INT’L. J. AGING AND HUMAN DEVELOPMENT, Vol. 78(2) 115-131, 2014

PREVALENCE AND RISK FACTORS FOR SELF-NEGLECT AMONG OLDER ADULTS LIVING ALONE IN SOUTH KOREA

MINHONG LEE, PH.D. Dong-Eui University, South Korea KYEONGMO KIM, MSW University of Maryland at Baltimore

ABSTRACT

This study aimed to explore the prevalence of and risk factors for self-neglect among older adults who live alone. Data were obtained through face-to-face interview responses of 1,023 older adults living alone in a metropolitan area in South Korea, selected via stratified random sampling, which considered the population variables gender, age group, and district. Descriptive statistics were used to characterize the prevalence of self-neglect, and hierarchical multiple regression analysis was conducted to identify significant risk factors of self-neglect. At least 22.8% of the participants could be considered to have one form of elder self-neglect. Consistent with previous research, self-neglect was more prevalent in the older people living alone who had higher levels of depressive symptoms or a lack of family social support. Unexpectedly, self-neglect was more prevalent among respondents with higher levels of education and cognitive abilities, lower levels of medical comorbidities, and more children. Additionally, social networks of friends and use of social services (formal social support) did not affect the frequency of self-neglect. The findings have implications for gerontological practice and policy, especially for older people living alone in South Korea. 115 Ó 2014, Baywood Publishing Co., Inc. doi: http://dx.doi.org/10.2190/AG.78.2.b http://baywood.com

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INTRODUCTION Policy makers and social and health service providers have overlooked the issue of elder self-neglect in Korean society. Because the family is the primary source of caregiving for aging members, Korean gerontological professionals have focused on elder abuse as a negative effect of family caregiving (Lee, 2009). However, the Korea Ministry of Health and Welfare (Korea MOHW, 2012) reported that only 27.3% of older Koreans lived with their children in 2011. Approximately 49% of the elderly population were living with a spouse, and 19.6% were living alone (Korea MOHW, 2012). These statistics indicate that research investigating or interventions directed against elder neglect or abuse by family members are insufficient to deal with all the types of abuse and neglect among older people. Korea’s Adult Protection Services agencies received 3,441 reports of elder abuse in 2011 (Korea National Center on Elder Abuse, 2013). Some of these reports included more than two types of abuse for a total of 5,765 instances of elder abuse. Of those that suffered from elder abuse, 24.6%, 40.0%, 1.2%, 10.5%, 18.0%, 4.1%, and 1.5% suffered from physical abuse, verbal or emotional abuse, sexual abuse, financial abuse, neglect, self-neglect, and abandonment, respectively. Recent national studies conducted in the United States showed that half or more of all cases reported to adult protective services were elder self-neglect (Dyer, Goodwin, Pickens-Pace, Burnett, & Kelly, 2007). Compared with the percentage of self-neglect (> 50%) clients reported to adult protective services in the United States (Iris, Ridings, & Conrad, 2010), the percentage in Korea (~ 4.1%) is relatively small (Korea National Center on Elder Abuse, 2013). This is because clients in Korea tend to attribute all kinds of reported neglect to family members. However, neglect of those elderly that are living alone or of frail older couples should be classified as self-neglect rather than family neglect. There is a lack of consensus concerning a standard definition of self-neglect in older populations even though a mass of literature has addressed the phenomenon of other forms of neglect (Dyer et al., 2007; Fulmer, 2008; Gordon & Brill, 2001; Peri, Fanslow, Hand, & Parsons, 2009). Because of a lack of agreement on the definition of self-neglect, the literature has the tendency to accept the broad, general definitions of elder self-neglect (Band-Winterstein, Doron, & Naim, 2012), rather than systematically trying to conceptualize or operationalize the definition of it. Results of estimate research on the prevalence of self-neglect of older adults are difficult to compare due to the lack of uniformity in the definition of it and different methods of assessment (Gorbien & Eisenstein, 2005; Lee, 2006). The term “elder self-neglect,” as defined by the National Center on Elder Abuse, is employed in this study in that its description is general and includes various phenotypes of self-neglect. The Korea National Center on Elder Abuse (2013) defines self-neglect on its website as “the behavior of an elderly person that threatens his/her own health or safety. Self-neglect generally manifests itself

