Elder Abuse and Neglect Among Rural and Urban Women

Keren Patricia Dimah, MPA, MPH Agber Dimah, PhD

ABSTRACT. Unlike urban older women, rural older women have inadequate health care and limited access to aging network services. Rural women who are part of dysfunctional family relationships are particularly disadvantaged in that they may not be able to gain access to preventive services due to isolation. Indeed, geographic and social isolation, family obligation, and caregiver stress are deemed leading contributory factors to family violence in rural settings. This study examined six forms of substantiated elder abuse, a form of family violence, among rural and urban women. Chi-square analysis and proportions were used to examine differences between 7,178 rural and 7,614 urban female victims, as were demographic characteristics of abusers. More rural women 2 were represented in physical abuse ( = 10.906; P = .001), emotional 2 2 abuse ( = 25.951; P < .001), and deprivation ( = 3.662; P = .056) categories than urban women. Urban women were represented in the passive 2 neglect category ( = 8.186; P = .004) than rural women. Approximately 88% of rural women compared to 86% of urban women were willing to accept intervention services following abuse. Abusers were
Keren Patricia Dimah is a doctoral student, Purdue University, Department of Health, Kinesiology and Leisure Studies, West Lafayette, IN 47907 (E-mail: kdimah@yahoo. com). Agber Dimah is Professor of Political Science, Chicago State University, 9501 South King Drive, Chicago, IL 60628-1597 (E-mail: adimah@csu.edu). Please address correspondence to Professor Agber Dimah. The authors are grateful to the Illinois Department on Aging for the data used in this study. Journal of Elder Abuse & Neglect, Vol. 15(1) 2003 http://www.haworthpress.com/web/JEAN 2003 by The Haworth Press, Inc. All rights reserved. Digital Object Identifier: 10.1300/J084v15n01_06

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mostly non-caregivers and offspring with no legal responsibility to the victims. Since elder mistreatment permeates every segment of society, intervention programs should be distributed equitably. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <docdelivery@haworthpress.com> Web site: <http://www. HaworthPress.com> 2003 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Abused women, domestic violence, elder mistreatment, rural older adults

INTRODUCTION Although there has not yet been a broad consensus on the definition of rurality, many acknowledge that rural or non-metropolitan elderly populations have far less access to aging network services than their urban counterparts (Alexy and Elnitsky, 1998; Clifford, Heaton, Voss, and Fuguitt, 1995; Coward, 1987; Dellasega and Fisher, 2001; Glasgow, Holden, McLauglin, and Rowles, 1993; Hornberger and Cobb-Kuckelman, 1998; Krout, 1886; 1994; 1997; Magilvy and Congdon, 2000; McCulloch and Kivett, 1995; Summer, 1999; Weinert and Boik, 1998). Some have argued that older rural women compared to their urban counterparts are more likely to be poor and have little or no access to resources necessary to enhance quality of life (Bull, 1993; Depoy and Butler, 1996; Martinez-Brawley, 1990; Richardson, 1988). In general, older rural women lack access to public transportation and housing, and may experience loss of informal support due in part to re-location of relatives to urban areas and low revenue-generating capacities of rural areas (Glasgow et al., 1993; Rowles and Johansson, 1993). Others maintain that although rural and urban older adults have similar needs, rural older adults tend to be poorer and lack access to needed services (Bushy, 1993; Craig, 1994; Hick, 1990; Krout, 1989; Pullen, Walker-Noble, and Fiandt, 2001; Rosswurm, 2001; Summer, 1999). While rural residents in general have limited access to resources, rural women who are part of dysfunctional family relationships are particularly disadvantaged in that they may not be able to gain access services due to isolation (Grama, 2000). Geographic and social isolation coupled with obligation to family are deemed contributory factors to domestic abuse in rural settings (Geissinger and Lazzari, 1993; Van Hightower and Gorton, 1998). Websdale (1997) posited that

