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A study of elder abuse in Korea
ARTICLE IN PRESS
International Journal of Nursing Studies 43 (2006) 203–214 www.elsevier.com/locate/ijnurstu
A study of elder abuse in Korea Jinjoo Oha,, Hesook Suzie Kimb, Diane Martinsb, Heegul Kimc a Dankook University, San29, Anseodong, Cheonan-City, ChoongNam-330-714, South Korea University of Rhode Island, College of Nursing, 21 Heathman Road, White Hall, Kingston, RI 02881-2021, USA c Kyungwon University, Korea, San29, Anseodong, Cheonan-City, ChoongNam-330-714, South Korea
b
Received 19 April 2004; received in revised form 23 February 2005; accepted 15 March 2005
Abstract This study investigates the state of elder abuse in Korea, and its related factors in a population-based survey. A total of 15,230 persons were interviewed at their homes in 1999. The rate of old people who experienced any one category of abuse was 6.3%, and emotional abuse was the most frequent while physical abuse was least prevalent. The experience of abuse seemed to be associated with personal characteristics such as age, gender, educational level, and economic dependency as well as the physical and mental health status. In addition, family characteristics such as the type of household, the family’s economic level, and the quality of family relations were found to be associated with the presence of abuse. r 2005 Elsevier Ltd. All rights reserved. Keywords: Elderly; Abuse; Korea
1. Introduction Korea is rapidly becoming ‘an aging society’ resulting from the lengthening of life expectancy that has occurred during the last two to three decades. The economic and social development Korea has experienced during the past few decades since the WWII brought about changes in every sector of Korean society, including those in family structure and processes, resulting in a changed dynamics in older adults’ lives. While traditionally the care of older persons was assumed by families under the commitment to filial piety as a strong value for family life, this commitment has weakened in general in the recent decades. In addition, Corresponding author. Tel.: +82 41 550 3884; fax: +82 41 550 3905. E-mail addresses: [email protected] (J. Oh), [email protected] (H.S. Kim), [email protected] (D. Martins).
the change from an extended family structure to a nuclear one and an increase in women working outside homes have created family situations in which older persons are often left alone at home to care for themselves. On the contrary, social preparedness for the aging society has been minimal. Although the social pension system was introduced in the mid-eighties, the income level from this pension system is very low, and the majority of older adults had not been oriented to ‘saving’ for old age and retirement. Hence, a large proportion of the elderly has no or very little independent income. It is not only necessary for many older adults to be economically dependent on their children but often the elderly parents have to rely on their children for other sorts of support because there is a lack of social and welfare facilities and services available to them (Department of Health and Welfare of Korea, 2001). Although there is no evidence linking the elderly’s dependency and abuse, or the decrease in filial piety and
0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.03.005
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abuse, there is a general suspicion that elder abuse is increasing in Korea (Cho, 2000). However, the problem of elder abuse has not received much attention either from researchers or policy makers in Korea, as the problem remains hidden behind the reluctance for public disclosure of family incidents. Elder abuse takes place in a range of settings. But, abuse in domiciliary settings is the commonest type of abuse, and the most difficult to combat. Contact between victims of abuse and statutory services may be limited, and those abused will often feel under threat, or obligation, to those abusing them. Nurses, as primary care-givers have shown great concern for the elder abuse (House of Commons Health Committee, 2004). The study by Pillemer and Finkelhor (1988) was the first large-scale random sample survey of elder abuse and neglect in the US in which they conducted interviews with 2020 community-dwelling elders. The overall prevalence rate of abuse was 3.2%, with physical abuse being most frequent. From this survey, it was estimated that between 700,000 and 1.2 million elderly individuals in the US would be victims of elder mistreatment annually. More recently the Senate Special Committee on Aging estimated nearly 5 million older persons are abused or neglected annually in the US (National Center on Elder Abuse, 2003). Based on the results of the few population-based studies in different countries, ‘‘between 4% and 6% of elderly people, are abused in some way in their homes’’. The rates from such findings, however, may not reflect the true picture, as under-reporting is greatly suspected. Douglass (1988) suggested that only 20% of all elder abuse cases were reported, so it is likely that the prevalence is underestimated. There are several possible reasons for under-reporting: (a) the elderly may not want their own family affairs revealed to others; (b) they may be afraid of negative repercussions from their abusers for the exposure; (c) the elderly may have false beliefs that the causes of abuse are within themselves (Kosberg, 1988), or (d) the elderly may not understand what is happening to them or they do not want to alert the authorities on a family member (Voelker, 2002). Voelker (2002) states that much of the literature on elder abuse is anecdotal and there is a paucity of systematic literature on the issue. The same is true regarding elder abuse in Korea. There have been problems in arriving at a satisfactory and standardized definition of abuse in general and elder abuse in particular. For example, elder abuse has been considered in terms of intentionality, outcomes, acts of omission and commission, and forms of maltreatment and neglect. Because of this confusion some researchers have adopted a definition of elder abuse restricting it to physical abuse (Rathbone-McCuan, 1980) while most researchers in the field use a broader definition that embraces all types of mistreatment or abusive behaviors
toward older adults (Pedirick-Cornell and Gelles, 1982). In this broad definition, abuse refers to an act of commission or omission, resulting in intentional or unintentional harm or injury, and in one or more types (Hudson, 1991). The Department of Health guideline on policies and procedures to protect vulnerable adults from abuse, sets out a definition of abuse as ‘‘a violation of an individual’s human and civil rights by any other person or persons’’ (Department of Health, 2000). Thus, elder abuse is not only consisting of active physical abuse of an older person (McCormack, 1980), but it also includes, in its most common and less dramatic form, exploitation, neglect, and psychological mistreatment (Pedirick-Cornell and Gelles, 1982). Within such a broad definition, elder abuse is found in a variety of types, making the classification of it difficult. Department of Health (2000) lists the main forms of abuse as physical abuse, sexual abuse, psychological abuse, financial abuse, neglects, and discriminatory abuse. American Medical Association (AMA), (2004) defined abuse in nursing homes as verbal abuse, sexual abuse, physical abuse, mental abuse, and involuntary seclusion. Korean literatures (Cho et al., 1999; Cheon and Song, 1997), after reviewing existing research, categorized elder abuse as physical, verbal and emotional, economic abuse, and neglect. There are several different explanations of elder abuse, some attributing it to the characteristics of the abused or of the abuser while others focusing on contextual characteristics such as life circumstances or family situations as the major forces that produce abuse. An explanation focusing on the characteristics of the abused has advanced the impairment and dependence hypothesis that the most likely older persons to be abused are women with severe physical or mental impairments (Lachs and Pillemer, 1995; Pillemer and Suitor, 1992), those with economic dependency (Pillemer and Finkelhor, 1988; Steinmetz, 1990), and with a low educational level (Shiferaw et al., 1994). An alternative explanation adopts the position that abuse results from certain characteristics of the family or abuser, such as family characteristics (Pillemer and Finkelhor, 1988), family dynamics (O’Rourke, 1981 [19], the quality of relationships (Cooney and Mortimer, 1995; Kosberg, 1988; Reis and Nahmiash, 1998), or personality traits of the abuser (Sengstock and Liang, 1982). Situational factors, such as caregiving stress and caregiver burden (Steinmetz, 1983) or economic crisis (Lachs and Pillemer, 1995) have also been found to be the factors present in elder abuse. O’Rourke (1981) suggests that abuse is more likely to be triggered by the interplay of several factors rather than by one single factor. While our understanding and explanation of elder abuse is incomplete, there is overwhelming evidence that elder abuse results in various sorts of negative outcomes in older persons. Elder abuse has been documented to
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cause not only specific harm, injury, or loss such as physical injury or financial loss, but also more insidious responses such as depression, anxiety, and psychological stress. Clinicians also suggest that other consequences of elder abuse include feelings of learned helplessness, alienation, guilt, shame, fear, anxiety, denial, and posttraumatic syndrome (Comijs et al., 1998). In Korea, nurses’ work as primary health providers in public health care centers located nationwide, in home care visiting center and in social welfare center. They are in good positions to keep on eye on elder abuse, and as advocates of the elderly can affect a great deal in detecting and reporting elder abuse, but we are concerned that the area of elder abuse does not currently form a mandatory part of the training for nurses. Often nurses take no action because they lack training in identifying abuse or are ignorant of the reporting procedures. This is from the low level of social awareness in part and from dearth of research in part. The lack of reporting results in difficulties in determining the true scale of the problem and this is compounded by a dearth of research. The literature on elder abuse in Korea is scanty, and the knowledge of it is mostly based on anecdotal findings or from studies with small, purposive samples, suggesting that there is a need for a comprehensive picture of elder abuse. Fundamental point in the prevention of elder abuse is the recognition that it exists within society. Given the scale of the problem, and the fact that care of older people will increasingly feature in nurses’ work given the aging of the population, we think that the research on elder abuse is the utmost important task. (House of Commons Health Committee, 2004). In recognition of this the present study was carried out in order to obtain the baseline data on elder abuse in Korea using a population-based sample of older persons. More specifically it investigated the prevalence rate of elder abuse by types of abuse, and examined the relationships between abuse and the characteristics of the older persons and family. The study was based on the premise that elder abuse is associated with the selected personal characteristics of the older persons, of the family, and the quality of family relationships.
