Background

Patterson and Malley-Morrison (Reference Patterson and Malley-Morrison2006) have maintained that older people are universally susceptible to abuse, and that this can be explained by several individual and social factors. Elder abuse among people from black and minority ethic (BME) groups in Western societies is a complex issue with five key currents. First, notions about the appropriate ‘treatment’ of older people vary cross-culturally, and notions of ‘mistreatment’ are therefore also likely to vary. Second, the general difficulties experienced by professionals in tackling elder abuse may be compounded since services and interventions lack capacity, skill and confidence in their responses to ethnic diversities (Butt and Mirza, Reference Butt and Mirza1996; Bowes and Dar, Reference Bowes, Dar and 2000). Third, family structures and communities are ethnically diverse, and the context of and explanations for abuse are likely to vary. Fourth, people from BME communities may experience additional exclusion through racism, which may compound the effects of ageism. Finally, older people from BME backgrounds are diverse and the impacts of migration, language, culture, age cohort, socio-economic status and social networks expose their heterogeneity (Iliffe and Manthorpe, Reference Iliffe and Manthorpe2004). These complexities may create variations in the form that elder abuse and neglect may take and its interpretations.

However, relatively little attention has been paid to elder abuse in BME communities, again for several possible reasons. Blakemore and Boneham (Reference Blakemore and Boneham1994: 83) made only passing reference to possible abuse in isolated Asian families; Biggs et al. (Reference Biggs, Phillipson and Kingston1995) referred to racism as an additional form of elder abuse, and note that migration may disturb family relationships and traditions, and, more speculatively, may increase the possibility of abuse. Similarly, Slater and Eastman's (Reference Slater and Eastman1999) discussion of elder abuse and responses to it did not address minority issues or possible cultural variation. Scott (Reference Scott1998) maintained that elder abuse is an issue for BME communities and discussed how some of the relevant cultural and other factors might come into play. As Bowes et al. (Reference Bowes, Avan and Macintosh2008) argued, there is a perception that for BME communities, experiences of, explanations for and service responses to elder abuse may differ from those currently available. These differences are partly to do with experiences of BME groups themselves, their particular cultural beliefs and family structures, but they are also related to wider social processes and practices, including racism, the marginalisation of minority groups and the limited ways in which practitioners and service providers have responded to diversity.

Internationally, researchers have been exploring elder abuse and cultural issues for far longer than in the UK, taking account of different cultural perspectives and experiences. Yan and Tang (Reference Yan and Tang2003), for example, analysed the literature on elder abuse in Chinese communities and linked increasing abuse with a breakdown in traditional values of filial piety. Tsukada et al. (Reference Tsukada, Saito and Tatara2001) examined knowledge and perceptions of elder abuse among Japanese older people. Others have examined familial abuse more generally, highlighting the interaction of culturally specific issues with experiences of exclusion (e.g. Harvie, Reference Harvie, Bowes and Sim1991; Samad and Eade, Reference Samad and Eade2003). However, there is debate concerning how far particular cultural factors affect experiences and understandings of elder abuse. Whereas some researchers detect connections between particular cultural ideals and particular experiences of abuse, others have concluded that the central influences are poverty and marginalisation of older people.

The diversity of the UK older population

From a public policy perspective, considering both prevention and responses, the UK demographic profile is changing. Currently, 16 per cent are aged 65 years and over, of whom 9 per cent are of black Caribbean origin, and 6 per cent of Asian Indian origin (Office for National Statistics, 2002). The largest predicted increases are among older BME people. By 2026, it is estimated that the number of older BME people in the UK will have risen tenfold, from 175,000 to over 1.8 million. Within this, there are wide local variations: for example, in London over 30 per cent of older people in the Borough of Brent and 20 per cent in Lambeth and Hackney are from BME backgrounds (Lowdell et al., Reference Lowdell, Evandrou, Bardsley, Morgan and Soljak2000). Moreover, there are differences between ethnic groups in patterns of ageing, with some groups much better off than others in terms of financial resources and health status (Bajekal et al., Reference Bajekal, Blane, Grewal, Karlsen and Nazroo2004). This growing diversity among people from BME communities reflects the great diversity among all older people (Moriarty and Butt, Reference Moriarty and Butt2004).

