Abstract

Most Brazilian state and municipal governments have used social distancing as the primary strategy for reducing the transmission speed of the new Coronavirus (SARS-CoV-2), which causes COVID-19. However, this social isolation has had several adverse repercussions, including increased intrafamily violence against children, adolescents, and women. Recently, violence against older adults (VAOA) during the pandemic has also been on the agenda of concerns, although discussing possible strategies for coping with VAOA during COVID-19 is still unimpressive worldwide. Aiming to broaden the debate on the theme in Brazil, this paper aims to offer theoretical elements and evidence from previous studies for a greater understanding of the situation of vulnerability of older adults to situations of violence, of the possible motivations for the increased number of cases of VAOA during the COVID-19 pandemic, and possible strategies to address the problem.

Key words
Domestic violence; Violence against older adults; Older adult abuse; Social distancing; COVID-19

Introduction

The world has experienced not only a health crisis with the pandemic of the New Coronavirus (SARS-CoV-2) that caused COVID-19, but also an unprecedented economic, political, and ethical crisis¹1 United Nations Development Programme (UNDP). Brief#2: Putting the un framework for socio-economic response to COVID-19 into action: insights United Nations Development Programme. New York: UNDP; 2020.

2 Pana-Cryan R, Ray T, Bushnell T, Quay B. Economic Security during the COVID-19 Pandemic: A Healthy Work Design and Well-being Perspective. Centers for Disease Control and Prevention; 2020 [cited 2020 Jun 29]. Available from: https://blogs.cdc.gov/niosh-science-blog/2020/06/22/economic-security-covid-19/
https://blogs.cdc.gov/niosh-science-blog... ^-33 Ortega F, Orsini M. Governing COVID-19 without government in Brazil: Ignorance, neoliberal authoritarianism, and the collapse of public health leadership. Global Public Health 2020; 15(8):1-21.. From the first confirmed COVID-19 case in Wuhan, China, in December 2019 to July 23, 2020, 15,012,731 cases and 619,150 deaths have been confirmed worldwide⁴4 World Health Organization (WHO). Coronavirus disease (COVID-19): Situation Report - 185. Geneve: WHO; 2020. [cited 2020 Jul 23]. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200723-covid-19-sitrep-185.pdf?sfvrsn=9395b7bf_2
https://www.who.int/docs/default-source/... , with 2,287,475 confirmed cases and 84,082 deaths in Brazil⁵5 Brasil. Ministério da Saúde (MS). Painel de casos de doença pelo coronavírus 2019 (COVID-19) no Brasil pelo Ministério da Saúde. Brasília: MS; 2020 [cited 2020 Jul 24]. Available from: https://covid.saude.gov.br/
https://covid.saude.gov.br/... . In the absence of a specific vaccine and effective treatments, strategies for coping with the issue have been based on individual measures commonly used to prevent respiratory transmission diseases, such as regular hand washing and wearing masks, and social distancing measures.

While extremely relevant for reducing the transmission of the disease and, consequently, the number of cases and deaths, such distancing, in the medium and long term, also severely harms economic activity at all levels and societal life²2 Pana-Cryan R, Ray T, Bushnell T, Quay B. Economic Security during the COVID-19 Pandemic: A Healthy Work Design and Well-being Perspective. Centers for Disease Control and Prevention; 2020 [cited 2020 Jun 29]. Available from: https://blogs.cdc.gov/niosh-science-blog/2020/06/22/economic-security-covid-19/
https://blogs.cdc.gov/niosh-science-blog... . The reduced purchasing power, especially for self-employed workers, traders, the service sector, civil construction, domestic employees, and tourism workers, further compromises Brazilians’ quality of life. The suspension of face-to-face activities that culminated in the closure of daycare centers, schools, and universities, interruption of many professional activities, and remote work, leads individuals to accumulate tensions inherent in full family life, often in unsafe, crowded homes⁶6 Marques ES, Moraes CL, Hasselmann MH, Deslandes SF, Reichenheim ME. A violência contra mulheres, crianças e adolescentes em tempos de pandemia pela COVID-19: panorama, motivações e formas de enfrentamento. Cad Saude Publica 2020; 36(4):e00074420.. Added to this is the fear of falling ill, losing loved ones, decreased formal and informal social support, and uncertainty about the future⁶6 Marques ES, Moraes CL, Hasselmann MH, Deslandes SF, Reichenheim ME. A violência contra mulheres, crianças e adolescentes em tempos de pandemia pela COVID-19: panorama, motivações e formas de enfrentamento. Cad Saude Publica 2020; 36(4):e00074420.. Guidance on the need to stay at home, especially those at risk for severe complications of the disease, and the fear of SARS-CoV-2 infection also hinder the regular monitoring of the population in health services, reducing the scope of health promotion, prevention, and lines of care for chronic non-communicable diseases and other clinical conditions.

