|Year : 2021 | Volume
| Issue : 2 | Page : 113-119
Elderly abuse and quality of life: A study of community living older people of Nepal
Mahendra Raj Joshi1, Hom Nath Chalise2
1 Department of Population Studies, Kailali Multiple Campus Affiliated to Tribhuvan University, Kathmandu, Nepal
2 Department of Public Health, Nobel College Affiliated to Pokhara University, Sinamangal; Population Association of Nepal, Kathmandu, Nepal
|Date of Submission||10-Mar-2020|
|Date of Decision||27-Mar-2021|
|Date of Acceptance||02-Jul-2021|
|Date of Web Publication||30-Aug-2021|
Dr. Hom Nath Chalise
Department of Public Health, Nobel College Affiliated to Pokhara University, Sinamangal, Kathmandu
Source of Support: None, Conflict of Interest: None
Background: The abuse and neglect of older people in the family context are emerging as a significant social, as well as a public health concern that is affecting the overall quality of life (QOL) of the elderly. Aims: The main objective of this paper was to study the experience of abuse and its relation with QOL of older people in rural Nepal. Methods: This is a cross-sectional, community-based survey carried out in the Kailali district of Nepal. The total sample size for this study was 547 people aged 60 years and older selected randomly. QOL was measured using the World Health Organization QOL scale popularly known as WHOQOL-BREF. Elderly abuse was measured by asking questions related to elderly abuse in the last 1 month. The descriptive technique is used to analyse the data. Descriptive, chi-square tests and F-test was used to analyze the data. Results: The findings show that about one-sixth of males (15.6%) and one in every seven females (14.3%) have faced any type of abuse in the last 1 month. This study found that overall QOL score of the Nepalese elderly was moderate (12.92 ± 1.75). The mean scores of the overall QOL index of people experiencing abuse were observed significantly low (12.28 ± 1.74) compared to those who did not experience any abuse (13.04 ± 1.73). Conclusions: Elderly experiencing abuse have significantly low QOL compared to not abused elderly in Nepal. The experience of abuse was elicited in the last 1 month. This study was carried out in specific rural area and cannot be generalised to all Nepali older people. Local activities and awareness to discourage older person's abuse should be encouraged that may help to enhance the QOL of older people.
Keywords: Abuse of elderly, ageing, Nepali elderly, quality of life, rural elderly
|How to cite this article:|
Joshi MR, Chalise HN. Elderly abuse and quality of life: A study of community living older people of Nepal. J Med Evid 2021;2:113-9
| Introduction|| |
Population ageing is a global phenomenon. It is a natural outcome of the demographic transition from high fertility and mortality to low fertility and mortality. In 2050, the number of persons aged 60 years and over is estimated to reach 2.1 billion worldwide, constituting the majority from today's developing countries. Rapid population ageing is a global phenomenon, regardless of a nation's level of development. Ageing is the result of both longer life expectancy and declining fertility rates. Factors that contributed to people living longer are advances in education, a revolution in technology, development in medicine, food distribution and public health. On the other hand, increasing age results decline in health and functional status, physical and cognitive capacities, but the number of chronic diseases and disability increases.
The World Health Organization defines 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 includes any physical, sexual, mental and/or financial abuse or neglect of elderly people. Similarly, the WHO defines the quality of life (QOL) as 'an individual's perception of his or her position in life in the context of the culture and value system where they live, and in relation to their goals, expectations, standards and concerns'. Ageing-related international action plans and conventions have endorsed the importance of QOL with recent research assessing QOL as a healthcare outcome for older adults.
Individuals aged 60 years and older are considered older people in Nepal. The number of people aged 60 years and over has been increased from 6.5% in 2001 to 8.1% in 2011, and the 65+population is expected to reach around 13% by 2050. This population trend can be seen as a success story for public health policies and socioeconomic development, but it also challenges society to provide the necessary care and maintain an optimal QOL. On the other hand, the last two decades data shows, life expectancy increased from around 60 to 71 years, that implies in every 2 years nearly 1 year life expectancy increased in Nepal, which means there will be more older people in Nepal in the coming days.
There is a little study carried out in Nepal focussing on elderly abuse of rural community-living elderly., A review study of developing countries shows that victims of elderly abuse are at increased risk of physical and mental health problems, decreased QOL, the likelihood of hospitalisation and finally death due to neglect and loneliness.
With the ageing population, more and more people may become dependent on the care of relatives and be vulnerable to neglect or even abuse. Many cases of elderly abuse in developing countries may go under-reported due to cultural differences, especially to uphold family honour. Hence, the physical as well as psychological health of elderly facing abuse is at striking which consequently affects the overall QOL and well-being of elderly people. It is thus an important public health concern that has a bearing on the QOL of elderly people.
