Prevention

Several States have a structured vision of how to combat mistreatment. This is the case of Québec, with its action plans AP-1 (2010) and AP-2 (2017). Both of these action plans cover three phases of intervention: primary prevention, case finding (also called identification or detection), and one-off interventions or follow-up for mistreated older adults and, more rarely, for people and organizations that mistreat. Since very few practices have undergone implementation or outcome assessments, this section is based mainly on descriptions of practices. The few components that have been validated are clearly indicated. The text deals essentially with primary prevention and, more specifically, certain guidelines, and provides a short list of programs and tools—used particularly in Québec—along with best practices recommendations derived from the scientific literature. Given the number of practices applied in Québec and around the world, this list is not exhaustive. Information dealing specifically with older adults living at home or in residential and care facilities is provided when available.

Table 10 shows that existing practices have four different focuses: individuals, interpersonal relationships, the community, and society as a whole. To our knowledge, all of the examples given in this table, except for psychological programs for people who mistreat, are practices commonly used in Québec. However, detection and case finding are not done systematically, and emergency shelters are not available in every region.

Table 10 - Overview of interventions and their effectiveness in preventing or reducing mistreatment of older adults

Source : Based on the report Recherche de cas de maltraitance envers des personnes aînées par des professionnels de la santé et des services sociaux en première ligne [106].

Policy and program directions

As indicated in Table 10, prevention of mistreatment of seniors involves actions aimed at “reducing at-risk situations for older adults as well as their family and friends” and “promoting positive attitudes towards older adults and raising awareness.” It also includes actions to inform and educate the general public [107] on the risk factors for mistreatment, as well as on best practices for reducing the risk that such situations will occur.

Examples of programs and tools

Preventing mistreatment involves, first and foremost, the transmission of information through promotional and public information campaigns [108,109]. This type of action targets the public as a whole with a view to effecting change on individual, relational, professional, and societal levels. Such campaigns use a range of strategies to enable people to take a critical view of interactions with a potentially negative impact on older adults. However, if we are to change ageist perceptions, we must go beyond mere awareness raising [109]. Québec has conducted four public awareness campaigns since 2010, as part of the implementation of AP-1. Various strategies have been used depending on the campaign: advertising on television, radio and the Web; production of posters and brochures; etc. While the first two campaigns were focused on explaining what mistreatment is, the third one illustrated the phenomenon by describing clear cases of mistreatment. The most recent campaign, in 2017, discussed actions to counter bullying, as well as actions to counter mistreatment.

Educational interventions help to improve knowledge and to change the attitudes of professionals towards the detection, reporting, and follow-up of mistreatment situations [106]. They enable professionals to play a more active role or to become more alert to signs of mistreatment as well as better equipped to take action in this regard. Educational interventions are just one of the 22 existing best practices identified in a systematic literature review [110]. Two validation studies were also identified in a systematic review of educational programs [33]. The first study discussed an educational presentation on older adult mistreatment that had been given to nursing assistants. The nursing assistants’ reactions were recorded, but without any pre- or post-test measurements, random assignment of participants or control group comparisons (Smith, Davis, Blowers, Shenk, Jackson and Kalaw, 2010, cited by Day et al. [33]). In the second study, dental hygienists with training on mistreatment completed a pre- and post- test using a mail-in questionnaire, with no comparison group. The results of this study suggest that this training increased the hygienists’ ability to recognize mistreatment and neglect (Harmer-Beem, 2005, cited by Day et al. [33]). A large number of educational interventions are offered in Québec; however, without a systematic survey, it is impossible to do a comprehensive review of these initiatives (number of hours, format, target audience, etc.). Nevertheless, here are three examples. The Elder Mistreatment Helpline team is responsible for training service providers in the public health and social services network throughout Québec, as well as for training trainers. University-level training programs for future practitioners (available, in particular, in the social work schools of Laval and Sherbrooke universities) offer 45 hours of credit courses on the fight against mistreatment or blocks of a few hours of training in undergraduate programs. Training is offered, as well, to various stakeholders, including the members of the Regroupement provincial des comités des usagers.