In this context, different institutions of the child, adolescent, and women protection network have been denouncing a significantly growing number of family violence cases. Initially, in China and later in Italy, France, Spain, Argentina, and other countries⁷7 Bassan P. Casos de violência doméstica no RJ crescem 50% durante confinamento. G1 Globo 2020; 23 mar.

8 EURACTIV. Domestic violence increases in France during COVID-19 lockdown. EURACTIV Network 2020; [cited 2020 Mar 30]. Available from: https://www.euractiv.com/section/politics/news/domestic-violence-increases-in-france-during-covid-19-lockdown/
https://www.euractiv.com/section/politic...

9 Godin M. As Cities Around the World Go on Lockdown, Victims of Domestic Violence Look for a Way Out. Time 2020. [cited 2020 Mar 18]. Available from: https://time.com/5803887/coronavirus-domestic-violence-victims/
https://time.com/5803887/coronavirus-dom...

10 Golfieri M, Andrian A. O aumento da violência doméstica em tempos de covid-19. Estadão 2020. [cited 2020 Abr 01]. Available from: https://politica.estadao.com.br/blogs/fausto-macedo/o-aumento-da-violencia-domestica-em-tempos-de-covid-19/
https://politica.estadao.com.br/blogs/fa...

11 UK WsA. The Impact of COVID-19 on Women and Children Experiencing Domestic Abuse, and the Life-Saving Services that Support Them. 2020 [cited 2020 Mar 17]. Available from: https://www.womensaid.org.uk/the-impact-of-covid-19-on-women-and-children-experiencing-domesticabuse-and-the-life-saving-services-that-support-them/.
https://www.womensaid.org.uk/the-impact-... ^-1212 World Health Organization (WHO). COVID-19 and violence against women: What the health sector/system can do. Geneva: WHO; 2020., the growing domestic violence cases against women and femicide have attracted attention. They have been the subject of constant warnings to managers responsible for contingency policies, protection network services to the most vulnerable groups, health professionals, and society. Researchers⁶6 Marques ES, Moraes CL, Hasselmann MH, Deslandes SF, Reichenheim ME. A violência contra mulheres, crianças e adolescentes em tempos de pandemia pela COVID-19: panorama, motivações e formas de enfrentamento. Cad Saude Publica 2020; 36(4):e00074420.^,1313 Campbell AM. An increasing risk of family violence during the Covid-19 pandemic: Strengthening community collaborations to save lives. Forensic Science International Reports 2020; 2:100089.

14 Cluver L, Lachman JM, Sherr L, Wessels I, Krug E, Rakotomalala S, Blight S, Hillis S, Bachman G, Green O, Butchart A, Tomlinson M, Ward CL, Doubt J, McDonald K. Parenting in a time of COVID-19. Lancet 2020; 395(10231):e64, 2020 04 11.

