Elder Abuse and Its Association with Mental Well-Being and the Associated Socio-Demographic Factors - A Community Based Cross-Sectional Study in Bengaluru, India

Background: Elderly abuse in form of neglect and disrespect has been an important risk factor affecting the mental well-being of elderly. This study estimated prevalence of elderly abuse, its association with their mental well-being and associated sociodemographic factors. Aims/Objectives: To determine the prevalence of the Elderly abuse in the Study area and to find the association of elderly abuse with mental well-being and sociodemographic factors Methodology: A cross-sectional study was conducted among 355 elderly persons in the field practice area of Vydehi Institute of Medical Sciences and Research Centre, Bengaluru from January 2020 to June 2021. The data was summarized as frequencies, proportions and association using regression. Results: The prevalence of elderly abuse was 18.3%. Abuse in elderly participants was associated with poor mental well-being, Odds Ratio (OR) 4.56 (95%CI,2.05-10.16) and among elderly with Risk of depression with AOR 5.72(95%CI,3.09-10.59). Abuse in all forms was significantly associated with poor mental well-being (p <0.001), presence of skeletal deformity and lack of physical activity (less than 30 minutes). Conclusions: The prevalence of elderly abuse is 18.3% in the study area and it is associated with poor mental well-being, higher risk of depression, and lack of physical activity.


INTRODUCTION
The elderly population is estimated to reach 13.1% of the total population in India by 2030. 1 Challenges of physical and psychosocial nature are associated with the ageing.It leads to a higher dependency on caregivers and power struggle.Elderly abuse is a consequence of widened intergenerational ties, ageism, social isolation. 2The changing needs of the younger generations are discordant with that of older person's needs sometimes pushing them to isolation and insecurity. 3,4rld Health Organization describes elder abuse as a single or repeated act where there is a lack of appropriate action and that occurs within a relationship where there is an expectation of trust that causes harm or distress to the older person. 3Elderly abuse leads to higher morbidity, reduced quality of life and survival. 2People usually responsible for perpetuating abuse are the closest family members where trust is broken often impacting them mentally. 4oss underreporting of elderly abuse is a reality.Globally, 15.7% of the older population in community settings undergo abuse annually. 5The different categories of abuse are physical, verbal, economic, psychological, neglect, and sexual.Psychological abuse has the highest prevalence of 11.6%. 4LASI study (Longitudinal Ageing study of India) showed that at least 5% of people (60 years or more) were abused annually.The highest abuse was reported in Bihar (11.7%),Karnataka (10.1%) and West Bengal (7.6%). 6nctional dependence was a major cause of elder abuse. 6Disability and limiting conditions led to reduced healthcare utilization, lesser social interaction, and poor mental well-being. 6The limitation arose from the need for physical dependency. 6Financial dependence led to exploitation of finances by perpetrators of their funds and assets.Elderly either never reported or delayed reporting fearing hostile retaliation.It leads to increased psychological stress. 7The risk of developing depression and anxiety also increases.One of the factors found to be inversely associated was the level of schooling. 8e occurrence of elder abuse is intertwined intricately with compromised mental well-being and is frequently overlooked or unreported. 9,10,11It is estimated that approximately 15% of the elderly population experiences mental disorders, further highlighting the significance of this issue. 10fortunately, there is a scarcity of evidence available, which hampers the timely societal response to address elder abuse effectively. 8,12Therefore, the present study examined the relationship of elderly abuse with sociodemographic factors and its association with their mental well-being in a rural setting.
The study was conducted with objectives to determine the prevalence of the Elderly abuse in the Study area and to find the association of elderly abuse with mental well-being and sociodemographic factors

