Journal of Elder Abuse & Neglect, 27:196–232, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0894-6566 print/1540-4129 online DOI: 10.1080/08946566.2015.1039154

Elder Abuse in Chinese Populations: A Global Review XINQI DONG, MD, MPH Rush University Medical Center, Chicago, Illinois, United States

This review focuses on the epidemiology of elder abuse in the global Chinese population with respect to its prevalence, risk factors, and consequences, as well as the perceptions of elder abuse. Evidence revealed that elder abuse and its subtypes are common among the global Chinese population with prevalence ranging from 0.2% to 64%. Younger age, lower income levels, depression, cognitive impairment, and lack of social support were consistently associated with self-reported elder abuse. Caregiver burden was a constant risk factor for the proclivity to elder abuse by caregivers. The adverse health outcomes of elder abuse included suicidal ideation and psychological stress. Some primary research gaps exist: such as, lack of consistency in measurements and recall periods, insufficient studies on the causal relationships between potential risk factors and elder abuse, consequences of elder abuse, and possible interventions. In order to reduce the risk of elder abuse in the global Chinese population, collaboration is encouraged among researchers, health care professionals, social service providers, and policy makers. KEYWORDS elder abuse, Chinese population

BACKGROUND Elder abuse is defined as “intentional actions that cause harm or create a serious risk of harm, whether or not intended, to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder, or failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (Wallace & Bonnie, 2003). Also referred to as elder Address correspondence to XinQi Dong, Rush Institute for Health Aging, Rush University Medical Center, 1645 West Jackson Boulevard, Suite 675, Chicago, IL 60612, USA. E-mail: [email protected] 196

Elder Abuse in Chinese Populations

197

mistreatment or elder maltreatment, elder abuse has multiple subtypes: psychological abuse, physical abuse, sexual abuse, financial exploitation, and neglect (Salmon, Stobo, & Cohn, 2002). Psychological abuse refers to the use of verbal, written or gestured communication towards an older adult that causes emotional distress; physical abuse is the force directed at an older adult that results in physical pain, injury or impairment; sexual abuse is any sexual contact with an older adult without consent; financial exploitation is defined as the illegal or improper use of an older adult’s funds or property (Chen, Chang, Simon, & Dong, 2014). Neglect is the failure by a caregiver (caregiver neglect) or oneself (self-neglect) to provide an older adult with necessities of life (Dong, in press). Elder abuse is a worldwide public health and human rights issue across all racial and ethnic groups. Based on a report from the World Health Organization, the prevalence of elder abuse in developed countries ranges from 1% to 10% (Chen et al., 2014). In the United States, more than 10% of community-dwelling older adults reported elder abuse or potential neglect in the past year, according to the 2008 US National Elder Mistreatment Study with a representative sample of 5,777 older adults (Acierno et al., 2010). Elder abuse has also been shown to be associated with distress and increased morbidity and mortality in older adults (Dong, Simon, et al., 2009; Lachs, Williams, O’Brien, Pillemer, & Charlson, 1998). Further, a 2011 Government Accountability Office report highlights the lack of research, education, training, and prevention strategies in the field of elder abuse (“Elder Justice: Stronger federal leadership could enhance national response to elder abuse,” 2011). Based on the urgent needs in advancing the field of elder abuse, the 2013 US Preventive Services Task Force report to Congress proposed elder abuse as a research priority area. The issue of elder abuse in Chinese populations warrants greater attention. It is estimated that 25% of the world’s elderly population will be Chinese by the year 2050 (Banister, 1992). The Chinese population – not only in Mainland China, Hong Kong, Macau, and Taiwan, but throughout the world – is culturally and linguistically diverse. The overseas Chinese, particularly the younger generations under the impact of acculturation, may be less likely to follow such traditional cultural values and practices as filial piety. Chinese older immigrants may be at higher risk for elder abuse, due to cultural and linguistic barriers, social isolation, and dysfunctional family relationships stemmed from different acculturation levels between generations (Dong, Chen, Fulmer, & Simon, 2014). Further, Chinese older immigrants have been identified as an underserved group requiring more attention from public health professionals (Collins & Fund, 2002). The purpose of this review is to better understand the issue of elder abuse in the global Chinese population. There is a growing body of research that has been conducted on elder abuse in the Chinese population around the world. This review will focus on the epidemiology of elder abuse in the

198

X. Dong

global Chinese population regarding its prevalence, risk factors, and consequences, as well as the perceptions of elder abuse and its related factors. Furthermore, we will discuss the primary research gaps on elder abuse in the global Chinese population and the key implications for research, practice, and policy.

METHODOLOGY The author conducted a search of global literature on PubMed, EBSCO, JSTOR, ProQuest, and PsycINFO, and limited the search to studies published in English after 1990. The searched keywords included the following: older persons/ elderly/ senior AND abuse/ neglect/ mistreatment/ maltreatment/ violence/ aggression AND Chinese/ Taiwan/ Hong Kong/ Macao. The exclusion criteria were studies published only as abstracts, case reports, and non-English publications. The author also examined the reference lists of previously identified works for relevant articles.

RESULTS Our search yielded 37 results which were then grouped into several categories: prevalence, risk and protective factors, adverse health outcomes, and perceptions of elder abuse among Chinese populations.

Prevalence of Elder Abuse The prevalence of overall elder abuse and its subtypes ranged from 0.2% to 64%, depending on the populations, settings, definitions, and research methods (Table 1). Based on a sample of 3,159 community-dwelling Chinese older adults aged 60 and above in Chicago, the overall prevalence of elder abuse was 15% (Dong, Chen, Fulmer, & Simon, 2014). However, the prevalence of elder abuse ranged from 13.9% to 25.8%, depending on the inclusion of certain subtypes (Dong, 2014). In Mainland China, the prevalence has been reported as 10.5% and 64% in separate studies (Dong, Simon, & Gorbien, 2007; Wu et al., 2012). In Hong Kong, the prevalence was 21.4% and 27.5% in two separate studies (Yan & Tang, 2001, 2004), 42.3% and 62.3% reported by family caregivers in two different studies (Yan, 2014a; Yan & Kwok, 2011), and 20.5% for the proclivity to elder abuse, which was the likelihood of displaying abusive behaviors if there was no social constraint and punishment (Yan & Tang, 2003). Regarding elder abuse subtypes, a U.S. study showed the prevalence of psychological abuse was 1.1% to 9.8%, financial exploitation was 8.8% to 9.3%, and caregiver neglect was 4.6% to 11.1% depending on strictness

199

Shibusawa, 2007

Dong, 2014

Dong, 2014

US Dong, 2014

Author, Year

3,159 community Chinese older adults in Chicago 77 community Chinese older adults in Southern California

3,159 community Chinese older adults in Chicago 3,159 community Chinese older adults in Chicago

Population

91.9%

NA

60 and older; In person 58.9% women 50 and older; Telephone the gender is NA.

