Barriers to Routine Screening for Abuse of Older Adults

The abuse of older adults is a significant public health issue that often goes undetected, particularly in rural healthcare settings. This study examined the barriers to routine elder abuse screening among healthcare providers in a rural community in Southeastern Utah. Guided by the Health Belief Model (HBM), the mixed-method study explored provider practices, perceptions, and systemic obstacles through a combination of quantitative survey items and open-ended qualitative responses. Thirty healthcare providers participated in the study, representing approximately 14% of licensed providers in the region. Quantitative data revealed wide variability in screening practices, with less than half of participants reporting regular screening and limited familiarity with standardized screening tools. Confidence in identifying abuse was moderate overall. Content analysis of 95 qualitative responses identified five key themes: Benefits to Screening, Provider-Level Barriers to Screening, Socio-Cultural Barriers to Screening, Policy and Practice Changes, and Additional Resources Needed. These themes were mapped to core HBM constructs, highlighting the influence of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action on screening behavior. Findings suggest that despite recognizing the importance of elder abuse screening, many rural providers face logistical, emotional, and structural challenges that limit routine practice. Providers emphasized the need for clearer screening protocols, enhanced education and training, and system-level support such as workflow integration and reimbursement incentives. This study underscores the complexity of screening in rural care and offers insights to inform policy, practice, and future research aimed at improving the safety and well-being of older adults.

1 BARRIERS TO ROUTINE SCREENING FOR ABUSE OF OLDER ADULTS by Christopher J. Gravett A project submitted to the faculty of The University of Utah In partial fulfillment of the requirements for the degree of Master of Science Gerontology College of Nursing The University of Utah April 2025 2 Copyright © Christopher J. Gravett All Rights Reserved 3 Dedication This work is dedicated to my wife and children who have supported me and put up with the late nights and all-weekend study sessions. Thank you. 4 Acknowledgements I am deeply grateful to the following individuals who provided essential support throughout this project. My graduate committee members—Dr. Kara Dassel, Dr. Lynn Reinke, and Dr. Rebekah Perkins—offered invaluable guidance, encouragement, and feedback, especially during moments of challenge with research processes, writing, and general frustration. I would also like to thank those who supported my ideas when they were still taking shape. Without the early encouragement of Ryan Hansen, Dr. Travis Engar, April Brown, and Christian Frankowski, I may not have continued to pursue this project. 5 Introduction and Background ..........................................................................................................8 Elder Abuse in Rural Settings .................................................................................................12 Problem Statement ..................................................................................................................13 Significance and Expected Implications.................................................................................13 Methods..........................................................................................................................................15 The Health Belief Model as a Theoretical Framework ..............................................................15 The Provider Perceptions about Elder Abuse Survey (PPEAS) .............................................16 Inclusion and Exclusion Criteria ................................................................................................17 Ethical Considerations................................................................................................................18 Materials and Data Collection ....................................................................................................19 Data Rigor and Trustworthiness .................................................................................................22 Introduction ................................................................................................................................24 Demographics.............................................................................................................................24 Table 1. .......................................................................................................................................25 Demographic Characteristics of Participants (N = 30) ..............................................................25 PPEAS Survey Results ...............................................................................................................26 Frequency of Seeing Patients 50 and Older............................................................................26 Table 2. ...................................................................................................................................26 Frequency of Seeing Patients Aged 50 and Older (N = 26) ...................................................26 Frequency of Screening Patients for Elder Abuse ..................................................................27 Table 3. ...................................................................................................................................27 Frequency of Screening Patients Aged 50 and Older for Abuse (N = 23)..............................27 Approaches to Screening ........................................................................................................27 Table 4. ...................................................................................................................................28 Approaches to Elder Abuse Screening Among Respondents (N = 14) ..................................28 Confidence in Identifying Elder Abuse ..................................................................................28 Figure 1. ..................................................................................................................................29 Confidence in Identifying Elder Abuse ..................................................................................29 Familiarity with Standardized Screening Instruments............................................................29 Figure 2. ..................................................................................................................................29 Familiarity with Standardized Elder Abuse Screening Instruments .......................................29 Perceptions of Screening as Essential ....................................................................................30 6 Table 5. ...................................................................................................................................30 Perceptions of Screening as an Essential Practice ..................................................................30 Open-Ended Responses: Content Analysis of Qualitative Findings ......................................30 Perceived Benefits of Screening .............................................................................................31 Provider-Level Barriers to Screening .....................................................................................31 Socio-Cultural Barriers to Addressing Abuse .........................................................................32 Policy and Practice Recommendations...................................................................................33 Resources Needed to Improve Screening Effectiveness ........................................................33 Summary of Qualitative Findings...........................................................................................34 Mapping of Qualitative Themes to the Health Belief Model .................................................34 Table 6. ...................................................................................................................................35 Mapping of Content Analysis Themes to Health Belief Model Constructs ...........................35 Discussion ......................................................................................................................................36 Introduction ................................................................................................................................36 Summary of Key Findings .........................................................................................................36 Interpretation of Key Findings with the Health Belief Model ...................................................38 Perceived Susceptibility and Severity ....................................................................................39 Self-Efficacy ...........................................................................................................................39 Perceived Benefits ..................................................................................................................40 Perceived Barriers...................................................................................................................41 Cues to Action ........................................................................................................................41 Study Limitations .......................................................................................................................42 Future Inquiry.............................................................................................................................43 Implications ................................................................................................................................44 Conclusion .....................................................................................................................................45 References ......................................................................................................................................46 Appendix 1 .....................................................................................................................................50 Provider Perceptions about Elder Abuse Screening Survey (PPEAS Survey) ..............................50 7 Abstract The abuse of older adults is a significant public health issue that often goes undetected, particularly in rural healthcare settings. This study examined the barriers to routine elder abuse screening among healthcare providers in a rural community in Southeastern Utah. Guided by the Health Belief Model (HBM), the mixed-method study explored provider practices, perceptions, and systemic obstacles through a combination of quantitative survey items and open-ended qualitative responses. Thirty healthcare providers participated in the study, representing approximately 14% of licensed providers in the region. Quantitative data revealed wide variability in screening practices, with less than half of participants reporting regular screening and limited familiarity with standardized screening tools. Confidence in identifying abuse was moderate overall. Content analysis of 95 qualitative responses identified five key themes: Benefits to Screening, Provider-Level Barriers to Screening, Socio-Cultural Barriers to Screening, Policy and Practice Changes, and Additional Resources Needed. These themes were mapped to core HBM constructs, highlighting the influence of perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action on screening behavior. Findings suggest that despite recognizing the importance of elder abuse screening, many rural providers face logistical, emotional, and structural challenges that limit routine practice. Providers emphasized the need for clearer screening protocols, enhanced education and training, and system-level support such as workflow integration and reimbursement incentives. This study underscores the complexity of screening in rural care and offers insights to inform policy, practice, and future research aimed at improving the safety and well-being of older adults. 8 Introduction and Background The abuse of older adults is a significant issue and often goes undetected. The World Health Organization (WHO) reports that up to 64% of institutionalized older adults have been victims of some form of abuse (World Health Organization, 2022). Hoover and Polson (2014) estimate that in the United States, abuse occurs in 1 out of every 10 older adults across all settings, including at home, inpatient hospitals, and long-term care. Determining the actual prevalence of abuse in general and in specific settings is hampered by the lack of systematic and robust reporting processes (Mercier et al., 2020). Jurkowski (2018) describes elder abuse as any intentional act intended to cause harm or an act the perpetrator should know is likely to cause harm. Abuse includes physical abuse, such as hitting or shoving; Psychological abuse, such as yelling, mocking, or belittling; Financial abuse, such as using the older adult's finances recklessly or for personal gain. Abuse also includes neglect or the failure to provide or obtain necessary medical or psychological care. The consequences of elder abuse can be profound and far-reaching, affecting individuals, healthcare systems, and society at large. For older adults, the effects include physical pain, injury, hospitalizations, and increased risk of early mortality. Elder abuse also has serious psychological consequences such as anxiety, depression, post-traumatic stress, and social withdrawal (Murphy et al., 2013). In addition to individual consequences elder abuse also places a considerable strain on the healthcare system. Hospitals, clinics, and long-term care facilities provide ongoing treatment and support to victims due to injuries, management of complications, and mental health support to older adults in crisis. The long-term consequences can result in increased hospital stays and 9 increased need for long-term care and rehabilitation services—all of which stretch healthcare resources (Jurkowski, 2018). Abusers are often individuals who are known to the older adult, with 71.5% of abuse cases involving someone familiar to the victim and 20.6% involving paid and unpaid caregivers. Abuse is most commonly perpetrated by family members, accounting for 46.8% of cases. These cases are also most likely to go unreported (Weissberger et al., 2019). Among the various forms of abuse, financial exploitation is the most common, occurring in 61.8% of reported cases (Weisberger et al., 2019). These findings highlight the important need for awareness and proactive measures in addressing elder abuse and caregiving relationships. In 2024, a new Centers for Medicare and Medicaid Services Age-Friendly Hospital Measure was introduced to address critical issues related to the safety and well-being of older adults during hospital discharge. This measure aims to ensure that hospital staff assess discharge placements for safety and appropriateness, including freedom from abuse and other hazards (Escobedo, 2024). Hospitals are required to track and report how effectively they conduct these assessments, emphasizing accountability and continuous improvement. Each hospital or health system will have their own process for meeting this requirement (Escobedo, 2024). To comply with this measure, hospital staff are required to evaluate the older adult’s discharge location by screening for and addressing any specific concerns (e.g., Will the person have adequate support to manage their condition? Is the location physically safe? Are there individuals in the environment who might pose a threat?). By incorporating these considerations into discharge planning, the CMS measure seeks to identify and address actual and potential elder abuse—thereby improving safety and quality of care for older adults and reducing healthcare costs associated with abuse (Escobedo, 2024). 10 In their most recent report, the United States Prevention Service Task Force (2022) found insufficient evidence that the current screening tools were adequate. They further concluded that the evidence was insufficient to determine if routine screening of older adults was effective in identifying instances of physical abuse of older adults. Feltner et al. (2018) obtained similar results regarding screening tools for other forms of abuse, such as verbal or psychological abuse. Current studies focused on elder abuse screening instruments have addressed internal consistency and diagnostic validity. Examples of tools evaluated include: the Hwalek-Sengestock Elder Abuse Screening Test (Neale et al., 1991) which was developed in 1986; the Elder Abuse Suspicion Index which is a brief assessment that can be completed in as little as two minutes (Patel et al., 2021); Elder Psychological Abuse Scale which was developed to focus on psychological distress indicators (Wang et al., 2007). These tools demonstrate moderate to good internal consistency, and some have been validated by population studies (Gallione et al., 2017). However, it has been suggested in the literature that there may not be evidence-based processes in all clinics to respond to a positive screening result (Brijnath et al., 2018). That is to say that the screening tools may reliably identify abuse, but providers do not have practical next steps on how to respond to a positive screen. While elder abuse screening tools are diagnostically valid, there remains a significant gap in evidence-based processes, interventions and training to effectively address identified cases of abuse. In their systematic review, Baker et al. (2016) raised concerns about the inconsistency of existing intervention programs—such as counseling, education, and social service visitation— and noted limited evidence of their efficacy in abuse reduction, particularly across diverse socioeconomic contexts. The absence of reliable data poses challenges for healthcare practitioners attempting to implement evidence-based practices. It also complicates their ability 11 to meet legal mandates for reporting abuse, leaving them without clear guidance on how to respond effectively to a positive abuse screening. In the state of Utah, reporting the abuse of vulnerable adults, including older adults, is done through Adult Protective Services (APS) central intake. They take phone calls from 8 am to 5 pm Monday through Friday and have an online form that is available anytime. Online referrals must still be processed during regular business hours. Even in cases where APS substantiates abuse, they are only able to take direct action to help the victim in the most egregious cases and only if there are funds remaining in their budget. The only thing they can do to the perpetrator is enter the perpetrator in the state abuse registry, which is private and only relevant to medical and human service professionals and refer the perpetrator to the police (Utah Adult Protective Services, 2024). In this current justice model, referral often worsens the situation for the older adult. Current models focus on prosecuting the alleged abusers and punishing them. Arresting the caregiver may result in the victim no longer having someone to care for them. In cases involving family caregivers the older adult’s situation may be worsened by arresting the caregiver. Not arresting the perpetrator and leaving them in the caregiver role raises concerns about retaliation (Lachs et al., 2021). The challenges of APS reporting and criminal justice involvement may present additional problems in an outpatient setting. The patient usually is with the provider for a short time and then leaves the office. If the patient screens positive, the provider likely does not have a clear path to protect the patient from further abuse. The patient will likely still leave the office and may return to the abusive environment. 