FULL 

REPORT 






“We See Things Other People Aren’t Going to See”: 
Facilitators and Barriers to Screening and Management 
of Elder Abuse by Tribal Health Care Providers 






A National Needs Assessment 



THE INTERNATIONAL ASSOCIATION FOR INDIGENOUS 

AGING 



2019 











National Resource Center for Reaching Victims logo

Contents 
Acknowledgements.............................................................................................. 4 
Report Authors ..................................................................................................... 5 
About IA2 ............................................................................................................ 5 
Funding Acknowledgement ................................................................................. 6 
Executive Summary .............................................................................................. 7 
New and Noteworthy Key Findings .................................................................................... 9 
Policy and Practice Recommendations ............................................................................. 11 
Conclusion ............................................................................................................................ 13 
Introduction ........................................................................................................ 14 
Background: ......................................................................................................................... 15 
Abuse Research Among AIAN Elders ............................................................................... 17 
Native Contextual Influences on Elder Abuse ................................................................. 18 
The Role of Health Care Providers in Addressing Elder Abuse .................................... 22 
Screening is Hampered ................................................................................................. 22 
Few Evidence-Based Interventions Exist ..................................................................... 23 
Methods ............................................................................................................. 26 
Analysis ................................................................................................................................. 29 
Sample .................................................................................................................................. 31 
Interviews ......................................................................................................................... 31 
Table 1 Interview participant demographic information and details about practice 
location ................................................................................................................................. 33 
Online Survey .................................................................................................................. 34 
Table 2 Survey participant demographic information and details about practice 
location ................................................................................................................................. 35 
Results ............................................................................................................... 36 
Interview Findings ................................................................................................................ 36 
Thematic Analysis ........................................................................................................... 36 
Content Analysis ............................................................................................................. 67 
Table 3 Interview Participant Responses on Elder Abuse and Mistreatment 
Experiences ........................................................................................................ 69 
Survey Findings .................................................................................................................... 70 
Comparison of Survey Findings to Interview Themes ..................................................... 84 
Individual Variables ....................................................................................................... 84 
Familial Variables .......................................................................................................... 85 
Cultural Variables .......................................................................................................... 88 
Community Variables..................................................................................................... 90 
Organizational Variables............................................................................................. 91 
Needs ............................................................................................................................... 91 
Discussion .......................................................................................................... 92 
Screening is Widely Accepted, But Not Being Widely Accomplished ......................... 93 
Desire for Training, Protocols and Tools ......................................................................... 93 
Findings Confirmed by Previous Research ....................................................................... 94 
Noteworthy or New Findings ............................................................................................. 94 
Historical and Current Traumas ................................................................................... 94 
Poverty and Other Social Determinants of Health .................................................. 97 
Community, Public Health and Home Health as Surveillance & Intervention ... 100 
Need to Explore the Link Between Culture and Abuse ........................................ 101 
MDTs, Another Promising Intervention ..................................................................... 103 
Self-Neglect Largely Absent in Assessment, But A Significant Issue .................. 105 
Policy and Practice Recommendations .......................................................................... 105 
Conclusion ....................................................................................................... 108 
Limitations ....................................................................................................... 109 
References ........................................................................................................ 112 
Appendix ......................................................................................................... 121 
Tribal Health Provider Interview Guide ......................................................................... 121 
Tribal Health Provider Online Survey ........................................................................... 128 

Acknowledgements 

This project was funded by a generous grant from The National Resource Center for 
Reaching Victims of Crime via the United States (U.S.) Department of Justice Office 
of Victims of Crime. 

 

The project team would first like to extend their deepest gratitude to the many 
tribal health care providers, staff, and elder and elder abuse advocates for 
sharing their time, expertise, and experience with us through interviews and surveys. 
Without their participation and the support of the many tribes, clinics, and 
organizations for whom they work this report and the lessons learned through this 
work would not be possible. Tribes, clinics, and participants were provided a 
guarantee of confidentiality to encourage their open and honest responses, as such, 
we are unable to acknowledge them individually by name. 

 

Special thanks to Dr. Susan Kools from the University of Virginia School of Nursing, 
who provided invaluable feedback on the project concept. Also, we extend our 
appreciation to Dr. Kim Dash from the Education Development Center for providing 
expert review and feedback on the interview guide and survey. We would also like 
to give thanks to all of the organizations and individuals that assisted us in reaching 
out to and identifying interview and survey participants. In particular, Cynthia 
LaCounte (Turtle Mountain Chippewa), Director of the Office for American Indian, 
Alaskan Native, and Native Hawaiian Programs at the U.S. Administration on 
Aging, an agency of the Administration for Community Living, was a staunch 
supporter, project advocate, and valuable source of connection to tribes, tribal staff 
participants, and other federal agencies engaged in elder abuse activities. We 
extend our gratitude to the National Center for Urban Indian Health (NCUIH), who 
was the first organization to promptly and warmly respond to our request for 
assistance in reaching urban Indian health centers. Rebecca Balog (Oglala Lakota, 


Mohawk, and Czechoslovakian Gypsy/Romani) formerly with the National 
Indigenous Women’s Resource Center (NIWRC) and now the Women of Color 
Network who was instrumental in making introductions to anti-violence advocates 
across the U.S. Captain Susan Karol, M.D. with the Centers for Medicare and 
Medicaid (CMS) Division of Tribal Affairs, made multiple introductions with national 
tribal organizations and tribal resource centers in an effort to assist in identifying 
participants. Finally, thanks to Dr. Bruce Finke, with the U.S. Indian Health Service 
(IHS), who facilitated outreach and communication with the entire network of IHS 
providers and staff. 

 

We also extend our gratitude to Jacki Chernicoff, Senior Program Associate at the 
Vera Institute of Justice, who served as our project officer over the course of this 
grant, and Katie Block from the National Clearinghouse on Abuse in Later Life 
(NCALL). Katie, Jacki and other support staff at the Vera Institute were an 
invaluable resource. 

Report Authors 

• Jolie W. Crowder, PhD, MSN, RN, CCM 
• Linda D. Carson, PhD, MPH, BSN 
• Kendra Kuehn, MSW 
• Dave Baldridge 


 

About IA2 

The International Association for Indigenous Aging, a 501(c)3 non-profit educational 
association, works to: 

(1) Ensure the provision of appropriate and quality services and resources for 
indigenous elders; 


(2) Expand opportunities for elders’ involvement in environmentalism, community 
participation, health maintenance, volunteerism/civic engagement, consumerism, 
senior enterprise; 

(3) Enhance the protection of the rights of elders including their freedom from abuse 
and neglect and their right to autonomy; 

(4) Educate the public, policymakers and practitioners about the status of 
indigenous elders; and 

(5) Improve the status of older people worldwide, especially indigenous 
populations. 

 

International Association for Indigenous Aging (IA2) 

11101 Georgia Ave.#320 

Silver Spring, MD, 20902 

Phone: 301.933.6492 

admin@iasquared.org 

 

IA2 Logo: International Association for Indigenous Aging


Funding Acknowledgement 

This report was produced by the International Association for Indigenous Aging (IA2). 
The original project and full final report were produced under award #2016-XV-GX-
K015, awarded by the Office for Victims of Crime, Office of Justice Programs, U.S. 
Department of Justice. The opinions, findings, and conclusions or recommendations 
expressed do not necessarily represent the official positions or policies of the U.S. 
Department of Justice. 

 

National Resource Center for Reaching Victims logo: Helping those who help others



Executive Summary 

The International Association for Indigenous Aging (IA2), with funding from The 
National Resource Center for Reaching Victims of Crime, sought to understand the 
current needs and experiences of tribal health care clinics in screening and 
managing elder abuse among American Indian and Alaska Native (AIAN) older 
adults. This is the first and most comprehensive national needs assessments designed 
to identify facilitators and barriers for screening and management of elder abuse 
by tribal health care providers. 

 

The project was developed based upon the belief that the diverse cultural, social, 
and health needs of tribal elders who are affiliated with or health care providers 
who serve the 573 federally recognized American Indian tribes and Alaska Native 
Villages in the United States (U.S.) (Bureau of 

Indian Affairs, n.d.) create a unique context in which to understand the recognition 
and management of elder abuse in outpatient clinical practice. 

 

The state of the science on elder abuse among AIAN people is similar to that of 
other minority and vulnerable groups; it is limited, progress has been slow, and 
solid comparable prevalence estimates are lacking (Jervis & Sconzert-Hall, 2017; 
Sapra et al., 2014). The available research demonstrates a potentially high 
prevalence of abuse of AIAN elders that occurs at the intersection of contextual 
factors that include inter-tribal cultural diversity, tribal sovereignty, complex tribal 
justice systems, 

historical trauma, acculturation, urban migration, and demographic and health 
disparities (Crowder, Burnett, Laughon, & Driesbach, 2019; Crowder et al., 2019). 

 

Health care providers in the United States (U.S.) are uniquely positioned to take an 
active role in addressing the epidemic of abuse and violence targeting elders. 


Though, little screening for elder abuse actually occurs. Perhaps owing to a host of 
barriers or related to the continued scarcity of 

high-quality research and availability of victim services for older adults, including 
AIAN elders. In spite of these barriers, providers are already forced to engage in 
handling cases of elder mistreatment in their clinical practice. 

 

The information obtained from this needs assessment is designed to fill a gap in 
practice and policy for tribal providers and perhaps lend useful insights for 
mainstream health providers. 

 

Project objectives include: 

• Describe provider, community, cultural, and systematic (clinic-level) factors 
that contribute to how victims of elder abuse are identified and managed in 
outpatient clinical settings; 
• Identify facilitators and barriers to recognition and management of elder 
abuse; 
• Explore the context of providing clinical care for abused elders; 
• Identify phenomena related to care of elders unique to AIAN cultures; and 
• Identify existing promising practices for screening and management of elder 
abuse among tribal health providers. 


 

To address the project objectives, a multi-phased mixed methods iterative design 
was employed, that incorporated qualitative and quantitative data collection and 
analysis across two data sets, including telephone interviews (n = 23) and an online 
survey (n=90) with participants from 22 states. 

 


New and Noteworthy Key Findings 

• Screening is widely accepted by not widely accomplished by tribal health 
care providers. 
o Just 54% routinely screen for elder abuse & only three clinics use an 
elder specific screening tool. 
o 85% believe they have the capacity to be able to identify all 
different types of elder abuse. 
o Only 43% agree that they are knowledgeable about how to screen 
and manage for cases of elder abuse. 



• Tribal health care providers are already dealing with elder abuse cases: 
70% have worked with patients experiencing financial exploitation, 60% 
have experience with neglect or emotional abuse, and 43% have experience 
with physical abuse. 


Chart: 89% Believe Providers Should Play A Role in Screeening for Elder Abuse
89%

BelieveProviders Should 
Play A Role in Screeening 
for Elder Abuse


• Providers say they lack proper protocols for managing cases of elder abuse, 
have received little training, and either lack information about how to access 
available community services or supports, or lack the actual community 
services and supports to address needs. 



• Essential services for Native elders face substantial deficits in funding. 
Provider concerns about funding deficiencies for elder services include 
community health, behavioral health, and access to other community and 
health services for elder victims of abuse including housing, food, and 
transportation. 
• There is a need to better understand the link between culture and abuse, 
specifically the role of acculturation and assimilation and historical trauma at 
the individual, family, and community level. 
• Community health representative (CHR), public health, and home health 
programs emerged as promising practices for both screening and as 
interventions in cases of alleged or confirmed abuse. 


Chart: 
51% Don't Have or Know 
of Protocol or Process 
for Handling 
Suspected Cases
51%

Don'tHave or Know 

of Protocol or Process 

for Handling 

Suspected Cases


• Programs designed to reinvigorate cultural traditions such as language, 
culture, and food; multidisciplinary teams (MDTs); tribally funded Adult 
Protective Service (APS) designated workers also appeared as potential 
promising practices. 



• Cultural programs may offer the opportunity to meaningfully engage elders 
and provide opportunities to reduce social isolation. 
• Additional funding is needed for identified priorities including: tribal 
outreach and awareness (greatest need), social workers, respite and in-home 
nursing care, research to establish a tribal-specific evidence base for 
screening and interventions. 


 

Policy and Practice Recommendations 

Based upon needs assessment findings and existing elder abuse literature specific 
to AIAN elders, the following policy and practice recommendations are offered for 
tribes, counties, state, and federal level policymakers as well as health care 
practitioners. 

 

Assessment findings indicate that screening tools, protocols, and training are 
the most pressing priorities for health care providers, though the list below is 
not in order of priority. 

• Development or adaptation of a tool(s) or best practices to systematically 
assess community supports, services, and assets for tribal health providers 
and elder abuse victims available within or adjacent to tribes and to tribal-
serving health care entities. 
• Dedicated tribal-funded APS staff person, social worker, case manager, or 
elder service worker(s) with APS-type roles and responsibilities (in tribes that 
do not currently have this type of position). 
• Enhance or establish relationships between existing tribal and county APS 
and MDT programs and outpatient tribal health centers to promote regular 
opportunities for training and ongoing support of clinical staff referrals; 
incorporate health center staff into existing MDTs. 



• Initiate or enhance tribal-run CHR and/or home health programs, or identify 
alternative funding streams to make current programs solvent. 
• Standardized provider training on elder abuse assessment and management 
that addresses complicated cases, red flags, and “grey areas” that 
incorporates a trauma-informed care approach specific to the needs of AIAN 
elders 
• Selection and testing of elder-specific abuse clinical screening tool including 
short- and long-term outcomes in tribal clinical setting. 
• Testing/adaption of cultural appropriate, specific tools specific to AIAN 
elders 
• Development of standardized screening protocols for assessing abuse and 
exploitation in older adults that is adaptable by local tribes and health 
providers for both outpatient clinic and home-based care settings. 
• Training on effective use of standardized screening protocol for all health 
center and homebased care staff including administrative staff who have 
direct patient contact. 
• Development of a standardized intervention protocol including suggested 
interventions and accompanying training that is adaptable by local tribes 
and health providers. 
• Support for existing MDTs and expansion to new tribes for assessment, 
development of an action plan and systematic approach to MDTs as an elder 
abuse intervention with process specific evaluation or assessment to assess 
outcomes and identify opportunities for improvement. 
• Development and empirical testing of strategies to enhance community 
outreach, awareness, and reporting of elder abuse including approaches to 
promote tribal leadership buy-in. 



• Empirical assessment of the direct and indirect impact on elder abuse and 
exploitation of programs designed to promote cultural revitalization. 


 

Conclusion 

Outpatient tribal health care provider participants are willing and ready to 
embrace screening for abuse among their older patients. These same providers are 
already required to intervene in clinical settings that more often than not lack 
proper protocols for managing cases of elder abuse, offer little training, and either 
lack information about available community services or supports or lac the actual 
community services and supports. 

 

Some findings from this assessment are reflective of previous elder abuse research 
inclusive of AIAN communities, or support findings from research among mainstream 
populations, e.g., health care providers’ barriers to screening. However, our project 
team believes the needs of tribal elders are unique, and the needs of each of the 
respective tribal clinics, villages, and communities is unique when it comes to 
addressing the issue of elder abuse. Systems, protocols, services, and supports must 
be designed and implemented, ideally by tribes and tribal providers themselves or 
in close collaboration to ensure they meet the unique needs of their tribal elders 
and their respective tribal clinics, villages, and communities. 

 


Introduction 

This report describes findings from what we believe is the first and most 
comprehensive national needs assessments to date designed specifically to identify 
facilitators and barriers for screening and management of abuse by tribal health 
care providers among American Indian and Alaska Native (AIAN) elders. The 
International Association for Indigenous Aging (IA2), with funding from The National 
Resource Center for Reaching Victims of Crime, sought to understand the current 
needs and experiences of tribal health care clinics in recognizing and managing 
elder abuse. This assessment is part of an overarching goal of promoting and 
implementing screenings, referrals, and/or interventions for AIAN elders who are 
victims of abuse. 

 

The project was developed based upon the belief that the diverse cultural, social, 
and health needs of tribal elders who are affiliated with or providers who serve the 
573 federally recognized American Indian and Alaska Native Villages in the 
United States (U.S.) (Bureau of Indian Affairs, n.d.) creates a unique context in which 
to understand the recognition and management of elder abuse in outpatient clinical 
practice. 

 

The objectives of the project were to: 

• Describe provider, community, cultural, and systematic (clinic-level) factors 
that contribute to how victims of elder abuse are identified and managed in 
outpatient clinical settings; 
• Identify facilitators and barriers to recognition and management of elder 
abuse; 
• Explore the context of providing clinical care for abused elders; 
• Identify phenomenon related to care of elders unique to AIAN cultures; and 



• Identify any existing promising practices for screening and management of 
elder abuse among tribal health providers. 


 

This report presents needs assessment findings with the intent of providing valuable 
practice and policy insights and recommendations for elder abuse screening and 
interventions in tribal health settings. A background of the state of the science on 
elder abuse from the lens of tribal elders and health care providers, the applied 
project methodology, findings, and a discussion that includes potential policy and 
practice recommendations are provided. 

 

Background 

Elder abuse is a global phenomenon that takes a distressing toll on individuals, 
families, and communities. Estimates suggest that 1 in 6 older adults, or 15.7%, 
have experienced some form of abuse worldwide, with a prevalence of 11.7% in 
the Americas (Yon, Mikton, Gassoumis, & Wilber, 2017). However, the problem is 
likely more widespread, as similar to other forms of abuse, elder abuse is 
underreported with an estimated 1 in 24 cases reported (Lifespan of Greater 
Rochester, Inc., Weill Cornell Medical Center of Cornell University, & New York City 
Department for the Aging, 2011). Though identification of a single definition is 
difficult (Killick, Taylor, Begley, Carter Anand, & O’Brien, 2015), the Elder Justice 
Roadmap, a plan supported by the U.S. Department of Justice (DOJ) and 
Department of Health and Human Services (HHS), defines it as: 

 

physical, sexual or psychological abuse, as well as neglect, abandonment, and 
financial exploitation of an older person by another person or entity, that occurs 
in any setting (e.g., home, community or facility), either in a relationship where 
there is an expectation of trust and/or when an older person is targeted based 
on age or disability (Connolly, Brandl, & Breckman, 2014, p.3). 

 


According to the U.S. Centers for Disease Control and Prevention (CDC), elder 
abuse, mistreatment, or maltreatment can take the form of physical, 
emotional/psychological, sexual, financial, or neglect (Hall, Karch, & Crosby, 2016). 
The CDC defines the types of elder abuse as follows: 

Physical abuse: “The intentional use of physical force that results in acute or chronic 
illness, bodily injury, physical pain, functional impairment, distress, or death” (p. 31). 

Sexual abuse: “Forced and/or unwanted sexual interaction (touching and non-
touching acts) of any kind with an older adult” (p. 32). 

Emotional/psychological abuse: “Verbal or nonverbal behavior that results in the 
infliction of anguish, mental pain, fear, or distress, that is perpetrated by a 
caregiver or other person who stands in a trust relationship to the elder” (p. 33). 

Neglect: “Failure by a caregiver or other person in a trust relationship to protect an 
elder from harm or the failure to meet needs for essential medical care, nutrition, 
hydration, hygiene, clothing, basic activities of daily living or shelter, which results in 
a serious risk of compromised health and/or safety, relative to age, health status, 
and cultural norms” (p. 34). 

Financial abuse or exploitation: “The illegal, unauthorized, or improper use of an 
older individual’s resources by a caregiver or other person in a trusting relationship, 
for the benefit of someone other than the older individual” (p. 35). 

 

Elder abuse results in multiple negative physical and psychological outcomes. The 
impact ranges from visible bruises to harder to identify psychological consequences 
such as depression, posttraumatic stress disorder, or higher rates of later life 
disability (Hall et al., 2016). Victims of abuse experience mortality rates twice those 
of people not subjected to abuse (Baker et al., 2009). The economic impact is 
severe for older adults and family caregivers, not only from direct losses due to 
financial exploitation (MetLife Mature Market Institute, 2009), but as a result of 


higher rates of hospitalization or placement in nursing homes (Rovi, Chen, Vega, 
Johnson, & Mouton, 2009). 

 

Elder abuse is a problem that will compound as the population continues to age. The 
shifting demographic profile of older adults will include a larger percentage of 
people who identify as Black, Asian, AIAN, and Native Hawaiian and other Pacific 
Islander, while the percentage of people who identify as white will decline. The 
AIAN and Hawaiian and Pacific Islander populations will grow at a rate two or 
more times faster than whites (Ortman et al., 2014), with the AIAN population 
having grown 27 percent from 2000 to 2010 (Norris, Vines, & Hoeffel, 2012). 
AIAN elders 65 and older will more than triple, numbering 1,624,000, and those 
85 years of age and older will increase more than sevenfold by 2050 (Ortman et 
al., 2014). 

 

Abuse Research Among AIAN Elders 

The state of the science on elder abuse among AIAN people is similar to that of 
other minority and vulnerable groups; it is limited, progress has been slow, and 
solid comparable prevalence estimates are lacking (Jervis & Sconzert-Hall, 2017; 
Sapra et al., 2014). A recent integrative review revealed nine research articles 
from studies that span 30 years, with only one research article published in the past 
five years (Crowder, Burnett, Laughon, & Driesbach, 2019). The available research 
demonstrates a potentially high prevalence. For studies exclusive to AIAN elders, 
abuse rates of 10 to 49% have been reported (Brown, 1989; Buchwald et al., 
2000). In studies that compared racial subgroups including American Indians, abuse 
rates were higher than whites (Baker et al., 2009; Mouton et al., 2004). 

