Attitude of Family Towards Elder Mistreatment: Cultural Perspective in Rural North India

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1 Original Article Attitude of Family Towards Elder Mistreatment: Cultural Perspective in Rural North India Muthuvenkatachalam Srinivasan, Sandhya Gupta Pal College of Nursing and Medical Sciences, Haldwani, Uttarakhand and All India Institute of Medical Sciences, New Delhi Contact: Muthuvenkatachalam Srinivasan, Abstract Background: Elder abuse is recognised as a socially and culturally constructed phenomenon and is a global burden. This quantitative cross sectional survey was carried out to ascertain the knowledge, attitude and perception of elder abuse among rural adults in a selected state of northern India. Material and Method: Eighty conveniently selected participants of a village were interviewed using self-developed structured questionnaire which consists 34 items regarding elder abuse and neglect. Results: Out of 80 participants, 42 (52.5%) were female, three fourth (75%) lives in nuclear family and 65% of the participants were educated upto high school or above. The mean age of the respondents was 34.7 ± 5.8 years. Thirty eight percent of the participants stated that the demanding behaviour of the elder leads to violent behaviour of the people in their household. Majority (60%) of the respondents agreed that the behaviour of the elderly is provocative which leads to abuse. Two third (70%) of the respondents stated that it is their individual responsibility to report elder abuse and neglect if they witness any. All the participants agreed that the elder abuse and neglect is a criminal act and they have the responsibility to prevent such abuse and neglect. All the respondents (100%) were aware of financial abuse but nearly half (42.5%) of the subjects believed that using swear words cannot be considered abuse and it is part of their culture. Most of them (92.5%) agreed that occasional manhandling of elderly is violence/abuse. Conclusion: There was a positive attitude from almost all the participants regarding negligence of the elderly. Public awareness and attitude related to some common issues of elder abuse are poor, especially regarding physical abuse, intolerance towards demands of elderly, cultural influence, sexual abuse and reporting of incidents. Key words: Elder abuse, Elder mistreatment, Neglect, Attitude Introduction Ageing is an inevitable and irreversible physiological process that affects all body systems. Elderly or old age consists of age nearing or surpassing the average life span of human beings. National policy on Older Persons (1999) defines elderly as a person who is of age 60 years and above. As a result of increased life expectancy, the proportion of elderly population in the country is steadily raising. Projections suggest that India s elderly population will be double in size between 2001 and 2026, the elderly will account for percent of overall population in The traditional Indian society and joint family system have been influential in safeguarding the social and economic security of the elderly people in the country. However, over the last decade, with the rapid changes in the social scenario and the emerging prevalence of nuclear family set-ups in recent years, the elderly people are likely to be exposed to emotional, physical and financial insecurity. Elderly face multiple medical and Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society 119

2 DELHI PSYCHIATRY JOURNAL Vol. 18 No. 1 APRIL 2015 psychological problems. Elder abuse is a type of harm to older adults involving abuse by trusted individuals in a manner that causes harm or distress to an older person. 2 It ranges from physical abuse to neglect of basic needs of an older person. Neglect is the failure of a caregiver to provide the necessities of life to an older person, i.e. adequate food, shelter, clothing, medical care or dental care. Ahmad M and Lachs MS in their review stated that reports of elder abuse to official agencies have been steadily increasing; physicians report only 2% of reported cases. 3 World Health Organization (WHO) defines elder abuse as a violation of human rights and a significant cause of illness, injury, loss of productivity, isolation and despair. 4 Forms of mistreatment include physical or verbal maltreatment, injury, sexual assault, violation, rape, unjust practices, financial wrongful practices or custom, offense; crime, and or otherwise verbal aggression. 