Elderly Abuse Experienced by Older Adults Prior to Living in Old Age Home in Kathmandu

The number and size of elderly homes are increasing in urban areas in Nepal, indicating that the number of elderly people living in old age homes is increasing. Anecdotal information indicates that some of the elderly residents experienced abuse prior to their residence in old age homes. The main objective of this article is to explore the nature of the abuse they experienced before they arrived at old age homes in the Kathmandu Metropolitan City. This study has used both quantitative and qualitative methods of data collection. Data were collected from five old age homes in Kathmandu. The research was conducted in the month of September in 2016 for three weeks. Total sample size for this study was 76 and three case studies were carried out. Mean age of the respondents was 78.34 (±10.18) years. The findings show that a majority (58 percent) of the respondents experienced five different types of abuse before they arrived at the old age homes. Neglect was the most common form of abuse that was experienced by 47% respondents, followed by behavioural or emotional abuse (37%), financial abuse (32%), physical abuse (8%) and 3% of abused elderly reported that they were sexually abused. Main reason of elderly abuse faced by abused elderly were disability (physical, mental) to look after themselves (42%), having no partner (death) (28%), the family was busy and there were no extra persons for care giving task (20%) and 16% reported they had no property. This finding based on sample of small population cannot be generalized to whole population. A detailed in depth study related to abuse of older adults living in urban area is required and government should make strict policy for the control of elder abuse. *Corresponding author: Sunita Rai, Department of Sociology, Padma Kanya Multiple Campus, Bagbazar, Kathmandu, Nepal, Tel: 97715250791; 9779851012622 E-mail: sunitarai1103@gmail.com Received January 24, 2018; Accepted February 02, 2018; Published February 06, 2018 Citation: Rai S, Khanal P, Chalise HN (2018) Elderly Abuse Experienced by Older Adults Prior to Living in Old Age Homes in Kathmandu. J Gerontol Geriatr Res 7: 460. doi:10.4172/2167-7182.1000460 Copyright: © 2018 Rai S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
The world's population is ageing: virtually every country in the world is experiencing growth in the number and proportion of older persons in their population [1]. Ageing of population occurred in the developed countries in the latter half of the 20th century and the similar situation is emerging in the developing countries in the recent periods [2].
As mentioned in a report by UNFPA and HAI [3] population ageing has important and far-reaching implications for all aspects of society. It presents both the positive and negative implications i.e., opportunities as well as challenges to the world community. The opportunities that this presents are as endless as the contributions that a socially and economically active secure and healthy ageing population can bring to society. On the other hand population ageing presents social economic and cultural challenges to individual's families societies and the global community [3]. Among many, the aging of the population has resulted in an increased need for long-term care of the elderly [4] which provides a background to the abuse of an elderly as proposed by caregiver stress theory. The theory asserts that without support the carers/ caregivers may be unable to manage adequately their responsibilities and become overwhelmed and frustrated leading to abuse [5].
Abuse of the elderly is an important social and public health issue arising from increase in longevity because longevity increases the number of elderly as well and more at risk of elder abuse. Most of the literature on elder abuse is based on studies conducted in developed countries and very little is known about elder abuse in developing and poor countries like Nepal [6]. Till date no commonly accepted definitions of older person's abuse is developed [6,7]. WHO and INPEA 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" [8]. The National Center on Elder Abuse (NCEA) identified six categories of elder abuse: Physical Abuse, Emotional Abuse, Neglect, Abandonment, Sexual Abuse, and Self-neglect [9]. For wider use international scholars have agreed upon five categories of elder abuse: physical abuse, psychological abuse, financial abuse, sexual abuse, and neglect [6,10].
Abuse takes different forms in different social, economic, political and cultural contexts and is certainly not limited to any one context or region. Increasing dependence, isolation and frailty can make older people particularly vulnerable to violence abuse and neglect [3]. Abuse can range from what might clearly constitute a criminal offence e.g. sexual or physical abuse, theft etc. to acts that cause harm to an older person whether by omission or otherwise e.g. neglect through lack of resources or difficulties with interpersonal relationships. Abuse and neglect have been distinguished depending on whether or not there has been an active violation of rights or an absence of action. The abuser can be a stranger, an acquaintance or a trusted other [11].
Research shows that elder abuse was first identified in developed countries where most of the existing research has been conducted, anecdotal evidence and other reports from developing countries have shown that it is a universal phenomenon [6]. In Nepal, very little study is carried out in this issue. Recently, one study carried out by Chalise and Basnet in community living elderly shows the prevalence of elder abuse is 47.4% among community living elderly. In Nepali culture, elderly generally prefer to stay with their children and living in old age home is not very common. But the number of old age homes is increasing rapidly in Kathmandu in the last decade. This study tries to explore situation of the elder abuse problem faced by elderly living in old age home before they come to live in old age home.