METHODOLOGY
Study design and participants: It was a crosssectional community-based study on 355 participants among elderly in a rural area using a multistage sampling method.Stage 1: From the four subcentres under the CHC (Community Health Centre) (where Rural Health Training Centre was situated), two subcentres were selected by lottery method.Stage 2: All the twelve villages in the two selected subcentres were enlisted.Nine villages were selected because the other three villages were industrial areas that had predominantly migratory population.Stage 3: In the nine villages, using Population proportionate to size sampling technique (Annexure 1), participants were included by continuous enumeration method till required number was met.
Participants aged 60 years and above residing in study areas for not less than six months were included in the study and those who were not present in their homes during three home visits were excluded from the study.The study duration extended from January 2020 to June 2021.Sample size was calculated based on an Indian study where prevalence of psychological distress among abused individuals was found to be 61.6% . 9It was estimated using the for- where, (Z{1-α/2}, standard normal deviate Data was collected through a semistructured validated questionnaire where at 95% confidence level; L, 5% relative error; P, prevalence; Q = 100 -prevalence) .

Outcome variable:
The outcome variable was elderly abuse based on Elderly survey questionnaire of UNFPA 10 .Questions elicited the presence of perceived abuse they underwent.Physical abuse included any physical harm.Verbal abuse included intimidation or humiliation.Economic abuse included abuse of money, property or assets without consent.Neglect indicated lack of care and disrespect represented lack of consideration and denying recognition.
Independent variables: Information on sociodemographic factors were obtained using Uday Pareek scale 13 .It had nine categories namely Caste, Occupation, Education, Land holding, Farm power, social participation, Type of Family, Type of House and Materials of possession.For measuring risk of depression, The Short form of Geriatric Depression Scale (GDS) 14 was used.For assessing psychological wellbeing, WHO(FIVE) well-being questionnaire was used for analysing mental well-being along with short GDS scale among the study participants. 14,15he participants were segregated into poor and good categories for WHO(FIVE)scores where Mental wellbeing scores of less than 52 were taken as poor while those with scores above 52 were considered to have good mental well-being.Elderly Cognitive assessment Questionnaire (ECAQ) was utilized for measuring Cognition, Orientation and Memory. 16In ECAQ, a subject without any changes in memory, orientation and cognition scored above 7 where highest score was 10.A subject scoring less than 7 indicated a problem of cognition, memory and orientation.Other variables included were self-rated health where a Five-scale Likert scale with categories of poor, fair, good, very good and excellent was employed.The Katz Index of Independence in Activities of Daily Living (ADL) 17 for basic and essential daily activities employs questions on their ability to perform bathing, dressing, toileting, transferring, continence and feeding were included.The score of 1 depicted no abnormality, 2 was given for partial assistance and 3 for requirement of assistance.Under Lawton Instrumental Activities of Daily Living (IADL) scales for instrumental daily activities 18 those who were without any abnormality or requiring partial assistance were given a score of 1 and those requiring Full assistance were given a score of 0. The subjects scoring less than 8 were considered to have limited ability to perform instrumental activities of daily living.The categories included were ability to use telephone, shopping, food preparation, housekeeping, laundry, mode of transportation, responsibility of own medication and the ability to handle finances.Assessment of mobility and risk of fall were measured using Timed up and Go test (TUG) 19 Elderly taking time above 12 seconds were considered to have a higher risk of fall.

Ethical considerations:
The ethical approval for the study was obtained from Institutional Ethics Committee (IEC number ECR/747/Inst/KA/2015/RR-18).Written informed consent was obtained and anonymity of participants was maintained throughout the study period.
Data Analysis: Data was presented in form of frequencies and percentages.Continuous variables were presented as means and standard deviation and means were compared using independent t test.Bivariate analysis and multiple logistic regression analysis were used to measure the association.Analysis of the association of individual type of abuse and the effects on mental well-being was performed us-ing Fisher's exact test.P-value of < 0.05 was considered statistically significant.

