Lifetime abuse and perceived social support among the elderly: a study from seven European countries

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26 Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med 2003;18:646–51.

27 Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med 2006;166:565–71.

28 Cohen G. Age and health status in a patient satisfaction survey. Soc Sci Med 1996;42:1085–93.

29 Rahmqvist M. Patient satisfaction in relation to age, health status and other background factors: a model for comparisons of care units. Int J Qual Health Care 2001;13:385–90.

30 Alkema GE, Frey D. Implications of translating research into practice: a medication management intervention. Home Health Care Serv Q 2006;25:33–54.

31 Ja¨ger C, Szecsenyi J, Steinha¨user J. Design and delivery of a tailored intervention to implement recommendations for multimorbid patients receiving polypharmacy into primary care practices. Biomed Res Int 2015;2015:938069.

32 Vandenberg AE, Vaughan CP, Stevens M, et al. Improving geriatric prescribing in the ED: a qualitative study of facilitators and barriers to clinical decision support tool use. Int J Qual Health Care 2017;29,117–123.

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The European Journal of Public Health, Vol. 27, No. 4, 686–692

doi:10.1093/eurpub/ckx047 Advance Access published on 11 April 2017

...

Lifetime abuse and perceived social support among the elderly: a study from seven European countries

Bahareh Eslami¹, Mirko Di Rosa², Henrique Barros³, Mindaugas Stankunas^4,5, Francisco Torres-Gonzalez⁶, Elisabeth Ioannidi-Kapolou⁷, Jutta Lindert^8,9, Maria Gabriella Melchiorre²

1 Division of Public Health Sciences, Department of Health Sciences, Mid Sweden University, Sundsvall, Sweden 2 Centre for Socio-Economic Research on Ageing, Italian National Institute of Health and Science on Aging, I.N.R.C.A,

Ancona, Italy

3 Department of Hygiene and Epidemiology, University of Porto Medical School, Porto, Portugal 4 Department of Health Management, Lithuanian University of Health Sciences, Kaunas, Lithuania

5 Department of Health Service Management, Centre for Health Innovation, School of Medicine, University of Griffith, Gold Coast, QLD, Australia

6 Centro de Investigacion Biomedica en Red de Salud Mental (CIBERSAM), University of Granada, Granada, Spain 7 Department of Sociology, National School of Public Health, Athens, Greece

8 Department of Public Health, University of Emden, Emden, Germany 9 Women’s Studies Research Center, Brandeis University, Waltham, MA, USA

Correspondence: Bahareh Eslami, Division of Public Health Sciences, Department of Health Sciences, Mid Sweden University, Holmgatan 10, SE-85170 Sundsvall, Sweden, Tel: +46 (0) 760850667,

e-mail: bahareh.eslami@miun.se

Background: Being a victim of abuse during one’s life course may affect social relations in later life. The aims of this study were to: (i) examine the association between lifetime abuse and perceived social support and (ii) identify correlates of perceived social support among older persons living in seven European countries. Methods: A sample of 4467 women and men aged 60–84 years living in Germany, Greece, Italy, Lithuania, Portugal, Spain and Sweden was collected through a cross-sectional population-based study. Abuse (psychological, physical, sexual, financial and injury) was assessed through interviews or interviews/self-response questionnaire based on the Conflict Tactics Scale-2 and the UK study on elder abuse. Perceived social support was assessed by the Multidimensional Scale of Perceived Social Support. Results: Victims of lifetime abuse perceived poorer social support in later life.

Multivariate analyses showed that high levels of perceived social support were associated with being from Greece and Lithuania (compared to Germany), being female, not living alone, consuming alcohol and physical activity. Poorer perceived social support was associated with being from Portugal, being old, having social benefits as the main source of income, experiencing financial strain and being exposed to lifetime psychological abuse and injuries. Conclusions: Our findings showed that exposure to psychological abuse and injuries across the lifespan were associated with low levels of perceived social support, emphasizing the importance of detection and appropriate treatment of victims of abuse during their life course. Future research should focus on coping strategies buffering the negative effects of abuse on social relationships.

...

Introduction

Social support, the provision of instrumental, informational and/or emotional assistance by family, friends and significant others, has a considerable impact on physical and mental health, and cognitive functioning by helping individuals to cope with critical situations in everyday life.^1–3 Perceived social support defined as perception of availability of support if needed, may represent a main source of personal care and subjective well-being especially in old age.^4,5 People with larger social networks are less likely to report loneliness which is a known risk factor for morbidity and mortality in old age.⁶

Furthermore, support/solidarity from family and friends may mitigate stress and loss of functions in older people,⁷facilitating healthy aging.

Acierno and colleagues⁸found low social support as a risk factor for emotional, physical, and sexual mistreatment, as well as neglect among adults aged 60 years or above. In a more recent literature review, Pillemer et al.⁹showed that living arrangements and social support have been two main factors strongly associated with elder abuse. High levels of social isolation, reduced independence in later life and low levels of social support in old age have been suggested as risk factors for all forms of elder abuse.^10,11The vulnerability of older people to abusive episodes has been related to their need for help and support.¹¹

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Elder abuse is a phenomenon with one-year incidence rate of 72 per 1000 and a prevalence rate between 3.2–27.5% in the general population, with emotional mistreatment being the most frequent type.^8,12–14With regard to prevalence of elder abuse over a lifetime, Eslami et al.¹⁵have reported 34% of psychological, 11.5% physical, 18.5% financial and 5%

sexual abuse and 4.3% injuries in a large European sample.

