Evaluation of Violence Against Elderly People of Different Cultures by Using The "Purnell Model for Cultural Competence".

AIM: This study aimed to evaluate the violence against the elderly from different cultures by using "The Purnell Model for Cultural Competence."
METHOD: The study population comprised of elderly people residing in a city in the Eastern Anatolia, the Southeastern Anatolia, and the Marmara Region. This is a qualitative study employing a purposeful sampling method. Data were gathered using questions to identify the sociodemographic characteristics, a semi-structured interview form prepared in accordance with "The Purnell Model for Cultural Competence," and the question form consisting of questions to determine the violence against the elderly. Data were collected through in-depth interviews and by means of recording, as well as recordkeeping. Permissions were obtained from the ethics committee, and written and verbal consents were obtained from the elderly to be interviewed before the study. Data were evaluated using the descriptive data analysis methods.
RESULTS: The study revealed that the elderly people were commonly exposed to psychological violence, whereas there was an elderly person subjected to physical violence. Seven elderly persons in the Southeastern Anatolia and three elderly persons in the Marmara Region expressed that they were exposed to psychological violence. Nonetheless, no indications were observed of economic and sexual violence among the elderly in both groups.
CONCLUSION: The study findings suggest that nurses should not ignore the cultural characteristics in the fight against violence against the elderly.

INTRODUCTION

At present, the rate of elderly population is increasing rapidly worldwide owing to reasons, such as early diagnosis and treatment of diseases, decreased fertility rate, and prolongation of life (Karadakovan, 2014). It is estimated that the elderly individuals constitute 8.9% of the world’s population. The first 3 countries with the highest aging population are Monaco with 32.2%, Japan with 27.9%, and Germany with 22.1%. Elderly population rate in Turkey was determined to be 8.5% in 2017. (Turkish Statistical Institute, 2018).

The increase in the elderly population has brought forth the inevitable problems related to old age. One of the major problems for the elderly is the violence against them regardless of factors, such as social, economic, ethnic, and geographical regions (Sethi et al., 2011). Violence against the elderly can be in the form of physical violence, psychological violence, sexual violence, economic violence, neglect, or abandonment. According to the World Health Organization (WHO), in the past year one in six elderly people have been exposed to one type of violence (WHO, 2018). According to the results of a meta-analysis conducted by Yon, Mikton, Gassoumis & Wilber (2017) that included 52 studies from 28 countries, 15.7% (95% CI 12.8–19.3) of the elderly were reported to be exposed to violence. On the other hand, the results of a meta-analysis performed by Ho, Wong, Chiu & Ho (2017) that included 34 studies, 10.0% (95% CI, 5.2%–18.6%) of the elderly were reported to be exposed to violence. The rate of violence varies among countries. The rate of violence against the elderly is 11.4% in the United States (Acierno et al., 2010), 29.3% in Spain (Garre-Olmo, Planas-Pujol, López-Pousa, Juvinyà, Vilà & Vilalta-Franch, 2009), 4.5% in Malaysia (Sooryanarayana et al., 2017), 23.5% in Portugal (Martins, Neto, Andrade & Albuquerque, 2014), and 11.0% in India (Skirbekk & James, 2014). The prevalence results obtained from various studies conducted in Turkey vary between 13.3%–70.9% (Artan, 1996; Aslan, 2012; Daşbaş, 2014; Ergin et al., 2012; Ilhan, 2006; Karbeyaz & Çelikel, 2017; Keser-Özcan, Boyacıoğlu & Sertçelik, 2017; Keskinoglu et al., 2007; Kıssal, 2008).

Risk of violence against the elderly is affected by living in a large family or alone; low or high economic status; decrease in physical, psychomotor, perceptual, and cognitive abilities; the need for care; and being old (Kalaycı & Özkul, 2018). Furthermore, the following factors play a role: elderly individuals being seen as weak and dependent in society, deterioration of family ties, inheritance law affecting the distribution of power and property in families, elderly parents being abandoned in consequence of children leaving the house, and the lack of income to meet the need for care as a result of that. In addition, in some cultures, it is stated that women are less valued than men, they are considered to be under the ownership of men, and they may be at a greater risk as violence against women is often tolerated (Sethi et al, 2011). Cultural values and beliefs play a crucial role in the perception, definition, and interpretation of violence against the elderly (Lafferty et al., 2009). Studies have shown that older individuals of different races or ethnic groups have different levels of tolerance to different types of violence (IOM & NRC, 2014; Malley, You & Mills, 2000; Moon & Benton, 2000). Even though violence against elderly is an issue that needs to be discussed as a social problem, it is challenging to identify it. It is stated that only 4% of the exploitation cases have been reported because elderly people are usually scared to report such cases to family members, friends, and authorities (WHO, 2018). It is indicated that when an elderly individual does not perceive neglect or abuse as a problem, it negatively affects the determination of violence (Fadıloğlu & Şenuzun-Aykar, 2012).

