Abuse and Neglect of Elderly in Indian Families: Findings of Elder Abuse Screening Test in Kerala

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1 Original Article and Neglect of Elderly in Indian Families: Findings of Elder Screening Test in Kerala D Sebastian *, T V Sekher ** Abstract Background: of the elderly within families is becoming a serious problem even in India. Even though there is a general perception about the mistreatment perpetrated on older adults, the exact magnitude and nature of abuse is still unknown in India. Material and Methods: The study is based on interviews with 300 elderly (age 60 years and above) living in households from Pathanamthitta district of Kerala state. The extent of elder abuse and neglect were assessed by using the Hwalek-Sengstock Elder Screening Test (EAST), which was modified and adapted to Indian situation. Results: Nearly 60 percent of the respondents experienced either mild or severe forms of abuse in their households. The extent of severe abuse among the females was almost 2.7 times higher than the male elderly. Neglect and verbal abuse were the most commonly reported forms of mistreatment followed by physical abuse and material exploitation. The main perpetrators were sons, son-in law and daughter-in-law. Conclusion: The study reveals that abuse and neglect of elderly exists in Indian families. It also indicates that female elderly, especially widows, those in oldest-old age group (80+ years) and physically immobile, are more vulnerable to abuse than others. Not only the poor, even the rich are susceptible to neglect and abuse in many families. (Journal of The Indian Academy of Geriatrics, 2010; 6: 54-60) Introduction Population ageing is a worldwide phenomenon. Even though ageing is a serious concern in developed nations, the implications of ageing are also visible in many developing countries. By the year 2025, nearly 75 percent of world s elderly population is likely to be found in developing countries including India. 1 Ageing is occurring at different pace in different parts of India. Among the Indian states, Kerala has the highest proportion of aged population (10.5 percent) in Elder abuse and neglect are increasingly acknowledged as a social problem internationally and India is no exception. The responsibility of caring for elderly in India is traditionally borne by the immediate family and most often by sons. However, with a trend towards nuclear family * Ms. Daliya Sebastian, Research Scholar, International Institute for Population Sciences, Mumbai. ** Corresponding Author: Dr. T.V. Sekher, Associate Professor, Department of Population Policies and Programmes, International Institute for Population Sciences, Mumbai tvsekher@gmail.com setup, the vulnerability of elderly is considerably increasing. The younger generation has little or no time for the aged because they are in the race to make both ends meet. The elderly expect more time and too much support from the younger family members but most often this does not happen. As a result there will be friction within the family which often results in abuse and neglect of elderly. Elder abuse is defined 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 2. Elder abuse can take many forms. The National Centre for Elder, USA categorizes the following major types of elder abuse: 3 (i) Physical abuse is defined as the use of physical force that may result in bodily injury, physical pain or impairment. (ii) Emotional or psychological abuse is defined as the infliction of anguish, pain or distress through verbal or non-verbal acts. (iii) Financial or material exploitation is defined as the illegal or improper use of an elder's funds, property or assets.

2 and Neglect of Elderly in Indian Families: Findings of Elder Screening Test in Kerala 55 (iv) Neglect is defined as the refusal or failure to fulfill any part of a person's obligations or duties to an elder. Elder abuse is a complex problem that can emerge from several different causes and often has roots in multiple factors. These factors include family situations, economic conditions, caregiver issues and cultural aspects. 3 Family situations that can contribute to elder abuse include discord in the family created by the older person s presence, the financial burden of paying for health care for an ageing parent, living in overcrowded houses, stress of the family members etc. Personal problems of the caregiver that can lead to abusing a frail older person include caregiver stress, mental or emotional illness, addiction to alcohol or other drugs, job loss or other personal crises and financial dependency on the older person etc. It is only recently that we have begun to recognize that abuse of older people does occur in Indian families. The possible reasons for this may be difficulty in collecting the information, especially from family settings. The families and relatives play an important role in the care of the elderly and most of the older persons are either completely or to a great extent dependent on the family for their day to day life. Many elderly are afraid of telling the truth to others thinking that revealing the fact may result in further harassment and isolation. Table 1. Studies of abuse of older people. Study Sample Measure Pillemer 1988 Wang 2005 Fulmer 2005 Beach 2005 Hirseh 1999 Random sample of people aged 65+ in private households