RATES OF AND RISK FACTORS FOR ELDER ABUSE IN JAPAN

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RATES OF AND RISK FACTORS FOR ELDER ABUSE IN
JAPAN

• Tokie Anme, PhD, Mary McCall, PhD, and Toshio
  Tatara, PhD

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INTRODUCTION HISTORY OF STUDY OF ELDER ABUSE

• Elder abuse and neglect more commonly studied in
  U.S. over the last 30 years and grew out of a
  history of examining child abuse in the 1960s and
  spousal abuse in the 1970s (Wolf, 2000).
• In Japan, the establishment in 1993 of the
  Society for Study of Elder Abuse (SSEA) prompted
  investigations into the incidence and prevalence
  of elder abuse in Japan.
• However, studies were small, and often based on
  cases reported by community care centers or
  health and social service professionals
  (Takasaki, et al., 1995 Tanaka, 1995 Ueda, et
  al., 1998).

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CULTURAL FACTORS AND CHANGES

• Traditionally, Japan has had a family-based
  caregiving system, private and respected as such.
  
• For example, typically the eldest sons spouse
  would be the caregiver of her co-residential
  in-laws, and this was expected and accepted by
  all as the appropriate arrangement (Koyano,
  1998a Soeda Araki, 1999).
• However, with major cultural changes occurring,
  especially in more urban areas of Japan,
  caregiving is shifting from that family model to
  a more formal, community-based caregiving system.
  
• Whereas in 1960, more than 85 of elders lived
  with adult children, currently between 50 and
  60 live with adult children (Lai, 2001 Yamada,
  1999).

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• In addition, with more adult women in the
  workforce, many Japanese families are beginning
  to see caregiving responsibilities as separate
  from co-residence (Lai, 2001).
• A 1994 survey found that 60 of caregivers felt
  their burden was too great (Lai, 2001).
• And some researchers speculate that the
  expectation of daughters-in-law to take care of
  their older in-laws may result in potentially
  negative emotional and interpersonal consequences
  (Koyano, 1998a Soeda Araki, 1999).
• Thus, with the advent of outsiders now being
  involved in the care of elders, the incidence of
  abuse and neglect is becoming more apparent.
• Understanding what contributes to abuse can help
  us respond and, hopefully prevent its occurrence.

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PREVIOUS RESEARCH

• An analysis of two Japanese studies (1993 and
  1997),and data from a helpline that was
  established in Japan in 1996, found that
• over 70 of abuse victims were female, and most
  were over 80 years old.
• 57 of the victims were neglected,
• 33-57 were physically abused
• 42-56 experienced psychological abuse
• In the Helpline study, the most common type of
  abuse was financial, and sons most commonly
  perpetrated it.
• approximately 25-35 of the abusers were
  daughters-in-law, up to 49 when elders were very
  dependent.
• None of these studies, however, reported basic
  prevalence rates of abuse in Japan (Soeda
  Araki, 1999 Yamada, 1996)

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FACTORS IN JAPANESE ABUSE

• The studies reported causes of abuse
• stress (39.6 )
• poor relationship (35.2), and this was
  especially true among daughters-in-law
  (60),related to different lifestyles between the
  generations. Since the traditional relationship
  of dominance by the mother-in-law has changed in
  the minds of todays adult women in Japan, this
  relationship and conflict is more acute perhaps
  than in years past.
• a perception of lack of appreciation by the
  victim for the care provided,
• physical fatigue from caregiving
• a sense of entitlement to the financial resources
  of the older person. This may not be surprising,
  given the pre-World War II inheritance law where
  the inheritance went to the oldest son.

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DESIGN AND METHODS

• Procedure
• A survey was conducted of all the frail elderly
  in the community who received any kind of
  care-related services (n1,134) and interviews
  were performed during a home visit by a health
  care professional.
• Participants
• The Japanese respondents were all frail elderly
  (n78), 60 years of age or older, in an
  agricultural village with an industrial seashore
  area that has a total population of 4,702.
  Fifty-four (69) of the elderly were female,
  while 24 were male (31).