The QOL of the elderly is one of the important aspects to assess how elderly people perceive their overall life. According to Smith, there is increasing research about the QOL of the elderly with challenges in terms of meeting the health and social care needs of increasing numbers of elderly people. In developing countries such as Nepal, the traditional filial piety system and inter-generational informal support and bonds are rapidly fading due to the changing socio-cultural context. These changes have resulted in an increased incidence of elder abuse and neglect. The main objective of this study was to study experience of abuse and its relation with QOL of older people in rural Nepal.
| Materials and Methods|| |
This is a cross-sectional study carried out in November to December 2017 in the western part of Nepal. For this study, the principal researcher chooses two areas (Village Development Committees [VDC]) having the highest proportion of older people from the district record. VDCs are lower-level administrative areas; Nepal had over 3200 of them at the time of the survey. Each VDC has nine wards (the lowest-level political unit). The total sample size for this study was determined through the Yamane formula, with 95% confidence level (Yamane, 1967).
where n = sample size, N = population size, e = sampling error (assumed as 0.05).
According to 2011 census of Nepal, the total eligible population (aged 60+) was 15,723 in rural area of Kailali district. Applying Yamane's formula to derive the required sample household was computed 390 for the given population size. Elderly people (aged 60 years and above) of the selected households were respondents of the study. In this study, 547 elderly people from 396 sampled households were successfully interviewed.
A multi-stage sampling design was adopted for this study. At the first stage, two VDCs named Hasuliya and Basauti (now renamed as Kailari Rural municipality) of Kailali districts were selected as they had the highest proportion of the older population. Second, all the 18 wards of selected VDCs were considered as a sampling cluster. At the last stage, 25 households from each cluster were fixed. Twenty-five households from each cluster were chosen with systematic random sampling. For systematic random sampling, households having older persons were listed (assigned numbers). The sampling interval was calculated by dividing the total number of the household by 25. After selecting the first household, another household was selected applying the sampling difference. If someone declined to participate, the next household was chosen. All the individuals 60 years and above of selected households were included as respondents. People having mental health problems as reported by family members were excluded. This yielded 450 households and 624 eligible elderly, of which 605 (96.9%) consented to be interviewed. Among them, 24 elderly did not complete the interview. Further, during the data entry, 34 questions were found incomplete and many had information missing. Thus, the total sample size for this analysis was 547 older adults. Face-to-face interviews were used to collect the information.
The study protocol was approved by the research committee of the Central Department of Population Studies, Tribhuvan University (Ref. No. 03/2017). Data were collected through personal interviews by trained interviewers in participants' home with privacy. The purpose of the study was explained, and verbal informed consent was obtained from participants before the interview. Respondents were assured of the confidentiality. The interviews were conducted in the respondents' homes and took 35 min on average. No other family members were present at the time of interview. They were free to leave the interview if they feel uncomfortable.
Measurement of variables
Elderly abuse was measured by asking a question 'Did you face any type of abuse (physical and emotional) in the last 1 month?' with a dichotomous response yes/no. A similar method was used to calculate older person's abuse in one previous study. The WHOQOL-BREF questionnaire was used to assess the QOL of participants. The WHOQOL-BREF consists of 26 items with response options ranging from 1 (very dissatisfied/very poor) to 5 (very satisfied/very good). The first two items general QOL and general satisfaction with health were not included in the overall QOL index. The remaining 24 items assessed four domains: physical, psychological, social and environmental. The physical domain (7 items) assessed activities of daily life, including dependence on medicine, energy and fatigue, mobility and work capacity. The psychological domain (6 items) assessed positive and negative feelings, including self-esteem, bodily image and appearance. The social domain (3 items) assessed personal relationships, social support, and sexual activity. The environmental domain (8 items) included questions related to financial resources, freedom, safety and security, health and social care, physical and home and transport. Finally, an overall QOL index was designed exclusively for this study by taking the means of all four domains of QOL, i.e., physical health, psychological state, social relations and environment. The potential score of the index ranges between 4 and 20. It is interpreted that 4 indicates the 'worst' and 20 indicates the 'best' level of QOL of elderly people.,,
The WHOQOL-BREF has been validated for assessing the QOL in a range of settings and used to assess QOL of older adults by a number of studies. The WHOQOL-BREF has been used among older adults in Nepal with the past application of the Nepalese version demonstrating high reliability., The WHOQOL-BREF scale in this study demonstrated high internal consistency with a Cronbach's alpha coefficient of 0.79. The questionnaire was administered in the local Nepali language.