2. Methods This was a population-based survey of a sample of older adults residing in Seoul, Korea conducted in 1999, carried out under the auspice of the Public Health Service Center of a district within the city. Seoul, the capital city of Korea, is composed of 25 Gu’s which are city districts dividing the city into geographic regions for administrative purposes. Songpa Gu within which this
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survey was conducted has the largest population among the entire districts in Seoul, with an estimated population of 668,900 persons in 1999 among which 4.4% (29,439) were older adults. The elderly population in this district has been increasing rapidly, which made it critical for the Public Health Center to consider developing a program for health promotion for older adults. The survey was carried out as an initial effort for the assessment of health care needs of the older adults in this district. And this paper reports on the results pertaining to elder abuse only. 2.1. Subjects
The
entire population of older adults aged 65 and older living in a Gu was the target population for the survey. The names and addresses of the older adults registered as residents of this district were obtained from the governmental administrative office, and the confirmation on each person’s actual living status was made by telephone. The final sample for the survey consisted of 15,700 persons, which was 53% of the entire elderly population in the district, obtained with the deletion of persons who moved to other districts, died, were unavailable for interview because they were staying someplace else, or refused to be interviewed. This study used the data from 15,230 persons of the total of 15,700 interviews, excluding those with missing data or suspected of having answered untruthfully or inaccurately to interview questions. There were two reviewers to examine all questionnaires one by one. They examined thoroughly if there was any inconsistency among items or if there were many missing items. The two population groups (those surveyed and not surveyed) could not be compared in terms of the demographic and other key characteristics, suggesting a possibility of some bias in the sample. However, there was no obvious factor that could be identified to have influenced the selection bias in the sample in a systematic fashion. The demographic and personal characteristics of the sample are shown in Table 1.
2.2. Method of data collection The data were collected by interviews held at the subjects’ homes during the period from January 1999 to December 1999. The interviews were carried out by 30 interviewers who were registered nurses and trained for interviewing during a 3-day training session conducted by three faculty members of colleges of nursing in Korea. The interviews were carried out using a structured interview schedule. Each potential subject was telephoned for an initial permission for a home visit. When the interviewers made the home-visits for
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Table 1 General characteristics of the subjects Total
Elderly
Family
N
%
Sex
Male Female
5287 9943
34.7 65.3
Age
65–69 years 70–74 years 75–79 years 80 years and older
4928 4264 3218 2820
32 28 21.1 18.5
Educational level
N schooling 1–6 years 7–9 years 10 years or more
5167 4396 1789 3878
33.9 28.9 11.7 25.5
Economic dependency
Independent and Support children Independent Partially supported Totally dependent
221 3647 1528 9834
1.4 23.9 10 64.7
Type of household
Living alone Living as a couple Living with the family of a married children Living with a single children Other arrangement
1528 4039 7966 1331 388
10 26.5 52.3 8.7 2.5
Economic level
Lowest Low Middle High Highest
3146 3668 5238 1993 1185
20.7 24.1 34.5 13 7.7
Family relationship
Very good Good Average Bad Very bad
3805 7077 4071 248 29
25.1 46.6 26.9 1.3 0.2
N ¼ 15230.
interview, they explained the aims of the study and reobtained the subjects’ consent before proceeding with the interviews. 2.3. Instruments The interview schedule consisted of five sections: (a) general demographic/personal characteristics, (b) health and functional status items, (c) items on abuse, (d) family characteristics, and (e) elderly family relationship. The items within the interview schedule were all close-ended, either structured in Likert-type scales, into sets of pre-established categories, or in numerical scales. A. Demographic/personal characteristics: The items included in this section were age in years, gender, years
of education completed, and economic dependency of the older adult measured in four categories of totally independent and supporting children, independent, partially supported by children, and totally dependent on children. B. Health and functional status: Four specific measures were used to measure these aspects: (a) activities of daily living (ADL) was measured by Barthel Index (Mahoney and Barthel, 1965) which is a Likert-type scale using three points resulting in scores ranging from 1 to 27, with lower scores indicating higher functional ability; (b) instrumental activities of daily living (IADL) was measured by PGC-IADL (Kane and Kane, 1988) which also is a Likert-type scale with three points resulting in a range of scores from 1 to 24 with lower scores indicating higher functional ability; (c) sick-days was measured by the number of
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sick days during the month immediately preceding the interview; and (d) cognitive function level was measured by MMSE-K developed by Kwon and Park (1989) for Korean older adults, which ranged from 0 to 30 with higher scores indicating higher cognitive function level. C. Measurements of abuse: Elder abuse was classified as physical, emotional, economic, and verbal abuse, and neglect. A total of 25 items, five for each type, were included in the instrument. The items were compiled through a comprehensive review of the literature (DoH, 2000; AMA, 2004; Cho et al., 1999; Cheon and Song, 1997; Han, 1996) and were validated by three nurse researchers with gerontological nursing expertise. The instrument was pretested with five older adults living in community in order to validate the clarity of meaning and appropriate use of the language. The responders were asked to indicate the number of incidences with which each item was experienced during the month preceding the interview. Two values were obtained from the responses to this instrument: (a) the presence/absence of abuse, for which the responders were categorized as the abused if they experienced abuse of any type for more than two times during the month, and (b) the total abuse by summing the number of incidences in all 25 items. Originally, the data were gathered using five likert scales for abuse ; above 3 times per week, 1–2 times per week, 2–3 times per month, below 1 time per month, none. But in the statistical process, we found that the most of the elder abuse in ‘‘below 1 time per month’’ a nd ‘‘none’’ was verbal abuse and they showed no statistical implication showing that they were in need of help. As the goal of this survey was to sort out the group of elderly who were in need of imminent intervention from official governmental organizations, we decided to categorize those who were in ‘‘above 3 times per week’’, ‘‘1–2 times per week’’, ‘‘2–3 times per month’’ as abused. By doing this we also found that it increased the reliability of the instrument from Chronbach’s a ¼ nearly .7–.92. D. Family characteristics: Two family characteristics were measured: (a) the types of household categorized as living alone, elderly couple by themselves, living with married child/children, living with unmarried child/children, and other arrangements; and (b) family economic level measured in five income levels. E. Family relationship: The older adult’s perception of his/her relationship with family members was measured by one item that rated the relationship as very good, good, average, bad, and very bad.
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2.4. Data analysis The general characteristics of the subjects were analyzed using descriptive statistics. T-test and w2 test were used to examine the differences in personal and family variables in relation to elder abuse, and logistic analysis was applied to examine the different magnitudes of influence by each variable on elder abuse. 2.5. Limitations Because the final sample for the study was not a randomly drawn one, and because the comparison between those surveyed and not-surveyed was not made in terms of the demographic and characteristics, suggesting a possibility of some bias in the sample, there is a possibility that it does not represent the population in the district. Furthermore, although the older persons living in SongpaGu may not be too different in their characteristics from those living in Seoul, this was not ascertained in this study. In this respect, the findings in this study may not be representative of those living in Seoul or the Korean elderly in general. This study used data which were collected through personal face-to-face interviews with the older persons at their homes. The responders might have not been totally free to talk about abuse especially when other members of the household were present at home during the interviews. And we could not exclude the possibility that the survey might not include the most frail and vulnerable older people who might be more at risk of abuse than the general older population. Thus, there is a possibility of abuse to have been under reported. In addition, the characteristics of the abuser or situational stress which are also suggested as major contributing factors on elder abuse in the literature were not included in this survey.
3. Results Table 2 shows the rates of abuse, indicating, in general, that between 1.6% and 3.7% of the older persons, experienced abuse of one type or another. The emotional abuse types occurred more frequently than other types, with more than 3% experiencing it in all five categories of emotional abuse. Abuses that are physically oriented were least frequent among the abuse types. Table 3 shows the number of older persons who experienced any one of the abuse types, which also indicates the highest prevalence rate in emotional abuse, with the total prevalence rate of 6.3% for this population. The identity of the abuser is given in Table 4, which shows more than two-third (75% to 80%) of all abuse was by the older persons’ sons or
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Table 2 The prevalence abuse by each items Item
Yes
No
N
%
N
%
Physical abuse
Throw things Push/grasp firmly Beat/kick Beat/threaten with objects Threaten with arms
281 263 265 256 254
1.9 1.7 1.7 1.7 1.6
14944 14964 14971 14972 14972
98.1 98.2 98.3 98.3 98.3
Emotional abuse
Use inconsistent approaches Insult/degrade Give signs of rejection Show dissatisfaction Show signs of indifference
499 455 551 548 497
3.2 3 3.5 3.7 3.3
14730 14774 14682 14681 14732
96.7 97.1 96.5 96.3 96.7
Economic abuse
Withhold spending money Refuse lending money when needed Forcibly take money or jewelry Spend money without permission Force to earn money
522 338 291 390 273
3.5 2.2 1.9 2.6 1.7
14706 14889 14937 14838 14935
96.6 96.7 98 97.4 98.1
Verbal abuse
Use reproachful languages Use hostile languages Express rejection Express despise or disregard Use violent language or tone.
514 467 496 430 385
3.4 3 3.3 2.8 2.6
14715 14763 14734 14806 14843
96.6 96.9 96.7 97.1 97.4
Neglect
Leave alone for a long time Do not give care when ill Do not help in seeking health care Withhold prescribed drugs Withhold food
327 353 337 311 297
2.1 2.3 2.2 2.1 1.9
14909 14875 14891 14917 14930
97.8 97.6 97.8 98 98
N ¼ 15230. Table 3 Prevalence of experience by categories of abuse Categories of abuse
Physical abuse Emotional abuse Economic abuse Verbal abuse Neglect Total abuse
Abused N
% of total
285 638 624 551 370 962
1.9 4.2 4.1 3.6 2.4 6.3
N ¼ 15230.
daughters-in-law. The total number of abused older persons in Table 3 and the total number of abuser are different because they were obtained in two different questions. Tables 5–7 show the distributions in the abused versus not-abused groups according to the older persons’ gender, age, educational level, economic dependency,
health-status indicators, and family characteristics. Of the background variables, the educational level was the only factor that showed a significant difference by w2 test. On the other hand, all four indicators of healthstatus were found to be significantly different by t-tests between the abused and not-abused groups, with the abused group having the lower levels of ADL, IADL, and cognitive functioning, and more sick days. Furthermore as shown in Table 7, the distributions in the abused and not-abused groups were significantly different according to the type of household, the family’s economic level, and the perceived family relationship by w2 tests. Those living alone, the family in the lowest economic level, and those with the perception of ‘very bad’ family relationships were mostly likely to be abused than the others of the sample. A logistic analysis to examine the contribution of different factors on elder abuse was performed including the background factors, health-status indicators, and family characteristics, the results of which are shown in Table 8. As indicated by the odds ratios shown in this table, the prevalence rates of abuse in the older men were significantly higher in
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Table 4 Main abuser by categories of abuse Categories of abuse Spouse
Physical Emotional Economic Verbal Neglect
Son
Daughter
Son-in-law
Daughter -in-law
Grandson
Etc.