 

More recent subgroup analysis of the National Elder Mistreatment Study (NEMS), 
the largest population-based study of elder abuse prevalence in the U.S., found 


that AIAN elder respondents had a cumulative prevalence almost double that of 
overall original study findings compared with white respondents (Crowder, Burnett, 
Byon, et al., 2019). The cumulative prevalence was 33% for emotional, physical, 
and sexual mistreatment in the past year; neglect; and financial abuse by a family 
member within the AIAN group. The prevalence of abuse since 60 ranged from a 
high of 

24.7% for emotional mistreatment to a low of .6% for sexual mistreatment. 

Lifetime prevalence rates ranged from 34.9% for emotional mistreatment to 17.6% 
for sexual mistreatment (lifetime neglect and financial exploitation rates were not 
measured) (Crowder, Burnett, Byon, et al., 

2019). 

 

Neglect and financial exploitation are suggested in research as the most common 
forms of abuse experienced in Indian Country (Brown, 1989; Jervis & Sconzert-Hall, 
2017; Kauffmann Associates, 2015; Maxwell & Maxwell, 1992). Potential risk 
factors are thought to include economic issues, substance abuse, gender (female), 
mental health problems, poor health, high rates of disability, single-parent 
households, lower education, marital status, employment status, acculturation, and 
caregiving-related issues (Baldridge, Nerenberg, & Benson, 2004; Brown, 1989; 
Buchwald et al., 2000; Jervis & Sconzert-Hall, 2017; Kauffmann Associates, 2015; 
Maxwell & Maxwell, 1992). 

 

Native Contextual Influences on Elder Abuse 

Inter-tribal cultural diversity, tribal sovereignty, complex tribal justice systems, 
historical trauma, acculturation, urban migration, and demographic and health 
disparities are just a few issues that create the unique ecology in which abuse of 
AIAN elders occurs and may contribute to increased risk (Baldridge et al., 2004; 


Brown, 1989; Goins et al., 2015; Jervis & Sconzert-Hall, 2017; Kauffmann 
Associates, 2015; Sapra et al., 2014). 

 

Article 1, Section 8 of the Constitution dating back to 1787 codified the special 
government-to-government relationship between Indian tribes, considered sovereign 
nations, and the Federal government (“About IHS,” n.d.). As sovereign nations, 
federally recognized tribes have legal jurisdiction over their lands and citizens 
residing on those lands. Each tribe is authorized to enact its own laws, courts, and 
justice systems through the Indian Self-determination and Education Assistance Act 
and the Tribal Self-Governance Act of 1994, though not all do (U.S. Department of 
the Interior Indian Affairs, n.d.). Some tribes manage the response system in cases of 
elder abuse while others rely on adult protective service (APS) programs managed 
by county or state entities. Tribes who choose to manage the response to elder 
abuse may develop tribal codes (similar to U.S. or state-based laws) to define 
abuse and outline the process for reporting, investigation, or response (Baldridge et 
al., 2004). Jurisdiction can vary by the location of the offense, whether that land is 
Indian trust land or tribally controlled, whether the elder resides on or off the 
reservation, the race and ethnicity of the victim and perpetrator, and the nature of 
the crime. Tribal, state, or federal courts could maintain jurisdiction based on these 
factors and may be concurrent (more than one 

jurisdiction can hear a case), or exclusive (only one government can hear a case). 
Non-tribal deputies and local police may be cross-deputized to allow them to 
respond. Jurisdiction limits imposed on tribal courts, including the inability to 
prosecute non-Indian perpetrators and federal law limiting tribal courts sentencing 
powers, is also an issue (Baldridge et al., 2004). The resultant system can be 
complicated, and navigation can be a challenge for both elders, elder advocates, 
and law enforcement. 


 The AIAN elder population’s demographic and health profile, is significantly 
different from whites and includes a higher prevalence of many known or suspected 
abuse risk factors. Older Indians are more likely to experience socioeconomic and 
health coverage disparities including lower incomes, higher rates of poverty, lower 
education, and higher rates of being uninsured than the general population (Goins 
et al., 2015). Native elders are also more likely to describe their overall health 
status as fair or poor, are twice as likely to be hospitalized, have higher rates of 
diabetes, stroke or heart attack, and reported suffering from depression more 
frequently than the overall U.S. population (Boccuti, Swoope, & Artiga, 2014). 
American Indians have also been found to experience a higher incidence of 
traumatic events and suffer related psychological issues over their lifetime (Çayır, 
Burke, Spencer, Schure, & Goins, 2018). 

 

In addition to socioeconomic and health issues, historical trauma and loss have been 
suggested as possible causative factors for higher rates of violence directed at 
Native elders (Baldridge, 2001; Maxwell & Maxwell, 1992; Sapra et al., 2014). 
Early American colonization including genocide, mandatory tribal relocation 
practices, forcible placement of Indian children into overcrowded or abusive 
boarding schools, and other policies and programs designed disrupt traditional 
ways of tribes and challenge tribal sovereignty have only been addressed in the 
last few decades (“American Indian boarding schools,” 2016; Garrett & Pichette, 
2000). The extent and duration of ongoing emotional and psychological trauma 
across the lifespan encompassing generations of a massive population of people is 
unique to AIAN people within the application of theories of historical trauma and 
loss. Many are faced with near-daily reminders of these losses that are manifested 
in destitute conditions on some reservations, poverty in urban settings, ongoing 


discrimination, and reminders of loss of culture and language (Armenta, Whitbeck, 
& Habecker, 2016; Whitbeck et al., 2004). 

 

Acculturation, assimilation, or the degradation of tribal customs and norms are 
another frequently cited causative factors of elder abuse among American Indians 
and Alaska Natives (Baldridge et al., 2004; Baldridge, 2001; Hudson, Armachain, 
Beasley, & Carlson, 1998; Jervis & Sconzert Hall, 2017; Maxwell & Maxwell, 
1992). Acculturation is the dynamic process of adapting to the mainstream culture 
that includes four adaptations: assimilation, integration, rejection, and deculturation 
(as cited in Padilla & Perez, 2003, p.37). Acculturation and assimilation (forced or 
otherwise) are thought to have contributed to the degradation of some tribe’s sense 
of duty and honor to elders or resulted in a weakening of community and social 
structures. From federally funded boarding school programs, that forcibly removed 
Native children from their homes and 

forbid them to engage in Native customs, practices and languages, to forced 
assimilation through urban relocation programs in the 1950s designed ultimately to 
terminate government support for tribes and end protected status of lands, AIAN 
history is fraught with attempts at assimilation and subdue Native culture. 

 

Boarding schools, mandatory relocation to reservations likened to concentration 
camps or penal colonies, forced loss of culture, policies promoting urban migration, 
and rampant discrimination (that persists) were among the lived experiences of 
many tribal elders alive today, and have created historical individual, community, 
and structural traumas, with intergenerational impacts (Braveheart & DeBruyn, 
1998). The relationship of historical trauma and loss, acculturation or assimilation, 
tribal culture and norms, tribal jurisdictional or policy issues, and geographic 
location (urban versus rural or tribal lands) to elder abuse or other forms of 
interpersonal violence appear to all as yet be untested. 


 

The Role of Health Care Providers in Addressing Elder Abuse 

Screening is Hampered 

Nearly two decades ago Buchwald and colleagues (2000), authors of one of the 
few research studies of elder abuse in the AIAN population, called for health care 
provider training to enable screening and an appropriate response to elder 
mistreatment in the clinical setting. Still today, health care providers conduct very 
little screening for abuse or risk factors, though they have multiple opportunities to 
do so, and are in a unique position to screen or intervene to prevent or minimize the 
effects of elder abuse (Burnett, Achenbaum, & Murphy, 2014; Dong, 2015; 
Twomey & Weber, 2014). 

 

In 2014, the U.S. Preventive Services Task Force (USPSTF) issued a recommendation 
for no general screening for elder abuse based upon insufficient evidence 
regarding benefits and harm from screening. Though, they did recommend routine 
screening of women of child-bearing age for intimate partner violence (IPV) based 
upon existing research (U.S. Preventive Services Task Force, 2014). The USPSTF 
noted that there was no direct evidence that screening for elder abuse could be 
harmful, though IPV literature indicated that there was the potential for small risk. 
Few studies supporting this assertation are available, thus the belief is largely 
theoretical and not based on rigorous existing evidence. Five years later, in the 
most recent update of the guidelines the USPSTF again found there are no existing 
studies assessing screening and treatment for elder abuse (Feltner et al., 2018). 

 

Little systematic screening for elder abuse occurs. This may be the result of the 
USPSTF recommendations or related to a variety of barriers identified by 
providers. According to Dong (2015), health professionals are reluctant to address 
elder abuse for a variety of reasons. This might include victim denial, lack of 


knowledge about reporting protocols, risk to physician patient rapport, concern 
over retaliation by perpetrators, time limitations, misperception that convincing 
evidence is necessary to report, fear of liability, lack of evidence-based 
interventions, and the challenge of assessing capacity in aging adults. Lack of 
education and training, psychological barriers on the part of providers, and 
reimbursement issues are additional issues providers have identified (Shefet et al., 
2007). The American Medical Association and researchers and providers 
contributing to elder abuse literature continue to support and provide solid 
rationale for health care provider involvement in screening and management of 
elder abuse (Burnett et al., 2014; Dong, 2015; Hoover & Polson, 2014), with some 
suggesting that abuse should be treated by providers like any 

other disease (Burnett et al., 2014). 

 

Few Evidence-Based Interventions Exist 

A consequence of chronic funding shortfalls to address elder abuse is a scarcity of 
high-quality research and availability of victim services geared towards older 
adults, including AIANs. Two published reviews of the international literature on 
elder abuse addressing interventions were identified; one a systematic review 
focused only on interventions (Ayalon, Lev, Green, & Nevo, 2016) and the second a 
scoping review that focused on prevention (Pillemer, Burnes, Riffin, & Lachs, 2016). 
Nineteen articles identified from 2000 to 2014 included interventions that targeted 
caregivers (institutional and unpaid/informal), three targeted older adults who 
were victims of abuse, and two targeted professionals responsible for preventing 
maltreatment. The strongest evidence base existed for interventions targeting 
physical restraints among paid long-term care providers, relying largely on 
provider education to reduce restraint use. 

 


Pillemer et al (2016) noted only approximately 10 intervention studies had been 
conducted “with even minimally acceptable methods,” and most of the results were 
negative or ambiguous (p. S200). As a result, their selection of five promising 
interventions relied on multiple case studies and program description that reported 
positive effects, but lacked a rigorous base of evidence. The interventions identified 
by Pillemer et al included: caregiver interventions, money management programs, 
helplines, emergency shelters, and multidisciplinary teams (MDTs). The authors also 
note that even though “there is a paucity of evaluation data, there is consensus in 
the field internationally regarding the need to expand the range of services for 
elder mistreatment” (p. S201– S202). 

 

A 2011 systematic review of the effectiveness of education programs designed to 
improve recognition and reporting of elder abuse identified just 14 articles 
published from 1996 to 2007 (Alt, Nguyen, & Meurer, 2011). Of these, only one 
program targeted practicing physicians; six programs targeted physicians-in-
training; five targeted allied health professionals and aging service providers; one 
targeted an entire hospital staff; one targeted emergency medical service 
providers; two programs trained dental professionals; and one described a social 
work degree program with a geriatric track. Interventions generally included brief 
training seminars from one hour to three days. While the evidence is limited and the 
only existing systematic review a bit dated specific to training and educational 
interventions targeting health care providers, what exists indicates that among 
mainstream health care providers, programs for screening and management of 
victims of elder abuse can meet with success. Health care providers, including those 
in the primary care setting, are irrefutably uniquely positioned to take an active 
role in addressing the epidemic of abuse and violence targeting elders by 
addressing the issues in multiple ways. In fact, they likely already are. Though, the 
present literature fails to reflect these activities. Further, none of the current 


literature on health care providers’ intersection with elder abuse, including provider 
screening or interventions in the clinical setting, are specific to or incorporate AIAN 
elders or tribal providers. The scarcity of research and information about elder 
abuse in the AIAN population, complexity of the contextual and social issues they 
face, and lack of clinical screening and intervention studies should not deter action. 
The information obtained from this needs assessment, we believe, will fill a major 
gap in practice and policy for tribal providers and perhaps even lend useful 
insights for mainstream health providers. 

 


Methods 

Answers to needs assessment questions were elicited through a multi-phased mixed 
methods iterative design, which incorporated qualitative and quantitative (to include 
demographic) data collection and analysis across two data sets including telephonic 
interviews and an online survey. Between January and May of 2019, a robust and 
comprehensive outreach effort was conducted to identify health care providers and 
later domestic violence advocates focused on elder abuse and tribal APS workers 
to participate in telephone interviews, and staff from tribal clinics to participate in 
the online survey. A nominal incentive identified to potential participants only as a 
“small gift card” was offered to interview participants and a “chance” to be 
entered into a drawing for survey respondents. Final incentives provided at the 
conclusion of data collection ranged from $20 - $25. Notably, almost one-third of 
interview participants initially offered incentives declined due to federal prohibition 
of the acceptance of gifts. 

An email list of 281 tribal health directors were contacted. Ten percent of email 
addresses on that list were undeliverable. Multiple major tribal advocacy 
organizations and resource centers were contacted for assistance in reaching 
interview and survey participants, including: 

• Area Indian Health Boards (11) – Variable responses 
• Association of American Indian Physicians (AAIP) – Lost to follow-up 
• National Center for Urban Indian Health Care (NCUIH) – Responded 
• National Center on Abuse in Later Life – Unable to assist 
• National Congress for American Indians (NCAI) – No response 
• National Indian Council on Aging – No response 
• National Indian Health Board (NIHB) – Unable to assist 
• National Indigenous Elder Justice Initiative – No response 
• National Resource Center for Alaska Native Elders – Lost to follow-up 



• National Resource Center on Native American Aging (NRCNAA), University of 
North Dakota (UND) – Lost to follow-up 
• Indians into Medicine Program, UND) – Responded 
• Women of Color Network (WOCN) - Responded 


 

In addition, multiple U.S. federal agencies were contacted including: 

• Administration for Community Living (ACL) – Responded 
• Bureau of Indian Affairs (BIA) – Responded 
• Centers for Medicare and Medicaid (CMS) Tribal Technical Advisory Group 
(TTAG) – Responded 
• Department of Justice (DOJ) – No Response 
• Indian Health Service (IHS) - Responded 


 

In total, project outreach tracking identified 366 contacts initiated for interview and 
survey recruitment or assistance with outreach. The total number of recipients 
reached via these requests is unknown as multiple tribal health directors, several 
Indian Health Board directors, and several 

IHS regional Chief Medical Officers indicated they had forwarded requests within 
their network of contacts. 

 

Due to the limited response from tribal health providers for interview requests, 
recruitment efforts were expanded to tribal APS and domestic violence staff and 
elder advocates including ACL-funded Older Americans Act Title VI Directors1. A 
modified copy of the health provider interview guide was created for non-provider 

1 Title VI programs are a part of the Older Americans Act and serve older Indians meals in 
congregate sites such as senior centers and provide home-delivered meals, in addition to the 
provision of other services both in home and in senior centers. 


interviews that focused on the health care provider role, but solicited feedback 
from the perspective of elder service workers and advocates. 


Several issues likely contributed to 1) a lack of initial response by organizations, 2) 
entities lost to follow-up, and 3) limited participation by health care providers. The 
primary issue we believe is the ongoing challenge of front-line health care 
providers who are overworked and under-resourced and unable to take time away 
from direct care. No guidance was provided by project staff regarding whether 
interview participants should be compensated by their clinic or organization for the 
time allocated for interviews or survey participation. Two providers specifically 
requested interviews be scheduled outside of their regular clinical hours to allow 
them to participate, and two additional providers were limited to scheduling 
interviews during their designated administrative time during the work week. 
Secondly, the issue of elder abuse may be potentially perceived as a lower priority 
than other health issues. Though, one national organization who stated they were 
unable to assist with distributing information about the project to their membership, 
indicated they did not believe the barrier to provider recruitment was perception of 
elder abuse as a lower priority among tribal health providers. Finally, lack of 
awareness or trust of the lead organization for the project among tribal health 
providers. Though, both organizations and individuals well known to the lead 
organization as well as those who had no former affiliation opted not to respond or 
participate. The implications of non-response by both organizations and individual 
providers is unknown, though it may have potentially impacted the number of 
providers recruited and willingness to participate. 

 

Informed consent was not required as part of this needs assessment, though consent 
to record interviews was obtained from participants after an assurance of 
confidentiality for project participation was discussed. Following, the co-principal 


investigators (co-PIs) for the project and an experienced project associate with a 
master’s degree in social work conducted telephonic 45 minute to two-hour 
interviews using a semi-structured interview guide. The guide contained 46 primarily 
open-ended and questions with prompts and several closed-ended questions. The 
online survey consisted of 48 primarily close-ended questions and several open-
ended questions. Where possible congruence was achieved between interview and 
survey question content and format. To minimize social desirability biases, 
participants were assured of confidentiality (for the individual, tribe, and 
organization) at the start of the survey and interview, and confidentiality assurances 
were again provided mid-way through the interview process. Personally 
identifiable information, tribe, or clinic names were not collected as part of the 
survey and were redacted from interview transcripts, with the exception of those 
choosing to participate in the gift card drawing who provided an email. 

 

The assessment protocol, including project overview and copies of the interview 
guide and online survey, were reviewed by the national Institutional Review Board 
(IRB) for the U.S. Indian Health Service (IHS) and two separate tribal IRBs who 
determined the project did not require IRB review. See the appendix for a copy of 
the tribal provider interview guide and survey. 

 

Analysis 

Assessment findings are important to consider both in the context of overall project 
questions and objectives (down to the individual question in some instances) and as 
part of the larger “big picture.” As a result, multiple methods of analysis were 
incorporated. This assessment used a mixed methods approach consisting of 
qualitative descriptive and interpretive designs for interviews, and descriptive 
analysis of quantitative data including frequency counts and percentages and 
content analysis of open-ended survey questions. 


 

All interviews were recorded and transcribed verbatim. Dedoose was used to 
organize interview data, which was then analyzed and coded to indicate further 
areas of inquiry. The approach to thematic analysis proposed by Braun and Clarke 
(2006) guided the analysis process. Systematic 

procedures of qualitative data analysis included: initial reading of interview 
transcripts conducted by each PI, team development of a preliminary set of parent 
and child codes based on initial transcript review informed by findings from a 
recent integrative review of elder abuse in the AIAN population (Crowder et al, 
2019), coding of one transcript by both researchers followed by discussion to 
validate coding methodology using first degree triangulation by researchers, 
intensive reading and coding of transcripts of remaining interviews conducted by 
co-PIs, content analysis as appropriate for interview data, and inductive thematic 
identification and interpretation. These processes were iterative and coding 
occurred concurrently from May to July for both researchers. Inconsistencies in the 
coding process, formulation of new parent or child codes, and differences in priority 
findings were resolved by the co-PIs during regular discussions. During the iterative 
coding process, researchers concluded that saturation was achieved when no new 
significant themes were elicited from subsequent coding of new transcripts 
compared with previous interviews. The codebook initially contained 102 parent 
and child codes loosely organized using the Social-Ecology of Health Model. The 
final codebook contained 150 parent and child codes. From this process core codes 
and sub-categories evolved to inductively generate emergent (axial codes) and 
convergent (selective) codes. Finally, to enhance methodological rigor, member 
checking was conducted by sharing a summary of analytic findings with interview 
participants for reflection and validation. 

 


Descriptive analysis of demographic variables, organizational data, and specific 
interview and survey questions was conducted. The two-phase analysis of 
qualitative data included content and then thematic analysis. Initial content analysis 
of code categories identified interviews consisted of 

assessing and comparing code frequencies for the entire set of interview 
respondents followed by a comparison of code frequencies for health care 
providers versus non-health care providers. Data was subsequently thematically 
analyzed (Patton, 2002; Fereday & Muir-Cochraine, 2006) and 

interpreted by both co-PIs based on the identified codes. Codes and themes were 
confirmed by both PIs during multiple encounters to ensure credibility and increase 
accuracy of the analysis. 

 

Sample 

Outreach efforts yielded a convenience sample that included n=24 interview 
participants, with one unable to attend the scheduled interview. There were n=123 
initial health care provider survey respondents, with ten excluded based on a 
response indicating they did not serve primarily AIAN patients (50 percent or 
greater) in an outpatient care setting. Twenty-three respondents noted that the do 
serve in this setting but did not provide further responses. The final survey sample 
was n=90. Interview and survey respondents represented 22 different states in 
total. To retain a degree of anonymity, participants were not asked their tribal 
affiliation or clinic location. 

 

Interviews 

The interview participants represent 15 different states, including two physicians 
that work for entities at the national level, who also have a history of local clinical 
experience with tribal patients. There are 13 respondents (57%) classified as 
health care providers and 10 classified as non-health care providers. 


Health care providers include: 

• 8 physicians or physician extenders (nurse practitioner or physician’s 
assistant), 
• 2 social workers, 
• 1 nurse, 
• 1 home health supervisor, and 
• 1 behavioral health specialist. 