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Measures

• Demographic data.
• Activities of Daily Living.
• Level of senility.
• Social role.
• Behavioral problems..
• Health conditions of caregivers.
• Ability to understand the nature of aging.
• Role conflict.
• Care burden.
• Support from family members.
• Kinds and frequency of abuse. Categories of abuse
  (physical, emotional, sexual, financial
  exploitation, neglect, and abandonment were based
  on those defined by the National Center on Elder
  Abuse (NCEA, 2004). A team of 4 professionals
  (three nurses and one social worker) discussed
  each case and then, based on observed and
  reported behaviors and symptoms, rated them as
  being a victim of any type of abuse, and what
  specific type was occurring.

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RESULTS

• Demographic factors. Of the 78 frail elderly who
  were interviewed, fourteen persons were found to
  have been abused (17.9).
• 78.6 of the abused were female.
• Average age was 80.3(12.4) for abused men and
  81.2( 7.0) for abused women. This was higher
  than the average age of non-abused men
  (75.47.73) and women (80.17.9).
• Eight of the fourteen (57) abused persons were
  females, 75 years or older.
• Fifty percent of the caregivers were
  daughters-in-law, while 25.9 were wives, 14.8
  were husbands and 7.4 were daughters.

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Types and frequency of abuse.

• emotional/psychological (50),
• neglect (42.8)
• financial abuse (35.7)
• physical abuse (21)
• substance abuse (for inappropriately or
  inadequately administering medications to the
  care recipient) (21)
• self-neglect (14)
• sexual abuse (7.1)
• multiple abuses (85.7)

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Caregiver risk factors

• 64.3 of the abusers were daughters-in-law
  (plt.05)
• Male abusers were 72 years old, non-abusers were
  75.9 years. Similarly, the average age of the
  female abusers was 59.2, while the non-abusers
  had an average age of 61.6 years.
• In addition, the percentage of caregivers who
  suffered from health problems was significantly
  greater among those who were abusers (50.0) than
  among those who did not abuse (7.8).
• Also, caregivers who abused elders were
  significantly more likely to misunderstand the
  elders problems(50) than those who did not
  abuse (1.6).
• Abusive caregivers also reported significantly
  more role conflict (28.6) and care burden
  (21.4)
• Abusers also received significantly less support
  from their families, including those members who
  lived elsewhere (28.6), and spouses (21.4)

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RISK FACTORS Single-variable relationships

• In the sample, those who were abused had
  significantly more behavioral problems than the
  non-abused elders, such as being noisy (14.3),
  being easily upset (35.7), being violent
  (14.3), being incontinent (50.0), or having
  sensory disorders (50.0) (all plt.01).
• A trend for the ratio of dependency in ADLs to be
  higher among those who were abused (57.1) than
  those who were not abused (32.8)(plt.10).
• 35.7 of the abused were senile, compared to only
  10.9 of the non-abused (.05ltplt.01).
• 57.1 of the abused had lost their social roles,
  compared to only 17.1 of those not abused
  (plt.01).

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RISK FACTORS Multiple-variable relationships

• Controlling for age and sex, the risk of abuse
  was higher for
• frail elderly who were senile (odds4.76)
• had lost their social roles (odds6.67)
• were incontinent (odds9.883)
• wandered due to senility (odds15.012)
• were over-eating (odds25.944)
• were having sensory disorders (odds6.981).

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RISK FACTORS Multiple-variable relationships

• The odds of being abused increased for
• daughters-in-law (odds4.749)
• caregivers who had health problems themselves
  (odds17.71)
• caregivers who misunderstood elders conditions
  (odds93.36)
• Odds of abusing were also higher for those
• who felt a serious care burden (odds8.093)
• who did not receive much family support from
  those family members living in other places
  (odds11.707).

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Odds of being abused in three different
situations

• In the first situation, where the elder does not
  wander and the caregiver has no health problems,
  the chance of the elder being abused is set at
  1.0 for analytical purposes. If, however, the
  elder does not wander, but the caregiver has
  health problems, the risk of the elder being
  abused is 9.4 times greater than in the initial
  situation. On the other hand, if the situation is
  such that the elder does wander but the caregiver
  does not have health problems, the risk of abuse
  is 5.88 times more than in the initial set of
  circumstances described above.

