 60–62, 66–80], economic/ financial [34–36, 39, 41, 43–45, 48–50, 61, 62,
64, 68, 71, 72, 74–78], sexual [27, 33, 34, 40, 42, 49, 50, 54, 57, 59, 60, 67, 72, 74–76, 80], verbal
[32, 40, 45, 52, 62, 68–70, 73, 77], controlling behaviors [45, 48, 49, 51, 53, 64, 67, 70, 76, 77],
and lastly, neglect [28, 35, 39, 61, 62, 68, 71, 76].
Older women’s experience of IPV was the most frequent form of violence reported (42
articles) [27, 29, 33, 34, 36–38, 40–42, 45–56, 59–65, 67–80]. Older women described on-
going instances of neglect, verbal abuse and financial exploitation in a study conducted in
India [41], in other cases, physical violence characterized earlier and on-going experiences of
violence within intimate partner relationships [37, 40, 47, 54]. IPV in particular was
described by older women as occurring throughout different stages in the relationship, span-
ning their youth and into older age. Older women often experienced an escalation of IPV
and controlling behaviors despite the age and/ or illness of their partner [36, 40, 46, 61, 69,
77]. Changing relationship dynamics due to ageing–including a husband’s retirement, chil-
dren leaving the home, women wanting to engage in activities outside of the home, or diag-
nosis of a chronic or terminal illness–triggered escalating IPV [36, 40, 46, 47, 56, 69]. Shifts in
types of violence, from predominantly physical violence to predominant psychological abuse
and neglect, were commonly described in studies that encompassed previous and on-going
IPV [34, 51]. Studies focused on IPV commonly described both previous and on-going vio-
lence, and a smaller number described only or primarily violence experienced while aged 50
or above [64, 69].
Violence occurring within the family was discussed in 15 articles [35, 39, 43, 44, 46, 48, 49,
55, 63, 66, 68, 69, 71, 76, 79], with perpetrators including family members not including chil-
dren [27, 43, 44, 48, 49, 59, 63, 68, 69, 71] and adult children [35, 39, 48, 66, 76, 79]. Studies
captured instances of physical and verbal aggression by mentally ill adult children against
older women [66], violence enacted by elderly with dementia against older women who were
caregivers [46], and forms of neglect, financial exploitation and emotional abuse enacted by
family members, including children [44]. The majority of these studies focused on violence
experienced in older age, while one study explored dynamics of abuse between children and
mothers across the lifespan [35, 39].
10 articles reported on experiences of elder abuse [28, 32, 35, 43, 44, 55, 57–59, 78] with per-
petrators including community members [43, 44], caregivers [57, 59], nursing home residents
[58] and health care providers [28]. Types of elder abuse included verbal abuse, physical assault
and inappropriate sexual advances [58] and sexual assault [59].
Financial control spanned instances of elder abuse, family violence and IPV [43, 53, 62, 64,
76, 78], and was described as co-occurring with and resulting in other forms of violence.
Financial exploitation could result in emotional and/ or physical violence if older women
resisted control [62, 64]. An older woman explained that in the context of her relationship
with her husband, “If I did not follow his control [over money], he would be verbally abusive”
[64].
Themes and sub-themes identified through coding are displayed in Table 3.

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PLOS ONE Violence against older women: a systematic review of qualitative literature

Table 3. Themes, sub-themes and quotations.


Theme Sub-theme Illustrative quotation[s] Supporting references
Intersection of ageing and violence
Suffering, loneliness, regret and “I lost my whole, beautiful life. I have a lot of anger in my heart. . .Today, I am real [33, 34, 37, 38, 40, 42, 44, 45, 47,
guilt angry about all the years, the good, beautiful years I could have had. I am angry, 50–52, 54, 56, 62, 66, 75, 78, 79]
because I was a good, loyal wife. . . With the wisdom I have today, I would have
gone out with anyone but him. Sixty wasted years” [37]
"There was violence along with suffering for many years; it was a suffering, but I
had a goal behind all this suffering, to have my children grow, get married and get
an education. . .. I don’t know if the suffering was worthwhile for me, I don’t know
if it was worthwhile as it was very difficult. Today I look and say that I was a
heroine, I was a heroine myself, with all the things I went through during the 40
years." [42]
“When I was bringing up the children, I thought of nothing else. . . I just wanted to
bring them up. Actually, my forgiveness was for the sake of the home and the
children, without any consideration for myself; I did not value myself at all. I was
the doormat of the entire household. . . When there was anger and quarrelling,
none of the children came to ask about it. . . They never said anything. When he
raised his hands, they did not go and ask him why he was hitting their mother.
Nothing. As if they didn’t care. I am real angry. They got used to the fact that mom
gets everything done. I had big expectations of life, I gave a lot, and today I am
really alone. The worst pain is from the children. Perhaps if I were stronger, I could
have changed things around. But I gave up a lot. I gave in." [38]
Violence, ageing and "When I was younger, I could overcome him faster, save myself, now that I’m old [33, 37, 39, 40, 43, 44, 47, 48, 52,
vulnerabilities and I have diabetes, now I have to be faster, and I got triglycerides in my blood. 53, 55–57, 59, 61, 62, 64, 66, 76]
Now I’m afraid for my life, afraid he [son with schizophrenia] will kill me." [39]
"Because of my nerves, my blood pressure was 200/100. My sugar was skyrocketing,
my cholesterol also. Since we’ve been living apart, everything has cooled down.
When we lived together, my whole body was sick. I was hurting. I was worried that
I had cancer. I couldn’t believe what he had done to me. I was going to the doctor
for checkups and tests all the time. I was sick with fear. My nerves made me sick.
The doctor knew I had problems at home. He would say ‘Ilana, you are nervous.’
He gave me some pills, but nothing helped. I did not sleep. Nerves make a person
sick. They make a woman sick. A sick woman without sickness." [37]
“I reached the point where. . . I didn’t care if I went and got my medicine. I would
have to argue with him that I needed $12 just to go to the clinic to get my pills.”
[61]
Perpetrator-related factors
Ageing perpetrators and “Although Mrs. V. had not been hit in many years, she was submissive to her [36, 41, 45, 47–51, 56, 59, 61, 72,
continuity of abuse husband and distraught about the continuing marital rape. Among the tactics used 76, 77]
by Mr. V. to control his wife were prohibiting her from driving, working outside of
the home, or managing money.” [59]
"Fifty years went by. I lost my whole life. He made me into an imbecile. . .. When I
needed to buy something for the children or for myself, I had to ask him for money
and he made me bring him the receipts. I have no friends, no family here; he
wouldn’t let the children come into the house. . . Because of the paralysis (CVA) I
walk sort of crooked. He walks behind me, imitating me and calling me names like
‘the limping,’ ‘the paralyzed’. Instead of feeling sorry about what happened to me,
he laughs. ‘Old whore’ he called me . . . A month into my marriage, he beat me. I
was pregnant. My mother was standing there and said to me: ‘Be patient with him.
Treat him well, take care of him and everything will be OK.” [47]
(Continued )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