12 Health Belief Model The Health Belief Model (HBM) of behavior change suggests that several key factors influence whether a particular behavior will be modified. These factors include perceived susceptibility, perceived severity, perceived barriers, self-efficacy, and cues to action (Alyafei & Easton-Carr, 2024). According to this framework, healthcare providers’ decisions to screen for abuse are governed by their perceptions of its likelihood. If a provider believes abuse is unlikely, they are less inclined to screen for it. Perceived severity also influences behavior; if the provider views abuse as a minor issue or considers the alternative to the abusive situation to be more harmful, they may choose not to screen. Barriers, such as institutional policies or personal constraints, also play a significant role. Examples include limited appointment times, inadequate reimbursement rates, and excessive documentation requirements, which can hinder the screening process. Considering these factors, if providers doubt their ability to screen successfully and lack cues or prompts to take action, screening is highly unlikely to occur. Elder Abuse in Rural Settings Rural healthcare settings face unique challenges when it comes to addressing elder abuse. In rural areas, older adults are often at higher risk due to factors like social isolation, limited access to support networks, and fewer resources to detect and respond to abuse (Warren & Blundell, 2019). Healthcare providers in these areas may also struggle with barriers such as lack of training, limited time, and the absence of tools specifically designed for rural settings. Additionally, in small, close-knit communities, it can be harder for victims to report abuse because of concerns about privacy or fear of community judgment (Williams-Burgess & Kimball, 1992). 13 Problem Statement It is unknown if outpatient healthcare providers in Carbon County, Utah, are regularly and systematically screening older adults for abuse. The objective of this project was to examine barriers to elder abuse screening in rural outpatient healthcare settings. Specifically, this project sought to answer the following: 1. Are outpatient providers regularly screening their patients for abuse in any way? 2. If outpatient providers are screening, what methods are they using? 3. If an outpatient provider is not screening, do they perceive any benefit to screening? 4. What are the barriers that interfere with regular screening? Significance and Expected Implications Elder abuse remains a pervasive and underreported issue, particularly in rural communities where healthcare resources are limited, and older adults face increased vulnerability (Warren & Blundell, 2019). Although validated screening tools exist, their use remains inconsistent due to systemic, institutional, and provider-level barriers (Feltner et al., 2018; Brijnath et al., 2018). This project addresses a critical gap between identification and intervention, especially in outpatient rural settings where the opportunity for proactive screening is often missed. The project also aligns with national initiatives such as the CMS Age-Friendly Hospital Measure, which mandates that discharge planning include assessment for abuse risks (Escobedo, 2024). However, even with national policies in place, healthcare providers often lack clear processes for responding to positive abuse screens, creating challenges in fulfilling both ethical and regulatory responsibilities (Baker et al., 2016). 14 By identifying modifiable barriers and examining provider decision-making through the lens of the Health Belief Model, this project contributes to the development of practical, evidence-informed strategies to support elder abuse detection and response (Alyafei & EastonCarr, 2024). The findings are expected to inform provider training, workflow protocols, and resource allocation in rural clinics. Ultimately, this work aims to enhance the safety and quality of care for older adults while addressing broader public health and policy concerns associated with unrecognized and unaddressed elder abuse. 15 Methods This section outlines the methods used to explore outpatient healthcare providers’ practices, perceptions, and barriers related to elder abuse screening in a rural setting as outlined in the problem statement above. The study employed a mixed-methods approach, integrating both quantitative and qualitative data collection and analysis. The HBM was used as the guiding theoretical framework to design the survey and interpret the findings. This section describes the sampling and recruitment process, ethical considerations, data collection, data management, and analytic strategies. The Health Belief Model as a Theoretical Framework The HBM (Abraham & Sheeran, 2015) served as the theoretical framework for developing the survey instrument and interpreting the findings. The HBM is widely used to understand and predict health behaviors by focusing on individuals' beliefs and perceptions about health risks and their capacity to take preventive action. The model includes six key constructs: • Perceived Susceptibility (belief about the risk of experiencing abuse). • Perceived Severity (belief about the seriousness of abuse consequences). • Perceived Benefits (belief in the efficacy of screening to reduce risks). • Perceived Barriers (perceived obstacles to screening, such as time constraints). • Cues to Action (triggers that prompt screening, like Electronic Health Record [EHR] prompts). • Self-Efficacy (confidence in the ability to conduct effective screenings). 16 The Provider Perceptions about Elder Abuse Survey (PPEAS) The Provider Perceptions about Elder Abuse Survey (PPEAS) was developed specifically for this project to assess healthcare providers’ experiences, attitudes, and barriers related to elder abuse screening. The survey was intentionally designed using the constructs of the HBM as a guiding framework. The HBM is a widely used theoretical model for understanding healthrelated behaviors and decision-making, making it well-suited to explore provider engagement in screening practices (Abraham & Sheeran, 2015). The PPEAS included both structured Likert-scale items and open-ended questions, each aligned to core HBM domains: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. For example, Likert items assessed providers' confidence in identifying abuse (self-efficacy), perceptions of screening importance (perceived benefits), and frequency of screening behaviors (cues to action). Open-ended items were used to explore individual and system-level barriers, as well as provider recommendations for improving screening practices. Applying the HBM to the survey design enabled a structured approach to understanding the factors that influence whether and how providers choose to screen for elder abuse. This framework also supported the analysis and interpretation of findings by linking provider beliefs to observable patterns in screening behavior, ultimately guiding recommendations for education, policy, and system-level changes. Sampling and Recruitment A purposive sampling strategy was employed to recruit healthcare providers (i.e., medical, nursing, and social work providers) practicing in Carbon County, Utah. Eligible 17 providers were identified using the Utah Department of Commerce, Division of Occupational and Professional Licensing (DOPL) database. The target population included those with mailing addresses in the following zip codes: 84501, 84520, 84526, 84529, 84539, and 84542. This approach ensured that participants were actively practicing in rural healthcare settings where older adults were likely to receive care. A total of 30 participants were recruited, representing approximately 14% of the licensed healthcare providers in the area. The relatively small sample size was appropriate given the rural context and limited number of healthcare providers serving older adults in these communities. Recruitment began with an initial email invitation sent by the Principal Investigator (PI). Included in the email was the project’s purpose and an attached consent cover letter, explaining the study procedures, potential risks, and benefits. Participants were informed that they would receive a $15 appreciation gift upon survey completion. The survey was distributed using the Qualtrics online platform, ensuring accessibility and ease of participation (Qualtrics, 2024). Participants were given 30 days to complete the survey, and to maximize participation, two reminder emails were sent during this period. A hard copy of the invitation was then delivered to the practice office of each provider who had not responded. Participation was voluntary, and participants could withdraw at any time without consequence. Inclusion and Exclusion Criteria Healthcare providers were eligible to participate if they were licensed physicians, advanced practice registered nurses (APRNs), physician assistants (PAs), nurses and other healthcare professionals (i.e., licensed practical nurses and social workers) with primary practice location in Carbon County, Utah, responsible for conducting patient screenings and intake assessments, and consented to participate. Exclusion criteria included providers who did not have 18 direct patient interactions (e.g., administrators or educators), temporary or as needed (PRN) providers, and non-English speakers. Providers specializing in pediatrics, obstetrics, or other areas unlikely to involve direct older adult care were also excluded. This ensured that the sample reflected providers most relevant to the focus of elder abuse screening among older adults. Ethical Considerations This study adhered to strict ethical standards to protect participant anonymity, privacy, and data security. Surveys were designed to collect no identifying