RESULTS
Sociodemographic factors were compared with elderly abuse.The participants' distribution as per age and gender showed that the total number of elderlies who were abused were 65 (18.3%)out of 355 participants.The majority, 38(58.46%),who underwent abuse belonged to the 60-69 years category.Table 1 shows the comparison of mean scores of continuous variables among the abused and not abused.It was evident that the mean age for elderly who were abused, was 69.08 + 7.6(SD) which was higher than those who were not abused.There was no significant difference between the means for scores of cognitions among the abused and not abused participants.Significant difference of scores for GDS was found between abused and not abused participants indicating a possible association between abuse and risk of depression(p<0.001).The mean scores for instrumental activities of daily living were significantly higher for those not abused than the abused elderly (p<0.04)showing that abused were able to perform only limited activities in comparison.The time taken in TUG test by the elderly who were abused was higher compared to those who were not abused (p<0.005)indicating an association between risk of fall and elderly abuse.
Table 2 summarized the association between the elderly abuse and the dependent factors using Bivariate analysis.The elderly abuse had higher odds for those who rated their health lower on the self-rated health scale, were widowed / widower OR   Table 3 showed that, among all forms of elderly abuse, prevalence of physical abuse was 12%, Verbal abuse was 15%, Neglect was 11%, Economic abuse (11%) and disrespect was 34%.Regression analysis between types of abuse and poor mental well-being showed that highest prevalence was that of verbal abuse OR of 12.88 (95%CI,4.8-34.4).On adjusting with all types of abuse, neglect had a significant association with poor mental wellbeing.)p<0.01) with OR6.2(3-13.01).
Table 4 depicts the distribution of the relationship of the perpetrators of elderly abuse.In more than 40% cases, the daughter in law alone or in unison with the son were abusing the elderly of their family.In 14 (21%) cases, although the perpetrator was a close relative but their identity was not revealed.In 10 (15%) cases they found that their own son was abusing the elderly parent while in 2 % cases, daughter was the abuser.In only 3(4.65%) elderly, spouse was the abuser.Figure 1(b) shows that in 8(12%), the number of perpetrators involved was more than one person.