15 Colbourn T. COVID-19: extending or relaxing distancing control measures. Lancet Public Health 2020; 5(5):E236-E237.^-1616 Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med 2020; 382(21):2049-2055., international organizations¹⁷17 End Violence Against Children. Protecting children during the COVID-19 outbreak: resources to reduce violence and abuse. End Violence Against Children 2020. [cited 2020 Mar 26]. Available from: https://www.end-violence.org/protecting-children-during-covid-19-outbreak
https://www.end-violence.org/protecting-...

18 ONU Mulheres. Gênero e COVID-19 na América Latina e no Caribe: dimensões de gênero na resposta. Geneva: ONU Mulheres; 2020.

19 Organização das Nações Unidas (ONU). Relatora da ONU: Estados devem combater violência doméstica na quarentena por COVID-19. Brasília: ONU Brasil; 2020. [cited 2020 Mar 27]. Available from: https://nacoesunidas.org/relatora-da-onu-estados-devem-combater-violencia-domestica-na-quarentena-por-covid-19/
https://nacoesunidas.org/relatora-da-onu...

20 World Health Organization (WHO). Coronavirus disease (COVID-19) advice for the public: Healthy Parenting. WHO; 2020. [cited 2020 Mar 30]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public/healthy-parenting
https://www.who.int/emergencies/diseases... ^-2121 WHO, UNICEF, Children EVA, Things IG, Health PfL, USAID, WWO, End Violence Agains Children, CDC, Childhood, Accelerate, University of Oxford, UNODC. COVID-19 parenting. 2020 [cited 2020 Mar 26]. Available from: https://www.covid19parenting.com/
https://www.covid19parenting.com/... , and the lay media²²22 BBC. Coronavirus: 'Domestic abuse pandemic likely due to shutdown'. London: BBC; 2020 [cited 2020 Mar 30]. Available from: https://www.bbc.com/news/uk-wales-52076789
https://www.bbc.com/news/uk-wales-520767...

23 BBC. Coronavirus: la preocupación por las víctimas de violencia de género que tienen que convivir en cuarentena con su agresor (y dónde buscar ayuda). BBC News Mundo; 2020. [cited 2020 Mar 24]. Available from: https://www.bbc.com/mundo/noticias-52009140.
https://www.bbc.com/mundo/noticias-52009...

24 Ribeiro D. Com isolamento, a questão da violência contra a mulher fica ainda mais grave. Folha de S Paulo 2020; Mar 27.^-2525 Salisbury H. What might we learn from the covid-19 pandemic? BMJ 2020; 368:m1087. have also drawn attention to the issue by indicating increased reports of violence against these population subgroups in different geographical regions and social contexts.

The pandemic exposed and escalated the context of economic inequalities that previously existed in the country, and social distancing reduced the already difficult access to health and social protection services. In this scenario, it is crucial to discuss the possible increased violence against older adults (VAOA), which is manifested through psychological, physical, sexual, property, and institutional violence, neglect, and financial abuse²⁶26 Brasil. Ministério da Mulher, da Família e dos Direitos Humanos. Violência contra a pessoa idosa: vamos falar sobre isso? Perguntas mais frequentes sobre direitos das pessoas idosas. Brasília: Ministério da Mulher, da Família e dos Direitos Humanos; 2020.. Considered a severe violation of human rights, VAOA is also a significant public health problem worldwide due to its high magnitude and severe consequences for physical and mental health, and the quality of life of its victims²⁷27 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002.^,2828 Yon Y, Mikton CR, Gassoumis ZD, Wilber KH. Elder abuse prevalence in community settings: a systematic review and meta-analysis. Lancet Global Health 2017; 5(2):e147-e56.. The situation is even more harmful, as it is often suffered in silence and covered up by the close and dependent relationships between victims and perpetrators, and by the fear of retaliation and abandonment.