It was emphasized that health professionals should demonstrate the cultural aspect of violence to find solutions for the emergence and prevention of violence (Erten & Bayraktar, 2015). In particular, health professionals working in the field are the first to communicate with victims of violence and they are the primary source of assistance (Tanrıverdi, 2015). In this context, nurses working in the field are able to evaluate the elderly individuals adequately in the society (Ercan-Şahin & Emiroğlu, 2017). Nurses are encouraged to use models to guide them in cultural evaluation. Several intercultural models exist, and one of the most widely used models is the “Purnell Model for Cultural Competence” (Tortumluoğlu, 2005). Purnell’s model of cultural competence is an ethnographic model that provides a cultural understanding of people in the process of health protection, development, and coping with diseases (Purnell, 2008). No nursing research has been conducted addressing the violence against the elderly by using a model or without a model within the cultural structure in Turkey. In this study, evaluating violence against the elderly with an intercultural nursing model will raise awareness among nurses and other health professionals in identifying cultural barriers of violence, as well as combating violence. It is thought that nurses will consider the effect of culture on violence when providing care to elderly people from different cultures and contribute to reflecting these results in practice.

In this context, this research was conducted using “Purnell’s Cultural Competence Model” to evaluate violence against elderly people from different cultural backgrounds.

METHOD

Study Design

This study was a qualitative study.

Sample

The study population comprised elderly people aged 65 years and above, living in a city located in western Turkey. The elderly individuals were divided into the following two groups: Eastern and Southeastern Anatolia Region (ESEAR) and the Marmara Region (MR). Snowball and criterion sampling, which is one of the purposeful sampling methods, was employed for sampling from the population. During the sample selection, migration of elderly people from one of the provinces in the Eastern and SA was determined as a criterion. After choosing the first elderly person in accordance with the criteria, the rest of the elderly people were determined afterwards based on the recommendation of the elderly person interviewed first and the sample number was increased in this way.

Overall, 30 elderly, 15 from ESEAR and 15 from MR, were included in the study. In qualitative research, it is stated that the number of samples could be even one person, increased in accordance with the purpose (Yıldırım & Şimşek, 2000). Elderly people aged 65 years and above who had cognitive sufficiency and were willing to participate in the study were included in the study.

Data Collection

Data were collected using questions defining socio-demographic characteristics and a semi-structured interview form prepared in line with Purnell’s Cultural Competence Model (Purnell, 2008). Data were collected from March to June 2016 over a four-month period. Interviews were conducted between 60 to 90 minutes with the elderly in the home environment of the elderly. Some of the interviews were audio recorded with the elderly individual’s permission and written record was performed for those who did not give permission for audio recording.

Statistical Analysis

Data were evaluated using the descriptive analysis method. The notes and voice recordings recorded during the interviews were transferred to the computer. During the transfer, all interviews were separated in accordance with 12 themes determined based on Purnell’s model. Under the themes, the statements of the participants were included. Speech texts were shown in italics. Every statement was explained per the region, gender, and allotted the number of the participant. The numbers with the letter M represent male participants, and the letter F represents female participants.

Ethical Considerations

Before starting the study, written informed consent was obtained from aUniversity Clinical Research Ethics Committee (050.99-201) and Public Health Directorate (97095925/605.99), as well as written and verbal informed consent was obtained from the elderly participants.

RESULTS

The findings of the research were discussed under the following three titles:

a. Sociodemographic Characteristics of the Elderly

The elderly from both regions were between 65–88 years old. Overall, 12 participants from MR and 13 from ESEAR were females. Most elderly individuals from the MR were primary school graduates, whereas most from ESEAR (the migration group) were illiterate. When the marital status of the elderly people was examined, most elderly individuals from MR had lost their partners and most elderly people from ESEAR were married. Eight elderly individuals from the MR lived with their children, six with their spouses, and one with a caregiver. On the other hand, nine elderly individuals who migrated from the ESEAR lived with their children and four lived with their spouses and single children. Sociodemographic characteristics of the elderly are presented in Tables 1 and 2.

Table 1

Sociodemographic characteristics of the elderly in Marmara Region

	Age	Gender	Educational level	Spouses education level	Marital status	Family type	Living with	Number of children	Working status	Income status
*MR1	88	Female	Primary school	Primary school	Widowed	Extended Family	Children	8	Not working	-
MR2	65	Female	Uneducated	Uneducated	Widowed	Extended Family	Children	2	Retired	Balanced
MR3	65	Female	Uneducated	Primary school	Widowed	Extended Family	Children	3	Retired	Balanced
MR4	65	Male	Primary school	-	Divorced	Extended Family	Children	2	Working	Balanced
MR5	75	Female	Primary school	Primary school	Divorced	Extended Family	Children	3	Not working	Balanced
MR6	80	Female	High school	University	Married	Nuclear family	Spouse	3	Not working	Balanced
MR7	73	Female	Primary school	Primary school	Widowed	Extended Family	Children	2	Not working	Balanced
MR8	71	Female	Uneducated	Uneducated	Married	Nuclear family	Spouse	4	Not working	Balanced
MR9	65	Female	Primary school	Primary school	Widowed	Extended Family	Children	2	Not working	Balanced
MR10	81	Male	Primary school	Uneducated	Married	Nuclear family	Spouse	5	Retired	Balanced
MR11	76	Female	Uneducated	Primary school	Married	Nuclear family	Spouse	5	Retired	Balanced
MR12	80	Female	Primary school	Primary school	Widowed	Extended Family	Children	2	Not working	Balanced
MR13	71	Female	Primary school	Middle school	Married	Nuclear family	Spouse	2	Not working	Balanced
MR14	89	Female	Uneducated	-	Widowed	-	Caregiver	4	Not working	Balanced
MR15	76	Male	Middle school	Primary school	Married	Nuclear family	Spouse	2	Retired	Balanced