Total
N
%
N
%
N
%
N
%
N
%
N
%
N
%
N
%
45 38 31 32 32
12.2 5.5 8.5 5.3 8
143 249 170 242 139
38.8 37.8 35.5 40 34.8
47 41 32 41 28
12.7 8.2 8.7 8.8 7
5 11 4 12 2
1.4 1.7 0.8 2 0.5
81 247 170 214 147
22 37.5 35.5 35.4 38.8
4 9 8 7 4
1.1 1.1 1.1 1.1 1.1
44 84 59 54 50
11.9 9.7 12.3 8.8 0.3
389 875 479 802 402
100 100 100 100 100
Dual response permitted.
Table 5 Influencing factors on elder abuse (I) Abused
X2
Non abused
N
%
N
%
Sex
Male Female
308 640
5.94 6.5
4979 9303
94.06 93.5
1.08 (p ¼ :08)
Age
65–69 years 70–74 years 75–79 years 80 years & older
279 269 230 186
5.64 6.29 7.12 6.56
4649 3995 2988 2664
94.36 93.71 92.88 93.44
7.59 (p ¼ :06)
Educational level
No schooling 1–6 years 7–9 years 10 years or more
435 278 105 155
8.35 6.24 5.67 3.9
4729 4116 1681 3721
91.65 93.76 94.33 96.1
75.89 (p ¼ :00)
Economic dependency
Independent & support children Independent Partially supported Totally dependent
15 216 106 628
5.56 5.85 6.76 6.36
206 3430 1422 9206
94.4 94.15 93.24 93.64
2.05 (p ¼ :56)
N ¼ 15230.
Table 6 Characteristics of elderly influencing on abuse (II) Abused
Physical health
Cognition
ADL IADL Sick days MMSE-K
Non-abused
X
SD
X
SD
.71 1.56 4.36 25.75
2.88 3.57 2.80 4.29
.46 .96 3.68 26.81
2.40 3.03 2.84 3.25
total abuse, emotional abuse, economic abuse, and verbal abuse than in the older women, and those in the oldest age group (over 80 years of age) were least likely to be abused in comparison to other age groups. Those with no education were most likely to be abused in comparison to those with above high school education
t
p
2.98 6.63 7.18 8.1
0 0 0 0
at the odd ratio of 1.61. Those who were partially supported were least likely to be abused, while those who were totally supported or independent were more likely to be abused in all types except with respect to economic abuse in which those who were independent and giving support to their children were most likely to
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Table 7 Family characteristics influencing on abuse Abused N
Non-abused %
N
%
X2
Type of household
Living alone Living as a couple Living with the family of a married children Living with unmarried children Other arrangement
128 227 496 88 26
8.32 5.6 6.22 6.55 6.49
1400 3812 7650 1243 361
91.68 94.4 93.78 93.45 93.51
45.2 (p ¼ :00)
Economic levela
Lowest Low 100–249 High Highest
360 281 244 95 37
11.12 7.36 4.43 4.17 2.07
2786 3388 4995 1899 1148
88.8 92.64 95.57 95.83 97.93
210.79 (p ¼ :00)
Family relationship
Very good Good Average Bad Very bad
92 251 590 123 44
1.17 3.2 3.76 14 49.74
3811 6768 3479 123 40
98.29 96.8 86 50.26 44.83
1390 (p ¼ :00)
N ¼ 15230. a Unit: million won.
be abused. The results of the logistic analysis regarding the health-status indicators were the same as the t-test results, with those having the lowest IADL and cognitive function level, and the sickest days being most likely to be abused. The results of the logistic analysis also show that those living with married children were most likely to be abused in general than others, and those in the lowest level of family income were also most likely to be abused in all areas at drastically higher levels in comparison to the highest income level. The older persons who perceived their family relationships to be ‘very bad’ were most likely to be abused in comparison to others, except in the case of physical abuse with which those with average or ‘bad’ family relationships seemed to have higher prevalence of abuse.
4. Discussion The results of this study show the prevalence rate of elder abuse in a Korean population group at 1.94.2% in various types of abuse. These rates are higher than the rates in the USA (.19–2.2%) (Pillemer and Finkelhor, 1988), but on par with the estimated rates of 3–5% by Levine (2003) who howed prevalence of elder abuse in USA varies from 3% to 5%. This level of elder abuse in Korea similar to those found in western societies may suggest a deterioration of the Korean traditional values of respecting elders and filial piety.
Although the abuse rates by type vary in different studies, it is often reported that psychological and physical abuse (Pillemer and Finkelhor, 1988) is the most frequent type. In this study, emotional abuse was the most frequent type while physical abuse was the least prevalent one. This result is similar to the results from other studies in Korea (Han, 1996; Kim, 1997). Since the idea of filial piety is still explicitly dominant in Korea and physical harm to old people is taboo, it seems that mainly emotional type of abuse may be the form which is taken. The most frequent abuser in every kind of abuse types was a son followed by a daughter-in-law in this study. Although this result is similar to the findings from other Korean studies (Han, 1996; Kim, 1997), it was different from studies done in other countries (Sengstock and Liang, 1982) in which a sister or a daughter was the most frequent abuser in USA This difference may be due to the fact that traditionally in Korea the burden of caring for parents rests with the eldest son and his wife in general. The finding that older men were more likely to experience abuse than women in this study, which is contrary to the findings from other studies (Hwalek et al., 1996), may be related to this tradition as well. Daughters-in-law may find it more difficult to care for their fathers-in-law than for mothers-in-law, resulting in abuse (Han, 1996). Otherwise, it may be that either the Korean older men were more outspoken about abuse than women or they were more able to consider smaller provocations from their children to be abusive than older women would. The finding that those younger
0.02 0.04 0.18 0.76 1
Fam. Relation
Very good Good Average Bad Very bad
4.84 3.5 1.61 1.92 1
4.42 3.19 1.41 1.19 1 0.11 0.18 2.51 1.91 1
0.01–0.04** 0.02–0.08** 0.08–0.39** 0.33–1.75 —
1.15 1
1.21 1.09
1.6
0.98
0.98
3.03–7.75** 2.20–5.55** 1.02–2.57* 1.16–3.15* —
0.88–2.70 —
1.54 1
Economic levela Lowest Low Middle High Highest
0.77–2.22 1.16–3.32*
1.3 1.96
Living as a couple Living with the family of a married children Living with a single children Other arrangements
0.69–2.05
1.19
1.02–1.08**
1.00–1.06
Living alone
1.05
Sick days
House hold type
1.03
IADL
0.01–0.9* 0.02–1.44 0.33–19.11 0.23–15.83 —
1.85–10.55** 1.34–7.53** 0.59–3.37 0.44–3.22 —
0.48–2.77 —
0.53–2.75 0.48–2.47
0.70–3.63
0.94–1.03
0.91–1.05
0.95–1.11
0.77–1.49 0.30–0.76** —
0.05–2.53
1.00–2.39* 0.78–1.78 0.63–1.69 —
0.80–1.81 0.79–1.74 0.71–1.62 —
0.85–1.61 —
C.I
0 0.01 0.14 0.6 1
4.1 4.09 1.66 2.56 1
1.14 1
1.25 1.71
1.7
1.05
1.02
0.97
1.01 0.51 1
0.64
1.36 1.14 1.09 1
1.1 1.07 1.36 1
1.49 1
OR
0.00–0.01** 0.00–0.02** 0.91–3.01** 1.36–4.81 —
2.23–7.55** 2.26–7.42** 0.92–3.01 1.37–4.81** —
0.57–2.26 —
0.66–2.36 0.91–3.23
0.89–3.23
1.01–1.09**
0.98–1.06
0.92–1.02
0.78–1.31 0.37–0.72** —
0.23–1.73
0.99–1.85 0.85–1.52 0.78–1.54 —
0.82–1.47 0.81–1.41 1.04–1.79* —
1.19–1.86** —
C.I
Emotional
0.03 0.06 0.2 0.58 1
9.8 5.41 2.22 1.42 1
2.57 1
1.9 2.74
1.99
1.01
1.01
0.98
1.16 0.73 1
1.65
1.98 1.32 1.12 1
1.32 1.16 1.07 1
1.39 1
OR
0.01–0.08** 0.02–0.13** 0.09–0.46** 0.24–1.39 —
0 0.01 0.15 0.61 1
3.63 3.38 1.61 2.6 1
1.15 1
1.23–5.40* — 4.89–19.60** 2.71–10.77** 1.11–4.45* 0.65–3.10 —
1.16 1.66
1.74
1.07
1.01
0.96
1.23 0.69 1
0.6
1.18 0.88 0.98 1
1.32 1.21 1.61 1
1.33 1
OR
Verbal
0.93–3.90 1.34–5.60**
0.96–4.11
0.97–1.04
0.97–1.06
0.93–1.04
0.91–1.46 0.54–0.99* —
0.79–3.47
1.46–2.69** 0.99–1.76 0.80–1.59 —
0.99–1.75 0.88–1.53 0.80–1.42 —
1.12–1.73** —
C.I
Economic
0.00–0.01** 0.00–0.02** 0.06–0.33** 0.26–1.44 —
1.92–6.86** 1.81–6.31** 0.86–2.99 1.34–5.02 —
0.56–2.37 —
0.60–2.25 0.86–3.21
0.89–3.39
1.03–1.11**
0.97–1.05
0.90–1.01
0.93–1.61 0.49–0.97* —
0.20–1.82
0.85–1.64 0.65–1.20 0.68–1.39 —
0.96–1.81 0.89–1.64 1.19–2.16** —
1.05–1.69* —
C.I
0.01 0.01 0.14 0.47 1
3.36 2.47 0.94 0.88 1
0.89 1
1.1 1
1.43
1.01
0.92
1.05
0.97 0.43 1
0.37
1.37 0.9 0.84 1
1.15 1.17 1.16 1
1.27 1
OR
Neglect
0.00–0.01** 0.00–0.03** 0.06–0.31** 0.19–1.12 —
1.67–6.74** 1.24–4.91* 0.47–1.89 0.39–2.01 —
0.41–1.89 —
0.55–2.20 0.50–1.99
0.72–2.84
0.96–1.06
0.85–0.99*
0.97–1.13
0.71–1.31 0.28–0.65** —
0.08–1.65
0.93–2.02 0.62–1.30 0.54–1.33 —
0.79–1.67 0.81–1.67 0.81–1.68 —
0.95–1.70 —
C.I
J. Oh et al. / International Journal of Nursing Studies 43 (2006) 203–214
N ¼ 15230. *po.05;**po.01. a Unit: million won.