91.9%

60 and older; In person 58.9% women

Participation Rate 91.9%

Survey Methods

60 and older; In person 58.9% women

Age, Gender

TABLE 1 Prevalence of Elder Abuse and Its Subtypes in Chinese Populations

Personal and environmental observations by interviewers Physical violence subscale of CTS

CTS, sexual abuse assessment, caregiver neglect assessment, financial exploitation assessment

H-S/EAST and VASS

Measure

8

27

56

10

NA

≥ 1 item

∗

≥ 1 item

# Item Cut-off Points

(Continued)

1-yr minor physical violence by spouses/ intimate partners: Women: 7.1%; Men: 5.6%; Life time minor physical violence: Women: 14.3%; Men: 13.9%; Life time severe physical violence: women: 3.6%; Men: 2.8%

Since 60 years old 13.9%-25.8%; psychological abuse: 1.1%-9.8%; physical abuse: 1.1%; sexual abuse: 0.2%; caregiver neglect: 4.6%-11.1%; financial exploration: 8.8%-9.3% Mild self-neglect: 18.2%; moderate to severe self-neglect: 10.9%

Since 60 years old 15.0%

Prevalence

200

Population

Age, Gender

Survey Methods

Hong Kong Yan, 2014

Dong, 2007

149 family caregivers of community older adults with dementia in Hong Kong

In person Caregivers: aged 17-85 years old; 69.8% women; Care recipients: aged 60-103 years old; 75.2% women.

60 and older; Self412 cognitively 34% women administered intact older survey adults from medical clinics in China

Mainland China Wu, 2012 2,000 community 60 and older; In person Chinese older 59.9% women adults in Hubei, China; 70% live in rural areas

Author, Year

TABLE 1 (Continued)

81%

84.4%

90.8%

Participation Rate

Subscales related to psychological aggression and physical assault from the Revised CTS2

H-S/EAST and VASS

H-S/EAST and VASS

Measure

18

13

14

≥ 1 item

≥ 1 item

≥ 1 item

# Item Cut-off Points

1-month: 42.3%. Verbal aggression: 40.3%, physical abuse: 15.4%.

1-yr 36.2%; ≥ 2 types 10.5%; Psychological abuse: 27.3%; Caregiver neglect: 15.8%; physical abuse: 4.9%; financial abuse: 2% Since 60 years old, 35.2%; one type 64%, two types 16%, three types or more: 20%. Caregiver neglect: 16.9%; abandonment: 0.7%; psychological abuse: 11.4%; physical abuse: 5.8%; sexual abuse: 1.2%; financial exploitation: 13.6%

Prevalence

201

In person Caregivers: aged 17-85 years old; 76.2% women; Care recipients: aged 59-103 years old; 74.6% women 1,870 community Aged younger In person than 34 to women in 55 or older Hong Kong, with 410 older women 276 community 60 and older; In person older adults in 67.4% women Hong Kong

Self464 Chinese from Aged from 18 to 70; administered community 51.5% women centers and professional organizations in Hong Kong

355 community 60 and older; In person older adults in 62% women Hong Kong

Yan, 2001

122 family caregivers of community older adults with dementia in Hong Kong.

Yan, 2003

Yan, 2004

Chan 2008

Yan 2011

NA

80%

Subscales of Verbal Abuse (8) and Physical abuse (12) of CTS2; Social abuse assessment (5)

Subscales of physical abuse (12) and verbal abuse (8) of the CTS2, violation of personal rights (5) Subscales of Verbal Abuse (8) and Physical abuse (12) of CTS2, social abuse (3)

CTS2

71%

81%

Subscales of psychological aggression (6) and physical assault (12) of the CTS2

90%

Lifetime IPV: 6.59%, 1-yr: 1.71%

1-yr 27.5%; verbal abuse: 26.8%; physical abuse: 2.5%; violation of personal rights: 5.1%; women: 29%; men: 24.4% Proclivity estimates of elder abuse: 20.5%; Men: 20.9%; women: 20.1%; verbal abuse: 20.3%; physical abuse: 2.4%; social abuse: 2.4% 1-yr 21.4%; Multiple types 17.1%; women: 23%, men: 18.3%; verbal abuse: 20.8%; physical abuse: 2%; social abuse: 2.5%

≥ 1 item

≥ 1 item

≥ 1 item

≥ 1 item

25

25

23

25

(Continued)

1-month: 62.3%. Verbal aggression: 62.3%, Physical abuse: 18%

≥ 1 item

18

202

Survey Methods

In person

60 and older; In person 54.9% women

Age, Gender

2,272 community 55 and older Chinese older adults in Canada

195 community Chinese older adults in Taiwan

Population

77%

NA

Participation Rate

A checklist with 18 types of maltreatment or neglect

PEAS

Measure

18

32

≥ 1 item

≥ 10 item

# Item Cut-off Points

Since 55 years old, 4.5% in the past year; one type 2%, two types 1.1%, three or more types 1.4%

22.6% psychological abuse; 62.6% desire to see relatives unfulfilled; 61% economic dependence on others; 40.5% left alone involuntarily

Prevalence

Note: EA: elder abuse; H-S/EAST: The Hwalek-Sengstok Elder Abuse Screening Test; VASS: The Vulnerability to Abuse Screening Scale; PEAS: Psychological Elder Abuse Scale. CTS: Conflict Tactics Scale; CTS2: Revised Conflict Tactics Scale; ∗ : The cut-off point varies by the subtype of abuse; NA: The information was cot clearly indicated in the study

Other Lai, 2011

Taiwan Wang 2006

Author, Year

TABLE 1 (Continued)

Elder Abuse in Chinese Populations

203

of definitional criteria, while physical abuse (1.1%) and sexual abuse (0.2%) were less prevalent (Dong, 2014). In Mainland China, two studies conducted in the community and clinical settings revealed differences regarding prevalence of psychological abuse and financial exploitation. The prevalence of psychological abuse in the community setting was higher (27.3%) than that in the clinical setting (11.4%), but financial exploitation was much more common in the clinical setting (13.6%) than that in the community setting (2%) (Dong, Simon, & Gorbien, 2007; Wu et al., 2012). A variety of instruments were employed to estimate the prevalence of elder abuse. The majority of research utilized the Conflict Tactic Scales (CTS) or Revised Conflict Tactic Scales (CTS2) when measuring overall elder abuse and its subtypes. Some used the Hwalek-Sengstok Elder Abuse Screening Test (H-S/EAST) and the Vulnerability to Abuse Screening (VASS); others chose self-developed instruments such as the Psychological Elder Abuse Scale (PEAS) or a checklist with 18 types of abuse or neglect. Even when using the same instrument, the number of items used to measure elder abuse and its subtypes varied. For instance, Yan measured verbal abuse using an 8-item subscale from 2001 to 2004 (Yan & Tang, 2001, 2003, 2004), but shortened the scale to 6 items in 2011 (Yan & Kwok, 2011). There is also a discrepancy between time periods when recalling elder abuse among these studies, which included “lifetime” (Chan, Brownridge, Tiwari, Fong, & Leung, 2008; Shibusawa & Yick, 2007), “since 60 years or older” (Dong, 2014a; Dong, Chen, et al., 2014), “since 55 years old” (Lai, 2011), “in the past year” (Wu et al., 2012; Yan & Tang, 2001, 2004), “within past month” (Yan, 2014a; Yan & Kwok, 2011), or an omission of timeframe (Wang, 2006). Only one article investigated the prevalence of elder self-neglect in the community-dwelling U.S. Chinese community. Based on personal and environmental observations by interviewers, 29.1% of the Chinese older adults in the study revealed self-neglect, with 18.2% characterized as experiencing mild self-neglect and 10.9% as experiencing moderate or severe self-neglect (Dong, 2014).

