Ageing is the universal phenomenon encountered by every human individual across the life span. All human beings expect for a healthy and happy old age but not many of them manage to get all those in reality. In this current century, world scenario is changing rapidly in the form of rise in elderly population than before. Many developing countries including Pakistan are affected by this global change. A report on global health and ageing shared recent statistics that in 2010, an estimated 524 million were aged 65 years or older making 8% of world population. It is interesting to note that by 2050 this number is expected to triple to about 1.5 billion signifying 16% of world’s population (WHO Report, 2011). Ironically, in developing countries, geriatric population between 2010 and 2050 is expected to increase more than 250 percent as compared to developed countries. Ali and Kaini (2003) add that this trend in ageing is the result of the demographic shift in fertility rates in combination with mortality rates resulting in ageing of the population (p. 1). Having a glance at our national scenario, it is estimated that the proportion of population 60 years and above in Pakistan will increase from 5.8 percent in the year 2000 to 7.3 percent in 2025 and 12.4 percent in 2050 (United Nations, 2002).
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Reason for the selection of this topic
I came up with my thesis topic as every year particularly on festivals such as Eid, different media channels broadcast programs where views of elderly who are residing in the shelter homes are taken. The eye catching moment was the pain and cry these ageing parents expressed, when their children neglected and dumped them in shelter homes, when they most need support in their last years of life. This event influenced me to work for my thesis in the field of geriatrics. Therefore, based on the significant global and national figures, increase in ageing will predispose the elders to suffer in chronic illnesses, disabilities and new disease patterns. Another, considerable growing fact is that, due to the shift of societal paradigm, elderly population will be the most vulnerable group requiring health attention currently and in the years ahead. Therefore, it is recommended that older adults should remain socially active in their later years (Bergstrom, Holmes & Pecchioni, 2000). The findings from the proposed research contribution in this area particularly in Pakistani context will assist in filling the gap where elderly population can regenerate themselves without being isolated from social life, and can live with quality, dignity and free of violence in their empty nest days.
Significance of the problem
Many decades ago the concept of violence against women and children was objected throughout the world but researches in these areas have resulted in the protection and formation of laws for these groups. Likewise, elderly abuse is yet another novel and critical public health and social issue that need prompt attention. Infact, it is one of the most serious subject which is under reported nationally and internationally resulting in thousands of silent victims. Numerous studies are being conducted in the developed countries on the various aspects of the ageing population in order to ensure optimum quality in the later phase of life time. However, many of the South Asian countries including Pakistan are facing serious challenges of decreased economy, low savings, high inflation rates; financial benefits for few percentages of government employees, lack of health insurance coverage are making the life of this vulnerable group questionable. Apart from these encounters, elderly population are confronting with the decline of extended family system and the emergence of nuclear families (Jalal & Younis, 2012). In Asian cultures, many of socio cultural practices are grounded on concept of extended family system. Old members of the family are taken care by the young generation and it is regarded as dishonorable if any elder lives alone or in nursing home. In addition to it, this transition has led to the decline in elder decision making power and position and to enjoy later years with dignity and self-worth. Due to this conversion “the elderly are at risk, as the younger and more productive members of the family take over, marginalizing the elderly into positions of dependence both social and economic”(Subzwari & Azhar, 2010, p. 2).
Another important change that has taken place in the last couple of years is that younger individuals are migrating for better employment opportunities leaving behind parents with no one to care for them, causing elderly to live alone or they are shifted to shelter homes. Sabzwari and Azhar (2010) supports that one in five patients at the tertiary care hospital in Karachi are elderly. It is estimated that at least 6-7 % of the elderly visiting geriatric clinics at the Aga Khan University Hospital Karachi are living alone with little assistance. Increase in life expectancy has led to substantial increase in aging population globally and it is predicted that the world’s elderly population will continue to increase with an estimated rate at 67 % residing in developing countries by the year 2020 (Karunakara & Stevenson, 2012, Ageing population section, para. 1). In Pakistani context, 60 years is designated as the age of elderly. Jalal and Younis (2012) shares WHO report that:
5.6 % of Pakistan’s population was over 60 years of age, with a probability of doubling to 11 % by the year 2025. Pakistan’s life expectancy was increased from 45.6 years in 1950 to 66.8 years in 2008 with a probability of increasing to 72 years by 2023 (p. 2).