Family
1.03
0.91–0.99*
0.96
ADL
1.08 0.74 1
*
1.07 0.48 1
0.88–1.34 0.57–0.96* —
Independent Partially supported Totally dependent
1.61 1.16 1.1 1
1.33 1.21 1.31 1
0.34
0.68–2.55
Independent and support children 1.32
Economic capacity
1.55 1.18 1.03 1
1.25–2.07** 0.92–1.47 0.83–1.46 —
No educated 1–6 years 7–9 years 10 years or more
Edu.
1.2 1.17 1.07 1
1.05–1.68* 0.97–1.53 1.04–1.65* —
65–69 years 70–74 years 75–79 years 80 years & older
Age
1.17 1
1.21–1.61** —
1.34 1
Male Female
Sex
OR
C.I
OR
Elderly
Physical
Total abuse
Categories
Characteristics
Table 8 Logistic analysis by characteristic variables of elderly and family
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than 80 years of age were more likely to be abused than this old–old group is puzzling, and requires further investigation. One probable explanation is that old persons as they age may learn helplessness from repeated abuse, and become unable to perceive or express abuse situations accurately. Economic situation of old persons seems to be a factor in elder abuse as suggested by Douglass (1988). It is possible that competent old people become the subject of exploitation by adult children and may be abused by their children for financial support. In this study the older persons who provided economic support to their children reported higher rates of economic abuse, suggesting that they were more likely to be the objects of financial exploitation that those who lack independent financial resources. The findings of this study regarding the health-status indicators on abuse suggest that lowered functioning and being sick in older persons may lead to the need for more dependent care by family members and create more situations for abuse to occur. Other studies also have shown that there is more likelihood of older persons with physical and cognitive disability to be abused (Lachs and Pillemer, 1995; Pillemer and Suitor, 1992). It seems necessary to examine this in a greater detail in order to understand the physical dependency on elder abuse. The findings regarding the family characteristics in this study provide an important insight into the relationships between family dynamics and elder abuse. The finding, especially that all kinds of abuse were more likely in the older persons living with married children, suggests the presence of a high level of conflict in this sort of household. Since there still are a large proportion of older persons who live with their married children in Korea, there is a need to examine this facet more carefully. In addition, the negative relationship between the perceived quality of family relationship and the prevalence of abuse points to the significance of family dynamics and abuse. It is possible that abuse occurs when emotional conflict between an older person and a family member has accumulated for a long time, and is an outlet for the expression of a past relationship (Kosberg, 1988). Alienation among family members and constraining of family relationships arising out of physical, emotional, and economic reasons may be factors that create a vicious cycle of abusive situations.
5. Conclusions and suggestions The study examined the prevalence of elder abuse in a population residing within a metropolitan district in Seoul, Korea, under the assumption that elder abuse is associated with older persons’ personal characteristics and family characteristics. The rate of older persons who experienced any one category of abuse was 6.3%, with
emotional abuse being the most frequent type and physical abuse the least frequent. The older persons’ age, gender, educational level, and economic dependency were significantly associated with abuse. Although the older persons’ ADL, IADL, and cognitive function level were associated with abuse, the number of sick days seems to have a large and significant effect on abuse. It may be that sick days in older persons result in situations that not only require dependency on family members but also economic burden to families. Since the family characteristics related to household type, economic level, and family relationships were also significantly related to the presence of abuse, it is critical to have an understanding of the processes of such relationships. Elder abuse is a complex phenomenon resulting from various interplay of factors in older persons, the abusers, and family characteristics as well as other contextual and situational factors, as suggested by various theoretical notions found in the literature. Although the findings from this study provides a gleaning of this interplay, there is a need to examine factors and their relationships in a more comprehensive manner, bringing into the analysis the factors related to abusers and contexts. A great deal of insights regarding elder abuse has emerged focusing on the situation of caregivers in the literature recently. A dependent older person, especially one who is cognitively or mentally deficient or disturbed, can bring about an abuse-prone situation within which the care-giver becomes over-burdened, sometimes aggravated by economic burden and stress of living with the dependent older person. However, the care-giver burden does not seem to affect elder abuse by itself, as studies have shown that family relationship is an important modifying factor. It is suggested that abuse arising from dependent victims and stressed caregivers need to be viewed in a wider context of the quality of relationships (Cooney and Mortimer, 1995; Reis and Nahmiash, 1998). In addition, the dependency of the abuser on the victim, the mental state of the abuser including emotional and psychiatric state, and a lack of external social support for the abuser continue to emerge as risk factors in the studies of elder abuse (Reis and Nahmiash, 1998; Grafstrom et al., 1994). Some in the literature have extended an explanation of abuse to a wider social context or to an ecological model incorporating individual, interpersonal, and societal factors as causal and interacting factors (Schiamberg and Gans, 1999; Kemp, 1998). The deviations found in this Korean study from those results in the US studies suggest possibilities for societal differences. The findings shown in this study point to elder abuse in Korea as a serious problem that may affect the quality of life of older persons. Often primary providers including nurses are in the best position to detect the presence of elder abuse, as
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older persons being abused may have contacts outside of the family context only in cases of illness. Nurses as advocates of older persons must not only be interested in but also be educated to be able to diagnose, report, and intervene in situations of elder abuse. The House of Commons Health Committee (2004) recommend that the identification of abuse of older people and the actions to take upon detection are instituted into the nursing curriculum. We also call for mandatory training in the recognition, reporting, and treatment of elder abuse for those professionals working and caring for older people in Korea. The introduction of regulation and national standards will, over time, bring about a process of cultural change in community-based services that should reduce of abuse. Given the scale of the problem, and the fact that care of older people will increasingly feature in nurses’ work given the aging of the population, nurses should have a consistent interest in elder abuse.
Reference AMA. 2004. Data on Violence Among Intimates. http://www. ama-assn.org/ama/pub/article/2036-5298www.ama-assn.org/ ama/pub/article/2036-5298. last assessed February 2004. Cheon, K., Song, H., 1997. A Study on the Elderly Abuse. The Korean Association of Organization for Counseling and Education. Cho, A., 2000. The state of and policy for elder abuse in Korea. Forum of Health and Welfare April, 49–61. Cho, A., Kim, S., Kim, Y., 1999. Case Study of the State on the Elderly Abuse: Among the Elderly Using the Welfare Facilities in 6 Big Cities. Korea Institute for Health and Social Affairs. Comijs, H.C., Pot, A.M., Smit, J.H., Bouter, L.M., Jonker, C., 1998. Elder abuse in the community: prevalence and consequences. Journal of the American Geriatric Society 46 (7), 885–888. Cooney, C., Mortimer, A., 1995. Elder abuse and dementia— a pilot study. International Journal of Social Psychiatry 41 (4), 276–283. Department of Health (DoH), 2000. No Secrets: Guidance on Developing and Implementing Multi-agency Policies and Procedures to Protect Vulnerable Adults from Abuse. Department of Health/Home Offices, London. Department of Health and Welfare of Korea, 2001. Report for Long-Term Care Service Development for Elderly in Korea. Douglass, R.L., 1988. Domestic Mistreatment of the Elderly Towards Prevention. American Association of Retired Persons, Washington, DC. Grafstrom, M., Nordsberg, A., Winblad, B., 1994. Abuse is in the eye of the beholder. Scandinavian Journal of Social Medicine 21 (4), 247–255. Han, D.H., 1996. A study of elder abuse. Doctor’s Thesis, Catholic University of Daegu. Korea. House of Commons Health Committee, 2004. Elder Abuse, vol. 1. HMSO, London.