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in an older person as a refusal or failure to provide himself/herself with adequate food, water, clothing, shelter, personal hygiene, medication (when indicated), and safety precautions” (para. 8). In addition, many recent researchers on the topic have widely used the definition established by the center (Dong, Simon, Beck, & Evans, 2010; Dong, Simon, & Evans, 2012; Dong, Simon, Mendes de Leon, Fulmer, Beck, Hebert, et al., 2009; Dyer et al., 2007; Gorbien & Eisenstein, 2005). Older people who engage in self-negligent behavior often live in unsanitary or unclean quarters and are more likely to experience mortality (Dong & Simon, 2013; Dong et al., 2009) and hospitalization or placement in a nursing home than elders who do not engage in self-neglect (Dong & Simon, 2013; Dong et al., 2009). Over the last few decades, extensive research of the topic of elder selfneglect has uncovered numerous risk factors, including living alone, advanced age (> 75 years old), poverty, psychiatric illness, physical function impairment, reduced cognitive capability, dementia, cerebrovascular disease, depression, chronic illness, nutritional deficiency, alcohol and substance misuse, lack of social network, or inadequate support services (Abrams, Lachs, McAvay, Keohane, & Bruce, 2002; Band-Winterstein et al., 2012; Day & Leahy-Warren, 2008; Dong, Simon, & Wilson, 2010; Levine, 2003; Mauk, 2011; Paveza, Vandeweerd, & Laumann, 2008; Pavlou & Lachs, 2006). Various theories have been suggested to explain the phenomenon of elder self-neglect and its causes. Sociological and psychological theories, including social constructionism, personal construct theory, structuralist-functionalist theories, interaction perspectives, and attribution theory, have provided a deeper understanding of the dynamic and interactive nature of elder self-neglect (Lauder, Anderson, & Barclay, 2002). In addition, psychomedical perspectives have attempted to explain self-neglect as a consequence of mental, physical, and social disturbances (Abrams et al., 2002; Band-Winterstein et al., 2012). This study employs the conceptual framework designed by Dyer et al. (2007) as a psychomedical perspective in that public health professionals have commonly applied it to provide better understanding for self-neglect and its risk-factors among older adults (Dong et al., 2010; Dong, Simmon, Beck, & Evans, 2010; Dyer et al., 2007; Iris et al., 2010; Paveza, Vandeweerd, & Laumann, 2008). Using the theoretical approach, empirical studies carried out in Western countries have found that self-neglect is associated with medical comorbidities, physical abilities, cognitive abilities, depressive symptoms, and a lack of a social network and social support (Dong et al., 2009). In this model, dementia, depression, and diabetes lead to executive dysfunction, which results in an inability to conduct activities of daily living (ADL) and instrumental ADL. The model hypothesizes that impaired ADLs and IADLs and inadequate support services lead to the syndrome of elder self-neglect, enlarged by lack of capacity for self-care and self-protection (Dong et al., 2009). In addition, extrinsic social issues (e.g., poverty, access, and lack of social support) can affect self-neglect (Dyer et al., 2007).

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Although demographic trends suggest that the number of older people living alone is rapidly increasing, elder self-neglect has rarely been studied, and the few empirical studies conducted in Korea have examined only elder neglect by family members. Thus, the aim of this study was to explore the present prevalence of self-neglect and identify risk factors for self-neglect among older adults who live alone. The prevalence indicates the proportion of the older adult population who are suspected to suffer from self-neglect. The results of this study support the idea that self-neglect is a serious societal problem. This study may provide a better understanding of the main factors associated with elder self-neglect so that effective coping mechanisms to prevent or address self-neglect can be developed. The main research question of the current study was based upon the conceptual framework designed by Dyer and colleagues (2007). Specifically, the main research question was to determine what variables, including chronic diseases, physical and cognitive impairments, depression, size of the social network, and use of social services, best explain the frequency of elder self-neglect. The current study is explorative research because it is the first such empirical study of its kind conducted in Korea. We speculate that the findings can contribute to the elder self-neglect literature by providing a basis for a richer understanding of self-neglect in this nation. METHODS Sample and Procedure The data were drawn from a regional survey of older adults living alone conducted in 2012 by the Busan Welfare Development Institute (BSWD) (Lee & Lee, 2013). The survey included questions about sociodemographic information, family relations, informal social network, economic status, depressive symptoms, self-neglect, leisure and social activities, chronic diseases, health behavior, housing environment, attitude toward social welfare services and policies, and the use of social services (Lee & Lee, 2013). The local government provided a regional directory that included each individual’s name, sex, age, location, and contact number. This directory contained information for 6,400 elderly individuals who were living alone. They consented to take part in research in order to help design social welfare programs or policies to target their problems. Stratified random sampling, which considered the population parameters gender (male and female), age group (60s, 70s, and > 80), and district, was used to recruit a total of 1,023 participants for this survey who lived in 1 of 16 districts (Gus) in Busan Metropolitan City. Each participant’s agreement to participate was confirmed via a phone call. During this phone call, we requested a specific time and place for the face-to-face interview. The face-to-face interviews were conducted by 36 trained middle-aged female interviewers who were dispatched to the districts to meet the older adult volunteers and obtain a signed