Previous research^8,16,17mostly focused on the buffering effect of social support on elder abuse, and there is a paucity of data regarding the association between experiencing abuse during a lifetime and interpersonal strain, loneliness, and decreased perceived social support in later life. We supposed that, lifetime abuse may result in social isolation and formation of dependent and vulnerable adults, which in turn may affect healthy old age negatively. It is important to note that in recent years there were mainly national studies on this topic, with related limited implications. Very few studies explored elder abuse from a cross-country perspective.¹³In this regard, the current study aimed to explore the association between lifetime abuse and level of perceived social support and to identify the correlates of perceived social support among older persons in seven European countries.

Methods

Design, sample, procedure and ethics statement This cross-sectional study draws on data from the "Elder Abuse: a multinational prevalence survey" carried out in urban centres in seven European countries: Ancona (Italy), Athens (Greece), Granada (Spain), Kaunas (Lithuania), Stuttgart (Germany), Porto (Portugal) and Stockholm (Sweden). Community-dwelling women and men fulfilling the following criteria were eligible to participate in this study: (i) being 60–84 years old, (ii) having intact cognitive functions (based on Mini-cog),¹⁸ (iii) being citizens or documented migrants and (iv) being proficient in the native language of one of the above-mentioned countries. Potential participants were informed about the study by means of a letter explaining aims and contents of the ABUEL project. Written informed consent from participants was obtained prior to data collection. The data were collected during January–July 2009 with two administration modes, face-to-face interview or interview/self-response. All survey materials (e.g. the questionnaire) were culturally adapted and followed a similar protocol for administration procedures and treating data. Ethical permission/approval was received in each participating state from the national/university or regional ethics review boards, except for Greece where the work was carried out by the QED Company, a member of ESOMAR providing ethical guidance through global guidelines. Mean response rate was 45.2%

across countries. Further details are described elsewhere.^19,20

Measures

Social support was measured with the Multidimensional Scale of Perceived Social Support,²¹ comprising 12 questions graded 1–7 ranging 12–84, which can be divided into three sub-scales, i.e.

support from family, friends and significant other. High scores correspond to high social support (sub-scales, total).

Lifetime abuse was assessed with 52 questions based on the UK study on elder abuse²²and the Conflict Tactics Scale-2.²³The participants were asked if they had been exposed to: psychological (11 items), physical (17 items), sexual (8 items) and financial abuse (9 items), and injuries (7 items) in their adult life (i.e. after the age of 18), excluding child abuse.

Demographic and socio-economic variables were age (i.e. 60–69, 70–84), gender, being in a partnership (i.e. yes = married/

cohabiting, no = single/divorced/widowed), living situation (type of relationship to the person living with the participant, i.e. alone, only with partners/spouse, with partner/spouse and others (e.g.

daughter), without partner/spouse and with others), habitation

(i.e. own property, other such as child’s home), level of education (i.e. low = primary school/similar, middle = high school/similar, high = university/similar), employment status (i.e. in paid work, yes/no), profession (i.e. blue collar, white collar, home), main source of income (i.e. work pension, work, social/other benefits such as sick-leave/unemployment, spouse/partner), and financial strain (yes/no).

Lifestyle variables included regular alcohol use, regular cigarette smoking, and physical activity (e.g. walking, swimming at least 4 times per week) assessed in a yes/no format, as well as Body Mass Index (BMI) calculated for each participant based on self-reported height and weight.

Statistical analyses

Categorical variables were presented as absolute frequencies and percentages, while continuous variables by mean, standard deviation and median. A Kolmogorov-Smirnov test was applied to check the normality of the distribution of the continuous variables.

The bivariate relation between perceived social support (total and subscales) and categorical variables (e.g. demographics/, socio- economics and lifetime abuse) was analysed with the Kruskall- Wallis test (means and standard deviations are reported), while association between perceived social support and BMI (which is a continuous variable) was analysed with the Spearman’s rank correl- ation test. Multivariate quantile regression model (based on median values²⁴) was used to examine the interrelations between perceived total social support and the independent variables expressed in un- standardized coefficients (B), and 95% confidence intervals (CIs).

Overall reliability of the model was expressed by the R-square (R²).

The statistical significant was set at P < 0.05. The PASW statistic package 22.0 (IBM/SPSS Inc., Chicago, IL) and STATA 11.2 were used to carry out the analyses.

Results

Demographic/socio-economic and lifestyle characteristics

As shown in table 1, of 4467 participants, 57.3% were women, 65%

married/in a relationship, 24% lived alone and 76% had their own accommodation. Furthermore, 21% had university education and 55% white-collar type profession. Additionally, 66% were supported by a work pension and 64% experienced financial strains. Finally, about 12% of persons in this sample smoked cigarettes, 64% consumed alcohol, 57% reported not to do regular physical activity and the BMI was 26.68 (SD = 4.19).