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Hudson, M.F., 1991. Elder mistreatment; a taxonomy with definitions by Delphi. Journal of Elder Abuse and Neglect 3 (2), 1–20. Hwalek, M.A., Neale, A.V., Goodrich, C.S., Quinn, K., 1996. The association of elder abuse and substance abuse in the Illinois elder abuse system. The Gerontologist 36 (5), 694–700. Kane, R.A., Kane, R.L., 1988. Assessing the Elderly— A Practical Guide to Measurement. Lexington Books, Massachusetts, Toronto. Kemp, A., 1998. Abuse in family: An Introduction. Brooks/ Cole pub. Kim, H.S., 1997. A study on the current situation of elder abuse. Master’s Thesis, Soongsil University, Korea. Kosberg, J.I., 1988. Preventing elder abuse: identification of high risk factors prior to placement decisions. The Gerontologist 28 (1), 43–50. Kwon, Y.C., Park, J.H., 1989. A study on standardization of mini-mental state examination for Korean elderly(II). Journal of Korean NeuroPsychiatric Association 28 (3), 508–513. Lachs, M.S., Pillemer, K., 1995. Abuse and neglect of elderly persons. The New England Journal of Medicine 332 (7), 437–443. Levine, J.M., 2003. Elder neglect and abuse: a primer for primary care physicians. Geriatrics 58 (10), 37–44. Mahoney, F.I., Barthel, D.W., 1965. Functional evaluation: the Barthel Index. Maryland State Medical Journal 14, 61–65. McCormack, Patricia., 1980. Battered elderly suffer at hands of loved ones. Atlanta Journal and the Atlanta Constitution 9, 11. National Center on Elder Abuse, 2003 http://www.elderabusecenter.org/default.cfm?p=statistics-cfm, last assessed February 2003. O’Rourke, M., 1981. Elder abuse; the state of the art. Paper Prepared for the National Conference on the Abuse of Older Persons, Boston, MA, March 23–25. Pedirick-Cornell, C., Gelles, R.J., 1982. Elder abuse: the status of current knowledge. Family Relations 31, 457–465. Pillemer, K.A., Finkelhor, D., 1988. The prevalence of elder abuse: a random sample. The Gerontologist 28 (1), 51–57. Pillemer, Suitor, J.J., 1992. Violence and violent feelings: what causes them among family caregivers? Journal of Gerontology 47 (4), S165–S172. Rathbone-McCuan, E., 1980. Elderly victims of family violence and neglect. Social Casework 61 (4), 296–304. Reis, M., Nahmiash, D., 1998. Validation of the indicators of abuse (IOA) screen. Gerontologist 38 (4), 5–30. Schiamberg, L.B., Gans, D., 1999. An ecological framework for contextual risk factors in elder abuse by adult children. Journal of Elder Abuse and Neglect 2 (1), 79–104. Sengstock, M.C., Liang, J., 1982. Identifying and Characterizing Elder Abuse. Wayne State University Institute of Gerontology, Detroit, MI. Shiferaw, B., Mittelmark, M.B., Wofford, J.L., Andeson, R.T., Walls, P., Rohrer, B., 1994. The investigation and outcome of reported causes of elder abuse: the Forsyth County Aging Study. The Gerontologist 34 (1), 123–125. Steinmetz, S.K., 1983. Depdendency, stress, and violence between middle-aged caregivers and their elderly parents.
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In: Kosberg, J.L. (Ed.), Abuse and Maltreatment of the Elderly. John Wright, Littleton, MA, pp. 134–139. Steinmetz, S.K., 1990. Elder abuse: myth and reality. In: Brubaker, T.H. (Ed.), Family Relationships in Later Life, second ed. Sage Publishing Incorporation, Beverly Hills, CA, pp. 193–221. Voelker, R., 2002. Elder abuse and neglect a new research topic. Journal of the American Medical Association 288 (18), 2254–2256.
Further reading WHO, 2002. Krug, E.G. (Ed), World Report on Violence and Health.
International Journal of Nursing Studies 43 (2006) 203–214 www.elsevier.com/locate/ijnurstu
A study of elder abuse in Korea Jinjoo Oha,, Hesook Suzie Kimb, Diane Martinsb, Heegul Kimc a Dankook University, San29, Anseodong, Cheonan-City, ChoongNam-330-714, South Korea University of Rhode Island, College of Nursing, 21 Heathman Road, White Hall, Kingston, RI 02881-2021, USA c Kyungwon University, Korea, San29, Anseodong, Cheonan-City, ChoongNam-330-714, South Korea
b
Received 19 April 2004; received in revised form 23 February 2005; accepted 15 March 2005
Abstract This study investigates the state of elder abuse in Korea, and its related factors in a population-based survey. A total of 15,230 persons were interviewed at their homes in 1999. The rate of old people who experienced any one category of abuse was 6.3%, and emotional abuse was the most frequent while physical abuse was least prevalent. The experience of abuse seemed to be associated with personal characteristics such as age, gender, educational level, and economic dependency as well as the physical and mental health status. In addition, family characteristics such as the type of household, the family’s economic level, and the quality of family relations were found to be associated with the presence of abuse. r 2005 Elsevier Ltd. All rights reserved. Keywords: Elderly; Abuse; Korea
1. Introduction Korea is rapidly becoming ‘an aging society’ resulting from the lengthening of life expectancy that has occurred during the last two to three decades. The economic and social development Korea has experienced during the past few decades since the WWII brought about changes in every sector of Korean society, including those in family structure and processes, resulting in a changed dynamics in older adults’ lives. While traditionally the care of older persons was assumed by families under the commitment to filial piety as a strong value for family life, this commitment has weakened in general in the recent decades. In addition, Corresponding author. Tel.: +82 41 550 3884; fax: +82 41 550 3905. E-mail addresses: [email protected] (J. Oh), [email protected] (H.S. Kim), [email protected] (D. Martins).
the change from an extended family structure to a nuclear one and an increase in women working outside homes have created family situations in which older persons are often left alone at home to care for themselves. On the contrary, social preparedness for the aging society has been minimal. Although the social pension system was introduced in the mid-eighties, the income level from this pension system is very low, and the majority of older adults had not been oriented to ‘saving’ for old age and retirement. Hence, a large proportion of the elderly has no or very little independent income. It is not only necessary for many older adults to be economically dependent on their children but often the elderly parents have to rely on their children for other sorts of support because there is a lack of social and welfare facilities and services available to them (Department of Health and Welfare of Korea, 2001). Although there is no evidence linking the elderly’s dependency and abuse, or the decrease in filial piety and
0020-7489/$ - see front matter r 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2005.03.005
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abuse, there is a general suspicion that elder abuse is increasing in Korea (Cho, 2000). However, the problem of elder abuse has not received much attention either from researchers or policy makers in Korea, as the problem remains hidden behind the reluctance for public disclosure of family incidents. Elder abuse takes place in a range of settings. But, abuse in domiciliary settings is the commonest type of abuse, and the most difficult to combat. Contact between victims of abuse and statutory services may be limited, and those abused will often feel under threat, or obligation, to those abusing them. Nurses, as primary care-givers have shown great concern for the elder abuse (House of Commons Health Committee, 2004). The study by Pillemer and Finkelhor (1988) was the first large-scale random sample survey of elder abuse and neglect in the US in which they conducted interviews with 2020 community-dwelling elders. The overall prevalence rate of abuse was 3.2%, with physical abuse being most frequent. From this survey, it was estimated that between 700,000 and 1.2 million elderly individuals in the US would be victims of elder mistreatment annually. More recently the Senate Special Committee on Aging estimated nearly 5 million older persons are abused or neglected annually in the US (National Center on Elder Abuse, 2003). Based on the results of the few population-based studies in different countries, ‘‘between 4% and 6% of elderly people, are abused in some way in their homes’’. The rates from such findings, however, may not reflect the true picture, as under-reporting is greatly suspected. Douglass (1988) suggested that only 20% of all elder abuse cases were reported, so it is likely that the prevalence is underestimated. There are several possible reasons for under-reporting: (a) the elderly may not want their own family affairs revealed to others; (b) they may be afraid of negative repercussions from their abusers for the exposure; (c) the elderly may have false beliefs that the causes of abuse are within themselves (Kosberg, 1988), or (d) the elderly may not understand what is happening to them or they do not want to alert the authorities on a family member (Voelker, 2002). Voelker (2002) states that much of the literature on elder abuse is anecdotal and there is a paucity of systematic literature on the issue. The same is true regarding elder abuse in Korea. There have been problems in arriving at a satisfactory and standardized definition of abuse in general and elder abuse in particular. For example, elder abuse has been considered in terms of intentionality, outcomes, acts of omission and commission, and forms of maltreatment and neglect. Because of this confusion some researchers have adopted a definition of elder abuse restricting it to physical abuse (Rathbone-McCuan, 1980) while most researchers in the field use a broader definition that embraces all types of mistreatment or abusive behaviors
toward older adults (Pedirick-Cornell and Gelles, 1982). In this broad definition, abuse refers to an act of commission or omission, resulting in intentional or unintentional harm or injury, and in one or more types (Hudson, 1991). The Department of Health guideline on policies and procedures to protect vulnerable adults from abuse, sets out a definition of abuse as ‘‘a violation of an individual’s human and civil rights by any other person or persons’’ (Department of Health, 2000). Thus, elder abuse is not only consisting of active physical abuse of an older person (McCormack, 1980), but it also includes, in its most common and less dramatic form, exploitation, neglect, and psychological mistreatment (Pedirick-Cornell and Gelles, 1982). Within such a broad definition, elder abuse is found in a variety of types, making the classification of it difficult. Department of Health (2000) lists the main forms of abuse as physical abuse, sexual abuse, psychological abuse, financial abuse, neglects, and discriminatory abuse. American Medical Association (AMA), (2004) defined abuse in nursing homes as verbal abuse, sexual abuse, physical abuse, mental abuse, and involuntary seclusion. Korean literatures (Cho et al., 1999; Cheon and Song, 1997), after reviewing existing research, categorized elder abuse as physical, verbal and emotional, economic abuse, and neglect. There are several different explanations of elder abuse, some attributing it to the characteristics of the abused or of the abuser while others focusing on contextual characteristics such as life circumstances or family situations as the major forces that produce abuse. An explanation focusing on the characteristics of the abused has advanced the impairment and dependence hypothesis that the most likely older persons to be abused are women with severe physical or mental impairments (Lachs and Pillemer, 1995; Pillemer and Suitor, 1992), those with economic dependency (Pillemer and Finkelhor, 1988; Steinmetz, 1990), and with a low educational level (Shiferaw et al., 1994). An alternative explanation adopts the position that abuse results from certain characteristics of the family or abuser, such as family characteristics (Pillemer and Finkelhor, 1988), family dynamics (O’Rourke, 1981 [19], the quality of relationships (Cooney and Mortimer, 1995; Kosberg, 1988; Reis and Nahmiash, 1998), or personality traits of the abuser (Sengstock and Liang, 1982). Situational factors, such as caregiving stress and caregiver burden (Steinmetz, 1983) or economic crisis (Lachs and Pillemer, 1995) have also been found to be the factors present in elder abuse. O’Rourke (1981) suggests that abuse is more likely to be triggered by the interplay of several factors rather than by one single factor. While our understanding and explanation of elder abuse is incomplete, there is overwhelming evidence that elder abuse results in various sorts of negative outcomes in older persons. Elder abuse has been documented to
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cause not only specific harm, injury, or loss such as physical injury or financial loss, but also more insidious responses such as depression, anxiety, and psychological stress. Clinicians also suggest that other consequences of elder abuse include feelings of learned helplessness, alienation, guilt, shame, fear, anxiety, denial, and posttraumatic syndrome (Comijs et al., 1998). In Korea, nurses’ work as primary health providers in public health care centers located nationwide, in home care visiting center and in social welfare center. They are in good positions to keep on eye on elder abuse, and as advocates of the elderly can affect a great deal in detecting and reporting elder abuse, but we are concerned that the area of elder abuse does not currently form a mandatory part of the training for nurses. Often nurses take no action because they lack training in identifying abuse or are ignorant of the reporting procedures. This is from the low level of social awareness in part and from dearth of research in part. The lack of reporting results in difficulties in determining the true scale of the problem and this is compounded by a dearth of research. The literature on elder abuse in Korea is scanty, and the knowledge of it is mostly based on anecdotal findings or from studies with small, purposive samples, suggesting that there is a need for a comprehensive picture of elder abuse. Fundamental point in the prevention of elder abuse is the recognition that it exists within society. Given the scale of the problem, and the fact that care of older people will increasingly feature in nurses’ work given the aging of the population, we think that the research on elder abuse is the utmost important task. (House of Commons Health Committee, 2004). In recognition of this the present study was carried out in order to obtain the baseline data on elder abuse in Korea using a population-based sample of older persons. More specifically it investigated the prevalence rate of elder abuse by types of abuse, and examined the relationships between abuse and the characteristics of the older persons and family. The study was based on the premise that elder abuse is associated with the selected personal characteristics of the older persons, of the family, and the quality of family relationships.