Demographic and socio-economic characteristics
Demographic variables included age, gender and marital status. Socio-economic variables included caste/ethnic group, living arrangements, level of education, land/property ownership and having pension/old age allowances. Marital status was coded as married or not married (widowed, divorced, separated or never married). Education included whether older adults were able to read or write.
Descriptive statistics (mean and percentages) were used to summarise the study variables. Statistical analysis involved Chi-square tests and F-tests, with Cronbach's alpha used to assess reliability. Data were analysed using the IBM SPSS Statistics for Windows, version XX (IBM Corp., Armonk, N.Y., USA).
The bivariate analysis was performed to present the distribution of elderly people experiencing abuse by various background characteristics. The items related to QOL were then scored (based on WHOQOL syntax) to calculate the mean values of four domains (physical health, psychological state, social relations and environment). Further, t-test was used to assess the group difference in QOL.
| Results|| |
Background characteristics of the respondents
The mean age of the research participants was 71.43 years (standard deviation [SD] = 8.01) [Table 1]. The majority of the respondents were female (58.9%). Over three-fifth (63.1%) of the respondents were married. The average household size was 6.87 (SD = 3.29). The overwhelming majority of the respondents (85.2%) reported that they were residing with their son/daughter in law followed by a spouse only (7.9%). Less than 5% (4.2%) of the respondents were residing with other family members. Furthermore, it was also found that about 3% (2.7%) of the respondents were residing alone. Majority of older populations were illiterate (75.9%), followed by literate but no formal education (18.6%) and formal education (5.5%). About half of the respondents (48.4%) had owned some land. Most of the respondents (74.8%) belong to Tharu (indigenous group) community. The majority (66.9%) of the respondents were receiving the old age allowance.
Experience of abuse by older people
In this study, about one in seven of the total respondents (14.8%) reported having faced some form of abuse in the last 1 month [Table 2]. On disaggregating the data by sex, male respondents (15.6%) were found to suffer more compared to female respondents (14.3%).
|Table 2: Elderly population by the status of experience of abuse according to selected background characteristics|
Click here to view
By disaggregating the age group, the abuse experienced was slightly higher for those aged 60–74 years (15.4%) compared to those elderly aged 75 years and above (13.3%). By disaggregating caste/ethnic group, the abuse experienced was slightly higher for Tharu ethnic group (14.9%) compared to non-Tharu (14.5%) elderly group. The abuse experience was found higher for currently married elderly people (15.4%) compared to others, which include single, widow/widower and divorced categories. Elderly abuse was observed the highest for those elderly (15.4%) who were illiterate, and it decreases with an increase in the level of education. Abuse experience was found slightly higher for those elderly (15.5%) who have no land/property owned compared to those elderly (14.2%) who have some land/property owned. Abuse experience was found higher for those elderly (17.1%) who have been receiving social security allowance compared to those elderly (13.7%) who did not receive any social security allowance. However, all the above results were not statistically significant.
Abuse experience was reported the highest for those elderly who were living alone (26.7%) followed by those elderly who were living with a spouse (23.3%) and with son/daughter-in-law (13.5). The living arrangement has statistically significant difference in elderly abuse (P < 0.05).
Experience of abuse and its relation with quality of life
The mean scores of various domains and overall QOL index were calculated to understand the impact of abuse on an elderly person's QOL [Table 3]. The result shows that elderly people experiencing abuse had low mean scores in all the domains of QOL. Mean scores of all domains were observed significant, except the mean score of the physical health domain. The highest differential was observed in the mean scores of social relations of elderly people experiencing abuse 13.73 (±1.98) and those not experiencing abuse 14.21 (±1.74). The mean score was found the lowest for the environmental domain of the elderly people experiencing abuse 9.73 (±1.71) and those not experiencing abuse 11.08 (±1.94).
|Table 3: Impact of experience of abuse on dimensions of quality of life of elderly people|
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The mean scores of the overall QOL index of elderly people experiencing abuse were found low (12.28 ± 1.74) compared to those who did not experience any abuse (13.04 ± 1.73). The result was observed significantly different. This indicates that older people experiencing any form of abuse have significantly low psychological health, hampered social relations, low mean scores for an environmental domain, as well as a poor overall QOL as compared to those not experiencing any form of abuse.
| Discussion|| |
Old age is a phase in life where there is a greater probability of social disruptions such as bereavement, social isolation, physical disability and cognitive decline, all of which contribute to depression. There is little research in Nepal on the issues of older adults.,, This is one of the important studies to assess the QOL of Nepalese elderly using internationally valid instruments. As Smith states, there is a need for more research on the QOL of the elderly to provide quality services to them, so they can have dignity in their retirement. This study helps assess the QOL of Nepalese community-living elderly in relation to older persons' abuse.