Risk Factors of Elder Abuse Potential risk factors for elder abuse across different geographical locations are presented in Table 2. VICTIM CHARACTERISTICS Sociodemographic. Studies regarding age, gender, education, income, and marital status as risk factors of elder abuse yielded mixed findings. Older age seemed to be a protective factor against elder abuse in global Chinese populations (Dong, Simon, & Gorbien, 2007). Those with younger age were more likely to experience elder abuse (Yan & Chan, 2012), which

204

CS

Dong, 2014

Mainland China Dong, 2013 CS

CS

CS

US Dong, 2014

Dong, 2014

Type

Author, Year

Depression, 269 urban and loneliness, social 135 rural patients at support a medical center in Nanjing, China, 60+

EA

SN

EA

Education, number 3,159 community of children, Chinese older overall health adults in Chicago; status, quality of 60+, 58.9% women life, health status changes Quality of life 3,159 community Chinese older adults in Chicago; 60+, 58.9% women

Outcome EA

Independent Variables Depressive symptomatology

78 Chinese older adults in the U.S., 60+, 52% women

Population and Setting

TABLE 2 Risk and Protective Factors for Elder Abuse in Chinese Populations Key Findings of Risk for Elder Abuse

Age, gender, education, Depression: urban population OR = 1.81 [1.31, 2.50]; rural population OR income, marital = 1.35 [1.02, 1.80]. Loneliness: urban status, number of population OR = 1.23 [0.97, 1.56]; children, medical rural population OR = 1.19 [0.92, co-morbidities 1.54]. Social support: urban population OR = 1.11 [1.04, 1.19]; rural population OR = 1.19 [1.08, 1.31]

Age, gender, education, Higher depressive symptomatology OR = 2.01 [1.23, 3.48]. marital status and household composition, health status, quality of life, physical function, loneliness and social support Age, gender, income, Higher levels of education (r = 0.16, p living arrangement < .001), fewer children (r = 0.1, p < .001), lower health status (r = 0.11, p < .001), poorer quality of life (r = 0.05, p < .01), worsening health over the past year (r = 0.08, p < .001) Sociodemographic Poorer QOL was associated with greater risk of SN of all severities OR = 1.93 [1.26, 2.96]; moderate to severe SN OR = 3.58 [1.79, 7.13]

Confounding Factors

205

Dong, 2010

Wu, 2012

CS

CS

Marital status, physical disability, living arrangement, living source, labor intensity, depression

Social support 411 patients at a medical center in Nanjing, China, 60+, 34.3% women

2,000 adults from three rural communities in Hubei, China. 60+, 59.9% women

EA

EA

(Continued)

Overall EA: not being married (p < 0.01), living alone (p < 0.01), depending solely on self-made income (p < 0.01), physical disability (p < 0.01), high labor intensity (p < 0.05), and depression (p < 0.01). Physical EA: depression OR = 6.3 [4.8, 8.3]. Psychological EA: depression OR = 6.9 [5.2, 9.1]; physical disability OR = 1.5 [1.1, 2.2]; not being married OR = 2.1 [1.5, 2.8]; chronic diseases OR = 1.3 [1.0, 1.6]. Caregiver neglect: depression OR = 2.6 [1.9, 3.5]; high labor intensity OR = 1.8 [1.3, 2.4]; female OR = 0.6 [0.5, 0.8]. Financial EA: physical disability OR = 2.8 [1.2, 6.6]; high labor intensity OR = 2.6 [1.4, 5.0] Women: lower levels of social support Sociodemographic OR = 5.39 [1.95, 14.85]; lower levels factors, of perceived social support OR = socioeconomic status, 1.71 [1.29, 2.27]; lack of contact with depression, someone to trust and confide OR = loneliness, medical 4.03 [1.53, 10.59]; lack of emotional conditions support OR = 5.92 [2.19, 15.99]. Men: lower levels of social support OR = 5.35 [2.18, 13.15]; lack of contact with someone to trust and confide OR = 3.68 [1.68, 8.04]; lack of emotional support OR = 4.98 [2.20, 11.26] Age, number of children

206

CS

Dong, 2010

CS

CS

Dong, 2010

Dong, 2009

Type

Author, Year

TABLE 2 (Continued) Independent Variables

Physical function

141 Older Chinese Loneliness, social women in an urban support medical center, 60+

412 patients in an urban medical center in Nanjing, China, 60+, 34% women

Depression 411 patients at a medical center in Nanjing, China, 60+, 34.3% women

Population and Setting

EA

EA

EA

Outcome

Key Findings of Risk for Elder Abuse

Age, education, income, marital status, number of children

Depression: men OR = 4.47 [1.52, 13.13]; women OR = 8.54 [2.85, 25.57]. After introducing the interaction between depression and overall social support, for men: depression (PE = 0.62±0.82, p = 0.454), for women (PE = 1.49±0.68, p = 0.029). Age, gender, education, ADL: OR = 0.86 [0.48, 1.53]. IADL: OR = 0.87 [0.49, 1.53] income, marital status, number of children, medical conditions, depression, loneliness, social support Demographic, Loneliness OR = 1.44 [1.11, 1.87]. psychological Feeling a lack of companionship OR variables = 2.68 [1.26, 5.69], feeling left out of life OR = 2.59 [1.16, 5.76]. After the interaction with perceived social support, loneliness OR = 0.95 [0.66, 1.37]; After the interaction with instrumental social support, loneliness OR = 1.49 [1.11, 2.01].

Confounding Factors

207

CS

CS

CS

CS

CS

Dong, 2008

Dong, 2008

Dong, 2007

Dong, 2007

Dong, 2007

Depression

412 adults in medical clinic in Nanjing, China, 60+, 34% women 412 adults in medical clinic in Nanjing, China, 60+, 34% women

412 patients in an urban medical center in Nanjing, China, 60+, 34% women

EA

EA

EA

Loneliness

Age, sex, education, income, marital status

EA

EA

Social support

NA 411 patients at a medical center in Nanjing, China, 60+, 34.3% women

412 patients in an urban medical center in Nanjing, China, 60+, 34% women

(Continued)

Dissatisfaction with life OR = 2.92 [1.51, 5.68]; being bored OR = 2.91 [1.53, 5.55]; helpless OR = 2.79, [1.35, 5.76]; worthless OR = 2.16 [1.10, 4.22]; depression OR = 3.26 [1.49, 7.10] NA Women: Lower levels of education (t = -2.19, p = 0.029), currently unmarried (X2 = 9.94, p = 0.002), depression (p < 0.001) loneliness (p < 0.001), social support (p < 0.001). Men: lower levels of education (t = 5.04, p < 0 .001), lower monthly incomes (t = 4.01, p < 0.001), more children (t = -2.29, p = 0.023), depression (p < 0.001) loneliness (p < 0.001), social support (p < 0.001). Age, gender, education, Increase on the social support EA OR = 0.94 [0.91, 0.97]. A medium level of income, marital social support EA OR = 0.52 [0.29, status, number of 0.92]. A high level of social EA OR = children, 0.41 [0.19, 0.90]. psychological variables Age, gender, education, Loneliness OR = 2.74 [1.19, 6.26]; Lacking companionship in life OR = income, marital 4.06 [1.49, 11.10]; left out of life OR = status, and depressive 1.69 [1.01, 2.84]. symptoms Age, gender Aged 65 to 69 OR = 0.79 [0.45, 1.37]; Aged 75 to 79 OR = 0.32 [0.13, 0.76]; Risk factors: female OR = 1.55 [1.01, 2.38]; elemental education level OR = 2.33 [1.19, 4.55]; illiterate OR = 3.03 [1.43, 6.45]; no income OR = 2.86 [1.33, 6.16]; Being widowed OR = 1.56 [0.92, 2.66] Age, income, number of children, level of education

208

CS

PS

Hong Kong Yan, 2014

Yan, 2012

Type

Author, Year

TABLE 2 (Continued) Independent Variables

937 older adults who were married or cohabiting in Hong Kong, 60+, 42.4% women

Age, employment, income, substance abuse, criminal history, social support, anger management, stressful condition

149 family caregivers Baseline abuse, demographics, of community older agitated adults with behaviors, dementia in caregivers’ Hong Kong, 69.8% burnout women. The care recipients’ age range from 60 to 103, with 75.2% women.