Despite the topic’s relevance, the discussion on possible strategies for coping with VAOA during COVID-19 is still unimpressive globally. In a recent review considering PUBMED database, only two scientific papers²⁹29 Elman A, Breckman R, Clark S, Gottesman E, Rachmuth L, Reiff M, Callahan J, Russell LA, Curtis M, Solomon J, Lok D, Sirey JA, Lachs MS, Czaja S, Pillemer K, Rosen T. Effects of the COVID-19 Outbreak on Elder Mistreatment and Response in New York City: Initial Lessons. J Appl Gerontol 2020; 39(7):690-699.^,3030 Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc 2020; 68(7):1386-1387. called attention to the possibility of increased violence against this population group during the pandemic. Publications in other media are also scarce. In Brazil, academic production on the topic is non-existent, and the first statement from the federal government warning about the increase in the number of cases of VAOA occurred just four months after the first confirmed case of the disease in the country.

On this occasion, the Ministry of Women, Family, and Human Rights (MMFDH) pointed to an increased number of complaints registered by the “Disque 100” from March to May, which went from 3 thousand in March to 8 thousand in April and 17 thousand in May (months with the highest social distancing rates), which corresponds to a growth of 267% and 567% in the period³¹31 Mazzi C. Denúncias de violência contra idosos quintuplicaram durante a pandemia, apontam dados do Disque 100. O Globo 2020. [cited 2020 Jun 15]. Available from: https://oglobo.globo.com/sociedade/denuncias-de-violencia-contra-idosos-quintuplicaram-durante-pandemia-apontam-dados-do-disque-100-24480857
https://oglobo.globo.com/sociedade/denun... . These data reinforce the importance of identifying and bringing the topic to the center-stage of academic and governmental discussions to conduct a collective reflection on possible strategies aiming at reducing the problem.

Some aspects on the vulnerability of older adults during the pandemic

In order to better understand the increased number of cases and complaints of VAOA during the COVID-19 pandemic, it is interesting to point out some vulnerabilities that can increase older adults’ difficulties in such situations³⁰30 Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc 2020; 68(7):1386-1387., which are the result of a series of conditions that involve macro-structural, contextual aspects, and those related to the physical, emotional, and cognitive health of older adults. Among the first, we highlight discrimination against older adults and the lack of a multidimensional, dynamic, and integrated policy to protect these individuals, which promotes dignified and healthy aging³²32 Giacomin KC, Firmo JOA. Velhice, incapacidade e cuidado na saúde pública. Cien Saude Colet 2015; 20(12):3631-3640.

33 Pereira JK, Giacomin KC, Firmo JOA. A funcionalidade e incapacidade na velhice: ficar ou não ficar quieto. Cad Saude Publica 2015; 31(7):1451-1459.^-3434 Alcântara AO, Camarano AA, Giacomin KC. Política Nacional do Idoso: velhas e novas questões. Rio de Janeiro: IPEA; 2016.. Furthermore, we have the unsafe living conditions of most Brazilian older adults who depend on pensions and retirement benefits, which are insufficient to purchase essential items (food, medication, and clothing) for their subsistence. These resources are often the only household income source made up of different generations living in the same household³⁴34 Alcântara AO, Camarano AA, Giacomin KC. Política Nacional do Idoso: velhas e novas questões. Rio de Janeiro: IPEA; 2016..