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consent-to-research form. Note that if there was some evidence of elder selfneglect, the research team reported the suspected cases to community welfare centers. Gerontological professionals are required to report suspected cases of self-neglect because of professional and legal obligations. This information was noted in the consent form. Measures Elder Self-Neglect

Elder self-neglect was measured by a subscale of the Screening Scale for Elder Abuse (SSEA), which was administered to older Korean individuals living in the community (Kim, Kwon, Lim, & Lee 2006). Kim and colleagues (2006) empirically verified the reliability and validity of the SSEA by using a sample of 481 individuals who worked in social service agencies for the elderly. The instrument included six subscales: physical abuse, verbal or emotional abuse, financial abuse, family neglect, elder self-neglect, and abandonment. Five items that assessed the frequency of elder self-neglect were adopted from the screening scale for elder abuse. The respondents were asked how often the following occurred during the past one year: 1. suffering from malnutrition due to intentionally eating inadequate food; 2. failing to maintain a minimum level of hygiene and sanitation; 3. refusing to ask for any kind of assistance although they were exposed to unsafe environments; 4. the presence of substance or alcoholic abuse causing a significant harm to their health; and 5. thinking of committing suicide. Response options for the above questions were as follows: 1 = never, 2 = rarely, 3 = often, 4 = always. A higher score indicates a higher frequency of self-neglect. Cronbach’s alpha, a measure of internal consistency reliability, was .76. Sociodemographic Variables

Gender, age, education level (none, elementary, middle/ high school, college/ graduate), marital status (widowed, divorced, separated, never married), number of children (alive only), and economic status (lower, middle, upper) were measured. Functional Disabilities

Functional disabilities were operationally defined as activities of daily living (ADLs) and instrumental activities of daily living (IADLs). This study used the Korean Activities of Daily Living (K-ADL) and Korean Instrumental Activities of Daily Living (K- IADL) scales developed by Kim and Lee (2009). The K-ADL

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index was designed to rate five activities by trained observers: bathing, dressing, eating, toileting, and transferring. The K-IADL included six activities: walking outside, using public transportation, shopping, doing one’s own housework, taking medication, and handing one’s own money. Each item of the K-ADL and the K-IADL was rated on a 4-point scale (1= totally independent to 4 = totally dependent). Cronbach’s alpha for the combination of the two scales was .91, which indicates good reliability. Cronbach’s alpha the K-ADL and the K-IADL was .88 and .86, respectively. Cognitive Disabilities

The Short Portable Mental Status Questionnaire (SPMSQ) was employed to assess the cognitive impairments of older adults living alone (Pfeiffer, 1975). The SPMSQ consists of 10 items that measure orientation, working memory, and calculation. The interviewers rated each response as either 1 (correct) or 2 (error). The reliability and validity of the instrument were confirmed by several studies (e.g., Foreman, 1987; Hooijer, Dinkgreve, Jonker, & Lindeboom, 1992; Lee, 2010). In this study, Cronbach’s alpha coefficient was .75. Number of Chronic Diseases

The number of chronic diseases was determined by questions about 16 diagnosed illnesses: arthritis, hypertension, stroke, cardiopathy, hepatocirrhosis, asthma, bone fracture, cataract or glaucoma, cancer, melancholia, Parkinson’s disease, neuralgia, osteoporosis, diabetes, and benign prostatic hyperplasia. The participants were asked to indicate whether each chronic disease was diagnosed at outpatient settings such as a physician’s office, clinic, and associated facility as well as inpatient settings (0 = no, 1 = yes). Social Support Networks (family network and friend network)