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geographic isolation accords abusers the opportunity to prey on vulnerable women in rural areas with hardly any intervention from law enforcement agencies (Websdale, 1995; Websdale, 1997). It is also argued that little attention is paid to family violence in rural areas because of the mistaken assumption that they are less prone to violence and crime. In addition, it is postulated that rural populations hold firmly to traditional values, have supportive family relationships, and are more homogenous than urban populations (Lee and Cassidy, 1985; Websdale, 1995; Dwyer and Miller, 1990). Others have argued that some values previously ascribed to rural populations are no longer applicable (Coward, McLaughlin, Duncan, and Bull, 1994; Fitchen, 1991). For instance, earlier studies on egalitarianism among older rural couples found that household roles that were viewed as gender-specific were in reality assumed by men rather than women, especially after retirement (Dorfman and Heckert, 1988; Scanzoni and Arnett, 1987). The notion of supportive family networks and evolving egalitarianism in rural settings is seldom an indication that older rural dwellers compared to urban dwellers are free from abuse and exploitation perpetrated by family members. Indeed, some studies on rural-dwelling residents show that although they may have strong family ties, including stable marriages, they do not differ significantly from their urban counterparts in terms of dysfunction within family networks (Wilson and Peterson, 1988). In fact, it has been suggested that domestic abuse in rural settings is still considered a private matter that requires no intervention from the community or law enforcement (Grama, 2000). POTENTIAL CAUSES OF ELDER MISTREATMENT IN RURAL OLDER ADULTS Several theories have been postulated to explain family violence including elder abuse and neglect. These include social and geographic isolation, dependency on the part of the abuser, transgenerational or family cycle of violence, mental health problems such as drugs and alcohol abuse, functional ability of the victim, caregiver burden (American Medical Association, 1992; Fulmer and OMalley, 1987; Homer and Gilleard, 1990; Hwalek, Sengstock, and Lawrence, 1986; Hwalek, 1986; Pillemer and Wolf, 1986). While each of these theories explains elder mistreatment in rural areas, geographic and social isolation as well as caregiver stress seem more persuasive because they have been di-

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rectly linked to other forms of family violence among rural populations (Geissinger and Lazzari, 1993; Van Hightower and Gorton, 1998, Websdale, 1995; Websdale, 1997). Other factors such as inadequate financial and community resources may indirectly contribute to other forms of family violence in rural settings (Grama, 2000). In other words, the limitations within which family members operate, in the process of caring for aging relatives, interfere with positive relationships of rural older adults (McCulloch, 1996). In addition, personal traits of the caregiver and the care recipient may also affect the quality of care especially were both are unyielding, thus creating a conducive environment for mistreatment (Anetzberger, 2000). In fact, in a study investigating differences in caregiving network by area of residence, Dwyer and Miller (1990) found that rural caregivers reported higher mean stress levels than urban caregivers. Another cause of elder abuse extant in rural populations is geographic as well as social isolation (Pillemer and Wolf, 1986; Brandl, 2000). Some have argued that, in general, family violence is more prevalent in rural settings because perpetrators have more opportunities to commit such acts and more likely to remain unpunished for their actions (Websdale, 1995; Websdale, 1997). It has also been posited that ethnic minority and immigrant victims of domestic abuse in rural settings are often marginalized because of cultural and historical factors that prevent them from seeking intervention from relevant agencies (Grama, 2000). Although studies on elder mistreatment among rural populations in the U.S. are scarce, two exploratory international studies have identified several themes shared by abused older rural women that speak to issues of both geographic and social isolation. An Australian national study exploring the needs of abused older rural women focused on: (1) the need for rural domestic abuse victims to be believed by other family members, friends, and professionals or practitioners; (2) the need for them to receive social support; (3) the need to have access to information on domestic violence; (4) the need to receive domestic violence assistance from professionals and practitioners; (5) the need to have access to accurate legal information and representation in the judicial system; (6) the need to have access to adequate income to be less dependent on adult offspring or other relatives; and (7) the need to have access to suitable and age-appropriate emergency accommodation when abuse has occurred (Schaffer, 1999). Another study involving 33 cases of elder abuse in rural Australia found that approximately 50% of the participants had experienced emotional or psychological abuse while 33% were financially exploited by relatives. Other forms of identified abuse were neglect, physical abuse, self-neglect, and violation of