MR-Marmara Region

Table 2

Sociodemographic characteristics of the elderly in Eastern and Southeastern Anatolia Region

	Age	Gender	Educational level	Spouses education level	Marital status	Family type	Living with	Number of children	Working status	Income status
*ESEAR1	65	Male	High school	Uneducated	Married	Nuclear family	Spouse	4	Retired	Balanced
ESEAR2	68	Female	Uneducated	Primary school	Married	Extended Family	Spouse and children	10	Not working	Balanced
ESEAR3	70	Female	Primary school	Primary school	Married	Extended Family	Spouse and children	8	Not working	Balanced
ESEAR4	65	Female	Uneducated	Uneducated	Married	Extended Family	Spouse and children	14	Not working	Balanced
ESEAR5	75	Female	Uneducated	-	Widowed	Extended Family	Children	7	Not working	-
ESEAR6	66	Female	Uneducated	Primary school	Widowed	Nuclear family	Children	5	Not working	Balanced
ESEAR7	75	Female	Uneducated	-	Widowed	Extended Family	Children	10	Not working	Balanced
ESEAR8	65	Male	Uneducated	Uneducated	Married	Nuclear family	Spouse and children	3	Retired	Balanced
ESEAR9	67	Female	Uneducated	-	Widowed	Extended Family	Children	3	Not working	Positive
ESEAR10	65	Female	Uneducated	Uneducated	Widowed	Extended Family	Children	7	Not working	-
ESEAR11	65	Female	Uneducated	Primary school	Married	Nuclear family	Spouse and children	3	Not working	Balanced
ESEAR12	68	Female	Uneducated	Primary school	Married	Extended Family	Spouse and Children	7	Not working	Negative
ESEAR13	80	Female	Uneducated	Primary school	Widowed	Extended Family	Children	6	Not working	Balanced
ESEAR14	65	Female	Uneducated	Primary school	Married	Extended Family	Spouse and Children	7	Not working	Balanced
ESEAR15	75	Female	Uneducated	Uneducated	Married	Nuclear family	Spouse and children	11	Not working	Negative

ESEAR-Eastern and Southeastern Anatolia Region

b. Cultural Characteristics of the Elderly

The cultural characteristics of the elderly were discussed under 12 titles in line with Purnell’s model.

1. Overview or Heritage

Settlement, migration, and the reasons of migration and its relationship with economic factors, educational status, and occupation are evaluated here. All but two elderly persons (one from Bulgaria and the other from Istanbul) from the MR stated that they were born in a city located in the west of Turkey. Eight elderly persons migrated from ESEAR from Van, two from Agrı, one from Mus, one from Elazig, one from Erzincan, one from Malatya, and one from Diyarbakir because of job opportunities in the West, better education for children, and family relationship. DGDAB6-F: “My mother’s family came from Konya and my father’s family came from Iran to Van. Our grandfathers settled in Ercis (province in Van) when they were still children. After my husband passed away eight years ago, we moved here because our relatives lived here.” Most elderly persons from the MR group were primary school graduates, whereas most elderly individuals from the ESEAR group were illiterates. Most elderly individuals from both regions stated that they never worked before. MR14-F: “I never worked in my life. I used to beg my husband to let me work, but he never did.” ESEAR6-F: “Women do not work here. Man’s income is very important for women. If she has a garden to work on, then she can work in her own garden. Otherwise, she doesn’t go anywhere else to work.”

2. Communication

Dominant language, dialect, tone of voice, eye contact, silence, greeting and touch are evaluated here. Six elderly migrants were noted to have Kurdish as their dominant language, and all other migrants and the elderly in the MR group had Turkish as their dominant language. All the elderly people in the ESEAR used dialects indigenous to their regions. Both groups expressed that they spoke using normal tone of voice. One male migrant participant from Van said: “We do not speak out loud.” Another female migrant participant from Van stated: “When I first got married, I wouldn’t sit and eat with our fathers-in-law or any elder in-laws. We would hide half of our face and not talk. We would use signs to communicate.” Except one person in the MR, none considered gender differences as an obstacle in making eye contact, whereas elderly migrant women stated that eye contact with men was not accepted for them. Although silence was seen as a sign of respect in ESEAR, the MR participants did not mention this. ESEAR5-F: “You can’t talk or sit with fathers-in-law or brothers-in-law.” Considering the greeting characteristics of the elderly in the MR, 12 elderly participants said that they had no problem having their hands kissed or shaken regardless of gender, three elderly participants said they only accepted greetings from their immediate circles. Five elderly participants in ESEAR stated that they were fine with having their hands kissed or shaken regardless of the gender, whereas the other elderly people did not accept greetings outside their immediate surroundings.

