The Effect of Implementation of an Elderly Respect Training Program in Families on Elder Abuse in Yazd

1. Department of Nursing, School of Nursing & Midwifery, Research Center for Nursing & Midwifery Care in Family Health, Shahid Sadoughi University of Medical Science, Yazd, Iran
2. Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
3. International Campus, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

ARTICLE INFO		ABSTRACT
Original Article Received: 27 Dec 2017 Accepted: 6 May 2018		Introduction: The elderly are among the most vulnerable group in the society, and elder abuse is poses a challenge in the domain of elderly care and support. The present study was conducted with the aim of exploring the effect of implementation of an elderly respect education program in families on the elder mistreatment in the city of Yazd in 2016. Methods: The present study was an experimental study of the field trial type that was conducted on 80 elderly people over the age of 65 years who were covered by Yazd Comprehensive Health Service Centers. This sample was randomly divided into two groups: the intervention group (n= 40) and non-intervention group (n= 40).The sampling units were invited for participating in the study through phone call by healthcare providers. Then, the interviewer completed the questionnaire, after introducing himself and giving explanations on the objective of the study. The data collection tool was the Elder Abuse Scale that included 49 items in eight subscales: care neglect, psychological abuse, physical abuse, financial abuse, authority deprivation, rejection and financial and emotional neglect. In the next step, the families of the elderly in the intervention group were invited to participate in the educational program. The content of this program included different elder abuse subjects, the importance of respecting the elderly in the family and the society, and the role of families in supporting and protecting the elderly. One month after the end of the educational program for families, the elderly in both the intervention group and non-intervention group were invited to be interviewed and the questionnaire was completed. Data analysis was done using software SPSS and through the independent t-test and chi-squared test. Results: Analysis of the mean of elder abuse dimensions in the intervention group indicated that there was a significant difference between the scores before and after the intervention (P< 0.05). The highest level of abuse was seen in the dimension of emotional neglect with the mean of 25.3 and the lowest was seen in the dimension of rejection with the mean of 2.7.The study of the mean of abuse dimensions in the elderly non-intervention group, no significant difference was seen before and after the intervention (P> 0.05). The highest level of abuse was seen in the dimension of emotional neglect and the lowest in the dimension of rejection. Conclusion: The findings indicated that the implementation of the program for educating elderly respect in family was effective in abuse reduction. Therefore, training elderly respect programs are recommended. Also, clarification of this phenomenon from different aspects is better to be considered as a priority. Keywords: Aged Abuse, Aged, Elderly Respect
Corresponding Author: Maryam Shaker