Overall, numbers of older people from BME groups are likely to rise (Katbamna and Matthews, Reference Katbamna and Matthews2006) but unevenly. Harris et al. (Reference Harris, Manthorpe and Lakey2008) considered some of the local implications, including:

• • People may continue to move out of inner cities, especially London, in retirement (Catney and Simpson, Reference Catney and Simpson2009), so other localities will need to develop greater competence in working with BME older people. Family networks may be less close knit and community networks less familiar.

• • Major changes in groups’ composition are emerging as more recent arrivals to the UK have different origins to those who arrived in the period 1960–1980. For example, new community languages will require a greater range of interpreters (e.g. Pashtun, Somali or Arabic) and links with different faith and cultural groups.

• • In some urban areas of England, BME communities are not ‘minority’ populations and this will be increasingly reflected in older populations. The implications of this move from numerical minority to majority are unknown. Some UK cities will become super-diverse or plural cities in which no one ethnic group comprises the majority and ‘where the country's immigrant and ethnic community can no longer be characterised by large, well organised African-Caribbean and South Asian communities’ (Barrow Cadbury Trust, 2007: 2).

• • Socio-demographic variations mean that, while there may be pockets of affluence, many BME older people face poverty in retirement, particularly those from Pakistani and Bangladeshi communities (PRIAE, 2005). Further, some BME groups are more likely to be in poor health in later life, particularly South Asian communities (DH, 2001).

The implications for adult safeguarding (the term used in the UK to respond to elder abuse and other abuse and neglect of ‘vulnerable’ adults) of these factors and changes are multilevel. The next section considers the scope of two studies that took place at the same time and are potentially ‘mutually informative’.

Studies’ scope

Surprisingly few analyses across research in the area of elder abuse, or other areas, take an in-depth comparative approach. There are, of course, many overviews of research; indeed the subject of elder abuse in the UK was for many years dominated by ‘overviews of overviews’ (Manthorpe et al., Reference Manthorpe2005) in the general absence of research. The present paper considers two studies relating to elder abuse and explores issues regarding ethnicity emerging from them. One study took age and ethnicity as its particular focus (Bowes et al., Reference Bowes, Avan and Macintosh2008); the other did not, but aimed nevertheless to be inclusive and recognised the potential importance of ethnicity and diversity among study participants and the contexts of their care and support (Mowlam et al., Reference Mowlam, Tennant, Dixon and McCreadie2007; O'Keefe et al., Reference O'Keefe2007). Bringing together and learning from the process of the studies and their findings have the potential, we suggest, to make more of the ‘sum of their parts’.

The two studies took place during the same period. The UK study of abuse and neglect of older people (National Elder Abuse Study – NEAS), funded by the charity Comic Relief and the Department of Health (DoH), sought nationally representative prevalence estimates of elder abuse and neglect (O'Keefe et al., Reference O'Keefe2007). As with many such studies, an advisory group of older people was set up to assist the research team. This group of 12 individuals advised on communications, ethics, research tools and approaches and debated findings as they emerged. Three members were from BME backgrounds and they further assisted with preparatory stages by putting the research team in touch with BME groups. One group, for example, meeting in a lunch club, debated possible ways of talking about mistreatment and managing discussion about other wider difficulties. Preparation for this survey was extensive (see McCreadie et al., Reference McCreadie2006) and further discussions with individual BME older people helped refine the survey, particularly establishing if people from diverse backgrounds were able to understand the meaning of questions and processes of informed consent.