2. Methods This was a population-based survey of a sample of older adults residing in Seoul, Korea conducted in 1999, carried out under the auspice of the Public Health Service Center of a district within the city. Seoul, the capital city of Korea, is composed of 25 Gu’s which are city districts dividing the city into geographic regions for administrative purposes. Songpa Gu within which this
205
survey was conducted has the largest population among the entire districts in Seoul, with an estimated population of 668,900 persons in 1999 among which 4.4% (29,439) were older adults. The elderly population in this district has been increasing rapidly, which made it critical for the Public Health Center to consider developing a program for health promotion for older adults. The survey was carried out as an initial effort for the assessment of health care needs of the older adults in this district. And this paper reports on the results pertaining to elder abuse only. 2.1. Subjects
The
entire population of older adults aged 65 and older living in a Gu was the target population for the survey. The names and addresses of the older adults registered as residents of this district were obtained from the governmental administrative office, and the confirmation on each person’s actual living status was made by telephone. The final sample for the survey consisted of 15,700 persons, which was 53% of the entire elderly population in the district, obtained with the deletion of persons who moved to other districts, died, were unavailable for interview because they were staying someplace else, or refused to be interviewed. This study used the data from 15,230 persons of the total of 15,700 interviews, excluding those with missing data or suspected of having answered untruthfully or inaccurately to interview questions. There were two reviewers to examine all questionnaires one by one. They examined thoroughly if there was any inconsistency among items or if there were many missing items. The two population groups (those surveyed and not surveyed) could not be compared in terms of the demographic and other key characteristics, suggesting a possibility of some bias in the sample. However, there was no obvious factor that could be identified to have influenced the selection bias in the sample in a systematic fashion. The demographic and personal characteristics of the sample are shown in Table 1.
2.2. Method of data collection The data were collected by interviews held at the subjects’ homes during the period from January 1999 to December 1999. The interviews were carried out by 30 interviewers who were registered nurses and trained for interviewing during a 3-day training session conducted by three faculty members of colleges of nursing in Korea. The interviews were carried out using a structured interview schedule. Each potential subject was telephoned for an initial permission for a home visit. When the interviewers made the home-visits for
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Table 1 General characteristics of the subjects Total
Elderly
Family
N
%
Sex
Male Female
5287 9943
34.7 65.3
Age
65–69 years 70–74 years 75–79 years 80 years and older
4928 4264 3218 2820
32 28 21.1 18.5
Educational level
N schooling 1–6 years 7–9 years 10 years or more
5167 4396 1789 3878
33.9 28.9 11.7 25.5
Economic dependency
Independent and Support children Independent Partially supported Totally dependent
221 3647 1528 9834
1.4 23.9 10 64.7
Type of household
Living alone Living as a couple Living with the family of a married children Living with a single children Other arrangement
1528 4039 7966 1331 388
10 26.5 52.3 8.7 2.5
Economic level
Lowest Low Middle High Highest
3146 3668 5238 1993 1185
20.7 24.1 34.5 13 7.7
Family relationship
Very good Good Average Bad Very bad
3805 7077 4071 248 29
25.1 46.6 26.9 1.3 0.2
N ¼ 15230.
interview, they explained the aims of the study and reobtained the subjects’ consent before proceeding with the interviews. 2.3. Instruments The interview schedule consisted of five sections: (a) general demographic/personal characteristics, (b) health and functional status items, (c) items on abuse, (d) family characteristics, and (e) elderly family relationship. The items within the interview schedule were all close-ended, either structured in Likert-type scales, into sets of pre-established categories, or in numerical scales. A. Demographic/personal characteristics: The items included in this section were age in years, gender, years
of education completed, and economic dependency of the older adult measured in four categories of totally independent and supporting children, independent, partially supported by children, and totally dependent on children. B. Health and functional status: Four specific measures were used to measure these aspects: (a) activities of daily living (ADL) was measured by Barthel Index (Mahoney and Barthel, 1965) which is a Likert-type scale using three points resulting in scores ranging from 1 to 27, with lower scores indicating higher functional ability; (b) instrumental activities of daily living (IADL) was measured by PGC-IADL (Kane and Kane, 1988) which also is a Likert-type scale with three points resulting in a range of scores from 1 to 24 with lower scores indicating higher functional ability; (c) sick-days was measured by the number of
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sick days during the month immediately preceding the interview; and (d) cognitive function level was measured by MMSE-K developed by Kwon and Park (1989) for Korean older adults, which ranged from 0 to 30 with higher scores indicating higher cognitive function level. C. Measurements of abuse: Elder abuse was classified as physical, emotional, economic, and verbal abuse, and neglect. A total of 25 items, five for each type, were included in the instrument. The items were compiled through a comprehensive review of the literature (DoH, 2000; AMA, 2004; Cho et al., 1999; Cheon and Song, 1997; Han, 1996) and were validated by three nurse researchers with gerontological nursing expertise. The instrument was pretested with five older adults living in community in order to validate the clarity of meaning and appropriate use of the language. The responders were asked to indicate the number of incidences with which each item was experienced during the month preceding the interview. Two values were obtained from the responses to this instrument: (a) the presence/absence of abuse, for which the responders were categorized as the abused if they experienced abuse of any type for more than two times during the month, and (b) the total abuse by summing the number of incidences in all 25 items. Originally, the data were gathered using five likert scales for abuse ; above 3 times per week, 1–2 times per week, 2–3 times per month, below 1 time per month, none. But in the statistical process, we found that the most of the elder abuse in ‘‘below 1 time per month’’ a nd ‘‘none’’ was verbal abuse and they showed no statistical implication showing that they were in need of help. As the goal of this survey was to sort out the group of elderly who were in need of imminent intervention from official governmental organizations, we decided to categorize those who were in ‘‘above 3 times per week’’, ‘‘1–2 times per week’’, ‘‘2–3 times per month’’ as abused. By doing this we also found that it increased the reliability of the instrument from Chronbach’s a ¼ nearly .7–.92. D. Family characteristics: Two family characteristics were measured: (a) the types of household categorized as living alone, elderly couple by themselves, living with married child/children, living with unmarried child/children, and other arrangements; and (b) family economic level measured in five income levels. E. Family relationship: The older adult’s perception of his/her relationship with family members was measured by one item that rated the relationship as very good, good, average, bad, and very bad.
207
2.4. Data analysis The general characteristics of the subjects were analyzed using descriptive statistics. T-test and w2 test were used to examine the differences in personal and family variables in relation to elder abuse, and logistic analysis was applied to examine the different magnitudes of influence by each variable on elder abuse. 2.5. Limitations Because the final sample for the study was not a randomly drawn one, and because the comparison between those surveyed and not-surveyed was not made in terms of the demographic and characteristics, suggesting a possibility of some bias in the sample, there is a possibility that it does not represent the population in the district. Furthermore, although the older persons living in SongpaGu may not be too different in their characteristics from those living in Seoul, this was not ascertained in this study. In this respect, the findings in this study may not be representative of those living in Seoul or the Korean elderly in general. This study used data which were collected through personal face-to-face interviews with the older persons at their homes. The responders might have not been totally free to talk about abuse especially when other members of the household were present at home during the interviews. And we could not exclude the possibility that the survey might not include the most frail and vulnerable older people who might be more at risk of abuse than the general older population. Thus, there is a possibility of abuse to have been under reported. In addition, the characteristics of the abuser or situational stress which are also suggested as major contributing factors on elder abuse in the literature were not included in this survey.
