Elderly people at risk: a Norwegian model for community education and response
Awareness of the problem of elder abuse was aroused in Norway in the early 1980s. A pilot project conducted between 1991 and 1994, described here, established an important body of knowledge based on casework. Central authorities believe that improved knowledge and competence will result in local change and further development to help the victims of violence.
key words elder abuse Norway improved knowledge victims of violence public awareness
This paper reports on the experience from a programme in Norway that has worked to accumulate and disseminate information about elder abuse in order to increase public awareness of this problem. The intention was that elderly victims of abuse at home could receive help. The paper will describe some aspects of the work in progress, highlighting the issue of elder abuse from its start until today. It will also briefly cover other practical measures that have arisen and which have a bearing on work relating to victims of violence in general.
Norway is an affluent country with about four and a half million inhabitants (Ministry of Foreign Affairs, 2003). It has a highly developed social welfare system with a reasonably wide range of services. It has a child welfare system on a par with the best in other countries. Norway is also well advanced in the field of support for battered and abused women. As an example, the first helpline for battered women was established as early as 1977 (Jonassen et al, 2003). However, very few elderly women contacted crisis centres, and still do not, as these were and are perceived as being for younger women, particularly those with small children.
We like to think that our welfare service is so advanced that few can equal it. But in the field of elder abuse we have a long way to go, at least in comparison with the USA. Compared with other Scandinavian and most European countries, however, we are ahead. It is through information and the dissemination of knowledge that we have arrived at our present level.
Awareness of the problem of elder abuse was awakened in Norway in the early 1980s through reading articles from the USA. Until then, with their conviction that the welfare state was functioning well, Norwegian researchers, health administrators and policy makers were ignorant of the problem. Several people steadfastly refused to recognise its possible existence. In 1982, a social worker wrote an article (Stang, 1982) where she posed the question: are elderly people prone to abuse even in Norway? She was met with scepticism by politicians and administrative and research personnel. Professionals working in the field had met the problem but not named it as abuse. The general attitude was that this was something that could only happen in the USA, not in our welfare society. The lack of awareness of the problem was alarming.
In 1983, the first survey among a small sample of home-care nurses in Oslo, found that one per cent of their patients were known to suffer abuse by a family member in one form or another. Following the presentation of these results, which were made public through the media, the Ministry of Health and Social Affairs initiated the task of accumulating knowledge and responding to the problem (Evensen, 1984; Stang & Evensen, 1985).
Since 1986 the Ministry of Health and Social Affairs has funded several projects with the aim of gathering information about and developing intervention measures directed at elderly people at risk of being abused in their homes. In 1986 the Ministry issued a pamphlet, Abuse and Neglect of Elderly People – a Communal Problem, written by Crete Stang, a social worker, and Ida Hydle, a physician, following a study tour in the USA. During this tour they also became acquainted with adult protective services. The USA has been a model and an inspiration for the development of knowledge about elder abuse in Norway (Hydle & Stang, 1986).
In 1988 the Ministry of Health and Social Affairs granted funding to a research project, engaging Ida Hydle and Sigurd Johns, a social anthropologist. Employing an interdisciplinary approach, the research centred on in-depth analysis of individual cases of abuse. Research findings showed that, in spite of a broad range of programmes supported by the welfare state, it did not follow that victims of elder abuse received the help they needed. The resulting report on elder abuse in Norway was published in 1992 (Hydle & Johns, 1992).
Elder Protective Services project
With their data collected and results beginning to emerge, Hydle and Johns applied to the Ministry of Health and Social Affairs for another round of funding to support further research on elder abuse. Believing that they had identified important causes for this problem, they now had some preliminary ideas about how to focus their work on designing interventions. From their study and also from earlier projects, it was concluded that there was a need for the problems of elder abuse to be handled by a key person or a key institution, and this is what gave the impetus to Elder Protective Services (Hydle & Johns, 1992; Sosial & Helsedepartement, 1994).
The author of this paper was responsible for the day-to-day running of the Elder Protective Services project, located at the Senior Citizen Centre in Manglerud, one of 25 urban administrative districts in Oslo, Norway’s capital. Oslo has about 500,000 inhabitants. The project aimed at developing methods for intervention and prevention of elder abuse, intended for future implementation on an extended scale throughout Oslo and the rest of Norway (Johns &Juklestad, 1995).
The project succeeded in implementing the concept of a key worker. Knowledge was obtained which could be shared with other social and health services so that they also benefited from it, using it in their work and in this way helping to further develop the concept of an elder protective service. Through work in the project, gaps in the assistance services and the barriers between the many different agencies and institutions (social and health services and police) became very apparent. Elderly victims of violence rarely obtained any form of assistance. When they did so they did not really get the help they needed because of the lack of understanding of their particular situation Quklestad & Johns, 1997).
One of the founding principles of the Elder Protective Services project was that elder protection should be an integral part of the ordinary health and social services offered to people in the local community, more closely resembling the child care model of service already in place. Experience from this pilot project and from research had shown that the problems of suspected and real abuse were widespread and help was ineffective. This problem had been neglected in social work (Stang, 1982; Hydle & Johns, 1992; Juklestad, 1995; Juklestad & Johns, 1997).