Following the preparatory stages, 2,111 face-to-face interviews were carried out with individuals aged 66 and over, living in private households (including sheltered accommodation) in the UK between March and September 2006. The survey was extended by a qualitative study involving follow-up interviews with 36 survey participants who had disclosed abuse and were willing to be interviewed further, and three interviews with older people accessed through BME organisations who had such experiences and were willing to be interviewed (Mowlam et al., Reference Mowlam, Tennant, Dixon and McCreadie2007: i). These in-depth interviews discussed specific experiences of abuse and mistreatment, and people's decisions about seeking help or modifying the impact or risks. The reasons for recruiting further participants in the qualitative study from BME backgrounds using a different route were, firstly, that the survey did not recruit people who did not speak English; and, secondly, that there turned out to be no BME participants among the volunteer sample for interviewing. Information was supplied to staff in voluntary sector organisations to pass to BME older people whom they knew or suspected of being mistreated or neglected. If individuals agreed, their contact details were passed to the researchers. In two instances, interviews were arranged and conducted through group workers owing to the difficulty of making arrangements where individuals did not communicate in English (Mowlam et al., Reference Mowlam, Tennant, Dixon and McCreadie2007: 18), acknowledging the difficulties that this may encounter in translation and analysis.

Briefly, those interviewed reported valuing help from community organisations which they contacted about any difficulties, including mistreatment and abuse. Their use of other agencies was restricted because they were not always aware of their scope and were uncertain of their confidentiality policies. They felt that community organisations understood their culture, and for some this was particularly important for language reasons (Mowlam et al., Reference Mowlam, Tennant, Dixon and McCreadie2007: 51).

The second study addressed a significant gap in knowledge concerning the perceptions and experiences of elder abuse in BME communities in the UK (Bowes et al., Reference Bowes, Avan and Macintosh2008). Funded by the Big Lottery Fund, with the University of Stirling being the research partner of Age Concern Scotland, it considered the implications of these perceptions and experiences for service responses to elder abuse. A UK-wide audit of available services was conducted to identify examples of good practice, in which a sensitive response to elder abuse takes account of cultural diversity. The study explored the perceptions of BME people themselves about elder abuse, interviewing 58 people from BME communities in depth. Participants included a wide range of ethnic origins, representing the broad categories of African Caribbean, Chinese, South Asian and White European (e.g. Polish, Jewish, Italian) minorities. Finally, a series of focus groups involving 56 people examined the ‘fit’ or lack of it between the service providers’ ideas about good practice and those of their potential clients. The focus was very much ‘on the ground’ and at the community and service front line.

All the service providers interviewed agreed that mistreatment of older people was an issue in BME communities. They perceived good services for BME communities to be those that had good connections with local BME communities, cultural competence and involvement in multi-agency working. They noted their scarcity, and that many service providers faced challenges, including the persistence of a ‘colour-blind’ approach to service provision, whereby services were assumed to be appropriate for all; funding and resourcing problems, especially for the BME voluntary sector; and the need to continue building links with BME community organisations. Throughout, service providers tended to emphasise mistreatment within families and only a minority considered mistreatment by services or wider society. They also used ‘official’ language, such as that referring to categories of abuse, and most were familiar with adult safeguarding developments. However, there were limited connections between the BME voluntary sector, despite its significant service delivery role, and statutory adult safeguarding services.

Interviews with community members revealed a common perception that older people are not treated well in today's society, both within families and more widely. Older people in BME communities were perceived to be experiencing mistreatment and two thirds of respondents knew of specific examples, which had occurred within families and outside. The most common type of mistreatment identified was lack of ‘respect’, named by three quarters of respondents. These views and experiences differed very little between ethnic categories. A wide range of reasons given for mistreatment of older people included difficulties in families, pressure on carers and the position of older people in society, with the most likely abusers said to be family members and care workers.