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civil rights (Cupitt, 1997). Cupitt also found that most of the community nurses and aging network staff surveyed identified respite care and short-term or long-term accommodation to be the most needed forms of services in rural areas. This study is undertaken to fill a void in the literature as well as examine differences in patterns of abuse, neglect, and exploitation between rural and urban women. Given the paucity of resources that can put tremendous pressure on family networks in rural settings, they will likely be more vulnerable to mistreatment than urban dwellers. Researchers have not yet adequately addressed various forms of family violence, including elder abuse; nevertheless, theoretical formulations thus far put forward illuminate the nature of elder mistreatment in rural settings (American Medical Association, 1992; Hwalek et al., 1996; Leifer and Smith, 1990; Anetzberger, 2000; Penhale and Kingston, 1997). This study compares how rural and urban older women differ in six forms of substantiated domestic mistreatment. The six forms of domestic abuse include physical abuse, emotional abuse, confinement, deprivation, passive neglect, and financial exploitation. The National Elder Abuse Incidence Study (National Center Elder Abuse and Neglect, 1998) describes all forms of domestic elder abuse, thus this study will not undertake that task but instead provide a brief description of each form of abuse. Differences and similarities between abusers will also be examined. METHODS Sample The study is based on an analysis of secondary data from the Illinois Elder Abuse and Neglect Program, implemented in 1989. Elder abuse victims were 60 years or older and drawn from 74 rural and 13 urban counties in Illinois. The sample embraced 7,178 urban and 7,614 rural older female victims of abuse, neglect, and exploitation. Data were collected between 1989-2001 for the purpose of tracking elder abuse and neglect in the state. Instruments The Illinois Elder Abuse and Neglect Program mandates its forty-six Elder Abuse Provider Agencies (EAPAs) to track all incoming reports

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of elder mistreatment. The statewide database called the Abuse, Neglect, and Neale, Hwalek, Goodrich, and Quinn (1996) described the Exploitation Tracking System (ANETS). The ANETS contains: (1) types of substantiated mistreatment; (2) victim and abuser demographic characteristics; and (3) indicators of each category of abuse. Other information in the ANETS includes victim and abuser living arrangement, priority rating of abuse or timeframe for responding to a report, type of reporter, status of case following substantiation, and victim and abuser legal status (Illinois Department on Aging, 1994, 2000). Hwalek (1996) described the Illinois Elder Abuse and Neglect program including data collection instruments and the state database. Elder abuse caseworkers and their supervisors play a vital role in the substantiation process by observing and documenting all the indicators, obtaining evidence from medical personnel, and interviewing abusers as well as victims concerning allegations of abuse and neglect. Under the Illinois Elder Abuse and Neglect Program, physical abuse is defined as any act that causes physical pain or injury to an older person. Indicators include burns, injuries in unusual places, strangulation, overmedication, repeated emergency room visits, and fearful behavior on the part of the older person. Emotional abuse means harassing, threatening, or intimidating an older person with the intent of preventing him or her from taking a certain course of action or merely causing emotional or mental anguish. Examples include humiliation, stalking, swearing, threatening with institutionalization or abandonment, using harsh tones, name calling, and blaming an older person for his or her problems. Confinement is defined as isolating or restraining an older person for non-medical reasons. Among the indicators are: gagging, tying to furniture, denial of visitors, using medication to restrain, and placing telephone out of reach. Passive neglect is failure on the part of an identified caregiver to provide an older person with life necessities including, but not limited to food, clothing, shelter, or medical care. Indicators include bed sores, improper hygiene, malnutrition, lying in feces, urine or food, wandering, decayed teeth, inadequate medication, animal feces in the house, inadequate heat, water, plumbing, or electricity, roach, mice, and rat infestation. Deprivation is willful denial of a dependent older persons needs such as medical care, therapeutic device, food, and shelter. Examples include not assisting with eating or toileting, not following prescribed medical care, withholding food, water, proper clothing, and medication. Financial exploitation refers to misusing or withholding an older persons resources by another person. Indicators include depleted bank account, unpaid bills, inappropriate execution of power of attorney or guardianship, sale of

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property without permission, stealing, and financial dependency on an older person (Illinois Department on Aging, 2000). DATA ANALYSIS This study examined differences between rural and urban women in their experience of elder abuse, neglect, and exploitation. Comparisons between the study groups were made using chi-square test for the six dependent variables. SPSS (SPSS, Inc., 2000) was used to examine differences in the experience of physical abuse, emotional abuse, confinement, deprivation, passive neglect, and financial exploitation. There are numerous indicators for each form of abuse, neglect, and exploitation the Illinois Elder Abuse and Neglect Program use to substantiate mistreatment. Mistreatment is substantiated based on a single or multiple indicators. RESULTS Victims Demographic characteristics of the victims are shown in Table 1. Proportionately, whites were more represented as victims of mistreatment in both rural (81.3%) and urban (94.7%) counties. Ethnically and racially, urban victims were more diverse than rural victims. The age distribution of rural victims and urban victims were quite similar. The mean age was 76.80 6.08 and 76.41 7.01 for rural victims and urban victims, respectively. Although more rural victims than urban victims had a monthly income of $100 to $499, rural victims ($503.13 308.10) had a higher mean income than urban victims ($476.30 378.14). A significant proportion of both groups were widowed, however, more rural victims (26.0% compared to 24.7% of urban victims) were married at the time mistreatment occurred. In terms of legal status, 73.4% of rural victims and 74.6% of urban victims were not under any legal authority of other persons. A majority of the elder mistreatment reports from both rural and urban counties were categorized as priority 2 (response by an elder abuse case worker within 72 hours) and priority 3 (response by an elder abuse case worker within 7 calendar days). More rural victims (78.1%) compared to urban victims (75.2%) were living in their own homes than elsewhere. Slightly more rural victims were living alone (34.3%) com-