information, and participants’ IP addresses were not recorded. Data were stored securely in the Qualtrics database, accessible only to the PI. Any physical materials were locked in a secured office space. A consent cover letter was provided to each participant at the time of recruitment. This letter explains the project’s purpose, procedures, potential risks, and benefits. Participants were encouraged to ask questions and were assured that participation was voluntary. The letter clarified that participants could withdraw at any time without penalty. To ensure ethical compliance, the project received approval from the Institutional Review Board (IRB) # 00186218 at the University of Utah, guaranteeing that all research procedures adhered to federal guidelines for human subject research. Upon completion of the project, any printed materials were securely shredded, and electronic data were permanently deleted from the PI's devices to ensure confidentiality. This study adhered to strict ethical standards to protect participant anonymity, privacy, and data security. Surveys were designed to collect no identifying information, and participants’ IP addresses were not recorded. Data were stored securely in the Qualtrics database, accessible only to the PI. Any physical materials were locked in a secured office space. A consent cover letter was provided to each participant at the time of recruitment. This letter explains the 19 project’s purpose, procedures, potential risks, and benefits. Participants were encouraged to ask questions and were assured that participation was voluntary. The letter clarified that participants could withdraw at any time without penalty. To ensure ethical compliance, the project received approval from the Institutional Review Board (IRB) # 00186218 at the University of Utah, guaranteeing that all research procedures adhered to federal guidelines for human subject research. Upon completion of the project, any printed materials were securely shredded, and electronic data were permanently deleted from the PI's devices to ensure confidentiality. Materials and Data Collection Data were collected using the Provider Perceptions about Elder Abuse Screening (PPEAS) Survey, an investigator-designed instrument developed based on the HBM constructs and current literature on elder abuse to assess outpatient providers' practices, perceptions, and barriers related to elder abuse screening. The survey included both quantitative and qualitative questions to comprehensively capture participants' experiences and perceptions. The survey consisted of four main sections. The first section captured demographic information, including age, gender, race, ethnicity, highest degree or certification, and years of professional experience. The second section focused on screening practices, including the frequency of elder abuse screening and familiarity with standardized screening instruments. The third section addressed perceptions and barriers, assessing providers’ confidence in identifying abuse and their perceptions of the importance of screening. The fourth section explored actions and tools, asking about the likelihood of taking specific actions when abuse is identified and recommendations for improving screening practices. Quantitative questions included Likert-scale and multiple-choice formats, while qualitative insights were captured through open-ended questions that encouraged detailed 20 responses. To ensure confidentiality, participants were assigned a unique participant ID number for data management. The survey was distributed via Qualtrics, and participants had 30 days to complete it. Two reminder emails were sent during this period to encourage completion. Data Management Data were managed with strict confidentiality. All responses were securely stored in the Qualtrics database, which did not collect identifiable information or Internet Protocol addresses. Data were cleaned by checking for missing responses, inconsistencies, and ensuring accurate entry. Any missing data were documented and considered in the analysis. Upon project completion, paper surveys were shredded, and electronic data were permanently deleted to uphold confidentiality. Quantitative Data Analysis Quantitative data were analyzed using descriptive statistics in Qualtrics (Qualtrics, 2024). Frequencies and percentages were calculated for categorical variables, while means and standard deviations were used for continuous variables such as age and years of experience. The results were presented through tables and figures, including bar charts and summary tables, to ensure clarity and enhance interpretation. Qualitative Data Analysis The qualitative data collected from five open-ended questions in the Provider Perceptions about Elder Abuse Screening (PPEAS) survey were analyzed using an inductive content analysis approach, following the methodology outlined by Elo and Kyngäs (2008). This approach was appropriate for the exploratory aims of the study and allowed patterns and categories to be identified directly from participant responses. 21 The analysis followed three systematic phases: preparation, organization, and reporting. Microsoft Excel was used to manage and organize the data across all phases, including tracking each participant response, associated codes, subthemes, and overarching themes. The PI conducted the analysis and met regularly with the faculty advisor to review coding decisions and ensure consistency and analytic rigor. In the preparation phase, the PI read all open-ended responses multiple times to become familiar with the data and identify responses relevant to the research questions. Each participant response was treated as an independent unit of analysis. In the organization phase, an open coding strategy was applied. Responses were reviewed line by line, and descriptive codes were applied to highlight meaningful content. Codes with similar content were grouped into categories, which were then organized into higher-level themes. This iterative process allowed for careful comparison and refinement. For example, responses describing “lack of time,” “short appointments,” or “busy schedules” were grouped under the subtheme Time Constraints, which was categorized under the broader theme Provider-Level Barriers. In the reporting phase, themes were reviewed for consistency, distinctiveness, and alignment with the original participant responses. Each response was assigned to one primary theme based on the most dominant concept expressed. Frequencies were calculated to quantify the number and percentage of responses in each theme. Representative quotations were retained to illustrate key themes in the Results section. To further contextualize the findings within the theoretical framework guiding the study, all themes and subthemes were mapped to the six core constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. This mapping supported interpretation of how providers' beliefs, knowledge, and 22 perceptions influence elder abuse screening practices and informed the integration of theoretical insights in the Results and Discussion sections. Data Management Data management for the qualitative analysis was conducted manually using Microsoft Excel. The spreadsheet was organized with dedicated columns for the original participant responses, initial codes, grouped categories, final themes, and accounting for all counts and frequencies of all responses in categories and themes. This structured approach allowed for systematic tracking and consistent refinement throughout the analysis process. Using Excel facilitated transparency by clearly documenting how each response evolved from initial coding to final theme development, ensuring that the analysis process was organized, traceable, and rigorous. Data Rigor and Trustworthiness To ensure rigor and trustworthiness of the qualitative analysis, the process was carefully documented to maintain transparency and traceability. The PI engaged in reflexive practices, including self-reflection on potential biases and meeting regularly with the project advisor to discuss strategies for minimizing subjective interpretation. Coding decisions were reviewed multiple times, and categories were refined iteratively to ensure consistency and alignment with the data. Project advisor oversight throughout the coding and theme development process enhanced credibility, helping ensure that themes authentically reflected participant perspectives (Elo & Kyngäs, 2008). Dependability was strengthened by using Microsoft Excel to manage and audit the coding process, allowing for systematic tracking from raw data through final themes. This structured and collaborative approach provided a sound foundation for identifying key 23 themes related to elder abuse screening and for generating recommendations that are grounded in the data. 24 Results Introduction The purpose of this project was to explore outpatient providers' practices and perceptions related to elder abuse screening. The study was guided by the following four questions: 1. Are outpatient providers regularly screening their patients for abuse in any way? 2. If outpatient providers are screening, what methods are they using? 3. If an outpatient provider is not screening, do they perceive any benefit to screening? 