Socio-demographic/life-style variables and perceived social support

As depicted in table 1, Lithuanians scored higher on total social support (mean value 70.22) and support from family than others, Swedes on support from friends and Italians on support from significant other, respectively. Of note, older adults from Portugal reported the lowest mean scores on total (mean value 63.18) and each scale of social support. Furthermore, male sex (P = 0.024, except for support from friends), younger age, being in partnership and living only with spouse/partner, having own accommodation and high education (except for support from family) were associated with higher social support (P < 0.001 for all these dimensions). Still working was not associated with support from family and significant other, while those having blue-collar profes- sions (except for significant other) and main income from social/

other benefits, and experiencing financial strain reported lower mean scores on social support. Drinking alcohol regularly and lack of physical activity were associated with lower total social support and in each sub-scale, except for alcohol consumption which was

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Table 1 Socio-demographic and life-style variables associated with social support (Total, from family, from friends, from significant other) among 4467 older persons aged 60–84 years in seven European countries

Variables Total sample

n (%)

Social support total mean (SD)

Support from family mean (SD)

Support from friends mean (SD)

Support from

significant other mean (SD)

Country

Germany 648 (14.5) 67.90 (14.91) 22.37 (6.40) 20.94 (6.67) 24.53 (5.01)

Greece 643 (14.4) 68.38 (15.39) 23.23 (5.85) 21.43 (5.93) 23.68 (5.45)

Italy 628 (14.1) 67.40 (12.42) 24.98 (4.40) 17.02 (7.49) 25.38 (4.42)

Lithuania 630 (14.1) 70.22 (12.87) 27.74 (4.16) 21.49 (6.49) 23.99 (4.59)

Portugal 656 (14.7) 63.18 (12.86) 21.52 (5.11) 18.55 (5.94) 23.07 (4.51)

Spain 636 (14.2) 67.19 (16.26) 23.83 (5.54) 19.21 (8.26) 24.15 (5.37)

Sweden 626 (14.0) 67.58 (16.43) 23.00 (5.56) 21.72 (6.15) 22.87 (6.04)

P <0.001 <0.001 <0.001 <0.001

Sex

Female 2559 (57.3) 66.78 (15.23) 23.13 (5.70) 20.07 (7.17) 23.56 (5.37)

Male 1908 (42.7) 68.18 (13.82) 23.71 (5.10) 20.01 (6.64) 24.45 (4.76)

P 0.024 0.030 0.110 <0.001

Age (group years)

60–69 2212 (49.5) 68.67 (13.94) 23.55 (5.20) 20.93 (6.44) 24.20 (4.94)

70–84 2255 (50.5) 66.11 (15.22) 23.20 (5.69) 19.18 (7.31) 23.70 (5.31)

P 0.000 <0.001 0.356 <0.001 0.003

Being in partnership

Yes 2903 (65.0) 69.87 (12.13) 24.44 (4.25) 20.27 (6.75) 25.13 (3.90)

No 1563 (35.0) 62.71 (17.56) 21.38 (6.75) 19.62 (7.29) 21.73 (6.31)

P <0.001 <0.001 0.029 <0.001

Living situation

Alone 1078 (24.2) 61.29 (18.31) 20.61 (7.05) 19.58 (7.31) 21.12 (6.58)

Partner/spouse 2208 (49.6) 70.09 (12.18) 24.40 (4.33) 20.50 (6.66) 25.17 (3.89)

Partner/spouse & others 706 (15.9) 68.77 (12.10) 24.30 (4.30) 19.53 (6.99) 24.89 (4.00)

Others 457 (10.3) 66.40 (15.28) 23.51 (5.34) 19.74 (7.23) 23.15 (5.41)

P <0.001 <0.001 0.002 <0.001

Housing

Own 2392 (75.9) 68.49 (13.92) 23.88 (5.08) 20.34 (6.86) 24.24 (4.86)

Other^a 1073 (24.1) 63.79 (16.33) 21.76 (6.26) 19.08 (7.17) 22.99 (5.84)

P <0.001 <0.001 <0.001 <0.001

Education

Low 1617 (36.2) 66.18 (15.45) 23.29 (5.65) 19.13 (7.37) 23.72 (5.30)

Middle 1782 (39.9) 67.88 (13.81) 23.52 (5.22) 20.30 (6.68) 24.13 (4.96)

High 928 (20.8) 69.49 (13.49) 23.49 (5.28) 21.70 (5.92) 24.31 (4.85)

P <0.001 0.969 <0.001 0.027

Still working

Yes 751 (17.6) 68.48 (14.16) 23.20 (5.37) 21.36 (6.05) 23.93 (5.01)

No 3518 (82.4) 67.24 (14.64) 23.40 (5.47) 19.85 (7.00) 23.96 (5.14)

P 0.022 0.076 <0.001 0.388

Profession

Blue-collar^b 1277 (28.6) 66.02 (15.59) 23.21 (5.74) 19.11 (7.37) 23.70 (5.30)

White-collar^c 2476 (55.4) 68.30 (13.83) 23.38 (5.30) 20.74 (6.44) 24.14 (4.93)

Home 656 (14.7) 66.81 (15.36) 23.74 (5.48) 19.20 (7.64) 23.85 (5.41)