Population and Setting

IPV

Key Findings of Risk for Elder Abuse

Verbal EA: baseline abuse (β = 0.622, p < 0.001); large number of co-residing days (β = 0.250, p < 0.01); higher levels of recipients’ agitated behavior (β = 0.269, p < 0.01); caregiver depersonalization (β = 0.206, p < 0.05). Physical EA: baseline abuse (β = 0.355, p < 0.001); male (β = 0.178, p < 0.05); a lack of chronic conditions other than dementia (β = -0.159, p < 0.05); high level of agitated behaviors (β = 0.196, p < 0.05) Physical IPV: younger age OR = 0.85 Gender, disability, [0.76, 0.94]; not employed OR = 0.11 chronic illness, living [0.02, 0.72]; no income OR = 0.19 arrangement, [0.04, 0.99]; low social support OR = immigrants or not, 0.15 [0.03, 0.76]. Psychological IPV: receiving social younger age OR = 0.97 [0.95, 0.99]; security, high stressful conditions OR = 1.40 indebtedness, conflict [1.02, 1.92]. Sexual IPV: no income with children in-law OR = 0.13 [0.02, 0.88];

Confounding Factors

EA at Demographics 6-month follow-up

Outcome

209

CS

CS

Yan, 2011

Yan, 2004

276 community older adults in Hong Kong, 60+, 67.4% women

Visual ability, participants’ dependence, caregivers’ dependence, memory, age

122 family caregivers Co-residing days, assistance from of community older domestic helper, adults with caregiver dementia in burden, care Hong Kong, 76.2% recipient agitated women. The care behavior recipients’ age rage from 59 to 103, with 74.6% women EA

EA

Caregivers’ kinship, chronic illness, training in dementia care, education level, number of months since first assuming care-giving duty, sense of filial piety, care-recipient’s chronic condition, IADL Gender, living arrangement, chronic illness

(Continued)

Verbal EA: a large number of co-residing days (r = 0.37, p < 0.01); a lack of assistance from a domestic helper (r = -0.26, p < 0.01); a high level of caregiver burden (r = 0.33, p < 0.01); a young age of the care recipient (r = 0.18, p < 0.05); and a high level of agitated behavior (r = 0.25, p < 0.01). Physical EA: a larger number of co-residing days (r = 0.24, p < 0.01) Overall EA: poor visual (β = -0.674, p = 0.03) and memory abilities (β = -0.095, p = 0.034), participants’ dependence (β = 0.417, p = 0.001), caregivers’ nondependence (β = -0.298, p = 0.038). Verbal EA: poor visual (β = -0.658, p = 0.037) and memory abilities (β = -0.093, p = 0.039), participants’ dependence (β = 0.461, p = 0.000), caregivers’ nondependence (β = -0.295, p = 0.041). Physical EA: caregivers’ nondependence (β = -2.093, p = 0.01), participants’ dependence (β = 1.212, p = 0.005). Violation of personal rights: age (β = 0.106, p = 0.007)

210

CS

CS

Wang, 2006

CS

Type

Taiwan Wang, 2009

Yan, 2003

Author, Year

TABLE 2 (Continued)

183 caregivers from the care facilities in southern areas of Taiwan, 97.3% women 195 Chinese older adults, 60+, 99 institutionalized, 96 community dwelling, 54.9% women

464 Chinese from community centers and professional organizations in Hong Kong, 51.5% women

Population and Setting

Hours worked each day, years of education, social resources, stress level Chronic disease, Cognitive and physical functioning, social economic status

Childhood experience of abuse, attitudes toward elderly, modernity, filial piety

Independent Variables

PEAB

PEAB

EA

Outcome

Key Findings of Risk for Elder Abuse

Age, education, number of children

Age, training, knowledge

Fewer hours (β = -0.23, p = 0.008), fewer years of education (β = -0.24, p = 0.014), lacked social resources (β = -2.08, p = 0.037), more work stress (β = 0.43, p = 0.000) Increase in chronic disease (r = 0.23, p = 0.001); cognitive functioning (r = -0.32, p < 0.001); physical functioning (r = -.0.362, p < 0.001); social economic status (p = 0.005)

Childhood experience of abuse: Age, gender, marital proclivity to overall EA (β = 0.386, p status, education < 0.001), verbal EA (β = 0.337, p < level, household size, 0.001), physical EA (β = 0.352, p < parents’ age 0.001), social EA (β = 0.335, p < 0.001). Negative attitudes toward elderly: proclivity to overall EA (β = -0.138, p < 0.01), verbal EA (β = -0.151, p < 0.01), physical EA (β = -0.106, p < 0.05), social EA (β = -0.105, p < 0.05). Negative attitudes toward modernity: proclivity to overall EA (β = -0.012, p < 0.01), physical EA (β = -0.187, p < 0.01), social EA (β = -0.157, p < 0.01). Filial piety was not related to proclivity to EA.

Confounding Factors

211

CS

CS

Wang, 2005

Other Lai, 2011

2,272 community Chinese older adults in Canada, 55+

92 family caregivers to community Chinese older adults in southern Taiwan, 69.6% women 114 formal caregivers in long-term care facilities, 89.5% women EA

PEAB

Caregiver burden, age

Religion, education, social support, access barriers for health services, chronic illness, general mental health, length of residency, Chinese cultural values

PEAB

Burden, age

Age, gender, marital status, living arrangement, English competency, income, ADL, IADL, country of origin, general physical health, attitudes toward aging

Education, geriatric care training, professional status

Gender, education

Religion OR = 0.62 [0.4, 0.98]; elementary education level OR = 0.39 [0.2, 0.78]; social support OR = 0.64 [0.44, 0.92]; access barriers for health services OR = 1.1 [1.0, 1.1]; chronic illness OR = 1.1 [1.0, 1.2]; general mental health OR = 0.96 [0.94, 0.98]; length of residency OR =1.0 [1.0, 1.0]; Chinese cultural values OR = 1.5 [1.0, 2.2]

Caregiver burden (β = 0.30, p = 0.001) and age (β = -0.29, p = 0.001)

Higher burden (β = 0.41, p < 0.01); younger age (β = -0.21, p < 0.05)

Note: EA: Elder Abuse; SN: Self-Neglect; PEA: Proclivity to elder abuse; PEAB: Psychological elder abuse behavior; DV: Domestic violence; PV: physical violence; CS: Cross Sectional; PS: Prospective; IPV: Intimate Partner Violence; ADL: Activities of Daily Living; IADL: instrumental activities of daily living.

