Elder Mistreatment Across Diverse Cultures

Abstract

Elder mistreatment, a pervasive public health issue, is of growing concern. Interpersonal relationships are culturally constructed, and attempts to understand elder mistreatment in different racial or ethnic groups should take into account cultural context. Culture affects how racial and ethnic groups perceive elder mistreatment and help-seeking behaviors, and how professionals and authorities could best engage populations, assess situations, and intervene to prevent mistreatment. Awareness and respect for cultural diversity must be integrated into research, practice, and policy related to elder mistreatment.

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Elder Mistreatment
Across Diverse Cultures
By Mengting Li, Ruijia Chen,
and XinQi Dong Studying various cultural perceptions of elder
mistreatment holds critical implications for
research, practice, and policy.
ABSTRACT Elder mistreatment, a pervasive public health issue, is of growing concern. Interpersonal
relationships are culturally constructed, and attempts to understand elder mistreatment in different racial
or ethnic groups should take into account cultural context. Culture affects how racial and ethnic groups
perceive elder mistreatment and help-seeking behaviors, and how professionals and authorities could
best engage populations, assess situations, and intervene to prevent mistreatment. Awareness and
respect for cultural diversity must be integrated into research, practice, and policy related to elder
mistreatment.
| key words: racial and ethnic minorities, perception of elder mistreatment, help-seeking
behavior, Community-Based Participatory Research, legislation, cultural humility
E
lder mistreatment is recognized worldwide as
a serious public health problem. Though defi-
nitions of elder mistreatment vary across nations,
states, disciplines, organizations, and studies, the
World Hea lt h O rgani zati on (W HO) d efines elder
mistreatment as “a single, or repeated act, or lack
of appropriate action, occurring within any rela-
tionship where there is an expectation of trust
which causes harm or distress to an older person”
(WHO, 2002).
The National Center on Elder Abuse (NCEA)
defines elder mistreatment as “any knowing,
intended or careless act that causes harm or seri-
ous risk of harm to an older person—physically,
mentally, emotionally or financially” (NCEA,
2005). The National Research Council (NRC)
defines elder mistreatment as “(a) intentional
actions that cause harm or create a serious risk
of harm (whether or not harm is intended) to a
vulnerable elder by a caregiver or other person
who stands in a trust relationship to the elder
or (b) failure by a caregiver to satisfy the elder’s
basic needs or to protect the elder from harm”
(NRC, 2003). Elder mistreatment is associated
with adverse health and well-being and a higher
mortality rate among older adults (Li, Liang, and
Dong, 2019).
Interpersonal relationships are culturally
constructed, and any attempt to understand
elder mistreatment in dierent racial or ethnic
groups should take into account cultural context.
The NRC’s 2003 landmark publication, Elder
Mistreatment: Abuse, Neglect, and Exploitation in
an Aging America, described an urgent need to
explore cultural issues related to elder mistreat-
ment (NRC, 2003).
In 2010, the National Academy of Sciences
and the National Institute on Aging organized a
state-of-the-science meeting on research issues
in elder mistreatment and abuse and financial
fraud, including discussion of research on minor-
ity populations. In 2015, a workshop on multi-
ple approaches to understanding and preventing
elder abuse and mistreatment, organized by the

