Abuse Experienced by Elderly Residing in a Community of Pokhara, Nepal

Background: Abuse of the elderly is a hidden problem in Nepalese community. Pokhara city is highly affected by urbanization, modernization and migration that predispose older adults to social isolation and financial difficulties increasing their risk to abuse. This study aims to fill the gap in the knowledge in the area of abuse of elderly in Pokhara city. Objectives: The major objective of this study was to determine the prevalence of caregiver abuse experienced by the older adults and find out the factors associated with the abuse. Method: This was a cross sectional study. Convenience sampling technique was used and data was collected from 192 elderly above the age of 60 years residing a community of Pokhara-28, Kaski at their households using a structured interview schedule. Data was collected in June 2018, for a period of one month. Before data collection, informed written consent was taken from participants. The data was analyzed by using SPSS-16 and chi-square test was used as inferential statistics to determine the association between the elder abuse and selected variables. Result: We found out that 65.6% of the elderly experienced at least one form of abuse in the last 6 months. The most common forms of abuse were caregiver neglect (55.2%) and psychological abuse (38.5%). The elderly abuse was statistically significant with female sex (p=0.001), unmarried/widow/widower/ separated/divorced (p=.021), illiterate (p=0.002), and among those having chronic illness (p=0.003). Conclusion: Almost 7 out of 10 elderly experienced abuse in the past 6 months. The most common form of abuse was caregiver neglect followed by psychological and financial abuse. Older adults who were females, unmarried/widowed/separated/ divorced, illiterate and those having chronic disease were at higher risk for abuse.


INTRODUCTION
Worldwide, older adults are the fastest growing segment of the population. 1 Many developed countries have adopted the chronological age of 65 years to define older adults, 2 however, in Nepal 60+ years is referred to as older citizens. 3 Abuse of the older adults is a social problem throughout the globe. World Health Organisation (WHO) has defined elder abuse as "a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person". Elder abuse can take various forms that include physical, psychological, sexual and financial. 6 It can also result from intentional or unintentional neglect. WHO estimates that 15.7% of people 60 years and older are subjected to abuse. 6 Various changes in older adults increase their risk of being abused. Older adults experience physical weakness and are dependent on others. [5][6] Further, longevity of the older adults, erosions of the norms and values that supported the elders and provided them with respect in the families and the community, have made older adults at risk for abuse. [7][8][9] The social security system of a country have some role in preventing abuse among the older adults. The Government of Nepal has implemented some provisions to support the older adults but studies suggest that they are not enough to address the needs of the older adults. [10][11] Studies suggest a high prevalence of abuse of elderly in Nepal. [12][13] Elder abuse is a growing problem in Nepal and urgently requiring the attention of the government. Older abuse is a hidden and an underestimated and understudied problem in Nepal. Studies on the abuse of elderly in Nepal are very scant. Pokhara is one of the cities from where a huge number of young adults migrate to the foreign land for job each year leaving behind their older parents at their homes. Family disintegration due to migration and increased dependence due to ageing causes social isolation and lack of support to the elderly which increases the risk of their abuse. [14][15] However, no any similar studies has been conducted in Pokhara to study the status of abuse of older adults. Therefore, the researchers have chosen this topic in order to explore the abuse faced by elders in the city to fill in the gap in the knowledge in the field.

MATERIALS AND METHODS
This is a cross sectional study carried out in Pokhara city to assess the prevalence of abuse among elders residing in the city. The population for the study was older adults aged over 60 years (completed 60 th birthday) residing in the community of Kalika, Pokhara-28.
Convenience sampling technique was used to collect data from 192 study participants. Male or Female elders aged who were above the age of 60 years and were residing in the community and willing to participate in the study were included in the study. Elders who could not communicate either due to language problem or due to hearing problem or having severe mental illness and those not willing to participate in the study were excluded from the study.
Structured interview schedule was used for data collection. The tool was developed by the researchers themselves being based on the literature review and other validated tools 16,17,18,19 Validity of the instrument was established by developing instrument on the basis of literature review and consultation with experts in the related area. Pretesting of the instrument was done in 10% population in ward no. 12 of total estimated size to assess clarity, adequacy, and consistency of the tool. After pretesting, some modification was made in the tool to make questions simpler and clear. The data was checked for reliability and the chronbach's alpha value for the tool was 0.71, which is within the acceptable level. 20 Prior to data collection permission was taken from the research committee of Pokhara Campus. Then formal permission for study was taken from concerned ward for the study. Then, the household were selected conveniently. The elderly living in the household were identified; they were explained about the purpose of the study and their participation in the study. They were explained that they can leave the interview any time if they wish to discontinue. Then, informed written consent for the study was taken, and after obtaining the consent, face to face interview was taken. Interview was taken in a separate room in the house. For those houses where there was no separate room to maintain privacy, data was collected in the field where no one was present. In the household with more than one elders, data was collected from all the elderly in the household separately. Data was collected for a period of one month in June, 2018.
The duration for interview for each participant was 20-30 minutes. Confidentiality was ensured by using the information for the research purpose only. Privacy was maintained while collecting data from each study participants by taking the data in a separate place, away from the family/group. Data was collected by researcher themselves. Obtained data was used for the study purpose only.
Further to data collection, in co-ordination with the "Mothers' Groups" of the ward, a class was organized to the community people regarding physical and psychological support for elderly and legal provisions set by the Nepal Government regarding protection and support of the elderly.
The collected data was reviewed, organized, edited and coded using SPSS (statistical Package for Social Sciences) version 16, data was analyzed using descriptive statistics (interpreted in terms of frequency, percentage, mean and standard deviation) and Chi-square test was used as an inferential statistics to find out the association of abuse with socio-demographic characteristics.
In this study, physical abuse refers to pushing, slapping, throwing something at, handling roughly, or beating the elderly. Psychological abuse in this study refers to yelling or speaking bitter words at elderly for their poor personal functioning, blaming elderly for anything they did not do, threatening or shouting cursing the elderly, and criticizing, insulting, excluding or ignoring the older adults. Financial abuse in this study refers to forcing elderly to spend their money against their will or restricting elderly to spend money against will and forcing elderly to sign financial papers against will. Neglect in this study refers to not including elderly in decision making related to them, refraining elderly from buying food, clothes, medicines and other commodities as needed. Sexual abuse in this study refers to forcing elderly by others including spouse for natural/unnatural sexual intercourse despite will. Elderly who scored positive response in any of the 10 questions indicating abuse were categorized as being abused.