Besides social and economic vulnerability, most Brazilian older women and men are subject to isolation and abandonment by relatives, often without structural conditions to receive and care for the relative during old age³⁵35 Freitas AVS, Noronha CV. Idosos em instituições de longa permanência: falando de cuidado. Interface (Botucatu) 2010; 14(33):359-369.^,3636 Rabelo DF. Configuração e funcionamento de famílias com idosos que apresentam diferentes condições psicológicas e de saúde. Campinas: Universidade Estadual de Campinas; 2014.. Some still live in long-term institutions, not always with adequate conditions for health promotion and healthy aging³⁷37 Tier CG, Fontana RT, Soares NV. Refletindo sobre idosos institucionalizado. Revista Brasileira de Enfermagem 2004; 57(3):332-335., and especially subject to the transmission of infectious diseases³⁸38 Moraes EN, Viana LG, Resende LMH, Vasconcellos LS, Moura AS, Menezes A, Mansano NH, Rabelo R. COVID-19 nas instituições de longa permanência para idosos: Estratégias de rastreamento laboratorial e prevenção da propagação da doença. Cien Saude Colet 2020; 25(9):3445-3458.^,3939 Richards C. Infections in residents of long-term care facilities: an agenda for research. Report of an expert panel. J Am Geriatr Soc 2002; 50(3):570-576.. A noteworthy health-related aspect is “immunosenescence” (decreased immune system functions) stands out, which predisposes older adults to adverse outcomes concerning infectious diseases, such as COVID-19⁴⁰40 Zhang W. Manual de Prevenção e Controle da Covid-19 segundo o Doutor Wenhong Zhang. São Paulo: Polo Books; 2020.. Most of the elderly population has one or more chronic non-communicable diseases, such as arterial hypertension, diabetes, asthma, chronic obstructive pulmonary disease, neoplasms, and heart diseases⁴¹41 Brasil. Ministério da Saúde (MS). Vigitel Brasil 2018: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico: estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2018. Brasília: MS; 2019.^,4242 Giacomin KC, Duarte YAO, Camarano AA, Nunes DP, Fernandes D. Care and functional disabilities in daily activities ELSI-Brazil. Rev Saude Publica 2018; 52(Supl. 2):9s., which are important prognostic factors for more severe conditions of the disease⁴³43 Wang L, He W, Yu X, Hu D, Bao M, Liu H, Zhou J, Jiang H. Coronavirus disease 2019 in elderly patients: Characteristics and prognostic factors based on 4-week follow-up. J Infect 2020; 80(6):639-645.

44 Centers for Disease Control and Prevention (CDC). People Who Are at Increased Risk for Severe Illness. CDC; 2020 [cited 2020 30 jun]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-at-increased-risk.html?deliveryName=USCDC_2067-DM31413
https://www.cdc.gov/coronavirus/2019-nco... ^-4545 Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ 2020; 368:m1198..

Another relevant point is that social distancing, which is fundamental for reducing transmission of COVID-19, especially for people over 60, limits older adults’ access to health services for regular care, which can aggravate or decompensate pre-existing clinical conditions³⁰30 Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc 2020; 68(7):1386-1387.^,4646 Ribeiro AP, Moraes CL, Sousa ER, Giacomin K. O que fazer para cuidar das pessoas idosas e evitar as violências em época de pandemia? Associação Brasileira de Saúde Coletiva: GT violência e saúde; 2020 [cited 2020 May 14]. Available from: https://www.abrasco.org.br/site/gtviolenciaesaude/tag/violencia-contra-o-idoso/
https://www.abrasco.org.br/site/gtviolen... . Social distancing can also cause mental health problems that further weaken older adults’ well-being, such as feelings of loneliness, insomnia, anxiety, loss of appetite, and depression⁴⁷47 Choi H, Irwin MR, Cho HJ. Impact of social isolation on behavioral health in elderly: Systematic review. World J Psychiatry 2015; 5(4):432-438.

48 Ong AD, Uchino BN, Wethington E. Loneliness and Health in Older Adults: A Mini-Review and Synthesis. Gerontology 2016; 62(4):443-449.