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Odds of being abused in three different situations

• In the second basic scenario, where the elder
  does not wander and the caregiver does not
  misunderstand the elders condition, the risk of
  elder abuse is set at 1.0 for analytical
  purposes. If, however, the situation changed to
  one in which the elder does not wander but the
  caregiver misunderstands the elders condition,
  the risk of being abused would be 52.0 times more
  than it is in the basic scenario. On the other
  hand, if the situation is such that the elder
  does wander, but the caregiver understands the
  elders condition, the chance of abuse would be
  only 6.5 times higher than in the basic scenario.

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Odds of being abused in three different situations

• In the third situation, where the caregiver does
  not misunderstand the elders condition and does
  not have health problems, the chance of the elder
  becoming abused is set at 1.0 for analytical
  purposes. If, however, the situation were that
  the caregiver understands the elders condition,
  but has health problems, the risk of abuse would
  be 14.4 times higher than in the initial
  situation. On the other hand, if the caregiver
  misunderstands the elders condition, but does
  not have a health problem, the risk of abuse
  occurring would be 72.0 times higher than in the
  basic situation.

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DISCUSSION

• This preliminary study found 17.9 of respondents
  in a community sample of elders using some form
  of care services were abused.
• This rate is several times higher than the rates
  found in the U.S. and other countries (Finland,
  Canada, Britain and Belgium), where studies
  report between 2 and 6 as maltreated (Lachs, et
  al., 1994 Pillemer Finkelhor, 1988 Tatara,
  1998 Wolf, 2000).
• However, these studies included healthy elders,
  and many researchers concluded that there was
  critical underreporting (Wolf, 2000).
• Studies that examined samples of frail elderly
  reported rates of abuse between 10 and 40
  (Compton, Flanagan and Gregg, 1997 Coyne,1993
  Lau and Kosberg 1979, Reis, 2000 Wolfe, 2000).
• Thus, the rates of abuse found in this study seem
  to be fairly similar to other countries among
  elders who are frail and using, or in need of,
  some kind of care or support services.

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DEMOGRAPHIC FACTORS

• As in the present study, most studies around the
  world show that women are more commonly abused
  than men (Wolf, 2000), although at least one
  study showed equal rates (Pillemer Finkelhor,
  1988).
• There seems to be clear evidence that victims of
  abuse are older, on average, than those who are
  not abused. This was also found in the sample
  analyzed here.

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ABUSERS ACROSS CULTURES

• In Japan, the most common abusers appear to be
  daughters-in-law. This study confirms earlier
  findings in Japan (Soeda Araki, 1999 Takasaki,
  et al., 1995 Tanaka, 1995 Ueda, et al., 1998
  Yamada, 1999).
• However, a study of abuse in Pennsylvania, U.S.,
  in the 1999-2000 year found that the most common
  abusers were family members (59), most often a
  30-59-year-old male family member.
• Interestingly enough, in a Pennsylvania study,
  fully 39 of the identified abusers were
  unrelated to the victim (Pennsylvania State
  Department on Aging, 2003).
• Thess differences most likely reflect the
  difference in cultural norms of caregiving.

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TYPES OF ABUSE ACROSS CULTURES

• In this study, the most prevalent types of abuse
  were psychological neglect, financial abuse, and
  physical abuse.
• The overall rates of the different types of abuse
  are comparable to the previous studies conducted
  in Japan, although some studies have a slightly
  different ordering in terms of prevalence in any
  given study.
• However, these results are somewhat different
  from U.S. studies, where studies found
  substantiated reports of abuse to be assault of
  various types (physical, sexual, etc.) and less
  to be financial. Similarly, however, they found
  that most victims suffered from multiple abuses
  (Pennsylvania State Department on Aging, 2003
  (Pillemer Finkelhor, 1988).

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REPORTING ABUSE ACROSS CULTURES

• The variations in rates of different types of
  abuse may be due to cultural differences in the
  reticence of reporting certain kinds of abuses.
  For example, sexual abuse in the U.S. is much
  more taboo than reporting psychological or
  physical abuse, while in Japan, the financial
  abuse may be more commonly accepted to be
  reported in comparison to physical abuse.
• Many elders will suffer in silence or keep the
  problem within the family rather than reveal the
  family shame to outsiders (Moon, 2000).
• Until there are more comprehensive studies of
  abuse in many countries, the analysis of
  variations in rates of specific types of abuse
  will remain difficult to truly understand.