Introduction

Elderly population increase is considered as one of the main socioeconomic and health challenges of the 21st century (1). According to an estimation by the United Nations, elderly population all over the world will increase from 350 million individuals in 1975 to 1.1 billion individuals in 2025, most of whom will be living in developing countries (2).
The elderly population in Iran was reported to be about 4,562,000 individuals in 2007, accounting for 5.6% of the population, and is estimated to reach 28% of the population by
2050 (3). According to statistical indices, the population of individuals over the age of 60 increased by 33% in the 55 years since 1956, which indicates that the mean age of the Iranian population has increased. According to the UN demographic forecast, the ratio of elderly population will increase from 10.5% in 2007 to 21.8% in 2050 (4).
The health issues of the elderly are completely different from those of children and younger adults, and their medical costs are twice the medical costs of the young (5). Further, as various organs undergo atrophy in old age, functionality is reduced and dependency on others is increased (6). Most retired old men experience loss of social status, insecurity and loneliness. Feelings of self-worth and security can be a significant factor in the control their affliction with mental and physical diseases (7).
With the increase of the elderly population and consequently chronic diseases, we will witness the increase of disability, dependency and inability in the elderly in the society (8). These factors, together with risk factors such as cognitive defects, weak health and the elderly’s dependency on caregivers, makes them vulnerable to abuse (9). Although the main cause of death and inability in the elderly is chronic disease, elder abuse, too, has a significant effect on the decline of health and feeling of security in the elderly (10).Despite the fact that Iranian families are among the best worldwide terms of their acceptance the elderly, today, social conditions such as urbanization, modernity and fading traditional values have resulted in families becoming unable to fulfill their duties with regard to the elderly. In such conditions, the elderly may be exposed to abuse by family, and its consequences (11). Unfortunately, it is shown that the probability of being subject to violence for the individual is higher in the family, compared with outside of the house (12).
Elder abuse takes the form physical, sexual, emotional, and financial abuse, neglect, and rejection (13). It can be defined as doing or not doing a specific behavior, whether intentionally or not, that results in violating human rights and life quality in the elderly (14). According to a report by the World Health Organization (WHO) (2002), elder abuse is constituted of repeated action(s) or lack of appropriate performance that occurs in any relationship with expectation of trust and results in damage, pain, distress, anxiety and discomfort in the elderly (15).
Nowadays, elder abuse and neglect are on the rise, and it is estimated that 4 – 10%of the elderly are abused by relatives, caregivers or others (16). The prevalence of elder abuse by home care providers is 12– 15% (17). According to statistics presented by WHO, elder abuse occurs in all developing and developed countries, but is not always reported. In Iran, there is no accurate report on different types of elder abuse as there is no specific authority responsible for dealing with elderly in Iran (18).
In a study by Morowati sharifabad et al., it was shown that, in Iranian families, out of the 250 elderlies over 60 years old, 79% had experienced these issues (19). In Ira, despite the regulation passed by the cabinet on April 14, 2014 regarding adoption of necessary measures by the related departments for preventing violence against the elderly in the family and society, no action has been taken for determining the extent of this problem. As elder abuse is one of the issues facing medical personnel including social workers, there is a need for planning to prevent this phenomenon and serious damages (16, 20). Social health among the elderly can result in the increase of the feeling of satisfaction with life in the society and consequently a higher quality of life. As the elderly prefer to live with their family or receive their support under any circumstances—even if there is abuse or inappropriate behaviors by the family—and as the family members may not be aware of their abuse of the elderly, the improvement of the family’s knowledge level for reducing abuse and increasing elderly care level is necessary. Therefore, the present study was conducted to determine the effect of implementation of an elderly respect in family training program on elder abuse in the city of Yazd.
Methods
The present study was an experimental study of field trial type.
First, a list of the Comprehensive Health Service Centers in Yazd was prepared and 4 centers were randomly selected. Then, 80 elderly individuals (40 in the intervention group and 40 in the non-intervention) were selected and entered in the study (20 individuals from each center). The sample size was determined from a study titled “Study of the Effect of Social Work Intervention on the Elderly Abuse Reduction” (21).In this formulaα=0.05 and β=0.2, also X1 was the relative frequency of misconduct
in non-interventional groups (66%) and X2 abundance was the relative incidence of misconduct in the intervention group (33%).
Inclusion criteria: Iranian elderly of age 65 years and older in the urban regions of the city of Yazd, being covered urban Comprehensive Health Service Centers, having a spouse or children (at least one of them residing in the city of Yazd), being able to talk in and understand Persian, voluntary consent for participating in the study, lack of affliction with mental diseases or deafness, having a spouse or children that interact with the elderly at least once a week), and literacy. Exclusion criteria were as follows: gaining score of 0 on the questionnaire, lack of cooperation of the elderly and his/her family, living alone (not having a spouse or a child) or being hospitalized in a retirement home, death of the elderly person and absence from more than one session. The data collection tool was an Iranian Domestic Elder Abuse Questionnaire that was prepared by Heravi et al., whose validity and reliability were measured (23). This questionnaire has three sections: the elderly demographic information, family-related information and elder abuse scale with 49 items divided into eight subscales including care neglect (11 items), psychological abuse (8 items), physical abuse (4 items), financial abuse (6 items), authority deprivation (10 items), rejection (4 items), financial neglect (4 items), and emotional neglect (2 items). The items of the aforementioned tool had options of “yes”, “no” and “not applicable”. The option “not applicable” indicates the life conditions that are not consistent with the elderly’s life conditions. The scores obtained are in the range of 0– 100, higher scores indicating a higher severity of the abuse signs. The psychometric characteristics of the aforementioned tool is explored and the tool has face, content and structure validities. The calculations of Cronbach’s alpha coefficient
(0.9-0.975) and consistency through retest
(99%) indicated favorable reliability of the questionnaire.
The sampling units were invited for participating in the study through phone call by healthcare providers. Then, the interviewer completed the questionnaire, after introducing himself and giving explanations on the objective of the study. The interviewer was given necessary explanations regarding the way of asking questions, uniformity of questionnaire completion and paying attention to the illiteracy or low literacy of the elderly.
In the next step, through phone calls, the families of the elderly in the intervention group were invited to participate in the educational program. The families, after completing informed consent form, physically participated in the educational sessions. The content of this program included different elder abuse subjects, the importance of respecting the elderly in the family and the society, and the role of families in supporting and protecting the elderly, which were taught based on a course design by a psychology expert. A previously prepared booklet addressing these subjects and given to them. Also, the booklet was sent to the children who did not participate in the educational sessions or were absent in some sessions.
The intervention was in a short-term format and was done during 2 sessions. The participants were educated in 5– 20individual sessions using lectures, group discussion, and question and answer session. The time of each session was 1 hour and the places of these sessions were Comprehensive Health Service Centers in Yazd. One month after the end of the educational program for families, the elderly in the intervention group were invited and the questionnaire was completed to assess the effect of elderly respect educational program. For the non-intervention group, the questionnaire was completed at the same time.
After the completion of the questionnaire, the information was coded and entered into SPSS version 21 for analysis. Descriptive statistics such as mean, standard deviation, frequency and percentage were used for displaying and depicting the information. The Friedman and Mann-Whitney tests were used for testing the hypotheses and thechi-squared test was used for theU test to determine status of the two groups of intervention.
Results
Through comparison of the qualitative demographic variables (table1), the results indicated that there was not a significant difference between the two groups in terms of background variables (P> 0.05) and the two groups studied were homogenous in this regard. Also, in the two group, most of the elderly women had elementary education, had a spouse, owned a home and had insurance. Most of the elderly individuals lived with their spouse and did not need help for their daily activities. The study of the mean of abuse dimensions in the elderly (table 2) indicated that in the non-intervention group, no significant difference was seen before and after the intervention (P> 0.05). The highest level of abuse was seen in the dimension of emotional neglect and the lowest in the dimension of rejection.
The study of the mean of the abuse dimensions among the elderly (table 3) indicated that in the intervention group, there was a significant difference before and after the intervention (P> 0.05). The highest level of abuse was seen in the dimension of emotional neglect and the lowest in the dimension of rejection