Methods and Materials
This is a cross-sectional study carried out in 5 different old age homes located in Kathmandu. Many elderly homes in Kathmandu have very limited capacity. Census survey was carried out in all the old age homes. Inclusion criteria were having 60 years and above, having good mental health as reported by authority in old age home living there since at least last one year. Exclusion criteria were having some problem to listening, not interested to participate in the survey. A total sample for this study was 76 elderly respondents. This study was approved by the research committee of the department of Sociology and Anthropology in Padma Kanya Multiple Campus, Tribhuvan University, Nepal.
This data used both quantitative and qualitative method of primary data collection. Face-to-face method of interview with semi structured questionnaire was used for data collection. It has also collected qualitative data through case studies. The purpose of the study was explained to respondents before each interview. Respondent's right to refuse and withdraw from the interview at any time was accepted with the maintenance of confidentiality. Respondents were assured of the confidentiality. Thereafter the study sought for the informed verbal consent of respondents before the interview which is already in use in Nepal due to some problem in the written informed consent [12][13][14][15][16]. Due to some fear among respondents that either their finger prints (those who are illiterate) or signature (among literate) would be misused, written informed consent is not well practiced in Nepal.
Data was analyzed using SPSS version 20.0. For the statistical analysis, tools like simple frequency table, percentage, mean and chisquare test were used. Table 1 shows the distribution of the respondents at the time of field study by each of the seven socioeconomic characteristics investigated. The mean age of the respondent was 78.34 [±10.18] years. The age composition of the sampled respondents was 60-70 years (17.1%) 70-80 years (32.9%) 80-90 years (32.9%) and 90 years and above (17.1%). Almost one sixth respondents (85.5%) were female, more than two third of the respondents (68.4%) were illiterate who didn't know how to read and write. The remaining less than one third of the respondents were at least literate and primary level (19.7%), Secondary level (9.2%) and grade 12 or above (2.7%). More than two third (69.7%) respondents were widow/widower and 18.4% had an alive spouse living together or separately while 7.9% of the respondents were never married. As regards disability of the respondents, 59.2% had either physical or mental or both kinds of disability while 40.8% had no disability at all at the time to field research.

Results
Further the respondents were categorized into three economic categories based on their monthly income during adulthood; no income and earning up to 6 thousands were kept in poor category, earning 7 to 12 thousands per month were categorized as middle class and those earning 13 thousands or more per month were considered rich. The composition of the sampled respondents according to economic status was poor (52.6%), middle class (21.1%) and rich (26.3%). By the occupation more than three fifth (63.2%) of the respondents were homemakers during adulthood followed by 23.6% of the business persons.   Table 2 presents the frequency and percent of the sampled respondents by their experience of abuse, types of abuse and reasons of abuse. Result shows 58% of respondents had experienced at least one form of elderly abuse before they came to old age homes. Among abused elderly, neglect was the most common one which was experienced by 47%of the respondents followed by behavioural or emotional abuse (37%), financial abuse (32%), physical abuse (8%) like beating pushing etc and 3% of abused elderly reported that they were sexually abused. Main reasons of elderly abuse faced by abused elderly were disability to look after themselves (42%), absence of partner (husband/wife) or having no partner (28%), the family was busy and there were no extra persons for care giving task (20%) and 16% reported they had no property. Table 3 shows the analysis of association between elderly abuse with other socio-economic variables. According to sex, 55% male and 58% female respondents had experienced one or more forms of abuse. Illiterate had slightly higher elder abuse (58%) and respondents up to 5 grade of schooling had the lowest (50%) elder abuse. With marital status, it was 55% among having surviving partner and 63% among widow/widower. It was very high 83% among unmarried. Analyzing the elderly abuse by the economic status of the respondents, there seems no greater variance in vulnerability to abuse. Out of the respondents in the poor category 55% of them had experienced abuse followed by 63% among the middle class category and 60% among the rich.
By the occupations adopted by the respondents during adulthood, 75% of the government employee's 66% farmer 61% business and 55% homemaker had experienced elderly abuse. According to the age distribution 61% respondents in age group 60-70 years 50% in the age group 70-80 54% respondents in the age group 80-90 and 83% in the age group 90+ were abused. Further 62% people having disability (either physical or mental) had experienced elderly abuse where as it was only 55% among those not having disability.
Analyzing the data further using Chi Square (X2) test, this study shows no significant association between the seven investigated socioeconomic characteristics and elderly abuse was found. At 5% significance level, P value is greater than the level of significance (P>0.05) in all the cases observed. Therefore we can conclude that socioeconomic characteristics sex, educational status, marital status, economic status, occupation, age and disability have no impact on the abuse elderly people experience. Since the sample size was small it may have also affected on the result of Chi Square test.