49 Runcan PL. Elderly institutionalization and depression. Procedia - Social and Behavioral Sciences 2012; 33:109-113.^-5050 Santini ZI, Jose PE, York Cornwell E, Koyanagi A, Nielsen L, Hinrichsen C, Meilstrup C, Madsen KR, Koushede V. Social disconnectedness, perceived isolation, and symptoms of depression and anxiety among older Americans (NSHAP): a longitudinal mediation analy-sis. Lancet Public Health 2020; 5(1):e62-e70.. Studies also point to an increased risk of cardiovascular, autoimmune diseases, neurological and cognitive problems⁵¹51 Gerst-Emerson K, Jayawardhana J. Loneliness as a public health issue: the impact of loneliness on health care utilization among older adults. Am J Public Health 2015; 105(5):1013-1019., and greater dependence on performing activities of daily living³⁰30 Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc 2020; 68(7):1386-1387.^,4646 Ribeiro AP, Moraes CL, Sousa ER, Giacomin K. O que fazer para cuidar das pessoas idosas e evitar as violências em época de pandemia? Associação Brasileira de Saúde Coletiva: GT violência e saúde; 2020 [cited 2020 May 14]. Available from: https://www.abrasco.org.br/site/gtviolenciaesaude/tag/violencia-contra-o-idoso/
https://www.abrasco.org.br/site/gtviolen... . As detailed below, these vulnerabilities are part of a set of processes and conditions that, while threatening older adults’ rights to dignified aging in good health, favor and trigger violence and must be addressed.

The ecological model as a pillar to understand the increased violence against older adults during Covid-19

We used the ecological model, proposed by the World Health Organization (WHO), as a basis for understanding the possible determinants of the increase in VAOA in the pandemic²⁷27 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002.. This model proposes that violence, especially interpersonal violence, is the result of macro-structural, community, relational, and individual factors, which provide feedback and interact, promoting scenarios that facilitate and hinder the occurrence of violence. As will presented below, many of which are significantly impacted by the health and economic crisis and prolonged social distancing during the pandemic.

At the macro-structural level, it is noteworthy that Brazil and other parts of the world have a culture that disparages and discriminates people because of their age, attitudes identified by the many terms defining “ageism”, even more evident in crisis scenarios. At the beginning of the COVID-19 pandemic, for example, increased discriminatory and prejudiced attitudes towards older adults was observed due to the high demand for health care in this group, their greater vulnerability to the development of more severe forms of the disease and, therefore, with a greater need for hospitalizations in ICUs³⁰30 Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc 2020; 68(7):1386-1387.. The lack of specific policies aimed at older adults to address the impacts of the pandemic also contributes to the feeling of abandonment and indicates public authorities’ neglect towards individuals of this age group, which is one of the examples of structural violence.

The economic crisis resulting from the pandemic and the reduced outreach of social policies to support workers who have lost their jobs or are prevented from carrying out their activities due to social distancing, or even those who have had their income reduced, also contributes to triggering or escalating situations of violence, by drastically reducing households’ income. In this scenario, financial abuse against older adults is mainly instigated, along with other forms of violence.

Again, at the structural level, violence in Brazil is expressed in 50% of homes without access to sanitary sewage services, 33 million Brazilians living without drinking water in several states in the northern region of the country and its numerous slums, and more than 20% of the homes with three or more people living in a single room. It is also worth mentioning older adults living on the streets who cannot even adopt the minimum hygiene measures recommended by health authorities and are neglected by the public authorities⁵²52 Associação Brasileira de Saúde Coletiva (Abrasco). Covid-19: pessoas idosas precisam de atenção especial. Rio de Janeiro: Abrasco; 2020..

At the community level, the reduced familiar social support is an indispuChart fact. Noteworthy is the interruption of religious activities, non-governmental organizations’ actions aimed at the well-being of older adults, social protection services, and the reduced access to health services, which contributes to the maintenance, aggravation, and emergence of new VAOA cases⁴⁶46 Ribeiro AP, Moraes CL, Sousa ER, Giacomin K. O que fazer para cuidar das pessoas idosas e evitar as violências em época de pandemia? Associação Brasileira de Saúde Coletiva: GT violência e saúde; 2020 [cited 2020 May 14]. Available from: https://www.abrasco.org.br/site/gtviolenciaesaude/tag/violencia-contra-o-idoso/
https://www.abrasco.org.br/site/gtviolen... . Moreover, social distancing is also a limiting factor for identifying and notifying cases of violence, which prevents the triggering of actions by the elderly protection network aimed at interrupting the situation⁴⁷47 Choi H, Irwin MR, Cho HJ. Impact of social isolation on behavioral health in elderly: Systematic review. World J Psychiatry 2015; 5(4):432-438.^,5353 Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. Gerontologist 2016; 56(Supl. 2):S194-S205..

