Introduction

Population aging has become an achievement, occurring especially due to reductions in fertility rates and increased life expectancy¹. According to projections, the world's older adults population will increase between 2015 and 2050 from 12% to 22%, corresponding to 2 billion individuals². At a national level, according to the Brazilian Institute of Geography and Statistics (IBGE), between 2015 and 2050 the older adults population will be 66,265,645, with an aging rate from 37% to 142%³.

As aging is a dynamic process, there are several physiological and pathological changes, such as decreased visual and hearing acuity, difficulty in locomotion, heart and respiratory diseases, among others. These factors predispose the older adults to changes in mental and physical capabilities and functionalities, increasing the chance of vulnerabilities, such as violence^4)-(5.

Violence includes embarrassment, use of physical superiority, power struggles, aggression, intra-family and community, economic and psychological abuse, among others. Such facts can lead to financial, mental and emotional losses for the victim and their family, health system expenses, reduced quality of life and death⁶.

Violence against the older adults, according to the World Health Organization, can be defined as any action, single or repeated, or even omission, in a relationship with an expectation of trust, causing harm or distress to the older adults. The literature points to six types of violence against older adults: physical, sexual, psychological, financial/economic, institutional, abandonment and neglect⁷.

According to the WHO, one in every six older adults in the world has experienced violence⁵. In Brazil, in 2019, violence against the older person was the second most reported cause of rights violations, around 48,446 cases (30%)⁸; it is estimated that 5% to 10% of the older population suffers violence^8),(9.

According to data from DATASUS in Brazil between the years 2011 - 2019, the region that achieved the highest rate of violence against the older adults was the Southeast with 10,874 cases, while the Northeast region had a milestone of 5,431 cases, ranking second and third place we have the central west region with 5,218 cases, in the south region 3,562 cases were recorded, and the last place is the north region with 1,084 cases.

Despite being a public health problem, violence against the elderly is still camouflaged due to the proximity of the victim to the aggressor, such as family members or health workers⁸, with 90% of the incidents occurring in the older adults’ home, 51% of the aggressors being their children and 69% occurring daily, signaling rights violations^5),(8),(9.

The older adults most vulnerable to violence are women¹⁰, aged between 76 and 80 years⁸, with financial and physical dependence. Furthermore, they have health problems, such as mental illnesses, low education, live with younger people and are socially isolated^11),(12.

The importance of early report of cases of violence by the health service is noted to also identify risk factors and take appropriate measures in the face of suspected and confirmed cases; in addition to raising awareness among the population¹³.

The profile identification and factors associated with this phenomenon in the older population enables appropriate health actions for prevention and control. There is still little research on the prevalence of violence against the older adults in Brazilian capitals. Therefore, the question arises: What are the characteristics of violence against older adults in Brazil according to the capitals of Brazil? It is believed that violence against the older person in our country is prevalent, more frequent in older adults with physical, economic and social vulnerabilities.

Therefore, the present work aims to analyze the profile of violence against the older adults in Brazil according to data from Brazilian capitals in the period between 2011 and 2019, emphasizing the characteristics of the victims, the aggressors and the violence.

Materials and Methods

This is a descriptive ecological epidemiological study. Information was collected about violence against the older adults in Brazilian capitals, totaling data from 26 (twenty-six) capitals and 1 (one) Federal District; the information was obtained from the Ministry of Health's DATASUS database, an online health information system consulted on the website: http://www.datasus.gov.br¹⁴. The population was made up of older adults with reported cases of violence (confirmed or suspected) between 2011 and 2019. The choice of beginning in 2011 was due to the landmark of violence as a compulsory report problem and the deadline of 2019 was the last year in which the data were updated in the Disease Report Information System (SINAN), within DATASUS, until the data collect. The dataset was stored in the Dryad Digital Repository DataSet¹⁵.

Results

It is observed that in population terms, during the period studied, there was a higher prevalence offemale victims (57.30%), white color/race (47.32%). As for the victims' education, the main level was incomplete 1st to 4th grade (30.02%), according to Table 1.

The main type of violence was physical (41.92%), the place of greatest occurrence was at home (77.32%), violence was repeated in 63.80% of cases and in the majority (66.87%) there was no suspected of alcohol consumption (Table 2).

In Table 3 we present the main characteristics of the aggressor of violence against the older person. The main relationship between aggressor-victim was that of son/daughter (41.55%), and in relation to the life cycle of this aggressor, the main one was the adult (70.32%).