P 0.001 0.019 <0.001 0.088

Financial support

Work 542 (12.1) 67.78 (14.30) 23.50 (5.36) 20.18 (6.81) 24.07 (5.01)

Work pensions 2939 (65.9) 69.60 (13.57) 23.52 (5.23) 21.86 (5.75) 24.25 (4.86)

Social/sick-leave/other pension benefit 243 (5.4) 62.15 (16.09) 21.67 (5.95) 17.86 (7.46) 22.72 (5.55)

Partner/spouse income 627 (14.1) 66.46 (15.67) 23.56 (5.69) 19.08 (7.70) 23.77 (5.62)

P <0.001 <0.001 <0.001 <0.001

Financial strain

Yes 2857 (64.0) 66.70 (14.93) 23.22 (5.52) 19.77 (6.96) 23.70 (5.27)

No 1605 (36.0) 68.62 (14.08) 23.64 (5.34) 20.56 (6.88) 24.37 (4.87)

P <0.001 0.004 <0.001 <0.001

Smoking

Yes 536 (12.0) 66.72 (15.34) 22.83 (5.99) 20.41 (6.90) 23.45 (5.64)

No 3927 (87.9) 67.46 (14.56) 23.45 (5.37) 20.00 (6.95) 24.01 (5.06)

P 0.463 0.098 0.158 0.140

Alcohol consumption

Yes 2866 (64.2) 68.10 (13.90) 23.45 (5.33) 20.43 (6.52) 24.20 (4.87)

No 1598 (35.8) 66.11 (15.83) 23.23 (5.68) 19.36 (7.61) 23.48 (5.55)

P 0.001 0.424 0.003 <0.001

Physical activity

Yes 1898 (42.5) 69.61 (13.65) 23.96 (5.10) 21.03 (6.77) 24.62 (4.61)

No 2564 (57.4) 65.74 (15.15) 22.94 (5.67) 19.32 (6.99) 23.45 (5.44)

P <0.001 <0.001 <0.001 <0.001

Note: The correlations between BMI (body mass index) and different types of social support are not presented in this Table as both are continuous variables in order to keep the format of the Table consistent, but is presented in the text in result part.

a: e.g. child’s house.

b: e.g. worker.

c: e.g. nurse.

n = number; SD = standard deviation.

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associated with support from family. BMI was positively related to support from family (r = 0.046, P = 0.003) and negatively to support from friends (r = –0.030, P = 0.049).

Lifetime abuse and perceived social support

As shown in table 2, 34.5% of the participants experienced psychological, 11.5% physical, 5% sexual and 18.5% lifetime financial abuse, while 4.3% reported experiencing injuries.

Participants exposed to psychological, physical and financial abuse and injury during their lifetime reported significantly lower scores in total social support and in each sub-scale than non-exposed participants. This was evident among those who experienced injuries (56.2 vs. 67.8, P < 0.001). Sexual abuse was significantly associated with lower total social support and in each sub-scale, except for support from friends.

Factors associated with total perceived social support As shown in table 3, participation from Greece (P < 0.001) and Lithuania (P = 0.021), compared to Germany, was associated with Table 2 Lifetime abuse (psychological, physical, sexual, financial, injury) associated with social support (Total, from family, from friends, from significant other) among 4467 older persons aged 60–84 years in seven European countries

Variables Total sample

n (%)

Social support total mean (SD)

Support from family mean (SD)

Support from friends mean (SD)

Support from significant other mean (SD) Psychological

Yes 1543 (34.5) 64.27 (15.65) 21.82 (6.02) 19.54 (6.84) 22.91 (5.56)

No 2924 (65.5) 69.03 (13.82) 24.20 (4.94) 20.31 (6.99) 24.49 (4.81)

P <0.001 <0.001 <0.001 <0.001

Physical

Yes 514 (11.5) 63.00 (16.44) 21.21 (6.31) 19.33 (7.03) 22.47 (5.95)

No 3953 (88.5) 67.95 (14.31) 23.66 (5.27) 20.14 (6.93) 24.14 (4.99)

P <0.001 <0.001 0.006 <0.001

Sexual

Yes 222 (05.0) 62.25 (17.50) 20.65 (6.65) 19.53 (6.41) 22.16 (6.39)

No 4245 (95.0) 67.65 (14.45) 23.52 (5.35) 20.07 (6.92) 24.04 (5.05)

P <0.001 <0.001 0.449 <0.001

Financial

Yes 825 (18.5) 64.20 (15.98) 22.13 (6.18) 18.76 (7.16) 23.25 (5.66)

No 3642 (81.5) 68.11 (14.24) 23.66 (5.23) 20.34 (6.87) 24.10 (5.00)

P <0.001 <0.001 <0.001 <0.001

Injuries

Yes 193 (04.3) 59.16 (17.92) 19.55 (6.83) 18.59 (7.40) 21.17 (6.54)

No 4274 (95.7) 67.75 (14.39) 23.54 (5.33) 20.11 (6.92) 24.07 (5.03)

P <0.001 <0.001 0.004 <0.001

n= number; SD = standard deviation.