Non-health care providers include: 

• 4 APS staff, 
• 3 elder services or domestic violence affiliated staff, 
• 2 elder services coordinators, and one additional non-medical social worker. 


A total of 52% of respondents identify their race as AIAN. The majority of health 
care providers (62%) do not identify as AIAN compared with the majority of non-
health care providers (70%) who do identify as AIAN. The average number of 
years for both groups working at the current location was 11.8, ranging from 1 to 
44 years. The average number of years working at the current location was slightly 
higher for health care providers (13.2 years +/-13.8). 

 

The vast majority of participants in both groups work in facilities that serve 
primarily rural populations, the majority of the population served by both groups is 
AIAN only (not non-Native populations), and the majority serve multiple tribes. The 
majority of health care providers (69%) indicate their clinic provides primary care, 
behavioral health, and specialty care services. The majority (62%) of tribal health 
clinic staff work in clinics run by their tribe. The distribution of the percentage of 
patients who are sixty and older is spread across three categories (0 – 30%, 31 – 
60%, and 61 – 100%), with the largest percentage of health care providers 
responding that 0 – 30% of their patient population is 60 and older, and the 


largest percentage of elder advocates and APS workers responding that 61 – 
100% of their client population is 60 and older (logically, given 

the focus of their role). See Table 1 for more details regarding health care 
provider and elder advocate interview participant responses. 

 

Table 1 Interview participant demographic information and details about practice location 





 



Non-health care 
providers 



Health care 



Total 



 

n=10 

n=13 

n=23 



Years working at current location 
(average) 

8.9 

(SD 11.0) 

13.2 

(SD 13.8) 

11.8 



Provider identifies as AIAN 

7 (70.0%) 

5 (38.5%) 

52.2% 



Types of services provided (select all 
that apply) 

 

 

 



Primary care 

0 (0.0%) 

9 (69.2%) 

39.1% 



Behavior health 

2 (20.0%) 

9 (69.2%) 

47.8% 



Specialty care/services 

1 (10.0%) 

9 (69.2%) 

43.5% 



Non-health care 

7 (70.0%) 

1 (7.7%) 

34.8% 



Information and referrals only 

2 (20.0%) 

1 (7.7%) 

13.0% 



Other 

3 (30.0%) 

5 (38.5%) 

34.8% 



Primarily Rural or urban population 

 

 

 



Rural 

8 (80.0%) 

11 (91.7%) 

86.4% 



Urban 

1 (10.0%) 

1 (8.3%) 

9.1% 



Suburban 

0 (0.0%) 

0 (0.0%) 

9.1% 



Multiple 

1 (10.0%) 

0 (0.0%) 

4.5% 



Clinic/practice managed by: 

 

 

 



Indian Health Service 

5 (50.0%) 

3 (23.1%) 

38.1% 



Tribe(s) 

4 (40.0%) 

8 (61.5%) 

57.1% 



Non-native entity 

1 (10.0%) 

0 (0.0%) 

4.8% 



Other 

0 (0.0%) 

2 (15.4%) 

9.5% 



Populations primarily served 

 

 

 



AIAN people only 

6 (60.0%) 

11 (84.6%) 

73.9% 



AIAN people and non-Native 
populations 

4 (40.0%) 

2 (15.4%) 

26.1% 



Primarily service one tribe or multiple 

 

 

 



One tribe 

4 (40.0%) 

5 (41.7%) 

40.9% 



Multiple 

6 (60.0%) 

7 (58.3%) 

59.1% 



Approximate % of people seen 60 
years and older 

 

 

 






0-30% 

2 (22.2%) 

5 (38.5%) 

31.8% 



31-60% 

3 (33.3%) 

4 (30.8%) 

31.8% 



61-100% 

4 (44.4%) 

4 (30.8%) 

36.4% 



 

Online Survey 

The survey participants represent sixteen different states. There are 79 respondents 
(88%) classified as health care providers and 11 respondents (12%) classified as 
non-health care providers. 

Health care providers include: 

• 17 physicians, 
• 13 nurse practitioners, 
• 3 physician’s assistants, and 
• 7 social workers. 


39 participants provided an “other” title that was re-categorized to the following 

• 4 behavioral/mental health staff, 
• 6 case worker/managers, 
• 3 community health staff, 
• 4 health directors, 
• 14 nurses, and 
• 8 other medical staff. 


 

A total of 32 respondents (36%) identify their race as AIAN. The majority of health 
care providers (71%) do not identify as AIAN compared with the majority of non-
health care providers (82%) who do identify as AIAN. The average number of 
years working at the current location was 8.13, ranging from 3 months to 41 years. 
Most respondents are from Midwest and Western states. States with the largest 
number of respondents include Wisconsin (34), California (12), Washington (9), 
Montana (8), Oregon (6), Alaska (4), and Wyoming (4). 

 


The majority in both groups serve primarily rural populations followed by suburban 
locations. Only health care providers note serving urban locations (5 respondents, 
6% of health care providers). The majority of non-health care providers serve both 
AIAN and non-Native populations (91%) while the majority of health care providers 
(61%) serve AIAN patients only. The majority of both groups serve multiple tribes. 

 

The majority of respondents work in clinics run by the IHS or the tribe itself. The 
majority of non-health care providers work in clinics managed by the tribe (73%) 
while the clinics of respondents who are health care providers is more evenly split 
between management by IHS (47%) and tribal management (49%). The distribution 
of the percentage of patients who are sixty and older is spread widely. The largest 
percentage of respondents indicate that 0 – 30% of their patient population is 60 
years and older (41%). See Table 2 for more details regarding survey participant 
responses. 

 

Table 2 Survey participant demographic information and details about practice location 





 



Non-health care 
providers 



Health care 



Total 



 

n=11 

n=79 

n=90 



Years working at current location 
(average) 

8.09 

(SD 6.42) 

8.13 

(SD 8.38) 

8.13 

(SD 8.13) 



Provider identifies as AIAN 

9 (81.8%) 

23 (29.1%) 

35.56% 



Types of services provided (select all that 
apply) 

 

 

 



Primary care 

8 (72.7%) 

58 (73.4%) 

73.33% 



Behavior health 

6 (54.5%) 

43 (54.4%) 

54.44% 



Specialty care/services 

8 (72.7%) 

36 (45.6%) 

48.89% 



Non-health care 

9 (81.8%) 

51 (64.6%) 

66.67% 



Other 

6 (54.5%) 

19 (24.1%) 

27.78% 



Primarily Rural or urban population 

 

 

 



Rural 

9 (81.8%) 

59 (74.7%) 

75.56% 



Urban 

0 (0.0%) 

5 (6.3%) 

5.56% 



Suburban 

1 (9.1%) 

10 (12.7%) 

12.22% 



Multiple 

1 (9.1%) 

5 (6.3%) 

6.67% 






Clinic/practice managed by: 









Indian Health Service 

2 (18.2%) 

37 (46.8%) 

43.33% 



Tribe(s) 

8 (72.7%) 

39 (49.4%) 

52.22% 



Non-native entity 

0 (0.0%) 

0 (0.0%) 

0.00% 



Other 

1 (9.1%) 

3 (3.8%) 

 (4.44%) 



Populations primarily served 









AIAN people only 

1 (9.1%) 

48 (60.8%) 

54.44% 



AIAN people and non-Native populations 

10 (90.9%) 

31 (39.2%) 

45.56% 



Primarily service one tribe or multiple 









One tribe 

3 (27.3%) 

25 (31.6%) 

31.11% 



Multiple 

8 (72.7%) 

54 (68.4%) 

68.89% 



Approximate % of people seen 60 years 
and older 









0-30%

3 (27.3%) 

34 (43.0%) 

41.11% 



31-60%

4 (36.4%) 

32 (40.5%) 

40.00% 



61-100%

4 (36.4%) 

13 (16.5%) 

18.89% 





Results 

The needs assessment results are based on the analysis of 23 interviews and 
separate analysis of findings from 90 online survey participants. 



Interview Findings 

Thematic Analysis 

Key findings from the thematic analysis of interviews comprise the bulk of the results 
section. Themes are interwoven with quotes from interview participants, which allow 
us to tell the story in their words. A concise overview of additional findings from a 
content analysis of specific questions posed during interviews follows the thematic 
analysis. 



The Social-Ecology of Health Model provides an exceptional framework for 
structuring results from the interview data. Variations of the ecological model have 
been employed in multiple elder abuse research studies. There are many 
formulations of the model but all have in common multilevel systems of mutual 


influence and interaction, moving from the level of the individual through linkages to 
the larger familial, community, and societal levels. For our purposes, we have 
placed identified variables into the following categories: Individual, Familial, 
Structural, Cultural, Community, and Organizational. 

Individual Variables 

Theme: Elder protection of family 



Family presence can be a barrier to screening. Health care providers report that in 
the clinical setting, elders are not likely to speak of abusive situations when other 
family members are present. Family member presence during health care visits 
presents a major barrier for providers in screening for elder abuse. Many times, it is 
family that transports the elder to the clinical setting. 



Again, I think them not always filling out the PHQ9 form themselves, if 
somebody else, one of their siblings, is with them, they’ll let them fill it out for 
them. I’m talking about extreme elders again, not a 65-year-old, but somebody 
in their 80s or 90s, or older. Them not filling out the forms themselves makes it 
difficult, some of them are very hard of hearing, so their child or spouse will 
answer for them, so not getting their answer makes it difficult. Time wouldn’t be 
an issue if I could go by the PHQ9 form, and believe that that is true, I could 
say, “Oh, you mentioned here that people are yelling at you, can you tell me 
more about that” rather than me, asking the same questions, asking the sibling 
or spouse to leave the room, like a child, and that takes time, and then it 
offends everybody, which doesn’t matter, “Sorry, you’re offended, but we have 
to do this.” 



(Physician, Western Urban Clinic) 



Reluctance to report and rights to self-determination. Even if family are not 
present, health care providers share that elders are very reluctant to report family 


members as abusers, and discuss elders right to refuse to report family members, 
and right to autonomy and self- determination. 



The problem is that almost always they’ll say, “I’m okay,” they’ll make an 
excuse, “No, that’s not an injury from being thrown into a wall, I fell into the 
couch.” The problem is a lot of the time, it’s the person in the room with that 
person. And then, immediately making a report, and trying to determine from 
there what kind of legal action we can set in place, but it isn’t anything we can 
do from that point if the person denies wanting help, or wanting to report the 
person who is neglecting or abusing them, and that’s pretty much the point 
where most of them fall down, the person flat out refuses to identify who it is, or 
to call it neglect or abuse, or to say that they were injured directly by another 
person. 



(Registered Nurse, Western Primary Clinic) 

Theme: Elder support of grandchildren 



Grandparents putting grandchildren first. A large number of respondents indicate 
that many elders are raising grandchildren and even great grandchildren, either 
because of substance abuse by the parents, out migration of the parents, neglect, 
or because financial circumstances prevent the parent from paying for care or 
dictate that one household must accommodate multiple generations. 



I’ve written note after note after note that they’re just not well enough to be 
taking care of six grandkids, and I’ve had to enlarge it so they can put it on the 
door. I’ve seen a number of elders go to the grave still being expected to take 
care of the grandkids. 



(Physician, Northwest Clinic) 




It’s really unfortunate. A lot of it is financial, and a lot of it is drugs and 
alcohol. Recently, meth has been such an insinuation, we have 160 cases of 
elders taking care of grandchildren because their parents have either died or 
been incarcerated. 

(Adult Protective Services, Western Tribe) 



Financial abuse sometimes is the result of older grandchildren taking undue financial 
advantage of the elder, even residing in their home. This is true even in the 
presence of impoverishment of the elder. 



I think a complicating factor with the native population is a core value of caring 
for your children, your grandchildren, your great-grandchildren, oftentimes the 
line between caring and enabling is crossed, and oftentimes elders will put 
themselves at risk by financially supporting people with addiction, and then 
allowing them to live in their homes…essentially living in a flop house where 
they’re a prisoner in their own home, which unfortunately happens pretty often, 
they’re like, “well, I don’t want them out on the streets, where they might 
overdose.” 



(Licensed Clinical Psychologist, Eastern Primary Care Clinic) 



Familial Variables 

Theme: Honor and duty to share resources 



Entitlement by younger generation; perceived honor and duty to share by 
elders. There is overall a perceived financial dependency of youth on elders, as 
well as a sense of entitlement by youth. However, there is a strong culturally held 


belief in one’s duty and honor to share resources with family members, upholding 
longstanding patterns of mutual assistance. 

 

Homes, snow machines, cars, and money. These elders have big hearts, they 
offer them everything they can. That’s how they were raised, and others are 
taking advantage of it. 

(Elder Services Worker, Village Social Services) 

 

Theme: Caregiving creates vulnerabilities for some 

 

Caregiving. Additionally, elders sometimes depend upon their children or 
grandchildren for care. It is at this point that the children or grandchildren may 
begin to take financial advantage of them. The elder may not want to report 
family but also does not want to lose them as caregivers, as 

marginal as it might be. 

 

The other thing is, they don’t want to be left alone. They might be taking care of 
them, most of the time they’re probably good caregivers, but there’s times that 
they aren’t, but they’re thinking, “If they’re not there, who’s going to take care 
of me?” 

 

(Elder Services Worker, Midwest Social Service Agency) 

 

Gray areas in caregiving. Caregiving issues were not always directly identified by 
participants. Often, discussion of caregiving issues arose as examples of a case of 
elder mistreatment. Situations they may identify as “gray areas,” where it is not 
always a clear-cut case of abuse or exploitation, rather a question regarding the 
need for additional services or resources such as respite care to alleviate spousal of 


family burnout home health care, homemaker services, or food and nutrition 
services. 

 

I did have a case where I almost called Adult Protective Services. I had an 
elderly patient with a spouse, and the elderly patient was declining and needing 
to be on hospice, and the spouse wanted to take care of the patient themselves, 
but unfortunately [the spouse] had Alzheimer's. So, the patient was not getting 
cared for appropriately, I contacted the daughter of the patient…The daughter, 
unfortunately just didn’t have a really solid relationship with the spouse, who 
had Alzheimer’s, …and it was like pulling teeth, to be allowed to have 
somebody come over to the house, because the spouse was all, “I can do it, I 
can care,” and have the heart to, there was no intention to hurt anyone. This was 
a couple that’s been together for 40 years, the spouse just wants to care for the 
patient, because that’s what they’ve always done. That was very difficult, finally 
the patient was sent to the nursing home, but even in the nursing home it was a 
continual battle with the spouse…it was a horrible situation, and from my 
standpoint, it was because I felt helpless. I probably should have called adult 
protective services, but he finally went into the nursing home, so then he was 
being watched and hopefully taken care of. I don’t know where to put that on 
the spectrum because I honestly don’t feel that he was being intentionally 
mistreated and neglected… Trying to get the family involved was hard, because 
they don’t live in the area, calling home health to come over and they were not 
being welcomed into the home as you would hope, because the spouse is like, 
“Why can’t I do it, I can care for him.” You can explain it, but they don’t 
remember it, the next day you have to explain it all over again. 

 

(Physician, Western Urban Clinic) 

 


Theme: Substance abuse and poverty as contributing factors 

 

Substance abuse most prevalent concern. The causal variable most cited as 
contributing to abusive situations, whether financial or neglectful in nature, is 
substance abuse by family members. Substance abuse among direct caregivers (as 
opposed to other family members) increases this possibility. 

 

One of our recent ones was this elder, she has cancer, she’s really fragile, tiny, 
she has a home, and this guy, grandson or nephew, I don’t remember the 
relationship exactly... He had been staying with her, and he was abusing 
alcohol, and the water was frozen or had stopped working, and she would 
make accidents in her bed and he wouldn’t help her, she’d have to wait until he 
woke up, and she was scared of him when he’d drink. 

 

(Domestic Violence Case Worker, Northern Village) 

 

Substance abuse, poverty, opioid addiction is off the charts. It is making our 
20-year-olds look like 50- year-olds, and making them do things against their 
grandmothers and grandfathers they wouldn’t have ever considered doing. 

 

(Adult Protective Services Worker, Southwest Tribe) 

A lot of it has to do with substance abuse. When people are in the throes of an 
addiction then these traditional values we’ve learned about- respecting elders 
and holding them in high regard- completely go out the window. That’s what 
I’ve seen quite a bit. A drug addict forcing an elder to go to the ATM and 
withdraw money for them. Or they are going to that person’s apartment and 
pretending to have a sick child in order to secure money for whatever it is. I 
think that’s a huge piece of this. 


 

(Physician, Eastern Tribal Specialty Clinic) 

 

Poverty is a factor. Even in the absence of substance abuse, impoverishment of 
families overall results in crowded and substandard living conditions. In the extreme, 
multiple families may exist in one home. These conditions may be detrimental to the 
elder’s well-being, contributing to neglect or financial exploitation. 

 

There’s lack of housing and resources to implement bedbug prevention, rodents, 
home repairs, lack of units. So, the elder don’t know how to say no, and so 
they’ve got a household of 14+ living with them. 

 

(Social Worker, Northwest Primary Care Clinic) 

 

I would say probably financial status – many times my experience has been 
mom or gramma is living in the home and somebody else is managing her 
income and her income is supporting the whole family. Because a large number 
of folks are ineligible for employment probably because of abuse, or I mean the 
instances of child abuse are pretty high too. So, for whatever reason they might 
not even be able to get a job so then they are living off that elder. And 
supporting the family off of that income. 

 

(Social Worker, Midwest Primary Care Clinic) 

 

Structural Variables 

Theme: Providers see patients who experience all types of abuse 

 


Physical abuse easiest to identify. Respondents indicate that the easiest type of 
abuse for providers to identify within the clinic setting is physical abuse. Though 
scenarios of providers identifying and responding to cases of emotional, physical, 
sexual, and financial exploitation were discussed. 

 

The physical is probably the easiest for providers, because that’s what we’re all 
obviously focusing on. We can see if they’re becoming cathectic or 
malnourished, and that leads us to ask more questions, to dig a little deeper, or 
if there are a lot of falls going on, or if they’re getting a lot of bed sores. That 
leads us to dig a little deeper, but with these others, you don’t necessarily see it 
with your eyes, you’re not looking at their bank account, so it’s a lot harder, 
actually, for me, and I’d say the other providers too, that’s probably the most 
difficult, whereas the physical is just something we see. 

 

(Physician, Western Urban Clinic) 

 

Financial exploitation most prevalent. According to respondents over all the most 
common type of abuse is deemed to be financial, followed by emotional abuse and 
neglect. 

 

I’m gonna posit it’s financial abuse because when I first started she was in a 
nursing home up until January or February of last year, her family pulled her 
out of the nursing home, they were trying to say it was because she didn’t want 
to be there, but in fact they weren’t getting her social security checks, so 
bringing her home ensured that they would get that financial assistance for them 
to be a little more solvent in their own home, and that was the thing that started 
that patient to be on my radar, because the public health nurses were going out 
there, they had discharged home health from seeing her abruptly, saying that 


she didn’t need it, with the public health services saying yes, she did need it. So, 
we tried to intervene, see about getting her back into a nursing home, well, it’s 
not that easy. So public health services set it up so that the daughter would do 
the personal care, and the son would do everything else, getting the groceries, 
picking up her medication, but then that broke down pretty rapidly. 

 

(Registered Nurse, Western Primary Care Clinic) 

 

Theme: Difficulties with abuse assessment 

 

Time and turnover key challenges for providers. There is a consensus that there 
are challenges identifying abuse in the clinical setting. Most commonly discussed 
reasons for the difficulty include the short amount of time allotted for patient-
provider interaction, provider turnover (which diminishes trust in the provider), and 
the presence of family members during the exam. 

 

…but you’re handicapped because you don’t know the entire social situation. 
You see the patient for a very short time, you don’t know if that black eye is 
because they fell, because somebody punched them, or something else, like the 
dog jumped on them. You’re a little bit limited because to have the info you 
have to have the family that the elder is usually with, and when there is no 
family it makes it even more difficult to ascertain the issues, there’s 
embarrassment, there’s guilt, they may not want you to know because you’re not 
family, you’re not the regular doctor that they see, because he’s on vacation. 
Medicine is very fragmented, nowadays, it’s hard to see the same person twice. 

 

(Physician, East Coast) 

 


…with the turnover rate that we have, training each individual to discern the 
types of abuse is really hard, because it’s really common in a rural community, 
the turnover rate of our nurses and doctors, it’s not consistent, let’s say a doctor 
starts seeing one of the elders, they don’t know them enough, or they don’t see 
them enough, to be able to see if something is going on. I think it’s really hard 
to even identify the elder abuse, because the elder doesn’t talk about it right 
away, especially if it’s their first time seeing them. 

 

(Domestic Violence Worker, Village Social Services) 

 

Damaging relationships. Some providers are concerned that reporting alleged 
cases of abuse may result in patients discontinuing care or it may disrupt the 
provider relationship. Though there is the more prominent belief that elder safety is 
paramount and the right response can allay concerns. 

 

Caretaker was a little upset, but it didn’t impact the relationship actually. The 
way it was expressed to him at the time, we are just worried about your mom 
and make sure she was okay. The kind of messaging to the son was, part of it 
was the caretaker had some insight into his own use and abuse of substance use 
and in a sense recognized that we were putting him on notice. But that was, so, 
he may not have liked it, but that’s part of the dimension of doing this work in 
tribal communities. There is more of an expectation the community is going to 
be looking after folks and keeping an eye on folks. 