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National Institutes of Health (NIH), addressed
challenges and opportunities related to cultural
diversity (NIH, 2015).
The Elder Justice Roadmap report regarded
diversity and inclusion of under-represented and
underserved populations as one of the universal
themes that cut across direct services, education,
policy, and research for elder mistreatment (Con-
nolly, Brandl, and Breckman, 2014).
The population in the United States is aging
and becoming more racially and ethnically
diverse. In 2017, people ages 65 and older num-
bered 50.9 million, representing 15.6 percent
of the U.S. population. By 2040, there will be
about 80.8 million people ages 65 and older, and
older adults are expected to make up 21.6 per-
cent of the population. Also in 2017, 23 percent
of people ages 65 and older were racial or ethnic
minorities: 9 percent were African Americans;
8 percent were of Hispanic origin; 4 percent
were Asian; 0.5 percent were American Indian
and Alaska Native; and 0.1 percent were Native
Hawaiian/Pacific Islander (Administration on
Aging, 2019).
Studies are needed to explore the perception
of elder mistreatment and help-seeking behav-
iors in specific sociocultural contexts. Studies
also are needed to understand the prevalence,
incidence, risk and protective factors, and conse-
quences associated with elder mistreatment and
its subtypes within diverse populations. Aware-
ness of and respect for cultural diversity must
be integrated into research, practice, and policy
related to elder mistreatment.
A Call for Community-Based
Participatory Research
Because of the emphasis on respect for elders
and the stigma associated with elder mistreat-
ment victims in minority communities, el d -
er mistreatment tends to remain hidden and
under-detected in these communities. Hence, it
is challenging to investigate the extent of elder
mistreatment and its risk factors with conven-
tional research methods, which often are carried
out by researchers from outside the community.
The community-based participatory research
(CBPR) appr oac h h as e merge d a s an eec-
tive way to uncover culturally sensitive issues,
including elder mistreatment. Using a collabora-
tive approach, it brings experts from academic
institutions, community organizations, and key
stakeholders into the research process. CBPR
has myriad advantages for studying minority
communities. Through working in partnership
with community residents, researchers are able
to identify a research topic that is of importance
to the community, engage minority participants
in the research activities, create measures to
capture culturally relevant factors (e.g., filial
piety in Chinese culture), and develop prevention
strategies and interventions to improve com-
munity health and well-being and to eliminate
health disparities.
There is a limited (but growing) body of
research on elder mistreatment that applies
CBPR principles (Jervis, Sconzert-Hall, and the
Shielding American Indian Elders Project Team,
2017). Jervis and Sconzert-Hall, guided by the
CBPR approach, examined how Native American
older adults perceived elder mistreatment and
found that substance abuse and culture loss were
major drivers of elder mistreatment in the con-
temporary Native American community.
Through collaborating with local community
organizations, Dong and colleag ues (2011) exam-
ined the perception of elder mistreatment among
thirty-nine Chinese older adults in the Chicago
area. Findings of the study suggest that Chinese
older adults typically characterize elder mis-
treatment in terms of caregiver neglect. In addi-
tion to facilitating the conceptualization of elder
mistreatment, the CBPR approach makes it pos-
An understanding of elder
mistreatment in different racial
or ethnic groups must consider
cultural context.

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sible for researchers to quantify the prevalence,
risk factors, and outcomes of elder mistreatment
in minority communities.
The Population Study of Chinese Elderly,
which leveraged the principles of CBPR to advance
scientific knowledge of elder mistreatment in Chi-
nese populations, is one example of a fruitful col-
laboration between researchers and a minority
community. The research team instituted a com-
munity advisory board of key stakeholders to
guide ongoing collaborations, and also nurtured a
grassroots educational initiative on elder mistreat-
ment issues facing the Chinese population.
The integration of grassroots civic engage-
ment with culturally appropriate activities (e.g.,
Tai-chi, Chinese poetry, and water painting)
encourages Chinese older adults to discuss and
disclose family conflicts and elder mistreatment
to researchers. Collectively, these studies sug-
gest that CBPR may be an eective approach
for investigating elder mistreatment issues in
underserved populations. However, it should
be noted that few studies have employed the
CBPR approach in elder mistreatment research
in Latino and African American communities.
Given the stigma around elder mistreatment
and the research barriers documented in Latino
and African American communities, future
research should investigate the eectiveness
of CBPR in elder mistreatment research in all
minority communities.
The Multidisciplinary Team Model
Elder mistreatment is a complex issue that
necessitates responses from diverse disciplines.
There has been a growing recognition that elder
mistreatment detection and intervention eorts
would benefit from adopting a multidisciplinary
team (MDT) model (Dong et al., 2013). An MDT
model refers to a team-based approach leverag-
ing the expertise of professionals from diverse
disciplines, including social service providers,
healthcare providers, researchers, and policy
makers, to review and respond to elder mistreat-
ment. An MDT model may improve the preven-
tion of and response to elder mistreatment in
minority communities, through promoting cul-
tural competency among members, improving
access to resources and services, and enhancing
the quality of care for clients in minority com-
munities. While promising, MDT model imple-
mentation has encountered many challenges and
barriers, including insucient funding, lack of
participation by certain disciplines, confiden-
tiality breaches, and MDT members’ failure to
take actions to which they have agreed. Further
research is needed on how to address the barri-
ers and support MDT model advancement.
Strategies for Working with
Diverse Populations
The perception of elder mistreatment varies
widely across dierent racial and ethnic groups.
Latino elders may not perceive financial exploi-
tation as elder mistreatment because interdepen-
dency is common among Latino families. African
American populations may be more likely to
perceive situations as abusive when compared to
other racial or ethnic groups (Moon and Benton,
2000). In many Asian cultures, disrespect is con-
sidered a form of elder mistreatment (Yan, Chan,
and Tiwari, 2015). One of the challenges in elder
mistreatment research is whether standardized
measures can encompass the varying concep-
tions of elder mistreatment among a range of
U.S. racial or ethnic groups. Sub-surveys of
minorities with more qualitative components to
reach a more nuanced understanding may need
to supplement large, epidemiological surveys.
Dierent racial and ethnic groups share sim-
ilarities in formal and informal help-seeking
behaviors. Familism is emphasized over the indi-
vidual in many Latino cultures, which can aect
Elder mistreatment necessitates
responses from diverse disciplines,
and may benefit from adopting a
multidisciplinary team model.