Social support networks were quantified by the abbreviated version of the Lubben Social Network Scale (LSNS-6) (Lubben, Blozik, Gillmann, Iliffe, Kruse, Beck, et al., 2006). The LSNS-6 consists of six items about the number of and frequency of contact with family or relatives and friends whom the respondents feel close to or ask for support. The instrument had two subscales: family network (family social support) and friend network (friend social support). Each item was rated on a 6-point scale (1 = none, 2 = one, 3 = two, 4 = three or four, 5 = five through eight, and 6 = nine or more). Cronbach’s alpha was .82 for the total scale and .93 and .91 for the family network and friend network subscales, respectively. Formal Social Support (use of care services)

Formal social support was measured in terms of utilization of social services designed for older adults living alone (Ho, Weitzman, Cui, & Levkoff, 2000;

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Lee, Yoon, & Kropf, 2007). The instrument consisted of three items that measured whether a respondent utilized home visiting, health education, and information and referral services during the past 6 months (Lee & Lee, 2013; Williams & Dilworth-Anderson, 2002). The services have been provided by public and private comprehensive care centers, which were established to prevent the elderly living alone from social isolation and to support their aging in place. The items were scored as dichotomously (0 = no service was utilized, 1 = at least one service was utilized). Depressive Symptoms

Depressive symptoms were measured by the Korean version of 15-item Geriatric Depression Scale (GDS) (Bae & Cho, 2004). The scale for older Korean adults is a revised version of the GDS, originally developed by Sheikh and Yesavage (1986). Bae and Cho (2004) empirically verified the reliability and validity of the revised instrument. It consists of 15 items rated on a 2-point scale (0 = yes, 1 = no), and participants were asked whether they experienced each depressive symptom during the previous week (a = .84). Data Analyses Descriptive statistics of the sample of individuals interviewed characterized the landscape of elder citizens living alone in Korea. The statistical method provided the frequencies and means for the sociodemographic information including gender, age, education level, marital status, number of children, and economic status. It also showed the level of our major variables of interest, including ADLs, IADLs, cognitive disabilities, number of chronic diseases, family network, friend network, formal social support, depressive symptoms, and elder self-neglect. In particular, items assessing elder self-neglect were descriptively analyzed to depict the prevalence of self-neglect. In addition, hierarchical multiple regression analysis was conducted to identify significant risk factors of self-neglect. Step 1 considered sociodemographic variables, and Step 2 included sociodemographic variables as well as risk factors for elder self-neglect, which were identified according to the conceptual framework designed by Dyer et al. (2007). RESULTS Sample Characteristics The characteristics of the older adults living alone are presented in Table 1. There were more women (82.8%) than men (17.2%). The mean age was 78.21 (standard deviation (SD) = 5.80). Ages ranged from 65 to 100 years (60s = 5.7%, 70s = 51.9%, and > 80 = 42.4%). About 48.7% of the sample did not have any education, 33.5% were elementary school graduates, 16.6% were middle or high

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Table 1. Sample Characteristics (n = 1,023) Variables

N (%)

M (SD)

Range

78.21 (5.80)

65-100

Number of children

2.47 (1.87)

0-8

ADLs

6.86 (2.24)

5-19

IADLs

9.85 (3.25)

6-24

11.16 (1.17)

10-20

Number of chronic diseases

2.38 (1.74)

0-11

Depressive symptoms

0.36 (3.79)

0-15

Family social network

3.44 (3.56)

0-15

Friend social network

4.00 (4.07)

0-15

Female

847 (82.8%)

Education None Elementary Middle or high school College or graduate

498 (48.7%) 343 (33.5%) 170 (16.6%) 12 (1.2%)

Marital status Widowed Divorced Separated Never married

840 (82.1%) 105 (10.3%) 35 (3.4%) 43 (4.2%)

Economic status Lower Middle Upper

547 (53.7%) 464 (45.6%) 8 (0.8%)

Use of care services

239 (23.4%)