4. What are the barriers that interfere with regular screening? The Provider Perceptions about Elder Abuse Screening (PPEAS) Survey collected both quantitative and qualitative data to address these questions. The results are presented in alignment with these project questions, beginning with providers’ frequency of contact with older adult patients, followed by their screening practices, methods, and perceived confidence. The section then explores perceptions of screening benefits, identifies individual and system-level barriers, and concludes with participants' recommendations to improve screening practices. Both closed-ended (quantitative) and open-ended (qualitative) responses are presented. Open-ended responses were analyzed using a content analysis approach to categorize recurring themes and quantify participant perspectives (Elo & Kyngäs, 2008). Demographics The study sample consisted of 30 healthcare providers with a mean age of 40.8 years (SD = 10.2). The majority of participants were female (66.7%) and identified as White (93.3%). Most participants were not Hispanic or Latino (80.0%), with a small portion self-identifying through alternative descriptors. Regarding professional qualifications, 70.0% of participants held 25 certifications such as RN, BSN, LPN, or Social Worker, while the remainder held advanced clinical degrees (e.g., MD, DO, DNP). Participants had an average of 10.8 years (SD = 6.5) of experience practicing in healthcare, with 30.0% having practiced for over 16 years. The majority reported frequent contact with older adults, with 46.7% seeing patients aged 50 and older "often" and 33.3% seeing them "always." Table 1 presents a detailed summary of the participants' demographic characteristics. Table 1. Demographic Characteristics of Participants (N = 30) Variable Age (years) Gender Race Ethnicity Category 25–34 35–44 45–54 55–64 65+ n 6 12 8 2 1 % 20.0 40.0 26.7 6.7 3.3 Mean (SD) — 40.8 (10.2) Male Female White Prefer not to answer Not Hispanic or Latino Self-described Prefer not to answer 10 20 28 2 24 2 4 33.3 66.7 93.3 6.7 80.0 6.7 13.3 1 3.3 3 1 2 2 10.0 3.3 6.7 6.7 21 70.0 2 6.7 Highest Professional MD Degree/Certification DO DNP APRN PA-C Other (e.g., RN, BSN, LPN, Social Worker) Years Practicing in Less than 1 year Healthcare 26 Variable Category 1–5 years 6–10 years 11–15 years 16+ years Mean (SD) Frequency of Seeing Rarely Patients 50+ Sometimes Often Always n 5 6 4 9 — % 16.7 20.0 13.3 30.0 10.8 (6.5) 2 6.7 4 14 10 13.3 46.7 33.3 Note. Percentages may not total 100% due to rounding. Means and standard deviations (SD) for age and years of practice were estimated using the midpoints of each categorical range. PPEAS Survey Results Frequency of Seeing Patients 50 and Older To establish the context for elder abuse screening practices, participants were first asked about the frequency of their interactions with patients aged 50 and older. Most participants reported frequent interactions with patients aged 50 and older. Specifically, 46.2% indicated they "often" see older patients, while 30.8% stated they "always" do. A smaller portion reported "sometimes" (15.4%) or "rarely" (7.7%) seeing patients in this age group (See Table 2). Table 2. Frequency of Seeing Patients Aged 50 and Older (N = 26) Frequency N % Rarely Sometimes Often Always 2 4 12 8 7.7 15.4 46.2 30.8 Note: Percentages are based on number of participants who responded (n=26) 27 Frequency of Screening Patients for Elder Abuse Given the frequency of contact with older adults, participants were then asked how often they screened these patients for elder abuse to assess consistency in screening practices. Screening for elder abuse among patients over 50 was variable. While 30.4% of participants reported screening "often," a notable portion (26.1%) indicated that they "rarely" or "never" screen for abuse. Only 17.4% stated they "always" conduct screening (See table 3). Table 3. Frequency of Screening Patients Aged 50 and Older for Abuse (N = 23) Frequency N % Never Rarely Sometimes Often Always 2 4 6 7 4 8.7 17.4 26.1 30.4 17.4 Note. Percentages are based on the number of participants who responded (N = 23). Approaches to Screening To explore how screening was conducted, participants who indicated that they screen were asked to describe their approach in an open-ended question. Fourteen providers offered responses. Content analysis revealed three primary approaches: 1. Observation of physical or behavioral indicators (35.7%) – Informal assessment through clinical cues. 2. Use of standardized questions or tools (35.7%) – Either written or verbal, sometimes embedded in the intake process or Electronic Health Records (EHRs). 3. Unscripted verbal inquiry (28.6%) – Informal conversations tailored to the clinical context. 28 These findings indicate that many providers rely on non-standardized methods, potentially limiting the consistency and reliability of abuse detection (See Table 4). Table 4. Approaches to Elder Abuse Screening Among Respondents (N = 14) Approach Description n % Observation of physical or behavioral indicators Informal assessment through clinical cues such as bruising, demeanor, or caregiver interaction. 5 35.7% Use of standardized questions or tools Unscripted verbal inquiry Written or verbal screening tools, often part of intake paperwork or EHR systems. 5 35.7% Informal conversations initiated based on provider discretion or concern. 4 28.6% Note. Participants could provide more than one response. Percentages are based on the number of participants who answered this question (N = 14). Confidence in Identifying Elder Abuse Understanding participants' confidence in identifying elder abuse is critical, as it can influence the likelihood and accuracy of screening practices. Confidence in identifying signs of elder abuse was moderate overall. Nearly half (47.8%) of respondents reported feeling moderately confident, while 21.7% felt very confident. Conversely, 30.4% expressed lower confidence, reporting they were either slightly confident (21.7%) or not at all confident (8.7%) (See Figure 1, below). 29 Figure 1. Confidence in Identifying Elder Abuse Confidence Level Very confident 21.7 Moderately confident 47.8 Slightly confident 21.7 Not at all confident 8.7 0 10 20 30 40 Percentage 50 60 Note. Percentages are based on the number of participants who responded (N=23) Familiarity with Standardized Screening Instruments Over half of participants (52.2%) said they were “not at all familiar” with standardized elder abuse screening tools, while 26.1% were “moderately familiar” and 21.7% were “slightly familiar.” This indicates limited exposure to or training with validated tools such as the Elder Abuse Suspicion Index (EASI) or Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) (Figure 2.) Figure 2. Familiarity Level Familiarity with Standardized Elder Abuse Screening Instruments Moderately familiar 26.1 Slightly familiar 21.7 Not at all familiar 52.2 0 10 20 30 Percentage 40 50 60 30 Note. Percentages are based on the number of participants who responded (N = 23). Perceptions of Screening as Essential To further understand attitudes toward elder abuse screening, participants were asked to rate their agreement with the statement that screening is an essential practice. Interestingly, more than half of respondents (56.5%) agreed or strongly agreed that screening patients over 50 for elder abuse is essential. However, surprisingly, 30.4% were neutral, and 13% disagreed or strongly disagreed with the statement (See Table 5, below). Table 5. Perceptions of Screening as an Essential Practice Response n % Strongly disagree Disagree Neutral Agree Strongly agree 1 2 7 10 3 4.3 8.7 30.4 43.5 13.0 Note. Percentages are based on the number of participants who responded (N = 23). Open-Ended Responses: Content Analysis of Qualitative Findings In addition to structured survey items, five open-ended questions were included in the Provider Perceptions about Elder Abuse Screening (PPEAS) survey. Using Elo and Kyngäs. (2008) analytic process, the PI explored providers’ perceptions of the benefits of screening, individual and systemic barriers, suggested changes to improve screening practices, and resources needed to improve confidence and effectiveness. A total of 95 responses were coded across all five open-ended questions. Responses were analyzed using an inductive content analysis approach, which allowed categories and themes to emerge directly from the data. The 31 results are organized thematically and presented in relation to the corresponding survey questions. Perceived Benefits of Screening Twenty-one participants responded to the open-ended item asking about perceived benefits of screening for elder abuse. Three subthemes were identified. The most common subtheme was Protecting Patient Health and Safety (n = 10, 47.6%), with participants emphasizing that screening helps prevent harm and ensures that vulnerable patients are safe. Closely related was the theme of Improving Patient Treatment and Outcomes (n = 9, 42.9%), in which providers stated that screening allows them to better tailor care and potentially improve the long-term well-being of older adults. A smaller group of participants (n = 2, 9.5%) discussed screening as a way to Improve the Patient’s Environmental Setting, referring to situations where elder abuse is influenced by unsafe or unsupportive home environments. Together, these responses reflect a patient-centered understanding of screening as a preventive and therapeutic tool. One provider described screening as “help[ing] ensure that the patient is safe, and they do not have individuals taking advantage of them.” Another emphasized the broader impact on care planning: “ensuring the patient is safe in their environment. Providing information and resources to help.” Provider-Level Barriers to Screening Twenty participants offered responses to a question asking about individual-level factors that prevent them from screening older adults for abuse. Three subthemes were identified. The most common was Time Constraints (n = 9, 45.0%), with providers citing busy clinical schedules and limited appointment durations as reasons they do not regularly screen. Others described Provider Discomfort with Screening (n = 7, 35.0%), highlighting the social and emotional 32 difficulty of initiating conversations about abuse. Some participants noted a Lack of Knowledge (n = 4, 20.0%) about how to conduct screenings or what steps to take after a positive result. These responses suggest that both emotional and procedural factors contribute to inconsistent screening practices at the individual level. One participant admitted discomfort in broaching the topic: “I don’t always know what to do after the screen is complete.” Another commented on the lack of time in their setting: “time constraints depending on the patient load of the Urgent Care.” Socio-Cultural Barriers to Addressing Abuse When asked about challenges in addressing abuse once it has been identified, twenty participants responded. Four subthemes were identified. The most common was Resource Barriers (n = 8, 40.0%), including uncertainty about available services or a lack of clear referral pathways. Family Barriers (n = 7, 35.0%) were also noted, including concern that the abuser might be a family member or that family members may resist interventions. Four responses (20%) described Patient Barriers, such as the patient’s reluctance to accept help or inability to recognize the abuse. One participant (5.0%) reiterated Time Constraints as a barrier to intervening after abuse is identified. These findings illustrate the complex interpersonal and environmental dynamics that hinder effective responses to elder abuse. Providers expressed concerns about addressing abuse when family members—who may be the abusers—are present or involved in care. One provider shared: “upset family members.” Others noted challenges in connecting patients to resources: “knowing who to contact, how to contact them.” These social and systemic complexities contribute to hesitation or uncertainty in how to respond to elder abuse even when it is suspected or confirmed. 