in Boston; those living with other people over-surveyed Random samples of people aged 60+ partially dependent on a carer living in (1) care homes (2) private households in 2 counties, Taiwan People aged 70+ attending four Emergency departments in New York and Tampa, USA CTS and OARS (neglect) Psychological elder abuse scale Elder abuse assessment instrument Cognitively or physically impaired Modified CTS people aged 60+ in private households in Texas, Georgia, Pittsburgh and Dallas; recruited from hospitals, social service agencies, support groups, local media People aged 60+ in Bonn Own questions Note: CTS- Conflict Tactics Scale, OARS-Older American Resources and Services; Source: Cooper et al., At the International level, many studies have come out with different methodologies to examine the elder abuse (Table 1). 4 However, there are not many studies or surveys available on elder abuse in the Indian context. So it is difficult to state the extent of elder abuse because of the lack of empirical data. In the absence of any nationally representative survey, it is difficult to categorize specific forms of abuse which are more common in Indian households. One can identify financial, physical and psychological abuse of aged as well as neglect. The newspaper reports and available case studies by researchers support this. These reports and micro-level studies shows that the elderly with low socio-economic status, females, especially widows, are more likely to be abused. 5 In a study in Pune by Bambawale, around 47 percent of the elderly women felt they were abused and 40 percent felt totally neglected by the family. 6 The neglect was in the areas of family members not talking to the elderly and the elderly not being consulted on important matters. Chokkanathan and Lee examined the correlates of elder mistreatment among 400 community dwelling older adults aged 65 and above in Chennai. 7 Their study revealed that the prevalence of mistreatment was 14 percent. Almost half of the respondents reported they have experienced more than one type of abuse. A study among 384 elderly in Delhi revealed that around 31 percent experienced mild physical abuse and 6 percent moderate physical abuse. 8 This study also indicated that physical abuse is more among households belonging to lowest social strata. Srinivas and Vijayalakshmi categorized four major forms of abuse physical abuse, verbal abuse, neglect and material abuse. 9 About 80 percent of the respondents reported that they had experienced verbal abuse; about 17 percent experienced some sort of physical abuse and 37 percent felt that their family members neglected them. In Haryana, around 70 percent of the elderly respondents were abandoned or had no kin to support them and around 68 percent felt that they were humiliated and mistreated by the family members. 11 In Tamil Nadu, almost all the elderly respondents stated that some form of abuse had been directed towards them at one time or other. Ushasree and Basha, based on their study in Andhra Pradesh found that the elderly had been neglected by denying proper medical care and food, and also exploited financially. 12 The elder abuse in the Indian cultural context suggests that a host of factors such as health problems, degree of dependency of the elderly, lack of space in the house, financial status and temperament of care-givers and perception of care burden are associated with elder abuse. 13 Even though there is a general perception about the mistreat-

3 56 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 2, June, 2010 ment perpetrated on older adults, the exact magnitude and nature of the problem in India is still unknown. In this context, the present paper examines the extent of elder abuse and its implications. Material and Methods Kerala state in India was selected for the present study as it has the highest proportion of elderly amongst all the states and union territories in India. Pathanamthitta district was selected for the present study due to its unique position among the districts of Kerala in demographic as well as social characteristics Census shows that this district has the highest proportion of elderly in the state (15 percent of the total population), much higher than the state average. This district also has large number of youngsters migrating to other parts of India and abroad. For every 100 households in the district, 62 households have at least one migrant and more importantly, 33 households out of every 100 have sent their family members abroad. 14 The survey was conducted in selected villages of two taluks of the district. The information was collected from 300 elderly respondents on their socio-economic and demographic characteristics, living arrangements, health conditions, support mechanism, elder abuse and intergenerational relationship. In order to understand the extent of abuse and neglect, a modified form of Hwalek- Sengstock Elder Screening Test (H-S/EAST) was used. 15 This scale was developed to provide a brief and easily self-administered screening instrument to determine an individual s risk of elder abuse. The H-S/EAST is a 15-item measure that is reported to assess the risk of elder abuse on three dimensions: violations of personal rights or direct abuse, characteristics of vulnerability and potentially abusive situations. The modified form of EAST has been found reliable in Australian Longitudinal Study on Women s Health. 