Forty-six people said that an older person from a BME community experiencing mistreatment would ‘do nothing’ about it. Reasons for this included cultural factors, shame, dependency, fear, lack of alternatives and wider social exclusion, referring to people's own traditions as well as the pressures of social context. Although doing nothing was seen as the most likely response, if help was sought outside the family it was thought most likely to be sought from the BME voluntary sector, perceived as able to respond more effectively than statutory services.

Main policy messages

The Secretary of State for Health (2004) in his response to the House of Commons Select Committee Inquiry into elder abuse made an early policy commitment to this area:

It is difficult to say that either study reported here has impacted on policy or practice, However, both were cited as background to the DoH review of the multi-agency guidance on adult safeguarding in England, with Bowes et al. (Reference Bowes, Avan and Macintosh2008) being the only study mentioned in the area of ethnicity:

This led to particular efforts in the consultation to obtain views of people from BME groups through the commissioning of special events and discussion groups to consider the questions raised by the review. At the time of writing (June 2009), the government response to the consultation is awaited.

Likewise, NEAS was also cited in the review as providing part of the evidence that justified the review. NEAS had itself origins in the call from the Health Select Committee inquiry into elder abuse that more needed to be done to answer some basic questions about incidence and prevalence (House of Commons, 2004).

The NEAS findings set out more than just these bare estimates, useful as they are for professionals and agencies making use of them to develop services and to command resources (Manthorpe et al., Reference Manthorpe2008). For example, it alerted wider agencies, such as the police and community safety partnerships, about potential risk situations, notably the vulnerability of older men living alone. In particular, the NEAS survey pointed to the risks faced by disabled older people being cared for by their partners and the ways in which this situation might lead unintentionally to poor quality care and neglect as the carer partner found their responsibilities increasingly difficult and perceived, rightly or wrongly, services to be inaccessible or inappropriate. Links between carers’ organisations and groups with a focus on elder abuse have not always been strong and this point has provided both with an opportunity to rebuild connections.

Thus, while a focus on national data can be helpful, and can inform national developments, the NEAS survey exposed local diversity and variations, within and across the four nations of the UK, presenting national, regional and local interest groups with national prevalence figures that could be applied to local populations. This may be helpful at several levels and needs to interweave with findings related to local populations. The research team argued that localities can compile and debate figures that have some meaning to local populations yet are backed up by a robust national study (Manthorpe et al., Reference Manthorpe2008), answering the perennial questions of policy makers, politicians, and commissioners about whether this is a matter with which they should be concerned. Such local calculations might usefully be applied to estimating the resources necessary to respond to the needs of people who are at risk or have been affected in any locality. The NEAS study provided evidence that support for people who are labelled as ‘perpetrators’ is needed in a preventative sense because risks of abuse and neglect may be reduced though service development, capacity building and investment. As mentioned above, the study's identification of situations of neglect that involved partners/spouses with disabilities who may be increasingly failing to provide adequate care raised questions about the scale of support available to older people and the ways in which such couples might be assisted to access help. In England and Scotland, new forms of social care provision, involving personalisation and self-directed support, are emerging to meet the policy goal of early intervention and prevention (DoH, 2007) and it may be timely for prevention and safeguarding to be linked, rather than prevention being cast as a way of avoiding unnecessary hospital admission and so on. This will necessitate new ways of thinking about how to address mistreatment of all older people in both policy and practice.

There have been few attempts to link prevention of ill health with prevention of elder abuse, implicit as safety and well-being may be for physical and mental wellness, still less in the area of ethnic and cultural diversity. Watson (Reference Watson2008) argued that prevention is a process of effective listening and communication – advocating, educating and guiding individuals and communities and she portrayed cultural sensitivity as being ‘at the heart of providing effective prevention strategies within the minority ethnic populations’. New research by Bowes and colleagues, funded again by the DoH and Comic Relief, may help unravel some of these complexities in care homes for older people, both those specifically geared towards BME residents and those which provide services to people from a range of backgrounds.