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RISK FACTORS ACROSS CULTURES

• Some of the same risk factors found in this study
  to be significant predictors of abuse are similar
  to those found in the United States across
  various studies exhibiting behavioral problems,
  senility, loss of social roles, and poor ADLs,
  health problems of the caregiver, their
  misunderstanding of aging conditions, high levels
  of role conflict and role burden, as well as lack
  of family support. Fulmer, et al., 2003
  Pillemer, 1992 Reis, 2000 Schiamberg Gans,
  1999).
• Thus, while culture may affect WHO is abusing, it
  seems to be less of a factor in WHY people abuse
  older care recipients.

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IMPLICATIONS FOR PREVENTION

• key considerations in efforts to prevent elder
  abuse
• provide education and support for caregivers to
  increase understanding of elders (especially
  dementia and other cognitive deficits)
• address caregivers health concerns/problems
• slow the rate of functional decline in the person
  being cared for
• Increase social support for caregivers both from
  other family members and from more formal,
  community-based sources
• In the Yamada (1999) study of calls on a
  helpline, 60 of the callers were not using
  services, reporting a lack of available services
  as the major barrier.
• As Japan begins to uncover and address elder
  abuse, these kinds of preventive services can
  hopefully be integrated into public health
  approaches that community health centers provide
  (Tsukada, et al., 2001).

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CONTEXTUAL THEORIES OF ABUSE

• Examine aging as a consequence of the ongoing
  relationship over the life course between the
  persons involved (Schiamberg Gans, 1999)
• In Japan, where daughters-in-law are in some
  sense forced to care for an older person with
  whom they have not had a life-long mutual
  relationship of exchange (as in many
  parent-children dyads), the resentment and
  potential for abuse makes logical sense.
• From a social exchange theory perspective, as
  well, daughters-in-law have less to see as a
  mutual exchange over many years, as they were not
  raised from childhood by their in-laws
  (Schiamberg Gans, 1999 Soeda Araki, 1999).
• Thus, a contextual approach (using
  Bronfenbrenners model) calls for greater support
  from government and workplace policies that would
  support caregivers through a variety of programs
  that could provide respite care, education, and
  support groups (Soede Araki, 1999 Yamada,
  1999).
• In the U.S., changes to the Older Americans Act,
  which resulted in the Elder Abuse Prevention
  Activities program, were a step in that
  direction.

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CULTURAL HISTORICAL FACTORS

• In the United States, cultural norms of
  individualism and self-sufficiency may prevent
  people from reporting abuse and neglect.
• In Japan, the cultural norm of seeing ones self
  only in relation to others (and most importantly,
  to ones family) may prevent reporting of abuse
  due to the inherent emotional and familial
  pressure to not violate that relationship (Moon,
  2000 San Antonio Rubinstein, 2004 Soeda
  Araki, 1999 Tomita, 1998).
• The clash between generational notions of in-law
  caregiving may be problematic for a while
  (Schiamberg Gans, 1999 Tsukada, et al., 2001).
  
• In order to begin to change the cultural context
  of Japanese abuse, Tsukada, et al., (2001)
  advises that Japanese elders need to be educated
  about the notions of Jiritsu and Shakasei
  which reflect the importance of independence, and
  awareness of elder abuse.
• In that way, elders themselves can become
  empowered to deal more effectively with their
  caregiving situation and work, alongside others,
  to decrease the occurrence of elder abuse.

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CONCLUSION

• With an increasing population of elders, and in
  the midst of a major cultural shift in care
  giving roles and circumstances, Japan must
  continue to focus on both the contributing and
  causal factors of elder abuse. Through
  understanding those factors, policymakers and
  service providers alike can develop effective
  methods for responding to and, ultimately,
  preventing the victimization of its older
  citizens. This study, through providing a
  realistic sense of the prevalence of abuse in one
  community, and the factors associated with its
  occurrence, can aid in that process.