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pared to urban victims (30.2%). More urban victims were living with their offspring (27.8%) compared to rural victims (24.7%). Even though both rural victims and urban victims accepted services after the assessment process, a slightly higher proportion of rural victims compared to urban victims consented to aging network services (87.7% and 85.8%, respectively). Differences between rural and urban women in six forms of substantiated mistreatment are shown in Figures 1-3. Statistically, the two groups differed in their experience of physical abuse, emotional abuse, passive neglect, and deprivation. More rural women than urban women experienced physical abuse (2 = 10.906; p = .001), emotional abuse (2 = 25.951; p = .0001), and deprivation (2 = 3.662; p = .056) as shown in Figures 1 to 3. On the other hand, urban women experienced passive neglect more often than rural women (2 = 8.186; p = .004). There was no statistical difference between rural victims and urban victims in substantiated financial exploitation (2 = 2.077; p = .150) and confinement (2 = .040; p = .842). Even though both urban victims (Figure 4a) and rural victims (Figure 4b) accepted services after the assessment process, a slightly higher proportion of rural victims compared to urban
FIGURE 1. A Bar Chart Showing Physical Abuse Victims by Geographic Location
Urban Victims
90 80 70 60

Rural Victims

Percent

50 40 30 20 10 0

Physical Abuse

No Physical Abuse

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TABLE 1. Demographic Characteristics of Victims by Geographical Location (N = 14,792)

Variable Race White Black American Indian Hispanic Other Age Mean () 60-69 70-79 80-89 90 + Monthly Income Mean () < 100 100-499 500-999 1000-1499 1500 + Marital Status Married Divorced Separated Widowed Not Married Unknown Legal Status None Guardian Power of Attorney Payee Unknown Priority Rating Priority l Priority ll Priority lll 836(11.6%) 3121(43.5%) 3221(44.9%) 860(11.3%) 3046(40.0%) 3708(48.7%) 5353(74.6%) 195(2.7%) 1334(18.6%) 151(2.1%) 145(2.0%) 5589(73.4%) 214(2.8%) 1544(20.3%) 125(1.6%) 142(1.9%) 1773(24.7%) 565(7.9%) 56(.7%) 3979(55.4%) 234(3.3%) 571(8.0%) 1982(26.0%) 539(7.1%) 72(.9%) 4451(58.5%) 291(3.8%) 279(3.7%) $476.30 308.10 128(1.8%) 3439(47.9%) 1228(17.1%) 1349(18.8%) 1034(14.4%) $503.13 378.14 115(1.5%) 3066(40.3%) 1689(22.2%) 1516(19.9%) 1228(16.1%) 76.41 7.01 1986(27.7%) 1754(24.4%) 1650(23.0%) 1788(24.9%) 76.80 6.08 1968(25.8%) 1868(24.5%) 1832(24.1%) 1946(25.6%) 5838(81.3%) 1237(17.2%) 10(.1%) 67(.9%) 26(.5%) 7207(94.7%) 342(4.5%) 8(.1%) 37(.5%) 20(.2%) Urban Victims (n = 7178) Rural Victims (n = 7614)

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JOURNAL OF ELDER ABUSE & NEGLECT TABLE 1 (continued)

Living Arrangement In Own Home/Apartment Relatives Home Senior Housing Short-Term Facility Homeless Other Living Status Alone With Spouse With Child (ren) With Spouse/Child (ren) With Other Relative Non-Relative Other Unknown Report Status Victim Consents to Services Victim Declines Services Victim Entered LTC Facility Victim Moved Out of Area Victim Deceased 6162(85.8%) 552(7.7%) 329(4.6%) 65(.9%) 70(1.0%) 6678(87.7%) 505(6.6%) 329(4.3%) 60(.8%) 42(.6%) 2165(30.2%) 1232(17.2%) 1997(27.8%) 280(3.9%) 794(11.0%) 415(5.8%) 274(3.8%) 21(.3%) 2612(34.3%) 1429(18.8%) 1881(24.7%) 305(4.0%) 724(9.5%) 384(5.0%) 266(3.5%) 13(.2%) 5396(75.2%) 937(13.1%) 654(9.1%) 59(.8%) 10(.1%) 122(1.7%) 5946(78.1%) 864(11.3%) 566(7.4%) 63(.8%) 11(.1%) 164(2.3%)