It is observed that in the prevalence of violence per year according to the capitals of Brazil, in 2019 there were more reports, 5.140 cases, followed by 2018 with 4.707, and 2017 with 4.286, as shown in Figure 1. Figure 2 shows the capitals of Brazil, represented by the name of their states, with the absolute frequencies of interpersonal violence. The highest values obtained were in São Paulo (SP) with 5.279 reports, followed by Campo Grande (MS) with 3.735 and Rio de Janeiro (RJ) with 3.456. The capitals with the lowest reported values were Macapá (AP) with 27, Porto Velho (RO) with 52 and Florianópolis (SC) with 108 reported cases.

Source: Ministry of Health/ SVS - Notifiable Diseases Information System - Sinan Net

Figure 1 Number of reports of violence against older adults per year, according to the sum of values for Brazilian capitals, 2011-2019 

Source: Ministry of Health/ SVS - Notifiable Diseases Information System - Sinan Net

Figure 2 Number of reports of interpersonal violence against older adults by Brazilian capital as representatives of Brazilian states, 2011-2019 

Discussion

The research identified a higher prevalence of female victims, white color/race, with incomplete 1st to 4th grade education. The main type of violence was physical, the place of greatest occurrence being the residence, indicated with repeated episodes and unrelated to alcohol consumption. Regarding the aggressor, the main one was the son/daughter, also showing a high prevalence of unknown aggressors; Furthermore, the aggressors were adults. Regarding reports per year in the capitals, 2019 had more cases, with the capital São Paulo having the highest values.

In this study, there was a prevalence of violence against older women, which may be related to gender/ sociocultural issues¹⁶. The literature reports a correlation between violence against the older adults and the feminization of old age, that is, there are older women than older men, explained by differences in life expectancy between the sexes^17),(18. Despite their longevity, women have more comorbidities, lower quality of life and greater dependence on caregivers, increasing the chance of violence^18),(19. Thus, although women live longer, they become more prone to abuse, contributing to the sociocultural aspects of gender and aging^16),(19.

Regarding the race of the victims, the study characterized a higher prevalence of the white race, probably related to the characteristics of the Brazilian population, the majority of which self-declare as white, 42.7% of the population, 45.1% of mixed race and 8.9% of black. Furthermore, this issue may be related to the process of inequality in access to information and studies for the black population²⁰.

Regarding education, there is a prevalence of incomplete grades 1st to 4th; however, there is no agreement in the literature between this level of education and violence against the older adults¹³. In Brazil, there is a greater distribution of older adults with no education or with incomplete elementary education, which could justify²¹. Even without consensus, literature justifies education in terms of older adults’ perception of violence suffered, that is: the higher the education, the lower the prevalence of violence^22),(25. According to the literature, it is possible to correlate low education with dependence in activities of daily living, a risk factor for abuse²⁰. There are also studies that link low education with income: the lower the education, the lower the income and the more prone to violence^12),(24.

Regarding the type of violence, physical violence stands out, which can be justified because it is more noticeable, that is, as it causes visible injuries, such as bruises, it becomes easier for another person to identify it^26),(27.

The study presented residence as the place of greatest occurrence, which is consistent with national literature. The older person, due to the aging process, such as dependence on certain activities, tend to stay at home longer, configuring a risk factor^21),(27),(29. Furthermore, it is possible to correlate the higher prevalence of cases involving older women and the cases of abuse occurring at home, since in the national culture, women spend more time at home, with less external contact^23),(30.

Repeated violence, listed as prevalent, is not explained in the literature, but studies assume explanations, such as failure to report the aggressor - who in most cases is known - due to fear of loss of connection, fear, shame, etc., causing the violence to continue^31),(33. In this way, whoever identifies the abuse becomes, in most cases, an outsider, especially because the older person seeks to justify the abuse suffered and does not identify it as violence³¹. Due to the proximity to their aggressor being linked to repetition, many older adults are unable to perceive the violence^16),(27),(31. Thus, repetition demonstrates that behind each reported case of violence, there were several unreported episodes^33),(34.

Regarding the aggressor, it is observed that children are the most prevalent in this study, as in the literature. This can be justified by changes in family structures, such as children separating from their spouses, lack of economic stability, among others^16),(27. There is, therefore, a need for family reorganization, as the child will take care of the older person (spontaneous or imposed)^10),(19),(35

Although the children become the caregivers, they often do so informally and empirically, not recognizing the aging process and making caring tiring and stressful, which can create a risk of violence^{10),(16),(35),(37}.

