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Elder Abuse and Its Prevention: Workshop Summary (2014)

Chapter: II.10 Elder Abuse in Asia - An Overview--Elsie Yan

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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
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concrete ways in which the opposite is true. The Hebrew Home’s partnership with the Weinberg Center has afforded the Home the opportunity to expand its network of relationship and alliances, opening new entry points to valuable community partnerships. The partnership has connected The Hebrew Home with a plethora of potential funding streams and has been the source of significant media attention for the Home. Additionally, the onsite presence of the Weinberg Center staff allows The Hebrew Home to continue to innovate regarding other family violence–related issues, including, most recently, the implementation of a workplace domestic violence program that includes mandatory training for all staff members.

Most critically, the partnership between The Hebrew Home and the Weinberg Center supports The Hebrew Home’s core value of celebrating older adults as unique individuals deserving of dignity and respect. Nationwide, there are currently nearly 5,000 nonprofit, long-term care facilities with more than 750,000 beds nation-wide (Nursing Home Data Compendium, 2010). The success of the partnership between the Weinberg Center and The Hebrew Home at Riverdale demonstrates that all of those beds might one day be part of the burgeoning shelter movement, serving as beacons of hope in the darkness of the lives of elder abuse victims.

II.10

ELDER ABUSE IN ASIA—AN OVERVIEW

Elsie Yan, Ph.D.
Department of Social Work and Social Administration,
University of Hong Kong

The rate of elder abuse is expected to increase as many Asian countries are aging at an unprecedented pace. In 2012, 11 percent of the population in Asia was 60 years and older. By 2050, this percentage is expected to reach 24 percent (Help Age International, 2013).

A substantial amount of research has accumulated on elder abuse in Asian populations, especially Chinese, Indian, Japanese, Korean, and Singaporean. This paper summarizes prevalence estimates of elder abuse in these populations. Special attention is paid to the reviewing of scholarly works that reflect on the unique culture in Asia relevant to the understanding of elder abuse.

Prevalence of Elder Abuse in Asia

Considerable variation, with rates ranging from 0.22 per 1,000 to 62 percent, has been observed in the prevalence estimates of elder abuse across

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×

Asia. Psychological abuse and neglect are frequently reported in studies using older persons or their caregivers as informants. Physical violence and financial abuse are more commonly observed in cases identified in the clinical setting and in cases reported to governmental or nongovernmental organizations.

People’s Republic of China (PRC)

Published work on elder abuse estimates in the PRC mainly came from two studies. In the first study of a convenience sample of 412 older Chinese attending an urban medical center in Nanjing, Dong and his colleagues (Dong et al., 2007a; Dong and Simon, 2008, 2010) reported a prevalence of 35 percent, with caregiver neglect being the most common form of mistreatment (16.9 percent), followed by financial exploitation (13.6 percent), emotional abuse (11.4 percent), physical abuse (5.8 percent), sexual abuse (1.2 percent), and abandonment (0.7 percent). Thirty-six percent of the participants in this sample experienced two or more types of abuse.

The second study involves 2,000 older Chinese recruited through two-stage cluster sampling, in Hubei. Wu and his colleagues (2012) reported similar prevalence rates of 36.2 percent, with psychological abuse being the most common form of mistreatment (27.3 percent), followed by caregiver neglect (15.8 percent), physical abuse (4.9 percent), and financial exploitation (2 percent). Ten percent of the participants in this study suffered multiple forms of elder mistreatment.

Hong Kong

Based on a convenience sample of 355 older Chinese, prevalence rates of 2 percent for physical abuse and 20.8 percent for verbal abuse have been reported (Yan and Tang, 2001). Another study of 276 older Chinese indicated that 27.5 percent of the older respondents reported having experienced at least one abusive behavior by their family caregiver during the surveyed year (Yan and Tang, 2004). The most common form of abuse in this sample was verbal abuse (26.8 percent), whereas violation of personal rights (5.1 percent) and physical abuse (2.5 percent) were comparatively rare.

In a sample of 122 family caregivers of older persons with dementia recruited from local community centers, 62 percent and 18 percent of the caregivers reported having verbally or physically abused the care recipients in the past month (Yan and Kwok, 2010). In a study of 464 younger adults, 20 percent, 2.4 percent, and 2.4 percent indicated they would verbally, physically, or socially abuse an older person if there is no social constraint and that no punishment whatsoever would follow (Yan and Tang, 2003).