DISCUSSION
Mental well-being among the elderly is not a priority area in many low-income countries and its nature of association with elder abuse requires more evidence in both the research and policy fields.In the present study the estimates for the prevalence of abuse patterns showed wide variations across studies. 8,12,22,23.
The prevalence of elder abuse in the present study was 18.3%, in line with studies by Chokkhanathan et al. (14%) 8 and Skirbek et al. (11%) 12 .Higher prevalence was found for physical abuse (25%) by Kaur J et al 22 .Chaurasia et al. found the prevalence of abuse to be 80%. 23In this study, majority, 38 (58.46%) of the elderly were from 60-69 years group, with 47 (72.31%) females and 18 (27.69%)males and it was in line with other studies. 9, Those belonging to the lower middle and lower classes were abused more than middle classes and above.Similar results by Sinha et al 16 showed that elder abuse was found in poorer wealth quintiles.
The factors with a significant association in the present study were lower ratings for Self-rated health, those considering themselves Not important or Somewhat Important for their families, and those who were widowed/widowers conforming with other studies. 8,24,25,26use showed higher association with those who had a risk of developing depression.A significant difference between the mean scores of GDS was found in this study.Higher GDS scores (indicating higher risk of developing depression) were found in the abused.This could be explained by the two-way relationship between abuse and state of developing depression as shown by Koga C et al. 27 The state of risk of developing depression is closely associated with symptoms of poor mental well-being as shown in the present study.Aged persons are vulnerable to becoming more isolated, unable to express their needs and feel less important due to their physiological changes in the face of changing societal structure.As their needs are not expressed clearly, their needs take a backseat.The elderly who are at higher risk of depression have symptoms of anxiety, boredom and tend to be socially handicapped.When such individuals experience abuse from their family members, it can result in full blown depression, as they may become anxious about the future and experience feelings of despair.In older adults who have no one to confide in about their abusive experiences, this isolation can contribute to the development of depressive symptoms.Thus, mental well-being of elderly and risk of developing depression are interlinked with abuse.However which one is the cause and which one is an effect is an area needing further research to establish a clear temporal relationship.
The findings of the present study revealed that elderly individuals who did not own any land had 2.63 times higher odds of experiencing abuse.This result aligns with previous research indicating a correlation between abuse and lower socioeconomic status, specifically within poorer wealth quintiles. 16In Indian society, owning land is often viewed as a symbol of self-sufficiency and economic security.Elderly individuals who possess land tend to receive more respect and social standing.On the other hand, economically deprived individuals, although they may provide care for the elderly, often rely on them for financial support.This situation arises because children are aware that the landholding may be inherited by them or used for their benefit when the need arises.Consequently, the absence of any asset, such as land ownership, could potentially contribute to an increased risk of experiencing abuse events.
The study revealed a higher prevalence of abuse among individuals who were not engaging in regular physical activity compared to those who exercised for at least 30 minutes daily.This finding could be attributed to the positive impact of exercise on mental well-being, primarily through the release of endorphins.As Sharma et al. described that engaging in physical activity was associated with improved mental well-being by reducing anxiety, depression, and negative emotions, while also enhancing self-esteem and cognitive abilities. 28Additionally, the higher instances of abuse in individuals who were not physically active could be influenced by other factors.These individuals were more likely to stay within their homes, leading to increased interaction with caregivers and potentially greater dependence on them for their daily needs.This increased dependence could create a power imbalance creating a dynamic where the caregiver would hold a significant control and influence over the individual.This power imbalance may make it easier for the caregiver to exert abusive behaviors or manipulate and exploit the vulnerable individual thereby increasing the risk of abuse. 29Therefore, the combination of increased dependence and limited social support increased the risk of abuse for elderly who were not engaging in regular physical activity.
Unlike other studies, no association was found between education and elderly abuse in this study. 23ale gender was protected against abuse compared to females, contrary to Chandanshiva et al. 30 , where no association was found between elder abuse and gender However, this observation aligned with the societal norms prevalent in Indian society, particularly in rural areas, where gender preferences and disparities are still evident.Predominantly in gender biased societies like rural Indian culture, being male can significantly influence the way caregivers provide care.Males are more likely to possess land, have pensions, and enjoy better economic security compared to females.They are often exempted from household chores and are generally accepted to spend extended periods outside the house without raising concerns.On the other hand, female elders are often expected to take care of grandchildren, assist with household chores, and have more interaction with caregivers.These gender-based expectations and societal conventions can contribute to differential treatment and protection against abuse for male elders compared to females.The economic advantages and reduced responsibilities placed upon male elders may create a more favourable environment for their well-being and protection against abuse.
The elderly with skeletal deformities or functional limitations (ADL scores) had higher odds of being abused thereby corroborating the strong association between functional ability and abuse in the present study. 5The presence of physical disability as discussed above could lead to power imbalance and increase risk of abuse.Also, verbal abuse had the highest association with poor mental well-being, similar to a study by Terry et al. that found it to be a strong predictor of mental health. 31They found that verbal mistreatment was a significant negative predictor of social functioning and mental health.In their study, people who underwent verbal abuse also reported higher levels of depression and poorer quality of life compared to elderly individuals reporting no verbal abuse.
It is seen from Table 4, that the majority perpetrators were family members and 57(88%) had been abused by more than one family member.Table 4 revealed the perpetrators of elderly abuse and it was evident that, in more than 40% cases, the daughter in law alone or along with the son were the abusers of the elderly in their family.It was seen that majority elderly (21.5%) were either abused by Son and daughter in law in unison or by only daughter in law.Thus, the present study conformed with the results of other studies that found family members to be the most common abusers of elderly in India. 8,12 14 (21%) cases, although the perpetrators were close relatives but their identity was not revealed.This observation shows how despite the abuse, societal stigma, fear of repercussions and love for their family members could be the factors responsible for the underreporting of such cases.In 10 (15%) cases they found that their own sons were abusing the elderly parent while in only less than 2 % cases, daughter was the abuser.In only 3(4.65%) cases, spouse was found to be the abuser.The reason behind the abuse by close members indicated a huge shift in family values in the modern times that clashes with the usual Indian societal expectations.In lowincome countries like India, a significant proportion of older people live in villages and experience poor socioeconomic conditions.They are often dependent on their families for financial and physical support.However, the changing dynamics of society, such as rural-to-urban migration, have led to a decrease in available caregivers for older individuals.Many young people from rural areas migrate to urban areas in search of employment opportunities, leaving fewer family members available to take care of the elderly.This shift in population distribution places an increased burden on non-migrant family members who are left responsible for the care of older individuals.The demands of caregiving can be physically and emotionally taxing, and without adequate support systems, it can lead to neglect or abuse of the elderly.Abuse can also occur due to caregivers being overburdened.These caregivers often face significant stress and societal pressure when taking on the responsibility of caring for the elderly, particularly when the elderly is unemployed, mentally or physically handicapped, and not contributing to the household income.The stress experienced by overburdened caregivers, combined with the absence of employment opportunities or economic security for the elderly, may contribute to the occurrence of abuse.Furthermore, the frequent interaction between caregivers and elderly individuals, as the elderly spend more time within the household due to their age-related limitations, can exacerbate the potential for abuse. 1,32While caregivers stress on one hand could be a potential risk factor, another possible reason behind abuse is the lack of empathy among young caregivers towards the elderly, particularly when the elderly are unable to participate in household duties due to physiological changes associated with aging.This lack of understanding and empathy regarding the elderly's limitations may contribute to abuse in some instances.In the Indian rural set up, abuse is more likely to be perpetrated by sons and daughters-in-law as they are the ones who are expected to be the caregivers by convention of society family structure.
Given that the primary factors contributing to elder abuse are largely sociodemographic in nature, the most effective means to address this issue is through the implementation of improved community support.However, addressing these issues require a comprehensive approach that should involve awareness programs regarding mental well-being of elderly, research, policy development to create age friendly environment and resource allocation for employment opportunities for elderly and families.
Elderly abuse is a societal predicament that necessitates further studies to better comprehend the behaviours, attitudes, and perceptions of both caregivers and victims.Additionally, it is crucial to examine how societal expectations contribute to the deterioration of mental well-being and the occurrence of abusive incidents.