33 Policy and Practice Recommendations Seventeen participants responded to an item asking what changes in policy, training, or practice would make screening more feasible. The most common recommendation was Improving Workload Efficiency and Productivity (n = 10, 58.8%), with participants suggesting system-level changes such as integrating screening tools into EHRs, automating intake prompts, or simplifying documentation processes. A few participants indicated a Need for Training (n = 3, 17.4%), suggesting that provider education could improve screening uptake. Four participants (23.5%) felt that No Changes Were Needed, reflecting satisfaction with current practices or the belief that screening was not applicable to their role. One provider suggested integrating screening into routine workflows: “a fast, easy method for screening the nursing staff could administer.” Another noted the potential of training to improve confidence: “teaching s/s [signs and symptoms] to look for...” These recommendations reflect a desire for more structured and supportive systems that empower providers to screen effectively and consistently. Resources Needed to Improve Screening Effectiveness When asked about what additional resources, training, or tools would help improve their screening practices, seventeen participants responded. The majority (n = 14, 82.4%) indicated a strong need for Education and Training, including instruction on how to identify signs of abuse, conduct screenings, and navigate follow-up processes. A few (n = 3, 17.6%) stated that No Additional Resources Were Needed, either because they felt confident in their current practices or perceived screening as outside the scope of their role. One provider emphasized the need for clearer guidance: “info on who to contact. How to contact.” Another suggested that their current tools were sufficient: “I feel as though the system my facility uses is effective.” Overall, this 34 theme reinforces the idea that gaps in knowledge and uncertainty about appropriate action hinder routine screening, and that providers are open to interventions that build their capacity. Summary of Qualitative Findings Across all five open-ended questions, a total of 95 responses were coded. The most commonly cited subthemes were Education and Training (82.4%), Protecting Patient Health and Safety (47.6%), and Improving Workload Efficiency (58.8%). Overall, participants emphasized the need for system-level support, structured protocols, and clear educational guidance to improve elder abuse screening practices. Many barriers were identified at both the provider and institutional levels, including time constraints, knowledge gaps, and workflow inefficiencies. At the same time, providers expressed strong recognition of the importance of elder abuse screening, especially in terms of ensuring patient safety and improving care quality. Mapping of Qualitative Themes to the Health Belief Model To better understand how providers' perceptions, behaviors, and recommendations aligned with the HBM framework guiding this study, the themes generated from the open-ended questions were systematically mapped to the six core constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. This mapping process enhances the interpretation of results by providing a structured lens through which to view the cognitive, emotional, and practical factors that influence elder abuse screening practices among healthcare providers in rural settings. It also helps identify which HBM domains were most prominent in providers' thinking and where there may be opportunities for targeted intervention. The mapping process involved reviewing each theme and subtheme for its conceptual alignment with one or more of the HBM constructs. Table 6 below displays the final mapping. 35 Table 6. Mapping of Content Analysis Themes to Health Belief Model Constructs Health Belief Model Theme Interpretation Perceived Susceptibility Benefits to Screening Providers recognize that older adults are vulnerable to abuse and neglect. Perceived Severity Benefits to Screening Abuse is viewed as harmful not only physically but also psychologically. Perceived Benefits Benefits to Screening & Policy and Practice Changes Screening is viewed as worthwhile for both patient safety and care quality. Perceived Barriers Provider-Level & Socio-cultural Barriers Personal, logistical, and systemic barriers interfere with routine screening. Self-Efficacy Provider-Level Barriers, Policy and Practice Changes, & Additional Resources Needed Providers expressed low confidence and a need for clearer guidance and training. Cues to Action Policy and Practice Changes External cues (e.g., systems, workflows) influenced whether screening occurred. Note: Percentages are based on 95 total coded responses. Some responses were assigned to multiple subthemes. 36 Discussion Introduction This project explored the abuse screening practices of healthcare providers in a rural community in Southeastern Utah. The project asked providers about their current screening practices, perceptions of elder abuse screening, and perceived barriers to more frequent screening. It also sought to understand the unique challenges providers face in rural settings where access to resources, time, and systemic support may be limited. The Health Belief Model (HBM) served as the theoretical framework for both the development of the survey instrument and the interpretation of provider responses. The HBM’s core constructs—perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action—offered a structured approach to examining the factors that influence provider behaviors and decision-making related to elder abuse screening. Findings from this project are interpreted through the lens of these HBM constructs. This framework provides a meaningful structure for analyzing how providers assess risk, weigh benefits and barriers, respond to prompts, and act—or fail to act—in response to elder abuse concerns. Organizing the discussion around the HBM allows for a theoretically grounded understanding of the challenges and facilitators of screening practices in a rural outpatient context. Summary of Key Findings This project revealed a wide range of elder abuse screening practices among outpatient healthcare providers in a rural setting. Providers were asked specifically about their perceptions of abuse screening, and their responses reflected multiple constructs of the HBM. These included perceived benefits to both patients and providers, perceptions of the patient population’s susceptibility to abuse and the severity of its consequences, and both internal and external 37 barriers to screening. Additionally, many participants noted the importance of cues to action such as EHR-based screening prompts. As predicted by the HBM, providers were more likely to screen when they perceived a high risk (perceived susceptibility) and serious consequences (perceived severity) of elder abuse, recognized clear benefits to screening (perceived benefits), felt confident in their ability to identify and respond to abuse (self-efficacy), experienced fewer barriers (perceived barriers), and had prompts or processes in place to support screening (cues to action). Conversely, providers were less likely to screen when they believed their patient population was not at risk (perceived susceptibility), when the consequences of abuse were perceived as minimal (perceived severity), or when they encountered systemic barriers such as time constraints, lack of training, or limited reimbursement (perceived barriers). In addition, many providers expressed hesitation about how to handle a positive screen and uncertainty around their ability to use screening tools effectively (self-efficacy), which further contributed to inconsistent screening practices. Providers reported a wide variety of screening behaviors, from never screening for abuse to screening every patient at every visit. The methods used were equally variable, including casual observation, informal questioning, and automated screening questionnaires embedded in intake processes. Many providers expressed a high confidence in their ability to identify abuse and a lack of awareness and confidence in administering screening tools. They also expressed concerns about how to approach a conversation after a positive screen—whether with the patient, or with others involved in their care, such as paid caregivers, family caregivers, or individuals who may themselves be potential abusers. Most providers were unfamiliar with standardized screening instruments, which further contributed to inconsistent practices. 