Preventing mistreatment also involves the use of various mechanisms and tools. The rare prevention tools that have a psychometric component are based on risk factors for mistreatment. One of these tools, the Social Vulnerability Scale, has been validated. It is not specific to a particular living environment, but it focuses on the social vulnerability of older adults with a view to detecting situations of financial exploitation before they occur [111]. The Trousse SOS Abus kit [112] has identified and made available to the general public a large number of prevention, detection, intervention, and training tools related to the problem of older adult mistreatment. Several of these tools have been developed since 2010. According to a number of community organizations approached in the course of various research projects, the most popular aspect of these tools are the skits, particularly those in which the public can participate.

In recent years, promotion of well-treatment has been developed in tandem with efforts to combat mistreatment in several French- and Spanish-speaking countries. Although Québec did not officially use the term “well-treatment” prior to the release of AP-2 in June 2017, some of the actions it has implemented are in keeping with this approach. Box 3 presents the key aspects of the promotion of well-treatment, which is centred in particular on the promotion of positive attitudes toward ageing [106].

Home-based prevention activities

A number of European countries have published guides on best practices in home settings. In 2016, the Ministère des Affaires sociales et de la Santé and the Secrétariat d’État chargé des Personnes âgées et de l’Autonomie in France worked together to publish the document Aide à domicile aux personnes âgées : le guide de bonnes pratiques. This best practices reference guide is based on: (1) freedom of choice for older adults and the delivery of quality information; (2) “fair prices”; and (3) professionals’ working conditions. In 2012, the Conseil Général de La Vienne proposed guidelines for each of the services provided to recipients in the Guide des bonnes pratiques pour les professionnels de l’aide à domicile.

Preventive strategies help not only to reduce the risk of mistreatment but also to prevent new mistreatment situations from arising [115,116]. For example, since caregiver burnout and depression can constitute risk factors for mistreatment, homemaking and meal preparation assistance, respite and education measures, and support groups are useful approaches that can be put in place. In Québec, organizations like the Regroupement des aidantes et aidants naturels (RAAN) have a mission to help caregivers improve their quality of life through participation in activities and access to services that meet their needs [117]. Other preventive measures like caregiver referral and help lines also have a role to play in prevention [110,118]. 

Prevention activities in care and residential facilities

Promotion of well-treatment in residential facilities helps to improve practices while fostering better quality of life for residents and service providers [119]. Since 2003-2004, Québec’s Ministère de la Santé et des Services sociaux has been conducting visits to CHSLDs in an effort to assess the quality of services offered there [120]. These assessments, like the certification required for private seniors’ residences under the Act respecting health services and social services, are aimed at ensuring the quality of home-care services and thus protecting clients. To obtain certification, services offered in seniors’ private residences must meet a series of standards [121,122]. Adopting a well-treatment approach in residential facilities is a positive step toward examining the [TRANSLATION] “conditions needed to successfully care for residents,” since it avoids focusing the spotlight on mistreatment [123].

Under the Act to combat maltreatment of seniors and other persons of full age in vulnerable situations [124], assented to in May 2017, all institutions in the health and social services network must adopt a policy involving prevention activities to combat mistreatment. The introduction of this Act bodes well for changes in practices in the near future. Table 11 provides a list of best practices identified in the literature.

Source : “Comment prévenir une crise? Les leçons tirées des plaintes de maltraitance au Centre de soins de longue durée Saint-Charles-Borromée” [123].

Table 11 - Best practices identified for residential and care facilities

The European Quality Framework for long-term care services [125], published in 2012, proposes a series of quality principles and areas of action.

Source : European Quality Framework for long-term care services. Principles and guidelines for the wellbeing and dignity of older people in need pf care and assistance [125].

Best practice recommendations

The best primary prevention practices recommended in the literature may be summarized as follows:

• Improve basic training for professionals who work with older adults [126,127];
• Provide ongoing professional training on older adult mistreatment [128];
• Encourage health professionals to use social media, online resources and public service messaging to combat ageism, and to raise the public’s awareness of older adult mistreatment and the associated consequences [129];
• Ensure better preparation of older adults and adult children who will take care of their aging parents through public awareness and caregiver education and training [129];
• Prioritize research on older adult mistreatment in all its forms [129];
• Improve knowledge on the subject of older adult mistreatment [106].