LIMITATIONS
Design effect was not taken into consideration in the present study.

CONCLUSION
The present cross-sectional study concluded that rural elderly was vulnerable to abuse by their own family members.It was experienced by 18.3% of the study population, mainly in the age group of 60-69 years.Female elderly was more vulnerable to getting abused in comparison to males.Abuse was associated with poor mental well-being, higher risk of depression, widowhood and lack of physical activity.
Neglect was the single most predictor for poor mental well-being.Vulnerability due to sociodemographic factors, as pointed out in this study showed that, it is a social evil that needs deeper understanding of family level problems and its relation to mental wellbeing.This raised important questions about the underlying factors contributing to abuse, such as chang-ing family structures, sedentary lifestyles, and ongoing urbanization.It also highlighted the need for a better support structure for the elderly in countries like India to prevent unnecessary dependence on their children.Elderly abuse being a highly sensitive subject of discussion pertaining to the stigma in Indian context, led to underreporting.It is therefore crucial to raise awareness about the mental well-being of older people.In addition, the relationship between mental well-being and elder abuse should be comprehensively studied in conjunction with sociodemographic factors.

Table 1 :
Comparison of Means between Those who were abused and not abused using independent t test (N=355)

Table 2 :
Distribution of Participants based on Study variables and Multiple Binary logistic regression analysis between factors and abuse (N= 65) [Variables showing p value <0.2 on bivariate analysis were included.] OR -Odds Ratio; CI -Confidence Interval; GDS -Geriatric Depression Scale; AOR-Adjusted odds ratio

Table 3 :
Association of the types of Elderly abuse and Mental well being OR -Odds Ratio; CI -Confidence Interval; AOR-Adjusted odds ratio

Table 4 :
Distribution of Elderly abuse victims based on (i)relationship of the perpetrators with them and (ii)the number of perpetrators responsible for abuse[N=65]