 

(Tribal Adult Protective Services, Northeast) 

 

Reports rarely seem to result in patients no longer seeking out health care services. 

 


Do you ever have elders who stop coming to the clinic or using services or do 
they always end up coming back? 



They’ll stop for a little while but they come back. Or they’ll say I don’t want 
anybody coming into my home and they’ll call in a couple weeks and want 
somebody to deliver their meds or want somebody to come out and sweep or 
mop their floors. It happens. They’ll kick us out or they’ll stop coming but they 
come back. 



(Social Worker, Midwest Primary Care Clinic) 



Theme: Few standardized protocols 



Screening and standardized protocols lacking. Most respondents indicate their 
clinic uses a standard IPV screening tool often accompanied by a mental health 
screening tool. Findings indicate that standardized protocols, to include elder abuse 
specific screening, are lacking. 



There really isn’t a protocol. It’s pretty much individual to whatever staff person 
there is who gets that person. One person might be more willing to refer than 
another person. 
(Tribal Adult Protective Services, Northeast) 

Only one provider currently uses an elder abuse screening tool, which has met with 
success. 



It started early last year with Dr. ___’s team….and we’ve started looking at 
ways that we can formalize training, We started using the Elder Abuse 
Suspicion Index. It’s a 6-question screening that was used for primary care, the 
provider basically assesses for broad abuse and mistreatment. We tested it last 


year, screening everyone in Dr. ____’s clinic, 55 and up, and last week we 
rolled it out to all the teams, currently now everyone that comes to the clinic is 
supposed to be screened, at least annually, for elder abuse. 

 

(Licensed Clinical Psychologist, Eastern Primary Care Clinic) 

 

Lack of standardized screening or protocols is sometimes a function of funding issues 
within the health care organization (see below under Organizational Variables). 
Various tribal systems sometimes establish their own protocols or are working on 
development of protocols. 

 

That’s something that I’m working on, getting some protocols in place, written 
down, “when we get a call, this is what we do.” When I first came on the job, 
there was nothing, and everything I had to learn by myself, and I just want to 
get everything in place, I want to get policies and procedures, protocols, 
everything in place, I don’t want anybody to be stuck in that place like when I 
first came. If I don’t know how to do something, I Google it, and that’s how I 
learn stuff. I also have a very good relationship with ____ services, it’s not a 
Native American agency, everyone’s white, but they are so helpful, they’ve been 
so helpful to me since I’ve been there. They have different subjects, they have 
different people coming in and presenting, and I’ve gotten guidance from some 
of those members, and it’s just been a big help to me. 

 

(Tribal Adult Protective Services, Midwest) 

 

Theme: Providers can and should play a role 

 


Providers can be successful and should be engaged. Even in the face of multiple 
challenges, with one exception, both health care providers and non-health care 
providers believe that providers can be successful and should be engaged in 
identifying and managing elder abuse. 

 

I think we should play the—I don’t want to say primary role, but that first 
screening, that first stage, we’re the ones who can actually pick up on it when no 
one else can. Even as simple as, we are able to touch and pull up the sleeve, and 
check the blood pressure and listen to the heart and lungs, so we see things that 
other people aren’t going to see, even without having to necessarily ask, and so 
by seeing that, it will prompt you to ask…. I think that we’re kind of that first 
line of defense, honestly. 

 

(Physician, Western Urban Health Clinic) 

 

Importance of building trust. Another issue is the importance of establishing trust 
and rapport with patients to encourage them to share concerns or respond honestly 
to screening tools, which is difficult given high provider turnover rates. 

 

Having enough of a rapport with a senior or the elder or an adult to want to 
talk about it. For them to admit or cop to any real concerns. You are going 
through a list of questions just reading them off and it’s easy for them to say, 
“nope, nope, nope.” Whereas, if you kind of talk to them and have a warm 
engagement with them, they might be willing to talk and just finish the checklist 
with you. 

 

(Adult Protective Services, Southwest Tribe) 

 


Cultural Variables 

Respect for elders as a function of culture 

Strengths: Respect, family first, community, pride, resiliency. Respect for elders is 
present within most communities and a strength of Native culture, but comments 
indicate that the respect traditionally shown to elders has decreased among the 
younger generation and virtually dissolves in the face of substance abuse. The 
assumption of elder respect due to the elder being “Indian” is not necessarily true 
“anymore.” 

 

Now that the younger generation is here, it’s sad to say... no. They’re not 
revered, there are younger adults that... I don’t know how to explain it, but 
elders aren’t respected the way they once were. The younger generation is a lot 
more careless, they don’t see the elders as important, I think. 

 

(Elder Services Worker, Village Social Services) 

 

Other strengths include putting family first, strong community connections, pride and 
resiliency. 

 

Their strengths are the same as the weaknesses. They are family. They live as 
family units. They frequent each other a lot, as far as visiting. They are pretty 
solid family units. Which is also the weakness. They are afraid to tell anybody 
or anybody in the law enforcement, they are family too. They eat dinner 
together, it’s definitely a strength. And they help each other out in quite a lot of 
ways. The Individualized ones where it is just one or two that are disconnected, 
that’s where the trouble is. In the larger families with 2 or 3 or 4 different 
households, they take care of each other. It’s like the Samoan they moved here 
together, they take care of each other, they take care of themselves, they all 


share, and they all eat like kings It’s pretty much the case here, but it’s a little 
different financially Not all the Native families came as a whole. So, the 
separated ones have trouble. 

 

(Elder Services Advocate, Village Social Services) 

Pride. Their protective factor of their families. Even though it can delay my work 
I still see that as a strength. They are protective of their families. They will go to 
the ends of the world for their families these elders will. With the little they 
receive they really take care of themselves and their families. Sharing resources. 

 

(Tribal Adult Protective Services 2, Midwest) 

 

Strengths do not always provide protection. Respondents caution that you cannot 
assume elders are not abused because of community strengths and indicate that 
culture does not always ensure protection. 

 

Very respected but again I say that then I look at the instances of abuse and 
exploitation and things we have and I struggle with saying that. 

(Social Worker, Midwest Primary Care Clinic) 

 

Theme: Role of acculturation is unclear 

 

Acculturation increases the likelihood for abuse. Respondents were asked to 
indicate whether they thought that acculturation into mainstream life increases the 
possibility of abuse. Some respondents believe acculturation does indeed increase 
the possibility of abuse; this includes the majority of non-health care providers. 

 


Yes absolutely. If you were to rate it from 1 to 10 it’d be 9 and . as being the 
major contributing factor. 

 

(Elder Services Advocate, Northwest Tribe) 

Yeah, I do. It makes it more likely. If they are truly traditional and have that 
strong belief, we don’t ever get calls to their house. It could be they just don’t 
call us, but at the same time I feel like that strong belief that elders are to be 
treasured is very strong with traditional belief system. As you get more into the 
mainstream, obviously there are people who believe they are still to be 
treasured but you start getting into drugs and alcohol. It’s not uncommon for 
grandkids to take advantage of grandparents, that kind of thing. 

 

(Tribal Adult Protective Services, Northeast) 

 

Maybe, or maybe not. However, this belief is not consistent across all interviews; 
particularly among health care providers. 

 

No. I don’t see it, other than—that, in itself, no, but the clash [between 
generations], yes. 

 

(Physician’s Assistant, Western Urban Indian Clinic) 

 

That’s kind of a difficult thing to make assumptions about. I think a lot of times 
being connected to your community and your cultural identity can be a strength 
and a resilience but I don’t know if it’s strong enough to stop someone from 
participating or being affected by abuse. I think that’s a tricky thing to make 
assumptions about. 


 

(Physician, Eastern Tribal Specialty Clinic) 

Boy you know I don’t think it has an effect either way. I really don’t. Because I 
see both sides of it. I see the family where there was never a history of abuse or 
neglect or anything and now it’s happening. I see the flipside of that where it 
has been a life cycle. 

 

(Social Worker, Midwest Primary Health Clinic) 

 

Theme: Abuse discouraged as community /familial topic 

 

“We don’t talk about that.” There was a sense that elder abuse not overtly talked 
about, coupled with “looking the other way” to protect the community and the 
family as part of cultural values. 

 

…. family values of helping versus enabling, and then at the same time the kind 
of traditional values where you don’t talk about your people, you don’t talk 
about that stuff, not just elder abuse but sexual abuse, drug abuse, I think 
discussing that is an ongoing struggle. 

 

(Licensed Clinical Psychologist, Eastern Primary Care Clinic) 

 

Theme: Historical trauma 

 

Forced assimilation, racism, cycle of violence, boarding schools, and providers 
as symbols of white authority plague tribal communities. The presence of 


historical trauma is thought to increase the probability of abuse, and have a 
connection to the incidence and prevalence of substance abuse in tribal communities. 

 

I had this opportunity to listen to a tribal elder who told me that she went out 
with her family, she has ancestors that are buried in a special place at Lake 
Tahoe, on one of the beaches, so she went to pay her respects with her family, 
to her ancestors, and because it was very close to a summer cabin, the people 
who were renting this summer cabin came out, and looked at her and her family 
and said, “What are you doing here?” And instead of saying, “We're here to 
respect our elders, this is their cemetery,” they left. And I said, “You’re kidding 
me, why wouldn’t you stand up to them, and say that these are our tribal 
ancestors?” And she looked at me and she said, “Because we would rather not 
engage with those people,” -- and boy, that was just said with pure and utter 
hatred-- “we decided to leave.” And that just gave me this microcosm of how 
they think, they don’t go to the lake even though that was their summer 
gathering ground, because they hate interacting with people who treat them like 
that. They don’t even want to go there, they don’t want to even have that 
interaction because it reminds them of what they’ve lost, what their cultures and 
ancestors have been through. It gave me this phenomenal insight into their 
thinking. The hatred of the white person is so totally justified, how would you 
like to be there? For a day, I was just devastated by that, thinking through what 
they go through, all the time, even down here they go through that stuff. They 
go through people even like in the emergency room that despise them, I’m like, 
“Are you kidding me?” I’m blown away, so how they deal with this stuff is truly 
amazing to me, that they find the courage to come to this clinic, that they do 
try, as hard as they can, in their own way, to get help. 

 

(Registered Nurse, Western Primary Care Clinic) 


Oh, it’s huge, I’ve seen a lot of that. Mental health and trauma, the 
combination. I’ve seen it lived in families right left and here and there. A lot of 
communities are worse than others. The folks who come in for help, to seek 
housing or whatever, just... The one trauma tool we use the ACEs [Adverse 
Childhood Experiences] survey, they say if there is 4 indicators or more there is 
going to be issues and they are mental health issues. Better than 50% of our 
survey respondents come in with 4 or more. The mental health, the things it does 
to the mind over time is just... I’ve been around it enough that I’m just happy 
that I think I’ve kept my mind pretty clean and straight. But it’s... they’re... Their 
minds are abused. More than physically. Or mental health is a side effect of 
social factors that has taken the brunt of it over the years….The employment, 
the drinking, the abuse. The folks that are being abused and the folks that are 
doing it. It probably it isn’t their fault. Their parents and when they were 
children …anybody that does stuff like that has a mental problem, but the cause 
of it. The why, why, why getting to the root of the problem. 

 

(Domestic Violence Worker, Village Social Services) 

 

Life under forced colonization and structural violence is one of emotional and 
cultural trauma. These intergenerational traumatic memories continue to affect the 
physical and emotional health of populations who have suffered abuse on multiple 
levels. 

 

They’ve been here for a long time, they know the situation that is at hand, they 
experienced the historical trauma on tribal lands, reservations, and that 
historical trauma is real. A lot of people don’t understand historical trauma, but 


you just have to spend some time on reservations to get a feel for how people 
take it out on each other. It’s a component of elder abuse. 

 

(Physician, East Coast) 

Elders of any native tribe, mine included, I feel like elders are vessels of cultural 
renewal, they hold the stories of creation for the tribe, and the tribe I work for 
now, they are trying to reinvigorate their language, and for me, for the Navajo 
side, I’ve heard my language spoken, but my mother, she was beaten at the 
boarding school, for speaking her language, as you talk about this ingrained 
abusive type of experience that the natives have had, it’s institutionalized. And 
so, the tribe we have now, we had an Indian school, not too far from here, in 
which children were actually, they lost their lives, and the parents didn’t know 
for months. And so, on a more serene note, the tribes themselves, they want the 
elders to come forward with the knowledge. 

 

(Physician, Western Primary Care Clinic) 

 

Theme: Cultural renewal as possible intervention 

 

“Culture as prevention.” Tribal efforts at cultural renewal are seen as a potential 
pathway to indirectly (or directly) address elder abuse. 

 

I deal with several tribes and those tribes with strong language programs and 
cultural programs don’t have high elder abuse because they still respect their 
elders, because children know what respect is, and children are happy to hold 
grandmas’ hand or attend a ball game. Linguistic or historical connection tribes 


should have. I see that on other reservations and other communities. I’ve seen 
tribes where culture is endangered and they have high incidence of elder abuse. 

 

(Elder Services Advocate, Northwest Tribe) 

 

There are so many strengths from what I see, cultural tradition being one of 
them. With our agency serving over 120 tribes, that means we have many 
different spiritual protocols, ceremonies, you name it, so many different cultural 
things. A huge thing that we implement here, because we see it as a strength of 
our community, is culture as prevention. So that’s why they often go to sweat 
ceremonies, we also have sage and we smudge clients as needed, we have 
connections with local spiritual healers, and so cultural identity is such a huge 
strength here, and we really try to promote that and I think sometimes it can be 
maybe some pressure for maybe some staff maybe who don’t identify as native, 
but also educating our staff can connect the individual, the client, with the 
cultural resources that they need, so when you ask me about strength, that’s 
definitely the primary one there, the cultural components, and that’s really why I 
think we’re one of the longest lasting urban Indian health organizations in 
______, because there have been others but they’ve closed down, and we’ve 
been the primary agency to continue our services and stay open, because we 
continue to provide those cultural services because it’s been an identified need 
by our community members throughout the many community needs assessments 
that we’ve completed, so that’s the community strength for sure. 

 

(Licensed Clinical Social Worker, Western Urban Indian Health Center) 

 

Community Variables 

Theme: Lack of priority 


 

Low priority and underreported. Many feel that elder abuse is not a priority in their 
tribal community. 

 

I can’t speak to that. What I understand is, our social service person focuses her 
energies on the young, the children, which is extremely noble. Those situations 
break my heart. But that leaves, definitely a problem with access to resources 
for elders or anybody else that might need social services help. We do have 
TANF and there are all types of other programs on paper that are supposed to 
help, CMS Native health, native this that and other but I don’t see us being able 
to access those resources. When I make a report, typically the thing is the thing 
I get back is that they don’t have any resources for this person. I just get the 
feeling that there is an expectation that social services are supposed to address 
everyone’s 

social service issues and needs, but if there is only one social services person, 
how is that supposed happen? 

 

(Registered Nurse, Western Primary Care Clinic) 

 

Each year when we have our elections for council members, it’s always like, 
“respect your elders,” but to be honest, I don’t see it. Like when the government 
shutdown happened, the first programs that were cut were elderly nutrition and 
my program, and commodities. And these are essential services for the elders, I 
was floored by that. Our leadership themselves didn’t think twice about cutting 
these programs, and I think that says a lot. 

 

(Tribal Adult Protective Services 2, Midwest) 

 


Overall, abuse is thought to be under-reported. The result of both individual, 
familial, cultural and community values and beliefs. 

 

It still remains underreported. We do a survey for our title VI funding every 3 
years it’s a survey that includes those same topics. Even on our survey we do to 
get our funding, what we see most of the time is they’ll answer the cigarette, 
alcohol, substance abuse like that but they won’t do the answers on elder abuse. 
We can’t force them to do it. Even though we know there is suspected abuse or 
there is credible evidence we can’t answer the questionnaire. I think it’s 
underreported because of intimidation or the love factor. 

 

(Elder Services Advocate, Northwest Tribe) 

 

Theme: Promising interventions 

 

Home health has a unique perspective and is a valuable tool. Surveillance by 
community health workers (CHRs), community health personnel, and home health 
programs is very instrumental in both the identification of, and intervention in, 
abusive situations. 

 

I would say any of the employee’s outpatient health care providers that are 
doing home visits or seeing clients in the home regularly probably have a better, 
they’ve got their finger on the pulse of what is going on so they have a better 
idea of the risk for a senior right away. Emotional abuse, living in unsanitary 
conditions. I think a lot of the outpatient providers who are going into the 
homes provide a lot of the referrals we get. We work very closely with them to 
wrap our client or elder in services through our services or any other at the tribe 
they may need to utilize. They are aware, talking to seniors if not daily than 


weekly. Helping with meds they sometimes get to see how the family interacts or 
what challenges that particular individual is having in their home. 

 

(Tribal Adult Protective Services, Southwest) 

When we are suspecting abuse and neglect possibly happening in a home that 
hasn’t been substantiated, you know we’ve reported it but the elder won’t 
substantiate it, we are increasing services. Maybe sending a homecare worker in 
twice a week or sending that community health representative in once maybe on 
Mondays to do blood pressures and on Wednesdays to do read their blood 
sugar monitors. We’ll find reasons to get staff into those homes a little bit 
more, if we can. That for even if they are finding things in the clinic that the 
docs are letting us know, hey I think something is going on, can you guys get 
some staff out there a little bit more. 

 

(Social Worker, Midwest Primary Care Clinic) 

 

Home health staff are a respected part of the community. 

I think they’re in the home more, they’re more engaged in the community. Need 
to have to report based on what they see. I also feel like, caring for that family 
they just feel like they need to do this. A lot of them share with the elders. I have 
to report this. I have concerns for you. After I’ve gone in to do an investigation, 
they’ll be like, “oh yeah I believe it was the community health nurse.” It’s okay 
and they start talking. 

 

(Tribal Adult Protective Services 2, Midwest) 

 


Home health programs at risk. However, public health programs are endangered 
or have already been eliminated in some areas. 

 

Yeah, home health is going away, and I think that is going to be a big loss, 
because we’re not going tohave the in-house monitoring. I think home health is 
more than just whatever education they’re doing, it’s actually having people in 
the house to see what the environment is like. 

 

(Physician’s Assistant, Western Urban Indian Health Clinic) 

 

Multidisciplinary teams are thought to be effective. The presence of more or 
dedicated elder abuse funding is associated with protocol/screening and the 
existence of tribal multidisciplinary teams (MDTs) or formal approaches to cross-
agency collaboration to address elder mistreatment. MDTs are seen as very 
effective in communities that use them. 

 

Last year I started a task force which consists of our diabetes, nurses, housing, 
incentives, low-income housing, heating programs, a protection worker, our 
medical social worker, our case manager... we kind of go over a lot of these 
cases, and we do referrals. Every quarter we meet with the dialysis center and 
let them know which individuals are new dialysis patients, we make sure we’re all 
versed, who hasn’t been going to their sessions. The hospitals have been great. 
Every year we actually go up there and do an introduction of our services and 
we’ve gone up to the hospitals several times to do cultural awareness 
presentations, like if they’re doing a prayer, what sweetgrass is, so people 
aren’t like, “they mistreated me because I’m native.” 

 

(Tribal Adult Protective Services, Midwest) 


 

Community outreach and education high priority. In our research, non-medical 
community members at times would make “drop-in” visits to those elders they felt 
were at risk. Elder abuse reports are often the result of anonymous reports by 
community members. For this reason, there is a strong consensus that one of the 
priority needs is community awareness (and community surveillance) about elder 
abuse. 

 

Raising awareness, and my coworker, she did a flyer, she sent it to the radio 
station, so they actually announce it, and they just talk about elder abuse. It just 
says, “Elderly Protection services, elder abuse, taking care of one elder at a 
time.” Since she did that, we have been getting more calls, I think. I think raising 
the awareness, would really make a difference. Just letting elders know they 
don’t have to live like that, if they’re not taken care of, or not feeling safe, you 
don’t have to live like that. 

 

(Tribal Adult Protective Services, Midwest) 

 

This should include helping elders and families understand the need for healthy 
boundaries and understanding what abuse is and is not. 

 

You know, I think educating those victims that what they are living with is not 
okay. You know just because it’s your daughter and you don’t want to get her in 
trouble. Just cause it’s your grandson and you love him. You still don’t deserve 
to be treated like that. I think that that’s the biggest roadblock we hit out here. 
Is letting that elder know that you deserve to be treated with dignity and love 
and respect and not taken advantage of and abused. 

 


(Social Worker, Midwest Primary Care Clinic) 

Organizational Variables 

Theme: Positive interactions with referral agencies essential, room for improvement 

 

APS and law enforcement important allies. Respondents indicate that working 
with APS is for the most part a positive experience, though this varies from one tribe 
to the next. Interactions with law enforcement are likewise perceived largely in a 
positive way though communication is at times an issue in some tribes. 

 

A positive example would be, I had a patient not too long ago who presented 
with some kind of depressive symptoms, and I went in and talked to her, and it 
was the same kind of situation we talked about, she had family members living 
with her, there was drug abuse, financially taking advantage of her, and she 
didn’t really know what to do about it. There was some violence, shoving, 
threats of violence, and so we reported to Protective Services, and they ended 
up showing up and she ended up being removed from her home, and so I think 
that pretty much worked pretty well. 

 

(Licensed Clinical Psychologist, Eastern Primary Care Clinic). 