RESULTS
This study revealed that more than half of the elderly were within the age of 60-69 years (53.1%) and were females (53.1%). Majority of elders were married and living with spouse (74.0%), 63.5% of them were from nuclear family and 97.9% had their children. More than half of the participants had attained primary education (52.6%) and 75% of the total participants were currently unemployed, and 31.2% of the elderly had their old age incentive as their major source of income. However, 77.1% of the participants had their own property, and 84.4% reported that they got help from their family members in need. (Table 1) Majority of the elderly living in the community had chronic illness (63.5%) and 61.5% were taking medicine for the conditions whereas 9.4% had disabilities. Among the elders, 4.2% had hearing problem. Regarding personal habits, 33.3% of elders reported that they smoke and/or intake   Table 2). Out of total respondents, 65.6% of the elderly reported that they experienced some form of abuse over the past 6 months. Among the total participants, 55.2% reported that they experienced neglect followed by psychological abuse (38.5%) while the least reported physical abuse (3.1%). (Table 3). This study showed a significant association of elderly abuse with female sex (p=0.001), female sex (p=0.001), illiteracy (p=0.002) and unmarried/widowed/separated/ divorced (p=0.021) and illiteracy (p=0.002) but no any significant association could be seen with age, type of family and employment status. (Table 4) This study showed that elder abuse is significantly associated with having chronic illness (p=0.003). However no significant association could be seen between abuse of elderly with alcohol intake, having property, having disabilities and dependency status. (Table 5)

Elder abuse is a common social problem in Nepal.
This study revealed that 65.6% of the elderly experienced some forms of abuse in the past 6 months. More than half of the elderly (55.2%) reported that they experienced caregiver neglect followed by 38.5% of the elders who reported psychological abuse. The finding is higher compared to other studies. 21    This study shows that 12.5% of the elderly experienced sexual abuse. The finding is higher to other studies. 21,22,23 Nepal is a male dominated society where females' interest are poorly considered. In Nepal, even for married couples, there is dominance of male partners in establishing the sexual relation without regards to the wish of their partner, and such physical relationship is considered normal. The query to this hidden aspect in married elderly addressed in the interview and the comfort in conversation with the female interviewer could have helped to generate the hidden feelings of sexual abuse among the participants.
This study showeds that elder abuse was associated with female sex (p=0.001). The study is consistent with other studies conducted in Western Nepal which showed that the older abuse was associated with female sex. 25 Similar studies conducted in India and Korea concluded that females were at a more risk for abuse than the males. 26,27 This may be related to the patriarchal dominance over the females both physically and emotionally. Further, gender differences in social roles of females, usually a passive role of women in Nepalese community may have increased the risk for abuse among female elderly. Similarly, this study revealed that illiteracy of the elderly was associated with their abuse (p=0.002). The finding is similar to a study conducted in India which showed that education is strongly associated with decreased vulnerability to abuse. 28 This may be because education increases the confidence, employment and a sense of selfrespect and respect by others in the society, decreasing the risk of being abused in the Nepalese society. However, this study revealed no significant association between age of participants and elder abuse (p=0.458). This study also showed no any significant association between elder abuse with type of family and employment status.
This study dipicted that marital status is associated with abuse among the elderly (p=0.021). In respect to the chronic diseases, this study showed significant association of abuse with chronic diseases among the elderly (p=0.002). The finding is supported by a study conducted in Brazil which showed that elder abuse is more common among divorced and separated elders and those with poor health. 29 This may be because being unmarried, widow/ widower, divorced and separated may have caused older adults to live alone and become socially isolated increasing their risk of being abused. Further, chronic disease is often associated with need for increased care of elderly by caregivers, more financial expenses and decreased physical capacity that increases their dependence to others for basic activities of living increasing their risk of being abused. Similarly, this study showed that majority of the participants (31.2%) had the old age incentive as a major source of income. However, the amount of the incentive is insufficient for the elderly to meet their basic needs. 30 A study conducted in Nepal showed that 30% of the elderly do not meet health care facility despite having a disease condition, and low annual income was associated with underutilization of health services. 31 Hence living with chronic diseases and physical limitation leads to physical suffering, functional disability and increased susceptibility to abuse.
There are some limitations to this study. The study was small scale ward based study conducted in a community of Pokhara city with limited sample size. This study excludes the elderly who were severely ill and on total dependent on caregivers in their houses, those who are at a higher risk for abuse. Further, the findings are based on the reported abuse on perception of the elderly and are not observed and validated with the caregiver.