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an elder’s willingness to admit abuse or seek
help. Latino families would prefer seeking res-
olutions on their own rather than from formal
social systems (Cardona et al., 2007).
African American elders might distrust insti-
tutions and be reluctant to seek help in the com-
munity, particularly if they consider themselves
or their families at risk of discrimination based
upon race (Horsford et al., 2011).
Asian populations are reluctant to seek help
for elder mistreatment, as they perceive elder
mistreatment to be a private family matter
(Dong, Simon, and Gorbien, 2007), and are less
aware of available resources.
Healthcare professionals and social ser-
vice providers should take culturally relevant
approaches when serving elder mistreatment
victims. For example, research has indicated
that it would be helpful to identify points of
entry for service delivery systems located in the
communities (e.g., senior centers), rather than
expecting African Americans to reach out to for-
mal institutions they may not trust (Horsford et
al., 2011). It also is important to investigate what
happens to elders, families, and communities
when elder mistreatment is reported in ethni-
cally diverse communities.
Language ability makes help-seeking more
complex among minorities. Compared with U.S.-
born elders, foreign-born elders are at higher risk
of social isolation and cultural conflicts. Lack of
English proficiency is considered a risk factor for
elder mistreatment because foreign-born elders
have limited access to healthcare and social ser-
vices. Further, they may need to rely upon a bilin-
gual person to seek help. Foreign-born elders are
more likely to be exposed to cultural conflicts
that may lead to depression or anxiety. They also
often lack health insurance coverage (Cardona
et al., 2007). Multilingual services are suggested
in clinical practice to avoid dependence upon
translation by family or friends who may be per-
petrators, and to reduce the diculty of report-
ing elder mistreatment and seeking help among
racial or ethnic minority groups.
Culture can be a source of risk and protec-
tive factors for elder mistreatment. For example,
family relations in Asian culture can play a cen-
tral role in individuals’ health and well-being
across the life span. One study investigated the
relationship between family relations and elder
mistreatment among Chinese Americans (Li et
al., 2019), and found that tight-knit families—a
traditional Chinese family typology that high-
lights filial piety and social exchange between
generations—had the lowest risk of elder mis-
treatment, while the highest risk of elder mis-
treatment was found in unobligated ambivalent
families, featuring high emotional closeness and
high family conflict.
These findings revealed that traditional fam-
ily typology in Chinese culture and filial piety
values were a protective factor for elder mistreat-
ment. Additionally, in immigrant families, cul-
tural disparities around family values between
younger and older generations (e.g., filial obli-
gation) can be major sources of family conflict,
increasing the risk of elder mistreatment. Future
research could investigate racial or ethnic dier-
ences in risk or protective factors associated with
elder mistreatment. Interventions could focus on
cultural factors of elder mistreatment in racial or
ethnic minority populations.
Culturally appropriate education and train-
ing could be provided to healthcare professionals,
social service providers, APS agencies, and others
having contact with older adults. Such education
and training activities will be critical for allevi-
ating factors exacerbating abusive situations and
preventing the recurrence of elder mistreatment
(Dong, 2012). Also, it is important to integrate
cultural humility into healthcare professional
education and training (Chang, Simon and Dong,
2012). Healthcare professionals could improve
‘Culture can be a source of risk and
protective factors for elder
mistreatment.’