 

Several respondents discussed the perception that APS is busy, overwhelmed, or has 
very high caseloads. 

 

What I understand is, our social service person focuses her energies on the 
young, the children, which is extremely noble. Those situations break my heart. 
But that leaves, definitely a problem with access to resources for elders or 
anybody else that might need social services help. We do have TANF and there 


are all types of other programs on paper that are supposed to help, CMS 
Native health, native this that and other but I don’t see us being able to access 
those resources. When I make a report, typically the thing is the thing I get back 
is that they don’t have any resources for this person. I just get the feeling that 
there is an expectation that social services are supposed to address everyone’s 
social service issues and needs, but if there is only one social services person, 
how is that supposed happen? 

 

(Registered Nurse, Western Primary Care Clinic) 

 

Feedback and reporting an issue; tribally run APS may have better outcomes. 
However, feedback after reporting and intervention is sometimes lacking or it is 
perceived that nothing is ever done. When the APS and law enforcement 
organizations are tribally run (versus county or state), results are more beneficial. 

 

Before we had our own tribal safety family program, before that we had to 
contact counties for that assistance and we had to submit a report or whatever 
and so when that was happening the communication was even worse. When we 
submitted an APS referral, we never heard anything back. It was always up to 
us to reach out and get an update on what was happening. And they’d say ‘oh 
it’s an open case’ or ‘it’s an open investigation’ and we would be like can you 
actually tell us where you are at in the process or should we change anything 
about when this person comes in? Is it only supposed to be a certain person 
bringing them in? And they never provided any helpful information about that. I 
felt like none of those were handled well. They were not communicating well with 
us about the progress in that case, timeline or any of those sorts of things. 

 

(Physician, Eastern Specialty Clinic) 


 

Theme: Jurisdictional issues a challenge 

 

Jurisdictional issues a major barrier. However, jurisdictional issues or conflicts in 
protocols between agencies are cited frequently. Many may be due to the 
overlapping geographic areas served by the health care system. Sometimes one 
clinic might serve several different states. For example, there are “border” 
communities with various confusing and conflicting jurisdictional issues. In other cases, 
tribal lands encompass multiple counties and require coordination with different 
APS or law enforcement agencies. 

 

It’s hard. We have ___ and tribal [APS]. What’s accepted by us is totally 
different than what the county will. For other counties it has to be extreme 
before they get involved. For better or worse we do a lot of preventive services. 
Part of that's because we have a low case load, so they expect us to do more 
and to accept more. It’s hard when a county doesn’t accept something we would 
have accepted. A lot of times we will at least do an intake and see if we can 
help resolve, like if it’s one phone call or something. 

 

(Tribal Adult Protective Services, Northeast) 

 

Theme: Funding underscores multiple needs 

 

According to respondents, the most frequent need is outreach and awareness (see 
previous section). There is also an expressed over-arching need for more funding 
for all elder services. 

 


Funding. More funding. For community events, incentives to get people to come 
out, or sit at the table to talk. Making everything, every engagement a warm 
place where they feel safe enough to talk and that may be an event, or food, or 
a meal that feeds and nurtures them in some way. More money for resources, 
for things we can use, technology in the community. Like research or assessment 
tools 

 

(Tribal Adult Protective Services, Southwest) 

I wish there was like elder abuse grants, it would be nice if there was more, if 
there was something specific to elders. We get federal funding, but not for 
elders, we get elder funding from the state. 

 

(Domestic Violence Director, Midwest) 

…we haven’t had psychiatry in over a decade, and we’ve got some need in that 
area, and there are 

some tribal health people that have been working really hard to get that 
reinstated. We just don’t have really good resources in that. We tend to cover 
those things only after the bad stuff has happened. Prevention is not realized to 
be the more cost-effective way of doing things, things have to go haywire 
before we address them. 

 

(Physician, Northwest Primary Care Clinic) 

 

More needs. Almost all respondents express a need for additional social workers, 
additional training in screening and intervention, and a standardized protocol for 


screening and intervention. In addition, there are needs for other services to be 
added such as respite care, in-home nursing 

care, food, safety inspections, transportation, and temporary housing for at risk 
elders. 

 

As well as resources available to our case manager, we need the ability of the 
elders to be fed, we need the ability for them to have a center, we need a place 
for them to go where family members can have a respite. 

 

(Physician, Western Primary Care Clinic) 

 

These needs are all expressed in the context of the need for a multidisciplinary or 
holistic response at assessing and meeting elder’s needs in order to prevent or 
address elder abuse and exploitation. 

 

Content Analysis 

Table 3 includes frequencies and percentages for several categorical questions 
asked as part of interviews. 

• 84.6% of health care providers agree/strongly agree that outpatient health 
care providers are capable of identifying all different types of elder abuse; 
55.5% of non health care providers agree/strongly agree that health care 
providers are capable 
• 69.2% of health care providers feel they have adequate training in elder 
abuse screening and management; 33.3% of non-health care providers feel 
they have adequate training 
• 76.9% of health care providers would like to receive additional training; 
88.9% of non-health care providers would like to receive additional training 



• 58.3% of health care providers say their state requires mandatory reporting 
of elder abuse; 70% of non-health care providers indicate this is the case 
• 54.5% of health care providers say their tribe requires mandatory reporting; 
66.7% of nonhealth care providers indicate this is the case 
• 69.2% of health care providers say their clinic has a screening process in 
place for elder mistreatment or domestic violence; 60% of non-health care 
providers are unsure if the clinic has screening in place 
• While many health care providers say they have screening tools in place for 
domestic violence, IPV, and/or mental health screenings that are non-elder 
specific used with elders, one clinic has implemented an elder specific tool. 
• Only a few health care providers indicate they have a clear protocol in 
place for handling instances of alleged elder abuse. 
• 58.2% of health care providers believe acculturation has no relationship or 
don’t know if it has no relationship to elder abuse; 80% of non-health care 
providers believe acculturation increases the risk for elder abuse 
• 69.2% of health care providers have made a referral to APS for suspected 
cases of elder abuse 
• 38.5% of health care providers have made a referral to law enforcement 
• 38.5% of health care providers have made a referral to another entity 
• The quality of relationships and communication with outside entities varies 
between tribal communities. For APS providers and law enforcement equal 
numbers of respondents identify issues with either entity, as said they are also 
an important resource or good ally. 
• Referrals to APS are the second most frequent intervention employed by 
health care providers. 
• Interventions for elder abuse listed in order of frequency include: 



o Employing additional resources such as nursing care, respite care, 
food, home repairs or shelter 
o Reporting to APS 
o MDTs or formal community cross-collaboration to address cases of 
abuse 
o Community health representatives and home health as prevention or 
intervention in cases of suspected or confirmed abuse 
o Availability of additional office staff to make and manage referrals 
for services 
o Outplacement of elders from their homes, primarily to nursing homes as 
most shelters can’t accommodate needs of elders 
o Reporting to law enforcement 
o Safety planning 
o Referral to behavioral health 
o Building trust and rapport to facilitate reporting of abuse by clients 
o Facilitating identification of power of attorney or guardianship 





Table 3 Interview Participant Responses on Elder Abuse and 
Mistreatment Experiences 





 



Non-health care 
providers 



Health care 



Total 



 

n=10 

n=13 

n=23 



Outpatient providers are capable of 

identifying all different types of elder 
abuse 

 

 

 



Strongly disagree 

0 (0.0%) 

0 (0.0%) 

0.0% 



Disagree 

2 (22.2%) 

1 (7.7%) 

13.6% 



Neutral 

2 (22.2%) 

1 (7.7%) 

13.6% 



Agree 

4 (44.4%) 

8 (61.5%) 

54.5% 



Strongly agree 

1 (11.1%) 

3 (23.1%) 

18.2% 






Have adequate training in elder 
mistreatment, detection, management, 
and reporting 

3 (33.3%) 

9 (69.2%) 

54.5% 



Would like to receive training in elder 
mistreatment, detection, management 
and reporting 

8 (88.9%) 

10 (76.9%) 

81.8% 



State requires mandatory reporting of 
suspected cases of elder abuse 

 

 

 



Yes 

7 (70.0%) 

7 (58.3%) 

63.6% 



No 

1 (10.0%) 

5 (41.7%) 

27.3% 



I don’t know 

2 (20.0%) 

0 (0.0%) 

9.1% 



Tribe requires mandatory reporting 

 

 

 



Yes 

6 (66.7%) 

6 (54.5%) 

60.0% 



No 

3 (33.3%) 

5 (45.5%) 

40.0% 



Clinic has a screening process for elder 
mistreatment or domestic violence 

1 (9.1%) 

48 (60.8%) 

54.44% 



Yes 

3 (30.0%) 

9 (69.2%) 

52.2% 



No 

1 (10.0%) 

4 (30.8%) 

21.7% 



I don’t know 

1 (10.0%) 

4 (30.8%) 

21.7% 



Does acculturation make a 
person/family more or less likely to 
experience abuse? 

 

 

 



Less Likely 

0 (0.0%) 

0 (0.0%) 

0.0% 



More Likely 

8 (80.0%) 

5 (41.7%) 

59.1% 



No Relationship 

0 (0.0%) 

4 (33.3%) 

18.2% 



I don’t know 

2 (20.0%) 

3 (25.0%) 

22.7% 



Made referral to APS 

- 

9 (69.2%) 

69.2% 



Made referral to law enforcement 

- 

5 (38.5%) 

38.5% 



Made a referral to another entity 

- 

5 (38.5%) 

38.5% 



Survey Findings 

As noted, results reflect feedback from 90 survey respondents that work in clinics 
serving primarily AIAN patients. Respondents were asked a series of questions 
regarding their own experience and the clinic’s experience with elder abuse 
including either closed-ended (categorical) or open-ended 


response options. Multiple questions asked providers to respond to a Likert-scale 
with scales for instance, ranging from strongly disagree (1), neutral (3) to strongly 
agree (5). 

 

The type of abuse respondents experience most frequently is financial abuse or 
exploitation (69%) followed by emotional abuse and neglect (61%). While health 
care providers note financial abuse or exploitation as the highest (70%) form of 
abuse seen, non-health care providers cite emotional abuse (67%). Financial abuse 
or exploitation is the most prevalent in clinical practice (61%). 

 

Chart: Abuse seen by providers and Prevalence of Abuse Types in Clinic
Clinical Practice: Financial Abuse: 61%; Neglect, 59%; Emotional Abuse, 41%; None, 18%; Physical Abuse, 4%; Sexual abuse, 0%; Other 5%
Seen by Provider Financial Abuse: 69%; Neglect, 61%; Emotional Abuse, 61%; None, 43%; Physical Abuse, 19%; Sexual abuse, 11%; Other 2%
0%


10%


20%


30%


40%


50%


60%


70%


80%


Financial abuse or exploitation


Neglect


Emotional Abuse


None, never had a patient suspected of elderabuse


Physical Abuse


Sexual Abuse


Other


Abuse Seen by Providers and Prevalence of Abuse Types 
in Clinic


Most prevlent in clinical practice


Type of abuse seen by provider


The majority of both health care providers and non-health care providers (53%) 
agree or strongly agree that outpatient providers are capable of identifying all 
types of elder abuse. 


 

Chart: Outpatient Providers Are Capable of Identifying All Different Types of Elder Abuse
Strongly Agree: 13%
Agree: 40%
Neutral: 31%
Disagree: 12%
Strongly Disagree: 4%
Strongly Agree13%


Agree40%


Neutral31%


Disagree12%


Strongly 
Disagree4%


Outpatient Providers Are Capable of Identifying All Different 
Types of Elder Abuse


Of the major types of abuse, respondents believe that providers are better suited 
to identify physical abuse (83%) and neglect (75%). A minority note that providers 
are best suited to identify sexual abuse. 


Chart: Outpatient Providers are Best Suited to Identify...
other: 1%
Sexual Abuse: 16%
Financial Abuse: 33%
Emotional Abuse: 46%
Neglect: 75%
Physical Abuse: 83%
0%


10%


20%


30%


40%


50%


60%


70%


80%


90%


Physical abuse


Neglect


Emotional Abuse


Financial abuse or exploitation


Sexual Abuse


Other


Outpatient Providers are Best Suited to Identify...


After identifying a case of potential elder abuse, slightly less than half (49%) have 
referred a case to another agency outside the clinic per protocol. Half of health 
care providers have made an outside referral and 44% of non-health care 
providers have referred outside the clinic. 

 

Of those who rated the handling of past cases by other entities, slightly more felt 
the case was handled poorly or very poorly (42%) compared to well or very well 
(40%). 

 

Top responses for why a case was not handled well by an outside agency include: 

• no follow-up (5), 
• inappropriate follow through with elder (4), 



• the elder was not eligible for the outside agency (3), 
• cases took a long time to resolve (2), and 
• cultural factors such as distrust, cultural awareness, and attendance to native 
elders, provided barriers (2). 


 

The feeling that a case was handled well was the top view of why providers felt an 
outside agency addressed the situation well. Other views address specific 
components of outside agencies‘. 

Chart: State Mandates Elder Abuse Reporting
Yes: 84%
No: 6%
Don't know: 10%
Yes84%


No 
6%


Don't Know10%


STATE MANDATES ELDER ABUSE REPORTING

 


The majority of responders note that both their state and tribe mandate 

reporting of elder abuse. Tribes are less likely to mandate reporting. 


 

Chart: Tribe Mandates Elder Abuse Reporting
Yes: 66%
No: 8%
Dont' know: 25%
Other: 1%
Yes66%


No8%


Don't Know25%


Other 1%


TRIBE MANDATES ELDER ABUSE REPORTING


When commenting on mandatory reporting most note it is positive. Barriers to 
mandatory reporting include lack of awareness, lack of enforcement, and difficulty 
when an elder denies apparent abuse. 

 

In addition to reporting, respondents commented on screening in tribal clinic settings. 
The majority (54%) do not routinely screen for elder abuse. This statement is true 
for both health care providers (54%) and non-health care providers (56%). When 
describing screening, of 29 respondents, 18 use informal screening tools while 7 
identify formalized tools. 

 





Formal Screening Tools 



Informal Screening Methods 





Domestic violence screening tool 
(unspecified) 



Asking the patient 






Elder Abuse, Neglect and Family 
Violence: A Guide for Health Care 
Professionals 

Home visit assessment 





GPRA 



Internal tool 



PHQ-9 (Depression) 

Patient History 





Promis-29 



Physical Exam 



PPMS 

Questionnaire 





Vulnerability to Abuse Screening Scale 
(VASS) 



 



 

On standard protocols and processes for handling suspected cases of elder abuse, 
approximately half of respondents’ clinics have protocols (49%) and half do not 
have a protocol or are not aware of a protocol (24% no protocol, 27% do not 
know of protocol). The majority of respondents note some form of reporting or 
referral process including to APS, tribal police, social services, or other agencies. 
Other protocols include documentation requirements and training. 

 

On the role of providers, the 89% of respondents agree or strongly agree that 
providers in outpatient settings should play a role in screening for elder 
mistreatment. 

 


 

Chart: All clinical providers in outpatient care settings should play a role in screening for elder abuse and mistreatment 
Strongly Agree: 56%
Agree: 33%
Neutral: 8%
Disagree: 2%
Strongly Disagree: 1%
Strongly 
Agree56%


Agree33%


Neutral8%


Disagree2%


Strongly Disagree1%


ALL CLINICAL PROVIDERS IN OUTPATIENT CARE 
SETTINGS SHOULD PLAY A ROLE IN SCREENING FOR 
ELDER ABUSE AND MISTREATMENT 


When asked to assess their own abilities, a minority of respondents strongly agree 
or agree (43%) that they are knowledgeable. 


 

Chart: I consider myself to be knowledgeabe about best practices for identifying cases of suspected elder mistreatment
Strongly Agree: 12%
Agree: 31%
Neutral: 37%
Disagree: 17%
Strongly Disagree: 3%
Strongly Agree12%


Agree31%


Netural37%


Disagree17%


Strongly 
Disagree3%


I CONSIDER MYSELF TO BE KNOWLEDGEABE ABOUT 
BEST PRACTICES FOR IDENTIFYING CASES OF SUSPECTED 
ELDER MISTREATMENT

 


The top barriers to screening selected from a pre-identified list are the presence of 
family and caregivers at the appointment, and larger community or agency 
barriers such as lack of screening tools and lack of services. Additional barriers 
offered are cultural awareness, trust, and not wanting to report family members 
who are perpetrators. 

 

 


 

Chart: Barriers to Elder Abuse Screening (1 of 3)
Presence or reliance on family members or caregivers in the assessment and treatment process: 44%
Lack of universal screening tools for elder abuse: 40%
Lack of community services for elders identified as abused or mistreated: 39%
Limitied or poor follow up when cases are reported, 39%
Difficulty distinguishing mistreatment from accidental trauma, illness, or quality of care issues, 29%
44%


40%


39%


39%


29%


Presence or relianceon family members orcaregivers in theassessment andtreatment process


Lack of universalscreening tools forelder abuse


Lack of communityservices for eldersidentified as abusedor mistreated


Limited or poor followup when cases arereported


Difficultydistinguishingmistreatment fromaccidental trauma,
illness, or quality ofcare issues


Barriers to Elder Abuse Screening

 


Chart: Chart: Barriers to Elder Abuse Screening (2 of 3)
Wide range of risk factors, 21%
Time constraints in the clinical setting, 25%
Lack of standards for talking with patients about potential abuse, 24%
Significant diversity in the types and manifestations of elder abuse, 24%
Communication difficulties with older adults (hearing, cognitive, etc.), 22%
Confusing or no guidance on how to respond if abuse is identified, 21%
21%


25%


24%


24%


22%


21%


Wide range of riskfactors


Time constraints inthe clinical setting


Lack of standardsfor talking withpatients aboutpotential abuse


Significantdiversity in thetypes andmanifestations ofelder abuse


Communicationdifficulties witholder adults(hearing, cognitive,
etc.)


Confusing or noguidance on howto respond if abuseis identified


Barriers to Elder Abuse Screening (Continued)



 

Chart: Barriers to Elder Abuse Screening (3 of 3)
Personal discomfort/uncomfortable (for provider) talking about abuse, 17%
Variation in definition of abuse, 11%
Variation in state or tribal laws regarding mandatory reporting, 10%
Confusing or no guideance about who to screen. 7%
Other, 6% 
17%


11%


10%


7%


6%

















Barriers to Elder Abuse Screening (Continued)

 


Respondents were also surveyed on a series of questions around needed resources, 
best practices, and trainings. When asked in an open-ended format what resources, 
tools, or information are needed to improve screening the predominant answer is 
protocol implementation followed by training, screening tools, and resources. 

 

Few respondents are able to cite specific examples of clinics employing best 
practices. In training, both health care and non-health care providers feel they do 
not have adequate training in elder abuse detection, management, and reporting 
(69%) and the majority express interest in more training (79%). A wide variety of 


training topics were suggested. The top suggestions are training on screening, 
identification of abuse, resources for victims, protocols for abuse cases, and how to 
work with victims. 

 

To further the inquiry into the experience of Indian Country specifically, providers 
were asked about the level of traditionalism or assimilation of the community served 
by their clinic. Only one provider notes that the community is assimilated (or strongly 
identified with the mainstream). The 

majority of providers identify their community as bicultural (64%) and 26% note 
their community is traditional (strongly identifying with native cultures). 

 

Chart: Community Culture
Bicultural (identifies with both native & mainstream cultures) 64%
Assimilated (idenifies strongly with mainstream culture), 1%
I dont' know, 9%
Tranditional (strongly identifies with native culture), 26%
Bicultural 
(identifies with 
both native & 
mainstream 
cultures)
64%


Assimilated 
(idenifies 
strongly with 
mainstream 
culture)
1%


I don't know9%


Tranditional 
(strongly 
identifies with 
native culture)
26%


COMMUNITY CULTURE


More respondents agree or strongly agree that acculturation has an effect on the 
prevalence of elder abuse (50%) compared to those that agree or strongly agree 


that traditionalism has an effect on the prevalence of elder abuse (40%). 
Respondents note that they believe traditional identification 

results in less abuse and is preventative, while acculturation increases the likelihood 
of abuse. They also note that there is more respect for elders in traditional native 
cultures. Substance abuse is also mentioned as a factor. The majority of respondents 
agree that differences in acculturation between caregivers and elders can increase 
the risk of abuse. 

 

 

Chart: To what extent do you believe differences in acculturation between caregivers and elders increase risk of abuse?
Strongly Agree: 11%
Agree: 44%
Neutral: 43%
Disagree: 2%
Strongly Disagree: 0%
Strongly Agree11%


Agree44%


Neutral43%


Disagree2%


Strongly Disagree0%


TO WHAT EXTENT DO YOU BELIEVE DIFFERENCES INACCULTURATION BETWEEN CAREGIVERS AND ELDERSINCREASE RISK OF ABUSE?

 


Forty-seven respondents listed additional significant factors contributing to elder 
abuse in their community. The most frequently occurring are substance abuse (25) 
and poverty (17). Other top factors include overreliance by the family on the elder, 
housing issues, lack of services, trauma history, and unemployment. 

 


To begin looking at addressing the issue, respondents were asked about the 
community perception of elder abuse. Respondent most frequently note that 
communities are aware of elder abuse but have not done anything to address it. 
Others note no community interest, no community awareness, or denial by the 
community that an issue exists. The majority of respondents feel that there are not 
adequate resources to address the needs of elder abuse victims (49%) or do not 
know if there are adequate resources (29%). 