Hence, the decline of popular extended family system and rise of career oriented families, and change in familial values compounded by substantial increase in ageing, subjects older population to maltreatment and this area requires immediate consideration. Jamuna (2003) rationalizes that “a series of developments, such as urbanization, industrialization, and migration, and a growing sense of materialism and individualistic orientations have threatened the culture of yesteryear (p.129). One significant cause for underreporting of abuse in Asian cultures is compliance to the value of respect for their elders whereas western cultures sideline them.
Older people are left with countless problems in their later phase of life where these years are believed to live in respect, solemnity and self-worth with their married children and grandchildren. On the contrary, this age group has to spend their lives in isolation at home or in shelter homes due to neglect and cruel treatment by them. Although, these old homes are answer to most in need yet they still not provide a solution to majority of the population. Our culture despite its gradual transformation still adheres to the value of caring for their elderly at home (Subzwari & Azhar, 2010). Elder abuse is the alarming public health issue present in both developed and developing countries. Very little information is available regarding the extent of maltreatment in elderly especially in developing countries, it is estimated that 4-6% of elderly people have experienced some form of maltreatment at home. (WHO fact sheet, 2011). However, older people are often afraid to report cases of maltreatment to family, friends, or to the authorities. There is no reliable data or research conducted in Pakistani context, where sufferings of these elderly populations living in nursing homes could be researched and addressed. Dildar, Saeed and Sharjeela (2012) mentions that “elder abuse and neglect are difficult to quantify as these occur in the privacy of the home, institutions and under reported in our country” (p. 662). Based on the above facts and literature I came up with the research question that, what are the experience and the perception of elderly people living in nursing home in Karachi, Pakistan?
Literature search strategy
Literature search was conducted in a systematic way by utilizing available electronic databases, in order to review and explore existing literature related to abuse of elderly population in nursing home. In order to detect relevant literature, two major databases, CINAHL plus with full text and PUBMED was used. Another search engine like Google scholar was also searched to find the relevant literature sources. These databases were searched for the time period between the year 2000 and 2012. Different key words or combination of key words along with the use of Boolean operators were used for all search engines, like elder abuse and nursing homes, elder maltreatment and nursing homes. A synonym for elder abuse like geriatric abuse and for nursing home like shelter home was typed on the search bar. Relevant articles were hunted when the key words were written in research title, abstract of review articles of all data bases. A separate search was carried out for identifying the available literature in Pakistan for this purpose the term Pakistan was added along with other key words to search relevant Pakistani sources. Reference lists of retrieved articles from these databases were also checked for relevant literature. Search from all data bases were narrowed down by the use search filters like year range, gender, age and language. For detail literature search and number of hits (See appendix A).
Literature review analysis on elderly abuse in nursing homes
The subject of elder abuse began to receive recognition since 1970, and the first boom on elder abuse appeared in UK medical journals in 1975 as “granny battering”. It was identified by British Gerontologist and the first population based study was done in USA in 1988.
International Network for the Prevention of Elder Abuse (INPEA) defines “elder abuse is a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person” (INPEA, 2002, p. 3). Age bracket for elderly is 60 years and above. Some predictions indicate that one million people turn 60 every month and 80 % of these are from the developing world (WHO/INPEA, 2002). All the susceptible victims of abuse who are 65 years or more largely depend on the funded institutions but if there is financial constraint then these vulnerable groups have to be confine to home (Paranitharan, Eidrisinghe &William, 2009).
There is considerable debate on the definition of elder abuse because some cultures foster certain behaviors that may be considered as abuse in different cultural context. In Australia, “elder” refers to older local people who have specific positions of power within native communities. It was recommended that “elder abuse” be replaced with “senior abuse” in an Australian context as it referred to original and senior population (Ryan, 2009). It can be argued that abuse occurs within a relationship where there is an expectation of trust, no matter different cultures gives different definitions on elder abuse. However McFerran (2009) asserts that research on domestic violence in elderly women, is based on unequal power relations and traditional devaluation of women, not on relationships based on trust” (as cited in Ryan, 2009, Definition of elder abuse, para. 3). Therefore, irrespective of the type of abuse, it will definitely result in pointless miseries, pains and sorrows, and decrease quality of life of elderly.