5 People consider old age to be a period when there is a decline in productivity, ability and independence in all areas of life. These attitudes can turn into behaviour. 6 These attitudes and behaviour toward elderly may result in abuse, negligence, compromised quality of care and health services. 7,8 In the last two decades, there has been increased awareness and action towards abuse and neglect of children and spouses. However, mistreatment of older people has been concealed from public view. 9 According to World Health Organization, 80 percent of elder abuse is unreported. 10 It is important to address the abuse, mistreatment, abandonment and negligence of older people, particularly in a community and culture where older people are dependent on care from family members. Knowledge of family members regarding elder abuse, its causes and prevention plays an important role in prevention and intervention of elder abuse. Sensitization of family members to the dimensions of problems of elder abuse may stimulate creative thinking about the realistic possibilities of prevention and intervention. In this regard, this study is planned to assess the perception and attitudes toward elder abuse, neglect and ageism among adult family members and healthcare personnel working at community level. The results of this study may guide us in planning the curriculum and implementation of education programmes regarding prevention and management of elder abuse to community level 120 healthcare personnel. Aims and Objectives Objectives of this study were to determine the perceptions and attitude towards elder abuse and neglect among adults of a selected rural community in Uttarakhand. Methods and Materials The study design was descriptive and cross sectional. The target population for the study was adults living in rural area of Uttarakhand. Convenient sampling technique was used to draw sample of 80 adults from Thano village of Doiwala Block of Uttarakhand State. Investigator visited all the homes of Thano village and screened for availability of at least one older person living in the family, if so, family members who aged between 18 and 60 years were requested to participate in the study. Participants who were willing to participate were enrolled in the study. Investigator made sure that the older person was not around to hear the conversation during data collection. Informed written consent was obtained from the participants of the study after explaining the purpose of the study. The participants of the study were interviewed by the researcher to fill the structured questionnaire on knowledge and attitude regarding elder abuse. Each interview took approximately 20 to 30 minutes. A self developed 34-item Likert Scale (6 point) and a socio-demographic profile was used to collect response from the participants. Questionnaire was prepared after extensive review of relevant literature and it was validated by mental health nursing professionals. Socio demographic features include age, gender, educational status, marital status, profession and type of family. Six-point Likert scale includes 34-items covering questions related to attitude of blaming elderly for their abuse (7 items), awareness about different types of abuse of elderly (13 items), attitude of social responsibility related to elder abuse (4 items) and knowledge regarding possible causes of elder abuse (10 items). The response for each item ranges from strongly agree to strongly disagree (6 point). The reliability of the tool was tested by test-retest method and crohnbach alpha was calculated to determine the internal consistency. The reliability was found to be r=0.92 with crohnbach alpha Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society

3 Data Analysis Socio-demographic characteristics were described using frequency and percentage. Likert scale (6 point) ranged from strongly agree to strongly disagree were grouped in to two major categories in order to describe the frequency and percentage of agreement and disagreement to each of the items of the attitude questionnaire. i.e. Agree (Strongly agree, agree and slightly agree) and disagree (Strongly disagree, disagree and slightly disagree). Results Socio-demographic characteristics of the study participants are described in Table 1. Majority (52.5%) of the participants were female and one third of the subjects were living in a joint family system. Items of the questionnaire were organized under four major categories to describe the knowledge and attitude of adults regarding elder