 

APS is the most frequent resource respondents have used (69%) followed by 
behavioral health (45%) and law enforcement (35%). 

 

Chart: agency referrals by providers
Adult Protective Services: 69%
Behavioral Health: 45%
Law Enforcement: 35%
Local council or area agency: 20%
Domestic violence shelter: 16%
69%


45%


35%


20%


16%


2%


16%


0%


10%


20%


30%


40%


50%


60%


70%


80%


Adult Protective Services


Behavioral health


Law Enforcement


Local council or area agency


Domestic violence shelter


Health care licensing


Other


Agency Referrals by Providers


In making referrals, the most frequent concern is no follow up or updates from the 
agency contacted. Other concerns are that nothing happened once referred and a 


lack of training. Overall, the majority of responders feel they know who to contact 
for elder mistreatment reports (55% strongly agree or agree). 

 

Chart: "I know who to contact for reporting elder mistreatment."
Strongly Agree: 30%
Agree: 25%
Neutral: 19%
Disagree: 17%
Strongly Disagree: 9%
Strongly Agree30%


Agree25%


Neutral19%


Disagree17%


Strongly 
Disagree9%


"I KNOW WHO TO CONTACT FOR REPORTING ELDERMISTREATMENT."


In community services, law enforcement, and government support for Native victims 
of elder abuse the most frequent gaps are in housing, resources needs in general, 
greater coordination between agencies and providers, and agency follow through 

 

Comparison of Survey Findings to Interview Themes 

Individual Variables 

Theme: Elder protection of family 

 

As in the interviews, survey respondents note elders are reluctant to make 
allegations against family members, particularly those who may be the elder’s 
caregiver. This is one of the biggest barriers to addressing abuse. As one 
respondent notes, “The only willing caregiver may be the abuser, then [the] elder 


will have no one to help them at all.” An added challenge is the presence of family 
members with the elder during clinic visits to provide transportation or other 
assistance. 

 

Theme: Elder support of grandchildren 

 

This was a theme that arose in interviews, but was not a significant theme in open 
ended survey comments or responses to other questions. 

 

Theme: Substance abuse as a contributing factor 

 

Unlike with interviews, substance abuse by the elder (not just family members or 
caregivers) is cited as a possible factor playing a role in abuse. AIAN communities 
have higher rates of substance misuse which reaches into the elderly as well. 

 

Familial Variables 

Theme: Honor and duty to share resources 

As in the interviews, there is an overall theme of family dependence, predominantly 
children and grandchildren, on the elder. This theme is apparent as both a 
preventative factor and a contributor to abuse. As in the interviews, the cultural 
belief of respect for elders and family support is present throughout. This traditional 
family component is cited as a benefit over acculturation. The theme is also a 
potential contributor to abuse when family members are over reliant on the elder or 
feel “entitled” to this support. One respondent notes that it can be unclear when 
familial support can be of benefit or detriment to the elder. 

 

Theme: Caregiving creates vulnerabilities for some 

 


This was a theme that arose in interviews, but was not a significant theme in open 
ended survey comments or responses to other questions. 

 

Theme: Substance abuse as a contributing factor 

 

As with interviews, respondents believe substance misuse is the most significant risk 
factor for elder abuse. Abuse that results from substance abuse may be in any 
form, but frequently manifests as neglect or financial exploitation. 

 

Theme: Impoverishment as a contributing factor 

 

High poverty levels experienced by both the victim and the perpetrator contribute 
to abuse, particularly financial abuse according to survey respondents. Poverty is 
linked to the need for familial support which also contributes to abuse. Many AIAN 
communities face continuing poor economic opportunities and high rates of 
unemployment perpetuating poverty for generations beyond the elder. This is the 
same major sentiment shared in interviews. 

 

Structural Variables 

 

Theme: Patients present to providers with all types of abuse experiences 

 

As with interviews, survey respondents indicate that the easiest type of abuse for 
providers to identify is physical abuse (83%). This is followed closely by neglect 
(75%), according to survey respondents. Similarly, survey respondents have 
experience caring for patients with all types of abuse, though most frequent is 
financial abuse and exploitation, followed by emotional abuse, and neglect. 

 

Theme: Difficulties in abuse assessment 


 

Theme: Providers can and should play a role 

 

As in the interviews, there is a consensus that there are barriers to screening and 
identifying abuse in the clinical setting. The most frequently identified barrier to the 
screening and management of elder abuse by survey respondents is presence of 
family members (44%), which was a primary theme in interviews. The interviews 
also identified time and provider turnover as key issues. Only 25% of survey 
respondents identified time as a barrier, however, and provider turnover was not 
an option in the question and not mentioned in open ended responses provided as 
follow up. 

 

Theme: Providers can and should play a role 

Theme: Few standardized protocols 

 

Although the majority agree that providers are capable of and should have a role 
in identification of abuse, less than half note that their clinic routinely screens 
specifically for elder abuse. A lack of screening tools, lack of training on screening, 
and a lack of clinic screening protocols are major 

challenges. Among the seven responses on formal screening tools use only two were 
elder abuse specific, one of which addresses only women. These survey findings are 
all similar to interview themes that emerged. 

 

Finally, the third most frequently cited barrier by survey respondents was 

lack of community resources. The need for additional services and resources was a 
theme identified in gaps and needs identified by interview respondents. 

 


In addition to a lack of screening ability, there is evidence of a lack of formalized 
protocols to address suspected cases of abuse among survey and interview 
respondents. While only half cite the existence of a protocol, few cite clinics with 
best practices. The need for protocols and policies is the most frequent cited need. 
Current protocols largely include reporting to a variety of authorities or other 
agencies. 

 

New Theme: Awareness of abuse by providers not universal 

 

Lack of awareness by some providers of the abuse victims in their clinics is a 
response unique to survey respondents. While most providers acknowledge abuse 
cases in their clinic, about 20% report not having experienced a suspected case 
themselves or at their clinic. 

 

Cultural Variables 

Theme: Respect for elders as a function of culture 

Theme: Abuse discouraged as community /familial topic 

New Theme: Traditional native cultures can both facilitate and protect against abuse 

 

Traditional native culture is generally viewed as a protective factor against abuse. 
Notably, in traditional culture elders receive greater respect and honor. Elders are 
seen as passing on knowledge and tradition to keep tribes safe and prosperous. 
However, the same traditional native 

cultural beliefs may play a contributing role to abuse in some cases. Household 
interdependence and high level of support for younger generations seen in 
traditional culture may be a risk factor for the elder. Additionally, elders may be 
reluctant to report or cooperate with outside agencies for the sake of protecting 
their family. All of these themes were identified by interview respondents as well. 


While overall it is apparent that providers feel that traditional native culture is 
protective these are open to consideration. 

 

Theme: Role of acculturation is unclear 

New Theme: Differing acculturation levels between elder and caregiver as a 
contributing factor. 

 

As most of the respondents note that their communities are not always fully 
traditional nor fully accultured, based on a line of questioning in the survey not 
pursued in interviews, there are cases where the elder and their caregiver differ in 
their cultural identification. Survey respondents strongly note that this difference can 
increase the risk of abuse. Traditional native culture can greatly differ from what is 
viewed as mainstream culture. Differing values between generations such as respect 
for elders or levels of family support may contribute to abuse by the caregiver. This 
was a sentiment a small number of interview respondents broached, though it was 
not a major theme. Among interview respondents, who were not asked to quantify 
their beliefs regarding acculturation, the role it plays in abuse was more ambiguous 
(maybe yes or not sure versus a definite yes or definite no), particularly among 
health care providers. 

 
Theme: Historical trauma 

 

Unlike in survey respondents, historical trauma was a major theme among interview 
respondents, though some discussions were the result of interviewer follow-up 
questions based upon participants who raised the subject in early interviews. The 
various concepts that encompass historical and present traumas (cycle of abuse, 
racism, historical trauma) were each mentioned by at least one respondent in 
surveys, but was not a major theme. 


 

Theme: Cultural renewal as possible intervention 

 

This was a theme that arose in interviews, but was not a significant theme in open 
ended survey comments or responses to other questions. 

 

Community Variables 

Theme: Community surveillance and identification 

 

This was a theme that arose in interviews, but was not a significant theme in open 
ended survey comments or responses to other questions. 

 

Theme: Lack of priority and awareness 

 

Within the communities served by respondent’s clinics, there is a notable lack of 
awareness of or attention to the issue of elder abuse. Where communities are 
aware of the issue, it generally goes unaddressed. Denial or ignoring an 
uncomfortable problem contributes to this low level of 

engagement. There appears to be room for traction and growth as many 
respondents note that the community sees a problem but are not able to address it. 
These were major theme present in interviews. 

 

Theme: Promising interventions 

 

This was a theme that arose in interviews, but was not a significant theme in open 
ended survey comments or responses to other questions. While there was a survey 
question about best practices, there were few responses. If respondents did reply 
they indicated they did not know of any best practices. 


Organizational Variables 

Theme: Positive interactions with referral agencies essential, room for improvement 

 

As with the interviews, by and large survey respondents reported positive outcomes 
when working with APS, law enforcement, and other entities on referrals of abuse 
allegations. Nearly 70% of respondents have made a referral to APS, 45% to 
behavioral health, and 35% to law enforcement. Though, there were concerns 
expressed from a small number of respondents primarily related to lack of follow-
up and concerns that “nothing was done” in response to referrals. 

 

Theme: Jurisdictional issues a challenge 

 

This was a theme that arose in interviews, but was not a significant theme in open 
ended survey comments or responses to other questions. There was a question with 
pre-identified barriers, and jurisdictional issues was not included, and there were 
only a few respondents who identified 

jurisdictional-related issues in the open-ended follow-up question. 

 

Needs 

Theme: Funding underscores multiple needs 

 

Contributing to the theme of lack of awareness and attention, there is a theme 
throughout the survey responses of a lack of resources in the community to address 
elder abuse. This lack of resources and funding is also seen in the interview analysis. 
The majority of respondents feel there are not a sufficient amount of resources to 
address the needs of older victims. A need for materials and educational resources 
for providers, victims, and the community is also seen. 


 

Theme: Need for additional training 

 

While providers feel capable, they need training. Unlike in the interviews, the 
majority of providers do not feel they had adequate training and similar to the 
interviews the vast majority would like to receive more training. Training suggestions 
differ, but the most frequent support the notion that providers are capable when 
given the tools. These suggestions include screening for abuse, identification, and 
resources for victims. Other areas of training that are more state or tribe specific 
include mandatory reporting requirements and investigative agency processes. 
These 

training topics also have the additional benefit of supporting greater collaboration. 

Discussion 

The findings from this national needs assessment fill a significant void in the 
knowledge and understanding of the manifestation of elder abuse viewed through 
the lens of tribal health providers. It is the first assessment, to our knowledge, of its 
kind. It utilizes two complementary methods of assessing similar questions and issues 
that results in rich, descriptive stories and examples that give a real voice to the 
needs and challenges faced by tribal providers. Using multiple methods of inquiry, 
we were able to triangulate most findings which is demonstrated through the 
remarkable congruence between survey results and the interview findings. Though 
there were a number of themes that were identified in interviews that were not 
identified across survey data, and a smaller number that were identified in the 
survey but not interview. While survey respondents were provided multiple 
opportunities to provide comments to specific questions and more generally, those 
answers tended to be very succinct and often provided little context or description 
of issues that were raised. Such is the nature of survey responses. 

 


Screening is Widely Accepted, But Not Being Widely Accomplished 

Of prime importance to our overarching goal, which is to promote and implement 
screenings, referrals, and/or interventions for AIAN elder victims of abuse, is that 
89% of survey respondents agree that all heath care providers should play a role 
in screening for elder mistreatment. Yet, only 54% of survey respondents report 
they routinely screen for elder abuse and only two interview participants (from the 
same tribe) report implementing an elder-specific screening tool and only one 
interview respondent reports implementing an elder-specific screening tool (within 
the last year). The desire for systematic provider engagement in screening is a 
sentiment generally supported in interview findings. While there are those who, 
through both methods of inquiry, express doubt, concern, or disagree with the 
concept of provider screening for elder mistreatment, they comprise a small 
minority. 

Desire for Training, Protocols and Tools 

However, findings also clearly indicate that at the present time the majority of 
providers lack the knowledge, training, appropriate tools or protocols, and 
community resources to properly equip them to respond. All the while they continue 
to care for elderly patients who they believe are being abused or exploited. 
Nearly 70% of providers have worked with patients experiencing financial abuse 
or exploitation according to survey results, and more than 60% have patients who 
have experienced neglect or emotional abuse. An astounding 43% of providers 
have encountered patients experiencing physical abuse, even though it is one of the 
less common forms of abuse. Yet in the face of these experiences, providers are 
largely left to fend for themselves in assessing and managing suspected cases of 
abuse and exploitation and generally lack the appropriate community services (as 
a means of intervention). 


 

Findings Confirmed by Previous Research 

Beyond screening, there are a number of findings from the current needs assessment 
that support previous elder abuse research or expert opinion in AIAN focused 
research. For instance: 

• financial exploitation and neglect are cited as the most prevalent forms of 
abuse by health care providers 
• substance abuse and poverty are thought to be the two most common 
correlates or causes of abuse; followed by mental health issues 
• respect for elders is the predominant cultural value discussed in interviews 
and surveys 
• jurisdictional issues are a significant challenge according to interviews 
• communities with more traditional views and that are less acculturated are 
thought to experience lower rates of abuse; conversely acculturation is 
thought to lead to higher rates of abuse though there were mixed findings on 
the part of some health care provides who see instances of abuse regardless 
of the degree of acculturation or traditionalism 


Noteworthy or New Findings 

There are several issues, which may have been broached in previous research or 
opinion pieces about elder abuse in AIAN communities that we believe warrant 
further discussion. 

 

Historical and Current Traumas 

Historical and current trauma, which have been discussed in previous abuse research 
among AIAN elders, though not a major theme or aspect, is a major theme in our 
interviews that is unique to the population. Boarding schools, the life cycle of family 
violence, persistent racism, and forced assimilation or acculturation are among the 


important issues identified by multiple respondents. As previously discussed in this 
report, the scope and duration of historical trauma experienced by the AIAN 
population is unique. As shared by interview participants in the current assessment, 
there are tribal elders alive today who were subjected to boarding school 
experiences, which existed until as late as the latter half of the last century and still 
others who continue to face persistent discrimination in their communities. Historical 
trauma couples with higher rates of trauma and adverse experiences across the 
lifespan. Research has shown that AIAN people experience higher rates of adverse 
childhood events (ACEs) (Kenney & Singh, 2016; Warne et al., 2017), a topic 
raised in two interviews in the present study. Recent analysis of the National Elder 
Mistreatment Study dataset found that 79% of all AIAN respondents had 
experience some form of trauma in their lifetime (e.g., natural disasters, accidents, 
or other situation they feared for their life); a significantly higher percentage than 
their white counterparts in the study (Crowder et al, 2019). Based on data from the 
same analysis, we know that AIAN elders in that study experienced higher lifetime 
rates of various types of abuse when compared with whites and were also 
significantly more likely to experience polyvictimization (multiple types of abuse) 
than white counterparts in their lifetime. 

 

The importance of the concept of polyvictimization and the dose-dependent 
response to exposure to multiple episodes of victimization is emerging in elder 
abuse research (Burnett et al., 2016; Hamby, Smith, Mitchell, & Turner, 2016; 
Teaster, 2017). Polyvictimization enhances the 

likelihood of psychological issues such as depression, anxiety, PTSD, other 
psychiatric diagnoses or suicidal ideation (Tossone, 2015), any or all of which can 
significantly impact physical health and wellness. Much like polyvictimization, the 
body on trauma or trauma-informed care among victims of elder abuse is sparse. 
Even less is known or written about the impact of compounding both historical and 


current life victimization and traumas, only that it occurs and is worthy of attention. 
Gustafsson et al. (2009) coined the term poly-traumatization, one not widely 
discussed in the scientific literature and essentially absent from the elder abuse 
literature. The term encompasses the co-occurrence of multiple types of victimization 
and traumatization such as family deaths, car accidents, or divorce. 

 

The concept of trauma informed care and the importance to the practice of working 
with elder abuse victims was raised by several interview respondents. As one 
participant noted, they have been practicing facets of trauma-informed care in 
their tribe for some time, but only in more recent years has someone put a formal 
name to the concept. The U.S. Substance Abuse and Mental Health Services 
Administration (SAMHSA) has outlined six key principles of trauma informed care 
(SAMHSA, 2014). SAMHSA indicates that these practices are integral not just in 
behavioral health settings, rather implementation is essential in any setting a person 
who has experienced trauma comes in contact, including primary care. Further, they 
state that not addressing trauma as part of the provision of care is a barrier to 
good patient outcomes. 

 

As it was not the focus of the current project, it is not known how broadly trauma 
informed care practices are employed across health sectors that serve tribal 
populations. The IHS website describes details about the “Trauma Informed Care 
Project,” offered through the Division of Behavioral Health, with archived training 
resources from 2013 -2017 and notes the availability of two providers for case 
consultation services (U.S. Indian Health Service, n.d.). Many of the training 
resources are focused on children and youth, though several focus on veterans and 
historical trauma. No participants in the current needs assessment referenced formal 
training, and it is unclear if the IHS Trauma Informed Care Project is still an active 
initiative offered by IHS. Health care providers and clinic staff, as well as elder 


advocates and APS staff, may benefit from training and exposure to trauma-
informed care practices and protocols, if not already provided, with focused 
content for elder tribal members and elder abuse victims. Like training in the 
recognition and response to elder abuse and exploitation, learning, understanding, 
and integrated trauma-informed 

care into clinical practice will require a systematic approach to implementation, but 
seems a logical adjunct to any planned effort to address elder abuse given the 
pervasive nature of the issue. 

 

Poverty and Other Social Determinants of Health 

Marked disparities exist for elders regarding the social determinants of health. 
When we examine the social determinants of health in regard to AIAN, Indigenous, 
and other colonialized peoples, it is apparent that among elders (defined by the 
IHS as >55 years of age) within these populations many experience “multiple 
jeopardy.” They are often politically disenfranchised, either presently or 
historically, are often poverty-stricken, and are in poor health, when compared to 
their counterparts in the general population (Sokolovsky, 2009; Henderson 2002; 
2010). When we look at the elders as descendants of a long history of structural 
violence then we expand the multiple jeopardy concept exponentially. 

 

The older AIAN population, will increase by 193% by 2030 (Administration on 
Aging). The fact that minorities are often more vulnerable to health and well-being 
deficits than the majority population coupled with significant increases in minority 
populations, means health care and social systems face a disparity crisis regarding 
health, aging, and minority status (Henderson and Henderson, 2008). Issues such as 
the ones discussed in our interviews about the perceived causal relationship of 
poverty, substance abuse, and other mental health issues, along with concerns about 
current funding deficiencies for elder services including community health, 


behavioral health, and access to other community and health services for elder 
victims of abuse that will only compound as a result of these demographic shifts. 

 

The IHS is currently confronted with the problem of providing care to the increasing 
numbers of elders, without having sufficient resources to care for the other age 
groups within the Indian population. IHS delivers free health care services to the 
Native American population who are members of federally recognized tribes that 
live in proximity to facilities that are geographically accessible. Funding for services 
is often deficient for its population needs. IHS services are an entitlement, and 
therefore the U.S. Congress makes funds available through an appropriation. HIS 
areas operate for the most part on limited budgets. There are expensive diagnostic 
and treatment services that are contracted for with other providers, but these 
become unavailable if the budget is insufficient (Henderson, 2001). The Indian Self-
determination Act places the responsibility for almost half of health programs on 
the tribes. In many cases, reimbursement from the federal government is low, and 
this places the tribe at a financial disadvantage. Self-determination has inflated 
costs and compromised service provisions, due to lack of coordination between, 
federal, state and tribal agencies (Henderson, 2001). 

 

Additional services essential to the health and wellbeing of Indian elders also face 
substantial deficits in funding and access. Long-term care is needed increasingly in 
Indian country, as more adult children find it necessary to move from rural areas to 
urban areas, in order to find employment. Multiple interview respondents discussed 
concerns about the lack of access to long term care facilities for out-placement of 
abused tribal elders to remove them from unsafe situations, and lack of respite care 
for over-burdened spouses and family caregivers. Caregiving issues such as 
increased dependency patterns of older adults or the complexities associated with 
sharing family caregiving roles, have been identified in previous elder abuse 


research among AIAN communities. However, caregiving issues were not as 
prominently discussed among participants in this assessment. Often, discussion of 
caregiving issues arose when participants were asked to share an example of a 
case of elder mistreatment. In many of those anecdotes, the caregiving 
responsibility fell to adult children or grandchildren and multiple cases involved 
elders with dementia or Alzheimer’s disease. The children as caregiver theme is not 
surprising though, given that a smaller percentage of AIANs age 

50 and over that are married or co-habiting compared with the rest of the U.S. 
population (Goins et all, 2015). These were often cases identified as “gray areas,” 
where it was not always a clear-cut case of abuse or exploitation, rather a question 
regarding the need for additional services or resources such as home health care, 
homemaker services, respite care, or food and nutrition services. 

 

Access to housing, food, and transportation were also service deficits identified by 
respondents. 