38 Despite a general agreement that screening is important and ultimately benefits patients, many providers acknowledged that systemic barriers continue to hinder routine implementation. These barriers included organizational time constraints, limited confidence in screening skills, and a lack of financial or institutional incentives. The following sections will provide a detailed discussion of these issues from the perspective of the HBM and other relevant literature. Interpretation of Key Findings with the Health Belief Model Findings from this study revealed considerable variability in providers’ elder abuse screening practices, with most reporting that they screen “sometimes” or less. This suggests that many older adult patients in rural settings may not be consistently screened for abuse, potentially allowing cases to go undetected. When abuse is not identified early, patients may continue to experience preventable harm, and the healthcare system may incur costs associated with repeated visits and untreated underlying issues. These findings are consistent with previous research by Mercier et al. (2020), who found that, on average, older adults visit the emergency department more than ten times for abuse-related concerns before abuse is recognized. Similarly, studies by Patel et al. (2021) and Brijnath et al. (2018) highlight the persistent under-detection of elder abuse in clinical settings, often due to a lack of systematic screening. Applying the HBM to these results helps explain the variability in provider behavior. According to the HBM, engagement in health-related actions—such as screening—is influenced by perceptions of susceptibility, severity, benefits, barriers, self-efficacy, and cues to action. In this study, providers generally acknowledged a high perceived susceptibility and severity of elder abuse, particularly in terms of patient harm. However, low self-efficacy, limited perceived benefit in relation to workflow and time, and substantial internal and external barriers were reported. The presence or absence of cues to action, such as EHR prompts, also shaped whether 39 screening occurred consistently. These findings reinforce the value of using the HBM to understand screening behavior. Addressing weaknesses in any one of these constructs— particularly by enhancing provider confidence and reducing systemic barriers—may be key to improving elder abuse screening practices in rural settings (Warren & Blundell, 2019). Perceived Susceptibility and Severity The constructs of perceived susceptibility and severity were reflected in providers’ emphasis on safety and protection of older adults. Many providers reported that they believed screening was beneficial, with over half indicating it was an essential component of their practice. Open-ended responses like “help those in need” and “get patients out of a dangerous situation” demonstrate recognition of both the likelihood of elder abuse occurring (susceptibility) and its serious consequences (severity). These concerns align with a person-centered approach, which prioritizes holistic care and the overall well-being of individuals (Lee et al., 2020). However, this awareness was not shared across all specialties. Providers in orthopedics and urgent care settings questioned the relevance of screening in their practice, with one stating, “Doesn’t really feel relevant to orthopedics and sports medicine.” These responses suggest a lower perception of susceptibility among providers in acute or specialty settings, potentially due to limited exposure to non-physical indicators of abuse. These gaps highlight the need for targeted education to reinforce the universality of elder abuse and the critical role of all providers in identifying it. Self-Efficacy Self-efficacy, or confidence in one’s ability to perform a specific behavior, was identified as a major barrier to screening among healthcare providers, especially in connection to the theme of Knowledge and Training Deficiencies. While some providers expressed belief in their ability 40 to recognize and respond to elder abuse, many reported discomfort, unfamiliarity with tools, or uncertainty about proper procedures. More than half of the respondents indicated a lack of comfort or knowledge, with one stating, “Asking someone if they are experiencing is an uncomfortable question.” This discomfort and lack of clarity were compounded by unfamiliarity with standardized screening tools and the absence of clear protocols following a positive screen. Many providers noted reliance on intake processes or EHR prompts but admitted they did not fully understand how to use these resources effectively. These findings are consistent with existing literature indicating that limited training and lack of confidence are major barriers to abuse identification (Patel, 2021; Mercier, 2020). To increase screening uptake, interventions must strengthen provider confidence through hands-on training, role-play, and clarity in workflow and response protocols. Perceived Benefits The perceived benefits of screening revealed a tension between patient benefit and provider or system-level constraints. While some providers acknowledged that screening could improve patient outcomes, others emphasized challenges such as time constraints and lack of reimbursement. One provider remarked, “Reimbursement would be nice,” underscoring the reality that screening is not billable in many settings and thus may reduce perceived efficiency or value from the provider’s standpoint. This reflects a broader issue in clinical environments where workflow demands and resource limitations can overshadow potential long-term patient benefits. Mercier et al. (2020) also highlighted how time constraints and fears of legal liability contribute to provider hesitancy in screening. Addressing these concerns through organizational support, policy advocacy for 41 reimbursement, and streamlined workflows may increase the perceived value of screening and shift the cost-benefit calculus for providers. Perceived Barriers Providers described interpersonal obstacles as Perceived Barriers, such as concerns about offending or alarming family members—who may themselves be the abusers—and challenges in addressing a patient’s own understanding or denial of abuse. For example, one provider noted difficulty in “convincing the patient to accept help,” while another asked, “Does the patient understand they are abused?” These reflections point to the complex emotional and social dynamics that hinder disclosure and response. In addition, structural challenges such as lack of training, unclear protocols, and unfamiliarity with tools compounded these barriers. As Hoover and Polson (2014) explain, elder abuse is often underreported due to these exact interpersonal and systemic obstacles. To reduce these barriers, training should not only focus on tools and workflows but also include communication strategies for navigating sensitive conversations with patients and families. Cues to Action Cues to action—the triggers that prompt behavior—were primarily described by providers as EHR or intake-based reminders. These system-level prompts played a key role in initiating screening behaviors. However, no providers mentioned other known cues, such as clinical red flags or behavioral signs. In fact, some providers noted that the presence of family members discouraged screening, without recognizing that these situations might signal a need to screen. This suggests that while technical prompts are useful, they may not be sufficient to encourage consistent screening. Williams-Burgess and Kimball (1992) noted that contextual 42 cues—such as who is present during the visit—should inform screening decisions. Expanding the use of cues through protocols, visual aids, and ongoing reminders within training and team communication could help address missed opportunities for identification and intervention. Study Limitations This study provides important insights into elder abuse screening practices in a rural outpatient setting, though several limitations should be considered when interpreting the results. First, the sample size was relatively small and limited to healthcare providers practicing in a specific geographic region in Southeastern Utah. While the study offers a rich, localized perspective, the findings may not be fully generalizable to urban settings where workflows, resources, and patient populations may differ. Second, although the study aimed to include a broad range of providers, the majority of respondents were nurses or nursing professionals. This may reflect the workforce composition of rural outpatient care, where nurses often serve as primary points of patient contact. While their perspectives are essential and highly relevant to abuse screening practices, the views of physicians, or advanced practice providers may be underrepresented. Differences in training, documentation responsibilities, and clinical decision-making roles could influence screening behaviors and merit further exploration in future research. However, this does not diminish the integrity of the current findings, as nurses are often the professionals most closely involved in screening processes. Third, the study relied on self-reported data, which is subject to potential response bias. Participants may have overreported desirable behaviors (e.g., screening frequency) or underreported challenges due to social desirability. While anonymity was preserved to reduce this risk, it remains a possible influence on the results. 