Abuse of Older Adults Residing in the Community of Nepal

Introduction: With the increasing global population concern on older person’s abuse is also increasing. There is dearth of research on the elder abuse of older persons in Nepal and very little is known about this. Objective: Objective of this paper is to explore the situation of abuse of older persons in community living older adults of Nepal. Methodology: This is a cross-sectional community based study carried out in eastern part of Nepal. Data was collected through face to face interview using structured questionnaire. Total number of participants were 158, sixty years and above. Mean age of the respondent was 72.1 years with age ranged 62-93 years. Majority of the participants were male (72.8%), married (50%), having some health problems (58.2%) and have some saving for future (61%). Findings: This study found 95% older persons have heard about abuse of older persons and prevalence of abuse was 47.4% in the last six month. Most common older person's abuse was neglect (35.4%), followed by showing disrespect (34.8%), verbal abuse (25.3%), economic abuse (8.1%) physical abuse (5.7%) and emotional abuse (5.1%). This study further found older men were more suffering from abuse compared to women, literate have higher abuse and elderly suffering from disease have higher elder abuse. Conclusion: Abuse of older adults is quite high in Nepal compared to other society. Further in depth study to explore the situation of abuse and associated factors that may prove helpful in development of effective interventions to prevent and manage abuse among the older persons is urgent.


Introduction
Globally, the number of older persons is growing faster than the numbers of people in any other age group. As a result, the share of older persons in the total population is increasing virtually everywhere. The pace of population ageing in many developing countries today is substantially faster than occurred in developed countries in the past [1].
Till date no commonly accepted definitions of older person's abuse is developed [2][3][4]. Older persons abuse is defined differently by various professionals to fit their purposes [2]. Concept of abuse of older adults is also understood differently by different professional [5][6][7]. World Health Organization [8] defined older persons abuse as "a single or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person".
Latest report shows estimated prevalence rates of older persons abuse in high or middle-income countries ranged from 2% to 14% [9]. Studies from developing countries shows the prevalence is quite higher compared to developed country [4,10,11]. A recent review study by Chalise [4] shows that victims of elder abuse are at increased risk of illness, injury, pain, anxiety, depression, likelihood of hospitalization, decreased quality of life and death due to neglect and loneliness.
Nepal is a least developed and one of the poorest countries in the world. Very little is known about the older persons of Nepal [12,13]. Research on the Abuse of older persons is also quite new in Nepalese society. As many older adults are living in the joint family with their children, reporting abuse is may be considered as a family crime and issues may go under reported. Main objective of this research is to explore the situation of older persons abuse in the community living older persons.

Study Site, Methods and Materials
Approval to carry out this cross-sectional study was obtained from Research Committee of the Asian College for Advance Studies, Purbanchal University, Nepal in 2013. For the purpose of this study, Easteran Terai based one community of Sunasari district was chosen conveniently. Participants of this study were older persons informally gathering in Chautari * [a rest stop usually found along the foot trails of rural Nepal]. Older persons generally gather in such a place to see each other and gossip as there is no other public place to gather. For the participation in this survey individual 60 years and above were considered eligible. Objective of the study was clearly explained to participants and participation was voluntary. Informed verbal consent was obtained prior to data collection, as Nepalese elderly people are not generally comfortable with signing their names considering this a legal act [12,13]. We tried to cover all the eligible older persons coming in Chautari in the day time during two weeks of period by two researchers. Face to face interview with structured questionnaire was used as a tool for data collection. It took on an average 30 minutes to complete the interview. We approached 191 older persons but 183 older persons agreed to participate in the survey and questionnaire was complete with 158. This study analyses the data of 158 older persons.
Pre-test of the structured questionnaire (which included sociodemographic and abuse of adults related questionnaire) was done in other area of the same district, and questionnaire was finalized based on the feedback of pretest questionnaire. Data was analyzed using SPSS software, 2016.
For the purpose of this study older person's abuse was considered if older persons have faced mistreatment/neglect in any one of the activities: physical, economic, verbal, emotional, neglect, disrespect and sexual.