 

The Older Americans Act mandates that certain services be provided to elders 
through Title III for the general population, and Title VI for the Indian population. 
These two acts differ significantly in the services that are mandated by the grants. 
Title III mandates that nutrition sites, home delivered meals, in-home services, 
transportation and access services, legal assistance, and ombudsman services be 
provided by the area program. In 2016, the Title VI programs served 64,464 
older Indians meals in congregate sites such as senior centers and provided home-
delivered meals to an additional 24,810 Native elders, in addition to the provision 
of other services both in-home and in senior centers. Title VI services presently offer 
the most systematic access and provision of services to and for AIAN elders, yet are 
not available in every tribe or village. For AIAN elders, however, Title VI mandates 
only that nutrition sites, referral and information services, and transportation be 


provided. Title VI is grossly under-funded, and even the services vary greatly 
between tribes. 

 

Community, Public Health and Home Health as Surveillance & Intervention 

Community Health Representatives (CHRs) and home health nursing programs came 
up frequently, identified as sources of surveillance and screening in the community 
as well as “interventions” employed in cases of alleged or confirmed abuse. Home 
health staff were often identified as the “eyes and ears” in the community. 

 

The CHR Program is a unique community-based outreach program, staffed by a 
cadre of well-trained, medically-guided, tribal and Native community people, who 
provide a variety of health services within AIAN communities. A CHR may include 
traditional Native concepts in his/her work and is funded with IHS-CHR 
appropriations (L.C. Carson, 2010). There continues to be a crucial shortage of 
home-health services for the elderly as fewer services funded and delivered by the 
IHS are community-based. There is a lack of financial support for ongoing service 
provision as well. Home care is provided by IHS, tribal health nurses, Public Health 
Nurses (PHNs) and CHRs. Public health nurses and CHRs are important sources of 
care for the elders because both make home visits and transport elders to health 
care facilities. The CHR program provides a cost-effective means to provide case 
management and home-health care for this population. However, the current 
demand for transportation and the need for specific training in geriatrics mitigate 
against further use of CHRs for this purpose (Carson, 2001). Several respondents 
indicated that standard home health resources funded by Medicare, for instance, 
could be hard to obtain or of such a short duration or intensity they provided little 
assistance. One urban Indian health center discussed with regret that their clinic-
funded home health program had recently been cut and would stop providing 
services in the near term. This was perceived as a catastrophic cut in a valuable 


resource as traditional publicly and private funded home health programs failed to 
provide the quality of service and intervention in a culturally sensitive manner. A 
systematic assessment of how to better leverage Medicare home health resources in 
cases of alleged or confirmed abuse may be warranted. In addition, assessing 
opportunities to initiate or expand tribal-run home health programs, including 
innovative funding models, to aid in assisting not only victims of elder abuse but 
other epidemic-level health issues such facing tribal elders and communities such as 
Alzheimer’s and dementia. 

 

Development and assessment of potential screening and intervention programs 
using home-based health service staff would be both innovative and warranted 
based upon findings from interviews. One such evidence-based model, the Domestic 
Violence Enhanced Home Visitation (DOVE) 

program could serve as a potential model. DOVE is an IPV intervention to reduce 
violence for prenatal and postpartum women with documented or high risk of IPV 
(Sharps et al., 2016). The DOVE intervention includes structured abuse screening for 
IPV and a six-session empowerment intervention. It is delivered primarily by nurses 
as part of a pre-existing home visiting programs. Staff received initial and ongoing 
training and support. Each of six sessions consisted of a review of a simple brochure 
on the cycle of violence, an assessment of risk factors, review of available 

resources, and safety planning. Staff were encouraged to modify the content of 
discussions to meet the needs of the patient and situation encountered in the home 
(Bacchus et al., 2016). 

 

Need to Explore the Link Between Culture and Abuse 

Previous research has identified acculturation and assimilation as potentially 
causative factors for abuse, as a result the subject was incorporated into the present 
study (Baldridge et al., 2004; Baldridge, 2001; Hudson, Armachain, Beasley, & 


Carlson, 1998; Jervis & Sconzert-Hall, 2017; Maxwell & Maxwell, 1992). Most 
non-health care providers were likely to indicate when asked that acculturation 
increased the potential for abuse, whereas health care providers were more likely 
to 

indicate it had no impact or the impact was unknown. The latter responses may be 
related to the high percentage of non-health care providers who identify as AIAN, 
thus, as a tribal member themselves they are more attune to issues related to 
culture. If the questions surrounding acculturation and traditionalism had not been 
included, it is unlikely that few participants would have raised the issue in interviews 
or surveys. Other than recognition of the issue, we simply know very little about the 
real impact of the issue on abuse. There are more questions than answers based 
upon existing literature. Does acculturation really make a difference when it comes 
to elder abuse? Is the impact direct or indirect? Are there important mediators and 
moderators? Does it matter “who” is more traditional, more mainstream or bicultural 
as proposed by our survey respondents? Does acculturation matter at the community 
level or individual level? 

 

Relatedly, several participants mentioned programs designed to reinvigorate 
cultural traditions such as language, culture, and food programs. These are posited 
as potential promising or best practices. A similar series of questions exist to 
explore the potential link to abuse or abuse prevention so we can better 
understand the mechanism of impact, if any. These programs may offer the 
opportunity to meaningfully engage elders and to reduce social isolation. Perhaps 
the impact is one of self-empowerment of elders or changing behavior or offering 
early interventions for potentially abusive family members. There are validated 
available tools to measure acculturation and assimilation among AIAN people. 
There are validated tools to measure elder abuse. There are programs in place 


focused on re-vitalizing culture. One needs only to invest in an assessment that 
brings all of these concepts and practices together. 

 

MDTs, Another Promising Intervention 

MDTs were another promising practice discussed in our interviews. In those tribes 
where they exist, they are seen as a very effective tool. Notably, virtually all of the 
communities who have an existing MDT also have a tribally-funded APS worker or 
another individual who serves as a single point of contact for alleged cases of 
abuse. These tribes also appear to employ the most comprehensive response to 
elder abuse when it occurs, and have the ability to engage multidisciplinary 
resources on behalf of elder victims. This is as opposed to relying on county or state 
APS workers or even a tribal social services staff member or social worker or 
department who had dual responsibility for both child and elder abuse complaints. 

 

A brief survey of 265 Title VI (elder services) program staff was conducted by as 
part of an informal assessment for a different project being undertaken. Of those 
responding, 20 tribal MDTs or other formal or informal boards, special councils or 
entities made up of multidisciplinary staff that regularly discusses and works with 
victims of elder mistreatment was identified. Forty-seven percent (47%) of 62 tribal 
elder service respondents also indicated that they had tribally funded APS staff, 
while 53% rely on county, state, or other non-tribal APS programs to refer and 
manage alleged cases of elder abuse or identified some “other” staffing scenario. 

 

The existence of MDTs and other structural and community supports in tribal 
communities is sporadic and has not been assessed systematically. Based on brief 
discussions of MDTS as part of interviews for the current project, we found that what 
constitutes an MDT and the roles and functions of the teams varies from one tribe to 
the next. Discussions with tribal staff indicate that membership, function, and 


outcomes of these MDTs vary. We also found that the tribal provision of services 
may include non-traditional services such as home repairs and transportation. 

 

However, the evidence-base supporting the use of MDTs includes only a handful of 
case studies or quasi-experimental research. What exists, seems to indicate that 
MDTs may be effective in enhancing coordination, increasing knowledge of 
professionals, better leveraging fragmented resources, and improving outcomes. In 
their international review, Pillemer and colleagues note that the needed response to 
aid victims of elder abuse spans multiple systems, such as health care, APS, mental 
health, criminal justice and more. They also advised, relevant to previous discussions 
in this assessment, that MDTs implemented in lower-income countries were likely to 
face significant barriers as services for victims must first be available before MDTs 
can be successfully implemented (2016). 

 

In 2019, the Office for Victims of Crime (OVC) issued a solicitation for proposals to 
fund 10 – 22 enhanced MDTs (e-MDTs), with up to 10 of those in tribal communities, 
and a national training and technical assistance center to support the OVC funded 
e-MDT program (Ivkovich 2019). The program and dedicated funding for tribal 
entities holds great promise. However, tribal-run programs have, in the experience 
of our project team, historically faced many barriers responding to traditional 
federal public solicitations. In addition, some tribal entities we spoke with about the 
funding announcement expressed concern that it appeared to require “enhanced” 
staffing models that may be out of reach for typical rural tribal-run MDTs. Coupled 
with a relatively short turnaround time for proposals, there were a number of 
barriers that may have ultimately limited tribal response to the first round of 
solicitations due in July of 2019. That said, any systematic assessment of processes, 
protocols and promising practices specifically within tribal MDTs will yield a 
significant contribution to the field and to tribal communities. Optimally, additional 


future additional opportunities will be made available to aid in establishing and 
managing MDTs (and other promising practices) with designated set asides for 
tribes and tribal entities. For tribes unable to respond to large, formal solicitations, 
alternative funding strategies to establish for improve MDT operations may be 
sought. 

 

Self-Neglect Largely Absent in Assessment, But A Significant Issue 

Finally, self-neglect was not specifically included in interview or survey questions, 
though was an issue raised by several interview participants. Self-neglect was not 
included in this needs assessment due to its unique nature and lack of an outside 
perpetrator. While social service providers and researchers generally incorporate 
self-neglect with other types of abuse, is often excluded from research in the justice 
field owing to the lack of a perpetrator. However, the U.S. Department of Health 
and Human Services, Administration for Community Living’s (2016) Voluntary 
Consensus Guidelines for State APS Systems, includes self-neglect as an area to be 
addressed by APS programs. Self-neglect is the primary type of elder abuse cases 
reported to APS and can be the most complex to address (Dong, 2017). Given the 
high prevalence and association with other forms of abuse such as financial 
exploitation, providers are likely to encounter self-neglect in their clinical practice. 
This is an area worthy of consideration for future work. 

 

Policy and Practice Recommendations 

Based upon finding from this needs assessment, with some integration of findings in 
the existing literature elder abuse literature specific to AIAN elders, the following 
set of policy and practice recommendations are offered. Recommendations are 
offered for consideration by tribes, counties, state, and federal level policymakers 
and health care practitioners. The list of recommendations is offered in no particular 
order of priority, though findings from the present needs assessment indicate 


that screening tools, protocols, and training are the most pressing priorities for 
health care providers. 

• Development or adaptation of a tool or best practices to systematically 
assess community supports, services, and assets for tribal health providers 
and elder abuse victims available within or adjacent to tribes and to tribal-
serving health care entities 
• Dedicated tribal-funded APS staff person, social worker, case manager, or 
elder service worker with APS-type roles and responsibilities (in tribes that 
do not currently have this type of position) 
• Enhance or establish relationships between existing tribal and county APS 
and MDT programs and outpatient tribal health centers to promote regular 
opportunities for training and ongoing support of clinical staff referrals; 
incorporate health center staff into existing MDTs 
• Initiate or enhance tribal-run CHR and/or home health programs, or identify 
alternative funding streams to make current programs solvent 
• Standardized provider training on elder abuse assessment and management 
that addresses complicated cases, red flags, and “grey areas” that 
incorporates a trauma-informed care approach specific to the needs of AIAN 
elders 
• Selection and testing of elder-specific abuse clinical screening tool including 
short- and long-term outcomes in tribal clinical setting 
• Testing/adaption of tools specific to AIAN elders to be cultural appropriate 
and specific 
• Development of standardized screening protocols for assessing abuse and 
exploitation in older adults that is adaptable by local tribes and health 
providers 
o Outpatient clinic settings 






o Home-based care settings 



• Training on effective use of standardized screening protocol 
o Health centers: health care providers, nursing staff, social workers/ 
case managers, auxiliary health providers situated in clinics that have 
direct patient contact 
o Home-based care programs: CHRs, public health nurses, home visiting 
nurses and auxiliary staff 



• Development of standardized intervention protocol that is adaptable by 
local tribes and health providers 
o Training on effective use of intervention protocol 
o Potential interventions identified in the present study include: 
 Assessment of multidisciplinary service and support needs 
 Referral to APS – relationship development, communication, and 
jurisdictional issues 
 Referral to law enforcement – relationship development, 
communication, and jurisdictional issues 
 Referral to additional agencies or departments 
 Placement in respite or other facility or shelter for safety 
 Training on roles, processes, policies of other agencies (i.e. 
depending on statute/regulation APS can’t give out information 
on cases and may not even be able to confirm an investigation is 
taking place; how providers can and should follow up or 
documentation needed) 






• Support for existing MDTs and expansion to new tribes for assessment, 
development of an action plan and systematic approach to MDTs as an elder 
abuse intervention. Consider process specific evaluation or assessment to 
identify: 
o Membership 






o Frequency of standard meetings of MDT 
o Interventions employed 
o Process to manage follow-up actions (for example, home visit, post-
APS or Law referral, additional interventions) 
o Communication and collaboration protocols 



• Development and empirical testing of strategies to enhance community 
outreach, awareness, and reporting of elder abuse 
o Identification of strategies to increase tribal leadership buy-in 



• Empirical assessment of the direct and indirect impact on elder abuse and 
exploitation of programs designed to promote cultural revitalization. 


Conclusion 

The present project employed a mixed-methods approach to assessment of 
facilitators and barriers to outpatient tribal health care provider engagement in 
screening and systematic management of the needs of elder victims of abuse 
encountered in daily practice. Great congruence between interview and survey 
findings occurred, however, interviews provided greater depth and opportunities to 
assess potential promising practices. Interviews also created the opportunity discuss 
more complex issues such as acculturation and historical trauma, both culturally-
specific and significant issues in the context of tribal communities. Most important, 
we found by and large outpatient tribal health care providers who participated 
are willing and ready to embrace screening for abuse among their older patients 
and community workers believe it is a role they should play. These same providers 
are already forced to intervene in clinical settings that more often than not lack 
proper protocols for managing cases of elder abuse, offer little training, and either 
lack information about available community services or supports or lack the actual 
community services and supports. 

 


Some findings from this assessment are reflective of previous elder abuse research 
inclusive of AIAN communities, or support findings from research among mainstream 
populations, e.g., provider barriers to screening. However, our project team 
believes the needs of tribal elders are 

unique, and the needs of each of the respective tribal clinics, villages, and 
communities is unique when it comes to addressing the issue of elder abuse. Systems, 
protocols, services, and supports must be designed and implemented ideally by 
tribes and tribal providers themselves or at the very least in close collaboration. 
Though, we offer a set of general recommendations based upon the convergence of 
the experiences of the tribal health providers and non-health care providers who 
participated in this project from across the country. This report addresses the 
original projective objectives, we: identify multiple factors that contribute to elder 
abuse identification and management, identify facilitators and barriers for tribal 
providers, share insight into the phenomenon of providing care for AIAN elders, 
identify important cultural factors, and discuss several existing and promising 
practices being employed by tribal health care providers. To the extent possible, 
we use the words of tribal providers and elder advocates themselves to 
substantiate our findings. Our hope is that this report is a stepping-stone to future 
conversations about how to address the epidemic of elder abuse facing tribal 
communities. 

 

Limitations 

As with any field research or needs assessment, limitations exist that impact the 
overall conduct of the research and analysis of the findings. Respondent selection 
utilized non-random intensity sampling. Intensity sampling requires that those 
respondents that are included in the study possibly have experiential knowledge of 
(in this case) usual care in the tribal health work environment with some knowledge 
of surveillance practices for elder abuse as compared to those who have limited or 


no experience. The intensity sampling technique employed was without selection 
bias in regard to the researcher. Additionally, the sample was considered to be a 
convenience sample, in that respondents were from lists presented to IA2 by 
contacts from various organizations. 

 

Inclusion in the research was based upon 1) experience with tribal health work 
environment, 2) availability on the day interviews were being conducted, and 3) 
willingness to participate. Participants were included in the assessment on a 
voluntary basis, as such there was likely some degree of selection bias on their part, 
meaning overall the group was likely more interested or had a greater degree of 
experience with elder abuse than the typical health care provider. It is not known if 
informants chosen by another selection process would differ from those who were 
recruited by the researchers. 

The interview and survey samples were small relative to the research methods 
employed and the universe of potential participants (which is assumed to be vast, 
but is unknown), particularly the survey. Though, both PIs independently confirmed 
that saturation was reached during interview data analysis. Respondents varied 
widely. The majority serve rural populations, though interviews included three urban 
Indian health center providers. Survey respondents represented a more diverse 
subset of geographic coverage and tribal versus IHS management. The universe of 
all tribal health organizations was not accessed. 

 

Objectively quantifiable measures of elder abuse screening frequencies and 
interventions were unavailable for this study as this was the first study of its kind. 
Medical records were not accessed for this research. If medical records had been 
used, a more accurate measure of elder abuse assessment and intervention would 
have been evaluated. 

 


While efforts were made to accurately represent the lived experiences of interview 
participants, there is likely a degree of distortion between researchers’ 
observations and analysis and representation. While both principal investigators 
have some degree of experience working with AIAN populations, both are 
Caucasian females, and themselves trained health care providers, which likely 
influence, to some extent, their analysis and conclusions. There was some evidence 
of social desirability bias on the part of interview participants when data on certain 
questions was triangulated with data from the health care provider survey. Social 
desirability bias is the tendency of participants to respond in a manner that they 
think is more acceptable to the interviewer, particular in the case of sensitive 
questions. For example, interview participants were more likely than survey 
respondents to say they had adequate training in elder abuse detection and 
management, though both groups had a relatively similar % of participants who 
indicated they in fact wanted more training. Several methods were employed to 
minimize the degree of social desirability bias for interviews (careful attention to 
question phrasing, prompts to ensure confidentiality, and triangulation of findings 
with survey data), however, it is an inherent challenge with qualitative research 
methods. 

 

 


References 

 

About IHS. (n.d.). Retrieved March 7, 2019, from https://www.ihs.gov/aboutihs/ 

Alt, K. L., Nguyen, A. L., & Meurer, L. N. (2011). The effectiveness of educational 
programs to improve recognition and reporting of elder abuse and neglect: 
A systematic review of the literature. Journal of Elder Abuse & Neglect, 
23(3), 213–233. http://doi.org/10.1080/08946566.2011.584046 

American Indian boarding schools. (2016, June 10). Retrieved June 11, 2016, from 
https://en.wikipedia.org/wiki/American_Indian_boarding_schools 

Armenta, B. E., Whitbeck, L. B., & Habecker, P. N. (2016). The Historical Loss Scale: 
Longitudinal measurement equivalence and prospective links to anxiety 
among North American indigenous adolescents. Cultural Diversity & Ethnic 
Minority Psychology, 22(1), 1–10. https://doi.org/10.1037/cdp0000049 

Bacchus, L. J., Bullock, L., Sharps, P., Burnett, C., Schminkey, D. L., Buller, A. M., & 
Campbell, J. (2016b). Infusing technology into perinatal home visitation in the 
United States for women experiencing intimate partner violence: Exploring 
the interpretive flexibility of an mHealth intervention. Journal of Medical 
Internet Research, 18(11), e302. 

Baker, M. W., LaCroix, A. Z., Chunyuan, W., Cochrane, B. B., Wallace, R., & Woods, 
N. F. (2009). Mortality risk associated with physical and verbal abuse in 
women aged 50 to 79. Journal of the American Geriatrics Society, 57, 
1799–1809. https://doi.org/10.1111/j.1532-5415.2009.02429.x 

Baldridge, D. (2001). Indian elders: Family traditions in crisis. American Behavioral 
Scientist, 44(9), 1515–1527 
https://doi.org/10.1177/00027640121956953 

Baldridge, D., Nerenberg, L., & Benson, W. F. (2004). A review of the literature: 
Elder abuse in Indian Country research, policy, and practice (p. 26). National 
Indian Council on Aging for the National Center on Elder Abuse. Retrieved 


from

http://nicoa.org/wpcontent/uploads/2014/05/elder_abuse_litreview.pdf

Boccuti, C., Swoope, C., & Artiga, S. (2014). The role of Medicare and the IndianHealth Service forAmerican Indians and Alaska Natives: Health, access and 
coverage. Kaiser Family Foundation.Retrieved fromhttp://kff.org/report-
section/the-role-of-medicare-and-the-indian-healthservice-for-american-
indians-and-alaska-natives-health-access-and-coverage-report/

Braveheart, M. Y., & DeBruyn, L. M. (1998). The American Indian holocaust: Healing 
historicalunresolved grief. American Indian and Alaska Native Mental HealthResearch, 8(2), 56–82.

Brown, A.S. (1989). A survey on elder abuse at one Native American tribe. Journalof Elder Abuse &Neglect, 1(2), 17–38.
https://doi.org/10.1300/J084v01n02_03

Buchwald, D., Tomita, S., Hartman, S., Furman,R., Dudden, M., & Manson, S. M. 
(2000).Physical abuse of urban Native Americans. Journal of GeneralInternal Medicine, 15(8), 562–564.

Bureau of Indian Affairs. (n.d.).About Us. Retrieved from U.S. Department of the 
Interior:https://www.bia.gov/about-u

Burnett, J.,Achenbaum, W. A.,& Murphy, K. P. (2014). Prevention and early 
identification ofelder abuse. Clinics in Geriatric Medicine, 30(4), 743–759.