victims consented to aging network service (87.7% and 85.8%, respectively). Abusers Abuser demographic characteristics are shown in Table 2. Although most rural and urban abusers were males (59.8% and 57.8%, respectively), the proportion of female-to-male abusers was slightly higher in urban counties than rural counties (Figure 5). Rural abusers were ethnically and racially more homogeneous than urban abusers. Rural abusers were made up of 91.3% whites compared to 74.5% among urban abusers. There were significantly more blacks (18.1%) in urban than rural areas (4.9%). The mean age of rural abusers was 49.11 7.90 and 47.30 8.10 for abusers in urban counties, although the age distribution of the abusers was basically similar in both groups. Offspring constituted the

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FIGURE 2. A Bar Chart Showing Emotional Abuse Victims by Geographic Location

Urban Victims
60

Rural Victims

50

40

Percent

30

20

10

Emotional Abuse

No Emotional Abuse

FIGURE 3. A Bar Chart Showing Passive Neglect Victims by Geographic Location

Urban Victims
80 70 60 50

Rural Victims

Percent

40 30 20 10 0

Passive Neglect

No Passive Neglect

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FIGURE 4A. A Pie Chart Showing Resolution of Elder Abuse Investigation for Urban Victims

Accepts Services Declines Services Nursing Home Victim Moved Deceased

FIGURE 4B. A Pie Chart Showing Resolution of Elder Abuse Investigation for Rural Victims

Accepts Services Declines Services Nursing Home Victim Moved Deceased

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TABLE 2. Demographic Characteristics of Abusers by Geographical Location (N =14,792)

Variable Gender Male Female Race White Black American Indian Hispanic Other Age Mean () > 20 20-29 30-39 40-49 50-59 60-69 70-79 80 + Relationship to Victim Child Spouse Former Spouse Other Relative Housemate Former Housemate Parent Caregiver Legal Guardian In-Home Worker Other Legal Status None Guardian Power of Attorney Payee Unknown 6099(85.0%) 113(1.6%) 774(10.7%) 91(1.3%) 101(1.4%) 6483(85.1%) 120(1.6%) 819(10.8%) 78(1.0%) 114(1.5%) 3126(43.5%) 1131(15.8%) 60(.8%) 1437(20.0%) 93(1.3%) 17(.5%) 12(.5%) 317(4.4%) 19(.3%) 77(1.1%) 846(11.8%) 3017(39.6%) 1258(16.5%) 50(.7%) 1633(21.4%) 90(1.4%) 30(.4%) 13(.4%) 355(4.7%) 17(.4%) 106(1.4%) 995(13.1%) 47.30 8.10 827(11.6%) 1046(14.6%) 1127(15.7%) 710(9.9%) 890(12.4%) 596(8.3%) 1080(15.2%) 883(12.3%) 49.11 7.90 939(12.3%) 959(12.6%) 985(13.0%) 711(9.3%) 1017(13.4%) 675(8.9%) 1196(15.7%) 1123(14.8%) 5346(74.5%) 1298(18.1%) 11(.2%) 84(1.2%) 439(6.0%) 6949(91.3%) 371(4.9%) 2(.0%) 44(.6%) 248(3.2%) 4152(57.8%) 3026(42.2%) 4549(59.8%) 3065(40.2%) Urban Abusers (n = 7178) Rural Abusers (n = 7614)

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JOURNAL OF ELDER ABUSE & NEGLECT TABLE 2 (continued)

Living Status Living with Victim Not Living with Victim Caregiving Role Informal Caregiver Formal Caregiver Non-Caregiver Victim Deceased 2916(40.6%) 504(7.0%) 3758(52.4%) 70(1.0%) 2854(37.5%) 674(8.8%) 4085(53.7%) 42(.6%) 3901(54.3%) 3277(45.7%) 3853(50.6%) 3762(49.4%)