3. Family Roles and Organization

The head of the household, gender-specific roles, roles of the elderly, single parents, childless marriages, and divorces are evaluated in this area. In both elderly groups, decisions were made together as a family only in the families of two elderly individuals living in a city located in the west of Turkeyand the other elderly people stated that the head of the house were men. MR2-F: “Head of the house is my husband. His word is law. He usually makes decisions. I don’t say much so that we get along.” Most elderly individuals from both groups defined men’s duties as working and bringing home the bread; two elderly migrants defined it as taking care of grandchildren. ESEAR1-M: “Man’s responsibility is to manage family life, to make sure children get along, to take care of the expenses of the house, and to make sure everything is well.” In both groups, elderly defined the roles of women as doing housework and raising children in general. Four elderly women also included having a job as a role of women. MR11-F: “Women clean, cook, welcome her guests, raise children, etc. What else can she do?” Both elderly groups gave similar statements regarding their roles, such as praying, taking care of grandchildren, guiding their kids, and getting care from them. MR2-F: “Elderly take care of their grandchildren and pray. No one expects them to work.” ESEAR6-F: “Elderly want food ready for them, clean environment, and constant attention. If the people around an elderly have a fear of God, they do these things for them.” MR11-F: “We respect the elderly.” ESEAR1-M: “We respect our fathers and mothers very much. When our father walks into a room, we all stand up.” ESEAR7-F: “Sending an elderly to a nursing home is unacceptable. Even if it takes begging for kids to take care of their elderly, they have to do it.” Participants in both groups made similar statements regarding the role of the children, like showing respect and love to the elderly, taking care of parents, studying, and earning money. MR11-F: “Children should take care of their parents when their parents are not able to work anymore. I also look after my mother-in law. Even though I get angry inside, I can’t say anything.” ESEAR12-F: “We want our children to study and save during their lives so that they don’t have to go through what we did. May they grow up with ease and without difficulties.” Based on the results of this study, three elderly individuals from the MR were divorced and most in the groups stated that divorce was normal when necessary. All migrant participants were against divorce but only one of them stated that he was accepting of his daughter’s divorce as she was exposed to violence in her marriage. MR4-M: “I also had a divorce. There is nothing to do when marriage doesn’t work anymore.’’ ESEAR5-F: “Divorce is not approved in our tradition. One of my daughters got divorced and we disowned her.” According to this study data, the elderly people in both groups stated that they consider childless marriages as normal and appropriate medical attention and counseling should be sought. Elderly individuals in both groups did not approve single parenting. Two elderly individuals from the migrant group stated that this might get a person killed.

4. Workforce Issues

Participants stated that they still work in various jobs or they were retired; two male migrant participants said they were retired, and all female participants in that group stated that women were not allowed to work, they only work in their own garden. ESEAR12-F: “They say women are not supposed to bring home the bread but do the housework and raise children.”

5. Biocultural Ecology

Skin color and other biological variables that are related to illnesses and health status are evaluated here. Most elderly in MR were fair-skinned, whereas most of the elderly individuals from the migrant group were dark-skinned. Both the elderly groups were identical regarding the most common health problems, such as diabetes, hypertension, and heart diseases. In addition, diseases were less common in MR group, whereas most from the migrant group suffered from orthopedic disorders.

6. High risk behaviors

Smoking and alcohol use, addiction to medicine, physical activity deficiency are included in this area. Few elderly individuals from MR stated that they had previously smoked and quit, whereas only one claimed that he still smoked and drank. Migrant group stated that none of them smoked or had alcohol. It is stated that the elderly individuals in MR only walk as an exercise, whereas the migrant elderly individuals are not physically active.

7. Nutrition

Food selection, prohibitions, illnesses, and food that are used to improve health are mentioned in this part. In the study, most elderly individuals from MR stated that they ate natural foods, they consumed milk and milk products, and they liked bread, whereas the elderly migrants preferred meat-based nutrition. MR3-F: “We consume dairy products. It is a sin to waste bread. I feel very sad when young people throw bread away.” ESEAR5-F: “Keledoş (a famous meat-based dish from Van) is consumed a lot. We love meat a lot. If meat is available, we can eat it for every meal.” All participants in the MR and all but one from ESEAR stated that pork is non-kosher. Moreover, some of them considered horse and donkey meat as non-kosher as well. Most elderly individuals from both groups paid attention to consuming various herbs, dairy products, and salt-free eating to improve disease and health. MR3-F: “When we get sick, we drink linden tea and when we have stomach problems, we drink mint and lemon tea. If it doesn’t get better, then we go see a doctor.”