mistreatment. Table 1. Socio demographic characteristics of study participants (N = 80) S.No. Socio-demographic characteristics Frequency Percentage 1. Gender Male % Female % 2. Education Never attended school 5 6.3% Primary School % Metric % Graduate & Above % 4. Monthly family income (in Rupees) 5,000-10, % > 10, % 7. Type of Family Joint 20 25% Nuclear 60 75% Attitude of blaming elderly for their abuse. Table 2 illustrates the frequency and percentage of agreement and disagreement for each of the items regarding attitude of blaming elderly for their abuse. Two thirds (67.5%) of the adults believes that the elderly would be less exposed to violence if they had more understanding of adult and children s problems. Majority (60%) of the participants blamed that elderly provokes aggressive behaviour in young people which leads to violence and 38% believes that the demanding attitude of elderly leads to violence behaviour of the family members. None of the participants agreed that there would be less family violence if the elderly lived in nursing home or live separately from their children. Awareness about different types of abuse of elderly. Table 3 shows that nearly two third (64%) of the interviewed adults agreed that physically touching elderly without their consent is a sexual abuse. 11% of adults do not agree that placing elderly in a old age home is a neglect and 9% disagree that abandoning of elderly is a neglect. 43% believes that using swear words on elderly cannot be considered abuse because it is their part of culture and 7.5% agreed that occasional manhandling of elderly is not an abuse. All the participants (100%) understood about neglect of elderly. Attitude of social responsibility related to elder abuse. Most (95%) of the participants agreed that elder abuse and neglect is a social problem. While all the participants (100%) agreed that they have responsibility of preventing elder abuse and negligence and elder abuse is a criminal act, surprisingly, a one third of them (30%) did not agree that it is their individual responsibility to report elder Table 2. Attitude of blaming elderly for their abuse S. No Items related to Attitude of blaming elderly for their abuse Agree Disagree Frequency (%) Frequency (%) 1 The elderly often complain and nag, which leads to abusive behaviour 80 (100%) 0 (0%) 2 The elderly are demanding, which leads to violent behaviour of the 30 (37.5%) 50 (62.5%) people in their household 3 The behaviour of the elderly provokes aggressive behaviour in young 48 (60%) 32 (40%) people which leads to abuse 4 The elderly would be less exposed to violence if they had more 54 (64.5%) 26 (32.5) understanding of the problems of their adult children 5 If the elderly and the young lived separately, there would be no violence 0 (0%) 80 (100%) 6 The elderly would experience less violence if they didn t live with their children 0 (0%) 80 (100%) 7 If the elderly lived in a nursing home with their peers, less family 0 (0%) 80 (100%) violence would occur. Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society 121

4 DELHI PSYCHIATRY JOURNAL Vol. 18 No. 1 APRIL 2015 Table 3. Awareness about different types of abuse of elderly (N=80) S. No. Items related to awareness about different types of abuse of elderly Agree Disagree Frequency (%) Frequency (%) 8 Borrowing money from elderly parents and not returning it is not violence 0 (0%) 80 (100%) 9 Using swear words cannot be considered elderly abuse because it is 34 (42.5%) 46 (47.5%) part of culture 10 Occasional manhandling of elderly parents/in-law is not violence/abuse 6 (7.5%) 74 (92.5%) 11 Physically touching elderly without their consent is not a sexual abuse 29 (36.3%) 51 (63.8%) 12 Abandoning of elderly is a neglect 73 (91.3%) 7 (8.7%) 13 Placement of elderly to the old age home is a neglect 71 (88.8%) 9 (12.2%) 14 It is neglect that if an elderly s hygiene, nutrition and safety 80 (100%) 0 (0%) requirements aren t met. 15 It is a neglect that if elderly s health needs are not met or retarded. 80 (100%) 0 (0%) 16 It is a neglect that if elderly lives in homes which have unsuitable conditions. 80 (100%) 0 (0%) 17 It is abuse that if elderly is exposed to violence such as beating, slapping, 80 (100%) 0 (0%) kicking, biting and throwing goods 18 It is abuse that if elderly is exposed to shouting, insulting and ridiculing. 