Table 3 Socio-demographics, lifestyle variables, and lifetime abuse association with social support among older adults from seven European countries in a multivariate quantile (median) linear regression analysis

Variables Total social support

B^e 95% CI

Country

Germany^a – –

Greece 3.72*^** 1.73–5.71

Italy –1.70 –3.55–0.15

Lithuania 2.21^* 0.34–4.08

Portugal –5.09^*** –6.95–3.24

Spain 1.68 –0.46–3.83

Sweden 1.40 –0.40–3.20

Female (yes) 2.56^*** 1.50–3.61

Age (group years)

60–69^a – –

70–84 –1.78^** –2.79–0.77

Living in partnership (yes) 2.81 –0.19–5.83

Living situation

Alone^a – –

Partner/spouse 4.48^** 1.39–7.58

Partner/spouse & others 3.86^* 0.61–7.12

Others 5.38^*** 3.65-7.12

Housing

Own^a – –

Other^b 0.32 –0.84–1.48

Education

High^a – –

Middle 0.38 –0.78–1.55

Low 0.79 –0.71–2.28

Still working (yes) –0.14 –2.03–1.75

Profession

Home^a - –

Blue-collar^c –1.09 –3.12–0.94

White-collar^d –0.98 –3.02–1.05

Financial support

Pension^a – –

Work 1.33 –0.83–3.50

Social/sick-leave/other pension benefit –3.61^*** –5.43–1.80

Partner/spouse income –0.60 –2.55–1.35

Financial strain (yes) –1.73^** –2.76–0.70

Smoking (yes) –1.30 –2.72–0.12

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Table 3 Continued

Variables Total social support

B^e 95% CI

Alcohol consumption (yes) 2.67^*** 1.59–3.74

Physical activity (yes) 3.19^*** 2.22–4.16

BMI 0.08 –0.04–0.19

Psychological abuse (yes) –3.13^*** –4.18–2.07

Physical abuse (yes) –0.43 –2.19–1.33

Sexual abuse (yes) –1.41 –3.60–0.78

Financial abuse (yes) 0.10 –1.20–1.40

Injury (yes) –3.02^* –5.70–0.34

R² 0.074

CI = confidence interval.

a: Reference.

b: e.g. child’s house.

c: e.g. worker.

d: e.g. nurse.

e: un-standardized coefficient beta.

*: P < 0.05.

**: P < 0.01.

***: P < 0.001.

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higher level of social support, even after controlling for other factors (e.g. demographics, abuse). Moreover, high levels of total social support were independently associated with female sex (P < 0.001), living with spouse/partner (P = 0.005), partner/spouse/others (P = 0.02), other persons e.g. daughters (P < 0.001), alcohol consumption (P < 0.001) and regular physical activity (P < 0.001). Low levels of total social support were independently associated with being from Portugal (P < 0.001), older age (P = 0.001), having social benefits as main financial source (P < 0.001), experiencing financial strain (P = 0.001), exposure to psychological abuse (P < 0.001) and injuries (P = 0.027). This model accounted for 7.4% of the variance in total social support.

Discussion

This study aimed to explore the association between lifetime abuse and level of perceived social support and to identify the correlates of perceived social support among older persons in seven European countries.

Perceived social support and lifetime abuse

Our data showed that lifetime exposure to psychological and severe physical abuse leading to injuries was independently associated with decreased social support, in accord with previous research.^19,25 Melchiorre et al.¹⁹ reported that exposure to elder abuse during the past 12 months, particularly psychological abuse, was associated with decreased social support. Also, Comijs et al.²⁵ observed that victims of elder abuse (verbal, physical, financial) scored lower on social support than non-victims. According to Elliott et al.,²⁶ victims of physical abuse were more likely to perceive themselves as more socially isolated than those who had not been abused. One could argue that older adults with experience of abuse during their lifetime, felt more uncertain and insecure about their interpersonal connections, which may have distorted their appraisal and perception of existing support. Findings from Comijs et al.²⁵ showing that victims of elder abuse adapt more avoidant and passive coping styles than non-victims could support our argument. Our results confirm that abuse prevention should be a priority.¹⁰Findings of the current study suggest that awareness of long-term negative consequences of abuse should be increased at the level of community, health care providers and policy makers.

Appropriate treatment to restore interpersonal trust should be offered to victims of abuse, in particular the elderly, as perceived social support is one of the main sources of personal care and subjective well-being⁴ while loneliness is a known risk factor for morbidity and mortality in old age.⁶

Perceived social support, country of residence and demographic/socio-economic variables

Our results revealed that the country of residence was independently associated with perceived social support. The pattern of support in each subscale differed among countries. For example, although older persons from Portugal reported lowest level of support from family, they perceived higher support from friends compared to older adults from Italy, and support from their significant other compared to older individuals from Sweden. This finding emphasizes the presence of cross-national/cultural variations in the provision of social support.²⁷Some previous studies²⁸show that across Europe, in a country-comparative perspective, older adults in the southern and central European countries were generally lonelier (due to not being married, economic deprivation and poor health) than their counterparts. Sa`nchez Rodrigues et al.²⁹suggested that cultural differences, e.g. more interdependent cultural values in Southern Europe and more independence related values in Northern Europe, influence social realities such as the exchanged social support (mainly instrumental in Spain and mainly emotional in

the Netherlands). However, in almost all countries, frequent contacts with family and social participation, were important in preventing/alleviating loneliness.²⁸ Moreover, the link between subjective well-being and satisfaction with friends and family seems strong across cultures.³⁰

Our findings suggest that national and international researchers and policy makers should take into account these cross-national/

cultural variations, differences and similarities between countries/

across Europe as they may affect cultural/societal attitude, perception and appraisal in relationships/perceived social support and even elder abuse. To be aware of these differences/similarities may help to better understanding these phenomenon, capacity building and developing more appropriate strategies and interventions addressing the real needs of citizens.