Table 3. (Continued)

Theme Sub-theme Illustrative quotation[s] Supporting references


Perpetrator’s illness as a cause of “We couldn’t get into the house one day; the key wouldn’t go in for some reason. [40, 46, 69]
violence He went berserk, kicking the door and I said, “Brian calm down, we’ll go to the
other door.” He just kept kicking; he was just in this rage. So I backed off and went
around and opened the door and came. It turned out there was damage done; he
almost kicked the door in and [doctor] said in hindsight that I could have called the
police then. I could have reported that because I was scared." [69]
"Look, I don’t know what’s going on with my husband, 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. After he assaults me, he behaves as if he
had done nothing, he seems another person.” [46]
"He used to work, [he was] a construction worker, and then suddenly he became
agitated one day, and threw me against the wall. I cracked my head open; they
stitched me up in the hospital and sent me right back home. Sometimes, he grabs
me—by the stomach, by the throat, starts running, pushes me aside, and runs from
room to room. I can’t rest, can’t watch TV, it bothers him. . .. He had become
someone else, not the person I knew, so we went to the doctor.” [40]
Social and gender norms regarding response to violence
Silence, stigma and family "I had a goal that my children would reach something good, and thank God, there [33–35, 38, 40–42, 46, 48, 57, 65–
was no other way, there was no other way. . . what I have suffered for so many years 69, 71, 73–76, 79, 80]
and I didn’t know. I knew how to get out for the kids’ sake, but not for myself. The
kids get married, and go on with their lives, and I am left, left with all I have gone
through. It is so difficult to speak about it, the same pain and with the same person,
and today I look on my plight and I cannot leave him. . . ." [42]
“If I complained about him, he said that when I called the police, before the police
arrive, I’d be dead. I did not know that there is help for intimate partner violence
cases. I did not know because I had no friends; I did not talk to anyone! My life was
from home to work and from work to home. He beat me sometimes.” [81]
Perceptions of abuse and violence "I mean I suppose you could say I have been abused, I’ve never been badly beaten, [27, 29, 32, 41, 55, 70, 71, 74, 75]
as normal but I have been hit and with all the temper and that sort of thing, but then there was
never anywhere to go and I’m really not aware that there’s anywhere specifically for
older people and I’m not aware that they even do anything.” [55]
“Most of the time, they [physicians] think you are just getting a little carried away,
you are a little high-strung, you are very nervous, you have al- ways been this way,
so calm down. . .So I didn’t go to the doctor when he beat me so badly. It’s a little
embarrassing at my age." [74]
Lifelong IPV
Continuation of patterns of IPV in "He started beating me on the second day of our marriage, he’s been hitting me all [33, 40, 49, 59, 70–72, 77]
old age these years." [71]
Earlier experiences of violence "He started beating me on the second day of our marriage, he’s been hitting me all [48, 49, 57, 61, 70, 71, 80]
these years." [71]
Cumulative impacts of violence "The worst thing is that so many years of abuse caused me many health problems, [34, 37, 41, 47, 50, 51, 54, 67, 68]
especially with my nerves, and depression. This was due to mistreatment. No one
can have happiness or live well dealing with so much trouble. I also have other
health problems, but the worst for me are those related to my nerves, depression,
and lack of sleep. I have back problems; high cholesterol, ulcers, anemia and I have
a liver problem. . . a lot of problems! It never ends. Even after getting divorce, we
still suffer the consequences." [81]
“I have a problem with my stomach. I did five tests and nothing was found! It is the
anger I swallow. I have this pain in my stomach because the anger I feel of him.”
[68]
“Bruises heal in time but words last forever. When you are told over and over how
stupid, ugly, and insane you are, you really believe it. I am not financially or
physically capable of going anywhere." [51]
(Continued )

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PLOS ONE Violence against older women: a systematic review of qualitative literature

Table 3. (Continued)