Burnett, J., Jackson, S. L., Sinha, A. K., Aschenbrenner, A. R., Murphy, K. P., Xia, R., &
Diamond, P. M. (2016). Five-year all-cause mortality rates across five 
categories ofsubstantiated elder abuse occurring in the community. Journalof Elder Abuse & Neglect, 28(2),59–75.
https://doi.org/10.1080/08946566.2016.1142920

Carson, L.D., Henderson, J. N.,and King, K. (2019). Depression, Diabetes, and 
Dementia:Historical, Bio-cultural, & Generational Factors among AmericanIndian and Alaska NativeElders. In W. Hulko, D. Wilson, and J. Balestrery

113


(Eds) Indigenous peoples and dementia: Experiencing and Understanding 
Memory Loss and Memory Care in Three Settler Nations. British Columbia: 
UBC Press. 

Çayır, E., Burke, M. P., Spencer, M., Schure, M. B., & Goins, R. T. (2018). Lifetime 
trauma and depressive symptomatology among older American Indians: The 
Native Elder Care Study. Community Mental Health Journal, 54(6), 740–747 
https://doi.org/10.1007/s10597-017-0179-7 

Connolly, M. T., Brandl, B., & Breckman, R. (2014). The Elder Justice Roadmap: A 
stakeholder initiative to responding to an emerging health, justice, financial, 
& social crisis. U.S. Department of Justice with support from the U.S. 
Department of Health and Human Services. 

Crowder, J., Burnett, C., Laughon, K., & Driesbach, C. (2019). Elder abuse in 
American Indian communities: An integrative review. Journal of Forensic 
Nursing. 

Crowder, J., Burnett, C., Byon, H., Yan, G., Laughon, K., & Acierno, R. (2019). 
Exploration of contextual characteristics and mistreatment prevalence among 
American Indian and Alaska Native respondents: Secondary analysis of the 
National Elder Mistreatment Study. Submitted for Publication. 

Dong, X.Q. (2015). Screening for elder abuse in healthcare settings: why should we 
care, and is it a missed quality indicator? Journal of the American Geriatrics 
Society, 63(8), 1686–1688. 

Dong X. (2017). Elder self-neglect: Research and practice. Clinical interventions in 
aging, 12, 949– 954. doi:10.2147/CIA.S103359 

Feltner, C., Wallace, I., Berkman, N., Kistler, C. E., Middleton, J. C., Barclay, C., … 
Jonas, D. E. (2018). Screening for intimate partner violence, elder abuse, and 
abuse of vulnerable adults: Evidence report and systematic review for the US 
Preventive Services Task Force. JAMA, 320(16), 1688–1701. 
https://doi.org/10.1001/jama.2018.13212 


Garrett, M., & Pichette, E. F. (2000). Red as an apple: Native American 
acculturation and counseling with or without reservation. Journal of Counseling 
and Development, 78, 3–13. 

Goins, R. T., Schure, M. B., Crowder, J., Baldridge, D., Benson, W. F., & Aldrich, N. 
(2015). Lifelong disparities among older American Indians and Alaska 
Natives (No. 2015–08). AARPPublic Policy Institute. Retrieved from: 
http://www.aarp.org/content/dam/aarp/ppi/2015/Lifelong-Disparities-
among-Older-American-Indians-and-Alaska-Natives.pdf 

Gustafsson P.E., Nilsson D. & Svedin C.G. (2009). Polytraumatization and 
psychological symptoms in children and adolescents. European Child & 
Adolescent Psychiatry, 18, 274-83. doi:10.1007/s00787-008-0728-2, 
10.1007/s00787-008-0728-2 

Hamby, S., Smith, A., Mitchell, K., & Turner, H. (2016). Poly-victimization and 
resilience portfolios: Trends in violence research that can enhance the 
understanding and prevention of elder abuse. Journal of Elder Abuse & 
Neglect, Online. https://doi.org/10.1080/08946566.2016.1232182 

Hall, J., Karch, D., & Crosby, A. (2016). Elder abuse surveillance: Uniform definitions 
and recommended core data elements (pp. 1–121). Atlanta, GA: National 
Center for Injury Prevention and Control, Centers for Disease Control and 
Prevention. Retrieved from 
http://www.cdc.gov/violenceprevention/pdf/ea_book_revised_2016.pdf 

Henderson, L.C. (2010). Divergent models of diabetes among American Indian 
elders. Journal of Cross-cultural Gerontology, 25, 303-316. 

Henderson, L.C. & Henderson, J.N. (2008). Public health and aging. In J. Coreil (Ed.) 
Social and behavioral foundations of Public Health, 2nd ed. Twelve Oaks: 
Sage Publications. 

Henderson, L. C. 2002. The Cultural Construction of Diabetes Mellitus among 
Oklahoma Choctaw Elders and Choctaw Nation Tribal Health Care Providers: 


An Examination of Concordance between Models and Implications for Care-
seeking and Compliance. PhD Diss., University of South Florida. 

Henderson, L.C. (2001).Unique issues in long term care of American Indian elders. 
The University of Florida Fourth Meeting of National Leaders in Women’s 
Health Research: Successful Aging: Women’s Health and Well-Being in the 
Second 50 Years, Gainesville, Florida. 

Holmes, E.R. and L. D. Holmes. 1995. Other Cultures, Elder Years. Thousand Oaks, 
CA: Sage. 

Hudson, M. F., Armachain, D., Beasley, C. M., & Carlson, J. R. (1998). Elder abuse: 
Two Native American views. Gerontologist, 38(5), 538–548. 

Ivkovich, L. (2019). OVC Fiscal Year (FY) 2019 Transforming America’s response to 
elder abuse enhanced multidisciplinary teams (E-MDTs) for older victims of 
abuse and financial exploitation. Retrieved from 
https://www.ovc.gov/grants/pdftxt/FY19_CompetitiveSolicitation-
EMDTPresentation.pdf 

Jervis, L. L., & Sconzert-Hall, W. (2017). The conceptualization of mistreatment by 
older American Indians. Journal of Elder Abuse & Neglect, 29(1), 43–58. 
https://doi.org/10.1080/08946566.2016.1249816 

Kauffmann Associates. (2015). LTSS research: Annotated literature review. 
Department of Health & Human Services, Centers for Medicare & Medicaid 
Services. Retrieved from https://www.cms.gov/Outreach-and-
Education/American-Indian-
AlaskaNative/AIAN/Downloads/Elder_Abuse_Lit_Review.pdf 

Kenney, M.K. & Sing, G.K. (2016). Adverse Childhood Experiences among American 
Indian/Alaska Native children: The 2011-2012 National Survey of Children’s 
Health. Scientifica, 2016. https://doi.org/10.1155/2016/7424239. 

Killick C., Taylor B.J., Begley E., Carter A.J., & O’Brien M. (2015). Older people’s 
conceptualization of abuse: A systematic review. Journal of Elder Abuse & 


Neglect, 27(2), 100–120.

https://doi.org/10.1080/08946566.2014.997374

Lifespan of Greater Rochester, Inc., WeillCornell Medical Center of CornellUniversity, &NewYork City Department for the Aging. (2011). Under the 
radar: New York State elder abuseprevalence study.

Maxwell, E. K.,& Maxwell, R. J. (1992). Insults to the body civil: Mistreatment ofelderly in twoPlains Indian tribes. Journal of Cross-Cultural Gerontology,
7(1), 3–23.https://doi.org/10.1007/BF00116574

MetLife Mature Market Institute. (2009). Broken trust: Elders, family and finances 
(pp. 1–38). NewYork, NY. Retrieved fromhttps://www.metlife.com/assets/cao/mmi/publications/studies/mmi-study-
brokentrust-elders-family-finances.pdf

Mouton, C. P., Rodabough, R. J., Rovi, S., Hunt, J. L., Talamantes, M. A., Brzyski, R. 
G., &Burge, S. K. (2004). Prevalence and 3-year incidence of abuse among 
postmenopausalwomen. American Journal of Public Health, 94(4), 605–612.
https://doi.org/10.2105/AJPH.94.4.605

National Center on Elder Abuse (2016) Elder abuse screening tools for healthcare 
professionals (Issuebrief). Retrieved 
http://eldermistreatment.usc.edu/wpcontent/uploads/2016/10/Elder-
Abuse-Screening-Tools-for-Healthcare-Professionals.pdf

Norris, T.,Vines, P. L., & Hoeffel, E. M. (2012). The American Indian and Alaska 
Native population:2010 (2010 Census Briefs No. (C2010BR-10)).
Washington, DC: U.S. Census Bureau.

Ortman, J. M., Velkoff, V. A., &Hogan, H. H. (2014). An aging nation: Theolder 
population in theUnited States (Current Population Reports No. P25-1140).

U.S.Department of Commerce:U.S. CENSUS BUREAU. Retrieved from: 
http://www.census.gov/content/dam/Census/library/publications/2014/demo/p25-1140.pdf

117


Pillemer, K. A., Burnes, D., Riffin, C., & Lachs, M. S. (2016). Elder abuse: Global 
situation, risk factors, and prevention strategies. The Gerontologist, 56(2), 
194–205. https://doi.org/10.1093/geront/gnw004 

Rovi, S., Chen, P.H., Vega, M., Johnson, M. S., & Mouton, C. P. (2009). Mapping the 
elder mistreatment iceberg: US hospitalizations with elder abuse and neglect 
diagnoses. Journal of Elder Abuse & Neglect, 21(4), 346–359. 

Rhoades, E. and Rhoades, D. 2000. Traditional Indian and modern western 
medicine. In American Indian Health: Innovations in Care, Promotion, and 
Policy. E. R. Rhoades, ed. Baltimore: Johns Hopkins University Press. 

Sapra, K. J., Jubinski, S. M., Tanaka, M. F., & Gershon, R. R. (2014). Family and 
partner interpersonal violence among American Indians/Alaska Natives. 
Injury Epidemiology, 1(1), 7–7. 

Sharps, P. W., Bullock, L. F., Campbell, J. C., Alhusen, J. L., Ghazarian, S. R., 
Bhandari, S. S., & Schminkey, D. L. (2016). Domestic Violence Enhanced 
Perinatal Home Visits: The DOVE randomized clinical trial. Journal of 
Women’s Health, 25(11), 1129–1138. 

Shefet, D., Dascal-Weichhendler, H., Rubin, O., Pessach, N., Itzik, D., Benita, S., & 
Ziv, A. (2007). Domestic violence: A national simulation-based educational 
program to improve physicians’ knowledge, skills and detection rates. 
Medical Teacher, 29(5), e133–e138. 
https://doi.org/10.1080/01421590701452780 

Sokolovsky, Jay. 2009. The ethnic dimensions of aging.” In The Cultural Context of 
Aging: Worldwide Perspective, edited by J. Sokolovsky. Westport CT: 
Praeger. 

Substance Abuse and Mental Health Services Administration. (2014). SAMHSA’s 
concept of trauma and guidance for a trauma-informed approach. HHS 
publication no. (SMA) 14-4884. Rockville, MD: Author. 


Teaster, P.B. (2017). A framework for polyvictimization in later life. Journal of Elder 
Abuse & Neglect, 29(5), 289-298. 
https://doi.org/10.1080/08946566.2017.1375444 

Tossone K., Jefferis E.S., Grey S.F., Bilge-Johnson S., Bhatta M.P. & Seifert P. 
(2015). Polytraumatization and harmful behaviors in a sample of emergency 
department Psychiatric Intake Response Center youth. Child Abuse & Neglect, 
40, 142-51. doi:10.1016/j.chiabu.2014.11.015 

Twomey, M. S., & Weber, C. (2014). Health professionals’ roles and relationships 
with other agencies. Clinics in Geriatric Medicine, 30(4), 881–895. 

U.S. Department of the Interior Indian Affairs. (n.d.). U.S. Department of the Interior 
Indian Affairs: Frequently asked questions. March 8, 2019. 

U.S. Health and Human Services. (2016). National Voluntary Consensus Guidelines 
for State Adult Protective Services Systems. Retrieved from: 
https://acl.gov/sites/default/files/programs/2017-03/APS-Guidelines-
Document-2017.pdf 

U.S. Indian Health Service. (n.d.). Trauma Informed Care. Retrieved from Indian 
Health Service: https://www.ihs.gov/dbh/traumainformedcare/ 

U.S. Preventive Services Task Force. (2014, December). Final recommendation 
statement: Intimate partner violence and abuse of elderly and vulnerable 
Adults: Screening, January2013. Retrieved June 21, 2016, from 
http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/intimate-partner-violence-and-abuse-of-elderly-and-
vulnerable-adultsscreening#consider 

Warne, D., Dulacki, K., Spurlock, M., Meath, T. Davis, M.M., Wright, B., & 
McConnell, K.J.(2017). Adverse Childhood Experiences (ACE) among 
American Indians in South Dakota and associations with mental health 
conditions, alcohol use, and smoking. Journal of Health Care for the Poor and 
Underserved, 28(4), 1559-1577. 


Yon, Y., Mikton, C., Gassoumis, Z. D., & Wilber, K. H. (2017). Elder abuse 
prevalence in community settings: A systematic review and meta-analysis. The 
Lancet Global Health, 5(2), e147–e156. https://doi.org/10.1016/S2214-
109X(17)30006-2 

 


Appendix 

 

Tribal Health Provider Interview Guide 

You have been asked to participate in a project about abuse of American Indian 
elders and how that is managed in health care providers who primarily work with 
American Indian or Alaska Native patient populations. We are talking with 
physicians, nurse practitioners, physician assistants and 

social workers to learn more about their experiences in the outpatient setting. You 
were identified as a key clinic staff person. 

 

The interview will take 1 – 1 ó hours and will be recorded so we can create a 
written transcript of your comments for our analysis. Because the interview is about 
elder abuse, which can be a sensitive subject, there may be questions that make you 
feel uncomfortable. You can refuse to answer any question and may withdraw from 
the interview at any time, if you wish. 

 

The interview results are anonymous, your individual responses are confidential 
and will only be reviewed by staff from the International Association for Indigenous 
Aging. Summary results will be shared in issue briefs and other resource documents, 
but only in aggregate form. Responses will never identify a provider, tribe, or 
clinic/ health care setting by name. 

After we have finished interviewing all of our participants, we will share our 
preliminary analysis with participants to solicit their feedback on our findings. Your 
review of this information is not required, but I hope you will take the opportunity to 
participate in that review. 

 

I will be recording our conversation today. 

Do I have your permission to proceed with the interview? 

 


Relevant experience 

1. Tell me a little bit about yourself and your role at your clinic 
2. Job title/role 
a. Physician 
b. Nurse practitioner 
c. Physician’s assistant 
d. Social worker 
e. Other, please describe 



3. How many years have you worked at the current outpatient clinic/practice? 
(please enter a number only; e.g., 6 years, 6 months = 6.5) 
a. [Number only] 



4. Are you American Indian or Alaska Native yourself? 
a. Yes 
b. No 



5. What types of services does your outpatient clinic/ office provide? (check all 
that apply) 
a. Primary care 
b. Specialty clinic/services 
c. Behavioral health services 
d. Referrals only 
e. Other, please specify 



6. What state is your office located in? 
7. Do you serve a primarily rural or urban population? 
a. Rural 
b. Urban 
c. Suburban 
d. Other 



8. Is your clinic / practice managed: 



a. Indian Health Services 
b. Tribe(s) 
c. Non-native entity 
d. Other, please specify 



9. What populations are served by your clinic / practice? 
a. American Indian and Alaska Native only 
b. American Indian and Alaska Native AND non-Native populations 
c. Other, please specify 



10. Does your clinic / practice serve primarily one tribe or multiple? 
a. One tribe 
b. Multiple tribes 



11. Approximately what percentage of the patients you see are 60 years and 
older? 
a. 0 – 10% 
b. 11 – 20% 
c. 21 – 30% 
d. 31 – 40%. 
e. 41 – 50% 
f. 51 – 60% 
g. 61 – 70% 
h. 71 – 80% 
i. 81 – 90% 
j. 91 – 100% 





 

Experience with elder mistreatment/abuse 

12. What are your thoughts about elder abuse in the Native community served 
by the clinic? 
13. How do you personally define elder abuse or mistreatment? 



14.Elder abuse can account for anarray of types of mistreatment-neglect,
financial, physical, emotional, sexual, etc. Are there certain types of abuseyou have found to be more prevalent in your experience working withtribal elders?
a.Do you think outpatient providers are capable of identifying differenttypes of abuse? Are they better able to identify some types of abuse vs.
others?
15.To what extent doyou agree or disagree with this statement:Outpatientproviders are capable of identifying all different types of elder abuse?
a.Strongly disagree
b.Disagree
c.Neutral
d.Agree
e.Strongly agree
16.Can you tell me about a situation you encountered in your clinical practicewith a patient who you thoughtor confirmed was abused? Please be 
reminded not to use names or other identifying information for patients orproviders involved in this situation. 
a.What is the protocol for handling this type of abuse in your clinic?
b.Do you feel like thesituation was handled well/ not well?
17.Just a reminder our conversations are confidential and findings are 
anonymous, and we ask that you not use patient, provider or clinic names. 
Can you describe a case where you feel like itwas/wasn’t handled well inyour experience as clinical provider? [if previous question was handled 
well, this question should focus on opposite, vice versa]
18.Do you feel you have adequate trainingin elder mistreatmentdetection,
management and reporting?
a.Yes
124


b. No 





 

Process for screening and interventions 

19. Would you like to receive training in elder mistreatment, detection, 
management and reporting? 
a. Yes 
b. No 



20. Does your state require mandatory reporting in suspected cases of elder 
abuse? 
a. Does the tribe (if the clinic is tribal run/specific)? 
b. Are there any legal/procedural conflicts between state mandatory 
reporting laws and your work with/for a tribe? 



21. Can you describe any screening processes or tools you or the clinic use to 
evaluate elder patients for abuse? 
a. [If none] What role do you think you clinical providers should play in 
screening for elder abuse and mistreatment? 



22. What, if anything, makes screening for elder abuse hard to do in your 
clinic? What barriers do you face? 
23. What happens in your clinic after a suspected case of abuse is identified? 
a. Does your clinic have staff to assist? 
b. Do you refer out? 
c. [If you aren’t interviewing a social worker, ask…] Do you have social 
workers on staff who assist? 
d. Does your clinic have any interventions they can employ directly in these 
situations? 



24. Can you describe an intervention or interventions you use in your clinic for 
managing suspected cases of elder abuse? 



25. If you could design an ideal program for screening for and managing 
suspected cases of elder abuse, what would it look like? What tools, 
policies, processes or structures… 
26. What resources, information or support do you need to better manage 
suspected cases of elder abuse? 
27. Do you have examples of clinic or practices (including your own) that you 
feel employ best practices in screening for and managing suspected cases 
of elder abuse? 


 

Cultural beliefs and practices related to elder mistreatment 

28. What are the strengths of the Native elders, people, and families served 
by your clinic? 
29. Do you feel as if the community members you serve are more acculturated 
(more mainstream beliefs) or more traditional (strong Native cultural 
identity)? 
30. What role or impact do you think acculturation has on elder abuse 
prevalence? 
a. Do you think acculturation makes a person/family more or less likely to 
experience abuse? 



31. Generally speaking, how are tribal elders perceived in the community 
served by your clinic? 
a. Revered? Respected? Maternalistic? Paternalistic? 



32. [If they say elders respected/revered…] What are your thoughts about 
why elder abuse still occurs in your community / patient population if the 
community holds elders in high regard? 
33. There are many societal, family and personal factors that can play a role in 
or contribute to elder abuse in any population or community? What do you 



think are the most significant factors in the Native community your clinic 
serves? 
34. How do you think the local tribal community/communities perceives the issue 
of elder abuse? 


 

Community resources and gaps in support 

35. What resources are there in the community to support victims of elder 
abuse? 
36. Have you ever made a referral to adult protective services? Can you 
describe how you felt that worked? 
37. Have you ever made a referral to law enforcement for suspected cases of 
elder abuse? Can you describe how you felt that worked? 
38. Have you ever made a referral to another entity for suspected cases of 
elder abuse? Can you describe how you felt that worked? 
39. What do you believe are the major gaps in resources needed to support 
Native victims of elder abuse? 
40. Is there anything we haven’t talked about or that you would like to add to 
any of your earlier answers? 


 


Tribal Health Provider Online Survey 

Online Survey Page 1, question 1



Survey Page 2, Demographics questions 2 through 7



Online survey page 3 questions 8-11



Online survey page 4 "experience with elder abuse and mistreatment" questions 12-14



Online Survey questions 15-16


Online survey questions 17-19, "Experience with elder abuse and mistreatment referrals"



Online survey questions 20-23 "experience with elder abuse and mistreatment, mandatory reporting"



Online Survey question 24, Experience with elder abuse and mistreatment, screening


Online Survey question 25, Experience with elder abuse and mistreatment, protocol


Online Survey question 26, Experience with elder abuse and mistreatment, protocol



Online Survey questions 27-29, Experience with elder abuse and mistreatment



Online Survey question 30-31, Experience with elder abuse and mistreatment



Online Survey questions 32-35, Experience with elder abuse and mistreatment, best practices and training


Online Survey question 36, Experience with elder abuse and mistreatment, best practices and training



Online Survey questions 37-41, page 15 Experience with elder abuse and mistreatment, cultural beliefs and practices



Online Survey questions 42-43, Experience with elder abuse and mistreatment



Online Survey questions 44-47, page 15 Experience with elder abuse and mistreatment, community resources and gaps



Online Survey question 48 Experience with elder abuse and mistreatment


Online Survey question 49, Experience with elder abuse and mistreatment