Case story I
Devi Shrestha (name changed), 91-year-old who woman lives with about 25 elderly women at an elderly home which provides free services to the helpless elderly women. She is an illiterate widow whose husband passed away 8 months ago. She is a Kathmandu born Newar woman who was married to a middle-range businessman from Kathmandu. She has 9 living children (six daughters and three sons) but none of them stay with her. She has no exact information what her children are doing however she recalls that her sons have their own business.
She informed that her husband had left her there before his death. The couple used to live in an elderly care home at another place before she came there. After 2 years of stay at the elderly care home, they ran out of money which is why she was taken to the old age home offering free service while her husband went back to the family their elder son's family.
"I didn't want him to return to any of our children's family. We had already suffered a lot of neglect and disrespect from our sons and their families. And I don't want to be burden to our married daughters too. Our daughters loved us very much but their families' in-laws didn't want us to stay with them. We were extra workload for them; extra care, extra sanitation, extra time where as our children had to go. " "So we lived in the elder care home for two years with my husband's savings. After we ran out of money, he brought me here and he went back to our elder son's family. As I heard the neighbors, my son had become even busier; my husband used to be all alone doing nothing. He lived just two months after going there. I had visited the family after my husband's death. My son and daughter-in-law were worried not because they had lost their father but because they had to spend a lot of money for death rites and rituals. It broke my heart (started sobbing). So I have  Shrestha's narrative shows that physical disability, lack of money and absence of spouse makes the elderly people more prone to the abuse.

Case story II
Shyam Lal (name changed), 75-year-old man is an educated elderly from Kathmandu. He completed Bachelor's degree and is Nepal Government's tax office pensioner. He owns a house in Kathmandu, the capital city where he lived for 20/25 years alone after his wife left him. His wife and son used to live at his wife's parental home but never visited him. He found it very difficult to live alone with his growing age so he joined an old age home where he pays for their services. His son comes to visit occasionally and ask for his share of property.
His eyes turned wet when he recalled his son's behavior "Better to transfer all your property in my name now. Who knows when you will breathe last" my son said. He not only pays for his stay but also supports the old age home as it also provides free services for poor elderly. He believes that lack of his wife's support was the cause of behavioral and financial abuse on him by his own son.

Case story III
Man Kumari (name changed), 83-year-old woman who lost her husband when she was 14. She is a child-widow (bal-bidhuwa). She was born in Sindhuli district's rural village. Her marriage was arranged when she was 13 and after 10 months of her marriage, her husband was killed in an accident in India. He had left his family for making money in India after some months of their marriage but he never returned back. After this disaster, she stayed in her parental home with her parents, brothers and their families. She was fine working and helping her family with the agricultural tasks until her parents were alive. After they passed away, she left home and went to her maternal uncle's home. When asked why she left her parental home she said that the home was no more home after her parents passed away. She reported no good terms with her brother and his spouse. She lived with her maternal brother and his family for 5 years. As she turned 60, she lost her appetite as well as energy so his brother's wife started having different types of abuses to her. She started neglecting and using abusive words so her brother could not see it. Therefore he requested an old age home in Janakpur to provide her shelter. She remained there for 14 years. Her sister's daughter later visited her and found out the poor condition of the old age home so she brought her to Katmandu. The old age home here was in better condition in her view. She frequently visits her. In her view, not having a spouse or income didn't matter much but disability which came along with growing age brought problem in her life.

