Copyright 1998 by
The Cerontological Society of America
The Gerontologist
Vol. 38, No. 5, 538-548
In order to gain a greater understanding of what "elder abuse" means to the American
public, a random sample of adults from seven culturally diverse counties in North Carolina
was interviewed. Two of the six Native American groups residing in North Carolina were
represented in the sample. The two Native American groups' responses were compared
with each other and with the views of a panel of elder mistreatment experts. There were
areas of agreement and disagreement. The relevance of the findings is discussed in
relation to research, practice, education, and policy.
Key Words: Elder abuse, Native American, Meaning, Definition, Types
Elder Abuse: Two Native American Views
Margaret F. Hudson, PhD, RN,1 William D. Armachain, BSN, RN,2
Cherry M. Beasley, MSN, RN,3 and John R. Carlson, MS4
What is the meaning of elder abuse to Native
Americans? How is it viewed by various Native American
groups? What are the commonalities and differences
of these views? What is the prevalence of elder abuse
within Native American groups? The answers to these
and other questions about elder abuse, and elder
neglect, are just beginning to be sought. But before
answers can be found, these and other relevant questions about elder mistreatment and cultural diversity
within and among racial groups have to be raised.
Despite 20 years of research and some 150 studies, little is known about elder mistreatment with regard to the various racial and cultural groups that
comprise the American public. Few studies have
looked at any aspect of elder abuse or neglect from
either a cultural or a racial perspective (Brown, 1989;
Griffin, 1994; Hudson, 1994; Longres, 1992; Maxwell
& Maxwell, 1992; Moon & Williams, 1993), and even
fewer have addressed the issue of what elder abuse
or neglect means to the American public and its racial
and cultural groups (Hudson, 1994; Hudson & Carlson,
1994; Moon & Williams, 1993). None of the research
has examined purposely what elder abuse means to
Native Americans and identified what forms of elder
abuse they recognize.
Neglect and abuse are culturally defined phenomena that reflect distinctions between acceptable and
This research was supported by a grant from the National Institute on
Aging (1 R01 AC 12575). The authors would like to also acknowledge
Elizabeth Tornquist for her editorial assistance and the staff of the Design
& Educational Support Center for their development of the figure and
tables, both of the School of Nursing at the University of North Carolina
at Chapel Hill.
department of Adult and Geriatric Health, School of Nursing, The
University of North Carolina at Chapel Hill. Address correspondence to
Margaret F. Hudson, PhD, RN, Associate Professor of Nursing, Carrington
Hall CB 7460, The University of North Carolina at Chapel Hill, Chapel
Hill, NC 27599-7460. E-mail: [email protected]
2
U.S. Public Health Service, Indian Health Service.
department of Nursing, The University of North Carolina at Pembroke.
department of Social and Administrative Systems, School of Nursing,
The University of North Carolina at Chapel Hill.
538
unacceptable interpersonal behaviors. These distinctions denote moral values, standards, and conduct.
Within complex societies such as the United States,
the perceptions of unacceptable behaviors, cultural
norms, and moral standards can vary. Therefore, it is
necessary to examine elder abuse and elder neglect
from the perspectives of various cultural groups in
order to understand the meaning of these phenomena. Also, this helps to ensure that societal definitions,
norms, and laws are sensitive to the various groups
they are intended to serve. Insensitivity to these issues
could block culturally accurate detection of elder
mistreatment, and could also keep help from being
offered and accepted.
Carson (1995) notes that the idea of the existence
of elder abuse within Native American groups may
be surprising due to their long history of respect for
elders. Basic tenets that are important in understanding Native American cultures include "a strong spiritual orientation to life and living in harmony with
nature, family and tribal interdependence and support, community responsibility and commitment to the
welfare of others, respect for the elderly, group participation and cooperation as more important than
individual achievement, an emphasis on the past
and present more than the future, nonindividualistic
competition, the unique value of children, and other
adaptive patterns that are deeply embedded in tribal
culture" such as sharing, humility, not hurting the feelings of others, and bravery (Carson, 1995, pp. 2 3 24). These tenets imply a normative prohibition against
the mistreatment of others, especially elders.
Yet, Native American cultures have recently experienced changes in status and the role of older adults
that may be risk factors for elder abuse and neglect.
These changes include poverty, the weakening of
kinship systems, acculturation stress, the financial dependency of adult children on their elderly parents,
the poor health of many Native American elders, the
negative effect of technology and progress, a value
switch from the wisdom of elders to the abilities and
The Gerontologist
ambitions of youth, young people's lack of interest
in older adults, and a change in tribal leadership
from elders to young and middle-aged adults (Carson,
1995).
Elder abuse and neglect have been found within
three Native American tribes in correlation with some
of the proposed risk factors. Maxwell and Maxwell
(1992), in their ethnographic study of the health care
delivery system on two geographically distinct Plains
Indian reservations in a western state, repeatedly encountered spontaneous comments from their informants that reflected elder mistreatment. They found that
abuse and neglect of elderly adults were considered
to be dysfunctions of the community as a whole, rather
than problems of individuals. Further, elder mistreatment was associated "with other indicators of community disorganizations such as unemployment and
substance abuse" (Maxwell & Maxwell, 1992, p.3). The
intergenerational mistreatment of older people was defined as "behavior in which a younger person violates
longstanding culturally specific norms for intergenerational relationships and the violation is remarkable to
others in the community . . . one acts contrary to role
expectations and his or her behavior is noticed"; also,
"physical elder abuse is assumed to occur when one
violates prescriptive norms governing physical relationships between generations such that the behavior of
the younger party is defined as inflicting personal harm
on a member of the older generation" (Maxwell &
Maxwell, 1992, p.6).
Brown (1989) conducted interviews on the Navajo
reservation with a random sample of 37 of the 110
members, aged 59-90 years, of the Oljato chapter.
Brown did not provide any theoretical definitions of
elder abuse or neglect; rather, he defined these constructs by 15 items in the interview schedule. Neglect
included being left alone and being denied food,
medicine, companionship, or bathroom assistance.
Psychological abuse comprised being insulted, humiliated, frightened, threatened, or treated like a child.