80 (100%) 0 (0%) 19 It is abuse that if elderly s money and goods are stolen, getting by 80 (100%) 0 (0%) force and misuse 20 It is abuse that behaving to elderly as if they weren t, imprisoning the 80 (100%) 0 (0%) room/home and excluding from society abuse or neglect when they witness one. Knowledge regarding possible causes of elder abuse (Table 4). Majority (61.3%) of the participants felt that elderly women are more exposed to abuse and neglect than male. A tiny portion (7.5%) of the sample believed that the elderly who live in a large family are exposed to abuse and neglect more often than others. Every fourth person thinks that elder abuse and neglect is seen more in families of low socioeconomic and cultural status. Association between responses to items of the questionnaire and Socio-demogrphic variables. Chi-square test was performed to find out association between the responses to each of the item of the questionnaire and selected sociodemographic variables. i.e. age (< 35 years and > 35 years), gender, educational status and family structure. The results of the chi-square analysis are illustrated in Table 5. Significantly less number of females and young age group (< 35 years) agreed that the demanding behaviour of elderly leads to violent behaviour of the people in their household. Significantly more number of males (30 out of 38) and members of joint family (16 out of 20) agreed that the behaviour of the elderly provokes aggressive behaviour in younger people. Significantly, more females than male had agreed that the elderly Table 4. Knowledge regarding possible causes of elderly abuse S. No. Items related to knowledge regarding possible causes of elderly abuse Agree Disagree Frequency (%) Frequency (%) 21 Elderly women are exposed to abuse and neglect more 49 (61.3%) 31 (38.7%) 22 Elderlies who have mental disability are exposed to abuse 80 (100%) 0 (0%) and neglect more often 23 Elderlies who have physical disability, stroke, handicapped or bedridden 80 (100%) 0 (0%) are exposed to abuse and neglect more often 24 Elderlies who live in a large family are exposed to abuse and neglect more often 6 (7.5%) 74 (92.5%) 25 Elderly abuse and neglect is seen more often in families whose socioeconomic 19 (23.8%) 61 (76.3%) and cultural status is low 26 Bad habits in family cause abuse and neglect of the elderly 80 (100%) 0 (0%) 27 Violence in family cause abuse and neglect of elderly 80 (100%) 0 (0%) 28 Individuals who have negative feeling, thought and bad experiences to 80 (100%) 0 (0%) elderly are more likely to neglect and abuse of elderly 29 Individuals who think looking after the elderly as a burden are more 80 (100%) 0 (0%) likely to neglect and abuse of elderly 122 Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society

5 Table 5. Association between response to items of the questionnaire and selected Sociodemographic variables women are exposed to abuse and neglect more while significantly more male than female had agreed that the elder abuse and neglect is seen more often in families whose socioeconomic and cultural status is low. There was no association found with other items of the questionnaire and socio-demographic variables. Discussion Elder abuse is recognised as a socially and culturally constructed phenomenon. 11 It is a global problem. International researches estimate between 3% and 10% of the older population experience some form abuse or neglect each year. 12,13 It has been estimated only 16 percent of all abuse incidents reach service agencies. 14 In this study, two third (70%) of the participants stated that it is their Socio-demographic Variables (frequency of agreement for each of the item) S. No. Attitude of blaming elderly for their abuse Age Gender Educational Family (< 35 vs (Male vs Status Structure > 35 yrs) Female) (Upto primary (Joint vs vs > high Nuclear) School) 2 The elderly are demanding which leads to violent 7.09* 8.35* behaviour of the people in their household 3 The behaviour of the elderly provokes aggressive * * behaviour in your people which leads to abuse 4 The elderly would be less exposed to violence if they had more understanding of the problems of their adult children 9 Using swear words cannot be considered elderly abuse because it is part of culture 10 Occasional manhandling of elderly parents/in-law is not violence/abuse 11 Physically touching elderly without their consent is not violence/abuse 12 Abandoning of elderly is a neglect Placement of elderly to the old age home is a neglect Elderly abuse and neglect is a social problem When I witnessed to elderly abuse and neglect reporting is my individual responsibility 26 Elderly women are exposed to abuse and neglect