This study found that an average of one in seven respondents (14.8%) reports facing some form of abuse in the past 1 month. The reporting of abuse experienced by elderly people is similar to the findings from a health and social care needs survey (12.8%), which uses similar tools to assess elderly abuse. This finding is quite low compared to other community-level studies carried out in Nepal.,, Previous research shows elderly abuse ranging from 47.4% to 50.3%,, among community-living elderly. This difference is due to the difference in instruments used to assess the elderly and the reference period of the studies., In this study, however, two types of assessments (physical and psychological) abuse of the elderly were utilised with a reference period of 1 month. Other studies, on the other hand, focus on physical, emotional, verbal, neglect, disrespect, economic abuse and sexual abuse and have duration of 6 months.
This study found elderly abuse to be highest for those elderly who were living alone (26.7%) and lowest for those who were living with their son/daughter-in law (13.5%). This result was statistically significant (P < 0.05). The low rate of abuse for those living with their son/daughter-in-law may be due to the informal social support exchange between family members. Other reasons may be the under-reporting of abuse caused by family members. Further, lower abuse in the elders living with their son/daughter-in-law can be more often due to the social desirability of not reporting abuse in those living with in-laws while not living alone. Moreover, abuse also may be one of the reasons for living alone. Further, abuse was highest for those elderly (15.4%) who were illiterate, and abuse decreased as the level of education increased. This finding is similar to other research that found the likelihood of experiencing abuse was reduced with the improvement in educational status.
This study found that the overall QOL score of Nepalese elderly was 12.92, which implies that Nepalese elderly have a moderate QOL. In similar research, Indian studies found overall QOL of the Indian elderly was also moderate., A study carried out in Kavre, Nepal, shows 49.2% rated their QOL as good. Another study that assessed QOL through a single-item Likert scale QOL question to assess the QOL of the elderly found 45.9% of elderly reported their QOL neutral (neither good nor bad), 35.1% reported as good and 19.0% reported poor. Further, by breaking down the QOL scores in relation to the four domains, the lowest QOL score was found for the environmental domain (10.88 ± 1.97), followed by the psychological domain (12.99 ± 2.33) and physical health (13.69 ± 2.56]). The highest score was seen in the social relations (14.44 ± 1.78). The previous study carried in Nepal shows the lowest score was on the physical domain and highest in the psychological domain.
This study found the psychological, social and environmental components to be negatively affected by elderly abuse. However, elderly abuse did not affect the physical health component of QOL. However, overall, elderly abuse did have a significant negative effect on the overall QOL of the elderly. Similar results were found in the studies carried out in India.,
In recent decades, the QOL of the elderly has been assigned more public health importance., The ageing population is susceptible to health problems, both physical and cognitive. Ageing may lead to major challenges for the related family members. The elderly person may experience the following: playing a less important social role, lowered independence, loss of authority and support. Several socio-demographic, psychological, emotional and physical factors can affect the QOL of the elderly. With increasing age, they will need more care and provisions from their families and from the public and health services. The situation of older persons' abuse in Nepal can be lowered and QOL of the elderly may potentially improve by care directed towards their physical and psychological health, by strengthening family relations and by financial independence.
Despite the importance of this research, it has limitations. The cross-sectional nature of the study is a limitation; no causal associations of the elderly abuse and QOL of the elderly can be made. This study is limited by respondents being from a rural community in the Kailali district and findings cannot be generalised to the whole population of elderly in Nepal. Face-to-face interviews were used to assess elderly abuse, and there may be some reporting bias from the respondents. This study assesses older persons abuse through one question (physical and psychological abuse), which does not cover all types of abuse.
Finally, this study found the prevalence of elderly abuse was 14.8% in rural Nepal. The QOL of the Nepalese older people was moderate. The experience of abuse was elicited in the last 1 month in a specific rural area of Nepal and difficult to generalise to Nepalese population. Further research with representative sample is needed on elderly abuse and its impact on older people's overall QOL. Local governments should introduce community programs to help prevent elderly abuse so that the QOL of the older people is enhanced.
We would like to acknowledge all our respondents for their generous support to carry out this research. Further, we would like to thank Dr James Brightman for editing this manuscript. Thanks go to Dr Padam Khatiwada for his comments and suggestions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]