Physical abuse included being hit, sexually molested,
burned, or restrained. Financial abuse was represented
by having money taken. Neglect was the most common form of mistreatment found (17 cases), followed
by psychological (8 cases), financial (8 cases), and physical (6 cases) forms of elder abuse. Of the 37 elders,
25 had experienced abuse and/or neglect. The mistreatment was viewed as intentional by 11 elders and
unintentional by 8 others.
Brown (1989) concluded that although elder mistreatment was not acceptable within this cultural group,
it was partly due to cultural changes. Further, he suggested that dialogue was needed between the generations about these changes and how they affect
family interdependency. Both Brown and Maxwell
and Maxwell (1992) suggest that elder mistreatment
among Native Americans is only inflicted by younger
family members. However, the elder mistreatment
literature does not support this limited view, nor do
the taxonomy and definitions of a panel of elder mistreatment experts (Hudson, 1988, 1991).
Research has not yet addressed the question of
what elder abuse ana elder neglect mean to Native
Vol. 38, No. 5, 1998
Americans. One of these topics is addressed in the
study reported here. Elder neglect is perceived by the
authors and other experts as an interrelated but
distinct construct that should be studied separately
(Hudson, 1988,1991; Pillemer & Suitor, 1988). Therefore, it was not included in this study of elder abuse.
The purposes of the study were to measure the
public's perceptions of the meaning of elder abuse,
identify significant differences of perceptions held by
defined groups of the public, and then identify possible reasons for those differences. The specific aims
of the study were to:
1. Examine the perceptions of elder abuse held by
middle-aged and older adults residing in seven culturally diverse counties in North Carolina;
2. Identify the demographic variables that show significant correlation with specific population groups'
definitions of elder abuse, including experience
with abuse as an abused person or an abuser;
3. Compare the types of elder abuse recognized by
the public with those in the experts' taxonomy;
4. Identify the types of abusive behavior believed
by the public to warrant professional intervention;
5. Develop a taxonomy of elder abuse that incorporates both public and expert perceptions of
its components; and
6. Develop a definition of elder abuse that incorporates both public and expert perceptions of its
essential components.
This article focuses on these aims in relation to two
Native Americans tribes' perceptions of the meaning of elder abuse. A comparison of the Caucasian,
African American, and Native American groups' responses is presented elsewhere as is a comparison
of the total public sample's responses to that of the
experts sample (Hudson & Carlson, in press-a & in
press-b).
539
Methods
Design, Setting, and Sampling Process
An exploratory, descriptive design was used because
there was no previous research with these aims. The
seven North Carolina counties that were selected
represented the main regions of and the largest racial
and cultural groups in the state. The random cluster
sample was stratified by race, age, and gender in
order to permit accurate estimations of subgroup responses. Numbers of respondents were determined a
priori by power analyses. The goal of the sampling
procedure was to efficiently obtain a random sample
that would allow comparisons between racial groups,
middle-aged and older adults, and men and women
to be made with adequate statistical power. Within
each region, census block groups (CBGs) were stratified by racial composition, and CBGs were randomly
chosen within eacn racial strata. Within each chosen
CBG, respondents were invited to participate starting
at a randomly selected entry point and following the
right-hand turn rule until age and gender quotas had
been filled. The leader of one of the Native American
groups felt that the tribal roll should be the basis for
sampling their views, and thus, for that group, a random sample was selected from the roll. Because this
group was geographically concentrated, the sample
drawn was from a relatively small area similar in size
to the other counties sampled in the study. Sample
sizes were calculated to provide 80% power with
alpha = .025 for detecting moderate differences
between groups within a region (.5 standard deviations; Cohen, 1988). Based on the pilot data this corresponded to about .5 points on the 7-point scale for
most Elder Abuse Vignette Scale items. Eligible participants were community-dwelling adults aged 40
and older who understood and spoke English, and
who had functional vision, hearing, and cognition. The
202 Native Americans were representatives of two distinct tribes residing in different regions of the state.
Instruments and Data Collection Process
Because there were no instruments relevant to the
research, two instruments for measuring public perceptions of elder abuse were developed from a 1988
expert panel's taxonomy of elder mistreatment and
definitions of elder mistreatment and elder abuse
(Hudson, 1988, 1991). The instruments were pilot
tested prior to the study (Hudson, 1994; Hudson &
Carlson, 1994). The experts' taxonomy and definitions
are presented in Figure 1; the definition of elder abuse
comes from that of elder mistreatment, but is limited
to the aspects that distinguish it from elder neglect.
One instrument, the Elder Abuse Vignette Scale
(EAVS), uses a semantic differential scale to elicit participants' definitions and types of elder abuse through
behavioral examples. The second instrument, the Elements of Elder Abuse Scale (EEAS), uses a Likert format to present statements on the essential characteristics of the 1988 expert panel's 1988 theoretical
definitions of elder mistreatment and elder abuse and
taxonomy categories. The scales comprise the first
parts of a formal interview schedule. Three versions
of the scales were created in order to vary the random order of the statements so that the sequencing
of the statements would not affect participants' evaluation of them.
The interview schedule also contained participant
characteristics, aging, and abuse experience sections.
General
Level I
Elder Mistreatment
Destructive behavior that is
directed toward an older adult,
occurs within the context of a
relationship connoting trust, and
is of sufficient intensity and/or
frequency to produce harmful
physical, psychological, social,
and/or financial effects of
unnecessary suffering, injury,
pain, loss, and/or violation of
human rights and poorer quality
of life for the older adult.
Level II
Principle:
Relationship
between victim
Self-mistreatment
(Diogenes syndrome)
and other selfmistreatment)
I
Elder
mistreatment
Crime
by stranger
and perpetrator
By person in
personal/social
relationship
Level III
Principle:
How the
destructive behavior
is carried out
Level IV
Elder Abuse
Aggressive or invasive behavior/
action(s) or threats of same,
inflicted on an older adult and
resulting in harmful effects for
the older adult.
Violence involving older adults
Neglect
(omission)
I
Abuse
(commission)
By person in
professional/
business
relationship
/
Neglect
\
Abuse
-Intentional Unintentional- -Intentional Unintentional-
Principle:
Purpose motivating
the destructive
behavior
Level V
Principle:
The specific type
of destructive
behavior
Physical
Physical
Psychological
Psychological
Social
Social
Financial
Financial
Specific
Figure 1. taxonomy and definitions by Delphi panel of elder mistreatment experts (Hudson, 1988, 1991; © Margaret Hudson).