CS

Wang, 2006

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was supported by a report from 122 family caregivers (Yan & Kwok, 2011). Women were more susceptible to elder abuse according to a clinical study of Chinese older adults in Mainland China (Dong, Beck, & Simon, 2010; Dong, Simon, & Gorbien, 2007). However, in another study of communitydwelling Chinese older adults in Mainland China, Wu et al. (2012) reported that older men suffered higher risk of neglect compared to older women. In addition, the relationship between education and elder abuse was inconclusive among Chinese populations. In the U.S., higher education (r = 0.16, p< 0.001) was positively correlated with elder abuse (Dong, Chen, et al., 2014), while older adults in Mainland China with lower education levels (OR = 2.33 [1.19, 4.55]) and illiteracy (OR = 3.03 [1.43, 6.45]) were more likely to suffer from abuse (Dong, Simon, & Gorbien, 2007). Additionally, Chinese older adults without any income were more likely to be abused (Dong, Simon, & Gorbien, 2007; Yan & Chan, 2012). Furthermore, existing literature on the relationship between marital status and elder abuse remained inconsistent. In Mainland China, not being married increased the risks of elder abuse among 2,000 rural community-dwelling older adults (Wu et al., 2012). However, Dong, Simon, and Gorbien (2007) reported that marital status was not associated with elder abuse, based on 412 older adults in an urban medical clinic. Health. A number of studies explored the relationships between psychological, physical, cognitive heath and elder abuse. The significant association between depressive symptomatology and elder abuse was identified by analyzing 78 Chinese older adults in the U.S. (Dong, Chang, Wong, & Simon, 2014), which was also supported by the studies conducted in Mainland China by Wu et al. (2012) and Dong (Dong et al., 2010; 2013; Dong, Simon, Odwazny, & Gorbien, 2008). Specifically, depression was associated with overall abuse, physical abuse, psychological abuse and caregiver neglect for the rural community-dwelling older adults in Hubei (Wu et al., 2012). It also remained a risk factor for 269 urban and 135 rural patients (Dong & Simon, 2013), and for both men and women at a medical center in Nanjing (Dong et al., 2010). With respect to physical health, physical disability was associated with increased risk of abuse in Mainland China (Wu et al., 2012). Poor visual ability was associated with verbal abuse and overall abuse in Hong Kong (Yan & Tang, 2004). The increase in chronic disease was linked with psychological abuse in Taiwan (Wang, 2006), and overall abuse in Canada (Lai, 2011). However, Dong and Simon (2010b) suggested that impairment of physical function was not independently associated with increased risk of elder abuse, after taking potential confounding factors into consideration. In terms of cognitive heath, the experience of overall abuse and psychological abuse increased with the impairment of cognitive functioning (Wang, 2006; Yan & Tang, 2004). Social variables. Several studies suggested the lack of social support and the feeling of loneliness were associated with higher risk of elder abuse.

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In Mainland China, Dong and Simon demonstrated that the increased level of social support was associated with lower likelihood of elder abuse report (Dong & Simon, 2007). Lack of social support was found to be a significant risk factor for elder abuse for urban and rural populations (Dong & Simon, 2013) and women and men (Dong & Simon, 2010a). Similar results were also found in Chinese older adults in Canada (Lai, 2011) and Hong Kong (Yan & Chan, 2012). Loneliness was a predictor of elder abuse based on the studies sampled 412 patients and 141 older Chinese women in an urban medical center in Nanjing, China (Dong, Beck, & Simon, 2009; Dong, Simon, Gorbien, Percak, & Golden, 2007). However, higher level of loneliness was not a significant risk factor for elder abuse in urban and rural populations (Dong & Simon, 2013). It was the perceived social support that mitigated the effects of loneliness on elder abuse (Dong, Beck, et al., 2009). POTENTIAL PERPETRATOR CHARACTERISTICS Regarding the abusive behaviors reported by caregivers and the proclivity to elder abuse, Yan and Wang conducted multiple studies. In Hong Kong, large number of co-residing days with older adults(Yan, 2014a; Yan & Kwok, 2011), a lack of assistance from a domestic helper (Yan & Kwok, 2011), a high level of caregiver burden (Yan, 2014a; Yan & Kwok, 2011) childhood experience of abuse, negative attitudes toward older adults, and modernity (Yan & Tang, 2003) were significantly linked to elder abuse. In Taiwan, fewer working hours of caregivers, lower education level, lack of social resources, higher working stress (Wang, Lin, Tseng, & Chang, 2009), caregiver burden, and younger age (Wang, 2005; Wang, Lin, & Lee, 2006) were identified as key factors associated with psychological elder abuse behavior.

Adverse Health Outcomes of Elder Abuse The adverse health outcomes of elder abuse included suicidal ideation and psychological stress (Table 3). In Mainland China, based on a sample of 2,039 community-dwelling older adults, psychological abuse and financial abuse were found to be associated with suicidal ideation (Wu et al., 2013). Specifically, psychological abuse significantly contributed to suicidal ideation for both men and women; the influence of physical abuse was stronger on women than men, while that of financial abuse was stronger on men than women in terms of suicidal ideation (Wu et al., 2013). In Hong Kong, an association had been identified between elder abuse and psychological stress. In particular, verbal abuse and physical abuse were significantly associated with anxiety, social dysfunction, depression, and somatic complaints, with verbal abuse being the best predictor of participants’ psychological distress (Yan & Tang, 2001).

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Type

CS

355 community older adults in Hong Kong, 60+; 62% women

2,039 adults from three rural communities in Hubei, China. 60+, 59.9% women

Population and Setting

Note: EA: Elder Abuse; CS: Cross Sectional

Hong Kong Yan, 2001

Mainland China Wu, 2013 CS

Author, Year

Verbal abuse, physical abuse, social abuse

Psychological abuse, financial abuse, physical abuse

Predictor

Confounding Factors

Key Findings

Psychological stress

Age, gender, participant dependence, caregiver dependence.

Verbal EA: overall psychological distress (β = 0.50, p = 0.000), anxiety (β = 0.39, p = 0.000), social dysfunction (β = 0.41, p = 0.000), depression (β = 0.27, p = 0.000), somatic complaints (β = 0.35, p = 0.000). Physical EA: overall psychological distress (β = 0.24, p = 0.000), anxiety (β = 0.16, p = 0.000), social dysfunction (β = 0.12, p = 0.032), depression (β = 0.40, p = 0.000), somatic complaints (β = 0.16, p = 0.006).

Psychological EA OR = 5.0 [2.5, 9.8], Suicidal ideation Age, education, financial abuse OR = 4.1 [1.2, marital status, 14.7]. Men: psychological abuse physical OR = 5.4 [2.6, 11.2]; financial disability, chronic abuse OR = 4.2 [1.1, 16.2]. diseases, living Women: physical abuse OR = 4.5 arrangement, [2.2, 9.2]; psychological abuse OR living source, = 2.6 [1.5, 4.4] depressive symptoms