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the quality of care and reduce health dispari-
ties among racial or ethnic minority populations
through improved understanding of patients’
social and cultural contexts, as well as the com-
plex interplay of patients’ values and beliefs with
their perceptions of health and illness.
Legislation Influencing the Field of
Elder Mistreatment
Federal legislation is critical for advancing our
understanding of cultural diversity issues of
elder mistreatment and responding to elder
mistreatment issues in minority communities.
For example, The Elder Just ice Act (E JA) is the
first comprehensive piece of federal legislation
to detect, prevent, and prosecute elder mistreat-
ment, neglect, and exploitation. Enacted in 2010
as a part of the Aordable Care Act, the EJA
authorized a number of programs to advance
training, services, research, and innovations in
the field of elder mistreatment. For example, in
2016, the Administration for Community Living
established the Elder Justice Innovation Grants
program to support emerging practices to pre-
vent and respond to elder mistreatment. Among
the programs awarded are mini-grants provided
by the University of North Dakota to enhance
awareness, support elder mistreatment policy
development and infrastructure, and improve
interventions among indigenous elders. Such
programs oer fundamental support for pro-
moting elder mistreatment research in minority
communities and eliminating disparities in elder
mistreatment.
The Violence Against Women Act (VAWA)
is another law that supports elder mistreatment
prevention and intervention in minority com-
munities. VAWA was enacted in 1994 and reau-
thorized in 2013, aiming to improve responses
to domestic and sexual violence. Its 2013 reau-
thorization recognized the higher rates of vic-
timization among communities of color and
placed emphasis on addressing barriers to seek-
ing and accessing help for socially disadvan-
taged groups.
However, funding of the prevention and
treatment of violence against older women con-
stitutes a small fraction of the legislation. VAWA
only authorized $9 million for each of fiscal years
2014 through 2018, in training healthcare pro-
viders and caregivers to detect warning signs of
elder mistreatment. This funding was decreased
to $5 million in the 2019 fiscal year (Congressio-
nal Research Service, 2019). Eective prevention,
investigation, and intervention in elder mistreat-
ment in underrepresented populations require
increased funding to support training and edu-
cation that improves the cultural competence
of service providers and researchers.
Conclusion
Elder mistreatment is a pervasive public health
issue and a growing concern. Culture aects
how racial and ethnic groups perceive elder
mistreatment and help-seeking behaviors. In
turn, culture also aects how professionals and
authorities engage, assess, and intervene in issues
around elder mistreatment. Significant gaps
remain in existing research to understand elder
mistreatment among racial and ethnic minority
populations and to improve health equity. The
lack of minority representation among research-
ers and a lack of funding for research on minority
aging might partially explain the gaps.
In the past ten years, less than 1 percent of
NIH funding was awarded to research focused
on U.S. Asians, and Asian investigators were less
likely to receive funding than were white inves-
tigators (Dong, 2019). Quantitative and qualita-
tive methods, community-based participatory
research approaches, multidisciplinary teams,
and the involvement of racial and ethnic mi -
nor ity investigators all are necessary to gain a
nuanced understanding of elder mistreatment
in diverse racial and ethnic populations. Collec-
tive federal, state, and community eorts also
are needed to address and integrate the unique
needs of racial and ethnic groups in direct ser-
vices, education, and policy on the issues of
elder mistreatment.

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distributed in any form without written permission from the publisher: American Society on Aging , 575 Market St.,
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Mengting Li, Ph.D., is an assistant professor at the
Institute for Health, Health Care Policy and Aging
Research, School of Nursing at Rutgers, The Univer -
sity of New Jersey, in New Brunswick. She can be
contacted at mengting.li@rutgers.edu. Ruijia Chen,
M.S., is a doctoral candidate in the Department of
Social and Behavioral Sciences at the Harvard T.H.
Chan School of Public Health, in Boston. She can be
contacted at ruijia.chen@mail.harvard.edu. XinQi
Dong, M.D., M.P.H., is the inaugural Henry Rutgers
Distinguished Professor of Population Health Sciences,
and director of Institute for Health, Health Care Policy
and Aging Research, at Rutgers. He can be contacted
at xdong@ifh.rutgers.edu.
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