Discussion
Research shows that elder abuse was first identified in developed countries where most of the existing research has been conducted, anecdotal evidence and other reports from developing countries have shown that it is a universal phenomenon [6]. Research on the abuse of elderly in Nepal is very scant [17]. This study is trying to explore the elderly abuse faced by elderly before they come to old age home which is first in its nature of study in Nepal.
This study found 58% older adults had suffered from some form of elder abuse before they came to old age homes i.e. in their previous residential setting. A study recently carried out in community living elderly shows 47.4% elderly were suffering from elder abuse [17]. This shows experience of prevalence of elder abuse by their family members is quite high among elderly living in old age home before they come to old age home. This may be one of the reasons why many older adults are attracted towards old age home in Kathmandu.
Similarly, a study involving 5600 older persons in 20 cities in India in 2012 found that 31 percent of those interviewed reported facing abuse. Over half of those abused were maltreated for more than four years [18]. Likewise, in a study of elder abuse in Europe, WHO estimates that annually 4 million people aged 60 or over experience physical abuse, 1 million experience sexual abuse, 29 million experience mental abuse and 6 million experience financial abuse [3].
In this study, neglect was the most common type of abuse experienced by a little below half (47%) of the sampled respondents which was followed by behavioural or emotional abuse (37%), financial abuse (32%), physical abuse (8%) like beating pushing etc and 3% of sampled elderly reported that they were sexually abused. Study carried out by Chalise & Basnet in a community living study in Nepal found most common form of elder abuse was neglect (35.4%) followed by followed by showing disrespect (34.8%), verbal abuse (25.3%), economic abuse (8.1%), physical abuse (5.7%) and emotional abuse (5.1%) [17]. Similarly, a study carried out based on reported Cases of Elder Abuse in Nepali Press which stated that physical abuse was reported in 43% of the cases and neglect was the second most common (33.3%) form of elderly abuse [19].
This study found major causes of elderly abuse faced by abused elderly were disability to look after themselves (72.7%), absence or death of spouse (47.7%), the family was busy and there were no extra persons for care giving task (34.1%) and 27.3% reported they had no property. A review study suggests older women are more likely than older men to become victims of abuse. Among older adults a younger age has been consistently associated with a greater risk of abuse including emotional, physical, financial abuse and neglect. A shared living environment is a major risk factor for elder abuse. Living with a larger number of household members other than a spouse is associated with an increased risk of abuse especially financial and physical abuse. Moreover, having a lower income is associated with a greater likelihood of financial abuse emotional and physical abuse and neglect [20].
Studies show that the abuse of the elderly has an impact on the health and well-being of elders and can lead to increased health care costs nationwide. 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 [6]. Elderly experiencing high risk of elder abuse in their prior residence shows elderly want to get rid of from their living arrangement and feel happy in the new settlement far from their family members. This is not a solution for the management of increasing number of older adults. Government should take appropriate action to settle elderly in their own community through some policy intervention.

Limitations of this study
Like many other studies, this study is also not free from limitations. First, this is a cross-sectional study and causality cannot be assumed. Second, old age homes are selected only from Kathmandu valley and cannot be generalized for all other older adults living in old age homes. Third, data was collected through face to face interview: there may be possibility of asking bias. Fourth, sample size was not big enough for the statistical test. Fifth, elderly abuse is not classified as recommendation given by other international studies [6].

Conclusion
This study found elderly having experience of elder abuse was very high (58%) prior they come to old age home in the Kathmandu. It has challenged our traditional belief of pitru devo bhava and matru devo bhava (your father and your mother shall be your god). A detailed in-depth study is necessary to know the real situation of elderly abuse of older adults living in urban area. Government should also take appropriate action to secure quality of life of elderly before the problem of elderly abuse get chronic for the poor country like Nepal where we generally assume that elderly are having good time with their children.