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×

Taiwan

In Taiwan, 195 older Chinese subjects, both institutionalized and community-dwelling older Chinese, completed the Psychological Elder Abuse Scale (Wang, 2006). Participants in this sample endorsed an average of 6.32 psychologically abusive behaviors. More commonly reported behaviors were: “wishes to see relatives unfulfilled” (62.6 percent), “economic dependence on others” (61 percent), and “being left alone involuntarily” (44.1 percent).

Wang (2005) collected information from 114 caregivers in institution settings on the Caregiver Psychological Elder Abuse Behavior Scale. On a possible range of 20-80, participants’ mean score was 31.93, indicating most participants engaged in some abusive behaviors. Indeed, only one participant in this sample reported never demonstrating any abusive behaviors toward a care recipient. “Accusing patient verbally” (mean = 2.18), “ignoring patient’s requests” (mean = 2.11), and “insulting patient” (mean = 2.02) were the items of the highest mean scores. A similar study of 92 family caregivers (Wang et al., 2006) found a mean score of 30.45, with “blaming him verbally” (mean = 2.06), “ignoring his request” (mean = 1.96), and “refusing to accept his opinions” (mean = 1.86) being the items of the highest mean scores.

Chinese Immigrants in Canada

Lai (2011) reported a prevalence of 4.5 percent in a random sample of 2,272 older Chinese residing in Canada. Of the respondents, 2.5 percent reported having experienced multiple types of mistreatment. The more common abusive acts included “being scolded” (2.5 percent), “being yelled at” (2.4 percent), “being treated impolitely all the time” (1.5 percent), and “being ridiculed” (1.2 percent).

India

In a survey of 864 older women in Pune city, 47 percent reported that they were abused and 40 percent believed they were neglected by their family (Bambawale, 1997).

Chokkanathan and Lee (2006) found a prevalence rate of 14.1 percent in a sample of 400 community-dwelling older Indians, with chronic verbal abuse being the most common (10.8 percent), followed by financial abuse (5 percent), physical abuse (4.3 percent), and neglect (4.3 percent). Among the abused elderly, nearly half reported they had experienced multiple forms of abuse (Chokkanathan and Lee, 2006).

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×

In a representative household survey of 300 older Indians, Sebastian and Sekher (2011) found that nearly half of the respondents (49 percent) reported that they had experienced abuse or neglect from their family members in the surveyed year. Neglect and verbal abuse (39 percent) were the most common forms of mistreatment, followed by physical abuse (13 percent).

In a large-scale representative study conducted by HelpAge India (2012), 31 percent of the 5,400 respondents had experienced abuse and 24 percent faced abuse on a daily basis. More than half of those who were abused had been enduring the abuse for more than 4 years. Among those who reported abuse, 44 percent identified disrespect as the most common form of abuse, 30 percent identified neglect, and 26 percent identified verbal abuse. Forty-six percent of the respondents in this sample had observed cases of abuse in their surroundings.

Singapore

In Singapore, Cham and Seow (2000) reviewed all cases of non-accidental injuries in older persons presenting to the emergency department of a major hospital. Among the 62,826 older patients received between 1994 and 1997, 17 cases of elder abuse were identified, yielding a prevalence rate of 0.3 percent. Using a similar research method, Phua and colleagues (2008) identified 42 cases in 31,145 patients (0.13 percent) presented to the emergency department over a 12-month period. The 42 cases identified involved physical mistreatment (N = 27), neglect (N = 25), psychological mistreatment (N = 6), financial mistreatment (N = 2), abandonment (N = 1), and self-neglect (N = 1).

Japan

In a sample of 78 older Japanese living in an agricultural village, 17.9 percent reported abuse (Anme et al., 2005). Among those who were abused, the most common type of abuse was psychological abuse (50 percent), followed by neglect (42.8 percent), financial exploitation (35.7 percent), physical abuse (21 percent), inadequate administration of medicine (21 percent), self-neglect (14.3 percent), and sexual abuse (7.1 percent) (Anme, 2004).

Attempts have also been made to investigate caregiver reports of abusive behaviors. In a survey of 412 family caregivers of older Japanese who used the visiting nursing services, 34.9 percent reported having engaged in potentially harmful behavior against the older care recipient in the past year (Sasaki et al., 2007). The most frequently reported behaviors were verbal aggression (16.8 percent) and ignoring (13.6 percent). In another survey of 123 Japanese caregivers of older persons referred to a memory

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×

clinic, 15.4 percent reported abuse (Kishimoto et al., 2013). Psychological abuse was reported in all cases, and two cases involved both physical and psychological abuse.