8. Pregnancy

Fertility practices, views toward pregnancy, postpartum practices, and child rearing practices are discussed here. When the reproductive practices of the elderly women in MR were examined, it was observed that they had an average of three pregnancies, whereas elderly women from ESEAR had nine pregnancies on an average. ESEAR5-F: “If we had been on birth control back then, we wouldn’t have had many kids. There is a distinction between boys and girls. One of our neighbors has seven daughters. She will give more birth until she has a son.” The elderly in MR stated that nowadays, in general, pregnant women are respected and taken care of, but they were not respected back in their pregnancy period. Most elderly women who migrated stated that pregnant women did not see much value and continued to do housework until in labor. ESEAR13-F: “They used to be so scared that there wouldn’t have children. People want lots of children here. Life was still same for us even when we were pregnant. We wouldn’t get any special treatment. We used to do housework until we delivered the baby. I don’t think anyone could lounge until delivery.” It was stated that the elderly in both regions were fed well for breastfeeding during postpartum periods, well-rested, and they were wrapped to prevent sagging post-baby belly and recover faster. ESEAR6-F: “People visit to congratulate the family and say good wishes. Mothers usually have their bellies wrapped to prevent sagging and keep staying warm. Puerperas are never left alone. If she is alone, they put something of iron material on her head.” It was found that swaddling, salting the babies’ bodies, and 20 or 40 days of confinement were common in both groups. MR12-F: “We used to swaddle the babies until they were 6 months old so that they could sleep comfortably and we used to put little bit salt in their first bath water so that wouldn’t be scared. After finishing the first 20–40 days of confinement, we would take them out.”

9. Death Rituals

Elderly people in both groups stated that they read Koran for the spirit of the dead on the seventh, fortieth, fifty-second days and every year. They brought food to the condolence house; television and radio were not switched on that day, and they put a knife on the body to prevent swelling. The elderly from ESEAR also stated that they put up condolence tents and they lamented as a way of mourning. ESEAR2-F: “We mourn. We cry continuously for 7 days. We set up condolence houses. We cook food and send out to people for 7 days. We read Koran on the 7, 40, 52 day and every year for the spirit of that person. We read the 36 Sura of the Koran 40 times until the body is interred. People don’t watch TV or listen to radio for 4 or even 5 months.”

10. Spirituality

Elderly people in each group stated that fulfilling the requirements of religion strengthened their spirituality. MR11-F: “Praying and reading Koran; we read the whole Koran once a year. We have a congregation here. I feel at ease when congregation performs prayers.”

11. Healthcare Practices

Views toward diseases, health care barriers, mental disorders, organ donation, organ transplantation, and sorcery topics are covered here. Most elderly individuals in both groups saw diseases as God’s wish so first they pray to God when they get sick and then see a doctor. Some elderly stated that they tightly wrap their heads with a cloth when they have a headache and see a doctor as a last resort. ESEAR15-F: “In the past, we used to continue our days even if we wouldn’t feel well. We used to wrap our head to get rid of headaches. We wouldn’t get sick most of the time. However, if someone is sick, it is common to visit them. When you get sick, you have guests visiting you from 4 or 5 villages.” Most of the elderly in both groups stated that they do not discriminate between female and male doctor; however, the elderly women stated that their first choice is generally a female doctor if there is one available. ESEAR13-F: “I do not want to be examined by a male doctor. I cried for two months after the gynecological surgery I had by a male doctor as I couldn’t believe that I had to be in that situation. But I go see male doctors now. There is nothing to do.” In both groups, most elderly individuals stated that mental illnesses are God’s wish and people with mental disorder should be taken care of. Two elderly people from the ESEAR stated that people with mental disorders are generally excluded, not socially allowed to get married, and considered dangerous. ESEAR5-F: “If there is someone with a mental disorder, they are excluded from society and they are not approved to get married. They are considered to be dangerous.” In this study, most elderly individuals in both groups stated that they were not against organ donation. Some elderly people said that they were against the organ donation because they wanted to keep the integrity of the body and they wished to die in the same body that they were born in. MR1-F “I am against organ donation. If I die, don’t ever give my organs away. I don’t want to be like that. Bury me the way I die. My daughter says it is a good deed but I don’t care about that.” Most of the elderly individuals in this study stated that they did not believe in sorcery and they were against it. MR1-F: ‘’I don’t believe in sorcery. I only believe in what I can see.”

12. Healthcare Practitioners

The position of health care practitioners and the approach to traditional healers are discussed here. In both groups, the majority of the elderly stated that they do not believe in the traditional healers. They usually protect themselves from evil eyes by prayers or by wearing amulets that has a special prayer inside of it written for that specific person. ESEAR9-F “I believe in evil eye. My daughter passed away when she was 5 months old because of the evil eye. When kid is affected by the evil eye, they carry blue beads, they get prayers from a Muslim preacher. When couples start having fights, they also get prayers to get purified by negative energies.”