43 Finally, although open-ended survey responses provided valuable qualitative data, some responses were brief or lacked elaboration. This may have limited the depth of insight gained through content analysis. Despite this, the analysis followed a systematic and transparent process, enhancing the credibility and trustworthiness of the findings. Together, these limitations suggest that while the results offer meaningful contributions to understanding elder abuse screening in rural outpatient care, further research is warranted to broaden perspectives and deepen analysis. Future Inquiry Future studies should aim to expand the sample size and include a more geographically diverse group of healthcare providers. A larger and more varied sample would strengthen the generalizability of the findings, allowing for broader inferences and potentially more nuanced conclusions regarding the challenges and facilitators of elder abuse screening in different contexts. Additionally, it would be beneficial for future research to examine the perceptions and practices of individual provider types and specialty practices separately. This would offer insights into how professional identity, training, and role responsibilities influence screening behavior and the adoption of best practices. Another important area for future inquiry is to assess the effectiveness of elder abuse screening in improving patient outcomes. Longitudinal studies tracking abuse incidence, as well as patient well-being over time, would provide critical evidence of the value of screening in reducing abuse and its long-term health consequences. Experimental or intervention studies could help determine whether more frequent screening directly correlates with better outcomes for elder abuse victims. 44 Implications Based on the study’s findings, several implications for practice can be drawn to improve elder abuse screening in rural outpatient settings. First and foremost, healthcare providers need additional training to feel more confident and capable of effectively screening for abuse. A trauma-informed approach to training would enhance providers' ability to address sensitive topics with greater empathy and reduce discomfort, ultimately leading to higher screening rates. A trauma-informed approach could support a restorative model, an approach which focuses on improving the situation for the victim and considers the context of the offense. Such an approach would support patients and their caregiver and likely lead to overall better outcomes. We want to make things better not worse. Furthermore, time constraints and lack of reimbursement emerged as significant barriers in this study. Providers need policies that provide financial incentives or reimbursement for screening, which would reduce the burden of additional time commitments associated with the process. Similarly, integrating standardized, validated screening tools into EHRs could streamline the process and serve as an external cue to action, making it easier for providers to incorporate screening into their workflow. Secure, private spaces for screening should also be prioritized, ensuring patients feel safe when disclosing abuse, especially when family members or caregivers may be involved. Lastly, a clear, structured response pathway for providers to follow when abuse is detected is essential. This pathway must be both feasible for providers and effective in addressing the patient’s needs, ensuring that the screening process leads to tangible improvements in patient safety and well-being. 45 Conclusion This study underscores that the challenges faced by rural healthcare providers regarding elder abuse screening are consistent with broader issues identified in previous research. The study highlights the significant time constraints and the sociocultural challenges providers face when working with older adults in family settings, where the perpetrator is often a family member. Despite these barriers, most providers recognized the importance of screening and expressed a desire for additional training and resources to improve their practices. These findings align with prior literature on the barriers to abuse screening and suggest that, in rural settings, addressing systemic issues like time constraints, lack of resources, and the absence of financial incentives are crucial to improving screening rates. Ultimately, the study contributes to the growing understanding of the unique challenges in rural healthcare settings and underscores the need for comprehensive strategies—ranging from better training to structural support in the form of policy and financial incentives—to promote more consistent and effective elder abuse screening. 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World Health Organization. https://www.who.int/news-room/fact-sheets/detail/abuse-of-older-people 50 Appendix 1 Provider Perceptions about Elder Abuse Screening Survey (PPEAS Survey) Introduction Thank you for participating in this survey. The purpose of the Provider Perceptions and Elder Abuse Screening Survey (PPEAS Survey) is to understand your practices, perceptions, and barriers related to screening older adults for abuse. Your responses will help inform strategies to improve screening practices and support healthcare providers in addressing this critical issue. This survey should take approximately 10–15 minutes to complete. Your participation is voluntary, and your responses will remain confidential. You will not need to provide your name or any other identifying information. Please answer each question honestly and to the best of your ability. If a question does not apply to you, select the option that best reflects your circumstances or write "N/A" in open-ended questions. Please mail the completed survey to Chris Gravett using the self-address and stamped envelope provided. Section 1: Demographics Instructions: Please provide information about yourself and your professional background by selecting or filling in the most appropriate responses. Do not include any identifying information. 1. What is your age? Under 25 25–34 35–44 45–54 55–64 65+ Prefer not to answer_________________ 2. What is your gender? Male Female Non-binary/Third gender Prefer to self-describe: ________________ Prefer not to answer__________________ 51 3. What is your race? (Select all that apply) American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Prefer to self-describe: ________________ Prefer not to answer: __________________ 4. What is your ethnicity? Hispanic or Latino Not Hispanic or Latino Prefer to self-describe: ________________ Prefer not to answer: __________________ 5. What is your highest professional degree or certification? (Select all that apply) MD DO DNP APRN PA-C Other (please specify): ________________ 6. How long have you been practicing in healthcare? Less than 1 year 1–5 years 6–10 years 11–15 years 16+ years 7. How often do you see patients older than 50? 1= Never 2= Rarely 3= Sometimes 4= Often 5= Always Section 2: Screening Practices Instructions: These questions focus on your current practices and confidence in screening older adults for abuse. Please select or fill in the most accurate responses. 52 Abuse is defined as: Causing physical, emotional, or financial harm through an intentional action or inaction when one has a duty to act. 8. How often do you screen patients over 50 for abuse? 1 = Never 2 = Rarely 3 = Sometimes 4 = Often 5 = Always 9. How confident are you in your ability to identify signs of elder abuse? 1 = Not at all confident 2 = Slightly confident 3 = Moderately confident 4 = Very confident 5 = Extremely confident 10. How familiar are you with standardized elder abuse screening instruments (e.g., Elder Abuse Suspicion Index (EASI), Hwalek-Sengstock Elder Abuse Screening Tool (H-S/EAST), Brief Abuse Screen for the Elderly (BASE))? 1 = Not at all familiar 2 = Slightly familiar 3 = Moderately familiar 4 = Very familiar 5 = Extremely familiar 11. If you do screen your patients please describe your process (below): Section 3: Perceptions and Barriers Instructions: Please share your perceptions about elder abuse screening and describe any barriers you face. For open-ended questions, write as much detail as you feel is necessary. 11. How strongly do you agree or disagree with the following statement: "Screening patients over 50 for elder abuse is an essential part of my practice." 1 = Strongly disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly agree 12. In your opinion, is there any benefit to screening patients for elder abuse? If so, what benefits do you see? (Open-ended) 53 13. What are the primary system-level factors (e.g., time, policies, protocols) that prevent you from screening older adults for abuse? (Open-ended) 14. What are the individual-level factors (e.g., confidence, knowledge, discomfort) that prevent you from screening older adults for abuse? (Open-ended). 15. What changes in policy, training, or clinical practice would make it easier for you to screen older adults for abuse effectively? (Open-ended) Section 4: Actions and Tools Instructions: These questions ask about actions you might take when elder abuse is identified and the tools or resources that could help you. For Likert-scale items, rate your likelihood using the provided scale. 16. If you became aware that one of your patients was being abused, how likely are you to take the following actions? (Rate each action below) • Report the abuse to Adult Protective Services. 1=Very unlikely; 2= Unlikely; 3= Neutral; 4= Likely; 5= Very Likely • Consult with a social worker or case manager. 54 1=Very unlikely; 2= Unlikely; 3= Neutral; 4= Likely; 5= Very Likely • Document the abuse in the patient’s medical record. 1=Very unlikely; 2= Unlikely; 3= Neutral; 4= Likely; 5= Very Likely • Engage with the caregiver or family members. 1=Very unlikely; 2= Unlikely; 3= Neutral; 4= Likely; 5= Very Likely • Other (please specify): ________________ 1=Very unlikely; 2= Unlikely; 3= Neutral; 4= Likely; 5= Very Likely 17. What challenges might you face in addressing the abuse once identified? (Open-ended) 18. What additional resources, training, or tools would help you feel more confident and effective in screening for elder abuse? (Open-ended) Thank you for taking the time to complete this survey! Your insights are invaluable and will contribute to understanding and improving elder abuse screening practices in outpatient settings. If you have any additional questions or concerns about this survey, please contact the Principal Investigator at [contact information].