3. Results Table 2 shows the rates of abuse, indicating, in general, that between 1.6% and 3.7% of the older persons, experienced abuse of one type or another. The emotional abuse types occurred more frequently than other types, with more than 3% experiencing it in all five categories of emotional abuse. Abuses that are physically oriented were least frequent among the abuse types. Table 3 shows the number of older persons who experienced any one of the abuse types, which also indicates the highest prevalence rate in emotional abuse, with the total prevalence rate of 6.3% for this population. The identity of the abuser is given in Table 4, which shows more than two-third (75% to 80%) of all abuse was by the older persons’ sons or
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Table 2 The prevalence abuse by each items Item
Yes
No
N
%
N
%
Physical abuse
Throw things Push/grasp firmly Beat/kick Beat/threaten with objects Threaten with arms
281 263 265 256 254
1.9 1.7 1.7 1.7 1.6
14944 14964 14971 14972 14972
98.1 98.2 98.3 98.3 98.3
Emotional abuse
Use inconsistent approaches Insult/degrade Give signs of rejection Show dissatisfaction Show signs of indifference
499 455 551 548 497
3.2 3 3.5 3.7 3.3
14730 14774 14682 14681 14732
96.7 97.1 96.5 96.3 96.7
Economic abuse
Withhold spending money Refuse lending money when needed Forcibly take money or jewelry Spend money without permission Force to earn money
522 338 291 390 273
3.5 2.2 1.9 2.6 1.7
14706 14889 14937 14838 14935
96.6 96.7 98 97.4 98.1
Verbal abuse
Use reproachful languages Use hostile languages Express rejection Express despise or disregard Use violent language or tone.
514 467 496 430 385
3.4 3 3.3 2.8 2.6
14715 14763 14734 14806 14843
96.6 96.9 96.7 97.1 97.4
Neglect
Leave alone for a long time Do not give care when ill Do not help in seeking health care Withhold prescribed drugs Withhold food
327 353 337 311 297
2.1 2.3 2.2 2.1 1.9
14909 14875 14891 14917 14930
97.8 97.6 97.8 98 98
N ¼ 15230. Table 3 Prevalence of experience by categories of abuse Categories of abuse
Physical abuse Emotional abuse Economic abuse Verbal abuse Neglect Total abuse
Abused N
% of total
285 638 624 551 370 962
1.9 4.2 4.1 3.6 2.4 6.3
N ¼ 15230.
daughters-in-law. The total number of abused older persons in Table 3 and the total number of abuser are different because they were obtained in two different questions. Tables 5–7 show the distributions in the abused versus not-abused groups according to the older persons’ gender, age, educational level, economic dependency,
health-status indicators, and family characteristics. Of the background variables, the educational level was the only factor that showed a significant difference by w2 test. On the other hand, all four indicators of healthstatus were found to be significantly different by t-tests between the abused and not-abused groups, with the abused group having the lower levels of ADL, IADL, and cognitive functioning, and more sick days. Furthermore as shown in Table 7, the distributions in the abused and not-abused groups were significantly different according to the type of household, the family’s economic level, and the perceived family relationship by w2 tests. Those living alone, the family in the lowest economic level, and those with the perception of ‘very bad’ family relationships were mostly likely to be abused than the others of the sample. A logistic analysis to examine the contribution of different factors on elder abuse was performed including the background factors, health-status indicators, and family characteristics, the results of which are shown in Table 8. As indicated by the odds ratios shown in this table, the prevalence rates of abuse in the older men were significantly higher in
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209
Table 4 Main abuser by categories of abuse Categories of abuse Spouse
Physical Emotional Economic Verbal Neglect
Son
Daughter
Son-in-law
Daughter -in-law
Grandson
Etc.
Total
N
%
N
%
N
%
N
%
N
%
N
%
N
%
N
%
45 38 31 32 32
12.2 5.5 8.5 5.3 8
143 249 170 242 139
38.8 37.8 35.5 40 34.8
47 41 32 41 28
12.7 8.2 8.7 8.8 7
5 11 4 12 2
1.4 1.7 0.8 2 0.5
81 247 170 214 147
22 37.5 35.5 35.4 38.8
4 9 8 7 4
1.1 1.1 1.1 1.1 1.1
44 84 59 54 50
11.9 9.7 12.3 8.8 0.3
389 875 479 802 402
100 100 100 100 100
Dual response permitted.
Table 5 Influencing factors on elder abuse (I) Abused
X2
Non abused
N
%
N
%
Sex
Male Female
308 640
5.94 6.5
4979 9303
94.06 93.5
1.08 (p ¼ :08)
Age
65–69 years 70–74 years 75–79 years 80 years & older
279 269 230 186
5.64 6.29 7.12 6.56
4649 3995 2988 2664
94.36 93.71 92.88 93.44
7.59 (p ¼ :06)
Educational level
No schooling 1–6 years 7–9 years 10 years or more
435 278 105 155
8.35 6.24 5.67 3.9
4729 4116 1681 3721
91.65 93.76 94.33 96.1
75.89 (p ¼ :00)
Economic dependency
Independent & support children Independent Partially supported Totally dependent
15 216 106 628
5.56 5.85 6.76 6.36
206 3430 1422 9206
94.4 94.15 93.24 93.64
2.05 (p ¼ :56)
N ¼ 15230.
Table 6 Characteristics of elderly influencing on abuse (II) Abused
Physical health
Cognition
ADL IADL Sick days MMSE-K
Non-abused
X
SD
X
SD
.71 1.56 4.36 25.75
2.88 3.57 2.80 4.29
.46 .96 3.68 26.81
2.40 3.03 2.84 3.25
total abuse, emotional abuse, economic abuse, and verbal abuse than in the older women, and those in the oldest age group (over 80 years of age) were least likely to be abused in comparison to other age groups. Those with no education were most likely to be abused in comparison to those with above high school education
t
p
2.98 6.63 7.18 8.1
0 0 0 0
at the odd ratio of 1.61. Those who were partially supported were least likely to be abused, while those who were totally supported or independent were more likely to be abused in all types except with respect to economic abuse in which those who were independent and giving support to their children were most likely to
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Table 7 Family characteristics influencing on abuse Abused N
Non-abused %
N
%
X2
Type of household
Living alone Living as a couple Living with the family of a married children Living with unmarried children Other arrangement
128 227 496 88 26
8.32 5.6 6.22 6.55 6.49
1400 3812 7650 1243 361
91.68 94.4 93.78 93.45 93.51
45.2 (p ¼ :00)
Economic levela
Lowest Low 100–249 High Highest
360 281 244 95 37
11.12 7.36 4.43 4.17 2.07
2786 3388 4995 1899 1148
88.8 92.64 95.57 95.83 97.93
210.79 (p ¼ :00)
Family relationship
Very good Good Average Bad Very bad
92 251 590 123 44
1.17 3.2 3.76 14 49.74
3811 6768 3479 123 40
98.29 96.8 86 50.26 44.83
1390 (p ¼ :00)
N ¼ 15230. a Unit: million won.
be abused. The results of the logistic analysis regarding the health-status indicators were the same as the t-test results, with those having the lowest IADL and cognitive function level, and the sickest days being most likely to be abused. The results of the logistic analysis also show that those living with married children were most likely to be abused in general than others, and those in the lowest level of family income were also most likely to be abused in all areas at drastically higher levels in comparison to the highest income level. The older persons who perceived their family relationships to be ‘very bad’ were most likely to be abused in comparison to others, except in the case of physical abuse with which those with average or ‘bad’ family relationships seemed to have higher prevalence of abuse.
4. Discussion The results of this study show the prevalence rate of elder abuse in a Korean population group at 1.94.2% in various types of abuse. These rates are higher than the rates in the USA (.19–2.2%) (Pillemer and Finkelhor, 1988), but on par with the estimated rates of 3–5% by Levine (2003) who howed prevalence of elder abuse in USA varies from 3% to 5%. This level of elder abuse in Korea similar to those found in western societies may suggest a deterioration of the Korean traditional values of respecting elders and filial piety.