540
The Gerontologist
The first addressed pertinent demographic variables
and the latter included questions about participants'
knowledge of and experience with older adults, abuse
in general, and elder abuse specifically. The last section contained five open-ended questions on elder
abuse. The interview schedule was purposively designed to have the open-ended questions follow the
two scales. Because most people do not routinely give
a lot of thought to elder abuse, presenting the scales
first provided the respondents with the scales as
stimuli, thus allowing them to think about elder abuse
and decide what it meant from their life views.
To ensure that the wording would be clear to
participants of most educational levels, the interview
schedule was evaluated using the SMOG formula
(Lynn, 1989; McLaughlin, 1969); it requires a sixthgrade reading level. Verbal interviews were chosen so
that the high illiteracy rate among North Carolinians
would not prevent the inclusion of a wide variety of
subjects. The interviews were conducted at a pace
that was comfortable for each participant, and most
were completed in an hour. Responses were both
tape-recorded (audio) and written on the interview
schedule.
A nurse was chosen from each county to conduct
the random sampling and data collection. The nurses
were matched either by race or culture to the population to be interviewed in their counties. Formal training of these nurses was conducted on five days during
a two-week period. Training included sampling and
interviewing practice, and time was allowed for questions, feedback, and problem resolution. The nurses
assessed participants' functional (vision, hearing, and
cognition) status prior to accepting them into the study.
The aim of the analysis was to fit a linear model
to the data that would estimate the net effects of region, age, gender, education, and abuse experience
on the item responses. When class variables are properly represented by binary coding, regression estimates
of their effects are differences between means adjusted
for the effects of the other variables in the model,
and likewise, the estimated effects of the other variables are the net of the effects of the class variable
(Neter & Wasserman, 1974). This was congruent with
the purpose of the study. Complete regression results
are not given because a purpose of this article, besides describing the views of the two groups as seen
through the items, is to examine differences in responses that are due solely to membership in one tribe
versus the other. Differences in responses for the Native Americans that are attributable to age, gender,
education, and abuse experience are not presented
because, although they are certainly of interest, they
are not the focus of this article, and could not be presented and discussed within the space limitations of
the journal.
Differences in responses between the two Native
American groups to the items on the two instruments
were tested in regression models with the five proposed variables as predictors of the meaning of responses to items on the two scales. Standard regression was used for the EAVS responses, which were
untransformed, and logistic regression was used to
Vol. 38, No. 5,1998
541
model the EEAS responses, which were collapsed to
reflect agreement or disagreement with the taxonomy
and definition components. The standard errors of the
estimates were corrected for the presence of sampling clusters using the methods implemented in the
SUDAAN software package (Shaw, Barnwell, & Bieler,
1996), and the responses were weighted to reflect the
age and gender proportions of each group.
Results
Sample Characteristics
The sample was composed of 944 communitydwelling adults aged 40-93 years; 424 (44.9%) of the
participants were Caucasian Americans, 318 (33.7%)
were African Americans, and 202 (21.4%) were Native Americans. Half (n = 475, 50.3%) of the sample
(and each racial subgroup) were middle-aged adults
(40-64 years) and half (n = 469, 49.7%) were older
adults (65 years and older); half were women (476,
50.4%) and half were men (n = 468, 49.6%).
The demographic characteristics of the two Native
American groups are given in Table 1. The Native Americans were similar to the sample as a whole in that
Table 1. Demographic Comparison
of the Two Native American Groups
NAW
NAE
n
%
n
%
0-8
17
9-11
11
20
12
17.0
11.0
20.0
12.0
15.0
16.0
22
24
29
19
2
3
21.6
23.5
28.4
18.6
9.0
3
19.0
16.0
23.0
17.0
42
24
20
7
3
1
0
5
Educational Level (in years)
12
13-15
16
17-23
Missing
Yearly Income (in $)
< 10,000
10,000-19,999
20,000-39,999
40,000-59,999
60,000-79,999
80,000-99,999
100,000+
Missing
Marital Status
Never married
Married
Separated/divorced
Widowed
Missing
Regularly Helped an Elder3'*
Yes
No
15
16
9
19
16
23
17
7
2
2
14
7.0
2.0
2.0
14.0
2.0
2.9
2.9
41.2
23.5
19.6
6.9
2.9
1.0
—
4.9
52.0
26.5
12.7
—
7
53
27
13
2
71
29
71.0
29.0
59
43
57.8
42.2
8
40
2
16
80
4
18
31
1
36
62
2
3
78
3
16
0
3.0
78.0
3.0
16.0
6.9
1.9
Been Helped as an Elder 6 **
Yes
No
Missing
a
NAE: n = 100; NAW: n = 102.
NAE: n = 50; NAW: n = 50.
*No significant difference; **p = .038.
b
they were mainly of the Protestant faith and had
grown up in rural areas. They were different in that
they were generally better educated and had higher
yearly incomes than the African American subsample,
but were less well educated with lower yearly incomes than the Caucasians. The Native American-East
(NAE) group was better educated and had higher
yearly incomes than did the Native American-West
(NAW) group. Also, members of the NAW group live
in a more self-contained manner, whereas those of
the NAE group are more dispersed and intermingled
with other racial and cultural groups.
The two groups' knowledge of and experience with
elder abuse are presented in Table 2 and Table 3. A
greater number of participants from the NAE group
than the NAW group had heard of elder abuse prior
to the interview. In contrast, a greater number of NAW
group members than NAE group members reported
they had personal knowledge of an elder abuse situation. In comparison to the other two racial/cultural
groups, higher percentages of the Native Americans
(25.5%) reported having been abused at some time
during their lives and having abused someone (8.1%)
than did the Caucasians (18.0% and 6.7%) and African Americans (16.6% and 4.3%). Yet, in contrast, the
percentage of Native Americans who reported having
been abused as elders (4.3%) was lower than that of
the other two groups, whereas the percentage who
reported having abused an elder (1.5%) was lower
than that of the Caucasian Americans (3.6%) and a bit
higher than the African Americans (.3%). In comparing the two Native American groups on abuse experience, it is noteworthy that although a similar
number of both groups reported having been abused
at some time in their lives, of the 16 self-reporting
abusers, 15 were from the NAE group and only 1 was
from the NAW group. Similarly, while 2 elders from
each group reported having been abused as elders,
only 3 participants admittedto abusing an elder; all
three were from the NAE group.