16 The advantages of this tool are that the respondents answer the question and the scoring of response is simple. The disadvantage of this test is that sometimes the respondents may not feel comfortable in disclosing private information. In order to adapt the scale to the Indian situation, some modifications were made in the scale and reliability test was conducted. This was done in consultations with psychologists and gerontologists. Results In our sample, 61.3 percent were women and the remaining were men. Around 44 percent of the respondents belonged to young old (60-69 years) age group, 35 percent were old-old (70-79 years) and the remaining (21 percent) in the oldest-old category (80 years and above) (Table 2). Majority of the respondents were literate and around 8.3 percent had education of higher secondary and above. 48 percent of the respondents were currently living with their spouse and 49 percent were widowed. It was found that 24.6 percent of the elderly were engaged in some income earning economic activity. Among them, 11 percent of the elderly were casual labourers and cultivators. 2.3 percent of the elderly were self- employed either in agricultural or non- agricultural sector. One-fifth of elderly male respondents were retired from regular service and corresponding figure for females were only 3.3 percent. Around 47 percent of the elderly were staying in nuclear families or alone (Table 2). Table 2. Demographic and socio-economic profile of the elderly. Background Characteristics Total Male Female Age Group Young-old (60-69) Old-old (70-79) Oldest old (80+) Sex Religion Hindu Christian Muslim Caste SC/ST OBC Others Literacy Illiterate Literate Education Below primary Below high school High school Higher secondary and above Marital Status Married Widowed Others Occupation Self employed Cultivators Casual labourers Housewives Retired from service Unemployed Type of family Nuclear Non-nuclear

4 and Neglect of Elderly in Indian Families: Findings of Elder Screening Test in Kerala 57 Nearly half of the respondents (49 percent) reported that they experienced some form of abuse or neglect from their family members recently (during one year prior to the survey) (Table 3). The prevalence of abuse reported was higher in this study compared to other Indian studies. 7 Earlier studies indicated that neglect and verbal abuse of elderly members in the family are the most commonly reported forms of abuse in India. 7,9 This study also revealed that neglect and verbal abuse (39 percent) were the most common forms of mistreatment as stated by the respondents, followed by physical abuse (13 percent) and material exploitation (10 percent). Those who did not experience any mistreatment during the last one year, further questions were asked to explore whether they experienced any form of abuse after they attained 60 years of age (Table 3). Table 3. Percentage of elderly experienced abuse by nature of abuse. Nature of Recently (during one year before survey) Any time after 60 years of age (not during last one year) Any form of abuse or neglect Physical abuse Slapped/kicked Physical harm in any way * Verbal/psychological abuse Calling bad names/using abusive language Threatened to harass Silent treatment # Financial abuse Misuse money/property Demand cash/kind for services rendered Stealing money Transfer of land/property without consent Neglect Isolation/marginalization Neglecting personal needs Kept hungry by not giving food in time Notes: * include throwing things/objects towards elderly, shaking/pushing them, etc. in order to harm physically. # Silent treatment means the caregiver may give the necessary service to the elderly but will not talk to him/her deliberately with an intension to harass Around one-fourth of the respondents reported that they were abused or neglected at some time in the past by their own relatives after they became aged or old. Majority of these respondents felt that they were verbally abused (13 percent) by the family members. Few elderly (6 percent) stated that they were victims of financial and material exploitation by their own family members on various occasions (Table 3). The elder abuse has another dimension in Indian context. Given the existing patriarchal society and gender discrimination, women are at greater risk of becoming victims of exploitation. Most of them were denied independent access to economic and social resources. Women and men enter their old age with different personal and social resources and these are the culmination of their lifetime experiences in the society influenced by gender disparity. As one of the widow, aged 75 stated- Until recently, my son and daughter-in-law used to discuss with me about all family matters and listened to my advice. After my husband s death they started ignoring me and now-a-days they are not even bothered to find out my medical requirements and personal needs. Perpetrators of mistreatment: The perpetrators were mostly adult children, especially sons (62.4 percent), followed by sons-in-law (59.2 percent), daughters-in-law (57.3 percent), daughters (26.1 percent), grand children (17.8 percent), spouse (12.1 percent), other relatives (8.3 percent) and others (5.7 percent) (Fig. 1). Others include servants, home nurses and other care givers. In the case of physical abuse, in 67 percent of the