Even though men reported higher levels of perceived support than women (in total and each subscale except for friends) in the bivariate analyses, female sex was significantly associated with high social support after adjusting for other potential confounders in the multivariate analysis. Kooshair et al.³¹revealed that older men had more emotional support than older women, whereas some other studies have found that women report more support from their social networks than men do.³² Thoits has shown that although men’s social networks seem to be larger, they receive lesser support from their informal networks.³² On the other hand, it is shown that women, in contrary to men who rely in the main on their partner, usually have various sources of support.³³ Additionally, Dahlberg and McKee³⁴ found, among other factors, that male sex, having low contacts with family/friends and low levels of activity, were significant predictors of social loneliness. In view of these inconsistencies, one could argue that the value of social support may differ between women and men.

In the present study, older age (70 years and older) was associated with lower support in total and each subscale, independent from other potential confounders, which is in accordance with some previous studies confirming that recent demographic changes (e.g.

declining marriage, increasing divorce) led to a reduction of the family caring activities towards the elderly, thus, the oldest are less socially supported.³⁵

In bivariate analyses, participants in partnership and living only with their partner/spouse had higher scores in social support from family, friends and significant other. However, the multivariate analysis showed that only those who did not live alone had high levels of total social support, and being in a partnership per se was not independently associated with higher social support, implying that the effective presence of a cohabitant, apart from being a partner, daughter or caregiver, and the quality of interpersonal ties may have a crucial role in providing social support. Some studies have revealed that the quality of social support (e.g. perceived satisfaction, timing) rather than quantity can have positive effects on individuals.³⁶

Results of this study, in accord with previous research,³⁷indicated that having any type of social benefits as the main source of financial support, and suffering from financial strain were linked to low levels of social support. Economic disadvantages may influence the older persons’ social inclusion negatively, for example, by restricting their participation in leisure activities.

Alcohol use and regular physical activity were associated with high scores in perceived social support among participants in the current study. In line with our findings, Tredal et al.³⁸have shown a positive association between high levels of leisure activities and alcohol consumption among older adults. Some previous research³⁹ has also revealed that older people drink when meeting friends. According to Berkman et al.,⁴⁰ social networks form the attitudes and behaviour of the members. Social networks influence individuals by entailing norms and values,⁴⁰ which can be healthy (e.g.

physical activity) or unhealthy (e.g. drinking alcohol). Our study highlights the significance of interventions engaging older adults in social activities.

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Limitations

This study has some limitations. The generalizability of the findings should be read with caution as the data were only from large urban centres in seven European countries, and older adults with cognitive impairments were excluded from the study. Moreover, the data were based on self-reports provided by the participants without objective assessment of the responses, thus a general and/or differential mis- classification may have occurred. Furthermore, to assess lifetime abuse, the participants were asked about experiencing different types of abuse after the age of 18 which may result in recall bias.

However, traumatic events tend to not be forgotten. The cross- sectional design of the study precludes the establishment of causal links between variables. This study had a relatively low mean recruitment rate (45.2%) across countries, which may have resulted in under-estimation of elder abuse. However low recruitment rate is inevitable in a large-scale community-based study which addresses a sensitive issue such as abuse. Despite these limitations, our study provides cross-national data on various aspects of elder abuse and related factors (e.g. social support), presents a workable definition of abuse and injuries and uses validated instruments to assess the phenomenon. It also provides findings and tools that could be used by policy makers, clinicians and researchers at the European and country levels for a range of activities (e.g. monitoring abuse, awareness campaigns).

Conclusions

Overall, our results revealed that older adults exposed to lifetime psychological abuse or injuries perceived lower social support across the seven European countries included in this study. Furthermore, this study found that older old, men, those living alone and being economically devastated, perceived poorer social support. Also, the country of residence was independently/differently associated with perceived social support suggesting the presence of cultural diversity associated with perceived social support, which needs to be taken into account by national and international policy makers. Moreover, awareness about abuse and its consequences should be increased at the level of community, health care providers and policy makers.

Our findings confirm that abuse prevention should be a priority, and they emphasize the significance of detection and providing appropriate treatment/interventions (e.g. engagement in social/physical activities) for victims of abuse during their lifetime. Future studies are warranted to evaluate the coping strategies/resilience which ameliorate the negative effects of victimization on social relationships.

Funding

This work was supported by Executive Agency for Health and Consumers, currently named Consumers, Health, Agriculture and Food Executive Agency (grant number A/2007123).

Conflicts of interest: None declared.

Key points

There are long-term negative consequences of abuse on social relationships.