highest proportion of abusers in both rural (39.6%) and urban (43.5%) areas. Most of the abusers in both rural and urban areas had no legal authority over their victims (85.0% and 85.1%, respectively). Approximately 50% of rural abusers and 54.3% of urban abusers were living with the victims when abuse occurred. This study examined differences between rural and urban older women in their experience of six forms of domestic mistreatment (Table 3). Although most abusers were noncaregivers, a significant portion of rural abusers (37.5%) and urban abusers (40.6%) were informal caregivers. DISCUSSION This study examined differences between rural and urban older women in their experience of six forms of domestic mistreatment (Table 3). Findings have shown that demographic characteristics of abusers (Table 2) and victims (Table 1) are similar irrespective of geographic location. With the exception to financial exploitation and confinement, results show that older rural and urban women differed in their experience of physical abuse, emotional abuse, deprivation, and passive neglect. Rural women represented more of the physical abuse, emotional abuse, and deprivation cases than urban women. On the other hand, urban women represented more of the passive neglect cases than rural women. The finding about emotional abuse is consistent with a previous study, which found that emotional abuse was more prevalent among rural older women than other forms of domestic mistreatment (Cupitt, 1997). However, due to the nature of the data, it is difficult to account for specific factors responsible for more emotional abuse in rural women other than the sense of helplessness that domestic abuse victims feel due to their inability to access domestic violence prevention ser-

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TABLE 3. Differences in Six Forms of Substantiated Abuse by Geographical Location (N = 14,792)

Urban Victims (n = 7178) Physical Abuse Yes No Emotional Abuse Yes No Confinement Yes No Passive Neglect Yes No Deprivation Yes No Financial Exploitation Yes No 3213(44.8%) 3963(55.2%) 3499(46.0%) 4115(54.0%) 2.077 .150 314(4.4%) 6862(95.6%) 384(5.0%) 7230(95.0%) 3.662 .056 2019(28.1%) 5157(71.9%) 1983(26.0%) 5631(74.0%) 8.186 .004 178(2.5%) 6998(97.5%) 185(2.4%) 7429(97.6%) .040 .842 3645(50.8%) 3531(49.2%) 4186(55.0%) 3428(45.0%) 25.951 .0005 1310(18.3%) 5868(81.7%) 1553(20.4%) 6061(79.6%) 10.906 .001 Rural Victims (n = 7614) 2 P value

vices in their communities. Also, it may be inferred that rural women are more likely to disclose emotional mistreatment by family members once abusive situations are reported to elder abuse provider agencies. Put alternatively, rural women are more likely than urban women to have their reports substantiated because they may feel more comfortable discussing their situations to elder abuse caseworkers during the investigative process. In terms of physical abuse, studies show that rural women are more vulnerable, due to geographic and social isolation, coupled with inadequate support from law enforcement agencies (Websdale, 1995, 1997). Additionally, rural women may be more represented in the physical category abuse because their perpetrators have more opportunity to commit such acts as well as go unpunished for their actions (Grama, 2000). With respect to why rural women are more represented in the deprivation category than urban women, there is hardly any indication from the foregoing analysis that offer meaningful clues. Further exploration utilizing qualitative approach is apposite. Regarding passive neglect to which urban women are more vulnerable, it would not be unreasonable

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FIGURE 5. A Bar Chart Showing Abusers by Gender and Geographic Location

Male
70 60 50

Female

Percent

40 30 20 10 0

Urban Abusers

Rural Abusers

to posit that the stress associated with urban living is a likely contributory factor. Dwyer and Miller (1990) found that urban caregivers compared to rural caregivers reported higher mean levels of burden. The authors added that caregiver burden might be related to the number of hours urban caregivers spend taking care of their relatives as well as the level of impairment of the care recipients. CONCLUSION This study contributes meaningfully to an emerging area of aging even though it has one important shortcoming. The nature of the data makes it impossible to address a variety of questions that arose from the analysis. For instance, it is impossible to state with certainty why rural women are more represented in certain categories of domestic abuse than urban women. Qualitative analysis may shed additional illumination on why rural populations, who by all accounts have strong family networks, turn against their aging relatives. In terms of strengths, it is obvious that not many studies of this nature have been undertaken, especially involving rural populations with a large sample size. A number