Theme Sub-theme Illustrative quotation[s] Supporting references


Needs of older women affected by violence
Social and community support “If my friends knew the truth about who I was living with, then they would become [41, 45, 52, 64, 65, 68, 75–78]
really angry with me. I was losing contact with my friends because they were saying,
“How could you let him treat you like this, particularly when you are in such dire
need of support?” It was easier for me to just be quiet, but it’s very difficult to go
through such an abusive situation without having friends to talk with, though I did
lose some friends.” [64]
"I never invite any of my friends or relatives to come home, because of the fear that
he will insult them. None comes to visit me, because I have stopped calling them”
(Participant in IDI)" [41]
“I have talked to them [my neighbours]. I have asked them to help me. The
neighbours know everything, but they keep quiet! They do not want to get involved.
No one comes here. No one! Only you came here today [crying]” [68]
Barriers to accessing services “My internist really could not deal much with this [IPV]. I mean he saw my [28, 29, 52, 54, 55, 57, 74, 76]
husband as a patient also. He [spouse] was a brittle diabetic, and then he had a
heart condition. . . he was a sick old man.” [74]
"My family doctor is a good friend. . .didn’t involve him because I didn’t
get. . .really hurt. I mean, I was choked, but I didn’t get my eyes beat up or. . .but no
I wouldn’t have gone to him." [74]
Coping mechanisms
Leaving a relationship “I didn’t like the way my daughter-in-law treated me. So I asked my son to find me [33, 34, 37, 38, 42, 45–48, 57, 65,
another place to stay. Another son of mine was here, so he found a place for both of 69, 70, 73, 76]
us to stay.” [76]
Isolation, substance use and ‘I coped by going into my own private world; I took Valium . . . I saw myself as a [33, 34, 37–39, 47, 50, 51, 61, 68,
emotion-based coping strategies failure and felt sorry for myself. [50] 69, 73, 79]
"Why would I need this kind of life? How can a man do things like that? Why did I
agree to that? What do I have inside me today? It is all empty; an empty shell. What
am I left with? Nothing. All together, my entire life was for nothing, a big loss. . .I
destroyed it all. I gave up on myself, became non-existent. I think I am a lost case. I
am the loser in all this. What is left? I am all eaten up. I have no emotional strength
left. I don’t feel like doing anything." [47]
Behaviors to enhance safety "The two years were coming up for the restraining order, I start getting these [36, 67, 69, 70, 75]
nightmares he’s going to be at my door wanting to move in. I was living here, and
he was living in [place] about a mile from home. So I go back to court and apply for
renewal of the restraining order, and I am told there is no such thing as a renewal,
you just apply again." [70]
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Intersection of ageing and violence


A number of sub-themes emerged emphasizing the interconnections between the experience
of ageing amongst older women, and dynamics, impacts, experiences and perceptions of
violence.
Suffering, loneliness, regret and guilt. Older women emphasized suffering, loneliness,
regret and guilt in their accounts of living and coping with violence, particularly psychological
violence [34, 37, 38, 40, 42, 44, 45, 47, 50–52, 54, 56, 62, 66, 75, 78, 79]. Within the context of
IPV, women described experiences of loneliness in terms of detachment from family members,
including abusive partners and adult children, who often criticized older women’s responses
to violence [33, 34, 37, 38, 40, 42, 56]. Respondents linked regret with time and age, emphasiz-
ing previous decisions, lost opportunities, and wasting time due to living with an abusive part-
ner [33, 34, 37, 45]. One respondent said, “I was an idiot woman. No woman lives like that,
cooking and serving him after the beating. . . I say that I was an idiot” [42]. Older women
expressed feelings of guilt over the abuse they experienced, and regret and guilt for exposing

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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].

Social and gender norms regarding response to violence


Older women described the ways in which social and gender norms shaped their experiences
of and responses to violence.
Silence, stigma and family. Descriptions of social and gender norms that encouraged
women to stay in abusive marriages and prioritize children’s needs above their own were com-
mon across studies [33–35, 38, 40–42, 46, 48, 57, 65–69, 71, 73–76, 79, 80]. Older women
described several social norms that shaped their past decisions in response to violence includ-
ing: silence surrounding violence and the reporting of violence [41, 80], fears of shame and
stigma related to leaving a marriage [65, 69, 73], and ideals of being a good mother by putting
up with violence for the sake of her children [38, 42, 74]. One woman explained, “There was
violence along with suffering for many years;. . .but I had a goal behind all this suffering, to
have my children grow, get married and get an education. . .. I don’t know if the suffering was
worthwhile for me, I don’t know if it was worthwhile as it was very difficult” [42]. Remaining
in a relationship as a strategy was often employed due to older women feeling obligated to care
for an abusive partner who was now sick or unable to live alone [33]. One respondent
explained, “If I leave him, it’s not good. My conscience won’t allow it. At his age, 76, it’s not
nice to leave and neglect him. I don’t have feelings for him (because of the violence). I respect
him because he’s old and because he’s my husband, I have to care for him” [33]. These studies
primarily focused on previous and current experiences of violence; social norms predominant
when women were younger shaped prior and current responses, while one study of Sri Lankan
immigrant older women focused on social norms governing current decisions relating to
women’s responses to abuse from children and children-in-law [76].
In several cases, remaining in the relationship was a coping mechanism of last resort, given
the multiple barriers present to women leaving the relationship, whether with an intimate part-
ner, other family member or caregiver [48]. Women also described strong beliefs in social
norms that supported staying with a sick or frail abusive partner or abusive child [33, 35, 40,
46, 57, 66, 76]. Many women viewed seeking help and confiding in others as embarrassing and
unacceptable; one woman explained, "I was ashamed. I just didn’t want to admit that’s the situ-
ation I was in" [80].
Perceptions of abuse and violence as normal. In some of the included manuscripts,
older women perceived violence as normal, sometimes explaining that they preferred not to
term their experiences as abuse or violence [32, 41, 55, 70, 71, 74, 75]. Older women infre-
quently perceived verbal and emotional abuse as violence [32], and some women did not iden-
tify as a victim of violence [55, 71]. One woman described her process of realizing that her
experiences were forms of abuse, “Well, I really didn’t recognize it as abuse. And as soon as I
got that message, I felt that I got on a very clear track. . ..Now, I know what I’m dealing with
and I can do something about it” [74]. Moreover, service providers and the legal system, often
failed to recognize financial exploitation or verbal abuse as abuse [41, 74], or that older women
could be affected by IPV [75]. In rural Kentucky, USA, older women explained that the longer
they were in the relationship with their abuser, the more the violence became more normalized
and accepted [70]. Studies also emphasized how ageist attitudes normalizes forms of coercive

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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].