Transfer of knowledge
A preliminary result from the initial phase of the project confirmed how important knowledge about the problem, further research and, most importantly, education were for addressing the ‘new’ problem of elder abuse and assisting social service professionals in the new possibility of contacting Elder Protective Services. Information brochures were sent out to all families in the area. They were also distributed to all welfare institutions considered to be important in a co-operative effort. Emphasis was placed on meeting elderly people in their own environments, such as senior citizen centres, pensioners’ clubs and meetings, committees dealing with problems of the elderly and church congregations. This was followed up by the key person visiting all agencies and institutions and others that meet elderly people, including the police and voluntary organisations, and talking about elder abuse. Also, the media were informed and encouraged to take up the problem of elder abuse. During this early phase of follow-up visits, few knew of any cases of elder abuse, but the meetings led to a higher level of awareness. An important feature of this phase was that they now had a contact person to ask questions and consult with about the nature of abuse. From the outset, it was made quite clear that this was not a job one person could do alone. To be successful it would require the fruitful co-operation of other welfare institutions.
Sources of initial contact
The accumulation and dissemination of knowledge within the social services was necessary for the project to fulfil its function as a point of contact and to assist the services to appreciate and look into problems.
The importance of positive contacts with local agencies and professionals working with the elderly can be illustrated by the overview of how cases were reported in Table 1.
What kind of abuse?
Abuse of elderly people within the family can take many forms. It can be physical, psychological, sexual or economic, and in combination. The reasons are usually complex and may be compounded by drug or alcohol addiction, and personal crises within the family.
The largest group of cases found during the project were marital conflicts. If we include widows suffering post-abuse trauma, these comprised more than half the cases in Manglerud. Wife abuse was common and had often been going on for a long time. Longlasting marital conflicts may be aggravated or even triggered by life transitions following retirement, illness or dementia.
Most of these children have some kind of social or psychological problem. Another large group of cases was adult children abusing their parents, mainly sons abusing their mothers. These cases were generally more dramatic and often more severe.
The needs of elderly, abused people
The project revealed that abused elderly people need particular types of after-care – for example, protection against abuse, sometimes a safe haven. They needed psycho-social support and follow-up, and counselling about the emotional aspects of their family relationships from someone they could trust. They needed information about their rights and the types and extent of assistance available, help in applying for social support, consulting a doctor or lawyer, contact and discussions with the police, and the availability of special alarms. Many elderly people needed practical help due to disabilities or immobility, in order that they could get in touch with the social services (Johns & Juklestad, 1995; Juklestad, 1995; 1999; 2000; Juklestad & Johns, 1997).
New services in Oslo and Drammen
By obtaining more knowledge about their particular situation, about how to expose abuse and improve co-operation between institutions, circumstances can be improved for individuals who experience abuse. However, it is tempting to compare this with assistance efforts for battered women and abuse of children. Newly identified areas of service require organisations that can concentrate on the specific need.
The Elder Protective Service project was able to demonstrate significant practical results during its three years. As the government funding came to an end in 1994, the authorities in Manglerud incorporated Elder Protective Services as part of their organisation. The Oslo City Council decided that all of Oslo’s urban administrative districts should be able to offer similar help by the year 2000, and there are now three Elder Protective Services offices staffed with a total of 10 social workers covering the whole of the city. It is hoped that these services will be an example to the rest of the country. One municipality outside Oslo (Drammen) has also established an Elderly Protective Service (Oslo Kommune, 2000).
The importance of knowledge and information dissemination has become increasingly apparent to the Norwegian government. The result was the creation of the Norwegian Resource Centre for Information and Studies on Violence, for all victims of violence – children, youth, elderly, women and men. The Norwegian parliament decided that a resource centre should be established. One of the tasks of this new resource centre was to ensure that this development in work on elder abuse continues (Sosial og Helsedepartementet, 1993; 1995).
The centre was established in 1996 as an agency under the governmental plan of action towards a safer society. Its purpose is to give increased attention to the victims of violence and to encourage future action aimed at safeguarding their situation on a national level.
The centre is located at the Oslo College, financed by the Ministry of Health and Social Affairs, the Ministry of Child and Family Affairs and the Ministry of Justice and Police. The centre is staffed by a project manager, three senior advisers (of whom the author is one), a secretary and a librarian. The staff represent a diversity of practical and theoretical experience in the field of violence, abuse and victim assistance. Targeted groups are professional and voluntary helpers, local and central governmental agencies, researchers, teachers and students as well as victims of violence, their families and others affected, the media and the general public (Sosial og Helsedepartementet, 1995).
The Norwegian Centre on Violence and Traumatic Stress
As from January 2004, the centre is part of a new group within Oslo University, the Nasjonalt kunnskapsenter om void og traumatisk stress – in English, the Norwegian Centre on Violence and Traumatic Stress. Others working together in the new group will be the National Resource Centre for Sexually Abused Children, the Psycho-Social Centre for Refugees and the Office of Catastrophe (Trauma) Psychiatry – altogether about 25 to 30 people. As the new contact details are not yet finalised, the present details will be valid for several months (see page 32).