c. Violence Against the Elderly

During the interviews, participants in both groups stated that they were generally respected and they have not been exposed to violence before; however, they did not always see the same respect from younger generation. MR1-F: “God bless my children. It’s been 18 years since they lost their father. I haven’t heard any bitter words from them so far. I see respect and love from my grandchildren and daughters-in-law. Some of the young people in society show respect to me, some do not. I don’t say anything. I go my own way. When I go to the hospital, I get the priority in line because of my age. They do a good service.” MR3-F: “There is love and respect for the elderly. You can’t use violence against them. You listen to their advices.” MR4-M: “There is reverence and respect for the elderly. There is no violence against them. However, new generation is very disrespectful to the elderly. Generally, people here are very respectful, but the students who come to study in this town are disrespectful in general. We have complaints about them.” MR6-F: “We respect the elderly very much. I can’t interfere with my kids. They don’t like it if we interfere a lot.” MR7-F: “We show reverence and respect for the elderly. I help them if they need my help. I have never heard anything disrespectful from my children and my bride-in-law. God bless them.” MR8-F: “The elderly people are highly respected in society. I am very pleased with my children. I have three daughters and a son. I have never experienced anything unpleasant with them. I gave four births. Of course, they take care of me. I trust my children.” MR10-M: “I respect the elderly a lot. I visit them and see how they are. Violence against the elderly is a primary sin and should not happen at all costs. I condemn it vehemently. I believe that God will take care of those people who use violence against elderly. None of my five kids have ever said anything against my word. I might have broken their hearts and they might have said anything behind my back, but they never said anything to me.” MR11-F: “We have respect for the elderly. I hear some pushing, hitting, and beating cases against elderly. It upsets me. We don’t have such things.” MR12-F: “I took care of my mother who was paralyzed for three and a half years. In the meantime, my husband got sick. My mother passed away and then my husband died from cancer. We don’t yell at the elderly or scold them.” MR15-M: “I take care of my father-in-law too. I respect him as the father of the family. We respect the elderly.” ESEAR1-M: “We respect our fathers and mothers very much. In the family, whenever the father enters the door, we all stand up in the room.” ESEAR3-F: “It is compulsory to look after the elderly. The word from the elderly is very important. We take care of the elderly well. Nursing home is not acceptable for us. We don’t raise our voice against them. Whatever they say is right.” ESEAR6-F: “We have great respect for the elderly. We don’t have a nursing home culture. Our conscience doesn’t allow us to send them to the nursing home. They are usually under their children’s or daughter-in-law’s care. If he doesn’t have any children, then relatives take care of him. Even some rich people do their groceries and visit them even if they personally don’t know each other.” ESEAR7-F: “Nursing home is absolutely unacceptable. Even if it takes begging on the street, children have to take care of their parents. There is no violence against the elderly.” ESEAR8-M: “The elderly people are very valuable. We treat them with great respect and take care of them well.” ESEAR10-F: “The elderly people are highly respected in society. We respect their decisions. We always ask their advice before deciding. We have respect not only for the elderly, but also anyone that is older than us. You can’t smoke around an elderly person. You would even have to hide the cigarette. There is absolutely no violence against the elderly and against the older ones, we don’t even raise our voice.” ESEAR11-F: “Elderliness is exactly like childhood. The elderly people are the most welcome ones in society. We have a lot of respect to them. We don’t raise our voice against them at all. I’ve never seen anything like that from my kids neither. There is so much respect for the elderly. You never raise your voice in front of them. Whatever our father says is always right for us. Nowadays young people do not listen to and care for elder people’s decisions. In old days when my husband used to work, we would still listen to his father and do whatever he told us to do. My husband used to bring his salary to his dad. He would immediately realize if it was missing a lira and question what he spent it on. My mother-in-law used to ask him not to do it because he might be buying something for his kids. She used to say it was inappropriate. Nowadays nobody listens to their elders. I have never heard a bad word from neither by husband nor any of my sons.” MR13-F: “I have an old father. We are three sisters. We all take care of him for three weeks in turn. My son, daughter, son-in-law, and daughter-in-law are very respectful to him.” ESEAR14-F: “We never raise our voice in front of him. Whatever he says is our truth.” ESEAR15-F: “Violence against the elderly is unimaginable, you can’t even raise your voice against them. You can’t even answer them.” During the interviews, two elderly people from ESEAR and one elderly from MR stated that they have been exposed to psychological violence within the family. ESEAR5-F: “There is absolutely no violence against the elderly in our culture. Only my daughter gets angry with me every now and then.” MR9-F: “We were always nice to the elderly in our times, but I am not really sure about the new generation. It is a bit difficult. There are times my daughter and I don’t get along well. She jokes but I can’t handle jokes all the time.” ESEAR13-F: “When my son tries to make a decision, he sometimes asks for an advice if he wishes to do so but sometimes, he doesn’t. My son never uses violence against me. Only sometimes he yells at me, but my kids never use violence against me like we hear in some cases. Sometimes he asks me if I am an idiot or stupid, and I tell him that there is no stupid like him. You don’t raise your hand against the elderly in our culture. If they do that to their elders, then I would question their mental health. It is not possible.”

Interviews revealed that two elderly individuals from MR were subjected to physical violence, one person by his son and the other by a young person on the street. MR14-F: “I have one son who drinks alcohol. One day he came home and grabbed me by the back of my arms and made me sit down so fast. My back got broken. I can’t stay with my kids. It is hard to get along with daughters-in-law. My sons come to visit once a week. They stop by for a bit then they leave.” MR5-F: “We used to give elderly people priority. Nowadays, the new generation is very disrespectful. The other day, I got pushed by one of them. Young people are very disrespectful to the elderly.”

DISCUSSION

The findings of the discussion were discussed under the following two titles: cultural evaluation of the elderly and violence.

Cultural Evaluation of the Elderly

It was stated that the reasons for the elderly to migrate were to improve their economic situation and education (Demirbağ & Adıgüzel, 2018). Most migrants speak Kurdish and they have different dialects. In research that has been conducted so far, it was noted that nurses mostly experience the communication-related problems when providing care (Tanriverdi, Bayat, Seviğ & Birkök, 2011; Tortumluoğlu, Karahan, Bakır & Türk, 2004). It has been stated that silence is seen as a sign of respect in the elderly who migrated from ESEAR per the Asian culture (Özcan, 2012; Tanrıverdi et al., 2011).