Needs of older women affected by violence


Older women who reported exposure to violence described various needs in terms of social
support, access to services, and issues accessing these services due to their age.
Social and community support. Older women commonly described isolation from fam-
ily and friends, and a lack of social and community support as a result of violent and control-
ling behaviors from an intimate partner [41, 45, 52, 64, 65, 75–78]. One older woman stated: “I
cannot remember, not one time, not having the hell beat out of me. Black and blue, I wasn’t
even allowed outside. I couldn’t open my mouth, I couldn’t talk, I couldn’t have friends. I had
neighbors, and they didn’t know me . . .He threatened to kill me if I ever told anyone what was
going on” [70]. Additionally, factors that were reported to impede access to social and commu-
nity support included being an immigrant with limited language skills [67, 68, 76], and living
in rural areas with strong norms against reporting IPV [52].
Barriers to accessing services. Several articles identified specific barriers for older women
to access services and for health care utilization, including lack of awareness of services [52, 54,
55, 57, 74, 76]. Older women reported several concerns when interacting with health care pro-
viders, including health care providers’ assumptions that older women could not be experienc-
ing violence due to their age, minimization of forms of abuse common to older women, and
lack of confidentiality when using the same provider as their spouse [74]. One respondent

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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].

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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,

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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,

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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.

Limitations and strengths


Several strengths and limitations should be considered while interpreting the findings of this
systematic review. In contrast to previous systematic reviews, we included all qualitative

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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.

Implications for future research


In light of the findings from this review, as noted above, there is an urgent need to address the
scarcity of research on violence against older women in low and middle-income contexts, and
to expand research in high-income contexts to diverse populations and age groups who may
have different risk profiles for violence in older age.
Our results indicate that the focus of the existing qualitative evidence-base is primarily on
IPV in older age. It is unclear whether this research focus reflects the actual burden of IPV
compared to other forms of violence against older women, and if the evidence-base cur-
rently adequately includes accounts of types of violence and perpetrators that are most sig-
nificant for older women. As noted, assessment of polyvicimization in the evidence-base is
lacking. As such, further studies of violence against older women that are inclusive of any
type of violence, by any perpetrator, or take an open-ended approach to older women’s
accounts of violence, are needed. In the quantitative evidence-base, systematic reviews have
focused on elder abuse and on IPV. A review of quantitative evidence on IPV identified 19
studies [15] and the review of elder abuse against women included 50 studies; as such, the
quantitative evidence-base appears to capture more in terms of forms of violence against
older women.

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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)

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PLOS ONE Violence against older women: a systematic review of qualitative literature

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.

References
1. WHO. Global and regional estimates of violence against women: prevalence and health effects of inti-
mate partner violence and non-partner sexual violence. Geneva World Health Organization,; 2013.
2. Ellsberg M, Jansen HA, Heise L, Watts CH, Garcia-Moreno C. Intimate partner violence and women’s
physical and mental health in the WHO multi-country study on women’s health and domestic violence:
an observational study. Lancet (London, England). 2008; 371(9619):1165–72.
3. Valladares E, Ellsberg M, Pena R, Hogberg U, Persson LA. Physical partner abuse during pregnancy:
a risk factor for low birth weight in Nicaragua. Obstetrics and gynecology. 2002; 100(4):700–5. https://
doi.org/10.1016/s0029-7844(02)02093-8 PMID: 12383537
4. Devries K, Watts C, Yoshihama M, Kiss L, Schraiber LB, Deyessa N, et al. Violence against women is
strongly associated with suicide attempts: evidence from the WHO multi-country study on women’s
health and domestic violence against women. Social science & medicine (1982). 2011; 73(1):79–86.
5. Pallitto CC, Garcia-Moreno C, Jansen HA, Heise L, Ellsberg M, Watts C. Intimate partner violence,
abortion, and unintended pregnancy: results from the WHO Multi-country Study on Women’s Health
and Domestic Violence. International journal of gynaecology and obstetrics: the official organ of the
International Federation of Gynaecology and Obstetrics. 2013; 120(1):3–9.
6. Garcia-Moreno C, Jansen HAFM, Ellsberg M, Heise L, Watts CH. Prevalence of intimate partner vio-
lence: findings from the WHO multi-country study on women’s health and domestic violence. The Lan-
cet. 2006; 368(9543):1260–9.
7. Brownell P. Neglect, abuse and violence against older women: Definitions and research frameworks
(Review article). South Eastern European Journal of Public Health 2014; 1.
8. Beaulaurier RLS, L. R.; Newman F. L.; Dunlop B. External barriers to help seeking for older women
who experience intimate partner violence. Journal of Family Violence. 2007; 22(8):747–55.
9. Souto RQ, Guruge S, Merighi MA, de Jesus MC. Intimate Partner Violence Among Older Portuguese
Immigrant Women in Canada. J Interpers Violence. 2016. https://doi.org/10.1177/0886260516646101
PMID: 27112506
10. Crockett C, Brandl B, Dabby FC. Survivors in the Margins: The Invisibility of Violence Against Older
Women. J Elder Abuse Negl. 2015; 27(4–5):291–302. https://doi.org/10.1080/08946566.2015.
1090361 PMID: 26371877
11. Tetterton S, Farnsworth E. Older women and intimate partner violence: effective interventions. Journal
of interpersonal violence. 2011; 26(14):2929–42. https://doi.org/10.1177/0886260510390962 PMID:
21156690
12. Stockl H, Watts C, Penhale B. Intimate partner violence against older women in Germany: prevalence
and associated factors. J Interpers Violence. 2012; 27(13):2545–64. https://doi.org/10.1177/
0886260512436390 PMID: 22328650
13. Department of Economic and Social Affairs. Neglect, Abuse and Violence against Older Women. New
York: United Nations 2013.