Victims of lifetime psychological abuse and injuries perceive low social support in later life.

Cultural diversity in social support should be considered by national and international policy makers.

Interventions engaging older adults in social activities should be provided.

References

1 Milla´n-Calenti JC, Sa´nchez A, Lorenzo-Lo´pez L, et al. Influence of social support on older adults with cognitive impairment, depressive symptoms, or both coexisting.

Int J Aging Hum Dev 2013;76:199–214.

2 Uchino BN. Social support and physical health outcomes: Understanding the health consequences of our relationships. New Haven, CT: Yale University Press, 2004.

3 Pierce GR, Sarason BR, Sarason IG. Integrating social support perspectives: working models, personal relationships and situational factors. In: Duck S, editor. Personal Relationships and Social Support. London: Sage Publications, 1990: 173–215.

4 Pinquart M, Sorensen S. Influences of socioeconomic status, social network, and competence on subjective well-being in later life: a meta-analysis. Psychol Aging 2000;15:187–224.

5 Uchino BN, Bowen K, Carlisle M, Birmingham W. Psychological pathways linking social support to health outcomes: a visit with the "ghosts" of research past, present, and future. Soc Sci Med 2012;74:949–57.

6 Luo Y, Hawkley LC, Waite LJ, Cacioppo JT. Loneliness, health, and mortality in old age: a national longitudinal study. Soc Sci Med 2012;74:907–14.

7 Muramatsu N, Yin H, Hedeker D. Functional declines, social support, and mental health in the elderly: does living in a state supportive of home and community- based services make a difference? Soc Sci Med 2010;70:1050–8.

8 Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health 2010;100:292–7.

9 Pillemer K, Burnes D, Riffin C, Lachs MS. Elder abuse: global situation, risk factors, and prevention strategies. Gerontologist 2016;56:S194–205.

10 Lacks MS, Pillemer K. Elder abuse. N Eng J Med 2015;373:1947–56.

11 Taylor BJ, Killick C, O’Brien M, et al. Older people’s conceptualization of elder abuse and neglect. J Elder Abuse Negl 2014;26:223–43.

12 Cooper C, Selwood A, Livingston G. The prevalence of older adult abuse: a systematic review. Age Ageing 2008;37:151–60.

13 Soares JF, Barros H, Torres-Gonzales F, et al. Abuse and Health Among Elderly in Europe. Kaunas: Lithuanian University of Health Sciences Press, 2010.

14 Lachs MS, Berman J. Under the radar: New York State Elder Abuse Prevalence Study, 2011. Retrieved January 2015 from New York State Office of Children and Family Services. Available at: http://www.ocfs.state.ny.us/main/reports/

Under%20the%20Radar%2005%2012%2011%20final%20report.pdf.

15 Eslami B, Viitasara E, Macassa G, et al. The prevalence of lifetime abuse among older adults in seven European countries. Int J Public Health 2016;61:891–901.

16 Chokkanathan S. Stressors social support and elder mistreatment. Aging Mental health 2015;15:1–8.

17 Melchiorre MG, Di Rosa M, Lamura G, et al. Abuse of older men in seven European countries: a multilevel approach in the framework of an ecological model. PLoS ONE 2016;11:e0146425.

18 Borson S, Scanlan JM, Brush M, et al. The Mini-Cog: a cognitive ‘vital signs’

measure for dementia screening in multi-lingualelderly. Int J Geriatr Psychiatr 2000;15:1021–7.

19 Melchiorre MG, Chiatti C, Lamura G, et al. Social support, socio-economic status, health and abuse among older people in seven European Countries. PLoS ONE 2013;8:e54856.

20 Lindert J, de Luna J, Torres-Gonzalez F, et al. Study design, sampling and assessment methods of the European study "Abuse of the Elderly in the European Region". Eur J Public Health 2012;22:662–6.

21 Zimet G, Dahlem N, Zimet S, Farley G. The multidimensional scale of perceived social support. J Pers Assess 1988;52:30–41.

22 O’Keeffe M, Hills A, Doyle M, et al. The UK study of abuse and neglect of older people. Prevalence Survey Report. London: National Centre for Social Research, 2007.

23 Straus MA, Hamby SL, Boney-McCoy S, Sugarman DB. The revised Conflict Tactics Scales (CTS 2)–Development and preliminary psychometric data. J Family Issue 1996;17:283–316.

24 Koenker R. Quantile Regression. Cambridge: Cambridge University Press, 2005.

25 Comijs HC, Penninx BW, Knipscheer KP, van Tilburg W. Psychological distress in victims of elder mistreatment: the effects of social support and coping. J Gerontol Soc Sci 1999;54:S240–4.

(7)

26 Elliott GC, Gunningham SM, Linder M, et al. Child physical abuse and self- perceived social isolation among adolescents. J Interpers Violence 2005;20:1663–84.

27 Beehr TA, Glazer S. A cultural perspective of social support in relation to occupational stress. In: Perrewe´ P, Ganster DC, Moran J, editors. Research in Occupational Stress and Well-Being. Greenwich: JAI Press, 2001: 97–142.

28 Fokkema T, De Jong Gierveld J, Dykstra PA. Cross-national differences in older adult loneliness. J Psychol 2012;146:201–28.