cases sons were the perpetrators. This study corroborates the findings of other studies that own children are the common perpetrators of elder abuse. In most Indian families elderly stay with sons and daughters-in-law. This might be the reason for the son and daughter-in-law being frequently reported as elder abusers. In the case of verbal abuse majority reported that either son-in-law or daughter-in-law (64 percent) were the main abusers. One old lady narrated her pathetic condition- When my son went abroad, my daughterin-law started behaving very rudely. She started ignoring me and days together never talked to me and did not allow her children to be with me. Sometimes I felt, even the dog in our house gets better attention and care than me. Nearly three- fourth of the abused elderly reported that there was more than one perpetrator. In case of physical abuse, around one-fourth were abused by more than one family member, mostly by sons and daughters-in law. Around 74 percent of the elderly who experienced verbal abuse stated that they were abused by more than one relative. Based on the score of the EAST, the extent of abuse was divided into three categories- no abuse (scale value 0), mild abuse (scale value ranges from

5 58 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 2, June, to 3) and severe abuse (scale value 4 and above). Around 32 percent of the elderly in our sample were experiencing severe abuse in their families. Another 30 percent were victims of mild abuse Figure 1: Alleged perpetrators of elder abuse Table 4 presents the extent of elder abuse by background characteristics of the respondents. The research conducted in India and other countries show that, women especially widows and the elderly in advanced ages are most vulnerable to elder abuse. 3,7 The present analysis also revealed that as age increases, the extent of abuse also increased. Among the oldest-old (80 years and above) category, around 36 percent experienced severe abuse and 38 percent reported mild abuse as compared to 28 and 30 percent respectively in the young old (60-69 years) category. The extent of severe abuse among the female elderly was almost 2.7 times more than the male elderly (42.4 and 15.5 percent respectively). Regarding to the education of the respondents, more than half (55 percent) of the illiterate elderly reported severe abuse compared to only 14.3 percent who had at least secondary school education. Among the widows, around 40 percent reported severe abuse compared to 23 percent of the respondents who were living with spouses. While observing the relationship with physical mobility and extent of elder abuse, 90 percent of the elderly who were confined to bed reported either mild or severe form of abuse as compared to 58 percent among the physically mobile category. Even those who were living alone, 54.5 percent reported severe abuse and 42.4 percent reported mild abuse from relatives, servants and others. Among the elderly who did not have any interaction with their children (with whom they were staying with), the extent of severe abuse was almost double than those who had some sort of intergenerational interaction. Among the elderly who perceived their physical health as poor experienced more abuse than those who felt that their health was in good condition Table 4. Extent of elder abuse by background characteristics. Background Characteristics Age group No Mild Severe Young old (60-69) Old-old (70-79) Oldest- old (80+) Sex Male Female Religion Hindu Non- Hindu Caste SC/ST OBC Others Education Illiterate Below high school High school and above Marital status Married Widowed Others Physical mobility Confined to bed Confined to home Physically mobile Economic dependency Fully dependent Partially dependent Not dependent Living arrangement Alone With spouse only With children Others Intergenerational interaction Regular interaction No interaction Perceived physical health Good Fair Poor Multinomial logistic regression of extent of elder abuse and neglect The analysis showed that for females, the chances of being abused in comparison to males were almost 41 percent higher in case of mild abuse and 3.75 times significantly higher in case of severe

6 and Neglect of Elderly in Indian Families: Findings of Elder Screening Test in Kerala 59 abuse (Table 5). The likelihood of mild abuse was 42 percent higher among the widows/ divorced/ single elderly and 14 percent higher for severe abuse than those who lived with their spouses. Literacy had negative significant association with elder abuse and neglect. The perceived physical health of the elderly had significant impact on the abuse of the elderly. It was found that those who reported their physical health as poor were 3 times more likely to be abused mildly and had 3.7 times at higher risk of being severely abused as compared to those who considered their physical health as good. Table 5. Multinomial logistic regression analysis of extent of elder abuse by background characteristics. Variables Sex Odds Ratio (Reference Category - No ) Mild Male Female 1.41 ( ) Marital Status Currently married Others 1.42 ( ) Living Arrangement Alone/with spouse only With children/ others Literacy Illiterate 0.45*** ( ) Literate 0.68 ( ) Perceived Physical Health Good/fair Poor 3.17*** ( ) Economic Status Dependent Not dependent 1.08 ( ) 95% CI Severe 95% CI 3.75*** ( ) 1.14 ( ) 