PLOS ONE | https://doi.org/10.1371/journal.pone.0239560 September 24, 2020 38 / 43


PLOS ONE Violence against older women: a systematic review of qualitative literature

14. Brownell P. A reflection on gender issues in elder abuse research: Brazil and Portugal. Ciencia &
saude coletiva. 2016; 21(11):3323–30. https://doi.org/10.1590/1413-812320152111.23142016 PMID:
27828565
15. Warmling D, Lindner SR, Coelho EBS. Intimate partner violence prevalence in the elderly and associ-
ated factors: systematic review. Ciencia & saude coletiva. 2017; 22(9):3111–25.
16. Yon Y, Mikton C, Gassoumis ZD, Wilber KH. The Prevalence of Self-Reported Elder Abuse Among
Older Women in Community Settings: A Systematic Review and Meta-Analysis. Trauma, Violence, &
Abuse. 2019; 20(2):245–59. https://doi.org/10.1177/1524838017697308 PMID: 29333977
17. Yon Y, Ramiro-Gonzalez M, Mikton CR, Huber M, Sethi D. The prevalence of elder abuse in institu-
tional settings: a systematic review and meta-analysis. European journal of public health. 2018.
https://doi.org/10.1093/eurpub/cky093 PMID: 29878101
18. Cook JM, Dinnen S, O’Donnell C. Older women survivors of physical and sexual violence: a system-
atic review of the quantitative literature. Journal of women’s health (2002). 2011; 20(7):1075–81.
https://doi.org/10.1089/jwh.2010.2279 PMID: 21668378
19. Roberto KA, McPherson MC, Brossoie N. Intimate partner violence in late life: a review of the empirical
literature. Violence Against Women. 2013; 19(12):1538–58. https://doi.org/10.1177/
1077801213517564 PMID: 24476758
20. Finfgeld-Connett D. Intimate partner abuse among older women: qualitative systematic review. Clini-
cal nursing research. 2014; 23(6):664–83. https://doi.org/10.1177/1054773813500301 PMID:
24045653
21. McGarry JA, Parveen; Hinchliff, Sharron. Older women, intimate partner violence and mental health: a
consideration of the particular issues for health and healthcare practice. Journal of Clinical Nursing.
2017; 26(15/16):2177–91.
22. Bows H. Sexual Violence Against Older People: A Review of the Empirical Literature. Trauma, vio-
lence & abuse. 2017:1524838016683455.
23. Pathak N, Dhairyawan R, Tariq S. The experience of intimate partner violence among older women: A
narrative review. Maturitas. 2019; 121:63–75. https://doi.org/10.1016/j.maturitas.2018.12.011 PMID:
30704567
24. Perel-Levin S. Discussing screening for elder abuse at primary health care level2008 4 August 2020.
https://apps.who.int/iris/bitstream/handle/10665/43523/9789241594530_eng.pdf.
25. WHO. Violence against women Intimate partner and sexual violence against women. Geneva: WHO;
2019.
26. Meyer SR, Lasater ME, Garcia-Moreno C. Violence against older women: a protocol for a systematic
review of qualitative literature. BMJ Open. 2019; 9(5):e028809. https://doi.org/10.1136/bmjopen-
2018-028809 PMID: 31142538
27. Barbosa JAG, Souza MCMRd, Freitas MIdF. Violência sexual: narrativas de mulheres com transtor-
nos mentais no Brasil. Revista Panamericana de Salud Pública. 2015; 37:273–8. PMID: 26208196
28. Ruelas-González MG, Pelcastre-Villafuerte BE, Reyes-Morales H. Maltrato institucional hacia el
adulto mayor: percepciones del prestador de servicios de salud y de los ancianos. salud pública de
méxico. 2014; 56(6):631–7. PMID: 25604415
29. Agoff C, Rajsbaum A, Herrera C. Perspectivas de las mujeres maltratadas sobre la violencia de pareja
en México. Salud pública de México. 2006; 48(S2):307–14.
30. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews.
BMC medical research methodology. 2008; 8:45. https://doi.org/10.1186/1471-2288-8-45 PMID:
18616818
31. Tong A, Flemming K, McInnes E, Oliver S, Craig J. Enhancing transparency in reporting the synthesis
of qualitative research: ENTREQ. BMC medical research methodology. 2012; 12:181. https://doi.org/
10.1186/1471-2288-12-181 PMID: 23185978
32. Ayres MM, Woodtli A. Concept analysis: abuse of ageing caregivers by elderly care recipients. Journal
of advanced nursing. 2001; 35(3):326–34. https://doi.org/10.1046/j.1365-2648.2001.01849.x PMID:
11489012
33. Band-Winterstein T. Narratives of aging in intimate partner violence: The double lens of violence and
old age. Journal of aging studies. 2012; 26(4):504–14. https://doi.org/10.1016/j.jaging.2012.07.003
PMID: 22939547
34. Band-Winterstein T. Aging in the shadow of violence: a phenomenological conceptual framework for
understanding elderly women who experienced lifelong IPV. Journal of elder abuse & neglect. 2015;
27(4–5):303–27. https://doi.org/10.1080/08946566.2015.1091422 PMID: 26362024
35. Band-Winterstein T. Whose suffering is this? Narratives of adult children and parents in long-term abu-
sive relationships. Journal of Family Violence. 2015; 30(2):123–33.

PLOS ONE | https://doi.org/10.1371/journal.pone.0239560 September 24, 2020 39 / 43


PLOS ONE Violence against older women: a systematic review of qualitative literature