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of policy implications are evident from the study: (1) elder mistreatment cuts across ethnic, racial and geographic boundaries; (2) geographic isolation renders women more vulnerable to abuse; (3) more often than not, offspring and other relatives are primary abusers; and (4) both rural and urban women do not differ in their willingness to accept aging network services following abuse. The most obvious implication is that, aging services and resources can no longer be concentrated in urban areas since studies have affirmed that elder mistreatment permeates every segment of society. REFERENCES
Alexy, B.B. and Elnitsky, C. 1998. Rural Mobile Health Unit: Outcomes. Public Health Nursing, 15(1): 3-11. American Medical Association. 1992. Diagnostic and Treatment Guidelines on Elder Abuse and Neglect, Chicago, IL. Anetzberger, G.J. 2000. Caregiving: Primary Cause of Elder Abuse? Generations, 46-51. Brandl, B. 2000. Power and Control: Understanding Domestic Abuse in Later Years. Generations, 39-45. Bull, N. (Ed.). 1993. Aging in Rural America. Newbury Park, CA: Sage. Bushy, A. 1993. Rural Women: Lifestyle and Health Status. Rural Nursing, 28, 197-197. Clifford, W.B., Heaton, T.B., Voss, P.R., and Fuguitt, G.V. 1995. The Rural Elderly in Demographic Perspective. In R. Coward and G. Lee (Eds.), The Elderly in Rural Society. New York: Springer Publishing Company. Coward, R.T. 1987. Poverty and Aging in Rural America Human Services in the Rural Environment, 10, 41-47. Coward, R.T., McLaughlin, D.K., Duncan, R.P., and Bull, C.N. 1994. An Overview of Health and Aging in Rural America. In R.T. Coward, G. Kulka, C.N. Bull, & J.M. Galliher (Eds.), Health Services for Rural Elders. New York: Springer Publishing Co. Craig, C. 1994. Community Determinants of Health for Rural Elderly. Public Health Nursing, 11(4): 242-246. Cupitt, M. 1997. Identifying and Addressing the Issues of Elder Abuse: A Rural Perspective. Journal of Elder Abuse & Neglect, 8(4): 21-30. Dellasega, C.A. and Fisher, K.M. 2001. Post-hospital Home Care for Frail Older Adults in Rural Locations. Journal of Community Health Nursing, 18(4): 247-260. Depoy, E. and Butler, S.S. 1996. Health: Elderly Rural Womens Conceptions. Journal of Women & Social Work, 11(2): 206-221. Dorfman, L.T. and Heckert, D.A. 1988. Egalitarianism in Retired Rural Couples: Household Tasks, Decision Making, and Leisure Activities. Family Relations, 37: 73-78.

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Dwyer, J.W. and Miller, M.K. 1990. Differences in Characteristics of the Caregiving Network by Area of Residence: Implications for Primary Caregiver Stress and Burden. Family Relations, 39: 27-37. Fitchen, J.M. 1991. Endangered Spaces, Enduring Places: Change, Identity, and Survival in Rural America. Boulder, CO: Westview Press. Fulmer, T. and OMalley, T. 1987. Inadequate Care of the Elderly: A Health Care Perspective on Abuse and Neglect. New York: Springer Publications. Geissinger, C.J. and Lazzari, M.M. 1993. Rural Women and Isolation: Pathways to Reconnection. Journal of Women & Social Work, 8(3): 277-301. Glasgow, N., Holden, K., McLauglin, D. and Rowles, G. 1993. The Rural Elderly and Poverty. In Rural Sociological Society Task Force on Persistent Rural Poverty (Eds.), Persistent Poverty in Rural America. Boulder, CO: Westview. Grama, J.L. 2000. Women Forgotten: Difficulties Faced by Rural Victims of Domestic Violence. American Journal of Family Law, 14: 173-1889. Hick, L.L. 1990. Availability and Accessibility of Rural Health Care. The Journal of Rural Health, 6, 485-506. Homer, A. and Gilleard, C. 1990. Abuse of Elderly People by their Carers. British Medical Journal, 301: 1359-1362. Hornberger, C.A. and Cobb-Kuckelman, A. 1998. A Rural Vision of a Healthy Community. Public Health Nursing, 15(5): 363-369. Hwalek, M., Sengstock, M., and Lawrence, R. 1986. Assessing the Probability of Abuse. Journal of Applied Gerontology, 5: 153-173. Hwalek, M., Neale, V., Goodrich, C. and Quinn, K. 1996. The Association of Elder Abuse and Substance Abuse in the Illinois Elder Abuse System. The Gerontologist 36:5: 694-700. Illinois Department on Aging. 1994. The Elder Abuse and Neglect Program: 1994 Annual Report. Springfield, IL: Author. Illinois Department on Aging. 2000. Illinois Elder Abuse and Neglect Program: Standards & Procedure Manual. Springfield, IL: Author. Kivett, V.R. 1988. Older Rural Fathers and Sons: Patterns of Association and Helping. Family Relations, 37: 62-67. Krout, J.A. 1994. Providing Community-based Services to the Rural Elderly. Thousand Oaks: Sage Publications. Krout, J.A. 1986. The Aged in Rural America. Westport, CT: Greenwood Press. Krout, J.A. 1989. Rural Versus Urban Differences in Health Dependence Among the Elderly Population. International Journal of Aging and Human Development, 23, 141-156. Krout, J.A., McCulloch, B.J. and Kivett, V.R. 1997. Rural Older Men: A Neglected Elderly Population. In Jordon I. Kosberg & Lenard W. Kaye (Eds.), Elderly Men: Special Problems and Professional Challenges. New York, NY: Springer Publishing. Lee, G.R. and Cassidy, M.L. 1985. Family and Kin Relations of the Rural Elderly. In R. Coward & G. Lee (Eds.), The Elderly in Rural Society. New York: Springer Publishing Company. Magilvy, J.K. and Congdon, J.G. 2000. The Crisis Nature of Health Care Transitions for Rural Older Adults. Public Health Nursing, 17(5): 336-345. Martinez-Brawley, E.E. 1990. Perspectives on Small Community: Humanistic Views for Practitioners. Washington, DC: National Association of Social Workers Press.

