Making the Invisible Visible: Ageism as a Social Determinant of Elder Abuse

E-Shien Chang, Yale University Graduate School of Arts and Sciences


Background: Elder abuse affects one in six community-dwelling older adults globally every year and can lead to great bodily and psychological harm and death. Despite elder abuse has been recognized as a global health problem, there are several knowledge gaps that have impeded the development of elder abuse prevention science. At the structural level, evidence regarding the effects of broader societal attitudes, laws and policies in enabling abusive acts toward older persons is lacking but critical for tailored preventions. At the individual level, existent research has disproportionately focused on victims rather than abusers, a problematic trend given abuser characteristics can be more predictive of elder abuse than victim information and the risk that it implies victims are the cause of abuse. The exclusive use of explicit measures further limits the understanding of the role played by implicit attitudinal determinants in the etiology of elder abuse perpetration, rendering an incomplete understanding of factors that may allow for abusers’ violence propensity in the first place. In contrast, this dissertation is the first to systematically examine whether ageism, or the systematic stereotyping and discrimination against people because of their age, could be a social determinant of elder abuse perpetration. Premised by the Stereotype Embodiment Theory and its supporting empirical research, ageism operates both at the structural and individual levels to harm health. However, the assumed link between ageism and elder abuse has not been vigorously tested. To address these knowledge gaps, this dissertation aims to 1) examine the association between structural ageism and prevalence rates of violence against older persons cross-nationally; 2) investigate the role of implicit dehumanization toward older persons – one of the most hateful age stereotypes that operate without one’s awareness – in predicting family caregivers’ risks for elder abuse proclivity; and 3) address whether and if so how levels of structural and individual ageism work together to predict elder abuse perpetration. Methods: Study 1: An ecological study that examined the association between country-level structural ageism and violence against older persons across 56 countries, by merging global survey and surveillance data from the World Values Survey, Global Burden of Diseases Study 2017, global databases from the World Health Organization, United Nations, and the World Bank. Study 2: A cross-sectional survey study that examined a previously unexplored relationship between implicit and explicit dehumanization of older persons and risks for elder abuse proclivity based on a sample of 585 family caregivers of older persons. Study 3: A theoretically-informed investigation that assessed, for the first time, whether structural ageism will trickle down through individual ageism, in the form of negative age beliefs, that in turn increase risks for elder abuse proclivity and actual abusive caregiving behavior, by presenting two study samples of individuals (n=1,580) and family caregivers (n=400). Results: Study 1: There was a wide variation in levels of structural ageism across countries. As predicted, structural ageism was significantly associated with higher prevalence rates of violence against older persons in multivariate models (β =205.7, SE=96.3, p=.03), after adjusting for relevant covariates. Sensitivity analyses supported the robustness of these findings. That is, structural ageism did not predict other types of violence and other types of prejudice did not predict violence against older persons. Study 2: As predicted, dehumanization was prevalent with 51% of the caregivers implicitly and 31% explicitly dehumanizing older persons. Also as predicted, implicit and explicit dehumanization uniquely contributed to elder abuse proclivity (OR=1.23, 95% CI=1.02-1.50, p=.03) and (OR=1.26, 95% CI=1.05-1.51, p=.01), respectively, after adjusting for relevant covariates including caregiver burden, and caregivers’ and care-recipients’ health. Study 3: As hypothesized, structural ageism and individual ageism simultaneously predicted elder abuse proclivity and perpetration. Also as predicted, individual ageism significantly mediated the association between structural ageism and elder abuse in both study samples. Conclusions: This dissertation is the first to empirically establish ageism as a key mechanism in the etiology of elder abuse perpetration. As one of the most prevalent and yet invisible forms of prejudice, findings from this dissertation research call for renewed attention to integrate ageism in developing much-needed elder abuse prevention intervention strategies. These approaches may include top-down societal-level campaigns that tackle the pervasiveness of ageism across all sectors of society, and reinforced by individual-based interventions that target both explicit and implicit negative age stereotypes. Incorporating efforts to combat ageism will hold promise to complement ongoing public health prevention programs in reducing elder abuse.