Variables		non- Intervention group	Intervention group	P- Value
		(percent) frequency	(percent) frequency
Sex *	Male	14 (35)	12 (30)	0.63
	Female	26 (65)	28 (70)
Education **	Illiterate	14 (35)	15 (37.5)	0.09
	Elementary	17 (42.5)	22 (55)
	Middle school	2 (5)	2 (5)
	Diploma	5 (12.5)	0 (0)
	University education	2 (5)	1 (2.5)
Marital status *	Has spouse	24 (60)	31 (77.5)	0.091
	Does not have spouse	16 (40)	9 (22.5)
Retired *	Yes	16 (40)	9 (22.5)	0.091
	No	24 (60)	31 (77.5)
House ownership **	Personal	33(82.5)	34(85)	0.69
	Rent	3(7.5)	3(7.5)
	House of children or relatives	3(7.5)	2(5)
	Free	0(0)	1(2.5)
	Other	1(2.5)	0(0)
Way of life **	Alone	8(20)	5(12.5)	0.70
	With spouse	17(42.5)	21(52.5)
	With single children	4(10)	2(5)
	With married children	2(5)	2(5)
	With spouse and children	8(20)	10(25)
	Other	1(2.5)	0(0)
Use of medical insurance *	Yes	37(97.4)	40(100)	0.34
	No	1(2.6)	0(0)
Use of complementary insurance *	Yes	17(42.5)	20(50)	0.50
	No	23(57.5)	20(50)
Needing help for daily activities **	Yes	10(25)	9(22.5)	0.85
	No	27(67.5)	29(72.5)
	To some extent	3(7.5)	2(5)

Dimensions	Time	Mean	Standard deviation	P-Value
Emotional neglect	Before	28.78	35.60	0.87
	After	27.50	35.71
Care neglect	Before	13.63	12.69	0.87
	After	14.09	12.17
Financial neglect	Before	23.75	26.52	0.83
	After	25.00	25.31
Authority deprivation	Before	8.25	9.30	0.35
	After	10.25	9.73
Psychological abuse	Before	18.12	14.96	0.84
	After	17.50	13.80
Physical abuse	Before	0.62	3.95	0.10
	After	4.37	13.73
Financial abuse	Before	7.91	16.44	1.00
	After	7.91	16.44
Rejection	Before	3.12	8.37	1
	After	3.12	8.37
Overall mean	Before	13.02	9.36	0.74
	After	13.71	9.92

Dimensions	Time	Mean	Standard deviation	P-Value
Emotional neglect	Before	42.50	36.77	0.00
	After	2.50	15.81
Care neglect	Before	15.00	15.34	0.00
	After	3.63	5.74
Financial neglect	Before	28.75	24.38	0.00
	After	2.50	7.59
Authority deprivation	Before	12.50	11.92	0.001
	After	4.75	5.98
Psychological abuse	Before	22.18	17.33	0.00
	After	1.25	3.79
Physical abuse	Before	3.12	8.37	0.09
	After	0.62	3.95
Financial abuse	Before	14.16	15.81	0.006
	After	5.83	9.65
Rejection	Before	1.87	66.66	0.69
	After	2.50	7.59
Overall mean	Before	17.51	8.65	0.001
	After	2.94	3.35

Psychological abuse in the present study the intervention group was found in22.18 before intervention, and 1.25 after. In the non-interventional group, it was found to be 18.12 before intervention, and 17.50 after. This rate was 25.4% in study (46) for the elderly who were the members of Senior Social Clubs in Tehran, 26.75 in the study on the elderly in Kalaleh (45), and 7.7% (8). Kissal et al (2011) (48), Amtadter et al(43), Pérez-Cárceles (42), and Oh et al (2006) (31). indicated in their studies that the psychological abuse was the most prevalent form of elder abuse, which is not consistent with the results of the present study in which psychological abuse does not have the highest rate. The differences in the results can be related to the cultural, economic and regional differences as well as belief differences regarding the way of dealing with and treating the elderly in different societies and regions.

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