Table 3. Abuse Experience of Two Native American Groups
n
Been Abused at
Some Time in Life
Caucasian Americans 76
African Americans
51
Native Americans
51
Total
178
NAE
NAW
Ever Abused
Another Person
Caucasian Americans
African Americans
Native Americans
Total
The EEAS is a 26-item Likert scale that contains one
statement for each of the expert panel's taxonomy
Table 2. Two Native American Groups'
Knowledge of Elder Abuse3
NAW
n
%
n
%
95
5
0
95.0
5.0
—
84
16
2
82.4
15.7
1.9
45
55
0
45.0
55.0
68
32
66.7
31.4
1.9
Had Heard or Read About Elder
Abuse Before Interview*
Yes
No
Missing
Personally Knew of an Elder
Abuse Situation**
Yes
No
Missing
—
2
28
13
16
57
422
308
200
930
who
who
who
who
answered
answered
answered
answered
2
10
_2_
14
2
0
6.7%
4.3%
8.1%
6.2%
of
of
of
of
416
303
198
917
who
who
who
who
answered
ansewred
answered
answered
15**
1**
8
15
4
27
O
4
7.7%
9.2%
4.3%
7.5%
of
of
of
of
207 who answered
153 who answered
92 who answered
452 who answered
2*
2*
Abused an Elder
Caucasian Americans 15
1
African Americans
Native Americans
3
Total
19
NAE
NAW
of
of
of
of
24*
27*
Abused After
Age 65
Caucasian Americans 16
14
African Americans
4
Native Americans
34
Total
NAE
NAW
18.0%
16.6%
25.5%
19.1%
3
6
8
17
5
3
3.6%
0.3%
1.5%
2.0%
of
of
of
of
419
316
195
930
3*
0*
who
who
who
who
answered
answered
answered
answered
5
2
7
14
7
0
"No significant difference; * * p = .001.
categories of elder abuse and each of the essential
characteristics of its theoretical definition of elder abuse
(Figure 1; Hudson & Carlson, 1994). The items based
on the taxonomy are indicated by a "T" and the definitional components by a " D " in Table 4.
A comparison of the two Native American groups'
responses to the EEAS items is presented in Table 4
along with a comparison of their responses to the expert panel's views. Patterns in the Native Americans'
responses include a high level of agreement between
the two groups on 22 of the 26 items, a high degree
of support for all categories of the expert panel's taxonomy of elder abuse, and also for all but one aspect
of its theoretical definition of elder abuse. In relation
to the latter, both groups indicated that one incidence
of yelling or swearing at (Item 3), slapping (Item 10),
or hitting (Item 25) an elder is sufficient to warrant
the labef of elder abuse. This view contrasts with the
expert panel's view as indicated in their definition
(Figure 1) by the phrase "of sufficient frequency and/
or intensity" (Hudson, 1988, 1991) and the expert
samples' view (Hudson & Carlson, in press-b). The Native Americans' responses clearly indicate that once is
Perceptions of Elder Abuse Based on the EEAS
NAE
NAE
NAW
Missing
%
a
NAE: n = 100; NAW: n = 102.
*p = .019; * * p = .002.
542
The Gerontologist
Table 4. Comparison of the Two Native American Groups' Responses to the EEAS
Items
NAE
NAW
% Who Fully or Somewhat Agreed3
1. Physically forcing an elder to do something that he/she does not want to do is a
form of elder abuse.
2. Verbally forcing (coercing) an elder to do something that he/she does not want
D *
to do is a form of elder abuse.
4. In contrast to pain after surgery, for example, elder abuse results in unnecessary
D *
suffering for the elderly person.
D *
5. Elders are at risk for abuse because they are seen as being physically weaker than
when they were younger.
T •
6. When an elder is harmed unnecessarily, it is elder abuse whether or not the person
intended to harm the elder.
7. Some elder abuse is committed by relatives—husbands, wives, sons, daughters,
T *
grandchildren, nieces, etc.
D •
8. Elder abuse can cause physical, emotional, social, and/or financial harm to an elder.
9. Healthy elders can be abused.
D •
D • • 10. Slapping an elder once is abuse.
D * 11. Elder abuse always includes some form of harm for the elder, such as pain, loss,
injury, suffering, etc.
T * 13. Elder abuse is doing something to an elder that harms the elder, while elder neglect
is the failure to do something one should do to help the elder.
T * 14. The use of physical force, such as slapping, hitting, or kicking, is one form of
elder abuse.
D • 16. Elder abuse is mistreatment because the behavior involved harms the elder.
T • 17. Some elder abuse is committed by friends and neighbors.
D * 18. Threatening to harm an elder is a form of elder abuse.
D • 19. Behavior that prevents the basic social needs of an elder from being met, such as
keeping the elder in one room all the time, is a form of elder abuse.
T * 2 1 . A person can abuse another without meaning to do so.
T * 22. Some elder abuse is committed by formal caregivers, such as nurse's aides, nurses,
orderlies, doctors, etc.
D * 23. In contrast to street crime by strangers, elder abuse is committed by a person the
elder knows and should be able to trust.
T *
24. Repeatedly preventing an elder's close friends from visiting without good reason
is a form of elder abuse.
T * 26. Stealing an elder's money or property is a form of elder abuse.
D *
88.63
94.70
NSD
83.25
92.66
NSD
87.77
84.27
NSD
78.54
96.00
<.001
75.20
84.25
NSD
100.00
100.00
NSD
98.56
93.50
94.99
89.93
100.00
96.61
97.60
95.02
NSD
NSD
NSD
NSD
86.29
88.89
NSD
100.00
98.45
NSD
94.73
98.87
95.98
98.00
93.84
95.39
96.93
94.21
NSD
NSD
NSD
NSD
83.90
99.04
84.96
92.20
NSD
85.82
91.02
NSD
98.00
98.52
NSD
98.56
98.45
NSD
82.04
78.78
NSD
95.58
97.68
90.09
86.41
.046
<.001
91.25
69.43
.002
92.27
95.63
NSD
% Who Fully or Somewhat Disagreed3
D
3. Yelling and swearing at an elder need to occur more than once to be called
elder abuse.