In a representative sample of 4,391 older Japanese, more than half had heard of the term “elder abuse” before, among which 18.1 percent personally knew an elder abuse victim (Tsukada et al., 2001).

Cases reported to social services agencies also allow a glimpse at the patterns of elder abuse in Japan. Reviewing a total of 150 elder abuse cases receiving telephone counseling service, Yamada (1999) concluded that financial abuse (49.8 percent) was the most common form of abuse in this sample, followed by psychological abuse (46 percent), physical abuse (35.3 percent), neglect (21.3 percent), self-neglect (1.3 percent), and sexual abuse (0.7 percent).

Despite the relatively high rates of elder abuse reported in the community, official records of elder abuse cases are relatively low in Japan. Reviewing cases identified by officials in 489 municipalities, Nakanishi and colleagues (2010) found a rate of 0.429 per 1,000 in 2008. Based on the responses from 917 municipalities, Nakanishi and other colleagues (2009) estimated that the rate of new reports of suspected cases over a 6-month period was 0.35 per 1,000 and the rate of substantiated cases was 0.22 per 1,000.

South Korea

Drawing from a representative sample of 15,230 older Koreans residing in Seoul, Oh et al. (2006) reported an overall prevalence rate of 6.3 percent for elder abuse. Prevalence of individual types of abuse were: emotional abuse (4.2 percent), financial abuse (4.1 percent), verbal abuse (3.6 percent), neglect (2.4 percent), and physical abuse (1.9 percent).

Lee and Kolomer (2005) interviewed 481 family caregivers providing care to older Koreans with dementia. They found that 16.4 percent had “often yelled at the care recipients,” 7.5 percent had often “confined the care recipients to a room,” 4 percent had often “left their care recipients unattended,” 2.9 percent had often “not prepare[d] a meal for the care recipient,” and 14.9 percent of caregivers had “hit the care recipients.” In a sample of 934 older Koreans recovering from stroke, prevalence of elder abuse was 13.5 percent (Kim et al., 2012). Emotional abuse was the most frequently reported (10 percent), followed by financial neglect (3.8 percent), caring neglect (3.3 percent), financial abuse (2.1 percent), and physical abuse (1.9 percent).

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×

Korean Immigrants in the United States

In a sample of 100 older Korean immigrants residing in Los Angeles, 34 percent indicated seeing or hearing about at least one incident of elder abuse and neglect among their Korean relatives, friends, and neighbors, amounting to 46 incidents (Chang and Moon, 1997). Financial exploitation was found to be the most frequently occurring type of abuse (36 percent), followed by psychological abuse (24 percent), culturally specific types of abuse such as “grown-up children refusing to live with their parents,” “lack of contact from grown-up children,” etc. (17 percent), neglect (15 percent), and physical abuse (4 percent).

Cultural Considerations

A handful of research studies have looked into how different cultural groups in Asia define elder mistreatment. As is evident, Asians identify culturally specific forms of mistreatment that differ from Western perspectives. The concept of “disrespect” captures actions and attitudes that violate basic Asian cultural norms of values and behaviors. Based on a qualitative study of home care workers, Tam and Neysmith (2006) reported that “disrespect” is the key form of elder abuse in the Chinese community. Examples of disrespect in this study include “family members being excessively bossy or rude,” or living in more than one place like “a ball being kicked around among relatives.” Qualitative interviews with older Chinese confirmed that disrespect results in unsettling feelings in older persons; examples provided by Chinese elders included “being ignored by children” and “behaving as if (the elder person is) the enemy” (Dong et al., 2011b). In Hong Kong Chinese elders, “being treated as if transparent” is considered a serious and common form of elder abuse (Hong Kong Christian Service, 2004).

Disrespect and lack of dignified living is also considered a major form of elder abuse by older Indians (Nagpaul, 1998; Help Age India, 2012). “Being taken for granted,” “being used as additional domestic help,” and “not being appreciated for contributions made in household chores” are other examples of elder abuse in India (Shah et al., 1995). In many circumstances, however, abuse incidents were attributed to the lifestyles in the younger generations that do not meet the expectations of their parents (Nagpaul, 1998).