Age

Cognitive impairments

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school graduates, and 1.2% had college level degrees. Regarding marital status, 82.1% were widowed, 10.3% were divorced, 3.4% were separated, and 4.2% were never married. The mean number of children of the older people living alone was 2.47 (SD = 1.87; range: 0-8). About 20% of the sample did not have any children. Additionally, 53.7% rated their economic status as lower class, 45.6% as middle class, and 0.8% as upper class The mean of the ADLs scores was 6.86 (SD = 2.24; range: 5–19), and that of IADLs scores was 9.85 (SD = 3.25; range: 6-24). The mean score on the SPMSQ, which assessed cognitive impairments, was 11.16 (SD = 1.17), and the mean number of chronic diseases was 2.38 (SD = 1.74; range: 0-11). High values for the above indicated more severe functional, cognitive, physical, and mental impairments. In addition, the mean family social networks score of the sample was 3.44 (SD = 3.79; range: 0-15). The mean friend social networks score was 4.00 (SD = 4.07; range: 0-15). High scores in social networks indicated a higher level of family or friend social networks. Finally, 23.4% of the older adults reported using care services during the past 6 months. Prevalence of Elder Self-Neglect among Older Adults Living Alone Table 2 demonstrates the prevalence of elder self-neglect. The prevalence of self-neglect was calculated by the proportion of the respondents who answered that they often or always experienced at least one form of self-neglect during the past one year. Around 23% of the research participants often or always experienced one form of elder self-neglect. A total of 13% of the respondents responded that they often or always suffered from malnutrition due to intentionally eating inadequate food, and 3.5% often or always failed to maintain a minimum level of hygiene and sanitation. Five percent reported that they often refused to ask for any kind of assistance in unsafe environments, and 2.5% always refused assistance in unsafe environments. Moreover, 1.8% often had substance or alcohol abuse that caused significant harm to their health, and 0.2% always had these problems. Furthermore, 4.1% had often thought of committing suicide, and 0.9% had always thought of doing so. Risk Factors for Self-Neglect Hierarchical multiple regression analyses were used to identify significant sociodemographic variables and risk factors for elder self-neglect (see Table 3). The absence of multicollinearity was confirmed by calculating the variance inflation factor (VIF) (cutoff: 10) and correlation coefficients between the explanatory variables (cutoff: .80). As VIF was below 3.0 and no correlation coefficient was over .08, multicollinearity was not a concern.

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Table 2. Frequency Distribution of the Scale Items of Elder Self-Neglect (n = 1,023) N (%) Scale item

Never

Rarely

Often

Always

1. Suffering from malnutrition due to intentionally eating inadequate food.

543 (53.3%)

344 (33.8%)

120 12 (11.8%) (1.2%)

2. Failing to maintain a minimum level of hygiene and sanitation.

612 (60.1%)

367 (36.0%)

35 5 (3.4%) (0.5%)

3. Refusing to ask for any kind of assistance although they were exposed to unsafe environments.

613 (60.2%)

330 (32.4%)

51 25 (5.0%) (2.5%)

4. The presence of substance or alcoholic abuse causing a significant harm to their health.

789 (77.5%)

209 (20.5%)

18 2 (1.8%) (0.2%)

5. Thinking of committing suicide.

719 (70.6%)

248 (24.2%)

42 9 (4.1%) (0.9%)

In Step 1, the relationship between sociodemographic variables and the frequency of elder self-neglect was analyzed (F = 19.64, p < .001). Sociodemographic variables explained 11.0% of the variance in elder self-neglect, which was significantly associated with marital status, number of children, and self-rated economic status. Widowed participants were less likely to commit self-neglect than divorced, separated, or never married participants (b = .097, p < .01). The frequency of self-neglect was positively related to the number of children (b = .065, p < .05). In addition, a lower frequency of self-neglect was reported by the participants who had a higher level of self-rated economic status (b = .312, p < .001). In Step 2, we added previously identified risk factors for elder self-neglect: ADLs, IADLs, cognitive impairments, number of chronic diseases, depressive symptoms, family social networks, friend social networks, and use of care services. Together, these explained 22.3% of the dependent variable (F = 20.679, p < .001). The value for the R-square significantly increased by ~.125 (p < .001). Regression analysis showed that the frequency of self-neglect was significantly associated with education, marital status, number of children, cognitive impairments, number of chronic diseases, depressive symptoms, and family social networks. Among the sociodemographic variables, only education was newly

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Table 3. Result of Hierarchical Regression Analysis of Risk Factors for Elder Self-Neglect (n = 1,023) Step 1