Outcomes

TABLE 3 Adverse Health Outcomes of Elder Abuse in Chinese Populations

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Perceptions of Elder Abuse, Interventions, Help-Seeking Tendency and Behaviors In terms of defining and identifying elder abuse, older adults in the U.S. and in Hong Kong all identified psychological abuse, physical abuse, financial exploration, and neglect as dimensions of elder abuse (Table 4). Sexual abuse, abandonment, and violation of personal rights were not consistently represented among identification of elder abuse subtypes (Dong, Chang, Wong, Wong, & Simon, 2011; Lee, Kaplan, & Perez-Stable, 2014; Yan, 2014b). In addition, transgressing the Chinese value and norm that dictates respect for older adults (Tam & Neysmith, 2006), “disrespect” was perceived as one form of elder abuse, which is different from a western perspective. Tam and Neysmith (2006) suggested that family members being excessively “bossy” or “rude”, having abrupt and unreasonable commands, giving dismissive comments, misnaming (“Mrs.___” rather than “Mother”) or name-calling were all cases of elder abuse. This disrespectful behavior can give rise to unsettling feelings for victims (Dong, Chang, et al., 2011). Both Lee, Kaplan, et al. (2014) and Shibusawa and Yick (2007)’s research participants consider contextual and situational factors when determining elder abuse. For the same elder abuse behavior, non-U.S. born Taiwanese American and U.S. born Chinese Americans had significantly different levels of tolerance (Moon, Tomita, & Jung-Kamei, 2002). Moreover, cultural factors, demographic factors, and isolation were examined as factors impacting the perceptions of elder abuse (Lee, Moon, & Gomez, 2014; Shibusawa & Yick, 2007; Tam & Neysmith, 2006). Regarding the perceptions of interventions, the author indicated the potential intervention may contain social support, empowerment, community-based dissemination, cultural adaptation, and familial integration, in two studies that involved 37 community-dwelling Chinese older adults in Chicago (Dong, Chang, Wong, & Simon, 2013). Recommendations included increasing education and public awareness about elder abuse, as well as setting a multidisciplinary team which involved social workers, physicians, policemen, lawyers, therapists, and psychologists (Dong, Chang, Wong, & Simon, 2014). Further, Dong, Chang, Wong, and Simon (2014) suggested that barriers for elder abuse intervention include stigma; fears; problem recognizing abuse; various definitions of what constitutes an elder abuse case; victims’ education level and cognitive impairment; and lack of awareness regarding intervention availabilities. Research findings on the help-seeking tendency and behaviors are mixed. Though over half of Taiwanese and Chinese Americans in Los Angeles tended to favor third party interventions, approximately 28% Taiwanese Americans still did not embrace reporting elder abuse to social service agencies or the police, which was significantly higher than Americanborn groups (Moon et al., 2002). Further, Chinese older adults in Chicago

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Study Design

Yan, 2014

Interviews

Perceptions of Elder Abuse Lee, 2014 Interviews, focus group

Author, Year

40 elder abuse survivors ≥ 60 years in Hong Kong, referred by a Cease Crisis Intervention Center, 65% women

20 local professionals working in Asian elderly advocacy, 60 community members in San Francisco Bay area, 40 Chinese with 92.5% women

Population and Setting

Key Findings

Psychological abuse: disrespect, silent Psychological abuse, neglect treatment, lack of love and affection, by a trusted person, intense level of child care, isolation of financial exploration, elderly grandparents from physical abuse, sexual abuse grandchildren, verbal aggression, etc. Neglect by a trusted person: lack of sincere intention to care for an older adult and failure to provide emotional care; unwillingness of an adult son and his wife to live with his elderly parents, sending an elderly parent to a nursing home, etc. Physical abuse: “Elder abuse—that’s Physical abuse, psychological being bullied, being beaten up . . . abuse, neglect, financial ”Psychological abuse: “Elder abuse exploitation, violation of includes psychological aggression.” personal rights Neglect: “If you don’t give an older person food, or keep ignoring his needs. Then it’s elder abuse.” Financial exploitation: “the subsidy they received from the government, any bonus, any financial assistance, they grab the money. That’s elder abuse. They steal their money.” Violation of personal rights: “if the person wants to go out and his partner wouldn’t allow that. “

Themes

TABLE 4 Perceptions of Elder Abuse, Intervention, Help-Seeking Tendency and Behaviors in Chinese Populations

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Semistructured and focus group interviews

Shibusawa, 2007 Quantitative telephone survey

Dong, 2011

77 community Chinese older adults ≥ 50 in Southern California

39 community Chinese older adults ≥ 60 years in Chicago, 56.4% women

Physical aggression as domestic violence, justifications for domestic violence

Caregiver neglect, psychological abuse, financial exploitation, physical abuse, abandonment

(Continued)

Caregiver neglect was mentioned most; Psychological abuse was the most serious form of mistreatment; disrespectable and emotionally abusive behavior resulted in unsettling feelings for participants. Financial exploitation: adult children deceived aging parents for monetary purpose, rent, property ownership, or food stamps. Physical abuse was not common in the Chinese community. Financial exploration: the transference of property from an elderly parent to adult children, etc. Physical abuse: pinching the skin as a disciplinary method for stopping or punishing certain behaviors, etc. Sexual abuse: women were the main victim; the perpetrators were usually known and trusted A majority of the Chinese men and women agreed that throwing objects at their spouse and punching them in the face were forms of domestic violence. A larger number of men than women believed that use of physical violence towards a woman was justified if the wife always nagged (F = 4.50, df = 1, p ≤ .037), was drunk (F = 4.22, df = 1, p ≤ .044), or was unwilling to have sex (F = 9.47, df = 1, p ≤ .003). A larger number of women than men believed that physical violence by the husband was justified when wives screamed hysterically (F = 6.50, df = 1, p ≤ .013).

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Tam, 2006

Author, Year

Focus group

Study Design

TABLE 4 (Continued)

33 Chinese home care workers Disrespect and 7 Chinese program coordinators in Canada

Population and Setting

Themes

Family members being excessively “bossy” or “rude”; abrupt and unreasonable commands, dismissive comments; misnaming or name-calling; threatened to send an elderly man to a nursing home against his wishes; relatives talked unkindly about death; a lack of direct communication with the older person; space and movement restrictions; relatives provided only the necessary food and shelter to the elder without others. Disrespect is a culturally specific form of abuse

Key Findings

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Interviews

Tolerance for potential EA, 272 Asian Americans ≥ tendency to victim blame 60 years in Los Angeles.50 U.S.-born Chinese Americans with 56% women, and 80 Non-U.S. born Taiwan Americans with 55% women.

Factors Affecting the Perceptions of Elder Abuse Lee, 2014 Focus group 30 community older adults ≥ Collectivism and family 60 years in San Franciso. harmony; filial piety; 20 Chinese with 90% women spiritual and religious beliefs; immigration and acculturation

Moon, 2002

(Continued)

Collectivism and family harmony: family preservation; sharing of financial resources with family members; prohibition of public disclosure about family matters. Filial Piety: respect and affection toward parents by their adult children; adult children’s caregiving obligation for aged parents, etc. Spiritual and religious beliefs: Buddhism, Confucianism, Taoism, endurance and perseverance, etc. Immigration and acculturation: immigration and acculturative stress, intergenerational conflicts, etc.

Tolerate adult children yelling occasionally at their elderly parents: 5%Taiwanese Americans, 30% U.S.-born Chinese Americans. Tolerate adult children using elderly parents’ money for him/herself: 13% Taiwanese Americans, 8% U.S.-born Chinese Americans. Tolerate adult children not paying back borrowed money: 9% Taiwanese Americans, 0% U.S.-born Chinese Americans. Agree that many elderly people are badly treated because they did something wrong to deserve it: 11% Taiwanese Americans, 6% Chinese Americans. Agree that elderly parents who abused their children deserve abuse from their grown-up children: 10% Taiwanese Americans, 0% Chinese Americans.