At the relational level, the increased dependence on relatives and caregivers to carry out basic and instrumental activities of daily living and the longer family time leads to the additional tensions and conflicts between those who live with relatives or formal caregivers. Social distancing from relatives who live in other households constitutes an even more significant burden on those who live with older adults, who become the only ones responsible for the care and help in their activities of daily living. On the other hand, older adults who live alone also end up being more exposed to SARS-CoV-2 because when having to leave home to buy food, medicines, and other needs. There is also the situation of those who live in long-term institutions, particularly vulnerable to the disease due to the high level of dependence on caregivers and interacting with many individuals in environments that are often poorly ventilated and overcrowded, who may also be even more vulnerable to violence.

Concerning the dimension that involves individual characteristics, the increased levels of stress and anxiety due to the fear of falling ill, not having access to health services, requiring hospitalization or even dying due to the disease, in parallel with the distancing of family members and friends and poor access to social support institutions, can exacerbate depressive symptoms, and deteriorate neurological and cognitive problems and pre-existing clinical conditions, as already mentioned, which favors new occurrences and worsening of existing situations of violence²⁹29 Elman A, Breckman R, Clark S, Gottesman E, Rachmuth L, Reiff M, Callahan J, Russell LA, Curtis M, Solomon J, Lok D, Sirey JA, Lachs MS, Czaja S, Pillemer K, Rosen T. Effects of the COVID-19 Outbreak on Elder Mistreatment and Response in New York City: Initial Lessons. J Appl Gerontol 2020; 39(7):690-699.^,3030 Han SD, Mosqueda L. Elder Abuse in the COVID-19 Era. J Am Geriatr Soc 2020; 68(7):1386-1387.^,4646 Ribeiro AP, Moraes CL, Sousa ER, Giacomin K. O que fazer para cuidar das pessoas idosas e evitar as violências em época de pandemia? Associação Brasileira de Saúde Coletiva: GT violência e saúde; 2020 [cited 2020 May 14]. Available from: https://www.abrasco.org.br/site/gtviolenciaesaude/tag/violencia-contra-o-idoso/
https://www.abrasco.org.br/site/gtviolen... . The overload of family caregivers who accumulate care for older adults with home chores, care for children and adolescents, and remote work, when applicable, or stress of job or income loss also make up this vulnerable picture. Social distancing is also associated with alcohol abuse by older adults and caregivers, which is often a risk factor for various forms of violence⁵⁴54 Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, Rubin GJ. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020; 395(10227):912-920..

Considering the immense structural inequalities in Brazilian society, we should mention that the accumulated situations mentioned above are not homogeneous in our country. Aging depends on the social, cultural, economic, and functional profiles that vary in different scenarios. Depending on older adults’ living context, the impacts of COVID-19 prevention measures can be decisive for exacerbating violent situations. The factors promoting the different expressions of violence in times of crisis are much more present in low-income communities, with lower access to health services, living in homes with poor sanitation conditions, without running water, a high degree of agglomeration and, consequently, greater difficulty in carrying out the individual and collective protective measures recommended for the prevention of disease and containment of the pandemic.

Strategies for reducing VAOA in the pandemic context

Without the intention of exhausting the topic, we could propose some initiatives that can reduce the factors facilitating violence against older adults and expanding those promoting a culture of peace and solidarity, protecting older adults and their caregivers in this moment of crisis. Just as the ecological model can support the reflections on the factors that favor the occurrence of violence, it can also help us propose strategies aimed at guaranteeing the rights of older adults, improving the home environment, and reducing situations of VAOA²⁷27 Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R. World report on violence and health. Geneva: World Health Organization; 2002..