more * 7.92* 2.98* 29 Elderlies who live in a large family are exposed to abuse and neglect more often 30 Elderly abuse and neglect is seen more often in families * whose socioeconomic and cultural status is low * Significant at p < 0.05 level. Note: All the subjects had either agreed or disagreed for item number 1,5,6,7,8,14,15,16,17,18,19,20,22,23,25,27,28,31,32,33 and 34. Hence, Chi-square was not computed for above said items. individual responsibility to report elder abuse and neglect if they witness any. All the participants agreed that the elder abuse and neglect is a criminal act and they have the responsibility to prevent such abuse and neglect. Thirty eight percent of the participants believed that the demanding behaviour of the elderly leads to violent behaviour of the people in their household. Majority (60%) of the respondents agreed that the behaviour of the elderly is provocative which leads to abuse. These responses suggest, to a great extent, that the intolerance of the adults towards elderly and discounts the needs of elderly to a great extend. All the study participants (100%) were aware of financial abuse but nearly half (42.5%) of them believe that using swear words cannot be considered abuse and it is part of their culture. Most of them Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society 123

6 DELHI PSYCHIATRY JOURNAL Vol. 18 No. 1 APRIL 2015 (92.5%) agreed that occasional manhandling of elderly is violence/abuse. There was a positive attitude from almost all the participants regarding negligence of the elderly (Item 7 to 13 of table no. 3). Majority (61.3%) believed that the elderly women are more exposed to abuse and neglect than men and significantly higher proportion of female than male believes so. Results of research studies also reveal that women are more vulnerable for abuse than male. 15 Nearly one fourth of the participants (23.8%) believed that the elder abuse is more common in families with low socio-economic status. Public awareness and attitude related to some common issues of elder abuse is poor especially regarding physical abuse, intolerance towards demands of elderly, cultural influence, sexual abuse and reporting of incidents. Significantly, more number of males than females and members of joint family than nuclear family were agreed that the provocative behaviour of elderly leads to elder abuse. Significantly, more number of adults aged above 35 years and males believed that the demanding behaviour of elderly leads to abuse than that of adults aged d 35 years and females respectively. According to earlier theoretical models, the stress level of caregivers was seen as a risk factor that linked elder abuse with care of an elderly relative. 16, 12 While the researchers do not disagree the component of stress as a factor of elder abuse, they expanded the context in which the quality of the overall family relationship is a causal factor in elder abuse. 17 So the attitude of family members towards elderly is an important factor in regard to elder abuse. Conclusion Public education and awareness are important component in preventing abuse and neglect. The objective of such efforts is to inform general public about the various types of abuse and negligence, counsel and educate regarding the needs of elderly, promote tolerance towards demands of elderly, how to identify the signs and symptoms of abuse, where help can be obtained and responsibility of individual in prevention and reporting of elder abuse. 18 The social networking sites and media can also be a powerful tool for bring changes in attitudes of public towards elderly. Creating awareness regarding elder abuse and neglect and changing the attitude 124 of public toward elderly may bring positive result in prevention of elder mistreatment. References 1. General Statistics Office. Government of India. Situation analysis of elderly in India nic.in/mospi_new/upload/elderly_in_india.pdf accessed on Dec 2. Gary Fitz Gerald G. Action on Elder Abuse Home Elderabuse.org.uk. accessed on 15 Mar 3. Ahmad M, Lachs MS. Elder abuse and neglect: What physicians can and should do. Leveland clinic journal of medicine 2002; 69 : World Health Organization. Active Ageing: A policy framework /who_nmh_nph_02.8.pdf accessed on Dec 5. National centre on elder a buse. Types of Abuse. accessed on Dec 6. Vefikulucay-Yilmaz D, Terzioglu F. Development and psychometric evaluation of ageism attitude scale among the university students. Turkish Journal of Geriatrics 2011; 14 : Akdemir