D + 12. Elder abuse does not decrease the elder's quality of life.
T + 15. The use of verbal force, such as yelling or swearing at or belittling an elder,
is not a form of elder abuse.
D + 20. In order to be abuse, the elder has to be dependent on the person who does
the abuse.
D -H- 25. Hitting an elder only .one time is not elder abuse.
NSD
Notes: D = item based on 1988 expert panel's definition of elder abuse; T = item based on 1988 expert panel's taxonomy.
"Percentages are weighted to reflect each county's proportions based on age, gender, and race.
•Agreement with item = agreement with 1998 expert panel; +Disagreement with item = agreement with 1988 expert panel;
"•Agreement with item = disagreement with 1988 expert panel; ++Disagreement with item = disagreement with 1988 expert panel.
enough, that the issue of frequency and/or intensity
with regard to behaviors deemed to be abusive seems
to be irrelevant to the determination of elder abuse.
Rather, frequency and intensity are related to the
determination of the severity of the abuse.
Four items showed significant differences between
the two Native American groups (Table 4). Although
most respondents from both groups agreed with Item
5, a larger percentage of the NAW than the NAE
group agreed with the idea that elders being seen as
Vol. 38, No. 5,1998
543
being weaker than in younger years is a risk factor
for eider abuse (p < .001). In contrast, although most
members of both groups disagreed with Items 12, 15,
and 20, a greater percentage of the NAE group disagreed than did the NAW group. The greater disparity on Item 20 may be due to the NAW group's high
degree of agreement with Item 5 (elder being seen
as weaker) and equating weakness with dependence,
or to the term dependence having different meanings
for different people.
Perceptions of Elder Abuse Based
on the EAVS
The EAVS is a 37-item semantic differential scale
that presents examples of behaviors exhibited toward
elders by persons having various roles with the elders
that connote trust (Hudson & Carlson, 1994). Examples
of the various forms of elder abuse included in the
experts' taxonomy are depicted—intentional and unintentional, domestic and nondomestic, physical, psychological, financial, and social—along with examples
of nonabusive behaviors. Group means of the Native
Americans' responses to each item were categorized
relevant to their placement on the very not abusive to
severely abusive scale in order to provide them with
practical meaning (Table 5 and Table 6) and to allow
meaningful comparisons of the tribes' responses. For
example, on Item 5 (Table 6), "In rushing past the
elder, the neighbor bumped the elder who fell down
the steps, breaking a wrist," the mean of the NAW
group's responses was 6.19, indicating that they viewed
this item as moderately abusive. In comparison, the
mean of the NAE group's responses was 4.93, indicating that they viewed this same item as borderline,
or bordering on but not actually, elder abuse. Differences in perceptions such as this, as well as congruent perceptions on other items, have pragmatic usefulness.
In contrast to the two groups' high level of agreement on the EEAS items, they exhibited some disagreement in their ratings of the more concrete EAVS
items (Table 5). The NAW group seemed to view the
items from an either/or perspective, whereas the NAE
group was more discriminating in rating the items along
the very not abusive to severely abusive scale.
Of trie 37 items (Table 6), the two groups agreed
that 28 of the items were abusive to some degree
and that 5 items were not abusive. They agreed on
Table 5. Categorization of EAVS Items
By Two Native American Groups
Number of Items per Category
on 7-Point Not Abusive
to Severely Abusive Scale
the specific rating category of 17 items, and they disagreed on the rating category of the other 20 items.
In general, these disagreements were due to the
NAW group's tendency to rate more items toward the
two ends of the abusiveness scale than did the NAE
group. The NAW group rated 27 items at higher levels of abusiveness than did the NAE group and one
item at the more extreme end of not abusive. There
was no significant difference on their ratings of the
other 9 items. In spite of these differences, most members of both Native American groups viewed most of
the EAVS vignettes as abusive.
With each of the EAVS items (Table 6), respondents
were asked, "Is professional help needed to deal with
this situation?" A majority of the NAW group felt that
such help was warranted with 31 of the vignettes—
all but one of the 32 vignettes they categorized as
abusive. Only 31.3% of this group felt that help was
needed on Item 33, which they categorized as slightly
abusive. A majority of the NAE group felt that help
was needed with 32 of the vignettes—all of the
vignettes they categorized as either abusive (28), borderline (3) or neutral (1).
Comparison by multiple regression indicated some
differences in perceptions of elder abuse held by respondents from these two Native American groups.
On the EEAS items, the variables of region, age, gender, abuse experience, and educational level accounted for 1.5% to 57.2% of the variance in the responses by the two groups. Region demonstrated a
significant effect on the greatest number of items (7),
followed by age (6), education (6), abuse experience
(4), and gender (2). On the EAVS items, these same
five variables accounted for 1.8% to 28.2% of the
variance in responses. Again, region demonstrated a
significant effect on the greatest number of items (28),
whereas the other four variables showed a significant
effect on a range of 1 to 8 items without a clear pattern of association except for abuse experience. Respondents with abuse experience were significantly
more likely than those without to rank Items 3, 4, 11,
21, 24, 25, and 29 at a higher level of abusiveness
(Table 6).
Open-Ended Responses
Not Abusive
Not Abusive
Neutral
Borderline
Total
Abusive
Slightly Abusive
Moderately Abusive
Severely Abusive
Total
NAW
NAE
4
0
1
5
4
2
3
9
3
8
21
32
6
12
10
28
All respondents were asked what the term elder
abuse meant to them. Many of the responses from
the two groups were similar. The responses given most
frequently were: hurting or harming an elder and/or
causing them pain or suffering; treating an elder wrong,
unkindly, unfairly, in an unjust manner; being mean
or cruel to an elder; and being disrespectful to or
not honoring an elder. Many respondents indicated
that elder abuse was demonstrated in physical, psychological, social, and financial ways. Further, it had
negative physical, emotional, social, and financial effects on elders. Three respondents' comments conveyed themes found in responses by members of both
groups: elder abuse is "being disrespectful of or not
honoring the elderly and their place in history"; "to
treat an elder as less than human"; and "injuries to
an elder's body, heart, mind, or spirit." Several said
Notes: Cut points based on group mean per item: not abusive
1.00-2.49; neutral 2.50-4.49; borderline 4.50-4.99; slightly
abusive 5.00-5.49; moderately abusive 5.50-6.49; and severely
abusive 6.50-7.00. EAVS scoring: 1 = very not abusive; 2 =
moderately not abusive; 3 = slightly not abusive; 4 = neither not
abusive nor abusive; 5 = slight abusive; 6 = moderately abusive;
and 7 = severely abusive.