36. Band-Winterstein T, Eisikovits Z. “Aging out” of violence: The multiple faces of intimate violence over
the life span. Qualitative Health Research. 2009; 19(2):164–80. https://doi.org/10.1177/
1049732308329305 PMID: 19074633
37. Band-Winterstein T, Eisikovits Z. Towards phenomenological theorizing about old women abuse. Age-
ing International. 2010; 35(3):202–14.
38. Band-Winterstein T, Eisikovits Z, Koren C. Between remembering and forgetting: The experience of
forgiveness among older abused women. Qualitative Social Work. 2011; 10(4):451–66.
39. Band-Winterstein T, Smeloy Y, Avieli H. Shared reality of the abusive and the vulnerable: The experi-
ence of aging for parents living with abusive adult children coping with mental disorder. International
psychogeriatrics. 2014; 26(11):1917–27. https://doi.org/10.1017/S1041610214001495 PMID:
25075607
40. Band-Winterstein T, Avieli H. Women Coping With a Partner’s Dementia-Related Violence: A Qualita-
tive Study. Journal of nursing scholarship. 2019.
41. Bhatia P, Soletti AB. Hushed Voices: Views and Experiences of Older Women on Partner Abuse in
Later Life. Ageing International. 2019; 44(1):41–56.
42. Buchbinder E, Winterstein T. “Like a wounded bird”: Older battered women’s life experiences with inti-
mate violence. Journal of Elder Abuse & Neglect. 2003; 15(2):23–44.
43. Chane S, Adamek ME. Factors contributing to elder abuse in Ethiopia. The Journal of Adult Protection.
2015; 17(2):99–110.
44. Chane S, Adamek ME. “Death Is Better Than Misery” Elders’ Accounts of Abuse and Neglect in Ethio-
pia. The International Journal of Aging and Human Development. 2015; 82(1):54–78. https://doi.org/
10.1177/0091415015624226 PMID: 26738998
45. Cronin VL. Silence Is Golden: Older Women’s Voices and The Analysis Of Meaning Among Survivor’s
Of Domestic Violence. Syracuse University, Dissertation. 2013.
46. do Rosário de Menezes M, Bastos Alves M, dos Santos Souza A, Almeida da Silva V, Nunes da Silva
E, Souza Oliveira CM. Aggressive Behavior in the relationship between old and the family caregiver in
dementias. Ciencia, Cuidado e Saude. 2013; 12(4).
47. Eisikovits Z, Band-Winterstein T. Dimensions of suffering among old and young battered women.
Journal of Family Violence. 2015; 30(1):49–62.
48. Grunfeld AF, Larsson DM, MacKay K, Hotch D. Domestic violence against elderly women. Canadian
Family Physician. 1996; 42:1485. PMID: 8792018
49. Hightower J, Smith M, Hightower HC. Hearing the voices of abused older women. Journal of geronto-
logical social work. 2006; 46(3–4):205–27. https://doi.org/10.1300/J083v46n03_12 PMID: 16803785
50. Lazenbatt A, Devaney J. Older women living with domestic violence: coping resources and mental
health and wellbeing. Current nursing journal. 2014; 1(1):10–22.
51. Lazenbatt A, Devaney J, Gildea A. Older women living and coping with domestic violence. Community
practitioner. 2013; 86(2):28–33. PMID: 23469739
52. Lichtenstein B, Johnson IM. Older African American women and barriers to reporting domestic vio-
lence to law enforcement in the rural deep south. Women & Criminal Justice. 2009; 19(4):286–305.
53. Lowenstein A, Ron P. Tension and conflict factors in second marriages as causes of abuse between
elderly spouses. Journal of Elder Abuse & Neglect. 1999; 11(1):23–45.
54. McGarry J, Simpson C. How domestic abuse affects the wellbeing of older women. Nursing older peo-
ple. 2010; 22(5). https://doi.org/10.7748/nop2010.06.22.5.33.c7795 PMID: 20617716
55. McGarry J, Simpson C, Hinsliff-Smith K. An exploration of service responses to domestic abuse
among older people: findings from one region of the UK. The Journal of Adult Protection. 2014; 16
(4):202–12.
56. Montminy L. Older women’s experiences of psychological violence in their marital relationships. Jour-
nal of gerontological social work. 2005; 46(2):3–22. https://doi.org/10.1300/J083v46n02_02 PMID:
16368672
57. Nahmiash D. Powerlessness and abuse and neglect of older adults. Journal of Elder Abuse & Neglect.
2004; 14(1):21–47.
58. Pillemer K, Chen EK, Van Haitsma KS, Teresi J, Ramirez M, Silver S, et al. Resident-to-resident
aggression in nursing homes: Results from a qualitative event reconstruction study. The Gerontolo-
gist. 2011; 52(1):24–33. https://doi.org/10.1093/geront/gnr107 PMID: 22048811
59. Ramsey-Klawsnik H. Elder sexual abuse within the family. Journal of Elder Abuse & Neglect. 2004; 15
(1):43–58.
60. Richards E, Zalwango F, Seeley J, Scholten F, Theobald S. Neglected older women and men: Explor-
ing age and gender as structural drivers of HIV among people aged over 60 in Uganda. African journal

PLOS ONE | https://doi.org/10.1371/journal.pone.0239560 September 24, 2020 40 / 43


PLOS ONE Violence against older women: a systematic review of qualitative literature

of AIDS research. 2013; 12(2):71–8. https://doi.org/10.2989/16085906.2013.831361 PMID:


25871376
61. Roberto KA, McCann BR. Violence and abuse in rural older women’s lives: a life course perspective.
Journal of interpersonal violence. 2018.
62. Ron P, Lowenstein A. Loneliness and Unmet Needs of Intimacy and Sexuality—Their Effect on the
Phenomenon of Spousal Abuse in Second Marriages of the Widowed Elderly. Journal of Divorce &
Remarriage. 1999; 31(3–4):69–89.
63. Rosen T, Bloemen EM, LoFaso VM, Clark S, Flomenbaum NE, Breckman R, et al. Acute precipitants
of physical elder abuse: qualitative analysis of legal records from highly adjudicated cases. Journal of
interpersonal violence. 2019; 34(12):2599–623. https://doi.org/10.1177/0886260516662305 PMID:
27506228
64. Sawin EM, Parker B. “If looks would kill then I would be dead”: intimate partner abuse and breast can-
cer in older women. Journal of gerontological nursing. 2011; 37(7):26–35. https://doi.org/10.3928/
00989134-20110307-01 PMID: 21446640
65. Schaffer J. Older and isolated women and domestic violence project. Journal of Elder Abuse &
Neglect. 1999; 11(1):59–77.
66. Smith JR. Expanding constructions of elder abuse and neglect: older mothers’ subjective experiences.
Journal of elder abuse & neglect. 2015; 27(4–5):328–55. PMID: 26565436
67. Souto RQ, Guruge S, Merighi MAB, de Jesus MCP. Intimate partner violence among older Portuguese
immigrant women in Canada. Journal of interpersonal violence. 2019; 34(5):961–79. https://doi.org/
10.1177/0886260516646101 PMID: 27112506
68. Souto RQ, Merighi MAB, Guruge S, de Jesus MCP. Older Brazilian women’s experience of psycholog-
ical domestic violence: a social phenomenological study. International journal for equity in health.
2015; 14(1):44.
69. Spencer D, Funk LM, Herron RV, Gerbrandt E, Dansereau L. Fear, defensive strategies and caring for
cognitively impaired family members. Journal of gerontological social work. 2019; 62(1):67–85. https://
doi.org/10.1080/01634372.2018.1505796 PMID: 30102135
70. Teaster PB, Roberto KA, Dugar TA. Intimate partner violence of rural aging women. Family relations.
2006; 55(5):636–48.
71. Yan E. Elder abuse and help-seeking behavior in elderly Chinese. Journal of interpersonal violence.
2015; 30(15):2683–708. https://doi.org/10.1177/0886260514553628 PMID: 25331371
72. Zink T, Jacobson CJ, Regan S, Fisher B, Pabst S. Older women’s descriptions and understandings of
their abusers. Violence against women. 2006; 12(9):851–65. https://doi.org/10.1177/
1077801206292680 PMID: 16905677
73. Zink T, Jacobson CJ Jr, Pabst S, Regan S, Fisher BS. A lifetime of intimate partner violence: Coping
strategies of older women. Journal of interpersonal violence. 2006; 21(5):634–51. https://doi.org/10.
1177/0886260506286878 PMID: 16574637
74. Zink T, Jeffrey Jacobson C Jr, Regan S, Pabst S. Hidden victims: The healthcare needs and experi-
ences of older women in abusive relationships. Journal of Women’s Health. 2004; 13(8):898–908.
https://doi.org/10.1089/jwh.2004.13.898 PMID: 15671705
75. Zink T, Regan S, Jacobson CJ Jr, Pabst S. Cohort, period, and aging effects: A qualitative study of
older women’s reasons for remaining in abusive relationships. Violence against women. 2003; 9
(12):1429–41. PMID: 21890424
76. Guruge S, Kanthasamy P., Kokarasa J., Wan T.Y.W., Chinichian M. Shirpak K. R. Older women
speak about abuse & neglect in the post-migration context. Women’s Health and Urban Life. 2010; 9
(2):15–41.
77. Cheung DST, Tiwari A, Wang AXM. Intimate partner violence in late life: a case study of older Chinese
women. Journal of elder abuse & neglect. 2015; 27(4–5):428–37. PMID: 26383961
78. Fakari FR, Hashemi MA, Fakari FR. A Qualitative research: Postmenopausal women’s experiences of
abuse. Procedia-Social and Behavioral Sciences. 2013; 82:57–60.
79. Tetterton S, Farnsworth E. Older women and intimate partner violence: Effective interventions. Journal
of Interpersonal Violence. 2011; 26(14):2929–42. https://doi.org/10.1177/0886260510390962 PMID:
21156690
80. Roberto KA, Brossoie N, McPherson MC, Pulsifer MB, Brown PN. Violence against rural older
women: Promoting community awareness and action. Australasian journal on ageing. 2013; 32(1):2–
7. https://doi.org/10.1111/j.1741-6612.2012.00649.x PMID: 23521727
81. Souto RQ, Guruge S, Merighi MA, de Jesus MC. Intimate Partner Violence Among Older Portuguese
Immigrant Women in Canada. J Interpers Violence. 2019; 34(5):961–79. https://doi.org/10.1177/
0886260516646101 PMID: 27112506

PLOS ONE | https://doi.org/10.1371/journal.pone.0239560 September 24, 2020 41 / 43


PLOS ONE Violence against older women: a systematic review of qualitative literature