Step 2

b

p

b

p

–.006

.868

.058

.073

Age

.031

.332

.051

.107

Education

.031

.346

.068*

.035

Marital status

.097**

.004

.088**

.005

Number of children

.065*

.042

.125***

< .001

< .001

–.144***

< .001

Gender

Economic status

–.312***

ADLs

.060

.167

IADLs

–.082

.066

Cognitive impairments

–.066*

.040

Number of chronic diseases

–.076*

.012

Depressive symptoms

.338***

< .001

Family social network

–.155***

< .001

Friend social network Use of care service

.022

.471

–.012

.700

F

19.64***

20.679***

R2

.110

.223

.110***

.125***

R2

change

Note: Dummy variables code: gender (0 = male, 1 = female), marital status (0 = widowed, 1 = other), and use of care service (0 = no, 1 = yes). *p < .05; **p < .01; ***p < .001.

identified as a statistically significant variable in Step 2. The effect of marital status, number of children, and economic status were in the same direction as described for Step 1. A greater frequency of self-neglect was slightly related with higher levels of education (b = .068, p < .05) and cognitive disabilities (b = .066, p < .05), and with a small number of chronic diseases (b = –.076, p < .05) in the sample. The level of depressive symptoms was positively related to the frequency of self-neglect (b = .338, p < .001). Finally, older adults who had larger family social networks were less likely to commit elder self-neglect (b = –.155, p < .001).

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DISCUSSION In previous literature on elder abuse in Western countries, elder self-neglect has been the type of elder abuse most frequently reported to adult protective services. It has been empirically associated with medical comorbidities, physical abilities, cognitive abilities, depressive symptoms, and a lack of a social network and social support. The purpose of this study was to describe the prevalence of elder self-neglect in older individuals living alone in the community and identify risk factors for self-neglect in Korea. The results showed that 22.8% of the research participants often or always experienced at least one form of elder self-neglect. The scale of self-neglect employed in the study included substance abuse and thoughts of committing suicide because these behaviors caused serious harm to older adults based on previous studies and reports from field professionals in Korea (Kim et al., 2006). However, substance abuse has been generally suggested as a risk factor for self-neglect (Gorbien & Eisenstein, 2005) and suicide as a consequence of self-neglect (Pavlou & Lachs, 2006) in the Western literature. A recent prevalence study on self-neglect (hoarding, lack of personal hygiene, house needing repair, unsanitary conditions, and inadequate utilities) among 4,627 community dwelling elderly in the United States reported prevalence rates across gender and race/ethnicity: 13.2% of black men and 10.9% of black women, 2.4% of white men and 2.6% of white women (Dong, Simmon, & Evans, 2012). The prevalence of self-neglect in the survey rose with lower selfrated health status and poorer cognitive function in both men and women (Dong, Simon, Mosqueda, & Evans, 2012). However, the present study revealed that the prevalence of self-neglect increased with higher cognitive function. Although the prevalence rate of self-neglect with Korean population was higher than that of Dong and colleagues’ survey of American participants, the two studies’ findings could not be meaningfully compared due to their different measurement and sampling approaches. Consistent with previous studies conducted in Western countries, the results of the current research identified significant risk factors for self-neglect. Similar to published reports (Abrams et al., 2002; Dong et al., 2009; Dyer et al., 2007), self-neglect was more likely among older people living alone who had depressive symptoms and lacked family social support. The present study also demonstrated the importance of economic status among elderly adults living alone because higher levels of self-rated economic status were related to lower frequency of self-neglect (e.g., Dong, Simon, & Evans, 2012). Finally, among elderly individuals living alone, those who were widowed were less likely to commit selfneglect than those who were divorced, separated, or never married. This study also presented some unexpected results. First, higher levels of education and cognitive abilities and lower levels of medical comorbidities were slightly associated with a higher frequency of self-neglect. One possible