544
The Gerontotogist
Table 6. Differences in Ranking of EAVS Items by Two Native American Groups
NAW
No.
16
Category
Item
a
SevA
The elder's body is covered with large and painful scrapes and bums
because the caregiver put the elder in hot water and scrubbed the
elder with harsh soap and a brush.
a
Mean
(SD)
P
NSD
7.00
(0.00)
SevA
6.97
(0.16)
NSD
SevA
7.00
(0.00)
SevA
6.93
(0.31)
NSD
The elder has a bruised back and hip and a broken back bone
because the home health aide pushed the elder across the room,
then shoved the elder, who fell across the foot of the bed.
SevA
7.00
(0.00)
SevA
6.89
(0.35)
.004
W>E
35
When the relative slashed at the elder with a kitchen knife, barely
missing the elder, the elder was terrified and left home to stay with
a neighbor.
SevA
7.00
(0.00)
SevA
6.84
(0.47)
.000
W>E
25
The elder has a large bruise and a cracked rib because when the
elder would not lend any money, the relative got angry and threw
a glass ashtray, hitting the elder in the chest.
SevA
6.99
(0.18)
SevA
6.78
(0.48)
.004
W>E
27
The elder has a black eye and two loose teeth and is afraid because
the relative hit the elder in the face with a fist.
SevA
7.00
(0.00)
SevA
6.75
(0.50)
.000
W>E
20
The elder is afraid and the urinary problem is getting worse because
the caregiver threatened to "beat the hell out of" the elder if the
elder did not quit wetting the bed.
SevA
7.00
(0.00)
SevA
6.73
(0.49)
.000
W>E
11
The elder is surprised and has a cut lip because during an argument
the relative slapped the elder's face and said, "Shut up!"
SevA
7.00
(0.00)
SevA
6.57
(0.59)
.000
W>E
15
Because the elder spills things, the caregiver keeps the elder in a
small bedroom all the time, and now the elder is becoming
depressed and confused.
SevA
6.95
(0.21)
SevA
6.56
(0.63)
.000
W>E
7
During an argument the relative began yelling and swearing at the
elder who became frightened and turned quickly, falling and
breaking an arm.
SevA
6.99
(0.12)
MA
6.46
(0.60)
.000
W>E
13
The elder is angry and feels cheated because the druggist has again
given the elder fewer pills than were ordered and paid for.
SevA
6.82
(0.75)
MA
6.23
(0.93)
.000
W>E
29
The elder is uncomfortable and cannot take a deep breath because
the nursing home aide puts the vest restraint on too tightly.
SevA
6.85
(0.47)
MA
6.17
(0.86)
.000
W>E
31
The elder feels helpless and lonely because the caregiver refuses to
let any of the elder's friends visit, giving the excuse that visits upset
the elder.
SevA
6.75
(0.72)
MA
6.12
(0.87)
.000
W>E
24
The elder was tense and the pain shot hurt because the nurse grabbed
the elder's arm and leg, and roughly turned the elder over before
giving the medicine.
SevA
6.88
(0.45)
MA
6.00
(0.92)
.000
W>E
2
The elder briefly felt some pain and heard a loud ringing when the
friend pushed the hearing aid into the elder's ear and said, "You are
going to wear this because I am tired of having to yell so you can
hear me."
SevA
6.79
(0.54)
MA
5.95
(1.10)
.000
W>E
1
The elder feels helpless and afraid because the caregiver repeatedly
threatens to put the elder in a nursing home if the elder does not
behave.
SevA
6.51
(0.77)
MA
6.02
(1.01)
.009
W>E
36
The elder started to cry when the caregiver slapped the elder's hand
and said, "Stop playing with your food and eat."
SevA
6.82
(0.56)
MA
5.77
(1.03)
.000
W>E
22
The elder feels childish and belittled because the caregiver spanked
the elder's bottom and said, "Now you stop that or you'll hurt
yourself."
MA
6.43
(1.11)
MA
5.88
(1.19)
.002
W>E
14
The elder was startled when the caregiver grabbed the elder's
shoulders and shook the elder while saying, "Now stop that!"
SevA
6.93
(0.34)
MA
5.66
(1.14)
.000
W>E
21
Now the elder is quiet, withdrawn and confused because the doctor
ordered a pill to stop the elder from bothering the nurses by ringing
the call bell frequently.
MA
6.14
(1.47)
MA
5.74
(1.35)
NSD
3
The elder has many bruises, internal injuries, and a broken arm
because the relative beat the elder with punches and kicks.
7.00
Category
7.00
(0.00)
23
SevA
Mean
(SD)
SevA
9
The elder is very upset and has cuts and tears in the private area
because the caregiver forced the elder to have sex.
NAE
Vol. 38, No. 5, 1998
545
(0.00)
(Table continued on next page)
Table 6. Differences in Ranking of EAVS Items by Two Native American Groups (Continued)
NAE
NAW
Item
No.
37
Category
The elder was surprised when the home health aide pinched the
elder's arm to get the elder's attention.
SevA
The elder is angry and hurt and feels trapped because the relative
charges the elder $20 to drive the elder to every doctor's appointment.
MA
The elder is ashamed and anxious because the caregiver threatened
to put diapers on the elder "just like a baby" if the elder does not
quit wetting everything.
MA
When calling the elder, the relative usually does not let the phone
ring long enough before hanging up; thus in rushing to answer the
phone, the elder tripped and fell.
SevA
When the neighbor who took the elder to the grocery store kept
telling the elder to hurry up, the elder became flustered and stumbled.
MA
The elder is ashamed and hurt because, while working together to
fix a cabinet, the relative said, "Can't you do anything right anymore?
I asked you to push and you pulled!"