In line with the literature, 13 participants from the MR and 14 from the ESEAR reported that the head of the family is the male (Campinha-Bacota, 2013; Meleis & Meleis, 2013; Tanrıverdi, 2018). Most from both elderly groups, in line with the literature, stated that (Ellis & Purnell, 2013; Huttlinger & Purnell, 2013; Kalaycı & Özkul, 2018; Kulwicki & Ballout, 2013; Tanrıverdi et al., 2011; Tanrıverdi et al., 2012), the role of a man is to bring money home, and the role of a woman is doing housework and taking care of children. Similarly, both in the international (Ellis & Purnell, 2013) and national (Kalaycı & Özkul, 2018; Tanrıverdi et al., 2012; Tanrıverdi et al., 2011) literature, woman’s roles are limited to households, maternity-related tasks, and more of caregiving roles. The role of the elderly was similarly explained in both groups as praying, taking care of grandchildren, guiding children, and receiving care from family. In African Americans, especially grandmothers play a critical role in childcare (Campinha-Bacota, 2013). In Haitian culture (Colin & Paperwalla, 2013) and in the Egyptians, it is emphasized that children and family members should care for the elderly (Meleis & Meleis, 2013). In the Turkish culture, considering the elderly as a wise person and even giving the main seat in the house to him shows the social and cultural importance of the elderly (Özmen, 2013). Tanrıverdi et al. (2012) stated that the role of the elderly, based on their qualitative research on gypsies living in Canakkale, was stated as “the elderly usually stay with their children and are taken care of by their children.” The results of this study are consistent with the information available, both domestic and foreign. In this study, most elderly individuals in both groups evaluated the role of the children as respecting the elders, showing love, taking care of their parents, and earning money. Filipino parents expect their children to continue their university studies, be economically productive, and have a family (Pacquiao, 2013). In Mexico, children are very valuable because they ensure the continuity of family and cultural values. Children are taught to respect parents and elderly family members, especially grandparents from an early age (Zoucha & Zamarripa, 2008). According to the results of the research, all participants from ESEAR and six from the MR opposed divorce. Three participants from MR were divorced, seven from MR considered divorce normal. Per the 2015 data of Turkey Statistical Institute (TSI), 2.8% of the elderly male population and 3.1% of the elderly women are divorced. This point of view toward divorce is thought to stem from the cultural structure. Although most of the elderly individuals in both groups lived in extended families, the elderly from ESEAR lived with the eldest son or with the child of their choice. According to Turkey Family Structure Survery, approximately 2 of every 10 households in rural areas and only 1 out of 10 households in urban areas had large family structures (Ministry of Family and Social Policies, 2013). According to the results of Canakkale Elderly Atlas (Uluocak et al., 2013), 9.7% of the elderly lived with their spouses and children. The literature is consistent with the results of this study. Although some of the elderly people in MR stated that they worked in various jobs or got retired, all women from ESEAR stated that women are not approved to have jobs, but they could work only in their garden if they had one. Purnell’s Cultural Competence Model and the results of the qualitative research in the study conducted on gypsies of Canakkale are consistent with the results of this study (Tanriverdi et al., 2012).

It is stated that five of the elderly from MR and 11 from ESEAR had hypertension, six from MR and seven from ESEAR had diabetes, two from MR and three from ESEAR had heart disease, two from MR and five from ESEAR had orthopedic disorders, and two elderly individuals from MR had bronchitis. It is noteworthy that the prevalence of common chronic diseases among the elderly in general is lesser in the MR group. A few elderly individuals from MR reported that they had previously smoked and quit smoking, whereas none from ESEAR smoked or had alcohol before. Even though consumption of alcohol among elderly Asians living in America is 16.5% (Cook, Mulia & Karriker-Jaffe, 2012), it is estimated as 0.6% in Ankara (Çakıroğlu & Haklı, 2009). MR participants stated that they only walked as an exercise, whereas ESEAR participants stated that they are not physically active. In a study conducted in Istanbul, it was determined that walking is a common exercise among the elderly (Otrar & Senturk, 2015). It has been reported that exercise is far from being a lifestyle behavior among women, especially in conservative societies (Tanrıverdi et al., 2018). It is thought that literature partially supports the results of this research and that the difference originates from the cultural structure. In this study, most MR participants stated that they try to consume all food groups, whereas the ESEAR participants preferred to have a meat-based diet. It was determined that the most preferred food group in two nursing homes in Isparta and Burdur was meat, and the most crucial reasons for choosing meat and meat products were that these products are more delicious and provide more energy (Öğüt, Mümin, Orhan & Küçüköner, 2008), and this finding shows similarities with the results from the ESEAR group. The nutrition-based differences between the two groups can be evaluated as a result of differences in local, climatic, and cultural conditions. All but one of the elderly individual from both groups stated that pork is non-kosher and some older people also considered horse and donkey meat as non-kosher. This result is thought to reflect the beliefs of Islam. It is determined that both elderly groups consumed various herbs in general to improve diseases and health, and they gave importance to consumption of all dairy products. A research conducted on elderly living in rural eastern Turkey also determined that the elderly in that region consumed a variety of foods for common health problems (Tortumluoğlu et al., 2004).