Similar observations have been made in other Asian cultures. Chang and Moon (1997) found that older Koreans consider lack of respect for and inappropriate treatments of elders by family members a prominent form of abuse. Korean elders tend to see insufficient attention from their daughters-in-law as a form of abuse. Some of the culturally specific examples of abuse include “failure to employ Korean language usage that denotes respect,”

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×

“direct expression of disagreement with the mother-in-law,” and “failure to acknowledge the elderly upon arriving and leaving the residence.” Studies on older Japanese provided another example of culturally specific types of elder abuse. When asked to generate examples of extreme abuse, respondents provided examples of “blaming,” that is, elderly parents being blamed for whatever problems the adult children were having (Arai, 2006).

Discussions

As is obvious, huge variation is observed in the reported rates of elder abuse and can be partly attributed to the methodological difference across studies.

Although most researchers have agreed on the definitions of elder abuse, many investigate different types of abuse in their studies. Some researchers include neglect and self-neglect in their studies, while many do not. To obtain more comparable results, a more consistent categorization of abuse is needed. Also contributing to the variation in prevalence estimates is the recall period used in these studies, which included 1 month, 6 months, and 1 year. With the variations in the recall period, it is extremely difficult to draw meaningful conclusions from the estimates obtained in these studies. To date, a majority of the studies on elder abuse are based on samples of non-representative groups such as clinical populations or members of community centers. They may not reflect the actual prevalence of abuse due to their small sample size and biased sample characteristics. It is observed that studies using representative samples generally reported lower rates as compared to those from non-representative samples.

This trend has several possible reasons. First, given the higher rates of abuse in older persons with physical or cognitive problems and their over-representation in the clinical samples, rates obtained in clinical samples are likely to be higher than those obtained from representative community samples. Second, older persons who were abused may be more inclined in participate in the research, resulting in higher rates being observed in convenience samples as compared to representative samples.

An argument has often been that much of the screening and assessment instruments developed in “Western societies” may not be able to capture culture-specific forms of elder abuse in Asian cultures. While developing local assessment tools may solve this problem, the downside of solely relying on a locally developed measure is that it would hamper efforts for cross-cultural comparison. Although it is desirable to use instruments that tap into culturally specific types of abuse, it is also essential to maintain some degree of similarity in instruments used so as to aid cross-cultural comparative studies. Furthermore, despite the fact that culturally specific types of abuse, such as disrespect or ignoring, have been identified, little is

Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Suggested Citation:"II.10 Elder Abuse in Asia - An Overview--Elsie Yan." Institute of Medicine and National Research Council. 2014. Elder Abuse and Its Prevention: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18518.
×
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Elder Abuse and Its Prevention is the summary of a workshop convened in April 2013 by the Institute of Medicine's Forum on Global Violence Prevention. Using an ecological framework, this workshop explored the burden of elder abuse around the world, focusing on its impacts on individuals, families, communities, and societies. Additionally, the workshop addressed occurrences and co-occurrences of different types of abuse, including physical, sexual, emotional, and financial, as well as neglect. The ultimate objective was to illuminate promising global and multisectoral evidence-based approaches to the prevention of elder maltreatment. While the workshop covered scope and prevalence and unique characteristics of abuse, the intention was to move beyond what is known about elder abuse to foster discussions about how to improve prevention, intervention, and mitigation of the victims' needs, particularly through collaborative efforts. The workshop discussions included innovative intervention models and opportunities for prevention across sectors and settings.

Violence and related forms of abuse against elders is a global public health and human rights problem with far-reaching consequences, resulting in increased death, disability, and exploitation with collateral effects on well-being. Data suggest that at least 10 percent of elders in the United States are victims of elder maltreatment every year. In low- and middle-income countries, where the burden of violence is the greatest, the figure is likely even higher. In addition, elders experiencing risk factors such as diminishing cognitive function, caregiver dependence, and social isolation are more vulnerable to maltreatment and underreporting. As the world population of adults aged 65 and older continues to grow, the implications of elder maltreatment for health care, social welfare, justice, and financial systems are great. However, despite the magnitude of global elder maltreatment, it has been an underappreciated public health problem. Elder Abuse and Its Prevention discusses the prevalence and characteristics of elder abuse around the world, risk factors for abuse and potential adverse health outcomes, and contextually specific factors, such as culture and the role of the community.

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