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Types of elder abuse
Elder abuse is categorized into five different types: physical abuse, psychological /emotional abuse, financial/material abuse, sexual abuse and neglect (WHO/INPEA, 2002). Most recent data from USA states that, there are about 570,000 cases of elder abuse reported each year, 55% of the cases suffer from neglect which is the most common form of elder maltreatment (Facts on elder abuse, 2012). Economic abuse is one of the most frequently reported forms of abuse, followed by neglect, psychological or emotional and finally physical abuse. Sexual abuse of elders is not reported as frequently as any other type of abuse (Ryan, 2009).
Another dimension of elder maltreatment is that it is not restricted to home environment, risk is even leaving them in nursing homes, hospitals and long term care facilities. An empirical study in New Zealand reveals that psychological abuse (59%) is followed by material/financial (42%) and physical abuse (12%) were most frequently identified types of abuse. Sexual abuse occurred in 2% of reported cases (Gadit, 2009).
Implications of the proposed research in nursing
It is a challenging task for all health care providers to efficiently assess the elderly group so that abuse can be identified and reported for the immediate interventions. Proposed research on this subject will make people aware, that elder abuse will prevent older members from being favorable and positive members of the society. Furthermore, evidence based knowledge on this matter will assist in safeguarding and promoting welfare of the elderly clients. According to Lachs and Pillemer (1995) guidelines from the American Medical Association suggest that “all older adults be asked by their physicians about family violence, even in the absence of symptoms potentially attributable to abuse or neglect” (p. 438). A careful history taking and interviewing technique is crucial in identifying accurate information on the possible abuse. If the violence on elder is confirmed then priority is to ensure safety of the elderly person by separating from the perpetrator. In the western countries, based on their cultural background, majority of the old age population resides in shelter homes. In Karachi, nursing homes are managed by private NGO’s or religious organizations. The Catholic Church runs three old homes in Karachi, and people residing in these old homes pay a minimal fees, and rest are generated through the church (Subzwari & Azhar, 2010). Some nursing homes are governed by religious communities functioning with the help of volunteer and donation support. Gadit (2009) identifies that “Edhi Foundation is one glaring example of a service where abandoned elderly people are housed. These elderly people are avoided by their children under different grounds like poverty, illness among elderly and general intolerance” (p. 3).
Recommendation for the prevention of elder abuse
A national policy for the promotion of better health of the elderly was designed in 1999, but implementation is yet to be seen. This policy involved the training of health care professionals. An equally important recommendation is the initiation of awareness programs among health care professionals on the subject and the formulation of assessment tools to detect abuse. Another suggestion is the workshops for nursing and medical graduates should be conducted to detect and manage elder abuse more effectively resulting in prompt treatment measures. Potential research on various aspects of care of elderly can urge in the development of policy at governmental level for the protection of geriatric population1.
At national level, electronic and print media can play a key role in raising awareness on this subject. It can act as a medium for the provision of specially funded and recreational shelter homes, free health care facilities, and formation of legislative policies (Marshal, Benton & Barzier, 2000).
The research approach which would best fix on the research question would be qualitative in nature. I would like to go for Phenomenological method as it deals with the truth about reality built in people’s lived experience (Polit & Beck, 2008, p. 227). This approach can be applicable on those concepts which are central to the life occurrences of the human being. The core goal is to completely understand persons lived experience and perceptions that it will generate.
Inclusion Criteria and Exclusion criteria
The inclusion criteria of this proposed research will be all elderly people with an age of 60 years and above in both the genders. Another standard would be all elderly population living in nursing homes in Karachi. The exclusion criteria of this planned study would be all elderly below 60 years of age.
Transition into old age is another experience which everyone has to encounter. Importance lies in the fact that to be old and live with self-respect, dignity and free from violence, neglect and maltreatment should be an important objective. Geriatric has always been a neglected area, but due to an increase in ageing population, challenge to meet the needs of the elderly is extremely crucial. Elder abuse occurs as a result of strained intergenerational relationship along with the gradual cultural transformations. This critical and under reported phenomenon needs prompt attention by the researchers and government in order to enhance quality of life in their remaining years of life.
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