A priority task has been to influence both the basic and also further education of professionals in social and health care, in order to improve their knowledge concerning violence and victim assistance.
As part of the plan of action against violence, Oslo City Council has offered an educational programme to health and social workers and the police. Staff at the centre have been instrumental in developing the programme and also act as teachers. The programme has focused on improving basic knowledge on victim assistance, the establishment of networks and co-operation across professional and administrative boundaries. Students have been able to take an examination at Oslo University College. The programme has proved to be very popular and subsequent evaluation and feedback have been very positive so far. For the future, it is hoped that the college will take over the administration of the course and offer it to professionals throughout Norway (Oslo Kommune, 2000).
The Norwegian Resource Centre has succeeded in including education on the subject of elder abuse into the formal curriculum of social studies at Oslo University College. The centre also wanted, additionally, to offer a course of further education, with special emphasis on the protection of elderly people, to graduates with a minimum of two years’ experience.
A new course, ‘Protection of the elderly’, was developed and also approved by the Oslo University College in 2001, but lack of funds prevented it from being started. A year later however, the authorities in the neighbouring county of Buskerud took on the financial responsibility for the course, provided that applicants from Buskerud had priority when applying for places on the course.
The target group
The target group in this education is key personnel in positions of responsibility for supervising care staff, management and counselling. The programme nevertheless contains a recommendation that each community should establish an education and awareness campaign, so that elderly victims can more easily obtain help and thus make this known to the public at large. Students were selected, where possible, to ensure a broad range of expertise, education and practice.
For the time being, the programme does not aim solely to educate specialists. It also aims to improve the level of competence of those service providers and others who may come into contact with those who may be the victims of abuse, and who can see existing or potential problems at an early stage and therefore prevent violence.
The students are given an insight into abuse and its consequences, to better enable them to uncover and identify abuse, implement interventions, to counsel victims, to co-operate with others and to follow victims in the process of extricating themselves from a difficult situation. The course also offers general knowledge about the rights of elderly people, health and social conditions and political questions. Abuse of elderly people, both at home and in institutions, is included in the curriculum.
Form and method of study
The course is part-time, with four study sessions in two terms during one year. Emphasis is placed on active participation, with students contributing from their own experience in both education and practice. Reading covers about 1,000 pages. The book Vern for Eldre, tiltak mot overgrep i hjemmet [Protection of the Elderly against Violence and Abuse in their Home], which was also a result of the Manglerud project, has been included in the curriculum. The first group of students took their exam in June 2003 with very good results. All candidates passed.
Following these encouraging results, we hope to be able to run the course in Oslo and to secure state funding to allow the course to be offered throughout the country.
Cases of abuse and violence are complex and require knowledge from many areas. Experience and knowledge from social work provide a good approach to these problems.
As cases of elder abuse are a new problem area, established assistance resources have not developed routines to deal with them. In order to achieve change, the problems need to be recognised and understood. It is also important that the needs of the individual are recognised and understood. In other words, it has to be realised that a new social problem does exist before new assistance programmes can be established in the social services.
Experience has shown in Norway that through a long process of public awareness, dissemination of information, promotion of education and training, there is an understanding that preventing violence to the elderly will not have any priority unless there is at least one key person who has knowledge on the subject. This key person could be a mediator between the different agencies involved.
In the development of the Elder Protective Service, Norway has succeeded, by starting short-term pilot projects where new ideas and actions in the local community can be tested and refined. The initial project was funded by the government, but with a high degree of local participation and organisation. Pilot projects have mainly had two purposes; one has been the development of knowledge and experience through evaluation of the activity, and the other to ensure a gradual and smooth introduction of services for victims of abuse.
At the time of writing, a law for mandatory reporting has not been under consideration, as it has not been perceived as a necessity. Rather, we consider that local authorities should recognise their responsibility and ensure that protection and services are provided for victims of abuse.
The Norwegian Resource Centre for Information and Studies on Violence has focused its mandate on the collection, systemisation, development and dissemination of knowledge. In this there is a strong belief, also from central authorities, that improved knowledge and competence will result in local change and further development to help the victims of violence.
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Senior Adviser, Norwegian Resource Centre for Information and Studies on Violence, Oslo University College
About the author
Olaug Juklestad is a senior adviser at the Norwegian Resource Centre for Information and Studies on Violence, Oslo University College, where abuse of elderly people is one of her main subjects for teaching, information collection, dissemination and writing. She is a social worker with masters degrees in pedagogic, gerontology, and theory and methodology in social work. From 1991 to 1994 she was responsible for the day-to-day running of the pilot project ‘Vern for eldre’ (Elder Protective Services) in Oslo. She is the principal author of the book Vern for eldre. Hjelp mot overgrep i hjemmet (Oslo 1997) and a number of articles. In 2002 she was was invited by Professor Toshio Tatara to take part in the Longevity Sciences Research Project of Shukutoku University Sociology Department, Chiba, Japan. The findings of this report are forthcoming.
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