82. Coker AL, Williams CM, Follingstad DR, Jordan CE. Psychological, reproductive and maternal health,
behavioral, and economic impact of intimate partner violence. Violence against women and children,
Vol 1: Mapping the terrain. Washington, DC, US: American Psychological Association; 2011. p. 265–
84.
83. Bacchus LJ, Ranganathan M, Watts C, Devries K. Recent intimate partner violence against women
and health: a systematic review and meta-analysis of cohort studies. BMJ Open. 2018; 8(7):e019995.
https://doi.org/10.1136/bmjopen-2017-019995 PMID: 30056376
84. Lagdon S, Armour C, Stringer M. Adult experience of mental health outcomes as a result of intimate
partner violence victimisation: a systematic review. Eur J Psychotraumatol. 2014; 5. https://doi.org/10.
3402/ejpt.v5.24794 PMID: 25279103
85. Campbell JC. Health consequences of intimate partner violence. Lancet (London, England). 2002;
359(9314):1331–6.
86. Stewart DE, Vigod SN. Mental Health Aspects of Intimate Partner Violence. Psychiatr Clin North Am.
2017; 40(2):321–34. https://doi.org/10.1016/j.psc.2017.01.009 PMID: 28477656
87. Devries KM, Mak JY, Bacchus LJ, Child JC, Falder G, Petzold M, et al. Intimate partner violence and
incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies. PLoS
Med. 2013; 10(5):e1001439. https://doi.org/10.1371/journal.pmed.1001439 PMID: 23671407
88. Beydoun HA, Beydoun MA, Kaufman JS, Lo B, Zonderman AB. Intimate partner violence against
adult women and its association with major depressive disorder, depressive symptoms and postpar-
tum depression: a systematic review and meta-analysis. Social science & medicine (1982). 2012; 75
(6):959–75. https://doi.org/10.1016/j.socscimed.2012.04.025 PMID: 22694991
89. McCleary-Sills J, Namy S, Nyoni J, Rweyemamu D, Salvatory A, Steven E. Stigma, shame and wom-
en’s limited agency in help-seeking for intimate partner violence. Glob Public Health. 2016; 11(1–
2):224–35. https://doi.org/10.1080/17441692.2015.1047391 PMID: 26156577
90. St Vil NM, Carter T, Johnson S. Betrayal Trauma and Barriers to Forming New Intimate Relationships
Among Survivors of Intimate Partner Violence. J Interpers Violence. 2018:886260518779596. https://
doi.org/10.1177/0886260518779596 PMID: 29884098
91. Kennedy AC, Prock KA. "I Still Feel Like I Am Not Normal": A Review of the Role of Stigma and Stig-
matization Among Female Survivors of Child Sexual Abuse, Sexual Assault, and Intimate Partner Vio-
lence. Trauma, violence & abuse. 2018; 19(5):512–27. PMID: 27803311
92. Murray CE, Crowe A, Overstreet NM. Sources and Components of Stigma Experienced by Survivors
of Intimate Partner Violence. J Interpers Violence. 2018; 33(3):515–36. https://doi.org/10.1177/
0886260515609565 PMID: 26467931
93. Shuman SJ, Falb KL, Cardoso LF, Cole H, Kpebo D, Gupta J. Perceptions and Experiences of Inti-
mate Partner Violence in Abidjan, Cote d’Ivoire. PLoS One. 2016; 11(6):e0157348. https://doi.org/10.
1371/journal.pone.0157348 PMID: 27310143
94. McMahon K, Hoertel N, Wall MM, Okuda M, Limosin F, Blanco C. Childhood maltreatment and risk of
intimate partner violence: A national study. J Psychiatr Res. 2015; 69:42–9. https://doi.org/10.1016/j.
jpsychires.2015.07.026 PMID: 26343593
95. Abajobir AA, Kisely S, Williams GM, Clavarino AM, Najman JM. Substantiated Childhood Maltreat-
ment and Intimate Partner Violence Victimization in Young Adulthood: A Birth Cohort Study. J Youth
Adolesc. 2017; 46(1):165–79. https://doi.org/10.1007/s10964-016-0558-3 PMID: 27624702
96. Richards TN, Tillyer MS, Wright EM. Intimate partner violence and the overlap of perpetration and vic-
timization: Considering the influence of physical, sexual, and emotional abuse in childhood. Child
Abuse Negl. 2017; 67:240–8. https://doi.org/10.1016/j.chiabu.2017.02.037 PMID: 28282597
97. Jones A, Vetere A. ’You just deal with it. You have to when you’ve got a child’: A narrative analysis of
mothers’ accounts of how they coped, both during an abusive relationship and after leaving. Clin Child
Psychol Psychiatry. 2017; 22(1):74–89. https://doi.org/10.1177/1359104515624131 PMID: 26763013
98. Baholo M, Christofides N, Wright A, Sikweyiya Y, Shai NJ. Women’s experiences leaving abusive rela-
tionships: a shelter-based qualitative study. Cult Health Sex. 2015; 17(5):638–49. https://doi.org/10.
1080/13691058.2014.979881 PMID: 25470526
99. Anderson DK, Saunders DG. Leaving an abusive partner: an empirical review of predictors, the pro-
cess of leaving, and psychological well-being. Trauma, violence & abuse. 2003; 4(2):163–91. PMID:
14697121
100. Wood SN, Kennedy SR, Hameeduddin Z, Asira B, Tallam C, Akumu I, et al. "Being Married Doesn’t
Mean You Have to Reach the End of the World": Safety Planning With Intimate Partner Violence Survi-
vors and Service Providers in Three Urban Informal Settlements in Nairobi, Kenya. J Interpers Vio-
lence. 2019:886260519879237. https://doi.org/10.1177/0886260519879237 PMID: 31587653

PLOS ONE | https://doi.org/10.1371/journal.pone.0239560 September 24, 2020 42 / 43


PLOS ONE Violence against older women: a systematic review of qualitative literature

101. Bermea AM, Khaw L, Hardesty JL, Rosenbloom L, Salerno C. Mental and Active Preparation: Examin-
ing Variations in Women’s Processes of Preparing to Leave Abusive Relationships. J Interpers Vio-
lence. 2020; 35(3–4):988–1011. https://doi.org/10.1177/0886260517692332 PMID: 29294651
102. Heise LL, Kotsadam A. Cross-national and multilevel correlates of partner violence: an analysis of
data from population-based surveys. The Lancet Global health. 2015; 3(6):e332–40. https://doi.org/
10.1016/S2214-109X(15)00013-3 PMID: 26001577
103. Sardinha L, Najera Catalan HE. Attitudes towards domestic violence in 49 low- and middle-income
countries: A gendered analysis of prevalence and country-level correlates. PLoS One. 2018; 13(10):
e0206101. https://doi.org/10.1371/journal.pone.0206101 PMID: 30379891
104. Jewkes R, Flood M, Lang J. From work with men and boys to changes of social norms and reduction
of inequities in gender relations: a conceptual shift in prevention of violence against women and girls.
The Lancet. 2015; 385(9977):1580–9. PMID: 25467578
105. Shannon K, Leiter K, Phaladze N, Hlanze Z, Tsai AC, Heisler M, et al. Gender inequity norms are
associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and
Swaziland. PloS one. 2012; 7(1):e28739–e. https://doi.org/10.1371/journal.pone.0028739 PMID:
22247761
106. Gupta J, Falb KL, Lehmann H, Kpebo D, Xuan Z, Hossain M, et al. Gender norms and economic
empowerment intervention to reduce intimate partner violence against women in rural Cote d’Ivoire: a
randomized controlled pilot study. BMC Int Health Hum Rights. 2013; 13:46. https://doi.org/10.1186/
1472-698X-13-46 PMID: 24176132
107. Dickens AP, Richards SH, Greaves CJ, Campbell JL. Interventions targeting social isolation in older
people: a systematic review. BMC Public Health. 2011; 11(1):647. https://doi.org/10.1186/1471-2458-
11-647 PMID: 21843337
108. WHO. Responding to intimate partner violence and sexual violence against women: WHO clinical and
policy guidelines: World Health Organization; 2013.
109. Postmus JL, Hoge GL, Breckenridge J, Sharp-Jeffs N, Chung D. Economic Abuse as an
Invisible Form of Domestic Violence: A Multicountry Review. Trauma, Violence, & Abuse.
2018:1524838018764160.

PLOS ONE | https://doi.org/10.1371/journal.pone.0239560 September 24, 2020 43 / 43

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