Regarding the prevalence of unknown aggressors, a finding of this study, violence can also be related to ageism, that is, prejudice due to age^38),(39. The existing prejudice against older adults can be evidenced by the way society looks at the older adults, for example, not recognizing the loss of certain skills and lack of knowledge about senescence and vulnerabilities^{16),(22),(35),(37),(40),(41}.

The data presented in “other ties” were not described in the form provided by SINAN, as they include other data than those already specified in the table. This is justified by underreporting and inadequate completion of forms at the time of report, which is a reality still present today, already covered in studies, it is estimated that there are five omitted or inconclusive cases for each reported¹⁶.

The data collected, based on chronology, tends to increase the number of cases over the years; however, there is still a consensus in the literature. However, some hypotheses, such as the fact that the issue of violence is more discussed and publicized, that is, dissemination of the rights of the older adults and the way to recognize when these rights are disrespected³².

Thus, as society begins to have more knowledge about the subject, there is greater encouragement to report cases (suspected or confirmed) of violence to the authorities, as well as more intense struggles to reduce the number of events^23),(42. In this way, it is possible to provide more training to health professionals, who can detect cases early, as well as readapting reporting tools^23),(43),(44.

It is observed that the State of São Paulo has the highest number of reports; however, there is no agreement in the literature. Even so, it is possible to point out that the State of São Paulo, due to its development, tends to have a structured support network^32),(33),(44. It is also observed how local political structures can influence the information that is transmitted, that is, São Paulo publicizes cases more, allowing greater knowledge of the problem and the adoption of resolving measures^32),(42),(43.

During the data collection, there was a lot of underreporting and filling failures in the SINAN database, which may occur due to differences between the physical form (paper) and the system form; that is, data filled in on the SINAN physical form is not included in the system, such as the presence of deficiencies or disorders, a factor that could help in understanding risk or protective factors.

The fact that underreporting is still observed means that the fight for the rights of the older person is hampered, as it hinders the action of public policies, as the amount of reliable data is scarce³². Underreporting can occur due to lack of preparation and fear, as well as professionals' lack of knowledge about filling out the form and even its importance for recording and using this data^31),(34),(45.

For nursing professionals, approaching the victim involves a complexity of factors, not analyzing the case in isolation, but the entire life context, as all factors can become a risk or protection for violence^31),(45. However, according to the literature, there is a lack of preparation among professionals regarding the identification of cases, how to proceed in confirmed or suspected cases and the fear of involvement with the aggressors. Another factor is the difficulty in referring/counter-referring, which may be related to the undergraduate degree of this professional^31),(45.

Nurses often feel afraid and choose to report only on Dial 100, which directly interferes with SINAN³¹⁾ reports. Therefore, it is important to train professionals and provide support to the health network^45),(46.

Finally, it is worth highlighting the importance of the Family Health Strategy (FHS) as with the multidisciplinary team it becomes easier to identify and report mistreatment. In this sense, it is possible to observe that the older adults’ registration in the FHS and the bond with the team becomes a protective factor, as in addition to having the monitoring of the nurses within the BHU, they are also able to make home visits that can report violence^13),(36.

In view of this, this study correlates with the practice to expand knowledge regarding the profile of violence against the older adults, allows new tools for measuring cases and greater investments in expanding and disseminating the service sectors and reports ofviolence against the older adults, proposing intervention measures to minimize damage.

Conclusion

The present study allowed us to characterize violence against the older adults in Brazil as more prevalent among females, white people and those with incomplete elementary education, with physical violence being the most recurrent, with repeated episodes, occurring within the residence and children being the aggressors. Although not justifiable, children as the main aggressors may be related to a lack of preparation, as well as the replication of aggressions suffered.

Inadequate completion of report forms results in data not being solid, indicating the uncertainty of the problem. It is also possible to consider that professionals have difficulties filling out the form or the importance of the data, fear, lack of preparation or, even if unjustifiable, excessive daily activities; Regardless, training must take place.

Nurses can notify cases; Those who work at the BHU have greater bonds with the patients, giving this population the opportunity to feel confident in talking about abuse. In other words, these professionals are capable of identifying violence and intervening.