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Study Design

Tam, 2006

Focus group

Shibusawa, 2007 Quantitative telephone survey

Author, Year

TABLE 4 (Continued) Themes Age, sex, acculturation, victim to minor or severe violence

33 Chinese home care workers Isolation and 7 Chinese program coordinators in Canada

77 community Chinese older adults ≥ 50 years in Southern California

Population and Setting

Higher acculturation scores were associated with higher possibility to define physical violence as domestic violence (β = 0.316, p < 0,05); Men (β = -0.357, p < 0.01) and older adults who were less acculturated (β = -0.305, p < 0.05) were more likely to believe use of physical violence towards women is justified; Men (β = -0.297, p < 0.05) and older adults who had minor violence experience as victims (β = 0.465, p < 0.01) more likely to view domestic violence as a growing problem Isolation resulted from the elders’ dependence on children owing to the finance and the English language proficiency, and the caregivers’ frustration and impatience because of the pressures and stress.

Key Findings

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Perceptions of Elder Abuse Interventions Dong, 2014 Focus group 37 community Chinese older adults ≥ 60 years in Chicago, women 56.8% Benefits for victims, benefits for family members, benefits for the community; cultural barriers, social barriers, structural barriers; increase education, integrate intervention with existing community-based services, setting a multidisciplinary team, increase public health awareness; understand caregiver burn-out, reduce caregiver stress, education and awareness

(Continued)

Benefits of EA intervention: promoting psychological wellbeing of victims, help family members to ease burdens and empower victims’ family members, etc. Perceived barriers to EA intervention: stigma, fears and problem recognizing abuse, various definitions of what constitutes an elder abuse case, not aware of intervention availabilities, etc. Perceived facilitators of EA intervention: increase education, acknowledgement of elder abuse; community services organization; increasing public health awareness through media and communication. Preferred components in perpetrator intervention programs: solving inter-generational conflicts, reduce caregiver stress by promoting mutual respect and anger management, understanding the real cause of abusive behavior.

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Study Design

Survey questionnaires and semistructured focus group

Author, Year

Dong, 2013

TABLE 4 (Continued) Key Findings Perceived effectiveness of EA interventions: social support, empowerment, and community-based interventions design are more effective. Advocacy and psychological intervention received least favorable views. Biggest challenge to advocacy was the fear of limited actions. Empowerment programs would only be helpful if linking with other elements. Culturally adapted interventions included nurturing filial piety values, improve peer support by organizing community social events and activities, more research and educational outreach efforts, and religious involvement.

Themes Social support, empowerment, community-based intervention, advocacy, psychological intervention; improve social support, provide financial independence, research, religion

Population and Setting 37 community Chinese older adults ≥ 60 years in Chicago, 1/3 elder abuse victims, 2/3 nonvictims, women 56.8%

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Dong, 2011

Semistructured and focus group interviews

39 community Chinese older adults ≥ 60 years in Chicago, 56.4% women

Perceptions of Help-Seeking Tendency and Behaviors Yan, 2014 Interviews 40 elder abuse survivors ≥ 60 years in Hong Kong, referred by a Cease Crisis Intervention Center, 65% women

Turn to community service center for help, report to the police, helplessness, potential solutions

Motivations, social networks, social isolation, cultural barriers, self-blame, lack of knowledge

(Continued)

Motivations: thought about seeking-help when “they couldn’t stand it any more”; worried about their own safety; worried about the wellbeing of the abuser. Social networks: someone from the social network identified the abuse and suggested that they seek help or referred them to an appropriate person. Professionals: identified by social, legal or health care professionals. Barriers to help seeking: cultural considerations (harmony, face, belief in fate); lack of knowledge about what constitutes elder abuse; frontline professionals failed to be wary of elder abuse issues and provide assistance. Community service center was the place that most participants sought assistance from; Reporting to the police would be appropriate only if the abuse case constituted a “criminal case”. Helplessness: no solution, fear of losing face, the role of health care professionals was unrecognized Potential solutions: ask the victims to move away or hide, community service center initiated a channel for reporting EM and create a community support group for victims.

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Study Design

Interviews

Note: EA: Elder Abuse.

Moon, 2002

Author, Year

TABLE 4 (Continued)

272 Asian Americans ≥ 60 years in Los Angeles, 50 Chinese Americans with 56% women, and 80 Taiwan Americans with 55% women.

Population and Setting Third-party intervention and reporting EA

Themes

62% Chinese Americans and 70% Taiwanese Americans had the tendency to favor third party intervention. 90% Chinese Americans and 68% Taiwanese Americans felt neighbor should report the EA to social service agencies and the police. 56% Chinese Americans and 48% of Taiwanese Americans felt the neighbor should not report the mistreatment until the neighbor was absolutely sure about it. 84% Chinese Americans and 54% Taiwanese Americans did not think reporting elder abusers to authorities will destroy the abusers’ lives.

Key Findings

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thought reporting to the police would not be appropriate unless the abuse was considered to be a “criminal case” (Dong, Chang, et al., 2011). Several themes have emerged in terms of intervention barriers: cultural considerations, lack of knowledge about the constitution of elder abuse, the role of health care professionals in reporting elder abuse in Chinese communities was unrecognized, and social service and health professionals failed to recognize elder abuse issues and provide assistance (Dong, Chang, et al., 2011).

DISCUSSION Through the limited English-language literature on elder abuse in the global Chinese population, we can still glimpse the prevalence and risk factors of Chinese elder abuse and its subtypes across different geographical locations, settings, and informants. The prevalence of overall elder abuse and its subtypes ranges from 0.2% to 64%, depending on the populations, settings, definitions, and research methods. In regard to those risk factors, younger age, lower income levels, depression, cognitive impairment, and lack of social support are consistently associated with the elder abuse reported by older adults; caregiver burden was a constant risk factor for the proclivity to elder abuse by caregivers. Elder abuse may result in psychological stress or suicidal ideation. By conducting qualitative studies, researchers have identified potential intervention approaches, perceived barriers to elder abuse intervention, help-seeking tendency/behaviors, explored the perceptions of elder abuse, and related factors. The research on elder abuse in the global Chinese population remains underrepresented in English-language journals. The current English- language literature on the prevalence of elder abuse and its subtypes employs various measurements and different version of the instruments and also utilized divergent recall periods, which complicates the degree to which the data may be synthesized or interpreted. With the exception of Yan (2014a)’s study, all studies on risk factors of elder abuse utilize a cross-sectional design, making it difficult to determine the causal relationship between potential risk factors and elder abuse or its subtypes. In addition, it is not clear about the relationship between the culture and elder abuse based on the current scarce studies. Lai (2011) suggested that Chinese cultural values played a key role in elder abuse in a study of 2, 272 community-dwelling Chinese older adults in Canada. On the other hand, a study of 464 Chinese in Hong Kong implied that filial piety was not related to proclivity to elder abuse (Yan & Tang, 2003). Moreover, the research on self-neglect has lagged behind research on other forms of elder abuse. Last but not least, there is limited work on the consequences and possible interventions of Chinese elder abuse.