It was found that women in ESEAR group had three times more pregnancy than the women in MR and most of them did not know the family planning method and they just applied traditional practices for birth and postpartum period. It is thought that the high number of pregnancies among migrant women is because of cultural barriers and cultural characteristics that prevent women from accessing healthcare. In addition, the cultural approaches that the elderly know regarding puerperium and childcare showed similarity between the two groups and in domestic studies (Çetişli et al., 2014; Karabulutlu, 2014). It was determined that the elderly in both groups performed some rituals compatible with postmortem literature (Hacıgökmen, 2013) and cultivated their spirituality by fulfilling the requirements of their religion. In a qualitative research conducted in the rural area of Erzurum, elderly women expressed their spirituality in support of the research results: “everyone in our village knows God’s command. Everyone performs ablution, prays, fasts, goes to the pilgrimage if possible, gives alms, reads the Quran, lives the way the Quran says.” (Tanrıverdi et al., 2011). Both elderly groups stated that they generally regarded illnesses as the God’s wish and they prayed when they got sick and then went to a doctor. Diseases in Arabs are attributed to various factors, such as malnutrition, changes in temperature, emotional or mental distress, envy or evil eye (Kulwicki & Ballout, 2013). In the study conducted in the rural area of Erzurum, it was observed that elderly people first apply remedies that were applied before by the villagers. If they still had persistence of the problem, then they would go to a doctor. Therefore, it has been determined that they first consulted the elderly and neighbors in case of an illness (Tanrıverdi et al., 2011). The results of the study showed these similarities. Most from the ESEAR group stated that they do not discriminate between male and female in the choice of doctors; however, the women in the group stated that if there is a female doctor, then she is their first choice. In Guatemala, it is stated that women refuse to be examined by men and men by female health personnel (Ellis & Purnell, 2013). Even though studies abroad indicate stigma against mental disorders, all elderly people from both groups stated that these individuals should be taken care of well. This aspect is considered a desirable approach. In both groups, most elderly individuals stated that they do not believe in the traditional healers and they only pray or carry an amulet against the evil eye. It is reported that when Guatemalan people become ill, they first consult their mothers, grandmothers, or a respected elderly person (Ellis & Purnell, 2013). In a study conducted in the countryside of Erzurum, it was noted that elderly people go to doctor, spiritual master, bonesetter, neighbors, and tomb depending on the situation (Tanrıverdi et al., 2011).

Violence Against the Elderly

In this study, two elderly from ESEAR and one elderly from MR stated that they were subjected to psychological violence in the family. In addition, the elderly in both groups stated that they have been exposed to verbal behaviors by the younger generation that they do not approve. Similar to the results of the study, psychological violence was identified as the most common type of violence in the literature (Jordanova-Peshevska et al., 2014; Sooryanarayana et al., 2017; Yon et al., 2017). According to the various surveys conducted in Turkey, psychological violence ranged between 8.4%–67.6% (Daşbaş, 2014; Ergin et al., 2012; Ilhan, 2006; Keser-Özcan et al., 2017; Kıssal, 2008). The literature reveals that the elderly individuals are mostly exposed to psychological violent behaviors, such as swearing and shouting (Markovik, 2014). Approximately, 66% of elderly people in a study that included seven provinces in Turkey stated that they suffered from mental pressure through gestures, verbal and facial expressions (Tufan, 2011). The results of the study are similar to the domestic and international literature.

In this study, it was determined that two elderly individuals from MR were subjected to physical violence, one from her son and the other by a younger person in public. In a study conducted by Ghodousi et al. (2011) in Isfahan, Iran, it was stated that all elderly individuals are exposed to abuse by the people they know and in almost half of the cases, abuser is the son himself. Karbeyaz and Çelikel (2017) examined 253 cases of physical violence evaluated by the Forensic Medicine Institute wherein all abusers were victims’ acquaintances, and in 114 cases (45.1±3.1%), abusers were noted to be victims’ sons. In this research, even though no evidence was noted of sexual and economic violence, it is thought that this stems from the perception of confidentiality toward domestic economy and sexuality, which are among the cultural taboos of the society.

CONCLUSION AND RECOMMENDATIONS

Based on the results of this study, cultural differences and similarities were determined among the elderly from ESEAR and MR. According to the statements, it was determined that there is a perception that elderly people should be taken care of, looked after, listened well, not forced to work, and have a say in decisions by the family members. All participants from both groups did not have a positive approach toward nursing homes. In this study, two participants from ESEAR and one from MR stated that they were exposed to psychological violence. Two participants from MR stated that they were subjected to physical violence-one person by her son and the other by a younger person in public. The elderly individuals in both groups were exposed to disrespectful behavior by the younger generation. None of the participants from ESEAR and MR stated anything about sexual or economic violence.

Based on these results, it may be recommended to researchers to conduct multidisciplinary studies that could reveal economic and sexual violence; change the negative perception toward nursing homes; plan initiatives to raise awareness regarding young people’s attitudes and behaviors toward the elderly; reduce communication barriers in older people who migrate; provide measures to ensure that elderly people are more involved in decisions within the family.