0.04*** ( ) 0.28*** ( ) 3.70*** ( ) 1.25 ( ) *: Significant at 10% level, **: Significant at 5% level, ***Significant at 1%level, CI: Confidence Interval Discussion It may be difficult to understand how in a country like India elder abuse could co-exist with cultural values which emphasize respect for older persons. While analyzing the magnitude and nature of elder abuse experienced by elderly, it was found that nearly half of the respondents had experienced some form of mistreatment from their family members verbal abuse and neglect were more prominent. The incidence of physical abuse was comparatively lower. The possible reason for this may be the societal pressure against individuals who abuse their parents or older members is still very strong in India. One out of ten elderly respondents was financially exploited by their children or relatives. A modified form of Elder Screening Test (EAST) was conducted to measure the extent of abuse. Around one-third of elderly experienced severe abuse and another onethird reported mild abuse in their families. This is much higher than the reported prevalence of mistreatment by earlier studies. 6,7 However, the extent of physical abuse observed in this study is lower than the one reported from Delhi. 8 This is partly due to the fact that most households in our sample belonged to better economic and social strata of the society. This study also supports the findings of other Indian studies that one s own children are the main perpetrators of elder abuse. Women are at higher risk of becoming victims of exploitation due to lack of access to economic resources. They are more vulnerable because they are not only aged but also widowed. The extent of severe abuse among the female elderly was almost three times higher than that of males. Isolation and neglect from one s own family will have serious social and psychological implications. The vulnerability of elderly is multi-dimensional and multi-layered emerging from differences in gender, economic position and physical condition. The evidence from the present study indicates that different forms of elder abuse and neglect exist in Indian families. Female elderly, especially widows and elderly in advanced ages are more susceptible to abuse. Sons, daughter-in-law and son-in-law are the major perpetrators of elder abuse. According to this study, 32 percent of elderly were victims of severe abuse and another 30 percent were subjected to mild abuse by their own family members. The general perception that the families are the safest place for the aged in India has been questioned by the findings emerging from this study. Not only the poor, but even the rich are vulnerable to various forms of abuse and neglect, though the extent and nature of abuse vary considerably. The elder abuse and neglect which received very little attention so far in India would require more attention and investigation in coming years.

7 60 Journal of The Indian Academy of Geriatrics, Vol. 6, No. 2, June, 2010 References 1. United Nations. Elder abuse widespread and unprotected says New Report by Secretary General. Report presented at the Second World Assembly on Ageing. Madrid, Spain, 8-12 April, Action on elderly abuse (AEA). Bulletin, May-June 1995, No 11, Astral house, London, UK, Adult Protective Services. of adults aged 60 years and above, Fact Sheet, National Centre on Elder. University of Delaware, Newark, USA; Cooper C, Selwood A, Livingston G. The prevalence of elder abuse and neglect: a systematic review. Age and Ageing 2008; 37: Shah G, Veedon R, Vasi S. Elder abuse in India. J Elder Neglect 1995; 6: Bambawale U. The abused elderly. Ind J Med Res 1997; 106: Chokkanathan S Lee, Alex EY. Elder mistreatment in urban India: A community based study. J Elder Neglect 2006; 17: Khan AM, Handa S. Physical abuse of elderly in Indian context. Ind J Gerontol 2006; 20 : Srinivas S, Vijayalakshmi B. and neglect of elderly in families. Ind J Soc work 2001; 62: Mahajan A. Problems of aged in unorganized sector, Mittal Publications, Delhi; Devi KR. Elderly abuse in the family. In Arvind K Joshi (ed.), Older Persons in India, Serials Publication, New Delhi; Ushasree S, Basha AS. Domestic abuse among the elderly. Ind J Gerontol 1999; 13 : Jamuna D. Ageing Women in India: A profile. Help Age Ind Res Develop J 1995; 1: Zachariah KC, Mathew ET, Rajan SI. Dynamics of migration in Kerala: dimensions, differentials and consequences, Orient Longman, New Delhi; Hwalek M, Sengstock M. Assessing the probability of abuse of the elderly: Toward development of a clinical screening instrument. J App Gerontol 1986; 5: Schofield MJ, Reynolds R, Mishra GD, et al. Screening for vulnerability to abuse among older women: Women's Health Australia Study. J App Gerontol 2002; 21: ERRURTUM Authorship of article Authorship of article as published in Dec 2009 issue of JIAG: M Bhatnagar. Comparison of sputum eosinophil count and bronchodilator reversibility on pulmonary function test in chronic obstructive pulmonary disease and asthma patient. Journal of the Indian Academy of Geriatrics 2009; 5 (4): Correct authorship of article as modified M Bhatnagar, Sanjay Gaur, Saurabh Singhal:. Comparison of sputum eosinophil count and bronchodilator reversibility on pulmonary function test in chronic obstructive pulmonary disease and asthma patient. Journal of the Indian Academy of Geriatrics 2009; 5 (4):