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FUTURE RESEARCH DIRECTIONS In order to further examine the incidence of elder abuse subtypes in diverse settings and the related risk/protective factors, as well as the underlying mechanisms between those factors and elder abuse, we need to conduct longitudinal studies on Chinese elder abuse from both the perspectives of older adults and potential perpetrators. Contrary to the common belief that potential perpetrators may underreport the proclivity to commit elder abuse behaviors due to social desirability, several studies conducted by Yan (Yan, 2014a; Yan & Kwok, 2011; 2003) display similar or higher prevalence rates compared to those reported by the victims. Therefore, future research should compare the prevalence of elder abuse from diverse informants. In addition, innovative approaches are necessary to understand the characteristics of potential perpetrators. Given the complexity of elder abuse, more rigorous studies are needed to determine the relationships between elder abuse and the variables of gender, marital status, living arrangement, education, and physical health in the Chinese population. When examining elder abuse and its subtypes in the Chinese population, it is important to take cultural issues into account since interpersonal relationships are culturally constructed (Yan, Chan, & Tiwari, 2014). Under the influence of Confucian traditions, Chinese cultural values stress filial piety and that it is children’s obligation to obey, respect, support and care for older adults (Ho, 1996). A study of 3,159 Chinese older adults in the US proves that Chinese older adults still have high expectations of filial piety (Dong, Zhang, & Simon, 2014). In contrast, some evidence indicates that the younger generation of Chinese has become less likely to adhere to filial piety in caring for their aging parents (Yan, So-Kum, & Yeung, 2002) and also interprets filial duty differently from their parents (Yan et al., 2014). This growing discrepancy in cultural values may result in family conflicts and increased caregiver burden that predispose older adults to elder abuse (Dong, Chen, et al., 2014). At the same time, the traditional Chinese values of harmony, saving face and belief in fate may preclude older adults from seeking help for elder abuse (Yan, 2014b). Owing to above cultural considerations, more quantitative and qualitative studies are needed to understand the influence of cultural variations on the incidence of elder abuse and the perceptions of elder abuse, as well as the help-seeking tendency/behaviors. As elder abuse is such a culturally sensitive issue that disclosing it may bring shame to the family (Yan et al., 2002), it is a challenge to conduct research on elder abuse in the Chinese communities. To overcome this barrier, Community-Based Participatory Research (CBPR), “a systematic inquiry with the participation of those affected by the issue being studied, for the purpose of education and taking action or affecting social change” (Green & Mercer, 2001), has been demonstrated as an useful model to explore the issues of elder abuse in minority populations (Dong, 2012; Holkup, Tripp-Reimer, Salois, & Weinert,

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2004). One example of CBPR for elder abuse in the Chinese community is the ” that has “PINE Study (Population Study of ChINese Elderly) established infrastructure and networks for community-engaged research and community-academic partnerships (Dong, Wong, & Simon, 2014). In addition, culturally sensitive instruments are essential to capture the culturally specific subtypes of Chinese elder abuse, like “disrespect,” by considering the contextual and situational factors that define elder abuse. In spite of the pervasiveness of elder abuse in the global Chinese population, there is a lack of evidence-based prevention and intervention strategies to assist victims of elder abuse or address the abusive behaviors of perpetrators in the global Chinese Population. Increasing education, integrating interventions with existing community-based services, and setting a multidisciplinary team are potential strategies of intervention programs (Dong, Chang, Wong, & Simon, 2014). Given the complexity of elder abuse in the current global Chinese population, intervention efforts and prevention strategies should be well developed through collaboration among different stakeholders. Future research efforts should enhance the partnership between community organizations and research institutions to better serve the needs of Chinese older adults. Rigorous experimental studies would likely be beneficial to examine the efficacy of potential interventions. Meanwhile, more evidence-based studies are required to further evaluate the cost-effectiveness of interventions for global Chinese population in diverse settings. IMPLICATIONS

FOR

PRACTICE

AND

POLICY

This review has implications for health care professionals, social service providers and health policy makers. Health care professionals are in a critical position to screen for elder abuse and detect potential risk factors (Dong & Simon, 2015). However, some elder abuse survivors perceived that these professionals failed to recognize elder abuse issues and provide assistance (Yan, 2014b). Hence, it is necessary to emphasize elder abuse issues when training the healthcare professionals. Additionally, routine screening for elder abuse should be established in the healthcare settings, and screening for abuse in older adults with depressive symptoms is particularly relevant, given the significant association between depressive symptomatology and elder abuse. At the same time, as lacking of social support is also a prominent risk factor for elder abuse, healthcare professionals should find ways to proactively reach out to older adults suffering from social isolation. Owing to the traditional cultural values, Chinese older adults are reluctant to disclose elder abuse to people outside of the family (Lee, Moon, et al., 2014). Accordingly, apart from proactive outreach efforts, the health care professionals can provide community-based services and mobilize the victims’

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social networks, which may involve family members or friends, to prevent or intervene in cases of elder abuse (Yan et al., 2014). It is worth noting that the role of health care professionals are unrecognized in reporting elder abuse in Chinese communities and the psychological interventions received least favorable views (Dong, Chang, Wong, & Simon, 2013; Dong, Chang, et al., 2011). To improve this situation, health care professionals may need to reach out and help Chinese older adults understand the health care professionals’ pivotal impact on elder abuse management. Furthermore, it is essential to utilize culturally appropriate psychological interventions when working with Chinese older adults. Given current psychological interventions such as the cognitive behavior model derived from western culture, it may need some modifications before applying to Chinese populations. Social service providers, like community organizations and Adult Protective Services (APS), play an important role in prevention and intervention of elder abuse among community-dwelling Chinese older adults. Increasing education and public awareness of elder abuse and reducing the stigma of elder abuse and caregiver stress will likely be helpful facets of community intervention programs. Community organizations should pay more attention to older adults’ social network, facilitating the support from both peer groups and families, especially regarding emotional support. Furthermore, it is beneficial for community organizations to cooperate with academic organizations to foster the understanding of the complexities of elder abuse situations and tackle these issues. Institutionally, there are no formal APS in Mainland China (Dong & Simon, 2013) and about 28% Taiwanese Americans do not endorse reporting elder abuse to APS (Moon et al., 2002). In the U.S., Chinese older adults are likely unaware of APS according to Dong, Simon, et al. (2011). Therefore, the APS should help the Chinese community to understand the process of reporting, the benefits to the victim of reporting, and the realistic consequences for the perpetrator (Moon et al., 2002). In addition, APS may need to equip itself with more culturally appropriate resources and services to Chinese older adults. With respect to the health policy, in the US, the Older Americans Act (OAA) and the Elder Justice Act (EJA) are two primary federal legislations dealing with issues of elder abuse (Dong & Simon, 2015). The OAA contains four provisions (Titles II, III, IV, and VII) that are closely relevant to the issues of elder abuse. Among these provisions, protection of older adults and elder justice-related activities should be fortified and expanded (Dong, Chen, Chang, & Simon, 2013). “A vehicle for setting national priorities and establishing a comprehensive multidisciplinary elder justice system in this country” (“Elder Justice: Stronger federal leadership could enhance national response to elder abuse,” 2011), the EJA is responsible for guiding human subject protection so as to assist researchers and establish elder abuse forensic centers (Dong & Simon, 2015). It also provides funding and incentives for long-term care staffing and electronic medical records technology, as well as

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collects and disseminates annual APS data. However, the EJA is at risk of dissolution since many EJA programs and activities have not yet received funding (Dong & Simon, 2015). Comprehensive advocacy and policy efforts are needed to address the issues of elder abuse in the legislations at the community, city, state, and federal levels (Dong & Simon, 2011).

CONCLUSION This review features the pervasiveness and complexities of elder abuse in the global Chinese population. Variations exist on the prevalence of elder abuse and its risk/protective factors, due to disparities in sample populations, settings, types of elder abuse examined, recall periods, and instruments employed. Longitudinal research is needed to further investigate the incidence of elder abuse, how diverse factors affect elder abuse and its subtypes, and the potential consequences of elder abuse. Evidence-based and culturally appropriate interventions are imperative to be developed through rigorous experimental studies. Researchers, health care professionals, social services providers, and health policy makers should collaborate with each other to reduce elder abuse and improve healthy aging of global Chinese population.

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