Description of study population
Mean age of the study population was 72.14 years and age ranged from 62 to 93 years. Study population participation was dominated by male (76.7%), 50% were married, 90% were living in joint family. Further living arrangement shows, 84% adults were living with their son, 10% spouse only and 6% with others. 94% male were literate on the other hand 53% woman were literate. Sixty one percent adults had some saving for their future, 58% were suffering from some chronic diseases and 17% older adults involving in income generating activities (  Most of the older persons (i.e. 95.5%) had heard about elder abuse. About different types of elderly abuse highest number of older adults had heard about neglect (86%), followed by disrespect to elders (75%), verbal abuse (70%), physical abuse (54%), economic abuse (20%) and emotional abuse (13%). Elderly were further asked whether they have experienced of any types of abuse in the last six month. This study found 47% older adults had experience of elder abuse in the last six month. Most common older persons abuse experienced was neglect (35%). Other abuses were disrespect (34.8%), verbal abuse (25.3%), economic abuse (8.2%), physical abuse (5.7%) and emotional abuse (5.1%).

Discussion
Due to decline in fertility and improvement in the mortality has resulted in the rapid increase of older person's population in the recent decades in Nepal [14]. This study is trying to explore the situation of abuse of older persons in community living older persons of Nepal.
This study found 95.5% older persons have heard about abuse of older persons. Further, 47.4% older persons were suffering from at least one form of elder abuse in the last six month. This finding is similar to the previous study by Yadav and Paudel [15], and higher than the study of Bista and Joshi [16] from Nepal. Bista and Joshi found 26% older people's people suffered from elder abuse in their family. Study from developed country reveals estimated prevalence rates of elder abuse in high or middle-income countries ranged from 2% to 14% [9]. On the other hand, nearly 50% of Thai elders living with family members were abused [17]. Indian study shows nearly 60% of the respondents experienced either mild or severe forms of abuse in their households [18]. Similarly, a study from Africa shows, more than 60% older persons experienced elder abuse [19]. This variation on estimate may be due to variations in operational definitions, as well as details of actions or behaviors considered to constitute elder abuse in different culture [4].
This study found most common elder abuse were neglect (35.4%), followed by showing disrespect (34.8%), verbal abuse (25.3%), economic abuse (8.1%), physical abuse (5.7%) and emotional abuse (5.1%). Similar to this study a study from India shows neglect and verbal abuse were the most commonly reported forms of mistreatment followed by physical abuse and material exploitation [20].
This study found men were more suffering from elder abuse compared to women. A study from Africa shows 64.3% of men and 60.3% of women experienced elder abuse [19]. In general, this finding is contrary to the findings from other countries. A study from India shows extent of severe abuse among the females was almost 2.7 times higher than the male older persons [18]. Similarly, in a study in Thailand [10] found female participants being approximately five times more likely to have been abused than the men. Lower reported in this study may be due to the feelings of shame, obligation to protect family name, stigma, fear of vengeful acts from perpetrators, or since many seniors have cognitive and physical impairments and may not be able to express any experiences of abuse [20].
Like many other studies [10,19] this study also found older persons who were suffering from some form of disease have higher elder abuse. Unlike many other studies, this study found literate have higher elder abuse compared to illiterate. Literate in this study were classified as those who can read and write. Very few Nepalese older persons have attained higher formal education at their school age. Many older persons were educated through informal education. A study from India [20] shows "with respect to schooling, only those having at least eight years or more education have a significantly lower likelihood of experiencing of abuse".

Limitations
There are some considerations that may have constituted limitations in this research. These factors might have limited the possible inferences that can be made from these results. First, this is a crosssectional study and causality cannot be assumed. Second, participants were not selected randomly and each volunteer participant was their own control. Third, data was collected through Face-to-face interview. Fourth, women may have under reported abuse thinking reporting abuse is crime, or afraid to report cases of abuse to family, friends, or to the authorities.

Conclusion
The findings of this research show prevalence abuse of older persons is quite high among community living older persons. These findings cannot be generalized for all older persons in Nepal. An in depth national level study should be carried out to know the nature of elder abuse and its predicting variables.

Key points
• This study found a prevalence of 47.4% for abuse of older persons. • This study found most common elder abuse were neglect (35.4%), followed by showing disrespect (34.8%), verbal abuse (25.3%), economic abuse (8.1%), physical abuse (5.7%) and emotional abuse (5.1%). • Older men, literate older person and older person having some health problems have higher prevalence of elder abuse