8
5
Mean
(SD)
Category
Mean
(SD)
P
5.59
(1.21)
W>E
5.48
(1.22)
W>E
5.39
(1.22)
W>E
5.20
(1.17)
W>E
5.29
(1.10)
W>E
6.55
(1.02)
MA
6.41
(0.80)
SliA
6.28
(1.35)
SliA
6.54
(0.88)
SliA
6.18
(1.09)
SliA
MA
5.94
(1.14)
SliA
5.21
(1.09)
.000
W>E
The elder feels angry and resentful because without talking with the
elder about it, the doctor told the elder's relatives to sell the elder's
car and not let the elder drive anymore.
SliA
5.48
(1.81)
SliA
5.37
(1.40)
NSD
In rushing past the elder, the neighbor bumped the elder who fell
down the steps, breaking a wrist.
MA
6.19
(1.38)
B
4.93
(1.11)
W>E
The elder is angry because when the elder refused to take the usual
three o'clock pill, the relative began crying and angrily said, "You are
so stubborn that it is impossible to take care of you. Now take this
pill like you are supposed to."
MA
6.38
(1.40)
B
4.80
(1.23)
W>E
The elder wonders why the relative suddenly stomped out of the
room slamming the door, after the elder refused to change out of
dirty clothes.
SliA
5.35
(1.81)
B
4.79
(1.08)
W>E
34
The elder is a bit disgusted because while talking with a friend, the
elder got sprayed in the face with some spit.
B
4.58
(1.60)
N
4.02
(1.25)
33
The elder feels insulted upon hearing the nurse say, "I just love caring
for these old folks. They are all such sweet, cute little 'ole things!"
SliA
5.10
(1.46)
N
3.23
(1.74)
The elder has a large bruise on the arm because when the elder
started to fall down, the nurse grabbed the elder by the arm.
NA
1.93
(1.62)
NA
2.23
(1.42)
The elder felt mixed up, for when the elder angrily said that the
relative was late, the relative calmly replied that they would not be
late for the doctor's visit, the elder was just mistaken about the time.
NA
1.53
(1.14)
NA
2.31
(1.53)
17
When the elder couldn't think of the name of a friend, the caregiver
said, "Now take your time and the name will come back to you."
NA
1.18
(0.86)
NA
1.30
(0.69)
NSD
32
The elder was excited and happy when the relative took the elder
for a ride to visit the elder's old home place.
NA
1.00
(0.00)
NA
1.01
(0.08)
NSD
28
26
30
18
19
6
12
10
4
.000
.000
.000
.000
.000
.000
.000
.021
NSD
.000
W>E
NSD
.015
E>W
"Categories: NA = not abusive; N = neutral; B = borderline; SliA = slightly abusive; MA = moderately abusive; SevA = severely
abusive.
b
W>E = West higher abuse severity than East.
the existence of elder abuse "hurt their [own] hearts."
Only a few respondents included elder neglect (acts
of omissions) as a form of elder abuse; most distinguished neglect from abuse and felt both were "not
right" or "bad things."
Discussion
The participants from the two Native American
groups provided three very clear messages. First, most
546
of the behaviors exhibited toward elders in the
EAVS were not acceptable, with a majority being
labeled as elder abuse. They felt that elders should be
treated with respect and honor, and that they should
be cared about and cared for. The Native American
respondents rated more of the EAVS vignettes as
abusive than did their Caucasian and African American counterparts (Hudson & Carlson, in press-a). This
indicates that the historical norm of respect for
elders (Carson, 1995) continues to hold true for these
The Gerontologist
Native Americans. Yet, the finding that two elders from
each group had been abused after age 65 may be an
indication that this norm is not an adequate protection against elder abuse. If this is the case, Brown's
(1989) suggestion that intergenerational dialogue in
Native American groups about cultural change and its
ramifications may be helpful in preventing elder abuse
in racial and cultural groups that have historically revered and protected their elderly members. In addition, it might be helpful to share this study's findings
about elder abuse by planning educational programs
with leaders of various Native American groups. Further research is needed to address the specifics of
elder abuse within Native American groups and the
efficacy of normative prohibition.
Second, when elder abuse occurs, most of the Native American respondents indicated that professional
help is warranted. Because respondents were not
asked to specify the type of professional help that
seemed warranted in each vignette, whether they
would seek or be accepting of such help, or from
whom they would prefer to accept help, this is an
area of inquiry that deserves further attention.
Third, most respondents from both Native American groups showed strong support for all aspects
of the expert panel's taxonomy of elder abuse and
also for all but one aspect of the panel's theoretical
definition of elder abuse (Hudson, 1988, 1991). In
contrast to the findings of Maxwell and Maxwell
(1992) and Brown (1989), these respondents did not
limit elder abuse to familial abuse by younger persons. Their main area of disagreement with the definition of elder abuse was the experts' decision that
the designation of elder abuse is partly dependent
on it occurring with "sufficient frequency and/or intensity." Rather, these respondents felt that one occurrence of any of the behaviors designated as elder
abuse was adequate to warrant that label.
The Native Americans' responses to the EEAS and
EAVS items indicate that the expert panel's taxonomy, theoretical definition of elder abuse, and operational example behaviors are acceptable. However,
with regard to research, practice, education, and policy
making, it should be remembered that some degree
of cultural diversity or heterogeneity exists within racial groups (Carson, 1995). For this reason, it is reasonable to expect some diversity of moral views on
interpersonal behavior. Prior to the further development of the taxonomy and definitions, their acceptability and sensitivity must be tested with other groups
of Native Americans and with other cultural and racial groups.
Both Native American groups designated as abusive all of the example behaviors given in Brown's
definitions, plus examples of social elder abuse and
additional examples of physical, psychological, and financial abuse (Hudson, 1988, 1991). These findings
are also congruent with their longstanding "harmony
ethic" of maintaining peaceful interpersonal relationships by not giving offense and the belief that sharing
one's self and possessions with others (Loftin, 1983)
is acceptable, whereas taking another's possessions is
not. These findings also have significance in that they
Vol. 38, No. 5,1998
suggest that the detection of elder abuse must be
culturally sensitive. Therefore, health care and human
services personnel who work with Native Americans
must be knowledgeable about the groups' cultural
norms. Cultural taboos against mistreating elders
could make detection very difficult, yet erroneous labeling of situations as elder abuse could destroy trust
and professionals' ability to help. When assessing
suspected elder abuse, it is useful to know how that
Native American group defines elder abuse and also
to ask the elder involved if he or she feels abused.