Keren Patricia Dimah and Agber Dimah

93

McCulloch, B.J. and Kivett, V. R. 1995. Characteristics of and Survivorship Among the Very Old: Implications for Rural Families and Service Delivery. Family Relations, 44(1): 87-96. McCulloch, B.J. 1996. Aging and Kinship in Rural Context. In Rosemary Blieszner and Victoria H. Bedford (Eds.), Aging and the Family: Theory and Research. Westport, CT: Praeger. Mercier, J.M., Paulson, L., and Morris, E.W. 1988. Rural and Urban Elderly: Differences in the Quality of the Parent-Child Relationship. Family Relations, 37: 68-72. National Center on Elder Abuse and Neglect. 1998. The National Elder Abuse Incidence Study. Washington, D.C. Neale, V. A., Hwalek, M.A., Goodrich, C.S., and Quinn, K.M. 1996. The Illinois Elder Abuse System: Program Description and Administrative Findings. The Gerontologist, 36(4): 502-511. Penhale, B. and Kingston, P. 1997. Elder Abuse, Mental Health, and Later Life: Steps Towards an Understanding. Aging and Mental Health, 1(4): 296-304. Pillemer, K.A. and Wolf, R.S. (Eds.). 1986. Elder Abuse: Conflict in the Family. Dover, MA: Auburn House. Pullen, C., Walker-Noble, S. and Fiandt, K. 2001. Determinants of Health-Promoting Lifestyle Behaviors in Rural Older Women. Family & Community Health, 24(2): 49-72. Richardson, H. 1988. The Health Plight of Rural Women. In C.A. Perales & L.S. Young (Eds.), Women, Health, and Poverty. New York: The Haworth Press, Inc. Rosswurm, M.A. 2001. Nursing Perspectives on the Health Care of Rural Elders. Geriatric Nursing, 22(5): 231-233. Rowles, G.D. and Johansson, H.K. 1993. Persistent Elderly Poverty in Rural Appalachia. Journal of Applied Gerontology, 12, 349-367. Scanzoni, J. and Arnett, C. 1987. Policy Implications from a Study of Rural and Urban Marriages. Family Relations, 36: 430-436. Schaffer, J. 1999. Older and Isolated Women and Domestic Violence Project. Journal of Elder Abuse & Neglect, 11(1): 59-77. Scott, J.P. and Roberto, K.A. 1987. Informal Supports of Older Adults: A Rural-Urban Comparison. Family Relations, 36: 444-449. SPSS, Inc. 2000. Statistical Package for the Social for the Social Sciences, Version 10.1. Chicago, IL: Author. Summer, L. 1999. Limited access: Health care for rural poor. Washington, DC: Center on Budget and Policy Priorities. Van Hightower, N.R. and Gorton, J. 1998. Domestic Violence Among Patients at Two Rural Health Care Clinics: Prevalence and Social Correlates. Public Health Nursing, 15(5): 355-362. Websdale, N. 1995. An Ethnographic Assessment of the Policing of Domestic Violence in Rural Eastern Kentucky. Social Justice, 102-122. Websdale, N. 1997. Rural Women Battering and the Justice System: An Ethnography. Thousand Oaks, CA: Sage Publications. Weinert, C. and Boik, R. 1998. MSU Ruralty Index: Development and Evaluation. In H.J. Lee (Ed.), Conceptual Basis for Rural Nursing. New York: Springer. Wilson, S.M. and Peterson, G.W. 1988. Life Satisfaction Among Young Adults from Rural Families. Family Relations, 37: 84-91.v