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explanation for this result is that individuals meeting this description might be more likely to possess the intellectual capacity to intentionally commit selfneglect than those with a lower level of education, medical comorbidities, and cognitive disabilities. Second, the frequency of self-neglect was positively related to the number of children. This finding indicates that older adults who have several adult children are not safe from self-neglect. Rather, the quality of the relationship between the older parent and the adult children or other relatives (e.g., siblings or grandchildren) is important because family social networks decreased the frequency of self-neglect. Additionally, the data showed that friend social networks and the use of social services (formal social support) did not affect the frequency of elder self-neglect. Due to the long-standing culture of family caregiving for older adults with impairments, Korean older adults are emotionally and instrumentally more dependent on family or relatives than on friends or other people. The older people who were living alone and received care services were already experiencing serious self-neglect. These individuals could meet the eligibility conditions for care services provided by comprehensive support centers for the elderly living alone in Korea. The findings of this study have implications for gerontological practice and policy, especially for older individuals living alone in Korea. First, policy makers must acknowledge that self-neglect already exists and is a very serious, pervasive, and rising problem in Korea. Thus, they should allocate more resources to intervention efforts aimed at helping those engaged in self-neglect behavior. Since elder abuse prevention and intervention policies have primarily focused on elder abuse by family members or by other people, these policies cannot be effective for those engaged in self-neglect behaviors. In the present study, the use of care services did not buffer the frequency of self-neglect; thus, the government needs to increase the proportion of care service recipients in order to prevent selfneglect. Furthermore, in Korea, all kinds of reported neglect by clients with family have been classified into the category of “neglect by family members” due to the long-standing traditions of family harmony and filial piety for parents. Instead of placing all forms of neglect in the same category, the adult protective service agencies in Korea should differentiate between self-neglect by elderly individuals who live alone or frail older couples and neglect by others. Gerontological professionals should be aware of the empirically verified risk factors for elder self-neglect that were identified in the present study. Selfneglect is related to multiple risk factors, including socioeconomic characteristics, cognitive impairments, medical comorbidities, depressive symptoms, and a lack of family social support. These professionals need to develop an integrated intervention and prevention program against self-neglect for those older individuals living alone; such a program should consider the multiple risk factors identified in the present study. Frontline workers should have the skills and knowledge to inform older adults who live alone about how to deal with selfneglect. In particular, since this study verified that depressive symptoms are the

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strongest risk factor in increasing the frequency of self-neglect, professional intervention to reduce the level of depressive symptoms should prove to be a very effective intervention strategy against self-neglect in the population. In addition, it is important for the public to be alert to elder self-neglect among community-dwelling older adults who live alone. Many citizens who discover that an older adult suffers from self-neglect in the neighborhood do not know how to refer the person to suitable organizations, such as adult protective agencies or comprehensive support centers for the elderly living alone. This may be because of weakened mutual trust and cooperation in the villages in Korea, perhaps due to rapid industrialization and urbanization. The government needs to enhance public awareness of this problem via the use of various media. Finally, increasing cross-generational activities and involving older adults living alone in community activities would be efficient means of preventing self-neglect. Despite these important implications, it is necessary to acknowledge several limitations of the generalizability of this study’s finding. The conceptual framework adopted for this study was originally designed to explain risk factors for elder self-neglect with a longitudinal research design (Dong, Simon, & Wilson, 2010). However, this study employed a cross-sectional design, which produces inadequate evidence with regard to causal relationships between variables. The participants were recruited using an informed consent process. Consequently, the results cannot be applied to older adults who did not agree to participate in the survey and those who did not have the cognitive abilities necessary to respond to the questions. In particular, self-neglect phenotypes could be precisely assessed by environmental observations (Halliday, Banerjee, Philpot, & Macdonald, 2000), but this study was measured by asking survey questions to the older adults. Finally, because this study employed a face-to-face interview, the findings might not be free from social desirability bias. REFERENCES Abrams, R. C., Lachs, M., McAvay, G., Keohane, D. J., & Bruce, M. L. (2002). Predictors of self-neglect in community-dwelling elders. American Journal of Psychiatry, 159, 1724-1730. doi: 10.1176/appi.ajp.159.10.1724 Bae, J., & Cho, M. (2004). Development of the Korean version of the geriatric depression scale and its short form among elderly psychiatric patients. Journal of Psychosomatic Research, 57(3), 297-305. doi: 10.1016/j.jpsychores.2004.01.004 Band-Winterstein, T., Doron, I., & Naim, S. (2012). Elder self-neglect: A geriatric syndrome or a life course story. Journal of Aging Studies, 26, 109-118. doi: 10.1016/j. jaging.2011.10.001 Day, M. R., & Leahy-Warren, P. (2008). Self-neglect 1: Recognizing features and risk factors. Nursing Times, 104(24), 24-27. Dong, X., & Simon, M. A. (2013). Elder abuse as risk factor for hospitalization in older persons. Journal of the American Medical Association Internal Medicine, 173(10), 911-917. doi: 10.1001/jamainternmed.2013.238

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