Researchers and educators need to be sensitive to and
respectful of cultural diversity in perceptions of elder
abuse.
The differences exhibited by these two groups of
Native Americans provide important clues relevant to
research, practice, education, and policy. Although the
majority of both groups had heard of elder abuse prior
to being interviewed, a greater percentage of the
NAW group had not heardf of it. mis finding may indicate that more members of the NAW group may
benefit from education about elder abuse.
Of the 16 persons who said they had abused someone during their lives, 15 were from the NAE group
and only 1 was from the NAW group, and all 3 of
the self-reported elder abusers were from the NAE
group. Because an almost equal number of participants from both groups reported that they had been
abused at some time in their lives and that they had
been abused as elders, these findings seem almost
contradictory. While it is plausible that people are
more likely to report being abused than being an
abuser, it is also possible that the NAW group underreported their experience as abusers, either out of
ignorance or fear of their culture's taboo against mistreating elders. It is also possible that this group did
not abuse elders, and that they included in their definition of elder abuse crime, racism, or mistreatment
of elders by persons whom the elders either did not
know or trust. This explanation seems plausible, especially in light of the fact that a greater percentage of
Native Americans than Caucasians or African Americans reported experience as abused persons and
abusers, yet fewer reported being abused as elders
and having abused elders than did participants in the
other two racial groups. Speculation about these differences indicates how little researchers know about
elder abuse within Native American groups and shows
that further research is needed on the subject.
The two Native American groups also differed in
their responses to the EAVS items. The NAE group
made finer distinctions among the vignettes than did
the NAW group. This may be due in part to the difference in the educational levels of the two groups. It
might also be that more of the members of the
geographically self-contained group (NAW) retained
their historical values concerning elders, while the more
dispersed NAE group members have intermingled with
other cultural groups and picked up some of their values.
Once again, more research is needed.
The effects of our five main variables accounted
for a small percentage of the variance in participants'
responses, thus leaving a large percentage unaccounted
547
for in terms of identified variables. However, the significance of the region variable in the multiple regression analysis with respect to EEAS and EAVS responses
warrants further study. This variable may be a reflection of differences in perceptions of elder abuse
among persons of the same race in different areas of
the state who may have different cultural backgrounds
and values. This finding is also a reminder of the
heterogeneity of persons who seemingly are of the
same race and that race does not equal culture.
This article examined two Native American groups'
views of elder abuse in light of an expert panel's initial work. This research in conjunction with Carson's
(1995) theoretical discussion indicates that much more
work needs to be done before researchers have a
sound understanding of elder abuse from the Native
American point of view. First, further research is
needed on the definition of elder abuse by Native
Americans. Then, the prevalence, antecedents, risk
factors, and consequences of elder abuse in Native
American groups need to be explored. Only then can
appropriate education, prevention, and treatment strategies, based on culturally inherent protective factors
(Carson, 1995), be planned by and with members of
various Native American groups.
References
Brown, A. S. (1989). A survey on elder abuse at one Native American
tribe. Journal of Elder Abuse & Neglect, 7(2), 17-37.
Carson, D. K. (1995). American Indian elder abuse: Risk and protective
factors among the oldest Americans. Journal of Elder Abuse & Neglect, 7(1), 17-39.
Cohen, J. (1988). Statistical power of the behavioral sciences (2nd ed.).
Hillside, NJ: Lawrence Erlbaum Associates.
Griffin, L. W. (1994). Elder maltreatment among rural African-Americans. Journal of Elder Abuse & Neglect, 6(1), 1-27.
Hudson, M. F. (1988). A Delphi study of elder mistreatment: Theoretical definitions, empirical referents and taxonomy. Dissertation Abstracts International (University Microfilms No. 50, UMI PUZ8909673).
Hudson, M. F. (1991). Elder mistreatment: A taxonomy with definitions
by Delphi. Journal of Elder Abuse & Neglect, 3(2), 1-20.
Hudson, M. F. (1994). Elder abuse: Its meaning to middle-aged and
older adults—Part II: Pilot results. Journal of Elder Abuse & Neglect,
6(1), 5 5 - 8 1 .
Hudson, M. F., & Carlson, J. R. (1994). Elder abuse: its meaning to
middle-aged and older adults—Part I: Instrument development. Journal
of Elder Abuse & Neglect, 6(1), 29-54.
Hudson, M. F., & Carlson, J. R. (in press-a). Elder abuse: Its meaning to
Caucasians, African Americans, and Native Americans. In T. Tatara
(ed.), Understanding elder abuse in minority populations. Philadelphia, PA: Taylor & Francis.
Hudson, M. F., & Carlson, J. R. (in press-b). Elder abuse: Expert and
public perspectives on its meaning. Journal of Elder Abuse & Neglect.
Loftin, J. D. (1983). The "harmony ethic" of the conservative eastern
Cherokees: A religious interpretation. Journal of Cherokee Studies,
8(1), 40-43.
Longres, J. F. (1992). Race and type of maltreatment in an elder abuse
system. Journal of Elder Abuse & Neglect, 4(3), 61-83.
Lynn, M. R. (1989). Readability: A critical instrumentation consideration.
Journal of Pediatric Nursing, 4(4), 295-297.
McLaughlin, C. H. (1969). SMOG grading: A new readability formula.
Journal of Reading, 12, 639-646.
Maxwell, E. K., & Maxwell, R. J. (1992). Insults to the body civil: Mistreatment of elderly in two Plains Indian tribes. Journal of CrossCultural Gerontology, 7, 3-23.
Moon, A., & Williams, O. (1993). Perceptions of elder abuse and helpseeking patterns among Asian American, Caucasian American, and
Korean American elderly women. The Cerontologist, 33, 386-395.
Neter, J., & Wasserman, W. (1974). Applied linear statistical models.
Homewood, IL: Richard D. Irwin, Inc.
Pillemer, K. A., & Suitor, J. J. (1988). Elder abuse. In V. B. VanHassell,
R. L. Morrison, A. S. Bellack, & M. Hersen (eds.), Handbook of
family violence. New York: Plenam.
Shaw, B. T., Barnwell, B. G., & Bieler, C. S. (1996). SUDAAN user's
manual (Version 6.10). Research Triangle Park, NC: Research Triangle Institute.
Received April 6, 1998
Accepted August 12, 1998
548
The Gerontologist