29 Sa`nchez Rodrigues MM, De Jong Gierveld J, Buz J. Loneliness and the exchange of social support among older adults in Spain and the Netherlands. Ageing Soc 2014;34:330–54.

30 Diener E, Oishi S, Lucas RE. Personality, culture, and subjective well-being. Ann Rev Psychol 2003;54:403–25.

31 Kooshair H, Yahaya N, Hamid TA, Abu Samah A. Gender as a moderator of the relation among social support functions and life satisfaction in older Malaysians.

J Women Aging 2014;26:22–38.

32 Thoits P. Stress, coping, and social support processes: where are we? what next?

J Health Soc Behav 1995;35:53–79.

33 Dalgard OS, Dowrick C, Lehtinen V, et al. Negative life events, social support and gender difference in depression. A multinational community survey with

data from the ODIN study. Soc Psychiatry Psychiatr Epidemiol 2006;41:

444–51.

34 Dahlberg L, McKee KJ. Correlates of social and emotional loneliness in older people: evidence from an English community study. Aging Mental Health 2014;18:504–14.

35 Heylen L. The older, the lonelier? Risk factors for social loneliness in old age. Ageing Soc 2010;30:1177–96.

36 Fernandez ME, Mutran EJ, Reitzes DC. Moderating the effects of stress on depressive symptoms. Res Aging 1998;20:163–82.

37 Weyers S, Dragano N, Mo¨bus S, et al. Low socio-economic position is associated with poor social networks and social support: results from the Heinz Nixdorf Recall Study. Int J Equity Health 2008;7:13–9.

38 Tredal I, Soares JF, Sundin O¨ , et al. Alcohol use among abused and non-abused older persons aged 60-84 years: an European study. Drugs Educ Prevention Policy 2013;20:96–109.

39 Gronkjaer M, Vinther-Larsen M, Curtis T, et al. Alcohol use in Denmark: a de- scriptive study on drinking contexts. Addict Res Theory 2010;18:359–70.

40 Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health:

Durkheim in the new millennium. Soc Sci Med 2000;51:834–57.

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The European Journal of Public Health, Vol. 27, No. 4, 692–699

doi:10.1093/eurpub/ckw246 Advance Access published on 18 April 2017

...

Binge drinking and well-being in European older adults: do gender and region matter?

Sonsoles Fuentes¹, Usama Bilal^1,2, In˜aki Gala´n^3,4, Joan R. Villalbı´^5,6,7,8, Albert Espelt^5,6,8,9, Marina Bosque-Prous^5,6,7, Manuel Franco^1,2, Mariana Lazo^2,10

1 Area de Epidemiologı´a y Salud Pu´blica, Grupo de Epidemiologı´a Social y Cardiovascular, Universidad de Alcala´ de Henares (UAH), Madrid, Spain

2 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 3 Department of Preventive Medicine and Public Health, School of Medicine, Universidad Auto´noma de Madrid,

Madrid, Spain

4 Instituto de Salud Carlos III, National Centre for Epidemiology, Madrid, Spain 5 Age`ncia de Salut Pu´blica de Barcelona (ASPB), Barcelona, Spain

6 Institut d’Investigacio´ Biome`dica (IIB Sant Pau), Barcelona, Spain 7 Universitat Pompeu Fabra (UPF), Barcelona, Spain

8 CIBER de Epidemiologı´a y Salud Pu´blica (CIBERESP), Madrid, Spain

9 Departament de Psicobiologia i Metodologia en Cie`ncies de la Salut, Universitat Auto`noma de Barcelona (UAB), Cerdanyola del Valle`s, Spain

10 Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA

Correspondence: Mariana Lazo, 2024 E. Monument Street, Suite 2-615, Baltimore, MD 21205, USA, Tel: +1 410 614 4096, Fax: +1 410 955 0476, e-mail: mlazo@jhu.edu

Background: We aimed to describe gender and region differences in the prevalence of binge drinking and in the association between binge drinking and well-being, among older adult Europeans. Methods: This is a cross-sectional study using the Survey of Health, Ageing and Retirement in Europe (SHARE) wave 4, conducted between 2011 and 2012, including 58 489 individuals aged 50 years or older. Sixteen European countries were grouped in four drinking culture regions: South, Central, North and East. We categorized drinking patterns as: never, former, no-binge and binge drinkers. We used the CASP-12 questionnaire to measure well-being. To assess the association between binge drinking and well-being, we fitted two-level mixed effects linear models. Results: The highest percentage of binge drinkers was found in Central Europe (17.25% in men and 5.05% in women) and the lowest in Southern Europe (9.74% in men and 2.34% in women). Former, never and binge drinkers had a significant negative association with well-being as compared with no-binge drinkers. There was a significant interaction in this association by gender and region. Overall, associations were generally stronger in women and in Southern and Eastern Europe. The negative association of binge drinking with well-being was especially strong in Southern European women ( = 3.80, 95% CI:

5.16 to 2.44, P value <0.001). Conclusion: In Southern and Eastern European countries the association between binge drinking and well-being is stronger, especially in women, compared with Northern and Central Europe.

Cultural factors (such as tolerance to drunkenness) should be further explored.

...