Although the abuse rates by type vary in different studies, it is often reported that psychological and physical abuse (Pillemer and Finkelhor, 1988) is the most frequent type. In this study, emotional abuse was the most frequent type while physical abuse was the least prevalent one. This result is similar to the results from other studies in Korea (Han, 1996; Kim, 1997). Since the idea of filial piety is still explicitly dominant in Korea and physical harm to old people is taboo, it seems that mainly emotional type of abuse may be the form which is taken. The most frequent abuser in every kind of abuse types was a son followed by a daughter-in-law in this study. Although this result is similar to the findings from other Korean studies (Han, 1996; Kim, 1997), it was different from studies done in other countries (Sengstock and Liang, 1982) in which a sister or a daughter was the most frequent abuser in USA This difference may be due to the fact that traditionally in Korea the burden of caring for parents rests with the eldest son and his wife in general. The finding that older men were more likely to experience abuse than women in this study, which is contrary to the findings from other studies (Hwalek et al., 1996), may be related to this tradition as well. Daughters-in-law may find it more difficult to care for their fathers-in-law than for mothers-in-law, resulting in abuse (Han, 1996). Otherwise, it may be that either the Korean older men were more outspoken about abuse than women or they were more able to consider smaller provocations from their children to be abusive than older women would. The finding that those younger
0.02 0.04 0.18 0.76 1
Fam. Relation
Very good Good Average Bad Very bad
4.84 3.5 1.61 1.92 1
4.42 3.19 1.41 1.19 1 0.11 0.18 2.51 1.91 1
0.01–0.04** 0.02–0.08** 0.08–0.39** 0.33–1.75 —
1.15 1
1.21 1.09
1.6
0.98
0.98
3.03–7.75** 2.20–5.55** 1.02–2.57* 1.16–3.15* —
0.88–2.70 —
1.54 1
Economic levela Lowest Low Middle High Highest
0.77–2.22 1.16–3.32*
1.3 1.96
Living as a couple Living with the family of a married children Living with a single children Other arrangements
0.69–2.05
1.19
1.02–1.08**
1.00–1.06
Living alone
1.05
Sick days
House hold type
1.03
IADL
0.01–0.9* 0.02–1.44 0.33–19.11 0.23–15.83 —
1.85–10.55** 1.34–7.53** 0.59–3.37 0.44–3.22 —
0.48–2.77 —
0.53–2.75 0.48–2.47
0.70–3.63
0.94–1.03
0.91–1.05
0.95–1.11
0.77–1.49 0.30–0.76** —
0.05–2.53
1.00–2.39* 0.78–1.78 0.63–1.69 —
0.80–1.81 0.79–1.74 0.71–1.62 —
0.85–1.61 —
C.I
0 0.01 0.14 0.6 1
4.1 4.09 1.66 2.56 1
1.14 1
1.25 1.71
1.7
1.05
1.02
0.97
1.01 0.51 1
0.64
1.36 1.14 1.09 1
1.1 1.07 1.36 1
1.49 1
OR
0.00–0.01** 0.00–0.02** 0.91–3.01** 1.36–4.81 —
2.23–7.55** 2.26–7.42** 0.92–3.01 1.37–4.81** —
0.57–2.26 —
0.66–2.36 0.91–3.23
0.89–3.23
1.01–1.09**
0.98–1.06
0.92–1.02
0.78–1.31 0.37–0.72** —
0.23–1.73
0.99–1.85 0.85–1.52 0.78–1.54 —
0.82–1.47 0.81–1.41 1.04–1.79* —
1.19–1.86** —
C.I
Emotional
0.03 0.06 0.2 0.58 1
9.8 5.41 2.22 1.42 1
2.57 1
1.9 2.74
1.99
1.01
1.01
0.98
1.16 0.73 1
1.65
1.98 1.32 1.12 1
1.32 1.16 1.07 1
1.39 1
OR
0.01–0.08** 0.02–0.13** 0.09–0.46** 0.24–1.39 —
0 0.01 0.15 0.61 1
3.63 3.38 1.61 2.6 1
1.15 1
1.23–5.40* — 4.89–19.60** 2.71–10.77** 1.11–4.45* 0.65–3.10 —
1.16 1.66
1.74
1.07
1.01
0.96
1.23 0.69 1
0.6
1.18 0.88 0.98 1
1.32 1.21 1.61 1
1.33 1
OR
Verbal
0.93–3.90 1.34–5.60**
0.96–4.11
0.97–1.04
0.97–1.06
0.93–1.04
0.91–1.46 0.54–0.99* —
0.79–3.47
1.46–2.69** 0.99–1.76 0.80–1.59 —
0.99–1.75 0.88–1.53 0.80–1.42 —
1.12–1.73** —
C.I
Economic
0.00–0.01** 0.00–0.02** 0.06–0.33** 0.26–1.44 —
1.92–6.86** 1.81–6.31** 0.86–2.99 1.34–5.02 —
0.56–2.37 —
0.60–2.25 0.86–3.21
0.89–3.39
1.03–1.11**
0.97–1.05
0.90–1.01
0.93–1.61 0.49–0.97* —
0.20–1.82
0.85–1.64 0.65–1.20 0.68–1.39 —
0.96–1.81 0.89–1.64 1.19–2.16** —
1.05–1.69* —
C.I
0.01 0.01 0.14 0.47 1
3.36 2.47 0.94 0.88 1
0.89 1
1.1 1
1.43
1.01
0.92
1.05
0.97 0.43 1
0.37
1.37 0.9 0.84 1
1.15 1.17 1.16 1
1.27 1
OR
Neglect
0.00–0.01** 0.00–0.03** 0.06–0.31** 0.19–1.12 —
1.67–6.74** 1.24–4.91* 0.47–1.89 0.39–2.01 —
0.41–1.89 —
0.55–2.20 0.50–1.99
0.72–2.84
0.96–1.06
0.85–0.99*
0.97–1.13
0.71–1.31 0.28–0.65** —
0.08–1.65
0.93–2.02 0.62–1.30 0.54–1.33 —
0.79–1.67 0.81–1.67 0.81–1.68 —
0.95–1.70 —
C.I
J. Oh et al. / International Journal of Nursing Studies 43 (2006) 203–214
N ¼ 15230. *po.05;**po.01. a Unit: million won.
Family
1.03
0.91–0.99*
0.96
ADL
1.08 0.74 1
*
1.07 0.48 1
0.88–1.34 0.57–0.96* —
Independent Partially supported Totally dependent
1.61 1.16 1.1 1
1.33 1.21 1.31 1
0.34
0.68–2.55
Independent and support children 1.32
Economic capacity
1.55 1.18 1.03 1
1.25–2.07** 0.92–1.47 0.83–1.46 —
No educated 1–6 years 7–9 years 10 years or more
Edu.
1.2 1.17 1.07 1
1.05–1.68* 0.97–1.53 1.04–1.65* —
65–69 years 70–74 years 75–79 years 80 years & older
Age
1.17 1
1.21–1.61** —
1.34 1
Male Female
Sex
OR
C.I
OR
Elderly
Physical
Total abuse
Categories
Characteristics
Table 8 Logistic analysis by characteristic variables of elderly and family
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than 80 years of age were more likely to be abused than this old–old group is puzzling, and requires further investigation. One probable explanation is that old persons as they age may learn helplessness from repeated abuse, and become unable to perceive or express abuse situations accurately. Economic situation of old persons seems to be a factor in elder abuse as suggested by Douglass (1988). It is possible that competent old people become the subject of exploitation by adult children and may be abused by their children for financial support. In this study the older persons who provided economic support to their children reported higher rates of economic abuse, suggesting that they were more likely to be the objects of financial exploitation that those who lack independent financial resources. The findings of this study regarding the health-status indicators on abuse suggest that lowered functioning and being sick in older persons may lead to the need for more dependent care by family members and create more situations for abuse to occur. Other studies also have shown that there is more likelihood of older persons with physical and cognitive disability to be abused (Lachs and Pillemer, 1995; Pillemer and Suitor, 1992). It seems necessary to examine this in a greater detail in order to understand the physical dependency on elder abuse. The findings regarding the family characteristics in this study provide an important insight into the relationships between family dynamics and elder abuse. The finding, especially that all kinds of abuse were more likely in the older persons living with married children, suggests the presence of a high level of conflict in this sort of household. Since there still are a large proportion of older persons who live with their married children in Korea, there is a need to examine this facet more carefully. In addition, the negative relationship between the perceived quality of family relationship and the prevalence of abuse points to the significance of family dynamics and abuse. It is possible that abuse occurs when emotional conflict between an older person and a family member has accumulated for a long time, and is an outlet for the expression of a past relationship (Kosberg, 1988). Alienation among family members and constraining of family relationships arising out of physical, emotional, and economic reasons may be factors that create a vicious cycle of abusive situations.
5. Conclusions and suggestions The study examined the prevalence of elder abuse in a population residing within a metropolitan district in Seoul, Korea, under the assumption that elder abuse is associated with older persons’ personal characteristics and family characteristics. The rate of older persons who experienced any one category of abuse was 6.3%, with
emotional abuse being the most frequent type and physical abuse the least frequent. The older persons’ age, gender, educational level, and economic dependency were significantly associated with abuse. Although the older persons’ ADL, IADL, and cognitive function level were associated with abuse, the number of sick days seems to have a large and significant effect on abuse. It may be that sick days in older persons result in situations that not only require dependency on family members but also economic burden to families. Since the family characteristics related to household type, economic level, and family relationships were also significantly related to the presence of abuse, it is critical to have an understanding of the processes of such relationships. Elder abuse is a complex phenomenon resulting from various interplay of factors in older persons, the abusers, and family characteristics as well as other contextual and situational factors, as suggested by various theoretical notions found in the literature. Although the findings from this study provides a gleaning of this interplay, there is a need to examine factors and their relationships in a more comprehensive manner, bringing into the analysis the factors related to abusers and contexts. A great deal of insights regarding elder abuse has emerged focusing on the situation of caregivers in the literature recently. A dependent older person, especially one who is cognitively or mentally deficient or disturbed, can bring about an abuse-prone situation within which the care-giver becomes over-burdened, sometimes aggravated by economic burden and stress of living with the dependent older person. However, the care-giver burden does not seem to affect elder abuse by itself, as studies have shown that family relationship is an important modifying factor. It is suggested that abuse arising from dependent victims and stressed caregivers need to be viewed in a wider context of the quality of relationships (Cooney and Mortimer, 1995; Reis and Nahmiash, 1998). In addition, the dependency of the abuser on the victim, the mental state of the abuser including emotional and psychiatric state, and a lack of external social support for the abuser continue to emerge as risk factors in the studies of elder abuse (Reis and Nahmiash, 1998; Grafstrom et al., 1994). Some in the literature have extended an explanation of abuse to a wider social context or to an ecological model incorporating individual, interpersonal, and societal factors as causal and interacting factors (Schiamberg and Gans, 1999; Kemp, 1998). The deviations found in this Korean study from those results in the US studies suggest possibilities for societal differences. The findings shown in this study point to elder abuse in Korea as a serious problem that may affect the quality of life of older persons. Often primary providers including nurses are in the best position to detect the presence of elder abuse, as
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older persons being abused may have contacts outside of the family context only in cases of illness. Nurses as advocates of older persons must not only be interested in but also be educated to be able to diagnose, report, and intervene in situations of elder abuse. The House of Commons Health Committee (2004) recommend that the identification of abuse of older people and the actions to take upon detection are instituted into the nursing curriculum. We also call for mandatory training in the recognition, reporting, and treatment of elder abuse for those professionals working and caring for older people in Korea. The introduction of regulation and national standards will, over time, bring about a process of cultural change in community-based services that should reduce of abuse. Given the scale of the problem, and the fact that care of older people will increasingly feature in nurses’ work given the aging of the population, nurses should have a consistent interest in elder abuse.
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In: Kosberg, J.L. (Ed.), Abuse and Maltreatment of the Elderly. John Wright, Littleton, MA, pp. 134–139. Steinmetz, S.K., 1990. Elder abuse: myth and reality. In: Brubaker, T.H. (Ed.), Family Relationships in Later Life, second ed. Sage Publishing Incorporation, Beverly Hills, CA, pp. 193–221. Voelker, R., 2002. Elder abuse and neglect a new research topic. Journal of the American Medical Association 288 (18), 2254–2256.
Further reading WHO, 2002. Krug, E.G. (Ed), World Report on Violence and Health.