As previously pointed out, as it is a complex social event, violence is produced by the interaction between different protective and risk factors. Thus, its prevention and line of care must be based on network responses, which combine intersectoral efforts involving public health policies, social assistance, emergency economic support, security and justice in actions to protect rights, health promotion and early detection, notification and care of existing cases⁵³53 Pillemer K, Burnes D, Riffin C, Lachs MS. Elder Abuse: Global Situation, Risk Factors, and Prevention Strategies. Gerontologist 2016; 56(Supl. 2):S194-S205.^,5555 World Health Organization (WHO). World report on ageing and health. Geneva: WHO; 2015.

56 World Health Organization (WHO). Abuse of older people on the rise - 1 in 6 affected. Geneva: WHO; 2017 [cited 2020 Jul 15]. Available from: https://www.who.int/en/news-room/detail/14-06-2017-abuse-of-older-people-on-the-rise-1-in-6-affected
https://www.who.int/en/news-room/detail/... ^-5757 Moraes CL, Reichenheim ME. Programa de Investigação Epidemiológica em Violência Familiar (PIEVF-IMS/UERJ). Rio de Janeiro: CNPq; 2020..

As can be seen in Chart 1, at the macro-structural level, strategies and social policies that promote society’s awareness of the rights and needs of older adults, besides those that facilitate access to health, assistance, and social security services, and the network protection are urgent. Policies aimed at providing economic support to low-income households to reduce social inequalities, which tend to increase even more during and after the pandemic, and to guarantee older adults’ rights are also essential.

From the community point of view, the importance of maintaining and expanding the social facilities of the formal and informal protection network for older adults is emphasized, such as police stations for older adults, councils, associations, and the informal network of neighbors, buildings’ janitors, and other people in the community to identify situations of greater vulnerability. It is still necessary to reinforce the importance of solidarity actions and the sharing of care for older adults among people living at home to reduce the burden on caregivers, almost all women⁵²52 Associação Brasileira de Saúde Coletiva (Abrasco). Covid-19: pessoas idosas precisam de atenção especial. Rio de Janeiro: Abrasco; 2020.^,5858 Souza ER, Ribeiro AP, Atie S, Souza AC, Marques CC. Rede de proteção aos idosos do Rio de Janeiro: um direito a ser conquistado. Cien Saude Colet 2008; 13(4):1153-1163..

At the relational level, it is necessary to pay attention to the fact that older adults are less accustomed to computer technologies and other equipment that facilitate remote contacts, such as electronic mail, telephone messages, digital platforms, and others. Thus, phone calls are an essential strategy for keeping contact with older adults physically isolated from other relatives. Identifying suspicious behavior, disorientation, refusal to speak on the phone, or even a sleep increase during the day should draw attention to the possibility of violence. The search for non-violent strategies for conflict resolution in this crisis scenario, where stress and overload are more frequent, is also essential. Finally, it is worth noting that actions to promote mental and physical health, in line with other well-being care, both for older adults and their principal caregivers, also contribute to the maintenance of a healthy family environment without violence.

Final considerations

COVID-19 and the social distancing needed to contain the pandemic brought to light a series of adverse consequences for individuals and life in society, including increased domestic and family violence. Older adults are most vulnerable to those problems due to a set of reasons. The usual social discrimination against aging and insufficient public policies to guarantee their rights and economic conditions are some of those violence determinants. The greater dependence on third parties to carry out their instrumental or basic activities of daily living, their weaknesses concerning health and well-being, and the reduced formal and informal social support resulting from social distancing also make this group the preferred target of the different forms of violence at this time.

Municipal, state, and federal governments must include different actions to combat VAOA in the COVID-19 coping policies in the country to prevent the occurrence of new cases of violence against this group or even to interrupt already existing ones. Only an intersectoral and network action can reduce the occurrence of this relevant problem, which is even more evident in times of health, political, economic, and ethical crisis like the one we are experiencing. Besides social distancing, social protection policies are imperative in this period of crisis, which requires immediate government action to mitigate the economic and social effects of the pandemic that prioritize the right to life over economic interests.

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