N, Gorgulu U, Cinar FI. Perception of ageing and ageism. Turkish Journal of Geriatric 2007; 10 : Akdemir N, Gorgulu U, Cinar FI. Elderly abuse and neglect. Hacettepe University Faculty of Health Sciences and Nursing Journal 2008; 15 : World Health Organization (2002). The Toronto Declaration on the Global Prevention of Elder Abuse. WHO, Geneva. ageing/projects/elder_abuse/alc_toronto_ declaration_en.pdf?ua=1 accessed on 10 Jan 10. World Health Organization, Geneva (2008). A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to deal with the Problem Worldwide: Main Report. DER_DocAugust08.pdf. accessed on 15 Jun 11. Alice G. (2011) National Centre for the protection of older people. wwncpopienewsandevents accessed on 10 Jan 12. Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, et al. (2010). Prevalence and correlates of emotional, physical, Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society

7 sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public 2010; 100(2) : Teaster PB, Dugar T, Mendiondo M, Abner EL, Cecil KA, & Otto JM. (2004). The 2004 survey of adult protective services: Abuse of adults 60 years of age and older. Washington DC: National Center on Elder Abuse. 14. Age Concern New Zealand (2012). World Elder Abuse Awareness Day [2012]. agewell.org.nz/pdf/about_elder_ abuse_ neglect_2012.pdf accessed on 10 Jan 15. Lowenstein A, Eisikovits Z, Band-Winterstein T, Enosh, G. Is elder abuse and neglect a social phenomenon? Data from the First National Prevalence Survey in Israel. Journal of Elder Abuse & Neglect 2009; 21(3) : Eastman M. Old age abuse: a new perspective, 2nd ed. San Diego, CA, Singular Publishing Group, Inc Reis M, Nahamish D. Validation of the indicators of abuse (IOA) screen. The Gerontologist 1998; 38 : World Health Organization. Abuse of the elderly. prevention/violence/world_report/factsheets/en/ elderabusefacts.pdf accessed on 15 Dec 19. General Statistics Office. Government of India. Situation analysis of elderly in India mospi.nic.in/mospi_new/upload/elderly_ in_india.pdf accessed on Dec 20. Gary FitzGerald G. Action on Elder Abuse Home. Elderabuse.org.uk. accessed on 15 Mar 21. Ahmad M, Lachs MS. Elder abuse and neglect: What physicians can and should do. Leveland clinic journal of medicine 2002; 69 : World Health Organization. Active Ageing: A policy framework /who_nmh_nph_02.8.pdf accessed on Dec 23. National centre on elder abuse. Types of Abuse. accessed on Dec 23. Vefikulucay-Yilmaz D, Terzioglu F. Development and psychometric evaluation of ageism attitude scale among the university students. Turkish Journal of Geriatrics 2011; 14 : Akdemir N, Gorgulu U, Cinar FI. Perception of ageing and ageism. Turkish Journal of Geriatric 2007; 10 : Akdemir N, Gorgulu U, Cinar FI. Elderly abuse and neglect. Hacettepe University Faculty of Health Sciences and Nursing Journal 2008; 15: World Health Organization (2002). The Toronto Declaration on the Global Prevention of Elder Abuse. WHO, Geneva. ageing/projects/elder_abuse/alc_toronto_ declaration_en.pdf?ua=1 accessed on 10 Jan 27. World Health Organization, Geneva (2008). A Global Response to Elder Abuse and Neglect: Building Primary Health Care Capacity to deal with the Problem Worldwide: Main Report. ELDER_DocAugust08.pdf. accessed on15 Jun 28. Alice G. (2011) National Centre for the protection of older people. httpwwwncpopienewsandevents. accessed on10 Jan 29. Acierno R, Hernandez MA, Amstadter AB, Resnick HS, Steve K, Muzzy W, et al. (2010). Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public 2010; 100(2) : Teaster PB, Dugar T, Mendiondo M, Abner EL, Cecil KA, & Otto JM. (2004). The 2004 survey of adult protective services: Abuse of adults 60 years of age and older. Washington DC: National Center on Elder Abuse. 31. Age Concern New Zealand (2012). World Elder Abuse Awareness Day [2012]. agewell.org.nz/pdf/about_elder_ abuse_ neglect_2012.pdf accessed on 10 Jan 32. Lowenstein A, Eisikovits Z, Band-Winterstein T, Enosh, G. Is elder abuse and neglect a social phenomenon? Data from the First National Prevalence Survey in Israel. Journal of Elder Abuse & Neglect 2009; 21(3) : Eastman M. Old age abuse: a new perspective, 2nd ed. San Diego, CA, Singular Publishing Group, Inc Reis M, Nahamish D. Validation of the indicators of abuse (IOA) screen. The Gerontologist 1998; 38 : World Health Organization. Abuse of the elderly. prevention/violence/world_report/factsheets/en/ elderabusefacts.pdf accessed on15 Dec Delhi Psychiatry Journal 2015; 18:(1) Delhi Psychiatric Society 125